Conditions and Rehabilitation of the Elbow, FA, WAH.pdf

Conditions and Rehabilitation of the Elbow, Forearm and Wrist and Hand PRAYER Objectives List down the unique clinical features and treatment approach of each of the following soft tissue injuries of the elbow and forearm. Review the clinical presentation of soft tissue injuries, fra...

Conditions and Rehabilitation of the Elbow, Forearm and Wrist and Hand PRAYER Objectives List down the unique clinical features and treatment approach of each of the following soft tissue injuries of the elbow and forearm. Review the clinical presentation of soft tissue injuries, fractures, and dislocations of the elbow and forearm. Develop Specific guidelines in the evaluation and rehabilitation of patients with disorders of elbow and forearm. Review 1. Patient complains of right shoulder pain since falling onto the right shoulder 3 weeks ago. There was no dislocation and x-rays were negative. AROM is 35o of flexion and abduction with scapular elevation noted. Passive ROM is nearly full, with mild pain and muscle guarding at the end of range. Resisted abduction is weak with pain noted in the anterior and lateral deltoid region. There is no atrophy. Based on the above findings, the physical therapist should MOST LIKELY suspect: A. Adhesive capsulitis B. Axillary nerve palsy C. Supraspinatus tendinitis D. Rotator cuff tear PRONATOR TERES SYNDROME Sites of median nerve compression Ligament of Struthers or supracondylar spur Lacertus fibrosis Pronator teres muscle Between the 2 heads of the flexor digitorum superficialis (FDS  Dull aching pain in the proximal FEATURES forearm just distal to the elbow. Numbness in the median nerve distribution of the hand. Symptoms exacerbated by pronation.  EMG/NCS Plain films: Rule out bone spur Tx: IMAGING & Conservative Modification of activities. TREATMENT Avoid aggravating factors. Stretching and strengthening program. Surgical: release of the median nerve at the location of the compression. PAST BOARDS Patient presents to an outpatient clinic with an order to evaluate and treat the R forearm and wrist secondary to nerve compression. The patient has the ff. signs and symptoms: pain with manual muscle testing of pronation, decreased strength of the flexor pollicis longus and pronator quadratus, and pain with palpation of the pronator teres. What nerve is most likely compromised? What is most the likely area of compression? A. Ulnar nerve – Guyon’s canal B. Median nerve – carpal tunnel C. Ulnar nerve – pronator quadratus D. Median nerve – pronator teres CUBITAL TUNNEL SYNDROME CUBITAL TUNNEL SYNDROME Factors that cause Ulnar nerve Clinical Features impingement Medial forearm aching pain with Arcade of Struthers- paraesthesias radiating distally Hypermobility of the ulnar nerve to the fourth and fifth digits. Excessive valgus force at the elbow Weakness intheulnar-innervated Impingement from osteophytes or hand intrinsic musculature loose bodies weak grip strength Pathology muscle atrophy. Hyperirritability or injury of the Positive Tinel’s sign at the elbow ulnar nerve. Positive Froment’s sign CUBITAL TUNNEL SYNDROME Imaging X-ray to evaluate for Treatment osteophytes or loose bodies. Conservative. Relative rest, NSAIDs, elbow Consider MRI for soft tissue protection (splinting) and technique abnormalities if indicated. modification. EMG/NCS above and below the Surgical: ulnar nerve elbow transposition OSTEOCHONDROSIS OF THE ELBOW (PANNER’S DISEASE) OSTEOCHONDROSIS OF THE ELBOW (PANNER’S DISEASE) General Clinical Features Epiphysial aseptic necrosis of the Symptoms relieved by rest and capitellum aggravated by activity. Mechanism tenderness and swelling on the lateral aspect of the elbow. interference in bloody supply to epiphysis, leading to resorption of Usually seen in dominant elbow of the ossification center initially, young boys. followed by repair/replacement. Limited extension seen on ROM. OSTEOCHONDROSIS OF THE ELBOW (PANNER’S DISEASE) Imaging Treatment Plain films: sclerosis, patchy Conservative: areas of lucency with immobilization, then gradual fragmentation. range of motion. RADIAL HEAD FRACTURE  Mason Classification General Dislocations of the elbow are commonly associated with radial head fractures Classification Type I: nondisplaced Type II: marginal radial head fracture, minimal displacement Type III: comminuted fracture Type IV: