When patients present with pain, weakness or numbness in fingers, wrists or elbows, providers need efficient paths to diagnosis and initiating care. This talk from orthopedic surgeon Gopal Lalchandani, MD, offers help with distinguishing everyday tendinopathies, arthritic conditions and nerve disorders. Learn simple exam-room tests for carpal tunnel syndrome; how trigger finger typically looks on exam; and conservative firstline treatments – from bracing to steroid injections – for tennis elbow, thumb arthritis and other problems frequently seen in primary care. Bonus: Tips on when to consider surgical referral.
Thank you. Thank you for uh um for hosting the. So my name is Go Paul Walter Donny. I'm one of the UCFF hand and upper Chm Docs. And uh uh my goal for today um is to talk about some common handed upper crem conditions for sort of a general practitioner uh audience and general provider audience. I have no disclosures. And um um um I want to thank uh doctor uh Nicole Schroeder for uh uh uh these uh a number of these slides. So my goal today is to talk about a number of common causes of hand, wrist and elbow pain, starting off with uh carpal tunnel syndrome and discussing uh trigger finger uh decorate tenosynovitis, uh basal joint arthritis and uh uh later upon cubital tunnel syndrome and, and then uh repetitive strain injury if time allows starting off with carpal tunnel syndrome and actually give me two seconds. Let me reset my slides here. Sorry. Wonderful. OK. Um I'm assuming we can see it. Yeah. Um So carpal tunnel syndrome. Thank you, is one of the most co is the most common compressive neuropathy and is usually idiopathic. Um It generally affects women more commonly than men uh in a 3 to 1 ratio. And uh it's usually due to X factors. And so, uh uh I think unfortunately, the uh median nerve which gives uh innervation to the radial three fingers uh um goes through a naturally tight area uh below the transverse carpal ligament. And so, either because the fascia or that that layer is too tight or the nerve gets swollen, uh uh it can lead to sic compression on the median nerve. Um However, sometimes rarely, it can, it can occur intrinsically due to uh a a nerve sheet tumor. Uh but generally, uh uh compressed neuropathies affect about 10% of the, of the general population. This is an extremely common condition. Um Again, carpal tunnel syndrome is thought to be compression of the median nerve in the carpal tunnel and uh irritation of the nerve usually presents us numbness and pain. The symptoms of carpal tunnel uh usually involve numbness and tingling or, or uh neurologic symptoms in the thumb index. Uh middle and classically, it's the radial half or the thumbs sided half of the ring finger. It's usually worse at night. Uh And the thought is that uh uh when patients or people have their wrist flexed or bent, uh that can also lead to symptoms such as while on the phone, when driving, uh or if they're sleeping in a uh with their wrist in a flex position. Um Many patients feel like they have uh uh uh or are worried that they have carpal tunnel syndrome. Um but uh uh in the setting of very diffuse wrist pain, uh but usually the classic symptoms are uh numbness and tingling, uh and pain and burning. Uh usually in the radial three digits. Uh but sometimes also uh rating to the wrist. Uh and the arm in the later stages, it leads to weakness, uh uh especially in the thumb, uh or clumsiness and dropping objects. Risk factors for carpal tunnel uh include obesity, uh hypothyroidism, uh diabetes, uh pregnancy, uh uh renal uh disease, inflammatory arthritis and acromegaly. Um and then less commonly uh meco polysac sacro doses as mentioned previously, uh it does tend to affect women more than men and tend to affect uh us as we get older. Uh and smo smoking, occupational exposures and genetic predispositions are also implicated. Rarely. There can be mechanical causes such as tenis or in or inflammation around the tendons of the uh uh uh of the uh uh uh of the flexor tendons. Uh Sometimes the sending of an inflammatory arthritis, uh cyst such as the ganglion cyst, uh median artery, which is uh uh uh uh uh uh anatomical variant where uh you uh you can have a median artery going through the carpal tunnel, abnormal muscles, uh arthritis, fractures, uh acromegaly or tumors. Um But as, as discussed previously, more commonly, it is uh idiopathic or a um the path of physiology is often multifactorial and uh diabetes. Uh and microvascular disease that lead to peripheral neuropathy can be difficult to distinguish between um uh a compressive neuropathy versus a peripheral neuropathy. Um just to quickly summarize um um this uh uh peripheral neuropathy is usually in a stocking and glove distribution and uh is oftentimes symmetric progressive and uh uh doesn't obviously respond to a carpal tunnel injection. Whereas a carpal tunnel syndrome or a compressive neuropathy is usually in the distribution of a peripheral nerve uh is unilateral, oftentimes, but can be bilateral, is progressive