UNDERSTANDING THE UPPER EXTREMITY Pr esented by Kar i M. - - PDF document

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UNDERSTANDING THE UPPER EXTREMITY

Pr esented by Kar i M. Komlofske, F NP-C & John Wor kinger , F NP-C Oc tober 2016

CARPAL TUNNEL SYNDROME

• Most common peripheral compression

(entrapment) neuropathy

• Prevalence 3-6 % of adults
• More common in women
• Etiology
• Idiopathic
• Trauma
• Tumor

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CARPAL TUNNEL SYNDROME

• Pain is NOT a primary symptom
• Paresthesias (pins & needles) in palmar pads of digit tips,

initially at night

• Numbness (loss of sensation)

(Semmes Weinstein monofilament testing)

• Weakness of thumb abduction

Loss of thumb dexterity (not grip) Wasting of thenar musculature

CARPAL TUNNEL SYNDROME

ASSOCIATED RISK FACTORS

• Genetics
• Hormonal factors
• Pregnancy
• Menopausal
• Hypothyroidism
• Obesity
• Diabetes
• Age
• Gender
• Rheumatoid arthritis
• Occupation
• Lozano-Calderon 2008

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CARPAL TUNNEL SYNDROME

OCCUPATIONAL EXPOSURE

• Keyboarding is NOT a risk factor
• Evidence supports regular keyboarding is protective
• Stevens 2001, Atroshi 2007, Mattioli 2009
• Vibration exposure
• Barcenilla 2012
• Forceful & sustained heavy grip activities
• Poultry/fish/meat processing
• Palmer 2007, van Rijn 2009

CARPAL TUNNEL SYNDROME

PHYSICAL EXAMINATION

• Median nerve Tinel’s testing
• Median nerve compression testing at

wrist

• Phalen’s maneuver
• Weakness/wasting Abductor Pollicis

Brevis

• Sensibility testing with Semmes

Weinstein monofilaments (index/little alone)

CARPAL TUNNEL SYNDROME

HISTORY CORRELATES WITH SEVERITY

• Mild
• Intermittent night time paresthesias
• Moderate
• Intermittent night time and day time symptoms

to include numbness

• Severe
• Constant symptoms
• Diminished protective sensation
• Loss of thumb dexterity
• Wasting of Abductor Pollicis Brevis

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WASTING OF ABDUCTOR POLLICIS BREVIS MUSCLE

CARPAL TUNNEL SYNDROME

Confirmatory Nerve Conduction Testing Required by CMS in Medicare/-aid patients prior to surgery No X-Rays needed

CARPAL TUNNEL SYNDROME

• Screen for hypothyroid and diabetes mellitus
• 3-6 month trial of wrist bracing with mild,

early symptoms

• Consider corticosteroid injection if symptoms

intermittent and no motor deficit

• No role for NSAIDs
• Reliable results with surgical release
• Occupational Therapy: Good evidence for

relief of mild CTS symptoms with use of wrist brace at night.

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TRIGGER DIGITS

• Mechanical catching of the digit during active

extension and flexion

• “Feels like my finger/thumb is coming out of

joint”

• “My finger gets stuck”
• Morning locking/stiffness that improves as day

progresses (similar to OA)

TRIGGER DIGITS

• Ring finger and thumb most common
• Association with flexor tendon sheath cysts in

palm

• Can be association with carpal tunnel syndrome
• Etiology
• Idiopathic
• Inflammatory
• Trauma
• Congenital

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TRIGGER FINGERS

• ASSOCIATED RISK FACTORS
• Diabetes Mellitus
• Gender
• Age
• Previous history of trigger digits, CTS
• Rheumatoid Arthritis
• Occupation?

