S1E45 MSK Upper Extremity

Okay, so let's do a CRAM session for MSK upper extremity. As always, I'm going to stick to the need to know stuff. I'm not going to bother your time with the stuff that I really feel is very low yield and that you don't need to know. So let's go ahead and get started. As always, thank you so much for the really nice comments. You guys are just the nicest people, So thank you so much. Let's go ahead and start with the shoulder and they'll work our way down. So anterior

gleno humeral dislocation, so this is your most common type. Anterior dislocation is going to account for around ninety five to ninety seven percent of cases of shoulder dislocations. Now, as far as the mechanism of injury, it's going to be a blow to the abducted, externally rotated and extended arm. So that's the most common mechanism of injury. So think like blocking a basketball shot your

arms up and out. Less commonly is going to be a blow to the posterior humorous or a fault on an outstretched arm can also cause an anterior dislocation, but focus on that arm being abducted. Abducted away from the body, extended and externally rotated, and then something hitting the arm in that position. Non physical exam. You need to know that you're looking for an abducted, abducted externally rotated arm, So an anterior dislocation of the shoulder causing the arm

to be slightly abducted and externally rotated. Diagnosis, you're going to do an X ray. X ray of the shoulder is normally going to be enough to diagnose. Going to get an ap view, scapular y view, axillary view. A few associated injuries you should know with an anterior dislocation. There's the hill Sacks, bank art lesions, axillary nerve injury. It wouldn't go crazy memorizing the specific injuries what they involved. Just know they're associated with anterior dislocation

hill sacks real quick. It's a cortical depression. Hill sax lesion is a cortical depression in the humoral head made by the glenoid rim. Bank art legions occur when the glenoid labrim is disrupted during the dislocation, and a bone fragment is a vols and an axillary nerve injury. This one's probably the most important

associated injury to know. So it's really important to assess the nerve vascular status in patients with an anterior shoulder dislocation because axillary nerve disfunction can actually show up to up to forty two percent of patients with an anterior dislocation. So you're gonna look for a loss of sensation on what's called the shoulder bags distribution. It's basically like on a cop uniform or a military uniform. Just think of the area of the arm that the shoulder badge would be. Where they have

a badge on the arm. That's where the axillary nerve innervates, and that's where they may have this loss of sensation. They may also have deltoid muscle weakness. So just be familiar that axillary nerve dysfunction is common in anterior dislocations. As far as treatment reduced in sling, there's not much to know here, certainly nothing to memorize. You reduce the dislocation, mobilize it with the sling, and then assess for axillary nerve dysfunction pre and post reduction. Okay,

so there's a lot of random things to know for anterior dislocations. So the way that you're going to remember them is by remembering a guy named Antonio. So this is visualization times is much easier on the YouTube channel. I have a nice little picture I'm made in MS paint, but let's just try to visualize this. So Antonio is this guy and in one hand he's holding

a picture and in the other hand he's holding an axe. The picture that he's holding is a bank on top of a hill like this nice pretty hill with a sunset in the background. And then there's a bank sitting on top of the hill. That's the picture. The other hand he's holding an axe. Now he's holding both of these up and out by his sides. His arms are abducted and they're externally rotated. So Antonio helps you to remember this

as an anterior dislocation. Antonio anterior dislocation. The picture that he's holding with the bank on top of a hill helps you remember bank art lesions and hill sack lesions that can commonly be seen in anterior dislocations. And then the axe he's holding in his other hands helps you remember axillary nerve dysfunction that's the most common in anterior dislocations. And then finally, the position of his arms.

Like I said, they're abducted and externally rotated. That helps you remember both the way the arms usually positioned during the physical exam and during the injury too. So remember a guy named Antonio holding a picture of a bank on top of a hill on one hand holding an axe, and the other both arms are abducted and externally rotated. And that should be all you need to know

for anterior dislocations for the exam, moving onto posterior glenohumeral dislocation. So these are much less common compared to anterior They only occur in around two to four percent of patients. Mechanism of injury for anterior dislocations wasn't very high yield, but for posterior dislocations it is, and it's because it's unique. And if you listen to any of my other content, you always know anytime there's something unique, they're going to ask you questions about it, So keep that in

mind. Mechanism for posterior dislocations is going to be seizure and electric shock, so those are the ones that you need to know. Of course, trauma like a blow to the anterior portion of the shoulder can cause a posterior dislocation, But what you should focus on is violent muscle contractions following a seizure or electrocution, because those are the unique components that they like to ask questions about seizure or electric shock. Remember those for your mechanism of injury in a posterior

dislocation. Now physical exam opposite of anterior So for a posterior dislocation, it's going to be adducted and internally rotated. So usually the patient's going to hold their arm in adduction and internal rotation and is usually unable to externally rotate again. And that's different than anterior dislocations, which was abducted, abducted and externally

rotated. Now, diagnosis, you're going to get an X ray, so you'll do your normal routine shoulder views, apyve you, etc. But be aware of the light bulb sign on posterior dislocations because they may ask about this. So on the AP view, the humoral head is going to be internally rotated and because of this, the twoberocities of the humorous they're not going to be visible. They're going to be normally, they're project out laterally, but

they're not going to be visible because the humoral heads internally rotated. And because of this, I have to take my word for it, the humoral head kind of takes on the circular appearance and supposedly looks like a light bulb. I guess it kind of does. So anyways, if you hear a light bulb sign, be thinking. Posterior dislocation treatment is going to be the same as an interior You're going to reduce and sling. Okay, So for posterior

dislocation, there's a few things that you need to know. Remember your caesar seizure and shock can be the mechanism of action, mechanism of injury. Remember the arm is likely going to be adducted and internally rotated. And remember the light bulb sign. Those are the high yel things. And the way that you remember that is I want you to visualize this warning on a poster board. So on the posterboard there's going to be a picture, and on the

posterboard there's going to be a picture of a broken light bulb. There's going to be a finger, and then there's going to be a picture of a guy being shocked. And it says if you add your finger into a broken light bulb, you'll get shocked, So add an into if you add your

finger into, that helps you remember adducted and internal rotation. So if you add your finger into adducted internal rotation, remember that's the most common presentation, the broken light bulb, because you remember the light bulb sign on X ray scene of posterior dislocations and shocked because remember the unique mechanism of injury, electric shock, and seizure. And then again this is all on a posterboard because

that posterboard helps remember posterior dislocation. So again, remember a poster board, and on the poster board it says if you add your finger into a broken light bulb, you'll get shocked. Visual a posterboard with a finger a plus sign, a broken light bulb and a guy being shocked, and you'll remember everything you need to know for posterior dislocations. All right, moving on to

a rotator cuff injury. This is definitely a high heel topic. There's a good deal to know for this, and you'll likely get a question on this. So let's go over a rotator cuff tears and impingement. So first, you need to know your muscles in the rotator cuff. I'm sure you've all heard of the famous mnemonic sits S I S so superspinatus infraspinatus tarifs minor and subscapularis mechanism of injury for rotator cuff. Injury is going to be a few

different things. So degeneration like chronic degenerative tear that's usually going to be seen in older patients. Impingement. Chronic and pingement can also lead to a tear and then overload, so like tension overload and athletes are continually throwing like in baseball or jobs with repetitive overhead movement. In general, the cause of rotator cuff tears, it's multifactorial degeneration and pingement, over they can all contribute.

