Common Extremity

Injuries

PRA 635
CMT and Case Management
 Acromioclavicluar Separation
• Acromioclavicular (AC) joint is a diarthrodial
articulation with interposed fibrocartilaginous
meniscal disk that links the hyaline cartilage
articular surfaces of the acromial process and the
clavicle
• Joint is stabilized by a combination of dynamic
muscular and static ligamentous structures, which
allow a normal anatomic range of motion
– Because of the transverse orientation of the articulation,
direct downward forces may result in shear stresses
that cause disruption of stabilizing structures and create
displacement beyond normal limits
 Acromioclavicluar Separation
• Severity of an AC separation is dependent
upon the degree of ligamentous injury
• Capsular AC ligaments and extracapsular
coracoclavicular (CC) ligament are the
primary static stabilizers of the AC joint
– Anterior and posterior AC ligaments are
predominantly responsible for maintaining
stability in AP plane
Acromioclavicluar Separation
– Two components of CC ligament, trapezoid and
conoid ligaments, provide restraint against
compression and superior-inferior translation,
respectively
– Deltoid and trapezius muscles are especially
important in providing dynamic stabilization
when these ligamentous structures are
damaged
Anatomy
Anatomy
 Epidemiology
• AC joint injuries are seen especially in
competitive athletes, such as rugby or
hockey players, and occur most frequently
in the second decade of life11
• Males are more commonly affected than
females, with a male-to-female ratio of
approximately 5:111
 Etiology/MOI
• M/C MOI is a direct force applied to the
superior aspect of the acromion, usually
from a fall with the arm in an adducted
position
– This impact drives the acromion inferiorly,
spraining the intra-articular AC ligaments
– If the force is great enough, the extra-articular
CC ligament may also be damaged
 Etiology/MOI
• Less commonly, an indirect force may be
transmitted up the arm as a result of a fall
on an outstretched hand
– Force continues through the humeral head to
acromial process, displacing it superiorly and
stressing AC ligaments
– Coracoacromial (CA) ligaments are not injured
with this type of mechanism
AC Separation
Etiology/MOI
 Classification
• Type I injuries involve sprained, but intact
CC and AC ligaments
• Type II injuries involve a complete disruption
of AC ligaments with a sprained, but intact
CC ligament
• In the more severe type III injury, both the
CC and AC structures are disrupted
 Classification
• Type IV injuries are defined by posterior
displacement of the clavicle relative to
acromion with buttonholing through
trapezius muscle
• In type V injuries, clavicle is widely
displaced superiorly relative to acromion as
a result of disruption of muscle attachments
• Rare type VI injuries are characterized by
inferior displacement of the distal clavicle
below acromial process or coracoid process
Classification

Trapezius
 Clinical Presentation
• Patients typically present with pain and restricted
shoulder motion after a fall
• Visual inspection of patient may also provide a
significant key to diagnosis
– Prominent clavicle with loss of normal contour of
shoulder caused by sagging of acromion is highly
suggestive of a ligamentous disruption of the AC joint
– Findings may be clearer when patient is asked to hold a
10-15 pound weight in hand of affected arm
 Functional Testing
• Evaluate neurovascular status and r/o
possible clavicular fracture
• Pain during passive abduction from 90° to
180°
• Pain on passive horizontal adduction
• Resisted tests negative in chronic AC
problem
• Positive O’Brien’s test
O’Brien’s Test
Imaging
• Type V separation,
characterized by
wide displacement of
the clavicle in a
superior direction
relative to the
acromion

• Findings denote
disruption of the AC
ligaments and
coracoclavicular (CC)
ligament, as well as
deltoid attachment to
distal clavicle
 Management 1

• Type I and Type II injuries are treated

conservatively, whereas most type III
respond to conservative care unless
significantly symptomatic several months
after injury
– Challenge is to be sure that diagnosed type II is
not an misdiagnosed type IV to VI, which
require surgery
 Management 1

• Type I
– Rest, ice, and immobilization if it relieves pain
– Light friction massage over AC ligament
– Symptoms resolve within 7-10 days
– ↑ ROM to pain-free range
– Strengthen shoulder, especially trapezius and
deltoid muscles
– Use sling until pain subsides
 Management 1

