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Evalua&onandTreatmentofCommonUpperExtremity
Problems&InjuriesJoshuaTuck,D.O.,M.S.
LECOMSportsandOrthopedicMedicineToronto2016
Objec&ves• Anatomicreviewofthe
elbow,wristandhand.• Discusscommonclinical
condi&onsineachanatomicregion.– Lateralandmedial
epicondyli&s,deQuervaintenosynovi&s,carpaltunnelsyndromeandtriggerfinger.
• Describeanddemonstrateevalua&ontechniques.
• Reviewosteopathicconsidera&onsineachregion.
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OsteopathicPrinciples
OverviewofEpicondyli&s
• Painatthemyotendinousjunc&onofthesemusclegroupsisreferredtoaslateralandmedialepicondyli&s,respec&vely.
• Lateralepicondyli&sisoSencalledtenniselbowandmedialepicondyli&s,golfer'selbow
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LateralEpicondyli&s• Introduc&on
– AUributedtodegenera&onoftheextensorcarpiradialisbrevisorigin,althoughtheunderlyingcollateralligamentouscomplexandjointcapsulealsohavebeenimplicated
– Overexer&onoftheextremitywithrepe&&vewristextensionandalterna&ngforearmprona&on/supina&on
• Epidemiology– 1%to3%ofadultseachyear– DiagnosiswasfirstmadebyRungein1873– Named“lawn-tennisarm”byMajorin1883duetoitsassocia&onwith
thesport– AdultinthefourthorfiShdecadeoflife– Affectsmenandwomenequally– Symptomsmorecommonindominatearm
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Epicondyli&s
• Thelateralepicondyleoftheelbowisthebonyoriginforwristextensors
• Themedialepicondyleisthebonyoriginforwristflexors.
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LateralEpicondyli&s
• Pa&entHistory– Painoverthelateralaspectoftheelbowisthemostconsistentsymptoms
– Painisusuallysharpandisexacerbatedbyac&vi&esinvolvingac&vewristextensionorpassivewristflexionwiththeelbowextended
– Characteris&ccomplaintistheinabilitytoholditems(ie:acoffeecup)duetopaininthelateralelbow
– Symptomonsetisfrequentlyinsidious,withnoclearinci&ngevent
LateralEpicondyli&s
• PhysicalExam– MaximaltendernessslightlyanterioranddistaltothelateralepicondyleovertheoriginoftheECRBandtheEDCmuscles
– Lessfrequentlylocalizedtendernessispresentattheapexofthebonylateralepicondyle
– Rarely,tendernessisaccompaniedbyswelling,erythema,orwarmth
– PainlocalizedtothelateralepicondyleorjustslightlydistaltotheextensororiginisoSenelicitedwithresistedwristanddigitextension
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SpecialTestsforElbowLateralEpicondyli&s
• Forearmpronatedandflatontable
• Fistwithextendedwrist• Pa&enttoresistflexion• PainattheLateral
Epicondylemeanspathology.
• “TennisElbow”
LateralEpicondyli&s
• Imaging
– Radiographs• Occasionallyrevealscalcifica&onwithintheextensormass
– MRI– Ultrasound
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LateralEpicondyli&s
• Differen&alDiagnosis
– RadialTunnelSyndrome– CervicalRadiculopathy– OCDlesionofradiocapitellarjoint– Posterolateralelbowplica– Posterolateralelbowinstability
LateralEpicondyli&s
• NonsurgicalTreatment(firstline)
– Rest– NSAID’s– PhysicalTherapy– Injec&on– Orthoses– ShockWaveTherapy– Acupuncture– PRP– Prolotherapy
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LateralEpicondyli&s
• SurgicalTreatment
– Maybeconsideredwhen6to12monthsofconserva&vetreatmenthasfailed
– OpenDebridement– EndosocpicECRBrelease– PercutaneousECRBrelease
deQuervainTenosynovi&s
• Introduc&on– Stenosingtenosynovi&softhefirstdorsalcompartmentofthewrist
– E&ologyisthoughttobesecondarytorepe&&veorsustainedtensiononthetendonsofthefirstdorsalcompartment
– Tensionproducesafibroblas&cresponse,resul&nginthickeningandswellingofthecompartmentanddiscomfortwithuseofthehandandwrist
– Firstdescribedin1895byFritzdeQuervain
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deQuervainTenosynovi&s• Thefirstdorsal
compartmentofthewrist(I)
• Abductorpollicislongusandextensorpollicusbrevis.
