Elbow Wrist and Hand - Pathology and Differential Diagnosis

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Elbow Wrist and Hand - Pathology and Differential Diagnosis
2014-02-13 10:59:52
Elbow Wrist Hand Pathology Differential Diagnosis
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  1. Mallet Finger
    • Disruption of extensor digitorum tendon 
    • Finger is jammed (sudden hyperextension of DIP)
    • Inability to extend DIP jt once flexed 
    • Want to keep it splinted in extension (6-8 weeks)
  2. Trigger Finger
    • Sudden catching/snapping/locking of flexor tendon
    • Painful
    • Commonly occurs at A1 pulley 
    • Idiopathic but suspected to be related to thickening (due to initial bout of tenosynovitis)
  3. Boutonniere Deformity
    • PIP flexion w/ DIP extension
    • Injury or RA → interruption of central slip of extensor tendon 
    • Lateral slips separate 
    • Inability to extend PIP
  4. Swan Neck Deformity
    • Volar plate loosens from disease or tears due to injury → creates tension imbalance
    • Flexed DIP joint
    • Hyperextended PIP joint
  5. DeQuervian's Tenosynovitis
    • Pain, tenderness, and swelling over radial aspect of the wrist w/ difficulty grasping
    • EPB and/or abd pollicis longs and synovial sheaths 
    • Idiopathic but considered an overuse injury
    • OVERDIAGNOSED! (r/o CMC joint dysfunction)
  6. Dupuytren's Contracture (Palmar Fibromatosis)
    • Painless inherited proliferative connective tissue disorder 
    • Involves palmar fascia → fascia contracts over time and tendons unable to move freely
    • 4th and 5th digits most commonly affected (1st and 2nd almost always spared)
  7. Gout
    • Hyperuricemia = a prerequisite 
    • "Diseases of excess"
    • Monosodium Urate (MSU) crystals in the joint 
    • Initially presents as brief twinges of pain
    • Attacks of gouty arthritis last 3-10 days
  8. OA Deformities
    • Heberden's Nodes (DIP)
    • Bouchard's Nodes (PIP)
  9. Triangular Fibrocartilage Complex (TFCC) Injury
    • Articular disc that covers distal end of ulna
    • Helps transmit weight up the ulna (increases ulnar WB)
    • Inhibited grip strength w/ local pain
    • Increased wrist girth @ USP w/ gripping
    • Falsely positive STTT due to TFCC compression
    • Decreased pain and increased grip strength when DRUJ is approximated
  10. Epicondylosis
    • Results from activities involving forceful/repetitive grasping
    • Observation: elbow seems normal, no swelling or redness
    • Full AROM
    • Tenderness at medial/lateral epicondyles
    • Pain w/ resisted wrist flexion (w/ elbow straight) and pronation OR passive wrist extension w/ forearm supinated and elbow extended and ulnar deviation
    • Musculotendinous junction of ECRB most commonly involved
  11. Carpal Tunnel Syndrome
    • Compression of median nerve in carpal tunnel → tingling, numbness, pain, weakness, and muscle atrophy
    • Results from repetitive stress (OVERDIAGNOSED!)
  12. Peripheral Nerve Entrapment: Median Nerve
    5 nerve sites:

    • 1) Ligament of Struthers 
    • 2) Lacertus fibrosis (bicipital aponeurosis)
    • 3) Pronator Teres hypertrophy
    • 4) Anterior Interosseous N
    • 5) Carpal tunnel (most common)
  13. Hand of Benediction
    • Median n. injury at level of elbow or upper arm
    • Loss of lateral 2 lumbricals and lateral half of FDP → Inability to flex 2nd and 3rd digits
    • Seen when pt. instructed to make a fist
  14. Peripheral Nerve Entrapment: Ulnar Nerve
    2 ulnar nerve sites:

    • 1) Cubital tunnel
    • 2) Guyon's canal
  15. Cubital Tunnel and Syndrome
    • Cubital tunnel: fibro-osseous canal that contains the ulnar nerve
    • Borders: MCL (floor), aponeurosis/arcuate ligament (roof), med. head of triceps (post. border), medial epicondyle (anterior border), and olecranon (lateral border)
    • Volume of cubital tunnel greatest w/ elbow in extension
  16. Cubital Fossa
    Triangular space over anterior surface of elbow joint

    • Contents:
    • Biceps tendon
    • Median n
    • Radial n
    • Brachial artery
    • Median cubital (intermediate cubital) cutaneous vein
  17. Ulnar Claw/"Claw Hand"
    • Abnormal resting position of the hand
    • Most commonly due to ulnar n. entrapment (cubital tunnel syndrome at the elbow) → denervation of medial two lumbricals 
    • 4th and 5th MCP joints extended
    • 4th and 5TH IP joints flexed
  18. Peripheral Nerve Entrapment: Radial Nerve
    4 radial neve sites:

    • 1) Fibrous bands anterior to radial head
    • 2) Vascular arcade
    • 3) Tendinous margin of ECRB
    • 4) Arcade of Frohse (proximal edge of supinator)
  19. Radial Nerve Palsy ("Wrist Drop")
    • Extensor muscles supplied by radial n
    • May be damaged w/ humeral fxs 
    • "Saturday Night Palsy" - high radial nerve compression (in the axilla) → sensory loss over radial nerve distribution and motor loss of wrist/thumb/finger extensors ("wrist drop")
  20. Volkmann's Ischemic Contracture
    • Due to brahcial a. injry/compression and resulting ischemia 
    • Commonly associated w/ supracondylar fx