Elbow-Wirst-Hand-Arm - MSK

Question 1

Acute elbow pain:

What to think about?

Answer 1

• fractures, dislocations, tendon/ligament ruptures

- less common than chronic elbow pain

Question 2

Chronic elbow pain: What to think about?

Answer 2

• majority of elbow pain lasts > 2 wks and is attributed to overuse injuries
• multiple etiologies

Question 3

Stiffness: What to think about?

Answer 3

• arthritis, trauma, immobilization

- mildly decreased ROM typically does not affect ADL’s

Question 4

Elbow Arthritis

Answer 4

-Includes RA, OA, gouty arthropathy (nonrheumatoid inflammatory arthritis), posttraumatic arthritis, and septic arthritis
-RA is the most common cause of elbow joint destruction
RA -early stages -> localized pain, swelling-advanced disease -> diffuse pain, instability
OA -pain and decreased ROM-catching and locking sensation if loose bodies present
-Gouty arthropathy (or pseudogout) -acute pain, swelling, effusion, warmth, decreased ROM
-Septic -acute and severe pain, stiffness, warmth, swelling, effusion -systemic sxs -> F/C, malaise
-RA: swelling/bogginess, tenderness (radial head or diffuse), possible nodules (olecranon and extensor forearm)
-OA/Posttraumatic: joint line tenderness, decreased ROM, typically NO effusion*
-Gouty arthropathy/Septic arthritis: severe pain w/ROM, large effusion, warmth, redness
DX: AP and lateral x-rays typically sufficient
-RA: symmetric joint narrowing, erosions, possible gross destruction
-OA: osteophytes, joint space narrowing, loose bodies
-Posttraumatic: malunion, nonunion, joint space narrowing
-Gouty/Septic: typically normal early on, later may show effusion
-Aspiration of joint fluid often beneficial for helping to distinguish b/w gouty and septic arthritis

Question 5

Elbow Arthritis-Treatment

Answer 5

• RA: PT, medications, intra-articular steroid injections, splints, synovectomy, total arthroplasty (if advanced)
• OA/Posttraumatic: analgesics, gentle stretching, arthroscopic surgery (remove foreign bodies), total arthroplasty (not generally beneficial)
• Gouty arthropathy: treat underlying cause, consider intra-articular steroid injections
• Septic: Prompt surgical drainage and antibiotics

Question 6

Elbow Dislocation

Answer 6

• Most commonly dislocated joint in children
• Typically results from a fall on an outstretched hand (FOOSH)
• Posterolateral dislocations most common
• May be complete or subluxated
• Lateral collateral ligament is nearly always disrupted
• Concomitant fractures or nerve injuries may occur
• Clinical Presentation: -significant pain, swelling, inability to bend elbow
• PE Findings:-deformities and tenderness -MUST assess radial pulse, capillary refill, medial/ radial/ulnar nerve function
• Diagnosis: -AP and lateral x-rays, look for fractures as well
• Complications: -persistent loss of motion or instability, arthritis

Question 7

Elbow Dislocation Tx

Answer 7

• reduction ASAP in ED or by Orthopedic surgeon
• after reduction, neurovascular exam must be repeated
• apply splint and obtain x-rays to confirm reduction
• ROM should begin 5-7 days after reduction, gradually progress over 3-6 weeks (while in brace)
• full extension should be achieved 6-8 weeks after dislocation (brace removed)
• NSAIDS can be helpful
• If at any time concerns arise  immediate referral

Question 8

Nursemaids Elbow

Answer 8

• Subluxation of the radial head
• Most common elbow injury in children < 5 yrs old
• Associated w/increased ligamentous laxity
• Mechanism of injury: pulling on the forearm when elbow is extended and forearm pronated
• Annular ligament slips proximally b/w radius and ulna
• Clinical presentation -immediate pain, child will cry, -pain will decrease but child will be very reluctant to use his/her arm
• PE Findings-tenderness over radial head, resistance to supination
• Diagnosis -x-rays are normal
• Tx: Reduction: 1. Place thumb over radial head and fully supinate forearm 2. If fails to reduce then flex the elbow 3. A snap may be perceived as annular ligament slips back into position -If successful, the child should begin using their arm again w/in minutes- If reduction attempts are unsuccessful-immobilization with cast/splint may be used

