Regional Adult Orthopaedics: Spine and Upper Limb Master Deck Flashcards
What is mechanical back pain?
Recurrent relapsing and remitting back pain with no neurological symptoms; pain is worsened with movement and relieved by rest
Hx of mechanical back pain?
Tend to be aged between 20-60 years and have had several flare-ups; no red-flag symptoms present
Causes inc: • Obesity, poor posture, poor lifting technique, lack of physical activity • Depression • Degenerative disc prolapse • Facet joint OA • Spondylosis
What is spondylosis?
Intervertebral discs lose water content with age, resulting in decreased cushioning and increased P on the facet joints, leading to secondary OA
Treatment of mechanical back pain?
Analgesia
Physiotherapy; also, maintain normal function (bed rest is not advised as it leads to stiffness and spasm of the back, exacerbating disability)
Spinal stabilisation surgery:
• Only if a single level (2 adjacent vertebrae) is affected by OA or instability
• If this has not improved with physio
• If there is no other adverse secondary gain or behavioural issues that may adversely affect the outcome of surgery, e.g: compensation claim
Why is surgery for mechanical back pain rare?
Most have multi-level disease of the spine
There may be recurrence of symptoms and no benefit around 5 years from surgery
Describe acute disc tears
Can occur in the outer annulus fibrosis of an intervertebral disc, which classically happens after lifting a heavy object, e.g: lawnmower
Can cause severe discogenic back pain
Management of acute disc tears?
Symptoms tend to resolve after 2-3 months
Analgesia and physiotherapy (mainstay of treatment)
How can prolapsed discs cause neurological symptoms?
If a disc tear occurs, the gelatinous nucleus pulposis can herniate/prolapse through the tear; this disc material can impinge on an exiting nerve root, causing:
• Pain and altered sensation in a dermatomal distribution
• Reduced power in a myotomal distribution
• Reflexes may also be reduced (there are LMN signs)
What is sciatica?
AKA lumbar radiculopathy
The commonest site for disc material impinging on nerve roots is in the lower lumbar spine (with the L4, L5 and S1 nerves comprising the sciatic nerve)
Pain radiates to the part of the sensory distribution of the sciatic nerve, i.e: buttock and/or leg pain, with neurological disturbance
Which nerve roots are compressed in the lumbar spine?
Nerve root corresponding to the lower of the 2 vertebrae in the affected segment
Typical patterns of lumbar spine nerve root compression and the symptoms and signs?
L3/4 prolapse (L4 root entrapment) - pain down to medial ankle (L4), loss of quadriceps power and reduced knee jerk
L4/5 prolapse (L5 root entrapment) - pain down dorsum of the foot and reduced power of the extensor hallucis longus and tibialis anterior
L5/S1 prolapse (S1 root entrapment) - pain to sole of foot, reduced power of planarflexion and reduced ankle jerk
Variable presentations of lumbar disc prolapse?
Very lateral disc prolapse can cause impingement of the nerve root corresponding to the vertebra above, e.g: an L4/5 impingement presenting with an L4 nerve radiculopathy
Treatment of sciatica (AKA lumbar radiculopathy)?
Most disc prolapses resolve spontaneously by 3 months
First line treatment - analgesia, remaining mobile and physio
Drugs for neuropathic pain - e.g: Gabapentin, can be used if leg pain is part. severe
Surgery (disectomy) is rare:
• If pain is not resolving with physio
• If there are localising signs suggesting a specific nerve root inv.
• +ve MRI evidence of nerve root compression
• Evidence of secondary gain or psychological dysfunction is a contraindication
How can bony nerve root entrapment occur?
OA of the facet joints can cause osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica
Treatment of bony nerve root entrapment?
Surgical decompression (trimming of the impinging osteophytes) in suitable candidates
Causes of spinal stenosis?
With spondylosis and a combination of bulging discs, bulging ligamentum flavum and osteophytosis
Cauda equina of the lumbar spine has less space and multiple nerve roots become compressed
Occurrence of spinal stenosis?
