Elbow + Hand Problems Flashcards
What is carpal tunnel syndrome?
Compression of the median nerve in the carpal tunnel in the wrist
What are the risk factors for carpal tunnel syndrome?
RA Injury, esp Colles fracture Pregnancy DM CKD Hypothyroidism
What are the clinical features of carpal tunnel syndrome?
Pain, numbness +/- paraesthesia
Thumb + radial 2 and 1/2 fingers
Worse at night
Wasting of thenar eminence if chronic
How can the symptoms of carpal tunnel be reproduced on examination?
Percuss over median nerve –> Tinel’s test
Hold wrist in full flexion for 1 minute –> Phalen’s test
How is carpal tunnel syndrome diagnosed?
Clinical diagnosis
Nerve conduction studies if any doubt
What is the non-surgical management of carpal tunnel syndrome?
Wear a wrist splint at night
Physio
Steroid injections
What is the surgical management of carpal tunnel syndrome?
If conservative management fails –> carpal tunnel release surgery
- cut through flexor retinaculum to decompress nerve
- local anaesthetic, day case
- usually successful but risk of nerve damage
What causes cubital tunnel syndrome?
Compression of ulnar nerve at the elbow behind the medial epicondyle (funny bone)
What are the clinical features of cubital tunnel syndrome?
Paraesthesia in ulnar 1 and 1/2 fingers
Weakness of index finger adduction + adductor pollicis
Which joint is responsible for flexion/extension at the elbow?
Humero-ulnar joint
Which joint is responsible for supination/pronation of the forearm?
Radio-capitellar joint
Where is the common extensor origin of the elbow?
Lateral epicondyle
Where is the common flexor origin of the elbow?
Medial epicondyle
What is epicondylitis?
Inflammation of the enthesis (attachment of tendons) at the epicondyles
What is another name for lateral epicondylitis?
Tennis elbow
What causes lateral epicondylitis?
Repetitive strain injury due to regular resisted extension of the forearm
What are the clinical features of lateral epicondylitis?
Pain at elbow, radiating down forearm
Worsening over weeks/months
Local tenderness over or distal to the lateral epicondyle
Pain on resisted middle finger + wrist extension
What is the management for lateral epicondylitis?
Self-limiting, conservation management: - rest - physio - NSAIDs - steroid injection - wrist/elbow brace Surgery very rare
What is golfer’s elbow?
Medial epicondylitis
What are the clinical features of medial epicondylitis?
Tenderness over pronator teres + flexor carpi radialis tendons and their insertion
What is the treatment for golfer’s elbow?
Same as tennis elbow
What causes trigger finger?
Tendonitis of a flexor tendon –> nodular enlargement of that tendon, usually distal to A1 fascial pulley over metacarpal neck
What are the clinical features of trigger finger?
Clicking sensation as nodule catches on pulley
Pain be painful
Finger may lock in flexed position
Which fingers are most commonly affected by trigger finger?
Middle + ring fingers
How is trigger finger managed?
- wear small finger splint at night
- steroid injections
- percutaneous trigger finger release (excision of A1 pulley)
What is Dupuytren’s contracture?
Contraction of the longitudinal palmar fascia –> severe limitation of digital movement
Which fingers are most commonly affected by Dupuytren’s contracture?
Ring + little fingers (ulnar digits)
What are some risk factors for Dupuytren’s contracture?
Male Familial AD Alcoholic cirrhosis Phenytoin side effect Diabetes
What are the management options for Dupuytren’s contracture?
Depends on severity:
- hand therapy exercises
- injectable collagenase clostridium histolyticum
- surgery –> fasciectomy (recurrence very common)
What are some features of OA in DIPs?
Heberden’s nodes (bony thickness)
Dorsal ganglion cyst (mucous cyst)
What are the surgical management options for DIP OA?
Removal of osteophytes/cysts
If severe –> arthrodesis (fusion of bones)
What are some features of PIP OA?
Bouchard’s nodes
What are the management options for ganglion cysts?
Monitor - usually disappear spontaneously
(Aspiration carries risk of infection and high risk of recurrence
Cyst excision only if symptomatic, not for cosmetic reasons)
What are the features of RA in the hands?
Tends to spare DIPs (in contrast to OA and psoriatic arthritis)
Synovitis + tenosynovitis –> erosion of joints, joint instability + tendon rupture
Deformities
What deformities might be seen in the hand of someone with RA?
Volar MCP subluxation Ulnar deviation Swan neck deformity Boutonniere deformity Z shaped thumb
What is a swan neck deformity?
Hyperextension at PIP, flexion at DIP
What is a Boutonniere deformity?
Flexion at PIP, hyperextension at DIP