TRIGGER DIGITS

• EXAMINATION
• Obvious mechanical triggering
• Tender at palmar base of finger (A-1 pulley)
• Can present with locked digit
• Mild flexion contractures in chronic cases
• Mobile “nodule” at A-1 pulley with finger

motion

• No X-Rays needed
• Don’t confuse with Dupuytren’s or OA

TRIGGER DIGITS

• TREATMENT
• Observation, rest
• No role for NSAIDs other than pain

relief

• Corticosteroid injection into tendon

sheath

• Reliable surgical release
• Role of Occupational Therapy,

splinting

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DE QUERVAIN’S SYNDROME

• More common in female population
• Associated with breast feeding hand

position “Mommy thumb”

• Pain at the radial side of the wrist
• Aggravated by thumb/wrist combined

motion

• Paresthesias in Sensory Branch Radial Nerve

in chronic cases

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DE QUERVAIN’ SYNDROME

• Tenderness at first dorsal compartment
• Radiating pain with Finkelstein’s test
• Swelling at first dorsal compartment
• Occasional cyst from leading edge of FDC
• Tinel’s over Sensory Branch Radial Nerve
• Basal joint is nearby so check grind test
• Wrist radiographs to assess for arthritis

FINKLESTEIN’S TEST

DE QUERVAIN’ SYNDROME

TREATMENT

• Bracing for symptomatic relief – Thumb Spica
• Acetaminophen and/or NSAIDs for symptomatic

relief

• Corticosteroid injections
• Role of Occupational Therapy – may be helpful

AFTER injection

• Surgical release is reliable

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DEQUERVAIN’S INJECTION BASAL JOINT ARTHRITIS

• Gender (F:M 6:1)
• Armstrong 1994, Xu 1998
• Age, 1/3 females over 50 yo
• Etiology
• Degenerative arthritis
• Role of joint laxity
• Kirk 1967, Eaton 1984, Pellegrini 1996
• Inflammatory arthritis –RA, psoriatic
• Post-traumatic arthritis

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BASAL JOINT ARTHRITIS

• ain and/or weakness with pinch and grip activities
• CMC joint tender to palpation
• Dorsal first CMC joint prominent with subluxation
• Thumb in palm contracture, MCP hyperextension
• Positive grind test
• Confirmatory X-Rays
• De Quervain’s can mimic basal joint OA, check

Finklestein’s test

BASAL JOINT ARTHRITIS TREATMENT

• Rest
• Bracing
• Custom rigid thermoplastic orthoses
• Soft supports
• Nutritional supplements
• Acetaminophen and/or NSAIDs
• Corticosteroid injection
• Role of Occupational Therapy – Hot Paraffin Dips,

Bracing and Adaptive Equipment

• Several reliable surgical options once conservative

measures fail, dependent upon the stage of arthritis

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LATERAL EPICONDYLOSIS

• Lateral Elbow pain
• Weakness in grip
• Symptoms aggravated by activities

that involve resisted wrist and elbow extension

• Insidious onset most common, but can

be attributed to an event or activity

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LATERAL EPICONDYLOSIS

• PHYSICAL EXAMINATION
• Tenderness
• Provocative Maneuvers
• STUDIES
• Plain films only if elbow motion reduced
• Pomerance 2002
• Resist the urge to order MRI
• Incidental extensor changes occur with age

with high false positive rate

• Steinborn 1999,

LATERAL EPICONDYLOSIS EXAM

LATERAL EPICONDYLOSIS

• Histologic findings lead to the

concept that this is a degenerative rather than inflammatory process – cortisone injections will likely not work in chronic cases.

• This is an “OSIS,” NOT an “ITIS”

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TRADITIONAL TREATMENT

• Rest/Ice
• NSAIDs
• Modification of activities
• Elbow strap/wrist brace
• Corticoid steroid injections
• Occupational therapy - bracing and modified

activities

• Surgery for refractory cases

CORTICOSTEROID INJECTION

• Most effective early in process (first three months)

in conjunction with occupational therapy

• Consent to include possibility of:
• Recurrence
• Permanently altered skin pigmentation
• Subcutaneous fat atrophy
• Steroid flare

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LATERAL EPICONDYLOSIS WHAT WE DO KNOW

• Enthesopathy of middle age
• Unknown pain generator
• No single reliable treatment
• Surgical results inconsistent
• Self limited condition, although it can

last greater than 12 months.

