Elbow, Wrist, Hand Flashcards
Treatment for a proximal vs. a distal biceps rupture
proximal may be therapeutic but distal is an orthopedic urgency
what is the role of long head of the biceps in the shoulder
it may contribute to anterior stability but it is also a common source of anterior shoulder pain
tenodesis
release the tendon and reattach
tenotomy
release the tendon and let it fall
in what cases would you want to do a tenodesis of the long head of the biceps over a tenotomy
manual labor and those in overhead athletics may want a tenodesis for improved supination strength and less cramping
otherwise best to do a tenotomy
T or F: a proximal biceps rupture may be therapeutic
T: sometimes it feels better after
SLAP lesion
superior labrum anterior to posterior
4 types of slap lesion procedures
repair, debridement, tenodesis, tenotomy
T or F: many slap tears are no longer repaired because they end up having pain after
T
T or F: recent evidence shows that their is no benefit to repair a SLAP lesion vs. doing a biceps tenodesis
T: much easier rehab with biceps tenodesis!
what is used to classify slap lesions? How many types of lesions are there?
snyder classification, 4 different types
special tests for slap lesions
active compression, speeds
T or F: slap lesions are usually an isolated injury
F: they are rarely seen in isolation
A trial of ______ can be helpful with SLAP to identify the source of symptoms
injection
*diagnosis is difficult
SLAP lesion postoperative management
period of immobilization, prevent stiff shoulder, progress based on impairments and healing
For both SLAP repair and biceps tenodesis you are typically in a sling for how long
2-4 weeks
which one can you start immediate passive motion with… biceps tenodesis or SLAP repair?
- biceps tenodesis
- SLAP repair has motion restriction for 4-6 weeks
people with biceps tenodesis can return to sport in about ____ months while those with SLAP repair take _____ months
3
6
what often causes a distal biceps rupture
unexpected eccentric load (tailgate drops and you catch with one hand)
what age are distal biceps ruptures most typical in?
40-60 year olds
special tests for distal biceps rupture
hook test
why is early surgical repair advocated for distal biceps rupture
because the tendon will retract
*inferior outcomes if delayed by >4 weeks
what pt population may not have surgery for distal biceps rupture?
older pt with co-morbidities
what movements do you want to avoid for 2-3 weeks after distal biceps repair?
full extension and hard supination
- starts with a period of immobilization and then several weeks of controlled motion in a brace
typically, pts with distal biceps repair have full motion by _____ to ____ weeks and can return to work fully in _____ to ______ months
6-8 weeks
2-4 months
what is the second most common dislocated joint? what way is it usually dislocated?
elbow, posterior lateral (named for position of ulna)
what is the most common MOI for an elbow dislocation?
hyperextension of elbow
simple elbow dislocation
- no fracture
- dislocation, brace, immediate rehab
- can return to sport in weeks
complex elbow dislocation
- often unstable, may involve a fracture
- controlled motion when cleared by ortho
- surgical fixation allows for early motion
terrible triad of the elbow
elbow dislocation, radial head fx, coronoid fx
** requires surgery
why is the elbow so susceptible to stiffness?
- congruity of humeroulnar articulation
- three joints in one capsule
- blending of ligaments with the capsule
capsular pattern of the elbow - what motion do you lose more of?
flexion > extension
how much elbow motion do you need for ADLs?
- 100 degree arc - extension/flexion 30-130
- 50 degree rotation - 50 pronation, 50 supination
the ulnar collateral ligament gives you ______ stability
valgus
two bands of the UCL
anterior - tight in extension, lax in flexion
posterior - tight in flexion, lax in extension
which band of the UCL gives you the most valgus resistance
anterior
what populations are UCL injuries common in
overhead throwers and athletes, gymnastics, wrestling
2 types of UCL injury
attenuation or acute traumatic
T or F: an attenuation UCL injury will not tighten or heal w/o surgery
T: but an acute could!
Is rehab appropriate for UCL injuries
a non-operative trial is appropriate for most
what was the first surgery for a UCL injury
Tommy John Surgery
T or F: all risk factors for UCL injuries are modifiable
T: decrease pitch counts/pitching time!
