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Y1 TP2 Musculoskeletal System > 9. Wrist Hand Peripheral Nerves > Flashcards

9. Wrist Hand Peripheral Nerves Flashcards

1
Q

Posterior Compartment of the Forearm Muscles

2 layers

A

Superficial

Deep

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2
Q

Superficial Layer: Brachioradialis

A
  • Forms lateral border of cubital fossa
  • Superficial on anterolateral forearm

• Posterior compartment muscle that flexes elbow (Does not cross wrist) - insert just before wrist

  • P: Lateral Supracondylar ridge of humerus
  • D: Lateral surface of distal radius, proximal to styloid process
  • I: Radial nerve (C5,6,7)
  • A: Weak flexion of forearm (esp midpronated)

Beer drinking muscle – action of holding and drinking beer

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3
Q

Superficial Layer: Extensor Carpi Radialis Longus

A

Inferior to brachioradialis

  • P: Lateral Supracondylar ridge
  • D: Dorsum of base of 2nd metacarpal
  • I: Radial nerve (C6,7)

• A: Extend and abduct hand at wrist joint (radially deviates)

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4
Q

Superficial Layer: Extensor Carpi Radialis Brevis

A

• Shorter than longus above – arises more distally

  • P: lateral epicondyle (common extensor origin)
  • D: Dorsum of base of 3rd metacarpal
  • I: Deep branch of radial nerve (C7, C8)
  • A: Extend and abduct hand at wrist joint
  • Important (esp ECRL) for clenching fist/ tight grip finger flexion – gripping something tightly you extend your wrist
  • ECRL and ECRB can act synergistically with FCR to produce pure abduction
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5
Q

Superficial Layer: Extensor Digitorum

A

• Occupies much of posterior surface of forearm

  • P: lateral epicondyle (common extensor origin)
  • D: Extensor apparatus of fingers
  • I: Deep branch of radial nerve (C7, C8)

• A: Extends fingers, primarily at MCPJs (also extends other joints) meta carpal pharyngeal joints

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6
Q

Superficial Layer: Extensor Digiti Minimi

A
  • P: lateral epicondyle (common extensor origin)
  • D: Extensor apparatus of little finger
  • Usually divides into 2 slips – radial one joined by tendon from extensor digitorum to little finger
  • (EDM is ulnar to ED)
  • I: Deep branch of radial nerve (C7, C8)

• A: Extends little finger, primarily at MCPJs (also extends other joints)
Distilly it splints into 2 tendons in little finger

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7
Q

Superficial Layer: Extensor Carpi Ulnaris

A
  • P: 2 heads – humeral head from lateral epicondyle (common extensor origin) – & ulnar head from posterior border of ulna
  • D: Dorsal base of 5th Metacarpal. Runs in groove between ulnar head and styloid process
  • I: Deep branch of radial nerve (C7, C8)
  • A: Extend and adduct hand at wrist joint
  • Important (like ECRL) clenching fist/ tight grip finger flexion
  • ECU can act synergistically with FCU- flexor carpi ulnaris to produce pure adduction
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8
Q

Superficial layer muscles

A 
Brachioradialis
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor digitorium
Extensor digit minimi
Extensor carpi ulnaris
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9
Q

Deep layer: Supinator

A

• P: osseofibrous origin = lateral epicondyle of humerus, radial collateral and anular ligament, supinator fossa and crest of ulna
Arises from humerus ulna and radius and ligaments around it
• D: Lateral (posterior and anterior) surfaces of proximal 1/3 of radius
• I: Deep branch of radial nerve (C7, C8) - passes between two heads
• A: Supinates forearm

• Deep branch of radial nerve passes between superficial and deep parts

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10
Q

Deep layer: Abductor Pollicis Longus

A
  • P: Ulna, radius and interosseous membrane (distal to supinator)
  • D: Base of 1st metacarpal (Nb commonly split into 2 – one may attach to trapezium)
  • I: Posterior interosseous nerve (C7,8) - continuation of radial nerve
  • A: Abducts thumb and extends CMC (? wrist abductor)
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11
Q

