Chapter 1: Upper Extremity Disorders

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dmshaw9
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Chapter 1: Upper Extremity Disorders
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2015-02-25 20:56:39
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UE Disorders
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NPTE: Chapter 1
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  1. Glenohumeral Subluxation and Dislocation: Directionality
    • Most dislocations (95%) occur in ant-inf direction
    • Ant-inf dislocation occurs when abd UE is forcefully ER --> causes tear of inf GH ligament, ant capsule, and occasionally glenoid labrum
    • Post dislocations rare - occur with multidirectional laxity of GH joint (horizontal add and IR)
  2. Glenohumeral Subluxation and Dislocation: Complications
    • Compression fracture of posterior humeral head (Hill-Sachs lesion)
    • Tearing of superior glenoid labrum from ant-->post (SLAP lesion)
    • Avulsion of anteroinferior capsule and ligaments associated with glenoid rim (Bankart's lesion)
    • Bruising of axillary nerve
  3. Glenohumeral Subluxation and Dislocation: Diagnostic Tests
    • Plain film imaging
    • CT Scan
    • MRI
    • Apprehension test = positive
  4. Glenohumeral Subluxation and Dislocation: Medications
    • Acetaminophen for pain
    • NSAIDs (pain and inflammation)
  5. Glenohumeral Subluxation and Dislocation: PT Goals, Outcomes, and Interventions
    • Pts should avoid apprehension position
    • Joint mobs to correct biomechanical faults
  6. Instability: 2 Categories
    • Traumatic: common in young throwing athletes
    • Atraumatic: individuals with congenitally loose connective tissue around the shoulder
  7. Instability: Definition and Characteristics
    • Characterized by popping/clicking and repeated dislocation/subluxation of the GH joint
    • Unstable injuries require surgery to reattach the labrum to the glenoid
    • Bankart's lesions require surgery
  8. Instability: CMedications
    • Acetaminophen for pain
    • NSAIDs for pain and inflammation
  9. Instability: PT Goals, Outcomes, and Interventions
    • Emphasize return of function without pain
    • Functional training
    • Restoration of muscle imbalances
    • Joint mobilizations
    • For patients requiring surgery: shoulder kept in sling for 3-4 weeks, after 6 weeks = sport specific training (full fitness may take 3-4 months)
  10. Labral Tears: Definition
    • Classified as either superior or inferior (position within glenoid socket)
    • SLAP Lesion: tear of the rim above the middle of the socket that may also involve the biceps tendon
    • Bankart's Lesion: tear of the rim below the middle of the glenoid socket, involves inferior GH ligament
    • Tears may often occur with other shoulder injuries (i.e. dislocation)
  11. Labral Tears: Characteristics
    • Shoulder pain that cannot be localized to a specific point
    • Pain made worse by overhead activities or when the arm is held behind the back
    • Weakness
    • Instability in the shoulder
    • Pain on resisted flexion of the biceps (bending the elbow against resistance)
    • Tenderness over the front of the shoulder
  12. Labral Tears: Diagnosis
    • Made by cynical examinations through comparing results of AROM, PROM, resistive tests, and palpation
    • MRI arthrograms very effective in identification
    • "Gold standard" = through arthroscopic surgery of the shoulder
  13. Labral Tears: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  14. Labral Tears: PT Goals, Outcomes, and Interventions
    • Emphasize return to function without pain
    • Functional training and restoration of muscle imbalances 
    • Any underlying causes that contributed to shoulder injury (i.e. shoulder instability) should be addressed
    • Joint mobs (to correct biomechanical faults caused by joint restrictions)
    • Following surgery, shoulder in sling for 3-4 weeks. Sport specific training after 6 weeks (full fitness may take 3-4 months)
  15. Thoracic Outlet Syndrome (TOS): Definition
    • Compression of neurovascualr bundle (brachial plexus, subclavian artery and vein, vagus and phrenic nerves, and sympathetic trunk) in thoracic outlet between bony and soft tissue structures
    • Compression occurs when size or shape of thoracic outlet is altered
  16. Thoracic Outlet Syndrome (TOS): Common Areas of Compression
    • Superior thoracic outlet
    • Scalene triangle
    • Between clavicle and 1st rib
    • Between pec minor and thoracic wall
  17. Thoracic Outlet Syndrome (TOS): Diagnostic Tests
    • Plain film imaging: identify abnormal bony anatomy
    • MRI: identify abnormal soft tissue anatomy
    • Electro-diagnostic test: assess nerve dysfunction
    • Clinical examination: Adson's, Roos, Wright, and Costoclavicular test
