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163 Cards in this Set
- Front
- Back
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What is the insertion site for EHL?
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bimalleolar line lateral to the tibial crest. Too superficial tibialis anterior, too lateral peroneus tertius
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What is the insertion site for FDL?
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medial edge of the mid Tibia, posterior to the tibia. Too superficial soleus, too deep tibialis pasoterior
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What is the insertion site for peroneus longus muscle?
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3 fingerbreadths below the fibular head
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How to activate the peroneus longus?
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plantar flex and evert the foot
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What is the site of soleus insertion?
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distal to belly of gastrocnemius muscle, medial and anterior to the Achilles tendon
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Where is the insertion site for tibialis posterior?
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one hand distal to the tibial tuberosity and one fingerbreadth of medial edge of tibia.
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What is the insertion site for adductors?
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Patient should be supine, flexed legs 15 degrees, and feel pubic tubercle four fingerbreadths down. if too lateral sartorius muscle, too medial gracilis, too deep adductor brevis, first adductor should be adductor longus
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What is the insertion site for SH of biceps femoris muscle?
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Feel the LH BF tendone, then go just medial to it. Too lateral LH of biceps femoris too medial semimembranosus. 4 fingerbreadths above the fibular head
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What is the insertion site for the semimembranosus?
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Feel between the LH biceps femoris tendon, semitendinosus tendon make a V and the top of the V is the semimembranosus. If too lateral SH biceps femoris, if too deep adductor
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What is the insertion site for tensor fascia latae?
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feel the greater trochanter and the iliac crest. Activate by having the patietn abduct thigh with hip flexed.
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What position should the patient be in for tibialis posterior?
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prone with the foot inverted?
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When needling tibialis posterior what muscles will be inserted?
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first layer is soleus, then the flexor digitorum longus
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What is the method of insertion for lfexor digitorum longus?
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It should go through soleus, then flexor digitorum longus. If too deep, then they are in tibialis posterior
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What is the insertion site for extensor digitorum communis?
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Put your thumb and middle finger on the radius and ulna bone. Then put the middle finger in the middle. Extend the middle finger to feel the muscle.
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What muscle will be hit if going too medial to the EDC?
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extensor carpi radialis brevis
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What muscle will be hit if inserting too laterally to the EDC?
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ECU
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What muscle will be hit if inserting too deeply past the EDC?
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extensor carpi radialis longus
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What is the innervation of EDC?
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posterior interosseous n. (radial)-posterior cord- middle & lower- C7-8
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What trunk is EDC derived from?
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both middle & lower
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What are the roots for EDC?
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C7-8
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If inserting too deeply in first dorsal interosseous what muscle may be hit?
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adductor pollicis
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What is the innervation of the 2nd through fourth dorsal interosseous muscles?
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can be shared by both median and ulnar nerves
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What is a possible innervation anomlay in the first dorsal interosseous muscle?
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rarely musculocutaneous branch
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What muscle may be spared in Guyon tunnel entrapment for ulnar nerve?
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abductor digiti minimi because it is innervated through superficial palmar branch
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What is the function of abductor digit minimi?
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abducts the 5th digit 45 degrees
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What is the pitfall of inserting abductor digiti minimi?
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if too deep will be in opponens digit minimi
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Where is the insertion for abductor digiti minimi?
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a line between the MP-5 and ulnar aspect of the pisiform
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What is a pitfall in inserting APB?
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if too deep in opponens pollicis
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What is Froment's sign?
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Trying to adduct thumb but because of weakness of adductor policus will make OK sign instead
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Where should one insert for adductor pollicis muscle?
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Radially abduct the thumb, go in the web space angled towards the first metacarpal bone
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What are the pitfalls of insertion of adductor pollicis?
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if too dorsal in 1st DI if too palmar in opponens pollicis
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What changes may occur in EMG MUAP if the limb is cold?
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increased duration, amplitude and phases
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What is the correction factor for conduction velocity based on a cold limb?
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1.5-2.5 meters/second
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What is the correction factor for distal latency based on a cold limb?
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0.2 milliseconds per degrees Celsius
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When do children reach adult range conduction velocities?
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75% adult at 1 year
adult range at 3-5 years |
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Why does cold temperature cause the changes that it does on NCV and EMG?
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cold temperature prolongs depolarization at the node of Ranvier
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Why does height affect NCV?
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because longer nerves tend to taper distallyb
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Where is the insertion point for supraspinatus muscle?
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rostral and medial to midpoint of spine of scapula
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If too superficial when trying to insert supraspinatus what muscle would you be needling?
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trapezius
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Where would one needle the trapezius muscle?
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the point where the shoulder meets the neck
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What is the innervatino for trapezius muscle?
