Elbow, Forearm, Hand, and Wrist Flashcards
Unlike the shoulder, the elbow is more stable with 3 distinct articulations:
- Ulnahumeral joint
- Radiocapitellar joint
- Proximal radioulnar joint
What is a fat pad on a xray mean?
- if fat pad sign, there is blood inside the elbow and ASSUME there is fracture somewhere
- Might need a CT
What is the normal AROM of the elbow
- Flexion/extension: 0-140/150
2. pronation/supination of 80degrees
Post-traumatic elbow is commonly stiff and the least “functional ROM” of ___ flex/ext. and ___ P/S
- flex/ext of 30-130 degrees
2. P/S of 50 degrees.
Pain with flexion/extension is must likely from the ____ joint and pain with pron/supp must likely from the ___ joint
ulno-humeral join
radio-capitellar
Most common joint to dislocate during childhood
elbow joint
*and it is second only to the shoulder and finger joints in adults.
MOI of an elbow joint disloctaion
Commonly after falling off with out-stretched hands (FOOSH)
Always check for ___, before and after any reduction and splinting/casting.
neuro-vascular injuries
What is the most common type of elbow dislocation?
More than 80% are posterior dislocations
*posterolateral
More than 80% are posterior dislocations with ___ and ___ associated injuries
- residual stiffness
- commonly with rupture of the ulnar collateral ligament*
-once you reduce an elbow dislocation you want to keep it in what position to keep it from going out?
hyperflexion and then pronate it to keep it from going out (posterolateral)
- Reduction maneuver with steady traction with elbow flexed to 45 degrees. Splinting at > 100 degrees of flexion and hyper pronation.
What is the tx of elbow dislocation?
- Closed reduction ASAP with sedation, and with or without joint aspiration and intra-articular anesthetic injection (lateral approach).
- Reduction maneuver with steady traction with elbow flexed to 45 degrees. Splinting at > 100 degrees of flexion and hyper pronation.
- Surgery if unable to reduce, usually because loose bodies and/or extensive soft tissue swelling.
When is surgery indicated for an elbow dislocation
Surgery if unable to reduce, usually because loose bodies and/or extensive soft tissue swelling.
Neurovascular complications after dislocation of the elbow occur in up to __% of cases
5%
Symptoms of elbow dislocation
- Symptoms related to neuropraxia may occur usually involving the ulnar or median nerve (Anterior Interosseous Nerve branch) with ulnar nerve palsy much higher in pediatric dislocations with an associated medial epicondyle fracture.
- Most neurologic deficits are short-termed.
What is the follow up management of elbow dislocations after reduction
- Early motion 5-7 days post-reduction,
2. progressing for the next 3-4 wks (PT consult recommended if persistent stiffness.)
Possible complications of elbow dislocations
- flexion contractures,
- heterotrophic ossification (OH)** and
- post-traumatic arthritis.
what is heterotrophic ossification (OH)
HO formation calcification is somewhere else (joint, soft tissue, just NOT MUSCLES!! If inside muscle it is called myocytis)
Most Condylar fractures need __
ORIF
*open reduction and internal fixation
What do Xrays of elbow fractures show?
X-rays with AP and lateral views:
- non-displaced fractures may show a (+) fat-pad sign on the lateral view.
- Also check cortical lines “hourglass” for displacement on lateral view.
Adverse outcomes of elbow fractures
- residual pain
- stiffness
- deformity
- mal-union/non-union
- AVN
- compartment syndrome
- ulnar neuropathy
What is the MC MOI of olecranon elbow fractures
after FOOSH injury and posterior dislocations
What is the tx of olecranon elbow fractures
- ORIF for displaced fractures,
- with splinting in 45 degrees of flexion with
- follow-up x-rays after 1, 2, and 4 wks post-injury.
What kind of fracture commonly happens from kids hanging from monkey bars
supracondylar elbow fracture
a radial head dislocation is also called _____
Nursemaid elbow
What kind of injury commonly happens from swinging a kid by their hands?
radial head dislocation
*nursemaid elbow
What is the treatment of radial head fractures
- usually non-displaced.
1. Treated in splint/sling with early motions.
2. May require cortisone / anesthetic injection for pain relief and mobilization.
3. Referral to ortho if >30% comminuted fracture
*if the fragment is depressed 2mm or more then consider surgery
What is the magic number in ortho
2mm
*if the fragment in a radial head fx is depressed 2mm or more then consider surgery
What are types of forearm fractures?
