When patients present with pain, weakness or numbness in fingers, wrists or elbows, providers need efficient paths to diagnosis and initiating care. This talk from orthopedic surgeon Gopal Lalchandani, MD, offers help with distinguishing everyday tendinopathies, arthritic conditions and nerve disorders. Learn simple exam-room tests for carpal tunnel syndrome; how trigger finger typically looks on exam; and conservative firstline treatments – from bracing to steroid injections – for tennis elbow, thumb arthritis and other problems frequently seen in primary care. Bonus: Tips on when to consider surgical referral.
Thank you. Thank you for, uh, um, for hosting this. So my name is Gal Walchandjani. I'm one of the UCSF hand and upper extremity docs and, um, uh, my goal for today, um, is to talk about some common hand and upper extremity conditions for sort of a general practitioner, uh, audience and general provider audience. I have no disclosures and um um um I want to thank uh Doctor uh Nicole Schroeder for uh uh uh these, uh, a number of these slides. So my goal today is to talk about a number of common causes of hand, wrist, and elbow pain. Starting off with uh carpal tunnel syndrome, then discussing, uh, trigger finger, uh, decorves tenosynovitis, uh, basal joint arthritis, and, uh, uh, lateral epicondylitis, cubital tunnel syndrome, and, and then, uh, repetitive strain injury if time allows. Starting off with carpal tunnel syndrome, and actually give me 2 seconds. Let me reset my slides here, sorry. Wonderful. OK. Um, I'm assuming we can see it. Yes, um, so carpal tunnel syndrome, thank you, is one of the most is the most common compressive neuropathy and is usually idiopathic. Um, it generally affects women more commonly than men, uh, in a 3 to 1 ratio, and, uh, it's usually due to extrinsic factors. And so, uh, uh, I think, unfortunately, the, uh, median nerve, which gives, uh, innervation to the radial 3 fingers, uh, um, goes through a naturally tight area, uh, below the transverse carpal ligament. And so either because the fascia or that, that layer is too tight or the nerve gets swollen, uh, uh, it can lead to robic compression on the median nerve. Um, however, sometimes or rarely it can, it can occur intrinsically due to, uh, a, a nerve-sheath tumor. Uh, but generally, uh, uh, compressive neuropathies affect about 10% of the, of the general population. This is an extremely common condition. Um, again, carpal tunnel syndrome is thought to be compression of the median nerve in the carpal tunnel, and, uh, irritation of the nerve usually presents as numbness and pain. The symptoms of carpal tunnel, uh, usually involve numbness and tingling or, or, uh, neurologic symptoms in the thumb index, uh, middle, and classically, it's the radial half or the thumb-sided half of the ring finger. It's usually worse at night. Uh, and the thought is that, uh, uh, when patients or people have their wrist flexed or bent, uh, that can also lead to symptoms such as while on the phone, when driving, uh, or if they're sleeping in a, uh, with their wrist in a flexed position. Um, many patients feel like they have, uh, uh, uh, or are worried that they have carpal tunnel syndrome. Um, but, uh, uh, in the setting of for a diffuse wrist pain. Uh, but usually, the classic symptoms are, uh, numbness and tingling, uh, and pain and burning, uh, usually in the radial three digits, uh, but sometimes also, uh, radiating to the wrist, uh, and the arm. In the later stages, it leads to weakness, uh, uh, especially in the thumb, uh, or clumsiness and dropping objects. Risk factors for carpal tunnel, uh, include obesity, uh, hypothyroidism, uh, diabetes, uh, pregnancy, uh, uh, renal, uh, disease, inflammatory arthritis, and acromegaly. Um, and then less commonly, uh, mucopolysaccharoidosis. As mentioned previously, uh, it does tend to affect women more than men and tends to affect, uh, us as we get older. Uh, and smoking, occupational exposures, and genetic predispositions are also implicated. Rarely, there can be mechanical causes such as tenosynovitis or in or inflammation around the tendons of the, uh, uh, uh, of the, uh, uh, uh, of the flexor tendons, uh, sometimes in the setting of an inflammatory arthritis, uh, cyst such as a ganglion cyst, uh, median artery, which is, uh, uh, uh, uh, uh, uh, anatomic variant where, uh, you, uh, you can have a median artery going through the carpal tunnel, abnormal muscles, uh, arthritis fractures, uh, acromegaly or tumors. Um, but as, as discussed previously, more commonly, it is, uh, idiopathic or unknown. Um, the pathophysiology is oftentimes multifactorial, and, uh, diabetes, uh, and microvascular disease that lead to peripheral neuropathy can be difficult to distinguish between Um, uh, a compressive neuropathy versus a peripheral neuropathy. Um, just to quickly summarize, um, Um, this, uh, uh, peripheral neuropathy is usually in a stocking and glove distribution and, uh, is oftentimes symmetric, progressive, and, uh, uh, doesn't obviously respond to a carpal tunnel injection. Whereas the carpal tunnel syndrome or a compressive neuropathy is usually in the distribution of the peripheral nerve, uh, it is unilateral, oftentimes, but