• Inflamma&oncausedbyrepe&&vemo&onsorkine&csoma&cdysfunc&ons.
• +Finklestein’stest
deQuervainTenosynovi&s
• Epidemiology– Nolong-termepidemiologicstudyhasbeendone– Caseseriessuggestthatitaffectswomenuptosix&mesmoreoSenthanmenandisassociatedwiththedominanthandduringmiddleage
– Occupa&onsrequiringrepe&&vetyping,liSing,andmanipula&onhavebeenconsideredriskfactors
– Pregnantandlacta&ngwomenrepresentanincreasingcohortofpa&entswithnew-onset,self-limiteddisease
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OverviewandIncidence
• Imbalancebetweenflexorsandextensors
• deQuervaintenosynovi&sisthemostcommonentrapmenttendoni&sofhandandwristaSertriggerfinger
• Itismostcommonlyseeninwomenbetween30and50yearsofage
deQuervainTenosynovi&s
• Pa&entHistory
– OSenpresentswithagradualonsetofpainthatmaybeexacerbatedbygrasping,thumbabduc&on,andulnardevia&onofthewrist
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deQuervainTenosynovi&s
• PhysicalExam– Loca&onoftendernessismorespecifictothefirstextensorcompartmentovertheradialstyloid
– Possibleradia&onofpaintotheforearmanddistallytothethumb
– TheFinkelsteinTest• Classicmaneuverfordiagnosis• Consideredpathognomonic• Performedbygraspingthepa&ent’sthumbandquicklydevia&ngthehandandwristulnarly
• Posi&vetestreproducesthepain
Finklestein’stest
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FirstDorsalCompartment
EPB
EPL
APL
deQuervainTenosynovi&s
• Imaging
– Diagnosedclinically– Wristradiographscanbeusedtoruleoutothercausesifdiagnosisisunclear
– MRI
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deQuervainTenosynovi&s
• Differen&alDiagnosis
– Intersec&onsyndrome– Radialstyloidfracture– Scaphoidfracture– Thumbinstability– Basilararthri&softhethumb
– Radialneuri&s
NonsurgicalTreatmentOp&ons
• Thumb/wristimmobiliza&onusingsplintorbrace
• Ice• NSAIDs• Improvearthrokine&cs/posturalmodifica&ons
• Steroidinjec&ons
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DeQuervainTenosynovi&s
• SurgicalTreatment
– Releaseofthefibro-osseousroofofthefirstdorsalcompartment
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SurgicalManagement*
Incision
SurgicalManagement
Radial Sensory Nerve
Extensor Retinaculum
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SurgicalManagement
EPB
APL
CarpalTunnelSyndrome
• Introduc&on
– Firstdescribedin1854bySirJamesPagetinpa&entswithdistalradiusfracture
– Mostcommoncompressiveneuropathyoftheupperextremity
– CausedbyMediannervecompressioninthecarpaltunnel
– MaybeAcuteorIdiopathic
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CarpalTunnelSyndrome
• Epidemiology– Between0.99and3.46casesper100,000intheUnitedStates
– 500,000surgicalproceduresannually– Economicimpactes&matedat$2Billionannually– WomenmorethatMen– Increasingincidencewithage
CarpalTunnelSyndrome• Commoncompressive
neuropathy.• Anatomiccarpaltunnelis
createdbythetransversecarpalligamentandhousesthefollowingstructures:
• Mediannerve• Flexordigitorumprofundus
andsuperficalis.• Palmarislongus
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CarpalTunnelSyndrome• Pa&entHistory
– Pain– NocturnalPain– Traumaand/orrepe&&vemovements
– Painmayradiatetoforearmorelbow
– Weakness– Paresthesiasinthumband1ormoreoftheradialdigits
– Decreaseddexterity– Commonlybilateral
CarpalTunnelSyndrome*
• PhysicalExam
– Necktofingers– Skinandmuscleatrophy– Tinel– Phalen– Durkan
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TestsforCarpalTunnel*
Phalen’s test Prayer test / Reverse Phalen’s
Tinel’s test
Spurling sign Durkan’s Test
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CarpalTunnelSyndrome
• Diagnos&cStudies
– EMG– WristRadiographs
CarpalTunnelSyndrome
• Associatedwithmanysystemiccondi&ons– Obesity– DrugToxicity– Alcoholism– Diabetes– Hypothyroidism– RheumatoidArthri&s– RenalFailure– Pregnancy(20%to45%)
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CarpalTunnelSyndrome
• Differen&alDiagnosis
– Overusesyndromes– Cervicalrootimpingement
– Thoracicoutletsyndrome
– Proximalmediann.compression
– CMCarthri&s
UpperLimbCutaneousInnerva&on
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UpperQuarterDermatomes
CarpalTunnelSyndrome
• NonsurgicalTreatment– Splin&ng(nightsplints)– OralMedica&ons
• NSAIDs• OralCor&costeroids
– Cor&costeroidInjec&ons
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GoalofCTSManualMedicine• Lengtheningorloosening
thetransversecarpalligament.
