My Purple Book Flash Cards

Functional elbow ROM extension/flexion?

-30 to 130

Normal elbow ROM

-5/145 and 75/85 pronation/supination

Recommended ergonomic handle width for power tasks:

1 1/4 to 2 inch

What are the Semmes cut-off levels?

2.83: normal, 3.61: diminished light touch, 4.31: diminished protective sensation, 4.56: loss of protective sensation, 6.65+: not testable

Overhead work requiring shoulder abduction shoulder be limited to what degrees of abduction?

30 (odd...)

What Semmes level is required before starting discriminative training?

4.31; diminished protective

Attrition rupture

A tendon moving across a roughened bone causing a rupture

Pronator syndrome can occur due to median nerve compression at any one of 4 distinct sites:

1) ligament of Struthers, 2) bicipital aponeurosis, 3) between the 2 heads of the pronator teres muscle where the nerve enters the forearm, or 4) at the fibrous ache of the FDS

Sympathetically maintained pain

Associated with dysregulation of the autonomic nervous system. Examples: may be, BUT NOT ALWAYS, associated with reflex sympathetic dystrophy/causalgia complex regional pain syndrome, type I, type II.

AMBRII

Atraumatic, Multiaxial, Bilateral, Rehabilitation, Inferior interval shift; likely born with this.

Quadrilateral Space Syndrome

Atrophy of the teres minor due to compression of the AXILLARY nerve within the quadrilateral space. Symptoms may include tenderness in the areas of teres major/minor and triceps

Crossed intrinsic transfer

Attempt to restore finger alignment and prevent ulnar drift. Intrinsics released from ulnar side and transferred to radial aspect of adjacent fingers to provide additional radial support and dynamic pull

Guillain-Barre syndrome

Autoimmune condition that causes acute inflammation of the peripheral nerves in which myelin sheaths on the axons are destroyed, resulting in decreased nerve impulses, loss of reflex response, and sudden symmetrical muscle weakness; generally affects the lower extremities but can progress to upper limbs

Marfan Syndrome

Autosomal dominant genetic connective tissue disorder that can cause a ruptured aorta. Can range from mild ligament laxity to severe kyphosis, concave chest wall, and flattened foot arches

Poland syndrome

Autosomal recessive disorder; Unilateral absence of sternocostal head of pectoralis major. Ipsilateral digit brachydactyly/syndactyly, Rib anomalies.

What nerve is most commonly injured with proximal humerus fractures?

Axillary

Which nerve is at risk with anterior shoulder dislocation? What would the presentation be?

Axillary Nerve; deltoid atrophy and parasthesias of the lateral arm.

Quadrangular space contains which nerve and artery?

Axillary nerve and POSTERIOR circumflex artery

Engineering controls:

Devices that isolate or remove hazard from the workplace. Controlling the environmental hazards are part of the directive to decrease the potential hazard or injury. -Hand washing stations -Replacement of a hazardous chemical with a safer one -Needleless systems for injection - Devices that contain the hazard, such as specimen containers, safety sharps, sharps disposal containers, and red bags

If the lateral collateral ligament is damaged, the most stable forearm position is?

Flexed to 90 and full Pronation

Apex patterns of finger fracture, proximal to distal:

MP fractures are Apex dorsal proximal phalanx fracture's are Apex volar middle phalanx fracture's proximal to the FDS insertion are Apex dorsal middle phalanx fracture's distal to the FDS insertion are Apex volar distal phalanx fracture's are Apex dorsal * they alternate from proximal to distal *

Congenital clasped thumb involves flexion at which thumb joint?

MPJ

What is the most common hand deformity following a dorsal burn?

Intrinsic minus hand (claw deformity)

In dupuytrens contracture, central cords leads to contracture at which joints?

MPJ and PIPJ

Typing is most hindered by injury to which thumb ligament?

MPj RCL

Identification of a malignant soft tissue tumor is best determined by which diagnostic study?

MRI

Overgrowth: examples?

Macrodactyly, Giantism

Elbow carrying angle "normal" degrees:

Male normally 11-14 degrees Females normally 13-16 degrees >15 degrees- cubitus valgus <5 degrees- cubitus varus/gunstock deformity

What structure maintains PIPJ extension?

Lateral bands

What is the most functional pinch pattern?

Lateral pinch

Quadrilateral Space

Lateral space bounded by teres minor, humerus, teres major, & long head of triceps brachii. Contains the axillary nerve & humeral circumflex arteries.

What muscles form the lateral and medial borders of the cubital fossa?

Lateral: Brachioradialis; Medial: Pronator Teres

What is the MOST important predictive factor regarding development of hypertrophic scarring? Why?

Length of time to wound closure; longer is take to close the more collagen that is deposited, resulting in thick, rigid scar formation.

Hansen's disease

Leprosy, bacterial infection, limb/face nerve paralysis, blindness; Radial, Median, and Ulnar nerves all affected, sensory loss first, then motor; curable with oral chemo and deformities can be prevented if caught early

What are the hallmark signs of RA in stage III?

Less pain, but obvious deformity

Onycholysis

Lifting of the nail plate from the nail bed without shedding, usually beginning at the free edge and continuing toward the lunula area.

Arthrograms are typically used to assess:

Ligament tears, such as the TFCC, SL ligament, or LT ligament; dye injected and xray taken, looking for leakage of the dye

Ligament vs Arcade of Struthers

Ligament: possible compression site for the MEDIAN nerve; remember L-M. Arcade: possible compression site for the ULNAR nerve; remember "see U at the arcade"

Madelung's deformity

Limited development of the distal radius results in short radius, asymmetric prominence of ulnar styloid, posterior subluxation of distal ulna; more common in females than males. Results in limited wrist extension and supination

Macrodactyly

Local gigantism of one or more toes/digits, usually unilateral, M>F, blood supply and tendons are not affected = poor circulation; involvement of 2 or 3 adjacent digits is more common than single digit involvement

Panner's disease

Localized AVN of capitellum, <10 y/o, etiology unknown

Lateral horn of spinal cord

Located at T1-L2 spinal levels lateral horns form an intermediolateral cell column of sympathetic preganglionic efferent neurons of the autonomic NS, assists with visceral organs

Natatory ligament

Located between the fingers creating web spaces and assists with abduction; often involved with webspace contracture in dupuytren's contracture

Pretendinous cords leads to contracture of what joint(s)?

Located in palmar fascia and are most superficial and becomes pathologic with Dupuytrens; causes MCP contractures. They are vertical fibers attached to the skin and in a typical hand serve to stabilize the skin

Which tendon is involved with SLAP lesions?

Long head of the biceps

What type of orthosis is used to treat Pronator Syndrome?

Long-arm orthosis in 90 degree and neutral forearm

Treatment for type I radial head fracture?

Long-arm splint/sling for 1-4 days and then begin gentle ROM

Treatment for type II radial head fracture?

Long-arm splint/sling for 2-3 weeks and then begin gentle ROM

What is the most significant deficit following hamate fracture?

Loss of strength

What is the most common long term complication of elbow dislocations?

Loss of terminal elbow extension, and some also lose 5-15 degrees of flexion

Which bones are fused in a 4-corner fusion?

Lunate, Capitate, Hamate, Triquetrum, with scaphoid typically removed

Vascular issues are most common in which three carpal bones?

Lunate, Scaphoid, Capitate

What is the first and second most common carpal coalition?

Lunotriquetral, and Capitohamate; More common in afro-carribean descent and more females than males

What is the order of lymphatic return?

Lymph capillaries to precollectors, to collectors, to lymph nodes, trunks, to venous angles

Paronychia

MOST common finger infect; "runaround" infection about the nail; staph introduced through a hang nail; treated with saline soaks and antibiotics; surgical drainage may be indicated for more extensive lesions with saline soaks re-initiated when inflammation reduces

The ulnar artery continues into the hand as which artery?

Superficial Palmar Arch

Meso-, Epi-, Peri-, and Endoneurium

Meso: surrounds the nerve trunk and allows gliding; Epi: surrounds the nerve trunk to allow gliding within the meso; Peri: surrounds each fascicle within the trunk and is also the blood-nerve barrier protecting the fascicles from toxins; Endo: surrounds each individual axon

The vincula are composed of what tissue?

Mesotenon

A 'clunk; with wrist ulnar deviation is indicative of what? Why?

Midcarpal instability; "catch up clunk" occurs as the proximal carpal row abruptly shifts from flexion to extension

Which finger is the most commonly injured extensor tendon?

Middle finger

Saggital band rupture is most common in which finger? And most common on which side?

Middle finger, radial side; ulnar displacement of the tendon

Primary symptom of Vasospasm?

Mild parasthesia with marked pallor; arterial spasm leads to vasoconstriction which can lead to tissue ischemia and tissue death/necrosis, particularly at the finger tips

Best sensory test to use with young children

Moberg Pick-Up test

Wright's Test/Maneuver; Hyperabduction Test)

Monitor radial pulse while hyperabducting the arm above the head w/ some extension; Positive Test = indicates compression of the neuromuscular bundle as it passes under the PECtoralis minor noted when there is severely decreased/absent radial pulse

Which arch gives blood supply to the digital arteries?

Superficial Palmar Arch gives off common digital arteries, which then divide to become the proper digital arteries

Is the midcarpal joint affected with RA? Why?

No; RA affects synovial tissue and ligaments, and affect area as badly with a paucity of ligaments such as the midcarpal joint

What is the most common cause of lymphatic system inflammation and lymphedema? What is it's AKA?

Parasitic infection; filariasis parasitic worms live in the host and destroy due to toxicity of waste buildup in the lymphatics. Comes from a mosquito bite, and then worms live in host for 4-6 years; **elephantiasis** is treatable with drugs

What are the most important outcomes following thumb reconstruction?

Opposition and Sensation

What are the two most important outcomes following thumb reconstruction?

Opposition and sensation

Forearm anterior compartment

Superficial layer flexor carpi ulnaris (FCU) palmaris longus (PL) flexor carpi radialis (FCR) pronator teres (PT) Intermediate layer flexor digitorum superficialis (FDS) Deep layer flexor digitorum profundus (FDP) flexor pollicis longus (FPL) pronator quadratus (PQ)

Major blood supply in the hand is from:

Superficial palmar arch and deep palmar arch

First degree burn

Superficial; Confined to the epithelial layer on skin; A mild burn characterized by heat, pain, and reddening of the burned surface but typically not exhibiting blistering or charring of tissues; heals in 5-10 days

What are the borders of the quadrangular space?

Superior: Teres minor, Inferiorly: Teres major, Medially: Long head of the triceps, Laterally: Shaft of the humerus

The annular ligament is taut in which forearm position?

Supination

Position in which ECU is more efficient with wrist extension

Supination, in contrast with pronation, during which it is a better ulnar deviator

In radial tunnel syndrome, pain can be reproduced with resisted testing of which muscle? Why?

Supinator; radial nerve enters the forearm between the two heads of the supinator

What are the initial exercises following an elbow lateral collateral ligament injury/dislocation?

Supine; with forearm pronated allow elbow extension to -30 and full flexion; supination/pronation allowed with elbow bent to 90 degrees; overhead motion protocol

Which nerve is at risk with shoulder traction and compression injuries? What would the presentation be?

Suprascapular Nerve; shoulder pain and weakness in shoulder abduction and external rotation

Treatment of stener lesion?

Surgical repair of the UCL, pin placed through MCPj for stability, and ROM initiated after 4-6 weeks; not repairing leads to chronic instability

MPJ ligaments: When are the propers taut? When are the accessories taut?

The propers are taut in flexion, and the accessory collateral ligaments are taut in extension. think: extended MPJs to show off your accessories

PIPJ ligaments: When are the propers taut? When are the accessories taut?

The propers are taut in flexion, and the accessory collateral ligaments are taut in extension. think: extended PIPJs to show off your accessories

Structures that pass through Guyon's Canal

The ulnar nerve and artery

Middle phalanx fractures can position either apex volar or dorsal: why?

Pending location of the fracture, the FDS pull will affect the Apex. Fractures and distal to the insertion of the FTS will result in a volar Apex, whereas fractures proximal to the FDS insertion will result in an Apex dorsal.

How soon can you clean a sutures wound?

Pending surgeon, as early at 24 hours with mild soap and water.

CRPS 2 AKA? Presentation?

Causalgia; has a well define nerve lesion; will present with neuro symptoms such as numbness along the peripheral nerve or nerve root distribution, or weakness related to a specific nerve

Patients are at risk for what deformity following hand transplant?

Claw deformity due to nerve repairs and a prolonged period of inability to activate the intrinsics

Opera glass hand

Clinical picture of Arthritis Mutilans

What are the 4 types of isotonic exercise?

Concentric, Eccentric, Plyometric, and variable loading

Mobilization with movement

Concurrent application of sustained accessory mobilization glide usually perpendicular, applied by a therapist and an active physiological movement to end range applied by the patient

Ventral horn of spinal cord

Contains bodies of MOTOR neurons to skeletal muscles; therefor the area is largest near the level of the limbs

Good test for jewelers?

Crawford small parts test

Dorsal horn of the spinal cord

Crescent shaped projection of gray matter within the spinal cord where sensory neurons enter the spinal cord

Order of sensory return

Please take very potent disease medicine today, cause the vaccines like to save dummies Pain and Temperature 30 Hz Vibration/Pin Prick/Deep Pressure Moving Touch Constant Touch 256 Hz Vibration Localization of touch Two Point Discrimination Stereognosis/Discrimination

Work hardening

Program using simulated or real job duties to build up strength and endurance; most appropriate for chronic conditions and workers with global deficits

Arterial symptoms (upper extremity)

Progressively worsening symptoms Pain and fatigue with increased arm use Arm/hand coolness and cold intolerance Limb pallor Typically develops spontaneously Occurs from compression at the subclavian artery in the area of the first rib or an arterial emboli

Ligament of Testut; AKA?

Radioscapholunate RSL ligament. It is relatively weak and lacks collagen bundles but has more vascular and neural tissues than other ligaments, functioning as a mechanoreceptor

Interscalene triangle

Region between the anterior and middle scalene muscles. Brachial plexus TRUNKS and subclavian ARTERY course between these two muscles; can become compressed and impair function.

Dermofasciectomy

Removal of both diseased skin and overlying skin; Requires use of skin graft or healing by secondary intention. Usually reserved for situations where there is longitudinal skin shortage or where there is recurrent disease with dense skin involvement.

Segmental fasciectomy

Removing one or more short segments of the cord/s; may be done at one level, for example, in the palm, or at multiple levels, but the disease in between is left; treatment of choice for some surgeons, mostly in Europe, but it may be especially indicated in certain situations such as 2 stage procedures for severe contraction

Pagett-Schoetter syndrome is also called:

Thoracic outlet syndrome

Apert's thumb

Thumb is often short and angulated, webspace is deficient and thumb must be separated away from the IF to allow function.

What motions are lost with high median nerve palsy?

Thumb opposition and flexion, flexion of MF and IF

Pre-axial polydactyly

Thumb-side, duplication of all or part of the first ray

Anterior oblique band of the medial collateral ligament: restrains against? most active at what degrees? how common is injury?

Restrain against valgus stress. most active in elbow flexion from 30-90 degrees, most commonly injury portion of the MCL particularly in throwers

Posterior band of the medial collateral ligament: restrains against? most active at what degrees? how common is injury?

Restrain against valgus stress. most active in elbow flexion past 120 degrees, less commonly injured than anterior bundle due to position of elbow flexion during function

Reverse bennett's vs boxer's fracture?

Reverse bennett's = base; boxer's = metacarpal neck

"CREST"

Scleroderma symptoms: Calcinosis: calcium deposits in skin, Raynaud's phenomenon, Esophageal dysmotility: acid reflux, Sclerodacytly: skin tightening, Telangiectasia: spider veins/red marks near surface of skin

Limited cutaneous systemic sclerosis

Sclerosis limited to extremities distal to the elbow and knees. Major variant is CREST syndrome

Neer Impingement Test

The patient is positioned in sitting or standing. The therapist positions one hand on the posterior aspect of the patient's scapula and the other hand stabilizing the elbow. The therapist elevates the patient's arm through flexion with the arm in internal rotation. A positive test is indicated by a facial grimace or pain and may be indicative of shoulder impingement involving the supraspinatus tendon

Whipple Test

Shoulder flexed to 90 and adducted to where the hands is in front of the opposite shoulder; therapist puts downward pressure; tests for supraspinatus integrity

p-value

The probability that an observed difference is due to sampling error; level which forms basis for deciding if results are statistically significant and not due to chance

The EI and EDM run along which aspect of the EDC?

Ulnar

The juncturea tendinum is thicker on which side of the hand?

Ulnar

Which nerve is at risk with a medial humeral fx pinning?

Ulnar

Which artery gives the greatest percentage of bloodflow to the hand? What percentage?

Ulnar artery; 60%

Egawa's Sign

Ulnar nerve test; due to interosseus muscle paralysis pt is able to flex the MF, but unable to abduct/deviate it radially or ulnarly

For ulnar abutment without DRUJ involvement, the procedure of choice would be:

Ulnar shortening osteotomy

Gelnohumeral distraction force can reach up to what percentage of a thower's body weight during deceleration?

Up to 90%

Rate of nerve regeneration in upper arm? In forearm/hand?

