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Year 2 Clinical > Regional Adult Orthopaedics: Spine and Upper Limb Master Deck > Flashcards

Regional Adult Orthopaedics: Spine and Upper Limb Master Deck Flashcards

1
Q

What is mechanical back pain?

A

Recurrent relapsing and remitting back pain with no neurological symptoms; pain is worsened with movement and relieved by rest

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2
Q

Hx of mechanical back pain?

A

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
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3
Q

What is spondylosis?

A

Intervertebral discs lose water content with age, resulting in decreased cushioning and increased P on the facet joints, leading to secondary OA

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4
Q

Treatment of mechanical back pain?

A

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

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5
Q

Why is surgery for mechanical back pain rare?

A

Most have multi-level disease of the spine

There may be recurrence of symptoms and no benefit around 5 years from surgery

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6
Q

Describe acute disc tears

A

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

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7
Q

Management of acute disc tears?

A

Symptoms tend to resolve after 2-3 months

Analgesia and physiotherapy (mainstay of treatment)

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8
Q

How can prolapsed discs cause neurological symptoms?

A

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)

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9
Q

What is sciatica?

A

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

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10
Q

Which nerve roots are compressed in the lumbar spine?

A

Nerve root corresponding to the lower of the 2 vertebrae in the affected segment

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11
Q

Typical patterns of lumbar spine nerve root compression and the symptoms and signs?

A

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

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12
Q

Variable presentations of lumbar disc prolapse?

A

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

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13
Q

Treatment of sciatica (AKA lumbar radiculopathy)?

A

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

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14
Q

How can bony nerve root entrapment occur?

A

OA of the facet joints can cause osteophytes impinging on exiting nerve roots, resulting in nerve root symptoms and sciatica

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15
Q

Treatment of bony nerve root entrapment?

A

Surgical decompression (trimming of the impinging osteophytes) in suitable candidates

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16
Q

Causes of spinal stenosis?

A

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

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17
Q

Occurrence of spinal stenosis?

A

Tend to be over 60 years

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18
Q

Symptoms/signs of spinal stenosis?

A

Characteristic spinal CLAUDICATION (pain in the legs on walking)

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19
Q

Compare and contrast spinal and vascular claudication?

A 
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
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20
Q

Treatment of spinal stenosis and claudcation?

A

Conservative (physio, weight loss)

Surgery (decompression to increase space for the cauda equina):
• If conservative Mx does not help
• MRI evidence of stenosis

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21
Q

What is cauda equina syndrome?

A

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

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22
Q

Treatment of cauda equina syndrome?

A

Prolonged compression can cause permanent nerve damage requiring colostomy and urinary diversion and urgent disectomy

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23
Q

Symptoms of cauda equina syndrome?

A

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

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24
Q

Which patients have cauda equina syndrome until proven otherwise?

A

Any patient with bilateral leg symptoms/signs with any suggestion of altered bladder or bowel function

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25
Q

Clinical examination of cauda equina syndrome?

A

PR exam is MANDATORY and it is considered negligent not to do this

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26
Q

Ix for cauda equina syndrome?

A

Urgent MRI (determine level of prolapse)

Urgent disectomy

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27
Q

What do “red flag” symptoms and signs indiation?

A

Significant underlying pathology, e.g: tumour, infection or spondyloisthesis

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28
Q

What are the spinal “red flags”?

A
  1. Back pain in the younger patient (<20 years)
  2. New back pain in the older patient (>60 years)
  3. Nature of pain as constant, severe and worse at night
  4. Systemic upset, e.g: fevers, night sweats, weight loss, fatigue and malaise
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29
Q

Causes of back pain in the younger patient?

A

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

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30
Q

Causes of new back pain in the older patient?

A

Arthritic change or a crush fracture (e.g: osteoporotic)

Higher risk of neoplasia, part. metastatic disease and multiple myeloma

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31
Q

Causes of systemic upset alongside back pain?

A

TUMOUR or INFECTION

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32
Q

Ix for tumour or infection suspicion as a cause of back pain?

A
  • 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
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33
Q

Causes of constant, unremitting, severe back pain that is worse at night?

A

TUMOUR or INFECTION

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34
Q

Describe osteoporotic crush fractures?

A

With severe osteoporosis, spontaneous crush fractures of the vertebral body can occur leading to acute pain and kyphosis

Some patient develop chronic pain

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35
Q

Treatment of osteoporotic crush fractures?

A

Conservative (usually)

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36
Q

Describe cervical spondylosis

A

Disc degeneration leads to increased load and accelerated OA of facet joints

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37
Q

Symptoms of cervical spondylosis?

A

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

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38
Q

Treatment of cervical spondylosis?

A

Physio and analgesics

Surgical decompression for severe symptoms of radiculopathy that are resistant to conservative management

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39
Q

Symptoms of cervical disc prolapse?

A

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

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40
Q

Which nerve root is typically inv. in cervical disc prolapse?

A

Lower nerve root, i.e: C7 root for C6/7 disc

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41
Q

Ix for cervical disc prolapse?

A

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

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42
Q

Mx of cervical disc prolapse?

