Free Orthopedics Review | Dr Hutaif General Orthopedics -...

C urrent consensus is that tennis elbow is associated with a strain or microtear of the EC RB origin, which lies beneath the
EC RL.

The clinical diagnosis of lateral epicondylitis is supported by specific provocative tests. The gold standard for diagnosis is the history and physical examination. Tenderness on examination is localized to the lateral epicondyle, which can radiate into the forearm; the area of maximum tenderness is approximately 2 mm to 5 mm distal and anterior to the midpoint of the lateral epicondyle. There is usually a history of overuse or of a repetitive activity. The pain is aggravated, with the elbow extended, by resisted wrist and finger extension or with passive finger and wrist flexion.

Ninety to 95% of all patients with tennis elbow respond to nonoperative treatment, and it remains the mainstay for treatment of lateral epicondylitis. Operative treatment may be indicated for debilitating pain in patients without other pathologic causes of pain for whom nonoperative treatment has failed after a reasonable length of time. This time period is usually a minimum of 6 to 12 months.

C urrent studies have found no benefit of extracorporeal shock wave therapy in the treatment of lateral epicondylitis.C orrect
Answer: Is ineffective

Peripheral beta-blockade has minimal effect on peripheral vasculature and is not typically used in patients with frostbite injury. Ibuprofen, tetanus booster, antibiotic prophylaxis, and appropriate pain medication are routinely used in the treatment of frostbite injuries.

People who have had previous frostbite injuries are at increased risk of thermal injury, whether cold or heat related. Joint contractures, localized osteoporosis, punched-out subchondral bony lesions, and cold intolerance are often present after frostbite injury.

Rapid rewarming in a 40° C to 42° C circulating water bath is the most effective early treatment of frostbite injury. Slow or fast rewarming in other temperatures and/or rewarming in air is not indicated.

Frostbite will generally not occur above â10° C , but the risk is significantly increased when the air temperature is below â25° C .

Superficial frostbite typically involves minimal tissue loss. Patients have pliable skin with sensation. Deep frostbite typically results in significant soft tissue loss with firm anesthetic tissue that forms hemorrhagic blisters.

High altitudes, prolonged exposure, and anything that would cause peripheral vasoconstriction increase the risk of frostbite injury. Humidity does not play a significant role in the development of frostbite injury.

Treatment of frostbite includes rapid rewarming (even when reperfusion pain occurs), early active motion, elevation, and avoidance of dry heat that can dessicate tissues. Massaging the frostbitten area is not recommended because it may induce additional trauma via shearing forces.

Arthritis of the wrist is estimated to affect 5.3% of the U.S. population, based on radiographic assessments of 4,000 wrists.1 After having rheumatoid arthritis (RA) for 10 years, 90% of patients experience arthritis in their wrist joints.2

The accessory ulnar collateral ligament inserts into the volar plate, whereas the proper collateral inserts into the base of the proximal phalanx.

Fukumoto and colleagues have used Wykeâs definition to explain primary and accessory innervation of the wrist. Primary articular nerves consist of small nerves that pass to each joint as independent branches of adjacent peripheral nerves. There are three primary articular nerves: the PIN, the lateral antebrachial cutaneous nerve, and the articular branches from the ulnar nerve. Accessory nerves originate from small, twig branches of intramuscular or cutaneous nerves that innervate the skin around the wrist joint. The accessory articular nerves have been identified as the anterior interosseous nerve (AIN), the palmar cutaneous branch of the median nerve, the deep and dorsal branches of the ulnar nerve, and the superficial branch of the radial nerve to the first intercarpal space.

The PIN is found on the deep radial wall of the fourth dorsal compartment, 1.2 cm ulnar to Listerâs tubercle. As the PIN approaches the radiocarpal joint, it is covered in fascia and gives one branch to the radioscaphoid joint and three to four terminal branches to the intercarpal joints. The PIN is the principal innervation to the central dorsal portion of the wrist. The AIN innervates the radial volar lip of the distal radius. The dorsal branch of the ulnar nerve contributes to innervation of the triangular fibrocartilage complex. The lateral antebrachial cutaneous nerve innervates the thumb carpometacarpal joint and the scapho- trapezotrapezoid joint.

