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MDD > Regional Periarticular Pain > Flashcards

Regional Periarticular Pain Flashcards

1
Q

what is de quervains tenovaginitis

A

Painful inflammation of the abductor pollicis longus and extensor pollicis brevis in the first dorsal compartment in the wrist (proximal to the snuff box)

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2
Q

how does de quervains tenovaginitis present

A

Acute pain/tenderness in 1st dorsal compartment of thumb on use +/- swelling 

Most commonly on unaccustomed intensive activity (painting fence) 

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3
Q

what patients classically have de quervains tenovaginitis

A

Women

Middle aged

Post partum  

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4
Q

what would you find on examination with de quervains tenovaginitis

A

Looks normal – potentially swelling on radial border

Feels normal – potentially tender over radial  border 

Active thumb abduction/opposition and active ulnar deviation  of the wrist may be affected 

Finkelsteins test positive

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5
Q

what test is positive in de quervains tenovaginitis

A

finklesteins

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6
Q

what are differentials of de quervains tenovaginitis

A

Base of the thumb OA 

OA = joint tender both on palm and dorsally (not found in DQT) 

Finkelsteins test +ve indicates DQT is more likely 

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7
Q

whats the management of de quervains tenovaginitis

A

Conservative
Most respond well to rest, analgesia and splintage with thumb immobilization for 3 weeks 
Steroid injections may be used 

Surgical
Very rarely longtitudinal compartment release may be required if there is recurrence

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8
Q

whats inside the flexor retinaculum

A

4 flexor digitorum profundus

4 flexor digitorum superficialis 

1 flexor pollicis longus 

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9
Q

what is carpal tunnel syndrome

A

median nerve compression

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10
Q

whats the aetiology of carpal tunnel syndrome

A

Idiopathic – 95% 

Diabetes

Rheumatoid Arthritis

Colles fractures (as well as other trauma) 

Acromegaly 

Hypothyroidism

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11
Q

how does carpal tunnel syndrome present

A

pain/parastesia in hand - some get numbness or tingling

weakness and wasting of thenar muscles, + sensory loss in palm/radial 3.5 fingers if left unnoticed

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12
Q

what tests are commonly positive in carpal tunnel syndrome

A

Phalens and tinels

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13
Q

how do you manage carpal tunnel syndrome

A

Conservative 
Rest
Night time splinting 
NSAIDS/steroid injections 

Surgical
Division of the flexor retinaculum – leads to a scar in the palm 

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14
Q

what causes cubital tunnel syndrome

A

chronic compression of the elbows (computer desk all day) 

Tight fascial bands

Ulnar fracture

Valgus deformity of the elbows 

Others

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15
Q

how does cubital tunnel syndrome present

A

Pain near elbow joint, may radiate down ulnar border of the forearm 

Paraesthesia and sensory loss in ulnar distribution 

Hand clumsiness and reduced pinch/grim strength

Severe = wasting of hypothenar and interosseus muscles leading to hand clawing 

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16
Q

what nerve is affected in cubital tunnel syndrome

A

ulnar nerve

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17
Q

what would you find on examination in cubital tunnel syndrome

A

Look - ‘guttering’ between metacarpals + hypothenar wasting (only if progressed) 

Feel – tenderness over cubital tunnel 

Move – elbow movement may be limited and patient may be unable to extend at the interphalageal joints, or actively abduct/adduct affected fingers 

Test – reduced first dorsal interosseus power, tinels positive along ulnar nerve, elbow flexion test positive (sustained elbow flexion with arm supination and wrist extension reproduces symptoms) 

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18
Q

whats the management of cubital tunnel syndrome

A

Conservative 
Night time splints 
NSAIDS
Activity modification

Surgical
Simple cubital tunnel decompression 
Anterior transposition of the nerve 

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19
Q

what is a ganglion cyst

A

Soft tissue swellings filled with a degenerative myxotic (mucus-y) fluid stemming from an underlying joint capsule, tendon or sheat

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20
Q

what is the typical patient for a ganglion cyst

A

woman, aged 20-40

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21
Q

what are common areas for a ganglion cyst

A

wrist - dorsal or polar

DIPJ

Base of finger from flexor sheath

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22
Q

how does a ganglion cyst feel

A

can be hard or soft but is never fixed to skin

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23
Q

how do you manage a ganglion cyst

A

Conservative
Rest + reassurance
30-50% disappear on their own – this may take years though
NSAIDS
Aspiration +/- steroid injection have 40% success rate