Upper arm: 8.5mm/day, ~8 inches/month Forearm/hand: 1-1.5mm/day, ~1 inch/month

Spastic paralysis suggests involvement of the:

Upper motor neurons; lack voluntary control and are at risk for contractures

Anti-TNF agents

Used for patients with RA and PA; also help patients with ankylosing spondilitis and IBS. Often ADDED to DMARD rather than given alone

Berger's Test

Used to asses lumbrical involvement in carpal tunnel syndrome. Patient holds fist with wrist in neutral for 30-40 sec. Positive = patient reports pain and parasthesia in 30-40sec and means lumbricals invade carpal tunnel. Splint MPJ in extension

Moberg flap

Used to cover thumb amputations distal to the IPJ

Linscheid test:

Used to detect IF & MF CMC injury; support the metacarpal shafts and press distally over the metacarpal heads in a palmar and dorsal direction. A positive test produces pain localized to the CMC joints

Steindler flexorplasty

Used with brachial plexus palsy C5-6-7, when elbow flexion is lost, transposes forearm flexor-pronator origin proximally on humerus to increase moment arm. Strength is limited to 5 lbs

What is the recommended orthosis position following WALANT flexor tendon repair?

Wrist at 20-45* of extension, MPs flexed to 30*, and IPs extended to 0*

Most common complication of radial head excision? Others?

Wrist pain due to ulnar head impaction as a result of the radius being shortened and proximal migration Others: grip weakness, elbow instability, HO, and arthritis

On a graph, where are dependent and independent variable depicted?

Y axis = dependent X axis = independent

Which colored wound(s) should be scrubbed with mild soap and water?

Yellow and Black, to remove debris.

Can electrical current affect wound healing?

Yes; some research shows beneficial effect on chronic dermal wounds; further research needed to establish dosage recommendations

Giant cell tumor of bone

Young adult of 20-30, osteolytic lesion with "soap bubble" look at the joint; presents with pain, swelling, decreased ROM; in hand can be seen at the metacarpals, phalanges, and carpals

Which flexor zone contains camper's chiasm?

Zone 2

What flexor zone is at the level of the carpal tunnel?

Zone 4

Which flexor zone contains the muskulotendinous junctions?

Zone 5

Which extensor zone is the most common site of injury?

Zone 6

Sodium amytal test

a test involving the anesthetization of first one cerebral hemisphere and then the other to help to differentiate conversion disorder from malingering and factitious behavior.

What are the ligaments of the radial/lateral elbow? AKA Lateral collateral ligament complex components

accessory lateral collateral ligament annular ligament lateral radial collateral ligament (LCL) lateral ulnar collateral ligament (LUCL)

Trapezius is innervation by which nerve?

accessory nerve, CN XI

Horner's syndrome

acquired or congenital T1 level sympathetic dysfunction; constricted pupil, inset orbit, drooping eyelid, dry eye, anhidrosis; associated with Klumpke's palsy C7, C8, T1

Total/Radical fasciectomy

aims to remove all the fascia, both diseased and normal, and therefore involves a more extensive dissection and exposure; no longer recommended and not typically performed

Regional/Partial fasciectomy

aims to remove the diseased tissue while leaving behind the normal fascia

Transverse deficiency

all elements beyond a certain level are absent, and the limb resembles an amputation stump. Amniotic bands are the most common cause; the degree of deficiency varies based on the location of the band, and typically, there are no other defects or anomalies. The remaining cases are mostly due to underlying genetic syndromes such as Adams-Oliver syndrome or chromosomal abnormalities.

2 Types of parasthesia/hyperasthesia:

allodynia: painful response to non-painful stimuli; pain with semmes testing hyperalgesia: heightened painful response to painful stimuli; pin prick = 10/10 hyperpathia: related concept = refers to prolonged pain response after stimuli

Peyronie's disease

also known as penile curvature, is a form of sexual dysfunction in which the penis is bent or curved during erection; form of dupuytren's

Hyperpathia

an extreme exaggerated response to pain; outlast initial stimulus and spreads beyond normal dermatomal borders

Check-rein ligaments

attaches proximal end of the volar plate to the proximal phalanx; most often implicated in PIPJ flexion contracture along with the volar plate and collateral ligaments

longitudinal arch

begins at the wrist and runs the length of the metacarpal and phalanges for each digit; allows for digital flexion at each joint to produce composite flexion

Transverse Hemimelia

below elbow amputation; all or majority UE missing distal to elbow

Neuroma

benign nerve "tumor" formed due to blocked nerve regeneration; regenerating sprouts become trapped and surrounded by connective tissue

Uticaria

can be a cold-sensitivity reaction; hives; an eruption of wheals on the skin accompanied by itch

Smith's fracture

fracture of the distal radius with volar displacement usually from fall onto a flexed wrist

In addition to their primary roles, both platelets and macrophages also release:

growth factors essential for tissue repair

Mycobacterium marinum

hand infection in aquarium handlers, fisherman, etc; most often affects the skin, flexor tendon sheath, carpal canal, and extensor tendons; may require surgery

Brachydactyly

hand with short or hypoplastic fingers; most commonly present with hypoplasia of the index through ring fingers; occurs sporadically and can often be associated with Poland's syndrome

mini-open rotator cuff repair

involves arthroscopic subacromial decompression followed by a deltoid-splitting approach for the repair. It is a well-established, excellent technique for treating full-thickness tears

Dart thrower's motion (DTM) is beneficial following SL ligament repair because:

it utilizes motion primarily at the midcarpal joint and not within the proximal carpal row, reducing strain on repaired structures.

Wound VAC is contraindicated in wounds that are: (3)

malignant, necrotic, or developing eschar

With iontophoresis, which pad should be smaller? And how far apart do they need to be placed?

cathode should be larger than anode to prevent burns and should be separated by the at least the same distance as the anode size

Sterile abscess

caused by an irritant like an injected medication that was not completely absorbed; not caused by infection, thus are called "sterile" abscesses; aren't as common as infected abscesses, but they can happen on occasion.

Anterior cord syndrome

caused by flexion injuries, occurs when 2/3 of the anterior cord is lost; proprioception is spared but variable loss of motor function, pain, and temperature sensation bilaterally below the lesion

A reduction in shoulder pain when the arm is elevated overhead would indicate:

cervical ridiculopothy

TAR (Thrombocytopenia with absent radii)

characterized by the absence of the radius in each forearm and a deficiency of platelet blood cells involved in clotting ; NORMAL THUMBS but also has GI issues and can present with phocomelia, ulna or humerus hypoplasia, club hand, and syndactyly

Systemic lupus erythematosus (SLE)

chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs; symptoms can include rash, photosensitivty, mouth ulcers, polyarthritis, serositis, renal disorders, neuro disorders, anemia. Methylprednisolone use to treat the lupus, NSAID to treat the arthritis, and methotrexate to treat the arthritis and dermatitis

Cryoglobulinemia

cold sensitivity condition; medical condition in which the blood contains large amounts of cryoglobulins - proteins; mostly immunoglobulins themselves that become insoluble at reduced temperatures.

Pilon Fracture

comminuted intraarticular fracture at the base of the middle phalanx; treated with ORIF, ex-fix, or dynamic traction

Mumford procedure

commonly done for pt with DJD of AC joint; distal resection of 4-5mm of clavicle

Anarchic hand syndrome

complex, goal-directed hand movements that the patient does not initiate voluntarily and cannot interpret; recognizes the hand as their own and are frustrated with the movements, unlike alien hand in which the pt does not recognize it as their own.

amyotrophic lateral sclerosis; ALS

condition of progressive deterioration of motor neurons within primary motor cortex, brainstem, and spinal cord; resulting in total loss of voluntary muscle control; symptoms advance from muscle weakness in the arms and legs, to the muscles of speech, swallowing, and breathing, to total paralysis and death; also known as Lou Gehrig disease

Phocomelia

congenital condition in which the proximal portions of the limbs are poorly developed or absent

biceps short head origin and insertion

corocoid process of the scapula to the radial tuberosity

Elbow Flexion Test

cubital tunnel test; hold elbow in flex for 5 min with wrist neutral to elicit symptoms

Dyesthesia

distortions of somesthetic sensation, usually associated with a partial loss of sensory innervation; unpleasant abnormal sensation

Horii circle

elbow posterolateral disruption sequence; lateral collateral ligament first injured and possible avulsed, with anterior band of the medial epicondyle being the last structure injured, if it is.

Available excursion

extent to which the joints and muscles have stretched during the previous months

What creates collagen?

fibroblasts

Patient presents with cardinal signs of Kanaval; what is going on and what is the treatment?

flexor tendon sheath infection/tenosynovitis; immediate surgical decompressions and drainage in hospital with antibiotics administered

Kaltostat

forms an absorbent gel-fiber matrix on contact with fluid; maintains a moist wound environment; used for debridement and for mod-heavy exuding wounds; good for infected wounds

standard deviation

the square root of the variance

venous stasis

the temporary cessation or slowing of the venous blood flow; contributes to nocturnal pain in CTS

CREST syndrome

type of limited scleroderma; only distal to knees/elbows & head are involved; Calcinosis, Raynaud's phenomenon, Esophageal dysmotility, Sclerodacytly, Telangiectasia; spider veins near surface of skin

Motor cell bodies are located in the:

ventral horn of the spinal cord, within the CNS

Brachial pulse difference of ______ is considered significant for Thoracic Outlet?

more than 30 mm Hg

Extensor digitorum brevis manus, EDBM

origin: distal radius and posterior radiocarpal ligament insertion: extensor hood of 2nd or 3rd digits (variable) innervation: posterior interosseous nerve action: extension of the digits Is thought to be present in ~3% of the population and can be bilateral in up to half of cases. Usually painless although rarely it can present as a painful mass over the dorsal aspect of the hand. Occasionally it may be associated with exercise-induced pain or tenosynovitis of the extensor tendons

Acrosyndactyly

partial joining of digits with proximal opening, usually due to IU environmental factors; fingers were once separated but then become rejoined

Lumbrical Plus effect

patient attempts to contract the FDP but the lumbrical instead is pulled proximally due to it's origination on the FDP tendon, extending the IPJs into lumbrical plus position

PIPJ Proper Collateral Ligaments (PCL)

primary stabilizer; tight in flexion and loose in extension test in 0 degrees extension, and in ~30 degrees of flexion

Replay flashbacks

replay of event prior to, during, and after injury; most likely to return to work.

Rotator cuff arthropathy

rotator cuff tears lead to loss of joint congruence and superior migration of the humeral head, results in abnormal glenohumeral wear, and leads to the specific pattern of degenerative joint disease

Forms the radial border of the carpal tunnel

scaphoid and trapezium

Which tendons can be transferred to APB for restoration of thumb opposition?

"Cheef" CAMITZ PL to APB HUBER ADM to APB EIP to APB ECRL to APB FDS of RF to ABP

Merkel cells

"Merkel the turtle (slow) constantly keeps his superficial fingers deep in his shell" -slow adapting -constant touch -superficial in skin -located in fingers -deep touch Test with SWMF (fingers), Static 2PD (fingers), tuning fork

What is MAMTT?

"Minimal active muscle-tendon tension"; the minimal tension required to overcome the resistance of the antagonist muscle with regard to tendon excursion

Meissner's corpuscles

"Mr. MeiSSner is young (30), fine (touch), fast, and hairleSS plus he gives me shivers (vibration) when he dances (movement)" -30 hz -fine touch -fast adapting -hairless skin -vibration sensation -movement Test with tuning fork (vibration), moving 2PD (movement/moving)

Hyaluronate injections

"ROOSTER COMB" Hyalgan and Synvisc; can be injected into a joint, not a cortisone derivative. Chemically stimulate synovial fluid composition and may provide months of relief; no heavy or high impact activity for 48 hours after injections. Typically 5 injection weekly, with some people having relief after 3.

Pacinian corpuscles

"The pacific ocean is 256 meters deep. So deep you can quickly feel the pressure, vibration, and motion of the ocean. And whales don't have hair." - 256 hz - in deep structures like joints and ligaments - fast adapting - pressure, vibration, and movement - hairless skin Tested with tuning fork (vibration)

Ruffini endings

"To hold up the roof (ruffini), I have to keep constant pressure through my fingers and joints, otherwise it will slowly stretch them back" - constant pressure - found in finger and joints - stretch sensation - slowly adapting

Carpal fractures, in order of frequency:

#1: Scaphoid (60-70%), #2: Triquetrum, #3: Trapezium

The splint classification system creates an orthosis "sentence" which include what features?

(1) articular or nonarticular, (2) anatomic focus, (3) kinematic direction, (4) primary purpose, (5) type or number of secondary joint levels, and (6) total number of joints included in an orthosis For example: Index-small finger PIP joint flexion mobilization orthosis, type 2 (9): volar application 2 indicates the number of accessory joint levels included in the orthosis which in this case would be the MPJ and wrist, and the 9 indicated the total number of joints in the orthosis, which is all IPJs, all MPJs, and the wrist.

Extrinsic wrist ligaments

(6) - Radial collateral, ulnar collateral, palmar radiocarpal, palmar ulnocarpal, dorsal radiocarpal, dorsal ulnocarpal; thicker and stronger on the VOLAR side

Acute compartment syndrome can be caused by

**Crush injury, thermal or electric burns, snakebite, or fracture

Diagnostic tests used with CRPS:

**Triple phase bone scan**, radiographs to look for osteoporosis, isolated cold stress test to look as vasomotor disturbances, and laser doppler velocimetry to look at total blood flow information

Types of thoracic outlet syndrome

- Vascular Arterial, less than 1% or Venous, 2-3% - Neurogenic True with signs of nerve compression and usually associated with bony anomaly such as presence of a cervical rib, or Disputed with vague symptoms of pain, weakness, spasms, and sensation changes

Lower Motor Neuron symptoms:

- hypotonia and flaccidity - atrophy, wasting, and fasciculations - loss of deep tendon reflexes - normal abdominal reflexes and Babinski response * ALS involves both upper and lower motor neurons *

Phases of bone healing

- inflammation: injury to day 5 - reparative: day 5 to 21); ROM can begin in this phase - remodeling: day 21-18 months

Spina Bifida Types

- occulta: incomplete fusion of vertebra, no external sac, few neurological issues - meningocele: external sac but contains only fluid - meningomyelocele AKA cystica: external sac contains meninges, fluid, and portions of spina cord - myeloschisis: most severe form, nerve tissue is fully bare and a dermal or meningeal covering is absent

Upper Motor Neuron symptoms:

- spasticity; increased tone - positive babinski sign - increased deep tendon and cutaneous reflexes - loss of superficial abdominal reflexes - autonomic dysreflexia * Parkinson's Disease results from upper motor neuron dysfunction *

The triceps reflex test looks primarily at which neurological level?

C7

Stage of Rheumatoid Arthritis:

-Stage 1: Early/Acute stage RA; involves the initial inflammation in the joint capsule and swelling of synovial tissue; joint pain, swelling, and stiffness; resting orthosis is needed for comfort -Stage 2: Moderate/Subacute, the inflammation of the synovial tissue becomes severe and creates cartilage damage; symptoms of loss of mobility and decreased joint range of motion become more frequent; night orthosis for pain relief and deformity prevention -Stage 3: Severe/chronic-active/destructive stage; Inflammation in the synovium continues to destroying cartilage, but now bone also; increased pain and swelling and a further decrease in mobility and even muscle strength; functional day orthosis, continue with night orthosis -Stage 4: Chronic-inactive/skeletal collapse and deformity; End stage of RA, the inflammatory process ceases and joints stop functioning altogether. Pain, swelling, stiffness and loss of mobility are still the primary symptoms in this stage; orthoses for comfort

1. Inflammatory/initial phase of wound healing

-immediate phase, lasts about 3-5 days -increased blood supply and phagocytosis; delivers oxygen, wbcs, and nutrient to the wound to support healing

3. Maturation and Remodeling phase of wound healing

-last stage, can last up to 2 years -continued granulation and strengthening of tissue -contraction and collagen degradation -scar formation

neuropraxia: axonotmesis: neurotmesis:

-neuropraxia: mildest, local compression, good recovery -axonotmesis: axon disruption leads to wallerian degeneration; can recover but takes time; typically 1 year for functional reinervation, 3 years to plateau -neurotmesis: most severe, complete transection; poor recovery unless surgery is performed

2. Proliferative/granulation phase of wound healing

-second phase, last until approximately 21 days -fibroblasts synthesize collagen -formation of granulation tissue -infected wounds cannot progress from 1 to 2

Ultrasound frequencies are meant to reach what depths? 1 MHz? 3 MHz?

1 MHz: 2cm and deeper; heats tissue 3x as fast 3 MHz: 1-2cm below the skin

By definition, and early active motion protocol must start motion within:

1 week

Gentle ROM following digit replantation begins at:

1 week post op; must achieve neurovascular stability to ensure replant is successful

ROM is initiated following ganglion cyst removal at...?

1 weeks post-op

What are the two possible sites for dorsal radial sensory nerve compression?

1) 8 cm proximal to the radial styloid at the fascial edge of the brachiradialis 2) At the radial styloid region

What are the possible DSRN compression sites? Resulting symptoms?

1) Between the BR and ECRL tendons, which squish the nerve during pronation; 2) In subcutaneous tissue of the distal forearm, irritated by repetitive wrist flexion/extension due to reduced nerve excursion

Osteoarthritis Quintet

1) CTS 2) CMC OA 3) DeQuervain's? 4) Trigger finger 5) Herberden's Node with mucoid cysts

CMC grind test

1) Examiner grasps pt's hand stabilizing the Trapezium bone (carpal), 2) With other hand grasp the pt's thumb at the metacarpal bone, 3) Examiner then pushes against the CMC joint and rotates-grinding the CMS joint. Positive = abnormal pain or increased pain/crepitation and instability with maneuver. This indicates possible osteoarthritis of the CMC joint.

Types of ectopic ossification:

1) HO heterotopic ossification: bone forms in non osseous tissue 2) MO myositis ossificans: bone forms within damaged muscle tissue 3) periarticular calcification: forms calcium deposits with affect the capsule and collateral ligaments

What are the primary benefits of using a non-meshed split-thickness skin graft vs meshed?

1) Less contraction of scar. 2) Heals without the mesh pattern for more natural looking presentation

What are the primary benefits of using a meshed split-thickness skin graft vs non-meshed?

