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210 Cards in this Set
- Front
- Back
What are other names that can be used to describe tunnel syndromes? (3)
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Canalicular, canal, channel
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How does Webster's define canalicular and canal?
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An enclosed passage.
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How does Webster's define channel?
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A "bed in which a material body may run."
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How does Webster's define tunnel?
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A bodily channel.
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What 5 things are tunnel type syndromes named for?
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1. Compressed Nerve 2. Anatomical Area 3. Anatomical Tunnel 4. Action producing the syndrome 5. Author's names
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What is neurapraxia?
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Temporary loss of function caused by minor trauma or pressure, like when an extremity falls asleep, recovery occurs w/in minutes.
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What is Axonotemesis?
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Loss of function d/t severe ischemia, recovery can occur w/in weeks.
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What is Neurotemesis?
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Loss of function d/t transection of nerve, no recovery unless nerve repaired.
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What are some common causes of nerve injury?
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tumor, trauma, infection, toxic exposure, muscular compression, iatrogenic, vascular, anatomic variation, idiopathic
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What does an EMG try to pick up and what can it confirm?
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Action potentials indicating muscle activity; axonal lesions in LMN lesions.
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What does an NCV evaluate and what does it measure?
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Condition of peripheral nerves; the speed at which an applied signal travels along a nerve.
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Why are EMG and NCV useful in tunnel syndromes?
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To localize the location of the lesion.
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What does a DC's approach to tunnel management depend on?
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Region, tissue and concomitant symptoms of the entrapment.
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What is the initial modality in treating a tunnel syndrome and how much is needed to relieve pain perception?
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cryotherapy, reduction of the skin temperature by around 5 degrees C reduces nerve transmission velocity which relieves pain perception (AP not coming from peripheral n.)
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What is the 2nd modality that should be used to treat a tunnel syndrome?
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Phonophoresis, in pulsed form, of low intensity w/ ointment (corticosteroid and lidocaine). If congestion starts resolving but pain still present interferential current can be added.
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What reasons are there for referring a tunnel patient out for an EMG/NCV?
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Previous 2 treatments failed to resolve, muscle atrophy or loss in muscle strength. If pathology is advanced refer to orthopedists for decompression.
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What is ergonomics?
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Defined the scientific study of human work; study of problems of people in adjusting to their environment; science relating to man and his work, anatomic, physiologic and mechanical principles affecting the efficient use of human energy.
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What is included in ergonomics?
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Office, industrial, injury prevention, treatment, work station design and layout including equipment design, personnel safety, manual material handling.
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What is meant by human factors?
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The discovery of information regarding human behavior, abilities and limitations and applies these characteristics to the design of systems, tasks, machines, tools and environments to enhance efficiency, safety and productivity in their use.
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What is human factors associated w/?
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Human psychology, human computer interface/usability, product design, person in the workplace, environmental considerations
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What is true neurologic TOS?
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Rare, typically painless, and caused by congenital anomalies (cervical rib)
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What are 3 categories of TRUE TOS?
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Anterior scalene syndrome
Costoclavicular syndrome Hyperabduction syndrome |
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What does thoracic outlet syndrome consist of?
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A group of distinct disorders that affect the nerves in the brachial plexus and various nerves and blood vessels b/w the base of the neck and axilla.
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What is the operculum?
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The “thoracic outlet”; upper lid of the chest cage called outlet/operculum b/c it is the site from where the arterial flow of the thorax goes out.
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What flows into the thorax at the operculum and does more flow in or out?
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Venous flow, ascending and descending terminal ducts of the lymph system, vagus n., phrenic n., and parts of brachial plexus, esophagus and trachea; more flows in than out.
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Where does ARTERIAL TOS occur?
Who is affected? Why does arterial TOS happen in the first place? |
UNILATERAL ONLY
both genders and more often in young people; often caused by a CONGENITAL anomaly. |
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What are Sx of arterial TOS?
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Sensitivity to cold in the hands and fingers, numbness or pain in the fingers and finger ulcers or severe limb ischemia.
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What causes VENOUS TOS and how does it develop?
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UNKNOWN
develops suddenly, usually following unusual, PROLONGED LIMB EXERTION |
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What causes TRAUMATIC TOS?
MOST COMMON symptom? EXACERBATES traumatic TOS sx? |
Traumatic or repetitive activities;
PAIN & TENDERNESS body postures can exacerbate. |
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What 2 TOS exams for ANTERIOR SCALENE syndrome are in the notes?
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A.A.R.B.
ADSON'S test for anterior scalene; REVERSE BAKODY Maneuver. |
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3 TOS tests for COSTOCLAVICULAR syndrome
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EDEN'S-HOSTAGE-SOLDIER'S cost
Costoclavicular Maneuver (Eden’s), Hostage position, Soldier’s Position. |
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TRUE NEUROLOGIC TOS treated and how are other forms treated?
