hand upper extremity - lecom education system · pdf fileupper extremity – caused by...

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Evalua&onandTreatmentofCommonUpperExtremity

Problems&InjuriesJoshuaTuck,D.O.,M.S.

LECOMSportsandOrthopedicMedicineToronto2016

Objec&ves•  Anatomicreviewofthe

elbow,wristandhand.•  Discusscommonclinical

condi&onsineachanatomicregion.–  Lateralandmedial

epicondyli&s,deQuervaintenosynovi&s,carpaltunnelsyndromeandtriggerfinger.

•  Describeanddemonstrateevalua&ontechniques.

•  Reviewosteopathicconsidera&onsineachregion.

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OsteopathicPrinciples

OverviewofEpicondyli&s

•  Painatthemyotendinousjunc&onofthesemusclegroupsisreferredtoaslateralandmedialepicondyli&s,respec&vely.

•  Lateralepicondyli&sisoSencalledtenniselbowandmedialepicondyli&s,golfer'selbow

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LateralEpicondyli&s•  Introduc&on

–  AUributedtodegenera&onoftheextensorcarpiradialisbrevisorigin,althoughtheunderlyingcollateralligamentouscomplexandjointcapsulealsohavebeenimplicated

–  Overexer&onoftheextremitywithrepe&&vewristextensionandalterna&ngforearmprona&on/supina&on

•  Epidemiology–  1%to3%ofadultseachyear–  DiagnosiswasfirstmadebyRungein1873–  Named“lawn-tennisarm”byMajorin1883duetoitsassocia&onwith

thesport–  AdultinthefourthorfiShdecadeoflife–  Affectsmenandwomenequally–  Symptomsmorecommonindominatearm

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Epicondyli&s

•  Thelateralepicondyleoftheelbowisthebonyoriginforwristextensors

•  Themedialepicondyleisthebonyoriginforwristflexors.

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LateralEpicondyli&s

•  Pa&entHistory–  Painoverthelateralaspectoftheelbowisthemostconsistentsymptoms

–  Painisusuallysharpandisexacerbatedbyac&vi&esinvolvingac&vewristextensionorpassivewristflexionwiththeelbowextended

–  Characteris&ccomplaintistheinabilitytoholditems(ie:acoffeecup)duetopaininthelateralelbow

–  Symptomonsetisfrequentlyinsidious,withnoclearinci&ngevent

LateralEpicondyli&s

•  PhysicalExam– MaximaltendernessslightlyanterioranddistaltothelateralepicondyleovertheoriginoftheECRBandtheEDCmuscles

–  Lessfrequentlylocalizedtendernessispresentattheapexofthebonylateralepicondyle

–  Rarely,tendernessisaccompaniedbyswelling,erythema,orwarmth

–  PainlocalizedtothelateralepicondyleorjustslightlydistaltotheextensororiginisoSenelicitedwithresistedwristanddigitextension

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SpecialTestsforElbowLateralEpicondyli&s

•  Forearmpronatedandflatontable

•  Fistwithextendedwrist•  Pa&enttoresistflexion•  PainattheLateral

Epicondylemeanspathology.

•  “TennisElbow”

LateralEpicondyli&s

•  Imaging

– Radiographs•  Occasionallyrevealscalcifica&onwithintheextensormass

– MRI– Ultrasound

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LateralEpicondyli&s

•  Differen&alDiagnosis

– RadialTunnelSyndrome– CervicalRadiculopathy– OCDlesionofradiocapitellarjoint– Posterolateralelbowplica– Posterolateralelbowinstability

LateralEpicondyli&s

•  NonsurgicalTreatment(firstline)

–  Rest– NSAID’s–  PhysicalTherapy–  Injec&on– Orthoses–  ShockWaveTherapy– Acupuncture–  PRP–  Prolotherapy

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LateralEpicondyli&s

•  SurgicalTreatment

– Maybeconsideredwhen6to12monthsofconserva&vetreatmenthasfailed

– OpenDebridement– EndosocpicECRBrelease– PercutaneousECRBrelease

deQuervainTenosynovi&s

•  Introduc&on–  Stenosingtenosynovi&softhefirstdorsalcompartmentofthewrist

–  E&ologyisthoughttobesecondarytorepe&&veorsustainedtensiononthetendonsofthefirstdorsalcompartment

–  Tensionproducesafibroblas&cresponse,resul&nginthickeningandswellingofthecompartmentanddiscomfortwithuseofthehandandwrist

–  Firstdescribedin1895byFritzdeQuervain

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deQuervainTenosynovi&s•  Thefirstdorsal

compartmentofthewrist(I)

•  Abductorpollicislongusandextensorpollicusbrevis.