A

Disectomy for cases resistant to conservative Mx but clinical symptoms must correlate with MRI findings

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43
Q

Causes of atraumatic cervical spine instability?

A

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)

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44
Q

Ix for cervical spine instability in Down syndrome?

A

Screening with flexion-extension X-rays shows abnormal motion

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45
Q

Treatment of cervical spine instability in Down syndrome?

A

Children with minor instability - prevent high impact/contact sports

Severe instability OR abnormal neurology - surgical stabilisation

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46
Q

Treatment of cervical spine instability in RA?

A

Less severe cases - collar to prevent flexion

More severe cases - surgical fusion

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47
Q

How do lower cervical subluxations occur in RA?

A

Due to destruction of synovial facet joints and uncovertebral joints; there is potential for cord compression (myelopathy) and UMN signs

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48
Q

UMN signs in lower cervical subluxations of RA?

A

Wide-based gait

Weakness

Increased tone

Upgoing platar sign

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49
Q

Ix and treatment of lower cervical subluxations in RA?

A

Measurements from flexion-extension X-rays

More severe cases require stabilisation/fusion

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50
Q

What is the shoulder joint?

A

AKA glenohumeral joint - ball and socket synovial joint formed by the humeral head and glenoid of the scapula

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51
Q

Components of the shoulder girdle?

A

Scapula, clavicle and proximal humerus

Also, the supporting muscles inc. the deltoid and rotator cuff muscles

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52
Q

Describe inherent instability of the shoulder joint

A

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

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53
Q

What are the rotator cuff muscles?

A
  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres minor
54
Q

Function of the rotator cuff muscles?

A

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
55
Q

Attachments of the rotator cuff muscles?

A

Supraspinatus, infraspinatus and teres minor - greater tuberosity of the humerus

Subscapularis - lesser tuberosity of the humerus

56
Q

Shoulder pathology?

A

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

57
Q

Shoulder pathology according to age group?

A

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

58
Q

What is impingement syndrome?

A

AKA painful arc syndrome - tendons of the rotator cuff (usually supraspinatus) are compressed in the subacromial space during movement, producing pain

59
Q

Symptoms and signs of impingement syndrome?

A

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

60
Q

Causes of impingement syndrome?

A
  • Tendonitis subacromial bursitis
  • AC joint OA with inferior osteophytes
  • Hooked acromion + rotator cuff tear
61
Q

DD of impingement syndrome?

A

Cervical radiculopathy should be excluded from Hx and examination

62
Q

Treatment of impingement syndrome?

A

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)

63
Q

Why do rotator cuff tears occur?

A

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

64
Q

Describe the origin and size of tears

A

May be partial or full-thickness but tend to inv. the SUPRASPINATUS

Large tears can extend into the subscapularis and infraspinatus

65
Q

Signs of rotator cuff tears?

A

Weakness of:
• Abduction initiation (supraspinatus)
• External rotation (infraspinatus)
• Internal rotation (subscapularis)

Wasting of supraspinatus may also be seen

66
Q

Ix for rotator cuff tears?

A

USS or MRI

67
Q

Mx of rotator cuff tears?

A

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

68
Q

What is adhesive capsulitis?

A

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

69
Q

Signs of adhesive capsulitis?

A

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)

70
Q

Causes of adhesive capsulitis?

A

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

71
Q

Treatment of adhesive capsulitis?

A

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

72
Q

What is acute calcific tendonitis?

A

Ca deposition in the supraspinatus tendon causes ACUTE ONSET of severe shoulder pain

73
Q

Ix for acute calcific tendonitis?

A

X-ray shows Ca deposition just proximal to the greater tuberosity

74
Q

Treatment of calcific tendonitis?

A

Self-limiting condition in which pain eases as the calcification resorbs

Subacromial steroid + local anaesthetic injection = great relief of pain

75
Q

What is shoulder instability?

A

Inv. painful abnormal translational movement or subluxation and/or recurrent dislocation

76
Q

Two patterns of shoulder instability?

A

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

77
Q

Treatment of the types of shoulder instability?

A

Traumatic - Bankart repair reattaches the labrum and capsule to the anterior glenoid, which was torn off in the 1st dislocation

Atraumatic - difficult

78
Q

Which patients tend to develop instability after an initial shoulder dislocation?

A

High re-dislocation rate in patients <20 years

Low rate in patients >30 years

79
Q

Describe biceps tendonitis

A

Inflammation of the tendon of the long head of biceps causes anterior shoulder pain with pain on resisted biceps contraction

80
Q

Treatment of biceps tendonitis?

A

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

81
Q

Describe tears in the glenoid labrum

A

Occurs where the long biceps tendon attach and it causes pain

82
Q

Ix for glenoid labrum tears?

A

MRI arthrogram with contrast injected into the joint

83
Q

Treatment of glenoid labrum tears?

A

Biceps tenotomy may be enough

Labral resection/repair may help

84
Q

Other causes of shoulder pain?

