Upper Extremity Diagnosis & Management Final

What is lateral epicondylitis?

Lateral elbow pain due to degenerative tendinopathy, periostitis, and probably adhesions at the lateral epicondyle of the humerus and the underlying lateral joint capsule

What is lateral epicondylitis typically called?

Tennis Elbow-Carpenters elbow-Dentist elbow-Yachtsman elbow-Potato picker's plight-Politician's paw

What does lateral epicondylitis typically involve?

-The extensor carpi radialis longus-Extensor carpi radialis brevis (m/c)-Brachioradialis-Extensor digitorum

What is the most common elbow condition?

lateral epicondylitis

Epidemiology of lateral epicondylitis

-Annual incidence 1-3% of population-Most often seen in 40-60 year olds-15% of workers with repetitive hand use -12 weeks of work loss in 30% of patients -50% of all tennis players have elbow pain at some time and 75-80% are lateral epicondylalgia in nature

What usually causes lateral epicondylitis?

Repetitive overuse involving-Wrist extension/flexion-gripping-finger movements-pronation and supination

How might lateral epicondylitis present?

-May start with acute inflammation of tendon but-Often leads to degeneration, micro-avulsion, scarring and adhesion to underlying tissues

What is the lateral epicondylitis etiology?

-Correlated with aging-35-55 y.o., but m/c in 40-60y.o.-Can occur in other age groups based on the presence of risk factors (below)-Prevalence increases 2x in males and 4x in females older than 40 years of ageThere is a correlation with Frequency, and amount of time spent playing tennis

What percentage of patients with lateral epicondylitis are actually associated with tennis?

Tennis is associated with condition in less than 10% of all patients;

What percentage of tennis players will develop lateral epicondylitis while they are actively playing?


What are some risk factors for lateral epicondylitis?

-Handling tools > 1kg OR-Handling loads > 20kg at least 10 times per day-Repetitive upper extremity movements more than 2 hours per day-Working with vibrating machinery > 2 hours per day-Prior local injection therapy-Hyperglycemia: HbA1c > 6.5% (normal = 4.0 -5.6%, pre-diabetic 5.7-6.4%)

What are lateral epicondylitis symptoms and when can they occur?

-Lateral elbow pain and stiffness-Onset often job related exacerbated by causative activity or similar activity-Weakness and pain during gripping, or with resisted wrist or finger extension-Stiffness after rest especially after prolonged elbow flexion

What is the Location of lateral epicondylitis?

Hallmark of this condition is precise localization at lateral epicondyle

What is the Onset/Chronology of lateral epicondylitis?

Progressive symptoms due to repetitive overuse

What are some DDXs for lateral epicondylitis?

-Acute onset requires differential diagnosis-RCL sprain-Local infection (e.g. bursitis due to fall, non-sanitary injection therapies)-Gouty arthritis-Radial head subluxation (Nursemaid's Elbow)

What is the Quality/Severity for lateral epicondylitis?

-Intense pain that waxes and wanes along with subjective stiffness-Stiffness requires DDx of osteoarthritis-Pain is severe with increased use/activity

Modifying Factors for lateral epicondylitis?

-Self-treatment is often not helpful -OTC braces may be helpful (low to moderate quality evidence; few RCTs and more observational studies)-Rest is most helpful of typical self-care therapies

When should you suspect lateral epicondylitis during the subjective part of the examination?

Think epicondylitis if patient reports repetitive overuse, or elbow sprain if sudden onsetThey may or may not have a past history of elbow symptomsDDx: sprains to the lateral/radial collateral ligament, especially in the presence of traumatic history

What are some associated symptoms with lateral epicondylitis?

-Absence of radiation-Numbness and tingling are rare but are indicative of local radial nerve irritation (radial tunnel syndrome)-Painful clicking is indicative of chronic epicondylitis and/or olecranon bursitis

What is the prognosis for painful clicking with lateral epicondylitis?

-Poor prognosis-Especially when compared to painless clicking (which is more likely indicative of tendinopathies, RCL sprains, osteoarthritis) and a better prognosis

How might lateral epicondylitis present on the physical exam?

Observation: Overt inflammation is uncommon (Infection/Bursitis)Fracture Screen:-Required if avulsion and/or radial head subluxation are suspected-Clinical Note: Pain + Trauma = X-Ray aROM/pROM: -Painful active wrist extension with or without painful active supination -Painful passive wrist flexion with or without painful passive pronation

What orthopedic test would you run if you suspect lateral epicondylitis?

