Test 2 Flashcards
(104 cards)
1
Q
1st Dorsal Compartment
Nerve
Muscle
Significance
A
Nerve: Posterior Interosseous (from radial nerve)
Muscle: Abductor Pollicis Longus and Extensor Pollicis Brevis (lower tendons of the snuff box)
Dequervain’s Syndrome
2
Q
Treat Dequervain’s Syndrome
A
- iontophoresis with antiinflammatory, photophoresis with antiinflammatory bu ultrasound, ice, parafin
- thumb spica splint (even include IP so they dont write)
-after surgery can do friction massage to stop it from getting bound down and to desensitize the incision –important to exercise so it doenst get bound down
3
Q
2nd Dorsal Compartment
Nerve
Muscle
Significance
A
Nerve: Radial Nerve
Muscle: ECRL, ECRB
Significance:
ECRB is stronger: it attaches to base of 3rd metacarpal so it is on the midline of the hand-mechanical advantage (dont take it off in surgery)
*ECRL attach to base of 2nd metacarpal
4
Q
Which is stronger:
ECRB ECRL
A
ECRB is stronger: it attaches to base of 3rd metacarpal so it is on the midline of the hand-mechanical advantage (dont take it off in surgery)
*ECRL attach to base of 2nd metacarpal
5
Q
3rd Dorsal Compartment
Nerve
Muscle
Significance
A
Nerve: Posterior Interosseous (radial)
Muscle: EPL (top of snuff box)
Significance: at listers tubercle it makes a 45 degree angle and then goes to the IP joint of the thumb
6
Q
Which muscle makes a 45 degree angle at listers tubercle?
A
EPL, then it goes to the IP of the thumb
7
Q
4th Dorsal Compartment
Nerve
Muscle
Significance
A
Nerve: Posterior Interosseous
Muscle: Extensor Digitorum
Significance:
- Only one muscle belly : can use to our advantage in rehab
- NO OTHER MUSCLE EXTENDS MCP
- shroud fibers attacked in RA so ED doesnt stay centralized and get ulnar deviation
8
Q
Which many tendon muscle has one muscle belly that we can use to our advantage in rehab?
A
ED
9
Q
Which muscles extend the MCPs?
A
ED ONLY due to shroud fibers
10
Q
Why is there ulnar deviation in the fingers in RA?
A
cannot extend the MCP and instead ulnar deviated because the disease attacks the shroud fibers which causes the ED tendon not to be centralized and get ulnar deviation
11
Q
5th Dorsal Compartment
Nerve
Muscle
Significance
A
Nerve: Radial Nerve
Muscle: Extensor Digiti Minimi
significance:
1. extends and abducts the pinky
inserts into the base of the 5th proximal phalanx
ALLOWS GRASP OF LARGE OBJECTS
- Abductor Digiti Minimi is ulnar nerve backup system
12
Q
how to measure girth
A
measure of girth between tip of pinky and pulp of thumb
13
Q
Backup system 5th finger
A
Ulnar Nerve: Abductor Digti Minimi
Radial Nerve: Extensor Digiti Minimi
THEY BOTH ABDUCT THE PINKY
14
Q
6th Dorsal Compartment
Nerve
Muscle
Significance
A
Nerve: Posterior Interosseous
Muscle: Extensor Carpi Ulnaris
2 large heads
15
Q
Which dorsal compartments have radial innervation?
A
2nd and 5th
ECRL and ECRB
Extensor Digiti Minimi
16
Q
Which Dorsal Compartments have posterior interosseous innervation?
A
1, 3, 4, 6
AbPL, EPB
EPL
ED
ECU
17
Q
Swan Neck Deformity Splint
A
hyperextension at PIP because RA or collatereal ligament issues
can use in a volar plate injury
18
Q
What are the Extrinsic wrist flexors? (3)
A
Median Nerve
- Flexor Carpi Radialis: inserts into the third metacarpal at the midline of the hand (direct antagonist to the ECRB)
- Flexor Carpi Ulnaris
- Palmaris Longus: inserts into the palmar fascia (missing in 15% of ppl, used for transplants)
19
Q
What is the antagonist of the FCR?
A
ECRB
20
Q
What is the antagonist of the FCU?
