Extremity


Elbow Pain

Rapid Review

  • Differentials
    • Anterior
      • Anterior capsule strain
      • Biceps tendinopathy
      • Gout
      • Intra-articular loose body
      • Osteoarthritis
      • Pronator syndrome
      • Rheumatoid arthritis
    • Lateral
      • Lateral epicondylitis
      • Osteochondral defect
      • Plica
      • Posterolateral rotatory instability
      • Radial Tunnel Syndrome
    • Medial
      • Medial epicondylitis
      • Ulnar collateral ligament injury
      • Cubital tunnel syndrome
    • Posterior
      • Olecranon bursitis
      • Olecranon stress fracture
      • Osteoarthritis
      • Triceps tendinopathy
      • Posterior impingement
  • History
    • Exact location of most pain
      • Narrow differentials based on location
    • Recent trauma
      • Consider fracture, dislocation, etc.
    • Play sports (tennis, golf, etc.)
      • Consider lateral/medial epicondylitis
    • Prolonged resting on the elbow
      • Consider olecranon bursitis
    • Fever/Chills
      • Consider septic arthritis
  • Physical Exam
    • (+) Elbow abduction stress test or Milking maneuver
      • Suggests ulnar collateral ligament injury
    • (+) Hook test
      • Suggests distal biceps tendon rupture
    • (+) Middle finger test
      • Suggests posterior interosseous nerve compression syndrome
    • (+) Tinel test
      • Suggests cubital tunnel syndrome
  • Work-Up
    • Labs
      • CBC, BMP, ESR, CRP
    • Procedures
      • Arthrocentesis (cell count, culture, gram stain, crystals, protein, glucose, lactate)
    • Imaging
      • Elbow X-ray series

Pearls

  • Beware the “fat pad” or “sail” sign on X-ray, suggesting an occult condylar fracture or radial head fracture that is otherwise not visible. 
  • Fractures in pediatric patients often occur through unossified cartilage. This makes X-rays difficult to interpret.
Video Credit: The Center for Medical Education


Knee Pain

Rapid Review

  • Differentials
    • Orthopedic/Trauma
      • Bursitis
      • Osteoarthritis
      • Hemarthrosis
      • Ligament tear (ACL, PCL, MCL, LCL)
      • Meniscus injury
      • Fracture
      • Dislocation
    • Infectious
      • Septic joint
      • Reactive arthritis
      • Osteomyelitis
      • Septic bursitis
    • Crystalline
      • Gout
      • Pseudogout
    • Other
      • Tumor
      • Deep Venous Thrombosis
      • Baker’s Cyst
  • History
    • Recent injury
      • Consider traumatic process
    • Hear a pop or snap
      • Consider fractures or ligament/meniscal injury
    • Fever/Chills
      • Consider infectious process
    • History of smoking, OCP’s, prolonged immobility
      • Consider DVT
  • Physical Exam
    • Recent injury
      • Likely traumatic process
    • Warm, swollen, erythematous
      • Gout vs septic joint
    • Recurrent knee effusion
      • Suggests meniscus injury
    • (+) Anterior drawer or (+) Lachman
      • Suggests ACL injury
    • (+) Posterior sag sign
      • Suggests PCL injury
    • Pain w/ Varus stress
      • Suggests LCL injury
    • Pain w/ Valgus stress
      • Suggests MCL injury
  • Work-Up
    • Labs
      • CBC, BMP, ESR, CRP
    • Procedures
      • Arthrocentesis (cell count, culture, gram stain, crystals, protein, glucose, lactate)
    • Imaging
      • Knee X-rays (2-3 view)

Pearls

  • Knee pain can often be referred pain from the hip. Be sure to do a thorough exam across the entire extremity. 
  • Maintain a high index of suspicion for popliteral artery injuries following knee dislocations. Consider Ankle-Brachial Index (ABI) measurements and/or CT angiography.
Video Credit: Dr. Nabil Ebraheim


