Elbow/Wrist/Hand Flashcards
Dorsal wrist Compartments
1) EPB AbPL
2) ECRB/ECRL
3) EPL
4) EDC/EDI
5) EDM
6) ECU
DeQuervain’s Tenosinovitis
*Most Common
Dx: (+ pain) Finkelstein *test Bilat.
Effects the 1st dorsal compartment (EPB/AbPL)
Tx: Rest with thumb spica to allow IP to move, steroids can also be effective if rest doesn’t help
Intersection Syndrome
*Also called texter’s or gamekeeper’s thumb
Effects 1st and 2nd dorsal compartments (AbPL/EPB and ECRB/ECRL)
Dx: Pain with wrist extension and thumb circumduction
TTx: Rest, Splint, NSAIDS
ECU subluxation
Consider in DDx of ulnar side wrist pain
Caused by traumatic UD and wrist flexion rupturing tendon sheath
Dx: ECU tendon subluxes with UD while in full supination
Tx: Cast in Pronation/Ext for 6 weeks
ECU tendonitis
2nd most common, occurs in racquet sports from overuse and trauma
*Associated with injury to TFCC
Tx:Rest, splint, NSAIDs, injections
MCP UCL rupture
Loss of Thumb pinch grip
MOI: “Skier’s thumb” rupture or “Gamekeeper’s thumb” laxity (microtrauma)
Dx: Valgus stress test (+ if >15 deg of uninvolved or >35 deg)
XR if Stener lesion suspected (non-healing avulsion fx)
Volar Plate Avulsion
MOI:Common in ball sports
Keep’s finger from hyperextension (normal flexion ROM approx. 110 deg @ PIP)
XR if swelling/pain in palmar PIP
FDB Avulsion “Jersey Finger”
4th finger is most common
MOI: Forced extension while trying to flex at DIP
Unable to make a fully closed fist due to lost DIP flx
Tx: Surgery referral
Bennett Fx
1st MCP fx (Most Common MC Fx)
MOI: Fall on Flexed Thumb
Avulsion Fx medially by APL tendon
Scaphoid Fx
TTP anatomical snuff box
(+) Watson’s test (Axial Thumb Load)
If Radial wrist pain with extension suspect fracture and may require CT scan to confirm
MOI is fall backward on to hand
Hook of Hamate Fx
MOI: Shearing from 4/5 flexor tendons
Dx: Made by CT/Bone Scan
Might present with ulnar neuropathy (Close to Guyon’s tunnel)
Tx:Surgical excision is most effective
Criteria to Dx a wrist Fx
Pain with gripping
Pain with supination
Pain with A/PROM wrist extension
Local tenderness/edema
Pisiform Fx
MOI: Direct blow or Racquet sport
Tx: Surgical Excision
Lunate Fx
*Rare, Kienbock’s disease (Lunate AVN)
Dec. Grip strength
Dx: MRI
Microtrauma
Distal Radius Fx (3 types)
Colles' Fx (Dorsal displacement) Smith Fx (Volar displacement) Barton Fx (Intra-articular fx, dorsal or volar dislocation)
Most common Fx seen in ED
Very Common and present with “dinner fork” deformity
*Important to examine the Median N.
Tx: Closed Reduction with splint followed by cast
Wrist Ligament injuries
Scapholunate (Most Common), MOI: FOOSH on pronated hand (wrist ext/UD), Dx: Stress view XR (Fist)
Lunotriquetral, MOI: FOOSH with wrist in ext/RD
Midcarpal instability (often Bilat.) Dx: XR, Tx: Splint immobilization
Carpal Dislocation, MOI: Collision sports and usually affects the scapholunate joint. Tx: Surgery
DRUJ injuries
Involved the TFCC which is main stabilizer (especially when wrist is in pronation)
MOI: FOOSH or tensile overuse (traction force)
Dx: Piano Key sign, Press Test (Use hands to stand up), hypermobility at DRUJ
Boxer’s Fx
MOI: Fracture of MC shaft/head from direct trauma
Tx: Splinting
Mallet Finger
Distal extensor tendon avulsion
MOI: rapid forced flexion of finger (ball hits finger tip)
Tx: Splint in full extension
CPR for Hand OA (4+/5)
Hand pain, ache, stiffness
Hard tissue enlargement of 2 or more joints (CMC, 2nd/3rd PIP/DIP)
Swan-neck deformity
DIP flexed and PIP hyperextends
will require surgery
Association with RA
Boutonniere deformity
DIP hyperextended
PIP flexed
Responds well to splinting and exercise
Trigger Finger
Usually involves the A1 pulley
Pronator Teres Syndrome
Volar forearm pain
Sensory neuropathy of thumb and 2,3, 1/2 of 4th finger on palmar surface
Weak thumb, index and middle fingers
(-) compression at pronator border
PT is spared
Carpal Tunnel Syndrome
Entrapment of Median N. in the flexor retinaculum
Presents with numbness and paraesthesia in finger tips of median nerve distribution, nocturnal paraesthesia
MOI: repetitive wrist flexion (i.e. typing, forceful gripping)
Thenar Atrophy
*R/O peripheral neuropathy in alcoholics, renal disease and DM