can be bilateral. It's progressive and certainly would thought to be improved with the carpal tunnel injection. So what is the carpal tunnel? The carpal tunnel is, uh, uh, a, uh, anatomic, uh, uh, uh, area in the wrist, uh, uh, that is bordered by the carpal bones and, uh, has the, uh, uh, uh, transverse carpal ligament overlying it, which is the roof of the carpal tunnel that's pictured here. And there are 10 structures running through the carpal tunnel, uh, um, and the median nerve is sort of the, the nerve that is implicated in, uh, as to why patients feel symptoms, uh, uh, of carpal tunnel. And then otherwise, there are the flexor tendons that help, uh, flex the fingers that are also running through the carpal tunnel pictured here in white. And um uh as we discussed, the carpets or the uh uh or the wrist and the carpal bones form the radial and ulnar borders on the floor of the carpal tunnel. In terms of the anatomy, so the median nerve as pictured here, uh, you know, in textbooks, uh, innervates the, uh, as we discussed, the radial 3.5 digits, so the thumb, index, long, and half of the ring finger. Uh, and then also the dorsal or the backside of the, uh, hands of this, uh, similar digits. Right. And, uh, uh, this can be variable. Uh, patients, of course, don't always uh uh walk in saying that they have numbness in these 3.5 fingers. Uh, but generally, numbness on the radial side of the hand, uh, uh, worse at night, uh, uh, affecting, going into the digits, uh, uh, uh, better with bracing or injections concerning for carpal. Uh, that's sort of what the median nerve innervates from a sensory standpoint, and I think importantly, there is also a motor innervation provided by the median nerve. And so, um, the median nerve, after, you know, as it goes through the carpal tunnel, uh, has a recurrent motor branch that gives innervation to, uh, the thenar muscles, which are the muscles at the base of the thumb that, uh, uh, include the opponent's pollicis, the abductor pollicis brevis, and the flexor pollicis brevis. So why does, why does carpal tunnel happen? So the normal pressure of the carpal tunnel is, is, uh, uh, 2.5 millimeters of mercury, and a decrease in blood flow around the nerve and, uh, swelling can occur with pressures going up to 20 to 30 millimeters of mercury. There can be slowing in nerve conduction as to how fast the nerve is able to conduct when pressures exceed 3030 millimeters of mercury, and if the pressure continues, that can lead to a complete block or numbness uh uh of the median nerve. So what are some of the things that are implicated in the diagnosis of uh carpal tunnel syndrome? So first of all, on history, we discussed the sort of history of numbness in the radial three digits. Uh, and then there are certain provocative tests and uh uh muscle testing that can be helpful to confirm the diagnosis. So I think the primary classic sort of sign of a compressive neuropathy is the Chanel sign on exam, where the examiner taps the nerve or the inflamed nerve, and in this case, this is over the median nerve overlying uh or immediately proximal to the carpal tunnel. And this should classically reproduce uh the symptoms that the patient is feeling. The Um, Phle's test is when the examiner helps flex the patient's wrist, um, uh, and it can be remembered as phalan's or flexion. Uh, and, uh, uh, that flex position can lead to, uh, reproducing the patient's symptoms, uh, of numbness or tingling in their radial three digits, uh, after a certain period of, of, of holding the position. And then finally, the Durkin's test for the uh uh carpal compression test is where the examiner presses on or immediately proximal to the carpal tunnel, and this is, uh, thought to be the most specific and sensitive test and it can lead to numbness and tingling if within 30 seconds, uh, that would be considered a positive test. From a motor standpoint, the only muscles innervated by the median nerve are the thenar muscles. And so testing the thenar muscles for weakness, uh, which can be graded on a, you know, uh, a 1 to 5 scale, uh, as in for any muscle group, or atrophy if patients have an obvious sort of loss of muscle. you here, that would be highly concerning for uh carpal tunnel syndrome. And then, uh, sensory testing can be tested just by asking the patients if they feel normally on that side, but more concretely or more uh objectively with two-point discrimination as demonstrated here or a STEM Weinstein monofi test. Commonly, patients, uh, uh, uh, do obtain a, a nerve conduction test, so it is not necessary for the diag for confirming the diagnosis of carpal tunnel syndrome. And, uh, um, this is where a neurologist or a physical medicine and, uh, rehabilitation, uh, uh, uh, uh, uh, provider, uh, can uh, stimulate the median nerve and place sensors in the tip or around the muscles of the median nerve. And the motor latency of 4.5, uh, uh, um, milliseconds or, uh, greater than 1 millisecond opposite the other side or sensory latency as described here is diagnostic of, uh, uh. Carpal tunnel syndrome. And so I think most importantly, the diagnosis of carpal tunnel syndrome is founded on a clear history of specific symptoms, apparent