The elbow, wrist, and hand evaluation and diagnosis – Flashcards
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Carrying Angle =
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long axis of humerus/ulna 15-20 degrees valgus men Slightly greater in women
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Gunstock Deformity =
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cubitus varus with reverse carrying angle. Usually occurs due to malunion of fracture
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Tinel's sign
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lightly tapping cubital tunnel over ulnar nerve; observe for symptoms in ulnar nerve distribution (medial forearm, ring/little fingers)
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Lateral Epicondylitis
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Hx - due to repetitive activity, c/o of pain at lateral epicondyle, no mechanism, pain with handshakes, grasping things. PE - point tenderness , pain with wrist/digit extension TX- NSAIDS, steroid inj., elbow strap and PT
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Medial Epicondylitis
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Hx-repetitive activities PE-Pain at medial epicondyle, pain with wrist/digit flexion; r/o cubital tunnel involvement
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Nurse's maid's elbow Etiology
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- head of radius subluxes under orbicular or annular ligament as longitudinal traction is placed on forearm, elbow ext., pronated. Commonly children <4 yoa
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Reduction of Nurse Maid's elbow
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elbow is passively flexed to 90 degrees, thumb is placed over radial head, posterior force placed on radial head; elbow is extended and suppinated; feel click, pain relief; causes radial head to slip/screw under annular ligament
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Olecranon Bursitis treatment
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Tx - aspirate?, steroids?, NSAIDS, elbow sleeve; Surgery. If septic, antibiotics vs. bursectomy
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Cubital Tunnel Syndrome etilology
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repetitive overuse of elbow/flexors; synovitis of joint; blunt trauma causing compression of ulnar nerve
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Cubital Tunnel Syndrome Sx and PE
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c/o of pain, parathesias along ulnar border of forearm, little, and ring fingers. PE - postive Tinel's Sign cubital tunnel; objective numbness ulnar nerve dist., weakness; Wartenburg Test
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Cubital tunnel syndrome treatment
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Studies - EMG....... Tx - splint, Steroids, NSAIDS, PT; Ulnar Nerve Transposition refer after EMG and round of steroids
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Ulnar Tunnel Syndrome
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-commonly found in cyclists. compression of ulnar nerve in guyon's canal, caused by tumor, ganglion, thrombosis of ulnar artery. Hx -c/o pain numbness/tingling ulnar nerve distally. Mostly hand or hypothenar eminence
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Rupture Distal Biceps Tendon
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Forceful isometric flexion of elbow,then audible "pop". distal biceps rupture from deltoid tuberosity. Usually occurs in people 30-50 yoa, with degenerative changes in tendon
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Rupture Distal Biceps Tendon PE
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weakness at elbow, palpable mass w/retraction well proximal to elbow, ecchymosis, edema; loss of 25% flexion and 40% supination
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Rupture Distal Biceps Tendon studies and treatment
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MRI Tx - Long arm splint, sling, then Surgery
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Ulnar Collateral Ligament Tear are seen in.....
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throwing athletes
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Ulnar Collateral Ligament Tear PE
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Pain over medial epicondyle positive valgus stress test Assess in full extension and at 90 deg flexion
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Ulnar Collateral Ligament Tear treatment
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Treatment: conservative...bracing/splinting initially...PT ~3 months ROM is key. fail conservative therapy-___ reconstruction using palmaris longus autograft or tibialis anterior allograft. "Tommy John" procedure
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Elbow Dislocation
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-usually Posterior, caused by fall on outstretched hand. Must confirm neurovascular integrity. Confirm via XR Needs immediate reduction, then post-reduction X-ray Traction on wrist w/ countertraction of shoulder. Splint, sling, F/U w/ortho
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Dislocation of Radial Head in Children
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Etiology - Trauma vs. congenital; FOOSH. 1. Congenital - posterior dislocation, bilateral, Ehlers-Danlos Syndrome. 2. Traumatic - Monteggia-type fracture. 3. Developmental - posterolateral dislocation; cerebral palsy or neuro pathology, usually no pain and no tx
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Supracondylar Elbow Fracture etiology
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Commonly children 6-7 yoa, falling on outstretched arm. Thin bone b/w coronoid fossa/olecranon fossa of humerus
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Supracondylar Elbow Fracture neurovascular comprimise
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Brachial artery Median nerve = posterolateral displacement Radial nerve = posteromedial displacement
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Supracondylar Elbow Fracture treatment
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Tx - no displacement = long arm splint...Refer. Displacement = ER or immediate referral to ortho with splint. Requires reduction and percutaneous pinning
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Radial Head fractures that are Not! comminuted or displaced.....
