Elbow, Wrist, and Hand Pathology Flashcards
cubital tunnel syndrome
defn and causes
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
cubital tunnel syndrome
dx: clinical presentation and physical exam findings
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
cubital tunnel syndrome
tx and prognosis
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
guyon canal syndrome
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
carpal tunnel syndrome
defn and causes
median nerve entrapment at carpal tunnel of wrist
beneath transverse carpal ligament = roof of carpal tunnel
median nerve = middle 3 digits
carpal tunnel syndrome
dx: clinical presentation and PE
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
carpal tunnel syndrome
tx and prognosis
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
supracondylar fracture
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
radial head frx
FOOS-arms
radial head pressed into capitulum of humerus
easily missed on xray, look for sail sign and displaced posterior fat pad
greenstick frx
incomplete frx d/t supple bones in kids
twisting + axial compression, e.g. F-backwards-OOSH
torus/buckle frx
“squishing” of bones in kids d/t supple bones
usually distal radius, can be any long bone
FOOS-arms
colles’ frx
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
scaphoid frx
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.
nursemaid’s elbow
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
olecranon bursitis
swelling of olecranon bursa on posterior elbow
acute or repetitive elbow trauma, eg elbows on desk while studying
trigger finger
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
wrist and hand rheumatoid arthritis
defn and causes
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
wrist and hand rheumatoid arthritis
dx: clinical presentation and physical exam
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
RA
note joint space erosion and narrowing without osteophytes or bony changes
also note a rhematoid nodule
wrist and hand RA
tx and prognosis
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
hand and wrist osteoarthritis
defn and causes
degenertive joint disease - cartilage degeneration
PIP, DIP, and CMC (carpometacarpal) of thumb
bony deformity, bony nodules
hand and wrist OA
dx: clinical presentation and PE findings
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
OA
note bony changes, non-uniform joint space narrowing
hand and wrist OA
tx and prognosis
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
lateral epicondylitis
defn and causes
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
lateral epicondylitis
dx: clinical presentation and PE findings
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
lateral or medial epicondylitis
tx and prognosis
nsaids, corticosteroid injection
rest and d/c aggrevating activities
ice, counterforce brace
passive stretching
usually good prognosis wih conservative tx
medial epicondylitis
defn and causes
“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
medial epicondylitis
dx: clinical presentation and PE findings
de quervain’s tenosynovitis
defn and causes
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
de quervain’s tenosynovitis
dx: clinical presentation and PE findings
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
de quervain’s tenosynovitis
tx and prognosis
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
