583 Shoulder and Elbow

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alannaheeres
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583 Shoulder and Elbow
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2012-12-09 15:12:21
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583 Shoulder Elbow
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583 Shoulder and Elbow
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  1. Where does the brachial begin and extend to?
    • Begins-neck
    • Extends to-axilla
  2. Brachial plexus:
    The 5 roots merge to form which three trunks?
    • Superior or upper (C5-C6)
    • Middle (C7)
    • Inferior or lower (C8 –T1)
  3. Brachial plexus:
    supplies anterior (flexor) compartments of the upper limb
    3 Anterior Divisions
  4. Brachial plexus:
    supplies posterior (extensor) compartments.
    3 Posterior Divisions
  5. Brachial Plexus:
    What are the 3 cords?
    • Posterior cord
    • Lateral cord
    • Medial cord
  6. Brachial plexus:
    It is divided into 2 nerves.
    • Supraclavicular
    • Infraclavicular
  7. Brachial plexus:
    The following nerves are derived from which nerve path?
    Dorsal Scapular - Long Thoracic- Nerve to subclavius- Suprascapular
    Supraclavicular
  8. Brachial plexus:
    The following nerves are derived from which nerve path?
    Lateral pectoral
    Musculocutaneous
    Median
    Median Pectoral
    Medial brachial cutaneous
    Medial antebrachial cutaneous
    Ulnar
    Upper Subscapular
    Thoracodorsal
    Lower Subscapular
    Axillary
    Radial
    Infraclavicular
  9. Injuries to the brachial plexus can affect?
    • Movements
    • Sensations
  10. What can cause brachial plexu injuries?
    • Disease
    • Stretching
    • Wounds/surgical procedures
    • Viruses
  11. What are signs and symptoms of brachial plexus injury?
    • Paralysis/weakness
    • Anesthesia
  12. How can you test for degree of paralysis from brachial plexus injury?
    ROM and MMT 
  13. How can you test for anesthesia from brachial plexus injury?
    Sensation testing, pain testing (e.g., from a pin prick)
  14. Where is the injury?
    Usually results from an excessive increase in the angle between the neck and the shoulder. This stretches or tears the superior part of thebrachial plexus.

    Injury e.g. being thrown from a motorcycle or horse, wrestling
    New born babies when excessive stretching of the neck occurs during delivery.
    “waiter’s tip position”
    Injury to superior parts of C5 and C6
  15. Brachial plexus injury:
    What has the following clinical presentation? (4 conditions)
    adducted shoulder
    medially rotated arm
    extended elbow
    loss of sensation
    • Erb palsy
    • Duchenne palsy
    • Duchenne-Erb Palsy
    • Upperradicular syndrome
  16. Brachial plexus injury:
    Produces motor and sensory deficitsin the distribution of themusculocutaneous and radial nerves.This may result in muscle spasmsand be very disabling.
    Backpacker's palsy
  17. Brachial plexus injury:
    Sudden onset of severe pain usually around the shoulder. Pain begins at night and is followed by muscle weakness and sometimes atrophy.
    Acute brachial plexus neuritis (brachial plexus neuropathy)
  18. Brachial Plexus Injury:
    May resultfrom prolonged hyper abductioneg. Overhead activities such as painting or plastering a ceiling.Cords impinged or compressed between the coracoid processof the scapula and the pectoralis minor tendon.
    cord compression
  19. Brachial Plexus Injury:
    Common neurologicalsymptoms are:
    Pain runningdown the arm
    Numbness
    Paresthesia (tingling)
    Erythema (redness of the skin caused bycapillary dilation) Weaknessof the hands.
    • Cord compression
    • These signs and symptoms result from compression of the axillary vessels and nerves.
  20. Brachial Plexus Injury:
    May occur when the upper limb is suddenly pulled superiorly – e.g. grasping something to prevent afall or breech birth

    These events injure the inferior trunk of the brachial plexus (C8 andT1) and may pull (avulse) the dorsal and ventral roots of the spinal nerves from the spinal cord. The short muscles of the hand are affected and claw hand results.