signs, uh, uh, sensory and motor deficits, and then the reproducible pro uh uh provocative diagnostic test. And if needed, uh, if there is concern for an additional compressive neuropathy or if there is a diagnostic uncertainty, electrodiagnostic test or an ultrasound can help with confirmatory testing. Um, in terms of stages, carpal tunnel syndrome, when it's mild, it usually, uh, has a duration of less than one year. Um, it, uh, leads to intermittent numbness, uh, normal sensory testing, um, no weakness or atrophy, and minimal changes on nerve conduction velocity testing. With no denervation. Moderate carpal tunnel is characterized by continued numbness and paresthesias, and uh uh uh increased distal motor latency, and severe, uh, uh, carpal tunnel syndrome is characterized by progressive loss of sensory and motor function and thenar atrophy where patients show up with loss of bulk or, or, or, or, uh, of their thenar musculature. In terms of treatments for carpal tunnel syndrome, um, there are generally 3, evidence-based, uh, treatments for carpal tunnel syndrome. So, uh, number 1, you know, certainly for mild cases without weakness, uh, non-surgical treatment is the appropriate first step. With nighttime splinting, uh, as the most accepted first step for, uh, uh, uh, uh, first diagnosis and treatment of carpal tunnel, for first-line treatment of carpal tunnel syndrome. The thought is that a, a wrist brace that keeps the wrist in neutral can help avoid patients uh uh flexing or extending their wrist, and it keeps the, uh, er the, the area of the carpal tunnel syndrome of the carpal tunnel at its widest to help avoid symptoms. Occupational therapy can be helpful, uh, uh, for nerve gliding exercises and also to create a custom sort of wrist brace in patients who, uh, may, uh, not, uh, be able to find an ideal fit with the, uh, off the shelf wrist brace. And, uh, corticosteroid injection is also an evidence-based, uh, treatment that can help both diagnostically and therapeutically with carpal tunnel syndrome. So, um Uh, um, in terms of therapy and bracing, uh, the patient education of avoiding, uh, activities where they have their wrist flexed or extended where they can, uh, decrease the circus surface area of the carpal tunnel can be helpful. A cock-up wrist brace to help bend the wrist and hold the wrist in neutral can be helpful, especially at night. And, uh, activity modification for patients who are typing or writing or driving, avoiding, uh, prolonged periods of wrist flexion or adjusting their ergonomic, uh, uh, uh, setup can be helpful to avoid provoking their symptoms. In terms of injections, injections, uh, uh, uh, uh, there, there is good evidence to support that injections can be helpful for treatment of carpal tunnel syndrome. The picture here shows, uh, um, uh, the loca the standard location of injection for, uh, uh, uh, uh, for carpal tunnel syndrome. Usually, uh, uh, this involves, uh, some sort of steroid, oftentimes Kenalog 40 and, uh, uh, and, uh, lidocaine to help with the pain. Um, is injected immediately ulnar to the palmaris tendon, which is marked here in white, which is the central wrist tendon, and, uh, the other white structure here is the SVU tendon to which we, uh, the, uh, uh, injector is placing the needle radial tube and directly proximal to the wrist for you. The benefit of injections is that, uh, in patients who may not be surgical candidates, uh, or inpatients for whom the diagnosis of carpal tunnel is uncertain, this can be helpful from both the therapeutic standpoint in terms of helping patients symptoms and also confirming their, uh, uh diagnosis and that if they have relief of their symptoms with the carpal tunnel injection, even if it's temporary, that can increase the certainty that, uh, further carpal tunnel surgery may be helpful if their symptoms return. The problem is, is that at 1-year follow-up after an injection, uh, there's only about a 50% uh uh rate of inject of patients being persistently symptom-free. And the risk of an injection is that, uh, certainly, uh, if there's any disruption to the skin, that can lead to infection, especially in the setting of steroid use, uh, or there can be iatrogenic injury to the median nerve during injection. And for this reason, uh, uh, the general teaching is to ask patients while injecting if they're feeling severe nerve pain, in which case, the examiner or the injector should withdraw the needle and try to avoid intramural, uh, uh, injection. Surgically, um, There is, uh, a carpal tunnel release is one of the most common hand surgeries that are performed. And the indications for carpal tunnel release, I think, are, are, are sort of, there's sort of two categories. Acutely, if patients have an acute trauma, uh, such as a, a, a distal radius fracture, or if they have uh an infection that is leading to progressive, rapidly progressive neurologic symptoms that correspond to the median nerve distribution, then carpal tunnel release is, is appropriate. And then, um, Uh, chronically, in patients who have chronic carpal tunnel syndrome, if they have weakness in their thenar muscles, if they have persistent numbness, uh, with, uh, uh, uh, uh, a severe carpal tunnel, or