Diagnosis and Non-operative Management of Common

Upper Extremity Disorders

Stephen Chambers MD
Hand and Upper Extremity Surgeon
Raleigh Orthopedic Clinic
About Me
Purpose

To assist primary care providers in managing

common problems of the musculoskeletal system

GOAL: Try to avoid talking about fractures =>

orthopedic surgeon.
Outline
• Upper Extremity
• Shoulder ( Dr. Evan James)

• Nerve

• Elbow

• Wrist

• Hand
Case Presentation

• Middle age female with wrist pain/numbness that wakes

her up at night and has to ”shake it out”

• Tried anti-inflammatories but no help

• Thinks she has “carpool tunnel”

What is Carpal Tunnel Syndrome
• Compressed median nerve
in the carpal canal of the • Occurs in 5% of the general
population
wrist
• Most commonly occurs in
• Women
• Overweight
• DM
• Thyroid dz
• Arthritis (OA/Gout/RA)
• Pregnancy
Dx

• History
• Numbness in Thumb, Index and
Middle finger,
• Pain can radiate up the arm,
• Night time Symptoms
Exam

Phalen Test Durkans Compression

Hold for 60 sec Hold for 30 sec
Sen 75%, Spe 47% Sen 87% Spe 90%
 EMG/NCV

• Not Perfect
• 30% false negative
• 22% false positive
U/S

• Nerve compression causes

swelling and this swelling can be
measured by u/s

• Meta-anaylsis in 2011 showed

there was not much difference
between EMG and U/S

• This technique is more cost

effective, less painful and can be
in office on the same day
Treatment

• Wrist splint- Decreases pressure in carpal canal

• Median nerve gliding w/ splint exercises can improve
symptoms

Carpal tunnel injection is a great diagnostic tool

• 81% get good/complete relief but only last 6-8 months
• Patients that get relief 94% have great outcomes with surgery
• From therapeutic standpoint, only young females get
complete relief from an injection

NSAIDs and/or Oral steroids have NOT been shown to be

effective in management of carpal tunnel syndrome
When should I refer?

Recommend trying conservative

treatment first (brace) in patients
with mild to moderate CTS

In patients that have severe CTS • Dotted line- Conservative

treatment
(muscle atrophy) recommend • Solid- Surgery
surgery

Waiting decreases the chance that

surgery will completely resolve
the symptoms
”DOC I think this is due to work”

Prevalent but unproven for most

occupations and multiple studies
have shown no causal link
between CTS and Occupation

What about computer use?

• When compared to general
population no correlation
•When compared to only office
workers weak association
Other Causes of Hand Numbness

• Cervical radiculopathy

• Thoracic outlet syndrome

• Cubital tunnel syndrome

• Ulnar tunnel syndrome

My elbow hurts and my fingers are numb
Cubital Tunnel Syndrome

Ulnar nerve compression at the elbow

Symptoms
•Numb RF/SF
•Worse with sustained elbow flexion
(driving, sleeping, typing)
•Weakness
Exam
• Tinel’s at elbow
• Elbow flexion test
• Subluxation ulnar nerve
• Intrinsic atrophy
• Weak grip and pinch
• Froments sign

• *If only motor loss think ALS vs guyon

EMG

• Is still useful but does still have false negative

especially in young people
Treatment

Mild/Moderate Symptoms (no atrophy)

•Elbow pad/ Activity Modification- 80% got improvement ( Dellon)

Serve Symptoms
•Surgery – Outcomes are not as good as carpal tunnel surgery (85% vs
95%)
• This is because the Ulnar nerve is more of a motor (muscle) nerve than the
median. With chronic compression muscle atrophies and does not regrow.
Therefore I feel cubital tunnel syndrome needs be addressed sooner than
carpal and do not wait.

Don’t wait to until the patient has constant numbness to refer

Elbow Pain
• Epicondylitis
• OCD Lesion (kids)
• Elbow Arthritis
• Distal biceps ruptures
Lateral Epicondylitis- Tennis Elbow

Very common diagnosis in adults in 40s-50s. Caused by “microtears” and

abnormal healing of the tendon insertion on the bone

Symptoms
•Tender at lateral epicondyle
•Worse with elbow extended and wrist extended
Treatment
• TIME and Stretching/Activity modification
• Majority (90%) of people get better at one year

• Counterforce brace- No clear evidence it helps

• Steroid Injection – Good short term relief but at 1 year people did
worse.
• PRP - 4 RCT showing no difference between PRP and Saline. $$$
My approach