-Cozen's-Mill's-Book Test (Squeeze book with thumb/fingers and hold it)-Varus/Valgus Stress (to determine comorbid ligamentous sprain) -Diminished dynamometer grip strength (Good objective outcome marker)

What would you do for acute treatment of lateral epicondylitis?

-P.O.L.I.C.E. -Ice massage -Supports/Braces-Mobilization/Manipulation -Massage (P&S/PIR/Lymphatic Drainage)-Ultrasound -LASER -K-Tape-Extracorporeal Shock Wave Therapy-PRP/Cortizone Injections

What would you do for Sub-Acute/Chronic Treatment of lateral epicondylitis?

-Manipulation/Mobilization: Add Ulnar Traction with manipulation to radial head-Transverse friction massage (Cross-Fiber) -Myofascial release: (ART/P&S/IASTM/Myofascial Cupping)-Nerve Flossing/Dermal Traction-Continuous US/LASER -Change technique/equipment-Avoid painful activities -Increase equipment handle size-Elbow/forearm/wrist splints

What is the prognosis for lateral epicondylitis?

-Most cases are self-limiting within 2 months but can take up to 6 years to resolve -Recent evidence suggests decreasing incidence -Steroids, prolotherapy, and PRP results are equivocal, especially in the long term-Those with neurologic s/sx's are more likely to experience poor short term outcome to conservative care -Poor long term prognosis with repetitive computer use

What is medial epicondylitis?

Medial elbow pain involving tendinopathy of the common flexor tendon at its attachment to the medial epicondyle of the humerus

What does medial epicondylitis typically involve?

-Flexor carpi ulnaris-flexor carpi radialis-Pronator teres-In children it often involves traction apophysitis of the medial epicondyle

Do golfers get lateral epicondylitis?

-Med. epicondylitis of trailing elbow-Lat. epicondylitis of the leading elbow

Is medial epicondylitis more or less common than thanes elbow

Medial epicondylitis is less common than tennis elbow

What causes medial epicondylitis?

Overuse:-Golfing-Valgus stress -Throwing -Wrist flexion/pronation -Tennis serve -Gripping Tools -Carpenter, plumber, butcher -Volleyball spike Muscular imbalance:-Dominant vs Non-Dominant hand-Tendon degeneration: Age as well as possible previous steroid injections

Where is pain felt with medial epicondylitis?

-Medial epicondyle is typical location, but may also involve radiation distally-Often insidious onset -Pain after rest -Pain during exercise

If numbness and tingling occur on medial elbow/forearm what would be on your DDX??

-Ulnar neuropathy either at the ulnar groove or distally

If numbness and tingling occur on ventral surface of forearm what would be on your DDX?

Median neuropathy (peripheral entrapment likely from pronator teres or at carpal tunnel)

If there is an acute onset of pain is felt on the medial side of the elbow what would you suspect?

MCL/Ulnar collateral ligament sprain

If there is an acute onset of pain with overt swelling on the medial side of the elbow what would you suspect?

Olecranon bursitis

What would your physical exam look like for medial epicondylitis?

-aROM-Orthopedic Testing: (Reverse Cozen's & Reverse Mill's)-Neuro Exam• Low Index Neuro/High Index Neuro -Palpation: Both global and segmental

What would you do for acute treatment of medial epicondylitis?

P.O.L.I.C.E-Protect with padding/sleeve (as necessary) -Optimal Loading -Widen grip of tools, racquet's, etc., if possible -Reduce frequency, intensity and/or duration of offending activities, if possible -Tension strap bracing -Mobilization toward medial humeroulnar glide: Manipulation if tolerated & Manipulation of distal joints (e.g. distal radioulnar joint, intercarpal joints, metacarpophalangeal joints, shoulder complex) -Ice without friction -Compress-Elevate

What would you do for acute treatment with PT modalities of medial epicondylitis?

-OTC and/or topical NSAIDs/analgesics-US/TENS/LASER/K-Tape/Iontophoresis-Light massage distal to medial epicondyle

What would you do for Sub-Acute/Chronic Treatment of medial epicondylitis?

-Manipulation as tolerated but now including humeroulnar joint in all directions -Transverse friction/IASTM to lateral epicondyle -Manage likely muscular imbalance-Myofascial Cupping/Dermal Traction

What are some specific muscle imbalances you would try to increase if you have a patient with medial epicondylitis?

