Elbow/Wrist/Hand Flashcards
Lateral Epicondylitis: mm involved
ECRB
Medial Epicondylitis: mm involved
FCR
Pronator Teres
Lateral Epicondylitis: key sxs
*P! with wrist extension.
-Agg by wrist + elbow ext (ECRB max excursion).
-Agg by radial deviation.
-Agg by finger ext.
-Grip strength decreased.
-ROM intact (but may be pain-limited).
Lateral Epicondylitis: MOI
Repeated wrist EXT
Medial Epicondylitis: MOI
Repeated wrist FLEX
Lateral Epicondylitis: special tests
P! with resisted middle finger ext.
-Cozen’s
-Mill’s
-Maudsley’s
Medial Epicondylitis: key sxs
*P! with wrist flexion.
-Agg by wrist ext + elbow ext + supination (pronator mass stretched).
Medial Epicondylitis: special tests
-P! with resisted pronation.
-P! with wrist flex.
-Reverse Cozen’s
-Reverse Mill’s
Cozen’s Test: procedure, purpose, (+)
Lateral Epicondylitis.
Forearm pronated, wrist ext, slight RD.
Resist wrist flex + UD.
(+) = P! in lateral epicondyle.
Reverse Cozen’s Test: procedure, purpose, (+)
Medial Epicondylitis.
Forearm supinated, wrist flex, slight RD.
Resist wrist ext + UD.
(+) = P! in medial epicondyle.
Mill’s Test: procedure, purpose, (+)
Lateral Epicondylitis.
PROM forearm pronation, wrist flex, elbow ext.
(+) = P! in lateral epicondyle.
Reverse Mill’s Test: procedure, purpose, (+)
Medial Epicondylitis.
PROM forearm supination, wrist ext, elbow ext.
(+) = P! in medial epicondyle.
Maudsley’s Test: procedure, purpose, (+)
Lateral Epicondylitis, Radial N involvement.
Forearm pronated.
Lift middle finger up.
Resist middle finger ext (don’t let me push down to the table).
(+) = weak, painful.
Olecranon Bursitis: pathophysiology & key sxs
“Student’ Elbow”
Inflammation of olecranon bursa.
Swelling on posterior elbow.
Posterior elbow pain & tender to pressure.
Agg by max elbow flex/ext.
Cubital Tunnel: nerve involved & key sxs.
Ulnar N compression.
-Paresthesia in digits 4+5.
-Pain in medial elbow, radiates down.
-Decreased grip strength.
-Agg by elbow flexion (most pressure in cubital tunnel).
Sxs of prolonged or severe Cubital Tunnel
Thenar atrophy.
Clawing.
Pinky abducts.
Cubital Tunnel Special Test
Tinel’s: tapping on cubital tunnel (medial epi) & along Ulnar N.
(+) pain or numbness in digits 4+5.
Most distal point where abnormal sensation is felt indicates “how far” N has regenerated.
Cubital Tunnel treatments
-Ulnar N glides.
-Stretch flexors & pronators.
-Avoid max elbow flexion.
-Orthosis with flexion block; or splint at 45 flex.
Pronator Syndrome: nerve involved & key sxs
Median N compression (at elbow or forearm).
-Pain in prox forearm.
-Agg by repetitive elbow motion & forearm pro/sup.
-Paresthesia in thenar, thumb, digits 2-4.
-Weakness of FPL & FDP & pronator teres.
Pronator Syndrome special test
P! with resisted pronation.
(+) Tinel’s at pronator teres.
(-) Tinel’s at wrist.
(-) Phalen’s.
How to differentiate Pronator Syndrome from Carpal Tunnel?
Pronator = thenar eminence tingling & paresthesia (this is not common with carpal).
Pronator Syndrome treatments
-Median N glides.
-STM to biceps, pronator teres, FDS.
-If irritable: posterior gutter orthosis (holds elbow at 90 flex).
Radial Tunnel: location, nerves involved, mm borders
-Located near radiohumeral joint.
-Radial N branches into superficial & deep.
-Deep Branch becomes PIN in the radial tunnel.
-Borders: ECRB, ECRL, supinator, brachioradialis.
Radial Tunnel Syndrome sxs
-Can occur w/ lateral epicondylitis (ECRB compressing PIN).
-Weakness in supinator & wrist/finger extensors.
-Point tenderness ~4cm distal to lateral epi.
-Agg by stretching Radial N: elbow ext, pronation, wrist flex.
Radial Tunnel Syndrome special tests
-P! with resisted supination.
-Rule out TOS & proximal N impingement.
Radial Tunnel Syndrome treatments
-Radial N glides.
-Stretching supinator & ECRB.
-Custom orthosis with wrist in extension.
Elbow fx: possible sites & initial medical interventions
-Distal Humerus: cast (2wk) then hinged brace. ORIF if bad.
-Radial Head: sling (1wk) & early AROM. ORIF if bad.
-Olecranon: typically requires ORIF.
-Capitulum/Trochlea: custom orthosis & early AROM.
