Elbow wrist hand CPG, SR, concepts Flashcards Preview

OCS Ciccarello > Elbow wrist hand CPG, SR, concepts > Flashcards

Flashcards in Elbow wrist hand CPG, SR, concepts Deck (18):
1

Rule in / out

UCL sprain 

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

2

CPR Lateral Epicondylagia MWM

(Vicenzino Man Ther 2008)

  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

3

Lateral epicondylagia intervention evidence

(Coombes 2015)

  • 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

4

Coombes 2015 

Treatment Guidelines

  • 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>13oC)
    • "not much better" after 8-12 weeks
    • -->multimodal PT AND pharamcological therapy

5

Carpal tunnel CPR

(Wainner 2005)

  • >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

6

CTS treatment

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

7

Median Nerve entrapment

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

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

8

Ulnar nerve entrapment 

(cubital tunnel vs. guyon vs. retrocondylar groove)

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

9

Radial Nerve entrapment

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

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

10

Wrist/hand conditions (non-trauma)

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

  • 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 

11

Wrist/hand conditions (trauma)

MCP collateral ligament

bennett's fracture

volar plate avulsion fx

flexor digitorum profundus avulsion

  • 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

12

Carpal fracture

CPR

  • 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%

13

Carpal fractures

 

  • 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 

14

carpal ligamentous injuries

  • 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
  •  

15

Distal radius / ulna fractures

  • 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
  •  

16

FInger injuries

  • 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

A image thumb
17

Hand OA

CPR (level III evidence only)

  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

 

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