Download Carpal Tunnel Syndrome

Ortho Tri 5 final
1
Ortho

Abbott Saunders – the biceps tendon will move lateral.



Humeral head goes into the glenoid fossa.
Clavicle joins the sternum, there’s synovium, and a disc, but very unlikely to subluxate/dislocate.
Middle 1/3 of the clavicle is most susceptible to a break.


Apprehension test.
Codman’s test.

Painful arc – 1 20 = supraspinatus. 70-120 = impingement.

As the deltoid pulls the humerus head superior, thus encroaching on the supraspinatus tendon and the
deltoid bursa.

Dawbasa

R.I.C.E. for acute tendentious, and quit activities that aggravate it, for a little while.

W/ capsular adhesion you’ll loose external rotation and abduction the most.



Rotator cuff tear will usually involves the supraspinatus.
Clinically the patient will lean or externally rotate to initiate the abduction process, eliminating the use
of supraspinatus.
Probably you will feel a soft end feel.


For every 2 of abduction of the humerus you get 1 external rotation of the scapula.
If you hold the scapula in place and there’s pain on abduction it’s probably a capsular problem.

When shoulders are hunched forward the stability comes from the rotator cuff muscles and no longer
the ligament.
They get short-term tendentious, but long-term capsular adhesion.
Change the patient’s posture, heat the capsule, stretch the rotator cuff muscles, and strengthen traps and
posterior cervical muscles.
May cause some short-term problems, due to using muscles which you should’ve been using but
haven’t, because of poor posture.
The new posture may cause some other pains, but w/ the management of that by the chiropractor, you’ll
get long-term benefits all the way around.




st


The humerus often dislocates anteriorly.
Impingement sign.


TMJ injury in whiplash occurs in hypertension phase and is called a lag injury.
TMJ injury may cause ear pain, pain during eating, and difficult to close.

If you eliminate muscular forces of the skull, the head will fall anteriorly. So you have to fire posterior
muscles to keep the skull mid-line.
Problems of the TMJ and c-spine kind of affect each other.

Ortho Tri 5 final
2

Eyes, semicircular canals (in ears), and proprioception (more in upper c-spine and S.I. joints), These 3
will assist in knowing your position in space.

CN V - mandibular division sensory t the TMJ.

In the gray matter of the spinal cord the nuclei for the TMJ are near the posterior neck muscles, so if 1 is
stimulated, the spill over will stimulate others.



When the jaw dislocates it goes anterior, either unilateral or bilateral.
If unilateral dislocation the jaw deviates to the non-affected side.
If you have a TMJ dislocation put your fist under your jaw when you yawn so it doesn’t further
dislocate.
Ligaments involved in the TMJ.
1. Capsular ligament goes around entire TMJ.
2. Temporolmandibular ligament -will limit anterior displacement.
3. Sphenomandibular ligament.
4. Stylomandibular ligament - resists anterior displacement.
5. Mandibular ligament - w/ TMJ dysfunction causes ear pain.
Muscles that close the mouth.
1. Temporalis muscle.
2. Masseter.
3. Lat./med. pterygoid
Superior head of the lateral pterygoid attaches to the TMJ capsule and disc.
ELBOW


Has 0 – 5 of extension.
Has 140 of flexion.

2 – collateral ligaments in elbow >> radial and ulnar collateral lig. There’s also an annular lig.


Valgus – ex. Knock-knees.
Varus – ex. Bow legged.


The ulnar has 3 portions, which resist valgus pressure. An anterior, posterior, and oblique portion.
If you avulse the medial epicondyl you’ll traction the ulnar nerve.
2 bursas around the olecranon
1. Superficial olecranon bursa – a.k.a. friction bursitis – golf ball shape present on elbow. Tx:
reduce inflammation.
2. Subtendinous olecranon bursa – b/w triceps tendon and olecranon. Common in weight lifters.
Tx: reduce inflammation.


Lateral epicondylitis = tennis elbow.
Enthesis – inflamed epicondyl.
3
Ortho Tri 5 final



Cozen’s test.
Elbow flexion test.
Kaplan’s test.
Carpal Tunnel Syndrome
Multiple etiologies for CTS
 Autoimmune/hereditary
 Congenital
 Idiopathic
 Infectious/ inflammatory
 Metabolic/hormonal
 Neoplasms
 Trauma
 Vascular


Tenosynovitis – inflammation of the synovial sheath of tendons. >> This will cause fibrotic changes.
Stenosing tenosynovitis - a chronic condition. M/c the outcropping muscles of the thumb (anatomical
snuff box).
Bones of the palm of the hand
Proximal to distal, medial to lateral.
Hamate, capitate, trapezoid, trapezium, pisiform, triquetral, lunate, and scaphoid.

DeQuervan’s disease – stenosing tenosynovitis of outcropping muscles of the thumb. >> Use
Finkelstein’s test.
Sites for production of blood in bone:
 Vertebral column (pedicles etc.), flat bones (ribs, scapula, skull, and sternum), and proximal ends of
long bones (ex. femur head and humeral head).

