Title: Bone Wizardry / OMM Mastery / 7.Upper Extremities
Tags: #BW_OMM::Region::Upper_Extremity #BW_OMM::Type::Cloze BoneWizardry bonewizardry-free omm omt
On every note of this deck, unless a note says otherwise:
Topic: Upper Extremities
Review Links: - Bone Wizardry upper extremity
- Practice: Upper Extremity QBank
Show outside sources
- MET for AC, clavicle, SC joint
- Stanford shoulder exam
- AAFP painful shoulder exam

Q: [...]: the bony strut that suspends the upper limb and allows its wide range of motion.
A: Clavicle
Q: The [...] is the only bone connecting the upper extremity and the axial spine.
A: clavicle
Bone Wizardry Lock: The clavicle is the only bony link between the upper limb and the trunk. A fracture here disrupts that connection and limits the entire arm.

Q: [...]: four muscles that compress the humeral head into the glenoid fossa and stabilize the shoulder through motion.
A: Rotator cuff
Bone Wizardry Lock: The rotator cuff compresses the humeral head into the glenoid. Pain with motion but full ROM is tendinitis. Pain plus lost ROM points to a tear.

Q: Rotator cuff is made up of:
1. [...]
2. Infraspinatus
3. Teres minor
4. Subscapularis
A: Supraspinatus
Q: Rotator cuff is made up of:
1. Supraspinatus
2. [...]
3. Teres minor
4. Subscapularis
A: Infraspinatus
Q: Rotator cuff is made up of:
1. Supraspinatus
2. Infraspinatus
3. [...]
4. Subscapularis
A: Teres minor
Q: Rotator cuff is made up of:
1. Supraspinatus
2. Infraspinatus
3. Teres minor
4. [...]
A: Subscapularis
Q: Patient presents with pain on abduction and flexion of shoulder muscles but has normal range of motion, what kind of injury is this most likely?
[...]
A: Rotator Tendinitis
Q: Patient presents with pain on abduction and flexion of shoulder muscles and has abnormal range of motion, what kind of injury is this most likely?
[...]
A: Rotator cuff tear
Comment 5: The tendon is inflamed but structurally intact, so the shoulder still completes its full arc of motion. Pain yes, but range holds.
Comment 6: A tear removes the mechanical force needed to complete the motion. Range drops on top of the pain.
Bone Wizardry Lock: SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis. Pain with intact motion is tendinitis. Pain plus restricted motion is a tear.

Q: Supraspinatus main action is [...]
A: abduction
Q: Infraspinatus main action is [...].
A: external rotation
Q: Teres minor main action is [...].
A: external rotation
Q: Subscapularis main action is [...].
A: internal rotation
Bone Wizardry Lock: Supraspinatus initiates abduction. Infraspinatus and teres minor externally rotate. Subscapularis internally rotates. Subscapularis is the only cuff muscle on the costal (anterior) scapular surface.

Q: The subclavian artery passes between the [...] and [...] scalenes.
A: anterior; middle
Q: The [...] artery passes between the anterior and middle scalenes.
A: subclavian
Q: The subclavian vein passes anterior to the [...] scalene.
A: anterior
Q: The [...] vein passes anterior to the anterior scalene.
A: subclavian
Q: The subclavian artery becomes the [...] artery at the lateral border of the first rib.
A: axillary
Q: The subclavian artery becomes the axillary artery at the lateral border of the [...] rib.
A: first
Q: The axillary artery becomes the [...] artery at the inferior border of the teres major muscle.
A: brachial
Q: The axillary artery becomes the brachial artery at the inferior border of the [...] muscle.
A: teres major
Q: The [...] artery is the first major branch of the brachial artery.
A: profunda brachii
Bone Wizardry Lock: The vessel renaming follows fixed landmarks: subclavian becomes axillary at the lateral border of rib 1, axillary becomes brachial at the inferior border of teres major. Profunda brachii is the first major branch off the brachial artery.

Q: The [...] artery accompanies the radial nerve in its posterior course of the radial groove.
A: profunda brachii
Q: The brachial artery divides into the [...] and [...] arteries under the bicipital aponeurosis.
A: ulnar; radial
Bone Wizardry Lock: The profunda brachii is the companion artery to the radial nerve in the spiral groove. Brachial bifurcation into radial and ulnar happens right at the bicipital aponeurosis.

