Upper Limb Flashcards
What are the main differences between medial and lateral epichondylitis?
How is diagnosis of epicondylitis confirmed?
Radiographs are typically normal and the diagnosis may be confirmed on USS.
Describe the management and prognosis of epicondylitis
Management
- Conservative: rest, physiotherapy, counterforce bracing
- Surgery to release the CEO is reserved for patients who fail to improve after conservative measures.
Prognosis:
- Episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks.
What are the features of distal biceps tendon rupture?
Distal biceps tendon rupture occurs suddenly on lifting. There is immediate bruising of the ante‐cubital fossa, and the biceps retracts proximally on resisted elbow flexion. The tendon cannot be palpated distally.
Describe the management of biceps tendon rupture
Significant weakness of supination and flexion are a direct consequence, and therefore, unlike LHB tendon rupture at the shoulder, urgent surgical referral for discussion of acute repair is indicated.
What are the features and management of olecranon bursitis?
Olecranon bursitis presents as a fluid‐filled collection at the posterior aspect of the elbow, superficial to the proximal ulna. Recurrent trauma from leaning on the elbow is usually the cause – hence the name student’s elbow. It is important when examining to look closely for stigmata of gout.
It typically affects middle-aged male patients, presenting with pain on the posterior aspect of the elbow, with swelling and erythema and warmth. The range of motion of the elbow is preserved.
The inflammation of an acute bursitis will respond to nonsteroidal anti‐inflammatory drugs (NSAIDs) and avoidance of pressure on the elbow.
What are the features of cubital tunnel syndrome?
Cubital tunnel syndrome presents with symptoms secondary to irritation and compression of the ulna nerve (ulna neuritis) at the level of the elbow as it passes behind the medial epicondyle.
- Mild cases cause intermittent paraesthesia in the medial (ulnar) 1.5 fingers.
- Severe compression leads to weakness of the small muscles of the hand, leading to weakness and difficulty with fine motor function.
Tinel’s testing over the cubital tunnel recreates the patient’s symptoms of paraesthesia.
Describe the types of distal radial fractures and their resulting deformities.
How should you examine a distal radial fracture?
On examination, it is important to assess for any evidence of neurovascular compromise (check nerve function - see below) and limb perfusion (capillary refill time and pulses).
The neurological examination for a suspected distal radius fracture should include the following nerves being assessed:
- Median nerve: motor – abduction of the thumb; sensory – radial surface of distal 2nd digit
- Anterior interosseous nerve: opposition of the thumb and index finger - ask for an ‘okay’ sign, if the DIPJ of the 2nd digit and IPJ of thumb extend, this signifies AIN nerve involvement/
- Ulnar nerve: motor – adduction of the thumb (‘Froment’s Sign’); sensory – ulnar surface of the distal 5th digit
- Radial nerve: motor – extension of IPJ of thumb; sensory – dorsal surface of 1st webspace
How should you investigate a distal radial fracture?
Plain radiographs are the quickest and definitive investigations of most fractures. CT or MRI imaging may be used in more complex distal radius fractures, particularly for operative planning, however this can be performed once initial management steps have been made.
Describe the management for distal radial fractures
As for any trauma case, suitable resuscitate and stabilisation of the patient is the priority.
Once stabilised, all displaced fractures require closed reduction in the emergency department. Various techniques can be employed, however all involve ensuring sufficient traction and manipulation under anaesthetic. This can be performed under conscious sedation with a haematoma block or Bier’s block.
Following reduction, the arm should be restricted to allow for bone healing:
- Stable and successfully reduced fractures can typically be placed in a below-elbow backslab case, then radiographs repeated after 1 week to check for displacement.
- Significantly displaced or unstable fractures can require surgical intervention, as they have a risk of otherwise displacing over time. Options of surgical management include open reduction and internal fixation (ORIF), K- wire fixation, or external fixation
Once sufficient bone healing has occurred, patients should be rehabilitated via physiotherapy to ensure the regaining of full function.
What is the epidemiology of scaphoid fractures?
The scaphoid is ‘boat’-shaped bone and is the most common carpus to be fractured.
- Scaphoid fractures are most common in men aged 20-30 years and are high-energy injuries.
- Approximately 10% have an associated fracture.