1) Meshing allows for drainage of fluid or exudate; build-up under a graft can inhibit adherence to the wound bed. 2) Allows for expansion of the graft for covering a larger area

Subluxation-Relocation Test/Traction-shift Test

1) Therapist applies traction to the thumb 2) pressure placed over the dorsal aspect of MC. Maneuver will reduce subluxation if presents and cause pain or crepitus)

Thumb adduction test

1) Therapist support pt's wrist in neutral with elbow at 90* and neutral forearm rotation 2) applied downward adduction force to the MC head to in line with the second MC midaxis or until a firm endfeel is felt; positive test if pain is reproduced

What are the ligaments of the ulnar/medial elbow? AKA Medial collateral ligament complex components

1) anterior oblique ligament (AOL); strongest and most significant stabilizer to valgus stress subdivides into anterior and posterior bands - anterior band is primary restraint to valgus stress, exhibiting nearly isometric strain during all elbow ROM - posterior band exhibits increasing strain during higher degrees of elbow flexion 2) posterior oblique ligament (POL); demonstrates the greatest change in tension from flexion to extension tighter in flexion 3) transverse ligament; no contribution to stability

What are the phases of burn healing?

1) the emergent phase; first 24-72 hours, 2) the acute phase, 3) the skin-grafting phase, and 4) the rehabilitation phase.

Thumb extension test

1) therapist extends thumb until parallel to the plane of the palm or firm endfeel is felt; positive test if pain is reproduced

Metacarpal base compression test

1) therapist grasps thumb MC with one hand 2) applied pressure on dorsum of the MC base with other hand to create shear across the CMC; positive test is pain is reproduced

NMES ramp time recommendations:

1-2 seconds; lower ramp when addressing spasm to fatigue the muscle, or when addressing edema to create muscle pump

How long does vascular repair need orthosis protection?

1-2 weeks; but must keep in mind the need for protecting other oft tissue may require longer period of immobilization

IASP criteria for CRPS (3):

1. An inciting noxious event or an immobilization 2. Continuing pain, allodynia, or hyperalgesia 3. Evidence of some time of edeme, change in skin blood flow, or abnormal sudomotor activity in area of pain

Stages of wound healing; order and timelines?

1. Inflammatory/initial -immediate phase, lasts about 3-5 days 2. Proliferative/granulation -second phase, last until approximately 21 days 3. Maturation and Remodeling -last stage, can last up to 2 years

Prehension Patterns

1. cylindrical 2. tip 3. hook or snap 4. palmar 5. spherical grasp 6. lateral

Recommended ergonomic handle width for precision tasks:

1/4 to 1/2 inch

How much of the body is made up of interstitium?

1/6

How many compartments are in the hand and forearm?

10 in the hand; 3 in the forearm

sedentary work

10# of force occasionally sitting most of the time

Systemic arthritis

10% of JIA cases Entire body affected, fevers, rash, inflammation of spleen, heart, lungs

What is the trend in tensile strength of a unstressed tendon following repair?

10%-50% decrease in strength between days 3 to 5, and from days 5-21 strength increases and collagen matures.

When wearing gloved, grip strength is reduced by what percentage?

10-20%

Martin-Gruber

10-20% have some form of connection between MN & UN in high forearm In this anastomosis, median nerve branches off to the ulnar nerve, allowing for intrinsic muscles to be innervated. Does NOT provide sensation, though. So pt would present with functioning intrinsics, but sensory deficits in the ulnar hand.

Wrinkle test: what temp? how long?

104 degree water fo 30 minutes denervated area will not wrinkle. Good for kids of the unconscious; determines sympathetic function.

What is the transport capacity of the lymphatic system?

10x the amount of lymphatic load; amount of lymph being carried at any given time

Palmar tilt of the distal radius:

11*

Parafin Bath should be at what temperature?

125*-127* F

The DIPJ contributes what % of functional to a digits?

15%

What percentage of people have a palmaris longus?

15%

What is the optimum capillary pressure for the reduction of scar hypertrophy?

15-40 mm Hg

NMES pulse width/duration recommendations:

150-200 microseconds for smaller muscles, 200-350 microseconds for larger muscles

Hydrocolator heat setting

158*-167* F

(Smith) What are the tendon excursions of the: 1) Wrist musculature 2) Digit extensors 3) Digit flexors

1: 3cm/30mm 2: 5cm/50mm 3: 7cm/70mm

Extensor compartments

1: APL, EPB 2: ECRL, ECRL 3: EPL 4: EDC, EI 5: EDM *5th digit, 5th compartment 6: ECU

Extensor compartment contents? Associated conditions?

1: APL,EPB = De Quervain's tenosynovitis 2: ECRL, ECRB = Intersection syndrome 3: EPL = Drummer's wrist, traumatic rupture with distal radius fx 4: EIP, EDC = Posterior interosseous nerve, Extensor tenosynovitis 5: EDM = Vaughn-Jackson Syndrome 6: ECU = Snapping ECU

Acromion types:

1: flat 15% 2: curved 43% (associated with impingement/tears) 3: hooked 39% (associated with impingement/tears) 4: convex 3%

3 concepts of post-skin graft splinting:

1: lubrication, to reduce chance of desiccation 2: Light compression, to avoid space between the wound and graft 3: Immobilization, of adjacent joints to prevent sheer

AC joint injury types:

1: sprain of AC or CC joint 2: subluxation of AC joint with AC ligament tear 3: Dislocation of AC joint with injury to both AC and CC ligaments 4: clavical is displace anteriorly through the traps 5: gross disparity between acromion and clavical 6: dislocated lateral end of clavical displaced inferior to the coracoid 1-3 = conservative, 4-6 = typically surgery

NMES duty cycle recommendations:

1:1 - 1:5; 6-10 seconds on for muscle re-ed or strengthening with greatest rest time to prevent fatigue; 2-5 seconds when addressing spas, or edema with 1:1 on/off

In intersection syndrome, which compartment crosses over which compartment?

1st crosses OVER the second

As a general rule, corticosteroids should not be injected into a joint more often than every # months.

3

What is the hand and wrist position for Ros Evan's zone I and II flexor tendon protocol during place/hold?

20 degrees of wrist extension, 83 degrees of MP flexion, 75 degrees of PIP flexion, and 40 degrees of DIP flexion

In CRPS, what is the ideal prescription of desentization?

20 minute session, 5x/day

What is the max time for cold treatment? What is the progression of sensation felt?

20 minutes max cold, burning, aching, pain/discomfort, tingling, numb

How much grip strength is needed to perform most ADLs?

20#

light work

20# of force occasionally 10# frequently may require walking/standing to significant degree or maintaining a production rate pace

How much grip and pinch strength is needed for most functional activities?

20# of grip, and 5-7# of pinch

What % of nerve "stretch" will result in fascicular disruption in a nerve and perineurium damage?

20%

In the Ros Evan's immediate Short Arm Motion (SAM) protocol for Zone III post-op central slip, what position would the wrist be in during the digit SAM?

20-30* of flexion. to reduce strain and the required force for extensor tendon excursion

Medium work

20-50# of force occasionally 10-25# frequently 10# constantly

What is function flexion for the thumb MPJ and IPJ?

21 and 18

The FDS of the small finger is absent in what % of the population?

21%

What is typical radial inclination, palmar tilt, and radial length?

22 degrees, 12 degrees, and 12mm

Radial inclination of the distal radius:

22*

It is best to keep hands above what temperature to enhance function?

25 degrees celsius; 77 fahrenheit

Polyarthritis

25% of JIA cases MORE THAN 4 joints involved; usually associated with autoimmune

Return as what sensory level indicates readiness for late sensory re-education including object recognition AKA discriminative sensation?

256-hz

How many compartments are in the forearm?

2; volar and dorsal Note: some resources consider the mobile wad of henry, the ECRL, ECRL, and brachioradialis, and separate compartment while other include it in the dorsal compartment.

When is flexion traction safe after MCPJ arthroplasty?

3 weeks; can be done with a flexion outrigger

The dominant hand volume is what % larger than the non-dominant, typically?

3%

What percentage of athletic injuries occur in the hand and wrist?

3%-30%

Vascular compression represents what percentage of thoracic outlet cases?

3%; 1% arterial, 2% venous

How much tendon glide is needed to prevent adhesion formation according to Duran?

3-5mm

When are patients expected to achieve good control of a tendon transfer?

3-6 months

In the MPJ, contracture at what level begins to impair function?

30 degrees

Surgeons typically will not release elbow flexion contractures at less than how many degrees of elbow extension?

30 degrees

What is the typical position of a shoulder arthrodesis?

30 degrees of abduction, 30 degrees of flexion, and 30 degrees of internal rotation

What % of of fluid can be stored in the interstitium before swelling is observed?

30%; sponge analogy... dry sponge can absorb 30% of the fluid before it becomes saturated and dripping

Functional elbow ROM

30-130, and 50/50 rotation

For lateral epicondylitis, what position should the wrist be splinted at?

30-45 degrees

Return at what sensory level indicates readiness for early sensory re-education, protective sensation?

30-hz; will perceive moving first, then eventually static; touch with eraser or cotton ball first with eyes open, then closed and have pt identify location

Complete medial nerve injury results in what % loss of grip? pinch?

32% power grip, 60% lateral pinch

NMES frequency recommendations:

35-80 Hz; greater frequency = smoother contraction, but greater muscle fatigue

Gapping of how many mm is detrimental to tendon healing?

3mm

What is the order of most common syndactyly webs?

3rd, 4th, 2nd, 1st (RF and MF most common, thumb web least common)

Syndactyly is most common in which websapce?

3rd; between the RF and MF

In some asian cultures, increased personal space is customary, sometimes up to:

4 feet; can affect treatment

Potential muscles for tendon transfer must have a muscle grade of:

4 or higher to allow for slight reduction of excursion/strength due to adhesion, imperfect reeducation, or drag

Following nerve transfer, when can AROM be initiated?

4 weeks

Ergonomic handle length:

4-6 inches

What is functional wrist ROM?

40 degrees each of flexion and extension 40 degrees of composite radial and ulnar deviation varies depending on the author

What is the most common type of Juvenile idiopathic arthritis?

40% are Oligoarthritis; 4 or fewer joints affected in the first 6 months) 10% are Systemic Arthritis; affects the whole body, including fevers, rash, spleen inflammation, and issues with membranes covering heart and lungs

Oligoarthritis

40%-60% of JIA Affects four or fewer joints; Primarily affects the knees, ankles, and elbows; More common in females 15%-20% of patients have uveitis eye inflammation

Tissue much reach what temperature to achieve therapeutic benefit?

40-45* C; 104-113* F

Following wrist implant arthroplasty, what ROM arc is an ideal outcome?

40-60*

With regard to metacarpal fracture, for every 1 degree of malrotation at the fracture site, there are X degrees of malrotation at the fingertips.

5 degrees

What is the permanent listing restriction for patient after a Total Elbow Arthroplasty?

5-10#

How long after a cigarette does nicotine continue to affect wound healing? In what ways?

50 minutes; decreases collagen production and increases platelet adhesion which can lead to thrombus and increased need for microvascular surgery

Functional forearm rotation ROM supination/pronation?

50 to 50

heavy work

50# occasionally 25-50# frequently 10-20# constantly to move objects

The EDC to the SF is absent in what % of the population?

50%

What percentage of grip strength is provided by the intrinsics?

50%

What are motion and strength outcomes following PRC?

50%+ AROM, and ~75% strength

A radian is approximately how many degrees?

57 degrees; refers to the amount of joint motion equal to the amount of tendon excursion. Duran and Gelberman suggested that in order to obtain the 5mm excursion to minimize adhesions a joint must be moved through .5 radian or 28.64 degrees of rotation/flexion, and movement of 1 radian/57.29 would yeild 10mm excursion.

When will sensation begin to return with examination following nerve repair?

6-8 weeks

Pt's with diabetes are X times more likely to develop carpal tunnel.

5x; cortisone injections may not be as effective in this group of pts and may spike blood sugar levels

How long does it take to regrow an entire nail?

6 months from germinal matrix to the free edge of the fingertip

Following tendon repair, use of NMES with high intensity is safe at hoe many weeks post-op?

6 weeks generally, but discuss with MD

What percentage of axial load is transmitted through the radiohumeral joint in full elbow extension?

60%, with 40% through the ulnohumeral joint

What is function flexion for the digit MPJ, PIPJ, and DIPJ?

61, 60, and 39 degrees

What % of complete thumb UCL lesions with result in a Stener lesion?

64% to 87%

At what temperature are sensory, motor, and circulatory impairments noted? At what temps should hand stay above?

68 and below leads to problems best to keep hands above 77 with glove, etc

How long should a nerve repair be protected with an orthosis?

7-10 days

Allen's test; how long of a delay is considered abnormal?

7-10 seconds; test radial side first and then ulnar

What % of hemangiomas are present at birth and fade by age 7?

70%; affects females up to 5x more than males

Osteopenia is seen in what % of patient with CRPS?

70-80%

How soon after a capsulotomy can a patient resume use of a static progressive orthosis?

72 hours

When is it safe to utilize compression over a hand burn?

72 hours

How many hours or prothetic wear is required per day to be considered a functional wearer?

8 hours

A compliant pt has what % chance of full recovery from cubital tunnel through conservative treatment?

80%

What % of patients with CRPS will improved if treated within 1 year? After 1 year?

80%, 50%

At what age does 2-point discrimination become reliable?

9

What is the recommended tool length?

9+ cm; 4-5 inches

What is the typical position for elbow arthrodesis?

90 degrees

Following elbow LCL reconstruction, the elbow is positioned in:

90 degrees of flexion and full pronation for the 1st 3 weeks, and progress from there per protocol

A non-functional hand (say, secondary to a burn) can lead to what % impairment rating in that arm?

95%

Very heavy work

>100# occasionally >50# frequently >20# constantly to move objects

Space of Poirier

A area of weakness between the "V" shaped volar wrist ligaments between the lunate and capitate, which allows the lunate to dislocated during high velocity injuries of the wrist

parametric statistics

A branch of statistics which assumes that sample data comes from a population that follows a probability distribution based on a fixed set of parameters. More precise and typically requires an interval scale for measurement.

Chauffers fracture

A chauffer's fracture is an oblique fracture through the base of the radial styloid in the forearm; classically, happened when a crank-car would backfire

Klinefelter syndrome

A chromosomal disorder in which males have an extra X chromosome, making them XXY instead of XY. Symptoms include lack of facial and body hair, tallness with extra large limbs, and may include social and learning disabilities.

Multiple sclerosis

A chronic disease of the central nervous system marked by damage to the myelin sheath. Plaques occur in the brain and spinal cord causing tremor, weakness, incoordination, paresthesia, and disturbances in vision and speech; affects nerve conduction, motor, and sensory function

Martin-Gruber anastomosis

A communicating branch from median/AIN to ulnar nerve occurs high in forearm therefore allows for intrinsic muscles to be innervated by median nerve; can function despite high injury to ulnar nerve.

Stener lesion

A complication of UCL injury to the thumb in which the adductor aponeurosis gets caught between the ruptured ends of the ligament and prevents healing

Bowler's Thumb

A compression of the digital nerve on the medial aspect of the thumb, leading to paresthesia in the thumb.

Radial tunnel syndrome

A condition caused by direct trauma or entrapment at the elbow as the radial nerve passes anterior to the cubital fossa, pierces the supinator muscle, and runs posterior again into the forearm. Pain in this area could be RTS of PIN palsy, but PIN would be motor only with weakness in wrist and digit extension.

What are situations in which autolytic debridement would be appropriate?

A dry, eschar-covered wound, a patient who cannot tolerate surgical debridement, or a patient with a coagulation disorder

Radial Nerve Compression sites:

A huge red lollipop tastes as sweet Axilla Humeral fracture Radial head bands Leash of Henry Tendonous edge of ECRB Arcade of Froshe Supinator Exit

Schwanomma

A rare neurilemmoma; tumor involving the myelin sheath of a nerve

Conversion disorder

A rare somatoform disorder in which a person experiences very specific genuine physical symptoms for which no physiological basis can be found. Examples include: glove anesthesia, postural deformities, clenched-fist deformity, hyperextension deformities and movement disorders like "ratchet hand"

Ratio data scale

A ratio scale allows you to compare differences between numbers. For example, use a rating scale of 1-10 to evaluate user responses, or weight on a scale from 0-200; has a true 0

Hill-Sachs lesion

A small defect usually located on the posterior aspect of the articular cartilage of the humeral head and caused by the impact of the humeral head on the anterior glenoid fossa as the humerus dislocates anteriorly. If large, may require bone grafting.

Curette

A small, scoop-shaped implement used for more efficient removal of debris such as in nail folds, eponychium, and hyponychium areas; SHARP debridement

Mallet classification system is used for what?

A standardized assessment for shoulder motion used in evaluation of brachial plexus palsy; Assesses abduction, external rotation, hand to neck, hand to spine, hand to mouth, and supination Grade 1 = no function; Grade V = normal function.

Ordinal data scale

A statistical data type that exists on an arbitrary numerical scale where the exact numerical value has no significance other than to rank a set of data points. Deals with the order or position of items such as words, letters, symbols or numbers arranged in a hierarchical order. Quantitative assessment cannot be made: likert satisfaction scales. -think "ORDer'

nonparametric statistics

A statistical method wherein the data is not required to fit a normal distribution. Often uses ordinal data. Good for ranks. Inferential.

What is a Thrill? And when is it heard?

A tremor or vibration felt of palpation. Heard in grade 4, 5, 6 heart murmurs

What is a bruit?

