Upper limb Flashcards
Describe kinematics at GHJ and appropriate glides
abduction = superior roll and inferior slide = inferior glide
ER - anterior slide and posterior roll - anterior glide
IR - posterior slide and anterior roll - posterior glide
Flexion - posterior spin - distraction
extension - anterior glide - distraction
What structures provide passive anterior stability to shoulder
- coracoacromial ligament
- coracohumeral ligament
- transverse humeral ligament
- anterior GH ligament (superior, middle and inferior)
Which muscular force couple prevents winging?
Which force couple controls elevation?
Which force couple controls end range elevation?
- Serratus anterior and lower traps
- Serratus anterior, lower traps and upper traps
- middle traps and serratus anterior
Red flags?
Cancer Signs of infection Trauma unexplained neurological signs metastatic disease fractures and dislocation Avascular necrosis Neurovascular compromise
Yellow flags?
RTW for older than 50 Higher pain intensity Long pain duration Previous injury Extensive time off work Co-morbidities Previous shoulder pain Activity avoidance High BMI Job satisfaction Poor social support
Imaging options for shoulder conditions
X-ray - OA and impingement
US - rotator cuff, LHB, bursa
MRI - rotator cuff
Arthrography- labrum, bony bankart-lesion, Hill-sachs lesion
4 phases of adhesive capsulitis
- Sharp pain at EOR, achy pain at rest and sleep disturbances
- Freezing- severe pain, early loss of ER
- Frozen - pain and loss of ROM
- Thawing- resolving pain but persistent stiffness
Impingement- primary and secondary causes
Primary - structural involvement (AC arthropathy, type 2 or 3 acromion, bone spurs, swelling of soft tissues
Secondary - functional problems (RC weakness, instability, scapular dyskinesias)
Typical presentation of scap dyskinesias
- Lack of upward rotation, external rotation and posterior tilt
- increased clavicular elevation and retraction
- scapular asymmetry
- scapular winging
Management options
- Advice and education
- Ergonomics
- Manual therapy
- taping
- exercise (strength, motor control, proprioception)
Open and closed packed positions of elbow
Humeral ulnar joint - open = 70 flexion 10 supination - closed = extension and supination Radiohumeral joint - open = elbow extension and supination -closed = 90 flexion and 5 supination Radiohumeral joint open - 35 supination and 70 flexion closed - 5 supination
Arthrokinematics at elbow + glide
flexion - ulna and radius glide anteriorly on humerus (longitudinal and PA)
extension - ulna and radius glide posteriorly on humerus (AP)
pronation - radius medially spins and posterior glides (AP)
supination - radius laterally spins and anteriorly glides (PA)
When are ligaments taut at elbow?
Anterior MCL - taut throughout range (first restraint)
Posterior bundle MCL - taut at full flexion
With no MCL - more instability in pronation
Lateral complex is uniform tension throughout range.
With no LCL - more instability in supination
Median nerve pathway and common site of compression at elbow
through cubital fossa, compressed at distal humerus under ligament of struthers and in between two heads of pronator teres.
Radial nerve pathway and common site of compression at elbow
- anterior to lateral epicondyle and radiohumeral joint where it divides into superficial branch and PIN. Compression at intramuscular tunnel in supinator (arcade of Frohse)
Ulnar nerve
Posterior to medial epicondyle, passing between humeral and ulnar heads of FCU. Compression at cubital tunnel if valgus instability
Acute injuries at elbo
Fracture or dislocation MCL rupture Tendon strain or rupture Joint overload Bursitis
Chronic injuries at elbow
Tendinopathy Chronic instability Neural entrapment Joint overload Stress fracture Referred pain Bursitis
TDT for lateral tendinopathy
- PA on radial head
- Lateral glide at radiohumeral joint
Not to miss conditions at elbow
Osteochondritis dissecans
referred pain
Causes of upper limb entrapment neuropathies
infection immune-related metabolic ischaemic hereditary compression traumatic toxic
Positive and negative symptoms of nerve entrapment
positive - pain, pins and needles, hyperalgesia and allodynia, spontaneous pain
negative- sensory loss, motor weakness, reduce impulse conduction
Clinical features of nerve entrapment
painful sensations (burning, deep ache, cramping, parasthesia) antalgic postures, AROM and PROM impairments, pain with nerve tension and compression, signs of impulse conduction loss, impairments in surrounding neural tissues.
