Lab 2 Elbow/Forearm white, Lab 3 Forearm/Wrist/Hand, Upper Extremities Ortho Indications, LECTURE 1 MIDTERMEXAM SHOULDER white
Rotator cuff pathology: There is a painful arc from __________-____________
50 to 60° up to 120° *Glenohumeral painful arc is 45-60° up to 120° and above 170° is the acromioclavicular painful arc
AC joint sprains IV through VI
IV- Posterior displacement of collarbone. Can also include distal clavicle fracture V-Upward displacement of collarbone greater than type III VI-All AC joint ligaments are torn with DOWNWARD dislocation of the collarbone
These three tests provide a 91% probability for a full thickness rotator cuff tear
Painful-arc, drop arm and infraspinatus muscle test
Phalen's Test & reverse phalens test
carpal tunnel syndrome with median nerve compression
Type one scapular dyskinesia involves the inferior medial border tilting dorsally with movement. This could be due to which musculature? (3) weak and tight (1) musculature
weak: Lower trapezius, latissimus dorsi and serratus anterior tight: Pectoralis minor
Tinel's Sign TAP
peripheral neruopathy in medial or ulnar nerve distribution
______________-Is determined by the measure of agreement between the clinical test and reference standard
test accuracy
Pronator Teres MMT? resist pt pronation
-Keep elbow flexed with forearm neutral make them pronate and you resist Handshake
Biceps Brachii MMT? make a fist
-Normal C5 Myotome
Maudsley's test Resisted Middle Finger Extension Test
-Pt. sitting w/ forearm pronated, wrist in neutral position, and the fingers extended Dr. resists the extension of the 3rd digit -Increased pain over lateral epicondyle region -Lateral Epicondylitis
What joints are affected respectively for a Shoulder separation and a dislocation
- Separation = AC joint -Dislocated = GH joint
Froment Paper Sign? WEAK THUMB ADDDUCTION
-Pt. grasps a piece of paper between the thumb and 2nd metacarpal -Failure to maintain the grip or flexing the thumb when the paper is pulled away (weak thumb adduction) -Ulnar Nerve Palsy (usu. Tunnel of Guyon Syndrome)
Reliability test values no reliability slight fair moderate substantial
<.10. 11-.40 .41-.60 .61-.80 >.81
1992, ortho residency program was studied. 86% preferred conservative intervention with no long-term difficulty with pain or loss of function. They used sling immobilization with pendulum exercises followed up by what? (2)
For passive range of motion after 2-3 weeks and graduated resistance exercises after pain improved **Surgery had similar outcomes to conservative care
After bilateral shoulder ultrasonography on 664 residents, What were the respective percentages for the following -Full thickness tears -symptomatic tears and -asymptomatic tears
Full thickness tears -22% -symptomatic tears and -35% -asymptomatic tears-65%
Motor, reflexes and sensory testing of the shoulder c5 c6 c7 c8 T1
c5 = Deltoid, BICEPS DTR; Skin over lateral brachium c6 =Wrist extensors; brachioradialis DTR; lateral anti-brachium/thumb/index c7= Triceps; triceps DTR; skin over third digit and hand c8= Finger flexors; N/A; Medial antebrachium/ring and little finger T1= Interossei; N/A; medial brachium
Mills Test (Elbow)
lateral epicondylitis
Cozens's Test
lateral epicondylitis radiohumeral bursitis
Valgus Stress Test
medial collateral ligament injury
Ligamentous Stability Test:
-Dr. stabilizes pt'selbow w/ one hand and grasps the wrist w/ the other hand, then slightly flexes pt'selbow and applies a valgus and then varus force to the elbow -Pain and or Laxity -Medial or Lateral Collateral Ligament Instability
Flexor carpi ulnaris and radialis MMT?
-Extend and flex wrist; hold and push back to its original position
extensor carpi radialis longus and brevis MMT?
-Extend and radial deviate wrist; hold and push back to its original position
Extensor Carpi Ulnaris MMT?
-Extend and ulnar deviate wrist; hold and push back to its original position
What are four mechanisms of injury for a SLAP tear?
-FOOSH -MVC- rear impact w/ hands on wheel -sudden deceleration of traction forces- catching a falling object -Chronic anterior & posterior instability
Brachioradialis MMT? thumb up fist
-Flex elbow; thumb up and push down
Which muscle could act as an entrapment site for the median nerve?
