DSA/LAB: MSK Upper extremity (10) + scoliosis (5)

Question 1

innervation to upper arm?

Answer 1

Most problems in the upper extremity are associated with a component of upper thoracic, upper rib and cervical somatic dysfunction.

Why? The sympathetic nerves innervating the upper extremity arise from the upper thoracic spine and are interconnected with the superior, middle and inferior cervical ganglion. Treating the upper thoracic, upper rib and cervical dysfunction before addressing the upper extremity will reduce the amount of sympathetic tone to the upper extremity, thereby relaxing the muscles and improving arterial supply to and lymphatic and venous return from that region.

If an upper extremity problem (especially shoulder) is slow or non-responsive to treatment, think of systemic problems like diabetes or hypothyroidism. The neuromusculoskeletal condition may not respond until the systemic problem is properly treated and under control.

Question 2

humerus BLT

Answer 2

pt. holds other side of shoulder and moves uninvolved shoulder posteriorly, disengagin the humerus. Perform BLT by gently internally or rotating the humerus

Question 3

Scapulothoracic BLT

Answer 3

placs pad of thumb on ribs at midaxillary line, and slides thumb posteriorly along ribs until its under the scapula - patient leans toward physician

place other hand on top of scalupa and apply inferior traction, hold until relaxation of seratus anterior occurs

modification for child:

• use only one finger in scapulothoracic space
• Give them a toy to play with to keep the hand more midline and humerus more internally rotated

Question 4

still technique

Answer 4

1. take tissue to ease
2. introduce force vector
3. take tissue through ROM and through restriction

Question 5

posterior radial head

Answer 5

resists anterior motion and supination (prefers pronation)

Question 6

anterior radial head

Answer 6

(prefers supination) resists posterior motion and pronation

Question 7

spencer’s technique

Answer 7

extention
flexion 
compression
traction
adduction/external rot
abduction
internal rot
joint pump

Question 8

nursemaid’s elbow

Answer 8

slippage of head of radius under annular ligament (occurs w/ traction and forearm pronation )

forearm flexed 15-20 degrees, and pronated

tx: immobilizing the elbow and palpating the region of the radial head with one hand. (place thumb over anterior portion of radial head)
• The other hand applies axial compression at the wrist while supinating the forearm and flexing the elbow.
• As the arm is manipulated, a click or snap can be felt at the radial head.

Question 9

C/S of supraspinatus, subscap, biceps brachii, medial epicondyle, radial head TP

Answer 9

-

Question 10

rotator cuff?

Answer 10

supra: abduction
infra: external rotation
teres minor: external rotation
subscap: internal rotation

Question 11

impingement interval

Answer 11

space b/w the acromion and superior aspect of humeral head – esp. the supraspinatus tendon as it traverses this space

• PE shows trouble w/ abduction, trapezius fires early and winging of inferior medial scapula seen — pt. has pain going from 90-120 degrees abduction

Question 12

tx of rotator cuff?

Answer 12

should try to tx conservatively whenever possible

• strengthening
• raining changes
• ice, deep massage, heat
• NSAIDs
• corticosteroids to reduce pain

Question 13

superior labrum anterior posterior lesion

Answer 13

SLAP lesion - seen in overhead throwing motion

deep shoulder pain w/ popping
- have trouble internal rotating

Question 14

biceps tendonitis

Answer 14

• palpation of biceps tendon in groove causes pain

Speed’s test: has pt. flex elbow to 90 degrees, then examiner extends and externally rotates

tx: limit activity, NSAIDs, ROM exercises
caution: injecting corticosteroids can cause further weakining of tendon and increase subsequent rupture

Question 15

lateral epicondylitis

Answer 15

(tennis elbow) - therapy is PT,, NSAIDs and addressing mechanics

Question 16

medial epicondylitis

Answer 16

(golfer’s elbow) - also seen in tennis, vball, - pain elicited w/ resisted pronation and wrist flexion

Question 17

+ fat pad sign

Answer 17

indicates elbow distention d/t hemorrhage, inflammation or trauma - if not present then significant intraarticular injury probably not present
= think fracture!

Question 18

greenstick fracture

Answer 18

Type II of SALTER classification, break is above the plate

Question 19

Still’s technique for posterior radial head

Answer 19

(posterior likes to pronate)

A gentle axial force is put through the distal radius to the radial head. Maintaining that compression, the forearm is brought into supination. Release the compression to recheck motion

Question 20

curves?