There's not really anything I'd say is super important to memorize. The high yield things for a rotator cuff is going to be the presentation of physical exam tests, so clinical manifestations. There's two things to know here. Overhead pain and pain at night. That's the key. So pain exacerbated by overhead activities. So the vignett they're going to describe the patient that's maybe reaching up to the shelf and experiencing pain, brushing their hair and having pain things like that,

definitely look out for. The location of the pain is usually going to be over their lateral deltoid, so the anterior lateral portion of the shoulder. And then they also may describe pain at night, so complaining like when the patient's lying on the shoulder at night, they're experiencing pain. That's the classic presentation. Will look out for in vignettes the pain over their lateral deltoid when they're reaching overhead, or complaining of pain at night and real life, though it's

possible that they may just develop weakness decreased range of motion. Other studies even suggest a large portion of rotator cuff tears. They're actually asymptomatic. But for the exam pain with overact, pain with overhead activities, pain at night done physical exam. So there's a lot of special maneuvers for the rotator cuff when you're looking for impingement and tears. So three that I feel you should be familiar with at seem to be tested on the most is the Hawkins test,

the near tests, and the empty Can test. Again, these are for both impingement and tears. So let's start with the Hawkin and the Near test. These are both really good tests to test to assess for impingement. So the Hawkins test, also known as the Hawkins Kennedy impingement test, the patient's going to have their shoulders stabilize and positioned in ninety degrees of elevation. The

elbow is going to be bent to ninety degrees. The examiner is going to place internal force on the patient's shoulder, and then any reproduction of pain elicited by the internal rotation would be a positive test for impingement. Again, if you need visuals on any of these, check out the YouTube channel. Have

a lot of different pictures and things like that that kind of help. So the way that I used to remember this test, the Hawkins test, was if you can visualize when you were a kid, did you ever call someone a chicken? You do the little arm flapping thing like wings. That's exactly what this looks like when you're doing the Hawkins test. Their shoulders up, their elbows bent. So when I see Hawkins test, it makes me think

of a hawk flapping its wings. And I'll help you remember this is the one where it looks like you're flapping your wings like a bird or a hawk, with the elbow bent, shoulder elevator elevated, and the examiner applying internal rotation. That's exactly what this looks like. You'll have to take my word for it or check out some pictures of the Hawkins test, but it looks

like somebody like flapping their wings like a hawk. So again remember that in your os keys and things like that, you'll remember what the Hawkins test looks like and what it involves. So remember Hawkins tests flapping your wing like a hawk. I let's talk about the near test. So the near test, the shoulder is going to be forcibly flexed and internally rotated. So one hand is going to be placed on the shoulder and the scapular area to keep the

shoulder from shrugging. The other hand is going to passively lift the arm all the way up to the ear. The arm is going to be internally rotated with the thumb facing down, and then any reproduction of pain is a positive test for impingement. May see some variations of this test with the arm and neutral position rather than internal, but most of the time it's going to have

internal rotation. Ice Remember near is by the ear because and this test, your arm goes all the way up and the shoulder winds up right next to the ear. So when you see the near test, remember near is the one by the ear. And then finally, the empty can test, also known as the Job's test. This is a good test to evaluate superspinatus function.

Sometimes it's considered the gold standard test due to how well it isolates the superspinatus in the way that the arm is position to really isolates it well. So the patient's going to place a straight arm out at about ninety degrees of ab duction and thirty degrees of forward flection, then internally rotating the arm completely. The thumb is going to be pointing down. And then the patient then resists. The clinicians attempts to depress the arm, so you're trying to push

it down. They're resisting. So again the patient raises their arm forward, elbow extended, thumbs down as if emptying a can. Examiner's going to apply pressure to the top of the arm, pushing it down. The patient attempts to resist. This. Pain without weakness is going to suggest tendinopathy. Pain with weakness is consistent with the tendon tear There's a lot of other tests, but in my experience, those are the three that seem to be most often

tested on, so definitely be familiar with those three. Now, treatment conservative versus surgical repair, there's nothing really specific to know here. Treatment is all going to depend on. It's really a several factors like the duration of the symptoms, the type of tear partial versus full thickness, patient age, activity level, etc. That's going to guide the treatment as to whether or not they're going to need surgical repair or if they're better suited for say physical therapy.

Now, if we're talking about tendonitis and the impingement of the rotator cuff, treatment is primarily going to be physical therapy and sets, etc. You're gonna find with most of MSK treatment is pretty repetitive. It's not very high yield. That's why I kind of run through them quickly because there's just not much to know from an exam standpoint, So from breezing over and I'm skipping in some cases, it's just because there's nothing really for you to memorize.

If there's something high yield for treatment, I'll definitely make sure to bring it to your attention, all right, so let's move on another area of the shoulder known as adhesive capsulitis, also known as a frozen shoulder. So this is a painful and stiff glenohumeral joint that has lost its distensibility and range of motion. So it's exactly what it sounds like. It's a frozen shoulder. It's hard to move. Passive and active range of motion are going to be

substantially reduced. Risk factors diabetes, this is a big one. Remember that frozen shoulder is very common in diabetics, and the vignette it will very very likely be a diabetic patient. There's actually a study that showed the incidence of frozen shoulder and patients with long standing type one diabetes had a lifetime prevalence of

up to seventy six percent. So diabetic patients remember that the other risk factor to know is thyroid disorders, particularly hypothyroidism, may increase the risk for frozen shoulder as much as two point seven times. And then there's some other causes that you shouldn't memorize should not memorize, like dyslipidemia, prolonged immobilization, stroke, auto immune disease. Secondary problem after shoulder injury. Focus on diabetes,

they got that sticky shoulder from all that extra sugar and thyroid disorders. And then also know that this is very common in women, particularly in the fifth and sixth decades of life. It's actually really rare to see the impatience under forty. So in the vignette, be looking for a female in their fifties or sixties with diabetes or thyroid disorder. For diagnosis, There's nothing I really know here. Frozen shoulder is very much a clinical diagnosis made on the basis

of the medical history. The physical exam imaging really has very little value except just to rule out your differentials like osteoarthritis and things like that. Treatment is also pretty low yield most cases. Frozen shoulders is self limited condition. Physical therapy is the most commonly employed treatment option. Google corticoid injections and SAIDs other supportive measures, but nothing really to commit to memory here, all right,

So moving on down the arm. Supercondular humorous fractures, so supercondular fractures of the distal humorous You're going to see this most common in children two to seven years old, so most frequently in children two to seven years old. So be looking for a child in the vignette. Supercondular fractures are actually the most common mediatric elbow fracture as far as the mechanism of injury. Foosh with the elbow extended. So foosh foosh with the elbow hyper extended. So you're gonna

hear me saying that a lot. So extension fractures are actually going to account for approximately ninety five percent of all supercondular fractures, and this is typically going to be from a foosh mechanism. So foosh stands for fall on outstretched hand and then in this case, the elbow is going to be hyper extended.

Like we talked about before, this is really seen very commonly in children, and the reason is because children have this increased flexibility in their joints, They have this ligamentous laxity, and when they fall with their arm extended out, they're more susceptible to hyper extending the arm when they fall, and then hyper extension is what generally leads to this type of fracture, to a supercondular fracture.