-Flexor Digitorum Superficialis
Posterior instability presentation (4)
-Loud clunk when shoulder is moved in to forward flexion - severe pain, limited external rotation and limited flexion -posterior prominence and rounding of the shoulder compared to other end -flattening of the anterior aspect of the shoulder
Mills' Test (maneuver) (Evans) - elbow
-Passively flex Pt's elbow, fingers, & wrist, then the forearm is pronated and elbow is extended -Increased pain over lateral epicondyle region -Lateral epicondylitis
Finklestein Test AKA Eichhoff Test/ DE QUERVAINS DISEASE/ TENOSYNOVITIS OF THE THUMB
-Procedure:* Pt. makes a fist w/ the thumb inside the fingers and ulnar deviates wrist. Dr. may have to passively ulnar deviate the wrist. -Pain over the APL & EPBat the wrist -De QuervainDisease, Tenosynovitis of the Thumb
Carpal Compression Test:/ compression of median n.
-Pt seated w/ elbow flexed, forearm supinated, & wrist neutral. Dr. places both thumbs over transverse carpal ligament & applies 6 lbs. of pressure for 30 seconds -Exacerbation of symptoms in median nerve distribution -Carpal Tunnel Syndrome compression of median n.
Supinator MMT?
-Same as pronator test just make them supinate instead
These three combined RC tests provide 95% probability for impingement syndrome
-Hawkins Kennedy, painful arc, and infraspinatus muscle test
Type three scapular dyskinesia is when the superior border of the scapula is elevated At rest and that movement. There is minimal winning however in this is typically seen with active motion. -DUE TO overactivity of what muscles (2) -imbalance of what? -Associated with what two things?
-Overactivity of levator scapula and upper trapezius -In balance of upper and lower trapezius -Associated with impingement and rotator cuff lesions
Inferior GH instability: is it common or uncommon? What is it caused by (2) and what is the typical presentation (2)?
-Very Uncommon -Caused by carrying heavy objects at one side or hyper abduction forces levering the humeral neck against the acromion -Typical presentation is the patient's arm locked and abduction and the presence of the sulcus sign
Which muscle travels all the way to the end of the hand: Flexor Digitorum Superficialis or flexor digitorum profundus ?
-flexor digitorum profundus
What are the three phases of the orthopedic evaluation process?
-history -exam -diagnosis
What are two causes of GH instability
-trauma (FOOSH and direct impact) -repetetive use (overhead movements the M/C)
Grade II A/C joint sprain
AC ligament is severely torn in the coracoclavicular ligaments are sprained. There's a slight displacement of the clavicle, this is key. Coracoclavicular inner space might be slightly increased but the deltoid and trapezius are still intact. Patient will exhibit moderate-severe pain and PROMs is painful at end range with horizontal adduction the worst. -With a grade 2, both abduction and adduction are painful **Treatment = ice; pain-free AROM/PROM; transcription Massage (day 4)
What are the three components to the mechanism of anterior dislocation?
Abduction, external rotation and extension
Patients with a painful arc W/O pain to resisted shoulder MM are likely to have what?
Acromial-subdeltoid bursitis versus rotator cuff pathology
What are the threeMechanisms of injury for rotator cuff
Compression Tensile overload macrotrauma
What two ligaments make up the Coracoclavicular ligament?
Conoid and trapezoid ligament (CT) Conoid is medial
What is the definition of instability?
Do you have normal symptomatic motion that affects normal joint kinematics and results in pain, subluxation or dislocation
The ability of discriminating between patients who have a specific disorder compared to patients who do not have it is called________
Diagnostic accuracy
Active/passive/resistive isometric movements of the shoulder Flexion & Etension Abducrtion and adduction Int. & Ext rotation horizontal Abduction & Adduction
Flexion & Etension: 160-180 & 50-60 Abduction and adduction: 170-180 & 50-75 Int. & Ext rotation: 60-100 and 80-90 horizontal Abduction & Adduction: 90 & 45
Intra vs Inter-reliability:
Intra = single person and same test at different times inter-examiner = 2 or more people obtaining results with the same test
Grade I A/C joint sprain
It is an isolated sprain of the AC ligament, coracoclavicular ligaments and the deltoid and trapezius muscles are intact. There is mild pain and tenderness at the AC joint and a painful arc of 160°-180°. Resisted adduction is painful but there is no displacement of the clavicle. **Treatment could be trans-friction massage, ice, pain-free active range of motion and taping
What allows supination of the forearm?
Lacertis Fibrosus
Triceps Brachii MMT?
Normal triceps myotome
What type of scans can detect a decline in glucose metabolism associated with decreased cognitive function particularly in the temporal and parietal lobe's?
PET scan *SPECT Single photon omission computed tomography can be used for depression
What are the four types of polyarthropathies in the shoulder?
