Upper limb pathology

Question 1

What two neuropathologies of the upper limb do we need to know?

Answer 1

Carpal Tunnel Syndrome

Cubital Tunnel Syndrome

Question 2

What is Carpal Tunnel Syndrome?

Answer 2

Compression of median nerve as it passes through the carpal tunnel. 8x more common in women than men.

Question 3

What causes carpal tunnel syndrome?

Answer 3

Idiopathic
RA (Synovitis leads to decreases space)
Fluid retention
Fracture

Question 4

What are the symptoms of carpal tunnel syndrome?

Answer 4

Paresthesia of thumb and 1st 2 1/2 fingers which is worse at night.
Loss of sensation
Weakness

Question 5

How do you treat carpal tunnel syndrome?

Answer 5

Splint at night to prevent flexion
Steroid injections
Divide transverse carpal ligament

Question 6

What is cubital tunnel syndrome?

Answer 6

Compression of ulnar nerve at elbow behind medial epicondyle.

Question 7

What are the symptoms of cubital tunnel syndrome?

Answer 7

Paresthesia of last 1 1/2 fingers.

Question 8

What causes cubital tunnel syndrome?

Answer 8

Tightness in fascia at origin of flexor carpi ulnaris to nerve sheath.

Question 9

What are the five shoulder conditions we need to know?

Answer 9

Instability
Rotator Cuff Tear
Adhesive Capsulitis
Impingement syndrome
Acute Calcified Tendonitis

Question 10

What is the most common cause of shoulder pain in young patients?

Answer 10

Instability

Question 11

What is the most common cause of shoulder pain in middle aged patients?

Answer 11

Rotator cuff tear and adhesive capsulitis

Question 12

What is the most common cause of shoulder pain in older patients?

Answer 12

OA of glenohumeral joint

Question 13

Pain from which location can radiate to the shoulder?

Answer 13

Neck

Question 14

What is a shoulder instability?

Answer 14

Lack of bony stability and muscular instability lead to recurrent subluxation or dislocation.

Question 15

What are the two forms of shoulder instability?

Answer 15

Traumatic- Anterior dislocation

Atraumatic- Posterior, anterior or inferior dislocation

Question 16

What is a traumatic instability of the shoulder?

Answer 16

Trauma causes anterior dislocation that can reduce and heal but some do not stabilize and are liable to dislocate again

Question 17

How do you treat a traumatic instability of the shoulder?

Answer 17

Bankart’s repair- reattach labrum and capsule to anterior glenoid

Question 18

What is an atraumatic instability of the shoulder?

Answer 18

Generalized ligament laxity (Marfan’s or Ehlers-Danlos) lead to recurrent dislocation.

Question 19

What is a rotator cuff tear?

Answer 19

A full or partial tear in the tendons of the rotator cuff muscles (supraspinatus usually) leading to weakness and pain.

Question 20

What causes a rotator cuff tear?

Answer 20

Degeneration of tendon followed by minor trauma.

Question 21

How do you diagnose a rotator cuff tear?

Answer 21

US or MRI

Question 22

How do you treat a rotator cuff tear?

Answer 22

Physio and subacromial steroid injection

ROtator cuff repair surgery but likely to reoccur

Question 23

What age group is most likely to suffer from shoulder instability?

Answer 23

Young

Question 24

What age group is most likely to suffer from rotator cuff tears?

Answer 24

Middle aged

Very rare in the young but can happen with major trauma.

Question 25

What is adhesive capsulitis?

Answer 25

Progressive pain and stiffening in the shoulder in 40-60YO which resolves.

Question 26

What is the main symptom of adhesive capsulitis?

Answer 26

Loss of external rotation.

Question 27

How does adhesive capsulitis progress?

Answer 27

Pain 2-9m -> Stiffness 4-12m -> Recovery

Question 28

What causes adhesive capsulitis?

Answer 28

Unclear but potentially: diabetes, injury, hypercholesterolemia, Dupuytren's

Question 29

How do you treat adhesive capsulitis?

Answer 29

Physio and analgesia Steroid injections Manipulation under anaesthetic Rarely surgical capsule release

Question 30

What is the common name for adhesive capsulitis?

Answer 30

Frozen shoulder

Question 31

What age group is most affected by adhesive capsulitis?

Answer 31

Middle aged (40-60). Can mimic OA but that's usually seen on older age group.

Question 32

What is impingement syndrome?

Answer 32

Where tendons of the rotator cuff (supraspinatus normally) are compressed in the subacromial space during movement.

Question 33

What is the common name for impingement syndrome?

Answer 33

Painful arc

Question 34

Between which degrees does impingement syndrome tend to be painful?

Answer 34

60-120 degree abduction

Question 35

What causes impingement syndrome?

Answer 35

Tendonitis subacromial bursitis, AC OA w/ osteophytes, rotator cuff tear

Question 36

How do you diagnose impingement syndrome?

Answer 36

Positive Hawkins-Kennedy test- 90 degree flexion at elbow and shoulder then internally rotate.

Question 37

Where does pain from impingement syndrome radiate?

Answer 37

Deltoid and upper arm

Question 38

How do you treat impingement syndrome?