A
actually it is a synergist with ___ ULNAR DEVIATION
21
Q
What is the synergist of the FCU?
A
ECU for ulnar deviation
22
Q
FDP
A
2 Nerves:
- anterior interosseous nerve (Median)
- ulnar nerve
1 muscle belly : mass action muscle 1 belly divides into 4 tendons (can work other tendons to prevent atrophy, but hard to clinically diagnose)
this muscle belly can get into the carpal tunnel and cause carpal tunnel syndrome
23
Q
Deep group: finger flexors (2)
A
- Flexor Digitorum Profundus (dual innervation: anterior interosseous of the median nerve and the ulnar nerve)
- Flexor Pollicis Longus (it is stronger than the EPL)
24
Q
Flexor Pollicis Longus
A
Median Nerve
Deep finger flexor
need for pinch and opposition
stronger than the EPL because more on the middle of the bone so more mechanical advantage
25
What is stronger EPL or FPL?
FPL stronger than the EPL because more on the middle of the bone so more mechanical advantage
FPL is median nerve
EPL is Posterior Interosseous (radial)
26
Finger Flexors: Superficial Group:
Flexor Digitorum Superficialis
* FOUR DIFFERENT MUSCLE BELLIES--in treating the FDS need to treat the specific muscle belly
- clinically can bend one and not the others in diagnosis to see what is ruptured
-median nerve
27
Flexor Digitorum Superficialis
median nerve
4 distinct muscle bellies
- in treating the FDS need to treat the specific muscle belly
- clinically can bend one and not the others in diagnosis to see what is ruptured
**after carpal tunnel surgery need to mobilize so it doesnt get bound down
(palpation: claw and feel radial to FCU and under the palmaris longus)
28
Vinicula Longus and Viniculum Brevis
blood supply to the tendons of FDP and FDS
come off digital artery of the finger
after a flexor tendon repair it pops because of loss of blood supply and now they repair the digital artery and get the vanicula longa and brevis which supply blood to the tendons
29
Kleiner's Traction
what is it, when is it used,
need to be able to follow instructions
for flexor tendon injury: ie after cut bagel
--suture through fatty part of finger and hook onto rubberband
--24/7: Dorsal Hood Splint on dorsal forarem pull MCP into 90 degrees of flexion and doesnt allow full extension so as not to stretch the new repair tendon
need to exercise with it
--they extend PIP so volar plate not get stuck (it is tight in extension)--collaterals would be fine because they are taut in all positions
actively make a fist at 3.5 weeks
full excursion open up to see if PIP can get straight at 5 weeks
30
Volar Plate Vs Collaterals
MCP collateral: oblique: tight in flexion, loose in extension (this is why splint needs to be before palmar crease so we can stretch it)
PIP and DIP collaterals: true collaterals are always taut
Volar Plate: prevent hyperextension at MCP, PIP, and DIP but allows most motion at MCP since it attaches to soft tissue fascia there
31
PT protocol with Kleiners traction
--24/7: Dorsal Hood Splint on dorsal forarem pull MCP into 90 degrees of flexion and doesnt allow full extension so as not to stretch the new repair tendon
need to exercise with it
--they extend PIP so volar plate not get stuck (it is tight in extension)--collaterals would be fine because they are taut in all positions
actively make a fist at 3.5 weeks
full excursion open up to see if PIP can get straight at 5 weeks
32
Pulley System
--what is A, what is C: which is most important
A = Annular: straight across
Most important = A2: base of proximal phalanx
---if tear A2 wont be able to have strength in tight excursion especially if ring finger or pinky (power fingers)
A4: middle of middle phalanx
need A2 and A4 for a good fist
C = Cruciate: criss cross: dont necessarily do a surgery if cut
33
A2
A = Annular: straight across
Most important = A2: base of proximal phalanx
---if tear A2 wont be able to have strength in tight excursion especially if ring finger or pinky
ring finger and pinky are the power fingers
