Exam 1 Flashcards
(173 cards)
1
Q
How long does it take for bone to achieve clinical union?
A
three weeks
2
Q
What are sources of bias in clinical research?
A
- examiner
- Patient being assessed
- Measurement device
- Examination procedure
- Clinical importance of differences
3
Q
What are sources of error in clinical reasoning?
A
- Pragmatic inferences
- Considering too few hypotheses
- Failure to sample enough information
- Confirmation bias
- Errors in detecting covariance
- Confusing covariance with causality
- Confusion between deductive and inductive logic
- Premise conversion
4
Q
Joint Pain of Systemic Origin
A
- awakens the patient at night
- typically is described as deep-aching or throbbing
- may be reduced by pressure
Symptoms include:
- jaundice
- migratory arthralgias
- skin rash
- fatigue
- unexplained weight loss
- low-grade fever
- muscular weakness
- cyclical, progressive symptoms
- hx of infection
5
Q
Joint Pain of Musculoskeletal Origin
A
- decreases with rest; “stiff”
- may be described as “sharp”
- reduced or eliminated when stressful action is stopped
- may increase with activity
6
Q
Frish “5-5” format
A
- Inspection
- Function
- Palpation
- Neurological Examination
- Special Tests
7
Q
Composite Motion
A
swing combined with spin
8
Q
Consequential Movement
A
spin due to successive swings
9
Q
Cyriax Interpretation for Resisted Motion
A
- painless and strong = no lesion
- painful and strong = minor lesion
- painful and weak = major lesion
- painless and weak = complete rupture
10
Q
Strength/Training Principles
A
0-3 weeks = neural adaptation
6-12 weeks = muscle response
10-12 weeks = tendon response
11
Q
Tendonitis
A
- macrotrauma and inflammatory
- single event
- extrinsic overload
- macroscopic injury (ie bleeding)
- significant event
12
Q
Tendonitis Timeline
A
- acute = less than 2 weeks
- subacute = 2-6 weeks
- chronic = 6 or more weeks
13
Q
Tendinosis
A
focal area of intra-tendinous degeneration that is initially asymptomatic and may remain such unless a specific stress is brought forth
- microtraumatic and degenerative
- repetitive action
- intrinsic trauma
- often eccentric demand
- stabilizing/absorbing
14
Q
What are the three areas of potential tendonosis?
A
- extensor radialis brevis tendon
- supraspinatus tendon
- patellar tendon
15
Q
Tenosynovitis
A
inflammation of paratenon surrounding tendon
16
Q
Treatment of Tenosynovitis
A
wrist cockup splint and NSAIDs for 3-4 days
17
Q
Stress-Strain Curve
A
1% = toe-in region 1-3% = linear region 3-6% = failure 6-8% = complete rupture
18
Q
Effects of Aging on Tendon
A
- increased cross links
- tougher collagen
- decreased tensile strength (stiffness and weaker)
- fewer enzymes - slower turn over and collagen deposition
19
Q
Repair Process (macrotrauma)
A
- inflammation = 3-5 days
- collagen generation = 5-21 days
- proliferation followed by cross linkage
- maturation is long term (months) “Wolff’s Law”
20
Q
Repair Process (microtrauma)
A
- repetitive loading - submaximal activity - function
- minimal reparative response (failed response)
- often vascular mediation
21
Q
Tendon Composition
A
- Collagen - Type 1 - 25-30%
- Elastin - 2% - decreases with age
- Water - 70+%
Note: fibroblasts control healing
22
Q
Principle 1
A
The Challenge of Homeostasis; Equilibrium of Exercise (i.e. patient must be challenged enough to properly load the tendon, but not overly challenged to cause re-injury)
23
Q
Principle 2
A
Transitions (i.e. most injuries occur during transitions); Wolff’s Law
24
Q
Principle 3
A
Pick Your Parents Wisely; impact on genetics, aging, adaptability
25
Isometric Contraction
Concentric Component - Series Elastic Component = Amount of Force Produced
26
Concentric Contraction
Concentric Component - Series Elastic Component = Amount of Force Produced
27
Eccentric Contraction
Concentric Component + Series Elastic Component = Amount of Force Produced
28
In terms of MT load vs. Tendon load, what happens as you increase the load?
increased EMG amplitude
29
How much more does concentric recruit than eccentric?
