Transcript Musculoskeletal Pathology of the Elbow, Wrist and Hand

Brian Lohrbach, MD
OSI Orthopedic Surgeon
Tendonitis
Tendonitis: Elbow
• Lateral epicondylitis • Pain with repetitive
supination/pronation
• “Tennis elbow”
and gripping
• Pain over lateral
epicondyle radiating to • Degeneration of origin
of Extensor Carpi
dorsum of wrist
Radialis Brevis
Lateral Epicondylitis: Diagnosis
• X-rays usually
negative
• Pain to palpation of
lateral epicondyle
• Pain with resisted
wrist extension in
pronation
Lateral Epicondylitis: Treatment
• Non-operative: 85%
success rate
• Activity modification,
NSAIDs, counterforce
strap, cortisone
injections (2-3)
• Therapy
– Ultrasound, massage,
iontophonophoresis,
stretching
Lateral Epicondylitis: Treatment
• Operative
– Removal of diseased
tissue
– Most patients improve
in 3-4 months
– 90% success rate
Lateral Epicondylar Release
Return to Work Protocol
• Week 0 – 1: off work
• Week 1 – 4: one-handed work, begin OT
• Week 4 – 12: light duty work, complete OT
• Week 12: regular duty work
Tendonitis: Wrist
• De Quervain’s tenosynovitis
• Intersection syndrome
• Flexor carpi radialis/ulnaris tendinits
DeQuervain’s Tenosynovitis
• Stenosing tenosynovitis of
1st dorsal compartment:
Abductor pollicis longus
(APL) and extensor
pollicis brevis (EPB)
• 30 to 50 year olds
• 10 times more common in
women
• Pain with thumb motion
over radial styloid
DeQuervain’s: Diagnosis
• Pain over radial
styloid
• Finkelstein’s
maneuver
DeQuervain’s:
Treatment
• NSAIDs
• Thumb spica splint
• 1 – 2 cortisone injections
• Operative release required
in 25% of patients after 6
weeks of failed conservative
treatment
First Dorsal Compartment Release
Return to Work Protocol
• Day 1 - 2: off work
• Week 1 – 3: one-handed work, home exercises
• Week 3 – 6: light duty work
• Week 6: regular duty work
Intersection Syndrome
• Pain where APL and
EPB cross over
underlying extensor
carpi radialis (ECR)
• Swelling, crepitus,
squeaking*
• Splint, NSAID,
occasional injection
Flexor Carpi Radialis/Ulnaris
Tendonitis
• Pain over volar wrist from
repetitive motion
• Splint, NSAIDs, activity
modification
• Cortisone injection
• Very rarely, surgical
tenolysis
Tendonitis: Hand
• Trigger finger
• Stenosing flexor tenosynovitis:
Inflammation of flexor tendon
limiting excursion under the
A1 pulley
• Inability to fully extend digit
or catching with flexion and
extension of digit
• Repetitive use and diabetes
are common causes
Trigger finger: Diagnosis
• Locked digit in flexion
• Painful nodule over volar
metacarpophalangeal joint
• *Beware: Patients with
trigger thumb often
complain of catching in
interphalangeal joint of
thumb
Trigger Finger: Treatment
• Nonoperative:
– NSAIDs
– Cortisone injection
under A1 pulley
• 60% success if seen
early
Trigger Finger: Treatment
• Operative: A1 pulley
release
– Outpatient procedure
under local
– 95% success rate
Trigger Finger Release
Return to Work Protocol
• 1 - 2 days off work
• Week 1 – 3: one-handed work, home exercises
• Week 3 – 6: light duty work
• Week 6: regular duty work
Compressive Neuropathies
Compressive Neuropathies:
Elbow
• Cubital tunnel syndrome (ulnar nerve)
• Radial tunnel syndrome
Cubital Tunnel Syndrome
• Compression of ulnar
nerve at the elbow
• Direct blow to elbow
• Repetitive flexion
• Diabetes
