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Pathomechanics > Exam 2: Shoulder, Elbow, and Wrist & Hand > Flashcards

Exam 2: Shoulder, Elbow, and Wrist & Hand Flashcards

1
Q

What muscles elevate the scapula?

A
  • upper trap [CN XI, C3-4]
  • levator scapulae [dorsal scapular n. [C5, C3-C4]
  • rhomboids [dorsal scapular n. [C4-C5]
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2
Q

What muscles depress the scapula?

A
  • lower trap [CN XI, C3-C4]
  • serratus anterior [long thoracic n. (C5-C7)]
  • pectoralis minor [medial pectoral n. (C6-T1)]
  • pectoralis major [medial and lateral pectoral n. (C5-T1)]
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3
Q

What muscles upwardly rotate the scapula?

A
  • lower trap [CN XI, C3-4]
  • upper trap [CN XI, C3-4]
  • serratus anterior [long thoracic n. (C5-C7)]
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4
Q

What muscles downwardly rotate the scapula?

A
  • levator scapulae [C5), C3-C4]
  • rhomboids [dorsal scapular n. [C4-C5)]
  • pectoralis minor
  • pectoralis major
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5
Q

What muscles protract the scapula?

A
  • serratus anterior [long thoracic n. (C5-C7)]
  • pectoralis minor
  • pectoralis major
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6
Q

What muscles retract the scapula?

A
  • middle trap [CN XI, C3-4]

- rhomboids [dorsal scapular n. [C4-C5)]

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7
Q

Scapular Pattern Classification System

A
  • Normal
  • Inferior angle pattern (Type I)
  • Medial border pattern (Type II)
  • Superior border elevation (Type III)
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8
Q

It is important to address the _____ ____ and the ________ ________ in pt’s with scapular dyskinesia

A

lower trap, serratus anterior

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9
Q

“Step sign”

A

indicates a AC joint separation

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10
Q

Static Stabilizers of the GH Joint

A
  • bony architecture
  • intra-articular pressure
  • joint cohesion
  • ligaments and capsule
  • labrum
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11
Q

Dynamic Stabilizers of the GH Joint

A
  • force couples
  • joint compression d/t muscle activity
  • dynamic stabilizers
  • neuromuscular control
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12
Q

Superior Glenohumeral Ligament

A

provides anterior stability below 45 degrees

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13
Q

Middle Glenohumeral Ligament

A

provides anterior stability at 90 degrees, secondary to rotator cuff

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14
Q

Inferior Glenohumeral Ligament

A

provides anterior stability at and above 90 degrees

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15
Q

What are the ideal mechanics of shoulder elevation?

A

scapula should face the frontal and sagittal planes, during flexion the twisting should decrease, and it should increase pulling of the humeral head during abduction. ER force results from pressure build-up and humerus passively externally rotates to provide clearance of the greater tubercle

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16
Q

Age-Related Shoulder Changes

A

40-50: more rotator cuff injuries
20-40: more calcific deposits in tendon
45-60: more adhesive capsulitis

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17
Q

Supraspinatus Resistance Test

A

.

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18
Q

Infraspinatus Resistance Test

A

.

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19
Q

Subscapularis Resistance Test

A

Gerber’s lift off position

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20
Q

Bicep’s Resistance Test

A

Speed’s test

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21
Q

Primary Impingement

A
  • subacromial crowding
  • posterior capsule tightness
  • excessive superior migration of the humeral head d/t/ rotator cuff weakness
  • poor healing d/t hypovascularity, especially w/ arm adducted
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22
Q

Coracoacromial Arch Abnormalities

A
  • os acromiale
  • AC joint degeneration with inferior spur
  • congenital abnormalities of coracoid process
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23
Q

Secondary Impingement

A

relative decrease of the subacromial space

  • instability of the glenohumeral joint
  • dysfunction of the scapulothoracic joint
  • postural malalignment
  • weakness of scapular girdle
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24
Q

Neer’s Classification of Pathology

A

Stage 1: hemorrhage and edema in tendon
Stage 2: fibrosis and tendinitis (seen in pts. >25 yoa)
Stage 3: cuff tear w/ or w/o biceps rupture and bone changes