30%
30
How should isometrics be incorporated in exercises? Why?
isometric holds should be added to exercises because they increase the number of fibers recruited
31
T/F: EMG = muscle tension
False
32
T/F: EMG = muscle tension
False
33
What are the two underlying reasons for tendinosis?
aging and significant use
34
What is the organization of tendon?
```
macroscopic = longitudinal orientation; crimped at rest
microscopic = tightly arranged parallel fibers
```
Tropocollagen - Microfibril - Subfibril - Fibril - Fascicle - Endotenon - Epitenon - Paratenon - Tendon
35
Treatment Concepts
- Rest (tincture of time)
- Thermo/Cryotherapy
- Wolff's Law
- NSAIDs for 3-4 days
- Pain: bad if with concentric/isometric; discomfort with isometric may be appropriate (Stanish; Alfredson)
- E-stim blasting: isometrics afterwards
- Exercise: Pain Guided Approach
- Isokinetics
- Isotonics
- Plyometrics
-
36
Isokinetic Different Responses
- multiple patterns (open/closed)
- sub-maximal efforts (concentric/eccentric)
- minimal high speed concentrics
- use multiple eccentric modes
*be progressive but monitor closely
37
Treatment of Strains
- recognize the limiting factors
- may use modalities to increase blood flow after initial phase
- NSAIDs from MD for 2-3 days
- PRICE
- no aggressive stretching
- progressive strengthening
- progressive function
- usually have a strong eccentric program (at low-levels)
- working at end-range (Mullaney, 2006)
38
Tendonitis Treatment in the Acute Stage
- Rest
- Ice
- NSAIDs
- Progressive adaptation
- Functional Sequence
- Maximal eccentrics
39
Tendonitis Treatment in the Subacute Stage
- Delayed or insufficient response, careful not to maintain status quo
- Progression with monitoring
- Isotonics to increase resistance - before speed
- Preload concentric/eccentric isokinetics
- Eccentrics
- Plyometrics (late)
40
Tendonitis Treatment in the Chronic Stage
- Education
- Eccentric emphasis
- Increase speed slowly
- Plyometrics
- Ice post-treatment
41
Rupture Treatment Post-Operatively
- get long operative report
- quality of tissues and repair
- passive/assistive/aquatics
- active
- 3 mos = protection; 6 mos = endurance; 12 = power
42
Elements of Functional Stability at the Shoulder
1. Passive Ligamentous Restraints (superior glenohumeral lig, middle glenohumeral lig, inferior glenohumeral lig)
2. Joint Geometry
3. Muscular Restraints
4. Joint Compressive Forces (deltoid and rotator cuff)
43
What controls the vertical displacement of the clavicle?
coracoclavicular ligaments (trapezoid and conoid)
44
Snyder Classification of SLAP Lesion
1: labral fraying w/ anchor intact; surgical debridement
2: labral fraying w/ detached biceps tendon; surgical repair
3: bucket-handle tear extends into the joint space causing "catching," "clicking," etc.; surgical debridement
4: bucket-handle tear extends into the biceps tendon; surgical repair
45
Musculature of the Shoulder in Concert
```
0-30˚ = roll and translation
30-60˚ = often as above
60-180˚ = primarily rotation
```
46
The Six Step Progression
- proximal muscles
- work individual muscles
- work muscles in patterns
- monitor patient and tissue response
- base rehabilitation on needs
- functional progression
*integrate, caution with closed-chain, compromise of shear and compression, functional progression related to specific actions or needs (SAID)
47
The Six Step Progression
- proximal muscles
- work individual muscles
- work muscles in patterns
- monitor patient and tissue response
- base rehabilitation on needs
- functional progression
*integrate, caution with closed-chain, compromise of shear and compression, functional progression related to specific actions or needs (SAID)
48
Anterior Glenohumeral Dislocation
90% of glenohumeral dislocations; d/t:
- weak area of the capsule
- position of weakness
- unstable position
49
Possible positions of the humeral following anterior dislocation
- subcoracoid
- subglenoid
- subclavicular
- luxatio recta
50
TUBS
Traumatic
Unidirectional and Unilateral
Bankart lesion
Surgery (90% in younger pts.; 70+% in total)
51
AMBRI
```
Atraumatic
Multidirectional
Bilateral
Rehabilitation (70% respond, but it's not perfect)
Inferior shift
```
52
AMBRI
```
Atraumatic
Multidirectional
Bilateral
Rehabilitation (70% respond, but it's not perfect)
Inferior shift
```
53
GH Lesions
1) Detached labrum-capsule (Bankart's lesion)
2) Erosion fx. of anterior glenoid
3) Post/lateral humeral head deflection (Hill-Sachs lesion)
54
Shoulder dislocation relates to:
1) age (relates to strength)
2) activities
3) cause of initial injury
4) stability status
5) initial treatment (newer concepts point to early surgery)
55
Dislocation Treatment Prior to Surgery
1) Restrict ROM (ER for anterior; IR for posterior)
2) Progressive strengthening (IR and Depressors for anterior; ER, RC, posterior deltoid for posterior)
3) Modify activities
4) Functional progression
56
Rehabilitation for Bankart Lesion - Direct Approach
- IR sling for 10-14 days
- isometrics but no ER
- 2-4 weeks continue to wear sling at night
- active ROM to 90˚
- restrict ER forces
- 4-8 weeks light function
- 8+ weeks functional progression
- return to work/play in 3-4 mos
57
When should a Laterjet approach be used?
