Common Problems of the Elbow, Wrist and Hand

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Common Problems of the Elbow, Wrist and Hand

• J. David Kuplic, MD

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Common Problems of the Elbow, Wrist, and Hand

• Lateral epicondylitis
• Medial epicondylitis
• Cubital tunnel syndrome
• Wrist tendonitis/ganglion
• Carpal tunnel
• Dequervains/1st dorsal compartment tenosynovitis
• 1st CMC arthritis
• Trigger finger
• Metacarpal/finger fractures
• Tendon ruptures

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Lateral Epicondylitis

• What Is It? / Causes
• Degeneration or microinjury of the
• extensor carpi radialis brevis origin
• Lateral ligaments and joint capsule
• may also be involved
• Repetitive use/grip, occasionally injury

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Lateral Epicondylitis

• Where is it?
• Lateral epicondyle of the elbow

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Lateral Epicondylitis

• Complaints
• Tender lateral elbow
• Pain with gripping or grasping,
• especially with the elbow extended
• Pain with wrist extension
• Usually insidious onset
• with repetitive activity

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Lateral Epicondylitis

• Physical exam
• Tender lateral epicondyle
• Pain with grip with elbow extended
• Pain with wrist extension (especially
• with elbow extended)
• Normal ROM usually no swelling or defect

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Lateral Epicondylitis

• Treatment
• Rest
• NSAIDs
• Tennis elbow strap
• PT/OT
• Injection
• Surgical release
• /- arthroscopy
• Controversial
• shock wave, botox,
• PRP

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Lateral Epicondylitis

• Return to Work
• Variable. Some can work with brace
• others need full rest. Usually limited
  grip/grasp and low weight
• P-op Very limited 1st 10 - 14 days. No force
  approx 6 weeks. Light duty 6 - 10 weeks

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Medial Epicondylitis

• What Is It?/Causes
• Degeneration/microinjury of the
• flexor/pronator origin
• Repetitive pronation/grip
• Valgus stress injury
• Much rarer than lateral epicondylitis

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Medial Epicondylitis

• Where is it?
• Medial epicondyle
• of the elbow

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Medial Epicondylitis

• Complaints
• Pain over medial epicondyle
• Pain with pronation or wrist flexion
• Usually insidious onset

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Medial Epicondylitis

• Physical exam
• Tender over epicondyle
• Pain with resisted pronation
• and wrist flexion
• Usually normal ROM and no swelling

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Medial Epicondylitis

• Treatment (all less effective than lateral
  epicondylitis)
• Rest
• NSAIDs
• Forearm brace
• PT/OT
• Injection
• Surgical release
• Controversial
• shock wave,
• ultrasound, PRP

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Medial Epicondylitis

• Return to Work
• Same as Lateral. Variable degrees
• of disability.
• P-op Very limited 1st 10 - 14 days then
• no force for up to 6 weeks. Light duty
• 6 - 10 weeks.

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Cubital Tunnel Syndrome

• What Is It? Causes
• Compression of the ulnar nerve at the elbow
• Direct blow to elbow
• Vibration tools
• Prolonged flexed elbow position
• Resting/leaning on elbow

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Cubital Tunnel Syndrome

• Where Is It?
• Ulnar groove
• of the medial
• elbow (funny bone)

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Cubital Tunnel Syndrome

• Complaints
• Posteromedial elbow pain
• Numbness/tingling small finger
• and half of ring finger
• Weak grip and key pinch
• Hand fatigue

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Cubital Tunnel Syndrome

• Physical exam
• Decreased sensation
• small finger half of
• ring finger
• Tinels at cubital tunnel
• Irritable nerve with palpation
• Weak 5th finger abduction
• Atrophy of 1st dorsal interosseous
• hypothenar muscles
• Positive NCTs/EMGs

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Cubital Tunnel Syndrome

• Treatment
• Avoid flexed elbow positions
• and resting on elbow (work ergonomics)
• Night splinting with
• arm at 45 degrees
• NSAIDs
• Cubital tunnel release,
• possible transposition

