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134 Cards in this Set
- Front
- Back
- 3rd side (hint)
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How to D/dx:
ADHESIVE CAPSULITIS vs. GLENOHUMERAL OA |
X-ray is clean for adhesive capsulitis but shows destruction of GH joint if OA of GH present.
*Plus, GH has limited active ROM in all planes |
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Most common cause of pain in AC joint
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OsteoArthritis (OA)
*overhead repetition or complication of ACJ injury prior. High incidence in HEAVY LABORERS |
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AC Osteoarthritis TYPICAL patient
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pain on PALPATION of AC joint
pain on CROSS-BODY adduction OA on X-RAY |
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What kind of mobilization/manipulation can we do for OA of the AC joint?
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Glides:
A-P P-A S-I I-S SternoClavicular, ScapuloThoracic & GlenoHumeral joints Cervical and Thoracic spine |
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Visual appearance of AC joint separation?
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STEP DEFECT
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major STABILIZING LIGAMENTS of the AC joint
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CORACO-CLAVICULAR ligament:
*Trapezoid & Conoid ligaments make up the coracoclavicular ligament. They keep the clavicle from moving. |
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Where does one fall on the shoulder most commonly and what 3 types of injury could occur to the AC joint?
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POINT OF SHOULDER:
1. Type I SPRAIN - partial disruption of AC ligaments and joint capsule 2. Type II SEPARATION - ruptured AC ligament and joint capsule INCOMPLETE CORACOCLAVICULAR LIGAMENT INJURY 3. Type III SEPARATION - everything: ruptured AC ligament, joint capsule and coracoclavicular ligament. The WORST CASE. |
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Type I AC injury
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1. Type I SPRAIN - partial disruption of AC ligaments and joint capsule
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Type II AC injury
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2. Type II SEPARATION - ruptured AC ligament and joint capsule INCOMPLETE CORACOCLAVICULAR LIGAMENT INJURY
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Type III AC injury
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3. Type III SEPARATION - everything: ruptured AC ligament, joint capsule and coracoclavicular ligament. The WORST CASE.
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When the AC ligament is injured, as in a type II or type III AC joint injury, we know a SEPARATION has occurred, even if not a complete one (type II). HOW do we know this?
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The AC ligament has ruptured but not the coracoclavicular ligament in type II separation, but in type III, both have sprung. The key is SEPARATION: the AC ligament pulls the acromion away, whereas the coracoclavicular ligament pulls the coracoid process away. Pull=separation, hence types II & III
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Why would trapezius and deltoid get injured in type I AC joint sprain?
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they both cross the joint
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We cannot adjust in acute phase of AC joint sprain type I or separation types II and III, but in what instance?
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RESIDUAL PAIN from type II separations
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Less severe than falling on point of shoulder
Damage to AC ligaments Coracoclavicular ligaments are spared |
FOOSH
*AC ligament damaged because slamming humerus up into AC joint when falling on outstretched hand |
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Why is the coracoclavicular ligament spared with a FOOSH?
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because the humerus jams up and back into the AC ligament (damaged), not forward and down into the Coracoclavicular ligament (spared w/ FOOSH)
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What condition of the AC joint may have impingement pain, just like a rotator cuff tear?
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FOOSH
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Difference b/w Primary and SECONDARY BICEPS TENDONITIS (long head)?
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Primary (rare). Transverse humeral ligament (front). Overuse from horizontal shoulder flexion (also rare).
SECONDARY - most common! IMPINGEMENT syndrome b/c Long head of Biceps passes thru subacromial space w/ SUPRASPINATUS & BURSA. The tendon is overused as a HUMERAL DEPRESSOR. |
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HUMERAL DEPRESSOR IMPINGEMENT SYNDROME MOST COMMON.
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SECONDARY biceps tendonitis (long head)
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Diagnose bicipital tendonitis:
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pain anteromedial
repetitive use impingement syndrome BICIPITAL GROOVE tenderness Speed's test Yergason's test |
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What type of glide is not advisable to treat LHBT and why?
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Inferior to superior glides would exacerbate pre-exisiting impingement syndrome (which also needs to be treated).
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Why would a young person rupture the long head of B. tendon? Treatment?