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spinal accessory nerve, C3-4
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What is the insertion point for infraspinatus?
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Have the patient lie on the side and go just below the mdipoint of the scapularspine
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What is the insertion point for extensor hallucis longus?
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just lateral to the tibialis anterior tendon
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Where would one insert for peroneus longus or brevis muscle?
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4 fingerbreadths distal to the fibular head
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Where is the insertion point for Iliopsoas muscle?
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Feel the femoral pulse and go 2-3 fingerbreadths lateral to the pulse below the inguinal ligament
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What 2 muscles does the recurrent thenar branch of the median nerve supply?
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APB and opponens
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What is the significance of having palmar hypesthesia in a possible CTS?
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the palmar cutaneous sensory branches arise proximal to the carpal tunnel (they should be spared)
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Explain how to perform the 3 comparison tests for CTS described in preston & shapiro.
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1. Ring finger ring electrode stimulate at the same distance between median and ulnar nerve
2. Orthodromic, record mixed nerve at median and ulnar recording in the palm 3. First lumbrical-1st interossei comparison test, feel the 3rd metacarpal midpoint and record electrode at 1st lumbrical and 1st interossei comparison |
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Describe the anatomy of the median nerve.
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Plexus: from medial +lateral cords
medial to humerus Ligament of struthers medial to brachail artery lacertus fibrosus pronater teres heads (between) anterior interosseous n. palmar cutaneous sensory carpal tunnel recurrent thenar motor |
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What is the ligament of struthers?
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fibrous band from medial epicndyle to spur occurs in 2% of the population
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What is lacertus fibrosus?
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fibrous band that occurs from medial biceps tendon to forearm flexor muscles
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What findings are unique to an anterior interosseous neuropathy + martin gruber anastomosis?
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involvement of both thenar and hypothenar muscles
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What 2 muscles are most commonly affected in proximal median neuropathy?
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FPL and FDP
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What is the normal peak latency, amplitude and conduction velocity for lateral antebrachial cutaneous nerve?
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peak <3.0 amplitude more than 10 cv more than 55
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How can 1 distinguish more T1 than C8 involvement clinically as might be seen in true neurogenic thoracic outlet syndrome?
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more thenar rather than hypothenar involvement
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What is the root for ECR Longus?
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C6,7
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What is the innervation of ECU?
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radial nerve posterior interosseous branch
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What are the roots for FCU?
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C7,8,T1
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How should one needle flexor pollicis longus?
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Feel radial artery and go lateral to it according to P&S
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Describe the insertion site of infraspinatus.
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Feel the scapular spine. Middle of the scapular spine 2 fingerbreadths below.
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What are the pitfalls of needline the infraspinatus?
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too superficial in trapezius, toolateral in posterior deltoid
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How would one find the insertion site for levator scapulae?
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Feel medial angle of scapula and 2 fingerbreadths cephalad, 1 FB medial
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What are the pitfalls for needling levator scapulae?
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too superficial trapezius, too deep paraspinals
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What are the roots innervated by levator scapula?
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C3,4,5
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What is the nerve that innervates levator scapulae?
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dorsal scapular nerve
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What is the trunk that innervates levator scapulae?
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trick q: comes off before the trunks branch
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Describe hte insertion method for Rhombods?
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Feel midway between superior spine of scapula and inferior angle, just medial to vertebral border
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What is the innervation (nerve) for rhomboids?
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dorsal scapular nerve
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What are the roots involved for rhomboids?
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C 4,5
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What is the trunk that supplies rhomboids?
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trick q branches off brachial plexus before the trunks
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Describe the insertion site for serratus anterior.
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Feel the inferior angle of the scapula. Insert the electrode just lateral to that
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What is the innervation of serratus anterior?
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long thoracic nerve
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What are the roots involved in serratus anterior?
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C5,6,7
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What 3 muscles could lead to winged scapula?
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serratus anterior
rhomboid trapezius |
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Describe the insertion site of supraspinatus?
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Feel the middle of the supraspinaous fossa in middle of the scpular spine
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What are the pitfalls for insertion of supraspinatus?
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too superficial in trapezius can cause a pneumothorax
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What is the innervation for supraspinatus?
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suprascapular nerve
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What are the roots for supraspinatus?
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C5,6
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What is the trunk that supplies supraspinatus?
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upper trunk
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Describe the insertion site for teres major.
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Feel the inferior angle of the scapula along the lateral border, go fingerbreadths above it
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How does one activate teres major?
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internally rotate and adduct the arm
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What is the innervation of teres major?
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subscpaular nerve
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What are the roots involved in teres major?
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C5,6
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What is the trunk that supplies teres major?
