Week 4 - D - Carpal and Cubital Tunnel Syndrome, Tennis (Lateral) and Golfer's (Medial) elbow, Elbow arthritis

Question 1

In contrast to cervical nerve root compression, peripheral nerve compression neuropathies will cause symptoms and signs affecting peripheral nerve sensory and motor territories rather than dermatomal and myotomal distributions. What forms the carpal tunnel and what passes through it?

Answer 1

The roof of the carpal tunnel is formed by the flexor retinaculum of the wrist (aka the transverse carpal ligament)

The floor of the carpal tunnel is formed by the carpal bones

Passing through the carpal tunnel is the FDP, FDS, FPL and median nerve

Question 2

What are the Carpal Bones called?

Answer 2

Scaphoid, Lunate, Triquetrum, Pisiform Trapezium, Trapezoid, Capitate, Hamate

S ome L overs T ry P ositions T hat T hey C annot H andle

Question 3

What is carpal tunnel syndrome?

Answer 3

Carpal tunnel syndrome is where there is compression of the median nerve as it passes under the flexor retinaculum of the wrist due to swelling within the confines of the carpal tunnel

Question 4

Whilst the flexor tendons passing under the carpal tunnel are not particularly susceptible to pressure, nerves are highly sensitive to this problem Many cases of carpal tunnel syndrome may be idiopathic, however what can it occur secondary to?

Answer 4

Secondary to

* Rheumatoid arthritis -> synovitis = less space

* Conditions resulting in fluid retention

* Pregnancy

* Diabetes

* Chronic renal failure

* Hypothyroidism (myoedema)

Could also be causes by fractures of the wrist

Question 5

Which sex is carpal tunnel syndrome more common in? In carpal tunnel syndrome due to pregnancy, what is the treatment?

Answer 5

Carpal tunnel syndrome affects far more female than males

In pregnancy related carpal tunnel, symptoms usually subside after birth

Question 6

What are the presenting symptoms of carpal tunnel syndrome?

Answer 6

Patients will present with

* paraesthesia (abnormal sensation - tingling or pins and needles) in median nerve distribution - thumb and radial 2.5 fingers

* Usually the paraesthesia / pain is worse at night

* Loss of sensation and sometimes weakness of the thumb and radial 2.5 fingers

Question 7

What may be seen on examination in carpal tunnel syndrome?

Answer 7

On examination, there may be demonstrable loss of sensation and/or weakness of the thenar eminence

Question 8

How can symptoms of carpal tunnel syndrome be reproduced on examination? (what two tests)

Answer 8

Tinnel’s test - percussing over the media nerve

Phalen’s test (reverse prayer) - holding the wrists hyper-flexed for 60 seconds which decreases space in carpal tunnel

(Phalens flexing, Tinnels tapping)

Question 9

How is median nerve compression in carpal tunnel syndrome diagnosed?

Answer 9

Nerve conduction studies confirm the diagnosis with slowing of conduction across the wrist.

Question 10

WHat is the non-operative management of carpal tunnel syndrome?

Answer 10

Non-operative management includes the use of wrist splints at night to prevent flexion

Injections of corticosteroids can also be used

Question 11

What is the surgical management of carpal tunnel syndrome?

Answer 11

Surgical management is carpal tunnel decompression

Involves division of the transverse carpal ligament under local anaesthetic - highly successful

Question 12

In cubital tunnel syndrome, what is compressed and where?

Answer 12

In cubital tunnel syndrome, the ulnar nerve is compressed at the elbow behind the medial epicondyle (where you would hit your funny bone)

Question 13

What do patients complain of in cubital tunnel syndrome?

Answer 13

Patients complain of paraesthesia in the ulnar 1.5 fingers and weakness of ulnar nerve innervated fingers

(hypothenar muscles and abduction index finger and adductor pollicis)

Question 14

What are the two examination tests that can be used in cubital tunnnel syndrome?