particularly if they've tried bracing, maybe tried an injection, and their symptoms are unresponsive, then patients can elect to proceed with carpal tunnel release. What does carpal tunnel release entail? So, um, uh, um. The, it generally involves releasing the carpal, uh, the transverse carpal ligament, which is the tight structure overlying the, uh, carpal tunnel. And, uh, uh, this can, uh, uh, routinely be done under local anesthesia. For a mini open carpal tunnel release as depicted here, uh, sutures can be removed at uh 1 to 2 weeks. And, uh, uh, this picture here shows the standard incision for an open carpal tunnel release and, uh, uh, below the, uh, uh, after releasing the transverse carpal ligament, which is, uh, highlighted here in the green asterisk, you can see the median nerve marked in M, which is, uh, hyperemic consistent with chronic compression. Um, outcomes are, uh, uh, uh, um, uh, determined by, uh, um, are determined by the, the level of severe symptoms beforehand, if that makes sense. So if patients have weakness or atrophy of their APB, their abductor pulse brevis, uh, then the recovery of motor, uh, can, uh, motor sort of strength can be unpredictable. If patients also didn't have relief of a steroid injection or have a predisposing condition that is causing their symptoms, uh, that is uncontrolled, then that can also lead to a suboptimal outcome. But generally, patients, uh, uh, uh, do consistently have improvement, uh, and, and, and are generally satisfied with carpal tunnel release, uh, in the upwards of 90, 95% range. Um, and 100% of patients, uh, with more than 6 months of relief of injection, from injection and when they tend to have a long-term or durable success with carpal tunnel relief. Um, we'll take questions at the end, and so I'll continue on with talking about another, uh, um, uh, important and common hand surgical condition called trigger finger. The trigger finger is uh um uh characterized by locking, clicking, or snapping of the of the uh finger, and is oftentimes the work upon awaking awakening. Many patients describe that their finger is uh uh in a flex position and they have to use their other hand to forcibly and painfully straighten their finger, and many patients, if it involves their thumb, complain of difficulty bending or flexing their thumb actively, but still have normal passive motion. Um, on exam, um, the, uh, uh, uh, uh, classic exam is that the patient has active, uh, finger motion, but they have crepitus or locking at the A one pulley, and the finger may actually get stuck in, in, uh, flexion. And so generally, gentle pressure over the A one pulley, which is at the level of the, uh, uh, MCP or the metacarpal, uh, uh uh uh phalangeal joint, uh, can reproduce the patient's symptoms. They can also have mild swelling, um, but the finger is not usually severely swollen. And if there's significant swelling or discoloration, then another diagnosis such as infection should be considered. And so, um, uh, as we discussed, the the patients generally have, uh, uh, uh, uh, present with their finger getting stuck or locked in a, uh, flex position. And, uh, that's because the flexor tendon is getting stuck under the A one pulley, which reflects the, which is also called the annular one pulley. And so what is this pulley? So this is a picture of the anatomy of the flexor-puley uh tendon system. This is sort of a view of the anterior side of it, and this is a lateral view of the pulley system. Here we have the two flexor tendons that are going through the pulley system of the finger with the metacarpal, proximal phalanx, middle phalanx, and distal phalanx characterized here. And um the thought is that this pulley system exists to help hold the flexor tendons, the FDP flexorated torum profundus, and FDS flexor torum superficialis down to the finger to allow uh getting the maximum force out of uh uh flexing uh at the uh muscles proximally and also to hold the, the tendons down to the finger or down the bone. If the pulley doesn't exist, then the fingers would take the shortest route between their origin and, and insertion, and they would, uh, bow string. However, uh, the, uh, tendon can sometimes either be swollen or have a, a nodule, uh, or the pulley can be too tight, uh, primarily at the A one pulley, and that can lead to this painful clicking or locking sensation. So if there can be nodular or inflammatory enlargement of the flexor tends in the sheath and uh attempted gliding of the uh tendon through the A one pulley is impeded. And, uh, uh, sometimes the finger can be locked in flexion and the patient can feel that when they, uh, extend their finger, they feel a palpable clump. Um, The thought is that this is due to fibrocardus metaplasia of the A1 pulley, but it's unclear if it's the tendon or the tendon sheath that is the initial driving factor of this process. Um. And in terms of treatment options, um, there are certainly non-operative options which, uh, uh, are appropriate for early trigger finger, and then operative release is, as always indicated of the failure of non-surgical measures. So non-operatively, one can consider observation, uh, anti-inflammatory medications, uh, splinting to