Examination of the Hand, Wrist, and Elbow Injuries...Examination of the Hand, Wrist, and Elbow...

Physical Medicine & Rehabilitation

Examination of the Hand, Wrist, and Elbow Injuries

Adam Lewno, DO

Department of Physical Medicine and Rehabilitation

10/3/2018


Or


Sports Injuries and Examination of the Hand, Wrist, and (hopefully)

Elbow

Adam Lewno, DO

Department of Physical Medicine and Rehabilitation

Physical Medicine & RehabilitationPhysical Medicine & Rehabilitation

No Disclosures


Objectives:

• Recognize the pertinent anatomy of the elbow, wrist, and hand.

• Demonstrate correlation of structure and function with sports related injures of the elbow, wrist, and hand.

• Recognize common sports related injuries of the elbow, wrist, and hand.


Road Map

• Wrist• Scaphoid fracture• Carpal instability• DeQuervian’s Tenosynovitis • TFCC

• Finger• UCL• Mallet finger• Jersey finger• PIP Collateral sprains

• Elbow (Cases discussed)


The Wrist


Scaphoid fracture

• Most common carpal facture

• “FOOSH” injury

• Symptoms• Radial wrist pain

• Snuff box tenderness

• Proximal pole tenderness


Scaphoid fracture: Exam


Watson Test (Scaphoid Shift test)

• Thumb over the scaphoid tubercle and index finger over the dorsal aspect of the scaphoid/scapholunate joint – in Ulnar deviation

• Apply dorsally directed force with thumb against the distal pole of scaphoid while moving wrist from ulnar to radial deviation


Scaphoid fracture

• 65% occur at the waist

• High rate of non union


Bones/Joints

• Some: Scaphoid*

• Lovers: Lunate*

• Try: Triquetrum

• Positions: Pisiform

• That: TrapeziuM*

• They: TrapezoiD

• Can’t: Capitate

• Handle: Hamate


So is it a Scaphoid Fracture?

• X-rays: • PA, lateral, oblique,

clenched fist

• Negative X-rays• Thumb Spica and repeat

X-rays in 2 weeks…and again?

• MRI/CT

• Bone scan


It’s a Scaphoid Fracture!

• Non operative• Non Displaced: (<1mm) or distal Pole• LA Spica with slight palmar flexion and radial deviation for 6

weeks• SA spica until radiological evidence of union

• If longer than 3-4 months: Bone stim, stim, surgery?

• Or early Screw fixation

• Operative• Displaced (>1mm)• proximal pole fracture• Unstable • Unsure (ask the hand guys!)


Carpal Instability

• Malalignment of the carpal bones

• Often traumatic but can be atraumatic

• Clench view X-rays

• Follows a pattern• Scapholunate

• Lunotriquetal

• Midcarpal (SLAC)


Scapholunate Instability

• Most common ligament injured

• Dorso radial pain after a FOOSH injury +/- weak grip

• Tenderness at the Scapholunate more then at the snuff box

• AP and Clench views• Positive >2mm• Cortical ring sign • Lots of different angles

• MRI Arthrogram


Scapholunate Instability

• Acute (3-4 weeks)• Percutaneous pinning

• ORIF K wires and capsulodesis

• Chronic• No OA: capsulodesis

and reconstruction

• OA: fusion

• High Stakes injury!!


Lunotriquetral Instability

• Often injured with an additional structures of the wrist

• Less common than Scapholunate instability

• FOOSH injury with dorsoulnar pain and tenderness

• Imaging: • X-ray with clench view

showing LT interval widening• MRI arthrogram

• Injections help with pain management

• Incomplete tear: • Inject for pain• Immobilize

• Complete tear or failure to progress• Possible Lunotriquetal

ligament repair • Ulnar shortening as needed• Less likely for arthrodesis


Lunotriquetral Instability

• Lunotriquetral ballotment (reagan test)

• Grasp the lunate between the thumb and index finger of one had

• Grasp the triquetrum/pisiform between the index finger and thumb of the second hand

• Shift the grasping hands in opposite directions


Wrist Extensor Compartments


De Quervain’s Tenosynovitis • Dorsoradial wrist pain involving compartment 1

• Racquet sports, javelin, discus, Golf (in the lead arm)