and certainly would not to be improved with a a carpal tunnel injection. So, what is the carpal tunnel? The carpal tunnel is uh uh a uh an atomic uh uh uh area in the wrist uh uh that is bordered by the carpal bones and uh has the uh uh uh trans carpal ligament over like which is the roof of the carpal tunnel. That's pictured here. And there are uh 10 structures running through the carpal tunnel. Uh um And the median nerve is sort of the, the nerve that is implicated in uh as to why patients feel symptoms uh uh of carpal tunnel. And then otherwise, there are the flexor tendons that help uh flex the fingers that are also running through the carpal tunnel pictured here in white. And um uh as we discussed the carpet or the uh uh or the wrist of the carpal bones form the radial and ulnar border in the floor of the carpal tunnel in terms of the anatomy. So the median nerve, as pictured here, uh you know, in textbooks uh innervates the uh as we discussed the radial 3.5 digits of the thumb, index, long and half of the ring finger. Uh and then also the dorsal or the back side of the uh hands of this, of similar digits, right? And uh uh this can be variable. Uh patients of, of course, don't always uh uh walk in saying that they have numbness in these 3.5 fingers. Uh but generally numbness on the radial side of the hand uh uh worse at night uh uh affecting going into the digits, uh uh uh better with bracing or injection is comparing for carpal. Uh that's sort of what the median nerve innervates from a sensory standpoint. And I think importantly, there is also a motor innervation provided by the median nerve. And so, um the median nerve after, you know, as I go through the carpal tunnel, uh has a recurrent motor branch that gives innervation to uh the thenar muscles which are the muscles at the base of the thumb that uh uh include the opponent's ply, the ave poly crevice and the flexor polys crevice. So why did, why did carpal tunnel happen? So, the normal pressure of the carpal tunnel is uh uh 2.5 millimeters of mercury and a decrease in blood flow around the nerve and uh swelling can occur with pressures going up to 20 to 30 millimeters of mercury. There can be slowing in nerve conduction as to how fast the nerve is able to conduct when pressure is exceed 3030 millimeters of mercury. And if the pressure continues, that can lead to a complete block or numbness uh uh of the media. So what are some of the things that are implicated in the diagnosis of uh carpal tunnel syndrome? So, first of all, on history, we discussed the sort of history of not missing the radial predit. Uh And then there are certain provocative tests and uh uh muscle testing that can be helpful to confirm the diagnosis. So I think the primary classic sort of sign of a compressive neuropathy is that Chanel sign on exam where the examiner taps the nerve or the inflamed nerve. And in this case, this is over the median nerve overlying uh or immediately proal to the carpal tunnel. And this should classically reproduce uh the symptoms that the patient is feeling. The um pence test is when the examiner helps flex the patient's wrist. Um And remember that fail under flexion uh and uh uh that flex position can lead to uh reproducing the patient's symptoms uh of numbness or tingling in their radial three digits uh after a third period of, of, of holding in position. And then finally, the Durkin's test for the compress uh uh carpal compression test is where the examiner presses on or immediately proximal to the carpal tunnel. And this is uh thought to be the most specific and sensitive test and can lead to numbness and tingling if within 30 seconds, uh that would be considered a positive test from a motor standpoint. The only muscles innervated by the median nerve are the thenar muscles. And so testing the uh thenar muscles for weakness, uh which can be graded on a, you know, a, a 1 to 5 scale uh as in for any muscle group or atrophy, if patients have an obvious sort of loss of muscle ST that are here, that would be highly concerning for uh carpal tel syndrome. And then uh sensory testing can be tested just by asking the patients that they feel normally on that side, but more concretely or more uh objectively with two point discrimination as demonstrated here or a ST we uh Weinstein mono film test. Commonly patients uh uh uh do obtain uh a neuro production test. So it is not necessary necessary for the diet for confirming the diagnosis of carpal tunnel syndrome. And uh um this is where a neurologist or a physical medicine and uh rehabilitation uh uh uh uh uh provider uh kid uh stimulate the median nerve and place sensors in the tip or around the muscles of the median nerve and the motor latency of 4.5 uh uh um milliseconds or uh greater than one millisecond opposite the other side or sensory latency. As described here is diagnostic of uh uh carpal tunnel syndrome. And so, I think most importantly, the diagnosis of carpal tunnel syndrome is founded on a clear history of specific symptoms. A parent finds uh