CLINICAL CARE OF THE ELBOW, HAND, AND WRIST Flashcards
1
Q
What is the medical term for tennis elbow?
A
Lateral (tendinosis) epicondylitis
2
Q
What is the medical term for Golfers elbow and Bowlers elbow?
A
Medial (tendinosis) epicondylitis
3
Q
What injuries are commonly seen in sports or activities that require excessive wrist and hand extension?
A
Lateral/Medial Epicondylitis
4
Q
What is an overuse injury involving excessive use of the flexor and pronator muscles just distal to the medial epicondyle?
A
Medial epicondylitis
Less common than lateral epicondylitis (lateral tendinosis)
5
Q
True or False
Activities that require excessive wrist and hand flexion lead to medial epicondylitis
A
True
6
Q
A patient presents with the following, what is the most likely diagnosis?
Gradual onset of pain in the lateral elbow and forearm during activities involving gripping and wrist extension
A
Lateral epicondylitis
7
Q
Lateral epicondylitis can be caused from things such as what?
A
- Lifting
- Turning screwdrivers
- Excessive typing
- less commonly results from direct blow to the lateral aspect of the elbow
8
Q
A patient presents with the following, what is the most likely diagnosis?
Gradual onset of pain at the medial aspect of the elbow, exacerbated by activities that involve wrist flexion and forearm pronation
A
Medial epicondylitis
9
Q
Medial epicondylitis can be caused from things such as what?
A
- Golf swing
- Baseball pitching
- Pull through stroke of swimming
- Weight lifting
- Bowling
- Many forms of manual labor
10
Q
Palpation of the elbow in a patient with possible lateral epicondylitis may reveal what?
A
- tenderness over common extensor origin
2. 1cm distal and slightly anterior to lateral epicondyle
11
Q
Palpation of the elbow in a patient with possible medial epicondylitis may reveal what?
A
Tenderness just distal to medial epicondyle
12
Q
True or False
Patients with medial/lateral epicondylitis may lose AROM
A
False
Full AROM
13
Q
True or False
In lateral epicondylitis wrist extension and grip strength may be limited by pain
A
True
14
Q
True or False
In medial epicondylitis wrist flexion and pronation is limited by pain
A
True
15
Q
Is the history and physical exam enough to diagnose medial/lateral epicondylitis?
A
Yes
16
Q
What imaging may be warranted in cases of medial/lateral epicondylitis not responding to conservative management?
A
Ultrasound/MRI
17
Q
Are plain radiographs needed in patients with elbow pain and no history of trauma?
A
Nope
18
Q
What is the treatment for Medial/lateral epicondylitis?
A
- LLD
a. limit repetitive activity - NSAIDS
- Tennis elbow strap for comfort
- Pain free stretching and forearm strengthening
- PT consult if conservative management fails
- Ortho consult if no improvement
- Steroid injections
19
Q
What is located superficially on the extensor side of the elbow making it susceptible to irritation and inflammation?
A
Olecranon Bursa
20
Q
What disease process of the elbow may occur secondary to trauma, inflammation, or infection?
A
Olecranon Bursitis
21
Q
Can rheumatoid arthritis (RA), gout or other systemic inflammatory processes cause Olecranon Bursitis?
A
Yes
22
Q
True or False
Olecranon bursitis
Elbow flexion and extension may be limited by pain
A
……Yes
23
Q
What diagnostic tests may be required for a patient with olecranon bursitis?
A
- aspiration (may be diagnostic and therapeutic)
a. test aspirate for WBC count, crystals, gram stain, and culture - X-ray to rule out fracture of olecranon process
24
Q
Light duty for patients with olecranon bursitis should be focused on activity modification to include avoiding what?
A
hyperflexion against hard surfaces
25
What is the treatment for mild cases of olecranon bursitis?
1. NSAIDS
2. Pressure wraps
3. Ice
26
What is the treatment for moderate to severe cases of olecranon bursitis?
1. aspiration of fluid
| 2. refer to ortho for evaluation
27
What are the more common forms of nerve compression syndrome of the upper extremities?
1. cubital tunnel syndrome
2. median nerve compression
a. occurs in the wrist/hand (carpal tunnel)
28
What are the less common forms of nerve compression syndrome of the upper extremities?
1. Posterior interosseous nerve compression
2. Pronator syndrome
3. Radial tunnel syndrome
29
Cubital tunnel syndrome is caused by the compression of what nerve?
