Elbow Wrist Injuries Edits - University of...
Transcript of Elbow Wrist Injuries Edits - University of...
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ELBOW, WRIST & HAND INJURIES
Dr James Fraser MBBS, MSpMed School of Medicine The University of Queensland
Elbow Disloca2on
Acute Fractures Supracondylar Fractures
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Acute Fractures
Olecranon fracture Radial head fracture
Elbow Injuries
• Lateral • Medial • Anterior • Posterior
Lateral Elbow Pain-‐Extensor Tendinosis • Repe22ve wrist extension, prona2on • Poor biomechanics, equipment selec2on • Site of injury distal to lateral epicondyle • ECRB origin • Tendinosis – not inflammatory Who Gets It?? • Non-‐athletes more than athletes • Tennis players 5-‐10% of cases • 30-‐50 year olds • Males = Females • Two predisposing factors– – Unaccustomed ac2vity – Sudden force
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Extensor Tendinosis Symptoms
• Pain – poorly localised – lateral epicondyle to lateral forearm – ini2ally a[er ac2vity – can be severe and incapacita2ng
Extensor Tendinosis Signs • Tender distal to lateral epicondyle
• Pain with passive wrist flexion – worse in prona2on with radial devia2on
• Pain with resisted wrist extension especially 3rd finger
Extensor Tendinosis Treatment • No single effec2ve treatment • Acute so[ 2ssue injury management • Wide range of treatments -‐ li^le objec2ve evidence for majority
• Assess & modify mechanical factors – Counter force bracing – Extensor muscle stretching – So[ 2ssue therapy – Cor2costeriod injec2on – Nitrous oxide – Botulinum toxin – Surgery
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Medial Elbow Pain
• Flexor, pronator tendinopathy • Medial collateral ligament sprain • Referred pain
• Ulnar nerve entrapment
• Apophysi2s/avulsion
Flexor, Pronator Tendinopathy • Less common than lateral • Repe22ve ac2vity -‐ wrist flexors
Symptoms, Signs & Treatment • Medial pain • Tender around epicondyle • Pain with resisted flexion & prona2on • Pain with passive extension • Weakened grip strength • Treatment much the same as lateral
MCL Injury
• Acute or over use injury
• Acute • Severe valgus stress
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Repe22ve Ac2vity
• Throwing – repe22ve valgus stress
• Microtears, inflamma2onè scarring, instability, rupture
MCL Injury
Symptoms & Signs • Medial pain
• Tender below medial epicondyle over radiohumeral joint
• Pain with valgus stress at 300
Treatment • Early – Rest, modify ac2vity – Check technique – So[ 2ssue therapy – Strengthening flexors, pronators
– Surgical repair
Anterior Elbow Pain
Biceps Tendinopathy • Overuse • Weight training flexion, supina2on
• Pain & weakness
• Rest, splint • Modify training type & volume
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Anterior Elbow Pain
Biceps Rupture • Most proximal few distal • Discrete forceful event • Maybe preceded by tendinopathy • Anabolic steroid use Symptoms & Signs • Acute pain & weakness with ac2vity • Deformity • Tender distal biceps • Bruising • Weak flexion & supina2on • Surgery
Posterior Elbow Pain
Triceps Tendinopathy • Repeated extension ac2vity • Tender & weakness • Rest, so[ 2ssue therapy • Stretching, strengthening
Posterior Impingement • Hyperextension • Osteoarthri2s • FFD
Posterior Elbow Pain Olecranon BursiLs • Single trauma2c episode or recurrent injury
• Res2ng on bursa for prolonged 2me
• May become infected
• Rest, compression • An2bio2cs, aspira2on, incision & drainage, excision of bursa
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Children
• Osteochondri2s dissecans capitellum or radial head
• Epicondyli2s especially medially
• Avulsion of epicondyle OCD
Wrist Injuries
• Acute vs. Chronic
• Frequently injured – fractures common
Acute Fractures Distal Radial Fractures • Mechanism – fall on outstretched hand -‐ FOOSH
• Most common ED fracture in all age groups • May be intra ar2cular or have associated wrist ligament injury
• Children – greens2ck fractures
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Colles Fracture • Fracture of distal radius with volar angula2on • Classic dinner fork deformity • Loss of func2on • Pain, swelling
Lateral x-‐ray
Management
• Field -‐ Splint
• ED – Pain relief – X-‐ray – Closed Reduc2on – Eleva2on – very important for all wrist, hand injuries – Open reduc2on, fixa2on – Rehab
