Elbow-Wirst-Hand-Arm - MSK Flashcards
Acute elbow pain:
What to think about?
- fractures, dislocations, tendon/ligament ruptures
- less common than chronic elbow pain
Chronic elbow pain: What to think about?
- majority of elbow pain lasts > 2 wks and is attributed to overuse injuries
- multiple etiologies
Stiffness: What to think about?
- arthritis, trauma, immobilization
- mildly decreased ROM typically does not affect ADL’s
Elbow Arthritis
-Includes RA, OA, gouty arthropathy (nonrheumatoid inflammatory arthritis), posttraumatic arthritis, and septic arthritis
-RA is the most common cause of elbow joint destruction
RA -early stages -> localized pain, swelling-advanced disease -> diffuse pain, instability
OA -pain and decreased ROM-catching and locking sensation if loose bodies present
-Gouty arthropathy (or pseudogout) -acute pain, swelling, effusion, warmth, decreased ROM
-Septic -acute and severe pain, stiffness, warmth, swelling, effusion -systemic sxs -> F/C, malaise
-RA: swelling/bogginess, tenderness (radial head or diffuse), possible nodules (olecranon and extensor forearm)
-OA/Posttraumatic: joint line tenderness, decreased ROM, typically NO effusion*
-Gouty arthropathy/Septic arthritis: severe pain w/ROM, large effusion, warmth, redness
DX: AP and lateral x-rays typically sufficient
-RA: symmetric joint narrowing, erosions, possible gross destruction
-OA: osteophytes, joint space narrowing, loose bodies
-Posttraumatic: malunion, nonunion, joint space narrowing
-Gouty/Septic: typically normal early on, later may show effusion
-Aspiration of joint fluid often beneficial for helping to distinguish b/w gouty and septic arthritis
Elbow Arthritis-Treatment
- RA: PT, medications, intra-articular steroid injections, splints, synovectomy, total arthroplasty (if advanced)
- OA/Posttraumatic: analgesics, gentle stretching, arthroscopic surgery (remove foreign bodies), total arthroplasty (not generally beneficial)
- Gouty arthropathy: treat underlying cause, consider intra-articular steroid injections
- Septic: Prompt surgical drainage and antibiotics
Elbow Dislocation
- Most commonly dislocated joint in children
- Typically results from a fall on an outstretched hand (FOOSH)
- Posterolateral dislocations most common
- May be complete or subluxated
- Lateral collateral ligament is nearly always disrupted
- Concomitant fractures or nerve injuries may occur
- Clinical Presentation: -significant pain, swelling, inability to bend elbow
- PE Findings:-deformities and tenderness -MUST assess radial pulse, capillary refill, medial/ radial/ulnar nerve function
- Diagnosis: -AP and lateral x-rays, look for fractures as well
- Complications: -persistent loss of motion or instability, arthritis
Elbow Dislocation Tx
- reduction ASAP in ED or by Orthopedic surgeon
- after reduction, neurovascular exam must be repeated
- apply splint and obtain x-rays to confirm reduction
- ROM should begin 5-7 days after reduction, gradually progress over 3-6 weeks (while in brace)
- full extension should be achieved 6-8 weeks after dislocation (brace removed)
- NSAIDS can be helpful
- If at any time concerns arise immediate referral
Nursemaids Elbow
- Subluxation of the radial head
- Most common elbow injury in children < 5 yrs old
- Associated w/increased ligamentous laxity
- Mechanism of injury: pulling on the forearm when elbow is extended and forearm pronated
- Annular ligament slips proximally b/w radius and ulna
- Clinical presentation -immediate pain, child will cry, -pain will decrease but child will be very reluctant to use his/her arm
- PE Findings-tenderness over radial head, resistance to supination
- Diagnosis -x-rays are normal
- Tx: Reduction: 1. Place thumb over radial head and fully supinate forearm 2. If fails to reduce then flex the elbow 3. A snap may be perceived as annular ligament slips back into position -If successful, the child should begin using their arm again w/in minutes- If reduction attempts are unsuccessful-immobilization with cast/splint may be used
Lateral Epicondylitis
- Lateral epicondylitis (“Tennis elbow”)
- Typically occurs in pt’s b/w age of 35-50
- Clinical presentation-mainly symptomatic w/activities that involve gripping and wrist extension (i.e.-lifting, turning, hitting a backhand)
