OSTEOPATHIC APPROACH TO UPPER EXTREMITY - PDF Document

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  1. OSTEOPATHIC APPROACH TO UPPER EXTREMITY ANATOMY, INJURIES, TREATMENTS & OMT DR. SAUNDRA HOLSETH FM/NMM FOMA SEPT. 2018

  2. DISCLOSURES • I HAVE NO COMMERCIAL, FINANCIAL OR LEGAL DISCLOSURES

  3. OBJECTIVES o BASIC ANATOMY REVIEW OF THE UPPER EXTREMITY, WITH KEY AREAS OF THE SHOULDER, ELBOW, WRIST AND HAND o COMMON INJURIES- SHOULDER, ELBOW, WRIST AND HAND o MECHANISM OF INJURY o DIAGNOSIS o TREATMENTS o UPPER EXTREMITY OSTEOPATHIC MANIPULATIVE TREATMENTS

  4. SHOULDER ANATOMY o SHOULDER IS THE PROXIMAL SEGMENT OF THE UPPER EXTREMITY AND CONNECTS IT TO THE AXIAL SKELETON o IT INCLUDES THE PECTORAL, SCAPULAR AND DELTOID REGIONS o LIGAMENTS- TRANSVERSE HUMERAL LIG, SUPERIOR ACROMIOCLAVICULAR LIG, CORACO- ACROMIAL LIG, CORACOCLAVICULAR LIG, INTERCLAVICULAR LIG, ANTERIOR STERNOCLAVICULAR LIG, COSTOCLAVICULAR LIG o JOINT CAPSULE- GLENOID LABRUM o TENDONS- BICEPS TENDON, SITS MUSCLES, TRICEPS TENDON o BURSAE- SEMITENDINOUS BURSAE OF SUBSCAPULARIS, SUBDELTOID BURSAE, SUBACROMIAL BURSAE, SUBCORACOID BURSAE o THE BONES THAT MAKE UP THE SHOULDER CONSIST OF o STERNUM o CLAVICLE o SCAPULA o HUMERUS

  5. SHOULDER ANATOMY- JOINTS THERE ARE 5 TOTAL JOINTS o ACROMIOCLAVICULAR JOINT DIARTHRODIAL JOINT THAT ALLOWS MOTION IN ALL 3 PLANES. ENCLOSED BY A CAPSULE. o STERNOCLAVICULAR JOINT JOINT CAPSULE THICKENED BY 4 LIGAMENTS. ALLOWS MOVEMENT OF DISTAL CLAVICLE IN SUPERIOR, INFERIOR, ANTERIOR AND POSTERIOR DIRECTION. o CORACOCLAVICULAR JOINT SCAPULA AND THE INFERIOR DISTAL CLAVICLE. ATTACHED BY THE CORACOCLAVICULAR LIGAMENT. VERY LITTLE MOVEMENT IS PERMITTED HERE. o SCAPULOTHORACIC JOINT CURVED SURFACE OF LOOSE CONNECTIVE TISSUE o GLENOHUMERAL JOINT HUMERUS) SYNOVIAL JOINT THAT PERMITS WIDE RANGES OF MOTION. HOWEVER, THIS MAKES THE JOINT RELATIVELY UNSTABLE. SURROUNDED BY A JOINT CAPSULE THAT IS REINFORCED BY THE SITS MUSCLES TO ADD STABILITY. THERE ARE 5 TOTAL JOINTS- - ACROMIOCLAVICULAR JOINT- - ACROMION OF THE SCAPULA AND THE DISTAL CLAVICLE. A STERNOCLAVICULAR JOINT- - MANUBRIUM OF THE STERNUM AND THE CLAVICLE. HAS A CORACOCLAVICULAR JOINT- - SYNDESMOSIS JOINT OF THE CORACOID PROCESS OF THE SCAPULOTHORACIC JOINT- - PERMITS THE SCAPULA TO GLIDE ALONG THE THORAX ON A GLENOHUMERAL JOINT- - BALL AND SOCKET (GLENOID FOSSA OF THE SCAPULA AND THE

  6. SHOULDER ANATOMY- MUSCLES o PECTORALIS MAJOR o PECTORALIS MINOR o SUBCLAVIUS o SERRATUS ANTERIOR o LEVATOR SCAPULAE o RHOMBOID MAJOR o RHOMBOID MINOR o DELTOID o CORACHOBRACHIALIS o SUPRASPINATUS o INFRASPINATUS o SUBSCAPULARIS o TERES MINOR o TERES MAJOR o TRICEPS o BICEPS o LATISSIMUS DORSI

