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!