Elbow, Wrist, and Hand Pathology

Question 1

cubital tunnel syndrome

defn and causes

Answer 1

ulnar nerve = branch of axillary nerve, medial aspect of arm and forearm, down into pinky

cubital tunnel = band of aponeurosis between 2 proximal heads of flexor carpi ulnaris (at medial epicondyl)

can also be compressed in the ulnar groove of the humerus

causes: direct trauma, prolonged leaning, head resting on flexed elbow during sleep, bone spurs, cysts

Question 2

cubital tunnel syndrome

dx: clinical presentation and physical exam findings

Answer 2

weakness and paresthesias distal to level of entrapment (i.e, along medial aspect of forearm and into pinky)

NOTE: distal to flexor carpi ulnaris in case of entrapment by this muscle does NOT include flexor carpi ulnaris, motor and sensory in this muscle is spared; DOES include 4th and 5th lumbricals, interossei, 3rd and 4th flexor digitorum profundus, hypothenar muscles, adductor pollicis

ulnar groove may be tender on palpation, normal ROM, weakness and paresthesias as noted above

in severe cases, may have muscle atrophy and weak grip

SPECIAL TESTING: Tinel’s test = tapping over cubital tunnel reproduces sx down arm

formal dx: nerve conduction study

Question 3

cubital tunnel syndrome

tx and prognosis

Answer 3

pain management, neuropathic pain meds if needed; corticosteroids usually not helpful

elbow cushions or splints/braces to prevent excessive flexion and entrapment. PT to help nerve “glide”

cubital tunnel release or nerve transposition surgery if severe

good prognosis if treated early, later may have some persisting hand weakness, PT helps

Question 4

guyon canal syndrome

Answer 4

entrapment of the ulnar nerve within the guyon canal

guyon canal = pisiform, hamate, and ligament between them

ulnar nerve bifurcates in this canal into sensory and motor domains. both may be compromisetod if pre-bifurcation. Sensory-only is rarely damaged, most often only motor deficits are observed.

Motor deficits = hypothenar, interossi, adducter pollicis weakness

Causes: prolonged tight grip on bicycle handles, garden shears, heavy weights; martial arts eg karate chop

Question 5

carpal tunnel syndrome

defn and causes

Answer 5

median nerve entrapment at carpal tunnel of wrist

beneath transverse carpal ligament = roof of carpal tunnel

median nerve = middle 3 digits

Question 6

carpal tunnel syndrome

dx: clinical presentation and PE

Answer 6

dull ache at wrist with radiation up arm

paresthesias in thumb and index finger esp in am d/t weird sleep positions, may progress to loss of sensation and weakness of thenar/hand muscles

ROM normal, pain in wrist on palpation

special testing: tinel’s sign (tapping over carpal tunnel) and phalen’s test (inverse prayer hands)

EMG is gold standard

Question 7

carpal tunnel syndrome

tx and prognosis

Answer 7

nsaids and/or neuropathic meds. corticosteroid injection is helpful.

braces, splints, ultrasound/deep heat, ergonomics, PT gliding stretching exercises

surgical release needed in moderate to severe cases

good prognosis if treated early

if later, sx may progress, pain and weakness restrict hand fx

Question 8

supracondylar fracture

Answer 8

fracture is just proximal to epicondyles, usually lateral epicondyle. extends distally.

FOOSH with hyperextended elbow

peds: most common and most potentially serious frx, highest incidence of neurovascular problems - median, ulnar, and radial nerve injuries all common, brachial artery damage –> ichemia and/or compartment syndrome of forearm

Question 9

radial head frx

Answer 9

FOOS-arms

radial head pressed into capitulum of humerus

easily missed on xray, look for sail sign and displaced posterior fat pad

Question 10

greenstick frx

Answer 10

incomplete frx d/t supple bones in kids

twisting + axial compression, e.g. F-backwards-OOSH

Question 11

torus/buckle frx

Answer 11

“squishing” of bones in kids d/t supple bones

usually distal radius, can be any long bone

FOOS-arms

Question 12

colles’ frx

Answer 12

posterior displacement, angulation, and rotation of distal radius, often + ulnar styloid frx

common in adults > 50yr

break fall by throwing hands out in front, whether or not outstretched

Question 13

scaphoid frx

Answer 13

most frequent frx of carpal bones

usually in waist

high risk of nonunion –> proximal fragment necrosis, since most of blood supply is to distal fragment

throwing hands and arms out front (whether or not outstretched) –> extension with radial deviation

easily missed d/t minimal bruising/swelling. easily mistaken for sprain. snuff box tenderness = high suspicion for scaphoid frx.