34
Why we need A2 and A4
need A2 and A4 for a good fist : holds flexor tendon to the bone
Most important = A2: base of proximal phalanx
A4: middle of middle phalanx
35
Annular vs Cruciate
annular goes straight across so it is more important than the cruciates that criss cross
36
Swan Neck Deformity
HYPEREXTENSION PIP
1) RA: ED falls into the gully because attack shroud fibers
2) FDS tendon is cut and ED pulls too hard into extension causing ricavatum or hyperextension of PIP
(ED and FDS are antagonists, so if FDS is cut, ED pulls into hyperextension)
37
What is cut to cause Swan Neck deformity
FDS
FDS tendon is cut and ED pulls too hard into extension causing ricavatum or hyperextension of PIP
(ED and FDS are antagonists, so if FDS is cut, ED pulls into hyperextension)
38
Thenar Eminance
Positioning Muscles (3)
Median Nerve
1. Opponins Pollicis
2. Abductor Pollicis Brevis
3. Superficial head of Flexor Pollicis Brevis
39
Thenar Eminance
Power Muscles (3)
Ulnar Nerve
1. Deep head of Flexor Pollicis Brevis
2. Adductor Pollicis
3. 1st Dorsal Interossei
40
Opponins Pollicis
Role in thumb
Power vs positioner
Positioner, median nerve
41
Abductor Pollicis Brevis
Role in thumb
Power vs positioner
Positioner, median nerve
42
Superficial head of Flexor Pollicis Brevis
Role in thumb
Power vs positioner
Positioner, median nerve
43
Deep Head of Flexor Pollicis brevis
Role in thumb
Power vs positioner
Power muscle, ulnar nerve
44
Adductor Pollicis
Role in thumb
Power vs positioner
Power muscle, Ulnar nerve
45
1st Dorsal Interossei
Role in thumb
Power vs positioner
Power Muscle, ulnar Nerve
46
Hyperthernar eminance
name the 5 muscles
1. Opponins pollicis
2. Abductor pollicis brevis
3. superficial head of FPB, deep head of FPB
4. adductor pollicis
5. 1st dorsal interossei
47
Hypothenar Eminance
name the muscles
1. aBductor digiti minimu
2. flexor digiti minimi
3. opponins digiti minimi
3. palmaris brevis
48
Palmaris Brevis
hyOthenar eminance (ulnar nerve)
this cups our hand, backup system for opponins pollicis (median nerve)
49
Dorsal Inerossei vs Palmar Interossei
DAB: there are 4 dorsal interossei: ABDUCT
PAD: there are 3 palmar interossei: ADDUCT
ULNAR NERVE
Pathway:
AT MCP: palmar
AT PIP: dorsal
At DIP: dorsal
50
Interossei Pathway
Pathway:
AT MCP: palmar: flexion at MCP
AT PIP: dorsal: Extension at PIP
At DIP: dorsal: Extension at DIP
51
Lumbricals
no bony attachment: attaches to tendon of the FDP
AT MCP: palmar: flexion at MCP
joins the interossei at the LATERAL BANDS
AT PIP: dorsal: Extension at PIP
At DIP: dorsal: Extension at DIP
52
What muscle pulls on the lumbricals, what happens when this happens?
When the FDP pulls on the lumbricals it flexes the MCP and extends the PIP and extends the DIP
53
Why are the lumbricals special?
the attach to tendons and not bone
FDP
then at PIP attach to lateral slips then at DIP attach into the insertion
54
The patient lacks full finger flexion
what is tight?
three things we must test
1. Extensor Digitorum Tightness: passively flex the MCP then passively flex PIP: positive is pain on total stretch
Now to be sure we extend MCP and flex PIP to put the ED on slack: if PIP can now flex then we RULE IN THE ED
2. Interossei: extend at MCP to put interossei on stretch and flex DIP and PIP (claw) to stretch the interossei fully, and if cant then it is tight intrinsics
3. MAKE A FIST
Interossei: since the lumbricals attach to the FDP: if you flex the MCP and make a fist now, the FDP will cause a change in the orientation of the lumbrical: do if you are tight it is interossei
Lumbricals: if the tightness is at 45 degrees of MCP flexion it is lumbricals
ED: if the tightness is all the way down into flexion it is ED
55
what is the most mobile unit in the hand?
most to less most
1. THUMB is most mobile
2. 2nd and 3rd prox/middle/distal phalanx
3. 4th and 5th metacarpal
56
Fingers: what is stronger, flexion or extension?
