Elbow, Hand and Wrist MDT Flashcards
Overuse injury involving excessive use of the extensor tendons
Lateral epicondylitis
Sports or activities that require excessive wrist and hand extension are a common cause of what injury?
Lateral epicondylitis
Overuse injury involving excessive use of the flexor and pronator muscles
Medial epicondylitis
Activities that require excessive wrist and hand flexion can cause what injury
Medial epicondylitis
What is the difference in hand and wrist movement in medial and lateral epicondylitis
Medial= flexion
Lateral= extension
Pt presents with:
-gradual onset of pain in lateral elbow and forearm during activities involving gripping and wrist extension
-Lifting
-Turning screwdriver
-Hitting backhand in tennis
-Excessive typing
- Less common, results from direct blow to lateral aspect of elbow
Lateral epicondylitis
Pt presents with:
-gradual onset of pain in medial elbow and forearm during activities involving wrist flexion and forearm pronation
-Golf swing
-Baseball pitching
-Pull-through stroke of swimming
-Weight-lifting
-Bowling
-Many forms of manual labor
Medial epicondylitis
Pt PE:
- Tenderness over common extensor origin
- Wrist extension and grip strength limited by pain
- Pain with resisted extension of the wrist
- 1cm distal and slightly anterior to lateral epicondyle
Lateral epicondylitis
Pt PE:
- Wrist flexion and pronation limited by pain
- Tenderness just distal to medial epicondyle
- Pain with resisted flexion of the wrist
Medial epicondylitis
Are plain films needed to dx epicondylitis? What radiologic study should be done if not responding to conservative management?
- Plain radiographs rarely needed in patients with elbow pain and no history of trauma
- Ultrasound/MRI in cases not responding to conservative management
Conservative treatment of epicondylitis
- Light Duty/ duty modifications
- NSAIDs
- Tennis elbow strap for comfort
- HEP
If conservative treatment of epicondylitis fails, what should be done next?
- PT
- Ortho consult if no improvement for steroid injections
Pt presents with:
- Sudden (infection or trauma) or gradual (chronic) swelling
- Pain ranges in severity
- Limited ROM from pain and or pressure
- As mass diminishes in size patient may feel firm lumps or nodules that result from scar tissue
- May occur secondary to trauma, inflammation or infection
- Trauma may vary from a direct blow to excessive leaning on elbows
Olecranon bursitis
What procedure for olecranon bursitis maybe diagnostic and therapeutic?
Aspiration
Why would you order radiographs for olecranon bursitis?
r/o fracture of olecranon
Treatment of mild cases of bursitis
- Light duty focused on activity modification to include avoiding hyperflexion against hard surfaces
- NSAIDS
- Pressure wrap
- Ice
Treatment of moderate to severe cases of olecranon bursitis
- should undergo aspiration of fluid-refer for orthopedic evaluation
- Septic olecranon bursitis requires organism-specific antibiotics-refer for treatment
More common or less common nerve compression syndromes?
- Cubital tunnel syndrome
- Median Nerve Compression
More common
More common or less common nerve compression syndromes?
- Posterior interosseous nerve compression
- Pronator syndrome
- Radial Tunnel syndrome
Less common
Where is the most common site of ulnar nerve?
Cubital tunnel
What can these cause?
- Direct blow to cubital tunnel
- Nerve stretched from flexed elbow for prolonged periods of time
- Cubitus valgus(carrying angle greater than 10 degree)
- Osteophytes or scar tissue
- Ulnar nerve subluxation or dislocation
Cubital tunnel syndrome (Ulnar nerve compression)
Pt presents with:
- Aching to medial aspect of elbow with numbness and tingling in the 4th and 5th digits
- May radiate proximally to shoulder and neck
- Inability to do activities of daily living (ADL) such as opening jars or turning key in door are late signs
- Intrinsic muscle atrophy implies nerve compression of several months
Cubital tunnel syndrome (Ulnar nerve compression)
Pt PE:
- Carrying angle greater than 10 degrees
- Visible muscle wasting
- Vibration and light touch will be affected in the 5th digit and ulnar half of the 4th digit
- Two point discrimination will be affected with progressive nerve degeneration
Cubital tunnel syndrome (Ulnar nerve compression)
What special tests should done for Cubital tunnel syndrome (Ulnar nerve compression)
Tinel Sign
What diagnostic test should be done for Cubital tunnel syndrome (Ulnar nerve compression)
Electromyographic/nerve conduction velocity(EMG/NCV) study with velocity reduction of 30% or more suggests significant ulnar nerve compression
When are radiographs of the elbow indicated for Cubital tunnel syndrome (Ulnar nerve compression)
Previous elbow trauma has occurred
Treatment of Cubital tunnel syndrome (Ulnar nerve compression)
- Modify activities to limit elbow flexion and direct pressure on the ulnar nerve is the most important step in treatment
- Splint elbow or wrap towel around elbow to avoid greater than 90 degree flexion at night
NSAIDS - Surgical decompression and transposition of ulnar nerve if 3-4 months of conservative management failed
What is the primary structure that:
- resists valgus stress at the elbow
- Trauma to this ligament is rare
-injury comes from excessive overhead throwing motions(baseball pitcher)
Ular collateral ligament
Pt presents with:
- With acute onset patient will describe a “pop” while throwing
- Most commonly patients experience a gradual onset of symptoms with progressive medial elbow pain with valgus stresses
- May experience symptoms consistent with ulnar neuritis
UCL tear
What special test will be positive with a UCL tear?
