Midterm 2 Flashcards
(114 cards)
1
Q
What 4 pairs of ranges of motion are relevant when assessing shoulder girdle injuries
A
- Flexion and extension
- Adduction and abduction
- Internal and External rotation
- Cross-flexion and Cross-extension
2
Q
AC Joint Sprain (seperated shoulder)
MOI, Muscular response, Role of gravity, Clinical presentation
A
MOI
- Direct blow to shoulder (on acromion process)
- FOOSH
MUSCULAR RESPONSE
- Increased activation of upper traps
- Decreased activation of rotator cuff
GRAVITY
- gravity acts to pull arm down, which is attached to scapula, but additional force on damaged ligaments
CLINICAL PRESENTATION
- Localized pain, bruising, swelling
3
Q
Rockwood Classifications
A
TYPE 1
- only damage to AC joint capsule and ligament
- CC still good
- won’t look deformed
TYPE 2
- AC joint capsule and ligament destroyed
- Damage to CC
TYPE 3
- Almost entirely, if not fully destroyed CC
- AC gone
- Could potential also have damaged to connecting fibers of anterior deltoid and upper/middle traps
OTHER TYPES RESULT IN SURGURY AND HAVE TO DO WITH DIRECTION OF DISPLACEMENT
4
Q
SC joint injury
A
- can range from sprain to sublux to dislocation
- similar MOI to AC joint sprain
5
Q
Clavicle Fractures
A
- commonly partnered with AC joint injury
- most common to occur in middle third (80%)
6
Q
What factors impact the likelihood of a fracture?
A
- low bone density
- small cross-sectional area
- at a point where shape is changing
7
Q
What important structures may be involved if a clavicle fracture occurs
A
- Lungs
- trachea
- esophagus
- Carotid artery
- brachial plexus
In general neurovascular structures
8
Q
Glenohumeral Dislocation MOI
A
- abduction 90+, cross extension, external rotation
- stretch GH ligaments
- most common to occur anteriorly where hummerus moves anterior and inferior
- can also be directly inferior or posterior
9
Q
Glenohumeral Dislocation Clinical Presentation
A
- Clear deformity in deltoid contour
- Subject will often want to grab arm
- significant difficulty moving (dead feeling)
10
Q
Continuum of instability (GHI)
A
range from sprain to subluxation to dislocation
SUBLUXATION
- feel a shift
- almost shift out of joint but not quite
DISLOCATION
- committed to leaving joint cavity
11
Q
What other structures should be considered with a GH dislocation
A
- GH ligaments
- Tendons of RC (mostly subscapularis)
- Axillary Nerve (if dislocation goes inferiorly)
- Bankart Lesions (Damage to posterior-inferior aspect of labrum)
- Hill-Sachs Lesion (Compression fracture to humeral head
12
Q
Bankart Lesions
A
- When dislocation occurs labrum is pulled with humeral head causing damage to the 6 to 9 O’clock region
- Occurs in up to 80% of first time dislocations (especially in young individuals)
13
Q
Hill-Sachs Lesion
A
When dislocation occurs, posto-lateral aspect of humeral head is compressed against glenoid when trying to pop back in
14
Q
Structures possibly damaged with AC joint sprain
A
- Deltoid attachment
- Upper traps attachment
- AC ligament
- AC joint capsule
- CC ligaments
- Brachial Plexus
15
Q
Which motions will hurt the least with an AC joint sprain
A
Internal and external rotation
16
Q
Which motions are most likely to produce pain with an AC joint sprain
A
- Sagittal Flexion (elevation of shoulder girdle)
- Cross- flexion (protraction)
- Cross- extension (Retraction)
- Abduction (elevation)
17
Q
Ranges of motion most likely to produce pain with anterior GH dislocation
A
- External rotation
- Cross-extension
- Abduction
Recreate MOI
18
Q
Paxino’s Sign test
A
Posteriorly translate clavicle and anteriorly translate the acromion to test the AC joint
19
Q
Clinical presentation of chronic shoulder condition
A
- Pain on edge of acromion, vague pain in deltoid region, pain in posterior scapula just below acromion process
- Aggravated by sport-specific training (often overhead sport)
- aggravated by ADL involving shoulder movement (reaching, overhead movement, sleeping positions)
20
Q
Impingement condtions
A
- Mechanism of chronic injury in the shoulder involving the pinching of tissues
- progressively leads to breakdown, tendinopathy and possibly bursitis
21
Q
Sub-acromial impingement (SAI) - What is it and where is it located
A
- Reduction in sub acromial space associated with overhead arm positions
- Space optimized when arm is down and decreased when arm is raised
- margins of this space marked by superior head of humerus, coracoacromial ligament and some of acromion
22
Q
What structures are most likely to be compromised within the subacromion
A
- Supraspinatus tendon ( anterior portion)
- Subacromial Bursa
- Tendon of the long head of the biceps
23
Q
What is a bursa
A
Little fluid sack filled that acts similar to a synovial membrane
24
Q
What are some mechanical factors that can cause SAI?