when a patient has lost >15% of the anterior-inferior glenoid; surgeons may bring a piece of the coracoid (or iliac crest) and rebuild the glenoid
58
Rehabilitation for Bankart Lesion - Laterjet Approach
- IR sling for 3 wks (up to 4-6 wks)
- forward flexion in scapular plane to tolerance; elbow flexed
- care with isometrics and elbow, plus limit extension and ER
- 4-6 wks passive-assist ROM and slow start of strengthening - 6 wks before pushing of loads
- 6-12 wks functional progression
59
Capsular Shifts
incision of the capsule at either the humeral head or the glenoid, followed by a longitudinal cut to create two flaps in the capsule; one side is folded down while the other is pulled tight and anchored to reduce redundancy in the capsule and make a thicker portion
60
Rehabilitation for Capsular Shifts
- support with a sling for 2 weeks, stay below 90˚
- 2-4 weeks: AROM but staying below 90˚ and no ER
- 4-6 weeks: protected increase in functional activities slowly increasing patterns of motion and utilizing aquatic therapy to work multiple patterns
- 6-8 weeks: slowly increasing functional progression leading into return to function in 8-12 weeks
61
Rehabilitation for Capsular Shifts
- support with a sling for 2 weeks, stay below 90˚
- 2-4 weeks: AROM but staying below 90˚ and no ER
- 4-6 weeks: protected increase in functional activities slowly increasing patterns of motion and utilizing aquatic therapy to work multiple patterns
- 6-8 weeks: slowly increasing functional progression leading into return to function in 8-12 weeks
62
What are potential complications of shoulder surgery?
infection, recurrent instability, nerve injury, hardware problems, loss of rotation
63
Instability Severity Index Score (ISIS)
examines factors such as age, sports level, pre-op sport, shoulder hyperlaxity, Hill-Sachs visible on ER film, and loss of bone; if 4+ points = don't perform the surgery arthroscopically (70% failure rate)
64
According to Dr. Malone, what tenets for RC rehabilitation are important to know before initiating therapy?
- type of surgery
- deltoid, size
- fixation - suture, staple
- anchor (single vs. double row - bridge - other materials)
- quality of tissue
- specifics (ex: biceps tenodesis, etc.)
65
What are the two ways to reattach a torn RC?
bone tunnel or an anchor
66
Important treatment concepts following RC repair:
- centered humeral head (rotator role)
- proper sequence of recruitment
- balance of active and passive structures
- proximal stability
- neuromuscular integration
67
Size of Rotator Cuff Tear
small: <1 cm
medium: 1-3 cm
large: 3-5 cm
massive: >5 cm
68
6 and 12 Month Rule
6 mos to have the motion and 12 months to have the power to use the motion; supraspinatus 60-70% compared to normal side at 6 mos, within 10-20% of normal side at 12 mos
69
PRE progression following RC repair
- multiple angle isometric - submaximal to maxmimal
- isotonic restricted ROM - concentric & eccentric efforts
- isokinetic - speed and ROM progressed
*have patient flex the elbow to decrease difficulty
70
Factors Relating to Success in RC Repairs
- age of patient and onset of injury
- size of tear
- surgical procedure (Deltoid, open, etc.)
