Tenosynovitis Flashcards
Lateral epicondylitis results from microtears at the origin of the common extensor tendon mass, specifically
the extensor carpi radialis brevis tendon
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Medial epicondylitis affects the common flexor tendon
mass, most often the pronator teres and flexor carpi raclialis.
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Conservative management is the mainstay of medial
epicondylitis treatment and some of the patients need to be assessed
for possible ulnar neuropathy.
F all patients should be assessed
for possible ulnar neuropathy.
Intersection syndrom approximately 4 cm proximal to the radiocarpal joint. It often resolves with nonoperative treatment
such as therapy and splinting.
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Trigger fingers in Diabetics are less likely to
respond to nonoperative treatment
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disorders involving the tendons of
the upper extremity are the result of degenerative or mechanical
stresses, rather than an inflammatory process
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The causes of tendinopathy?
Degenerative, mechanical, inflammation,and infection
Lateral epicondylitis occurs in male more than female
F It is equally common in men and women
the
classic finding of lateral epicondylitis includes ECRB tendon pathology.
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lateral epicondylitis involve ECRP only
F the extensor digitorum communis (EDC), and the ECU.
Although each of these tendons may be involved in the process
s within the ECRB tendon
substance represent the sine qua non for lateral epicondylitis.
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Historically tendinosis rather than tenosynovitis was thought to occur in the lateral epicondylitis
F historically was thought it was inflammation rather than degenerative
Inflammatory cell are present in the histopathological study of lateral epicondylitis mainly macrophage
F Inflammatory cells, such as macrophages and neutrophils,
are lacking
repetitive contact between
the capitellum and the ECRB tendon may be the causative problem.
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provocative maneuver
that may elicit increased pain
resisted wrist extension with the
elbow extended and the wrist pronated
Imaging studies add limited information in the diagnosis of lateralepicondylitis
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Ultrasound (US) and magnetic resonance imaging (MRI) have both
been utilized for diagnosis, to assess disease severity and for purposes ofpreoperative planning
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Ultrasound has been found to have higher sensitivity than MRI
F MRI is often the modality of choice, with
a higher sensitivity of 90% to 100%
However, the severity ofdisease
present on MRI does not necessarily correlate with symptoms
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patients with resolved pain may continue to have pathologic findings
present on MRI
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MRI is often reserved for recalcitrant cases in which
the patient fails to improve with 6 months of conservative treatment
or when the diagnosis in unclear
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the condition usually clears up in eight to twelve months without any treatment except
perhaps avoidance of the painful movements
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the mainstay of treatment for
lateral epicondylitis
activity modification
up to 40% of people continue to have discomfort after 1 to 5 years of
nonoperative treatment
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Despite numerous randomized controlled
studies, none of these interventions has been definitively proven to
work better than rest and therapy alone.
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Physical and occupational therapy for lateral Epicondylitis patients improved in the short term and in the long term
F short term only
Injections into and around the lateral epicondyle remain highly
controversial
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Some studies have shown an
improvement in pain at 4 to 6 weeks after steroid injection , but this advantage usually is not
present at 12 months
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Transient loss of
finger extension is a potential side effect of botox injection
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Indication of surgery
patients who fail 6 to 12 months of conservative management and who remain significantly affected by pain
release of the ECRB from the lateral epicondyle, open,
or arthroscopic debridement of the ECRB tendinosis, denervation of
the lateral epicondyle, and anconeus rotation
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Disadvantages of arthroscopic approach
include decreased visualization of the ECRB tendon, resulting in potential
incomplete debridement of diseased tissues, and greater possibility of radial nerve injury
the arthroscopic
approach has similar results to the open approach
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Medial epicondylitis, also known as golfer’s elbow, is a common cause
of medial elbow pain
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Medial epicondylitis occurs more than lateral epicondylitis
F medial elbow pain. Although less prevalent than lateral epicondylitis (<l% versus 3.4%)
medial epicondylitis is associated with repetitive movements and is
often found in patients 40 to 50 years old
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Muscle involved in the medial epicondyle
The common flexor tendon is composed of five muscles including
the pronator teres (PT), FCR, flexor carpi ulnaris, palmaris longus,
and flexor digitorum superficialis
the pathophysiology of the medial epicondylitis
Microtrauma from repetitive motion, specifically repetitive valgus loads, may result in mucoid degeneration of the tendons resulting in
the histopathologic findings of angiofibroblastic hyperplasia, fibrosis, and calcification
DDX of medial epicondylitis?
elbow arthritis, osteochondral defects, medial collateral
ligament instability, cervical radiculopathy, pronator syndrome, and
ulnar neuritis/cubital tunnel syndrome
Ulnar neuritis is especially
important as 23% to 61% of patients with medial epicondylitis also
have concurrent ulnar neuropathy
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Ultrasound can be used to assist in the diagnosis of medial epicondylitis, as it has been shown to be both specific and sensitive
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Treatments
Activity modification
Physical therapy, with common flexor mass stretching and strengthening
Counterforce bracing has shown some success
Elbow extension bracing
Corticosteroid injections for short term relieve( 6 week )
Overall, in 88% to 96%
ofcases, nonoperative management and the passage oftime has been
shown to result in resolution ofsymptoms.