A

Neck pain can be referred to the shoulder

Angina and diaphragmatic irritation (biliary colic, hepatic or subphrenic abscess) can present with shoulder pain

85
Q

Compare and contrast peripheral, e.g: upper limb, nerve compression neuropathies to cervical nerve root compression?

A

Peripheral nerve compression neuropathies cause symptoms and signs affecting the peripheral nerve SENSORY AND MOTOR territories rather than dermatomal and myotomal distributions

86
Q

Formation of the carpal tunnel?

A

Formed by the carpal bones and flexor retinaculum

87
Q

Structures within the carpal tunnel?

A

Median nerve

9 flexor tendon (FDS and FDP to 4 digits + FPL)

88
Q

Cause of carpal tunnel syndrome?

A

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

89
Q

Occurrence of carpal tunnel syndrome?

A

Far more common in women

90
Q

Symptoms and signs of carpal tunnel syndrome?

A

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

91
Q

Examination findings in carpal tunnel syndrome?

A

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)

92
Q

Ix of carpal tunnel syndrome?

A

Nerve conduction studies

93
Q

Treatment of carpal tunnel syndrome?

A

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)

94
Q

What is cubital tunnel syndrome?

A

Compression of the ulnar nerve at the elbow, behind the medial epicondyle (“funny bone” area)

95
Q

Symptoms of cubital tunnel syndrome?

A

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

96
Q

Causes of cubital tunnel syndrome?

A

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

97
Q

Ix and treatment of cubital tunnel syndrome?

A

Nerve conduction studies confirm the diagnosis

May need surgical release of tight structures

98
Q

What is the elbow joint?

A

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)

99
Q

Which muscles flex-extend the elbow?

A

Triceps muscles (inserts onto the olecranon process) - elbow extension

Biceps (inserts onto the bicipital tuberosity of the radius) - flex the elbox

100
Q

Which muscles cause supination?

A

Biceps brachii and supinator muscles

101
Q

Which muscles cause pronation?

A

Contraction of:
• Pronator teres proximally
• Pronator quadratus distally

102
Q

Where are the common extensor and flexor origins?

A

Common extensor origin - lateral epicondyle

Common flexor origin - medial epicondyle

103
Q

Pathologies of the elbow?

A

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

104
Q

What is tennis elbow?

A

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)

105
Q

Symptoms and signs of tennis elbow?

A

Painful and tender lateral epicondyle

Pain on resisted middle finger extension and wrist extension

106
Q

Treatment of tennis elbow?

A

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)

107
Q

What is Golfer’s elbow?

A

AKA medial epicondylitis - can be a consequence of:
• Repeated strain
• Degeneration of the common flexor origin

LESS COMMON than lateral epicondylitis

108
Q

Treatment of Golfer’s elbow?

A

Self-limiting condition

Conservative Mx - physio, rest and NSAIDs

NO INJECTIONS, as it carries a risk of injury to the ulnar nerve

109
Q

Treatment of elbow arthritis?

A

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)

110
Q

What is Dupuytren’s contracture?

A

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

111
Q

Occurrence of Dupuytren’s contracture?

A

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)

112
Q

Which people have a more aggressive form of Dupuytren’s?

A

Young patients and patients with fibromatosis elsewhere tend to have more aggressive forms of the disease

113
Q

Treatment of Dupuytren’s contracture?

A

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)

114
Q

Pathology of Dupuytren’s?

A

Proliferation of myofibroblast cells and production of abnormal collagent (type 3 rather than 1)

115
Q

Describe trigger finger

A

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

116
Q

Symptoms and signs of trigger finger?

A

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

117
Q

Treatment of trigger finger?

A

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)

118
Q

Symptoms and locations affected in OA of the hands and wrist?

A

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

119
Q

Treatment of hand and wrist OA?

A

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

120
Q

Sites in the hands spared in RA?

A

Spares the DIPJs (in contrast with OA and psoriatic arthritis)

121
Q

Natural history of RA?

A
  1. Synovitis and tenosynovitis – inflammation within the joints and the tendon sheath lead to swelling and pain
  2. Erosions of the joints – inflammatory pannus denudes the joints of articular cartilage
  3. 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
122
Q

Deformities present in RA?

A
  • 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
123
Q

Treatment of RA?

A

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

124
Q

What are ganglion cysts?

A

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)

125
Q

Symptoms and signs of ganglion cysts?

A

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)

126
Q

Treatment of ganglion cysts?

A

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”)

127
Q

Occurrence of giant cell tumour of tendon sheath?

A

2nd most common soft tissue swelling of the hands (after ganglions)

128
Q

Location of GCT of tendon sheath?

A

Usually on the palmar surface, esp. around the PIPJ of the index and middle fingers

129
Q

Symptoms and signs of GCT of tendon sheath?

A

Typically well-circumscribed but can be diffuse

May/may not cause pain (may develop a digital nerve or artery that erodes into bone)

130
Q

Histological appearance of GCT of tendon sheath?

A

Contain multinucleate giant cells and haemosiderin (causes brown appearance)

131
Q

Treatment of GCT of tendon sheath?

A

Excision (to prevent local spread and to treat symptoms)

Recurrence can happen

Year 2 Clinical (119 decks)

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