Physical Medicine & Rehabilitation
Examination of the Hand, Wrist, and Elbow Injuries
Adam Lewno, DO
Department of Physical Medicine and Rehabilitation
10/3/2018
Physical Medicine & Rehabilitation
Or
Physical Medicine & Rehabilitation
Sports Injuries and Examination of the Hand, Wrist, and (hopefully)
Elbow
Adam Lewno, DO
Department of Physical Medicine and Rehabilitation
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No Disclosures
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Objectives:
• Recognize the pertinent anatomy of the elbow, wrist, and hand.
• Demonstrate correlation of structure and function with sports related injures of the elbow, wrist, and hand.
• Recognize common sports related injuries of the elbow, wrist, and hand.
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Road Map
• Wrist• Scaphoid fracture• Carpal instability• DeQuervian’s Tenosynovitis • TFCC
• Finger• UCL• Mallet finger• Jersey finger• PIP Collateral sprains
• Elbow (Cases discussed)
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The Wrist
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Scaphoid fracture
• Most common carpal facture
• “FOOSH” injury
• Symptoms• Radial wrist pain
• Snuff box tenderness
• Proximal pole tenderness
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Scaphoid fracture: Exam
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Watson Test (Scaphoid Shift test)
• Thumb over the scaphoid tubercle and index finger over the dorsal aspect of the scaphoid/scapholunate joint – in Ulnar deviation
• Apply dorsally directed force with thumb against the distal pole of scaphoid while moving wrist from ulnar to radial deviation
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Scaphoid fracture
• 65% occur at the waist
• High rate of non union
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Bones/Joints
• Some: Scaphoid*
• Lovers: Lunate*
• Try: Triquetrum
• Positions: Pisiform
• That: TrapeziuM*
• They: TrapezoiD
• Can’t: Capitate
• Handle: Hamate
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So is it a Scaphoid Fracture?
• X-rays: • PA, lateral, oblique,
clenched fist
• Negative X-rays• Thumb Spica and repeat
X-rays in 2 weeks…and again?
• MRI/CT
• Bone scan
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It’s a Scaphoid Fracture!
• Non operative• Non Displaced: (<1mm) or distal Pole• LA Spica with slight palmar flexion and radial deviation for 6
weeks• SA spica until radiological evidence of union
• If longer than 3-4 months: Bone stim, stim, surgery?
• Or early Screw fixation
• Operative• Displaced (>1mm)• proximal pole fracture• Unstable • Unsure (ask the hand guys!)
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Carpal Instability
• Malalignment of the carpal bones
• Often traumatic but can be atraumatic
• Clench view X-rays
• Follows a pattern• Scapholunate
• Lunotriquetal
• Midcarpal (SLAC)
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Scapholunate Instability
• Most common ligament injured
• Dorso radial pain after a FOOSH injury +/- weak grip
• Tenderness at the Scapholunate more then at the snuff box
• AP and Clench views• Positive >2mm• Cortical ring sign • Lots of different angles
• MRI Arthrogram
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Scapholunate Instability
• Acute (3-4 weeks)• Percutaneous pinning
• ORIF K wires and capsulodesis
• Chronic• No OA: capsulodesis
and reconstruction
• OA: fusion
• High Stakes injury!!