flexors are 40% stronger
57
Dynometer grip strength dominant vs nondominant hand
we expect the dominant hand to be able to be 10 units stronger
measure in pounds per square inch
expect dominant hand to be ten pounds stronger and that is how we can set our goal
58
Pinch Strength
dominant hand is 2 pounds stronger than the nondominant hand
ie key pinch
3 jaw chuck
59
The difference dominant vs nondominant
Grip
Pinch
Grip: 10lbs
Pinch 2 lbs
60
Prepatory Nerve
RADIAL NERVE
61
Manipulator NERVE
MEDIAN NERVE
62
Power Nerve
ULNAR NERVE
63
Evaluation Sensory Testing
```
pain, pinprick
low frequency vibration 30cps
high frequency vibration 225 cps
light moving touch (pencil)
static touch (pencil)
2 pt discrimination with small tool
```
document regeneration of nerve
64
Boutonniere Deformity
extensor tendon injury characterized by
PIP flexion
DIP extension
Mechanism
caused by rupture of the central slip over PIP joint from
laceration
traumatic avulsion (jammed finger)
capsular distension in rheumatoid arthritis
65
Mallet Finger
A finger deformity caused by disruption of the terminal extensor tendon distal to DIP joint
the disruption may be bony or tendinous
66
Checkouts for the Splint
1. below the crease for MCP flexion
2. full opposition
(note that the splint should be 2/3 length of the forearm)
67
6 points on the splint
1. ulnar side under MCP
2. inch away from forearm (bottom of splint)
3. inch away from forearm (bottom of splint)
4. radial carpal joint at wrist crease (where watch goes)
5. distal palmar crease MCP joint
6. webspace
68
What attaches to the ulnar styloid process?
1. ECU attaches: extend and ulnar deviate the wrist because ECU will pop out (to palpate):
- -problem pain here if fracture ulnar styloid when extend or ulnar deviate
- --also pain if inflammation of ECU
2. UCL: ulna collateral ligament attaches to ulnar styloid
69
FOOSH what is injured?
Fall on outstretched hand- the TFCC sits under ECU and can be damaged in a fall with force on hand, can tear the soft tissue. most people focus on the radial side (usually broken) but all the ulnar stuff can be inflamed and hurt-
modality of ultra sound can decrease pain and inflammation
70
Darrach procedure-
ulnar head taken out of the hand prophylactically
a. prophylactic surgery for pts with RA
b. remove ulnar head because it is not smooth, they then tack down distal end of ulnar to soft tissue so it doesn’t flail up and down during rotation, they smooth the distal ulna, and may cap the distal ulna with an implant
c. this allows extensor tendons to slide and glide over the distal ulna –don’t want tendons to fray
71
which styloid process extends further?
Radial Styloid process: extends a little further than ulnar styloid process
72
what makes up the distal R-U joint according to dr schilirio?
distal radial ulnar joint is only scaphoid, lunate and distal radius, it does not include the ulna because disc between this and so ulnar not part of this joint!
73
Listers tubercle:
why is it important
where is it
what tendon comes around it
what goes over it
it is the beginning of the midline of the hand
1. It is a prominent area on distal radius
2. EPL tendon comes down forearm from insertion and at listers tubercle is a pulley system where it goes => 45 degrees redirection here to the thumb
- -- Listers tubercle act as razor in RA and ruptures the EPL, so repair surgically if find early
3. Extensor Digitorum Longus (EDC) tendon of the index finder is superficial and goes over listers tubercle
74
x movements of wrist
1. flexion
2. extension
3. radial deviation
4. ulnar deviation
5. supination
6. pronation
75
Patient comes in 6 weeks after distal radial fracture: 6 weeks post can start to work on…
1. EXTENSION: very important to work on extension because harder to regain because the extensors are 4x WEAKER than flexors. If they are immobile for 4-6 weeks and atrophy they will be very weak.