Symptoms
• < 3m – Activity modification +/- Strap
• > 3m – Above + PT
• If incredibly painful and cant function, discuss inj and how it may prolong
healing.
• >9m – Last Resort: Surgery with understand only 80% good outcomes

• Patient Education
• Preform daily activities with palms up and arms close to the body
• Avoid
• Lifting objects with elbow extended and repetitive movement of the forearm
Medial Epicondylitis- Golfers Elbow
• Similar to tennis elbow and same approach

• R/o Cubital Tunnel syndrome

Case Presentation
• 13 year old pitcher
with elbow pain
• Can’t fully extend elbow
• Elbow “locks”
OCD Lesions
• Common in children (10-15 yo)
• Baseball
• Gymnast
• Softball
• Need referral when suspected
• My next step
• Order MRI to evaluate lesion
Elbow Arthritis

Occurs in manual laborers and

patients with previous trauma

Conversative management
•Injections
•NSAIDS
•Activity Modification
Distal Biceps
• Often a male in 50s felt a pop
while under eccentric load
(carrying a couch)
• Dx
• Hook Test- Hook the distal biceps
and compare to contralateral side
• MRI
• Treatment
• Needs referral ASAP to discuss
surgery vs non op
Wrist Pain
• Scaphoid Fx
• Ganglion cyst
• Tendinopathies
• Wrist Sprain
• Ulnar sided wrist pain
• Wrist Fractures
Case: Wrist pain Saturday after football game
Friday

Need Scaphoid
Oblique ->>
SCAPHOID Oblique

->
Scaphoid fractures
• Often occur with a fall on an outstretch hand
• Exam
• TTP over snuffbox and dorsal scaphoid

• Need high suspicion as 25% of fx are not visible on xray

• If Xrays are normal but concerned then cast/splint and refer
• MRI if x-rays are negative after 2wks and still concerned

• Scaphoid fracture don’t heal without immobilization

SL Tear
• Occur after an extension injury
• Xray may show Terry Thomas sign->

• Often is an old injury and asymptomatic or due to inflammatory

arthritis (gout/CPPD)
• In young individuals may lead to arthritis and therefore we treat these
more aggressive
Ganglion cyst

Non painful mass most often of the dorsal wrist

Treatment
•Reassurance and conservative treatment (brace when painful)

Recurrence rate
•Surgery - 20% Trading a bump for a scar
•Aspiration - 60% (do not aspirate volar ganglion)
De Quervains tenosynovitis
• Often occurs in new mothers and patient who
perform repetitive wrist motions
• Exam
• TTP and swelling over the radial side of the wrist
• Finkelstein test
• Mgmt
• Patient education/Steroid injection – 65% success
rate
• Splints- Not a fan of because can apply additional
pressure to tendon
Hand Pain
• Amputation
• Fight bite
• Finger Onchomycosis
• Trigger finger
• Melanonychia
• Jammed Finger
• Dupuytrens
• Mallet finger
• Zebras…..
 We used to perform a lot fancy flaps
but literature has shown healing by
Finger Tip Amputation secondary intention provides the best
outcomes ( sensation/length)
2 wks

5 Wks 8 wks 12 wks

Fight Bite
• Clinically underwhelming but often are
intra-articular injuries and commonly
become infected

• Often needs a debridement in the OR

Finger Onychomycosis

• Multiple antifungal treatment options -> not great results

• Best success if nail plate removal + Topical + Oral ~70% effective

Melanonychia
• Benign steak in the nail bed
• Malignant subungual melanoma
• Streaks larger than 6mm wide
• Bands are wider proximally
• Need biopsy if concerned
Trigger finger

Most commonly seen in ring finger and thumb

Caused by swelling in the tendon when trying to
through the pulley
Treatment
•Injections 60% cure rate with single injection
• Less effective in diabetics
• I will offer patients 2-3 injections before surgery
Jammed Finger (PIP injury)
• Most commonly occurs during sport
• If no fracture or dislocation. Start motion
immediately (Buddy Tape). DO not splint
for more than few days. These injuries
become stiff
• The PIP joint may be swollen for months
Mallet finger

Injury to the extensor tendon to the tip of the finger

Most often seen in basketball player

Treatment
•Full time DIP Extension splint for 6 weeks
•Part time for another 4 weeks
Dupuytren’s Specturm
Dupuytren’s Dz

Painless contracture disease of the palm and fingers.

Will it get worse? 10% of nodules resolve, 20% will progress and 70% will stay the
same

When to refer?
•Table top test – when they can place there hand flat on a table

Options
•In office percutaneous needle release
•Xiaflex
•Surgery
Questions

Email:
schambers@raleighortho.com

Website:
RaleighWrist.com