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Elbow_ Wrist_ and Hand

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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

Check neuro-                                   Attempt to
vascular status                               determine the

                  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
• 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
Volkmann’s Ischemic
            Radial Head Fracture
• Fracture occurs with:
   – fall on outstretched hand
   – severe valgus force
   – direct blow
• Significant pain on pronation and supination
• X-ray to determine fracture (include radio-capitellum
  view), however, fat pad sign may be only indicator
• Sling or posterior splint for 3-4 weeks unless severely
  fragmented or displaced
            Nursemaid’s Elbow
• Sudden jerking or swinging child (ages 2-4) by arms may
  cause damage or entrapment of the annular ligament
• Significant pain on pronation and supination
• Palpation may reveal malpositioned radial head
• 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

• Muscular hypertrophy of the flexor carpi

• Subluxation out of the groove
    Lateral Compression Injury
•  Lateral compression due to a valgus force may lead
   – 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
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
• Triceps tendinitis at the olecranon insertion

• Impingement causing posteriomedial
  osteophytes on the olecranon

• Olecranon bursitis and avulsion fractures
    Orthopedic Testing of the
• 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
• 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
•    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
         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
      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
• 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
       Scapholunate Dissociation
• Mechanism
   – disruption of scapholunate interosseous and
     radioscaphoid ligaments due to a fall on an outstretched
• 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
• 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
          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
• Localization of the involved tendon is based
  – 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
• 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)
• 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.
• Point tenderness over dorsum of middle phalanx associated
  with generalized swelling of PIP; the PIP cannot be fully
• PIP splinted alone in extension to approximate central slip;
  followed by exercises to extended PIP & flex DIP.
Boutonnere Deformity
 Pseudo-Boutonniere’s Deformity
• Extension injury of the DIP with damage to the volar plate.
• 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.
• PIP splinted alone in safety-pin splint
PIP Extension Brace
                  Jersey Finger
• Avulsion of FDP when a player grabs another player
• Unable to flex finger with FDP
• Tendon may be displaced as far as the palm
• X-ray to determine avulsion
• Surgical repair is necessary
                  Mallet Finger
• Avulsion of extensor tendon from DIP usually due to a
  blow to the finger (e.g. baseball finger).
• A “dropped” DIP in acute cases; swan neck in chronic
• Tenderness at dorsal DIP
• X-ray to determine avulsion
• DIP only splinted in extension for 6-8 weeks
Mallet Finger
Swan Neck Deformity
  MC Collateral Ligament Injury
• Radial or ulnar stress to a flexed MCP joint may cause
  injury; usually due to fall on ground or player contact
• 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
• Immobilization in flexion for 3 weeks; buddy taping for 3
   PIP Collateral Ligament Injury
• Very common; finger pulled sideways and often subluxates
  and spontaneously reduces
• 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
• Immobilization in flexion followed by buddy taping for if
  grade 1 & 2; grade 3 may need surgery
           Gamekeeper’s Thumb
• Sprain of ulnar collateral ligament when player falls or strikes
  opponent with thumb abducted
• 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
• Taping with cinch or sort-arm cast based on degree; grade 3
  needs surgery
                Boxer’s Fracture
• Fracture of the neck of the fifth metacarpal
• Usually the result of heating an object with an uprotected wrist
• Look for rotational deformity
• Percussion test on tip of finger painful.
• Pain and weakness on pinch test
• X-ray
• Angular deformity up to 40 degs. Acceptable
• With closed-reduction use thermoplastic gutter splinting or
  butterfly clamp
              Bennett’s Fracture
• 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
• Significant pain and swelling at first metacarpal
• X-ray to determine avulsion and distinction from similar
• Open reduction with fixation
Bennett’s Fracture
• Benign tumorous masses that may be intra- or extra-articular
• Thought to be due o congenital weakness or traumatic damage to
  ligaments or tendon
• 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
• Rest and immobilization may help; surgical excision may be
      Dupuytren’s Contracture
• Nodular thickening of the fourth & fifth finger
• 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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