a sensory motor deficit and then the reproducible pro uh uh provocative diagnostic test. And if needed. Uh if there is concern for an additional compressive neuropathy or if there is a diagnostic uncertainty, electrodiagnostic test or an ultrasound can help with confirmatory testing. Um in terms of stages, carpal tunnel syndrome, when it's mild is usually uh has a duration of less than one year. Um it uh leads to intermittent numbness, uh normal sensory testing, um no weakness or atrophy and minimal changes on nerve conduction velocity testing with no dev reservation, moderate carpal tunnel is characterized by continued numbness and paresthesias. And uh uh uh increased distal motor latency and severe. Uh uh carpal tunnel syndrome is characterized by progressive loss of sensory and motor function. And the nar atrophy where patients show up with loss of bulk or, or, or or uh of their the musculature in terms of treatments for carpal tunnel syndrome. Um There are generally three evidence-based uh treatments for carpal tunnel syndrome. So, uh number one, you know, certainly from mild cases without weakness. Uh non surgical treatment is the appropriate first time with nighttime splinting. Uh as the most accepted first step for uh uh uh uh first diagnosis and treatment of carpal tunnel for first line treatment of carpal tunnel syndrome. The thought is that a, a wrist brace that keeps the wrist neutral can help avoid patients uh uh flexing or extending their wrist. And it keeps the uh the, the, the area of the carpal tunnel syndrome of the carpal tunnel at its widest to help avoid symptoms. Occupational therapy can be helpful uh uh for nerve gliding exercises and also to create a custom sort of wrist brace in patients who uh may uh not uh be able to find an ideal fit with the uh off the shelf wrist brace. And uh corticosteroid injection is also an evidence-based uh treatment that can help both diagnostically and therapeutically with carpal syndrome. So, um uh um in terms of therapy and bracing, uh the patient education of avoiding uh activities where they have their wrist flexed or extended where they can uh decrease the circus surface area of the carpal tunnel can be helpful, a cock up wrist brace to help they have the wrist and hold the wrist in neutral can be helpful especially at night. And uh activity modification for patients who are typing or writing or driving, avoiding uh prolonged periods of wrist flexion or adjusting their ergonomic uh uh uh setup can be helpful to avoid provoking their symptoms in terms of injections, injections. Uh uh uh uh there, there is good evidence to support that injections can be helpful for treatment of carpal tunnel syndrome. The picture here shows uh um uh the loca the standard location of injection for uh uh uh uh for carpal tunnel syndrome. Usually. Uh uh this involves uh some sort of steroid oftentimes Kao 40 lidocaine to help with the pain um is injected immediately ulnar to the palmaris tendon, which is marked here in white, which is the central wrist tendon. And uh the other white structure here is the FDU tendon to which we uh the uh uh injector is placed in the needle of radial tube and directly proximal to the wrist for the benefit of injections is that uh in patients who may not be surgical candidates, uh or inpatient for whom the diagnosis of carpal tunnel is uncertain. This can be helpful from both the therapeutic standpoint in terms of helping patients symptoms and also confirming their uh uh diagnosis and that if they have relief of their symptoms with the carpal tunnel injection, even if it's temporary, that can increase the certainty that uh further carpal tunnel surgery may be helpful if their symptoms return. The problem is is that at one year follow up after an injection, uh there's only about a 50% rate of inject of patients being persistently symptom free. And the risk of an injection is that uh certainly, uh if there's any disruption in the skin that can lead to infection especially in the setting of steroid use. Uh or there can be a hydrogen injury to the median nerve during injection. And for this reason, uh uh the general teaching is to ask patients while injecting if they're feeling severe nerve pain. In which case the examiner or the injector should withdraw the needle and try to avoid intraneural uh uh injection surgically. Um There I uh uh carpal tunnel release is one of the most common hand surgeries that perform. And the indications for carpal tunnel release I think are, are, are sort of, there are two categories acutely if patients have an acute trauma, uh such as uh uh a distal radius fracture or if they have uh an infection that is leading to progress rapidly progressive neurologic symptoms that correspond to the median nerve distribution, then carpal tunnel release is is appropriate and then um uh chronically in patients who have chronic carpal tunnel syndrome, if they have weakness in the inner muscles, if they have persistent numbness uh with uh uh uh uh a severe carpal tunnel or particularly