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Managing Clinical Cases MSK > Lecture 4 - Elbow, wrist and hand > Flashcards

Lecture 4 - Elbow, wrist and hand Flashcards

1
Q

What is lateral epicondylitis?

A

Enthesopathy of the extensor tendons of the forearm,

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2
Q

What are the usual and other potential causes of lateral epicondylitis?

A

Usually chronic overuse of the extensor tendons - repetitive extension of wrist i.e. in typing, driving, playing tennis

Can very occasionally be traumatic

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3
Q

Why is early morning stiffness common in lateral epicondylitis despite it being an extra-articular issue?

A

Blood flow to tendons already limited and when sleeping it is limited further due to lack of movement

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4
Q

What movements would you expect to be painful in lateral epicondylitis (literally not functionally)

A
  • Gripping - this is an extensor movement
  • Resisted extension of the wrist and middle finger
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5
Q

Describe what objective assessment you would perform for someone with lateral epicondylitis

A
  • Observation - limited observation but patient may be holding wrist in a more flexed position to avoid pain
  • Palpation - Tenderness of the anterior facet of the lateral epicondyle with the common extensor tendon originates
  • Movements - Extend the elbow and flex the wrist then test for pain on resisted wrist extension and resisted middle finger extension
  • Mill’s test - Shoulder abducted to 90, elbow flexed to 90, pronated, flexed and bring elbow into extension, have finger over the common extensor tendon, if tenderness reproduced then +ve for lateral epicondylitis
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6
Q

How would you treat lateral epicondylitis

A
  • Identify and remove causative factors - think about ergonomics, technique etc
  • Splint - splinting can be effective as it creates a new false origin for the tendon to pull on rather than the inflamed origin
  • Mill’s movements
  • Eccentric loading - elbow extension, wrist starts in flexion, assist to bring into extension, hold for 5 seconds, lower slowly into flexion
  • Stretching - flexion wrist movements
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7
Q

Why should you do eccentric loading for epicondylitis with your elbow in extension

A

The common flexor and extensor origins are on the humerus so if you practiced in elbow flexion you could end up with a shortened complex

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8
Q

What is medial epicondylitis

A

Enthesopathy of the flexor tendons in the forearm

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9
Q

What are usual causes of medial epicondylitis

A

Chronic overuse of the flexor tendons i.e. by golfers and by people lifting and hitting things such as hammering

Occasionally traumatic

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10
Q

Why is early morning stiffness particularly prevalent in medial epicondylitis

A

People often sleep with their arms in a flexed position so the tendons shorten

In addition their is reduced blood flow to tendons (which already receive a smaller blood supply)

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11
Q

What movements would you expect to be painful in medial epicondylitis

A

Resisted wrist flexion

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12
Q

What objective assessment would you do for someone with suspected medial epicondylitis and what would you expect to find?

A

Observation - patient might be holding their hand in a more extended position to protect the tendons

Palpation - Exquisite pain over the anterior facet of the medial epicondyle of the humerus where the common flexor tendons originate

Mill’s test - Shoulder abducted to 90, elbow flexed to 90, wrist supinated and extended, shoulder extended and elbow then brought into extension, pain produced = positive

Resisted wrist flexion - if painful, indicates medial epicondylitis

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13
Q

What would treatment be for medial epicondylitis

A
  • Eccentric loading - elbow in extension and wrist in flexion, extend and hold for 5-10 seconds, gradually lower down as slowly as possible - can hold with weight
  • Mill’s movements
  • Identify and remove/fix/alter causative factors
  • Stretching of the muscles - extension movements of the wrist
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14
Q

What is ulnar neuritis

A

Inflammation of the ulnar nerve

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15
Q

Where does the ulnar nerve sit at the elbow

A

In the ulnar groove on the medial side of the humerus behind the medial epicondyle and the olecranon process

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16
Q

What are the usual cause of ulnar neuritis

A

Repetitive elbow extension in a valgus elbow

Contact injuries - leaning on your elbow in the car, riding bikes, on desks etc

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17
Q

What symptoms would a patient with ulnar neuritis report

A

Pins and needles (paraesthesia) in the 5th and half of the 4th digit

Swelling and tenderness around the medial elbow

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18
Q

What might you observe in patients with ulnar neuritis

A
  • Swelling around the medial elbow
  • Wasting/weakness in the hypothenar eminence
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19
Q

What might you pick up on palpation of someone with ulnar neuritis

A
  • Swelling around the medial elbow
  • Wasting of the hypothenar eminence
  • Altered sensation of 5th and half of 4th digit
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20
Q

What movements and special tests would you do for someone with ulnar neuritis and what would you expect to see?