  7. MOTION AT THE SHOULDER o EXTENSIVE ROM AT THE SHOULDER IS DUE TO THE LOOSE GLENOHUMERAL JOINT AND LIMITED BONY ARTICULATIONS o MOVEMENT TYPICALLY INVOLVES ROTATION AT THE SC, AC AND GH JOINTS IN COMBINATION o SCAPULOHUMERAL RHYTHM IS A KEY ELEMENT IN ANY MOVEMENT AT THE SHOULDER, IT ENABLES GREATER ROM o THE SCAPULA HAS ITS OWN ROM o PRIMARY MOTIONS AT THE GH INCLUDE: FLEXION, EXTENSION, ABDUCTION, ADDUCTION, MEDIAL AND LATERAL ROTATION

  8. SCAPULAR MOTION

  9. SHOULDER ANATOMY- NERVES o MOST NERVES OF THE UPPER EXTREMITY ARISE FORM THE BRACHIAL PLEXUS o IT EXTENDS FROM THE NECK TO THE AXILLA o FORMED FROM THE ANTERIOR RAMI OF C5-C8 AND T1

  10. DIAGNOSING A SHOULDER INJURY

  11. STINGERS o AKA BURNER SYNDROME o TRANSIENT STINGING AND BURNING SENSATIONS FROM FORCEFUL CONTACT TO NECK AND ANTERIOR SHOULDER REGION o TRANSIENT DYSFUNCTION TO THE BRACHIAL PLEXUS o USUALLY OF THE UPPER PLEXUS o SYMPTOMS USUALLY RESOLVE IN MINUTES TO HOURS TO DAYS o EMG IF SYMPTOMS LAST GREATER THAN 3 WEEKS o USUALLY DON'T NEED TO WORK UP, NO SPECIAL TESTS. o R/O OTHER INJURIES

  12. AC SPRAINS o SPRAINS- RUPTURE OR PARTIAL RUPTURE TO THE AC AND OR CORACOCLAVICULAR LIGAMENT o USUALLY THE RESULT OF A DIRECT BLOW TO THE AC JOINT, FALL TO THE POINT OF THE SHOULDER, FOOSH INJURY o CLASSIFICATION IS BASED ON THE SEVERITY AND THE LIGAMENT INVOLVED

  13. AC SPRAIN TX TX- - I AND II: ONLY IF PAIN IS PRESENT. INJECTION MAY BE BENEFICIAL IF PAIN AND SWELLING ARE PERSISTENT. III: WEEKS THEN PENDULUM EXERCISES, ELBOW ROM EXERCISES, ALL PLANE ISOMETRICS, ROPE AND PULLEY EXERCISES AS TOLERATED. SURGICAL FIX- START PENDULUM AND ISOMETRIC EXERCISES BEFORE SURGERY, LIMITED ABDUCTION AND FLEXION ROM FOR 3-4 WEEKS AFTER SURGERY. RETURN TO SPORTS MAY TAKE 10-12 WEEKS, WITH CONTACT SPORT RETURN AT 3-5 MONTHS. IV FROM 4-6 WEEKS AFTER WHICH A PROGRESSIVE ROM AND STRENGTHENING PROGRAM IS BEGUN. RETURN TO SPORT PERMITTED ABOUT 6 MONTHS AFTER RE- MOBILIZATION BEGINS AND ISOMETRIC TESTING IS EQUAL TO THE CONTRALATERAL SIDE. I AND II: RICE, NSAIDS, ROM EXERCISES AS TOLERATED. IMMOBILIZATION IN SLING o III: MOST TREATED CONSERVATIVELY- IMMOBILIZATION IN A SLING FOR 2-4 o IV- -VI: VI: OPEN OR ARTHROSCOPIC INTERVENTION IS NECESSARY. IMMOBILIZATION o

