111: Upper Extremity Part 2 & an Exercise to Boost your Scores

Hello and welcome to episode 111 of the Physician Assistant Exam Review Podcast. Today we’re going to continue with the upper extremity, specifically working on trauma and the ribs. I’m Brian Wallace, the founder and creator here at Physician Assistant Exam Review, where we teach PA students to dominate PA school and ultimately pass their PANCE and land their dream job. If you find this show helpful, if you find that I present the material in a way that you can use and you think that you’re getting something out of it, please do me and your friend, your classmate or cohort member, a favor and share it with them. Share it with your faculty. Share it with your classmates. Anyone who you think this could help, that’s really the goal here is to help as many people as I can get through PA school, pass their PANCE, and land their dream job.

That’s the goal. That’s what I do. I want to teach, I teach medicine, right? But I do it so that students can have a better understanding or I do it in a way that students can have a better understanding of what they need to get through PA school. There’s a whole long time to gather all of medicine and to learn all of medicine and to perfect your craft. At the moment, the goal is to get through PA school, pass the PANCE, get a job, and then become an amazing practitioner. It’s a stepwise process.

You can’t do it all at once. But anyway, if you find value, if you think the show is helpful, please, please, for my sake, for your friends’ sake, for your program’s sake, please share the show with them. As always, you can find all of the notes over on the website, physicianassistantexamreview.com. If you click on Blueprint, you’ll find all of the notes for everything that we’ve ever covered on the website there. You can also find them inside the Physician Assistant Exam Review app, along with every single podcast are in there too.

Now, one more thing you can do, we’re covering musculoskeletal here, specifically upper extremity and upper extremity trauma today. If you’re looking for questions on musculoskeletal, you can find questions pulled directly from The Final Step at physicianassistantexamreview.com/MSK. It’s for musculoskeletal. Backslash MSK. And that’ll bring you up to where you can get a hold of and download, I think it’s like 20, 25 questions pulled straight from The Final Step on musculoskeletal. This section is incredibly easy to pull questions from. I know a lot of students struggle with musculoskeletal.

A lot of students don’t love it. I feel like I talked to a lot of students who find it difficult because it is a lot of memorization. In my head, that’s what makes this a little bit difficult is it’s a lot of memorization. The nice thing, and I’ve mentioned this in the past, is you have a model with you, right? So, attaching what you’re learning to things as you already know is a learning concept we’ve talked about. I talk about a lot, actually. The good news is you bring a model with you into the classroom on this one, right?

If we’re talking about carpal tunnel, you can look at your hand. You have your hand with you. So as you’re studying it, use your hand as the thing to anchor it to, right? If we’re talking about your elbow, golfer’s elbow or tennis elbow, use your elbow as you’re thinking about it, as you’re studying it. Use what you have to solidify that learning so it becomes less a list of things to memorize and more something that you actually know and understand and something that you have cues to inside your brain. I’m going to show you how easy it is to write questions on this section. This section is not even that long, but it’s so easy to write questions on.

So be aware of that as you go through it. So here are our priming questions for today. X-ray shows a silver fork deformity. What type of fracture are we thinking? X-ray shows a silver fork deformity. What type of fracture are we thinking? If you have pain with palpation over the anatomical snuff box, pain with palpation over the anatomical snuff box, what fracture are we thinking?

I’m going to throw in one from last week just for fun. Medial epicondylitis. Which one is that? Is that golfer’s elbow or tennis elbow? Medial epicondylitis. A fracture of the neck of the fourth and often the fifth metacarpal would be what type of fracture? What does the crossover test evaluate?

What does the crossover test evaluate? Wait. And our last one for this section, what does a fat pad sign indicate? What does a fat pad sign indicate? And we’ll get to the answers to those as we go. But I ask that you think about them as we move through this. You try to pull out the answers.

You think you participate. You don’t just listen as you’re falling asleep or listen as you’re running and not pay attention. It’s not even paying attention. It’s using your brain to think through the things that we’re talking about so that they solidify in your mind. So again, silver fork deformity, anatomical snuff box, medial epicondylitis, fracture of the fourth and fifth metacarpal, crossover test, fat pad sign.