Cubital Tunnel Syndrome
Entrapment of Ulnar N. at cubital tunnel or arcade of struthers
Froment’s sign (+) unable to maintain key grip due to weakness of the AddPB and FPB, uses FPL instead (AIN innervation)
(+) Wartenberg’s sign (unable to adduct pinky)
(+) Ulnar Nerve compression test
(+) Elbow flexion test (AROM held for 60 sec) excellent test to R/I, moderate to R/O
Nerve Injuries
Neuropraxia (compression or strain injury which heals between a few days and a few months, great prognosis)
Axonotmesis (crush or traction injury which takes longer to heal, 1mm per day or 1” per month)
Neurotmesis (nerve transection, poor healing and requires surgery)
*Ventral Root is motor, Dorsal Root is sensory
Ulnar Nerve Palsy (C8-T1)
Entrapped at Pec. Minor, Cubital Tunnel or Guyon’s tunnel
Hypothenar atrophy
Volkmann’s Ischemia
Compartment syndrome characterized by: Palor Pulselessness Paresthesia Pain Pain with passive stretch
Radial Nerve Palsy (C5-C8)
Drop Arm caused by compression of the Radial Nerve
MOI: Honeymooner’s palsy, Saturday Night Palsy, fracture through the radial groove
Proximal injury: Crutch Palsy, Humeral shaft fracture
Distal injuries at arcade of frohse will effect the PIN (no sensory involvement)
Musculocutaneous Nerve (C5-C7)
Biceps, Brachialis, Coracobrachialis
Ant.Lat. arm cutaneous sensation
Dupuytren Disease
Fibrosis of the palmar aponeurosis
Presents as flexion contractures of the MP and PIP joints
DRUJ Fx
Essex-Lopresti Fx (Radial head Dx, DRUJ dislocation) Galeazzi Fx (Distal 1/3 radius, DRUJ dislocation)
AIN syndrome (FDP, FDL, PQ)
Inability to make the “OK sign”, weak FPL and FDP (lateral 2)
NO sensory loss
PIN syndrome
Lateral forearm/elbow pain
Wrist extension with radial deviation (ECU weakness)
Weakness of the finger extensors
Thumb extension elicits pain at lateral epicondyle
NO sensory loss
CRPS
Hyperaesthesia Sudomotor changes Allodynia Inc. temperature Redness
Guyon’s tunnel
Entrapment sites proximal (sensory and motor), distal to ulnar tunnel (sensory), between ADM and FDM (motor only)
Wartenberg Syndrome
Causes pain and paraesthesia along the lateral dorsum of the hand usually from tight casting
Claw deformities
Median Nerve (Ape Hand: unable to make a oppose thumb, or flex 2nd/3rd fingers due to loss of DFP and lumbricals) Ulnar Nerve (unable to extend the 4th/5th digits due to loss of IO)
UCL injury
Moving valgus test 70-120 deg (excellent to R/O)
Valgus stress test at 25 deg
TTP at ant. UCL
Lateral epicepicondylitis
ECRB test
Dec. grip strength (wrist extension required for strong gripping)
TTP anterior epicondyle
Tx: responds well to dorsal to volar HVLA at the wrist
Always R/O C2-C7 involvement
MWM also effective
Counter-force brace good for pain-free grip
P.T. > injection early on due to tendency to return to activity too soon after injection due to immediate relief
Radial Tunnel Syndrome
Painless weakness through the EPL, EDM, supinator
Normal grip strength
76 lbs. +/- 13 lbs. for setting goals (1N = .22 lbs)
Medial Epicondylalgia
Weak flexors and pronators but grip strength not usually affected
CPR for CTS (4+/5)
Age > 45
Shaking hands relieves symptoms
Wrist Ratio index > .67 (wrist width A/P divided by M/L)
Reduced median sensory field 1st digit (thumb sensation vs. thenar eminence)
Symptom severity scale >1.9
Tendon glides
5 steps into making a fist:
Straight, hook, fist, tabletop, straight fist
Nerve glides
6 steps into opening the hand followed by the thumb
Wartenberg’s sign
Inability to Abduct 5th digit after finger have been passively spread (IO weakness)
Martin-Gruber Anastomosis
Ulnar nerve to median nerve allows for funky patterns of regeneration as well as altered symptom distribution
Axillary Nerve Palsy
Deltoid weakness and Teres Minor weakness caused by dislocation or surgical neck fracture
LTN Palsy
Backpacker’s palsy, scapular winging due to SA weakness
CNXI Palsy
Shoulder Sag due to trap weakness
Carpal Bones (Radial to Ulnar)
*Some Lovers Try Positions That They Can’t Handle
Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate
Lig. of Struther’s syndrome
PT Syndrome + PT Involvement (sensory and motor)