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True usually treated w/ SURGERY~
; other forms need symptomatic Tx requiring conservative care: analgesics, PT for neck and shoulders and strengthen mm. to improve posture. |
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What is used in chiropractic management of TOS?
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Educate patient, address subluxations, Address acute phase, Address fibrotic tissue, Address musculature.
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ACCOMODATION
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When the lens capsule in the eye changes shape to focus on a close object.
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What is RPA and its measurement?
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Resting Point of Accommodation (RPA) is 30 inches for young people and farther as we age.
DEFAULT FOCUS DISTANCE AT WHICH WE STARE WHEN THERE IS NOTHING TO LOOK AT. |
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CONVERGENCE
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HARDER than accomodation. ~ Akin to going cross-eyed to aim at an approaching object
RESTING POINT of VERGENCE is default focus distance & is also called DARK (think dull witted staring) vergence. RPV = 35" away at 30* downward |
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What is RPV and its measurement?
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Resting point of vergence is 45 inches when looking straight ahead and averages 35 inches when looking downward at a 30 degree angle. Default distance when nothing to look at. AKA dark vergence.
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How does lowering the monitor help a person working on a computer?
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It will reduce the RPV and improve overall posture, reducing craning of the neck.
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Where should the top of the monitor sit to help the computer user?
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The top of the screen should be at or below eye level.
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What is the most common neurological disorder of the shoulder?
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SCAPULAR WINGING
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What 7 muscles attach the scapula to the chest wall and help control the scapula?
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trapezius, levator scapulae, rhomboids major and minor, pec MINOR, omohyoid and serratus anterior.
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WINGED SCAPULAE are always associated with what 2 muscles partially or completely paralyzed?
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SERRATUS ANTERIOR & TRAPEZIUS
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Trapezius is innervated by the ______________ nerve.
Trapezius actions: (3) |
SPINAL ACCESSORY NERVE (CN IX)
STABILIZATION during rotation - ELEVATION - RETRACTION |
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WHERE can the spinal accessory nerve become entrapped?
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Multiple points along its course behind the SCM, scalenes and upper trap; may be caused by muscle, vascular distention or lymph.
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How can chiropractors treat spinal accessory nerve compression?
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Adjust cervical subluxations and work on muscles: stretch upper traps; graston to SCM, scalenes and proximal trap; strengthen lateral cervical flexors, shoulder elevators and GHJ abductors.
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What does long thoracic nerve compression cause?
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Weakness or paralysis of the serratus anterior, secondary to palsy of the long thoracic nerve is most common cause of scapular winging.
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How may a patient w/ injury to the long thoracic nerve present? C5-C8
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Pain, weakness, limitation of shoulder elevation, scapular winging w/ medial transition of the scapula, ROTATION OF INFERIOR ANGLE TOWARD MID-LINE (downward rotation) and prominence of the vertebral border.
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What causes long thoracic nerve compression?
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Rapid head motion (esp. lateral), whiplash, poorly adjusted crutches, injury or tumor in the axilla.
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What is the typical posture of a person w/ dorsal scapular nerve syndrome?
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Lateral tilt and rotation of the cervical spine
. The head tilt and rotation take some tension off the scalenes, giving some release of the nerve. The DS nerve innervates the levator scapulae and rhomboids, both of which downwardly rotate the glenoid fossa. |
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How does a patient w/ dorsal scapular nerve syndrome typically present?
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General aching; rhomboid and levator tenderness to deep palpation; tenderness of the middle scalene, palpation to the middle of the middle scalene may increase pain in the rhomboids and levator and in the arm.
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What does unilateral entrapment of the dorsal scapular nerve cause?
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An imbalance b/w the bilateral rhomboid major and minor muscles and/or the bilateral levator scapulae muscles.
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What can occur d/t the levator origin?
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Subluxations in the cervical and/or thoracic spine or at least chronic strain. After the dorsal scapular nerve entrapment is corrected and muscles return to normal, vertebral corrections will be maintained.
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GOWER SIGN
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=DELTOID ATROPHY
=UPPER TRAPS TAKE OVER WHEN RAISING ARM + supraspinatus =AXILLARY NERVE COMPRESSION |
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What can cause axillary nerve entrapment/quadrilateral space syndrome?
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SSpace Occupying Lesion (SOL), humeral Fx, GHJ dislocation, sleeping w/ arm under head, organizing hematomas.
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How can axillary nerve entrapment/quadrilateral space syndrome be managed?
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Verify lack of SOL, address adhesions surrounding muscle hypertrophy, reduce fascial scar tissue, address C/T subluxations,
**REHAB DELTOIDS W/ WEIGHTS FIRST (rotator cuff, internal/external rotation, flexion/extension w/ 1 lb. weights first) |
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How does a patient feel w/ scapulocostal syndromel?
