Upper limb

Question 1

Erb’s palsy

Answer 1

upper roots of brachial plexus
affected, C5 and C6

limbs hangs by side in medial rotation with an adducted arm and extended elbow
Waiters tip position

an excessive increase in angle between neck and shoulder

May occur in trauma or during birth of a baby if the shoulders become impacted in the pelvis (shoulder dystocia) and excessive traction is applied to baby’s neck

Question 2

Klumpke’s palsy

Answer 2

Injury to lower roots of brachial plexus

Nerve roots C8 and T1 affected

Occur due to forced hyperextension or hyperabduction
Ie. When someone falls from a height and grabs onto a tree branch on the way down
○ If baby’s arm is delivered first and traction is applied to arm to deliver the rest of baby

Question 3

Klumpke’s palsy symtpoms

Answer 3

The paralysis affects the intrinsic muscles of the hand and those flexors within the forearm that are supplied by the ulnar nerve (i.e. flexor carpi ulnaris and the ulnar half of flexor digitorum profundus).

affects those muscles supplied by the C8 and T1 fibers within the median and radial nerves, so is not just a straightforward high ulnar nerve injury (compare the image on the next page with the ‘high ulnar claw’ in session 9 here).

'claw hand' with 
hyperextension of all of the metacarpophalangeal joints (not just the ring and little finger seen in an ulnar nerve injury), 
flexion of the interphalangeal joints
abduction of thumb
wasting of the interossei

Question 4

Rupture of biceps tendon

Answer 4

Popeye sign

Long head may rupture near to its scapular origin

Patients >50 following quite minimal trauma

‘head something snap’ in shoulder whilst lifting

Flexion of the arm at the elbow produces a firm lump in lower part of the arm - unopposed contracted muscle belly of the bicep = Popeye sign

Patient will not notice much weakness in upper limb due to action of the brachialis and supinator muscle, mamagenet is usually conservative

Weightlifters: distal tendon of the biceps sometimes snap near to its insertion instead

Question 5

Dislocated shoulder

Answer 5

Will be visibly deformed and there may be visible swelling and/or brushing around the shoulder
Restriction of movement
90-95% are anterior dislocations

Head of humerus sits anterior to the glenoid fossa, glenoid fossa is shallow

Joint is stressed on its superior, anterior and posterior aspects, it is weak at its inferior aspect

Head of humerus usually dislocates anteroinferioyl but then often displaces in an anterior direction due to pull of muscles and disruption of the anterior capsule and ligaments

Subcoracoid locatio = 60% of cases

Head of humerus may come to lie anterior-inferior to the glenoid (subglenoid location in 30% of cases0

Both are types of anterior dislocation

Question 6

anterior dislocation arm look like

Answer 6

held in position in a position of external rotation an slight abduction

Question 7

Bankart lesion/labral tear

Answer 7

Force of humeral head popping out of the socket often causes part of the glenoid labrum to be torn off

Small piece of bone can be torn off with the labrum

Question 8

Hill Sachs lesion

Answer 8

-When humeral head is dislocated anteriorly, the tone of the infraspinatus and teres minor muscles means that the posterior aspect of the humeral head becomes jammed against the anterior lip of the glenoid fossa

Causes a dent (indentation fracture) in the posterolateral humeral head = Hill-Sachs lesion

50% of people <40 with anterior shoulder dislocation, and up to 80% of those with recurrent dislocations will have this

Assocaited with Anterior dislocation

Question 9

Posterior dislocation

Answer 9

Less common - 2-4% of cases
Violent muscle contractions due to:
epileptic seizure
Electrocution
lightning strike
blow to the anterior shoulder
or when arm is flexed across the body and pushed posteriorly

Question 10

Pos. Dislocation arm look like

Answer 10

internally rotated and adducted

Flattening/saying of the shoulder with a prominent coracoid process
○ Arm cannot be externally rooted into the anatomical position

Question 11

What injuries are commonly assocated with Post.Dislocations

Answer 11

fractures rotator cuff tears, and hill-Sachs lesions

Question 12

Inferior dislocations

Answer 12

0.5%
Head of humerus sits inferior to the glenoid

Mechanism is forceful traction on the arm when it is fully extended over eh head, may occur when grasping an object over the head to break fall i.e. hyperabduction injury

Injuries associated with inferior dislocation include damage to nerves 60%, rotator cuff tears (80%) and injury to blood vessels (3%)

Question 13

In dislocations, which is more common nerve or arterial injuries?

