Ortho Block 2 Flashcards
Define Type 1-6 AC injuries
What is the most common mechanism of injury?
1: joint sprain
2: widening w/ less than 100% elevation
3- 100% superior displaced clavicle w/ inc CC interspace
4- superior/posterior clavicle displacement
5- 100-300% superior displaced clavicle
6- distal clavicle in subacromical subcoracoid space
Fall onto lateral shoulder
Types 3-6 will present to exam with what differentiating finding?
Radiographs with weighted bilateral films are needed for AC injury types ? and regular films are needed for ?
How are these injuries treated non-op?
Visible elevation of distal clavicle, pain w/ arm abduction
Bilateral weighted for 1, 2
Normal for 2-5
Type 1 and 2- wear slings until pain ends
Type 3 can also be treated non-op
When are AC injury PTs surgical candidates?
What are the ? types of shoulder arthritis?
Young doing heavy overhead work w/ Type 3
Generally Type 4-6 refer
Primary- most common, age and no HxFx/Trauma
Secondary- trauma, FxHx
Rhematoid- multiple joints involved and crosses midline
Crystaline- zebra of shoulder
When are AC injuries referred for further eval?
How is shoulder arthritis characterized?
4-6
Athletes/throwers
Laborers w/ Type 3
Chronic pain
Destruction of joint cartilage w/ pain, lost joint space, and function
How do PTs w/ shoulder arthritis present?
What type of osteophyte is associated with OA of the shoulder?
Diffuse/deep pain in posterior
Limited ROM
Pain w/ daily living activities
Goat’s beard
What does a Hx of Fx/dislocation in a PT w/ suspected shoulder arthritis suggest?
What happens in these PTs that also have long-standing rotator cuff tears w/out Tx?
Osteonecrosis/Post-traumatic arthritis
Superior migration of humeral head leading to loading of glenoid, leading to rotator cuff tear arthropathy
Shoulder arthritis has pain located where?
What type of ROM do they have?
Deep anterior pain, radiates to posterior shoulder
Dec A/PROM equally
What findings on an x-ray support a Dx of shoulder OA?
What would be seen if rheumatoid arthritis was present?
Flattened humeral head
Inferior osteophyte
Posterior erosion of glenoid
Periarticular erosions, osteopenia, central wear of glenoid
What are the long term risks for shoulder arthritis that goes w/out Tx?
How is this Tx?
Chronic pain
Loss of strength
Loss of motion
All of these even w/ joint replacement
Non-surgical w/ NSAIDs, heat, ice
Corticosteroid injection, injection from posterior for best access to glenoid space
Mild-mod: Arthroscopy debrisment/capsule release for
How are advanced cases of shoulder arthritis Tx?
What are two possible adverse outcomes of this Tx method?
Total shoulder replacement or hemiarthroplasty if advanced
Thrombophlebitis
Embolus
When do PTs w/ shoulder arthritis get referred?
Burners/stingers are medically called?
Intolerable pain
Dec motion (unable to do bra/occupation)
3mon of non-surg Tx
Transient brachial plexopathy
Define Burners of Brachial Plexus
What causes transient brachial plexopathy
Transient stretch injury to upper trunk of brachial plexus at C5-6 roots
High energy MVA, fall, gunshot down to athletic injuries
What is the most common MOI for the two types of Brachial Plexus Burners?
Upper trunk: burner/transient
forceful shoulder depression w/ head/neck are tilted away
MC Post-ganglionic (C5-6)
Painful rhomboids, serratus snterior
Lower trunk injury: longitudinal stretch w/ arm in abduction
MC pre-ganglionic (C8-T1)
Horner Syndrome- ipsilateral ptosis, myosis, anhidrosis, anophthalmos
The cornerstone of a good Dx for Burners/Stingers and ones that are recurrent suggest what underlying issue?
What are the adverse outcomes of this Dz?