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Cubital Tunnel Syndrome

• Return to Work
• Relatively quick recovery from surgery
• or ergonomic changes. Slower from chronic
  exposure
• Transposition has similar RTW
• schedule as epicondylar release

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Wrist Tendonitis/Ganglion

• What is it?
• Inflammation of the tendons or wrist joint
• If there is enough inflammatory fluid,
• the capsule will pooch out
• and become a ganglion
• Over time, the fluid gels
• to the consistency of
• apple jelly

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Wrist Tendonitis/Ganglion

• Where is it?
• Synovial cyst at mid dorsum
• of wrist (70) volar wrist near
• radial artery (20), and rest
• usually base of finger
• or finger joint.
• Various tendons on each side
• of wrist

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Wrist Tendonitis/Ganglion

• Complaints
• Tendonitis Pain with grip/grasp,
• flex/extend, and rotation
• Ganglion Pain at cyst site, though can be
  assymptomatic. Occasionally, numbness
• in area

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Wrist Tendonitis/Ganglion

• Physical exam
• Tender wrist/tendon
• occasionally warm,
• no redness
• Pain with specific motions
• Firm lump
• Transillumination

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Wrist Tendonitis/Ganglion

• Treatment
• NSAIDs
• Wrist splint
• Avoid repetitive wrist use
• Injection as last resort
• Benign neglect
• Cyst aspiration - approx. 50 recurrence risk
• Surgical resection - less than 10 recurrence

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Wrist Tendonitis/Ganglion

• Return to Work
• Tendonitis limited duty with hand
• until Sxs resolve
• P-Op no hand duty for 10 -14 days,
• then limited lifting, grip, repetition
• for next 4 weeks

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Dequervains Tenosynovitis

• What Is It? Causes
• Stenosing tendonitis of the
• 1st dorsal tendon compartment
• Usually due to frequent
• thumb abduction with
• the wrist ulnarly deviated
• Usually gradual onset

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Dequervains Tenosynovitis

• Where Is It?
• Involves APL
• and EPB tendon
• sheaths at the level
• of the radial styloid

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Dequervains Tenosynovitis

• Complaints
• Radial sided wrist pain
• with thumb motion
• 40s-50s
• Women 4 - 6x more than men

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Dequervains Tenosynovitis

• Physical exam
• Tenderness and
• swelling 1-2 cm
• proximal to
• radial styloid
• Pain with resisted
• thumb abduction
• Positive Finklesteins test
• Negative X-rays

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Dequervains Tenosynovitis

• Treatment
• Thumb abduction
• splint
• NSAIDs
• Steroid injection
• (80 response)
• First dorsal compartment release (90 response)

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Dequervains Tenosynovitis

• Return to Work
• Limited pinch/grip.
• May need to work
• in thumb splint
• P-Op No hand duty
• for 10 - 14 days. Very
• limited 2 - 4 weeks
• as Sxs allow

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Carpal Tunnel Syndrome

• What Is It? Causes
• Increased pressure on the median nerve at the
  wrist.
• Swelling of lining of tendons
• Fluid retention
• Underlying nerve
• problems
• Repetitive Stress
• Vibrating tools
• Repetitive motions
• Poorly placed
• keyboard

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Carpal Tunnel Syndrome

• Where Is It?
• At the base of the palm
• Formed by bones of
• the wrist transverse
• carpal ligament
• Space in the wrist
• that holds nine tendons
• and the median nerve

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Carpal Tunnel Syndrome

• Complaints
• Numbness in the thumb, index, long,
• and ½ ring fingersusually worse at night
• Pain in wrist may extend into fingers
• and forearm
• Weak grip and clumsiness

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Carpal Tunnel Syndrome

• Physical Exam
• Positive Tinels
• Positive Phalens
• Thenar Atrophy
• NCT/EMGs
• (motor lat. gt 4.5,
• sensory lat. gt 3.5)

