Orrin Franko East Bay Hand Medical Center wwwEBHMCcom Cell 8583377149 wwwebhmccomreferral Table of Contents Shoulder AC dislocation Shoulder dislocation Biceps tendonitis Elbow Lateral epicondylitis ID: 774605
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Slide1
Upper Extremity Strains and Sprains
Orrin Franko
East Bay Hand Medical Center
Slide2www.EBHMC.com
Slide3Cell: 858-337-7149www.ebhmc.com/referral
Slide4Table of Contents
ShoulderAC dislocationShoulder dislocationBiceps tendonitisElbowLateral epicondylitisMedial epicondylitis
Wrist
DeQuervain tendonitis
Sprains
Fingers
PIP joint dislocation/subluxation/sprain
Mallet finger / Central slip avulsion
Thumb UCL rupture
Trigger Finger
Slide5General Knowledge
SprainsA sprain is a stretch or tear of a ligament.Ligaments connects one bone to another. Ligaments have poor blood supply (that’s why they are white!) so healing can take 3-12 months
Slide6Grades
Sprain Classification Grade 1: some stretching and some damage to the fibersGrade 2: A partial tearing with some subluxationGrade 3: Complete tears and dislocations
Slide7Signs and symptoms
PainSwellingBruisingInflammation
Grade 1RICEPhysical Therapy Grade 2 Bracing Grade 3 Surgery to repair the torn ligaments.
Treatment
Slide8Strains
A direct injury to muscles or tendons. Tendons connect muscles to bonesLike ligaments, they have poor blood supplyThey are often under “high stress” and require modified activity or protection to heal
Slide9Symptoms
Pain Muscle spasm Muscle weakness Swelling InflammationCramping
RICE Specific exercises to regain mobility Surgery
Treatment
Slide10Strains
Slide11“Shoulder Separation” = AC Dislocation
Def: A sprain of the acromioclavicular ligament
Mechanis
: fall on the outstretched arm tip of the shoulder
Cyclists
Slide12Anterior View
Posterior View
Slide13•
Sx
: Point tenderness over AC joint
- inability or pain with abduction
- in some cases, gross deformity
• Tx: Immobilization with a sling
- ice
- NSAIDS
- if grade III or above, refer to a surgeon
- if grade I protective padding
Slide14Rotator Cuff Strain
3 degrees
Most involve supraspinatus
Tears usually at insertion on humerus
Slide15Rotator cuff strain
Slide16Mechanism
Dynamic rotation of arm at high velocity (overhead throwing)
Usually involves individuals with a history of impingement or instability
Slide17Signs & symptoms
Pain w/ muscle contraction
Tenderness over greater tuberosity
Loss of strength
Complete tear produces pain, loss of function, swelling and POT
Slide18Treatment
RICE
Decrease level of activity
Exercises to strengthen rotator cuff
Slide19Biceps tendon rupture
Slide20Mechanism
Direct blow
Severe contraction of biceps
Slide21Signs & symptoms
Pain and bruising through arm
Deformity of biceps—balling up of muscle belly
Pain with elbow flexion or supination
Slide22Treatment
Ice
Immobilization (short term)
Physical therapy
Slide23Tendonitis
Rotator cuff
Biceps
Common among athletes performing overhead motions due to overuse or muscle weakness
Slide24Mechanism
Repetitive overhead motion causing inflammation of tendon
Slide25Signs & symptoms
Tenderness to palpation
Swelling
Crepitus
Pain with motion
Slide26Treatment
Rest
Ice
Heat
NSAIDS
Stretching
Strengthening
Activity modification (reduction in pitching for adolescents)
Slide27Impingement syndrome
Involves compression of supraspinatus tendon, subacromial bursa, long head of biceps tendon (all are under the coracoacromial arch)
Slide28Impingement
Slide29Impingement
Slide30Mechanism
Repetitive overhead motions
Slide31Signs & symptoms
Diffuse pain around the acromion process when arm is in overhead position
External rotators are weak
“+” impingement test
