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7/25/2019 Hand Surgery-A Guide for Medical Students Revision
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HandSurgery:
A
Guide
for
MedicalStudents
TrevorCarrollandMargaretJainMD
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Tableof
Contents
Trigger Finger
3Carpal Tunnel Syndrome 13
Basal Joint Arthritis 23
Ganglion Cyst 36
Scaphoid Fracture 43
Cubital Tunnel Syndrome 54
Low Ulnar Nerve Injury 64
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TriggerFinger
(stenosingtenosynovitis)
AnatomyandMechanismofInjury
RiskFactors
Symptoms
PhysicalExam
Classification
Treatments
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TriggerFinger:AnatomyandMOI
(ThompsonandNetter,p191) Theflexortendonsrunwithinthesynovialtendinoussheathinthefinger
Duringflexion,
the
tendons
contract,
running
underneath
the
pulley
system
Overtime,theflexortendonsand/ortheA1pulleycangetinflamedduringfingerflexion.
Occassionally,theflexortendonsand/ortheA1pulleyabnormallythicken.Thisdecreases
thenormalspacebetweenthesestructuresnecessaryforthetendontosmoothlyglide Inmoreseverecases,patientscanhave
theirfingers
momentarily
or
permanentlylockedinflexionusuallyat
thePIPjoint
(TriggerFingerOrthoInfo )
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TriggerFinger:
Risk
Factors
Age:4060
Female>Male
Repetitivetasksmayberelated
Computers,
machinery
Gout
Rheumatoidarthritis
Diabetes(poorprognosticsign)
Carpaltunnelsyndrome(oftenconcurrently)
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TriggerFinger:
Subjective
C/Ofocaldistalpalmpain
Paincan
radiate
proximally
in
the
palm
and
distallyinfinger
C/Ofinger
locking,
clicking,
stickingoften
worseduringsleeporintheearlymorning
Sometimessnappingduringflexion
Canimprove
throughout
the
day
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TriggerFinger:
Objective
Focaltendernesstopalpationatthefingerbase(atA1pulley)
Mayappreciate
nodule
in
this
location
Tendernessmayincreasewith
finger
extension
Radiographsnotnecessary
BewaresnappingatMPjointmayresembletriggerfingers
BewareassociatedMParthritisptwillhavedorsal
jointtenderness
(Hubspot)
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TriggerFinger:
Classification
GreenClassification
(McKean)
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TriggerFinger:Management
1st line
Stoppingtheoffending
activityNightsplinting
NSAIDS
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TriggerFinger:
Management
2nd line Steroid
injection
Notice
the
steroid
is
placedwithinthe
tendonoussheath.
(ThompsonandNetter,p199)
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TriggerFinger:
Management
3rd Line:SurgicalreleaseofA1pulley
Operation Surgicalsite:~1cmproximal
toproximaldigitalcrease.
Incisioncenteredoverthemetacarpaltoavoid common
digitalarteries
and
nerve
SharpreleaseofA1pulleytorestoresmoothtendongliding
Havept demonstratesmoothflexionbeforeclosingincision
Postoperatively
EarlypassiveandactiveROM.
Complications:infection,PIPstiffness,digitalnerveinjury,bowstringing
(Steffens)
A1Pulley
ProximalDigitalCrease
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WorksCited
Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedicanatomy.Philadelphia,PA:SaundersElsevier,2010.Print.
"TriggerFinger
OrthoInfo
AAOS."
Trigger
Finger
OrthoInfo
AAOS.
N.p.,n.d. Web.08Mar.2014.http://orthoinfo.aaos.org/topic.cfm?topic=a00024
http://cdn2.hubspot.net/hub/30688/images//TriggerFingerlabel.jpg?t=1424796877421
McKean,Jason."TriggerFinger."Orthobullets.N.p.,n.d. Web.08Mar.2014..
Steffens,Kurt."SurgeryofTriggerFinger(SnappingFinger)."
Surgeryof
Trigger
Finger
(Snapping
Finger).
N.p.,
n.d. Web.
08
Mar.
2014..