Fracture of a bone w/ yellow marrow can cause a fat emboli.
Bones, which outline the carpal tunnel.
1. Hamulus (hook of hamate).
3. Tubercle of trapezium.







2. Pisiform
4. Tubercle of scaphoid.
Ischemia aggravates neurological tissue. >> Use tourniquet test – compress the distal forearm w/
sphygmomanometer. (+) if  in symptoms or discomfort.
Tests for carpal tunnel syndrome:
Tinel’s, Phalan’s test (80% sensitivity), Wormser (reverse Phalan – 80%), tourniquet (83%), thenar
atrophy, pressure test, Durkan’s
Patient standing arms extended out in front w/ wrist in question extended, w/ the other hand the patient
puts pressure on the extended wrist. Pain w/in 30 sec. = (+). >> 90% sensitivity.
Old wormser – dorsum of hands pointing down. Not very reliable because it elevates shoulders and
could give impingement symptoms.
Positioning during immobilization is in the neutral position or slightly extended.
Lipoic acid and EFA’s help  inflammation process of CTS. >> Drink lots of H20, take B6, and?.
Ortho Tri 5 final
4
HIP
 Very stable.
 Synovial articulation.
 The normal angle b/w the femoral neck is 125.
 Coxa vera has a 100 femoral neck angle.
 Coxa valga has a 150 femoral neck angle.

Trendelenburg gait – may be due to gluteus medius weakness or coxa vera. [Measure leg length].

Measure legs in the same position because a leg in abduction will appear shorter than actual, and a leg
in adduction will  leg length.
Measure from umbilicus to medial malleolus. This will give you an apparent leg length. (The size of
the stomach and position of the umbilicus varies in people, so take that into account when measuring).
Measure from the ASIS to medial malleolus will give you true leg length. . (It would be more accurate
to measure to the lateral malleolus, because you’re not crossing over thigh muscles, which may be
asymmetrical).
If apparent is different than true (1 normal and 1 not), maybe a sign of a pelvic tilt or unleveling.




Bryant’s triangle – draw a straight line from ASIS to greater trochanter. Draw a perpendicular line
from that, and check the angle.

Néiaton’s sign – measures from ischial tuberosity to ASIS. >> If the greater trochanter is above this
line it may be a fracture, dislocation, congenital defect, trauma, etc.…
 Shoemaker’s line – measure from the greater trochanter through the ASIS’s. Both sides should
intersect about the belly button (provided that there’s not a Milwaukee tumor, etc.…).
 If the line intersects in the middle below the umbilicus, both femoral necks have a ’ed angle.
 If the line intersects to 1 side more, the opposite side has a ’ed femoral neck angle.
 Salter-harris classification – (classes 1-5), fractures in the epiphyseal plate.
 Type I – slip of epiphyseal plate.
 Type II – slip and chip.
 Type III – slip and crack.
 Type IV – slip, chip, and crack.
 Type V – crushed/demolished bone.
Slipped femoral epiphysis – common to occur to both sides (usually 1 at a time).
Legg calve – Perth’s disease
 Occurs in young kids (4-9 yrs.), due to multiple infarctions (blood supply gets cut off).
 Femoral head shape changes, changing the acetabulum, creating coxa magnum.
 This disease is idiopathic.

Chiene’s test
 Measure around greater trochanter
 Discrepancy side to side indicates hip problem.

Avascular necrosis will cause deterioration and remodeling of bone – D.J.D.



Gauvain’s test.
Jansen’s test.
Guilland’s sign.
Ortho Tri 5 final




5
 Common in meningitis
Signs/symptoms of meningitis.
 Headache, nuchal rigidity (80%), fever, nausea, vomiting, mental confusion, and disorientation.
 The patient doesn’t want their neck flexed because this stretches the meningies.
 Opisthotonus – can result. Complete extension, arched back, and body going through spasm to
make room for the cord.
The CNS has no normal flora, and protective measures like the blood/brain barrier to keep it that way.
So an infection here is deadly. There’s nothing to compete w/ it (the virus/bacteria will undergo 4
phases) and the barrier makes it tough for antibiotics to get through.
 The 4 phases are incubation, lag, log (exponential growth Phase), and death.
Why don’t we always have strep?
 They emit waste products and chemicals to keep other microbes out.
 In brain, microbes go into log, no competition and lots of food.

Posterior femoral dislocation – usually has small acetabular fracture.

Trochanteric bursitis – pain around greater trochanter.


2 hip extensors: G. max, g. med, TFL, IT band.
1 flexor of the hip is psoas. M/c contracture you’ll see.
Ludloff’s sign
Thomas test
Ober’s test – testing IT band tightness. Patient is in side posture. Keep knees straight; don’t bend (this  the
stretch).
Patrick’s test – a.k.a. Fabere
Phelps’s test
3 classifications of sprain/strain - 1, 2, 3.
Knee has 3 separate articulations –
1. Lateral femoral tibial articulation.
2. Medial femoral tibial articulation.
3. Patellofemoral articulation.