So remember supercondular foosh with hyper extension diagnosis, you're going to get an X ray and once you're looking for here is fat pad. So the only thing I really think you should be aware of, at least for imaging when comes to supercondular fractures for the exam are fat pads. So in a non displaced or minimally displaced fracture of this region, sometimes you actually can't see the

fracture. Sometimes it can't be visualized. And the only indication that a fracture is present is an elbow effusion like seen in an anterior sale or posterior fat pads signs. So let's talk about fat pads for a second. In the elbow, you have fat pads. Usually they're not visible on X ray. I'm going to talk about this a little bit more when we get to radio head fractures. Next your interior verus posterior which you can be normal, which

you cannot. But generally fat pads, particularly posterior fat pads, they're not visible unless you have an acute injury and then this blood starts to collect. This hemarthrosis elevates the fat pads out of the coronoid and the electronoid electro non fossa, and that's what makes them visible on radiographs and actually in more than ninety percent of cases where imaging shows posterior fat pad displacement, a fracture is

seen on initial or follow up radiographs. So at the elbow will be looking for your fat pads and then also be aware there is something called an interior humeral line. If there's any displacement of this line, this can also indicate a displaced fracture. I don't think they're going to ask you about this though,

Just really focus on your fat pads now. Complications. There's a lot of complications that can arise from a supercondular fracture, vascular insufficiency, nerve injury, compartment syndrome, So I want to make sure you're doing a complete neurovascular evail in these patients. You need to check the sensory and the motor function of the medial, of the median, radio owner nerves. You want to assess the radio and brakual pulses. What you really need to be looking out

for. An exam question when it comes to complications of a supercondular fracture is something called Volkman's schemic contracture. So this isn't common, but it's definitely tested on. So when you have this type of fracture and you have a vascular injury and swelling. This can potentially lead to compartment syndrome, and if that compartment syndrome isn't treated in a timely manner, the associated a schemia and infraction

can lead to Volkman's a schemic contraction. So what this causes is you have this fixed flection of the elbow, the extension of the MCP joints. But it really simply it's this claw like deformity of the hands fingers and the risk risk. So for the exam, if you see Volkman's contracture right away, be thinking of a supercondular fracture, because while this can be seen with other types of injuries of the arm, it's most commonly seen with supercondular fractures.

So associate those two in your head Volkman's supercondular, supercondular Volkman's or just remember what I did and remember my vocal at my Volkswagens in super condition, so Volkswagen helps remember Volksman contracture. Supercondition helps remember supercondular fracture. So my Volkswagen's

in supercondition Volkswagen Volkman's contracture supercondition helps you remember supercondular fracture. All right, so treatment is going to be splint verse surgical most displaced or minimally displaced fractures, you're going to apply a posterior your splint and sling. Displaced fractures generally be repaired surgically closed versus open reduction with percutaneous pin play. Nothing really to memorize here. So for supercondular fractures, remember this is very likely going to

be a young child in the vignette. It's going to be a foosh injury with hyper extension. You remember fall on outstretched hand, Look for your fat pads on X ray, and then finally remember your Volksman's contracture for potential complications. Remember by Volkswagens in supercondition. Okay, so next radiohead fractures. There's really just a few things to know here. The mechanism of injury is going to be another foosh, So another foushure like in supercondular humeral fractures and many

other fractures of the arm. Really, so falling onto an outstretched hand is the most common mechanism for radiohead or neck fractures. Because this type of injury there's this sudden impaction on the radius and onto the capitulum. So as far as diagnosis, you're going to get your X ray. You're looking for fat

pads here again. Now, the fat pads in radiohead fractures are even more important than supercondular fractures that we just discussed before, because non displaced radiohead fractures can very very often be missed and an elevated interior and posterior fat pads maybe the only sign of an occult radiohead fracture. So be looking for those fat pads in the vignette and in real life. Wanted to give you a little bit of extra knowledge while we're on the topic of fat pads, so I

interior fat pads can actually be a normal variant, particularly in children. While a posterior fat pad should really never be visible. It'll almost always indicate trauma. So again, remember anterior fat pads can sometimes be a normal finding, while posterior will almost always indicate a fusion caused by trauma. And I used to remember and tieror fat pads and tior with an A can be AOKA,

and posterior fat pads with a P are always problematic. So anterior AOKA posterior problematic helps you remember which one can be normal, which one is always bad. Treatment is going to be splint for a surgical nothing really to know here. Depending on the severity of the fracture and mobilization with a sling or posterior splint may be sufficient for surgical repair for your displaced For more severe fractures, again, little mill for radiohead fractures, just remember your food injury. You

know your fat pad sign for those occult fractures. Occult fractures. If I didn't mention this before, it just means a hidden fracture that's not visible on imaging. Let's move on to ulner shaft or night stick fractures. Really, very little to know for this one. I only bring it up for some reason. This does come up on exams. Main takeaway here is to know the type of injury that's related to the specific fracture. So this is going

to be an isolated ulner shaft fracture. The mechanism of injury is going to be a direct blow to the forearm. So these types of fractures almost always result from a direct blow to the forum. So this happens when the patient was using the forum to protect their head from their torso, like from a blow with a night stick or a pool stick or something like that. So if you're familiar with the mechanism of injury, when you see it in a

vignette, you'll know you'll be looking for an ulner fracture. In the answers, treatment is going to be non operative treatment verse surgical repair. So casting splinting is the accepted approach for uncomplicated night sticks fractures. But if the fracture is comminuted over fifty percent displacement, these types of fractures are suited for better

suited for surgical repair. Okay, Montezia and Galiazzi fractures. So with Montezia and Galiazzi fracture is the only thing I feel you really need to remember that's normally tested on is what bonus fracture and dislocated in each. The rest of the stuff's pretty low yield that you need to know. So Montezia is going to be a proximal ulnar fracture accompanied by a radial head dislocation. So again

Montesia proximal ulnar fracture companied by a radial head dislocation. Galiazzi is going to be a radial midshaft fracture associated with a dislocation of the distal radial ulnar joint. So both of these are not just fractures, but they're also dislocations, and you need both to meet the criteria for either a Montezia or a Galiazzi fracture, you need to have both a fracture and the dislocation. Diagnosis is going to be done with an X ray. Treatment is going to be surgical

repair. Generally, in both of Montezia and a Galiazzi fracture, treatment is almost always going to be surgical. Montega fractures in particularly are almost in particular, almost always unstable and always require surgical treatment. Most of the time this is going to be with an RIF open reduction internal fixation. So again the highest yield thing is remembering which fracture and dislocation is of what bone in each condition. So the way that you remember that is by remembering gruesome murder.