*this is usually a parent/player issue
Hip_____ rotation deficits and decreased rotator cuff and core strength are risk factors for UCL injury
internal
What is a major issue sometimes seen in Tommy John surgeries?
mistaking the median nerve for the palmaris longus and using it for the graft
are most athletes able to return to sport after a UCL injury
yes, but this does not always mean a return to prior level of function
how long should players wait after a UCL repair to return to full throwing
10-18 months
lateral epicondylitis causes pain with what motions? what about medial epicondylitis?
lateral = pain with extension and supination
medial = pain with flexion and pronation
epicondylitis is common in what decades
4th and 5th
what muscle is affected in lateral epicondylitis
extensor carpi radialis brevis
what kind of exercise is good for chronic (tendinosis) epicondylitis
eccentric
T or F: there is good evidence for forearm support band for epicondylitis
F: limited evidence
special tests for lateral epicondylitis
cozens
mills
maudsley
where does the ulnar nerve often become entrapped? (2) where does it cause pain?
cubital tunnel, guyon’s canal
medial elbow pain
where does the median nerve often become entrapped? (3)
where does it cause pain
pronator teres, FDS, carpal tunnel
aching pain and weakness in forearm
where does the radial nerve often become entrapped? where does it cause pain?
posterior interosseous nerve within radial tunnel
lateral elbow and supinator pain
special test for nerve entrapment
tinel’s
whis is the 2nd most common compressive US neuropathy
cubital tunnel syndrome
why is night splinting often important for cubital tunnel syndrome?
the cubital tunnel narrows during elbow flexion so keeping the arm straight at night can help decrease the pressure
non-operative treatment for cubital tunnel
ergonomic changes, compliance with night splinting, activity mods
what can cubital tunnel turn into chronically?
claw deformity
*continue monitoring for neuro worsening/motor involvement
T or F: cubital tunnel is highly associated with throwing and UCL injury
T
Gunyon’s canal
hook of hamate and pisiform
Compression of the ulnar nerve at Gunyon’s canal is common in
cyclists (handlebar palsy)
how to distinguish between compression in the cubital tunnel and compression in the gunyon’s canal
test the flexor capri ulnaris (most proximal innervation of ulnar nerve)
special tests for ulnar neuropathy
froment’s sign (loss of adductor pollicis)
wartenberg’s sign (unapposed 5th digit)
tinnels sign
pressure provocation test
elbow flexion test
what nerve is froment’s sign testing?
ulnar nerve - tests adductor pollicis (flexor pollicis longus innervated by AIN compensates on positive test)
median nerve roots
C5-T1
what often causes median nerve compression
repetitive forearm movements (carpenter, mechanic, tennis, baseball)
What is the most common entrapment site for the median nerve
carpal tunnel
where does pronator syndrome cause numbness
first 3 digits
how to differentiate between pronator syndrome and carpal tunnel syndrome
with carpal tunnel, the palmar cutaneous branch is spared and you have forearm pain
T or F: anterior interosseous nerve compression is a motor only palsy
T
Two signs/symptoms of anterior interosseous nerve compression
1) pronator quadratus weakness
2) inability to flex thumb IP joint (OK sign)
radial nerve roots
C5-C8, T1
what fracture may sacrifice the radial nerve?
humeral shaft
is there motor or sensory loss with radial tunnel syndrome
no – it is a painful condition but no motor or sensory losses
is there motor or sensory loss with PIN compression
yes, significant motor loss
provocation ttests for radial runnel
1 - resisted supination
2 - resisted wrist ext
3 - middle finger extension
4 - elbow extension, pronation, wrist flexion (stretching it)
what is the common site of compression for the PIN
arcade of frohse
what movement is weak with PIN entrapment
- weakness of thumb and finger extension
- radial deviation during extension
what is the only wrist extensor innervated by pure radial nerve (not PIN)
extensor carpi radialis longus (this is why you radially deviate during extension if you have PIN entrapment)
what surgical procedure can lead to PIN syndrome
distal biceps repain
do you know you extensor compartments?