Deep layer: Extensor Pollicis Brevis

A
  • P: Distal third radius and interosseous membrane
  • D: Dorsal base of thumb proximal phalanx
  • I: Posterior interosseous nerve (C7,8)
  • A: Extends proximal phalanx at MCPJ metacarpal pharyngeal joint (extend CMC and abduct wrist)- extesnor for the thumb
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12
Q

Deep layer: Extensor Pollicis Longus

A
  • P: Middle third ulna & interosseous membrane
  • D: Dorsal base of thumb distal phalanx. [change its line of pull on radial tubercle = a pulley]
  • I: Posterior interosseous nerve (C7,8)
  • A: extends distal phalanx at IPJ intralaryngeal joint (extend MCPJ & CMC)

• Tendons of APL and EPB anteriorly and EPL posteriorly form the anatomical snuff box

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13
Q

Deep layer: Extensor Indicis

A
  • P: Distal third ulna and interosseous membrane
  • D: Extensor apparatus of index finger
  • I: Posterior interosseous nerve (C7,8)
  • A: Extends index finger, allows independent extension – extend index finger alone
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14
Q

Extensor Retinaculum

A

• Tunnels formed by attachment of retinaculum to the distal radius and ulna
• Tendons have synovial sheaths as they pass in tunnels
Keep tendons close to bone

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15
Q

• Wrist compartments

A

– 1: APL & EPB – abductor pollucis longus and extenser pollucis brevis
– 2: ECRL & ECRB –extensor carpiradiallis longus and brevis
– 3: EPL – extensor pollucis longus
– 4: EDC & EI - extensor digiti and indicies
– 5: EDM exteonsor digiti minimi
– 6: ECU extenosir carpi ulnaris

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16
Q

• Oblique inter-tendinous connections (Juncturae tendinum)

A

• Oblique inter-tendinous connections (Juncturae tendinum) [stabilize, support, limit individual movement of individual fingers]

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17
Q

Radial Nerve in Forearm

A
  • Enters cubital fossa anterior to lateral epicondyle
  • Between brachioradialis and brachialis

Branches
• Divides into a superficial branch and deep branches

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18
Q

Radial nerve Deep branch

A
  • Posterior interossus nerve / Deep Branch passes under proximal edge of the supinator (arcade of Frohse)
    • passes Between 2 superficial and deep layers of supinator
    • Runs in plane between superficial and deep extensor muscles (close to posterior interosseous artery)
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19
Q

Radial nerve Superficial branch

A
  • Superficial Branch travels with radial artery, deep to brachioradialis
    • Emerges into subcutaneous plane (approximately 9 cm proximal to radial styloid) by passing between BR and ECRL
    • NB. Posterior cutaneous nerve of forearm comes off in radial groove and runs independently
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20
Q

Bones of Hand

A

‘• 8 carpal bones, arranged into 2 rows – distal row and proximal row

  • Metacarpals & phalanges similar to feet
  • Each has base, shaft, head
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21
Q

Proximal row:

A
  • Scaphoid (Gk Boat) – articulates proximally with radius. Largest bone in proximal row. Prominent tubercle = bridges both rows in wrist joint
  • Lunate (L Moon) - articulates proximally with radius
  • Triquetrum (L 3 cornered) – pyramidal bone. Articulates proximally with disc of DRUJ
  • Pisiform (L pea) –lies anterior to triquetrum. A sesamoid, increases leverage of FCU flexor carpi ulnaris
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22
Q

