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Just A Sprain?. Tendonitis Finger joint injury Extrinsic ligament injury Intrinsic ligament injury TFCC injury.

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Presentation on theme: "Just A Sprain?. Tendonitis Finger joint injury Extrinsic ligament injury Intrinsic ligament injury TFCC injury."— Presentation transcript:

1 Just A Sprain?

2 Tendonitis Finger joint injury Extrinsic ligament injury Intrinsic ligament injury TFCC injury

3 Tendinopathy de Quervain's Tenosynovitis Intersection Syndrome EPL Entrapment Extensor Tendinitis FCR Tendinitis

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5 de Quervain Tenosynovitis Entrapment of APL & EPB in the 1st dorsal compartment of the wrist Cause: Repeated thumb abduction with simultaneous wrist ulnar deviation Symptoms: Radial wrist pain aggravated by thumb movement 6:1 women; Age group 40-60

6 de Quervain's Tenosynovitis

7 de Quervain Tenosynovitis Splint - 30% effective Splint + corticosteroids % effective Surgery % effective 20% textbook anatomy Separate EPB Compartment or >1 APL slips

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9 de Quervain Tenosynovitis Post-op Thumb Spica Splint for 14 days Localized soreness for 4-6 weeks

10 Intersection Syndrome Tendon entrapment in 2nd dorsal compartment Cause: Repetitive Wrist Motion Common in athletes Weightlifting, Rowing, Racquet sports Symptoms: Pain & Swelling 4 cm proximal to wrist joint at intersection of APL, EPB, and wrist extensors. Possible crepitus

11 Intersection Syndrome

12 Modification/cessation of aggravating activity NSAIDs Wrist splint in 15 degrees extension Corticosteroid injection 2nd dorsal compartment release

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14 Intersection Syndrome Post-op Wrist splint days Strengthening after 5-6 weeks

15 EPL Tendinitis Entrapment of EPL in 3rd compartment Cause: Watershed area disrupted by undisplaced distal radius fracture or rheumatoid arthritis Symptoms: Tenderness, swelling, & crepitus at Lister's tubercle

16 EPL Tendon Entrapment

17 EPL Tendinitis EPL tendon transposition after 3rd compartment release

18 EPL Tendinitis Post-op Splinting not needed Use as tolerated

19 ECU Tendinitis Entrapment of ECU tendon in 6th compartment Cause: Twisting wrist injury or excessive ulnar deviation Symptoms: Ulnar wrist pain & swelling with extension & ulnar deviation; Nocturnal pain Differentiate from TFCC disruption

20 ECU Tendinitis Diagnosis MRI - Differentiates: ECU Subluxation peritendinous synovitis longitudinal splitting of tendon shallow ECU groove anomolous tendon anatomy Confirmed with Lidocaine injection into ECU sheath

21 ECU Tendinitis Wrist splint, NSAID, ice Corticosteroid injection 6th dorsal compartment release Excise septum Repair retinaculum

22 ECU Tendinitis

23 ECU Tendinitis Post-op Ulnar gutter splint 2-4 weeks Progressive use as tolerated

24 FCR Tendinitis Entrapment of FCR in tight fibrosseous tunnel Occupies 90% of cross-sectional area Cause: Most cases insidious/neighboring degenerative process Repetitive flexion/extension or trauma rare Symptoms: Pain at scaphoid tubercle aggravated by resisted wrist flexion/radial deviation

25 FCR Tendinitis Wrist splint, NSAID, ice for 4 weeks Corticosteroid injection FCR sheath release Excise frayed fibers Debride trapezial groove spurs

26 FCR Tendinitis Post-op Wrist splint for 2 weeks Gradually increasing activity after 14 days

27 Finger Joint Injury Skier's Thumb Thumb Radial Collateral Ligament Injury Finger Collateral Ligament Injury

28 Skier's Thumb Acute Ulnar Collateral lLigament injury at the thumb MP joint 10x more common than RCL injury Cause: Sudden forced radial thumb deviation Symptoms: Ulnar thumb MP joint tenderness, ecchymosis, and swelling Signs: Ulnar thumb MP joint tenderness with radial deviation

29 Complete tear Radial deviation > 30 degrees in extension or in 40 degrees flexion Radial deviation > 15 degrees greater than other thumb Stener Lesion Associated proximal phalanx ulnar base avulsion fracture possible Distal tear more common Skier's Thumb