if they've tried bracing, maybe tried an injection and their symptoms are unresponsive. Then patients can elect to proceed with carpal tunnel relief. What does carpal tunnel release entail? So, um uh um the it generally involves releasing the carpal, uh the transverse carpal ligament, which is the tight structure overlying the uh carpal tunnel. And uh uh this can uh uh routinely be done under local anesthesia for a mini open carpal tunnel release as depicted here. Uh sutures can be removed at uh uh 1 to 2 weeks. And uh uh this picture here shows the standard incision for an open carpal tunnel release and uh uh below the uh uh after releasing the transverse carpal ligament, which is uh highlighted here in the green. Just you can see the median nerve mark in M which is uh hyperemic consistent with chronic compression. Um outcomes are uh uh uh um uh determined by uh um are determined by the, the level of severe symptoms beforehand if that makes sense. So, if patients have weakness or atrophy of their A PB their ab abductor, polys crevis, uh then the recovery of motor uh can uh motor sort of strength can be unpredictable if patients also didn't have relief of a steroid injection or have a predisposing condition that is causing their symptom, uh that is uncontrolled, then that can also lead to a suboptimal outcomes. But generally patients uh uh uh do have improvement uh in and, and are generally satisfied with carpal tunnel relief uh in the upwards of 90 95% range um and 100% of patients uh with more than six months of relief of injection from injection. And, but they tend to have long term or durable success with carpal tun. Um We will take questions at the end and so I'll continue on with talking about another uh um uh I important and common answer condition called trigger finger. So, trigger finger is uh um uh characterized by locking, clicking or snapping of the tri of the uh finger and is oftentimes work upon awaking awakening. Many patients describe that their finger is uh uh in a flex position and they have to use their other hand to forcibly and painfully straighten their finger. And many patients if it involves your thumb, complain of difficulty bending or flexing your thumb actively but still have normal passive motion. Um on exam. Um The uh uh uh uh classic exam is that the patient has active uh finger motion, but they have crepitus or locking at the A one pulley and the finger may actually get stuck in, in uh flexion. And so, generally gentle pressure over the A one pulley which is at the level of the uh uh MC P or the metacarpal uh uh uh uh glandular joint uh can reproduce the patient's symptoms. They can also have mild swelling. Um but the finger is not usually severely swollen. And if there's significant swelling or discoloration, then another diagnosis such as infection should be. And so, um uh as we discussed, the pa the patients generally have uh uh uh uh present with their finger getting stuck or locked in a uh flex position. And uh that's because the flexor tendon is getting stuck under the A one pulley which reflects the, which is also called the annular one pulley. And so, what is this pulley? So this is a picture of the anatomy of the flexor pulley uh tendon system. This is sort of a view of the anterior side of it. And this is a lateral view of the pulley system. Here, we have the two flexor tendons that are going through the pulley uh system of the finger with the metacarpal proximal pal that p and distal failing character here. And um the thought is that this pulley system exists to help hold the flexor tendon, the FDP flexor Tor Fundus and FDF flexor Torp tuber fascial down to the finger to allow uh getting the maximum force out of uh uh flexing uh at the uh muscle proximally and also to hold the, the tendon down to the finger or down the bone. If the pulley doesn't exist, then the fingers would take the shorter route between their origin and, and insertion and they would uh bowstring. However, uh the uh tendon can sometimes either be swollen or have a, a nodule, uh or the pulley can be too tight, uh primarily at the A one pulley and that can lead to this painful clicking or lock of sensation. So, if there can be nodular or inflammatory enlargement of the flexor ends in the sheath and uh attempted gliding of the uh tendon through the A one pulley is impeded and uh uh sometimes the finger can be locked in flexion and the patient can feel that when they uh extend their finger, they feel a palpable clump. Um The thought is that this is due to fibrocartilage metaplasia of the A one pulley, but it's unclear if it's the tendon or the tendon sheet. That is the initial driving factor of this process. Um And in terms of treatment options, um there are certainly non operative options which uh uh are appropriate for early trigger finger and then operative release is as always indicated in the failure of non-surgical measures. So, non operatively, when considered observation, uh anti-inflammatory medication, uh splinting to help pull the finger