O&T: Upper Limb Painful Conditions Flashcards
Upper limb painful conditions
Classification:
- Acute / Subacute / Chronic
- Shoulder / Elbow / Hand / Wrist
Acute:
- Infection
- Trauma / Fracture
Subacute / Chronic:
- Overuse conditions
- Inflammatory conditions
- Degenerative conditions
4 Subcategories:
1. Overuse conditions
- Tennis elbow
- Golfer’s elbow
- De Quervain disease
- Trigger finger
- Wrist pain / Wrist sprain
- ECU - Inflammatory arthritis
- RA
- Gout
- Other sero-negative arthropathies - Osteoarthritis
Overuse conditions
- Very common in primary care, sports medicine, occupational medicines, orthopaedic practice
- Very heterogeneous group of diseases
1. Tennis elbow
2. Golfer’s elbow
3. De Quervain disease at wrist
4. Trigger finger
Cause: Unknown
Pathogenesis:
Mechanical overload, Micro-trauma
—> Inflammation —> Try to Heal
—> Continuous inflammation + healing
—> Tissue damage
—> Degeneration, Rupture
Pathology:
1. Tendon involvement
- Tennis elbow
- Golfer’s elbow
- Surrounding tissue around tendon
- De Quervain disease at wrist
- Trigger finger
Diagnosis:
- History
- Clinical examination
Investigations (not much needed):
- X-ray (for malalignment)
- Ultrasound / MRI (for confirmation of diagnosis / see involvement of which tissue)
Etiology of Overuse conditions
Often multi-factorial, some factors maybe more important in one patient than other
- Extrinsic factors:
- Repetitive mechanic load
- Equipment problems (e.g. wrong tennis racquet)
- Drugs (e.g. steroids) - Intrinsic factors
- Anatomic factors
—> Malalignment
—> Joint inflexibility
—> Joint laxity
—> Muscle weakness
—> Muscle imbalance
- Age-related factors
—> Tendon degeneration
—> ↓ Vascularity
—> ↑ Tendon stiffness
—> ↓ Healing response
- Tendon involvement
- Characterised by **Degeneration
—> Inflammatory cell infiltration seems to be **absent in chronic tendon injury - Common in ***bone-tendon insertion
Pathology:
- **Tennis elbow
- **Golfer’s elbow
- Surrounding tissue around tendon
- Inflammation of tendon sheath
- Tendon unaffected
Tissue affected:
- **Tendon sheath
- **Peritendinous tissue
Pathology:
- **Tenosynovitis (Inflammation of synovium that surrounds a tendon)
- **Peritendinitis
Examples:
- **De Quervain disease
- **Trigger fingers
Tennis Elbow
aka **Lateral epicondylitis
- Painful condition involving **tendons that attach to the bone on the lateral elbow (Lateral epicondyle)
- Muscle involved: Extensor Carpi Radialis Brevis (ECRB) (help extend + stabilise wrist)
—> Degeneration of tendon attachment of ECRB
Mechanical overload:
- Occurrence correlates with time of tennis playing
- Occur with many different types of activities (non-work / work-related) and sports activities
Pathophysiology:
- Activities that causes stress on ***Extensor muscle-tendon unit
—> Stress on tendon attachment
—> ↑ Strain to tendon
E.g.