Empty can test may increase pain
Pinching sensation
Slide32Treatment
RICE
Restore normal biomechanics to shoulder
Strengthen RC muscles and muscles that produce movement of scapula
Stretch posterior and inferior joint capsule
Slide33Elbow
Slide34Lateral Epicondylitis (tennis elbow)
Pathology
30 – 50 years old
Repetitive micro-trauma
Chronic tear in the origin of the extensor carpi radialis brevis
Slide35Lateral Epicondylitis (tennis elbow)
Mechanism of InjuryOveruse syndrome caused by repeated forceful wrist and finger movements Tennis players (rarely)Prolonged and rapid activities
Slide36Lateral Epicondylitis (tennis elbow)
Clinical Signs and Symptoms
Increased pain around lateral epicondyle
Tenderness in palpation
Tests
AROM; PROM
Resisted tests
Lidocaine
Slide37Slide38TimeTimeTimeSteroid shotTimeTherapyTime…and give it more time
Treatment of Tennis Elbow
Slide39Medial Epicondylitis (golfer’s elbow)
Pathology 30 - 50 years oldRepetitive micro trauma to common flexor tendon
Slide40Medial Epicondylitis (golfer’s elbow)
Mechanisms of injury
Throwing a baseball
Racquetball or tennis
Swimming backstroke
Hitting a golf ball
Slide41Medial Epicondylitis (golfer’s elbow)
Clinical signs and symptoms
Increased pain over medial epicondyle
Tenderness on palpation
Tests
AROM; PROM
Resisted tests
Lidocaine
Slide42Medial Overload Syndrome in Throwers
Pathology Lateral joint line- compressive forcesShear forces posteriorly in olecranon fossaTensile forces along medial joint line
Slide43Medial Overload Syndrome in Throwers
Clinical signs and symptoms
Persistent medial elbow soreness
Arm fatigue is the 1
st
indicator of impending injury
Medial tenderness
Elbow pain
Slide44Medial Overload Syndrome in Throwers: Treatment
Pre throwing stretches
Adequate gentle warm up with gradual increase to higher velocity throws
Using safe pitch counts for adolescents
Post throwing stretching
ICE after throwing
Surgical Intervention
Slide45Wrist
Slide46Wrist Sprain
Mxn:
Abnormal forced movement of the wrist
Falling on hyperextended or hyperflexed wrist
Violent torsion
Slide47Wrist Sprain
Slide48S/S:
Pain
Point tenderness
Swelling
Difficulty moving wrist—limited ROM
Slide49TX:
RICE for mild/ moderate
Physician referral to rule out fx for severe
Splint if necessary
Exercises for strengthening and ROM
Tape for support
Slide50Treatment for wrist injuries
Slide51Wrist Tendonitis
Mechanism: repetitive motion at wrist—usually in flexion/extension
Seen more often in athletes involved ins sports with repetitive acceleration and deceleration
i.e. weight lifters, rowers
Slide52TX:
Ice
Heat
Analgesics
Modify activity
NSAIDS
Splint
Strengthening and ROM exercises
Slide53DeQuervain’s Tenosynovitis
Tendonitis specifically to the 1
st
Dorsal Compartment
+
Finklestein
test
90% response to a single steroid injection
Splinting temporarily may help
NSAIDs can help
Remaining require surgery for pain relief
Slide54DeQuervain’s Tenosynovitis
Slide55PIP Joint Dislocations / Subluxations
Dorsal more common
Simple dorsal dislocation: reduce, buddy tape
Fracture-dislocation
Splint in stable position
Volar dislocation:
Open reduction required in most cases
Slide56Reduction Techniques
Digital block: 5cc 1% lidocaineVolar at the digital crease – right in the middleOne shot – works every time.
Slide57Reduction Techniques
Re-create deformity, traction
Slide58Mallet Finger / Central Slip
Slide59Slide60MALLET FINGER
Slide61MALLET FINGER
ANATOMYDorsal avulsionExtensor digitorum tendon tearMECHANISM:Forced flexion of extended digitTREATMENT:No fracture: DIP extended for 6-8 weeksFRACTURE: if <30% joint surface, splint x 4 weeksIf >30% Might need ORIFLess than full passive extension?????