LATERAL EPICONDYLOSIS

• Shared decision making with patient

for treatment

• Reassurance
• Nothing is being damanaged
• PAIN ≠ HARM
• Improving coping strategies
• Multidisciplinary effort

LATERAL EPICONDYLOSIS: BRACES

Use of Braces = Inconclusive

• Wrist brace:
• Consider trial of wrist brace

at night if awakening with pain.

• May also be helpful with

heavy lifting.

• Counterforce brace:
• Caution: compression can

irritate radial and ulnar nerves.

• Wear with activity and use

model with built-in pad.

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CUBITAL TUNNEL SYNDROME

• Second most common peripheral

compression (entrapment) neuropathy

• Prevalence 2-3 % of adults
• Equal male/female involvement
• Etiology
• Idiopathic
• Traction
• Compression

CUBITAL TUNNEL SYNDROME

• Associated risk factors
• Diabetes Mellitus
• Previous h/o elbow fracture
• Nerve Subluxation
• Elbow arthritis/synovitis

CUBITAL TUNNEL SYNDROME

• Paresthesias (pins & needles) in the

ulnar nerve distribution including ulnar aspect of hand

• Weak grip
• Weak pinch
• Loss of dexterity “my hand does not

do what I tell it to do”

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CUBITAL TUNNEL SYNDROME

Examination

• Ulnar nerve tinel’s at elbow
• Altered sensation by monofilament testing
• Positive elbow flexion test
• Weak inter-osseous musculature
• Flexible ulnar clawing, Wartenburg’s T sign,

Froment’s sign

• Wasting of hand intrinsics
• Confirmatory NCS “IR NCS”
• X-Rays of the elbow

CUBITAL TUNNEL SYNDROME

• Treatment
• Avoiding aggravating activities and positions
• Prolonged elbow flexion
• Direct pressure on medial elbow
• Corticosteroid injections are discouraged –

due to risk of nerve injury

• Surgery in recalcitrant cases
• Role of Occupational Therapy – night bracing

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DUPUYTREN’S DISEASE

(PALMAR FIBROMATOSIS)

• Typically painless other than onset
• Sub-Q nodule in palm of hand at distal

palmar crease (level in line with ring/little metacarpal)

• Over time form pretendinous cords
• +/- Contracture of MCP joint
• +/- Extension into digit & PIP joint

contracture

• Knuckle pads at MCP/PIP joints

PALMAR FASCIA

Dupuytren’s Disease

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DUPUYTREN’S DISEASE

• Strong familiar predisposition
• Northern European descent
• Males > Females 6:1
• Fifth through seventh decades
• Bilateral in 65% of cases
• Association with common/chronic

disease likely coincidental than causative

DUPUYTREN’S DISEASE

• Reassurance, reassurance, reassurance
• Cannot be cured
• Goal of treatment is to maintain hand

function

• Avoid manipulation or massage
• Corticosteroid injection plays no role
• Pre-operative OT not shown to be effective
• Presence of contracture and impaired

function is indication for surgical treatment

DUPUYTREN’S DISEASE

• Radiation treatment in early cases
• IR Radiation Oncology
• Keilholz 1996 & 2001, Seegenschmiedt 2001,

Betz 2010

• Once contracture present and interfering with

function

• Needle aponeurotomy
• Collagenase Clostridium histolyitcum injection
• Partial palmar fasciectomy
• Post-operative therapy intensive

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GANGLION CYSTS

• Most common “tumor” of hand
• 60-70 % dorsal wrist
• History of variable size/resolution
• Etiology
• Mucoid degeneration
• Idiopathic
• Association with hypermobility
• Underlying arthritis
• Trauma

GANGLION CYST

• Does not move w/ digit flexion/extension as in

extensor tenosynovitis

• Dorsal cysts prominent with flexion of wrist
• Volar cysts adjacent radial artery, +/-pulsatile
• Firm/hard due to hydraulic phenomenon
• Trans-illumination test
• Allen’s test
• Radiographs

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GANGLION CYSTS

• 26-50% symptomatic (annoying pain)
• Lowden 2005, Westbrook 2000
• Appearance is a common concern 38%
• Westbrook 2000
• Concern about malignancy 28%
• Westbrook 2000

GANGLION CYST

• Reassurance/observation
• 50 % spontaneous resolution rate
• Loder 1988, Mackie 1984
• Rupture
• Manual pressure
• Needle aspiration – NEVER ON VOLAR
• Role of Occupational Therapy:
• No referral indicated.
• If seen, 1x visit for pt education, activity modification, and

splinting if needed to rest joint and reduce inflammation.

