Common Extremity Injuries

8/8/2019 Common Extremity Injuries

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Acromioclavicluar SeparationAcromioclavicluar Separation

Acromioclavicular (AC) joint is a diarthrodialarticulation with interposed fibrocartilaginousmeniscal disk that links the hyaline cartilage

articular surfaces of the acromial process and theclavicle

Joint is stabilized by a combination of dynamicmuscular and static ligamentous structures, whichallow a normal anatomic range of motion Because of the transverse orientation of the articulation,

direct downward forces may result in shear stressesthat cause disruption of stabilizing structures and createdisplacement beyond normal limits

Acromioclavicular (AC) joint is a diarthrodialarticulation with interposed fibrocartilaginousmeniscal disk that links the hyaline cartilage

articular surfaces of the acromial process and theclavicle

Joint is stabilized by a combination of dynamicmuscular and static ligamentous structures, whichallow a normal anatomic range of motion Because of the transverse orientation of the articulation,

direct downward forces may result in shear stressesthat cause disruption of stabilizing structures and createdisplacement beyond normal limits


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Severity of an AC separation is dependent

upon the degree of ligamentous injury

Capsular AC ligaments and extracapsularcoracoclavicular (CC) ligament are the

primary static stabilizers of the AC joint

Anterior and posterior AC ligaments are

predominantly responsible for maintainingstability in AP plane

Severity of an AC separation is dependent

upon the degree of ligamentous injury

Capsular AC ligaments and extracapsularcoracoclavicular (CC) ligament are the

primary static stabilizers of the AC joint

Anterior and posterior AC ligaments are

predominantly responsible for maintainingstability in AP plane


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Two components of CC ligament, trapezoid and

conoid ligaments, provide restraint against

compression and superior-inferior translation,

respectively Deltoid and trapezius muscles are especially

important in providing dynamic stabilization

when these ligamentous structures are

damaged

Two components of CC ligament, trapezoid and

conoid ligaments, provide restraint against

compression and superior-inferior translation,

respectively Deltoid and trapezius muscles are especially

important in providing dynamic stabilization

when these ligamentous structures are

damaged


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AnatomyAnatomy


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AnatomyAnatomy


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EpidemiologyEpidemiology

AC joint injuries are seen especially in

competitive athletes, such as rugby or

hockey players, and occur most frequently

in the second decade of life1

Males are more commonly affected than

females, with a male-to-female ratio of

approximately 5:11

AC joint injuries are seen especially in

competitive athletes, such as rugby or

hockey players, and occur most frequently

in the second decade of life1

Males are more commonly affected than

females, with a male-to-female ratio of

approximately 5:11


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Etiology/MOIEtiology/MOI

M/C MOI is a direct force applied to the

superior aspect of the acromion, usually

from a fall with the arm in an adducted

position

This impact drives the acromion inferiorly,

spraining the intra-articular AC ligaments

If the force is great enough, the extra-articularCC ligament may also be damaged

M/C MOI is a direct force applied to the

superior aspect of the acromion, usually

from a fall with the arm in an adducted

position

This impact drives the acromion inferiorly,

spraining the intra-articular AC ligaments

If the force is great enough, the extra-articularCC ligament may also be damaged


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Less commonly, an indirect force may be

transmitted up the arm as a result of a fall

on an outstretched hand

Force continues through the humeral head to

acromial process, displacing it superiorly and

stressing AC ligaments

Coracoacromial (CA) ligaments are not injuredwith this type of mechanism

Less commonly, an indirect force may be

transmitted up the arm as a result of a fall

on an outstretched hand

Force continues through the humeral head to

acromial process, displacing it superiorly and

stressing AC ligaments

Coracoacromial (CA) ligaments are not injuredwith this type of mechanism

AC Separation


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ClassificationClassification

Type I injuries involve sprained, but intact

CC and AC ligaments

Type II injuries involve a complete disruptionof AC ligaments with a sprained, but intact

CC ligament

In the more severe type III injury, both the

CC and AC structures are disrupted

Type I injuries involve sprained, but intact

CC and AC ligaments

Type II injuries involve a complete disruptionof AC ligaments with a sprained, but intact

