Upper limb problems III Flashcards
What is carpal tunnel syndrome
Neuropathy caused by acute or chronic compression of the median nerve in carpal tunnel
Cause of carpal tunnel syndrome
Idiopathic
RA
Pregnancy
Diabetes
Chronic renal failure
Hypothyroidism (myxoedema)
Fractures around the wrist
Acromegaly
How does RA cause carpal tunnel syndrome
Synovitis reduces space in carpal tunnel
How does pregnancy, diabetes, chronic renal failure and hypothyroidism cause carpal tunnel syndrome
Cause retention of water -> reduces space
Which wrist fracture causes carpal tunnel syndrome
Colles fracture - complete fracture of distal radius causing dorsal displacement of radius
Do carpal tunnel syndrome symptoms persist after pregnancy if pregnancy was the only cause
No, it tends to reside after childbirth
Motor innervation of the hand by median nerve
LOAF muscles
-lateral 2 lumbricals
-opponens pollicis
-abductor pollicis brevis
-flexor pollicis brevis
Sensory innervation of the hand by median nerve
Palmar aspect of lateral 3 and 1/2 fingers (thumb, index, middle and half of ring finger)
Dorsal aspect of nail beds of those fingers too
Symptoms of carpal tunnel syndrome
Weakness in thumb and radial 2 1/2 fingers
Tingling, burning sensation of those 3 fingers worse at night
Tingling, burning sensation relieved by shaking/ hanging out the hand at night
Clumsiness in fingers
Loss of sensation
Signs of carpal tunnel syndrome
Muscle wasting at thenar eminence (base of thumb)
Investigations for carpal tunnel syndrome
Tinel’s test - causes symptoms
Phalen’s test - causes symptoms
Nerve conduction studies
Describe tinel’s test
Percuss over median nerve
Positive = tingling, burning sensation over the area innervated by median nerve
Describe Phalen’s test
Ask patient to hold his wrists hyper-flexed
Positive = tingling, burning sensation over the area innervated by median nerve
Management of carpal tunnel syndrome
Wrist splints at night to prevent flexion
Corticosteroids injections
Carpal tunnel decompression surgery
What is De Quervain’s tenosynovitis
Inflammation of the extensor pollicis longus and extensor pollicis brevis tendons
Risk factors of De quervain’s
Women
30-50
Pregnancy
RA
Occupation - musicians, office workers who need to perform thumb abduction repetitively
Symptoms of De Quervain’s tendinopathy
Pain at the base of the thumb
Pain exacerbated by abduction of the thumb, gripping and ulnar deviation of the wrist
Swollen wrist
Investigations for DeQuervain’s tendinopathy
Finklestein’s test
US - rule out CMC OA
Xray - rule out CMC OA
Describe Finklestein’s test
Patient’s thumb is flexed, making a fist
Hand is ulnar deviated
Postive = pain
How to differentiate between CMC OA and De Quervain’s tendinopathy
CMC OA Finkelstein’s test is usually negative but positive in grind test
Management of DeQuervain’s tendinopathy
Splint
Rest
Physio
Analgesics
Steroid injections
Surgical decompression
What is Dupuytren’s contracture
progressive, fibrotic thickening of the palmar fascia progressing into contractures at MCP and PIP joints
Pathology of Dupuytren’s contracture
Proliferation of my-fibroblast cells
Production of type 3 collagen rather than type 1 = thickened palmar fascia
Risk factors of Dupuytren’s contracture
Males
Diabetes
Smoking
Alcohol
Cirrhosis
Epilepsy, epileptic medications
Repetitive trauma to hand
Which joints are involved in Dupuytren’s contracture
MCP
PIP
Symptoms of Dupuytren’s contracture
Painless
Starts as palmar nodule then progresses into flexion contracture of fingers
Symmetrical and bilateral
Which fingers are the most commonly involved in Dupuytren’s contracture
Ring and little fingers
What is Dupuytrens diathesis
Severe form of Dupuytren’s
Dupuytren’s contracture of the 4th and 5th fingers + Ledderhose + Peyronie’s
What is Ledderhose disease
Plantar fibromatosis - growth of fibrous nodules on soles of feet
What is Peyronie’s disease
FIbromatosis of the penis
Signs of Dupuytren’s contracture
Palpable hard nodules
fixed flexion deformity of the 4th and 5th digit (painless)
Investigations for Dupuytren’s contracture
Clinical
Management of Dupuytren’s contracture
Stretch
Observe
Surgery
Name A-E
A- Distal phalanx
B- Proximal phalanx
C- Sesamoid bone
D- Metacarpal
E- Middle phalanx
Name A-D
A- DIP joint
B- PIP joint
C- IP joint
D- MCP joint
Name A-H
A- Scaphoid
B- Lunate
C- Triquetrum
D- Pisiform
E- Trapezium
F- Trapezoid
