9/26/2016

UNDERSTANDING THE UPPER EXTREMITY

Presented by Kari M. Komlofske, FNP-C & John Workinger, FNP-C October 2016

CARPAL TUNNEL SYNDROME

• Most common peripheral compression (entrapment) neuropathy • Prevalence 3-6 % of adults • More common in women • Etiology • Idiopathic • Trauma • Tumor

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CARPAL TUNNEL SYNDROME

• Pain is NOT a primary symptom • Paresthesias (pins & needles) in palmar pads of digit tips, initially at night • Numbness (loss of sensation) (Semmes Weinstein monofilament testing) • Weakness of thumb abduction Loss of thumb dexterity (not grip) Wasting of thenar musculature

CARPAL TUNNEL SYNDROME

ASSOCIATED RISK FACTORS • Genetics • Hormonal factors • Pregnancy • Menopausal • Hypothyroidism • Obesity • Diabetes • Age • Gender • Rheumatoid arthritis • Occupation • Lozano-Calderon 2008

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CARPAL TUNNEL SYNDROME

OCCUPATIONAL EXPOSURE • Keyboarding is NOT a risk factor • Evidence supports regular keyboarding is protective • Stevens 2001, Atroshi 2007, Mattioli 2009 • Vibration exposure • Barcenilla 2012 • Forceful & sustained heavy grip activities • Poultry/fish/meat processing • Palmer 2007, van Rijn 2009

CARPAL TUNNEL SYNDROME

PHYSICAL EXAMINATION • Median nerve Tinel’s testing • Median nerve compression testing at wrist • Phalen’s maneuver • Weakness/wasting Abductor Pollicis Brevis • Sensibility testing with Semmes Weinstein monofilaments (index/little alone)

CARPAL TUNNEL SYNDROME

HISTORY CORRELATES WITH SEVERITY • Mild • Intermittent night time paresthesias • Moderate • Intermittent night time and day time symptoms to include numbness • Severe • Constant symptoms • Diminished protective sensation • Loss of thumb dexterity • Wasting of Abductor Pollicis Brevis

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WASTING OF ABDUCTOR POLLICIS BREVIS MUSCLE

CARPAL TUNNEL SYNDROME

Confirmatory Nerve Conduction Testing Required by CMS in Medicare/-aid patients prior to surgery

No X-Rays needed

CARPAL TUNNEL SYNDROME

• Screen for hypothyroid and diabetes mellitus • 3-6 month trial of wrist bracing with mild, early symptoms • Consider corticosteroid injection if symptoms intermittent and no motor deficit • No role for NSAIDs • Reliable results with surgical release • Occupational Therapy: Good evidence for relief of mild CTS symptoms with use of wrist brace at night.

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TRIGGER DIGITS

• Mechanical catching of the digit during active extension and flexion • “Feels like my finger/thumb is coming out of joint” • “My finger gets stuck” • Morning locking/stiffness that improves as day progresses (similar to OA)

TRIGGER DIGITS

• Ring finger and thumb most common • Association with flexor tendon sheath cysts in palm • Can be association with carpal tunnel syndrome • Etiology • Idiopathic • Inflammatory • Trauma • Congenital

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TRIGGER FINGERS

• ASSOCIATED RISK FACTORS • Diabetes Mellitus • Gender • Age • Previous history of trigger digits, CTS • Rheumatoid Arthritis • Occupation?

TRIGGER DIGITS

• EXAMINATION • Obvious mechanical triggering • Tender at palmar base of finger (A-1 pulley) • Can present with locked digit • Mild flexion in chronic cases • Mobile “nodule” at A-1 pulley with finger motion • No X-Rays needed • Don’t confuse with Dupuytren’s or OA

TRIGGER DIGITS

• TREATMENT • Observation, rest • No role for NSAIDs other than pain relief • Corticosteroid injection into tendon sheath • Reliable surgical release • Role of Occupational Therapy, splinting

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DE QUERVAIN’S SYNDROME

• More common in female population • Associated with breast feeding hand position “Mommy thumb” • Pain at the radial side of the wrist • Aggravated by thumb/wrist combined motion • Paresthesias in Sensory Branch Radial Nerve in chronic cases

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DE QUERVAIN’ SYNDROME

• Tenderness at first dorsal compartment • Radiating pain with Finkelstein’s test • Swelling at first dorsal compartment • Occasional cyst from leading edge of FDC • Tinel’s over Sensory Branch Radial Nerve • Basal joint is nearby so check grind test • Wrist radiographs to assess for arthritis

