Orthopedics 5

Elbow pain from repetitive wrist extension

Site of origin of wrist extensors-supinators

Pain over lateral epicondyle with resisted wrist extension & supination

Ice, stretch, strap, iontophoresis, surgical release

At the tender pt at lateral epi.; Marcaine, Kenalog, 25 g needle, down to the bone

Nursemaids Elbow

Annular ligament entrapment

Traction (swinging kids by wrists)

Flexed and IR

Tx x-ray; Hyper-pronation; Flexion/ supination/ extension; Feel a pop; Quick relief

UCL sprain or tear (UCL primary valgus stabilizer)

throwing athletes

Pop while throwing & medial elbow pain & hand paresthesia; Pain on valgus testing

X-ray, MRI

Rest, NSAIDs, PT, slow return to sports; poss Tommy John Surgery; education

May be traumatic or insidious

Infection, Gout, triceps rupture

Red, swollen joint, + pain

Compressive sleeve; ant. splint if recur; Bursectomy if chronic

Infection

(high threshold for this): 18g needle, poss 60 ml syringe

suspect infection; send for crystal, cx, gm stain

Marcaine/ Kenalog

Total elbow arthroplasty

Mehne & Matta

Supracondylar; Transcondylar; Intracondylar; T condyle fracture; lateral, medial condylar fractures

splinting for 10 days, then protected ROM

Most are unstable and require ORIF

Supracondylar Fx

Extension, distal fragment posterior; N/V injury common

Casting vs. ORIF vs. CRPP

Medial epicondyle fx

Lateral epicondyle fx

Cast immobilization

CRPP vs. ORIF

closed reduction & percutaneous pinning

FOOSH, valgus force

Swelling lateral elbow; Pain over radial head; Limited pronosupination & extension

AP, lat, obliq

Posterior splint/sling for 3-5 days; Early ROM exercises

Tx as in Type I if < 30% head displaced (Otherwise: ORIF)

Excision of frags or complete radial head

Same as III

N/V function; Ulna n.

Posterior splint @ 45 degrees; Re-image 1 week; ROM at 2 wks

ORIF

FOOSH

Posterior

radial head or distal humerus fracture

N/V status

Reduction / fx care

APL & EPB

ECRL, ECRB

EPL

extensor digitorum comunis (four tendons) & extensor indicis (EDC, EI)

extensor digiti minimi (EDM)

extensor carpi ulnaris (ECU)

Wrist flexors, thumb opposition

Volar thumb, radial 2 ½ digits

Intrinsics, Adductor Pollicis

Ulnar 1 ½ digits volar & dorsal

Wrist extensors, APL, EPB

Dorsal thumb & radial half of hand

Handedness; Occupation; trauma; location of pain; numbness, paresthesias

swelling, scars, masses

Tinel, Phalen; Finkelstein; Foveal; Watson

Stabilize volar scaphoid w/ thumb & bring wrist from ulnar to radial deviation; there will be a clunk or pain

Scapholunate dissociation

Ulnar deviation

Hamate, pisiform injuries

Growth plate injuries

Check 2-20 degree palmar tilt of articular surface of radius; dorsal aspect of distal radius is smooth; capitate sits in lunate

Check radius lies distal to ulna; radial border of Scaphoid is intact; No more than 2mm of intercarpal joint space; no abnormalities of radius or ulna cortex;

increased density at radial metaphysis

not a fracture; IS a physeal scar

parallel, joint spaces similar width & parallel cortical margins

joint injury

Radial wrist pain

1st Dorsal compartment; APL & EPB tendon moves over radial styloid

Pos Finkelstein

Ice, thumb spica, rest, ionto

Marcaine/ Kenalog In 1st dorsal compartment; directed toward radial styloid

Surgical release

Pain, numbness, paresthesia in median n. distn

10 structures pass through carpal tunnel (9 tendons, 1 (median) n.)

Positive Tinel’s and Phalen’s

EMG, Neurometrics

Splinting, ergonomics

1ml Marcaine/40mg Kenalog; ulnar to palmaris longus at proximal wrist crease at 30 degrees

cut transverse carpal ligament

Percuss over median n. carpal tunnel; tingling or pain in median n. distn = Pos

Acute flexion of wrists for 60-90 sec => numbness & tingling over median n. distn

Swelling at wrist; Leak of joint fluid

Painful or painless

65% Dorsal (SL joint), 25% radio-volar, 10% other flexor tendon sheaths (retinacular), occult

18 g needle & 10 cc syringe; instill 40 mg Kenalog; compressive bandage; surg excision for recurrence

10 % recurrence after excision

Traumatic SL ligament tear; >2mm space at SL joint

Wrist pain & instability; Letterman sign; Watson Test

dorsal intercalated segment instability (DISI) & SL advanced collapse (SLAC)