-Increase wrist extensor flexibility-Increase biceps flexibility-Increase RCT strength-Increase pronation/supination strength

What specific nerve flossing would you do for someone with medial epicondylitis?

-Ulnar Nerve flossing

What is the prognosis of medial epicondylitis?

-Most cases are self-limiting and usually respond to conservative care within 2 months, but some may take up to 6 years to fully resolve-Recent evidence suggests decreasing incidence overall

If a patient with medial epicondylitis is not getting better what might you refer them out for?

-Prolotherapy-PRP injection

If you have catching or locking on the lateral side of the elbow, what might you suspect?

-Catching or locking in young males (<15 y.o.) indicates possible OCD-X-Rays required to r/o OCD

What is the definition of olecranon bursitis? What is it most commonly characterized as?

-Swelling/inflammation of the olecranon bursa-Most common Dx is superficial bursitis

What are some alternative is olecranon bursitis known as?

-Miner's elbow-Student/draftsman's elbow-Dart thrower's elbow

How can olecranon bursitis be caused?

-Repetitive friction or pressure -Blunt trauma to tip of elbow-Infectious inflammation -20% of acute cases due to staphylococcus or other gram-positive infections -Gout/pseudogout are associated risk factors-Tight triceps or tendinitis has shown a increased correlation with developing Olecranon Bursitis

What are some risk factors for olecranon bursitis?

-Manual jobs with repetitive stress or trauma to elbow -Trauma with skin lesions increase chance of developing septic bursitis (ex Psoriasis )-Chronic hemodialysis: Electrolyte imbalances due to Kidney failure

What are some symptoms of olecranon bursitis?

-Pain or tenderness is not common-Mild to obvious swelling -Stiffness common

What would you diagnose olecranon bursitis due to trauma and how would you do it?

-Fracture-Order X-Rays to r/o

What would you diagnose olecranon bursitis due to a Triceps Tear and how would you do it?

-Bruising/swelling-Dx MSK US to evaluate soft tissues

What ortho tests would you do with olecranon bursitis?

-Instability tests-Ortho Tests (Valgus/Varus Stress Tests)

What systemic diseases would you suspect with olecranon bursitis?

-Infection-Gout-Inflammatory arthritis

How would you treat olecranon bursitis?

-P.O.L.I.C.E. -U.S.•Superficial setting to avoid periosteal burning (3 MHz)Three-MHz Ultrasound Heats Deeper Into the Tissues Than Originally Theorized.-Laser-K-Tape for lymphatic drainage-Manipulation (if tolerated) -Elbow/Shoulder -Cervical Spine

What is usually the prognosis of olecranon bursitis?

With Conservative care:-Slow to heal-Can take weeks to months to fully resolve

Who would you refer to if olecranon bursitis is unresponsive to care?

-Appropriate follow-up procedures-Fluid Aspiration -Corticosteroid injection -Possible Surgery (rare)

What is the definition of elbow OCD?

Inflammatory pathology of bone and cartilage resulting in localized necrosis and fragmentation of the bone and cartilage.

What is elbow OCD also referred to as?

Panner's disease(Lesion of the capitellum usually)

Is OCD of the elbow common or uncommon?

-Overall Uncommon Pathology

What population is Panner's disease most seen in?

-Adolescent athletes: Less than 15 years of age-Genetics: Familial Hx increases risk-Sports: Contact/Collision sports increase risk

What is the most common site of OCD?

-In the upper limb-Usually involves the Capitellum but may also involve the olecranon and trochlea

What is OCD most commonly due to?

Repetitive high stress compression on the joint into a valgus direction compressing the radial head against the capitellum

What can OCD of the elbow lead to?

Can Lead to AVN of the Capitellum

What some of the risk factors for OCD?

-Hx of Medial epicondylitis or current sx's-Elbow Instability-Repetitive high stress into a valgus direction

What specific sports might increase the risk of OCD?

-Baseball pitchers-Javelin Throwers-QuarterbacksAnything that will cause repetitive high stress into a valgus direction

What are the key signs and symptoms for OCD?

-Gradual onset of mild lateral elbow pain with or without crepitus and catching -Diminished aROM, especially extension-Tender, enlarged radial head -Lateral elbow pain with valgus stress testing (@ 0 and 20)-Feeling of Posterior-lateral instability-Becomes more painful with "popping," "catching," "Locking" with jt. loading

On x-rays, how is stage I of OCD classified?

