Common Injuries of the Hand, Wrist, & Elbow. Terry M. Messer, MD October 25, 2007
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1 Common Injuries of the Hand, Wrist, & Elbow Terry M. Messer, MD October 25, 2007
2 Introduction! Hand, Wrist, & Elbow Injuries are common! Increase in intensity/frequency of sports training! Sedentary lifestyle Computer/Desk job! Age related changes occur in bones, joints, ligaments, & muscle-tendon units
3 Introduction! Acute traumatic event or continuum of overuse " bone or soft tissue injury! Stages of Healing! Inflammatory! Proliferative! Maturation! Fibrosis
4 Introduction! Healing Times General! Bone heals faster than ligament (exception carpal bones)! Phalangeal fractures 3-4 wks.! Metacarpal fractures 4-5 wks.! Distal radius 6 wks.! Scaphoid 6-20 wks.! Ligaments 6-12 wks. (depends upon location & severity of injury)! Children heal faster than adults! Smoking, Diabetes, Kidney Disease, Malnutrition " Prolonged Healing
5 Age Related Changes in Tendon, Ligament, Joint Capsule, & Bone! Fibroblasts! Form major part of tendon, ligament, capsule! With aging, cells flatten, elongate, & lose most of protein producing cell organelles " less able to respond to injury! Several factors may contribute to age-related increase in injury! Decreasing blood supply! Decrease in collagen cross-links (and water content)! Decrease in collagen organization! " decrease in tensile stiffness and ultimate load to failure! Orthopaedic Knowledge Update 8! Body makes less new bone after age 35 " Osteopenia or Osteoporosis
6 Introduction! Treatment of Upper Extremity Injuries! NSAIDs! Ibuprofen Motrin, Advil! Naprosyn Alleve! Mobic,, Relafen, Feldene! Celebrex! Splinting! Therapy! Corticosteroid Injection! Surgery
7 Introduction! Prompt, appropriate treatment " quicker healing time & more rapid return to function
8 Introduction! Overview of Common Injuries! Hand! Wrist! Elbow! Sprains! Tendon Injuries/Tendonitis! Fractures
9 Hand
10 Mallet Finger/Mallet Fracture! Jammed finger! Pain, swelling, inability to extend at DIP joint! X-ray
11 Mallet Finger/Mallet Fracture! Treatment - Splint DIP joint in full extension for 8 weeks! Therapy sometimes needed! Surgery rarely indicated
12 Jersey Finger! Making a tackle; catching a ball! Pain, swelling, unable to flex DIP joint! Xray! Ultrasound or MRI
13 Jersey Finger
14 Jersey Finger! Surgical Treatment repair tendon to bone! Post-op Therapy for 2-4 months
15 Proximal Interphalangeal (PIP)! Jammed finger! Swollen, painful PIP joint! Tender to palpation, dec.. ROM; increased laxity! X-ray Joint Sprain
16 PIP Joint Sprain! Dislocation more severe variant
17 ! Treatment: PIP Joint Sprain! SPLINT for 7-10 days, then buddy tape to adjacent digit for 3-5 wks.! Younger patient chronic volar plate laxity
18
19 ! Treatment: PIP Joint Sprain! Older patient - Stiffness biggest problem! Swelling & DEC. ROM can persist for 3-6 months
20 26 yr old NC State Grad. Student who injured finger playing basketball Lateral X-ray post reduction
21 At 1 week, transitioned to mallet splint & dorsal extension block splint Xrays 6 wks. post injury; Patient had no pain or tenderness
22 34 yr old male with unstable PIP fx.- disloc.
23 Central Slip Rupture/ Boutonniere Deformity! Clinical presentation similar to sprain! Tender central slip! Unable to fully extend at PIP joint! X-ray
24 Central Slip Rupture/ Boutonniere Deformity! Treatment! Splint PIP joint in full extension for 6-8 weeks! Surgery when splinting fails! Chronic injuries difficult to treat early diagnosis & referral is essential!
