Elbow and downwards Flashcards
Conditions of the elbow/forearm
OA elbow
Tennis elbow
Golfer’s elbow
Ulnar neuritis/entrapment
Olecranon bursitis
Tennis elbow - clinical features
What is it? –overuse (very occasionally traumatic) enthesopathy of the wrist extensors
Pain lateral elbow with Hx of overuse/unaccustomed use, esp repetitive movts of fingers or static posns of wrist eg typing, gripping. Eased by rest
Possible night pain and early morning stiffness
Full painless ROM all joints
** Pain resisted wrist/middle finger extension + gripping**
Tenderness, often exquisite, common ext orig
Possible +ve Mills’s test
Golfers elbow - clinical features
What is it? –overuse (very occasionally traumatic) enthesopathy of the wrist flexors
Pain medial elbow with Hx of overuse/unaccustomed use, esp lifting and hitting eg moving home, hammering
Eased by rest
Possible night pain and early morning stiffness
Full painless ROM all joints
Pain resisted wrist flexion
Tenderness, often exquisite, common flexor orig
Wheres the origins of common extensor and flexor tendons
Anterior facet of epicondyles
Treatment of tennis/golfers elbow
As always, Rx will be influenced by chronicity and severity
Of primary importance is to remove the causative factor(s). Other than in very mild cases, if the patient persists in repeating the irritative action, your Rx will not work
Selective rest –splint
Ergonomics
Stretching
Eccentric strengthening
Possible acupuncture
Injection
Ulnar neuritis/entrapment - clinical features
Sharp pain medial elbow + paraesthesia in 4th/5thdigits, often assoc with repetitive elbow extension in a valgus elbow
Often assoc with contact pressure eg leaning on elbow at
desk, leaning on window ledge in car, cyclists
Painless resisted movts
Swelling around medial elbow
Tenderness of ulnar groove
Possible wasting medial forearm/hypothenar eminence
Possible weakness esp ulnar deviation and 5thdigit abd
+ve Tinel’s sign
What is ulnar neuritis/entrapment
inflam/impingement of ulnar nerve at the elbow
What is golfers elbow
Overuse (very occasionally traumatic)
enthesopathy of the wrist flexors
What is tennis elbow?
Overuse (very occasionally traumatic)
enthesopathy of the wrist extensors
Treatment of ulnar neuritis/entrapment
May need nerve conduction studies to confirm diagnosis
Selective rest from causative factor normally settles condition
Ulnar n is superficial at elbow, so topical agents –ice, gels etc –may have some beneficial effect
Appropriate mobilisation –ULTT 3
Maintenance exercises to affected muscles
Injection
If entrapment suspected or Rx ineffective, may require surgery
Olecranon bursitis - clinical features
Obvious golf ball-like swelling posterior elbow
May be hot and/or red –commonly infected
Full painless ROM of elbow should be present
Often only mild/no tenderness
Pt often c/o bursa being space-occupying –getting in the way -rather than painful
What is olecranon bursitis
Inflam of olecranon bursa, normally as
a result of contact pressure, either overuse or traumatic
Treatment of olecranon bursitis
Usually you simply need to remove causative factor and it will settle
NSAIDs. Local and topical agents can be
effective, esp ice
If any signs of infection –antibiotics are
imperative
If bursa is esp painful –this is particularly true after trauma when there is often bleeding in to the bursa –or fails to resolve, then aspiration +/ injection can be performed
Avoidance of recurrence with ergonomic advice and/or splinting/padding
Conditions of the wrist/hand
OA dist rad/ulnar jt
OA radiocarpal jt
TFCC –triangular fibrocartilage complex
Carpal tunnel syndrome
Arthropathy 1st CMC jt
Tenosynovitis –de Quervain’s, extensor
Trigger finger/thumb
What is carpal tunnel syndrome?
Compression of median nerve as it passes
through carpal tunnel
Causes of carpal tunnel syndrome
↑ pressure in tunnel due to ↓ volume, often resulting from ↑ peripheral oedema eg obesity, pregnancy, overuse,
thyroid, renal/cardio-vas problems, or positional trauma esp at night
Carpal tunnel contains…
Median nerve and 9 tendons
- Four tendons of the flexor digitorum superficialis
- Four tendons of the flexor digitorum profundus
- The tendon of the flexor pollicis longus
Clinical features of carpal tunnel syndrome
Pain, paraesthesia, numbness in wrist + hand. Classically the palmar surface of 3.5 radial digits, but in practice, the Sx can be in all digits + occasionally dorsal surface as well
Worse with overuse + esp at night, when pt has to shake arm to ease
Possible wasting of thenar eminence m. Poss weakness of thenar eminence m. Resisted thumb abd/add is the discriminating test (abd –median n, add –ulnar n)
+ve Phalen’s test. +ve Tinel’s sign
Vast majority of carpal tunnel patients are diagnosed…
Symptomatically
Treatment of carpal tunnel syndrome
If diagnosis uncertain, may need nerve
conduction studies to clarify
Rx depends upon causative factor(s) –weight loss, medical review, ergonomics, night splint, education
Proximal restriction of median nerve may be a factor. Posture, Cx/Tx mobs, ULTT 1+2 mobs, neural glides
Injection
Surgery
What position –> carpal tunnel in least tension
30 degrees wrist flexion/ neutral
Arthopathy/arthritis of 1st CMC- what is it
Degenerative changes to/inflam of 1st
carpometacarpal jt
Arthropathy of 1stCMC joint
Clinical features
Can be traumatic, but usually OA
Pain around base of thumb, worse on
gripping/dexterous movts
Pain on add/ext test (cf de Quervain’s)
Painful stiffness acc movts CMC jt
Painful weakness of grip + thumb opposition
X-Rays often show OA
Visible/palpable OA changes
Treatment of 1stCMC jt arthropathy
Mobilisations CMC + other affected joints
Stretching exs
Strengthening exs for thumb m, esp grip + opposition
Advice re NSAIDs/analgesics
Resting splint
? TENS/acupuncture
Injection
If severe, surgery
De Quervain’s tenosynovitis- what is it?
inflam of Abductor pollucis longus/Extensor pollucis longus tendon sheath due to overuse
Clinical features of De Quervain’s tenosynovitis
Pain +/-crepitus around radial styloid on repetitive thumb movts
Swelling radial side wrist
Pain res thumb abd/ext, but painless pass add/ext
+ve Finkelstein’s test
Can also get tenosynovitis of extensor tendons of wrist, giving pain on dorsal surface of wrist + often gross crepitus. Common in typists, rowers, canoeists
Treatment of de Quervain’s/extensor
tenosynovitis
Overuse condition, so pt MUST stop overusing it or your Rx is doomed to failure
Splinting –thumb spica de Q, wrist splint ext teno
Stretching often beneficial
Tendon sheaths superficial, so ice, gels etc will help
Advice on NSAIDs/analgesics
? DTF
Injection
Very occasionally surgery
What is trigger finger/thumb
Nodule in flexor tendon which catches
in flexor pulley system causing digit to ‘lock’ in flexion + forcing pt to manually extend digit
Trigger finger/thumb - clinical features
Nearly always due to overuse
Palpable flexor nodule with palpable
catching/release
** Must be able to demonstrate triggering for diagnosis to be made. Often confused with ‘sticking’ due to OA digital joints**
