Regional Periarticular Pain Flashcards
what is de quervains tenovaginitis
Painful inflammation of the abductor pollicis longus and extensor pollicis brevis in the first dorsal compartment in the wrist (proximal to the snuff box)
how does de quervains tenovaginitis present
Acute pain/tenderness in 1st dorsal compartment of thumb on use +/- swelling
Most commonly on unaccustomed intensive activity (painting fence)
what patients classically have de quervains tenovaginitis
Women
Middle aged
Post partum
what would you find on examination with de quervains tenovaginitis
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
what test is positive in de quervains tenovaginitis
finklesteins
what are differentials of de quervains tenovaginitis
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
whats the management of de quervains tenovaginitis
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
whats inside the flexor retinaculum
4 flexor digitorum profundus
4 flexor digitorum superficialis
1 flexor pollicis longus
what is carpal tunnel syndrome
median nerve compression
whats the aetiology of carpal tunnel syndrome
Idiopathic – 95%
Diabetes
Rheumatoid Arthritis
Colles fractures (as well as other trauma)
Acromegaly
Hypothyroidism
how does carpal tunnel syndrome present
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
what tests are commonly positive in carpal tunnel syndrome
Phalens and tinels
how do you manage carpal tunnel syndrome
Conservative
Rest
Night time splinting
NSAIDS/steroid injections
Surgical
Division of the flexor retinaculum – leads to a scar in the palm
what causes cubital tunnel syndrome
chronic compression of the elbows (computer desk all day)
Tight fascial bands
Ulnar fracture
Valgus deformity of the elbows
Others
how does cubital tunnel syndrome present
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
what nerve is affected in cubital tunnel syndrome
ulnar nerve
what would you find on examination in cubital tunnel syndrome
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)
whats the management of cubital tunnel syndrome
Conservative
Night time splints
NSAIDS
Activity modification
Surgical
Simple cubital tunnel decompression
Anterior transposition of the nerve
what is a ganglion cyst
Soft tissue swellings filled with a degenerative myxotic (mucus-y) fluid stemming from an underlying joint capsule, tendon or sheat
what is the typical patient for a ganglion cyst
woman, aged 20-40
what are common areas for a ganglion cyst
wrist - dorsal or polar
DIPJ
Base of finger from flexor sheath
how does a ganglion cyst feel
can be hard or soft but is never fixed to skin
how do you manage a ganglion cyst
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
what is trigger finger
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
what patient population is most commonly affected by trigger finger
women over 40
whats the aetiology of trigger finger
RA
Diabetes
what do you find on examination for trigger finger
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
whats the management of trigger finger
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)
what is dupuytrens contracture
Painless progressive thickening of the palmar fascia causing flexion deformity and functional interference
usually little and ring finger contracted
whats the aetiology of dupuytrens contracture
M>F
Nordic race
Fhx
Trauma
Diabetes
Cirrhosis
Phenytoin
Alcoholism
what is the treatment of dupuytrens contracture
Conservative
No impairment = do nothing
Surgical Needle aponeurotomy Enzymatic fasciotomy Fasciotomy Fasciectomy Dermofasciectomy
what is the presentation of base of the thumb OA
pain on pinching/gripping + swelling/deformity of CMCJs
how do you manage base of the thumb OA
Conservative – as for any OA patient
Surgical Denervation Trapeziectomy Basal thumb arthroplasty Joint fusion
what is golfers elbow
medial epicondylitis - tendinopathy of the common flexor-pronator origin
what test is fairly diagnostic for golfers elbow
pain on resisted flexion of the hand
what is the presentation of golfers elbow
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
how do you manage golfers elbow
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)
what is tennis elbow
lateral epicondylitis - inflammation of the common extensor origin
what is more common, golfers or tennis elbow
tennis
whats the aetiology of tennis elbow
Obesity
Smoking
Carpal tunnel syndrome and other tendinopathies
Repetitive gripping/grasping movements
what tends to be diagnostic of tennis elbow
pain on resisted wrist extension
what is the treatment of tennis elbow
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)
what is olecranon bursitis
PAINLESS enlargening of the bursa due to increased use
how do you differentiate between articular and periarticular shoulder pathology
articular pathology = more global symptoms
how does a chronic rotator cuff tendonitis present
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
whats the management of chronic rotator cuff tendonitis
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
how does a rotator cuff tear present
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)
how does a steroid injection help differentiate between full and partial tears of the rotator cuff