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CarpalTunnelSyndromeThemostcommonentrapmentneuropathy
AnatomyandMechanismofInjury
RiskFactors
Symptoms
PhysicalExam
Treatments
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CarpalTunnelSyndrome:Anatomyand
MOI
Themediannerveis
entrappedwithin
the
tunnel,whichcreateslocal
nerveischemia
Thiscreatesnumbness,
tingling,andorpaininthe
mediannerve
distribution
Chronicentrapmentcan
producethenar atrophy
(seenatright)
(McKean)
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CarpalTunnel
Syndrome:
Risk
Factors
Females>Males
Inheritingasmallertunnel
Womentend
to
have
smaller
tunnels
OlderAge(mean~54years)
Pregnancy(oftenresolveswithdelivery)
Heavyworkwithhandsandvibrationalequipment Machineryworkers,autoindustry
Usingjackhammer
Thyroiddisease
Trauma
Rheumatoidarthritis
Ganglion
cyst
Amyloidosis
Note:Nogooddatatosupporttypingorkeyboardingasacause
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CarpalTunnel
Syndrome:
Subjective
Fingernumbnessorpainusuallysparespalms
Numbness,tingling,
burning
Radiatingtofirst3digitsandtheradialof
the
ring
finger Sx areoftenatnight,evenwakingpatientsup
Obligatorywristflexionduringsleepdecreases
crosssectional
size
of
the
tunnel,
increases
pressureonthenerve
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CarpalTunnel
Syndrome:
Objective
Handandwristusuallyappearnormal,butmayshowthenaratrophy
Provocativetests:positiveiftheyreproducetheptssymptoms
Tinels testtapoverthemediannerveatthewrist
Phalens Testholdforcedflexionfor60seconds
Durkans Test(Carpalcompressiontest)pressthumbovercarpaltunnelfor30seconds
Radiographsnotnecessary
EMGandNCVobjectivetesttoquantifynerveinjury
Tinnel's Test(MusculoSkeletalExamination)
Phelan'sTest(MusculoSkeletalExamination)
Durkan's Test
(Mckean)
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CarpalTunnel
Syndrome:
Assessment
Diagnosisisclinical
EMGand
NCV
often
obtained
notabsolutelynecessaryfordiagnosis
Generally
recommended
prior
to
surgical
release
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CarpalTunnel
Syndrome:
Plan
1st line
Nightsplints
Activitymodificationavoidwristflexionandextension
2nd
line Steroidinjection
Mostpatientshavesomeimprovementwithinjection
Typically(~75%)Sx return
UsefulinpregnancyandtoconfirmDx
MostsuccessfulinmildCTS(>1yr preservedsensation)
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CarpalTunnel
Syndrome:
Plan
3rd lineCarpalTunnelRelease
Surgicalrelease
of
the
transverse
carpal
ligament
increasessizeofthecarpaltunnel
Decreasespressureonnerve
Keepincision
just
ulnar
to
thenar crease
Thishelpsavoidsinjurytotherecurrentmotorbranch.
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WorksCited
"CarpalTunnelSyndrome."HEALTH,MEDICINEANDANATOMYREFERENCEPICTURES.Health,
MedicineandAnatomyReferencePictures,13Oct.2013.Web.http://healthfavo.com/carpal
tunnel
syndrome
2.html. Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedic anatomy.Philadelphia,
PA:SaundersElsevier,2010.Print.
MusculoSkeletalExamination."APracticalGuidetoClinicalMedicine.Universityof
California,SanDiego,n.d. Web.09Mar.2014.
. McKean,Jason."CarpalTunnelSyndrome."Orthobullets.N.p.,8Mar.2014.Web.09Mar.
2014.