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Splint 7 days or less, ROM. Kids <30 degrees angulation, treat conservatively
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Lateral Epicondyle Fracture in Kids and adults
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commonly Salter-Harris 4 type fracture; non-displaced = splint/cast 4-6 wks. Displaced = percutaneous pinning vs. ORIF
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Monteggia's Fracture
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- dislocated radial head and fx of proximal 1/3 of ulna....may not always be obvious in children. Splint...REFER. May require ORIF w/great degree of displacement
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Kids always get....
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bilateral x-rays
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Froment Sign
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-due to ulnar nerve paralysis. -pt to pinch piece of paper bw thumb and index finger...if adductor pollicis weak ...IP joint of thumb will flex to hold paper as pulled away
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Finkelstein Test
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thumb flexion/ulnar deviation of wrist...pain over 1st dorsal compartment indicates de Quervain's tenosynovitis.
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Durken Carpal Compression Test
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examiner holds thumb over carpal tunnel for apprx. 30 seconds...observe for numbness/tingling in median nerve distribution, CTS
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Phalen Maneuver
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passively hyperflex pt's wrists and hold for 30-60 seconds. Numbness/tingling and pain indicate CTS
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Animal Bites
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90% by dogs. 30-50% of cat bites become infectious. -Pasteurella multocida most common organism...others include S. aureus, Bacteroides and Fusobacterium
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rabies...
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bats, skunks, raccoons, and foxes.
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animal bite treatment
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Copious irrigation of wound. Pt may require a digital block. Do not suture!!! abx-Augmentin... tetanus shot! consult plastics or hand surgeon with nervous, tendinous or bony involvement. May require surgical Irrigation/Debridement with IV antibiotics
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OA
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-loss of cartilage and joint space, formation of subchondral cysts. - DIPJ and PIPJ
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RA
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synovial hypertrophy, pannus formation invade joint space. - wrist and MPJ
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RA expanded upon...
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-complain of pain first thing in morning. -have edema multiple joints and symmetrical. Boggy over dorsum of hand and crepitus. Flexor tenosynovitis. Ulnar drift! Contracture of PIPJ (boutonniere deformity) and hyperextension of PIPJ/flexion of DIPJ (swan-neck deformity)
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CTS symptoms
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-c/o pain from wrist sometimes to shoulder ; worse at night numbness/tingling median nerve dist.; weakness, atrophy
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Carpal Tunnel Syndrome PE
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PE - positive Phanlen's test; Positive Tinel's Sign; possible atrophy; r/o c-spine and motor deficits with EMG
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de Quervain's Tenosynovitis
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-Overuse injury caused by repetitive overuse of thumb. Extensor pollicis brevis Abductor pollicis longus
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de Quervain's Tenosynovitis PE and treatment
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-pain over 1st dorsal compartment; positive Finkelsteins Test; check status of radial sensory nerve for numbness/tingling.
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de Quervain's Tenosynovitis studies and Tx
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X-Ray for spur/calcification Tx - injection; NSAIDS; thumb spica splint! surgical release
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Extensor Carpi Radialis Tenosynovitis
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-Pain/crepitus over wrist extensors. -repetitive movement at forearm/wrist. Usually 6-8 cm proximal to radial styloid! "Intersection syndrome" Extensor pollicus brevis Abductor pollicis longus These tendons cross over wrist extensors
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CMC OA
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women usually > 40 years old. Most common form of OA in hand. Hx - pain at base of ____ joint; weakness; dropping things! PE - positive grind test! (pain w/compression of metacarpal over trapezium); adduction deformity Tx - NSAIDS; Thumb spica splint!