All right, shoulder separation or an AC joint sprain. This is a partial or complete disruption of the ligaments at the AC joint. The causes of this are usually a direct blow or falling on an outstretched hand. Clinical presentation, shoulder pain following trauma, tenderness over the AC joint. My shoulder is drooping. And that tends to be one that becomes, hopefully the patients say that and becomes kind of obvious. Lab studies and physical exam findings, tenderness over the AC joint, right?

Obvious stuff here. This is not something to memorize. If they have tenderness over the AC joint, you should be thinking about the AC joint being a problem. Deformity of the AC joint, especially with shoulder distraction. Crossover test. This squeezes the AC joint and causes pain in that joint. Pain relief with an injection of lidocaine into the joint.

So this is one way we can test things. There’s a couple of different things we test this way. A Morton’s neuroma being one of them. We inject the area with lidocaine. If the pain goes away, we sort of have a better understanding of what it can be. This can, this is, you know, it’s mildly therapeutic for the moment, but really it’s a, it’s a diagnostic exam. And then an X-ray of the shoulder showing the separation.

Treatment. What do we do for a shoulder separation? Well, a lot of the things, this is kind of one of the nice things about orthopedics. A lot of people don’t like orthopedics, but there’s not a lot of treatments, right? Rest, ice, sling, physical therapy, severe case may need surgery. One of the reasons I like orthopedics is because there aren’t really medication names to memorize. So from that perspective, treatments are a lot easier.

In orthopedics, yes, there’s a lot more definitions. Yes, there’s a lot more memorization to the diagnoses and the tests and all these things. But to me, it’s a lot more straightforward because I don’t have to memorize long names of medications that I struggle with. A shoulder dislocation. This happens due to powerful abduction or extreme rotation. This is where the humerus and the glenoid separate. One way you can think about this is think of spiking a volleyball or blocking a shot in basketball.

This causes the humerus to move forward in an anterior dislocation, the humeral head, right? So 95% are anterior dislocations. Think about the mechanism, how that would work, and it’ll make more sense. Clinical presentation, shoulder pain, right? Limited range of motion, lab studies and physical exam findings. Here you have an obvious deformity. The patient will not allow any motion of the shoulder, and an x-ray will show that dislocation.

Treatment. So stop and think for a second. Don’t memorize this. What’s the treatment for a shoulder dislocation? I want you to be able to rebuild these thoughts, not memorize them. Some things you have to memorize. But whenever you can rebuild an idea, rather than memorizing it, to me, you’re better off rebuilding it.

So what’s the treatment for a shoulder dislocation? Initially, we’re going to need manual reduction. We’re going to need to put that thing back in place. Then you might move on to rest, ice, that kind of thing. But initially, it’s a manual reduction. The next one on my list is nursemaid’s elbow. This is like a subluxation of the radial head.

This is kind of a weird injury. And it occurs when you have a child who’s like, three, four, five years old. Five might be old. And you pull them by their extended arm. You can get this subluxation of the radial head. And the clinical presentation here is that the child just doesn’t use the arm. He’s not complaining of pain.

They’re not complaining of, they’re not crying. It doesn’t hurt. Five is probably too old. Probably two, three, four. And they’re not crying. They’re not complaining of pain, but they’re not using it. They sort of hold it up against their body.

And the reason I can describe this so well is because I’ve given my son at least two, maybe three nursemaids elbows that I can remember when he was a child. He’s 14 now. He doesn’t remember. It’s fine. Once was lifting him out of the bathtub. I lifted him up by his arms and immediately he started holding his arm up against his body. Thankfully, I knew what it was and I was able to reduce it myself.

Another time we were actually at my brother-in-law’s parents’ house, and he was sitting on the floor, and we were ready to go, and I picked him up by his arms again, and boom, it popped out again. And again, once again, I knew what it was, so I was able to reduce it. Not a big deal. If you don’t know what it is, though, it sort of can seem like a big deal. This is a nursemaid’s elbow. Lab studies and physical exam finding. Again, the child will not use the affected arm.

They will allow passive motion of the arm again. They’re not really in any pain. X-ray here will be normal. And the treatment is manual reduction. So you supinate the wrist and extend the elbow while applying pressure over the radial head and it just sort of pops back in and then they go about their business. Elbow fractures. Radial head fractures are fairly common.