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BasalJointArthritisThe
2nd most
common
hand
osteoarthritis
(after
DIP
OA)
AnatomyandMechanismofInjury
RiskFactors
Symptoms
Physical
Exam
RadiographsandClassification
Treatments
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BasalJoint
Arthritis:
anatomy
and
MOI
Basaljointarthritisoccursbetweenthetrapeziumandthebaseofthefirstmetacarpal
Thisisalsocalledthecarpalmetacarpaljoint(CMC)
Basaljoint
allows
thumb
opposition
Duringpinching,CMCjointsreactiveforceistwelvetimesgreaterthanthepinching
force(Abbasi)
(DoctorRe)
_________
_____
(ThompsonandNetter,p185)
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BasalJoint
Arthritis:
Risk
Factors
Female>Male
Olderthan
40
Priorinjuriestothearea(sprains)
Rheumatoid
arthritis
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BasalJoint
Arthritis:
Symptoms
Painwithgrasping/pinchingactivities
Worsewith
use
Decreaserangeofmotioninthumb
Up
to
40%
have
coexisting
carpal
tunnel
syndrome,orwilldevelopitovertime
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BasalJoint
Arthritis:
Exam
Inspectionmayshow:
BumpatdorsalthumbduetoMCsubluxing dorsallyonthetrapezium
Adductiondeformityof1stmetacarpalinlatestagesofdisease
Ifsevere,
MCP
joint
hyperextension
(seen
in
red)
occurs
to
compensate
for
decreaseCMCmotion
Grindtest:Axiallyloadthefirstmetacarpalandrotateatthejoint,willreproducepain.
1st metacarpaladductiondeformity
Badia
(IndianapolisHandSurgeons)
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BasalJointArthritis: Radiographsand
Classification
EatonandLittlerClassificationofBasilarThumbArthritis
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BasalJointArthritis: Radiographsand
Classification
WidenedJointSpace NarrowedJointSpace
Osteophytessmaller
than
2mm
(EORIF) (EORIF)
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BasalJointArthritis: Radiographsand
Classification
Osteoporotic
signs
in
the
scaphtrapezoidaljoint
Sclerosis
Cysticchanges
Osteo h tes>2mm
(EORIF) (EORIF)
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BasalJoint
Arthritis:
Treatment
1st line
NSAIDS
Spicasplint
thumbimmobilization
2nd line
Corticosteroids
Rarely
provided
prolonged
relief
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BasalJointArthritis:SurgicalTreatment
Alwaysinvolvessomeexcisionofthe
articularsurface
of
the
trapezium
Mostcommonprocedure:trapeziectomy
+interpositionofFCRtendon+/
reconstruction
of
the
volar
ligament
(AKA
LTRIorBurtonsarthroplasty)
Incisionatdorsalthumb
Anatomy
to
identify
(above
right) I.1st Metacarpal
II.2nd MetacarpalwithFCRinsertion
b.InterpositiongraftofFCRtendon
3rd lineBasalJointArthroplasty
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BasalJointArthritis:Burtons
Arthroplasty(LRTI)
Excisetrapezium
Harvest
all
or
of
FCRtendonproximally,leavingdistalinsertionat2nd
MCbase
intact
TransferFCRtothe1st
MCbase
Interposeremained
ofcoiledFCRintothespaceleftbytrapeziumexicison
(VanHeest andKallemeier)
TrapeziumremovedandcoiledFCRtendon
occupyingthe
space
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WorksCited
Abbasi,David."BasilarThumbArthritis."Hand.Orthobullets,10Feb.2014.Web.15Mar.2014..
"DoctorRe.com |CommonInjuriesWrist&Hand."DoctorRe.com |CommonInjuriesWrist&
Hand.
N.p.,
n.d. Web.
15
Mar.
2014.
. Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedic anatomy.Philadelphia,PA:
SaundersElsevier,2010.Print.
Badia,Alejandro."TotalJointArthroplastyintheTreatmentofAdvancedStagesofThumbCarpometacarpalJointOsteoarthritis."OsteoarthritisThumbBasalJointOrthopedicFingerSurgeonDr.AlejandroBadia HandtoShoulderCenterHandHospitalMiamiThumbCarpometacarpalJointOsteoarthritis.Badia:HandtoShoulderCenter,12Apr.2007.Web.15Mar.2014.
.
"ArthritisattheBaseoftheThumb."IndianapolisHandSurgeons.IndianaHandtoShoulderCenter,n.d. Web.15Mar.2014..