- ---In the cast work on claw or make a fist to work on extensors
2. SUPINATION- cast in slight pronation which puts the INTEROSSEOUS on slack
a. Casted in supination because the interosseous ligament is on slack so that you can heal and no tension on the fracture
b. Then come out of cast with this slack on interosseous membrane and have a hard time with supination
c. We can take advantage of proximal radial ulnar joint to get more supination because this joint is not involved, this encourages them that they can do it
76
Scaphoid
significance
most likely to be fractured
77
younger than 30 break
fall on outstretched hand, can break the scaphoid bone
Younger than 30 years old break scaphoid, AVN (radius is strong and hits the scaphoid in total wrist extension and so you fracture the scaphoid)
---Need an above elbow cast for three months
78
older than 30 break
all on outstretched hand
Older than 30 years old break distal radius (because start to develop osteopenia at the distal radius, it is weaker and fractures)
79
Broken scaphoid:
how long cast
what motion does cast need to prevent
why long recovery
a. above elbow cast for up to 3 months
b. cast above elbow to block proximal R-U joint to prevent pronation/supination which moves the scaphoid
c. long recovery bc retrograde blood supply
d. usually if xray and nothing and distal radius is ok, they come back to see is scaphoid injury later
80
Lunate:
significance
Proximal Row:
number one to be dislocated because of where it sits, distal radius pops it out
1. midline of the hand
2. most likely to be dislocated
3. easy to view on lateral
longitudinal view X-ray, on dislocation “c” faces up or down, measure to see how far it faces up and to what degree (measure dislocation based on this to decide if surgery or not, it is not fractured it is dislocated)
81
Triquetrium:
significance
Proximal Row: Triquetrium:
1. #3 to be fractured
2. palpate by radially deviating the hand then it is just distal to ulnar styloid process it will pop up
82
Pisiform
significance
Proximal Row::
FCU attaches to the pisiform
83
Trapezium
significance
Distal Row:
#1 bone affected in OA: women 40s-60s
forms basal joint = base of thumb
- --OA basal thumb common in women who knit in 4th, 5th, 6th, decade of life
- --May do surgery to get rid of the arthritic pain
---Texters thumb is inflammation of the structures of first metacarpal involving trapezium, they excise the trapezium and fill it with a spacer or take Palmaris longus tendon and they roll it up like an anchovy and shove it in and pin it in so body encapsulates the anchovy, you wont reject it because it is yours.
84
Trapazoid
where is it
Distal Row: Trapazoid:
articulated with 2nd metacarpal
never gets injured
85
Capitate
how to find it
Distal Row::
1. Go down listers tubercle proximal to 3rd metacarpal
2. It is in the midline of the hand
3. There is a gully in extension and then it pops out to palpate in flexion
86
Hamate
significance
1. ulnar nerve runs under hook (in Guyons canal)=> lots of compression
2. Guyon’s Canal: ulnar nerve under hook of hamate: common area for compression of the ulnar nerve (do an EMG)
87
Radial carpal joint = scaphoid, lunate & distal end of radius
Mid-carpal joint = most motion
Distal R/U jt has the next most motion
Carpal Metacarpal joint
Radial carpal joint = scaphoid, lunate & distal end of radius
Mid-carpal joint = most motion
Distal R/U jt has the next most motion
Carpal Metacarpal joint
88
CMC joint of thumb =
basal joint: base of thumb with trapezium
saddle joint – how a person on a horse sits in the saddle: side to side motion, front to back motion, rotation
89
what injury usually happens at the base of the metacarpal ?
1. Fracture at the base of metacarpal: doesn’t usually affect motion because CMCs don’t have a lot of motion, crush injury (something fell and crushed it)
2. Fracture at the shaft of metacarpal: from crush injury
3. Fracture at the headof metacarpal:
90
Boxers fracture
Boxers fracture: fracture on 5th MC, only way to get it from punching something
A true Boxer’s Fracture can only come from a punch by compression and rotation
(if someone is a boxer they do not usually get a boxers fracture and gets fracture at 2nd and 3rd metacarpal)
in surgery they pin it to the 3rd metacarpal for healing because the 4th metacarpal would not give enough stability (the 4th and 5th metacarpals have a lot of mobility)
this person has to regain cupping because they lost the transverse arch while in the cast and hypothenar muscles are atrophied from being immobilized
91
What do you need to regain after a Boxers fracture?