The clinical presentation here, elbow pain and stiffness following trauma, lab studies and physical exam findings. The patient will not allow movement of the elbow. A fat pad sign on x-ray indicates an occult fracture. So you get a little change in the x-ray around the elbow. And you should definitely look up this image because it’s an image that I could see them putting on the PANCE of an elbow with a fat pad sign indicating an occult fracture. When I say occult fracture, what I mean is an occult fracture is something you don’t see on x-ray, hidden. So it’s broken.

But an x-ray, you know, x-rays, MRIs, CAT scans, all these things are great EKG. Think about EKGs. We learn EKGs. It’s hard. They’re not clear. There’s no direct indicator, right? That’s why you have to be trained to read them.

Same thing with x-rays, same thing with CAT scans and MRIs. You have to be trained to read them. And still, it’s a little bit of an art. So a lot of times, not a lot of times, there will be times when you can’t see a fracture on an x-ray. I recently was in a car accident and I broke the base of my fifth metacarpal in my right hand. And I’m friends with the hand surgeon. So I went to see him.

He took an x-ray right away and we’re looking at it. And he’s like, man, the only thing I see, because I couldn’t move my hand, I just, I was swollen. I was stiff. This was two, three days after the accident. I went to see him. And he’s like, the only thing I see is this little thing at the base of your fifth metacarpal. And then he pushed on, I’m like, well, you found the spot.

That was it. Yeah, you nailed it. But it wasn’t like the x-ray was real clear. It’s not a super clear break per se. It’s a little shadowing almost. So when you get that fat pad sign, that’s an indicator that there’s something else going on.

All right, that’s as deep as we’re going to take elbow fractures. Colles’ fractures. This is the most common wrist injury. That probably shouldn’t be injury. That should probably be fracture. This results from a fall onto a dorsiflexed hand. Dorsal angulation of the hand and wrist.

So you think about it, you put your hand out and you fall on your, the way that you would stick your hand, you’d lift up your fingers as you’re falling. And this would cause the Colles’ fracture. Clinical presentation, I fell on my hand and now it hurts. Lab studies and physical exam finds x-ray shows a silver fork or dinner fork deformity. Again, this is an audio podcast, right? So look this up, find an image of this. You’re going to need to see it.

You’re going to need to see the x-ray. It’s something that you will absolutely be totally fair game to put on your PANCE and ask you to identify it and talk about it. Treatment, closed reduction and immobilization or surgical correction if unable to achieve stable satisfactory reduction. So we fixed a lot of these. Gamekeeper’s thumb or skier’s thumb.

Now, the thing that I struggled with in PA school when they give you things like gamekeeper’s thumb, they’re not talking about a goalie, right? And it took me a while to understand that, so I don’t laugh at you. I’m laughing at me. I always thought they were talking about a goalie. They’re not. What they were talking about was game, like hunting. Like you would call a rabbit.

If you’re hunting rabbits, you would call that game. That’s what you’re hunting for. So a gamekeeper would be the person who would take someone hunting. And then would be also, and where this comes from is they would be in charge of breaking the necks of the small animals like the rabbits or the squirrels or whatever. And the way that they would do it over and over and over repetitively would injure the ulnar collateral ligament of their thumb. So this particular occupation, which you don’t really know about anymore, would develop this problem, this ulnar collateral ligament injury. So that’s why we call it gamekeeper’s thumb.

And sometimes the problem is you might be better off just calling it an ulnar collateral ligament injury because that might be more clear to you than gamekeeper’s thumb because you don’t know where that came from. And I find that that can happen quite a bit with a lot of the things we talk about. You know, I use current jelly stool as an example. I don’t know what current jelly looks like. That doesn’t help me. It actually makes it more complicated. But something like strawberry tongue makes it easier.

Same thing here. Game keepers, I’m most, you know, I don’t want to say most of it. I’m going to take you into, say what you know or you don’t know. I didn’t know what this was. And I find it sometimes these analogies are more confusing, not less confusing. And this is one of those cases. Skier’s thumb is one way to think about it because what will happen is a skier will get their hand in their poles and the poles will stick in the ground and their thumbs will go back and this will cause that same problem.