"ThumbBasilarJointArthritis715.14."EORIF.N.p.,n.d. Web.15Mar.2014..
Mohanty,Satyajit.
"Physiotherapy
Blogging."
:Differential
Diagnosis
of
Anatomic
(Radial)
Snuffbox
Pain:ItIsNotAlwaysDeQuervains Tenosynovitis.N.p.,12May2012.Web.16Mar.2014..
VanHeest,AnnandKallemeier,Patricia, ThumbCarpalMetacarpalArthritis.JAmAcad Orthop SurgMarch2008;16:140151.
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GanglionCyst
Overview
DorsalGanglion
Cysts
VolarWristGanglions
VolarRetinacular
Cysts
SymptomsandPhysicalExam
Treatments
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GanglionCysts:
Overview
Mucinfilledsynovialcystattachedbyastalktothejoint
capsule(Hughes)
70%dorsalcarpal(green)
20%volarcarpal(notpictured)
10%volarretinacular(red)
Occurat
the
A1
or
A2
pulley
commonly
SlowGrowing
Benign
tumor
(Ihealthspot)
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DorsalGanglionCysts
Typicallyoccuroverthescapholunateligament
~70%ofallganglioncysts
Thoughtto
occur
from
recurrent
stress
of
scapholunate
ligament
70%occur2nd4th decade
NearListerstubercleofthedistalradius
(Divya andOsterman ) (Trumble)
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VolarWristGanglions
~20%ofallgangliacysts
UsuallybetweentheFCRandAPLatthe
scaphotrapezoid joint
Notrecommendedtoaspirateb/cradial
artery
is
nearby
(Trumble)(Trumble)(HSSH)
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Digital
Mucous
Cysts
Occuratthedistalinterphalangealjoint
10%
of
hand
cysts
(Hughes) Associatedw/osteoarthritis
usuallyanosteophyteatthe
DIP Women
5070yearsold
Often
with
Heberdens
Nodes
(WheelessTextbook)
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Symptoms Usually
asymptomatic
Canbepainfulwithwristextension
Cosmeticcomplaints
PhysicalExam Firm
Rubbery
Well
circumscribed Transilluminates with
flashlight
Radiographs
normal
(usually)
Ganglion
Cysts
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Ganglion
Cyst:
Treatment1st line
Observation,splintwear
2nd line
Aspiration
Usuallynotrecommendedwithvolarcystsduetoradialartery
50%90%
recurrence
rate
CansendsampleforcytologytoR/Omalignancyifconcerningcharacteristics/location
3rd line
Surgicalexcisionofthecystandstalktopreventrecurrence
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Works
Cited Hughes,Michael."GanglionCysts."Orthobullets.N.p.,06Oct.2013.Web.23Mar.
2014..
"GanglionCystsWristAndHandLumpsAndBumps."GanglionCysts.IHealthSpot,
Inc,n.d. Web.
23
Mar.
2014.
.
Divya,Singh,andA.LeeOsterman."Ganglionectomy."HandSurgery1stEdition.LippincottWilliams&Wilkins,n.d. Web.23Mar.2014.
Trumble,Thomas.
"Ganglion
Cyst."
Ganglion
Cyst.
BBPJ:
Hand
and
Upper
Extremity
Institute,n.d. Web.23Mar.2014..
"GanglionCystTreatment|HandSurgerySpecialistsofHouston."HSSH.HandSurgerySpecialistsofHoustonDallas BeverlyHills LasVegas,6Mar.2013.
Web.
23
Mar.
2014.
. "MucousCyst."Wheeless'TextbookofOrthopaedics.N.p.,20June2010.Web.23
Mar.2014..
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Scaphoid
Fractures AnatomyandMechanismofInjury
RiskFactors
Symptoms
Presentation Imaging
Radiographs
Classification&Treatments
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ScaphoidFracture:AnatomyandMOI
Thescaphoidistheradial
borderof
the
carpal
bones
Mostcommonlyfractured
carpalbone
75%oftheboneisarticular
cartilage
LeftHandPalmarview(wikipedia)
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Scaphoid
Fracture:
Anatomy
and
MOI 80%ofthescaphoidbloodsupplyisfromthedorsalcarpalbranchoftheradialartery
Aminorityofbloodsupplyisfromthesuperficialpalmararchviapalmarbranch
The
most
proximal
portion
of
the
bone
relies
on
retrograde
flow. implicationforfracturesishigherratesofAVN.
