PDII UE Elbow

medial epicondylitis

inflammation of tendon insertions at the medial epicondyle (wrist flexion)

special test for medial epicondylitis

golfer’s elbow test

(wrist flexion against resistance)

lateral epicondylitis

inflammation of tendons inserting at lateral epicondyle (extension)

more common

special test for lateral epicondylitis

tennis elbow test

s/sx of epicondylitis

elbow pain*

weakness with various activities

epicondylitis RF

• repetitive movements

• incidence inc with age

• smoking

• obesity

epicondylitis exam findings

• usually none on inspection, possible atrophy

• localized tenderness/point tenderness

• pain with resistance

radial head subluxation names

nurse maid’s elbow, pulled elbow, annular ligament displacement

radial head subluxation mech of injury

axial traction on pronated forearm with elbow in extension

portion of the annular ligament slides into radio-humeral joint

radial head subluxation pop

<5 y/o (5+, ligament is stronger)

radial head subluxation s/sx

• pain with movement (no pain when not moving)

• loss of ROM

radial head subluxation exam

• usually little distress

• arm is held close to body extended/slightly flexed

• possible tenderness

• active ROM limited

• passive ROM intact to flexion but pain with supination

radial head subluxation reduction methods

• hyper-pronation method

• supination/flexion method

hyper-pronation method

support arm at elbow and place mod pressure on radial head while holding distal forearm and hyper-pronating the forearm

(will feel click)

supination/flexion method

support arm at elbow and exert mod pressure at radial head and apply gentle traction

examiner fully supinates the forearm and fully flexes elbow in one movement

olecranon bursitis

superficially located

limited vascularity = risk for trauma or inflammation (tender, soft, firm, if infection present → erythema and warm)

common cause olecranon bursitis

trauma (leaning on elbow, repeated use)

olecranon bursitis s/sx

• ± pain

• swelling over olecranon bursa

olecranon bursitis exam findings

• swelling of olecranon bursa

• ± tenderness/warmth tenderness

• ROM: intact

olecranon bursitis work-up

bursal aspiration and lab analysis

Rheumatoid Nodules

nodules on pressure points along extensor surface of ulnar (firm and NON-tender)

ulnar collateral (medial collateral) ligament originates from?

medial epicondyle of humerus and attaches to proximal humerus

has 3 bands (anterior, posterior, transverse)

primary stabilizer of elbow and provides valgus support

ulnar collateral ligament (UCL)

mechanism of injury of UCL injury

overhead throwing athletes (baseball pitcher, javelin throwers)

repetitive forces -. hypertrophy and adaptive laxity of UCL/MCL

UCL injury s/sx

• acute/insidious onset of medial elbow pain, worse with overhead throwing

• dec pitching velocity/arm fatigue, grip weakness

• palpation posterior to flexor pronator origin → tenderness in acute injury (absent if chronic)

test for UCL injury

valgus stress

+ if affected elbow = 1-3 mm laxity

scaphoid bone

carpal bone most likely damaged

de quervain’s tendonitis s/sx

• tenderness over extensor and abductor tendons of thumb at radial styloid

de quervain’s tendonitis tendons affected

abductor pollicis longus and extensor pollicis brevis tendons (passing through fibro-osseous tunnel)

de quervain’s tendonitis s/sx

• wrist thumb pain w/ movement

• weakness of grip

de quervain’s tendonitis exam

• inspection: n/a

• palpation: tenderness at abductor pollicis longus and extensor pollicus brevis

• Functional ROM of wrist

• pain with abduction against resistance

de quervain’s tendonitis test

finklestein’s test

finklestein’s test

used to evaluate de quervain’s tendonitis

looks for pain/crepitus along tendon sheaths

tenosynovitis

tenderness and swelling along flexor tendon sheath

entire finger is erythematous

dec ROM

assoc. w/ local injury/overuse/infection

finger held in slight flexion

why is flexor tendons more common with tenosynovitis?

flexor tendons are on palms

tenosynovitis definition

inflammation of tendon and synovial sheath, occurs at hand and wrist

tenosynovitis causes

• trauma (laceration/puncture/bite from staph/strep)

• spread from infected adjacent soft tissues

• hematogenous spread (N. gonorrhea)

tenosynovitis exam findings

kanavel signs

• tenderness along flexor sheath

• symmetric enlargement on digit (entire finger)

• finger is slight flexion

• pain along tendon with passive extension

carpal tunnel syndrome

entrapement of median nerve

carpal tunel syndrome s/sx

numbness, tingling, burning in medial nerve distribution

weakness of hand, dropping objects

exam findings for carpal tunnel syndrome

atrophy of thenar eminence

s/sx carpal tunnel worse with?

sleep, repetitive movements, sustained hand/wrist position

carpal tunnel RFs

• obesity

• female

• DM

• pregnancy

• RA

• hypothyroidism

• connective tissue dz

• genetic predisposition

carpal tunnel syndrome exam findings

• possible sensory/motor deficits in medial distribution

• thenar weakness w/ thumb adduction and opposition

• thenar atrophy

• positive special tests

phalen’s test

hold wrist in flexion 60 seconds

evaluates for numbness/tingling in median nerve

tinel’s sign

light tap over flexor retinaculum

pain in median nerve distrubtion

thumb abduction (test)

for carpal tunnel or de quervain’s tendonitis

look @ weakness of abductor pollicis longus

carpal tunnel syndrome work-up

• lab testing (glucose, A1C, TSH, RA)

