Elbow, Wrist, and Hand Pathology

• The presentation is about pathology of the elbow, wrist, and hand

Can the QuickDASH PROM be Altered by First Completing the Tasks on the Instrument?

• Health systems and payers use patient-reported outcome measures (PROMs) for quality improvement and value-based payment models
• One study determined the effect of completing functional tasks before completing the PROM questionnaire
• 140 patients presented with a hand or upper-extremity problem at the clinic during a two-month period
• The patients spoke and read English and were 18 years old or older
• 132 (94%) patients met the inclusion criteria and agreed to participate
• 112 patients were in the intervention group (85%), and 20 patients were in the control group (15%)
• Intervention patients completed functional tasks on the QuickDASH and completed a follow-up QuickDASH
• Control patients completed the QuickDASH at baseline and a follow-up QuickDASH 5 minutes after
• QuickDASH scores change after patients complete tasks on the questionnaire
• The change in QuickDASH score in an intervention group is different than that of in a control group
• A higher proportion of patients in the intervention group improve their QuickDASH scores by greater than a minimally clinically important difference (MCID) of 14 points

Altering Outcome Measures

• Tasks 1-6 replicated in the clinic
• MCID is achieved after performing tasks
• An effect size of 0.6 is achieved
• The Carpal tunnel release effect size is 0.7
• The ASAD effect size is 0.9
• PROMs are used in reimbursement models
• PROMs are also often used to assess quality of care
• PT research is performed on interventions linked to PROM
• PROM is only a part of the overall examination

Agenda

• Biceps – SLAP to distal biceps
• Elbow dislocation, post-traumatic stiffness
• Ulnar collateral ligament injuries
• Nerve compressions
• Medial and lateral epicondylitis
• Carpal tunnel, cubital tunnel
• Wrist and hand injuries / tendinopathies
• Flexor tendon repair

Elbow X-Ray Series

• AP View Right Elbow
• Lateral View Right Elbow

Biceps

• The Long Head (LH) of the biceps plays a role in the shoulder
• It is a potential source of anterior shoulder pain
• The LH biceps may contribute to anterior stability of the shoulder joint
• Long head biceps issues are differentiated with tendon sheath injection
• Treatment options for biceps issues are surgical, with tenodesis vs tenotomy
• Proximal vs distal ruptures can occur
• Proximal ruptures may be therapeutic
• Distal ruptures are an orthopedic urgency
• Biceps issues complicate symptoms with SLAP lesions

SLAP Lesion

• These are superior labral anterior posterior lesions
• The SLAP lesion has the Snyder Classification
• Normal vs symptomatic anatomy - difficult to distinguish on advanced imaging.
• Tears are noted in 72% asymptomatic subjects over 40
• Treatment trends include debridement or repair which is dependent on tear type
• The LH biceps released with either tenodesis or tenotomy
• Rehab implications are BT vs labral repair

SLAP Lesion: Examination

• Conducted with consideration of age and onset
• Assessed by location of pain, anterior shoulder
• Determined by chief complaint, pain vs instability
• Special tests include active compression and Speeds
• Management may include pain relief with debridement and biceps tenodesis
• Trend toward biceps procedure for all
• It is often seen with other shoulder issues

Evolving Treatment for SLAP Lesions

• Highly variable results with SLAP repair
  • Over 35 have less than 50% successful
  • Often results in need for 2nd procedure.
• Younger and higher demand patients
  • Previous thought repair beneficial
  • Especially in throwers and overhead occupations
• Recent evidence suggests tenodesis helpful
  • In military members under the age of 35
  • No observed benefit to repair vs biceps tenodesis

SLAP Current Trends

• Trial of nonoperative care with impairments like GIRD, post cuff, scapula for 8 weeks is adequate.
• Identify source of symptoms by trial of injection, helpful for pain, SAPs, LHB tendonitis, and ACJ.
• Larger labral tears cause instability
• Diagnosis remains difficult, requires MRA or 3T MRI for Variable anatomy

SLAP Lesion Postoperative Management

• Repair vs debridement
• Associated procedures are RCR (size, shape, quality, patient demands), instability procedure, or SAD, DCE and biceps tenodesis
• Period of immobilization
• Important to maintain motion and prevent stiff shoulder
• Progress based on impairments and healing
• Set patient centered functional goals