RA, Crystal deposition disease,(CDD), other inflammatory arthropathies, generalized osteoarthritis
Stage one of conservative care for a partial tear focuses on what
Reducing pain and inflammation *Some examples are PT modalities, activity modification, NSAIDs, strengthening other areas and core stability, Manual techniques like a RT, Grasston, Massage and fix restricted motion in the AC and SC joint
Stage two of conservative care for a partial tear focuses on__________
Restoring range of motion *Self mobilization and stretching, manual techniques, resisted exercise accentuating the eccentric contraction of the rotator cuff, resisted upper trapezius, deltoid and Cerritos anterior exercises along with neuromuscular reeducation
This is the ability of a test to correctly identify the patients that actually have a disorder compared to the reference standard (true positive rate)
SENSITIVITY
Finkelstein's Test
Tenosynovitis abductor pollicis longus and extensor pollicus brevis tendons
What is the reference standard? The criterion that best represents a particular disorder
The criterion that best represents a particular disorder
In a highly sensitive test, What is the difference between the negative and positive result?
The negative result is reliable to rule out the disorder While the positive result further supports your suspicions. In both cases you need to be aware of false positives or false negatives
For a highly specific test what is the difference between the negative and positive results?
The negative result would be reliable to rule out the disorder while a positive would be reliable regarding the presence of the disorder. Beware of false positives for both
Specificity is the ability of a test to Identify what?
The patients who do not have a disorder (true negative rate)
Microtrauma mechanism of injury for RC.
When force is generated by trauma exceed the tensile strength of the tendon
Which muscle travels all the way to the end of the thumb: Abductor Pollicis Longus or Abductor Pollicis Brevis?
abductor pollicis brevis/weird one
the most common shoulder instability direction is_____________
anterioinferior (over 90%): * Young patient with recurrent dislocation have a greater risk of Moderate-severe 08 and almost 15% of anterior shoulder dislocations are in the age of 15-29
What makes the superior labrum prone to injury?
The close attachment of the long head of the biceps. So, SLAP (Superior labrum anterior posterior) Is talking about the relationship to the long head of the biceps
What can also happen in a Bankart lesion injury is the anterior rim of the glenoid impacts the posterior lateral humeral head resulting in this
The hill-Sachs lesion, basically a big chip in the posterior lateral humeral head
What is the probability of having a disease highly dependent on?
The prevalence of the disease before the test is conducted
Froment's Paper Sign
Ulnar nerve paralysis
Although anterior subluxation/dislocation of the GH joint is rare in children, it is common in adolescent and under 25 years of age there is a ____________% chance of recurrence after the initial event. Over 50, the occurance is rare
-95%
Before we get into grade I-VI A/C Joint sprains, what are the two categories of AC joint sprain'?
-Acute traumatic: fall onto a shoulder with the arm at the side and the ground reaction force displaces the scapula in relation to distal clavicle OR...your classic FOOSH injury -Chronic: Atraumatic or post traumatic: Such as osteoarthritis and inflammatory arthritis
What are too conservative treatment options for a slap tear
-Address associated scapular dyskinesis -improve strength and coordination of dynamic stabilizers **Aggressive options-arthroscopic labral debridement, not typically effective long-term and capsulolabral reconstruction which has better outcomes
What is a bankart lesion ? What causes it?
-An anterioinferior labral tear (3 o'clock to 7 o'clock position) -Cause typically occurs with traumatic anterior dislocation leading to anterior instability *A bony Bankart lesion is when the inferior portion of the glenoid fossa actually has a fracture
Scapular dyskinesia is present at what percentages in the following: Athletes with shoulder injuries Asymptomatic non-overhead athletes Asymptomatic overhead athletes Why athletes??
-Athletes with shoulder injuries = 67-100% Asymptomatic non-overhead athletes = 33% Asymptomatic overhead athletes = 61% Most likely because of reliance on unilateral upper extremity function
Type to scapular dyskinesia (the classic winning of the scapula) Is when the whole medial border of the scapula is prominent and lifting away from the thorax. This may indicate the presence of ____________. Also, which muscles are weak (3), tight (1) and what nerve can have a problem?
-SLAP tear/lesion weak: Lower/mid/upper trapezius, rhomboid or serratus anterior tight: Humeral rotators Long thoracic nerve problem
Posterior instability of the glenohumeral joint is rare, typically less than or equal to 2% of all shoulder dislocations. What are the four mechanisms?
-Seizures -electric shock -diving into a shallow pool -motor vehicle crash
The Extensor Carpi Ulnaris goes into which space?
-TFCC
Prevalence rate of rotator cuff injuries based on age
20-40s - 0% 50s - 11% 60's-15% 70's-27% 80s-37% *Significantly greater than males than females in the 50 to 60 group however not significantly greater in the 70's to 80s group. General population was 22% incidence and asymptomatic tears are twice as common as symptomatic
AC joint sprain's make up what percentage of all patients with shoulder pain?
31%
Although a slap lesion is similar to other rotator cuff disease and instability and difficult to diagnose, what is a hallmark the patient will complain of?
