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THUMB BASAL JOINT OSTEOARTHIRITIS

WHAT IS IT? Pain and/or weakness in the first thumb joint. There may also be stiffness, tenderness, swelling, clicking or catching.

WHAT CAUSES IT? Arthritis or degenerative changes of the base of the thumb joint. Very common in middle-aged women. WHAT MAY I EXPECT? The pain in your thumb increases with activities such as pinching, gripping or writing and eases with rest. Symptoms usually come on gradually and may come and go depending on activity, weather and amount of use. WHAT CAN I DO TO HELP MYSELF? · · · · · · Modify your activities to be pain free; avoid forceful pinching activities Medication: Speak with your health care provider about antiinflammatory medications or consult your Healthwise Handbook. It may take 10-14 days for the medication to become effective A splint that supports your thumb may be helpful during painful activities for a few weeks at a time. Use ice, moist heat, or parabath for 10-15 minutes, 4-6 times a day Strengthen your thumb with isometric exercise, that is, to push your thumb against resistance without movement Use adaptive devices: key holders, jar openers, electric can openers, spring loaded scissors, etc.

WHEN SHALL I CALL MY HEALTH CARE PROVIDER? If you have followed the advice of this handout for 6 weeks and experience no further improvement If you develop pain radiating into the upper arm or neck, or numbness in your thumb or index finger. 4/04, CN

TRIGGER FINGER

WHAT WILL I FEEL? Pain, clicking or popping when bending a finger or the thumb. A finger may get "locked" in a bent position and be very painful to straighten out. Symptoms are often worse in the morning. Sometimes pain is minimal.

WHAT CAUSES IT? A swollen tendon causes trigger finger. The tendon may become swollen due to overuse, repetitive or unaccustomed movements. When the fingers open and close, the swollen tendon acts like a knotted rope. It catches as it slides through the tight fibrous tissue bands at the base of the finger. WHAT MAY I EXPECT? Your finger or thumb may feel much better after a period of rest, but may require several weeks to months to heal fully. WHAT CAN I DO TO HELP MYSELF? · Modify you activities to be pain-free. Do not continue to stress the tendon. Avoid all repetitive activities and tight gripping. No clicking for a period of 3 weeks. · Contrast bathes: alternate your hand between 2 small tubs of water (or a double sink), 1 minute in cold (68 degree) water, 1 minute in warm (98 degree)water, back and forth for 10-15 minutes; end in cold water. · Aggressively massage base of finger towards the palm twice a day with lotion for 3-5 minutes. · Keep wrist in neutral, trying not to flex or extend to end position. · Use opposite hand to flex finger fully, 2 times a day. WHEN SHOULD I CALL MY HEALTH PLAN PROVIDER? If you have increasing pain, swelling, redness, or develop a fever or chills. If you develop pain radiating into the upper arm or neck, or have numbness in your thumb or fingers. If you have consistently followed the advice of this handout for 6 weeks and experience no further improvement. 4/04, CN

WRIST TENDONITIS/'Tennis elbow'/'Golfer's elbow'

WHAT IS IT? Inflammation of the wrist tendons sometimes accompanied by pain and swelling. The wrist tendons cross over the wrist bones attaching forearm muscles to the fingers.

WHAT CAUSES IT? Wrist tendonitis is caused by overuse, repetitive, forceful or twisting motions of the wrist or hand. Repeated use of weakened, stiff muscles can result in injury. May be more painful with wrist extension as with tennis elbow, or with wrist flexion as with golfer's elbow. WHAT MAY I EXPECT? Your wrist and forearm may feel much better after a period of rest, but the problem will most likely return if you do not take steps to protect muscles from further injury. In most cases, this condition takes several weeks to months to fully heal. WHAT CAN I DO TO HELP MYSELF? · Modify your activities to be pain-free. Do not continue to stress the muscle. · Apply ice for 10-15 minutes 3-6 times a day. · Maintain wrist in neutral, straight position during activities for strongest support. · Stretch 3 times a day after applying moist heat for 3-5 minutes. · Increase circulation by reducing caffeine/nicotine/alcohol and increasing aerobic activity such as walking 1 hour daily. · Use a wrist splint and tennis elbow strap during activities if severe pain with use of hand. WHEN SHOULD I CALL MY HEALTH CARE PROVIDER? If you have consistently followed the advice of this handout for 6 weeks and experience no further improvement. If you develop pain radiating into the upper arm or neck. 4/04, CN