Question 14

nursemaid’s elbow

Answer 14

don’t yank that child by the hand mama

partial dislocation of radio-ulnar joint annular ligament sliding over head of radius into joint space, becoming entrapped

most common in 1-3 years old

pain on elbow movement, child usually refuses to move arm, holds in slight flexion. very limited ROM d/t pain. tenderness over joint.

can be reduced, increased risk for future dislocation, but overall no long-term consequences

Question 15

olecranon bursitis

Answer 15

swelling of olecranon bursa on posterior elbow

acute or repetitive elbow trauma, eg elbows on desk while studying

Question 16

trigger finger

Answer 16

locking/snapping/clicking of flexor tendon of hand on flexion or extension

swelling of tendon sheath (tenosynovitis) –> catching in MCP joint

most common in women >40 w/ hx diabetes or RA

Question 17

wrist and hand rheumatoid arthritis

defn and causes

Answer 17

inflamed synovium d/t autoimmune disease, progressively damages flexor and extensor tendons in hand

advanced stages possible joint fusion

MCP and PIP (proximal interphalangeal) joints + thumb

Question 18

wrist and hand rheumatoid arthritis

dx: clinical presentation and physical exam

Answer 18

bilateral, but one side may be affected more than other

swelling, warmth, morning stiffness

rheumatoid nodules

systemic symptoms

ulnar deviation at MCP joints

hyperextension of PIP w/ flexion of PIP (Swan-neck) and/or flexion of PIP w/ hyperextension of DIP (boutonniere)

mild to severe, constant deep aching and throbbing

pain worse on movement

limited ROM d/t structural damage

Question 19

Answer 19

RA

note joint space erosion and narrowing without osteophytes or bony changes

also note a rhematoid nodule

Question 20

wrist and hand RA

tx and prognosis

Answer 20

NSAIDs, DMARDs, corticosteroid injection

ice

splints, paraffin wax, contrast baths

assistive devices such as built-up utenesils and grab bars

surgery to prevent tendon rupture, or reconstructive surgery when severe deformities are present

progressive, can be slowed with DMARDs but will get worse over time

Question 21

hand and wrist osteoarthritis

defn and causes

Answer 21

degenertive joint disease - cartilage degeneration

PIP, DIP, and CMC (carpometacarpal) of thumb

bony deformity, bony nodules

Question 22

hand and wrist OA

dx: clinical presentation and PE findings

Answer 22

localized pain at base of thumb (CMC) or over PIP, DIP

gradual, starts w/ intermittent pain worse with repetitive movement, progression to constant pain

stiffness and swelling may be present, but not specific to morning

may be unilateral or bilateral, if bilateral typically not symmetric

possible joint deformity, bony nodules

decreased ROM d/t pain and stiffness

reproducible pain over affected joints

Question 23

Answer 23

OA

note bony changes, non-uniform joint space narrowing

Question 24

hand and wrist OA

tx and prognosis

Answer 24

NSAIDs +/- acetaminophen

corticosteoid injection if severe

hand therapy, wax, contrast baths, protective splinting, adaptive equipment

progressive, usually not debilitating, focus on pain relief and preventing further damage

Question 25

lateral epicondylitis

defn and causes

Answer 25

tennis elbow (backhand)

overuse or improper mechanics of wrist extensors and/or supinators (which attach at the lateral epicondyle) –> inflammation of common extensor tendon @ lateral epicondyle

usually extensor carpi radialis longus

Question 26

lateral epicondylitis

dx: clinical presentation and PE findings

Answer 26

gradual onset of aching pain over lateral epicondyle

worse with lifting and wrist extension

better with rest

active ROM at wrist and elbow may be limited d/t pain, passive is fine (no structural damage)

worse on palpation to lateral epicondyle and extensor carpi radialis brevis tendon

special testing: resisted wrist extension or supination, or passive stretching of extensors –> pain

possible tendon calcificationi d/t inflammation, but usually not

Question 27

lateral or medial epicondylitis

tx and prognosis

Answer 27

nsaids, corticosteroid injection

rest and d/c aggrevating activities

ice, counterforce brace

passive stretching

usually good prognosis wih conservative tx

Question 28

medial epicondylitis

defn and causes

Answer 28

“golfer’s elbow” - fronthand

occupational - repetitive wrist flexion and pronation

overuse of wrist flexors and/or pronator teres –> inflammation of common flexor tendon @ medial epicondyle

Question 29

medial epicondylitis

dx: clinical presentation and PE findings

Question 30

de quervain’s tenosynovitis

defn and causes

Answer 30

inflammation of extensor pollicis brevis and aBductor pollicis longus tendons @ radius –> thickening of tendon sheath –> obstructed movement of tendons through sheath

repetitive extension and/or aBduction of thumb, lateral hand motion - writing, strumming guitar, video games,pipetting…

commonly mistaken for OA at CMC of thumb

Question 31

de quervain’s tenosynovitis

dx: clinical presentation and PE findings

Answer 31

Finkelstein’s test - flexion of MCP and ulnar deviation

tenderness and possible swelling to radial styloid and CMC joint

palpable crepitus with thumb motion

r/o OA w/ xray

Question 32

de quervain’s tenosynovitis

tx and prognosis

Answer 32

nsaids, corticosteroid injections

rest thumb and wrist, avoid repetitive wrist motion

thumb-spica splint may help immobilize tendons

normal activity w/in 3 weeks of corticosteroid injection