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GREEN
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|
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• Intro:
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- Degenerative condition of the thumb
- Second most common site of degenerative disease in the hand after DIP |
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• Aetiology (risk factors):
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- >40 yrs
- F>M (6:1) - Risk factors: FHx, occupation w/ high load on hands, obesity, PMHx of joint injury, menopause |
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• Pathophysiology:
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- Correlation between basal joint laxity & MCP OA
|
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• Clinical presentation:
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- Px at the MC joint
- Aggravated: opening of a lid, turning door knob / car key |
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• Physical examination:
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- Resisted pinch
- Palpation - Swelling - Crepitus |
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• Management:
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- NSAIDs
- Activity modification - SMT / STW - Mobs - Support brace - Surgery |
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• Ddx:
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- Ganglion
- Tendinopathy of flexor carpi radialis - Carpal fracture - UCL sprain - Quervain's tenosynovitis - Carpal tunnel syndrome - Trigger thumb - RA |
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GREEN
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• Intro:
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- Lesion of the motor branch of the median nerve
- Forearm px & weakness in index & thumb pincer movement |
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• Aetiology (risk factors):
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- Very rare
- Causes: spontaneous or traumatic - Pronator teres muscle most common - Associated w/ RA & gout |
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• Pathophysiology:
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- Occurs due to 1° entrapment, direct trauma, or viral neuritis
- Proximal lesions like brachial plexus neuritis can cause similar syndromes - Suspicion for pts w/ motor loss after related Ssx like intense shoulder px or recent viral illness/exposure |
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• Clinical presentation:
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- No sensory deficits
- No radiation - No numbness - 1° complaint: poorly localised px in forearm in cubital fossa |
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• Physical examination:
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- Pinch sign
- Decreased strength of flexor policies longus & flexor digitorum profundus |
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• Management:
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- Prognosis is usually good and doesn't need surgery
- Rest - Observation - Splinting of the elbow at 90° of FX - Improves usually in 6-12 weeks - NSAIDs - SMT / STW - Surgery |
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• Ddx:
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- Stenosing tenosynovitis
- Flexor tendon adherence or adhesion - Flexor tendon rupture - Brachial neuritis |
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GREEN
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• Intro:
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- Entrapment neuropathy caused by compression the median nerve in the carpal tunnel
|
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• Aetiology (risk factors):
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- 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 |
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• Pathophysiology:
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- 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 |
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• Clinical presentation:
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- 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 |
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• Physical examination:
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- 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 |
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• Management:
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- 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 |
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• Ddx:
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- 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 |
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GREEN
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• Intro:
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- Involves tendon entrapment in the 1st dorsal compartment of the wrist
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• Aetiology (risk factors):
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- F>M
- Peak 40-50 yrs - Bilateral common in new mothers or child care providers - Spontaneous resolution often occurs once lifting of the child is less frequent - Pregnancy & manual labour significant risk factor - Associated w/ repetitive wrist movements, particularly thumb radial ABD, EXT, & radial deviation - Acute injury to the wrist, increased frictional forces, pathogenic causes, inflammatory ailments, & anatomical variations |
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• Pathophysiology:
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- Risk of entrapment in acute trauma or repetitive motion
- Thickening of tendon sheath in 1st compartment causes stenosing tenosynovitis - Fibrocartilage formation in response to increased stress over tendon sheaths, leading to thickening |
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• Clinical presentation:
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- Pts w/ radial-sided wrist px worsened by thumb & wrist motion
- Associated w/ difficulty opening a jar lid - Common in 3rd trimester pregnant women or breastfeeding mothers |
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• Physical examination:
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- Tenderness over radial styloid usually present
