Elbow Wrist and Hand - Conservative Management

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Elbow Wrist and Hand - Conservative Management
2014-02-13 11:04:35
Elbow Wrist Hand Conservative Management
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  1. Humeroulnar Joint
    • Uniaxial hinge joint formed between ulnar trochlear notch and trochlea of humerus
    • Angulation forms "carrying angle"
  2. Humeroradial Joint
    • Uniaxial hinge joint formed between the capitulum of humerus and head of radius
    • Allows elbow to flex and extend and radius to rotate
    • No true capsular pattern although clinically an equal limitation of pronation and supination is observed
  3. Elbow Ossification Centers (First Appearance)

    • Capitellum (1 year)
    • Radial head (5 years)
    • Medial (Internal) Epicondyle (7 years)
    • Trochlea (10 years)
    • Olecranon (10 years)
    • Lateral (External) Epicondyle (11 years) 
  4. Joint Capsule
    • Does not respond well to injury/prolonged immobilization
    • Thick scar tissue results in flexion contractures
    • Treatment = aggressive stretching, mobilizations or LLPS/LLLD bracing
  5. Lateral (Radial) Collateral Ligament
    • Consists of:
    • Annular ligament
    • Fan-like radial collateral ligament
    • Accessory collateral ligament
    • Lateral ulnar collateral ligament 

    LCL functions to maintain humeralulnar and radiohumeral joints in reduced position when elbow is loaded in supination 
  6. Medial (Ulnar) Collateral Ligament
    • Broader and fan-like
    • Most impornat ligament in the elbow for providing stability against valgus stress (especially in 20-130 degrees of flexion and extension) 
  7. Distal Radioulnar Joint
    • Concave ulnar notch on distal radius articulates w/ convex portion of head of the ulna
    • W/ physiological movements, articulating surface of the radius glides in the same direction 
  8. Proximal Radioulnar Joint
    • Uniaxial pivot joint formed between convex radial head and concave radial notch of the ulna
    • Annular ligament forms 80% of the articular surface
    • Interosseous membrane prevents proximal displacement of radius on ulna (esp. in pulling or pushing)
  9. Wrist Articulations
    • Most flexion occurs in midcarpal joint
    • Most extension occurs in radiocarpal joint 

    (Wrist functions in parts/rows)
  10. Cubital Tunnel Syndrome: Conservative Management
    • Conservative management typically recommended unless muscle wasting present
    • NSAIDS
    • Steroid injections - risk of direct trauma to nerve
    • Night splinting
    • Ulnar nerve gliding exercises
    • Education regarding positioning and posture
    • Ergonomics assessment
  11. Wrist/Hand OA
    • Relative rest
    • Self-application of heat
    • General hand exercises
    • Pharmaceutical management 
  12. PIP Dislocation
    • Exercises begin after splinting period (not during)
    • Exercises depend on direction of dislocation 
  13. Mallet Finger
    • RICE
    • Stax splint for 6-8 weeks
    • Not all heal fully - some have residual extensor lag
    • Education regarding maintaining full extension until instructed to flex the joint
    • Do not stretch aggressively
    • K-wire fixation offered if splinting fails
  14. Trigger Finger
    • Splinting
    • Glucocorticoid steroid injection
    • Open surgical release
  15. DeQuervain's Tenosynovitis
    • Thumb spica splint for acute cases
    • Iontophoresis using dexamethasone
    • Cross friction mobiliation
    • Glucocorticoid steroid injections
    • Ergonomic modifications 
  16. Triangular Fibrocartilage Complex
    • Education regarding self-management
    • Relative rest
    • Wrist splinting
    • NSAIDs/acetaminophen
    • Surgical repair 
  17. Little League Elbow
    • Medial elbow pain attributable to throwing by skeletally immature athletes
    • Throwing motion creates valgus force
    • Medial epicondyle is last ossification center in elbow to clsoe
    • Overuse injury of common flexor tendon
    • Avulsion of apophysis from medial epicondyle of the humerus
    • May cause osteochondritis dissecans of the capitellum of the humerus (collapse/deformity) 
  18. Little League Elbow: Risk Factors and Symptoms
    • Risk Factors
    • - Pitchers age 10-15 years old
    • - Throwing specialty pitches (esp. curveballs and sliders)

    • Symptoms
    • - Gradual onset
    • - Medial elbow pain
    • - Local swelling
    • - Pain w/ throwing, gripping, carrying heavy objects
  19. Little League Elbow: Conservative Management
    • Rest - perform no painful activities, no sports until pain is gone
    • Cryotherapy during acute phase
    • Analgesics - discuss w/ physician due to masking of symptoms
    • Gradually return to pitching, avoiding specialty pitches initially
    • Surgery in rare cases
  20. Little League Elbow: Prevention
    • Warm-up and stretching before pitching
    • Do not play in two leagues concurrently
    • Limit pitches to: 80-100 pitches per game; 30-40 pitches per practice 
    • Emphasize proper pitching mechanics
    • No curveballs or sliders until high school (growth plates should be closed by then)
  21. Little League Elbow: Guidelines of Little League Baseball, Inc.
    • Guidelines similar toAmerican Academy of Pediatrics
    • Pitches limited to: 90 per outing, 200 per week
    • Slow increase in pitching repetition/intensity early in the season
    • Emphasis on proper pitching mechanics
  22. Nursemaid's Elbow
    • Radial head subluxation at 2-4 years old
    • Radial head slips out of annular ligament 
    • Some sources don't consider this a true dislocation
    • Caused by sudden traction force on extended, pronated arm 
    • Radial head does not ossify until ~ 5 years old; annular ligament thickens w/ age
  23. Pain and Inflammation Impairment
    • Result of injury, surgery, central/local nerve compression
    • OA/RA also produce pain and inflammation

    • Treatment
    • - Grade I oscillations (+ ice)
    • - No large amplitude or end-range mobs for RA due to possible joint instability 
  24. Treatment of Musculotendinous Injuries
    • Relative rest
    • Occasional/short-term bracing
    • Inflammation control 
    • Friction massage
    • Therapeutic exercise (stretching, strengthening)
  25. Endurance Impairment
    • Often seen at hand and wrist
    • Imbalance of flexor and extensors and other factors

    • Treatment
    • - High repetition/low resistance for involved muscles with appropriate rest
    • - Posture emphasized 
    • - Subsequent exercises should focus on strengthening at length muscles will be at during functional activities 
  26. Posture and Movement Impairment
    • Most common - work/hobby related
    • Lateral/medial epicondylitis, CTS, etc.

    • Treatment
    • - Allow adequate rest time
    • - Ensure proper tool size
    • - Reinforce good posture
    • - Control cycle time, recovery time, exertion frequency
  27. Disuse and Deconditioning
    • Need proximal stability before you can get distal mobility!
    • Proximal deconditioning leads to distal overuse

    • Treatment
    • - Postural training in neutral range
    • - Muscle endurance training proximal - distal 
  28. Therapeutic Exercise Interventions for Common Diagnoses: Cumulative Trauma Disorders (CTD) Factors
    • Work pace
    • Same task, little variability
    • Concentrated forces on smaller physiologic elements
    • Decreased time for rest
    • Increase in service and high tech jobs
    • Aging workforce
    • Reduction in staff turnover
    • Increased awareness of problem 
  29. Hypomobility
    Surgery, neurologic injuries, burns, falls

    • Treatment
    • - Heat and joint mobs for capsular mobility
    • - Passive prolonged stretch + heat
    • - Postural correction and strengthening of antagonist
    • - Neural gliding techniques if immobility of neural tissue is present