- Hold too large a racquet grip
- Meating cutting
- Plumbing
- Painting
- Weaving
Clinical features:
- 30-50 yo
- M=F
- Pain on **outside aspect of elbow
- Pain starts at **elbow —> down to forearm —> hand
- Produced by any activity which places stress on tendon e.g. **Gripping / **Lifting
Signs:
- Tenderness at **Lateral epicondyle of elbow
- Pain elicited by **moving elbow
- Pain on ***resisted wrist extension (DDx: Radial head OA)
DDx (SpC Revision):
1. C6 / C7 radiculopathy
2. PIN syndrome (Posterior interosseous nerve syndrome)
3. Radial head OA
Treatment:
1. Rest
2. **Counter force strap
3. **Steroid + LA injection
4. Operation
Golfer’s elbow
aka **Medial epicondylitis
- less common
- Painful tendinitis on **inner aspect of elbow
- at the origin of “Flexor / Pronator” muscles (i.e. Medial epicondyle)
Mechanical overload:
- Repeated **swing stress to elbow
- Heavy lifting / Hammering
- Sport activities that involve a lot of **throwing e.g. Archery, Baseball, Softball, Javelin
- Repeatedly use ***wrist / clench fingers (flexion) e.g. Weight training
Clinical features:
- >35 yo
- M=F
- Pain / Tenderness on **medial epicondyle
- Elbow stiffness (sometimes)
- Pain when try to make a **fist, **swing golf club, turn doorknob, lift weight, pick up something with palm down (pronation), **flex wrist
- Weakness in ***hand and wrist
De Quervain disease
Stenosing Tenosynovitis of 1st Extensor compartment of wrist
- **Extensor Pollicis Brevis (EPB)
- *Abductor Pollicis Longus (APL)
(aka 媽媽手)
Epidemiology:
- Occurs most commonly in women in their sixth decade of life
- Increase incidence in patients with Dupuytrens’ disease, RA, gout or DM
- Bilateral involvement in 30% of patients
Clinical features:
- **Middle-aged women
- Repetitive activities e.g. **Keyboarding, Assembly line work, Carpentry, ***Lifting newborn babies
- Pain / Swelling in radial wrist
- Aggravated by thumb motion
- Pain often radiates up to the forearm or down to the thumb
P/E:
- Tenderness over **radial styloid
- **Finkelstein test: Ulnar deviation of wrist with fist formed around thumb stretches EPB, APL tendon —> causes pain over styloid process
Treatment:
1. Conservative
- Injection
- Splintage
- Surgery
- Decompression
Trigger finger
Aka ***Flexor Stenosing Tenosynovitis
Pathophysiology:
- Chondrocytes proliferation —> ↑ Extracellular matrix —> Fibrocartilage metaplasia in **A1 pulley of Flexor tendon (*MCP joint) —> Size disproportion between a flexor tendon and its tendon sheath
Clinical features:
- 50-60 yo
- F>M
- Dominant hand
- Thumb, (Middle), Ring finger most affected
Pathology:
- Primary (Idiopathic)
- Secondary:
—> **Carpal tunnel syndrome (18-23%)
—> **De Quervain’s disease
—> DM
—> ***RA
—> Dupuytren’s contracture
—> Giant cell tumour, Schwannoma
Risk factors:
- **Repetitive grasping —> **thickening of pulley
- ***Occupation
Grading:
Grade 1: Pre-triggering
- pain in A1 pulley
Grade 2: Active triggering
- active extension
Grade 3: Passive triggering
- 3a: need passive extension
- 3b: unable active extension
Grade 4: Contracture
- fixed flexion contracture of PIPJ
Treatment:
1. Conservative
2. Steroid (SE: discolouration of skin) / LA injection (SpC Revision)
3. Surgical release (open / percutaneous)
Treatment for Overuse conditions
Conservative treatments
1. Avoidance of mechanical overload
2. Activity modification, Change occupation
3. Appropriate protective device
4. ***Physiotherapy
- stretching / strengthening exercise (esp. if muscle imbalance)
- USG / heat treatment (to ↓ pain)
- ***Intermittent splintage
- tennis elbow brace
- ↓ tension on tendon —> allow it to heal - Extracorporeal shock wave therapy
- no level 1 evidence
- persistent calcifying tendinitis of shoulder —> 62% partial / complete disintegration of deposit —> functional improvement
- some success in 50-60% tennis elbow patients - ***NSAID
- short term effect as analgesic
- ∵ no inflammation in some overuse conditions —> unclear whether NSAID can alter the natural history of tendinopathies -
**Steroids
- oral steroid: NO proven benefit
- **Local injectable steroid
—> minimal invasive
—> high initial success rate
—> risk: possibility of **steroid atrophy + **tendon rupture (if inject >=3 times), recurrence, complications
Surgery
- Failure of conservative treatment
