Orthopedic Conditions of UE part 2 Flashcards
Orthopedics Conditions of the Elbow
- Lateral Epicondylitis
- Medial Epicondylitis
- Little League Elbow
- Osteochondritis
Dissecans - Myositis Ossificans
- Heterotrophic Ossification
- Olecranon Bursitis
- Elbow Dislocation
- Pulled Elbow
- Volkmann’s Ischemic
Contracture - Ulnar and Radial Nerve
Injuries
Orthopedics Conditions of the Elbow
- Lateral Epicondylitis
- Medial Epicondylitis
- Little League Elbow
- Osteochondritis
Dissecans - Myositis Ossificans
- Heterotrophic Ossification
- Olecranon Bursitis
- Elbow Dislocation
- Pulled Elbow
- Volkmann’s Ischemic
Contracture - Ulnar and Radial Nerve
Injuries
Lateral Epicondylitis
Caused by: ___________________________
Aka: ___________________________
MOI: ___________________________
Muscles involved: ____>____>____>____>____
S/sx: ___________________________
: ____________
: pain with ____________ & ____________
: ____________
Orthosis: ____________
DDx: ____________ v.s. ____________
Caused by: repetitive microtrauma to the origin of wrist extensor muscles
Aka: Tennis Elbow
MOI: inexperienced backstroke
Muscles involved: ECRB>EDC>Brachiorads>ECRL>ECU
S/sx: aching pain at lateral epicondyle
: ↓ elbow ROM
: pain with AROM & PROM
: Pain & weakness in wrist & hand may develop
Orthosis: FA band
DDx: Lat Epi v.s. Radial Tunnel Syndrome
- Lateral Epicondylitis
- DDx: Lat Epi vs Rad Tunnel Synd
Apply pressure at Lat Epicondyle
If decreased pain = Tennis elbow – de-loading technique
De-loading the tendon
If increased pain = Radial syndrome – impinging
Special Test
Method 2 (Mill’s) Will You Marry Meills
Special tests for Lateral Epicondylitis
- 2.
3.
- Method 1 (Cozen’s)
- Method 2 (Mill’s)
- Method 3 (Maudsley’s)
Method 1 (Cozen’s)
Procedure:
(+):
Indication:
❑ Stabilize at lat epi
❑ Px FA pronation, wrist ext
& RD while PT resists
❑ Active
❑ (+): pain at lat epi
Method 2 (Mill’s)
Procedure:
(+):
Indication:
❑ Palpate lat epi
❑ Elbow ext, FA pronation,
Wrist flex
❑ Passive
❑ (+): pain at lat epi
Method 3 (Maudsley’s)
Procedure:
(+):
Indication:
❑ PT resist ext of 3rd distal
phalanx
❑ Test: EDC ms & tendon
Medial Epicondylitis
Aka: ____________
MOI: ____________
Muscles involved: ____________
Signs and symptoms:
Pain with ____________& ____________
Pain with ____________ as well in severe injuries
Point tenderness and mild swelling at the ____________
Tx: ____________
Aka: Golfer’s/ Medial Tennis/ Swimmer’s Elbow
MOI: repeated wrist flex c valgus force on the elbow
Muscles involved: wrist flexors & FA pronators
Signs and symptoms:
Pain with AROM & PROM
Pain with wrist flexion as well in severe injuries
Point tenderness and mild swelling at the medial epicondyle
Tx: Curvilinear brace below the elbow to reduce stress at the elbow jt
Little League Elbow/Pitcher’s Elbow
D/t repetitive valgus stress (young): microtrauma from
throwing motions
Presentation: ____________
Onset: ____________
Other s/sx: ____________,
____________, ____________ or ____________, ____________
esp in FA ____________ & ____________
MNEMONIC: CAVSMCL
Throwing activities: postpone for ____________
May lead to: ____________
D/t repetitive valgus stress (young): microtrauma from
throwing motions
Presentation: pain at medial epicondyle
Onset: slow/gradual
Other s/sx: slight flexion contracture, tight ant capsule,
weakness in triceps, locking or catching sensation, ↓ ROM
esp in FA pronation & supination
MNEMONIC: CAVSMCL
Throwing activities: postpone for 1 year
May lead to: OCD → AVN
Little League Elbow/Pitcher’s Elbow
“CAVS MCL”
Compression fracture HR jt.
