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PHTY207 > Wk 7 > Flashcards

Wk 7 Flashcards

1
Q

4 requirements to maximise healing

A
  1. minimise pain, swelling, inflammation, haemorrhage, to offer the best possible conditions for healing
  2. protection of DAMAGED tissue
  3. controlled mobilisation during the collagen
    maturation and remodelling initiation phase.
  4. progressive loading of the tissue
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2
Q

what is radial head fracture Mx guided by?

A

surgeon

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3
Q

Type I radial head # Mx

A
  • Short-term immobilisation (sling/brace) for 2-7 days then early ROM (especially
    extension)
  • Some evidence that doing ROM too early (i.e. day 1 or 2) can increase pain and
    delaying ROM (>7 days) can lead to stiffness
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4
Q

Type II-IV radial head # Mx

A
  • typically require ORIF
  • Type III might need arthroplasty (i.e. partial elbow replacement) if > 3 fragments
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5
Q

complications of elbow dislocations

A
  • long term loss of extension
  • heterotropic ossification
  • chronic posterolateral instability
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6
Q

elbow dislocation Mx

A

early active management

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7
Q

EBP elbow disloc Mx

A

started active ROM after 2 days
(within pain) but no passive ROM for first 3 weeks (sling
for first 2-3 days as needed).

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8
Q

Complex dislocation Mx
e.g. after terrible triad

A

ORIF typically required for majority cases

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9
Q

what do you do post ORIF for terrible triad?

A
  • follow surgeon’s orders
  • commence hand and wrist ROM immediately
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10
Q

what is kept on after ORIF for terrible triad?

A

brace for 24/24 except during ROM exercises (regular short sessions through day) which start day 7-10

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11
Q

what position helps stabilise elbow by activating triceps

A

Gentle elbow AROM can be done with lying supine with shoulder supported at 90 degrees flexion - active assist flexion and extension to -30 degrees

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12
Q

COMPLEX DISLOCATION MX
how many weeks is the protext repair phase?

A

0-2

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13
Q

COMPLEX DISLOCATION MX
instructions for protect repair phase

A
  • Keep brace on except when doing exercises
  • Commence hand/wrist ROM immediately
  • Gentle elbow AROM can usually start after ~7-
    10 days (check with surgeon!)
  • Avoid extremes of flexion & extn
  • Static isometrics (biceps, triceps, brachialis) in
    brace`
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14
Q

COMPLEX DISLOCATION MX
Increase ROM and strength phase week

A

2-12

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15
Q

COMPLEX DISLOCATION MX
instructions for increase ROM and strength phase

A
  • Brace usually removed by week 3
  • Continue elbow AROM
  • Commence gentle PROM (no aggressive
    stretching or pushing PROM due to HO risk)
  • Commence graduated strengthening from
    ~week 6 around elbow and shoulder
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16
Q

COMPLEX DISLOCATION MX
Strength and conditioning phase week

A

12 +

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17
Q

COMPLEX DISLOCATION MX
Strength and conditioning phase instructions

A
  • Incorporate more functional activities/demands
     think about kinetic chain
  • Typically avoid high impact activities/sports
    until 6 months post-op
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18
Q

signs & symptoms of medial epicondyle avulsion #’s

A
  • sudden ‘pop’ during a throw followed by pain
  • point tenderness is elicited over the medial epicondyle
  • although a fracture is usually an acute traumatic event, MEA # is frequently preceded by a history of medial elbow pain
  • often associated with an elbow dislocation
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19
Q

MEDIAL EPICONDYLE AVULSION MX
<5mm displacement

A

above-elbow backslab @ 90* elbow flexion for 3 weeks
- backslab & sling should be worn under clothing

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20
Q

MEDIAL EPICONDYLE AVULSION MX
5-15mm displacement

A

Mx = dependent on number of factors, including; age, sporting activities

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21
Q

MEDIAL EPICONDYLE AVULSION MX
>15mm displacement with elbow disloc

A
  • reudction +/- ORIF
  • closed reduction for dislocation performed –> order repeat X-rays to check that the medial epicondyle fracture is not trapped in the jt (any doubt, urgent ORIF)
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22
Q

MOI MCL tear/ medial instability

A

repeated strain on MCL via throwing

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23
Q

MCL tear/ medial instability presentation

A
  • laxity on valgus stress test (/ pain with moving stress test)
  • pain over medial elbow during flexion, throwing
  • possible swelling (absent often in chronic)
  • loss of ROM ext
  • unable to throw at full speed
  • Ulnar nerve sensitivity
  • positive radiographic exam
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24
Q

when is conservative Mx of MCl tear needed?

