UE - Elbow, Wrist, and Hand Pathology Flashcards
systematic approach criteria
- 2 important questions
- ask chief complaint
- agg/ease factors
- radiating or radicular complaints
- patient reported outcome measures
- develop differential diagnoses
- body chart
What is a patient reported outcome measure you can always use?
PSFS
patient specific functional scale
What questions are on the PSFS?
list activities the patient has difficulty doing and rate the difficulty on a scale of 1-10
systematic approach to objective exam
- point to pain
- clear joints above and below (& cervical)
- observe area
- bruising, effusion, swelling
- quantity and quality of motion
- strength assessment
- special testing
- palpation
biceps tendon is more involved with shoulder pathology or function?
pathology
What is a common source of anterior shoulder pain?
biceps tendon
t or f? proximal biceps rupture is an orthopedic urgency
false!
- proximal may be therapeutic
- distal is an ortho urgency
SLAP stands for
superior labrum anterior posterior (lesion)
how to tell normal vs symptomatic anatomy for SLAP lesion
- difficult to see on imaging
- discrepancy even at time of arthroscopy
-sublabral recess is a normal finding
0 tears noted in 72% asymptomatic subjects over 40
Common treatments for SLAP lesions
- debride or repair (depends on tear type)
- release the LH biceps
Slap management depends on age
- over 40: tenodesis vs tenotomy
- young overhead athlete: repair and protect
SLAP is rarely seen in isolation. What are other conditions that may be concurrent?
- RC repair
- chronic instability
- internal impingement
- chronic pain
tenodesis
Biceps tenodesis is done by detaching your biceps tendon from your labrum and moving the tendon to your upper arm bone (humerus).
tenotomy
Biceps tenotomy means cutting off one tendon and not reattaching it, allowing it to heal to the humerus over a few weeks.
SLAP lesion postop management
- depends on surgery
- period of immobilization (longer for repair, so rehab is slower)
- want to maintain motion (prevent stiffness)
- progress is based on impairments and healing
- SMART goals
What increases chances for a distal biceps rupture?
- 40-60 years old
- usually active with high BMI
- 7.5x more likely with smokers
- 86% occur in dominant arm
What causes a distal biceps rupture?
unexpected eccentric load
How to diagnose distal biceps rupture?
-hook test
-visible deformity
-ecchymosis
-palpable gap
- mechanism of injury
-supination weakness
-tender to palpate radial tuberosity
how to manage a distal biceps tear
- early surgical intervention is a must (otherwise >4 weeks the tendon will retract and may need a graft)
- can loose supination strength and elbow flexion
- non-op is only older patients with co-morbidities
common complications to distal biceps tear surgery
rupture
infection
fracture
postop management of distal biceps tear
- period of immobilization
- several weeks of controlled motion in a brace
- full motion by 6-8 weeks
- return to work/sport depends
Elbows are the ______ most commonly dislocated joint
2nd
What direction is the elbow most commonly dislocated in?
posterolateral (named for direction the ulna travels)
What are the 2 types of elbow dislocations?
- simple: no fracture, reduction, brane, immediate rehab and motion
- complex: fracture, often unstable and requires surgery
What is the terrible triad of the elbow?
- elbow dislocation
-radial head fracture - coronoid fracture
Which band of UCL is tight in flexion?
Posterior band
Which band of UCL is tight in extension?
Anterior band
What population is UCL injuries most common in?
Overhead throwers and athletes
What is the resconstruction surgery first described in 1974 for UCL injuries?
Tommy John surgery
What are some UCL injury risk factors?
high pitch counts
pitch on consecutive days
pitch for multiple teams
pitching velocity
pitching while fatigued
GIRD
decreased rotator cuff strength
core weakness
T or F. non-operative treatment for UCL injuries should be attempted for all athletes
true! but most team physicians tend to be ortho surgeons. must be willing to stop throwing. structural diag must be made via MRI
What tendon do they use for surgical UCL reconstruction?
palmaris longus or hamstring autograft
UCLR postop care?
- period of immobilization
- bracing and return of motion by 6-8 weeks
- return to throwing 10-18 months
Is RTS the same as return to PLOF?
No! especially for high level athletes, may see some deficits
Where does ulnar nerve entrapments occur?
cubital tunnel
guyon’s canal
Where do median nerve entrapments occur?
pronator teres
carpal tunnel
Where do radial nerve entrapments occur?
Pin within radial tunnel (motor only)
radial tunnel syndrome (pain only, no motor)
What are some ways to treat cubital tunnel syndrome without surgery
- education
- ergonomic changes
-night splinting/wrap with towel - activity modification
- monitor for increased muscle involvement
Where is guyons canal?
between hook of hamate and pisiform
What are two potential causes for guyons canal syndrome?
handlebar palsy and computer mouse
Describe the 3 zones of injury for guyons canal
1 - motor and sensory
2 - motor only
3 - sensory only
What is the floor of guyons canal?
Pisohamate ligament
What are some ways to test for ulnar neuropathy diagnosis?
- froments sign
- wartenbergs sign
- tinels sign
pressure provocation test
elbow flexion test
What are some pathologies that effect the radial nerve?
humeral shaft fracture
proximal humeral fracture
saturday night palsy
radial tunnel syndrome
PIN entrapment
Where do you palpate the radial tunnel?
3 cm distal to LE
T or F? Radial tunnel syndrome is painless and only has motor loss
F, radial tunnel syndrome is very painful with no motor or sensory loss
- no lateral epicondyle tenderness
T or F? PIN syndrome is only characterized by motor loss
True! PIN is only a motor nerve
What nerve are we concerned with being damaged after a distal biceps tear repair?