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25
Q

SLAP - Type I

A

superior labrum demonstrates fraying and degeneration; the labrum is intact with glenoid and biceps is intact with glenoid and labrum; surgical debridement

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26
Q

SLAP - Type II

A

superior labrum detached from glenoid and biceps is detached from superior glenoid, allowing superior labrum and biceps to arch away from glenoid; surgical repair

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27
Q

SLAP - Type III

A

superior labrum demonstrates a bucket handle tear, remaining labrum is intact with glenoid and remaining biceps is intact; surgical debridement

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28
Q

SLAP - Type IV

A

superior labrum demonstrates a bucket handle tear and tear expands into biceps, torn biceps and labrum are displaced into the joint; surgical repair

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29
Q

On average, the elbow has __ degrees of pronation and __ degrees of supination

A

80 degrees of pronation and 85 degrees of supination; total excursion is 165-170 degrees

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30
Q

On average, the ulnohumeral joint has ___ degrees of flexion

A

145 degrees

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31
Q

Ligaments of the UCL complex

A

anterior band, posterior band, and oblique band

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32
Q

Ligaments of the LCL complex of

A

radial collateral ligament, annular ligament, lateral ulnar collateral ligament, and accessory collateral ligament

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33
Q

Lateral Epicondylitis

A

commonly occurs in the 5th decade and usually results from wrist flex-ext, pronation-supination; associated with microvascular damage, degenerative cellular processes, and disorganized healing

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34
Q

Pathophysiology of Lateral Epicondylitis

A

degenerative/failed healing tendon response resulting in increased presence of fibroblasts, vascular hyperplasia, and disorganized collagen

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35
Q

Lateral Epicondylitis Exhibits _____ on US Imaging

A

intratendinous calcification, tendon thickening, bone irregularity, focal hypoechogenicity, and diffuse heterogeneity

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36
Q

Lateral Epicondylitis Signs and Symptoms

A

proximal-lateral forearm pain, exquisite point tenderness at CEO, pain w/ resisted isometric wrist ext, may have pain w/ stretch of involved structures if acute and irritable

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37
Q

Treatment of Lateral Epicondylitis

A

reduce stressful mechanics, ice, exercise, iontophoresis w/ dexamethasone, ultrasound, achieve extensible repair, counterforce brace

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38
Q

Medial Epicondylitis

A

usually results from repetitive grasping, wrist flexion, ulnar deviation contributions; associated with local pain, exquisite point tenderness, symptoms increased w/ grasping and resisted wrist flexion

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39
Q

Triceps Tendinitis

A

unusual in isolation and often accompanies other pathologies; S&S include local pain and tenderness, pain w/ resisted ext

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40
Q

Triceps Tendon Rupture/Avulsion Fx.

A

atypical and usually traumatic; S&S include pain and swelling at posterior elbow, deformity, palpable depression, loss of ext strength

Fx: std rads
Tendon rupture: MRI

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41
Q

Distal Biceps Tendon Rupture

A

typically in men 50-70 and in dominant extremity; results from sudden or prolonged load and usually involves the tendinosseous junction of the radial tuberosity; S&S include audible “pop” and acute pain, decreased strength w/ flexion and supination, and possible deformity

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42
Q

Distal Biceps Tendon Rupture Rx

A

surgical repair is required; pt. is immobilized 4-8 wks, then PT works to improve gradual ROM in 6-8 wks and gradual PRE w/ full ROM in 12 weeks; full activity usually around 6 mos.

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43
Q

Olecranon Fx.

A

usually results from a fall onto tip of elbow in which displacement is typical; ORIF is usually performed and allows early motion & better alignment of fragments

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44
Q

Medial Epicondyle Fx.

A

results from valgus stress to jt. w/ traction injury from flexor mm. and may accompany dislocation; if extra-articular = closed reduction and ORIF; if intra-articular or w/ displacement = ORIF

45
Q

Supracondylar Fx.

A

results from falls and typically requires ORIF;

46
Q

T or Y-Condylar Fx.

A

caused by falling on a flexed elbow in which the olecranon is driven into the distal humerus resulting in fx. that extends into the jt. line; surgical repair w/ ORIF or total arthroplasty

*Note: may compromise nearby neurovascular structures

47
Q

Monteggia Fx.