Answer 38

NSAIDs, analgesia, physio and steroids. | Subacromial decompression to create space for tendon to pass through.

Question 39

What is acute calcific tendonitis?

Answer 39

Ca deposits in the supraspinatus tendon cause acute severe shoulder pain.

Question 40

How do you diagnose acute calcific tendonitis?

Answer 40

Ca deposits proximal to greater tuberosity of humerus on XR.

Question 41

How do you treat acute calcific tendonitis?

Answer 41

Steroids and anaesthetics for pain. Self limiting so will resolve as Ca is reabsorbed.

Question 42

What are the three elbow conditions we need to know?

Answer 42

Lateral epicondylitis Medial epicondylitis Arthritis

Question 43

What are the two joints involved in the elbow?

Answer 43

Humeroulnar joint- Flexion and extension | Radiocapitellar joint- Pro/supination

Question 44

What is the common name for lateral epicondylitis?

Answer 44

Tennis elbow

Question 45

What in lateral epicondylitis?

Answer 45

RSI of resisted wrist extension or degenerative enthesopathy (inflammation of tendon/ligament on bone)

Question 46

What features characterise lateral epicondylitis?

Answer 46

Microtears in common extensor origin | Painful lateral epicondyle and pain on resisted elbow extension

Question 47

How do you treat lateral epicondylitis?

Answer 47

Self limiting: Rest, NSAIDs, physio, steroid injection, brace. Very rarely surgery

Question 48

What is medial epicondylitis?

Answer 48

RSI of wrist flexor origin

Question 49

What is the common name for medial epicondylitis?

Answer 49

Golfers elbow

Question 50

How do you treat medial epicondylitis?

Answer 50

Self limiting: Physio, rest and NSAIDs

Question 51

What kinds of arthritis do you get in the elbow?

Answer 51

Primary OA is rare OA secondary to trauma possible RA is common

Question 52

How do you treat arthritis in the elbow?

Answer 52

Conservative treatment same as rest of OA or RA Radiocapitellar can have surgical excision of radial head Humeroulnar joint can get total elbow replacement but limited to lifting 2.5kg

Question 53

What are the five pathologies of the hand we need to know?

Answer 53

``` Dupuytren's Contractures Trigger finger OA RA Ganglion Cyst ```

Question 54

What is a ganglion cyst?

Answer 54

Mucinous filled cyst adjacent to a tendon or synovial joint- outpouching of synovial membrane

Question 55

Where do you commonly get ganglion cysts?

Answer 55

DIP and wrist. | Baker's cyst in knee

Question 56

How do ganglion cysts present?

Answer 56

Local pain and irritation but mainly cosmetic. | Firm, smooth, rubbery, transilluminate cyst

Question 57

How do you treat ganglion cysts?

Answer 57

Can be aspirated but usually recur | Can be surgically removed but can leave painful scar.

Question 58

What joint does RA most commonly affect?

Answer 58

PIP- Bouchard's nodes

Question 59

What is the progression of RA in the PIP?

Answer 59

Synovitis and tendonitis Erosion of joint Joint instability and tendon rupture

Question 60

What malformations are common with RA?

Answer 60

Swan neck- PIP hyperextended and DIP flexed | Boutonniere- Flexed PIP and extended DIP

Question 61

How do you treat RA in the hands?

Answer 61

Same as other joints then: | Tenosynovectomy to prevent tendon rupture and lengthening of soft tissue

Question 62

Where does OA commonly occur in the hands?

Answer 62

DIP- Heberden's nodes PIP- Bouchard's nodes Rarely affects MCPs but can be secondary to other insult- 1st MCP most common.

Question 63

How do you treat OA in the hands?

Answer 63

Mild- remove osteophytes and mucous cysts Severe- arthrodesis General- steroid injections and joint replacement

Question 64

What is trigger finger?

Answer 64

Tendonitis of flexor tendon to digit. Formes nodule which gets stuck.

Question 65

How does trigger finger present?

Answer 65

Clicking sensation which is painful and can lead to locking.

Question 66

WHich fingers are most commonly affected by trigger finger?

Answer 66

Middle and ring

Question 67

How do you treat trigger finger?

Answer 67

Steroid injections round sheath and surgery to open sheath in recurrent cases.

Question 68

What is Dupuytren's contractures?

Answer 68

Hyperplasia of palmar fascia which forms nodules and bundles leading to contractures of MCP and PIP

Question 69

Which fingers are most commonly affected by Dupuytren's?

Answer 69

Ring and little

Question 70

Which abnormal type of collagen in present in Dupuytren's?

Answer 70

Type 3 instead of type 1

Question 71

What are some potential causes of Dupuytren's?

Answer 71

Alcohol cirrhosis, diabetes, male, phenytoin therapy, Peyronie's disease and Ledderhose disease

Question 72

How do you treat Dupuytren's?

Answer 72

Mild- Leave unless interfering with life in which case operate. Operation: remove all diseased tissue or divide cords. Severe- Amputate

Question 73

WHat is the cut off for surgery in mild Dupuytren's?

Answer 73

MCP over 30 degree flexion or and PIP flexion