18/05/12  

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ELBOW,  WRIST  &  HAND  INJURIES  

Dr  James  Fraser  MBBS,  MSpMed    School  of  Medicine    The  University  of  Queensland  

Elbow  Disloca2on  

Acute  Fractures  Supracondylar  Fractures  

18/05/12  

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Acute  Fractures  

Olecranon  fracture   Radial  head  fracture  

Elbow  Injuries  

•  Lateral  •  Medial  •  Anterior  •  Posterior  

Lateral  Elbow  Pain-­‐Extensor  Tendinosis  •  Repe22ve  wrist  extension,  prona2on  •  Poor  biomechanics,  equipment  selec2on  •  Site  of  injury  distal  to  lateral  epicondyle  •  ECRB  origin  •  Tendinosis  –  not  inflammatory  Who  Gets  It??  •  Non-­‐athletes  more  than  athletes  •  Tennis  players  5-­‐10%  of  cases  •  30-­‐50  year  olds  •  Males  =  Females  •  Two  predisposing  factors–    –  Unaccustomed  ac2vity  –  Sudden  force  

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Extensor  Tendinosis    Symptoms  

•  Pain    – poorly  localised  –  lateral  epicondyle  to  lateral  forearm  –  ini2ally  a[er  ac2vity  – can  be  severe  and  incapacita2ng    

 

Extensor  Tendinosis  Signs  •  Tender  distal  to  lateral  epicondyle  

•  Pain  with  passive  wrist  flexion  –  worse  in  prona2on  with  radial  devia2on  

•  Pain  with  resisted  wrist  extension    especially  3rd  finger  

Extensor  Tendinosis  Treatment  •  No  single  effec2ve  treatment  •  Acute  so[  2ssue  injury  management  •  Wide  range  of  treatments  -­‐  li^le  objec2ve  evidence  for  majority  

•  Assess  &  modify  mechanical  factors  –  Counter  force  bracing  –  Extensor  muscle  stretching  –  So[  2ssue  therapy  –  Cor2costeriod  injec2on  –  Nitrous  oxide  –  Botulinum  toxin  –  Surgery  

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Medial  Elbow  Pain  

•  Flexor,  pronator  tendinopathy  •  Medial  collateral  ligament  sprain  •  Referred  pain  

•  Ulnar  nerve  entrapment  

•  Apophysi2s/avulsion  

Flexor,  Pronator  Tendinopathy  •  Less  common  than  lateral  •  Repe22ve  ac2vity  -­‐  wrist  flexors  

Symptoms,  Signs  &  Treatment  •  Medial  pain  •  Tender  around  epicondyle  •  Pain  with  resisted  flexion  &  prona2on    •  Pain  with  passive  extension  •  Weakened  grip  strength  •  Treatment  much  the  same  as  lateral  

MCL  Injury  

•  Acute  or  over  use  injury  

•  Acute  •  Severe  valgus  stress  

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Repe22ve  Ac2vity  

•  Throwing  –  repe22ve  valgus  stress  

•  Microtears,  inflamma2onè  scarring,  instability,  rupture  

MCL  Injury  

Symptoms  &  Signs  •  Medial  pain  

•  Tender  below  medial  epicondyle  over  radiohumeral  joint  

•  Pain  with  valgus  stress  at  300  

 

Treatment  •  Early  –  Rest,  modify  ac2vity  –  Check  technique  –  So[  2ssue  therapy  –  Strengthening  flexors,  pronators  

–  Surgical  repair    

Anterior  Elbow  Pain  

Biceps  Tendinopathy  •  Overuse  •  Weight  training  flexion,  supina2on  

•  Pain  &  weakness  

•  Rest,  splint  •  Modify  training  type  &  volume  

 

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Anterior  Elbow  Pain    

Biceps  Rupture  •  Most  proximal  few  distal  •  Discrete  forceful  event  •  Maybe  preceded  by  tendinopathy  •  Anabolic  steroid  use  Symptoms  &  Signs  •  Acute  pain  &  weakness  with  ac2vity  •  Deformity    •  Tender  distal  biceps  •  Bruising  •  Weak  flexion  &  supina2on  •  Surgery  

