Common MSK problems _ upper limb Flashcards
Examination findings in subacromial pain/impingement syndrome
- Painful arc of abduction between 60 and 120 degrees
- Tenderness over the anterior acromion
Pathology in Impingement syndrome/painful arc
Entrapment of supraspinatus tendon and subacromial
bursa between acromion and grater tuberosity of
humerus.
• → subacromial bursitis and/or supraspinatous tendonitis
Presentation of impingement syndrome (shoulders)
- Painful arc: 60-120O
- Weakness and ↓ ROM
- +ve Hawkin’s test
Ix for shoulder impingement syndrome
- Plain radiographs: may see bony spurs
- US
- MRI arthrogram
Management of shoulder impingement syndrome
Conservative
- Rest
- Physiotherapy
Medical
- NSAIDs
- Subacromial bursa steroid ± LA injection
Surgical
- Arthroscopic acromioplasty
Causes of anterior and posterior shoulder dislocations
Anterior
- 95% of shoulder dislocations
- Direct trauma or falling on hand
- Humeral head dislocates antero-inferiorly
Posterior
- Caused by direct trauma or muscle contraction (seen in epileptics and electric shocks).
Demographics in adhesive capsulitis
Adhesive capsulitis (frozen shoulder) is a common cause of shoulder pain
- most common in middle-aged females
- aetiology of frozen shoulder is not fully understood
- diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder
Features of adhesive capsulitis/frozen shoulder
Features typically develop over days
- external rotation is affected more than internal rotation or abduction
- both active and passive movement are affected
- bilateral in up to 20% of patients
How long does adhesive capsulitis last?
the episode typically lasts between 6 months and 2 years
Examination findings/presentation of adhesive capsulitis
- Progressive ↓ active and passive ROM
- ↓ ext. rotation <30o
- ↓ abduction <90o
- Shoulder pain, esp. @ night (can’t lie on affected side)
Management of adhesive capsulitis
Conservative
- rest
- physio
Medical
- NSAIDs
- Subacromial bursa steroid ± LA injection
Spectrum of rotator cuff injury (4)
Rotator cuff injuries are the most common cause of shoulder problems.
A spectrum of disease is recognised:
- Subacromial impingement (also known as impingement syndrome, painful arc syndrome)
- Calcific tendonitis
- Rotator cuff tears
- Rotator cuff arthropathy
A symptom of rotator cuff injury
Symptom
- shoulder pain worse on abduction
Signs on examination of (2) rotator cuff injuries
Painful arc of abduction:
- subacromial impingement → between 60 and 120 degrees
- rotator cuff tears → the pain may be in the first 60 degrees
- tenderness over anterior acromion
Signs of the complete tear (complete rotator cuff injury)
Complete tear
- Shoulder tip pain
- Full range of passive movement
- Inability to abduct the arm
- Active abduction possible following passive abduction to 90O
- lowering the arm beneath this → sudden drop
- “drop arm” sign
(2) types of rotator cuff tears
- Partial tears → painful arc
- Complete tear
Management of rotator cuff injuries
open or arthroscopic repair
Cause and demographics of lateral epicondylitis
Lateral epicondylitis
Cause: typically follows unaccustomed activity such as house painting or playing tennis (‘tennis elbow’).
- most common in people aged 45-55 years
- typically affects the dominant arm
Features of lateral epicondylitis
- pain and tenderness localised to the lateral epicondyle
- pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
How long does lateral epicondylitis last?
- Episodes typically last between 6 months and 2 years
- Patients tend to have acute pain for 6-12 weeks
Management of lateral epicondylitis
- advice on avoiding muscle overload
- simple analgesia
- steroid injection
- physiotherapy
What’s Finkelstein test used for?
Finkelstein’s test is a test used to diagnose de Quervain’s tenosynovitis in people who have wrist pain
Finkelstein’s test:
when the examiner grasps the thumb and ulnar deviates the hand sharply. If sharp pain occurs along the distal radius de Quervain’s tenosynovitis is likely.
What’s de Quervain tenosynovitis?
De Quervain’s tenosynovitis
- common condition
- the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
- typically affects females aged 30 - 50 years old
Features of de Quervian Tensinosis
- pain on the radial side of the wrist
- tenderness over the radial styloid process
- abduction of the thumb against resistance is painful
- Finkelstein’s test positive
Management of de Quervain Tensynovitis
- analgesia
- steroid injection
- immobilisation with a thumb splint (spica) may be effective
- surgical treatment is sometimes required
What happens in Carpal Tunnel syndrome?
