MSK cases UE

Question 1

what are the mechanics of carpal bone movement

Answer 1

The flexor and extensor carpi ulnaris and radialis, as well as some of the muscles of the digits will initiate motion, but the mechanics of carpal bone movement are governed by the carpal ligaments through their nonelastic properties and their position.

The placement of the carpal ligaments creates various fulcrums and checks within which the complex movements of the carpal bones occur

Question 2

what is reciprocal tension

Answer 2

throughout the physiological range of motion of any given joint, the associated ligaments maintain a constant level of tension.

They do not stretch, nor do they become lax.

In normal movements as the joint changes position, the relationships between the joint’s ligaments also change, but the total tension within the articular mechanism does not

Question 3

what are the principles of the balanced ligamentous articular mechanisms in treatment and what is the point of balanced ligamentous tension

Answer 3

In general, the technique combines a fulcrum introduced by the physician with an activating force provided by the patient

The first and most important step in treatment is establishing balanced ligamentous tension in the articular mechanism so that the body’s inherent forces can resolve the strain

The point of balanced ligamentous tension is the point in the range of motion of an articulation where the ligaments and membranes are poised between the normal tension present throughout the free range of motion and the increased tension preceding the strain…which occurs as a joint is carried beyond it’s normal physiology

Question 4

balanced ligamentous tension

Answer 4

Initially, the physician can learn to establish a neutral in a strained articular mechanism.

The physician will hold this position while the activating forces within the body such as breathing resolve the strain.

When the strain corrects, the physician will feel a shift or change in the tension in the joint such that the neutral that he created is no longer the point of minimal tension.

Question 5

a hypertonic serratous anterior will place the scapula in what position

Answer 5

The physician assesses position of scapula on thorax, i.e., scapulo-thoracic joint. A hypertonic serratus anterior will produce elevation and lateral displacement of scapula.

Question 6

still technique

Answer 6

move joint into position of ease

3. Exaggerate the position of ease sufficiently to relax the affected tissue and those surrounding it.
4. Introduce a vector of force (compression or traction) of about five pounds or less through the affected tissue. The point of initiation of the force vector should be on a part of the body that can be used as a lever that can introduce movement in the restricted tissue. The vector of force may be along the long axis of the body for the spine or its orientation may follow a different vector. In every case the vector of force must be through the affected tissue.
5. Using the force vector as if it were a lever, the tissue is taken through its range of motion towards and through the initial restriction. This movement will typically be a composite that utilizes all of the tissue’s normal planes of motion.
6. As the coupled force vector and tissue motion takes the tissue past its area of previous restriction there is a palpable release, sometimes accompanied by a click such as is commonly heard in HVLA treatments.
7. The force vector is then released and the tissue is passively returned to neutral and retested.

Question 7

what is a sensing hand or sensing finger

Answer 7

the hand placed on the affected spinal segment, joint, muscle, or ligament.

1. It acts as a feedback sensor providing information about the adequacy of the initial positioning. That is the tissue will palpably relax when the appropriate position is achieved.
2. The sensing finger can provide information during the articulation that the track of motion is appropriate.
3. The sensing finger will be able to feel the release as the tissue passes through the barrier.

Question 8

what is the operating hand

Answer 8

the hand and arm that sets the initial position of the patient’s tissue, provides the force vector through the tissue, and articulates the tissue along its motion path through the barrier.

Question 9

how do you treat the scapulothoracic joint with BLT

Answer 9

The physician stands on the side of the shoulder to be treated, placing the pad of his thumb on the ribs at the mid-axillary line as superior as possible. The physician then slides his/her thumb posteriorly along the patient’s ribs until it is under the scapula with the pad of the physician’s thumb on the thoracic cage and the thumbnail against the scapula.

The physician asks the patient to lean towards him/her so that the thumb slides further under the scapula until he/she reaches the resistance of the serratus anterior. His/her thumb will act as a fulcrum for movement of the scapula. The physician places his/her other hand on top of the scapula, grasping the spine of the scapula with her fingers. An inferior traction is placed on the scapula to achieve balance between the serratus anterior, rhomboids and teres muscles. The physician holds this position until a relaxation of the serratus anterior is achieved (Figures 15, 16, 17).

