Upper limb disease Flashcards
How is peripheral nerve compression different to cervical nerve root compression?
Does not cause dermatomal or myotomal changes, instead affects peripheral nerve and motor locations.
What forms the carpal tunnel of the wrist?
The carpal bones and the flexor retinaculum
What nerve passes through the carpal tunnel?
The medial nerve
What causes carpal tunnel syndrome?
Mostly idiopathic
BUT RA and conditions which cause fluid retention also cause
What is the presenting complaint in carpal tunnel syndrome?
Parasthesia in thumb and radial 2 1/2 fingers
worse at night
sometimes weakness of thumb
What can be seen on examination of the hand with carpal tunnel syndrome?
Loss of sensation or muscle wastage of thenar eminence
What is Tinel’s test?
Percussing over median nerve over the wrist and the transverse ligament, across the thumb
What is a positive Tinel’s test?
Pins and needles felt
What is Phalen’s test?
Hands together with dorsal surfaces touching for 30-60 seconds
What is a positive Phalen’s test?
Tingling in thumb, middle and half of ring finger.
What non-operative methods can be used to treat carpal tunnel syndrome?
Wrist splints at night
Steroid injection
What does the surgical treatment of carpal tunnel syndrome involve?
Division of the transverse carpal ligament under local anaesthetic.
What causes cubital tunnel syndrome?
Compression of the ulnar nerve at the elbow behind the medial epicondyle
How does cubital tunnel syndrome present?
Parasthesia in ulnar fingers.
On examination, what is expected in carpal tunnel syndrome?
Positive Tinel’s test
Positive Froment’s test (paper between fingers)
What bones make up the elbow joint?
Humerus
Radius
Ulna
What muscle causes elbow extension and where does it insert?
Triceps muscle
Olecranon process of the ulna
What muscle causes elbow flexion and where does it insert?
Biceps brachii
Bicipital tuberosity of the radius
Which is more common in the elbow:
RA or OA?
RA
What is lateral epicondylitis also called?
Tennis elbow
What is lateral epicondylitis?
Repetitive strain injury which results in micro-tears in the common extensor origin
How does lateral epicondylitis present?
Painful and tender lateral epicondyle and pain on resisted middle finger extension
What is the treatment for lateral epicondylitis?
Rest from exacerbating activities, NSAIDs and steroid injections.
Sometimes an elbow clasp brace
What is golfer’s elbow?
Medial epicondylitis
Why are steroid injections not used in golfers elbow as treatment?
Risk of injury to the ulnar nerve
When does OA occur of the elbow?
Most commonly after trauma
What surgical options are there with RA/OA of the elbow?
Surgical excision of the radial head
TER which restricts lifting severely
What is Dupuytren’s contracture?
Hyperplasia of palmar fascia
What is the pathology behind Duputryen’s contracture?
Proliferation of myofibroblast cells Type III (abnormal) collagen production
What fingers are most commonly affected by Duputryen’s contracture?
Ring and little
Half of cases are bilateral
Who tends to get Duputryen’s contracture?
Men
Alcohol cirrhosis
Diabetes
What surgical procedures are indicated for Duputryen’s contracture?
Fasciectomy- removal of all diseased tissue
Fasciotomy- division of cords
What is trigger finger?
Tendonitis of a flexor tendon
How does trigger finger present?
Painful, clicking sensation of the finger which does not release on extension.
What is the treatment of trigger finger?
Steroid injection
What is the pulley called in trigger finger?
A1 pulley.
What are nodes at the DIPs of OA called?
Heberdens nodes
What are the nodes at the PIPs of OA called?
Bouchard’s nodes
What is swan necking?
PIP goes down
What is Boutonniere?
DIP is stuck straight
What are ganglion cysts?
Mucous filled cysts adjacent to a tendon or synovial joint
What is a ganglion cyst called if found in popliteal fossa?
Baker’s cyst
Where are ganglions cysts most commonly found?
DIP
wrist
What do ganglions cysts look like?
Firm, smooth, rubbery and transilluminates
What benign tumours can also be found on the palmar surface of the hand?
Giant cell tumours
Why do giant cell tumours look brown?
They contain haemosiderin
What is the humero-ulnar joint responsible for?
Flexion and extension
What is the radiocapitellar joint responsible for?
Supination and pronation
What muscle is Froment’s test testing?
Adductor pollicis
True or False.
Pain and swelling at the sternoclavicular joint is more common that at the acromioclavicular joint
False.
Acromioclavicular joint disease is more common
Glenohumeral OA presents with what signs?
Crepitus
Loss of external rotation
True or False.
Shoulder joint replacements have a better long term outcome than THR
False at 10 years
What are the two joints of the elbow called?
Humeroulnar
Humeroradial
What restrictions exist with elbow replacements?
Limited to 5kg load lifting
What is Phalen’s test?
Test for carpal tunnel syndrome.
Flexion of wrist for 1 minute.
Positive test is tingling.
What is the average speed of nerve transmission?
30m/s
What is tendinopathy?
Disease of a tendon
What is tendonitis?
Tendon injuries with inflammation
What is tendonosis?
Chronic tendon injury with damage to a tendon at cellular level
What is tenosynovitis?
Inflammation of the tendon sheath
What is enthesopathy?
Inflammation of the tendon origin or the insertion into bone
Where does de Quervain’s tenosynovitis affect?
Extensor pollicis brevis
abductor poliicis longus
at thenar aspect
Embryologically, where do tendons originate?
Lateral plate of the mesoderm
What do tendons do?
Joins muscle to bone
In which conditions are steroid injections indicated?
Rotator cuff
Tennis elbow
When are splints indicated?
Achilles tendonitis
What are the clinical findings of a rotator cuff pathology?
Achy pain with shoulder tenderness
Difficulty sleeping on affected side or reaching overhead
Painful arc 60-120
How is a rotator cuff injury treated?
Conservative management with arthroscopic suturing as a last resort
Which method of imaging is gold standard for a rotator cuff injury?
USS
Which part of the biceps is affected in biceps tendinopathy?
Long head of biceps which inserts into labrum/glenoid
What causes biceps tendinopathy?
Overuse, instability, impingement or trauma
Where does pain radiate to in biceps tendinopathy?
Anterior shoulder to elbow
What is the classic sign on examination of a biceps tendon rupture?
Popeye sign with extensive bruising
What is medial epicondylitis also known as?
Golfer’s elbow
What makes the pain of medial epicondylitis worse?
Wrist flexion and pronation,
Also worse on grasping e.g. opening jars
What is the management of medial epicondylitis?
Rest and modification of activities
Physio
In what condition is Mill’s test useful?
Lateral epicondylitis
What is lateral epicondylitis known as?
Tennis elbow
Who is most likely to get De Quervain’s tenosynovitis?
Women aged 30-50
Pregnancy
What makes up the extensor mechanism of the knee?
Quadriceps muscle
Quadriceps tendon
Patella
Patella tendon
What makes extensor knee problems more likely?
Trauma
Steroids or abx
DM
What can be found on examination if there is an extensor knee problem?
Palpable gap
No straight leg raise
What is the treatment for extensor knee problems?
Surgical repair
What can be found on examination in achilles tendon?
Palpable gap posteriorly
Unable to tiptoe stand
ecchymosis
What test can be done for Achilles tendon?
Simmonds test.
Squeezing calf should cause plantarflexion of the ankle
In which patients is Achilles tendon more common in?
RA
Steroid users
patients with existing tendonitis
What are the two options for management of Achilles tendon?
Plaster
Surgical repair
