Conditions of the elbow, wrist and hand Flashcards
What are 5 possible categories for differential diagnosis?
- visceral
- osseous
- neurovascular
- articular
- muscular
MOI of supracondylar #?
fall onto an outstretched arm from a height
Surpacondylar #’s are more common in ~ ___ yo compared to adults
12
MOI of olecranon #?
fall onto an outstretched hand or from direct trauma to the elbow
____ ____ # = most common # of elbow in athletes
radial head
MOI of radial #?
fall onto an outstretched hand
Coronoid # most commonly occurs with ______ _____
terrible triad
What 3 things makes up the terrible triad in the elbow?
- radial head #
- elbow dislocation
- coronoid #
_____ _____ is the most serious acute elbow injury
posterior dislocation
MOI of post dislocation?
FOOSH with shoulder abducted, axial compression, forearm in supination and then forced flexion of elbow
Radial head subluxation = common in children under ___ years old
5
With radial head subluxation, child will usually hold arm in ______ by their side and does not use it due to pain
extension
Radial head subluxation requires reduction (T/F).
TRUE
When doing the elbow extension test, is pt is unable to fully extend, there is a ___ % of an elbow #
50
Lateral elbow tendinopathy = most common in __ - __ yo
30-60
Lateral elbow tendinopathy = worse with _____ or wrist ______
grippig; extension
Lateral elbow tendinopathy = most common in what tendon?
ECRB
What are 3 findings in the objective exam of someone with lateral elbow tendinopathy?
- reduced pain-free grip strength
- neurodynamic tests, particularly radial nerve test
- decreased cervical ROM
3 components of exercise treatment for lateral elbow tendinopathy ?
- increased strength and endurance in forearm muscles
- increased flexibility in forearm muscles
- include upper limb coordination exercise
Lateral elbow tendinopathy manual therapy: _______ glide of radius and ulna on humerus while the pt either grips of extends the wrist against resistance as long as it is now pain free
lateral
Lateral elbow tendinopathy: if using counter force brace, apply __ cm below elbow jt
10
_____ collateral ligament is primary restraint to varus forces
lateral
Symptoms of lateral ligament sprain?
- pain
2. clicking, catching, often with elbow extension of when pushing arms off chair
Treatment for acute lateral ligament strain?
- relative rest; allow ligament to heal as best as possible until swelling goes down
- AROM to surrounding joints
Treatment for lateral ligament strain, after acute phase?
- ROM to elbow joint
- strengthening of muscles around joint
- proprioceptive exercises
Radial tunnel syndrome is also known as?
posterior interosseous nerve entrapment
The radial nerve divides into the superficial radial nerve and the PIN at the ________ joint
radiohumeral
PIN enters the arcade of _____ where is may become compressed
Frohse
Where is the arcade of Frohse located, and what is it made out of?
semicircular fibrous arch at the proximal head of the supinator muscle
Radial tunnel syndrome is seen in pt’s who repetitively ____/____ the forearm
pronate/supinate
4 symptoms of radial tunnel syndrome?
- pain over forearm extensor muscle
- aching wrist and middle of upper 1/3 forearm pain
- tenderness over supinator muscle
- neurodynamic tests for radial nerve may reproduce symptoms
What are 3 treatments of radial tunnel syndrome?
- soft tissue techniques over supinator muscle at site of entrapment
- neural tissue mobilization (radial n glides)
- strengthening exercises targeting strength deficits in forearm muscles
_______ ______ = pain associated with excessive activity of wrist flexors
flexor/pronator tendinopathy
_______ _______ = localized tenderness just at or below the medial epicondyle with pain on resisted wrist flexion and resisted forearm pronation
flexor/pronator tendinopathy
_____ produces valgus elbow stress
throwing
4 aspects of treatment of MCL sprains?
- modify activity
- correcting faulty throwing technique
- soft tissue techniques to the medial ligament
- strengthen forearm flexors and pronators
Inflammation of ulnar nerve can occur because of what 5 things ?
- traction injury to the nerve due to throwing
- compression at the cubital tunnel due to inflammation and adhesions from repetitive stresses
- compression between 2 heads of FCU due to muscle overdevelopment
- recurrent subluxation of the nerve due to laxity from receptive stress of trauma
- irregularities in the ulnar groove in older throwers
Ulnar nerve entrapment 5 S&S’s?
- posteromedial elbow pain and numbness/tingling in ulnar nerve distribution
- tenderness to palpation behind medial epicondyle
- tingles tap may reproduce symptoms
- Froments’ sign - adductor pollicus
- Wartenburg’s sign - 5th finer adduction
Treatment of olecranon bursitis?
ice, rest, compression, anti-inflammatories
What is the most common cause of posterior elbow pain?
posterior impingement
Posterior impingement causes in the young athlete?
repetitive hyperextension valgus stress leading to impingement of the posteromedial corner of the olecranon tip on the olecranon fossa
Posterior impingement causes in the older athlete?
OA with the growth of osteophytes
Treatment of post impingement?