When the leg is fully extended the foot externally rotates.
When the leg is fully flexed the foot internally rotates.
Abduction stress test
Patella grinding test
Clarke’s sign
Chonromalacia patella = patellofemoral arthralgia/ retropetallar dysfunction.
Q angle – the angle of shaft of femur on the tibia.
6
Ortho Tri 5 final
Valgus
Varus

Semitendonosous, gracilis, and satorius tendons all insert on the medial aspect of the knee at the pes
anserinus.
 This is above the anserine bursa.



There may be no significant swelling around the knee after a traumatic injury due to tendons and
capsule keeping the swelling down.
Stretch a ligament 10% of original length and it will stay stretched due to historesis and creep.
The cruciate ligaments are responsible for rotatory stabilization of the knee.



Effusion containing blood indicates tear of medial cruciate ligament.
Effusion of fat indicates bone break/fracture.
Effusion of clear yellowish fluid indicates chronic meniscal problem.
Meniscal tear and repair
 Medial meniscus.
 Bucket handle tear.
 Radial tear leads to parrot beak tear.
 Horizontal tear leads to flap tear.



Lateral meniscus isn’t connected to lateral collateral ligament, so it’ll move more.
Medial meniscus is connected to the medial collateral ligament, so it won’t move much and is therefore
more susceptible to pain and injury.
Plica – happens in the knee, a fold of synovium…(?)
Clicking or locking knee – exam and x-ray
 Objective findings.
1. Abnormal findings – apply specific treatment.
2. Snapping tendons – no exostoses – apply quad program, and observe (wait 8-10 weeks).
3. Patellofemoral abnormality – quad rehab, knee corset, and activity adjustment.





Chronic knee effusion/swelling and hot – take Hx, palpate, and take temp. >> If  temperature it could
be infection, arthritis, acute inflammation due to exacerbation of a chronic condition.
Bilateral effusion – medial meniscus breakdown occurs 1st and varus deformity occurs. There’s medial
instability.
Osteoarthritis is not symmetrically affected unlike rheumatoid arthritis.
OA usually affects the knee and hip and Herberden’s nodes are assoc. with OA in the hands.
People with OA have stiffness, pain, swelling,  pain with movement, barometric pressure changes (it’s
gonna rain) will  pain due to expansion of cyst.
Signs and symptoms of OA (osteoarthritis)
Ortho Tri 5 final

7
Pain, morning stiffness, joint swelling, etc.
RA (rheumatoid arthritis)
 Presents in 4th and 5th decade of life, most common in women, manifests bilateral, symmetrical, hot,
swollen joints,  immune system, and subcutaneous nodules.
 Distal interphalengeal joints don’t get involved.

1st synovitis

Pannus formation leads to destruction of cartilage, mild osteoporosis, and joint will fibrose (fibrosing
ankylosis). Leads to bony ankylosing then advanced osteoporosis. The end stage is destruction.

1.
2.
3.
4.
Plica – 4 in the knee.
Suprapatellar plica.
Lateral plica.
Medial plica (shelf).
Infrapatellar plica.
Mediopatellar plica test
 Patient supine flexes leg to 30, and dr. pushes patella medially.
Plica stutter test
 Patient seated, dr. palpates patella then patient extends knee between 45 and 60.
 There’ll be a click/jump/stutter during the mvt.
Hughston plica test
 Patient supine, dr. presses patella medially and grips under the patella.
 Then have the patient flex and medially rotate.
 Feel for popping.
Osteochondritis dissecans – actually a fracture of the medial femoral chondyle.
Osgood – Schlatter lesion
 A.k.a. traction apophysitis.
Scoliosis
Children under 11 yr. check for Arnold Chiari syndrome and sphingomyelia.
Ortho Tri 5 final
List the 1 curve – it’s the 1st to show or the most curved. Tends to be the least flexible.
Cardiorespiratory problems may occur; shortness of breath, look for Café Au lai spots, changes in skin
and/or tuft of hair indicating spina bifida/occulta.
Full spine x-ray best for observing scoliotic spine.
Scoliosis may occur due to:
1. Ribs fusing on one side.
2. Wedge shaped vertebrae.
3. Hemishaped vertebrae.
4. Congenital bar – unilateral failure of vertebral segmentation.
5. Block vertebrae – bilateral failure of vertebral segmentation.
“The dr. who treats disease is a secondary practitioners; the higher dr. prevents disease”.
Russian stim for scoliosis – put leads on convex side above and below curve to de-rotate the spine.
Measure curve using Cobb angles.
4 major curves >> 1-4 names (?)
Measure rotation on convex side
+1 rotation – pedicle is slightly towards midline.
+2 rotation – pedicle 2/3 way towards midline.
+3 rotation – pedicle is in midline.
+4 rotation – pedicle is past midline.
Riessors sign – grade 1-5.
 An incomplete fusion of the iliac crest.
 Looks like a thin fracture on x-ray.
 Grade 1 – is slight crest length involvement.
 Grade 5 is the full length of the crest is involved.
8