Ulnar nerve
30
Compression of the ulnar nerve is second only to what as a source of nerve entrapment in the upper extremities?
Carpal tunnel syndrome
31
True or False
Cubital tunnel syndrome
The most common site for nerve compression is where the ulnar nerve passes in the groove on the posterior aspect of the medial epicondyle (cubital tunnel)
True
32
These are all potential causes of what nerve compression syndrome?
1. direct blow to the cubital tunnel
2. nerve stretched from flexed elbow for prolonged periods of time
3. Cubitus valgus (carrying angle greater than 10 degrees)
4. Osteophytes or scar tissue
Cubital tunnel syndrome
33
A patient experiencing the following symptoms may have what form of nerve compression of the upper extremities?
1. numbness/tingling of the 4th and 5th digits
2. elbow pain/ache
3. may radiate proximally to shoulder and neck
4. activities of daily living (ADL) such as opening jars or turning keys in doors are late signs
5. intrinsic muscle atrophy implies nerve compression for months
Ulnar nerve compression (cubital tunnel syndrome)
34
Physical exam: Ulnar nerve compression
Visual exam is usually unremarkable, but a carrying angle greater than ___ degrees may be aggravating findings for ulnar nerve neuritis; and visible muscle wasting implies ulnar nerve compression of ____ to ____ in duration
1. 10 degrees.
| 2. several months to years
35
Ulnar nerve compression
Vibration and light touch will be affected in the ____ digit and the ulnar half of the ___ digit
1. 5th digit
| 2. 4th digit
36
True or False
Ulnar nerve compression
Two point discrimination will be affected with progressive nerve degeneration
True
37
What special test would be used to identify ulnar nerve compression?
Tinnel sign: firm percussion over the ulnar nerve in the ulnar groove over the cubital tunnel
Positive if it reproduces the symptoms
38
Nerve compression syndrome
Electromyographic/nerve conduction velocity(EMG/NCV) study with velocity reduction of ____% or more suggests ulnar nerve compression
30%
39
When are radiographs indicated for cubital tunnel syndrome?
history of elbow trauma
40
What is the treatment for Ulnar Nerve Compression?
1. Limiting elbow flexion and direct pressure on the ulnar nerve is the MOST IMPORTANT STEP IN TREATMENT
2. Splint elbow or wrap towel around elbow to avoid greater than 90 degree flexion at night
3. NSAIDS
4. Surgical decompression and transposition of ulnar nerve if 3-4 months of conservative management failed
41
What is the primary structure that resists valgus stress at the elbow?
Ulnar collateral ligament
42
True or False
Trauma to the ulnar collateral ligament is common
False
Trauma to this ligament is rare
43
A common injury to the ulnar collateral ligament comes from what?
excessive overhead throwing motions (baseball pitcher)
44
Repetitive valgus stress to the elbow may result in instability or disability of what ligament?
Ulnar collateral ligament
45
The following are symptoms of what?
1. Acute onset, patient will describe a "pop" while throwing
2. Most commonly patients experience a gradual onset of symptoms with progressive medial elbow pain with valgus stresses
3. May experience symptoms consistent with ulnar neuritis
Ulnar collateral ligament tear
46
Ulnar collateral ligament tear
Positive Moving valgus stress test - valgus stress is applied to the elbow while moving elbow into full flexion and extension. The test is positive when more pain is felt between ___ degrees and ___ degrees of flexion
1. 70 degrees
| 2. 120 degrees
47
Ulnar collateral ligament tear
What radiographs are needed to rule out a fracture?
AP and lateral
48
Posteromedial olecranon osteophytes, loose bodies and spurring may be seen in chronic cases of what?
Ulnar collateral ligament tears
49
What is a reasonable diagnostic tool for ulnar collateral ligament pathology?
MRI with contrast
50
What is the treatment for an ulnar collateral ligament tear?
1. LLD- activity mod
2. Ice for acute injuries
3. NSAIDS
4. Pain free elbow and wrist stretching and strengthening exercises
51
Failed nonsurgical management in patients with an ulnar collateral ligament tear that are consistently performing activities that result in valgus stress should be consulted to where?
Ortho
52
What is the most common dislocation in children and third most common in adults?
Elbow dislocation
53
Elbow dislocations result from what?
FOOSH
54
What percentage of elbow dislocations are posterior?
80%
55
True or False
Elbow dislocations may be complete or perched
True
56
What ligament is always disrupted with an elbow dislocation?