Thickening of cartilage and is considered a stable lesion

On x-rays, how is stage II of OCD classified?

Articular cartilage interrupted but is considered a stable lesion

On x-rays, how is stage III of OCD classified?

Articular cartilage interrupted with fragmentation of underlying subchondral bone, and is considered an unstable lesion.

On x-rays, how is stage IV of OCD classified?

Loose body, and is considered unstable

Which stages of OCD require an orthopedic consult?

Stages III and IV require an Orthopedic Consult

When would you refer out on a patient with OCD?

-Stage III or IV OCD-If conservative care fails after 2 weeks-Refer to an Orthopedic Surgeon or D.O.

How would you treat OCD of the elbow?

-P.O.L.I.C.E. -Massage (P&S/IASTM/PIR/ART)-EMS (IFC/TENS) for pain control-Hand exercises (In the absence of fragmentation and/or post-surgical)

What type of treatment is absolutely contraindicated with OCD?

Manipulation is contraindicated!

What is the definition of carpal tunnel syndrome?

Median nerve compression or irritation as it passes through thecarpal tunnel

What are some examples of internal pressure that can cause carpal tunnel syndrome?

Pressure increases from -Ganglions-Fractures or dislocations can actively compress the median nerve

What are some examples of external pressure that can cause carpal tunnel syndrome?

More commonly pressure from prolonged flexion or extension and external forces work to compress the median nerve.

What can contribute to the causes of tarsal tunnel syndrome? What are some examples?

-Factors that increase fluid retention can aid in compression of the nerve.-Diabetes-Pregnancy-Rheumatoid arthritis.

What is typically the location that a patient with carpal tunnel syndrome would report?

Location - The palmar surface of the hand and first 3 digits are "tingly" and feels like they are "going to sleep.

How would a patient with carpal tunnel syndrome report their onset and the chronology?

Onset/MOI - Unsure but find it more aggravated when they do lots of lifting. No trauma either the neck or the shoulder.Chronology - Periodic in nature. Be sure to ask if there is a trigger?

How would a patient with carpal tunnel syndrome report their pain?

Patient reports minimal pain but a distinct wrist discomfort coupled with tingling/weakness

What associated symptoms would a patient with carpal tunnel syndrome report?

Patient reports no popping, clicking, locking or any other noticeable symptoms beyond the numbness.

What are some jobs besides working at a desk can cause carpal tunnel syndrome?

lifting and moving heavy objects regularly

What can cause median nerve entrapment?

-Ligament of Struthers -Pronator Teres (can mimic it a lot of the times)-Carpal Tunnel

What would be your DDX for Carpal tunnel syndrome?

-Median Nerve Entrapment-Early Onset Degenerative O.A.-Flexor Compartment Tendonitis -C6 Radiculopathy

What are some inclusion and exclusion tests and evaluation tools that can help confirm carpal tunnel syndrome?

Inclusion tests-Hypoalgesia in median nerve-Classic/probably Katz diagrams 2.3-Weak thumb abduction Exclusion tests-Normal thumb abduction-Unlikely Katz diagram

What are some orthopedic tests and signs that can help diagnose carpal tunnel syndrome? *(These tests are incredibly reliable and have come under scrutiny)

-Phalens -Tinels -Thenar atrophy -Nocturnal paresthesia

How would you treat carpal tunnel syndrome? What are some CMT, STM, BM, and Rehab interventions you would perform?

CMT: AdjustmentSTM: Flexor tendon workBehavioral Modifications:-Avoid aggravating behaviors-Modify existing habits-Reduce use (if possible)Rehabilitation:-Nerve/tendon gliding-Exercises-Possible Splint While Working

How would you manage carpal tunnel syndrome?

-Laser-Ultrasound-Ice massage-Splinting in neutral(day/night)-Corticosteroid Injections-PRP Injections-Acupuncture-Surgery (carpal tunnel release)

What is a ganglion cyst?

Non-cancerous lump that most commonly develop along the tendons or joints of your wrists or hands (they also may occur in the ankles and feet) and are typically round or oval and are filled with a jellylike fluid.

What are the Two types of a ganglion cyst and where do they occur?

-Arthrosynovial: Swelling or bulge overlying a joint -Tenosynovial On a tendon

Who is most likely to get a ganglion cyst?

Females > males (3:1) -Develops in teens through late 40's -Very commonly seen

What are some causes of ganglion cysts?

