Upper limb pathology Flashcards
What two neuropathologies of the upper limb do we need to know?
Carpal Tunnel Syndrome
Cubital Tunnel Syndrome
What is Carpal Tunnel Syndrome?
Compression of median nerve as it passes through the carpal tunnel. 8x more common in women than men.
What causes carpal tunnel syndrome?
Idiopathic
RA (Synovitis leads to decreases space)
Fluid retention
Fracture
What are the symptoms of carpal tunnel syndrome?
Paresthesia of thumb and 1st 2 1/2 fingers which is worse at night.
Loss of sensation
Weakness
How do you treat carpal tunnel syndrome?
Splint at night to prevent flexion
Steroid injections
Divide transverse carpal ligament
What is cubital tunnel syndrome?
Compression of ulnar nerve at elbow behind medial epicondyle.
What are the symptoms of cubital tunnel syndrome?
Paresthesia of last 1 1/2 fingers.
What causes cubital tunnel syndrome?
Tightness in fascia at origin of flexor carpi ulnaris to nerve sheath.
What are the five shoulder conditions we need to know?
Instability Rotator Cuff Tear Adhesive Capsulitis Impingement syndrome Acute Calcified Tendonitis
What is the most common cause of shoulder pain in young patients?
Instability
What is the most common cause of shoulder pain in middle aged patients?
Rotator cuff tear and adhesive capsulitis
What is the most common cause of shoulder pain in older patients?
OA of glenohumeral joint
Pain from which location can radiate to the shoulder?
Neck
What is a shoulder instability?
Lack of bony stability and muscular instability lead to recurrent subluxation or dislocation.
What are the two forms of shoulder instability?
Traumatic- Anterior dislocation
Atraumatic- Posterior, anterior or inferior dislocation
What is a traumatic instability of the shoulder?
Trauma causes anterior dislocation that can reduce and heal but some do not stabilize and are liable to dislocate again
How do you treat a traumatic instability of the shoulder?
Bankart’s repair- reattach labrum and capsule to anterior glenoid
What is an atraumatic instability of the shoulder?
Generalized ligament laxity (Marfan’s or Ehlers-Danlos) lead to recurrent dislocation.
What is a rotator cuff tear?
A full or partial tear in the tendons of the rotator cuff muscles (supraspinatus usually) leading to weakness and pain.
What causes a rotator cuff tear?
Degeneration of tendon followed by minor trauma.
How do you diagnose a rotator cuff tear?
US or MRI
How do you treat a rotator cuff tear?
Physio and subacromial steroid injection
ROtator cuff repair surgery but likely to reoccur
What age group is most likely to suffer from shoulder instability?
Young
What age group is most likely to suffer from rotator cuff tears?
Middle aged
Very rare in the young but can happen with major trauma.
What is adhesive capsulitis?
Progressive pain and stiffening in the shoulder in 40-60YO which resolves.
What is the main symptom of adhesive capsulitis?
Loss of external rotation.
How does adhesive capsulitis progress?
Pain 2-9m -> Stiffness 4-12m -> Recovery
What causes adhesive capsulitis?
Unclear but potentially: diabetes, injury, hypercholesterolemia, Dupuytren’s
How do you treat adhesive capsulitis?
Physio and analgesia
Steroid injections
Manipulation under anaesthetic
Rarely surgical capsule release
What is the common name for adhesive capsulitis?
Frozen shoulder
What age group is most affected by adhesive capsulitis?
Middle aged (40-60). Can mimic OA but that’s usually seen on older age group.
What is impingement syndrome?
Where tendons of the rotator cuff (supraspinatus normally) are compressed in the subacromial space during movement.
What is the common name for impingement syndrome?
Painful arc
Between which degrees does impingement syndrome tend to be painful?
60-120 degree abduction
What causes impingement syndrome?
Tendonitis subacromial bursitis, AC OA w/ osteophytes, rotator cuff tear
How do you diagnose impingement syndrome?
Positive Hawkins-Kennedy test- 90 degree flexion at elbow and shoulder then internally rotate.
Where does pain from impingement syndrome radiate?