help hold the finger in an extended position and avoid getting flexed, and, uh, steroid injection. So this is an example. There are multiple different types of trigger finger braces that exist and the goal is to prevent the MCP or PIP, the proximal phal joint, from, uh, going into flexion. Patient education and symptom management can be helpful, and icing can be helpful to help decrease inflammation. Uh, splinting in either site or even extension has been described. And, um, uh, anti-inflammatories are also often used for patients with a lot of sort of painful symptoms. But the thought, but most studies suggest that injection is more effective than splints for this problem. So while there are a number, number of studies on the topic, um, and the numbers of, uh, the rates of effectiveness can vary based on the study quoted, uh, about 60 to 70% of patients can resolve after a single injection. So there is a lower rate in patients with diabetes. Patients with, uh, who are younger, uh, who may have a longer sort of, uh, time to fail, uh, multiple fingers where, uh, um, uh, there is a good chance that any one finger doesn't resolve with the injection and, uh, uh, up for other, uh, concomitant tendinopathies. And uh it is debated, but some, some studies suggest that it is most effective if symptoms are uh have been onset for less than 6 to 12 months. How are injections done. So, um, generally, this involves the injection of a steroid medication and a, uh, a local anesthetic, and it's done at or around the area of the A one pulley as de pictured, as pictured here, uh, and ideally right over the A one pulley, which is right here where my arrow is. Um, and, uh, the thought is that the local anti-inflammatory effect of the steroid injection can help decrease inflammation and lead to Certainly, there are risks with an injection, uh, including infection, fat atrophy, atrophy, skin necrosis, uh, bleaching of the skin, and tendon rupture. And so, um, the, uh, a common sort of, uh, workflow is to Uh, uh, start off with non-surgical measures. So if patients have, uh, a failure after, you know, one or two, injections, then discussing surgical decompression of the flexor tendon sheath, uh, uh, uh, rather than continuing injections if there's not consistent improvement. In diabetics, it's important to counsel patients that there can be increases in, in blood glucose and the greatest effect in uh lasts for 24 hours after injection. Um, but the effect can last for up to 10 days. And here you have a picture of a, uh, uh, of, uh, an injection that's delivered into the, uh, tendon sheath, uh, at the level of the A1 pulley. And surgery, I discussed is indicating the setting of failure of non-surgical management, uh, and can be considered in diabetics as a first-line treatment, uh, uh, uh, uh, or in, uh, patients with a locked finger. Uh, I think that would probably be a better reason to, uh, jump to surgery if the patient has their finger stuck and is unable to move it as, uh, as, uh, if this continues for a long period of time, uh, that can lead to irrevocable stiffness. How is the trigger finger surgery done? Um, uh, this is done through a transverse, uh, uh, oblique or longitudinal incision, usually about 1 to 2 centimeters over the A1 pulley over the palm of the hand. And, um, there are digital arteries and Nerves, uh, to, uh, the digit on both sides of the flexor tendon sheath, and so those are carefully protected and the, uh, A1 foe, uh, which is the most common cause of triggering is, uh, uh, uh, can be released. And this can be done, um, routinely under a local only anesthesia so the patient doesn't have to, uh, uh, doesn't necessarily have to uh have any other, uh, systemic, uh, uh, anesthesia for this, uh, for treatment of this. Moving on to another type of tendonitis that decurving tenosynovitis is, uh, uh, uh, uh, a common tendinopathy of the upper extremity that involves the first dorsal compartment, which is the, uh, tendons that uh help extend and abduct the thumb on the dorsal side of the wrist. It generally involves pain of the thumb on the radial side of the wrist as discussed before, and it worse with lifting or repetitive activity. The classic for a patient who's affected by this problem is uh uh mothers of very young children. And another term for this is called uh mommy's thumb, uh, where the thought is that, uh, uh, repetitive, uh, lifting of the baby can lead to this, uh, problem. It's worse at night and, uh, worse with thumb motion. And as discussed previously, it involves the, uh, uh, the first dorsal compartment, uh, where the abductor pulse is longest and the extensor pulses brevis tendons, uh, uh, lie, and the sheath is either, uh, enclosing the tendons is either, uh, uh, narrowed or the tendons are inflamed, which can lead to this painful syndrome. Um, the, uh, uh, thought is that thickening of the sheath, uh, uh, uh, is, uh, associated with, uh, causing these symptoms as similar to the pulley being thickened and trigger finger. And this picture here demonstrates the relationship of the first dorsal compartment with the APL and EPB tendons pictured here to the radial sensory nerve, which is overlying the first dorsal compartment. And