• 10:1 ratio of F:M


De Quervain’s Tenosynovitis

• Non operative: • Rest• NSAID• Thumb Spica splint with

IP free• Physical therapy• Injection (septum 20-

40% of the time)

• Surgical • Tenontomy and sheath

resection • 6-9 week recovery

Radiology: Volume 260: Number 2—August 2011


De Quervain’s Tenosynovitis

• Non operative: • Rest

• NSAID

• Thumb Spica splint with IP free

• Injection (septum 20-40% of the time)

• Surgical tenotomy• 6-9 week recover

Radiology: Volume 260: Number 2—August 2011


Triangular Fibrocartilage Complex (TFCC)

• Degenerative (Chronic) vs acute twisting injury (Fall/Younger)

• US limited, improved imaging with MRI

• Triangular (articular) disk

• Primary stabilizer of the DRUJ

• Central and radial portions are avascular


TFCC

• Degenerative vs acute twisting injury

• US limited, improved imaging with MRI

• Triangular (articular) disk

• Primary stabilizer of the DRUJ

• Central and radial portions are avascular


TFCC

• Non operative: • Relative rest, splinting, NSAID, CSI

• Long arm cast in neutral rotation for 6 weeks

• Surgical• Central tear (most typical)

• Debridement, potential Ulnar shortening

• Peripheral (15-20%)• Repair and Potential ulnar shortening if noted impaction

• DRUJ • reconstruction with immobilization above the elbow


Fingers – Phalanges!


Jersey Finger

• Overwhelming extension moment (when finger flexed)

• FDP Avulsion at the DIP• Most often D3 (Ring)

• No active DIP flexion • Full PROM – No AROM

• Xray to rule out avulsion

heritance.me/anatomy


Jersey Finger

• Overwhelming extension moment (when finger flexed)

• FDP Avulsion at the DIP• Most often D3 (Ring)

• No active DIP flexion • Full PROM – No AROM

• Xray to rule out avulsion

Leggit, et al. American Family Physician 2006


Jersey treatment

• Non operative• Splint in neutral

• Operative repair: • Retrieve tendon

• stabilize


Jersey Finger Classification

F. Lapegue, et all. Traumatic Flexor tendon injuries, 2015


Mallet Finger

• Compression force to the end of finger• D3, D4, D5 most

frequent

• DIP flexion deformity• NO extension AROM

• Maintained PROM

• Swan neck

• Xrays and/or US for avulsion fracture


Mallet Finger

• Compression force to the end of finger• D3, D4, D5 most

frequent

• DIP flexion deformity• NO extension AROM

• Maintained PROM

• Swan neck

• Xrays and/or US for avulsion fracture

American Hand surgery


Mallet Finger

• Terminal extension tendon

• With or without avulsion

(no FDS rupture)


Mallet Finger- Treatment

• Extensor splint!!• Continuously for 6 weeks

• 2-4 more weeks at night

• Surgery• Large fracture

• Open wound

• Tendon subluxation


Thumb Motion


UCL Injury (Game Keepers/skiers)

• Forceful radial deviation

• Symptoms: • Pain

• Swelling/ecchymosis

• loss of motion

• Decr pinch

• X-ray's to rule out fracture• US – MRI?


UCL Stress test

• Performed at 0 and 30

• Compare to the contralateral side

• How? • Immobilize thumb MC in

one hand and the proximal phalanx with the other

• Apply ulnarly directed force to the radial side of the joint to gap the thumb MCP on ulnar side


UCL- Stenor Lesion

• Interposition of adductor aponeurosis up to 70%

• Gross instability or mass


UCL Treatment (Evolving)

• Non operative• Thumb spica splint for 4 weeks

• 3 months of non strenuous activity (debated length)

• Operative• >30-35 degree opening in flexion

• >15 degree opening compared to contralateral

• Stener lesion ( >2mm displacement)

• Large bony avulsion


PIP Collateral injury (jammed finger)• Radial more often then the ulnar side

• Index finger most common with tenderness and laxity• Must rule out dislocation!

• May radially dislocated and spontaneously reduce

• Buddy tape for 3-6 weeks


Thank You

• Rebecca McConnell, DO

• Daniel Lueders, MD

Examination of the Hand, Wrist, and Elbow Injuries...Examination of the Hand, Wrist, and Elbow...

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