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CLASS 22010 MSK > CLINICAL CARE OF THE ELBOW, HAND, AND WRIST > Flashcards

CLINICAL CARE OF THE ELBOW, HAND, AND WRIST Flashcards

1
Q

What is the medical term for tennis elbow?

A

Lateral (tendinosis) epicondylitis

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2
Q

What is the medical term for Golfers elbow and Bowlers elbow?

A

Medial (tendinosis) epicondylitis

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3
Q

What injuries are commonly seen in sports or activities that require excessive wrist and hand extension?

A

Lateral/Medial Epicondylitis

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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)

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5
Q

True or False

Activities that require excessive wrist and hand flexion lead to medial epicondylitis

A

True

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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

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7
Q

Lateral epicondylitis can be caused from things such as what?

A
  1. Lifting
  2. Turning screwdrivers
  3. Excessive typing
  4. less commonly results from direct blow to the lateral aspect of the elbow
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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

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9
Q

Medial epicondylitis can be caused from things such as what?

A
  1. Golf swing
  2. Baseball pitching
  3. Pull through stroke of swimming
  4. Weight lifting
  5. Bowling
  6. Many forms of manual labor
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10
Q

Palpation of the elbow in a patient with possible lateral epicondylitis may reveal what?

A
  1. tenderness over common extensor origin

2. 1cm distal and slightly anterior to lateral epicondyle

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11
Q

Palpation of the elbow in a patient with possible medial epicondylitis may reveal what?

A

Tenderness just distal to medial epicondyle

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12
Q

True or False

Patients with medial/lateral epicondylitis may lose AROM

A

False

Full AROM

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13
Q

True or False

In lateral epicondylitis wrist extension and grip strength may be limited by pain

A

True

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14
Q

True or False

In medial epicondylitis wrist flexion and pronation is limited by pain

A

True

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15
Q

Is the history and physical exam enough to diagnose medial/lateral epicondylitis?

A

Yes

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16
Q

What imaging may be warranted in cases of medial/lateral epicondylitis not responding to conservative management?

A

Ultrasound/MRI

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17
Q

Are plain radiographs needed in patients with elbow pain and no history of trauma?

A

Nope

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18
Q

What is the treatment for Medial/lateral epicondylitis?

A
  1. LLD
    a. limit repetitive activity
  2. NSAIDS
  3. Tennis elbow strap for comfort
  4. Pain free stretching and forearm strengthening
  5. PT consult if conservative management fails
  6. Ortho consult if no improvement
  7. Steroid injections
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19
Q

What is located superficially on the extensor side of the elbow making it susceptible to irritation and inflammation?

A

Olecranon Bursa

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20
Q

What disease process of the elbow may occur secondary to trauma, inflammation, or infection?

A

Olecranon Bursitis

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21
Q

Can rheumatoid arthritis (RA), gout or other systemic inflammatory processes cause Olecranon Bursitis?

A

Yes

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22
Q

True or False

Olecranon bursitis

Elbow flexion and extension may be limited by pain

A

……Yes

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23
Q

What diagnostic tests may be required for a patient with olecranon bursitis?

A
  1. aspiration (may be diagnostic and therapeutic)
    a. test aspirate for WBC count, crystals, gram stain, and culture
  2. X-ray to rule out fracture of olecranon process
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24
Q

Light duty for patients with olecranon bursitis should be focused on activity modification to include avoiding what?

A

hyperflexion against hard surfaces

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25
Q

What is the treatment for mild cases of olecranon bursitis?

A
  1. NSAIDS
  2. Pressure wraps
  3. Ice
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26
Q

What is the treatment for moderate to severe cases of olecranon bursitis?

A
  1. aspiration of fluid

2. refer to ortho for evaluation

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27
Q

What are the more common forms of nerve compression syndrome of the upper extremities?

A
  1. cubital tunnel syndrome
  2. median nerve compression
    a. occurs in the wrist/hand (carpal tunnel)
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28
Q

What are the less common forms of nerve compression syndrome of the upper extremities?

A
  1. Posterior interosseous nerve compression
  2. Pronator syndrome
  3. Radial tunnel syndrome
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29
Q

Cubital tunnel syndrome is caused by the compression of what nerve?

A

Ulnar nerve

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30
Q

Compression of the ulnar nerve is second only to what as a source of nerve entrapment in the upper extremities?

