Elbow, Wrist & Hand Flashcards
What are the red flags for elbow, hand and wrist pain?
Fracture
- trauma (including FOOSH)
- exquisite point tenderness
Infection:
- fever
- night sweats
- open wound / exposure to infection / underlying disease process / immunocompromised
Malignancy:
- over 50
- Hx malignancy
- unexplained weight loss
- failure to improve
- vomiting
CVD (DVT)
- unilateral UL oedema
- unilateral UL fatigue / heaviness
- unilateral UL discolouration
- visible veins
What are the signs of an upper limb DVT?
Unilateral:
- UL pain
- UL fatigue
- UL heaviness
- UL oedema
- UL discolouration
- visible veins
- SOB / dyspnoea
- palpitations / tachycardia
- fatigue
(systemic signs exacerbated by activity)
What are the signs of a fracture in the wrist, hand or elbow?
- traumatic onset (including FOOSH)
- sharp pain on impact
- oedema
- bruising
Exquisite point tenderness:
- over snuffbox (scaphoid)
- over distal radius (wrist)
- over elbow joint line (elbow)
What are the 4 serious conditions that need to be considered in elbow, wrist or hand pain?
DVT
Malignancy
Osteomyelitis
Fracture (carpals, wrist, elbow)
What are the 3 major soft tissue pathologies that need to be considered in elbow, wrist or hand pain?
De Quervain’s
Medial epicondylitis
Lateral epicondylitis
What are the major PROMs that can be used in a case of elbow, wrist or hand pain?
- DASH (disabilities of the arm, shoulder and hand) or Quick DASH
- UEFI (upper extremity functional index)
- BCTQ (Boston Carpal Tunnel Questionnaire)
What are 6 neurological conditions that need to be considered in elbow, wrist or hand pain?
Cx radiculopathy Thoracic outlet syndrome Median nerve neuropathy Radial nerve neuropathy Ulnar nerve neuropathy Carpal tunnel
What are the 4 hand signs that can be used to quickly screen for peripheral nerve function?
- Peace sign (ulnar)
- Thumbs up (radial)
- Fist (median)
- OK (median - anterior interosseous)
What are the 3 major bony injuries that can be caused by a FOOSH?
Scaphoid fracture
Distal radial fracture
Elbow dislocation
Describe the presentation of a scaphoid fracture including mechanism, pathology, presentation and prognosis
Mechanism: FOOSH
Pathology:
- fracture of scaphoid bone, can also cause necrosis of scaphoid by damaging arterial supply to bone
Presentation:
- deep, dull aching pain over snuffbox
- pain agg. by pinching, gripping, palpation over scaphoid
- oedema / bruising
Findings:
- increased pain with passive and active movements
- pain on palpation
- pain with grip
- decreased strength gripping / squeezing
Prognosis:
- referral for imaging
- surgical fixation and immobilization 6-12 weeks to avoid risk of scaphoid necrosis and achieve healing
- full recovery expected, can increase risk of OA
Describe the presentation of a distal radial fracture, including mechanism, pathology, findings, and prognosis
Mechanism:
- FOOSH
- sharp pain and maybe audible or tangible snap at onset
Pathology:
- fracture of distal radius
- Colle’s fracture (over-extension of wrist) or Smiths fracture (over flexion of wrist)
Presentation:
- visible deformity
- oedema / bruising
- sharp pain with wrist movement
- may have numbness or an inability to move hand
Findings:
- increased pain and decreased motion with passive and active wrist movements, esp. supination
- point tenderness at radial head
Prognosis:
- referral for imaging
- immobilization and fixation 6-12 weeks
- full recovery expected
Describe the condition of an elbow dislocation, including mechanism, pathology, presentation, findings and prognosis
Mechanism:
- FOOSH
- traumatic impact to elbow (valgus, varus, hyperextension)
Pathology:
- dislocation of humeroulnar and/or humeroradial joints
- can injure nerves and arteries passing around elbow joint
Presentation:
- sharp pain and popping sensation at onset
- visible deformity
- oedema / bruising
- pain with elbow movements and elbow palpation
- elbow instability
Findings:
- pain with elbow movements and palpation
- need to do peripheral CVD and UL neuro: may have vascular or neuro deficits if vessels around elbow injured (numbness, coldness, motor deficit)
Prognosis:
- immobilization for 1-3 weeks
- ligaments will not fully heal but return to function expected within 4-8 weeks
Which medical tests need to be conducted in a suspected elbow dislocation?
