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NYCC T7 extremity 1
Dr. Homack's Dx & Management of Extremity Conditions midterm
Question | Answer |
---|---|
Describe the relationship b/w anxiety and depression and how it affects treatment. | Anxiety preceded depression; they go together; whole body illness; depression can delay recovery; depressed people less compliant |
What is health the cornerstone of? | One’s self-esteem, social welfare, economic welfare |
What are the 5 stages of grief? | Denial, anger, bargaining, depression, acceptance |
Who is at a higher risk for successful suicide? | Men, highest incidence is elderly men |
Who attempts suicide more often? | Women |
What is the number cause of suicide? | Untreated depression |
What are the 4 types of depression? | Adjustment disorders; Depressive disorders; Dysthymia; Bipolar/histrionic disorders |
What are the 4 types of overriding anatomic and functional considerations of the UE? | Osseous/interosseous; Muscular/tendinous; Neurologic; Vascular |
Describe muscular/tendinous as an anatomic/functional consideration of the UE. | Rotator cuff, muscular synergy, tendonitis |
Describe the importance of the rotator cuff with the shoulder complex. | At least 17 muscles are active each time the GHJ is in motion; cuff muscles and their condition help align the humerus in the glenoid fossa, increasing performance and decreasing chance of injury |
Describe neurologic as an anatomic/functional consideration of the UE. | Brachial plexus, peripheral entrapment syndromes/palsy, double crush syndrome, TOS; Dx accuracy depends on knowledge of nerves in arm, muscles of arm, UE pure patches, dermatomal patterns |
How many compartments are in the body, how many of these are in the extremities and UE? | 46 in body; 38 in extremities; 34 in UE |
Where is the median nerve in reference to the cubital fossa? | Anterior in the cubital fossa |
What is the course of the Ulnar nerve in reference to the elbow? | Down the medial arm, through the cubital tunnel (proximal ulnar tunnel/groove) |
What is the course of the radial nerve? | Wraps around the posterior humerus to the lateral elbow, travels anterior to the epicondyle crossing the elbow, then splits w/ half under the supinator to the hand. |
What is the MC point for radial nerve injury? | Spiral groove of the humerus |
How much pressure does extension of the wrist place on the median nerve? | Can increase pressure as much as 3x |
What test evaluates the integrity of the arm, wrist and hand? | The grip strength test |
Describe vascular as an anatomic/functional consideration of the UE. | Vascular TOS, Raynaud’s/vibration, aneurysms, arthrosclerosis |
What is double crush syndrome? | Proximal compression of a nerve may lessen the ability of the nerve to withstand more distal compression |
What does irritation of a nerve cause? | Swelling along the pathway of the nerve |
Describe 3 examples of double crush syndrome. | people w/ cervical arthritis develop CTS; TOS leads to cubital tunnel problems; Cubital tunnel problems lead to carpal tunnel problems |
What joints are affected in a FOOSH? | Hand, wrist, elbow, shoulder, AC, SC and/or cervical spine trauma |
Where do shear injuries occur with a FOOSH? | RUJ, GHJ, ACJ |
Where do torque injuries occur w/ FOOSH? | GHJ, ACJ, Humeral-ulnar, Radial-ulnar |
Where do lateral bending injuries occur w/ FOOSH? | Cervical spine (area of compression and an area of distraction |
What splits the scaphoid at the waist? | Radial styloid; scaphoid is bone most carpal prone to injury |
Where does pain occur with scaphoid Fx? | Anatomical snuffbox |
When do most scaphoid Fx’s occur? | sports activities of MVAs |
What are symptoms of the wrist that result from scaphoid nonunion or AVN? | Aching in the wrist, decreased ROM of wrist, pain w/ activities like lifting or gripping |
What is the most commonly dislocated carpal bone? | Lunate |
What could cause lunate fracture? | Direct impact onto the heel of the hand |
What causes a triquetrum fracture? | Direct blow on the back of the hand or bending the wrist back to far |
What causes a trapezium fracture? | Usually a direct blow on the back of the hand |
Why is the trapezoid rarely injured on its own? | It is well protected but if it is injured alone it heals w/o complications |
What treatment is common for all carpals with displaced fractures? | Open reduction and internal fixation surgery |
If the capitate is fractured, where should you also look for injury? | Wrist dislocation or a fractured scaphoid |
What could cause the capitate to be fractured on its own? | Load transmitted through the 3rd metacarpal |
