Elbow, Wrist, Hand

Elbow Physical Exam

Palpate

• Medial/lateral epicondyle

• Olecranon

• Cubital tunnel

• Neurovascular status

Assess ROM

• Flexion/extension

• Pronation/supination

• Intact, full, smooth motion?

Strength

• Biceps/triceps

• Forearm pronator/supinator

• Resistance to rotation

• Purely muscular/tendons

Elbow Anatomy

• Olecranon important

• Medial and lateral epicondyle

• Fractures

  • Look for sail sign

  • Anterior and posterior

  • Anterior are typical and can be seen normally

  • Posterior almost always pathologic

Medial Epicondylitis (Golfer’s Elbow)

• Involves the tendons of the forearm flexors at the medial epicondyle

• Causes

  • Overuse/activity (repetition)

  • Heavy lifting

  • Trauma

  • Weak UE

• Presentation

  • Most common in dominant arm

  • Pinpoint tenderness over the medial epicondyle

    • +/- swelling along the medial epicondyle or proximal forearm

  • Soreness of the forearm flexors

• Diagnosis

  • Is a clinical diagnosis: do not need imaging

• Treatment

  • Conservative

    • Rest

    • Activity modification

    • Brace

    • NSAIDs: mainstay

    • Topicals

    • Cortisone injections

    • PT/OT

  • Surgical

    • Medical epicondylar debridement

      • Tendon is reinforced with suture to decrease micro-friction

      • Multilayer closure

      • Immobilization: long arm splint for up to 2 weeks

Golfer’s Elbow Test

Purpose

• Assess for medial epicondylitis/epicondylagia

Position

• Sitting or standing

Technique

• Examiner palpate medial epicondyle of the humerus while supporting elbow with one hand

• Examiner’s other hand passively supinates the patient’s forearm and fully extends the elbow, wrist, and fingers

Interpretation

• (-): patient experiences no pain

• (+): patient has sudden pain or discomfort along the medial aspect of the elbow or in the region of the medial epicondyle suggestive of medial epicondylitis

Lateral Epicondylitis (Tennis Elbow)

• Involves the tendons of the forearm extensors at the lateral epicondyle

• Causes

  • Overuse/activity

  • Heavy lifting

  • Trauma

  • Weak UE

• Presentation

  • Most common in dominant arm

  • Pinpoint tenderness over the lateral epicondyle +/- swelling along the lateral epicondyle or proximal forearm

  • Soreness of the forearm extensors

• Treatment

  • Conservative

    • Rest

    • Activity modification

    • Brace

    • NSAIDs

    • Topicals

    • Cortisone injections

    • PT/OT

  • Surgical

    • Lateral Epicondylar Debridement

      • Tendon is reinforced with suture to decrease micro-friction

      • Multilayer closure

      • Immobilization: long arm splint for up to 2 weeks

Cozen’s Test

Purpose

• Assess for lateral epicondylitis/epicondylagia

Position

• Sitting or standing

Technique

• Examiner positions patient’s forearm in pronation, hand in fist, slightly radially deviated

• Examiner palpates lateral epicondyle of the humerus with one hand while placing other hand over the dorsum of the patient’s fist

• Patient is asked to extend wrist against the examiner’s resistance

Interpretation

• (-): patient experiences no pain

• (+): patient has sudden pain or discomfort along the lateral aspect of the elbow or in the region of the medial epicondyle suggestive of lateral epicondylitis

Medial/Lateral Epicondylitis Post-Op

10-14 days

• Wound check and suture removal

• Gentle ROM with PT

• No lifting

6 weeks

• ROM check

• Tenderness over operative site?

• Strengthening program

3 months

• ROM

• Strength check

• If no pain or deficit, may release to normal activity

Ulnar Collateral Ligament Injury: Tommy John Surgery

Pitching Injury

• UCL gets torn

Tommy John Surgery

• Cannot use the torn ligament

• Harvest one from the forearm or the leg

• Can do figure 8 formation: tunnel through ulna and humerus and create a new one

Post-Op Plan

• Splinted

• Initiation of PT/OT: ROM and strength

• Very tailored to the patient and the long term goal

Cubital Tunnel Syndrome

Have stenosis or compression of the ulnar nerve in the cubital tunnel

Symptoms

• Elbow pain

• Numbness/tingling/pain at the 5th digit and ulnar border of 4th digit

• Muscle atrophy (late finding)

Diagnosis

• Is clinical

• May see edema or stenosis on MRI

Treatment

• Conservative

  • Avoid provoking activities (compression)

  • Elbow pad to reduce elbow flexion

  • NSAIDs

  • PT/OT

• Surgical

  • Ulnar nerve transposition

    • Decompression and release of the ulnar nerve from the medial aspect of the elbow

    • Long arm splint with elbow flexed to 90 degrees and the forearm in neutral

Tinel Sign

Purpose

• Assess for cubital tunnel syndrome/ulnar nerve compression

Position

• Sitting or standing

Technique

• Examiner locates the ulnar nerve between the olecranon process and the medial epicondyle

• Examiner repeatedly taps or percusses the trapped nerve with index finger or middle finger

Interpretation

• (-): patient experiences no pain, numbness, or tingling

• (+): patient experiences pain, numbness, or tingling in the ulnar nerve distribution along the forearm and/or hand associated with the tapping/percussing suggestive of cubital tunnel syndrome

Cubital Tunnel Syndrome Post-Op Plan

3-5 days

• Early mobilization?