Q: Treatment to relieve lymph congestion of the upper extremity:
1. Open the [...]
2. Redome the thoraco-abdominal diaphragm
3. Posterior axillary fold technique.
A: thoracic inlet
Q: Treatment to relieve lymph congestion of the upper extremity:
1. Open the thoracic inlet
2. Redome the [...]
3. Posterior axillary fold technique.
A: thoraco-abdominal diaphragm
Q: Treatment to relieve lymph congestion of the upper extremity:
1. Open the thoracic inlet
2. Redome the thoraco-abdominal diaphragm
3. [...] fold technique.
A: Posterior axillary
Bone Wizardry Lock: Drain proximal to distal. The thoracic inlet is the outlet for upper extremity lymph, so it opens first. Skipping that step leaves the downstream work without a pathway.

Q: The brachial plexus is composed of nerves from roots [...] and [...].
A: C5-C8; T1
Bone Wizardry Lock: The brachial plexus spans C5 through T1, five roots total. Missing a level shortchanges the motor and sensory territory that root feeds.

Q: [...] exit the spinal cord to form
Trunks which form
Divisions which form
Cords which form
Branches
A: Roots
Q: Roots exit the spinal cord to form
[...] which form
Divisions which form
Cords which form
Branches
A: Trunks
Q: Roots exit the spinal cord to form
Trunks which form
[...] which form
Cords which form
Branches
A: Divisions
Q: Roots exit the spinal cord to form
Trunks which form
Divisions which form
[...] which form
Branches
A: Cords
Q: Roots exit the spinal cord to form
Trunks which form
Divisions which form
Cords which form
[...]
A: Branches
Bone Wizardry Lock: Robert Taylor Drinks Cold Beer: Roots, Trunks, Divisions, Cords, Branches. Work through the chain from the symptom pattern to localize the lesion.

Q: Normally, the arm can abduct to [...]° with active motion, [...]° is due to glenohumeral motion and [...]° is due to scapulothoracic motion.
A: 180; 120; 60
Q: Normally, the arm can abduct to 180° with active motion, 120° is due to [...] motion and 60° is due to [...] motion.
A: glenohumeral; scapulothoracic
Comment: Therefore, for every 3° of abduction, the glenohumeral joint moves 2° and the scapulothoracic joint moves 1°.
Bone Wizardry Lock: Full abduction is 180 degrees. Two thirds is glenohumeral, one third is scapulothoracic. That 2:1 ratio is testable and the calculation is a single step.

Q: The most common somatic dysfunction of the shoulder is restriction in [...] and [...] rotation.
A: internal; external
Q: The second most common somatic dysfunction of the shoulder is restriction in [...].
A: abduction
Q: The least common somatic dysfunction of the shoulder is restriction in [...].
A: extension
Bone Wizardry Lock: Shoulder somatic dysfunction restricts rotation first, abduction second, extension last. If a vignette says extension is the restricted motion, that is the rare finding, not the default.

Q: Motions at either end of the clavicle are in [...] directions.
A: opposite
Comment: For example, if the lateral end of the clavicle has moved superior (e.g shoulder shrug) the medial end would move inferior.
Bone Wizardry Lock: The clavicle pivots like a lever. Elevation at the lateral end means depression at the medial end. The somatic dysfunction is named at the restricted end, not the displaced one.

Q: [...]: Compression of the neurovascular bundle (subclavian artery and vein, and the brachial plexus) as it exits the thoracic outlet.
A: Thoracic outlet syndrome
Q: Thoracic outlet syndrome can compress in three places:
1. Between the [...] scalenes.
2. Between the clavicle and the first rib.
3. Between the pectoralis minor and the upper ribs.
A: anterior and middle
Q: Thoracic outlet syndrome can compress in three places:
1. Between the anterior and middle scalenes.
2. Between the [...] and the [...] rib.
3. Between the pectoralis minor and the upper ribs.
A: clavicle; first
Q: Thoracic outlet syndrome can compress in three places:
1. Between the anterior and middle scalenes.
2. Between the clavicle and the first rib.
3. Between the [...] and the [...] ribs.
A: pectoralis minor; upper
Bone Wizardry Lock: Three tunnels, same neurovascular cord: the interscalene triangle, the costoclavicular space, and the space under pectoralis minor. The provocative test identifies which tunnel is compressing.