A

Carpal tunnel syndrome

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31
Q

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)

A

True

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32
Q

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
A

Cubital tunnel syndrome

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33
Q

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
A

Ulnar nerve compression (cubital tunnel syndrome)

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34
Q

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

A
  1. 10 degrees.

2. several months to years

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35
Q

Ulnar nerve compression

Vibration and light touch will be affected in the ____ digit and the ulnar half of the ___ digit

A
  1. 5th digit

2. 4th digit

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36
Q

True or False

Ulnar nerve compression

Two point discrimination will be affected with progressive nerve degeneration

A

True

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37
Q

What special test would be used to identify ulnar nerve compression?

A

Tinnel sign: firm percussion over the ulnar nerve in the ulnar groove over the cubital tunnel

Positive if it reproduces the symptoms

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38
Q

Nerve compression syndrome

Electromyographic/nerve conduction velocity(EMG/NCV) study with velocity reduction of ____% or more suggests ulnar nerve compression

A

30%

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39
Q

When are radiographs indicated for cubital tunnel syndrome?

A

history of elbow trauma

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40
Q

What is the treatment for Ulnar Nerve Compression?

A
  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
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41
Q

What is the primary structure that resists valgus stress at the elbow?

A

Ulnar collateral ligament

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42
Q

True or False

Trauma to the ulnar collateral ligament is common

A

False

Trauma to this ligament is rare

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43
Q

A common injury to the ulnar collateral ligament comes from what?

A

excessive overhead throwing motions (baseball pitcher)

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44
Q

Repetitive valgus stress to the elbow may result in instability or disability of what ligament?

A

Ulnar collateral ligament

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45
Q

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
A

Ulnar collateral ligament tear

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46
Q

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

A
  1. 70 degrees

2. 120 degrees

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47
Q

Ulnar collateral ligament tear

What radiographs are needed to rule out a fracture?

A

AP and lateral

48
Q

Posteromedial olecranon osteophytes, loose bodies and spurring may be seen in chronic cases of what?

A

Ulnar collateral ligament tears

49
Q

What is a reasonable diagnostic tool for ulnar collateral ligament pathology?

A

MRI with contrast

50
Q

What is the treatment for an ulnar collateral ligament tear?

A
  1. LLD- activity mod
  2. Ice for acute injuries
  3. NSAIDS
  4. Pain free elbow and wrist stretching and strengthening exercises
51
Q

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?

52
Q

What is the most common dislocation in children and third most common in adults?

A

Elbow dislocation

53
Q

Elbow dislocations result from what?

54
Q

What percentage of elbow dislocations are posterior?

55
Q

True or False

Elbow dislocations may be complete or perched

56
Q

What ligament is always disrupted with an elbow dislocation?

A

Lateral collateral ligament

57
Q

DONT FORGET NEUROVASCULAR EXAM WITH ELBOW DISLOCATION

A
  1. Possible neuropathy

2. Check radial pulses and cap refill

58
Q

What radiographs are adequate to make a diagnosis and to rule out a fracture?

A

AP and Lateral

59
Q

When should you consider an emergency reduction in a patient with an elbow dislocation?

A

Delayed MEDEVAC time or neurovascular compromise

repeat neurovascular checks after reduction

60
Q

How do you perform a reduction of a dislocated elbow?

A
  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
Q

True or False

Elbow dislocation

Reduction should be performed as soon as possible by an orthopedic surgeon

62
Q

True or False

Elbow dislocation

Patients with neurovascular compromise or bony injury require immediate referral/MEDEVAC

63
Q

True or False

Elbow dislocation

Flexion contracture that limits activities of daily living (ADLs) require further evaluation

64
Q

What is the most common neuropathy of the upper extremities?

A

Carpal tunnel syndrome

65
Q

What neuropathy commonly affects middle aged or pregnant women?

A

Carpal tunnel syndrome

66
Q

What is caused by any condition that reduces the size of the carpal tunnel resulting in median nerve entrapment?

A

carpal tunnel syndrome

67
Q

What are some conditions that may cause carpal tunnel syndrome?

A
  1. tenosynovitis of flexor tendons
  2. tumors
  3. pregnancy
  4. DM
  5. thyroid dysfunction
68
Q

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
A

Carpal tunnel syndrome

69
Q

True or False

Patients with carpal tunnel syndrome will have weakness with thumb opposition and possible reduced grip strength

70
Q

True or False

Patients with carpal tunnel syndrome will have numbness and paresthesia in the median nerve distribution

71
Q

What special tests are used to confirm carpal tunnel syndrome but are only positive in about half of the patients affected?

