Regional Peri-Articular Pain - Hand/Wrist Flashcards
What are the common presenting features of overusage/strain injuries?
Exact time/mechanism of injury identifiable Pain non-progressive Pain produced by one/few movements Localised tenderness Pain on active movement/stress testing
What are the peri-articular syndromes affecting the wrist/hand?
De Quervain's Tenovaginitis Median Nerve Compression Cubital Tunnel Syndrome Ganglion Cyst Trigger Finger Dupuytren's Contracture Base of thumb OA
What is De Quervain’s Tenovaginitis?
Painful inflammation of abductor pollicis longus & extensor pollicis brevis tendons in 1st dorsal compartment
What causes De Quervain’s Tenovaginitis??
Unkown
Most common after unaccustomed intensive activity
-classically middle aged/post-partum women
What is the 1st dorsal compartment?
Area just proximal to anatomical snuff box
How does De Quervain’s Tenovaginitis present?
Acute pain over 1st dorsal compartment
- worse when using thumb
- tenderness/swelling
What are the signs on examination of De Quervain’s Tenovaginitis ?
LOOK - normal/swelling over radial border
FEEL - normal/tender over radial border
MOVE - active thumb abduction/ulnar deviation affected
TEST - Finkelstein’s +ve
What is Finkelstein’s test?
Thumbs across palm, ulnar deviation causes pain over the tunnel
What is the key differential for De Quervain’s Tenovaginitis?
Base of thumb OA
What is the conservative management of De Quervain’s Tenovaginitis?
Rest
Analgesia
Splintage w/ thumb immobilisation (3wks)
What is the surgical management of De Quervain’s Tenovaginitis ?
Longitudinal compartment release
-required if recurrence
What structures make up the carpal tunnel?
Carpal bones
Covered by flexor retinaculum
What are the carpal bones?
Proximal row = Scaphoid, Lunate, Triquetrum, Pisiform
Distal row = Trapezium, Trapezoid, Capitate, Hamate
SOME LOVERS TRY POSITIONS THAT THEY CAN’T HANDLE
What structures does the Carpal Tunnel contain?
Nine flexor tendons -4 flexor digitorum profundus -4 flexor digitorum superficialis -1 flexor pollicus longus Median nerve
What is Carpal Tunnel Syndrome?
Compression neuropathy of median nerve as it passes through the carpal tunnel
-technically median nerve compression until there is thenar eminence wasting
What causes Carpal Tunnel Syndrome?
Idiopathic (95%) Entrapment in other conditions -DM -RA -hypothyroidism -acromegaly -trauma (Colles' fracture)
In which group is Carpal Tunnel Syndrome more common?
Women
-3x more common
How does Carpal Tunnel Syndrome present?
Pain/paresthesia in hand, worst in morning
-due to wrist flexion when asleep
-may wake pt/sleep w/ hand over bed
Thenar muscle weakness
-noticed as clumsiness
Sensory loss in palm/radial 3 1/2 fingers
-often not noticed
What are the signs on examination of Carpal Tunnel Syndrome?
LOOK - normal/thenar wasting
FEEL - reduced thenar bulk
MOVE - active thumb abduction/opposition affected
TEST - Tinel’s +ve, Phalen’s +ve, dec sensation
What is Tinel’s test?
Tapping over carpal tunnel leads to paraesthesia
What is Phalen’s test?
Flexion for 60s leads to pain
What investigations may be appropriate in suspected carpal tunnel syndrome?
Nerve conduction studies
- slowed at wrist
- may be normal
What is the conservative management of Carpal Tunnel Syndrome?
Rest
Night time splinting
NSAIDs/steroids
What is the surgical management of Carpal Tunnel Syndrome?
Division of flexor retinaculum
-scar in palm
What is Cubital Tunnel Syndrome?
Compression neuropathy of ulnar nerve at cubital tunnel of elbow
What is the Cubital Tunnel?
Area medial & posterior on elbow joint (in anatomical position)
What causes Cubital Tunnel Syndrome?
Flexion of elbows for long periods
Tight fascial bands
Ulnar fracture
Valgus deformities
How does Cubital Tunnel Syndrome present?
Pain near elbow joint
-may radiate down ulnar forearm
Paraesthesia/sensory loss over ulnar distribution
Hand clumsiness/reduced pinch/grip strength
Clawing of hand
-if severe
-due to wasting of hypothenar/interosseus muscles
What are the signs on examination of Cubital Tunnel Syndrome?