DEQUERVAIN'S TENOSYNOVITIS

WHAT IS IT? Inflammation of the thumb tendons accompanied by swelling and pain with thumb movement.

WHAT CAUSES IT? Using the thumb for forceful, repetitive, twisting motions or with forceful thumb extension as with picking up an infant. WHAT MAY I EXPECT? Your thumb will feel much better in 3-4 weeks with rest, but can become painful again if you continue to do activities which inflame the tendon. WHAT CAN I DO TO HELP MYSELF? · Wear the thumb splint for 23 hours a day for three weeks (remove for hygiene activities) · Moist heat 2 times a day, then use the opposite hand to fully flex and extend the injured thumb · Tuck thumbs against side of hand when lifting (as with infant) · Use index/middle finger for the spacebar when typing ­ not the thumb WHEN SHALL I CALL MY HEALTH PLAN PROVIDER? If you have followed this advice for 2-3 weeks and experience no further improvement If you develop pain radiating into the upper arm or neck, or numbness in your thumb or index finger CAN 4/04

CARPAL TUNNEL SYNDROME

WHAT IS IT? Compression of the median nerve at the wrist causing swelling with numbness of the thumb, index finger, middle finger and half of the ring finger.

WHAT CAUSES IT? Using the hand for repetitive, forceful and awkward activities can inflame the tissues and cause the swelling. WHAT MY I EXPECT? Your hand should feel less numb in 2-3 weeks by wearing a wrist splint at night and doing cardiovascular activities to increase your circulation. WHAT CAN I DO TO HELP MYSELF? · Walk, swim, or dance 60 minutes daily if cleared by your MD · Wear wrist splints at night to keep the wrist in a neutral position · Avoid forceful, repetitive activities · Desk stretch every 15 minutes if you have a sedentary job · Drink 8 glasses of water daily, avoid caffeinated drinks such as coffee and colas WHEN SHALL I CALL MY HEALTH PLAN PROVIDER? If you have followed this advice for 2-3 weeks and experience no further improvement If you develop pain radiating into the upper arm or neck, or increased numbness in your thumb or fingers CAN 4/04

MALLET FINGER

WHAT IS IT? The tendon is torn at the last joint of the finger causing the tip to drop.

WHAT CAUSES IT? A sudden impact to the finger tip, as with a baseball hitting the tip hard during a catch or the impact of a basketball, causing a forceful flexion and tearing of the tendon. WHAT MAY I EXPECT? Full straightening of the finger can be achieved after 4 to 6 weeks of continuous splinting with it fully straight. WHAT CAN I DO TO HELP MYSELF? · Do not let your finger tip drop or bend at all, if it does, the 4-6 weeks begins from that time forward · Bend the middle joint at least twice daily · Monitor skin for breakdown; change splint or dry finger with the help of someone else as needed · Move finger actively after 4-6 weeks, no helping with the other hand · If the finger begins to drop or bend, replace the splint for an additional 2 weeks WHEN SHALL I CALL MY HEALTH PLAN PROVIDER? If you have followed this advice for 2-3 weeks and experience no further improvement If you develop pain radiating into the upper arm or neck, or numbness in your thumb or fingers CAN 4/04

REFLEX SYMPATHATIC DYSTROPHY (RSD) OR COMPLEX REGIONAL PAIN SYNDROME (CRPS)