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overloading (showing off, probably)
Weakness of forearm supination (weakness b/c other mm are intact) SURGICAL REPAIR IF YOUNG |
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An older patient 50+ ruptures the LHBT...
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Secondary to degeneration and chronic tendinitis of LHBT
Pain often relieved after rupture! Ahh! No surgery - minimal disability |
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Produce intense referred pain, often in front of the shoulder. Described as 'DEEP WITHIN THE JOINT'.
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INFRASPINATUS
**PAIN IS NOT AT TRIGGER PT. Can also refer to lateral arm, forearm and thumb/index fingers. |
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What's weird about an infraspinatus trigger point?
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there is no pain at the point - it's all referred to the front
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Joints involved in elbow flexion/extension
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Ulno-Humeral joint
Radio-Humeral joint |
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Elbow joints supination/pronation
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Radio-Humeral joint
PROXIMAL Radio-Ulnar joint & DISTAL Radio-Ulnar joint |
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3 joints of the ELBOW:
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1. Radiohumeral
2. Ulnohumeral 3. PROXIMAL radioulnar |
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Lateral stiffness of elbow - adjust?
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RHJ (radiohumeral joint)
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Stiffness in P-A direction of elbow - adjust?
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Radiohumeral & Ulnohumeral joints
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Difficulty or stiffness with pronation of elbow - adjust?
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PROXIMAL radioulnar joint
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Most elbow fractures are caused by FOOSH, but the most common elbow fracture in adults is _______ fracture, caused by a FOOSH!
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RADIAL HEAD
adults 50% of elbow fx caused by a FOOSH supinated (falling back'ards) |
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Adults fx radial head via FOOSH 50% of time. Children?
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NURSEMAID'S ELBOW -the 'yank' of the kid off the curb outta traffic that dislocates the radial head right outta the ANNULAR ligament!
Yank yer ass back onto the sidewalk! |
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NURSEMAID'S ELBOW reduction
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flexion and supination
children 2-4 radial head pops right back into annular ligament |
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THROWER'S elbow
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THROWER'S = VALGUS stress
Traction to Ulnar Collateral Ligament (think baseball pitcher in full overhead windup) |
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Thrower's elbow stresses (3)
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Ulnar Collateral Ligament
Radio-humeral joint Impinges olecranon |
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You don't have to be a baseball pitcher to get thrower's elbow...
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waitress/waiter, someone carrying heavy boxes or trays and putting
VALGUS STRESS ON ELBOW (UCL) |
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Repetitive microtrauma to the origin of wrist extensor muscle group
REPETITIVE OVERUSE |
Lateral epicondylitis (tennis elbow)
EXTENSOR CARPI RADIALIS BREVIS most involved - origin most involved. |
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What can we use Cozen's and Mill's test to help dx?
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Lateral epicondylitis due to repetitive overuse (ECRB)
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Joint dysfunction of radiohumeral joint may be present in this repetitive overuse syndrome
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Lateral epicondylitis (ECRB)
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Radiohumeral adjustments:
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~A-P, P-A pincer grip
~P-A glide in pronation Ninja move-wrist break ~Varus Tilt to gap the radiohumeral jt. |
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Why would adjusting CERVICAL spine help lateral epicondylitis (overuse - ECRB)?
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PAIN INHIBITION @ cord = relief!
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Lateral epicondylitis ancillary treatments
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adjust cervicals (and radiohumeral)
rest, ice friction massage MFTP therapy stretch-strength COUNTERFORCE BRACING |
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repetitive overuse syndromes cont.:
MEDIAL EPICONDYLITIS Treatment similar to lateral epicondylitis... |
WRIST microtrauma
golf (little duffer's) elbow or due to tennis/racquetball wrist flexion |
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most commonly involved muscles of MEDIAL epicondylitis
*think tennis toss/serve |
wrist flexors:
1. FCU 2. Pronator teres (the tennis serve muscles) |
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muscles of lateral epicondylitis:
muscles of medial epicondylitis: |
lateral epi: ECRB
medial epi: FCU & Pronator teres |
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Posterior elbow swelling and tenderness, often visible, palpable
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Olecranon BURSITIS
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ALERT: Olecranon bursitis can be _____/_____.
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septic/aseptic
Acute or repeated trauma can lead to HEMATOGENOUS spread so direct innoculation to blood = sepsis. |
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If the elbow bursa feels warm and erythematous, suspect?