Q: Patient presents with neck pain that radiates to the left arm. On examination there is a left positive Adson's test. What is the likely diagnoses? [...]
A: Thoracic outlet syndrome
Comment: Neurovascular bundle can be compromised by tight scalene muscles. While monitoring the patient's pulse, the arm is extended at the elbow, the shoulder is extended, externally rotated and slightly abducted. The patient takes a deep breath and turns their head toward the ipsilateral arm. Test is positive with a severely decreased/absent radial pulse.
Bone Wizardry Lock: Adson's targets the interscalene triangle. Head turns ipsilateral, patient holds a deep breath to close it. A disappearing radial pulse is the positive finding, pointing to scalene compression.

Q: Patient presents with tenderness to palpitation of the right acromion. There is a "painful arc" when the patient abducts their arm. What is the likely diagnoses? [...]
A: Supraspinatus tendinitis
Q: When a Patient presents with pain that is exacerbated by abduction, especially from 60° - 120°, this is known as a "[...]."
A: painful arc
Comment: Pathogenesis: Continuous impingement of the greater tuberosity against the acromion as the arm is flexed and internally rotated.
Bone Wizardry Lock: The painful arc sits between 60 and 120 degrees of abduction, the window where the supraspinatus passes under the acromion. Pain inside that arc, relief above and below it.

Q: Patient presents with pain over the anterior portion of their shoulder that radiates to the biceps. They have pain to palipitation over the bicipital groove and it is aggravated by resisted flexion and supination of the forearm. What is the likely diagnosis?
[...]
A: Bicipital tenosynovitis
Q: [...] is an inflammation of the bicipital tendon and its sheath of the long head of the biceps.
A: Bicipital tenosynovitis
Q: Bicipital tenosynovitis is an inflammation of the bicipital tendon and its sheath of the [...] head of the biceps.
A: long
Q: Bicipital tenosynovitis is usually due to [...].
A: overuse
Comment: Treatment: Rest and ice for acute injury. For severe cases, an injection with lidocaine or steroids may provide relief.
Bone Wizardry Lock: Anterior shoulder pain that gets worse with resisted supination and flexion points to the long head biceps tendon. The bicipital groove is the chokepoint and repetitive overhead loading is the usual culprit.

Q: Which rotator cuff muscle is most commonly torn?
[...]
A: Supraspinatus
Bone Wizardry Lock: The supraspinatus runs through the subacromial space and takes mechanical stress with every overhead motion. It tears more than the other three rotator cuff muscles and is the answer when a question asks which one fails first.

Q: Patient presents with a sharp pain in their shoulder that has lasted for a couple of days. They have a positive drop arm test. What is the likely diagnosis? [...]
A: Rotator cuff tear
Comment: Treatment: For minor tears rest, ice and NSAIDs in the acute stages. Surgery is often required for complete avulsion.
Bone Wizardry Lock: Positive drop arm test means the patient cannot slowly lower the arm from 90 degrees of abduction. That failure points to a structural rotator cuff tear, not simple impingement.

Q: 40-year-old patient presents with pain and restriction in their shoulder that has progressively gotten worse over the last year. They have decreased range of motion with active and passive movements. What is their likely diagnosis? [...]
A: Adhesive capsulitis/frozen shoulder syndrome
Q: Adhesive capsulitis is typically caused by prolonged [...] of the shoulder.
A: immobility
Q: What motions are typically affected in adhesive capsulitis?
[...]
A: Abduction, Internal and External rotation
Q: What OMT technique is used in a patient with adhesive capsulitis? [...]
A: Spencer
Comment 3: Extension is typically preserved. Pain is often present at the end of the range of motion.
Comment 4: The main goal is prevention. Early mobilization following shoulder injury is essential. Injection of corticosteroids and NSAIDs may help.
Technique:
-Extension
-Flexion
-Circumduction with compression
-Circumduction with traction
-Internal Rotation
-Joint pump
Bone Wizardry Lock: Spencer technique is the OMT for frozen shoulder. All steps move the joint through different planes to restore capsular mobility. Extension is usually the last motion lost, which separates adhesive capsulitis from rotator cuff pathology.