Tend to be over 60 years
Symptoms/signs of spinal stenosis?
Characteristic spinal CLAUDICATION (pain in the legs on walking)
Compare and contrast spinal and vascular claudication?
In spinal claudication: • Pain is inconsistent • Burning pain (rather than cramping) • Pain lessens on walking uphill (spine flexion creates more space for the cauda equina) • Pedal pulses are preserved
Treatment of spinal stenosis and claudcation?
Conservative (physio, weight loss)
Surgery (decompression to increase space for the cauda equina):
• If conservative Mx does not help
• MRI evidence of stenosis
What is cauda equina syndrome?
Occasionally, a very large central disc prolapse can compress all the nerve roots of the cauda equina; symptoms and signs of cauda equina syndrome are “red flags”
SURGICAL EMERGENCY as the affected nerve roots inc. sacral nerve roots, mainly S4 & 5) controlling defaecation and urination
Treatment of cauda equina syndrome?
Prolonged compression can cause permanent nerve damage requiring colostomy and urinary diversion and urgent disectomy
Symptoms of cauda equina syndrome?
Bilateral leg pain
Paraesthesiae or numbness and complain of “saddle anaesthesia) - numbness around the sitting area and perineum
Altered urinary function (usually urinary retention but could also be incontinence)
Faecal incontinence and constipation may occur
Which patients have cauda equina syndrome until proven otherwise?
Any patient with bilateral leg symptoms/signs with any suggestion of altered bladder or bowel function
Clinical examination of cauda equina syndrome?
PR exam is MANDATORY and it is considered negligent not to do this
Ix for cauda equina syndrome?
Urgent MRI (determine level of prolapse)
Urgent disectomy
What do “red flag” symptoms and signs indiation?
Significant underlying pathology, e.g: tumour, infection or spondyloisthesis
What are the spinal “red flags”?
- Back pain in the younger patient (<20 years)
- New back pain in the older patient (>60 years)
- Nature of pain as constant, severe and worse at night
- Systemic upset, e.g: fevers, night sweats, weight loss, fatigue and malaise
Causes of back pain in the younger patient?
Younger children are more susceptible to infections, e.g: osteomyelitis, discitis
Adolescence is the peak age for spondyloisthesis and some benign (e.g: osteoma) and malignant (e.g: osteosarcoma) primary bone tumours
LOW INDEX OF SUSPICION FOR MRI/REFERRAL
Causes of new back pain in the older patient?
Arthritic change or a crush fracture (e.g: osteoporotic)
Higher risk of neoplasia, part. metastatic disease and multiple myeloma
Causes of systemic upset alongside back pain?
TUMOUR or INFECTION
Ix for tumour or infection suspicion as a cause of back pain?
- Blood tests, inc. CRP, FBC, U&Es, bone biochemistry, plasma protein electrophoresis, PSA (males)
- Blood culture if suspicious of infection
- Spine X-ray (may show vertebral collapse OR loss of a pedicle on an AP view)
- CXR
- Bone scan
- MRI scan
Causes of constant, unremitting, severe back pain that is worse at night?
TUMOUR or INFECTION
Describe osteoporotic crush fractures?
With severe osteoporosis, spontaneous crush fractures of the vertebral body can occur leading to acute pain and kyphosis
Some patient develop chronic pain
Treatment of osteoporotic crush fractures?
Conservative (usually)
Describe cervical spondylosis
Disc degeneration leads to increased load and accelerated OA of facet joints
Symptoms of cervical spondylosis?
Slow-onset stiffness and pain in the neck; can locally radiate to shoulders and occiput
Osteophytes may impinge on exiting nerve roots, resulting in a radiculopathy inv. upper limb dermatoms and myotomes
Treatment of cervical spondylosis?
Physio and analgesics
Surgical decompression for severe symptoms of radiculopathy that are resistant to conservative management
Symptoms of cervical disc prolapse?
