1. Periarticular Disorders Elbow & Wrist 15.feb.2015 M.Lashkari.M.D

2. Olecranon bursitis The olecranon bursa overlies the olecranon process of the ulna. Olecranon bursitis is common after chronic local trauma and in rheumatic diseases, including rheumatoid arthritis and gout. Septic olecranon bursitis may occur.

3. Olecranon bursitis usually with a swelling over the olecranon process, which is often tender and may be erythematous. Sometimes a large collection of fluid over the area is palpable as a cystic mass, often requiring aspiration and drainage. There is generally no pain with elbow movement.

4. Treatment of bursitis consists : Prevention of the aggravating situation, rest NSAID Local glucocorticoid injection

5. Lateral Epicondylitis (Tennis Elbow) A painful condition involving the soft tissue over the lateral aspect of the elbow. The pain originates at or near the site of attachment of the common extensors to the lateral epicondyle and may radiate into the forearm and dorsum of the wrist. The pain usually appears after work or recreational activities involving repeated motions of wrist extension and supination against resistance. Most patients with this disorder injure themselves in activities other than tennis, such as pulling weeds, carrying suitcases or briefcases, or using a screwdriver.

6. The injury in tennis usually occurs when hitting a backhand with the elbow flexed. Shaking hands and opening doors can reproduce the pain. Striking the lateral elbow against a solid object may also induce pain.

7. Treatment : Rest NSAID Ultrasound, icing, and friction massage Injection of a glucocorticoid Forearm band Surgical release

8. Medial Epicondylitis (golfer's elbow) Medial epicondylitis is an overuse syndrome resulting in pain over the medial side of the elbow with radiation into the forearm. The cause of this syndrome is considered to be repetitive resisted motions of wrist flexion and pronation, which lead to microtears and granulation tissue at the origin of the pronator teres and forearm flexors, particularly the flexor carpi radialis.

9. >35 years Less common than lateral epicondylitis It occurs most often in work-related repetitive activities but also occurs with recreational activities such as swinging a golf club (golfer's elbow) or throwing a baseball.

10. Tenderness just distal to the medial epicondyle over the origin of the forearm flexors. Pain can be reproduced by resisting wrist flexion and pronation with the elbow extended. Radiographs are usually normal.

11. Conservative treatment: Rest, NSAIDs, friction massage, ultrasound, and icing Splinting Injections of glucocorticoids Surgical release

12. Carpal Tunnel Syndrome CTS is the most commonly compression neuropathy in the upper extremity. An isolated phenomenon Systemic diseases :CHF, multiple myeloma, tuberculosis Conditions such as pregnancy, diabetes, obesity, RA, gout

13. Symptoms : Nocturnal paresthesias in the affected digits,paresthesias or hypesthesias in the thumb, index, and long fingers, and weakness of the hand. Patients often complain of forearm and elbow pain that is aggravated by activities but is poorly localized and aching in nature. Occasionally, more proximal symptoms such as shoulder pain are the main presenting complaint.

14. F/M: 3/1 40-60 yr The diagnosis of CTS is usually clinical. Tinel’s sign Phalen

15. Tinel’s sign - Phalen Test

16. Decreased sensibility and thenar atrophy are late signs seen in advanced median nerve entrapment. Bilateral electrodiagnostic tests, NCV. DDx: Cervical root compression,TOS.

17. Conservative treatment: Splinting NSAIDs Injections of corticosteroid Surgical release : Patients with confirmed CTS who have failed a course of conservative treatment. Early surgery should be recommended for objective sensory loss or thenar atrophy.

18. Cubital Tunnel Syndrome Medial forearm pain and irritability of the ulnar nerve at the elbow. Presenting symptoms usually consist of paresthesias or numbness or both in the small and ring fingers. Percussion of the nerve in the cubital tunnel (Tinel’s sign). Electrodiagnostic studies

19. Conservative treatment: Avoid having the elbow flexed for prolonged periods, particularly at night. Soft, or semirigid, elbow splints prevent elbow flexion beyond 50 to 70 degrees. Medial elbow pads NSAIDs Surgical decompression

20. Ulnar Nerve Entrapment: Guyon’s Canal Combination of sensory and motor symptoms in the ulnar nerve distribution. Numbness and paresthesias of the palmar aspect of the ring and small fingers. Motor symptoms are usually described as a cramping weakness with grasping and pinching. As with median neuropathy, atrophy of the intrinsics and objective sensory loss are late findings.

21. Repeated blunt trauma, fracture of the hamate or the metacarpal bases, fracture of the distal radius, space- occupying lesions such as a ganglion, lipoma, or anomalous muscle. Splinting and activity modification. Surgery

22. Ganglion 50% to 70% of all soft tissue tumors of the hand and wrist. 60% to 70% occur around the dorsal wrist. These mucin-filled cysts usually arise from an adjacent joint capsule or tendon sheath. Most ganglia occur as a well-circumscribed and obvious soft mass, some are subtler and are evident only with the wrist in marked volar flexion. DDx: Extensor tenosynovitis, lipomas, other hand tumors.

23. Plain radiographs are usually normal(intraosseous cyst or an osteoarthritic joint). Ultrasound and MRI for “occult” ganglia.

24. Not all ganglia are painful. Patients may present with complaints of wrist weakness or simply because of the cosmetic appearance of the cyst. In approximately 10% of cases, there is evidence of associated trauma to the wrist. The ganglia may appear suddenly or develop over many months. Intermittent complete resorption and reappearance months or years later is common.

25. Conservative treatment: Splinting and rest Aspiration in conjunction with injection of corticosteroids. Excision: Occasionally, a ganglion can become so large that can interfere with the function of the wrist by limiting the motion, especially in extension. Pressure of the mass on the terminal branches of the posterior interosseous nerve may be painful.

26. With proper excision,recurrence is less than 10%. Arthroscopic resection (safe and effective method)

27. De Quervain’s Disease One of the most common sites of tendon irritation around the wrist is in the first dorsal extensor compartment. The tendons involved are the extensor pollicis brevis and the abductor pollicis longus. At the level of the radial styloid, these two tendons pass through an osteoligamentous tunnel composed of a shallow groove in the radius and an overlying ligament.

28. F>M, 30-40 yr Postpartum women Patients complain of pain along the course of these tendons with grasping activities. Tenderness along the affected compartment and there may be swelling over the radial styloid. Finkelstein’s test

29. Finklestein’s Test

30. Primary treatment: Rest with splinting Anti-inflammatory medication(2-4 wk) Injection of corticosteroid Surgery

31. Thanks