A

Phalen maneuver and Tinel sign

72
Q

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

73
Q

What is the treatment for carpal tunnel syndrome?

A
  1. Splint wrist in neutral position - especially at night
  2. NSAIDS
  3. LLD for activity mod
  4. Ergonomic modifications
74
Q

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?

A

You guessed it…..Ortho

75
Q

What is swelling or stenosis of the sheath that surrounds the abductor pollicis longus and extensor pollicis brevis tendon at the wrist?

A

de Quervain Tensosynovitis

76
Q

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
A

de Quervain Tenosynovitis

77
Q

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?

A

de Quervain Tenosynovitis

78
Q

True or False

de Quervain Tenosynovitis

Swelling may be present at the distal radius region

79
Q

Patients with de Quervain Tenosynovitis will usually have tenderness over what?

A

radial styloid

80
Q

What special test is used for de Quervain Tenosynovitis?

A

Finkelstein Test

will be positive

81
Q

Are plain radiographs indicated for de Quervain Tenosynovitis?

A

Not required

82
Q

What is the treatment for de Quervain Tenosynovitis?

A
  1. NSAIDS
  2. Thumb spica splint
  3. LLD activity mod

Ortho consult with failed conservative management

83
Q

What is the most commonly fractured carpal bone?

84
Q

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
A

Suspected scaphoid fracture

85
Q

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
A

Suspected scaphoid fracture

86
Q

Patients with a suspected scaphoid fracture will have tenderness where?

A
  1. snuffbox region

2. over the scaphoid tubercle on the underside of the wrist

87
Q

Are there any special tests indicated for a suspected scaphoid fracture?

88
Q

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

89
Q

If repeat radiographs for a suspected scaphoid fracture remain normal but pain persists, what imaging is then warranted?

90
Q

What is the treatment for a suspected scaphoid fracture?

A
  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
Q

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

92
Q

What are the most common soft-tissue tumors of the hand?

A

Ganglion of the wrist

93
Q

What ages are commonly affected by ganglions of the wrist?

A

15-40 years old

94
Q

What is a cystic structure that arises from a capsule of a joint or a tendon synovial sheath?

A

Ganglion of the wrist

95
Q

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
A

Ganglion of the wrist

96
Q

True or False

Ganglions (Hand and fingers)

Bumps are at the MCP or on the dorsum of the finger distal to the DIP

97
Q

True or False

Ganglions of the wrist are usually directly over the scapholunate joint

98
Q

What ganglion is usually less well defined between the flexor carpi radialis tendon and the radial styloid?

A

Volar radial ganglion

99
Q

Will ganglions of the wrist typically transilluminate?

A

Yes, solid tumors will not

100
Q

What imaging is useful in differentiating ganglia from other types of masses?

A

Ultrasound/MRI

101
Q

Where should patients with a ganglion of the wrist be referred to?

A

Ortho for aspiration or surgical excision

102
Q

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?

A

Jersey finger

103
Q

When the flexed DIP joint is suddenly and forcefully hyperextended it can lead to the rupture of what?

A

Flexor digitorum profundus

104
Q

What finger is involved in 75% of cases of jersey finger?

A

Ring finger

105
Q

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?

A

Jersey finger

106
Q

Jersey finger

Should you get plain films of the fingers to rule out avulsion fractures?

107
Q

Jersey finger

What imaging should you get if the diagnosis remains in question or in chronic cases?

108
Q

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

109
Q

Do all cases of jersey finger require a referral to ortho?

110
Q

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?

A

Mallet finger

111
Q

What is usually caused by a direct blow to the finger causing sudden forced flexion of the DIP/distal phalanx?

A

Mallet finger

112
Q

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?

A

Mallet finger

113
Q

How should a patient with mallet finger be splinted?

A

Full extension for 6-8 weeks

114
Q

When should a patient with mallet finger be referred out?

A
  1. unable to passively extend the DIP
  2. full laceration of the extensor tendon
  3. fracture
  4. failure of treatment
115
Q

What is known as an extensor tendon rupture at the insertion on the middle phalanx?

A

Boutonniere deformity

116
Q

What is the treatment for a boutonniere deformity?

A
  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

CLASS 22010 MSK (12 decks)

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