Arm/hand pain Flashcards
What are the probable diagnosis’ for arm, forearm and hand pain?
- Cervical spine dysfunction (Radiculopathy/somatic)
- Shoulder disorders that refer (SAPS)
- Medial/lateral epicondylitis
- Wrist tendonitis (De quervains)
- Carpal tunnel syndrome
- OA of the thumb and DIP joints
What goes through the carpal tunnel?
- 4 FDS tendons
- 4 FDP tendons
- 1 Flexor policus longus
- Median nerve
What conditions are often missed in arm, forearm and hand pain?
- Cervical myelopathy
- Thoracic outlet
- Entrapment neuropathies (ulnar, median, radial)
- Elbow inflammation (OA, RA, bursitis)
- Ischaemic necrosis (scaphoid fracture)
What is carpel tunnel? What test can help it be diagnosed?
- Pain in the carpal tunnel/hand due to excess pressure in your wrist compressing the median nerve where it passes through the retinaculum
- Most common peripheral nerve entrapment compressing the medial nerve as it passes through the carpal tunnel causing sensory and motor deficits beyond this point (into the hand)
- Upper limb neurological tension test, compression test, tinnels test and phalens test
Clinical features of carpel tunnel?
- Pain over the wrist
- Aggravated by finer motor movements
- Neurological symptoms over the thumb, 2-4th digits
- Swelling and weakness of the hand and fingers
- Atrophy of thenar eminence
What are some risk factors for carpel tunnel?
- Diabetes
- thyroid
- HTN
- # or wrist trauma
- Sedentary lifestyle (keyboard occupations)
- Smoking
- Women 40-60yo
- Pregnancy (fluid retension)
- High BMI
- Manual labour jobs
What is De Quervains/Tenosynovitis
Inflammation of the synovium of the abductor pollicis longus and extensor polis brevis tendons as they pass in their synovial sheath in a fibro-osseous tunnel at the level of the radial styloid
What are some tests to help diagnose De Quervains?
- WHAT test (wrist hyperflexion, abduction test)
* Finkelsteins
What is the difference between medial and lateral epicondylitis? What tests can be used for each?
- Lateral epicondylitis is more common and is due to tendinopathy of the forearm extensors due to overuse or overloading while medial is the same but overuse of the flexor compartment
- Lateral tests include: maudsleys and cozens
- Medial tests include: Resisted isometric wrist flexion, vagus force testing
What condition should hand/wrist pain always be treated as until proven otherwise and why?
Scaphoid fracture and due to avascular necrosis risk
What muscles arise from the common flexor origin?
- Pronator teres
- Flexor carpi radialis
- Palmaris longus
- Flexor carpi ulnaris
- Flexor digitorum superfificalis
What are the ligaments of the elbow?
- MCL
- annular ligament (wraps around radial head)
- joint capsule
What is another name for medial epicondylitis?
Golfers elbow
Aetiology for medial epicondylitis?
- Athletes – particularly those with excessive throwing e.g. pitchers
- Overuse or repetitive movement of wrist flexion
- Manual workers/laborer
What is another name for lateral epicondylitis?
Tennis Elbow
What ortho tests should be used for tennis elbow/ lateral epi?
- Cosens
- Maudsleys
What ortho tests should be used for golfers elbow/ medial epi?
- Valgus test (group 2 MCL would be weakened or affected)
- Gripping weakness
- Ulnar nerve symptoms associated in 20% of patients
What order should you treat epicondylitis?
- Education, Rest, Maintaining ROM
- education the patient about what may be causing the pain
- De-loading the tendons/ stopping aggravating factors
- NSAIDs and analgesics
- possible brace and splints - Progressive strengthening and stretching
- isometric
- eccentric/ concentric
- Dynamic
Population/ aetiology of lateral epicondylitis
- 40 - 50yo
- insidious/ overuse/ no incident
- wrist extension movements: mouse, screw drivers, tennis players
- pain radiating down posterior aspect of forearm
- tenderness over site
Pathophysiology of DeQuervains?
The tendons of the abductor pollicis longus and the extensor pollicis brevis are tightly secured against the radial styloid by the overlying extensor retinaculum. Any thickening of the tendons from acute or repetitive trauma restrains gliding of the tendons through the sheath.
Some historial factors for DeQuervains?
- Patients are commonly mothers of infants 6-12 months (repetitive lifting of the baby as it becomes heavier)
- Texting
- Athletes /sports people
What are the clinical features of FOOSH?
- Pain and swelling in the snuff-box, at the base of the thumb
- Pain is aggravated by movements of the wrist and thumb, especially extension
- Pain not always severe, may seemed like that of a generalized sprain
- Swelling over the snuff box, 1st metphal joint
- Wasting in the right hyper thenar muscles
- POP in snuff box, over carpal tunnel, hyper thenar
- ROM–
What are the likely findings of a FOOSH injury?
Examination: Decreased wrist ROM in all directions in comparison to the other wrist and pain on thumb extension active & passive
Neuro testing:
Decreased sensation to light touch over the thenar skin and 1st & 2nd fingers
Weakness is noted on right thumb adduction & opposition
Diagnostic tests:
• +ve scaphoid shift/provocation
• +ve carpal tunnel tests (Tinnels & Phalens) due to bleeding and oedema
• +ve Finkelstien test
• +/-ve vascular test - Allen’s
• Upper limb neural tension tests (+TOS)
• Plain film x-ray (CT/MRI may be indicated if suspicious of avascular necrosis)
Where does the force transmit when FOOSH + falling forward?
distal carpals, radius and possibly AC joint