•  Inflamma&oncausedbyrepe&&vemo&onsorkine&csoma&cdysfunc&ons.

•  +Finklestein’stest


•  Epidemiology– Nolong-termepidemiologicstudyhasbeendone–  Caseseriessuggestthatitaffectswomenuptosix&mesmoreoSenthanmenandisassociatedwiththedominanthandduringmiddleage

– Occupa&onsrequiringrepe&&vetyping,liSing,andmanipula&onhavebeenconsideredriskfactors

–  Pregnantandlacta&ngwomenrepresentanincreasingcohortofpa&entswithnew-onset,self-limiteddisease

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OverviewandIncidence

•  Imbalancebetweenflexorsandextensors

•  deQuervaintenosynovi&sisthemostcommonentrapmenttendoni&sofhandandwristaSertriggerfinger

•  Itismostcommonlyseeninwomenbetween30and50yearsofage


•  Pa&entHistory

–  OSenpresentswithagradualonsetofpainthatmaybeexacerbatedbygrasping,thumbabduc&on,andulnardevia&onofthewrist

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•  PhysicalExam–  Loca&onoftendernessismorespecifictothefirstextensorcompartmentovertheradialstyloid

–  Possibleradia&onofpaintotheforearmanddistallytothethumb

–  TheFinkelsteinTest•  Classicmaneuverfordiagnosis•  Consideredpathognomonic•  Performedbygraspingthepa&ent’sthumbandquicklydevia&ngthehandandwristulnarly

•  Posi&vetestreproducesthepain

Finklestein’stest

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FirstDorsalCompartment

EPB

EPL

APL


•  Imaging

–  Diagnosedclinically– Wristradiographscanbeusedtoruleoutothercausesifdiagnosisisunclear

– MRI

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–  Intersec&onsyndrome–  Radialstyloidfracture–  Scaphoidfracture–  Thumbinstability–  Basilararthri&softhethumb

–  Radialneuri&s

NonsurgicalTreatmentOp&ons

•  Thumb/wristimmobiliza&onusingsplintorbrace

•  Ice•  NSAIDs•  Improvearthrokine&cs/posturalmodifica&ons

•  Steroidinjec&ons

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DeQuervainTenosynovi&s


– Releaseofthefibro-osseousroofofthefirstdorsalcompartment

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SurgicalManagement*

Incision

SurgicalManagement

Radial Sensory Nerve

Extensor Retinaculum

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SurgicalManagement

EPB

APL

CarpalTunnelSyndrome

•  Introduc&on

– Firstdescribedin1854bySirJamesPagetinpa&entswithdistalradiusfracture

– Mostcommoncompressiveneuropathyoftheupperextremity

– CausedbyMediannervecompressioninthecarpaltunnel

– MaybeAcuteorIdiopathic

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•  Epidemiology– Between0.99and3.46casesper100,000intheUnitedStates

– 500,000surgicalproceduresannually– Economicimpactes&matedat$2Billionannually– WomenmorethatMen–  Increasingincidencewithage

CarpalTunnelSyndrome•  Commoncompressive

neuropathy.•  Anatomiccarpaltunnelis

createdbythetransversecarpalligamentandhousesthefollowingstructures:

•  Mediannerve•  Flexordigitorumprofundus

andsuperficalis.•  Palmarislongus

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CarpalTunnelSyndrome•  Pa&entHistory

–  Pain–  NocturnalPain–  Traumaand/orrepe&&vemovements

–  Painmayradiatetoforearmorelbow

–  Weakness–  Paresthesiasinthumband1ormoreoftheradialdigits

–  Decreaseddexterity–  Commonlybilateral

CarpalTunnelSyndrome*

•  PhysicalExam

– Necktofingers– Skinandmuscleatrophy– Tinel– Phalen– Durkan

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TestsforCarpalTunnel*

Phalen’s test Prayer test / Reverse Phalen’s

Tinel’s test

Spurling sign Durkan’s Test

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•  Diagnos&cStudies

– EMG– WristRadiographs


•  Associatedwithmanysystemiccondi&ons– Obesity– DrugToxicity– Alcoholism– Diabetes– Hypothyroidism– RheumatoidArthri&s– RenalFailure– Pregnancy(20%to45%)

