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Elbow, Wrist, and Hand

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Elbow, Wrist, and Hand Intersection Syndrome Inflammation of the tenosynovium of the radial wrist extensors where they cross under the APL and EPB; 4-8 cm proximal to ... – PowerPoint PPT presentation

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Title: Elbow, Wrist, and Hand


1
Elbow, Wrist, and Hand
2
Patient Presentation
  • A 10 year old patient fell off monkey bars and
    braced his fall with an outstretched arm
  • He is grabbing his elbow close to him and appears
    in severe pain
  • What do you do next?

3
Highest on Differential List
  • Posterior Dislocation
  • Fracture including supracondylar fracture
  • Soft Tissue Injury

4
Check for deformity
INJURY EVALUATION
Check neuro- vascular status
Attempt to determine the mechanism
Determine need for x-rays
-Relocate? - Refer? - Radiograph?
5
Radiography of the Elbow
  • Trauma evaluation of the elbow should include
  • A-P in full extension (if possible)
  • 90 degree flexed lateral view
  • both obliques
  • an axial view with elbow flexed to 110 degrees
    and beam angled 45 degrees
  • Special views include
  • stress view performed supine with arm off table
    (gravity stress)
  • radial head-capitellum view
  • cubital tunnel view

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10
Dislocation of the Elbow
  • Most often posterior due to hyperextension
    injury
  • Posterior (and often lateral) displacement of the
    ulna and radius on the humerus
  • Damage to the UCL, anterior capsule, and
    brachialis muscle
  • Apply ice, splint, check neurovascular status
    refer for x-rays and treatment
  • Immobilization is usually for a number of weeks
  • Movement of the arm after immobilization must
    not be passive always active movement
  • Complications include myositis ossificans, scar
    tissue formation, and ulnar nerve damage

11
Supracondylar Fractures
  • Injury occurs in children under age of 12
  • May look like a dislocated elbow do not try to
    relocate an apparent dislocation without x-rays
  • At time of injury arm is splinted and
    neurovascular status is checked (especially
    median)
  • Usually there is rapid swelling which may lead
    to Volkmanns ischemic contracture
  • Refer for immediate orthopedic consultation
  • Fracture occurs with a fall on hand of
    outstretched arm or with severe valgus force or
    direct blow
  • Pronation and supination are usually very
    painful x-ray for fracture, however, fat pad
    sign may be only indicator
  • Sling or posterior splint for 3-4 weeks unless
    severely fragmented or displaced

12
Volkmanns Ischemic Contracture
13
Radial Head Fracture
  • Mechanism
  • Fracture occurs with
  • fall on outstretched hand
  • severe valgus force
  • direct blow
  • Evaluation
  • Significant pain on pronation and supination
  • X-ray to determine fracture (include
    radio-capitellum view), however, fat pad sign may
    be only indicator
  • Treatment
  • Sling or posterior splint for 3-4 weeks unless
    severely fragmented or displaced

14
Nursemaids Elbow
  • Mechanism
  • Sudden jerking or swinging child (ages 2-4) by
    arms may cause damage or entrapment of the
    annular ligament
  • Evaluation
  • Significant pain on pronation and supination
  • Palpation may reveal malpositioned radial head
  • Treatment
  • Reduction through flexion and rotation

15
Patient Presentation
  • A 20 year old patient is active in sports, in
    particular, baseball
  • He has pain at his medial elbow made worse by
    throwing
  • What do you do next?

16
Static Stability of the Elbow
  • Medial stability - anterior oblique UCL
  • Ant. oblique tight in extension posterior -
    flexion
  • Lateral stability - lateral ulnar collateral
    lig. (LUCL)
  • Sectioning/rupture of LUCL causes a pivot shift
    of the humeroulnar joint
  • The anconeus muscle is a major lateral
    stabilizer
  • Medial stabilization also from pronator/flexor
    group lateral assistance from the extensor wad

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19
Ulnar Collateral Ligament Sprain
  • Occurs with pitching, hitting forehand stroke in
    tennis, the training arm of batters, arm
    wrestling, and collegiate wrestling
  • With throwing pain may be sudden, sharp, and
    often with a popping sound
  • Pain is increased with valgus testing
  • Chronic stress may lead to calcification of the
    UCL