    Injuries to inferior parts of the plexus
  21. Which nerve?
    May beinjured when the GH jointdislocates because of itsclose relation of theinferior part of thearticular capsule of thehead of the humerus intothe quadrangular spacedamages the nerve.
    Result: paralysis of thedeltoid and loss ofsensation in a small areaof skin covering thecentral part of the deltoid.
    Axillary nerve injury
  22. Which nerve?
    injury to thisnerve in the axilla resultsin paralysis ofcoracobrachialis, biceps,and brachialis. Flexion ofthe elbow joint andsupination of the forearmare greatly weakened.
    Loss of sensation on the lateral surface of the forearm supplied by thelateral antebrachial cutaneous nerve.
    Musculocutaneous Nerve Injury
  23. Which nerve?
    Injuries superior to the origin of its branches to the Triceps brachii results in paralysis of the triceps, brachioradialis,supinator, and extensor muscles of the wrist and digits
    Results in an inability to extend the wrist upward when the hand is palm down and inability to straighten the fingers.
    Loss of sensation in areas ofskin supplied by this nerve also occurs ( numbness of the back of the hand and wrist).
    Radial Nerve Injury
  24. Radial nerve injury:
    Name the condition:
    Results from falling asleep with one’s arm hanging over the arm rest of achair, compressing the radial nerve at the spinalgrove.
    Saturday night palsy
  25. Radial Nerve Injury:
    Name the condition:
    Results from another individual sleeping on and compressing one’sarm overnight.
    Honeymoon palsy
  26. Radial Nerve Injury:
    Name the condition:
    Rrom tight handcuffs compressing the superficial branch of the distal radial nerve
    Handcuff Neuropathy
  27. Which nerve is injured?
    Commonly occurs where the nerve passes posterior to the medial epicondyle of the humerus
    The injury results when the lateral part of the elbow hits a hard surface, fracturing the medial epicondyle (“funny bone”).
    Ulnar nerve 
  28. Which nerve is injured?
    An injury to the nerve in the distal part of the forearm denervates most intrinsic handmuscles. Power of adduction is impaired and when an attempt is made to flex thewrist, the hand is drawn to the lateral side by the flexor carpi radialis
    Ulnar nerve
  29. Which nerve is injured?
    Patients have difficulty making a fist because they can’t flex their 4th and 5th digits at the DIP joints. This results in claw hand deformity.This is due to atrophy of the interosseous muscles of the hand supplied by the this nerve. The claw is produces by the opposed action of the entensors and flexor digitorum profundus muscles.
    Ulnar nerve
  30. Which nerve is injured?
    Flexion of the PIP joints of digits 1 to 3 is lost and flexion of digits 3 to 5 is weakened
    Flexion of the DIP joints of the 2nd and 3rd digits is also lost The 4th and 5th are not affected
    Flexion of metacarpopharangeal joints of the 2nd and 3rd digits will beaffected
    Median Nerve
  31. Median Nerve Injury:
    When a patient attempts to make a fist, digits 2 and 3 remain partiall extended.
    Hand of benediction
  32. Median Nerve Injury:
    Caused by compression of the median nerve near theelbow. The nerve may be compressed between the heads of the pronatorteres. Symptoms follow activities that involve repeated elbow movements
    Pronator Syndrome
  33. Treatment for Median Nerve Injury in elbow region
    Non operative RX: Changing activities of daily living and in work enviornmentsmay require an ergonomic evaluation. Splinting wrist in neutral position.
  34. Which Syndrome?
    Pain out ofproportion to the eliciting event.
    Disease that develops from an initialnoxious/painful event.
    Spontaneous pain (pain with lighttouch) occurs. Hyperesthesia(increased sensitivity with touch)occurs beyond the territory of a single peripheral nerve and isdisproportionate to the inciting event
    Complex Regional Pain Syndrome (CRPS)
  35. Which type of CRPS is this?
    Disease that develops from an initial noxious event. Cannot be linked to any pathologic process.
    Type I
  36. Which type of CRPS is this?
    Associated with an identifiablenerve injury
    Type II
  37. Pain state maintained bysympathetic efferent innervation,circulating catecholamines, orneurochemical action. Patients have apositive response to sympatheticblockade.
