Common MSK problems _ upper limb

Question 1

Examination findings in subacromial pain/impingement syndrome

Answer 1

• Painful arc of abduction between 60 and 120 degrees
• Tenderness over the anterior acromion

Question 2

Pathology in Impingement syndrome/painful arc

Answer 2

Entrapment of supraspinatus tendon and subacromial

bursa between acromion and grater tuberosity of

humerus.

• → subacromial bursitis and/or supraspinatous tendonitis

Question 3

Presentation of impingement syndrome (shoulders)

Answer 3

• Painful arc: 60-120^O
• Weakness and ↓ ROM
• +ve Hawkin’s test

Question 4

Ix for shoulder impingement syndrome

Answer 4

• Plain radiographs: may see bony spurs
• US
• MRI arthrogram

Question 5

Management of shoulder impingement syndrome

Answer 5

Conservative

• Rest
• Physiotherapy

Medical

• NSAIDs
• Subacromial bursa steroid ± LA injection

Surgical

• Arthroscopic acromioplasty

Question 6

Causes of anterior and posterior shoulder dislocations

Answer 6

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).

Question 7

Demographics in adhesive capsulitis

Answer 7

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

Question 8

Features of adhesive capsulitis/frozen shoulder

Answer 8

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

Question 9

How long does adhesive capsulitis last?

Answer 9

the episode typically lasts between 6 months and 2 years

Question 10

Examination findings/presentation of adhesive capsulitis

Answer 10

• Progressive ↓ active and passive ROM
• ↓ ext. rotation <30^o
• ↓ abduction <90^o
• Shoulder pain, esp. @ night (can’t lie on affected side)

Question 11

Management of adhesive capsulitis

Answer 11

Conservative

• rest
• physio

Medical

• NSAIDs
• Subacromial bursa steroid ± LA injection

Question 12

Spectrum of rotator cuff injury (4)

Answer 12

Rotator cuff injuries are the most common cause of shoulder problems.

A spectrum of disease is recognised:

1. Subacromial impingement (also known as impingement syndrome, painful arc syndrome)
2. Calcific tendonitis
3. Rotator cuff tears
4. Rotator cuff arthropathy

Question 13

A symptom of rotator cuff injury

Answer 13

Symptom

• shoulder pain worse on abduction

Question 14

Signs on examination of (2) rotator cuff injuries

Answer 14

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

Question 15

Signs of the complete tear (complete rotator cuff injury)

Answer 15

Complete tear

• Shoulder tip pain
• Full range of passive movement
• Inability to abduct the arm
• Active abduction possible following passive abduction to 90^O
• lowering the arm beneath this → sudden drop

- “drop arm” sign

Question 16

(2) types of rotator cuff tears

Answer 16

• Partial tears → painful arc
• Complete tear

Question 17

Management of rotator cuff injuries

Answer 17

open or arthroscopic repair

Question 18

Cause and demographics of lateral epicondylitis

Answer 18

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

Question 19

Features of lateral epicondylitis

Answer 19

• 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

Question 20

How long does lateral epicondylitis last?

Answer 20

• Episodes typically last between 6 months and 2 years
• Patients tend to have acute pain for 6-12 weeks

Question 21

Management of lateral epicondylitis

Answer 21

• advice on avoiding muscle overload
• simple analgesia
• steroid injection
• physiotherapy

Question 22

What’s Finkelstein test used for?

Answer 22

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.

Question 23

What’s de Quervain tenosynovitis?

Answer 23

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

Question 24

Features of de Quervian Tensinosis

Answer 24

• 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

Question 25

Management of de Quervain Tensynovitis

Answer 25

* analgesia * steroid injection * immobilisation with a thumb splint (spica) may be effective * surgical treatment is sometimes required

Question 26

What happens in Carpal Tunnel syndrome?