Cubital Tunnel Syndrome
• Symptoms
– Numbness in small and
ulnar half of ring finger,
including dorsum of hand
– Decreased grip strength
– Medial elbow pain
• Awakens at night
• Worse when holding
phone,elbow on desk,
driving
Cubital Tunnel Syndrome: Diagnosis
• Positive Tinel’s sign at
cubital tunnel
• Positive elbow flexion
test
• Decreased 2-point
discrimination at small
finger
Cubital Tunnel Syndrome: Diagnosis
• Positive Froment’s
sign (weak adductor)
• Wasting of dorsal 1st
webspace
• Electrodiagnostic tests
(EMG/NCV)
Cubital Tunnel Syndrome: Treatment
• NSAIDs, activity
modification, elbow pads,
nighttime splinting in 20
degrees of flexion (Poorly
tolerated)
• Surgical release and/or
anterior transposition
– 80-90% good results
Radial Tunnel Syndrome
• Compression of radial
nerve under extensors
in forearm
• Deep, lateral forearm
pain, often at night
• No sensory component
• Often confused with
lateral epicondylitis
(they co-exist 5% of
the time) pain is more
distal
Radial Tunnel Syndrome: Diagnosis
• Extended middle finger
test
• Electrodiagnostic tests not
helpful
• Injection of local
anesthetic into radial
tunnel completely relieves
symptoms and is
diagnostic
Radial Tunnel Syndrome: Treatment
• NSAIDs
• Activity modification
• Surgical decompression
– 50% success rate
Cubital and Radial Tunnel Release
Return to Work Protocol
• Week 0 – 1: off work
• Week 1 – 6: one-handed work, begin OT
• Week 6 – 12: light duty work, complete OT
• Week 12: regular duty work
Compressive Neuropathies: Wrist
• Carpal tunnel syndrome (median nerve)
• Ulnar tunnel syndrome (Guyon’s canal)
Carpal Tunnel Syndrome
• Compression of median
nerve under transverse
carpal ligament
• Pain/parasthesias of
palmar/radial aspect of
hand; weakness over time
• Often worse at night,
reading paper, holding a
coffee cup, driving
Carpal Tunnel Syndrome:
Risk Factors
•
•
•
•
•
•
Diabetes
Alcoholism
Pregnancy
Hypothyroidism
Distal radius fracture
Vibrational exposure
Carpal Tunnel Syndrome:
Diagnostic Tests
• Moving 2-point discrimination
greater than 5mm
• Tinel’s: tingling to percussion
over carpal tunnel
• Phalen’s: wrist palmarflexion
produces parasthesia in 60
seconds
• Compression test: direct
compression over carpal tunnel
with parasthesia at 30 seconds
Carpal Tunnel Syndrome:
Diagnostic Tests
• Weakness of abductor
pollicis brevis or wasting
of the thenar eminence
(advanced stage)
• Electrodiagnostic tests
– Nerve conduction velocity:
slowed at wrist
– Electromyography (EMG):
indicates advanced stage of
disease
– 5% false-negative rate
Carpal Tunnel Syndrome: Treatment
• Conservative
– Splinting in neutral at
night
– NSAIDs
– Ergonomic
modification
– Steroid injections
• Best in early stages
• Diagnostic tool
• 20% asymptomatic at
12 months
Carpal Tunnel Syndrome: Treatment
• Carpal tunnel release
– 95% success rate
– Outpatient, local
anaesthetic
– Recovery 6 weeks to 6
months depending on
the occupation of the
patient
– Pillar (incisional) pain
Ulnar Tunnel Syndrome
(Guyon’s Canal)
• Ulnar nerve passes
between hook of
hamate and pisiform at
wrist
• Much less common
than carpal tunnel
syndrome
Carpal Tunnel Release
Return to Work Protocol
• 3 – 7 days: off work
• Week 1 – 6: one-handed work, +/- OT
• Week 6 – 12: light to regular duty, +/- OT
• Week 12: regular duty
Getting