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septic infection or gout
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2nd most common COMPRESSIVE NEUROPATHY of the upper extremity
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CUBITAL TUNNEL syndrome
elbow |
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How does cubital tunnel syndrome occur, since it is the second most common compressive neuropathy of the upper ex?
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compression, traction, direct trauma
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Causes of carpal tunnel
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Compression
Traction Direct trauma |
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(the second most common compressive neuropathy of the upper extremity)
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CARPAL TUNNEL
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Diagnose carpal tunnel
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Sensory sx: 4 & 5th digits
Pain: medial elbow/forearm Weakness: Interossi muscles (finger Ab/Adduct) |
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How would you mobilize/manipulate for carpal tunnel?
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Varus tilt
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THIS QUESTION IS ON THE TEST:
3 muscle tests used to differentiate ULNAR neuropathy at the Elbow, C8 and T1 Radiculopathies: |
1.) INTEROSSEI:
finger abductors/adductors) = T1, Ulnar 2.) FLEXOR DIGITORUM PROFUNDUS ~in 4th & 5th digits - C8, Ulnar n. ~in 2nd & 3rd digits - C8, Median n. 3.) ABDUCTOR POLLICIS BREVIS - T1, Median n. |
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Where can pain in the elbow come from, referred?
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Cervical spine
Shoulder Wrist |
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Wrist ARTICULATIONS
(3 true & 1 complex) |
1. Midcarpal Joint
2. Radiocarpal Joint 3. Distal Radioulnar Joint 4. Fibrocartilage COMPLEX *the carpo-metacarpal joint is not considered in the lecture |
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MIDCARPAL joint bones
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Distal carpal row (trapezium, trapezoid, capitate)
ARTICULATES WITH... Proximal carpal row (scaphoid, lunate, triquetrum) |
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RADIOCARPAL joint bones
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Radius
ARTICULATES WITH... Proximal carpal row (scaphoid, lunate, triquetrum) |
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DISTAL radioulnar joint bones
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Radius
ARTICULATES WITH... Ulna |
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FIBROCARTILAGE complex of wrist
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Ligaments & Cartilage with Meniscus & Articular Disc
Ulna ARTICULATES WITH... Lunate & Triquetrum (using abovementioned tissues) |
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What bone is not included in any of the 4 wrist articulations?
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Pisiform
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Joints responsible for Flexion/Extension & Radial/Ulnar deviation
of the wrist: |
Midcarpal joint (all bones except pisiform)
& Radiocarpal Joint (radius to scaphoid/lunate/triquetrum) |
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Supination/Pronation actually originates at the forearm, not the wrist. What wrist joint is involved?
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DISTAL radioulnar joint
*forearm originators: Humeroradial joint Proximal Radioulnar joint |
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Wrist traumas (4)
#, >>^>, }{, ~~~ |
# Fracture
>>^> Dislocation }{ Impingement ~~~Sprain |
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Wrist Fracture
MOST common |
Distal Radius fracture:
*COLLE's fX - distal radius fX with posterior angulation of distal fragment *FOOSH with extended hand |
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The distal radius is the most common fracture of the wrist in general. What is the most common CARPAL bone fractured?
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SCAPHOID
~FOOSH w/ wrist HYPERextension ~Most common site for OCCULT fracture (HIDDEN until collagen repair of bone makes it visible on x-ray in 7-10 days) |
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why should a distal wrist fracture be immediately MRI
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to see if there is no damage to a major vessel
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The scaphoid is the first most common carpal to fracture and the second most common carpal to _____________?
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DISLOCATE
*first dislocate is lunate |
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First most common carpal to DISLOCATE
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LUNATE
*2nd most common - scaphoid |
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most common carpal to dislocate
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LUNATE
DUE TO HYPEREXTENSION |
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second most common carpal to dislocate (after lunate hyperextension)
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SCAPHOID
(this one fractures; the lunate dislocates) |
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Gymnast's wrist
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RADIAL impact on SCAPHOID due to
WRIST HYPEREXTENSTION w/ axial loading |
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What kind of activity results in gymnast's wrist?