20
Medial Stretch Injury
  • Damage to the ulnar nerve
  • Strain of the flexor/pronator muscle group
  • Sprain of the anterior oblique portion of the
    ulnar collateral ligament
  • Strain and avulsion of the epicondyle
  • Inflammation of the joint capsule medially

21
Medial Epicondylitis
  • Often referred to as Little League elbow occurs
    in 9-12 year olds
  • In the adult, golfers elbow is the common
    diagnostic tag injury due to throwing club down
    at ball
  • Swimmers elbow is another example improper
    pull-through mechanics with the backstroke

22
Ulnar Nerve Problems
  • Compression or irritation by fibrous cubital
    tunnel
  • Muscular hypertrophy of the flexor carpi
    ulnaris
  • Subluxation out of the groove

23
Lateral Compression Injury
  • Lateral compression due to a valgus force may
    lead to
  • articular cartilage damage at the distal humerus
  • osteocartilagenous lesion of the radial head
    which may lead to loose bodies
  • If progressive occurring during growth phase,
    permanent damage is likely with some severe
    restrictions in movement
  • Diagnosis made with radiographs (capitellum view)

24
Little Leaguers Elbow
  • Includes soft tissue and osseous injury
  • Pt. presents with medial pain made worse by
    pitching, passive extension of the fingers/wrist,
    limitation of complete extension and occasionally
    a popping sound
  • Radiographs may show accelerated growth,
    separation or fragmentation of the medial
    epiocondylar epiphysis
  • Little League rules should be enforced and no
    curves or breaking pitches should be allowed in
    the 9-14 age group
  • Fracture displaced more than 1 cm needs surgical
    repair

25
Osteochondritis Dissecans
26
Patient Presentation
  • A 25 year old patient fell on his elbow
  • Subsequently he has developed swelling at the
    olecranon
  • During his workout, he felt a pop at the back of
    his elbow
  • What do you do next?

27
Posterior Compartment Pathology
  • Triceps tendinitis at the olecranon
    insertion
  • Impingement causing posteriomedial osteophytes
    on the olecranon
  • Olecranon bursitis and avulsion fractures

28
Orthopedic Testing of the Elbow
  • Tinels - ulnar nerve
  • Cozens/Mills and reverse - lateral and medial
    epicondylitis respectively
  • Stability testing - valgus for ulnar
    collateral/varus for radial (performed with 25-30
    degrees of flexion)
  • Valgus extension - valgus extension overload
    causing posteromedial impingement
  • Repeated supination/pronation - for
    radiocapitellar chondromalacia

29
Eccentric Exercise for the Elbow
  • Stretch using a static approach 15-30 seconds
    repeat 3-5 xs
  • Eccentric exercise performed with 3 sets of 10
  • Slow sets first 2 days, intermediate next 2, and
    fast last 2
  • Stretch statically as before exercise after each
    days session
  • Ice for 5-10 minutes
  • The third set of each day should cause some pain
    if not slightly increase weight
  • If pain is felt during the first two sets reduce
    resistance or discontinue

30
Patient Presentation
  • A 33 year old assembly line worker is complaining
    of both pain and numbness from the forearm to the
    hand
  • The symptoms are worse with work
  • He also notices some weakness with specific
    movements
  • What do you do next?

31
Entrapment Syndromes
  • Median
  • Pronator Syndrome
  • Carpal tunnel Syndrome
  • Anterior Interosseous Syndrome (motor only)
  • Ulnar
  • Cubital Tunnel Syndrome
  • Tunnel of Guyon Syndrome
  • Radial
  • Radial Tunnel Syndrome
  • Posterior Interosseous Syndrome (motor only)

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34
Pronator Syndrome
  • The median nerve may be entrapped at
  • lacertus fibrosis
  • pronator teres
  • fibrous arch of flexor digitorum superficialis
  • ligament of Struthers or enlarged bursa
  • Symptoms include
  • aching forearm pain worse with repetitive
    pronation or flexion
  • sensory findings in radial 3 1/2 digits