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Pain in medial scapular border, neck, shoulder, upper arm and later the thorax; can be mistaken for angina or heart attack; pain, numbness, tingling may be felt in medial forearm into hand.
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What TRIGGER POINT is usually found in someone suffering from scapulocostal syndrome?
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MYOFASCIAL PERIOSTITIS: a trigger area at the site of the attachment of levator scap to the upper medical angle of the scapula.
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What is the usual mechanism of forming a myofascial periostitis?
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Usually postural causing tension traction irritation of the attachment site; fascial in nature, may have cervical paraspinals involved, subluxation; posture and occupation related.
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What muscles have a branch of the suprascapular nerve?
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Supraspinatus: branch after comes through suprascapular notch and Infraspinatus: an external rotator.
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How do you test for suprascpular nerve syndrome?
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External shoulder rotators (affecting infraspinatus at infrascapular notch) and abductors (affecting supraspinatus and suprascapular notch) to find where trapped.
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What causes intercostobrachial nerve syndrome?
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Intercostal neuritis, entrapment in the medial triceps fascia, axillary compression d/t tumor, infection or direct trauma.
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What generates more power pushing or pulling and why?
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Generate more power pushing than pulling; large leg muscles activated in pushing VERSUS low back uses small stabilizers for pulling.
SAFER TO PUSH than pull objects especially for the shoulder, low back, knees and ankles. |
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What does the musculocutaneous nerve innervate?
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coracobrachialis, brachialis and biceps brachii and carries sensory to the lateral aspect of the forearm.
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How would a patient w/ musculocutaneous nerves syndrome of the shoulder present?
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Sensory changes to lateral forearm, weakness across elbow, diminished or absent biceps reflex, wasting and atrophy of biceps brachii.
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What sort of history would a patient w/ musculocutaneous nerve syndrome of the shoulder have and how should chiro treat?
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Hx of frequent and/or heavy workouts w/ a FLEXED ARM & HANDS PRONE
responds well to conservative Tx; R/O biceps tendon rupture, C5-6 radiculopathy, brachial plexus injury or compression. |
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Where can compression of musculocutaneous nerve occur for musculocutaneous nerve syndrome of the elbow?
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Where musculocutaneous nerve pierces the brachial fascia proximal to the elbow; this location makes nerve prone to impact injury like falling and landing on side, football, MVA.
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Where is the pure patch for the musculocutaneous nerve so sensory testing can be done?
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Directly OVER the brachioradialis muscle body = = carried by the lateral antebrachial cutaneous nerve.
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What can radial nerve compression in the axilla affect?
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Triceps, anconeus and majority of the extensors of the forearm (posterior interosseous branch of the radial nerve).
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Where would radial nerve compression in the upper arm occur and what can be affected?
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Most vulnerable at the spiral groove (wraps around humeral shaft); sensory changes of the radial nerve can be evaluated at the pure patch; motor paralysis gives typical wrist drop.
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What is involved in typical wrist drop and what is involved in sensory loss with radial nerve compression in the upper arm?
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Extension of elbow, wrist, knuckles and all joints of the thumb, supinator and brachioradialis; dorsum of 1st, 2nd and 3rd metacarpals (1/2 of 4th too).
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What else can affect the radial nerve?
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Heavy metal toxicity.
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What depends on BLINKING for health?
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cornea & sclera
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___% more of cornea is exposed when looking straight ahead compared to gazing down at __ degrees.
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40%
30* (degrees) |
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On average, humans blink every 1.5 sec. What is the average when browsing the web?
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every 7 sec.
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Minimum distance the monitor should be from your face
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25" - the further, the better!
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The top of the computer screen should be
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at or below eye level
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What is the KEY COMPONENT of office lighting?
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SCREEN BRIGHTNESS
(the 75-100 lumens is too much. 50 lumens is sufficient, then add task lighting) |
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The WEIGHT OF A BACKPACK should weigh less than ___% of your child's body weight.
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Kids: less than 10%
Adults: no more than 15% |
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What should you avoid when packing a backpack?
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Dynamic shifting loads
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Because the serratus anterior mm. is weak, the ___________ muscle now does all the work (winged scaps). Accessory nerve palsy causes:
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trapezius mm.
dysfunction, weakness, pain of trapezius mm. |
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Most common IATROGENIC causes for spinal accessory nerve palsy
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Lymph node biopsy
Neck dissection Carotid endarterectomy DIRECT TRAUMA (gunshot, glass) |
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Only diagnostic method to detect spinal accessory nerve palsy
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ELECTRODIAGNOSIS for CN IX
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S.A.N. syndrome
caused by muscle, vascular distention or lymph |
Spinal Accessory Nerve syndrome:
1. Dropping shoulder 2. Winging of scapula 3. Weakness during forward elevation |
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How much is a headset?
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10-50$ home use
75-300$ good one may require amplifier |
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Do I need a headset amplifier?