30 Stener's Lesion

31 Skier's Thumb Partial Rupture Hand-based thumb spica splint for 6 weeks AROM last 2 weeks Resisted thumb activity after 3 months Aching pain can last > 6 months

32 Skier's Thumb Complete Rupture Operative Repair Hand -based thumb spica splint for 6 weeks MRI or Ultrasound to rule out Stener lesion

33 Skier's Thumb Post-op Hand-based thumb spica splint for 6 weeks Controlled AROM 4x daily last 2 weeks UCL stress (pinch, grasp) avoided for 12 weeks Vague aching expected up to 1 year

34 Thumb Radial Collateral Ligament Injury Cause: Forced adduction of flexed MP joint Proximal & distal tears equally Symptoms: Symptoms: Radial thumb MP joint tenderness, ecchymosis, and swelling Signs: Radial thumb MP joint tenderness with ulnar deviation

35 Thumb Radial Collateral Ligament Injury Complete tear Ulnar deviation > 30 degrees in extension or in 40 degrees flexion Ulnar deviation > 15 degrees greater than other thumb Associated proximal phalanx radial base avulsion fracture possible Proximal and distal tears equally common MP joint volar subluxation more common

36 Thumb Radial Collateral Ligament Injury Partial Rupture Hand-based thumb spica splint for 6 weeks AROM last 2 weeks Resisted thumb activity after 3 months Aching pain can last > 6 months Complete Rupture Operative Repair

37 Thumb Radial Collateral Ligament Injury Post-op Hand-based thumb spica splint for 7 weeks Controlled AROM 4x daily last 2 weeks RCL stress avoided for 12 weeks Vague aching expected up to 1 year

38 Finger Collateral Ligament Injury Classified by stability Grade I: Pain, no laxity Grade II: Laxity, firm endpoint, stable arc of motion MP tested in 60 degrees flexion Grade III: Grossly unstable, no firm endpoint

39 Finger Collateral Ligament Injury Grade I & II Buddy taping, early ROM MP: 30 degree flexion splint 3 weeks, then buddy tape Grade III Surgical repair MP: 45 degree flexion splint 6 weeks, then buddy tape PIP: Extension splint 6 weeks, then buddy tape

40 Extrinsic Ligament Injuries Palmar radiocarpal Palmar ulnocarpal Dorsal radiocarpal

41 Intrinsic Ligament Injury Scapholunate Interosseous Ligament Dorsal component stronger Lunotriquetral Interosseous Ligament Volar component stronger Dorsal Intercarpal Ligament

42 TFCC Injury Radioulnar ligaments stabilize DRUJ Articular disk supports carpus and absorbs compressive forces

43 TFCC Injury Cause: Axial load on wrist with pronation (fall on outstretched hand or forceful rotational injury) Symptoms: Ulnar wrist pain (with/without clicking) exacerbated by ulnar deviation or forceful rotation Signs: Tenderness at ulnar wrist between FCU and ECU Piano key sign Axial compression and ulnar deviation Studies: MRI MR Arthrogram Arthroscopy

44 TFCC Injury Palmer's Classifications of Triangular Fibrocartilage Complex Lesions Class 1: Traumatic A: Central perforation B: Ulnar avulsion With styloid fracture Without styloid fracture C: Distal avulsion (from carpus) D: Radial avulsion With sigmoid notch fracture Without sigmoid notch fracture Class 2: Degenerative (Ulnar Impaction Syndrome) A: TFCC wear B: TFCC wear Plus lunate or ulnar head chondromalacia C: TFCC perforation Plus lunate or ulnar head chondromalacia D: TFCC perforation Plus lunate or ulnar head chondromalacia Plus lunotriquetral ligament perforation E: TFCC perforation Plus lunate or ulnar head chondromalacia Plus lunotriquetral ligament perforation Plus ulnocarpal arthritis

45 TFCC Injury Immobilization 4 to 6 weeks Long arm if peripheral tear Arthroscopy if not improved after 3 months Arthroscopy Repair if peripheral Debride if central Add wafer resection or ulnar shortening for ulnar positive variance Open repair

46 TFCC Injury Post-op Ulnar gutter splint with early motion exercises following debridement Long arm splint/cast for 4 weeks following repair followed by short arm splint for 2 weeks PROM and gentle strengthening Full activities at 12 weeks

47 TFCC Injury

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