Q: Patient is an athlete that presents with severe anterior shoulder pain after playing football with some friends. What is the likely diagnosis? [...]
A: Shoulder dislocation
Q: Injury to the [...] nerve can occur with shoulder dislocation.
A: axillary
Comment: Humeral dislocation usually occurs anteriorly and inferiorly.
Bone Wizardry Lock: Anterior shoulder dislocation can stretch the axillary nerve where it wraps around the surgical neck. After reduction, check deltoid strength and the patch of lateral arm skin it innervates. That sensory check is the clinical tell.

Q: Winging of the scapula occurs due to a weakness of the anterior serratus muscle due to a [...] nerve injury.
A: long thoracic
Q: Winging of the scapula occurs due to a weakness of the [...] muscle due to a long thoracic nerve injury.
A: anterior serratus
Comment: This condition is evident if the scapula protrudes posteriorly while the patient is pushing on a wall.
Bone Wizardry Lock: The long thoracic nerve runs exposed along the lateral chest wall and is vulnerable to backpack straps and poor surgical positioning. Have the patient push against a wall. If the scapula pops off the ribs, the serratus is weak and the nerve is out.

Q: [...] is by far the most common form of brachial plexus injury.
A: Erb-Duchenne's palsy
Q: Erb-Duchenne's palsy is an upper arm paralysis caused by injury to [...] nerve roots usually during childbirth.
A: C5 and C6
Q: Klumpke's palsy is due to injury to [...].
A: C8 and T1
Comment 3: Klumpke's palsy is much less common.
Bone Wizardry Lock: Erb-Duchenne injures C5-C6 and produces the waiter's tip posture: arm adducted, extended, and internally rotated. Klumpke injures C8-T1 and produces intrinsic hand weakness with claw posturing. Know the level by the posture.

Q: The [...] nerve is the most common nerve injured in the upper extremity due to direct trauma.
A: radial
Q: Radial nerve injuries will typically result in [...] drop, and possibly [...] weakness.
A: wrist; triceps
Q: [...] nerve injuries will typically result in wrist drop, and possibly triceps weakness.
A: Radial
Comment: lt may be injured in the axilla by direct pressure, such as crutch palsy, caused by improper use of crutches.
Bone Wizardry Lock: The level of radial nerve injury tells you what is lost. Axillary injury takes out the triceps too. Mid-humeral injury spares the triceps but drops the wrist. Knowing what is preserved pins the lesion.

Q: [...]
A: Scaphoid
Q: [...]
A: Lunate
Q: [...]
A: Pisiform
Q: [...]
A: Capitate
Q: [...]
A: Hamate
Q: [...]
A: Trapezoid
Q: [...]
A: Trapezium
Q: [...]
A: Radius
Q: [...]
A: ulna
Bone Wizardry Lock: Some Lovers Try Positions That They Cannot Handle. That mnemonic goes proximal row lateral to medial, then distal row. The scaphoid is the most commonly fractured carpal bone and the most commonly missed on initial x-ray.

Q: Primary extensors of the hand are innervated by the [...] nerve.
A: radial
Q: Most of the flexors of the wrist and hand are innervated by the [...] nerve.
A: median
Q: The primary supinators of the forearm are the [...] and the [...] muscle.
A: biceps; supinator
Q: The biceps muscle is innervated by the [...] nerve.
A: musculocutaneous
Q: The supinator muscle is innervated by the [...] nerve.
A: radial
Q: The primary pronators of the forearm are the [...] and [...].
A: pronator teres; pronator quadratus
Q: The pronator teres and quadratus muscles are innervated by the [...] nerve.
A: median
Q: Muscles in the thenar eminence are innervated by the [...] nerve.
A: median
Q: Muscles in the hypothenar eminence and interossi are innervated by the [...] nerve.
A: ulnar
Comment 2: Flexor carpi ulnaris is innervated by the ulnar nerve.
Comment 8: Except for adductor pollicis brevis, ulnar nerve.
Bone Wizardry Lock: Radial extends, median flexes and pronates, ulnar owns the hypothenar and interossei. The board exception is adductor pollicis: thenar location but ulnar innervation. That one exception shows up constantly.