Distal row

A
  • Trapezium (G – table) – 4 sided bone. Articulates with 1st & 2nd Metacarpals and scaphoid and trapezoid. Prominent tubercle – articukatr wuth thumn
  • Trapezoid – wedge shaped. Articulates with 2nd metacarpal, trapezium, capitate and scaphoid
  • Capitate (L head) – largest bone. Articulates with 3rd metacarpal. With trapezoid, scaphoid, lunate and hamate
  • Hamate (L little hook) – wedge shaped. Articulates with 4th & 5th metacarpals, capitate and triquetral bones. Hook of hamate anteriorly
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23
Q

Metacarpals & phalanges of hund

A
  • 1st metacarpal is shortest and thickest
  • Thumb has 2 phalanges, others 3
  • Thumb phalanges are stouter
  • Proximal, middle distal phalanges – reduce in size
  • Distal phalanges flattened and expanded at end, under nailbed.
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24
Q

The Wrist Joint (radiocarpal joint)

A

• Formed proximally by concave distal end of radius and articular disk and distally by convex proximal row of carpal bones (not pisiform)

  • Ulna not part of wrist joint (articulates with radius at DRUJ distal radial ulna joint)
  • Fibrocartilaginous, triangular articular disc (part of Triangular FibroCartilage Complex (TFCC)
  • Attachments ulnar notch of radius and (lateral side of base of) styloid process of ulna
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25
Q

Radio carpal joint ligaments

A
  • Palmar radiocarpal –from radius to both rows of carpal bones. Increases stability & ensures that hand follows forearm during supination
  • Dorsal radiocarpal –from radius to both rows of carpal bones. Increases stability & ensures that hand follows forearm during pronation
  • Ulnar collateral –from ulnar styloid process to triquetrum and pisiform
  • Radial collateral –from radial styloid to scaphoid and trapezium
  • Collateral ligaments prevent excessive lateral joint displacement
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26
Q

Flexion muscles - forearm

A

Flexor carpi radialis
Flexor carpi ulnaris

(assistance from finger flexors and Palmaris longus)

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27
Q

Extension muscles - forearm

A

• Extension – ECRL, ECRB, ECU (assistance from finger and thumb extensors)

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28
Q

Addiction muscles

A

• Adduction – ECU, FCU

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29
Q

Abduction muscles

A

• Abduction – APL, FCR, ECRL, ECRB

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30
Q

Intercarpal joints -

A

• Intercarpal joints - between carpal bones

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31
Q

Midcarpal joint

A

• Midcarpal joint - between prox and distal row

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32
Q

Joints of hand

A
  • Intercarpal joints - between carpal bones
  • Midcarpal joint - between prox and distal row
  • Pisotriquetral joint
  • Carpometacarpal and Intermetacarpal joints
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33
Q

Carpometacarpal joints

A

– plane type, except 1st CMC = saddle

– 2/3 CMC almost no movement, 4 slightly, 5 moderately mobile increasing movemenet as you move more medially

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34
Q

Palmar Fascia

A

• Fascia of palm is continuous with antebrachial (forearm fascia)

  • Thenar and hypothenar fascia is thin Palmar aponeurosis = thick, triangular, central fascia
    • Over thenar muscle

• Proximally (apex) continuous with flexor retinaculum & palmaris longus tendon
• Distally forms 4 longitudinal digital bands (rays) attach to
– bases of proximal phalanges
– become continuous with fibrous digital sheaths (= tubes that enclose synovial sheath and flexor tendons)

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35
Q

Palmar aponeurosis

A
  • Thick triangular fascia

* Test for palmaris longus – feel it when press pinky finger with thumb

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36
Q

Hypothenar (medial) compartment

A

• Medial fibrous septum from medial border of palmar aponeurosis to 5th metacarpal
– Medial to septum = Hypothenar (medial) compartment

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37
Q

Thenar (Lateral) compartment

A

• Lateral fibrous septum from Lateral border of palmar aponeurosis to 3th metacarpal
– Lateral to septum is Thenar (Lateral) compartment

