PCL 5 - Physical Examination of Hands & Wrists

History

1. Pain

   - vague/diffused → radiated from shoulder or neck / carpal tunnel syndrome

   - localised → arthritis

2. Stiffness

   - worse in mornings for rheumatoid arthritis

3. Swelling

   - wrist → arthritis / tendon sheath inflammation

   - individual joints → arthritis

4. Deformity

   - fingers & hand → rheumatoid arthritis

   - fingers → arthritis / gouty tophi (tohpi - nodular masses of uric acid crystals deposited in different soft tissue areas in body, most commonly fingers, elbow and big toe)

   - sudden onset of deformity → tendon rupture

5. Locking or snapping of finger (trigger finger)

   - inflammation of flexor tendon sheath (tenovaginitis)

6. Loss of function

   - history should include assessment of difficulties patient has in using hands and wrists

7. Neurological symptoms due to nerve compression

   - paraesthesiae (abnormal skin sensations (as tingling or tickling or itching or burning)
   usually associated with peripheral nerve damage)

   - limitation of complicated hand functions

Examination

- sit patient over side of bed and place hands of pillows with palms down

1. LOOK

   → wrists & forearms

   - erythema

   - atrophy

   - scars

   - rashes

   - swelling and its distribution

   - deformity

   - ulnar and hyloid prominence

   - muscle wasting of intrinsic muscles of hand (appearance of hollow ridges between metacarpal bones)

   
   

→ metacarpophalangeal joints

• skin abnormalities

• swelling

• deformity

• ulnar deviation & volar (palmar) subluxation of fingers (characteristic of rheumatoid arthritis (RA) but NOT pathognomonic)

→ proximal & distal interphalangeal joints (IPJ)

• skin changes & joint swelling

• characteristic deformities of RA

  - swan neck (hyperextension at proximal IPJ (subluxation) & fixed flexion deformity at distal IPJ (tendon shortening))

  - boutonniere deformity (fixed flexion of proximal IPJ & fixed extension of distal IPJ)

  - Z deformity of thumb (hyperextension of IPJ & fixed flexion and subluxation of metacarpophalangeal joint)

• characteristic changes of osteoarthritis (OA)

  - Heberden's nodes (osteophytes at distal IPJ)

  - Bouchard's nodes (osteophytes at proximal IPJ)

→ nails

• characteristic psoriatic nail changes (nail disease common in those suffering from psoriasis)

  - pitting (small depressions in nails)

  - onycholysis

  - hyperkeratosis (thickening of nail)

  - ridging & discolouration

→ palmar surface (hands turned over)

• scars (from tendon repairs or transfers)

• erythema

• muscle wasting of thenar (the fleshy area of the palm at the base of the thumb) / hypothenar (group of three muscles of the palm that control the motion of the little finger)eminences (due to disuse, vasculitis, peripheral nerve entrapment)

2. FEEL & MOVE

   (palm down position)

   → palpate wrists (both thumbs placed on dorsal surface by the wrists supported underneath by index fingers)

   - feel gently for synovitis (boggy swelling) & effusions

   - dorsiflex wrists gently (normal – possible to 75 degrees) & palmar flex (possible to 75
   degrees) with examiner's thumbs

   - test radial and ulnar deviation (20 degrees)

   - note tenderness / limitation of movement / joint crepitus

   - palpate ulnar styloid for tenderness (can occur in RA)

   - palpate tip of radial styloid for tenderness (de Quervain's tenosynovitis)

   - tenderness in anatomical snuff box (scaphoid injury)

   - tenderness distal to head of ulna for extensor carpi ulnaris tendonitis

→ metacarpophalangeal joints (MCPJ) (both thumbs)

• flex MCPJ with proximal phalanx held between thumb & forefinger → rock MCPJ backwards & forwards

• normal joint – very little movement

• ligamentous laxity / subluxation – considerable movement

→ interphalangeal joints (proximal & distal)