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GANGLION CYST

• Surgical excision is discouraged
• Customary risks of surgery as well as:
• Unsightly Scar
• Keloid formation
• Scar tenderness
• Loss of wrist motion
• Sensory nerve injury/neuroma
• Radial artery injury
• Continued wrist pain
• Recurrence 10-40%

MUCOUS CYST

• Tumor of Distal Interphalangeal Joint
• Associated with underlying arthritis
• History of variable size/resolution
• Adjacent nail plate groove deformity
• Pain with underlying synovitis from adj. joint

Mucous Cyst

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MUCOUS CYST

• EXAMINATION
• Mass in eponychium/proximal nail fold
• Thin or thickened overlying dermis
• Contains clear gelatinous fluid
• Herberdan’s/Bouchard’s nodes

(osteophytes)

• History of redness, heat and pain when

underlying joint arthritis inflamed

• X-Rays are helpful

MUCOUS CYST MUCOUS CYST

TREATMENT

• Reassurance/observation
• Spontaneous resolution
• Discourage aspiration
• NSAIDs if underlying joint inflamed
• Pad with Band-Aid or Coban

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OLECRANON BURSITIS

• Fluid filled synovial tissue lined sac
• Boggy swelling/mass over posterior elbow
• More common in middle aged men
• Spontaneous
• Frequently follows an aggravating activity
• Prolonged direct pressure, flexion/extension

activity

• Following trauma
• With/without skin break

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OLECRANON BURSITIS

• Etiology
• Aseptic
• Trauma
• Inflammation
• Gout/Pseudogout
• Rheumatoid/SLE
• Septic
• Hematogenous
• Direct inoculation

OLECRANON BURSITIS

• Aseptic Bursitis 2/3 of cases
• Variable erythema 25%
• Variable tenderness 40%
• Variable warmth to touch 50%
• No fever/chills
• Rare leukocytosis, left shift (±

inflammatory)

• Rare elevated inflammatory markers (“)

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OLECRANON BURSITIS

• Septic Bursitis 1/3 of cases
• Erythematous/cellulitis 60%
• Tender to touch 100%
• Warmth to touch 100%
• Allodynia
• Fever/chills 40%
• Leukocytosis, left shift
• Elevated inflammatory markers (CRP/ESR)

OLECRANON BURSITIS

• To aspirate or not to aspirate?
• We discourage this even in septic cases as 95% are

community acquired GPC sensitive to first generation Cephalosporins

• Definitive but not without risk
• iatragenic infection risk
• Sinus tract development
• Never inject corticosteroids
• Infection risk is 10-25%
• Overlying skin atrophy

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ASEPTIC OLECRANON BURSITIS

• Reassurance
• Neoprene sleeve or elbow pad for comfort
• No therapy referral needed.
• Avoid aggravating positions
• Direct pressure over point of elbow
• Holding elbow flexed for prolonged periods
• Resist temptation to aspirate
• Never inject corticosteroids
• Surgical excision is discouraged as this condition

reliably responds to conservative care

SEPTIC OLECRANON BURSITIS

• Intravenous First Generation Cephalosporin
• 95% of positive cx are community acquired GPC and can

be treated empirically observing for defervescence.