Answer 14

Tinel’s test - tapping over the cubital tunnel reproduced paraesthesia

Froment’s test - weakness of the aductor pollicis due to ulnar nerve compression means the patient will compensate by flexing flexor pollicis longus of the thumb to maintain grip strength - can asssess this by placing both thumbs on a table

Question 15

Compression of the ulnar nerve can be due to a tight band of fascia forming the roof of the cubital tunnel What is this band of fascia known as? What muscle does the ulnar nerve pass through? another potential point for ulnar nerve compression

Answer 15

Osbourne’s fascia forms the roof of the cubital tunnel - can cause comrpession of the ulnar nerve

Ulnar nerve can be compressed when passing through or between the two heads at the origin of the flexor carpi ulnaris

Question 16

How is the diagnosis of cubital tunnel syndrome confirmed and how is it treated?

Answer 16

Nerve conduction studies confirm the diagnosis and the patient may need surgical release of any tight structures.

Question 17

The elbow joint describes the articulation between the humerus and the bones of the distal forearm. Which part of the elbow joint allows for flexion / extension? Which part of the elbow joint allows for supination / pronation?

Answer 17

The humero - ulnar joint allows for flexion / extension of the elbow

The radio-capitellar joint along with the proximal and distal radioulnar joints allows for supination / pronation

Question 18

Which epicondyle of the humerus does the common extensors and flexors of the wrist arise from?

Answer 18

Common extensor origin of the wrist is from the lateral epicondyle of the humerus

Common flexor origin of the wrist is from the medial epicondyle of the humerus

Question 19

The enthesis (attachment) of the common extensor and flexor origins can become painful (known as an enthesopathy). This gives rise to the conditions of lateral and medial epicondylitis. What is lateral epicondylitis also known as? What can it be caused by?

Answer 19

Lateral epicondylitis is also known as Tennis elbow

It can occur as a repetitive strain injury in tennis players and others who regularly perform resisted extension at the wrist (backhand shot) It can also be a degenerative enthesopathy

Question 20

What does pathology demonstrate in tennis elbow? What are the clinical features of tennis elbow?

Answer 20

Pathology demonstartes micro-tears in the common extensor origins in tennis elbow

Pain is felt at the lateral condyle, and in extension of the wrist and middle finger against resistance

Question 21

What is the treatment of tennis elbow?

Answer 21

Condition is normally self limiting

* NSAIDs can help with the pain

* Treatment involves a period of rest from activities that exacerbate the pain as well as phsyiotherapy

Question 22

If symptoms of tennis elbow persist after rest, NSAIDs and physiotherapy, what can be given to the patient?

Answer 22

Corticosteroid injections into the elbow can be considered or the use of an elbow brace (known as an elbow clasp)

Question 23

For refractory cases of tennis elbow, what treatment may be required?

Answer 23

Rarely, refractory cases may be offered surgical treatment which involves division and/or excision of some fibres of the common extensor origin however has variable results.

Question 24

What is medial epicondylitis also known as and what causes it?

Answer 24

Medial epicondylitis is also known as golfer’s elbow

It is a consequence of repeated strain or degeneration of the common flexor origin

Question 25

Is medial or lateral epicondylitis more common? What is the treatment of medial epicondylitis?

Answer 25

Golfers elbow (medial epicondylitis) is less common than Tennis elbow

It is also self limiting with physio, rest and NSAIDs being the mainstay of treatment

Question 26

Why is steroid injection of medial epicondylitis more risky than in lateral epicondyltiis?

Answer 26

Injection in medial epicondylitis area carries a risk of injury to the ulnar nerve.

Question 27

Is the elbow more commonly involved in osteoarthritis or rheumatoid arthriits?

Answer 27

Primary OA of the elbow is uncommon.

The elbow is often involved in rheumatoid arthritis and OA can occur after trauma (intra‐articular fractures).

Question 28

How are intra-articular fracturs of the elbow treated?

Answer 28

ORIF - open reduction internal fixation

Question 29

How is arthritic change at the radio-capitellar joint which has failed non-operative maagement treated? How are outcomes?

Answer 29

Arthritic change at the radio-capitellar joint which has failed non-operative management can be treated with surgical excision of the radial head - afford good pain relief with minimal functional limitation

Question 30

An elbow severely affected by RA or OA at the humero‐ulnar joint which isn’t satisfactorily treated with conservative management can be treated surgically What is the surgery carried out? What are patients restricted to lifting post-operatively?

Answer 30

Surgery for patients severely affected with RRA or OA which inst satisfactorily treat with conservative management can be treated surgically with a total elbow replacement

Lifting in these patients is restricted to 2.5kg post-cooperatively