A

for partial tears and even with full tears

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25
Q

what is used to protext the elbow from valgus stress in MCL injry

A

rest and splint bracing / taping

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26
Q

what do you avoid with conservative Mx with MCL tear?

A

passive ROM ext

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27
Q

what should you restrore with MCL tear?

A

elbow/ wrist flexor/ extensor synergies important

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28
Q

what do you avoid with MCL/ medial instability

A

actitvies that promote valgus stress

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29
Q

exercise guidelines for MCL tear/ medial instability

A
  • Pain free ROM - while avoiding valgus stress
  • Proprioception
  • Strength (wrist flexors, elbow flexors/ extensors) – initially in brace
  • Sport specific activities
  • Isometric –> isotonic –> proprioceptive –>plyometric/functional
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30
Q

what happens if conservative Mx fails for complete tears?

A

then surgery is required (UCL reconstruction), also know as Tommy John surgery

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31
Q

long-term problems of acute traumatic elbow injuries

A
  • Loss of ROM (especially extn) – linked to duration of immobilisation
  • Loss of strength (elbow/wrist/shoulder)
  • Recurrent instability
  • Heterotopic ossification
  • Neurovascular compromise
  • Chronic pain syndromes
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32
Q

ulnar nerve injury typical MOI

A

traction with throwing activities

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33
Q

causes of ulnar nerve injury

A
  • Anatomical/congenital
    variations
  • Perineural adhesion
  • Joint disease/osteophytes
  • Prolonged bed rest
  • Leaning on elbow
    (repetitive minor trauma)
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34
Q

signs & symptoms of ulnar nerve injury

A
  • Common in 30-60 yr olds
  • Posteromedial elbow pain
  • P & N / numbness / weakness
  • Pain on palpation of nerve
  • History – traction versus compression (secondary
    to valgus instability)
  • Radiographs – osteophytes and DJD
  • May report snapping – hereditary subluxation
    over the medial epicondyle (stretch aetiology
    rather than compression)
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35
Q

ulnar nerve injury Rx

A
  • Avoid sustained elbow flexion
  • e.g. when sitting, sleeping – splinting may help
  • Avoid repetitive elbow flexion and pronation
  • Avoid vibratory tools
  • Vitamin B6 (evidence??)
  • Improve flexibility of forearm/wrist flexors and
    pronators
  • Surgical intervention if conservative management
    fails
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36
Q

what is lateral elbow tendinopathy?

A

pain over the lateral humeral epicondyle/ radiate distally into forearm due to a degeneration/ trauma to the common extensor tendon over time.

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37
Q

risk factors of LET

A
  • handling tools heavier than 1
    kg
  • handling loads heavier than 20 kg at least 10 times per day
  • and repetitive movements for more than 2 hours per day
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38
Q

CLINICAL PRESENTATION OF LET
History

A

may be associated with repetitive use

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39
Q

CLINICAL PRESENTATION OF LET
Area of Pain

A
  • lateral epicondyle +/- into forearm
  • not radiating above elbow
  • not neural symptoms (DDx with RTS)
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40
Q

CLINICAL PRESENTATION OF LET
Painful activities

A
  • POP over lateral epicondyle
  • pain on resisted iso wrist extension or 2nd/3rd finger extension
  • pain on gripping
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41
Q

CLINICAL PRESENTATION OF LET
Behaviour of symptoms

A
  • functional movement = sore –> grip, twist, lift
  • LE specific patient functional questionnaires (PRTEE)
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42
Q

3 components of the integrated model of multifactorial pathology for LET:

A
  • tendon pathology
  • motor control impairments
  • sensory system impairments
43
Q

when is medication and/or interventionist medical Rx recommended?

A

with those with poor prognosis / failure to progress after 12 weeks of conservative Mx

44
Q

which tendon is most affected in LET?

A

ECRB

45
Q

pathophysiology of the tendon pathology changes in LET?

A

increased solularity, increased ground substance –> Neurovascular ingrowths that can = more pain

46
Q

how do you Mx the tendon pathology impairment of LET

A

EPA, MWM, Polidocanol, steroid, exercise

47
Q

how is the sensory system affected in LET?

