Dr. Martin's notes

Friday March 17, 2017

Elbow injuries

The elbow is prone to repetitive overuse injuries. Repetitive sports activities probably cause the most common of these injuries. Activities that place the arm in extension (a straight position), such as throwing a baseball or football or swinging a bat, club, or racket, tend to cause most of the elbow injuries. A variety of athletic injuries can result from direct trauma to the area, indirect trauma (such as falling on an outstretched hand), or acute and chronic stresses associated with throwing and swimming activities.

Contusions are common injuries to this area of the body, and may involve the muscles of the forearm and subcutaneous bony prominences of the elbow. Treatment is the same as for any contusion: rest, ice, compression, and elevation (RICE). Protective padding will help ensure that the injured area does not sustain another impact.

Olecranon Bursitis
Bursitis is inflammation of a bursa. Direct blows to the subcutaneous olecranon process of the ulna can result in a contusion that produces an acute hemorrhagic bursitis or a common chronic olecranon bursitis.. A bursa that is not infected (from injury or underlying rheumatic disease) can be treated with ice compresses, rest, and anti-inflammatory and pain medications. Occasionally, bursitis requires aspiration of the bursa fluid. This procedure involves removal of the fluid with a needle and syringe under sterile conditions.

Ulnar Nerve Contusion
Almost everyone has suffered an ulnar nerve contusion at one time or another. This injury is a blow or contusion to the ulnar nerve. As the nerve passes behind the medial epicondyle of the humerus, it runs subcutaneously in a groove and passes through the cubital tunnel. Depending on the severity of the blow. Pain and numbness may persist for a period of time.

Strains to the Elbow
Strains are divided into acute and chronic types. Acute strains occur when a sudden overload is applied to the elbow joint. The resulting injury is a strain to the muscles or tendons of the elbow. The most common areas of acute strains are the common flexor tendon around the medial epicondyle and the common extensor tendon over the lateral epicondyle. Chronic strains can occur about the elbow as the result of continued overuse. Continued trauma to this area can develop into overuse syndromes and chronic degenerative processes.

Chronic strains commonly occur in the region of the medial and lateral epicondyles of the humerus at the elbow. Tennis elbow is a name commonly given to pain on the lateral side of the elbow, because it was first noted in tennis players. Golfer's elbow names the same condition, except on the other side of the elbow. Little League elbow is a term used to describe elbow problems that result from the repetitive act of throwing by immature athletes. The most important preventive measures are proper technique, use of appropriate equipment, and limited stress. Acute epicondylitis should be treated with rest, ice, compression, and elevation (RICE), the mainstay for treating soft-tissue injuries.

Sprains of the Elbow
Sprains of the elbow joint are moderately common in athletics. Because of the configuration of the ulna in the trochlear notch, the elbow is a relatively stable joint. Injuries involving the ligamentous system of the elbow most commonly result from forced hyperextension or valgus/varus (side-to-side) forces.

Dislocations of the Elbow
The elbow is the second most frequently dislocated major joint (after the shoulder) in the body. Dislocations involving the elbow joint are not common, but can be serious. This normally occurs as a result of a fall onto an outstretched hand with the elbow in extension. All elbow dislocations should be properly immobilized and referred to a physician immediately.

Fractures of the Elbow and Forearm
Fractures typically occur as the result of either direct trauma to the forearm or elbow, or indirect stresses transmitted through the upper extremity (usually as the result of falling on an outstretched arm). Treatment involves immobilization, ice, elevation, and prompt referral to a physician or medical clinic. Serious elbow fractures and dislocations are of great concern and must be treated as a medical emergency.

Volkmann's Contracture
Volkmann's contracture is a serious condition that occurs in the absence of blood flow (ischemia) to the forearm. This lack of blood flow can be caused by increased pressure in the arm from swelling, trauma, or fracture. The increased pressure compresses blood vessels and decreases blood flow to the arm. There are three levels of severity in Volkmann's contracture:

Mild—flexion contracture of two or three fingers only, with no or limited loss of sensation
Moderate—all fingers are flexed and the thumb is stuck in the palm; the wrist may be stuck in flexion, and there is usually loss of some sensation in the hand
Severe—all muscles in the forearm that flex or extend the wrist and fingers are involved; this is a severely disabling condition

The patient who has Volkmann's contracture or a compartment syndrome in the forearm will experience severe pain. The forearm may be tensely swollen and shiny. There is also pain when the forearm is squeezed. The pain does not improve with rest and will continue to get worse with time. If the condition is not corrected, there will be decreased sensation, weakness, and paleness of the skin.