  18. Thoracic Outlet Syndrome (TOS): Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  19. Thoracic Outlet Syndrome (TOS): PT Goals, Outcomes, and Interventions
    • Includes postural reeducation
    • Functional training and restoration of muscle imbalances
    • Joint mobs
    • Manipulations (typicallly 1st rib) to diminish pain and soft tissue guarding
  20. Acromioclavicular and Sternoclavicular Joint Disorders: Characteristics
    • MOI: fall onto shoulder with UE adducted, or collision with another individual during sporting event
    • Degree of injury graded from 1st - 3rd degree (Rockwood classification scale grades from I-IV)
    • UE positioned in neutral with use of sling in acute phase -- avoid shoulder elevation during acute phase of healing
    • Surgical repare is rare due to tendency of AC jt degeneration following repair
  21. Acromioclavicular and Sternoclavicular Joint Disorders: Diagnostic Test
    • Plain Film Imaging 
    • Shear Test
  22. Acromioclavicular and Sternoclavicular Joint Disorders: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  23. Acromioclavicular and Sternoclavicular Joint Disorders: PT Goals, Outcomes, and Interventions
    • Return of function without pain
    • Functional training
    • Restoration of muscle imbalances
    • Manual techniques to AC and SC joints and surrounding connective tissue (soft tissue/massage, joint oscillations, mobilizations)
  24. Subacromial/Subdeltoid Bursitis: Definition and Characteristics
    • Subacromial and subdeltoid bursae (which may be continuous) have close relationship to RC tendons -- makes them susceptible to overuse
    • Can also become impinged beneath acromial arch
  25. Subacromial/Subdeltoid Bursitis: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  26. Rotator Cuff Tendonosis/Tendonopathy: Definition and Characteristics
    • Tendons of RC susceptible to tendonitis, due to relatively poor blood supply near insertion of muscles
    • Results from mechanical impingement of distal attachment of RC on anterior acromion and/or coracromial ligament with repetitive overhead activities
  27. Rotator Cuff Tendonosis/Tendonopathy: Diagnostic Tests
    • MRI may be used - sometimes not sensitive enough for accurate assessment
    • Supraspinatus test
    • Neear's impingement test
  28. Rotator Cuff Tendonosis/Tendonopathy: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  29. Impingement Syndrome: Definition and Characteristics
    Characterized by soft tissue inflammation of shoulder from impingement against acromion with repetitive overhead AROM
  30. Impingement Syndrome: Diagnostic Tests
    • Arthrogram
    • MRI
    • Neer's impingement test
    • Supraspinatus test
    • Drop arm test 
  31. Impingement Syndrome: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  32. Impingement Syndrome: PT Goals, Outcomes, and Interventions
    • Restoration of posture
    • Correct muscle imbalances and biomechanical faults (strengthening, endurance, coordination, and flexibility exercises)
    • Joint mobilizations
    • Surgical repair = pt should avoid elevation greater than 90 degrees 
  33. Internal (Posterior) Impingment: Definition and Characteristics
    • Characterized by an irritation between the RC and greater tuberosity or posterior glenoid and labrum
    • Often seen in athletes performing overhead activities
    • Pain commonly noted in posterior shoulder
  34. Impingement Syndrome: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  35. Impingement Syndrome: PT Goals, Outcomes, and Interventions
    • Correction of muscle imbalances and biomechanics faults
    • Joint mobilizations 
  36. Bicipital Tendonosis/Tendonopathy: Definition and Characteristics
    • Most commonly an inflammation of the long head of the biceps
    • Results from mechanical impingement of proximal tendon between the anterior acromion and bicipital groove of the humerus  
  37. Bicipital Tendonosis/Tendonopathy: Diagnostic Tests
    • MRI may be used but sometimes not sensitivity enough
    • Speed's test
  38. Bicipital Tendonosis/Tendonopathy: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  39. Proximal Humeral Fractures: Definition and Characteristics 
    Humeral neck fractures: frequently occur with a FOOSH among older osteoporotic women; generally does not require immobilization or surgical repair (fairly stable fracture)

    Greater tuberosity fractures: more common in middle aged and elder adults; usually related to a fall onto the shoulder; does not require immobilization for healing 
  40. Proximal Humeral Fractures: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  41. Proximal Humeral Fractures: PT Goals, Outcomes and Interventions
    • Emphasize return of function without pain
    • Functional training and restoration of muscle imbalances