25
26
27 Thumb Metacarpophalangeal (MCP) Joint Ulnar Collateral Ligament Tear! Skier s s or Gamekeeper s thumb! Fall, Ski pole, ball striking thumb! Painful, swollen thumb MCP joint! PE swelling, deformity, tenderness, inc. laxity, dec. ROM
28 Thumb MCP Joint Ulnar Collateral Ligament Tear! X-ray, +/- stress views! US or MRI! Treatment:! Partial injuries! Immobilize for 4 weeks! Then gentle ROM exercises but continue splinting for 6-8 more weeks! Radial collateral ligament injuries treated similarly
29 Thumb MCP Joint Ulnar Collateral Ligament Tear! Treatment:! Complete injuries surgical repair
30 Sagittal Band Sprain Pain & swelling at MCP joint ( knuckle( knuckle ) Tender, dec.. ROM, possible tendon subluxation
31 Sagittal Band Sprain! Splint! Surgery when due to laceration or when splinting fails! Therapy
32 Metacarpal or Phalangeal Fracture! Swollen, painful digit/hand after trauma! PE! Soft tissue wound, swelling! Deformity evaluate in flexion & extension! Tenderness! X-ray! Finger only if single digit! Hand if metacarpal or multiple digits
33 Metcarpal or Phalangeal Fracture! Treatment - for non-displaced & certain minimally displaced fractures " splint! Thermoplast vs. Plaster! Immobilize joint proximal & distal to affected bone! Intrinsic plus position minimizes joint stiffness
34 Metcarpal or Phalangeal Fracture! Treatment - for displaced, angulated fractures or those with clinical/rotational deformity " CRPP vs. ORIF! Articular fractures more worrisome! Post-op. splinting & therapy
35 Wrist
36 Scapholunate Ligament Tear! Fall onto outstretched hand (FOOSH)! Pain! +/- swelling! +/- dec.. ROM! PE swelling; focal tenderness over S-L ligament; + Watson test
37 Scapholunate Ligament Tear! X-ray! +/- MRI (MR arthrogram best!)
38 Scapholunate Ligament Tear! Treatment! Partial tear cast/splint! Complete tear surgical treatment! Cast/splint for 8-10 wks.! Therapy
39 Scapholunate Ligament Tear
40 Scapholunate Ligament Tear! Untreated injuries " Severe arthritis
41 TFCC Tear! Fall, Twisting injury of wrist, Golf injury! Ulnar sided wrist pain +/- popping! PE foveal sign; +/- DRUJ instability
42 TFCC Tear! X-rays often normal! MR Arthrogram
43 TFCC Tear! Treatment! Cast for 4-6 weeks Above elbow! Splint for another 2-4 weeks! Arthroscopic debridement vs. repair! Splint for 2-8 weeks! Therapy
44
45 DeQuervain s s Tenosynovitis! Radial sided wrist pain & swelling! Overuse! Pregnancy/Peri Peri- partum! PE tender to palpation; + Finkelsteins
46 DeQuervain s s Tenosynovitis! Treatment! NSAIDs! Splint/activity modification! Therapy! Cortisone shot! Surgical release
47 Intersection Syndrome! Dorsal wrist/forearm pain & swelling; squeaking! Rowers, weight lifters; overuse injury! PE - tender to palpation; crepitance; ; audible squeaking
48 Intersection Syndrome! Treatment! Rest/Immobilization! NSAIDs! Therapy! Corticosteroid injection! Surgical release (rarely required)
49 Carpal Bone Fractures Scaphoid! FOOSH! Young males! Pain! +/- swelling! +/- dec.. ROM! PE swelling; snuff box tenderness; + thumb compression test! X-ray
50 ! MRI vs. CT Carpal Bone Fractures
51 Carpal Bone Fractures! Scaphoid - Treatment! Cast for non-displaced, stable fractures only! Prolonged healing time! Surgical! Percutaneous screw fixation! Arthoscopically-assisted ORIF! ORIF! Post-op therapy
52
53 Carpal Bone Fractures Scaphoid! Untreated fractures " Non-union & Arthritis
