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Common Conditions, Management and Imaging > Common upper limb conditions > Flashcards

Common upper limb conditions Flashcards

1
Q

What is subacromial impingement syndrome?

A

A painful condition of the shoulder involving narrowing of the subacromial space
Can be primary or secondary

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2
Q

What is primary subacromial impingement?

A

Structural abnormalities
(bone spurs, bursal swelling)

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3
Q

What is secondary subcromial impingement?

A

Functional deficits
(rotator cuff weakness, instability, scapular dyskinesis)

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4
Q

What is the most common gender and age for subacromial impingement?

A

M>F 2:1
25-40 years

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5
Q

What is the aetiology of subacromial impingement?

A

Intrinsic, extrinsic and combined factors
Rotator cuff or biceps pathology
Scapular dyskinesis
Shoulder instability
SLAP lesions
Capsular restriction
Thoracic posture and hypomobility

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6
Q

What are the risk factors of subacromial impingement?

A

Intrinsic
Tendon histology
Age
Genetics

Extrinsic
Muscle extensibility
Anatomical osseous
GH joint kinematics
Posture/ergonomics

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7
Q

What is the pathophysiology of subacromial impingement?

A

Chronic repetitive process in which the conjoint tendon of the rotator cuff undergoes repetitive compression and micro trauma as it passes under the coracoacromial arch

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8
Q

What is the onset of subacromial impingement?

A

Acute or insidious

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9
Q

What are the clinical features of subacromial impingement?

A

Typically diffuse
Usually in ant/sup/lat aspect of shoulder
Worse with overhead movements, lifting and reaching, sleeping on affected shoulder
Pain often radiates to the elbow or neck
Painful arc (between 70-120 degrees)

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10
Q

What are the ROM and findings with subacromial impingement?

A

ROM:
Limited
Pain &/or capsular restriction
Findings:
Muscle weakness
Scapular dyskinesis
Thoracic spine dysfunction

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11
Q

What is rotator cuff tendinopathy?

A

Inflammation of the tendons of the rotator cuff muscles

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12
Q

What is the aetiology of rotator cuff tendinopathy?

A

Occur secondary to direct trauma
Poor throwing mechanics
Extrinsic compression
Intrinsic mechanisms
Vascular changes
Due to age related changes
Age, sex, genetics
Collagen disorientation and myxoid degeneration

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13
Q

What is the pathophysiology of rotator cuff tendinopathy?

A

Repetitive rotator cuff injury triggers a recurrent pathological cycle that results in acute on chronic tendonitis
Combination of extrinsic impingement from structures surrounding he cuff and intrinsic degeneration from changes within the tendon itself

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14
Q

What is the onset of rotator cuff tendinopathy?

A

Insidious
Can predispose complete/partial tears which present acute pain

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15
Q

What are the clinical features of rotator cuff tendinopathy?

A

Pain:
With overhead activities
Painful arc on abduction 70-120 degrees
Sleeping on affected side
Referred pain into the arm, chest wall or neck
ROM:
Reduced

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16
Q

What are the clinical findings with rotator cuff tendinopathy?

A

Reduced ROM
Muscle weakness
Scapular dyskinesis
Thoracic spine dysfunction
Tenderness over RC tendons and insertions
Positive impingement, muscle specific, and reactive resisted testing

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17
Q

What is bicep tendinopathy?

A

Inflammation or degeneration of the long head of biceps tendon

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18
Q

What is the most common gender and age for biceps tendinopathy?

A

M>F 2:1
20-30 years

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19
Q

What is the aetiology of biceps tendinopathy?

A

Repetitive overhead activities
Overuse
Direct trauma

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20
Q

What are the risk factors for biceps tendinopathy?

A

Athletes in sport likes tennis, swimming, or baseball
Older age
Poor shoulder mechanics

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21
Q

What is the pathoanatomy of biceps tendinopathy?

A

Inflammation, microtears, or degeneration in the biceps tendon
Particularly where it travels through the bicipital groove

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22
Q

What is the pathophysiology of biceps tendinopathy?