    • Early PROM important in preventing capsular adhesions 
  42. Adhesive Capsulitis (Frozen Shoulder): Definition and Characteristics 
    • Characterized by a restriction in shoulder motion as a result of inflammation and fibrosis of the shoulder capsule
    • Usually due to disuse following injury or repetitive microtrauma
    • Restriction follows capsular pattern of limitation
    • Commonly seen in association with diabetes mellitus 
  43. Adhesive Capsulitis (Frozen Shoulder): Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  44. Adhesive Capsulitis (Frozen Shoulder): PT Goals, Outcomes and Interventions
    • Emphasizes return to function with out pain
    • Joint mobs
    • Functional training and restoration of muscle imbalances 
  45. Elbow Contractures: Definition and Characteristics
    • Loss of motion in capsular pattern (flex>ext)
    • Loss of motion in non capsular pattern as the result of a loose body in the joint, ligamentous sprain, and/or CRPS
  46. Elbow Contractures: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
  47. Elbow Contractures: PT Goals, Outcomes, and Interventions
    • Joint mobs
    • Soft tissue/massage
    • Modalities
    • Flexibility exercises
    • Functional exercises 
    • Splinting
  48. Lateral Epicondylosis/Epicondylopathy: Definition and Characteristics 
    • Tennis Elbow
    • More often a chronic degenerative condition of the ECRB tendon at its proximal attachment to the lateral epicondyle 
    • Onset = gradual
    • Usually the result of sports activities or occupations that require repetitive wrist extension or strong grip w/ the wrist extended 
    • Must rule out involvement/relationship to c-spine condition
  49. Lateral Epicondylosis/Epicondylopathy: PT Goals, Outcomes, and Interventions
    • Correction of muscle imbalances and biomechanics faults
    • Endurance and strength exercises (emphasize eccentrics)
    • Joint mobs
    • Education on prevention
    • Cryotherapy, thermotherapy, hydrotherapy, sound agents and TENS
    • Counterforce bracing (reduces forces along ECRB)
  50. Medial Epicondylosis/Epicondylopathy
    • Golfer's elbow
    • Usually a degenerative condition of pronator trees and FCR tendons at their attachment to medial epicondyle 
    • Occurs with overuse in sports (baseball pitching, golf swings, swimming) or occupations that require a strong hand grip and excessive pronation of the forearm
  51. Distal Humeral Fractures: Definition and Characteristics 
    • Complications include loss of motion, myositis ossificans, malalignment, neuromuscular compromise, ligamentous injury, and CRPS
    • Supraconydlar fractures must be examined quickly for neuromuscular status (high number of neurological (radial nerve) and vascular structures that pass through this region (Volkmann's ischemia)) 
    • Important to assess growth plate in youth 
    • Fractures have a high incidence of malunion
    • Lateral epicondyle fractures fairly common in young people (typically require ORIF to ensure absolute alignment) 
  52. Distal Humeral Fractures: PT Goals, Outcomes, and Interventions
    • Pain reduction and limiting inflammatory response following trauma and/or surgery
    • Improve flexibility of shortened structures
    • Strengthening
    • Training to restore functional use of UE 
  53. Osteochrondrosis of Humeral Capitellum: Definition and Characteristics
    • Affects central and/or lateral aspects of capitellum or radial head 
    • An osteochondral bone fragment becomes detached from articular surface, forming a loose body in the joint
    • Caused by repetitive compressive forces between radial head and humeral capitellum
    • Occurs in adolescents between 12-15 years
    • Panner's disease
  54. Panner's Disease
    • Localized avascular necrosis of capitellum
    • Leads to loss of subchondral bone with fissuring and softening of articular surfaces of radiocapitellar joint
    • Etiology unknown
    • Occurs in children age 10 and younger
  55. Osteochrondrosis of Humeral Capitellum: PT Goals, Outcomes, and Interventions
    • Rest with avoidance of any throwing or upper extremity loading activities
    • When pt is pain-free, initiate flexibility and strengthening/endurance/coordination exercises
    • Late phases of rehab = slowly increase load on joint 
    • If symptoms persist, surgical intervention is necessary
    • After surgery, initial focus is to minimize pain and swelling using modalities 
    • Flexibility exercises immediately following surgery
  56. Ulnar Collateral Ligament Injuries: Definition and Characteristics
    • Occurs as result of repetitive valgus stresses to medial elbow with overhead throwing 
    • Clinical signs = pain along medial elbow at distal insertion of ligament
    • In some cases, paresthesias are reported in ulnar nerve distribution with positive Tinel's sign