CC ligament

In the more severe type III injury, both the

CC and AC structures are disrupted


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Type IV injuries are defined by posteriordisplacement of the clavicle relative toacromion with buttonholing through

trapezius muscle In type V injuries, clavicle is widely

displaced superiorly relative to acromion asa result of disruption of muscle attachments

Rare type VI injuries are characterized byinferior displacement of the distal claviclebelow acromial process or coracoid process

Type IV injuries are defined by posteriordisplacement of the clavicle relative toacromion with buttonholing through

trapezius muscle In type V injuries, clavicle is widely

displaced superiorly relative to acromion asa result of disruption of muscle attachments

Rare type VI injuries are characterized byinferior displacement of the distal claviclebelow acromial process or coracoid process


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Trapezius


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Clinical PresentationClinical Presentation

Patients typically present with pain and restricted

shoulder motion after a fall

Visual inspection of patient may also provide a

significant key to diagnosis Prominent clavicle with loss of normal contour of

shoulder caused by sagging of acromion is highly

suggestive of a ligamentous disruption of the AC joint

Findings may be clearer when patient is asked to hold a10-15 pound weight in hand of affected arm

Patients typically present with pain and restricted

shoulder motion after a fall

Visual inspection of patient may also provide a

significant key to diagnosis Prominent clavicle with loss of normal contour of

shoulder caused by sagging of acromion is highly

suggestive of a ligamentous disruption of the AC joint

Findings may be clearer when patient is asked to hold a10-15 pound weight in hand of affected arm


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Functional TestingFunctional Testing

Evaluate neurovascular status and r/o

possible clavicular fracture

Pain during passive abduction from 90 to180

Pain on passive horizontal adduction

Resisted tests negative in chronic AC

problem

Positive OBriens test

Evaluate neurovascular status and r/o

possible clavicular fracture

Pain during passive abduction from 90 to180

Pain on passive horizontal adduction

Resisted tests negative in chronic AC

problem

Positive OBriens test


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OBriens TestOBriens Test


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ImagingImaging

Type V separation,characterized bywide displacement ofthe clavicle in asuperior direction

relative to theacromion

Findings denotedisruption of the AC

ligaments andcoracoclavicular (CC)ligament, as well asdeltoid attachment todistal clavicle

Type V separation,characterized bywide displacement ofthe clavicle in asuperior direction

relative to theacromion

Findings denotedisruption of the AC

ligaments andcoracoclavicular (CC)ligament, as well asdeltoid attachment todistal clavicle


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Management1Management1

Type I and Type II injuries are treated

conservatively, whereas most type III

respond to conservative care unless

significantly symptomatic several months

after injury

Challenge is to be sure that diagnosed type II is

not an misdiagnosed type IV to VI, whichrequire surgery

Type I and Type II injuries are treated

conservatively, whereas most type III

respond to conservative care unless

significantly symptomatic several months

after injury

Challenge is to be sure that diagnosed type II is

not an misdiagnosed type IV to VI, whichrequire surgery


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Type I

Rest, ice, and immobilization if it relieves pain

Light friction massage over AC ligament

Symptoms resolve within 7-10 days

ROM to pain-free range

Strengthen shoulder, especially trapezius and

deltoid muscles Use sling until pain subsides

Type I

Rest, ice, and immobilization if it relieves pain

Light friction massage over AC ligament

Symptoms resolve within 7-10 days



deltoid muscles Use sling until pain subsides


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Type II

Treated symptomatically, but taping, bracing, or

a Kenny-Howard sling for 1-2 weeks for up to 8

weeks



deltoid muscles

Type II

Treated symptomatically, but taping, bracing, or

a Kenny-Howard sling for 1-2 weeks for up to 8

weeks



deltoid muscles


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Type III

Definite support, such as Kenny-Howard sling

Perform early ROM tests as pain

Vigorous strengthening program

Type III

Definite support, such as Kenny-Howard sling

Perform early ROM tests as pain

Vigorous strengthening program


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Kenny-Howard Sling (AC Sling)Kenny-Howard Sling (AC Sling)

http://www.tartanortho.com/AC62A2.html.pdf http://www.tartanortho.com/AC62A2.html.pdf


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Lateral EpicondylopathyLateral Epicondylopathy

