Elbow, Wrist, Hand Flashcards
Describe the symptoms of lateral epicondylitis (Writer’s cramp/tennis elbow)
- progressively worsening dull ache of proximal elbow
- numbness or tinging of the hand
- radiating pain down the distal forearm
- aggravated by repetitive tasks - wrist extension and lifting
Clinical tests for lateral epicondylitis
- positive chair lift test
- cozen
- positive hand shake
- pain on palpation 2cm anterior and distal to the lateral epicondyle’s center
What indicates poor prognosis of lateral epicondylitis
if pain not alleviated when repeated with elbow in 90 degrees
What causes medial epicondylitis (golfer/little league elbow)
- overuse of wrist flexors
- repetitive throwing, curling wrist during weight lifting, carpentry and other occupational
Describe the symptoms of medial epicondylitis
- pain with movement and making a fist
- weakness of wrist and hand
- tingling and numbness of ring and 5th finger
- stiffness, edema, erythema of elbow
clinical test for medial epicondylitis
- supinate and extend wrist while extending the elbow
which nerve might be compressed in medial epicondylitis
ulnar nerve
What is a bursa?
Synovial cavity over boney prominences when the overlying skin is subject to friction and pressure
Describe the presentation of olecranon bursitis
swelling, pain over the posterior elbow
Describe the two different types of olecranon bursitis and their incidence
- septic - 30%
- aseptic - 70%
Describe the three causes of aseptic olecranon bursitis
- idiopathic
- traumatic
- crystal induced
Describe the symptoms of aseptic olecranon bursitis
- painless ROM
- peribursal edema and warmth
- no systemic complaints
Describe the symptoms of septic olecranon bursitis
- fever, chills,
- history of abrasion
- pain of bursal sac
- edema
- erythema
- warmth
What are the 2 MOI for radial head and neck fracture
- falling onto outstretched pronated hand - resists elbow dislocation and produces a valgus load, drives forearm posterior to the upper arm
- falls with direct hit to elbow - produces fractures of olecranon and distal humerus
How to diagnose radial head and neck fracture
- x-ray
- CT scan
Are radial head and neck fractures benign?
no - will result in loss of terminal extension, instability, loss of strength, arthritis and neurovascular injury
Describe the carpal tunnel
made up of carpal bones which form a C shaped ring dorsally and the transverse carpal ligament volarly attaching to the scaphoid and trapezium radially and pisiform and hook of the hamate ulnarly
Describe the contents of the carpal tunnel
median nerve and nine flexor tendons
Clinical tests for carpal tunnel syndrome
- phalen maneuver
- reverse phalen maneuver
- tinnel sign
- thenar atrophy
- light touch
- two-point discrimination
- decreased sweat patterns
Differential diagnosis for carpal tunnel
- C6-C7 radiculopathy
- pronator teres syndrome
- forearm compression of medial nerve
- polyneuropathy -
Diagnostic tests for carpal tunnel
x-ray
lab work
EMG-NCV
which test confirms carpal tunnel
EMG-NCV
What are the 3 treatment options for carpal tunnel
- eliminate specific medial conditions
- conservative - only 25% long term relief with injection of ulnar bursa
- surgery
what are the indications for surgery for carpal tunnel
- acute progressive condition following trauma
- persistent progressive symptoms
- two-point discrimination greater than 7mm
- weakness of abductor pollicis brevis
What is De Quervain Tendinitis
Stenosing tenosynovitis of the first extensor compartment - considered entrapment tendinitis
What are the clinical symptoms of De Quervain Tendinitis
- localized swelling
- tenderness
- prominent tendon sheath
- ganglion
- limited wrist ROM especially ulnar deviation
How to diagnose De Quervain Tendinitis
- Finkelstein: make a fist around the deviate the wrist
- Hitch hiker sign: abduct the thumb against resistance
- Brunelli test: active abduction of thumb with wrist in radial deviation
- Thumb grinding to rule out OA at the carpo metacarpal joint
- X-ray
- MRI
Differentials for De Quervain tendinitis
- JV
- Mocking bird
- intersection syndrome
Stenosing Flexor Tenosynovitis - “trigger finger” presentation
- achy tender nodule on the metacarpal head at the palm
- inability to smoothly flex or extend the digit
- morning stiffness of one or more fingers
- achy palm
- symptoms can progress to severe pain, triggering and the inability to fully extend the finger
Etiology of trigger finger
Tenosynovitis of superficial and deep flexor tendons leading to:
- nodular thickening on the distal edge of the A1 pulley
- diffuse thickening of the tenosynovium
Exam for trigger finger
- lump at the metacarpal head
- triggering or locking
- x-ray for:
- trauma
- thumb involvement as degenerative changes are found
What is Dupuytren Contracture
- progressive fibrosis and contracture of the palmar fascia
Describe the clinical findings of Dupuytren Contracture
- Thick longitudinal cords with skin dimpling
- Loss of full extension
- MCPJ, PIPJ stiffness
- Rarely painful
- B/L involvement starting on the ulnar side
- Web space contracture thumb-index web’-
Clinical exam for Dupuytren Contracture
- skin dimpling over flexor tendons exaggerated by passive extension
- nodules over the flexor tendons
- thickening of the palm
- decreased extension
- flexion contracture - “the claw” ***
At which joint is finger dislocation most common?
PIPJ
Describe the MOI for a finger dislocation
- hyper extension - injury of the velar plate and collateral ligaments
- less forceful ligaments sprain: jammed finger
- severe: capsule and tendon avulsion
Describe the how finger dislocation happens
Dorsal translation
- Volar plate rupture
- central slip rupture of extensor tendon (attachment to base and middle phalynx)
- rotary subluxation (by looking at the nails in the same plane)
- instability
What are some things to look for during finger dislocation evaluation
- extensor or flexor avulsion and/or collateral damage
- rupture of flexor profundus tendon at the base of distal phalynx
Which ligament is usually ruptured in thumb dislocation
Ulnar collateral ligament
- radial collateral injury in 10-25% of injuries
What are the most common finger avulsion fractures
- avulsion of the volar plate at phalynx base
- avulsion of the extensor at dorsal base of phalynx
When do you do an open reduction for a finger dislocation?
- if its non reducible due to soft tissue interposition or patient is a few days late in presentations
- unstable joint after reduction due to collateral ligament laxity
- complex fracture
- volar dislocation with loss of complete extension
What are diffuse enlargement of the DIPJ due to idiopathic OA of the hand called?
Heberden nodes
What are diffuse enlargement of the PIPJ due to idiopathic osteoarthritis in the hand called
Bouchard nodes
Which joints does erosive OA affect and which does it spare?
Affect the DIPJ and PIPJ
Spares the MCPJ
What are some classic x-ray signs for heberden nodes
- Joint narrowing
- osteophytes formation
- sclerosis
- subchondral cysts
What is the most common joint in the hand dot be affected by OA
CMCJ
- it is a saddle joint with low intrinsic stability which makes it able to move in flexion, extension, abduction and opposition
-
What are the 4 stages of OA
1 - effusion
2 - narrowing <2mm and osteophytes
3 - narrowing >2mm and osteophytes
4 - pan trapezoidal arthritis