- Significant symptoms affecting ADL / Secondary joint contracture
- Percutaneous vs Arthroscopic vs Open
- Tendon
- **Debridement of degenerative tendon
- Reinsertion
- **Repair
- ***Tendon grafting (if whole tendon degenerated) - Tendon sheath
- **Synovectomy
- **Retinaculum release - Excision of bony structure
- if bony malalignment
Wrist pain
Often caused by ***Trauma instead of Overuse
Ulnar side:
1. Extensor Carpi Ulnaris (ECU) tendonitis / dislocation
2. Distal Radioulnar Joint (DRUJ) subluxation / dislocation (∵ Triangular fibrocartilage complex (TFCC) tear)
Radial side:
3. **Scapholunate ligament tear
4. +/- **Scaphoid fracture
- ECU tendonitis / subluxation
Extensor Carpi Ulnaris (ECU):
- **6th Extensor compartment of wrist
- Strong stabiliser of **wrist (Extend + Adduct wrist)
ECU tendonitis:
- Pain along extensor tendon
- ***ECU synergy test: Supinated forearm
—> spread out Thumb, Index, Middle finger
—> grasps patient’s thumb and long finger with one hand, palpates the ECU tendon with the other hand
—> the patient abduct the thumb against resistance (which require ECU to stabilise joint / keep wrist in extension)
—> Recreation of pain along dorsal ulnar aspect of wrist: Positive result
ECU subluxation:
- ECU tendon subluxed over ulnar styloid when in Supination, recover when Pronation
- Snapping of wrist
- Repetitive subluxation —> ECU tendonitis
- Treatment: ***ECU pulley reconstruction
- TFCC tear
Triangular fibrocartilage complex:
- Strong stabiliser of ***Distal Radioulnar Joint (DRUJ)
—> Tearing
—> DRUJ Subluxation
Causes:
- Falling on outstretched hand —> younger people few distal-radius fracture —> DRUJ instability instead
Clinical features:
- Pain when rotating forearm
Treatment: TFCC repair / reconstruction
- Scapholunate ligament tear
(Scapholunate ligament: (from youtube)
- Strong ligament between Scaphoid and Lunate bone
- Stabiliser of wrist)
Diagnosis:
***Watson test:
- Grasps the wrist with their thumb over Scaphoid tubercle (volar aspect of the palm) in order to prevent the scaphoid from moving into its more vertically oriented position in ulnar deviation
- Wrist in slight extension —> move from ulnar to radial deviation —> release thumb over scaphoid —> examiner will feel a significant ‘clunk’ and patient will experience pain
- If SL ligament disrupted —> Scaphoid will subluxate over the dorsal lip of distal radius
Treatment:
- **Scaphoid fixation
- **SL repair
- Bone graft if non-union
- Scaphoid fracture
- Easily missed
- Radial wrist pain
Treatment of Wrist pain
- Rest
- Splintage / Cast
- Physiotherapy
- Surgery
- for high demand patients e.g. Athletes
- affect ADL
—> Debridement
—> Repair
—> Reconstruction
E.g. ECU pulley reconstruction, TFCC repair / reconstruction, Scaphoid fixation / SL repair
Inflammatory conditions / Systemic autoimmune disorders
- Affecting multiple joints
- Hands, Wrists, Elbows
- RA
- Gout
- Psoriatic arthritis
- RA
- Inflammatory arthritis of synovial joints
- Systemic chronic inflammatory disease
- Proliferative synovium (***Pannus) erodes into surrounding structures:
—> Articular cartilage
—> Bone
—> Ligament
—> Tendon
Epidemiology:
- 0.3-0.4% in HK
- F:M = 3:1
- Age of presentation: 4-5th decade
- Very strong familial hereditary history
—> ***HLA DR4, DR1
—> 1st degree relative 3x risk
Pathogenesis:
Injury to synovial microvascular endothelial cells
—> Trigger inflammatory reaction
—> Influx of PMN leukocyte, monocytes, macrophages
—> Inflammatory mediators produced
—> Stimulate osteoclasts
—> **Subchondral osteopenia (Inflammation of joint —> Pain + Swelling —> Immobilisation —> further enhance osteopenia)
—> **Joint destruction (from ***Persistent inflammatory reaction)
Clinical features:
1. Synovitis
- with swelling + pain
- Ruptured extensor tendon at wrist joint
- Mallet finger / Drop finger (DIP drop / flexed)
- Boutonniere deformity (PIP flexed, DIP hyperextended)
- Swan neck deformity (DIP flexed, PIP hyperextended) -
**Flexor tenosynovitis
- Transverse carpal ligament (Flexor retinaculum) + Flexor tendon sheath —> more resistant to distension than Extensor retinaculum
—> **Carpal tunnel syndrome + Digital tenosynovitis
—> Treatment: Radical synovectomy - Extra-articular manifestations:
- Vasculitis
- Pericarditis
- Pulmonary nodules
- Episcleritis
- SC nodules (most common, 25% of patients with RA)