FINKLESTEIN’S TEST

DE QUERVAIN’ SYNDROME

TREATMENT • Bracing for symptomatic relief – Thumb Spica • Acetaminophen and/or NSAIDs for symptomatic relief • Corticosteroid injections • Role of Occupational Therapy – may be helpful AFTER injection • Surgical release is reliable

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DEQUERVAIN’S INJECTION

BASAL JOINT ARTHRITIS

• Gender (F:M 6:1) • Armstrong 1994, Xu 1998 • Age, 1/3 females over 50 yo • Etiology -Degenerative arthritis • Role of joint laxity • Kirk 1967, Eaton 1984, Pellegrini 1996 -Inflammatory arthritis –RA, psoriatic -Post-traumatic arthritis

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BASAL JOINT ARTHRITIS

• ain and/or weakness with pinch and grip activities • CMC joint tender to palpation • Dorsal first CMC joint prominent with subluxation • Thumb in palm , MCP hyperextension • Positive grind test • Confirmatory X-Rays • De Quervain’s can mimic basal joint OA, check Finklestein’s test

BASAL JOINT ARTHRITIS TREATMENT

• Rest • Bracing • Custom rigid thermoplastic orthoses • Soft supports • Nutritional supplements • Acetaminophen and/or NSAIDs • Corticosteroid injection • Role of Occupational Therapy – Hot Paraffin Dips, Bracing and Adaptive Equipment • Several reliable surgical options once conservative measures fail, dependent upon the stage of arthritis

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LATERAL EPICONDYLOSIS

• Lateral Elbow pain • Weakness in grip • Symptoms aggravated by activities that involve resisted wrist and elbow extension • Insidious onset most common, but can be attributed to an event or activity

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LATERAL EPICONDYLOSIS

• PHYSICAL EXAMINATION • Tenderness • Provocative Maneuvers • STUDIES • Plain films only if elbow motion reduced • Pomerance 2002 • Resist the urge to order MRI • Incidental extensor changes occur with age with high false positive rate • Steinborn 1999,

LATERAL EPICONDYLOSIS EXAM

LATERAL EPICONDYLOSIS

• Histologic findings lead to the concept that this is a degenerative rather than inflammatory process – cortisone injections will likely not work in chronic cases. •This is an “OSIS,” NOT an “ITIS”

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TRADITIONAL TREATMENT

• Rest/Ice • NSAIDs • Modification of activities • Elbow strap/wrist brace • Corticoid steroid injections • Occupational therapy - bracing and modified activities • Surgery for refractory cases

CORTICOSTEROID INJECTION

• Most effective early in process (first three months) in conjunction with occupational therapy

• Consent to include possibility of: • Recurrence • Permanently altered skin pigmentation • Subcutaneous fat atrophy • Steroid flare

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LATERAL EPICONDYLOSIS WHAT WE DO KNOW

• of middle age • Unknown pain generator • No single reliable treatment • Surgical results inconsistent • Self limited condition, although it can last greater than 12 months.

LATERAL EPICONDYLOSIS

• Shared decision making with patient for treatment • Reassurance • Nothing is being damanaged • PAIN ≠ HARM • Improving coping strategies • Multidisciplinary effort

LATERAL EPICONDYLOSIS: BRACES

Use of Braces = Inconclusive

• Wrist brace: • Consider trial of wrist brace at night if awakening with pain. • May also be helpful with heavy lifting.

• Counterforce brace: • Caution: compression can irritate radial and ulnar nerves. • Wear with activity and use model with built-in pad.

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CUBITAL TUNNEL SYNDROME

• Second most common peripheral compression (entrapment) neuropathy • Prevalence 2-3 % of adults • Equal male/female involvement • Etiology • Idiopathic • Traction • Compression

CUBITAL TUNNEL SYNDROME

• Associated risk factors • Diabetes Mellitus • Previous h/o elbow fracture • Nerve Subluxation • Elbow arthritis/

CUBITAL TUNNEL SYNDROME

• Paresthesias (pins & needles) in the ulnar nerve distribution including ulnar aspect of hand • Weak grip • Weak pinch • Loss of dexterity “my hand does not do what I tell it to do”

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CUBITAL TUNNEL SYNDROME

Examination • Ulnar nerve tinel’s at elbow • Altered sensation by monofilament testing • Positive elbow flexion test • Weak inter-osseous musculature • Flexible ulnar clawing, Wartenburg’s T sign, Froment’s sign • Wasting of hand intrinsics • Confirmatory NCS “IR NCS” • X-Rays of the elbow

