Hands/Upper Limb/ Tendinopathies (UL + LL) [week 5] Flashcards
Mucous cyst
> Outpouching of synovial fluid from DIPjt OA
> i.e. a ganglion at the DIPJt is known as a mucous cyst
> May be painful
> May fluctuate/discharge
> May deform nail, cause ridging
> Due to underlying OA (usually)
Joints are trying to lubricate themselves more to move –> nowhere for extra fluid to go –> mucous cyst
Can be excised if particularly bad
- may need to remove osteophytes too.
Ganglion
- what is it?
- common sites?
- management
- danger with solar ganglion
Outpouchings of synovial cavity
- common in wrist
Fibrous outer lining; Filled with synovial fluid
These fluctuate (get bigger and smaller)
Usually painless, tight feeling
Resolve with time
Volar (palmar) or dorsal wrist ganglion. DIPJ, Foot, ankle
Transilluminates
May be underlying joint damage
Commonest hand swelling
Management
- Benign neglect
- Aspiration: looks like gel in the syringe.
- Excision (if painful)
- Volar ganglions can be quite close to the radial artery –> be careful with aspiration.
Trigger Finger
- common site?
- pathology?
- examination
- management
Tendons run within the flexor tendon sheath
Any swelling on tendon leads to irritation –> more swelling and gets caught on edge of A1 pulley
i.e.
Stenosing tenosynovitis –> Fibrocartilagenous metaplasia –> Nodule FDS tendon affecting A1 pulley
Nodule catches of A1 causing triggering.
Tenderness / palmar pain
Can bend finger but cannot extend it and it suddenly gives.
Common site: A1 pulley (MC head)
Examination
- demo triggering
- tender over A1 pulley
- feel nodule pass beneath pulley
- distinguish from Dupuytren’s
Management
Conservative
- resolves spontaneously
- splint to prevent flexion
Tendon sheath injection
- steroidd + LA
- curative
- up to 3 times
Surgery
- under GA or LA
- divide A1 pulley
dividing any other pulley would severely affect finger movement
DeQuervain’s tenosynovitis
Specific test
Swollen tendon at base of thumb - locally tender. First extensor compartment
Spontaneous
PAINFUL
Swollen/red
Pain over radial styloid process
Extensor Pollicis Brevis and the Abductor Pollicis Longus tendons
Extensor tendons located in extensor compartments of hand.
Finkelstein’s test
Ix
- USS, XR rule out carbo-metacarpal OA
Management
- NSAIDs
- Splint
- rest
- steroid injection
- surgery - decompression (release both tendons in compartment - incision of the tunnel)
Gamer’s thumb
Dupuytren’s contracture
- is it to do with tendons?
- what do fibroblasts change into?
Thickening and contracture of subnormal Palmar fascia –> fixed flexion deformity of fingers.
Metaplasia of aponeurotic fibres.
Fibroblasts –> myofibroblasts (contractile)
Commonly middle and ring fingers
NOT tendons.
> Painless
Gradual progression
O/E
Feel cords
MCP/PIP joint involvement
Table top test
Genetics DM Alcohol/cirrhosis smoking epilepsy/ anti epilepsy meds
Common in Scandinavians/Scotland/Northern europe
Management
Conservative
- stretches
- activity modification
Surgery
- segmental fasciotomy
- fasciectomy
- dermofasciectomy
- amputation
Newer treatments
- collagenase injection: early dupuytren’s
- percutaneous needle fasciotomy
High rate of recurrence
May require a skin graft if there is skin involvement (the fascia may have fused to skin)
Dupuytren’s diathesis
Acute onset of Dupuytren’s contracture
Aggressive - in women, younger men, affects more of the fingers and progresses more rapidly
Contractures of feet - Lederhosen’s
Contractures of penis - Peyronie’s
Peyronie’s contracture
Dupuytrens of the penis
Zig zag incisions
You do not want to make an incision across a flexor crease
Paronychia
- common in?
Infection within the nail fold.
Painful
Red
Swollen
–> Pus
Can spread under the eponychium.
Common in children
Nail biters
--- Management - elevate - abx - incise and drain
Flexor tendon sheath infection
SURGICUAL EMERGENCY
Infection within sheath
Tracking up palm + arm
Extremely painful.