Surgical
Excision
40% recurrence rate

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24
Q

what is trigger finger

A

idiopathic fibrosis of flexor tunnel leading to interruption of the flexor movement usually involving ring/middle finger

finger gets stuck in flexion, with continued effort it may snap into extension

severe cases = finger locked perfectly

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25
Q

what patient population is most commonly affected by trigger finger

A

women over 40

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26
Q

whats the aetiology of trigger finger

A

RA

Diabetes

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27
Q

what do you find on examination for trigger finger

A

Look – potential flexion at PIP/DIP joint

Feel – can feel triggering of the tendon if finger placed on palm whilst patient flexes finger, a nodule may also be felt at the base of the finger

Move – jerky/hesitant extension/flexion of the finger

No test

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28
Q

whats the management of trigger finger

A 
Conservative  
Usually resolves spontaneously 
Activity modification  
NSAIDS 
Tendon sheath corticosteroid injection

Surgical
Release of the A1 pulley
Most proximal insertion of the flexor tendon
Tenosynovetomy in RA patients
(Excision of the tendon sheath of the wrist)

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29
Q

what is dupuytrens contracture

A

Painless progressive thickening of the palmar fascia causing flexion deformity and functional interference

usually little and ring finger contracted

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30
Q

whats the aetiology of dupuytrens contracture

A

M>F

Nordic race

Fhx

Trauma

Diabetes

Cirrhosis

Phenytoin

Alcoholism

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31
Q

what is the treatment of dupuytrens contracture

A

Conservative
No impairment = do nothing

Surgical 
Needle aponeurotomy 
Enzymatic fasciotomy  
Fasciotomy 
Fasciectomy  
Dermofasciectomy
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32
Q

what is the presentation of base of the thumb OA

A

pain on pinching/gripping + swelling/deformity of CMCJs

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33
Q

how do you manage base of the thumb OA

A

Conservative – as for any OA patient

Surgical  
Denervation  
Trapeziectomy 
Basal thumb arthroplasty  
Joint fusion
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34
Q

what is golfers elbow

A

medial epicondylitis - tendinopathy of the common flexor-pronator origin

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35
Q

what test is fairly diagnostic for golfers elbow

A

pain on resisted flexion of the hand

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36
Q

what is the presentation of golfers elbow

A

Subacute pain occuring from weeks to months, with exacerbation on use and relief on rest

Pain can be very severe, and radiate up and down the arm – especially when flexor/pronator muscles are in use, such as carrying a tray

On examination – tenderness around medial epicondyle and pain triggered by resisted flexion of the hand

Normal range of movements, and no neurological symptoms (tingling/numbness) - otherwise suspect cubital tunnel syndrome

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37
Q

how do you manage golfers elbow

A

Simple analgesia and activity modification (NSAIDS + rest)

Physiotherapy referral (strengthening exercises)

Epicondylar clasp

If all of these are unsuccessful – X-ray the joint to make sure it isnt OA

Surgical option - golfers elbow release (80% success)

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38
Q

what is tennis elbow

A

lateral epicondylitis - inflammation of the common extensor origin

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39
Q

what is more common, golfers or tennis elbow

A

tennis

40
Q

whats the aetiology of tennis elbow

A

Obesity

Smoking

Carpal tunnel syndrome and other tendinopathies

Repetitive gripping/grasping movements

41
Q

what tends to be diagnostic of tennis elbow

A

pain on resisted wrist extension

42
Q

what is the treatment of tennis elbow

A

Simple analgesia and activity modification (NSAIDS + rest)

Physiotherapy referral (strengthening exercises)

Epicondylar clasp

If all of these are unsuccessful – X-ray the joint to make sure it isnt OA

Surgical option - tennis elbow release (80% success)

43
Q

what is olecranon bursitis

A

PAINLESS enlargening of the bursa due to increased use

44
Q

how do you differentiate between articular and periarticular shoulder pathology

A

articular pathology = more global symptoms

45
Q

how does a chronic rotator cuff tendonitis present

A

Pain in shoulder, characteristically worse at night and when elevating/abducting the arm