Question 9

Lateral Epicondylitis

Answer 9

• Lateral epicondylitis (“Tennis elbow”)
• Typically occurs in pt’s b/w age of 35-50
• Clinical presentation-mainly symptomatic w/activities that involve gripping and wrist extension (i.e.-lifting, turning, hitting a backhand)
• PE Findings -localized tenderness just distal and anterior to lateral epicondyle (0ver common extensor origin) -pain when extending wrist against resistance or lifting object with the palm down

Question 10

Medial Epicondylitis

Answer 10

• (“Golfer’s elbow, Bowler’s elbow)
• Much less common than lateral epicondylitis
• Clinical presentation: -mainly symptomatic w/activities that involve wrist flexion and forearm pronation (i.e.-swinging a golf club, baseball pitching, swimming, weight lifting, bowling, labor)
• PE Findings: -localized tenderness just distal to medial epicondyle (0ver common flexor/pronator origin), -pain when flexing wrist against resistant or lifting object with the palm up

Question 11

Lateral & Medial Epicondylitis-Dx, Complications

Answer 11

Diagnosis

• AP and lateral x-rays to r/o arthritis, loose bodies
• MRI can confirm dx and severity but rarely necessary

Complications
-persistent pain, weakness w/heavy lifting, difficulty w/strenuous activities/athletics

Question 12

Lateral and Medial Epicondylitis Treatment

Answer 12

Treatment

• activity modification or complete rest/restriction
• NSAIDS, anti-inflammatory creams for flare-ups
• elbow strap worn below elbow may be helpful
• heat/ice, gentle stretching, strengthening exercises
• referral to PT if pain persists past 3-4 weeks
• consider steroid injection if sxs persist
• surgery rarely performed

Question 13

Overuse Tendinopathy

Answer 13

• tendon thickening and chronic, localized pain
• Most commonly results from overuse
• Historically referred to as tendinitis, which implicated inflammation as main cause of sxs
• Later found that a classic inflammatory reaction is not usually present in overuse tendinopathy
• Pathophysiology in most cases is now thought to be tendinosis (chronic degenerative changes that lead to scarring/failed healing response)
• Increased incidence w/increased number of middle-aged and elder adults participating in activities
• Awkward hand, wrist, and shoulder postures during activities can strain tendons
• Training errors (sudden increase in activity or inadequate rest) can increase risk for tendinopathy
• Overuse tendinopathy is a general term that encompasses many different tendons
• Synonymous w/epicondylitis in UE

Question 14

Olecranon Bursitis

Answer 14

• Inflammation of bursa in elbow joint
• Occurs secondary to trauma, inflammation, infection, or underlying medical conditions (i.e.-RA, gout)
• Clinical presentation: -gradual or abrupt swelling, pain
• PE Findings: -large mass on posterior elbow, possible redness, possible warmth and F/C if infection present, -significant tenderness (if infectious or traumatic), -gouty tophi or rheumatoid nodules may be present
• Diagnosis:-If large and symptomatic: aspiration may be diagnostic and therapeutic, -If small, mild, and w/o signs of infection: can observe, -If occurred in presence of trauma -> obtain x-rays

Question 15

Olecranon Bursitis Tx

Answer 15

• If large and symptomatic:
• aspirate under sterile conditions (gm stain, culture)
• if no sign of infection-> apply compression bandage and f/u in 2-7 days
• if cultures are negative but fluid reaccumulates, reaspirate and if sterile -> inject corticosteroid
• if infected -> oral abx and daily aspiration or IV abx and surgical drainage (depending on pt)
• If small and mild:
• activity modifications, NSAIDS, elbow pad