• Removable splint

10-14 days

• Suture removal

• ROM

• Symptom check

6 weeks

• ROM

• Wound healing

• Sensitivities

Olecranon Bursitis

• Bursa sac is such a finite space

  • Etiology does matter

  • Sometimes do not know what happened

• Causes

  • Overuse/repetitive activity (more common)

  • Trauma

  • Gout

  • Autoimmune

  • Infectious

• Treatment

  • Conservative

    • NSAIDs

    • Medrol pack: should not be taking NSAIDs (bleeding risk) and should be on GI protection (PPI)

    • Warm compresses

    • ACE wrap/compression

    • Aspiration/injection

      • Use aseptic technique

      • Should be going parallel: collection is protruding so far out that you have so much space and have decreased risk of injecting the bone

      • If fluid is suspicious, then aspirate should be sent for culture, crystals, cell count, gram stain, etc… → do not inject cortisone

      • If fluid straw colored, then cortisone can be injected to help decrease inflammation

      • Always clean site, Band-Aid, and ACE wrap to help compress dead space

      • Can re-accumulate: may need serial aspirations

  • Surgical

    • Olecranon bursectomy

      • May sedimentize with crystals if they have had serial injections with cortisone (> 3 times in a lifetime) → over injection has reverse effect and causes more issues

Olecranon Bursitis Post-Op Plan

10-14 days

• Wound check

• Suture removal

• Splint check

6 weeks

• Wound healing

• ROM

• Return to normal activity

Posterior Elbow Dislocation

• Very rare

• Force from front pushes through forearm

• See protrusion of olecranon posteriorly

• Traction down and pull forward to reduce: should not be done outside of an emergent setting

  • Worried about nerves and blood vessels: brachial artery/entrapment

  • Need to check for perfusion first before reduction because fracture itself can cause bleeding/entrapment

Elbow Fractures

• When elbow fractures occur, it should be an elbow specialist

• Not held responsible for the image

• Every single type of fracture can result in functional deficit

Fat Pad/Sail Sign

• Suggests the presence of an occult fracture of the elbow

  • Anterior fat pad → often normal

  • Posterior fat pad → always abnormal → consider CT/MRI

Supracondylar Elbow Fractures

• Can be very devastating

• Have vital structures in ante-cubital fossa → often occurs with a dislocation

• Have shift of anatomy and shards of bone that can puncture structures

Supracondylar ORIF

Complications

• Volkmann’s Contracture

  • Occurs in the absence of blood flow to the forearm

  • Causes muscles to shorten and contracture of forearm

  • Usually associated with elbow fractures, bleeding disorders, and animal bites

  • Sometimes cannot be reversed

Supracondylar ORIF Post-Op Plan

Splinted intra-operatively by surgeon

• Splints are perfectly tailored to the patient

7-10 days

• Wound check

• Suture removal

• Splint check

• +/- X-rays

2-4 weeks

• X-rays

• Wound healing

• PT/OT: a lot

Forearm Fractures

• Happen anywhere along the ulna and radius

• Usually have to be fixed with plates and screws

Monteggia Fracture

• Ulnar fracture and radial head dislocated

Galeazzi Fracture

• Radial fracture and ulna dislocated

Distal Radius Wrist Fractures

• Use intra-operative fluoroscopy and open reduction internal fixation

• K wires are used to hold the reduction internally until the hardware can be placed in a stepwise formation

Colle’s Fracture

• Falls outward

  • Hand goes forward and the bone goes anteriorly

Smith Fracture

• Falls inward

  • Force generated dorsally/posteriorly: bone shifted that way

Wrist/Hand Exam

Palpate

• Distal radius: styloid

• Distal ulna: styloid

• Carpals: scaphoid (snuffbox) and scaphoid tubercle (volar)

Assess ROM

• Flexion/extension

• Radial/ulnar deviation

Strength

• Wrist flexors/extensors

• Resistance to rotation

Wrist/Hand Anatomy

• Scaphoid injury most important

Carpal Tunnel Syndrome

• Compression of the median nerve as it passes through the carpal tunnel

  • Transverse carpal ligament

  • Pulls inward and compresses the median nerve underneath

• Causes

  • Diabetes

  • Hypothyroidism

  • Obesity

  • Pregnancy (retention of fluid)