Smith’s Fracture
• ‘Reverse’ Colles Fracture • Fall onto dorsum of hand • Dorsal 2lt of distal fragment
• Majority require surgery
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Scaphoid Fracture • Most common carpal fracture -‐ 75% • FOOSH • ‘Missed’ fractures cause significant problems • High degree of suspicion based on mechanism and examina2on
• Lateral wrist pain
• Swelling & tender in snuff box • Tender with dorsal, volar palpa2on with radial devia2on of wrist
• Pain with axial thumb compression
Never just a “wrist sprain”
• Retrograde blood supply
• Most fractures through waist
• Disrupted blood supply causes Avascular necrosis
Scaphoid Fracture
AVN
Non union
Inves2ga2ons
• X-‐ray Ø Fracture seen Cast 6 – 8 weeks ORIF Ø No fracture seen Splint re x-‐ray 10 days Bone scan 72 hours CT MRI
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Scapholunate Ligament Injury
• FOOSH
• Similar presenta2on to scaphoid fracture
• X-‐ray may show widening of gap • MRI best inves2ga2on
• May result in scaphoid instability, chronic pain and disability
Chronic
• Carpal tunnel syndrome Median nerve compression in carpal tunnel Can be acute with wrist fracture • Carpal tunnel – FDP, FDS, FPL, Median Nerve
• Roof is flexor re2naculum, base proximal carpal row
Carpal Tunnel Symptoms
Symptoms • Pain -‐ o[en nocturnal Burning Volar wrist Numbness in median nerve distribu2on Tinels Sign Decreased sensa2on Decreased 2 point discrimina2on
Treatment • Occasionally will se^le with
NSAIDS or steroid injec2on or splin2ng
• Surgery with division of flexor re2naculum
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Ulnar Nerve Compression
• Cyclists • Compression in Guyons Canal –between pisiform and hamate
• Pain, paraesthesia li^le and half of ring finger
• Weakness late
• NSAIDS, splint, technique changes
De Quervains Tenosynovi2s Synovial inflamma2on Abuctor pollicis longus and Extensor pollicis brevis • Occurs at level of radial tuberosity • Racquet sports, golf, ten pin bowling • Swelling, tenderness, crepitus • Finkelstein’s test
Treatment • Splin2ng • Stretching, strengthening • Steroid injec2on • Surgery rarely needed
Ganglions • Synovial cysts • Painless swellings, reduced movement • Common scapholunate joint • USS, MRI
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Hand Injuries
• Common • O[en mistreated • Rehab very important
Fractures Thumb • Abduc2on force / fall on thumb • Metacarpal sha[ / intraar2cular • Maybe disloca2on (Benne^’s Fx) • All require ORIF • Rehab for ROM • Brace for return to sport
Metacarpals • Punching, falls • Boxers fracture • Pain, deformity, swelling,
rota2on, shortening • X-‐ray • Closed reduc2on / ORIF
Fractures -‐ Phalanges
Proximal • May impact on tendon
func2on • Shortening, rota2on • Intrar2cular? • Reduc2on • ORIF • Splint – posi2on of safety
wrist slight extension, MCP 70 degrees flexion
Distal • O[en caused by crush
injury
• O[en compound
• High rate non union
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Disloca2ons -‐ Phalanges • PIPJ (& Dorsal) most common • Injury to volar plate,
collateral ligament
• X-‐ray before reduc2on ideally • Definitely x-‐ray a[er reduc2on
• Buddy strap
• Need to be examined for instability – especially extension
• Volar disloca2ons uncommon hard to reduce
• DIPJ – o[en associated lacera2on on dorsal surface = compound injury
PIPJ DislocaLon
Mallet Finger
Avulsion of extensor mechanism • Ball hiqng 2p of finger • Maybe associated with fracture • Distal phalanx held in flexion Treatment • Fracture > 30% joint surface – ORIF • Ligament injury – splint in slight
hyperextension • 8 wks full 2me + addi2onal 4 at night
and 8 for sport • If not healed surgery
Ulnar Collateral Ligament – Skier’s Thumb
• Abduc2on, hyperextension
• Complete rupture greater than 20 degrees with stressing
• Splint for par2al, surgery for complete
• O[en ignored by pa2ents
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FDP Avulsion
• Ring most common • Jersey finger
• Sits in extension compared to other fingers
• X-‐ray -‐ ? Fracture • Surgery
Hand & Finger Lacera2ons
• Important to exclude neurovascular or tendon injury
• Associated fractures, disloca2ons • Infec2on risk high
• Tooth lacera2on over MCPJ important – always go bad