35
Pronator Syndrome
  • Provocative maneuvers based on site of
    entrapment
  • resisted forearm flexion - lacertus fibrosis or
    ligament of Struthers
  • forearm pronation/wrist flexion - pronator teres
  • middle finger flexion - flexor digitorum
    superficialis

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Anterior Interosseous Nerve (AIN) Syndrome
  • AIN is motor only
  • impinged or entrapped at
  • the pronator teres
  • the flexor digitorum superficialis
  • Symptoms include pain in proximal forearm with no
    sensory findings
  • Weakness of the FPL, pronator quadratus, and FDP
    of the 2nd 3rd digits leads to pulp-to-pulp
    sign

38
Management of Median Nerve Problems
  • Identify site of compression
  • For carpal tunnel use of neutral, nocturnal
    splint, myofascial release, ultrasound, distal
    radioulnar or lunate adjusting, modifying work
    activity
  • For pronator syndrome or anterior interosseous
    syndrome myofascial release, functional taping,
    work or recreational activity modification

39
Cubital Tunnel Syndrome
  • Entrapment of the ulnar nerve may occur at
  • the arcuate ligament, or at the
  • flexor carpi ulnaris
  • Irritation may be due to tension with subluxation
    at the posterior condylar groove or with condylar
    osteophytes
  • Aching pain at medial elbow with radiation some
    sensory findings in 4th and 5th digits motor
    findings are uncommon
  • Provocative maneuvers
  • subluxating the nerve or Tinels
  • flexion of forearm for up to 3 minutes

40
Ulnar Tunnel (Guyon) Syndrome
  • Ulnar nerve may be compressed in tunnel formed by
    pisiform and hook of hamate
  • Causes include
  • trauma, ganglions, hook of hamate fractures,
    ulnar artery thrombosis
  • Signs may be purely motor, purely sensory, or
    mixed
  • Claw hand may occur ulnar lesions proximal to
    branches to FDP will not result in this deformity

41
Radial Tunnel Syndrome
  • Entrapment or compression of the radial nerve or
    its motor branch, the posterior interosseous
    nerve (PIN)
  • Four potential entrapment sites and associated
    provocative maneuvers
  • arcade of Frohse - forearm pronation with passive
    wrist flexion
  • extensor carpi radialis brevis - resisted middle
    finger extension
  • radial head - resisted elbow flexion and forearm
    supination

42
Carpal Tunnel Syndrome
  • Mechanical Causes
  • Overuse
  • RA/Tenosynovitis
  • Lipoma
  • Fractures/Dislocations
  • Physiologic
  • Diabetes
  • Hypothyroidism
  • Pregnancy

43
Carpal Tunnel Syndrome
  • Symptoms may include wrist or hand pain that may
    radiate to the forearm, elbow, and shoulder
  • Numbness /paresthesias of the radial 3 1/2 digits
    sparing the thenar eminence nocturnal
    exacerbations
  • Differentiate from or overlap with other median
    nerve entrapment sites and double-crush from
    cervical spine

44
Carpal Tunnel Syndrome
  • Testing includes
  • physical examination
  • Phalens (reverse Phalens)
  • Tinels or compression
  • Abductor policis brevis weakness
  • objectifiable sensory loss over radial 3 1/2
    digits
  • eventual thenar atrophy
  • electrodiagnostic studies
  • latency with NCV studies

45
Carpal Tunnel Syndrome General
  • 30-70 of patients respond to non-surgical
    management of CTS (some of whom continue to work
    with some discomfort) compared to 70 of patients
    who have full resolution of CTS with surgical
    management

46
Evaluation Objectives
  • Rule out other causes and confirm CTS through
    history and exam
  • Determine possible work-related risks, and the
    risk for prolonged disability
  • Refer patients with thenar atrophy

47
  • Determine if the patients pattern of involvement
    indicates median nerve involvement by evaluating
    whether the patients Katzs diagram indicates
    median nerve involvement or not
  • Determine if there are other sites of entrapment
    other than the carpal tunnel (e.g. pronator,
    ligament of Struthers, etc.) and whether
    myofascial involvement is a cause or simulator of
    median nerve involvement