Lateral collateral ligament
57
DONT FORGET NEUROVASCULAR EXAM WITH ELBOW DISLOCATION
1. Possible neuropathy
| 2. Check radial pulses and cap refill
58
What radiographs are adequate to make a diagnosis and to rule out a fracture?
AP and Lateral
59
When should you consider an emergency reduction in a patient with an elbow dislocation?
Delayed MEDEVAC time or neurovascular compromise
**repeat neurovascular checks after reduction**
60
How do you perform a reduction of a dislocated elbow?
1. Elbow extended to 45 degrees
2. slow, steady downward traction of forearm in line with long axis of the humerus
3. gentle pressure over the olecranon tip
4. repeat neurovascular checks after reduction**
61
True or False
Elbow dislocation
Reduction should be performed as soon as possible by an orthopedic surgeon
True
62
True or False
Elbow dislocation
Patients with neurovascular compromise or bony injury require immediate referral/MEDEVAC
True
63
True or False
Elbow dislocation
Flexion contracture that limits activities of daily living (ADLs) require further evaluation
True
64
What is the most common neuropathy of the upper extremities?
Carpal tunnel syndrome
65
What neuropathy commonly affects middle aged or pregnant women?
Carpal tunnel syndrome
66
What is caused by any condition that reduces the size of the carpal tunnel resulting in median nerve entrapment?
carpal tunnel syndrome
67
What are some conditions that may cause carpal tunnel syndrome?
1. tenosynovitis of flexor tendons
2. tumors
3. pregnancy
4. DM
5. thyroid dysfunction
68
These are symptoms of what neuropathy?
1. Numbness/tingling into radial three digits of the hand ( 1st, 2nd, and 3rd)
2. Pain/paresthesia/numbness of the median distribution (thumb, index, long finger, and radial half of ring finger)
3. Worse at night, pts report the need to rub hands to "get circulation back"
4. Frequently drops objects or cant open jars with twist lids
5. worse after repetitive motion of the hand or stationary tasks of the wrist that require long term flexion or extension
Carpal tunnel syndrome
69
True or False
Patients with carpal tunnel syndrome will have weakness with thumb opposition and possible reduced grip strength
True
70
True or False
Patients with carpal tunnel syndrome will have numbness and paresthesia in the median nerve distribution
true
71
What special tests are used to confirm carpal tunnel syndrome but are only positive in about half of the patients affected?
Phalen maneuver and Tinel sign
72
Electrophysiologic testing is most useful to support history and physical findings in patients with carpal tunnel syndrome but ___% to ___ % of patients with it have normal nerve conduction studies
5%-10%
73
What is the treatment for carpal tunnel syndrome?
1. Splint wrist in neutral position - especially at night
2. NSAIDS
3. LLD for activity mod
4. Ergonomic modifications
74
Where should patients be referred to for carpal tunnel syndrome if they fail conservative management or those who have fixed sensory loss or weakness/atrophy of the muscles?
You guessed it.....Ortho
75
What is swelling or stenosis of the sheath that surrounds the abductor pollicis longus and extensor pollicis brevis tendon at the wrist?
de Quervain Tensosynovitis
76
What is the following?
1. Precipitated by repetitive use of the thumb
2. pain, swelling and triggering phenomenon results in locking or sticking of the tendon as the patient moves the thumb
3. commonly affects middle aged women
de Quervain Tenosynovitis
77
A middle aged female patient presents with pain at the radial aspect of the wrist that is exacerbated by movement of her thumb or wrist; what is the most likely diagnosis?
de Quervain Tenosynovitis
78
True or False
de Quervain Tenosynovitis
Swelling may be present at the distal radius region
True
79
Patients with de Quervain Tenosynovitis will usually have tenderness over what?
radial styloid
80
What special test is used for de Quervain Tenosynovitis?
Finkelstein Test
will be positive
81
Are plain radiographs indicated for de Quervain Tenosynovitis?
Not required
82
What is the treatment for de Quervain Tenosynovitis?
1. NSAIDS
2. Thumb spica splint
3. LLD activity mod
Ortho consult with failed conservative management
83
What is the most commonly fractured carpal bone?
Scaphoid
84
The following is associated with the suspected fracture of what carpal bone?
1. usually results from FOOSH injuries
2. diagnosis often delayed or missed and has a significant incidence of nonunion and osteonecrosis
3. major blood supply enters bone in the distal third and is disrupted with injury
4. displacement greater than 1mm has a high rate of nonunion
Suspected scaphoid fracture
85
These are clinical symptoms of what?
