MSK: Hand and Shoulder

Question 1

What are some of the extra-articular manifestations of RhA?

Answer 1

Ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, hydrochloroquine retinopathy

Respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy

Cardiac: IHD, pericarditis, pericardial effusion

Nervous system: polyneuropathy, mononeuritis multiplex, carpal tunnel syndrome

Systemic: osteoporosis, infections (e.g. septic arthritis), depression, anaemia, malaise, lethargy, amyloid

Rare: Felty’s syndrome (RA + splenomegaly + low white cell count)

Question 2

Causes of carpal tunnel

Answer 2

idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
acromegaly

Question 3

X-Ray changes for OA

Answer 3

Loss of joint space
Subchondral cysts
Subchondral sclerosis
Osteophyte formation at the joint margin

Question 4

Features of Ankylosing Spondylosis

Answer 4

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis

Question 5

RA deformities you would find in the hand?

Answer 5

 Boutonniere’s
 Swan neck
 Z-thumb
 Ulnar deviation @ the MCPs 
 MCP volar subluxation

Question 6

Loss of thenar eminence

Answer 6

Damage to the median nerve

Question 7

Loss of 1st dorsal interroseus

Answer 7

Damage to the ulnar nerve

Question 8

Autonomous sensory areas of the hand (i.e. supplied by one nerve)

Answer 8

 Median: pulps of index and middle fingers

 Ulnar: pulp of little finger

 Radial: 1st dorsal web space

Question 9

Autonomous motor areas of the hand (i.e. supplied by one nerve)

Answer 9

 Median: abductor pollicis brevis

 Ulnar: 1st dorsal interosseous

 Radial: MCP extension

Question 10

Causes of Dupuytren’s Contracture?

Answer 10

BAD FIBERS

 Bent penis: Peyronie’s (3%)
 AIDS
 DM

 FH: AD
 Idiopathic : commonest
 Booze: ALD
 Epilepsy meds and epilepsy: phenytoin
 Reidel’s thyroiditis and other fibromatoses

Question 11

Signs of OA in the hand

Answer 11

 Heberden’s nodes: swelling of DIPJs

 Bouchard’s nodes: swelling of PIPJs

 Squaring of the thumb CMC

Question 12

Signs of ulnar nerve palsy

Answer 12

Look

 Partial claw hand: little and ring fingers

Wasting of:
Hypothenar eminence
Dorsal interossei

Movement

 Weak abduction and adduction of fingers
 Weak flexion of DIPJ in little and ring fingers

Question 13

Compound movements tested at the start of the shoulder examination

Answer 13

Hand behind back

Hand behinds head

Question 14

What are the muscles of the thenar eminence

Answer 14

Lateral lumbricals
Opponens pollicis muscle
Abductor pollicis brevis
Flexor pollicis brevis

Question 15

What are the motor and sensory function of the radial nerve?

Answer 15

Motor: Extension (forearm, wrist, fingers, thumb)
Sensory: Small area between the dorsal aspect of the 1st and 2nd metacarpals

Question 16

What are the motor and sensory function of the ulnar nerve?

Answer 16

Motor: Intrinsic hand muscles except LOAF* and Wrist flexion

Sensory: Medial 1½ fingers (hypothenar)

Question 17

What are the motor and sensory function of the median nerve?

Answer 17

Motor: LOAF* muscles

Features depend on the site of the lesion:

• Wrist: paralysis of thenar muscles, opponens pollicis
• Elbow: loss of pronation of forearm and weak wrist flexion

Sensory: Palmar aspect of lateral 3½ fingers

Question 18

Volkmann’s Ischaemic contracture

Answer 18

Permanent shortening (contracture) of forearm muscles, usually resulting from injury, that gives rise to a clawlike deformity of the hand, fingers, and wrist.

Due to brachial artery injury in a supracondylar fracture

Question 19

5 characteristic patterns of psoriatic arthritis?

Answer 19

DIPs
Symmetrical polyarthritis
Asymmetrical oligoarthritis
Spondyloarthropathy
Arthritis mutilans

Question 20

What test for shoulder instability? Which joint is it assessing?

Answer 20

Shoulder apprehension test

Glenohumeral

Question 21

What test for shoulder impingement syndrome?

Answer 21

Hawkins test or Neer test

Question 22

What test for supraspinatous pathology?

Answer 22

Jobe’s test (empty can)

Question 23

What test for subscapularis pathology?

Answer 23

Gerber’s lift-off test

Question 24

What test for teres minor/infraspinatous pathology?

Answer 24

Resisted external rotation (Hornblower’s test)

Question 25

How do you test froment’s sign and what is it assessing?

Answer 25

Ulnar palsy - weakness of abductor pollicis
Ask pt to hold paper between index and straight thumb
If thumb DIP bends then positive test for weakness (long flexors are compensating)

Question 26

Causes of flexion deformity on praying position?

Answer 26

RA
OA
Scleroderma
Dupuytren’s

Question 27

What are you looking for in the hands?

Answer 27

Nails: pitting, oncholysis, clubbing, koilonychia, leuconychia, nailfold infarcts

Fingers: scars, swelling, erythema, Swan-neck, boutonniere, z-thumb, heberden’s, bouchard’s

MCP: swelling, ulnar deviation, subluxation

Dorsum: tight waxy skin of telangiectasia, interossei wasting, rheumatoid nodules, psoriatic plaques

Wrists: radiocarpal subluxation, prominent ulnar styloid

Question 28

What are you looking for in the elbows?

Answer 28

Scars
Rheumatoid nodules
Psoriatic plaques

Question 29

What are you looking for in the ears?

Answer 29

Psoriatic plaques

Gouty tophi

Question 30

Key SEs of DMARDs?

Answer 30

Marrow suppression
Hepatotoxicity
Rash
GI upset (nausea and oral ulcers)

Methotrexate: pneumonitis, fibrosis, megaloblastic anaemia

Hydroxychloroquine: retinopathy

Question 31

How do you test the integrity of the acromioclavicular joint?

Answer 31

Scarf test

Question 32

How do you test the function of the serratus anterior?

Answer 32

Wall push test