1.6. Elbow, Wrist, and Hand Complaint Flashcards by Deleted Deleted

What reflexes would you test for the elbow joint exam? What scale do you use?

Biceps
Triceps
Brachioradialis
0-4 scale, 2 is normal

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What is the vascular exam for the elbow?

Checking brachial pulse

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What are the 5 specialty exams for the elbow?

Valgus stress test: sprained medial collateral l.
Varus stresst test: sprained LCL
Tinel test: ulnar nerve entrapment (cubital tunnel)
Medial (golfer) epicondylitis test
Lateral (tennis) epicondylitis test

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What are the most common issues with anterior elbow pain?

gout

2. osteoarthristis

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What is the most common causes of lateral elbow pain?

lateral epicondylitis

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What are the most common causes of medial elbow pain?

Cubital tunnel syndrome (ulnar n.)

2. Medial epicondylitis

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What is the most common cause of posterior elbow pain?

olecranon bursitis

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What is the classic presentation of Tennis Elbow (lateral epicondylitis)?

Gradual onset of pain at lateral elbow

- Pain is aggregated by resisted wrist extension (lateral epicondylitis test)

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What is the etiology of Tennis Elbow (lateral epicondylitis)?

Caused by repeated motion like playing tennis or activities which result in micro tears or micro avulsions of common extensor tendons

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What are common treatments for Tennis Elbow (lateral epicondylitis)?

Rest, ice, bracing, short course NSAIDs
Steroid injection
PT

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What is the classic presentation of Medial Epicondylitis (Golfer’s Elbow)?

gradual onset of pain at medial elbow with or without grip weakness
pain localized over medial epicondyle and aggravated by resistent wrist flexion (medial epicondylitis test)

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What is the etiology of Medial Epicondylitis (Golfer’s Elbow)?

repetitive motions from playing golf or other activities which result in micro tears or microavulsions of common flexor tendons

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What is the common treatment of Medial Epicondylitis (Golfer’s Elbow)?

Rest, ice, bracing, short course NSAIDs
Steroid injection
PT

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What is the most common bursitis seen?

Olecranon bursitis

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What are the 2 types of olecranon bursitis?

Septic and aseptic

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What is the typical etiology of olecranon bursitis?

Common after trauma from leaning on elbow, however can have inflammatory or infectious etiologies (inflammatory arthritis, gout, trauma, hemorrhage, infection)

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Why do you have to be careful about aspirating fluid from a joint? When would you do this?

Concern that you might introduce bacteria to aseptic joint

- concern about infection or crystal disease

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What is the treatment for olecranon bursitis?

ice, compression, dressing, avoiding aggravating factors
antibiotic if septic
therapeutic aspiration
bursectomy

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What is the epidemiology of ulnar nerve entrapment (cubital tunnel syndrome)?

2nd most common compressive neuropathy in UE, 2nd to carpal tunnel
60% of pt’s with medial epicondylitis have ulnar n. entrapment as well

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What is the etiology of ulnar nerve entrapment (cubital tunnel syndrome)?

Compression of ulnar n. anywhere allow course, but most common at cubital tunnel of medial elbow

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What is the clinical presentation of ulnar nerve entrapment (cubital tunnel syndrome)?

medial elbow pain with repetitive activity, associated with paresthesia in ulnar border of forearm, hand, and 4th/5th digits
Can have atrophy of intrinsic hand muscles if prolonged
pain at night when elbow is fully flexed

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How would you diagnose ulnar nerve entrapment (cubital tunnel syndrome)?

Tinel sign
Nerve conduction/EMG testing
MRI

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What is the Tinel sign?

Tapping in ulnar groove between medial epicondyle and olecranon
-positive if elicits tingling in arm/hand

What is the treatment for ulnar nerve entrapment (cubital tunnel syndrome)?

night splinting, elbow pads, avoiding leaning on elbows and prolonged flexed arm
PT
Surgical decompression or translocation

What are 4 common specialty exams for the wrist and hand joint exam?

1. Phalen's sign: testing for carpal tunnel 2. Tinel's sign: testing for cubital tunnel 3. Finkelstein test: testing for de Quervain's tenosynovitis 4. Assess for trigger finger

What is a Mallet finger?

loss of terminal extension of the DIP joint

What are 3 common infections of the hand?

