Final Exam: Wrist & Hand, UE, and LE Flashcards
How many bones are in the wrist and hand?
28 bones
What bones are in the proximal carpal row?
-Scaphoid
-Lunate
-Triquetrum
-Pisiform
What bones are in the distal carpal row?
-Trapezoid
-Capitate
-Hamate
What structure is between the ulna and the proximal carpal row? What structure is it similar to?
-Triangular fibrous cartilage complex
-Structurally and functionally similar to a meniscus
What two tendons is the anatomical snuff box between? What artery runs through the snuff box?
-Between extensor pollicis brevis and longus
-Radial artery
What are wrist flexion ROM norms?
80-90
What are wrist extension ROM norms?
70-90
What are radial deviation ROM norms?
15
What are ulnar deviation ROM norms?
30-45
What are the major ligaments at the wrist?
-Radio-ulnar ligaments strengthen capsule anteriorly and posteriorly
-Carpal ligaments
-Ulnar collateral
-Radial collateral
What movement at the wrist tightens the anterior capsule?
Supination
What movement at the wrist tightens the posterior capsule?
Pronation
What is the functional splint position of the hand?
-Wrist in 20-30 degrees of extension and slight ulnar deviation
-Fingers in 45 degrees of MCP flexion, 15 degrees of PIP and DIP flexion
-Thumb in 45 degrees of abduction
What is the open pack position of the distal radio-ulnar joint?
5-10 degrees of supination
What is the open and closed pack position between the radius and ulna and the proximal carpal row?
-Open: neutral and slight ulnar deviation
-Closed: full extension with radial deviation
What are questions to ask a patient with a wrist or hand injury?
-When and how trauma occurred
-Position of wrist and hand at time of trauma
-“popping” or “clicking”
-Past behavior of wrist, hand, or finger deformities
In the presence of trauma, what is the most common cause of radial side wrist/hand pain?
Scaphoid fracture
In the absence of trauma, what is the most common cause of radial side wrist/hand pain?
DeQuervain’s tenosynovitis
What is the most common cause of wrist/hand pain on the posterior side?
-Radial carpal athritis
-Ganglion cyst
What is the most common cause of wrist/hand pain on the ulnar side?
Tear of the triangular fibrocartilage complex (TFCC)
What is the most common cause of wrist/hand pain on the anterior side?
-Carpal tunnel
-Ganglion cyst
-Formation of tenosynovitis
What are common orthopedic conditions of the wrist?
-Carpal tunnel syndrome
-De Quervain tenosynovitis
-Fracture of the distal radius
-Fracture of the scaphoid
-Gamekeeper’s thumb
-OA of the thumb CMC joint
-Flexor digitorum profundus avulsion
-Trigger finger
-Mallet finger
-Boutonniere deformity
-Swan neck
What is carpal tunnel syndrome?
-Compression of the median nerve that occurs under the transverse carpal ligament at the wrist
-Can also be associated with pregnancy, diabetes, trauma,
or tumors in the carpal tunnel
What are the subjective findings of carpal tunnel syndrome?
-Complaints of numbness in the median nerve distribution, primarily the tips of the first 3 fingers
-Complaints of pain in the forearm and wrist
-Symptoms may awaken the patient from sleep
-Activities involving wrist flexion are uncomfortable
What are the objective findings of carpal tunnel syndrome?
-Thenar atrophy may be present
-+ Phalen
-+ Tinel
-+ Carpal tunnel compression test
What imaging might be done if carpal tunnel syndrome is suspected?
-Radiograph to rule out bony causes
-EMG or nerve conduction studies to rule out other conditions
What are possible interventions for carpal tunnel syndrome?
Splinting, especially at night
What is De Quervain tenosynovitis? What is it caused by?
-Inflammation of the extensor and abductor tendons of the thumb
-Caused by repetitive or unaccustomed use of the thumb
What are the subjective findings of De Quervain tenosynovitis?
-Wrist pain on the radial side
-Difficulty with grasping and gripping
What are the objective findings of De Quervain tenosynovitis?
-Possible swelling at the radial styloid process
-Palpation elicits pain at the side of the retinaculum at the radial styloid
-+ Finkelstein’s
-+ WHAT test
-+ Eichoff
What are possible interventions for De Quervain?
-Reduce inflammation, prevent adhesions from forming, and prevent recurring tendonitis
-Splint the thumb (spica splint)
-Steroid injections made directly into the fibrous sheath of the first dorsal compartment
-Electrotherapeutic and thermal modalities to help decrease inflammation
-Gentle AROM for short periods
-Grasping and releasing of small objects emphasizing a wide variety of prehensile patterns
What is the prognosis for De Quervains?
-Patients who receive treatment within 6 months of developing the condition have an excellent prognosis
-90% of non-severe cases may expect relief with conservative care
What are the different types of distal radius fractures?
-Colles
-Smith
-Barton
-Chauffeurs
-Die-punch
What is a Colles fx?
-Most common type of distal radius fracture
-Distal radius fracture fragment is tilted upward or dorsally
What is a Smith fx?
-Opposite of Colles
-Distal fragment is tilted downwardly or volarly/palmarly
What is a Barton fx?
