Elbow, Wrist, and Hand Pathology Lecture Slides - ECU

Elbow, Wrist, Hand Pathology Michael Garrison, PT, DSc, OCS, SCS Clinical Associate Professor  Altering Outcome Measures Tasks 1-6 replicated in the clinic MCID achieved after performing tasks Effect size of 0.6 achieved – Carpal tunnel release effect size = 0.7 – ASAD...

Elbow, Wrist, Hand Pathology Michael Garrison, PT, DSc, OCS, SCS Clinical Associate Professor  Altering Outcome Measures Tasks 1-6 replicated in the clinic MCID achieved after performing tasks Effect size of 0.6 achieved – Carpal tunnel release effect size = 0.7 – ASAD effect size = 0.9 PROMs used in reimbursement models PROMs often used to assess quality of care PT research on interventions linked to PROM PROM 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 Xray Series AP View Right Elbow Lateral View Right Elbow  Biceps Role of LH biceps in the shoulder – Common source of anterior shoulder pain – May contribute to anterior stability Differentiated with tendon sheath injection Treated surgically with tenodesis vs tenotomy Proximal vs distal rupture – Proximal may be therapeutic – Distal is an orthopedic urgency Complicates symptoms with SLAP lesions  SLAP Lesion Superior labral anterior posterior lesions Snyder Classification Normal vs symptomatic anatomy – Difficult to distinguish on advanced imaging – Tears noted in 72% asymptomatic subjects over 40 Treatment trends – Debride or repair – dependent on tear type – Release the LH biceps – tenodesis vs tenotomy Rehab implications – BT vs labral repair  SLAP Lesion Examination – Age and onset – Location of pain – anterior shoulder – Chief complaint – pain vs instability – Physical demands – Special tests – active compression, Speeds Management – Pain – debridement and biceps tenodesis – Trend towards biceps procedure for all – Often seen with other shoulder issues  Evolving Treatment Highly variable results with SLAP repair – Over 35 – less than 50% successful – Often result in need for 2nd procedure Younger and higher demand patients – Previous thought repair is beneficial – Throwers and overhead occupations Recent evidence suggest tenodesis helpful – Military members under the age of 35 – No benefit to repair vs biceps tenodesis  SLAP Current Trends Trial of nonoperative care – Impairments – GIRD, post cuff, scapula – 8 weeks is adequate Identify source of symptoms – Trial of injection can be helpful – Pain – SAPs, LHB tendonitis, ACJ – Instability – larger labral tear Diagnosis is difficult – Often requires MRA or 3T MRI – Variable anatomy  SLAP Lesion Postoperative Management Repair vs debridement Associated procedures – RCR – size, shape, quality, patient demands – Instability procedure – SAD, DCE and biceps tenodesis Period of immobilization Maintain motion – prevent stiff shoulder Progress based on impairments and healing Patient centered functional goals  Postoperative Management SLAP repair vs biceps tenodesis – Sling – 2 – 4 weeks – Biceps tenodesis – immediate passive motion – SLAP repair – motion restriction 4 – 6 weeks Repair – younger and less likely to tighten Repair – higher demand, allow healing Full motion by 6 – 8 weeks Strength progressions by 6 – 8 weeks RTS – biceps – 3 months, SLAP repair – 6 months  Distal biceps Hook test Visible deformity Ecchymosis Palpable gap Tobacco use is risk factor Mechanism of injury Supination weakness TTP radial tuberosity  Distal Bicep Rupture Early surgical repair is advocated Inferior outcomes if delayed by > 4 weeks – Tendon retraction – Need for graft SH attaches distally and more of elbow flexor LH is a strong supinator 40-60% loss of supination strength 30% loss of elbow flexion Non-op – older patient with co-morbidities  Distal Bicep Postop Complications – rupture, infection, fracture – Tendon integrity is crucial for strength return – PIN check during postop visit Period of immobilization – avoid end EXT Several weeks of controlled motion – brace Full motion by 6-8 weeks Return to work or sport – Dependent on job – Most return fully within 2-4 months  Ulnar Collateral Ligament Bony constraint – 50% valgus stability Soft tissue – 50% valgus stability – Flexor pronator mass, FCU, joint capsule – UCL – anterior and posterior bands Reciprocal function AB – tight in extension, laxer in flexion