- work or activity levels
- specifics of patient (motivation, quality of tissues)
71
General Time Frame for Post-Operative RC Repair
Phase 1: 3-8 wks
Phase 2: 6-12/16 wks
Phase 3: 15-24/30 wks
Phase 4: 6 mos to 1 yr
72
Phase 1
primary healing, passive motion, and pain modulation
73
Phase 2
active motion, normalization of ROM
74
Phase 3
strengthening isolated-integrated-functional progression (pattern of six)
75
Phase 4
advanced as required by patient-sports activities
76
Normal Biomechanics of the Shoulder
- centered humeral head
- proper sequence of recruitment
- balance activities and passive structures
- proximal stability
- neuromuscular integration
77
Impingement - Stage 1
- edema and hemorrhage
- age 25 or less
- reversible with treatment
- painfree exercise
78
Impingement - Stage 2
- fibrosis and tendinosis
- age 25-50
- pain with activity
- surgery???
79
Impingement - Stage 3
- spurs and ruptures
- age > 40-50
- progressive disability
- acromioplasty with cuff repair
80
Jobe Scheme - Classification
1. primary impingement - no instability
2. secondary impingement - traumatic instability
3. hypermobility - secondary impingement
4. pure instability - no impingement
81
Tests for Impingement
1. Elevation overpressure
2. Painful arc of motion with AROM at 60-120˚
3. Hawkins-Kennedy test
82
Systemic Origins (non-self limiting) of Pain in the Neck
- bone tumors
- metastasis
- tuberculosis
- nodes in neck
- cervical cord tumors
83
Systemic Origins (non-self limiting) of Pain in the Chest
- angina, MI
- lung cancer
- breast disease
- aortic aneurysm
- hiatal hernia
- pancoast tumor
84
Systemic Origins (non-self limiting) of Pain in the Abdomen
- liver disease
- ruptured spleen
- spinal metastasis
- upper UTI
- dissecting aortic aneurysm
- gall bladder disease
85
Systemic Disease and Origins (non-self limiting) of Pain
- gout
- sickle-cell anemia
- rheumatic disease
- metastatic lesions (breast, prostate, lung)
86
Causes of muscle atrophy and dysfunction around the shoulder
- mechanical lesions
- C5, 6 radiculopathy
- Brachial plexopathy
- Neuralgic amyotrophy (Parsonage-Turner syndrome)
- Isolated nerve lesions
- muscle disease
- Post-traumatic neurogenic inflammation
87
Clinical Presentation of Suprascapular Nerve Entrapment
- posterior shoulder pain
- isolated muscle atrophy
- rotator cuff weakness
- insidious onset
88
What are the recognized locations of suprascapular nerve entrapment?
1. suprascapular notch ligament = "sling effect"
| 2. spinoglenoid notch - highly repetitive motions
89
Treatment for Suprascapular Nerve Entrapment
1. Benign neglect
2. Surgical release
3. Muscle stimulation
4. Other PT
90
Scapular Dysfunction "Winging" Scapula
- spinal muscular atrophy
- spinal accessory nerve lesion (upper trap)
- long thoracic nerve lesion (serratus anterior)
- scapular dyskinesis
91
How do you distinguish between spinal accessory and long thoracic nerve lesions?
spinal accessory nerve lesion will show scapular winging in abd; long thoracic nerve lesion will show scapular winging in flex
92
How do you distinguish between spinal accessory and long thoracic nerve lesions?
spinal accessory nerve lesion will show scapular winging in abd; long thoracic nerve lesion will show scapular winging in flex
93
Instability
- decreased IR strength
| - excessive ER mobility
94
Impingement
- decreased ER strength
| - posterior capsule tightness (dec IR ROM)
95
What are the four methods for relocating a dislocated shoulder?
- Hippocratic ("unshod" foot in axilla; NAVL injury)
- Kocher (most likely to fx proximal humerus)
- Stimson (prone, weighted arm)
- Milch (gentle)
96
Mid-humerus Fracture
Rx: often ORIF
Complications: radial n. injury; delayed union, mal-union, non-union
97
Characteristics of Primary Frozen Shoulder
- patient age, 40-65 yrs
- insidious or minimal event resulting in onset
- significant limitations of active and passive shoulder motion in more than 1 plane
- 50% or greater than 30% loss of passive ER
- all end ranges painful
- significant pain and/or weakness of the IR
98
Gross Anatomical findings of Adhesive Capsulitis
- adhesions (inferior capsule recess, humeral head, no synovial fluid)
- rotator cuff changes
- pectoral fibrosis
- no inflammatory cells; doesn't respond to NSAIDs
99
Adhesive Capsulitis Diagnosis
- pain
- lose of AROM and PROM
- capsular pattern (ER>ABD>IR>Flex)
- loss of shoulder joint play
- loss of component motion
100
What tests can be used to diagnose adhesive capsulitis?
