1. Common Elbow, Wrist, and Hand Problems
5/14/03
Elbow, Wrist & Hand Disorders
Brian Lohrbach, MD
OSI Orthopedic Surgeon
Brian L. Lohrbach, M.D.

2. Common Elbow, Wrist, and Hand Problems
5/14/03
Tendonitis
Brian L. Lohrbach, M.D.

3. Common Elbow, Wrist, and Hand Problems
5/14/03
Tendonitis: Elbow
Lateral epicondylitis
“Tennis elbow”
Pain over lateral epicondyle radiating to dorsum of wrist
Pain with repetitive supination/pronation and gripping
Degeneration of origin of Extensor Carpi Radialis Brevis
Brian L. Lohrbach, M.D.

4. Lateral Epicondylitis: Diagnosis
Common Elbow, Wrist, and Hand Problems
5/14/03
Lateral Epicondylitis: Diagnosis
X-rays usually negative
Pain to palpation of lateral epicondyle
Pain with resisted wrist extension in pronation
Brian L. Lohrbach, M.D.

5. Lateral Epicondylitis: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
Lateral Epicondylitis: Treatment
Non-operative: 85% success rate
Activity modification, NSAIDs, counterforce strap, cortisone injections (2-3)
Therapy
Ultrasound, massage, iontophonophoresis, stretching
Brian L. Lohrbach, M.D.

6. Lateral Epicondylitis: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
Lateral Epicondylitis: Treatment
Operative
Removal of diseased tissue
Most patients improve in 3-4 months
90% success rate
Brian L. Lohrbach, M.D.

7. Lateral Epicondylar Release Return to Work Protocol
Common Elbow, Wrist, and Hand Problems
5/14/03
Lateral Epicondylar Release Return to Work Protocol
Week 0 – 1: off work
Week 1 – 4: one-handed work, begin OT
Week 4 – 12: light duty work, complete OT
Week 12: regular duty work
Brian L. Lohrbach, M.D.

8. Common Elbow, Wrist, and Hand Problems
5/14/03
Tendonitis: Wrist
De Quervain’s tenosynovitis
Intersection syndrome
Flexor carpi radialis/ulnaris tendinits
Brian L. Lohrbach, M.D.

9. DeQuervain’s Tenosynovitis
Common Elbow, Wrist, and Hand Problems
5/14/03
DeQuervain’s Tenosynovitis
Stenosing tenosynovitis of 1st dorsal compartment: Abductor pollicis longus (APL) and extensor pollicis brevis (EPB)
30 to 50 year olds
10 times more common in women
Pain with thumb motion over radial styloid
Brian L. Lohrbach, M.D.

10. DeQuervain’s: Diagnosis
Common Elbow, Wrist, and Hand Problems
5/14/03
DeQuervain’s: Diagnosis
Pain over radial styloid
Finkelstein’s maneuver
Brian L. Lohrbach, M.D.

11. DeQuervain’s: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
DeQuervain’s: Treatment
NSAIDs
Thumb spica splint
1 – 2 cortisone injections
Operative release required in 25% of patients after 6 weeks of failed conservative treatment
Brian L. Lohrbach, M.D.

12. First Dorsal Compartment Release Return to Work Protocol
Common Elbow, Wrist, and Hand Problems
5/14/03
First Dorsal Compartment Release Return to Work Protocol
Day 1 - 2: off work
Week 1 – 3: one-handed work, home exercises
Week 3 – 6: light duty work
Week 6: regular duty work
Brian L. Lohrbach, M.D.

13. Intersection Syndrome
Common Elbow, Wrist, and Hand Problems
5/14/03
Intersection Syndrome
Pain where APL and EPB cross over underlying extensor carpi radialis (ECR)
Swelling, crepitus, squeaking*
Splint, NSAID, occasional injection
Brian L. Lohrbach, M.D.

14. Flexor Carpi Radialis/Ulnaris Tendonitis
Common Elbow, Wrist, and Hand Problems
5/14/03
Flexor Carpi Radialis/Ulnaris Tendonitis
Pain over volar wrist from repetitive motion
Splint, NSAIDs, activity modification
Cortisone injection
Very rarely, surgical tenolysis
Brian L. Lohrbach, M.D.