So gruesome murder helps to remember which bonus fracture and then secondly which is dislocated, So remember gruesome murder. So for Montigia and Galiazzi fracture, so gruesome The first three letters in gruesome are gru, so the G stands for Galiazzi, the R stands for radius fracture, and then the U stands for owner dislocation. So that's in gruesome Galiazzi our radius fracture, and then the U

stands for owlnar dislocation. I know, technically I said this is a dislocation or instability of the radio owner joint, not specifically in older dislocation, but in most cases, what we actually see is this dorsally displaced owner head, which will be very evident on X ray, so you'll see the owner hopped out of place. So remember gruesome gru Galiazzi, radius fracture, owner dislocation,

and then murder the second part of the sentence. The first three letters are Mu, R, and that stands for M stands for Montezia, U stands for ulnar fracture, and then the R stands for radial head dislocation. So again remember gruesome murder. First three letters of gruesome, Galiazzi, radius fracture, owner dislocation, first three letters of murder. Help you remember Montezia, ulner fracture and radio head dislocation. Okay, radial head subluxation This is

also known as a nursemaide elbow. It's important to know this because not only may it come up on an exam, but if you wind up working anywhere with pediatric patients, you're going to see this very frequently. So what happens here you have the movement of the head of the radius that slips under the annular ligament. So we talked about this before, but the ligaments and children

are much more lax and weak. So in a child, when you have this sudden pulling on the arm, pulling on the distill radius, the annular ligament, which is a band of fibers that encircles the head of the radius, it slips right over the head the radius, and then this slides into the radio humeral joint where it becomes trapped and these children start to have pain. It's most common in one to four years of age, so common between the ages of one to four years. Eighty percent of cases are actually going

to fall within the one to three year range. So if it's not a young child in the vignette, it's not a nursemaid elbow. This is a one hundred percent going to be a young child. The reason we see this more frequently in young children not adults. Is because the attachment of the annular ligament is much weaker and children than adults. As the child grows, the attachment between the annular ligament and the radius becomes thicker and stronger, and it

prevents the subluxcation. Usually by the age of five years, the ligament is going to be strong enough and thick enough that it's highly unlikely to tear to become displaced. So generally you're looking for a child one to four years. I'm not saying it's impossible to see this like in a seven or eight year old, but probably not very common at all. Look for a very young child. In the vignette mechanism of injury, this is going to be a

polling injury. So the classic mechanism for a radiohead subluxation is going to be consisting of a pull injury. So, for instance, a parent grabs the arm of the child to prevent them from falling, maybe the child's being swung by the forearms or during play with their siblings or parents. You're looking for

some type of pull or tug on the arm. And even yet, the reason why this is actually called a nursemaid elbow was because back in the day, when nursemaids as they were called back in the day, took care of children, they were often blamed for causing this injury by tugging on the child's arm. So look for that pulling or tugging of the arm. Diagnosis is going to be clinical. So a majority of the time this is a clinical

diagnosis. They had a pulling or tugging type injury. They fit the age range on physical exam, they don't have any bony tenderness, no deformity, no swelling. Usually that's all you need to make the diagnosis. Imaging is usually not necessary. Now treatment there's very few things in medicine where we can fix someone's problems and a matter of seconds and make them feel completely back to

normal. But this is one of those few circumstances. So with treatment it's going to be a close reduction, and there's a couple of ways to do this. The technique preferred by up to date, which has a higher rate of success, is reduction with hyperpronation rather than the other alternative, which is this supernation flection method. So the way you do the hyperpronation method is going

to be you hold the child's arm at the elbow. You place pressure with a finger on the radio head and then the other hand holds the discal forum and you hyper pronate the forum, so you turn the arm all the way over and in a lot of times you're going to feel this click or this pop over the radial head. But it reduces and then these kids within minutes are going to be back to normal and playing and smiling in most cases,

at least from my experience. So for radial head subluxation, main takeaways here looking for a child under five looking for a pulling injury. It's a clinical diagnosis and treatment is going to be with a closed reduction, very straightforward. All right, Medio versus lateral epicond litis. These are really simple, there's very little to know. But the reiblement is you can easily get them mixed

up and miss out on an easy exam question. So let's go over what you need to know the little differences between the two and in the monic to remember them. So, lateral epicondolitus, which is also known as tennis elbow, it's a frequent complaint of tennis players, actually up to fifty percent of tennis players. It's mostly due to poor technique. So it's an overuse injury of the origin of the common extensor tendon which leads to tendinosis and inflammation of

the extensor carpi radialis brevis precipitated by repetitive wrist extension. And the reason why you have painted the lateral epicondyle is because the lateral epicondo of the elbow is the bony origin for the wrist extensors. So who are you looking out for? This is going to be of course tennis players. Like I said before, tennis is the most common sport to cause lateral epicondolitus. It can be seen in other sports squash, badminton, as well as certain occupations like carpenters,

bricklayers, seamstresses. But for the sake of the exam, be looking for your tennis player, and on exam you're going to be looking for localized tenderness over the lateral epicondyle and pain with resisted wrist extension. So lateral epicondo lightis associated with extensive extension and extensor so pain with risk extension. On physical exam, overuse of the extensor tendon, the extensor carpi radialist brevis precipitated from

repetitive risk extension. Remember what I keep saying, extension extensor, lateral epikind of lightis. Remember extension extension extension That's how they're going to get you on an exam question if you don't remember this and you get it mixed up with medial epicind of lightis, which is the opposite involving flexion rather than extension treatment. It's going to be conservative and SAIDs activity modification, steroid injections, counter

force braces, not anything really important to know here. Medial epicondo lightis. So this is also known as golfer's elbow. It is an overuse injury involving the proximal tenders of the pronator, terrace and flex or carpi. Radialists probably mispronouncing all of these overt imachin I am. It's primarily due to repetitive forceful

forearm pronation and risk flection. So this is the opposite and lateral we were talking all about extension extens or tendence down medial It's all about the flection flex or carpon radialis caused by repetitive risk flection and just like we talked about before in lateral epicondolitis, the reason why you have pain in the medial epicondo in this case is because the medial epicondyle is the common origin of the forearm flexor

and and the pronator muscles. So in the vignette you're probably going to get a golfer medial epicondolitis, as we know is called golfer's elbow. But interestingly enough, around ninety percent of cases are actually non sports related, in particular occupational settings with repeated forceful gripping during heavy labor like plumbers, carpenters, construction workers. But for the exam, I probably remember and focus on your golfers

on physical exam. They're going to have localized tenderness over the medial epicondyle and pain with resisted wrist flection, so flection flection, flection treatment is going to be the same as in lateral conservative and SAIDs activity modifications, steroid injections,

counterforce braces. Nothing to memorize there, all right, So the main thing to remember for both later epicondolitis remember tennis players pain with wrist extension against resistance problem with the extensor tendence caused by repetitive risk extension, Lateral should equal extension in your mind. Now, medial epicondolitis golfers pain with risk flection against resistance problem with the flex or muscles caused by repetitive wrist flection. Medial should equal

flection in your mind. If you can remember one by method of exclusion, you can remember the other. And here's how you're going to do that. So with medial epicondolitis aka golfer's elbow, I want you to remember mini golf is fun. The M and mini helps you remember this is medial epicondel involved

in golfer's elbow golf obviously because this is also known as golfer's elbow. And then the F and fun helps you remember this involves flexion, whether it's pain with risk, flection against resistance on exam or the fact that the flex or carpyrradialis or that it's caused from repetitive flection. Mini golf is fun. Mini stands for media up a condal golfer golfer's elbow, and F and fun for reflection flexor. And then you know ladder up condolitis is the opposite problems with

extension not flection. So remember mini golf is fun on your exam. When you get a question on one of these, because you're very you very likely will. And honestly, I had so much trouble remembering which was which until I came up with anemonic, and now I never forget. So remember mini golf is fun. Okay. Next, I wanted to talk about two conditions that are also really easy to get mixed up on an exam, and they can have similar presentations, and then I'll teach you some ways to help differentiate.

