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Ortho Block 2 Flashcards

1
Q

Define Type 1-6 AC injuries

What is the most common mechanism of injury?

A

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

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2
Q

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?

A

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

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3
Q

When are AC injury PTs surgical candidates?

What are the ? types of shoulder arthritis?

A

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

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4
Q

When are AC injuries referred for further eval?

How is shoulder arthritis characterized?

A

4-6
Athletes/throwers
Laborers w/ Type 3
Chronic pain

Destruction of joint cartilage w/ pain, lost joint space, and function

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5
Q

How do PTs w/ shoulder arthritis present?

What type of osteophyte is associated with OA of the shoulder?

A

Diffuse/deep pain in posterior
Limited ROM
Pain w/ daily living activities

Goat’s beard

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6
Q

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?

A

Osteonecrosis/Post-traumatic arthritis

Superior migration of humeral head leading to loading of glenoid, leading to rotator cuff tear arthropathy

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7
Q

Shoulder arthritis has pain located where?

What type of ROM do they have?

A

Deep anterior pain, radiates to posterior shoulder

Dec A/PROM equally

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8
Q

What findings on an x-ray support a Dx of shoulder OA?

What would be seen if rheumatoid arthritis was present?

A

Flattened humeral head
Inferior osteophyte
Posterior erosion of glenoid

Periarticular erosions, osteopenia, central wear of glenoid

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9
Q

What are the long term risks for shoulder arthritis that goes w/out Tx?

How is this Tx?

A

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

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10
Q

How are advanced cases of shoulder arthritis Tx?

What are two possible adverse outcomes of this Tx method?

A

Total shoulder replacement or hemiarthroplasty if advanced

Thrombophlebitis
Embolus

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11
Q

When do PTs w/ shoulder arthritis get referred?

Burners/stingers are medically called?

A

Intolerable pain
Dec motion (unable to do bra/occupation)
3mon of non-surg Tx

Transient brachial plexopathy

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12
Q

Define Burners of Brachial Plexus

What causes transient brachial plexopathy

A

Transient stretch injury to upper trunk of brachial plexus at C5-6 roots

High energy MVA, fall, gunshot down to athletic injuries

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13
Q

What is the most common MOI for the two types of Brachial Plexus Burners?

A

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

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14
Q

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?

A

Neuro exam
Cervical stenosis
Risk for severe spinal cord injury

Pain, 
Sensory loss 
Paresthesias 
Weakness 
Paralysis 
Amputation
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15
Q

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?

A

Spinal cord injury until proven otherwise

Resolution of pain
Resolution of Neuro Sxs
Normal neuro exam
Cervical spine full ROM

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16
Q

Frozen shoulder is AKA ? and defined as ?

What are the common risk factors and what issue can NOT be associated with it?

A

Adhesive capsulitis- idiopathic loss of AROM and PROM

DM Type 1, Hypothyroid, Dupuytren Dz
No trauma relation

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17
Q

Where is pain usually located in Frozen Shoulders?

What is seen on PE?

A

Deltoid insertion site

+50% loss of A/PROM
Loss of external rotation due to contracture of coracohumeral ligament (unique and differentiates from arthritis)

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18
Q

What phrase is pathognomonic for frozen shoulder?

How does MRI/CT confirm a frozen shoulder Dx?

A

Contracture of coracohumeral ligament

Shows contracted capsule, loss of inferior pouch

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19
Q

How are frozen shoulders Tx non-surgically?

How are these Tx w/ surgery?

A

NSAIDs/non-opiate analgesics, moist heat, stretch

Arthroscopic capsule release

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20
Q

What are the goals for frozen shoulder rehab?

What can be an adverse outcome of this Tx method?

A

Reduce pain
Increase glenohuemeral and scapula mobility

Fx of humerus

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21
Q

When do frozen shoulder PTs need to be referred?

What type of treatment/therapy needs to be avoided in these PTs?

A

No improvement after 3mon

Multiple cortisone injections

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22
Q

What is the primary muscle that raises the arm?

Flexion of this muscle causes the rotator cuff to slide under what structure?

A

Supraspinatus

Coracoacromial arch

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23
Q

What are the characteristic PE findings of a shoulder impingement?

What movement causes the most pain?

A

Lateral pain exacerbated w/ overhead activity
+ Nears, Hawkin, Jobes

90-120* abduction and lowering

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24
Q

What finding on PE of an impingement is indicative of a long standing rotator cuff teat

How are impingement’s Tx?

A

Narrowing between humeral head and acromion space +7mm

Stretching, injections
Don’t repeat injection if relief for 4-6wks was NOT achieved

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25
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
26
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
27
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
28
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
29
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
30
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
31
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
32
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
33
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
34
# 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
35
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
36
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
37
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
38
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
39
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
40
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
41
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
42
What causes most of the presenting Sxs of TOS? What can these presenting Sxs mimic?
Compressed brachial plexus Distal entrapment of ulnar nerve*
43
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
44
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
45
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 ```
46
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
47
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
48
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
49
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
50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
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
58
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
59
# Define Pronator Syndrome Why is this difficult/rarely Dx?
Muscular compression of median nerve in proximal forearm Vague Sxs Common in worker comp claims
60
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
61
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
62
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
63
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
64
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
65
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
66
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
67
When do elbow nerve compression cases need to be referred to Ortho?
Weakness, Inc numbness, Persistant Sxs
68
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
69
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
70
Wrist arthritis causes 4 labs to be ordered
Secondary OA RA Psuedogout Primary OA ``` ESR Rheumatoid factor Antinuclear Abs Uric acid Lyme Dz ```
71
When are wrist arthritis cases referred to ortho?
Non-surgical Tx failure | Septic arthritis
72
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
73
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
74
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
75
Kienbock Dz
Osteonecrosis of lunate bone due to trauma, presenting w/ TTP and dec grip strength Xray shows sclerosing/focal density of lunate bone

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