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yoga, gymnastics, push-ups, waiting tables
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Recover from GYMNAST'S WRIST
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-rest (no hyperex. or axial loads)
-Dorsal wrist block (prevent hyperex) -stretch/strength -Mobilization |
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DISTAL RADIUS STRESS FX
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REPETITIVE microtrauma
due to axial loading + extension or hyperextension |
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NON-traumatic WRIST injuries
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stiffness & chronic pain
repeteetettivitiveee overuse misc. like ganglion cyst Nerve entrapment |
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Treat wrist STIFFNESS & CHRONIC minor pain:
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Adjust:
1. Radio-carpal (band of pain) 2. Distal Radio-Ulnar (local/deep) 3. Intercarpal joints (includes midcarpals - usually felt locally/pinpoint) |
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Explain END FEEL MOBILIZATION of:
Radiocarpal (PROXIMAL) and Midcarpal (DISTAL) adjustments for wrist stiffness and chronic minor pain: |
(RADIOCARPAL/PROXIMAL):
Bimanual Grasp/Distal Forearm and Proximal Carpal Row for A-P/P-A Glide and M-L/L-M Glide and Tilt. or (MIDCARPAL/DISTAL) Bimanual Grasp/ Proximal and Distal Carpal Rows, for A-P/P-A Glide and M-L/L-M Glide and Tilt ~ |
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Explain P-A GLIDE MIDCARPAL JOINT:
for wrist stiffness and chronic minor pain |
(MIDCARPAL/DISTAL):
Bimanual Thenar/ Distal and Proximal Carpal Row SHEAR, for P-A Glide Dorsal thenar contact on Distal carpal row Palmar thenar contact on Proximal carpal row |
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Explain SUSTAINED long axis DISTRACTION of WRIST:
for wrist stiffness and chronic minor pain |
(RADIOCARPAL/PROXIMAL & MIDCARPAL/DISTAL) sustained:
Bimanual Palmar Grasp / Hand, with Arm Axillary Stabilization, for SUSTAINED Long Axis Distraction *doctor's arm OVER patient's arm (doc's triceps on patient's biceps) |
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Explain LONG AXIS DISTRACTION
for wrist stiffness and chronic minor pain |
RADIOCARPAL/PROXIMAL & MIDCARPAL/DISTAL regular long axis distraction (NOT sustained):
Manual grasp / Carpal Base, with Web / Distal Humerus Stabilization, for Long Axis Distraction |
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Explain intercarpal adjustment for MEDIAL and LATERAL individual intercarpals:
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for Scaphoid, Trapezium, Hamate, Triquetral and Pisiform (LATERAL & MEDIAL CARPAL BONES):
Thumb Index PINCH / Carpal, for A-P and P-A Glide |
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Explain intercarpal adjustment for MIDDLE individual intercarpals:
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for Capitate and Lunate (MIDDLE):
REINFORCED THUMBS / Carpal, for A-P and P-A Glide |
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Explain P-A and A-P Glide using PISIFORM on THUMB
and how does the patient stand in relation to the doctor for covered thumb carpal adjustment? |
for capitate and lunate (any carpal):
COVERED thumb / Carpal, for A-P and P-A Glide STAND SHOULDER TO SHOULDER: Place thumb of doctor's outside hand on carpal to be adjusted. COVER thumb with pisiform of inside hand. |
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Explain The distal radioulnar adjustment
P-A/P-A GLIDE AND ROTATION -using thenar pinch contact for wrist stiffness and chronic minor pain |
DISTAL RADIOULNAR joint SHEAR:
Bimanual Thumb - Thenar Grasp / Distal Radius and Distal Ulna SHEAR, for A-P and P-A Glide Pt. flexes arm and faces you. Grasp wrist at ulna and radius with your thumb/thenar on either side and SHEAR the two (breaking crackers) |
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Explain COMPRESSION on the distal radioulnar joint for wrist stiffness and chronic minor pain
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Distal Radioulnar joint COMPRESSION is doctor grasping distal radioulnar joint with one hand, distal radiocarpal joint with other and applying compressive joint traction (explained by picture in notes)
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cause of a SIMPLE STRAIN (grade I)
of wrist |
HYPEREXTENSION
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diagnosis of exclusion of wrist
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simple strain injury
*bone scan would be definitive. This is the LAST diagnosis after completely ruling out fracture or dislocation |
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DE QUERVAIN'S
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TENOSYNOVITIS
Abductor Pollicis Longus Extensor Pollicis Brevis |
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2 tendons of the De Quervain's tenosynovitis
"mini snuff" |
ABductor Pollicis Longus
Extensor Pollicus Brevis "mini snuff" meaning EPB and AbPL *when they do a basal joint arthroplasty on you in April, they will use the EPB as one of the tendons |
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Etiology of De Quervain's tenosynovitis
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ULNAR deviation/repetition like painting or typing or using the mouse or playing video games or holding a beer - or a pistol. Or pointing at the dog or the two year old, somebody shorter than you.