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38
Q

Central compartment

A

– Contain flexor tendons and their sheaths, lumbricals, superficial palmar arch, digital vessels and nerves
• Adductor and interossei compartments, contain adductor pollicis and interossei
• Adcuctor myscles

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39
Q

Spaces - in the forearm

A
  • Potential deep spaces – deep to thenar and central compartment = thenar and midpalmar spaces
  • (Between spaces is fibrous septum)
  • Midpalmar space is continuous with anterior compartment of forearm (via carpal tunnel) - infecrion in arm can spread to forearm
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40
Q

Thenar Muscles - Abductor Pollicis Brevis

A

• Forms anterolateral part of thenar eminence

  • P: Flexor retinaculum and tubercle of scaphoid (and trapezium)
  • D: Lateral side of base of proximal phalanx of thumb
  • I: Recurrent branch of median nerve (C8,T1)
  • A: Abducts thumb, helps oppose it
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41
Q

Thenar Muscles - Flexor Pollicis Brevis

A

• Medial to APB abductor pollucis brevis

• P: 2 muscle bellies
– superficial head from flexor retinaculum & trapezium
– deep head from trapezoid & capitate
• D: Lateral side of base of proximal phalanx of thumb
–with APB via a sesamoid containing common tendon
• I: Superficial head: recurrent branch of median nerve (C8,T1)
• Deep head: Deep branch of the ulnar nerve (C8, T1)
• A: Flexes thumb (CMCJ and MCPJ) and aids in opposition

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42
Q

Thenar Muscles - Opponens Pollicis

A

• Deep to APB and lateral to FPB

  • P: Flexor retinaculum and tubercle of trapezium (& scaphoid)
  • D: Lateral side of 1st metacarpal
  • I: Recurrent branch of median nerve (C8,T1)
  • A: Oppose thumb = draws 1st metacarpal medially and rotates it at CMCJ
43
Q

Adductor Pollicis (adductor compartment)

A

• P: 2 heads (Radial artery see later)
– Oblique: Bases 2nd & 3rd metacarpals, capitate
– Transverse: Shaft of 3rd metacarpal
• D: Medial side of base of proximal phalanx of thumb – via a sesamoid containing tendon
• I: Deep branch of ulnar nerve (C8, T1)
• A: adducts thumb

44
Q

Hypothenar Muscles – Abductor digiti minimi

A

• Most superficial

  • P: Pisiform
  • D: Medial side of base of proximal phalanx of little finger
  • I: Deep branch of ulnar nerve (C8, T1)
  • A: Abducts little finger (assists in flexion of proximal phalanx)
45
Q

Hypothenar Muscles – Flexor digiti minimi brevis

A

• Lies lateral to ADM

  • P: Hook of hamate and flexor retinaculum
  • D: Medial side of base of proximal phalanx of little finger
  • I: Deep branch of ulnar nerve (C8, T1)
  • A: Flexes proximal phalanx of little finger (at MCPJ)
46
Q

Hypothenar Muscles – Opponens digiti minimi

A
  • Deep to other 2
  • P: Hook of hamate and flexor retinaculum
  • D: Medial border of 5th metacarpal
  • I: Deep branch of ulnar nerve (C8, T1)
  • A: Draws 5th metacarpal anteriorly and rotates it laterally (at CMCJ) for opposition with thumb- make a cup in your hand
47
Q

lumbricals

A

Arise from tnedon and isnert into tendon
4 of them

1st & 2nd
• P: lateral 2 tendons of FDP (unipennate muscles)
• D: lateral sides of extensor expansion of fingers
• I: Median nerve (C8,T1)
• A: flexes MCPJ, extends IPJ of fingers

3rd & 4th
• P: medial 3 tendons of FDP (bipennate muscles)
• D: lateral sides of extensor expansion of fingers
• I: deep branch of ulnar nerve (C8,T1)
• A: flexes MCPJ, extends IPJ of fingers

48
Q

Short Muscles - Interossei

A

• 4 Dorsal Interossei (1st – 4th)

