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NYCC T7 extremity 1

Dr. Homack's Dx & Management of Extremity Conditions midterm

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
Created by: kabrown