Hand Pain Flashcards
_______ known as ‘effort thrombosis’, causes swelling in the arm with pain high in the axilla
Subclavian or axillary vein thrombosis,
The commonest cause of the thoracic outlet
syndrome is sagging musculature related to ageing, obesity, and heavy breasts and arms, aptly described by Swift and Nichols as ‘the _______
droopy shoulder syndrome’
Arm claudication is also rare. It can occur with
arterial obstruction due to occlusion of the _________
proximal left subclavian artery or the innominate artery.
Sleep DO associated with hand pain
- thoracic outlet syndrome—______
- CTS—______
- cervical spondylosis—wakes the patient with pain and stiffness that persists well into the day
patients cannot fall asleep
patients wake in the middle of the night
Arm pain in children
The main concerns with children are the _______
effects of trauma, especially around the elbow
This typically occurs in children under 8 years of age, usually at 2–5 years, when an adult applies sudden traction to the child’s extended and pronated arm
Pulled elbow
Signs of pulled elbow
• The elbow is flexed slightly (any flexion will be strenuously resisted).
• The forearm is pronated or held in mid-position.
• The arm is tender around the elbow (without
bruising or deformity).
Types of tennis elbow
‘backhand’ tennis elbow, or_______, and ‘forehand’ tennis elbow, or _________ which is also known as golfer’s or pitcher’s elbo
lateral epicondylitis
medial epicondylitis,
In ‘forehand’ tennis elbow, or golfer’s elbow, the lesion is the _________
common flexor tendon at the medial epicondyle
The pain is felt on the inner side of the
elbow and does not radiate far. The main signs are localised tenderness to palpation and pain on resisted
flexion of the wrist.
Medial tennis elbow (medial
epicondylitis
Difference in the treatment of medial and lateral epicondylitis
The treatment is similar to that for lateral
epicondylitis except that in a dumbbell exercise program that palm must face upwards.
What to avoid in lateral and medial epicondylitis
During a game they should avoid elbow bending and ‘wristy’ shots
Acute olecranon bursitis with redness and warmth can occur in
1
2
3
rheumatoid arthritis, gout, pseudogout,
haemorrhage and infection (sepsis). 13
Chronic recurrent traumatic olecranon bursitis with a synovial effusion may require surgery but most cases can resolve with ___________
partial aspiration of the fluid and then injection of corticosteroid through the same needle.
What syndrome?
Pain is often experienced in the belly of a muscle, such as the flexors and extensors, following unaccustomed use of the wrists and elbows.
There is pain on contraction and stretching of the muscles and
tenderness on palpation.
Overuse syndromes of forearm
muscles
A positive ___________produces a tingling sensation (usually without pain) in the
distribution of the median nerve
Tinel sign
What test?
- The patient approximates the dorsum of both hands, one to the other, with wrists maximally flexed and fingers pointing downwards.
- This position is held for 60 seconds
Phalen test
The test that has the highest specificity of all basic clinical tests is______________, but it has low sensitivity for CTS.
two point discrimination
Sx management of CTS
Surgical release (flexor retinaculotomy) is necessary for patients with sensory or motor deficits and those with recalcitrant CTS
In the fingers the common work-induced condition is stenosing flexor tenosynovitis, also known as
trigger thumb and finger
Associations of trigger finger
It is associated with type 1 diabetes,
rheumatoid arthritis, gout, hypothyroidism and amyloidosis
Tx gof trigger finger
Although surgery is simple and effective, treatment by injection is often very successful
Where to inject in pts with trigger finger?
The injection is made under the tendon sheath and not into the
tendon or its nodular swelling.
This contracture, which causes discomfort and dysfunction rather than pain, is fibrous hyperplasia of palmar fascia leading to nodular formation and contracture over the fourth and fifth fingers in particular
Dupuytren contracture
Associations of Dupuytren
It is associated with smoking, alcoholism, liver cirrhosis, COPD, diabetes
and heavy manual labour.
Triad for Dupuytren
- Tenderness to palpation over and just proximal to radial styloid
- Firm tender localised swelling in area of radial styloid (may be mistaken for exostosis)
- Positive Finkelstein sign
pathognomonic test for Dupuytren
Positive Finkelstein sign
It is an overload injury caused by excessive strain on the extensor muscles
of the forearm resulting from wrist extension
lateral tennis elbow
Physical signs of lateral tennis elbow
1 localised tenderness to palpation over the
anterior aspect of the lateral epicondyle
2 pain on passive stretching at the wrist with the elbow held in extension and the forearm prone
3 pain on resisted extension of the wrist with the elbow held in extension and the forearm prone
_______ and _______exercises for the forearm muscles represent the best management for tennis elbow.
Stretching and strengthening
______may occur in other extensor compartments of the wrist and hand with unusual repetitive stressful actions, such as power drills jamming, and in conveyor quality control where an object is picked up with the forearm prone, supinating to examine it
and pronating to replace it
Tendonitis
Tx of Tendonitis
Treatment is rest from the provoking activity,
splintage and tendon sheath injection with longacting corticosteroid in a manner similar to that described for de Quervain tenosynovitis.