Radial head fracture with elbow dislocation  Clinical Features Fall on an outstretched arm Treatment: Orthopedic Referral causing pain, swelling, ecchymosis Type I (nondisplaced): around the elbow. Conservative: short period of Pain and decreased range of immobilization (3–5 days) followed by early ROM. motion in elbow flexion and extension, pronation, and Type II (minimal displacement): supination. Surgical fixation for fracture greater than 2-mm displacement or 30% radial head involvement. Imaging Type III (comminuted fracture): Plain films of the elbow Surgical fixation CT: comminuted fx MRI: if with ligamentous affectation OLECRANON FRACTURE  General Direct blow to the elbow such as a fall onto the elbow with the elbow flexed. Fall on an outstretched arm in association with a dislocation. mean age is ~57 years Bimodal distribution high energy injuries in the young low energy falls in the elderly Classification ( Mayo Classiification Nondisplaced Displaced  Clinical Features Swelling and ecchymosis with an Treatment obvious deformity. Pain on gentle range of motion. Nondisplaced: conservative Numbness and paresthesias with (immobilization-- cast -. Early ROM radiation distally to the fourth and at 1 week) fifth digits with Displaced: surgical ( ORIF) ulnar nerve involvement. Imaging Plain films: A/P lateral and oblique Conditions and Rehabilitation of Wrist and Hand PAST BOARDS 1.Which of the ff. muscle tendons most commonly ruptured in patients who suffer from RA? A. Flexor digitorum profundus B. Extensor carpi ulnaris C. Extensor carpi radialis longus D. Flexor pollicis longus ARTHRITIS  Types Rheumatoid arthritis (RA) Osteoarthritis (OA) Autoimmune attack on the synovial tissue destroying the Noninflammatory disorder with articular cartilage leading to bone deterioration of the articular destruction cartilage and formation of new bone at the joint margins. Clinical Features Osteoarthritis Rheumatoid arthritis Heberden’s and Bouchard’s Swelling of the joints of the hand nodules involving the DIP and and wrist (MCP and PIP joints). – Ulnar deviation of the wrist. (ulnar PIP drift ) Tenderness along the area of Dorsal subluxation of the ulna. involvement and crepitus with Erosion of the ulnar styloid at the wrist ROM. end stage. Common in the first CMC Swan neck deformity joint of the thumb. Boutonnière Deformity Cyst formation in the joint space.  Imaging Treatment Plain films of the wrist and digits Conservative- NSAIDS Modalities Thera Ex Splinting Joint conservation techniques ADL modification DE QUERVAIN’S TENOSYNOVITIS DQT Clinical Features Pain and tenderness on the Most common tendinopathy of dorsal radial side of the wrist wrist associated with movement. ( racquet sports or fly fishing) Repetitive or direct trauma to the sheath of the extensor Edema and crepitus may also be pollicis brevis and abductor present. pollicis longus tendon Provocative Test Repetitive activities that require Finkelstein’s Test-pathognomonic forceful gripping with ulnar deviation or repetitive use of thumb  Imaging Treatment None needed Conservative- rest , modalities – in the peritendinous first dorsal compartment- reduces 62% to 100 % of cases Thumb spica splint to immobilize the thumb NSAIDs Corticosteroid injection Surgical Intersection syndrome- — It is irritation of the tendons of the second dorsal compatment. — It is associated with the frequent and repetitive use of the wrist and typically occurs in athletes. Clinical Features — Pain is located at the intersection of the first and second dorsal extensor compartments and is speculated to be related to rubbing of the EPB/APL against the radial wrist extensors. — The wrist discomfort is more proximal than that seen in de Quervain synovitis,and is exacervated by wrist motion,particularly resisted wrist extension — Palpable or audible crepitus — The diagnosis is based on the — Treatment history and clinical examination. — The initial treatment is non surgical : NSAIDS, — DIAGNOSIS: rest,activity modification — Differential local anaesthetic and forearm based wrist injections may help in splinting at about 15 degree supporting the diagnosis or in of wrist extension. differentiating between — Corticosteroid injection intersection syndrome and de — If nonsurgical management fails : quervain syndrome. surgical release of the second dorsal extensor compartment A patient complains of