|
GREEN
|
|
|
• Intro:
|
- Entrapment neuropathy caused by compression the median nerve in the carpal tunnel
|
|
• Aetiology (risk factors):
|
- Typically in 40 - 60 yrs
- 1-5% in general population - F>M (3:1) - Risk factors: carpal tunnel modifications, fluid imbalance, neuropathic factors - Examples: carpal dislocation/subluxation, radius #, arthritis, cysts/tumours, pregnancy/menopause, obesity/kidney failure/hypothyroidism, oral contraceptives/heart failure/diabetes/alcoholism, vitamin deficiency/toxicity |
|
• Pathophysiology:
|
- Caused by various factors
- Involves compression & traction affecting the median n. - Compression leads to increased pressure, obstruction of venous outflow, localised edema, & impaired microcirculation of the median n. - Lesions on the myelin sheath & axon cause inflammation & loss of normal physiological functions of surrounding tissues - Worsening structural integrity of the nerve exacerbates the dysfunctional environment - Repeated traction & wrist movements further injure the nerve - Inflammation of any of the 9 flexor tendons passing through the carpal tunnel can compress the median nerve - Sensory fibres are often affected before motor fibres, & autonomic nerve fibres may also be affected |
|
• Clinical presentation:
|
- Numbness, tingling, & px in the thumb, 2nd, & radial portions of the 4th digits
- Ssx worsen at night - Variability in Ssx distribution from wrist to shoulder - Initially intermittent, worsen w/ activities like driving, reading, painting - Nighttime exacerbation, relieved by shacking hand/wrist - Leads to permanent sensory loss, muscle weakness, & clumsiness - Challenges in tasks like opening doorknobs & buttoning clothes - Dominant hand usually affected first |
|
• Physical examination:
|
- Sensory loss or weakness in median n. distribution
- Thenar eminence spared in sensory loss - Diminished thumb ABD & opposition strength, thenar eminence atrophy - Tinel's sign - Carpal tunnel compression test - Phalen's test - Median n. tension test - Motor & sensory testing |
|
• Management:
|
- 70-90% of mild to moderate cases respond to conservative care
- Some degree of recurrence, even after surgery - Pts w/ CTS 2° to diabetes or wrist # have less favourable prognosis - SMT / STW - Nerve release - Support brace at night - Taping |
|
• Ddx:
|
- Brachial plexopathy
- Cx myofascial px - Cx spondylosis - Compartment syndrome - Ischemic stroke - Mononeuritis multiplex - Multiple sclerosis - Median neuropathy in the forearm - Motor neuron disease - Diabetic neuropathy - Cx radiculopathy - Overuse injury - Traumatic brachial plexopathy - Neuropathies - Tendonitis - Tenosynovitis - TOS |
|
GREEN
|
|
|
• Intro:
|
- Also known as tennis elbow & lateral epicondylitis
- Overuse injury - Occurs due to eccentric overload of the extensor carpi radialis brevis (ECRB) tendon - Results from repetitive strain during activities involving gripping, wrist EXT, radial deviation, & forearm supination - Common in tennis, squash, & badminton |
|
• Aetiology (risk factors):
|
- Most common cause of elbow Ssx
- F=M - More common in pts >40 yrs - Risk factors: smoking, obesity, repetitive movement for at least 2 h daily, & vigorous activity (loads >20kg) |
|
• Pathophysiology:
|
- Condition: degenerative overuse process
- involves: extensor carpi radialis brevis & common extensor tendon - Findings: granulation tissue, micro-rupture, abundance of fibroblasts, vascular hyperplasia, instructed collagen, lack of inflammatory cells |
|
• Clinical presentation:
|
- Px w/ an insidious onset
- Overuse Hx is common, often w/o a specific traumatic event - Px occurs 1-3 days after unaccustomed activities involving repeated wrist EXT - Triggers: new equipment use or atypical workout circumstances - Acute injuries or strains (e.g. lifting heavy objects, hard backhand swing) - Acute injuries may lead to chronic overuse injury - Px is usually located over the lateral elbow - Worsens w/ activity, improves w/ rest - Px severity varies, from mild discomfort during activities to severe px triggered by simple tasks (e.g. picking up coffee) |
|
• Physical examination:
|
- Point of max. tenderness usually over lateral epicondyle or slightly distal