A

fx. of proximal 1/3 of ulna and radial head dislocation, can be treated with closed reduction or ORIF; results from direct blow, hyperpronation or hyperextension.
* Note: may compromise the radial n.

48
Q

Tommy John Procedure

A

medial collateral ligament complex reconstruction using palmaris longus tendon (or similar);

49
Q

Post-Op Rx After Tommy John Procedure

A
  • immobilized in 90 degrees for 1 wk
  • gradual recovery AROM by 6 wks
  • Slow PRE
  • Light throwing at 4-5 mos
  • Higher level activity apx 7-8 mos
  • Return to competition apx 12 mos
50
Q

Elbow Dislocation

A

usually from FOOSH and involves extension w/ varus force; progression w/ circle of failure: LUCL, anterior capsule, MUCL

51
Q

Elbow Dislocation Rx.

A
  • if no fx, immobilization for 1 wk
  • AROM recovery over 6-8 wks
  • Slow PRE
  • 80-90% by 3 mos

*Note: there is potential for residual laxity; radial head and coronoid process fx are most common

52
Q

Radial Head Dislocation

A

aka “Nursemaid’s Elbow”; usually occurs in children 1-3 yoa. d/t the spherical shape of the radial head; result of traction and extension forces

53
Q

Cubital Tunnel Syndrome

A

compression of the ulnar n. at the elbow; direct compression w/ repetitive flexion-extension activity

54
Q

What is innervated by the ulnar n.?

A

.

55
Q

Signs and Sx. of Cubital Tunnel Syndrome

A

pain/paresthesia ulnar aspect hand & digits 4-5, decreased sensation of same, decreased grip and finger abd/add

56
Q

Radial Tunnel Syndrome

A

compression of PIN (branch of radial n.) under supinator and/or ECRB

57
Q

What is the course of the ulnar n.?

A

.

58
Q

Signs and Sx. of Radial Tunnel Syndrome

A

proximal lateral forearm pain, similar to lateral epicondylitis and may also accompany, pain limited weakness, no sensory loss, often worsened with pronation/supination

*motor loss is variable

59
Q

Pronator Syndrome

A

includes compression under FDS, between heads of pronator teres, under lacertus fibrosis, and under ligament of Struthers

*atypical and underdiagnosed b/c it appears similar to CTS

60
Q

Signs and Sx. of Pronator Syndrome

A

volar arm pain, sx. increase w/ pronation/supination activities, parasthesia digits 1-3, absence of nocturnal exacerbation

61
Q

Rx for Neural Compression

A
  • remove the stressors
  • neural immobilization
  • iontophoresis w/ dexamethasone
  • corticosteroid injections
  • surgical decompression
62
Q

Tunnels of the Wrist and their Contents

A

1) abductor pollicis longus and extensor pollicis brevis
2) extensor carpi radialis longus and brevis
3) extensor pollicis longus
4) extensor digitorum and extensor indicis
5) extensor digiti minimi
6) extensor carpi ulnaris

63
Q

Colles Fx

A

dorsal displacement of the distal radius, usually the result of a FOOSH injury; associated w/ a “dinner-fork deformity” if malunion occurs

Rx: closed reduction with external fixation for 6-8 wks for unstable fx; closed reduction with cast for less complicated fx

64
Q

Complications of Colles Fx

A
  • malunion
  • loss of reduction
  • CRPS
  • CTS
  • Rupture of EPL (d/t proximity to Lister’s tubercle)
65
Q

Smith’s Fx

A

ventral displacement of the distal radius, usually the result of falling on a flexed wrist; associated w/ “garden spade deformity” if malunion occurs

66
Q

Barton Fx

A

intraarcitular fx of distal radius; unstable, resulting in ORIF

67
Q

Scaphoid Fx

A

most commonly fractured carpal bone, but 1/5 are missed on standard radiographs (require a special view); poor vascularity resulting in variable healing time and results (ie nonunion, avascular necrosis, and infection)

68
Q

Kienbock’s Fx

A

stress fx of the lunate, usually of insidious onset; Kienbock’s disease: avascular necrosis of the lunate requiring internal fixation, excision of the lunate, or implant arthroplasty/bone graft

*MRI, bone scan is often diagnostic

69
Q

Bennet’s Fx

A

1st MC fx w/ CMC dislocation, usually resulting from blow against a partially flexed MC; closed reduction w/ external fixation (percutaneous pinning) OR internal fixation if >3mm displaced

70
Q

Boxer’s Fx

A

5th MC fx w/ dorsal displacement of the distal segment

71
Q

How do you passively stress the extrinsic wrist extensors?

