Quiz #8 Flashcards
loss of sensation on volar and dorsal medial hand
cubital tunnel
intact sensation of the dorsal medial hand
guyon’s canal
weakness of medial hand with strong FDS FDP and weak lumbricals (intrinsics)
tunnel of guyon
weakness of the medial hand with intrinsic loss and FDP FDS loss
cubital tunnel
what fractures are notoriously difficult to get back full ROM?
intraarticular fractures
how are intraarticular fractures rehabed?
low load, long time
soft tissue work
where is the ulnar nerve often compressed?
behind the medial epicondyle
how do we test for ulnar nerve damage?
Fromen’s sign
what is the functional loss with a median nerve injury?
loss of pronation, wrist flexion, radial deviation, thumb flexion/abduction/opposition, and gripping
ape hand deformity
what is the functional loss with an ulnar nerve injury?
loss of wrist flexion, ulnar deviation, 5th digit PIP flexion, finger abduction/adduction,
benediction hand deformity (loss of extension of DIP and PIP of 4th and 5th digits)
what is the functional loss with a radial nerve injury?
loss of supination, wrist extension, gripping, wrist stabilization, finger extension, and thumb abduction
what is being described?: entrapment of the ulnar nerve at the medial intermuscular septum which slopes from a thick wide base at the medial epicondyle to a thin edge on the humeral shaft
cubital tunnel syndrome
what causes cubital tunnel syndrome?
superfical traction from flexion and entrapment from the anconeus
what signs are associated with cubital tunnel syndrome?
pain and paresthesia of digits 4-5 in the ulnar nerve distribution on the dorsal and volar aspect of the forearm and hand
inability to adduct/abduct finger
loss of grip
worsens throughout the day
atrophy of intrinsics, FDP and FDS
(+) Tinnel sign
what is an ulnar nerve transposition?
removing the medial muscles, taking the nerve and moving it in front then reattaching the muscle
what is an insitu ulnar nerve transposition?
debridement to loosen the nerve IN PLACE
what is pronator teres syndrome?
median nerve entrapment at the ligament of suthers causing pain at the wrist, medial forearm, and with increased extension and pronation
paresthesias in digits 2-3 and possibly the thumb
which occurs more carpal tunnel syndrome or pronator teres syndrome?
carpal tunnel syndrome
what are the sites for entrapment with pronator teres syndrome
biceps aponeurosis, pronator teres, FDS
how can pronator teres symptoms be replicated?
with direct pressure over pronators (4cm distal to cubital crease), resisted pronation(PT), supination, long finger flexors(FDS), elbow and wrist flexion
what is one differentiating factor b/w pronator teres syndrome and carpal tunnel syndrome?
carpal tunnel has nocturnal symptoms, while pronator teres may not
how can pronator teres syndrome be tested?
handshake with resisted pronation, extend elbow passively (+=reproduction of pain)
what makes up the carpel tunnel?
pisiformis, triquetrum, lunate, scaphoid, and trapezium
transverse carpal ligament
9 tendons
median nerve
what ligament surrounds the TFCC?
radioulnar lig
what does the radioulnar lig do around the TFCC?
increases the depth of the jt so the wrist becomes a smooth continuous jt
what is negative ulnar variance?
shorter ulna
what is positive ulnar variance?
longer ulna
what is the motion at the 1st CMC?
15 deg flex
70-80 deg ext
70 deg abd
what is the motion at the 1st MCP jt?
75 deg flex
10-15 deg ext
what is the motion at the 2nd-5th MCP jts?
90-110 deg flexion
30-50 deg ext
what is the motion at the PIP jts?
70-110 deg flex
9-20 deg ext
what is the motion at the DIP jts?
80-90 deg flex
15-20 ext
t/f: the intrinsics balance flex/ext
true
what is the only extensor of the MCP?
extensor digitorum communis
the lateral bands of what muscle wraps around the volar plate of the MCPs?
extensor digitorum
what muscle continues to form the extensor hood over the proximal phalanx
EDC
what is the central slip?
extension of the EDC that attaches to the middle phalynx that extends the PIP
t/f: the actions of the extensors in the hand are really bc of the tension increated by the lumbricals
true
what is the transverse retinacular ligament?
the ligament extending from the PIP volar plate that encircles the PIP and prevents the lateral bands from migrating/bowstringing dorsally
creates extension force at PIP
what does laxity of the transverse retinacular lig result in?
swan-neck deformity!!!
hyperextension of PIP, flexion of DIP
what is a swan neck deformity?