WHAT IS IT? A pain cycle causing swollen skin, red or white color to the tissues, a shine on the skin surface, burning pain, and a hesitancy to let others touch or move your hand. WHAT CAUSES IT? An abnormal nerve response WHAT MAY I EXPECT? The pain will normally subside with time. The biggest concern is to maintain good movement of the fingers and hand during this painful cycle. You don't want to aggravate the pain cycle and make it worse; the idea is to find ways to relieve the pain so that movement and use of the hand is possible. WHAT CAN I DO TO HELP MYSELF? · Soak in warm water with epsom salts 2-4 times a day; if swollen, use a contrast bath (1 minute warm epsom salted water, one minute cool water. Alternate for 10-15 minutes). · Moist heat if not too swollen, then actively move fingers and hand as much as possible · Touch hand with various textures to decrease sensitivity and help to shut down the abnormal nerve message; a vibrator is often helpful to overstimulate the nerve WHEN SHALL I CALL MY HEALTH PLAN PROVIDER? If you have followed this advice for 2-3 weeks and experience no further improvement If you develop pain radiating into the upper arm or neck, or numbness in your thumb or fingers CAN 4/04

BOUTONNIERE DEFORMITY

WHAT IS IT? The tendon at the middle joint of the finger is torn causing the finger to not be able to fully straighten.

WHAT CAUSES IT? Normally, a sudden impact to the finger causes a tear in the extensor mechanism of the finger. Very common with impact from a basketball. WHAT MAY I EXPECT? Full straightening of the finger after 4-6 weeks of continuous splinting of just the middle joint. WHAT CAN I DO TO HELP MYSELF? · Keep splint in place at all times and do not allow finger to flex or bend at the middle joint; if it does bend at the middle joint, the 4-6 weeks begins at that time · Actively bend the end joint for 5 seconds twice daily · Monitor skin for breakdown, change splint or dry as needed · Begin to actively move the finger (no help from the other hand) after 4-6 weeks; if it starts to not fully straighten, put the splint back on for 2 more weeks continuously · Wear night splint for an additional 3-4 months WHEN SHALL I CALL MY HEALTH PLAN PROVIDER? If you have followed this advice for 2-3 weeks and experience no further improvement If you develop pain radiating into the upper arm or neck, or numbness in your thumb or fingers CAN 4/04

CUBITAL TUNNEL SYNDROME

WHAT IS IT? Compression of the ulnar nerve at the elbow causing numbness of the ring finger and small finger. There may also be electrical shock feelings at the inside of the elbow if tapped.

WHAT CAUSES IT? Using the arm for repetitive, forceful and awkward activities can inflame the tissues and cause the swelling and nerve compression. Resting on your elbows and sleeping with elbows bent can also cause the numbness. WHAT MY I EXPECT? Your hand should feel less numb in 2-3 weeks by wearing an elbow pad and wrist splint at night to keep the joints straight while sleeping. Cardiovascular activities to increase your circulation may also help relieve the symptoms. WHAT CAN I DO TO HELP MYSELF? · Walk, swim, or dance 60 minutes daily if cleared by your MD · Wear wrist splints and wrap a thick towel around the elbow to keep the wrist and elbow straight while you sleep · Avoid prolonged bending of the elbow more than 90 degrees during daily activities · Avoid forceful, repetitive activities; avoid leaning on elbows · Desk stretch every 15 minutes if you have a sedentary job · Drink 8 glasses of water daily, avoid caffeinated drinks such as coffee and colas · The position of rest is palm up in your lap; assume this position to relieve numb fingers WHEN SHALL I CALL MY HEALTH PLAN PROVIDER? If you have followed this advice for 2-3 weeks and experience no further improvement If you develop pain radiating into the upper arm or neck, or increased numbness in your thumb or fingers CAN 5/04