Question 16

Ulnar Nerve Compression

Answer 16

• 2nd most common site of nerve entrapment in UE
• Most likely site: where ulnar nerve passes in groove on the posterior aspect of med epicondyle
• Clinical presentation: -Early: aching pain at medial aspect of elbow and numbness/tingling in 4th and 5th digits, -Advanced: weakness, visible muscle wasting
• possible tenderness of the ulnar nerve w/palpation
• numbness/tingling in 4th-5th digits may be reproduced w/light tapping of ulnar nerve
• numbness/tingling may be reproduced w/the elbow in full flexion x 60 seconds
• possible decreased sensation in distal 4th and 5th digits
• possible weakness when testing abduction/adduction of 4th and 5th digits
• Diagnosis -EMG studies -elbow x-rays if trauma has occurred
• Treatment: -activity modification to limit elbow flexion-crucial! -elbow splint at night -NSAIDS acutely, steroid injections NOT recommended
• surgical correction if sxs severe and refractory

Question 17

Fracture of the Distal Humerus

Answer 17

• Relatively uncommon but can be serious as often intraarticular
• significant swelling, ecchymosis, pain, deformity
• pain exacerbated by elbow flexion
• swelling, deformity, possible effusion w/gentle flexion
• MUST assess radial pulse, capillary refill, medial/ulnar/radial nerve function
• AP and lateral elbow x-rays
• if no evidence of fracture look CLOSELY for a fat pad sign indicative of bleeding into joint from occult fracture
• CT may be necessary if highly suspicious but unable to see fracture or fat pad
• TX: -Stable/non-displaced fractures: splint x 10 days, followed by ROM -Displaced (most common) or open fractures: most require immediate surgery

Question 18

Olecranon Fracture

Answer 18

-Easily fractured based on location
-Most are displaced fractures, often comminuted
-history of trauma (fall or direct force to the elbow)
-significant ecchymosis and swelling
-possible numbness/tingling in 4th/5th digits if compressing ulnar nerve
-superficial abrasions or deep wounds
-significant swelling diffusely around elbow joint
-pain w/flexion, possible defect w/gentle palpation
-must assess radial pulse, capillary function, median/radial/ulnar nerve function
-always assess joint above and below
-Diagnosis- AP and lateral x-ray
Treatment
-Nondisplaced fractures: posterior splint, f/u x-rays 7-10 days later to ensure fracture remains nondisplaced, ROM and strengthening exercises within 2-3 weeks
-Displaced fractures (most common): surgery unless poor candidate for surgery

Question 19

Fracture of Radial Head

Answer 19

-FOOSH injury (fall on outstretched hand)
-pain and swelling over lateral elbow
-decreased ROM
-may present in combination w/an elbow dislocation
-tenderness on lateral aspect of joint
-joint effusion often present
-flexion/extension often limited secondary to pain
-always assess joint above and below
-AP and lateral x-rays
-Consider CT if necessary
Treatment
-Type I: sling or splint, early ROM as soon as possible
-Type 2: surgery preferred unless no interference w/rotation of arm
-Type 3: surgery

Question 20

Wrist/Hand Arthritis - Osteo

Answer 20

OA: “degenerative joint disease”

• Characterized by loss of articular cartilage, bony changes, and subchondral cyst formation
• DIP and PIP joints most often affected
• Most common cause of arthritis in hand
• Sxs: Stiffness (shorter duration in the am than RA), pain, decreased ROM
• PE: Nodules may form at DIP joints (Heberden nodes) or PIP joints (Bouchard nodes)
• Diagnosis: PA and lateral x-rays (joint space narrowing, spurs, nodes, osteophytes)
• Complications: decreased mobility/function, loss of strength
• Tx: NSAIDS, PT (keep moving), steroid injections, +/-surgery

Question 21

Wrist/Hand Arthritis - RA

Answer 21

• Autoimmune condition, affects synovial tissue
• Wrist and MCP joints most often affected
• Sxs: increased pain in the morning and after activities
• PE: swelling, bogginess, ulnar drift of fingers, contractures at PIP joints (boutonniere) or hyperextension at PIP w/flexion at DIP (swan neck)
• Diagnosis: PA and lateral x-rays (deformities, thinning, erosions), ESR, ANA, RF
• Complications: deformities, loss of function/strength
• Tx: NSAIDS, steroid injections, temporary splint, Enbrel, Remicade, surgery