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Newer models have them integrated into the sets
Older ones require multi-purpose or modular amps |
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Controls your incoming speaker volume and your out going voice volume
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amplifier
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headset that works fine for people who spend time on the phone talking to coworkers
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monaural (single speaker)
binaural (2 speakers) for little interaction between co-workers |
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A noise cancelling headset will reduce up to ___% of surrounding noise.
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75%
-designed for 20+ offices with people surrounding you |
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COMMONEST cause of WINGING
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Weakness or palsy of the SERRATUS ANTERIOR, secondary to compression of the LONG THORACIC NERVE is the commonest cause of winging.
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Shoulder pain especially when tired
Difficulty w/ full flexion of shoulder Rapid head motions - LATERAL/whiplash Poorly adjusted CRUTCHES Injury as TRACTION or direct TRAUMA |
LONG THORACIC NERVE COMPRESSION
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tumor of axilla could cause
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long thoracic nerve compression
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The nerve to serratus anterior
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Long thoracic nerve
i.e., crutches, whiplash laterally, traction injury |
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What diagnostic test for long thoracic nerve compression
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Serratus anterior is weak or paralyzed so use ELECTRODIAGNOSIS to distinguish from Amytrophic neuralgia (large early pain component)
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Causes of Long thoracic n. compression leading to weak or paralyzed serratus anterior:
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rapid head motion (esp. lateral)
whiplash crutches axillary tumor or traction injury/direct impact |
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Hallmark of injured long thoracic nerve
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Patient CANNOT AB-DUCT ARM ABOVE HORIZONTAL PLANE because the serratus anterior is unable to rotate the glenoid cavity superiorly to allow complete abduction of the limb. The nerve is especially vulnerable when arms are elevated, as in a knife fight.
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What muscles does the DORSAL SCAPULAR nerve innervate?
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LEVATOR SCAPULAE
RHOMBOIDS minor and major |
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action of levator scapulae
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elevates scapula and rotates the or points the glenoid fossa downward)
Dorsal scapular n. |
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action of rhomboids
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retracts scapula and rotates the or points the glenoid fossa downward. Fixes scapula to thoracic wall.
Dorsal scapular n. |
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Action of both levator scapulae and rhomboids in common
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both rotate glenoid fossa downward
When dorsal scapular n. injured, these two muscles cannot downward rotate the scap. and the rhomboids 'let go' of the scapula, causing subtle scapular winging. |
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Mr. Spock's Vulcan grip would affect the
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Dorsal scapular nerve (the levator scapulae and rhomboid mm.)
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mostly C5 but also C4 (a thread) and C6
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Dorsal scapular n. to levator scapulae and rhomboids
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Nerve affected by middle scalene, presenting as SLIGHT LATERAL TILT & ROTATION to take pressure off.
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Dorsal scapular n.
*pierces the Middle scalene |
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Describe DORSAL SCAPULAR N. syndrome
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DSN:
slight lateral tilt and rotation to alleviate middle scalene pressure (DAN transects) levator scapula and rhomboid tenderness (DSN innervates) & possibly arm RHOMBOID muscle test WEAK because rhomboids hold scap to thorax (slight winging if DSN pissed) |
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Because of the muscles' origin on the spinal column, unilateral entrapment of the ______________ n. may cause subluxations in cervical and thoracic spine. Why?
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DORSAL SCAPULAR NERVE
~Rhomboids ~Levator scapulae Unilateral entrapment may cause BILATERAL MUSCLE IMBALANCE; ie, you keep adjusting the spine but until you address the rhomboids and levators, you got nothing. |
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Borders and contents of MEDIAL axillary hiatus
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TRIANGLE SHAPE:
Teres Minor roof Teres Major floor Long head of triceps wall *Circumflex scapular artery |
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Borders and contents of LATERAL axillary hiatus
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RECTANGLE shape:
Teres Minor Roof Teres Major Floor Long head triceps medial wall Humerus lateral wall *Axillary n. *Posterior circumflex humeral artery |
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Everyday reason for Axillary nerve entrapment in lateral axillary triangle causing QUADRILATERAL SPACE SYNDROME:
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sleeping with arm UNDER HEAD (as in medially rotated, palm prone)
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What two major things should a chiropractic treatment for Quadrilateral space syndrome (lateral axillary n. compression) involve?
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ADJUST C/T vertebral subluxation
REHAB DELTOIDS WITH WEIGHTS first |
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How would a patient 'wear' the SCAPULO-COSTAL SYNDROME pain pattern ?
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Posterior: occiput to inferior angle of scapula over rhomboids, curve over scapula following trapezius, down posterior arm to olecranon.
Anterior: Mastoid SCM to clavicular and sternal attachments, cover upper trapezius area and down to mid forearm. *basically a pain cardigan shrug |
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May be mistaken for ANGINA PECTORIS
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the pain cardigan shrug of SCAPULO-COSTAL SYNDROME
*no particular nerve assoc. |
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No particular nerve associated with this syndrome and why not?