- ROM
- VAS; NPRS
- Arthrography (normal = 15-20ml; dec to 5-10 ml
- examination under anesthesia
- MRI findings
101
What is the rationale for joint mobilization in patients with adhesive capsulitis?
1. histopathology (capsular fibrosis, dec joint capacity, and marked reduction in synovial fluid)
2. pathomechanics
3. treatment (enhance AROM/PROM by improving joint play, avoid traumatization of thickened fibrotic capsule between acromion process and greater tuberosity)
102
Why is the elbow mechanically "compound"
- 3 axes in same joint
- axes aren't at right angles
- "plane" gliding joints w/o the usual axes
103
Humeroulnar joint
bi-axial sellar
104
Humeroradial joint
- tri-axial spheroid
- un-modified ovoid (like "ball and Socket")
- held together by ligaments
105
Proximal radioulnar joint
- bi-axial trochoid
- modified ovoid
- "rotating"
- "wheel-like"
106
What is the resting position of the humeroulnar joint?
70˚ flexion; 10˚ supination
107
What is the closed packed position of the humerolunar joint?
extension with supination
108
Capsular pattern
flexion > extension; pronation and supination WFL
109
What is the resting position of the radiocapitellar joint?
full extension and full supination
110
What is the closed packed position of the radiocapitellar joint?
90˚ flexion; 5˚ supination
111
What is the capsular pattern of the radiocapitellar joint?
flexion, extension; pronation and supination WFL
112
What is the resting position of the superior radioulnar joint?
35˚ supination, 70˚ elbow flexion
113
What is the closed pack position of the superior radioulnar joint?
5˚ supination
114
What is the capsular pattern of the superior radioulnar joint?
equal limitation of supination and pronation
115
What are the reasons for loss of motion of the elbow?
1. capsular pattern plus antecubital fossa fibrosis
| 2. other causes (bony fusion/osteophytes, ligamentous adhesions, antecubital fibrosis, osteochondral fragment)
116
What are Cyriax's ten test movements to examine elbow pathologies?
- passive (extension, flexion, pronation, supination)
- resisted at the elbow (extension, flexion, pronation, supination)
- resisted at the wrist (extension = tennis elbow; flexion = golfer's elbow)
117
Monteggia Fracture
combination of fracture of the proximal 1/3 of the ulna and radial head dislocation
118
Galeazzi Fracture
combination of radius fracture and distal ulna dislocation
119
What are the two indicators of a radial head fracture on a radiograph?
- fat pad sign
- radial head-shaft defect (angulation)
*extension deficit post-fracture
120
What are potential complications following fracture at the elbow?
- bony deformity
- vascular compromise
- nerve injury
- CT loss of motion
121
Supinator syndrome
sensation on the back of the wrist and hand is usually normal
122
What are the potential sites of entrapment of the radial n.?
1. fibrous band anterior to radial head
2. Recurrent vessels anterior to lateral epicondyle
3. Extensor carpi radialis brevis
4. Arcade of Frohse
5. arcade at distal edge of supinator
123
Clinical signs of supinator syndrome
- weak grip strength
- tenderness
- Tinel's sign
- AROM pain in wrist flexion and forearm supination
- PROM pain in elbow extension with wrist and finger flexion
- resisted supination with elbow extension
- middle finger test
- EMG/NCS findings
124
Treatment for supinator syndrome
- splint to limit wrist flexion
- improve mm. flexibility
- modalities
- rest
- anti-inflammatory medication
- work modification
- surgical release (rare)
125
What are the three clinical tests that can be used to diagnose pronator syndrome?
