Wrist and Elbow Injuries Flashcards
What is another name for Lateral Epicondylitis and what is it?
“Tennis Elbow”
It is Tendinitis/Tendinosis of the extensor wad of the elbow - MC to the ECRB (Extensor Carpi Radialis Brevis).
Who gets Tennis Elbow?
30-50 y/o; M=F - laborers w/frequent heavy lifting/gripping/grasping, tennis players.
Clinical Presentation of Tennis Elbow?
- Pain w/gripping/grasping.
- Focal lateral elbow pain; may radiate into proximal forearm and described as dull/achy/toothache type pain; may feel like dropping an object they are holding.
- Aggravated w/activity.
- Alleviate w/Rest/Ice/NSAIDs.
- Insidious onset.
PE of Tennis Elbow?
- No abnormality on inspection.
- Mild - Severe TTP to lateral epicondyle.
- Pain reproduced w/resisted wrist extension.
What is Cozen’s Test?
Test for Tennis Elbow - pain that is reproduced w/resisted wrist extension.
Diagnostics for Tennis Elbow?
- X-ray = likely normal; may see changes such as cystic or enthesopathic.
- U/S = can eval integrity of the tendon, low cost, noninvasive.
- MRI = surgical planning; not required for Dx.
Treatment for Tennis Elbow?
- Treatment is listed from least invasive to most invasive:
- Rest, activity modification, bracing, compression sleeves.
- NSAIDs.
- PT (strengthening, massage, taping, dry needling).
- CS Injections.
- PRP (platelet rich plasma).
- Surgery, which is reserved for pt’s who have exhausted the above options; have severe tendon degradation.
What is Olecranon Bursitis? What are the causes?
Inflammation of the bursa of the elbow.
-Bursa is the thin-fluid filled sac acting as a cushion b/t bony prominences and soft tissue structures.
Causes:
- Trauma (acute injury to the elbow).
- Repetitive microtrauma.
- Infection = injury to tip of elbow breaking skin and inoculating the bursa w/bacteria.
- Rheumatoid, Gout.
Clinical Presentation of Olecranon Bursitis?
- Likely an inciting even or pertinent medical condition.
- Focal swelling about posterior elbow; unilateral.
- Aggravated w/direct pressure, elbow flexion.
- Alleviated w/compression, activity modification, aspiration.
- May or not be painful - infx/gout are usually painful.
- Infection (erythematous, warm to touch, +/- wound, +/-purulence.
- Gout/Pseudogout; tophi may be present.
Diagnostic tests for Olecranon Bursitis?
- X-ray = eval for any bony trauma, retained FB.
- Fluid analysis = cell count/sed rate, ESR/CRP, gram stain, crystals, culture.
- MRI/US = less common; better to eval assoc. injuries, abscess, osteomyelitis, tumor, etc.
Treatment for Olecranon Bursitis?
- Rest, activity modification, reassurance.
- NSAIDs, compression sleeve, elbow pad - the mainstay for acute trauma and chronic bursitis.
- Aspiration, +/- CS injection (can be diagnostic and therapeutic).
- Surgery - reserved for chronic noninfectious bursitis and infectious bursitis (septic pt’s).
- *Trial of Abx in healthy pt’s w/infectious olecranon bursitis.
What is Distal Biceps Rupture and who gets it?
A rupture of the insertion of the biceps from the radial tuberosity.
- *Accounts for 10% of bicep ruptures (rare compared to proximal long head biceps rupture).
- Men»_space; Women (93%) in 40-60 y/o.
Clinical Presentation of Distal Biceps Rupture?
- Acute injury - typically eccentric injury (flexed elbow forced into extension); can occur lifting a heavy object.
- Focal anterior elbow pain - may have felt a “pop.”
- Aggravated w/motion.
- Alleviated = may be none; Rest/Immobilization.
- Pain described as sharp/stabbing/throbbing pain.
PE of Distal Biceps Rupture?
Inspection:
-Reverse Popeye Sign (tendon retraction), ECCHYMOSIS at ant. elbow/AC space.
Palpation:
- Complete rupture will have a palpable defect.
- Weakness w/supination, some loss of elbow flexion strength.
- (+) Hook Test.
What is the Hook Test?