To date No clearly established Mechanism has been identifiedHowever there are many competing theories such as-Congenital-Blunt Force Trauma -Collagenous degeneration

Are ganglion cysts symptomatic or asymptomatic?

-Asymptomatic -The cyst can become symptomatic depending on size-Waxing and waning of swelling and pain can occur

How would you treat a ganglion cyst?

-Protect-Rest-Splint-NSAIDS (if symptomatic) -Watch and wait -Aspiration -Surgical excision

What is an old school way of treating a ganglion cyst that is not recommend and should never be performed because it can cause the ganglion cyst to come back bigger and badder?

Book Drop (Bible) Method

What is a lipoma?

A lump under the skin that occurs due to an overgrowth of fat cells.

Are lipomas benign or malignant and should they be removed?

-Lipomas are considered benign tumors-It is suggested to have them removed if they cause pain, complications, or other symptoms.

Where can lipomas occur?

-Lipomas can occur anywhere in the body however they commonly occur in the-Neck-Shoulders-Back-Abdomen-Arms-Thighs

How do lipomas present?

-Soft and doughy to the touch.-Move easily with slight finger pressure.-Generally small, typically less than 2 inches (5 centimeters) -Can grow-Lipomas can be painful if they grow and press on nearby nerves or if they contain many blood vessels.-Typically situated just under the skin.

What are some risk factors for lipomas?

-They are generally Idiopathic-They usually occur between the ages of 40 and 60 years old. -Lipomas tend to run in families.

How are lipomas treated?

-They are usually excised-A lipoma is considered a benign cancer and is usually harmless so if it bothers you, is painful or is growing, you may want to have it removed.

What is gamekeeper's thumb?

-Sprain of the ulnar/ medial collateral ligament (UCL) of the -At the metacarpophalangeal joint of the thumb

What is an alternative name for gamekeepers thumb?

Skier's thumbBull Riders thumb

What is the MOI of gamekeeper's thumb?

Pt reports "My thumb bent backwards"-Forceful hyper-extension and/or -Hyper-abduction of the thumb

How might a patient report with game keepers thumb?

-Local pain with antegrade and/or retrograde referral-Usually local pain, but increases with thumb movement-Pain and/or inflammation at the ulnar aspect of the metacarpophalangeal joint (MCP Jt)-Bruising of the MCP Jt may also be present-Moderate to significant interference with ADL's-Difficulty holding objects-Difficulty squeezing with thumb

What type of lesion are you checking for with gamekeepers thumb?

-Stener's lesion:Torn UCL and Volar plate causing significant thumb instability

What signs are you looking for with a gamekeepers thumb

(+) Thumb Abduction stress test=Local pain -Pain around thumb and weakness with muscle testing

What would a grade I gamekeepers thumb look like?

Local mild pain around thumb with no signs of instability/laxity

What would a grade II gamekeepers thumb look like?

Local moderate pain around thumb with slight laxity

What would a grade III gamekeepers thumb look like?

Moderate to severe pain with marked instability/laxity

A grade III gamekeepers thumb is at risk for what?

-Stener's lesion: a torn UCL and volar plate causing significant thumb instability-Palpable nodule/seed over the UCL in the presence of instability helps identify the lesion

How would you manage gamekeeper's thumb?

P. O.L.I.C.E. P: splinting or casting-Usually 4-6 weeks for healing with bracing and activity modifications-Laser therapy to reduce inflammation and increase tissue healing

How would you manage gamekeeper's thumb in the sub-acute/chronic phase?

-Use Clinical Judgement on whether or not to Adjust the thumb -Rubber band / squeeze ball / silly putty exercises / rice bucket exercises-Prophylactic Athletic/Kinesio-taping-Special / modified gloves for support-Short thermoplastic splint -Protect /Avoid pain provoking activities by activity modification

What is the most common type of MOI for wrist sprains?

-Fall on an out-stretched hand (FOOSH) -The wrist is hyper-extended with ulnar deviation.

What else should be considered when assessing a wrist sprain?

-The thumb should be considered as either a concurrent site of injury or as an independent site of injury. -As with any other traumatic injuries, fractures are a reasonable differential diagnosis.

What is another common MOI other than FOOSH that can cause wrist sprains and instability?

-Repetitive overuse injuries of the wrist -More common than traumatic injuries of the wrist. -The differential diagnosis of most wrist conditions amenable to conservative care depends on the mechanism of injury (MOI).