forces AbPL and EPB to angulate around wrist to reach insertion. Check via FINKLESTEIN'S TEST -why? that's the ulnar nerve, I know. I would use, um...de Quervain's test. |
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FIRST (most commonly) involved wrist tendon(s) in pathology/irritation?
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ABductor Pollicis Longus
Extensor Pollicis Brevis |
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SECOND most commonly involved tendon(s) in wrist pathology/irritation?
(swinger's club) |
Extensor Carpi ULNARIS tenosynovitis (swinger's club)
*think TIGER WOODS - racquet, golf clubs, baseball PAIN on RESISTED wrist extension with ulnar deviation AND PAIN on PASSIVE radial stretch deviation |
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PAIN on RESISTED wrist extension with ulnar deviation AND
PAIN on PASSIVE radial stretch deviation |
Extensor Carpi Ulnaris tenosynovitis
(swinger's club) |
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snuffers vs. swinger's club?
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snuffers most commonly injured:
abductor pollicus longus and extensor pollicus brevis swinger's club second most injured: extensor carpi ulnaris only hurts when resisted ulnar extension or passive radial deviation |
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3 phases of a wrist tendinopathy
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INFLAMMATION
PROLIFERATION REMODELING/MATURATION |
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Describe INFLAMMATORY phase of wrist tendinopathy
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48hrs to 2 weeks
PAIN, swelling, redness R.I.C.E. |
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describe PROLIFERATION phases of wrist tendinopathy
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1-2 weeks
FIBROBLASTS making weak tissue (collagen + matrix) easily TORN LIGHT manual treatment of friction massage, myofascial, active release Manipulation/mobilize RESTRICTIONS |
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describe REMODELING/MATURATION phase of wrist tendinopathy
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6-12 weeks
ORGANIZATION & CROSS LINKING of immature collagen more VIGOROUS manual treatment to RETURN structure and PREVENT FIBROSIS and chronicity Friction massage, myofascial, active, manipulation/mobiliation |
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Ganglion cysts are filled (usually) with
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mucopolysaccharide-rich fluid
*usually attached to tendon SHEATH |
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HANDLEBAR SYNDROME
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GUYON'S ULNAR TUNNEL
compression or direct trauma to tunnel of Guyon |
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Would a patient with Guyon's ulnar tunnel syndrome experience dorsum of the hand pain? Why or why not?
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NO! the dorsal branch of ulnar nerve splits before the tunnel.
Only the PALMAR branch makes it through tunnel, ergo symptoms on PALMAR SURFACE ONLY *dorsum could happen w/ cubital tunnel syndrome |
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Where is tunnel of Guyon?
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between HAMATE & PISIFORM
containing the PALMAR branch of ULNAR N. |
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Guyon tunnel syndrome sx
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medial forearm pain (radiation from ulnar nerve tunnel through wrist)
palmar sensory on ulnar side of hand weakness of intrinsic interossei m. FINGER ABDUCTOR AND ADDUCTOR MM. innervated by ULNAR N, T1 |
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weakness of intrinsic interossei m.~
FINGER ABDUCTOR AND ADDUCTOR MM. innervated by ULNAR N, T1 |
Guyon's tunnel syndrome (handlebar)
weak ab/adductors of fingers due to Ulnar and T1 innervation |
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D/dx
GUYON'S tunnel syndrome (handlebar) |
C8, T1 radiculopathy (ring and pinky versus inside of biceps)
TOS (lower: C8-T1) Cubital Tunnel syndrome (Tinel's test) |
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cubital tunnel syndrome is compression of the ________ nerve
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ULNAR= cubital tunnel
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Like the median nerve, the ulnar nerve has no branches in the arm, but provides innervation to the forearm and hand. Unlike the median nerve, the motor fibers of the ulnar nerve predominately innervate the ________rather than the forearm
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hand
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Would a person w/ "handlebar syndrome" have sensory pain/paresthesia on dorsum of hand?
