Boutonniere deformity A boutonniere deformity is a finger condition where the PIP joint is flexed while the DIP is hyperextended. This condition is a consequence of trauma where a force is applied to the top of a bent middle joint of the finger (Binstead et al., 2023). The deformity is a result of a rupture of the PIP central slip. This injury is common in football and basketball players (Binstead et al., 2023). The tell-tale finding to diagnose this boutonniere deformity is the characteristic appearance of the finger. Knowing the mechanism of injury can be relevant and helpful for diagnosis. The Elson test, as described for PIP dislocation, can be used to assess tendon integrity (Binstead et al., 2023). Case Study: Jared Johnson Mr. Johnson is a 43-year-old driver for UPS who presents to therapy complaining of right “shoulder” pain. The onset of symptoms began two weeks ago after a long, busy day of driving and delivering packages. He reports that his symptoms got much worse two days ago when he was replacing boards on his deck. He rates his pain at 7/10 and, when directed, he locates his pain to his upper outer right arm down to the elbow. Question The location of this client’s pain correlates with the C5 dermatome, which may indicate cervical disc pathology. What test(s) could you use to differentiate a cervical versus shoulder pain origin? Discussion Cervical radiculopathy is typically associated with arm pain. The Spurling test is a highly specific and sensitive test for diagnosing this condition. This test constricts the patency of the cervical neural foramen, thus increasing compression on the nerve root. If this test reproduces the client’s symptoms, it is considered positive for cervical radiculopathy. Three other tests that can be used to differentiate cervical versus shoulder pathology are the shoulder abduction test (which is positive if it relieves the client’s symptoms), loss of biceps reflex, and the arm squeeze test (which is positive if it reproduces the client’s pain).
Case Study: Maggie Miller Maggie is a very active middle-aged schoolteacher. She presents to therapy complaining of right wrist pain. She sustained an injury when she fell on her outstretched right hand on the pavement while roller skiing. She has not seen a physician. Question What are three possible fractures associated with a fall on an outstretched hand, and how would you differentiate them? Discussion A Galeazzi fracture occurs with a fall on an outstretched hand with wrist extension and forearm pronation, so the mechanism of injury might help differentiate this injury. Evaluation would include inspection for deformity as well as palpation of the distal radius and distal radioulnar joint to localize the injury site. A Colles’ fracture would also involve the distal radius, but typically with dorsal displacement. Evaluation would include inspection for deformity, palpation to localize the injury site, and assessment of wrist range of motion (which would be reduced). A Smith’s fracture also involves the distal radius, but with volar displacement. It is a FOOSH injury that occurs with the wrist flexed. Evaluation includes inspection for deformity, palpation, and assessment of wrist range of motion (which is typically reduced). Case Study: Maria Garcia (Implicit Bias) Ms. Garcia works the night shift at a factory, where she performs repetitive grasping. She presents to therapy via referral from her workers compensation case worker. The client has difficulty both speaking and understanding English, but with the help of her son (who is present for the visit), she reports having pain in her right wrist with tingling in her hand. These symptoms make it difficult for her to do her job and to sleep at night. The assessing clinician concludes that the client is experiencing symptoms of carpal tunnel syndrome. In the past, clients with this diagnosis have received an average of four treatments consisting of education, manual therapy, a home exercise program, and a splint. However, in this case, because of the language barrier and difficulty with communication, the physical therapist assumes that the client will not benefit from more complex treatment and sees the client for one session only, providing a splint and some basic education. Question What is the implicit bias in this scenario? Discussion The implicit bias in this case study is that the number of visits planned for this client was influenced by the language barrier, not by her physical needs. should always include a thorough medical history and attention to the mechanism of injury. Many special tests have been developed to help with differential diagnosis, and knowledge and use of these tests can be helpful during assessment.
Conclusion Because of the complexity of shoulder and upper extremity function and the myriad number of possible injuries to these structures, differential diagnosis can be very challenging. Many viscerogenic and systemic structures/ conditions can cause referral of pain to the shoulder, and screening of multiple systems is important. History taking
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