PB – tight in flexion, laxer in extension Anterior bundle – most valgus resistance  UCL Injury Common in overhead throwers and athletes – Baseball, football, javelin – Gymnastics, wrestling Attenuation injury – 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 – High pitch counts, >100 innings per year – Pitching on consecutive days, 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 increasing in frequency UCLR – Tommy John surgery – Nonoperative management attempted for most – Timing for athletes can dictate treatment Double bundle reconstructions Can benefit from some preop rehab – Address any shoulder or hip deficits – Emphasize conditioning and explain rehab process  UCLR Postop Rehab Period of immobilization Bracing and return of motion by 6-8 weeks – Monitor motion progress – Can depend on concomitant procedures – Ulnar nerve involvement – Hamstring autograft – rehab graft site Return to throwing – Prefer 10-18 months return to full throwing – Can depend on timing and career trajectory – Dependent on position – pitcher vs DH  UCL Summary Rise in high school athletes Must be willing to stop throwing Non-op trial appropriate for most Risk factors can be addressed Surgery an option if non-op Rx fails Most athletes return to sport – 80% Return to sport is not return to PLOF Postop return to throwing – 12 – 18 months Elbow Dislocation  Elbow Dislocation Posterolateral is most common Named for direction of the ulna Simple – No fracture, immediate motion, hinged brace – Can return to sport in weeks Complex – often unstable – Associated with fracture – Controlled motion when cleared by ortho – Surgical fixation allows for early motion  Terrible Triad Elbow Elbow dislocation Radial head fracture Coronoid fracture FOOSH with rotation Majority treated operatively – ORIF – LCL reconstruction – UCL reconstruction Pain, instability, stiffness  Stiff Elbow Capsular pattern – loss of flexion > extension Avoidance of prolonged immobilization Elbow predisposition to contracture – Congruity of ulnohumeral articulation – Three articulations in one capsule – Blending of ligaments with the capsule Elbow motion for ADLs – 100-degree arc – extension/flexion 30 – 130 – 50-degree rotation – 50 pronation, 50 supination Functional impact – patient dependent  Stiff Elbow Physical Therapy management – Motion exercises based on impairments – Therex integrated with functional tasks – Dynamic splinting – Low load long duration flexibility – Weighted stretching – Mobilization with movement – Contract relax techniques Break  Epicondylitis Lateral epicondylitis – pain with ext, supination Medial epicondylitis – pain with flex, pronation Age – 4th and 5th decades Repetitive stress – sport, occupation, recreation Ergonomic considerations Increased risk associated with tob use Inadequate physical conditioning Impairments beyond the elbow  Lateral Epicondylitis Degenerative condition of the ECRB Repetitive wrist extension 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 is important  Lateral Epicondylitis Cozen’s Test Mill’s Test Maudsley Test  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 – resisted pronation and flexion Tenderness at the medial epicondyle Rx – education and resistance training  Physical Therapy Management Education – natural history, reassurance Local Rx – ice, heat, medicated patches Grip modifications – Type of grip – palms down, hammer, palm up – Size of grip – larger grip = less strain Wrist splinting / FSB – limited evidence Eccentric vs concentric training No role for passive interventions in isolation Objectively measure progress  Posterior Elbow Pain Olecranon bursitis Primarily inflammatory Septic bursitis – Open wound – Previous aspiration Compressive wrapping, elevation, NSAIDs Tricep tendonitis – Relative rest, address impairments – Progressive tendon loading Tricep rupture – pop, swelling, weakness  Nerve Entrapments Ulnar nerve – Cubital tunnel syndrome – Guyon’s canal Median nerve – Carpal tunnel syndrome – Pronator syndrome Radial nerve – Radial nerve proper injury with humeral fx – PIN entrapment at radial tunnel  Cubital Tunnel Syndrome Cervical spine (C8-T1), TOS, brachial plexus Associated with UCL injuries Pressure vs tension 2nd most common UE compression neuropathy Anatomy – Roof – FCU and Osborne’s