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the pain cardigan shrug of SCAPULO-COSTAL SYNDROME has no one nerve associated = it's POSTURAL!!
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The cardigan shrug of pain (Scapulo-costal syndrome) has no nerve associated. It is due to
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POSTURAL tension tractioning irritating an attachment site of levator scapulae (C1,2,3)
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Where is the cardigan pain shrug of scapulo-costal pain perceived?
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Upper interscapular area between vertebral/medial scap border and the underlying rib cage.
Comes and goes. Insidious, sneaky onset. |
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What is posture/profession of the people who wear a cardigan pain shrug?
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DROPPED HEAD, HANDS OUT FRONT
of scapulo-costal syndrome... dentists, surgeons, mechanics, uh...massage therapists. |
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Describe the SUPRASCAPULAR n.
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from C5 mostly, the ssn passes laterally across the cervical region (the posterior triangle) superior to brachial plexus, then THROUGH THE SUPRASCAPULAR NOTCH.
**innervates: SUPRAspinatus (abduction) & INFRAspinatus (external rotation), glenohumeral joint |
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The supraspinatus is affected and person cannot abduct arm (10-15%)
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Suprascapular n. affected where comes out under suprascapular notch ligament to innervate supraspinatus
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The supraspinatus is affected and person cannot externally rotate arm well.
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The suprascapular n. affected after suprascapular notch but as it runs under ligament of infrascapular notch.
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The suprascapular nerve runs under 2 _______, each of which affects a different muscle
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2 notches
~suprascapular notch for supraspinatus ~infrascapular notch for infraspinatus *compression of suprascapular n. under ligament of each/either notch will affect that muscle. |
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Peripheral cutaneous nerve innervation of the proximal inside arm and axilla
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INTERCOSTO-BRACHIAL NERVE
from T2 (mostly posterior along medial triceps, not so much on anterior) |
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Nerve(s) affected by CRUTCHES
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Long thoracic n. (to serratus anterior) & Intercostobrachial nerve (exits at 2nd intercostal space)
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T1 dermatome then T2 mid-humerus to axilla n.
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Intercostobrachial nerve
*intercostal neuritis |
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Presents with TINGLING IN AXILLA
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INTERCOSTOBRACHIAL N.
*tumor, trauma, infection or ENTRAPMENT in medial triceps *d/dx from long thoracic n. to serratus anterior, same sx except not entrappped by medial triceps |
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comfortable upper extremity desk position in inches
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elbow flexed, hand ~ 25" away
body equally spaced to either elbow (room) at ~ 60" total |
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PUSH or PULL?
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PUSH = USE YOUR QUADS AND GLUTES
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Nerve MOST PRONE TO INJURY FROM POSTERIOR DISLOCATION (shooting a gun = recoil)
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AXILLARY n.
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Describe the MUSCULOCUTANEOUS n.
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Terminal branch of lateral cord, C5-7.
Exits axilla by piercing coracobrachialis, supplies anterior compartment of arm and skin of lateral forearm. *CORACOBRACHIALIS, BRACHIALIS BICEPS brachii |
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Injury to Musculocutaneous n. in axilla
(from Essential Clinical Anatomy - Moore) |
Inflicted by weapon such as a knife.
PARALYSIS of coracobrachialis, brachialis and biceps brachii = weakened flexion of elbow and supination of forearm. Loss of sensation on lateral forearm (lateral antebrachial cutaneous) |
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Musculocutaneous injury sx (notes)
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Weakness across ELBOW
Sensory changes to forearm WASTING of BICEPS Less or absent bicipital reflex |
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Major pathology to rule out for musculocutaneous n. syndrome of the shoulder
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C5-C6 radiculopathy
*this person works out with hands prone, forearms flexed. Looks cool, but is stupid. |
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If musculocutaneous n. syndrome of shoulder, what muscle ?
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CORACOBRACHIALIS
*nerve pierces it |
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If musculocutaneous n. syndrome of elbow, what is compressing the nerve (muscle or fascia?)
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Not a muscle compression but a FASCIAL compression at brachial insertion, just proximal to elbow.
*Location makes nerve prone to injury (football helmet crush) |
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What muscles are SPARED in musculocutaneous n. syndrome of ELBOW?
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BICEPS & BRACHIALIS
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Describe the RADIAL n. origins and branches
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POSTERIOR cord C5-T1 (extensors): Nerve to subscapularis (upper subscapular n.). Nerve to Latissiumus dorsi (thoracodorsal n.), Nerve to teres major (lower subscapular n.), Axillary n., Radial n.,
Passes posterior to humerus in Radial Groove with deep artery of arm, between lateral and medial heads of triceps. Perforates lateral intermuscular septum, enters cubital fossa and divieds into SUPERFICIAL (cutaneous) and DEEP (motor) radial nerves. |
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Injury to the RADIAL nerve superior to the origin of its branches results in
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AXILLA: paralysis of the triceps, brachioradialis, supinator, and extensor muscles of the wrist and fingers.