- Swelling over wrist typically seen proximal to radial styloid - Finkelstein test - Eichhoff test - WHAT test |
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• Management:
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- Prognosis is good w/ proper care
|
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• Ddx:
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- Thumb OA
- Scaphoid fracture - Radial styloid fracture - Sensory branch of radial nerve neuritis (Wartenberg's syndrome) - Intersection syndrome - Trigger thumb |
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YELLOW
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• Intro:
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- Umbrella term for all non-inflammatory disorders of the peripheral nerve system/neuropathy that occur as a late complication of diabetes & include diabetic mononeuropathy, diabetic polyneuropathy & diabetic autonomic neuropathy
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• Aetiology (risk factors):
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- 50% of pts w/ DM
- Incidence higher in pts w/ DM2 - Risk factors: smoking alcohol, poor control/compliance regarding blood sugar, hypertension |
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• Pathophysiology:
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- Exact cause unknown - metabolic, neurovascular, autoimmune causes
- Hyperglycaemia damage blood vessels → compromise oxygen & nutrients to nerves - Risk factors contribute |
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• Clinical presentation:
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- Burning, numbness, or tingling worsen at night
- Often presents as a "stocking-glove distribution" over several years - Proprioceptive & sensory changes resulting in motor changes |
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• Physical examination:
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- Trophic changes, motor Ssx, autonomic Ssx
- Px & cramps - Foot problems, reoccurring amputations - Radial n. test - Kemps test - Tinel's sign - Dellon sign |
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• Management:
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- Worse prognosis w/ bad control of DM
- TENS, low intensity laser therapy - Radial n. floss - STW - Support brace - Exercises |
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• Ddx:
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- Alcohol-associated neuropathy
- Nutritional linked neuropathy - Uremic neuropathy - Vasculitic linked neuropathy - Vitamin B-12 deficiency - Toxic metal neuropathy |
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GREEN
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|
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• Intro:
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- Genetic disorder
- 1° affects the palmar & digital fascia of the hand - Leads to contracture deformities, particularly the 4th & 5th digit - Predominantly in whites & often bilateral |
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• Aetiology (risk factors):
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- Most common in Northern European/Scandinavian descent
- M>F (2:1), w/ more severe impact - Younger age of onset associated w/ increased severity - Multifactorial etiology - Associated w/: diabetes, seizure disorders, smoking, alcoholism, HIV, vascular disease - NOT associated w/ occupation or activities - Ectopic manifestations: *Ledderhose disease (plantar fascia) 10-30%, Peyronie disease (dartos fascia of the penis) 2-8%, Garrod disease (dorsal knuckle pads) 40-50% |
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• Pathophysiology:
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- Disease starts w/ painless nodules forming along lines of tension in the palm
- These nodules progress into cords that cause contracture deformities in hand tissues - Progresses through proliferative, involution, & residual phases |
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• Staging:
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- Starts as a palpable nodule in the palm
- Nodules enlarge into cords - Early stage: palpable cords along the palm - Progression: cords thicken & shorten, causing fixed FX contractures of fingers at MCP & PIP joints |
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• Clinical presentation:
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- Loss of ROM of the hand
- Palpable cords in the palm extending into affected digits - Pathogenic signs: nodules, cords, & finger contractures - Rarely associated w/ px - Affected digits: 4th digit most commonly affected, followed by the 5th digit, B cases may not exhibit symmetrical severity - Px & tenderness: palpation of nodules usually painless unless ulnar n. is compressed, nodules may become tender in presence of tenosynovitis |
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• Physical examination:
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- Hueston's tabletop test
- Observation: blanching of skin when finger EXT, pits & grooves may be present, knuckle pads over the PIP may be tender - Decreased ROM - If plantar fascia involved, indicates more severe disease (Ledderhose disease) |
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• Management:
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- US, heat therapy, brace/splint, ROM exercise
- Needle aponeurotomy, corticosteroid injections - Medications - Surgery |
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• Ddx:
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- Stenosing flexor tenosynovitis
- Callus - Epitheliod sarcoma - Ganglion - Giant cell tumour - Trigger finger - Ulnar nerve palsy - DJD of hand - Post trauma - Infection - Volkmann's contracture - Diabetic cheiroarthropathy |
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YELLOW
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• Intro:
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- Partial or complete rupture of the ulnar collateral ligament
- It can either be acute or chronic injury - Results from recurrent thumb hyperEXT, leading to degeneration & tears of the UCL |
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• Aetiology (risk factors):
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- 86% of injuries to the base of the thumb
- 2nd most common ski-related injury, common in other sports using stick or ball - Can occur due to mechanisms like falls or strikes that forcefully ABD the thumb |
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• Pathophysiology:
