Ch 6 MDT Elbow, Hand, & Wrist Flashcards
Lateral Tendinosis is also known as:
Tennis Elbow
Medial Tendinosis is also known as:
Golfer’s elbow or Bowler’s elbow
Overuse injury involving excessive use of extensor tendons
Commonly seen in sports or activities that require excessive wrist and hand extension
Lateral Epicondylitis
Overuse injury involving excessive use of flexor or pronator muscles
Activities that require excessive wrist and hand flexion
Medial Epicondylitis
From activities that involve gripping and wrist extension
- Lifting
- Turning a screwdriver
- Hitting backhand in tennis
- Excessive typing
Lateral Epicondylitis
Exacerbated by activities that involve wrist flexion and forearm pronation
- Golf swing
- Baseball pitching
- Pull-through stroke swimming
- Weight lifting
- Bowling
Medial epicondylitis
Lateral epicondylitis will have tenderness __ cm distal and slightly anterior to lateral epicondyle
1 cm
Wrist extension and grip strength limited by pain
Lateral epicondylitis
Wrist flexion and pronation limited by pain
Medial epicondylitis
Diagnostic tests for Lateral/Medial epicondylitis
Diagnosed clinically
U/S or MRI in cases not responding to conservative management
Treatment for medial/lateral epicondylitis
Light duty, limit repetitive activity to allow for healing
NSAIDs
Tennis elbow strap
Pain free stretching
Treatment for medial/lateral epicondylitis if conservative management fails
Physical therapy
Ortho consult
Steroid injection
Olecranon bursitis may occur secondary to:
Trauma
Inflammation
Infection
Disease processes that can cause olecranon bursitis
Rheumatoid arthritis
Gout
Systemic inflammatory process
Large mass over elbow
Tenderness over elbow
ROM limited by pain
Olecranon Bursitis
Diagnostic tests for olecranon bursitis
Aspiration
Radiographs to rule out fracture
Treatment for olecranon bursitis
NSAIDs
Pressure Wrap
Ice
Moderate or severe cases of olecranon bursitis should under go:
Aspiration of fluid - refer for orthopedic evaulation
Treatment for olecranon bursitis with signs of infection
Antibiotics
Referral/Red Flags for olecranon bursitis
Septic bursitis or recurrence of fluid despite repeated aspirations
Most common site of ulnar nerve compression
Groove on the posterior aspect of the medial epicondyle (cubital tunnel)
Etiologies of ulnar nerve compression
Direct blow to cubital tunnel
Stretched nerve for prolonged periods of time
Cubitus valgus (carrying angle greater than 10 degrees)
Osteophytes or scar tissue
Numbness and tingling in the 4th and 5th digits
Elbow pain/ache
May radiate to shoulder or neck
Unable to open jars or turn keys (late sign)
Muscle atrophy implies nerve compression of several months
Ulnar nerve compression
Neurovascular test that will be affected on the 4th and 5th digits in patients with ulnar nerve compression
Two-point discrimination
Special tests that are positive in ulnar nerve compression
Tinel sign
Diagnostic tests for ulnar nerve compression
Electromyographic/nerve conduction velocity (EMG/NCV) study
Radiographs to see previous trauma
EMG/NCV study with velocity reduction of ___% or more suggests significant ulnar nerve compression
30%
Treatment for ulnar nerve compression
Modify activities that limit elbow flexion and direct pressure
Splint elbow to avoid 90 degree flexion at night
NSAIDs
Most important step in the treatment of ulnar nerve compression
Modify activities to limit elbow flexion and direct pressure
Ulnar nerve compression
Surgical decompression and transposition of ulnar nerve if ___ months of conservative management failed
3-4 months
Primary structure that resists valgus stress at the elbow
Ulnar collateral ligament
Common injury to ulnar collateral ligament comes from:
Excessive overhead throwing motions (baseball pitcher)
“Pop” while throwing
Gradual onset of symptoms with progressive medial elbow pain with valgus stresses
May have symptoms consistent with ulnar neuritis
Ulnar collateral ligament tear
Tenderness over ulnar collateral ligament
Possible loss of terminal elbow extension
Positive moving valgus stress test
Ulnar collateral ligament tear
Valgus stress test is positive when more pain is felt between _____ degrees of flexion
70-120
Diagnostic tests for Ulnar collateral ligament tear
AP and Lateral radiographs to rule out fracture
MRI with contrast
May be seen on X-ray for chronic cases of Ulnar collateral ligament tear
Posteromedial olecranon osteophytes, loose bodies, and spurring
Treatment for Ulnar collateral ligament tear
Light duty - Activity Modification
Ice
NSAIDs
Pain free elbow and wrist stretching/strengthening exercises
Most common dislocation in children and third most in adults
Results from a fall on an outstretched hand (FOOSH)
Elbow dislocation
__% of elbow dislocations are posterior
80%
What ligament is always disrupted in elbow dislocations
Lateral collateral ligament
Extreme pain, swelling of elbow, inability to bend elbow
Obvious deformity
No elbow flexion or extension
Supination and pronation severely limited
Elbow Dislocation
What exam do you not want to over look in patients with elbow dislocations?