These people will complain about things like they won’t be able to, they’ll be able to move their thumb and their hand, but they won’t be able to do something like pick up a cup of coffee. If they have, that’ll be, it just won’t work because that ligament, the collateral ligament of their thumb isn’t functioning. They get instability of the metacarpal joint of the thumb, so they have a weak pinch or grasp. That’s how you can test it in the office. And swelling or bruising over the thenar eminence. Minor tears may be treated with a thumb spica splint, and more significant tears are going to need to be surgically repaired. Scaphoid fractures.

This is the most commonly fractured carpal bone. And be sure to consider this in clinical practice. Because they have a high rate of non-union. This needs to get fixed. I didn’t think I had a scaphoid fracture. I did think I had a carpal fracture, but it turned out it was a metacarpal fracture. Very, very close.

So when I was trying to press on it myself, I couldn’t really tell. Clinical presentation for a scaphoid fracture. Pain after a fall on an outstretched hand. Pain with use of the thumb. And the thing you’re looking for here is pain with palpation of the anatomical snuff box. And this can be missed on x-ray. This can be an occult fracture, and it doesn’t heal well, so you have to be aware of it and be thinking about it.

An MRI will demonstrate the fracture more clearly if you’re concerned. Treatment, cast, thumb spica splint, and surgical correction. Our last upper extremity trauma would be a boxer’s fracture. A boxer’s fracture is the fracture of the fourth and possibly fifth metacarpal neck. So everyone who I said I had a fifth metacarpal fracture, like, Oh, a boxers fracture. It actually really wasn’t. It was really just at the base, a crack at the base, not at the neck.

Clinical presentation here is generally speaking, when I see this, when I talk about this, it’s a teenage boy who punched a wall. That’s nine out of 10 of these. And what happens is they hit that fourth and fifth knuckle and it just cracks. The metacarpals crack. I was actually talking with the CRNA lately and I was talking about my injury and she said, yeah, anytime that I have a teenage boy come in with a broken hand, I ask them what they punched and they think that I’m a mind reader. But it’s so routine at this point as far as she was concerned. And I see that in my son who’s put a few holes in our walls.

We actually have one currently he’s going to have to fix. But that tends to be a common occurrence for teenage males. Lab studies and physical exam findings. Knuckles may no longer be prominent. Obvious deformity may be present and an x-ray to visualize the fracture. Treatment, splinting, closed reduction pinning and open reduction and internal fixation may be necessary. And I take it for in stride here when I say open reduction and internal fixation or closed reduction pinning.

And I said that a couple of times and I realized just like Gamekeeper’s Thumb or some of these other things, you may know what that means, but you may not. So let me run through it real quick. A closed reduction in pinning, what we mean by that is you reduce the bone, you reduce the fracture. Without closed means I don’t make an incision. So I reduce the fracture, and then I take a wire, and I put it across the fracture to hold it in place. And that’s it. It’s a little, it’s a handheld drill with a wire.

And you just simply and you put that wire across the fracture and then you cut the wire and you bend it over so that it doesn’t bother the person so much. But that’s what a closed reduction pinning is. An open reduction and internal fixation is where we go and make an incision and we find the fracture, we line it up and internal fixation, what we’re usually talking about, so you would put a screw across the fracture to compress it together, usually called a lag screw. And then you might put a plate on it. So you’d put a plate across the fracture, probably four or five-hole plate, and if you can picture it, you’d put two screws on the proximal portion through the plate, into the bone and you’d put two screws distally to the fracture through the plate and into the bone. So now you’re holding the fracture in place in a very rigid structure. So that’s an open reduction internal fixation.

All right, let’s talk a very little bit about the chest and ribs. I’m not going to go into a lot of detail here, but it is in this section. So we’re going to just mention it. There are really only two things I want to talk about here. Everything else got into with more pulmonary stuff. But as far as the chest and ribs goes for musculoskeletal, costochondritis is one that I think can definitely come up on your exam and will absolutely, if you’re in family practice, if you have kids, if you have a family, this will come up. I’ve probably diagnosed this, I don’t know, five, 10 times in my career, not in my career, in my life.

