Common Elbow, Wrist, and Hand Problems 5/14/03 Elbow, Wrist & Hand Disorders Brian Lohrbach, MD OSI Orthopedic Surgeon Brian L. Lohrbach, M.D.

Common Elbow, Wrist, and Hand Problems 5/14/03 Tendonitis Brian L. Lohrbach, M.D.

Common Elbow, Wrist, and Hand Problems 5/14/03 Tendonitis: Elbow Lateral epicondylitis “Tennis elbow” Pain over lateral epicondyle radiating to dorsum of wrist Pain with repetitive supination/pronation and gripping Degeneration of origin of Extensor Carpi Radialis Brevis Brian L. Lohrbach, M.D.

Lateral Epicondylitis: Diagnosis Common Elbow, Wrist, and Hand Problems 5/14/03 Lateral Epicondylitis: Diagnosis X-rays usually negative Pain to palpation of lateral epicondyle Pain with resisted wrist extension in pronation Brian L. Lohrbach, M.D.

Lateral Epicondylitis: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 Lateral Epicondylitis: Treatment Non-operative: 85% success rate Activity modification, NSAIDs, counterforce strap, cortisone injections (2-3) Therapy Ultrasound, massage, iontophonophoresis, stretching Brian L. Lohrbach, M.D.

Lateral Epicondylitis: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 Lateral Epicondylitis: Treatment Operative Removal of diseased tissue Most patients improve in 3-4 months 90% success rate Brian L. Lohrbach, M.D.

Lateral Epicondylar Release Return to Work Protocol Common Elbow, Wrist, and Hand Problems 5/14/03 Lateral Epicondylar Release Return to Work Protocol Week 0 – 1: off work Week 1 – 4: one-handed work, begin OT Week 4 – 12: light duty work, complete OT Week 12: regular duty work Brian L. Lohrbach, M.D.

Common Elbow, Wrist, and Hand Problems 5/14/03 Tendonitis: Wrist De Quervain’s tenosynovitis Intersection syndrome Flexor carpi radialis/ulnaris tendinits Brian L. Lohrbach, M.D.

DeQuervain’s Tenosynovitis Common Elbow, Wrist, and Hand Problems 5/14/03 DeQuervain’s Tenosynovitis Stenosing tenosynovitis of 1st dorsal compartment: Abductor pollicis longus (APL) and extensor pollicis brevis (EPB) 30 to 50 year olds 10 times more common in women Pain with thumb motion over radial styloid Brian L. Lohrbach, M.D.

DeQuervain’s: Diagnosis Common Elbow, Wrist, and Hand Problems 5/14/03 DeQuervain’s: Diagnosis Pain over radial styloid Finkelstein’s maneuver Brian L. Lohrbach, M.D.

DeQuervain’s: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 DeQuervain’s: Treatment NSAIDs Thumb spica splint 1 – 2 cortisone injections Operative release required in 25% of patients after 6 weeks of failed conservative treatment Brian L. Lohrbach, M.D.

First Dorsal Compartment Release Return to Work Protocol Common Elbow, Wrist, and Hand Problems 5/14/03 First Dorsal Compartment Release Return to Work Protocol Day 1 - 2: off work Week 1 – 3: one-handed work, home exercises Week 3 – 6: light duty work Week 6: regular duty work Brian L. Lohrbach, M.D.

Intersection Syndrome Common Elbow, Wrist, and Hand Problems 5/14/03 Intersection Syndrome Pain where APL and EPB cross over underlying extensor carpi radialis (ECR) Swelling, crepitus, squeaking* Splint, NSAID, occasional injection Brian L. Lohrbach, M.D.

Flexor Carpi Radialis/Ulnaris Tendonitis Common Elbow, Wrist, and Hand Problems 5/14/03 Flexor Carpi Radialis/Ulnaris Tendonitis Pain over volar wrist from repetitive motion Splint, NSAIDs, activity modification Cortisone injection Very rarely, surgical tenolysis Brian L. Lohrbach, M.D.