ligament – Floor – Capsule and UCL – Medial – Medial epicondyle – Lateral – Olecranon  Cubital Tunnel Syndrome Compression vs traction mechanisms Narrows during elbow flexion – Pain with prolonged postures, AM pain – Role for night splinting Traction with valgus stress – Highly associated with throwing and UCL injury – Transposition procedures with UCLR Risk of complications increases – Decompression – Arcade of Struthers to FCU – Transposition – alleviate tension  Cubital Tunnel Syndrome Non-Operative Treatment Education – positional nature of the diagnosis Patient must be active part of treatment plan – Ergonomic changes – Compliance with night splinting – Activity modification – resting elbow Towel wrap more tolerable at night Soft padding to eliminate compression Patients without motor involvement – try PT Continued neuro monitoring for worsening  Guyon's Canal Hook of hamate and pisiform Handlebar palsy, computer use Distinguish from other sites Zones of injury – I – motor and sensory – II – motor only – III – sensory only Sparing of FCU and FDP 4&5 Hypothenar and intrinsic weakness  Ulnar Neuropathy Diagnosis Froment sign – Loss of adductor pollicis – Compensatory FPL (AIN) Wartenberg – Unapposed 5th digit ABD – EDM and EDC – radial nerve Tinel’s sign Pressure provocation test Elbow flexion test  Pronator Syndrome Median nerve – C5 – T1 root levels – Two heads of pronator teres – Proximal aspect of FDS Volar forearm pain, pronator tenderness Numbness of first three digits Exacerbated by repetitive physical activity Differentiate from carpal tunnel compression – Sparing of the palmar cutaneous branch – Forearm pain  Anterior Interosseous Nerve Terminal motor branch of median nerve AIN compression usually transient neuritis Motor only palsy – deep anterior forearm FDP to index and middle finger Pronator quadratus and FPL weakness OK sign – inability to flex thumb IP joint  Carpal Tunnel Syndrome Most common compressive neuropathy Accounts for nearly 50% of work injuries Compression of the median nerve Repetitive wrist motions, pregnancy, DM, RA Pain and tingling at night Thenar atrophy Phalen’s, reverse Phalen’s, Tinel’s, compression Rule out cervical radiculopathy  Carpal Tunnel Syndrome Pregnancy risk related to edema and hormones Symptom presentation – Intermittent nocturnal paresthesia – Progression to thenar weakness and atrophy Physical examination – Phalen’s and Tinel’s – AbPB strength – hand dynamometry vs MMT – Pinch dynamometry Distinguish from cervical radiculopathy, TOS CTS-6 Symptom Scale  Carpal Tunnel Syndrome Treatment Activity modification and education – Avoidance of repetitive stress – Ergonomic considerations Splinting and night splinting Impairment based rehab interventions – Therapeutic exercise – Mobilizations Aggressive observation, reassurance Surgical release  Radial Nerve C5-T1 nerve roots, C-spine, TOS Humeral shaft fractures – 10 – 20% of fractures – Nerve status dictates initial management Saturday night palsy – Compressive neuropraxia – Also seen with improper crutch use Radial tunnel syndrome – pain only PIN entrapment – motor loss only  Radial Tunnel Syndrome Commonly confused with lateral epicondylitis Provocation tests – Resisted supination – Resisted wrist extension – Middle finger extension – Elbow extension, pronation, wrist flexion Radial tunnel palpation – 3 cm distal to LE Painful condition – no motor or sensory loss  PIN Syndrome Distinct from RTS – significant motor loss Arcade of Frohse – Common site of compression – Supinator arch, superior portion of the supinator Weakness of thumb and finger EXT Radial deviation during extension – ECU – PIN innervation – ECRL – Radial nerve proper innervation Complication after distal biceps repair  Extensor Compartments ECRL – Radial 221211  Proximal / Distal Innervations Ulnar nerve – Proximal – FCU – Distal – Intrinsics Median nerve – Proximal – Pronator teres – Distal – Lumbricals 1st and 2nd Radial nerve – Proximal – Triceps – Distal – Extensor indices  Innervations Understand functional implications – Ulnar nerve – fine motor tasks – Median nerve – pronation weakness Turning a key – ulnar nerve Buttoning a shirt – AIN Writing – median nerve (CTS), AIN Unscrewing top on a jar – CTS, AIN Swiping a key card – ulnar nerve  Hand Deformities