Osteoarthritis + Carpal tunnel syndrome

Question 1

What is osteoarthritis?

Answer 1

Osteoarthritis is characterised by progressive loss of articular cartilage and remodelling of the underlying bone.

Question 2

Osteoarthritis has a multifactorial aetiology and can be primary (with no obvious cause) or secondary (due to trauma, infiltrative disease or connective tissue diseases).

What are the risk factors for primary osteoarthritis?

Answer 2

• Obesity
• Increasing age
• Female gender
• Manual labour occupation

Question 3

Which joints are most commonly affected by osteoarthritis?

Answer 3

• Small joints of the hands and feet
• Hips and knees

Question 4

Symptoms of osteoarthritis

Answer 4

Patients typically present with symptoms that are insidious, chronic, and gradually worsening. Often asymmetrical.

• Pain and stiffness in joints
  
  • worsened with activity, relieved by rest
  • stiffness lasts for <30 minutes in morning
• Prolonged OA results in deformity and reduced range of movement

Question 5

Osteoarthritis - on examination:

Answer 5

• Inspect for deformity
  
  • Bouchard nodes (swelling of PIPJs) or Heberden nodes (swelling of DIPJs) in the hands
  • Fixed flexion deformity or varus malalignment in the knees
• Feel for crepitus throughout the range of movement. Movement of the joint is generally reduced and painful.

Question 6

General differential diagnosis for osteoarthritis

Answer 6

• Inflammatory arthropathies (e.g. rheumatoid arthritis)
• Crystal arthropathies (e.g. gout or pseudogout)
• Septic arthritis
• Fractures
• Bursitis
• Malignancy (primary or metastatic)

Question 7

Differential diagnosis for osteoarthritis in the hand

Answer 7

• De Quervain’s tenosynovitis
• Rheumatoid arthritis
• Gout

Question 8

Differential diagnosis for osteoarthritis in the hip

Answer 8

• Trochanteric bursitis
• Radiculopathy
• Spinal stenosis
• Iliotibial band syndrome

Question 9

Differential diagnosis for osteoarthritis in the knee

Answer 9

• Referred hip pain
• Meniscal or ligament tears
• Chondromalacia patellae

Question 10

The classical radiological features of osteoarthritis are:

Answer 10

Loss of joint space

Osteophytes

Subchondral cysts

Subchondral sclerosis

Question 11

Conservative management of osteoarthritis

Answer 11

• Weight loss for patients who are overweight
• Strengthening and exercise
• Ice packs
• Joint support and physiotherapy

Question 12

Medical management of osteoarthritis

Answer 12

• Simple analgesia
• Topical NSAIDs
• Intra-articular steroid injections

Question 13

If conservative and medical interventions fail, then surgical intervention may be considered, especially if their joint symptoms have a substantial impact on their quality of life.

Surgical management choice will depend on the site affected. Options include:

Answer 13

• Osteotomy
• Arthrodesis (joint fusion)
• Arthroplasty

Question 14

What is carpal tunnel syndrome?

Answer 14

Carpal tunnel syndrome is a condition involving a compression of the median nerve within the carpal tunnel of the wrist, due to a raised pressure within this compartment.

Question 15

Risk factors for carpal tunnel syndrome

Answer 15

• Increasing age
• Female
• Pregnancy
• Obesity
• Previous injury to wrist

Question 16

Symptoms of carpal tunnel syndrome

Answer 16

Throughout the median nerve sensory distribution (lateral three digits):

• Pain
• Numbness
• Parasthesia

Symptoms are worse a night and can be temporarily relieved by hanging the affected arm over the side of the bed or shaking it back and forth.

Question 17

The palm is often spared in carpal tunnel syndrome, why is this?

Answer 17

The palmar cutaneous branch of the median nerve branches proximal to the flexor retinaculum and passes over the carpal tunnel.

Question 18

Carpal tunnel syndrome - on examination:

Answer 18

• Sensory symptoms can be reproduced by:
  
  • Percussing over the medical nerve (Tinel’s test)
  • Holding the wrists in full flexion for one minute (Phalen’s test)
• In the later stages:
  
  • Weakness of thumb abduction (due to denervation atrophy of the thenar muscles)
  • Wasting of the thenar eminence

Question 19

Conservative and medical management of carpal tunnel syndrome:

Answer 19

• Wrist splint (commonly worn at night, prevents wrist flexion)
• Physiotherapy
• Cortiocosteroid injections - administered directly into carpal tunnel to reduce swelling

Question 20

Surgical treatment of carpal tunnel syndrome is only undertaken in severely limiting cases where previous treatments have failed.

What does carpal tunnel surgery involve?

Answer 20

Carpal tunnel release surgery decompressed the carpal tunnel, involving cutting through the flexor retinaculum, reducing pressure of the median nerve.