    SMP
  38. Pain state in which patients donot respond to sympathetic blocs.
    SIP
  39. After fracture of the ______, the sternocleidomastoid muscle elevates the medial fragment of the bone. Because the trapezius muscle is unable to hold the lateral fragment up because of theweight of the upper limb, the shoulder drops.
    clavicle
  40. The following are symptoms of what?
    Sagging shoulder (down and forward)
    Inability to lift the arm because of pain
    A grinding sensation if an attempt is made to raise the arm
    A deformity or “bump” over the break
    Bruising, swelling and/or tenderness over the area
    Broken clavicle
  41. These injuries are common in elderly people, especially those with osteoperosis.
    Are often the result of a minor fall on the hand
    humerus fracture
  42. Usually results from a fall on the hand when the arm is abducted
    humerus fracture ->avulsion fracture of the greater tubercle
  43. _________ fractures of the body of the humerus frequently result from a direct blow to the arm. The pull of the deltoid carries the proximal fragment of the fractured humerus laterally.
    Transverse 
  44. _____ fractures are the result of an indirect injury resulting from a fall on the outstretched hand (rotational component).
    Spiral
  45. ______ fractures of the humerus result from a severe fall on the “point” of elbow flexion. The olecranonof the elbow is driven like a wedge into the condyle ofthe humerus, separating one or both parts from the humeral body.
    Intercondylar
  46. The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
    Surgical neck
    Axillary nerve
  47. The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
    Radial groove
    Radial nerve
  48. The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
    Medial epicondyle
    Ulnar nerve
  49. The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
    Distal end of humerus
    median nerve
  50. Which joint?
    • ball and socket joint
    • wide range of movements
    • relatively unstable
    Glenohumeral Joint
  51. Name the rotator cuff muscles.
    • (SITS) muscles:
    • Supraspinatus
    • Infraspinatus
    • TeresMinor
    • Subscapularis.
  52. What is the function of the glenohumeral ligaments?
    Strengthens anterior aspect of joint
  53. What is the function of the coracohumeral ligament?
    • strengthens capsule superiorly
    • intrinsic ligaments – part of the fibrous capsule
  54. What is the function of the transverse humeral ligament?
    strengthens the capsule and bridges the gap between the greater and lesser tubercles of the humerus.
  55. Deposition of calcium in thesupraspinatus tendon is common.inflammation and calcification of the subacromial bursa results in pain,tenderness and limitation of movement of the glenohumeral joint
    Calcific Supraspinatus Tendinitis
  56. The calcium deposit in the supraspinatus tendon may also irritate the overlying subacromail bursa producing andinflammatory condition called ________ ________
    The pain usually develops in males 50 yearsor older after unusual or excessive use of the shoulder (e.g., during atennis game).
    Subacromial bursitis
  57. The pain from subacromial bursitis occurs during 50-130 degrees of abduction because during this arc the supraspinatus tendon is in intimate contact with the inferior surface of the acromion. This is called the ...
    painful arc syndrome
  58. Commonly injured during repetitive use of the upper limb above the horizontal (e.g.,during throwing or racquet sports, swimming and lifting weights).

    Common cause of shoulder pain
    Rotator cuff injuries
  59. Rotator Cuff Injuries:
    positive when the subjectcannot hold the arm elevated against gravity.
    Drop Arm Sign
  60. What are the 3 clinical signs of rotator cuff injury?
    • Pain
    • Loss of motion
    • Loss of strength
    • Pain is primary clinical manifestation, usually over the lateral aspect of the deltoid.
  61. Rotator Cuff Injury:
    Pain with elevation of the arm between 70 and 120 degrees of abduction
    Painful Arc
  62. What are 3 treatments for rotator cuff injuries?
    • Steroid injections
    • Pendular exercises
    • Graded strength exercises
  63. What direction are most dislocations of the humeral head?
    Downward due to the presence of the coracoacromial arch and the support of the rotator cuff
  64. Occurs most often in young adultscaused by excessive extension and lateral rotation of the humerus.
    Anterior dislocation of the GH joint
  65. Occurs in athletes who throw a baseball or football or in those who have shoulder instability and partial dislocation (subluxation) of the glenohumeral joint.