What causes hamate body fracture and what are they associated w/? | Direct trauma or by crushing the hand in machinery; associated w/ unstable dislocations of the 4th or 5th cetacarpals |
What causes hamate hook fractures? | Stress fractures, caused by direct trauma or avulsion fractures |
Why do patients ignore the pain from hamate fractures? | They believe they just sprained their wrist |
How is the pisiform bone fractured? | Direct blow to the palm giving pain and tenderness on the little finger side of the palm near the wrist |
What is avulsed in a Skier’s thumb fracture/game-keepers thumb? | Ulnar collateral ligament of the PIP of the thumb; caused by thumb being forced inwards |
If you have a FOOSH, what is the amount of body weight your wrist will endure? | 3-5x (this is mentioned many times in the notes!) Who is at higher risk for Colles’ fracture? |
What does elbow disability represent? | 60% loss of arm function |
What do elbow fractures represent? | 7% of all fractures |
What signs are seen on radiographs for a radial head compression/fracture? | Sail sign; Fat pad sign |
What is the MC direction of shoulder dislocation? | Anterior/inferior |
What do all shoulder and arm problems involve? | The rotator cuff! What is the O, I, Fxn and innervation of the supraspinatus? |
What is the O, I, Fxn and innervation of the infraspinatus? | Infraspinous fossa; greater tubercle; externally rotates arm; suprascapular nerve (C5-6) |
What is the O, I, Fxn and innervation of the teres minor? | Lateral border/scapula; greater tubercle; externally rotates arm; Axillary nerve (C5) |
What is the O, I, Fxn and innervation of the subscapularis? | Subscapular fossa; lesser tubercle; internally rotates humerus; upper and lower subscapular nerve (C5-6) |
Why do rotator cuff injuries most frequently occur at or near the attachments to the tuberosities? | Avascular |
What is the MC injured rotator cuff muscle? | Supraspinatus |
What is the most clinically relevant rotator cuff muscle? | Subscapularis; difficult to diagnose, tough to treat |
10% of TOS patients have a _______________. | Cervical rib |
What are the entrapment areas of TOS? | Cervical rib; Scalenes; Costoclavicular interval or space; Subcoracoid space/pec minor |
Who gets TOS and why? | More commonly women 5:1; May be d/t bra straps, back packs, hand bags; also smaller spaces on women |
What grip strength is considered normal? | 20lb (10kg); TOS decreases |
What night symptom is experienced by people with TOS? | Awakened at night to shake hands |
What type of adjustments will help TOS patients w/ SCJ tenderness? | Pelvic |
What percentage of TOS patients have a disc bulge in the C-spine? | 60% |
What is worse for the shoulder than football is for the knee? | Bench press (football knee injuries 900x general population |
What adjustments can be utilized for TOS and why? | CT junction: rotation affecting ribs 1 and 2>manubrium>sternum>SCJ; 1st rib: anterior and middle scalenes; 2nd rib: posterior scalene; S-I of SCJ: short, tight SCM |
What does SLAP mean? | Superior Labrum Anterior to Posterior |
What are the 3 principle concepts of the LE? | Subtalar joint; pathologic pronation; closed kinetic chain |
What are the 4 arches of the foot? | Medial longitudinal, lateral longitudinal, transverse arch, anterior transverse arch |
Which arch of the foot is highest and most important? | medial longitudinal; talus is the keystone |
What bones are involved in the medial longitudinal arch? | Calcaneus, talus, navicular, cuneiforms 1&2, metatarsals 1&2 |
What is the weakest part of the medial longitudinal arch and what normally maintains its integrity? | The joint b/w the talus and navicular bone; spring/calcaneonavicular ligament – plastic deformity is permanent |
Describe the lateral longitudinal arch. | Arch is lower and flatter than medial; calcaneus, cuboid and 4th and 5th metatarsals, cuboid is the keystone; Bears weight |
Describe the transverse arch. | Goes across the foot; Cuneiforms 1,2,3 and cuboid with middle cuneiform as keystone; Middle cuneiform also sustains the arch; Foot leveler’s disputes importance of this arch |
Describe the anterior transverse arch. | Composed of metatarsal heads 1-5; flattens out w/ weight bearing on flat surface; conforms to uneven terrain; Foot leveler’s emphasizes this arch |
How many bones are in the foot and how is it divided? | 26 bones; 3 regions: hindfoot, midfoot, forefoot |
What is included in the hindfoot? | Talus and calcaneus |
What is included in the midfoot? | Navicular, cuboid, all 3 cuneiforms |
