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Elbow, Wrist, Hand Abnormality Presentation Elbow arthritis Anterior elbow pain Distal Biceps Tendon Rupture Anterior elbow pain Explanation of abnormality Physical Exam findings/Dx Treatment Tenderness and defect (if complete rupture) in antecubital fossa; ecchymosis early on; muscle bulge w/ resis...

Elbow, Wrist, Hand Abnormality Presentation Elbow arthritis Anterior elbow pain Distal Biceps Tendon Rupture Anterior elbow pain Explanation of abnormality Physical Exam findings/Dx Treatment Tenderness and defect (if complete rupture) in antecubital fossa; ecchymosis early on; muscle bulge w/ resisted elbow flexion/supination Complete rupture- most do best w/ surgical repair -RA -OA/post-traumatic OA -non-rheum inflammatory arthritis (gout/PG) -septic arthritis Sudden, sharp pain in anterior elbow following an excessive force on the flexed elbow 40 y/o Dx: +/- MRI to determine avulsion of tendon from radial tuberosity vs. rupture at muscle-tendon junction Cubital Tunnel Syndrome Posterior elbow pain Olecranon Bursitis Posterior elbow pain Pain at medial elbow and numbness and tingling of the ring and small finger Compression of the ulna nerve at the elbow Traumatic or anatomical + Tinel’s at elbow, EMG/NCS Should be referred to ortho w/i 1-2 weeks of injury max Decompression and transposition of the nerve Impingement may also occur at Guyon’s May be traumatic or insidious DDx: infection, gout, triceps rupture PE: +/- red, swollen bursa, +/- pain Aspiration: sterile prep, spray, 18g needle, 30mL syringe -if cloudy, suspect infection (send for crystal, sx, gm stain) Olecranon Fracture Posterior elbow pain Incomplete ruptureactivity modification and intermittent splinting MOI: FOOSH/direct fall onto elbow Check N/V function; ulna nerve +/- Injection: 1mL marcaine/40mg Kenalog Other care: -compressive sleeve -anterior splint if recurrent -bursectomy if chronic -caution: asp/inj can cause infection! Non-displaced: -posterior splint at 45 deg -re-image 1 week; ROM at 2 weeks Displaced= ORIF Olecranon dislocation Posterior elbow pain MOI: FOOSH 90% are posterior May have radial head or distal humerus fracture Check N/V status- ulnar nerve Reduction/fracture care MC in overhand throwing athletes (repetition) Valgus stress test MRI to confirm Non-surgical: rest, NSAID, PT s/s, activity modification Surgical: reconstruction (tommy john surgery) Return to play possible in 1 year Medial epicondylitisGolfer’s elbow Medial elbow pain Much less common! Mechanism: repeated flexion Resisted wrist flexion/pronation NSAIDs, forearm compression brace, stretches, PT/OT, corticosteroid -caution ulnar nerve! Supracondylar (distal humerus) fracture Lateral elbow pain MC elbow fracture in children R/o N/V injury Casting vs ORIF vs CRPP Radial head fracture Lateral elbow pain FOOSH, valgus force Ulnar Collateral Ligament Tear Medial elbow pain Sx: pop, followed by pain -distal fragment posterior Look for posterior fat pad on lateral XR Swelling lateral elbow Pain over radial head laterally Limited ROM XR: AP, lat, obliq. Type 1 (non-displaced): -sling for 3-5 days, early ROM exercises Type 2 (displaced): -treat as in Type 1 if 1mm displaced, surgical fixation 3rd degree, complete tear -significant laxity, surgical fixation needed Boutonniere deformity Loss of central slip insertion on proximal middle phalanx; seen in RA Flexion of PIP and hyperextension of DIP Surgical correction Swan neck deformity Joint synovitis secondary to RA Flexion of DIP and hyperextension of PIP Surgical correction Dupuytren’s contracture Thickened palmar fascia forms nodules over the flexor tendons causing a flexion contracture -MC in men over 40 y/o -+ fam hx Ring/small finger MC Needling- in office Enzyme-collagnease clostridium histolyticm (Xiaflex) Surgery indicated for fixed contracture of more than 30 deg -more common in RA, OA, DM -congenital (children) Painful thickened flexor tendon or nodule at the A1 pulley Injection: At site of tenderness or nodule into sheath, not tendon Trigger Finger (stenosing tenosynovitis) Finger will lock, hurt, or be stiff W/ recurrence after 2 injections surgical release is indicated Prone to triggers in other fingers Septic tenosynovitis Fusiform swelling of the finger Significant tenderness along the course of the tendon Marked pain on passive extension Flexed finger at rest Paronychia Felon Localized erythema, swelling, throbbing pain Bacterial infection of a tendon and tendon sheath Hx of puncture, bite, or tooth wound (fight bite) Progressive swelling and pain over 24-48 hours Consider tetanus and rabies prophylaxis Most need I&D, IV abx Etiology: Staph, Strep, MRSA MC digital infection Localized staph. Cellulitis in the gutter along the fingernail Soaks, PO abx Abscess of pulp space (finger pad) of distal phalanx Requires I&D, PO, IV abx Digital block and I&D when abscess is organized Subungual hematoma Crush injury mechanism XR Evacuate hematoma -trephination to relieve pressure If >50% of nail is affected, nail is removed and laceration sutured Bennet’s fx Abductor Pollicis longus inserts onto base of thumb MC causing displacement of fragment Fx of the thumb metacarpal base into CMC joint -axial blow or abduction stress to thumb Unstable fx- needs ORIF Metacarpal fractures Metacarpal neck: 5th MC neck fracture= Boxer’s fracture (MOI= punching someone/something) 40 deg angulation ro extension lag→ closed reduction, percutaneous pinning Mallet Finger Rupture of extensor tendon distal to DIP; may include an avulsion fracture -axial load causing forced flexion “jam tip of finger” Unable to actively extend DIP Jersey finger Forceful extension of DIP Flexor Digitorum Profundus avulsion Unable to flex DIP Ring finger MC Surgical repair PIP dislocation Dorsal: MC disruption of volar plate and collateral ligament XR Tx of dorsal: reduction after digital block, splint PIP 30 deg flexion x 2 wk Volar: rare, disruption of collateral ligaments and central slip Stable if 50% needs CRPP Tx of volar: reduction, extension splint 4 wk