MSK So Far

exam findings for cubital tunnel syndrome

**another condition where we pay attention to weakness as it may become permanent** can see intrinsic atrophy positive tinels at the elbow reproducing dysesthesias and or pain along the peripheral ulnar nerve distribution 2 point discrimination > 5 mm diminished intrinsic muscle strength

Etiology: overuse (weight lifters) Inflammation of the distal biceps tendon Pain in antecubital fossa Pain in the elbow area with resisted supination. Diffuse antecubital fossa tenderness. Tx: RICE, activity modification, NSAIDs, rare: sling (remind patients not to use it), surgical exploration (brings more blood supply to area)

distal biceps tendonitis

what fx can develop acute carpal tunnel syndrome

distal radius fx

common, volar tilt is lost

distal radius fx (colles)

supplies muscles of posterior compartment of forearm

deep branch of radial nerve

exam findings for a both bone forearm injury

deformity frequent, significant swelling NV injury is rare diffusely tender at fracture site check radial, median, and ulnar sensorymotor function, 2 point discrimination/cap refill -Allens test to see if artery is disrupted

tendinitis on radial side of wrist- pick up baby

dequervain's tenosynovitis

Always check circulation and sensation ______ to the injury.

distal

Assessing strength of muscles: No movement

0

Assessing strength through movement/ROM: what are the 5 levels you can ascribe to the patient's injury?

0: No movement 1: Trace movement 2: Movement and full PROM, but unable against gravity 3: Full AROM, but not against resistance 4: Full ROM against gravity & resistance, but weak 5: Full ROM against gravity, full resistance

Assessing strength of muscles: Trace movement

1

Assessing strength of muscles: Movement and full PROM, unable against gravity

2

Assessing strength of muscles: Full AROM, but not against resistance

3

Assessing strength of muscles: full ROM against resistance and gravity, but weak

4

Assessing strength of muscles: full ROM against gravity, full resistance

5

Cervical: how many bones, how many nerves

7, 8 (C8 leaves below the pedicle)

What does a fat pad sign indicate?

An occult elbow fx

The anterior compartment of the arm contains what muscles and whats the innervation

Brachialis, biceps brachii; musculocutaneous nerve

Which nerve roots leave below the pedicle?

C-8, T- 1-12, L- 1-5

Which nerve roots leave above the pedicle?

C1-C7

Relatively solid, found on external surface of bone, dense part of structure

Compact/cortical bone

type of synovial joint that is convex or concave movement of two articulating surfaces not dissociable example: knee, temporomandibular joint

Condylar

Spiral groove of humerus: whats special

Contains the radial nerve and deep artery (profunda brachial artery)

Exam findings for a distal biceps tendon rupture

Deformity of biceps, diffuse swelling and ecchymosis about the elbow and antecubital fossa Focal antecubital fossa pain and tenderness often cant assess strength due to discomfort high energy mechanism: get an X-ray

etiology: overuse of extensor muscles of forearm Very TTP over the medial or lateral epicondyle Lateral epicondylitis: resisted wrist extension and forearm supination Medial epicondylitis: resisted wrist flexion and forearm supination Lateral: Arm extended, push long finger down Medial: Arm extended, push long finger up Piano key test

Elbow overuse: Tennis elbow (lateral epicondylitis) golfers elbow (medial epicondylitis)

exam for dequervain's tenosynovitis

FINKELSTEINS

type of synovial joint that is flat, planar motion: in one plane; flexion, extension Example: Interphalangeal joints of hand and foot, elbow

Hinge

Exam findings for distal biceps tendonitis

I: Normal P: focal antecubital fossa pain and tenderness S: Pain in elbow area with resisted supination

Findings for a proximal humerus fx

I: dramatic eccyhmosis of entire upper arm/chest wall P: focal proximal upper arm pain and tenderness S: cant assess NV: Sensory motor: musculocutaneous, radial, median, ulnar M: ok to perform gentle motion of the elbow, wrist, and fingers--crepitance of shoulder w/ this exam

exam findings for a supracondylar humerus fx

I: significant swelling and guarding P: diffuse tenderness most exquisite at supracondylar regions Neuro: Check radial, median, ulnar sensorimotor

exam findings for midshaft humerus fx

I: upper arm swelling P: be gentle, tenderness is diffuse NV: Radial-> can you bring the wrist up, extend the fingers (if not, surgery immediate) Sensation over dorsal forearm and hand and wrist extensor / Extensor Pollicis Longus strength.