A
- Scapular Mechanics
- Not enough superior rotation of the scapula
- insufficient posterior tilt (responsible for getting the acromion out of the way of the humerus when lifting arm) - Excessive anterior translation of humerus (catches on anterior margin of subacromial sapce)
- Reduced acromio-humeral distance (based on individual differences)
25
Posterior Internal Impingement
- Pinching between posterior edge of glenoid rim and posterior aspect of humeral head
- Tissues get caught between the two i the vulnerable position
26
Possible structures involved in PII
Posterior and superior structures:
1. Supraspinatus
2. Infraspinatus
3. Labrum
27
Position leading to PII
90 degrees abduction and external rotation
28
MOI PII
When placed in vulnerable position of shoulder, posterior tissues get gathered and pinched by GH joint and then lifted/sucked in as joint humerus continues to rotate
29
Mechanics that may increase risk of IIP
1. Excessive Scapular protraction (must pull GH joint apart rather than move shoulder girdle)
2. Excessive Cross-extension (Also leads to pulling apart GH joint, not moving shoulder girdle)
3. Glenohumeral internal rotation deficiency (GIRD) (arch of movement shifted backwards)
30
What is the odds ratio for PII if GIRD > 10 degress
1.5
31
What range of motion is most likely to be painful with supraspinatus tendonopathy?
Active and resisted abduction
32
Which special test is used for supraspinatus tendinopathy?
Empty can and full can
33
What ROM is most likely to be painful with infraspinatus pathology
- Active and resisted external rotation
- Passive internal rotation
34
Where is the pain located of SAI
- Inferior and maybe anterior to acromial process
- Into deltoid region
- maybe posterior shoulder
35
What ROM would be painful for long head of biceps tendonopathy
- Active and resisted flexion of GH in sagittal plane
- Passive Extension
36
What special test is used to test the long head biceps tendon
Speed's test
37
What is the special test for SAI
Hawkin's Kennedy
38
What is the special test that will show labral tear
O'Brien and maybe Speed's
39
What is involved in the MOI of a posterior dislocation of the elbow
1. Axial loading (always)
2. Extended elbow
3. Valgus (not always but more common than varus)
40
Simple vs complex posterior elbow dislocation
Complex dislocation also involves some level of dislocation in the radius or ulna
41
Clinical presentation of Elbow dislocation
- Deformation
- Loss of ability to move
- Swelling/bruising
42
What is the actually movement that occurs when dislocating an elbow
Ulna moves posterior relative to humerus
43
What ligaments are associated with elbow dislocation
Most Likely: MCL complex (limits valgus)
Potentially:
- Anular ligament
- LCL complex
- Lateral ulnar collateral ligament
- Radial Collateral ligament
44
Other than ligaments, what other structures may get damaged in an elbow dislocation
Capsular sprain
Tendon damage
- Biceps
- Brachioradialis
-Pronator teres
- Wrist flexors
45
Valgus Extension Overload syndrome (VEOS or VEO)
- Common in overhead throwing athletes
- Chronic medial or posteromedial elbow pain
- Sensations: Locking or catching, crepitus
- Results in reduced throwing velocity
- pain primarily occurs at ball release
- Natural valgus with extension of elbow
46
MOI of VEOS
Overhead throwing with Valgus stress and tensile load
47
What other structures may become damaged with VEOS
- Wrist flexors or pronator teres
- Ulnar nerve, median nerve
48
At what 2 points does valgus elbow stress peak in throwing cycle
1. Late cocking phase: at point of peak external roation of GH - ball in hand
2. Acceleration phase: depends on elbow flexion angle at release - those who reach full extension in release are at higher risk