Postoperative Management: SLAP Repair vs Biceps Tenodesis

• Sling for 2–4 weeks
• Biceps tenodesis provides immediate passive motion
• SLAP repair limits motion for 4–6 weeks
  • More repair is done for younger patients because of lower likelihood of tightness
  • Repair allows for healing in higher-demand patients
• Full motion occurs by 6–8 weeks
• Strength is increased by 6-8 weeks
• Return to Sports timeline: Biceps (3 months), SLAP repair (6 months)

Distal Biceps

• Hook test
• Visible deformity
• Ecchymosis
• Palpable gap
• Tobacco use as risk factor
• Injury mechanism
• Supination weakness
• Tenderness to palpation (TTP) radial tuberosity

Distal Bicep Rupture

• Early surgical repair is advocated and leads to better outcomes
• Delays greater than 4 weeks can lead to inferior outcomes
  • Tendon retraction
  • Need for graft
• Short head attaches distally and more of elbow flexor
• Long head is the stronger supinator
• There is a 40-60% loss of supination strength following rupture
• There is a 30% loss of elbow flexion following rupture
• A nonsurgical approach is an option for older patients with co-morbidities

Distal Bicep Postop

• Potential complications include rupture, infection, and fracture
  • Tendon integrity is crucial for strength to return
  • Monitor the PIN during postop visits
• Period of immobilization to avoid end extension
• Several weeks of controlled motion with a brace
• Full motion occurs by 6-8 weeks
• Return to work or sport depends on the job
  • Most return fully within 2-4 months

Ulnar Collateral Ligament

• Bony constraint accounts for 50% valgus stability
• Soft tissue accounts for 50% valgus stability
  • Includes flexor protonator mass, FCU, joint capsule
  • UCL includes anterior and posterior bands
• The UCL requires reciprocal function, AB is relaxed in flexion while PB is relaxed in extension
• The anterior bundle provides the most valgus resistance

UCL Injury

• Common in overhead throwers and athletes such as Baseball, football, and javelin
• Also seen in Gymnastics and wrestling
• Attenuation injury results from constant strain and stretch
  • Will not tighten or heal without surgery
• Acute traumatic injury (One time event)
  • Can heal with period of bracing

UCL Injury Risk Factors

• Fatigue leading to high pitch counts and >100 innings per year
  • Includes pitching on consecutive days or for multiple teams
• High velocity pitching
• GIRD
• Hip internal rotation deficits
• Decreased rotator cuff strength
• Core weakness

UCL Injury Management

• Risk factors are preventable
• UCLR and revisions are increasingly frequent
• UCLR = Tommy John surgery
  • Nonoperative management for most
  • Timing for athletes can dictate treatment
• Benefits from preop rehab to address shoulder and hip deficits
  • Emphasize conditioning and explain rehab process Double bundle reconstructions

UCLR Postop Rehab

• Period of immobilization
• Bracing and return of motion by 6-8 weeks
  • Monitor motion progress
  • Concomitant procedures must be considered
  • Look for Ulnar nerve involvement
• Return to throwing
  • Prefer 10-18 months to return to throwing fully
  • Depends on timing and career trajectory
  • Dependent on position, pitcher vs DH

UCL Summary

• The number of UCL injuries is rising in high school athletes
• Athletes must be willing to stop throwing
• A Non-op trial is often appropriate
• Risk factors can be addressed
• Surgery is an option if non-operative Rx fails
• Most athletes return to sport, 80%
• Return to sport is not return to prior level function
• Postop return to throwing happens in about 12-18 months

Elbow Dislocation

• Posterolateral is most common
• Named for direction of the ulna
• Simple: No fracture, immediate motion, hinged brace, with patients returning to sport in weeks
• Complex: Often unstable with associated fracture, controlled motion after ortho clears, surgical fixation allows for early motion

Terrible Triad Elbow

• Includes Elbow dislocation, Radial head fracture, & Coronoid fracture due to a FOOSH with rotation
• Usually treated operatively through:
  • ORIF
  • LCL reconstruction
  • UCL reconstruction
• Patients experience Pain, instability, and stiffness