Findings of long head of biceps tendonitis:

Inspection: Normal (the pic is a rupture) Palpation: Focal anterior shoulder pain and tenderness radiating inferior to biceps muscle. Strength: Focal pain with resisted shoulder forward flexion and resisted elbow flexion and resisted forearm supination.

branches of lateral cord of brachial plexus

LML Lateral pectoral nerve Muscluocutaneous Lateral root of median nerve

Difference in exam findings between lateral and medial epicondylitis

Lateral epicondylitis: resisted wrist extension and forearm supination Medial epicondylitis: resisted wrist flexion and forearm supination

Etiology: Use/overuse (overhead use, swimmers, tennis, etc.) Tendon becomes frayed/worn between lesser and greater tuberosity Anterior shoulder pain with resisted supination/forward flexion of the shoulder Sometimes it ruptures and there is a deformity. Tx: RICE, activity modification, NSAIDs, injection is an option.

Long head of biceps tendonitis (a rupture is also known as popeyes deformity)

branches of medial cord of the brachial plexus

MMMMU Medial pectoral nerve Medial root of median nerve Medial cutaneous nerve of arm Medial cutaneous nerve of forearm Ulnar nerve

Fx with radial nerve effected wrist drop, numb on back of hand Immediate surgery

Midshaft humerus fx

Tx for skier's/gamekeeper's thumb

Minor-Thumb spika RICE, PT, etc Major-Surgical repair

When you pick up a child typically under 4 by the arms you might pop the elbow out (radial head dislocation). They don't have pain, their

Nursemaid's elbow, reduce it by supinating wrist and extending arm, apply pressure over radial head

what type of scaphoid fx has poor healing, high non-union rate, therefore needs surgery?

Proximal pole

Tx options for elbow overuse

RICE Corticosteroid injections for short term relief new,wont be tested on:Nitroglycerin patches applied 1/4 daily

mechanism: fall on outstretched hand (FOOSH), direct blow focal tenderness on radial head

Radial head fracture

Why should you not miss a scaphoid fx? Why would this be easy to miss? What can you do about that?

Scaphoid fx have a very high rate of non-union (poor blood supply to scaphoid), but they may be occult on x-ray. Get an MRI to be sure.

Injury to ulnar collateral ligament of thumb "I fell on my hand and now I cant have a cup of coffee (weak pinch or poor grasp)" swelling or bruising over the thenar eminence instability of metacarpal joint of thumb

Skier's thumb/Gamekeeper's thumb

type of synovial joint with convex surface in concave cavity movement:wide-ranging, flexion, extension, abduction, adduction, rotation, circumduction ex. shoulder, hip

Spheroidal (ball and socket)

Soft part of bone

Spongy/cancellous/medullary bone

Test and Tx option for metacarpal fx

Tx: ulnar gutter or radial gutter splint for 1 week followed by buddy taping and progressive motion OR buddy taping and range of motion from the onset Examine these with finger flexion and extension. Check motion with fist closed Focal tenderness at fx site

branches of posterior cord of the brachial plexus

ULTRA Upper subscapular Lower subscapular Thoracodorsal Radial Axillary

Consider that LBP is effected by knee problems, and knee pain is effected by foot problems. This is why you must always consider the joint _____ and joint ____ as there are many contributory factors effecting more than the joint of pain.

above, below

deep vein accompany an _______

artery

what type of cartilage covers bones at joints to protect them

articular cartilage (type of hyaline cartilage)

continuation of subclavian artery, three branches (gives rise to posterior circumflex humeral artery)

axillary artery

Surgical neck of humerus is important bc it is a site that is prone to fracture, it contains two structures:

axillary nerve posterior circumflex humeral vessels

exits axilla via quadrangular space, winds around surgical neck of humerus with the posterior circumflex humeral vessels, innervates deltoid, teres minor, skin over deltoid region and joint capsule of shoulder

axillary nerve (c5, c6)

ganglion cyst test

big-mushy small-hard transillumination is diagnostic-flashlight on the bump that pops up when you put the index finger down

difference between osteoblasts and clasts?

blasts-build bone clasts-crush bone

99% of the body's calcium is found in the ___

bones

Fracture of necessity surgery inherently unstable Referal

both bone forearm injury ((one on left-apex volar one on right-slight valgus))

formed by ventral rami of c5-c8 and T1, gives rise to nerves that innervate the upper limb

brachial plexus

how is cephalic vein formed, terminated

by lateral end of dorsal venous arch, axillary vein

pressure on median nerve-motor branch to thenar weakness (chronic-atrophy). numbness.