Question 22

Fracture of the Distal Radius

Answer 22

• One of the most common fractures
• FOOSH “Fall on outstretched hand”
• Colles fracture: (most common type) -distal radius fragment is tilted dorsally, ulnar styloid is often fractured
• Smith fracture: -opposite of Colles, fragment tilted volarly
• Barton fracture: -intraarticular fracture associated w/subluxation of carpus and displaced articular fragment
• Sxs: acute pain, swelling, deformity of wrist
• PE: swelling, deformity, ecchymosis, tenderness, possible open wound/abrasions
• Must assess sensation and circulation distally and joint above for other injuries
• Diagnosis: AP and lateral x-rays-forearm AND wrist
• Complications: malunion, decreased motion, persistent pain, arthritis, compartment syndrome
• Tx: initial focuses on reduction and splinting -non-displaced: sugar tong splint x 2-3 wks, followed by cast for 2-3 wks, removable splint x 3 wks, continue checking x-rays weekly for several weeks
• displaced: surgery

Question 23

Scaphoid (Navicular) Fracture

Answer 23

-Most commonly fractured carpal bone, often FOOSH injury
-Diagnosis often delayed or missed ->problematic
-Significant incidence of nonunion OSTEONECROSIS (limited blood supply)
-Sxs: pain in “anatomic snuffbox”-classic, pain w/gripping and wrist motion, swelling on radial side
-PE: significant tenderness-snuffbox, decreased motion and grip strength
-Must assess sensation/circulation distally, joint above
-Diagnosis: PA and lateral x-rays-if normal -> check PA and oblique of wrist in ulnar deviation-if normal and pain persists -> repeat in 2-3 weeks-if still normal->MRI
Tx:
-Fracture on initial x-ray: long arm thumb spica splint x 6 weeks. If healing on f/u x-ray -> short arm cast, if not  surgical consult
-If NO fracture on initial x-ray but pain in snuffbox: thumb spica splint x 1-2 wks, repeat x-ray. If f/u x-ray negative but pain persists -> MRI, if x-ray positive treat as above

Question 24

Metacarpal Fractures

Answer 24

• Metacarpal fractures are very common in adults
• Typically w/hx of trauma
• MC metacarpal fracture-Boxer’s fracture
• Boxer’s fracture: distal metaphysis of 5th MC, results when a closed fist strikes an object (punching)

Question 25

Phalanges Fractures

Answer 25

• Distal phalynx most commonly fractured > proximal > middle
• In children-phalange fractures more common than metacarpal fractures
• Typically w/hx of trauma

Question 26

Metacarpal and Phalange Fractures Sxs, Tx

Answer 26

-Sxs (metacarpal and phalange fractures): localized pain, swelling, deformity, decreased ROM
-PE: localized swelling at fracture site, involved finger may appear shorter
-Assess sensation in distal fingertips
-Diagnosis: PA and lateral x-rays-phalanges, PA, lateral and oblique-metacarpals
-Complications: malunion, nonunion, arthritis
Tx:
-Boxer’s fracture: ulnar gutter splint x 2-3 wks unless significant angulation -> surgery
-Nondisplaced MC and phalangeal shaft fxs: cast or splint x 3 wks (phalangeal) x 4 wks (MC)
-*Immobilize joint above/below, adjacent digits
-Displaced MC and phalangeal shaft fxs: Ortho
-Intra-articular fxs: Nondisplaced: splint x 3 wks, repeat x-ray
Displaced: Ortho

Question 27

Sprains

Answer 27

-Sprains-partial or complete tear of a collateral or volar ligament
-Majority of sprains can be managed conservatively
-Exception -> Gamekeepers thumb*
Tx of sprains:
-typically conservative, buddy taping to adj. finger -incomplete tears of ulnar collateral lig -> thumb spica cast x 2-4 wks

Question 28

Gamekeepers Thumb

Answer 28

• Gamekeepers Thumb: complete rupture of ulnar collateral ligament of thumb MCP
• Often seen in skiier’s with forced abduction of thumb against ski pole
• Also occurs w/falls, sports
• Sxs: localized pain and swelling
• PE: localized pain and swelling on ulnar aspect of thumb MCP joint
• Diagnosis: PA and lateral x-ray to f/u fracture/dislocation, if no fx-test joint stability (instability/laxity indicates complete tear)
• Complications: persistent pain, decreased ROM
• Tx: surgery