- taping to minimize hyperextension
- manual therapy
- strengthening and flexibility exercises
_____ _____ syndrome = median nerve entrapment
pronator teres
Pronator teres syndrome presents as diffuse _______ elbow pain that radiates distally into the forearm with paraesthesia in the median nerve distribution and weakness of the _____ muscles
anterior; thenar
Most common cause of pronator teres syndrome?
forceful pronation such as throwing sports
Treatment for pronator teres syndrome?
- soft tissue techniques to pronator teres
2. nerve mobilization of median nerve
______ # is the most common type of distal radius #
colles
In colles #, posterior displacement of radius leads to “_____ ____” deformity
dinner fork
Stable colles #’s are reduced and casted for ~ ___ weeks
6
Management of distal radius # during immobilization period?
- AROM at shoulder, elbow and hand
- Maintain web space and shoulder ROM
- Reduction of edema
- elevation of UE above shoulder height
- Report S & S and severe pain, numbness, persistent edema and shiny skin
Management of distal radius # after cast is removed?
- edema mngment
2. begin ROM several times a day
6 treatments in mngment of distal radius # once # is healed?
- joint mob to restore joint play
- modalities to decease pain/increase circulation
- stretching
- progress to resistive exercises
- isokinetics may begin at 8 weeks
- functional activities/ job simulation
5 complications of colles #?
- malunion
- median n damage
- CRPS
- CTS
- late rupture of EPL tendon
CRPS is more common following ____ fracture than any other injury
colles
_____ # = most common carpal #
scaphoid
6 key findings in scaphoid #?
- tenderness in anatomical snuffbox
- may have minimal swelling
- loss of grip strength
- pain with loaded wrist extension
- pain on axial compression of thumb towards radius
- pain with direct pressure on scaphoid tuberosity while radially deviating the wrist
Unstable or displaced scaphoid #’s require surgery due to risk of ______ ______; fracture may disrupt blood supply to ____ pole of scaphoid
avascular; proximal
How long are scaphoid #’s immobilized for?
8-12 weeks
Based on amsterdam wrist rules, for a distal radius #, what 7 factors increase likelihood of #?
- increased age
- swelling of wrist
- visible deformation
- distal radius tender to palpation
- pain on palmar flexion
- pain on supination
- painful RU ballottement test
Based on amsterdam wrist rules, for any wrist #, what 7 factors increase likelihood of #?
- increased age
- male sex
- visible deformation
- swelling of wrist
- swelling of anatomical snuffbox
- distal radius tender to palpation
- pain on radial deviation
_________ tenosynovitis = affects synovial sheath of the abductor pollicus longus and extensor pollicis brevis tendons
DeQuervains
______ ______ is common in new mothers
DeQuervains tenosynovitis
DeQuervains tenosynovitis = + _______ test
Finkelsteins
Treatment for DeQuervains tenosynovitis ?
- change ergonomics of aggravating task
- splinting
- stretches
- strengthening
What is the main difference between radial sensory nerve compression and DeQuervains tenosynovitis ?
DeQuervains tenosynovitis does not have sensory changes
Radial sensory nerve compression = compression of the _____ _____ sensory nerve
dorsal radial
4 causes of radial sensory nerve compression?
- radial styloid fracture
- tight cast
- repetitive trauma in sports
- compression between brachioradialis and ECRL tendons during rapid repeated supination/pronation
Radial sensory nerve compression has sensory changes over ________ aspect hand
radiodorsal
______ ______ # = present in 50% of distal radius #’s
ulnar styloid
Fracture of hook of hamate typically occurs with direct blood and may compress branches of _____ nerve, leading to sensory and motor changes
ulnar
Symptoms of hook of hamate #?
decrease grip strength and ulnar wrist pain
of ________ = second most common carpal #
triquetrum
of ______= pain on ulnar side of wrist after dorsal impact, trauma or falling on an outstretched hand
triquetrum
of ______ = point tenderness over dorsal wrist and pain with wrist flexion
triquetrum
TFCC = sandwiched between distal end of ___ and proximal ____ row
ulna; carpal
TFCC = major stabilize in _______ ______ jt
distal radioulnar
Central portion of TFCC is ______ and not able to heal if damaged
avascular
Symptoms of TFCC tear?
- ulnar sided wrist pain
2. worst with grip, rotation, WB
5 findings on assessment of TFCC tear?
- tenderness, swelling over dorsal wrist
- pain on reissued wrist extension and ulnar deviation
- wrist clicking on movement
- reduced grip strength
- “press test” = ulnar axial load reproduces symptoms
The _____ and _____ aspects of the TFCC act as the ligaments of the distal RU jt
dorsal; volar
Damage to the dorsal and solar ligaments of the TFCC results in ______ of the ulna
subluxation
Dorsal subluxation of the ulnar head more common due to repetitive or forceful _______
pronation
TFCC tear management ?
- Brace for 4-6 wks
- NSAIDs; possible cortisone injection
- AAROM
- resisted strengthening
- plyometrics
- sports specific training
What are the borders of the carpal tunnel?
- scaphoid tubercle
- ridge of trapezium
- hook of hamate
- pisiform
- roof = flexor retinaculum
What 10 things are in the CT?