COMPLICATIONS:Pressure necrosis from splintPermanent extensor lag
Slide62Mallet Finger Presentation
Pain at dorsal DIP jointInability to actively extend the jointCharacteristic flexion deformityOn exam, very important to isolate the DIP joint to ensure extension from DIP and not the central slipIf can’t passively extend consider bony entrapmentAll of these need x-rays
Slide63CENTRAL SLIP AVULSION
ANATOMYExtensor digitorum communis tendon disruptionLateral bands migrate in volar directionMECHANISM:Volar-directed force on middle phalanx against semi-flexed finger attempting to extend
Slide64CENTRAL SLIP AVULSION
EXAM:Pain, swelling over dorsal PIPPIP in 15-30 degrees flexionMay have limited extension (better at 0 degrees than 30 degrees)TREATMENTSurgery if >30% joint surface involved with avulsion fxPIP splint in full extension 4-5 weeksProtect 6-8 weeks for sports*allow DIP to flex- relocates lateral bandsCOMPLICATIONS:Boutonierre deformity
Slide65Central Slip Extensor Tendon Injury- Boutonnière deformity
PIP joint is forcibly flexed while actively extendedVolar dislocation of the PIP jointExamine with PIP joint in 15-30 degrees of flexion, can’t active extend but can passively extendTenderness over dorsal aspect of the middle phalanx
Slide66Central Slip Extensor Tendon Injury Treatment
A delay in proper treatment will cause boutonniere deformityDeformity can develop over several weeks or occasionally acutelySplint PIP in extension for 6 weeksCan still play sports
Slide67Central Slip Extensor Tendon Injury
Avulsion fracture involving more than 30 percent of the jointInability to achieve full passive extension
Slide68Volar Plate Injury
Hyperextension, such as dorsal dislocationPIP is usually affectedCollateral damage is often presentThe loss of joint stability can cause hyperextension deformity
Slide69VOLAR PLATE RUPTURE
EXAM FINDINGS:Tender volar PIPBruising, swellingMECHANISM:Hyperextension injury Ruptures distally from attachment at middle phalanx
Slide70VOLAR PLATE RUPTURE
TREATMENT:Early mobilizationExtension block splintBuddy tapeSurgery if >30% joint involvedCOMPLICATIONS:Swan neck deformity: extensor tendons pull PIP into hyperextension, DIP flexion
Swan Neck Deformity
Slide71Volar Plate Injury- Treatment
Progressive splinting starting at 30 degrees flexionFollowed by buddy tapingIf less severe, can buddy tape immediatelyCan play sports if splinted
Slide72GAMEKEEPER’S THUMB
MECHANISM
Hyperabduction of thumbEXAM:Weak, painful pinchPain over ulnar thumbXRAYS BEFORE STRESS
Slide73GAMEKEEPER’S THUMB
SIGNSPain over ulnar thumbStress testing positiveTesting in Extension and 40 degrees of FLEXION of MCP
Slide74Ulnar Collateral Ligament Injury of the Thumb (Skier’s Thumb)
Caused by forced abduction of the 1st MCP jointLeft untreated the joint will be unstable with weak grip strength
Slide75Skier’s Thumb- Diagnosis
Difficulty opposing pinky to thumbSwelling and black and blue over thenar eminenceCan’t hold an OK signConsider digital block and to facilitate ligament testing
Slide76Stener Lesion
Slide77Skier’s Thumb Grading/Treatment
Grade 1
Pain without instability with stress
Splinting 1-2 weeks
Grade 2
Pain with mild instability: gapping <20 degrees
Casting 3-6 weeks
Grade 3
Stenner’s Lesion
Instability: gapping > 20 degrees or > 35 degrees compared to
unaffect
thumb
Early surgical intervention within 2-3 weeks
Slide78Skier’s Thumb Treatment
Slide79Stenosing Tenosynovitis (Trigger Finger)
Background2% lifetime risk of developingAt least 2 times as common in womenNot an inflammatory condition!Ring finger most commonly affected digitMultiple trigger digits more common in patients with:DiabetesThyroid problems
Slide80Stenosing Tenosynovitis (Trigger Finger)
2% lifetime risk of developingSymptomsPainful triggering, often worse in the AMPatient often describes the popping as being their PIPPain over the A1 pulleyMay describe that the finger “no longer bends”
Slide81Stenosing Tenosynovitis (Trigger Finger)
Pathoanatomy
Slide82Stenosing Tenosynovitis (Trigger Finger)
Pathoanatomy
Slide83Stenosing Tenosynovitis (Trigger Finger)
TreatmentCorticosteroid Injection86% effective at 3 months50% effective at 12 monthsMay take up to 6 weeks to be effective!Open surgical Release of A1 pulleyCan be done wide awake under local anesthesia onlyOral MedicationsTend not to be effectiveSplintingMay be helpful for symptoms but not long term treatment
Slide84Trigger Finger Injection Technique
1.5cc total in 3cc syringe (25g x 5/8” needle)
0.5cc
celestone
0.5cc 1% lidocaine
0.5cc 0.5%
marcaine
Warn patient that finger tip may be “numb and tingly” for 4-6 hours
Slide85Trigger Finger Injection Technique
Thenar
Crease
Distal Palmar Flexion Crease
Palmar Digital Flexion Crease
Inject halfway between distal palmar crease and palmar digital flexion crease (except thumb)
This is right over A1 pulley
Insert needle and inject a little to anesthetize the skin
Then advance needle and wait for “give” as you have gentle pressure on the syringe plunger
Can also do this in reverse as you withdraw
Be aware of trajectory of flexor tendons!
Studies show no difference whether or not
injxn in sheath
X
X
X
X
X
Slide86Stenosing Tenosynovitis (Trigger Finger)
When to Refer
Patient does not want to undergo injection
Patient has recurrent symptoms after 1 or 2 injections
Locked trigger finger (*)
Slide87