Upper Extremity Pathology Flashcards
Trigger Finger
Definition: A stenosing tenosynovitis, inflammation, nodules in the tendon sheath. Most common fourth and fifth digits. Often associated with carpal tunnel.
Epidemiology: more common women and diabetics.
Presentation: pain at MCP joint, mechanical symptoms: catching, locking, clicking.
Physical exam: tenderness over MCPJ, reproducible mechanical symptoms or pain with flexion/extension, palpable palmar nodule. No imaging necessary.
Treatment: conservative: rest, activity mod, splinting, NSAIDs, cortisone injections. Refractory: percutaneous, open release.
Skiers Thumb
AKA gamekeepers thumb sprain or tear in the ulnar collateral ligament
presentation: acute pain, swelling at base of thumb, difficulty grabbing/throwing objects, thumb instability, bruising at thumb base.
Work up: xray- may reveal associated avulsion fracture, stress views may demonstrate instability, MRI gold standard.
Treatment: laxity/partial tear- rest, ice, thumb spica. complete tear-surgical UCL repair
Metacarpal fracture
5th MC most common (boxers fx)
Epidemiology: More common in males (men are dumb)
Presentation: Acute pain in the hand or affected digit
Physical exam: tenderness to palpation over hand or digit, pain with ROM, reduced grip strength, maybe deformity
Work up: radiographs
Treatment: stable fracture patterns, minimal displacement, no rotation- splint (ulnar gutter 4th and 5th MC, radial gutter 1st, 2nd, 3rd MC) , displaced/unstable-ORIF.
*To note any bites need to be prescribed antibiotics, wound should not be fully sutured closed.
Carpal tunnel syndrome
compressive median nerve neuropathy
Risk factors: female sex, obesity, pregnancy, hypothyroidism, RA, advanced age, smoking, alcohol abuse, repetitive wrist movements
Mechanism of injury: inflammation from repetitive motion and/or space occupying lesion
Presentation: numbness/paresthesia in the median nerve distribution, symptoms worse at night. If experiencing motor deficits (hand clumsiness, dropping objects) patient could be left with permanent dysfunction.
Physical exam: in chronic cases; atrophy of the thenar muscles, may see decreased grip strength, Tinels sign test: tapping over median nerve to try to reproduce numbness and paresthesia. Phalens test: flexion of both wrists to 90 degrees until numbness and paresthesia stimulated.
Diagnostics: Clinical diagnosis, lidocaine injection (diagnostic not long term treatment), EMG-NCV study
Treatments: 1. NSAIDs and bracing, 2. corticosteroid injection (permanent to no relief), 3. Surgical: Carpal tunnel release-cutting of the transverse carpal ligament
ganglion cyst
mucin filled synovial cyst at the wrist
Epidemiology: Most common between ages 10-40, slightly more common in females
Presentation**: usually asymptomatic but can cause mild pain or contribute to compressive neuropathies-patient presents for cosmetic reasons
Physical exam: palpable mass often at the dorsal wrist, somewhat mobile, none to mild tenderness to palpation, transilluminates
Work up-Primarily a clinical diagnosis, imaging to r/o other tumors or vascular anomalies
Treatment- if asymptomatic, treatment is not necessary. If symptomatic or patient requests-surgical excision preferred, can try to aspirate but has a high chance of recurrence. Home remedy-closed rupture by hitting cyst with force (not recommended)
radial ulnar midshaft fractures
Epidemiology: More common in men
Mechanism of Injury: High impact events such as MVC, Motorcycle accidents, sports injuries, high falls, etc.