100%AVNinfractureofproximal5th and33%AVNinfractureofproximalthird
(Abassi)
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Scaphoid
Fracture:
Mechanism Mostcommonly
associated
with
low
impactfalls
Youngmalesmost
common Extremedorsiflexionof
thehand
Frequentlyoccurs
with
fallsbackward
(FXRX)
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ScaphoidFracture:Presentation
History:
Pts complainofwristpain,
reduced
motion
and/or
grip
weakness
Oftengiveahistoryofsprainedwristnotimproving
withtime
Exam:
Tenderdorsalanatomic
snuffboxScaphoidtubercle
tendernessonvolaraspect
Limitedwristextension
AnatomicSnuff
Box
(Jones)
ScaphoidTubercle
Tenderness
(Abassi)
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Scaphoid
Fracture:
Imaging Xrays
AP,LateralandScaphoidview
Ifinitial
films
are
negative,
cast
and
repeat
in
1week
Bonescanhighestsensitivityandspecificitywithinfirst72hrs.
MRI Generallypreferredexamforoccultfractures
Highestsensitivitywithin1st 24hrs
Usefulforseveralweeksafterinjury
Showsligamentous
damage
and
vascularity
CT Idealfordeterminingfracturedisplacement
Oftenusedforsurgicalplanningortoevaluatehealing
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Scaphoid
Fracture:
Imaging Fxs classifiedbylocation
Mostcommon
fx is
nondisplacedofthe
waist(middle)
Distalfx tendtohealquicklyduetoblood
supply Proximalfx havehighest
rateofnonunion
(Seiler)
S h id F t R di h
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ScaphoidFracture:Radiographs
NonDisplacedwaistfracturemostcommonpattern
12hrspostinjury
Slightlucency
1weekpostinjury
Greaterspacing
3monthspostinjury
NonUnionwithgreater
lucency
(Ren) (Ren)(Ren)
Scaphoid Fracture: Classification and
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ScaphoidFracture:Classificationand
TreatmentNonDisplacedFractures
Majorityof
the
fractures
Tx:ThumbSpicaorshort
armcastuntilunion
Castingcan
be
prolonged upto45
monthsforproximal
fratures
(Boyd)
S h id F t S
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ScaphoidFracture:Surgery
DisplacedFractures
Indications
>1mm
displacment
Comminuted
Pt preferencetoliberatefromcast
Generallytreatedwithscreworpinfixation. Cannulated screwmostcommon(right)
Platesrarely
used
(below)
PercutaneousScrew
(Boyd)LockingPlate(StratMed)
Works Cited
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WorksCited
"ScaphoidBone."Wikipedia.WikimediaFoundation,24Mar.2014.Web.28Mar.2014.
.
Abassi,David."ScaphoidFracture."Orthobullets.N.p.,26Mar.2014.Web.27Mar.
2014..
"TraumaticInjuries
to
the
Hand
&
Wrist
Info
from
an
AZ
Orthopedic."
Traumatic
InjuriestotheHand&Wrist.FXRX:Orthopedics&Bracing,26May2013.Web.27Mar.
2014..
Jones,Oliver."TheAnatomicalSnuffbox."TeachMeAnatomy.N.p.,14Mar.2014.Web.
27Mar.
2014.
.
Seiler,John."EssentialsofHandSurgery1stEdition."CarpalFractures.Lippincott
Williams&Wilkins,n.d. Web.28Mar.2014.
.
Ren,Jack."ScaphoidFracture."Radiopaedia BlogRSS.Radiopedia.org,n.d. Web.29
Mar.2014.
.
Boyd,AnneS.,HollyBENJAMIN,andChadASPLUND."SplintsandCasts:Indicationsand
Methods."AmericanFamilyPhysician.AmericanAcademyofFamilyPhysicians,1Sept.