Neuro exam
Cervical stenosis
Risk for severe spinal cord injury
Pain, Sensory loss Paresthesias Weakness Paralysis Amputation
Bilateral upper extremeties or radicular Sxs of burners/stingers should be treated as ?
What PE findings are required prior to releasing athletes to return to play?
Spinal cord injury until proven otherwise
Resolution of pain
Resolution of Neuro Sxs
Normal neuro exam
Cervical spine full ROM
Frozen shoulder is AKA ? and defined as ?
What are the common risk factors and what issue can NOT be associated with it?
Adhesive capsulitis- idiopathic loss of AROM and PROM
DM Type 1, Hypothyroid, Dupuytren Dz
No trauma relation
Where is pain usually located in Frozen Shoulders?
What is seen on PE?
Deltoid insertion site
+50% loss of A/PROM
Loss of external rotation due to contracture of coracohumeral ligament (unique and differentiates from arthritis)
What phrase is pathognomonic for frozen shoulder?
How does MRI/CT confirm a frozen shoulder Dx?
Contracture of coracohumeral ligament
Shows contracted capsule, loss of inferior pouch
How are frozen shoulders Tx non-surgically?
How are these Tx w/ surgery?
NSAIDs/non-opiate analgesics, moist heat, stretch
Arthroscopic capsule release
What are the goals for frozen shoulder rehab?
What can be an adverse outcome of this Tx method?
Reduce pain
Increase glenohuemeral and scapula mobility
Fx of humerus
When do frozen shoulder PTs need to be referred?
What type of treatment/therapy needs to be avoided in these PTs?
No improvement after 3mon
Multiple cortisone injections
What is the primary muscle that raises the arm?
Flexion of this muscle causes the rotator cuff to slide under what structure?
Supraspinatus
Coracoacromial arch
What are the characteristic PE findings of a shoulder impingement?
What movement causes the most pain?
Lateral pain exacerbated w/ overhead activity
+ Nears, Hawkin, Jobes
90-120* abduction and lowering
What finding on PE of an impingement is indicative of a long standing rotator cuff teat
How are impingement’s Tx?
Narrowing between humeral head and acromion space +7mm
Stretching, injections
Don’t repeat injection if relief for 4-6wks was NOT achieved
Narrowing between what two structures suggests a long standing rotator cuff tear
What differentiates impingement from AC arthropathy?
Humeral head, under surface of acromiom
Cross arm test
What type of motion limitation is seen in rotator cuff tears?
What finding can be elicited by the provider?
Normal PROM, limited AROM
Can’t hold arm elevated when parallel to ground
TTP insertion of supraspinatus on greater tuberosity
+ Drop arm, Jobes test
What type of x-ray findings may be seen in old/long standing rotator cuff tears?
What is the Tx exception to non-surgical repair?
AP show high riding humerus Lack of subacromial bursa
Acute traumatic tear, surgery 6wks after MRI evaluation
What are the 4 goals of rotator cuff tear PT?
Proximal bicep tendon tears usually occur in what PT population?
Reduce pain
Inc strength/ROM
Restore overhead function
Long Hx of shoulder pain secondary to rotator cuff Dz
Where does the proximal bicep tendon pass through in it’s last/most proximal area?
What test can PTs do to accentuate a tear here?
What term is attached to these injuries but lack specificity of which end is torn?
Intertubercular groove, is intra-articular for proximal 3cm
Ludington test- supination and flexion enhances bulge
Popeye’s arm/bulge
What is an adverse outcome for PTs who don’t seek Tx of proximal bicep tears?
When is surgical repair considered and what intervention step is done here?
Loss of 10% elbow flexion and forearm supination strength
MRI evaluation stat
Young athletes
PTs younger than 40y/o
Screwed back in distally to surgical neck of humerus
What type of shoulder instability is more common?