Avulsion fracture medial epi
Valgus stress of the elbow
Stressed epicondylar growth plate
MCL stretched/tear
Osteochondritis Dissecans
____________ → ____________ → ____________ & ____________
MOI: ____________
MC: ____________ – If AVN = ____________
Impaired blood supply at bone underneath the cartilage → articular
cartilage degeneration → formation of loose bodies & AVN
MOI:repetitive trauma
MC: Capitulum – If AVN = Panner’s Dse
Myositis Ossificans
Cause: ____________
____________ & ____________
(+): ____________
MC involved: ____________
Usually occurs after injury: ____________, ____________, ____________
S/sx: ____________ & ____________, ____________, ____________
CI: ____________
Best Mx: ____________ = allow ____________ before ____________
D/t aggressive mobilization of elbow ff
dislocation (post) & supracondylar Fx
(+): Ca deposits in ms belly
MC involved: Brachialis
Usually occurs after injury: post elbow
disloc, brachialis tear, lower humerus Fx
S/sx: painful stretch & resistance, palpable
mass, flex contracture
CI: vigorous PT (massage & strenuous exercise)
Best Mx: just IMMOB (splint in pain free ROM) bec NO SURGERY in early
stage = allow 6-12 mos before aspiration
Heterotopic Ossification
Ectopic bone formation
MOI: ____________ (____________)
MC affects: ____________
CI: ____________ (____________& ____________)
Mgt: ____________
Meds: ____________
Ectopic bone formation
MOI: formed ff trauma (Fx, disloc, burn, or head
trauma)
MC affects: elbow>hip>Sh in burn px
“bony block” -> LOM
CI:vigorous PT (massage & strenuous exercise)
Mgt: Just IMMOB (splint in pain free ROM)
Meds: Disodium Etidronate
Olecranon Bursitis
Aka: Student’s, Miner’s, Draftsman
Caused by: ____________
Pt c/o: ____________
S/Sx: “____________”
____________
Mgt: ____________, ____________, ____________
Acute: ____________
Chronic: ____________
If conservative mgt fails - ____________
Aka: Student’s, Miner’s, Draftsman
Caused by: infection, prolonged repetitive trauma
Pt c/o: post elbow pain
S/Sx: “Goose Egg Appearance”
Pain, swelling, & point tenderness
Swelling will appear almost spontaneously s the pain & heat
Mgt: compression, US, FES
Acute: compression for at least 1 hr
Chronic: compression + therapy
If conservative mgt fails - aspiration
Elbow Dislocation
MOI: ____________
MC direction: ____________ and ____________, ____________, ____________, ____________
____________& ____________ nerves may be compromised
Blood vessels may be compromised
Terrible Triad:
1. ____________
2. ____________
3. ____________
Tx: ____________
____________
MOI:FOOSH or severe twisting of a flexed elbow
MC direction: Posterolateral
Signs and Symptoms
Swelling, severe pain, disability
Median & radial nerves may be compromised
Blood vessels may be compromised
Terrible Triad:
1. Radial head Fx (often involved)
2. Coronoid process Fx
3. Ruptured collateral ligaments
Tx: repair ligaments, ORIF of Fxc plates & screws,
NO elbow extbeyond 30 deg for 1 mos
Pulled Elbow
Aka: ____________
MOI: ____________ &____________
LOM: ____________
____________ disloc of ____________
Assoc c ____________Fx d/t ____________
Aka: Nursemaid’s elbow
MOI: forceful pull on child’s extended
&_pronated arm causing Inf subluxation
of the radial head from the annular
ligament
LOM: supination d/t pain & mechanical
locking
Proximal disloc of radial head
Assoc c Colle’s Fx d/t FOOSH
Volkmann’s Ischemic Contracture
MOI: ____________, which compromises the ____________
and inhibits circulation to ____________
Most important Sx: ____________
S&Sx:
1. ____________
2. ____________
3. ____________
4. ____________
Dx: ____________
N = ____________
(+) = ____________
Tx: decompressive fasciotomy, immediate reduction of Fx, cast
must allow swelling
MOI: impaired circulation or ischemia
Supracondylar Fx, which compromises the brachial artery
and inhibits circulation to forearm
Most important Sx:severe pain accentuated by stretch
S&Sx:
1. Pain in FA which ↑ c PROM finger ext
2. Cessation of brachial and radial pulses
3. Coldness in arm
4. Decreased ROM
Dx: Manometer (intercompartmental pressure)
N = <15mmHg
(+) = 30-40mmHg
Tx:decompressive fasciotomy, immediate reduction of Fx, cast
must allow swelling
Ulnar Nerve Injury
- 2.
