Elbow wrist hand CPG, SR, concepts

Question 1

Rule in / out

UCL sprain

Answer 1

• moving valgus stress
  
  • 120–>70^o with valgus stress
  • Sn 1.0 - LR 0.0
  • Sp .75, +LR 4.0
    *

Question 2

CPR Lateral Epicondylagia MWM

(Vicenzino Man Ther 2008)

Answer 2

1. <49 +LR2.6
2. Affected UE pain free grip >25# +LR 2.3
3. Unaffected UE PF grip < 75# +LR2.1

3/3 +LR infinite, 100%

2/3 +LR 3.7

1/3 +LR 1.8

Question 3

Lateral epicondylagia intervention evidence

(Coombes 2015)

Answer 3

• CSI
  
  • Strong evidence
    
    • short-term pain relief
    • worse outcomes @ 6/12 mos compared to PT or wait and see
• Manual Therapy
  
  • Moderate evidence
    
    • immediate effects pain/grip strength
    • c & tspine provide addtl benefit
• Exercise
  
  • Strong evidence (either alone or with MT)
    
    • no exact dosage etc
• Dry needling or acupuncture
  
  • Biased, but perhaps short term results

Question 4

Coombes 2015

Treatment Guidelines

Answer 4

• Low risk
  
  • PRTEE < 33/100
  • no negative prognostic factors
  • –>wait and see for 6-12 weeks
• Moderate risk - one or more of:
  
  • “not much better” after 6-12 weeks
  • PRTEE > 33/100
  • repetive manual tasks/heavy labor
  • low job control
  • significant neuromuscular impairments
  • co-existing path
  • –>multi-modal PT
• High risk - one or more of:
  
  • PRTEE > 54/100
  • co-existing neck/shoulder pain
  • central sensitization (CPT>13^oC)
  • “not much better” after 8-12 weeks
  • –>multimodal PT AND pharamcological therapy

Question 5

Carpal tunnel CPR

(Wainner 2005)

Answer 5

• >45
• reports shaking hands relieve sxs
• wrist ratio index > 0.67
• reduced median sensory field D1
• symptom severity score >1.9

4/5 Sn .77, Sp .83, -LR .28 +LR 4.6

5/5 Sn .18, Sp .99 -LR .83 +LR 18.3

Question 6

CTS treatment

Answer 6

• Ultrasound > placebo
• Tendon gliding / nerve gliding = custom volar splint = carpal bone mobilizations?

Question 7

Median Nerve entrapment

(AIN vs. pronator teres vs. ligament of struthers)

Answer 7

AIN

• deep branch of median nerve
• MOTOR only: FDL, FDP, pronator quadrutus (“OK”–>pinch)
• NO SENSORY LOSS

Pronator teres

• Motor: FCR, PL, FDS, APB, FPB, OP, 1-2 lumbricals
• Sensory: central volar wrist, lateral palm, volar 3 1/2 digits

Struthers ligament

• bony spur
• weakness of pronator teres

Question 8

Ulnar nerve entrapment

(cubital tunnel vs. guyon vs. retrocondylar groove)

Answer 8

Cubital tunnel

• Elbow flexion test (Sn.75, -LR .25, Sp .99 +LR 75)
• Warternberg’s sign (can’t ADD D5)
• ulnar nerve compression test (Sn.89 -LR.11, Sp .98 +LR 44.5)
• froment’s sign (paper b/t D1-D2, D1 DP flexes)

Guyon tunnel pattern

• can be motor or sensory

Retrocondylar groove

• typically requires surgery

Question 9

Radial Nerve entrapment

(PIN vs. entrapment at arm, entrapment at axilla)

Answer 9

PIN (radial n. in supinator arcade of frohse)

• MOTOR
  
  • ECRB/L (nml), supinator (nml), ED, ECU, EDM, APL, EPB, EPL, EI
  • Pain with resisted supination
• Sensory = NORMAL

Arm entrapment

• normal triceps; brachioradialis weak & drop wrist

Axilla entrapment

• weakness entire radial nerve
• pain at posterior

Question 10

Wrist/hand conditions (non-trauma)

(deQuervains, intersection syndrome, ECU tendonitis, ECU subluxation)

Answer 10

• deQuervains’
  
  • most common injury @ wrist
  • • Finklestein
  • Rest = most curative; CSI helpful
• intersction
  
  • 1st (APL, EPB) and 2nd (ECRL/B) dorsal compartment
• ECU tendonitiis
  
  • 2nd to deQuervains
  • compensation for TFCC

Question 11

Wrist/hand conditions (trauma)

MCP collateral ligament

bennett’s fracture

volar plate avulsion fx

flexor digitorum profundus avulsion

Answer 11

• MCP collateral ligament
  
  • valgus stress
    
    • laxity in flexion
    • lacxity in extension
  • Stener lesion (UCL dsplaced under adductor)
• Bennett’s
  
  • most common 1st MC fx
• Volar plate avulsion
  
  • forced hyper-ext
  • “v-sign” on X-ray
  • 40% involvement –>surgical
• FDP avlusion (“jersey” finger)
  
  • forced finger extension against active flexion
  • loss of AROM at DIP (fingertip not touching palm with fist)
  • surgical referral

Question 12

Carpal fracture

CPR

Answer 12

• edema in wrist (PPV 95%)
• TTP to wrist (Sn . 94, PPV 67.3%)
• AROM pain ext/flexion Sn .97, PPV 77%
• PROM pain ext/flexion Sn. 94 PPV 91%
• Pain with grip PPV 89.6%
• Pain with supination PPV 96%

Question 13

Carpal fractures

Answer 13

• scaphoid
  
  • 70% of all carapl fx; 15-30yo; proximal pole = worse prognosis
  • TTP snuffbox; limited wrist EXT, swelling
  • axial load to thumb –> high Sn and Sp
• hook of hamate
  
  • low incidence; x-rays not diagnostic
  • excision better than ORIF
• lunate
  
  • keinbocks; x-ray false negative
• pisiform
  
  • excision

Question 14

carpal ligamentous injuries

Answer 14

• scapholunate
  
  • Watson’s Sn .69, -LR .47, Sp.66, +LR 2.0
  • • lunotriquetral
  • FOOSH, click with loading; lunotriquetral shear test
  • immobilization 80% success
• mid-carpal instability
• DRUJ & TFCC
  *

Question 15

Distal radius / ulna fractures

Answer 15

• Colles - dorsal angulation/displacement; extra articular
• Smith’s - volar angulation/displacement; extra-articular
• Barton’s - volar/dorsal displacement; intra-articular
• Boxers - rotational malalignment of finger in flexion; loss of MCP/PIP extension
  *

Question 16

FInger injuries

Answer 16

• Mallet
  
  • avulsion distal slip of extensor tendon
  • splint 6-8 wks full extension
• Boutounierre
  
  • DIP hyperextended, PIP flexed
  • splint & exercise
• Swan neck
  
  • DIP flexion, PIP hyperextended
  • surgical

Question 17

Hand OA

CPR (level III evidence only)

Answer 17

1. Hand pain, aching or stiffness AND
2. Hard tissue enlargement of >2/10 selected joints
3. <3 swollen MCP joints and either
4. hard tissue enlargement of >2 DIP OR
5. deformity of >2/10 selected joints

>4/5 +LR4.6, -LR 0.1