Elbow, Wrist, & Hand
T/F: Tinel's sign is a general term for tapping (or "percussing") over a nerve to observe for radicular symptoms.
TRUE
What is considered a normal degree of cubitus valgus in men?
15-20 deg
de Quervain's Tenosynovitis is an overuse injury caused by repetitive overuse of the thumb and is tenosynovitis of the __________________ which includes __________ & _____________.
1st dorsal (extensor) compartment / Extensor pollicis brevis / Abductor pollicis longus
Why are tendon sheath infections a serious problem?
B/C tendons go up your arm and the purulent material produced as a result of the infection causes a decrease in blood supply and inevitably necrosis!
A boxer's fracture often results in shortening of the 5th digit. A shortening of <__mm is considered acceptable (splint and send them home) otherwise you should refer to a hand surgeon.
5
A boxers fracture is generally due to poor punching technique and is a fracture of the __________.
5th Metacarpal
The ________ muscle lives in the triangle between the radial head, olecranon, and the lateral epicondyle. What is significant about this space?
Anconeus *It it the space used for aspiration/injection of the elbow.*
___________ are generally caused by a *FOOSH with forced extension of the wrist* and then fracture. It causes a dorsal "dinner fork" deformity.
Colles Fracture
When should you refer a case of Lateral/Medial Epicondylitis?
If you have seen no improvement after one shot, PT, and NSAIDS for *one month*.
Clinical pearl for diagnosing a radial head dislocation. The imaginary line running through the long axis of the radius should always meet the _______, no matter the x-ray view.
capitellum
On an elbow X-ray, the fat pad sign, also known as the sail sign, suggests a __________.
occult fracture (In children, a posterior fat pad sign suggests a condylar fracture of the humerus. In adults it suggests a radial head fracture)
How do you treat a ganglion cyst?
some resolve on own; aspirate/inject; surgical excision.
T/F A non-displaced Supracondylar Elbow Fracture requires an immediate referral to ortho (or ER w/splint of course...) and will require reduction and percutaneous pinning.
False, this is the treatment for a *displaced Supracondylar Elbow Fracture*. All you need to do for a non-displaced fracture is splint them.
T/F Men have slightly greater carrying angle than women.
False, women have a slightly greater carrying angle.
How do you repair a nail bed injury?
- Requires *digital nerve block prior to procedure* (NO EPI!) - Use 6-0 chromic interrupted stitches. - It will take ~ 12 weeks to heal
How do you treat a radial head fracture?
- Usually non-operative: Unless comminution (broken in multiple pieces) or displacement. - Splint 7 days or less, ROM is key - Kids <30 deg angulation, tx conservatively
_______________ is caused by forced hyperextension of the DIPJ while the flexor muscles of the forearm are maximally contracting. The __ finger is the most commonly injured and they are unable to flex this finger.
Flexor Digitorum Profundus Rupture / ring
__________ is a fracture of the distal radius w/a dislocation of the distal radioulnar joint.
Galeazzi Fracture
A patient presents to the clinic with a painful hard bump over the wrist that gets worse with activity. The lump is palpable and located near the scapholunate ligament and is painful to the touch. What's your diagnosis? How would you confirm your suspicion?
Ganglion Cyst / MRI (especially for deep non-palpable cysts)
Cubitus valgus is a medical deformity in which the forearm is angled away from the body to a greater degree than normal when fully extended. A small degree of cubitus valgus is considered normal and is known as the __________.
carrying angle.
A patient presents to the ER with a crush injury to the fingertip. This commonly results in a ________ and/or a __________. If ___% of the nail plate is involved you should suspect a nail bed injury. How do you treat?
subungual hematoma / phalanx fracture / 50% / Decompress the subungual hematoma w/a 18 gauge needle
An X-Ray of the scaphoid may not show fractures initially and requires *serial XR's for ___wks*.