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Lunotriquetral Instability
• Often injured with an additional structures of the wrist
• Less common than Scapholunate instability
• FOOSH injury with dorsoulnar pain and tenderness
• Imaging: • X-ray with clench view
showing LT interval widening• MRI arthrogram
• Injections help with pain management
• Incomplete tear: • Inject for pain• Immobilize
• Complete tear or failure to progress• Possible Lunotriquetal
ligament repair • Ulnar shortening as needed• Less likely for arthrodesis
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Lunotriquetral Instability
• Lunotriquetral ballotment (reagan test)
• Grasp the lunate between the thumb and index finger of one had
• Grasp the triquetrum/pisiform between the index finger and thumb of the second hand
• Shift the grasping hands in opposite directions
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Wrist Extensor Compartments
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De Quervain’s Tenosynovitis • Dorsoradial wrist pain involving compartment 1
• Racquet sports, javelin, discus, Golf (in the lead arm)
• 10:1 ratio of F:M
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De Quervain’s Tenosynovitis
• Non operative: • Rest• NSAID• Thumb Spica splint with
IP free• Physical therapy• Injection (septum 20-
40% of the time)
• Surgical • Tenontomy and sheath
resection • 6-9 week recovery
Radiology: Volume 260: Number 2—August 2011
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De Quervain’s Tenosynovitis
• Non operative: • Rest
• NSAID
• Thumb Spica splint with IP free
• Injection (septum 20-40% of the time)
• Surgical tenotomy• 6-9 week recover
Radiology: Volume 260: Number 2—August 2011
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Triangular Fibrocartilage Complex (TFCC)
• Degenerative (Chronic) vs acute twisting injury (Fall/Younger)
• US limited, improved imaging with MRI
• Triangular (articular) disk
• Primary stabilizer of the DRUJ
• Central and radial portions are avascular
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TFCC
• Degenerative vs acute twisting injury
• US limited, improved imaging with MRI
• Triangular (articular) disk
• Primary stabilizer of the DRUJ
• Central and radial portions are avascular
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TFCC
• Non operative: • Relative rest, splinting, NSAID, CSI
• Long arm cast in neutral rotation for 6 weeks
• Surgical• Central tear (most typical)
• Debridement, potential Ulnar shortening
• Peripheral (15-20%)• Repair and Potential ulnar shortening if noted impaction
• DRUJ • reconstruction with immobilization above the elbow
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Fingers – Phalanges!
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Jersey Finger
• Overwhelming extension moment (when finger flexed)
• FDP Avulsion at the DIP• Most often D3 (Ring)
• No active DIP flexion • Full PROM – No AROM
• Xray to rule out avulsion
heritance.me/anatomy
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Jersey Finger
• Overwhelming extension moment (when finger flexed)
• FDP Avulsion at the DIP• Most often D3 (Ring)
• No active DIP flexion • Full PROM – No AROM
• Xray to rule out avulsion
Leggit, et al. American Family Physician 2006
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Jersey treatment
• Non operative• Splint in neutral
• Operative repair: • Retrieve tendon
• stabilize
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Jersey Finger Classification
F. Lapegue, et all. Traumatic Flexor tendon injuries, 2015
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Mallet Finger
• Compression force to the end of finger• D3, D4, D5 most
frequent
• DIP flexion deformity• NO extension AROM
• Maintained PROM
• Swan neck
• Xrays and/or US for avulsion fracture
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Mallet Finger
• Compression force to the end of finger• D3, D4, D5 most
frequent
• DIP flexion deformity• NO extension AROM
• Maintained PROM
• Swan neck
• Xrays and/or US for avulsion fracture
American Hand surgery
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Mallet Finger
• Terminal extension tendon
• With or without avulsion
(no FDS rupture)
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Mallet Finger- Treatment
• Extensor splint!!• Continuously for 6 weeks
• 2-4 more weeks at night
• Surgery• Large fracture
• Open wound
• Tendon subluxation
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Thumb Motion
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UCL Injury (Game Keepers/skiers)
• Forceful radial deviation
• Symptoms: • Pain
• Swelling/ecchymosis
• loss of motion
• Decr pinch
• X-ray's to rule out fracture• US – MRI?
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UCL Stress test
• Performed at 0 and 30
• Compare to the contralateral side
• How? • Immobilize thumb MC in
one hand and the proximal phalanx with the other
• Apply ulnarly directed force to the radial side of the joint to gap the thumb MCP on ulnar side
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UCL- Stenor Lesion
• Interposition of adductor aponeurosis up to 70%
• Gross instability or mass
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UCL Treatment (Evolving)
• Non operative• Thumb spica splint for 4 weeks
• 3 months of non strenuous activity (debated length)
• Operative• >30-35 degree opening in flexion
• >15 degree opening compared to contralateral
• Stener lesion ( >2mm displacement)
• Large bony avulsion
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PIP Collateral injury (jammed finger)• Radial more often then the ulnar side
• Index finger most common with tenderness and laxity• Must rule out dislocation!
• May radially dislocated and spontaneously reduce
• Buddy tape for 3-6 weeks
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Thank You
• Rebecca McConnell, DO
• Daniel Lueders, MD