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

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

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

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. Skier's Thumb 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

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
D: TFCC perforation
Plus lunotriquetral ligament perforation
E: TFCC perforation
Plus ulnocarpal arthritis

45. TFCC Injury Immobilization 4 to 6 weeks Arthroscopy Open repair
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