54 Carpal Bone Fractures Hook of Hamate Fracture! Bad golf swing; Fall; Hockey, baseball players! Pain! +/- swelling! +/- dec.. ROM! +/- tendon rupture! PE swelling; focal tenderness over hook of hamate! X-ray! CT Scan vs. MRI
55
56 Carpal Bone Fractures Hook of Hamate Fracture! Treatment! Cast/Splint! Surgical excision when nonop.. treatment unsuccessful
57 Distal Radius Fracture! FOOSH; MVC! Pain! swelling, +/- deformity! dec.. ROM! +/- numbness! PE swelling, deformity; tenderness; dec.. ROM; Neurovascular exam! X-ray! CT for certain fractures
58 Distal Radius Fracture
59 !Treatment!Cast for non- displaced, stable fractures!66 weeks!surgical Distal Radius Fracture!Percutaneous pinning!external fixation + pinning!orif!arthroscopically assisted ORIF!Therapy
60
61 Elbow
62 Lateral Epicondylitis! 1 st described in 1883 Br Med Journal as lawn tennis elbow! Lateral elbow pain! Increased with use, grasping, lifting! More non-athletes! Tendinosis = angiofibroblastic hyperplasia OR non-inflammatory degeneration of ECRB +/- EDC! lack of acute inflammatory cells; RC, patellar, Achilles
63 Lateral Epicondylitis! PE! Tender over (or just distal to) epicondyle! Pain with resisted wrist extension, stretch test! X-rays! Can coexist with radial tunnel syndrome in 5-20% of patients
64 Lateral Epicondylitis! Treatment! Ice! NSAIDs! Splinting! Therapy US & e-stim stim.! Activity modification/ correct technique! Corticosteroid Injections! Extracorporeal shock wave therapy! Surgery! > 90% of patients will improve by 6-12 months without therapy
65 Lateral Epicondylitis
66 Lateral Epicondylitis - Arthroscopic Treatment
67 Medial Epicondylitis! Golfer s s elbow! Tendinosis! Origin of flexor-pronator muscle group! Local tenderness, pain with resisted pronation, wrist flexion! Associated with ulnar nerve compression
68 Medial Epicondylitis
69 Medial Epicondylitis! Nonsurgical Treatment: > 90% Success! Rest, Bracing, NSAIDs, Injection! Surgical Treatment excise involved tissue & flexor- pronator repair; +/- ulnar nerve decompression
70 Medial Epicondylitis
71 Elbow - Ulnar Collateral! Throwing athlete! Late cocking/acceleration phase " extreme valgus stress at elbow " injury to ulnar collateral ligament! Also seen in overhead athletes, gymnasts! Medial elbow pain & tenderness! Check for ulnar nerve pathology Ligament Tear
72 Elbow - Ulnar Collateral Ligament Tear! Instability testing elbow flexed 25 deg.! X-rays/Stress X-rays! MRI/MR Arthrogram
73 Elbow - Ulnar Collateral Ligament Tear
74 Elbow - Ulnar Collateral Ligament Tear! Treatment! Rest, NSAIDs,, local modalities, Therapy! Competitive athletes desiring to return to sport " UCL reconstruction with tendon graft! +/- Ulnar nerve transposition
75 Distal Biceps Tendon Rupture! Long & short head of biceps " distal biceps tendon " radial tuberosity! Account for only 3% of all Biceps Brachii tendon ruptures (Proximal long head = 96%)! Sudden tearing/ pop pop with weakness of flexion & supination! PE swelling & echymosis, proximal retraction of biceps brachii muscle belly! Tx = Surgical repair of tendon to bone
76 Distal Biceps Tendon Rupture
77 Conclusion! Overview of common hand, wrist, & elbow injuries & their treatment! Prompt intervention " decreased recovery time! Advances in surgical techniques " more rapid return to work/sports, etc.! Most injuries effectively treated without surgery
78 QUESTIONS???
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