  14. AC SPECIAL TESTS oAC SHEAR TEST oPIANO KEY TEST- SPRING TEST oAC COMPRESSION / DISTRACTION TEST

  15. ADHESIVE CAPSULITIS o AKA FROZEN SHOULDER A CONDITION OF VARYING SEVERITY CHARACTERIZED BY THE GRADUAL DEVELOPMENT OF GLOBAL LIMITATION OF AROM AND PROM WITHOUT OSTEOPENIA AND WITH SEVERE SHOULDER PAIN PAINFUL PROGRESSIVE STIFFENING OF THE SHOULDER PRIMARILY IDIOPATHIC, BUT MAY BE ASSOCIATED WITH OTHER DISEASE OR INJURIES SY: 3 PHASES: 1) PAIN THAT’S WORSE AT NIGHT WITH INCREASED STIFFNESS OVER 2-9 MONTHS, 2) INTERMEDIATE STIFFNESS, LOSS OF ROM, LESS PAIN OVER 4-12 MONTHS, 3) RECOVERY, GRADUAL RETURN OF ROM OVER THE NEXT 5-24 MONTHS DG: USUALLY A CLINICAL DIAGNOSIS BASED ON HISTORY AND PHYSICAL EXAM TX: SHORT COURSE ORAL STEROIDS, OMT, PT, INJECTIONS, DILATIONS, SURGICAL RELEASE o o o o o o

  16. ROTATOR CUFF INJURIES o TENDINOPATHY, RUPTURE, PARTIAL TEARS o SY: TENDERNESS AT THE INSERTION POINTS OF THE TENDON, NORMAL TO DECREASED ROM, NORMAL TO DECREASED STRENGTH, PAIN WITH ROM AND OR TESTING o DG: PHYSICAL EXAM, US, MRI, SPECIAL TESTS o TX: o CONSERVATIVE: ICE, REST, ACTIVITY MODIFICATIONS, NSAIDS, PT, OMT, STIM o INJECTIONS, CRYOTHERAPY, SURGERY

  17. ROTATOR CUFF SPECIAL TESTS oLIFT OFF TEST (GERBER’S TEST)- SUBSCAPULARIS, SHOULDER INSTABILITY oDROP ARM TEST – SUPRASPINATUS oEMPTY CAN TEST- SUPRASPINATUS oFULL CAN TEST- SUPRASPINATUS oINFRASPINATUS TEST oHORNBLOWER’S TEST (PATTE TEST) oRENT SIGN

  18. IMPINGEMENT o IMPLIES THAT THERE IS AN ACTUAL MECHANICAL ABUTMENT OF THE ROTATOR CUFF AND THE SUBACROMIAL BURSA AGAINST THE CORACOACROMIAL LIG AND THE ACROMION o USUALLY DUE TO A FORCE OVERLOAD TO THE ROTATOR CUFF OF AND BURSA DURING ABDUCTION, FORWARD FLEXION AND MEDIAL ROTATION- RESULTING IN COMPRESSION BETWEEN THE HUMERAL HEAD AND THE ACROMION o SY: PAIN THAT IS USUALLY DEEP, WORSE AT NIGHT, WORSE WITH IMPINGEMENT ACTIVITIES, TENDER TO PALPATION AT THE SUBACROMIAL SPACE, +/- SITS MUSCLE ATROPHY o THERE ARE MULTIPLE STAGES OF IMPINGEMENT o DG: PHYSICAL EXAM, X-RAYS, US, MRI OR CT, SPECIAL TESTS, o TX: REST, NSAIDS, STIM, MESSAGE, CRYOTHERAPY, PT, OMT, INJECTIONS, SURGERY

  19. IMPINGEMENT SPECIAL TESTS oHAWKINS- KENNEDY TEST oJOBE TEST oHORIZONTAL ADDUCTION TEST oNEER TEST

  20. LABRUM INJURIES o TEARS MAY OCCUR DUE TO DEGENERATION, TRAUMA, OR AGE, MANY TIMES ARE INCIDENTAL FINDINGS AND ASYMPTOMATIC o BANKART LESION- TEARING OF THE LABRUM AND INFERIOR GLENOHUMERAL LIG, ASSOCIATED WITH ANTERIOR SHOULDER INSTABILITY o SLAP LESION- SUPERIOR LABRUM TEAR THAT DISRUPTS THE ATTACHMENT OF THE LONG HEAD OF THE BICEPS TENDON. THERE ARE 4 TYPES OF SLAP TEARS o SY: PAIN, CATCHING OR WEAKNESS, ESPECIALLY WITH OVERHEAD MOTION, +/- POPPING AND CLICKING IN JOINT o DG: PHYSICAL EXAM, MRI OR CT OR US, SPECIAL TESTS o TX: o CONSERVATIVE: REST, NSAIDS, PT, OMT, INJECTIONS o SURGICAL- ARTHROSCOPIC DEBRIDEMENT, SURGICAL REPAIR/FIXATION

  21. LABRAL SPECIAL TESTS oBICEPS LOAD TEST- TESTS THE SUPERIOR LABRUM oCOMPRESSION ROTATION TEST oO’BRIEN TEST- SLAP LESION oCLUNK OR GRIND TEST

