Hand, Wrist and Elbow Flashcards
What is the most common neuropathy in the arm?
Carpal Tunnel Syndrome
Explain what carpal tunnel syndrome is?
Carpal tunnel of the wrist is formed by the carpal bones and the flexor retinaculum. The median nerve passes through the tunnel and any swelling can result in median nerve compression.
Things associated with carpal tunnel syndrome?
Over 30s, females more than males, pregnancy (hormonal fluctuations), hypothyroidism, diabetes, obesity, RA.
Reason behind association not fully understood.
What may patient complain of in carpal tunnel syndrome?
Parathesiae in the thumb and radial 2.5 fingers which is usually worse at night, loss of sensation and weakness of thumb or clumsiness in the areas of the hand supplied by the median nerve.
Examination of carpal tunnel syndrome? Diagnosis?
Loss of sensation, wasting of thenar muscles in chronic and severe syndrome, symptoms can be reproduced by Tinels (percussing over the median nerve) or Phalens ( hyper flexed wrist to decrease carpal tunnel space)
Kenneth and Stothard questionnaire then nerve conduction studies.
Treatment of carpal tunnel syndrome?
Non operative: use of wrist splints at night to prevent flexion, physio and steroid injections
Operative: usually for severe cases- carpal tunnel decompression to stop permanent nerve damage. Operation is highly successful.
What is cubital tunnel syndrome? Causes?
Compression of the ulnar nerve at the elbow behind the medial epicondyle (funny bone area). Usually caused by prolonged or recurrent pressure (cysts, tumours, osteophytes) and elbow fractures.
Presentation of cubital tunnel syndrome? Tests?
Paraesthesiae in 1 and half ulnar fingers and positive Tinels test over cubital tunnel. Weakness of interossei, hypothenar and medial two lumbricals. Can test adductor pollicis also innervated by ulnar nerve by Froment’s test. NCS to confirm diagnosis.
What is Froment’s test?
Checks for paralysed ulnar nerve- patient holds paper with 2 thumbs, shouldn’t be able to pull it away, also positive if patient has to flex the terminal phalanx and use the side of the thumb.
Treatment of cubital tunnel syndrome?
Mild/ moderate: elbow splintage, physio and NSAIDs
Severe: ulnar nerve decompression
Causes of tennis elbow?
Can be a RSI in those who perform resisted extension at wrist ie TENNIS or as a degenerative enthesopathy
Tennis elbow is also known as?
Lateral Epicondylitis- as it is the common extensor origin.
Presentation and treatment of tennis elbow?
Painful and tender lateral epicondyle and pain on resisted middle finger and wrist extension
Self limiting so need rest, physio, NSAIDs, steroids and a brace. Rarely surgery is offered.
Golfers elbow is also known as?
Medial Epicondylitis as it is the common flexor origin
Which is more common golfers or tennis elbow?
Tennis is much more common
Treatment of Golfers elbow?
Self limiting- NSAIDS, physio and rest. Injections tend not to be done as comes with a risk of injury to the ulnar nerve.
Is primary OA of the elbow common?
No
When can arthritis of the elbow occur?
Often with RA and OA can occur following trauma
Explain difference in surgical treatment for radio capitellar arthritis vs humeral ulnar arthritis?
Arthritic change at the radio‐capitellar joint which has failed non-operative management can be treated with surgical excision of the radial head which affords good pain relief with minimal functional limitation.
An elbow severely affected by RA or OA at the humero‐ulnar joint which isn’t satisfactorily treated with conservative management can be treated surgically with a Total Elbow Replacement, which has reasonable long term results. However, lifting in these patients is restricted to 2.5kg postoperatively.
OA of the wrist is mainly…
post traumatic- secondary OA after scaphoid fracture due to avascular necrosis and delicate blood supply
Common finger joint affected by OA?
DIPs
After DIPs what is second most common joint in hand to be affected by OA?
Base of thumb
1st carpo‐metacarpal joint (trapziometacarpal joint)
What is dupuytrens contracture?
Thickening and contracture of subnormal fascia leading to fixed flexion deformity of the fingers. Pathology is in the palmar fascia not the tendon.
Causes of dupuytrens?
Not entirely known- more males than females
Thought to be a genetic component and then a trigger such as alcohol, cirrhosis, smoking, epilepsy medication and trauma.
Presentation of dupuytrens?
Painless gradual progression
The skin of the hand may be adherent to the diseased fascia and puckered, palpable nodules may be present. Contractors most commonly affect the ring and little finger and approx 1/2 have bilateral involvement.
Dupuytrens can occur with other fibromatoses and these patients tend to have more aggressive forms of the disease.
Treatment of Dupuytrens?
Mild contractors may be tolerated but surgery offered if interfering with function.
Fascietomy (remove diseased tissue), Fasciotomy (division of cords) or Amputation if severe. Can recur.
Explain what causes trigger finger?
Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon usually distal to a fascial pulley over the metacarpal neck resulting in a clicking sensation when the finger moves as it passes through and then locked flexion as the nodule can’t fit back through.
Explain what trigger finger would look like in a patient?
Painful flexion and click of finger then inability to extend finger back again, the patient may have to forcibly manipulate the finger to regain extension usually this causes pain.
Fingers affected by trigger finger?
Can be any but most commonly the middle and ring.
Treatment of trigger finger?
In most cases injection of steroid around the tendon within the sheath will relieve the symptoms.
What is a ganglion cyst?
Outpouching of synovial cavity filled with synovial fluid (thick viscous fluid).
Features of ganglion cysts?
They fluctuate and are trans-illuminate (pen torch shine and can see light through the other side), painless but arthritis below may be causing pain. They may feel tight. Usually resolve in time.
Treatment of ganglion cysts?
Physio- convince patient out of surgery which leaves a large scar and is difficult and risky as close to so many nerve and often the cysts are stuck to the radial artery.
Explain DeQuervain’s Tenosynovitis? What is treatment?
Inflammation and swelling of tendons that run in the first extensor compartment (Abductor policies longus and extensor pollicis brevis)
Pain in the manual tasks of the thumb, swollen, red
NSAIDs, splint and rest
Occasionally steroid injection or surgery needed
Flexor tendon sheath infection is rare but ______
emergency surgery is required