48
CLASSIC
PROBABLE
UNLIKELY
The classic and probable patterns on a hand
symptom diagram have 64 percent sensitivity for
carpal tunnel syndrome. Only 9 percent of
patients with an unlikely pattern have carpal
tunnel syndrome
49
TABLE 3.DIAGNOSTIC VALUE OF HISTORY AND PHYSICAL
EXAMINATION FINDINGS FOR CARPAL TUNNEL SYNDROME
50
The flick sign predicts electrodiagnostic
abnormalities in 93 percent of cases and has a
false-positive rate of less than 5 percent
51
  • Determine if there is a cause other than carpal
    tunnel syndrome including trauma (fracture,
    instability, dissociation), systemic diseases
    (e.g. diabetes, rheumatoid conditions),
    pregnancy, or tumor
  • Perform standard tests for thumb abduction and
    opposition strength, provocative tests (Tinels,
    Phalens, or compression test), and sensory
    testing and combine with history and Katz
    findings to determine if CTS is present
  • Order or refer for EDT if the patient is
    non-responsive to 6-8 weeks of conservative
    management

52
  • Measure the patients functional involvement
    using a questionnaire such as the Carpal Tunnel
    Syndrome Questionnaire to establish baseline
    effects of condition and response to care.
  • Evaluate work environment and determine the level
    of risk for CTS and for disability related to
    CTS. Consider a site inspection to determine
    possible work and worksite modifications.

53
  • Median nerve involvement evident on
    electrodiagnostic testing (EDT), specifically
    nerve conduction velocity (NCV) studies, strongly
    predicts those patients who have the best
    response to surgery, however, diagnostically
    there is inconsistent evidence for correlation to
    signs and symptoms for CTS.
  • There is some question regarding the value of
    EDT if it does not change decision making in the
    management of CTS

54
  • Confirmation of median nerve involvement via EDT
    should be sought if a trial of non-surgical
    management is unsuccessful at reducing or
    eliminating symptoms and surgery is being
    considered
  • The primary non-surgical approach is the use of a
    neutral wrist nocturnal splinting.

55
Neutral Splinting for CTS
56
  • A multimodal approach coupled with splinting
    should be attempted including carpal bone
    mobilization, soft-tissue massage/nerve gliding,
    and exercise.
  • If conservative management is unsuccessful, prior
    to surgical referral, consider work hardening or
    a multidisciplinary occupational rehabilitation
    program if conservative management is
    unsuccessful

57
Management Directives
  • Attempt a trial of conservative care to determine
    effectiveness
  • Modify work environment if appropriate
  • Obtain EDT for patients who do not respond and
    are considering surgery
  • Refer for surgical consultation if conservative
    management is unsuccessful and EDT findings
    indicate median nerve involvement

58
Weeks 1-2
  • Attempt an initial trial of conservative care
    with the cornerstone being neutral wrist
    nocturnal splinting and worn as needed during the
    day. Consider a multimodal approach that includes
    mobilization, myofascial treatment, stretching,
    pulsed ultrasound, and exercise. Implement
    work-restrictions and modifications based on
    patient history and site inspection

59
Weeks 3-6
  • If successful at reducing symptoms, continue with
    an attempt at weaning the patient off of
    splinting. If unsuccessful at reducing symptoms,
    consider a different combination of splinting
    with the above-suggested list of options.

60
Weeks 7-8
  • If successful at reducing symptoms, continue with
    an attempt at weaning the patient off of
    splinting. If unsuccessful, and surgery is being
    considered, order EDT to determine median nerve
    involvement. If involvement is found, refer for
    surgical consult. If not, consider a
    work-hardening program or a multi-disciplinary
    occupational rehabilitation program for 1-2
    months.

61
Greater than 2 months
  • If work-hardening or multi-disciplinary
    rehabilitation is unsuccessful at reducing
    symptoms or the patient is unable to perform
    required work, refer for surgical consult

62
EVALUATION OBJECTIVES FOR CARPAL TUNNEL SYNDROME
(CTS)
63
CTS MANAGEMENT TIMELINE
64
Patient Presentation
  • A 22 year old patient fell off his skateboard and
    braced his fall with an outstretched arm
  • He is grabbing his wrist close to him and appears
    to be in severe pain
  • What do you do next?