1. Paronychia 2. Cellulitis or abscess 3. Herpetic whitlow (HSV of finger)

Would osteoarthritis present as symmetric or asymmetric?

asymmetric

Would rheumatoid arthritis present as symmetric or asymmetric?

symmetric

What are 5 common risk factors for carpal tunnel syndrome?

1. Female, especially during pregnancy 2. Obesity 3. Autoimmune diseases: dm, RA, hypothyroidism 4. Osteoarthritis 5. Repetitive movement/workplace factors

What is the clinical presentation for carpal tunnel syndrome?

- wirst pain with paresthesia along 1st 3 digits and half of 4th - Symptoms often worse at night - Patient shakes hand to relieve pain (flick sign test)

How do you perform Phalen's sign?

Flex wrists against one another | -positive if numbness/tingling in median n. distribution within first 60 secs

What is the etiology of de Quervain's Tenosynovitis?

inflammation of tendon and synovial sheath covering ext policies braves and abductor pollicis longus (snuff box)

What are the risk factors for de Quervain's Tenosynovitis?

- female - 30-50 years of age - repetitive activities - new mother (picking up children)

What is the classic presentation of de Quervain's Tenosynovitis?

- subacute radial wrist pain at base of thumb and distal radius with thumb movement - pain worsens with gripping or holding objects

How would you clinically diagnose de Quervain's Tenosynovitis?

- Finkelstein test: flexion of thumb elicits pain | - Imaging not typically performed, but could consider US

What is the treatment for de Quervain's Tenosynovitis?

- thumb spika splint - NSAIDs or steroid injection - surgery

What is the etiology of Rheumatoid Arthritis?

- autoimmune | - inflammatory arthritis

What are the risk factors for Rheumatoid Arthritis?

- female - smoking - obese - family historyu - HLA-DRB1 genotype

What is the classic presentation of Rheumatoid Arthritis?

- SYMMETRIC joint pain, swelling, stiffness lasting LONGER THAN 1 HOUR - common wrist, MCP and PIP joint

What exam findings would be present in RA?

- Edema, synovitis - Ulnar deviation - swan neck deformities - Boutonniere deformities (PIP hyperextension and DIP flexion) - + MCP squeeze test - Rheumatoid nodules

What would you use to diagnose RA?

- Labs: ESR, CRP, RF, anti cyclic citrullinated peptide (Anti-CCP) - X-ray findings: marginal bone erosion, ulnar deviation at MCP, joint space narrowing, periarticular osteopenia

What 3 medication categories would you use to treat/manage RA?

1. NSAIDs 2. Glucocorticoids 3. Disease modifying anti rheumatic drugs (DMARDS) (ex: methotrexate, leflunomide)

What are the risk factors for osteoarthritis?

- age >50 - obesity - female - joint trauma - genetics

What are the clinical pearls for OA?

- Asymmetric joint pain lasting <1 hour after waking up and improves with activity - Herberden's nodes: @ DIP joint - Bouchard's nodes: @ PIP joint

What is the etiology of ganglion cysts?

thought to arise from herniation of CT from tendon sheaths, ligaments, joint capsule, bursa

What age group does ganglion cysts typically first present in?

20's-40's

What is the classic presentation of ganglion cysts?

- painful, smooth, firm to rubbery cyc=stic lesion in wrist, hand, feet, etc - typically on dorsal wrist or palmar wrist over fingers

How would one clinical diagnose a ganglion cyst?

- transulluminate cyst to differentiate from solid tumor | - ultrasound or MRI

What is the classic presentation of a scaphoid fracture?

- wrist pain on radial aspect in anatomical snuff box | - decreased grip strength

When would a scaphoid fracture be an emergency?

open fractures, displaced fractures, neurovascularly compromised fractures

what is the classic presentation of a distal radial fracture (Colle's fracture)?

distal wrist pain and swelling with possible deformity (dinner fork appearance), although some have no deformities

What type of splint would you use for a Colle's fracture?

volar or sugar tong

What is the etiology of trigger finger "stenosing flexor tenosynovitis"?

disparity in size of flexor tendon to surrounding reticular pulley system/sheath, impairing gliding of flexor tendon

What is the cause of Dupuytren's contracture?

- progressive fibrosis of palmar fascia which results in gradual joint stiffness and inability to fully extend finger - Pope's sign