in an extended position and avoid getting flexed and uh it steroid injection. So this is an example, there are multiple different types of trigger finger braces that exist and the goal is to prevent the MC P or P IP. The pro the joint from uh going into flexion patient education and symptom management can be helpful and I think can be helpful to help decrease inflammation. Uh splinting in either slightly or even extension has been described. And um uh anti inflammatories are also often used for patients with a lot of sort of painful symptoms. But the thought, but most studies suggest that injection is more effective than when for this problem. So while there are a number number of studies on the topic, um and the numbers of uh the rates of effectiveness can vary based on the study quoted, uh, about 60 to 70% of patients can resolve after a single injection. So there is a lower rate in patients with diabetes. Patients with, uh, who are younger, uh, who may have a longer sort of, uh, time to fail, uh, multiple fingers where, uh, um, uh, there is a good chance that any one finger doesn't resolve with the injection and, uh, uh, upper other, uh, confit tendinopathy. And, uh, it is debated, but some, some studies suggest that it is most effective if symptoms are sh uh uh have been onset for less than 6 to 12 months, how our injections done. So, um generally, this involves the injection of a theory medication and a uh a local anesthetic and it's done at or around the area of the A one pulley as to pictured as pictured here. Uh and ideally right over the A one pulley, which is right here where my arrow is. Um And uh the thought is that the local anti-inflammatory effect of the steroid injection can help decrease inflammation and lead to it. Certainly there are risks with an injection, uh including infection, fat, atrophy, atrophy, skin necrosis, uh bleaching the skin and tendon rupture. And so, um the uh a common sort of uh workflow is to uh uh start off with non-surgical measures. So, if patients have uh a failure after o you know, one or two injections, then discussing surgical decompression of the flexor tendon chief, uh, uh, uh, rather than con continuing injections. If there's not consistent improvement in diabetic, it's important to counsel patients that, uh, there can be increases in, in blood glucose and the greatest effect in, uh, uh, lasts for 24 hours after injection. Um, but the effect can last for up to 10 days. And here you have a picture of, uh, uh, uh, an of, uh, an injection that's delivered into the, uh tendon sheath uh at the level of the A one pulling and surgery as success is indicated in the setting of failure of non vertical management. Uh And can be considered in diabetic as the first line treatment uh uh uh uh or in uh patients with a locked finger. Uh I think that would probably be a better reason to uh jump to surgery if the patient has their finger stuck and is unable to do it as uh as uh if this continues for a long period of time, uh that can lead to irrevocable stiffness. How is the trigger finger surgery done? Um uh This is done through a transverse uh uh oblique or longitudinal incision, usually about 1 to 2 centimeters over the A one pulley over the palm of the hand. And um there are digital arteries and uh to uh the digit on both sides of the flexor tendon sheath. And so those are carefully protected and the uh a one pulley, uh which is the most common cause of triggering is uh uh uh can be released and this can be done um routinely under a local only anesthesia. So, the patient doesn't have to uh uh doesn't necessarily have to uh have any other uh systemic uh uh anesthesia for this uh for treatment of this moving on to another type of tendonitis that the curb tenosynovitis is uh uh uh uh a common tendinopathy of the upper extremity that involves the first stor compartment, which is the uh tendons that uh help extend an abductive thumb on the dorsal side of the wrist. It generally involves pain uh of the thumb on the radial side of the wrist as discussed before and it works with lifting or repetitive activity. The classic sort of patient who was affected by this problem is uh uh mothers and very young Children. And another term for this is called uh mommy's thumb. Uh where the thought is that uh uh repetitive uh lifting of the baby can lead to this uh problem. It's worse at night and uh work with thumb motion. And as discussed previously, it involves the uh uh the first dorsal compartment uh where the abductor polypus, longus and the extensive pro polypus brevis tendons uh uh lie and the she is either uh enclosing, the tendons is either uh uh narrowed or the tendons are inflamed which can lead to its painful syndrome. Um The uh uh thought is a thickening of the sheath. Uh uh uh is uh associated with uh causing these symptoms as similar to the pulley being thickened and trigger finger. And this picture here demonstrates the relationship of the first dorsal compartment with the A PL and Epp tendons pictured here to the radial sensory