LOOK - guttering b/w metacarpals, hypothenar wasting
FEEL - tenderness around cubital tunnel
MOVE - elbow movements limited, unable to actively extend IPJs, or avtively abduct/adduct finger
TEST - loss of sensation, reduced 1st dorsal interosseus power, Tinels +ve, elbow flexion +ve
What is the elbow flexion test?
Sustained elbow flexion, w/ forearm supinated & wrist extended will reproduce sx
What investigations may be appropriate in Cubital Tunnel Syndrome?
X-rays - pathogenic osteophyte
Nerve conduction studies - slowed at elbow
What is the conservative management of Cubital Tunnel Syndrome?
Night time splinting
NSAIDs
Activity modification
What is the surgical management of Cubital Tunnel Syndrome?
Simple cubital tunnel decompression
Anterior transposition of nerve
What is a ganglion cyst?
Soft tissue swelling filled w/ degenerative myxoid fluid stemming from underlying joint capsule, ligament or tendon sheath
How does a ganglion cyst present?
Lump in hand/wrist
Cosmetic concerns/associated pain
What are the causes of Ganglion cysts?
Idiopathic
Post trauma
In which group are ganglion cysts most common?
Women 20-40yrs
What are the signs on examination of ganglion cysts?
LOOK - swelling
FEEL - hard/soft, not fixed to skin
MOVE - obvious w/ joint movements/limit end range of movement
TEST - transilluminate
What are the common sites of ganglion cyst formation?
Scapholunate joint (dorsum of wrist)
Scaphotrapezial joint (volar aspect of wrist)
Base of finger (seed ganglion)
DIPJ (mucous cyst)
What is the conservative management of ganglion cysts?
Reassurance
NSAIDs
Aspiration +/- steroid injections
What is the surgical management of ganglion cysts?
Excision
-40% recurrence rate
What is Trigger Finger?
Idiopathic fibrosis of flexor tunnel leading to intratendinous nodule interrupting normal finer movement
How does Trigger Finger usually present?
Ring/middle finger affected Finger gets stuck in flexion -on further effort can snap into extension May be permanently locked -if severe
In which group is Trigger Finger most common?
Women >40yrs
RA & DM
What are the signs on examination of Trigger Finger?
LOOK - flexion at PIPJ/DIPJ
FEEL - can feel triggering on flexion, nodule at base of finger
MOVE - jerky/hesitant active flexion/extension, full extension limited
TEST - n/a
What is the conservative management of Trigger Finger?
Activity modification
NSAIDs
Tendon sheath corticosteroid injection
What is the surgical management of Trigger Finger?
Release of A1 pulley
Tenosynovectomy
-in RA pts
What is Dupuytren’s Contracture?
Progressive, painless thickening of palmar fascia, causing flexion deformities in fingers & functional difficulties
What are the risk factors for Dupuytren’s Contracture?
Males Nordic Family hx Trauma DM Alcoholism Phenytoin Liver cirrhosis
How does Dupuytren’s Contracture present?
Flexion deformities of fingers
Functional difficulties
What are the signs on examination of Dupuytren’s Contracture?
LOOK - nodules/cords in palm/fingers w/ flexion of MCP/PIP (middle/ring)
FEEL - thickened palmar fascia, Garrod’s pads on dorsum of PIPJs
MOVE - loss of active/passive extension
TEST - n/a
What is the conservative management of Dupuytren’s Contracture?
No treatment req if no functional impairment
What is the surgical management of Dupuytren’s Contracture?
Needle aponeurotomy Enzymatic fasciotomy Fasciotomy Fasciectomy Dermofasciectomy
How does Base of Thumb OA present?
Pain on activities involving gripping/pinching
Swelling, deformity, tenderness at CMCJ
What are the signs on examination of Base of Thumb OA?
LOOK - shoulder sign +ve, base of thumb swelling, thenar wasting
FEEL - pain/warmth, thenar wasting
MOVE - global pain/stiffness of CMCJ movements (add, palmar/radial abd, opposition)
What is the conservative management of Base of Thumb OA?
As for any OA pt
What is the surgical management of Base of Thumb OA?
Denervation
Trapeziectomy
Basal thumb arthroplasty
Joint fusion
What is the Shoulder Sign?
Radial prominence at base of thumb from dorsal subluxation
-sign of base of thumb OA
What is the Tuck sign?
Combined finger & wrist extension causes abnormal tenosynovium/dorsal skin to “tuck” under the extensor retinaculam of the wrist
What causes the Tuck Sign?
Inflamed synovial sheaths pressed up against flexor retinaculum
-disappears on flexion
What is the Tuck Sign characteristic of?
Extensory Tynosinovitis