Posterior  Elbow  Pain  

Triceps  Tendinopathy  •  Repeated  extension  ac2vity  •  Tender  &  weakness  •  Rest,  so[  2ssue  therapy  •  Stretching,  strengthening    

Posterior  Impingement  •  Hyperextension    •  Osteoarthri2s  •  FFD    

Posterior  Elbow  Pain  Olecranon  BursiLs  •  Single  trauma2c  episode  or  recurrent  injury  

•  Res2ng  on  bursa  for  prolonged  2me  

•  May  become  infected  

•  Rest,  compression  •  An2bio2cs,  aspira2on,  incision  &  drainage,  excision  of  bursa  

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Children  

•  Osteochondri2s  dissecans  capitellum  or  radial  head  

•  Epicondyli2s  especially  medially    

•  Avulsion  of  epicondyle   OCD  

Wrist  Injuries  

•  Acute  vs.  Chronic  

•  Frequently  injured  –  fractures  common  

Acute  Fractures  Distal  Radial  Fractures  •  Mechanism  –  fall  on  outstretched  hand  -­‐    FOOSH  

•  Most  common  ED  fracture  in  all  age  groups  •  May  be  intra  ar2cular  or  have  associated  wrist  ligament  injury  

•  Children  –  greens2ck  fractures    

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Colles  Fracture  •  Fracture  of  distal  radius  with  volar  angula2on  •  Classic  dinner  fork  deformity  •  Loss  of  func2on  •  Pain,  swelling  

Lateral  x-­‐ray  

Management  

•  Field  -­‐  Splint  

•  ED    –  Pain  relief  –  X-­‐ray  –  Closed  Reduc2on    –  Eleva2on  –  very  important  for  all  wrist,  hand  injuries  – Open  reduc2on,  fixa2on  –  Rehab  

Smith’s  Fracture  

•  ‘Reverse’  Colles  Fracture  •  Fall  onto  dorsum  of  hand  •  Dorsal  2lt  of  distal  fragment  

•  Majority  require  surgery  

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Scaphoid  Fracture  •  Most  common  carpal  fracture  -­‐  75%  •  FOOSH  •  ‘Missed’  fractures  cause  significant  problems  •  High  degree  of  suspicion  based  on  mechanism  and  examina2on  

•  Lateral  wrist  pain    

•  Swelling  &  tender  in  snuff  box  •  Tender  with  dorsal,  volar  palpa2on  with  radial  devia2on  of  wrist  

•  Pain  with  axial  thumb  compression  

Never  just  a  “wrist  sprain”  

•  Retrograde  blood  supply  

•  Most  fractures  through  waist  

•  Disrupted  blood  supply  causes  Avascular  necrosis  

Scaphoid  Fracture  

AVN  

Non  union  

Inves2ga2ons  

•  X-­‐ray  Ø Fracture  seen    Cast  6  –  8  weeks  ORIF  Ø   No  fracture  seen  Splint  re  x-­‐ray  10  days  Bone  scan  72  hours  CT  MRI    

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Scapholunate  Ligament  Injury  

•  FOOSH  

•  Similar  presenta2on  to  scaphoid  fracture  

•  X-­‐ray  may  show  widening  of  gap    •  MRI  best  inves2ga2on  

•  May  result  in  scaphoid  instability,  chronic  pain  and  disability  

Chronic    

•  Carpal  tunnel  syndrome  Median  nerve  compression  in  carpal  tunnel  Can  be  acute  with  wrist  fracture      •  Carpal  tunnel  –  FDP,  FDS,  FPL,  Median  Nerve  

•  Roof  is  flexor  re2naculum,  base  proximal  carpal  row  

 

Carpal  Tunnel  Symptoms  

Symptoms  • Pain  -­‐  o[en  nocturnal  Burning  Volar  wrist  Numbness  in  median  nerve  distribu2on    Tinels  Sign  Decreased  sensa2on  Decreased  2  point  discrimina2on  