1-3
A distal biceps tear is caused by forceful isometric flexion of the elbow resulting in a *audible "pop"*, and rupture of the distal biceps tendon from the __________. Usually occurs in people 30-50 yoa, thus w/degenerative changes in their tendons.
radial tuberosity
Nurse Maid's Elbow describes a subluxation of the head of the ____ under the ______ or _______ ligament as longitudinal traction is placed on the forearm with the elbow extended and pronated.
radius / orbicular / annular
____________ is a common complaint of *cyclist*. A) Carpal Tunnel Syndrome B) Cubital Tunnel Syndrome C) Ulnar Tunnel Syndrome D) Lateral Epicondylitis
*C) Ulnar Tunnel Syndrome*
How do you treat a ulnar collateral ligament tear?
*Usually* Conservative Care.... - Bracing/splinting initially - Rest (Take them out of play)...soon after.... - PT (usually requires apprx. 3 months)
Ganglion cysts are typically caused by repetitive overuse or trauma. Where are they most commonly found?
*dorsum of the hand/wrist near scapholunate ligament*
What must you rule out with a mallet finger injury and how do you treat?
- Must rule out an avulsion fracture via True lateral X-Ray. - Splint in extension 6-10 wks (do not splint PIPJ)
How do you treat a animal bite?
1. Copious irrigation of the wound (May require surgical Irrigation/Debridement with IV antibiotics.) 2. Augmentin (if any doubt consult a plastic or hand surgeon)
Treatment options for Osteochondritis Dissecans? (4)
1. Elbow arthroscopy 2. Microfracture 3. Osteochondroplasty/Chondroplasty 4. TEA (Total Elbow Arthroplasty)
How do you treat Nurse Maid's Elbow?
1. Elbow is passively flexed to 90 deg 2. Thumb is placed over radial head 3. Posterior force placed on the radial head 4. Elbow is flexed/supinated 5. You should feel a click and they will have instant pain relief (causes radial head to slip/screw under annular ligament)
How do you treat de Quervain's Tenosynovitis? (4)
1. Injection 2. NSAIDS 3. *Thumb spica splint* 4. *Surgical release*
A patient comes into the ER with an animal bite how should you work them up? (5)
1. Must rule tendinous or nervous involvement 2. Observe for lymphangitis 3. Palpate medial elbow and axilla for lymphadenopathy. 4. XR = A/P and Lateral to rule out fx or foreign body...perhaps gas in soft tissue. 5. Culture wounds and send for gram stain, culture and sensitivity. 6. Confirm tetanus is up to date
What might you find on an x-ray that could be the cause of Olecranon Bursitis?
A spur at the olecranon
When should you send a patient with lateral/medial epicondylitis for a MRI?
After failure of conservative treatment (one shot, PT, and NSAIDS for *one month*) MRI = tear ---> refer
What should you always order when treating kids for a orthopedic injury?
Always get *bilateral X-rays* when treating children. You need to compare the sides to see if it has effected a growth plate.
How should you assess your patient for a ulnar collateral ligament tear? (position)
Assess in full extension and at 90 deg flexion
A __________ is caused by a *FOOSH* and results in a distal radius fracture w/ a dislocation of the radiocarpal joint. *It differs from a Smith/Colles in that the dislocation is most obvious on XR greater than the fracture*.
Barton's Fracture
What four animals are common carriers of rabies?
Bats, skunks, raccoons, and foxes
What should you be worried about if a kid comes in to the ER with a lateral epicondyle fracture? How would you treat?
Be worried about a Salter-Harris fracture. (A fracture of the epiphyseal growth plate. Important as they can result in premature closure, limb shortening and abnormal growth) Non-displaced = splint/cast 4-6 wks. Displaced = percutaneous pinning vs. ORIF
__________ is a intra-articular fracture of the CMC joint of the thumb.
Bennett's Fracture (Nearly always require ORIF due to displacement)
A patient presents with a complaint of pain at base of the 1st CMCJ and weakness. She states that her grip strength is gone and she *drops things* all the time. PE reveals a +grind test (pain w/compression of metacarpal over trapezium) and an adduction deformity. What is your diagnosis? How would you treat?
Carpometacarpal (CMC) osteoarthritis - NSAIDS - *Thumb spica splint* - Injection - CMC arthroplasty
What is the most common form of OA in the hand and who does it occur in more commonly?