Moving valgus stress test
What is needed to r/o fracture for UCL tear?
Plain film radiographs
What is the only radiologic study that can diagnose UCL tear?
MRI w/contrast
Treatment of UCL tear
- Light Duty- Activity Modification
- Ice for acute injury
- NSAIDS
- Pain free elbow and wrist stretching and strengthening exercises
When should UCL tear be referred and to whom?
- Failed nonsurgical conservative management that results in valgus stress
- Refer to ortho
What is the Most common dislocation in children and third most common in adults
Elbow dislocation
Which ligament is always disrupted during elbow dislocation?
Lateral collateral ligament
Pt presents with:
- a fall on an outstretched hand (FOOSH)
- Extreme pain
- Swelling
- Inability to bend elbow
Elbow dislocation
Pt PE:
- Obvious elbow deformity
- Tenderness noted throughout elbow joint
- No elbow flexion and extension
- Supination and pronation severely limited
Elbow dislocation
What is the most important exam for elbow dislocation?
Neurovascular exam
-Possible median, radial and ulnar nerve neuropathy
- Check radial pulse and capillary refill
What radiological studies is adequate for dx of elbow dislocation and to r/o fracture?
Plain films
Treatment of elbow dislocation
- Ice
- Appropriate pain management
- Splint
When should you considered emergency reduction of elbow dislocation and what should be checked after?
- Neurovascular compromise
- delayed MEDEVAC
- Repeat neurovascular check after
Procedure for elbow reduction
- Elbow extended to 45 degrees
- Slow, steady downward traction of forearm in line with long axis of humerus
- Gentle pressure over olecranon tip
- Repeat neurovascular examination after reduction
What is the most common neuropthy of upper extremity?
Carpal tunnel syndrome
What neuroapthy commonly effects midde aged or pregnant women?
Carpal tunnel syndrome
The following conditions reduce size or space of carpal tunnel resulting in
- Tenosynovitis of flexor tendons
- Tumors
-Pregnancy
- Diabetes Mellitus
- Thyroid dysfunction
Carpal tunnel syndrome
Pt presents with:
- Worse at night, patients typically report the need to rub hands to “get circulation back”
- Frequently drops objects or cannot open jars with twist lids
- Worse after repetitive motion of the hand or stationary tasks of the wrist that require long term flexion or extension
Carpal tunnel syndrome
Pt PE:
- Numbness and tingling into radial three digits of the hand(1st,2nd and 3rd digits)
- Pain and paresthesias or numbness of the median distribution(thumb, and index finger, long finger, and radial half of ring finger)
- Atrophy of the thenar eminence in long standing cases
- Weakness with thumb opposition
- Possible reduced grip strength
Carpal tunnel syndrome
What special tests would likely be positive for carpal tunnel syndrome
- Phalen maneuver
- Tinel Sign
WHat diagnostic testing should be done for carpal tunnel syndrome
Electrophysiologic testing is most useful to support history and physical findings
Treatment of carpal tunnel syndrome
-Splint wrist in neutral position- especially at night
-NSAIDS
-Light duty for activity modification
-Ergonomic modifications
What should be done if conservative treatment of carpal tunnel fails?
Ortho consult
Swelling or stenosis of the sheath that surrounds the abductor pollicis longus and extensor pollicis brevis tendon at the wrist is called?