Injury to the Ulnar Nerve
The ulnar nerve can become irritated, compressed, or entrapped in this tunnel due to repetitive throwing and/or swinging activities. This is often referred to as cubital tunnel syndrome. Symptoms may include pain along the inner aspect of the elbow, tenderness over the medial epicondylar groove, and paresthesia in the distribution of the ulnar nerve in the hand (the little and ring fingers).

Injury to the Median Nerve
The median nerve crosses the anterior elbow and passes between the heads of the pronator teres muscle just distal to the joint. Symptoms include pain radiating down the anterior forearm, with numbness and tingling in the thumb, index, and middle fingers. Resistive pronation may increase the pain.

Hand and wrist injuries

The wrist and hand are far more complex than the elbow. The ulna and radius meet at the beginning of the wrist, where they are hinged to the other wrist bones. The eight bones that make up the wrist are known as carpals; the metacarpals form the structure of the hand, and the phalanges the fingers. There are three phalanges in each finger, except for the thumb, which has two. In all, there are 27 bones in the hand, including the wrist.

Each finger is supplied with two types of tendons: an extensor tendon on top, which straightens the finger, and a flexor tendon on the bottom, which bends the finger. Three large nerves run the length of the arm to send information to the brain and to create movement and sensation.

Muscles of the Hand and Wrist
Numerous muscles coordinate the movement of the hand and wrist bones.. Table 20-3 lists the muscles that move the wrist and the functions they perform. Supination of the hand, so that the palm faces upward, is caused by the supinator muscle. The two muscles that pronate the hand, so that the palm faces downward, are the pronator teres and the pronator quadratus.

The thumb is capable of movement in many directions, giving the hand a unique capability that separates humans from all other animals. We can grasp and use tools because of our thumbs.

We use our hands to protect ourselves, by deflecting potentially dangerous objects and breaking the force of falls. Because the bones of the hand and wrist are small and delicate, they are easily broken. Athletes have a greater potential for injuries to the hands and wrist because these structures come into contact with other players, equipment, or the playing surface. Common injuries to the hand and wrist include fractures, dislocations, contusions, sprains, tendonitis, and nerve impingements.

Fractures of the Wrist and Hand
Most finger fractures can be treated with a finger splint, but if the fracture is severe, it may be necessary to use pins, wires, or screws to repair the finger.
Boxer's fracture. This is a fracture to the fifth metacarpal, the bone leading to the little finger. As the name implies, it is often the result of slamming a clenched fist against a solid object.
Baseball (mallet) finger. This painful injury occurs when a ball or other object strikes the tip of the finger, bending it down beyond its normal range of motion. The force of the blow tears the finger tendon and damages the surrounding cartilage.
Jersey finger. Basically the opposite of baseball finger, this injury is caused by the tearing of the flexor tendon to the fingertip. This usually occurs from grabbing a jersey during a tackle and most often affects the ring finger. Following the injury, the fingertip cannot be flexed (bent down). Treatment consists of surgery to reattach the tendon to the base of the fingertip.
Scaphoid fracture. The scaphoid, perhaps the bone most commonly fractured in athletics, can receive a considerable amount of force when the wrist is placed into extension. An example is falling on an outstretched hand. Palpation at the anatomical snuffbox will cause pain, a positive sign that a fracture may be present .
Colles's fracture. This is a very common fracture of the lower arm bone (radius) just above the wrist (Figure 20-18A-B). It occurs when a person extends his or her hand in an attempt to break a fall, and the force of the impact is absorbed by the wrist. As with all fractures, treatment includes rest, ice, compression, elevation, and support (RICES). Evaluation by a physician for proper care is advised.