49
What 3 areas of the elbow are effected by VEOS
1. Stretching of the MCL complex
2. Pinching of olecranon process and its fossa
3. Compression of radio-humeral joint
50
What is Osteophyte (bone spur) development and where does it occur with VEOS
Margins of the bone become bumpy as pieces break off - occurs mostly on olecranon process
51
What is Chondromalacia and where does it occur with VEOS
Breakdown of cartilage (not breaking off, just sick) - mostly at radio-humeral head
52
What is Osteochondritis Dissecans
Breaking off of bone and Cartilage which floats around joint - occurs mostly at radio-humeral joint
53
Lateral Epicondylalgia
- Common in tennis players ( aggravated by backhand stroke and pain may spread into dorsal forearm
- Aggravated by tasks that require gripping
- can be brought on by changes in equipment
54
What muscle is associated with lateral epicondylalgia
Extensor Carpi Radialis brevis
- Origin: lateral epicondyle
- Insertion: base of the 3rd metacarpal
55
What changes occur to the tendon with tendinopathy
- Disrepair and progressive degeneration
- Increased CSA
- Decreased stiffness
- less competent with ECC
56
How can wrist position contribute to eccentric loading with lateral epicondylalgia
Extensors must fight wrist flexion when fingers are flexed and ulnar deviation
57
What 2 ROM tests are most likely to be painful if you have has a posterior elbow dislocation
Active and passive Extension
58
What 3 ROM tests are most likely to be painful if you have strained your distal biceps tendon
- A and R Flexion
- A and R Supination
- Passive elbow extension
59
If you experience neurological damage following an elbow dislocation, which nerve is most likely to be affected
Ulnar
- tingling and numbness on ulnar side into pinky
Median
- tingling and numbness on radial palmar side
- middle finger to thumb
60
What do VEOS and posterior elbow dislocation have in common
Damage to MCL complex
61
Which two active and resisted tests are most likely to be positive for an athlete with lateral epicondylalgia
wrist extension and radial deviation
62
Which passive test is most likely to be positive for an athlete with lateral epicondylalgia
Wrist flexion and ulnar deviation
63
How is a sports-related concussion classified
Mild traumatic brain injury
64
How long does it take SRC symptoms to present
May present immediately or evolve over minutes or hours, commonly resolve within days but may be prolonged
65
Clinical Presentation of concussion
1. Symptoms
- Physical, mental, emotional
2. Cognitive Deficits
- Orientation, memory and concentration
3. Motor Deficits
- Co-ordination and balance
66
Structural overview of the brain
- A tethered organ (via spinal cord)
- Texture like nearly ripe avocado
- In a shallow bath of about half a cup of CSF (same consistency as water)
- High H2O content (70 to 75% giving tissue squishiness)
- Grey soma on outside, white axons on insde
67
What are the 3 MOI of a SRC
External forces applied to body through different mechanisms transferring mechanical energy to brain
1. Moving object strikes head
2. Head strikes a stationary object
3. Head acceleration-deceleration without direct head contact
68
Cause of pathophysiology
Mechanical energy transferred onto brain causes angular acceleration around axis located in neck
- Causes grey matter to move with acceleration
- stretches white matter as it tries to follow grey matter
69
Pathophysiology through mechanoporation
Stretching of axons mechanically opens ion channels allowing ions to flow through and disrupt homeostasis - K+ out and Na+/Ca++ in
- Causes depolarization - facilitating communication between neurons and leading to an acute release of glutamate