Define TUBS
Define AMBRI
Anterior (most common)
Multidirectional
Traumatic Unidirectional / Bankart lesion needing surgery- tear of anterior glenoid labrum
Atraumatic Multi-directional, Bilateral sign of laxity, Rehab is preferred Tx, Inferior capsular shift- procedure of surgery
Usually subluxation
What position is that arm in for a posterior dislocation of the shoulder to occur?
A PTs ability to voluntarily dislocate a shoulder is associated with ? and indicates ? prognosis
Adduction, internal rotation from seizure/electrical shock
Multidirectional
Poor
What nerve in particular needs to be assessed in shoulder dislocations?
What 4 tests need to be performed on PTs w/ suspected recurrent instability?
Axillary in anterior shoulder girdle
Aprehension/Relocation test- anterior stability
Sulcus test- inferior laxity
Jerk- posterior laxity
General laxity- thumb to volar surface
Define Hill-Sach/Bankart lesion and what causes them?
What type of nerve issue is commonly seen but self resolved?
Compression Fx of posterior humeral head hitting against anterior/inferior edge of glenoid best seen on scapular Y view
Axillary nerve- deltoid dysfunction and lateral arm numbness
What PT population will have a higher risk of recurrent instability
How are PTs with a first time dislocation Tx?
Young w/ multiple episodes of dislocation
Neutral immobilization x 3wks
Rehab rotator/subscapularis strength
How are PTs w/ atraumatic/voluntary shoulder instability Tx?
What type of shoulder dislocations need referral for red flags?
Avoid aggravating movements/actions
Rehab
Closed manipulation fails to reduce acute dislocation
Two or more dislocations in 3mon despite rehab
Intolerable Sxs in multi-directional instability
SLAP tears involve injury to what 2 structures?
What does the bicep anchor composed of and originate from?
Superior glenoid labrum
Bicep anchor
Long head of tendon originating from superior aspect of glenoid labrum
What tests are performed during PE for a SLAP lesion?
What imaging modality is the gold standard for assessing SLAP lesions?
Resisted supination/external rotation
Speed
Compression, Crank/Clunk tests
MRA w/ gadalinium contrast
What are the non-surgical rehab methods for SLAP lesions?
What is the only alternative if these methods fail?
NSAID
Rotator/periscapular stabilization
Posterior capsule stretching
Dx shoulder arthroscopy
What are the two goals of SLAP lesion rehab?
What is the most common adverse effect following surgical repair of SLAP lesions?
Reduce pain
Protect from further damage
Shoulder stiffness
What causes thoracic outlets syndrome
What are the congenital causes of this syndrome?
Compression of brachial plexus and/or subclavian vessels as they exit between superior girdle/clavicle and first rib
Normal variants: Cervical rib
Long C7 transverse process
Abnormal: Pancoast tumor, Anomalous fibromuscluar band
What causes most of the presenting Sxs of TOS?
What can these presenting Sxs mimic?
Compressed brachial plexus
Distal entrapment of ulnar nerve*
What tests are performed during PE of TOS?
How is this syndrome Dx?
Roos test Palpate supraclavicular fossa Auscultation for buit Compare distal pulses bilateral Assess sensory and motor function of all arm nerves
AP/Lat- for bone causes
PA/Lat- r/o apical lung tumor
What are two rare but possible adverse outcomes of TOS?
How are most of these PTs treated in 3-6mon?
When do they need to be referred?
Ulcerations
Raynaud
At home exercise w/ posture education
Normal variant alteration
Neurovascular
How is arthritis of the elbow Dx?
If there is an effusion present in the elbow, the fluids needs to be aspirated and assessed for ?
What would be seen on x-ray of primary OA, secondary OA, RA and crystaline in the elbow?
AP/Lat x-ray
WBC, Crystals, Gram stain, Culture
1*- Joint space narrowing Sub-chondral cyst Articular bone spurs 2*- Hx of trauma with Sxs of primary RA: osteopenia, margin margins Crystaline- subchondral bony erosion, peripheral bone spurs
What ROS answers will be common in PTs w/ elbow RA?