  • Overuse/compression (typing)

  • Masses

• Presentation

  • Numbness, tingling, pain

    • Thumb, index, middle and radial border of ring finger

  • Night pain

  • Weakness of abductor pollicis brevis

  • Thenar atrophy

    • Impaired thenar innervation due to chronic median nerve compression, if left untreated, can lead to thenar atrophy

    • Will have permanent deficit

  • Act on sensory issues before motor issues become a problem

• Diagnosis → clinical

• Treatment

  • Conservative

    • Braces/splints

    • PT/OT

    • +/- NSAIDs

    • +/- PO corticosteroids (Medrol packs: can cause high BGL in diabetics and cause SVT)

    • Cortisone injections with

  • Surgical

    • Carpal tunnel release

      • Can be open vs endoscopic

      • Place blade to slice the ligament and unroofs it to give the median nerve more room

Phalen’s Test

Purpose

• Assess for carpal tunnel syndrome

Position

• Sitting with elbows flexed on the table, wrists filly flexed

Technique

• Ask patient to push the dorsal surface of the hands together and hold position for 30-60 seconds

Interpretation

• (-): patient has no CTS symptoms during the test, even for prolonged time

• (+): patient experiences reproducible CTS symptoms including numbness, tingling, and/or burning along the distribution of the median nerve suggestive of CTS

Tinel’s Sign

Purpose

• Assess for carpal tunnel syndrome

Position

• Sitting with forearms supinated

Technique

• Examiner supports patients supinated wrist and hand in one hand while using the index or middle fingertip to percuss over the transverse ligament

Interpretation

• (-): patient has no CTS symptoms while percussing

• (+): patient experiences reproducible CTS symptoms including numbness, tingling, and/or burning along the distribution of the median nerve suggestive of CTS

Carpal Tunnel Release Post-Op Plan

Post-op follow up within 1 week of surgery

• Wound healing/dressing/splint fit

• Check motor and sensory function

• PT/OT plan

• Overall plan per surgeon’s protocol

Dupuytren’s Contracture

• Palmar fascia

  • Protective barrier between the skin and tendons: helps bend fingers

  • Thickens and drawn inward: causes finger to become bent by the force of the contracture

  • Most common affects 4th and 5th digits

• Can be linked to alcoholism/overuse

• Presentation

  • Scar like band at base of fingers

  • Inability to lay hand flat on table

  • Unable to straighten finger mechanically: fascia has contracted and cannot push past it

• Treatment

  • PT/OT

  • Steroid injections

  • Radiation therapy

  • Enzyme therapy

  • Needling

  • Surgery → skin grafting

Trigger Finger

• Tendon

  • Helps finger bend toward the palm

  • Surrounded by sheath

    • Lined with synovium: produces fluid to help tendon glide as finger bends and straightens

  • In trigger finger, tendon inflames and sheath thickens

    • Typically involves one finger: tendon or sheath becomes very inflamed and enlarged and cannot fit through smoothly and becomes stuck in a bent position (usually at lower portion of finger)

    • Finger remains bent when asked to straighten finger: may feel a pop as it straightens

    • Can be mechanically extended: is the pulley of the flexor tendon that is the problem

• Treatment

  • Conservative

    • NSAIDs

    • Cortisone injection: need U/S guidance to make sure you do not rupture the structures

    • PT/OT

    • Splinting

  • Surgical

    • Tendon sheath incision/A1 pulley release

      • Open the tendon sheath and unroof it

Trigger Finger Post-Op

10-14 days

• Suture removal

• Wound check

• PT/OT protocol

4 weeks

• Final ROM

• Wound check

Infectious Flexor Tenosynovitis

• SURGICAL URGENCY

  • People can lose fingers or hand

• Four Kanavel Signs

  • Finger held in flexed position for comfort

  • Intense pain with passive extension

  • Uniform (fusiform) swelling of digit (not just localized)

  • Tenderness along the entire flexor tendon sheath

• Patient needs incision and drainage and IV antibiotics

  • May need to go in, unroof, and debride to allow for antibiotics to penetrate (may not penetrate)

De Quervain’s Tenosynovitis

• Inflammation of the tendon/tendon sheath along the thumb (radial side)

• Cause → repetitive motion

• Presentation

  • Pain/tenderness along the wrist/base of thumb

• Treatment

  • Conservative

    • Thumb spica splint (immobilization)

    • PT/OT (anti-inflammatory modalities)

    • Cortisone injection

  • Surgical

    • Incision of the extensor tendon sheath

      • An incision is made through the extensor retinaculum to release the tendons from underneath and remove the friction that was causing the tendon sheaths to become inflamed with repetitive activity

Finkelstein Test

Purpose

• Assess for tenosynovitis involving the extensor pollicis brevis and abductor pollicis longus

