Musculoskeletal Disorders of the Upper Limb Flashcards
(163 cards)
1
Q
tests for anterior glenohumeral joint instability.
A
Anterior Apprehension and Relocation Tests
2
Q
patient is placed in the supine position. The examiner abducts the patient’s shoulder 90 degrees and flexes the elbow 90 degrees.
A
Anterior Apprehension and Relocation Tests
3
Q
patient is placed in the supine position. The examiner abducts the patient’s shoulder 90 degrees and flexes the elbow 90 degrees. The examiner uses one hand to slowly externally rotate the patient’s humerus using the patient’s forearm as the lever. At the same time, the examiner’s other hand is placed posterior to the patient’s proximal humerus and exerts an anteriorly directed force on the humeral head
A
Anterior Apprehension and Relocation Tests
4
Q
Anterior Apprehension and Relocation Tests
considered positive if
A
feeling of impending anterior dislocation
5
Q
from anterior apprehension test
the examiner removes the hand from behind the proximal humerus and places it over the anterior proximal humerus and then exerts a posteriorly directed force, and the patient subsequently reports a reduction in apprehension, this has occurred
A
positive relocation test has occurred
6
Q
test evaluates posterior glenohumeral joint stability.
A
Posterior Apprehension Test
7
Q
patient’s affected shoulder is forward flexed to 90 degrees and then maximally internally rotated. A posteriorly directed force is then placed on the patient’s elbow by the examine
A
Posterior Apprehension Test
8
Q
Posterior Apprehension Test
positive test
A
50% or greater posterior translation of the humeral head or a feeling of apprehension in the patien
9
Q
used to evaluate inferior glenohumeral joint instability
A
Sulcus Sign
10
Q
patient is seated or standing with the arm relaxed in shoulder adduction. The patient’s forearm is grasped by the examiner, and a distal traction force is placed through the patient’s arm.
A
Sulcus Sign
11
Q
In the presence of i rior instability
in sulcus sign
+ test is
A
sulcus will develop between the humeral head and the acromion
12
Q
evaluates for acromioclavicular (AC) joint and labral abnormalities
A
O’Brien Test
13
Q
The shoulder is flexed to 90 degrees with the elbow fully extended. The arm is then adducted 15 degrees, and the shoulder is internally rotated so that the patient’s thumb is pointing down. The examiner applies a downward force against the arm, which the patient is instructed to resist. The shoulder is then externally rotated so that the patient’s palm is facing up, and the examiner applies a downward force on the patient’s arm, which the patient is instructed to resist
A
O’Brien Test
14
Q
A positive test result is indi cated by pain during the first part of the maneuver with the patient’s thumb pointing down, which is then lessened or eliminated when the patient resists a downward force with the palm facing up
A
O’Brien Test1
15
Q
+ result obrient test
A
A positive test result is indi cated by pain during the first part of the maneuver with the patient’s thumb pointing down, which is then lessened or eliminated when the patient resists a downward force with the palm facing up
16
Q
Obrien test
Pain in the region of the AC joint indicates
A
AC pathology
17
Q
pain or painful clicking deep inside the shoulder suggests
A
labral pathology
18
Q
The shoulder is passively flexed to 90 degrees and then horizontally adducted across the chest.
A
Horizontal Adduction Test
19
Q
+ test
Horizontal Adduction Test
A
Pain located in the region of the AC joint- suggests AC joint pathology
posterior shoulder pain suggests posterior capsular tightness.
20
Q
test is for biceps tendonitis
A
Speed’s Test
21
Q
patient’s shoulder is forward flexed to 90 degrees with the elbow fully extended and the palm facing up. The examiner applies a downward force against the patient’s active resistance.
A
Speed’s Test
22
Q
+ pain
speed’s test means
A
Pain in the region of the bicipital groove suggests bicipital tendonitis
23
Q
With the patient’s arm at the side, the elbow is flexed to 90 degrees and the forearm is pronated. The patient then tries to simultaneously supinate the forearm and externally rotate the shoulder against the examiner’s resistance.
A
Yergason’s Test
24
Q
This test can provoke bicipital region pain in patients with bicipital tendonitis, and a painful “pop” in patients with bicipital tendon instability.