-Intra-articular fracture associated with subluxation of the carpus, along with displaced fragments of the radius
What is a Chauffeurs fracture?
Oblique fracture through the base of the radial styloid
What is a Die-punch fx?
Depressed fracture of the articular surface opposite the lunate or scaphoid bone
What are subjective findings of fracture of the distal radius?
-Acute pain, tenderness, swelling, and deformity of the wrist
-Hx of falling onto an outstretched hand or arm
What are the objective findings of fracture of the distal radius?
-Swelling, deformity, and discoloration around the distal radius
-May have associated skin injury and bleeding
-May have decreased sensation in the median, radial, or ulnar nerve distribution
-May have decreased circulation to the hand
What are possible interventions for fx of the distal radius?
-Conservative care can begin while the fx is immobilized and involves AROM of the shoulder, elbow, and fingers
-Finger exercises must include isolated MCP flexion, complete flexion and intrinsic fisting
-After immobilization, extension and supination commonly limited and need to be mobilized
-Wrist ext. exercises are performed with the fingers flexed
-PROM performed according to MD protocol
What is the prognosis of a distal radius fx?
-Typically an uncomplicated course
-Occasional malunion or post-traumatic wrist arthritis can occur
What patient population is a fx of the scaphoid most common in?
-Most common in young male adults
-Diagnosis often delayed or missed
What is the most commonly fractured carpal bone? Why?
-Scaphoid is the most commonly fractured carpal bone
-Because it spans the distal and proximal rows of the carpals and consequently is more vulnerable to FOOSH injuries
What are the subjective findings of a scaphoid fx?
-Hx of a FOOSH
-Complaints of dorsal wrist pain, especially with any type of wrist motion or activity such as gripping
-Tenderness over the anatomical snuffbox
What are the objective findings of scaphoid fx?
-Palpation over the anatomic snuff box markedly tender
-Decreased AROM of the wrist
-Decreased grip strength
-Normal neuro exam
What is a clinical pearl for the scaphoid?
When wrist pain is severe, snuff box or dorsal wrist tendonitis is dramatic, and the ROM of the wrist has been decreased by 50%, you should suspect a scaphoid fx, lunate dislocation, or carpal avascular necrosis
What are confirmatory tests for scaphoid fx?
-Axial compression of the thumb along its longitudinal axis, which translates force directly along the scaphoid and elicits pain if there is a fx
-Often not visible on PA and lateral radiographs, but can get a scaphoid view (clenched fist with wrist in ulnar deviation)
What are possible interventions for scaphoid fx?
-No agreement on optimal position for immbolization
-Current management is immobolization in a long-arm or short-arm thumb spica cast
-Following immobilization, capsular pattern of the wrist will dominate
-AROM, PROM, and gentle stretching
What is Gamekeeper’s thumb?
-Injury to the ulnar collateral ligament of the thumb
-Whether by injury or repetitive use, disrupted ligament can lead to instability of the MCP joint and decreased functioning in both pinching and opposition involving the thumb
What are the subjective findings of Gamekeeper’s thumb?
-Pain and swelling along the ulnar side of the thumb MCP joint
-Complaints of pain, weakness, or loss of stability
What are the objective findings of Gamekeeper’s thumb?
-Local tenderness and swelling with palpation along the ulnar side of the MCP joint of the thumb
-Pain or excessive motion with valgus stress test of the ulnar collateral ligament
-Impaired MCP joint flexion and extension, especially when acute and swollen
-Decreased pinching strength resulting from instability or acute pain
What are confirmatory special tests for Gamekeeper’s thumb?
-Valgus stress test in full extension
-Valgus stress test at 30 degrees of MCP flexion
What are possible interventions of Gamekeeper’s thumb?
-Grade I and II tears are treated with immbolization in a thumb spica cast for 3 weeks, with 2 additional weeks of splinting
-AROM of flexion and extension begins at 3 weeks progressed to strengthening by 8 weeks
-NO abduction stress to the MCP joint for 6 weeks
-Grade III tears are treated with surgery
What patient population is OA of the thumb most common in?
-More common in women than in men, and usually occurs after 40 years of age
-Prior fractures or other injuries to the joint may increase the likelihood of developing this condition
What are subjective findings of thumb OA?
-Pain with activities that involve gripping or piching, such as turning a key, opening a door, or snapping your fingers
-Loss of strength in gripping and pinching activities
-An aching discomfort after prolonged use
What are objective findings of thumb OA?
-Swelling and tenderness at the base of the thumb
-An enlarged, “out of joint” appearance
-Development of a bony prominence or bump over the joint
-Limited motion in all planes
What are the surgical options for thumb OA after conservative management has failed?
-Ligament reconstruction
-Ligament reconstruction and tendon interposition
-Total joint arthroplasty
-Arthrodesis (fusion)
What is the ligament reconstruction surgery for thumb OA? What are pros and cons?
-Stabilizes the CMC joint by removing the damaged ligament and replacing it with a piece of the patients wrist flexor tendon
-Pros: most people with very early OA experience good to excellent pain relief
-Cons: does not repair damaged cartilage or bone
What is the ligament reconstruction surgery and tendon interposition (LRTI) for thumb OA? What are pros and cons?