A

central changes have occurred –> can tolerate less pain e.g. less ice time

48
Q

Mx of sensory impairments for LET

A

Blood, Prolotherapy, Polidocanol, Exercise

49
Q

motor control impairments in LET

A
  • grip in a more flexed position
  • extend through MCPs
  • poorer rxn time on each side
  • weaker generally
50
Q

how to Mx motor control impairments of LET

A

EXERCISE

51
Q

what does the EBP recommend as a Rx pathway for LET?

A
  • Advice and Education (First level) vs wait and see
  • Exercise (+/- MWM)- graded and progressive for 8 weeks
  • Manual Therapy- MWM’s and C/Spine mobilisations
52
Q

components of A&E for LET

A
  • Tendinopathy explanation
  • Load management
  • Palm up lifting
  • WHS review- tools/ work station/ equipment/rest breaks
  • Self-management
  • Lifestyle modifications- sleep, nutrition, exercise, smoking
  • Counsel regarding injections
53
Q

components of exercise for LET

A
  • Isometrics (pain) – not terribly effective in isolation
  • Concentric
  • Eccentric (better than concentric for pain relief in early stages)
  • General upper limb strengthening (RC, deltoids, biceps, triceps…)
  • Functional strength
  • CV fitness
54
Q

components of manual therapy for LET?

A
  • MWMs (pain Mx)
  • cervical spine mobs
  • NDT mobs
55
Q

what A&E is most important for LET?

A
  • what tennis elbow is
  • activity modification
56
Q

CST injection for tennis elbow

A
  • short term benefits (4-6 wks)
  • > > likelihood of recurrence vs placebo/ no injection
57
Q

specific elbow considerations
1. grip posture retraining

A
  • palm down/ thumb up (avoid MCP extn)
  • extended wrist posture = very importnat
58
Q

when are isos good for LET?

A

if too painful to do isotonic
exercise

59
Q

aim of isos

A

pain relief

60
Q

when the aim = to increase strength and function, what happens to isos?

A

not in isolation

61
Q

dosage of isotonics for LET?

A

typically 3 sets of 10-15 reps, rest of ~1min between sets, 5-7 sessions per week.

62
Q

dosage of isos for LET

A

3-5 sets x up to 45-60secs daily.

63
Q

what do you do, for LET, if most painful gripping/ extending wrist when elbow in extension + pronation ?

A

try strengthening in elbow flexion and in a neutral pron/sup position (or even supinated)

64
Q

If it is too painful to move through full range at the wrist for LET…

A

start with isometrics or perform in a limited ROM

65
Q

If they can do some repetitions of isotonic exercise (LET)…

A

start there (not always start with Isos)

66
Q

other Rx options for LET

A
  • Manual therapy – particularly MWMs
  • Taping
  • Bracing
67
Q

what is an MWM effective for doing in LET?

A

increasing pain-free grip strength (acutely)evide

68
Q

evidence for elbow brace

A

= mixed; may be effective short term for pain

69
Q

RTS MOI

A

repeated use of extensor/ supinator muscle mass

70
Q

RTS definition

A

compression of deep branch of radial nerve (posterior interosseous nerve- PIN as it passes through the supinator

71
Q

when is the PIN particularly vulnerable?

A

with humeral #’s and post-surgery

72
Q

RTS SIGNS & SYMPTOMS
where is the pain?

A

relatively deep in upper forearm (distal to elbow)

73
Q

RTS SIGNS & SYMPTOMS
When is the pain agg?

A

gripping & twisting tasks

74
Q

RTS SIGNS & SYMPTOMS
what is TOP and where?

A

radial nerve - between triceps and biceps laterally, over supinator, in snuff box

75
Q

RTS SIGNS & SYMPTOMS
What can RTS lead fo?

A

weakness of thumb abduction /
extension, extensor digitorum & ECU and sensation
changes around dorsum of hand (btw thumb and
index finger)

76
Q

what is the dominant feature of RTS?

A

pain&raquo_space; strength loss / sensation change

77
Q

RTS Rx
Proposed Physio Mx =

A
  • Early management is crucial to try and prevent damage to the
    nerve through either ongoing trauma or secondary inflammation and swelling.
  • Flexibility and postural exercises–> trunk, cervical and thoracic spine to reduce any role posture may have on the nerve tissue.
  • Cervical/ thoracic mobilisations and NDT techniques (radial
    nerve ULNT2B) sliders to assist with the mobility of the nerve.
78
Q

characteristics of osteochondritis dissecans

A

Poorly localised lateral elbow pain, with crepitus,
catching and locking

79
Q

are swelling and flexion contractures present with OD?