• Role of immediate surgery is controversial
• Painful packings required post-op
• Chronic draining sinus tracts
• Soft tissue defects
• Painful scar
• Is it really warranted if IV abx will cure 95%?
• Surgical required in systemic septicemia or patients not

responsive to IV antibiotic therapy

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FLEXOR TENOSYNOVITIS FLEXOR TENOSYNOVITIS

• Infectious or Inflammatory – present similarly
• Through HISTORY
• Four Cardinal Symptoms
• Sausage finger – uniform swelling
• Pain with passive extension
• Flexed positon
• Tenderness along the Flexor tendon sheath

Treatment – Surgical emergency appropriate antibiotics if indicated

INJECTIONS

• Celestone = betamethasone, 6mg/1ml. Kenalog = triamcinolone, 40mg/1ml.
• Sterile procedural method for injections into joints/tenosynovium/cysts is mandatory.
• CTS: 6mg Celestone or 40mg Kenalog with 2ml plain lidocaine – 3ml total.
• Trigger finger: 3mg Celestone or 20mg Kenalog with 0.5ml plain lidocaine – 1ml total.
• De Quervains: 6mg Celestone or 40mg Kenalog with 2ml plain lidocaine – 3ml total.
• Thumb CMC: 3mg Celestone or 20mg Kenalog with 0.5ml plain lidocaine - 1ml total.
• Lateral epicondyle: 6mg Celestone or 40mg Kenalog with 2ml plain lidocaine – 3ml total.

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FRACTURES OF THE UPPER EXTREMITY

• Humerus
• Olecranon
• Forearm
• Wrist
• Hand

PROXIMAL HUMERUS FRACTURES

• Epidemiology
• Most common fracture of the humerus
• Higher incidence in the elderly, thought to be

related to osteoporosis

• Females 2:1 greater incidence than males
• Mechanism of Injury
• Most commonly a fall onto an outstretched

arm from standing height

• Younger patient typically present after high

energy trauma such as MVA, bikes, ladders

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HUMERUS SHAFT FRACTURES

• Mechanism of Injury
• Direct trauma is the most common especially

MVA

• Indirect trauma such as fall on an outstretched

hand

• Fracture pattern depends on stress applied
• Compressive- proximal or distal humerus
• Bending- transverse fracture of the shaft
• Torsional- spiral fracture of the shaft
• Torsion and bending- oblique fracture usually

associated with a butterfly fragment

HUMERUS SHAFT FRACTURE

• Clinical evaluation
• Complete history and

physical

• Patients typically

present with pain, swelling, and deformity

• f the upper arm
• Careful NV exam

important as the radial nerve is in close proximity to the humerus and can be injured

HUMERUS SHAFT FRACTURE

• Radiographic evaluation
• AP and lateral views of the humerus
• Sometimes Traction radiographs may be

indicated for hard to classify secondary to severe displacement or a lot of comminution, these can be painful

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HUMERUS SHAFT FRACTURES

• Conservative Treatment
• Goal of treatment is to

establish union with acceptable alignment

• >90% of humeral shaft

fractures heal with nonsurgical management, can take 6-9 months for union

• Most treatment begins with

application of a coaptation spint or a hanging arm cast followed by placement of a fracture brace called a Sarmiento brace

HUMERUS SHAFT FRACTURE

Operative Treatment

• Indications for operative treatment include

inadequate reduction, nonunion, associated injuries,

• pen fractures, segmental fractures, associated

vascular or nerve injuries

• Most commonly treated with plates and screws

but can get an Intrameduallary nail

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ELBOW FRACTURE AND DISLOCATION

• Epidemiology
• Accounts for 11-28% of injuries to the elbow
• Posterior dislocations most common
• Highest incidence in the young 10-20 years and usually

sports injuries

• Mechanism of injury
• Most commonly due to fall on outstretched hand or elbow

resulting in force to unlock the olecranon from the trochlea

• Posterior dislocation following hyperextension, valgus stress,

arm abduction, and forearm supination

• Anterior dislocation ensuing from direct force to the

posterior forearm with elbow flexed

ELBOW DISLOCATIONS

• Clinical Evaluation
• Patients typically present guarding the injured

extremity

• Usually has gross deformity and swelling
• Careful NV exam in important and should be

done prior to radiographs or manipulation

• Repeat Radiographs after reduction
• AP and lateral elbow films should be obtained

both pre and post reduction

• Careful examination for associated fractures

ELBOW DISLOCATION

• Associated injuries
• Coronoid process

fractures (5-10%)

• Medial or lateral

epicondylar fx (12-34%)

