MSK CIS Handout Flashcards
Increased uric acid level is necessary, but not sufficient for onset of gout. There is a known multifactorial inheritance, which is _________, and has polymorphisms at ______ and ______
X-linked; URAT1; GLUT9
_______ toxicity increases risk of saturnine gout
Lead
Use of _____ diuretics impedes excretion of urate, thus increasing risk for gout
Thiazide
Elevated _______ fit with alcohol abuse, which can predispose to gout
LFTs
The number of co-morbidities in gout patients is related to disease severity. What co-morbidities are highly prevalent in gout patients?
Hypertension Diabetes mellitus CV disease Renal disease Dyslipidemia
Gout is an independent risk factor for ______ and _____ mortality, and is associated with increased co-morbidity, thus an EKG is often performed on pts presenting with gout
Cardiovascular; all-cause
Patients with recurrent hospital admissions for gout have a higher number of comorbid medical conditions, particularly higher rates of _____ disease
Heart
Uric acid crystals can form ____ in heart valves
Tophi
T/F: Pts hospitalized for gout have higher rates of tophaceous disease and higher serum urate concentrations
True
T/F: Pts hospitalized for gout are more likely to be on high doses of allopurinol
False — hospitalized cases are less likely to be on allopurinol, and those on allopurinol areon lower doses
Rotator cuff muscles
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Anterior deltoid and coracobrachialis are responsible for GH joint _______ with a normal ROM of ______
Flexion; 180
Latissimus dorsi and teres major are responsible for GH joint _______ with a ROM of ______
Extension; 60
Pec major and latissimus dorsi are responsible for GH joint ________ with ROM of ______
Horizontal adduction; 40-50 (or 130-140)
Supraspinatus and mid-deltoid are responsible for GH joint _________ with ROM of _______
Horizontal abduction; 40-55 (or 130-145)
Infraspinatus and teres minor are responsible for GH joint _________ with ROM of _____
ER; 90
Subscapularis and pec minor are responsible for GH joint ______ with ROM of ____
IR; 90
ROM for axial rotation at the AC joint
~10 degrees
Rhomboid major and minor mm. are responsible for scapular ______
Retraction
Serratus anterior is responsible for scapular _____
Protraction
Upper trapezius and levator scapulae are responsible for scapular _____
Elevation
Lower trapezius and lower rhomboids are responsible for ______ of the scapula
Depression
2 tests for GH instability
Apprehension test
Sulcus sign
Apprehension test
Pt seated or supine. Shoulder abducted to 90 and elbow flexed to 90. Stabilize shoulder with 1 hand and force arm into ER with other hand
+ test = pt apprehensive of repeat dislocation
Indicates GH instability
Sulcus sign
Grasp pts elbow and apply inferior traction
+ test = indentation in area beneath acromion
Indicates GH instability
2 tests for long head of the bicep
Yergason’s
Speed’s
Yergasons test
Pts arm at side with elbow flexed at 90. Examiner uses one hand to palpate bicipital groove and monitors there, while other hand grasps the pts wrist. Have pt supinate and ER against resistance
+ test = pain and/or tendon subluxation out of groove
Indicates unstable bicipital tendon/subluxation bicipital tendonitis
Speeds test
Pts arm forward flexed (50-90 deg) at the shoulder with hand supinated. Slightly flex pts elbow. Resist at forearm while pt forward flexes shoulder (resistance to cephalad/superior motion)
+ test = pain in bicipital groove
Indicates bicipital tendonitis of longhead biceps
2 rotator cuff tests indicative of supraspinatus pathology
Empty can test
Drop-arm test
Empty can test
Flex pt shoulders/arms to 90 while horizontally abducting to 45 deg. Then IR both arms so thumbs point down. Press down on forearms while pt resists
+ test = pain or weakness
Indicates rotator cuff pathology of supraspinatus
Drop-arm test
Pt abducts arms to 90 deg then slowly drop arms
+ test = arm will drop or gentle tap on wrist will cause arm to drop