What will be seen on PE or elbow RA?
How is RA and Crystaline of the elbow treated?
Bilateral shoulder, wrist and hand arthritis
Lateral swelling
Boggy joint
RA: DMARDs
CCS injection
Surgery
Crystal- alopurinol, colchicine
Injections
What is an indication a PT needs a surgical procedure for Sx relief of elbow arthritis?
What muscle originates from the lateral epicondyle of the humerus and what issue arises from this origin?
Loss of daily living ability
Arthroscopic debrisment and removal of loose bodies
Extensor carpi radialis brevis
Lateral epicondylitis/tennis elbow
What muscle originates from medial humerus epicondyle?
What movement replicates the pain in medial and lateral epicondylitis?
Flexor/pronator muscle
Golfer/Bowler elbow
Lateral- Gripping w/ wrist extension
Medial- gripping w/ wrist flexion and forearm pronation
What imaging modality helps confirm a medial/lateral epicondylitis Dx?
Why do Dx’s of involving medial/lateral epicondye need to be accurate?
MRI
Surgical failure if mis-Dx
Entrapment syndromes- posterior interosseous nerve in lateral epicondylitis; ulnar nerve in medial epicondylitis
What is the most important step in Tx of lateral epicondylitis and what can be done?
What are the 4 stages of Tx in humeral epicondylitis?
Stopping activities that hurt
CCS, PRP injection w/ buffy layer, dry needling
Medial Tx done by Orthopod under US guidance
Reduction
Promotion
Return
Maintenance
What is the most common adverse outcome of humeral epicondylitis surgery?
What makes the olecranon bursitis so susceptible to irritation and inflammation?
Incomplete pain relief despite adequate release
Superficial location on extensor side of elbow
What can be done for Dx and Therapeutc relief for large elbow bursitis?
What is the job of the bursa in the shoulder?
Aspiration for WBC, Gram stain, culture and crystals
Pad greater tubercle and acromion
How are small/barely Sx elbow bursitis Tx?
If there are no S/Sxs of septic bursitis, what type of wrap can be applied?
Left alone, activity modification, NSAID
Compression bandage w/ 8cm circular foam
How are septic olecranon bursitis cases Tx?
How are chronically inflamed aseptic bursitis cases Tx?
ABX w/ penicillin resistant Staph A coverage
Surgical drain/daily aspiration
Avoid excision/chronic drainage to avoid sinus infection
When are olecranon bursitis cases referred?
What are the first and second most common nerve entrapment syndromes in the UE?
Recurrent despite 3 or more drainages
Carpal tunnel syndrome
Compression of ulnar nerve
What are the 2 most common sites for ulnar nerve compression?
How do chronic cases develop?
Cubital tunnel on posterior aspect of medial epicondyle
Passage site between humeral and ulnar head of flexor carpi ulnaris muscle
Prolonged pressure on nerve from leaning or prolonged elbow flexion
How does ulnar nerve palsy develop?
What is a common cause of a mis-Dx of lateral epicondylitis?
Instability from repetitive subluxation or dislocation of ulnar nerve
Compression of posterior interosseous nerve causing lateral elbow pain
What does the posterior interosseous nerve innvervate?
What is the most common cause of this nerve being compressed?
Thumb and finger extensor
Extensor carpi ulnaris
Fibrous bands between two heads of supinator muscle in the radial tunnel
Define Pronator Syndrome
Why is this difficult/rarely Dx?
Muscular compression of median nerve in proximal forearm
Vague Sxs
Common in worker comp claims
What are the presenting Sxs of ulnar, radial, posterior interosseious nerve compression syndrome?
Ulnar- pain in medial elbow, numbness of ring/little finger
Radial- pain similar to tennis elbow but distal in origin
Posterior- only motor fibers; late finding is difficulty innervating finger/thumb
What special tests can be done when assessing nerve compression syndromes of the elbow?
What is the difference in location of pain with Posterior Interosseous nerve compression and radial tunnel syndrome?