Stages of carpal tunnel
stage 1:
- severe pain may be from wrist to shoulder
- tingling in hands and fingers
- flick sign relieves symptoms
- wake up night feeling hand is swollen and then stiff in morning
2
- symptoms also in day with sustained positions and repeated movements
- drop things cause they can’t feel fingers
3
sensory symptoms diminish
- aching in thenar eminence
- weakness and atrophy of thenar muscles
Classification of wounds
Black = necrotic yellow = sloughy tissue red = granulation pink = epithelium tissue
Outcome measures for hand
DASH
PRWE
VAS
How can you describe a wound
- tidy (clean surgical incision)
- untidy (loss of tissue +/- soft tissue coverage)
- type of closure (primary, delayed primary, secondary intention, closure)
What is total active motion of fingers?
Flexion at MCP + IPs - any loss of extension. Actively. TPM is same but passive
Treatment of oedema
pressure (coban, glove, tubigrip)
effleurage (pat the cat_
What can cause stiffness in hand?
Oedema
Immobilisation
Scarring
General treatment principles in hand
- Wound management
- Oedema control
- therapeutic exercise and manual therapy
- Splinting
- Scar management
- Sensory re-education
- functional use
Strength of repair timeline
1-20 days depends on type of surger
1-10 = strength decreases (worst at day 5)
3-6 weeks = strength increases
12 weeks = full strength
What will influence post op management of hand?
- type of surgery and what was injured in surgery
- surgeon’s preference
- condition of tendon
- any other injuries
- rate and quality of scar
- patient age, general health and social influences
Treatment aims in hand management
- restore maximal tendon gliding without adhesions
- prevent contractures
- maintain full ROM of uninvolved joints
- return to previous level of function
Tendon gliding exercises
Fist (maximum FDP)
Straight fist (maximum FDS)
Hook (maximum differential glide (more FDP than FDS)
Management of crush injury
- oedema control
- pain management
- manage stiffness (exercise, heat, splintage)
- gradual strength and endurance
Management of amputations
- wound management
- oedema control
- stump shaping
- hand and finger ROM
- scar management
- desensitisation
- functional use
- psychological aspect
Joint protection principles for rheumatoid arthritis
- respect pain
- use larger joints if possible
- distribute load
- avoid deforming positions
- avoid prolonged positions
- avoid repeated jarring of joints
- use adaptive equipment
- balance work and rest
Pinch strength alternatives
Lateral pinch
Chuck pinch
Tip pinch
Test sensation in hand
- 2 point discrimination
Moberg’s pick up test
What are the 4 levels of involvement in AHTA
- accredited hand therapist
- associate
- affiliate
- newsletter subscriber
Pre-op considerations in hand
- allergies
- bleeding disorders
- recent or long term illness
- psychological illnesses
- keyloid scars or poor healing
- explain risks to patient
- ask about general health
Post op considerations in hand
- minimise swelling
- relieve pain
- limit immobilisation
- consider prior injury and what’s been injured in the surgery
Aims of splinting?
- protect healing structures
- facilitate healing structures
- maintain optimal anatomical position
- assist weak structures
- restrict/control movement
- improve/promote ROM
- promote function
POSI?
25 wrist extension, 60 MCP flexion, 10 PIP flexion, 5 DIP flexion
- facilitates veinous drainage, minimises stiffness of collateral ligaments, maintains balance of long F, E and intrinsics
When to use which splints in healing process
Inflammatory - static, serial static, static progressive (at end)
proliferative - serial static, static progressive, dynamic
remodelling - serial static, static progressive
Classification of splints
Immobilisation - static splint
mobilisation - dynamic, serial static, static progressive.
Restrictive- static and dynamic
Arch system of hand
- longitudinal (flexion of MCP, IPs)
- proximal transverse (fulcrum for wrist and long flexors)
- distal transverse (through MC head)
What is dual obliquity?
the length of 2nd to 5th MC gradually decrease- need to consider when making splint
Considerations when splinting
- leverage
- fit/comfort
- strength
- pressure areas
- skin
- bony prominences
- friction
- oedema
- circulation/sensory loss
- convenience
- is it only restricting the things that need to be
PROCESS of splinting
- pattern
-refine pattern
-options for material
-cut and heat - evaluate fit when moulding
- strapping and components
-splint finishing touches
evaluate if it worked and explain to the patient.
Go over materials for splinting and pros and cons for them i
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