  22. BURSITIS o USUALLY ASSOCIATED WITH OTHER INJURIES o I.E.: IMPINGEMENT, DEGENERATIVE CHANGES, TENDINOPATHIES, ROTATOR CUFF PATHOLOGY o WITH CERTAIN MOVEMENTS BURSA BECOME IMPINGED o SY: SUDDEN SHOULDER PAIN, POINT TENDERNESS AT THE ANTERIOR AND LATERAL ACROMION PROCESS, PAINFUL ARC BETWEEN 70-120 DEGREES, INABILITY TO SLEEP ON AFFECTED SIDE, PAIN MAY BE REFERRED TO THE DISTAL DELTOID ATTACHMENT SITE o DG: PHYSICAL EXAM, US o TX: REST, NSAIDS, ICE, PT, OMT, INJECTION o TREAT THE UNDERLYING CAUSE: ADJUST MOVEMENTS, STRENGTHING THE SURROUNDING MUSCLES, ETC.

  23. SHOULDER DISLOCATIONS o 3 MAIN DIRECTIONS OF DISLOCATION- ANTERIOR, POSTERIOR AND INFERIOR o ACUTE: HAVE ASSOCIATED FRACTURE AND NERVE DAMAGE, CONSIDERED A SERIOUS INJURY, NEEDS TO BE REDUCED RIGHT AWAY o INTENSE PAIN, +/- NUMBNESS o CHRONIC: RECURRENT OR “TRICK” DISLOCATIONS, TEND TO BE ANTERIOR AND INTRACAPSULAR, DECREASED FORCE NEED TO OCCUR, CREPITUS AND CLICKING NORMAL, DEAD ARM SYNDROME o DG: PALPATION, MOI, VISUALIZATION, X-RAYS o TX: REDUCTION, +/- IMMOBILIZATION 3-6 WEEKS, REST, ICE, NSAIDS, PT, OMT, SURGERY

  24. SHOULDER DISLOCATIONS ANTERIOR- - BLOW TO THE SHOULDER WITH THE ARM ABDUCTED, EXTERNALLY ROTATED AND IN EXTENSION, HUMERAL HEAD IN FRONT OF THE ACROMION, PROMINENT ACROMION PROCESS, WONT MOVE ARM ACROSS CHEST o POSTERIOR ADDUCTION AND INTERNAL ROTATION, FLAT ANTERIOR SHOULDER, PROMINENT POSTERIOR, CORACOID PROCESS PROMINENT, CANT EXTERNALLY ROTATE ARM, LIGHT BULB SIGN ON X-RAY o INFERIOR OR FORCEFUL HYPERABDUCTION, FALL AND OPPOSITE ARM USED TO CATCH SELF, ARM HELP ABOVE HEAD AND CAN NOT ADDUCT ARM, FOREARM PRONATED, HUMERAL HEAD BELOW THE CORACOID OR GLENOID o ANTERIOR POSTERIOR- - BLOW TO THE ANTERIOR SHOULDER WITH AXIAL LOADING OF INFERIOR- - AKA LUXATRO ERECTA, AXIAL LOADING WITH ARM FULLY ABDUCTED

  25. Light bulb sign Hill-sachs deformity

  26. GLENOHUMERAL INSTABILITY/DISLOCATION SPECIAL TESTS oAPPREHENSION TEST (CRANK TEST) oANTERIOR/ POSTERIOR LOAD AND SHIFT TEST oJERK TEST oRELOCATION TEST oPOSTERIOR APPREHENSION TEST oSULCUS SIGN- INFERIOR OR MULTIDIRECTIONAL INSTABILITY

  27. SCAPULAR FRACTURES o FRACTURE MAY OCCUR DUE TO A FOOSH OR A DIRECT BLUNT TRAUMA TO THE SCAPULA o SY: MOST RESULT IN MINIMAL DISPLACEMENT, LOCALIZED HEMORRHAGE OR EDEMA, RELUCTANCE TO MOVE ARM, PAINFUL ABDUCTION, PATIENT KEEPS ARM IN ADDUCTION o DG: X-RAYS WITH MULTIPLE VIEWS, CT SCAN o TX: o CONSERVATIVE: IMMOBILIZATION IN SLING AND SWATHE, CRYOTHERAPY WITHIN THE FIRST 48 HRS, THEN MINIMAL MOVEMENT AND PASSIVE STRETCHING o SURGICAL: IF SIGNIFICANT DISPLACEMENT OR OTHER ASSOCIATED FRACTURES, ANGULATION OF THE NECK OF THE SCAPULA- METAL PLATES AND SCREWS ARE USED TO HOLD THE PIECES TOGETHER, THEN BRACING AND REHAB