persistent wrist pain after painting a house 3 weeks ago. The patient demonstrates signs and symptoms consistent with de Quervain’s tenosynovitis. An appropriate special test to confirm the diagnosis is: A. Finkelstein’s test B. Phalen’s test C. Froment’s sign D. Craig’s test GANGLION CYST General Synovial fluid-filled cystic structure that arises from the synovial sheath of the joint space. Clinical Features Small smooth mass on the dorsal or volar aspect of the wrist: occurs on the dorsal aspect in 60% of cases. Pain may occur with ranging the wrist or slight pressure GANGLION CYST Imaging Plain films of the wrist if Treatment indicated. Immobilization Aspiration of the cyst (90% recurrence) Surgical removal if needed (10% recurrence) In which of the following conditions is a nerve conduction velocity test MOST appropriate? A. CVA B. CTS C. Myotonia D. DMD Nerve Entrapment Syndromes Carpal tunnel syndrome Clinical Features Median nerve, finger flexors, and § Awakening pain in middle of flexor pollicis longus night; often relieved by “shaking Due to direct trauma, repetitive out their hands” overuse, or anatomic anomalies § Pain, numbness, or tingling sensation only in fingertips on palmar aspect of thumb, index, and middle finger § + Phalen’s maneuver; + Tinel’s sign (+) Reverse Phalen’s § Weak thumb abduction  Diagnostics studies: Management: None needed but UTZ can be done Rest EMG-NCV Medications: NSAIDS, Gabapentin or Pregablin, Nerve supplements steroid injections, physical therapy OT: splinting, taping, CTS release if not responsive to therapy and if severe Ulnar nerve entrapment § Numbness in the ulnar nerve Ulnar tunnel syndrome distribution (especially little Due to repetitive finger) compressive trauma to the + Froment’s sign palmar aspect of the hand Slight weakness in grip strength S&S + Tinel’s sign  Diagnostic Studies Management: splinting, NSAIDs; UTZ activity modification EMG-NCV Surgical  A patient presents with ape hand deformity secondary to a peripheral nerve injury. Which of the following findings would MOST likely be noted on examination? A. Decreased strength with thumb opposition B. Fixed flexion of the metacarpophalangeal joints C. Fixed hyperextension of the metacarpophalangeal joints D. Wasting of the hypothenar eminence Hand-Arm Vibration Syndrome (Vibration White Finger) HAVS is a constellation of vascular and neuromuscular symptoms associated with high levels of exposure to vibration. MOI: results from both increased duration and intensity of exposure to handling vibrating tools or objects, such as jackhammers, drills, or chain saws. Onset : occur as rapidly as within 3 months of full-time, daily vibration exposure Signs and Symptoms The clinical presentation of HAVS includes vascular, sensorineural, and musculoskeletal symptoms. The vascular : Raynaud’s phenomenon and may be triggered by a cold environment. There is initial digital blanching (associated with vasoconstriction), followed by cyanotic discoloration that eventually resolves into erythema when blood vessels dilate allowing reperfusion.  Neurologically: tingling paresthesias or numbness , intermittent aching pain in their hands. Grip strength may be reduced due to weakness of the finger flexors or intrinsic hand muscles. In chronic cases, skin ulceration may develop, usually at the fingertips. Diagnosis Treatment limiting exposure to hand Physical exam : two-point vibration, using antivibration discrimination and vibration gloves and coated tool handles, perception testing, which can and ensuring proper technique uncover sensorineural dysfunction in handling equipment Duplex ultrasonography: patency Medications : calcium channel of arteries of the upper limbs. blockers, nitrates, pentoxifylline, Cold provocation testing and NSAIDs recording finger systolic blood pressures (FSBP) at baseline and again after exposure to cold  A patient demonstrates a significant loss of strength when trying to grasp a cup. However, the patient has much less difficulty when holding onto a pencil. This type of clinical scenario is consistent with pathology affecting the: A. Median nerve B. Suprascapular nerve C. Musculocutaneous nerve D. Ulnar nerve OSTEONECROSIS OF THE LUNATE  Also known as Kienböck’s Risk Factors disease. Poor vascular supply to Mechanism of Injury the area. Idiopathic loss of blood supply to Short ulnar variance the lunate, vascular impairment and/or repeated trauma (repeated stress or fracture). Bone collapse results in degenerative changes at the wrist.  