Limited extension (inc. passive extension) due to pain
May have tracking lymphangitis - check axilla, or groin (if infection in the foot)
Risk of tendon adhesion.
Management
Wash out the tendon sheath
Incision at tip and further down - drain it.
History of a swelling
Examination of a swelling
> Duration
Pain
- dull, chronic –> ?cancer
- sharp?
> Change in size - growing - fluctuating > Hx of injury > Solitary or multiple
O/E
> Site > Size > Definition - well/ill defined > Consistency > Surface - smooth/irreg? > Mobile or fixed -- to skin or deep tissues > Temperature > Transilluminable - solid or cystic > Pulsatility > Overlying skin changes > lymphadenopathy
Consistency - Hard = forehead, Firm = cartilage of nose, Soft = lips
Benign soft tissue swelling - on examination
> Smaller size (<5cm) > Fluctuation in size > Cystic/fluid filled > Well defined > Soft/ fatty
Potential malignant soft tissue swellings - O/E
>5cm Rapid growth Solid Ill defined Irregular surface Systemic upset Lymphadenopathy
Soft tissue swellings - Investigations
> Ultrasound
- solid or cystic
> MRI (GOLD STANDARD)
- Better anatomic def
- – tissue type
- – relationship to nerves and vessels
- good at diagnosing benign lesions
- can identify aggressive/worrying features
–> BIOPSY
MRI - soft tissue swellings worrying features
- > 5cm
- Deep location
- Heterogeneity / necrosis
- Bone or neuromuscular involvement
- crossing any boundaries?
- Gadolinium enhancement
- malignant tend to enhance more
- Enlarged lymph nodes
Lipoma
In the Subcut fat (can occur in muscle)
Fatty consistency
Painless
Can be large
Entirely benign
(Tethered to the skin)
Giant Cell Tumour (GCT)
- where do they originate
- pigmented? which iron complex is found?
- management
> Arise from synovium tendon sheath or joint
> can occur in knees, toes, hands
> PIGMENTED and HAEMOSIDERIN
Management
> Excise if painful
radiotherapy may help
can become malignant
Pigmented Villonodular Synovitis (PVNS)
- types
- arise from
- Management
Similar to Giant Cell Tumours
Tumours from synovium.
Nodular and diffuse types
Commonest in knee, can affect other large joints
–>Joint destruction and arthritis
Management
synovectomy
may require knee replacement
recurrence of 15%
Baker’s Cyst
- should you excise or leave alone? why?
Cyst in popliteal fossa
Arises from egress synovial fluid through one way valve to semimembranosis brush or medial gastrocnemius bursa
In adults – usually intrartiuclar pathology/arthritis
Children – resolve
High recurrence if excised.
Bursitis
- common places
- why shouldn’t you aspirate it?
Bursae normally prevent friction
Can become INFLAMED.
Painful.
Commonly:
- olecranon
- prepatellar
- infra patellar
- 1st metatarsal head (bunion)
Arthroscopic bursectomy
DO NOT ASPIRATE. FORMS A SINUS
Implantation Dermoid
Penetrating trauma –> epithelial cells into subcutaneous tissue
Reactive cyst forms with pseudo capsule
Greyish fluid
Epidermoid (Sebaceous cyst)
- where can they NOT occur
- blackhead in the middle is known as?
Common
Can occur anywhere (apart from palms and soles)
Epidermal cells find their way into subcutaneous tissue
Epidermoid cells lining cyst secrete keratin
PUNCTUM (dead blackhead) which tethers cyst to epidermis - little black spot in the middle of the cyst.
Abscess
> May arise from cellulitis, infected wound, epidermoid cyst, blocked sweat gland, injection site
> Painful
> Fluctuant
> Once abscess is formed, must be incised and drained.
> May erupt/discharge itself.
Heterotropic Ossification (or Myositis ossificans)
- NSAID which can help? (Indo-?)
- Management
Formation of bone in the wrong places.
Blunt trauma –> intramuscular haematoma –> calcifies
Hard to the touch
Painless (usually)
Can be confused with osteosarcoma on MRI.