2009.Web.28Mar.2014..
"Aptus ScaphoidPlate."Stratmed.co.za.N.p.,n.d. Web.28Mar.2014.
.
Cubital Tunnel Syndrome
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CubitalTunnelSyndrome
Anatomy
Mechanismof
Injury
and
Risk
Factors
Presentation
Physical
Exam
Treatments
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Cubital
Tunnel
Syndrome:
Anatomy Theulnarnerverunsthroughthecubitaltunnelattheelbow
BordersofCubitalTunnel Medialepicondyleofthehumerus(green)
Olecranonprocess
of
the
ulna
(blue)
Osbornsligamentrunsbetweenthemedialepicondyleandtheolecranonmaycompresstheulnarnerveattheelbow
(ThompsonandNetter,p120)
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Cubital
Tunnel
Syndrome:
AnatomyUlnarnerve
Sensoryto4th and5th digits Palmardigitalsensorybranches
Dorsalsensorybranchemerges5cmproximaltothewrist.Differentiatesitfromamoredistalneuropathy
(blue)
Motor
Flexorcarpiulnaris
Flexdigitorumprofundus(4th and5th digits)
Hypothenarmuscles
Adductorpollicis
(Wikipedia)
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Cubital
Tunnel
Syndrome
MOIandetiology
2nd mostcommon
upper
extremitycompression
neuropathy(afterCTS)
Canoccur
due
to
nerve
rubbingovermedial
epicondyleduringelbow
flexionand
extension
RiskFactors
Repetitiveelbow
motion
canexacerbatesymptoms
Phonetalking
DiabetesMicroischemiaincreases
vulnerability
Congenitallytight
tunnel
Historyofdirectblow
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Cubital
Tunnel
Syndrome:
Presentation
4th and5th digitnumbnessandtingling
Includingdorsal
aspect
C/Ohandclumsinessordroppingthings
Sx worsewithelbowflexion
Repetitiveactivities
Prolongedpositionalactivities driving,resting
arm
on
armrestSleep
CubitalTunnelSyndrome:PhysicalExam
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Inspection
Interosseousatrophy
(in
severe
disease)
Sensory
Decreasedin4th and5th digit
Motor
Weakpinch
Froments
signthepatientgraspsthepieceofpaperandresistsitbeingremoved. Withulnarpalsy,weakenedadductorpolliciscompensatedwithflexingflexorpollicislongus(FPL)
Wartenbergsign5th digitabductionduringattemptedadduction. Fromweaksmallfingerlumbricaland3rd palmarinterosseous(Allen)
Cannotcrossindexandmiddlefingers(DIOweakness)
(Giovannoni)
Wartenbergs
Sign
(OrthopaedicsOne)
Cubital Tunnel Syndrome: Physical Exam
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CubitalTunnelSyndrome:PhysicalExam
ProvocativeTests
TinelsSign Lightlytappingposteriortothemedialepicondyleoverthe
nervehighlysensitive(oftenoverlysensitive)
Elbow
flexion
Test Holdfor>60sec
(IndianaHandtoShoulder)
TinelsSign ElbowFlexionTest (CRTechnologies)
C bi l T l S d T
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CubitalTunnelSyndrome:Treatment
NonOperative
Activity
modification
NSAIDS
Nighttimeelbow
extensionsplinting
At45degreesina
neutralposition
(HandTherapyCanada)
Cubital Tunnel Syndrome: Treatment
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CubitalTunnelSyndrome:Treatment
Operative
UlnarnerveInsituDecompression
Releasecubitaltunnelretinaculum(red)
Ulnarnerve
Decompression
and
with
anterior
transposition
Ulnarnerveismovedanteriorinthearm eithersubcutaneously,
submuscularly orintramuscularly.
(IndianaHand
to
Shoulder)
(IndianaHandtoShoulder)
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Works
Cited "UlnarNerve."Wikipedia.WikimediaFoundation,24Mar.2014.Web.29Mar.2014.
.
"CompressionNeuropathiesoftheArm."MusculoskeletalMedicineforMedicalStudentsOrthopaedicsOne.N.p.,n.d. Web.29Mar.2014.