So that's going to be cubital tunnel syndrome and carpal tunnel syndrome. So let's start with cubital tunnel syndrome, which is ulnar neuropathy. It's a compressive neuropathy of the ulnar nerve caused by compression in the medial elbow. Clinical manifestations, this is the highest yield thing to know right here. So paristhesia of the fifth finger and half of the fourth so numbness tingling in the older nerve distribution. That's going to be your most common initial complaints. So paristesia is

the small finger and older half of the ring finger. It's also possible to have radiating pain down from the elbow. Usually you're looking for paristesis and the little finger and half of the ring finger. That's the key to remember here. So you're going to get a question, the patient's gonna have some tingling in their hand. The answer choices, they're going to have both cubital tunnel syndrome and carpal tunnel. You need to remember which has which nerve distribution,

and this is the way that you remember it. So cubital tunnel starts at the little finger, the pinky and half of the ring finger. Carpal tunnel starts at the big finger, the opposite end the thumb or the first digit, all the way through the other half of the ring finger. So how do you remember that for the exam, Well, cubital starts with the letters sub sub cub and as we know, cubs are little bears, bear cubs.

And then help to remember that cubital cub is the one that starts at the little finger, the pinky, and by method of exclusion, you crewmember, carpal tunnel started at the other end, the big finger, the thumb. So as soon as you see cubital tunnels syndrome. Think of a cub, cub a little bear. Remember this is the one that starts at the little finger. Carpal tunnel starts at the other hand, at the big finger, the thumb. So I remember for the exam, and I got the

question right because I remember cubs or little animals. Cubical tunnel syndrome starts at the little finger. So on physical exam, there's a few different provocation tests for cubital tunnel, but the one physical test I'd remember for this is the Tannell sign, as this is the one you'll hear most often, or the Tennel test. So this is just percussion or tapping over the ular nerve and

the umlar groove of the elbow at the cubital tunnel. So when you do this, if they have parastesia and the fourth and the fifth finger, that's a positive Tennell sign. There's also a Tannel sign or test and carpal tunnel as well, so don't get them mixed up. We'll go over that. Next treatment for cubital tunnel is going to be conservative for a surgical Initially, start with activity modification. If this is from some sort of repetitive trauma or

occupational cause. You can use splints and SAIDs. Surgery is really only going to be for severe or progressive symptoms. Now let's talk about carpal tunnel syndrome. So this is compression of the media nerve as it travels through the carpal tunnel. So cubital tunnel syndrome was ulder nerve compression. Carpal tunnel is media nerve compression. Different nerves affected, different nerve distribution, and different area affected.

So again this is the really important thing you need to remember to differentiate the two. So in carpal tunnel syndrome, you're going to have pain and parasthesia of the first three digits and half of the fourth. So a lot

of times the pain is going to be present at night. It's going to wake them from sleep, the hallmark presentation paint or parasthesia, and the distribution that includes the media nerve territory, so thumb, the first digit all the way through the fourth digit, the radial or lateral half, so first, second, and third and half of the fourth fingers different than cubital tunnel, which we know started at the opposite end of the hand at the little finger,

fifth digit and half of the other half of the fourth digit on the ulner side, so carpal tunnel fingers one, two, three and a half of four, cubital tunnel finger five and half of four. Other things to look out for, although not as important. They may have weakness or clumsiness when using their hands. They may have difficulty holding objects, turning keys or door knobs, buttoning clothing. They may have atrophy of the theen or eminence

in advanced cases. So those are just some other things to be aware of now. Risk factors. There's a lot of risk factors for carpal tunnel obviously repetitive hand and risk use, particularly with some occupations authritis, obesity, female gender, but the ones that I would focus on for the exam are pregnancy. Third trimester is usually where the symptoms will start to manifest. It can be diagnosed earlier on than this though diabetes molitis. Both type one and type

two diabetes can be associated with carpal tunnel syndrome and then hypothyroidism. So hypothyroidism contributes to the development of carpal tunnel by increasing peripheral tissue aedema. So those are usually the ones you're going to get tested on. Let's talk about one other high yield area for carpal tunnel that you'll definitely need to know for your OSCIS. That's your physical exam tests. So there's a few revocative maneuvers you'll

hear about for carpal tunnel. The two that you need to know, the one that frequently come up are the Tannelle test and the Phalin test. So Tannell test just like in cubital tunnel, or we tapped on the cubital tunnel, now we're tapping or percussing over the carpal tunnel. It's easy to get these physical exam tests mix up. So I used to remember the t and

Tannell stood for tapping because it helps you remember the test is performed. So you're tapping, tapping, tapping on the median nerve over the carpal tunnel. Positive test is defined as pain or parasthesia of the median innervated fingers, remember first finger through half of the fourth and then we have the Phalin test.

So the Phalin test is performed by having the patients bring the dorsal surfaces so the back of the hands against each other, pushing them up against each other at the top of the hands push them together and this provides hyperflection of the risks while the elbows are going to remain flexed. You do this for one minute straight and a positive test is going to be pain or parastesia again and the media innervated fingers. The way that I used to remember this is if

you actually look at a picture of the phalin test. When you flop your hands down like this, it looks like your hands have just kind of like flopped over. They've fallen over. So when I see phalin tests, I just remember that your hands have phalin over. Because the hands are flopped over, they look like they've fallen or phalin over. So I just remember phalin. Your hands have phalin or fallen over. Tannell. Remember t for tannel

and tapping tapping on the media nerve phalin. Hands have phalin over pressed up against each other for a minute. So those are the two provocation tests i'd know for a carpal tunnel. Also be aware there are nerve conduction studies, electromiography. Those are some other diagnostic tests can help you with the diagnosis, but focus on those physical exam tests. I talk about the tannel and the

phalin treatment. Conservative or surgical so splinting glucocorticoids, whether it's PO or VA injections are going to be useful for symptom relief, and up to two thirds of patients with mild or monitor carpal tunnel severe refractory cases, of course, surgical decompression may be needed. Let's move on to our scafloid or our navicular fracture. This is your most common carpal fracture. So scaffoid fractures are the

most common carpon bone fracture. They're seen in around sixty to seventy percent of all carbal fractures, so that's an important one to know. That's often tested on mechanism. Another foocher so foosh fallen an outstretched hand will likely be the cause of a scafoid fracture, or really any other injury that involves an axial load placed on the wrist. On physical exam, they're obviously gonna have some pain in the wrist, But where is the pain going to be. It

gonna be a few different places. It can be distal to the listers, tubercle, the volar prominence. But the only one that you have to know, the one that will ninety nine percent be how it's described in the vignette, will be pain or tenderness at the anatomic snuffbox. Know this for the exam. As soon as you hear anatomic snuffbox tenderness, be thinking scaffoid fracture always, so any tenderness in the snuffbox should be treated as a scaffoid fracture

until proven otherwise. The snuffbox is located just proximal to the base of the thumb. Now diagnosis, you're gonna order a risk X ray. Obviously you want to include a scaffoid view. The thing about scaffoid fractures, though, is that they can be missed on X ray. Is pretty often X rays taken soon after the injury can be missed up to fifty four percent of cases,