Answer 13

injuries of the axillary nerve which occur in around 10-40% of shoulder dislocations

Axillary nerve wraps around neck of femur and supplies the deltoid muscle and skin overlying the insertion of deltoid

Regents badge area as it corresponds with where a shoulder badge woul be worn on the sleeve of a jacket

Most with xaxiallry nerve damage will recover full as ymptoms resolve when the should is reduced/aka put back into place

Less commonly dislocation of shoulder may damage the cords of the brachial plexus or msuculocutanous nerve

Question 14

what are the rotator cuff muscles

Answer 14

Supraspinatus, infraspinatus, subscapularis,

teres minor

Question 15

rotator cuff muscle tears

Answer 15

• Association with shoulder dislocation commonly in older people

Common complication of inferior dislocation in all age groups - 80% of inferior dislocations are associated with a rotator cuff tear

Integrity of the rotator cuff should always be assessed as part of the follow up patients after reduction of dislocated shoulder

Question 16

Clavicle fracture

Answer 16

3-5% of all fractures
peak in children and young adults

Clavicle acts as a structure to brace the shoulder from the trunk so the arm has freedom of motion and transmits force from the upper limb to the axial skeleton
Provides protection to the brachial plexus, subclavian vessels and the apex of the lung

80% of fractures occur in middle third of the clavicle - midclavicualr fracure

Most result from falls onto the affected shoulder or onto the outstretched hand

Question 17

Clavicle fracture treatment

Answer 17

conservatively without surgery, using a sling

Surgical fixation:
Complete displacement- so bone ends are not in apposition and cannot unite

Severe displacement causing tending o the skin with risk of puncture

Open fractures - fracture associated with a break in the integrity of skin

Neurovascualr comprimse

Fractures with interposed muscle

Floating shoulder - clavicles fracture with ipsilateral fracture of glenoid neck

Question 18

What will happe to the position of the arm and clavicular fragments in a displaced mid-claviclular fracture - fracture at the midpoint of the clavicle?

Answer 18

Sternocleiodomastoid muscle elevates the medial segment

Because the trapezius muscle is unable to hold the lateral segment up, and also because of the weight of the upper limb, the shoulder drops

Arm is pulled medially by pectoralis major - addiction

Question 19

What are general complications with fracture healing?

Answer 19

General complications associated with fracture healing i.e. non-union (failure to unite) and malunion- uniting in a suboptimal position, there are potential local complications such as pneumotorax or injury to surrounding neurovacular structures

Suprascapular nerve may be damaged by the elevation of the medial part of the fracture

Supraclavicualr nerves c3 and 4 may also be damaged = paraesthesia over the upper chest anterioly

Question 20

Cause of rotator cuff tears

Answer 20

age relegated degeneration
Age, blood supply to the rotator cuff tendons decreases, impairing the body’s ability to repair inor injury
Degenerative-microtauma model
Age related tendon degeneration compounded by chronic micro trauma results in partial tendon tears that develop into full rotator cuff tears
Inflammatory cells are recruited
Oxidative stress leads to tenocyte - tendon cell apoptosis, leading to further dengue ration

Recurrent lifting and repetitive overhead activity are also risk factors e..g carpenters, painters, as are support tht invovle repeated overhead motion e.g swimming volleyball, tennis, weightlifting

More common in shoulder of domianant arm for rotator cuff tears,but a tear in one shoulders shoulda an increased risk of a tear in the opposite shoulder

Question 21

Rotator cuff tears symptoms

Answer 21

asmyptomatic

Clincial presetiaon is aterolatera shoulder pain, often radiating down the arm

May occur with activity particular shoulder activity above the horizontal position but is may also be present at rest

Patents experience pain in their shoulder hen they lean o their elbow and push downwards e..g learning on an armrest of a chair, as this pushes te head of the humerus superiority and decrease the space between the humeral head and the coracoacromial arch

pain in shoulder when reaching forward - flexing the shoulder e.g. to take a bottle of milk from the refrigerator