  57. Ulnar Collateral Ligament Injuries: PT Goals, Outcomes, and Intervensions
    • Initially, rest and pain management
    • After resolution of pain and inflammation, strengthening exercises that focus on elbow flexors
    • Taping for protection during return to activities 
  58. Ulnar Nerve Entrapment: Causes
    • Various causes:
    • Direct trauma at cubital tunnel
    • Traction due to laxity at medial aspect of elbow
    • Compression due to thickened retinaculum or hypertrophy of FCU muscle
    • Recurrent subluxation or dislocation
    • DJD that affects cubital tunnel
  59. Ulnar Nerve Entrapment: Clinical Findings 
    • Medial elbow pain
    • Paresthesias in ulnar distribution
    • Positive Tinel's sign 
  60. Median Nerve Entrapment: Causes
    • Occurs within pronator trees muscle and under superficial head of FDS
    • Repetitive gripping activities required in occupations
  61. Median Nerve Entrapment: Clinical Signs
    • Aching pain with with weakness of forearm muscles
    • Positive tinel's sign
    • Paresthesia in median nerve distribution 
  62. Radial Nerve Entrapment: Definition and Causes
    • Entrapment of distal branches (posterior interosseous nerve)
    • Occurs within radial tunnel (radial tunnel syndrome) 
    • Result of overhead activities and throwing
  63. Radial Nerve Entrapment: Clinical Signs
    • Lateral elbow pain
    • Pain over supinator muscle
    • Paresthesias in radial nerve distribution (Tinel's sign may be positive) 
  64. Nerve Entrapment: Diagnostic Tests
    Electrodiagnostic Tests
  65. Nerve Entrapment: Medications
    • Acetaminophen for pain
    • NSAIDs for pain and/or inflammation
    • Neurotonin for neuropathic pain 
  66. Nerve Entrapment: PT Goals, Outcomes, and Interventions
    • Early intervention = rest, avoiding exacerbating activities, NSAIDs, modalities, soft tissue/massage to reduce inflammation and pain 
    • If abnormal neurotension is present, neurodynamic mobilization may be indicated
    • Protective padding and night splints to maintain slackened position of nerves
    • With reduction in pain and paresthesias, rehab program should focus on strengthening/endurance/coordination exercise of involved muscles to achieve muscle balance between agonists and antagonists, normal flexibility of shortened structures, and normalization of strength, endurance, and coordination
    • Functional training
    • Pt education
    • Self-management techniques 
  67. Elbow Dislocations: Definition and Characteristics 
    • Posterior dislocations = account for most dislocations at elbow
    • Posterolateral most common: occur as result of elbow hyperextension from FOOSH
    • Post dislocations frequently cause avulsion fractures of medial epicondyle secondary to traction pull of MCL
    • Anterior and radial head dislocations rare 
    • Complete dislocation = UCL will rupture with possible rupture in ant capsule, LCL, brachialis muscle, and/or wrist flex/ext muscles 
    • Clinical signs = rapid swelling, severe pain at elbow, deformity 
  68. Elbow Dislocations: PT Goals, Outcomes, and Interventions
    • Initially = reduction of dislocation 
    • If elbow is stable, there is an initial phase of immobilization followed by rehab focusing on regaining flexibility within limits of stability and strengthening 
    • Surgery indicated for elbow that is not stable 
  69. Carpal Tunnel Syndrome: Definitions and Characteristics 
    • Compression of median nerve at carpal tunnel of wrist due to inflammation of the flexor tendons and/or median nerve
    • Result of repetitive wrist motions or gripping, with pregnancy, diabetes, and RA
    • Must rule out potential c-spine dysfunction. TOS, or peripheral nerve entrapment 
  70. Carpal Tunnel Syndrome: Diagnostic Tests
    Electrodiagnostic Testing 
  71. Carpal Tunnel Syndrome: Common Clinical Findings 
    • Exacerbation of burning, tingling, pins and needles and numbness into median nerve distribution at night
    • Positive Tinel's sign and/or Phalen's test
    • Long term compression --> atrophy and weakness of thenar muscles and lateral two lumbricals 
  72. Carpal Tunnel Syndrome: PT Goals, Outcomes, and Interventions 
    • Joint mobilizations
    • Soft tissue/massage
    • Modalities
    • Flexibility exercises
    • Functional exercises 
  73. DeQuervain's Tenosynovitis: Definition and Characeristics
    • Inflammation of EPB and APL tendons at first dorsal compartment 
    • Results from repetitive micro trauma or as a complication of swelling during pregnancy
    • Clinical signs = pain at anatomical snuffbox, positive Finkelstein's test, decreased grip and pinch strength
  74. DeQuervain's Tenosynovitis: PT Goals, Outcomes, and Interventions
    • Joint mobilizations 
    • Soft tissue/massage
    • Modalities
    • Flexibility exercises