Presentation: acute forearm pain, loss of forearm, wrist, hand function, deformity
Physical exam: gross deformity, edema, tenderness to palpation, pain with ROM, MUST ASSESS NEUROVASCULAR STATUS AND FOR COMPARTMENT SYNDROME
Diagnostics: radiographs
Treatment: Surgical (if displaced, dislocated, open, unstable, articular surface involvement) ORIF, non-operative: reduction and splinting
Monteggia fracture
Ulna fracture with dislocation of radial head
Galeazzi fracture
Radius fracture with dislocation of the distal radial ulnar joint
Elbow dislocation
Epidemiology: up to 28% of all elbow injuries, most common in 10-20 year olds (sports injuries), most commonly posterior dislocation
MOI: FOOSH (high impact) most common
Presentation: Acute elbow pain with deformity, unwillingness to use UE
Physical Exam: Gross deformity, MUST PERFORM SERIAL NEUROVASCULAR CHECKS both pre and post reduction.
Diagnostics radiographs, sometimes CT if concern for non-visible fracture, possible angiography if concern for vascular injury.
Treatment: Closed reduction, if neurovascularity intact and stable, splint in 90 degress flexion, hinged brace, if neurovascular deficit, associated fracture, or unstable-operative management required.
Nursemaids elbow
subluxation of the annular ligament and radial head
Epidemiology: mostly children 6 months to 6 years (peak incidence ages 2-3), about 70% of cases left elbow
Mechanism of Injury: Longitudinal traction to extended elbow, commonly seen in kids whose parents swing the around by their arms, or abrupt pulling on the hand/wrist
Signs/symptoms: Heard or felt pop/snap, initial pain subsides quickly, forearm resting in pronation and slightly flexed, child refuses to use arm
Diagnostics: radiograph or US
Treatment: closed reduction, sling or splint not necessary, open reduction if closed unsuccessful
Increased risk of recurrence
Medial epicondylitis
AKA golfers elbow-inflammation of the flexor tendon insertion site.
Epidemiology: Affects males and females equally, 75% of cases involve the dominant extremity
MOI: Overuse injury, wrist flexion and pronation; golfers, weight lifters, throwers, other racquet sports
Symptoms: medial elbow pain, may radiate down arm, increased pain with wrist flexion/pronation, may have associated edema
Physical exam: tenderness to palpation over the medial epicondyle, pain with resisted wrist and finger flexion, pain with resisted pronation, cheek press special test
Diagnostics: Clinical diagnosis, MRI if not improving
Treatment: rest, activity modification, NSAIDs, OT/PT, tennis elbow strap, corticosteroid injection (typically avoided) vs. PRP, if surgical intervention required, tendon release and debridement
lateral epicondylitis
AKA tennis elbow, inflammation of the common extensor tendon insertion, #1 cause elbow pain
Epidemiology: affects males more, typically between ages of 35-50.
MOI: repetitive wrist extension and pronation. Common in tennis players, manual laborers, heavy lifting, repetitive grasping
Symptoms: lateral elbow pain, may radiate down arm. Pain with wrist extension/pronation
Physical exam: tenderness to palpation over lateral epicondyle, pain with resisted wrist and finger extension (middle finger-Maudsley test), pain with resisted pronation.
Diagnostics: clinical diagnosis, consider XR, US, MRI if not improving.
Treatment: Rest and activity modification (may need up to 3 months), NSAID’s, OT/PT, tennis elbow strap, corticosteroid injection (often avoided) vs PRP, if surgical intervention required, tendon release and debridement
olecranon bursitis
inflammation of the bursa of the elbow.
Mechanism of injury: repetitive elbow motions, trauma, infection (septic)
Symptoms: elbow pain, edema-may be intermittent with activity, if severe pain and redness check for animal bites, dental work, open wounds
Physical exam: tenderness over olecranon bursa, deformity, if septic: erythema, demarcation pain, possibly systemic symptoms.
Diagnostics**: Imaging not necessary, clinical diagnosis. If septic, labs, possibly aspiration, xray, MRI
Treatment: heat/ice, immobilization splinting 1-2 weeks. Avoid resting on a hard surface, padding, possible corticosteroid injection, surgical intervention usually avoided