Indicates full thickness tear of supraspinatus
2 tests for rotator cuff impingement
Neer impingement
Hawkins test
Neer impingement test
Stabilize pts shoulder, forearm is pronated, passively flex shoulder to fully flexed position
+ test = pain
Indicates subacromial bursa or rotator cuff impingement
Hawkins test
Flex shoulder to 90, flex elbow to 90, and passively rotate the humerus into IR. This opposes rotator cuff against coracoacromial ligament and acromion
+ test= pain
Indicates rotator cuff or subacromial bursa impingement
Ortho test for subscapularis pathology
Lift off test
Lift off test
Place pts arm into internal rotation and extension. Pt pushes arm into further IR as doc resists
+ test = weakness (inability to resist)
Indicates subscapularis weakness
Ortho test for AC joint pathology
Cross arm test
Cross arm test
Doc passively adducts pts arm across their chest and rests pts hand on opposite shoulder
+ test = pain in AC joint with end range adduction
Indicates AC joint pathology
2 maneuvers for apley scratch test
Upper — pt abducts arm placing palm of hand behind their neck with palm facing toward the body. Pt should attempt to scratch the lowest possible vertebrae (coupled ER and abduction)
Lower — pt places arm behind their back with palm facing outward and dorsum of hand resting on their mid-back. Pt should attempt to scratch highest possible vertebrae (coupled IR and adduction)
Normal elbow carrying angle in males vs females
Males = 5 degrees
Females = 10-15 degrees
Cubitus varus = _____ degrees
Cubitus valgus = _____
<5 degrees
> 15 degrees
Biceps brachii, brachialis, brachioradialis, and coracobrachialis are responsible for elbow _____ with ROM of _______
Flexion; 140-150
Triceps brachii and anconeus are responsible for elbow _______ with ROM of ______
Extension; 0 to -5
Supinator m. and biceps brachii are responsible for elbow _______ with ROM of ______
Supination; 90
Pronator teres and pronator quadratus mm. are responsible for elbow _______ with ROM of ______
Pronation; 90
What nerve roots are tested with biceps, brachioradialis, and triceps reflexes?
Biceps = C5
Brachioradialis = C6
Triceps = C7
Valgus stress test for elbow
Arm slightly abducted and ER. Forearm supinated and flexed to 30 degrees. Slight medial directed valgus stress applied
+test = pain/tenderness with palpation and valgus stress; increased laxity
Indicates sprained medial (ulnar) collateral ligament
Varus stress test
Arm slightly abducted and IR. Elbow flexed to approx 15 degrees. A slight lateral directed varus stress is applied to elbow
+ test = pain/tenderness with palpation; increased laxity
Indicates sprained lateral (radial) collateral ligament
Tinel test for ulnar nerve entrapment
Tap between olecranon and medial epicondyle in ulnar groove
+ test elicits tingling sensation don forearm within ulnar nerve distribution
Indicates ulnar nerve entrapment/cubital tunnel syndrome
Golfer’s elbow test
[anterior forearm/flexor compartment]
Pts elbow flexed to 90 and forearm placed in supination with wrist neutral and palm facing up. Examiner places one hand under proximal forearm for stabilization and the other hand over the pts wrist to resist movement. Instruct pt to FLEX the wrist
+ test = pain/tenderness around medial epicondyle
Indicates medial epicondylitis
Tennis elbow (Cozen’s) test
[posterior forearm/extensor compartment]
Pts elbow flexed to 90 and forearm placed in pronation with wrist neutral and palm down. Examiner places one hand under proximal forearm for stabilization and the other hand over pts hand to resist movement. Instruct pt to EXTEND the wrist
+ test = pain around lateral epicondyle, may radiate down lateral forearm
Indicates lateral epicondylitis
Clinical presentation of olecranon bursitis in terms of pain and ROM
Region is often painless and ROM is normal
Little league elbow refers to a group of problems related to stress of throwing in young athletes. How does the pathology change from childhood to adolescence to young adulthood?