- Discomfort may extend along the tendon, w/ tightness in connecting muscle - Px exacerbated by resisted wrist EXT, especially w/ EXT elbow & pronated forearm - Resisted middle finger EXT w/ EXT elbow particularly painful, indicating increased tendon stress - Absence of radicular Ssx or numbness/tingling - Suggests alternative process such as radial n. entrapment if present, though conditions can coexist |
|
• Management:
|
- Spontaneous recovery within 1-2 yrs in 80-90%
- RICE - NSAIDs - Bracing - Forearm stretching & strengthening - Progression to eccentric muscle strengthening of the common extensor tendon - Invasive techniques if conservative care fails - Surgery (if no improvement after 6-12 months) |
|
• Ddx:
|
- Elbow bursitis
- Cx radiculopathy - Posterolateral elbow plica - PLRI - Radial n. entrapment - Radial n. syndrome - Occult fracture - Capitellar osteochondritis dissecans - Triceps tendinitis - Radiocapitellar OA - Shingles |
|
GREEN
|
|
|
• Intro:
|
- Also known as medial epicondylitis, pronator tendinopathy, & golfer's elbow
- Overload or overuse of the medial common flexor tendon - Medial epicondyle is a common origin: pronator teres, flexor carpi radialis, palmar is longus, flexor digitorum superficialis, & flexor carpi ulnaris - Innervated by median n. - Together, they form the conjoined FX tendon (3cm long) - This tendon crosses the medial ulnohumeral joint & acts as a 2° stabiliser parallel to the ulnar collateral ligament |
|
• Aetiology (risk factors):
|
- 90% of cases are not sports related
- F>M - 45-64 yrs - Athlete risk factors: training errors, improper technique, equipment, lack of strength, endurance, flexibility - Occupation risk factors: heavy physical work, excessive repetition, high BMI, smoking, comorbidities, high psychosocial work demands - General risk factors: smoking, overuse, dominant arm, DM 2 |
|
• Pathophysiology:
|
- Caused by overuse tendinopathy from repetitive loading of wrist flexors & pronator teres
- Leads to angiofibroblastic changes in the affected tendons - Repetitive activity causes microtears in the tendon, resulting in tendonosis - All muscles may be affected equally, except for palmaris longus - Bony inflammation is not involved in this condition - Microtears lead to collagen fibre remodelling & increased mucoid ground substance - Focal necrosis or calcification can develop in the tendon - Collagen strength decreases over time, leading to increased fragility & scar tissue formation - Acute trauma can also cause medial epicondylitis from sudden violent muscle contractions, though less common |
|
• Clinical presentation:
|
- Hx of acute traumatic blow or repetitive elbow use, gripping, or valgus stress
- Aching px on the medial or ulnar side of the elbow, which radiates from the epicondyle into the forearm & wrist - Exacerbated: forearm motion, gripping, or throwing activities (overhead throwing, tennis, golf) - Relief: rest - Elbow stiffness, weakness, numbness, or tingling, 1° in an ulnar n. distribution - Chronic cases may exhibit weakness w/ grip strength - Ulnar n. Ssx in up to 20% |
|
• Physical examination:
|
- Acute cases: swelling, erythema, or warmth
- Chronic cases: less likely to show abnormalities - Tenderness: 5-10mm distal & anterior to medial epicondyle - Pronator teres & flexor carpi radialis involvement - Px elicited by resisted pronation or FX of wrist - Weakness in affected arm - ROM typically normal - Golfer's elbow test: px during manoeuvre - Tinel's test: +ve for ulnar neuropathy - Valgus stress test: stressing ulnar collateral ligament (especially throwing athletes) |
|
• Management:
|
- Good prognosis
- RICE - NSAIDs - Conservative care: aims for full, painless motion at wrist & elbow - Strength exercises w/ focus on eccentric activity - Dry needling, shock wave therapy, etc. - STW/SMT - Night splinting - Elbow taping - Corticosteroid injections, US, platelet-rich plasma injections - Surgery |
|
• Ddx:
|
- Neuropathy: C6 or C7 radiculogpthy, CTS, ulnar/median neuropathy, ulnar neuritis, anterior interosseous n. entrapment, tardy ulnar n. palsy