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66
Wrist Radiographs
  • Routine Series
  • PA
  • lateral
  • radial oblique
  • scaphoid axial projection
  • Supplementary Views - Fracture/Instability
  • PA in neutral, radial and ulnar deviation
  • laterals in neutral, full radial and ulnar
    deviation
  • bilateral AP views with fist actively clenched
  • other views include carpal tunnel view, oblique,
    and 30 degree semisupinated view

67
Scaphoid Fractures
  • Proximal pole fractures result in 100 incidence
    of avascular necrosis 30 for distal fractures
  • distal fractures 10 of total
  • proximal fractures 20 of total
  • waist fractures 70 of total
  • Pain at anatomical snuffbox following a fall on
    an outstreched hand provocation test is to
    pronate and gently stress in ulnar plane
  • Scaphoid radiographic series includes
  • PA, lateral, right left obliques, PA with
    radial and ulnar deviation with fingers flexed
  • Bone scan or CT is diagnostic

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69
Always Include an Oblique
70
Scaphoid Fractures
  • If initial films negative, immobilize for 2 weeks
    with follow-up films taken
  • Distal fractures heal in 4-6 weeks with a short
    arm cast
  • Fracture of the proximal 2/3rds is oblique to the
    long axis of wrist requiring a long arm cast with
    thumb spica for as long as 3-6 months

71
Hook of Hamate Fracture
  • Hook of hamate is impacted from a bat, golf club,
    or raquet or all on an outstretched hand
  • Pain/tenderness at hamate decreased, painful
    grip test
  • Carpal tunnel view or 20 degree supination view
    bone scan or CT often necessary
  • 4th and 5th fingers in flexion and base of thumb
    in short arm cast for 10-12 weeks
  • Non-union common

72
Radiographic Evaluation of Lunate on Lateral View
  • DISI - Dorsal Intercalated Segmental Instability
    is found with radial instability with rupture of
    scapholunate ligament lunate rotates dorsally
  • PISI - Palmar (also called volar) Intercalated
    Segmental Instability found with rupture of the
    lunotriquetral ligament lunate rotates into
    palmar-flexion
  • DISI pattern scapholunate angle gt 80 degrees or
    capitolunate angle gt 30 degrees
  • PISI (or VISI) - scapholunate angle lt30 degrees

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Normal Alignment on Lateral
76
DISI Instability
77
DISI
78
DISI
79
VISI
80
Scapholunate Dissociation
  • Mechanism
  • disruption of scapholunate interosseous and
    radioscaphoid ligaments due to a fall on an
    outstretched hand
  • Evaluation
  • wrist pain, decreased grip strength, catch-up
    click
  • positive Watsons test
  • PA radiograph reveals a Terry-Thomas sign 2-3
    mm space between scaphoid and lunate DISI
    pattern is visible
  • Treatment
  • Surgery

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82
Lunotriquetral Dissociation
  • Mechanism
  • fall on outstretched hand or similar compressive
    maneuver
  • Evaluation
  • painful clicking over ulnar aspect of wrist
  • positive Ballotement test
  • possible PISI pattern on lateral radiograph
  • Treatment
  • Immobilization for 1st or 2nd degree sprain
  • Surgery may be necessary with more serious cases

83
PISI
84
Midcarpal Instability
  • Mechanism
  • Damage to the ligaments between the hamate and
    triquetrum occurs with a fall or blow to the
    medial side of the hand with hyper-pronation
  • Evaluation
  • positive popping/clicking with pain with active
    pronation coupled with ulnar deviation
  • DISI pattern may be visible on x-ray
  • Treatment
  • Immobilization for 6 weeks in ineffective,
    several stabilizing surgeries are available