Carpometacarpal (CMC) osteoarthritis / >women usually > 40 yoa
What are some possible causes of a radial head dislocation in children?
Congenital - Ehlers-Danlos Syndrome Traumatic - Monteggia-type fx (dislocation of the radius due to a ulnar fracture) Developmental - posterolateral dislocation; cerebral palsy or neuropathology, usually no pain and no treatment
A _________ is considered diagnostic of Carpal Tunnel Syndrome.
EMG/NCV
_________ is the triangular area formed by the brachioradialis (lateral border), pronator teres (medial border), and the imaginary line connecting the medial/lateral epicondyles (proximal border).
Cubital Fossa
A patient presents with a complaint of pain and parathesias along the ulnar border of the forearm, little, and ring fingers. PE reveals a +Tinel's Sign at the cubital tunnel, objective numbness along the ulnar nerve distribution, weakness, and a + Wartenburg Test. What is your diagnosis?
Cubital Tunnel Syndrome
A patient presents to the clinic with a complaint of pain and stiffness of the hand and digits. Physical exam reveals a *fixed flexion deformity of the MCP or PIP and fibrous nodules over the palm*. (The fourth digit is the most frequently affected, followed by the fifth digit) What is your diagnosis and how would you treat it?
Dupuytren Contracture / Serial steroid injections into nodules over palm or surgery
_______________ usually occurs in patients 40-60 yoa and is *associated w/epilepsy, alcoholism, and diabetes.* The etiology is related to the proliferation of myofibroblasts and type III collagen which causes contraction of the palmar fascia.
Dupuytren's Contracture
In _____________ the examiner holds their thumb over a patient's carpal tunnel for ~30 seconds and will observe for numbness/tingling in median nerve distribution which indicates CTS.
Durken Carpal Compression Test
Which of the following is NOT a physical exam finding a/w RA? A) Edema of multiple joints B) Bogginess and crepitus over dorsal surface of the hand C) Flexor tenosynovitis D) Boutonniere deformity E) Bouchard nodes
E) Bouchard nodes (a/w OA)
T/F: An X-Ray is diagnostic of Osteochondritis Dissecans.
False! MRI is diagnostic.
T/F: Raynaud's is a benign condition that occurs more often in men it is usually a unilateral condition that affects the toes/fingers.
False, occurs more often in women and is bilateral/symmetric.
Normal Elbow ROM? Flexion = _______________ Extension = _____________ Pronation/Supination =_____
Flexion = 145-155 deg Extension = 0 deg Pronation/Supination = 170-180 deg (approx. 90 deg each way)
A patient presents to the clinic with a complaint of the *inability to flex her ring finger*. She claims she was *walking her dog* the other day and heard a pop in her hand when she had to jerk the leash to keep her dog from chasing a squirrel. Upon physical exam you notice the tendon is retracted to the palm. What is your diagnosis and how would you treat?
Flexor Digitorum Profundus Rupture / Splint to elbow and refer for surgical repair
What are some potential causes of carpal tunnel syndrome? (4)
Flexor tenosynovitis Hypothyroidism Autoimmune disease Pregnancy
Pain with resisted wrist/digit flexion is considered a positive ___________.
Golfer's Elbow Test
_________ is cubitus varus with reverse carrying angle.
Gunstock Deformity
What is the Finkelstein Test and what does it indicate?
Have patient flex their thumb while ulnar deviating their wrist. Pain over the 1st dorsal compartment is a positive test and indicates *de Quervain's tenosynovitis*.
How do you treat paronychia?
I/D & Antibiotics...if not better in 3 days, then refer to hand surgeon.
How do you treat a felon?
Incision/Drainage in office Betadine soaks Antibiotics
The _______ muscles begin in hand and function to perform the delicate movements of the fingers.
Intrinsic
__________ is a clinical sign found in patients with an infection of a flexor tendon sheath in the hand (flexor tenosynovitis). This is a serious condition which can cause rapid loss of function of the affected finger.
Kanavel's sign
How do you treat a distal biceps tendon rupture?