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- UCL tear at the distal attachment of the proximal phalange → can lead to avulsion of the bone fragment
- Chronic: repetitive valgus stress - Acute: hyperABD trauma |
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• Clinical presentation:
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- Acute presentation post-injury or delayed presentation for chronic injuries
- Discomfort localised to 1st MCP joint area - Swelling near or at the thumb base - Hx of falls or trauma, causing extreme thumb ABD or hyperEXT Ssx: - Px, occasionally weakness - Difficulty holding onto objects, especially w/ pincer grasp |
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• Physical examination:
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- Decreased ROM
- Valgus stress test +ve (increased laxity in partial tears; lack of endpoint indicates complete tear w/ total instability) |
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• Management:
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- Tend to heal well but long period of immobilisation
- Wait at least 6 weeks before returning to work or sport - RICE - Immobilisation - If bony injury refer to A&E - If significant laxity also refer for surgery |
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• Ddx:
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- Tendinous injuries (e.g. ADD pollicis disruption)
- Thumb dislocation - Bennett fractures - Stener lesion - RA - OA |
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GREEN
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• Intro:
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- Benign soft tissue tumours most commonly encountered in the wrist & hand, but may occur in any joint
- Majority asymptomatic, but can cause px, tenderness, weakness, & cosmetic concerns |
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• Aetiology (risk factors):
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- F>M (3:1)
- Common in women 20-50 yrs - 60-70% of hand & wrist soft-tissue masses - Associated w/ gymnasts - likely due to repetitive trauma & stress on wrist joint |
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• Pathophysiology:
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- Synovial cysts filled w/ connective tissue
- Can be filled w/ fluid from tendon sheath or joint - 70% on the dorsal aspect, originating from the scapholunate ligament / articulation - 20% on the viral aspect, originating from the radoiocarpal / scaphotrapezial joint - 10% from various areas of the body - Commonly found in women aged 40-70 w/ OA |
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• Clinical presentation:
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- Majority are asymptomatic
- Ssx may inc. px, tenderness, or weakness exacerbated by wrist motion - Aching of wrist, might radiate into arm |
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• Physical examination:
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- Px on palpation
- Possible decreased ROM, grip strength - Solar wrist ganglion cysts may lead to carpal tunnel s. or trigger finger due to compression of median n. or intrusion on flexor tendon sheath - They can also cause ulnar n. neuropraxia & compression of radial artery, resulting in ischemia |
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• Management:
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- Asymptomatic pts may regress spontaneously
- Surgery is an option for persistent Ssx - Recurrence is the most common complication of surgery |
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• Ddx:
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- Aneurysmal bone cyst
- Chondroblastoma - Chondromyxoid fibroma - Enchondroma - Giant cell tumour - Non-ossifying fibroma - Osteoid osteoma - Osteoblastoma - Simple bone cyst |
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GREEN
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• Intro:
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- Relatively rare peripheral ulnar neuropathy
- Involves injury to the distal portion of the ulnar n. as it travels through a narrow anatomic corridor at the wrist |
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• Aetiology (risk factors):
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- Distal ulnar n. injury can occur from various causes inc. compression, inflammation, trauma, or vascular issues
Etiologies include: - Ganglion cyst - Fracture or displacement of the hook of hamate - Tumours (e.g. lipoma) - Repetitive trauma (e.g. cyclist's handlebars) - Aberrant muscle or excess fat tissue within the canal - Ulnar artery thrombosis or aneurysm (e.g. HHS) |
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• Pathophysiology:
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- Compression, inflammation, trauma or vascular insufficiency
- Most commonly due to ganglion cyst or repetitive trauma - 4 borders of Guyana canal: volar carpal ligament, transverse carpal ligament, hamatum, pisiform - Inside: ulnar nerve + artery - Mixed sensory, motor nerve |
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• Clinical presentation:
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- Hx of repetitive trauma / direct trauma
- Ssx/Sx can be motor, sensory, or mixed - Motor complaints: weakness/paralysis of intrinsic muscles, weakening grip, clawing of 4th/5th digits - Hypothenar atrophy in advanced cases Differentiation between Guyon canal vs. cubical tunnel compression: - Sparing of dorsal ulnar dermatome indicates Guyon canal involvement |
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• Physical examination:
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- Tinel sign +ve
- Paper gripping test shows weakness of ADD pollicis muscle - Froment sign: thumb IP joint hyperFX due to ADD inability - Wartneberg sign: 5th digit over-ABD at rest - Allen test: arterial supply evaluation |
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• Management:
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- Ssx duration: acute, subacute, chronic
- Conservative vs. operative: depends on duration, severity of Ssx & etiology - Splinting: avoidance of aggravating factors (1-12 weeks) - US & nerve grinding exercises |
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• Ddx:
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- Alcoholic neuroapthy
- ALS - Brachial plexus abnormalities - Cx radiculopathy - Epicondylitis - Pancoast tumour - TOS |