What is included in the forefoot? | Phalanges and metatarsal bones |
What are the main 4 actions of the foot and what do they lend to? | Eversion and inversion, abduction and adduction; combination gives supination and pronation |
What parts of the foot are involved in eversion and inversion? | Hindfoot and subtalar joint |
What parts of the foot are involved in abduction and adduction? | Midfoot and midtarsal joint |
Describe the subtalar joint. | The talus floats on the calcaneus; talus has no muscular attachments; subtalar joint seat of upright balance and proprioception |
What is the open pack position of the subtalar joint? | Foot dorsiflexion |
Describe the Achilles tendon. | Largest tendon in the body; injury more common in males and more frequent on the left; Rupture of Achilles occurs 2-4cm above calcaneus b/c of insufficient blood supply |
What creates a more stressful toe off? | As we age Achilles loses ability to dorsiflex |
What causes tarsal tunnel syndrome and how does entrapment happen? | Pathologic pronation; pressure on flexor retinaculum or at tarsal tunnel w/ excessive pronation |
What is the primary function of the tibialis posterior? | Decelerate mid-foot pronation at the subtalar joint w/ heel strike |
What muscle is important in dorsiflexion of the foot? | 80% from tibialis anterior; first sign of anterior compartment syndrome is hypesthesia of first 2 digits |
How many ligaments surround the metatarsal phalangeal joint and how much body weight is on the toes at toe-off? | 9 ligaments surround MTP joint (turf toe is the spraining of these ligaments); 40% of bodyweight on toes at toe-off (mostly medial) |
What is Caillet’s triad in diagnosis of foot problems? | Foot and ankle pain must always be caused by either: 1. Abnormal stresses on normal structures; 2. Normal stresses on abnormal structures; 3. Abnormal stresses on abnormal structures |
Why do foot problems occur? | Hard level floors, weak foot, shoes that don’t fit, 60% of people wear shoes too small for foot, tight shoes inhibit shock absorption |
What controls velocity of mid-foot pronation and where does it occur? | Tibialis posterior; around the talo-navicular-cuneiform complex |
Describe pathologic pronation. | dorsiflexion, eversion, abduction; Too much too soon to long; Navicular drop test; midfoot deceleration controlled by tibialis posterior; medial longitudinal arch supported by plantar calcaneal ligament; begins chain reaction of closed kinetic chain |
What toe shapes are common with Morton’s foot? | Hammertoes and Claw toes |
What treatments are available for the feet? | Foot drills; foot stretches; foot strengthening (towel crunch; ABC’s); night splint; adjustments |
Bilateral orthotics lead to higher overall _____________, why? | Balance; proprioceptors in feet; recommended for elderly for fall prevention |
Use of heel cups may do what? | Increase shock absorption at heel strike by 49% |
What is the female triad? | Anorexia, amenorrhea, osteoporosis |
What are the 3 types of orthotics? | Rigid, semi-rigid, flexible |
What are the 3 goals of an orthotic? | Decrease shock, absorb shear stress, realign the foot |
What does the rearfoot or medial post do? | Controls calcaneal eversion, controls tibial internal rotation, works from heel strike to mid-stance |
What is a medial post for an orthotic? | A firm foam and/or plastic device that when inserted to the rear arch side portion of the shoe’s midsole, adds support and controls the excess movement of the rearfoot |
What does a varus wedge do? | Medial lift to control pronation; controls velocity of midfoot pronation |
What type of casting does foot leveler’s use? | Weight bearing/functional orthotic w/ foot in natural posture; use scan or foam casting |
What makes up the carpal tunnel? | Tubercle of scaphoid, pisiform, hamulus of hamate and tubercle of trapezium; roof: transverse carpal ligament |
What is inside the carpal tunnel? | Tendons of flexor digitorum profundus, flexor pollicus longus, flexor digitorum superficialis and the median nerve (9 tendons 1 nerve) |
What is outside the carpal tunnel? | Flexor carpi radialis tendon, flexor carpi ulnaris, radial artery |
Which muscle is not in the carpal tunnel and is innervated by the median nerve and is the first to show CTS affects? | Abductor pollicus brevis, first to atrophy, thumb cannot pronate |
What branch of the median nerve lies over the roof of the carpal tunnel? | Palmar branch; if the skin over the carpal tunnel has sensory changes the entrapment is more proximal since this innervation branches off before the carpal tunnel |