- They are very commonly referred to orthopaedics, due to diagnostic uncertainty; however, only around 1 in 10 referred patients actually have a scaphoid fracture.
Why are scaphoid fractures prone to avascular necrosis?
The dorsal branch of the radial artery, which supplies 80% of the blood, enters in the distal pole and travels in a retrograde fashion towards the proximal pole of the scaphoid. This means that fractures can compromise the blood supply, leading to avascular necrosis (AVN) of the scaphoid.
- The more proximal the fracture, the higher the risk of AVN
What are the clinical features of scaphoid fractures?
The scaphoid is fractured following trauma, which is often high energy. Patients will complain of sudden onset wrist pain and bruising may be present.
There is tenderness in the floor of the anatomical snuffbox, pain on palpating the scaphoid tubercle, and pain on telescoping of the thumb.
What are the borders of the anatomical snuffbox?
The anatomical snuffbox (also termed the radial fossa) is a triangular depression found on the lateral aspect of the dorsum of the hand, located at the level of the carpal bones. It is defined:
- Laterally by the abductor pollicis longus and extensor pollicis brevis tendons (the 1st extensor compartment)
- Medially by the extensor pollicis longus tendon (the 3rd extensor compartment).
- The floor of the snuffbox is made of the scaphoid, along with the trapezium (distally) and the radial styloid.
Describe the investigations for scaphoid fractures
For suspected cases of scaphoid fracture, initial plain radiographs should be taken. A “scaphoid series” should be requested, including anteroposterior, lateral, oblique views.
- Scaphoid fractures are not always detected by initial radiographs (especially undisplaced fractures); if there remains sufficient clinical suspicion, despite negative initial imaging, the patient should have the wrist immobilised in a thumb splint and repeat plain radiographs in 10-14 days for further evaluation.
If repeat radiographic imaging is negative, however clinical findings are still in keeping with a scaphoid fracture, an MRI scan of the wrist is indicated. This is the definitive investigation and, whilst it is awaited, the interim management is as for a fracture.
Describe the management of scaphoid fractures
The treatment of scaphoid fractures is determined by location of the fracture and degree of the fracture:
- Undisplaced fractures can typically be managed with strict immobilisation in a plaster with a thumb spica splint.
- However, undisplaced fractures of the proximal pole have a high risk of AVN and surgical treatment may be advocated, particularly if it is the dominant hand of a working-age patient.
- All displaced fractures should be fixed operatively. The most common operative technique is using a percutaneous variable-pitched screw, which can be placed across the fracture site to compress it.
What are the potential complications of scaphoid fractures?
- Avascular necrosis is common complication of a scaphoid fracture (in around 30% of cases), with its risk increasing the more proximal the fracture.
- Non-union is the bone failing to heal properly, most commonly due to a poor blood supply. It is particularly common in scaphoid fractures (in around 10% of cases) that go undiagnosed or are inappropriately managed. Such cases can be managed with internal fixation and bone grafts, although the morbidity is high, even with surgical repair.
What is the definition and epidemiology of De Quervain’s Tenosynovitis?
De Quervain’s tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
- It typically affects females aged 30 - 50 years old.
What is the definition and epidemiology of Dupuytren’s Contracture?
A Dupuytren’s contracture is a common condition involving contraction of the longitudinal palmar fascia. Typically starting as painless nodules, fibrous cords and flexion contractures develop at the MCP and interphalangeal joints, which can severely limiting digital movement and reduce patient quality of life.
- The condition is around six times more common in men, with peak onset aged 40-60yrs.
- It most commonly affects the ulnar digits (ring and little finger).
What are the clinical features of Dupuytren’s Contracture?
Patients will present at varied stages of progression. Symptoms may therefore range from reduced range of motion and nodular deformity through to a complete loss of movement.
The ring and little finger are most commonly involved; however, the other digits may be involved. The condition is bilateral in 45% of cases.
On examination, a thickened band or firm nodule adherent to the skin may be palpable. Skin blanching may occur on active extension of the affected digits. In advanced disease, the MCP and/or PIP joints of the affected digit may be in contracture.
What are the clinical features of a shoulder dislocation?
What are the common associated injuries of a shoulder dislocation?
What are the investigations for a shoulder dislocation?