Question 29

Trigger Finger

Answer 29

• Occurs when a flexor tendon becomes thickened over time -> limited motion -> snapping/locking-flexion
• 3rd and 4th fingers most commonly affected
• RF’s: idiopathic, DM, RA, CTS, de Quervains
• Sxs: pain, catching, feeling “locked” in the morning
• PE: tenderness, +/-nodule in palm, pain-flexion
• Diagnosis: clinical
• Complications: contracture, stiffness
• Tx: NSAIDS, steroid injections, surgery if ineffective

Question 30

Ganglion Cyst

Answer 30

• Most common benign soft tissue tumor of hand
• Cystic-arise from capsule of joint or tendon sheath
• Attached deeply, contain thick fluid
• Sxs: lump, +/- aching pain w/activities/movement
• PE: smooth, round mass on dorsal or ventral aspect of wrist, base of finger, or PIP. Mild tenderness w/pressure, may transilluminate
• Diagnosis: often clinical, x-rays to r/o bony pathology
• Complications: decreased ROM, persistent pain
• Tx: observation, aspiration (often recur), or surgery

Question 31

De Quervain Tenosynovitis

Answer 31

-Swelling and thickening of sheath surrounding abductor pollicis longus and brevis tendons in the wrist
-Leads to constriction of tendon -> pain, swelling, locking, sticking
-Sxs: swelling, pain w/thumb movement
PE: swelling and tenderness-distal radius, + Finkelstein test
-Diagnosis: clinical, can consider PA and lateral x-rays to r/o bony abnormality
-Tx: NSAIDS x 2 wks + thumb spica splint, if ineffective -> steroid injection, surgery for refractory cases

Question 32

Dupuytren Contracture

Answer 32

• Nodular thickening and contracture in palmar fascia
• RF’s-genetic*, males > 50, DM, smoking, repetitive trauma
• Sxs: painless nodule(s)/thickening in palm, trouble grasping, pulling
• PE: painless nodule(s)/thickening in distal palmar crease, cords extending toward finger, flexed finger (4th digit-MC)
• Diagnosis: Clinical
• Complications: flexion contracture, decreased function
• Tx: observation, night splints may help to slow progression, surgery

Question 33

Mallet Finger

Answer 33

• Deformity caused by rupture, laceration, or avulsion of extensor tendon at base of distal phalynx
• Sxs: pain, inability to straighten finger at DIP joint
• PE: DIP in flexion, unable to actively extend DIP, tenderness, swelling
• Diagnosis: lateral x-ray may reveal small avulsion fracture
• Complications: permanent deformity, loss of motion
• Tx: Splinting of DIP joint in extension x 6 wks (acute) and x 8 wks (chronic), followed by gently movement and night splinting x 2-4 additional wks
• If the fingertip flexes at any time during tx, the healing process will be delayed

Question 34

Boutonniere Deformity

Answer 34

• Occurs when middle portion of extensor tendon ruptures at insertion of middle phalynx -> flexion of PIP joint
• May not be evident immediately after injury
• Sxs: affected finger flexed at PIP joint, localized tenderness
• PE: PIP joint flexed, DIP joint extended or hyperextended
• Diagnosis: AP and lateral x-rays to r/o fracture
• Complications: Contractures of DIP and PIP joints
• Tx: Splinting of PIP joint in extension x 6 wks, (3 wks-elderly), surgery if deformity does not heal

Question 35

Flexor Tendon Injuries

Answer 35

-When flexor tendons are completely lacerated or ruptured -> immediate loss of flexion at PIP and DIP
-Trauma commonly the cause- “jersey finger”, others include OA, RA
-4th finger injured most frequently
-2 flexor tendons in each finger:
1. flexor digitorum sublimis (FDS) -> inserts onto distal phalynx
2. flexor digitorum profundus (FDP) -> inserts
onto middle phalynx
-Sxs: decreased ROM (based on location of laceration), pain
-Level 1: If FDP is lacerated and FDS is intact = flexion at PIP and MCP, but not DIP
-Level 2: If both FDP and FDS are lacerated = flexion at MCP but not DIP or PIP
-Level 3: If FDS is lacerated but FDP is intact = flexion at DIP, PIP, and MCP
-With traumatic rupture of FDP (i.e.-jersey finger) the FDP and possibly bony fragment are avulsed

