11c. elbow, forearm, hand Flashcards
what conditions affect the elbow specifically
Olecranon bursitis - students elbow
Lateral epicondylitis - tennis elbow
Medial epicondylitis - golfer’s elbow
what are bursae
Bursae are sacs created by synovial membrane filled with a small amount of synovial fluid. They are found at bony prominences (e.g., at the greater trochanter, knee, shoulder and elbow). They act to reduce the friction between the bones and soft tissues during movement.
what is bursitis? what causes it?
Bursitis is inflammation of a bursa. This causes thickening of the synovial membrane and increased fluid production, causing swelling. This inflammation can be caused by a number of things:
Friction from repetitive movements or leaning on the elbow
Trauma
Inflammatory conditions (e.g., rheumatoid arthritis or gout)
Infection – referred to as septic bursitis
presentation of olecranon bursitis
The typical presentation is a young/middle-aged man with an elbow that is:
Swollen
Warm
Tender
Fluctuant (fluid-filled)
what is the most important thing to rule out when exmaining an elbow ?olecranon bursitis
It is important to identify where bursitis is caused by infection. Features of infection are:
Hot to touch
More tender
Erythema spreading to the surrounding skin
Fever
Features of sepsis (e.g., tachycardia, hypotension and confusion)
An important differential diagnosis is septic arthritis. Consider septic arthritis if there is:
Swelling in the joint (rather than the bursa)
Painful and reduced range of motion in the elbow
plan when infection olecranon buristis is suspected
Aspiration of fluid from the bursa when an infection is suspected. They advise that the appearance can give an indication of the underlying cause:
Pus indicates infection
Straw-coloured fluid indicates infection is less likely
Blood-stained fluid may indicate trauma, infection or inflammatory causes
Milky fluid indicates gout or pseudogout
Aspiration should ideally be performed before starting antibiotics. The fluid is sent to the lab for microscopy and culture. During microscopy, they will examine for crystals (gout and pseudogout) and gram-staining for bacteria.
Management olecranon buristis
When infection is suspected or cannot be excluded, management involves:
1. Aspiration of the fluid for microscopy and culture
2. Antibiotics
The NICE CKS recommend flucloxacillin first-line, with clarithromycin as an alternative.
Patients that are systemically unwell (e.g., immunocompromised or have sepsis) need admission to hospital for further management, including:
Bloods (including lactate)
Blood cultures
IV antibiotics
IV fluids
Management options for olecranon bursitis include:
Rest
Ice
Compression
Analgesia (e.g., paracetamol or NSAIDs)
Protecting the elbow from pressure or trauma
Aspiration of fluid may be used to relieve pressure
Steroid injections may be used in problematic cases where infection has been excluded
what type of injuries is epicondylitis
Repetitive strain injury
symptoms epicondylitis
Usually, there will be a history of repetitive activities, often related to work.
Symptoms will be located in an area related to the activity. They can include:
Pain, exacerbated by using the associated joints, muscles and tendons
Aching
Weakness
Cramping
Numbness
On examination, the area may be tender to palpation. There may be mild swelling in the area. It may be possible to recreate the pain by having the patient perform specific movements that add resistance to the affected soft tissues.
plan ?epicondylitis
The diagnosis is usually made clinically, based on the history and examination findings, without investigations.
Investigations may be necessary to rule out other differential diagnoses (e.g., arthritis, inflammatory conditions or nerve compression), such as:
X-rays (e.g., to look for osteoarthritis)
Ultrasound (e.g., to look for synovitis in rheumatoid arthritis or rotator cuff tears)
Blood tests (e.g., inflammatory markers and rheumatoid factor for rheumatoid arthritis)
The RICE mnemonic can be applied to most soft tissue injuries. This stands for:
R – Rest
I – Ice
C – Compression
E – Elevation
Rest and adapting activities are essential. If the repetitive movement continues, the condition will get worse. This often involves the patient discussing their duties with the occupational health department at their place of work to amend their work tasks.
Other potentially helpful options include:
Analgesia (e.g., NSAIDs)
Physiotherapy
Steroid injections (in specific scenarios)
what is an epicondyle
- A prominence that sits atop of a condyle. The epicondyle attaches muscle and connective tissue to bone, providing support to this musculoskeletal system
what is medial epicondylitis? how to test it?