- resisted forearm pronation with elbow extended
- resisted elbow flexion with forearm supinated
- resisted middle finger
126
Clinical signs of pronator syndrome
- proximal forearm tenderness
- occasional numbness in median n. distribution into hand (esp. thumb)
- pain aggregated with repetitive motions
- thumb opposition and flexion weakness
- + Tinel's sign over pronator teres
127
Treatment for pronator syndrome
- rest
- activity modification
- injection
- modalities
- surgical release
128
Clinical signs and symptoms of cubital tunnel syndrome
- pain in medial proximal aspect of forearm
- numbness, tingling, and falling asleep during repetitive elbow motions
- less severe hand pain than with carpal tunnel syndrome
- weakness and loss of dexterity
- positive special tests: Tinel's sign, neurotension tests, elbow flexion test, pinch grip test, Wartenberg's sign
- intrinsic hand atrophy
- clawing of 4th and 5th digits
- positive EMG/NCV tests
129
Treatment for cubital tunnel syndrome
- work and sleep position modifications
- limit elbow flexion/compression activities
- NSAIDs
- iontophoresis; local steroid injection
- splinting
- neural mobilizations
- surgical intervention
130
Signs and symptoms of Volkmann's ischemic contracture
- excruciating pain with passive flexion and extension of fingers
- persistent pain unrelieved by position
- pallor
- parasthesia
- pulselessness
- paralysis
- muscle necrosis/nerve injury
131
Treatment for Volkmann's ischemic contracture
- relieve the cause
- fasciotomy (early)
- muscle tendon transfer (late)
- PT focuses on muscle "re-education"
132
What two fractures of the upper extremity often result in myositis ossificans?
supracondylar humeral fracture and posterior elbow dislocation
133
Signs and symptoms of myositis ossificans
- pain
- edema
- increased tissue temperature
- decreased AROM
- decreased PROM
- hard, palpable mass as pain decreases
- mass viewable on x-ray (3-6 wks)
- bone scan possible for earlier evidence
134
Treatment for myositis ossificans
- ice
- TENs
- pulsed ultrasound
- gentle motion
- surgical excision (later)
135
Treatment for myositis ossificans
- ice
- TENs
- pulsed ultrasound
- gentle motion
- surgical excision (later)
136
Treatment for lateral epicondylitis
- NSAIDs
- rest
- cortisone shot
- surgery
- rehabilitation
- autologous blood injection
- decrease pain (TENs, ice, iontophoresis, ultrasound?)
- dry needling
- isotonic exercises
- multi-angle isometrics
- isokinetics
137
What are the three sensory organization options?
- dermatomal
- brachial plexus (cutaneous distribution)
- autonomous distribution
138
Greater arc
fractures with or without ligamentous disruption
139
Lesser arc
ligamentous disruptions/dislocations
140
What joint(s) does flexion and extension of the wrist come from?
flexion: 60% from proximal carpal row; 40% from intercarpal row
extension: 40% from proximal carpal row; 40% from intercarpal row
141
Dinner-Fork deformity
2˚ to Colles' fracture; abrupt dorsal prominence; gently rounded volar prominence; broadened wrist radially deviated hand
142
Smith's Fracture
may r/in garden-spade deformity = dorsal prominence of distal end of proximal fragment, volar "fullness" secondary to displaced distal fragment, radial deviation of hand
143
What are the four types of scaphoid fracture?
- tuberosity:
- distal 1/3:
- middle 1/3: 80%
- proximal 1/3: 15%; most likely to r/in avascular necrosis
144
How long does it take scaphoid fractures to heal? Why?
approximately 6-12 mos because of the retrograde blood supply
145
What are the signs and symptoms of deQuervain's disease?
- insidious onset
- pain primarily with thumb movements (wringing and grasping)
- pain with resisted thumb extension and abduction
- neural symptoms d/t spread of stimulus
- pain with ulnar deviation of the wrist with the thumb fixed in flexion
- tenderness over tendon sheath in the region of the radial styloid process
- + Finkelstein's test
- "silken crepitus"; visual edema
146
Management of deQuervain's disease
- pain control; iontophoresis; ice
- rest; thumb spica splint
- ROM
- strengthening (eccentrics)
- functional progression
- work modification
147
What are the clinical signs and symptoms of Kienbock's disease?
- staged disease
- more prevalent in males
- occurs between 20-40 years of age
- associated with manual laborers
- wrist pain and stiffness
- decreased grip strength
- decreased wrist ROM
- MRI, x-ray, bone scan, tomogram
148
Management of Kienbock's disease (surgically)
- lunate excision
- implant arthroplasty
- immobilization
- wrist arthrodesis
- ulnar lengthening/radial shortening
149
Management of Kienbock's disease (PT)
- recovering from the effects of surgical management
- pain reduction
- motion acquisition
- strengthening
- functional progression
150
Clinical signs and symptoms of TFCC
- pain on forced ulnar deviation causing ulnar impaction
- + supination lift test
- grip dynamometry
- bone contusion demonstrable on MRI
151
What are the three basic functions of the volar plate?