CUBITAL TUNNEL SYNDROME

• Treatment • Avoiding aggravating activities and positions • Prolonged elbow flexion • Direct pressure on medial elbow • Corticosteroid injections are discouraged – due to risk of nerve injury • Surgery in recalcitrant cases • Role of Occupational Therapy – night bracing

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DUPUYTREN’S DISEASE (PALMAR )

• Typically painless other than onset • Sub-Q nodule in palm of hand at distal palmar crease (level in line with ring/little metacarpal) • Over time form pretendinous cords • +/- Contracture of MCP joint • +/- Extension into digit & PIP joint contracture • Knuckle pads at MCP/PIP joints

PALMAR FASCIA

Dupuytren’s Disease

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DUPUYTREN’S DISEASE

• Strong familiar predisposition • Northern European descent • Males > Females 6:1 • Fifth through seventh decades • Bilateral in 65% of cases • Association with common/chronic disease likely coincidental than causative

DUPUYTREN’S DISEASE

• Reassurance, reassurance, reassurance • Cannot be cured • Goal of treatment is to maintain hand function • Avoid manipulation or massage • Corticosteroid injection plays no role • Pre-operative OT not shown to be effective • Presence of contracture and impaired function is indication for surgical treatment

DUPUYTREN’S DISEASE

• Radiation treatment in early cases • IR Radiation Oncology • Keilholz 1996 & 2001, Seegenschmiedt 2001, Betz 2010 • Once contracture present and interfering with function • Needle aponeurotomy • Collagenase Clostridium histolyitcum injection • Partial palmar fasciectomy • Post-operative therapy intensive

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GANGLION CYSTS

• Most common “tumor” of hand • 60-70 % dorsal wrist • History of variable size/resolution • Etiology • Mucoid degeneration • Idiopathic • Association with • Underlying arthritis • Trauma

GANGLION CYST

• Does not move w/ digit flexion/extension as in extensor • Dorsal cysts prominent with flexion of wrist • Volar cysts adjacent radial artery, +/-pulsatile • Firm/hard due to hydraulic phenomenon • Trans-illumination test • Allen’s test • Radiographs

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GANGLION CYSTS

• 26-50% symptomatic (annoying pain) • Lowden 2005, Westbrook 2000 • Appearance is a common concern 38% • Westbrook 2000 • Concern about malignancy 28% • Westbrook 2000

GANGLION CYST

• Reassurance/observation • 50 % spontaneous resolution rate • Loder 1988, Mackie 1984 • Rupture • Manual pressure • Needle aspiration – NEVER ON VOLAR • Role of Occupational Therapy: • No referral indicated. • If seen, 1x visit for pt education, activity modification, and splinting if needed to rest joint and reduce inflammation.

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GANGLION CYST

• Surgical excision is discouraged • Customary risks of surgery as well as: • Unsightly Scar • Keloid formation • Scar tenderness • Loss of wrist motion • Sensory nerve injury/neuroma • Radial artery injury • Continued wrist pain • Recurrence 10-40%

MUCOUS CYST

• Tumor of Distal Interphalangeal Joint • Associated with underlying arthritis • History of variable size/resolution • Adjacent nail plate groove deformity • Pain with underlying synovitis from adj. joint

Mucous Cyst

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MUCOUS CYST

• EXAMINATION • Mass in eponychium/proximal nail fold • Thin or thickened overlying dermis • Contains clear gelatinous fluid • Herberdan’s/Bouchard’s nodes (osteophytes) • History of redness, heat and pain when underlying joint arthritis inflamed • X-Rays are helpful

MUCOUS CYST

MUCOUS CYST

TREATMENT • Reassurance/observation • Spontaneous resolution • Discourage aspiration • NSAIDs if underlying joint inflamed • Pad with Band-Aid or Coban

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OLECRANON

• Fluid filled synovial tissue lined sac • Boggy swelling/mass over posterior elbow • More common in middle aged men • Spontaneous • Frequently follows an aggravating activity • Prolonged direct pressure, flexion/extension activity • Following trauma • With/without skin break

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OLECRANON BURSITIS

• Etiology • Aseptic • Trauma • Inflammation • Gout/Pseudogout • Rheumatoid/SLE • Septic • Hematogenous • Direct inoculation

OLECRANON BURSITIS

• Aseptic Bursitis 2/3 of cases • Variable erythema 25% • Variable tenderness 40% • Variable warmth to touch 50% • No fever/chills • Rare leukocytosis, left shift (± inflammatory) • Rare elevated inflammatory markers (“)

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OLECRANON BURSITIS

• Septic Bursitis 1/3 of cases • Erythematous/cellulitis 60% • Tender to touch 100% • Warmth to touch 100% • Allodynia • Fever/chills 40% • Leukocytosis, left shift • Elevated inflammatory markers (CRP/ESR)