    Results in sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum. Usual symptom is pain while throwing, especially during the deceleration phase, but a sense of catching or snapping may be felt in the GH joint during abduction and lateral rotation of the arm.
    Glenoid Labrum Tear
  66. Adhesive fibrosis and scarringbetween the inflamed articular capsule of the GH joint, RC, subacromialbursa and deltoid. Patient will have difficulty abducting arm. They can obtain an apparent abduction of up to 45° by elevating and rotating the scapula.
    Conditions that may initiate acute ______ _____are glenohumeral dislocation, calcific supraspinatus tendinitis, partial tearing ofthe rotator cuff and bicipital tendinitis.
    Adhesive Capsulitis (Frozen Shoulder)
  67. True or false?
    Isolated fractures of the radius or ulna may occur, but are rare.
    True
  68. True or false?
    Fractures of the distal end of theradius are common in adults older 50 + years, more women than men (osteoporosis).
    True
  69. the most common fracture of the forearm and results from forced dorsiflexion of the hand.
    Colles' fracture
  70. The subcutaneous olecranon bursa is exposed to injury after a fall on the elbow and to infection from abrasions of the skin covering the olecranon. Repeated excessive pressure and friction may cause this bursa to become inflamed
    Bursitis of the elbow
  71. Known as “student’s elbow”, “miners elbow” or dart thrower’s elbow.
    Bursitis of the elbow
  72. May occur when children fall on their hands with their elbows flexed.
    Results from hyperextension or a blow that drives the ulna posterior or posterolateral.
    The distal end of the humerus is driven through the weak anterior part of thefibrous capsule as the radius and ulna dislocate posteriorly.
    The ulnar collateral ligament is often torn and an associated fracture ofthe head of the radius, coronoid process or olecranon may occur resulting in numbness of the little finger and weakness flexion and adduction of the wrist.
    Dislocation of the elbow joint
  73. Results when the child is lifted bythe upper limb while the forearm is pronated (e.g. lifting a child into a bus)
    The child may refuse to use the limb.
    Tears the distal attachment of the anular ligament where it is loosely attached to the neck of the radius.
    Preschool children are at risk for incomplete dislocation of the head of the radius
    Pulled elbow
  74. What condition is the following treatment for?
    Treatment consists of supinationof the child’s forearm with theelbow in a flexed position andusually heals in a sling in 2 weeks.
    Pulled elbow
  75. Caused by overuse. It is the inflammationof the tendons that join the forearms muscles on the outside of the elbow. Forearm muscles and tendons become damaged from repeating the same motions over and over again.
    Pain and tenderness on the outside of the elbow and may have a weak grip.
    Tennis Elbow (Lateral Epicondylitis)
  76. Like tennis elbow but onthe medial aspect of the elbow leads tomedial epicondylitis in trailing arm.
    Golfer's Elbow
  77. True or false?
    Majority of spinal cord injuries are complete.
    False, most are incomplete
  78. Where is the lesion?
    Upper limbs more profoundly affected. There is oftenflaccid weakness of the arms, due to the lower motor neuron (LMN) lesionsand spastic patterning in the arms and legs due to upper motor neuron(UMN) injury.
    Central Cord Lesion
  79. Where is the lesion?
    Upper limb is weak or flaccid.
    Nerve conduction studies used to determine if brachial plexus lesion exists ,only an intact nerve will produce muscle contraction. It is important to identify such a lesion at the earliest opportunity in order to facilitate a primary repair 
    Brachial Plexus Lesion
  80. Characterized by progressive andirreversible deterioration of upper anlower motor neurons, resulting in bothupper and lower motor signs.Degeneration within the corticospinaland corticobulbar tracts gives rise toupper motor weakness andhypertonia. The hardening of thetracts as the degenerated neurons arereplaced by gliosis explains the term“lateral sclerosis”.
