Elbow, Wrist, Hand Conditions (Week 3--Module and Pham Lecture)

Question 1

Elbow, wrist, hand conditions

Answer 1

Bones: supracondylar fracture, ulnar shaft fracture, radial head dislocation (Monteggia), radial head fracture, greenstick fracture, torus fracture of radius, Colles’ fracture, scaphoid fracture, metacarpal #5 angulated neck fracture, phalanx growth plate injury, distal phalanx fracture

Joints: nursemaid’s elbow, wrist and hand RA, hand OA, scapholunate dissociation

Muscles/tendons: medial epicondylitis, lateral epicondylitis, olecranon bursitis, DeQuervain tenosynovitis, trigger finger

Nerves/vessels: carpal tunnel syndrome, cubital tunnel syndrome, radial tunnel syndrome, guyon tunnel syndrome

Question 2

Supracondylar fracture

Answer 2

Fracture of distal humerus just proximal to epicondyles (at supracondylar line) but extends distally

Most common and potentially most serious fractures in children; highest incidence of neurovascular problems (median, ulnar, radial nerve inuries, maybe brachial artery causing ischemia or compartment syndrome, Volkmann ischemic contracture (when muscles scars))

Caused by fall on outstretched hand with elbow in hyperextension

Question 3

Ulnar shaft fracture

Answer 3

When forearm struck with object, called “nightstick fracture” or parry fracture

Transverse and nondisplaced

Question 4

Radial head dislocation (Monteggia fracture-dislocation)

Answer 4

Fracture to proximal third of ulna and associated anterior dislocation of radial head within proximal radioulnar joint (Monteggia)

Need to x-ray elbow if you have a fracture of a long bone to see if dislocation is present

Caused by fall on outstretched hand with forearm in excessive pronation

Question 5

Radial head fracture

Answer 5

Fall on outstretched arms causes force of impact transmitted to radial head which is pressed into capitulum of humerus

On x-ray, can see displaced posterior fat pad which indicates hemarthrosis and high probability of fracture if there has been trauma (fracture itself is really hard to see!)

Question 6

Greenstick fracture

Answer 6

Cortex of bone on one side fractures but cortex of bone on other side just bends and doesn’t break

Happens in kids because bones are supple/easily bent

Usually occurs from quick twisting motion accompanied by axial compression (fall backwards on outstretched hands)

Question 7

Torus fracture of radius

Answer 7

Bending of bone results in raised buckle without fracturing on the other side

Common in kids because bones are supple/easily bent, but very rare in adults

Can occur in any long bone but distal radius is most common site

Question 8

Colles’ fracture

Answer 8

Fracture of distal radius where there is posterior displacement, angulation and rotation of distal fragment

More than 50% accompanied by fracture of ulnar styloid process

Common in older adults (>50), and usually occurs when person attempts to break fall by throwing hands in front of them

X-ray to diagnose

Management: NSAIDs, opioids, splinting/casting if good alignment of fracture, and closed/open reduction with internal/external fixation

Question 9

Scaphoid fracture

Answer 9

Most frequently fractured carpal bone; 80% occur in waist of scaphoid bone

Not uncommon for bones not to come together again, or to be delayed; this can cause avascular necrosis of proximal fragment because most of blood supply to distal half of bone (high risk of non-union or avascular necrosis if left untreated)

Happens when person tries to break fall by throwing hands in front of them

Scaphoid bone is floor of anatomical snuff box

Easy to miss because no bruising so people think its just a sprain, also x-ray may be normal; if tenderness over snuff box or volar aspect of wrist at distal wrist crease, suspect scaphoid fracture

NSAIDs, analgesics, thumb spica splint, surgery if fracture displaced >1mm or fracture/dislocation

Question 10

Metacarpal #5 angulated neck fracture

Answer 10

“Boxer’s fracture” even though professional boxers rarely sustain this injury

5th metacarpal moves toward palm, forcing MCP joint into hyperextension and collateral ligaments become slack

Question 11

Phalanx growth plate injury

Answer 11

Salter Harris fracture of the phalanx, most common location for growth plate injury (radius is next)

Growth plate injuries usually caused by acute event but can also result from overuse (gymnasts!)