A
Yergason’s Test
25
patient’s shoulder is internally rotated while at the side. The examiner passively forward flexes the patient’s shoulder to 180 degrees while maintaining internal rotation. Pain in the subacromial area suggests rotator cuff tendonitis.
Neer-Walsh Impingement Test
26
The patient’s shoulder and elbow are each passively flexed to 90 degrees, respectively. The examiner then grasps the patient’s forearm, stabilizes the patient’s scapulothoracic joint, and uses the forearm as a lever arm to internally rotate the glenohumeral joint.
Hawkins-Kennedy Impingement Test
27
A positive test result is i cated by pain in the subacromial region occurring with the internal rotation.
Hawkins-Kennedy Impingement Test
28
The examiner passively abducts the patient’s shoulder 90 degrees. The patient is then asked to slowly lower the arm back to the side. A positive test result is indicated by pain and an inability to slowly lower the arm to the side, suggesting a rotator cuff tear.
Drop Arm Test
29
Shoulder special tests
```
Anterior Apprehension and Relocation Tests
Posterior Apprehension Test
Sulcus Sign
O’Brien Test
Horizontal Adduction Test
Speed’s Test
Yergason’s Test
Neer-Walsh Impingement Test
Hawkins-Kennedy Impingement Test
Drop Arm Test
```
30
patient is asked to fully extend the elbow, pronate the forearm, and make a fist. The examiner then resists the patient’s attempt to extend and radially deviate the wrist. Pain over the lateral epicondyle represents a positive test result and suggests the presence of lateral epicondylitis.
Cozen’s Test
31
examiner flexes the patient’s elbow 20 to 30 degrees and stabilizes the patient’s arm by placing a hand at the elbow and a hand on the distal forearm. Varus and valgus forces are placed across the elbow by the examiner to test the stability of the radial and ulnar collateral ligaments (UCL), respectively.
Ligamentous Instability Test
32
Wrist and Hand Special Tests
Finkelstein Test
| Watson Test
33
This test is used to detect tenosynovitis of the extensor pollicis brevis and abductor pollicis longus tendons (de Quervain’s tenosynovitis).
Finkelstein Test
34
The patient makes a fist with the thumb inside the fingers, and the examiner passively deviates the wrist in an ulnar direction
Finkelstein Test
35
test assesses scapholunate stability.
Watson Test
36
The patient’s wrist begins in an ulnarly deviated position. The examiner places a dorsally directed force against the proximal volar pole of the scaphoid. The examiner then radially deviates the wrist while continuing to place the same force against the scaphoid. A “pop” or subluxation of the scaphoid indicates a positive test result.
Watson Test
37
stage of rehabilitation focuses on reducing the patient’s symptoms and facilitating tissue healing. In specific circumstances, immobilization through splinting or casting might be used
acute stage of rehabilitation
38
core strengthening and aerobic conditioning should be emphasized during this phase of rehabilitation
acute stage of rehabilitation
39
Kinetic chain deficits should be identified and treated during the
acute r bilitation stage.
40
can be used for acute injuries to decrease pain, inflammation, muscle guarding, edema, and local blood flow
cryotherapy
41
increases blood flow, reduces muscle “spasm,” reduces pain, and can be used in the acute phase of rehabilitation for chronic injuries.
Heat
42
often used during the acute phase of rehabilitation to reduce muscle guarding and increase local circulation.
High-frequency electrical stimulation
43
might be required for pain control during the acute phase of rehabilitation.
Opioid and nonopioid analgesics
44
Randomized, placebo-controlled trials have demonstrated reduced pain, edema, and tenderness, and a faster return to activity in
NSAID-treated athletes
45
can cause significant gastrointestinal, renal, c vascular, hematologic, dermatologic, and neurologic side effects
Nonsteroidal antiinflammatory drugs (NSAIDs)
46
NSAIDs should be used only if
if local physical modalities and less toxic medications such as acetaminophen are not effective.
47
for pain control and reduction of inflammation during the acute phase of rehabilitation
Oral and injected corticosteroids
48
side effects include suppression of the hypothalamic–pituitary–adrenal axis, osteoporosis, avascular necrosis, infection, and tendon or ligament rupture.