A

flex fingers, then add wrist flexion

72
Q

How do you passively stress the extrinsic wrist flexors?

A

extend fingers, then add wrist extension

73
Q

How do you passively stress the intrinsics of the hand?

A

hold fingers flexed, while extending MCPs

74
Q

Phalanx Fx

A

immobilization and internal fixation

Rx: facilitate tendon gliding, normalize ROM, normalize strength and function

75
Q

Mallet Finger

A

rupture of ext tendon as it inserts on distal phalanx or intraarticular fx of the distal phalanx; DIP flexion deformity

76
Q

Lunate Dislocation

A

usually results from high impact or FOOSH injury; requires closed reduction and immobilization, sometimes external fixation

Dorsal Intercollated Segmental Instability (DISI): lunate dislocates dorsally (scaphoid goes ventrally)

Ventral Intercollated Segmental Instability (VISI): lunate dislocated ventrally, may compromise the carpal tunnel

77
Q

Murphy’s Sign

A

make a fist, 3rd MC head should extend further distally, if not, then suspect lunate dislocation

78
Q

Wallerian Degeneration

A

disintegration of axon and myelin sheaths distal to injury, regeneration begins after 3-4 weeks, 1-3 mm/day (1-4 in/month)

79
Q

Radial Nerve Lesion

A

associated with humeral and radial fx, elbow dislocation, radial tunnel syndrome

loss if distal to elbow: MCP joint ext (ED), thumb abd and ext (APL, EPL, EPB), wrist extension (ECU, ECRL, ECRB), decreased supination

80
Q

Pt’s w/ loss of radial n. will exhibit

A

forearm pronated, wrist flexed, fingers unable to extend, and thumb adducted

81
Q

Median Nerve Lesion

A

associated with humeral and radial fx, elbow dislocation, lunate dislocation into CT, CTS, and pronator teres syndrome

loss if distal to elbow: thumb opposition (may also have loss of web space), fine prehension (index, middle), lumbricals 1 and 2

82
Q

Pt’s w/ loss of median n. will exhibit

A

flattening of thenar eminence, thumb is next to hand (loss of opposition), clawing of index and middle finger

83
Q

Ulnar Nerve Lesion

A

associated with humeral and ulnar fx, wrist laceration, cubital tunnel syndrome, compression in Guyon’s canal

loss if distal to elbow: grip strength (interossei), pinch and fine prehension (interossei, lumbricals), lateral pinch (AddPL), finger abd and add (interossei), MCP flexion of the ring and small finger (lumbricals 3 and 4)

84
Q

Froment’s Sign

A

positive test = compensation for loss of adductor pollicis with activation of the flexor pollicis longus resulting in flexion of the IP to hold the paper, implies ulnar n. dysfunction

85
Q

In order to identify nature, level, and extend of lesion it is essential to utilize _______

A

NCV/EMG studies

86
Q

Dexterity

A

the fine, voluntary movements used to manipulate small objects during a specific task

Jebsen-Taylor Test Hand Function, Purdue Pegboard, Minnesota Rate of Minipulation

87
Q

Symptom Severity Index

A

self-report instrument for carpal tunnel syndrome; 0 (no disability) to 55 (most severe)

88
Q

Rx for Nerve Lesions

A

acute period: normalize ROM, continue some protection, splints to prevent deformity, and education about rx progression

subacute period: strengthening exercises, functional and coordination activities, desensitization/resensitization, mild nerve gliding phases, and gentle mobilization

89
Q

DeQuervain’s Disease

A

tenosynovitis of extensor pollicis brevis and abductor pollicis longus (contents of Tunnel 1); Finkelstein’s test

