COMMON CONDITIONS OF THE UPPER LIMB Flashcards
Name the four muscles that make up the rotator cuff.
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
What movement(s) is the supraspinatus involved in?
Abduction of the shoulder
How do you test the function of the supraspinatus?
Empty can test - patient’s arms out at 45 degrees, get them to internally rotate so that their thumbs point downwards, then test abduction against examiner. Looking for pain or weakness.
What movement(s) are the infraspinatus and teres minor involved in?
External rotation at the shoulder
How do you test the function of the infraspinatus and the teres minor?
Jobe’s test - External rotation whilst examiner stabilises shoulder to prevent abduction. Looking for pain or weakness.
What movement(s) is the subscapularis involved in?
Internal rotation at the shoulder
How do you test the function of the subscapularis?
Wall push off test - patient puts their arm behind their back placing their palm on the wall and tries to push off from the wall using their arm. Looking for pain or weakness.
Belly press test - patient pushes their hands into their abdomen. This should push their arms out forwards. Looking for pain or weakness.
What is shoulder impingement?
Tendinopathy of one of the rotator cuff muscles. Most commonly affects the supraspinatus.
What is the underlying pathology in supraspinatus impingement?
Narrowing of the subacromial space will cause irritation and inflammation of the tendon as it passes through the space.
What are the causes of supraspinatus impingement?
Bony structures such as subacromial spurs, osteoarthritic spurs on the acromialclavicular joint.
Acromion deformity.
Thickening or calcification of the coracoacromial ligament.
Thickening of the subacromial bursa.
In a shoulder examination, which special test might you do to look for shoulder impingement?
Hawkin’s test - looking for pain when the elbow is flexed to 90 degrees, the shoulder is flexed to 90 degrees and the arm is internally rotated. This narrows the subacromial gap and hence will elicit the symptoms of supraspinatus impingement.
What might you see on a radiograph of a patient with supraspinatus impingement?
Osteophytes
Soft tissue inflammation
What are the management options for a patient diagnosed with shoulder impingement?
Non-operative:
Physio
Steroid Injection
Operative:
Laparoscopic shaving of the subacromial space to reduce irritation.
Which of the rotator cuff muscles is most frequently torn?
Supraspinatus
What might cause an acute tear of the supraspinatus?
Dislocation of the shoulder
In a shoulder examination, how might you test whether there was a tear in the supraspinatus?
Drop arm sign - passively abduct the arm and then ask patient adducts it slowly. If there is damage to the supraspinatus, they will feel a catching pain at 30 degrees of abduction.
How would you treat a patient with a tear of the one of the rotator cuff muscles?
Non-operative:
Physio
Steroid Injection
Operative:
Repair laparoscopically
Reverse polarity replacement - the ball is placed where the glenoid cavity was and the cup is attached to the humerus. This moves the point of leverage medially and allows the deltoid muscle to play a greater role in initiating abduction.
What are the causes of ACJ arthritis?
Wear and tear
Overhead lifting
Contact sports
ACJ dislocation
In a shoulder examination, what special test might you use to help you diagnose ACJ arthritis?
Scarf test - patient brings a forward flexed arm across the front of their body and around their neck. Looking for pain or weakness.
What are the treatment options for a patient with ACJ arthritis?
Non-operative:
Physio
Steroid Injection
Operative:
Excision of the AC joint is often done to relieve symptoms of ACJ arthritis. The bone ends will scar over which along with increased joint space will alleviate the pain.
What is the proper name for frozen shoulder?
Adhesive capsulitis
What will a patient with adhesive capsulitis initially complain of?
Pain on external rotation
Will adhesive capsulitis heal without intervention?
Yes. After about 18 months.
What is the underlying pathophysiology of adhesive capsulitis?
The connective tissue surrounding the glenohumeral joint becomes inflamed and stiff. There is also a lack of synovial fluid.
What symptoms might a patient with suspected adhesive capsulitis present with?
Pain/stiffness on external rotation
Pain/stiffness on abduction
Worse at night
Worse in cold weather
Is the loss of movement in adhesive capsulitis passive as well as active?
Yes
What are the risk factors for adhesive capsulitis?
Diabetes Reduction in use Rheumatological disease Connective tissue disease Thyroid disease Heart disease
What are treatment options for someone with adhesive capsulitis?
Non-operative:
Physio
Steroid Injection
Operative:
Manipulation under anaesthetic
Capsular release
What is phase 1 of adhesive capsulitis?
Phase 1 - severe generalised pain associated with stiffness. Daily activities are limited (eg, putting on a jacket). It can last up to nine months.
What is the second phase of adhesive capsulitis?
Phase 2 - pain usually gradually subsides but the shoulder is stiff. Movement can become more limited. External rotation is usually very limited. This phase lasts between 4-12 months.
What is the third phase of adhesive capsulitis?
Phase 3 - the shoulder becomes less stiff. There is an increase in the range of movement. This phase usually lasts 1-3 years.
What is the proper name for tennis elbow?
Lateral epicondylitis
What is the underlying pathology in lateral epicondylitis?
Inflammation of extensor forearm muscle origins
What is the cause of lateral epicondylitis?
Repetitive micro trauma (stress) at the muscle-tendon junction and its origin at the lateral epicondyle
What are the risk factors for lateral epicondylitis?
Tennis Golf Using a computer Driving DIY
How might a patient with suspected lateral epicondylitis present?
Unilateral pain and tenderness over the lateral epicondyle of the humerus.
Radiating into the forearm
Restricted dorsiflexion of the wrist and middle finger.
Gradual and worsening onset of pain
What tests can be used to assess a patient with suspected tennis elbow?