  28. SCAPULAR WINGING o SCAPULA PROTRUDES POSTERIORLY, APPEARS LIKE A WING ON THE BACK o USUALLY ASYMPTOMATIC o DG: EMG TO NERVE, MUSCLE AND STRENGTH TESTING, SHOULDER STABILITY TESTING o 2 MAIN TYPES o TO COMPRESSION INJURY, REPETITIVE STRETCH INJURY OR PREVIOUS ANESTHESIA. WEAKNESS WITH LIFTING AWAY FROM BODY OR OVERHEAD. TX CONSERVATIVELY, STRENGTHENING, o NECK SURGERY. DROOPING OF SHOULDER, ANTERIOR SCALENE WASTING. TX: CONSERVATIVE-TRAP STRENGTHENING MEDIAL WINGING- SERRATUS ANTERIOR AND LONG THORACIC NERVE. DUE LATERAL WINGING- TRAPEZIUS AND SPINAL ACCESSORY NERVE. HX OF

  29. SCAPULAR DYSKINESIS o SCAPULAR MALPOSITION, ASYMMETRIC SCAPULAR POSITIONING AND ALTERED MOTION o USUALLY CAUSED BY NEUROLOGIC INJURY, KYPHOSIS OF THE THORACIC SPINE, PERISCAPULAR MUSCLE FATIGUE, POOR MOVEMENT MECHANICS, SECONDARY TO PAIN o SY: ANTERIOR SHOULDER PAIN, AFFECTED SCAPULA LOWER AND DISPLACED, MINIMAL SCAPULAR WINGING, SCAPULOTHORACIC CREPITUS o DG: PHYSICAL EXAM (X-RAYS USUALLY UNREMARKABLE) o TX: CONSERVATIVE- NSAIDS, PT TO STRENGTHEN AND STABILIZE THE SHOULDER GIRDLE, OMT, INJECTIONS

  30. SCAPULAR SPECIAL TESTS oSERRATUS WALL TEST (SCAPULAR WINGING TEST) oSCAPULAR REPOSITIONING TEST (SCAPULAR STABILIZATION OR SCAPULAR RETRACTION) oSCAPULAR ASSISTANCE TEST

  31. ELBOW ANATOMY o CARRYING ANGLE- ANGLE BETWEEN THE HUMERUS AND THE ULNA IN ANATOMICAL POSITION, AS THE FOREARM ANGLES AWAY FROM THE BODY. o LIGAMENTS- LATERAL (RADIAL) COLLATERAL LIG, MEDIAL (ULNAR) COLLATERAL LIG, ANNULAR LIG o CAPSULOLIGAMENTOUS STRUCTURE REINFORCES THE ELBOW, FORMS A THICK CAPSULE AROUND THE JOINT o BURSAE- THERE ARE SEVERAL SMALL BURSAE IN THE ELBOW. THE MOST RELEVANT IS THE SUBCUTANEOUS OLECRANON o BONES- o HUMERUS o RADIUS o ULNA

  32. ELBOW ANATOMY JOINTS o HUMEROULNAR JOINT- HINGE JOINT, MOVEMENT IN FLEXION AND EXTENSION. MOST STABLE JOINT IN THE UPPER EXTREMITY o HUMERORADIAL JOINT- GLIDING JOINT, RESTRICTED IN THE SAGITTAL PLANE o PROXIMAL RADIOULNAR JOINT- PIVOT JOINT, WITH MOTION OF SUPINATION AND PRONATION. HELD IN PLACE BY ANNULAR LIGAMENT JOINTS MOTION AT THE ELBOW o 3 JOINTS ALLOW MOTION IN 2 PLANES o FLEXION AND EXTENSION IN THE SAGITTAL PLANE o BRACHIALIS IS THE PRIMARY FLEXOR o TRICEPS IS THE PRIMARY EXTENSOR o PRONATION AND SUPINATION IN LONGITUDINAL ROTATION MOVEMENTS. OCCURS AT THE PROXIMAL RADIO-ULNAR JOINT o PRONATOR QUADRATUS IS THE PRIMARY PRONATOR o SUPINATOR IS THE PRIMARY SUPINATOR MOTION AT THE ELBOW