carpal tunnel syndrome

pectoral (shoulder) girdle components

clavicle and scapula

what is the most commonly broken bone in body, was it poorly designed?

clavicle, no. its there to break to protect apex of lung and other vital structures. its like the bumper of a car

elbow overuse carpal tunnel of the elbow, affects ulnar nerve etiology: insidious/over use/resting on elbow persistently

cubital tunnel syndrome

6 diff nerves (subclavius, suprascapular, c5, c6, anterior and posterior division of upper trunk) form this

erb's point

bones originate as _____ cartilage (a 2 year old kid will look like they don't have a lot of bones on x-ray, but they just haven't ossified yet)

hyaline

attach bone to bone

ligaments

thenar muscles are innervated by

median nerve

testing the sensorimotor function for musculocutaneous, median, and ulnar nerv

musculocutaneous m: biceps, s: radial aspect of forearm radial s: back of hand, m: wrist extensors median s: thumb index long radial half of ring finger, m: thenar muscles ulnar s: ulnar side of hand m: intrinsics abduction)

tests for carpal tunnel syndrome

normal inspection-possible thenar atrophy and dry skin over median nerve distribution if late Phalen's maneuver and Tinel's test test abductor pollicus longus 2 point discrimination

deep elbow flexion test-numb fingers is good for ulnar nerve ulnar nerve abducts fingers (intrinsics)

ok

etiology: trauma, slip on ice is common fat pad signs cant extend the elbow treated surgically

olecranon fx

Fx of the humerus in the proximal third (close to surgical neck) Predisposition: Osteroporosis Tx: immobilize with sling PT: pendulums

proximal humerus fracture

flip to see normal radius x-rays and what to look for

radial inclination should be 30 degrees wrist joint slight tilt toward palm

branch of posterior cord of brachial plexus exits axilla traversing through lower triangular space divides into two branches: superficial (courses anteriorly along with radial artery, supplies skin of lateral dorsum of hand) and deep (runs posterior to forearm, supplies all muscles in posterior compartment of forearm)

radial nerve

anatomic snuff box tenderness or diffuse tenderness and guarding with ASB tenderness = ________ until proven otherwise. what to do?

scaphoid fx (MRI, thumb spica, reeval n 1 week or bone scan if cannot do MRI)

anatomic snuffbox tenderness is bascially diagnostic for what

scaphoid waist fx

buckle fx in kid/distal radius torus fx. what is the treatment?

short arm cast

the superficial veins typically supply the ____

skin

Tx for radial head fx

sling for 7-10 days ROM exercises as early as day 2 (elbows are terrible about stiffness)

supplies skin on lateral dorsum of hand

superficial branch of radial nerve

Apex posterior angulation (radius should normally point to condyle) Have to be perfectly reduced to heal (refer to specialized ortho surgeons) Gunstock deformity: cant extend

supracondylar humerus fx

fat pad signs (which are bleeding) on xray in which fxs?

supracondylar humerus fx radial head fx olecranon fx

gunstock deformity can come from what fx

supracondylar humerus fx--- refer

Radial head fracture exam findings

swelling, bruising, careful examination of the skin tenderness over the radial head-focal neuro: sensorimotor to radial, median, and ulnar nerve low risk of nerve injury

exam findings for olecranon fx

swelling, bruising, palpable indentation at the olecranon. don't assess the strength neuro: sensorimotor to radial, median, and ulnar nerve

exam findings for a distal radius fx

swelling, often deformity diffuse tenderness about the wrist check radial, median, ulnar nerve sensorimotor, including 2 point discrimination. median nerve is most at risk can develop acute carpal tunnel syndrome>hematoma into carpal tunnel the bruising in this pic might come overnight

thick viscous fluid inside joint capsules

synovial fluid

attach muscle to bone

tendon

good test for motor median nerve

testing the abductor pollicis longus; turn palm up, thumb toward push toward index

Proximal pole scaphoid fractures, which have good blood supply, low non-union rate. what tx?

thumb spica cast

typical question on a test: appropriate tx for scaphoid waist fx?

thumb spica cast

The posterior compartment of the arm contains what muscle and what is the innervation

triceps brachii, radial nerve