Dr. Colin Jackson Orthopaedic - PowerPoint Presentation

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Dr. Colin Jackson

Orthopaedic Surgeon, University of British Columbia,Hand and Upper Extremity Reconstruction

Common Conditions of the Elbow, Wrist and Hand

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OutlineCommon Conditions of the Elbow, Wrist and Hand

For each topic:What is it? Brief OverviewHow do patients present? How is the condition diagnosed?Treatment optionsQuestion and answer session

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Elbow

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Tennis Elbow

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Tennis Elbow

What is it?An overuse injuryTendinopathy (-

osis

) at site of ECRB/EDC insertion (

angiofibroblastic

degeneration)

Incidence/Prevalence:

Most common cause of elbow pain

May affect up to 50% of recreational tennis players

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Tennis Elbow

Presentation:Pain with use and load through extensorsTrouble gripping/lifting and decreased strengthPhysical Exam:

Point tenderness at origin of ECRB

Swelling at ECRB origin when more severe

Weak grip and loss full elbow extension

Provactive

Tests:

Pain with resisted wrist extension (elbow straight)

Pain with maximal wrist flexion

(flexion stretch)

Pain with resisted finger extension

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Tennis Elbow

Treatment optionsNon-operative:PATIENT EDUCATION: rest & activity modificationIce and NSAIDs (for acute presentation)Brace/strap (must be used correctly)Stretching, gentle strengthening

TIME!!

– avoid referral as long as possible

Steroid Injections (I try to avoid)

Evidence to support: ESWT, PRP,

Prolotherapy

, etc.

Operative: a last resort, after failure of non-op management

 release and debridement of ECRB origin (open or arthroscopic)

**Life long condition – always at risk of recurrence, irrespective of treatment

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Golfer’s Elbow

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Golfer’s Elbow

What is it?

An overuse syndrome of the flexor-

pronator

mass

Repetitive flexion and forearm

pronation

cause

microtrauma

to the origins of FCR and

pronator teres

Incidence/Prevalence:

~5x less common than lateral

epicondylosis

Athletes (golf, baseball, racquet sports)

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Golfer’s Elbow

Presentation:Pain localized over the medial epicondylePain worsens with wrist flexion and pronation activities

Physical Exam:

Point tenderness at and distal to the flexor-

pronator

tendon origin on the medial

epicondyle

May have associated

ulnar

n. symptomsProvactive Tests:Pain with resisted forearm pronation

Pain with resisted

wrist flexion

Extension stretch

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Golfer’s Elbow

Treatment optionsPhysiotherapy:Patient education: activity modification (coaching on appropriate swing and throwing techniques)Not as extensively studied  ?extrapolate findings re: efficacy of common modalities (ESWT, Tens, PRP, U/S)

Other non-operative:

NSAIDs

Brace (must be used correctly)

Steroid Injections

Operative: Debridement of pathologic portion of tendon +/-

release of ulnar nerve

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Radial Tunnel Syndrome

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Radial Tunnel Syndrome

What is it?A compressive neuropathy of the posterior interosseous nerve (PIN) with

pain only

No sensory or motor deficits

Incidence/Prevalence:

Rare: annual incidence ~0.003%

May coexist with lateral

epicondylitis

in ~5% of patients

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Radial Tunnel Syndrome

Presentation:Deep, aching pain in the

dorsoradial

forearm

Pain radiates from the lateral elbow to the dorsal aspect of the wrist

Physical Exam:

Tenderness to palpation

in the mobile wad

Provactive

Tests:

Pain with resisted long finger extensionPain with resisted supination

Pain with maximal stretch on nerve: elbow extension + forearm

pronation

+ wrist flexion

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Radial Tunnel Syndrome

Treatment optionsPhysiotherapy:Patient education: activity modification – avoidance of prolonged periods of elbow extension and forearm pronation and wrist flexion

Stretching

Primarily anecdotal ‘evidence’

only

Encourage conservative and avoid referral

Other non-operative treatments:

NSAIDs

Splinting

Steroid Injections

Operative: Radial tunnel release

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Distal Biceps Rupture

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Distal Biceps Rupture

What is it?An avulsion of distal biceps tendon from the radial tuberosity

Typically occurs during eccentric loading of the tendon

Incidence/Prevalence:

Mainly in men aged 40 – 60 years of age

Often on their dominant side

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Distal Biceps Rupture

Presentation:History of pain in

antecubital

fossa

after unexpected extension force applied to flexed elbow

Pain with associated weakness (particularly

supination

)

Physical Exam:

Ecchymosis and tenderness in antecubital fossaAbnormal hook test

Asymmetry of biceps contour (# of fingers between elbow crease and

muscle belly)