KIENBOCK’S DISEASE Clinical Features Ulnar-sided pain, stiffness, and swelling over the dorsal aspect of the wrist directly over the lunate. Reduced grip strength. Imaging Plain films: may see a compression fracture, flattening, or sclerosis of the lunate Bone scan: increase, uptake MRI: decreased signal intensity on T1 imaging. Treatment Orthopedic referral SCAPHOID FRACTURE  Classification: Anatomical Location SCAPHOID FRACTURE Waist (65%) One of the most common Tubercle (2%) fractures of the wrist comprising 70% of carpal bone fractures. Distal pole (10%) Proximal pole (15%) Mechanism of Injury A fall or blow on a hyperextended (dorsiflexed) wrist. Osteonecrosis of the bone may develop secondary to its blood supply. SCAPHOID FRACTURE Complications Clinical Features Osteonecrosis, which may lead to Swelling and tenderness in the carpal bones collapse areas of the thumb and wrist (scapholunate) if not treated (anatomical snuff box). correctly.  Imaging TX: Plain films: PA and oblique view of Immobilize the wrist in a thumb the wrist in ulnar deviation spica cast for 10–14 days CT scan can be done if there is a Non displaced < 2 mm: question of fracture. Long thumb spica cast 6 weeks wrist in neutral Bone scan can be positive as early as 24 hours after injury. Change to Short thumb spica after Displaced > 2mm: Inc risk of AVN Refer to Ortho If: (+) proximal third fx (+) delayed healing more than 2-3 weeks HAMATE FRACTURES  Body fractures often from direct Clinical Features trauma. Ulnar and palmar wrist pain with Fractures of the hook of the racquet, bat, or club swing. hamate can occur at end swing Pain over the hook of the hamate. while holding a racquet, bat, or Pain over the dorsoulnar hamate. club.  Imaging Treatment X-rays with PA, lateral, carpal Nondisplaced body fractures: 4– tunnel, and 45o supinated oblique 6 weeks short arm cast views. CT may be needed for fractures at Displaced body fractures: the base of the hook. surgical referral  A 32-year-old tennis player is referred to PT/OT after being diagnosed with median nerve entrapment. The patient's chief complaints include paresthesias in the hand and progressive weakness. Which muscle would MOST likely contribute to the entrapment? A. abductor pollicis longus B. flexor digiti minimi C. flexor digitorum profundus D. pronator teres TRAPEZIUM FRACTURES General Isolated fractures are rare. Types May occur when the base of the Body thumb metacarpal is forced by axial Trapeziometacarpal load into the trapezium. Trapezial ridge can occur also as an avulsion fracture Clinical Features Body and trapeziometacarpal fractures (+) tenderness of the dorsal wrist proximal to the thumb CMC joint. Trapezial ridge fractures (+) tender point distal to the scaphoid tuberosity.  Imaging Treatment X-rays with PA, lateral, oblique, Nondisplaced body, proximal carpal tunnel, and Bett’s View trapezial ridge fractures, and trapeziometacarpal fractures Trapeziometacarpal require a short arm thumb spica cast for 4 weeks Displaced body and distal trapezial ridge fractures require surgical referral. A 66 year old had a history of a fall outstretched arm and sustained fracture of the distal radius with dorsal angulation. This is called: A. Colles’ fracture B. Monteggia fracture C. Smith fracture D. Greenstick fracture FRACTURE OF THE DISTAL RADIUS FRACTURE OF THE DISTAL RADIUS Colles’ fracture Smith’s fracture Most common type of fracture Fracture of the distal radius with Fracture of the distal radius with volar displacement and angulation dorsal displacement and Reverse of Colles’ fracture. angulation Garden spade deformity Dinner Fork Deformity MOI: fall into a flexed wrist Associated with TFCC tears and scapholunate dissociation MOI: FOOSH  Clinical Features Imaging Acute pain, swelling at the wrist AP and lateral plain films of the usually after a fall on an wrist and hand outstretched arm. Treatment Orthopedic referral for closed reduction depending on the location, degree of displacement, and reproducibility The 14 year old male patient came in to the clinic with a referral from the Orthopedic service. His diagnosis is a Monteggia fracture. What does this comprise? A. Fracture of the ulna with ulnar subluxation B. Fracture of the ulna with radial head subluxation