A
  • Resisted movements - painless unlike with epicondylitis
  • Resisted ulnar deviation - weakness
  • Resisted 5th digit abduction - weakness
  • Tinel’s sign - repeatedly tap over the ulnar nerve and see if symptoms are elicited - would expect symptoms elicited
  • Upper Limb Tension Test 3 (to test mobility of the nerve) - elbow flexed, wrist pronated, wrist extended, abduct shoulder (you can also rotate the shoulder to test range) - would expect reduced mobility due to inflammation
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21
Q

How to treat ulnar neuritis

A
  • Identify and remove causative factors - don’t want to further inflame the nerve
  • Appropriate mobilisation - variations on ULTT 3
  • Maintenance and strengthening for the affected muscles i.e. hypothenar eminence
  • If treatment isn’t effective and/or entrapment is suspected then surgery may be applicable
22
Q

Identify the clinical features of olecranon bursitis

A
  • Usually due to contact pressure and can be traumatic or atraumatic
  • Obvious golf ball sized swelling at the olecranon process of the elbow ‘
  • Usually limited pain
  • Patients complain of the swelling getting in the way/taking up space rather than pain
  • If angry, hot, painful and red it could be infected
  • Full painless ROM of elbow

-

23
Q

What would your treatment be of olecranon bursitis?

A
  • If infected, antibiotics
  • If really painful and swollen, aspirate
  • Remove causative factor and prevent recurrence with advice/splinting/padding
  • NSAIDs to control swelling (can be local or topical)
  • Ice for swelling
24
Q

What is the hypothenar eminence?

A
  • Muscular/fleshy mound at the base of the pinky finger containing muscles supplying the fingers
25
Q

What is the thenar eminence

A
  • Muscular/fleshy mound at the base of the thumb containing muscles supplying the thumb
26
Q

What is the carpal tunnel bordered by?

A
  • Lateral - Bordered by scaphoid tubercle and trapezium
  • Medially - hook of hamate and pisiform
  • Palmarly - flexor retinaculum/transverse carpal ligament
  • Dorsally - Proximal carpal row
27
Q

What does the carpal tunnel contain

A

9 flexor tendons (4 flexor digitorum profundus, 4 flexor digitorum superficialis and flexor pollucis longus)

The median nerve

28
Q

What is carpal tunnel syndrome?

A

Compression of the median nerve due to an increase in pressure in the carpal tunnel (either decreased volume or increased size of contents)

29
Q

What can carpal tunnel syndrome be caused by?

A

Overuse
Positional trauma
Obesity
Pregnancy
Thyroid, renal or cardiovascular problems

30
Q

What would you expect the pain/symptom presentation to be for someone with carpal tunnel syndrome?

A

Pain, paraesthesia and numbness on radial 3.5 digits on the palmar surface
- In more serious cases can affect all fingers and dorsal surface

Pain worsens with use and at night - patient has to shake arm to ease pain

31
Q

What would you expect to observe in someone with carpal tunnel syndrome

A

Wasting of the thenar eminence

32
Q

How can you distinguish between ulna nerve and median nerve irritation

A

Ulna nerve = painful resisted adduction of the thumb

Median nerve = painful resisted abduction of the thumb

33
Q

Describe what objective assessment you would do if you suspected carpal tunnel syndrome and what would you expect to see?

A

Phalen’s test - hold hands in an upside down prayer position with dorsal surfaces touching - hold for 30-60 seconds, this increases pressure in the carpal tunnel so if positive would elicit symptoms in the median nerve

Tinel’s test - tapping over the median nerve elicits symptoms if positive - to locate median nerve at the wrist, put thumb and pinky together and flex wrist to make the palmaris longus tendon prominent, the median nerve sits just deep to it

34
Q

If tests for carpal tunnel syndrome are negative does that mean the patient doesn’t have it?

A

No - clinically a lot of carpal tunnel tests are negative, carpal tunnel diagnosis are mainly based off symptomatic reporting

35
Q

How would you treat carpal tunnel syndrome?