Q: First and second lumbricals are innervated by the [...] nerve.
A: median
Q: [...] and [...] lumbricals are innervated by the median nerve.
A: First; second
Q: Third and fourth lumbricals are innervated by the [...] nerve.
A: ulnar
Q: [...] and [...] lumbricals are innervated by the ulnar nerve.
A: Third; fourth
Bone Wizardry Lock: Lumbricals 1 and 2 sit on the radial side and follow the median nerve. Lumbricals 3 and 4 sit on the ulnar side and follow the ulnar nerve. The radial-ulnar split runs down the middle of the hand on that 2 to 3 border.

Q: A carrying angle > 15° is called cubitus [...] or [...] of the ulna if SD is present.
A: valgus; abduction
Q: A carrying angle > [...]* is called cubitus valgus or abduction of the ulna if SD is present.
A: 15
Q: A carrying angle < 3° is called cubitus [...] or [...] of the ulna if SD is present.
A: varus; adduction
Q: A carrying angle < [...]* is called cubitus varus or adduction of the ulna if SD is present.
A: 3
Q: The carrying angle has a direct influence on the position of the [...].
A: wrist
Q: Due to a parallelogram effect, an [...] in the carrying angle (abduction of the ulna) will cause an adduction of the wrist.
A: increase
Q: Due to a parallelogram effect, an increase in the carrying angle ([...] of the ulna) will cause an [...] of the wrist.
A: abduction; adduction
Q: A [...] in the carrying angle (adduction of the ulna) will cause an abduction of the wrist.
A: decrease
Q: A decrease in the carrying angle ([...] of the ulna) will cause an [...] of the wrist.
A: adduction; abduction
Bone Wizardry Lock: The parallelogram effect flips the wrist opposite to the elbow. Cubitus valgus, meaning the elbow angles outward, drives the wrist into adduction. Cubitus varus drives the wrist into abduction. Think of it as the forearm compensating downstream.

Q: When the forearm is [...], the radial head will glide posteriorly.
A: pronated
Q: When the forearm is pronated, the radial head will glide [...].
A: posteriorly
Q: When the forearm is [...], the radial head will glide anteriorly.
A: supinated
Q: When the forearm is supinated, the radial head will glide [...].
A: anteriorly
Bone Wizardry Lock: Pronation pushes the radial head posteriorly, supination pulls it anteriorly. A radial head SD named posterior means it got stuck in the pronated position. Treatment moves it anteriorly to restore supination.

Q: Falling forward on a pronated forearm is often a common cause of [...] radial head.
A: posterior
Q: Falling forward on a [...] forearm is often a common cause of posterior radial head.
A: pronated
Q: Falling backward on a supinated forearm is often a common cause of [...] radial head.
A: anterior
Q: Falling backward on a [...] forearm is often a common cause of anterior radial head.
A: supinated
Comment: Findings:
- Restricted supination of the forearm.
- Restricted anterior glide of the radial head.
Comment 3: Findings:
-Restricted pronation of the forearm.
- Restricted posterior glide of the radial head.
Bone Wizardry Lock: Match the fall to the direction of the SD. Pronated forearm fall produces a posterior radial head with restricted supination. Supinated forearm fall produces an anterior radial head with restricted pronation. The position at impact is the position of restriction.

Q: [...] compresses the median nerve as it passes through the fibro-osseous tunnel at the wrist.
A: Carpal tunnel syndrome
Q: Carpal tunnel syndrome compresses the [...] nerve as it passes through the fibro-osseous tunnel at the wrist.
A: median
Q: What physical tests are commonly used to reproduce the symptoms of carpal tunnel syndrome?
[...]
A: Tinel's, Phalen and prayer
Q: What is the gold standard test used to diagnose carpal tunnel syndrome? [...]
A: EMG/nerve conduction studies
Bone Wizardry Lock: Tinel's and Phalen provoke the same nerve at the same tunnel. EMG/nerve conduction confirms what the exam predicts.