-LTRI is the most commonly performed surgery for thumb OA
-Arthritic joint surfaces are removed and replaced with a cushion of tendon that keeps the bones separated
-Surgeons remove all or part of the trapezium bones
-Helps adults with moderate to severe arthritis with pain and difficulty pinching or gripping
-Pros: removing trapezium eliminates possibility of arthritis returning
-Cons: lengthy and painful recovery
What is the total joint arthroplasty surgery for thumb OA? What are pros and cons?
-Total joint replacement
-Replaces joint with an artificial implant
-Pros: thumb arthroplasty is less invasive because there is no grafting
-Cons: spacers have high complication rates for some patients
What is the arthrodesis surgery for thumb OA? What are pros and cons?
-Eliminates pain by fusing the bones in the joint together
-Surgeons create a socket by hollowing out the thumbs metacarpal bone and then shaping the trapezium into a cone that fits into the socket
-A metal pin holds bones together to maintain proper alignment
-Pros: a stable, pain-free thumb that can grasp and pinch
-Cons: high complication rate, can damage nearby joints, and causes loss of ROM in CMC
What is flexor digitorum profundus avulsion? What is the mechanism of injury?
-Avulsion of the FDP can occur in any digit, but most commonly the ring finger
-Usually occurs when a hyperextension stress is applied to a flexed finger such as when an athlete grabs an opponents jersey
-Often misdiagnosed as a sprained or “jammed” finger
-FDP is anatomically weaker in the middle finger
What are the subjective findings of flexor digitorum profundus avulsion?
Hx of trauma involving the digit
What are the objective findings of flexor digitorum profundus avulsion?
-Specific testing of the isolated DIP joint flexion in all digits reveals the involved digit
-Inability to flex DIP, while PIP is held in extension
-Tenderness along the flexor
What are possible interventions for flexor digitorum profundus avulsion?
Primarily surgical
What is the prognosis for flexor digitorum profundus avulsion?
Depends on acuteness of the diagnosis, rapidity of surgical intervention, and level of tendon retraction
What is trigger finger? What fingers are most effected? What is the cause?
-Inflammation of the 2 flexor tendons of the finger, which become thickened and narrowed as they cross the MCP head in the palm, causing a painful snapping
-Thumb, long, and ring fingers most commonly affected
-Cause is idiopathic
What are the subjective findings of trigger finger?
-Complaints of a painful finger or loss of smooth motion (catching) of the finger when gripping or pinching
-May be complaints of painful nodule in the distal palm usually at the level of the distal flexion crease
What are the objective findings of trigger finger?
-Local tenderness with palpation at the base of the finger, directly over the tendon as it courses over the metacarpal head
-May palpate crepitus or a moving nodular mass
-Pain typically aggravated by stretching the tendon into extension or by resisting the action flexion isometrically
-Clicking or locking with active flexion may or may not be present
-Full flexion of the finger may not be possible
What are possible interventions for trigger finger?
-Goals are to reduce swelling and inflammation in the flexor tendon sheath and to promote smooth movement of the tendon
-Corticosteroid injections into the flexor sheath now considered the treatment of choice
What is the prognosis of trigger finger?
-Spontaneous long-term resolution of trigger finger is rare
-Patient with recurring tenosynovitis or mechanical locking need to evaluate their work and recreational habits
-Surgical release of the trigger finger is reserved for recalcitrant cases (uncooperative)
What is Mallet finger?
-Deformity of a finger causes when the extensor tendon is damaged (DIP)
-Finger/DIP unable to extend
-Also called “baseball” finger
What is the mechanism of injury of Mallet finger?
-When a ball or object strikes the tip of the finger or thumb
-The force damages the thin tendon that straightens the finger
What is the treatment for Mallet finger?
-Surgery with Mallet splint for 6-8 weeks
-OR extension block k-wire for 4 weeks
What is the Mallet splint?
-Splint that allows the tendon to return to normal length
-If the finger is bent during these weeks, the healing process must start all over again
When is surgery performed for Mallet finger?
Surgery is performed within a week to reattach the tendon
What is the prognosis of Mallet finger?
Will recover completely with surgery
What is Boutonniere deformity?
-Injury to the tendons that straightens the PIP joint of the finger
-PIP of the injured finger will not straighten, while the DIP bends back
What happens if Boutonniere deformity is not treated promptly?
The deformity may progress, resulting in permanent deformity and impaired functioning
What is the mechanism of injury of Boutonniere deformity?
-Generally caused by a forceful blow to the top side of a flexed PIP joint of a finger
-Also can be caused by a cut on the top of the finger which can sever the central slip (tendon) from its attachment to the bone
-Could also be caused by arthritis
What are the symptoms of Boutonniere deformity?
-The finger at the PIP cannot be straightened and the fingertip cannot be bent
-Swelling and pain occur and continue on the top of the middle joint of the finger
What is non-surgical treatment of Boutonniere deformity?
-Splint
-Applied to the finger at the PIP joint to straighten it
-Keeps the ends of the tendon from separating as it heals
-Also allows the end joint of the finger to bend
-Splint is worn for 6 weeks, and after 6 weeks may still have to wear it at night
What is a Swan neck deformity? What is the cause?