Radial
Where is arcade of frohse and why do we care about it?
Where radial nerve pierces supinator. common site of compression
pronator syndrome affects which nerve?
median nerve compression at two heads of pronator teres
What are some symptoms of pronator syndrome?
volvar forearm pain
numbness of first 3 digits
pain worse with physical activity
How do you differentiate pronator syndrome from carpal tunnel compression?
- sparing of palmar cutaneous branch
- forearm pain
AIN - test how?
Okay sign - can’t flex thumb IP joint is abnoramal
pronator quadratus weakness
What are some risk factors for developing carpal tunnel syndrome?
repetitive wrist motions
pregnancy
diabetes
rheumatoid arthritis
What exams do you complete for carpal tunnel syndrome?
phalens
reverse phalens
tinels
APB strength!
What are some treatments for carpal tunnel syndrome
activity mod and education
splinting and night splinting
impairment based rehab
aggressive observation (don’t want to progress to muscle wasting)
surgical release
tennis elbow
lateral epicondylitis
(pain with resisted wrist and finger extension)
golfers elbow
medial epicondylitis (pain with resisted weist flexion and pronation)
What muscle is the most likely issue with lateral epicondylitis
ECRB
What are some special tests for tennis elbow?
mills, maudsleys, cozens
tenderness at lat. epicond.
What muscles are issues with medial epicondylitis
pronator teres and flexor carpi radialis
What tests should you use for golfers elbow?
resisted pronation and flexion
tenderness at medial epicondyle
How to treat olecranon bursitis?
supportive care
1-2 months minimum recovery
compressive wrapping
elevation
NSAIDs
education
What are some concerns for septic bursitis?
- ed and primary care
- need antibiotics and surgical debridement
- education (many patients want it drained)
- INCREASED RISK FOR TRICEPS RUPTURE
Why is the elbow predisposed to be stiff?
- congruity of ulnohumeral articulation
- three articulations in one capsule
- blending of ligaments with the capsule
According to the capsular pattern, which ROM is lost first with stiff elbow
flexion
How much elbow flexion can you lose before it impacts ADLs?
30 degrees
Which carpal bone is most likely to fracture?
Scaphoid
Scaphoid has a ______________ blood supply
retrograde
must place a _____________ on hand to treat a scaphoid fracture
thumb spica
T or F. A scaphoid fracture is always plain and visible on xrays
false!!!!
Scapholunate injuries are due to?
hyperextension injuries
What special test do we use for sacpholunate injuries
watson scaphoid test
How do we treat scapholunate injuries?
normal films = treat like sprain
short period of splint mobilization, control inflammation
progression based on exam and interventions based on impairements
What are 3 possible radial sided tendonopathies?
- De Quervain’s tenosynovitis
- intersection syndrome
- flexor carpi radialis tendonitis
What is De Quervains
- inflammation of the 1st extensor compartment (EPB and AbPL)
- caused by repetitive thumb extension and abduction
What special test can be used to ID De Quervains
positive finkelsteins test
Intersection syndome
where 1st and 2nd extensor compartment muscle bellies meet in the extensor compartment
ECRL ECRB - 2nd compartment
flexor carpi radialis tendonitis
radial sided tendinopathie
What are possible ulnar sided wrist pathologies?
-Triangular fibrocartilage complex (TFCC)
- hyperextension injuries
- repetitive stress injuries
TFCC management
period of mobilization
NSAIDs
cortisone injection
impairment based rehab
surgery
what are 3 possible surgical procedures to handle TFCC
- debridement
- repair with sutures
- correction of ulnar variance (by shortening bone)
Gamekeepers thumb
UCL injury of thumb
ABD stress of 1st MCP joint
chronic insufficiency
thumb spica
Skier’s thumb
UCL injury of thumb
ABD stress of 1st MCP joint
acute injury
stener lesion
adductor aponeurosis between torn UCL and PP
surgery necessary for healing
how to treat gamekeepers thumb?
thumb spica for 2-6 weeks!
understand injury and healing
avoid stress to ucl region
impairment based rehab progression
splinting or taping to support RTP
amount of laxity and functional impact
presence of bone involvement
What is a central slip rupture characterized by?
forced PIP flexion
lateral bands migrate volarly
What can happen if a central slip rupture isn’t addressed promptly?
boutonniere deformity is development.
PIP flexion with DIP hyperextension
What should you look for on a physical exam when you suspect a central slip rupture?
- ask about history of PIP injury (jamming or dislocation)
- tenderness to central slip insertion
- DIP stiffness with PIP in extension
How do you treat a central slip rupture?
must recognize early
splint so PIP is in full extension and DIP is free to move
What characterizes a jersey finger?
- forced hyperextension of the DIP joint
- avulsion of the FDP
- typically on ring finger
how do you manage a jersey finger?
early management is important
surgery!! to stop tendon from traveling up hand
What does the deformity for jersey finger look like?
when they try to make a fist one of their fingers cannot flex the DIP joint and it is straight
What is a mallet finger characterized by?
- forceful flexion of the extended DIP joint
- disruption of the terminal extensor tendon
- unable to extended DIP
- dorsal swelling and pain
How do you treat mallet finger?
- early management critical
- DIP splinted in full extension for 6-8 weeks with PIP joint free to move
What deformity can form when mallet finger goes untreated?
swam neck deformity
What is swan neck deformity characterized by?
- flexed DIP, hyperextended PIP
What can cause swan neck?
untreated mallet finger
FDS rupture = unopposed PIP extension
Rheumatoid arthritis
how do you treat swan neck?
double ring splint
