Lecture 9: Approach to Elbow, Wrist, Hand Complaint

Question 1

Lateral Epicondylitis (Tennis Elbow)

Answer 1

• gradual onset of lateral elbow pain (aggravated by resisted wrist extension)
• microtears/microavulsions of common extensor tendons

Question 2

Medial Epicondylitis (Golfer’s Elbow)

Answer 2

• gradual onset of medial elbow pain (aggravated by resisted wrist flexion)
• microtears/microavulsions of common flexor tendons

Question 3

Olecranon Bursitis

Answer 3

• most common bursitis seen (septic or aseptic)
• seen after trauma from leaning on elbow, but can have inflammatory or infectious etiologies
• fluid aspiration only needed if concerned about infection or crystal disease (Gout)

Question 4

Ulnar Nerve Entrapment (Cubital Tunnel Syndrome)

Answer 4

• 2nd most common compressive neuropathy in upper extremity (Median N. compression or Carpal Tunnel Syndrome is MOST common)
• common impingement as it passes through cubital tunnel of medial elbow

Question 5

Carpal Tunnel Syndrome

Answer 5

• most common clinical compression neuropathy
• compression of median nerve
• wrist pain w/paresthesia (numbness/tingling) along 1st 3 digits and half of 4th; symptoms worse at night
• shake hands to relieve pain
• use Phalen and Tinel tests

Question 6

de Quervain’s Tenosynovitis

Answer 6

• inflammation of tendon and synovial sheath covering extensor pollicis brevis/adductor pollicis longus
• subacute radial wrist pain at thumb base and distal radius with thumb movement (worsens w/gripping or holding objects)
• use Finkelstein test –> flexion of thumb elicits pain

Question 7

Rheumatoid Arthritis (RA) and extra-articular manifestation

Answer 7

• autoimmune, inflammatory arthritis of unclear etiology
• symmetric joint pain, joint swelling, stiffness of hands, wrists, feet (lasts > 1 hr after awakening and improves)
• commonly involved joints: wrists, MCP, PIP
• EA manifestations: Felty Syndrome (severe RA, neutropenia, splenomegaly)

Question 8

Rheumatoid Arthritis X-Rays

Answer 8

• joint space narrowing
• marginal bone erosions
• ulnar deviation of MCP joints

Question 9

Boutonniere Deformity and Swan Neck Deformity (RA)

Answer 9

B: PIP flexion, DIP hyperextension

SN: PIP hyperextension, DIP flexion

Question 10

Osteoarthritis Arthritis (OA) and X-Rays

Answer 10

• most common arthritis in adults
• asymmetric joint pain and stiffness in DIP/PIP
• stiffness lasts < 1 hr after awakening and improves w/activity

X Rays –> Heberdens nodes (DIP joint) and Bouchards nodes (PIP joint)

Question 11

Ganglion Cyst

Answer 11

• common soft tissue finding of hand/wrist
• 2nd to 4th decade of life
• herniation of CT from tendon sheaths, ligaments, joint capsules, bursa
• typically on dorsal wrist but can be on palmar and over fingers
• 50% spontaneously resolve, 50% will reoccur within 1 year; surgical removal

Question 12

Scaphoid (Navicular) Fracture

Answer 12

• most commonly fractured carpal bone (FOOSH)
• can result in avascular necrosis
• wrist pain on radial aspect in anatomical snuff box, decreased grip strength

Question 13

Distal Radial Fracture (Colle’s)

Answer 13

• most common fracture site in upper extremity (FOOSH)
• distal wrist pain and swelling with dinner fork deformity
• volar/sugar-tong splinting

Question 14

Trigger Finger

Answer 14

• stenosing flexor tenosynovitis
• disparity in size of flexor tendon to surrounding retinacular pulley system/sheath, impairing gliding of flexor tendon
• commonly affects ring finger and thumb (5th decade)
• painless/painful snapping, catching, locking of fingers during flexion

Question 15

Dupuytren’s Contracture

Answer 15

• progressive fibrosis of palmar fascia resulting in gradual joint stiffness and inability to fully extend the finger
• most common in white males over 50 yo, gradual loss of finger extension, palpable cord or discrete nodules present (thickening or nodule in palm)

Question 16

Elbow/Wrist/Hand Dermatomes (5)

Answer 16

C5 - lateral arm
C6 - lateral forearm and thumb
C7 - middle finger
C8 - medial forearm and little finger
T1 - medial arm

Question 17

Valgus Stress Test (positive test and what it indicates)

Answer 17

positive test = inc. laxity, pain/tenderness

indicates: sprained medial collateral ligament

Question 18

Varus Stress Test (positive test and what it indicates)

Answer 18

positive test = inc. laxity, pain/tenderness

indicates: sprained lateral collateral ligament

Question 19

Tinel Test for Ulnar Nerve Entrapment

Answer 19

• between olecranon and medial epicondyle

positive = tingling sensation down forearm

indicates: ulnar nerve entrapment/cubital tunnel syndrome

Question 20

Golfer’s Elbow (Medial Epicondylitis) Test

Answer 20

• pain w/resisted elbow flexion

positive = pain/tenderness medial epicondyle

indicates: medial epicondylitis

Question 21

Tennis Elbow (Lateral Epicondylitis) Test

Answer 21

• pain w/resisted elbow extension

positive = pain/tenderness lateral epicondyle

indicates: lateral epicondylitis

Question 22

Tinel’s Sign

Answer 22

• tap over transverse carpal ligament/flexor retinaculum

positive = numbness/tingling to thumb/index/middle finger

indicates: carpal tunnel syndrome

Question 23

Phalen’s Sign

Answer 23

positive = any reproduction of symptoms paresthesai in distribution of medial nerve

indicates: carpal tunnel syndrome

Question 24

Finkelstein Test

Answer 24

• make fist w/thumb inside and ulnar deviate wrist

positive = inc. pain in first dorsal compartment

indicates: deQuervain’s tenosynovitis