Long arm splint, sling, then Surgery (if not performed within a week of the injury the patient will just have to live with it)
A ________ is considered diagnostic of a ulnar collateral ligament tear.
MRI
__________ is an acute injury involving the extensor tendon group caused by forced flexion of the DIPJ.
Mallet finger
Patients with __________ usually present with a history of (trauma inducing) repetitive activity, a complaint of pain at the medial epicondyle, no mechanism of injury, and pain with wrist/digit flexion.
Medial Epicondylitis
Thenar eminence contain the intrinsics muscles of the thumb and is innervated by the ________, while the Hypothenar eminence is supplied by the _________.
Median Nerve / Ulnar nerve
__________ usually develop dorsally over the DIPJ due to OA/osteophytes and is the result of an arthritic process.
Mucous Cysts
What nerves & arteries run through the Cubital Fossa?
Musculocutaneous nerve Median nerve Radial artery Brachial artery Ulnar artery
Treatment options for Olecranon Bursitis? (6)
NSAIDS Elbow sleeve +/-Steroids & joint aspiration Surgery If septic: antibiotics vs. bursectomy
A 3 year old boy is brought in to your urgent care clinic with a complaint of elbow pain. When you walk into the exam room you note the boy's elbow is *flexed and pronated at his side*. Upon PE you note *anterolateral pain around the radial head*. When asking the patients caregiver about the mechanism of injury she states that she jerked his arm in order to prevent him from running across the street. What is your diagnosis?
Nurse Maid's Elbow
What are the most common joints of the hand involved with OA? What about RA?
OA = DIPJ and PIPJ RA = wrist and MCPJ
_________ is usually due to chronic irritation or trauma. Common PE findings include tenderness and swelling of the superficial fluid-filled sac b/w the skin and the olecranon.
Olecranon Bursitis
A 8 year old male presents to the clinic with an effusion of the elbow. Upon PE you note *pain at the capitellum*, stiffness, and decreased ROM. X-ray reveals *segments of hypodense bone*. What is your diagnosis?
Osteochondritis Dissecans (Usually occurs in pediatric populations. A small segment of bone begins to separate from its surrounding region due to a lack of blood supply. As a result, the small piece of bone and the cartilage covering it begin to crack and loosen forming loose bodies in the joint)
Bouchard's nodes are associated with the _____ joint while heberden's nodes are associated with the ______ joint and are a result of OA.
PIP / DIP
Treatment options for Lateral/Medial Epicondylitis? (5)
PT (stretching) Injection NSAIDS Elbow strap Surgery
___________ is a infection along the edge of the nail at the distal phalanx and is usually due to _________ or ________.
Paronychia / nail biting or manicure
What is the most common infectious pathogen associated with animal bites?
Pasteurella multocida
In _________ the examiner passively hyperflexes the pt's wrists and holds it for 30-60 seconds. Numbness/tingling and pain indicate CTS.
Phalen Maneuver
Pronation = palm ______. Supination = palm _____. Neutral = ___________.
Pronation = palm down Supination = palm up Neutral = thumb up
What causes a Boutonniere Deformity?
Rupture of central aspect of the extensor tendon at it's insertion onto the middle phalanx. (This causes *flexion of the PIPJ* due to loss of opposing extension which causes displacement of the lateral extensor tendon bands resulting *hyperextension of the DIPJ*)
Pain in the anatomical "snuff box" & edema =
Scaphoid Fracture (Untreated causes early OA)
How do you differentiate a simple from a complex phalanx dislocation?
Simple - easy reduction w/o soft tissue interposition (most are simple) Complex - difficult reduction w/soft tissue interposition Usually requires open reduction
How do you treat Cubital Tunnel Syndrome? (5)
Splint Steroids NSAIDS PT *Ulnar Nerve Transposition*
What is the most common pathogen a/w Paronychia?
Staph Aureus
Pain with resisted wrist/digits extension is considered a positive ___________.
Tennis Elbow Test
T/F Dog bites are more common but cat bites are more likely to become infected.
True
A ____ reconstruction aka a ____________ procedure is indicated for the treatment of patients with chronic instability (usually throwing athletes or those who fail conservative therapy).
