CORTEXT 4 - Upper limb Flashcards by Rachel Gordon

Rotator cuff muscles

Supraspinatous
Infraspinatous
Subscapularis
Teres minor

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Common shoulder problems relating to age

Young = Instability 
Middle = Rotator cuff tears (grey hair, cuff tear)
Old = Glenohumeral OA

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Impingement syndrome- what happens?

Tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight acromial space during movement, producing pain

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During impingement, at what degrees does the pain hurt most?

60-120 degrees

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3 cases associated with impingement

Tendonitis subacromial bursitis
Acromioclavicular OA with inferior osteophyte
A hooked acromion rotator cuff tear

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Mx of Impingement

NSAIDS, Analgesics, Physio, Subacromial injections (3 usually needed)
Pain still not away? - Subacromial decompression (creates more space for tendon to pass)

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Rotator cuff tear affects which muscle most commonly?

Just supraspinatus = partial tear

A large tear can ALSO tear the infraspinatus and subscapularis

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Ix & Mx Rotator cuff tear

Ix = US or MRI
Mx = (controversial)
Non operative = Physio + Subacromial injections
Operative = Rotator cuff repair with subacromial decompression (doesn’t work on big tears and 1/3 of surgeries fail!)

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How is adhesive capsulitis/ ‘frozen shoulder’ characterized?

Progressive pain and stiffness of the shoulder in patients between 40 & 60, resolves after 18-24 months

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What is the principle clinical sign of frozen shoulder?

Loss of external rotation

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Mx frozen shoulder

Analgesics, physio, subacromial injections, MUA (manipulation under anaesthesia)

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Instability: Traumatic

Shoulder may stabilize itself with rest & physio

If not, Bankhart repair needed (reattach the labrum and capsule to anterior glenoid)

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Rate of re-dislocation in:

<20 and >30

<20 = 80% re-dislocation 
>30 = 20% re-dislocation

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Who are the patients vulnerable to atraumatic instability?

Patients with Ehlers-Danlos or Marfans syndrome

i.e. people with ligamentous laxity

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Carpal tunnel syndrome causes

Usually idiopathic but is secondary to many conditions including:
RA
Pregnancy 
Diabetes 
Chronic renal failure

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Symptoms of carpal tunnel syndrome

Parenthesis (burning sensation) of the thumb and radial 2.5 fingers
Symptoms worse at night
Loss of sensation in affected fingers
Weakness of thumb

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Carpal tunnel syndrome Mx

Non-operative = wrist splints,  corticosteroid injection
Operative = Carpal tunnel decompression - division of the carpal ligament

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Cubital tunnel syndrome - explain

Compression of the ulna nerve causing parenthesis (burning sensation) over the ulnar 1.5 fingers

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What are the 2 joints within the elbow and what actions do they allow?

Humero-ulnar joint (responsible for flexion/extension)

Radio-capitellar joint (responsible for supination and pronation)

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Where does the triceps muscle attach and what movement is it primarily used for?

Attaches to olecranon process

Powers elbow extension

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Where does the brachialis muscle attach and what movement does it produce?

Coronoid process

Flexes the elbow

Where does the biceps attach and what movement do they produce?

The bicipital tuberosity of the radius

Flexes the elbow

What muscles are involved in supination?

Biceps & Supinator

What muscles are involved in pronation?

Prorator teres muscle

Pronator quadratus muscle

What arises from the medial and lateral epicondyle of the elbow

Medial epicondyle = Common flexor origin | Lateral epicondyle = Common extensor origin

Is the elbow affected in RA and OA?

Affected in RA, rarely affected in OA

Tennis elbow - Explain How it happens Pathology

Lateral Epicondylitis Repetitive strain injury to those who always perform resisted extension at the wrist Micro-tears in common extensor origin

Tennis elbow symptoms

Tender lateral epicondyle | Pain on resisted middle finger and wrist

Tennis elbow Mx

``` Rest from activities that exacerbate the pain Physio NSAIDS Steroid injection Brace Surgical treatment = rare ```

Golfer's elbow- Explain: How it happens Mx

Medial epicondylitis. Repetitive strain of the common flexor origin Less common than tennis elbow Mx = Rest, physio, NSAIDS (injection = high risk of injury to ulnar nerve)

If an elbow is really badly affected by RA/OA, what can you do?

A total elbow replacement (but they should limit the load they carry to 2.5kg)

Pathology behind Dupuytren's contracture

Proliferative connective tissue disorder when specialized palmar fascia undergoes hyperplasia Proliferation of myofibroblasts & production of abnormal collagen (type 3) rather than type 1

Clinical symptoms of Dupuytren's contracture

Fingers are quite contracted | Nodules forming mostly at ring or little finger

Who is commonly affected by Dupuytren's?

MEN | Alcoholics (cirrhosis)

Mx Dupuytren's

``` Fasciectomy = remove all diseased tissue Fasciotomy = division of cords Severe = amputation ```

What is trigger finger

when a flexor tendon of a digit becomes inflamed and it results in a nodule - usually in the A1 pulley

Clinical signs of trigger finger

Clicking noise when moving the finger and finger may get locked in flexed position

Fingers most commonly affected in trigger finger?

Ring and middle

Mx Trigger Finger

Steroid injection around the tendon | In persistent cases - do a surgical incision of the pulley

What joint does OA most commonly affect in the hand

DIP

Clinical signs of OA in the hands

Stiffness and bony thickening Herberden's nodes (DIP) Bouchard's nodes (PIP) Mucous cyst

Mild & Severe Mx for OA

``` Mild = removal of osteophytes and excision of any mucous cyst Severe = arthrodesis ```

Where else can OA affect in the hand? | And what can be done for treatment?

1st CMC joint (base of thumb) Radiocarpal joint of wrist Mx = Arthroplasty and Fusion

RA of the hands: | Where is it found?

PIP, NOT DIP

Natural history of RA in hands

1. Synovitis and tenosynovitis - inflammation within joints & tendon sheath = pain + swelling 2. Erosions of the joints 3. Joint instability & tendon rupture

Clinical signs of RA

Swan neck Boutonniere Z-shaped thumb

Mx of RA

``` DMARDS DMARDS DMARDS !! Surgical: Tenosynovectomy (excision of synovial tendon sheath) Soft tissue releases MCP/PIP replacements = severe RA ```

Ganglion cyst: Where in the body are they found and what are they called? What do they look like? Mx

DIPJ = Mucous cyst Popliteal fossa = Baker's cyst They are firm, smooth, rubbery and tranilluminable Needle aspiration (but recurrence rate high) Surgical excision

What soft tissue swelling is usually found on the PIPJ

Giant cell tumour

Symptoms of Giant cell tumour | Mx Giant cell tumour

May be painful/painless | Excision to prevent spread and to treat symptoms