so half the time. So if the history and physical exam findings are suspicious for a scaffoid fracture but the X rays are negative, you're often gonna have to send these patients for a CTRMRI because if you miss a scaffoid fracture, the scaffoid, unfortunately has a crappy blood supply. And can be at risk for non union osteon necrosis. So if it fits the picture of a scaffoid fracture but the X rays are negative, you still treat it like a

fracture until you can definitively say otherwise. Treatment thumb spike up. Treatment for majority of patients with a non displaced fracture or those patients who have negative X rays but have snuffbox tenderness, you give these patients a thumb spike until you can roll out a fracture with the scaffoid. Again, treat it like a

fracture until you know it ain't surgery. If it's a displaced fracture or there's neurovascular compromise, surgical repair will be appropriate, but in most cases it's going to be your thumb spike of splint will be the answer. Choice. All right, let's talk about distal radius fractures are Colleagues versus our Smith fractures. There's really just a few things to know here, mainly just being able to

differentiate between a Collie and a Smith fracture mechanism. Again, Foush, most common mechanism of the distal radius fracture is going to be falling on an outstretched hand. More of the more often the risk is going to be extended in a Collie fracture injury, and often you'll see it's flexed in a Smith fracture. So just a little side note there on physical exam, collies fractures have what's known as a dinner fork deformity, and this is due to the dorsal

displacement of the distal fragment. Collige type fractures are often said to have this dinner fork appearance. If you want to see some pictures that have it in the YouTube video. And then Smith fractures are sometimes described as a garden spade deformity. Don't go too crazy memorizing these names dinner fork, garden spade, because they're likely not going to use these buzzwords. You just need to remember

that one has dorsals displacement, the other has eventual displacement. I'm going to give you anemonic for that in a second, but remember, I guess Smith fracture sometimes known as a garden spade deform me, and that's if you see like a spade or a shovel and has this little bump on it, and that's because of the eventual displacement. It looks like that anyways. Diagnosis,

this is what you really need to know. So when you take an X ray on a Collie's fracture, you're going to see dorsal displacement of the distal radius fracture, dorsal displacement of the disarradius fracture, and a Collie's fracture and a Smith fracture, you're going to see volar or palm our displacement of the distal radius fracture. So remember Collie's dorsal displacement Smith volar or palm our displacement

of the distal radius fracture. That's the highest heal thing to know because this was differentiates the two and it may be the only difference in the vignette. So remember Collie's fractured, dorsal angulation of the radius, Smith fracture of volar angulation of the radius. The way that you remember that a Collie's fracture is dorsal displacement is because a Collie is actually a breed of a dog. Nice and conveniently it's the same dog that Lassie was on that show a number of

years ago. So a Collie dog when you think of a Collie fracture, Think of a Collie dog and the first two letters in dog are the first two letters in dorsaldo. So this helps you remember Collie's fractures are doo dorsally dorsally alculated radial fractures and by method of exclusion, smith is the opposite volar angulated radial fractures. So when you see collie fracture, think of a Collie dog doo dorsal dog treatment splint splint, reduction for surgery. So some fractures

can be treated with closed reduction sugar tongue splint. Other fractures are gonna require surgical or repair defend, depending on the severity. Remember your Collie dog dorsal angulation for your Collie fracture. Just knowing that one thing may get you the question. Very likely it will if you ever forget which side is the dorsal side of the hand or the risk. Remember the dorsal fin of a dolphin is on its back. Therefore, a fracture with dorsal angulation will be angulated

for the back or the top of the wrist area. All right, lunate fractures. So, lunate fractures are pretty uncommon. Their only account for about four percent of all carpal bone injuries, but they do have some pretty serious applications if they're not treated. So mechanism of injury is going to be another fall on an extended wrist or any other type of risk hyper extension injuries. These are going to be your most common mechanisms of injuries for a lunar fracture

diagnosis, so X ray. Main thing to know about X rays of the lunate is that they're missed quite often with playing radiographs. If there's any clinical suspicion, it's important to obtain vanced imaging like ctrmri CT is going to be preferred. One of the thing that I wanted to mention because it may come up if you have a dislocation of the lunate bone. The lunate gets displaced and angled in this volar direction and in comparison to the surrounding structure is the

distal radius metacarpals which are all in normal alignment. It looks like a tea cup spilling over on lateral X rays, at least that's what they say, and it's called a spilled tea cup sign. So just in case, you hear that being mentioned at any point you'll know. This is what can be seen in a lunate dislocation. So you need to know a complication a vascular necrosis and kind box disease. So aggressive collapse of the lunate mechanism of injury

is really unclear. This is kind box disease, so it's a progressive collapse of the lunate mechanism of mechanism is really unclear. It evolves to appear some disruption of the blood supply. It's likely related to undiagnosed fractures of the lunate. Some other complications with lunar fractures are complex regional pain, syndrome, osteoarthritis.

Nothing specific I would know for the treatment for lunar fractures, except in the case of a dislocation, in which immediate reduction is really important to prevent a number of complications. So again that's your lunate fractures and a little bit about dislocations. Not a lot to know there. Let's talk about decoreving tendinopathy next. So this is a thickening of the abductor policis longest the apl and extensor policis brievious, the EPV tendons and the tunnel or the sheath and the

first extensor compartment. So the abductor policis longest apl the extensor policies brievious EPB tends. They pass through this tunnel called the fibro osseous tunnel from the forearm into the hand, and any thickening of these tendons passing through here, or thickening of the tunnel itself can restrain the gliding motion through the sheath, which

can lead to the clinical manifestations will go over. So think of a rope going through a little hole and the rope's getting bigger or the holes getting smaller. Eventually it's going to get stuck. I don't recommend memorizing abductor polysis longest an extensor polysis brevist. Those are hard enough to say. It's just too

much brainpower to memorize those complicated names. What I would recommend memorizing, though, is apples with extra peanut butter are delicious, because if you can remember that apples spelled apl apl as an APL tendon with extra peanut butter EPB as

an EPB tendon are delicious as in decore vein tendinopathy. If you can remember that, that helps you remember your APL tendon and your EPB tendon are going to be involved in this decorvein sendingpathy, and this should be enough for you to be able to pick them out on the multiple choice question by remembering the letters involved in the full name. So if you can remember abductor policies as long as an extensor policies breathes, in addition of the twenty thousand other things

you need to for PA school, more power to you. But I just remember apples with extra peanut butter are delicious. That was enough for me to help pick out the right answer on my clinical medicine exam. So apples again, APL, extra peanut butter EPB are delicious. Decorva intentanopathy. You're done,

all right, So what about the patient demographic you're looking for? So you are going to be looking for women between the ages of thirty to fifty years of age, and then it's also prevalent in a subset of women in the postpartum period. Symptoms usually going to present about four to six weeks after delivery. There's a lot of theories why this happens in the postpartum period, repetitive motion of the hands required to lift and hold newborns, hormonal causes for

fluid retention, whatever the case. In the vignette, you're looking for both women in the thirty to fifty year age range and also postpartum women clinical menifs stations, they're going to have pain at the radial side of the wrist.