-PIP of a finger is extended more than normal while the DIP is flexed
-Caused by a weakness or tearing of the ligament and tendon
What are the treatment options for Swan neck deformity?
-Treatment varies!
-Splint/brace
-Surgery
-Replace the joint
What are the 4 joints at the shoulder?
-Sternoclavicular
-Acromioclavicular
-Glenohumeral
-Scapulothoracic
How much of the humeral head is in contact with the glenoid?
-25% humeral head in contact with glenoid
-75% in contact with labrum
What is the most commonly dislocated joint in the body? Why?
-GHJ
-It lacks bony stability
What is the GHJ composed of?
-Fibrous capsule
-Ligaments
-Surrounding muscles
-Glenoid labrum
What muscles form part of the capsule?
-The rotator cuff
-Supraspinatus
-Infraspinatus
-Subscapularis
-Teres minor
What is joint approximation and what is it typically used for?
-Compression of a joint surface
-Used to promote reflexive stability, often used with weight bearing activities
-Thought to stimulate type 1 receptors and facilitate postural stabilizers
What is joint centration achieved by?
Achieved by the combined neuro-motor tasks of:
-Stabilization
-Dissociation
What is the self perpetuating pattern of movement dysfunction?
Any stressor to the nervous system, including acute and repetitive trauma, emotional stress, can up-regulate the sympathetic nervous system and pain which alter movement strategies that further increase dysfunction
What are local vs global muscles?
-Local: involved in joint stabilization; oxidative
-Global: movers; aerobic
Which of the rotator cuff muscles is the only one that pulls the humeral head posteriorly? Why?
Subscapularis, because internal rotation causes a posterior glide of the humerus
What is closed pack position of the GHJ?
90 degrees of abduction and full ER
What is open pack position of the GHJ?
55 degrees abduction, 30 degrees horizontal adduction
What is the capsular pattern of the GHJ?
-ER
-Abduction
-IR
What are special questions for the shoulder that a PT should ask the patient?
-Feeling of instability
-Popping, catching, painful popping
-Tingling
-Night time awakening
-Trouble lifting, reaching, etc.
What does night time awakening suggest for the shoulder?
Internal derangement
What are common causes of shoulder injuries?
-Traumatic
-Sports
-Overuse
-Insidious onset
What are the 3 types of Kibler classification for scapular dyskinesis?
-Type 1: inferior medial border
-Type 2: Medial border off ribs
-Type 3: elevated superior border
What is Kibler Type 1 scapular dyskinesis? What muscles are tight? Which are weak?
-Inferior medial border more prominent
-Anterior tilt of scapula
-Coracoid process often TTP
-Tight: pec minor, biceps SH
-Weak: lower trap, lats, serratus anterior
What is Kibler Type 2 scapular dyskinesis? What muscles are tight? Which are weak?
-Entire medial border off ribs
-Points glenoid fossa anteriorly
-Weak serratus anterior and lower traps
What is Kibler Type 3 scapular dyskinesis? What muscles are tight? Which are weak?
-Superior border of the scapula is elevated
-Usually with adhesive capsulitis
-Tight: upper trap
-Weak: lower trap
What level of the spine is the acromion at?
C7
What level of the spine is the medial portion of the spine of the scapula at?
T3
What level of the spine is the inferior border of the scapula at?
T7
What are common causes of shoulder pain that do not originate from the shoulder joint?
-C-spine nerve impingement
-Peripheral nerve entrapment
-Diaphragm irritation
-Intrathoracic tumors
-Gallbladder problems
-Myocardial ischemia
-Pancoast tumor
What are common shoulder orthopedic conditions?
-Acromioclavicular joint separation
-Adhesive capsulitis
-Biceps tendonitis
-Glenohumeral joint instability
-Glenohumeral joint OA
-Impingement syndrome
-Rotator cuff tear
-SLAP lesion
-Thoracic outlet syndrome
What is the mechanism of injury of acromioclavicular joint separation? What patient population is it more likely in?
-Commonly occurs in men and younger people
-Usually caused by a traumatic event such as FOOSH or direct blow to the anterior shoulder that results in AC joint ligament tears
-4-5x more prevalent than SC injuries
What are the 6 types of AC joint separation?
-Type I: AC joint ligaments are partially or completely disrupted
-Type II: AC joint ligaments are torn and coracoclavicular ligaments are partially disrupted
-Type III: coracoclavicular ligaments are completely disrupted
-Types IV-VI: uncommon; periosteum of the clavicle or deltoid/trap muscle are also torn
What are the subjective findings for AC joint separation?
-Relief reported with cradling the involved arm
-Localized pain over the AC joint
-Pain when lifting the arm
What are the objective findings for AC joint separation?
-Patient supports the arm in adducted position
-Swelling at the ACJ
-Pain is consistently aggravated by passively horizontally adducting arm
-+ cross body test
-+ AC resisted extension test
What are the interventions for ACJ injury?
-Acute: protection and rest
-Sub-acute: strengthening of surrounding muscles
What is frozen shoulder? What are the two types?
-Adhesive capsulitis of the shoulder
-Characterized by progressive and painful loss of active and passive ROM that follows capsular patterns
-Primary: idiopathic
-Secondary: traumatic or related to a disease process
What are the subjective findings of frozen shoulder?