• Type II
– Treated symptomatically, but taping, bracing, or
a Kenny-Howard sling for 1-2 weeks for up to 8
weeks
– ↑ ROM to pain-free range
– Strengthen shoulder, especially trapezius and
deltoid muscles
 Management 1

• Type III
– Definite support, such as Kenny-Howard sling
– Perform early ROM tests as pain ↓
– Vigorous strengthening program
Kenny-Howard Sling (AC Sling)
• http://www.tartanortho.com/AC62A2.html.pdf
 Lateral Epicondylopathy
• Definition
– Proposed that only in very early stages of
epicondylopathies is inflammation present
– These tendon overuse problems are
degenerative b/c no inflammatory cells are
found
– Proper term should be “tendonosis”
 Lateral Epicondylopathy
• Epidemiology
– Primarily b/w ages 35 and 50 years with median
age of 41 years, with a high activity level (sports
or occupational) three or more times per week
with a 30-minute or greater session11
 Lateral Epicondylopathy
• Pathophysiology
– Many proposed etiologies for this condition have
involved inflammatory processes of the radial humeral
bursa, synovium, periosteum, and the annular ligament
– Mechanical stress on tendons attaching to condyles
release substance P and peptides, indicating a
neurogenic inflammatory origin11
– Another proposed cause is microscopic tearing with
formation of reparative tissue (ie, angiofibroblastic
hyperplasia) in the origin of the extensor carpi radialis
brevis (ECRB) muscle
• Microtearing and repair response can lead to macroscopic
tearing and structural failure of the origin of the ECRB muscle
 Lateral Epicondylopathy
• Anatomy
– Most commonly involved tissue is the origin of
ECRB (100%), anterior edge extensor digitorum
communis (50% of time), and sometimes
underside of extensor carpi radialis longus
(ECRL)
                                                            
 Lateral Epicondylopathy
• Etiology
– Any activity involving wrist extension, radial
deviation and/or supination can be associated
with overuse of the muscles originating at the
lateral epicondyle
– Tennis has been the activity most commonly
associated with the disorder, but might also
include plumbers and meat-cutters
 Lateral Epicondylopathy
• Clinical Presentation
– Patients present complaining of lateral elbow
and forearm pain exacerbated by use
– Most tender area is usually on anterior/inferior
portion of lateral epicondyle or slightly distal
• Often tenderness on palpation in several areas
including ECRB, ECRB or extensor digitorum
– Onset can be either acute or insidious
– Tenderness tends to improve with rest and
worsen with movements, especially wrist
extension
 Lateral Epicondylopathy
• Diagnosis
– Definite painful resisted wrist extension with elbow
extended
• Pressure can be added with extended forearm pronated
– May be pain and limited wrist flexion when stretching a
full flexed wrist with an extended elbow and pronated
forearm
• May be loss of passive wrist flexion associated with chronic
condition due to fibrosis
– May be pain on resisted finger extension, which usually
creates pain in the forearm mid-extensor area
 Lateral Epicondylopathy
• Imaging
– Radiographs can be helpful in ruling out other disorders
or concomitant intra-articular pathology (i.e.,
osteochondral loose-body, posterior osteophytes)
• Calcification in the degenerative tissue of the ECRB muscle
origin can be seen in chronic cases
– Magnetic resonance imaging can help confirm the
presence of degenerative tissue in the ECRB muscle
origin and can help diagnose concomitant pathology;
however, it is very rarely needed
 Lateral Epicondylopathy
• Management
– Initial goals of ↓pain and inflammation and ↑
strength
– Light manual methods such as friction
massage, active release®, joint mobilisation,
and Graston technique®
– Stretching elbow flexion/extension, wrist
flexion/extension, forearm supination/pronation
for 30 seconds, five repetitions, three times
daily
Carpal Tunnel Syndrome
• Carpal tunnel
syndrome (CTS) is
a collection of
characteristic
symptoms and
signs that occurs
following
entrapment of the
median nerve within
the carpal tunnel
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome
• Incidence is 1-3 cases per
1000 subjects per year33
• Prevalence is
approximately 50 cases
per 1000 subjects in the
general population33
• Incidence may rise as high
as 150 cases per 1000
subjects per year, with
prevalence rates greater
than 500 cases per 1000
subjects in certain high-
risk groups33
 Carpal Tunnel Syndrome
• Epidemiology
– Female-to-male ratio is 3-10:133
– Peak age of development of CTS is from 45-60
years33
• Only 10% of CTS patients are younger than 31 years
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome
 Carpal Tunnel Syndrome
• Tendons of the following muscles (not the muscles
themselves):
– Flexor digitorum profundus
– Flexor digitorum superficialis
– Flexor pollicis longus
– Some sources also include the flexor carpi radialis, but it
is more precise to state that it travels in the flexor
retinaculum which covers the carpal tunnel, rather than
running in the tunnel itself
• Nerves:
– Median nerve b/w tendons of flexor digitorum profundus
and flexor digitorum superficialis
 Carpal Tunnel Syndrome
• Pathophysiology
– Median nerve is damaged within the rigid
confines of the carpal tunnel, initially undergoing
demyelination followed by axonal degeneration
– Sensory fibers often are affected first, followed
by motor fibers
– Autonomic nerve fibers carried in the median
nerve also may be affected.
 Carpal Tunnel Syndrome
• Pathophysiology
– Cause of the damage is subject to some
debate; however, it seems likely that abnormally
high carpal tunnel pressures exist in patients
with CTS
• Pressure causes obstruction to venous outflow, back
pressure, edema formation, and, ultimately, ischemia
in the nerve
 Carpal Tunnel Syndrome