Treatment  •  Occasionally  will  se^le  with  

NSAIDS  or  steroid  injec2on  or  splin2ng  

•  Surgery  with  division  of  flexor  re2naculum  

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Ulnar  Nerve  Compression  

•  Cyclists    •  Compression  in  Guyons  Canal  –between  pisiform  and  hamate  

•  Pain,  paraesthesia  li^le  and  half  of  ring  finger  

•  Weakness  late  

•  NSAIDS,  splint,  technique  changes  

De  Quervains  Tenosynovi2s  Synovial  inflamma2on  Abuctor  pollicis  longus  and  Extensor  pollicis  brevis  •  Occurs  at  level  of  radial  tuberosity  •  Racquet  sports,  golf,  ten  pin  bowling  •  Swelling,  tenderness,  crepitus  •  Finkelstein’s  test  

Treatment    •  Splin2ng  •  Stretching,  strengthening  •  Steroid  injec2on  •  Surgery  rarely  needed  

Ganglions  •  Synovial  cysts  •  Painless  swellings,  reduced  movement  •  Common  scapholunate  joint  •  USS,  MRI  

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Hand  Injuries  

•  Common  •  O[en  mistreated  •  Rehab  very  important  

Fractures  Thumb  •  Abduc2on  force  /  fall  on  thumb  •  Metacarpal  sha[  /  intraar2cular  •  Maybe  disloca2on  (Benne^’s  Fx)  •  All  require  ORIF  •  Rehab  for  ROM  •  Brace  for  return  to  sport  

Metacarpals  •  Punching,  falls  •  Boxers  fracture  •  Pain,  deformity,  swelling,  

rota2on,  shortening  •  X-­‐ray  •  Closed  reduc2on  /  ORIF  

Fractures  -­‐  Phalanges  

Proximal  •  May  impact  on  tendon  

func2on  •  Shortening,  rota2on  •  Intrar2cular?  •  Reduc2on  •  ORIF    •  Splint  –  posi2on  of  safety  

wrist  slight  extension,  MCP  70  degrees  flexion    

Distal  •  O[en  caused  by  crush  

injury  

•  O[en  compound  

•  High  rate  non  union  

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Disloca2ons  -­‐  Phalanges  •  PIPJ  (&  Dorsal)  most  common  •  Injury  to  volar  plate,                                                                                                                                  

collateral  ligament  

•  X-­‐ray  before  reduc2on  ideally  •  Definitely  x-­‐ray  a[er  reduc2on  

•  Buddy  strap  

•  Need  to  be  examined  for  instability  –  especially  extension  

•  Volar  disloca2ons  uncommon  hard  to  reduce  

•  DIPJ  –  o[en  associated  lacera2on  on  dorsal  surface  =  compound  injury  

PIPJ  DislocaLon  

Mallet  Finger  

Avulsion  of  extensor  mechanism    •  Ball  hiqng  2p  of  finger  •  Maybe  associated  with  fracture  •  Distal  phalanx  held  in  flexion  Treatment  •  Fracture  >  30%  joint  surface  –  ORIF  •  Ligament  injury  –  splint  in  slight  

hyperextension  •  8  wks  full  2me  +  addi2onal  4  at  night  

and  8  for  sport  •  If  not  healed  surgery    

Ulnar  Collateral  Ligament  –  Skier’s  Thumb  

•  Abduc2on,  hyperextension  

•  Complete  rupture  greater  than  20  degrees  with  stressing  

•  Splint  for  par2al,  surgery  for  complete  

•  O[en  ignored  by  pa2ents  

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FDP  Avulsion  

•  Ring  most  common  •  Jersey  finger  

•  Sits  in  extension  compared  to  other  fingers  

•  X-­‐ray  -­‐  ?  Fracture  •  Surgery    

Hand  &  Finger  Lacera2ons  

•  Important  to  exclude  neurovascular  or  tendon  injury  

•  Associated  fractures,  disloca2ons  •  Infec2on  risk  high  

•  Tooth  lacera2on  over  MCPJ  important  –  always  go  bad