Oral and injected corticosteroids h
49
when the pain has been adequately controlled and tissue healing has occurred
patient can advance to the recovery phase of r bilitation
50
recovery phase of rehabilitation indicated by
full pain-free ROM and the ability to participate in strengthening exercises for the injured limb
51
emphasis of the recovery phase of rehabilitation involves the
restoration of flexibility, strength, and proprioception in the injured limb.
52
should be corrected in recovery phase of rehabilitation
Strength and flexibility imbalances and m tive movement patterns and muscle substitutions
53
can be beneficial when correcting strength imbalances
Open kinetic chain exercises
54
are frequently used to provide joint stabilization through muscle co-contraction
closed chain exercise
55
Sternoclavicular joint dislocations account for less than % of all joint dislocations
1%
56
Two thirds of s lar joint dislocations occur
anteriorly
57
Two thirds of s lar joint dislocations occur anteriorly, whereas one third of dislocations occur
posteriorly
58
can cause the medial end of the clavicle to become more prominent
Anterior sternoclavicular joint injuries
59
typically have more pain with a less prominent medial clavicular end.
posterior joint injuries
60
can also be associated with vascular compromise to the ipsilateral upper limb, neck and upper limb venous congestion, difficulty breathing, or difficulty swallowing. Sternoclavicular joint dislocations
Posterior dislocations
61
Ligament injuries are commonly graded on a scale of
1 to 3
62
The presence of tenderness at the sternoclavicular joint without subluxation or dislocation indicates a
grade 1 injury
63
tenderness with subluxation
| at the sternoclavicular joint
grade 2 injury
64
tenderness with associated dislocation
at the sternoclavicular joint
indicates
grade 3 injury
65
radiologic evaluation of sternoclavicular joint i ries includes an
anteroposterior radiograph of the chest or sternoclavicular joint and a serendipity view, which involves a 40-degree cephalic tilt view of the sternoclavicular joints
66
frequently used for definitive evaluation of sternoclavicular joint injuries.
computed t phy (CT) scan
67
treatment of grade 1 and 2 injuries
| sternoclavicular joint
nonoperative
| Sling immobilization
68
grade 1 and 2 injuries
Activity can progress as tolerated with an anticipated return to activity after
activity after 1 to 2 weeks for a grade 1 injury and 4 to 6 weeks for a grade 2 injury.
69
Grade 3 sternoclavicular joint sprains frequently can be treated
nonoperatively
| unstable postreduction - surgical intervention
70
Because c tions frequently arise with grade 3 posterior dislocations, a thorough evaluation to rule out
pulmonary or vascular damage should be undertaken
71
If mediastinal compression is present, posterior grade 3 dislocations require
immediate surgical intervention
72
Because of the significant risk of vascular complications, posterior sternoclavicular joint dislocations should be reduced in the
hospital setting with a vascular surgeon present.
73
A majority of clavicular fractures occur in childhood and adults less than
25 years of age
74
Eighty percent of clavicular fractures occur in the
middle third of the clavicle
75
clavicular fractures
| 15% occur in the
lateral one third
76
clavicular fractures
| 5%
medial one third
77
Most clavicular fractures occur as a result of a
blow to the point of the shoulder, but a small percentage occur from a fall onto an outstretched arm
78
Clavicle Fractures
| important to rule out
associated neurovascular and pulmonary injuries
79
type of radiograph
| usually adequate for visualization of clavicular middle third fractures
Routine anteroposterior radiographs
80
type of radiograph used for proximal third fractures
serendipity view + Routine anteroposterior radiographs
81
When a lateral third fracture is suspected
radiograph
15-degree cephalic tilt anteroposterior view centered on the AC joint using a soft tissue technique (Zanca view) and an axillary lateral view are usually diagnostic when combined with anteroposterior radiographs
82
clavicular fractures
| what imaging if more definitive evaluation is required
CT scanning
83
If the clavicular fracture has good alignment
| treatment of choice
partial immobilization is the treatment of choice using an immobilization device such as a sling or figure-of-eight bandage
84
If 15 to 20 mm of shortening occurs as a result of displacement (clavicular fracture)
tx
surgical intervention should be considered
85
Other common indications for surgical intervention
| clavicular fractures
15 to 20 mm of shortening occurs as a result of displacement
displaced fractures with tissue interposition between the fracture ends, open fractures, neurovascular compromise, tenting of the skin over the fracture site that might lead to tissue necrosis, and displaced fractures located in the lateral third of the clavicle.