Stiff Elbow

• Capsular pattern includes a loss of flexion > extension
• Avoidance of prolonged immobilization is key
• Elbow has a predisposition to contracture from:
  • Congruity of ulnohumeral articulation
  • Three articulations in one capsule
  • Blending of ligaments with the capsule Elbow motion for ADLs must include 100-degree arc - extension/flexion 30-130 & 50-degree rotation (50 pronation, 50 supination),

Stiff Elbow Functional Impact

• Patient dependent
• Physical Therapy management includes Motion exercises based on impairments
• Exercises including Therex integrated with functional tasks, dynamic splinting, low load long duration flexibility, weighted stretching, mobilization with movement, and contract relax techniques

Epicondylitis

• Lateral leads to pain with extension and supination
• Medial leads to pain with flexion and pronation
• Age - 4th and 5th decades
• Repetitive stress from sport, occupation, and/or recreation
• Ergonomic considerations
• Increased risk associated with tobacco use
• Inadequate physical conditioning
• Can include Impairments beyond the elbow

Lateral Epicondylitis

• Degenerative condition of the Extensor Carpi Radialis Brevis (ECRB)
• Repetitive wrist extension is a primary cause
• Rule out the cervical spine, TOS
• Special tests – Mill's, Maudsley, Cozen's
• Tenderness at the Lateral Epicondyle
• Rx – reassurance, strengthening
• Eccentric for chronic conditions
• Loading the tendon (stress) is important

Medial Epicondylitis

• Degenerative condition vs inflammatory
• Inflammatory – use anti-inflammatory methods
• Degenerative – load tendons, some discomfort
• Overuse in sports and occupational tasks
• Rule out cervical spine and TOS
• Rule out other medial elbow conditions
• Special tests include resisted pronation and resisted flexion
• Tenderness at the medial epicondyle
• Rx includes education and resistance training

Physical Therapy Management of Epicondylitis

• Education – natural history, reassurance
• Local modalities: ice and/or heat with medicated patches
• Grip Modifications: - Grip type including palms down, hammer, palm up - Grip size where larger grips are equal to less strain
• Wrist splinting and Front Sling Bow (FSB) has limited evidence
• Eccentric vs concentric training
• No role for passive interventions in isolation
• Must Objectively Measure progress

Posterior Elbow Pain

• Olecranon bursitis often is primarily inflammatory
• Septic bursitis
  • Look for Open wound
  • History of Previous aspiration
• Management
  • Compressive wrapping, elevation, NSAIDs
• Always check Tricep tendonitis
  • Relative rest, address impairments & Progressive tendon loading
• Tricep rupture findings of a pop, swelling, + weakness

Nerve Entrapments

• Ulnar nerve: Cubital tunnel syndrome and Guyon's canal.
• Median nerve: Carpal tunnel syndrome and Pronator syndrome.
• Radial nerve

Radial nerve proper injury with humeral fx PIN entrapment at radial tunnel

Cubital Tunnel Syndrome

• C8-T1, TOS, brachial plexus contribute to pain
• Associated with UCL injuries
• Pressure vs tension contribute to pain
• 2nd most common UE compression neuropathy
• Anatomy of the Roof including Flexor Carpi Ulnaris (FCU) and Osborne's ligament, Floor (capsule and UCL), Medial location (medial epicondyle) & Lateral aspects olecranon are entrapped

Cubital Tunnel Syndrome

• Involves Compression vs traction mechanisms
• Narrows during elbow flexion
  • Pain with prolonged postures and occurs in the AM
  • Potential Role for night splinting
• Traction with valgus stress
  • Strongly association with throwing and UCL injury
  • Transposition procedures for UCLR
• Risk of complications increases
  • Decompression involving Arcade of Struthers to FCU
  • Transposition alleviates tension

Cubital Tunnel Syndrome: Non-Operative Treatment

• Education about positional nature of the diagnosis is key
• Requires the patient to be an active part of the treatment plan
  • Make ergonomic changes
  • Use Compliance with night splinting
  • Activity modification where they rest their elbow
• Towel wrap is more tolerable at night
• Soft padding used to eliminate compression Patients without motor involvement can try PT
• Continued neuro monitoring for worsening