- CUBITAL TUNNELSYNDROME
- Tardy Ulnar Palsy
CUBITAL TUNNELSYNDROME
* ____________
* Compressed at: ____________,
____________, or ____________
* S&Sx:
o ____________
o ____________
o ____________
o ____________
- Highest point where the ulnar nn can be injured
- Compressed at: Arcade of Struthers,
Osborne Fascia, or 2 heads of FCU - S&Sx:
o Pain on medial aspect of elbow
o Point tenderness in cubital tunnel
o Pain with hyperflexion
o Intermittent paresthesia in 4th and 5th fingers
Tardy Ulnar Palsy
* ____________
onset of ulnar neuropathy
* ____________
- Chronic condition characterized by delayed
onset of ulnar neuropathy - Injury from olecranon Fx
CUBITAL TUNNELSYNDROME
Special Test:
- Elbow Flexion Test
- Tinel’s
- Wartenbergs
- Elbow Flexion Test:(most sensitive)
Px actively holds elbow in full flex for 3-5 mins
(+): tingling - Tinel’s – tapping bet the olecranon process
& medial epicondyle
(+): tingling → regeneration - Wartenbergs – passively spread fingers apart
& ask px to bring fingers together
(+) inability to squeeze little finger
Check Drive Ulnar Nerve Injury
Check Drive Ulnar Nerve Injury
Radial Nerve Injury
Radial Nerve Levels of Entrapments
- Axilla
❑________ Crutch Palsy
❑Too much weight ____________
❑____________ are affected
❑(+) ____________ - Spiral Groove
❑Aka: Honeymoon’s/ Saturday’s Night/ Tourniquet
❑Spared: ____________& ____________
❑____________ - Arcade of Frohse
❑ Aka: ____________/ ____________/
❑ Deep branch of ____________
❑ Pure v
❑ (+): ____________
❑ If no wrist drop ____________ - Superficial Branch
❑ Aka: Cheiralgia Paresthetica/ Wartenburg
❑ Under the ____________
❑ Pure sensory deficit at ____________
thumb, dorsal 1st WS
❑ Wrist level: ____________
Radial Nerve Injury
Radial Nerve Levels of Entrapments
- Axilla
❑ Chronic Crutch Palsy
❑Too much weight bearing on the crutch
❑All innervations are affected
❑(+) weakness of triceps, loss of sensation in post arm,
FA, & hand - Spiral Groove
❑Aka: Honeymoon’s/ Saturday’s Night/ Tourniquet
❑Spared: Triceps & Anconeus
❑↓ sensation starting at post FA down to hand - Arcade of Frohse
❑ Aka: Radial Tunnel/ Supinator/ PIN Syndrome
❑ Deep branch of radial nn
❑ Pure motor deficit
❑ (+): weakness of the hand
❑ If no wrist drop (ERCB intact) – PIN “Palsy” - Superficial Branch
❑ Aka: Cheiralgia Paresthetica/ Wartenburg
❑ Under the brachiorads
❑ Pure sensory deficit at dorsal wrist, dorsal
thumb, dorsal 1st WS
❑ Wrist level: NO weakness
Active Papal
Procedure: ____________
(+): Papal sign - ____________lat half of FDS, FDP cannot flex = ____________
Passive Papal
Procedure: ____________
(+): Papal sign - ____________
med half of intrinsic cannot ext = ____________
Active Papal
Procedure: Ask px to close hand
(+): Papal sign - Cannot close lat side of hand
lat half of FDS, FDP cannot flex = median nn patho
Passive Papal
Procedure: Ask px to open hand (relax hand)