86
account for only 9% of all shoulder i ries, are most frequent in males in their third decade of life
AC joint sprains
87
AC joint sprains
| Most injuries occur as a result of
direct trauma from a fall or blow to the acromion
88
point tenderness, a positive horizontal adduction test, and a positive O’Brien test.
AC joint sprains
89
Positive test: pain and inability to slowly lower the arm to the side
•Suggesting a rotator cuff tear
The examiner passively abducts the patient’s shoulder 90 degrees. The patient is then asked to slowly lower the arm back to the side.
Drop Arm Test
90
arus and valgus forces test the stability of the radial and ulnar collateral ligaments (UCL)
Ligamentous Instability Test
91
The examiner flexes the patient’s elbow 20 to 30 degrees and stabilizes the patient’s arm by placing a hand at the
•elbow and a hand on the distal forearm.
•Varus and valgus forces are placed across the elbow by the examiner to test the stability of the radial and ulnar collateral ligaments
•(UCL), respectively.
Ligamentous Instability Test
92
•Distal segment is fixed or stabilized relative to proximal segment
Closed Kinetic Chain exercises
93
•Distal segment is mobile and not fixed
Open Kinetic Chain exercises
94
injured limb has regained 75% to 80% of normal strength compared with the uninjured limb
•no strength and flexibility imbalances
•address maladaptive movement patterns and muscle substitutions
•full strength should be obtained
Functional stage
95
rockwood classification
ac joint sprain
96
sprains involve a mild injury to the AC ligaments, and radiologic evaluation is normal
Type 1
97
injuries involve the complete disruption of the AC ligaments but with intact coracoclavicular ligaments
type 2
| Radiographs might demonstrate clavicular elevation relative to the acromion but less than 25% displacement
98
sprains result in the complete disruption of the AC and coracoclavicular ligaments, but the deltotrapezial fascia
•remains intact. Radiographs reveal a 25% to 100% increase in the coracoclavicular interspace relative to the normal
Type 3
99
sprains involve complete disruption of the coracoclavicular and AC ligaments, with posterior displacement
•of the distal clavicle into the trapezius muscle
type 4
100
coracoclavicular and AC ligaments are fully disrupted along with a rupture of the deltotrapezial
•fascia. This results in an increase in the coracoclavicular interspace to to greater than 100% of the normal shoulder.
type 5
101
sprains involve complete disruption of the coracoclavicular and AC ligaments, as well as the deltotrapezial
•muscular attachments, with displacement of the distal clavicle below the acromion or the coracoid process.
type 6
102
Type 1, 2, and 3 AC joint sprains are usually treated
non-operatively
| •A brief period of sling immobilization might be required for pain control
103
Indications for surgical intervention for type 3 sprain
| AC
* persistent pain
| * unsatisfactory cosmetic results
104
Type 4, 5, or 6 sprains
AC
require surgical treatment
105
snapping scapula or scapular crepitus
| •The three primary types of sound:
gentle friction sound
loud grating sound
loud snapping
106
scapula sound
| physiologic
gentle friction sound
107
```
scapula
sound
•Causes:
•suggests soft tissue disease
•bursitis
•fibrotic muscle
•muscular atrophy
•anomalous muscular insertion
excessive thoracic kyphosis
•thoracic scoliosis
•scapulothoracic dyskinesis
•scapular winging
```
Loud grating sound
108
```
sound, scapule
caused by bony pathology such:
•osteophyte
•a rib or scapular osteochondroma
•hooked superomedial angle of the scapula
•malunion of rib fractures
```
Loud snapping
109
Injuries to the rotator cuff
| causes
repetitive microtrauma and outlet impingement between the acromion and greater tuberosity of the humerus
110
category rotator cuff injury
neer
| bigliani
111
rotator cuff injury
| inflammation and edema
stage 1
112
RC injury
| fibrosis and tendonitis
stage 2
113
partial or complete rotator cuff tear occurred
stage 3
114