Pain restricted movements above the horizontal position may be present, as well as weakness of shoulder abduction but weakness only found on physical examination, as it is the pain that predominately limited the patients activities and leads them to seek medical attention

Question 22

Impingement syndrome

Answer 22

Supraspinatus tendon impinges - rubs or catches on the coraco-acromial arch, leading to irritation and inflammation

Space between the head of the humerus and coracoacromial arch is small,

- Impingement may be caused by anything that narrows this space further   e. g thickening of the coracoacromial ligament, 

inflammation of supraspinatous tendon,

subacromial osteophytes in OA

Question 23

Impingement syndrome symptoms

Answer 23

grinding or popping sensation during movement of shoulder

Question 24

Calcific supraspinatus tendinopathy/ tendonitis

Answer 24

Macroscopic depositis of hydroxyapatite - crystalline form of calcium phosphate in the tendon of supraspinatus

Can occur in any tendon of the rotator cuff

Most common in supraspinatus
- Present with acute or chronic pain, aggregated by abducting or flexing the arm above the level of the shoulder, or by lying on the shoulder

Mechanical symptom may occur due to hyiscl presence of a large deposition = stiffness, snapping sensation, catching, or reduced range of movement of the shoulder

Question 25

Cause of Calcific supraspinatus tendinopathy / tendonitis

Answer 25

Disease believed to be multifactoral

Regional hypoxia leads to tenocytes being transformed into chrondrocyes and laying down cartialge in tendon. Calcium depositions are then formed through a process resembling endochondral ossification

Ectopic bone theory. Formation from metaphase of mesenchymals stem cells normally present in tenons into osteogenic cells

Question 26

Calcification dspesiit are visible on x rays

- explain

Answer 26

Crystalline in their ‘resting phase’

Eventually reaborsbed by phagocytes and it is during this reabsorption stage that they end to cause the most pain

During the reabsoprtion stage thy look microscopically like ‘toothpase’ and often appear ‘cloudy’ i.e. less well defined on x ray

Question 27

Treatment of Calcific supraspinatus tendinopathy / tendonitis

Answer 27

conservative with rest and analgesicsa, surgical treatment is sometimes required for persistent symptoms

Question 28

Adhesive capsulitis / frozen shoulder

Answer 28

Painful and disability disroder

Capsule of the glenohumeral joint becomes inflamed and stiff

Restricting movement and causing chronic pain

Constant pain, worse at night and exacerbated by movements and cold weather

Question 29

Adhesive capsulitis / frozen shoulder - risk factors

Answer 29

Female,
epilepsy with tonic seizures - sudden muscle contractions,
DM - glucose bonds to capsular collagen,
trauma to shoulder,
CT disease,
thyroid disease - hypo/hyper, cardiovascular disease,
chronic lung disease,
breast cancer,
polymyaliga rheumatica - inflammatory condition using msucle pain and weakness and
Parkinson’s disease

Question 30

Adhesive capsulitis / frozen shoulder - treatment

Answer 30

physio therapy, analgesia and antinflammatory medication

Manipulation under anaeastheisa hich breaks up the adhesions and scar tissue in the oint to help restore range of motion

Intense post op physio this then helps maintain the movement that has been gains

Typically resolves with time and Evian 90% of their shoulder motion

Once frozen shoulder has resolved, the opposite shoulder becomes affected in 6 to 17% of patients within 5 years, lending further weight to the autoimmune hypothesis

Question 31

OA of shoulder

Answer 31

Can occur in shoulder joint and has radiological features similar to osteoarthritis occurring in other joints

People > 50 years of age

Affects acromicoclavicualr joint than the glenohumeral shoulder joint

Question 32

OA of shoulder treatment

Answer 32

Activity modification - avoiding activities that precipitate symptoms
Analgesia
Anti-infalmmtaories - NSAIDs

Some report a benefit fro taking nutritiaonl supplements e..g glucosamine and chondrotin sulfate

Steroid injections can be performed into joint to reduce swelling and thereby alleviate shoulder stiffness and pain