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GREEN
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|
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• Intro:
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- Inflammatory tenosynovitis at the intersection of the 1st dorsal compartment (APL, EPB) & 2nd dorsal compartment (ECRL, ECRB) of the wrist
- Often caused by overuse |
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• Aetiology (risk factors):
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- F=M
- Associated w/: rowing, canoeing, skiing, racquet sports, & horseback riding - Results from repetitive EXT & FX |
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• Pathophysiology:
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- Repetitive EXT-FX causes friction injury at the crossover junction of 1st dorsal compartment (APL, EPB) & 2nd dorsal compartment (ECRB/ECRL) tendons
- Leads to inflammatory response & tenosynovitis |
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• Clinical presentation:
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- Px or tenderness over dorsal aspect of wrist proximal to radial styloid
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• Physical examination:
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- Swelling, palpable crepitus w/ wrist or thumb EXT
- Pronation more uncomfortable than supination - Swelling around Lister's tubercle - Intersection syndrome test +ve - Cozen's test +ve - Resisted thumb EXT +ve - Finkelstein's test +ve |
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• Management:
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- RICE
- Splinting - Steroid injections - NSAIDs |
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• Ddx:
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- DeQuervain tenosynovitis
- Muscle strain - Wartenberg's syndrome - EPL tendinitis |
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GREEN
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• Intro:
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- Avascular necrosis of the lunate
- Known as lunatomalacia |
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• Aetiology (risk factors):
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- 20-40 yrs
- M>F - Multifactorial etiology |
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• Pathophysiology:
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- Shortened ulna when compared to the radius, increased mechanical stress, repetitive microtrauma
- Low number of supporting blood vessels - Bigger size of lunate - Increased radial inclination angle - Venous plexus abnormalities leading to an obstructed venous drainage - Repetitive compression of the wrist |
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• Clinical presentation:
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- Unilateral px over dorsal aspect of the wrist
- Limited ROM - Weakness - Exacerbated: EXT & axial loading - Ssx: mild to debilitating - Rarely B - Trauma is often absent |
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• Physical examination:
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- Swelling, tenderness
- Synovitis - Loss of grip strength |
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• Management:
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- Reduction of compressive load
- Maintenance, improvement of ROM - Stretching - Massage to increase blood circulation |
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• Ddx:
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- Ulnar impaction s.
- Lunate intraosseous ganglion - Bone contusion - Arthritis - Osteoid osteoma - Enostosis/bone island |
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YELLOW
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|
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• Intro:
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- Common autoimmune disorder of the joints
- Characterised by inflammatory arthritis as well as extra-articular involvement - Can levelly impair physical function & quality of life - Typically B & symmetrical - MCPs & PIPs most commonly affected |
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• Aetiology (risk factors):
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- F>M
- 30-50 yrs (can occur at any age) - Northern Europe & North America - Multifactorial nature involving genetic (caucasians, FHx) & environmental factors - Risk factors: females, smoking (strongest), microbiota, Western diet, stress, infections |
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• Pathophysiology:
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- Exact cause unknown
- Multifactorial - Hypothesis: results from the interaction between genetic predisposition & environment → autoimmune response |
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• Clinical presentation:
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- Morning stiffness >1h (gelling phenomenon)
- Involvement of small hand joints affecting ADLs (e.g. opening jars, wringing washcloths) - Decreased strength may cause issues (e.g. dropping objects) - Pts struggle w/ ADLs (e.g. showering, combing hair, dressing, or using handgrips to unlock doors) - Constitutional Ssx: fatigue & malaise are common - Weight loss & low-grade fevers can accompany onset or flares of RA - FHx of inflammatory joint disease or autoimmune collagen vascular disease is present in up to 50% of cases Typical Ssx: - Joint px - Joint swelling, notably in the MCPs - Decreased strength - Limited ROM - Stiffness in affected joints, particularly after long periods or rest or sleep |
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• Physical examination:
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Synovitis:
- Key clinical finding in RA: palpable synovial hypertrophy - Joints appear swollen, fusiform/spindle-shaped PIPs - Decreased ROM - Grip strength may be reduced - RA synovitis feels "doughy" - Erythema & warmth may or may not be present Tenosynovitis: - Flexor tendon frequently involved, leading to swelling & thickening - Triggering & locking of fingers possible - Poor prognosis if flexor tenosynovitis present - Extensor tendons of wrist commonly involved - Tenosynovial effusions can compress median n., causing CTS Hand & wrist deformities: - Boutonniere deformity - Swan-neck deformity - Subluxation of MCPs - Ulnar drift/deviation - Hitchhiker thumb/Z deformity - Piano key sign/floating ulnar styloid - Subluxation of wrist - Vaughan-Jackson deformity Subcutaneous nodules: - Seen in seropositive RA (-ve HLA-B27), especially on pressure areas - Firm, contender, not freely mobile - Poor prognostic marker if present early in disease |
