MSK pathology (UL)

Question 1

What is the typical presentation of overuse/strain injuries at presentation?

Answer 1

• exact time/mechanism of injury can be identified
• pain is non-progressive, and produced by one/few movements
• on examination there is local tenderness and pain reproduced on resisted active movement/stress testing

Question 2

What are the most common places to get tendonitis?

Answer 2

Shoulder
Elbow
Achilles tendon

Question 3

What is De Quervain’s tenovaginitis?

Answer 3

disease of unknown cause with painful inflammation of the abductor pollicis longs and extensor policies brevis tendons in the first dorsal compartment of the wrist

Question 4

How does De Quervain’s tenovaginitis present?

Answer 4

acute pain over first dorsal compartment when using the thumb and swelling/tenderness over the area
most common after unaccustomed intensive activity

Question 5

What is the special test for De Quervain’s tenovaginitis?

Answer 5

Finkles test positive

thumbs across palm, ulnar deviation causes pain over the tunnel

Question 6

What is carpal tunnel syndrome?

Answer 6

compression neuropathy of the median nerve as it passes through the carpal tunnel

Question 7

What is the cause of carpal tunnel syndrome?

Answer 7

95% are idiopathic
also seen in other conditions - DM, RA, hypothyroidism, acromegaly and trauma (Colle’s fracture)

3 times more common in women

Question 8

How does carpal tunnel syndrome present?

Answer 8

• pain/paraesthesia in the hand, worst in the morning
  due to wrist flexion when you sleep. may wake patient when they sleep and they shake hand for relief
• thenar muscle weakness/wasting, first noticed as clumsiness
• sensory loss in the palm/radial 3.5 fingers

Question 9

What is seen on examination of carpal tunnel?

Answer 9

• thenar wasting
• difficulty with thumb abduction and active thumb opposition
• positive tinsel’s (tapping leads to parathesia) and positive Phalen’s (pain for flexion for 60sec)

Question 10

What investigations should be carried out to investigate cubital tunnel syndrome?

Answer 10

X-rays showing pathological osteophytes

nerve conduction studies can be used to show slowing at the elbow

Question 11

What is the conservative management of cubital tunnel syndrome?

Answer 11

night time splints
NSAIDs
Activity modification

Question 12

What is the surgical management of cubital tunnel syndrome?

Answer 12

simple cubital tunnel decompression

anterior transposition of the nerve

Question 13

What is a ganglion cyst?

Answer 13

A soft tissue swelling filled with degenerative myoxoid fluid that stems from an underlying joint capsule, ligament or tendon sheath

Question 14

How does a ganglion cyst present?

Answer 14

patient will complain of a lump in the hand or wrist with cosmetic concerns or associated pain

majority of patients are women aged 20-40, they can be idiopathic or follow trauma

Question 15

What is seen on examination in a ganglion cyst?

Answer 15

Most common sites are on dorsal of the wrist, volar aspect of the wrist and at the base of the finger from the flexor sheath
they are not fixed to the skin and can become more obvious with some movements
they transilluminate

Question 16

What is trigger finger?

Answer 16

Idiopathic fibrosis of the flexor tunnel leading to an intratendinous nodule that interrupts normal finger movement
usually involves the ring/middle finger

Question 17

What is the presentation of trigger finger?

Answer 17

potential flexion at PIPJ/DIPJ
can feel triggering of the flexor tendons and a nodule can be felt at base of finger
jerky movement on flexion and full extension may be limited due to secondary joint problems

Question 18

What is the management for trigger finger?

Answer 18

Spontaneous resolution is possible with activity modification, NSAIDS, tendon sheath corticosteroid injection
Surgical Mx: release of the A1 pulley, or tenosynovectomy in RA patients

Question 19

What is Dupuytren’s contracture?

Answer 19

Progressive painless thickening of the palmar fascia causing flexion deformities of the fingers and functional difficulties
more common in males, FHx, also linked to trauma, liver cirrhosis, phenytoin, diabetes

Question 20

What is the presentation of Dupuytren’s?

Answer 20

Nodules/cords in the palm or fingers, with flexion of MCP/PIP joints, classically affecting middle and ring fingers
thickened palmar fascia, ‘Garrod’s’ pads on the dorsal of the PIPJs
Loss of passive and active extension of joints

Question 21

How is Dupuytren’s managed?

Answer 21

conservative - no specific treatment is required if the patient has no functional impairment

surgical - needle aponeurotomy, enzymatic fasciotomy, fasciotomy or dermfasciectomy

Question 22

What is medial epicondylitis (golfers elbow)?

Answer 22

tendinopathy of the common flexor-pronator origin

it is caused by recurrent microtrauma to the elbow joint

Question 23

How does media epicondylitis present?

Answer 23

pain develops sub acutely, exacerbated by use and settles with rest
pain can be severe and radiate up arm

Question 24

What is seen on examination of golfers elbow?

Answer 24

tenderness around the medial epicondyle and pain triggered by resisted flexion of the hand
normal range of movement
no neuro symptoms (otherwise think about ulnar nerve entrapment)

Question 25

What is the management of medial epicondylitis?

Answer 25

Simple analgesia (NSAIDS) and rest (activity modification)
Referral to physic for strengthening
Epicondylar clasp (provided by the splint department)
Steroid injection
X-ray of the joint if all the above are unsuccessful to rule out OA
Surgical management - golfers elbow release

Question 26

What is lateral epicondylitis (tennis elbow)?

Answer 26

Tendinopathy of the common extensor tendon origin
more common than golfers elbow, peak in incidence at 40-60 years
caused by repetitious gripping/grasping movements

Question 27

How does tennis elbow present?

Answer 27

pain develops subacutely
exacerbated by movement and relieved by rest
pain may radiate up/down arm

Question 28

What is seen on examination of tennis elbow?

Answer 28

tenderness distal to the lateral epicondyle
pain reproduced by resisted extension of the wrist
passive range of movement is normal

Question 29

What is the management of tennis elbow?

Answer 29

Conservative management same as for golfers elbow

Surgical intervention with tennis elbow release

Question 30

What is olecranon bursitis?

Answer 30

the olecranon bursa becomes enlarged as a result of pressure or friction
it is not a painful condition, so if the pain is present consider differentials (gout/RA/infection)