—
Management
Can be excised once bone has matured
Indomathacin can help (NSAID)
Angiosarcoma
Fibrosarcoma and Malignant fibrous histiocytoma
Liposarcoma
Rhabdomyosarcoma
Synovial sarcoma
Definitions
Angiosarcoma - blood vessel malignant cancer
Fibrosarcoma and Malignant fibrous histiocytoma - malignancy of fibrous tissue
Liposarcoma - malignancy of fat tissue (deep tissue rather than subcut)
Rhabdomyosarcoma - skeletal muscle malignancy
Synovial sarcoma - malignancy of synovium joint or tendon sheath
Soft tissue swellings - when should biopsies be performed?
If nature of lesion is indeterminate on clinical assessment and MRI
Treatment of malignant lesion
Wide local excision
Radiotherapy (neo-adjuvant or adjuvant)
Large lesion may greatly reduce function of limb.
Amputation w/neurovascular involvement
Hand Injury history - what to consider
Examintion
> Handedness
PMHx
Occupation
Hobbies/sports
Description of injury
- crush, sharp, burn
- gloves, protection? (fabric in wound?)
- timing of injury?
- degloving
- level of energy estimate
Symptoms
- pain
- weakness
- sensory
Morbidity is mostly associated with the soft tissues.
Examination
- wound itself
- nails
- deformity
- swelling
- point of tenderness
- movement
- movement
- neurological
Hand wound examination
Where is it How long/deep Clean/dirty (farm injury, grease) Skin loss Obvious structures in wound - bone - tendon - foreign bodies - dirt / grit
In crush injuries, are we more worried about the bones or soft tissue?
Soft tissue.
Subungual Haematoma
- if causing pain, best course of action is
Collection of blood underneath the fingernail or toenail
Nail may eventually fall off and grow back.
If pressure is causing pain –> trephination (hot needle/paper clip to pierce nail and relieve the pressure)
Nail /nailbed injuries
- Types of injury (5 types)
Keep nail if possible
- act as a splint to maintain nail fold
- protects nail matrix during healing process.
Repair the nail bed
Types: 1 - Soft tissue (ST) only 2 - ST + nail 3 - ST + nail + bone 4 - Proximal half of phalanx 5 - proximal to DIPjt
Amputation of fingerTIP - levels
Level 1 involved only skin.
Level II involves both skin and bone.
Level III involves some loss of nailbed.
Level IV involves the germinal matrix and often some of the nail fold.
Level V involves the insertion of the tendon.
Each amputation level has unique implications for treatment and outcome
Level 1 & 2 - dressing only
Level 3 - repair nail bed + stabilise bone
Level 4 - as 3, unless <5mm of nail bed –> ablate
If tip not available, terminalise, or V-Y flap
Terminalisati
Fingertip terminalisation
Shortening the bone so that the soft tissue can cover it properly and heal
How many phalanges are in the thumb?
2
Proximal and distal
Only one Interphalangeal joint
Treatment for hand fractures
- What is key to recovery?
Stable fractures - can splint
Unstable fracture- surgery, straighten. Plates, screws, wires.
Stabilise the joints
GET THE JOINTS MOVING
MOVEMENT IS THE BEST THING FOR THEM
Boxer’s fracture
Minimal displacement
Fracture of metacarpal neck
No rotation
Index/middle finger commonly
More distal
“Buddy strap” and early mobilisation
Rotational deformity of fingers
Bend fingers in both hands to compare
Can occur after fracture of metacarpals.
Mallet Finger
A mallet finger is an extensor tendon injury at the DIPjt
Inability to extend the finger tip without pushing it.
Pain and bruising at the back side of the DIPjt
Typically this occurs when a ball hits an outstretched finger and jams it.
This results in either a tear of the tendon or the tendon pulling off a bit of bone (Avulsion fracture)
Mallet splint for 6 weeks 24/7
If large displaced avulsion fragment - surgery, wire inserted
Dermatotenodesis in chronic cases
PIPjt dislocation
Common
Must be treated quickly.
- pull to reduce
- buddy strap
Delayed presentation is a disaster –> Impossible to reduce and may require fusion
May lead to if post traumatic arthritis if not done quickly
Fracture
- fixation
- stabilisation
Bennet’s fracture
Intraarticular fracture/dislocation of base of the first metacarpal bone
Chunk of bone pulled off/avulsed by tendon can occur.