G- Capitate
H- Hamate
Name A-F
A- Palmar aponeurosis
B- Flexor tendon sheaths
C- Hypothenar fascia
D- Tendon of palmaris longus
E- Flexor retinaculum
F- Thenar fascia
Which tendons pass through the flexor tendon sheath to the digits
Flexor digitorum superficialis
Flexor digitorum profundus
Flexor pollicis longus
What is the thenar eminence
Muscles of the thumb at the base of thumb
Superficial muscles in thenar eminence
Abdcutor pollicis brevis
Flexor pollicis brevis
Deep muscle in thenar eminence
Opponens pollicis
Name A-C
A- Flexor pollicis brevis
B- Abductor pollicis brevis
C- opponens pollicis
Attachment of abductor pollicis brevis
Origin: flexor retinaculum and tubercles of scaphoid and trapezium
Attachment: Lateral side of base of proximal phalanx of thumb
Function of abductor pollicis brevis
abducts the thumb
helps opposition of the thumb
Attachment of flexor pollicis brevis
Origin: flexor retinaculum and tubercles of scaphoid and trapezium
Attachment: Lateral side of base of proximal phalanx of thumb
Function of flexor pollicis brevis
flexes the first MCP joint of the thumb
Attachment of opponens pollicis
Origin: flexor retinaculum and tubercles of scaphoid and trapezium
Attachment: lateral side of 1st metacarpal
Function of opponens pollicis
Opposition of thumb (by medially rotate and flex the metacarpal on trapezium)
Innervation of thenar eminence
Recurrent branch of median nerve
What are the hypothenar muscles
Muscles that control the movement of little finger at the base of the little finger
What are the superficial hypothenar muscles
Abductor digiti minimi
Flexor digiti minimi
What are the deep hypothenar muscles
Opponens digiti minimi
Name A-C
A- Flexor digiti minimi
B- Abductor digiti minimi
C- Opponens digiti minimi
Attachment of flexor digiti minimi
Origin: Hook of hamate and flexor retinaculum
Attachment: Medial side of base of proximal phalanx of 5th digit
Function of flexor digiti minimi
Flexes proximal phalanx of 5th digit
Attachment of abductor digiti minimi
Origin: Pisiform
Attachment: Medial side of base of proximal phalanx of 5th digit
Function of abductor digiti minimi
Abduct the 5th digit
Assist in flexion of proximal phalanx of 5th digit
Attachment of opponens digiti minimi
Origin: Hook of hamate and flexor retinaculum
Attachment: Medial border of 5th metacarpal
Innervation of hypothenar eminence
Deep branch of ulnar nerve
Which hand bone is the most frequently fractured
Scaphoid
Mechanism of injury of scaphoid fracture
Fall on outstretched hand
Symptoms of scaphoid fracture
Pain and tenderness in anatomical snuffbox
Investigations for scaphoid fracture
Xray - AP, lateral, 2 obliques
If not visible - repeat xray in 10 days or do MRI
If scaphoid fracture is not visible on xray initially but highly suspicious of it, what should be done
Start treatment (scaphoid plaster and splint)
Repeat Xray or MRI after 10 days
Management of scaphoid fracture
Wrist in beer glass position
Cast
ORIF / screw fixation if needed
Complication of scaphoid fracture
Compromise blood supply causing
- avascular necrosis
- increased risk of non-union
- early OA
how may scaphoid fracture compromise blood supply
The fracture can damage dorsal branch of radial artery which supplies 70-80% of blood supply to scaphoid
What is trigger finger
Impingement at the level of A1 pulley inhibiting smooth gliding of the tendon
What is a pulley
Bands of tissues along the tendon sheath which holds the flexor tendons close to the finger bones
Risk factors of trigger finger
Female
>50 (but can occur at any age)
Diabetes
RA
Occupation that requires prolonged gripping
Pathophysiology of trigger finger
- flexor tenosynovitis from repetitive movements
- causes fibrocartilaginous metaplasia which forms nodules distal to the pulley on the tendon
- When fingers are flexed, the nodule moves proximal to the pulley but when the patient tries to extend finger, the node cannot pass back under the pulley
- so the finger is locked in flexed position
Symptoms of trigger finger
Pain over A1 pulley (around metacarpal head)
Finger locked in flexion
Difference between trigger finger and dupuytren’s contracture
Dupuytren’s contracture is painless, fixed and cannot be passively corrected
Clinical signs of trigger finger
Feel nodule pass beneath pulley
Management of trigger finger
Often resolves spontaneously
Splint
Steroid injections into tendon sheath
Surgical release
