UNDERSTANDING THE UPPER EXTREMITY · CARPAL TUNNEL SYNDROME Confirmatory Nerve Conduction Testing Required by CMS in Medicare/-aid patients prior to surgery No X-Rays needed CARPAL

9/26/2016

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UNDERSTANDING THE UPPER EXTREMITY

Presented by Kari M. Komlofske, FNP-C & John Workinger, FNP-COctober 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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• 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


ASSOCIATED RISK FACTORS• Genetics• Hormonal factors

• Pregnancy• Menopausal• Hypothyroidism

• Obesity• Diabetes• Age• Gender• Rheumatoid arthritis• Occupation

• Lozano-Calderon 2008

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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


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)


HISTORY CORRELATES WITH SEVERITY• Mild

• Intermittent night time paresthesias• Moderate

• Intermittent night time and day time symptomsto 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


Confirmatory Nerve Conduction TestingRequired by CMS in Medicare/-aidpatients prior to surgery

No X-Rays needed


• 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 contractures 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 contracture, 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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• 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


• 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

• Enthesopathy of middle age • Unknown pain generator • No single reliable treatment • Surgical results inconsistent • Self limited condition, although it can

last greater than 12 months.


• 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


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


• 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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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


• 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 FIBROMATOSIS)

• 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’sDisease

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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


• 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


• 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 hypermobility• Underlying arthritis

• Trauma

GANGLION CYST

• Does not move w/ digit flexion/extension as in extensor tenosynovitis

• 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 BURSITIS

• 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• Soft tissue 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.

• Trigger finger: 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


• 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 coaptationspint or a hanging arm cast followed by placement of a fracture brace called a Sarmiento brace


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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• 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


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


• 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?

Documents

UNDERSTANDING THE UPPER EXTREMITY · CARPAL TUNNEL SYNDROME Confirmatory Nerve Conduction Testing Required by CMS in Medicare/-aid patients prior to surgery No X-Rays needed CARPAL