PIP hyperextension
DIP flexion
what is the oblique retinacular lig (ORL)?
originates on PIP volar plate and runs obliquely to the terminal extensor tendon
PIP extension
what are the wrist flexors?
flexor carpi radialis
flexor pollicus longus
flexor digitorum superficialis
flexor digitorum profundus
what are the intrinsics of the hands?
lumbricals and interossei
what is the role of the intrinsics of the hand?
to balance flexor and extensor activities
do the interinsics of the hand flex or extend the IPs?
extend
do the intrinsics of the hand flex or extend the MCPs?
flex
what is the primary action of the lumbricals?
IPJ extension via the proximal pull on the dorsal hood
t/f: as the lumbricals contract, they pull the flexor tendon distally, lessening the force of the FDP contraction
true
what is the role of the palmar/volar interossei?
allow MP flexion, IP extension
assists the lumbricals
what is a Boutoneire’s deformity?
PIP flex, DIP hyperext
what is Mallet finger injury?
injury to the extensor hood causes DIP flexion
what are Bouchard’s/Heberden’s nodes?
Bouchards-PIP
Heberdens-DIP
hyperplasia of the IPS
arthritic change
what is ulnar drift?
pull of the fingers in the ulnar direction
common in RA
what is an “ape hand” injury
median nerve injury proximal to the wrist
inability to abd, flex, or oppose the thumn so it is in the same plane at the other digits
may see atrophy of the thenar eminence
normal PROM
what is the opening hand of benediction?
MCP ext, no IP ext
what is the closing hand of benediction?
digits 2 and 3 can’t flex
likely to see MCP flexion still at digits 2 and 3
what are the characteristics of an ulnar nerve injury?
deficit of the 4th and 5th digits
prominent at rest and when extending fingers inability to abd/add digits 2-5
atrophy of the dorsal interossei
what are the characteristics of a median nerve injury?
deficit of digits 2-3
prominent when making a fist
difficulty opposing the thumb
atrophy of thenar eminence
what is the claw hand/intrinsic minus position?
MCP extension with IP flex
ulnar and median nerve atrophy of intrinsics
predominence of extensor digitorum bc flexion is taken
what is carpal tunnel syndrome?
compression of median nerve at the carpal tunnel
usually idiopathic but can be related to overuse
what are the causes of acute carpal tunnel syndrome?
trauma, infection, hemmorhage, high-pressure injection, acute thrombosis, and burns
what is the average age of people with carpal tunnel syndrome?
40-60 y/o
are men or women affected by carpal tunnel syndrome more?
women
what are the manifestations of carpal tunnel syndrome?
numbness/tingling of digits 1-4
weak thumb abduction
dropping objects
worsens at night
atrophy of thenar eminence
what is the Phalan test?
press the backs of the hands together to get max wrist flexion to see if they feel anything
what is the Tinnel sign?
tapping a superficial nerve to see if it creates pain
what is Guyon’s canal syndrome?
compression of the ulnar nerve at Guyon’s canal in the ulnar wrist
what are the causes of Guyon’s canal syndrome?
overuse
direct pressure on handlebar, barbell, construction equipment
excessive gripping, twisting, or repeated wrist and hand motions
what are the manifestations of Guyon’s canal syndrome?
numbness/tingling of digits 4-5
hyperthenar and interossei atrophy
intact dorsal sensation
what is the treatment for guyon’s canal or carpal tunnel syndrome?
