Hand Pain

Question 1

_______ known as ‘effort thrombosis’, causes swelling in the arm with pain high in the axilla

Answer 1

Subclavian or axillary vein thrombosis,

Question 2

The commonest cause of the thoracic outlet
syndrome is sagging musculature related to ageing, obesity, and heavy breasts and arms, aptly described by Swift and Nichols as ‘the _______

Answer 2

droopy shoulder syndrome’

Question 3

Arm claudication is also rare. It can occur with

arterial obstruction due to occlusion of the _________

Answer 3

proximal left subclavian artery or the innominate artery.

Question 4

Sleep DO associated with hand pain

• thoracic outlet syndrome—______
• CTS—______
• cervical spondylosis—wakes the patient with pain and stiffness that persists well into the day

Answer 4

patients cannot fall asleep

patients wake in the middle of the night

Question 5

Arm pain in children

The main concerns with children are the _______

Answer 5

effects of trauma, especially around the elbow

Question 6

This typically occurs in children under 8 years of age, usually at 2–5 years, when an adult applies sudden traction to the child’s extended and pronated arm

Answer 6

Pulled elbow

Question 7

Signs of pulled elbow

Answer 7

• The elbow is flexed slightly (any flexion will be strenuously resisted).
• The forearm is pronated or held in mid-position.
• The arm is tender around the elbow (without
bruising or deformity).

Question 8

Types of tennis elbow

‘backhand’ tennis elbow, or_______, and ‘forehand’ tennis elbow, or _________ which is also known as golfer’s or pitcher’s elbo

Answer 8

lateral epicondylitis

medial epicondylitis,

Question 9

In ‘forehand’ tennis elbow, or golfer’s elbow, the lesion is the _________

Answer 9

common flexor tendon at the medial epicondyle

Question 10

The pain is felt on the inner side of the
elbow and does not radiate far. The main signs are localised tenderness to palpation and pain on resisted
flexion of the wrist.

Answer 10

Medial tennis elbow (medial

epicondylitis

Question 11

Difference in the treatment of medial and lateral epicondylitis

Answer 11

The treatment is similar to that for lateral

epicondylitis except that in a dumbbell exercise program that palm must face upwards.

Question 12

What to avoid in lateral and medial epicondylitis

Answer 12

During a game they should avoid elbow bending and ‘wristy’ shots

Question 13

Acute olecranon bursitis with redness and warmth can occur in
1
2
3

Answer 13

rheumatoid arthritis, gout, pseudogout,

haemorrhage and infection (sepsis). 13

Question 14

Chronic recurrent traumatic olecranon bursitis with a synovial effusion may require surgery but most cases can resolve with ___________

Answer 14

partial aspiration of the fluid and then injection of corticosteroid through the same needle.

Question 15

What syndrome?

Pain is often experienced in the belly of a muscle, such as the flexors and extensors, following unaccustomed use of the wrists and elbows.

There is pain on contraction and stretching of the muscles and
tenderness on palpation.

Answer 15

Overuse syndromes of forearm

muscles

Question 16

A positive ___________produces a tingling sensation (usually without pain) in the
distribution of the median nerve

Answer 16

Tinel sign

Question 17

What test?

• The patient approximates the dorsum of both hands, one to the other, with wrists maximally flexed and fingers pointing downwards.
• This position is held for 60 seconds

Answer 17

Phalen test

Question 18

The test that has the highest specificity of all basic clinical tests is______________, but it has low sensitivity for CTS.

Answer 18

two point discrimination

Question 19

Sx management of CTS

Answer 19

Surgical release (flexor retinaculotomy) is necessary for patients with sensory or motor deficits and those
with recalcitrant CTS

Question 20

In the fingers the common work-induced condition is stenosing flexor tenosynovitis, also known as

Answer 20

trigger thumb and finger

Question 21

Associations of trigger finger

Answer 21

It is associated with type 1 diabetes,

rheumatoid arthritis, gout, hypothyroidism and amyloidosis

Question 22

Tx gof trigger finger

Answer 22

Although surgery is simple and effective, treatment by injection is often very successful

Question 23

Where to inject in pts with trigger finger?

Answer 23

The injection is made under the tendon sheath and not into the
tendon or its nodular swelling.

Question 24

This contracture, which causes discomfort and dysfunction rather than pain, is fibrous hyperplasia of palmar fascia leading to nodular formation and contracture over the fourth and fifth fingers in particular

Answer 24

Dupuytren contracture

Question 25

Associations of Dupuytren

Answer 25

It is associated with smoking, alcoholism, liver cirrhosis, COPD, diabetes and heavy manual labour.

Question 26

Triad for Dupuytren

Answer 26

* Tenderness to palpation over and just proximal to radial styloid * Firm tender localised swelling in area of radial styloid (may be mistaken for exostosis) * Positive Finkelstein sign

Question 27

pathognomonic test for Dupuytren

Answer 27

Positive Finkelstein sign

Question 28

It is an overload injury caused by excessive strain on the extensor muscles of the forearm resulting from wrist extension

Answer 28

lateral tennis elbow

Question 29

Physical signs of lateral tennis elbow

Answer 29

1 localised tenderness to palpation over the anterior aspect of the lateral epicondyle 2 pain on passive stretching at the wrist with the elbow held in extension and the forearm prone 3 pain on resisted extension of the wrist with the elbow held in extension and the forearm prone

Question 30

_______ and _______exercises for the forearm muscles represent the best management for tennis elbow.

Answer 30

Stretching and strengthening

Question 31

______may occur in other extensor compartments of the wrist and hand with unusual repetitive stressful actions, such as power drills jamming, and in conveyor quality control where an object is picked up with the forearm prone, supinating to examine it and pronating to replace it

Answer 31

Tendonitis

Question 32

Tx of Tendonitis

Answer 32

Treatment is rest from the provoking activity, splintage and tendon sheath injection with longacting corticosteroid in a manner similar to that described for de Quervain tenosynovitis.

