Lecture 4 - Elbow, wrist and hand Flashcards
What is lateral epicondylitis?
Enthesopathy of the extensor tendons of the forearm,
What are the usual and other potential causes of lateral epicondylitis?
Usually chronic overuse of the extensor tendons - repetitive extension of wrist i.e. in typing, driving, playing tennis
Can very occasionally be traumatic
Why is early morning stiffness common in lateral epicondylitis despite it being an extra-articular issue?
Blood flow to tendons already limited and when sleeping it is limited further due to lack of movement
What movements would you expect to be painful in lateral epicondylitis (literally not functionally)
- Gripping - this is an extensor movement
- Resisted extension of the wrist and middle finger
Describe what objective assessment you would perform for someone with lateral epicondylitis
- Observation - limited observation but patient may be holding wrist in a more flexed position to avoid pain
- Palpation - Tenderness of the anterior facet of the lateral epicondyle with the common extensor tendon originates
- Movements - Extend the elbow and flex the wrist then test for pain on resisted wrist extension and resisted middle finger extension
- Mill’s test - Shoulder abducted to 90, elbow flexed to 90, pronated, flexed and bring elbow into extension, have finger over the common extensor tendon, if tenderness reproduced then +ve for lateral epicondylitis
How would you treat lateral epicondylitis
- Identify and remove causative factors - think about ergonomics, technique etc
- Splint - splinting can be effective as it creates a new false origin for the tendon to pull on rather than the inflamed origin
- Mill’s movements
- Eccentric loading - elbow extension, wrist starts in flexion, assist to bring into extension, hold for 5 seconds, lower slowly into flexion
- Stretching - flexion wrist movements
Why should you do eccentric loading for epicondylitis with your elbow in extension
The common flexor and extensor origins are on the humerus so if you practiced in elbow flexion you could end up with a shortened complex
What is medial epicondylitis
Enthesopathy of the flexor tendons in the forearm
What are usual causes of medial epicondylitis
Chronic overuse of the flexor tendons i.e. by golfers and by people lifting and hitting things such as hammering
Occasionally traumatic
Why is early morning stiffness particularly prevalent in medial epicondylitis
People often sleep with their arms in a flexed position so the tendons shorten
In addition their is reduced blood flow to tendons (which already receive a smaller blood supply)
What movements would you expect to be painful in medial epicondylitis
Resisted wrist flexion
What objective assessment would you do for someone with suspected medial epicondylitis and what would you expect to find?
Observation - patient might be holding their hand in a more extended position to protect the tendons
Palpation - Exquisite pain over the anterior facet of the medial epicondyle of the humerus where the common flexor tendons originate
Mill’s test - Shoulder abducted to 90, elbow flexed to 90, wrist supinated and extended, shoulder extended and elbow then brought into extension, pain produced = positive
Resisted wrist flexion - if painful, indicates medial epicondylitis
What would treatment be for medial epicondylitis
- Eccentric loading - elbow in extension and wrist in flexion, extend and hold for 5-10 seconds, gradually lower down as slowly as possible - can hold with weight
- Mill’s movements
- Identify and remove/fix/alter causative factors
- Stretching of the muscles - extension movements of the wrist
What is ulnar neuritis
Inflammation of the ulnar nerve
Where does the ulnar nerve sit at the elbow
In the ulnar groove on the medial side of the humerus behind the medial epicondyle and the olecranon process
What are the usual cause of ulnar neuritis
Repetitive elbow extension in a valgus elbow
Contact injuries - leaning on your elbow in the car, riding bikes, on desks etc
What symptoms would a patient with ulnar neuritis report
Pins and needles (paraesthesia) in the 5th and half of the 4th digit
Swelling and tenderness around the medial elbow
What might you observe in patients with ulnar neuritis
- Swelling around the medial elbow
- Wasting/weakness in the hypothenar eminence
What might you pick up on palpation of someone with ulnar neuritis
- Swelling around the medial elbow
- Wasting of the hypothenar eminence
- Altered sensation of 5th and half of 4th digit
What movements and special tests would you do for someone with ulnar neuritis and what would you expect to see?
- Resisted movements - painless unlike with epicondylitis
- Resisted ulnar deviation - weakness
- Resisted 5th digit abduction - weakness
- Tinel’s sign - repeatedly tap over the ulnar nerve and see if symptoms are elicited - would expect symptoms elicited
- Upper Limb Tension Test 3 (to test mobility of the nerve) - elbow flexed, wrist pronated, wrist extended, abduct shoulder (you can also rotate the shoulder to test range) - would expect reduced mobility due to inflammation
How to treat ulnar neuritis
- Identify and remove causative factors - don’t want to further inflame the nerve
- Appropriate mobilisation - variations on ULTT 3
- Maintenance and strengthening for the affected muscles i.e. hypothenar eminence
- If treatment isn’t effective and/or entrapment is suspected then surgery may be applicable
Identify the clinical features of olecranon bursitis
- Usually due to contact pressure and can be traumatic or atraumatic
- Obvious golf ball sized swelling at the olecranon process of the elbow ‘
- Usually limited pain
- Patients complain of the swelling getting in the way/taking up space rather than pain
- If angry, hot, painful and red it could be infected
- Full painless ROM of elbow
-
What would your treatment be of olecranon bursitis?
- If infected, antibiotics
- If really painful and swollen, aspirate
- Remove causative factor and prevent recurrence with advice/splinting/padding
- NSAIDs to control swelling (can be local or topical)
- Ice for swelling
What is the hypothenar eminence?
- Muscular/fleshy mound at the base of the pinky finger containing muscles supplying the fingers