    • Functional exercises 
  75. Colles' Fractures: Definition and Characteristics 
    • Most common wrist fracture
    • Results from FOOSH
    • Fractures are immobilized for 5-8 weeks
    • Complication of median nerve compression can occur w/ excessive edema
    • Characteristic "dinner fork" deformity of wrist and hand results from dorsal or posterior displacement of distal fragment of radius, with radial shift of wrist and hand 
  76. Colles' Fracture: PT Goals, Outcomes, and Interventions
    • Early focus = normalizing flexibility 
    • Joint mobs
    • Soft tissue/massage
    • Modalities
    • Flexibility exercises 
    • Functional exercises 
  77. Smith's Fracture: Definition and Characteristics
    • Similar to Colles' fracture
    • Distal fragment of radius dislocates in a volar direction --> causes characteristic "garden spade" deformity
  78. Scaphoid Fracture: Definition and Characteristics
    • Results from FOOSH in younger person
    • Most commonly fractured carpal 
    • Complications include high incidence of avascular necrosis of proximal fragment of scaphoid secondary to poor vascular supply
    • Carpals immobilized for 4-8 weeks 
  79. Scaphoid Fracture: PT Goals, Outcomes, and Interventions
    • Early intervention includes maintenance of flexibility of distal and proximal joints while UE is casted 
    • Later intervention = strength, stretching, joint and soft tissue mobs
  80. Dupuytren's Contracture: Definition and Characteristics
    • Observed as banding on palm and digit flexion contractures, resulting from contracture of palmar fascia that adheres to skin
    • Men affected more than women
    • Contracture usually affects MCP and PIP joints of 4th and 5th digits in non diabetic individuals and 3rd and 4th in individuals with diabetes 
  81. Dupuytren's Contracture: PT Goals, Outcomes, and Interventions
    • Flexibility exercises
    • Splint fabrication/application
    • Functional exercises for restoration of normal hand function
    • PT following surgery includes wound management, edema control and progression of functional exercises 
  82. Boutonniere Deformity: Definition and Characteristics 
    • Results from rupture of central tendons slip of extensor hood
    • Observed deformity = ext of MCP and DIP with flexion of PIP
    • Commonly occurs following trauma or in RA with degeneration of central extensor tendon
  83. Boutonniere Deformity: PT Goals, Outcomes, and Interventions
    • Edema management
    • Flexibility exercises
    • Splinting or taping
    • Functional strengthening/endurance/ coordination 
  84. Swan Neck Deformity: Definition and Characteristics
    • Results from contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons
    • Observed deformity = flex of MCP and DIP with ext of PIP
    • Commonly occurs following trauma or with RA following degeneration of lateral extensor tendons 
  85. Swan Neck Deformity: PT Goals, Outcomes, and Interventions
    • Edema managemnt
    • Flexibility
    • Splinting/taping
    • Strengthening
    • Endurance
    • Coordination
  86. Ape Hand Deformity: Definition and Characteristics
    • Observed as thenar muscle wasting
    • 1st digit moving dorsally until it is in one with second digit
    • Results from median nerve dysfunction
  87. Ape Hand Deformity: Diagnostic Tests
    Electrodiagnostic testing
  88. Ape Hand Deformity: PT Goals, Outcomes, and Intervention
    • Edema management
    • Flexibility
    • Splinting/taping
    • Strengthening
    • Endurance
    • Coordination
  89. Mallet Finger: Definition and Characteristics
    • Rupture or avulsion of extensor tendon at its insertion into distal phalanx of digit
    • Observed deformity = flexion of DIP joint
    • Usually occurs from trauma -- forcing distal phalanx into flexed position
  90. Mallet Finger: PT Goals, Outcomes, and Treatment
    • Edema management
    • Flexibility
    • Splinting/taping
    • Strengthening
    • Endurance
    • Coordination
  91. Gamekeeper's Thumb: Definition and Characteristics
    • A sprain/ruptur of UCL of MCP joint at 1st digit
    • Results in medial instability of thumb
    • Frequently occurs during fall while skiing, when increasing forces are plead on thumb through ski pole
    • Immobilized fo 6 weeks 
  92. Gamekeeper's Thumb: PT Goals, Outcomes, and Intervention
    • Edema management
    • Flexibility
    • Splinting/taping
    • Strengthening
    • Endurance
    • Coordination
  93. Boxer's Fracture: Definition and Characteristics 
    • Fracture of neck of 5th met
    • Frequently sustained during fight or from punching a wall in anger or frustration 
    • Casted for 2-4 weeks
  94. Boxer's Fracture: PT Goals, Outcomes and Interventions
    • Edema management
    • Flexibility
    • Strengthening/Endurance/Coordination

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