Hyaluronic acid injections into joint - viscosupplementation may increase lubrication, although evidence is omitted

Arthroscopy - key whole surgery- can be performed to remove loose pieces of damaged crialge from glenohumeral joint but some patients will progress to hemiarthroplasty - replacement of humeral head or total shoulder replacement - replacement of humeral head and glenoid

Question 33

Supracondylar fracture

Answer 33

Fracture line = extraarticualr (joint is not involved) and distal fragment is posteriorly displaced

Falling from a moderate height ont an outstreched hand with elbow hyperextened (i.e. monkey bars)

90% seen in children <10 with a peak age: 5-7 years , more in boys

Child presents with pain, deforming and loss of function

Less common mechanism (5%) - falling onto a flexed elbow

‘flexion supracondylar fractures’ occur more in elderly

Question 34

Supracondylar fracture - complications

Answer 34

Malunion - resulting in cubitus varus / gunshock deformity

Damage to median nerve (most common), radial or ulnar nerve

Ischaemic contracture - brachial artery passes v.close to the fracture site and can occasionally by damaged or occluded by a displaced fracture

If reflex spasm of collateral circualtion around elbow occurs - ischamei of muscles in atnerior compartment of forearm. Results in oedema and a rise in compartment pressure (compartment syndrome) = further exacerbrate the ischameia as it impeded arterial inflow and if untreated the muscle bellies will undergo infarction

During repair phase: dead muscle tissue becomes replaced by scar tissue through fibrosis
Fibrotic tissue contracts by myofibroblast activity = flexion contracture known as Volkman’s ischaemic contracture

Question 35

Supracondylar fracture - what does the wrist look like

Answer 35

flexed, fingers extened at MCPJ and flexed at the interphalangeal joints, forearm pronated and elbow flexed

Question 36

Dislocated elbow

Answer 36

Person often child, falls on their outstretched hand with the elbow partially flexed

More likely to cocur in mid flexion

90% are posterior (named by the displacement of distal framgnet i.e. ulnar and radius and not the proximal fragment - humerus)

Distal end of humerus is driven through the joint capsule anteriorly

Ulnar collaterla ligament is torn and can be an associated fracture and/or ulnar nerve involvement

Question 37

Dislocated elbow - anterior dislocations

Answer 37

<10%
direct blow to posterior aspect of a flexed elbow

Assocaited fractures of he olecranon are common seen due to degree of force requreid to dislocate joint

Question 38

Nursemaid’s elbow/pulled

Answer 38

Subluxation of radial head (subluxation = partial disruption of a joint with some remaining but abnormal apposition of the articular surfaces i.e. it is an incomplete dislocation)
Occurs in chldren agen: 2-5 years

Reduced movement of elbow and pain over lateral aspect of the proximal forearm - ‘not using their arm’

50% = 50% during falls or over-reaching for an object

Injury occurs most commonly in pronation becaue the annular ligament is tauty in supination and more relaxed in pronation so it is easier for subluxation to occur

Longituadionl traciton on radial head tears the distal attachement of the annular ligament from where it is losely attached to neck of radius

Radial head is then displaced distally through the torn ligament

As children age, the annular ligament naturally strenghteshn making conition less common

Question 39

Mechanism of action of pulled elbow

Answer 39

Mechanism: longitudinal traction is applied to arm with forearm pronated (tugging an uncooperative child or swining a child by their arms during play) = 50% iof cases

Question 40

Radial Head/neck fractures

Answer 40

Result from a fall on an outstertched hand when radial head impacts on the capitellum of humerus

Patient presents with pain in the lateral aspect of their proximal forearm and loss of range of movement

Swelling asociated with these fraactures - modest in comparision with supracondylar fracture

Fracture by red arrow

Fat pad sign (or sail sign) is an indicator that an effusion is present

Setting of trauma, due to a haemarthrossi (blood in joint) secondary to an intra-articular fracture
Displacement of the anterior fat pad
Displaced fat pad is relatively radio-lucent and therefore appears black on the X ray

Question 41

RA of elbow

Answer 41

Autoimmune disease in which autoantibiodes (rheumatoid factor) attack the synovial membrane

