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Elbow, Wrist, and Hand Patient Presentation • A 10 year old patient fell off “monkey bars” and braced his fall with an outstretched arm • He is grabbing his elbow close to him and appears in severe pain • What do you do next? Highest on Differential List • Posterior Dislocation • Fracture including supracondylar fracture • Soft Tissue Injury Check for deformity Check neuro- Attempt to vascular status determine the mechanism INJURY EVALUATION Determine need -Relocate? for x-rays - Refer? - Radiograph? Radiography of the Elbow • Trauma evaluation of the elbow should include: – A-P in full extension (if possible) – 90 degree flexed lateral view – both obliques – an axial view with elbow flexed to 110 degrees and beam angled 45 degrees • Special views include: – stress view performed supine with arm off table (gravity stress) – radial head-capitellum view – cubital tunnel view Dislocation of the Elbow Most often posterior due to hyperextension injury • Posterior (and often lateral) displacement of the ulna and radius on the humerus • Damage to the UCL, anterior capsule, and brachialis muscle • Apply ice, splint, check neurovascular status; refer for x- rays and treatment • Immobilization is usually for a number of weeks • Movement of the arm after immobilization must not be passive; always active movement • Complications include myositis ossificans, scar tissue formation, and ulnar nerve damage Supracondylar Fractures • Injury occurs in children under age of 12 • May look like a dislocated elbow; do not try to relocate an apparent dislocation without x-rays • At time of injury arm is splinted and neurovascular status is checked (especially median) • Usually there is rapid swelling which may lead to Volkmann’s ischemic contracture • Refer for immediate orthopedic consultation • Fracture occurs with a fall on hand of outstretched arm or with severe valgus force or direct blow • Pronation and supination are usually very painful; x-ray for fracture, however, fat pad sign may be only indicator • Sling or posterior splint for 3-4 weeks unless severely fragmented or displaced Volkmann’s Ischemic Contracture Radial Head Fracture Mechanism • Fracture occurs with: – fall on outstretched hand – severe valgus force – direct blow Evaluation • Significant pain on pronation and supination • X-ray to determine fracture (include radio-capitellum view), however, fat pad sign may be only indicator Treatment • Sling or posterior splint for 3-4 weeks unless severely fragmented or displaced Nursemaid’s Elbow Mechanism • Sudden jerking or swinging child (ages 2-4) by arms may cause damage or entrapment of the annular ligament Evaluation • Significant pain on pronation and supination • Palpation may reveal malpositioned radial head Treatment • Reduction through flexion and rotation Patient Presentation • A 20 year old patient is active in sports, in particular, baseball • He has pain at his medial elbow made worse by throwing • What do you do next? Static Stability of the Elbow • Medial stability - anterior oblique UCL • Ant. oblique tight in extension; posterior - flexion • Lateral stability - lateral ulnar collateral lig. (LUCL) • Sectioning/rupture of LUCL causes a pivot shift of the humeroulnar joint • The anconeus muscle is a major lateral stabilizer • Medial stabilization also from pronator/flexor group; lateral assistance from the extensor wad Ulnar Collateral Ligament Sprain • Occurs with pitching, hitting forehand stroke in tennis, the training arm of batters, arm wrestling, and collegiate wrestling • With throwing pain may be sudden, sharp, and often with a popping sound • Pain is increased with valgus testing • Chronic stress may lead to calcification of the UCL Medial Stretch Injury • Damage to the ulnar nerve • Strain of the flexor/pronator muscle group • Sprain of the anterior oblique portion of the ulnar collateral ligament • Strain and avulsion of the epicondyle • Inflammation of the joint capsule medially Medial Epicondylitis • Often referred to as Little League elbow; occurs in 9-12 year olds • In the adult, golfer’s elbow is the common diagnostic tag; injury due to throwing club down at ball • Swimmer’s elbow is another example: improper pull-through mechanics with the backstroke Ulnar Nerve Problems • Compression or irritation by fibrous cubital tunnel • Muscular hypertrophy of the flexor carpi ulnaris • Subluxation out of the