Can have negative outcomes

Question 12

Distal phalanx fracture

Answer 12

Intra-articular fracture of distal phalanx associated with extensor tendon injury (dorsal) or flexor tendon injury (volar)

Commonly sport injury due to forced flexion of DIP which puts tension on extensor tendon and results in avulsion of dorsal proximal margin of distal phalanx (that tiny piece of bone avulsed and seen on dorsal part of joint!)

Question 13

Nursemaid’s elbow

Answer 13

Pathophysiology: partial dislocation of proximal radioulnar joint which causes annular ligament to slide over head of radius into joint space and be entrapped; occurs when traction of the arm while elbow in extension (kids 1-3 years old being swung by arms)

Clinical presentation: pain increased with elbow movement, elbow held in slight flexion, no swelling, limited ROM, tenderness, x-rays usually normal

Management/prognosis: reduce joint dislocation (support radial head, supinate and flex forearm at same time until hear or feel a click); can have recurrence but no long-term consequences

Question 14

Hand RA

Answer 14

Pathophysiology: usually affects MCP, PIP joints, and thumb interphalangeal; inflamed synovium damages flexor/extensor tendons in hand and causes deformities (ulnar deviation at MCP, swan-neck, bounonniere); joint fusion in advanced stages

Clinical presentation: local pain in hand/fingers, gradual onset before deformity, constant deep aching and throbbing pain in joints, pain increases with movements (limited ROM), symmetric swelling, warmth and morning stiffness, rheumatoid nodules, fatigue, weight loss, do x-ray to diagnose (will see erosions and joint destruction)

Management/prognosis: NSAIDs, antirheumatic agents, ice, splints, self-help devices for at home/work, corticosteroid injection for pain, surgery; progressive disease

Question 15

Hand OA

Answer 15

Pathophysiology: osteoarthritis (degenerative joint disease) involves PIP, DIP, CMC joints, develop bony deformity and nodules at PIP (Bouchard’s nodes) and DIP (Heberden’s nodes)

Clinical presentation: localized pain at base of thumb or over PIP and DIP joints, gradual onset, pain increases with movement and decreases with rest and heat/ice, stiffness and swelling (difficulty gripping), do x-ray to diagnose (non-uniform joint space narrowing, bone sclerosis, osteophytes)

Management/prognosis: NSAIDs, hand therapy (paraffin wax, contrast baths), protective splinting, adaptive equipments, corticosteroid injections for pain; progressive disease

Question 16

Scapholunate dissociation

Answer 16

Pathophysiology: tear of intercarpal ligaments of lunate, scaphoid, capitate bones; most common carpal instability; abnormal movement of carpal bones and unstable wrist causes early OA of wrist

Clinical presentation: wrist pain/discomfort over scapulo-lunate junction, can be acute or gradual, intermittent then constant pain, weak grip and swelling, clicking with some movements, limited ROM especially flexion/extension, gap between scaphoid and lunate bones >2mm on x-ray

Management/prognosis: NSAIDs, immobilization, surgery; most patients improve with treatment but gradual loss in ROM despite surgical intervention

Question 17

Medial epicondylitis

Answer 17

Pathophysiology: “Golfer’s elbow” overuse or improper mechanics of wrist flexors and/or pronators of radioulnar joint; common flexor tendon insertion at medial epicondyle inflamed (medial and anterior)

Clinical presentation: gradual increasing pain over medial epicondyle radiating into forearm, pain increases with lifting and wrist flexion and pain decreases with rest, no swelling, active ROM may be limited due to pain, tender over medial epicondyle, resisted wrist flexion and pronation reproduce pain, sometimes passive wrist extension with elbow extended will illicit pain, normal x-ray unless tendon calcification from healing

Management/prognosis: NSAIDs, stop activity causing injury, ice daily, counterforce brace to distribute tension, splint, corticosteroid injection, PT, surgery is rare and only after conservative tx fails after 6-12 months; normally resolve with conservative treatment

Question 18

Lateral epicondylitis

Answer 18

Pathophysiology: “Tennis elbow” result of overuse or improper mechanics of wrist extensors and/or supinator muscles of proximal radioulnar joint, common extensor tendon that inserts at lateral epicondyle gets inflamed; extensor carpi radialis brevis muscle tendon (smallest guy!) is most involved (lateral and posterior)