sometimes patients can also in the setting of inflammation in this area, complain of numbness or tingling in that, uh, in the dor in the dorsum of the first web space, um, uh, um, and this can be found in association. The symptoms are more common in women, uh, uh, in a 6 to 1 ratio, and as mentioned previously, often occurs in new mothers and in later stages of pregnancy with overuse of the thumb. So there is a concern that there are some hormonal implications, especially in the thinning of, uh, uh, uh, onset of symptoms prior to the birth of the child. Um, usually involve pain at the base of the thumb on the radial wrist, and patients sometimes complain of clunking or clicking of the thumb. The most common, uh, uh, sort of diagnostic test that is, uh, uh, uh, uh, that is referenced for this pathology is, uh, uh, the Finkelstein's test where, um, the patient is instructed to put their thumb in their fist, put their fingers over, over the top of it, and then the examiner moves the fist ulnarly, which usually reproduces a sharp pain in the, uh, uh, radial side of the wrist. Uh, um, and well this is, uh, likely actually a better term than ICO test, uh, commonly people refer to as the fecal test. Um, and patients often also, uh, uh, uh, refer, uh, complain of tenderness at the, at the thumb side of the wrist or the radial side of the wrist. Uh, similar to our other, uh, uh, uh, tendinopathies, treatment can involve, uh, conservative management or, uh, uh, surgical treatment. Uh, conservative management, it consists of, uh, bracing. Uh, uh, thumbs like a brace or something that holds the thumb, uh, uh, or a custom-made splint is a reasonable first step, icing activity modification, of course, patient education on avoiding these, uh, uh, triggers. Um, and, uh, injections are also quite effective just as in the treatment of trigger finger. Um, the risk of the injection should be considered, and in this part of the body, patients can have thinning of skin. And so generally, there's a limit to the number of injections that it's tried, uh, uh, usually 2 to 3, uh, because injections in the subcutaneous location can lead to skin bleaching, fat necrosis, skin thinning, uh, subcutaneous tissue atrophy, and, uh, uh, uh, um, sometimes there can be Uh, flare reaction after a steroid, uh, injection. In diabetics, patients can have a short-term increase in blood glucose and, uh, the thought is that this injection is ideally done into the first dorsal compartment. Uh, surgical treatment is indicated only if patients do not have improvement, uh, uh, with, uh, conservative measures which include bracing and injections, just like for trigger finger. Um, the, uh, uh, this is usually done through a small, uh, 2 centimeter incision on the radial aspect of the wrist. And, um, after carefully sort of protecting the radial sensory nerve as described previously, the tunnel, uh, or the sheath over the tendons is opened, and then the tendons themselves, the APB and APL, uh, uh, sorry, APL and EPB tendons are identified, uh, uh, uh, and allowed to sort of move more freely outside of this sort of tight tunnel. Um The thought is that uh some patients can have a subcompartment, so that the first dorsal compartment that most people have, have smaller tunnels for each of these tendons or tendon slips. And those are the patients who may uh uh uh not improve with an injection where the medication is only delivered. To 11 compartment. Uh, and they may have incomplete, uh, improvement after surgery if that is not identified. Uh, and so generally, uh, uh, uh, you know, answers are careful to look for multiple separate subcompartments to ensure that there is complete relief of the, of, uh, the first dorsal compartment. Moving on to another sort of pathology affecting the radial or thumb side of the wrist is uh basal joint arthritis. And, uh, I'm sure many of the listeners have patients who complain of this, uh, uh, uh, which is arthritis or, uh, degeneration of the thumb, uh, uh, CMC joint, uh, on the, uh, radial side of the thumb. Um, so the history for this, uh, uh, problem are patients who have difficulty with pinching, writing, uh, opening a tight jar, uh, uh, carrying a shopping bag, or using a knife to cut food, and generally affects, uh, uh, elderly patients, uh, uh, from sort of years of, you know, youth of the thumb. On exam, uh, early on, patients can have some swelling over the CMC, uh, uh, over, for that joint of the thumb. And later findings is the patient has, uh, a tightness in this area and they have an abducted first web space and then they then, uh, uh, extend, hyperextended their MCP joint, their metacarpophalangeal joint to compensate for a stiff CMC joint. Patients are usually tender right over that area, right over the thumb CMC joint, and uh uh over the dorsal capsule in that area. As we discussed, the appearance of it is classic with pain and a tightened for subspace and, uh, uh, um, and a prominence in the area and then tenderness over the, uh, uh, CMC joint of the thumb. The grind test is when pain is reproduced when the first metacarpal is loaded and it causes pain at the CMC joint. And, uh, treatment options, uh, similar to the prior, uh, uh, uh, pathologies