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(Distal) Biceps Rupture

Treatment optionsOperative: * Time Sensitive * (refer early!), distal biceps tendon reattached to radial

tuberosity

Non-operative:

Patient education:

anticipate weakness in flexion and

supination

Greater loss of

supination

strength

Earlier fatigueAnalgesics

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Thrower’s Elbow

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Thrower’s Elbow

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Thrower’s Elbow

What is it?Repetitive injury (valgus overload) to the UCL of the elbow

Leads to pain and valgus instability (usually subtle)

Incidence/Prevalence:

Common in throwing athletes (particularly baseball pitchers)

Incidence correlated with volume of pitching and insufficient rest period between pitching

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Thrower’s Elbow

Presentation:Acute injuries: may describe hearing/ feeling a ‘pop’ (usually acute on chronic)

Patient notes medial elbow pain, may also note decreased throwing performance (decreased velocity, decreased accuracy)

Physical Exam:

Point tenderness near UCL/MCL origin

May have associated

ulnar

n

.

findingsProvactive Tests:

Valgus

stress test and moving

valgus

stress test

Milking maneuver

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Thrower’s Elbow

Treatment options

Physiotherapy:

Flexor-

pronator

strengthening (after

period of rest)

Patient education:

improved throwing mechanics

Stretching

Other non-operative treatments:

NSAIDs

Operative: Medial Collateral Ligament Reconstruction

(Tommy John Procedure)

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Wrist

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Carpal Tunnel Syndrome

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Carpal Tunnel Syndrome

What is it?A compressive neuropathy involving the median nerve in the carpal tunnel

Incidence/Prevalence:

0.1% to 10% of the general population

Many ‘risk’ factors including: female, diabetic, pregnancy, hypothyroid, older age, renal failure…

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Carpal Tunnel Syndrome

Presentation:Numbness/tingling in radial 3 ½ digits

Commonly night symptoms

Weakness,

clumsiness, pain

Physical Exam:

May see

thenar

wasting/weakness

May have

altered sensationProvactive Tests:Tinel’s

,

Phalen’s

,

Durkan’s

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Carpal Tunnel Syndrome

Treatment optionsNon-operative:Patient education: activity modification

Night splints

NSAIDs

Steroid Injections

Physiotherapy - controversial

Operative: for failure of non-op treatment or if condition is severe; open and endoscopic procedures

 important role of physiotherapists in managing subset of post-op patients

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DeQuervain’s

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DeQuervain’s

What is it?Entrapment

tendonopathy

(

stenosing

tenosynovitis,

tendovaginitis

)

Involves tendons in first dorsal extensor compartment (APL and EPB)

Etiology

Likely rheumatologic and age related

Forceful repetitive use may be factor

Postpartum, lactating

Demographics

Women >> Men and peaks age 55-60

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Presentation:

Radial wrist pain usually for weeks or monthsSignificantly limits use involving thumbPhysical Exam:Point tender (swelling) over 1st extensor compartment

Loss of active thumb extension

Provactive

Tests:

Pain with resisted thumb extension

Positive Finkelstein’s test

DeQuervain’s

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DeQueryvain’s

Treatment optionsNon-operative:Brace – often uncomfortable, bulky and 70% failure

Maybe postpartum (often resolve – keep comfortable)

NSAIDs (pain meds) – treats pain only

Therapy – no good evidence

Steroid Injections – 50-80% effective (1-2)

Operative:

First extensor compartment release

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Wrist Ganglion

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Wrist Ganglion

What is it?Mucin filled cyst attached to underlying joint capsule

Incidence/Prevalence:

Relatively common

More prevalent in women

70% in 2

nd

to 4

th

decades

10% may have traumatic etiology

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Wrist Ganglion

Presentation:Dorsal wrist mass, usually over scapholunate interval (can be anywhere over dorsal wrist – long stalk)

Usually cosmetic; may have associated pain

Size and symptoms fluctuate. May disappear.

Physical Exam:

Fixed

d

orsal fluctuant mass, may be tender

May have pain with forced wrist extension

Transillumination

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Wrist Ganglion

Diagnosis:Transillumination

and aspiration are diagnostic

Must rule out other masses and tumors

MRI for occult ganglion (dorsal pain NYD)

Treatment:

Educate patient; encourage observational treatment

May resolve on own

Aspiration/injection steroid 20-30% effective (I have had little success and have all but abandoned)

Bible

Surgery – open or arthroscopic excision

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Wrist Sprain

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Wrist Sprain

What is it?Traumatic injury usually FOOSH, possible torsionA ligament injury (minor strain to rupture)

Incidence/Prevalence:

Common in sports & other outdoor activities

Middle aged doctors who take up mountain biking

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Anatomy:

Intrinsic and extrinsic ligamentsMost common injuries to scapholunate and dorsal radiocarpal ligaments

Wrist Sprain

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Presentation:

Wrist pain, stiffness, swelling, possible ecchymosis Increased pain with use, load and forced motionPhysical Exam:Dorsal wrist swelling, loss of motion, bruisingPoint tenderness over strained ligament or avulsion

Provactive

Tests:

Watson’s scaphoid shift test

Pain with forced wrist motion

Wrist Sprain

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Wrist Sprain

Diagnosis:Need xrays prior to starting treatmentr/o fracture, avulsion, rupture

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Wrist Sprain

Treatment options

Non-operative:

RICE for acute injury

Pain meds

Wrap, tape, brace

Time!!!