.
Giovannoni,Gavin."TeachNeurology:Froment'sSign."TeachNeurology:Froment'sSign.N.p.,n.d.Web.29Mar.2014..
Allen,Deborah."CubitalTunnelSyndrome."Orthobullets.N.p.,6Feb.2014.Web.29Mar.2014..
"CubitalTunnelSyndrome."IndianaElbowSurgeons.N.p.,n.d. Web.29Mar.2014..
CRTechnologies."ElbowFlexionTest."YouTube.YouTube,12Oct.2009.Web.29Mar.2014..
"HandTherapyCanadaTheCanadianHandTherapyResource."HandTherapyCanadaTheCanadianHandTherapyResource.N.p.,n.d. Web.29Mar.2014..
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Low
Ulnar
Nerve
Injury
Anatomy
Causes Presentation
Physical
Exam Testing
Management
LowUlnarNerveInjuryorcompression:
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Anatomy
GuyonsCanal
Beginsatflexorretinaculum
Betweenpisiformandhamate
Containsulnarnerveandartery ulnarnerveulnarinthecanal
Ulnarnervebranchesafterexitingcanal Superficial
branch
of
ulnar
nervethe
sensory
of
palmar4th and
5th digits
Deepbranchofulnarnervemotorbranch
Note:Thedorsalbranchoftheulnarnervebranchesabout5cmproximaltothewrist,soindividualswithlowulnarinjurywillnothavedorsalsensorycomplaints
(Humpal) (Humpal)
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Low
Ulnar
Nerve
Injury:
Causes CompressiontoGuyonscanal
Ganglion
cyst
Cycling(handlebarpalsy)
RepetitiveTasks
Diabeticneuropathy
Knifestaborgunshotwound
LowUlnarNerveInjury:Presentationd
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HandWasting
4th and5th digitpalmarnumbness
4th and5th digitcurling(ulnarclaw)whentryingtoextendfingers ShowsHyperextensionatMCPandflexedatIPjoint
From
loss
of
lumbricalsNote:Thereisalsolossoflumbricalfx incubitaltunnel(CTS),howevertheulnarclawisnotaspronouncedinCTS,becausethereisalsolossofflexordigitorumprofundustothe4th and5th digits,decreasingIPjointflexion.
(StanfordSchoolofMedicine)
Low Ulnar Nerve Injury: Physical Exam
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LowUlnarNerveInjury:PhysicalExam
SimilartoCubitalTunnelSyndrome(seeslide59)
PositiveFromentsSign
PositiveWartenbergs
Sign
Weaknessorinabilitytocrossindexandlongfinger
Tinelsmaybepositiveatthesiteofcompressionorinjury
Differsfrom
CTS
in
that
Sensationintactondorsalaspectof4th and5th
NegativeTinelssignattheelbow
Negative
Elbow
Flexion
Test
Low Ulnar Nerve Injury: Testing
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LowUlnarNerveInjury:Testing
RadiographsandXrays
Usefultoexaminehamatefracture,whichcancause
ulnar
nerve
compression
if
displaced
MRI
Typicallyusedintheworkupofatraumatic ulnar
nervepalsy
Mayshowspacyoccupyinglesion(ganglioncysts)compressingthenerve
Nerve
Conduction
Test
and
Electromyogram Usefultoobjectivelydemonstrateneuropathy
Low Ulnar Nerve Injury: Management
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LowUlnarNerveInjury:Management
NonOperative
Activitymodification
NSAIDS
Wristbrace
Operative
DecompressionofFlexorRetinaculumifcompressionoccursatGuyonsCanal
TendonTransfersifnervehaspoorrecovery Improves
pinch
strength
Amelioratestheclawhand
Works Cited
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WorksCited
"Guyon'sCanalSyndrome."Humpal:PhysicalTherapyandSportsMedicineCenter,n.d. Web.
30Mar.
2014.
.
"#19TheHandinDiagnosis."TheHandinDiagnosis.StanfordSchoolOfMedicine,n.d.Web.31Mar.2014.
.
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