as partial tears regain abduction movement once the pain has been abolished whereas full tears cannot move thee arm properly
whats the management of rotator cuff tears
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
what is adhesive capsularis
increasing stiffness of the shoulder
what is the main risk factor for adhesive capsularis
diabetes
whats the presentation for adhesive capsularis
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
what shoulder movement is most affected in adhesive capsularis
limited external rotation
whats the management of adhesive capsulais
Reassurance - resolves in 18 months
NSAIDS
Intra-articular steroid injections
how does subacromial bursitis present
burning pain worse when lifting arm over head
stiffness when abducting arm
how do you diagnose subacromial bursitis
mainly clinical but MRI/USS used to rule out tendon rupture/rotator cuff tears
whats the prognosis of subacromial bursitis
Dependent on mechanism – trauma (days-weeks) usually heals sooner than overuse injuries (several weeks)
whats the management of subacromial bursitis
Non-surgical
NSAIDS
Avoid exacerbating movements
how do you differ between impingement in articular and periarticular syndromes
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)
what is trochanteric bursitis
inflammation of the bursa between the greater trochanter and the fascia lata, caused by acute or repetitive trauma
what are the symptoms of trochanteric bursitis
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
how do you manage trochanteric bursitis
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
what is osgood-schlatters disease
Traction injury of patellar ligament on the growth plate, leading to a prominent and tender tibial tuberosity
what population is osgood-schlatters disease most common in
common in active adolescents
what advice is given in osgood-schlatters disease
Recovery is spontaneous and takes time (few weeks to months), restriction of activity is wise
what is the classic mechanism of injury for menisceal tears?
twisting on a flexed weight-bearing knee
which menisci is most commonly affected in menisceal tears
medial
how does a meniscal tear present
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
what investigations should be done for a ?menisceal tear
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
whats the management of menisceal tears
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
what is the most common ligament tear in the knee
ACL
what clinical sign indicates a tendon rupture
swelling within the first hour
what should you find on examination with an ACL rupture
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
what investigations should be done for ?ACL rupture
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
when is a diagnostic arthroscopy required for a ?ACL tear
Diagnostic arthroscopy
Required if there is clinical ACL dysfunction but MRI is normal
whats the management for ACL rupture
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
what is housemaids knee
prepatellar bursitis
what is clergymans knee
infrapatellar bursitis
what is the cause of pre/infrapatellar bursitis
excessive unaccustomed kneeling
how does knee bursitis (clergymans/housemaids knee) present
anterior knee pain and fluctuant knee swelling
whats the management of knee bursitis
Avoid kneeling
Corticosteroid Injections for troublesome symptoms
what is anersine bursitis
Pain and a bursa in the insertion of the MCL into the upper tibia
Pain worse on standing/stressing MCL
what are risk factors for anersine bursitis
obesity
breast stroke swimmers
whats the management for anersine bursitis
Physio
Corticosteroid injection
how does a semimembranous bursa swelling present
Bursa between semimembranous and gastrocnemius becomes enlarged, presenting as a painless bump on the back of the knee
how does a bakers/popliteal cyst present
Bulging of the posterior capsule of the knee with synovial herniation leading to a swelling In the popliteal fossa
what are risk factors for formation of popliteal/bakers cyst
OA
RA
DVT
how do you treat a popliteal cyst
if non ruptured aspiration and injection of corticosteroid
what is plantar fasciitis
inflammation of the insertion of the plantar fascia tendon in the calcaneum causing midline pain on walking/standing
how do you manage plantar fasciitis
Reduced walking
Heel pads
Splinting of foot in dorsiflexed position to stretch tendon
whats the prognosis of plantar fasciitis
tends spontaneously recovers ina year once treatment is done
what is subcalcaneal bursitis
pressure induced bursa in the heel often due to tight shoes
how does subcalcaeneal bursitis present
pressing heel pads causes pain
pain on walking/standing
how do you manage achilles tendinitis
Raising shoe heel to reduce pain
Low pressure corticosteroid injection near enthesis
what is complex regional pain syndrome
Abnormal neuroinflammatory response to trauma
Commonly occurs after surgery
what are the key symptoms of complex regional pain syndrome
Allodynia
Persistent pain in area affected
Stiffness
Swelling
Abnormal hair/nail changes
whats the management of complex regional pain syndrome
Pain team
Psychologist
Physiotherapy
Focus is preventing such syndromes at the time of injury with adequate analgesia and immbolisation