- Ligamentous injury: ulnar / medial collateral ligament instability, sprain, tear - Intra-articular issues: adhesive capsulitis, arthrofibrosis, loose bodies - Osseous concerns: medial epicondyle avulsion fracture, osteophytes - Myofascial difficulties: flexor / pronator strain - Tendinopathy: lateral epicondylitis, triceps tendonitis - Synovitis - Valgus extension overload - Herpes zoster (dermatological) |
|
YELLOW
|
|
|
• Intro:
|
- Benign, self-limiting ossifying lesion that can affect any type of soft tissue
- Most common form of heterotrophic ossification (HO), usually within large muscles |
|
• Aetiology (risk factors):
|
- M>F
- 1° in young adults as result of trauma |
|
• Pathophysiology:
|
- Metaplasia of the intramuscular connective tissue resulting ion extra osseous bone formation (w/o inflammation)
- Histologically can appear similar to osteosarcoma, thus, can lead to inappropriate management |
|
• Staging:
|
3 stages:
Stage 1 (0-4 weeks): - Following injury - Inflammatory cascade that preceded ossification - Calcification not apparent radiographically Stage 2 (4-8 weeks): - Calcification becomes radiographically seen Stage 3: - Peripheral bone formation - Lamellar cortical & trabecular bone |
|
• Clinical presentation:
|
- Onset followed by trauma, repetitive trauma
- Px, joint stiffness, oedema - Lesion causes mechanical irritation of bursa, tendon, joint |
|
• Physical examination:
|
- Px durance longer than of a sprain/strain
- Decreased ROM |
|
• Management:
|
- Up to 70% of cases are asymptomatic
- Prognosis good after surgery - Very little than can be done to accelerate the resorptive process (i.e. process of removing bone from the bruised region) - Rest from aggravating activities - Implementation of gentle px-free ROM exercises - Surgical resection of mature bone once it has fully matured - Can take 12-18 months after initial presentation - Surgery only if there will be improvement in function as demonstrated by mobility, transfers, hygiene, & ADLs |
|
• Ddx:
|
- Osteosarcoma
|
|
YELLOW
|
|
|
• Intro:
|
- Inflammation of the synovial bursa
- Susceptible to trauma & infection due to superficial location, limited vascularity |
|
• Aetiology (risk factors):
|
- M>F
- 30-60 yrs - Underlying inflammatory conditions: RA, psoriatic arthritis, gout, etc - Chronic medical conditions: diabetes, alcoholism, HIV - Infection usually occurs through a transcutaneous route due to poor vascularity, often from direct inoculation via mild trauma |
|
• Pathophysiology:
|
- Inciting events (trauma or infectious), trigger reactive inflammation in the bursa
- Leads to the extravasation of protein & synovial type fluid into the affected bursa - Consequence is the development of a pronounced round swelling characteristic of this condition - Trauma causes bleeding within bursa & release of inflammatory mediators, increasing recurrence risk |
|
• Clinical presentation:
|
- Swelling over the olecranon process
- Initially, doesn't restrict elbow movement, setting it apart from swelling within the joint - Swelling can progress & eventually limit elbow movement - Characteristic appearance is round or "golf ball" shaped due to fluid confinement within the bursa |
|
• Physical examination:
|
- Caused by infection shows signs of erythema & tenderness
- Systemic Ssx like fever & malaise can accompany infectious bursitis - Fever is present in around 70% of septic bursitis cases, but its absence doesn't rule out infection entirely |
|
• Management:
|
- Low risk of progression to systemic infection from infectious bursitis in healthy pt
Non-infective: - Self-limiting & managed conservatively - RICE - NSAIDs - Elastic bandage application - Corticosteroid injections (risk of iatrogenic infection) - Bursectomy considered for related episodes, especially w/ underlying bone spur - Recurrent non-infective bursitis w/o a spur may benefit from surgical bursa excision Infective: - Requires antibiotics - Aspiration & drainage are recommended - Oral antibiotics for 7 days (longer courses don't reduce recurrence) - Bursectomy may be necessary - Systemic infection warrants further evaluation & appropriate treatment for sepsis or septic shock |
|
• Ddx:
|
- Cutaneous abscess
- Hematoma - Olecranon fracture - Cellulitis - Tendon rupture - Septic arthritis - Gouty arthritis - Neoplasm - Ligament rupture |
|
GREEN
|
|
|
• Intro:
|
- Compression neuropathy of the posterior interosseous n. (branch of radial n.)
