MSK - Upper limb tendinopathies

Question 1

A pt presents with pain on radial side of wrist/base of thumb, esp. with movement (no Hx of trauma). What is the likely Dx?

Answer 1

De Quervain’s tenosynovitis: inflammation of sheath containing extensor pollicis brevis and abductor pollicis longus.

Question 2

Who does de Quervain’s tenosynovitis typically affect?

Answer 2

• 30-50 yo females
• pregnancy
• repetitive movs. of hand and wrist

Question 3

What examination findings suggest de Quervain’s tenosynovitis?

Answer 3

• tenderness, swelling +/- palpable thickening of tendon group fibrous sheath
• pain on abduction of thumb against resistance
• +ve FINKELSTEIN’S TEST: which thumb flexed across palm of hand, pain is reproduced by mov. of wrist into ulnar deviation and flexion

Question 4

How would you manage a pt with de Quervain’s tenosynovitis?

Answer 4

1. Advise wrist +/- thumb splint (spica)
2. ?NSAIDs
3. Steroid injection
4. Surgical decompression

Question 5

A pt presents with pain, numbness and paraesthesia in lateral 3 1/2 digits, worse at night. What is the likely Dx?

Answer 5

Carpal tunnel syndrome: compression of median n. within carpal tunnel

Question 6

Which pts does carpal tunnel tend to affect?

Answer 6

• 45-60 yo females
• pregnancy
• obesity
• prev. injury to wrist
• hypothyroidism
• Cushing’s syndrome

Question 7

What examination findings suggest carpal tunnel syndrome?

Answer 7

• +ve Tinel’s test (percussion over median n.)
• +ve Phalen’s test (holding wrists in full flexion)
• weakness of thumb abduction or wasting of thenar eminence in later stages
• nerve conduction studies

Question 8

How would you manage a pt with carpal tunnel syndrome?

Answer 8

1. advise rest, wrist splint at night and physio
2. ?NSAIDs
3. steroid injection
4. carpal tunnel release surgery (90% have improved symptoms)

Question 9

why is palm of hand spared in carpal tunnel syndrome?

Answer 9

palmar cutaneous branch of median n. branches off before entering carpal tunnel

Question 10

a pt presents with pain and tenderness over lateral epicondyle, which radiates down posterior forearm. What is the likely Dx?

Answer 10

Tennis elbow: damage to common extensor tendon as a result of repetitive stress

Question 11

What examination findings suggest tennis elbow?

Answer 11

• pain exacerbated on resisted dorsiflexion of wrist

- +ve Mill’s test (pain when: straighten pt’s arm and palpate lateral epicondyle, fully flex wrist, pronate forearm)

Question 12

how would you manage a pt with tennis elbow?

Answer 12

1. restrict activities, physio
2. ?NSAIDs
3. steroid injections (no long term benefit, best avoided)
4. glycerile trinitrate patches (off-label)
5. surgery

Question 13

what is the prognosis of tennis elbow?

Answer 13

Self-limiting: typical episode usually resolves <1 yr

Question 14

a pt presents with pain and tenderness over medial epicondyle, which radiates down forearm. What is the likely Dx?

Answer 14

Golfer’s elbow: damage to common flexor tendon as a result of repetitive stress

Question 15

What examination findings suggest golfer’s elbow?

Answer 15

• +ve Golfer’s elbow test (pain on simultaneous pronation and wrist flexion)
• may have associated ulnar neuropathy causing numbness/paraesthesia in 4th and 5th fingers