Definition

Proposed that only in very early stages of

epicondylopathies is inflammation present

These tendon overuse problems are

degenerative b/c no inflammatory cells are

found

Proper term should be tendonosis

Definition

Proposed that only in very early stages of

epicondylopathies is inflammation present

These tendon overuse problems are

degenerative b/c no inflammatory cells are

found

Proper term should be tendonosis


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Epidemiology

Primarily b/w ages 35 and 50 years with median

age of 41 years, with a high activity level (sports

or occupational) three or more times per weekwith a 30-minute or greater session1

Epidemiology

Primarily b/w ages 35 and 50 years with median

age of 41 years, with a high activity level (sports

or occupational) three or more times per weekwith a 30-minute or greater session1


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Pathophysiology Many proposed etiologies for this condition have

involved inflammatory processes of the radial humeralbursa, synovium, periosteum, and the annular ligament

Mechanical stress on tendons attaching to condylesrelease substance P and peptides, indicating aneurogenic inflammatory origin1

Another proposed cause is microscopic tearing withformation of reparative tissue (ie, angiofibroblastichyperplasia) in the origin of the extensor carpi radialisbrevis (ECRB) muscle

Microtearing and repair response can lead to macroscopictearing and structural failure of the origin of the ECRB muscle

Pathophysiology Many proposed etiologies for this condition have

involved inflammatory processes of the radial humeralbursa, synovium, periosteum, and the annular ligament

Mechanical stress on tendons attaching to condylesrelease substance P and peptides, indicating aneurogenic inflammatory origin1

Another proposed cause is microscopic tearing withformation of reparative tissue (ie, angiofibroblastichyperplasia) in the origin of the extensor carpi radialisbrevis (ECRB) muscle

Microtearing and repair response can lead to macroscopictearing and structural failure of the origin of the ECRB muscle


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Anatomy

Most commonly involved tissue is the origin of

ECRB (100%), anterior edge extensor digitorum

communis (50% of time), and sometimesunderside of extensor carpi radialis longus

(ECRL)

Anatomy

Most commonly involved tissue is the origin of

ECRB (100%), anterior edge extensor digitorum

communis (50% of time), and sometimesunderside of extensor carpi radialis longus

(ECRL)


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Etiology

Any activity involving wrist extension, radial

deviation and/or supination can be associated

with overuse of the muscles originating at thelateral epicondyle

Tennis has been the activity most commonly

associated with the disorder, but might also

include plumbers and meat-cutters

Etiology

Any activity involving wrist extension, radial

deviation and/or supination can be associated

with overuse of the muscles originating at thelateral epicondyle

Tennis has been the activity most commonly

associated with the disorder, but might also

include plumbers and meat-cutters


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Clinical Presentation

Patients present complaining of lateral elbowand forearm pain exacerbated by use

Most tender area is usually on anterior/inferiorportion of lateral epicondyle or slightly distal

Often tenderness on palpation in several areasincluding ECRB, ECRB or extensor digitorum

Onset can be either acute or insidious Tenderness tends to improve with rest and

worsen with movements, especially wristextension

Clinical Presentation

Patients present complaining of lateral elbowand forearm pain exacerbated by use

Most tender area is usually on anterior/inferiorportion of lateral epicondyle or slightly distal

Often tenderness on palpation in several areasincluding ECRB, ECRB or extensor digitorum

Onset can be either acute or insidious Tenderness tends to improve with rest and

worsen with movements, especially wristextension


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Diagnosis

Definite painful resisted wrist extension with elbow

extended

Pressure can be added with extended forearm pronated May be pain and limited wrist flexion when stretching a

full flexed wrist with an extended elbow and pronated

forearm

May be loss of passive wrist flexion associated with chronic

condition due to fibrosis

May be pain on resisted finger extension, which usually

creates pain in the forearm mid-extensor area

Diagnosis

Definite painful resisted wrist extension with elbow

extended

Pressure can be added with extended forearm pronated May be pain and limited wrist flexion when stretching a

full flexed wrist with an extended elbow and pronated

forearm

May be loss of passive wrist flexion associated with chronic

condition due to fibrosis

May be pain on resisted finger extension, which usually

creates pain in the forearm mid-extensor area


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Imaging

Radiographs can be helpful in ruling out other disorders

or concomitant intra-articular pathology (i.e.,

osteochondral loose-body, posterior osteophytes) Calcification in the degenerative tissue of the ECRB muscleorigin can be seen in chronic cases