Claw Hand – Injury to ulnar nerve – Loss of interossei – Loss of lumbricals 4 and 5 – 2 and 3 mostly unaffected – EDC action unopposed – Hyperextension at the MCP – Hyperflexion at the IP joints  Hand Deformities Ape Hand – High median nerve injury – Thumb normally ventral – Thenar muscles paralyzed – Unopposed adductor pollicis – Hand position in the same plane  Hand Deformities Sign of Benediction – High median nerve injury – Active sign when making fist – Resting position is ape hand – Loss of FDS, FPL, FPB, FDP 2 and 3 – FDP 4 and 5 remain innervated – Similar appearance to claw hand Claw hand – ulnar nerve, resting position Benediction – median nerve, making fist Break  Wrist and Hand Imaging AP View Wrist and Hand Lateral View Wrist and Hand  Scaphoid fracture Most commonly injured carpal bone Hyperextension, radial deviation, pronation Can be disabling pain with swelling Can also be chronic with remote Hx of injury Anatomic snuff box tenderness – EPL (ulnar border), EPB (radial border) – Radial styloid – proximal border Testing with axial thumb loading  Scaphoid fracture Risk of AVN due to retrograde blood supply Proximal and displaced fractures – ortho Fractures not always present on 1st Xray Treat like fracture – thumb spica Xray again if symptomatic Advanced imaging – No Xray evidence – Still symptomatic  Scaphoid fracture Proximal pole fracture ORIF waist fracture  Scaphoid Study Points Proximal carpal row Most commonly injured carpal bone Anatomic snuffbox tenderness Risk of AVN due to retrograde blood supply Treat like a fracture – Fracture not always visible on acute plain films – CT or MRI may be needed if films normal  Scapholunate Injuries Range of hyperextension injuries – Sprain with no SL widening – Unstable dissociation Clenched fist view to demonstrate widening Terry Thomas sign Normal films – treat as a sprain Ortho for separation Watson Scaphoid Test  Kienbock’s Disease Avascular necrosis of the lunate Trauma Skeletal variations – ulna bone too short Unknown causes, rarely affects both wrists Pain, swelling, stiffness Early stages – splinting, activity modification Restore motion and limit functional loss Later stages – surgical options  DeQuervain’s Tenosynovitis Repetitive stress injury, thumb EXT and ABD 1st EXT compartment – EPB, AbPL Positive Finkelstein’s Thumb spica Ergonomic adjustments Anti-inflammatory treatments Impairments based rehab plan Injections, surgical release  Intersection Syndrome Repetitive use injury – 1st and 2nd compartments AbPL, EPB and ECRL, ECRB Common in rowers, clenched fist, thumb Abd 4 – 6 cm proximal to Lister’s tubercle Activity modification, reassurance, CSI  Ulnar Sided Wrist Injury TFCC Triangular fibrocartilage complex – Soft tissue complex – Supports DRU joint with gripping and rotating – Provides cushion during weightbearing Hyperextension injuries Repetitive stress – rotation and grabbing Diagnosis – Palpation – Mechanical symptoms – Imaging  TFCC Management Period of immobilization NSAIDs Cortisone injection Impairment based rehab Surgical options – Debridement – Repair with sutures (open or arthroscopic) – Correction of ulnar variance  Ulnar Abutment Syndrome Ulnar neutral wrist – 20% of force goes through the ulna – Majority of force through the DRUJ Ulnar positive wrist – anatomy meets activity – Increased ulnocarpal forces – Increased incidence of ulnar sided wrist pain – Can be related to TFCC injury  Ulnar Abutment Syndrome Short period of immobilization Management of inflammation – Activity modification – NSAIDs and/or injection Impairment based rehab TFCC evaluation Distal ulnar shortening osteotomy – Amount dependent on level of variance – May be combined with TFCC repair/debridement Ulnar Abutment Syndrome  Forearm Fractures Colles fracture – Distal radius fracture – Dorsal angulation of distal segment – FOOSH mechanism – Classic dinner fork deformity Smith fracture – Distal radius fracture – Volar angulation of distal segment – Fall on flexed wrist  Forearm Fracture Barton fracture – Intra-articular distal radius fracture – Associated radiocarpal dislocation – MVAs and sports in younger population – Osteoporosis and falls in older population Monteggia fracture – Proximal 1/3 of the ulna, radial head dislocation – Most common between 4-10 years