What are the common entrapment sites of the median nerve? | Thenar muscles, carpal tunnel, flexor digitorum superficialis, pronator teres, ligament of struthers |
Which hand gets CTS, who gets it most, what movement increases carpal tunnel pressure? | Dominant hand; females 3:1; wrist extension |
What does bilateral CTS indicate? | Strong systemic influence like hypothyroid or pregnancy |
What does CTS do to 2-point discrimination? | Increases, >5mm for median nerve |
What muscle atrophies in late stages of CTS? | Opponens pollicus |
What causes CTS? | Repetitive motion injuries, FOOSH, MVA, Athleticism, Pregnancy, Double crush syndrome |
What is the flick test? | Shaking or wringing of the hands to restore normal sensation (not the same as the TOS nighttime shaking) |
When will conservative treatments not work for CTS? | Neurological deficit plus neurologic signs of median nerve neuropathy |
What are Kaplan’s 5 criteria to predict non-surgical response to treatments? | Patient 50+; Sx >10 months; Constant paresthesias; concurrent stenosing tenosynovitis; Positive Phalen’s test; 1 factor = 60% failure rate, 2 factors =83% failure rate, 3 factors = 93% failure rate |
What nutrition recommendations should be used for non-surgical treatment of CTS? | B6, castor oil, pineapple, bromelain |
What other non-surgical treatments are available for CTS? | Soft tissue, Adjustments and orthopedic splints |
What are muscle tissue facts? | Represents 40% of body weight; over 700 muscles in the body; health and function of muscle leads to life at higher level; anything that detracts from the smooth function of muscles detracts from the quality of life |
What causes MFTP? | Acute muscular overload; trauma; fatigue; chilling |
What are constellation patterns with MFTP? | Joint complexes have recurrent MFTP patterns from patient to patient |
What is the shoulder constellation pattern? | Levator, pec minor, rotator cuff, rhomboids, upper trap, serratus anterior, occipitals |
What is the elbow constellation pattern? | Pronator teres, biceps brachii, wrist extensor group |
What is the neck constellation pattern? | SCM, scalenes, levator scap, occipitals, upper trap (with C0-C2 subluxation) |
What is the low back constellation pattern? | Psoas, erector spinae, QL, glut med/max, piriformis, TFL |
What is the knee constellation pattern? | Vastus medialis, adductor magnus |
What is the most common trigger point in the body? | #1 in the upper trapezius |
What is the finger flexion test and what does it mean? | Have pt flex fingers, if normal then no MFTP; If positive w/ incomplete index finger flexion there is an extensor digitorum MFTP; If positive w/ incomplete flexion of all fingers there is a scalene MFTP affecting flexor digitorum (pics in notes on pg 23) |
What muscle is chief source of proprioception in the head? | SCM; Always injured in MVAs; NO neck circles for rehab! |
What is the 2nd most common MFTP and how does it associate with subluxations? | Levator scapulae; low MFTP = high subluxation (C1, C2), high MFTP = low subluxation (C3, C4) |
What muscle when short leads to increased SCJ pressure? | Pec minor |
If there’s a recurrent MFTP in rhomboids, what to suspect? | SCJ subluxation |
What is the 3rd most common MFTP in the body? | Infraspinatus; Do lie test will tell either GHJ dysfunction or infraspinatus MFTP |
What sort of referral pattern does the subscapularis give? | Strap-like referred pain and tenderness around the wrist like a bracelet |
Describe the closed kinetic chain of the LE. | Sacrum nutates anterior on support side -> body rotation of L5 to support side; femur drops S-I and pelvis tips post-inf; eccentric stretch of piriformis and psoas; femur drops S-I d/t arch drop; internal rot of femur and tib; path pronation |
What does the hip have more of than the shoulder? | Bone/joint problems |
What hip gets more SCFE what can increase the chance of SCFE? | 2:1 L:R; 1 in 1000-1500 but with renal failure 1 in 15 |
What is the ratio of white women and hip fractures? | 1/6 white women will fracture a hip in a lifetime |
Discuss age and percentage of females w/ osteoporosis. | By age 60-70 30% of females will have osteoporosis; by 80, 70-80% |
Describe psoas sign. | Pain w/ internal rotation and extension (looks similar to lewin-gaenslen’s sign); Pain on passive rotation of the thigh, examiner extends thigh while applying resistance to hip |
What nerve and roots are affected in meralgia peresthetica? | Lateral femoral cutaneous n; L2-L3 nerve roots; runs under inguinal ligament 2 in medial to ASIS |