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Dupuytren's Contracture
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-proliferation of myofibroblasts/Type III collagen causes contraction of palmar fascia. -causing, fixed flexed deformity of MP/PIPJ; fibrous nodules over palm. treat with steroid injections
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Trigger Finger
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-tenosynovitis of flexor tendons (deep/superficial) at A1 pulley/MCPJ. -usually nodule at middle and/or ring finger. -steroid injections or surgical release for treatment
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suturing rules for hands
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Requires digital nerve block prior to procedure; use 6.0 chromic interrupted stitches. -NO EPINEPHRINE ears, nose, fingers, toes, hose! 12 wks to heal
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Mallet Finger
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-injury involving the extensor tendon group and may result in rupture. Causing forced flexion of DIPJ.
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Mallet finger studies and treatment
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XR - true lateral to r/o avulsion fx Tx - splint DIDJ in extension 6-10 wks., do not splint PIPJ; surgery rarely required
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Flexor Digitorum Profundus Rupture
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1. Forced hyperextension of DIPJ!!! 2. while FDP is maximally contracting. Inability to flex the distal phalanx... opposite of mallet finger.
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Flexor Digitorum Profundus studies and treatment
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XR - may show avulsion of phalanx Tx - requires surgical repair...Splint to elbow and refer
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Boutonniere Deformity
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-Rupture of central aspect of the extensor tendon at it's insertion onto the middle phalanx. -proximal insertion of tendon sheath at the middle phalange is ruptured and the extensor tendon is displaced laterally. -causing "button holes"
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Boutonniere Deformity treatment
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Treatment PIPJ splinted in extension x 6 wks...DIPJ left free.
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Paronychia
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Staphylococcus Aureus Erythema, edema, purulence Tx involves I/D; abx...if no better 3 days, then refer to hand surgeon.
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Tendon Sheath Infections, Four cardinal sign of Kanavel
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1. Uniform swelling of digit 2. Finger in flexion for comfort 3. Passive extension causes pain 4. Exquisite pain entire length of tendon Tx - Immediate referral to ER or Hand surgeon
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Galeazzi Fracture-Dislocation
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Fracture of distal radius with dislocation of distal radioulnar joint. Splint and refer for surgery
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Colles Fracture
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-dorsal "dinner fork" deformity. - FOOSH tx- closed reduction. sugar tong splint! for simple fractures... otherwise splint/refer.
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Smith's Fracture
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-"reverse dinner fork deformity'. opposite Colles's fx. - volar displacement due to striking top of wrist while flexed
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Barton's Fracture
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-FOOSH -Distal radius fx w/dislocation of radiocarpal joint Differs from smith/colles in that dislocation is most obvious on lateral X-Ray greater than fx Tx - closed reduction splint vs. ORIF...refer
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Scaphoid Fractures
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-FOOSH -fractures thru middle of bone causes avascular necrosis. Untreated causes early OA PE - "snuff box" tenderness; edema XR - may not show fracture initially. XR's 1-3 wks. Later. If patient still symptomatic with negative x-ray, then MRI/CT Tx - splint with thumb/wrist splint and always refer
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Boxer's fracture
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Fifth metacarpal fracture that is dorsally angulated due to interosseous muscle contraction. Shortening of <5mm acceptable, o/w refer to hand surgeon. Ulnar gutter splint!!
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Bennett's Fracture
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Intraarticular fracture of CMC joint of thumb. Nearly always require ORIF due to displacement
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Phalanx Fractures splinting and pinning....
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-dependent on pattern/displacement of fracture. Splint 4 wks. is usually acceptable, displacement may require ORIF vs. Pinning
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Reducing dislocated fingers...
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To reduce: traction, increase deformity, and return to anatomical position.
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Heberden's Nodes
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- osteophytes occuring at the DIPJ commonly due to OA; causing deformity
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Bouchard's Nodes
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osteophytes occuring at the PIPJ commonly due to OA; causing deformity
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Olecranon Process fracture
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- fall on olecranon no displacement = splint 2 wks w/gradual ROM Displacement = ORIF