found a relationship between the acromial shape and the presence of rotator cuff tears
Bigliani
115
acromions into three types
| flat
type 1
116
acromions into three types
| curve
type 2
117
acromions into three types
| hook
type 3
118
shape acromion inc incidence
progress type 1-> 3
119
rotator cuff tear
| acute rehabilitation stage
Strengthening exercises for the scapular stabilizing muscles rather than the rotator cuff should be emphasized in the acute rehabilitation stage
•Specifically, strengthening muscles that retract and depress the scapula (e.g., serratus anterior and inferior trapezius)
•Stretching muscles that protract and elevate the scapula (e.g., pectoralis minor and upper trapezius
120
Characterized by painful, restricted shoulder ROM in patients with normal radiographs
•occurs in 2% to 5% of the general population
•2 to 4 times more common in women than men
•Most frequently seen in individuals between 40 and 60 years of age
Adhesive capsulitis
121
Adhesive capsulitis
| etiology
```
idiopathic condition but can be associated with
•Diabetes mellitus
•Inflammatory arthritis
•Trauma
•Prolonged immobilization
•Thyroid disease
•Cerebrovascular accident
•Myocardial infarction
•Autoimmune disease
```
122
occurs for the first 1 to 3 months and involves pain with shoulder movements but no significant
•glenohumeral joint ROM restriction when examined under anesthesia
Stage 1
123
“freezing stage,” symptoms have been present for 3 to 9 months and are characterized by pain
•with shoulder motion and progressive glenohumeral joint ROM restriction in forward flexion,
•abduction, and internal and external rotation.
stage 2
124
or the “frozen stage,” symptoms have been present for 9 to 15 months and include a
•significant reduction in pain but maintenance of the restricted glenohumeral joint ROM
stage 3
125
stage 1,2 adhesive capsulitis
| tx
physical modalities, analgesics, and activity modification to reduce pain and inflammation
•Up to three intraarticular corticosteroid injections can be used during stages 1 and 2 of adhesive capsulitis to reduce inflammation and pain, facilitate rehabilitation, and shorten the duration of this condition
126
common tendinopathy of the lateral elbow and is frequently referred to as tennis elbow
•more common in patients more than 35 years of age and peaks in those between 40 and 50 years old
•It is more common in male than in female tennis players
LATERAL EPICONDYLITIS
127
pathologic changes are not inflammatory but rather degenerative
•A more appropriate term for this condition is lateral epicondylosis rather than epicondylitis
•The degenerative changes occur most commonly in the origin of the extensor carpi radialis brevis but also involve the extensor digitorum communis origin
lateral epicondylitis
128
The backhand swing in tennis frequently exacerbates the symptoms and also gripping and activities that require repetitive wrist extension and forearm pronation and supination
•Physical examination can reveal point tenderness over the lateral epicondyle and a positive Cozen’s test
LATERAL EPICONDYLITIS
129
Lateral epicondylitis tx
discontinuation of provocative activities
•oral analgesics
•physical modalities
•Orthosis
•lateral counter-force strap or neutral wrist splint
•eccentric strengthening of the wrist extensors appears to be the most effective exercise regimen
130
stenosing tenosynovitis
•Shear and repetitive microtrauma in the first dorsal compartment of the wrist
•contains the abductor pollicis longus and extensor pollicis brevis tendons
•most common tendonitis of the wrist
•most frequently seen in patients who perform activities requiring forceful gripping with ulnar deviation of the wrist or repetitive use of the thumb
De Quervain’s Syndrome
131
is performed by placing the patient’s elbow in extension, with the forearm in neutral rotation and the
•wrist in radial deviation.
•The patient should be asked to place the thumb in the palm and grip the thumb with the fingers.
•The examiner should then passively bring the wrist into ulnar deviation.