- Na-K pumps require energy to restore ion balance leading to increased energy demand
70
Pathophysiology in the mitochondria
- Calcium gets in the way of mitochondrial function
- Blocks aerobic production of energy must switch to anaerobic (glycolysis) but lack of blood flow
71
Pathophysiology cerebral blood flow
Decreases with concussion, limiting delivery of glucose which is needed for anaerobic metabolism
72
What is the clinical and physiological time to recovery after concussion
Physiological imprint out lasts clinical symptoms
- Clinical symptoms on average 14 days
- Cerebral blood flow up to 30 days or even a year
73
Emergency Head trauma situations
- Includes skull fractures or intracranial hematomas
WHAT TO WATCH OUT FOR:
- Severe and worsening headache
- Vomiting
- Impaired pupil response
- Fluid Leaks and bruising (eyes and ears)
74
What is the relative risk of concussion for participants wearing interventional protective equipment compared with those that wore standard or no protective equipment
RR= 0.82 CI 0.56 to 1.2 with a p=0.30
75
What is the relative risk of superficial head injury in participants that wore interventional protective equipment relative to their counterparts?
RR= 0.41 CI 0.31 to 0.56 p<0.0001
- Helmet decrease impact but doesn't stop whipping head around
76
What is the average time until a concussion patient is symptom free in daily living
14 days
77
What is the average time until a concussion patient can return to sport
20 days
78
What drop is understudied in recovery periods of concussions and why is this significant
Para sport athletes
- Different MOI
79
Persistent post concussion symptoms (PPCS)
- Symptoms lasting beyond 4 weeks
- Occurs in up to 30% of children and adults (value drops with athletes - could be a result of under reporting)
80
What variables are thought to influence prognosis
- Severity: initial symptom burden
- Age: Children have longer recover times compared to adults
- Gender
- History of concussion
81
Acute testing of concussions
Using SCAT 6
- Useful for diagnosis, but not assessing recovery
- used by health care professionals
82
Assessing recovery of concussions
Test physiological and clinical presentation
- Cerebral blood flow
- Balance
- Coordination
- Functional capacity in daily living and sport
- Visual and cognitive improvements
83
RTS stages
- 6 stages
- Minimum 24 hours at each stage
- If symptoms worsen, return to previous stage
84
RTS Stage 1
Active Rest
- Occurs with symptoms present
- ADL activites like walking
- Shouldn't make symptoms worse
- 24- 48 hours post-injury
85
RTS Stage 2
Light Aerobic
- Up to 55% MHR, then 70% MHR
- Stationary bike (don't need balance)
- Walking
- Light resistance
86
RTS Stage 3
Sport-specific Exercise
- Done individually (lower risk)
- More Movement
- Running
- Drills/ running patterns/ direction changes (increase cognitive load)
87
RTS Stage 4
Non-Contact Drills
- Risk of physical contact is introduced
- Symptom-free and monitored closely
- Done with team
- High intensity
- More coordination
- Cognitive load
- Must get medical clearance to move to next step
88
RTS Stage 5
Full Contact Practice
- Requires medical clearance
- No symptoms and closely monitored
89
RTS Stage 6
Return to Competition
- Requires medical clearance
- No symptoms and closely monitored
90
Exercise as medicine
- Psychological and social benefits
- Physiological
- Normalize autonomic function (CBF or PNS/SNS balance)
91
Buffalo Concussion Treadmill Test
- Use VAS for baseline Symptoms
- Walk at 5 km/h with increasing incline (1 degree per min)
- Measure HR, RPE, VAS
- Determine when patient reaches threshold based on 90% of age predicted max HR, 17/20 RPE, 3 increase from baseline VAS
- HR at threshold is used to prescribe exercise regime