C. Fracture of the radius with radial head subluxation D. Fracture of the radius with subluxation of the ulna Monteggia Vs. Galleazi Monteggia Galleazi Fracture of proximal 1/3 Ulna Fracture of the radial shaft with with dislocation of the proximal dislocation of the distal radioulnarjoint ( (PRUJ) radioulnar joint ( DRUJ) DUPUYTREN’S CONTRACTURE General Thickening and contraction of the Clinical Features palmar fascia due to fibrous Painless nodules in the distal palmar proliferation. crease. initially nontendernodules and may become tender as the disease Etiology progresses. Unknown. The involved finger is drawn into Has dominant genetic component flexion as the nodules thicken and (Northern European descent). contract. Has also been called the Viking Flexion is commonly seen at the MCP disease. joint involving the ring finger. Commonly associated with: DM, ETOH, epileptics, pulmonary TB. Typically seen in men > 40 years old.  Imaging Treatment None needed Conservative: corticosteroid injection, ultra- sound, splinting, massage Surgical release if severe and affects function. STENOSING TENOSYNOVITIS (TRIGGER FINGER) General Repetitive trauma that causes an inflammatory process to the flexor tendon sheath of the digits. This process forms a nodule in the tendon resulting in abnormal gliding through the pulley system. As the digit flexes, the nodule passes under the pulley system and gets caught on the narrow annular sheath resulting in the finger locked in a flexed position.  Imaging Clinical Features None needed A painful catching or locking with Treatment finger flexion and/or extension. Conservative: corticosteroid Palpable nodule may be tender injection, immobilization by on exam. splinting, NSAIDs. Surgical release: After failure of conservative treatment. LIGAMENTOUS INJURIES General Mechanism of Injury Involve the ligaments of the MCP and PIP ligamentous digits (PIP and MCP) and/or the injury to the digits and/or thumb (MCP). thumb (MCP) Ligaments: collaterals and volar Collateral ligament: valgus or plate varus stress with the finger in Injury may result in a partial tear an extended position (sprain) or complete dislocation. Volar plate: hyperextension with dorsal dislocation, which is usually reducible LIGAMENTOUS INJURIES Skier’s Lesion Stener’s Lesion Also known as gamekeeper’s interposition of the adductor thumb or skier’s thumb pollicis aponeurosis between Test by placing valgus stress at the the base of the proximal MCP joint of the thumb phalanx and ruptured end of the UCL Grade 3 UCL sprain Clinical Features History of trauma to the finger with IMAGING: an immediate obvious deformity. AP and lateral and oblique views to rule out fracture or subluxation (+) popping and feeling of MRI instability in the joint Local tenderness over the UCL If with stener lesion- (+) palpable mass on the ulnar side of the first MCP joint Palpate both sides and assess the stability of the joint by applying a stress to the medial and lateral aspect ( UCL STRESS EXAM) LIGAMENTOUS INJURIES Treatment Simple Dislocations Conservative: Joint reduction by stabilization of Patial tears: modalities, Analgesics proximal end and applying a distal thumb spica for 10-14 days traction. wrist hand thumb spica for two Buddy splinting of the finger - weeks approximately 2 weeks. Thumb spica 3 to 6 weeks for MCP hand based spica orthosis for 2 to 4 injuries more weeks Surgical: complex lesions or Taping complete ruptures particularly with ROM twice daily sterner lesion Scapholunate Instability General most common type of wrist ligament injury MOI: falls on a pronated outstretched hand with the wrist in extension and ulnar deviation DISI or dorsal intercalated segmental instability is a pattern of injury after scapholunate ligament disruption, the scaphoid moves into a flexed position whereas the lunate and triquetrum become extended  Clinical Features: (+) wirst edema Imaging: ecchymosis Xray AP with clenched fist , Lateral ( can reveal presence of DISI )and LOM oblique (+) tenderness on the scapholunate MRI or arthrography joint ( dorsum of the wrist) Wrist arthroscopy: Gold standard for diagnosis: (+) Watson test Treatment: Acute injury and chronic injuries: require surgical intervention ( partial wrist arthrodesis and proximal row carpectomy) PAST BOARDS 1.Which of the ff. is not a part of the triangular fibrocartilage complex of the