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Carpal Tunnel Syndrome

• Treatment
• NSAIDs if early
• Night splints
• Modify work environment
• Cortisone injection
• (best if lt 6 mos. sxs)
• Surgical release
• Laser, ionto, u/s,
• exercises all
• controversial

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Carpal Tunnel Syndrome

• Surgical treatment
• Goal is to enlarge tunnel
• and release pressure
• Accomplished by cutting
• transverse carpal ligament
• Outpatient procedure
• ¾ to 2 incision
• Local anesthetic
• Good relief of numbness pain
• Weakness may not improve entirely
• 90 satis. rate and 5 recurrence rate

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Carpal Tunnel Syndrome

• Return to Work
• Early with environment
• modifications
• P-Op Limited hand/finger duty
• first 14 days, then limited grasp
• for 2 - 8 weeks depending on Sxs

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Trigger Finger

• What Is It? Causes
• Painful catching, popping, or locking as digit is
  flexed
• and extended
• Pathology involves disproportion in size between
  flexor tendons and their retinacular pulley at
  the level of the metacarpal head
• Most significant changes involve hypertropy of
  the A-1 pulley
• Etiology is disputed (inflammation of tendon
  sheath and pulley, nodular tendon)
• More common in women than men
• Peak ages 55 60
• Most commonly affected digit thumbgtringgtlonggtlit
  tlegtindex

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Trigger Finger

• Where Is It?
• A1 pulley
• of flexor tendon
• Distal-most palmar crease

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Trigger Finger

• Complaints
• Mechanical catch or lock of finger
• when flexed
• Common 1st thing in the morning
• Pain at A1 pulley

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Trigger Finger

• Physical exam
• Tender A1 pulley
• Palpable catch at pulley
• Occasionally feel thickened nodule

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Trigger Finger

• Treatment
• NSAIDs (if early)
• Splinting (if early)
• Cortisone injection (if lt 6 mos.)
• Surgical release

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Trigger Finger

• Return to Work
• Usually can work through
• conservative treatment
• P-Op Limited hand duty 1st 10 -14 days,
• then some limited grip next 2 - 4 weeks

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Tendon Rupture

• What Is It? Causes
• Inability to flex or extend finger
• Usually associated with laceration
• Mallet or jersey fingers often
• without laceration
• Jamming finger or sudden flex/
• extension of set digit

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Tendon Ruptures

• Where Is It?
• Centrally along
• the tendon path
• from proximal
• to wrist
• to DIP joint

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Tendon Ruptures

• Complaints
• Inability to flex or extend finger

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Tendon Ruptures

• Physical Exam
• Inability to flex or extend finger
• Deep laceration adjacent to tendon, sometimes
  with pearly-white tendon visible

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Tendon Ruptures

• Treatment
• Splint for mallet finger
• (must be worn all the time!)
• Can pin mallet finger
• All other complete tendon tears need repair

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Tendon Ruptures

• Return to Work
• Mallet fingers usually can work
• with splint on or pin in
• Other repairs need long-term protection
• and avoidance or unrestricted use
• Extensor tendons 8 - 12 weeks
• Flexor tendons 12 - 20 weeks

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Hand Fractures

• What is it? Causes
• Direct or indirect blow to hand

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Hand Fractures

• Complaints
• Swollen painful
• finger/hand
• often unable to
• touch area
• Often deformity
• of finger

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Hand Fractures

• Physical Exam
• Focally tender area,
• often with deformity
• Check flex/extension/
• rotation of digit
• If laceration, then
• emergency treatment
• X-ray is diagnostic

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Hand Fractures

• Treatment
• Non-displaced get splint
• Displaced gt 2 mm get surgery/reduction
• Angulated/rotated get surgery/reduction

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Hand Fractures

• Return to Work
• Fractures take at least
• 6 weeks to heal
• Difficult to work with
• most splints, especially
• first 10 - 14 days
• Plates/screws offer earlier mobilization but not
  healing
• Often weak for 2 - 3 months

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Thank You!