Upper limb condition

Wednesday, 28 December 2022 13:40

Overuse conditions
- Patho: Mechanical overload-> microtrauma=> inflammation
- Tendon degeneration: tennis/ golfer elbow
- Tendon sheath (tenosynovitis), peritendinous tissue (peritendinitis): de Qu
triggeer finger
- Etiology
(Extrinsic): repetitive mechnical load, drug (steroid)
(Intrinsic):
- anatomic (malalignment, inflexibility, joint laxity, muscle weakness/ imba
- age-related (tendon degeenreation, decreeased vascularity-> increeased ten
stiffness & decreased healing response

Carpal tunnel syndrome

- P: Median nerve compressd by flexor retinaculum at wrist

Tennis elbow: lateral epicondylitis

- Patho: Overuse injury of common extensor tendon origin (lateral epicondyle) w
tendonitis w/o inflammation at tendon attachment of externsor carpi radialis bre
- Involve extensor carpi radialis brevis: extend & stabilise wrist
- RF: Repetitive wrist extension & forearm pronation (ex. Tennis playing, repetiti
gripping & lifting)
- SY: Pain at outer elbow-> down forearm & hand
- SI: Tenderness at lateral epicondyle & wrist extensor muscle (elicted by moving
- DT: Pain at lateral epicondyle with resisted wrist extension

Golfer's elbow: medial epicondylitis

- Patho: Tendonitis at origin of flexor/ pronator muscle muscles (medial epicondl
- RF: Repetitive swing stress at elbow, use of wrist/ clenched fingers (ex. heavy li
hammering)
- SY: Pain at inner elbow (when making a fist, turn doorknob, heavy lifting)
- SI: Tenderness at medial epicondyle, elbow stiffness, weakness in hand and wr

De Quervain disease
- P: Tenosynovitis of sheath covering wrist compartment 1 (extensor pollicis brev
abductor pollicis longus)
- RF:
-> Middle aged woman, pregnancy, breastfeeding (Decreased estrogen), repetiti
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De Quervain disease
- P: Tenosynovitis of sheath covering wrist compartment 1 (extensor pollicis brev
abductor pollicis longus)
- RF:
-> Middle aged woman, pregnancy, breastfeeding (Decreased estrogen), repetiti
thumb
- SY: Pain & swelling at wrist/ thumb (worsened with thumb motion), difficulty i
gripping
- SI: Tenderness/ swelling at radial styloid (during active movement)
- DT:
-> Pain in active extension & abduction of thumb against resistance
-> Finkelstein test: grasp thumb & ulnar deviate wrist sharply-> pain at distal ra
-> Eichoff maneuver: pt form fist around thumb & ulnar deviate wrist-> pain

Intersection syndrome
- Similar but site more proximal than de quervain (inner part than radial styloid)
- Affect crossing point (musculotendinous junction) of first (APL & EPB) &
compartment
(exteensor carpi radialis longus/ brevis)

Trigger finger (Stenosing tenosynovitis)

- Patho: Fibrocartilage metaplasia of A1 pulley (chondrocyte proliferation)
- Etiology: 50-60, F>M, dominant hand
- Cause: idiopathic
- Grading
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- MX: Rest
- Physiotherapy
§ Stretching or strengthening exercise
§ Ultrasound/ heat treatment
- Intermittent splintage
§ Ex. Tennis elbow brace: reduce tension on tendon
- For tennis elbow: Extracorporeal shock wave therpay
- NSAID: analgesics: acute pain relief
- Local injectable steroid to tendon sheath: for chronic?
§ Less than 3 times: since risk of tendon atrophy and rupture
§ X prefer systemic oral: higher SE
- Surgery: Percutaneous, arthroscopic (for joint), open
§ If failure of conservative Tx for 6m, affect ADL
§ Tendon:
□ Debridement of degenerated tendon (since risk of rupture)=> g
□ Reinsertion, repair, grafting
§ Tendon sheath (peritenum): synovectomy, retinaculum release
§ If malalignment: excision of boney structure

