DPT731: Final Exam (elbow, wrist, hand, peds)

elbow flexion MMT muscles and nerve root

-biceps (supinated): musc C5-C6
-brachioradalis (neutral): radial C5, C6, C7
-brachialis (pronated): musc C5-C6

elbow extension MMT muscles & nerve root

triceps & anconeus = radial nerve C7-C8

forearm supination MMT muscles and nerve root

-supinator and biceps
-deep branch of radial nerve = C7-C8

forearm pronation MMT muscles and nerve root

-pronators (teres & quad)
-C7 & C8 via median & AIN

normal range for elbow flexion and extension

0-145/150°

normal ROM for forearm supination and pronation

0-80/90°

what special tests assess for UCL/MCL instability

-valgus stress test
-moving valgus stress test
-milking manuever

what special tests assess for RCL/LCL instability

varus stress test

what special tests assess for lateral epicondylitis/tennis elbow

-cozens
-resisted middle finger ext of 3rd digit
-mills

what special tests assess for medial epicondylitis/golfers elbow

-reverse cozens
-reverse mills

what special test assesses PLRI

-lateral pivot shift test of elbow
-stand up/push up test

what special tests assess for median nerve dysfunction at the elbow

-ligament of struthers (elbow flexion)
-lacterus fibrosis
-pronator syndrome
-FDS arch
-pinch grip test (OK sign) = AIN

what special tests assess for radial nerve dysfunction

-EDC
-supinator syndrome

what special tests assess for ulnar nerve dysfunction

-elbow flexion test
-tinel's test at cubital tunnel
-wartenbergs sign

function of humeroulnar medial glide

increase extension

function of humeroulnar lateral glide

increase flexion

function of proximal radioulnar posterior glide

increase pronation

function of proximal radioulnar anterior glide

increase supination

function of distal radioulnar joint anterior glide of distal radius

increase pronation

function of distal radioulnar joint posterior glide of distal radius

increase supination

normal ROM for wrist flexion and functional ROM

-0-80/85°
-functional: 40°

normal ROM for wrist extension & functional ROM

-0-70/80°
-functional = 40°

normal and functional ROM for radial deviation

-0-15/20°
-functional = 10°

normal and functional ROM for ulnar deviation

-0-30/35°
-functional: 30°

normal ROM range for CMC flexion and extension

flexion = 0-15°
extension = 0-20°

normal ROM range for MCP flex/ext of thumb and digits

-thumb: 0-60°
-digits flexion: 0-90°
-digits extension: 0-45°

normal ROM ranges for IP flex/ext of thumb and PIP/DIP flex/ext of digits

-IP thumb = 0-80°
-PIP flexion = 0-100°
-DIP flexion = 0-90°
-DIP extension = 0-10°

wrist flexion w/ ulnar deviation MMT muscle & nerve root

-flexor carpi ulnaris
-ulnar (C7-C8)

wrist flexion w/ radial deviation MMT muscle and nerve root

-flexor carpi radialis
-median (C6-C7)

wrist extension w/ ulnar deviation MMT muscle and nerve root

-extensor carpi ulnaris
-posterior IO (C7-C8)

wrist extension w/ radial deviation MMT muscle and nerve root

-ECRB & longus
-radial nn (C6-C7) & deep branch of radial nn (C7-C8)

MCP digit flexion MMT muscles and nerve root

-lumbricals & interossei
-median nn & deep branch of ulnar nn (C8, T1)

PIP digit flexion MMT muscle and nerve root

-FDS
-median nn (C7, C8, T1)

DIP digit flexion MMT muscle and nerve root

-FDP
-AIN (fingers 2/3 = C8) & ulnar nn (fingers 4/5 = T1)

MP digit extension MMT muscles and nerve root

-ED, extensor indicis, extensor digiti minimi
-posterior IO (C7-C8)

finger ABD MMT muscles and nerve root

-dorasl interossei (DAB) & ABD digiti minimi
-deep branch of ulnar nn (C8-T1)

finger ADD MMT muscle and nerve root

-palmar interossi (PAD)
-deep branch of ulnar nn (C8-T1)