• Wrist fracture
• Radial head fx (5-11%)
• Treatment
• Type I- Conservative
• Type II/III- Attempt ORIF
• vs. radial head

replacement

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FOREARM FRACTURES

• Epidemiology
• Highest ratio of open to closed than any other fracture

except the tibia

• More common in males than females, most likely secondary

MVA, contact sports, altercations, and falls

• Mechanism of Injury
• Commonly associated with mva, direct trauma

missile projectiles, and falls

FOREARM FRACTURE

• Clinical Evaluation
• Patients typically present with gross deformity of the forearm

and with pain, swelling, and loss of function at the hand

• Careful exam is essential, with specific assessment of radial,

ulnar, and median nerves and radial and ulnar pulses

• Tense compartments, unremitting pain, and pain with

passive motion should raise suspicion for compartment syndrome – HIGH RISK COMPARTMENT SYNDROME WITH HIGH ENERGY TRAUMA

• Radiographic Evaluation
• AP and lateral radiographs of the forearm
• Don’t forget to examine and x-ray the elbow and wrist

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FOREARM ULNA FRACTURES

• Ulna Fractures
• These include nightstick and

Monteggia fractures

• Monteggia denotes a fracture of the

proximal ulna with an associated radial head dislocation

FOREARM FRACTURES

• Will need surgical fixation

DISTAL RADIUS FRACTURE

• Epidemiology
• Most common fractures of the upper extremity
• Common in younger and older patients. Usually a

result of direct trauma such as fall on out stretched hand

• Increasing incidence due to aging population
• Mechanism of Injury
• Most commonly a fall on an outstretched

extremity with the wrist in dorsiflexion

• High energy injuries may result in significantly

displaced, highly unstable fractures

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DISTAL RADIUS FRACTURE

• Clinical Evaluation
• Patients typically present with gross

deformity of the wrist with variable displacement of the hand in relation to the wrist. Typically swollen with painful ROM

• Always exam joint above and below injury
• NV exam including specifically median

nerve for acute carpal tunnel compression syndrome

DISTAL RADIUS FRACTURE

• Radiographs
• Evaluate three views of the wrist ap/lat and oblique views

DISTAL RADIUS FRACTURE

• Colles Fracture
• Combination of intra and extra articular fractures of the distal radius

with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortenting

• Most common distal radius fracture caused by fall on outstretched

hand

• Smith Fracture (Reverse Colles)
• Fracture with volar angulation (apex dorsal) from a fall on a flexed

wrist

• Barton Fracture
• Fracture with dorsal or volar rim displaced with the hand and carpus
• Radial Styloid Fracture (Chauffeur Fracture)
• Avulsion fracture with extrinsic ligaments attached to the fragment
• Mechanism of injury is compression of the scaphoid against the styloid

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THINGS YOU DON’T WANT TO MISS

• Scaphoid fracture
• Boxer fracture
• Metacarpal fracture
• Mallet Finger
• Dislocations – Perilunate, PIP

SCAPHOID FRACTURE

• Pain over scaphoid
• If unsure always

thumb spica splint

• r cast
• Follow up with
• rthopeidcs

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BOXERS FRACTURE

• Usually involved with

4th or 5th MC neck

• History relevant – hit

something

• Needs Ulnar gutter

splint/cast

• Usually non surgical
• Follow up
• rthopedics
• NVI, CMS

METACARPAL FRACTURE

• Any shaft bone
• Surgical fixation can

be indicated

• Always splint or cast

with non fractured metacarpal – ulnar gutter but include the third in this example

• Orthopedic follow up
• NVI, CMS

MALLET FINGER

• Can occasionally have

a small avulsion fracture – splint DIP ONLY in neutral for 6 weeks WITHOUT LAPSE

• NEVER REMOVE SPLINT
• IF NO FX SPLINT 8 WEEKS
• Can be managed by

PCP – intraarticular fracture refer to ortho

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DISLOCATIONS DISLOCATIONS

• Finger
• Commonly PIP
• Digital block and reduce, splint in slight flexion
• Follow up ortho
• Perilunate
• Surgical emergency - even if you can’t describe what’s

wrong on this xray, it looks wrong doesn’t it? Very wrong.

• NVI, CMS: risk for permanent damage to median nerve

Questions?