Magnetic resonance imaging can help confirm the

presence of degenerative tissue in the ECRB muscle

origin and can help diagnose concomitant pathology;however, it is very rarely needed

Imaging

Radiographs can be helpful in ruling out other disorders

or concomitant intra-articular pathology (i.e.,

osteochondral loose-body, posterior osteophytes) Calcification in the degenerative tissue of the ECRB muscleorigin can be seen in chronic cases

Magnetic resonance imaging can help confirm the

presence of degenerative tissue in the ECRB muscle

origin and can help diagnose concomitant pathology;however, it is very rarely needed


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Management

Initial goals of pain and inflammation and

strength

Light manual methods such as friction

massage, active release, joint mobilisation,

and Graston technique

Stretching elbow flexion/extension, wristflexion/extension, forearm supination/pronation

for 30 seconds, five repetitions, three times

daily

Management

Initial goals of pain and inflammation and

strength

Light manual methods such as friction

massage, active release, joint mobilisation,

and Graston technique

Stretching elbow flexion/extension, wristflexion/extension, forearm supination/pronation

for 30 seconds, five repetitions, three times

daily


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Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Carpal tunnel

syndrome (CTS) is a

collection of

characteristic

symptoms and signs

that occurs following

entrapment of the

median nerve within

the carpal tunnel

Carpal tunnel

syndrome (CTS) is a

collection of

characteristic

symptoms and signs

that occurs following

entrapment of the

median nerve within

the carpal tunnel


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Incidence is 1-3 cases per1000 subjects per year3

Prevalence isapproximately 50 cases

per 1000 subjects in thegeneral population3

Incidence may rise as highas 150 cases per 1000subjects per year, with

prevalence rates greaterthan 500 cases per 1000subjects in certain high-risk groups3

Incidence is 1-3 cases per1000 subjects per year3

Prevalence isapproximately 50 cases

per 1000 subjects in thegeneral population3

Incidence may rise as highas 150 cases per 1000subjects per year, with

prevalence rates greaterthan 500 cases per 1000subjects in certain high-risk groups3


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Epidemiology

Female-to-male ratio is 3-10:13

Peak age of development of CTS is from 45-60

years3

Only 10% of CTS patients are younger than 31 years

Epidemiology

Female-to-male ratio is 3-10:13

Peak age of development of CTS is from 45-60

years3

Only 10% of CTS patients are younger than 31 years


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Tendons of the following muscles (not the musclesthemselves): Flexor digitorum profundus

Flexor digitorum superficialis

Flexor pollicis longus

Some sources also include the flexor carpi radialis, butit is more precise to state that it travels in the flexorretinaculum which covers the carpal tunnel, rather than

running in the tunnel itself Nerves:

Median nerve b/w tendons of flexor digitorum profundusand flexor digitorum superficialis

Tendons of the following muscles (not the musclesthemselves): Flexor digitorum profundus

Flexor digitorum superficialis

Flexor pollicis longus

Some sources also include the flexor carpi radialis, butit is more precise to state that it travels in the flexorretinaculum which covers the carpal tunnel, rather than

running in the tunnel itself Nerves:

Median nerve b/w tendons of flexor digitorum profundusand flexor digitorum superficialis


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Pathophysiology

Median nerve is damaged within the rigid

confines of the carpal tunnel, initially undergoing

demyelination followed by axonal degeneration

Sensory fibers often are affected first, followed

by motor fibers

Autonomic nerve fibers carried in the mediannerve also may be affected.

Pathophysiology

Median nerve is damaged within the rigid

confines of the carpal tunnel, initially undergoing

demyelination followed by axonal degeneration

Sensory fibers often are affected first, followed

by motor fibers

Autonomic nerve fibers carried in the mediannerve also may be affected.