Used to identify a distal biceps rupture.
*Pt. flexes elbow to 90 degrees, full supination, examiner is able to place their finger 1 cm beneath the tendon.
Will a pt with a distal biceps rupture be able to flex their elbow?
Yes - the problem is with supination.
Diagnostic tests to order for a distal biceps rupture?
X-ray = may have an avulsion from the radius. U/S = identify ruptured tendon. MRI = non-contrast; operative planning - GOLD Standard.
Treatment for a distal biceps rupture?
Non-Operative mgmt:
- reserved for partial tears, pt’s who are low demand.
- PT, bracing, analgesia (NSAIDs).
Surgery:
- pt’s who are high functioning and active that will benefit from operative intervention.
- will require PT post-op to regain ROM, strength.
- surgery should occur w/in a few days to weeks from injury.
What is an Ulnar Collateral Ligament tear (UCLT)? Who gets it?
It is a rupture of the ulnar collateral ligament of the medial elbow from acute trauma (dislocation) or repetitive microtrauma.
Overhead athletes placing excessive valgus stress on the elbow (baseball, javelin thrower); high-velocity trauma (dislocation - wrestler, MVC, fall from height).
Clinical presentation of an Ulnar Collateral Ligament Tear?
- Usually an acute injury - elbow dislocation, one pitch “felt a pop,” may have anteceded elbow pain.
- Focal medial elbow pain; no radiation.
- Aggravated w/motion.
- Alleviated by mostly rest/immobilization.
- Pain described as sharp/stabbing/throbbing pain and may describe a feeling of “tightness” in the elbow, which is due to hemarthrosis.
PE of an Ulnar Collateral Ligament Tear?
- may have an abnormality to inspection.
- +/- swelling, ecchymosis.
- Tenderness at medial epicondyle of humerus.
- Laxity to valgus stress:
- -flex elbow to 30 degrees, apply valgus stress to elbow and will have soft endpoint w/complete tear.
Diagnostic tests to order for UCLT?
- Xray - may have bony avulsion, but uncommon.
* MRI - GOLD standard; operative planning. w/an arthrogram - will allow for eval of partial vs full thickness tear.
Treatment of UCLT?
Non-operative:
- Rest, PT, activity modification.
- Often 1st line therapy for most pt’s.
Surgery:
- “Tommy John” surgery; UCL reconstruction.
- Reserved for high level athletes; those who want to continue high level overhead sports.
- Lengthy recovery, extensive PT.
What is Radial Nerve Palsy? Who gets it?
It is an injury to the radial nerve in the upper arm (radial nerve courses through the spiral groove of the humerus); it results in inability to extend the wrist, digits and 1st dorsal web space numbness.
Often associated w/humerus fractures; nerve injury may occur at time of Fx, during reduction or operative intervention.
Clinical presentation of radial nerve palsy?
“Wrist Drop” is clinical; it is an inability to extend the wrist, digits and thumb.
- Inability to independently extend index finger.
- Numbness - 1st dorsal web space, dorsal aspect of the radial 3.5 digits.
Diagnostic tests for radial nerve palsy?
EMG/Nerve conduction study:
- it will help follow nerve recovery.
- order 3-4 months post injury.
- follow pt for PE in clinic every few weeks (wrist extension returns 1st and index finger extension last.
X-ray will not tell you anything about a nerve injury.
Treatment for radial nerve palsy?
Non-operative:
- “Watch and Wait” Dx.
- PT for passive stretching.
- Wrist cock-up splint.
- NMES/TENS for muscle re-education.
Surgery:
-primary radial nerve repair; often does not yield return to function.
What is Cubital Tunnel Syndrome? Who gets it?
Nerve compression at the elbow.
Overuse, prolonged elbow extension, unstable ulnar nerve (“snapping”); no diff in M/F, age.
Clinical Presentation of Cubital Tunnel Syndrome?
- Numbness/tingling/burning on ulnar side of 4th digit, 5th digit - worse w/elbow flexion.
- Decreased grip strength and pinch.
- Claw hand.
- (+) Tinels at the elbow.
- (+) Froments sign.
- +/- subluxation of ulnar nerve.
What is Fromet’s Sign?