(+): Papal sign - Cannot open med side of hand
med half of intrinsic cannot ext = ulnar nn patho
Carpal Tunnel Syndrome
Compressed Nerve: ____________ d/t ____________
____________
____________; If unilateral = ____________
CAUSE: ____________
____________ may
increase risk of sustaining CTS
Diagnostic test: ____________
Sensory affectation: ____________
Motor affectation: ____________, ____________
Spared: ____________
(____________)
Compressed Nerve: median nerve at the carpal tunnel of wrist d/t inflammation
of flexor tendons and/or median nerve
F>M; If unilateral = dominant hand first, can be bilateral
CAUSE: idiopathic
Overuse (computer), edema & connective tissue diseases may
increase risk of sustaining CTS
Diagnostic test: EMG NCV
Sensory affectation: Lat 3 & 1⁄2 fingers
Motor affectation: Thenar ms (AFO), Lat half of lumbricals
Spared: sensation thenar eminence (superficial palmar branch med nn)
Orthopedic Conditions of the Wrist and Hand
- CTS
- Pronator Teres Syndrome
- Wrist Fractures
- Madelung’s Deformity
- Boxer’s Fx
- Scaphoid Fx
- DQT
- Dupuytren’s Contractures
- Trigger Finger
- Gamekeeper’s Thumb
- Boutonniere Deformity
- Swan Neck Deformity
- Mallet Finger
- CTS
- Pronator Teres Syndrome
- Wrist Fractures
- Madelung’s Deformity
- Boxer’s Fx
- Scaphoid Fx
- DQT
- Dupuytren’s Contractures
- Trigger Finger
- Gamekeeper’s Thumb
- Boutonniere Deformity
- Swan Neck Deformity
- Mallet Finger
- Carpal Tunnel Syndrome
Compressed Nerve: ____________ nerve at the carpal tunnel of wrist d/t ____________
of ____________ and/or ____________
F>M; If unilateral = ____________
CAUSE: ____________
____________, ____________& ____________ may increase risk of sustaining CTS
Diagnostic test: ____________
Sensory affectation: ____________
Motor affectation: ____________
Spared: ____________
Compressed Nerve: median nerve at the carpal tunnel of wrist d/t inflammation
of flexor tendons and/or median nerve
F>M; If unilateral = dominant hand first, can be bilateral
CAUSE: idiopathic
Overuse (computer), edema & connective tissue diseases may
increase risk of sustaining CTS
Diagnostic test: EMG NCV
Sensory affectation: Lat 3 & 1⁄2 fingers
Motor affectation: Thenar ms (AFO), Lat half of lumbricals
Spared: sensation thenar eminence (superficial palmar branch med nn)
- Carpal Tunnel Syndrome
Clinical findings:
____________, ____________, ____________,
____________
(+) Tinel’s sign and/or Phalen’s test/ Reverse Phalens
Long term compression: causes ____________& ____________.
Median nn mob: ____________
Tx: ____________ = ____________ degrees ____________
____________ > ____________
Clinical findings:
Burning, tingling, pins and needles,
Numbness into median nerve distribution at night
(+) Tinel’s sign and/or Phalen’s test/ Reverse Phalens
Long term compression: causes atrophy & weakness of thenar muscles & 2
lumbricals.