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Structure at risk in medial epicondylitis surgery
the ulnar nerve, the MCL and the medial antebrachial
cutaneous nerves
De Quervain disease is a stenosing tendiopathy involving the first
dorsal extensor compartment
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radial-sided
wrist pain exacerbated by ulnar deviation of the wrist and thumb
abduction.
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De Quervain mor common in male
It is most common in the fifth and sixth decade of life
and is up to six times more common in women than men
It is also more commonly seen in pregnant and
lactating women
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(APL) and extensor pollicis brevis (EPB)
travel together within the first dorsal compartment, which overlies
the radial styloid.
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the EPB can travel through its own
separate subsheath within the first compartment
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DDX od deQuervian
CMC joint arthritis of the
thumb, scaphotrapezial-trapezoid arthritis, intersection syndrome,
scaphoid fracture, and radial sensory nerve pathology
Non operative treatment
nonsteroidal antiinflammatory medications along with splint immobilization with or without corticosteroid injection
80% had complete and lasting
reliefofsymptoms after corticosteroid injection.
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patients who fail to improve
with corticosteroid injections have been found to have a higher rate
ofEPB subsheath than the general population
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The EPB should be
clearly identified and passively tested to ensure thumb metacarpal
extension before the surgical release is complete
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The percentage of EPB sub sheath
44% in the normal population and 62% in de Quervain disease patients.
Intersection syndrome involves the contents of the second dorsal
compartment, the ECRL and ECRB as they cross beneath the first
compartment muscles (APL and EPB)
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Erythema and crepitation may be present.
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intersection syndrome is
an uncommon cause of wrist pain,
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MRI and ultrasound can be useful modalities for distinguishing between intersection syndrome and other
pathologies, such as de Quervain disease.
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Controversy exists as to whether stenosis of the second compartment
sheath alone versus friction between the first and second compartments is the underlying etiology
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Nonsteroidal antiinflammatory drugs (NSAIDs) combined with
splinting of the wrist in 20° ofextension for 2 to 3 weeks resolves most
cases. Refractory cases can be treated with a corticosteroid injection
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Trigger finger, also known as stenosing tenosynovitis
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lifetime risk percentage
of 2.6% in the general population and up to 10% in those with diabetes
The Al pulley, located at the level of the metacarpal head is the site
of mechanical impingement seen in trigger finger
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The thumb’s Al
pulley is located near the MCP joint crease and is the site of flexor
pollicis longus triggering.
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repetitive motion of the flexor tendons
through the Al pulley leads to friction within the flexor sheath,
causing both thickening of the pulley and nodule formation within
the flexor tendon
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it
is not uncommon for patients to localize the problem to the proximal
interphalangeal (PIP) joint rather than the Al pulley
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association with specific
occupations has not been found
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patients with diabetes,
hypothyroidism, rheumatoid arthritis, gout, and renal failure develop
trigger fingers at higher rates
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there
is no evidence ofinflammation but there is evidence of fibrocartilage
metaplasia and upregulation of type 3 collagen
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Splinting of the MCP joint has been
shown to be successful in up to 66% of cases
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Splinting of the MCP joint has been
shown to be successful in up to 66% of cases
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with a higher success
rate (70%) in digits versus thumbs (50%) with splining
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The PIP joint can also be
splinted, instead of the MCP joint, with similar effect.
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Splinting is
recommended for 6 to 10 weeks both during the day and night, to
which some patients can find difficult to adhere
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Corticosteroid has proven effective in treating trigger fingers and
can be the first line intervention
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a second injection
increases the success rate
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The injections should be intrasheath
F Intrasheath injections are not required for effect,
and intratendinous injections should be avoided to reduce the risk of
tendon rupture
Patients with diabetes do not respond as well to steroid injections;
some studies advocated for immediate surgical release or only one
attempt at injection before surgical intervention is considered
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number of injections
that should be attempted before proceeding to surgical release has
not been established
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Percutaneous
techniques have been shown to be successful with up to 95% resolution of symptoms in all patients
F except for the diabetic patient sand hypothyroidism
statistically
significant increase in digital nerve injury with percutaneous release
versus open release
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complications of open release
chronic pain, infection, iatrogenic digital
nerve injury, incomplete release, and bowstringing
trigger finger and de Quervain disease are the most common tendinopathies of the hand and wrist
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treatment of EPL tendinitis is often surgical
with complete release of the third dorsal compartment, to prevent
rupture of the EPL
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The floor of the ECU tendon sheath is an important contributor
to the triangular fibrocartilage complex
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Injecting local anesthesia into the ECU subsheath can be a helpful
diagnostic tool
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Almost every
tendon in the hand and wrist can cause pain if irritated through
mechanical stresses or stenosing forces
T but Atypical conditions has been recorded
include tendinopathy of the extensor carpi ulnaris (ECU), flexor
carpi radialis (FCR), and extensor pollicis longus (EPL
Green classification of the trigger finger
Grade one pain only at the A1 LEVEL
Grade 2 catching finger
Grade 3 Looked digit passively corrected
Grade 4 fixed flexion
Percutaneous
techniques have been shown to be successful with up to 95% resolution of symptoms
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statistically
significant increase in digital nerve injury with percutaneous release
versus open release,44 which may be most germane to the thumb
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