This is inflammation of the cartilage that connects the ribs to the sternum. It’s also known as chest wall pain or costosternal syndrome. So what happens is a person comes in complaining of chest pain. And immediately we all start thinking, MI, what’s going on? And the answer in this case is they have a little inflammation in the cartilage between the rib and the sternum. And what’s nice about this is it’s really reproducible. This is how you can separate it out from an MI right away.

Sometimes it’ll hurt when they take a deep breath. And so that’s very reproducible. But the other thing you can do is press on it, right? You shouldn’t be able to cause an increase in pain if a patient’s having MI by pressing on their chest. Here, you can find the spot and push on it and they will wince and complain. The nice thing is this is usually self-limiting, gets better in a couple of weeks, was usually due to some kind of strain or trauma. Some ibuprofen or something will help to decrease the pain and decrease that inflammation and they’ll get better.

But it’s really that reproducibility that’s the key in diagnosing this. Next we have rib fractures, which is some sort of trauma, right? Generally speaking, we don’t fix rib fractures. They can cause other trauma and I don’t want to go down that road like I said, but certainly you can get things like a pneumothorax or a tension pneumothorax or a hemothorax or all of these things can be involved. You have to be aware of those. But as far as the bones themselves goes, they’re generally not operated on. The little bit, or the lot worse condition is the flail chest.

And this is something I never really understood in PA school. But this is where you have multiple ribs fractured in two or more places. So essentially you have a segment of a rib that’s disconnected from the rest of the rib. So if you think about one rib that’s fractured in two spots, so now you have a segment of that rib that’s fractured, right? That moves now separately from the rest of the chest. A flail chest is when you have two of those next to each other, or at least two. So you have two ribs, sections of ribs that are now free floating.

And again, if that doesn’t make sense, go find a video on it, go pull up an image. It’s not hard, but definitely something you want to have seen and have in your head. So that little segment, that little piece, let’s just call it two or three ribs that are cut off or broken from the rest of the rib cage, they will move differently than the rest of the ribs. In fact, what will happen is they will move paradoxically to the chest wall. So as you breathe in and the rest of the chest expands, they’ll kind of stay where they were, so they’ll be sunken in. Then as the patient breathes out and the chest, I’m just opposite of expands. I can’t think of a word off the top of my head.

The chest gets smaller. I don’t know. And those ribs, that flail part, that part is detached, will actually move out as the rest of the ribs and the rest of the chest will all come in. So it’s paradoxical movement to the breathing. We’ll show you that flail chest. That’s what we’re talking about. And again, depending on the trauma, this can be the the broken ribs themselves aren’t necessarily the problem.

It’s what happened underneath there. It’s the lung trauma. It’s the lung contusion. It’s the, the you know, what’s going on inside of there. That’s the problem.

All right. So that’ll wrap up our, the medical content for today’s show. I just want to talk about before we do to the priming questions, our study tip for today. Today’s study tip is going to to be a little off the wall for most of you, but it’s really important. I was out in Ashland, Ohio last week. It’s our PA program. Shout out to you guys.

You guys were amazing, super receptive, incredibly kind. Really appreciate you guys having me out there. It was a ton of fun and really great to meet all of you. But one thing that stood out to me, and it has stood out to me in the 33 Days program as well. But it’s the idea of this limiting thought process we have. And you can hear it in your speech and in the speech of others. And I would constantly pointed it out over the two-day workshop I put on there because students would always be limiting themselves, would always be putting a governor on their successes.

And I really, you really need you to believe in yourself. You really need you to trust yourself in order to get through PA school, in order to pass the PANCE, in order to practice medicine, right? Everyone talks about imposter syndrome and how you feel like, oh, I shouldn’t be here. I don’t know why I’m here. I can’t handle this. Everybody’s smarter than me. That’s a real problem, right?

But the way that you get through that is not talking yourself down, but talking yourself up. You know, some people, I forget what book it was, but something I read not too long ago talked about this irrational confidence. And I thought that was kind of a good idea because we spend so much time beating ourselves up and bringing ourselves down. We spend so little time building ourselves back up. So this irrational confidence might actually make sense, even though we feel like it’s a little awkward. So what I’m talking about is when people say things like, you know, the example that made me bring this to your attention was, like I said, when I was in Ashland, I asked the students there to write a list of their successes. And at first they struggled mightily.