MEDial epicondylitis
also known as GOLFers elbow
due to repetitive FLEXion of the wrist
pain on FLEXion of the wrist in the SUPinated position with resistance
what is lateral epicondylitis
also known as tennis elbow
due to excessive extension of the wrist
pain on extension of the risk in the pronated position with resistance
Causes carpal tunnel
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
management carpal tunnel
NICE Clinical Knowledge Summaries currently recommends a 6-week trial of conservative treatments if the symptoms are mild-moderate
- corticosteroid injection
- wrist splints at night
if there are severe symptoms or symptoms persist with conservative management:
- surgical decompression (flexor retinaculum division)
what invetsigation might you do for ?mononeuropathy
nerve conduction studies
management cubital tunnel
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases
Osteoarthrtiis signs in the hands
heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in PIP joints)
Squaring at the base of the thumb at carpo-metacarpal joint
Weak grip
Reduced range of motion
rheumatoid arthritis signs in the hands
Palpation of synovium wll give a “boggy” feeling
Z shaped deformity of the thumb
Swan neck deformity (flexed DIP with hyperextended PIP)
Boutonnieres deformity (hyperextended DIP with flexed PIP)
Ulnar deviation of the fingers at the knuckle (MCPs)
what is de Quervains tenosynovitis
De Quervain’s tenosynovitis is a condition where there is swelling and inflammation of the tendon sheaths in the wrist. It primarily affects two tendons:
Abductor pollicis longus (APL) tendon
Extensor pollicis brevis (EPB) tendon
It is a type of repetitive strain injury and results in pain on the radial side of the wrist.
Repetitive movement of the APL and EPB under the extensor retinaculum result in inflammation and swelling of the tendon sheaths.
what is the colloquial name for de quervains tenosynovitis?
“mummy thumb”
One notable cause of bilateral De Quervain’s tenosynovitis is in new parents repetitively lifting newborn babies in a way that stresses the tendons of the thumb. For this reason, it is sometimes referred to as “mummy thumb”.
Presentation de quervains tenosynovitis
Patients present with symptoms at the radial aspect of the wrist near the base of the thumb. Typical symptoms include:
Pain, often radiating to the forearm
Aching
Burning
Weakness
Numbness
Tenderness
spceial test for de quervains tenosynovitis
Finkelstein’s test
Finkelstein’s test (or maybe Eichhoff’s test) involves the patient making a fist with their thumb inside their fingers. Then, the wrist is adducted (ulnar deviation), causing strain on the APL and EPB tendons. If this movement causes pain at the radial aspect of the wrist, the test is positive, indicating De Quervain’s tenosynovitis.
management de quervains tenosynovitis
Rest and adapting activities
Using splints to restrict movements
Analgesia (e.g., NSAIDs)
Physiotherapy
Steroid injections
Rarely, surgery may be required to release (cut) the extensor retinaculum, releasing the pressure and creating more space for the tendons.
what is trigger finger?
Trigger finger is a condition causing pain and difficulty moving a finger. It is also known as stenosing tenosynovitis.
In trigger finger, there is thickening of the tendon or tightening of the sheath. This prevents the tendon from smoothly moving through the sheath when the finger is flexed and extended, causing pain, stiffness, or catching symptoms.
The most commonly affected part of the sheath is the first annular pulley (A1) at the metacarpophalangeal (MCP) joint.
risk factors trigger finger
In their 40s or 50s
Women (more often than men)
People with diabetes (more with type 1, but also type 2)
presentation trigger finger
Is painful and tender (usually around the MCP joint on the palm-side of the hand)
Does not move smoothly
Makes a popping or clicking sound
Gets stuck in a flexed position
Symptoms are typically worse in the morning and improve during the day.
management of trigger finger
Rest and analgesia (a small number resolve spontaneously)
Splinting
Steroid injections
Surgery to release the A1 pulley
what is dupuytrens contracture
Dupuytren’s contracture is a condition where the fascia of the hand becomes thickened and tight, leading to finger contractures.