Guyon's Canal

• Consists of Hook of hamate and pisiform
• Typically see Handlebar palsy from computer use Zones of injury include:
  • Zone I & II. Motor
  • Zone III: Sensory
• Spares FCU and FDP 4&5
• Causes Hypothenar and intrinsic weakness

Ulnar Neuropathy Diagnosis

• Includes Froment sign with Loss of adductor pollicis & Compensatory FPL by the Anterior Interosseous Nerve (AIN) -Wartenberg due to Unopposed 5th digit ABD & EDM and EDC (radial nerve)
• Tinel's sign
• Pressure provocation test
• Elbow flexion test

Pronator Syndrome

• Includes the C5 – T1 root levels Two heads of pronator teres Proximal aspect of FDS
• Symptoms include Volar forearm pain & pronator tenderness Numbness of first three digits Exacerbated by repetitive physical activity
• Differentiated from carpal tunnel compression with Sparing of the palmar cutaneous branch Presence of Forearm pain

Anterior Interosseous Nerve

• Terminal motor branch of median nerve
• A typical occurrence is AIN compression that leads to transient neuritis
• Motor only palsy – deep anterior forearm
• Weakness shown in FDP to index and middle finger & Pronator quadratus and FPL
• Leads to a compromised OK sign causing inability to flex thumb IP joint

Carpal Tunnel Syndrome

• Most common compressive neuropathy that accounts for 50% of work injuries
• Compression of the median nerve
• Risk factors include Repetitive wrist motions, pregnancy, DM, and RA
• Results in Pain and tingling at night & Thenar atrophy
• Tested by Phalens, reverse Phalens, Tinel's, and compression tests
• Rule out cervical radiculopathy in each case

Carpal Tunnel Syndrome

• Symptoms worsen due to Pregnancy that increase edema and influence hormones
• Symptom presentation includes intermittent nocturnal paresthesia followed by Progression to thenar weakness and atrophy
• Tests include assessment of strength with hand dynamometry vs MMT and Pinch dynamometry
• Distinguish from cervical radiculopathy or TOS

CTS-6 Symptom Scale

• Finding include Numbness that predominantly or exclusively in median nerve distribution Nocturnal symptoms Thenar atrophy or weakness Positive Phalen test Loss of 2-point discrimination (>5 mm) Positive Tinel sign
• The CTS-6 (as reference standard clinical tool) has:

12 = 0.80 probability of carpal tunnel syndrome 5 = 0.25 probability of carpal tunnel syndrome

Carpal Tunnel Syndrome Treatment

• Activity modification and education about Avoiding repetitive stress and Ergonomic considerations
• Utilizes Splinting and night splinting for stability
• Incorporates Impairment-based rehab interventions like Therapeutic exercises & Mobilizations
• Aggressive observation and reassurance
• Surgical release can be employed

Radial Nerve

• C5-T1 nerve roots, C-spine, and TOS can contribute
• Humeral shaft fractures affect 10 – 20% of fractures & Nerve status dictates the initial course of management
• Saturday night palsy involves Compressive neuropraxia
• Also occur with improper use of crutches
• Radial tunnel syndrome leads to pain
• PIN entrapment leads to motor loss

Radial Tunnel Syndrome (RTS)

• RTS is Commonly confused with lateral epicondylitis
• Provocation tests include resisted supination, resisted wrist extension, middle finger extension, and elbow extension with pronation and wrist flexion
• Radial tunnel palpation can be checked 3 cenimeters distal to the lateral epicondyle
• Painful condition – no motor or sensory loss

PIN Syndrome

• Distinct from the Radial Tunnel Syndrome (RTS) due to significant motor loss
• Compression at the Arcade of Frohse & Supinator arch, superior portion of the supinator
• Can cause Weakness of thumb and finger EXT
• Radial deviation is checked checked during extension
• Extensor Carpi Ulnaris (ECU) is caused by PIN innervation
• Extensor Carpi Radialis Longus(ECRL) is caused by Radial nerve proper innervation
• Major Complication of distal biceps repair