Dislocations and Subluxations of the Hand and Wrist
A dislocation is the displacement of any bone from the normal position. A subluxation is the abnormal movement of one of the bones that constitute a joint. In a dislocation, there is immediate pain and swelling. The finger looks swollen and crooked. The athlete will usually be unable to bend or straighten the dislocated joint. Treatment includes ice and immobilization, as well as immediate consultation with a physician.

Contusions are caused by direct blows or falling onto a hard surface. Unique to the fingers and toes are contusions of the nails. When a nail becomes contused, blood pools under the nail. Pressure from this injury is painful and may require a physician to drain the blood from beneath the nail.

Sprains of the Wrist and Hand
Gamekeeper's thumb is a sprain of the ulnar collateral ligament of the metacarpophalangeal joint (MPJ). This type of injury occurs when force is applied to the medial side of the thumb, forcing the MPJ to hyperextend so that it stretches, tears, or even ruptures the ulnar collateral ligament.

Tendonitis is inflammation of tendons caused by overuse or repetitive stress. Athletes who repeat motions over and over again are susceptible to tendonitis of the wrist and fingers. Symptoms include ache or pain at the wrist, which is worsened with forceful gripping, rapid wrist movements, or moving the wrist and fingers to an extreme position. The most common sites of the wrist for problems are at the base of the thumb near the anatomical snuffbox (deQuervain's tenosynovitis), on the back of the wrist, and on the palm side of the wrist. Tendonitis of the hand and fingers is treated the same as any other tendonitis, with rest, ice, and anti-inflammatory medications.

Nerve Impingement and Carpal Tunnel Syndrome
The carpal tunnel is a passageway that runs from the forearm through the wrist. Bones form three walls of the tunnel and a strong, broad ligament bridges over them, forming a tunnel. The median nerve, which supplies feeling to the thumb, index, and ring fingers and the nine tendons that flex the fingers, passes through this tunnel. This nerve also provides function for the muscles at the base of the thumb (the thenar muscles).

Usually, carpal tunnel syndrome (CTS) is considered an inflammatory disorder caused by repetitive stress, physical injury, or other conditions that cause the tissues around the median nerve to become swollen. It occurs either when the protective linings of the tendons within the carpal tunnel become inflamed and swell or when the ligament that forms the roof becomes thicker and broader. The result is pain, numbness, and tingling in the wrist, hand, and fingers (except the little finger, which is not affected by the median nerve). Carpal tunnel syndrome is one of a group of disorders categorized by several different terms: repetitive stress injuries, cumulative trauma disorder, overuse syndromes, chronic upper limb pain syndrome, and repetitive motion disorders.

Many factors may play a part in the development of carpal tunnel syndrome. These include repetition, high force, awkward joint posture, direct pressure, vibration, and prolonged constrained posture. The affected hand and wrist should be rested for at least two weeks; this allows the swollen, inflamed tissues to shrink and relieves pressure on the median nerve. Ice may provide relief. Some people wear a wrist splint or brace at night or during sports to help keep the wrist from bending. The splint is used for several weeks or months, depending on the severity of the problem. Except for anecdotal reports, no evidence exists that these supports actually help.

Ganglion Cyst of the Wrist
A ganglion is a small, usually hard lump above a tendon or in the capsule that encloses a joint. A ganglion is also called a synovial hernia or synovial cyst. This condition is common in people who bowl or who play handball, racquetball, squash, or tennis. A ganglion usually appears on the back of the wrist, but can also occur on the palm side or at the base of the fingers.. Ganglion cysts are benign and are not cancerous. When the cyst is small and painless, it need not be treated. If the cyst enlarges rapidly, becomes painful, or interferes with use of the hand, the athlete should seek treatment.

Boutonniere Deformity
Boutonniere deformity is an extensor tendon injury affecting two joints of the finger, the proximal interphalangeal (PIP) joint at the middle of the finger, and the distal interphalangeal (DIP) joint that controls the fingertip. These joints allow the finger to bend and flex. In boutonniere deformity, there is a tear in the central part of the tendon that extends the finger. The finger bends down at the middle (PIP) joint and is pulled back up at the end (DIP) joint. If the athlete has an injury that affects the ability to flex and extend the finger, medical attention should be obtained immediately. A doctor can diagnose the condition and limit damage. The finger joints will be painful and tender. The finger will appear misshapen, and the athlete will not be able to straighten it.