this person has to regain cupping because they lost the transverse arch while in the cast and hypothenar muscles are atrophied from being immobilized
92
MCP: Collateral ligaments
what is it
when is it tight
collatereal ligaments are oblique at the MCP joint
Collateral ligaments start at dorsal metacarpal head and angles downward to the base of the proximal phalanx
Provides lateral stability
Extension of MCP: This collateral ligament is on slack (redundant)
Flexion of MCP: collateral ligament gets tighter
Full flexion MCP: most taut of collateral ligaments
*****cannot abduct when fingers are in flexion, need to be in extension to abduct because collateral ligaments provide lateral stability
93
Why cannot abduct when fingers are in flexion?
*****cannot abduct when fingers are in flexion, need to be in extension to abduct because collateral ligaments provide lateral stability at MCP
94
Where must splint go in the check outs?
****Splint must go proximal to the DISTAL PALMAR CREASE because that is where we flex: we flex at the distal palmar crease: we cannot splint wrist with the MCP collateral ligament on slack in MCP extension because then they will not be able to stretch the collateral ligaments and so they will not be able to flex MCP joints: checkout: be able to flex MCP down to 90 degrees
95
When is MCP collateral loose vs tight?
Extension of MCP: This collateral ligament is on slack (redundant)
Flexion of MCP: collateral ligament gets tighter
Full flexion MCP: most taut of collateral ligaments
96
PIP collateral loose vs taut?
PIP and DIP Collateral Ligaments:
True collaterals so taut no matter position the PIP is in (full flex -> full ext)
97
DIP collateral loose vs taut?
PIP and DIP Collateral Ligaments:
True collaterals so taut no matter position the PIP is in (full flex -> full ext)
98
Volar plate = palmar plate
1. fibrocartilagenous structure that prevents hyperextension at MCP, PIP and DIP joints
injuries: jammed finger, only tear by cutting bagel etc
2. Different:
MCP joint: can get more extension
--- it attaches to soft tissue/fascia and so we can get more motion (it can get more stretched out, ie massage therapist, everyone is different) and anchors into bone distally
PIP & DIP joints- anchors firmly into bone at origin and insertion (can also get more extension at the DIP joint but it is more stable)
99
Volar plate = palmar plate at MCP
MCP joint: can get more extension
--- it attaches to soft tissue/fascia and so we can get more motion (it can get more stretched out, ie massage therapist, everyone is different) and anchors into bone distally
PIP & DIP joints- anchors firmly into bone at origin and insertion (can also get more extension at the DIP joint but it is more stable)
100
Volar plate = palmar plate at DIP
MCP joint: can get more extension
--- it attaches to soft tissue/fascia and so we can get more motion (it can get more stretched out, ie massage therapist, everyone is different) and anchors into bone distally
PIP & DIP joints- anchors firmly into bone at origin and insertion (can also get more extension at the DIP joint but it is more stable)
101
Volar plate = palmar plate at IP
MCP joint: can get more extension
--- it attaches to soft tissue/fascia and so we can get more motion (it can get more stretched out, ie massage therapist, everyone is different) and anchors into bone distally
PIP & DIP joints- anchors firmly into bone at origin and insertion (can also get more extension at the DIP joint but it is more stable)
102
Jammed Finger:
injuries to volar plate are jammed fingers. Volar plate is so strong they will avulse the bone they got an intra-articular fracture, the volar plate ligaments are so strong that the ligaments are not torn and instead it pulls off the bone.
103
Tear of the Volar Plate:
4. Tear of the Volar Plate: only way to hurt these is to cut them (ie cutting an avocado or a bagel)
104
Extensors – 6 dorsal compartments:
note extensor tendons in their compartments surrounded by synovium, seams around each compartments, so if someone has an inflammation and the tendons have to slide and glide under the tight ligament it doesn’t fit very well, like a string in a straw that becomes inflamed by injury or repetitive use it becomes like a piece of rope that is getting chaffe and more and more inflamed so in surgery they will actually take it and open the top of the compartment to take away the mechanical pressure on the tendon and allow tendon to rest a few weeks, and send to therapy for splinting and pain management. It needs to be caught early before everything becomes inflamed