Pain with overhead activities and a catching or locking
This maneuver is when the patient is prone on the table with the affected limb hanging freely over the edge with a 10-15 pound weight suspended with gradual traction.
Stimson maneuver *the Hennepin Technique is where the practitioner adducts the dislocated arm with the elbow at 90° and the dude is supine *Traction/counter traction technique is when the towel is wrapped around the armpit in the other person pose
Brachialis MMT? palm down
-Do biceps test but pronate forearm
Longitudinal Thumb Compression:
-Dr. holds pt's thumb & applies long-axis compression through metacarpal bone into scaphoid -Pain at Scaphoid -Scaphoid Fx
Resisted Supination External Rotation Test
-Dr. holds pt'shand in handshake position & directs pt to resist supination -Pain at Scaphoid -Scaphoid Fx
Tinel Sign at cubital tunnel
-Dr. applies 4-6 taps to pt's ulnar nerve just proximal to cubital tunnel -Tingling sensation in the ulnar nerve distribution -Cubital Tunnel Syndrome (compression of ulnar n.)
Sources of shoulder disorders: Five sources of referred pain
-Cervical spine disorders -Pancoast tumor (NSCLC Of the superior sulcus), -Diaphragmatic irritation -gastric/pancreatic/cardiac diseases -disorders of the elbow or hand
in RC pasthology, what are the three areas of palpable tenderness?
-Coracoacromial ligament -Biceps tendon -Supraspinatus insertion
Tinel Sign at the Carpal Tunnel? COMPRESSION OF MEDIAN NERVE
-Pt's elbow is flexed, forearm is supinated and wrist is slightly extended. Dr. percusses the volar surface of the wrist over the carpal tunnel & median nerve w/ a reflex hammer -Pain or paresthesia sensation in median nerve distribution -Carpal Tunnel Syndrome compression of median n
Phalen Sign AKA Prayer Sign/ CARPAL TUNNEL SYNDROME
-Pt's wrists are flexed maximally & position is held for up to 1 minute while the dorsal surfaces are pushed together -Tingling sensations that radiate into the thumb, index finger, middle finger and lateral . of ring finger -Carpal Tunnel Syndrome
Reverse Mills Test
-Pt. seated Dr. extends pt's elbow, wrist, and fingers -Pain over medial epicondyle region -Medial Epicondylitis
Golfer Elbow test - reverse Cozen
-Pt. seated w/ elbow extended slightly and forearm supinated, and flexes the wrist against the resistance of the dr. -Pain over medial epicondyle region -Medial Epicondylitis
Cozen Test/cruisen
-Pt. seated w/ elbow flexed to 90°; clinches fist, pronates forearm and extends wrist Dr. stabilizes forearm and resists the wrist extension -Increased pain over the region of the lateral epicondyle -Lateral epicondylitis or radiohumeral bursitis
Carpal Lift Sign/ CARPAL FRACTURE
-Pt. seated w/ elbow flexed, forearm pronated & wrist & hand resting flat on the table. Dr. applies pressure to the dorsum of the affected digit. Pt. attempts to lift the extended finger -Pain in the dorsum of the wrist -Carpral Fracture or Wrist Sprain
What are the three types of posterior instability classifications?
-Subacromial: M/C: Posterioinferior to acromion -sub glenoid: posterioinferior to glenoid rim -sub spinous: medial to acromion & inferior to scapular spine)
Sensitivity is known as the true__________rate, While specificity is known as the_________. -
-True positive -Treue negative
How many articulations does the shoulder joint complex have?
4 Glenohumeral, acromioclavicular, sternoclavicular, scapulothoracic
Stage three and four of conservative care For a partial tear of the rotator cuff focuses on____________
Functional range of motion and sport/work specific training.
Grade III A/C joint sprain
The AC ligament in the coracoclavicular ligaments are both torn AC joint is this located in the shoulder is displaced inferiorly. Distal clavicle is actually displaced upward (Shoulder separation) The deltoid and trapezius may be detached from the distal clavicle and there could be a fracture of the distal clavicle under 13 years of age. Patient will hold their arm against their body in adduction and exert upward pressure through the humerus AROMs Are painful especially abduction -Piano key phenomenon
Varus Stress Test
lateral collateral ligament injury
Golferes Elbow Test
medial epicondylitis
Primary compression of the rotator cuff pathology involves three types. What are they and what is the secondary type? (1)
primary: Type III acromion: Typical of a hooked acromion squeezing down on the space -congenital thickness of the coroacromial ligament -osteophyte on the inferior surface of the acromion Secondary: decreased GH joint stability
Tensile overload mechanism of injury. Primary versus secondary
primary: Basically any of the shoulder movements where there is too much tensile overload including deceleration phase of throwing or hammering Secondary: GH instability place in greater distractive and tensile forces on the rotator cuff with eventual failure