*Ben Franklin's printer dropsy due to lead poisoning |
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Injury to RADIAL nerve which spares the TRICEPS (weakens it). Where and why?
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Compression at the SPIRAL GROOVE (most vulnerable Radial n. site) weakens the triceps but only compresses the medial head. Below it, however, muscles in POSTERIOR forearm are paralyzed..
Clinical sign of radial n. injury: WRIST DROP (no extension) |
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Clinical sign of radial n. injury at spiral groove.
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Weakened triceps (medial only affected), WRIST DROP (forearm flexors shot, nothing opposes tonus of flexor muscles so waiter tip hand results)
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Describe wrist drop
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Motor paralysis of Radial n:
~loss of extension of elbow, wrist, knuckles, all thumb joints ~loss of supinator and brachioradialis ~sensory loss of dorsum of 1st, 2nd, 3rd fingers & hand |
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RADIAL n. pure patch
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web of index and thumb
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Describe SUPRACONDYLAR PROCESS syndrome
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LIGAMENT OF STRUTHERS (yeah, her) attaches a SUPRACONDYLAR PROCESS to the medial epicondyle.
ULNAR n. runs under ligament of Struthers and is compressed AND elbow extension + forearm supination mya occlude the RADIAL ARTERY in some people |
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Vitamin script for supracondylar process syndrome
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If my ulnar nerve's trapped by Sally Struthers,
then I'll need some... B /C /D /K / and Calcium |
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Test for supracondylar process syndrome
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Flex elbow completely
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Tx for supracondylar process syndrome
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Surgical resection if cannot reduce adhesions near ligament. Reduce inflammation. Nutritional support (BCDK and Calcium)
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The ulnar nerve is often injured with fractures of the _______________
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medial epicondyle
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Motor paralysis of the ULNAR n. results in
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CLAW HAND & HYPOTHENAR WASTING
*Adductor Pollicis |
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Which muscle will be on the test regarding the ULNAR n.?
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ADDUCTOR pollicis
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The ulnar nerve motor injury resulting in claw hand and hypothenar wasting is due to the loss of: (only need to know one)
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ADDUCTOR POLLICIS
ulnar flexion of wrist flexors of terminal phalanx of digits 4 + 5 Muscles of hypothenar eminence Palmar brevis Interossei and medial 2 lumbricals Sensory loss over little and half of ring finger |
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PURE PATCH for ulnar n. sensory loss
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outside of pinky nail (medial distal 5th digit phalange)
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Where is the adductor pollicis and what is its nerve supply?
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from base of first metacarpo-phalangeal joint of thumb, it fans outward to the 3rd/middle metacarpal bone. Brings thumb to index finger, as in a salute, and is tested by FROMENT'S paper test for ULNAR n. lesion (most distal muscle of Ulnar n.)
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Thumb muscles innervated by Recurrent branch of Median n.
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ABductor pollicis
Flexor pollicis brevis Opponens pollicis |
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Describe ULNAR n.
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MEDIAL cord from C7-8, T1
Gives off posterior division Gives off anterior division: Medial pectoral n., Medial brachial cutaneous n., Medial antebrachial cutaneous n. Gives off branch to radial n. Continues as Ulnar n: FCU and ulnar half of FDP, most intrinsic mm of hand, skin of hand medial to axial line of 4th digit Most distal muscle: ADDUCTOR POLLICIS (test) |
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What nerve is often injured by PENETRATING wounds of the forearm
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ULNAR n.
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4 places of ulnar n. injury
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1. posterior to medial epicondyle of humerus (most common)
2. in cubital fossa formed by the tendinous arch connecting the humeral and ulnar heads of the FCU 3. at the wrist (Tunnel of Guyon) 4. in the hand |
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An injury to the distal forearm ulnar nerve
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denervates most of the intrinsic hand muscles. The power of wrist adduction is impaired, and when the patient flexes the wrist IT DEVIATES TO LATERAL SIDE BY FCR because absence of balance of FCU. Person has difficulty making a fist due to opposition affected and MCP joints become hyperextended. Cannot flex 4th and 5th digits to make a fist. Cannot extend interphalangeals to straighten fingers = CLAW HAND
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This deformity results from atrophy of the interosseous muscles of the hand. It is produced by the unopposed action of the extensors and FDP
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CLAW HAND = ulnar nerve damage
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Entrapment of nerve at ulnar tunnel
Medial-Ulnar Groove Flexor Carpi Ulnaris Syndrome all called>>> |
CUBITAL TUNNEL SYNDROME
compression of Ulnar n. in the ulnar groove (notch) at the elbow OR between the 2 heads of FCU muscle under the epicondylo-olecranon ligament (aka Arcuate Ligament of Ozzy Osborne) |
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Where is the Arcuate ligament of Ozzy Osborne?