  33. ELBOW ANATOMY- MUSCLES MANY MUSCLES AT THE ELBOW CROSS THE JOINT AND EXTEND DOWN INTO THE HAND o BICEPS BRACHII LONG AND SHORT HEADS o BRACHIORADIALIS o BRACHIALIS o PRONATOR TERES HUMERAL AND ULNAR HEADS o PRONATOR QUADRATUS o TRICEPS BRACHII LONG, LATERAL AND MEDIAL HEADS o ANCONEUS o SUPINATOR

  34. OLECRANON BURSITIS o USUALLY CAUSED BY A DIRECT BLOW TO THE ELBOW OR A FALL ONTO THE POSTERIOR ELBOW o MAY ALSO BE CAUSED BY REPEATED MICROTRAUMA OR MOTIONS OF FLEXION AND EXTENSION WITH RESISTANCE o SY: USUALLY PAINLESS AND FLUCTUANT SWELLING TO THE POSTERIOR ELBOW, THERE MAY BE IMMEDIATE TENDERNESS, SWELLING AND REDNESS TO THE AREA POST TRAUMA- A GOOSE EGG FORMATION, MOTION MAY BE LIMITED IN FLEXION o DIAGNOSIS MADE BY PHYSICAL EXAM o RECOMMEND AN X-RAY BE ONE TO R/O FRACTURE o TX: o CONSERVATIVE: ICE, REST AND COMPRESSION WRAP FOR AT LEAST 24 HRS o CAN ASPIRATE THE BURSAE TO REMOVE THE FLUID THEN PLACE A COMPRESSION WRAP OVER. o AFTER ASPIRATION CAN INJECT A CORTICOSTEROID o CHRONIC: NSAIDS, CRYOTHERAPY, ELBOW CUSHIONS o LONG TERM: REGULAR ASPIRATIONS OR BURSAL EXCISION

  35. OLECRANON BURSITIS o NON-SEPTIC BURSITIS- MAY BE A CRYSTALLINE DEPOSIT OR RHEUMATOID ASSOCIATED WITH AN ATOPIC DERMATITIS- TREAT THE UNDERLYING CAUSE o SEPTIC BURSITIS- IF THE BURSAE IS INFECTED NEED TO TREAT APPROPRIATELY. o SOURCE OF INFECTION MAY BE AT A DISTANT SITE o SIGNS OF INFECTION- MALAISE, FEVER, SIGNIFICANT PAIN TO THE ELBOW, LOCAL HEAT, TENDERNESS, SWELLING, RESTRICTED MOTION, +/- OVERLAYING CELLULITIS o TX: ASPIRATE AND CULTURE THE FLUID, IMMOBILIZE AND PLACE IN SLING, HOT PACKS, ORAL ANTIBIOTICS

  36. CAPSULITIS OF THE ELBOW oUSUALLY CAUSED BY HYPEREXTENSION INJURY TO THE ELBOW JOINT, SPECIFICALLY THE ANTERIOR COMPARTMENT oMAY BE CAUSED BY REPETITIVE MOVEMENTS WITH MICRO-TEARING TO THE CAPSULE oSY: DIFFUSE ANTERIOR ELBOW PAIN WITH TENDERNESS TO PALPATION, +/- NERVE ENTRAPMENT- NUMBNESS AND TINGLING IN THE HAND oTX: IMMOBILIZE THE JOINT FOR 3-5 DAYS THEN BEGIN ACTIVE ROM EXERCISES

  37. ELBOW DISLOCATIONS- RADIUS o SUBLUXATION OR DISLOCATION OF THE PROXIMAL RADIAL HEAD- “NURSE MAIDS” ELBOW o USUALLY FROM A LONGITUDINAL TRACTION, EXTENSION AND PRONATION TO THE UPPER EXTREMITY THAT LEADS TO A TEAR IN THE ANNULAR LIG. o DG- X-RAY (NEED TO CONFIRM DISLOCATION AND R/O FRACTURE), PAIN WITH PRONATION AND SUPINATION o TX: RELOCATION OF NON FRACTURED JOINT, IMMOBILIZATION 3-6 WEEKS IN A FLEXED POSITION. THEN PROGRESSIVE ROM AND STRENGTHENING EXERCISES