A

Repeated stress or trauma leads to inflammation followed by degenerative changes in the tendon, resulting in pain and functional impairment

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23
Q

What are the clinical features of biceps tendinopathy?

A

Anterior shoulder pain, especially with overhead movements
Tenderness in bicipital groove
Pain on resisted shoulder flexion
Becomes sharp with certain movements (shoulder flexion, forearm supination)
Typical pattern of radiation: down towards elbow
Muscle weakness
+/- localised swelling, morning stiffness, palpable crepitation
Positive biceps pathology tests

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24
Q

What are the aggravating factors of biceps tendinopathy?

A

Overhead and repetitive activities, reaching, pulling and lifting, sleeping on the affected side

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25
What is an acromioclavicular joint sprain?
Injury to AC joint ligaments
26
What gender and age are most common for AC sprains?
M>F 5:1 15-25 years
27
What is the aetiology of AC joint sprains?
Direct trauma to the shoulder, such as fall on shoulder or direct blow
28
What are the risk factors for AC joint sprains?
Contact sports Falls Accidents
29
What is the pathoanatomy of AC sprains?
Damage to the AC and CC ligaments, potentially leading to joint instability
30
What is the pathophysiology of AC joint sprains?
Mechanical: repetitive overload causes degeneration and inflammation Neurogenic: neural mechanisms mediate a response to repetitive load Apoptosis: cell death and remodelling augmented by repetitive strain Vascular: vascular disruption leading to tendon degeneration
31
What are the clinical features of AC sprains?
Pain over AC joint Localised pain over AC joint; worse with movement (horizontal flexion) Palpable tenderness +/- step deformity +/- swelling, bruising, soft tissue injury
32
What can recurrent injuries to the AC joint cause?
Predispose OA
33
What are the classifications of AC sprains?
1. Sprain of joint capsule 2. Complete tear of AC ligaments with sprain of CC ligaments 3-5. Complete tears of the AC and CC ligaments
34
What are glenoid labral tears?
Can be either referred to as SLAP or non-SLAP lesions
35
What does SLAP refer to?
Superior labrum anterior to posterior
36
What is the most common gender and age for labral tears?
M>F 5:1 20-40 years
37
What are the risk factors for glenoid labral tears?
Trauma and instability Repetitive stress (throwing, swimming) Direct trauma (dislocation, subluxation, direct blow to shoulder, FOOSH, overhead activity) Instability can result in labral tear
38
What is the pathophysiology of SLAP glenoid labral tears?
Types of glenoid labrum lesions SLAP more common – tearing superior labrum anterior posterior
39
What are the types of SLAP lesions?
1. Fraying of the labrum, but biceps anchor is intact 2. Tear of superior labrum that results in instability of biceps anchor (most common) 3. Bucket-handle tear of the superior labrum 4. Bucket-handle tear that expands into biceps tendon
40
What is the pathophysiology of Non-SLAP lesions?
Degenerative
41
What are GLAD lesions?
Tear of anti-inf. Labrum and adjacent articular cartilage Forced adduction injury when arm in ABD and ER
42
What are Bankart Lesions?
Damage to ant-inf labrum with # of glenoid rim Usually associated with anterior shoulder dislocation
43
What are the clinical features of glenoid labral tears?
Potential clue in history: mechanism Pain is usually localised to posterior or posterosuperior joint line Worse with abduction, overhead movements and behind-the-back arm motions +/- popping, catching or grinding Palpable tenderness over anterior aspect of shoulder Pain on active resisted testing of biceps Several tests for labral pathology exist
44
What is adhesive capsulitis?
Frozen shoulder is an idiopathic condition characterised by stiffness and pain in the shoulder due to the thickening and tightening of the joint capsule
45
What is the most common gender and age for adhesive capsulitis?
F>M 2:1 40-60 years
46
What are the risk factors for adhesive capsulitis?
Over 40 Prolonged immobility of the shoulder increases risk of developing frozen shoulder Systemic diseases (diabetes, hyperthyroidism) Prior trauma