Q: [...] (tennis elbow) develops as a result of overuse of the forearm extensors and supinators.
A: Lateral epicondylitis
Q: Lateral epicondylitis (tennis elbow) develops as a result of overuse of the forearm [...] and [...].
A: extensors; supinators
Q: What motions aggravate lateral epicondylitis? [...]
A: wrist extension
Comment: Aggravating activities include hitting a ball in racquet sports (tennis) with improper technique and turning a screwdriver.
Bone Wizardry Lock: Lateral epicondylitis loads with wrist extension. Every forearm extensor anchors at that epicondyle, so repetitive extension overloads the enthesis.

Q: [...] (golfer's elbow) develops as a result of overuse of the forearm flexors and pronators.
A: Medial epicondylitis
Q: Medial epicondylitis (golfer's elbow) develops as a result of overuse of the forearm [...] and [...].
A: flexors; pronators
Bone Wizardry Lock: The medial epicondyle is the anchor for the flexor-pronator mass. Golfer's elbow is the cumulative cost of driving that attachment into repeated overload.

Q: What type of deformity is this known as? [...]
A: Swan neck
Q: What is a swan-neck deformity associated with? [...]
A: Rheumatoid arthritis
Comment: Flexion contracture of the MCP and DIP. Extension contracture of the PIP.
Bone Wizardry Lock: Swan neck: the PIP hyperextends while the MCP and DIP flex. Remember the shape, not just the name. Rheumatoid drives the intrinsic muscle imbalance behind it.

Q: What type of deformity is this?
[...]
A: Boutonniere deformity
Comment: Extension contracture of the MCP and DIP. Flexion contracture of the PIP. Is also associated with rheumatoid arthritis.
Bone Wizardry Lock: Boutonniere is swan neck flipped at the PIP: PIP flexes here, while MCP and DIP extend. Central slip disruption is the classic mechanism.

Q: Claw hand results from [...] nerve injury.
A: median and ulnar
Q: Ape hand results from [...] nerve damage.
A: median
Q: [...] deformity shows fixed contracture of the ring and little fingers with wasting of the hypothenar muscles.
A: Bishops
Q: Bishops deformity shows fixed contracture of the ring and little fingers with wasting of the [...] muscles.
A: hypothenar
Q: Bishops deformity occurs due to [...] nerve damage.
A: ulnar
Comment: Loss of intrinsic muscles and overacting of the extensor muscles.
Comment 2: Ape hand adds thenar wasting and thumb adduction on top of the claw pattern, all from median nerve loss.
Comment 3: Also known as hand of benediction
Bone Wizardry Lock: Claw, ape, and bishop's each map to a specific nerve. Know which digits drop, which eminence wastes, and which nerve is out.

Q: [...] progressively pulls the ring and little fingers into fixed flexion as the palmar fascia thickens and fibroses.
A: Dupuytren's contracture
Q: Dupuytren's contracture progressively pulls the ring and little fingers into fixed flexion as the [...] thickens and fibroses.
A: palmar fascia
Bone Wizardry Lock: Dupuytren's is fascial fibrosis, not tendon tightness or nerve injury. The fingers cannot extend because the palmar fascia itself is contracting.

Q: What nerve is most commonly injured with a mid-shaft fracture?
[...]
A: radial nerve
Q: A lateral epicondyle injury will damage the [...] nerve.
A: radial
Q: A medial epicondyle injury will damage the [...] nerve.
A: ulnar
Q: A supra-condylar fracture will injure the [...] nerve.
A: median
Q: Carpal tunnel syndrome will affect the [...] nerve.
A: median
Q: An injury to Guyon's canal will affect the [...] nerve.
A: ulnar
Comment 4: This occurs right around the elbow.
Comment 5: Patients report tingling and numbness across the lateral 3.5 fingers, the classic median nerve distribution.
Bone Wizardry Lock: Match the fracture site to the nerve: lateral epicondyle hits radial, medial epicondyle hits ulnar, supracondylar catches median. Carpal tunnel traps that same median nerve again distally.