Exam 2: Shoulder, Elbow, and Wrist & Hand Flashcards
What muscles elevate the scapula?
- upper trap [CN XI, C3-4]
- levator scapulae [dorsal scapular n. [C5, C3-C4]
- rhomboids [dorsal scapular n. [C4-C5]
What muscles depress the scapula?
- 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)]
What muscles upwardly rotate the scapula?
- lower trap [CN XI, C3-4]
- upper trap [CN XI, C3-4]
- serratus anterior [long thoracic n. (C5-C7)]
What muscles downwardly rotate the scapula?
- levator scapulae [C5), C3-C4]
- rhomboids [dorsal scapular n. [C4-C5)]
- pectoralis minor
- pectoralis major
What muscles protract the scapula?
- serratus anterior [long thoracic n. (C5-C7)]
- pectoralis minor
- pectoralis major
What muscles retract the scapula?
- middle trap [CN XI, C3-4]
- rhomboids [dorsal scapular n. [C4-C5)]
Scapular Pattern Classification System
- Normal
- Inferior angle pattern (Type I)
- Medial border pattern (Type II)
- Superior border elevation (Type III)
It is important to address the _____ ____ and the ________ ________ in pt’s with scapular dyskinesia
lower trap, serratus anterior
“Step sign”
indicates a AC joint separation
Static Stabilizers of the GH Joint
- bony architecture
- intra-articular pressure
- joint cohesion
- ligaments and capsule
- labrum
Dynamic Stabilizers of the GH Joint
- force couples
- joint compression d/t muscle activity
- dynamic stabilizers
- neuromuscular control
Superior Glenohumeral Ligament
provides anterior stability below 45 degrees
Middle Glenohumeral Ligament
provides anterior stability at 90 degrees, secondary to rotator cuff
Inferior Glenohumeral Ligament
provides anterior stability at and above 90 degrees
What are the ideal mechanics of shoulder elevation?
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
Age-Related Shoulder Changes
40-50: more rotator cuff injuries
20-40: more calcific deposits in tendon
45-60: more adhesive capsulitis
Supraspinatus Resistance Test
.
Infraspinatus Resistance Test
.
Subscapularis Resistance Test
Gerber’s lift off position
Bicep’s Resistance Test
Speed’s test
Primary Impingement
- 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
Coracoacromial Arch Abnormalities
- os acromiale
- AC joint degeneration with inferior spur
- congenital abnormalities of coracoid process
Secondary Impingement
relative decrease of the subacromial space
- instability of the glenohumeral joint
- dysfunction of the scapulothoracic joint
- postural malalignment
- weakness of scapular girdle
Neer’s Classification of Pathology
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
SLAP - Type I
superior labrum demonstrates fraying and degeneration; the labrum is intact with glenoid and biceps is intact with glenoid and labrum; surgical debridement
SLAP - Type II
superior labrum detached from glenoid and biceps is detached from superior glenoid, allowing superior labrum and biceps to arch away from glenoid; surgical repair
SLAP - Type III
superior labrum demonstrates a bucket handle tear, remaining labrum is intact with glenoid and remaining biceps is intact; surgical debridement
SLAP - Type IV
superior labrum demonstrates a bucket handle tear and tear expands into biceps, torn biceps and labrum are displaced into the joint; surgical repair
On average, the elbow has __ degrees of pronation and __ degrees of supination
80 degrees of pronation and 85 degrees of supination; total excursion is 165-170 degrees
On average, the ulnohumeral joint has ___ degrees of flexion
145 degrees
Ligaments of the UCL complex
anterior band, posterior band, and oblique band
Ligaments of the LCL complex of
radial collateral ligament, annular ligament, lateral ulnar collateral ligament, and accessory collateral ligament
Lateral Epicondylitis
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
Pathophysiology of Lateral Epicondylitis
degenerative/failed healing tendon response resulting in increased presence of fibroblasts, vascular hyperplasia, and disorganized collagen
Lateral Epicondylitis Exhibits _____ on US Imaging
intratendinous calcification, tendon thickening, bone irregularity, focal hypoechogenicity, and diffuse heterogeneity
Lateral Epicondylitis Signs and Symptoms
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
Treatment of Lateral Epicondylitis
reduce stressful mechanics, ice, exercise, iontophoresis w/ dexamethasone, ultrasound, achieve extensible repair, counterforce brace
Medial Epicondylitis
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
Triceps Tendinitis
unusual in isolation and often accompanies other pathologies; S&S include local pain and tenderness, pain w/ resisted ext
Triceps Tendon Rupture/Avulsion Fx.
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
Distal Biceps Tendon Rupture
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
Distal Biceps Tendon Rupture Rx
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.
Olecranon Fx.
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
Medial Epicondyle Fx.
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
Supracondylar Fx.
results from falls and typically requires ORIF;
T or Y-Condylar Fx.
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
Monteggia Fx.
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.
Tommy John Procedure
medial collateral ligament complex reconstruction using palmaris longus tendon (or similar);
Post-Op Rx After Tommy John Procedure
- 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
Elbow Dislocation
usually from FOOSH and involves extension w/ varus force; progression w/ circle of failure: LUCL, anterior capsule, MUCL
Elbow Dislocation Rx.
- 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
Radial Head Dislocation
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
Cubital Tunnel Syndrome
compression of the ulnar n. at the elbow; direct compression w/ repetitive flexion-extension activity
What is innervated by the ulnar n.?