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upper trunk
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Describe the insertion site for teres major.
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Feel the inferior angle of the scapula along the lateral border, go fingerbreadths above it
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How does one activate teres major?
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internally rotate and adduct the arm
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What is the innervation of teres major?
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subscpaular nerve
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What are the roots involved in teres major?
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C5,6
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What is the trunk that supplies teres major?
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upper trunk
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Describe the insertion site for teres major.
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Feel the inferior angle of the scapula along the lateral border, go fingerbreadths above it
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How does one activate teres major?
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internally rotate and adduct the arm
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What is the innervation of teres major?
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subscpaular nerve
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What are the roots involved in teres major?
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C5,6
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What is the trunk that supplies teres major?
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upper trunk
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What is hte cord that suplies teres major?
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posterior cord
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What is the action of teres minor?
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It externally rotates humerus along with the infraspinatus
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What trunks supply teres minor?
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C5,6
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What nerve supplies teres minor?
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axillary nerve
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What cord supplies teres minor?
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posterior cord
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What is hte innervation of trapezius?
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spinal accessory nerve
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What are the roots that supply trapezius?
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at least C3 and C4, ??C5
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What muscle is deep to biceps brachii and shares the same innervation?
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brachialis
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What is the action of coracobrachialis?
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Flexion and adduction of the arm
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What is the innervation of corachobrachialis?
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C6,7 roots, upper trunk, lateral cord, anterior, musculocutaneous
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What is the action of anconeus?
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elbow extension
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What is the innervation of anconeus?
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C7,8, middle/lower trunk, posterior division, posterior cord, radial nerve
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Describe the insertion site of brachioradialis.
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Halfway between the biceps tendon and lateral epicondyle along the flexor crease
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Describe the inserition site for ECR longus.
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Feel the lateral epicondyle, and insert 2 FB distal to that
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What are the roots that supply ECR longus
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C6,7
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What is a swing muscle that would distinguish between a spiral groove radial nerve lesion versus a posterior interosseous nerve syndrome?
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Insertion of ECR longus which would be spared in PIN and involved in radial nerve at spiral groove
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Describe the insertion site of brachioradialis.
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Halfway between the biceps tendon and lateral epicondyle along the flexor crease
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What nerve supplies ECU?
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radial nerve posterior interosseous nerve
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What roots supply ECU?
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C7,8
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Describe insertion site for ECU?
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Feel the shaft o fhte ulna and enter in the midpoint just above the shaft of the ulna.
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What are pitfalls for insertion to ECU?
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too proximal anconeus, too radial extensor pollicis longus
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Explain the insertion site of EDC.
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Put your thumb on the radius and middle finger on the ulna bone at the junction of upper/middle third of forearm. Then extend middle finger, EDC is there
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What roots are involved for EIP?
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C7,8
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What roots supply extensor pollicis brevis?
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C7,8
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Describe insertion site of extensor pollicis brevis.
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Feel the radial shaft, go the ulnar side of the shaft, 4 FB above the wrist
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What are the pitfalls for needling FCR?
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too deep FDS and FPL, if too medial PT if too lateral palmaris longus
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What is the innervation of the lateral division of the adductor magnus?
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sciatic nerve
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What 5 factors contribute to "size principle" of motor neurons?
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1. neuron size
2. axon size 3. myelin thickness 4. conduction velocity 5. type of fiber (fast or slow) |
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How does age affect the morphology of MUAP?
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With age, normal dropout of motor units with normal reinnervation at a rate of 1%/year can lead to higher amplitude starting at age 30
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What does duration characterize?
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Muscle fiber dispersion/depolarization over time
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What does polyphasia characterize?
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measure of synchrony
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What is the difference between serrations and polyphasia?
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Serrations do not cross the baseline
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What is the normal firing rate of soleus?
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15 hertz
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What is the difference between activation and recruitment?
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Both contribute to the pattern seen, activation is the ability to increase the firing rate, a central process. Recruitment indicates adding motor units as firing rate increases.
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How can one distinguish IBM from a neuropathic condition?
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IBM should have normal recruitment
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What factors influence the time it takes for denervation potentials to develop?
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1) proximity of the muscle to nerve (paraspinals develop denervation potentials in a few weeks)
2. Rate of reinnervation as well as type of injury/trauma |
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What is pseudoconduction block and the circumstance in which it occurs?
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Pseudoconduction block can occur in a transection of nerve. If the studies are done too early in an axonal lesion due to transection (before wallerian degeneration) pseudo-conduction block will develop
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Describe what electrophysiologic studies help to time an axonal loss lesion.
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1. Hyperacute: Normal conductions, Normal EMG except decreased recruitment. Less than 3 days after injury.