Extensor Compartments

• Compartment 1: extensor pollicis brevis and abductor pollicis longus
• Compartment 2: Extensor carpi radialis brevis and Extensor carpi radialis longus
• Compartment 3: Extensor pollicis longus
• Compartment 4: Extensor indicis and Extensor digitorum
• Compartment 5: Extensor digiti minimi
• Compartment 6: Extensor carpi ulnaris
• Extensor Carpi Radialis Longus (ECRL) – Radial

Proximal / Distal Innervations

• Ulnar nerve: Proximal(FCU) and Distal(Intrinsics)
• Median nerve: includes Proximal(Pronator teres) and Distal(Lumbricals 1st and 2nd)
• Radial nerve. Proximal(Triceps) and Distal(Extensor indices)

Innervations

• Understand functional implications relating to
• Ulnar nerve, fine motor tasks
• Median nerve with pronation weakness
• Turning a key and swiping a key card requires the ulnar nerve
• Buttoning a shirt requires the AIN to function
• Writing utilizes the median nerve, CTS, and AIN
• Unscrewing top on a jar also utilizes the CTS and AIN

Hand Deformities, Claw Hand:

• Injury is to the ulnar nerve
• Loss of interossei
• Loss of lumbricals 4 and 5 causes
• The 2nd and 3rd digits remain mostly unaffected as the EDC action is unopposed
• This compromises the Hyperextension at the MCP & Hyperflexion at the IP joints

Hand Deformities, Ape Hand

• High median nerve injury
• Thumb is kept normally ventral
• Thenar muscles are paralyzed thereby paralyzing adductor pollicis
• With such paralysis, the hand lays in the same plane

Hand Deformities, Sign of Benediction

• High median nerve injury
• Results in an Active sign when asked to make a fist
• At resting position the hand assumes a ape hand
• Loss of FDS, FPL, FPB, FDP 2 and 3 with spared FDP 4 and 5
• Appears similar to claw hand but is distinguished by a
• Claw hand occurs with ulnar nerve issues and a resting position
• A benediction hand occurs from median nerve compromises when the patient tries to make a fist

Scaphoid fracture

• Most commonly injured carpal bone
• Injury occurs due to hyperextension, radial deviation, and/or pronation
• Presents with disabling pain with swelling
• Can also be chronic with remote history of injury
• Patient has reported Anatomic snuff box tenderness
  • Can occur at the EPL(ulnar border) with tenderness in the EPB (radial border) or Radial styloid with proximal tenderness
• Diagnose with axial thumb loading

Scaphoid Fractures

• Risk of AVN due to retrograde blood supply
• Proximal and displaced fractures are treated with orthopedic consultation
• Fractures aren't always present on the 1st X-ray, requiring the condition to be treated as a fracture in the interim thumb spica
• Xray again if symptomatic
• Advanced imaging is needed when there is no Xray evidence but still symptomatic

Scaphoid Study Points

• The scaphoid represents the Proximal carpal row
• Is considered the Most commonly injured carpal bone
• Test this bone with Anatomic snuffbox tenderness
• Can experience Risk of AVN due to retrograde blood supply if untreated
• Treat it like a fracture with radiographs
• Fracture is not always visible on acute plain films requiring CT or MRI if films come up as normal

Scapholunate Injuries

• Injuries occur over a Range of hyperextension
  • Can be diagnosed as Sprain with no SL widening with consideration of Unstable dissociation
• May be tested with a Clenched fist view that can demonstrate widening
• Must consider presence of a Terry Thomas sign through X-ray
• With normal films, splint the injury and treat it as a sprain
• Injuries are diagnosed with Watson Scaphoid Test
• The athlete must complete full Ortho evaluation for separation

Kienbock's Disease

• Involves Avascular necrosis of the lunate often caused from Trauma or Skeletal variations due to a ulna that is too short
• Unknown causes, rarely affects both wrists, with symptoms that include pain and overall stiffness
• Early stages have shown to benefit from splinting and activity modification
• Aim to Restore motion and limit functional loss
• Later stages require surgical options