Question 10

what is nursemaid elbow

Answer 10

the normal anatomical alignment of two of the three bones that form the elbow joint is disrupted

Girls are more commonly affected than boys; the left arm is more often injured than the right.

The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn.

The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm.

The common belief that nursemaid elbow is due to children having a radial head smaller than the radial neck is incorrect.

Question 11

what will you find on physical exam of a child with nursemaid’s elbow

Answer 11

commonly reveals an anxious child who is protective of the affected arm. In most children, anxiety is greater than pain. The forearm is usually flexed 15-20 degrees at the elbow, and the forearm is partially pronated. Often, the weight of the affected arm is supported with the other hand. Erythema, warmth, edema, or signs of trauma are absent. Distal circulation, sensation, and motor activity are normal. A reluctance to move digits or the wrist is common, probably from fear of eliciting pain in the elbow. Tenderness at the head of the radius may be present. The patient resists supination/pronation as well as flexion/extension of the forearm.

Question 12

how do you treat a nursemaid’s elbow

Answer 12

Treatment consists of manipulating the child’s arm (closed reduction) so that the annular ligament and radial head return to their normal anatomic positions. Traditionally,the manipulation consists of forearm supination and elbow flexion, as follows

• This is accomplished by immobilizing the elbow and palpating the region of the radial head with one hand.
• The other hand applies axial compression at the wrist while supinating the forearm and flexing the elbow.
• As the arm is manipulated, a click or snap can be felt at the radial head.

Question 13

Most problems in the upper extremity are associated with a component of upper thoracic, upper rib and cervical somatic dysfunction. Why?

Answer 13

The sympathetic nerves innervating the upper extremity arise from the upper thoracic spine and are interconnected with the superior, middle and inferior cervical ganglion. Treating the upper thoracic, upper rib and cervical dysfunction before addressing the upper extremity will reduce the amount of sympathetic tone to the upper extremity, thereby relaxing the muscles and improving arterial supply to and lymphatic and venous return from that region.

If an upper extremity problem (especially shoulder) is slow or non-responsive to treatment, think of systemic problems like diabetes or hypothyroidism. The neuromusculoskeletal condition may not respond until the systemic problem is properly treated and under control.

Question 14

what does the radiocapitellar line tell you in an X-ray

Answer 14

radial dislocation

Question 15

what does the anterior humeral line tell you on an X-ray

Answer 15

supracondylar fractures

A line drawn on a lateral view along the anterior surface of the humerus should pass through the middle third of the capitellum..
This line is called the Anterior Humeral line .
In cases of a supracondylar fracture the anterior humeral line usually passes through the anterior third of the capitellum or in front of the capitellum due to posterior bending of the distal humeral fragment.

Question 16

what does the fat pad sign tell you on Xray

Answer 16

sign of effusion and occult fracture

If a positive fat pad sign is not present in a child, significant intra-articular injury is unlikely.

A visible fat pad sign without the demonstration of a fracture should be regarded as an occult fracture.

They concluded that in trauma displacement of the posterior fat pad is virtually pathognomonic of the presence of a fracture.

Displacement of the anterior fat pad alone however can occur due to minimal joint effusion and is less specific for fracture.

Question 17

most common fx in children

Answer 17

greenstick fracture

it is a fx without cortical bone disruption

Question 18

SALTER harris fractures?

Answer 18

Type I - straight across

Type II - above - metaphysis

Type III lower or below - epiphysis

Type IV - two or through . both metaphysis and epiphysis

Type V - crush injury of growth plate

Question 19

if you are suspecting nursemaids elbow , what findings on PE would alert you to this being more than nursemaid’s

Answer 19

A visible fat pad sign without the demonstration of a fracture should be regarded as an occult fracture.