Place a piece of paper b/t the thumb and index finger, bilaterally; ask the pt to prevent you from pulling the paper from their grip. If one of the thumbs compensates for the decreased pinch strength due to weakness of thumb adduction = +Fromets Sign.
Diagnostics for Cubital Tunnel Syndrome?
- X-ray - eval bony abnormality; will likely be normal.
- U/S - eval for space occupying lesion; likely normal.
- EMG/Nerve conduction study:
- Mainstay but not required for Dx.
- Can help eval severity of nerve damage.
- Can help eval “double crush” – nerve entrapment elsewhere.
Treatment for Cubital Tunnel Syndrome?
1: NSAIDs, nighttime extension splinting to allow nerve to heal.
- PT.
- Surgery – cubital tunnel release, possible ulnar nerve transposition for those w/subluxing ulnar nerve.
Carpel Tunnel Syndrome and who gets it?
MC compressive neuropathy - compression of the median nerve at the wrist.
F>M; assoc. w/DM, pregnancy, hypothyroidism, RA, Amyloidosis, +many others.
Clinical presentation of Carpel Tunnel Syndrome?
- Numbness/tingling/burning in thumb, index, middle, radial fingers.
- Pain/numbness/tingling worse at night - “wake and shake.”
- Clumsiness, drops things, difficulty w/fine motor activity.
- Chronic carpal tunnel – Thenar atrophy.
Phalen’s test and Tinel’s sign for Carpel Tunnel Syndrome?
Phalen’s test - reverse prayer; reproduces pain when median nerve compressed.
Tinel’s Sign - tapping at wrist reproduces pain.
Diagnostics for Carpel Tunnel Syndrome?
X-ray = eval bony abnormality; likely normal.
U/S = eval for space occupying lesion; likely normal.
EMG/Nerve conduction study:
-help eval severity of nerve damage.
-diff. b/t DN and carpal tunnel.
-eval “double crush” – nerve entrapment elsewhere.
-not required for Dx.
What “double crush” mean?
a nerve entrapment elsewhere.
Treatment for carpal tunnel?
NSAIDs, nighttime wrist bracing, activity modification.
**CS Injections - can be diagnostic and therapeutic.
Surgery - carpal tunnel release.
What is Kienbock’s Disease? Who gets it?
AVN of the lunate; it is not much of a disease as a sequala of trauma.
Males 20-40 w/Hx of wrist trauma.
Why are we so concerned about such a small bone (lunate) involved with Kienbock’s Disease?
The lunate provides a significant amount of stability and ROM to the wrist.
Clinical presentation of Kienbock’s Disease?
- Hx of remote wrist trauma; does not have to be acute.
- Dorsal wrist pain worse w/wrist ROM, weight-bearing throughout wrist (pushing out of chair, pushups, picking up something heavy).
- Wrist stiffness/decreased ROM compared to other side.
- May be incidental finding/pt may be asymptomatic at time of Dx.
Diagnostics for Kienbock’s Disease?
- X-ray = can be normal early; will show bony resorption in later stages.
- MRI = ideal for early disease (x-ray normal).
- CT = ideal in later disease, once lunate has collapsed (CT better bony detail).
Treatment for Kienbock’s Disease?
- NSAIDs/observation in early disease.
- Wrist bracing.
- activity modification.
- Surgery:
- most surgical options lead to decrease in ROM, function/strength but improved pain.
What is a Ganglion cyst?
A synovial cyst caused by trauma, synovial herniation.
anyone can get it; slight prevalence in women 20-40 y/o.
What is the most common hand mass?
Ganglion Cyst. Dorsal side»_space; Volar side.
Clinical presentation of a ganglion cyst?
- Hx of trauma; may be insidious onset.
- usually painless.
- may cause decrease in ROM, depending on size of the mass.
- mas may fluctuate in size.
Diagnostics for a ganglion cyst?
- X-ray = usually unremarkable, can eval for abnormality in the setting of ganglion w/trauma.
- U/S = used for aspiration; can eval mass contents.
- Transillumination = should illuminate; solid masses no.
Treatment of a ganglion cyst?
- Reassurance - benign; no treatment required.
- Aspiration - high recurrence rates.
- Surgery:
- excision of mass, closure of joint capsule where stalk of the cyst originates.
- recurrence lower at 3-10%.