- Passes through radial tunnel (Arcade of Frohse) - Results in paresis & paralysis of the finger & thumb EXT - Preserves wrist EXT due to innervation patterns |
|
• Aetiology (risk factors):
|
- M>F (2:1)
- Dominant arm - Trauma or space-occupying lesions (RA, brachial neuritis, spontaneous compression) - Most common site: Arcade of Frohse (proximal edge of supinator) - Also repetitive pronation/supination |
|
• Pathophysiology:
|
- Nerve injury severity varies based on compression severity
3 categories of nerve injury: - Neuropraxia: mildest form, demyelination, from compression/traction, slows conduction, may cause muscle weakness, -ve Tinel sign, recovery prognosis: days to 12 weeks - Axonotmesis: demyelination & axon damage, muscle weakness, may have +ve Tinel sign - Neurotmesis: severe, nerve completely transected, no nerve conduction, surgical correction needed for recovery |
|
• Clinical presentation:
|
- Hx of trauma or fracture of the extremity
- Can be present in Monteggia fractures or radial head fracture-dislocations |
|
• Physical examination:
|
- Weakness w/ finger EXT
- When asked to make a fist, wrist may deviate radially due to extensor carpi ulna's weakness - Depending on injury severity, may be +ve Tinel sign |
|
• Management:
|
- Pretty good prognosis
- Pts continue to improve months after surgery - Athletes may return to play once full ROM & strength Conservative: - Splinting - NSAIDs - Physical therapy - Activity modification Surgical: - Unsuccessful conservative therapy for at least 3 months |
|
• Ddx:
|
- Radial tunnel syndrome: same sites of compression, however presents w/ forearm px w/o motor weakness
- Wartenberg syndrome: compression of superficial sensory radial n., no motor weakness, may present w/ paresthesia / numbness / ill-defined px over the dorsal radial aspect of hand |
|
GREEN
|
|
|
• Intro:
|
- Compression of the median n. by the pronator teres muscle in the forearm
- Innervation: C6-7 - |
|
• Aetiology (risk factors):
|
- Rare & often overlooked & mistaken for CTS
- M>F - Especially common in pts w/ additional fibrous bands - PTS can occur due to: local trauma, compression w/ Schwanoma (rare tumour), & pts undergoing anticoagulation therapy & renal dialysis |
|
• Pathophysiology:
|
Quick & repetitive grasping or pronation movements can lead to PT muscle hypertrophy & entrapment of the median n.