• palpate for tenderness , swelling, osteophytes

  
  

→ palmar tendon crepitus

• palmar aspects of examiner's fingers placed against palm of patient's hands while he / she flexes and extends the MCPJs

• tenosynovitis – inflamed palmar tendons can be felt creaking in their thickened sheaths and nodules can be palpated

  
  

→ trigger finger

• same manoeuvre as for palmar tendon crepitus

• RA → thickening of a section of digital flexor tendon is such that it tends to jam when passing through a narrowed part of its tendon sheath

• flexion of finger occurs freely up to a certain point where it sticks and cannot be extended (flexors are more powerful than extensors)

• application of greater force overcomes the resistance with a snap

→ carpal tunnel syndrome

• flex both wrists for 30 seconds (Phalen's wrist flexion test)

• if syndrome is present – paraesthesiae (pins & needles) precipitated in affected hand in distribution of median nerve

• more reliable than Tinel's sign (tapping over the flexor retinaculum which lies at the proximal part of the palm – produce similar paraesthesiae)

  
  

  → test active movements

  - wrist flexion and extension

  - compare both sides

  - test passive movements

  
  

  → thumb movements (hand flat, palm upwards & examiner's hand holds patient's fingers)

  - extension (stretch thumb outwards)

  - abduction (thumb pointed straight upwards)

  - adduction (asking patient to squeeze examiner's fingers)

  - opposition (get the patient to touch little finger with the thumb)

  *look for limitation of these movements and discomfort caused by them

  
  

  → metacarpophalangeal & interphalangeal movements

  - ask patient to make a fist then to straighten out the fingers

  - test fingers individually

  - if active flexion of one or more fingers is reduced → test superficialis and profundus flexor tendons

  - hold proximal finger joint extended and istruct patient to bend it

  - distal fingertip will flex if flexor profundus is intact

  - hold other fingers extended (to inactivate the profundus) and check finger flexion (inability – supercialis unable to work)

  
  

  3. FUNCTION

  - grip strength

  - getting patient to squeeze two of the examiner's fingers

  - key grip

  - hold key between the pulps of thumb and forefinger

  - ask patient to hold his grip tightly and try to open up his or her fingers

  - opposition strength

  - patient opposes thumb and individual fingers

  - difficulty by which these can be forced apart is assessed

  - practical test

  - ask patient to undo a button / write a pen

  - completed by formally assessing for neurological changes

  
  

  Videos

  http://www.youtube.com/watch?v=ysWOHe4dfpI

  OR

  http://www.youtube.com/watch?v=65mjCLGrGTE&p=53CC110348635B55&playnext=1&index=52

PCL 5- Carpal Tunnel Syndrome Investigation

Carpal Tunnel Investigations

An early diagnosis and appropriate treatment may aid a rapid return to normal function and avoid permanent damage to the median nerve.

Some doctor's feel that the clinical symptoms and the physical signs that they elicit are so classic of carpal tunnel syndrome they will offer the patient treatment on this basis

If there is any suggestion of any cause for the carpal tunnel syndrome this may be investigated.
1. Blood tests to exclude diabetes, thyroid problems, rheumatoid arthritis.
2. Plain x-rays can be obtained if there is a suggestion of an old bone abnormality.

The most common investigation for carpal tunnel syndrome:

Nerve conduction studies/ Electroneurography (ENG)

These are electro-diagnostic tests. In this investigation small electrodes are placed on the hand, wrist and tips of fingers. Small electrical current shocks are then applied to the electrodes and the speed in which the nerve travels through the carpal tunnel can be recorded. This can be compared with the opposite side or if a patient has symptoms in both sides, can be compared with a large database of normal individuals that is stored centrally

85% sensitivity and specificity greater than 95% for diagnosing CTS.

Electromyography (EMG)

Very occasionally further tests can be performed inserting tiny needles into the muscles of the base of the thumb to assess muscle damage. However this is rarely undertaken for a classic carpal tunnel syndrome.

