Elbow, wrists, and hand Flashcards
elbow
-Complex joint, with 3 sets of articulations.
-Capitulum / prox. Radius, trochlea / prox. Ulna, prox. Radioulnar joint.
-Is capsulated, annular ligament, bursa
-Lateral aspect forearm; wrist/finger extensors, supinator (radial nerve)
-Medial aspect forearm; wrist/finger flexors, pronator (median/ulnar nerve)
elbow blood and nerve supply
-Brachial artery – bifurcates into the ulnar and radial artery at cubital tunnel
-Ulnar nerve crosses elbow posteriorly at cubital tunnel
A 42-year-old plumber with right elbow pain presents to the clinic. The pain had been present off and on for years, but is now getting worse and causing him to drop objects. There is no history of injury or trauma. The symptoms worsen when the patient engages in lifting activities with the elbow and wrist in extension
lateral epicondylitis
-Overuse / repetitive use injury
-Very common
-Pain is localized to lateral humeral epicondyle, at tendinous insertion of wrist extensors (ECRB).
-Pain is reproduced with wrist extension against resistance and palpation.
-“Tennis Elbow”
-tx:
-Activity modification
-Unloader brace/band- compresses muscle -> takes load off the tenson and puts on the muscle
-NSAIDS
-Physical Therapy
-Steroid injection
-PRP injection
-Surgical release
medial epicondylitis
-Mechanism: Overuse / trauma to area
-Often seen in throwing sports (“Pitchers elbow” & “Golfer’s elbow”)
-Less common
-Pain is localized to medial humeral epicondyle. (Medial Common Flexor Tendon)
-Reproduced by action, palpation
-tx:
-Activity modification
-NSAIDS
-Physical Therapy
-Steroid injection
A PA student has been experiencing swelling and pain in his right elbow for a couple of weeks. He admits to studying excessively with his elbows resting on the table and now complains of a large mass overlying the posterior aspect of his elbow
olecranon bursitis
-May be large edema at olecranon, usually non-tender, not “infected”—aspirate clear, Treatment includes aspiration (send for C+S if at all suspicious of septic bursitis)
-Compression with ACE wrap
-NSAIDS
-Steroid injection
-Activity modification.
-ABX if infected. Possible surgical I&D
non septic vs septic elbow
A 40 year old account executive was horseback riding when she was thrown from her horse and landed on her right arm. She has immediate onset of pain, swelling and bruising around her elbow. She has also been complaining of increased stiffness.
radial head fracture
-MC elbow fracture in adults
-Fall on outstretched hand
-Type I: difficult to identify
-Type II: <30% of radial head
-Type III: comminuted
-Type IV: complex
-Pain & stiffness with forearm supination & pronation
olecranon fracture
-Mechanism: Fall on flexed elbow
-Sx: Pain, swelling, unable to extend elbow
-Tx:
-Nondisplaced: Reduction, long arm splint with elbow in 90 deg flexion
-Displaced: Surgical with tension band, plate & screw or IM screw
-Complications: Ulnar Neuropathy
cubital tunnel syndrome
-Ulnar nerve trapped at elbow, +paresthesia, +tinnel sign, +froments sign
-In severe cases patient will have a “claw hand”
-Treatment;
-Night splint
-Activity modification
-NSAIDS
-Surgical release (Ulnar nerve decompression and possible anterior transposition)
hand
-Articulations include:
-Distal radioulnar joint
-Radiocarpal joint
-Midcarpal joint
-Carpometacarpal joint
-1st carpal - metacarpal joint (thumb basal joint) is the trapezio-metacarpal joint.
-Thumb basal joint M/C site of arthritis in the hand. Repetitive motion injury.
-Thumb basal joint is a “saddle joint”
-Lunate – Kienbock’s Dx. (AVN)
-Scaphoid (Navicular)- most important (and fx’ed) bone in wrist, in constant motion, a lot of ligament attachment, precarious blood supply
wrist (dont need to know)
-Ligaments of the wrist are numerous. They are critical in articulation stabilization.
-Consider ligamentous damage with chronic pain and negative X-ray
-Radius and Ulnar
-scaphoid, lunate, triquetrum, pisiform
-trapezium, trapezoid, capitate, hamate
dorsal tunnel (dont know this)
-6 dorsal tunnels transport extensor tendons to the hand
-Each tunnel has its own tendon compartment.
-Tunnel 1- abductor pollicis longus, extensor pollicis brevis.
-Tunnel 2- extensor carpi radialis longus, extensor carpi radialis brevis.
-Tunnel 3 -extensor pollicis longus
-Tunnel 4 - extensor digitorum communis, extensor indicis
-Tunnel 5 - extensor digiti minimi
-Tunnel 6 - extensor carpi ulnaris
A 32-year-old female presents with a chief complaint of right wrist pain. The pain is located to the radial aspect of the wrist and is worse when she lifts her newborn or if the wrist is forced into ulnar deviation.
de Quervain Tenosynovitis
-Stenosis of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon sheaths in the 1st Dorsal compartment of the wrist.