Where do the posterior and anterior branches of the lateral femoral cutaneous nerve run? | Posterior branch runs deep under fascia lata to innervate skin of the gluteal region; anterior branch pierces the fascia to innervate the anterolateral thigh region |
What can cause compression leading to meralgia paresthetica? | Tumor/surgery, obesity, pregnancy, direct trauma, over-stretching |
How does one evaluate for meralgia paresthetica? | Reverse Lasegue’s, femoral stretch, palpation along inguinal ligament, pinwheel, observe for trophic changes and hair loss w/ long term condition |
What is Dr. Homack’s opinion on the piriformis muscle? | It is the only muscle that crosses the SI joint |
What are the 6 criteria for piriformis syndrome? | 1.History of trauma to SI or area 2.Pain at SI, greater sciatic notch; pain down leg and trouble walking 3. Acute exacerbation of pain w/ stopping or walking w/ some relief w/ traction 4.Tender mass at piriformis muscle 5.+ Lasegue’s 6.+ gluteal atrophy |
What does causes piriformis syndrome? | Fibrosis d/t trauma; 50% of patients have a Hx of trauma w/ either direct buttock contusion or hi/lower back torsional injury ; muscle anomalies w/ hypertrophy; partial or total nerve anatomical abnormalities |
What are other causes of piriformis syndrome? | pseudoaneurysms of ing. Gluteal artery; bilat piriformis d/t prolonged sitting during extended neurosurgical procedure; CP; total hip arthroplasty; myositis ossifcans; vigorous physical activity esp w/ external rotation |
What is the common posture w/ piriformis syndrome? | Swayback; shoulders behind a line through the back of the buttocks; fully locked knees and hip joints; poor gluteal development |
How do you evaluate for piriformis syndrome? | Piriformis stretch test, bonnet’s test, freiberg’s maneuver (forceful internal rotaion of extended thigh), Mirkin test (pressing on piriformis muscle after pt has bent forward w/ straight knees), Pace’s maneuver, Beatty’s maneuver |
What is conservative treatment for piriformis syndrome? | heat, stretch, strengthen, deep tissue massage |
Describe medical treatment of piriformis syndrome. | Injection of saline, corticosteroids, anesthetics, botox; surgery of cutting tendon |
What is knee injury in football? | 900x sedentary population |
What is the screw home mechanism of the knee activated? | A moment before heel strike |
What is patellar tendonitis? | Jumper’s knee; pain inferior to patella, responds well to conservative Tx |
What direction does patellar dislocation commonly go? | Superior lateral |
What is the MC patellar injury? | Chondromalacia patella; pain w/ prolonged sitting; pain going down stairs |
What is the patellar loading with activity; walking, climbing stairs, descending stairs and squatting? | Walking = 0.3x body weight; climbing stairs = 2.5x body weight; descending stairs = 3.0x body weight; squatting = 7x body weight |
What treatment can be used for the patella? | Mobilization, decrease aggravating activities, chopat strap, nutrition, decrease inflammation, strengthen associated leg muscles |
What is the menisci function? | stabilization, shock absorption, lubrication, mobile buffering and load bearing |
What is the most commonly injured peripheral nerve? | Peroneal (disputed); injury gives rise to weakness or paralysis of anterior and lateral compartment leg muscles |
What to do w/ vague knee pain? | Adjust fibular head P to A |
What do 4% of people have in reference to the Q angle? | 4 degree difference in Q angle in one leg to the other |
What is the #1 trigger point in the knee? | Vastus medialis w/ referral to the knee and up the belly of the muscle |
What is the #2 trigger point in the knee? | Adductor magnus w/ referral along the antero-medial leg |
What are the secondary functions of the ACL? | Risist IR of the tibia and resist varus/valgus w/ knee in full extension |
What gives knee stability in males and females? | F: ligaments; M: muscles; hamstrings major stabilizers in males and quads in females |
What type of sports are the majority of ACL injuries seen? | non-contact sports like basketball, soccer and volleyball |
What occurs w/ ACL tears? | 70% of the time w/ medial meniscus |
What is the best ACL repair according to notes? | hamstrings makes ACL 240% stronger |
If there is a quick onset of swelling w/ ACL injury what has occurred? | Osteochondral fracture leading to ACL damage and damage to other structures |
Is there a genetic predisposition for ACL injury? | Yes, increased posterior arch height to total area of distal femur; intracondylar stenosis may cause ACL injury |