Elbow/wrist/hand Flashcards
Elbow deformities- cubits varus
Aka gun-stock
Most obvious when elbows are ext + elevated
Most common cause is malunion of sypracondyl ar fracture (abnormal healing) s
Can be corrected by wedge osteopathy of lower humerus
Larger q-angle
Elbow deformities- cubits valgus
Most common cause is non-union of fractured lat epicondyle, may give gross deformity + bony knob on inner side of Jt
Increases liability of ulnar palsy development years after injury, Pt notices weakness of hand, numbness + tingling of ulnar fingers (ring + little)
Doesn’t need treatment, but for delayed ulnar palsy the nerve needs to be transposed to front of elbow (stops pinching)
Elbow deformities- stiff elbow
Can be severe impediment
Pt may be unable to reach out to, or bring back from, their environment
Cannot turn palm downwards to pick something up, or palm up to lift
Causes include congenital disorders, trauma, and arthritis
If physio doesn’t help, surgery is needed
Clinical presentation of TB
TB rarely seen until arthritis supervenes
Onset is insidious, long Hx of aching + stiffness
Marked wasting
While disease is active, Jt is held flexed, looks swollen, feels warm + tender
Limited ROM
P + spasm
Prognosis of TB
Anti-TB drugs
Rest in splint
Later treatment- collar + cuff
Surgery rarely needed
RA clinical presentation
Elbow involved in more than 50% of cases
Rheumatoid nodules can be detected over olecranon
P + tenderness, especially around head of radius
Eventually whole elbow becomes swollen + unstable
Often bilateral
X-ray shows bony erosion, gradual destruction of radial head + widening of trochlear notch of ulnar
Prognosis of RA
Splinted during periods of synovitis
If entire Jt is severely damaged, replacement should be considered
OA clinical presentation
Uncommon site for OA
P + stiffness
Jt may become unstable
Elbow looks + feels enlarged
Limited ROM
X-ray shows reduced Jt space with sub Honduran sclerosis + osteopahytes, one or more loose bodies may be seen
Prognosis of OA
Rarely requires more than symptomatic treatment
Loose bodies should be removed if they cause locking
If stiffness is disabling, removal of osteopahytes can improve ROM
If signs of ulnar neuritis the N can be transposed to front of elbow
Loose bodies epidemiology
Trauma
Osteochondritis dissects of capitulum
Multiple may occur with OA or synovial chondromatosis
Clinical presentation of loose bodies
Locking of elbow
Prognosis of loose bodies
Can be removed= reduction in symptoms
Olecranon bursitis epidemiology
Olecranon bursa can enlarge due to pressure or friction
When accompanied with P, cause is more likely to be from infection- gout (if Hx of previous attacks), RA
Clinical presentation of olecranon bursitis
Bilateral
X-ray shows calcification of bursa (gout)
Swelling + nodularity over olecranon, erosion of Jt may cause instability- RA
Prognosis of olecranon bursitis
Underlying disorders must be treated
Septic bursitis may need draining
Chronically large may need to be removed
Difference between tennis + golfers elbow
Tennis- lateral epicondylitis
Golfers- medial epicondylitis
Lateral epi Hx
Repetitive motion (gripping, hammering, lifting, tennis backhand)
Lat epi SSx
Tender to palpation over lateral epicondyle/common extensor tendon
Initiated/aggravated by movement
Risk factors of tennis/golfers
Resistive flex/ext
Certain jobs
Medial epi SSx
Tender to palpation over medial epicondyle/common flexor tendon
Prognosis of tennis/golfers elbow
Rest/avoiding precipitating activity
Splint + physio may help
If P severe area of max tenderness is injected with mixture of corticosteroid + local anaesthetic
Persistent P with no response to treatment may require surgery
Pronator teres syndrome Hx
Repetitive motions (gripping with pronation)
Tingling and weakness in hand
Pronator teres syndrome SSx
Tender to palpation over mid pronator teres
Weakness in wrist flexion
UCL rupture Hx
Prior elbow dislocation
Throwing injury or chronic overload
UCL rupture SSx
Tenderness to palpation of UCL
+ve valgus stress test
Wrist deformities- congenital variation
Embryonic abnormalities of upper limb, likely to affect more than one segment of limb
Anomalies occur together in forearm, wrist, hand
Other organs may be affected + may be associated congenital abnormalities
Overall incidence of upper limb abnormalities estimated to be 1/600 live births, only a fraction severe enough for surgery
Wrist deformities- radial dysplasia
Infant born with marked radial deviation
Aka club hand
1/2 Pt affected bilaterally
Absence of whole or part of radius, usually small thumbs
Treatment of radial dysplasia
Neonatal includes gentle stretching + splintage
Serious cases treated with distraction prior to tension free soft tissue correction
Has less effect on growth of carpus + distal ulnar
Prolonged splintage still required to avoid reoccurrence of deformity
If function deteriorates, centralisation over ulnar recommended, preferably before age 3
Wrist deformities- Madelung’s disease
Rare- effects growth plate of radius, with growth= misalignment of ulnar + radius on carpals
Present at birth, but rarely seen until around age 10
Despite deformity, function usually undisturbed
Treatment may not be necessary, if severe lower end of ulnar can be shortened
Wrist deformity- acquired deformity