Childhood = medial apophysitis
Adolescence = medial epicondyle avulsion fracture
Young adulthood = medial collateral ligament tear
[as bone development matures, the most common injury evolves from apophysitis to avulsion to ligament injury]
Little league elbow presents as pain over the _____ epicondyle, initially after throwing (repetitive ______ distraction forces), progresses to persistent pain
Medial; valgus
Injury that is often the result from trauma by tractioning the child’s extended arm
Radial head instability “nursemaid’s elbow”
[Annular ligament tear and/or radial head subluxation from annular ligament]
Radial head instability due to annular ligament tear presents with pain with palpation of radial head with _____ displacement of radial head, and restriction to _____ glide
Anterior; posterior
Ulnar _______ is coupled with supination at the elbow
Ulnar ______ is coupled with pronation at the elbow
Adduction
Abduction
Radial head ______ glide is paired with supination at the elbow
Radial head ______ glide is paired with pronation at the elbow
Anterior
Posterior
Medial, lateral, and proximal borders of anatomic snuffbox
Medial border — extensor pollicis longus
Lateral border — extensor pollicis brevis, abductor pollicus longus
Proximal border — radial styloid process
Name the carpal bones
Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate
Flexor carpi radialis, flexor carpi ulnaris, and palmaris longus are responsible for wrist ______ with ROM of ______
Flexion; 80-90
Extensor carpi radialis longus and brevis along with extensor carpi ulnaris are responsible for wrist ______ with ROM of ______
Extension; 70
Flexor carpi ulnaris and extensor carpi ulnaris are responsible for wrist ______ with ROM of ______
Adduction; 30-40
Flexor carpi radialis, extensor carpi radialis longus and brevis are responsible for wrist ______ with ROM of ______
Abduction; 20-30
_______ of the wrist is coupled with dorsal/posterior carpal glide
Flexion
Adduction of the wrist is coupled with ulnar _______
Abduction of the wrist is coupled with ulnar ______
Abduction
Adduction
Motor branch of median nerve that innervates flexor pollicis longus, deep flexors of digits 2 and 3, and pronator quadratus (responsible for making “ok” sign)
Anterior interosseous nerve
Tinel’s sign of the wrist is elicited by tapping over the _________ ligament with wrist held in extension
Transverse carpal
What is the Allen test?
Evaluates functioning of radial and ulnar aa.
Occlude both aa. while pt makes a fist. Have pt open and close fist; palm should be pale
Release pressure on ulnar a. and observe for color return to hand w/i 5-10seconds. Repeat with radial a.
A positive Allen test indicates lack of dual blood supply to the hand and would be a contraindication for what procedure?
Radial catheterization
3 possible inflammation sites in DeQuervain’s tenosynovitis
Tendon sheath
Abductor pollicis longus
Extensor pollicis brevis
Test used to detect dequervains tenosynovitis
Finkelstein test
It is important to diagnose and treat a scaphoid fracture due to risk of ________ _______ secondary to blood supply. Treatment is with thumb spica cast/splint. Note that immediate radiographic evidence is not always visible and may require repeat imaging. CT or MRI to confirm if necessary
Avascular necrosis
Fracture of the distal radius in the forearm with dorsal (posterior) and radial displacement of the wrist and hand; classic “dinner fork” deformity with bony stepoff
Colle’s fracture
Fracture of proximal ulna + dislocation of radial head
Monteggia fracture
Fracture of the distal radius + dislocation of the ulna
Galeazzi fracture
Isolated fracture of the midshaft/distal ulna from a direct blow
Nightstick fracture
Biomechanical OMT considerations in acute gout of the elbow
Avoid direct treatments to the elbow during acute flare
Consider treating any areas that may be compensating for limited use of elbow — opposite shoulder, lumbar spine, sacrum, innominates
Respiratory circulatory OMT considerations in acute gout of the elbow
Consider use of lymphatics to assist with clearing of uric acid crystal deposition; may also help with inflammation
Treat zink patterns
Do effleurage/petrissage proximal to elbow as tolerated
Check for restrictions of lymph drainage by treating fascial restrictions in the axilla and hypertonicity of the pec minor m (can use pec minor CS therapy or pectoral traction)
Sequence of treatment for successful lymphatic treatment
- Open pathways to remove restriction to flow — transverse myofascial restrictors: thoracic inlet, myofascial restrictors, broad fluid movement
- Maximize diaphragmatic functions — abdominal and pelvic diaphragms
- Increase pressure differentials or transmit motion using fluid pumps
- Mobilize targeted tissue fluids (localized to specific SDs)
Neurologic OMT considerations for acute gout of the elbow
Restore homeostasis for sympathetics for UE by targeting T2-T7
Restore homeostasis for parasympathetics for UE by targeting OA, AA
Behavioral model OMT considerations for acute gout of the elbow
Educate pt on aspects leading to development of gout flares
Reduce alcohol and other dietary purine consumption
Encourage weight loss which will complement dietary purine reduction
Encourage increased hydration, especially if on a thiazide