    Motor Neuron Disease
  81. Leads to lower motor weakness, wasting and involuntary flickering of muscle fibres, which is known as fasciculations. The atrophyof denervated muscle fibres leads to the use of term Amyotrophy
    Motor Neuron Disease
  82. What is a classical amyotrophic lateral sclerosis?
    • ALS
    • Makes up 2/3rds of theMND population
  83. What are the signs of classical amyotrophic lateral sclerosis?
    progressiveweakness with muscle wasting.
  84. What is the principle member of a group of disorders known as demyelinating diseases.These diseases have animmune-mediated destructionof myelin as the primarypathological finding.
    MS - Multiple Sclerosis
  85. What are 2 symptoms of MS?
    • Tremor – some MS patientsmay have a tremor which in its most severe form can be incapacitating such that any attempt to move the limbs precipitates violent uncontrollable movements.
    • Spasticity – one of the mostcommon symptoms and is often associated with painful cramps and spasms.
  86. An accident with rapidly developing clinical signs of focal or global disturbance of cerebral function with symptoms lasting 24 hours or longer or leading to death with no apparent cause other than of vascular origin.
    May have motor and/or sensory impairments in the upper limb.
    cerebrovascular accident (CVA) - aka stroke
  87. Symptom of stroke:
    loss of detection to touch sensation, proprioception loss,vibration, light touch and loss of pin prick sensation.
    Sensory impairment
  88. Symptom of stroke:
    shoulder subluxation, spasticity,frozen shoulder, rotator cuff injury, complex regional pain syndrome and altered sensitivity.
    Hemiplegic Shoulder pain
  89. Symptom of stroke:
    Is caused by a lack of adequate support of the shoulder while the patient is in the upright position causing overstretchingof the joint capsule as a result of the gravitational pull on the weak/inactive arm.
    Shoulder Subluxation
  90. True or false?
    Swelling of the hand is a symptom of stroke.
    True, the lack of movement and muscle activity can lead to swelling.
  91. What condition?
    Broken pieces of cartilage in joint
    Common in the capitullum
    Gradual onset (1 to 2 years), throwingcurveballs, gymnastics, wrestling, trauma
    Limited ROM, clicking, locking,
    Treatment: Rest from stress.
    Good prognosis if diagnosed early
    Surgery for severe cases.
    Osteochondritis Dissecans
  92. Which condition?
    Disruption of biceps from attachment (usuallydistal)
    Pain at area of biceps
    Quick forceful biceps contraction
    Discontinuity of biceps with bulge
    Loss of elbow flexion strength
    May need surgical intervention
    Biceps Muscle Rupture
  93. Which condition?
    One-third of all elbow fractures males > females 30 to 40 years old, pain overthe radial head.
    Stiff joint, unable to fully flex or extend, pain with supination-pronation.
    Immobilization for short period, ROM once fracture is stable, progressive strengthening.
    Radial Head Fracture
  94. Which condition?
    Calcification of muscle
    From Trauma
    Decreased ROM. Palpation of mass.
    Treatment is Rest, Gentle ROM and medical management of symptoms.
    Myositis Ossificans
  95. Which condition?
    Parasthesia in thumb, index finger, middle fingerthat is aggravated with activity, also have pain on thevolar aspect of the forearm.
    Symptoms include weakness in the muscles of theforearm and hand innervated by the median nerve(FCR, PL, FD).
    Pronator Teres Syndrome
  96. Which condition?
    Median nerve compression
    Sudden severe arm pain that resolves in a fewhours, no loss of sensation
    Weakness of FPL, PQ, FDP; unable to pinchtip to tip.
    Treatment: relative rest, splinting
    Anterior Interosseous Syndrome
  97. Pain over the lateral humeral epicondyle,tender radial head, numb radial nerve.
    Resisted middle finger extension.
    Radial Tunnel Syndrome
  98. Radial nerve compression at arcade of Frohse.
    Tender to palpation distal from lateralepicondyle.
    Symptoms with resisted wrist extension,unable to extend thumb or fingers at MCP.
    Treatment: relative rest, splinting
    Posterior Interosseous Syndrome
  99. True or false?
    Pain is a part of healing.
    True, it serves as a warning signal that assists us in making the correct decisions regarding motions and tissue loading patterns.

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