Neck pain
Nerve root compression causes shooting neuralgic pain down a dermatomal distribution with weakness and loss of reflexes (depends on the nerve root)
A large, central prolapse can compress the cord leading to a myelopathy with UMN symptoms and signs
Which nerve root is typically inv. in cervical disc prolapse?
Lower nerve root, i.e: C7 root for C6/7 disc
Ix for cervical disc prolapse?
MRI will aid diagnosis of the affected level; the no. of patients with asymptomatic disc prolapse increases with age, resulting in more false +ves or incidental findings on MRI
Mx of cervical disc prolapse?
Disectomy for cases resistant to conservative Mx but clinical symptoms must correlate with MRI findings
Causes of atraumatic cervical spine instability?
Can occur in Down syndrome and RA
Down syndrome - risk of developing atlanto-axial (C1/C2) instability with subluxation potentially causing spinal cord compression
RA - atlanto-axial sublucation can also occur due to destruction of the synovial joint between the atlas and dens and rupture of transver ligament; subluxation can cause cord compression (can be fatal)
Ix for cervical spine instability in Down syndrome?
Screening with flexion-extension X-rays shows abnormal motion
Treatment of cervical spine instability in Down syndrome?
Children with minor instability - prevent high impact/contact sports
Severe instability OR abnormal neurology - surgical stabilisation
Treatment of cervical spine instability in RA?
Less severe cases - collar to prevent flexion
More severe cases - surgical fusion
How do lower cervical subluxations occur in RA?
Due to destruction of synovial facet joints and uncovertebral joints; there is potential for cord compression (myelopathy) and UMN signs
UMN signs in lower cervical subluxations of RA?
Wide-based gait
Weakness
Increased tone
Upgoing platar sign
Ix and treatment of lower cervical subluxations in RA?
Measurements from flexion-extension X-rays
More severe cases require stabilisation/fusion
What is the shoulder joint?
AKA glenohumeral joint - ball and socket synovial joint formed by the humeral head and glenoid of the scapula
Components of the shoulder girdle?
Scapula, clavicle and proximal humerus
Also, the supporting muscles inc. the deltoid and rotator cuff muscles
Describe inherent instability of the shoulder joint
Offers a wide range of movement but, due to the lack of bony stability, the joint depends on the surrounding muscles for stability, esp. the rotator cuff muscles
What are the rotator cuff muscles?
- Supraspinatus
- Infraspinatus
- Subscapularis
- Teres minor
Function of the rotator cuff muscles?
Collectively pull the humeral head into the glenoid to provide a stable fulcrum for the deltoid muscles to abduct the arm
- Supraspinatus - initiates abduction (taken over by the deltoid)
- Infraspinatus and teres minor - external rotation
- Subscapularis - internal rotation
Attachments of the rotator cuff muscles?
Supraspinatus, infraspinatus and teres minor - greater tuberosity of the humerus
Subscapularis - lesser tuberosity of the humerus
Shoulder pathology?
Rotator cuff muscles are under repeated stresses and acute/degenerate TENDON TEARS can occur; subsequently, chronic rotator cuff insufficiency can lead to GH joint OA
Primary OA of the GH and AC joints can occur
Other soft tissue disorders
Shoulder pathology according to age group?
Younger adult - instability is the usual source of pain
Middle age - rotator cuff tears (GREY HAIR, CUFF TEAR) and frozen shoulder are common
Elderly - GH joint OA
What is impingement syndrome?
AKA painful arc syndrome - tendons of the rotator cuff (usually supraspinatus) are compressed in the subacromial space during movement, producing pain
Symptoms and signs of impingement syndrome?
Painful arc between 60-120 degrees of abduction (variable values); this occurs as the inflamed area of the supraspinatus tendon passes through the subacromial space
Pain characteristically radiations to deltoid and UPPER ARM
Tenderness below the lateral edge of the acromion
Hawkins-Kennedy test (internally rotating the flexed shoulder) recreates pain
Causes of impingement syndrome?