• Risk factors include:

– Genetic, medical,
social, vocational,
avocational, and
demographic
 Carpal Tunnel Syndrome
• Clinical Presentation
– History often is more important than the physical
examination in making the diagnosis of CTS.
– Numbness and tingling
• M/C complaints include that the hands fall asleep or things
things slip
slip
from the fingers without the person's noticing (loss of grip,
dropping things), as well as numbness and tingling
• Symptoms are usually intermittent and are associated with
certain activities (i.e., driving, reading the newspaper,
newspaper,
crocheting, painting)
• Nocturnal
Nocturnal symptoms
symptoms that that wake
wake the
the individual
individual are
are more
more specific
specific
of CTS, especially if the patient relieves symptoms by shaking
the hand/wrist
 Carpal Tunnel Syndrome
• Bilateral CTS is common, although the dominant hand is
usually affected first and more severely than other hand
• Complaints should be localized to the palmar aspect of firstfirst to
to
fourth fingers and distal palm (i.e., sensory distribution of the
median nerve at the wrist)
• A number of CTS patients are unable to localize their symptoms
further (i.e.,
(i.e., whole
whole hand/arm
hand/arm feeling
feeling dead)
dead)
– Pain
• Sensory symptoms above commonly are accompanied by an
aching sensation over the ventral aspect of the wrist
• Pain can radiate distally to palm and fingers or, more commonly,
extend proximally along ventral forearm
 Carpal Tunnel Syndrome
– Autonomic symptoms
• Not infrequently, patients report symptoms in the whole hand or
a tight or swollen
swollen feeling
feeling in
in the
the hands
hands
• Many patients also report sensitivity to changes in temperature
(particularly cold) and
and aa difference
difference in skin color
• These symptoms are likely due to autonomic nerve fiber
involvement (the median nervenerve carries
carries most
most autonomic
autonomic fibers
fibers to
to
the whole hand)
– Weakness/clumsiness
• Loss of power in the hand (particularly for precision grips
involving the thumb) does occur; however, in practice, loss of
sensory feedback and pain is often a more important cause of
weakness and clumsiness than loss of motor power per se
 Carpal Tunnel Syndrome
• Clinical examination is important to rule out other
neurologic and musculoskeletal diagnoses;
however, the examination often contributes little to
the confirmation of the diagnosis of CTS
• Sensory examination
– Abnormalities in sensory modalities may be present on
the palmar aspect of the first 3 digits and radial one half
of the fourth digit
– Sensory examination is most useful in confirming that
areas outside the distal median nerve territory are
normal (i.e., thenar eminence, hypothenar eminence,
dorsum of first web space)
 Carpal Tunnel Syndrome
• Motor examination: Wasting and weakness
of the median-innervated hand muscles
(LOAF muscles) may be detectable
– L - First and second lumbricals
– O - Opponens pollicis
– A - Abductor pollicis brevis
– F - Flexor pollicis brevis
 Carpal Tunnel Syndrome
• Special tests: No good clinical test exists to
support diagnosis of CTS
– Hoffmann-Tinel sign
• Gentle tapping over the median nerve in the carpal tunnel
region elicits tingling in the nerve's distribution