wrist? A. Dorsal radioulnar ligament B. Ulnar collateral ligament C. Radial collateral ligament D. Ulnar articular cartilage TRIANGULAR FIBROCARTILAGE COMPLEX INJURIES TFCC The triangular fibrocartilage complex (TFCC) (+) avascular central articular disc and vascular dorsal and palmar radioulnar ligaments. primary stabilizer of the distal radioulnar joint MOI: falling on an outstretched hand ( axial loading on the wrist with rotational stress) or through repetitive microtrauma such that can occur in gymnastics TFCC Risk factor: positive ulnar Feature: variance ( longer ulna than radius insidious onset or single at the level of the wrist can result traumatic event in the load bearing function of More on young athletes ( traumatic the TFCC tears) older adults more of degenerative (+) wrist catching and locking (+) tenderness in the hollow between FCU tendon and ECU tendon distal to the ulnar styloid process TFCC Imaging: MX: Xray- ulnar variance on AP view when the central articular disc of Tricompartment wrist the TFCC has been acutely Arthrography injured- surgical debridement is MRI or MR arthrography the TOC Peripheral tear also surgical but with slower recovery process FLEXOR DIGITORUM INJURY: JERSEY FINGER General Complete or incomplete injury to the flexor tendon (superficialis and/or profundus). More commonly due to trauma as seen in athletes (football, wrestling). May also be spontaneous (as in the case of RA). MOI: in athletes : when a player’s finger gets caught in the jersey of another in attempting to grab him.  Clinical Features Imaging The patient is unable to actively Plain films may show an avulsed flex the DIP joint fragment near tendinous insertion. Test FDP and FDS Treatment Conservative: little regained by conservative care Orthopedic referral: early surgical repair MALLET FINGER General Also known as baseball finger. Clinical Features Sudden passive flexion of the A flexed DIP joint that cannot be DIP joint when the finger is actively extended. extended, causing a rupture of DIP joint tenderness and edema at the distal dorsal area. the terminal extensor tendon communis. (+) avulsed fragment of the distal phalanx  Imaging Treatment X-Ray : An avulsed fragment of the Conservative: splinting of the distal phalanx may be seen. DIP in extension for 6–8 weeks Mallet finger. Top: Rupture of the with a stack splint or custom extensor tendon at its insertion. made splint. UTZ At the end of the 6-week course, gentle active flexion with night splinting should be done for 2–4 weeks. Surgical repair Reserved for poor healing or if an avulsed fragment involves > 1/3 of the joint. 1.Which of these findings is characteristic of a boutonniere deformity of the finger? A. Flexion of the distal interphalangeal joint B.Contracture of the extensor digitorum communis tendon C.Rupture of central slip with volar slippage of the lateral bands D.Hyperextension of the proximal interphalangeal joint FRACTURE OF THE BASE OF THE FIRST METACARPAL BENNET’S OR ROLANDO’S FRACTURE General Bennet’s fracture: oblique fracture-subluxation at the base of the thumb metacarpal. Rolando’s fracture: fracture at the base of the thumb metacarpal that may be classified as a T, Y, or comminuted configuration.  Complications Imaging An avulsed metacarpal fragment Plain films: AP lateral and oblique in a Bennet’s fracture may subluxate secondary to the proximal pull of the abductor Treatment pollicis longus muscle. Conservative- Non displaced ( immobilization Clinical Features Orthopedic referral- Displaced Tenderness and swelling at the ORIF and Closed reduction base of the digit (thumb or fifth digit) following a direct blow to a flexed thumb or digit. METACARPAL NECK OR SHAFT FRACTURE General Also known as boxer’s fracture. Imaging Fracture of the metacarpal neck/shaft usually seen after a person Plain films strikes a wall or another person with poor technique. May occur at any digit but commonly Treatment seen in the fifth digit. Orthopedic referral. Clinical Features Tenderness and swelling in the area of the hand seen after traumatic event. review A patient is referred to physical therapy after an anteroinferior dislocation of the right shoulder. What positive examination finding is expected as a result of this diagnosis? A. Weak rhomboids B. Positive drop arm test C. Positive Neer’s test D. Weak deltoids References: Braddom Delisa Orthobullets