They looked at me like I was crazy. But the idea is I wanted them to see how successful they’d been just to be sitting in those chairs just to be this close to graduation. It’s unbelievable the amount of success that you must have had to be there. But we can’t think of any of it. And one person wrote down that they’d played professional basketball. So I asked them, I said, wow, this is amazing. You know, can you tell me more?

And the response I got was, yeah, but it was just in Denmark. And that’s what I want to point out to you. And this person’s not alone, by the way. I get this kind of response from so many people. Diminishing their successes, diminishing what you’ve done. You know, my wife played Division I lacrosse, but when she tells the story, she’ll talk about how small the school was. Like, that’s ridiculous, right?

And I don’t mean to just use sports knowledge, it comes up all over the place. But if you watch your speech, if you watch your friend’s speech, if you watch your parents’ speech, we all place these limits on ourselves and bring ourselves down constantly in the way that we talk. One of the main things that you need to get through the PANCE, through a five-hour exam, through a 300-question exam, is confidence in your own abilities, confidence in your brain to be able to handle this information and do this. I don’t believe in wishing for competence. I don’t believe in people telling you you have competence. You have to create the competence in yourself. And when we’re constantly tearing that down, it becomes a major problem when we have to perform at the highest level because we doubt ourselves.

And I find on exam day that that’s just as important is all the medical content you’ve learned. If that doubt creeps in, it’s very hard to answer those questions. So the exercise for today is just keep an eye on how you speak, how you answer questions. You know, when your preceptors ask you, have you done this before? Do you cower? Or do you say, no, can you show me? You know, it’s really simple.

Some very simple different techniques in the way that you think and the way that you speak can have a huge impact.

All right, let’s move on to our answering our priming questions. An x-ray shows a silver fork deformity. What are we talking about? We are talking about a Colles’ fracture. Pain with palpation over the anatomical snuffboxes tends to be an easier one. Scaphoid fracture. Which was medial epicondylitis?

Was that golfer’s elbow or tennis elbow? Do you remember? I literally do, when I have to think about this, I literally hold my elbow and I do forced supination. And I feel where that hurts. And that to me is a tennis elbow. Or I think about tightening a screwdriver. That to me is a tennis elbow.

So that leaves medial epicondylitis as my golfer’s elbow. But I’m literally doing the motion so that I can figure it out. I don’t memorize it. A fracture of the fourth and often fifth metacarpal is what type of fracture? This is a boxer’s fracture. What does the crossover test evaluate? It evaluates the AC joint and what does a fat pad sign indicate?

This isn’t enough to know that name. You have to look at the x-ray. You will not be given that as a name on the test. I can’t imagine they would give that to you as a name on the test. They’d show you the picture and ask you what’s going on. And you have to know occult elbow fracture, occult meaning hidden, right? That’s hard to see on the…

you don’t actually see the fracture on the x-ray. You just see that gray patch that indicates that there’s a fracture that you can’t see on x-ray. But if you got a CAT scan or an MRI, it would show up. Make sense?

Excellent so that wraps up episode 111 of the Physician Assistant Exam Review Podcast. Again, you can get all the notes over at physicianassistantexamreview.com. And if you go to physicianassistantexamreview.com/MSK, you can get questions pulled right from The Final Step on musculoskeletal. Next week, we’ll be moving on to, I believe, spinal issues. Then we’ll be almost wrapping up the bony side of musculoskeletal and then moving into rheumatology and then wrapping up rheumatology, hopefully fairly soon to get to the end of musculoskeletal. So that’d be really exciting. One more thing to add in here before we wrap it up for today.

I do want to just let you know that if you’re interested in the 33 Days to Pass the PANCE program, I will be running only two more cohorts this year and they will be limited in size. They will be August and November of this year. So for 2023, I’ll be running two more cohorts, August and November. So if you’re interested, hop on the email list, make sure you’re getting those emails and then you’ll be able to see those when they go live. And when you can get into those classes, because like I said, they’ll be limited.

All right. Take care.