• Increasingcarpaltunneldiameter.
• Improvinglympha&cflow.• Restoringfunc&onand
mobilitytotheradiocarpalandulnocarpaljoints.
• Restoringbalancebetweenthewristflexorsandextensors.
CarpalTunnelSyndrome
• SurgicalTreatment
– OpenRelease– EndoscopicRelease
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TriggerFinger
• Introduc&on– Stenosingtenosynovi&s– Isapathologicaldispropor&onbetweenthevolumeofthere&nacularsheathanditscontentsasitmovesthroughtheA1pulley
– Inabilitytoflexorextenddigitsmoothly
– Alldigitscanbeaffected– Ringfingerismostcommon
TriggerFinger
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TriggerFinger
• Epidemiology– Morecommoninwomen– AverageAgeis52to62yearsold– Associatedwith
• RheumatoidArthri&s• Gout• Diabetes• Amylodosis• CHF• CTS
TriggerFinger
• Pa&entHistory
– Mayreportamild,nonpainfulclicktoinabilitytofullyflexdigit.
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CochraneReview
• Noar&clesthatdirectlycomparedsteroidinjec&onwithsurgicaltreatment.
• However,tworeferencedar&cles,whichwereexcludedfromthereview,reportedcureratesof89to97percentforsurgeryand60to90percentforsteroidinjec&on.
• Aseparatear&clecomparedsplin&ngwithsteroidinjec&onandfoundcureratesof70and82percent,respec&vely.
TriggerFinger
• PhysicalExam
– Painatpalmarbaseofinvolveddigit
– PossiblenodulenearA1– Palpableclicking– Lockeddigitflexionthatmustbereduced
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TriggerFinger
• Imaging
– Generallynotindicated
TriggerFinger
• Differen&alDiagnosis
– CarpalTunnelSyndrome– DupuytrenContracture– RheumatoidArthri&s
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TriggerFinger
• NonsurgicalTreatment
– Ac&vitymodifica&on– NSAIDs– Splints– Cor&costeroidInjec&ons
TriggerFinger
• SurgicalTreatment
– A1pulleyrelease
• Open• Percutaneous
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References:
• Scarpone,M.Theefficacyifprolotherapyforlateralepicondylosis.ClinJSportMed.2008May;18(3)248-254
• Keith,Michaelet.al.DiagnosisofCarpalTunnel.JAmAcadOrthopSurg2009:17;389-396.
• Cranford,CS.CarpalTunnelSyndrome.JAmAcadOrthopSurg2007;15;537-548.
Pre-testQues&ons:
• 1.Whichloca&onoftheelbowismostpronetoepicondyli&s?
• A.Lateral• B.Medial• C.Posterior• D.Radialhead
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• 2.Allofthefollowingarepartofthedifferen&aldiagnosisfor“golfer’selbow”except:
• A.Flexor-pronatorstrain• B.Medial(ulnar)collateralligamentsprain• C.Ulnarneuri&s• D.Radialheadsoma&cdysfunc&on
• Agolferhasbeenstrugglingwithelbowpainfor5yearsandpresentstoyourofficebecausethepainisnowlimi&nghisabilitytogolf.Whichismostlikely?
• A.Medialcollateralligamentrupture• B.Lateralepicondylosis• C.Medialepicondyli&s• D.Radialheadsoma&cdysfunc&on