The Wrist ­ Examination I. Visually examine wrist and compare to opposite side II. Check six dorsal compartments A. B. C. D. E. F. III. IV. V. VI. VII. APL, EPB (Dequervains) ECRL, ECRB (Tendonitis, intersection syndrome) EPL (Tendonitis) EDC, EIP (tendonitis, RA) EDM (RA) ECU (tendonitis, subluxation) ROM Strength for edema sensation 5 zones IAW Brown and Lichtman

Check Check Check Check Check

A. Radial Dorsal pain i. Distal radial sensory nerve irritation as with Wartenburgs syndrome. Radial Styloid checked for contusion, fracture, radioscaphoid arthritis ii. Scaphoid fx has positive snuffbox tenderness, nonunion, instability iii. CMCJ pain with OA, positive grind test iv. EPB/APL pain with positive Finklesteins/DeQuervains v. EPL laceration with Lister's tubercle or adhesion with DRF vi. Intersection syndrome occurs at the crossover of the first and second dorsal compartment with edema along distal dorsal forearm with pain in position of clenched fist with thumb abducted, as with rowing B. Central Dorsal pain i. Examine the lunate, scapho-lunate interval, lister's tubercle (dorsal rim of the radius), capitate, base of the 2nd and 3rd metacarpal, PIN. RSI can occur with repeated hyperextension of the wrist causing a spur on the dorsal rim of the radius and impinge upon the scaphoid causing pain with hyperextension and radial deviation. SST ­ Scaphoid Shift Test. Watson found SST had a 69% sensitivity to scaphoid instability. Test by pressure over the volar scaphoid (base of

ii.

thenar crease), with wrist flexed move from ulnar to radial deviation; painful response without scaphoid emergence is positive. iii. Ballotment Test for scaphoid instability involves grasping the scaphoid and lunate with shift; positive to pain indicates scaphoid instability. iv. Positive third metacarpal to capitate pain would suggest SL or LT instability or CL degeneration as with SLAC wrist (scapholunate advanced collapse). C. Ulnar dorsal pain i. Areas to examine include the ulnar styloid, ulnar head, DRUJ, TFCC, hamate, triquetrum, lunotriquetral interval, 4th/5th CMCJ, ECU. ii. A prominent DRUJ can indicate DRUJ instability; the piano key test is done with downward pressure on the ulnar styloid with a spring back to position with a note of discomfort indicating DRUJ instability. iii. The TFCC (triangular fibrocartilage complex) can be assessed with the TFCC load test which is pressure into the ulnar direction with axial load and move volar and dorsal; the test is positive if there is a painful or clicking response. iv. The ECU can be tested with resistance to extension on the ulnar border of the dorsal palm. v. Ulnar snuffbox tenderness can suggest LT instability. vi. The Ballotment test for LT instability is done by stabilizing the lunate and displacing the triquetrum volarly. vii. Midcarpal instability can be demonstrated with a midcarpal shift test ­ palmar load on the capitate with ulnar deviation and axial load causing a painful clunk. D. Radial Volar pain i. ii. Examine the radial styloid, scaphoid tuberosity, STT joint, trapezial ridge, FCR, PL, FDP/FDS, median nerve, and radial artery. Tender along the radial styloid may indicate DRF or radiocarpal ligament injury. 30% have lasting complaints from FOOSH/DRF.

iii. OA changes may be present at the trapizium if pain occurs with pressure over the STT joint (just distal to the scaphoid tuberosity) with radial deviation E. Ulnar Volar area pain i. Examine the pisaform at the base of the hypothenar eminence at the flexion crease which is mobile over the triquetrum within the FCU; tenderness here is indicative of fracture or OA changes ii. Hook of the hamate is located at the hypothenar eminence, 1-2 cm distal to the pisaform; pain during SF/RF flexion in ulnar deviation would suggest fracture iii. Ulnar nerve checked with tinels. "Cyclist's palsy" is compression of the UN in Guyon's canal. iv. Ulnar artery tested with the Allen test and presents cold ulnarly.