Potential complication of elbow fractures & key sign
Heterotopic Ossificiation
Significantly impaired ROM & hard end feel.
What may increase risk of Heterotopic Ossification?
Aggressive ROM too early
UCL injury risks
-Pitching velocity & volume (overuse).
-Throwing mechanics (esp curveballs).
-Humeral Retrotorsion (due to GIRD).
UCL injury sxs & special tests
-Ulnar N paresthesia.
-Pain during cocking phase.
-UCL tender to palp.
(+) Tinel’s
(+) Valgus Stress
Valgus Stress Test procedure & purpose
UCL stability.
-Elbow in slight flex.
-Stabilize above elbow.
-Valgus force (pull outward) below elbow.
(+) excess motion & P!
Varus Stress Test procedure & purpose
RCL stability.
-Elbow in slight flex.
-Stabilize above elbow.
-Varus force (push inward) below elbow.
(+) excess motion & P!
Moving Valgus Stress Test procedure & purpose
UCL stability (functional).
-Sh abd 90, elbow max flex.
-PROM elbow ext + apply valgus force (quick movement).
(+) P! typically at greater elbow flex.
Modified Milking Maneuver procedure & purpose
UCL stability (functional).
-Elbow at 90, forearm supinated (thumbs up).
-Pull by thumb into shoulder ER while stabilizing elbow.
(+) reproduces symptoms.
Distal Biceps Tendon Rupture: MOI & presentation
-MOI: violent pull into ext while biceps active.
-Pop at moment of rupture.
-Middle aged men.
-Reverse Popeye deformity.
-Weakness of elbow flex + sup.
(+) Hook Test
Hook Test procedure & (+)
-Sh abd 90, elbow 90.
-Supinate against resistance (not a break test).
-Hook finger to palpate for distal biceps tendon.
(+) = tendon cannot be felt.
Distal Biceps Tendon Rupture treatments
Initial strengthening of triceps & shoulder.
Strengthen biceps later once ROM restored.
Elbow capsular tightness pathophysiology & interventions
-Stiffness can happen quickly after immob, fx, surgery, etc.
-Serial casts or splinting (using creep).
Example: JAS splint = cranks into ext until stretch felt, hold there, crank more once it’s relaxed, continue.
Myositis Ossificans: definition & common locations
-Same as HO, but specifically bone growing into mm.
-UE flexors & LE extensors.
Myositis Ossificans: sxs
-Significant ROM decrease (often ext more affected than flex).
-Lymphedema.
-Weakness.
-Compression of neurovascular; paresthesia.
Myositis Ossificans: treatment & prevention
-Avoid aggressive stretching/ROM after period of immobilization or trauma.
-Immob for a few days.
-Cryotherapy, RICE.
Distal Radius Fractures: types, MOIs, & deformities
Colle’s: radius goes dorsal.
-MOI = FOOSH
-Dinner Fork deformity.
Smith’s: radius goes volar.
-MOI = fall on back of hand.
-Garden Spade deformity.
Common causes of ulnar wrist pain
-TFCC ligament or disc tear.
-Degenerative (RA).
-ECU instability.
-FCU/FCR tendonitis.
-Ulnar Tunnel Syndrome: Ulnar N compression at Guyon’s Canal.
Ulnar N Compression (wrist) special test & treatment
(+) Tinel’s at Guyon’s Canal.
Orthosis to maintain neutral wrist position.
Scaphoid Fx: MOI & possible complication
-FOOSH + radial deviation.
-Avascular Necrosis (very likely if proximal part)
Lunate Fx: MOI & possible complication
-FOOSH
-Avascular Necrosis
Hamate Fx: MOI & presentation
-Force thru base of palm during forceful grip (racket sports, golf).
-Ulnar neuropathy.
-Flexor tendon rupture often also occurs.
Carpal Fractures: which is most common?
Scaphoid most common.
Hamate kinda common.
Lunate rare.
Carpal Fractures: treatment
- Long-term immob.
- Once cast removed, ROM & control edema.
- Strengthen once bone & ligament healed.
Carpal Malalignment common patterns
Distal (DISI) vs. Volar Intercalated Segment Instability (VISI).
DISI = lunate abnormally extended.
VISI = lunate abnormally flexed.
DISI causes…
Capitate displaces, creating gap btwn scaphoid & lunate.
VISI causes…
Gap btwn lunate & triquetrum
Scaphoid Shift Test purpose, procedure, & (+)
Integrity of scaphoid-lunate ligament & DISI.
Feel Scaphoid movement during RD/UD.
(+) = audible thunk when scaphoid relocates & subluxes.
Ballotment Test purpose, procedure, & (+)
Integrity of lunate-triquetrum ligament & VISI.
Wiggle lunate & triquetrum back & forth dorsally & volarly.
(+) = pain.
Structures within the Carpal Tunnel
Median N
Flexor Retinaculum
FPL
FDP
FDS
Carpal Tunnel Syndrom key symptoms
-Paresthesia along Median N distribution (volar thumb & digits 2+3).
