MSK Flashcards
When should you consider ulnar nerve compression at elbow?
Also called cubital tunnel syndrome
Pain at the medial elbow, with numbness and tingling in the little and ring fingers.
grip weakness.
loss of hand dexterity.
Can occur from prolonger elbow flexion but also distal humeral fracture
Chronic: 4th 5th finger clawing, hypothenar muscle wasting
Tennis vs golfer’s elbow
Tendonopathy
Tennis: lateral epicondylitis, pain resisted wrist extension
Golfers: medial epicondylitis, pain resisted wrist flexion
Management of tendinopathy (golfers, tennis, achilles)
Progressive loading >12 weeks physio, isometric first,
Modify activity
Ice
Pain relief
Steroid injection 6 weeks pain relief but doesn’t fix problem
Management ulnar nerve compression
If muscle wasting/progressive neurological signs- urgent T+O
Otherwise:
Modify activities
Keep the elbow extended with a soft pad or towel in the antecubital fossa overnight
Neural glides/slides, physio
If persistent paraesthesia, routine T+O ?surgery
Features of carpal tunnel
Median nerve compression
Pain/paraesthesia wrist/hand, worse at night
The patient often shakes their hand or dangles it out of bed to ease the symptoms.
Provoked by flexing (Phalen) or extending wrist, or tapping (Tinel)
May have weakness of hand grip, specifically with thumb abduction and pincer grip.
If severe, thenar muscle wasting
Management carpal tunnel
Modify activities
Wrist splinting at night
Exercises, neural glides
Consider steroid injection
Routine ref T+O ?surgery if:
-Permanent sensory loss
-Motor weakness
-Muscle wasting
-Failure conservative treatment 3 months
What is DeQuervian’s tenosynovitis?
radial-sided wrist pain on flexing and extending the thumb, especially with radial or ulnar deviation.
Abductor pollicis longus and extensor pollicis brevis
Women, age 30-55, esp lifting young baby
Test for DeQuervian’s
Finklesteins Test-
In neutral sup/pronation, adduct the thumb across the patient’s palm and place the wrist into ulnar deviation.
Management DeQuervian’s
NSAIDs
Strengthening exercises
Modify activity
Wrist thumb splint
Consider steroid injection
What are Dupytrens contractors associated with?
Smoking
Alcohol excess
Diabetes
Hypercholesterolaemia
FHx
Peyronies disease
Management Dupytrens
Physiotherapy, splints, exercises, and steroid injections do not appear to alter the course of the problem.
Routine T+O for surgery if impacting job/ADLs/function
When should you consider hand therapy for base of thumb CMCJ OA?
Simple measures and splints not helping and:
Experiencing barriers to recovery.
Loss of strength, range of movement, proprioception, or function.
Pain is a key feature.
Can also consider steroid injection
Referral criteria for ganglion
Ganglion should transilluminate
Routine hand clinic if:
significant pain.
functional impairment affecting ADLs
Pressing on neighbouring structures, e.g. nerves.
Diagnostic uncertainty (USS not usually needed)
What underlying diagnosis could there be with trigger finger?
Usually none
RA, amyloidosis, diabetes, carpal tunnel syndrome, and in patients on dialysis
Referral criteria trigger finger
Urgent hand clinic if:
Finger is locked
Routine hand clinic ?surgery if:
Diabetes
Severe symptoms.
Preference for surgery
Steroid injections fails/not available in GP
Features and management of ACJ pain
Pain over ACJ on scarf test
Rest, NSAIDs
Steroid injection
Physio
Risk factors and phases of frozen shoulder
Age 40-60
Diabetes
Severe pain, esp at night, can radiate down arm
Painful freezing pahse, 3-9m, can’t lie on affected side, stiff, global loss of ROM, steroid injection helps pain
Stiff frozen phase, 3-18m, stiff, pain improves, exercise helps
Recovery thaw phase, stretching pain only, gradual return of function, 12-36m
Examination features of frozen shoulder
Global reductions active and passive movement, pain, external rotation most obvious
Describe 4 step shoulder examination
-Check neck movement, looking for stiffness or pain in the neck or down the arm.
-Identify the acromioclavicular joint and look for tenderness over the joint.
-Identify the glenohumeral joint and check external rotation. Asymmetrical external rotation suggests a glenohumeral joint problem.
-Identify the subacromial space and look for pain on elevation of arm or on resistance. Pain on internal rotation at 90° or a painful arc suggests a subacromial space problem.
What features would suggest glenohumeral joint OA
Age>60
Insidious
Pain variable, related to movement, pain free at rest
Internal and external rotation limited
Crepitus
Features of rotator cuff pathology
Age>35
Limited active but full passive movement
Pain tip of shoulder/lateral deltoid.
Gradual onset.
Painful arc from 70 to 120 degrees of active abduction
Management rotator cuff pathology
Activity modification, self help
Physio 6 weeks
if no improvement steroid injection
Refer routine T+O if no improvement 12w physio/steroid injection or full thickness rotator cuff tear>1 cm
What’s Thompson’s test?
Lie pt prone.
Resting position of injured foot is more dorsiflexed than other side,
Squeeze the calf of the affected leg, looking for normal plantar flexion. Absence of plantar flexion indicates a tendon rupture- admit
Ottowa ankle rules that signify need to do ankle X-ray
Ankle X‑ray series is indicated if there is pain near either of the malleoli and either of the following:
Inability to weight bear both immediately after the injury and when examined acutely (4 steps)
Bone tenderness at the posterior edge or tip of either malleolus
Ottowa ankle rules that signify need to do foot X-ray
Pain in the midfoot and either of the following findings:
Inability to weight bear after the injury and when examined acutely (4 steps)
Bone tenderness at the navicular or the base of the fifth metatarsal
Advice after a sprain
Modify activities according to pain- early mobilisation is important.
Apply ice for 20m every 2hrs for the first 2-3 days after injury.
OTC analgesia. Avoid ibuprofen in the first 48hrs
Elevate ankle when resting.
Use elasticated tubular bandage doubled over to provide compression, and remove at night.
Rehab exercises
(If grade 3 sprain ankle, ED assessment + moon boot)
Risk factors for achilles tendinopathy
Overuse injury
Recreational athletes aged 30-50
Poor running technique
vascular disease, T2DM, inflammatory arthritis
ciprofloxacin, steroids
Features of gout
deposition of monosodium urate crystals within and around joints, acute + chronic inflammation-> joint damage
Pain sudden in onset, peaking 24- 72 hours, resolving over 1-2 weeks
May see gouty tophi joints/ears