- restrains joint hyperextension
- adds surface to base of proximal phalanx
- limits "pinching" of long flexor tendons
152
Clinical signs and symptoms of Gamekeeper's thumb
- weak, unstable thumb
- sensitive to weather changes
- + valgus stress test to thumb UCL
153
Dupuytren's contracture
shortening of the palmar aponeurosis resulting in flexion contracture at the MPs or PIPs; affects men > women; age 50-70 yoa.; increased incidence in epileptics, alcoholics, diabetics, tobacco users
begins in distal palmar crease; most commonly affects 4th and 5th digits; decreased ROM in MPs/PIPs
154
Management of Dupuytren's contracture
- surgical: "z plasty"
- series of collagenase injections
- wound and skin care
- edema control
- scar mobilization
- joint ROM
- strengthening
155
Acute Stage of CRPS
- increasing pain from an initial injury
- burning and aching pain
- edema
- early trophic changes
156
Dystrophic Stage of CRPS
- edema in duration
- increased dystrophy
- bony changes
- constant pain increased by ANY stimulus
157
Atrophic Stage of CRPS
- irreversible tissue damage
- bony demineralization or ankylosis
- tendency toward emotional instability
158
Clinical signs and symptoms of carpal tunnel syndrome
- numbness to median n. distribution
- nocturnal symptoms
- clumsiness and decreased hand dexterity
- weakness of thenar musculature
- + phalen's sign
- + tinel's sign
- + carpal compression test
- decreased 2-point discrimination
159
What are the stages of CTS?
1. Early: intermittent or position dependent sx.
2. Moderate: intermittent and progressive sx.; motor weakness; hyperalgesia; + special tests
3. Severe: persistent symptoms; muscle wasting; possible denervation of potentials in thenar muscles on electromyogram
160
What are the three ways to measure the position of the scapula using the scapular slide test?
1. hands at side; inferior angle to T7 spinous process
2. hands on hips
3. 90˚ ABD and IR
* Greater than 1.5-2 cm is clinically significant
161
What are the tests used to assess the capsule?
- sulcus = tests superior GH lig. and coracohumeral lig.
- load & shift = tests sup and middle portion of ant/post capsule
- apprehension (relocation if +) = tests ant capsule
- posterior drawer (Jerk test) = tests post capsule
162
What tests are used to asses the AC joint?
palpation, cross arm adduction, O'Brien's test, AP (acromioclavicular ligament) and horizontal (coracoclavicular ligements)
163
What tests are used to assess the labrum?
audible clunks, slides, compressions, O'Brien's test, biceps load II, etc.)
164
What are the components of the Frisch's 5-5 evaluation scheme?
1. Inspection
2. Function
3. Palpation
4. Neurological Exam
5. Special Tests
165
What are the five components of the inspection category from the Frisch's 5-5 evaluation scheme?
1. posture
2. shape (deformity, shape, swelling)
3. functional movements (gait, ADL activity)
4. skin
5. assistive devices
166
What are the five components of the function category from the Frisch's 5-5 evaluation scheme?
1. AROM (painful arc)
2. PROM (end-feel)
3. Resisted motion (Cyriax interpretation)
4. ROM with joint compression/gliding
5. Gliding (accessory motion)
167
What are the five components of the palpation category from the Frisch's 5-5 evaluation scheme?
1. skin and subcutaneous tissue
2. bony landmarks, joints, capsule, ligaments, etc.
3. muscle and tendons with attachments to bone
4. tendon sheaths and bursae
5. nerves and blood vessels
168
What are the five components of the neurological exam category from the Frisch's 5-5 evaluation scheme?
1. neurotension signs
2. motor exam (myotome)
3. sensory exam (dermatome)
4. reflexes (DTR/MSR)
5. coordination (CNS involvement)
169
What are the five components of the special tests category from the Frisch's 5-5 evaluation scheme?
1. imaging procedures
2. Electrodiagnosis
3. Laboratory tests
4. Punctures
5. Other medical specialties
170
Sensitivity
= true positives/ true positives + false negatives
171
Specificity
= true negatives/ true negatives + false positives
172
Positive Likelihood Ratio
= Sensitivity/ 1-Specificity
173
Negative Likelihood Ratio
= 1-Sensitivity/ Specificity
