Elbow and Wrist pain DD Dr.Huma Riaz Supracondlar # of humerus • # of childhood. • h/o of fall on outstretched hand. • Complication??? • damage to brachial artery, median or radial nerve may occur. • Assess distal circulation. Dislocation of elbow • In children or adults. Pulled elbow • Radial head slips out of the annular ligament. • Children with age 2-6years • Child may have been swinging with parents holding the hands. Nursemaid’s Elbow Olecranon #s • Fall on point of elbow or by sudden contraction of the triceps. • Condylar or epicondylar #s – Are rare and easily missed. – Test integrity of Ulnar nerve Myositis ossificans • h/o of supracondylar # or dislocation of the elbow. • Calcified hematoma forms in front of the joint. • Movement esp. flexion is limited. • May follow ill-advised physiotherapy with passive stretching of the joint after trauma or after surgery. Osteoarthritis of Elbow • Osteoarthritis of the elbow is rare. • May occur in heavy manual workers or following complicated fractures involving the joint. • swelling., loss of motion, crepitus. • most pain during terminal flexion and extension of the joint. • Radiographic evidence of osteoarthritis includes osteophyte formation. These osteophytes usually are near the ulnohumeral joint and occasionally impinge on the ulnar nerve. • MR and CT images of the elbow help show the joint surfaces and detect loose bodies or spurs. Gout • Elevated uric acid levels can result in monosodium urate crystals to infiltrate the synovial fluid of joint spaces and lead to gout. • Gout usually is found in the joint spaces of the toes but can appear at the elbow. • Evidence of gout is obvious in patients with advanced disease but is not often apparent on images of early cases. • MR images are better for evaluating synovial involvement, and CT is better for displaying intraosseous lesions. • Ultrasonography also can highlight thickening of the synovial fluid, along with inflammation. Rheumatoid Arthritis • Rheumatoid arthritis commonly begins in the radiohumeral joint. The radial head may move out of its regular position and cause problems with other elbow anatomy. • Bone erosion from rheumatoid arthritis is better displayed on CT images than on MR images or radiographs. • Ultrasonography can show inflammation related to rheumatoid arthritis. Osteocondritis Dissicans • elbow pain. • Restrict movement because of loose body in the joint. • loss of motion, crepitus, joint locking • A 24 year old woman comes to you complaining of pain in her right elbow on the medial side. The pain sometimes extends into the forearm and is often accompanied by tingling in to the little finger and half of the ring finger. The pain and paresthesia are particularly bothersome when she plays recreational volleyball. Nerve Entrapment Problems Where nerve passes through awkward place between tendons over bone under ligaments Can be pinched or rubbed Nerve Entrapment Problems • Complaints – nerve injury – Pain – Impaired sensation – numbness – Impaired motor - weakness Nerve Entrapment Problems The “Funny Bone” What is its real name? Nerve Entrapment Problems The Ulnar Nerve Nerve Entrapment Problems • Ulnar Nerve – Entrapment sites Nerve Entrapment Problems Ulnar nerve Exposed to trauma bumping, pressing on table or arm rest Stretched by anatomy and position holding telephone receiver, sleeping with elbow flexed Cubital tunnel syndrome • Ulnar nerve is compressed as it enters the cubital tunnel at the elbow, resulting in pain that is like “hitting your funny bone.” Persons who perform repetitive bending of the elbow by pulling levers, reaching, or lifting are at risk. What is it called? When pain and tingling in the hand on ulnar side occurs as the nerve is compressed due to thickening of flexor retenaculum and pissohamate ligament ?? Nerve Entrapment Problems • Numbness Olecranon bursitis/students elbow • student’s elbow because the condition can be caused by leaning excessively on the elbow. • Chronic olecranon bursitis is seen in people who throw repetitively, such as baseball pitchers. • acute cases usually occur after a direct fall onto a hard surface. • Red, tender, hot swelling. • U/S Cubital Bursitis/ bicipitoradial bursitis • antecubital fossa swelling and tenderness,redness and limited movement.. • The bicipitoradial bursa surrounds the biceps tendon in supination. In pronation, the radial tuberosity rotates posteriorly, which compresses the bicipitoradial bursa between the biceps tendon and the radial cortex which consequently increases the pressure within the bursa. • Epidemiology • It typically presents in adults and may be more common in males Mr. G was a 44 year old accountant who presented to the clinic with a 7 week history of right elbow pain radiating into his forearm. Right-handed, he found it increasingly more difficult to do very basic day to day activities requiring wrist extension, such as shaving, driving and use a computer mouse. His symptoms started gradually…he was prescribed a two week course of Naproxen that resulted in transient improvement of his symptoms. • What is the most likely diagnosis? Tennis elbow • Lateral epicondylitis is the most common sportsrelated injury of the elbow and a primary cause of elbow pain. • The mechanism of injury depends on repeated, forceful contraction of the wrist extensor muscles; contraction occurs with frequent forearm pronation and supination, along with wrist extension. The abuse of the extensor muscles causes inflammation at the lateral epicondyle. Case report • A 35 year old male presented with a complaint of right forearm pain that had been worsening gradually