-Up to 6 times more common in Women
-Common during pregnancy and lactation
-often seen in overuse / repetitive athletics
-pain is localized to radial aspect 1st compartment, and can be severe.
-pain increased with palpation and motion of thumb
-+ finkelsteins is dx
-Treatment:
-Non-op:
-Activity modification
-NSAIDS
-PT
-Steroid injection. 50-80 % report relief after 1-2 injections.
-Sx: surgical release; incision of 1st dorsal compartment
hand (nerves)
-Radial – sensation to the dorsum of the hand on radial side of third metacarpal & dorsal thumb, index & middle fingers as far as the distal phalanges. !First web space! is most “pure” area to test for radial nerve sensation, motor test thumb and wrist extension
-thumbs up
-Ulnar – Provides sensation to the ulnar side of hand (dorsal and palmer) , ring, & little fingers. The !volar tip of the little finger! is the most “pure” area to test for ulnar nerve sensation. Motor –test opposition, and ab & adduction
-thumb to finger
-jaz hand
-Median – provides sensation to palm & palmer surface of thumb, index, middle & half of the ring finger; may supply dorsum of terminal phalanges of these fingers. The !distal palmar aspect of the index finger! is the most “pure” area to test median nerve sensation, motor – test opposition
-thumb to finger
carpal tunnel syndrome
Repetitive use, pregnancy, RA, Gout, DM, ETOH abuse
Onset is usually spontaneous
gradually increasing night pain is common
numbness and tingling in median nerve distribution of hand
sense of weakness/clumsiness in hand.
symptoms precipitated by manual activity.
Thenar atrophy is a sign of chronic disease. Weakness with thumb opposition.
-Special tests:
-+ Tinel’s sign - tap
-+Phalen’s test - pray
-Consider obtaining EMG/NCS to R/O other peripheral neuropathies or cervical radiculopathy
-Tx:
-Non-op;
-activity modification
-cock-up wrist splint
-NSAIDS
-Physical therapy
-Steroid injection
-Surgery: Carpal tunnel release
dislocations of the wrist
-Perilunate, lunate, and trans-scaphoid perilunate dislocations are variations of the same injury and are caused by hyperextension of the wrist, FOOSH
-capitate-lunate dislocation is M/C and is visible on lateral view of Xray of wrist
-“cup tilt” appearance
-note areas of ecchymosis, fullness, tenderness
-Check ROM, Snuffbox, N/V status
-Generally the wrist appears shortened, movement will produce pain, and edema will vary from slight to significant.
-X-rays to include 4 views…..AP in neutral, AP in ulnar deviation, oblique, and lateral.
-Tx: reduction ASAP to minimize risk of nerve injury.
-Axillary or Beir block for anesthesia, finger traps for traction, reduce, and place in thumb spica splint with wrist in neutral or slight palmar flexion . Post-Redux film
-Non-reducible dislocations will require ORIF.
colles fracture (dorsal angulate radius fracture)
-extra-articular fracture with !dorsal! angulation and tilt, often impaction
-M/C fracture of the wrist
-90% of wrist fractures are this pattern
-Mechanism: Fall on hand with wrist in extension
-edema, ecchymosis, and loss of ROM
-X-ray (3 views) reveals typical “Dinner fork!” deformity
-Tx: All displaced fractures should undergo closed reduction regardless if the plan is surgery. This will provide comfort, minimize swelling, and reduce risk of neurovascular injury.
-Non-op – Cast immobilization for Non-displaced or minimally displaced fractures. Hematoma block. Obtain post-reduction X-ray.
-Sx- ORIF (Percutaneous pinning, Plate and screws)
smith’s fracture (volar angulated radius fracture)
-Smith’s fracture (reverse colles) - distal radius fracture with volar angulation
-Fall on hand with wrist in flexion
colles vs smiths MOA (test)
-Fall on hand with wrist in extension = Colles
-Fall on hand with wrist in flexion = Smith’s
scaphoid fracture
-M/C fractured carpal bone
-Approx 50-80% of carpal injuries
-Blood supply from scaphoid branches of radial artery is tenuous, from distal to proximal, with no direct arterial supply.
-Tend to develop delayed union or AVN
-The more proximal the fx site the greater the likelihood of AVN
-Mechanism: m/c fall on outstretched hand. Direct trauma.
-+ Snuffbox tenderness!, pain with radial deviation
-X-ray to include AP, lateral and scaphoid views. X-ray may not show fx for up to 4 weeks.
