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)