  • Between metacarpals
  • P: Adjacent sides of 2 metacarpals (bipennate)
  • D: Bases of proximal phalanges and extensor expansions of fingers
  • I: Deep branch of ulnar nerve (C8,T1)
  • A: Abducts index and ring fingers from axial line; acts with lumbricals as above
49
Q

Extensor Mechanism

A
  • Tendons flatten at distal ends of metacarpals
  • Extensor expansions (“hood”) hold tendon in middle

• Tendon divides into
– central slip, inserts into base of middle phalanx
– 2 lateral bands, insert into base of distal phalanx (unite over middle phalanx)

  • Deep transverse metacarpal ligament connects (heads of) metacarpal bones
  • Lumbrical tendon is anterior passes volar to ligament, on radial side of digit, attaches to radial lateral band flexes mcp joint but extends others
  • Interossei tendons are posterior pass dorsal to ligament, to join lateral bands near the extensor expansion
  • Note interossei and lumbricals anterior to MCPJ centre of axis => cause flexion
50
Q

Finger Flexor Tendons

A

• Pass deep to flexor retinaculum, common flexor sheath

  • Enter central compartment
  • Fan out to individual digital synovial sheaths individual fingers

• FPL has own synovial sheath
– Passes between two sesamoid bones at head of 1st metacarpal
• Over proximal phalanx, FDS splits to allow passage of FDP (tendinous chiasm)
• FDS attached to margins of anterior aspect of base of middle phalanx
• FDP attaches to anterior aspect of base of distal phalanx

51
Q

Finger Flexor Tendons Fibrous digital sheaths

A
  • Strong ligamentous tunnels (contain tendons and synovial sheaths), prevent bowstringing
  • Anular and Cruciform parts (pulleys) are thickened reinforcements
  • Small blood vessels pass within synovial folds called vincula, from perisoteum to flexors
52
Q

Ulnar Artery in the Hand

A

Runs on ulnar side superficial to flexor retinaculum
• Anterior to flexor retinaculum (TCL)
• Deep to palmar (volar) carpal ligament
• Between pisiform and hook of hamate via ulnar canal (Guyon’s)
• Artery lies lateral to nerve
• Divides into superficial and deep palmar arches - Superficial palmar arch is completed by branch from radial = give common digital artery

53
Q

• 3 common (palmar) digital arteries

A

– anastomose with palmar metacarpal arteries from deep palmar arch
– divide into a pair of (proper palmar) digital arteries
– run along adjacent sides of each finger

• (sometimes) anastomoses with superficial palmar branch of the radial artery

54
Q

Radial Artery in the Hand

A

• After branch, curves dorsally and crosses floor of anatomical snuff box

• Enters palm by passing between heads of
– 1st dorsal interosseous
– Adductor pollicis

Ends by anastomosing with deep branch of ulnar artery to form deep palmar arch
• Arch lies just distal to metacarpal bases
• 3 palmar metacarpal arteries
• Princeps pollicis artery – artery to thumb split into 2 branches
• Radialis indicis - usually from radial artery but may arise from princeps pollicis- supply radial side of index finger

55
Q

Median nerve in the Hand

A
  • median nerve passes Through carpal tunnel (with 9 tendons under flexor retinaculum, TCL)
  • attachments - Tubercles of scaphoid & trapezium and pisiform & hook of hamate

Supplies
• 2 ½ thenar muscles
• 1st & 2nd lumbricals

Sensory to
• Palmar surface & sides of radial 3 digits, lateral half of ring finger and dorsum of distal halves of these digits
• Palmar cutaneous branch supplies central palm (arises proximal to flexor retinaculum)

56
Q

Ulnar nerve in the Hand

A

2 branches
• Palmar cutaneous branch proximal to wrist
• Dorsal cutaneous branch – approx. medial half of dorsum of hand and little & ring fingers