A

sometimes

80
Q

OD creates…

A

laxity of MCL

81
Q

where is OD TOP?

A

capitellum through elbow flex/ext

82
Q

what is the Rx goal for OD?

A

prevent symptoms, not cure it

83
Q

Rx for a non-displaced lesion

A
  • Sports physician/Orthopaedic RV required
  • Rest, gentle ROM ex initially (prevent loss of extension ROM)
  • Gradual strengthening around shoulder, elbow, wrist and kinetic chain to prepare for loads associated with throwing
  • No throwing until symptoms gone and full ROM restored
84
Q

Rx for a displaced OD lesion

A
  • Sports physician/Orthopaedic RV required
  • Rest
  • Arthroscopic debridement, removal of loose bodies
  • Post-op physiotherapy Mx will focus on restoring ROM then strength
  • Poor prognosis – older patient, larger lesion, lesion on a weight-bearing area
85
Q

medial epicondylalgia presentation

A

More typical tendinopathy presentation– reactive
(inflammatory) through to degenerative. Presentation may be
acute, sub acute or chronic

86
Q

what does golfers elbow respond well to

A

conservative Mx

87
Q

area of pain for golfers elbow

A

over the medial epicondyle, forearm flexors, pronator teres

88
Q

golfers elbow aggs

A
  • Resisted wrist flexion and ulnar deviation
  • Resisted pronation
  • Passive elbow and wrist extension in supination
  • History of increased load or change of
    technique/ equipment
89
Q

Golfer’s elbow Rx

A
  • Isometrics - to target pain if necessary (30-45second holds x 5)
  • Isotonics- long slow load/ concentric/ eccentric strengthening and progressive load
  • Eccentric programs (3 sets 15 reps twice daily)
  • Counterforce brace
  • Address technique/equipment/biomechanical faults
  • Kinetic chain- address shoulder, trunk, lower limbscreening and global strengthening and flexibility
  • Functional rehabilitation- links to shoulder approaches
  • Surgical intervention if conservative treatment fails
    (unusual)
90
Q

what is posterior impingement caused by (3)?

A
  • repetitive hyperextension / valgus stress overload syndrome - adolescent throwers
  • valgus instability
  • OA in the older patient of the radiohumeral jt
91
Q

what can Repetitive hyperextension/ valgus stress overload syndromeadolescent throwers (chronic issue) cause

A

bony spurs at olecranon tip on fossa -> flexion
deformity (ie. elbow can’t fully extend)

92
Q

what does valgus instability, posterior impingement, cause

A

Olecranon not fitting into fossa -> postero-medial pain

93
Q

how can OA in the older patient cause posterior impingement

A

generalised osteophyte formation- flexion deformity and
pain on extension

94
Q

posterior impingement of the elbow Rx

A
  • Rest from aggravating factors- may use ROM limiting
    brace if compliance poor
  • Restriction of extension movements and throwing
  • Return of pain free ROM
  • Increase strength and stability at joint- supinators/
    pronators, flexor/ extensor strength
  • Correction of throwing technique
95
Q

where can the median nerve get entrapped?

A
  • above elbow at
    ligament of Struthers
  • or below elbow between pronator teres and at carpal
    tunnel
96
Q

symptoms of median nerve entrapment

A

sensation changes and/or
pain at palmar aspect of hand and fingers
+/- weakness in wrist flexors

97
Q

where does the radial nerve divide and into what branches?

A

at elbow into
superficial sensory and
deep motor branches

98
Q

what does entrapment of the superficial branch of the radial nerve cause?

A

pain/ altered sensation over
radial aspect of wrist or
thumb

99
Q

what can radial nerve entrapment impact?

A

wrist ext

100
Q

where can the ulna nerve be entrapped?

A

at Arcade of Struthers (above elbow)
- at medial epicondyle
- cubital tunnel
*Sometimes between two heads of flexor carpi ulnaris

101
Q

symptoms of ulna nerve entrapment

A

Pain or paraesthesia in sensory distribution

102
Q

+ve… for ulnar nerve entrapment

A

tinels sign

103
Q

nerve entrapment Mx

A

address causes
- posture
- anatomical/ biomechanical reasons
- muscle imbalances e.g. stretch tight muscles, improve core strength etc.
- NDs +/- mobilisation: sliders and tensioners
Medical
- cortisone injection
- surgery
- NSAIDS

104
Q
A

PHTY207 (7 decks)

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