Wrist sprain definition

Traumatic stretching or tearing of the ligaments at the wrist

What ligaments are at risk of being sprained at the wrist?

-Radio-carpal-Ulnocarpal-Distal radioulnar-Intercarpal-Carpometacarpal

With wrist sprains, how are you likely going to determine which ligaments are injured?

-Which ligamentous structures are at most risk of excessive stretch is dependent on the exact MOI-Clearly identify the position of the wrist, thumb, fingers, and elbow when a patient can recall the traumatic incident.

What is the most common injury at the wrist?

-Mild sprains-more common than fractures, subluxations, and dislocations

What is the most common injury at the wrist for kids?

Commonly more fractured

What portion of the wrist is the most vulnerable to injury?

Proximal carpal row is most vulnerable to injury

What is the most common position the wrist will be in with a wrist fracture?

Extension with radial deviation

What is the most common position the wrist will be in with a wrist sprain, dislocation, or TFC tears?

Extension with ulnar deviation

What can the MOI of Hyper-Extension at the wrist lead to?

-Proximal carpal row forced anterior with FOOSH -The palmar radiocarpal and scapholunate ligaments-Most common MOI Increased injury of

What can the MOI of ulnar deviation at the wrist lead to?

-RCL tear-Pure deviation rare

What can the MOI of radial deviation at the wrist lead to?

-UCL tear-Pure deviation rare

What can the MOI of Hyper-Flexion at the wrist lead to?

-Increased injury of the dorsal radiocarpal & lunotriquetral ligaments -Rare-Proximal carpal row forced posterior with a FOOSH

What can the MOI of Pronation/supination at the wrist lead to?

-Increased injury of the distal radioulnar ligaments-Rare

What are the symptoms of wrist sprains?

Trauma like other sprain sx's (mild/moderate/severe)-Pain with end-range loading -Pain poorly localized within wrist-Swelling less visible than other sprains-Bruising is not typically seen

What are the signs of wrist sprains?

-Tenderness: lunate articulations most tender with provocation-increased Pain w/ tension on injured ligaments especially end aROM/pROM pain-Decreased ROM in general -Clicking/crepitus with joint plays-Painful vs Painless clicking -(+) scapholunate/lunotriquetral ballottement/shear test

What is needed to make a specific diagnosis at the wrist?

-X-ray's and special imaging (Dx MSK US/MRI) -With more severe sprains, cartilage tears, and instabilityTrauma + Pain = X-Ray's

What the definition of instability at the instability at the wrist?

Excessive movement of the radiocarpal and/or intercarpal joints (collectively known as the 'intercalated segment)

What is the most common cause of instability at the wrist?

Most commonly as a result of traumatic disruption of ligamentous structures of the wrist

What are the two types of wrist instability?

-Dorsal Intercalated Segmental Instability (DISI)-Ventral Intercalated Segmental Instability (VISI)

What is the most common form of instability at the wrist and how is it caused?

-Dorsal Intercalated Segmental Instability (DISI)-Due to a Hyper-Extension/FOOSH injury

What is the most common result from instability at the wrist?

Results in disassociation of the scaphoid and lunate

What is another form of instability at the wrist? How is it cause and what are the dissociations?

-Due to Hyper-Flexion/FOOSH injury-Uncommon-Disassociation between lunate and triquetrum

What is a Boutonneire deformity and how is it caused?

Forced flexion causing extensor tendon rupture at the PIP

How would you treat Boutonneire deformity?

Boutonneire: Finger extension splinting for 6-8 weeks minimum

What is a Mallet Finger and how is it caused? Where is it most commonly seen?

-Forced flexion causing extensor tendon rupture at the DIP-Most commonly Seen in the 3rd digit

How would you treat mallet finger?

Mallet finger: Finger extension splinting for 6-8 weeks minimum

What is a Jersey Finger and how is it caused?

Forced finger extension causing a rupture of the flexor digitorum profundus

What is a Jersey Finger/ Sweater sign?

Inability to flex finger completely while making a fist

What is ape hand deformity?

Median neuropathy causing de-rotation of the thumb and atrophy of the thenar eminence

What are some finding with ape hand? Is it reversible?

-Slight clawing of the index and middle fingers-Lost opposition-Thenar atrophy/trophic changes-Irreversible nerve damage

What is Volkman's Ischemic Contracture and what population is it most commonly seen in?

-Permanent forearm flexion contracture commonly -Most commonly seen in children

What is Volkman's Ischemic Contracture caused by?