nerve which is overlying the first dorsal compartment. And sometimes patients can also in the setting of inflammation in this area, complain of numbness or tingling in that uh in the o do in the dorsum of the first web space. Um uh um and this can be found in association. The symptoms are more common in women uh uh in a 6 to 1 ratio. And as mentioned previously, often occurs in new mothers and in later stages of pregnancy, it overuse of the thumb. So there is a concern that there are some hormonal of a patient, especially in the pending of uh uh uh onset of symptoms prior to the birth of the child. Um usually involve pain at the base of the thumb on the radial wrist. And patients sometimes complain of clunking or clicking the thumb. The most common uh uh through a diagnostic test that is uh uh uh uh that is referenced for the pathology is uh uh the Finkel, the test where um the patient is instructed to put their thumb in their fist, so their finger is over over the top of it. And then the examiner moves the f ully which usually reproduces the sharp pain in the uh uh radial side of the wrist. Uh um And well, this is uh likely actually a better term the I cough that uh commonly people refer to as the people. Um And patients often also uh uh uh refer to a complaint of tenderness at the, the thumb side of the wrist or the radial side of the wrist. Uh Similar to our other uh uh uh tendinopathy treatment can involve uh conservative management or uh uh surgical treatment. Uh conservative management. It consists of uh bracing, uh uh thumb, like a brace or something that holds the thumb. Uh uh or a custom made splint is a reasonable for the icing activity modification. Of course, patient education on avoiding these uh uh triggers. Um and uh injections are also quite effective just as in the treatment of trigger finger. Um the risk of the injection can should be considered. And in this part of the body, patients can have thinning of skin. And so generally, there is a limit to the number of injections that it's tried. Uh uh usually 2 to 3. Uh because injections in this subcutaneous location can lead to skin bleaching, fat necrosis, skin thinning, uh subcutaneous tissue atrophy. And uh uh uh um sometimes there can be a flare reaction after a steroid uh injection in diabetics, patients can have a short term increase in blood glucose. And um the thought is that this injection is ideally done into the first Doral compartment sheet, uh surgical treatment is indicated only if patients do not have improvement. Uh uh with uh conservative measures which include bracing and injections just like Richard or finger. Um The uh uh this is usually done through a small uh two centimeter incision on the radial aspect of the wrist. And um after carefully for protecting the radial sensory nerve, as described previously, the tunnel uh or the sheath over the tendon is open and then the tendons themselves, the A PB and EPL uh uh sorry, A PL and Epp tendons are identified uh uh uh and allowed to sort of move more freely outside of the third tight tunnel. Um The thought is that uh some patients can have a sub compartment so that the first dorsal compartment that most people have, have smaller tunnels for each of these tendons or tendon flips. And those are the patients who may uh uh uh not improve with an injection where the medications only delivered to 11 compartment. Uh And they may have incomplete uh improvement after surgery if that is not identified. Uh And so generally, uh uh uh you know, an are careful to look for multiple separate sub compartments to ensure that there is complete release of the of uh the first source of compartment moving on to another sort of pathology affecting the radial or thumb side of the wrist is uh basal joint arthritis. And uh I'm sure many of the listeners have patients who complain of this uh uh uh which is arthritis or uh degeneration of the thumb, uh uh C MC joint uh on the uh radial side of the thumb. Um So, the history for this uh uh problem are patients who have difficulty with pinching writing, uh opening a tight jar, uh uh carrying a shopping bag or using a knife to cut food and generally affect uh uh elderly patients. Uh uh from years of, you know, youth of the thumb on exam, uh early on patients can have some swelling over the C MC uh uh over for that joint of the thumb. And later findings is the patient has uh a tightness in this area and they have an abducted burst web space and then they then uh uh extend hyperten at their MC P joint. Their metacarpal pal joint to compensate for a stiff C MC joint. Patients are usually tender right over that area right over the thumb C MC joint and uh uh over the dorsal capsule of that area. As we discussed, the appearance of it is plastic with pain and a tightened first up space and uh uh um and a prominence in the area and then tenderness over the uh uh B MC joint of the thumb. The grind test is when pain is reproduced when the first metacarpal is loaded and causes pain at the E MC joint. And uh treatment