Elbow, wrists, and hand Flashcards
(49 cards)
elbow
-Complex joint, with 3 sets of articulations.
-Capitulum / prox. Radius, trochlea / prox. Ulna, prox. Radioulnar joint.
-Is capsulated, annular ligament, bursa
-Lateral aspect forearm; wrist/finger extensors, supinator (radial nerve)
-Medial aspect forearm; wrist/finger flexors, pronator (median/ulnar nerve)
elbow blood and nerve supply
-Brachial artery – bifurcates into the ulnar and radial artery at cubital tunnel
-Ulnar nerve crosses elbow posteriorly at cubital tunnel
A 42-year-old plumber with right elbow pain presents to the clinic. The pain had been present off and on for years, but is now getting worse and causing him to drop objects. There is no history of injury or trauma. The symptoms worsen when the patient engages in lifting activities with the elbow and wrist in extension
lateral epicondylitis
-Overuse / repetitive use injury
-Very common
-Pain is localized to lateral humeral epicondyle, at tendinous insertion of wrist extensors (ECRB).
-Pain is reproduced with wrist extension against resistance and palpation.
-“Tennis Elbow”
-tx:
-Activity modification
-Unloader brace/band- compresses muscle -> takes load off the tenson and puts on the muscle
-NSAIDS
-Physical Therapy
-Steroid injection
-PRP injection
-Surgical release
medial epicondylitis
-Mechanism: Overuse / trauma to area
-Often seen in throwing sports (“Pitchers elbow” & “Golfer’s elbow”)
-Less common
-Pain is localized to medial humeral epicondyle. (Medial Common Flexor Tendon)
-Reproduced by action, palpation
-tx:
-Activity modification
-NSAIDS
-Physical Therapy
-Steroid injection
A PA student has been experiencing swelling and pain in his right elbow for a couple of weeks. He admits to studying excessively with his elbows resting on the table and now complains of a large mass overlying the posterior aspect of his elbow
olecranon bursitis
-May be large edema at olecranon, usually non-tender, not “infected”—aspirate clear, Treatment includes aspiration (send for C+S if at all suspicious of septic bursitis)
-Compression with ACE wrap
-NSAIDS
-Steroid injection
-Activity modification.
-ABX if infected. Possible surgical I&D
non septic vs septic elbow
A 40 year old account executive was horseback riding when she was thrown from her horse and landed on her right arm. She has immediate onset of pain, swelling and bruising around her elbow. She has also been complaining of increased stiffness.
radial head fracture
-MC elbow fracture in adults
-Fall on outstretched hand
-Type I: difficult to identify
-Type II: <30% of radial head
-Type III: comminuted
-Type IV: complex
-Pain & stiffness with forearm supination & pronation
olecranon fracture
-Mechanism: Fall on flexed elbow
-Sx: Pain, swelling, unable to extend elbow
-Tx:
-Nondisplaced: Reduction, long arm splint with elbow in 90 deg flexion
-Displaced: Surgical with tension band, plate & screw or IM screw
-Complications: Ulnar Neuropathy
cubital tunnel syndrome
-Ulnar nerve trapped at elbow, +paresthesia, +tinnel sign, +froments sign
-In severe cases patient will have a “claw hand”
-Treatment;
-Night splint
-Activity modification
-NSAIDS
-Surgical release (Ulnar nerve decompression and possible anterior transposition)
hand
-Articulations include:
-Distal radioulnar joint
-Radiocarpal joint
-Midcarpal joint
-Carpometacarpal joint
-1st carpal - metacarpal joint (thumb basal joint) is the trapezio-metacarpal joint.
-Thumb basal joint M/C site of arthritis in the hand. Repetitive motion injury.
-Thumb basal joint is a “saddle joint”
-Lunate – Kienbock’s Dx. (AVN)
-Scaphoid (Navicular)- most important (and fx’ed) bone in wrist, in constant motion, a lot of ligament attachment, precarious blood supply
wrist (dont need to know)
-Ligaments of the wrist are numerous. They are critical in articulation stabilization.
-Consider ligamentous damage with chronic pain and negative X-ray
-Radius and Ulnar
-scaphoid, lunate, triquetrum, pisiform
-trapezium, trapezoid, capitate, hamate
dorsal tunnel (dont know this)
-6 dorsal tunnels transport extensor tendons to the hand
-Each tunnel has its own tendon compartment.