15. Common Elbow, Wrist, and Hand Problems
5/14/03
Tendonitis: Hand
Trigger finger
Stenosing flexor tenosynovitis: Inflammation of flexor tendon limiting excursion under the A1 pulley
Inability to fully extend digit
or catching with flexion and extension of digit
Repetitive use and diabetes
are common causes
Brian L. Lohrbach, M.D.

16. Trigger finger: Diagnosis
Common Elbow, Wrist, and Hand Problems
5/14/03
Trigger finger: Diagnosis
Locked digit in flexion
Painful nodule over volar metacarpophalangeal joint
*Beware: Patients with trigger thumb often complain of catching in interphalangeal joint of thumb
Brian L. Lohrbach, M.D.

17. Trigger Finger: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
Trigger Finger: Treatment
Nonoperative:
NSAIDs
Cortisone injection under A1 pulley
60% success if seen early
Brian L. Lohrbach, M.D.

18. Trigger Finger: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
Trigger Finger: Treatment
Operative: A1 pulley release
Outpatient procedure under local
95% success rate
Brian L. Lohrbach, M.D.

19. Trigger Finger Release Return to Work Protocol
Common Elbow, Wrist, and Hand Problems
5/14/03
Trigger Finger Release Return to Work Protocol
days off work
Week 1 – 3: one-handed work, home exercises
Week 3 – 6: light duty work
Week 6: regular duty work
Brian L. Lohrbach, M.D.

20. Compressive Neuropathies
Common Elbow, Wrist, and Hand Problems
5/14/03
Compressive Neuropathies
Brian L. Lohrbach, M.D.

21. Compressive Neuropathies: Elbow
Common Elbow, Wrist, and Hand Problems
5/14/03
Compressive Neuropathies: Elbow
Cubital tunnel syndrome (ulnar nerve)
Radial tunnel syndrome
Brian L. Lohrbach, M.D.

22. Cubital Tunnel Syndrome
Common Elbow, Wrist, and Hand Problems
5/14/03
Cubital Tunnel Syndrome
Compression of ulnar nerve at the elbow
Direct blow to elbow
Repetitive flexion
Diabetes
Brian L. Lohrbach, M.D.

23. Cubital Tunnel Syndrome
Common Elbow, Wrist, and Hand Problems
5/14/03
Cubital Tunnel Syndrome
Symptoms
Numbness in small and ulnar half of ring finger, including dorsum of hand
Decreased grip strength
Medial elbow pain
Awakens at night
Worse when holding phone,elbow on desk, driving
Brian L. Lohrbach, M.D.

24. Cubital Tunnel Syndrome: Diagnosis
Common Elbow, Wrist, and Hand Problems
5/14/03
Cubital Tunnel Syndrome: Diagnosis
Positive Tinel’s sign at cubital tunnel
Positive elbow flexion test
Decreased 2-point discrimination at small finger
Brian L. Lohrbach, M.D.

25. Cubital Tunnel Syndrome: Diagnosis
Common Elbow, Wrist, and Hand Problems
5/14/03
Cubital Tunnel Syndrome: Diagnosis
Positive Froment’s sign (weak adductor)
Wasting of dorsal 1st webspace
Electrodiagnostic tests (EMG/NCV)
Brian L. Lohrbach, M.D.

26. Cubital Tunnel Syndrome: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
Cubital Tunnel Syndrome: Treatment
NSAIDs, activity modification, elbow pads, nighttime splinting in 20 degrees of flexion (Poorly tolerated)
Surgical release and/or anterior transposition
80-90% good results
Brian L. Lohrbach, M.D.

27. Radial Tunnel Syndrome
Common Elbow, Wrist, and Hand Problems
5/14/03
Radial Tunnel Syndrome
Compression of radial nerve under extensors in forearm
Deep, lateral forearm pain, often at night
No sensory component
Often confused with lateral epicondylitis (they co-exist 5% of the time) pain is more distal
Brian L. Lohrbach, M.D.

28. Radial Tunnel Syndrome: Diagnosis
Common Elbow, Wrist, and Hand Problems
5/14/03
Radial Tunnel Syndrome: Diagnosis
Extended middle finger test
Electrodiagnostic tests not helpful
Injection of local anesthetic into radial tunnel completely relieves symptoms and is diagnostic
Brian L. Lohrbach, M.D.