A vascular sound that reflects partial arterial occlusion

Herpetic whitlow

An infection caused by herpes simplex virus infection that involves the distal phalanx of a finger

SLAP lesion

An injury to the superior labrum that typically begins posteriorly and extends anteriorly, disrupting the attachment of the long head of the biceps tendon to the superior glenoid tubercle.

forearm posterior compartment

Abductor pollicis longus Anconeus Extensor carpi ulnaris Extensor digitorum Extensor digiti minimi Extensor indicis Extensor pollicis brevis Extensor pollicis longus Supinator

Thumb retroposition

Ability to lift thumb off of a flat surface; achieved ONLY by the EPL and will be absent in tendon laceration/avulsion

Tendon transfer - Immobilization:

Typically casted for 3-4 weeks, with another 3 weeks of protective orthosis

heterotopic ossification

Abnormal extraskeletal bone formation, high risk diagnoses for this condition include: spinal cord injury, traumatic brain injury, burns, direct contusion, fractures. Typically begins forming between 3 and 12 weeks after injury

Reverse Total shoulder arthroplasties test to dislocation in which motion?

Adduction and IR, hence the no hands behind back restriction

The oblique pulley of the thumb is in close relationship to the insertion of which muscle?

Adductor Pollicis

What is the stronger intrinsic hand muscle?

Adductor Pollicis

The most important digit pulleys to prevent bowstringing

A2 and A4

ASIA scale for SCI

A=complete: no motor or sensory function is preserved below injury level B=incomplete: sensory but no motor function is preserved below the neurological level C=incomplete: motor function is preserved below the neurological level, but majority of key muscles below the level have a muscle grade less than 3 D=incomplete: motor function is preserved below level and majority of key muscles below the level have muscle grade of 3+ E=normal motor and sensory function

Which muscle is most often involved in SF dupuytrens?

ADM

Biceps Load Test

AKA Kim Test II; Examiner abducts the pt's arm to 120, with arm laterally rotated, elbow flexed to 90 and forearm supinated; Patient is asked to flex their elbow against the examiner's resistance; Positive finding: apprehension remains the same or more painful; positive test indicates SLAP lesion in the presence of recurrent dislocations

Digital gigantism

AKA Macrodactyly, enlarged digits

Ulnar collateral ligament UCL/MCL

AKA Medial collateral ligament; Connects the medial epicondyle of the humerus to the ulna and includes the anterior bundle, the transverse bundle AKA Cooper's ligament, and the posterior bundle

Moersch-Woltmann Syndrome

AKA Stiff-Man Syndrome; An autoimmune disorder affecting the nervous system, causing rigidity and spasms of the spine and lower-extremity muscles

Subacromial Decompression SAD

AKA acromioplasty; surgical intervention may be used to remove the cause of the impingement; coracoacromial ligament is detached from the acromion to remove pressure for the supraspinatus tendon

Congenital Constriction Band Syndrome

AKA amniotic band syndrome, congenital band syndrome, constriction band syndrome, and Streeter's disease. Is characterized by partial or complete circumferential constriction around the digits or extremities; can produce nerve compression, acrosyndactyly, vascular compromise, and muscular hypoplasia to the distal extremity. Structures proximal to the banding are normal.

Jobe's test

AKA empty can test; indicates weakness/tear of supraspinatus muscle. Patient internally rotates with thumb pointing to floor, arm is then abducted to 90 degrees, and resistance applied downwards.

What are the primary, and the secondary, deforming forces of a bennet's fracture?

APL primarily, but also the EPL and AP. They draw the shaft proximally and dorsally away from the volar/ulnar lip of the articular surface.

Total shoulder arthroplasties test to dislocation in which motion?

Abduction and ER, hence ER is limited initially.

Huber Transfer for low median nerve injury:

Abductor Digiti Minimi to Abductor Pollicis Brevis (ADM to APB) for abduction of thumb; most commonly used for congenital reconstruction of the thumb Splint: Hand based opponens with max palmar abduction.

Which muscle assists with thumb IPJ extension and can compensate if EPL is ruptured?

Abductor pollicis brevis

Ectrodactyly

Absence of any number of digits; AKA split hand

Nerve of henle

Accompanies ulnar artery n if resected helps vasoconstriction tone; is composed of predominantly sympathetic fibers. Disruption of the nerve can aid in managing vasospastic disease

distal transverse arch

Across metacarpal heads; allows conformability of hand and deepens with digit flexion

Abductor digiti minimi cord

Acts like a spiral cord on the small finger, where there is no natatory ligament; close relationship to the neurovascular bundle and requires careful dissection

Frostbite

Actual freezing of tissue fluid resulting in damage to the skin and underlying tissue; severe injury that can result in tissue loss and permanent disability

Ergonomics

Adapting the workplace or works tasks to the worker

Spray and stretch

Aerosol vapocoolant spray applied to skin at area of trigger point while progressively increasing passive stretch; minimal research support

Kinesiophysical approach to work restrictions

Allows the evaluator to base reasons for difficulty of tasks on musculoskeletal or physiologic observations

Psychosocial approach to work restrictions

Allows the patient to determine max levels; allows for bias and inaccuracy

Phentolamine/Regitine

Alpha blocker that reduces peripheral vascular resistance an can be used to treat Sympathetic Maintained Pain (SMP); blocks sympathetic receptors for receiving circulating norepinephrine and epinephrine

Tendon transfer - Amplitude:

Amplitude of 40% of resting length needed ie. MCP extension requires 5cm, FDP requires 7cm

Tendon transfer principals:

Amplitude, Power, Direction, Phase, Immobilization

Gantzer's muscle

An accessory slip off the origin of the FPL muscle. It can be a site of compression in the AIN pathology

Bankart lesion

An avulsion or damage to the anterior lip of the glenoid and anteroinferior labrium as the humerus slides forward in an anterior dislocation.

Type II error

An error that occurs when a researcher concludes that the independent variable had no effect on the dependent variable, when in truth it did; a "false negative". Beta level is the probability of this happening.

O'Brien Test; Active Compression Test

An isometric contraction with the humerus flexed to 90° and horizontally abducted once with the humerus internally rotated (A) and then again with the humerus externally rotated (B). Positive test is pain in IR relieved by rotating the shoulder in ER. Pain on "top" of the shoulder indicates AC joint pathology, while pain "inside" the shoulder indicates a SLAP lesion.

Which ligament(s) stabilize the radial head?

Annular ligament, and Radial Collateral

The brachial plexus is comprised of which rami: Anterior or Posterior?

Anterior

Which band is the crucial component of the elbow UCL, and the most injured in throwers?

Anterior band

Infraspinatus refers pain to the:

Anterior deltoid regin, shoulder joint, medial border of the scapula, and front/lateral aspects of the arm and forearm

Which glenohumeral glides(s) would be most beneficial to improve external rotation?

Anterior glides

Work practice controls:

Are intended to reduce the likelihood of exposure by changing the way a task is performed. -procedures for handwashing -sharps disposal -lab specimen handling -laundry handling -contaminated material cleaning

Valpar Component Work Sample (VCWS)

Assess groups of skills required for specific employment tasks and basic functional capabilities; 23 work samples, quality and time scored; adults with and without disabilities

Functional capacity exam

Assess physical and functional ABILITY to perform specific work duties

McCarron-Dial System (MDS)

Assess prevocational, vocational, and educational abilities; Cognitive, verbal and spatial, sensory, motor, emotional, coping, integrative, and adaptive behaviors Pre-screening interview, work samples, systematic observation; Individuals age 16 or older with neurophysiological/psycho impairment

House Classification of Hand Function

Assessed hand functional is patient with cerebral palsy 0 = does not use 1 = uses as stabilizing weight only 2 = can hold object placed in hand 3 = can hold and stabilize for the other hand to manipulate 4 = actively grasp and hold object weakly 5 = active grasp and stabilize well 6 = actively grasp, hold, and manipulate against other hand 7 = easily perform bimanual tasks spontaneously 8 = uses hand independently

Yergason's Test

Assesses the stability of biceps tendon in bicipital groove; pt flexes elbow to 90 and pronated while physician grasps elbow w/ one hand and wrist other; pt attempts to pull into supination of forearm + external rotation of shoulder while therapist resists; Positive Test = pain or biceps tendon pops out of bicipital groove

Glomus tumor

Benign, painful, red-blue tumor under the fingernails. Arises from modified smooth muscle cells of glomus body; leads to cold sensitivity and can spread to the bone.

What is normal tissue pressure?

Between 8-10 mm Hg; critical pressure is between 30-45 mm Hg

Triple phase bone scan

BEST TEST to assess presence of CRPS Phase 1: early blood flow phase shows increase in perfusion Phase 2: blood pool or tissue phase demonstrates increased periarticular activity in joints Phase 3: delayed metabolic phase monitors uptake for 2-4 hours following injection and is the most important diagnostic phase

What are safe antibiotics for wound application?

Bacrtoban, polysporin, and silvadene. Soreful to not oversaturate the wounds.

What muscle action is considered the indicator for progress and intervention is children post- obstetric brachial plexus injury?

Biceps flexion

Contrast bath parameters

Begin in 104-111 deg F water: 4 mins Cold water 55-65 F: 1 min Continue in sequence of 4:1 for 4-5 cycle End in warm water for vasodilation; ending in cold for 1 minute may help with edema Inadequate evidence to support for use with edema, but can help with pain and desensitization

Work Style

Behavioral, cognitive, and physiologic responses that can occur with increased work demands

What is the triphasic presentation of Reynaud's?

Black/white indicating complete lack of arterial inflow, dusky blue/purple indicating pooled deoxygenated blood, and then red as blood flow returns

CMC Boss: What is is? Post-op procedures?

Bony spur at the MC base, typically the 2nd and 3rd metacarpal; is surgically excises, wrist is immobilized for 3-6 weeks to allow ligament healing

What structures can be impinged between the 1st rib and clavicle?

Brachial Plexus, Subclavian Artery, and Subclavian Vein

What is the major inflow vessel to the forearm and hand?

Brachial artery

This elbow flexor is highly vascular, crosses the anterior capsule, and at high risk for tears during an elbow dislocation.

Brachialis

What muscles make up the mobile wad of henry?

Brachioradialis, ECRB, and ERCL

Undergrowth: examples?

Brachydactyly, Hypoplasia

Timeline of limb development

By 28-30 days the arm bud is well developed During days 34-38, the arm bud elongates By day 52, full finger separation can be seen

Klumpke's palsy

C7, C8, T1; ulnar nerve, loss of finger flexion, extension, and intrinsics, fall from tree or hand being pulled up, sensory loss can be severe, associate with horner's syndrome T1, writing/typing is probable; LOWER BP injury

Clicking/clunking with wrist circles and/or with radial to ulnar deviation is most indicative of:

CIND

Disadvantages of K-wires?

Cannot provide compression, is not considered "rigid" fixation which prevents early ROM, pin tract infections, may distract fracture if placed incorrectly

What is the 3rd most common carpal bone to sustain avascular necrosis?

Capitate; Lunate is most common and called Kienbock's disease, and second most common is the Scaphoid called Preiser's disease.

Order of elbow bone ossification:

Capitellum, ~1 years Radial Head, ~3 years Medial Epicondyle, ~5 years Trochlea, ~7 years Olecranon, ~9 years Lateral Epicondyle, ~11 years CRMTOL

Which type of dressing is appropriate for an infected wound?

Calcium alginate dressing (CAD) such as Sorbsan or Kaltostat

Administrative controls:

Can be implemented anytime, particularly when engineering controls, work practice controls, and PPE aren't available/effective. -Limiting overtime -Job Rotation -Decreasing productivity rates

What is the role of Vitamin A in wound healing?

Can be used topically in patient taking steroids, because it will inhibit the anti-inflamatory properties of the steroid to allow wound healing to occur

TFCC Load Test

Can indicate either a peripheral or central lesion of TFCC; peripheral likely with history or trauma, central may be degeneration. Place wrist in UD and rotation with axial load applied.

Most common compression neuropathy after an upper extremity blunt trauma injury:

Carpal Tunnel Syndrome

Carpal Instability adaptive CIA

Carpal malalignment secondary to external factors, such as a distal radius angulation

Low-level laser therapy (LLLT) or "cold laser" is FDA approved for which diagnoses?

Carpal tunnel and iliotibial band syndrome

Scratch collapse test can be used to assess...?

Carpal tunnel syndrome and Cubital tunnel syndrome

The epiphysis of which bone is last to appear in the body? When? and when does the it close?

Clavicle; 18-20yr, 23-25yr

ASIA Classification for Functional Motor Levels

C5: elbow flexors C6: wrist extensors C7: elbow extensors C8: finger flexors T1: 5th finger abduction

The brachioredialis reflex test looks primarily at which neurological level?

C6

Which digit pulley is variably present?

C3

Brachial Plexus Myotomes

C4: shrug, C5: shoulder abduction/elbow flexion, C6: wrist extension/elbow flexion, C7: wrist flexion/elbow extension, C8: thumb abduction/grip, T1: finger ab/adduction

The bicep reflex test looks primarily at which neurological level?

C5

Which is the most common spinal cord injury level?

C5

Most common level(s) of brachial plexus injury? What is this termed?

C5 and C6; Erb's Palsy

COX-2 inhibitors

Celebrex, Vioxx, Bextra; increased risk of MI & CVA; only Celebrex used now, with caution and for shortest time possible; NSAID for pain; primarily arthritis pain

What initiates PIPJ extension from a fully flexed position?

Central slip; rupture leads to boutonniere

The superficial venous "M" at the at the elbow includes which veins?

Cephalic vein runs laterally and the basilic vein runs medially, linking with the median cubital vein to form the "M"; photo points to median cubital; note the cephalic and basilic more proximally

Symbrachydactyly

Child is born with small or missing fingers or a missing hand; Exact cause is unknown

What are some circumstances where a surgeon may choose to go forward with a finger replant?

Child, thumb, special requirements such as musicians, multiple fingers involved

Arthrogryposis Multiplex Congenita: AMC

Chromosome 5 anomaly, Results in multiple joint contractures, lack of fetal movement, May require surgical intervention; Contracture's, fibrosis, poor bone formation due to lack of movement stress on the bone, Impaired ROM, functional mobility, but Most become ambulatory by 18 months; creeping is very difficult, No cognitive deficits; non-progressive

Arthrogryposis Multiplex Congenita (AMC)

Chromosome 5 anomaly; Results in multiple joint contractures - lack of fetal movement and may revert to this position and may require surgical intervention. Contractures, fibrosis, poor bone formation due to lack of movement stress on the bone leads to impaired ROM and functional mobility. Most become ambulatory by 18 months; No cognitive deficits and non-progressive.

Fibromyalgia diagnostic indicators:

Chronic pain, widespread, bilateral and across all 4 quadrants, tenderness on palpation of 11+/18 defined tender points, fatigue, disrupted sleep, headaches, and mood disorders

CRPS 1 AKA? Presentation?

Classic RSD; response to trauma but no obvious nerve lesion; more common type

Dermatome Testing

Clavicle C4, Deltoid region C5, radial forearm/thumb C6, middle finger C7, ulnar hand/small finger C8, medial elbow T1, axilla peak T2

Frostnip

Cold exposure at freezing temperatures; numbness, pallor, and paresthesias that resolve immediately on warming

What workplace factors increase change of developing trigger fingers?

Cold temperatures, wearing gloves, and use of small handles tools.

What thermo modality should be avoided in patients with CRPS?

Cold therapy; can increase symptoms

Signs of venous insufficiency

Color = bluish/cyanotic, Temperature = Normal/warm, Pulse = Normal, Edema = Often marked, Skin changes = Brown pigmentation around ankles

Signs of arterial insufficiency

Color = pale; worsened by elevation of extremity; dusky red when extremity is lowered, Temperature = cool, blood flow blocked to extremity, Pulse = decreased or absent, Edema = absent or mild, Skin changes = thin, shiny skin; decreased hair growth; thickened nails; avoid extreme elevation and instead keep at heart level

Essex-Lopresti fracture

Comminuted radial head fracture with interosseous membrane disruption and distal radioulnar joint subluxation; typically results from fall from height

Rolando's fracture

Comminuted/displaced metacarpal base fracture resulting in Y or T shaped intra-articular fx; Thumb spica splint and/or Open reduction and internal fixation. Worse prognosis than bennet's because accurate reduction is often not possible due to so many fragments.

Tetracycline

Common antibiotic, however has fluorescence to demonstrate wound manipulation; can build up under fingernails showing that pt has been inflicting or prolonging wound

L'episcipo tendon transfer

Common for brachial plexus injury; Lats and teres major transferred to posterior and lateral insertion on the humerus to make them external rotator instead of internal rotators

Arcade of Froshe

Common impingement site for PIN; radial tunnel syndrome; Fibrous band that arises as a semi circular structure from tip of medial aspect of lateral epi. Located at proximal edge of supinator

Burner Syndrome; Stinger Syndrome

Common injury in sports medicine. Results from nerve traction and/or direct compression of nerve fibers. Symptoms include burning or stinging pain that radiates down the arm(s) with or without parasthesias and weakness. Primarily UPPER cervical root injury or UPPER brachial plexus injury, or possibly combination. Most severe form of the injury would be a nerve root avulsion = permanent paralysis.

Nail ridging

Common with psoriasis

Nail pitting

Common with psoriasis; presence of more than 20 pits is suggestive of psoriasis nail changes

Parsonage-Turner syndrome

Commonly occurs after a viral infection; AIN nerve and LT nerve involved, resulting in serratus anterior weakness winging and poor/absent FPL and FDP IF flexion = inability to make an OK sign; often spontaneous resolution

Berretini anastomosis

Communicating branch from ulnar 4th common digital nerve to the medial 3rd common digital nerve

Marinacci anastomosis

Communicating branch from ulnar nerve to to median nerve in the forearm; reverse Martin-Gruber

Volkman's ischemia

Compartment Syndrome; Pain with Passive stretch, Paresthesia, Pallor, Absent/diminished pulses

What is a "flare reaction" regarding dupuytren's, and what is a possible cause?