Wrist pain
- Cause: Wrist sprain
(Radial)
- Extensor carpi ulnaris: tendonitis, dislocation
§ Compartement 6 of wrist
§ Tendonitis: Ask pt spread fingers (esp thumb & middle finger) + resi
ABduction=> +ve pain at extensor tendon
§ Dislocation:
□ May reduce if in pronation; sublux if circular motion
□ With repetitive dislocation=> teendonitis
- Distal radial ulnar joint subluxation, dislocation (from triangular fibrocarti
complex tear)
§ TFCC stabilize DRUJ
§ Press test: ask pt push themselves out of a chair-> +ve if pain
grafting

ist

ilage
 complex tear)
§ TFCC stabilize DRUJ
§ Press test: ask pt push themselves out of a chair-> +ve if pain

(Ulnar)
- Scapholunate ligament tear
§ Watson test: Thumb press on scaphoid tubercle-> ulnar to radial dev
pain/ clicking sound if radial deviate
- Scaphoid fracture
- MX
- Splintage, cast, taping
- Surgery: repair & reconstruction
§ Scaphoid fixation for SLT

Inflammatory condition

RA
- Inflamatory arthritis of synovial joint
- RF: Female, HLADR4/1
- Diagnostic criteria: ARA
viate wrist:
 RA
- Inflamatory arthritis of synovial joint
- RF: Female, HLADR4/1
- Diagnostic criteria: ARA
- Usually start at wrist

- Extra-articular complication
- Vasculitis, pericarditis, pulmonary nodules, episcleritis, subcutaneous nod
- Xray
- Soft tissue swelling
- Periarticular osteopenia
- Joint space narrowing
- Periarticular erosion
- Subluxation and fusion of joints

Gout
- Chronic heterogenous disorder of urate metabolism
- Cause
- Primary: inborn error of metabolism
- Secondary: from renal failure (uric acid buildup)
- Etiology: >40y/o M
- Site: esp 1st MTP

- Staging
- Asymptomatic hyperuricemia
dules
 - Staging
- Asymptomatic hyperuricemia
- Acute gouty attack
- Intercritical gout
- Chronic tophaceous gout (tophi erode bone)
- DT:
- Elevate serum uric acid
- Synovial tap: uric crystals

Psoriatic arthritis
- Systemic condition associated with psoriasis (dry red, scaly skin rashes)
- Site: hands, spine, feet, jaw
- Asymmetrical distribution
- S/S
- Dry red scaly skin lesion (May not be evident: very small patch)
- Pitting , ridging or crumbly nails
- Usually affect PIP/ DIP first-> then MCPJ, wrist or tendon
- May also occur with vasculitis (Raynaud's phenomenon)
- DT
- Skin biopsy
- Xray: pencil in cup deformity at DIPJ
- Joint space narrowing, joint erosion or spontaneous joint fusion
- Swelling of non-bony structure

- MX: systematic medication

- Splint/ physiotherapy
- Steroid: decrease inflammatory response
- Surgical synovectomy
- Surgical reconstruction

Osteoarthritis
- Degenerative joint disease: cushioning cartilage
- Primary: wear & tear
- Secondary: post traumatic/ inflammation/ infection
- Pathophysiology
- Disruption of cartilage lining articular surface-> joint mice (cartilage fragment
space)
- Eburnation of subchondral bone-> Subchondral cyst or sclerosis
- Osteophyte
- Synovitis + joint capsule thickening (synovial hypertrophy)
- Common site: DIP, thumb CMC joint, hip, knee, C/L spine
- S/S:
- Deep aching pain worsened by movement/ loading & relieved by rest
- Stiffness, swelling & pain
ts in joint
 - Osteophyte
- Synovitis + joint capsule thickening (synovial hypertrophy)
- Common site: DIP, thumb CMC joint, hip, knee, C/L spine
- S/S:
- Deep aching pain worsened by movement/ loading & relieved by rest
- Stiffness, swelling & pain
- Heberden's (DIP), Bouchard's (PIP) node- osteophyte
- Deformity of joint
- Diminished grip and pinch strength
- DT: Xray
- Narrowing of joint space
- Formation of osteophyte, subchondral sclerosis/ cyst
- Deformity
- TX:
- Conservative: analgesic, splint
- Steroid injection
- Hyaluronic acid injection
- Surgrey:
§ Excisional arthorplasty
§ Arthrodesis: fuse & stabilize joint
§ Replace

For multiple joint surgery approach

- Cervical spine stabilization
- WINNER Procedure (LL-> UL)
- Hip & knee: replacement
- Finger & wrist: fusion> replacement
- If young active pt: fusion (joint dislocation in replacement)