-Diffuse aching at the shoulder
-Difficulty sleeping on the involved side
-Difficulty dressing and grooming
What are the objective findings of frozen shoulder?
-Insidious onset of severe shoulder pain
-Shoulder stiffness with markedly reduced external rotation
-Negative radiographic findings
-Varies according to stage
-Inability to elevate shoulder
-ER, abduction, IR limited
-Restriction of anterior and inferior glide of the GHJ
-Negative neuro tests
-Pain at end range of shoulder motions
What are the stages of adhesive capsulitis? How long does each stage last?
-Prefreezing: 1-3 months
-Freezing: 3-9 months
-Thawing: 9-14 months
What are possible interventions for frozen shoulder?
-Patient education
-NSAIDs
-Steroid injection
-PT: ROM, joint mobilizations, pain management
What is the prognosis of frozen shoulder?
18 months to 3 years- some patients may never get back to their PLOF
What are three pathological disorders that can cause biceps tendonitis?
-Inflammatory/degenerative conditions
-Instability of the biceps tendon such as subluxation or dislocation of the tendon
-SLAP (superior labrum anterior or posterior) lesion
What is the mechanism of injury for biceps tendinopathy and SLAP lesions?
-FOOSH
-Traction mechanism: eccentric firing of the biceps muscle that causes injury to the superior labrum complex
-Peel-back: the arm is abducted and maximally externally rotated and the twisting of the biceps tendon may result in the “peel-back” of the anchor and its subsequent gradual or acute detachment from the superior glenoid
What are the subjective findings of biceps tendonitis?
-Diffuse and vague pain in the anterior shoulder or over the bicipital groove
-Painful AROM of shoulder flexion
What are the objective findings of biceps tendonitis?
-Tenderness over bicipital groove
-Possible loss of shoulder ROM
-May have painful arc
-Pain with resisted elbow flexion
-+ speeds test
-+ Yergason test
What are possible interventions for biceps tendonitis?
-Acute phase: pain and inflammation management
-Subacute phase: AROM exercises and early strengthening
-Phase 3: strengthening with emphasis on enhancing dynamic stability
-Phase 4: return to sport or high workloads
What are the different types of glenohumeral joint instability?
-Anterior inferior
-Multidirectional
-Posterior
-Inferior
What is TUBS?
-Instability caused by a Traumatic event, is Unidirectional, associated with a Bankart lesion, often requires Surgery
-TUBS= traumatic, unidirectional, bankart, surgery
What is AMBRI?
-Atraumatic, Multidirectional, may be Bilateral, best treated by Rehabilitation, Inferior capsular shift is the surgery performed if rehab fails
-AMBRI= atraumatic, multidirectional, bilateral, rehabilitation, Inferior capsular shift surgery
What is the most common type of shoulder dislocation?
Anterior
What are the subjective findings of glenohumeral joint instability?
-Complaints of looseness of the shoulder or a “noisy” shoulder
-May or may not have a history of trauma
-Patients with anterior instability typically describe the sensation of the shoulder slipping out of joint when the arm is abducted and ER
-Tend to support arm in neutral position
-Patients with multidirectional instability may have vague symptoms, but tend to be activity related
What are the objective findings of glenohumeral joint instability?
-+ Sulcus sign
-Variable degrees of crepitation or popping
-Apprehension in extreme ROM such as IR and ER
-Generalized ligamentous laxity
-+ apprehension test
-+ surprise test
-+ posterior instability tests (Jerk)
What are possible interventions for glenohumeral joint instability?
-Rotator cuff strengthening
-Shoulder stability exercises
What is OA in the shoulder typically a result of?
Usually a long term consequence of trauma such as dislocation, fx, large RC tears
What are the subjective findings of shoulder OA?
-Gradual onset, deep-seated shoulder pain and stiffness
-Worst pain is typically in the posterior aspect
-Progressive loss of ROM
-Hx of trauma to the shoulder
What are the objective findings of shoulder OA?
-Forward humeral head, protracted scapula
-GH joint line tenderness
-Swelling around the joint
-Decreased active and passive ROM
-Crepitation with circumduction may or may not be present
-Radiographs will show joint space narrowing
-May have pseudolaxity
What are possible interventions for shoulder OA?
-Improve GHJ flexibility
-RC strengthening
What is subacromial pain syndrome (SAPS)?
-Mechanical impingement of the rotator cuff between the coracoacromial arch and the humeral head
-Anything that decreases the volume of this space can cause impingement
-Hypertrophy of the AC joint secondary to OA can also cause impingement
What are the 3 different types of acromions? Which is most likely to cause SAPS?
-Type 1: flat 17% of people
-Type 2: curved 43% of people
-Type 3: hooked 40% of people
What are the contents of the coracoacromial tunnel?
-Supraspinatus tendon
-Long head of biceps tendon
-Subacromial/subdeltoid bursa
-Coracohumeral ligament
What is subacromial decompression (SAD) and distal clavicular resection (DCR) surgery?
It is where the surgeons shave down part of the clavicle that can be causing impingement as well as some of the subacromial arch
What are the subjective findings of SAPS?