  38. ELBOW DISLOCATIONS- ULNA o HYPEREXTENSION INJURY OR SUDDEN VIOLENT UNIDIRECTIONAL VALGUS FORCE THAT LEADS TO THE ULNA GOING POSTERIOR OR POSTERIOR-LATERAL o +/- FRACTURES, ANTERIOR CAPSULE DISRUPTION, ARTERY/VEIN OR NERVE DAMAGE o SY: SNAPPING OR CRACKING SOUND, SEVERE PAIN AT THE JOINT (ESPECIALLY MEDIALLY), RAPID SWELLING, TOTAL LOSS OF FUNCTION, OBVIOUS DEFORMITY, +/- NERVE PALSIES IN THE HAND, +/- CREPITUS (IF ASSOCIATED WITH A FRACTURE) o DG: X-RAY, PHYSICAL EXAM, OBSERVATION o TX: o CLOSED REDUCTION- IF LIGAMENTS APPEAR INTACT AND THERE ARE NO FRACTURES, LIMITED IMMOBILIZATION AND EARLY ROM AND PROPRIOCEPTION TRAINING o IF ASSOCIATED WITH FRACTURE SURGICAL FIX MAY BE NECESSARY, 3-6 WEEKS IMMOBILIZATION AND THEN GRADUAL ROM AND STRENGTH AND PROPRIOCEPTION

  39. RUPTURED TENDONS BICEPS BRACHII “POPEYE DEFORMITY” o DEGENERATIVE CHANGES MAKE THE TENDON VULNERABLE TO TEAR, ESPECIALLY WITH ECCENTRIC LOADS, PROXIMAL>DISTAL, FEMALES<MALES o SY: TENDERNESS, SWELLING, ECCHYMOSIS IN THE ANTECUBITAL FOSSA. BICEPS TENDON NOT PALPABLE , RETRACTED, PAINFUL ARC, WORSE AT NIGHT o DG: PHYSICAL EXAM, US, MRI OR CT o TX: o NON-OPERATIVE- (PARTIAL TEAR OR NOT A CANDIDATE) WILL JUST HAVE DEFORMITY WITH DECREASED FUNCTION o SURGICAL: REATTACHMENT OF THE TENDON TO THE RADIAL TUBEROSITY. IMMOBILIZATION AT 90 DEGREES FLEXION WITH MODERATE SUPINATION FOR 8 WEEKS. THEN GRADUAL AROM AND STRENGTHENING BICEPS BRACHII “POPEYE DEFORMITY” TRICEPS BRACHII o DIRECT BLOW TO THE POSTERIOR ELBOW OR CONTRACTION DUE TO A FALL o SY: PAIN AND SWELLING OVER THE DISTAL ATTACHMENT OF THE OLECRANON. PALPABLE DEFECT OR A STEP OFF DEFORMITY TO THE OLECRANON. WEAKNESS OR ABSENT ACTIVE EXTENSION o DG: PHYSICAL EXAM, US, MRI OR CT o TX: o PARTIAL TEAR- CONSERVATIVE: ICE, COMPRESSION, IMMOBILIZATION IN SLING o COMPLETE TEAR- SURGICAL REATTACHMENT, IF THERE IS AN AVULSION FRACTURE THEN ORIF. IMMOBILIZE FOR 4WEEKS IN 45 DEGREES FLEXION, THEN DECREASE FLEXION AND IMMOBILIZE FOR ANOTHER 4 WEEKS. GRADUAL ROM AND STRENGTHENING TRICEPS BRACHII

  40. TENDON SPECIAL TESTS oBICEPS: oSPEEDS TEST oYERGASONS TEST

  41. LATERAL EPICONDYLITIS o EXTENSOR TENDON OVERLOAD, USUALLY FORM REPETITIVE MOTIONS, ECCENTRIC LOADING. ESPECIALLY IN THE DECELERATION PHASE o OFTEN INVOLVING THE EXTENSOR CARPI RADIALIS BREVIS o CAUSES CAN INCLUDE FAULTY MECHANICS, POOR FITTING EQUIPMENT, REPETITIVE MOTIONS OR RECURRENT INJURY, AGE 30-50 YO o DG: PHYSICAL EXAM, US o SY: PAIN ANTERIOR OR DISTAL TO THE LATERAL EPICONDYLE THAT RADIATES INTO THE FOREARM EXTENSOR MUSCLES. PAIN INCREASED WITH RESISTED WRIST EXTENSION, PAIN WORSE WITH REPETITIVE MOTIONS o TX: o ICE, COMPRESSION, NSAIDS, REST, ACTIVITY MODIFICATION (AVOID GRASPING IN A PRONATED POSITION) o INCREASE STRENGTH, ENDURANCE AND FLEXIBILITY OF THE EXTENSOR MUSCLE GROUP o CAN WEAR A COUNTERFORCE STRAP 2-3 INCHES DISTAL TO THE JOINT (AT THE MUSCLE BELLY) o INJECTIONS- HOMEOPATHIC OR STEROID o PHYSICAL THERAPY o OMT