MP thumb flexion MMT muscle and nerve root

-flexor pollicis brevis
-recurrent branch of median nn/deep branch of ulnar nn (C8-T1)

IP thumb flexion MMT muscle and nerve root

-flexor pollicis longus
-AIN (C8-T1)

MP thumb extension MMT muscle and nerve root

-extensor pollicis brevis
-posterior IO (C7-C8)

IP thumb extension MMT muscle and nerve root

-extensor pollicis longus
-posterior IO (C7, C8)

thumb opposition MMT muscles and nerve roots

-opponens pollicis: recurrent branch of median (C8-T1)
-opponens digiti minimi: deep branch of ulnar (C8-T1)

thumb ADD MMT muscle and nerve root

-ADD pollicis
-deep branch of ulnar (C8, T1)

thumb ABD MMT muscle and nerve root

-ABD pollicis longus
-posterior IO (C7, C8)

radiocarpal joint dorsal glide function

increase flexion

radiocarpal joint ventral glide function

increase extension

radiocarpal joint radial glide function

increase ulnar deviation

radiocarpal joint ulnar glide function

increase radial deviation

midcarpal joint dorsal glide function

increase flexion

midcarpal joint volar glide function

increase extension

midcarpal joint radial glide function

increase ulnar deviation

midcarpal joint ulnar glide function

increase radial deviation

what special tests assess median nerve dysfunction at wrist

-phalens & reverse phalens
-carpal compression test
-tinels sign
-OK sign (AIN injury)

what special tests assess ulnar nerve dysfunction at wrist

-forments sign
-tinels sign at guyons canal

what special test assesses muscle length of intrinsics

Bunnel-littler test

what special test asseses for DeQuervain's

Finklesteins

what special test asseses for vascular issues

Allens

what special test assess for instability at hand

-UCL of thumb/collateral lig testing
-watson test (scaphoid shift test)
-scapholunate ballottement test (SL joint)
-lunotriquetral ballottement test (LT joint)
-piano key test/DRUJ ballottement

what special tests assess joints of hand

-grind test (DJD of MCP or metacarpotrapezial)
-TFCC load test
-pisotriquetral grind test

normal valgus carrying angle in males and females

-male = 5-10°
-female = 10-15°

describe cubitus valgus

excessive carrying angle >15°

describe cubitus varus

decreased carrying angle < 5°

What are the hallmark signs of elbow fracture?

-fat pad sign
-hx of trauma
-inability to fully extend elbow**

describe olecranon fx

-most common in elderly
-FOOSH & land on olecranon
-displaced fx most common

What accounts for 1/3 of all elbow fractures

-females > males

-20-60 y/o

-occur in 10% of all elbow dislocations

-MOI: FOOSH, directly blow, or hyperflexion

radial head fx

supracondylar fx prevalence & population

-common in children under age of 10
-boys > girls
-fall on extended elbow

what makes up a terrible triad

-elbow dislocation
-radial head fx
-coronoid fx

complex dislocation/instability ORIF indications

-elbow instability fx (most commonly radial head/neck)
-extensive tissue damage

radial head excision indications

-substantial fx of radial head
-UCL intact

radial head replacement indications

-severe fx
-w/ UCL or RCL injury leading to instability

total elbow arthroplasty (TEA) indications

-advanced age
-low physical demand
-chronic instability, pain
-advanced RA (primary indication)
-post-traumatic OA
-ankylosis of elbow
-elbow stiffness, functional ROM loss

common complications related to elbow surgical intervention

-elbow stiffness (#1 = loss of elbow ext & supination)
-heterotopic ossificans
-instability
-non-union
-post-traumatic arthrosis

management of elbow stiffness

-early AROM/PROM
-modalities/meds for pain; MT
-sustained stretching program (low load prolonged stretches)
-surgical mgmt if contracture present for 12 months or lack functional ROM

When & where does heterotopic ossification commonly occur in the arm?