Median nn mob: 5-30SH, 3-4x/day
Tx: night wrist splint = 0-5 degrees ext
Local corticosteroid injection > surgical decompression
- Pronator Teres Syndrome
Aka: ____________
____________ SPARED
MOI: ____________
Nn involved: ____________
Affectation: ____________> ____________
Motor: ____________
Sensory: ____________
(palmar cutaneous branch)
Aka: Grocery Bag Syndrome
Pronator SPARED
MOI: entrapped by 2 head of pronator teres (hypertrophy)
Nn involved: Median nn
Affectation: Motor > Sensory
Motor: Thenar ms, AIN
Sensory: Thenar eminence
(palmar cutaneous branch)
- Wrist Fractures
COLLE’S FRACTURE
Aka: ____________
MOI: ____________
Displacement: ____________
MC Fx in hand esp in ____________ d/t ____________
Dx Test: ____________
Tx: ____________
COLLE’S FRACTURE
Aka: Dinner fork deformity
MOI: FOOSH
Displacement: Radial Fx c dorsal
displacement of its fragments
MC Fx in hand esp in elderly d/t osteoporosis
Dx Test: Plain films
Tx: Immob 5-8 wks
SMITH’S FRACTURE
Aka: ____________ or ____________
MOI: ____________(____________)
Displacement: ____________
Dx: ____________
Aka: Reverse Colle’s or Garden
Spade deformity
MOI: FOBOTH (back of the hand)
Displacement: distal fragments in a
volar direction
Dx: Xray
- Madelung’s deformity
____________, ____________
____________
- ____________
Pushes the wrist
into ____________→ LOM: ____________
Congenital, develops during puberty
D/t retarded & asymmetric growth of epiphyseal plate at distal
end of radius
Ulna dislocates dorsally & distally, articulating c the lateral side of
pisiform
- Prominent Ulna, Retarded growth of Radius
Pushes the wrist into ext → LOM: wrist flexion
Madelung’s deformity picture gdrive
- Boxer’s Fracture
Aka: ____________
Fx of the ____________
MOI: ____________/____________or ____________
Tx: ____________
Dx Test: ____________
Aka: Street Fighter Fx
Fx of the 5th MC neck
MOI: fighting/punching a wall in anger
or frustration
Tx:Cast for 2-4 wks
Dx Test:Xray
- Scaphoid Fracture
MOI: ____________
MOST commonly fractured carpal bone
Can affect: ____________ & ____________
Diagnostic test: ____________
CC: tenderness @ ____________
Complication: AVN – ____________
Tx: Immob ____________
MOI: FOOSH
MOST commonly fractured carpal bone
Can affect: median nn & radial artery
Diagnostic test: Plain film
CC: tenderness @ anatomic snuffbox
Complication: AVN – Preisser’s Dse
Tx: Immob 4-8 wks
- De Quervain’s Tenosynovitis
Aka: ____________/ ____________
MC ____________
F>M; ____ y/o
MOI: ____________
Presentation: ____________
Most difficult activity: ____________
Muscles involved:
Special test: (+) ____________ Test (procedure of test)
Tx: thumb spica splint (FA based)
Aka: Washerwoman’s/ Hoffman’s Thumb
MC tendinitis of hand
F>M; 30-50 y/o
MOI: overuse or repetitive microtrauma
Presentation: pain at radial styloid/anatomic
snuffbox; swelling; ↓ grip & pinch strength
Most difficult activity: Hammering
Muscles involved:
Special test: (+) Finkelstein Test (make a fist c
thumb inside then passive UD)
Tx: thumb spica splint (FA based)
- Dupuytren’s Contracture
____________.
M>F
Non-DM: ____________
DM is a possible risk factor: ____________
Tx: Release of ____________ fascia
Banding on palm/digit flexors d/t
contracture/ thickening of palmar fascia.
M>F
Non-DM: contracture of MCP & PIP of 4th &
5
th digit
DM is a possible risk factor: 3rd & 4th digits
Tx: Release of palmar fascia
Trigger Finger
Aka: ____________
Cause: ____________
Result to: ____________
F>M; ____________y/o
Presentation: ____________; passive ext produces ____________
MC involved: A1 pulley =
Children: ____________
Adult: ____________
Aka: Digital Tenovaginitis Stenosans, Snapping finger
Cause: Idiopathic
Result to: thickening of flexor tendon sheath
F>M; 40 y/o
Presentation: painless; passive ext produces
snapping sensation
MC involved: A1 pulley =
Children: FPL of thumb
Adult: FDS of 3rd & 4th finger
Game Keeper’s Thumb
Aka: ____________
MOI: ____________
Fall while skiing when increasing forces
are placed on thumb through the ski pole
Pathophysiology: ____________
Tx: Immob ____ wks
Dx Test: ____________
Special Test:
Aka: Skier’s Thumb
MOI: Fall on abducted hand
Fall while skiing when increasing forces
are placed on thumb through the ski pole
Pathophysiology: Valgus >35 degrees →
sprain/ rupture of thumb UCL
Tx: Immob 6 wks
Dx Test: MRI
Special Test:
Thumb UCL laxity or instability test
❑ Stabilize ____________bone
❑ Apply ____________force
❑ N = ______degrees
❑ <______ = ____________ tear of UCL
❑ >______ = ____________tear
❑ Stabilize MC bone
❑ Apply valgus force
❑ N = 15 degrees
❑ <30-35 = partial tear of UCL
❑ >30-35 = complete tear
Boutonniere Deformity
Rupture of: ____________
Deformity: ____________
MOI: ____________or ____________
Swan Neck Deformity
____________
Deformity: ____________
Boutonniere Deformity
Rupture of: central tendinous slip rupture
Deformity: EFE
MOI: trauma or RAc degen of central band
Swan Neck Deformity
Contracture of intrinsic muscle/ dorsal
subluxation of lateral extensor tendon
Deformity: FEF
real deformity: extension of the proximal interphalangeal joint.