-No paresthesia in thenar eminence or palm (key sign of Pronator Syndrome).
-Later stages: thenar atrophy, loss of dexterity.
Carpal Tunnel Syndrome risk factors
Repeated forceful gripping + wrist flex (typing, construction).
Carpal Tunnel Syndrome special tests
(+) Tinel’s
(+) Phalen’s
(+) Carpal Compression
Carpal Tunnel Syndrome treatment
Median N glides
Splint to maintain neutral wrist
FDS/FDP tendon glides
Phalen’s Test procedure & (+)
Hold max wrist flex for 1min.
(+) = reproduces symptoms.
Carpal Compression Test procedure & (+)
Apply direct pressure to Carpal Ligament for 30sec.
(+) = reproduces symptoms.
Radial N Injury deformity
Wrist drop
High vs Low Radial N Injury: key symptom to differentiate
Low = no sensory loss bc PIN is motor only.
High = sensory and motor loss.
Ulnar N Injury deformity
Claw hand
Thumb UCL injury MOI
Hyperext + radial deviation.
May be acute rupture (Skier’s Thumb) or chronic overuse (Gamekeeper’s Thumb).
Thumb UCL Stress Test procedure & (+)
Valgus stress to MCP (push away from other fingers).
When thumb ext = assessing UCL + accessory ligament.
When thumb slightly flexed = assessing UCL only.
(+) = excess valgus.
>30deg = complete rupture.
>15deg = partial tear or sprain.
Boutonniere Deformity: what does it look like & what causes it?
Flexed PIP
Extended DIP
Extensor tendon injury
Swan Neck Deformity: what does it look like & what causes it?
Extended PIP
Flexed DIP
RA & cerebral palsy
Mallet Finger: deformity & what causes it?
Flexed DIP
DIP tendon injury
DeQuervain’s: involved structures, MOI, key sxs
APL & EPB
MOI = repeated UD + thumb abduction.
P! with UD.
P! with thumb flexion & adduction (stretching tendon).
(+) Finklestein’s Test
Dupuytren’s Disease: deformity & pathophysiology
Digits 4+5 contracted in flex.
Fibrosis of fascia.
Trigger Finger deformity & presentation
Flexed PIP + DIP.
Not completely stuck in a contracture, but difficult & painful to extend.
Popping/clicking when extending.
Proximal RUJ Posterior Glide: procedure & promotes what motion?
Pronation.
Push posteriorly on radial head at elbow.
Proximal RUJ Anterior Glide: procedure & promotes what motion?
Supination.
Push anteriorly on radial head at elbow.
Distal RUJ Posterior Glide: procedure & promotes what motion?
Supination.
Supinate forearm, push down on radius at wrist.
Distal RUJ Anterior Glide: procedure & promotes what motion?
Pronation.
Pronate forearm, push down on radius at wrist.
Radiocarpal Dorsal glide: procedure & promotes what motion?
Wrist extension.
Move prox carpal row dorsally.
Stabilize radius/ulna.
Radiocarpal Palmar glide: procedure & promotes what motion?
Wrist flexion.
Move prox carpal row palmarly.
Stabilize radius/ulna.
Radiocarpal Radial glide: procedure & promotes what motion?
Ulnar Deviation.
Hand off edge of table, thumb up.
Stabilize radius/ulna.
Pull upward on prox carpal row (and slightly distally bc radial styloid in the way).
Radiocarpal Ulnar glide: procedure & promotes what motion?
Radial Deviation.
Hand off edge of table, thumb up.
Stabilize radius/ulna.
Push down on prox carpal row (and slightly distally bc ulnar styloid in the way).
Mid-Carpal Palmar Glide: procedure & promotes what motion?
Wrist extension.
Stabilize radius/ulna.
Push palmarly on distal carpal row.
Mid-Carpal Dorsal Glide: procedure & promotes what motion?
Wrist flexion.
Stabilize radius/ulna.
Push dorsally on distal carpal row.
Thumb CMC Radial Glide: procedure & promotes what motion?
Extension.
Hand positioned w/ thumb up.
Stabilize radius/ulna.
Glide 1st MCP towards radius.
Thumb CMC Ulnar Glide: procedure & promotes what motion?
Flexion.
Hand positioned w/ thumb up.
Stabilize radius/ulna.
Glide 1st MCP towards ulna.
Thumb CMC Palmar Glide: procedure & promotes what motion?
Adduction.
Hand positioned w/ palm down.
Stabilize radius/ulna.
Glide 1st MCP towards palm.
Thumb CMC Dorsal Glide: procedure & promotes what motion?
Abduction.
Hand positioned w/ palm down.
Stabilize radius/ulna.
Glide 1st MCP dorsally.
MCP & IP Dorsal Glide: procedure & promotes what motion?
Extension.
Stabilize proximal bone.
Glide distal bone dorsally.
MCP & IP Palmar Glide: procedure & promotes what motion?
Flexion.
Stabilize proximal bone.
Glide distal bone palmarly.