- Tendonitis subacromial bursitis
- AC joint OA with inferior osteophytes
- Hooked acromion + rotator cuff tear
DD of impingement syndrome?
Cervical radiculopathy should be excluded from Hx and examination
Treatment of impingement syndrome?
Conservative (most settle) - NSAIDs, analgesics, physio and subacromial steroid injection (up to 3)
If no improvement, subacromial decompression surgery to create more space for the tendon (open procedure or minimally invasive arthroscopic techniques)
Why do rotator cuff tears occur?
Can tear with minimal/no trauma due to degenerative tendon changes and so it tends to be patient >40 years; tearing in young patients is rare, even if there is significant injury
Classic Hx is a sudden jerk, e.g: holding a rail on a bus that suddenly stops
Describe the origin and size of tears
May be partial or full-thickness but tend to inv. the SUPRASPINATUS
Large tears can extend into the subscapularis and infraspinatus
Signs of rotator cuff tears?
Weakness of:
• Abduction initiation (supraspinatus)
• External rotation (infraspinatus)
• Internal rotation (subscapularis)
Wasting of supraspinatus may also be seen
Ix for rotator cuff tears?
USS or MRI
Mx of rotator cuff tears?
Non-operative:
• Many do well with physio to strengthen the remaining cuff muscles, which compensated for supraspinatus loss
• Subacromial injection may alleviate symptoms
Operative:
• Rotator cuff repair with subacromial decompression can improve/maintain strength and to prevent OA from chronic cuff deficiency
• Failure of repair often occurs due to the tendon being diseases
What is adhesive capsulitis?
AKA frozen shoulder - characterised by progressive pain and stiffness of the shoulder in patients between 40-60 years, resolving after 18-24 months
Capsule and GH joint are inflamed and they thicken and contract
Signs of adhesive capsulitis?
Pattern of pain:
• Pain, which subsides (after around 2-9 months)
• As pain decreases, stiffness increases (for 4-12 months)
• Stiffness gradually “thaws” over time, usually with good recovery of shoulder motion
LOSS OF EXTERNAL ROTATION (PRINCIPLE CLINICAL SIGN)
Restriction of other movements (also occur in OA but OA is a disease of elderly)
Causes of adhesive capsulitis?
Unclear aetiology
Sometimes, Hx of innocuous triggering injury but there often is not; may occur after shoulder surgery
Assoc. with DIABETES, hypercholesterolaemia and Dupytren’s disease
Treatment of adhesive capsulitis?
Non-operative (majority) - aim is to relieve pain and prevent further stiffening while natural healing occurs:
• Physio and analgesics
• Intra-articular (GH joint rather than subacromial) injections help in the painful phase
Once pain has settled but the patient cannot tolerate function loss due to stiffness: • Manipulation under anaesthetic can be used to tear the capsule
• Surgical capsular release divides the capsule
What is acute calcific tendonitis?
Ca deposition in the supraspinatus tendon causes ACUTE ONSET of severe shoulder pain
Ix for acute calcific tendonitis?
X-ray shows Ca deposition just proximal to the greater tuberosity
Treatment of calcific tendonitis?
Self-limiting condition in which pain eases as the calcification resorbs
Subacromial steroid + local anaesthetic injection = great relief of pain
What is shoulder instability?
Inv. painful abnormal translational movement or subluxation and/or recurrent dislocation
Two patterns of shoulder instability?
Traumatic instability - can experience a traumatic anterior dislocation and have it reduced and good stability; sometimes, shoulders will not stabilise and people develop recurrent dislocations/subluxations, often with minimal force
Atraumatic instability - patients with generalised ligamentous laxity (idiopathic, Ehlers-Danlos, Marfan’s) can have pain from recurrent multi-directional subluxations/dislocations
Treatment of the types of shoulder instability?
Traumatic - Bankart repair reattaches the labrum and capsule to the anterior glenoid, which was torn off in the 1st dislocation
Atraumatic - difficult
Which patients tend to develop instability after an initial shoulder dislocation?