47
What is the pathophysiology of adhesive capsulitis?
Hyperplastic fibroplasia and excessive type III collagen secretion that leads to soft tissue contractures of GH joint capsule Loss of synovial membrane and decreased capsular volume Stiffened and thick CHL ligament
48
What are the mechanisms of adhesive capsulitis?
Inflammation: Elevated inflammatory cytokines (interleukins, TNF-a, COX) Fibrosis: Dysregulation of collagen-degrading enzymes Excessive collagen formation compared to breakdown
49
What are the 3 stages of adhesive capsulitis?
1. Painful: shoulder pain occurs with movement and ROM starts to become limited 2. Frozen: shoulder pain occurs with movement and 3. Thawing: shoulder ROM begins to improve and return to normal
50
How long does it take for adhesive capsulitis to resolve?
Typically within 1-3 years
51
What is lateral epicondylitis?
Tennis elbow Pain on the outside of the elbow due to tendinosis and periostitis, often affecting the common extensor tendon
52
What are the affected muscles of lateral epicondylitis?
Extensor carpi radialis brevis primarily Extensor digitorum and extensor carpi ulnaris
53
What is the aetiology of lateral epicondylitis?
Overuse that leads to damage in the common extensor tendon Particularly the extensor carpi radialis brevis (ECRB) Inflammation leads to microtears in the tendon followed by fibrosis
54
What are the risk factors of lateral epicondylitis?
Repetitive microtrauma or overuse involving wrist extension and alternating supination/pronation Specific activies: tennis, typing, gardening, video games, certain occupations Handling tools heavier than 1kg, lifting loads heavier than 20kg at least 10 times per day and repetitive movements for more than 2 hours per day
55
What is the pathoanatomy of lateral epicondylitis?
Microtears and inflammation occur in extensor carpi radialis brevis tendon Less commonly, the condition may affect the extensor digitorum or extensor carpi ulnaris
56
What is the pathophysiology of lateral epicondylitis?
Overuse leads to inflammation, resulting in microtears and subsequent fibrosis in affected tendons
57
What are the clinical features of lateral epicondylitis?
Lateral elbow pain following activity without direct trauma Difficulty gripping objects or weak grip strength Tenderness localised just distal and anterior to lateral epicondyle Pain with resisted wrist extension and wrist flexion (stretch of ECRB)
58
What tests would be positive with lateral epicondylitis?
Maudsley's and cozen's
59
What are the clinical FINDINGS of lateral epicondylitis?
Decreased joint play in elbow joint dysfunction of lower Cx and upper Tx spine (tenderness and decreased ROM) Active trigger points in periscapular soft tissues
60
What is medial epicondylitis?
Golfer’s elbow Pain on the inside of the elbow due to tendinosis and periotitis affecting common flexor tendon
61
What muscle is primarily affected by medial epicondylitis?
Pronator teres
62
What are the risk factors for medial epicondylitis?
Repetitive work or sports Athletes who throw overhand (golf, baseball, racquet sports) Factory workers Manual labourers Office workers Handling heavier than 5kg frequently High hand grip forces Working with vibrating tools for extended periods
63
What is the pathophysiology of medial epicondylitis?
Repetitive use of flexor and pronator forearm muscles can cause microtraumas, inflammation and possibly micro-tears where the common flexor tendon of the forearm attaches Histologically: damage to involved tendons is described as Angio fibroblastic hyperplasia, tendinosis and fibrillary degeneration of collagen
64
What are the clinical features of medial epicondylitis?
Medial elbow pain following activity without direct trauma to the elbow Pain typically worse with wrist flexion, forearm pronation, gripping activities Some patients may experience occasional tingling or numbness radiating into their fourth and fifth fingers (suggests ulnar nerve involvement)
65
What are the clinical FINDINGS of medial epicondylitis?
Palpable tenderness and tightness of muscle Decreased joint play in elbow joint dysfunction of lower Cx and upper Tx spine (tenderness and decreased ROM) Active trigger points in periscapular soft tissues