-Tunnel 1- abductor pollicis longus, extensor pollicis brevis.
-Tunnel 2- extensor carpi radialis longus, extensor carpi radialis brevis.
-Tunnel 3 -extensor pollicis longus
-Tunnel 4 - extensor digitorum communis, extensor indicis
-Tunnel 5 - extensor digiti minimi
-Tunnel 6 - extensor carpi ulnaris
A 32-year-old female presents with a chief complaint of right wrist pain. The pain is located to the radial aspect of the wrist and is worse when she lifts her newborn or if the wrist is forced into ulnar deviation.
de Quervain Tenosynovitis
-Stenosis of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon sheaths in the 1st Dorsal compartment of the wrist.
-Up to 6 times more common in Women
-Common during pregnancy and lactation
-often seen in overuse / repetitive athletics
-pain is localized to radial aspect 1st compartment, and can be severe.
-pain increased with palpation and motion of thumb
-+ finkelsteins is dx
-Treatment:
-Non-op:
-Activity modification
-NSAIDS
-PT
-Steroid injection. 50-80 % report relief after 1-2 injections.
-Sx: surgical release; incision of 1st dorsal compartment
hand (nerves)
-Radial – sensation to the dorsum of the hand on radial side of third metacarpal & dorsal thumb, index & middle fingers as far as the distal phalanges. !First web space! is most “pure” area to test for radial nerve sensation, motor test thumb and wrist extension
-thumbs up
-Ulnar – Provides sensation to the ulnar side of hand (dorsal and palmer) , ring, & little fingers. The !volar tip of the little finger! is the most “pure” area to test for ulnar nerve sensation. Motor –test opposition, and ab & adduction
-thumb to finger
-jaz hand
-Median – provides sensation to palm & palmer surface of thumb, index, middle & half of the ring finger; may supply dorsum of terminal phalanges of these fingers. The !distal palmar aspect of the index finger! is the most “pure” area to test median nerve sensation, motor – test opposition
-thumb to finger
carpal tunnel syndrome
Repetitive use, pregnancy, RA, Gout, DM, ETOH abuse
Onset is usually spontaneous
gradually increasing night pain is common
numbness and tingling in median nerve distribution of hand
sense of weakness/clumsiness in hand.
symptoms precipitated by manual activity.
Thenar atrophy is a sign of chronic disease. Weakness with thumb opposition.
-Special tests:
-+ Tinel’s sign - tap
-+Phalen’s test - pray
-Consider obtaining EMG/NCS to R/O other peripheral neuropathies or cervical radiculopathy
-Tx:
-Non-op;
-activity modification
-cock-up wrist splint
-NSAIDS
-Physical therapy
-Steroid injection
-Surgery: Carpal tunnel release
dislocations of the wrist
-Perilunate, lunate, and trans-scaphoid perilunate dislocations are variations of the same injury and are caused by hyperextension of the wrist, FOOSH
-capitate-lunate dislocation is M/C and is visible on lateral view of Xray of wrist
-“cup tilt” appearance
-note areas of ecchymosis, fullness, tenderness
-Check ROM, Snuffbox, N/V status
-Generally the wrist appears shortened, movement will produce pain, and edema will vary from slight to significant.
-X-rays to include 4 views…..AP in neutral, AP in ulnar deviation, oblique, and lateral.
-Tx: reduction ASAP to minimize risk of nerve injury.
-Axillary or Beir block for anesthesia, finger traps for traction, reduce, and place in thumb spica splint with wrist in neutral or slight palmar flexion . Post-Redux film
-Non-reducible dislocations will require ORIF.
colles fracture (dorsal angulate radius fracture)
-extra-articular fracture with !dorsal! angulation and tilt, often impaction
-M/C fracture of the wrist
-90% of wrist fractures are this pattern
-Mechanism: Fall on hand with wrist in extension
-edema, ecchymosis, and loss of ROM
-X-ray (3 views) reveals typical “Dinner fork!” deformity
-Tx: All displaced fractures should undergo closed reduction regardless if the plan is surgery. This will provide comfort, minimize swelling, and reduce risk of neurovascular injury.
-Non-op – Cast immobilization for Non-displaced or minimally displaced fractures. Hematoma block. Obtain post-reduction X-ray.
-Sx- ORIF (Percutaneous pinning, Plate and screws)