Position

• Sitting or standing

Technique

• Examiner asks the patient to position hand so the thumb is facing toward the ceiling

• Patient is asked to adduct the thumb and wrap the fingers around it (makes a fist around the thumb) then perform an ulnar deviation

Interpretation

• (-): patient has no pain or discomfort during the test

• (+): patient experiences pain over the first extensor compartment over the wrist and potentially proximally along the forearm, originating at the thumb

Osteoarthritis of the Hand

• Symptoms

  • Increase as day progresses

  • Pain during and after use

  • Bouchard’s (PIP) and Heberden’s (DIP) nodes

  • Majority of symptoms can be from soft tissue swelling

• Treatment

  • Conservative

    • NSAIDs/PO pain relievers

    • Aspiration/cortisone injection

    • Activity modifications

    • +/- intermittent PT/OT

    • +/- intermittent splinting

  • Surgical

    • Can do a joint replacement → only definitive treatment but is a last ditch effort (have to exhaust all other options)

Osteoarthritis Post-Op Plan

7-14 days

• Wound check

• Suture removal

• +/- X-ray

• PT/OT

Post-op visits per MD protocol

• Wound check

• ROM

• Strength

• X-rays

• PT/OT progress

Metacarpal Fractures

• Causes

  • Trauma

    • Striking with a closed fist

      • Boxer’s only used for 5th metacarpal

• Presentation

  • Pain and reduced motion

• Mechanism

  • Closed or open fracture

  • What did the hand make contact with? (human saliva, rusty metal, etc…)

Metacarpal Fracture ORIF Post-Op Plan

5-7 days

• Wound check

10-14 days

• Wound check

• Suture removal

• X-ray

• Immobilization in splint or cast

• PT ROM protocol

4 weeks

• Wound and motion check

• Strengthening

6-8 weeks

• Motion check

• X-ray

Phalanx Fractures

• Causes

  • Trauma/sports → jammed finger

• Presentation

  • Pain and reduced motion

• Mechanism

  • Closed or open fracture

  • What did the hand make contact with

  • Other questions to ask

    • Which part of the phalanx is implicated

    • Intra-articular or extra-articular

    • Simple or comminuted

    • Displaced or non-displaced

• Can usually leave alone but if it is intra-articular, angulated, comminuted → patients will lose function and it needs to get fixed

Phalanx Fracture ORIF Post-Op Plan

5-7 days

• Wound check

10-14 days

• Wound check

• Suture removal

3-4 weeks

• PCP can be removed if present

• Wound healing

• Aggressive PT

Bennet Fracture

• Fracture/dislocation of the metacarpal bone at the base of the thumb

Scaphoid Fracture

• Mechanism

  • Fall on outstretched hand

• Patient report

  • Pain in anatomic snuffbox

  • Pain with ROM

  • Pain with weight bearing

• Treatment

  • Conservative

    • Non-displaced fracture < 3 weeks old

      • Thumb-spica (used for anything that affects radial side of the wrist) splint for immobilization (88-95% healing rate)

      • Follow up every 3-4 weeks for splint change and X-ray

      • Continue conservative splinting or discuss surgery if non-union

  • Surgical

    • ORIF

Avascular Necrosis

• Disruption of blood flow to the bone → bone cell death, destruction/collapse of the bone, disability, pain

  • Does start immediately

  • Can be reversible if it is dealt with in the first couple of weeks → after that it is irreversible

• Radial artery comes up and flows backwards

  • The distal portion of the scaphoid had the best flow while the proximal portion has close to none

  • Have break midway or proximally: chances of union are very low especially if it is displaced

• Osteoarthritis usually develops 10-15 years later

Scaphoid ORIF Post-Op Plan

10-14 days

• Wound check

• Suture removal

• PT protocol

6 weeks

• Wound healing

• Motion

• X-ray healing

3 months

• Motion

• Tenderness

• X-ray healing

• If no evidence of healing → bone stimulator

• If no healing > 6 months → non-union

Subungual Hematoma

• Huge blood collection under nail plate and causes pressure → can kill the plate if left untreated

• Trephination

  • Hot coil and burn hole into plate and erupts

  • Immediate pain relief and evacuates the hematoma

Paronychia

• Will pack the negative space

Felon

• Collection of infectious fluid in the fingertip (have compartments that become filled)

• Treatment

  • Incision and drainage

    • Incision made on one or both sides of the fingertip

    • Break up the compartments

    • Gauze will be placed into the wound to aid the initial drainage

    • Flush out with a sterile solution

  • Antibiotics

Ganglion Cyst

• Benign

• Can be recurrent

• Encapsulated

  • Can be loculated

• Usually filled with joint fluid

• Usually from overuse/activity/inflammation

• Can feel hard or firm

• Can restrict movement

• Usually leave alone if causing no symptoms