The AIN is a branch of the median nerve. Its muscular innervations include the flexor pollicis longus, the radial half of the flexor digitorum profundus, and the pronator quadratus. The AIN terminates as a sensory branch to the volar radial surface of the distal radius. The TFC C is innervated by components of the ulnar nerve. The dorsal radiocarpal joint is innervated by the posterior interosseous nerve. The thumb carpometacarpal is innervated by the sensory branch of the radial nerve and the lateral antebrachial cutaneous nerve.

In 1983, Ekerot and colleagues reported his results in 48 patients. They used the technique described by Wilhelm but only denervated the radial side of the wrist for patients with scaphoid or lunate pathology. However, the entire wrist was denervated in patients with global degenerative wrist disease or wrist pain with an unknown etiology. Pain relief occurred in only 56% of the patients. They noted the best results occurred in patients with scaphoid nonunion, osteonecrosis of the lunate, and primary radiocarpal arthritis.

Kupfer and colleagues presented a podium presentation of a single-incision approach to the resection of the PIN and AIN for denervation of the radial side of the wrist. Weinstein and Berger published their results in 2002 with a similar technique. They described a 2-cm long dorsal incision that was 3 to 5 cm proximal to the ulnar head. They then resected a 2-cm segment of the PIN and AIN. In their group of 20 patients, 85% were satisfied with their procedure after an average follow-up of 2.5 years. If failure were to occur, it occurred within the first year.

The single dorsal incision approach to wrist denervation involves resection of the posterior interosseous nerve (PIN) and the anterior interosseous nerve (AIN). Distally, the PIN is purely sensory and does not give off motor branches in the vicinity of the wrist joint. The terminal portion of the AIN has both motor and sensory components. A majority of this is motor, and it innervates the pronator quadratus right up to the radiocarpal articulation. Resection of the AIN close to the radiocarpal joint has a high probability of denervating the pronator quadratus. The extensor indicis is usually the last motor branch of the PIN, but this terminal portion of this branch is more than 5 cm proximal from the distal radioulnar joint. The flexor pollicis longus is innervated by the AIN, but motor branches to this muscle are more proximal than branches to the pronator quadratus. The flexor digitorum profundus muscle is innervated by the AIN and ulnar nerve. However, the motor branches are more proximal than the incision for dorsal innervation.

Posterior interosseous nerve palsy is described as painless finger drop. This syndrome is commonly associated with trauma to the lateral elbow.

Painless finger drop is characteristic of posterior interosseous nerve palsy. This syndrome may also involve elbow tenderness in the absence of other clinical findings. Pain in the dorsum of the hand is not associated with this condition because the posterior interosseous nerve contains no sensory component.

The most common site of posterior interosseous nerve entrapment is at the arcade of Frohse, which is a fibrotendinous ring found within the fibers of the supinator muscle as the posterior interosseous nerve originates from the radial nerve.

The posterior interosseous nerve innervates a number of muscles involved primarily in finger extension, including the extensor carpi ulnaris, extensor digitorum, extensor digiti minimi, extensor pollicis brevis and longus, abductor pollicis longus, and extensor indices.

Only the metacarpophalangeal joints are involved in posterior interosseous nerve palsy, as the muscles of the interphalangeal joints are innervated by the ulnar and median nerves.

This patient displays the classic signs and symptoms of bilateral carpal tunnel syndrome, which involves median nerve entrapment at the base of the palm. This entrapment leads to numbness and dysesthesias that are worse at night and upon exertion. Pain is typically relieved by shaking the hand. Furthermore, the median nerve innervates several muscles of the hands, and entrapment may lead to muscle atrophy.

Lumbricals 1 and 2 are innervated by the median nerve, in addition to the opponens pollicis brevis, abductor pollicis brevis, and flexor pollicis brevis.

The carpal tunnel is made by the flexor retinaculum, also known as the transverse carpal ligament.

All of the above statements are true regarding the transverse carpal ligament.

The palmar cutaneous branch of the median nerve originates proximally to the carpal tunnel and travels superficial to the tunnel.

