What is carpal tunnel syndrome?
Compression of the median nerve as it passes through the carpal tunnel
What forms the carpal tunnel?
The carpal bones and the flexor retinaculum at the wrist
What passes through the carpal tunnel?
9 flexor tendons
What can carpal tunnel syndrome be secondary to?
Rheumatoid arthritis (synovitis > less space)
Chronic renal failure
Which fracture in particular can predispose to carpal tunnel syndrome?
How does carpal tunnel syndrome present?
Parathesiae in the median nerve innervated digits (thumb and radial 2½ fingers)
Worse at night
Loss of sensation
Weakness of thumb
Clumsiness in areas of hand supplied by median nerve
What signs on examination would indicate carpal tunnel syndrome?
In severe cases, thenar muscle wasting
Symptoms reproduced by Tinels test
Symptoms reproduced by Phalen’s test, holding the wrists hyper‐flexed (which decreases space in the carpal tunnel)
What test can confirm the diagnosis of carpal tunnel syndrome?
Nerve conduction testing
Shows slowed conduction across the wrist
What is the non-surgical treatment avaliable for carpal tunnel syndrome?
Wearing splints at night
Injection of corticosteroid
What is the surgical treatment of carpal tunnel syndrome?
Carpal tunnel decompression involves division of the transverse carpal ligament under local anaesthetic
What is cubital tunnel syndrome?
Compression of the ulnar nerve at the elbow behind the medial epicondyle
How does cubital tunnel syndrome usually present?
Paraesthesiae in the ulnar 1½ fingers
What is Osborne's fascia?
A tight band of fascia forming the roof of the cubital tunnel
What can cause cubital tunnel syndrome?
Tightness at the intermuscular septum as the nerve passes through or between the two heads at the origin of flexor carpi ulnaris
What test on examination is indicative of cubital tunnel syndrome?
What does Froment's test involve?
Ask the patient to grip an object e.g. a piece of paper between thumb and index finger to test strength of adductor pollicis
In a positive test, the weakness of adductor pollicis will mean the patient compensates by flexing flexor pollicus longus of the thumb to maintin grip strength
What is the repetitive strain injury in Tennis elbow/lateral epicondylitis?
Resisted extension at the wrist
What are the two ways that tennis elbow can occur?
Repetitive strain injury
Degenerative enthesopathy (inflammation of the origin or insertion of a tendon or ligament into bone)
What is tennis elbow?
What is the pathology in tennis elbow?
Micro‐tears in the common extensor origin
How does tennis elbow present?
Painful and tender lateral epicondyle and pain on resisted middle finger and wrist extension
What is the conservative treatment of tennis elbow?
Rest from the activities that exacerbate the pain
Use of a brace (known as an elbow clasp)
What is the surgical treatment for tennis elbow?
Division and/or excision of some fibres of the common extensor origin
What is golfers elbow?
Medial epicondylitis - repetitve strain or degeneration of the common flexor origin
Which is more common: tennis elbow or golfers elbow?
Tennis elbow - lateral epicondylitis
What is the risk associated with steroid injection to treat golfers elbow?
Risk of ulnar nerve damage
How can arthritic change at the radio-capitellar joint that has not responded to conservative management be treated?
Surgical excision of the radial head
How can arthritic change at the humero-ulnar joint that has not responded to conservative management be treated?
Total elbow replacement
How does radial nerve injury due to humeral shaft fracture present?
Loss of sensation in 1st dorsal web space
How are most cases of humeral shaft fracture treated?
Non-operatively with a functional humeral brace which compresses the fragments into acceptable alignment and provides some stability
What is the treatment for intra-articular fractures of the distal humerus?
Ppen reduction, internal fixation (ORIF)
Anatomic reduction and rigid fixation to minimize loss of function
How do olecranon fractures occur?
Usually occur with a fall onto the point of the elbow with contraction of the triceps muscle
How are olecranon fractures usually managed?
ORIF to restore triceps function and restore the articular surface
How can a simple transverse avulsion fracture of the olecranon be treated?
Tension band wiring which compresses the tension side of the fractures
How do radial head and neck fractures usually occur?
Fall on an outstretched hand
How might an undisplaced radial head or neck fracture present?
Lateral elbow pain on supination / pronation
'Fat pad' on lateral xray (a triangle like a sail anterior to the distal humerus)
How are minimally or undisplaced radial head or neck fractures treated?
Early elbow exercises to minimise stiffness
How can restricted range of movement following radial head/neck fracture be assisted, or differentiated from a mechanical block?
Aspiration of hemarthrosis
Injection of local anaesthetic
When is ORIF performed in radial head/neck fractures?
If the fragment is large enough or excision if not amenable to fixation
In what direction do most elbow dislocations occur and how?
In the posterior direction after a fall onto the outstretched hand
What is the treatment for uncomplicated elbow dislocations?
Closed reduction under sedation
1-3 weeks in sling
What fractures are associated with elbow dislocation?
Coronoid process of the ulna
How are epicondyle fractures fixed?
With a screw