Useful in some cases but is not as sensitive as ENG

Ultrasonography
This is being used increasingly as a confirmatory test. Enthusiasts cite its wide availability, lower cost, noninvasiveness, and shorter examination time than electrophysiological studies. Ultrasound views of the median nerve show widening at the inlet of the carpal tunnel or flattening along the length of the tunnel

MRI scan- this can be used as an alternative to ultrasonography and when electrophysiological studies are ambiguous.7

These are useful in patients whose clinical features yield a high index of suspicion for carpal tunnel syndrome (CTS) but who fail to respond to first-line treatment.9
There is increasing evidence that nerve conduction studies performed before treatment can give a guide as to future outcomes of further surgery if initial surgery has not been successful.

PCL5- Signs and Symptoms of Carpal Tunnel Syndrome

Signs and Symptoms

- Pain, Numbness and tingling of the palmar surface of any of the five digits, except for the little finger.

- Sensations are often more pronounced at night and can awaken people from sleep- Due to flexed-wrist sleeping position and/or fluid accumulating around the wrist and hand while lying flat.

- May also experience pain in the elbow or shoulder, as fibers of the median nerve originate from the spinal cord in the neck and travel through the shoulder and elbow areas.

- Repetitive use activities involving the hands often initiate or worsen the symptoms.

- As the disease progresses, patients can develop a burning sensation, and/or cramping and weakness of the hand- Decreased grip strength can lead to frequent dropping of objects from the hand.

- Chronic carpal tunnel syndrome can also lead to atrophy of the hand muscles, particularly those near the base of the thumb in the palm of the hand. (Thenar muscles)

Zaharah's Pin and Needles ! = |

Zaharah’s Pins and Needles

- Writer
- Feelings pins and needles in her right hand ( except little finger)
- Put on 20kg’s
- Spoke to her sister about it
- Happens at night
- Feelings goes away when she shakes her hands
- Median Nerve ?
- Neuropathic Pain

Risk Factors
- Typing a lot recently
- Some Carpal Tunnel ( anatomical variation )
- Injury in the wrist
- Fluid retention during pregnancy ( cardiac output to be increased )
- Rheumatoid Arthritis
- Hypothyroidism
- Lack of growth hormone



Learning Issues
- fluid balance? Where is the fluid? - Revathy
- Why fluid retention in the pre-menstrual phase, menopausal women. Revathy
- What is carpal tunnel syndrome? Pathophysiology - Gurki
- Anatomy of the wrist , retinaculum - Dev and Deena
- Signs and Symptoms - Amlah
- Causes and Risk factors? - Jon
- Epidemiology - Rezza
- Differential Diagnosis - Rezza
- Investigations - Teh
- Treatment and management – Jin Li
- Prognosis - Jon
- Median Nerve/ Ulnar Nerve function (motor and sensory ) - Nicole
- Movements possible at the joints ( condyloid and saddle thumbs mainly , affected by
carpal tunnel syndrome? ) - Valerie and Lincoln
- Ulnar Nerve “Syndrome” – Sharvin
- Physical Examination – Charlene !

PCL 4- Differential Diagonsis(Tendonitis,Bursitis and Impingement Syndrome)

Hey ppl!
Sorry i posted it up so late!!
i was held up with stuff over the weekend :/ sorry again :)
see u guys soon! :)

Tendonitis

The tendons become inflamed and the action of pulling the muscle becomes irritating. If the normal smooth gliding motion of your tendon is impaired, the tendon will become inflamed and movement will become painful. This is called tendonitis, and literally means inflammation of the tendon.

Tendonitis can occur in any tendon in the body, but tends to occur in one of a small handful of the hundreds of tendons scattered throughout our body.

Types of Tendonitis

Wrist Tendonitis

· common problem that can cause pain and swelling around the wrist

· due to inflammation of the tendon sheath

· Wrist tendonitis usually does not require surgery.

Achilles Tendonitis

· Causes pain and swelling in the back of the heel.