options uh similar to the prior uh uh uh pathologies c always start with non-surgical measures including the use of a brace. Uh The thought is that anything that immobilizes a thumb can be helpful uh such as uh uh the thumb is like a brace, but generally this is an activity related pain. And so patients oftentimes are looking for a smaller brace that allows them to uh use the thumb uh and avoid symptoms. Um Anti inflammatories can also be helpful and there are studies that suggest that uh both oral and even topical anti-inflammatory such as uh topical diclofenac can be helpful to decrease symptoms in this area. Injected. They also reasonable for uh early uh C MC arthritis and uh can be done uh uh under landmark guidance uh at the base of the first metacarpal uh uh next to the E PB tendon and with fraction pulling on the thumb as this is a small and it can be difficult to deliver medication in the area. Here's another picture describing that uh the basal joint can be found between the MC P joint and the radial styloid about two thirds of the distance to um in terms of surgical treatment options. Uh uh uh The main uh plastic treatment for this problem in the setting of failure of non-surgical of non-surgical measures is uh uh A uh um uh L RT I or an A PL suspension plasty. There are many studies on this topic, but the main consensus is that removing the trapezium uh or taking out this uh sort of arthritic bone can lead to improvement in patients pain. Uh And many surgeons have concerns that removing the bone alone can lead to uh uh can lead to subsidence of the first metacarpal. And so, there are multiple uh um uh uh techniques that are described including using the A PL tendon to suspend the thumb or using uh uh the FDR tendon to uh reconstruct the uh ligament for the thumb and then uh place be placed inside the gap leaf left by taking out the trapezium to uh uh uh uh uh avoid the thumb or the first ray from settling into the hole removed uh from removing of the trapezium. Uh There is early evidence that suggest that de Nerv or uh targeting uh the uh small muscle, sorry uh uh nerve branches that give uh feeling to the uh thumb joint can be helpful. But the long term results of the Nerv are unclear. The um one of the sort of final pathologist I wanted to discuss that I think is relevant to all sort of practitioners is lateral epochs, which is also known as tennis, elbow, tennis level was one of the most common Ovary uh syndromes that count in the upper extremity and is uh um uh was initially described by uh m in 1882 and not to be caused by lawn tenants. And what this is is tendonitis at the extensor organ. And it is extremely common affecting males and females equally. And uh uh usually affecting patients between the age of 35 and 50. And it is not always associated with tennis. So it can be certainly. Um but can also be associated with patients who are manual laborers who uh perform repetitive activities, uh uh who have a dominant arm or have uh uh con uh concomitant or comorbid depression or promote coping mechanism. It's generally characterized by pain at the lateral aspect of the elbow, located at the lateral epicondyle, which is sort of the bump on the lateral side of the elbow or just distal to it. Um It generally involves radiating pain along the course of the wrist extensors. And the thought is is that the thing, the wrist extensors that straight to your wrist, they originate on the lateral epicondyle and uh pain inflammation or uh uh tendonitis, tendonitis. That area can lead to symptoms of the location. It's usually characterized by uh night pain. Um and is uh uh uh uh patients, oftentimes describe stiffness on awakening and pain with even light daily activity. As as discussed previously, the origin of the wrist center is on the uh lateral of the condyle where the ecrbe DC and AD Q all uh start uh and the lateral ulnar collateral ligament of the elbow is also in that location. And the thought is that lateralis starts as a micro growth here. Um and always involves the uh ECRP which has uh uh deeper uh uh fibers that are more secure or possible. There is generally uh uh histologically demonstrated tendinosis with disorder of collagen meo degeneration and uh angiofibroma hyperplasia. And patients often have point tenderness just as described just at or distal to the lateral of a condyle marked with this uh bump. And uh uh the examiner can look for tenderness in the radial tunnel, uh uh which can be uh omic pathology. Um Patients also report pain with resistor wrist extension, uh and also pain with uh resisted long finger extension. Uh treatments include uh activity modification, limiting lifting when patients are symptomatic, uh avoiding uh uh uh uh vibrational tools uh lifting with the elbow flex. Uh uh uh uh uh but it doesn't, you know, it can be can continue as is. But the main thought is that uh repetitive wrist motion can lead to worsening symptoms. Uh And then changing equipment, especially if it's in the setting of tennis, uh changing the grip