  42. MEDIAL EPICONDYLITIS o REPEATED MEDIAL TENSION/ LATERAL COMPRESSION (VALGUS) FORCES PLACED ON THE ARM, ESPECIALLY DURING ACCELERATION o COMMON TENDONS INVOLVED: PRONATOR TERES (HUMERAL HEAD) AND FLEXOR CARPI RADIALIS o MEDIAL EPICONDYLE AND MEDIAL SUPRACONDYLAR RIDGE INVOLVED o IN KIDS, IF THE MEDIAL HUMERAL GROWTH PLATE IS AFFECTED KNOW AS “LITTLE LEAGUE ELBOW” o DG: PHYSICAL EXAM, US o SY: SWELLING, ECCHYMOSIS, POINT TENDERNESS OVER THE HUMEROULNAR JOINT, THE FLEXOR/PRONATOR ORIGIN, OR DISTAL AND LATERAL TO THE MEDIAL EPICONDYLE. PAIN THAT IS SEVERE AND AGGRAVATED BY RESISTED WRIST FLEXION AND PRONATION OR VALGUS STRESS. +/- NUMBNESS OR TINGLING o TX: o ICE, NSAIDS, ACTIVITY MODIFICATIONS o ABOVE + IMMOBILIZATION IN SLING FOR 2-3 WEEKS WITH WRIST IN SLIGHT FLEXION o TENS, US, EARLY ROM, GENTLE RESISTED ISOMETRIC EXERCISES AND STRENGTHENING THAT PROGRESSES o INJECTIONS, PHYSICAL THERAPY, OMT

  43. SPECIAL TESTS FOR THE ELBOW oCOMMON EXTENSOR TENDINITIS TEST (LATERAL) oMEDIAL EPICONDYLITIS TESTS oLIGAMENTOUS INSTABILITY TESTS- VALGUS/ VARUS TESTING OF THE ELBOW oTINEL’S FOR ULNAR NEURITIS

  44. FOREARM, WRIST & HAND ANATOMY o THE WRIST AND HAND ARE COMPOSED OF NUMEROUS SMALL BONES AND ARTICULATIONS THAT ALLOW FOR DEXTEROUS MOVEMENTS TO BE PERFORMED. o RETINACULA OF THE WRIST- 2 (FLEXOR AND EXTENSOR) STRONG FIBROUS BANDS THAT SURROUND THE WRIST. FORMS A PROTECTIVE PASSAGEWAY FOR THE TENDONS, NERVES AND VESSELS THAT PASS TO THE HAND. o TENDON SHEATHS- STARTS AT THE METACARPAL HEADS. PROVIDES LOW FRICTION GLIDING. PULLEYS AT THE JOINTS PREVENT BOWSTRINGING. o THE EXTRINSIC FLEXORS OF THE HAND ARE 2X AS STRONG AS THE EXTRINSIC EXTENSORS- THEY GRIP, GRASP AND PINCH DAILY

  45. FOREARM, WRIST & HAND ANATOMY BONES BONES JOINTS JOINTS o RADIUS o CARPOMETACARPAL JOINTS- THUMB IS A SADDLE JOINT AND THE FINGERS ARE GLIDING JOINTS. ALL SURROUNDED BY JOINT CAPSULE o INTERMETACARPAL JOINTS- GLIDING JOINTS, SURROUNDED BY A JOINT CAPSULE o METACARPOPHALANGEAL JOINTS- “KNUCKLES” OF THE HAND, CONDYLOID JOINTS, ENCLOSED IN A CAPSULE REINFORCED BY COLLATERAL LIGS, o ULNA o CARPAL BONES- SCAPHOID LUNATE TRIQUETRAL o INTERPHALANGEAL JOINTS- PIP AND DIP ARE ALL HINGE JOINTS, SURROUNDED BY AN ARTICULAR CAPSULE o RADIOCARPAL JOINT- MOST WRIST MOTION OCCURS HERE, IS A CONDYLOID JOINT o DISTAL RADIOULNAR JOINT- HAS A TRIANGULAR FIBROCARTILAGE AT THE DISTAL END AND IS A STABILIZER TO THE JOINT PISIFORM TRAPEZIUM TRAPEZOID CAPITATE HAMATE o INTERCARPAL JOINTS o METACARPALS o PHALANGES: PROXIMAL, MIDDLE AND DISTAL