Mill’s test
Crozen’s test
What is involved in Mill’s test?
Clinician palpates the lateral epicondyle with one hand, whilst pronating forearm, fully flexing the wrist and extending the elbow. Pain indicates positive result.
What is involved in Crozen’s test?
Clinician palpates the lateral epicondyle and stabilises the elbow with one hand, whilst the other hand puts the patient’s arm into radial deviation and forearm pronation. The patient is then asked to resist wrist flexion. Pain indicates positive result.
What are the treatment options for someone diagnosed with lateral epicondylitis?
Non-operative: Rest Physio Splints Activity modification Steroid injection
Operative:
Very rare
What is the proper name for golfer’s elbow?
Medial epicondylitis
What is the underlying pathology in medial epicondylitis?
Inflammation of flexor forearm muscles
What is the cause of medial epicondylitis?
Repetitive micro trauma (stress) at the muscle-tendon junction and its origin at the medial epicondyle
What are the risk factors for medial epicondylitis?
Golf
Tennis
Driving
DIY
How might a patient with suspected medial epicondylitis present?
Unilateral pain and tenderness over the medial epicondyle of the humerus.
Radiating into the forearm
Restricted plantar flexion of the wrist and pronation of the forearm.
Pain doing things like opening jars.
Gradual and worsening onset of pain
What tests can be used to assess a patient with suspected tennis elbow?
Golfer’s elbow test
What is involved in the Golfer’s elbow test?
The examiner palpates the medial epicondyle with one hand and grasps the patient’s wrist with his/her other hand. The examiner then passively supinates the forearm and extends the elbow and wrist.
What are the treatment options for someone diagnosed with lateral epicondylitis?
Non-operative: Rest Physio Splints Activity modification Steroid injection
Operative:
Very rare
Which is more common, lateral epicondylitis or medial epicondylitis?
Lateral epicondylitis is much more common
Which joint is carpal metacarpal joint arthritis most commonly seen in?
Thumb CMC
What is the carpal bone involved in CMC arthritis at the base of the thumb?
Trapezium
Is osteoarthritis of the thumb more common in men or women?
Women
What might an x ray of the affected CMC joint show in someone with osteoarthritis?
Loss of joint space
Osteophytes
Joint dislocation
Slight subchondral sclerosis
What are the treatment options for someone diagnosed with CMC joint arthritis at the base of the thumb?
Non-operative:
Splints
Steroid injection
Pain relief
Operative:
Trapziectomy
What is Dupuytren’s disease/contracture?
Fixed flexion contracture of the hand due to palmar fibromatosis
Which fingers are normally affected by Dupuytren’s contracture?
The ring finger and little finger
How might someone with Dupuytren’s contracture present? (Name 3 symptoms)
Pain
Itching
Inability to hold objects
What is the underlying pathology in Dupuytren’s contracture?
The palmar fascia becomes abnormally thick due from a change of collagen type. Normally, the palmar fascia consists of collagen type I, but in Dupuytren sufferers, the collagen changes to collagen type III, which is significantly thicker than collagen type I.
What are the risk factors for developing Dupuytren’s contracture?
Scandinavian or Northern European ancestry. Male Age over 40 Family history Liver cirrhosis Rock climbers Diabetes Smoking Anti-epileptics (phenytoin)
What test might you use to see whether someone with Dupuytren’s contracture required interventional treatment?
Table top test
What is involved in the table top test as part of the hand exam?
Patient places his hand on a table. If the hand lies completely flat on the table, the test is considered negative. If the hand cannot be placed completely flat on the table, leaving a space between the table and a part of the hand as big as the diameter of a ballpoint pen, the test is considered positive.
What are the treatment options for someone with Dupuytren’s contracture?
Non-operative:
Pain relief
Radiation therapy
Collagenase Injection (Xiaflex)
Operative: Needle aponeurotomy Limited Fasciectomy Wide awake fasciectomy Dermofasciectomy
What is carpal tunnel syndrome?
An entrapment neuropathy where inflammation in the carpal tunnel leads to an increase in pressure and then compression of the median nerve.
What are the components of the carpal tunnel?
4 tendons of the flexor digitorum profundus
4 tendons of the flexor digitorum superficialis
Tendon of the flexor pollicis longus
Median nerve
How might a patient with carpal tunnel syndrome present?
Weakness in abducting thumb Numbness of the thumb, index, middle and radial half of the ring finger. Worse at night Wrist pain Loss of grip strength
On examination of the hand, what might you notice in someone with suspected carpal tunnel syndrome?
Wasting of thenar eminence
Pain during Phalen’s test
Pain during Tinnel’s test
Parasthesia or loss of sensation over the radial border of the index finger.
What is Phalen’s test?
Hyperflexion of the wrist, by placing dorsal side of patients hands together. Pain is a positive result.
What is Tinnel’s test?
Tapping repetitively on palmar aspect of the wrist to reproduce pain, which would be a positive result.
What are the treatment options for someone with carpal tunnel syndrome?
Non-operative:
Pain relief
Splint at night
Steroid injection
Operative:
Carpal tunnel release (decompression)
Will symptoms be relieved immediately following carpal tunnel release?
No. Compression damage will take a long time to heal so symptoms will persist as nerve is repaired.
Where do you test sensation for the radial nerve?
First radial web space on the dorsal aspect of the hand
Where do you test sensation for the ulnar nerve?
Ulnar border of the little finger
Where do you test sensation for the median nerve?
Radial border of the index finger
What is cubital tunnel syndrome?
An entrapment neuropathy where inflammation in the cubital tunnel leads to an increase in pressure and then compression of the ulnar nerve.