Testing the Flexor Digitorum Profundus (FDP)
Hold pip joint straight
Then bend finger tip
If it bends, the FDP is intact.
Testing the Flexor Digitorum Superficialis
Hold all fingers straight onto flat surface.
Bend middle finger (it will bend at PIP, not DIP)
FDS is intact if flexion at PIP
Severe mutilating injuries
Industrial Degloving Amputation. --- Preserve amputated parts on ice
Debridement
Establish stable bony support
Establish vascularity
Repair all tissues, nerves, tendons
Establish skin cover
- grafts
- flaps
Prevent/treat infection
If unreconstructable or unable to re establish nerve supply - AMPUTATION.
Burn injuries
- treatment
Standard principles:
- Respiratory (are lungs okay?)
- Infection
- dehydration
- pain relief
Rule of 9s
Skin loss –> more risk of dehydration. Skin is normally a barrier to excessive fluid loss. Without this, fluid is lost at an alarming rate.
Treatment for fingers and hands
- excise damaged skin and perform split skin grafts early
- aggressive mobilisation to prevent finger stiffness
- escharotomy (removal of thick, leathery, inelastic skin)
Eschar
Thick, leathery, inelastic skin which can form after burns
May require surgical release to allow movement
Can cause contracture.
Enthesitis
inflammation of the entheses, the sites where tendons or ligaments insert into the bone.
Type of collagen in tendons
Predominant cell type in tendons
Type 1 collagen.
Fibroblast
Tendinopathy – aetiology (intrinsic and extrinsic)
Intrinsic > age > gender > obesity > pre-disposing diseases (RA) > anatomical factors -- mal-alignment -- LLD
Extrinsic
> Trauma/injury > repetitive injury > drugs --steroids --abx (fluoroquinolone) > sports related factors
Fluorquinolones are known to cause…
Tendon ruptures
Ciprofloxacin
Tendinosis
> Histologic degeneration of collagen and extracellular matrix
> Due to Matrix Metalooproteinases (MMPs)
– more with age and repetitive strain
> Can be present and NOT painful. Painful in others
> Usually occurs at areas of poor blood supply
Tendon injuries - management
Conservative > rest > physio (ECCENTRIC strengthening) > analgesia --NSAIDS > Injections -- rotator cuff -- tennis elbow -- NOT achilles tendon or extensor knee mechanism (risk of rupture)
> Splinting
– achilles tendon
SURGICAL
> Debridement > Decomrpession > Synovectomy -- helps prevent rupture -- extensor tendons at wrist -- tibialis posterior
> Tendon transfer
- tib post
- EPL
What kind of strengthening exercises is good for tendon injuries?
Eccentric strengthening.
Inject or splint in an achilles tendinopathy
SPLINT
Most common muscle of rotator cuff to be injured
Suprasinatus
Rotator cuff pathology - clinical findings and management
Clinical findings
- achy pain down arm
- regimental badge area
- pain present in all 4 tendons of RC
- difficulty sleeping on
affected side, reaching overhead and on lifting - painful arc ± RC weakness
- positive impingement tests
Management
- Physio, inject
- surgical - subacromialdecomrpession
USS is gold standard
Impingement tests
Painful arc
Hawkin’s Kennedy - Supraspinatus
Jobe’s - supraspinatus
Scarf test
Gold standard for Rotator cuff imaging?
Ultrasound scan
Biceps Tendinopathy
- where is pain, radiating
- where is long head of biceps normally affected?
> Proximal or distal
Overuse, instability, impingement or trauma
Long and short head of biceps
> Pain anterior shoulder radiating to elbow
- aggravated by shoulder flexion, forearm pronation, elbow flexion
- snapping/clicking with shoulder movements if subluxation.
> Long head of biceps is normally affected in bicipital groove on humerus
Clinical signs of biceps rupture
Popeye sign
extensive bruising
The muscle bunches up at the opposite side to the tendon rupture
Biceps tendinopathy - management
Conservative treatment
- rest and physio
Surgical repair sometimes. - high risk of neuromuscular complications.
Lateral Epicondylitis (tennis elbow)
> Pain and tenderness over lateral epicondyle (origin of forearm extensors)
> Pain w/resisted extension of middle finger.