over the past month. • He reported that although he has had pain and has noted some weakness in his grip, he has continued to play squash and notices that forearm pain increases after playing squash. reaching and gripping increases his pain. • He reports that this pain has been worsening, dull and achy in nature and he rates the pain as a 3/10 in intensity. • He indicates that the pain is specifically in his medial right ventral forearm just inferior to the elbow and described it as being “in between the bones.” • The patient denies pain referral and the presence of any parathesias in the arm or hand. He reports that he has never had this pain before. Examination • No bruising, redness or edema in the area. tenderness and a tender point in the pronator teres muscle and over the medial epicondyle. • Neurological testing was found to be unremarkable. • negative: – Pronator teres test – Mills test for lateral epicondylitis • positive: – Passive test – active resistive medial epicondylitis test Golfer elbow • Medial epicondylitis is common in individuals who overuse their wrist flexors and forearm pronator but is seen far less frequently than lateral epicondylitis. • Medial epicondylitis primarily affects the insertion point of the flexor carpi radialis. The patient presents with pain at the medial aspect of the elbow. • As with lateral epicondylitis, radiographic evidence of medial epicondylitis can be difficult to find, but small calcifications or spurs next to the medial epicondyle are common. MR imaging most often is used for diagnosis. Cubitus valgus/varus Biceps tear Tendonitis and Tendon Tears • Tendonitis of the biceps muscle can lead to rupture on either end. • • • • • occurs in men aged 45 to 60 years. When the distal end of the biceps muscle ruptures, symptoms include proximal elbow pain and weakness, especially during supination. When the rupture occurs, the patient can experience a snapping sensation followed by the appearance of a bulbous deformity, or “Popeye sign,” near the distal bicep. Radiographs may show an avulsion fracture of the radial tuberosity in cases of complete tears, but enlargement or abnormality of the radial tuberosity is the most common finding. MR imaging is useful to assess a possible tear or degeneration of the biceps tendon. Ultrasonography may be helpful in determining the extent of any tears. Tendonitis and Tendon Tears • Triceps tendonitis is common with repetitive elbow use in young athletes. The individual often experiences a sensation on the medial border of the elbow that patients describe as something snapping into place. Common Injuries • Distal Radius Fracture – Colles’ Fracture • Most common • Fall onto volar surface with displacement dorsally Smith’s Fracture • “Reverse Colles’” • Fall with displacement palmarly 1st Dorsal Compartment Syndrome or deQuervain’s Tenosynovitis • – Pain with abduction and extension of the thumb • – Pain located at the anatomic snuffbox • – Tendonitis of the EPB and APL • – + Finkelstein’s test Intersection Syndrome • – Irritation of the muscle bellies of the EPB and APL • where they cross over the tendons of the radial wrist extensors • – 4-5 cm proximal to radial styloid • – Repetitive wrist flexion and extension with radial deviation (rowing activities) Wartenberg’s Syndrome • – Irritation of the distal radial sensory nerve • – Pain 1-2 cm proximal to radial styloid and • radiates distally along dorsal thumb and dorsal web space • – Compression between ECRL and Brachioradials muscle • + Finkelstein’s Test and + Tinels at the anatomical • snuffbox Wrist ganglions – Dorsal wrist ganglion • Most common mass on dorsum of hand • Often found at the scapho-lunate interval – Volar wrist ganglion • 2nd most common mass on the hand • Often found at the radiocarpal or STT joint Central Slip Extensor Tendon Injury • Tender at dorsal aspect of the PIP joint (middle phalanx) • Inability to actively extend the PIP joint • Splint in full extension for 6 weeks • Refer: Avulsion fracture involving more than 30 percent of the joint or inability to achieve full passive extension Boutonniere Deformity • Can occur acutely, but more often after several weeks • Extensor tendon/Central slip ruptures at PIP • Lateral bands slip volar and flex PIP, DIP extends Extensor tendon injury-Mallet finger • Tear or stretch of extensor tendon prior to insertion on distal phalanx • Exam: Soft tissue swelling, lack of full extension of DIPJ Jersy finger Flexor tendon injury-Jersey finger • • Inability to actively flex distal phalanx Ring finger most commonly affected – • • Protrudes further than other fingers on grasping Forced extension of actively flexed DIP joint Examples – – Football player grabs a player's jersey on tackle Lifting latch on car door Jersey Finger • Avulsion of Flexor Digitorum Profundus (FDP) as DIP is forcibly extended • Can be seen with a laceration of the volar aspect of the phalanx • Tendon may retract to the PIP or as far as the palm • Surgical referral Dupuytren's disease Volar Plate Injury • Maximal tenderness at the volar aspect of involved joint • Test for full flexion and extension as well as collateral ligament stability. • Splint at 30 degrees of flexion and progressively increase extension for two to four weeks.Buddy tape at the joint if injury is less severe. • Refer: Unstable joints or large avulsion fragments UCL Injury-Skier’s Thumb • AKA “gamekeeper’s thumb” • Caused by hyperextension of Ulnar collateral ligament • Exam: – Tender at UCL = x-ray first – Abduction stress at MCP with MCP in flexion – Abnormal if > 15 degrees from opposite side, or 35 degrees absolute Thank You!