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ligament between the 2 heads of the flexor carpi ulnaris muscle connecting epicondyle to olecranon - houses ulnar n.
can compress the ulnar nerve |
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Ligament closely assoc. with cubital retinaculum
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Ligament of Ozzy Osborne (olecranon to epicondyle ligament that covers Ulnar n.)
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Test for Ulnar n. sx
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FROMENT'S PAPER TEST
why? Because ADDUCTOR POLLICIS is furthest muscle innervated by Ulnar n. If see tip of thumb try to assist, also + finding. |
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Sx of CUBITAL TUNNEL SYNDROME
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pain and tingling numbness along ulnar n. distribution; 1/2 or 4th and 5th digit
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Management of cubital tunnel syndrome
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reduce inflammation
splint surgical relocation |
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Exacerbating cubital tunnel activities
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leaning on a bar (hard and sharp) or leaning on a bar and reaching over the peanuts for a beer
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Describe medial antebrachial cutaneous dermatome
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If you dipped just above your elbow to just above your wrist into a paraffin bath and covered the 'elbow' side of your arm, you got the medial antebrachial cutaneous n. coverage.
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Where does the Medial AnteBrachial Cutaneous (MABC) nerve come from?
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Directly off the medial cord C8-T1.
That's why you can't find it on an arm map - it comes from the brachial plexus itself. MABC, MBC, MP >>towards origin. |
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C8 Initially runs with ulnar nerve (and is often confused for it), pierces deep fascia with basilic vein and enters subcutaneous tissue, dividing into anterior and posterior branches
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Medial Antebrachial Cutaneous N. (MABC): directly off medial cord...
~C8 ~injured most frequently due to surgery of medial elbow ~Anterior ramus innervates anterior medial forearm ~Posterior ramus innervates posterior medial forearm |
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MABC nerve management
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Break up adhesions fascial
Reduce scar tissue from medial elbow surgery Nutritional support *I lost this nerve when I had surgery. Massage would be horrible. Don't do this. |
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Often misdiagnosed as carpal tunnel syndrome
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PRONATOR TERES SYNDROME
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Describe the Pronator Teres muscle
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Has an ulnar head and a humeral head
Median nerve C7 Pronates and flexes the forearm (elbow) |
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How to differentiate between carpal tunnel syndrome and PRONATOR TERES syndrome?
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Sensory changes mimic CTS except PRONATOR TERES SYNDROME WILL AFFECT THE AREA OVER THE FLEXOR RETINACULUM
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Why does PRONATOR TERES syndrome affect the area over the retinaculum (not under it) so you can distinguish it from carpal tunnel syndrome?
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Because a PALMAR CUTANEOUS BRANCH of the MEDIAN nerve, the one that also innervates the pronator teres, goes all the way down to the palm just under the skin. If Pronator teres is weak, the skin over the flexor retinaculum will feel distorted sensation, too.
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How to test for PRONATOR TERES syndrome? (vs. carpal tunnel)
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Handshake test:
force forearm into supination while supporting elbow. If there is pain with RESISTED SUPINATION, then it's pronator teres syndrome. |
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nerve of pronator teres
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Median nerve
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The median nerve (C8) splits into the posterior interosseous (deep) for pronator teres and a little brachioradialis. The anterior interosseous nerve does what?
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FPL of thumb, FDP of index and middle
Pronates the forearm via pronator quadratus. |
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Nerve that basically lets you make the "OK" sign
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Anterior Interosseous n. (median C8)
Decreased fcn leads to making a duck instead of ok sign, and also making a fist like a girl with your thumb sticking out and index finger not quite curled |
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I can only make a shadow puppet of a duck and I make a fist like a girl; what nerve have I ruined?
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Anterior interosseous n. (median C8)
*cannot hold against traction |
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When doing a sensory evaluation, follow the points along the _________ of the digital nerve.
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distribution (ie, straight lines)
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What evaluates carpal tunnel syndromes (2)
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1. PAIN
2. THENAR EMINENCE IS ALSO INNERVATED BY MEDIAN N. thru tunnel sooo.... Use TWO POINT DISCRIMINATION |
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What two types of sensitivity tests could you compare sensation with?
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Two point discrimination & Wartenberg Pinwheel findings
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Tests grip strength (2)
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Handheld jamar DYNAMOMETER &
PINCHOMETER dynamometer 3x each side, in kg or lbs, compare |
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When wrist is flexed, we lose ___lbs of strength
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10 lbs
*also lose when wrist extended |
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Size assessment techniques (ah hem...)
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Water displacement is questionable.
Circumference via JEWELERS RINGS is good - stop at knuckle. Record ring size. Tape measure body parts - metric units |
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Manual DEXTERITY tests
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Outcomes assessment measures!