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Pathophysiology

Cause of the damage is subject to some

debate; however, it seems likely that abnormally

high carpal tunnel pressures exist in patientswith CTS

Pressure causes obstruction to venous outflow, back

pressure, edema formation, and, ultimately, ischemia

in the nerve

Pathophysiology

Cause of the damage is subject to some

debate; however, it seems likely that abnormally

high carpal tunnel pressures exist in patientswith CTS

Pressure causes obstruction to venous outflow, back

pressure, edema formation, and, ultimately, ischemia

in the nerve


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Risk factors include:

Genetic, medical,social, vocational,

avocational, and

demographic

Risk factors include:

Genetic, medical,social, vocational,

avocational, and

demographic


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Bilateral CTS is common, although the dominant hand is usually

affected first and more severely than other hand

Complaints should be localized to the palmar aspect of first to

fourth fingers and distal palm (i.e., sensory distribution of the

median nerve at the wrist)

A number of CTS patients are unable to localize their symptoms

further (i.e., whole hand/arm feeling dead)

Pain

Sensory symptoms above commonly are accompanied by an

aching sensation over the ventral aspect of the wrist Pain can radiate distally to palm and fingers or, more

commonly, extend proximally along ventral forearm

Bilateral CTS is common, although the dominant hand is usually

affected first and more severely than other hand

Complaints should be localized to the palmar aspect of first to

fourth fingers and distal palm (i.e., sensory distribution of the

median nerve at the wrist)

A number of CTS patients are unable to localize their symptoms

further (i.e., whole hand/arm feeling dead)

Pain

Sensory symptoms above commonly are accompanied by an

aching sensation over the ventral aspect of the wrist Pain can radiate distally to palm and fingers or, more

commonly, extend proximally along ventral forearm


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Autonomic symptoms

Not infrequently, patients report symptoms in the whole hand or

a tight or swollen feeling in the hands

Many patients also report sensitivity to changes in temperature

(particularly cold) and a difference in skin color These symptoms are likely due to autonomic nerve fiber

involvement (the median nerve carries most autonomic fibers to

the whole hand)

Weakness/clumsiness

Loss of power in the hand (particularly for precision gripsinvolving the thumb) does occur; however, in practice, loss of

sensory feedback and pain is often a more important cause of

weakness and clumsiness than loss of motor power per se

Autonomic symptoms

Not infrequently, patients report symptoms in the whole hand or

a tight or swollen feeling in the hands

Many patients also report sensitivity to changes in temperature

(particularly cold) and a difference in skin color These symptoms are likely due to autonomic nerve fiber

involvement (the median nerve carries most autonomic fibers to

the whole hand)

Weakness/clumsiness

Loss of power in the hand (particularly for precision gripsinvolving the thumb) does occur; however, in practice, loss of

sensory feedback and pain is often a more important cause of

weakness and clumsiness than loss of motor power per se


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Clinical examination is important to rule out otherneurologic and musculoskeletal diagnoses;however, the examination often contributes little tothe confirmation of the diagnosis of CTS

Sensory examination Abnormalities in sensory modalities may be present on

the palmar aspect of the first 3 digits and radial one halfof the fourth digit

Sensory examination is most useful in confirming thatareas outside the distal median nerve territory arenormal (i.e., thenar eminence, hypothenar eminence,dorsum of first web space)

Clinical examination is important to rule out otherneurologic and musculoskeletal diagnoses;however, the examination often contributes little tothe confirmation of the diagnosis of CTS

Sensory examination Abnormalities in sensory modalities may be present on

the palmar aspect of the first 3 digits and radial one halfof the fourth digit

Sensory examination is most useful in confirming thatareas outside the distal median nerve territory arenormal (i.e., thenar eminence, hypothenar eminence,dorsum of first web space)


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Motor examination: Wasting and weakness

of the median-innervated hand muscles

(LOAF muscles) may be detectable

L - First and second lumbricals

O - Opponens pollicis

A - Abductor pollicis brevis

F - Flexor pollicis brevis

Motor examination: Wasting and weakness

of the median-innervated hand muscles

(LOAF muscles) may be detectable

L - First and second lumbricals

O - Opponens pollicis

A - Abductor pollicis brevis

F - Flexor pollicis brevis


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Special tests: No good clinical test exists to

support diagnosis of CTS

Hoffmann-Tinel sign

Gentle tapping over the median nerve in the carpal tunnelregion elicits tingling in the nerve's distribution

This sign still is commonly looked for despite the low sensitivity

and specificity

Phalen sign

Tingling in the median nerve distribution is induced by fullflexion (or full extension for reverse Phalen) of the wrists for up

to 60 seconds

This test has 80% specificity but lower sensitivity

Special tests: No good clinical test exists to

support diagnosis of CTS

Hoffmann-Tinel sign

Gentle tapping over the median nerve in the carpal tunnelregion elicits tingling in the nerve's distribution