groove Lateral Compression Injury • Lateral compression due to a valgus force may lead to: – articular cartilage damage at the distal humerus – osteocartilagenous lesion of the radial head which may lead to loose bodies • If progressive occurring during growth phase, permanent damage is likely with some severe restrictions in movement • Diagnosis made with radiographs (capitellum view) Little Leaguer’s Elbow • Includes soft tissue and osseous injury • Pt. presents with medial pain made worse by pitching, passive extension of the fingers/wrist, limitation of complete extension and occasionally a popping sound • Radiographs may show accelerated growth, separation or fragmentation of the medial epiocondylar epiphysis • Little League rules should be enforced and no curves or breaking pitches should be allowed in the 9-14 age group • Fracture displaced more than 1 cm needs surgical repair Osteochondritis Dissecans Patient Presentation • A 25 year old patient fell on his elbow • Subsequently he has developed swelling at the olecranon • During his workout, he felt a pop at the back of his elbow • What do you do next? Posterior Compartment Pathology • Triceps tendinitis at the olecranon insertion • Impingement causing posteriomedial osteophytes on the olecranon • Olecranon bursitis and avulsion fractures Orthopedic Testing of the Elbow • Tinel’s - ulnar nerve • Cozen’s/Mill’s and reverse - lateral and medial epicondylitis respectively • Stability testing - valgus for ulnar collateral/varus for radial (performed with 25-30 degrees of flexion) • Valgus extension - valgus extension overload causing posteromedial impingement • Repeated supination/pronation - for radiocapitellar chondromalacia Eccentric Exercise for the Elbow • Stretch using a static approach 15-30 seconds; repeat 3-5 x’s • Eccentric exercise performed with 3 sets of 10 • Slow sets first 2 days, intermediate next 2, and fast last 2 • Stretch statically as before exercise after each days session • Ice for 5-10 minutes • The third set of each day should cause some pain; if not slightly increase weight • If pain is felt during the first two sets reduce resistance or discontinue EVALUATION OBJECTIVES FOR CARPAL TUNNEL SYNDROME (CTS) CTS MANAGEMENT TIMELINE Patient Presentation • A 22 year old patient fell off his skateboard and braced his fall with an outstretched arm • He is grabbing his wrist close to him and appears to be in severe pain • What do you do next? Wrist Radiographs • Routine Series – PA – lateral – radial oblique – scaphoid axial projection • Supplementary Views - Fracture/Instability – PA in neutral, radial and ulnar deviation – laterals in neutral, full radial and ulnar deviation – bilateral AP views with fist actively clenched – other views include carpal tunnel view, oblique, and 30 degree semisupinated view Scaphoid Fractures • Proximal pole fractures result in 100% incidence of avascular necrosis; 30% for distal fractures: – distal fractures = 10% of total – proximal fractures = 20% of total – waist fractures = 70% of total • Pain at anatomical snuffbox following a fall on an outstreched hand; provocation test is to pronate and gently stress in ulnar plane • Scaphoid radiographic series includes: – PA, lateral, right & left obliques, PA with radial and ulnar deviation with fingers flexed – Bone scan or CT is diagnostic Always Include an Oblique Scaphoid Fractures • If initial films negative, immobilize for 2 weeks with follow-up films taken • Distal fractures heal in 4-6 weeks with a short arm cast • Fracture of the proximal 2/3rds is oblique to the long axis of wrist requiring a long arm cast with thumb spica for as long as 3-6 months Hook of Hamate Fracture • Hook of hamate is impacted from a bat, golf club, or raquet or all on an outstretched hand • Pain/tenderness at hamate; decreased, painful grip test • Carpal tunnel view or 20 degree supination view; bone scan or CT often necessary • 4th and 5th fingers in flexion and base of thumb in short arm cast for 10-12 weeks • Non-union common Radiographic Evaluation of Lunate on Lateral View • DISI - Dorsal Intercalated Segmental Instability is found with radial instability with rupture of scapholunate ligament; lunate rotates dorsally • PISI - Palmar (also called volar) Intercalated Segmental Instability found with rupture of the lunotriquetral ligament; lunate rotates into palmar-flexion • DISI pattern = scapholunate angle > 80 degrees or capitolunate angle > 30 degrees • PISI (or VISI) - scapholunate angle <30 degrees Normal Alignment on Lateral DISI Instability DISI DISI VISI Scapholunate Dissociation • Mechanism – disruption of scapholunate interosseous and radioscaphoid ligaments due to a fall on an outstretched hand • Evaluation – wrist pain, decreased grip strength, catch-up click – positive Watson’s test – PA radiograph reveals a “Terry-Thomas” sign = 2-3 mm space between scaphoid and lunate; DISI pattern is visible • Treatment – Surgery Lunotriquetral Dissociation • Mechanism – fall on outstretched hand or similar compressive maneuver • Evaluation – painful clicking over ulnar aspect of wrist – positive Ballotement test – possible PISI pattern on lateral radiograph • Treatment – Immobilization for 1st or 2nd degree sprain – Surgery may be necessary with more serious cases PISI Midcarpal Instability • Mechanism – Damage to the ligaments between the hamate and triquetrum occurs with a fall or blow to the medial side of the hand with hyper-pronation • Evaluation – positive popping/clicking with pain with active pronation coupled with ulnar deviation – DISI pattern may be visible on x-ray • Treatment – Immobilization for 6 weeks; in ineffective, several stabilizing surgeries are available Ulnar Variance Distal TFCC TFC Injury Distal Radio-Ulnar Injury • Mechanism – Usually a fall with wrist hyperextended and forearm hyperpronated; injury may occur at • Evaluation – swelling and tenderness over distal articulation – pain is increased with active or passive pronation – ulna may be slightly more prominent – radiographic findings are subtle • Treatment – ulna is reduced by dorsal pressure while supinating wrist; long arm cast for 4-6 weeks Keinbock’s Disease • Avascular necrosis of the lunate • Due to repetitive minor trauma; possibly related to ulnar variance • Lunate becomes more radiopaque as necrosis progresses • If detected, cast immobilization for 8 weeks • If unsuccessful, surgery may be necessary Rheumatoid Wrist Patient Presentation • A 22 year old patient complains of wrist pain primarily on the dorsum of the wrist • She is a classical pianist and has problems with practicing recently due to the pain • What do you do next? Diagnosis of Tendon Involvement • Localization of the involved tendon is based on: – insertion point tenderness or pain – resisted movement accomplished by tendon or stretch into opposite pattern • Other conditions must be differentiated such as fracture or ligament sprain before assuming tendon only problem DeQuervain’s Disease • Disorder of the abductor policis longus and extensor policis brevis • Is often an overuse syndrome due to repeated thumb extension/abduction • Pain & swelling over radial styloid is irritated by wrist ulnar deviation and thumb adduction with flexion (Finkelstein’s test) • Rest from inciting activity, myofascial and cross friction proximal to site of involvement Intersection Syndrome • Inflammation of the tenosynovium of the radial wrist extensors where they cross under the APL and EPB; 4-8 cm proximal to Lister’s tubercle • May result from trauma or repeated flexion/extension • Occurs in rowers, canoeists, and weight lifters • Rest and modification of inciting activity • Myofascial work proximal to site of involvement Treatment of Wrist Tendinitis • Cross-friction massage proximal to insertion point for a period of 1-3 weeks every other day • Cryotherapy and/or pulsed ultrasound • Stretching using PNF hold-relax technique • Adjust carpals • Mild isometric contractions into direction of pain may help • Avoid stretching tension that occurs with holding objects in hand such as a briefcase Patient Presentation • A 16 year old female was playing rugby • In a collision with another player she hurt her finger • There is no deformity, however, she cannot move the finger without significant pain • What do you do next? Quick Hand Evaluation • Allen’s • Two-point discrimination • Sensory – ulnar - volar tip of small finger – radial - dorsum of thumb web – median - volar tips of index & long fingers • Motor – ulnar - cross long finger over dorsum of index – median - point thumb towards ceiling; palm up Finger Motor Function • FDP - with MP & PIP joints held in extension, flex DIP joint • FDS - examiner holds all untested fingers in extension while patient flexes free finger • EDC - with wrist extension, extend at MP & IP joints • FDL - thumb held in extension at MP; ask patient to flex