Divides into
• superficial branch – (PB &) cutaneous branches to anterior surfaces of the medial and half digits
• deep branch – hypothenar muscles, medial 2 lumbricals, adductor pollicis, deep head of FPB and all interossei

57
Q

Radial nerve in the Hand

A
  • Superficial branch of radial nerve pierces deep fascia near dorsum of wrist
  • Supplies skin and fascia over approx. lateral half of dorsum of hand, dorsum of thumb, index and middle fingers
58
Q

Taking a history - what to include

A
  • Age, handedness, occupation hobbies – right or left handed
  • Presenting complaint
  • Symptoms – probing qs
  • Functional problems – what they can’t do due to problem
  • Past medical history
  • Drugs
  • Allergies
  • Social history
59
Q

Examination

A
  • Neck
    • Nerves in upper limb are connected to neck, so pathology in neck can impact hand
    • Check for pain and movement
  • Shoulder
  • Elbow – flex and extend
  • Wrist
  • Hand
60
Q

Special investigations

A
  • Blood tests
    • Useful if it is an infection e.g. infection in tendon sheeth or RA (elevation of rheumatory factors)
  • Imaging
  • Neurophysiology
    • Test of nerve and muscle action using electricity

Not always needed

61
Q

4 types of Imaging in Hand surgery

A
  • X-Rays
  • Ultrasound
  • CT scan
  • MRI
62
Q

X-Rays -views

A

• Minimum three views
• AP, Lateral, Oblique
Important ot have alll 3 vies as some may not spot abnormaliteis

63
Q

Ultrasound

A

• Operator dependent
• Real time
Probe over area for suspected pathology
• Tendons and ligaments

64
Q

CT scan

A
  • Uses radiation

* Visualises bones and joints

65
Q

MRI

A
  • Uses magnetic field

* Visualises bones and soft tissues

66
Q

Common Elective Hand conditions

A
  • Arthritis
  • Tendinopathies
  • Nerve compressions
  • Lumps – ganglia
  • Dupuytren’s contracture
67
Q

Arthritis

A
  • Degeneration of the joints
  • Several types
  • Osteoarthritis
  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Gouty arthritis
  • Post-traumatic arthritis
68
Q

Osteoarthritis

A
  • Autosomal dominant - Maternally inherited
  • Affects multiple joints
  • No effective medical treatments
  • Diagnosed based on history and X-Rays

• In hands commonly first CMC joint of thumb joint and DIP most distl on fingers joints
Osteophytes, narroewing of joint space, sclerosis of bones

69
Q

Osteoarthritis base of thumb

A
  • Pain base of thumb
  • Base of thumb subluxed, causes ‘squaring of thumb’ - more rectangle than square
  • Grind test positive – hold aptient thumb, push it = pain
  • patient struggles to use thumb so Compensates using MCP joint = hyperextension
    • Results in ‘z- deformity’
70
Q

Osteoarthritis base of thumb

Treatment

A
  • Analgesics
  • Splint
  • Steroid injection

Surgical treatment
• Joint fusion – fuse 1st metacarpal to trapezium
• Trapeziectomy - remove trapeziuma nd reconstruct ligaments using piece of tendon
• Joint replacement – can fade overtime

71
Q

Trapeziectomy

A

• Trapezium is removed
Maintain sapce between thumb metacarpal and scaphoid
• Ligament reconstruction may be added

  • Good pain relief
  • Risk of instability – MCP joint hyperextension
72
Q

CMC joint fusion

A

—> fusion of first carpal metacarpal joint

  • Gives stability
  • Good for manual workers
  • Unable to make a flat hand
73
Q

Joint replacement

A
  • Give relative stability
  • Expensive
  • Risk of failure
74
Q

DIP joint arthritis – distal interphalangeal joints

A
  • Seen as Heberden’s nodes – nodules
  • Pain, loss of movements
  • Mucous cysts may be seen – osteophytes corrdoe joint capsule fill with fluid
  • Treated with NSAIDs, splints or joint fusion
75
Q