Question 33

_______ is caused by a bursitis that develops at the site where the extensor pollicis brevis and abductor pollicis longus tendons cross over the extensor carpi radialis tendons

Answer 33

Intersection syndrome

Question 34

Where is the tenderness in intersection syndrome?

Answer 34

palpation tenderness is found dorsally on the radial side with swelling and crepitus

Question 35

Look for a _________________ | (which causes wrist instability) with tenderness 2 cm distal to the tubercle on the radial side of the lunate.

Answer 35

scapholunate ligament tear

Question 36

_______ particularly of the scaphoid, can occur following failure to recognise a fracture

Answer 36

Ischaemic necrosis,

Question 37

Tenderness in the ‘anatomical snuff box’ following trauma should be treated as a ________until repeated X-rays prove negative

Answer 37

scaphoid

Question 38

In children, chronic pain in the | region of the lunate suggests avascular necrosis— _________, presenting with dorsal wrist pain

Answer 38

Kienböck disease

Question 39

usual location of ganglionic tumors

Answer 39

The vast majority arise from the dorsal scapholunate ligament.

Question 40

The basic feature of _______which is a vasospastic disorder, is sequential discolouration of the digits from pallor to cyanosis to rubor upon exposure to cold and other factors

Answer 40

Raynaud phenomenon,

Question 41

Aggravating factors for Raynaud

Answer 41

* Smoking * Cold, wet weather * Stress or emotional upset

Question 42

Tx of severe Raynaid

Answer 42

topical glyceryl trinitrate 2% ointment—applied to the base of the affected fingers two to four times daily or applied over the radial artery or dorsum of the hand

Question 43

Tx of severe Raynaid

Answer 43

``` amlodipine 5–20 mg (o) once daily or nifedipine SR 30–60 mg (o) once daily or diltiazem SR 180–240 mg (o) once daily ```

Question 44

This condition is characterised by erythema (redness), a burning sensation and swelling of the hands (and feet) after exposure to heat and exercise

Answer 44

Erythromelalgia (erythermalgia)

Question 45

``` Treatment of primary erythromelalgia includes trials of 1 2 3 4 ```

Answer 45

aspirin, phenoxybenzamine (Dibenyline), methysergide or sympathectomy.

Question 46

This unusual syndrome involves the sudden onset of pain and cyanosis of the ventral aspect of the digit initially, and then the entire digit

Answer 46

Acute blue fingers syndrome | in women

Question 47

cause of Acute blue fingers syndrome | in women

Answer 47

The cause is probably spontaneous rupture of a vein at the base of the finger

Question 48

Precautions in Chilblains (perniosis

Answer 48

* Think Raynaud phenomenon * Protect from trauma and secondary infection * Do not rub or massage injured tissues * Do not apply heat or ice

Question 49

Tx of Chilblains (perniosis

Answer 49

Apply glyceryl trinitrate vasodilator spray or | ointment or patch (use plastic gloves and wash hands for ointment)

Question 50

* Throbbing, burning pain, worse at night * Paraesthesia * Initial: red, swollen hand; warm, dry skin * Later: cold, cyanosed and mottled, moist skin; shiny and stiff finger

Answer 50

Regional pain syndrome

Question 51

______ is avascular necrosis of the carpal lunate bone which may fragment and collapse, eventually leading to osteoarthritis of the wrist

Answer 51

Kienböck disease

Question 52

Osteoarthritis commonly involves the ____ and _______

Answer 52

``` interphalangeal joints of the fingers (especially the DIP joints) and the carpometacarpal (CMC) joint of the thumb ```

Question 53

Osteoarthritis of the thumb This is very common, especially in women. Pain is felt at the _____, and tenderness on palpation of the______ is typical

Answer 53

base of the thumb CMC joint

Question 54

``` In rheumatoid arthritis the________ are often spared (only about 30% involved) but the metacarpophalangeal and proximal interphalangeal joints and wrist joints are generally affected symmetrically and bilaterally ```

Answer 54

DIP joints

Question 55

More frequently see in osteoarthritic joints | of the hand (especially DIP joints) in elderly people taking diuretics. This clinical feature is known as

Answer 55

nodular gout.

Question 56

What is the etiology infected wounds with superficial cellulitis or lymphangitis _________

Answer 56

( Streptococcus pyogenes )

Question 57

_______—this is a specific infection in one finger of fishermen or meat handlers, caused by Erysipelothrix insidiosa. There is a purplish erythema that gradually extends over days. It is rapidly cured by penicillin

Answer 57

erysipeloid

Question 58

tendon sheath infection (__________—this is a dangerous and painful infection that can cause synovial adhesions with severe residual finger stiffness

Answer 58

suppurative | tenosynovitis)

Question 59

aquarium’ or ‘swimming pool’ granuloma—nonpainful infection of the tendon sheath due to ____________following a minor cut of the finger

Answer 59

Mycobacterium marinum

Question 60

__________(gardener’s arm)—a chronic fungal infection from contaminated spikes of wood or rose thorns presenting as hard nontender nodules in the skin of the hand and extending along the lymphatics of the arm

Answer 60

sporotrichosis

Question 61

Mx of Streptococcus pyogenes (mild to moderate cellulitis, lymphangitis

Answer 61

procaine penicillin 1.5 g IM daily, 3 to 7 days or phenoxymethylpenicillin 500 mg (o) 6 hourly for 10 days

Question 62

Mx of severe Streptococcus pyogenes

Answer 62

If severe to cover both S. pyogenes and | Staphylococcus aureus infection (suspected or proven