UCL reconstruction aka *"Tommy John" procedure* (palmaris longus or tibialis anterior allograft)
*What is the primary medial stabilizer of the elbow?*
Ulnar Collateral Ligament (UCL) (Provides up to 50% of elbow stability)
A 34 year old patient presents to the clinic with pain over medial epicondyle. PE reveals + valgus stress test and A/P and Lateral X-Ray stress views show widening of the joint. What is your diagnosis?
Ulnar Collateral Ligament Tear
A patient presents with a complaint of pain and numbness/tingling of the hand particularly at the *hypothenar eminence*. When asked if there is anything that seems to aggravate his pain he states that it is *worse after he goes for a long bike ride*. What is your diagnosis?
Ulnar Tunnel Syndrome
How do you treat a boxer's fracture?
Ulnar gutter splint
List the 8 carpal bones:
[Some Lover Try Positions That They Can't Handle] Scaphoid Lunate Triquetrium Pisiform Trapezium Trapezoid Capitate Hamate
A patient presents to the clinic with a complaint of wrist pain. They have no history of trauma but the patient admits that they noticed their pain around the same time they took up a new hobby of painting. PE reveals pain over the 1st dorsal compartment and a +Finkelsteins Test. An X-Ray shows a small spur/calcification of the distal radius. What is your diagnosis?
de Quervain's Tenosynovitis (the spur is the cause of the inflamed tendon sheath)
Epinephrine can be used to control bleeding in surgery but where should you NEVER inject epinephrine?
ears, nose, fingers, toes, and hose
A ___________ is a *infection* of the closed space of the *pad of the distal phalanx* and is usually caused by a ____________.
felon / puncture wound
The carrying angle is established by the long axis of the ______ & ______.
humerus and ulna
A Gunstock Deformity generally occurs due to a _______ fracture.
malunion
Elbow dislocations generally occur __________ and is typically caused by a __________.
posteriorly / FOOSH
The blood supply to the _______ is distal and anytime there is a fracture through the middle of this bone it can cause avascular necrosis (bone death).
scaphoid
OA of the hand involves the progressive loss of articular cartilage resulting in decreased joint space and __________ formation.
subchondral bone cyst
What should you always check for with a elbow dislocation or ANY dislocation for that matter?
Check the neurovascular integrity
How do you treat a tendon sheath infection?
Immediate referral to ER or Hand surgeon!
A ____________ is a soft tissue mass/cyst filled w/mucinous material adjacent to the tendinous sheath on the hand or wrist.
Ganglion Cyst
What is the treatment for carpal tunnel syndrome? (4)
NSAIDS Injection (right into the carpal tunnel) Wrist splint Carpal Tunnel Release (CTR) (Refer if no difference with early tx.)
What should you never do with a bite wound?
Never close it or suture!
____________ are caused by a *FOOSH with forced flexion of the wrist* and then fracture. It causes a *reverse dinner fork" deformity.
Smith's Fracture
What are the most common pathogens a/w human bites?
Staphylococcus Aureus & Streptococci
Which arteries supply the superficial and deep palmar arches?
Superficial = Ulnar Artery Deep = Radial Artery
_____________ commonly occurs in children 6-7 yoa, by falling on a outstretched arm. It involves a fracture of the thin bone between the coronoid fossa and olecranon fossa of the humerus. How do you treat it?
Supracondylar Elbow Fracture Urgent tx required (w/displacement)...can cause neurovascular compromise.
When your assessing for ___________ you lightly tap on the cubital tunnel over the ulnar nerve and observe for sx's in ulnar nerve distribution (medial forearm, ring/little fingers).
Tinel's Sign
How do you reduce a dislocated finger?
Traction (pull), increase deformity, and return to anatomical position.
__________ is a tenosynovitis of the flexor tendons (deep/superficial) at the A1 pulley/MCPJ.
Trigger finger
What are some potential causes of Cubital Tunnel Syndrome? (3)
1. Repetitive overuse of elbow/flexors 2. Synovitis of joint 3. Blunt trauma causing compression of ulnar nerve.
What are the *four cardinal signs of Kanavel*?
