Common Extremity Injuries

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Common Extremity Injuries

• PRA 635
• CMT and Case Management

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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

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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

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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

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Anatomy
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Anatomy
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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 life1
• Males are more commonly affected than females,
  with a male-to-female ratio of approximately 511

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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

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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
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Etiology/MOI
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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

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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

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Classification
Trapezius
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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
  

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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 OBriens test

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OBriens Test
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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

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Management1

• 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

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Management1

• 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

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Management1

• 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

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Management1

• Type III
• Definite support, such as Kenny-Howard sling
• Perform early ROM tests as pain ?
• Vigorous strengthening program

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Kenny-Howard Sling (AC Sling)

• http//www.tartanortho.com/AC62A2.html.pdf

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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

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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 session1

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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 origin1
• 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

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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)

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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

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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

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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

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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

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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

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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

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Carpal Tunnel Syndrome
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Carpal Tunnel Syndrome

• Incidence is 1-3 cases per 1000 subjects per
  year3
• Prevalence is approximately 50 cases per 1000
  subjects in the general population3
• 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 groups3

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Carpal Tunnel Syndrome

• Epidemiology
• Female-to-male ratio is 3-1013
• Peak age of development of CTS is from 45-60
  years3
• Only 10 of CTS patients are younger than 31 years

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Carpal Tunnel Syndrome
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Carpal Tunnel Syndrome
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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

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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.

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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

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Carpal Tunnel Syndrome

• Risk factors include
• Genetic, medical, social, vocational,
  avocational, and demographic

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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 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, crocheting,
  painting)
• Nocturnal symptoms that wake the individual are
  more specific of CTS, especially if the patient
  relieves symptoms by shaking the hand/wrist

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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 first 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., whole hand/arm
  feeling 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

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Carpal Tunnel Syndrome

• Autonomic symptoms
• Not infrequently, patients report symptoms in the
  whole hand or a tight or swollen feeling in the
  hands
• Many patients also report sensitivity to changes
  in temperature (particularly cold) and a
  difference in skin color
• These symptoms are likely due to autonomic nerve
  fiber involvement (the median nerve carries most
  autonomic fibers 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

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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)

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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

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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 extension for
  reverse Phalen) of the wrists for up to 60
  seconds
• This test has 80 specificity but lower
  sensitivity

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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 restriction
• This palpatory test has been noted to have a
  sensitivity over 90 and a specificity of 75 or
  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

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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)

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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)

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Carpal Tunnel Syndrome

• Medical conditions
• Wrist fracture (Colles)
• Acute severe flexion/extension injury of wrist
• Space-occupying lesions within the carpal tunnel
  (eg, flexor tenosynovitis, ganglions, hemorrhage,
  aneurysms, 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

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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

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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), are the first-line investigations
  in suggested CTS

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Carpal Tunnel Syndrome

• Management
• Wrist supports
• Ultrasound
• Exercise
• Carpal bone mobilization/manipulation
• Surgical intervention
• Steroid injection/oral steroids

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