Tinel sign
Resisted pronation
PIN- tenderness over radial tunnel
RTS- pain in proximal forearm elicited by middle finger test
When is decompression of the radial tunnel of pronator syndrome w/ surgery considered?
What amount of movement is lost if distal bicep tears are not treated in a timely manner?
Discomfort after 3-6mon of non-surg Tx
30-50% loss of strength in elbow flexion and forearm supination
Cubital Tunnel Syndrome
Ulnar nerve compression
Pain/weakness along pinky/ring finger
Ache/pain in hypothenar muscle
MC from hyperflexion of elbow or can be from resting arms when driving
Radial nerve compression
Median Nerve Compression
Lateral elbow pain distal to lateral epicondylitis pain site
Late Dz sign= PIN pain/difficulty w/ thumb/finger extension
Pronator Syndrome
Vague Sxs
Pain w/ pronator movement/resistance
What is done during PE for elbow nerve compression issues?
What imaging/tests can be done for nerve issues in the elbow?
Neurovasular tests
Tinels signs
Resisted pronation
Electomyographic/nerve conduction velocity study
What are the long term adverse outcomes of nerve compressions in the elbow?
How are some rarely Tx?
Dec strength/sensation
Ulnar- OT/avoidance of compression, surgical relocating nerve to anterior elbow
Radial/Median- OT, surgical release
When do elbow nerve compression cases need to be referred to Ortho?
Weakness, Inc numbness, Persistant Sxs
Distal Bicep Tendon Rupture
Inserts on radial tuberosity, rupture is proximal to insertion
Older PT who shouldn’t be curling but w/ more pain than proximal rupture
X-ray, MRI ASAP
Greater loss of supination/flexion movement
Tx w/ surgery
Adv: radial nerve injury, heterotrophic ossification across interosseous membrane between radius/ulna (bony bar)
Refer everyone
Ulnar collateral ligament tear
Located on medial elbow
Connects humerus medial condyle to tubercle between coranoid/olecranon
Avoids valgus stress- throwing stabilizer
Pain w/ palpation/valgus stress w/ 30* flexion
Xray, MRI
Adv= dec ROM
Tx, non-surg= rest, RICE, NSAID, PT
Tx, surg= competitive athlete w/ Tommy John procedure
Wrist arthritis causes
4 labs to be ordered
Secondary OA
RA
Psuedogout
Primary OA
ESR Rheumatoid factor Antinuclear Abs Uric acid Lyme Dz
When are wrist arthritis cases referred to ortho?
Non-surgical Tx failure
Septic arthritis
Carpal Tunnel
Entrapment of medial nerve, most common nerve compression neuroapthy
Occurrence during pregnancy= bilateral, self resolving
PE- thenar atrophy, Reverse/Phalens, Carpal compression, Tinels
Test- electric conduction velocity
Tx- splint, education; surgery= carpal tunnel release
Refer= fine motor loss, neuropathy, near constant Sxs
de Quervains Tenosynovitis
Lateral wrist pathology w/ pain during ulnar deviation
Seen in mothers w/ young kids from picking them up
PE- TTP @ 1st dorsal compartment, proximal to snuff box, + FInklestein test (pain at radial styloid)
Tx- thumb spica cast, surgical nerve release
Ganglion cyst of the wrist
Most common soft tissue tumor of the hand, most commonly at center of dorsal wrist, second most common site- volar surface near median nerve/radial artery
Hand- A1 pulley on palmar side
Finger- DIP/PIP called mucus cyst
Transilluminates but reqs MRI prior to surgery
Tx- aspirate, surgery (never aspirate finger cyst)
Adv Tx: recurrence, neurovascular damage, loss of extension
Refer: abnormal location, failed aspriation, septic joint
Kienbock Dz
Osteonecrosis of lunate bone due to trauma, presenting w/ TTP and dec grip strength
Xray shows sclerosing/focal density of lunate bone
