trauma to elbow, elbow frature

1. WRIST INJURIES
-Dr. Krupal Modi (MPT)
21/9/2018

2. Acute wrist injuries
 Injuries to the wrist often occur due to a fall on
the outstretched hand (FOOSH).
 In sportspeople, the most common acute
injuries are fractures of the distal radius or
scaphoid, or damage to an intercarpal
ligament.

3. 1) Fracture of the scaphoid
 Most common carpal fracture involves the
scaphoid
 Mechanism is a fall on the outstretched
hand.
 As the patient’s pain may settle soon after the
fall, he or she may not present to a clinician
until some time after the injury.

4.  The key examination finding is tenderness in the
anatomical snuffbox.
 Accompanied by swelling and loss of grip
strength.

5.  A more specific
clinical test for
scaphoid fracture is
pain on axial
compression of the
thumb towards the
radius or direct
pressure on the
scaphoid
tuberosity with
radial deviation of
the wrist.

6.  If a scaphoid fracture is suspected clinically
but the radiograph is normal, a fracture cannot
be ruled out.
 MRI is an ideal diagnostic test for an acute
injury. Bone scan also has excellent sensitivity
for scaphoid fracture.

7. Treatment of stable and unstable
scaphoid fractures
 A stable scaphoid
fracture should be
immobilized for eight
weeks in a scaphoid
cast extending from
the proximal forearm
to, but not including, the
interphalangeal joint of
the thumb.
 Unstable or significantly
displaced fractures
require immediate
percutaneous fixation
or open reduction and

8. 2) Fracture of the hook of
hamate
 Fracture of the hook of
hamate may occur while
swinging a golf
club,tennis racquet or
baseball bat.
 The fracture is especially
likely to occur when the
golf club strikes the
ground instead of the
ball, forcing the top of
the handle of the club
against the hook of the
hamate of the top hand.

9.  Symptoms - reduced grip strength and
ulnar wrist pain.
 Examination reveals volar wrist tenderness
over the hook of hamate.

10.  This fracture often fails to heal with
immobilization.
 If diagnosis is delayed, or the fracture fails to
heal clinically within four weeks of
immobilization, current surgical practice is
excision of the fractured hook followed by
three weeks’ wrist immobilization.

11. 3) de Quervain’s tenosynovitis
 de Quervain’s
tenosynovitis is an
inflammation of the
synovium of the
abductor pollicis
longus(APL) and
extensor pollicis
brevis(EPB) tendons
as they pass in their
synovial sheath in a
fibro-osseous tunnel at
the level of the radial

12.  This is the most
common radial-
sided
tendinopathy in
athletes and
occurs particularly
with racquet
sports.

13.  There is local tenderness and swelling,
which may extend proximally and distally
along the course of the tendons.
 In severe cases, crepitus may be felt.
 A positive Finkelstein’s test is diagnostic but
not pathognomonic because flexor carpi
radialis tendinopathy also causes a positive
test.

15.  Treatment:
 De Quervain’s tendon release - to reduce
pressure on a tendon.
 splint on your hand for 1 to 4 weeks after
surgery.

16. 4) Injuries to the distal radial
epiphysis
 Injuries to the distal
radial epiphysis occur
in elite young
gymnasts.
 Fractures may occur
but overuse injury to
the epiphysis is
more common.

17.  The gymnast complains of pain and limitation
of dorsiflexion
 Examination reveals minimal swelling and
tenderness about the distal radial
epiphysis with no signs of tendinopathy,
synovial cysts or joint dysfunction.
 Common radiographic findings include
widening of the growth plate.

18.  If there is narrowing of the growth plate, the
possibility of a Salter Harris V stress fracture
must be considered.
Compressi
ve forces
Widening of
epiphysis

19. 5) Triangular fibrocartilage complex
tear
 The TFCC lies between
the ulna and the carpus.
 It is the major stabilizer of
the distal radioulnar joint.
 The ‘complex’ consists of
the triangular
fibrocartilage, ulnar
meniscus homolog, ulnar
collateral ligament,
numerous carpal ligaments
and the extensor carpi
ulnaris tendon sheath.
 The TFCC is a common
site of ulnar wrist pain.

20.  Compressive loads to the wrist, especially if
accompanied by ulnar deviation (e.g. in
gymnastics, diving, golf and racquet sports),
may tear the central portion of the cartilage.
 It can also be disrupted after a distal radial–
ulnar fracture or potential with disruption to the
distal radioulnar joint.

22. Examination
 tenderness and
swelling over the
dorsal ulnar aspect of
the wrist,
 pain on resisted wrist
dorsiflexion and ulnar
deviation,
 a clicking sensation on
wrist movement and
 reduced grip strength.
 The ‘press test’ may
be helpful.

23. 6) Kienböck’s disease
 Kienböck’s disease is avascular necrosis of
the lunate, possibly because of repeated
trauma.
 This can present as chronic dorsal or volar
wrist pain in an athlete who has repeated
impact to the wrist.
 localized tenderness over the lunate and
loss of grip strength.

24.  Radiographs may show a
smaller lunate of
increased radio-opacity
but false negatives can
occur, so clinical
suspicion warrants further
investigation with isotopic
bone scan or MRI.
 In the acute stage,
immobilization may be
therapeutic, whereas in
chronic cases surgery
is required, although
results are not superior to
conservative

25. 7) Carpal tunnel syndrome
 The median nerve may be compressed as it
passes through the carpal tunnel along with the
flexor digitorum profundus, flexor digitorum
superficialis and flexor pollicis longus tendons.

26. CLINICAL FEATURES:
 This condition is characterized by burning volar
wrist pain with numbness or paresthesia in the
distribution of the median nerve (thumb, index
finger, middle finger and radial side of the ring
finger).• Nocturnal
paresthesiae are
characteristic.
• The pain can radiate
to the forearm, elbow
and shoulder.
• Tinel’s sign may be
elicited by tapping
over the volar aspect

27.  Neurophysiology:
 NCV and EMG can be done.
 Diabetes mellitus should be excluded as it
is a risk factor for carpal tunnel syndrome.
 Mild cases may be treated conservatively
with NSAIDs and splinting. A single
corticosteroid injection may provide relief
 But, persistent cases require surgical
treatment.

28.  Surgery may be either open or endoscopic
and systematic reviews to date show no
difference between the two techniques for
symptom relief.

29. 8) Ulnar nerve compression/cyclist
palsy
 The ulnar nerve may be
compressed at the wrist
as it passes through
Guyon’s canal.
 This injury is most
commonly seen in
cyclists due to
supporting body weight
over a long duration
ride because of poor
bike fit or a failure to
use several relaxed
handlebar grip
positions.

30.  It also occurs in
karate players, and
a recent study
highlighted the risk
of hand
neurovascular
changes in
baseball players,
especially catchers,
from repeated
trauma associated
with catching a

31.  Within Guyon’s canal, the nerve lies with the ulnar
artery between the pisiform bone on the ulnar side
and the hamate radially.
 Symptoms include pain and paresthesia to the
little finger and ulnar side of the fourth finger.
 Weakness usually develops later.
 Conservative treatment involves splinting, NSAIDs
and changes in the cyclist’s grip on the
handlebars .
 Surgical exploration of Guyon’s canal may be
required.