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86
Ulnar Variance
87
Distal TFCC
88
TFC Injury
89
Distal Radio-Ulnar Injury
  • Mechanism
  • Usually a fall with wrist hyperextended and
    forearm hyperpronated injury may occur at
  • Evaluation
  • swelling and tenderness over distal articulation
  • pain is increased with active or passive
    pronation
  • ulna may be slightly more prominent
  • radiographic findings are subtle
  • Treatment
  • ulna is reduced by dorsal pressure while
    supinating wrist long arm cast for 4-6 weeks

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91
Keinbocks Disease
  • Avascular necrosis of the lunate
  • Due to repetitive minor trauma possibly related
    to ulnar variance
  • Lunate becomes more radiopaque as necrosis
    progresses
  • If detected, cast immobilization for 8 weeks
  • If unsuccessful, surgery may be necessary

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93
Rheumatoid Wrist
94
Patient Presentation
  • A 22 year old patient complains of wrist pain
    primarily on the dorsum of the wrist
  • She is a classical pianist and has problems with
    practicing recently due to the pain
  • What do you do next?

95
Diagnosis of Tendon Involvement
  • Localization of the involved tendon is based on
  • insertion point tenderness or pain
  • resisted movement accomplished by tendon or
    stretch into opposite pattern
  • Other conditions must be differentiated such as
    fracture or ligament sprain before assuming
    tendon only problem

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97
DeQuervains Disease
  • Disorder of the abductor policis longus and
    extensor policis brevis
  • Is often an overuse syndrome due to repeated
    thumb extension/abduction
  • Pain swelling over radial styloid is irritated
    by wrist ulnar deviation and thumb adduction with
    flexion (Finkelsteins test)
  • Rest from inciting activity, myofascial and cross
    friction proximal to site of involvement

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Intersection Syndrome
  • Inflammation of the tenosynovium of the radial
    wrist extensors where they cross under the APL
    and EPB 4-8 cm proximal to Listers tubercle
  • May result from trauma or repeated
    flexion/extension
  • Occurs in rowers, canoeists, and weight lifters
  • Rest and modification of inciting activity
  • Myofascial work proximal to site of involvement

100
Treatment of Wrist Tendinitis
  • Cross-friction massage proximal to insertion
    point for a period of 1-3 weeks every other day
  • Cryotherapy and/or pulsed ultrasound
  • Stretching using PNF hold-relax technique
  • Adjust carpals
  • Mild isometric contractions into direction of
    pain may help
  • Avoid stretching tension that occurs with holding
    objects in hand such as a briefcase

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102
Patient Presentation
  • A 16 year old female was playing rugby
  • In a collision with another player she hurt her
    finger
  • There is no deformity, however, she cannot move
    the finger without significant pain
  • What do you do next?

103
Quick Hand Evaluation
  • Allens
  • Two-point discrimination
  • Sensory
  • ulnar - volar tip of small finger
  • radial - dorsum of thumb web
  • median - volar tips of index long fingers
  • Motor
  • ulnar - cross long finger over dorsum of index
  • median - point thumb towards ceiling palm up

104
Finger Motor Function
  • FDP - with MP PIP joints held in extension,
    flex DIP joint
  • FDS - examiner holds all untested fingers in
    extension while patient flexes free finger
  • EDC - with wrist extension, extend at MP IP
    joints
  • FDL - thumb held in extension at MP ask patient
    to flex IP joint

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108
Boutonnieres Deformity(Central Slip Tear)
  • Mechanism
  • Hyperextension of MCP DIP with flexion of PIP
    resulting from a flexion injury of the PIP
    tearing the dorsally located central slip. The
    lateral bands (the hood) drops anteriorly holding
    the PIP flexed.
  • Evaluation
  • Point tenderness over dorsum of middle phalanx
    associated with generalized swelling of PIP the
    PIP cannot be fully extended.
  • Treatment
  • PIP splinted alone in extension to approximate
    central slip followed by exercises to extended
    PIP flex DIP.