discussed always starts with non-surgical measures. Including uh use of a brace. Uh, the thought is that anything that immobilizes the thumb can be helpful, uh, such as, uh, uh, the thumb is like a brace, but generally, this is an activity-related pain. And so patients oftentimes are looking for a smaller brace that allows them to, uh, use the thumb, uh, and avoid symptoms. Um, anti-inflammatories can also be helpful, and there are studies that suggest that, uh, both oral and even topical anti-inflammatories such as, uh, topical diclofenac can be helpful to decrease symptoms in this area. Injections are also reasonable for uh early uh CMC arthritis and uh can be done uh uh under landmark guidance uh at the base of the first metacarpal, uh, uh, next to the EPB tendon and with traction, pulling on the thumb as this is a small and it can be difficult to deliver medication in the area. Here's another picture describing that uh the basal joint can be found between the MCP joint and the radial styloid, about 2/3 of the distance between the two. Um, in terms of surgical treatment options, uh, uh, uh, the main, uh, plastic treatment for this problem in the setting of failure of non-surgical, of non-surgical measures is, uh, uh, a, uh, um, uh, LRTI or an APL suspension plasty. There are many studies on this topic, but the main consensus is that removing the trapezium, uh, or taking out this, uh, sort of arthritic bone can lead to improvement in patients' pain. Uh, and many surgeons have concerns that removing the bone alone can lead to, uh, uh, can lead to subsidence of the first metacarpal. And so there are multiple, uh, um, Uh, uh, techniques that are described including using the APL tendon to suspend the thumb or using, uh, uh, the SCR tendon to, uh, reconstruct the, uh, ligaments for the thumb and then, uh, place, be placed inside the gap leave left by taking out the trapezium to, uh, uh, uh, uh, uh, avoid the thumb or the first ray from settling into the hole remove, uh, from removing of the trapezium. Uh, there is early evidence to suggest that denervation or, uh, targeting, uh, the, uh, small muscle, sorry, uh, uh, nerve branches that give uh feeling to the, uh, thumb joint can be helpful, but the long-term results of the innervation are unclear. The, um, one of the sort of final pathologies I wanted to discuss that I think is relevant to all sort of practitioners is lateral epicondylitis, which is also known as tennis elbow. Tennis elbow is one of the most common overuse syndromes encountered in the upper extremity, and is, um, uh, was initially described by Morris in 1882 and thought to be caused by lawn tennis. And what this is, is tendonitis at the extensor organ and it's extremely common affecting males and females equally and uh uh usually affecting patients. Between the age of 35 and 50. And it is not always associated with tennis, though it can be certainly, um, but can also be associated with patients who are manual laborers, who, uh, perform repetitive activities, uh, uh, who have a dominant arm or have, uh, a con uh concomitant or comorbid depression or promote coping mechanisms. It's generally characterized by pain at the lateral aspect of the elbow, located at the lateral epicondyle, which is sort of the bump on the lateral side of the elbow or just distal to it. Um, it generally involves radiating pain along the course of the wrist extensors, and the thought is, is that the thing, the wrist sensors that straighten your wrist, they originate on the lateral epicondyle and, uh, pain, inflammation, or, uh, uh, tendonitis, tendonitis of that area that can lead to symptoms of location. It's usually characterized by uh night pain, um, and is, uh, uh, uh, uh, patients oftentimes describe stiffness upon awakening and pain with even light daily activities. As, as discussed previously, the origin of the wristic sensors is on the uh lateral epicondyle where the ECRB, EDC, and ADQ all, uh, start, uh, and the lateral ulnar collateral ligament of the elbow is also in that location. And the thought is that lateral epicondylitis starts as a microgrowth here, um, and always involves the uh ECRB which has, uh, uh, deeper, uh, uh, fibers that are more secure or comfortable. There is generally a histologically demonstrated tendinosis with disordered collagen, mucoid degeneration, and, uh, angiofibroblastic hyperplasia, and patients often have point tenderness just as described, just at or distal to the lateral epicondyle marked with this uh bump. And, uh, uh, the examiner can look for tenderness in the radial tunnel, uh, uh, which can be, uh, omic pathology. Um, patients also report pain with resistor wrist extension, uh, and also pain with, uh, resistant long finger extension. Uh, treatments include, uh, activity modification, limiting lifting when patients are symptomatic, uh, avoiding, uh, uh, uh, uh, vibrational pools, uh, lifting with the elbow flex, uh, uh, uh, uh, uh, but it doesn't, you know, can be, can, can continue as is, but the main thought is that, uh, repetitive wrist motion can lead to worsening symptoms. Uh, and then changing equipment, especially if it's in the setting of tennis, uh, changing the grip size or restraining