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no, ulnar splits before and heads to dorsum.
the other half of ulnar continues to palmar surface and interossei (weakness of finger AB/ADductors = ulnar, T1) |
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Treatment for Handlebar/Guyton's syndrome
P.R.I.S.M. |
Passive movement
Rest Ice Splint Manipulation restricted to carpals |
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Cause of CARPAL TUNNEL syndrome
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COMPRESSION under flexor retinaculum
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Carpal tunnel syndrome may cause
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forearm pain
sensory sx in median/LATERAL hand WEAK ABDUCTOR POLLICIS BREVIS |
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D/Dx for CTS
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C6 (index and thumb), C7 (half middle finger)
TOS (C5, C6) PRONATOR TERES syndrome |
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ulnar nerve test for adductor pollicis/Ulnar nerve
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Froment's paper test
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wasting of first dorsal interosseous and hypothenar eminence is indicative of
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ulnar nerve damage (with clawing)
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Tests for thoracic outlet C5/C6
Test for C6 (C7) Radiculopathy Test for Pronator Teres Syndrome |
TOS - Roo's test for radial artery, Biceps brachi C5/C6 for musculocutaneous n.
C6/C7 Flexor Carpi Radialis for median n. Pronator Teres C6/C7 median nerve |
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Elbow/forearm nerves:
MEDIAL WRIST FLEXORS = LATERAL WRIST FLEXORS = WRIST EXTENSORS = |
medial wrist flexors = ULNAR n.
Lateral wrist flexors = MEDIAN n. wrist extensors = RADIAL n. |
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sensory sparing
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CTS:
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Treating CTS
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P.R.I.S.M + friction massage, myofascial release or active release
Passive/Rest/Ice/Splint/Manipulation or Mobilization |
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Sensory to hand is C__-C__
Motor to hand is? |
Sensory C6-C8
Motor C8-T1 |
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Adjustments for carpal tunnel syndrome (4)
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Carpal A-P/P-A bimanual thenars
Reinforced thumb A-P/P-A on capitate and lunate Wrist compression of radioulnar and radiocarpal space Distal radioulnar shear A-P/P-A Carpal long axis distraction using humerus |
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1st carpometacarpal (trapeziometacarpal) joint is a _________joint that is very mobile.
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saddle
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2nd to 5th carpometacarpal joints are _____ joints (not so mobile!).
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Gliding
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Most common sites of skeletal injury in the ENTIRE freakin' skeleton?
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PHALANGES & metacarpals
*Phalanges are more common (think hitting a finger with a hammer) |
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Trigger finger location
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thumb
middle ring |
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Explain trigger finger presentation
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~thumb, middle, ring fingers
~Pt. aware of popping/clicking/locking on EXTENSION of fully flexed finger ~Palpable NODULE near A1 pulley (MCP) joint ~ |
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Trigger finger cause and effect
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Flexor Digitorum PROFUNDUS
& Flexor Digitorum SUPERFICIALIS cannot slide smoothly under the A1 (MCP) pulley. Flexor tendons become THICKENED. A1 pulley becomes STENOTIC. |
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Trigger finger treatment
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ULTRASOUND w/ stretching and cross fiber friction (low success)
CORTISONE (33% success rate) SURGICAL RELEASE |
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DUPUYTREN'S CONTRACTURE
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contracture of PALMAR FASCIA and related structures
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Cause of DUPUYTREN'S
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UNKNOWN or ALCOHOLISM or GENETICS
I am telling you it is from tippling a beer bottle and from joint laxity, the latter of which is linked on chromosome 18 to anxiety tendencies, hence the alcohol, hence the du Puytren's syndromeN |
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FINGERS involved in DUPUYTREN'S
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4th and 5th digits
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PRESENTATION of DUPUYTREN'S
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tightness and inability to extend fingers
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TREATMENT of DUPUYTREN'S
*triple S |
surgery/splinting/stretching
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