Tenderness below anterior edge of acromion

Painful arc at 60-120 degrees

Less pain when passively abducted

Power is normal despite pain – separates it from a tear

46
Q

whats the management of chronic rotator cuff tendonitis

A

NSAID analgesia

Corticosteroid injections + physio if severe

If that fails to control symptoms
Arthroscopic decompression of the rotator cuff can take place
This is the excision of the coraco-acromial ligament and any osteophytes

47
Q

how does a rotator cuff tear present

A

Sprain of shoulder

Limited abduction after the event

O.E
Tenderness over acromion
Arm may be lifted above shoulder and held there by deltoid, but as soon as it lowers it drops (abduction paradox)

48
Q

how does a steroid injection help differentiate between full and partial tears of the rotator cuff

A

as partial tears regain abduction movement once the pain has been abolished whereas full tears cannot move thee arm properly

49
Q

whats the management of rotator cuff tears

A

Local anaesthetic
Heat
Exercises

Longer term treatment
After 3 weeks the extent of the rupture can be assessed
Complete tears in young are usually surgically repaired
Partial tears are conservatively treated to allow natural healing

50
Q

what is adhesive capsularis

A

increasing stiffness of the shoulder

51
Q

what is the main risk factor for adhesive capsularis

A

diabetes

52
Q

whats the presentation for adhesive capsularis

A

Initial progressive deep pain that stops the patient sleeping on their side

Starts to subside after a few months

Then increasing stiffness over 6-12 months

Resolution after about 18 months

53
Q

what shoulder movement is most affected in adhesive capsularis

A

limited external rotation

54
Q

whats the management of adhesive capsulais

A

Reassurance - resolves in 18 months

NSAIDS

Intra-articular steroid injections

55
Q

how does subacromial bursitis present

A

burning pain worse when lifting arm over head

stiffness when abducting arm

56
Q

how do you diagnose subacromial bursitis

A

mainly clinical but MRI/USS used to rule out tendon rupture/rotator cuff tears

57
Q

whats the prognosis of subacromial bursitis

A

Dependent on mechanism – trauma (days-weeks) usually heals sooner than overuse injuries (several weeks)

58
Q

whats the management of subacromial bursitis

A

Non-surgical

NSAIDS

Avoid exacerbating movements

59
Q

how do you differ between impingement in articular and periarticular syndromes

A

Impingement due to articular causes leads to pain in both active and passive movements

Impingement due to peri-articular causes leads to less pain in passive movements – as the muscle (which is the issue) isn’t contracting as much)

60
Q

what is trochanteric bursitis

A

inflammation of the bursa between the greater trochanter and the fascia lata, caused by acute or repetitive trauma

61
Q

what are the symptoms of trochanteric bursitis

A

Hip pain radiating down lateral aspect of thigh to knee

Worse at night/with use or when lying on affected side

Point tendernesss when palpating the greater trochanter

Simple test is to get them to adduct a slightly flexed leg at the hip and knee over the midline to the other side, tightening the fascia lata over the inflamed bursa causing more pain

62
Q

how do you manage trochanteric bursitis

A

Corticosteroid injection
If patient is presenting after a total hip replacement injections should be done in a laminar flow theatre

Physio
After initial presentation and injection if they don’t work
Involves stretching fascia lata
2/3 improve with this regimen

Rarely, refractory disease leads to surgical relief of the fascia lata and excision of the bursa

63
Q

what is osgood-schlatters disease

A

Traction injury of patellar ligament on the growth plate, leading to a prominent and tender tibial tuberosity

64
Q

what population is osgood-schlatters disease most common in

A

common in active adolescents

65
Q

what advice is given in osgood-schlatters disease

A

Recovery is spontaneous and takes time (few weeks to months), restriction of activity is wise

66
Q

what is the classic mechanism of injury for menisceal tears?

A

twisting on a flexed weight-bearing knee

67
Q

which menisci is most commonly affected in menisceal tears

A

medial

68
Q

how does a meniscal tear present

A

Variable immediate pain, followed by swelling hours later

Swelling subsides with rest but may recur with trivial injury

The loose tag of meniscus from the tear may get into the intercondylar notch, causing mechanical irritation leading to these symptoms (Locking of the knee, Spontaneous giving way)

O.E
Effusion, swelling with fixed leg deformity and medial joint line tenderness

69
Q

what investigations should be done for a ?menisceal tear

A

X-ray
Lateral, AP and skyline essential
Will be normal – but required to exclude fractures/OA