9-hole peg test from Crackerbarrel for pre-employment screening to see if you are gay (they don't hire gay people - neither does Chik Filet. Morons!)) Purdue chicken pegboard test for tedious assembly and dissembly of small ordered parts to see if you are accurate and anal |
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80% of left handed people have _____ strength when comparing their left to right hands.
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equal
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Bony landmarks of Carpal Tunnel
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Scaphoid tubercle
Pisiform Hamulus of Hamate (hook) Tubercle of trapezium |
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Contents of Carpal tunnel and location of nerve (abbreviated)
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9 tendons, 1 nerve
*MEDIAN NERVE IS MOST SUPERFICIAL OF ALL STRUCTURES in the carpal tunnel |
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Carpal tunnel flexors and nerve
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Tendons of FDProfundus
Tendons of FDSuperficialis Flexor Pollicis Longus Median n. |
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What is OUTSIDE the carpal tunnel (3)
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FCR - FCU - Radial artery
*FCR isn't in the tunnel but could affect i |
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Muscle affected by carpal tunnel
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ABductor pollicis brevis (due to recurrent branch of median nerve that pops out of the tunnel and up, over the thumb)
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The MEDIAN nerve has two terminal sensory branches that supply the skin of the hand; hence _____________ (tingling) and ___________(diminished sensation) or ___________(absence of tactile sensation) may occur in the lateral 3.5 digits.
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paresthesia (tingling)
hypothesia (diminished sensation) anesthesia (absence of tactile sensation) |
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Why is sensation to the CENTRAL PALM unaffected by carpal tunnel syndrome but the lateral 3 and 1/2 digits may experience sensation change?
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The palmar cutaneous branch of the median nerve pops out BEFORE the larger median nerve dives through the carpal tunnel. Thus sensation to the central palm remains unaffected with carpal tunnel (but is diminished with pronator teres syndrome).
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Any sensory changes over the tunnel itself mean the lesion is
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proximal to it.
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Causes of CTS
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HypOthyroidism
Pregnancy Repetitive Stress Syndrome (RSI) Ganglion, mass Infection Direct trauma |
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Conservative tx for CTS
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adjust the carpals
ART to wrist flexors Graston to carpal tunnel and wrist flexors AVOID repetitive hand motions, heavy grasping, vibrating tools (aww), or working with a flexed wrist ulnarly deviated |
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10% of patients with ___ have carpal tunnel sydrome
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DJD
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Wrist brace for CTS
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early sx
resting position so nerve has room ease night pain and numbness keep wrist straight during sleep |
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Medication for CTS
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NSAIDS + aspirin
VITAMIN B-6 exercise cortisone (no relief means it ain't CTS) surgical release of transverse carpal ligament |
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PT or OT for CTS
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reduce or eliminate cause of pressure
ergonomic check |
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surgery for CTS
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thickened, scarred nerve
Open-incision or ENDOSCOPIC CT RELEASE (fiberoptic camera, small incision) |
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Rehab for CTS *******************
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****************4-6 weeks************** improvement if conservative tx succesful
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Common sense says wrists should remain neutral while typing. What is the elbow angle range?
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90-120 degrees
No gel pads! |
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Where should you use support for wrists
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firm and under palm
No gel pads! |
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Tenosynovitis of the ABductor & Extensor pollicis tendons
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deQuervain's syndrome
Pain and tingling at lateral wrist into thumb (snuff box area) |
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mechanism that causes deQuervain's
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gripping and twisting
buffing grinding polishing sanding assembly pressing sawing cutting surgery |
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diagnostic procedures for deQuervain's
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FINKELSTEINS TEST
ROM history palpation |
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Cheiralgia Parestheica
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Handcuff neuropathy
Similar to deQuervain's |
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Describe Tunnel of GUYON
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Ulnar nerve
C8 Runs between hook of hamate and pisiform GRIPPING TOOLS |
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TINGLING THAT PULSATES IN THE TUNNEL OF GUYON
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Ulnar artery aneurysm
assembly work, catching (not pitching), using hand as a hammer, wheelchair, mountain biking |
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How to diagnose ulnar artery aneurysm
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Ultrasound
Contrast arteriogram |
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MUST differentiate this from Guyon tunnel syndrome
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Ulnar artery aneurysm
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Describe TRIGGER FINGER
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special case of tenosynovitis where the tendon develops a bump that causes the finger to lock or jump as the nodule passes through the sheath on flexion
PIPs straight with DIPs bent (wide handles) |
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Raynauds
Vibration Hand Arm Vibration Syndrome (HAVS) all present with ____________ syndrome |
WHITE FINGER/DEAD FINGER syndrome
palpate the peripheral pulses, use your visual senses and take a good history (jackhammer, power tools too big for small hand, paint scraping, cold environments) |