Inflamed synovial cells proliferate to form a pannus, which penetrates through the cartialge and adjacent bone = joint erosion and deformity

Affects the metacarpophalagneal joints and proximal interphalngeal joints of hands, feet and cervical spine, involve the large joints

Autoimmune process leads to damage to other organs, inclduign eyes, skin, lungs, heart and blood vessels and kidneys

Commonly have anaemia of chronic disease

Women ore affected than men (2:1 or 3:1)

Question 42

X ray features of RA

Answer 42

Joint space narrowing
Periarticular osteopenia
Juxta-articular (called marginal) bony erosions (in non-cartilage protected bone)
Subluxation and gross deformity

Question 43

RA of elbow

Answer 43

Managed medically rather than surgically through presciprtion of dsiease-modifying medication

Surgery in severe cases to relieve pain and improve mobility

X ray - extensive erosion of the humeroulnar joint with most of the trochlear of humerus having been destroyed and sigmoid fossa of the olecranon being sig enlarged

Question 44

Tennis elbow

Answer 44

lateral epicondylitis

Tendinopathy - chronic overuse disorders in tendons

3% of persons aged 40-60 years

Present with pain due to tendinopathy of common extensor tendon (common extesor origin) at lateral epicondyle

Extensor carpi radilais brevis (ECRB) muscle helps stabilise wrist when eblow is traight. Occurs during ateensi groundstroke.

When ECRB is weakened from oversue, microscopic tears form in tendon where it attaches to lateral epicondyle. Leads to inflammation and pain

Pain over lateral epicondyle during extension of the wrist

Tennis players, painters, plumbers and carpenters are prone - due to repetitive nature of their activity at wrist and elbow

Patients are advides to modify activities to give tendon an opportunity to heal.

Disorder is self-limiting and 90% of patients recover within 1 years.

Physio and bracing required sometimes, and a small number of patients need injections or surgery

Question 45

Golfer’s elbow/ medial epicondylitis

Answer 45

10x less common than tennis elbow

Affects common flexor origin at the medial epicondyle
Associated with golfing and with throwing sprots that palce valgus stress on the elbow.

Most comon site of patholgogy - inferface between the pronator teres and the flexor carpi radialis (FCR) origins

Patients present with an aching pain over the medial elbow, assocaited with accelearation phase of throwing

Pain is produced on resisted flexion or pronation of the wrists

Ulnar nerve symptoms are present in up to 20% of cases due to proximity of the ulnar nerve to the medial epicondyle

Question 46

Student’s elbows/ Olecranonn bursitis

Answer 46

Inflammation of olecranon bursa

Situated between skin and the olecranon process of ulna

Usually due to repeated minor trauma e.g. students leaning with elbows on desk for many hours whilst studying

Contnets will be serous fluid

Swelling = soft cystic (fluid-filled) and transilluminates (light can be shined through it)

Question 47

Student’s elbows/ Olecranonn bursitis - treatment

Answer 47

conservative with compression bandagin +- aspiration

Hydrocortiosne injection sometimes necessary in chronic cases
Sometimes, bursitis is a result of infection of the bursa (septic bursitis e.g. following a minor penetrating injury to the elbow), then aspirton, compression and antibotics are required

Occosaionally, surgical draininage and washout under anaesthetic will be needed to resolve the infection

Question 48

Rheamtoid nodules

Answer 48

extra-articualr manifestions of RA

Firm lumps. Not usually painful

Affects 20% of patients with RA
Those who develop them, are smokers, and more aggressive joint disease, and more prone to other extra articular (outside of the joint) manifesations of rheumatoid disease including vasculitis (inflammation of blood vessels) and lung disease

Occur over exposed regions that are subject to repeated minor trauma

Affects elbow reign, fingers and forearms and occasionally over back of heel

Non-tender athlout overlying skin can occasionally ulcerate and become infected

Patients present due to cosmetuc concers

Question 49

Rheumatoid nodules - treatment

Answer 49

improvming medicla control of underlying RA, although response of exisiting nodules to this is somewhat variable

Question 50

Gouty trophi

Answer 50

Tophi are nodular masses of monosodium urate crystals deposited in soft tissues

Late complication of hyperuricaemia and devleop in >50% of patients with untreated gout