·

Posterior Tibial Tendonitis

· Occurring near Achilles tendonitis, but is less common,

· If left untreated, posterior tibial tendonitis can result in a flat foot.

Patellar Tendonitis.

· Inflammation of the patellar tendon.

· Treatment of patellar tendonitis usually consists of rest and anti-inflammatory medication.

Rotator Cuff Tendonitis

· Inflammation of the tendons of the shoulder muscles can occur in sports requiring the arm to be moved over the head repeatedly.

· Chronic inflammation or injury can cause the tendons of the rotator cuff to tear.

· Pain associated with arm movement

· Pain in the shoulder at night, especially when lying on the affected shoulder

· Weakness with raising the arm above the head, or pain with overhead activities

Lateral Epicondylitis

· Type of tendonitis that causes pain over the outside of the elbow.

· Can occur in people who perform other sports or repetitive activities of the wrist and elbow.

Bursitis

Bursitis is inflammation of a bursa. A bursa is a tiny fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body.

A bursa can become inflamed from injury, infection (rare in the shoulder), or due to an underlying rheumatic condition.

Bursitis is identified by

· localized pain

· swelling

· tenderness

· Pain with motion of the tissues in the affected area.

Impingement Syndrome

- caused by the tendons of the rotator cuff becoming 'impinged' as they pass through a narrow bony space called the Subacromial space.

- With repetitive pinching, the tendon(s) become irritated and inflamed.

- can lead to thickening of the tendon which may cause further problems because there is very little free space, so as the tendons become larger, they are impinged further by the structures of the shoulder joint and the muscles themselves.

- Impingement Syndrome in itself is not a diagnosis, it is a clinical sign.

- If left untreated, shoulder impingements can result in a rotator cuff tear.

- Impingement Syndrome could be classified as external (either primary or secondary) or internal.

Symptoms

• Shoulder pain comes on gradually over a long period.

· Pain at the front and/or side of the shoulder joint with overhead activity

· Pain at the back and/or front of the shoulder when the arm is held out to the side (abducted) and turned outwards (external rotation)

· Pain when lifting the arm above 90 degrees

· Pain on internal (medial rotation) movements

RISK FACTORS.

* Age: 30 and over
* Always using the arm in an overhead position or throwing motion, as in:
o Tennis or other racquet sports
o Swimming
o Baseball
o Jobs (eg, overhead assembly work, butchering, or using an overhead pressing machine)
* Pre-existing degeneration.

* some medications

* collagen diseases (eg Marfan’s)

* genetics (eg blood group ‘O’)

* medical conditions such as rheumatoid arthritis or diabetes mellitus.


SIGNS AND SYMPTOMS.


Symptoms develop gradually over time and pain slowly increases with use.

* Pain (a dull ache) in the shoulder and upper arm
* Pain at night, especially when sleeping on the injured side
* Pain when trying to reach for a back zipper or pocket
* Pain with overhead use of the arm
* Shoulder weakness, usually due to pain with effort
* Shoulder stiffness with some loss of motion

Regardless of the site of the tendinopathy, the history is likely to be similar, and can usually be plotted against increased loading of the tendon. Symptoms develop gradually. Many clients will admit to a recent change in training volume and/or intensity. Pain and stiffness are often worse first thing in the morning, particularly after a hard training session the previous day, and will improve once they ‘get moving’. Pain at the onset of activity that settles during performance and worsens again afterwards is typical. As the condition intensifies, clients may report pain throughout training and competition and, in the worst cases, during rest. Often functional exercises are required to elicit pain

PCL 4- Surgical repair of rotator cuff tendinopathy

SURGICAL REPAIR OF ROTATOR CUFF TEARS

The need to surgically repair a torn rotator cuff depends upon your age, activity level, and the severity of your tear.

- Surgical repair is usually recommended for people with a complete rotator cuff tear, especially if the person is young and/or active. Surgery is usually recommended soon after the injury, if possible, to prevent the tendon and muscle from shrinking.