– opening a jar
> Non inflammatory
> Self limiting, can inject, surgical release is last resort
> Rest, physio, steroids
> Extending wrist is painful
> Enthesiopathy
Medial epicondylitis
> Inflammation of flexor forearm muscles.
> Medial elbow pain
> Repetitive stress
> Self limiting
> AVOID INJECTION
RA and extensor tendon rupture
Autoimmune attack on synovium –> tendon degeneration –> rupture
Weakness wrist extension or dropped finger
Tendon transfer
Synovectomy can prevent
EPL (Extensor pollicis longus) rupture
Can occur with RA or after Colle’s fracture.
Loss of function
Requires a tendon transfer
Knee extensor mechanism tendinopathy
Extensor mechanism = quadriceps muscle, quadriceps tendon, patella and patellar tendon
Tendon ruptures –> due to sports, blunt/penetrating trauma; diabetes
Palpable gap where tendon should be.
Xray may show an effusion or patella sitting in wrong place.
No straight leg raise (SLR)
Patella alta or baja on xray
Management
- surgical repair
- physio
- DO NOT INJECT
Patella alta - could be due to rupture of which tendon
Patellar tendon
so quadriceps tendon is pulling the patella superiorly with no resistance
Patella baja - rupture of which tendon
Quadriceps tendon
patellar tendon is pulling the patella inferiorly against no resistance
Traction Apophysitis
AT TIBIAL TUBERCLE = Osgood-Schlatter’s disease
> Insertion of patellar tendon into tibial tuberosity
> Adolescent active boys
> Leaves a prominent bony lump
> Can also happen at patella and achilles
Osgood schlatters
Common knee pain problem
Inflammation of the patellar ligament at tibial tuberosity/tubercle
overuse syndrome associated with physical exertion before skeletal maturity.
it is a traction apophysitis caused by multiple avulsion fractures of the secondary ossification center of the tibial tubercle (into which part of the patellar tendon is inserted)
Achilles tendinopahty
> Common in middle aged
> Sudden acceleration / deceleration
> Feels like being kicked or shot
LOUD POPPING SOUND
> Common in:
- RA
- Steroids
- tendonitis
Clinical findings
- palpable gap
- unable to tiptoe stand
- Simmond’s test +ve (cannot plantar flex)
- BRUISING
Management
> plaster; serial casts
> rehab and early ROM
> surgery
Tibialis posterior tendinopathy
> Tenosynovitis –> progressive elongation –> rupture
> Leads to progressive flat foot and valgus hind foot
– too many toes visible from back
Management
- NSAIDs
- orthotics / cast / inject
- ? tendon transfer
Age and shoulder pathologies
20s-30s - Instability 30s-40s - impingement 40s-50s - frozen shoulder 50s-60s - cuff tear >60 - arthritis setting in
Shoulder joint
4 joints.
Gelnohumeral joint
Acromio-clavicular
Sternoclavicular
Scapular thoracic
Glenohumeral Arthritis
Over 60s
Uncommon
Gradual onset
pain at rest and at night
stiffness
intermittent exacerbations
Functional difficulties
O/E
- asymmetry
- wasting
- limitation external rotation
- global restriction of ROM and pain
Treatment
- Non operative
- analgesia
- physio
- GH steroid injection
- Operative
- surface replacement
- GH arthroplasty (reverse polarity ?? wtf that is)
Carpal tunnel syndrome - median nerve neuropathy
> 30s
Commoner in females
- pregnancy
- hormonal fluctuations
Hypothyroidism
Diabetes
Obesity
RA
Median nerve compression.
Symptoms//
Early: pins & needles, pain, clumsiness
Late: numbness, weakness
Signs//
Thenar atrophy
Altered sensation
Weakness APB
Phalen’s test
Tilen’s (percussion)
Treatment//
- decompression surgery
- division transverse carpal ligament
Cubital tunnel syndrome - ulnar nerve
Ulnar nerve compression
Medial. (funny bone nerve)
Symptoms//
Early - ulnar pins and needles, pain, clumsiness
Late - numbness, weakness
Functional - at night, leaning
Signs//
- hypothenar and interosseous atrophy
- clawing
- altered sensation
- weakness at digits minimi
- weakness of grasp and pinch
Tinel’s test
Phalen’s test
Froment’s test
Treatment//
- decompression
- releases nerve from arcade of Struthers
- avoid exacerbating activities
Froment’s test
Tests for palsy of the ulnar nerve, specifically, the action of adductor pollicis.