29. Radial Tunnel Syndrome: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
Radial Tunnel Syndrome: Treatment
NSAIDs
Activity modification
Surgical decompression
50% success rate
Brian L. Lohrbach, M.D.

30. Cubital and Radial Tunnel Release Return to Work Protocol
Common Elbow, Wrist, and Hand Problems
5/14/03
Cubital and Radial Tunnel Release Return to Work Protocol
Week 0 – 1: off work
Week 1 – 6: one-handed work, begin OT
Week 6 – 12: light duty work, complete OT
Week 12: regular duty work
Brian L. Lohrbach, M.D.

31. Compressive Neuropathies: Wrist
Common Elbow, Wrist, and Hand Problems
5/14/03
Compressive Neuropathies: Wrist
Carpal tunnel syndrome (median nerve)
Ulnar tunnel syndrome (Guyon’s canal)
Brian L. Lohrbach, M.D.

32. Carpal Tunnel Syndrome
Common Elbow, Wrist, and Hand Problems
5/14/03
Carpal Tunnel Syndrome
Compression of median nerve under transverse carpal ligament
Pain/parasthesias of palmar/radial aspect of hand; weakness over time
Often worse at night, reading paper, holding a coffee cup, driving
Brian L. Lohrbach, M.D.

33. Carpal Tunnel Syndrome: Risk Factors
Common Elbow, Wrist, and Hand Problems
5/14/03
Carpal Tunnel Syndrome: Risk Factors
Diabetes
Alcoholism
Pregnancy
Hypothyroidism
Distal radius fracture
Vibrational exposure
Brian L. Lohrbach, M.D.

34. Carpal Tunnel Syndrome: Diagnostic Tests
Common Elbow, Wrist, and Hand Problems
5/14/03
Carpal Tunnel Syndrome: Diagnostic Tests
Moving 2-point discrimination greater than 5mm
Tinel’s: tingling to percussion over carpal tunnel
Phalen’s: wrist palmarflexion produces parasthesia in 60 seconds
Compression test: direct compression over carpal tunnel with parasthesia at 30 seconds
Brian L. Lohrbach, M.D.

35. Carpal Tunnel Syndrome: Diagnostic Tests
Common Elbow, Wrist, and Hand Problems
5/14/03
Carpal Tunnel Syndrome: Diagnostic Tests
Weakness of abductor pollicis brevis or wasting of the thenar eminence (advanced stage)
Electrodiagnostic tests
Nerve conduction velocity: slowed at wrist
Electromyography (EMG): indicates advanced stage of disease
5% false-negative rate
Brian L. Lohrbach, M.D.

36. Carpal Tunnel Syndrome: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
Carpal Tunnel Syndrome: Treatment
Conservative
Splinting in neutral at night
NSAIDs
Ergonomic modification
Steroid injections
Best in early stages
Diagnostic tool
20% asymptomatic at 12 months
Brian L. Lohrbach, M.D.

37. Carpal Tunnel Syndrome: Treatment
Common Elbow, Wrist, and Hand Problems
5/14/03
Carpal Tunnel Syndrome: Treatment
Carpal tunnel release
95% success rate
Outpatient, local anaesthetic
Recovery 6 weeks to 6 months depending on the occupation of the patient
Pillar (incisional) pain
Brian L. Lohrbach, M.D.

38. Ulnar Tunnel Syndrome (Guyon’s Canal)
Common Elbow, Wrist, and Hand Problems
5/14/03
Ulnar Tunnel Syndrome (Guyon’s Canal)
Ulnar nerve passes between hook of hamate and pisiform at wrist
Much less common than carpal tunnel syndrome
Brian L. Lohrbach, M.D.

39. Carpal Tunnel Release Return to Work Protocol
Common Elbow, Wrist, and Hand Problems
5/14/03
Carpal Tunnel Release Return to Work Protocol
3 – 7 days: off work
Week 1 – 6: one-handed work, +/- OT
Week 6 – 12: light to regular duty, +/- OT
Week 12: regular duty
Brian L. Lohrbach, M.D.

40. Common Elbow, Wrist, and Hand Problems
5/14/03
Getting
Brian L. Lohrbach, M.D.