What is trigger finger?
“Locking” of ROM during finger flexion from adhesions
in flexor tendon sheaths that presents with pain on the volar side of the MCP joint.
Tendon “release” often presents as an audible “snap” as finger moves into flexion
In this, an inflamed nodule of tendon gets trapped behind/underneath tendon sheath, and finger becomes stuck in flexed position and may be swollen initially
Treated: NSAIDs, corticosteroid injections (successful usually), and then surgical release
How do finger sprains present?
Commonly presents with localized tenderness/swelling, may see echymosis on the volar aspect with swelling of the digit
-Volar plate should be intact
-Treat with splint for 4-6 weeks (only immobilize joint of interest)
What is Mallet Finger?
Avulsion of extensor tendon from distal phalanx, inability to
actively extend DIP joint (passive OK), commonly occurs if
fingertip hits ball
cant extend DIP of the involved finger
What is Jersey Finger?
Avulsion of profundus tendon from distal phalanx, inability to
actively flex DIP joint if PIP joint stabilized, commonly occurs
when grabbing jersey and joint forcefully extended against
What are these?
Reduce, then splint normally
What is DeQuervain’s Syndrome?
Tenosynovitis of extensor pollicis brevis and abductor pollicis longus tendons from repetitive stress (radial deviation).
How does DeQuervian's Syndrome present?
Presents with pain/swelling to proximal thumb/ distal radius, pain with radial/ulnar wrist deviation and thumb extension and abduction.
Treatment: immobilization, NSAIDs
Extensor Pollicus Brevis- injured in DeQuervian's Syndrome
What are the most common fractures of the wrist?
-Colles fracture (distal radius) and Smith fracture (distal radius)
Bones of the Hand
One of the most common causes of wrist fracture is falling on an outstretched hand. What are some risk fatcors that make a fall more likely to result in fratcure?
osteoporosis, smoking, calcium and/or vitamin D deficiency
Common Wrist Fractures
Immediate swelling after injury suggest what?
Either blood enters the joint or a ligament tare
Late swelling suggests a MCL or cartilage structure without good blood supply
What is this test designed to diagnose?
Finkelstein's Test- pull the thumb into the palm, thendeviate
When is a CT scan indicated for a musculoskeltal injury?
When injuries to soft tissue, blood vessels, fracture alignment, or articular invovlement are suspected
When is an MRI indicated for a musculoskeltal injury?
when ligament injuries or injuries to small bones in the wrist (e.g. scaphoid fracture) are suspected
What are some potential complications of unaddressed distal radial fractures?
-loss of motion
What is Carpal Tunnel Syndrome?
Compression of the median nerve at the wrist in carpal tunnel where thickening from irritate tendons or other swelling narrows the tunnel and entrapment neuropathy is seen
What forms the top of the carpal tunnel?
The transverse carpal ligament
Where is median nerve entrapment from carpal tunnel felt?
burning, tingling in the radial aspect of palmar surface skin, index and middle finger, half the ring ringer, and the nail bed of these fingers
and symptoms are worse at night due to the wrist being flexed during sleep
some patients might feel like the wrsit is swollen even though it is not
Distribution of the Median Nerve in the Hand
What are some possible causes of Carpal Tunnel Syndrome?
-Pituitry gland overactive
What are some other risk factors for Carpal Tunnel?
Female sex: women are 3 times more likely than men to
develop carpal tunnel syndrome (smaller tunnel?)
Dominant hand usually affected first and more severely.
Diabetes or other metabolic disorders that affect nerves
What occupations predispose to Carpal Tunnel?
3 times more common in assembly-line workers than in
What are some physical exam tests for carpal tunnel?
Tinel Exam- tapping or pressing on median nerve results in shock-like sensation
Phalen Exam- patient holds hands upright with fingers down and backs of hand together for 30-60 seconds –reproduces symptoms
Ultrasound and nerve conduction studies or electromyography are also useful
How is Carpal Tunnel treated?
Drugs- NSAIDs, Oral cortisone (prednisone), Cortisone/lidocaine injection. And then get the nerve conduction study (goal standard). If positive, think carpal tunnel release
Not likely to recur but can get fibrous scar tissue and recurrent tenosynovitis (or can have incomplete ligament release)
What is the main stabilizing ligment of the elbow? What is the primary structure of the elbow invovled in throwing?
stabilizing ligament- ulnar collateral ligament (Tommy John)
throwing- anterior bundle
85% of throwers with medial elbow instability (UCL injury) complain of pain in the _______ phase of throwing
acceleration phase (deceleration typically = shoulder problems)
How does a UCL injury present?
Acute medial pain
- Onset during throwing, inadequate warmup
- “Pop” heard or felt
- Can be one pitch or can be insidious
What is this?
Complete UCL tear on MRI (need an MRI because hard to test stability of the joint)- look for ecchymoses
Lateral Epicondylitis is common in what sport?
Describe Lateral Epicondylitis. Muscle most commonly invovled?
-More common (9:1) than medial epidcondylitis
-Degenerative process: “tendinosis”
- Extensor Carpi Radialis Brevis (ECRB) most commonly involved
How does lateral epicondylitis present?
You might be able to palpate a mobile wad while resisting active wrist extension
-pain at lateral epicondyle or over muscle mass usually present
-no neurologic symptoms and sensation normal
How is lateral epicondylitis treated?
Up to 90% of epicondylitis resolves spontaneously. If not, Rehab focus on stretching wrist extensors, eccentric wrist extensors, NSAIDs, and eventually surgery if needed.
Medial Epicondylitis is common what sport?
Golf and some baseball
How does medial epicondylitis present?
you may see pain with resisted wrist flexion or PRONATION. Tenderness may be within the muscle belly or directly over the medial epicondyle
What is Panner's Disease?
Osteocondrosis of the capitellum of the elbow. (elbow's version of Legg'Calve-Perthes Disease). Presents with later elbow pain and perhaps stiffnes in a sports-active youngster (think young baseball pitcher, gymnast, cheerleader)
Patient population for Panner's Disease?
Usually seen in children under 10
What is this?
Panner's Disease- fracture of the capitulum of te elbow
What is this?
Olecranon Bursitis - typically due to direct trauma. Treat with rest, compression and NSAIDs. If persists, aspirate.
Elbow dislocations are often the result of what?
-trochlea levered over the coronoid process
What direction are most elbow dislocations?
The vast majority are posterior (most common posterolateral)
usually injure adjacent ligaments and potential for neurovascular involvment
What is this?
What is this?
Supracondylar fratcure with posterior elbo dislocation
What is this? Treatment?
Olecranon process fracture. If stable/nondisplacedm short immobilization period (45-90 degree of flexion). If displaced, ORIF surgery with longer immobilization period and early ROM if tolerated
What is this?
Most treated non-operatively
What is Tinnel's Test?
Gentle percussion of the ulnar nerve above or within the cubital tunnel should not elicit pain in the normal elbow- pain or paresthesias into the ring and small fingers with tapping over the ulnar nerve in the cubital tunnel is considered a positive test
Normal Shoulder Anatomy
Bony Anatomy of the Scapula
What are the structures of the subacromial space?
Identify the Muscles of the rotator cuff (posterior view)
Top: Supraspinatus (abduction)
Left (small arrow): Teres minor (external rotation)
Right (long arrow): Infraspinatus (external rotation)
Identify muscle (anterior view)
Subscapularis (internal rotation and adduction)
How could you test the integrity of the infraspinatus/Teres minor?
Have the patient flex the elbows to 90 degress and fully adduct to the side and ask them to attempt external rotation against your resistance
How could you test the subscapularis muscle?