- 80% of threshold for 20 min 5 days a week for 2 weeks and then re-assess
92
What is HR variability
- Beat to beat variability in time and frequency
93
How does HRV change following concussion
- Decreases in HRV for 1 to 2 weeks
- Increase in SNS and decrease in PNS
- Causes symptoms of anxiety and difficulty sleeping
94
Spinal Cord Injury
- MOI: Compression, contusion, or distraction of spinal cord
- Can be complete or incomplete loss of motor and/or sensory function
- Level of injury determines where the deficits will lie - distal function impaired
95
What are common ways to sustain a spinal cord injury
- Axial load
- High velocity fall on pelvis
- ZA joint dislocation
- Spinal fracture
96
In what sports are cervical spinal cord injures most prominent
Hockey, Skiing, diving, football
- also prominent in horse-riding and snowboarding
97
What half of the spinal cord holds most motor information and which half holds most sensory information
- Ventral = motor
- Dorsal = Sensory
98
Cervical Cord Neuropraxia
- MOI: Cervical hyperflexion or hyperextension
- Mimics the signs and symptoms of cervical SCI, but transient in nature
- Reverses within minutes to 24-48 hours (could be up to 2 weeks tho)
- Sometimes called Spinal cord concussion cause it mimics the physiology and metabolic disfunction
99
Neurapraxia
- axon still fully intact
- Epineural protective layer been stressed but still connected
- Function able to return within max 2 weeks
100
Axonotmesis
- Axon broken - interrupts signal
- Epineural layer stressed but still intact
- Up to 3 months recover
101
Neurotmesis
Both axon and epineural layer broken
- 1 year + recover
102
Congenital Spinal Stenosis
- Narrowing of the vertebral foramen
- Determined by comparing the diameter of the spinal canal to vertebral body - normally 1:1 ratio
- Canal 80% of vertebral diameter with stenosis
- more likely stressed
103
What conditions are associated with congenital spinal stenosis?
- Cervical Cord Neuropraxia
- Brachial Plexus Neuropraxia
104
Brachial Plexus Neuropraxia
- MOI
1. Traction mechanism (pull apart)
2. Compression Mechanism (Nerve roots get compressed) - often associated with extension mechanism
3. Direct blow (to exposed plexus between Clavicle, sternocleidomastoid and upper trapezius)
- Burner/stinger sensation
- Most commonly effects C5 and C6
- Unilateral pain, paresthesia, numbness, weakness
- Decreased cervical ROM, with pain
- Most RTP under 24 hours
105
What is the range of spinal nerves involved in the brachial plexus
C5-T1
106
How to test Neurological Injuries
- Check sensory using dermatomes with sharp and dull objects
- Check motor using myotomes with resistance tests graded out of 5
107
Def: Dermatome
An area of skin that a specific spinal nerve collects sensory information from
108
Dermatomes C5 to T1
- C5: lateral side of elbow and upper arm
- C6: Finger 1 and 2, radial side of forearm
- C7: Finger 3
- C8: Fingers 4 and 5
- T1: Ulnar side of elbow and forearm
109
Def: Myotome
A joint action produced by a group of muscles that rely heavily on the motor messages traveling along that spinal nerve
110
Myotome Patterns C5 to T1
- C5: Elbow flexion
- C6: Wrist extension
- C7: Elbow extension
- C8: finger flexion
- T1: Finger abduction
111
Expected AC sprain recover timeline
4 weeks for every Rockwood type
112
Reoccurrence rates for Shoulder injury operative vs non-operative
6% for operative
47% for non-operative
113
Sling Support
- Up to 10 days or until comfortable without
- Recurrent instability, higher odds for some groups
- Sling duration may have little impact on recurrence
114
ER vs IR immobilization
RR risk ratio 0.56
In those aged 20 to 40 but not younger than 20 years
- 10 degrees?
