upper limb conditions Flashcards
impingement syndrome
where tendons of rotator cuff are compressed in the tight subacromial space during movement producing pain
supraspinatus = commonest
impingement syndrome presentation
30-40s
painful arc
pain radiates to deltoid + upper arm
tenderness may be felt lateral edge of acromion
special test for rotator cuff impingement
arc
Hawkins-Kenedy test - internally rotating flexed shoulder
management of impingement
resolves in most cases
NSAIDs, physio
subacromial steroid injections - up to 3
surgery = subacromial decompression - create more space for tendon, open or arthroscopic
causes of rotator cuff tears
acute injury - FOOSH
degenerative changes
overhead activities - playing tennis, construction
rotator cuff tear presentation
acute or gradual
shoulder pain - disrupt sleep
weakness + pain with specific movement relating to side of tear
–> supraspinatus = abduction
rotator cuff tear investigation
US or MRI
x-ray for exclusion of bony pathology - OA
rotator cuff tear management
degenerative = conservative
active/young = surgery if physio fails
-> arthroscopic rotator cuff repair
adhesive capsulitis (frozen shoulder)
inflam + fibrosis in joint capsule leads to adhesions (scar tissue) - adhesions bind the capsule + cause it to tighten around the joint + restrict movement
primary - no trigger
secondary - trauma, surgery, immobilisation
risk factors for adhesive capsulitis
middle aged, diabetes, thyroid problems
test for acromioclavicular OA
scarf test
adhesive capsulitis (frozen shoulder) presentation
3 phases -
- painful - may be worse at night
- stiff - esp external rotation
- thawing - gradual improvement in stiffness -> normal
lasts 1-3yrs
- 6ish months in each phase
- 50% have persistent symptoms
diagnosis of adhesive capsulitis
CLINICAL
US, CT, MRI show thickened joint capsule
- x-ray to exclude OA
adhesive capsulitis management
conserv = NSAIDs, physio, intra-articular steroid injections, hydrodilation (injecting fluid to stretch capsule)
surgery (resistant/severe)
- manipulation under anaesthesia - forcefully stretching capsule
- arthroscopy - cut adhesions
most common type of shoulder dislocation
anterior (90%)
cause of anterior shoulder dislocations
arm forced backward whilst abducted + extended
fall with shoulder in external rotation
causes of posterior shoulder dislocation
seizures
electric shocks
fall in internal rotation, direct blow anteriorly
what else must be assessed for in shoulder dislocations?
fractures
vascular damage - pulses, cap refil, palor
nerve damage - loss of sensation in regimental patch area (axillary nerve
posterior shoulder dislocation on xray
hard to see
“light bulb” sign
complications of shoulder dislocations
Bankart lesions - tear to anterior part of labrum
fractured humeral head (Hill-Sachs lesion)
axillary nerve damage - anterior dislocation
how would you check for axillary nerve damage?
loss of sensation in “regimental badge” area
motor weakness in deltoid + teres minor muscles
(comes from C5 + C6)
shoulder dislocation investigations
apprehension (recurrent subluxs)
x-ray - not always before, always after to confirm reduction + check for fractures
magnetic resonance arthrography (MRI with contrast injected into shoulder joint)
-> Bankart + Hill-Sachs lesions
why is important to reduce dislocations ASAP
muscle spasms occur over time making it harder to relocate + increasing risk of neurovascular damage
ulnar nerve damage checks
sensation to pinkie + half ring finger on both sides of hand
ability to abduct all fingers
radial nerve damage checks
sensation between thumb + index finger and DORSAL surface of hand
ability to extend wrist
median nerve damage checks
sensation between thumb + index PALMAR surface
ability to to bring thumb and pinkie together
what sport is associated with lateral epicondylitis?
tennis (elbow)
the tendon that inserts to the lateral epicondyle acts to extend the writst
what sport is associated with medial epicondylitis?
Golfer’s elbow
tendon that inserts into medial epicondyle acts to flex the wrist
management of epicondylitis
analgesia, physio orthotics (elbow braces) steroid injections - avoid nerves platelet rich plasma (PRP) injections extracorpeal shockwave therapy
cubital tunnel syndrome pathophysio
compression of ulnar nerve behind medial epicondyle (funny bone area)
-> can be due to tight band of fascia forming roof (Osbourne’s fascia) or tightness at intermuscular septum
cubital tunnel syndrome presentation
parathesia in ulnar fingers = pinkie + half of ring finger
cubital tunnel syndrome investigations
Tinel’s test over cubital tunnel
Froment’s test - paper between thumb + fist
nerve conduction studies to confirm diagnosis
what 2 tendons are primarily affects in De Quervains tenosynovitis?