Common with RA
Bunnel-Littler (Finochietto-Bunnel) Test
❑ Aka: Intrinsic (+) Test – test for intrinsic contracture/tightness
❑ Tests structures around the MCP jt
❑ 1.
Yes –
No –
❑ 2.
Yes –
No –
- Passively ext MCP, PIP flex
Yes - NORMAL
No – either tight intrinsic or tight capsule - DDx
- Passively ext MCP, PIP flex
- Passively flex MCP: PIP flex
Yes - tight intrinsic
No – tight capsule
- Passively flex MCP: PIP flex
Hanes Zancolli Test
p471 Figure 7-64, Magee 6th ed
❑ Aka: Test for retinacular ligament
❑ Tests structures around the PIP jt
❑ 1.
Yes –
No –
❑ 2.
Yes –
No –
- Passively ext PIP, DIP flex
Yes - NORMAL
No – either tight retinacular ligament or tight capsule - DDx
- Passively ext PIP, DIP flex
- Passively flex PIP: DIP flex
Yes - tight retinacular ligament
No – tight capsule
- Passively flex PIP: DIP flex
Mallet Finger
Aka: ____________
MOI: ____________
Terminal slip
Rupture or avulsion of ____________ at its ____________.
Deformity: ____________
Aka: Baseball finger
MOI: trauma forcing DIP flexion
Terminal slip
Rupture or avulsion of extensor tendon at its insertion into distal phalanx of digit.
Deformity: EEF
FLEXOR TENDON ZONES
I. - ____________
II.– ____________
III.– ____________
IV – ____________
V – ____________
TI – ______joint
TII – ______joint
TIII – ______joint
I. - DIP joint
II.– NO MANs LAND
III.– Metacarpals
IV – Carpal Tunnel
V – Distal Forearm
TI – IP joint
TII – MCP joint
TIII – CMC joint
EXTENSOR TENDON ZONES
I.– ______joint
II.– middle phalanx
III –______joint
IV.– proximal phalanx
V.– ______joint
VI.– dorsum of hand
VII – dorsal wrist
I.– DIPjoint
II.– middle phalanx
III –PIPjoint
IV.– proximal phalanx
V.– MCP joint
VI.– dorsum of hand
VII – dorsal wrist
Upper Limb Neurodynamic (Tension) Test
Reference: OPA Magee 7th Ed. Page 205
Other Names: ULTT, ULNT, Elvey Test
❑ Supine, passive
❑ Start c Sh, FA, wrist, finger, elbow
❑ **Sh depression
❑ C/L neck SB (sensitizing test)
❑ Hold position 6-10 secs
❑ (+): reproduction of sx
Drill
A physical therapist performs the test
shown in the photo. Upon examination,
the patient felt deep stretch in the cubital
fossa. What structure is most likely
affected:
a. Median nerve
b. Anterior Interosseus nerve
c. Musculocutaneous nerve
d. None of the above
OA & Gastrectasis: (HD Blue Picture)
- Heberden nodes – dorsal surface of ______
- Bouchard nodes - dorsal surface of ______
Flexor Tendon Zone (structures involved)
I –
II–NOMANSLAND:FDPandFDS(poorprognosis,needssurgery)
III - + lumbricals
IV – FDP, FDS, FPL
V – median and ulnar nn; ulnar and radial arteries
TI-II – FPL and FPB
TIII – thenar mm
Extensor Tendon Zone
I-II: inability to actively extend DIP
- mallet finger & swan neck
III-IV: inability to actively extend the PIP
- boutonniere