Question 36

Flexor Tendon Injuries DX

Answer 36

• Check flexion of DIP: hold PIP in place while pt flexes at DIP joint
• Check flexion of PIP: hold fingers straight while pt flexes each finger at PIP joint independently
• Tendon ruptures may have more swelling and tenderness in affected area
• Always check distal sensation
• Partial lacerations are difficult to diagnose, may have improved ROM but more pain than expected w/flexion
• Diagnosis: PA and lat x-rays to look for avulsion and r/o fracture
• Complications: loss of strength and flexion
• Tx: place in flexor tendon splint and refer to Ortho, surgical repair if complete laceration/rupture

Question 37

Felon

Answer 37

• Infection in the pulp of the fingertip
• MC etiology-Staph Aureus
• Typically a puncture wound in thumb or index finger
• Sxs: severe pain, swelling (does not extend proximally past distal flexion crease), redness, and warmth on finger pad
• PE: tenderness, swelling, erythema, fluctuance, +/- puncture wound
• Diagnosis: x-rays will reveal soft tissue swelling, osteomyelitis possible (late finding)
• Complications: osteomyelitis, deformities
• Tx: digital block for surgical drainage, culture wound, use hemostat to ensure abscess has been removed, pack x 1-2 days, NEVER CLOSE WOUND

Question 38

Human Bite

Answer 38

-Occurs directly (bite) or indirectly (i.e.-when hand strikes a fist)
-Very serious-can progress quickly, early tx is crucial
-MC etiology-Staph aureus, alpha-hemolytic Strep
-Sxs: swelling, pain, bleeding, purulent discharge, redness, warmth, bruising, decreased ROM
-PE: see above. If severe-possible streaking, decreased ROM in flexor or extensor tendons, decreased sensation distally, epitrochlear lymphadenopathy
-Diagnosis: PA, lateral, and oblique x-rays to r/o fx, wound cultures, WBC
-Complications: tendon laceration, osteomyelitis, joint sepsis, stiffness
Tx:
-Mild-Moderate (evaluated w/in 8 hrs): anesthetize and explore wound, debride necrotic tissue, irrigate w/saline, NEVER CLOSE WOUND, +/- splint, oral Abx, Tdap
-Severe (established infection w/joint, bone, or tendon involvement): URGENT referral for surgical debridement and IV Abx

Question 39

Carpal Tunnel Syndrome

Answer 39

-Occurs with compression of the median nerve in the wrist
-MC in middle-aged females, pg
-Often precipitated by repetitive overuse trauma
-Sxs: numbness/tingling into 1st-3rd digits, aching sensation, difficulty twisting/opening jars etc., talking on phone, driving, blowdrying hair, often worsens at night or after repetitive activities
-PE: possible thenar atrophy/weakness, +Phalen and + Tinel signs, possible decreased 2 pt discrimination
-Diagnosis: often clinical, EMG to confirm
-Complications: persistent loss of sensation, strength, fine motor skills
Tx:
-Mild/Moderate: wrist splint, NSAIDS (short term), ice, PT, if sxs persist-consider steroid injection, ergonomic modifications
-Moderate/Severe: refractory sxs consider surgery

Question 40

Wrist/Hand Arthritis - RA

Answer 40

• Autoimmune condition, affects synovial tissue
• Wrist and MCP joints most often affected
• Sxs: increased pain in the morning and after activities
• PE: swelling, bogginess, ulnar drift of fingers, contractures at PIP joints (boutonniere) or hyperextension at PIP w/flexion at DIP (swan neck)
• Diagnosis: PA and lateral x-rays (deformities, thinning, erosions), ESR, ANA, RF
• Complications: deformities, loss of function/strength
• Tx: NSAIDS, steroid injections, temporary splint, Enbrel, Remicade, surgery