Pattern of joint involvement in RA
Hand / Wrist
1. Proximal interphalangeal joint (PIP) (Thumb無呢個joint)
2. Metacarpophalangeal joint (MCP)
3. Carpometacarpal joint (CMC)
***NO Distal interphalangeal joint (DIP)!!!
Large joint:
1. Knee
2. Ankle
3. Elbow
4. Shoulder
Spine:
1. Cervical spine
Criteria of diagnosing RA
O/T: use ***1987 ARA —> Good screening tool before referral to Rheumatologist
- Cell-mediated
- > = 4 of 7 + must > 6 weeks:
1. **Morning stiffness >=1 hour
2. **Arthritis of >=3 joint areas
3. Arthritis of hand joints
4. **Symmetric arthritis
5. **Rheumatoid nodules
6. ***Serum rheumatoid factor (IgM)
7. Radiographical changes
Radiological changes of RA
Start with Wrist —> Fingers
- Soft tissue swelling
- joint space widened - Periarticular osteopenia
- Peripheral cartilage + Bone erosion
- Joint space narrowing
- Subchondral bone + Surface cartilage erosion - Joint subluxation + Deformity
- Gout
- Chronic heterogenous disorder of Urate metabolism
—> Deposition of ***Monosodium urate crystals in the joints + soft tissues
—> Inflammation + Degenerative changes
Types:
1. Primary gout (90%)
- inborn error of metabolism
- Secondary gout (10%)
- i.e. renal failure
Only 5% hyperuricemia patients will develop gout
Clinical features:
- ***Men
- >40yo
- Progressive if untreated:
1. Asymptomatic hyperuricemia
2. Acute gouty attack
3. Intercritical gout
4. Chronic tophaceous gout (Chalky gouty tophi)
Hallmarks of Gout:
1. Elevation of serum uric acid (usually)
2. Recurrent attacks (Flares) of acute inflammatory arthritis with monosodium uric crystals demonstrated in synovial fluid
3. Bone + Joint **destruction (some)
4. Aggregates of uric acid crystals (Tophi) in / around **joints, soft tissues
5. Tophi in ***bone —> Erosion (some)
6. Kidney disease + Stones
Investigations:
1. X-ray
- ***Tophi replacing joint
- Aspiration of synovial fluid
- **inflammatory cells
- **monosodium urate crystal
Common sites of acute flares
- ***1st MTP joint (most common)
- Olecranon bursa, Elbow, Wrist, Fingers
- Knee, Ankle, Subtalar, Midfoot
- Psoriatic arthritis
- Systemic condition
- May be associated with Psoriasis: dry, red, scaly skin patches
- 5-20% develop associated arthritis —> Inflamed synovium
- Usually affect ***hands but also affect spine, feet, jaw
Epidemiology:
- M=F
Clinical features:
- Affect joints **asymmetrically (vs Symmetrical in RA)
- Red, dry, scaly skin lesion (vs Distinct nodules in RA)
- **Pitting, ridging, crumbly appearance of nails
- ***Fingers first: Swelling in PIP + Deformities of DIP —> Larger joint (MCP) / Wrist / Over tendons (vs RA: affect wrist first)
Extra-articular features:
- Vasculitis / Raynaud’s phenomenon