-If X-ray is negative at 2 weeks and patient is symptomatic obtain MRI
-Tx: Initially, thumb spica splint
-Non-op: thumb spica cast 4-6 weeks for non displaced distal 1/3rd fractures, tuberosity fracture
-Surgery: ORIF, (? Bone grafting)
-Proximal scaphoid fractures are prone to non-union
boutonniere deformity
Disruption of central slip of extensor digitorum communis tendon from its insertion at the dorsal base of the middle phalanx.
Results in a flexed PIP joint and hyperextended DIP joint. This may develop from 10 –20 days after injury.
Tx: splint PIP joint into full extension with passive and active flexion of DIP joint.
Sx: for moderate deformities and rigid contractures. K-wire, Tendon repair, PIP joint arthrodesis/arthroplasty.
swan neck deformity
-Caused by an extensor tendon pulling +/or laxity of flexor tendon.
-Hyperextension at PIP with flexion at DIP
-Can be traumatic, usually RA.
-Tx: is splinting, surgical repair.
-In RA patients, treatment is usually medical. Non-surgical splinting is often unsuccessful.
mallet finger
-Disruption of the extensor tendon over the distal phalanx with flexion deformity at the DIP , with extension at PIP.
-Treatment – splint x 6 weeks with hyperextension of DIP , flexion of PIP, K-wire, direct tendon repair.
-Can have an associated avulsion fx of the dorsal proximal aspect distal phalange
mallet vs swan vs boutonniere
extensor tendon lacerations
-Less emergent, tend not to retract as much, do better with splinting.
-Often require surgical repair, ABX, splinting
-Ortho hand consult if available
Skier’s Thumb or Gamekeeper’s
-Injury is to the ulnar collateral ligament of the MCP joint of the thumb, may vary from sprain to rupture.
-Destroys joint stability
-Impairs ability to pinch / oppose
-Stener lesion! – the ruptured proximal portion of UCL gets hooked on the extensor hood.
-will be difficult to send texts
-Evaluation includes stress x-ray of the MC/P by forcing the thumb into radial deviation . With > 15 degree variance compared B/L. An opening of > 45 degrees surgical repair is required.
-Sprain or partial tear is treated with thumb spica cast x 6 weeks, NSAIDS, Ice
jersey finger
-Caused by a sudden forceful extension of the DIP while held in forceful flexion. Typically when a tightly held jersey is torn out of the grip of a would be tackler.
-Active flexion at DIP is lost
-Treatment is splint in extension, ice, NSAIDS, possible surgical repair of tendon.
trigger finger
-Swelling of the flexor tendon and sheath makes passage of the tendon through a constricted sheath difficult.
-Can develop flexor tendon nodules which causes impingement.
-Impingement M/C at the A1 pulley
-Result is snapping or “triggering” with MCP joint flexion of the affected finger.
-Tenderness and edema at flexor aspect of the MCP (flexor pulley)
-Finger may lock in flexion or extension (flexion M/C extension)
-When locked in flexion manipulation may be needed to extended and palpable snap is detected.
Tx:
-Non-op: NSAID’s, Steroid injections
-Surgery: Surgical release of pulley
finger dislocation
-Hyperextension force is most frequent cause
-Radial and ulnar collateral ligaments are disrupted; N/V compromise as well
-X-ray obtained to R/O avulsion fx after reduction (? Digital block for reduction)
-Treatment: Splint / buddy tape , limit ROM, ice, NSAIDS, F/U eval at 2-3 weeks for ligament evaluation
-Dorsal PIP dislocation = splint in flexion
-Volar PIP dislocation = splint in extension
distal phalanx fractures (tuft fracture)
-Closed – Supportive treatment to surrounding soft tissue. splint, buddy tape, ice, analgesia
-Open – digital block, irrigation, loose closure (sutures), sterile dressing, splint, analgesia. Ortho Hand consult if nail bed injury!!
ganglion cyst
-Outpouching of the synovial membrane, usually on the dorsum of the wrist (carpals) which is indicative of synovial irritation
-May wax and wane, or persist
-Usually non tender, mobile, firm nodule
-Patient may state size fluctuates with activity.
-+Transillumination
-Treatment ; Watch and wait may resorb on its own, needle aspiration w/wo lidocaine injection, surgical excision. Have tendency to recur
Dupuytrens Contracture
-Fibrous band proliferation in palmar fascia causing a flexion contracture. M/C in the 5th MCP, PIP, but can extend into the entire palmar fascia and involve all fingers.
-Northern Europeans, ETOH, and seizure D/O have association
-Correlation with plantar fibromatosis
-cant pop the finger to full extension (unlike trigger finger)
-Treatment; Collagenase injections; 30 degrees or > at MCP or any PIP / DIP involvement require surgery. Extensive dissection and release of fibrotic tissue.
felon (left)
herpetic whitlow (right)