de Quervain Tenosynovitis
Pt presents with:
- Precipitated by repetitive use of thumb
- Pain, swelling and triggering phenomenon results in locking or sticking of the tendon as the patient moves the thumb
- Commonly affects middle-aged women
- Pain at radial aspect of the wrist exacerbated by movement of thumb or wrist
- Occasionally may be edema
de Quervain Tenosynovitis
Pt PE:
- Swelling may be present is the distal radius region
- Tenderness over the radial styloid
de Quervain Tenosynovitis
What special test will be positive for de Quervain Tenosynovitis
Finkelstein test
Treatment of de Quervain Tenosynovitis
- NSAIDs
- Thumb spica splint
- Light duty- activity modification
When would you refer a patient with de Quervain Tenosynovitis
Orthopedic consult with failed conservative management
What is:
- Most commonly fractured carpal bone
- Usually fractured from falls with outstretched hand
- Diagnosis is often delayed or missed and has a significant incidence of nonunion and osteonecrosis
- Major blood supply enters the bone in the distal third and be disrupted with injury
- Displacement greater than 1mm has a high rate of nonunion
Scaphoid
Patient presents with:
- dorsiflexed wrist injury
- Pain about the radial side of the wrist in the anatomical snuffbox
- Pain with wrist motion and gripping
Scaphoid fracture
Pt PE:
- Edema focal to the distal radial aspect of the wrist
- Tenderness in the snuffbox region
Tenderness on the underside of wrist
- Decreased grip strength
Scaphoid fracture
What is the timeline for scaphoid fracture radiographs and when should an MRI be ordered?
- Scaphoid series radiographs should be obtained at time of injury
- If normal but pain persists for 2-3 weeks then studies should be repeated
- If radiographs are still normal, an MRI should be ordered
Treatment of scaphoid fracture
- Thumb spica splint
- Light duty- no use of affected hand
- Treatment strategy should focused on definitive diagnosis with radiographs or MRI as soon as possible
- Consult to orthopedics
- Analgesics as needed
What condition describes the following:
- Most common soft-tissue tumors of the hand
- Affects ages 15-40 years old
- Cystic structure that arises from capsule of a joint or a tendon synovial sheath
- Through degeneration or tearing of the joint capsule or tendon sheath, a connection to the joint or tendon sheath with a one way valve established. Thus synovial fluid can enter but flow freely back into synovial cavity
Ganglion of the wrist
Pt presents with:
Wrist
- Firm nodular swelling in wrist that may vary in size and increase in size
- May be painful and pain may increase with wrist motion
- Cyst may be recurrent
- May have sensory symptom if cyst compresses median or ulnar nerve
Hand and finger
- Bump at the MCP or on the dorsum of the finger distal to the DIP
Ganglion of the Wrist and Hand
Pt PE:
- Smooth round multilobulated structure on the dorsoradial aspect of wrist that becomes more prominent with flexion
- Usually directly over scapholunate joint
- Volar radial ganglion usually is less well defined between the flexor carpi radialis tendon and the radial styloid
Ganglion of the wrist
How do you differentiate between a ganglion of the wrist and a tumor?
Ganglion will transilluminate
Solid Tumors will not
What radiologic study should be done for ganglion of the wrist
Ultrasound/MRI useful in differentiating ganglia from other types of masses
Treatment of ganglion of the wrist
- Splint wrist or finger
- NSAIDS
- Consult to orthopedics for aspiration or surgical excision
What injury is described by the following:
- Flexed DIP joint is suddenly and forcefully hyperextended
- Ring finger involved in 75% of cases
- Rupture of the flexor digitorum profundus tendon from its distal attachment
- Common in contact sports
- Often overlooked as “jammed” finger
“Jersey Finger”
Pt presents with:
- Acute pain and swelling of the DIP/distal phalynx
- Inability to actively flex the DIP joint
Jersey Finger
What radioligc studies should be done for jersey finger?
- Obtain plain films to rule out avulsion fracture
- MRI if the diagnosis remains in question or in chronic cases
Treatment of Jersey finger
- Splint the finger with PIP and DIP joint slightly flexed
Prevents extension of the DIP joint - Avoid extension of the DIP until eval by ortho hand
- All cases require referral to ortho hand
What injury is described by the following:
- Injury to the Extensor Tendon
- Rupture, laceration or avulsion of the insertion of the extensor tendon and base of distal phalanx
- Direct blow to the finger causing sudden forced flexion of the DIP/distal phalanx
Mallet finger
Pt presents with:
- Pain at the DIP joint
- Possible swelling, ecchymosis, deformity
- Commonly a flexed DIP at rest
- Inability to extend the DIP joint fully
Mallet finger
What are you looking for when obtaining plain films of mallet finger?
Avulsion fracture
Treatment of mallet finger
- Splint the finger in full extension
- If fractured do not attempt to reduce fracture
- Splint type does not affect outcome according to available clinical trials
- 6-8 weeks of splinting!
- Sleep with the splint on as well
What condition is described by the following:
- Extensor tendon ruptures at the insertion onto the middle phalanx
- Causes flexion of PIP and extension of DIP
Boutonniere Deformity
Pt presents with:
- Patient reports trauma to digit with painful PIP joint
- Deformity may not be present until 7 to 21 days post injury
Boutonniere Deformity
Pt PE:
- With the finger extended, PIP will be flexed and DIP hyperextended
- Tenderness to PIP
- PIP flexed more than 30 degree when attempting to extend digit
- Hyperextended DIP
- Limited PIP and DIP extension
Boutonniere Deformity