66
What is De Quervain's tenosynovitis?
Inflammation of the synovium surrounding the abductor pollicis longus and extensor pollicis brevis tendons
67
What is the common age and gender of De Quervain's tenosynovitis?
F>M 30-50 years
68
What is the aetiology of De Quervain's tenosynovitis?
Irritation or inflammation of the tendons in the dorsal compartment of the wrist Due to repetitive or excessive thumb use causing friction and swelling in tendon sheath
69
What are the risk factors of De Quervain's tenosynovitis?
Repetitive hand and thumb movements Texting, typing, gaming, lifting Pregnancy and post partum period Middle age Gender Inflammatory conditions Direct trauma
70
What is the pathoanatomy of De Quervain's tenosynovitis?
Tendons involved Abductor pollicis brevis and extensor pollicis brevis Anatomical constriction Tendons pass through a fibro-osseous tunnel (extensor retinaculum) at the radial styloid, where swelling or thickening of the tendon sheath can lead to constriction and increased friction
71
What is the pathophysiology of De Quervain's tenosynovitis?
Repetitive motion injury Inflammation and thickening Pain and limited motion
72
What are the clinical features of De Quervain's tenosynovitis?
Localised wrist pain *Can radiate along course of tendons Palpable tenderness +/- swelling, crepitus Positive irthopaedic tests
73
What is carpal tunnel syndrome?
A condition caused by compression of the median nerve as it passes through the carpal tunnel in the wrist
74
What are the contributing factors to carpal tunnel?
Oedema Tendon inflammation Hormonal changes Manual activity
75
What are the risk factors for carpal tunnel?
Diabetes -Nerve damage can cause peripheral neuropathy Obesity -Increased fat deposition narrows the canal Menopause -Hormonal changes and tissue elasticity changes Pregnancy -Fluid retention and increased blood volume Hypothyroidism -Myxedema; accumulation of mucopolysaccharides causing swelling Wrist arthritis -Joint inflammation and bone spurs
76
What are the clinical features of carpal tunnel?
Paraesthesia and dysthesias: usually begin as intermittent and nocturnal but may become more frequent and diurnal Sensation may be spared over the palm and thenar eminence due to the palmar cutaneous branch of the median nerve Burning pain may not always be present but can occur and may radiate to the forearm, elbow or shoulder Chronicity can lead to axonal degeneration, resulting in weakness and thenar muscle atrophy
77
What is wrist and hand OA?
Progressive degeneration of joint cartilage and underlying bone
78
What is the pathoanatomy of wrist and hand OA?
Involves multiple joints including IP and CMC
79
What is the pathophysiology of wrist and hand OA?
Biomechanical factors Inflammatory factors -Proinflammatory cytokines and chemokines identified in OA synovial fluid -Include interleukins, TNFa from lymphocytes and macrophages -Adipocytokines also implicated Enzymatic factors -Upregulation of genes responsible for cartilage enzymes -Drives degradation of articular cartilage
80
What are the clinical features of wrist and hand OA?
Pain aggravated by joint use and relieved by rest Stiffness and reduced ROM Decreased grip/pinch strength Inflammation which may cause redness, warmth, joint effusion, soft tissue swelling Deformity: Heberden nodes (distal IP joints), bouchard nodes (proximal IP joints) and squaring of the thumb base Crepitus
81
What are FOOSH injuries?
Injuries relating to a fall on outstretched hand which can include scaphoid fractures, carpal ligament damage and instability, distal radius fractures, elbow medial collateral ligament sprain, labral tear and posterior shoulder dislocation
82
What are the clinical features of FOOSH injuries?
Scaphoid fracture: Most common carpal injured Complications can occur on their own or in combination Avascular necrosis (through waist can disrupt proximal pole) Delayed union or non-union
83
What are the clinical findings of FOOSH?
Tenderness in anatomixal snuffbox Pain with axial compression of thumb, radial deviation +/- swelling; loss of grip strength

Common Conditions, Management and Imaging (7 decks)

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