Compilation of increase edema, redness, pain, and stiffness typically seen at 2-4 weeks following surgical excision; some believe it may be due to orthoses that apply too much tension.

Lateral colateral ligament LCL

Connects lateral epicondyle to the radius and ulnas; includes the radial collateral ligament, the lateral ulnar collateral ligament, and the annular ligament

Brown-Sequard Syndrome

Contralateral loss of pain, temperature, and light touch sensation, and ipsilateral loss of motor control, proprioception, and deep touch

Macrophages

Critical during inflammatory phase of. Phagocytes that destroy bacteria, cancer cells, and other foreign matter and particles.

Sensory loss difference between cubital tunnel and guyon's canal compression?

CuTS: sensory deficits and volar and dorsal aspectf of ulnar hand, RF, and SF Guyon's Canal: sensory deficits only at volar aspect of unlar hand, RF, and SF

What deformity is likely to occur following supra condylar fracture in a child?

Cubitus varus deformity/gunstock deformity

Syrinx

Cyst in the spinal canal that grows anteriorly. Posterior tracts which carry touch and pressure are preserved, but ventral motor neurons are damaged resulting in intrinsic muscle wasting and weakness, and deficits with pain and temperature.

What is the best agent to use for cleaning crusted exudate around an ex-fix pin?

Hydrogen peroxide; reduce or dilute once the would exhibits healthy granular tissue

Best absorption products for a yellow, draining wound?

Hydrocolloids and alginates

Should blisters be removed from frostbitten skin?

Debatable. Some believe early removal reduces tissue damage. Clear blisters may be gentle debrided, but hemorrhagic blisters should be left alone.

Scapular dyskinesias related to impingement

Decreased upward rotation, increased anterior tipping, and increased downward rotation of the scapula

The radial artery continues into the hand as which artery?

Deep Palmar Arch

What types of dressings assist with autolytic cleansing?

Hydrocolloids, alginates, and hydrogels

Which would return first after nerve injury: Dellon or Weber?

Dellon moving 2-point would return first, usually returning to "normal" 2-6 months earlier than Weber static 2-point

Most commonly affect hand joint in OA? Second most common?

DIPJs, then the thumb CMCJ

Piano key sign is indicative of:

DRUJ instability

Connus Medullaris Syndrome

Damage to sacral cord and lumbar roots typically resulting in flaccid paralysis of the lower extremities

Interval data scale

Data are based on numeric scales in which we know the order and the exact difference between the values. Organised into even divisions or intervals and intervals are of equal size. 1 week, 2 weeks, 3 weeks, etc. No true 0. -think VALue

When is repaired tendon weakest?

Days 3-5

What are the two most common type of tenovaginitis in the upper extremity?

De Quervain's and Trigger Digit

What is the orthosis protocol for CONSERVATIVE zone 3 extensor laceration?

Digit extension at 0 degrees for 6 weeks

What are the maximal warm ischemic and cooled ischemic times for digital and proximal (prox to carpus) replants?

Digital: 12 hours warm, 24 hours if cooled Proximal: 6 hours warm, 12 hours if cooled

What gross hand deformities are most common in RA patients?

Digits: Intrinsic plus, MPJ ulnar drift, and swan necks Thumb: boutonierre

What method of paraffin application would be contraindicated for a patient with an acute RA flare up?

Direct dipping, because of the heat intensity. Instead, paint, pour, or dip-wrap instead for less intensity of temperature.

Early active motion is NOT appropriate for which extensor tendon zones? (4)

I, II, TI, and TII

Capitate fracture is mostly likely due to:

Direct trauma to the dorsal aspect of the wrist, or from extreme wrist extension and radial deviation

Ulna shaft fracture is mostly likely due to:

Direct trauma to the mid forearm

Contraindications to laser light therapy?

Direct treatment to eye can permanently damage retina, cancer, thyroid area, radiation therapy within previous 6 months, hemorrhaging regions, or endocrine glands

DMARD

Disease modifying anti-rheumatic drug Slows or stops the inflammatory process that can damage the joints Used in patients with RA

Seymour's fracture

Displaced distal phalangeal physeal/growth plate fracture with an associated nailbed injury; Salter-Harris Type 1 & 2; can mimic mallet fingers; "pediatric mallet finger"

Most common complication following boxer's fx?

Disproportionate dorsal edema

Carpal instability Non-Dissociative

Disruption between rows; less common than CID

Carpal instability Dissociative

Disruption within a common row such as SL tear; more common than CIND

Which artery is most used for blood gas analysis or other arterial procedures?

Distal radial artery

Bower's Procedure

Distal ulna hemiresection with interposition arthroplasty to treat DRUJ issues; does NOT correct ulnar positive variance/abutment

What is the initial orthosis fabricated for "no tension" following dupuytren's release?

Dorsal static protective orthosis with MPJs at 35-40* of flexion, IPJs at relaxed extension, and wrist neutral.

Components of the scapholunate ligament

Dorsal: strongest and disruption can lead to DISI deformity, volar, and central membrane

Lederhosen disease

Dupuytrens of the plantar fascia

What is a precautions regarding dynamic orthoses in patients with CREST syndrome?

Dynamic orthoses MAY exacerbate Raynaud's

Surgical treatment of choice for severely comminuted proximal phalanx base fracture?

Dynamic traction or dynamic external fixator with early motion

What is the ideal pencil grasp?

Dynamic tripod grasp

Roos Test AKA

EAST Test; Pt in sitting or standing. Move pts shoulder into ABD 90 deg, full ER, & elbow flexion 90 deg. pt instructed to open and close the hands slowly for 3 minutes. Positive test = pt unable to keep arms in starting position for 3 min, suffers ischemic pain, heaviness or profound weakness of the arm, numbness & tingling of the hand. Negative if only minor fatigue and distress. Indicates thoracic outlet pathology.

Which muscle is the strongest wrist extensor?

ECRB

What muscles are innervated by the PIN?

ECRB, EDC, EDM, ECU, APL, EPB, EPL, EI

The strongest/most efficient wrist extensor

ECRB: longest extension moment arm and inserts more mid-line of the hand; in contrast ECRL is a more efficient radial deviator as it inserts more radially, and ECU is primarily an ulnar deviator, but is more efficient with extension in supination

Strengthening of what muscle would be contraindicated in a patient with SL ligament disruption?

ECU, because it encourages SL disassociation; dart throwers motion neutralizes the ECU and protects the SL ligament

What muscle is active during all wrist motions?

ECU; strong extensor in supination, strong ulnar deviator in pronation

Best tendon transfer for EPL rupture? Other options?

EIP to EPL Others: EDM, PL, or ECRL to EPL

Structures that form the anatomic snuffbox

EPL: ulnar border, APL and EPB: radial border, and scaphoid: base

Shoulder Capsular Pattern

ER most limited>ABD>IR

Rucksack palsy

Eell-recognised, but rare, complication of carrying heavy packs; mostly described in cadets during strenuous training, but sporadic cases of brachial nerve impairment have been reported in children and young adults; brachial palsy with injury to the longthoracic nerve, with axonal denervation of C5-C7 motor roots. May have scapular winging and pain.

Most commonly dislocated joint in children?

Elbow

What is the most unstable position for an elbow with lateral instability, such as Posterolateral Rotatory Instability?

Elbow extension paired with supination

Presentation of the arm in patients with radial deficiency:

Elbow flexion and possible extreme radial deviation of the wrist, and subluxation of the ulna. Static long-arm orthosis can help for improve posturing of the upper extremity

Typical treatment timeline following biceps tenodesis:

Elbow immobilized at 90 degrees for 2-3 weeks, then allow active elbow extension and passive flexion, at 4 weeks can allow active flexion. Move to light resistance at 8 weeks. Full activity without restriction at 4 months

How often should a pediatric pt be reassessed during prosthetic training?

Every 3-4 months, secondary to residual limb changes and growth, and skin integrity as a result

Per joint protection principals, how often should a patient with RA change their body position?

Every 30 minutes

What is the biological mechanism of abnormal scaring?

Excess collagen formation

Precipitating factors for Gouty Arthritis?

Excessive alcohol intake, dehydration/diuretics, consumption of foods high is purine like red meat, seafood; acute flare pain peaks within 24 hours

Closed-chain kinematics

Exercise transfers forces across more than one joint and includes pushing, pulling and weight bearing exercises while the distal segment is fixed, such as pushing a cart

The ICAM protocol is appropriate for which tendon injuries, and which zones?

Extensor zone IV-VII

What motion may be increase as result of a subscapularis tear? Why?

External Rotation; unopposed motions due to subscap tear

Primary muscles involved in medial epicondylitis:

FCR and pronator teres

Medial epicondylosis is associated with degeneration at which 3 tendons?

FCR, PT, PL

The ulnar nerve travel between the 2 heads of which muscle:

FCU

Which 2 muscles attach to the pisiform?

FCU and ADM

What is the most common tendonopothy of the wrist flexors?

FCU tendonitis

Zancoli-lasso procedure

FDS divided at the P1 of each finger, looped through A1 pulley and folded back to form a lasso effect. FDS then becomes MP flexor, with goal to restore MP flexion and control clawing. Splint with MPJs in 60-70 degrees of flexion post-operatively; PASSIVE procedure using tenodesis effect

Modified Stiles/Bunnell transfer (FDS 4-tail)

FDS of the MF is split into 4 tails and tied into the radial lateral band of the MF, RF, and SF and the ulnar band of the IF. Dorsal block orthosis post-operatively; ACTIVE procedure and will require muscle re-ed

Bunnel tendon transfer:

FDS of the RF to the APB; wrapped around the pisiform to create the opposition pull, for patients with median nerve loss

Tendon most commonly involved with trigger finger

FDS: swelling and thickness of the tendon; most often at A1 pulley due to poor tendon vascularity in this region

Mannerfelt Lesion

FPL attritional rupture over a scaphoid bony spicule that pierces through the volar wrist capsule; can progress to lesions of the IF or MF FDP tendons later

Pt's with widspread sensory changes in the arms due to CRPS may experience sensory changes at what other areas the body?

Face; due to close proximity of the sensory homunculus

Radial head fracture is mostly likely due to:

Fall on an outstretched hand

Olecranon fracture is mostly likely due to:

Fall onto the posterior elbow

True/False: Muscle tissue can regenerate across scar following partial tear

False; dense scar tissue forms and mends the torn segments, but muscle tissue does not regenerate, so the segment isolated from the motor point loses innervation and loses ability to contract

Myofibroblasts

Fibroblasts that have some of the characteristics of smooth muscle cells, such as the ability to contract. They contract wound edges to aid in speeding up the healing process.

Felon (finger)

Finger pulp infection; usually history of puncture wound; intense pain, pressure, throbbing, tenderness, redness, and swelling over fingertip pad.

FATS Program

Firearm Training System; 5-phase work hardening protocol that helps wounded warriors improve marksmanship until they are ready to qualify for active duty on a live fire ranges

What types of touch are best used for patients with CRPS?

Firm and without removing hand repetitively; cyclic or light touch can create temporal summation and increase pain response

When is the "Golden Period" of prosthetic fitting to improve prosthetic success?

First 30 days; success rate with fitting within first month is 93%, whereas after 1 month success rate down to 42%

May's "4-finger" protocol

Flexor tendon protocol which places all 4 fingers, regardless of which is injured, into rubber band traction with palmar pulleys

McCash technique

For dupuytren's contracture; transverse incisions and leave open in palm, don't skin graft, heals secondarily; "open palm technique" allows early ROM and decrease in stiffness, hematoma, and pain

Boyes tendon transfer

For radial nerve palsy. Ring or Middle finger FDS to EDC to restore digital extension. Lacks synergy as a flexor is used as extensor and retraining may be difficult

ICAM Extensor Tendon Protocol

For zones IV-VII, involves use of a wrist orthosis at 20* of extension and a relative motion yoke orthosis. Weeks 1-3, both are worn full time, Week 4-5 yoke continuously and wrist for medium activities, Week 6-7 yoke/buddy during activity and wrist orthosis DCed.

Orthosis positioning following radial nerve palsy tendon transfers:

Forearm in full pronation Wrist extended 45* MPJs fully extended Thumb in full extension and abduction

Proximal transverse arch

Formed by distal row of carpal bones Static, rigid arch that forms carpal tunnel Capitate bone is keystone of this arch

What is the most/least commonly injured ice hockey position?

Forward, Goalie

Bisphosphonates

Fosamax: inhibits bone resorption used in osteoporosis.

Barton's fracture

Fracture and dislocation of the posterior lip of the distal radius and carpus; intraarticular and involving the wrist joint itself

Reverse Bennett's fracture

Fracture dislocation at the base of the 5th metacarpal. Tend to be unstable. Can often be managed with closed reduction & pinning; not treating can lead to loss of grip strength and painful arthritis. Displacement due to strong pull of the ECU.

Middle phalanx fracture WHERE would result in apex volar?

Fracture distal to the insertion of the FDS

Galeazzi fracture

Fracture of radius shaft with dislocation of distal ulna at DRUJ "MU/GR": montaggia = Ulna fx, galeazzi = Radius fx

Bennett's fracture

Fracture of the base of the first metacarpal bone, extending into the carpometacarpal joint, complicated by subluxation with some posterior displacement due to strong pull of primarily the abductor pollicis longus, but also the extrinsic extensors and adductor pollicis; NO ligament disruption

Boxer's fracture

Fracture of the metacarpal neck, most commonly the 5th

Montaggia fracture

Fracture of ulna shaft with dislocation of radial head at elbow; Most typically seen in older women after low-energy fall onto elbow "MU/GR": montaggia = Ulna fx, galeazzi = Radius fx

What senses pain and temperature?

Free Nerve Endings; "I can feel PAIN AND TEMPERATURE freely all over the SKIN"

Brand's intrinsic transfer (ECRL 4-tail)

Free tendon graft, usually the plantaris tendon, is sutured from distal ECRL through the interossius space dorsal to volar, to the radial lateral bands of the MF, RF, and SF and ulnar band of the IF. Cast/splint in 50 degree of MPJ flexion; this is an ACTIVE procedure and will require muscle re-ed

A tight coracohumeral ligament can prevent ER in what shoulder position?

Full adduction

What is the safe position following PIPJ volar dislocation?

Full extension to allow central slip to heal

Third degree burn

Full-Thickness; Severe burn characterized by destruction of the skin through the depth of the dermis and possibly into underlying tissues, loss of fluid, and sometimes shock; not painful, will require skin graft; may heal in 4-6 weeks but will scar

What type of graft would be best for a palmer wound? Why?

Full-thickness skin graft, because it is more durable and contracts less. May also require less therapy.

Four Corner Fusion

Fusion of the capitate, hamate, lunate, and triquetrum; typically includes excision of the scaphoid bone.

Thumb UCL injury AKAs?

Gamekeeper's thumb = sudden/traumatic event -mild: immobilize for 2 weeks in flight flexion -moderate: immobilize for 4 weeks in slight flexion Skier's thumb = cumulative events

What is the most common cause of skin graft failure?

Hematoma below the graft prevents adherence to the wound bed

Maffucci syndrome

Genetic condition; Multiple enchondromas, often preferring the hands and feet and venous malformations in the form of hemangiomas; stiffness and deformity can been seen in the hands; radiographically looks the same as Ollier's disease

Ollier's disease

Genetic condition; Multiple enchondromas, often preferring the hands and feet; stiffness and deformity can been seen in the hands; radiographically looks the same as Maffucci's disease

osteogensis imperfecta

Genetic disorder characterized by bones that break easily with little or no apparent cause. Genetic defect in the structure or synthesis of collagen. Role of OT can include gentle ROM/strengthening, splinting/bracing, and activity modifications.

Muscular dystrophy

Genetically inherited diseases characterized by aggressive fibrotic changes in muscle tissue, leading to progressive weakness and degeneration of muscle fibers without involvement of the nervous system, and eventually muscle fiber death

Xanthomas, AKA?

Giant cell tumor. Second most common soft tissue tumor; yellow deposits of cholesterol in tendons and soft tissues. Often seen around the eyes.

Which modalities are good/bad for systemic sclerosis?

Good: parafin baths, not too high of temperature Bad: Fluidotherapy: dry heat is not good for sclerotic skin, whirlpool: drying effect of the heat not good for sclerotic skin, Cold packs or contract baths: cold not good for the Reynaud's associated

What is the most common donor muscle for the upper extremity?

Gracilis

Scar Grading Scale

Grade 0: Soft, pliable, nonpainful flat scar = Light massage, longitudinal paper tape at 2 weeks. Grade 1: Thick, widened scar with no joint limitation, tender, hypersensitive = Silicone gel sheets ultrasound, orthosis use, massage. Grade 2: Hypertrophic, inflexible scar with joint limitation, hyperemic, itching, pain = Silicone gel sheets ultrasound, iontophoresis, orthosis use, serial casts, massage

Gamekeeper's thumb/UCL injury treated how based on grade?

Grade 1 and 2: hand-based spica with IPJ free Grade 3: typically requires surgery If Stener lesion is present, with the UCL trapped under the ADDuctor pollicis, surgery is required.

Maitland joint mobilization grades

Grade I - Small amplitude rhythmic oscillating mobilization in early range of movement Grade II - Large amplitude rhythmic oscillating mobilization in midrange of movement Grade III - Large amplitude rhythmic oscillating mobilization to point of limitation in range of movement Grade IV - Small amplitude rhythmic oscillating mobilization at end of available range of movement Grade V Thrust Manipulation - Small amplitude, quick thrust at end of available range of movement

Grades of stenosing tenosynovitis:

Grade I: Palm pain and tenderness at A-1 pulley Grade II: Catching of digit but full ROM Grade III: Locking of digit, passively correctable Grade IV: Fixed, locked digit in contracture

Sulcus Sign

Hallmark sign of inferior instability; pull inferiorly to see the sulcus; should be reduced if repeated in shoulder ER due to tightening of the rotator cuff musculature. Positive test would be reproduction of instability symptoms

Spontaneous rupture of the EPL tendon following conservative treatment of a distal radius fracture is hypothetically due to:

Hemotoma and localized swelling within the 3rd dorsal compartment leads to ischemia and weakening of the tendon; in this case the tendon is probably not healthy enough for a direct repair and may require EIP to EPL transfer

Bear Hug Test

Hand of affected shoulder crosses body to place on opposite shoulder; flex affected shoulder up to 90 degrees, and then press down on opposite shoulder, or resist upward pressure from therapist at the wrist. Tests for subscapularis involvement, with pain indicating a positive test.

