Elbow, wrist and hand

1. Elbow, wrist and hand Sarah Rayner (ESP Physiotherapist) and Dr Tim Hughes January 2015

2. Anatomy: Surface Marking Exercise • Medial and lateral epicondyles • Radial Head • Olecranon • Radial and ulna styloids • Radiocarpal joint • 1st CMC joint • MCP, PIP and DIP joint • Scaphoid, Pisiform, Capitate, Hook of hamate • Flexor carpi radialis and ulnaris tendons • Isolation offlexor digitorum superficialis and profundus • Palmaris longus tendon • Extensor pollicis longus and brevis, abductor pollicis brevis tendons • Sensory distribution of ulna, median and radial nerves

3. Assessment SUBJECTIVE ASSESSMENT • Site/type/severity of pain • Altered sensation/Weakness/other symptoms • Other joint involvement • Aggravating and easing factors • Diurnal pattern • HPC • Functional limitations /SH • Hand dominance • PMH • DH • What do they think is the matter? What are their concerns OBJECTIVE ASSESSMENT • Observations: posture, deformity, swelling, scaring, colour • Palpation • Clear cervical spine and shoulder asnecessary • Active ROM • Passive ROM • Resisted tests • Neurological assessment if required • Special tests

4. Lateral Elbow Tendinopathy: Tennis Elbow • Pathophysiology is degenerative. Non-inflammatory, chronic degenerative changes of the origin of the extensor carpi radialis brevis (ECRB) muscle have been identified. • Exact cause unknown, thought to be due to repetitive use of ECRB (small origin and transmits large forces during grasping). • Causes pain overlateral epicondyle and proximal forearm felt on wrist extension and gripping activities. Diagnosis: • Pain on resisted wrist extension, passive wrist flexion and on palpation lateral epicondyle Treatment: • Epiclasp +/- futura splint • Physiotherapy : eccentric loading and stretching programme • Steroid injections (short term success but delayed recovery and greater recurrence than wait and see approach) • If failed 12 weeks conservative management refer to MSK Service /Orthopaedics • Platelet rich plasma injections, shockwave therapy, Arthroscopic/Open debridement.

5. Medial Elbow Tendinopathy: Golfer’s Elbow • Involves primarily the flexor-pronator muscles (i.e., pronator teres, flexor carpi radialis, palmaris longus) at their origin on the anterior medial epicondyle. • Less often, can also affects the flexor carpi ulnaris and flexor digitorum superficialis. • Repetitive stress at the musculotendinous junction and its origin at the epicondyle leads to irritation and degeneration of the tendon Diagnosis: • Pain on resisted wrist flexion and pronation • Pain on passive wrist extension • Pain on palpation medial epicondyle Treatment: • As for lateral epicondylitis

6. Elbow Conditions: loose bodies • More common in heavy manual workers and weightlifters • Symptoms: • Pain • Clicking • Locking • Investigations: • X-ray • Treatment: • Pain relief • Physiotherapy • Arthroscopy

7. Elbow OA • Symptoms: • Pain • EMS • Reduced ROM (active and passive): flexion, extension, pronation and supination. • Crepitus on movement • Reduced function • Previous history of trauma, manual work • Investigations: • x-ray • Treatment • Pain relief and elbow injections • Physiotherapy • Surgery: OK procedure, elbow replacement

8. Ulna Nerve Entrapment / Cubital Tunnel Syndrome • Symptoms: • Numbness and tingling in ulna nerve distribution with elbow flexion or resting on elbow. • Loss of grip strength • Signs: • Loss of sensation in ulna nerve distribution • Muscle wasting of intrinsics • Claw hand deformity • Positive Tinnel’s test at the elbow • Elbow flexion test • Froment’s sign • Management: • Avoidance of aggravating activities • Splinting • Surgical release

9. Carpal Tunnel Syndrome Median nerve entrapment at the wrist • Predisposing factors: diabetes, obesity, pregnancy, hypothyroidism, heavy manual work, vibration tools, repetitive work. • Symptoms: • Numbness, tingling, burning in thumb, index, middle and radial half ring finger • Weakness and clumsiness • Aggravated bywrist flexion activities • Woken with symptoms, eased with shaking • On examination: • Sensory blunting in median nerve distribution • Thenar eminence wasting • Weakness of thumb abduction • Positive Tinnel's and Phalanstests • Management: • Splinting • Steroid injection • Surgical release

10. Dupuytren’s contracture • Contracture of the palmer fascia producing cords and nodules causing flexion contractures of the digits. • Exact process still unknown. • Most common in white males of northern European descent. • Predisposing conditions: genetic, diabetes, hypothyroidism, smoking, trauma, vibration exposure. • Treatment: • Indicated when function affectedand patient unable to place hand flat on a table • Fasciotomy • Fascietomy

11. Trigger Finger or Stenosing Tenosynovitis • Inflammation causing swelling of the flexor tendon. • Inflamed nodule gets stuck in the A1 pulley as the finger is flexed. • Typically starts with clicking/sticking of the tendon which becomes more painful and difficult to straightened. • Often locked first thing in the morning. • More common in women over 40 or jobs involving increased use of the palm. • Treatment: • NSAID’s and rest • Splinting • Injection • Surgical release

12. De Quervain’sTenosynovitis • Symptoms: • Radial sided wrist pain at the level of the radial styloid due to inflammation of the tendons of extensor pollicis brevis and abductor pollicis longusas they pass in their synovial sheath. • Pain on gripping or abduction and extension activities • Pain eased with rest • Signs: • Pain on resisted abd / ext of thumb • Positive Finklestein’s test • Tenderness on palpation EPB and APL • Management: • Rest • Splinting • Eccentric loading exercises and stretches • Steroid Injections • Surgery

13. Ganglion cysts • Frequently occur around the dorsum of the wrist and fingers • Commonly in association with joint and tendons “herniation hypothesis”. • 80% in the scapho-lunate area • Management: • Nothing • (Hit with a heavy book) • Aspiration (50% reoccurrence) • Surgery (12-41% reoccurrence)

14. 1st CMC joint OA • Frequent site for OA due to relative instability of the joint • Symptoms: • Pain felt at the base of the thumb • Stiffness • Swelling • Loss of function and strength • Signs: • Deformity (adduction of the thumb) • Tenderness on palpation of the joint • Positive grind test • Management: • Splinting • Physiotherapy • Injections • Surgery: trapeziectomy

15. Wrist and Hand OA vs RA • Rheumatoid Arthritis • Symmetrical, multiple joint involvement • MCP and wrist involvement • EMS > 30 mins • Joint swelling • Positive squeeze test • Deformities: boutonniere, swan-necking, ulna drift • Osteoarthritis • Unilateral, fewer joints involved • 1st CMC, PIP and DIP joint involvement • EMS <30 mins • Less joint swelling • Deformities: Heberdon’s and Bouchard’s nodes

16. Case Scenarios • One person to play the role of the patient and act out the condition • One person acts as the GP • Others members of the group to observe and give the GP feedback • GP to take the history and perform the examination and then stop • Feedback to GP on history taking and examination. Discuss diagnosis and differential diagnosis. Discuss management plan. • GP resumes consultation and shares diagnosis with the patient and management plan agreed. • Feedback given to GP for the patient on this aspect of the consultation