.
Signs and Sx. of Cubital Tunnel Syndrome
pain/paresthesia ulnar aspect hand & digits 4-5, decreased sensation of same, decreased grip and finger abd/add
Radial Tunnel Syndrome
compression of PIN (branch of radial n.) under supinator and/or ECRB
What is the course of the ulnar n.?
.
Signs and Sx. of Radial Tunnel Syndrome
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
Pronator Syndrome
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
Signs and Sx. of Pronator Syndrome
volar arm pain, sx. increase w/ pronation/supination activities, parasthesia digits 1-3, absence of nocturnal exacerbation
Rx for Neural Compression
- remove the stressors
- neural immobilization
- iontophoresis w/ dexamethasone
- corticosteroid injections
- surgical decompression
Tunnels of the Wrist and their Contents
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
Colles Fx
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
Complications of Colles Fx
- malunion
- loss of reduction
- CRPS
- CTS
- Rupture of EPL (d/t proximity to Lister’s tubercle)
Smith’s Fx
ventral displacement of the distal radius, usually the result of falling on a flexed wrist; associated w/ “garden spade deformity” if malunion occurs
Barton Fx
intraarcitular fx of distal radius; unstable, resulting in ORIF
Scaphoid Fx
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)
Kienbock’s Fx
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
Bennet’s Fx
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
Boxer’s Fx
5th MC fx w/ dorsal displacement of the distal segment
How do you passively stress the extrinsic wrist extensors?
flex fingers, then add wrist flexion
How do you passively stress the extrinsic wrist flexors?
extend fingers, then add wrist extension
How do you passively stress the intrinsics of the hand?
hold fingers flexed, while extending MCPs
Phalanx Fx
immobilization and internal fixation
Rx: facilitate tendon gliding, normalize ROM, normalize strength and function
Mallet Finger
rupture of ext tendon as it inserts on distal phalanx or intraarticular fx of the distal phalanx; DIP flexion deformity
Lunate Dislocation
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
Murphy’s Sign
make a fist, 3rd MC head should extend further distally, if not, then suspect lunate dislocation
Wallerian Degeneration
disintegration of axon and myelin sheaths distal to injury, regeneration begins after 3-4 weeks, 1-3 mm/day (1-4 in/month)
Radial Nerve Lesion
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
Pt’s w/ loss of radial n. will exhibit
forearm pronated, wrist flexed, fingers unable to extend, and thumb adducted
Median Nerve Lesion
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
Pt’s w/ loss of median n. will exhibit
flattening of thenar eminence, thumb is next to hand (loss of opposition), clawing of index and middle finger
Ulnar Nerve Lesion
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)
Froment’s Sign
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
In order to identify nature, level, and extend of lesion it is essential to utilize _______
NCV/EMG studies
Dexterity
the fine, voluntary movements used to manipulate small objects during a specific task
Jebsen-Taylor Test Hand Function, Purdue Pegboard, Minnesota Rate of Minipulation
Symptom Severity Index
self-report instrument for carpal tunnel syndrome; 0 (no disability) to 55 (most severe)
Rx for Nerve Lesions
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
DeQuervain’s Disease
tenosynovitis of extensor pollicis brevis and abductor pollicis longus (contents of Tunnel 1); Finkelstein’s test
Tendon Injury: Surgical Repair
primarily: performed in first 24 hours
delayed: 1 day - 3 wks
secondary: > 3 wks
Tenolysis
surgical removal of adhesions
Tendon Graft
surgical replacement of tendon or compensatory replacement, usually taking palmaris longus or palmaris brevis
Boutionniere’s Deformity
rupture of central extensor tendon at proximal phalanx; results in ext of DIP, flex of PIP
Swan Neck Deformity
lateral bands of extensor tendon become lax and slip ventrally results in PIP hyperextension and DIP flex when ext tendon contracts
Dupuytren’s Contracture
fibrous contracture of palmar fascia; unknown etiology and usually painless
Rx of Rheumatoid Arthritis of the Wrist and Hand
splinting, pain management, AROM, adaptive devices, and education
Signs and Sx. of Radial Head Dislocation
- elbow flexed and protected, pronated
- local pain and tenderness
- possible deformity: prominent radial head
Rx for Radial Head Dislocation
- 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
Which muscles are affected w/ cubital tunnel syndrome?
- 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
Which muscles are affected w/ radial tunnel syndrome?
- 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
Which muscles are affected w/ pronator syndrome?
- 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
Anterior Interrosseus Nerve Syndrome
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
What are the ideal biomechanics of the scapulae?
50 degrees of upward rotation, 30 degrees of posterior tilt, and 25 degrees of external rotation
Bankart Lesion
anterior-inferior lesion of the labrum
Posterior Impingement Symptoms
- pain superior, either posterior or anterior
- hx. of overhead activities/athlete
- pain relieved with posterior pressure (relocation test)
- pain relieved with scapular assistance
Rotator Cuff Classification
- Partial (acromial surface vs. articular surface)
- Complete (full-thickness
- Size (small: <1cm; moderate: 1-3cm; large: 3-5cm; massive: >5cm)
Post-op After Rotator Cuff Tear
- 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
Important Considerations for Extensor Tendon Repairs
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
What is the clinical prediction rule for carpal tunnel syndrome (CTS)?
- 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