• electrodiagnostic confirmation (if mod-severe sx)

carpal tunnel syndrome tx

splints

colles fracture + mech

extensor fracture of distal radius (more common)

mech: falling on outstretched hand with wrist in extension

smith fracture

flexor fracture of distal radius (not common)

scaphoid fracture (short)

tenderness at anatomical snuffbox → avascular necrosis

RF colles fracture

• high energy falls (athletics)

• low energy falls (osteoporotic pop)

distal radius

most common fracture site in UE

colles fracture s/sx

wrist pain

deformity

limited ROM

looks like a “dinner fork” appearance

colles fracture exam findings

1. swelling and deformity*

2. ROM: limited with flexion/extension, radial/unar deviation, supination/pronation

3. check neurovascular status, make sure no nerve compression

4. rule out scaphoid tenderness

colles fracture work0up

• xrays

• orthopedic referral

colles fracture tx

• ortho referral

• reduction if needed

• splinting (sugar tong splint)

smith fracture definition

volar angulated fracture of distal radius

mech of injury of smith fracture

fall/direct blow on dorsum of hand and wrist

fall on outstretched hand in flexed position/supination then shifting into pronated position

scaphoid fracture mech

fall on outstretched arm, with wrist extended

RF of scaphoid fracture

trauma

male

why are scaphoid fractures so serious?

palmar carpal branch of radial artery supplies scaphoid bone, so fractures can interrupt blood flow

scaphoid fracture findings

• tenderness over the anatomical snuffbox

• tenderness with axial loading

scaphoid fracture pitfalls

may not see on xray

if normal, treat like fracture

scaphoid fracture work-up

XRAYS!

scaphoid fracture tx

short arm cast w or wo thumb immobilization (thumb spica splint)

ganglion cyst

cystic round nontender swelling along tendon sheaths

tends to be located on dorsum of wrist, hands, ankles, feet

RF ganglion cyst

• all ages (most common 20-40)

• female

s/sx of ganglion cyst

swelling, ± pain, sensory complaints

ganglion cyst exam findings

• firm, smooth, rounded rubbery fluid0filled swelling over joint of tendon sheath (most often on DORSUM of wrist)

• ± tenderness to palpation

• ROM: should be intact, if cyst is extremely large, may have impact on ROM

dupuytren’s contraction

benign, progressive fibro-proliferative disease

dupuytren’s contraction appearance

flexion contractures of 3rd, 4th, and 5th fingers

thickening of palmar fascia

dupuytren’s contracture RF

• age >50

• genetic predisposition

• northern euoprean ethnicity

• tasks with repeated hand use or exposure to vibration

• DM

• smoking

• ETOH use

dupuytren’s contractions s/sx

• Painful thickening of palmar fascia

• LROM of affected fingers

dupuytren’s contraction exam findings

• Visible contracture

• Rope-like thickening of palmar surface of hand

• Fixed flexion of digit (active and passive ROM)

• Weakness in hand grip

trigger finger

Painless nodule in flexor tendon in palm near metacarpal head that limits passage through tendon sheath during extension

pain comes from tendon moving through area and being irritated near MCP head

trigger finger exam findings

• Normal

• Finger flexed

• Crepitus with movement near pulley

• Tenderness to base of finger

• Reproducible trigger

trigger finger RF

• Female

• 50-60s

• DM

• RA

• Amyloidosis

s/sx of trigger finger

• Snapping, locking/catching of finger with attempts to extend

• Finger flexed

• Possible pain

paronychia

• Superficial infection of proximal and/or lateral nail fold

  • Could lead to tenosynovitis

RF of paronychia

• Manicuring

• Nail binding

• Thumb sucking

• Picking at hangnail

• Ingrown toenails

paronychia definition

inflammatory process with or without abscess formation, involving proximal and lateral nail folds

what causes paronychia

mechanical/chemical trauma that disrupts nail fold

acute <6 weeks or chronic >6 weeks

paronychia s/sx

• Acute OR chronic

• Erythema, swelling, pain to nail fold

paronychia exam findings

• Swollen, tender proximal or lateral nail folds

• Possible purulent fluid collection

paronychia tx

Warm soaks in water

felon

• Injury to finger top -> infection of fascial space of phalanx pad

• Pain, swelling erythema

  • Can be complication of paronychia

what fingers are most affected in felons?

thumb and index finger

why is a felon an issue?

increased pressure → ischemic necrosis of tissue, osteomyelitis, flexor tenosynovitis, septic arthritis of DIP

felon RF

1. Trauma (minor cuts),

2. FB penetration (splinters)

3. paronychia

felon s/sx

• Pain: severe and throbbing, worse in dependent position (below level of heart)

• Swelling and erythema

felon exam findings

• Edema to distal phalanx

• Erythema

• Severe tenderness to palpation

gout

acute or chronic

uric acid crystals deposits in joint space

gout RF

• Meds

• Men

• ETOH

• Renal insuff

• cancer/chemo

• diuretics

herpetic Whitlow

Vital infection of hand caused by HSV

RF of herpetic whitlow

• Children <10 y/o or young adults 20-30 yo

• HSV spread for secretion, lesions of infected pts, or secretions of asymptomatic carriers

s/sx herpetic whitlow

• Single vesicle/cluster of vesicles (typically ONE digit)

• Tingling and burning of hand (out of proportion)

• Can go dormant and reoccur

how to differentiate b/w osteoarthritis vs. RA?

history, sx, and physical exam findings (not RF)

Osteoarthritis RF

• Age: more common as age inc

• Female

• Genetics