_______ is caused by a bursitis that develops at the site where the extensor pollicis brevis and abductor pollicis longus tendons cross over the extensor carpi radialis tendons
Intersection syndrome
Where is the tenderness in intersection syndrome?
palpation tenderness is found dorsally on the radial side with swelling and crepitus
Look for a _________________
(which causes wrist instability) with tenderness 2 cm distal to the tubercle on the radial side of the lunate.
scapholunate ligament tear
_______ particularly of the scaphoid, can occur following failure to recognise a fracture
Ischaemic necrosis,
Tenderness in the ‘anatomical snuff box’ following trauma should be treated as a ________until repeated
X-rays prove negative
scaphoid
In children, chronic pain in the
region of the lunate suggests avascular necrosis— _________, presenting with dorsal wrist pain
Kienböck disease
usual location of ganglionic tumors
The vast majority arise from the dorsal scapholunate ligament.
The basic feature of _______which is a vasospastic disorder, is sequential discolouration of the digits from pallor to cyanosis to rubor upon exposure to cold and other factors
Raynaud phenomenon,
Aggravating factors for Raynaud
- Smoking
- Cold, wet weather
- Stress or emotional upset
Tx of severe Raynaid
topical glyceryl trinitrate 2% ointment—applied to the base of the affected fingers two to four times daily or applied over the radial artery or dorsum of the hand
Tx of severe Raynaid
amlodipine 5–20 mg (o) once daily or nifedipine SR 30–60 mg (o) once daily or diltiazem SR 180–240 mg (o) once daily
This condition is characterised by erythema (redness), a burning sensation and swelling of the hands (and feet) after exposure to heat and exercise
Erythromelalgia (erythermalgia)
Treatment of primary erythromelalgia includes trials of 1 2 3 4
aspirin, phenoxybenzamine (Dibenyline), methysergide or sympathectomy.
This unusual syndrome involves the sudden onset of pain and cyanosis of the ventral aspect of the digit initially, and then the entire digit
Acute blue fingers syndrome
in women
cause of Acute blue fingers syndrome
in women
The cause is probably spontaneous rupture of a vein at the base of the finger
Precautions in Chilblains (perniosis
- Think Raynaud phenomenon
- Protect from trauma and secondary infection
- Do not rub or massage injured tissues
- Do not apply heat or ice
Tx of Chilblains (perniosis
Apply glyceryl trinitrate vasodilator spray or
ointment or patch (use plastic gloves and wash hands for ointment)
- Throbbing, burning pain, worse at night
- Paraesthesia
- Initial: red, swollen hand; warm, dry skin
- Later: cold, cyanosed and mottled, moist skin; shiny and stiff finger
Regional pain syndrome
______ is avascular necrosis of the carpal lunate bone which may fragment and
collapse, eventually leading to osteoarthritis of the wrist
Kienböck disease
Osteoarthritis commonly involves the ____ and _______
interphalangeal joints of the fingers (especially the DIP joints) and the carpometacarpal (CMC) joint of the thumb
Osteoarthritis of the thumb
This is very common, especially in women. Pain is felt at the _____, and tenderness on palpation of the______ is typical
base of the thumb
CMC joint
In rheumatoid arthritis the\_\_\_\_\_\_\_\_ are often spared (only about 30% involved) but the metacarpophalangeal and proximal interphalangeal joints and wrist joints are generally affected symmetrically and bilaterally
DIP joints
More frequently see in osteoarthritic joints
of the hand (especially DIP joints) in elderly people taking diuretics. This clinical feature is known as
nodular gout.
What is the etiology
infected wounds with superficial cellulitis or
lymphangitis _________
( Streptococcus pyogenes )
_______—this is a specific infection in one
finger of fishermen or meat handlers, caused
by Erysipelothrix insidiosa.
There is a purplish erythema that gradually extends over days. It is rapidly cured by penicillin
erysipeloid
tendon sheath infection (__________—this is a dangerous and painful
infection that can cause synovial adhesions with severe residual finger stiffness
suppurative
tenosynovitis)
aquarium’ or ‘swimming pool’ granuloma—nonpainful infection of the tendon sheath due to ____________following a minor cut of
the finger
Mycobacterium marinum
__________(gardener’s arm)—a chronic
fungal infection from contaminated spikes of
wood or rose thorns presenting as hard nontender nodules in the skin of the hand and
extending along the lymphatics of the arm
sporotrichosis
Mx of Streptococcus pyogenes (mild to moderate cellulitis, lymphangitis
procaine penicillin 1.5 g IM daily, 3 to 7 days
or
phenoxymethylpenicillin 500 mg (o) 6 hourly for 10 days
Mx of severe Streptococcus pyogenes
If severe to cover both S. pyogenes and
Staphylococcus aureus infection (suspected or proven