A

Adjust causative factors - these can be medically related so refer for a medical review

Night splinting - prevents flexion while sleeping

Gliding exercises - start in a fist with your thumb facing you, open palm to neutral, extend wrist, extend thumb, pronate wrist and then with other hand gently pull thumb into abduction

36
Q

How can you distinguish cervical radiculopathy and carpal tunnel for causing median nerve symptoms

A
  • If cervical the paraesthesia will follow a dermatomal pattern whereas if carpal tunnel will follow a peripheral pattern
  • Symptoms are produced with neck movement in cervical radiculopathy
37
Q

How would you treat cervical radiculopathy induced median nerve symptoms in the hand?

A

ULTT1 - Shoulder girdle depression, external rotation, abduction to 110 degrees, supination, wrist, finger and thumb extension, bring the elbow into extension

Cervical and thoracic mobilisations

Neck ROM exercises

38
Q

What are the clinical features of 1st carpometacarpal joint arthropathy?

A

Degenerative changes to/inflammation of 1st CMC joint

Can have traumatic cause but usually gradual onset due to osteoarthritis

Early morning stiffness

Pain around thumb, worse on gripping, weakness in gripping

Pain on adduction and extension

39
Q

What would you do in an objective assessment if you suspected 1st CMC joint arthropathy and what would you expect to see?

A

Observation - visible OA changes i.e. bony lumps

Palpation - palpable OA changes i.e. bony lumps

Tests:
- Distinguish from De Quervain’s - put your web on their web, pull the thumb into an adducted and extended position and if pain is experienced over the 1st CMC joint then OA indicated

40
Q

How would you treat 1st CMC joint arthropathy?

A
  • Medication i.e. NSAIDs, pain relief
  • Accessory movements - mobilise 1st CMC and other affected joints
  • Stretching exercises - apply ice after
  • Strengthening exercises - strengthen surrounding muscles for stability to reduce pain
  • Resting splints - don’t overuse as this will create stiffness
  • TENS/acupuncture for pain
  • If severe, surgery
40
Q

What are the clinical features of De Quervain’s tenosynovitis?

A

Pain on resisted abduction and extension of the thumb

Inflammation of APL and EPB tendon sheaths due to overuse - for example working in the garden, playing golf, racket sports or lifting up a baby

Pain , swelling and crepitus around radial styloid particularly after repetitive thumb movements

41
Q

What are the clinical features of tenosynovitis of extensor tendons of wrist?

A

Causes pain on dorsal surface of the wrist

Gross crepitus

Common in typists, rowers and canoeists

42
Q

What objective assessment would you do if you suspected De Quervain’s tenosynovitis?

A

Adduction and extension movement distinguishes 1st CMC joint arthropathy (if this is positive it is not De Quervain’s)

Finkelstein’s test - patient flexes their thumb and wraps their fingers around the thumb and then ulna deviates the wrist, if pain then this is positive for De Quervain’s

43
Q

What treatment would you provide for De Quervain’s tenosynovitis?

A

Overuse - relieve the source of overuse

Splinting = thumb splint for EPB and APL

Stretching

Ice and topical gels for the tendon sheaths

NSAIDs and analgesics

Injections and very rarely surgery

44
Q

What is trigger thumb/finger?

A

Nodule in the flexor tendon of a digit due to inflammation catches in the tunnels it is contained in which causes the digit to lock into flexion and you have to manually extend the digit

It occurs due to overuse

45
Q

What would you see in an objective assessment of someone with Trigger finger?

A

Palpation - you can feel a nodule in the tendon and a catch and release during flexion of the finger

46
Q

How would you treat trigger thumb/finger

A

NSAIDs or steroid injections
Remove causative overuse factor
Topical agents as lesion is superficial
Very rarely surgery
Some clinicians massage to soften nodule but this can irritate and further inflame the nodule

47
Q

Describe the gliding movements you can do in the wrist and hand

A

Radius - carpal

Lunate - capitate

Lunate - scaphoid

48
Q

How do you palpate capitate and lunate?

A

Slide down 3rd metacarpal joint and fall into a divet - this is capitate

Move proximally - this is lunate

49
Q

What can cubitus valgus cause?

A

Ulnar neuropathy
Puts strain on ulna collateral ligament which leaves people prone to chronic traction on medial structures

50
Q

Why might the end feel of elbow extension be springy?

A

If the biceps is shortened - to test this press on the biceps tendon then relax and bring the arm further into extension

Managing Clinical Cases MSK (6 decks)

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