- Monteggia’s fracture dislocation:
- Galeassi’s fracture dislocation:
- Night stick fracture:
- “Both bones” fracture
What is a Monteggia’s fracture dislocation
fracture of the ulna shaft w/ radial head dislocation
*must have an ulnar fx!!
What is a Galeazzi’s fracture dislocation
Fracture of distal third of Radius with associated radioulnar dislocation
What is a night-stick fx
mid-shaft ulnar fx
What is the tx of both-bone forearm fractures
- Most DO NOT have a neurovascular injury**
- Very hard to reduce and keep it reduce–> NEEDS SURGERY, very unstable
Most commonly in pediatrics
*arm is pointing in the wrong direction
What are types of elbow epicondlyitis
- Medial (Golfer’s elbow)
2. lateral epicondylitis (tennis elbow):
elbow epicondlyitis is best described as
Best described as tendinosis with the pathological process described as tissue degeneration with fibroblast hypertrophy and MINIMAL inflammation
What is the tx of elbow epicondlylitis (medial and lateral)
- stop what makes it worse,
- NSAIDs, ice/heat massage, cortisone injection and
- elbow strap, with >95% of cases non-surgical
What causes Golfer’s elbow
aka medial epicondlyitis
*Caused by overuse of the muscles of the forearm leading to inflammation and pain around the elbow joint
What are causes of olecranon bursitis
- Acute vs chronic;
1. secondary to trauma,
2. inflammation or
3. infection (20% acute bursitis have a septic cause);
4. also seen secondary to Gout or RA.
Olecranon bursitis requires __ for definitive etiology
aspiration
*if it looks like cottage cheese–> gout
What labs should you get for an olecranon bursitis
- CBC,
- ESR, CRP with
- aspirate fluid: WBC cell count, GS, cultures/sensitivity and crystals.
What is the treatment of olecranon bursitis
- include NSAIDs,
- oral or IV antibiotics,
- elbow pad and/or splint (avoid splinting in hyperflexion) and surgical resection.
What is another name for ulnar nerve compression
cubital tunnel sydnrome
*Second only to carpal tunnel syndrome
Where is the most common site of compression for cubital tunnel syndrome
compression at the medial epicondyle groove
Cubital tunnel syndrome most commonly occurs in who
ages 30-60y/o
What are the PE findings of cubital tunnel syndrome
- tenderness over cubital tunnel and
2. a (+) Tinel’s sign (tapping over the nerve)
Symptoms of cubital tunnel syndrome
- aching pain,
- numbness and
- tingling in SF and RF and
- late findings of intrinsic muscles weakness and hypothenar compartment atrophy
- interosseous muscle atrophy
- chronic ulnar nerve atrophy
What is the diagnostic test of cubital tunnel syndrome
EMG/NCV tests with a reduction in velocity of 30% or more suggestive of significant compression
What are the treatment options for cubital tunnel syndrome
- activity modification,
- night splint keeping the elbow from flexing to 90 degrees and
- NSAIDs.
- Surgical decompression and
- possible nerve transposition.
*No cortisone injections recommended.
What is no man’s land?
-zone 2 of the hand (top of palm and bottom of fingers)
- If injury in that area–> wash it but don’t go exploring for things in there bc you may damage nerves
- STAY AWAY FROM HERE
Common symptoms of hand and wrist complaints
- pain
- instability- sensation of slipping, snapping, or clunking with certain wrist motions.
- stiffness
- swelling
- weakness
- numbness
- masses
common symptoms in OA, trigger finger and Carpal Tunnel Syndrom
stiffness
Most common cuases of masses in the hand and wrist
- ganglion cyst
- Giant cell tumors
- Dupuytren’s nodules
- RA/OA nodules
- Carpal boss deformity
What are special tests of the hand and wrist
- Finkelstein test
- Allen’s test
- Phalen’s maneuver
- Tinel’s sign
What is the Finkelstein test?
-tuck thumb in palm and rotate wrist down
+) test indicate tenosynovitis of the first dorsal compartment (de Quervain tenosynovitis.
What is Allen’s test
compression of radial and ulnar arteries and assessment of blood refill.
**Do this test prior to surgery (in no mans land) to assess blood flow
What is Phalen’s maneuver?
numbness or tingling of the median nerve with wrist flexion within 60 seconds.