size or restring BRAC helpful. The treatment for tennis elbow uh is, is generally nonsurgical. Um And I think this is uh this can be very challenging for patients to accept if they're really struggling with this. Uh In the long term, a wrist brace can be helpful for uh to immobilize the wrist extensors and stretching and uh soft tissue massage. In patient education can be helpful and then uh uh physical therapy is the mainstay of treatment. So, the nural exercise is focused on increasing strength, flexibility and endurance and stretching of the wrist extensors. Uh with the elbow extended can help lead to stretching and improvement in symptoms in this area. Um And then uh um uh working on uh starting with eccentric strengthening exercises and, and progressing to isometric and concentric strengthening can be helpful with physical therapy. Um physical therapy can also work on massage, uh uh anti inflammatories, ultrasound eris and then anti-inflammatory with oral and topical uh can be helpful for this problem. Um There are other braces that are described that are little less effective uh than a wrist brace, including a counter fourth brace which theoretically creates a more distal muscle origin and a cock up wrist brace that decreases the uh uh uh use of the wrist extensors. And uh uh the challenge is that surgical or uh options or interventions have generally unreliable uh benefits. So, uh uh steroid injections uh uh can temporarily improve symptoms but have been associated with a longer course of symptom. Uh The uh data on uh platelet rich plasma and surgery is unclear. And as such, uh uh non-surgical management is the mainstay of treatment surgically for patients with symptoms that are refractory to a, you know, sometimes a year of symptom. One can consider this knowing that the outcomes are uh uh uh unreliable uh where pa where uh it, it's been described that you can identify the ECRB, uh uh the risk sensor, you know, inflamed tissues and remove the disease tissues. Uh But again, I personally generally, uh you know, based on the data uh uh prior to patients to consider non-surgical measures and avoid intervention for this problem, um I'll briefly review cubital tunnel cause. Uh I think that's the sort of the final extremely common compressive neuropathy that, that uh affects the upper extremity. And then, uh do you wanna leave time to discuss questions? The cubital tunnel is uh uh uh ulnar nerve compression at the elbow. Uh And uh uh uh unlike carpal tunnel syndrome, the uh cubital tunnel affects uh the ulnar nerve which is characterized by numbness and tingling or similar symptoms in the small and ring finger weakness of the intrinsics of the hand and uh um and diminished sensation over the door of the hand. The thought is that this is due to a similar problem where the nerve is running through a naturally tight area in the cubital tunnel, uh posterior to the medial epicondyle and uh uh edema in the nerve uh can lead to uh uh uh inflammation and pain and symptoms dra the small finger. It can be associated with the sitting of arthritis of the elbow instability uh or if the nerve uh uh with motion is sub Luc thing or moving over the media epa Conal that can lead to symptoms. Patients often are a tender in that area. But also as discussed previously, have a positive balance or tapping over the Nove leads to uh reproducing symptoms. Uh The flexion compression test for patients um have uh pre pressure is applied and the elbow is flexed is is uh another uh reliable way to reproduce symptoms of uh fil coma syndrome. The ulnar nerve gives uh uh motor strength to the intrinsics of the hand. And so testing, the intrinsics is important and evaluated for cubital tunnel syndrome. And uh uh this is a picture demonstrating intrinsic atrophy where the patient has lots of muscle of their uh uh intrinsic uh of their hand due to chronic cubital tunnel syndrome. Um The uh there are a number of signs associated with C little tunnel syndrome with the Wartenburg sign where the nerve where the small finger is held in abduction uh as depicted here, uh Vermont sign where the patient uses uh bend their thumb for key pinch rather than uh uh using their intrinsic and then uh uh um uh loss of the metacarpal arch and con convexity of the ness out of the hand due to loss of the hypothenar. Another kind of atrophy uh the treatments I think are unfortunately twofold. Uh uh One is uh uh keeping the elbow straight at night or nighttime bracing. And this can be done either with a formal brace or with a uh a night towel. But to keep the elbow in a straighter position since elbow flexion generally reproduce the symptoms and patient education to avoid uh uh putting their uh elbow in a prolonged flex position, which can lead to worse symptoms and surgically for patients who have failed non-surgical measures or for patients who have severe atrophy uh uh inside your decompression or transposition of the nerve may be indicated. I'll leave things uh uh there. So we have time for question. Thank you.