Neurovascular
-Check radial pulse and cap refill
Diagnostic tests for elbow dislocation
AP and lateral radiographs
Treatment for elbow dislocation
Ice
Pain management
Splint
Consider emergency reduction if delayed MEDEVAC or neurovascular compromise
Steps to perform an elbow reduction
Elbow extended to 45 degrees
Slow, steady downward traction of forearm in line with long axis of humerus
Gentle pressure over olecranon tip
Repeat neurovascular examination after reduction
Elbow reduction should be performed as soon as possible by:
Orthopedic surgeon
Most common neuropathy of the upper extremity
Commonly affects middle aged or pregnant women
Median nerve entrapment
Carpal Tunnel
Carpal tunnel can be caused by:
Tenosynovitis of flexor tendons
Tumors
Pregnancy
Diabetes Mellitus
Thyroid dysfunction
Numbness and tingling into radial three digits of hand (1st, 2nd, 3rd digits)
Pain and paresthesia/numbness at median nerve distribution
Worse at night, patient has to rub hands together to “get circulation back”
Frequently drops objects and cannot open jars with twist lids
Worse after repetitive motion
Carpal Tunnel
Atrophy of the thenar eminence in long standing cases
Tenderness over carpal tunnel
Weakness with thumb opposition
Reduced grip strength
Carpal Tunnel
Special tests for Carpal Tunnel
Phalen Maneuver
Tinel Sign
Diagnostic testing for carpal tunnel
Electrophysiologic testing
___% of patients with carpal tunnel syndrome have normal nerve conduction velocity studies
5-10%
Treatment for Carpal Tunnel
Splint wrist in neutral position - especially at night
NSAIDs
Light duty for activity modification
Ergonomic modifications
Carpal Tunnel patients should be referred to Ortho if:
Failed conservative management
Fixed sensory loss or weakness/atrophy of muscles
Swelling or stenosis of the sheath that surrounds the abductor pollicis longus and extensor pollicis brevis tendon of the wrist
de Quervain Tenosynovitis
Precipitated by repetitive use of thumb
Pain, swelling and triggering phenomenon results in locking or sticking of tendon as the patient moves thumb
de Quervain Tenosynovitis
Pain at radial aspect of the wrist exacerbated by movement of thumb or wrist
May have edema
Tenderness over radial styloid
de Quervain Tenosynovitis
What test is positive in patients with de Quervain Tenosynovitis?
Finkelstein test
Diagnostic studies for de Quervain Tenosynovitis
Diagnosed clinically
Treatment for de Quervain Tenosynovitis
NSAIDs
Thumb spica splint
Light duty activity modification
Usually fractured from falls with outstretched hand
Major blood supply enters the bone in the distal third
Scaphoid fracture
Scaphoid fracture
Displacement greater than __ mm has a high rate of nonunion
1 mm
Patient describes a dorsiflexed wrist injury
Edema and pain around distal radial aspect of wrist
Decreased grip strength
Scaphoid Fracture
Diagnostic tests for Scaphoid Fracture
Scaphoid series radiographs
Scaphoid Fracture
If scaphoid series X-rays are normal but pain persists for __ weeks then studies should be repeated
2-3 weeks
Treatment for Scaphoid Fracture
Thumb spica splint
Light duty
Imaging ASAP
Consult to Orthopedics
Analgesics
Scaphoid fracture with wrist ligament injuries require an urgent referral to:
Hand Surgeon
Most common soft-tissue tumors of the hand
Affects 15-40 y/o
Cystic structure that arises from capsule of a joint or a tendon synovial sheath
Ganglion of the wrist
Through degeneration or tearing of the joint capsule or tendon sheath, a connection to the joint or tendon sheath with a one-way valve established, synovial fluid can enter but cannot flow freely back into synovial cavity
Ganglion
Ganglion is usually directly over _______ joint
Scapholunate joint
How to tell the difference between a Ganglion and a Tumor?
Ganglion will transilluminate
Diagnostic imaging for Ganglion
US/MRI to differentiate ganglion from other masses
Treatment for Ganglion
Splint wrist or finger
NSAIDs
Consult to orthopedics for aspiration or surgical excision
Rupture of the flexor digitorum profundus tendon from its distal attachment
Common in contact sports
Flexed DIP joint is suddenly and forcefully hyperextended
“Jersey Finger”
Jersey Finger
Ring finger involved in __% of cases
75%
Treatment for Jersey finger
Splint the finger with PIP and DIP joint slightly flexed
Evaluation by Ortho Hand
Injury to the extensor tendon of the finger
Direct blow to the finger causing sudden forced flexion of the of the DIP
Flexed DIP at rest
Inability to extend DIP joint fully
Mallet finger
Treatment for mallet finger
Maximize function, minimize discomfort
Splint the finger in full extension
How long do you splint a Mallet finger?
6-8 weeks
Most cases of Mallet Finger can be managed by:
Primary Care
Extensor tendon rupture at insertion on middle phalanx
- Flexion of PIP/Extension of DIP
- History of trauma
- Painful PIP joint
- Deformity up to 3 weeks
Boutonniere Deformity
Treatment for Boutonniere Deformity
Splint PIP joint in extension for 3-6 weeks
Allow DIP to move freely
Physical therapy for ROM
Ortho consult for ongoing deformity