IP joint Boutonniere’s Deformity (Central Slip Tear) Mechanism • Hyperextension of MCP & DIP with flexion of PIP resulting from a flexion injury of the PIP tearing the dorsally located central slip. The lateral bands (the hood) drops anteriorly holding the PIP flexed. Evaluation • Point tenderness over dorsum of middle phalanx associated with generalized swelling of PIP; the PIP cannot be fully extended. Treatment • PIP splinted alone in extension to approximate central slip; followed by exercises to extended PIP & flex DIP. Boutonnere Deformity Pseudo-Boutonniere’s Deformity Mechanism • Extension injury of the DIP with damage to the volar plate. Evaluation • Point tenderness at volar, middle phalanx associated with generalized swelling of PIP; the PIP cannot be fully flexed or extended. • Progressive calcification seen radiographically at vola plate in 3-6 months. Treatment • PIP splinted alone in safety-pin splint PIP Extension Brace Jersey Finger Mechanism • Avulsion of FDP when a player grabs another player Evaluation • Unable to flex finger with FDP • Tendon may be displaced as far as the palm • X-ray to determine avulsion Treatment • Surgical repair is necessary Mallet Finger Mechanism • Avulsion of extensor tendon from DIP usually due to a blow to the finger (e.g. baseball finger). Evaluation • A “dropped” DIP in acute cases; swan neck in chronic • Tenderness at dorsal DIP • X-ray to determine avulsion Treatment • DIP only splinted in extension for 6-8 weeks Mallet Finger Swan Neck Deformity MC Collateral Ligament Injury Mechanism • Radial or ulnar stress to a flexed MCP joint may cause injury; usually due to fall on ground or player contact Evaluation • Pain and tenderness over MCP joint • Pain elicited on flexion with radial & ulnar deviation • Stress test at 70 degs. • X-ray may show an avulsed fragment at base of proximal phalanx Treatment • Immobilization in flexion for 3 weeks; buddy taping for 3 more PIP Collateral Ligament Injury Mechanism • Very common; finger pulled sideways and often subluxates and spontaneously reduces Evaluation • Pain and tenderness over collateral ligament and volar plate • Stress test only possible immediately after injury • X-ray may show an avulsed fragment at volar plate Treatment • Immobilization in flexion followed by buddy taping for if grade 1 & 2; grade 3 may need surgery Gamekeeper’s Thumb Mechanism • Sprain of ulnar collateral ligament when player falls or strikes opponent with thumb abducted Evaluation • Pain and tenderness over anteromedial aspect of MCP • Stress test applied at 0 & 30 degs. • Pain and weakness on pinch test • X-ray may show an avulsed fragment at proximal phalanx; stress x-rays may demonstrate instability Treatment • Taping with cinch or sort-arm cast based on degree; grade 3 needs surgery Boxer’s Fracture Mechanism • Fracture of the neck of the fifth metacarpal • Usually the result of heating an object with an uprotected wrist Evaluation • Look for rotational deformity • Percussion test on tip of finger painful. • Pain and weakness on pinch test • X-ray Treatment • Angular deformity up to 40 degs. Acceptable • With closed-reduction use thermoplastic gutter splinting or butterfly clamp Bennett’s Fracture Mechanism • Axial compression injury causing a trans-articular fracture of the first MCP joint with a triangular fragment of bone in place while shaft dislocates and held proximally by pull of APL Evaluation • Significant pain and swelling at first metacarpal • X-ray to determine avulsion and distinction from similar fractures Treatment • Open reduction with fixation Bennett’s Fracture Ganglions Mechanism • Benign tumorous masses that may be intra- or extra-articular • Thought to be due o congenital weakness or traumatic damage to ligaments or tendon Evaluation • Pain and tenderness over palpable mass • When deep, may not be palpable • Most common locations are dorsally at scapholunate ligament and ventrally in FCR tendon or other flexors Treatment • Rest and immobilization may help; surgical excision may be necessary Dupuytren’s Contracture • Nodular thickening of the fourth & fifth finger flexors • Eventually fingers flexed at the MCP & PIP with DIP held in extension • Management includes frequent stretching and possibly immobilization at night in a soft cast • Eventually surgery may be necessary to release the fibrous tissue Dupuytren’s Contracture
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