High re-dislocation rate in patients <20 years
Low rate in patients >30 years
Describe biceps tendonitis
Inflammation of the tendon of the long head of biceps causes anterior shoulder pain with pain on resisted biceps contraction
Treatment of biceps tendonitis?
Tendon may spontaneously rupture, relieving symptoms but some patients are left with bunched-up muscles (pop-eye deformity)
Surgical division of the tendon with/without attachment to the proximal humerus
Describe tears in the glenoid labrum
Occurs where the long biceps tendon attach and it causes pain
Ix for glenoid labrum tears?
MRI arthrogram with contrast injected into the joint
Treatment of glenoid labrum tears?
Biceps tenotomy may be enough
Labral resection/repair may help
Other causes of shoulder pain?
Neck pain can be referred to the shoulder
Angina and diaphragmatic irritation (biliary colic, hepatic or subphrenic abscess) can present with shoulder pain
Compare and contrast peripheral, e.g: upper limb, nerve compression neuropathies to cervical nerve root compression?
Peripheral nerve compression neuropathies cause symptoms and signs affecting the peripheral nerve SENSORY AND MOTOR territories rather than dermatomal and myotomal distributions
Formation of the carpal tunnel?
Formed by the carpal bones and flexor retinaculum
Structures within the carpal tunnel?
Median nerve
9 flexor tendon (FDS and FDP to 4 digits + FPL)
Cause of carpal tunnel syndrome?
Any swelling within the confines of the carpal tunnel can cause median nerve compression
Tends to be idiopathic but may also be secondary to RA (synovitis) and conditions causing fluid retention, like pregnancy (symptoms tend to subside after childbirth), DM, chronic renal failure, hypothyroidism
Can occur due to fractures around the wrist, e.g: Colles fracture
Occurrence of carpal tunnel syndrome?
Far more common in women
Symptoms and signs of carpal tunnel syndrome?
Paraesthiae in the median nerve innervated digitis (thumb, index, middle and 1/s of the ring finger) tends to be WORSE AT NIGHT
Loss of sensation and weakness of the thumb/clumsiness in the areas of the hand supplied by the median nerve
Examination findings in carpal tunnel syndrome?
Demonstratable loss of sensation and/or muscle wasting of the thenar eminence (with chronic severe cases)
Tinnel’s test (percuss over the median nerve) or Phalen’s test (holding the wrists hyper-flexed; upside-down prayer sign)
Ix of carpal tunnel syndrome?
Nerve conduction studies
Treatment of carpal tunnel syndrome?
Non-operative - use of wrist splints at night to prevent flexion; corticosteroid injections can be used
Surgical treatment - carpal tunnel decompression inv. division if the transverse carpal ligament under local anaesthetic (highly successful although there is a risk of damage to the median nerve or one of its smaller branches)
What is cubital tunnel syndrome?
Compression of the ulnar nerve at the elbow, behind the medial epicondyle (“funny bone” area)
Symptoms of cubital tunnel syndrome?
Paraesthesiae in half of the ring finger and the little finger
Tinnel’s test is +ve over the cubital tunnel
Weakness of ulnar nerve innervated muscles may be present inc. the 1st dorsal interosseous (abduction index finger) and adductor pollicis; latter is tested with Froment’s test
Causes of cubital tunnel syndrome?
Compression can be sue to:
• Osborne’s fascia (tight band of fascia forming the roof of the tunnel)
• Tightness of the intermuscular septum as the nerve passes through OR between the 2 heads at the origin of the flexor carpi ulnaris
Ix and treatment of cubital tunnel syndrome?
Nerve conduction studies confirm the diagnosis
May need surgical release of tight structures
What is the elbow joint?
Articulation between the humerus and the bones of the distal forearm; consists of the:
• Humero-ulnar joint (flexion-extension)
• Radio-capitellar joint (supination-pronation along with the proximal and distal radioulnar joints)
Which muscles flex-extend the elbow?