Peripheral vascular
UL neuro
(injury can damage nerves or blood vessels around elbow)
What are risk factors for De Quervain’s tenosynvitis?
- overuse of thumb abduction with radial deviation (racquet sports, golfing, phone use, musicians, office workers)
- previous injury
- arthritis
- pregnant or post-partum
Which tendons are affected in De Quervain’s tenosynovitis?
EPB (extensor pollicis brevis)
APL (abductor pollicis longus)
Describe the condition of De Quervain’s including mechanism, pathology, presentation, findings and prognosis
Mechanism:
- usually an overuse injury of the thumb caused by repetitive abduction and radial deviation (this compresses the EPB and APL tendons against the styloid process)
- can also be caused by trauma, scar formation, or inflammatory arthritis
Pathology:
- inflammation of EPB and APL tendons as they pass under the extensor retinaculum reduces space in tunnel, if untreated inflammation and progressive stenosis can cause permanent scarring
Presentation:
- pain over radial wrist
- insidious becoming constant
- agg by: thumb abduction, gripping, ulnar deviation
ADLs:
- difficulty gripping, lifting and twisting with hand
Findings:
- oedema at snuffbox
- pain at radial styloidi process
- decreased strength and increased pain in resisted isometric thumb abduction, thumb extension, grip and radial deviation
Tests:
- WHAT
- Finkelsteins
Prognosis:
- return to activity 4-6 weeks
- requires relative rest and may need splinting
Which 5 tendons attach to the common flexor origin at the medial epicondyle?
Flexor carpi radialis Pronator teres Palmaris longus Flexor carpi ulnaris Flexor digitorum superficialis (humeral head)
Which 4 tendons attach to the common extensor origin at the lateral epicondyle?
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor carpi ulnaris
Extensor digitorum
Describe the pathology of medial and lateral epicondylitis, and the findings and prognosis for each
Mechanism:
- chronic overuse of forearm flexors (medial) or extensors (lateral)
Risk factors:
- overuse at work or sport, manual professions, diabetes, heavy lifting
Pathology:
- inflammation of tendons can cause degeneration, and irreparable fibrosis, thickening and calcification if untreated
Presentation:
- insidious onset pain becoming persistent
- pain over medial or lateral epicondyle
Medial:
- pain agg. by wrist flexion, carrying, gripping
- decreased strength grip, wrist flexion, pronation
- decreased ROM elbow and forearm
Lateral:
- pain agg. by wrist extension, elbow extension
- decreased strength elbow extension, elbow flexion, finger grip, finger extension
- decreased ROM wrist flexion, ulnar deviation, pronation, finger extension
Prognosis:
- 90% have full recovery within 1 year non-surgically
- reduce inflammation 2 weeks - 4 months
- rehab and return to activity 2 weeks - 2 years
What are the healing timeframes and prognosis for lateral and medial epicondylitis?
- 90% achieve full recovery within 1 year non-surgically
- return to activity can take anywhere from 2 weeks to 2 years depending on degree of inflammation and tendon degeneration
What are the contents of the carpal tunnel?
Median nerve
4 x FDS tendons
4 x FDP tendons
1 x flexor pollicis longus tendon
What are the two most common sites of compression for the ulnar nerve, and which aspects of the hand does the ulnar nerve supply?
Compression sites:
- cubital tunnel (medial elbow)
- ulnar tunnel (Guyon’s canal, medial wrist)
Cutaneous hand:
- medial one and a half digits and corresponding area of skin over hand (hypothenar eminence and same area dorsally)
Motor:
- flexor carpi ulnaris
- flexor digitorum profundus (medial half)
- intrinsic muscles of hand (except thenar mm and 2 lateral lumbricals)
What are the 3 most common sites for median nerve compression, and what is the motor and cutaneous supply of the motor nerve?
Compression sites:
- carpal tunnel
- between two heads of pronator teres
- anterior interosseous compartment
Cutaneous:
- palmar surface of hand, except lateral one and a half digits and corresponding area of palm / dorsum
- dorsal tips of digits 1-3
Motor:
- anterior forearm (except FCU and median half of FDP)
- thenar mm and lateral 2 lumbricals
What is the most common site of compression for the radial nerve, and what is the motor and cutaneous supply of the radial nerve?
Compression:
- radial tunnel (anterior to proximal radius, between heads of supinator)
- compression of posterior interosseous branch only
Motor:
- posterior forearm
Cutaneous:
- dorsal surface digits 1-3 (except tips)
Which peripheral nerves supply cutaneous innervation to which areas of the hand?