-Supracondylar fracture (crush injury)-Tightly fitting cast/bandage-Acute compartment syndrome

What are the 6P's you would look for with Volkman's Ischemic Contracture?


What is Claw Hand/Fingers and what anomaly is it commonly associated with?

-Finger and thumb flexion caused by injury to the ulnar nerve (multiple level radiculopathy, and/or plexopathy)-Seen with Volkman's Ischemic Contracture

What are some findings and signs of claw hand/fingers

-Flattening of the normal arches of the hand-Hyper-extension of the MCP and flexion in the PIP and DIP of 4th and 5th fingers-Unable to abduct and adduct fingers

What is Drop hand and how is it caused?

-A condition in which the wrist and the fingers cannot extend at the metacarpophalangeal joints -Caused by radial nerve palsy

What else is drop hand referred to as?

-Crutch paralysis-Saturday night palsy-Honeymoon palsy

What does the acronym "Dr. CUMA" stand for?

Drop Hand Radial N.Claw Hand- Ulnar N.Ape Hand- Medial N

What are Heberden's Nodes and what are they indicative of?

Non-tender nodes indicative of Osteoarthritis (O.A.) of the distal interphalangeal joints (most common site)

What are Bouchard's Nodes and what are they indicative of?

Non-tender nodes indicative of Rheumatoid Arthritis (R.A.) of the proximal interphalangeal joints (most common site)•

What are Haygarth's Nodes and what are they indicative of?

Tender nodes indicative of Rheumatoid Arthritis of the metacarpophalangeal joints (most common site)

What is Depuytren's contracture, and what are some predications?

-Hypertrophic nodular fibroplasia-Knots of tissue form under the skin-Commonly affects digits 4 and 5-Male predilection-Diabetic predilection

What is Ape Hand?

Irreversible median nerve pathology with resultant derotation of the thumb and atrophy of the thenar eminence

What is Claw Hand?

Finger and thumb flexion cause to damage to ulnar nerve (can occur as a result of brachial plexus injury or multiple level radiculopathy)

What is Madelung Deformity? What can It predispose people to?

-Genetic disorder involving a radial growth plate disturbance -Affecting female, adolescent dwarfs-Causing decrease and late increase -Predisposes to Kienboch's disease and TFC tearsMust be surgically treated

What is Kienbock's disease?

AVN of the lunate

What is seal fin deformity? How is it caused and what other disease is it associated with?

-A condition that involves growth malformations of the arms and legs-Genetic predisposition -Use of the drug thalidomide during pregnancy-RA is associated with this condition

What is Dupuytren's contracture? What is an alternative name for it?

Where one or more fingers become permanently bent in a flexed position.AKA: hypertrophic nodular fibroplasia

How does Dupuytren's contracture progress? Where is the most common site?

-Starts as small hard nodules just under the skin of the palm-Then worsens over time until the fingers can no longer be straightened.-Ring finger followed by the little and middle fingers are most commonly affected.

What are some signs and predispositons associated with Dupuytren's Contracture

-Typically not painful but some aching or itching may be present-3:1 male > female -Diabetics -Genetic predisposition

What does a Fracture Screen of the wrist consist of?

-aROM-Palpation-Percussion-Vibration-Scpahoid fracture test: Compression to floor of anatomical snuff box

What can a scaphoid fracture lead to?

AVN without adequate follow-up

Scapholunate ballotment positive

Excessive AP-PA glide with DISI

Lunotriquetral ballotment positive

Excessive AP-PA glide with VISI

Finkelstein'stest positive

For DeQuervain'sPain in the anatomical snuff box

Thumb grind test positive

For OA of the 1st MCP joint

Phalen's/Reverse Phalen's/Tinel's tests

For carpal tunnel syndrome

What is Thumb pinch and ULTT commonly used for?

For median, ulnar, radial neuropathy

What would you use plain film x-rays for?

Fractures, dislocation or instability determination -Serial radiographs required to confirm scaphoid AVN -Oblique - scaphoid fracture/AVN

What would you use the PA and clenched fist view for?


What would you use the lateral view for?

-Instability-Lunate dislocation

What would you use the Tunnel view for?

-Pisiform dislocation -hamulus fracture -carpal tunnel

What would you use MRI for?

-Soft tissue evaluation-AVN -Carpal tunnel evaluation

What would you use US for?