ADL mods
wrist mobs
tendon glides
nerve glides (neuromobilization)
splinting
bike fit
modalities
surgery to curt the lig and create more space
how do we perform ulnar nerve glides?
flex the elbow and wrist
how do we perform median nerve glides?
extend the elbow and wrist
how do we perform radial nerve glides?
extend the elbow and flex the wrist
what is DeQuervain’s tenosynovitis?
overuse of the abductor pollicus longus (APL) and extensor pollicus brevis
tension under the extensor retinaculum
how is DeQuervain’s tenosynovitis diagnosed?
pain with thumb extension
tender and swelling over the tendons at the radial styloid process
crepitus with motion
(+) Finkelstein’s sign
what is a positive Finkelstein’s sign?
tuck the thumb in and make a fist then ulnar deviate
pain=(+)
in the initial phase, what is the treatment of DeQuervain’s tenosynovitis?
modalities for pain and inflammation reduction
NSAIDs
ADL modification
splinting (spica)
surgical release
as pain subsides, what is the treatment of DeQuervain’s tenosynovitis?
AROM
gentle stretching
painfree resistive motion progression
what is Colles fx?
distal radial fx w/dorsal angulation
dinner fork deformity
most common fx among women up to age 75
how is a Colles fx treated?
casting, surgery (ext fix, int fix, pinning, bone substitutes)
pain and edema management, ROM, manual therapy, and strengthening
what is a TFCC injury?
due to axial load and compression through the wrist wearing at the central portion of the TFCC
tears of peripheral portion of the disc
disc perforation in 50-60% of cases
what is the cause of type 1 TFCC injuries?
acute trauma, tear in lig or fovea
what is the cause of type 2 TFCC injuries?
degenerative/repetative injury
how is a TFCC injury diagnosed?
TFCC load test where the wrist is ulnar deviated with long axis compression
MRI
Hx
how are TFCC injuries treated?
conservative measures (pain management, movement restoration, strengthening, fxn)
surgery
what is a trigger finger?
thickening of the flexor tendon sheath or tendon causes teh finger to lock then snap or trigger with flex/ext as the nodule pulls through the pulley
nodule often palpable on flexor tendon
what causes trigger finger?
insidious or due to repetitive gripping of sharp edges
how is trigger finger treated?
rest
hand-based splint that blocks MCP motion, but allows IP motion
modalities (not well supported by evidence)
injections
surgery
what is a Boxer’s fx?
fx of the 5th metacarpal
can see a depression of the 5th metacarpal
how is a Boxer’s fx treated?
immobilization or surgery
what is a game keeper’s thumb/skier’s thumb?
game keeper’s-chronic
skier’s-acute
tear of the 1st MCP
can cause avulsion fx
how is game keeper’s/skier’s thumb treated?
hand-based splint (stop MCP motion, allow IP motion)
modalities
ROM to tolerance
eventual strengthening
what is a ganglion cyst?
ganglia arise from a jt capsule/tendon sheath causing possible pain or tenderness
pressure form cyst on a nerve can cause focal neurologic symptoms
what are the 2 general groups of forces acting on the hips?
GRF (ground rxn forces)
HAT (head, arms, trunk)
what are the 3 bones of the pelvis?
illium, ischium, pubis
what connects the inferior part of the acetabulum?
the transverse acetabular lig
what is the role of the labrum at the hip?
deepen the acetabulum
what is the center edge angle?
help deepen the fossa
normal: 22-42 deg
amount of overhang the labrum has
determines the angle of femoral head coverage
what is the acetabular anteversion angle?
men-18.5 deg; women-21.5 deg
the extent to which the acetabulum contains the anterior aspect of the femoral head
larger angle=risk for dislocation
what is the angle of inclination?
the angle made b/w the femoral neck and shaft
influence leg length
normal: 125 deg (larger in children, smaller in older adults)
what is coxa vara?
angle of inclination <125 deg
appearance of shorter leg ipsilaterally
more prominent GT
femurs appear more abducted –> genu valgus
increased glut med moment arm–>more compression of the hip
contralateral genu recurvatum
contralateral knee/hip flexion
ipsilateral pelvis rotates ant; contralateral pelvis rotate post
what is coxa valga?
angle of inclination >125 deg
larger appearing leg
may see genu varus
smaller glut med moment arm–>less compression of the hip–>risk for dislocation
ankle dorsiflexion to drop the knee angle
foot pronation to shorten the leg
genu valgum ispilaterally
ipsi pelvis rotates post, contra pelvis rotates ant
LBP is possible if the leg length discrepancy is greater than __mm
5
clinically significant leg length discrepancy is greater than ___mm
20
how do you measure true leg length?
measure from the ASIS to the distal med malleolus
how do you measure apparent leg length?
measure from the AIIS to the distal med malleolus
what is the angle of torsion?
the angle of anteversion of the femur
normal=15-25 deg of anteversion
what is retroversion?