|
|
• Clinical presentation:
|
- Px in volar forearm region
- Weakness may be significant - Muscle wasting rare, but mild weakness in: flexor pollicis longus (FPL), abductor pollicis brevis (APB), some involvement of flexor digitorum profundus (FDP) in 2nd & 3rd digits - PT commonly spared due to early innervation |
|
• Physical examination:
|
- Reproduction: resisted pronation + FX of elbow
- +ve Tinel sign over proximal edge of PT - +ve Phalen test over PT muscle in 50% Variable sensory loss: - Involving palm or mimicking CTS - Including thenar eminence, thumb, index, middle, & ring fingers |
|
• Management:
|
- Good prognosis
- Light duty in 3-6 weeks (conservative care speeds up) - Surgical cases: light duty in 6-8 weeks, regular duty in 10-12 weeks - Rest, activity modification, NSAIDs, physical therapy - Pts may usually continue work unless prominent motor or sensory deficits are present - Surgery considered after fail of >6 weeks of conservative care |
|
• Ddx:
|
- CTS
- AIN s. - Ligament entrapments - MN entrapment of hypertrophied lacertus fibrosis (bicipital aponeurosis) - Brachial plexus injury - Cx radiculopathy |
|
RED
|
|
|
• Intro:
|
- Also Nursemaid elbow or radial head subluxation
- Common injury in young children - Radial head subluxation caused by axial traction resulting in px & inability to supinate forearm |
|
• Aetiology (risk factors):
|
- 1-4 yrs
- 20% of upper extremity injuries in children - Less common in >5 yrs because annular ligament strengthens w/ age - F>M - Recurrence rate: 20% |
|
• Pathophysiology:
|
- Trauma: axial traction on pronated forearm + elbow EXT
- Lifted/swung by arms or pulling child's arm to prevent fall - Displacement of the annular ligament leads to discomfort & px during arm movement - Longitudinal traction (e.g. baby rolling onto their arm) can also lead to radial head subluxation (<6 months old) |
|
• Clinical presentation:
|
Child's behaviour:
- Often nervous & may support affected arm protectively w/ opposite hand - Arm held in complete or almost complete EXT + pronation - Refusal to move the arm & becoming upset during examination - Generally no px unless the arm is manipulated Caregivers may report: - Arm pulled upwards by the wrist or swung around by the arms prior to Ssx onset - No known trauma or awareness of the incident causing the injury - Onset of Ssx after FOOSH (less common) |
|
• Physical examination:
|
- Tenderness at radial head
- Resistance to forearm pronation, supination, FX, & EXT - Absence of ecchymosis, erythema, edema, or signs of trauma - Intact circulation, sensation, & motor ability distal to the elbow - Possible lack of cooperation w/ the exam - Spontaneous reduction: radial head may spontaneously reduce before exam, reassurance to parents after exam is usually sufficient |
|
• Management:
|
Closed reduction (brief but potentially painful):
- Px resolves post-reduction (within minutes) - Techniques for reduction: hyperpronation (preferred) & supination/FX - Arm function should be regained post-reduction; imaging if not - Referral to orthopaedic surgeon if arm not used post-reduction - No splinting or sling required Post-treatment instructions: - Avoid activities causing axial traction to arm to prevent recurrence - Excellent prognosis post-reduction |
|
• Ddx:
|
- Elbow fracture
- Fractured wrist - Green stick fracture - Hand injury - Monteggia fracture - Sypracondylar fracture - Soft tissue damage of hand |
|
• Intro:
|
- Stretching or tearing of ligaments, due to abnormal or excessive forces applied to a joint
- Classified in 3 grades |
|
Grade 1:
|
- Mild stretching of the ligament complex w/o joint instability
|
|
Grade 2:
|
- Partial rupture of the ligament complex w/o joint instability
|
|
Grade 3:
|
- Complete rupture of the ligament complex w/ instability of the joint
|
|
Causes of MCL injury:
|
- Overstretched in a single incident, e.g. unnatural bending or twisting of elbow
- Repetitive ligament stretching, e.g. overhead throwing activities |
|
Outcome of MCL injury:
|
- Increased valgus stress
|
|
Prognosis:
|
- Grade 1-2: 2-6 weeks & high-end sports in 8 weeks
- Grade 3 ruptures: significantly longer rehabilitation depending on whether surgical intervention was required & how much damage is present |
No comments yet.
Cheatography n. The art of mapping complex subjects into clear, instantly navigable reference guides.