-Pain felt down the lateral aspect of the upper arm near the deltoid insertion, over the anterior proximal humerus, or in the periacromial area
-Functional loss of the shoulder attributable to pain, stiffness, weakness, and catching, especially when the arm is in flexion and IR
-Difficulty sleeping on the involved side
-Pain provoked by everyday activities such as putting on a coat, pouring coffee, etc.
What is stage I SAPS?
-Tenderness at supraspinatus insertion and anterior acromion
-Painful arc
-Weakness at 90 degrees abduction and flexion
What is stage II SAPS?
Physical exam reveals crepitus or catching at 100 degrees of elevation and restriction of PROM
What is stage III SAPS?
-Atrophy of the infraspinatus and supraspinatus
-More limitation in AROM than PROM compared to the other stages
What are the possible interventions for SAPS?
-Strengthen RC
-IR and ER isometrics initially
-Address strength deficits
What is a rotator cuff tear?
-Can be acute/traumatic or chronic/degenerative
-Described by size, location, direction, and depth
-Tears are usually longitudinal
-Occur in critical zone (avascular) situated at the anterior portion of the cuff within the subacromial space between the supraspinatus tendon and coracohumeral ligament
-Uncommon before age 40 unless associated with trauma
What are the subjective findings of a rotator cuff tear?
-Significant weakness and pain with activities that involved abduction and ER
-Localized pain over the upper back, deltoid, shoulder, and arm
-A popping sensation may be present
What are the grades of rotator cuff tears?
-Small: < 1cm
-Medium: 1-3 cm
-Large: 3-5 cm
-Massive: > 5cm
What are the objective findings of rotator cuff tears?
-May reveal muscle asymmetry or atrophy
-Pain located at the greater tuberosity
-Loss of PROM and AROM
-+ special tests
-Weakness
-Massive tears present with sudden profound weakness
What are the diagnostic tools for rotator cuff tear?
-Special tests: drop arm, empty can, lift off test, ER lag sign
-Medical imaging
What are possible interventions for rotator cuff tears?
-Small or partial tears: intervention is directed toward strengthening the rotator cuff and scapular stabilizers
-Full thickness tears usually require surgery followed by PT
What is the criteria for operative interventions for rotator cuff tears?
-Patient younger than 60 years old
-Failure to improve after conservative regimen of at least 6 weeks
-Presence of a full thickness tear, either clinically or by imaging
-Patient’s need to use the involved shoulder in a vocation or an avocation
-Ability or willingness of the patients
What are the rotator cuff repair options? Which option leads to better tendon healing?
-Single row, double row, suture bridge, or transosseous repairs are all commonly performed
-Double row tends to repair more of the tissue back to the humeral insertion point which has led to better tendon healing
What are possible post-operative rotator cuff repair complications? How can these be avoided?
-Re-tear rates range anywhere between 25-70% of the time
-Those that do fail or re-tear do so within the first 3-6 months
-Avoiding early motion protects the surgical site
What percent muscle activation level must a post-operative RCR patient stay below?
Below 15% for 6 weeks post-op
What should be the protocol for the first 2 weeks following RCR?
Strict immobilization for 2 weeks, such as a sling
What is the strength of a RCR at 6 weeks post-op? What about at 12 weeks?
Only about 19-30% strength of normal and 29-50% at 12 weeks
When can AAROM be performed post RCR?
7 weeks
What is a SLAP lesion?
-Superior labral anterior posterior (SLAP) lesion
-Involve an injury to the superior glenoid labrum and the biceps
-Several injury mechanisms speculated- range from single traumatic to repeptitive microtraumatic injuries
What is the mechanism of injury of a SLAP lesion?
Typically results from FOOSH, sudden deceleration or traction forces such as catching a falling object, or chronic anterior or posterior instability
What are the subjective findings of SLAP lesions?
-History of trauma or overuse
-Complaints of pain and/or instability with overhead activities and symptoms of painful clicking, catching, or locking
What are the objective findings for a SLAP lesion?
-Symptoms very similar to those of instability and rotator cuff tears
-Positive findings of pain or clicking with maneuvers that place tensile or torsional load on the biceps, thereby stressing the loose anchor of the biceps-superior labrum complex
What are confirmatory special tests for SLAP lesions?
-O’Brien’s active compression
-Compression rotation test
-Crank test
-Biceps load II (or I)
-Kim test
-Jerk test
What are possible interventions for SLAP lesions?
-Conservative interventions should address the underlying hypermobility
-Dynamic stabilization exercises of GHJ
What is the prognosis for SLAP lesions?
-If conservative management fails, diagnostic arthroscopy is recommended
-Studies of surgical labral repairs are generally good to excellent in terms of returning patients to their prior level of activity
What is thoracic outlet syndrome (TOS)?
-Clinical syndrome characterized by symptoms attributable to compression of the neural or vascular anatomic structures (brachial plexus, subclavian artery or vein) that passes through the thoracic outlet
-Bony boundaries of the thoracic outlet include the clavicle, first rib, and scapula
What patient population is TOS more common in?
More common in women with onset of symptoms between 20-50 years old
What are the subjective findings of TOS?