OLECRANON BURSITIS

• To aspirate or not to aspirate? • We discourage this even in septic cases as 95% are community acquired GPC sensitive to first generation Cephalosporins

• Definitive but not without risk • iatragenic infection risk • Sinus tract development

• Never inject corticosteroids • Infection risk is 10-25% • Overlying skin atrophy

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ASEPTIC OLECRANON BURSITIS

• Reassurance • Neoprene sleeve or elbow pad for comfort • No therapy referral needed. • Avoid aggravating positions • Direct pressure over point of elbow • Holding elbow flexed for prolonged periods • Resist temptation to aspirate • Never inject corticosteroids • Surgical excision is discouraged as this condition reliably responds to conservative care

SEPTIC OLECRANON BURSITIS

• Intravenous First Generation Cephalosporin • 95% of positive cx are community acquired GPC and can be treated empirically observing for defervescence. • Role of immediate surgery is controversial • Painful packings required post-op • Chronic draining sinus tracts • defects • Painful scar • Is it really warranted if IV abx will cure 95%? • Surgical required in systemic septicemia or patients not responsive to IV antibiotic therapy

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FLEXOR TENOSYNOVITIS

FLEXOR TENOSYNOVITIS

• Infectious or Inflammatory – present similarly • Through HISTORY • Four Cardinal Symptoms • Sausage finger – uniform swelling • Pain with passive extension • Flexed positon • Tenderness along the Flexor tendon sheath

Treatment – Surgical emergency appropriate antibiotics if indicated

INJECTIONS

• Celestone = betamethasone, 6mg/1ml. Kenalog = triamcinolone, 40mg/1ml. • Sterile procedural method for injections into joints/tenosynovium/cysts is mandatory.

• CTS: 6mg Celestone or 40mg Kenalog with 2ml plain lidocaine – 3ml total.

• : 3mg Celestone or 20mg Kenalog with 0.5ml plain lidocaine – 1ml total.

• De Quervains: 6mg Celestone or 40mg Kenalog with 2ml plain lidocaine – 3ml total.

• Thumb CMC: 3mg Celestone or 20mg Kenalog with 0.5ml plain lidocaine - 1ml total.

• Lateral epicondyle: 6mg Celestone or 40mg Kenalog with 2ml plain lidocaine – 3ml total.

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FRACTURES OF THE UPPER EXTREMITY

• Humerus • Olecranon • Forearm • Wrist • Hand

PROXIMAL HUMERUS FRACTURES

• Epidemiology • Most common fracture of the humerus • Higher incidence in the elderly, thought to be related to osteoporosis • Females 2:1 greater incidence than males • Mechanism of Injury • Most commonly a fall onto an outstretched arm from standing height • Younger patient typically present after high energy trauma such as MVA, bikes, ladders

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HUMERUS SHAFT FRACTURES

• Mechanism of Injury • Direct trauma is the most common especially MVA • Indirect trauma such as fall on an outstretched hand • Fracture pattern depends on stress applied • Compressive- proximal or distal humerus • Bending- transverse fracture of the shaft • Torsional- spiral fracture of the shaft • Torsion and bending- oblique fracture usually associated with a butterfly fragment

HUMERUS SHAFT FRACTURE

• Clinical evaluation • Complete history and physical • Patients typically present with pain, swelling, and deformity of the upper arm • Careful NV exam important as the radial nerve is in close proximity to the humerus and can be injured

HUMERUS SHAFT FRACTURE

• Radiographic evaluation • AP and lateral views of the humerus • Sometimes Traction radiographs may be indicated for hard to classify secondary to severe displacement or a lot of comminution, these can be painful

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HUMERUS SHAFT FRACTURES

• Conservative Treatment • Goal of treatment is to establish union with acceptable alignment • >90% of humeral shaft fractures heal with nonsurgical management, can take 6-9 months for union • Most treatment begins with application of a coaptation spint or a hanging arm cast followed by placement of a fracture brace called a Sarmiento brace

HUMERUS SHAFT FRACTURE

Operative Treatment -Indications for operative treatment include inadequate reduction, nonunion, associated injuries, open fractures, segmental fractures, associated vascular or nerve injuries -Most commonly treated with plates and screws but can get an Intrameduallary nail

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ELBOW FRACTURE AND DISLOCATION