De Quervain's Tenosynovitis

• Repetitive Stress to the thumb performing Extension and Abduction exercises the 1st Extensor (EXT) compartment EPB , AbPL
• Tested for Pain with Positive Finkelstein's Test
• Treated with a Thumb spica
• Requires Ergomonic adjustments & Anti-inflammatory treatments, coupled with an Impairments-based rehab plan following Injections and/or surgical release

Intersection Syndrome

• Repetitive use injury – 1st and 2nd compartments
• Often includes AbPL , EPB and ECRL (ECRB) as the athlete does actions that require the forearm and wrist to be fully engaged in gripping and using forearm to create motion
• 4 – 6 centimeters Proximal to Lister's tubercle
• Treated with Activity modification and reassuring statements

Ulnar Sided Wrist Injury: TFCC

• Issues with the Triangular fibrocartilage complex with
  • Soft tissue complex
  • The TFCC supports DRUJ joint with gripping and rotating the forearm
  • It provides cushion during weightbearing
• Caused by Hyperextension injuries from Repetitive stress & rotation and grabbing
• Diagnosis through Palpation as the patient describes Mechanical symptoms, the patient must complete Imaging

Management of a typical TFCC tear includes : -Period of immobilization -NSAIDs for pain & reducing inflammation -Cortisone injection that reduce inflammation -Impairment-based rehab -In cases that have become more advanced the best route of treatment would be Surgical options . -debridement - repair with sutures with arthroscopic surgery - A TFCC can be treated with correction of ulna variance if severe

Ulnar Abutment Syndrome

-With a neutral wrist the : Force going through the Ulna is 20 % The majority DRUJ The wrist if it's anatomy meets its activities or in the situation ulnar positive we have Increased ulnar Carpal Forces , increased incidence of ulnars side wrist pain and it can be related to TFCC injury Ulna management include short immobilization and for a longer solution that works

• Include the follow with Management of inflammation with activity modification

• NSAIDs and or Injection

• impaired based rehab and TFCC evaluation.

• Distal ulnar shortening osteotomy -The amount depended on level of variances and may be combined with TFCC repair/ debridement

Forearm Fractures

• Colles fracture Distal radius fracture occurs with dorsal angulation of distal segment due to a FOOSH mechanism & Classic dinner fork deformity
• Smith fracture as occurs with distal radius fracture with volar angulation of distal segment from a Fall on flexed wrist

More Forearm Fractures

Barton fracture

• Intra-articular distal radius fracture
• Comes with associated radiocarpal dislocation
• MVAs and sports in younger population
• Falls in older population with Osteoporosis
• Monteggia fracture is a Proximal 1/3 of the ulna that causes a radial head dislocation Most common between 4-10 years old, Rare in adults and caused by a pronated FOOSH

Hand and Finger Injuries: Gamekeeper's Thumb

• UCL injury of the thumb. Acute (Skier's thumb) or Chronic (Gamekeeper's thumb)
• ABD stress is applied to the 1st MCP joint

Gamekeeper's Thumb

• Stress examination must be performed on the thumb
• Treat by applying a Thumb spica
• Film can be taken to r/o bony avulsion.
• Apply an Impairment-based rehab progression
• Avoid stress on the UCL region
• Can progress to Stener lesion caused by Adductor aponeurosis between torn UCL and PP that require Surgery to fix

Hand and Finger Injuries: Central Slip Rupture

• Caused by Forced PIP flexion and/or Lateral bands migrating volarly that leads to Boutonniere deformity Common in basketball and volleyball players. In this deformity, PIP flexion with DIP hyperextension occurs during Physical

• Examination findings History of PIP injury (jamming or dislocation), Tenderness to the central slip insertion DIP stiffness with PIP in extension

Hand and Finger Injuries: Management of Central Slip Rupture

• Best managed with acute care physical therapy and Injury is recognized acutely
• Splinting occurs in the acute phase to keep the PIP in full extension while ensuring the DIP is free to move
• Chronic deformities are very difficult to manage from this injury that causes a normal film with a PIP injury that must be splinted with continuous follow up. Avoid over or under managing injury

Hand and Finger Injuries: Jersey Finger

• Forceful hyperextension injures the DIP. joint as the FDP tendon is exposed to an avulsion
• Symptoms occur as jersey tears away from a finger Early awareness and management critical and delayed management = retraction
• Often present late – just a "jammed finger" that benefits from the repair surgery that follows and delayed surgery needs a additional graft during its session.
• To diagnose it, the examiner shall hold PIP and ask for DIP flexion to test integrity & stability.