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• Management:
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- Imaging: x-ray, MRI, MSK US
- Labs: RF, ACPAs, ANA, ANCAs - Presence of RF, anti-CCP indicate RA being seropositive (seronegative RA also occurs) - Not associated w/ HLA-B27 - Medical treatment - Improvement of general fitness - Manual therapy (thermo-therapy, TENS, rest during flare-ups) - Surgery is rarely needed - Cx adjustment contraindicated due to Atlanta-axial subluxation |
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• Ddx:
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- Infections
- OA - Seronegative spondyloarthroapthies - Crystalline arthropathies - Other autoimmune connective tissue diseases - Others |
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YELLOW
|
|
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• Intro:
|
- Rotatory subluxation of the scaphoid
- Most frequent pattern of carpal instability & is classified as an acute or chronic & static or dynamic instability - Disruption of the ligamentous complex holding the scaphoid & lunate together - Refers to abnormal orientation of the scaphoid relative to the lunate |
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• Aetiology (risk factors):
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- Typically after FOOSH, ulnar-deviated hand
- Atraumatic: infection, inflammatory arthritis, neurological disorders, & certain congenital malformations - These conditions disrupt the 1° & 2° ligamentous stabilisers of the scapholunate joint |
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• Pathophysiology:
|
- Axial loading in hyperEXT shifts scaphoid proximal pole dorsally
- High-speed trauma like motorcycle accidents may cause bony avulsions leading to scapholunate dissociation - Isolated scapholunate ligament rupture alters wrist biomechanics & kinematics - Gradual attenuation of scapholunate joint 2° stabilisers follows ligament rupture - Failure of 2° stabilisers leads to apparent radiographic evidence |
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• Complications:
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- Degenerative changes
- Rotational alterations in the scapholunate joint |
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• Clinical presentation:
|
- Can be isolated or associated w/ distal radius or carpal bone #
- Persistent wrist px after FOOSH - Decreased grip strength - Popping or clicking during activities loading the wrist - Exacerbated px w/ wrist EXT & radial deviation - Limited ROM due to px - Chronic cases: wrist ROM normal until degenerative changes occur Presentation varies w/ Watson staging: Stage 1: predynamic Stage 2: dynamic Stage 3: static Stage 4: osteoarthrotic |
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• Physical examination:
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- Tenderness to palpation dorsally over the scapholunate joint
- Localised swelling in acute cases - Watson shift test: +ve w/ palpable clunk & presence of dorsal wrist px |
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• Management:
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- Injury acute if it has occurred within 6 weeks
- Conservative care (non-displaced & chronic asymptomatic): immobilisation & NSAIDs - Surgery normally required to prevent long-term complications |
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• Ddx:
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- Scaphoid fracture
- Kienbock disease - Ganglion cyst - Flexor carpi radialis tendinopathy - Extensor carpi radialis brevis/longus tendinopathy - CIND-DISI |
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GREEN
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• Intro:
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- Tenosynovitis in the flexor sheaths of the fingers & thumb
- Result of overuse - Causes significant functional impairment |
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• Aetiology (risk factors):
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- 1st peak: young age <8yrs, F=M (mostly thumb)
- 2nd peak: 40-50yrs F>M (dominant hand) - Multifactorial etiology - Trauma cause hypertrophy & narrowing of tendon & sheath, leading to catching & locking - Adult comorbid diseases associated: diabetes, amyloidosis, CTS, gout, thyroid disease, RA - In children: seems developmental, w/ size mismatch between flexor tendon & sheath, often idiopathic but associated w/ conditions like Hurler s., juvenile RA |
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• Pathophysiology:
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- Microtrauma leads to inflammation & injury of the flexor tendon-sheath complex
- A1 pulley experiences greatest force & commonly affected - Inflammation over time causes tendon sticking within its sheath, perceived as locking by the pt - Flexor tendon apparatus is stronger than the extensor tendon apparatus - Pts can FX fingers w/o difficulty but experience locking during EXT due to inflammation causing tendon catching in the flexor sheath |
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• Clinical presentation:
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- Discomfort or functional limitations in the affected digit
- Thumb, ring finger most common sites (dominant hand) - Swelling or a nodule may be present - Complaints of a painful click in the digit - Locking of finger during EXT or inability to move it from fixed FX position - Ssx may develop gradually or be acute |
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• Physical examination:
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- Tender nodule (due to inflammation) at the distal palmar crease
- Affected digit may be FX or locked on observation - Moving may cause px &/or swelling |
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• Management:
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- Good prognosis w/ treatment, sometimes spontaneous resolution
- Conservative: splinting (6-10 weeks) & steroid injections - Surgery (if conservative care fails or trigger thumb during infancy) |
|
• Ddx:
|
- Abnormal sesamoid
- Acromegaly - Ganglion cyst - Infection within the tendon sheaths - Presence of loose body in MCP joint - Subluxation of extensor digitorum communis |
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