Triceps muscles (inserts onto the olecranon process) - elbow extension
Biceps (inserts onto the bicipital tuberosity of the radius) - flex the elbox
Which muscles cause supination?
Biceps brachii and supinator muscles
Which muscles cause pronation?
Contraction of:
• Pronator teres proximally
• Pronator quadratus distally
Where are the common extensor and flexor origins?
Common extensor origin - lateral epicondyle
Common flexor origin - medial epicondyle
Pathologies of the elbow?
Enthesopathy - enthesis (attachment) of the common extensor and flexor origins can become painful (medial and lateral epicondylitis)
Primary OA of the elbow is rare (OA is more common secondary to trauma here, e.g: intra-articular fractures) but RA commonly affects the elbow
What is tennis elbow?
AKA LATERAL epicondylitis - micro-tears in the common extensor origin
May occur as a:
• Repetitive strain injury in tennis players and other who regularly perform RESISTED EXTENSION AT THE WRIST
• May also be a degenerative enthesopathy (inflammation of the origin/insertion of a tendon/ligament into bone)
Symptoms and signs of tennis elbow?
Painful and tender lateral epicondyle
Pain on resisted middle finger extension and wrist extension
Treatment of tennis elbow?
Self-limiting condition
Conservative Mx - rest from activities that exacerbate pain, physio, NSAIDs, steroid injection and use of a brace; USS therapy is also used but unclear benefit
Refractory cases - surgical treatment (division and/or excision of some fibres of the common extensor origin)
What is Golfer’s elbow?
AKA medial epicondylitis - can be a consequence of:
• Repeated strain
• Degeneration of the common flexor origin
LESS COMMON than lateral epicondylitis
Treatment of Golfer’s elbow?
Self-limiting condition
Conservative Mx - physio, rest and NSAIDs
NO INJECTIONS, as it carries a risk of injury to the ulnar nerve
Treatment of elbow arthritis?
Arthritic change at the radio‐capitellar joint which has failed non-operative Mx:
• Surgical excision of the radial head
Elbow severely affected by RA/OA at the humero‐ulnar joint, which is not responding to conservative Mx:
• Total Elbow Replacement (lifting in these patients is restricted to 2.5kg post-operatively)
What is Dupuytren’s contracture?
Proliferative CTD where the palmar fascia undergoes hyperplasia, with normal fascial bands forming nodules and cords; this leads to contractures at the MCP and PIP joints, typically at the ring and little fingers
Occurrence of Dupuytren’s contracture?
More common in MALES
It can be familial (autosomal dominant) and has a high prevalence in those of Northern European/Scandinavian descent
Also seen as a feature of alcoholic cirrhosis and also more common in diabetes
Side effect of phenytoin therapy
Assoc. with other fibromatoses, inc. Peyronie’s disease (penis) and Ledderhose disease (plantar fibromatosis affecting the feet)
Which people have a more aggressive form of Dupuytren’s?
Young patients and patients with fibromatosis elsewhere tend to have more aggressive forms of the disease
Treatment of Dupuytren’s contracture?
Mild contractures may be tolerated (up to 30 degrees contracture can be tolerated at the MCPJ)
Surgical treatment - if contractures interfere with function; PIPJ readily stiffens and any contracture here is usually an indication for surgery; surgery inv. removal of diseased tissue (fasciectomy) OR division of cords (fasciotomy)
Pathology of Dupuytren’s?
Proliferation of myofibroblast cells and production of abnormal collagent (type 3 rather than 1)
Describe trigger finger
Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck (the A1 pulley)
Any finger can be affected but commonly the middle and ring fingers are
Symptoms and signs of trigger finger?
Movement of the finger produces a clicking sensation, as the nodule catches on and then passes underneath the pulley
Sensation may be painful and the finger can lock in a flexed position as the nodule passes under the pulley but cannot go back though on extension; patient may have to forcibly manipulate the finger to regain extension, usually with pain
Treatment of trigger finger?