Answer 26

Compression of median nerve in the carpal tunnel

Question 27

Symptoms that pt with carpal tunnel syndrome may complain of

Answer 27

* 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

Question 28

Signs on examination of a patient with Carpal Tunnel Syndrome

Answer 28

* 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

Question 29

Causes of carpal tunnel syndrome

Answer 29

* idiopathic * pregnancy * oedema e.g. heart failure * lunate fracture * rheumatoid arthritis

Question 30

What can be seen if electrophysiology is performed in a patient with Carpal Tunnel Syndrome?

Answer 30

motor + sensory: prolongation of the action potential

Question 31

Management of Carpal Tunnel Syndrome

Answer 31

* corticosteroid injection * wrist splints at night * surgical decompression (flexor retinaculum division)

Question 32

Features of Carpometacarpal joint OA

Answer 32

* 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

Question 33

Ix of carpometacarpal OA

Answer 33

* X-rays will confirm the diagnosis → OA in 1st carpometacarpal joint * usually a clinical diagnosis

Question 34

Pathophysiology of Carpometacarpal OA

Answer 34

* This joint is formed by the [trapezium](https://en.wikipedia.org/wiki/Trapezium_(bone)) bone of the wrist and the first [metacarpal](https://en.wikipedia.org/wiki/Metacarpal) bone of the thumb * Because of its relative instability, this joint is a frequent site for [osteoarthritis](https://en.wikipedia.org/wiki/Osteoarthritis) * cushioning cartilage of the joint surfaces wears away, resulting in damage of the joint

Question 35

Symptoms of carpometacarpal OA

Answer 35

* 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

Question 36

Management of Carpometacarpal OA

Answer 36

* 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

Question 37

Risk factors for degenerative cervical myelopathy

Answer 37

* smoking → due to its effects on the intervertebral discs * genetics * occupation - those exposing patients to high axial loading

Question 38

Symptoms of degenerative cervical myelopathy

Answer 38

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

Question 39

Investigations of degenerative cervical myelopathy

Answer 39

MRI of the cervical spine: * gold standard t * may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change

Question 40

Management of degenerative cervical myelopathy

Answer 40

* 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.

Question 41

Causes of radial tunnel syndrome

Answer 41

* 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

Question 42

Features of radial tunnel syndrome

Answer 42

* 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

Question 43

Features of medial epicondylitis

Answer 43

* *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

Question 45

Diagnosis of radial tunnel syndrome

Answer 45

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.

Question 46

Treatment of radial tunnel syndrome

Answer 46

* rest * NSAID * therapy with modalities * work modification * steroid injection if associated with lateral epicondylitis * decompressive surgery → if do not respond to prolonged conservative treatment

Question 47

Pathophysiology of cubital tunnel syndrome

Answer 47

Compression of ulnar nerve

Question 48

Features of cubital tunnel syndrome

Answer 48

* 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

Question 49

Investigations and diagnosis of cubital tunnel syndrome

Answer 49

* clinical diagnosis usually → follows pattern of ulnar n. damage e.g. ulnar nerve paralysis →[ulnar claw](https://en.wikipedia.org/wiki/Ulnar_claw) position of the hand at rest * Clinical tests: such as the [card test](https://www.youtube.com/watch?v=yJTIhm1VfSI) for [Froment's sign](https://en.wikipedia.org/wiki/Froment%27s_sign) * [ultrasound](https://en.wikipedia.org/wiki/Ultrasound) or [MRI](https://en.wikipedia.org/wiki/Magnetic_resonance_imaging), may reveal anatomic abnormalities or masses responsible for the impingement

Question 50

Management of cubital tunnel syndrome

Answer 50

* pain symptoms → [NSAID](https://en.wikipedia.org/wiki/NSAID), [amitriptyline](https://en.wikipedia.org/wiki/Amitriptyline), or [vitamin B6](https://en.wikipedia.org/wiki/Vitamin_B6) supplementation * physiotherapy * identify positions and activities that aggravate symptoms and to find ways to avoid them