Deltoid and upper arm
How do you treat impingement syndrome?
NSAIDs, analgesia, physio and steroids.
Subacromial decompression to create space for tendon to pass through.
What is acute calcific tendonitis?
Ca deposits in the supraspinatus tendon cause acute severe shoulder pain.
How do you diagnose acute calcific tendonitis?
Ca deposits proximal to greater tuberosity of humerus on XR.
How do you treat acute calcific tendonitis?
Steroids and anaesthetics for pain. Self limiting so will resolve as Ca is reabsorbed.
What are the three elbow conditions we need to know?
Lateral epicondylitis
Medial epicondylitis
Arthritis
What are the two joints involved in the elbow?
Humeroulnar joint- Flexion and extension
Radiocapitellar joint- Pro/supination
What is the common name for lateral epicondylitis?
Tennis elbow
What in lateral epicondylitis?
RSI of resisted wrist extension or degenerative enthesopathy (inflammation of tendon/ligament on bone)
What features characterise lateral epicondylitis?
Microtears in common extensor origin
Painful lateral epicondyle and pain on resisted elbow extension
How do you treat lateral epicondylitis?
Self limiting: Rest, NSAIDs, physio, steroid injection, brace.
Very rarely surgery
What is medial epicondylitis?
RSI of wrist flexor origin
What is the common name for medial epicondylitis?
Golfers elbow
How do you treat medial epicondylitis?
Self limiting: Physio, rest and NSAIDs
What kinds of arthritis do you get in the elbow?
Primary OA is rare
OA secondary to trauma possible
RA is common
How do you treat arthritis in the elbow?
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
What are the five pathologies of the hand we need to know?
Dupuytren's Contractures Trigger finger OA RA Ganglion Cyst
What is a ganglion cyst?
Mucinous filled cyst adjacent to a tendon or synovial joint- outpouching of synovial membrane
Where do you commonly get ganglion cysts?
DIP and wrist.
Baker’s cyst in knee
How do ganglion cysts present?
Local pain and irritation but mainly cosmetic.
Firm, smooth, rubbery, transilluminate cyst
How do you treat ganglion cysts?
Can be aspirated but usually recur
Can be surgically removed but can leave painful scar.
What joint does RA most commonly affect?
PIP- Bouchard’s nodes
What is the progression of RA in the PIP?
Synovitis and tendonitis
Erosion of joint
Joint instability and tendon rupture
What malformations are common with RA?
Swan neck- PIP hyperextended and DIP flexed
Boutonniere- Flexed PIP and extended DIP
How do you treat RA in the hands?
Same as other joints then:
Tenosynovectomy to prevent tendon rupture and lengthening of soft tissue
Where does OA commonly occur in the hands?
DIP- Heberden’s nodes
PIP- Bouchard’s nodes
Rarely affects MCPs but can be secondary to other insult- 1st MCP most common.
How do you treat OA in the hands?
Mild- remove osteophytes and mucous cysts
Severe- arthrodesis
General- steroid injections and joint replacement
What is trigger finger?
Tendonitis of flexor tendon to digit. Formes nodule which gets stuck.
How does trigger finger present?
Clicking sensation which is painful and can lead to locking.
WHich fingers are most commonly affected by trigger finger?
Middle and ring
How do you treat trigger finger?
Steroid injections round sheath and surgery to open sheath in recurrent cases.
What is Dupuytren’s contractures?
Hyperplasia of palmar fascia which forms nodules and bundles leading to contractures of MCP and PIP
Which fingers are most commonly affected by Dupuytren’s?
Ring and little
Which abnormal type of collagen in present in Dupuytren’s?
Type 3 instead of type 1
What are some potential causes of Dupuytren’s?
Alcohol cirrhosis, diabetes, male, phenytoin therapy, Peyronie’s disease and Ledderhose disease
How do you treat Dupuytren’s?
Mild- Leave unless interfering with life in which case operate. Operation: remove all diseased tissue or divide cords.
Severe- Amputate
WHat is the cut off for surgery in mild Dupuytren’s?
MCP over 30 degree flexion or and PIP flexion