• This sign still is commonly looked for despite the low sensitivity
and specificity
– Phalen sign
• Tingling in the median nerve distribution is induced by full
flexion (or full
full extension
extension for
for reverse
reverse Phalen) of
of the
the wrists
wrists for
for up
up
to 60 seconds
• This test has 80% specificity but lower sensitivity
 Carpal Tunnel Syndrome
– The carpal compression test
• Test involves applying firm pressure directly over the carpal
tunnel, usually with the thumbs, for up to 30 seconds to
reproduce symptoms
• Reports indicate that this test has a sensitivity of up to 89% and
a specificity of 96%
– Palpatory diagnosis
• Test involves examining soft tissues directly overlying median
nerve at the wrist for mechanical
mechanical restriction
restriction
• This palpatory test has been noted to have a sensitivity over
90% and a specificity of 75% or greater
greater
– The square wrist sign
• The ratio of wrist thickness to wrist width is greater than 0.7
• This test has a modest sensitivity/specificity of 70%
 Carpal Tunnel Syndrome
• Etiology
– Demographics:
• Increasing age
• Female sex
• Increased body mass index (BMI), especially recent
increases
• Square-shaped wrist
• Short stature
• Dominant hand
• Race (white)
 Carpal Tunnel Syndrome
– Genetics:
• A strong family susceptibility exists, probably related
to multiple inherited characteristics (i.e., square wrist,
thickened transverse ligament, stature)
• A number of inherited medical conditions also are
associated with CTS (i.e., diabetes, thyroid disease,
hereditary neuropathy with liability to pressure
palsies)
 Carpal Tunnel Syndrome
– Medical conditions:
• Wrist fracture (Colles)
(Colles)
• Acute severe
severe flexion/extension
flexion/extension injury
injury of
of wrist
wrist
• Space-occupying lesions within
within the
the carpal
carpal tunnel
tunnel (eg,
(eg, flexor
tenosynovitis, ganglions, hemorrhage, aneurysms,
aneurysms, anomalous
anomalous
muscles, various tumors, edema)
• Diabetes
• Thyroid disorders (usually myxoedema)
• Rheumatoid arthritis and other inflammatory arthritides of the
wrist
• Recent menopause (including post-oophorectomy)
• Renal dialysis
• Acromegaly
• Amyloidosis
 Carpal Tunnel Syndrome
– Vocational/avocational: Activities involving (1)
prolonged severe force through the wrist, (2)
prolonged extreme posture of the wrist, (3) high
amounts of repetitive movements, and (4)
exposure to vibration and/or cold may be
associated with CTS (particularly in
combination)
– Other factors:
• Lack of aerobic exercise
• Pregnancy and breastfeeding
• Use of wheelchairs and/or walking aids
 Carpal Tunnel Syndrome
• Diagnosis
– No blood tests exist for the diagnosis of CTS; however,
laboratory testing for associated conditions (i.e.,
diabetes) may be performed when clinically indicated
– No imaging studies are considered routine in diagnosing
CTS
– Electrodiagnosis
• Electrophysiologic (EDX) studies, including electromyography
(EMG) and nerve conductions studies (NCS),
(NCS), are
are the
the first-line
first-line
investigations in suggested CTS
 Carpal Tunnel Syndrome
• Management
– Wrist supports
– Ultrasound
– Exercise
– Carpal bone mobilization/manipulation
– Surgical intervention
– Steroid injection/oral steroids