2. Acute: Abnormal conductions. (Wallerian degen.), Normal EMG x dec. recruitment. 3. Subacute: Abnl Conductions. Spontaneous activity + dec. recruitment (No sign of reinnervation. 4. Subacute to chronic. Abnl conductions. Spontaneous activitiy, dec. recruitment, reinnervation signs 5. Chronic. Abnl conductions, no spontaneous, reinnervation signs |
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What are 4 situations in which one could have diffuse low amplitude motor ncs sparing sensory?
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1) Myopathy
2) Polyradiculopathy 3) Anterior Horn cell or motor neuropathy 4) Hyperacute lesion pre-Wallerian degneration 4) |
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What nerve innervates Abudctor pollicis longus?
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Radial nerve
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What 3 muscles act jointly for thumb opposition?
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1. opponens pollicis
2. Flexor pollics brevis- ulnar 3. Flexor pollicis longus- AIN |
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What is the change in sensitivity of routine CTS diagnostic studies compared to more sensitive studies (transpalmar)
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increases sensitivity from 75% to 95%
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What is a high median mononeuropathy hand posture?
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Patient asked to grip and then the first,2nd and 3rd DIP digits are straight due to weakness of FPL, FDP, fingers abducted due to weakness of palmar interossei
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What 3 sites of entrapment are considered causes of pronator syndrome?
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1) heads of pronator teres
2) Lacertus fibrosus 3) Ligament of Struthers |
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What is lacertus fibrosus?
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a fibrous band from the forearm flexors to the medial biceps tendon
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What is ligament of struthers?
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bony spur in the humerus to the medial epicondyle (Clue: decreased radial artery)
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What differences can be seen in EMG evaluation of facial muscles compared to limb muscles?
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Facial muscles have smaller units and faster frequency firing rate 8-10 hertz
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Describe the course of the facial nerve
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1. Brain stem
2. CPA 3. Internal auitory meatus 4. Bony facial canal 5. Geniculate ganglion- greater petrosal lesser petrosal 6. Branch to stapedius 7. Chorda tympani (joined by lingual nerve) taste 8. Stylomastoid foramen |
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What are the 8 muscles that the facial nerve supplies?
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Temporal- Frontalis
Zygomatic- orbicularis oculi Buccal- orbicularis oris Mandibular- mentalis Cervical- platysma |
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What is the significance of "sural sparing" in a clinical AIDP picture?
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It is a function of the larger diameter and greater myelination of the sural nerve
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What viruses can cause paralytic poliomyelitis (5)?
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poliovirus
coxsackie virus echovirus enterovirus west nile virus |
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What are the roots for flexor digitorum sublimis?
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C7-8
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What are hte roots for EIP?
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C7-8
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What are the roots for EDC?
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C7-8
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What are the roots for ECU?
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C7-8
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What are the roots for FCU?
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C8-T1 (may be some 7)
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What are roots for FDP?
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C7-8-T1
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What are roots for ECR long head?
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C6-7
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What forms the floor, distal end and proximal part of Guyon's canal?
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floor transverse carpal ligament
distal hook of hamate prooximal pisiform bone |
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How does ulnar nerve branch through guyon's canal?
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superficial sensory branch
deep palmar motor branch (hypothenar) distal deep palmar motor branch |
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How can one differentiate ulnar neuropathy at the wrist from ulnar neuropathy at the elbow?
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unequivocal involvement of dorsal ulnar cutaneous and FDP 4,5 weakness
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What test can unequivocally localize an ulnar lesion to the wrist?
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recording FDI and stimulating at the wrist and palm with conduction block or drop in CV
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What are the 2 more common types of UNW?
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2 pure motor make up 75%: distal palmar and deep palmar
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What are the four sensory branches of the radial nerve?
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posterior cutaneous nerve of arm, posterior cutaenous nerve of forearm, lower lateral cutaneous nerve and superficial radial sensory nerve
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What generates myokymia? Motor neuron or muscle fiber?
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motor neuron
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What are 2 situations in which lumbrical-interossei studes should be interpreted with caution for UNW?
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DML difference >0.4 ms
1. coexistent median mononeuropathy at the wrist 2. If severe axonal loss from a higher ulnar lesion (low CMAPs) then it will look low across the wrist regardless) |
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What percentage of patients have an accessory peroneal nerve?
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15-20%
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What is important to note about clinical testing of inversion in a peroneal neuropathy?
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The foot must be held dorsiflexed prior to testing because in the plantar flexed position, there may be a mistaken impression that inversion is weak
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What is the origin of the lateral femoral cutaneous nerve?
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l2-l3 roots
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