Physeal injuries result in malunited fractures or subluxation of distalradioulnar Jt
Osteotomy of radius or stabilisation of Jt may be needed
Non-traumatic deformities- seen typically in RA + cerebral palsy
TB arthritis clinical presentation
Sometimes occurs at wrist
P + stiffness is gradual
Hand feels weak
Forearm looks wasted, wrist swollen + feels warm
Involvement of flexor tendon compartment may cause swelling across wrist into palm
Restricted + painful ROM
Unilateral
Prognosis of TB arthritis
Anti-TB drugs
Splinted
Drain any abscesses
OA epidemiology
Unusual except as sequel to intro-articulate injuries of distal radius or carpal bones, or a vascular necrosis of lunate
May forget about injury then later complain of P
Keinbock disease
Blood supply to lunate interrupted
Epidemiology of Keinbock disease
Exact cause unknown
Often associated with injury to wrist, such as fall
Repetitive microinjuries e.g., from jackhammer use
Age groups affected by Keinbock disease
Usually young adult
Risk factors of Keinbock disease
Trauma
Underlying medical conditions
Relative shortening of ulnar - excessive stress applied to lunate
Occupation (manual labour)
Clinical presentation of Keinbock disease
Related dorsal wrist P with activity
Decreased wrist motion in flex/ext
Poor grip strength, swelling + tenderness over radiocarpal Jt
Prognosis of Keinbock disease
No cure
Prompt treatment can preserve wrist function + relieve P
Later cases- Jt replacement considered
Triangular fibrocartilage complex (TFCC)
Fans out from base of ulnar styloid process to medial adage of distal radius
Acts like meniscus of wrist
Tears of TFCC epidemiology
May be due to old sprain being looked over, May actually be damage to TFCC
FOOSH
TFCC degeneration risk factors
May be associated with long ulnar, impaction of ulnar head against ulnar side of lunate + ulnarcarpal arthritis
Tear of TFCC clinical presentation
Loss of grip strength and ROM
Clicking on supination in forearm
Local P with ROM
Prognosis of TFCC tear
Operative treatment may be needed
Peripheral tears can be reattached by arthroscopic techniques
Taping/bracing
NSAIDs
DDX TFCC tear
Lunate dislocation
Ulnar styloid #
OA
Prognosis of TFCC degeneration
Analgesics, splintage + steroid injections
Chronic carpal instability epidemiology
Following trauma to carpus, may be partial collapse of scaphoid
May not be recognised at time of incident
Clinical presentation of chronic carpal instability
Years after initially injuring, Pt complains of P + weakness of wrist
Prognosis of chronic carpal instability
Prevention best method
Acute wrist sprains should be assessed for carpal displacement + instability
Can be treated with splintage, analgesics + specific physio
Tenosynovitis epidemiology
Unaccustomed movement, sometimes occurs spontaneously
Resulting in synovial inflammation causing secondary thickening of sheath + stenosis of compartment, which further compromises tendon
Clinical presentation of tenosynovitis
Swelling, localised to radial side of wrist
Tendon sheath feels thick + hard
Tenderness most acute at tip of radial styloid process
Finklestein’s test
Prognosis of tenosynovitis
Early treatment includes rest, anti-inflam medication + injection of corticosteroid
Hopefully breaks cycle of inflammation
Tenovaginitis
Women between 30-50
Hx of unaccustomed activity, such as cutting with scissors or wringing clothes
Quite common straight after child birth
Ganglion cyst
Ubiquitous ganglion seen most on back of wrist
Soft, gel-like mass that changes size
Caused by fluid leaking out of Jt
Epidemiology of ganglion
Arises from cystic degeneration in Jt capsule or tendon sheath
Jt/tendon leaking fluid
Age groups affected by ganglion cysts
Young makes
Clinical presentation of ganglion cyst
Painless or painful lump, usually on back of wrist, sometimes on front
Occasional slight ache
Lump well-defined, cystic, not tender, may be attached to tendon
Prognosis of ganglion cyst
Often disappears after some months
If lesion continues to be troublesome, i can be aspirated
If it recurs, excision justified, 30% chance of recurrence post surgery
Carpal tunnel syndrome
Most common nerve entrapment
In normal carpal tunnel there is limited movement, therefore any swelling is likely to cause compression + ischaemia of nerve
Age groups affected by carpal tunnel syndrome
50-54
75-84
Risk factors of carpal tunnel syndrome
During menopause
RA
Pregnancy
Myxoedema
Clinical presentation of carpal tunnel syndrome
Insidious onset
P + paraesthesia occur in distribution of median nerve
Woken with burning P, tingling + numbness
Pt tends to seek relief by hanging arm over side of bed + shaking arm
Later cases- wasting of thenar muscles, weakness of thumb, abduction + sensory dulling in median nerve territory
Prognosis of carpal tunnel syndrome
Light splint prevents wrist flexion
Steroid injection into carpal canal provides temporary relief
DDX Carpal tunnel
Pronator teres syndrome
TOS
C6-7 radiculopathy
Wrist sprain Hx
Traumatic extension or flexion of wrist (FOOSH)
Wrist sprain SSx
Palpable tenderness over ligaments
Limited AROM and PROM
Wrist sprain DDx
Scaphoid #
TFC tear
Lunate dislocation Hx
FOOSH
Impact or trauma on hand
Lunate dislocation SSx
Tenderness in wrist in line with 3rd metacarpal
Visible on X-ray
Lunate dislocation DDx
Lunate or scaphoid #
OA
