ortho iii exam 2 study guide

posterior interosseous nerve injury presentation

• lateral forearm pain

• weak finger ext

• preserved wrist ext but it radially deviates (ECU paralyzed)

posterior interosseous nerve injury special tests

• resisted supination

• resisted 2nd digit ext, thumb ext & ABD (resisted L, L lift, hitchhiker)

anterior interosseous nerve injury presentation

• can’t do “ok” sign

• weak thumb IP flexion and index DIP flexion

• no sensory loss

anterior interosseous nerve injury special tests

• pinch grip/ok sign

• pronator teres syndrome (median nerve)

carpal tunnel syndrome presentation

• numbness/tingling in tips of thumb/fingers

• decreased pinch grip

• night time numbness!!!!!!!

• weak FPL, FDP, & APB

carpal tunnel syndrome special tests

• phalen’s

• tinel’s @ carpal tunnel

• durkan’s

medial (ulnar) collateral ligament injury presentation

• medial elbow pain w/ throwing and overhead activities

• swelling

• limited PROM/AROM

• instability

medial (ulnar) collateral ligament special tests

• valgus stress

• moving valgus stress

• milking maneuver

lateral collateral ligament special tests

• varus stress

• lateral pivot shift

• chair push up

lateral collateral ligament injury presentation

• lateral elbow pain

• sense of instability

• clicking/locking

MOI of lateral collateral ligament

• varus stress/trauma

• posterolateral rotatory injury (LUCL)

MOI of medial (ulnar) collateral ligament

• repetitive valgus overload (throwing)

• active valgus stress (FOOSH)

cozen’s interpretation

positive test = pain @ lateral epicondyle → lateral epicondylitis (ECRB & ECRL)

maudsley’s interpretation

positive test = pain over lateral epicondyle → lateral epicondylitis/epicondylalgia (ECRB & ED tendon involvement)

mill’s interpretation

positive test = pain @ lateral epicondyle → lateral epicondylitis due to PASSIVE TENSION

how to manage medial/lateral epicondylitis

acute/conservative

• activity modifications

• RICE, NSAIDS

• splint/orthotics

surgery

• only do if they don’t get better after 6-12 months

what exercises do u do for medial/lateral epicondylitis

• eccentric loading

• stretching

• manual therapy

• TFM

• soft tissue mob

• isometrics

cubital tunnel syndrome presentation

• sensory changes in medial forearm & digits 4/5

• intrinsic muscle weakness

cubital tunnel syndrome special tests

• tinel’s sign over cubital tunnel

• pressure provocation

guyon’s canal presentation

• sensory changes in digits 4 & 5 PALMAR side

• hypothenar atrophy

• claw hand @ rest

guyon’s canal special tests

• froment

• claw hand

• wartenberg

carpal tunnel syndrome special tests

• tinel’s

• phalen’s

• durkan’s, 2 point discrimination > 5mm

pronator teres syndrome presentation

• pain over proximal volar (palmar) forearm

• pain w/ repetitive pronation or elbow flexion

• sensory loss to palm and digits 1-3

• weakness of FPL, FDP, APB

pronator teres syndrome special tests

• pronator teres

• pain w/ resisted pronation & elbow flexion

radial tunnel syndrome presentation

• TTP distal to lateral epicondyle

• difficulty gripping

• pain worsens w/ forearm movements

• no sensory/motor disturbances

what do u use nirschl’s phases for

medial/lateral tendinopathy phases

nirschl’s phase 0

no pain or soreness

nirschl’s phase 1

• no stiffness/soreness @ rest

• soreness after activity and gone within 24 hours of activity

nirschl’s phase 2

• mild stiffness/soreness @ rest

• no pain during activity

• mild soreness lasting 24 hrs after activity

nirschl’s phase 3

• mild-moderate stiffness/soreness @ rest

• mild pain during activity → does NOT affect activity

nirschl’s phase 4

pain during activity that ALTERS activity

nirschl’s phase 5

constant pain even @ rest

what nirschl phases do u not work w/

3-5

swan neck presentation

inability to make a fist → due to loss of PIPJ flexion

boutonniere presentation

• inability to actively extend PIP

• prominent flexion deformity

what is swan neck & boutonniere deformities

• swan neck: DIPJ flexion and PIPJ hyperextension

• boutonniere: PIPJ flexion and DIPJ extension

what does a posterior glide of distal RU joint help

supination

what does an anterior glide of distal RU joint help

pronation

what does an anterior glide of RC & UC joints help

wrist extension

what does an posterior glide of RC & UC joints help

• wrist flexion

• MOVING IN DORSAL DIRECTION

what does a medial glide of RC & UC joints help

radial deviation

what does an lateral glide of RC & UC joints help

ulnar deviation

OPP for distal radioulnar joint

10° supination

OPP for RC, UC, and MCP joints

slight wrist flex & ulnar deviation

varus instability special test

ligamentous varus instability

valgus extension overload syndrome special tests

• arm bar

• extension/posterior impingement test

ulnar nerve involvement special tests

• elbow flexion

• pressure provocation

• tinel’s @ elbow

median nerve involvement special tests

• pronator teres syndrome

• pinch grip

what is radial tunnel syndrome

compression of posterior interosseous nerve from the SUPINATOR

how to perform active test

• Sitting

• pt actively moves hand into wrist flexion, forearm pronation

• PT applies resistance in supination and wrist ext

how to perform passive test

• Palpate medial epicondyle

• passively supinate and extend the elbow and wrist

how to perform cozen’s

• sitting

• Stabilize elbow with thumb rested on lateral epicondyle, actively make a fist, pronate and radially deviate → ext wrist while PT resists motion