Other hand joints

A
  • Can affect STT joint, scaphoid, trapexium, trapzoid MCP joints or PIP joints
  • Treated with NSAIDs, steroid injections, joint
  • fusions or replacements
76
Q

Rheumatoid Arthritis

A
  • Autoimmune disease
  • Can affect young people
  • Affects multiple joints and other body systems
  • Progressive
77
Q

Pathology of RA

A
  1. IgMs against Fc portion of IgG
    1. AntigenAntibody complexes
    2. Inflammatory cells
    3. Phagocytosis of immune complexes
    4. release Lysozymes Free radicals Leukotrienes
    5. Joint destruction
78
Q

Joint pathology in Rheumatoid arthritis

A
  • Fluid in joint
    • Inflamamtion of joint
    • Stretch joint capusle and ligaments
    • Bone erosisn
79
Q

Wrist involvement

A
  • Subluxation of the carpus
  • Prominent ulna
  • ‘Piano key sign’
  • Pain
  • Limitation of movements
  • Tendon ruptures over prominent ulna or synovitis
80
Q

Wrist involvement - treatment

A
  • Wrist fusion - with minimal effort due to inflammation- but limits movement
  • Wrist replacement
  • Excision of distal ulna(Darrach’s procedure)
  • Tendon reconstruction(EIP extensor indices propius tendon may be used) if rupture of tendons
81
Q

Other joints affected

A
  • Thumb
  • MCP joints
  • PIP joints
  • DIP joints rarely affected
82
Q

Thumb

A
  • Can cause CMC and MCP joint
  • Boutonniere or Swan neck deformity
  • Treatment based on disability
    • Splints, NSAIDs, joint fusion
83
Q

MCP joints

A
  • Ulnar drift of fingers
  • Subluxation of the joints
  • Treatment using splint, fusion or joint
  • replacement
  • Silicone joints - hinge to move joint , pyrocarbon joints or metal – no problem with subluxation
84
Q

PIP joints

A

Flexion DIP
Hyperextension of PIP

  • Swan neck deformity
  • Boutonniere deformity
  • Treatment using splints, steroid injections or surgery
  • Surgery mainly joint replacement or fusion – silicone or metal
85
Q

4 Tendinopathies

A
  • Tennis elbow
  • Golfer’s elbow
  • De Quervain’s tenosynovitis
  • Trigger fingers
86
Q

Tendinopathies

Treatment principles

A
  • Rest, splint
  • NSAIDs
  • Steroid injections
  • Physiotherapy
  • Release of tendon sheath, muscle origin – help tendon glide or reduce pain
87
Q

Tennis and golfer’s elbow

A

—> either side of elbow joint

  • Often middle aged (35 - 50)
  • Pain can commence after minor trauma.
  • May be recent history of excessive activity involving that elbow (rarely tennis ! Dusting,
  • sweeping, heavy gardening etc).
  • Golfer’s elbow similar history but medial pain less than Tennis elbow
88
Q

• Tennis elbow:

A

• Lateral elbow pain reproduction on resisted wrist extension(Mills’ Test)= pain

89
Q

• Golfer’s elbow:

A

• Medial elbow pain reproduction on resisted = pain

90
Q

Treatment of tennis and Golfer’s elbow

A
  • Non operative
    • Activity modification
    • NSAIDS
    • Clasp – support muscle and ease pain
    • Physiotherapy – stretched inflammaed muscles in either extensors or flexors
    • Ultrasound
    • Steroid injections

• Surgery

91
Q

Trigger finger / thumb

A
  • Thickening of the flexor tendon such that it does not pass through the sheath.
  • Local injection injected into tendon sheath to relax It
  • Surgical release

Pain over MCP joint, inability to flex finger, need other hand to flex it, or it locks