-Symptoms are often vague and variable, chief complaint is diffsue arm and shoulder pain especially above 90 degrees of elevation
-Potential symptoms include pain localized in the neck, face, UE, chest, shoulder, and axilla
-Could have UE paresthesias, numbness, weakness, heaviness, fatigability, swelling
-Neural compression symptoms occur more frequently
What are the objective findings of TOS?
-Swelling or discoloration of the arm
-Auscultation may reveal the presence of bruits (abnormal sound/murmur) especially when doing provocative measures during special tests
-Difference in distal pulses compared to opposite side
-+ special tests
What trunk of the brachial plexus is most commonly effected by TOS? What specific symptoms would this cause?
-Lower trunk, which is made up of C8 and T1 nerve roots
-Supplies sensation to 4th and 5th digits, so there may be symptoms in those fingers
What are confirmatory special tests for TOS?
-Adson vascular test
-Allen pectolaris minor test
-Costoclavicular test
-Roos test
-Hyperabduction maneuver
-Passive shoulder shrug
What are possible interventions for TOS?
-Correction of postural abnormalities of the neck and shoulder girdle
-Pec minor release/stretches
-Strengthening of scapular muscles
-1st and 2nd rib mobilizations
What is the prognosis for TOS patients?
50-90% of patients with TOS respond rapidly to conservative interventions and regain normal, pain-free function of the UE
What is the criteria for surgical interventions for TOS?
-Failure to respond to conservative intervention within 4 months
-Signs of muscle atrophy
-Intermittent paresthesias being replaced by sensory loss
-Pain becoming incapacitating
What are the most common surgical interventions for TOS?
-Depression of the scalene muscles and resetting of the 1st rib
-Removal of the cervical rib (if present)
-Removal of the clavicle
-Severing of the pec minor
-Transection of the subclavius muscle above the coracoid ligament
What are the upward rotators of the scapula?
-Upper trap
-Serratus anterior
-Lower trap
What are the downward rotators of the scapula?
-Rhomboids
-Levator scapulae
-Pectoralis minor
What are the 3 articulations at the elbow?
-Humeroradial
-Humeroulnar
-Proximal radioulnar
What is the open and closed pack positions of the humeroulnar joint?
-Open: 70 degrees of flexion and 10 degrees of supination
-Closed: maximum extension and supination
What is the capsular pattern of the humeroulnar joint?
-Flexion > extension
What is the open and closed pack positions of the humeroradial joint?
-Open: extension and supination
-Closed: 90 degrees of flexion and 5 degrees of supination
What is the capsular pattern of the humeroradial joint?
There is none
What is the open and closed pack positions of the proximal radioulnar joint?
-Open: 70 degrees of flexion and 35 degrees of supination
-Closed: 5 degrees of supination
What is the carrying angle of the elbow? What is the normal carrying angle?
-The angle between the humerus and ulna
-10-15 degrees
What is the normal end feel of the humeroulnar joint?
-Flexion: soft tissue
-Extension: bony
What is the normal end feel of the radioulnar joint?
-Supination: capsular
-Pronation: bony
What are the major ligament of the elbow? What motions do they restrict?
-Ulnar collateral ligament (UCL): resists valgus stress
-Radial collateral ligament: resists varus stress
-Annular ligament: supports radial head
What are the 2 bands of the UCL? Which band is more important? When is each band taut?
-Anterior and posterior bands
-Anterior band is more important as it resists valgus stress
-Anterior band: taut from 0-70 degrees of flexion
-Posterior band: taut between 60-120 degrees of flexion
How much stability does the radial collateral ligaments provide to the lateral elbow?
-RCL provides 30-50% stability
-Boney structures provide the other 50-70% of stability
What is the “4th” joint of the elbow?
The interosseous membrane between the ulna and radius
What is the most common diagnosis for lateral elbow pain?
Lateral epicondylalgia
What is the most common diagnosis for medial elbow pain?
-Medial epicondylalgia
-UCL sprain
-Ulnar nerve compression
What is the most common diagnosis for posterior elbow pain?
-Olecranon bursitis
-Triceps tendinosis
-Valgus extension overload (VEO)
What is the most common diagnosis for cubital fossa elbow pain?
-Tear of the brachialis
-Biceps brachii tear
What are common orthopedic conditions of the elbow?
-OA
-Fracture of the radial head
-Olecranon bursitis
-Biceps tendon rupture
-Triceps tendon rupture
-Lateral epicondylalgia
-Medial epicondylaglia
-UCL tear
-“Little league elbow”
What patient population is elbow OA most common in?
Most common in men ages 40-60 with a history of strenuous work, throwing sports, or trauma
What are the subjective findings of elbow OA?
-Pain, stiffness
-Mechanical locking
-Deformity
What are the subjective findings of elbow RA?
Pain and swelling
What are the subjective findings for septic arthritis of the elbow?
-Acute and severe pain, stiffness, and warmth
-Swelling
-Effusion
-Fever, chills, malaise
What is septic arthritis?
A painful joint infection that occurs when bacteria, viruses, or fungi invade a joint’s tissues and fluid
What are the objective findings for elbow RA?
-Joint swelling
-Rheumatoid nodules over the olecranon and extensor surface of the forearm
-Tenderness
-Joint instability
What are the objective findings of elbow OA?