how to perform mill’s

• Sitting

• PT passively moves forearm into pronation, wrist flexion, elbow extension 

• *can compress radial nerve = false positive → use Maudley’s to differentiate

how to perform maudsley’s

• Sitting

• Neutral wrist, forearm pronated, fingers relaxed, resist 3rd digit extension

how to perform valgus stress

• Sitting/supine

• Patient’s elbow slightly flexed 20-30 degrees

• apply a valgus force

how to perform moving valgus stress

• Sitting

• Patient’s arm is in 90 ABD, 120 elbow flexion, apply a valgus force at elbow as the patient reached full ER

• In full flexion = posterior bundle, in extension – anterior bundle

how to perform milking maneuver

• Sitting

• The patient supports elbow with opposite forearm, and pulls thumb laterally. PT can palpate UCL or pull them for patient

how to perform varus instability

• Sitting/ Standing

• Apply varus force at elbow

how to perform extension impingement test/posterior medial impingement

• sitting

• apply valgus stress as u extend elbow

how to perform arm bar

• sitting

• fully IR arm, hyperextend the elbow

• forceful extension

how to perform lateral pivot shift

• supine w/ arm overhead

• palpate radial head

• supinate forearm and apply valgus force when u flex the elbow

how to perform chair push up

• Seated in a chair

• Maximally supination position + tension of radius is similar to lateral pivot shift

• supination → stand up (pain present)

• pronation → stand up (should have no complaints of pain)

how to perform elbow flexion

• sitting

• Flex elbows, supinate arms, and extend both wrists

• can add overpressure

how to perform pressure provocation

• sitting

• Place pressure just proximal to the cubital tunnel (proximal to medial epicondyle)

how to perform tinel’s sign @ elbow

• Sitting

• Tap the cubital tunnel / ulnar groove

how to perform pronator teres syndrome test

• Sitting

• Elbow is flexed to 90 degrees, PT grabs patient’s hand in a handshake position

• pt pronates

• PT supinates & pasisvely moves arm into ext.

how to perform pinch grip

make OK sign

how to perform resisted supination

• Elbow is flexed to 90 degrees

• PT grabs patient’s hand in handshake position

• pt resists supination

radial nerve involvement tests

• Patient sitting or standing

• can be one of the following

  • resisted L shape

  • lifting L off table

  • hitchiker

positive test for active test

pain @ medial epicondyle

positive test for passive test

pain @ medial epicondyle

positive test for cozen’s

sudden pain over lateral epicondyle

positive test for mill’s

pain over lateral epicondyle

positive test for maudsley’s

• pain over lateral epicondyle (ED and ECRB)

positive test for valgus stress

pain or increased excursion over UCL

positive test for moving valgus stress

pain

positive test for milking maneuver

pain & laxity over UCL

positive test for varus instability

pain or laxity

positive test for extension impingement test/posterior medial impingement

posterior pain

positive test for arm bar

posterior pain

positive test for lateral pivot shift

• apprehension - radial head will dislocate

• palpable clunk w/ subluxed radial head

positive test for chair push up

• apprehension w/ supination

• radial head will dislocate

• palpable clunk w/ subluxed radial head eduction

positive test for elbow flexion

tingling or paresthesia in ulnar nerve distribution

positive test for pressure provocation test

tingling or paresthesia in ulnar nerve distribution

positive test for tinel’s sign @ elbow

tingling or paresthesia in ulnar nerve distribution

positive test for pronator teres syndrome test

pain or discomfort → compression of medial nerve

positive test for pinch grip

can’t touch tips of finger

positive test for resisted supination

pain or discomfort

positive test for radial nerve involvement tests

• reproductive of symptoms

• general lack of control

• weakness

how to perform phalen’s

press dorsum of hands together with fingers pointing down

• reverse praying

positive test for phalen’s

tingling in digits 1-3 and lateral half of ring finger

how to perform froment’s

• hv pt grab piece of paper w/ thumb and index finger

• pull paper away

positive test for froment’s

DIP of thumb flexed

how to perform wartenburg’s sign

• hand on table (palm down) with fingers ext.

• hv pt ABD/ADD fingers

positive test for wartenburg’s sign

5th digit stays ABD

what does a posterior glide of humeroradial joint help

extension

what does an anterior glide of humeroradial joint help

flexion

OPP for humeroradial joint

full ext and supination

OPP for proximal radioulnar joint

• 70° elbow flex

• 35° supination

what does a posterior glide of proximal radioulnar joint help

pronation