-Soft tissue evaluation-Severity of sprains-Inflammation-Ligaments-TFC evaluation

Sub-Acute/Chronic Treatment of wrist instability

-Wean from bracing to tolerance and increase rehab/Active care focus-Manipulation to tolerance: Clinical tip: Adjust carpals toward anterior glide rather than posterior glide while avoiding Hyper-Extension of the wrist-Concentric/Eccentric strengthening mimicking functional movements to tolerance

Which carpal row is more vulnerable to injury?

Proximal carpal row more vulnerable than distal

Which carpal is the most frequently dislocated?

Lunate is most frequently dislocated carpal

What two carpal bones move apart when wrist Hyper-Extended?

Scaphoid & lunate

Which ligament of the wrist is the most commonly torn?

Scapholunate ligament most commonly torn ligament

Which MOI is the most common at the wrist?

Hyper-Extension/FOOSH is most common mechanism

What MOI and predisposition is most likely to lead to a sprain at the wrist?

Hyper-Extension + ulnar deviation

What MOI and predisposition is most likely to lead to a fracture at the wrist?

Hyper-Extension + radial deviation

What complex at the wrist is vulnerable to injury due to traction or compression on the ulnocarpal joint

TFC also vulnerable to tears

What type of injury usually presents with less swelling than finger injuries?

Wrist/carpal injuries

What is the definition of De Quervain's tenosynovitis?

A painful condition affecting the tendons on the lateral wrist and base of the thumb (especially the APL and EPB).

What are some other names for De Quervain's tenosynovitis

Stenosing TenosynovitisAlso known as "squeaky thumb

What is the age range and gender that is most likely to be associated with De Quervain's tenosynovitis?

Age: 30-50 y.o.Gender: Females > malesAnd also may be assoc. w/ pregnancy

What are some risk factors associated with De Quervain's tenosynovitis?

-Previously diagnosed wrist tendinopathy -Cycling-Increased video game Playing/Texting-Certain job occupations w/ repetitive hand use-Construction workers/manual labor jobs

What is the main MOI that can cause De Quervain's tenosynovitis?

Repetitive overuse of thumb

What are some other MOI's that can cause De Quervain's tenosynovitis?

-Twisting of wrist -Pinch grip -Racket sports, fishing, golf, etc.. -Typing, secretarial work, use of hand tools, rock climbing, etc-Recently due to increased texting

What are some symptoms of De Quervain's tenosynovitis?

-Gradual onset gradual -Local pain (especially at base of thumb)-Tenderness along lateral wrist -Diminished thumb grasp/pinch strength

If you suspect De Quervain's tenosynovitis what else should you suspect that might be an underlying condition?

-Intersection Syndrome -OA if stiffness is reported and they are in the older population (>55.y.o) or Younger population with previous hand/wrist injury-RA (other co-factors reported)

What are some signs of De Quervain's tenosynovitis? What specific orthopedic test would you run with it and expect to be positive?

-Swelling without bruising -Pain with resisted thumb extension & when stretching the tendons -Finkelstein's Test

What is Intersection Syndrome and how is it caused?

-Tenosynovitis of the radial wrist extensors-Due to repetitive injury to ECRB and ECRL -Due to repetitive wrist motion -Also known as "squeaky wrist

How is Intersection Syndrome different from DeQuervain's Tenosynovitis?

-Intersection syndrome involves two wrist tendons and one thumb tendon.-Similar presentation as De Quervain's but with posterolateral wrist pain -Commonly seen in conjunction with De Quervain's tenosynovitis

How would you treat DeQuervain's Tenosynovitis? What is the overall goal of the the treatment?

P.O.L.I.C.E. •Bracing/splinting may not be enough to help-Goal is to reduce inflammation/irritating mechanism-Laser/K-Tape-Avoid painful activities

How long should you treat DeQuervain's Tenosynovitis if conservative treatment isn't working? Who should you refer out to?

-Consider referral options after 4-6 weeks-Orthopedic Surgeon•-N.D. for PRP injections

What are some signs and symptoms of First Carpometacarpal Joint OA?

-Joint enlargement -Grinding crepitus not "squeaking" + thumb grinding test-Thumb compression with circumduction

What are some risk factors for First Carpometacarpal Joint OA?

-Age (>55 y.o.) -Previous thumb injury-DJD elsewhere

What should you consider doing if First Carpometacarpal Joint OA is unresponsive to conservative care?

-X-rays if unresponsive to care -Blood work to rule out RA