Shoulder
Describe the shape of the SC joint and how the convex/concave joint partners change with protraction/retraction and elevation/depression. What movements of the SC joint do you see with FULL shoulder elevation?
Elevation/Depression: Convex-Clavicle, Concave-Manubrium
Retraction/Protraction: Convex-Maubrium, Concave-Clavicle
SC Joint Movement in Full Shoulder Elevation: 20-35 degrees posterior rotation
Describe how the alar ligament contributes to upper cervical spine coupling when initiating with occipital side bend to the LEFT?
L occipital SB --> R alar ligament becomes taut --> L rotation of C2 on C1--> C1 is relatively fixed--> relative R rotation of C1 on C2
Describe the upper VS. lower costotransverse articulations. How will this affect motion in the upper VS. lower cervical spine?
Upper: Articulates anterior to the TP, oriented more in the frontal plane and are more concave
Lower: Articulates superior to the TP, oriented more in the transverse plane and are more convex
Why? Allows the lower t-spine to be more compliant to weight bearing and allows for greater mobility
What is the attachment and function of the annular ligament? Name a common injury involving this ligament, the MOI and the patient population.
Attachment: Surrounds the radial head and attaches on either side of the radial notch of the ulna
Function: Resists distraction forces while still allowing rotation during supination and pronation
Common Injury: Nurse maids elbow or radial subluxation of the radial head from the annular ligament
MOI: Unexpected distraction while the elbow is in an extended position
Patient Population: Children under the age of 5
Describe the articulation and arthrokinematic motion of the distal carpal row in flexion. Is it the same or different at the proximal row?
Distal Carpals: convex capitate on concave lunate provides a palmar roll and dorsal glide
This remains the same at the proximal row of the carpals
Explain why with ST retraction, you may see ER or IR at the AC joint?
AC ER: Allows for retraction without scapular winging but the medial boarder of the scapula may abut against the ribs
AC IR: Allows for retraction without abutment of the medial boarder on the ribs but may allow scapular winging
Your patient comes to you after a car accident. Would her injury be worse due to the hyperflexion or hyperextension force of a MVA and why? Name a ligament that can be damaged in whiplash injury and describe that ligaments purpose.
Hyperextension, flexors have smaller MAs causing less torque producing capabilities and they have overall decreased PCSA causing decreased force production
Transverse Ligament: keeps the dens secured to C1 and prevent anterior translation. Damage to this ligament could cause impingement of the SC by the dens
Describe the AOR of rib rotation. What motion occurs about this axis with full inhalation?
AOR: Between the CT and CV joint about 35 degrees horizontally to the frontal plane
Full Inhalation: Lateral and superior motion (out and up)
You have a 10-year-old patient with elbow pain due to hypermobility. Give an example of one biceps exercise that can be used to improve compression and stability within the joint using a free weight/DB?
Elbow in 0-90o of flexion to encourage compressional force and avoid distraction forces
Degeneration of the anterior oblique ligament causes OA of the 1st CMC. 1st CMC flexion, MIP hyperextension and DIP flexion
What are the causes of AC joint separation? List the structures affected in the varying degrees of separation from mild to complete?
Causes: "Piano key deformity" is caused by falling on the tip of the shoulder with the humerus ADDucted
Mild Separation: AC ligament
Severe Separation: AC and CC ligament
Complete Separation: Complete separation of the AC joint
Describe a cervical spine condition that incorporates both upper and lower cervical coupled motions. If your patient shows hypomobility of the lower cervical spine what deviation from this position would you see?
Pure R or L side bend
Hypomobility would cause contralateral rotation of the head. Ex. L side bend with hypomobility would cause R cervical rotation
Thoracic kyphosis is typically calculated via ______ and is typically____ degrees. What are the consequences of excessive kyphosis on the cervical and lumbar spine?
Cobb's Angle
40o
Excessive kyphosis -----> increased lordosis
DAILY DOUBLE BITCHESSS
Pick any peripheral artery and trace it's path back to the brachial plexus. Indicate one area of entrapment and one treatment you would use to address this.
T/F The MA for finger flexion at the IP joints peak at midrange of joint motion and then decrease again? Why or why not?
False, the tendons of the IP flexors are fixed to the phalanges via the tendon sheath and ligaments
Describe the single row and double row correction surgery for RTC tears. Describe the functional and biomechanical differences in outcomes of the two?
Single Row: One anchor placed at the greater tuberosity of the humerus
Double Row: One anchor placed at the lateral edge of the articular surface of the humerus and another at the greater tuberosity of the humerus
Functionally: No differences
Biomechanically: Double row has higher load to failure, decreased stress due to increased CA and better cuff integrity when analyzed by MRI
Upper: facet joints, intact vertebral ring and alar ligament
Lower: facet joints, intact vertebral ring and uncovertebral joints
Your patient is a professional free diver and sometimes holds his breath for upwards of 5 minutes. Once he exits the water, he takes very deep, forced breaths in out. Name the muscles he is using for inspiration and expiration.
Inspiration: Pec major, pec minor, lats, SA and SP inferior
Expiration: 4 Abdominals, transverse thoracis and internal intercostals
Consider a pull-up exercise, describe how the following ligaments react to this force. (IO membrane, annular ligament and oblique cord)
Distraction force causes the annular and oblique cord to become taut while the IO membrane is put on slack
If the trapezium relatively extends during radial deviation, describe the joint mobilizations you could apply to both the trapezium and the scaphoid?
Trapezium is concave it glides dorsally
Scaphoid is convex it glides dorsally
You would apply a dorsal mobilization
Your patient is a star quarterback, he has been plagued with shoulder dislocations his whole career. These dislocations often happen when he is about the throw a pass and he is hit from behind. Explain what is happening anatomically that causes these dislocations and why this has been a recurring injury? Describe to your CI the relative positions of the SC, AC and GH joints when your patient is in this throwing position?
Why? When the humerus is ABD to 90o and fully ER the IGHL translate superiorly above the humeral head causing instability anteriorly and inferiorly. Additionally, this is where the labrum is the weakest.
Recurring Injury: Shoulder dislocations will often reoccur due to the ligamentous structures being compromised with the initial shoulder dislocation injury
Relative Positions: GH is ABD and ER, SC is elevated and retracted, AC is elevated and ER
Describe how you would perform a VBI test for the RIGHT vertebral a? (What side becomes kinked/stays open)
Extension, R rotation and R side bend. This kinks the L vertebral a. and the R vertebral a. is left open
List the 5 structural abnormalities that occur to the vertebrae and ribs that occur with a left thoracic curve?
SP deviates to the L
L axial rotation of the vertebrae
L rib hump and sharper posterior angle/ Flattened posterior angle on the R
Thicker pedicle on the L and thinner on the R
Muscle and ligaments exert a torque resistant to the rotation so it will go to the L
What band of the UCL is most often torn? Why?
Anterior band because it is the primary structure resisting valgus forces. The posterior band is only taut in flexion and the transverse band provides no resistance to valgus forces.
What muscle is better suited for quick radial deviation, ECRL or ECRB?
ECRL because it has longer fibers and a shorter MA