Where would you expect to see sensory loss with damage to the Median Nerve?
1) Palmar aspect of the hand in the thumb, index, middle, and lateral half of the ring finger
2) Dorsal aspect of the hand in the distal 1/3 of the index and middle fingers and the lateral 1/2 of the distal 1/3 of the ring finger
What functional losses would you expect to see with damage to the Median Nerve
1) Pronation weak or lost 2) Weak wrist flexion and abduction 3) Radial deviation @ wrist is lost 4) Inability to oppose or flex thumb 5) Weak thumb abduction 6) Weak grip 7) Weak or no pinch (Ape hand deformity)
What nerve roots does the median nerve originate from?
Where does the Anterior Interosseous Nerve originate from?
It is a branch of the median nerve
What motor loss would you expect to see with damage to the Anterior Interosseous Nerve?
What sensory loss would you expect to see with damage to the anterior interosseous nerve?
What functional losses would you expect to see with damage to the anterior interosseous nerve?
1) Weak pronation, especially @ 90 degrees elbow flexion 2) Weak opposition and flexion of the thumb 3) Weak finger flexion 4) Weak pinch (inability to to tip-to-tip) --> instead pulp-to-pulp
Where does the ulnar nerve originate from?
What motor loss would you expect to see with damage to the ulnar nerve?
1) Flexor Carpi Ulnaris 2) Medial 1/2 of Flexor Digitorum Profundus 3) Palmaris Brevis 4) Hypothenar eminence 5) Adductor Pollicis 6) Medial 2 lumbricals 7) All interossei (not all need to be weak, there may be a selective few that are weak)
What sensory loss would you expect to see with damage to the ulnar nerve?
Dorsal and palmar aspect of the: - Little finger - Medial 1/2 of the ring finger
What functional losses are associated with damage to the ulnar nerve?
1) Weak wrist flexion 2) Loss of ulnar deviation @ the wrist 3) Loss of distal flexion of the little finger 4) Loss of abduction and adduction of fingers 5) Inability to extend 2nd and 3rd phalanges of little and ring fingers (benediction hand deformity) 6) Loss of thumb adduction
Where does the radial nerve originate from?
What motor loss would you expect to see with damage to the radial nerve?
1) Anconeus 2) Brachioradialis 3) Extensor carpi radialis longus and brevis 4) Extensor digitorum 5) Extensor pollicis longus and brevis 6) Abductor pollicis longus 7) Extensor carpi ulnaris 8) Extensor indices 9) Extensor digiti minimi
What sensory loss would you expect to see with damage to the radial nerve
1) Dorsum of the hand (lateral 2/3) 2) Dorsum and lateral aspect of the thumb 3) Proximal 2/3 of the dorsum of index and middle finger 4) Medial 1/2 of the proximal 2/3 of the dorsum of the ring finger
What functional losses are associated with damage to the radial nerve?
1) Loss of supination 2) Loss of wrist extension (wrist drop) 3) Inability to grasp 4) Inability to stabilize the wrist 5) Loss of finger extension 6) Inability to abduct thumb
Where does the posterior interosseous nerve originate from?
It is a branch of the radial nerve
What motor loss would you expect to see with damage to the posterior interosseous nerve?
1) Extensor carpi radialis brevis 2) Extensor digitorum 3) Extensor pollicis longus and brevis 4) Abductor pollicis longus 5) Extensor carpi ulnaris 6) Extensor indices 7) Extensor digiti minimi
What sensory loss would you expect to see with damage to the posterior interosseous nerve?
What functional losses would you expect to see with damage to the posterior interosseous nerve?
1) Weak wrist extension 2) Weak finger extension 3) Difficulty stabilizing wrist 4) Difficulty with grasp 5) Inability to abduct thumb
Name the 5 flexors of the elbow and their nerve supply
What manipulation technique would you use for a patient suffering from lateral epiconylitis?
Mills manipulation, only if elbow extension has full PROM and painless
What treatment would you use for lateral epicondylitis at the following sites: 1. ECRL (origin)- Supracondylar 2. Common extensor tendon- tenoperiosteal 3. Body of extensor tendon- tendinous 4. Belly of muscle- muscular
2. DFM and Mills manipulation (only if passive extension is full and painless)
4. Injection of Procaine
What is the most common site for Lateral Epicondylitis
UCL Repair: 1. What is the goal of the surgery? 2. What is the most common donor tissue?
1. Restore static stability of the anterior band 2. Palmaris longus
Describe the steps of an UCL repair
1. Dissection down to the flexor mass, retracted anteriorly
2. Visualization and inspect of the UCL a. Complete rupture- joint will be visible b. Potential undersurface tear examined through longitudinal incision in anterior band
3. Remnants of ligament augment repair
Describe the surgical steps of an UCL repair
1. 2 drill holes are made @ right angles just anterior and posterior to the sublime tubercle @ the level of insertion of the anterior band
2. Proximally, 2 convergent tunnels are drilled to meet @ the insertion of the ligament on the medial epicondyle
3. The graft if passes through the ulna and crossed in a figure 8 across the joint
4. Tensioned at 30 degrees and secured with non-absorbable sutures
What degree of ROM of safe immediately following an UCL repair? Why?
30 degrees of ROM is safe because during the surgery the ligament is tensioned at 30 degrees
What are the general ROM that are allowable following an UCL repair from weeks 1-6 post-surgery?
Week 1 - locked @ 90 degrees Week 2- -30 to 100 degrees in hinge brace - Progress in brace 10/10 degrees per week Week 4 (0-135 degrees) Week 5- D/C brace Week 6- AROM
What strengthening exercises can you perform after an UCL repair? When?
Week 9- more agressive strengthening (may not be until week 12)
Throwers 10 protocol- Kevin Wilk
1. Diagonal pattern- D2 flexion/extension 2. ER and IR tubing 3. Shoulder abduction 4. Full can 5. Side lying ER 6. Prone- horizontal abduction, horizontal abduction @ 100 degrees, row, and row into ER 7. Press-ups 8. Push-ups starting from the wall in standing 9. Elbow flexion and extension 10. Wrist extension and flexion, pronation and supination
Describe the steps of an ECRB release
1. Retract ECRL 2. Debride or release ECRB 3. Check for extensor digitorum involvement 4. Partial decortication of epicondyle 5. Scope Db same but from inside joint
Describe the ROM rehab following ECRB release
Week 1-2: at least 60% PROM (extension will be more limited b/c of increase tautness of tissue)
Week 3- Full PROM
Describe the Strengthening rehab follow ECRB release
Start @ 2 weeks post-op
Progress as tolerated (maintain good skin closure)
Isometric --> Isotonic
No isotonics until full PROM
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