Injection of steroid around the tendon within the sheath will relieve symptoms
Surgery can be offered in recurrent and persistent cases (incision of the pulley to allow the tendon to move freely; due to the system of other pulleys, division of the A1 pulley does not affect function)
Symptoms and locations affected in OA of the hands and wrist?
DIPJ OA is very common in post-menopausal women (painful, swollen and tender eventually affecting all fingers); assoc. mucous cyst may be present
Stiffness and bony swelling at the DIPJs (Heberden’s nodes) and PIPJs (Bouchard’s nodes)
Rarely, MCPJs can be affected by OA (usually a specific cause, like previous injury, gout, infection, etc)
1st CMCJ (trapzio-metacarpal joint) at the base of the thumb metacarpal is commonly affected by OA, part. in women with up to 1/3 of women >40 having X-ray signs
Joints between the scaphoid, trapezium and trapezoid (STT joint) can be affected by primary OA
OA of the radio‐carpal joint of the wrist usually occurs as a consequence of trauma, e.g: scaphoid non‐union, carpal dislocation
Treatment of hand and wrist OA?
Mild to moderate OA may be treated with removal of osteophytes and excision of any mucous cyst; for severe pain arthrodesis may be performed
For the index finger, arthrodesis may be required to preserve pinch grip; for other fingers, replacement arthroplasty may be required
Surgical treatment for MCPJ OA and replacements can be used
STT joint OA - fusion of the inv. carpal bones or wrist fusion for severe symptoms
OA of the radio-carpal joint - wrist arthroplasty or fusion
Sites in the hands spared in RA?
Spares the DIPJs (in contrast with OA and psoriatic arthritis)
Natural history of RA?
- Synovitis and tenosynovitis – inflammation within the joints and the tendon sheath lead to swelling and pain
- Erosions of the joints – inflammatory pannus denudes the joints of articular cartilage
- Joint instability and tendon rupture – following the progressive destruction of the bony and soft tissue structure in the hand, patients can have subluxation; chronic tenosynovitis predisposes to extensor tendon ruptures
Deformities present in RA?
- Volar MCPJ subluxation
- Ulnar deviation
- Swan-neck deformity (hyperextension at PIPJ with flesion DIPJ)
- Boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ)
- Z-shaped thumb
Treatment of RA?
Tenosynovectomy (excision of synovial tendon sheath) may prevent tendon rupture; when extensor tendons to the wrist/fingers rupture, direct surgical repair is not possible as repair of the diseased tendon will fail, i.e: tendon transfers or joint fusions may be required to preserve function
Soft tissue releases (lengthening) may be required for contractures
MCP & PIP replacements or fusions and wrist replacement or fusion may be required for severe arthritic change
What are ganglion cysts?
Common mucinous-filled cysts found adjacent to a tendon or synovial joint
Common in the hand (DIPJ – mucous cyst, flexor tendon) and wrist (dorsal or volar)
Can also occur in the foot and ankle, as well as the knee (Baker’s cyst)
Symptoms and signs of ganglion cysts?
Can cause localized pain or irritation
Firm, smooth and rubbery and should transilluminate (when a light is shined on them, the whole thing lights up indicating that it fluid-filled)
Treatment of ganglion cysts?
Removal is for cosmetic reason (scarring can occur)
Needle aspiration may be attempted but recurrence is common
Surgical excision if the swelling causes localised discomfort (do not burst the swelling with a heavy book, “bible technique”)
Occurrence of giant cell tumour of tendon sheath?
2nd most common soft tissue swelling of the hands (after ganglions)
Location of GCT of tendon sheath?
Usually on the palmar surface, esp. around the PIPJ of the index and middle fingers
Symptoms and signs of GCT of tendon sheath?
Typically well-circumscribed but can be diffuse
May/may not cause pain (may develop a digital nerve or artery that erodes into bone)
Histological appearance of GCT of tendon sheath?
Contain multinucleate giant cells and haemosiderin (causes brown appearance)
Treatment of GCT of tendon sheath?
Excision (to prevent local spread and to treat symptoms)
Recurrence can happen