*for carpal tunnel
What is Tinel’s sign
tapping over median nerve w paresthesia
*for carpal tunnel
What are contributing factors to hand infections
- Diabetes
- Immuno-compromised patient
- Environmental / occupational
- Smoking
What is cellulitis
diffuse skin involvement infection
*Beware of a septic joint or a deep space infection overlying cellulitis
causes of cellulitis
trauma
ulceration
lymphedema
How do you dx celluliits
primarily a clinical diagnosis
What is tx of cellulitis
- Oral abx
- If no resolution in 24 to 48 hrs, then IV antibiotics with 1st generation cephalosporin or Vancomycin. - Immobilization/splint
- Elevation
If worry about septic joint at MCP due to pain with ROM (can get MRI) but in general w/ diffuse redness not just at the site it is __
cellulitis!!!!
-tx w/ antibiotics
What is paronychia
infection beneath eponychial fold
What organism most commonly causes:
- paronychia
- Felon
- Flexor tenosynovitis
- S. aureus
- S. aureus
- S. aureus
What is the tx of paronychia
- Abx
- warm soaks
- drainage (do a nail nerve block)
- elevation of nail fold
*Solution for pollution is dillution!!
What is felon
digital pad infection
*Closed, poorly compliant compartment
Sx of felon
intense throbbing pain (VERY PAINFUL)
What is the tx of felon
- incision and drainage (“the solution for pollution is dilution”).
- spread tweezers until pus is found
* **Stay away from the neurovascular bundle
Complications of felon
- necrosis
- osteomyelitis (rare)
- flexor tenosynovitis
What is herpetic whitlow and what is it commonly confused with?
- Herpes virus hand infection
- Clinically confused with felon
Sx of herpetic whitlow
painful cytolytic lesion 2-14 days
2. vesicle mature over 14 days
what is the tx of herpetic whitlow
self limited disease, clearing in 7-10 days
Anatomy:
- ___ is a closed space.
- Sheath of thumb contiguous with ___.
- Sheath of small finger is contiguous with ___.
- In 50-80% of pts the radial burase and ___ communicate.
- Flexor sheath
- radial bursa
- ulnar bursa
- ulna bursae
What is flexor tenosynovitis and what are common causes
*bacterial infection of flexor tendon sheath
Causes:
- penetrating trauma
- hematogenous- gonoccal infections
- S. aures (MC)
What are the 4 Kanavel cardinal signs
- FLEXED resting posture
- tenderness over flexor sheath
- fusiform swelling (sausage finger)
- severe pain on passive extension
*signs of infectious flexor tenosynovitis
What is the tx of infectious flexor tenosynovitis
incision, irrigation and IV antibiotics
Common causes of infections from human bites
- Group A strep
- S aureus
- Eikenella corrodens
Bites presenting ___ hours old are usually infected.
over 24
When doing a PE on a human bite on the hand it is important to ___
do an exam with an open and closed fist bc that is how it was injured and a closed fist can assess the tendon
What is the tx of infected human bites
- Irrigation and debridement with delayed wound closure
2. IV antibiotics
W/ human bites, beaware of joint involvement:
- Fight bite with clenched fist injury
- Examine hand with finger in full flexion
- With a dorsal MCP joint injury, always assume joint involvement.
What organisms most commonly cause infected animals bites
- staph
- strep
- pasturella multocida
___% cat bites become infected
30 - 50%
What is the treatment of animal bites
- Meticulous wound irrigation
- Exploration and delayed wound closure
- Antibiotic– prophylactic treatment:augmentin /amoxicillin or with pcn allergy: clindamycin
**Any hand infection, you do not want to close all the way– can do close approximation closure
What is the most common compression neuropathy
carpal tunnel syndrome
*entrapment of the median nerve at the wrist
Carpal tunnel is most common in who
Most common in middle-aged or pregnant women
Causes of Carpal tunnel syndrome
- overuse
- DM
- thryoid dz
- RA
- pregnacy
How do you dx Carpal tunnel
- Tinel’s,
- Phalens and
- EMG/NCT
What is the treatment of carpal tunnel syndrome
- NSAIDs
- night splint
- cortisone injection (less frequently done bc can numb the whole nerve)
- surgical release
Symptoms of DeQuervain Tenosynovitis
Swelling or stenosis of the Abductor Pollicus Longus (APL) and Extensor Pollicus Brevis tendon sheaths.