YES
ulnar nerve proximal and distal innervation
proximal = FCU
distal = intrinsic hand
median nerve proximal and distal innervation
proximal = pronator teres
distal = lumbricals 1st and 2nd
radial nerve proximal and distal innervations
proximal = triceps
distal = extensor indicis
functionally, impairment of the ulnar nerve will lead to difficulties with what tasks? what about median nerve?
ulnar = fine motor
median = pronation
what is the most common compressive neuropathy
carpal tunnel syndrome
what can cause carpal tunnel syndrome
repetitive wrist motions, pregnancy, DM, RA
symptoms of carpal tunnel
- intermittent noctural parestheis
- progression to thenar weakness and atrophy
special tests for carpal tunnel
tinel and phalen
carpal tunnel treatment
activity modification, education, splinting, impairment based rehab
what are 3 things that can cause radial sided wrist pain
scaphoid fracture
scapholunate dissociation
radial sided tendinopathies
what are three things that could cause ulnar sided wrist pain
ECU injury/tendinopathy
TFCC injury
ulnar abutment
claw hand deformity
- ulnar nerve
- hyperextension at MCP and hyperflexion at IP
ape hand
- median nerve injury
- thenar muscles atrophy so you have unopposed adductor pollicis
sign of benefiction
- only appears actively
- when trying to make a fist digits 4 and 5 can close (ulnar innervated) but not the first three digits
most commonly injured carpal bone
scaphoid
where do you have tenderness with a scaphoid fracture
anatomical snuff box
what is a major concern with a scaphoid fracture
risk of avascular necrosis due to retrograde blood supply
due to retrograde blood supply, do to proximal or distal pole scaphoid fractures heal better
distal
what kind of splint for radial sided wrist pain
thumb spica
why should you always treat scaphoid pain as a fracture
because the fracture is not always visible on plain films
*CT or MRI may be needed if films are normal
with a scapholunate injury, if the films are normal treat it as a
sprain
triangular fibrocartilage complex (TFCC)
supports distal radioulnar joint with gripping and rotating
special test for scapholunate
watson
s
kienbock’s disease
- avascular necrosis of the lunate
- unknown cause
- pain, swelling, stiffness
special test for sequervain’s
finkelstein’s test
dequervain’s tenosynovitis involves what muscles
1st extensor compartment
- abductor pollicis longus and extensor pollicis brevis
intersection syndrome is a repetitive use injury involving what muscles
1st and 2nd extensor compartments
- abductor pollicis longus, extensor pollicis brevis, extensor carpi radialis longus and brevis
management of TFCC
- period of immobilization
- NSAIDs
- cortisone injections
- surgical options
ulnar abutment syndrome
- puts more force on the ulnocarpal and increases incidence of ulnar sided wrist pain
- could be related TFCC injury
- manage same as TFCC
boutonniere deformity
- central slip injury
- flexion of PIP and hyperextension of DIP joint
what are the four forearm fractures
1 - colles - distal radius - FOOSH
2 - smith - distal radius (fall on flexed wrist)
3 - barton - intra-articular distal radius (MVA, sports, falls, osteoporosis)
4 - monteggia fracture - proximal 1/3 of ulnar, radial head dislocation (FOOSH with pronation)
what is the most common forearm fracture
distal radius
gamekeeper’s thumb
UCL injury of thumb
pain and swelling along 1st MCP
how is a boutonniere deformity (central slip) splinted
PIP in full extension, DIP free to move
jersey finger
forceful hyperextension of the DIP joint
do jersey fingers need surgery
yes
how to eval a jersey finger
hold PIP and ask for DIP flexion
mallet finger
forceful flexion of the extended DIP joint
- extensor hood rupture
how is the finger splinted in mallet finger
DIP in full extension
swan neck deformity
hyperextension of PIP
what kind of splint for swan neck deformity
double ring
what hand deformities do you see with RA? OA?
RA = ulnar deviation and swan neck
OA = herberden’s nodes
what is dupuytren’s contracture
palmar fascia contracture
- not really a role for PT
T or F: if someone had a flexor tendon repair, immediate passive ROM is important to encourage lack of adhesions
T: you need early protected motion within 3-5 days
*passive flexion is important
how many annular flexor tendon pulleys? how many cruciate?
5 annular
3 cruciate
tendons have poor _______ healing capacity
intrinsic
what can you wear to help with trigger finger
night splint