Cortisone

Therapy – as for all sprains

ROM, proprioception, strengthening, modalities

Operative:

Acute ligament repair for rupture

Scope for failed non surgical treatment

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Hand

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First CMC Joint OA

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First CMC Joint OA

What is it?Degenerative arthritis at base of thumb between metacarpal and trapeziumIncidence/Prevalence:

1/3 Women and 1/8 men develop

prematrure

arthritis

Most common arthritis in the hand

Usually 5

th

decade and later, unless post-traumatic

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Anatomy:

Saddle shaped joint – allows wide ROM and gives us our opposable thumbsVolar beak ligament thought to become lax, allowing dorsal metacarpal subluxation with abnormal load and wear to volar MC base and dorsal Tm (shoulder deformity)

First CMC Joint OA

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Anatomy:

Thumb stiffens in flexion and adductionVolar plate of MP stretches out to allow web space opening (Z-deformity)

First CMC Joint OA

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Presentation:

Pain with pinching, gripping, opening jars, doors, turning keysCosmetic deformity as becomes more severePhysical Exam:

Assess for swelling, shoulder and Z-deformity

Point tenderness at joint, especially

volarly

Laxity (early) or Stiffness (late)

Weak pinch and

thenar

wasting

Grind test

Degree of MP laxity

First CMC Joint OA

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First CMC Joint OA

Treatment optionsNeed to get radiographs to assess stage Non-operative:Most patients respond well/adequately Patient education and activity modification

NSAIDs

Bracing (soft or rigid) – up to 6 weeks if acute

Steroid and HA injections

Exercises and therapy/OT

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First CMC Joint OA

Operative: Failure of conservative measuresEarlyLigament reconstructionMetacarpal extension osteotomyArthroscopy

Late

Ligament reconstruction tendon interposition (LRTI)

Hematoma

arthroplasty

Joint replacement

Fusion

MP joint (possible fusion or volar

capsulodesis

)Post Surgical:Bracing and therapy are essential to obtain a good resultRecovery is often prolonged

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Trigger Finger

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Trigger Finger

What is it?Entrapment

tendonopathy

similar to

deQuervain’s

Any flexor tendon at A1 pulley

Hypertrophy and fibrosis of sheath impedes gliding and causes catching or locking

Unknown etiology

Incidence/Prevalence:

Very common

Middle aged Women (about 2-6x men)

Diabetes, gout,

thryroid

, renal disease, RA

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Trigger Finger

Presentation:Painful catching/locking of digit with motionDigit stiffness and pain in palm

Trouble gripping

Worse in a.m., limbers throughout day

Physical Exam:

Tender flexor nodule at MP level

Catching or locking (active or passive)

Pain forcing extension

Loss of PIP joint motion

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Trigger Finger

Treatment optionsNon-operative:Injection steroid – about 80% cure with 2 injectionsSplinting – especially at night to prevent lockingOperative:

If fail 2 injections

Open A1 pulley release

Percutaneous release (U/S?)

Therapy – for wound or stiffness problems

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Dupuytren’s

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Dupuytren’s

What is it?Benign fibromatosis of the palmar and digital fascia

Palmar and digital nodules and cords

Causes digital flexion contractures

Incidence/Prevalence:

Most common in men over 40

Usually of northern European descent

Trauma/surgery may flare

Diathesis subgroup have more severe

disease and more resistant to treat

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Dupuytren’s

Presentation:Nodules and cords in palm and digit(s)Possible fixed digital contractures (MP and PIP)

Rarely have pain

Complain of trouble putting hand in pocket and tight spaces

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Dupuytren’s

Treatment optionsNon-operative:Observation until MP contracture 30deg or any PIP contractureSteroid injection for painful nodule

Splinting/therapy not effective

Operative:

Needle

aponeurotomy

(higher recurrence)

Open

fasciectomy

(longer recovery)

Enzymatic fasciotomy (Xiaflex- Clostridium toxin)Therapy very important for splinting, wound care and ROM post surgery. Less important for NA & Xiaflex

.

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Dupuytren’s

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Questions?