- PE Findings -localized tenderness just distal and anterior to lateral epicondyle (0ver common extensor origin) -pain when extending wrist against resistance or lifting object with the palm down
Medial Epicondylitis
- (“Golfer’s elbow, Bowler’s elbow)
- Much less common than lateral epicondylitis
- Clinical presentation: -mainly symptomatic w/activities that involve wrist flexion and forearm pronation (i.e.-swinging a golf club, baseball pitching, swimming, weight lifting, bowling, labor)
- PE Findings: -localized tenderness just distal to medial epicondyle (0ver common flexor/pronator origin), -pain when flexing wrist against resistant or lifting object with the palm up
Lateral & Medial Epicondylitis-Dx, Complications
Diagnosis
- AP and lateral x-rays to r/o arthritis, loose bodies
- MRI can confirm dx and severity but rarely necessary
Complications
-persistent pain, weakness w/heavy lifting, difficulty w/strenuous activities/athletics
Lateral and Medial Epicondylitis Treatment
Treatment
- activity modification or complete rest/restriction
- NSAIDS, anti-inflammatory creams for flare-ups
- elbow strap worn below elbow may be helpful
- heat/ice, gentle stretching, strengthening exercises
- referral to PT if pain persists past 3-4 weeks
- consider steroid injection if sxs persist
- surgery rarely performed
Overuse Tendinopathy
- tendon thickening and chronic, localized pain
- Most commonly results from overuse
- Historically referred to as tendinitis, which implicated inflammation as main cause of sxs
- Later found that a classic inflammatory reaction is not usually present in overuse tendinopathy
- Pathophysiology in most cases is now thought to be tendinosis (chronic degenerative changes that lead to scarring/failed healing response)
- Increased incidence w/increased number of middle-aged and elder adults participating in activities
- Awkward hand, wrist, and shoulder postures during activities can strain tendons
- Training errors (sudden increase in activity or inadequate rest) can increase risk for tendinopathy
- Overuse tendinopathy is a general term that encompasses many different tendons
- Synonymous w/epicondylitis in UE
Olecranon Bursitis
- Inflammation of bursa in elbow joint
- Occurs secondary to trauma, inflammation, infection, or underlying medical conditions (i.e.-RA, gout)
- Clinical presentation: -gradual or abrupt swelling, pain
- PE Findings: -large mass on posterior elbow, possible redness, possible warmth and F/C if infection present, -significant tenderness (if infectious or traumatic), -gouty tophi or rheumatoid nodules may be present
- Diagnosis:-If large and symptomatic: aspiration may be diagnostic and therapeutic, -If small, mild, and w/o signs of infection: can observe, -If occurred in presence of trauma -> obtain x-rays
Olecranon Bursitis Tx
- If large and symptomatic:
- aspirate under sterile conditions (gm stain, culture)
- if no sign of infection-> apply compression bandage and f/u in 2-7 days
- if cultures are negative but fluid reaccumulates, reaspirate and if sterile -> inject corticosteroid
- if infected -> oral abx and daily aspiration or IV abx and surgical drainage (depending on pt)
- If small and mild:
- activity modifications, NSAIDS, elbow pad
Ulnar Nerve Compression
- 2nd most common site of nerve entrapment in UE
- Most likely site: where ulnar nerve passes in groove on the posterior aspect of med epicondyle
- Clinical presentation: -Early: aching pain at medial aspect of elbow and numbness/tingling in 4th and 5th digits, -Advanced: weakness, visible muscle wasting
- possible tenderness of the ulnar nerve w/palpation
- numbness/tingling in 4th-5th digits may be reproduced w/light tapping of ulnar nerve
- numbness/tingling may be reproduced w/the elbow in full flexion x 60 seconds
- possible decreased sensation in distal 4th and 5th digits
- possible weakness when testing abduction/adduction of 4th and 5th digits
- Diagnosis -EMG studies -elbow x-rays if trauma has occurred
- Treatment: -activity modification to limit elbow flexion-crucial! -elbow splint at night -NSAIDS acutely, steroid injections NOT recommended
- surgical correction if sxs severe and refractory