Answer 20

named for dxn of convexity - the vertebra sidebend away from the convexity, and rotate towards it

Question 21

C curve

Answer 21

right C curve: right short leg

pelvis shifts opposite (left)
internally rotated/pronated foot opposite (left)

• right short leg, right anterior sacrum, right shoulder higher

** shoulder (cephalad planes) are depressed on opposite side of the curve - opposite to the depressed pelvic plane

Question 22

S curve

Answer 22

compensatory curve, happens after C curve

(right

• pelvis shifts oppt. short leg
• internally rotated/pronated oppt. short leg
• shoulder higher opposite short leg

** short leg and anterior sacrum on on same side as shoulder droop

** shoulder and greater trochanter planes are depressed on same side as depressed sacral base

Question 23

un level sacral base?

Answer 23

lumbar vertebrae SB away (curve is towards), the lower sacral base –> type 1 lumbar curve

Question 24

gravity?

Answer 24

sacral base rotates anterior, innoms rotate posterior

Question 25

leg length discrepancy

Answer 25

tx: sacrum, innoms, quad. lumborum ----------------------------------------- * * lumbar spine SB away from low sacral base (short leg), rotates toward short leg * * pelvis rotates toward long leg * * innom on short leg is anterior * * pronated foot on long leg, interanlly rotated on long leg ---------------------------------------- Short leg on right = right C curve (SB away) - shoulder higher on short leg side (right) - pelvis rotates toward long limb (left) - anterior innom rotates on short limb side to lengthen it, posterior innom rotation on long leg side - long leg is internally rotated and foot is pronated (left)

Question 26

functional vs. structural curve?

Answer 26

functional - goes away w/ forward bending and swinging side to side, structural does not

Question 27

what do you see w/ "short leg syndrome"

Answer 27

see un-level sacral base- iliolumbar ligament is first on side of convexity to react to unlevel sacral base causing tendernes to palpation over L4/L5 TPs --> referring pain to groin ** often see PSIS and iliac crest depressed on lower sacral side

Question 28

single thoracic scoliosis

Answer 28

most common is Left paraspinal hump - SBR, RL | * can compromise heart

Question 29

single lumbar scoliosis

Answer 29

think arthritis

Question 30

** S vs. C curve?

Answer 30

C curve = (short leg same side as curve, opposite SB) - anterior sacrum on same side as short leg - shoulder droop, pelvic shift, internal rotation on opposite side of short leg S curve = (short leg same side as lower curve, opposite SB) - anterior sacrum AND shoulder droop on same side as short leg - pelvic shift and internal rotation on opposite side of short leg

Question 31

case: 47 y/o presents w/ upper thoracic pain and short left leg, what do you find?

Answer 31

- right posterior innom - left anterior innom - pelvic sideshift right - right lower extremity internal rotation

Question 32

right rotoscoliosis

Answer 32

SB left, rotated right toward convexity

Question 33

pt has short left leg d/t recent femur fracture, what will you find?

Answer 33

left short leg = SB to the right, rotated left = curve on the left, left convexity - see paraspinal mm. elevation (side of rotation), this is indicative of a structural scoliosis, more chronic.

Question 34

curves of spine? when to do surgery for scoliosis?

Answer 34

cervical and lumbar are lordotic - curves greater than 40% are bad prognosis (want to do surgery!) - pulmonary 50% - cardio 75%

Question 35

70 y/o woman w/ osteoarthritis and short leg would correct w/ ?

Answer 35

1/16 inch = for fragile pt. - increase by 1/16th every two weeks! (just replace until landmarks get evened out and w/out sx) 1/8 = someone w/ flexible spine - every two weeks full increase = pts. w/ acute injury

Question 36

scoliotic curve most likely to progress in which patient?

Answer 36

adolescent - d/t rapid growth changes (10-15 years, need to be screened, esp. adolescent females)

Question 37

ligamentous strain w/ short legs?

Answer 37

- short leg side = strain in iliolumbar ligament (from L4/5 to iliac crest), when it creates pain it can refer to groin area - mm. on side of convexity lengthen and weaken, on SB side the mm. are getting shortened ex: left short leg, will have left iliolumbar pain, left groin pain, left anterior innominate,, lengthening of left paraspinal mm. (on side of curve), tenderness on left SI joints

Question 38

simple thoracic scoliotic curve, SB left rotated right

Answer 38

= hump on right, short leg on right - right paraspinal mm. elevation, lengthened mm. - elevation of right shoulder - depression of left shoulder, w/ left index finger shorter, left scapula shorter

Question 39

pt. has short right leg, what do you expect to find on structural exam?

Answer 39

= right hump (SB left, rotated right) - right elevated shoulder, lower left shoulder - right anterior sacrum - left pelvic shift and internally rotated LE

Question 40

what happens when 13 y/o given a heel lift for right short leg?

Answer 40

- compression stimulates bone growth - stimulates increased growth and lengthening of right leg! - stimulates more growth on short leg side!