Dupuytrenâs contracture most frequently involves the ring and small fingers. Although Dupuytrenâs cords at the thumb have been described, they are rare.

Gabbiani and Majno noted the abnormal appearance of fibroblasts found in patients with Dupuytrenâs contracture. They used the term myofibroblasts to describe these cells because they showed characteristics of fibrous and muscular tissue.

No association exists between high blood pressure and Dupuytrenâs disease, but all of the other listed conditions have been associated with Dupuytrenâs contracture. HIV has recently been described as a risk factor; patients with Dupuytrenâs contracture have been in advanced stages of HIV.

C lostridial collagenase works by breaking the collagen connections. The Dupuytrenâs cord is ruptured manually; surgery is not necessary.

C ompared to normal palmar fascia, the fibrous bands in Dupuytrenâs disease have an increased ratio of type III to type I
collagen, and an overall increase in the amount of type III collagen.

The SLIL is a c-shaped structure, which is thickest dorsally. The dorsal fibers have an average thickness of 3 mm and are composed of transversely oriented fibers, which afford the greatest resistance to translation between the scaphoid and the lunate, preventing the characteristic radiographic separation and flexion deformity of the scaphoid.

Magnetic resonance imaging is commonly used among patients with concern for ligamentous injuries of the wrist, particularly in the presence of an abnormal physical exam when plain radiographs are normal. However, the sensitivity of MRI has been shown to be less than 40% in comparison with arthroscopy. Arthroscopy has become the gold standard for the diagnosis of ligamentous injuries to the wrist. A classification scheme has been proposed based on both radiocarpal and midcarpal arthroscopic findings.

On a lateral view of the wrist, when the lunate slips into a statically dorsiflexed position greater than 10°, the condition is defined as dorsal intercalated segmental instability (DISI). DISI deformity is also present when the scapholunate angle is greater than 60 degrees (45+/- 15 degrees is normal). The VISI deformity is seen on the lateral radiograph is characteristic of lunotriquetral dissociation. The other signs are seen on the anteroposterior projection.

Arthroscopy has become the gold standard for the diagnosis of ligamentous injuries to the wrist. A classification scheme has been proposed by Geissler and colleagues, based on both radiocarpal and midcarpal arthroscopic findings (Table).
Table. Arthroscopic C lassification of Interosseous Ligament Injury1 1
Grade Findings
I Attenuation of the interosseous ligament with no radiocarpal or midcarpal step-off
II Incongruence of the scapholunate interval seen from the midcarpal joint
III C omplete separation of scaphoid and lunate visualized from both spaces;
a 1-mm probe can be passed between the two bones
IV Ability to pass 2.7-mm arthroscope between the scapholunate interval

C onservative management includes a period of splinting and activity modification, followed by proprioception training of the flexor carpi radialis to act as a dynamic scaphoid stabilizer.

Experts recommend treating congenital thumb duplication before the age of 6 months, when the potential for growth and remodeling is greatest. The condition usually presents unilaterally, lacking association with other systemic abnormalities, and usually presents with a hypoplastic radial duplicate and dominant ulnar duplicate.

Wassel II (also categorized as IP in the universal classification system) occurs when the duplication begins at the interphalangeal joint of the thumb, resulting in complete bifurcation of two distal phalanges that articulate proximally with a single proximal phalanx.

A Z-deformity, with ulnar deviation at the MC P joint and radial deviation at the IP joint, is one of the most common complications after reconstruction. Weakness, paresthesias, and wound complications are uncommon possible complications.

Ultrasound is considered a deep heat modality and does not heat the superficial tissues.

Thermal uses of ultrasound include increasing pain threshold, decreasing scar, and improving extensibility of the ligaments and joint capsule. Ultrasound has not been shown to have an effect in Dupuytrenâs contracture.

Phonopheresis is delivery of medicine through the skin using ultrasound. Although there is some question as to whether the medications are more effectively absorbed or delivered with ultrasound use, this is a described modality.

Iontophoresis uses a direct or galvanic current to âdriveâ medications transdermally and is used for scar management and pain control.

Iontophoresis is effective in soft tissue conditions such as rotator cuff bursitis and lateral epicondylitis.