Leg Pain

Rapid Review

  • Differentials
    • Vascular
      • Deep vein thrombosis
      • Peripheral artery disease
      • Arterial occlusion 
      • Thrombophlebitis
    • Infectious
      • Necrotizing fasciitis
      • Septic joint
      • Osteomyelitis
    • Musculoskeletal
      • Compartment syndrome
      • Fracture/sprain
      • Spinal stenosis (pseudoclaudication)
    • Cardiac
      • Congestive heart failure (venous stasis, edema)
  • History
    • Pain w/ exertion
      • Suggest PAD
    • Sudden onset pain
      • Suggests arterial occlusion
    • History of trauma
      • Consider fracture or compartment syndrome
    • Fever/chills
      • Consider necrotizing fasciitis, osteomyelitis, septic joint
    • Shortness of breath
      • Consider pulmonary embolism secondary to DVT
  • Physical Exam
    • Homan Sign
      • Suggests DVT
    • Absent pulses
      • Consider arterial occlusion
    • Overlying warmth, erythema
      • Consider cellulitis/necrotizing fasciitis
    • Non-healing ulcers
      • Suggests peripheral vascular disease
    • Swelling/deformity
      • Consider fracture/compartment syndrome
  • Work-up
    • Labs
      • CBC, BMP, CPK, lactate
    • Procedures
      • ABI measurement
        • If suspect vascular etiology
      • Compartment pressure measurement
        • If suspect compartment syndrome
    • Imaging
      • Ultrasound (DVT)

Pearls

  • Tibial plateau fractures on commonly missed on plain film. Perform a CT scan if you have high clinical suspicion for this injury. 
  • Remember the 6 P’s for acuter limb ischemia (pain, pallor, paresthesias, poikilothermia, pulselessness, and paralysis). 
Video Credit: Dr Swe Yin Khin-Htun


Shoulder Pain

Rapid Review

  • Differentials
    • Non-traumatic/chronic
      • Subacromial bursitis
      • Biceps tendinitis
      • Adhesive capsulitis
      • Impingement syndrome
      • Calcific tendinitis
    • Traumatic/acute
      • Shoulder dislocation
      • Clavicle fracture
      • Humerus fracture
      • Scapula fracture
      • Acromioclavicular joint injury
      • Rotator cuff tear
      • Biceps/triceps tendon rupture
      • Septic Joint
    • Referred Pain/Non-orthopedic
      • Brachial plexus injury
      • Thoracic outlet syndrome
      • Myocardial infarction
      • Pulmonary embolism
      • Axillary artery thrombosis
      • Subclavian Steal Syndrome
  • History
    • Recent injury
      • Likely acute process
    • Hear a pop/snap
      • Consider fracture
    • Recent seizure
      • Consider dislocation
    • Pain radiate to the elbow
      • Consider cervical disc disease
    • Clunking sound w/ overhead motion
      • Labral disorder
  • Physical Exam
    • Deformity
      • Suggests dislocation/fracture
    • Apley scratch test
      • Suggests rotator cuff problem
    • Neer’s Sign
      • Suggests subacromial impingement
    • Hawkin’s test
      • Suggests supraspinatus tendon impingement
    • Drop arm test
      • Suggests rotator cuff injury
  • Work-Up
    • Labs
      • CBC, BMP, ESR, CRP
    • Procedures
      • Arthrocentesis (cell count culture, crystals, gram stain)
    • Imaging
      • Shoulder X-rays (2-3 view)

Pearls

  • Consider acute coronary syndrome as a source of shoulder pain if the patient does not have a clear history of overuse or injury.
  • A CT scan is usually not needed unless there is a suspicion for intrathoracic injuries as well. 
Video Credit: The Center for Medical Education


Wrist Pain

Rapid Review

  • Differentials
    • Traumatic
      • Scaphoid fracture
      • Hook of hamate fracture
      • Distal radius fracture
      • Scapholunate ligament tear
      • Perilunate dislocation
    • Non-traumatic
      • Carpal tunnel syndrome
      • De Quervain tenosynovitis
      • Ulnar neuropathy
      • Radial neuropathy
  • History
    • Fall forward on hands
      • Consider distal radius or scaphoid fracture
    • Fall backward on hands
      • Consider injury to distal ulna, ulnar stylus, triquetrum, or lunate
    • Occupational activity
      • Computer based activities suggestive of carpal tunnel
      • Child-care activities may cause De Quervain tenosynovitis (from lifting children repeatedly) 
  • Physical Exam
    • Snuffbox tenderness
      • Scaphoid fracture until proven otherwise
    • Neurosensory deficit
      • Warrants orthopedic consultation
    • Tinnel or Phalen sign
      • Suggests carpal tunnel syndrome
    • Finklestein test
      • Suggests De Quervain tenosynovitis
  • Work-up
    • Labs
      • None usually needed
    • Imaging
      • Wrist X-ray

Pearls

  • Plain films miss approximately 40% of all scaphoid fractures. If you suspect this injury, the patient must be splinted (thumb spica) and referred to orthopedics.
  • Scapholunate dissocations are the most commonly missed ligament injury of the wrist. The “Watson test” on physical exam and “clenched fist” views on X-ray can help make the diagnosis. 
Video Credit: nabil ebraheim

Brandon Simpson, PA-C
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  • Blog - 25 Feb 2021