BPK 241 Lecture 11

Contusions

• Hx = direct blow

• SSx = pain, swelling, bruising, tenderness, increased warmth, reduced ROM

• Tx = POLICE, padding, physio

Elbow area contusions

• Laterally:

  • Radial nerve at risk

  • Extensor muscle weakness

  • Posterolateral numbness

• Medially:

  • Ulnar nerve at risk

  • “funny bone” injury

  • Numbness in medial forearm and digits IV & V; flexor muscle weakness

• Posteriorly:

  • Olecranon bursitis

Strains & Tendinopathy

• Hx = resisting a force, fall, overuse

• SSx = pain (worse with movement against resistance), tenderness, swelling, crepitus?

• Tx = POLICE, ROM exercises, physio, taping or splints, rehab

Biceps Tendinopathy

• Hx: Tendinosis in biceps, on average male athletes 45 to 60 years old

• SSx: pain anterior shoulder, pain with 90 to 120º shoulder flexion

• Tx: Rest, ice, modified activities, ROM, strengthening

• Can lead to biceps rupture

Biceps Rupture

• SSx: snap, weakness, bruising, popeye’s sign

• MRI or diagnostic ultrasound

• Tx: surgery, rehab

Medial/ Lateral Epicondylalgia - Golfer’s/Tennis Elbow

• Also pitchers etc..

• Mixed tendinopathy periostitis

• SSx: aching pain, worse with movement of affected muscles vs.. resistance; tenderness, bogging

• Tx: Prolonged rest, splints, ice, physio (eccentric loading), NSAIDs, rehab surgery?

Forearm and wrist areas strains and tendinopathy

• May result in ganglion

• Cyst in tenosynovium or swelling within joint capsule

• Mobile, swollen, tender, painful, boggy, possible crepitus with movement

• May lead to carpal tunnel syndrome if on palmer side

• Tx: surgical

Carpal Tunnel Syndrome

• Swelling in tunnel causes compression of median nerve

• Hx = Repeated wrist flexion (tendinopathy) trauma (sprain, fracture, dislocation), ganglion, tumour, pregnancy

• SSx:

  • Pain (worse at night, at rest)

  • Numbness and weakness thumb

  • Atrophy of thenar eminance?

Carpal Tunnel Syndrome Treatment

• POLIE; treat underlying cause

• Splint

• Send to MD for referral for NCS or EMG

• NSAIDs (unless pregnant, allergic)

• May need surgical decompression

De Quervain’s Tenosynovitis

• Cause: Repetitive use of wrist/thumb, particularly with wrist in ulnar deviation

• Inflammation of Abductor pollicis longus and Extensor pollicis brevis tendon sheaths

De Quervain’s Tenosynovitis SSx and Tx:

• Pain/ swelling at base of thumb/radial side of wrist, pain stiffness with radial deviation of wrist and thumb flexion

  • Pain with resisted extension of thumb

  • +ve Finklestein’s test - make fist with thumb curled in fingers, ulnar deviation of wrist

• POLIE, rest, brace?, physio, cortiocosteroid injection?, surgery

Hand strains & tendinopathy

• Beware of possible avulsion fracture

• Do not test muscle strength of finger vs FULL resistance - may convert 2nd degree to 3rd degree injury!

Upper Extremity Sprain and Dislocations

• Hx:

  • Torsion

  • Resisting a force

  • FOOSH

• SSx:

  • Pain, tenderness

  • Swelling

  • Deformity if dislocated

  • Bruising

  • Reduced ROM

• Tx:

  • Check neurovascular status!

  • POLICE, splint, transport to hospital

  • X-Ray, splint or cast as necessary

  • Tape, physiotherpy, NSAIDs, rehab

Ulnar Collateral Ligament Sprain

• UCL is primary restraint to valgus stress to elbow

• UCL sprain increases instability in elbow, higher stresses on other tissues

• Pitchers, rugby/football tackles

• SSx: Pain medial elbow, pain/laxity with valgus stress test, possible ulnar nerve injury

• Tx: POLICE, NSAIDs, CH joint and elbow mechanics, pitching motion, surgery?

Elbow Sprain/ Dislocation

• Hyperextension of annular ligament sprains (± radial head dislocation) are common (esp. wrestling)

• Dislocation of elbow = emergency?

• Tx:

  • Check neurovascular status

  • Splint, NPO, to hospital ASAP

  • X-Ray, splint or surgery as necessary, physio, NSAIDs, rehab

Wrist sprains and dislocations

• Check neruovascular status

• Complications = Lunate or other dislocations, carpal tunnel syndrome, scaphoid fracture

Hand Sprains and Dislocations

• Check neurovascular status, avulsion?

Gamekeeper’s Thumb

• Hx: Forceful abduction combined with hyperextension of 1st MCP joint

• Ulnar collateral ligament (UCL)

• SSx: Pain over UCL, weak and painful pinch, tenderness, swelling

• Tx: POLICE, splint, taping, rehab

Upper Extremity Fractures

• Recognize fracture likelihood

  • Hx

  • Deformity

  • Crepitus

  • Point tenderness over bone

• If in doubt, send to MD for referral for X-Rays

• Open fractures lead to high risk of infection (including osteomyelitis), especially of reduced “on site”

• Tx = cleanse, disinfect, splint or cast, then physio, rehab, tape or splint when returns to sport

Radial Head Fracture

• Hx: Radial head fracture common with FOOSH with forearm in pronated position

• Among most common elbow fractures in adults

• SSx: Swelling, limited pronation & supination, flexion and extension also affected

• Tx: stabilize, NPO, surgery, rehab

Colles Fracture

• Dinner fork deformity

Scaphoid Fractures

• Hx = fall, direct blow, sprain

• SSx:

  • Tenderness in floor of anatomical snuffbox

  • X-Ray may be positive, but negative X-Ray does not rule out fracture!

Scaphoid Fracture Tx

• Tenderness? Then X-Ray

• X-Ray positive?

  • Cast for 8 weeks, then physio and rehab

• X-Ray negative?

  • Cast for 10 days, then re X-Ray, if positive for fracture, cast for 6 more weeks; if second X-Ray is negative, then physio, rehab

Avulsion

• Tx = keep clean, send to MD, may need antibiotics, padding

Subungual hematoma

• Hx = contusion, crush

• If bleeding openly, have MD assess (X-Ray); beware of open fracture → osteomyelitis

• Otherwise, Tx = Decompression under sterile conditions, then POLICE

Hand abrasions, lacerations

• Cleanse wound throughly

• Apply topical antibiotic

• Beware of possible tendon injury

• Monitor carefully for signs of infection, send to MD ASAP for antibiotics if needed!