- Conservative treatment is usually recommended first if one does not have a complete rotator cuff tear or are older, less active, or if there is minimal pain. Conservative treatments (eg, stretching and strengthening exercises, injection of a steroid) are usually recommended first.

- Surgery may be recommended if patient does not improve after stretching and strengthening exercises and have persistent pain, limited strength, have arthritis or spurs that cause pain and interferes with rehabilitation, or if a new injury occurs and the patient has a previous rotator cuff injury.


Surgery...

Surgery may be used to treat a rotator cuff disorder if the injury is very severe or if nonsurgical treatment has failed to improve shoulder strength and movement sufficiently. Subacromial smoothing involves shaving bone or removing growths on the upper point of the shoulder blade (acromion). It removes scar tissue and damaged tendon and bursa from the joint. The surgeon may also remove small amounts of bone from the underside of the acromion and the acromioclavicular joint (acromioplasty). The goal is to take away roughness while keeping as much of the normal supporting structures as possible. This surgery creates more room in the subacromial space so that the rotator cuff tendon is not pinched or irritated and can glide smoothly beneath the acromion.

There are several ways to repair the rotator cuff, including open and arthroscopic techniques.
• Open-shoulder surgery involves making a larger incision in the shoulder, to open it and directly view the repair.
• Arthroscopy uses a thin viewing scope called an arthroscope that is inserted into a joint through a small incision in the skin. Then the surgeon will remove loose fragments of tendon, bursa, and other debris from the shoulder (debridement). Additional instruments are then arthroscopically inserted to shave the bone or remove growths.


What Is Done In Rotator Cuff Surgery?

During rotator cuff surgery, the patient is put in a half-sitting position, with the head supported. Most operations are performed under general anesthesia, where the patient is asleep. Sometimes a regional (or local) anesthetic is used to block the nerves leading to the arm. In that case, the patient is conscious but cannot feel pain. Usually a sedative is also given, putting the patient in a conscious but dreamy state.
Rotator cuff surgery usually takes one to two hours.

Types of procedures include:
• Impingement surgery
• Rotator cuff repair
• Arthroscopic surgery


Impingement Surgery (Also Called Acromioplasty Or Subacromial Decompression)

If the space between the upper arm and the part of the shoulder blade known as the acromion is too narrow, the rotator cuff cannot move freely. Rotator cuff tendons get pinched between the two bones, gradually damaging the rotator cuff.
To resolve this problem, the surgeon shaves a small portion of bone from the underside of the acromion, giving the tendons more room to move and preventing them from being pinched. The surgeon also removes any bone spurs and either excises or removes swollen or irritated bursa.
Impingement surgery is sometimes performed to relieve severe, chronic tendinitis that does not respond to nonsurgical treatment. Impingement surgery is also done as part of most rotator cuff repair surgeries.

Rotator Cuff Repair

In order to repair a torn rotator cuff, the surgeon reattaches the damaged tendon (or tendons) to the upper arm (humerus). (Some rotator cuff injuries involve more than one torn tendon.)

This surgery involves several key steps:
• In order to gain access to the injured rotator cuff, the surgeon makes a two- to three-inch incision in the shoulder, then cuts through the deltoid muscle.
• The surgeon removes any scar tissue that has built up on the tendon.
• The surgeon carves a small trough at the top of the upper arm, then drills small holes through the bone.
• Finally, the surgeon sews the tendon to the bone, with the sutures going through the tiny holes in the upper arm. (Sometimes a surgeon will use permanent anchors to attach the tendon to bone.)
During this operation, the surgeon also removes bone spurs and releases any ligaments that are pressing on the tendon. If a bursa is inflamed, the surgeon excises or removes it. The surgeon also may remove a small portion of the acromion to make sure the repaired rotator cuff has enough room to move.
Afterwards, the patient's arm is placed in a sling. With time, healing occurs, as scar tissue connects the tendon to bone. Because tendons receive such poor blood supply, this is a slow process.