- median nerve
- FDP (4 tendons)
- FDS (4 tendons)
- FPLT
_____ = most common peripheral neuropathy
CTS
In CTS, ________ thickens from irritation or inflammation which causes pressure to increase within the carpal tunnel;
tenosynovium
CT cannot stretch in response to added swelling and the _____ n is compressed against flexor retinaculum
median
5 clinical features of CTS?
- tingling and numbness in tips of first 3 fingers
- nocturnal pain
- pain in forearm and wrist
- activities involving wrist flexion are uncomfortable
- weakness of clumsiness of the hand
2 objective findings of CTS?
- thenar atrophy and muscle weakness
2. sensory loss with more advanced stages including 2-pt discrimination
5 special tests for CTS?
- Tinel’s tap
- Phalens, reverse phalens
- carpal compression test
- ULTT with median n bias
- sensory testing
Having 4/5 of what 5 positive tests has a high level of specificity, meaning it rules in the condition?
- flick maneuver
- thumb sensation reduced compared to thenar eminence
- wrist ratio index (ratio of anterior/posterior width to medial/lateral width >0.67)
- hand symptom severity scale >1.9
- over 45 yo
4 potential differential diagnosis for CTS?
- general overuse syndromes
- ulnar neuropathy
- cervical nerve root compression (C6/C7)
- TOS
7 managements of CTS?
- wrist splint in neutral position for nighttime wear
- day splint during acute stage
- postural correction
- manual therapy
- median nerve gliding
- anti-inflammatory medication
- cortisone injections into CT
Ulnar nerve may become compressed as it passes through ______ ______
guyons tunne l
Where is guyons tunnel located
between pisiform and hamate
Ulnar nerve compression is common in ______
cyclists
Zone 1 compression of ulnar nerve?
mixed motor and sensory
Zone 2 compression of ulnar nerve?
motor only
Zone 3 compression of ulnar nerve?
sensory only
2 symptoms of ulnar nerve compression ?
- pain and paraethesia to 5th finger and ulnar border of 4th finger
- weakness to dorsal and palmar interossei, 3rd and 4th lumbricals, adductor pollicis and part of flexor pollicis brevis
2 objective findings of ulnar nerve compression?
- wasting of intrinsic muscles of hand
2. sensory exam of ulnar nerve distribution distal to Guyons tunnel
4 special tests for ulnar nerve compression?
- card test
- tinels tap at guyons tunnel
- ulnar neurodynamic test
- Froment’s test
4 management for ulnar nerve compression?
- splinting to protect Guyon tunnel during function
- NSAIDs
- change bike set up
- home exercises to address impairments in strength, ROM, ulnar nerve gliding
PT management of MC #’s?
- edema control in early stages
- splinting
- AROM above and below
- tendon gliding
- passive motion
- strengthening
- functional tasks
Tendon gliding exervises FITT principles?
10x every 3-4 hrs, daily
Distal tuft fractures usually splinted in extension for __ - __ weeks
2-3
______ _____ = # at base of distal phalanx + rupture or avulsion of the extensor tendon
mallet finger
For mallet finger, splint in DIP extension for __ weeks
8
With mallet finger, expect a slight extensor lag of __ - __ degrees after immobilization; if there is > __ deg extensor lag, should splint for another 1-2 months
5-10; 20
Most extra-articular, non-displaced shaft #’s of the middle and proximal phalanges can be treated with ____-____ and early motion for 3-4 weeks
buddy-taping
2 common sites of OA in the thumb?
- CMC
2. trapezioscaphoid
______ _____ = caused by disparity in size of flexor tendons and pulley system at first annular (A1) pulley at MCP
trigger finger
Acute management of trigger finger?
- custom splint
- activity modification
- glucocorticoid injection
________ contracture = progressive fibrosis of the palmar fascia
dupuytrens
dupuytrens contracture will lead to loss of full _______ of affected fingers at MCP joint
extension
Is dupuytrens painful?
No
With dupuytrens, discrete _____ may be visible and palpable near distal palmar crease
nodules
In dupuytrens, nodules or cords may also originate in the digits which can lead to ____ joint contraction
PIP
How big of a role does PT have in dupuytrens?
small; maybe help with modifying tools if mild
_____ ______ = avulsion of flexor digitorum profundus
jersey finger
Treatment for jersey finger?
surgical repair within 10 days
Complete ulnar collateral ligament teat of 1st MCP joint?
laxity in radial direction >15 degrees with soft end feel
Partial tear of ulnar collateral ligament of 1st MCP joint ?
laxity in radial direction < 15 degrees with soft end feel
Treatment of partial tears of PIP joint sprains?
10 days of finger based splinting with PIP in neutral, then buddy-taping, swelling management and active exercises
Treatment of complete tears of PIP joint sprains?
splint in 10 degrees of flexion more than the point of instabilty; gradually adjust splint toward neutral over period of 3 weeks
_______ Raynauds = no underlying disease of associated medical problem that could provoke vasospasm; most common form
primary
________ Raynauds = caused by underlying problem and tends to be a more serious disorder
secondary
_______ = chronic regional pain that is out of proportion to the original injury
CRPS
______ will present with abnormal sensory, motor, vasomotor and trophic findings
CRPS