SL ligament repair, PRC, Arthrodesis

Triangular Fibrocartilage Complex

Stabilizes distal radioulnar joint

Acute or repetitive overuse

TTP over TFCC; (+) Foveal sign

X-Ray (Look for ulnar variance); MRI / Arthrogram

Splint, NSAIDs, PT; injection; arthroscopic repair

Ulnar wrist pain, swelling & weakness

Ulna head impinges carpi

cystic or sclerotic changes of the lunate &/ or triquetral

lunotriquetral ligament attrition

Ulna shortening

Lunatomalacia

Repetitive microtrauma => lunate collapse secondary to vasc insuff & avascular necrosis

Radiating wrist pain & swelling over lunate; pain on middle finger dorsiflexion

Surgical unloading, fusion, vascular implantation

Ulna shaft fx; Proximal radius dislocation

ORIF vs long arm cast for 6 weeks

Radial fracture; distal Ulna dislocation

ORIF vs long arm cast 6 weeks

monteggia = ulna; Galeazzi = radial

Incomplete fx

thick periosteum in children prevents displacement; dorsal cortex intact

Reduction (if needed) & short arm cast for 3-4 weeks

Isolated Ulna fracture

Cast or splint for 4 wks; then functional splint for several wks

Fall or direct hit

needs ORIF

may be put in long arm cast 6 wks

Colles Fx

FOOSH injury; dorsal angulation of distal fragment

acceptable; short arm cast for 4-6 wks

reduction, CRPP, ORIF

Fall on back of hand; Hyperflexion injury; volar angulation of distal fragment

acceptable; short arm cast 4-6 wk

Reduction, CRPP, ORIF

Intra-articular fracture; displaced radial articular fragment

ORIF

Oblique fx through the base of the radial styloid

Long arm cast for 1 mo. followed by short arm cast for 2 wks

Buckle fracture with intact periosteum

Children

3-4 weeks immobilization in a short arm cast; young kids need long arm cast (lest they take cast off)

Scaphoid Fx

FOOSH injuries

Waist

Osteonecrosis

6 weeks

3 months

4 months

Percutaneous screw fixation; ORIF w/ bone graft

AP, Lat, oblique, scaphoid views; MRI; Bone scan 72 hrs post injury

Immobilize in thumb spica or cast; repeat radiographs in 10-14 days

Handedness; Trauma; Numbness, paresthesias; Triggering

Swelling, nodules, masses

Tenderness

Symmetry; Triggering; FDP and FDS

Grip, abduction

Sensation; 2 pt discrim; Capillary refill

Flexion; Extension; Abduction; Adduction

AP. Lateral, Oblique; Order specific thumb or finger films

Alignment of joints; Cortical defects; Joint space narrowing; periarticular bony erosions, sclerosis, or spurring

Pain over Thumb CMC

Compression test; Grind test

moving CMC Joint w/ longitudinal load applied

grab the metacarpal base & rotate thumb

marginal osteophytes, joint space narrowing, & sclerosis

Trial of thumb spica & NSAIDs; Corticosteroid injection; CMC arthroplasty with tendon interposition

Thickened palmar fascia forms nodules over flexor tendons causing flexion contracture

Ring & Small fingers

men over 40 yo (get FH)

No conservative Rx; Surgery indicated for fixed contracture of more than 30 degree

Stenosing Tenosynovitis

Finger will lock, hurt, or be stiff

RA, OA & DM

Congenital

Painful thickened flexor tendon or nodule at the A1 pulley

At site of tenderness/ nodule; Marcaine/ Kenalog; 25 g needle into sheath, not tendon

surgical release is indicated

Pt prone to triggers in other fingers

tendon integrity

btw distal palmar crease & PIP joint crease

by hand surgeon

Infection

Bacterial infection of a tendon & tendon sheath

puncture, bite, or tooth wound (fight bite); progressive swelling & pain over 24-48 hr; Kanavel Sx:

Fusiform swelling of finger; sig tenderness along course of tendon; marked pain on passive extension; flexed finger at rest

Staph, Strep, MRSA

IV Abx, I&D if progressing; consider tetanus & rabies prophylaxis

Infection: Paronychia

Localized staph cellulitis in gutter along fingernail

Soaks, PO antibiotics; digital block & I&D when abscess is organized

Abscess of pulp space of distal phalanx

Localized erythema, swelling & throbbing pain

I & D, PO or IV antibiotics

Crush injury

Evacuate hematoma; trepanation (burr hole into nail); X-ray

nail s/b removed & laceration sutured

DIP joint

PIP joint

Hard & painless; Bony overgrowth; Thumb CMC early sx in women

NSAIDs, injections, arthrodesis, arthroplasty

Ulnar deviation of fingers; chronic swelling, decreased ROM; Rheumatoid nodules

Swan neck deformity; Boutonniere deformity

DMARDs, surgery