-Joint line tenderness
-Reduced ROM
What are the objective findings of septic arthritis of the elbow?
Severely painful and restricted ROM in the presence of significant effusion and warmth
What are possible interventions for OA of the elbow?
-Rest
-NSAIDs
-Gentle stretching
-Activity modification
What are possible interventions for RA of the elbow?
-Intra-articular corticosteroid injection
-PT
-Splints
What is the primary indication for total elbow arthroplasty?
-Patients with RA with advanced joint destruction and severe limitations
-Patients with OA with severe limitations and/or pain
What is the mechanism of injury for a fracture of the radial head?
-Usually from a FOOSH
-Force of impact transmitted up the hand through the wrist and forearm to the radial head
What are the 4 types of radial head fractures?
-Type I: non-displaced or minimally displaced fx
-Type II: displaced more than 2 mm at the articular surface
-Type III: severely comminuted (bunch of pieces) fx of the radial head and neck
-Type IV: associated with ulnohumeral dislocation
What are the subjective findings of a radial head fracture?
-Complaints of pain and swelling over the lateral aspect of the elbow
-Loss of elbow motion related to pain inhibition and joint diffusion
What are the objective findings of a fracture of the radial head?
-Palpate carefully and feel for deformity at radial head
-Assess neurovascular function for all nerves of the forearm and hand
-Tender over the lateral aspect of the elbow joint
-Passive forearm pronation/supination is typically limited and may have palpable crepitus
-AROM and PROM with flexion and extension may be limited
What are confirmatory tests for radial head fracture?
-Patient history and physical exam findings
-Radiographs
What are possible interventions for type I radial head fx?
-Sling or splint initially
-Early AROM as soon as pain allows
-Strengthening begins at 3 weeks
What is the rule of 3’s for type II radial head fx?
-Non-surgical is considered if the fx involves less than 1/3 of the articular surface
-Less than 30 degrees of angulation
-Displacement is less than 3mm
What are the possible interventions for type III radial head fx?
-Surgical excision of bone fragments or internal fixation
-Rehab after fixation usually lasts 12 weeks
-Do NOT begin AAROM pronation/supination until week 6
What is olecranon bursitis?
-Inflammation of the bursa located between the olecranon process of the ulna and the overlying skin
-Easily bruised through direct trauma or irritated through repetitive weight bearing
What patient population is olecranon bursitis most common in?
-Students and wrestlers
-Athletes who play basketball, football, indoor soccer, and hockey in which the potential for falling and striking an elbow on hard playing surfaces is high
What are the subjective findings of olecranon bursitis?
-Complaints of pain and swelling that can be gradual as in chronic cases or sudden acute injury
-Patients often note decreased ROM or an inability to don a long-sleeved shirt
What are the objective findings of olecranon bursitis?
Swelling over the olecranon process that can vary in size from a slight distention to a mass as large as 6cm
What is a sign of infection with olecranon bursitis?
Redness and heat
What are confirmatory special tests for olecranon bursitis?
-Lab eval of the bursal aspirate
-Aspiration also helps reduce the level of discomfort and restriction of movement
-Cell count, gram stain, and crystal analysis to differentiate between traumatic, infection, or gout
What are possible interventions for olecranon bursitis?
-RICE
-Early motion
-Infected bursa needs prompt medical attention
What is the mechanism of injury of a biceps tendon rupture?
Involve a sudden contraction of the biceps against a significant load with the elbow in 90 degrees of flexion
What population is biceps tendon ruptures most common in?
Most commonly occurs in muscular males in their 50’s
What is the subjective findings of biceps tendon ruptures?
-Sharp, tearing pain concurrent with an acute injury
-Patient often describes loss of strength in activities involving elbow flexion and supination
What are the objective findings of biceps tendon rupture?
-Ecchymosis in antecubital fossa
-Visible deformity (full rupture)
-Loss of strength in elbow flexion
-Loss of forearm supination strength
What are the possible treatment options for biceps tendon rupture?
-Most active individuals have a repair
-If older, they usually do not repair it
What is the mechanism of injury of a triceps tendon rupture?
Occurs when a deceleration force occurs during elbow extension or with an uncoordinated contraction of the triceps muscle against the flexing elbow
What are the objective findings of a triceps tendon rupture?
Commonly has loss of elbow extension strength and an inability to extend overhead against gravity
What are possible treatment options for triceps tendon rupture?
-Surgical repair indicated with complete rupture
-Partial tear can be treated conservatively with immobilization for 3 weeks then gradual progression of ROM and strength
What is lateral epicondylalgia?
-Pathological condition of the common extensor muscles at their origin on the lateral humeral epicondyle
-Specifically involves the tendons that control wrist extension and radial deviation resulting in pain on the lateral side of the elbow
-Affects between 1-3% of the population
What population is lateral epicondylalgia most common in?
-Occurs most commonly between the ages of 35-50
-Seldom seen in those less than 20 y.o.
-Usually effects the dominant arm
What is the mechanism of injury of lateral epicondylalgia?
-Repetitive grasping with wrist extension
-Participants of tennis, baseball, racquetball, etc.
Which tendon is the most commonly effected in lateral epicondylalgia?
Extensor carpi radialis brevis