Key components of an ergonomics program:

Hazard Analysis Management commitment Employee commitment Training Program evaluation

For total body surface area (TBSA) calculations in adults, how is the body divided?

Head 9%, each arm 9%, front torso 18%, back torso 18%, each leg 18%, neck 1%

What two traumas increase the likelihood of HO formation?

Head injury and burns

For total body surface area (TBSA) calculations in children, how is the body divided?

Head/neck 18%, each arm 9%, front torso 18%, back torso 18%, each leg 14%

Most common cause of skin graft failure?

Hematoma

Conventional TENS parameters

High frequency: 50-100 pps Short phase duration: 20-75 microseconds low intensity: 10-20 milliamps 20 minutes

A successful Stellate Ganglion Block should cause what?

Horner's syndrome, nasal congestion, facial anhidrosis, increased temperature in the limb, venous engorgement of the hand, dry skin, and changes in skin color

In a below-elbow transradial amputations, what motion would be used to voluntarily open a hook?

Humeral flexion or biscapular abduction

Volar plate is most likely injured in what type of injury?

Hyperextension/Dorsal dislocation

Hypo- and Hyper-reflexia corresponded compromise of which motor neurons?

Hypo= lower motor neuron, Hyper = upper motor neuron

What is the most common tendon transfer for regaining DIP flexion in the RF and SF following high ulnar nerve palsy?

IF and MF FDP tenodesis to the RF and SF

What are the ROM goals following MCPJ arthroplasties?

IF and MF: 45-60* of flexion RF and SF: 70* of flexion

PIPJ replacement is contraindicated for which finger? Why?

IF; too much force through the finger with pinch for function will lead to failure; typically fuse instead

What medication may reduce tendon adhesions?

Ibuprofen; COX-1 and COX-2 inhibitor

Tendon transfer - Direction:

Ideally, the pathway of the transferred muscle should be as straight as possible to it's new insertion

What is the treatment of choice for grade I PIPJ dorsal dislocation?

Immobilization in slight PIPJ flexion until the acute pain subsides

Which condition is associated with ulnar positive?

Impaction syndrome

The Active Movement Scale

Impairment Based Test for Brachial Plexus Injury. Documents UE function during treatment and recovery; Involves 15 diff active UE movements: Gravity eliminated then against gravity. Tests all movements in shoulder, elbow, forearm, then wrist finger and thumb flexion and extension.

When can joint mobilizations be initiated in a burned limb?

In the scar maturation phase; before this the skin is too fragile and friction could damage

Stemmer's sign

Inability to pick up a fold of skin at the base of the second toe of the affected extremity. Indicative of lymphedema.

Lymphangitis

Infection and inflammation of the lymphatic vessels; most serious and progressive hand infection; may produce generalize infection within hours

The KEY component regarding development of work-related musculoskeletal disorders

Inflammation

Stenosing tenosynovitis

Inflammation of the synovial sheaths; 1) on the back of the wrist that causes pressure to develop under the retinaculum, producing pain in the wrist. 2) in the form of a trigger finger in flexor tendon sheaths

Three stages of wound healing

Inflammatory: 0-5 days Proliferative: 5-28 days Maturation: 28 days to 24 months

Charcot Marie-Tooth disease

Inherited disease of the peripheral nervous system; Marked by progressive motor weakness and sensory deficits, primarily distal leg muscles; impaired sensation and deep tendon reflexes; Occurs teenage years or earlier

Boxers Knuckle

Injury involving tear of the MPJ capsule, where significant edema is present around the area of the dorsal MPJ. Results from boxing classes/working out. Rest, immobilization/RMO/buddy straps, and NSAIDS manage the problem. May or may not have concomitant sagittal band injury.

Carpal Instability Dissociative CID

Instability between 2 carpal bones within the SAME row

Carpal Instability NonDissociative CIND

Instability between the two rows; midcarpal or radiocarpal instability

Carpal instability complex CIC

Instability both WITHIN and BETWEEN rows

Lindberg's Sign

Interconnection of the FPL and FDP of the IF; could be due to anomalous tendon, muskulotendinous slip, or adherence to tenosynovium

Neuropraxia

Interruption in conduction of the impulse down the nerve fiber brought on by compression or relatively mild blunt blows close to the nerve. Results in temporary loss of function; will recover in a few days/weeks; endo, peri, and epineuriums are all intact

Passive structures that maintain glenohumeral stability

Joint capsule, labrum, superior GH ligament, and inferior GH ligament; middle GH ligament is variable and frequently absent or small

Osteocondritis Dissecans

Joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. This bone and cartilage can then break loose, causing pain and possibly hindering joint motion. Occurs in children GREATER than 10 years of age. One cause of "little league elbow"

Which condition is associated with ulnar negative?

Kienbock's Disease

Retroflexible thumb

Lack of active extension at the thumb IPJ

Ergonomic handle width:

Large enough so that thumb does not overlap fingers by anymore than the fingernails

Quantitative Sudomotor Axon Reflex Test; QSART

Measures sweat output which would indicate increased and prolonged hyper-functioning sympathetic nervous system; used for diagnosis of CRPS

Little League Elbow

Medial epicondyle epiphysis avulsion due to constant snapping at the elbow joint; common in adolescent baseball pitchers; may be due to Osteocondritis Dissecans

The peripheral nerves enter the forearm between 2-heads of which muscles: Median? Radial? Ulnar?

Median: Pronator Teres = pronator syndrome, Radial: Supinator, Ulnar: FCU

50% of all sport-related hand injuries are related to which sport?

Men's football

Recurrence of dupuytrens is seen more in which of the joints?

More frequent in the PIPJ, but can still occur in the MPJ

Apert Type 2: Mitten/Spoon hand

More serious anomaly since the thumb is fused to the index finger by simple complete or incomplete syndactyly. Only the distal phalanx of the thumb is not joined in the osseous union with the index finger and has a separate nail. Because the fusion of the digits is at the level of the distal interphalangeal joints, a concave palm is formed. Most of the time, we see complete syndactyly of the fourth webspace.

Apert Type 1: Spade hand

Most common and least severe type of deformation. The thumb shows radial deviation and clinodactyly but is separated from the index finger. The index, long and ring finger are fused together in the distal interphalangeal joints and form a flat palm. During the embryonic stage, the fusion has no effect on the longitudinal growth of these fingers, so they have a normal length. In the fourth webspace, we always see a simple syndactyly, either complete or incomplete.

Chamay Procedure

Most common indications for a radiolunate RL fusion include rheumatoid arthritis, posttraumatic osteoarthritis following an intraarticular distal radius fracture, Kienböck disease, or ulnar translocation of the or the carpus.

Neurogenic Thoracic Outlet Syndrome TOS

Most common type 95%, true neurogenic shows compression of brachial plexus resulting in arm pain, weakness, and tingling. Sensory loss and/or weakness in the ulnar nerve distribution limits ability to complete ADLs.

Apert Type 3: Hoof/Rosebud hand

Most uncommon type but also most severe form of hand deformity in Apert syndrome. There is a solid osseous or cartilaginous fusion of all digits with one long, conjoined nail. The thumb is turned inwards and it is often impossible to tell the fingers apart. Usually proper imaging of the hand is very difficult, due to overlap of bones, but physical examination alone is not enough to measure the severity of deformation.

Deep branch of radial nerve

Motor to the extensor muscles and the supinator; AKA the Posterior Interosseus Nerve PIN

Dellon 2-point Test AKA? Norms?

Moving 2-point test; Normal = 2mm

Ratchet Hand

Moving the hand in a robotic "cogwheel" fashion, as if clicking through various ratchet positions; conversion disorder

What type of estim may be beneficial for patients with CRPS?

NMES to regain motion/strength, Brief intense TENS for pain, reduce excessive vasodilation and reduce blood flow), Intense BURST TENS to reduce excessive vasoconstriction and increase blood flow, traditional TENS for pain

Where would you avoid elastic taping a pregnant woman?

Neck, shoulder, or medial aspect of the lower leg; pressure points that may induce labor

What procedure would be used of application of Dexamethasone via iontophoresis?

Negative dex would be applied to negative cathode- and pad placed of side of pain. Positive anode+ pad placed more proximally. "A+ is better than a C-"

Spinal muscle atrophy

Neuromuscular disorder caused by anterior horn cell degeneration; recessively inherited; clinical presentation includes progressive muscle weakness. Facial muscles are not typically involved with this disorder, although swallowing and respiratory issues are common. Sensation typically spared

Charcot elbow

Neuropathic arthropathy with lack of protective sensation leads to degeneration in the joint; caused by cervical syringmyelia, diabetes, late stage syphilis, alcoholism, and end stage renal disease; Charcot-Marie-Tooth may contribute but not the main factor; often painless/low pain, due to the syrinx blocking pain/temperature signals; although syrinx affects both sides, charcot elbow is typically unilateral;

Nitric oxide vs Endothelin

Nitric oxide is a vasoDILATOR, Endothelin is a vasoCONSTRICTOR; balance is essential

Nominal data scale

Nominal means 'by name' and used in classification or division of objects into discrete groups. Each of which is identified with a name and the scale does not provide any measurement within or between categories; marital status, shirt color, car make, etc -think "name"

Treatment option for nondisplaced and displaced hook of hamate fractures:

Nondisplaced: ulnar gutter casting for 3 weeks and then orthosis; Displaced: excision or ORIF; ORIF preferable in athletes due to 15% loss in strength following excision

Buford complex

Normal variant with Absent anterior/superior labrum and Thickened middle glenohumeral ligament

When is Kirner's deformity noted? Boys or girls more affected?

Not til after the age of 12, typically; seen more in girls.

What travels along the FPL in it's flexor sheath?

Nothing

Clinical signs of frostnip:

Numbness, pallor, and paresthesia

Which type of arthritis primarily affects the articular cartilage?

OA

Landsmeer's Ligament; AKA?

ORL; Oblique Retinacular Ligament

O'Rians Wrinkle test

Objective measure of sympathetic responses used to test peripheral nerve function by immersing client's hand in warm water for approximately 5 to 15 minutes; no wrinkle indicates denervation.

Lidocaine Scalene Block

Objective test in which the anterior scalene is injected with lidocaine, with the pt experiencing pain relief for up to 4 hours. Would indicate thoracic outlet syndrome.

Which is the most important flexor pulley of the thumb?

Oblique Pulley

Landsmeer's ligament AKA?

Oblique Retinacular Ligament (ORL)

Loss of which pulley results in reduced thumb IPJ flexion?

Oblique pulley

Which type of dressing should NOT be used on an infected wound?

Occlusive dressing

Riche-Cannieu anastomosis

Occurs in palm communicating branch between the deep branch of ulnar nerve and the recurrent branch of median nerve in thenar eminence; results in ulnar innervation of the thenar muscles, or median innervation of the intrinsics

Vaughn-Jackson syndrome

Occurs with caput ulnae and is a rupturing of the tendons of the 4th 5th and 6th extensor compartment

Central Cord Syndrome

Occurs with hyperextension of the cervical area. Symptoms include weakness or paresthesia in the upper extremities but normal strength in lower.

Characteristics of pediatric CRPS?

Often no preceding event, more often in lower extremity, osteoporosis is rare, bone scan more inconsistent, and more favorable prognosis than in adults; females more than males

How many vincula feed the FPL?

One

Why is the FPL more likely to retract into the palm, compared to a digit FPD?

Only 1 vincula and no lumbrical muscle to hold it in place

Post-Polio Syndrome (PPS)

Onset: 15yrs after recovery from polio; Symptoms: new onset weakness, easily fatigued, muscle pain, joint pain, cold intolerance, atrophy, loss of functional skills. Medical Management: bracing w/ orthoses, pacing daily activities, stretching program, exercise program.

WALANT flexor tendon protocol

Orthosis: Wrist at 20-45* of extension, MPs flexed to 30*, and IPs extended to 0* First 3-5 days focus on elevation for edema management Then PROM following with active 1/3 to 1/2 fist til wk 3 Then active 1/2 to 3/4 fist and orthosis reduced to hand-based By week 4, full fist encouraged At 5 weeks, can exercise out of orthosis

Arcuate ligament AKA?

Osborne's Ligament, cubital tunnel retinaculum; creates the roof of the cubital tunnel; Slack in elbow extension and taut in flexion, increasing pressure of the ulnar nerve

What forms the "roof" of the cubital tunnel?

Osborne's ligament and the FCU fascia = tighter in flexion, which reduced tunnel space and leads to pressure on the ulnar nerve

Wound vac contraindications:

Osteomyelitis, malignancies, necrotic wounds, and uncontrolled bleeding.

What is the treatment of choice for grade II PIPJ dorsal dislocation?

Oval-8 or dorsal block in 20-30 degrees of flexion for 1-3 weeks to allow healing of volar structures, including volar plate. This would be followed with buddy taping. Grade III are treated the same unless reduction is not maintained, which may require surgery.

How can one differential between PIN compression and radial tunnel?

PIN compression will present with motor abnormalities ranging from wrist weakness to complete loss of function, whereas radial tunnel compression leads primarily to pain

Lateral cord in dupuytrens leads to contracture at which joint(s)?

PIP and DIP joints

Central Cord in dupuytren's leads to contracture and which joint(s)?

PIP joint primarily, but could be PIP and MP joint combo

Treatment timeline following subacromial decompression SAD:

PROM immediately moving to gentle AROM as pain allows; resistance started around 3-4 weeks

What are some typical OT interventions for a baby/child with Arthrogryposis Multiplex Congenita (AMC)?

PROM, serial casting, bracing, adaptive equipment training

Which thumb motions can be initiated first at 4 weeks), and which later at 8 weeks?

PROM: CMC abduction and extension AROM: CMC abduction, oppositon, circumducation

What parameters should but used with NMES to elicit muscle contraction?

Pad placement over the motor unit, aim for 10 strong contractions, frequency of 35-80 pps

Allodynia

Pain due to a stimulus that does not normally provoke pain; can be assess/measured with semmes-weinstein monofilaments which typically would not be painful

Radial tunnel differential from Lateral epicondylitis

Pain is more localized in the mobile wad: ECRL, ECRB, and BR, complaint of deep, burning pain made worse my pronation and wrist flexion. **Resisted middle finger extension will be painful with elbow extended, resisted supination with elbow extended will be painful**

Lindburgs syndrome

Pain on distal volar forearm. Pain with flexion of IP of thumb. Simultaneous flexion of dipj of index. It is restrictive thumb and index tenosynovitis due to anatomical interconnection between FPL and Index FDP. Positive Lindberg sign: inability to flex thumb ip without flexing index dipj. Avoid this movement, cortisone injection, NSAIDS.

A patient with acute compartment syndrome presents with

Pain out of proportion and an intrinsic minus claw posture

Testing for saddle syndrome

Pain with Bunnel intrinsic tightness test, during gripping, and during forceful intrinsic plus posturing. Deviating the MCP away from the painful side should increase symptoms indicating intrinsic adhesion.

What are the 4 P's of compartment syndrome?

Pain with passive stretch, Parasthesias, Pallor, Pulselessness

With radial tunnel syndrome, are symptoms primarily motor, pain, or sensory?

Pain; no sensory loss would be present

3-jaw chuck prehension AKA

Palmar prehension

Longitudinal Hemimelia

Partial amputation; One of the long bones of the forearm is missing; Fingers or thumb may or may not be missing

Second degree burn

Partial thickness; Superficial = A burn marked by severe pain, blistering, and superficial destruction of dermis with edema and hyperemia of the tissues beneath the burn; 14-21 days Deep = less pain because nerve endings are burned, extends to depth of dermis, NO blisters; 3-4 weeks for healing

Cozen's Test

Patient's elbow is flexed to 90 degrees with the forearm pronated and fist extended. Stabilize the elbow, palpate the ECRB, and resist the patient's extension. Positive for pain in the lateral elbow indicating lateral epicondylitis.

Cozen's test

Patient's elbow is flexed to 90 degrees with the forearm pronated and fist extension; therapist stabilizes the elbow and resists wrist extension. Positive if pain in the lateral elbow indicating lateral epicondylitis

Open-chain kinematics

Performed for mobility in which one joint or muscle group is isolated, like elbow flexion & extension, and the distal segment is freely mobile.

What is the blood-nerve barrier?

Perinerium; surrounds each nerve fascicle

Chillblains; AKA?

Pernio; an inflammation of the hands and feet caused by repeated exposure to cold temperature above freezing, but with little protection. Acute resolved within a week, but can become chronic; includes a patch of erythematous, edematous, and pruritic skin.

spinal shock

Physiologic response that may occur between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. Includes hypotension loss of bowel and bladder reflexes. Presents with total flaccid paralysis and loss of all reflexes below the level of injury.

What would a dynamic traction "hoop" orthosis be used to treat?

Pilon fracture

Pinch Grip Test

Pinch thumb and index finger together in an "O" position Inability to touch fingers together indicates entrapment of anterior interosseous nerve AIN between heads of pronator muscle

Post-axial polydactyly

Pinky-side, presence of supernumerary digit that is not a thumb or hallux

Which of the proximal carpal row is the ONLY bone to have a tendinous insertion? What muscle?