old – Rare in adults – FOOSH with pronation  Hand and Finger Injuries Gamekeeper’s Thumb UCL injury of the thumb Acute injury – Skier’s thumb Chronic insufficiency – Gamekeeper’s thumb ABD stress of the 1st MCP joint  Hand and Finger Injuries Gamekeeper’s Thumb Stress examination of the thumb Thumb spica Plain films to r/o bony avulsion Impairment based rehab progression Avoid stress on UCL region Stener lesion – Adductor aponeurosis between torn UCL and PP – Surgery necessary for healing  Hand and Finger Injuries Central Slip Rupture Forced PIP flexion Lateral bands migrate volarly Boutonniere deformity – Common in basketball and volleyball – PIP flexion with DIP hyperextension Physical examination – History of PIP injury – jamming or dislocation – Tenderness to the central slip insertion – DIP stiffness with PIP in extension Hand and Finger Injuries Central Slip Rupture  Hand and Finger Injuries Central Slip Rupture Physical Therapy management Recognize injury acutely Role for splinting in the acute phase – PIP in full extension – DIP free to move Chronic deformity difficult to manage PIP injury – normal films – Splint and follow up regularly – Avoid over or under managing  Hand and Finger Injuries Jersey Finger Forceful hyperextension of the DIP joint Avulsion of the FDP Jersey tearing away from a finger Early awareness and management critical Delayed management = retraction – Often present late – just a “jammed finger” – Early surgery – repair is advised – Delayed surgery – need for graft or fusion Eval – hold PIP and ask for DIP flexion  Hand and Finger Injuries Mallet Finger Forceful flexion of the extended DIP joint Disruption of terminal extensor tendon Sometimes called baseball finger Early awareness and management critical Fingertip drooped in flexion Unable to extend DIP or hold DIP extension Dorsal swelling and variable pain  Hand and Finger Injuries Mallet Finger DIP splinted in slight hyperextension – Encouraged to wear 24/7 for up to 6 weeks – PIP joint free to move Plain films for avulsion injury  Hand and Finger Injuries Swan Neck Deformity Hyperextension injury of the PIP Direct traumatic injury to volar plate Indirect injury – Mallet finger deformity – FDS rupture = unopposed PIP extension – Rheumatoid arthritis – can lead to volar plate laxity Volar plate tenderness on exam Double ring splint  Rheumatoid Arthritis Systemic autoimmune disorder Inflammatory reaction in synovial tissue Hand deformity common MCP ulnar deviation Radiocarpal radial deviation Supportive Rx Medical Rx of RA Osteoarthritis  Dupuytren’s Contracture Genetic component Palmar fascia contracture Build-up of collagen tissue Tob, ETOH increase risk Nodule Table-top test Splinting, ROM in early stages Surgical release Injectable medications Recurrence is common (20-30%) Contracture Flexor Tendon  Flexor Tendon FDP, FDS, FPL 5 annular pulleys – Thicker and stiffer – Keep tendons close to the bone 3 cruciate pulleys – Flexible and collapsible – Allows for flexion without pulley deformation Thumb – 2 annular and 1 oblique pulley Pulley Locations  Flexor Tendon Healing 2 pathways for tendon healing – Intrinsic – proliferation of extracellular matrix – Extrinsic – healing from surrounding synovium Tendons have poor intrinsic healing capability Extrinsic healing dominates with sheath injury Extrinsic healing = adhesion formation Rehab is a delicate balance – Protect repair and allow time for healing – Maintain motion and prevent adhesions  Flexor Tendon Rehabilitation Some surgeries performed wide awake – Assess integrity throughout ROM – Ensure no adhesions through pulley system Close coordination with surgeon * Early protected motion – within 3-5 days * – Improves healing – Reduces adhesions – Enhances final outcomes  Flexor Tendon Rehabilitation Protective dorsal splint for 6 weeks Restore passive flexion before active flexion Commence motion 3-5 days after surgery Early AROM with robust repair Active extension is allowed Protective night splinting in some cases Most return to normal activities at 3 months Flexor Tendon Rehabilitation  Trigger Finger Common cause of pain and disability Snapping or clicking sound is common Entrapment tendinopathy Thickened tendon Narrowed A1 pulley Night splinting Inflammation control A1 pulley release Questions