Question 20

after you treat a nursemaid’s elbow, what happens

Answer 20

Sedation – usually not required
Splinting – usually not indicated
Meds – may give OTC acetaminophen, but frequently unnecessary. If stronger med needed, suspect other diagnoses
Rehab – usually none

the child usually starts using the elbow right away again

Question 21

what is hawkin’s impingement sign

Answer 21

flex the pt’s shoulder and elbow to 90 degree with palm facing down. then with one hand on the forearm and one on the arm, rotate the arm internally by applying upward force at the elbow and downward force in the forearm. this compresses the greater -tuberosity against the coracoacromial ligament

Question 22

what is neer’s impingement sign

Answer 22

press on the scapula to prevent scapular motion with one hand, and raise the pt’s arm with the other. this compresses the greater tuberosity of the humerus against the acromion

Question 23

what is speeds’ test

Answer 23

raise the pt’s straight arm forward to be parallel with the floor. with the palm facing upward. ask the pt to resist you pushing it back down.

if pain occurs in the area of the bicipital groove the test is positive

Question 24

what is the crossover test?

Answer 24

testing AC joint

adduct the pt’s arm across their chest

Question 25

what is friction injury

Answer 25

prototype - impingement syndrome

Question 26

subscap

Answer 26

internal rotation

downward rotation of the humeral head into the GH joint

Question 27

supraspinatous

Answer 27

elevation and abduction of the humerus and for upward traction of the humeral head into the GH joint

major muscle affected in impingement syndrome

Question 28

infraspinatous

Answer 28

external rotation

downward traction of humeral head into the GH joint

Question 29

teres minor

Answer 29

external rotation

downward traction of humerus into the GH joint

Question 30

what is the impingement interval

Answer 30

space b/w the under surface of the acromion and the superior aspect of the humeral head

maximally narrowed when arm is abducted

Question 31

by what two mechanisms/types does the rotator cuff impingement occur

Answer 31

primary impingement b/c of the inherently small space under the acromion —> with repetitive motion tendonitis will occur
-more likely to occur in elderly pt’s

secondary impingement due to pain of the shoulder which leads to weakness and reflex inhibition of the rotator cuff muscles –> muscles fail to center the humeral head into the glenoid.

more likely to occur in younger pt’s

Question 32

what are the symptoms of impingement syndrome

Answer 32

pain
weakness
loss of motion

look at the scapula–> if there is impingement, the affected side usually has early firing of the upper traps and weakness of the scapula –> slight winging of the inferior medial scapula border

Question 33

neer stage 1-3 impingement

Answer 33

edema and hemorrhage of the supraspinatous tendon and subacromial bursa

stage II - fibrosis

stage III - pt’s over 50. fibrosis can culminate in a full thickness tear

Question 34

what xray view/image is helpful b/c it shows the subacromial space and can differentiate 3 types of acromial processes

Answer 34

Scapular Y view

Question 35

AP view for rotator cuff

Answer 35

helps asses the GH joint and sclerosis of the greater tuberosity

Question 36

conservative managment of lesser rotator cuff injuries involves what

Answer 36

strengthening

biomechanical and training changes

adequate core strength

ice- for 10- 15 minutes after exercise

heat and deep muscle massage
-before exercise

electrical stimulation

Medications - NSAID’s

Corticosteroid injection - important to reduce pain to start the rehabilitation process

Rest

Prevention - stretch, strengthen

Question 37

how does a SLAP lesion present

Answer 37

vague deep shoulder pain

popping, catching or grinding sensation with overhead movements

Question 38

biceps tendonitis

Answer 38

tenderness when palpated in the groove

speed’s test is positive

Question 39

treatment of biceps tendonitis

Answer 39

limiting activity until asymptomatic

NSAID’s

ROM exercises

can be associated with impingement syndrome

Question 40

should you use corticosteroids for biceps tendonitis

Answer 40

they can contribute to further weakening of the tendon and increase the possibility of subsequent rupture , especially if they are repeated

this should be discouraged

Question 41

lateral epicondylitis

Answer 41

tennis elbow

pain with resistance to wrist and third digit extension

Question 42

medial epicondylitis

Answer 42

golfers elbow

pain elicited with resisted pronation, wrist flexion, and grip strength testing

Question 43

in the adult patient, are elbow dislocations more common in males or females

Answer 43

males

Question 44

fall on an outstretched hand can cause what elbow pathology

Answer 44

posterior elbow dislocation

whereas an anterior dislocation might occur by impact on the posterior forearm in a slightly flexed position

Question 45

what is the mean age of pts with nursemaid’s elbows

Answer 45

2-3 years

rarely occurs after age 7

Question 46

if you suspect a dislocated elbow, what should you check!