Finkelstein’s
132
tx de quervain
* Rest
* Modalities
* Analgesics
* thumb spica splint
* corticosteroid injection
133
Approximately 6% of all fractures involve the carpal bones
| •70% of carpal fractures involve th
scaphoid
134
primary restraint to excessive wrist extension and is therefore prone to injury
scaphoid
135
The scaphoid receives its blood supply from a branch of the
radial artery that enters the scaphoid through its distal pole
136
Consequently, proximal or middle third fractures of the scaphoid are prone to
to avascular necrosis and nonunion as a result of a disruption in the blood supply
137
* For non-displaced middle and proximal third fractures
| * first 6 weeks
immobilization with a long arm–thumb spica cast
| •switched to a short arm–thumb spica cast after 6 weeks for 12 to 20 weeks depending on radiographic union
138
Fracture occurs in the distal third of the scaphoid
Immobilization with short arm–thumb spica cast for 10 and 12 weeks
139
scaphoid fracture
| Radiographs should be repeated every
2 to 3 weeks until radiographic union is documented
140
most frequently fractured area of the body
| •MOI: falling on an extended wrist
Distal Radial Fractures
141
fracture called the Colles fracture
Frykman type 1 fracture
142
extraarticular fractures
distal radial
frykman
types 1 and 2
143
intraarticular fractures involving the radiocarpal joint
distal radial
frykman
types 3 and 4
144
intraarticular fractures involving the radioulnar joint
types 5 and 6
145
intraarticular fractures that involve both the radioulnar and radiocarpal joints
types 7 and 8
146
Minimally displaced Frykman type 1 or 2 fractures can be managed with
closed reduction and immobilization with a double sugar-tong splint
147
Frykman type 3 fractures or higher should be
referred to an orthopedist for management
148
rupture of the central slip of the extensor tendon at the base of the middle phalanx that results in a boutonnière injury
Extensor Tendon Central Slip Disruption
149
characterized by the inability to actively extend the proximal interphalangeal (PIP) joint
Boutonnière injury
150
This deformity can occur in patients with uncontrolled rheumatoid arthritis
Boutonnière injury
151
Boutonnière injury
| tx
within approximately 6 weeks
•continuous extension splinting of the PIP joint for 5 to 6 weeks
educate the patient
•a single episode of PIP joint flexion can prevent successful treatment
•compliance is critical
152
If the patient is not able to regain significant PIP joint extension ROM
surgical intervention to repair the extensor mechanism can be warranted
153
Disruption of the distal extensor tendon at its insertion on the dorsal proximal aspect of the distal phalanx
•caused by a tendon rupture or an avulsion fracture of the dorsal proximal distal phalanx
•(+) DIP joint pain and the inability to extend the DIP joint
Mallet finger
154
DIP joint in a flexed position that the patient is unable to extend actively
Mallet finger
155
mallet finger
| tx
treatment is usually nonoperative:
•splinting the DIP joint in extension 24 hr/ day for 6 to 8 weeks:
•Dorsal padded aluminum splint
• Volar aluminum splint without a pad
•Stack splint
never allowing DIP flexion during this period because any flexion can prevent adequate healing and predispose to a permanent extension lag
156
mallet finger
| large avulsion
surgical intervention can be required
157
occurs with vigorous gripping activities
•“jersey finger”
•flexor digitorum tendon to the ring finger has a lower breaking strength than the other FDP tendons
•Sudden severe pain, frequently associated with a “pop”
Flexor Digitorum Profundus Rupture
| •Distal disruption of the flexor digitorum profundus (FDP) tendon
158
The patient will subsequently be unable to actively flex the affected DIP joint.
Flexor Digitorum Profundus Rupture
| •Distal disruption of the flexor digitorum profundus (FDP) tendon
159
Flexor Digitorum Profundus Rupture
•Distal disruption of the flexor digitorum profundus (FDP) tendon
tx
surgical
tendon has retracted to the palm
•repair should be performed within 7 to 10 days
•If the tendon does not retract below the PIP joint
•repair can be performed within 6 to 8 weeks of the injury
160
is the most frequently dislocated joint in the hand
PIP joint
161
Associated injuries include
•radial and UCL sprains, central slip injuries, partial volar plate injuries, and fracture
•usually presents with deformity, pain, ecchymosis, and edema
•Physical examination
•reveals tenderness to palpation over the injured structures
Proximal Interphalangeal Joint Dislocations
162
Proximal Interphalangeal Joint Dislocations tx
45-degree extension block splint of the PIP joint
| •angle can be reduced by 10 degrees each week with a return to full extension in the fifth week
163
Surgical indications for PIP joint injuries
radiologic or gross instability after reduction
•fractures involving greater than 50% of the articular surface
•inability to reduce the dislocation
•pilon fractures