<15 deg anteversion
what is anteversion?
> 25 deg anteversion
is there IR or ER with retroversion?
ER
is there IR or ER with anteversion?
IR
what is the Craig test?
lie pt in prone, move the leg in and out and feel when the pelvis gets to it most lateral portion and observe how much the leg goes out
in a lot=retroversion
out a lot=anteversion
used to get insights on anteversion and retroversion
what provides stability of the hip?
capsuloligamentous complex (CLC)
what is the illiofemoral lig (Y lig of Bigelow)?
lig from AIIS and ant acetabulum to intertrochanteric line
can hang on the y lig with weak hip flexors
what is the pubofemoral lig?
ant pubic ramus to intertrochanteric line
what is the ischiofemoral lig?
post acetabulum rim to femoral neck
limits ext, IR, add from flexed position
what is the ligamentum teres?
ligament from the acetabulum notch to fovea capitis
interarticular but extrasynovial
carries blood supply
other than the ligamentum teres, what else supplies blood to the hip?
circumflex and retinacular arteries around the head and neck of the femur
what fx usually disrupts blood flow to the hip?
femoral neck fx
why would a femoral fx disrupting blood supply be dangerous?
it could lead to avascular necrosis
a transphyseal fx has a ___ % AVN risk
90-100%
a transcervical fx has a ___% AVN risk
50%
a cervico-trochanteric (or basicervical) fx has a ___% AVN risk
25%
an intertrochanteric fx has a ___% AVN risk
10%
what is osteoarthritis?
focal loss of articular cartilage w/subchondral bone sclerosis, loss of jt space, and osteophytes (spurring)
what are predisposing factors for OA?
obesity
family history
hypermobility
previous injury
what are the s/s of OA?
stiffness following inactivity (AM) - often the first symptom
pain unrelated to imaging present in buttock, groin, thigh, and knee
pain after exercise may persist
loss of motion in a capsular pattern (IR>ext>abd)
capsular end feel
lat hip pain is not usually a primary sign
what does radiographic imaging of OA show?
jt space<2.5 mm
osteophyte formation
subchondral bone sclerosis and cysts
lack sensitivity
what is the sequelae of OA?
supporting capsule and ligaments are slacken
alterations in proprioceptive input
altered muscle length-tension relationships
compensation from adjacent regions (lumbar, knee, ankle, foot)
muscles can’t generate as much force
what is the intervention for OA?
education and ADL modification
regular controlled loading w/periods fo rest
ROM and prolonged stretching (FABER)
why is ROM helpful with OA?
it increases the ability of the jt to move and allows other portions of the jt to absorb forces
why is manual therapy helpful for OA?
it reduces pain w/low grade and high grade for improving mobility
what is femoral grind (scour) test?
axial compression down the femur and moving it around to see where there is pain
what is the FABER test?
put the pt in FABER and add force to the jt
test for OA or SI compression
what are the THA options for OA?
open vs mini
cemented vs noncemented
posterior vs anterior approach
hemiarthroplasty
hip resurfacing
arthroscopic debridement
are more THAs cemented or noncemented?
cemented
which THA approach preserves the glut and vastus lateralis?
posterolateral approach
which THA approach has less hip precautions, longer open time, and heterotopiuc bone formation ?
anterolateral approach
what are the hip precautions with the posterior hip approach?
no flexion beyond 90 deg, no add, no IR
what are the hip precautions with the anterior hip approach?
ER
what is the average lifespan of a hip replacement?
10-15/15-20 years
with a hemiarthroplasty, what is replaced?
just the femoral side
with a total hip replacement, what is replaced?
the femoral and acetabular sides
with hip resurfacing what is replaced?
just the femoral head
what is arthroscopic debridement?
cleaning up the joint space