Pisiform; FCU

Pyogenic granuloma

Polypoid capillary hemangioma that can ulcerate and bleed; proud flesh. Treat with silver nitrate.

Wrestlers and gymnasts are at increased risk of damaging this nerve, do to frequent hyperextension of the wrist:

Posterior Interosseus Nerve PIN; leads to dorsal wrist pain and possible ganglion cyst. No sensory disturbances, as PIN is motor only. Surgical options include PIN denervation.

Which glenohumeral glides(s) would be most beneficial to improve internal rotation?

Posterior and Inferior glides

Subscapularis refers pain to the:

Posterior deltoid area, scapula, and posterior arm and wrist

Potassium (K+) and sodium (Na+): Which is higher inside/outside the bell body?

Potassium K+ is higher within the cell, Sodium NA+ is higher outside of the cell.

What situation would be a contraindication for joint mobilizations in a stiff hand?

Presence of edema; can increase inflammation response

Spiral cords leads to contracture of what joint(s)?

Primarily severe PIPJ contractures; Originates from 5 structures: pretendinous band, spiral band of Gosset, lateral digital sheath, vertical band, and Grayson's ligament; intertwined with the neurovascular bundle and requires careful dissection

What are the primary and secondary shoulder extenders?

Primary: Lats, Posterior delt, and Teres Major Secondary: Teres minor, Long head of the Triceps

First Rib Resection and Scalenectomy FRRS

Procedure to treat persistent arterial or venous thoracic outlet syndrome that does not respond to conservative treatment

Work Method

Procedures used to accomplish a work objective

Which type of arthritis primarily affects the synovium?

RA

Fracture disease

Prolonged immobility leads to so-called "fracture disease"; begins with uncorrected deformities of bone and joints, acute pain, and persistent edema; without intervention, fracture disease evolves to include stiffness, tendon adhesion, capsular and ligamentous contracture or attenuation, central slip attenuation, infiltrative scar formation, and pseudoclawing.

When treating ECU subluxation, how should an orthosis position a patient? How long?

Pronation, slight wrist extension, and radial deviation 6-12 weeks

With ECU snapping/subluxation, what is the best position for immobilization?

Pronation, wrist extension, and radial deviation; this seats the ECU into it's groove, while the opposite motions, like scooping ice cream, will sublux it.

In what position in the lacertus fibrosis tight?

Pronation; active elbow flexion + pronation can increase pressure on the median nerve due to the tight bicipital aponeurosis

Muscles that originate from the common flexor tendon (5):

Pronator Teres (PT), Flexor Carpi Radialis (FCR), Palmaris Longus (PL), Flexor Digitorum Superficialis (FDS), Flexor Carpi Ulnaris (FCU)

Kerlix

Proprietary name of a type of stretchy gauze used to hold dressings in place

The Washington Regimen

Protocol that is a combination of Kleinert's controlled active extension with rubber-hand passive flexion, Duran's controlled passive techniques, and the modification of the Kleinert orthosis that uses a palmar pulley system

Canted Hook: advantage?

Provides greater visual feedback with use due to their lateral configuration

During Dellon's moving two-point discrimination testing, the points are moved in what direction?

Proximal to distal

Wallerian degeneration happens in what direction?

Proximal to distal

Middle phalanx fracture WHERE would result in apex dorsal?

Proximal to the FDS insertion

How to differentiate between psoriatic and rheumatoid arthritis?

Psoriatic will have skin lesions, nail changes, and DIPJ involvement

What is the shoulder abduction test? What does a positive test indicate?

Pt places hand of the involved arm on top of their head. If after 30 seconds, shoulder pain improves the test would be considered positive and indicate cervical spine involvement.

Replay/Projection Flashbacks

Pt relives the trauma, but also feels completely out of control and feels the injury was not worse because of things out of their control; high anxiety and and stimuli associated with the trauma are avoided.

What is the best position for infraspinatus tendon palpation?

Pt seated, 90 degrees of shoulder flexion, slight horizontal adduction, and external rotation

Pseudoaneurysm

Pulsatile hematoma that results from leakage of blood into soft tissues abutting the punctured artery with fibrous encapsulation and failure of the vessel wall to heal

Epidermal Inclusion Cyst (EIC)

Puncture wound drive a piece of epithelium into subQ tissue; debris collects within a sack --> may discharge foul-smelling, cheesy white material; HARMLESS, unless they rupture and create an abscess. Tx: complete surgical excision is the only way to get rid of this lesion; if they turn into abscess: incision and drainage (I&D); tend to be sterile and, therefore, do not require oral antibiotics.

Good test for factory workers?

Purdue peg board test

Lindgren test

Purpose: To assess the contribution of 1st rib hypomobility to brachial plexus pain. Test Position: Sitting. Performing the Test: Rotate the head away from the painful side to end range. While maintaining end range rotation, attempt to laterally flex toward the chest as far as possible on the tested side. If unable to laterally flex the head, the test is considered positive.

In what manner should a frostbitten extremity be rewarmed?

QUICKLY! And at 104 to 112 degree F! May be very painful and require IV analgesics; blisters appear within hours after rewarming.

Lumbricals insert onto which lateral band?

Radial

What nerve is most commonly injured with humeral shaft fractures?

Radial

Which nerve is at risk with an anterolateral elbow approach?

Radial

Which artery passes through the anatomical snuff box?

Radial artery, which branches from the brachial artery in the level of the elbow flexion crease

What flap has been termed the "reconstructive chameleon" due to its versatility with hand wound coverage?

Radial forearm flap

What structure separates the lateral and medial heads of the triceps?

Radial nerve

Sail sign, elbow

Radiograph shows effusion in the anterior fat pad of the elbow; combined with typical posterior fat pad, looks like a boat sail

Shoulder Terrible Triad

Rare combination of anterior shoulder dislocation, rotator cuff tear, and neurologic injury

Fanconi anemia

Rare genetic anemia from defects in DNA repair; autosomal recessive; results in radial deficiency or absence; predisposed to cancer and will experience long term bone marrow failure

GRIT Test

Ratio = supinated grip strength over / pronated grip strength If GRIT ratio is greater than 1.0, this indicatee ulnar impaction

Duty cycle calculation:

Ratio of on time to off time 10s on and 30s off = 40s total 10s on/40s total = 25% duty cycle

Pt's with scleroderma are often diagnosed with _______ within a year of onset of skin changes.

Raynaud's phenomenon; typical first complains are non-pitting edema and tightness in the hands, feet, and face, progressing to ROM limitations, skin temperature changes, and pigmentation changes

Reiter's Syndrome

Reactive arthritis in joints secondary to bacterial infection in other part of body, such as an STD **conjunctivitis, urethritis, and arthritis**

Marion Lab Wound Classification

Red, yellow, black, or combination

What is the expectation for composite digit wrist extension AROM following FCU to EDC tendon transfer?

Reduced tendon excursion means simultaneous digit and wrist extension will not be possible; pt will utilize tenodesis to achieve full digit extension

Clinodactyly

Refers to a curvature of a finger in a mediolateral plane. It may be radial or ulnar in direction and may involve any finger. Usually refers to a radial deviation of the fifth finger at the distal interphalangeal joint and is most often associated with a short middle phalanx which is shorter on its radial than ulnar side

Test for Pronator Syndrome

Resisted pronation with elbow extension would elicit pain; indicated compression of the median nerve between the two muscle heads.

Pyramid of Progressive Force Application; Groth Pyramid

Resistive Isolated Joint Motion Resistive Hook and Straight Fist Resistive Composite Fist * DC Protective Orthosis * Isolated Joint Motion Hook and Straight Fist Composite Fist Place and Hold Passive Protective Flexion/Extension

Which digit is the most common jersey finger?

Ring finger; some say it has the weakest insertion, others say it's because it doesn't have independent extension due to the juncturae

Best way to clean a "red" wound?

Ringer's solution, mild soap, and sterile saline

Disadvantages of Intermedullary rod?

Rotational instability and rod migration; humeral rod patients are safe for pendulums within the first week

SICK scapula

S- scapula I- Infera C-Coracoid K- Dyskenesis An asymmetrical malpositioned scaupla caused by muscular overuse fatigue syndrome.

Where do the majority of dorsal wrist ganglions originate?

SL ligament

Shroud Fiber AKA

Saggital band; centralizes the EDC tendon =, preventing subluxation

What structure is responsible for an elevated first rib?

Scalenes

What is the most commonly fractured carpal bone?

Scaphoid

Pectoralis Minor Syndrome

Secondary to trauma at the chest, condition causing pain, numbness and tingling in the hand and arm. It often coexists with thoracic outlet syndrome (TOS) but can also occur alone. The symptoms are similar to those of TOS: Pain, weakness, numbness and tingling in the hand and arm

Wallbanger's disease AKA

Secretan's Syndrome

Workplace Environment Impact Scale WEIS

Semi-structured interview and rating scale reflecting on social and physical environment, supports, temporal demands, objects used, and daily job junctions to assist therapists with gathering info on how an employee with disabilities perceives the work environment.

SAD and MOVE

Sensory, afferent, dorsal horn Motor, ventral root, efferent

Divergent dislocation

Separation of radius and ulna both medially and laterally

Push-up Plus activates which muscles?

Serratus anterior, middle trap, and lower trap

Quadrangular space syndrome

Shoulder pain and parasthesia down the arm with weakness about shoulder region

Myotome testing

Shoulder shrug C2-4, Shoulder abduction C5, Elbow flexion C5-6, Wrist extension C6, Elbow extension C7, Wrist flexion C7, Thumb abduction/finger flexion C8, Finger abduction/Finger adduction T1

Diffuse cutaneous systemic sclerosis

Skin thickening at trunk and proximal extremities; worse prognosis, involvement of kidneys, heart, and can be worse hand deformities

Correct positioning of thumb in CMC orthosis?

Slight palmar abduction and supination; CMC is more unstable to pronation

Hyponychium

Slightly thickened layer of skin that lies between the fingertip and free edge of the natural nail plate

Median Nerve Compression sites:

Some Love Athletes but Pro Golfers Arent Cool Supracondylar Process Ligament of Struthers Arch of the FDS Biceps Apponeurosis Pronator heads Gantzer Muscle (FPL slip) AIN compression Carpal Tunnel

Treatment for type III radial head fracture?

Sometimes with surgical excision of the fragment, followed with long arm cast or orthosis for up to 3 weeks. Then begin ROM.

What is recovery expected to be seen in radial nerve injury/at what point would an MD begin to consider tendon transfer?

Spontaneous recovery can occur anywhere between a few days to 3-4 months... after that tendon transfers would need to be considered

Bowen's Disease

Squamous Cell Carcinoma In Situ; epidermal patches of red or yellow/gray; surgical excision

Grayson's Ligament

Stabilizes digit skin; originates from volar aspect of flexor sheath running volar to NV bundle and inserts into skin; contributes to PIPJ flexion contracture in Dupuytren's

Cleland's ligament

Stabilizes digit skin; passes dorsally to the NV bundle and inserts into skin; tight during flexion to allow for stability during grasp; Remember "CD" clelands-dorsal

Linea Jugata

Stabilizes the ECU during supination and ulnar deviation

Which muscle has the most stabilizing effect on the CMCj, and which has the most DEstabilizing effect?

Stabilizing: First dorsal interossei, strengthen! DEstabilizing: abductor pollicis longus, avoid strengthening!

Weber 2-point Test AKA? Norms?

Static 2-point test; Normal = 1-5mm, Fair = 6-10mm, Poor = 11-15mm, Protective = one point perceived, Anesthetic = no points perceived

Type I error

Stating that there is an effect when none exists; accepting an experimental hypothesis when the null is true. False positive. Alpha level is the accepted level of this happening.

Statistics vs. Parameters

Statistics are sample values from a small group vs. parameters are corresponding population values

What does "Travell" consider the "workhorse of myofascial therapy"?

Stretch and spray technique

Which zone II flexor tendon protocol is known for utilizing a tenodesis orthosis?

Strickland/Cannon

Eponychium

Structure from which nail is developed at the back of the nail near the cuticle

Fourth degree burn

Sub-dermal burn; Severe burn in which full thickness of the skin and underlying muscle and bone is damaged; due to prolonged thermal contact; requires skin grafting, scars heavily, often associated with electrical burns

Subluxation vs. Dislocation

Subluxation = joints partially contact but not in normal alignment; can usually be reduced back into position Dislocation = articular surfaces are no longer in contact and no potential for normal motion

Internal Rotation Lag Sign

Subscapularis tear; place pt into "lift off" position and ask them to hold

Which is the only muscle detached and reattached in a shoulder arthroplasty?

Subscapularis, which is why post-op precautions usually involve ER limited to some degree

Symptoms magnifier "Identified Patient"

Symptoms ensure survival and maintenance of the patient role or lifestyle. For the Identified Patient, the patient role eclipses and contains all other possible roles. Roles of father, husband, brother, uncle, friend, neighbor, and others are frequently seen to have been lost

Reynaud's Syndrome vs Reynaud's Phenomenon/Disease

Syndrome is a symptom secondary to another condition, such as scleroderma. Phenomenon/Disease is the standalone condition.

Tendon transfer - Phase:

Synergistic movements best when possible, such as wrist extension and digit flexion

The major blood supply of the extensor tendons is from what? And what %?

Synovial diffusion = 70% Vascular perfusion provides the other 30%

Gerber lift off test

TESTING for Subscapularis tear. POSITION Patients hand behind their back and ask them to pull it away from their back. Positive TEST = Inability to perform the movement.

Spurling's Test

TESTING: dysfuction of cervical nerve root POSITION: sitting, head side bent to uninvovled side, apply pressure through head straight down, repeat with head bent toward involved Positive TEST: pain and/or paresthesia in dermatomal pattern; reproduction of symptoms

What is the primary stabalizer of the DRUJ?

TFCC

Ischemic rupture

Tenosynovitis that causes tendon compression, weakens the tendon and decreases the blood supply and results in rupture

Durkan's test

Test for carpal tunnel by placing thumbs over the transverse carpal ligament and applying pressure for 30-60 seconds.

Anterior Slide Test

Tests for a labral tear. Pt is sitting with the hands on the waist, thumbs posterior. Examiner stands behind the pt and stabilizes the scapula and clavicle with one hand. The other hand applies an anterosuperior force at the elbow. If the humeral head slides over the labrum with a pop or crack, and the pt complains of anterosuperior pain, it indicates a positive test.

Catch up clunk test

Tests for midcarpal instability active RD to UD of wrist and back positive test = clunk and pain just beyond neutral as wrist moves into ulnar deviation clunk is the abrupt shift of the proximal row from flexion to extension

Jahnke test

Tests for posterior instability. The affected arm is placed in maximal horizontal adduction and internal rotation and a posterior force applied. This causes posterior subluxation. Next the shoulder is brought back from horizontal adduction while maintaining posterior force on the humerus at the elow. As the shoulder approaches normal a cluck may herald reduction of the subluxed shoulder, which is a positive test.

External rotation lag sign

Tests supraspinatus and infraspinatus muscles; with elbow at side arm is taken to end range ER and pt instructed to hold. A 5-10 degree lag is indicative of supra tear, more than 10 degree lag indicates both suprs and infra tear.

Bennet's test

The Bennett Mechanical Comprehension Test (BMCT) is a mechanical aptitude test developed by Pearson Assessments. The BMCT is used as a prerequisite during the recruitment process for technical roles.

Mucous cysts are most common seen at:

The DIPJs of the dominant hand in index and middle fingers

What muscle overlays the elbow UCL, effectively stabilizing it?

The FCU; strengthening this in throwers may protect against ligament injury

Which portions of the brachial plexus run between the anterior and middle scalene?

The TRUNKS, plus the subclavian artery! The subclavian vein does NOT travel in this space

What area of the capsule do the majority of adhesions form in adhesive capsulitis?

The anteroinferior capsule; should be the focus area for modalities, mobilizations, and stretching.

TFCC components

The articular disc. The dorsal and volar radioulnar ligaments. The meniscus homologue. The extensor carpi ulnaris tendon sheath. The ulnocarpal ligaments.

What are the 3 primary constraints for elbow stability?

The coronoid process, the ulnar collateral ligament, and the anterior band of the medial collateral ligament

Describe the carpal movements when the wrist moves in radial deviation:

The distal row extends and the proximal row flexes

Describe the carpal movements when the wrist moves in ulnar deviation:

The distal row flexes and the proximal row extends

Ulnar Nerve Compression sites:

The men and monsters order crispy fried gizzards Thoracic outlet Medial intermuscular septum Arcade of Struthers Medial epicondyle Osborne's Ligament Cubital Tunnel FCU heads Guyon's Canal

Neutrophils

The most abundant type of white blood cell. Phagocytic and tend to self-destruct as they destroy foreign invaders, limiting their life span to a few days. Destroys bacteria during the inflammatory phase.

Enchondroma

The most common bone tumor of the hand; most typically seen in the proximal phalanx

Hitchhiker's Test

Therapist applied resistance against thumb MPJ extension; pain = a positive test, indicating inflammation of the EPB tendon in the first compartment

Hyperkeratosis nail

Thickening of the skin/nail caused by a mass of keratinocytes

What test would indicate presence of axon during nerve regeneration?

Tinel's sign, at the most distal level of nerve return at that time

Which exercise places strain on on the thumb UCL and shoulder be avoided until 8 weeks?

Tip/chuck pinch

Modified Ashworth Scale

To test for abnormal tone; apply quick stretch to muscle so it is lengthened quickly 0= no increase in tone 1= slight increase in tone, catch and release or minimal resistance at end of ROM when affected part moved in flex or ext 1+= slight increase in tone, catch, followed by min. resistance t/o remainder (< half) of ROM 2= more marked increase in tone through most of ROM, but affected parts easily moved 3= considerable increase in tone, passive movement difficult 4= affected parts rigid in flex or ext

Total shoulder arthroplasty vs Reverse total shoulder arthroplasty; why would an MD choose one over the other?