How do you dx DeQuervain Tenosynovitis
finkelstein test and x-rays
what is the tx of DeQuervain Tenosynovitis
- Thumb spica splint,
- NSAIDs,
- cortisone injection and
- rarely needs surgical release.
**Does well w/ injections
What is Dupuytren’s Disease
- Nodular thickening and contraction of palmar fascia.
- Has a dominant genetic component involving northern European descent.
Dupuytren’s Disease is most common in who
men older than 50
Associated factors of Dupuytren’s Disease
- DM
- epilepsy
- COPD
- alcholism
- smoking
- trauma
What are 3 common findings of Dupuytren’s Disease
- Tight cord that CANNOT extend the finger (can release it at 30 degrees)
- Pit on the nodule
- Flexion contracture
What is the tx of Dupuytren’s Disease
- surgical release, but not recommended until flexion contracture of 30 degrees or more.
- Xiaflex (collagenase clostridium histolyticum) injection for cord deformity only.
what is the etiology of Trigger finger
Nodule of flexor tendon entrapment at A1 pulley
what is the treatment of trigger finger
cortisone injection of tendon sheath and/or surgical release
How can you differentiate trigger finger and Dupuytren disease
**THIS ONE YOU CAN CAN REDUCE AND GET INTO FULL EXTENSION PASSIVELY UNLIKE Dupuytren Disease
The most common fracture in adults
distal radius fx
*fractures of the distal radius accounting for one-sixth of all fractures seen in the emergency department.
Types of distal radial fractures
** based off MOI
- Colles
- Smith
- Barton
- chauffeurs
- die-punch
What is the tx of distal radial fx
- Closed reduction with hematoma block or conscious sedation,
- splint/casting or ORIF.
What is a Barton’s fractire
: It is an intra-articular fracture-dislocation of the VOLAR RIM OF THE RADIUS with the displaced volar fragment taking the carpus with it
What is Chauffeur’s fracture
an isolated fracture of the radial styloid process
-Displacement of the fragment is uncommon
- also called a Hutchinson’s fracture.
Associated injurys w/ Chauffeur’s fx
- associated injury to the scapholunate ligament
2. In most cases a fracture of the radial styloid process is part of a comminutive intraarticular fracture
What is a Die-punch fracture
a depression fracture of the lunate fossa of the distal radius from a transverse load through the lunate.
What are Triangular Fibrocartilage Complex (TFCC) tears
- cartilage tissue attaching the ulna to the distal radius and creates a concave surface for articulation with the lunate and triquetrium.
- The ulnar side of the wrist is supported by the TFCC, which articulates w/ both the lunate and the triquetrum.
TFCC tears are commonly associated with
- an avulsion of ulnar styloid,
- scaphoid fracture and
- distal radius fracture
TFCC is prone to injury due to
the axial and shear forces that are applied to it as the carpi rotate over the radius and ulna
What is the most common fx of the metacarpals and phalanges
Boxers fx (5th MC)
what is the tx of a boxer’s fx
- closed reduction with hematoma block or sedation,
2. splint/casting or ORIF
w/ Boxer’s fx, __ indicates unstable fracture
Malrotation
- Have the pt close the hand (all fingers should point to the scaphoid– if one does not, there is malrotation)
- Document no rotational defomrity noted
What is a Boxer’s fx
a break through the bones of the hand that form the knuckles.
Most commonly fracture of a carpal bone
Scaphoid fracture
*20% of fractures in the proximal pole, 60% in the middle and 20% distal pole
Complications associated w/ scaphoid fractures
High incidence of non-union and osteonecrosis
why do scaphoid fractures have a high incidence of non-union and osteonecrosis
- 80% of this bone has articular cartilage and blood supply is commonly interrupted with injury.
- Therefore, displaced fractures have up to 90% rate of non-union
What is the treatment of scaphoid fractures
- Casting may be needed for 8-12 weeks.
* *If there is a non-union you need to restart the clock so try to catch it early!
What are common signs of scaphoid fracturs
snuff box tenderness
Xray: empty cup sign
Perilunate dislocation
common causes of prox. carpal row instability
- perilunate dislocation
2. scapho-lunate disassociation
What are common finger deformities
- Mallet finger
- Swan neck deformity
- Boutonniere deformity
What is the difference between swan neck deformities and boutonniere deformities
Swan neck deformity: PIP is hyperextended
Boutonniere deformity: PIP is hyperflexed
Common cysts seen on the wrist
Volar/dorsal ganglion cyst