This sign still is commonly looked for despite the low sensitivity

and specificity

Phalen sign

Tingling in the median nerve distribution is induced by fullflexion (or full extension for reverse Phalen) of the wrists for up

to 60 seconds

This test has 80% specificity but lower sensitivity


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Etiology

Demographics:

Increasing age

Female sex

Increased body mass index (BMI), especially recent

increases

Square-shaped wrist

Short stature

Dominant hand

Race (white)

Etiology

Demographics:

Increasing age

Female sex

Increased body mass index (BMI), especially recent

increases

Square-shaped wrist

Short stature

Dominant hand

Race (white)


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Genetics:

A strong family susceptibility exists, probably related

to multiple inherited characteristics (i.e., square wrist,

thickened transverse ligament, stature)

A number of inherited medical conditions also are

associated with CTS (i.e., diabetes, thyroid disease,

hereditary neuropathy with liability to pressure

palsies)

Genetics:

A strong family susceptibility exists, probably related

to multiple inherited characteristics (i.e., square wrist,

thickened transverse ligament, stature)

A number of inherited medical conditions also are

associated with CTS (i.e., diabetes, thyroid disease,

hereditary neuropathy with liability to pressure

palsies)


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Medical conditions: Wrist fracture (Colles)

Acute severe flexion/extension injury of wrist

Space-occupying lesions within the carpal tunnel (eg, flexortenosynovitis, ganglions, hemorrhage, aneurysms, anomalousmuscles, various tumors, edema)

Diabetes

Thyroid disorders (usually myxoedema)

Rheumatoid arthritis and other inflammatory arthritides of thewrist

Recent menopause (including post-oophorectomy) Renal dialysis

Acromegaly

Amyloidosis

Medical conditions: Wrist fracture (Colles)

Acute severe flexion/extension injury of wrist

Space-occupying lesions within the carpal tunnel (eg, flexortenosynovitis, ganglions, hemorrhage, aneurysms, anomalousmuscles, various tumors, edema)

Diabetes

Thyroid disorders (usually myxoedema)

Rheumatoid arthritis and other inflammatory arthritides of thewrist

Recent menopause (including post-oophorectomy) Renal dialysis

Acromegaly

Amyloidosis


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Vocational/avocational: Activities involving (1)prolonged severe force through the wrist, (2)prolonged extreme posture of the wrist, (3) highamounts of repetitive movements, and (4)

exposure to vibration and/or cold may beassociated with CTS (particularly incombination)

Other factors:

Lack of aerobic exercise

Pregnancy and breastfeeding

Use of wheelchairs and/or walking aids

Vocational/avocational: Activities involving (1)prolonged severe force through the wrist, (2)prolonged extreme posture of the wrist, (3) highamounts of repetitive movements, and (4)

exposure to vibration and/or cold may beassociated with CTS (particularly incombination)

Other factors:

Lack of aerobic exercise

Pregnancy and breastfeeding

Use of wheelchairs and/or walking aids


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Diagnosis

No blood tests exist for the diagnosis of CTS; however,

laboratory testing for associated conditions (i.e.,

diabetes) may be performed when clinically indicated

No imaging studies are considered routine in diagnosing

CTS

Electrodiagnosis

Electrophysiologic (EDX) studies, including electromyography

(EMG) and nerve conductions studies (NCS), are the first-lineinvestigations in suggested CTS

Diagnosis

No blood tests exist for the diagnosis of CTS; however,

laboratory testing for associated conditions (i.e.,

diabetes) may be performed when clinically indicated

No imaging studies are considered routine in diagnosing

CTS

Electrodiagnosis

Electrophysiologic (EDX) studies, including electromyography

(EMG) and nerve conductions studies (NCS), are the first-lineinvestigations in suggested CTS


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Management

Wrist supports

Ultrasound

Exercise

Carpal bone mobilization/manipulation

Surgical intervention

Steroid injection/oral steroids

Management

Wrist supports

Ultrasound

Exercise

Carpal bone mobilization/manipulation

Surgical intervention

Steroid injection/oral steroids


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Documents

Common Extremity Injuries