Common Elbow, Wrist, and Hand Problems 5/14/03 Tendonitis: Hand Trigger finger Stenosing flexor tenosynovitis: Inflammation of flexor tendon limiting excursion under the A1 pulley Inability to fully extend digit or catching with flexion and extension of digit Repetitive use and diabetes are common causes Brian L. Lohrbach, M.D.

Trigger finger: Diagnosis Common Elbow, Wrist, and Hand Problems 5/14/03 Trigger finger: Diagnosis Locked digit in flexion Painful nodule over volar metacarpophalangeal joint *Beware: Patients with trigger thumb often complain of catching in interphalangeal joint of thumb Brian L. Lohrbach, M.D.

Trigger Finger: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 Trigger Finger: Treatment Nonoperative: NSAIDs Cortisone injection under A1 pulley 60% success if seen early Brian L. Lohrbach, M.D.

Trigger Finger: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 Trigger Finger: Treatment Operative: A1 pulley release Outpatient procedure under local 95% success rate Brian L. Lohrbach, M.D.

Trigger Finger Release Return to Work Protocol Common Elbow, Wrist, and Hand Problems 5/14/03 Trigger Finger Release Return to Work Protocol 1 - 2 days off work Week 1 – 3: one-handed work, home exercises Week 3 – 6: light duty work Week 6: regular duty work Brian L. Lohrbach, M.D.

Compressive Neuropathies Common Elbow, Wrist, and Hand Problems 5/14/03 Compressive Neuropathies Brian L. Lohrbach, M.D.

Compressive Neuropathies: Elbow Common Elbow, Wrist, and Hand Problems 5/14/03 Compressive Neuropathies: Elbow Cubital tunnel syndrome (ulnar nerve) Radial tunnel syndrome Brian L. Lohrbach, M.D.

Cubital Tunnel Syndrome Common Elbow, Wrist, and Hand Problems 5/14/03 Cubital Tunnel Syndrome Compression of ulnar nerve at the elbow Direct blow to elbow Repetitive flexion Diabetes Brian L. Lohrbach, M.D.

Cubital Tunnel Syndrome Common Elbow, Wrist, and Hand Problems 5/14/03 Cubital Tunnel Syndrome Symptoms Numbness in small and ulnar half of ring finger, including dorsum of hand Decreased grip strength Medial elbow pain Awakens at night Worse when holding phone,elbow on desk, driving Brian L. Lohrbach, M.D.

Cubital Tunnel Syndrome: Diagnosis Common Elbow, Wrist, and Hand Problems 5/14/03 Cubital Tunnel Syndrome: Diagnosis Positive Tinel’s sign at cubital tunnel Positive elbow flexion test Decreased 2-point discrimination at small finger Brian L. Lohrbach, M.D.

Cubital Tunnel Syndrome: Diagnosis Common Elbow, Wrist, and Hand Problems 5/14/03 Cubital Tunnel Syndrome: Diagnosis Positive Froment’s sign (weak adductor) Wasting of dorsal 1st webspace Electrodiagnostic tests (EMG/NCV) Brian L. Lohrbach, M.D.

Cubital Tunnel Syndrome: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 Cubital Tunnel Syndrome: Treatment NSAIDs, activity modification, elbow pads, nighttime splinting in 20 degrees of flexion (Poorly tolerated) Surgical release and/or anterior transposition 80-90% good results Brian L. Lohrbach, M.D.

Radial Tunnel Syndrome Common Elbow, Wrist, and Hand Problems 5/14/03 Radial Tunnel Syndrome Compression of radial nerve under extensors in forearm Deep, lateral forearm pain, often at night No sensory component Often confused with lateral epicondylitis (they co-exist 5% of the time) pain is more distal Brian L. Lohrbach, M.D.

Radial Tunnel Syndrome: Diagnosis Common Elbow, Wrist, and Hand Problems 5/14/03 Radial Tunnel Syndrome: Diagnosis Extended middle finger test Electrodiagnostic tests not helpful Injection of local anesthetic into radial tunnel completely relieves symptoms and is diagnostic Brian L. Lohrbach, M.D.