Usually painless, but complaications can include pain, soft tissue damage and deformity, joint destructuin and nerve comrpession

Common sites: fingers and ears, but can be found in the olecranon bursa and subcutaneous tisue of elbow where they can resemble rheatoid noduels I appearance

Contain white ‘pasty’ materal and as they enlarge, they work their way towards skin surface to drin, either foriming a sinus tract or a continusoly draininage ulcer

Question 51

Cubital tunnel syndrome

Answer 51

Flexor carpi ulnaris muscle has 2 heads - one head orignating form common flexor origin on medial epicondyle and a seond head originating from medial margin of the olecranon

2 heads untied by a tendinous arch

Ulnar nerve passes beneath this tendinous arch to enter the cubital tunnel - this area forms a common site for ulnar nerve compression = cubital tunnel syndrome

Question 52

Cubital tunnel syndrome

Answer 52

to ‘decompress’ nerve - surgically release it and transpose it anterior to medial epicondyle

Question 53

Scaphoid fracture

Answer 53

70-80% of all carpal bone fractures, and 10% of hand fractures

Proximal pole = 20%

Distal pole = 10% = 10% scaphoid tubercle

Question 54

Scaphoid fracture - mechanisms of actions

Answer 54

FOOSH - fall onto an outstretched hand
=hyperextensin and impaction of scaphoid against rim of radius or in direct axial (‘end on’) compression of scaphoid

Complain of pain in the anatomical snuffbox. Exaccerbed by moving the wrist. passive rang eof mtion is reduced but not dramatically. Can get swelling around the radial and posterior aspects

Question 55

Scaphoid fracture risk

Answer 55

Blood supply to scaphoid is retrograde (from distal to proximal pole) = asvscaulr necrosis

Displaced fractures through the waist of the scaphoid have high risk of non-union (8-10%), malunion, avascualr necrosis and late complications of carpal instability and secondary osteoarthritis

Question 56

Colle’s fracture

Answer 56

Extra-articular fracture of distal radial metaphysis, with dorsal angulation and impaction

An associated ulnar styloid fracture is present in 50% of cases

Common type of distal radial fracture

Common in: osteoporotic (reduced bone density) and post menopasual women

High imoact trauma e.g. skiing

FOOSH with a pronated foream and wrist in dorsiflexion

Energy transmistted from carpus to distal radius in a dorsal direction and along the long axis of the radius
Fracture: dorsally angulated and impacted

Question 57

Colles fracture treatment

Answer 57

Reduction and immobilisation in cast

Question 58

Colles fracture complications

Answer 58

Malunion - can cause dinner fork deformity

Median nerve palsy and Post traumatic carpal tunnel syndrome

Secondary osteoarthtris (more common with intra-aticular fractures)

Tear of extensor polllicis longus tnednon (through attrition of tendon over a sharp fragmenet of bone)

Question 59

Smith Fracture

Answer 59

Fracture of distal radius with volvar (palmar) angulation of the distal fracture fragments
85% are extra-articular

Thought as a ‘reverse colles’ fracture

Question 60

Smith fracture- mechanism

Answer 60

Occur in young ales and elderly femlaes

Fall onto a fleed wrist or a direct blow to back of wrist

Malunion of a smith fracutre with residual volar displacement of distal radius = cosmetic deformity = ‘garden spade defomrity’

Narrows and distorts carpal tunnel

Carpal tunnel syndrome can be a result form this

Question 61

RA of MCPJ and IPJs

Answer 61

Inflammaed synrovial cells proflieratite to forma pannus which penetrates through the cartialge and adjacent bone, leading to joint erosion and deformity

RA described as a symmeetircal polyarthritis = affects multiple joints in a snyovial distriction e.g. L and R wrist at same time

Symmetircal inflammation can make mild swelling in hand difficult to diagnose as there is no ‘normal’ hand with which to make a comparison

Question 62

RA of MCPJ and IPJs symtpoms

Answer 62

Pain and swelling of PIPJs and MCPJs of the fingers

Erythema (redness) overlyign joints = idnicates inflammation

Stiffness, worst in morning or after periods of inactivity = causing difficulty with tasks such as doing up buttosn)

Carpal tunnel syndorme due to synrovial swelling

Fatigue and flu-like symtpomts due to systemic nature of rheumatoid disease

Question 63

2 deformities of RAof MCPJ and IPJs

Answer 63

Swan neck - PIPJ hyperextends and MCPJ and DIPJ are flexed

Boutonniere - MCPJ and DIPJ are hyperextened and PIPJ is flexed.