Ulnar:
- lateral one and a half digits and corresponding areas of skin (palmar and dorsal)
Median:
- palmar surface (except hypothenar eminence and medial one and a half digits)
- dorsal tips of digits 1-3
Radial:
- dorsum of hand (except medial one and a half digits and corresponding area of skin, and tips of digits 1-3)
Which peripheral nerves provide motor innervation to the forearm and hand?
Radial:
- posterior forearm
- dorsum of hand
Ulnar:
- FCU and medial half of FDP
- intrinsic hand mm (except thenar and lateral 2 lumbricals)
Median:
- anterior forearm (except FCU and medial half of FDP)
- thenar mm
- lateral 2 lumbricals
Describe the conditions of ulnar nerve compression including mechanism, pathology, presentation, findings and prognosis
Mechanism:
- cubital tunnel compression can b caused by leaning on elbow for prolonged periods, inflammation or bursitis in elbow or elbow trauma
- Guyon’s canal compression can be caused by leaning on wrist for prolonged periods (ie: typing), compression caused by inflammation (arthritis, diabetes, pregnancy), cyst or dislocation
Pathology:
- compression of ulnar nerve at the cubital tunnel (elbow) or Guyon’s canal (wrist)
Findings:
- sensory deficit / paraesthesia digits 4-5 and skin over hypothenar eminence and corresponding area of dorsum
- atrophy intrinsic mm hand / hypothenar eminence
- ‘claw’ posture dig 4-5
Tests:
- ULNT3
- Tinel’s
Prognosis:
- 90% have SSX resolution in 2-3 months without surgery
- relative rest and may need splinting
Describe the conditions of carpal tunnel syndrome, pronator teres syndrome and anterior interosseous syndrome including mechanism, pathology, presentation, findings and how to differentiate between the conditions, and prognosis
Pathology:
- compression of the median nerve in the carpal tunnel, between the heads of the pronator teres in the forearm, or in the anterior interosseous compartment of the forearm
Mechanism:
- carpal tunnel: overuse and associated hypertrophy / inflammation of tendons in the carpal tunnel (FDP, FDS and flexor pollicis longus)
- pronator teres syndrome: overuse and associated hypertrophy of pronator teres (weight lifting, gripping, medial epicondylitis)
- anterior interossous syndrome: often secondary to elbow dislocation / fracture or biceps tendon bursitis
Differentiating:
- if sensory deficits present: carpal tunnel or pronator teres (not anterior interosseous)
- carpal tunnel: sensory in digits 1-3 only
- pronator teres: sensory in digits 1-3 and thenar eminence
Motor:
- clumsiness / weakness / difficulty with fine movements in thumb and fingers (all)
- pain resisted pronation (pronator teres only)
- can’t form OK sign (anterior interosseous only)
- positive pinch test (anterior interossous only)
Tests:
- carpal compression
- Tinel’s
- ULNT1
- Phalen’s
Prognosis:
- 90% have resolution non-surgically within 2-3 months and return to activity within 4-6 weeks
How can you differentiate between compression of the median nerve at the carpal tunnel, in pronator teres syndrome, and in anterior interossous syndrome?
Anterior interosseous:
- motor only (no sensory)
- can’t form OK sign
- positive pinch test
Carpal tunnel:
- sensory in digits 1-3 but not thenar eminence
- positive carpal compression test
Pronator Teres:
- sensory in digits 1-3 and thenar eminence
- increased pain isometric resisted pronation
Describe the presentation of radial tunnel syndrome including pathology, mechanism, presentation, findings and prognosis
Pathology:
- compression of anterior interossous nerve in radial tunnel (between heads of supinator)
Mechanism:
- overuse of supinator mm, inflammation or trauma
Presentation:
- lateral elbow pain (dull, aching)
- agg by: elbow and wrist extension, elbow traction, forearm pronation, wrist flexion, finger extension
Findings:
- paraesthesia digits 1-3
- decreased strength finger extension, wrist extension, thumb abduction, grip
- altered triceps and brachioradialis reflexes
- tenderness over supinator
- pain with wrist flexion, resisted pronation, resisted supination, resisted extension dig 3
Tests:
- Cozens
- ULNT2
- Tinels (supinator)
Prognosis:
- resolution in 3 months
Which nerve roots are tested in the biceps, triceps and brachioradialis reflexes?
Biceps and brachioradialis C5-6
Triceps C7-8