Radial Tunnel Syndrome: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 Radial Tunnel Syndrome: Treatment NSAIDs Activity modification Surgical decompression 50% success rate Brian L. Lohrbach, M.D.

Cubital and Radial Tunnel Release Return to Work Protocol Common Elbow, Wrist, and Hand Problems 5/14/03 Cubital and Radial Tunnel Release Return to Work Protocol Week 0 – 1: off work Week 1 – 6: one-handed work, begin OT Week 6 – 12: light duty work, complete OT Week 12: regular duty work Brian L. Lohrbach, M.D.

Compressive Neuropathies: Wrist Common Elbow, Wrist, and Hand Problems 5/14/03 Compressive Neuropathies: Wrist Carpal tunnel syndrome (median nerve) Ulnar tunnel syndrome (Guyon’s canal) Brian L. Lohrbach, M.D.

Carpal Tunnel Syndrome Common Elbow, Wrist, and Hand Problems 5/14/03 Carpal Tunnel Syndrome Compression of median nerve under transverse carpal ligament Pain/parasthesias of palmar/radial aspect of hand; weakness over time Often worse at night, reading paper, holding a coffee cup, driving Brian L. Lohrbach, M.D.

Carpal Tunnel Syndrome: Risk Factors Common Elbow, Wrist, and Hand Problems 5/14/03 Carpal Tunnel Syndrome: Risk Factors Diabetes Alcoholism Pregnancy Hypothyroidism Distal radius fracture Vibrational exposure Brian L. Lohrbach, M.D.

Carpal Tunnel Syndrome: Diagnostic Tests Common Elbow, Wrist, and Hand Problems 5/14/03 Carpal Tunnel Syndrome: Diagnostic Tests Moving 2-point discrimination greater than 5mm Tinel’s: tingling to percussion over carpal tunnel Phalen’s: wrist palmarflexion produces parasthesia in 60 seconds Compression test: direct compression over carpal tunnel with parasthesia at 30 seconds Brian L. Lohrbach, M.D.

Carpal Tunnel Syndrome: Diagnostic Tests Common Elbow, Wrist, and Hand Problems 5/14/03 Carpal Tunnel Syndrome: Diagnostic Tests Weakness of abductor pollicis brevis or wasting of the thenar eminence (advanced stage) Electrodiagnostic tests Nerve conduction velocity: slowed at wrist Electromyography (EMG): indicates advanced stage of disease 5% false-negative rate Brian L. Lohrbach, M.D.

Carpal Tunnel Syndrome: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 Carpal Tunnel Syndrome: Treatment Conservative Splinting in neutral at night NSAIDs Ergonomic modification Steroid injections Best in early stages Diagnostic tool 20% asymptomatic at 12 months Brian L. Lohrbach, M.D.

Carpal Tunnel Syndrome: Treatment Common Elbow, Wrist, and Hand Problems 5/14/03 Carpal Tunnel Syndrome: Treatment Carpal tunnel release 95% success rate Outpatient, local anaesthetic Recovery 6 weeks to 6 months depending on the occupation of the patient Pillar (incisional) pain Brian L. Lohrbach, M.D.

Ulnar Tunnel Syndrome (Guyon’s Canal) Common Elbow, Wrist, and Hand Problems 5/14/03 Ulnar Tunnel Syndrome (Guyon’s Canal) Ulnar nerve passes between hook of hamate and pisiform at wrist Much less common than carpal tunnel syndrome Brian L. Lohrbach, M.D.

Carpal Tunnel Release Return to Work Protocol Common Elbow, Wrist, and Hand Problems 5/14/03 Carpal Tunnel Release Return to Work Protocol 3 – 7 days: off work Week 1 – 6: one-handed work, +/- OT Week 6 – 12: light to regular duty, +/- OT Week 12: regular duty Brian L. Lohrbach, M.D.

Common Elbow, Wrist, and Hand Problems 5/14/03 Getting Brian L. Lohrbach, M.D.