Question 64

Psoriatic arthropathy

Answer 64

Only a minority of patients with psoriasis will develop arthritis.

Develops an asymmetrical oligoarthritis (it develops in one joint at a time, progressing in an asymmetrical manner e.g. left big toe then right index finger).

Psoriatic arthritis involves the small joints of the hands and feet most commonly.

The patients present with fusiform (sausage-shaped) swelling of the digits, known as dactylitis (=swollen digits).

The affected joints stiffen and if the disease progresses, it can progress to a widespread joint destruction called arthritis mutilans.

Question 65

Psoriatic arthropathy

smyptoms

Answer 65

affects the DIPJs.

80% of patients also have nail lesions, such as pitting and onycholysis (separation of the nail from the nail bed). [note: onycholysis can also be caused by hyperthyroidism and fungal nail infections, but the nail pitting is very typical of psoriasis]

Question 66

OA of hand

Answer 66

Osteoarthritis of the 1st CMC joint and DIPJs, including Heberden’s nodes.
The joint in the hand that is most commonly affected by osteoarthritis is the 1st carpometacarpal joint (between the trapezium and the first metacarpal). This is more common in women

Question 67

OA of hand - symtpoms

Answer 67

The patients complain of pain at the base of their thumb. The pain is exacerbated by movement and relieved by rest. Stiffness increases following periods of rest (e.g. in the mornings).

There may be some swelling evident around the base of the thumb.

In the later stages, the first metacarpal subluxes in an ulnar direction, resulting in loss of the normal contour and ‘squaring of the hand’.

Question 68

Herberdens nodes

Answer 68

classic sign of osteoarthritis and affect the DIPJ of the fingers. They typically develop in middle age, are more common in women than men and tend to run in families, suggesting a genetic predisposition.

Question 69

Carpal Tunnel syndrome

Answer 69

compression of the median nerve as it passes through the carpal tunnel from the forearm into the hand.

common site of nerve entrapment in the body

Question 70

Carpal Tunnel syndrome - risk factors

Answer 70

Obesity
repetitive wrist work
Pregnancy
Rheumatoid arthritis Hypothyroidism

Question 71

Guyon’s canal syndome/ Handlebar palsy

Answer 71

The ulnar nerve can be compressed in Guyon’s canal, as it passes
radial (lateral) to the pisiform bone over the volar surface of the flexor retinaculum.

Called Ulnar tunnel syndome, Guyon’s canal syndome or Handlebarpasly (due to postioning of cylsists wrists on handlebards leading to ulnar nerve compression)

Question 72

Guyon’s canal syndome/ Handlebar palsy

smyptoms

Answer 72

reports paraesthesia in the ring and little fingers,
progressing to weakness of the intrinsic muscles of the hand supplied by the ulnar nerve (notably adductor pollicis and the palmar and dorsal interossei; also lumbricals to ring and little fingers and deep head of flexor pollicis brevis, but these are not usually noticed by patients)

Question 73

Dupuytren’s contracture

Answer 73

common condition in which there is localised thickening and contracture of the palmar aponeurosis leading to a flexion deformity of the adjacent fingers.

Question 74

Dupuytren’s contracture -conditions that increase risk of developing this

Answer 74

Type 1 diabetes
Having had adhesive capsulitis of the shoulder (‘frozen shoulder’, here)
Epilepsy, taking certain medications e.g. barbiturates, phenytoin
Liver disease and/or excessive alcohol consumption (more than a bottle of wine per day)
Smoking
Hypercholesterolaemia
Heart disease
HIV
Hypo- or hyperthyroidism
Trauma to the hand or fingers
Vibration-related hand injury (e.g. working with vibrating tools regularly for > 10 years)