Hand, Wrist and Elbow

Question 1

What is the most common neuropathy in the arm?

Answer 1

Carpal Tunnel Syndrome

Question 2

Explain what carpal tunnel syndrome is?

Answer 2

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.

Question 3

Things associated with carpal tunnel syndrome?

Answer 3

Over 30s, females more than males, pregnancy (hormonal fluctuations), hypothyroidism, diabetes, obesity, RA.
Reason behind association not fully understood.

Question 4

What may patient complain of in carpal tunnel syndrome?

Answer 4

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.

Question 5

Examination of carpal tunnel syndrome? Diagnosis?

Answer 5

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.

Question 6

Treatment of carpal tunnel syndrome?

Answer 6

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.

Question 7

What is cubital tunnel syndrome? Causes?

Answer 7

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.

Question 8

Presentation of cubital tunnel syndrome? Tests?

Answer 8

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.

Question 9

What is Froment’s test?

Answer 9

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.

Question 10

Treatment of cubital tunnel syndrome?

Answer 10

Mild/ moderate: elbow splintage, physio and NSAIDs

Severe: ulnar nerve decompression

Question 11

Causes of tennis elbow?

Answer 11

Can be a RSI in those who perform resisted extension at wrist ie TENNIS or as a degenerative enthesopathy

Question 12

Tennis elbow is also known as?

Answer 12

Lateral Epicondylitis- as it is the common extensor origin.

Question 13

Presentation and treatment of tennis elbow?

Answer 13

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.

Question 14

Golfers elbow is also known as?

Answer 14

Medial Epicondylitis as it is the common flexor origin

Question 15

Which is more common golfers or tennis elbow?

Answer 15

Tennis is much more common

Question 16

Treatment of Golfers elbow?

Answer 16

Self limiting- NSAIDS, physio and rest. Injections tend not to be done as comes with a risk of injury to the ulnar nerve.

Question 17

Is primary OA of the elbow common?

Answer 17

No

Question 18

When can arthritis of the elbow occur?

Answer 18

Often with RA and OA can occur following trauma

Question 19

Explain difference in surgical treatment for radio capitellar arthritis vs humeral ulnar arthritis?

Answer 19

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.

Question 20

OA of the wrist is mainly…

Answer 20

post traumatic- secondary OA after scaphoid fracture due to avascular necrosis and delicate blood supply

Question 21

Common finger joint affected by OA?

Answer 21

DIPs

Question 22

After DIPs what is second most common joint in hand to be affected by OA?

Answer 22

Base of thumb

1st carpo‐metacarpal joint (trapziometacarpal joint)

Question 23

What is dupuytrens contracture?

Answer 23

Thickening and contracture of subnormal fascia leading to fixed flexion deformity of the fingers. Pathology is in the palmar fascia not the tendon.

Question 24

Causes of dupuytrens?

Answer 24

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.

Question 25

Presentation of dupuytrens?

Answer 25

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.

Question 26

Treatment of Dupuytrens?

Answer 26

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.

Question 27

Explain what causes trigger finger?

Answer 27

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.

Question 28

Explain what trigger finger would look like in a patient?

Answer 28

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.

Question 29

Fingers affected by trigger finger?

Answer 29

Can be any but most commonly the middle and ring.

Question 30

Treatment of trigger finger?

Answer 30

In most cases injection of steroid around the tendon within the sheath will relieve the symptoms.

Question 31

What is a ganglion cyst?

Answer 31

Outpouching of synovial cavity filled with synovial fluid (thick viscous fluid).

Question 32

Features of ganglion cysts?

Answer 32

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.

Question 33

Treatment of ganglion cysts?

Answer 33

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.

Question 34

Explain DeQuervain’s Tenosynovitis? What is treatment?

Answer 34

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

Question 35

Flexor tendon sheath infection is rare but ______

Answer 35

emergency surgery is required