Positive = compensatory flexion of interphalangeal joint of thumb
Upper Limb arthritis - symptoms
…causes
> Pain > Swelling > Stiffness > Deformity > ...Loss of function
Causes
- Degenerative
- inflammatory (RA, psoriasis, gout)
- post traumatic
- septic
Basic treatment principles for upper limb arthritis
> nothing > rest / analgesia / splintage > steroid injections > replace > fuse > excise
Sternoclavicular joint arthritis
> Rare > Swelling / pain at SC jt > Mx --- physio -- injection -- excision (rare)
CT scan
Acromioclavicular joint arthritis
Very common
Impingement
May be due to trauma
Mx
- injection
- excision
Glenohumeral Joint arthritis
> Less common than hip/knee
> Can be due to
- cuff tear
- instability
- previous srugery
- idiopathic (most)
> PAIN
Crepitus
Loss of movement
– esp. external rotation
Treatment
- analgesia
- rest
- surgery; shoulder replacement
Cuff tear arthropathy –> OA
Rotator cuff centres humeral head on glenoid
If torn, deltoid pulls head upwards
Abnormal forces on glenoid leads to OA
Anatomic shoulder replacement will fail
– so other replacement needed…
- -> Reverse geometry shoulder replacement
- reverses ball - socket
- increases lever arm of deltoid
- lengthens deltoid
- resurfaces joint
- prevents upward migration
- however not much research/data
Elbow arthritis
Rheumatoid
- erosion
- instability
Osteoarthritis
- pain
- restriction of movement
- osteophytes
- may be radiocapitellar only
Radiocapitellar OA
Radial head is only a secondary stabiliser so is not vital
Can be excised and replaced
Wrist arthritis
> RA
OA
Post traumatic
Instability
DRUJ
Distal Radio Ulnar Joint
Really important fro wrist rotation
Rheumatoid surgery
Synovectomy
Tendon realignment
Replacement
Fusion
Scapholunate Advanced Collapse (SLAC)
Terry thomas sign (big gap between the bones)
Scapholunate dislocation
Painful
Due to a fall/trauma
Scaphoid Nonunion Advanced Collapse (SNAC wrist)
Can occur due to scaphoid fractures
Fracture is failing to heal and scaphoid cannot union with adjacent bones
Progressive arthritis
Small joint OA
DIPjt commonly affected.
Pain, deformity, Heberden’s or Ostler’s nodes
NSAIDs, activity modification, capsaicin gel
Injections
Fusion
Base of thumb OA
2 site in body (after DIP)
Very common
Results in subluxation of CMCjt
Pain especially in pinch
Thumb CMCjt OA
Rest, analgesia, splints, capsaicin gel
Steroid injection
Surgery
Thumb can sublux
Psoriatic arthritis
Inflammatory arthritis
Systemic - skin, hair, nails, hips, knees, hands, wrists
Sausage fingers (dactylics)
Similar xray to RA (pencil in cup sign)
Swan neck deformity
Volar plate of PIP jt becomes attenuated
Small ligaments + lumbrical tendons fall more dorsal to joint centre
Boutonnière deformity
Extensor hood of PIPjt becomes attenuated
Slips of extensor tendon move from dorsal to volar to centre of rotation
- results in flexion of PIPjt
- middle phalangeal head buttonholes through extensor hood
lateral slips of extensor tendon stretched around PIPjt
- become taut
- results in hyperextension of DIPjt
Shoulder pathology - GP
How does the pain affect the individual?
Look how patient undresses
Asymmetry
Deformity
Scars
Feel
- Bony landmarks
- tenderness
- check axilla
- get patient to pinpoint site of pain
Move
- abduction
- active and passive
- external and internal rotation
Management
- mobilise
- NSAIDs (short term)
- local injection
- physio
- time
- referral (not resolving, stuck, instability)
Common problems - GP
Rotator cuff problems (esp supraspinatus tendonopathy)
Sub-acromial bursitis
Acromioclavicular disease (trauma in younger, arthritis in older)
Less common
- frozen shoulder
- OA/RA of shoulder
- recurrent dislocation