Compression of median nerve in the carpal tunnel
Symptoms that pt with carpal tunnel syndrome may complain of
- pain/pins and needles in thumb, index, middle finger
- unusually the symptoms may ‘ascend’ proximally
- patient shakes his hand to obtain relief
- classically at night
Signs on examination of a patient with Carpal Tunnel Syndrome
- weakness of thumb abduction (abductor pollicis brevis)
- wasting of thenar eminence (NOT hypothenar)
- Tinel’s sign: tapping causes paraesthesia
- Phalen’s sign: flexion of wrist causes symptoms
Causes of carpal tunnel syndrome
- idiopathic
- pregnancy
- oedema e.g. heart failure
- lunate fracture
- rheumatoid arthritis
What can be seen if electrophysiology is performed in a patient with Carpal Tunnel Syndrome?
motor + sensory: prolongation of the action potential
Management of Carpal Tunnel Syndrome
- corticosteroid injection
- wrist splints at night
- surgical decompression (flexor retinaculum division)
Features of Carpometacarpal joint OA
- functionally disabling
- squaring of base of thumb
- may be wasting of the muscles of the thenar eminence
- ‘Grind test’ positive
- ROM of thumb joint reduced
Ix of carpometacarpal OA
- X-rays will confirm the diagnosis → OA in 1st carpometacarpal joint
- usually a clinical diagnosis
Pathophysiology of Carpometacarpal OA
- This joint is formed by the trapezium bone of the wrist and the first metacarpal bone of the thumb
- Because of its relative instability, this joint is a frequent site for osteoarthritis
- cushioning cartilage of the joint surfaces wears away, resulting in damage of the joint
Symptoms of carpometacarpal OA
- Pain at the base of the thumb occurs when moving the thumb and might eventually persist at rest
- stiffness
- swelling
- loss of strength of the thumb
Management of Carpometacarpal OA
- doesn’t usually respond to oral analgesics although topical NSAIDsmay help
- Splints can help
- Steroid injection
- Surgery if can’t be managed conservatively with trapeziectomy, fusion or joint replacement performed
Risk factors for degenerative cervical myelopathy
- smoking → due to its effects on the intervertebral discs
- genetics
- occupation - those exposing patients to high axial loading
Symptoms of degenerative cervical myelopathy
DCM symptoms can include any combination of [1]:
- Pain (affecting the neck, upper or lower limbs)
- Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
- Loss of sensory function causing numbness
- Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
- Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick
Investigations of degenerative cervical myelopathy
MRI of the cervical spine:
- gold standard t
- may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change
Management of degenerative cervical myelopathy
- urgent referral for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery)
*early treatment (within 6 months of diagnosis) offers the best chance of a full recovery
- decompressive surgery is the only effective treatment
*Physiotherapy should only be initiated by specialist services, as manipulation can cause more spinal cord damage.
Causes of radial tunnel syndrome
- compression of the posterior interosseous branch of the radial nerve
- thought to be a result of overuse
increased pressure on the radial nerve as it travels from the upper arm (the brachial plexus) to the hand and wrist
- radial nerve becomes irritated and/or inflamed from friction caused by compression by muscles in the forearm
Features of radial tunnel syndrome
- symptoms are similar to lateral epicondylitis making it difficult to diagnose
- however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
- symptoms may be worsened by extending the elbow and pronating the forearm
Features of medial epicondylitis
- *Medial epicondylitis** (golfer’s elbow) Features
- pain and tenderness localised to the medial epicondyle
- pain is aggravated by wrist flexion and pronation
- symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
Diagnosis of radial tunnel syndrome
The diagnosis:
- based on symptoms and signs alone
- may be clinically tested by flexing the patients long finger while the patient extends the wrist and fingers. Pain is a positive finding.
Treatment of radial tunnel syndrome
- rest
- NSAID
- therapy with modalities
- work modification
- steroid injection if associated with lateral epicondylitis
- decompressive surgery → if do not respond to prolonged conservative treatment
Pathophysiology of cubital tunnel syndrome
Compression of ulnar nerve
Features of cubital tunnel syndrome
- initially intermittent tingling in the 4th and 5th finger
- may be worse when the elbow is resting on a firm surface or flexed for extended periods
- later numbness in the 4th and 5th finger with associated weakness
Investigations and diagnosis of cubital tunnel syndrome
- clinical diagnosis usually → follows pattern of ulnar n. damage e.g. ulnar nerve paralysis →ulnar claw position of the hand at rest
- Clinical tests: such as the card test for Froment’s sign
- ultrasound or MRI, may reveal anatomic abnormalities or masses responsible for the impingement
Management of cubital tunnel syndrome
- pain symptoms → NSAID, amitriptyline, or vitamin B6 supplementation
- physiotherapy
- identify positions and activities that aggravate symptoms and to find ways to avoid them
