NMS Q&A Family Medicine

Musculoskeletal Problems of the Upper Extremities 147Examination Answers1. The answer is B. DeQuervain syndrome, also calledDeQuervain tenosynovitis. The maneuver that producesthe pain with ulnar deviation while “making a fist” iscalled Finkelsteins maneuver. Treatment is conservativewith physical therapy modalities in the vast majority ofcases. Carpal tunnel syndrome exhibits the typical mediannerve distribution of numbness and weakness of thumbto finger opposition. Scaphoid fracture seldom if everoccurs without a clear cut history of fall onto the outstretchedhand and manifests tenderness in the anatomicsnuffbox as well as the scaphoid tuberosity. Stress fractureof the distal radius is a non-entity but in traumatic fracturethis injury too results from falling onto the outstretchedhand. Reflex sympathetic dystrophy presentswith marked palor, rubor, pain, and regional sweating.2. The answer is C. A short arm cast as described proximaland distal to the fracture. A Volar splint extendingfrom the mid forearm to the distal palmar crease is tooshort and allows too much movement at the fracture, thatis, forearm pronation and supination. The long arm posteriorsplint extending from the axilla to the proximal palmarcrease may be used but is overly long for the Colles ordistal radius fracture and thus immobilizes more lengththan necessary while not adequately immobilizing thedistal radius fracture, especially if the latter were unstable.The long arm cast may be applicable in cases initiallytreated with the long posterior splint but are not appropriatefor the distal radius alone. It may be utilized in childrenwho often have combined radius and humerusfractures. The sugar-tong splint from the elbow is no moreimmobilizing for the distal radius than the posteriorsplint.3. The answer is E. Torn superior labrum is diagnosed bythe described maneuver, called the “anterior slide test.”The tear diagnosed by the slide test is common and iscalled the superior labrum anterior to posterior lesion, orSLAP lesion. Impingement syndrome, usually associatedwith rotator cuff injury, is diagnosed by the Hawkins test(pain with passive inversion of the shoulder while flexedforward to 90 degrees) among other tests that involveflexion and internal rotation of the shoulder. Biceps tendonitisis best diagnosed by the Yergason’s test, pain withsupination of the forearm against resistance while theelbow is flexed and the upper arm at the side. Supraspinatusinjury is diagnosed by the finding of pain and/orweakness in the ability to hold the outstretched arm at 90degrees abduction with the thumb pointed downward,resistance being supplied by the examiner or, when severe,gravity alone, sometimes called the “empty bucket test.”Clavicle fracture is shown by obvious deformity (causedby a direct blow or by falling laterally against the shoulder.4. The answer is A. This patient has, of course, classiccarpal tunnel syndrome, compression of the mediannerve, secondary to relative contraction of the flexor retinaculumof the wrist that contains the tendons, bloodsupply, and median nerve. It occurs commonly and isaggravated by repetitive hand gripping. Involvement ofthree cervical disc levels is unlikely. More important,however, is that this patient does not exhibit dermatomaldistribution of the sensory symptoms, because the dorsaof the thumb, index, middle, and (half) of the ring fingersare not involved proximal to the PIP joints. The scaleneanticus syndrome is a variant of thoracic outletsyndrome wherein the scalene anticus muscle in the thoracicoutlet contracts and causes compression of theperipheral roots of C7, C8, or both, thus involving a distributionthat approximates the ulnar nerve (sensation tothe ring and fifth fingers). Herpes zoster, or “shingles,”causes mostly superficial pain rather than hypesthesiaand is associated with a painful varicelloid rash in a dermatomaldistribution. Ulnar nerve lesions cause fourth(ulnar half) and fifth finger sensory involvement andweakness of lumbrical and interosseous musculature ofthe hand (abduction or spreading) of the fingers, notopposition movements.5. The answer is D. The chance of indefinite alleviationwith conservative management is 6.8%. See the table thatfollows here.TABLE 23–1 Predicting the Outcome ofConservative Treatment forCarpal Tunnel Syndrome1. Have symptoms been present for morethan 10 months?2. Does the patient have constantparesthesias?3. Does the patient have tenosynovitis(triggering of the digits)?4. Is the Phalen maneuver positivewithin less than 30 seconds?5. Is the patient older than 50 years ofage?Yes___Yes___Yes___Yes___Yes___No___No___No___No___No___Source : Used with permission from Viera (2003).Notes : Score 1 point for each yes answer and 0 for each no answer.The scoring key for success rate is as follows: 0 points, 65%; 1point, 41.4%; 2 points, 16.7%; 3 points, 6.8%; 4 or 5 points, 0%.