-high risk 2 months after trauma
-common location = b/t brachialis & anterior capsule or b/t triceps & posterior capsule

describe neuropraxia

-focal demyelination or ischemia
-compression but no disruption to sheath or nerve
-leg falling asleep

describe axonotmesis

-damage to connective tissue
-axon disrupted but sheath remains intact
-LT carpal tunnel

describe neurotmesis

-complete transection of nerve
-axon and sheath disrupted

sxs of forearm compartment syndrome (5 P's)

-pain
-pallor
-passive stretch pain
-paresthesias
-pulselessness

lateral elbow pain (lateral epicondylalgia) diff dx

-cervical radic C6-C7
-radial tunnel syndrome
-PLRI
-posterior interosseous syndrome
-intra-articular disease

medial elbow pain diff dx

-medial epicondylitis
-cervical radic C7-T1
-TOS
-shoulder conditions
-ulnar nerve entrapment
-UCL injury/instability

role of anterior joint capsule

restraint against varus & valgus force w/ elbow in full ext

RCL/LCL function

-varus restraint (restricts medial angulation of ulna on humerus)
-posterolateral rotatory restraint
-taut in supination

MCL/UCL function

-valgus restraint
-medial posterior rotatory stability

common entrapment sites of ulnar nerve at elbow

-arcade of struthers
-cubital tunnel
-flexor carpi ulnaris

common entrapment sites of median nerve at elbow

-ligament of struthers
-lacterus fibrosis
-pronator teres
-FDS

common entrapment sites of radial nerve at elbow

-fibrous bands at radial head
-leash of henry
-ECRB
-arcade of frohse
-supinator

what signs would occur if the superficial radial nerve becomes entrapped

sensory changes and pain (no motor changes)

what signs would occur if the PIN became entrapped

motor changes/weakness and pain (no sensory changes)

what are the contraindications when working with a child who has osteogenesis imperfecta

-do not put force across long bones
-do not use pull-to-sit maneuver
-do not use infant baby walkers or jumping seats

how to diagnose a child w/ arthrogryposis multiplex congenita

child must demonstrate >=2 contractures
-foot (clubfoot deformity)
-hip (flexed, ABD, ER)
-wrist (volar & UD)
-knee (flexion deformity)
-elbow (extension & pronation)
-shoulder (IR deformity)

What are the precautions when working w/ a child who has arthrogryposis multiplex congenita?

avoid activities that pose risk of increased deformity

describe benign paroxysmal torticollis

recurrent head tilts, accompanied by vomit, pallor, irritability, ataxia, & drowsiness

describe congenital muscular torticollis

-tightness & thickening of SCM w/ or w/o fibrotic thickening w/in muscle belly
-unilateral shortening of SM, lateral cervical flexors, & levator scap resulting in ↓ ipsilateral rot, ↓ contralateral lateral flex, asymmetric flexion & ext
-often caused by positioning in utero, overuse of positioning in car seats/bouncy seats, lack of prone play

describe neurogenic torticollis

an acute episode that usually occurs in older children w/ neurological abnormalities

describe osseus torticollis

congenital cervical spine malformations often including vertebral anomalies (hemivertebrae)

describe postural torticollis

-the infants postural preference but no tightness or tumor of SCM
-mildest form of torticollis

treatment methods for child with torticollis

-alternate positioning of crib & changing table, feeding position
-minimize time in car seat & infant carriers
-carry infant in side lying w/ tighter side down
-position infant in side lying on affected side
-prone lying w/ neck turned to affected side

What involves C5-C6 (all musculature at these levels, including scap & UE)
-UE positioned in shoulder ext, IR, & ADD, elbow ext, forearm pronation & wrist flex (waiters tip)

Erb's palsy

describe klumpkes palsy/paralysis

-involves C7-T1
-shoulder & elbow position are typical, but forearm is held in supination
-atrophy & weakness of forearm muscles, hand, & triceps
-sensory loss on ulnar side of forearm & hand

What involves T1 (avulsion of T1 w/ autonomic sxs)
-ptosis (drooping of upper eyelid)

Horners syndrome