Total MUST have decent rotator cuff to mobilize the prosthetic; Reverse would be for those with arthritis AND deficit rotator cuff, because it uses the deltoid ad the primary mover.

Upper extremity impairment levels

Total amputation, or 100% loss of the limb, is evaluated as a 60% impairment of the whole person. Amputation of the upper extremity from the level of the biceps insertion to the level proximal to the metacarpophalangeal (MCP) joints is equivalent to a 95% loss of upper extremity or 57% of the whole person. Amputation at the MCP joints is rated as a 90% loss of the upper extremity and 54% of the whole person. Individual digits assigned values in relation to the whole hand: thumb is evaluated as 40%, index and long fingers 20% each, and ring and little fingers 10% each

Failure of formation/arrest of development; examples?

Transverse deformities, radial/ulnar deficiency, and Phocomelia

What ligament restrains lateral bands to prevent a swan neck?

Transverse retinacular ligaments

Joint affected in thumb CMC OA?

Trapeziometacarpal

Joint affected in thumb CMC OA?

Trapeziometacarpal can progress to involve the scaphotrapezial joint also

Least common carpal fracture:

Trapezoid

What is the least commonly fractured carpal bone?

Trapezoid; less than 1% of all carpal fracture. Would be from high-energy, axially directed forces through the IF metacarpal base

TUBS

Traumatic, Unidirectional, Bankart, Surgery

Suave Kapandji Procedure

Treats DRUJ issues; Ulnar neck is excised and ulna head fixed to the radius; can lead to instability of the proximal stump of the ulna

Darrach Procedure

Treats DRUJ issues; excision of the distal ulna but can lead to ulnar translation of the carpus and thus is reserved for low demand patients or those with RA

Immersion Injury; AKA?

Trench foot; result of prolonged exposure to above-freezing cold temperatures and moisture. Initially the foot is blanched or mottled, and the patient experiences an anesthetic effect described as "walking on air".

Articular disc of the wrist; AKA?

Triangular Fibrocartilage TFC; part of the TFCC. Found between the distal end of the ulna and carpal bones; Ulna does not articulate with the carpal bones due to this structure. Central portions absorb compressive forces between the ulna and triquetrum, and is relatively avascular with poor healing potential.

What is the 2nd most commonly fractured carpal bone?

Triquetrum; typically occurs with other carpal fractures or radius fracture; usually cast for 6 weeks

Which types of thoracic outlet syndrome are surgical candidates?

True neurogenic and Vascular

Pancoast tumor

Tumor of the upper lung; Arm pain and muscular atrophy due to C8 and T1 brachial plexus involvement. Horner syndrome can occur with ptosis, anhydrosis, miosis, from involvement of sympathetic chain. Shoulder pain from chest wall invasion.

Soft tissue sarcoma

Tumor that is more rare than a carcinoma that occurs in younger age groups and metastasizes via blood vessels rather than lymphatic channels; stems from connective tissue

About 70% of rotator cuff tears occur in patients with which type of acromion?

Type 3, hooked

Salter-Harris Classification

Type I: fracture through the physeal plate; often not detected radiographically Type II: fracture through the metaphysis and physis; most common; up to 75% of all physeal fractures Type III: fracture through the epiphysis and physis Type IV: fracture through the metaphysis, physis and epiphysis Type V: crush injury involving part or all of the physis

Which Salter-Harris types damage the epiphysis? What can be a complication from this?

Types III, IV, and V; can result in growth abnormalities or growth cessation

When does HO formation begin?

Typically around 2 weeks post-trauma

When does collagen production begin in wound healing?

Typically at 3-5 days; 2nd stage, proliferative

When does collagen production end in wound healing?

Typically between day 14-28; 2nd stage, proliferative)

Symptoms magnifier "Refugee"

Uses symptoms to escape and irresolvable conflict; symptom behavior provides an escape from an apparently irresolvable conflict or life situation, perhaps a job they do not like.

What is the most common cause of limb deficiency?

Vascular disruption, such as amniotic band syndrome

White finger

Vascular issue caused by overuse of vibratory tools causing muscle fatigue, pain, numbness and blanching of affected fingers. Can be a classic raynauds phenomenon in response to cold stimulation or stress. Up to 50% of people working with vibratory tool, such as a jack hammer, report symptoms of raynaud's.

Therapeutic water temperatures: Vasoconstriction/analgesia? Best temp for exercise? Vasodilations/analgesia?

Vasoconstriction/analgesia: 33-55* F Best temp for exercise: 81-92* F Vasodilations/analgesia: 97-99* F

VACTERL syndrome

Vertebral anomalies Anal atresia Cardiovascular anomalies Tracheoesophageal fistula Esophageal atresia Renal anomalies Limb anomalies Associated with radial deficiencies

Workplace risk factors for development of muskuloskeletal disorders:

Vibration, Fixed postures, Job related psychosocial factors, repetition, awkward or extreme positions, cold temperatures, and use of force.

What type of orthosis would be fabricated for a patient with grade II PIPJ collateral ligament tear?

Volar gutter with PIPJ and DIPJ extended

Which ligament is reconstructed in a thumb CMC LRTI procedure? And what is the most common donor?

Volar oblique/beak ligament, and FCR

What structure can become interposed and prevent reduction of a dorsal MPJ dislocation?

Volar plate

What major soft tissue is torn in dorsal dislocation of the PIPJ? How is this treated? What can be a result?

Volar plate; dorsal blocking orthosis with PIPJ at 30 degrees of flexion to allow healing; pseudo-boutonierre

What area of the scaphoid is most commonly fractured? What area has the worst prognosis?

Waist is most common; proximal pole has the worst prognosis secondary to poor blood supply

Necrotic wounds are treated with:

Wet to dry dressings

Potential excursion

When a muscle contracts from its fully stretched position through a distance that is equal to it's resting length

How common is Hill-Sachs lesion with anterior dislocations?

Will occur in 35-40% of anterior dislocations, and in up to 80% of recurrent dislocations.

Napoleon Test

With hand pressed to belly, inability to move the elbow anteriorly; somewhat reverse belly press test

Grind Test, Shoulder

With the patient standing or supine, and examiner standing facing the patient. Examiner grasps the patient's flexed elbow, shoulder is passively abducted in the scapular plane to 90° (Hawkins-Kennedy test position), and the examiner's other hand is placed over the patient's shoulder overlying the anterior acromion and greater tuberosity. The examiner passively compresses and internally/externally rotates the shoulder detecting the presence of palpable crepitus, indicated labrum tear.

Safe Position

Wrist 0-20 ext, MCP 70-90 Flex. IPJs fully extended, and thumb abducted/extended

Myositis ossificans

a condition in which a calcium mass forms within a muscle three to four weeks after a muscle injury; direct trauma leads to hematoma, which then results in calcium deposits in the muscle.

Osteochondritis Dissecans (OCD)

a condition that develops in joints, most often in children and adolescents. It occurs when a small segment of bone begins to separate from its surrounding region due to a lack of blood supply

Primary lymphedema is caused by

a developmental abnormality, either congenital or hereditary

Ankylosing spondylitis

a form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae

isokenetic exercise

a muscle has different levels of strength while moving through a complete range of motion; the use of specially designed machines

Kirner's deformity

a rare entity which presents with painless, progressive, bilateral radiovolar curving of the terminal phalanges of the little fingers

Alien hand syndrome

a rare neurological disorder that causes hand movement without the person being aware of what is happening or having control over the action. This usually occurs after a person has had the two hemispheres of the brain surgically separated, as in split-brain surgery to treat epilepsy but can also occur post- CVA or infection.

Work conditioning

a rehabilitation technique in which a person learns/preforms a series of strength building or safety exercises that will aid their ability to function in a work environment; most appropriate for early referrals without psychological and vocational complications

Arthritis Mutilans

a severe disabling form of psoriatic arthritis that destroys the small hand bones, leading to shortening of digits and "opera glass hand" deformity

t-test

a statistical test used to evaluate the size and significance of the difference between two means

Bankart procedure

a surgical technique for the treatment of recurrent anterior dislocation of the shoulder; the detached anterior labrum and joint capsule are reattached to the glenoid rim; axillary nerve is at risk

Pulsatile mass

aneurysm

Thumb clutched hand

anomaly which is characterized by a fixed thumb into the palm at the metacarpophalangeal joint in one or both hands; due to lack of or weak thumb extensors

Articular disk shear test

assess central lesions of TFCC; elbow on table, FA in neutral; stabilize radius w/1 hand while placing thumb of other hand dorsally over distal ulna and other finger on pisotriquetral complex volarly; squeeze fingers causing dorsal glide of pisotriquetral on ulnar head and shearing of central disk; NO DEVIATION NEEDED

Splinting of choice for a stable, nondisplaced PIP fracture?

buddy taping to adjacent digit

Camptodactyly

denotes a permanent flexion of one or more of the fingers. The deformity is located at the proximal interphalangeal joint and also usually involves the fifth finger

Glenohumeral Internal Rotation Deficit: GIRD

difference in internal rotation range of motion between an individual's throwing & non-throwing shoulders

Cellulitis

diffuse, acute infection of the skin and subcutaneous tissue marked by local heat, redness, pain, and swelling; absence of pus or localized abscess

Peripheral TFCC tears usually occur due to:

direct compressive or shearing force, often associated with distal radius fractures. Pain with rotation and sometimes a painful click is noted. Peripheral lesions often treated with surgical repair. May also require ulnar shortening.

Lindberg Syndrome

discomfort over the radiopalmar aspect of the distal forearm and thumb related to the interconnection of FPL and FDP of the IF

Sensory cell bodies are located in the:

dorsal root ganglion, outside of the CNS

What would the presentation be if a patient had Spinal Accessory nerve damage?

drooping shoulder girdle and flat traps with weakness in serratus, traps, and sternocleidomastoid.

Garrod's disease

dupuytrens of the knuckle pad

Plyometrics phases

eccentric, amortization, concentric Rapid stretching of a muscle group that is undergoing eccentric stress; the muscle is exerting force while it lengthens, followed by a rapid concentric contraction

coorelation coefficient

examines the degree to which variations or differences in one variable are related to variations or differences in another. if a correlation exists, a 2nd score may generally be predicted from a known score. 0 = no relationship

Hyperalgesia

excessive sensitivity to minimally painful stimuli

Most common cause of flap failure?

excessively compressive dressing/splint

Transverse Amelia

forequarter amputation all or most of the arm is missing from the shoulder and below

Quadrigia effect

following FDP tendon repair, patient exhibits flexion contracture of the involved digit with decreased flexion force in the adjacent fingers due to reduced tendon excursion; occurs if the surgeon advances more than 1cm during repair

Steindler flexorplasty:

for brachial plexus injury to restore elbow flexion function- transposes the flexor/pronator origin more proximally on the humerus giving ability to flex against weight up to 5#

Forms the ulnar border of the carpal tunnel

hook of hamate, triquetrum which is not a ligament attachment site, and the pisiform

Appraisal flashbacks

image of the injured hand right after the trauma

Projected flashbacks

image of the injury beyond what actually happened; envisioning worse than reality.

Clamp sign

indicates scaphoid fracture; when asked where the pain is the patient will clamp their hand around their wrist at the scaphoid bone area

Septic arthritis

inflammation of the joint caused by infection typically following penetrating trauma; symptoms include pain, swelling, decreased ROM, loss of function, and purulent exudate within the joint capsule; Fever may or may not be present; not common, but can be fatal and needs immediate attention; diagnosed by synovial fluid gram stain

Bone fracture healing phases:

inflammation: until day ~5, repair: from day ~5 to ~21, remodeling: from day ~21 up to 18 months

Hutchinson's fracture

intra-articular fracture of radial styloid sustained with forced ulnar deviation of the wrist causing avulsion of the radial styloid (AKA Chauffeur's Fx)

Pain with resisted MF PIPJ flexion indicates:

median nerve compression at the FDS aponeurotic arch

Supraspinatus refers pain to the:

lateral deltoid region

Pain with resisted elbow flexion and in supination indicates:

median nerve compression at the lacertus fibrosis

Denuded skin

loss of the epidermal layer of skin, often from sheering force

Rhomboids refer pain to the:

medial/vertebral border of the scapula

Tendon transfer - Power:

muscle-tendon unit loses 1 muscle grade after transfer, so need a strong donor

Levator refers pain to the:

neck and vertebral border of the scapula; area around the eye

Pneumatic pump parameters

no higher than 40mmHG for patient with compromised lymphatic systems; ratio of 3:1 or 4:1 inflation to deflation, pressure not to exceed pt's diastolic blood pressure; systolic over diastolic

Glove anesthesia

numbness begins sharply at the wrist and extends evenly right to the fingertips; conversion disorder

Parameter

numerical summary of a population

Best dressings for red, granular wounds?

occlusive, semiocclusive, or semipermeable

Retrovascular cord

on its own it does NOT cause contracture of the PIP joint, but in combination with the lateral cord can result in a hyperextension contracture of the distal interphalangeal joint

Upper trap refers pain to the:

posterolateral aspect of the neck, behind the ear, and temporal area

beta level

probability of making a type II error, accepting the null hypothesis when it is false

Muscles innervated by the anterior interosseous nerve:

pronator quadratus PQ, FPL, and FDP of the IF and MF

Pedicle

provides the bloodflow for a flap

Scalene Trigger Points can lead to pain where?

radial hand/forearm; differential diagnosis with deQuervain's and intersection syndrome

Rothmund-Thomson syndrome (RTS)

rare genetic disorder: early signs include rashes on dorsal aspects of both forearms; short stature, thumb, and/or radial anomalies, juvenile cataracts, gastrointestinal issues, osteopenia, absent patella(s), alopecia baldness, high risk of bone cancers

Appraisal/Projected Flashbacks

re-experiences the injury, but also magnifies the injury; assumes little control over the situation and avoids stimuli associated with the injury. Least likely to return to work.

Allodynia

sensation of pain in response to a stimulus that would not typically produce pain

Most commonly dislocated joint in the body?

shoulder (glenohumeral), and then elbow

Hypothenar Hammer Syndrome

single or repetitive blunt impact on hypothenar eminence leads to ulnar artery thrombosis or aneurysm; hook of hamate functions as an anvil, causing thrombosis; vibration and smoking increase risk; 80-90% of people who develop this are smokers

PIPJ Accessory Collateral Ligaments (ACL)

stabilizes the volar plate; tight in extension and loose in flexion

Speed's Test

stretching or lengthening of the biceps tendon to assess the possibility of tenosynovitis of the long head

Nursemaid's elbow

subluxation of the radial head out of the annular ligament; annular ligament is typically not ruptured and subluxation may be due to ligament laxity. Occurs with longitudinal traction of the forearm; seen most in children between 6 months and 3 years, prior to ossification of the radius

biceps long head original and insertion

supraglenoid tendon to the radial tuberosity

rotator interval

the region between the superior edge of the subscapularis and anterior edge of the supraspinatus tendons, reinforces by the coracoacromial ligament. Injury can result in posteroinferior instability.

Dolphin or Fowler tenotomy:

terminal tendon tenotomy to restore DIPJ flexion related to chronic boutonniere; ROM allowed immediately but intermittent mallet orthosis wear may be indicated pending extensor lag

Clunk Test

test to identify a glenoid labrum tear, with audible "clunk" is heard while performing test; Pt in supine, with shoulder in full abduction. Push humeral head anterior while rotating humerus externally

Triangular Fibrocartilage Complex (TFCC)

the TFCC is a fibrous and cartilaginous structure that separates the radiocarpal joints and inferior radioulnar joints of the wrist. it is a major ligamentous stabilizer and provides flexible mechanism for stable rotation. it is most often injured from violent twist of the wrist, forced hyherextension, or falling on an out stretched hand. there will be pain along ulnar side, pain with wrist extension, clicking or catching, swelling. refer to physician. immobilized for 4 weeks, surgery may be needed

Required excursion

the length needed to put the joint through the whole ROM

halo-effect bias

the observer's perception of one characteristic of an individual dominates other perceptions to result in undifferentiated overall impression, positive (halo), negative (horns)

alpha level

the probability level used by researchers to indicate the cutoff probability level, highest value, that allows them to reject the null hypothesis when it is true; type 1 error

Gate-control theory

the theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small "C" achy/throbbing pain and "Ao" intense/acute pain nerve fibers and is closed by activity in larger "AB" non-painful stimuli fibers or by information coming from the brain. NMES stimulates the "AB" fibers and thus, blocks pain.

M1 thumb

thumb injury sustained by WWII or Korean War era military personal where a part of a rifle slammed into the thumb; no lasting effects

failure of differentiation/separation; examples?

thumb-clutched hand, syndactyly, camptodactyly, clinodacyly, polydactyly, and kirner's deformity

xenograft

transplantation from a foreign donor, usually a pig, and transferred to a human; also called heterograft

allograft

transplantation of healthy tissue from one person to another person; also called homograft

autograft

transplantation of healthy tissue from one site to another site in the same individual

Isograft

use of identical twin's tissue

Situational Assessment

used to assess a client's ability to perform the exact same tasks in an environment identical to that of the actual target vocation.

Characteristic xray findings with scapholunate ligament tear

widening of the interval to great that 4mm, "ring sign", and SL ligament will exceed 60 degrees

A wound infected with pseudomonas is distinct because it:

will have a strong odor and yellow/green appearance

How long after a Hep B vaccine should a person wait to give blood?

~2 weeks

Typical treatment timeline following Bankart repair:

~3 weeks of sling wear with pendulums, and PROM in therapy to 30 degree max ER and 90 degrees max flexion. Active and passive motion progressed over another 3 weeks, with light strengthening initiated at 6 weeks. Full ER should be achieved by 8 weeks. Return to unrestricted activity at 3 months.