It's going to be worse with thumb and wrist movement. So the tendons we went over before, the EPB in the apple, the EPP in the apple, the EPB and the APL are responsible for movement of the thumb, So you can imagine a lot of the complaints are going to be related to thumb movements, and so the EPB and the APL are responsible for movement of the

thumb. Diagnosis so decavent tendonopathy is based upon the history of an atraumatic radial wrist pain and positive physical exam findings, So imaging like X ray is not really necessary except to rule out other differentials which may have a similar presentation like osteoarthritis. The main thing to know for diagnosis is a physical exam maneuver called

the Finkel steam test. So the Finkel steam provocation test involves the patient wrapping their fingers around their thumb, clasping it in their palm, and then you apply ulnar deviation to the wrist. If they have pain over the radio styloid area so the basic of the thumb, this is considered a positive test. Again, that's the Finkel Steing test. Treatment thumb spike a splints going to be the big one and SAIDs google cordecoid injections. So decoving tendonopathy is generally

non progressive. It's typically self limited, so most of your conservative measures are going to be your mainstay. Again, thumb spike a splint is commonly used, and said steroid injection surgery really is going only to be for refractory cases. Talk about mallet fingernecks. So this is a finger deformity caused by traumatic disruption of the terminal slip of the extensor tendon at the distal interfalangeal joint,

so the dip joint. So you have some sort of trauma to the finger, usually caused by a direct blow to the tip of the finger, so maybe a ball striking the fingertip or the fingertip strikes a hard surface. The trauma causes a tear in the extensor tendon at the dip joint. And this is the tendon that allows you to extend your fingers so to hold them out straight, and with this being torn, you can no longer do that, so the finger remains in this constant slit state of flexion. Now on physical

exam, they're going to have an inability to extend the dip joint. This is going to result in that flex DP So it's really simple. Patient's going to have this constant flection of the dip joint. They're not going to be able to extend the finger at that joint. This specific degree of the dip angulation is often going to reflect the severity of the tendon disruption. Now diagnosis

X ray. So in some cases with the mallet finger, you're going to visualize a bony evulsion of the distal failings at the site where the tendon attaches. It just got ripped off during the injury. It's also possible just to have just a ligamentous injury with normal bony anatomy, so you can see either

one. Now, treatment really important extension splinting of the dip joint for six to eight weeks with twenty four hours of maintaining this extension, So the dip joint must be maintained at full extension throughout the entire period, including during sleep. If the joint extension is lost at any point during this initial treatment period, the treatment clock is reset and an additional six weeks of splinting has to be performed. So if you think about it, you're keeping those horn tendon

edges aligned. So as soon as you bend that finger just rips it tears all over again. So the only wayfer it to completely heal is to have that finger in full extension with the torn ligament aligned for six to eight weeks. The majority of malletfingers are amendable to treatment with just splinting. Surgery is really only going to be a reserved for large displaced fractures or other complex injuries that may warrant with surgical referral. But really focus on splinting as that's going

to be your most common, your main state treatment. So maletfinger again, extensor extensor tendon injury. Dip joint now flex all of the time. They can't extend it, straighten it out with a splint done. That's your mallet finger. Let's talk about ulnar collateral ligament injury aka a gamekeeper or skiers thumb. It's an injury caused by damage to the ulnar collateral ligament of the thumb. Mechanism of injury is going to be a forced abduction, abduction and hyper

extension of the thumb. This is going to be at the metacarpul philangial joint. That's going to be your most common cause. So the thumb is stretched and forced into extreme abduction, whether this is from a fall and athletic injury skiing accidents where the thumb strikes a fixed ski pull, and that's where the names skier stumb came from or the name gamekeeper stumb, so not so relevant anymore. But basically this was this chronic degeneration of the owlner collateral ligament from

twisting the necks of too many birds and rabbits. So I'm making that up. That's what gamekeeper stumb came from. So yeah, probably won't be the reason why your patient comes in with this, but seventy plus years ago when the name was created, it was today most often this is going to be a skiing related injury or another athletic related injury. On physical exam, you can pretty much confirm a UCL injury with your physical exam findings combined with your

appropriate clinical manifestations. So Valgus stress testing is going to reveal a loss of integrity of the UCL, so the injured thumb will have increased laxity of the MCP joints, so the thumb you're going to be able to pull much further away compared with the uninjured thumb. When Valgus stress is applied, the test is positive and the patient has the classic clinical manifestations paintings ascerbated by thumb extension or abduction, and swelling along the owner aspect of the thumb at the MCP

joint. This is going to help to confirm the diagnosis, but you also want to get an X ray of the thumb to rule out any possible bony evulsion, fractures and definitive diagnosis can be made with an MRI or ultrasound, but generally it's not necessary treatment. Thumb spike is splint so a mobilization with the thumb spika will be sufficient in most patients. Some patients with a complete tear or patients that don't respond to conservative therapy may require surgical intervention. Boxer's

fracture. This one's pretty much straightforward. It's a fracture of the fifth metacarpal neck. Generally the fifth metacarpal neck fractures when we're talking about boxer fractures. Occasionally sometimes we'll hear being referred to fractures of the fourth metacarpal as well.

But now it's common mechanism of injury direct trauma to a clenched fist. So obviously the most common situation where you're gonna have direct trauma to a closed finch or just say a clenched fist would be punching something, so that's going to be the most common cause. So whether they're punching a wall, a solid object, a face, that's why it's called a boxer's fracture. In reality,

though experienced boxers actually rarely sustained this type of fracture. It's more the wild roundhouse punching motion that's common in street fights that cause this, Or someone who punched a brick wall who's going to come in with this type of fracture, rather than in a floyd Mayweather who's trained to punch the right way. Diagnosis are going to be made with X ray so plaine radiographs of the hand. This is going to establish the diagnosis of a metacarpal neck fracture and this

will also help to determine the degree of the fracture angulation. So treatment is going to be with a mobilization with an gut or splint. So gut or splint is going to be It's going to be used to mobilize fractures of both the fourth and the fifth metacarpal necks. If the patient does have an open fracture, a severely common unit fracture, or if they have significant angulation normally over thirty to four where your degrees, this is going to require surgical consult

Otherwise, immobilize it with a splint. All right, let's finish up with something a little bit different, and because I feel like I can no longer talk, keep getting stumbling on my words, let's finish up with complex regional pain syndrome. So this is an array of painful conditions that are characterized by a continuing regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion. That's the official definition. So

basically, these patients have this prolonged pain. It's completely disproportionate to the initiating event. Most frequently this is going to follow a bone or soft tissue injury. So most cases there's going to be some sort of injury sprain, fracture, et cetera. In some cases there may be no precipitating factor. It's not common, and then weeks later they're going to start to develop this range of clinical manifestations, autonomic dysfunction, pain out of proportion to the initial injury,

hair and nail changes. The path though, is really unknown, and there's some proposed mechanisms, but definitely nothing to know for the exam. Now, in clinical manifestations, this is the most important thing about complex regional pain syndrome. It's the presentation. The diagnostic criteria is low yield, the treatments low yield. It's all about being able to recognize the clinical manifestations. That's

what you need to know for the exam. So the main clinical manifestations of complex regional pain syndrome are pain, sensory changes, motor impairments, autonomic syntoms and trophic changes in the affected limb. This is usually going to occur four to six weeks after the inciting event. The reason I'm covering this under the upper extremity section for the pants is because this most commonly occurs in the upper

extremity around sixty percent of the time. So the way that I used to remember the common clinical manifestations that you're going to see in a vignette for complex regional pain syndrome is by remembering instead of complex regional pain syndrome, I want you to remember complex regional paint syndrome. So PAI nt complex regional paint syndrome.