Arthroscopic Surgery

Arthroscopic surgery is a technique for performing an operation using pen-shaped instruments with a miniature video camera attached to the end.
• The surgeon makes a small incision in the shoulder about the size of a buttonhole.
• He or she then inserts the thin tube that contains the tiny video camera and surgical instruments.
• The surgeon performs the operation with these remotely controlled instruments while watching on a video screen.
Because arthroscopic surgery requires only limited surgical access, the incision is much smaller than is necessary for open surgery, resulting in fewer risks. The patient's recovery time is also shorter.
However, because repairing a torn rotator cuff can be a complicated procedure, it is often performed as an open procedure. However, arthroscopic repairs are becoming more common, especially for small size tears.


After Surgery...

You may go home a few hours after waking up from anesthesia. In some cases, the doctor may suggest that you stay overnight for help with pain management and for observation.

Discomfort after surgery may be relieved by:
• Applying ice to the surgical site 3 times a day.
• Taking pain medicines as prescribed.
• Immobilizing and protecting your shoulder by wearing a sling as directed. Your health professional will advise you whether you need a sling after surgery. Some health professionals do not recommend this, because the shoulder joint may become stiff.
With a doctor's approval, you may be able to return to light work within a few days after surgery even if you are using a sling.

Risks

In addition to the general risks of surgery, such as blood loss or problems related to anesthesia, complications of subacromial smoothing surgery for rotator cuff disorders may include:
• Persistent pain.
• Nerve damage.
• Stiffness.
• Infection.

Benefits of Arthroscopic Surgery

The benefits of needing only arthroscopic surgery for subacromial smoothing rather than open surgery include:
• A shorter recovery time.
• A shorter hospital stay, which may cost less.
• Keeping the deltoid muscle attached, which aids rehabilitation.
• The surgeon's ability to inspect and debride both surfaces of the rotator cuff, rather than just the outside.
• Detecting other damage to the inside of the shoulder joint.

After Surgery

Physical therapy after surgery is crucial for a successful recovery. A typical rehabilitation schedule includes the following:
• Range-of-motion exercises may start the day after subacromial smoothing surgery.
• Strength training may begin several weeks after arthroscopic surgery.
When normal shoulder strength and range of motion return, usually after about 6 to 8 weeks, one can gradually resume playing sports.


Arthroscopic Surgery vs Traditional "Open" Surgery?

Open surgery, a procedure using larger incisions and enabling the surgeon to look inside the joint, may be better for certain procedures under certain circumstances.
Arthroscopic surgery has some advantages--smaller incisions, less tissue damage--but these are usually not helpful if the overall procedure cannot be performed as well

Return to activities

After surgical repair, most people require 6 months of rehabilitation before strength and shoulder function return to normal. Post-surgical rehabilitation is necessary and use of the shoulder must be limited. Immediately after surgery, you will be allowed to use the affected arm with your elbow at your side for eating, using the keyboard, using the telephone, and driving. Above-the-shoulder activities are not usually allowed for three months after surgery.
Sporting activities can be gradually restarted, including golfing at four months, light weight lifting at four months, swimming at five months, and throwing and tennis playing at five to six months.


Rotator Cuff Tendinopathy and Swimming...

Swimming is rough on the rotator cuff, especially if the form is not good. Most triathletes do not have good swimming form.

So the athlete is encouraged to have a coach video tape their swimming stroke and make sure shoulder movements during swimming are showing proper form.

Rotator cuff exercises during healing are generally not done until after a few Prolotherapy sessions. If caught early only a few session of Prolotherapy are needed. If the problem has been going on a long time then up to six sessions may be needed. Soft tissue oral nutritional supplements again are ordered. The athlete can of course cycle and run during the Prolotherapy healing. Often times, the triathlete can do some swimming drills as these do not cause the pain. If a drill reproduced the pain, this then is not practiced.