abductor pollicis longus (APL)
extensor pollicis brevis (EPB)
–> both act to abduct thumb + wrist
notable cause of de querbains tenosynovitis in babies
parents repetively lifting newborns in a way that stresses tendons of the thumb
-> sometimes referred to as “mummy thumb”
de quervains tenosynovitis
swelling + inflammation of tendon sheaths in the wrist
repetitive strain injury
causes pain on radial side of wrist
de quervains tenosynovitis pathophysio
APL + EPB pass under the extensor retinaculum which wraps across the back of the wrist
repetitive movement of APL + EPB under extensor retinaculum results in inflammation + swelling of tendon sheaths
de quervains tenosynovitis presentation
symptoms at radial aspect of the wrist - near base of thumb >pain - radiate forearm > aching, burning > weakness, numbness > tenderness
special tests for de quervains tenosynovitis
finklesteins = examiner flexes patients thumb into palms causing wrist to adduct (pos = pain)
eichoff’s = fist with thumb inside, wrist abducting
de quervains tenosynovitis management
rest, analgesia, physio
splints
steroid injections
surgery (rarely) - cut extensor retinaculum
carpal tunnel syndrome risk factors
obesity menopause rheumatoid arthritis diabetes acromegaly hypothyroidism
what is the carpal tunnel made up of / what does it contain?
between carapal bones + flexor retinaculum
contains = median nerve + flexor tendons of forearm
what motor function does the median nerve supply?
to 3 thenar muscles (bulge at base of thumb responsible for its movements)
- abductor pollicis brevis - abduction
- opponens pollicis - opposition (reaching across palm to touch fingertips)
- flexor pollicis brevis - flexion
- adduct pollicis - adduction (innervated by ulnar)
is palmar sensation of thumb, index + middle finger affected in carpal tunnel syndrome?
yes
palmar DIGITAL cutaneous branch of median nerve passes through tunnel
carpal tunnel syndrome presentation
gradual onset symptoms
- initially intermittent
- often worse at night
- shake hand to relieve
sensory (palmar thumb half)
- numbness, paraesthesia
- burning, pain
motor (thenar, thumb movements)
- weak thumb movements
- weak grip strength
- difficult with fine movements
- wasting of thenar muscles
carpal tunnel syndrome special tests
phalens - flexing hands, putting backs of hands together
tinel’s - tapping over carpal tunnel
positive = triggering of symptoms - numbness/paraesthesia
carpal tunnel syndrome management
- rest, altered activities
- wrist splints that maintain a neutral position of the wrist that can be worn at night (min 4 weeks)
- steroid injections
- surgery - cut flexor retinaculum
which fingers are most commonly affected in trigger finger?
middle + ring finger
risk factor for trigger finger (stenosing tenosynovitis)
40s, 50s
women
diabetes
which pulley is most commonly affected in trigger finger?
first annular pulley (A1) at MCP joint
trigger finger (stenosing tenosynovitis) pathophysio
thickening of tendon or tightening of sheath that tendons pass through
-> prevents tendon from smoothly runnign through - pain,stiffnes + catching symptoms
nodule can get stuck at entrance to pulley - causing finger to lock/stuck in bent position
–> may release with painful pop/click
trigger finger (stenosing tenosynovitis) presentation
movement of finger produces clicking sensation - may be painful
finger may lock in position - patient may have to forcibly manipulate finger to regain extension (with PAIN)
trigger finger management
most resolve spontaneously - rest, analgesia
splinting
steroid injections
surgery to release A1 pulley - division of A1 does not affect function
dupuytren’s pathophysio
fascia of hand becomes thickened + tight leading to finger contractures (flexed, can’t fully extend)
proliferation of myofibroblasts + production of abnormal type 3 collagen
contracture = shortening of soft tissue that leads to restricted movement
most common finger affected by dupuytren’s
ring + pinkie
dupuytren’s risk factors
age family history - autosomal dominant pattern male manual labour (vibrating tools) diabetes (esp type 1) epilepsy smoking + alcohol
high prevalence in scandinavian
dupuytren’s managment
conservative
surgery, needle fasciotomy, limited fasciectomy, dermofasciectomy
recurrence in young
severe (fingers in palm) = amputation
ganglion cyst pathophysio
thought to occur when the synovial membrane of tendon sheath or joint herniates forming a puch
synovial fluid flows from the tendon sheath or joint into the pouch forming a cyst
ganglion cyst presentation
visible + palpable lump
firm + non-tender on palpation
skin mobile - fixed to underlying structures
transilluminates (shing a torch into cyst causes it to light up)
ganglion cyst diagnosis
clinical
US can help confirm + exclude other causes of lumps
ganglion cysts management
conservative - 40-50% resolve spontaneously (can take years)
needle aspiration - not really done, recurrence in >50%
surgical excision - open/endoscopic