And what does paint stand for? So paint stands for the P stands for perspiration, and this is due to the auto aconomic dysfunction, so forty percent of patients are going to experience increased sweating on the side where they're experiencing

this. The A in paint stands for after injury, So after injury for the A, because remember this is most commonly going to take place after some sort of bone or soft tissue injury, So look for some sort of injury mentioned in the vignette weeks prior the eye, and PAINT stands for inappropriate pain because remember the pain experience is inappropriate, it's out of proportion to the initial injury. Pain is typically the most prominent in debilitating symptom of complex regional pain

syntems. So remember I stands for inappropriate pain because it's not appropriate to have ten out of ten pain in your risk from a sprain you had two months ago, So remember inappropriate pain for I. The END stands for nail changes. So remember I talked about before your trophic changes, so these patients may have increased or decreased nail growth. Also look for hair growth changes as well, but remember END stands for nail changes from your trophic changes. And then

the last letter T and paint stands for temperature changes. This relates back to those autonomic changes. Again, these patients can have and some patients are going to see a difference in skin temperature and the affected side versus the unaffected side of over one degree celsius. So remember if you have a vignette you think

the patient they're talking about may have complex regional pain syndrome. Remember to look for paint perspiration after injury and appropriate pain, nail changes, temperature, changes, and that should be enough to get you there and get the right answer. Now, diagnosis clinical features based on your H ANDP, So the diagnosis is really just based upon the clinical features determined by your history and physical So nothing really to know for the exam question. You're basically looking to see are

they having pain, sensory changes, motor symptoms, autonomic dysfunction? Are these symptoms weeks out from an initial injury that would no longer be appropriate to persist at this point in time. There are some imaging tests that can be used three phase bone syntigraphy, radiographs, but there's nothing high yield, there's no gold standard tests. Definitely nothing I would memorize for the exam, So just know this is generally clinical diagnosis. Are the experiencing paint? If so?

Complex regional pain syndrome treatment it's multifaceted physical therapy and SAIDs tricyclic antidepressence, sympathetic nerve blocks. Physical and occupational therapy are more or less considered first line treatment for complex regional pain syndrome. But again it's a multifaceted, multi disciplinary approach. There's not one specific thing to know for treatment. The main takeaway for complex regional pain syndrome. To identify in a vignette is to remember the symptoms

that you're seeing in these patients. The treatments really not high yield. Diagnostic criteria is really not that high yield. It's being able to recognize it in a vignette. So remember complex regional paint syndrome, perspiration after injury, inappropriate pain, nail changes, temperature changes. That's the main takeaway here, and

we are done with the upper extremity. Let's do five quick questions. Question one, thirty two year old female presents the office complaining of pain at the radial sign of her wrist that is most prominent upon movement of the thumb. She has four weeks postpartum. Pasthematical history is otherwise unremarkable. On exam, tenderness is noted over the radial styloid and pain. His experience with passive ulner deviation of the wrist with the thumb flexed in the palm. What is the

likely diagnosis in this patient? So that is going to be decore vain tendinopathy. So decarevyin tendonopathy we know is most commonly seen in women between the thirty to fifty year age rage also common to see and postpartum women four to six weeks after delivery. So she fits this criteria to the tea. Then she states she has pained on the radio side of the wrist, and then a physical exam tenderness over the radio styloid. She has a positive Finkelstein test for

the patient's wrist as put into Olnar deviation. All the patient's fingers are folded over the thumb. This is a classic presentation for decorevain tendeonopathy. Question two. A forty three year old female presents at the office complaining of numbness and tingling in her hands, mostly affecting the thumb, index and middle finger, and part of the ring finger. She states it is worse at nights, sometimes awaking her from sleep. Both a Tannell and a Palin test are positive.

On physical exam. His patient is likely experiencing compression of which nerve, so that is going to be the median nerve. So this patient is experiencing carpal tunnel syndrome, which is compression of the medial nerve median nerves. So we know this because the patient parastages in the median nerve. Territory, which will be the first three fingers and radial half of the fourth. In addition, she states it's worse at night, which is very common for carpal tunnel.

Finally, we have a positive Tannell and Phalin test that seals the deal. We know this is carpal tunnel, which is median nerve compression. Question three. Twenty seven year old Mail presents to the er after a bicycle accident he had earlier on in the day. He states his bike hit a pothole

which sent him flying off his bike, landing onto his outstretched hands. He's now complaining of pain along the radial side of the wrist and is tender just proximal to the base of the thumb at the anatomic snuffbox fracture of which bone should be suspected. And this patient until proven otherwise, so that is going to be the scaffoid. This is a simple one scaffoid or avicular fracture.

You have a patient had to fall into an outstretched hand, which is often the mechanism of injury for a scaffoid fracture, and he has pain on the radial side of the wrist. Snuffbox tenderness. You are done. That is a scaffoid fracture until proven Otherwise, as soon as you hear snuffbox, always be thinking of a scaffoid fracture. Question four. Sixty seven year old Mail

presents to the office today complaining of persistent elbow pain. He does not recall any trauma to the elbow, but the painting he is experiencing in his elbow is affecting his golf game, as he is an avid golfer. On exam, pain is elicited by performing risk flection against resistance. Tenderness would likely be felt in which part of the elbow in this patient, so that would be at the medial epicondyle. So you have a classic case of medial epicondolitis aka

golfer's elbow. If you have a sixty seven year old male avid golfer with elbow pain, no preceding trauma, and then the key is that the pain is reproduced on exam with the risk being flexed against resistance. So in this case the patient wouldn't have pain and the medial epicondyle. And then of course remember the demonic mini golf is fun and in mini helps you Remember this is the media up a condal involved in golfer golfer's elbow golfs because this is known

as golfer's elbow. And then the f and fun helps you remember this is going to involve flection, whether it's pain as pain with risk, flection against resistance on exam the fact that it involves the flex or copper radialis or that it's caused from repetitive flection. Mini golf is fun helps you remember all the things that you need to know. And then by method of exclusion, you know lateral epicond of lytis is the opposite problems with extension not flection. Last

question question five. Seventeen year old Mail presents to the er after sustaining an injury to his right arm. After X rays are complete, the attending physician assistant and forbs him that the X ray revealed a proximal owner fracture accompanied by a radial head dislocation. This type of injury is also known as a and

that is going to be a Montegia fracture. So remember grew some murder Montegia and Galiazzi fracture grew some first lead letters in russom stand for Galiazzi our stands for radius fracture, U stands for owning dislocation aka the radio owner joint, and then murder, which is the first three letters mu R montigia U stands for owner fracture, and our stands for radiohead dislocation, which is the type of injury we see here in this patient. All right, that is the

upper extremity for the MSK section for the pants. Thank you so much for listening to the podcast, and good luck on you in paschool. Good luck on your pants or pantry ears, and thank you again