1. Patient describes a dorsiflexed wrist injury
2. Pain about the radial side of the wrist in the anatomical snuffbox
3. pain with wrist motion and gripping
Suspected scaphoid fracture
86
Patients with a suspected scaphoid fracture will have tenderness where?
1. snuffbox region
| 2. over the scaphoid tubercle on the underside of the wrist
87
Are there any special tests indicated for a suspected scaphoid fracture?
No
88
True or False
Scaphoid series radiographs should be obtained at the time of injury, but if normal and pain persists for 2-3 weeks studies should be repeated
True
89
If repeat radiographs for a suspected scaphoid fracture remain normal but pain persists, what imaging is then warranted?
MRI
90
What is the treatment for a suspected scaphoid fracture?
1. Thumb spica splint
2. LLD - no use of affected hand
3. Treatment should be focused on definitive diagnosis with radiographs or MRI ASAP
4. Consult to ortho
5. Analgesics as needed
91
True or False
Displaced fractures of the scaphoid require ortho eval for possible surgical eval, while scaphoid fractures with wrist ligament injuries require urgent referral to a hand surgeon
True
92
What are the most common soft-tissue tumors of the hand?
Ganglion of the wrist
93
What ages are commonly affected by ganglions of the wrist?
15-40 years old
94
What is a cystic structure that arises from a capsule of a joint or a tendon synovial sheath?
Ganglion of the wrist
95
The following are signs and symptoms of what?
1. firm nodular swelling in wrist and may vary/increase in size
2. may be painful and pain may increase with wrist motion
3. may be recurrent
4. may have sensory symptoms if mass compresses median or ulnar nerve
Ganglion of the wrist
96
True or False
Ganglions (Hand and fingers)
Bumps are at the MCP or on the dorsum of the finger distal to the DIP
True
97
True or False
Ganglions of the wrist are usually directly over the scapholunate joint
True
98
What ganglion is usually less well defined between the flexor carpi radialis tendon and the radial styloid?
Volar radial ganglion
99
Will ganglions of the wrist typically transilluminate?
Yes, solid tumors will not
100
What imaging is useful in differentiating ganglia from other types of masses?
Ultrasound/MRI
101
Where should patients with a ganglion of the wrist be referred to?
Ortho for aspiration or surgical excision
102
What is the term for a rupture of the flexor digitorum profundus from its distal attachment, common in contact sports, and is often overlooked as a "jammed" finger?
Jersey finger
103
When the flexed DIP joint is suddenly and forcefully hyperextended it can lead to the rupture of what?
Flexor digitorum profundus
104
What finger is involved in 75% of cases of jersey finger?
Ring finger
105
A patient presents with acute pain and swelling of the DIP/distal phalynx and the inability to actively flex the DIP joint; what is the most likely diagnosis?
Jersey finger
106
Jersey finger
Should you get plain films of the fingers to rule out avulsion fractures?
Yes
107
Jersey finger
What imaging should you get if the diagnosis remains in question or in chronic cases?
MRI
108
True or False
Jersey finger
Splint the finger with PIP and DIP joint slightly flexed, this prevents extension of the DIP joint which should be avoided until an eval by ortho
True
109
Do all cases of jersey finger require a referral to ortho?
yes
110
What is known as an injury to the extensor tendon of the fingers; rupture, laceration, or avulsion of the insertion of the extensor tendon an base of the distal phalanx?
Mallet finger
111
What is usually caused by a direct blow to the finger causing sudden forced flexion of the DIP/distal phalanx?
Mallet finger
112
A patient presents with pain at the DIP joint after a direct blow to the third digit of his left hand, you notice swelling, ecchymosis, and a small deformity along with the DIP joint being flexed at rest. What is the most likely diagnosis?
Mallet finger
113
How should a patient with mallet finger be splinted?
Full extension for 6-8 weeks
114
When should a patient with mallet finger be referred out?
1. unable to passively extend the DIP
2. full laceration of the extensor tendon
3. fracture
4. failure of treatment
115
What is known as an extensor tendon rupture at the insertion on the middle phalanx?
Boutonniere deformity
116
What is the treatment for a boutonniere deformity?
1. splint PIP joint in extension for 3-6 weeks
2. allow DIP to move freely
3. Physical therapy for ROM
4. Ortho consult for ongoing deformity