Answer 46

neurovascular status

(brachial artery, median and ulner nerves) –> most vulnerable to entrapment during manipulation

Question 47

how do you reduce a nursemaid’s elbow

Answer 47

the reduction maneuver for a nursemaid’s elbow entails placing the thumb over the radial head and maximally supinating the forearm

if no audible or palpable click is heard , the forearm is flexed up while maintaining a supinated position

Question 48

13. Explain the mechanics of and apply the chin pivot HVLA technique for treating flexed somatic dysfunction in the upper thoracic area.

Diagnosis T1FRSL

Answer 48

this is with the pt prone
for Type II flexed thoracic dysfunctions

physician stands at the head of table

Lift the pt’s head and neck and sidebend until motion is palpated at T1. then place the pt’s chin on the table

place the heel of your left hand over teh posterior transverse process of T1 and apply a gentle anterior, lateral and caudal force to engage the barrier

place your right hand on the left side of the pt’s head and slightly rotate the pt’s head to the left (pivoting on the chin) localizing to T1. sidebending is toward the barrier and rotation is toward the ease **

engage the barrier, instruct the pt to inhale and exhale take up slack and maintain localization during exhalation

the final corrective force is quick, anteriorly, laterally, and caudally directed from your left hand over the left transverse process of T1

return to neutral

Question 49

16. Explain the mechanics of Spencer’s articulatory technique and muscle energy modification and apply in the evaluation and treatment of shoulder dysfunction. Know all the stages! Technique questions do appear on written exams!

Answer 49

Extension
Flexion
Compression with circumduction 
traction with circumduction 
adduction and external rotation 
abduction 
internal rotation
traction with inferior glide "joint pump"

Question 50

17. Explain the mechanics for diagnosing anterior and posterior radial head dysfunction.

Answer 50

anterior radial head
-pronate the forearm to engage barrier

posterior -
put the radial head in supination and have the patient pronate

Question 51

how do you perform shoulder balancing

Answer 51

used for pathology in the sternoclavicular, acromioclavicular, or glenohumeral joints

place palms of hands over the AC joints with fingers over proximal humerus

find a point of equal tension among ligamentous attachments

hold until release is palpated

Question 52

15. Explain the mechanics of and apply counterstrain treatment for supraspinatus, subscapularis, biceps brachii, medial epicondyle and radial head tenderpoints.

Answer 52

supraspinatous

• found superior to the spine of the scapula
• flex, abduct to 45 degree, external rotation of humerus

Question 53

15. Explain the mechanics of and apply counterstrain treatment for, subscapularis,

Answer 53

anterior and lateral surface of scapula

extend, abduct, internal rotate humerus

Question 54

15. Explain the mechanics of and apply counterstrain treatment for biceps brachii,

Answer 54

flex elbow
minor flexion of arm
adduction and internal rotation of arm as needed

Question 55

15. Explain the mechanics of and apply counterstrain treatment for, medial epicondyle

Answer 55

found at the common flexor tendon and attachment of pronator teres

flex elbow to 90 degrees
pronate wrist and fine tune with internal/external rotation

Question 56

Explain the mechanics of and apply counterstrain treatment for, radial head tenderpoints.

Answer 56

found on lateral surface of radial head

full extension of elbow
supinate wrist, and fine tune with abduction/adduction of forearm

Question 57

how do you treat a posterior radial head with the still technique

Answer 57

Initial position: The sensing hand gently contacts the radial head and supports elbow. The patients arm should be relaxed. The operating hand encircles the patients’ wrist. The forearm is brought into pronation until tissue balance is sensed at the radial head.
Final position: A gentle axial force is put through the distal radius to the radial head. Maintaining that compression, the forearm is brought into supination. Release the compression to recheck motion