92
Q

De Quervain’s Tenosynovitis

A

—> first extensor compartment

  • Inflammation affecting APL and EPB tendons and their sheaths
  • Women more often affected
  • 30-50yrs
  • Finkelstein’s test = make fist with thumb causes pain
  • Treatment
  • Rest and NSAID’s
  • Corticosteroid injection
  • Surgical Decompression
93
Q

Nerve compressions

A

• Can affect Median nerve and Ulnar nerve

  • Radial nerve compression rare
  • Median nerve commonly at wrist- Carpal tunnel syndrome
  • Ulnar nerve at Elbow- Cubital tunnel syndrome
94
Q

Carpal tunnel syndrome

A
  • Compression of median nerve under flexor retinaculum
  • Retinaculum is tight or contents of carpal tunnel increase
  • Pain, tingling, pins and needles in hands
  • Nocturnal symptoms – flex hands at night cause symptoms and fluid shift
  • Later weakness or wasting of thenar muscles
95
Q

Diagnosis of carpal tunnel syndrome

A
  • Typical history
  • Examination of median nerve
  • Provocative tests
    • Phalen’s - flex and hold wrist = symptoms
    • Carpal compression test = presure over carpal tunnel with thumb = symptoms
    • Tinel’s sign

• Nerve conduction studies – conduction velocity of medial nerve across carpal tunnele

96
Q

Treatment of carpal tunnel syndrome

A
  • Splint
  • Steroid injection
  • Carpal tunnel release = Open procedure, Endoscopic
97
Q

Cubital tunnel syndrome

A
  • Ulnar nerve compression at elbow
  • Both compression and tension on the nerve as you flex elbow
  • Symptoms along ulnar nerve
  • Pain, numbness, tingling – over ring and little fingers
  • Weakness of small muscles of hand – interossir and abductor pollucius
  • Positive elbow flexion test
98
Q

Cubital tunnel syndrome

Treatment

A
  • Activity modification - limit elbow flexion
  • Splint – keep elbow straight
  • Nerve gliding exercises
  • Cubital tunnel release

• May need a nerve transposition or medial epicondylectomy – reduce tension on nevre

99
Q

Dupuytren’s disease

A
  • Common in Northern Europe
  • ‘Viking disease’
  • Causes contractures of fingers
  • Associated with feet fibromatosis(Ledderhosen’s disease) and penile fibromatosis(Peyronie’s disease

Affects multiple digits and joint MCP and pip

100
Q

Dupuytren’s disease

Aetiology and pathogenesis

A
  • Genetic
  • Environmental-smoking, DM, epilepsy, alcoholism
  • Microngiopathy - proliferation of Myofibroblasts – produce muscle fibres causing contraxtion
101
Q

‘Dupuytren’s disease

Treat ment

A
  • Needle fasciotomy – needle brak cords and straighten finger
  • Collagenase – inject enzymes into finger
  • Limited fasciectomy – excise disease part
  • Dermofasciectomy – excsise skin and disese
102
Q

Lumps in the hand

A
  • Ganglia – cystic swelling around tendon and joints
  • Lipomas – fatty lumps
  • Cysts – epithelieum lined fluid filled lumps
  • Giant cell tumours of tendon sheath – solid benign
  • Nerve sheath tumours
  • Sarcomas- malignant tumours
103
Q

Ganglia

A
  • Usually occur spontaneously
  • Contain gelatinous fluid due to mucoid degeneration of the synovium.
  • Develop around joints or tendon sheaths, and usually communicates with the joint.
  • Most common around the wrist.
  • Dorso radial or volar radial
  • Can be intermittently painful

• Treatment=aspiration or excision
Best to treat them by leaving them they will eventually go away
• Beware of recurrence!

104
Q

Carpal tunnel bones

proximal to distal

A

Scaphoid
Lunate
Triquetrium
Pisiform

Distal row

Trapezoid
Trapezium
Capitate
Hamate

Y1 TP2 Musculoskeletal System (10 decks)

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