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–  Overusesyndromes–  Cervicalrootimpingement

–  Thoracicoutletsyndrome

–  Proximalmediann.compression

–  CMCarthri&s

UpperLimbCutaneousInnerva&on

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UpperQuarterDermatomes


•  NonsurgicalTreatment– Splin&ng(nightsplints)– OralMedica&ons

•  NSAIDs•  OralCor&costeroids

– Cor&costeroidInjec&ons

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GoalofCTSManualMedicine•  Lengtheningorloosening

thetransversecarpalligament.

•  Increasingcarpaltunneldiameter.

•  Improvinglympha&cflow.•  Restoringfunc&onand

mobilitytotheradiocarpalandulnocarpaljoints.

•  Restoringbalancebetweenthewristflexorsandextensors.



– OpenRelease– EndoscopicRelease

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TriggerFinger

•  Introduc&on–  Stenosingtenosynovi&s–  Isapathologicaldispropor&onbetweenthevolumeofthere&nacularsheathanditscontentsasitmovesthroughtheA1pulley

–  Inabilitytoflexorextenddigitsmoothly

–  Alldigitscanbeaffected–  Ringfingerismostcommon

TriggerFinger

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TriggerFinger

•  Epidemiology– Morecommoninwomen– AverageAgeis52to62yearsold– Associatedwith

•  RheumatoidArthri&s•  Gout•  Diabetes•  Amylodosis•  CHF•  CTS

TriggerFinger

•  Pa&entHistory

– Mayreportamild,nonpainfulclicktoinabilitytofullyflexdigit.

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CochraneReview

•  Noar&clesthatdirectlycomparedsteroidinjec&onwithsurgicaltreatment.

•  However,tworeferencedar&cles,whichwereexcludedfromthereview,reportedcureratesof89to97percentforsurgeryand60to90percentforsteroidinjec&on.

•  Aseparatear&clecomparedsplin&ngwithsteroidinjec&onandfoundcureratesof70and82percent,respec&vely.

TriggerFinger

•  PhysicalExam

–  Painatpalmarbaseofinvolveddigit

–  PossiblenodulenearA1–  Palpableclicking–  Lockeddigitflexionthatmustbereduced

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TriggerFinger

•  Imaging

– Generallynotindicated

TriggerFinger


– CarpalTunnelSyndrome– DupuytrenContracture– RheumatoidArthri&s

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TriggerFinger

•  NonsurgicalTreatment

– Ac&vitymodifica&on– NSAIDs– Splints– Cor&costeroidInjec&ons

TriggerFinger


– A1pulleyrelease

•  Open•  Percutaneous

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References:

•  Scarpone,M.Theefficacyifprolotherapyforlateralepicondylosis.ClinJSportMed.2008May;18(3)248-254

•  Keith,Michaelet.al.DiagnosisofCarpalTunnel.JAmAcadOrthopSurg2009:17;389-396.

•  Cranford,CS.CarpalTunnelSyndrome.JAmAcadOrthopSurg2007;15;537-548.

Pre-testQues&ons:

•  1.Whichloca&onoftheelbowismostpronetoepicondyli&s?

•  A.Lateral•  B.Medial•  C.Posterior•  D.Radialhead

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•  2.Allofthefollowingarepartofthedifferen&aldiagnosisfor“golfer’selbow”except:

•  A.Flexor-pronatorstrain•  B.Medial(ulnar)collateralligamentsprain•  C.Ulnarneuri&s•  D.Radialheadsoma&cdysfunc&on

•  Agolferhasbeenstrugglingwithelbowpainfor5yearsandpresentstoyourofficebecausethepainisnowlimi&nghisabilitytogolf.Whichismostlikely?

•  A.Medialcollateralligamentrupture•  B.Lateralepicondylosis•  C.Medialepicondyli&s•  D.Radialheadsoma&cdysfunc&on

hand upper extremity - lecom education system · pdf fileupper extremity – caused by...

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