Mallet Finger

• Forceful flexion of the extended DIP joint during an injury disrupts terminal the extensor tendon and leaves a "baseball finger" deformity
• Early awareness/management is critical for better outcomes
• Presents with drooped fingertip that's stuck in flexion
• Patient can move, but can't stay stable during extension
• Dorsal has variable swelling with pain. but not to much.

Hand and Finger Injuries: Management of Mallet Finger

• Keep athlete's DIP splinted in slight hyperextension by encouraging them to to wear it at all times for up to 6 weeks and encouraging them to keep full PIP motion Plain xray to check for Avulsion injury

Hand and Finger Injuries: Swan Neck Injury

• Hyperextension injury results from a variety of mechanisms including Direct traumatic injury to volar plate Indirect Injury Mallet finger deformity FDS rupture (unopposed PIP extension) Rheumatoid arthritis (volar plate laxity)
• Physical inspection will show Volar plate tenderness on exam and allow for double ring splint

Rheumatoid Arthritis

• Systemic autoimmune disorder
• Inflammatory reaction in the synovial tissue
• Hand deformity
• MCP Ulnar deviation
• Radiocarpal.
• With proper supportive management and medical prescription.
• Good treatment of R.A
• Should bring a better patient outcomes to treat better results.

Osteoarthritis

• Can lead to formation of Heberden's nodes and Bouchard's nodes.

Dupuytren's Contracture

• Involves a genetic component that results in Palmar fascia contracture from Build-up of collagen tissue
• Patients with both Tobacco and EtOH dependencies experience higher risks
• Table-top test can provide more diagnostic insight Symptoms can be allieved with Splinting and ROM in early stages
• Surgical release and Injectable medications can provide long term relief, but Recurrence is common with 20-30% of patients

Flexor Tendon

• Include FDP, FDS, and FPL
• 5 Annular pulleys: Thicker and stiffer.Keep tendons close to the bone 3 Cruciate pulleys that are Flexible & collapsible. Allow for flexion without pulley deformation Thumb: 2 annular is required the other which is first oblique pulleys.

Pulley Locations

• A1-A5
• C1-C4

Flexor Tendon Healing

• 2 pathways for tendon healing:
  • Intrinsic - proliferation of extracellular matrix -Extrinsic - healing from surrounding synovium
• Tendons have poor intrinsic healing capability, however Extrinsic healing dominates with sheath injury
• Extrinsic healing = adhesion formation
• Rehab = delicate balance
  • Protect repair and allow time for healing
  • Maintain motion and prevent adhesion

Flexor Tendon Rehabilitation

• Some surgeries performed wide awake to Assess integrity throughout ROM, but Ensure no adhesions through pulley system
• Requires Close coordination with surgeon
• Employs Early protected motion within 3-5 days and improves healing through Reduces adhesions
• Enhances final outcomes

Flexor Tendon Rehabilitation

• A Protective dorsal splint is used for 6 weeks to Restored passive flexion before active flexion
• The treatment shall commence with motion three to five days after surgery with AROM
• When there's a robust repair the patient is allowed full active extension and night splinting that returns most patients to normal activities in 3 months

Trigger Finger

• Trigger finger is a common source of pain that occurs when the individual exhibits a Snapping or clicking sound near the flexor canal
• It occurs after an Entrapment tendinopathy happens that leads to Thickened tendon
• Symptoms are exacerbated by. Narrowed A1 pulley due to chronic inflammation
• This is best treated with long term night splinting to allow Inflammation control while avoiding an A1 pulley release

Presentation on the pathology of the elbow, wrist, and hand. It includes information about patient-reported outcome measures (PROMs) used in health systems and value-based payment models. The presentation determines the effect of completing functional tasks before completing the PROM questionnaire.