Common Problems of the Elbow, Wrist and Hand - PowerPoint PPT Presentation

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Common Problems of the Elbow, Wrist and Hand

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J. David Kuplic, MD 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 ... – PowerPoint PPT presentation

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Title: Common Problems of the Elbow, Wrist and Hand


1
Common Problems of the Elbow, Wrist and Hand
  • J. David Kuplic, MD

2
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

3
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

4
Lateral Epicondylitis
  • Where is it?
  • Lateral epicondyle of the elbow

5
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

6
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

7
Lateral Epicondylitis
  • Treatment
  • Rest
  • NSAIDs
  • Tennis elbow strap
  • PT/OT
  • Injection
  • Surgical release
  • /- arthroscopy
  • Controversial
  • shock wave, botox,
  • PRP

8
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

9
Medial Epicondylitis
  • What Is It?/Causes
  • Degeneration/microinjury of the
  • flexor/pronator origin
  • Repetitive pronation/grip
  • Valgus stress injury
  • Much rarer than lateral epicondylitis

10
Medial Epicondylitis
  • Where is it?
  • Medial epicondyle
  • of the elbow

11
Medial Epicondylitis
  • Complaints
  • Pain over medial epicondyle
  • Pain with pronation or wrist flexion
  • Usually insidious onset

12
Medial Epicondylitis
  • Physical exam
  • Tender over epicondyle
  • Pain with resisted pronation
  • and wrist flexion
  • Usually normal ROM and no swelling

13
Medial Epicondylitis
  • Treatment (all less effective than lateral
    epicondylitis)
  • Rest
  • NSAIDs
  • Forearm brace
  • PT/OT
  • Injection
  • Surgical release
  • Controversial
  • shock wave,
  • ultrasound, PRP

14
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.

15
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

16
Cubital Tunnel Syndrome
  • Where Is It?
  • Ulnar groove
  • of the medial
  • elbow (funny bone)

17
Cubital Tunnel Syndrome
  • Complaints
  • Posteromedial elbow pain
  • Numbness/tingling small finger
  • and half of ring finger
  • Weak grip and key pinch
  • Hand fatigue

18
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

19
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

20
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

21
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

22
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

23
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

24
Wrist Tendonitis/Ganglion
  • Physical exam
  • Tender wrist/tendon
  • occasionally warm,
  • no redness
  • Pain with specific motions
  • Firm lump
  • Transillumination

25
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

26
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

27
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

28
Dequervains Tenosynovitis
  • Where Is It?
  • Involves APL
  • and EPB tendon
  • sheaths at the level
  • of the radial styloid

29
Dequervains Tenosynovitis
  • Complaints
  • Radial sided wrist pain
  • with thumb motion
  • 40s-50s
  • Women 4 - 6x more than men

30
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

31
Dequervains Tenosynovitis
  • Treatment
  • Thumb abduction
  • splint
  • NSAIDs
  • Steroid injection
  • (80 response)
  • First dorsal compartment release (90 response)

32
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

33
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

34
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

35
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

36
Carpal Tunnel Syndrome
  • Physical Exam
  • Positive Tinels
  • Positive Phalens
  • Thenar Atrophy
  • NCT/EMGs
  • (motor lat. gt 4.5,
  • sensory lat. gt 3.5)

37
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

38
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

39
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

40
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

41
Trigger Finger
  • Where Is It?
  • A1 pulley
  • of flexor tendon
  • Distal-most palmar crease

42
Trigger Finger
  • Complaints
  • Mechanical catch or lock of finger
  • when flexed
  • Common 1st thing in the morning
  • Pain at A1 pulley

43
Trigger Finger
  • Physical exam
  • Tender A1 pulley
  • Palpable catch at pulley
  • Occasionally feel thickened nodule

44
Trigger Finger
  • Treatment
  • NSAIDs (if early)
  • Splinting (if early)
  • Cortisone injection (if lt 6 mos.)
  • Surgical release

45
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

46
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

47
Tendon Ruptures
  • Where Is It?
  • Centrally along
  • the tendon path
  • from proximal
  • to wrist
  • to DIP joint

48
Tendon Ruptures
  • Complaints
  • Inability to flex or extend finger

49
Tendon Ruptures
  • Physical Exam
  • Inability to flex or extend finger
  • Deep laceration adjacent to tendon, sometimes
    with pearly-white tendon visible

50
Tendon Ruptures
  • Treatment
  • Splint for mallet finger
  • (must be worn all the time!)
  • Can pin mallet finger
  • All other complete tendon tears need repair

51
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

52
Hand Fractures
  • What is it? Causes
  • Direct or indirect blow to hand

53
Hand Fractures
  • Complaints
  • Swollen painful
  • finger/hand
  • often unable to
  • touch area
  • Often deformity
  • of finger

54
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

55
Hand Fractures
  • Treatment
  • Non-displaced get splint
  • Displaced gt 2 mm get surgery/reduction
  • Angulated/rotated get surgery/reduction

56
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

57
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