A contracture is a shortening of the soft tissues that leads to restricted movement in a joint. In Dupuytren’s contracture, the finger is tightened into a flexed position and cannot fully extend.
presentation dupuytrens contreacture
- nodule
- skin thickening and pitting
- finger pulled into flexion, impossible to fully extend
+ no pain usuually
test dupytrens contracture
The table-top test is a straightforward test for Dupuytren’s contracture. The patient tries to position their hands flat on a table. If the hand cannot rest completely flat, the test is positive, indicating Dupuytren’s contracture.
management dupytrens contracture
- nothing
- surgery
- Needle fasciotomy (also known as needle aponeurotomy) involves inserting a needle through the skin to divide and loosen the cord that is causing the contracture
- Limited fasciectomy involves removing the abnormal fascia and cord to release the contracture.
- Dermofasciectomy involves removing the abnormal fascia and cord, as well as the associated skin. A skin graft is used to replace the removed skin.
hand signs psoriatic arthritis
Plaques of psoriasis on the skin
Pitting of the nails (nail pitting)
Onycholysis, separation of the nail from the nail bed
Dactylitis, inflammation of the full finger
Enthesitis, inflammation of the entheses, which are the points of insertion of tendons into bone
what is systemic sclerosis
Systemic sclerosis is an autoimmune connective tissue disease involving inflammation and fibrosis (hardening or scarring) of the connective tissues, skin and internal organs. The cause is unclear.
scleroderma vs systemic sclerosis
Scleroderma translates directly to the hardening of the skin. The terms systemic sclerosis and scleroderma are often used interchangeably. Most patients with scleroderma have systemic sclerosis. However, a localised version of scleroderma only affects the skin.
whata re the two types of systemic sclerosis
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
features of limited cutaenous systemic sclerosis
C – Calcinosis
R – Raynaud’s phenomenon
E – oEsophageal dysmotility
S – Sclerodactyly
T – Telangiectasia
features of diffuse cutaenous systemic sclerosis
Diffuse cutaneous systemic sclerosis includes the CREST features and also affects internal organs, causing:
Cardiovascular problems (e.g., hypertension and coronary artery disease)
Lung problems (e.g., pulmonary hypertension and pulmonary fibrosis)
Kidney problems (e.g., glomerulonephritis and scleroderma renal crisis)
describe sclerodactyly o/e
Sclerodactyly refers to the hardening of the skin, giving the appearance of shiny, tight skin without the normal skin folds.
what is sclerodactyly
Sclerodactyly describes the skin changes in the hands. (scleroderma in hands). Skin tightening around the joints restricts the range of motion and reduces function. The fat pads on the fingers are lost. The skin can break and ulcerate.
why does systemic sclerosis cause oeseophageal dysmotility
Oesophageal dysmotility is caused by atrophy and dysfunction of the smooth muscle, as well as fibrosis of the oesophagus. It causes swallowing difficulties, chest pain, acid reflux and oesophagitis.
where are calcium depositis in systemic sclerosis
calcium deposits under the skin, most commonly found on the fingertips.
pattern of colours raynauds
First white, due to vasoconstriction
Then blue, due to cyanosis
Then red, due to reperfusion and hyperaemia
most important secondary cause of raynauds phenomenen
systemic sclerosis
treatments for raynauds
Keeping the hands warm (e.g., gloves and hand warmers)
Calcium channel blockers (e.g., nifedipine)
Other specialist drugs include losartan, ACE inhibitors, sildenafil and fluoxetine
what drugs can worsen raynauds
beta blockers
autoantibodies systemic sclerosis
ANA positive in 90%
RF positive in 30%
anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis
anti-centromere antibodies associated with limited cutaneous systemic sclerosis
what invetsigation, other than autoantibodies is used for the invetsigation of systemic sclerosis
Nailfold capillaroscopy
is a technique to magnify and examine the peripheral capillaries where the skin meets the base of the fingernail (the nail fold). Abnormal capillaries, avascular areas and micro-haemorrhages suggest systemic sclerosis. Patients with Raynaud’s disease (without systemic sclerosis) have normal nailfold capillaries.
Management of systemic sclerosis
inflammation
- immunosuppressants such as corticosteroids or methotrexate
vasodilators
- Calcium channel blockers (nifedipine), phosphodiesterase-5 inhibitors, and prostacyclin analogues can help raynauds, PH,
gastro
- PPI, motility
renal
- ACEi promt for renal crisus