90
Q

Tendon Injury: Surgical Repair

A

primarily: performed in first 24 hours
delayed: 1 day - 3 wks
secondary: > 3 wks

91
Q

Tenolysis

A

surgical removal of adhesions

92
Q

Tendon Graft

A

surgical replacement of tendon or compensatory replacement, usually taking palmaris longus or palmaris brevis

93
Q

Boutionniere’s Deformity

A

rupture of central extensor tendon at proximal phalanx; results in ext of DIP, flex of PIP

94
Q

Swan Neck Deformity

A

lateral bands of extensor tendon become lax and slip ventrally results in PIP hyperextension and DIP flex when ext tendon contracts

95
Q

Dupuytren’s Contracture

A

fibrous contracture of palmar fascia; unknown etiology and usually painless

96
Q

Rx of Rheumatoid Arthritis of the Wrist and Hand

A

splinting, pain management, AROM, adaptive devices, and education

97
Q

Signs and Sx. of Radial Head Dislocation

A
  • elbow flexed and protected, pronated
  • local pain and tenderness
  • possible deformity: prominent radial head
98
Q

Rx for Radial Head Dislocation

A
  • closed reduction
  • no immobilization after first occurrence
  • splinted in 90 flex & sup for 10 days if reduction delayed
  • casted for three weeks if recurrent injury
99
Q

Which muscles are affected w/ cubital tunnel syndrome?

A
  • flexor carpi ulnaris
  • flexor digitorum profundus (4th and 5th)
  • adductor pollicis
  • flexor pollicis brevis
  • 1st dorsal and palmar interossei
  • lumbricals (3rd and 4th)
  • hypothenar compartment
100
Q

Which muscles are affected w/ radial tunnel syndrome?

A
  • brachioradialis
  • extensor carpi radialis longus
  • extensor carpi radialis brevis
  • supinator
  • extensor carpi ulnaris
  • extensor digitorum
  • extensor digiti minimi
  • abductor pollicis longus
  • extensor pollicis brevis
  • extensor pollicis brevis
  • extensor indicis
101
Q

Which muscles are affected w/ pronator syndrome?

A
  • pronator teres
  • flexor carpi radialis
  • palmaris longus
  • flexor digitorum superficialis
  • flexor digitorum profundus (1st and 2nd)
  • flexor pollicis longus
  • pronator quadratus
  • lumbricals (1st and 2nd)
  • thenar compartment
102
Q

Anterior Interrosseus Nerve Syndrome

A

median n. branch compression by pronator teres, FDS, or a blood vessel; accounts for less than 1% of UE neuropathies

Signs and Sx include volar forearm pain, increased sx with repetitive forearm motion, difficulty writing, picking up objects, decreased strength in FPL, FDP 1 & 2, PQ, but NOT associated w/ parasthesia

103
Q

What are the ideal biomechanics of the scapulae?

A

50 degrees of upward rotation, 30 degrees of posterior tilt, and 25 degrees of external rotation

104
Q

Bankart Lesion

A

anterior-inferior lesion of the labrum

105
Q

Posterior Impingement Symptoms

A
  • pain superior, either posterior or anterior
  • hx. of overhead activities/athlete
  • pain relieved with posterior pressure (relocation test)
  • pain relieved with scapular assistance
106
Q

Rotator Cuff Classification

A
  • Partial (acromial surface vs. articular surface)
  • Complete (full-thickness
  • Size (small: <1cm; moderate: 1-3cm; large: 3-5cm; massive: >5cm)
107
Q

Post-op After Rotator Cuff Tear

A
  • PROM for GH jt for 4 wks
  • EHW & cervical ROM
  • Position in 30 degrees flex and abd
  • AAROM starts in 3-6 wks
  • scapular stabilization
108
Q

Important Considerations for Extensor Tendon Repairs

A

they are more superficial, thus they are more vulnerable to injury; they are easily overpowered by the flexors; they must be immobilized for a longer period of time

109
Q

What is the clinical prediction rule for carpal tunnel syndrome (CTS)?

A
  • shaking hands to relieve sx.
  • wrist ratio index >.67
  • carpal tunnel syndrome severity score >1.9
  • decreased sensation of thumb
  • age >45

*If 5/5 are present, then LR of CTS = 18.3

Pathomechanics (4 decks)

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