Clinical presentation: gradual, increasing aching pain over lateral epicondyle (and distal to it, over extensor carpi radialis brevis), pain increases with lifting or wrist motion (wrist extension) and decreases with rest, no swelling, active ROM limited due to pain, resisted wrist extension (third finger extension with elbow extended) or supination and passive stretching reproduces pain, normal x-ray unless tendon calcification from healing

Management/prognosis: NSAIDs, stop activity causing injury, ice daily (after activity), counterforce brace to distribute tension, splint, passive stretching, PT, corticosteroid injection, surgery is rare and only if conservative tx fails after 6-12 months; normally resolve with conservative treatment

Question 19

Olecranon bursitis

Answer 19

Pathophysiology: swelling of olecranon bursa (between olecranon process of ulna and the skin) on posterior elbow, due to acute or repetitive trauma (resting elbows on desk while studying), could be due to infection or systemic disease (gout, RA)

Clinical presentation: gradual onset with moderate to severe pain with any pressure or elbow motion, if acute, sharp pain may radiate to posterior forearm, pain decreases if elbow rested, soft tissue over olecranon may have swelling or be erythematous

Management/prognosis: NSAIDs, PRICE, aspiration to relieve pain or rule out septic bursitis; most recover spontaneously

Question 20

DeQuervain tenosynovitis

Answer 20

Pathophysiology: inflammation of extensor pollicis brevis and abductor pollicis longus (SEx LAb) tendon sheaths on radial side of wrist, due to repetitive or cumulative trauma to tendons from repeated extension and abduction of the thumb, when tendon sheath heals it produces dense fibrous tissue that thickens tendon sheath and tendons are obstructed as they attempt to move within tendon sheath; is often confused with OA of CMC joint of the thumb

Clinical presentation: pain on radial side of wrist over styloid process and CMC joint of thumb, pain moderate and throbbing/aching superimposed with sharp pain with thumb movements, pain increases with pinching, grasping, making fists, stretching, and decreases with rest/heat/ice, have swelling and limined ROM in thumb and wrist, crepitus palpable on flexion/extension of thumb, Finkelstein’s test, do x-ray to rule out OA

Management/prognosis: NSAIDs, rest, avoid repetitive motions, thumb-spica splint to immobilize, corticosteroid injection, surgery; return to full function after tx, resume normal activity within 3 weeks after corticosteroid injection

Question 21

Trigger finger

Answer 21

Pathophysiology: palpable and audible snapping when flex and extend fingers due to inflammation of one of flexor digitorum superficialis (FDS) or flexor digitorum profundus (FDP) tendon sheaths of fingers (tenosynovitis), tendon sheath swells and becomes caught in narrow osteofibrous sheath anterior to MCP joint, more in women, >40yo, hx diabetes or RA

Clinical presentation: gradual onset with mild/moderate pain which increases after prolonged period of inactivity or after repeated gripping or tapping hard surface, swelling/small nodule at MCP joint, extension limited and fingers lock as they extend

Management/prognosis: NSAIDs, rest/splint while treating inflammation with corticosteroid injection, surgery to widen osteofibrous tunnel to allow tendon to slide more easily; most cases improve with conservative tx and those that need surgery recover in a few weeks

Question 22

Carpal tunnel syndrome

Answer 22

Pathophysiology: median nerve compressed beneath transverse carpal ligament that forms roof of carpal tunnel

Clinical presentation: dull aching pain at wrist extending up to forearm and arm, paresthesias in thumb and index (and middle) finger particularly in morning, pain worse at night bc sleep with flexed wrist which further compresses carpal tunnel, pain worse with repetitive motion of wrist (typing, hairstyling, gardening), sensation may decrease at volar pads of thumb, index, middle fingers, in chronic cases get weakness in hand or thenar muscle atrophy or abductor pollicis brevis atrophy, Tinel’s sign, Phalen’s test, electrodiagnostic exam (nerve conduction study of EMG) is gold standard

Management/prognosis: NSAIDs, opioids for severe pain, wrist brace, ultrsound tx, ergonomic positioning, corticostaroid injection, surgery; if detected early, good hand function but if left untreated get increased pain/weakness that restricts hand function

Question 23

Cubital tunnel syndrome

Answer 23

Ulnar nerve compressed at cubital tunnel or within band of aponeurosis between proximal heads of flexor carpi ulnaris muscle

Pain follows ulnar distribution: numbness, tingling, burning in 4th and 5th digits and/or weak grip