racket is helpful. The treatment for tennis elbow, uh, is, is generally non-surgical. Um, and I think this is, uh, this can be very challenging for patients to accept if they're really struggling with this, uh, in the long term. A wrist brace can be helpful for us to immobilize the wrist extensors, and stretching and, uh, soft tissue massage and patient education can be helpful. And then, uh, uh, physical therapy is the mainstay of treatment. So the inertial exercises focus on increasing strength, flexibility, and endurance, and stretching of the wrist extensors, uh, with the elbow extended can help lead to stretching and improvement in symptoms in this area. Um, and then, uh, um, uh, working on, uh, starting with eccentric strengthening exercises and, and progressing to isometric and concentric strengthening can be helpful in physical therapy. Um, physical therapy can also work on massage, uh, uh, anti-inflammatories, ultrasoundonophoresis, and then anti-inflammatories with oral and topical, uh, can be helpful for this problem. Um, there are other braces that are described that are a little less effective, uh, than a wrist brace, including a counterforce brace, which theoretically creates a more distal muscle origin and a cock-up wrist brace that decreases the, uh, uh, uh, use of the wrist extensors. And, uh, uh, the challenge is that surgical or, uh, options or interventions have generally unreliable, uh, benefits. So, uh, uh, steroid injections, uh, uh, can temporarily improve symptoms but have been associated with a longer course of symptoms. Uh, the, uh, data around, uh, platelet rich plasma and surgery is unclear and as such, uh, uh, non-surgical management is the mainstay of treatment. Surgically, for patients with symptoms that are refractory to a, you know, sometimes a year of symptoms, One can consider this knowing that the outcomes are, uh, uh, uh, unreliable, uh, where, where, uh, it's been described that you can identify the ECRB, uh, uh, the riskistic center, you know, inflamed tissues and remove the diseased tissues. Uh, but again, I personally, generally, uh, you know, based on the data, uh, uh, encourage patients to consider non-surgical measures and avoid intervention for this problem. Um, I'll briefly review cubital tunnel cause, uh, I think that's the sort of the final extremely common compressive neuropathy that, that, uh, affects the upper extremity, and then, uh, I do wanna leave time to discuss questions. The cubital tunnel is, uh, uh, uh, ulnar nerve compression at the elbow. Uh, and, uh, uh, uh, unlike carpal tunnel syndrome, the, uh, cubital tunnel affects, uh, the ulnar nerve, which is characterized by numbness and tingling or similar symptoms in the small and ring finger, weakness of the intrinsics of the hand, and, uh, um, and diminished sensation over the dorsum of the hand. The thought is that this is due to a similar problem where the nerve is running through a naturally tight area in the cubital tunnel, uh, posterior to the medial epicondyle. And, uh, uh, edema in the nerve, uh, can lead to, uh, uh, uh, inflammation and pain and symptoms rating in the small finger. It can be associated with the sitting of arthritis of the elbow instability, uh, or if the nerve, uh, uh, with motion is subluxing or moving over the medial epicondyle, that can lead to symptoms. Patients often are tender in that area, but also, as discussed previously, have a positive nels or tapping over the ulnar nerve leads to, uh, reproducing symptoms. Uh, the flexion compression test for patients, um, have, uh, pressure is applied and the elbow is flexed is, is, uh, another, uh, reliable way to reproduce symptoms of, uh, cubital tunnel syndrome. The ulnar nerve gives uh a motor strength to the intrinsics of the hand and so testing the intrinsics is important in evaluating cubital tunnel syndrome. And, uh, uh, this is a picture demonstrating intrinsic atrophy where the patient has loss of muscle of their, uh, uh, intrinsic, uh, of their hand due to chronic cubital tunnel syndrome. Um, the, uh, there are a number of signs associated with cubital tunnel syndrome, including Wartenberg sign where the nerve, where the small finger is held in abduction, uh, as depicted here, uh, Vermont sign where the patient uses, uh, bends their thumb for key pinch rather than, uh, uh, using their intrinsics, and then, uh, uh, um, uh, loss of the metacarpal arch and con convexity of the ulnar side of the hand due to loss of the hypophars, another sign of atrophy. Uh, the treatments, I think, are unfortunately twofold. Uh, uh, one is, uh, uh, keeping the elbow straight at night or nighttime bracing. And this can be done either with a formal brace or with a, a, a night towel, but to keep the elbow in a straighter position since elbow flexion generally reproduces symptoms, and patient education to avoid, uh, uh, putting their, uh, elbow in a prolonged flex position which can lead to worsening symptoms. And surgically, for patients who have failed non-surgical measures or for patients who have severe atrophy, uh, uh, in-situ decompression or transposition of the nerve may be indicated. I'll leave things uh uh there so we have time for questions. Thank you.