• Epidemiology • Accounts for 11-28% of injuries to the elbow • Posterior dislocations most common • Highest incidence in the young 10-20 years and usually sports injuries • Mechanism of injury • Most commonly due to fall on outstretched hand or elbow resulting in force to unlock the olecranon from the trochlea • Posterior dislocation following hyperextension, valgus stress, arm abduction, and forearm supination • Anterior dislocation ensuing from direct force to the posterior forearm with elbow flexed

ELBOW DISLOCATIONS

• Clinical Evaluation • Patients typically present guarding the injured extremity • Usually has gross deformity and swelling • Careful NV exam in important and should be done prior to radiographs or manipulation • Repeat Radiographs after reduction • AP and lateral elbow films should be obtained both pre and post reduction • Careful examination for associated fractures

ELBOW DISLOCATION

• Associated injuries • Coronoid process fractures (5-10%) • Medial or lateral epicondylar fx (12-34%) • Wrist fracture • Radial head fx (5-11%) • Treatment • Type I- Conservative • Type II/III- Attempt ORIF vs. radial head replacement

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FOREARM FRACTURES

• Epidemiology • Highest ratio of open to closed than any other fracture except the tibia • More common in males than females, most likely secondary MVA, contact sports, altercations, and falls • Mechanism of Injury • Commonly associated with mva, direct trauma missile projectiles, and falls

FOREARM FRACTURE

• Clinical Evaluation • Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of function at the hand • Careful exam is essential, with specific assessment of radial, ulnar, and median nerves and radial and ulnar pulses • Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for compartment syndrome – HIGH RISK COMPARTMENT SYNDROME WITH HIGH ENERGY TRAUMA • Radiographic Evaluation • AP and lateral radiographs of the forearm • Don’t forget to examine and x-ray the elbow and wrist

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FOREARM ULNA FRACTURES

• Ulna Fractures • These include nightstick and Monteggia fractures • Monteggia denotes a fracture of the proximal ulna with an associated radial head dislocation

FOREARM FRACTURES

• Will need surgical fixation

DISTAL RADIUS FRACTURE

• Epidemiology • Most common fractures of the upper extremity • Common in younger and older patients. Usually a result of direct trauma such as fall on out stretched hand • Increasing incidence due to aging population • Mechanism of Injury • Most commonly a fall on an outstretched extremity with the wrist in dorsiflexion • High energy injuries may result in significantly displaced, highly unstable fractures

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DISTAL RADIUS FRACTURE

• Clinical Evaluation • Patients typically present with gross deformity of the wrist with variable displacement of the hand in relation to the wrist. Typically swollen with painful ROM • Always exam joint above and below injury • NV exam including specifically median nerve for acute carpal tunnel compression syndrome

DISTAL RADIUS FRACTURE

• Radiographs • Evaluate three views of the wrist ap/lat and oblique views

DISTAL RADIUS FRACTURE

• Colles Fracture • Combination of intra and extra articular fractures of the distal radius with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortenting • Most common distal radius fracture caused by fall on outstretched hand • Smith Fracture (Reverse Colles) • Fracture with volar angulation (apex dorsal) from a fall on a flexed wrist • Barton Fracture • Fracture with dorsal or volar rim displaced with the hand and carpus • Radial Styloid Fracture (Chauffeur Fracture) • Avulsion fracture with extrinsic ligaments attached to the fragment • Mechanism of injury is compression of the scaphoid against the styloid

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THINGS YOU DON’T WANT TO MISS

• Scaphoid fracture • Boxer fracture • Metacarpal fracture • Mallet Finger • Dislocations – Perilunate, PIP

SCAPHOID FRACTURE

• Pain over scaphoid • If unsure always thumb spica splint or cast • Follow up with orthopeidcs

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BOXERS FRACTURE

• Usually involved with 4th or 5th MC neck • History relevant – hit something • Needs Ulnar gutter splint/cast • Usually non surgical • Follow up orthopedics • NVI, CMS

METACARPAL FRACTURE

• Any shaft bone • Surgical fixation can be indicated • Always splint or cast with non fractured metacarpal – ulnar gutter but include the third in this example • Orthopedic follow up • NVI, CMS

MALLET FINGER

• Can occasionally have a small avulsion fracture – splint DIP ONLY in neutral for 6 weeks WITHOUT LAPSE • NEVER REMOVE SPLINT • IF NO FX SPLINT 8 WEEKS • Can be managed by PCP – intraarticular fracture refer to ortho

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DISLOCATIONS

DISLOCATIONS

• Finger • Commonly PIP • Digital block and reduce, splint in slight flexion • Follow up ortho • Perilunate • Surgical emergency - even if you can’t describe what’s wrong on this xray, it looks wrong doesn’t it? Very wrong. • NVI, CMS: risk for permanent damage to median nerve

Questions?

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