1. Uniform swelling of digit 2. Finger in flexion for comfort 3. Passive extension causes pain 4. Exquisite pain along the entire length of tendon
How do you treat a trauma induced Boutonniere Deformity?
3 way x-ray to rule out fracture *PIPJ splinted in extension x 6 wks...DIPJ left free.*
Nurse Maid's Elbow commonly occurs in children <__ yoa.
4
What is the most common animal bite?
Dog bite
*What is the most common form of osteoarthritis in the hand?*
CMC OA
A patient presents to the clinic with a complaint of pain at the wrist that sometimes radiates all the way to the shoulder and is worse at night. You note the patient has numbness/tingling along the median nerve distribution, weakness, and atrophy. What should you be thinking?
Carpal Tunnel Syndrome
__________ is an increase in volume or pressure that causes entrapment of the median nerve in the tunnel under the transverse carpal ligament.
Carpal Tunnel Syndrome
How do you treat a Colles Fracture?
Closed reduction and *sugar tong splint* for simple fx'... otherwise splint/refer.
T/F: Patients with RA ultimately develop ulnar deviation of the wrist and digits.
False, they develop *radial deviation of the wrist and ulnar deviation of the digits.*
____________ is a congenital abnormality of the collagen which results in hypermobility. Children with this disorder typically dislocate the head of their radius *(anteriorly/posteriorly)* and can occur bilaterally.
Ehlers-Danlos Syndrome / posteriorly
______________ is similar to de Quervain's Tenosynovitis and is caused by repetitive movement at the forearm/wrist. It is referred to as a "Intersection syndrome" because the pathology of this condition involves crossing over of the Extensor pollicus brevis and the Abductor pollicis longus proximal to the radial styloid generating a inflammatory response.
Extensor Carpi Radialis Tenosynovitis
What is the most common musculotendinous attachment involved in lateral epicondylitis?
Extensor carpi radialis brevis
What is Froment sign and what does it indicate?
Have patient pinch a piece of paper between their thumb and index finger and pull the piece of paper a way. If the *IP joint of the thumb flexes* to hold the paper as it is pulled away it is *considered a positive sign* and *indicates adductor pollicis weakness due to ulnar nerve paralysis*.
Treatment for elbow dislocation?
Immediate Reduction then post-reduction XR (How to? Traction on wrist w/ countertraction of shoulder. May require ext. to free olecranon)
Patients with __________ usually present with a history of (trauma inducing) repetitive activity, a complaint of pain at the lateral epicondyle, no mechanism of injury, and pain with handshakes, grasping things.
Lateral Epicondylitis
____________ is usually due to chronic inflammatory changes of the musculotendinous attachment of the common extensor group at lateral epicondyle of humerus.
Lateral Epicondylitis
A _____________ fracture involves a dislocated radial head and the fx of the proximal 1/3 of the ulna. They may not always be obvious in children.
Monteggia
How do you treat a Olecranon Process fracture?
No displacement = splint 2 wks w/gradual ROM Displacement = ORIF
_____________ is a subchondral bone death (avascular necrosis) causing the overlying cartilage to slough off, thus forming "loose body".
Osteochondritis Dissecans
What should you tell your patient with Raynaud's Phenomenon to avoid?
Stop smoking! Smoking causes blood vessels to narrow even more.
__________ is due to compression of the ulnar nerve in guyon's canal, caused by a tumor, ganglion, thrombosis, or the ulnar artery.
Ulnar Tunnel Syndrome
T/F Animal bites most commonly involve the digits of the dominant hand and are most commonly seen in children.
True
Treatment options for Ulnar Tunnel Syndrome? (4)
Wrist splint NSAIDS Steroids Surgery
Human Bites are dangerous due to the potential for direct inoculation of bacteria into the joint, soft tissue, or tendon. Most human bites are caused by ________ and most commonly involve the _____ joint of the ______ & ______ fingers.
fist fights / MCP / middle & ring fingers
UCL injuries are often seen in _________ or patients who chronically their stress elbow in a valgus fashion.
throwing athletes