MRI
Mainstay of imagine
Picks up 90% of tears

70
Q

whats the management of menisceal tears

A

Arthroscopic repair is reccomended if tolerated
Repair is especially important as small avascular tears may propagate a secondary arthritis

Tears in vascular zone are amenable to repair

Avascular zone repair surgery tends to be a partial meniscectomy to prevent mechanical symptoms

Full meniscectomy avoided due to high risk of secondary OA

In degenerative tears secondary to OA, treating conservatively is appropriate due to poor response to debridement

71
Q

what is the most common ligament tear in the knee

A

ACL

72
Q

what clinical sign indicates a tendon rupture

A

swelling within the first hour

73
Q

what should you find on examination with an ACL rupture

A

No firm stop point, only a soft one as the soft tissues stop the force

Partial tears do not give increased mobility, but give pain on testing

For ACL pathology, lachmans test is much more sensitive than the anterior draw test

74
Q

what investigations should be done for ?ACL rupture

A

X-ray
Lateral, AP, skyline
Shows displacement, fractures and any OA

MRI
Gold standard diagnosis

Diagnostic arthroscopy
Required if there is clinical ACL dysfunction but MRI is normal

75
Q

when is a diagnostic arthroscopy required for a ?ACL tear

A

Diagnostic arthroscopy

Required if there is clinical ACL dysfunction but MRI is normal

76
Q

whats the management for ACL rupture

A

Conservative
Sprains/partial tears will heal with physiotherapy
Adhesions will complicate this process if the joint is rested so active movement with a brace is encouraged
Prolonged physio and patient education about activity limitation can be used in older patients, or patients with a low physical requirement
Always initial option for treatment unless there is multi-ligament pathology

Surgery  
ACL 
Arthroscopic tendon graft repair  
Hamstring or semitendinosus tendon used as graft  
Graft secured by two bone screws
77
Q

what is housemaids knee

A

prepatellar bursitis

78
Q

what is clergymans knee

A

infrapatellar bursitis

79
Q

what is the cause of pre/infrapatellar bursitis

A

excessive unaccustomed kneeling

80
Q

how does knee bursitis (clergymans/housemaids knee) present

A

anterior knee pain and fluctuant knee swelling

81
Q

whats the management of knee bursitis

A

Avoid kneeling

Corticosteroid Injections for troublesome symptoms

82
Q

what is anersine bursitis

A

Pain and a bursa in the insertion of the MCL into the upper tibia

Pain worse on standing/stressing MCL

83
Q

what are risk factors for anersine bursitis

A

obesity

breast stroke swimmers

84
Q

whats the management for anersine bursitis

A

Physio

Corticosteroid injection

85
Q

how does a semimembranous bursa swelling present

A

Bursa between semimembranous and gastrocnemius becomes enlarged, presenting as a painless bump on the back of the knee

86
Q

how does a bakers/popliteal cyst present

A

Bulging of the posterior capsule of the knee with synovial herniation leading to a swelling In the popliteal fossa

87
Q

what are risk factors for formation of popliteal/bakers cyst

A

OA
RA
DVT

88
Q

how do you treat a popliteal cyst

A

if non ruptured aspiration and injection of corticosteroid

89
Q

what is plantar fasciitis

A

inflammation of the insertion of the plantar fascia tendon in the calcaneum causing midline pain on walking/standing

90
Q

how do you manage plantar fasciitis

A

Reduced walking

Heel pads

Splinting of foot in dorsiflexed position to stretch tendon

91
Q

whats the prognosis of plantar fasciitis

A

tends spontaneously recovers ina year once treatment is done

92
Q

what is subcalcaneal bursitis

A

pressure induced bursa in the heel often due to tight shoes

93
Q

how does subcalcaeneal bursitis present

A

pressing heel pads causes pain

pain on walking/standing

94
Q

how do you manage achilles tendinitis

A

Raising shoe heel to reduce pain

Low pressure corticosteroid injection near enthesis

95
Q

what is complex regional pain syndrome

A

Abnormal neuroinflammatory response to trauma

Commonly occurs after surgery

96
Q

what are the key symptoms of complex regional pain syndrome

A

Allodynia

Persistent pain in area affected

Stiffness

Swelling

Abnormal hair/nail changes

97
Q

whats the management of complex regional pain syndrome

A

Pain team

Psychologist

Physiotherapy

Focus is preventing such syndromes at the time of injury with adequate analgesia and immbolisation

MDD (22 decks)

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