Pain worse with pressure over ulnar nerve at elbow

Use Tinel’s test and nerve conduction study (gold standard)

Question 24

Radial tunnel syndrome

Answer 24

AKA posterior interosseous nerve syndrome

Compression of radial nerve near lateral elbow, often confused with lateral epicondylitis

Radial nerve originates from posterior cord of brachial plexus in axilla –> curls around posterior humerus –> pierces lateral intermuscular septum to enter deep muscular groove between brachioradialis and brachialis muscle –> divides and deep radial nerve penetrates supinator muscle to become posterior interosseous nerve

Between lateral intermuscular septum and formation of posterior interosseous nerve, radial nerve becomes compressed which results in this entrapment syndrome

Predominantly a motor neuropathy so you get weakness during elbow supination and finger extension (esp middle finger w/posterior interosseus nerve) but no weakness proximal to elbow; get dull aching pain over lateral elbow distal to lateral epicondyle (over supinator) but no other sensation changes (SOME sensory fibers of the radial nerve affected!)

Diagnose with nerve conduction study and EMG

Question 25

Guyon tunnel syndrome

Answer 25

Ulnar nerve compressed within ulnar tunnel (Guyon’s tunnel) at the wrist

Ulnar nerve bifurcates within ulnar tunnel into superficial (sensory) and deep (motor) branch so if compression prior to bifurcation get both sensory and motor problems, but if compression after bifurcation to deep branch only then only motor deficit

Question 26

For tendonitis in general, what hurts?

Answer 26

Stretching the tendon hurts

Resisting contraction hurts

Question 27

Avascular necrosis in scaphoid fracture

Answer 27

Occurs as a result of disrupted blood supply to proximal pole of scaphoid at site of fracture

Scaphoid receives blood supply from dorsal vessels off radial artery that ender at or just distal to waist of scaphoid, so vessels perfuse proximal pole in retrograde manner (blood supply from distal to proximal!)

Dense appearance of proximal pole indicates avascular necrosis

Question 28

How do you tell the difference between DeQuervain tenosynovitis and OA of the hand?

Answer 28

With DeQuervain you can palpate along the tendon (LAb SEx) and get pain

With OA will just have pain at the joint

Question 29

How do you distinguish carpal tunnel syndrome from C6 radiculopathy?

Answer 29

C6 radiculopathy will have more widespread sensory or motor (weakness and atrophy) symptoms (numbness in C6 dermatomes, weakness in C6 myotomes (deltoid, biceps), loss/reduced bicep reflex), will have positive Spurling’s test, and will have neck symptoms

Capral tunnel syndrome will only have pain in hand (thumb and index finger) and Tinnel’s and Phalen’s tests may be positive

Question 30

With weakness and tingling at 4th and 5th digits how do you distinguish between cubital tunnel syndrome, C8/T1 radiculopathy, thoracic outlet syndrome, or guyon tunnel syndrome?

Answer 30

Cubital tunnel syndrome: Tinnel’s test positive at elbow, weakness of hypothenar and hand intrinsic muscles (interossei and ulnar lumbricals), usually spares forearm muscles (branches that supply forearm muscles are usually proximal to lesion)

C8/T1 radiculopathy: in addition to symptoms of lower trunk brachioplexopathy, neck pathology usually present, cervical paraspinal muscles affected

Thoracic outlet syndrome: compression of lower trunk of brachial plexus, neurogenic type most common, affects entire ulnar nerve, affects C8/T1 component of median nerve which supplies thenar muscles and other hand intrinsic muscles, Adson’s sign may be positive

Guyon’s tunnel syndrome: compression at ulnar side of wrist, usually distal to branching of dorsal cutaneous nerve, weakness of hypothenar with no sensory involvement

Question 31

Summary of nerves compressed in different tunnels

Answer 31

Radial tunnel: radial nerve (or posterior interosseous nerve) in radial tunnel (spare ex carp radialis (bc it’s in superficial lateral compartment?))

Carpal tunnel: median nerve

Cubital tunnel: ulnar nerve

Guyon’s tunnel: ulnar nerve

Question 32

When a mixed nerve is compressed, what symptoms do you see first?

Answer 32

Sensory fibers are fatter and are affected first

If severe compression, then you’ll get motor symptoms also!

Question 33

Double crush syndrome

Answer 33

Compression at C5-6 level and compression at the carpal tunnel