VIII. A.

Common Wrist Injuries Carpal Instabilities i. DISI ­ Dorsally intercalated segmental instability; the lunate flexes dorsally while the scaphoid is displaced vertically. Sequelai of FOOSH when younger with radioscaphiod ligament tear ii. VISI ­ volarly intercalated segmental instability; the lunate is flexed palmward; may be associated with RA iii. Rotatory subluxation of the scaphoid; associated with radioscaphocapitate and scapholunate tears

B. TFCC ­ Triangular fibrocartilage complex injuries; most commonly associated with lunate triquetral tears, less frequently with scapholunate tears. It is the most common internal derangement of the wrist. Injury often from rotational, wrist extension trauma. Composed of: triangular fibrocartilage, minescal homologue, ulnolunate and ulnotriquetral-volar ligaments, and extensor carpi ulnaris tendon. It originates from the distal radius, ulnarly, and extends to the ulnar styloid head. Best viewed from the coronal images, 3D gradient echo sequence or MRI. Most often the central tears are of degenerative origin. Ulnar sided tears are most frequently missed on MRI. TFCC tears are most often immobilized unless the DRUJ is unstable or there is an unstable fracture.

Arthroscopy/debridement is useful for central tears as they do not heal. Medial/distal/radial tears can heal with immobilization alone if good reduction with wrist positioning is achieved. C. Ulnar variance greater than 2.5 mm is biomechanically significant. Negative ulnar variance is weakly associated with Keinbock Disease. Positive ulnar variance is associated with TFCC tears of the degenerative origin. Treatment includes Darrach procedure (distal inch of ulna resected) or SuaveKapandji (head of ulna screwed into the radius while the 12mm segment of the proximal ulna is removed). D. AVN is associated with steroid usage, systemic lupus and Keinbock Disease of the overuse origin. E. SLAC wrist is scapholunate-advanced collapse. OA is often associated with scapholunate/lunotriquetral ligament tears. Proximal migration of the capitate leads to focal OA at the capitoscaphoid and capitolunate joints. F. Scaphoid fracture ­ snuff box tenderness, MRI is test of choice. High incidence of occult fracture and nonunion. G. Ganglions are most common wrist mass and can extend intraosseosly to the lunate, a sign of internal derangement. Volar ganglions often arise from the RC or STT joint. Second most common wrist mass is the lipoma.

The Elbow

1. Examination a. b. c. d. e. f. g. h. History of trauma. The humerus be a high energy impact leaving deformity Pain scale, 1-10 Reduced ROM Reduced strength Instability Inspect ulnar nerve medially Inspect median nerve at cubital PT/BR Inspect biceps tendon insertion elbow centrally fracture would edema and

fossa bound by at the anterior

2. Common elbow injuries a. b. Biceps rupture common with middle aged men with sudden elbow extension UCL injury leads to posterolateral rotatory instability. The shift test is normally done under anesthesia with extreme supination, valgus and compressive stress, with the external rotation causing posterior subluxation as the elbow is extended. Heterotopic ossification may be prevented with AROM and gentle PROM, low load strengthening and avoidance of pain. Biceps tendonitis is identified with pain with resisted elbow flexion and supination causing pain at the radial tuberosity. Injections are avoided because of the neurovascular area. Treatment includes immobilization of the elbow at 90 degrees of flexion, 0 degrees of rotation for 3-4 weeks, deep/soft tissue massage, friction massage of the tendon, moist heat, ice, ultrasound and eventual strengthening.

c.

d.

e. f.

Triceps tendonitis is pain with resisted elbow extension. Steroid injection is OK. Lateral epicondylitis is common over the age of 30 as a degenerative process. Pain with gripping and/or wrist extension; test with elbow extended, FA pronated, wrist flexed which presents with reduced elbow extension. Treatment included in handout. Golfer's Elbow identified as pain with resisted extension of the elbow in supination with wrist extended, or resisted wrist flexion.

g.

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