109
Boutonnere Deformity
110
Pseudo-Boutonnieres Deformity
  • Mechanism
  • Extension injury of the DIP with damage to the
    volar plate.
  • Evaluation
  • Point tenderness at volar, middle phalanx
    associated with generalized swelling of PIP the
    PIP cannot be fully flexed or extended.
  • Progressive calcification seen radiographically
    at vola plate in 3-6 months.
  • Treatment
  • PIP splinted alone in safety-pin splint

111
PIP Extension Brace
112
Jersey Finger
  • Mechanism
  • Avulsion of FDP when a player grabs another
    player
  • Evaluation
  • Unable to flex finger with FDP
  • Tendon may be displaced as far as the palm
  • X-ray to determine avulsion
  • Treatment
  • Surgical repair is necessary

113
Mallet Finger
  • Mechanism
  • Avulsion of extensor tendon from DIP usually due
    to a blow to the finger (e.g. baseball finger).
  • Evaluation
  • A dropped DIP in acute cases swan neck in
    chronic
  • Tenderness at dorsal DIP
  • X-ray to determine avulsion
  • Treatment
  • DIP only splinted in extension for 6-8 weeks

114
Mallet Finger
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116
Swan Neck Deformity
117
MC Collateral Ligament Injury
  • Mechanism
  • Radial or ulnar stress to a flexed MCP joint may
    cause injury usually due to fall on ground or
    player contact
  • Evaluation
  • Pain and tenderness over MCP joint
  • Pain elicited on flexion with radial ulnar
    deviation
  • Stress test at 70 degs.
  • X-ray may show an avulsed fragment at base of
    proximal phalanx
  • Treatment
  • Immobilization in flexion for 3 weeks buddy
    taping for 3 more

118
PIP Collateral Ligament Injury
  • Mechanism
  • Very common finger pulled sideways and often
    subluxates and spontaneously reduces
  • Evaluation
  • Pain and tenderness over collateral ligament and
    volar plate
  • Stress test only possible immediately after
    injury
  • X-ray may show an avulsed fragment at volar plate
  • Treatment
  • Immobilization in flexion followed by buddy
    taping for if grade 1 2 grade 3 may need
    surgery

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Gamekeepers Thumb
  • Mechanism
  • Sprain of ulnar collateral ligament when player
    falls or strikes opponent with thumb abducted
  • Evaluation
  • Pain and tenderness over anteromedial aspect of
    MCP
  • Stress test applied at 0 30 degs.
  • Pain and weakness on pinch test
  • X-ray may show an avulsed fragment at proximal
    phalanx stress x-rays may demonstrate
    instability
  • Treatment
  • Taping with cinch or sort-arm cast based on
    degree grade 3 needs surgery

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Boxers Fracture
  • Mechanism
  • Fracture of the neck of the fifth metacarpal
  • Usually the result of heating an object with an
    uprotected wrist
  • Evaluation
  • Look for rotational deformity
  • Percussion test on tip of finger painful.
  • Pain and weakness on pinch test
  • X-ray
  • Treatment
  • Angular deformity up to 40 degs. Acceptable
  • With closed-reduction use thermoplastic gutter
    splinting or butterfly clamp

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Bennetts Fracture
  • Mechanism
  • Axial compression injury causing a
    trans-articular fracture of the first MCP joint
    with a triangular fragment of bone in place while
    shaft dislocates and held proximally by pull of
    APL
  • Evaluation
  • Significant pain and swelling at first metacarpal
  • X-ray to determine avulsion and distinction from
    similar fractures
  • Treatment
  • Open reduction with fixation

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Bennetts Fracture
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Ganglions
  • Mechanism
  • Benign tumorous masses that may be intra- or
    extra-articular
  • Thought to be due o congenital weakness or
    traumatic damage to ligaments or tendon
  • Evaluation
  • Pain and tenderness over palpable mass
  • When deep, may not be palpable
  • Most common locations are dorsally at
    scapholunate ligament and ventrally in FCR tendon
    or other flexors
  • Treatment
  • Rest and immobilization may help surgical
    excision may be necessary

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Dupuytrens Contracture
  • Nodular thickening of the fourth fifth finger
    flexors
  • Eventually fingers flexed at the MCP PIP with
    DIP held in extension
  • Management includes frequent stretching and
    possibly immobilization at night in a soft cast
  • Eventually surgery may be necessary to release
    the fibrous tissue

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Dupuytrens Contracture
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