Musculoskeletal
Question 151 of 180
A 50 year old woman presents to the Emergency Department complaining of worsening intermittent pain and tingling in her right thumb which is waking her up at night. The symptoms are worse when driving. She has also noted that her right thumb and index finger feel weak and she has difficulty doing up buttons. What is the most likely diagnosis?
Answer:
Typical symptoms of carpal tunnel syndrome include intermittent tingling, numbness or altered sensation and burning or pain in the distribution of the median nerve (the thumb, index finger, middle finger, and radial half of the ring finger). Symptoms are often worse at night and can disrupt sleep. Symptoms may affect one or both hands. Pain in the hand may radiate up the arm into the wrist or as far as the shoulder. The person may complain of loss of grip strength, clumsiness and reduced manual dexterity for example when doing up buttons.Upper Limb Pain and Swelling
Musculoskeletal
Last Updated: 12th February 2021
Wrist
Carpal tunnel syndrome
- Carpal tunnel syndrome (CTS) is a collection of symptoms and signs caused by compression of the median nerve in the carpal tunnel at the wrist. The carpal tunnel is an anatomical compartment bounded on three sides by carpal bones and on the palmar side by the transverse carpal ligament. It contains the median nerve and the flexor tendons. Reduction in the dimensions of the carpal tunnel or increase in the volume of its contents produce an intermittent or sustained high pressure in the tunnel which causes ischaemia of the median nerve and impairs nerve conduction leading to paraesthesia, pain and decreased function of the nerve. If pressure on the nerve is continued this can lead to segmental demyelination with more constant and severe symptoms which are in some cases associated with muscle weakness and wasting. Nerve dysfunction may become irreversible if axonal injury secondary to prolonged ischaemia occurs.
- Factors that have strong evidence supporting an increased risk of CTS include activities with high hand/wrist repetition rate and obesity. Other risk factors include: overuse of hand and wrist, peri-menopause, osteoarthritis, rheumatoid arthritis, hypothyroidism, diabetes mellitus, acromegaly, wrist trauma and space-occupying lesions such as osteophytes and ganglion cysts.
- Typical symptoms include intermittent tingling, numbness or altered sensation and burning or pain in the distribution of the median nerve (the thumb, index finger, middle finger, and radial half of the ring finger). Symptoms are often worse at night and can disrupt sleep. Symptoms may affect one or both hands. Pain in the hand may radiate up the arm into the wrist or as far as the shoulder. The person may complain of loss of grip strength, clumsiness and reduced manual dexterity for example when doing up buttons.
- Signs of CTS include:
- Sensory loss in median nerve distribution
- Weakness or atrophy of thenar muscles
- Reduced strength of thumb abduction
- Dry skin of the thumb, index, and middle fingers
- Positive Phalen’s test (flexing the wrist for 60 seconds causes pain or paraesthesia in the median nerve distribution)
- Positive Tinel’s sign (tapping lightly over the median nerve at the wrist causes pain or paraesthesia in the median nerve distribution)
- Positive carpal tunnel compression test (pressure over the proximal edge of the carpal ligament (proximal wrist crease) with thumbs cause paraesthesia to develop or increase in the median nerve distribution)
- Management may include:
- Avoidance/modification of exacerbating activities
- Wrist splinting in a neutral position
- Corticosteroid injection
- Surgical decompression
Rupture of wrist/ hand tendons
- Rupture of tendons may occur without penetrating trauma.
- The most common rupture involves the extensor pollicis longus a few weeks after a (usually undisplaced) fracture of the distal radius. Rupture of other extensor (and occasionally flexor) tendons occurs in association with OA, rheumatoid arthritis (RA), scaphoid non- union, CRF, and SLE.
- Refer to a hand surgeon.
Radial tenosynovitis (‘intersection syndrome’)
- This typically follows unaccustomed repetitive activity such as gardening, DIY, or decorating. Over hours to days, a painful fusiform swelling develops over the radial aspect of the distal forearm.
- Movement of the wrist produces pain and palpable (occasionally audible) crepitus.
- Immobilise in a simple adjustable wrist splint, and unless contraindicated, prescribe an NSAID for 7– 10 days. After this, allow gradual mobilisation of the wrist and educate about eliminating the cause. Immobilise severe cases in a forearm POP for 2 weeks before beginning mobilisation.
De Quervain's tenosynovitis
- Affects the tendon sheaths of the abductor pollicis longus and extensor pollicis brevis.
- Pain, swelling, and crepitus occur over the lateral (dorsoradial) aspect of the radial styloid. Symptoms can be reproduced by thumb or wrist movement.
- Finkelstein described grasping the patient’s thumb and rapidly ‘abducting the hand ulnarward’, but probably more useful is pain on ulnar movement of the wrist with the thumb clenched in a fist.
- Treat with an NSAID and splintage for 7– 10 days. A removable fabric wrist splint (including the thumb) may suffice, but consider a POP for severe pain.
- Persistent symptoms may respond to steroid injection of the tendon sheath using an aseptic technique.
Elbow
Lateral epicondylitis
- This is commonly called ‘tennis elbow’. It follows repetitive or excessive stress to the origin of the forearm and hand extensor muscles at the lateral epicondyle. It can occur spontaneously but usually follows repetitive lifting, pulling, or sports (e.g. as a result of an incorrect backhand technique in tennis).
- Inflammation, oedema, and microtears occur within the extensor insertion.
- Look for localised swelling, warmth, or tenderness over the lateral epicondyle and immediately distal to it.
- Examine movements— dorsiflexion of the pronated wrist against resistance will reproduce symptoms.
- X- ray if the problem follows an acute injury. Refer to the orthopaedic surgeon if there is an avulsion fracture.
- Treat with analgesia (preferably an NSAID) and ice application. Support the arm in a broad arm sling and advise rest, followed by progressive exercise and avoidance of aggravating movements. If symptoms are recurrent or prolonged, refer as steroid injection, forearm clasp, physiotherapy, and occasionally surgery may help. Current evidence suggests that corticosteroid injection may provide short- term relief, but long- term benefit remains unproven.
Medial epicondylitis
- Often called ‘golfer’s elbow’, this condition has a similar pathophysiology to lateral epicondylitis— it is frequently seen in racket sports and golf.
- Examine for localised tenderness and swelling over the forearm flexor insertion at the medial epicondyle. Flexion of the supinated wrist against resistance will reproduce symptoms. There may be decreased grip strength and many patients have some symptoms of associated ulnar neuritis.
- Treat as for lateral epicondylitis.
Olecranon bursitis
- Inflammation, swelling, and pain in the olecranon bursa may follow minor trauma or occur spontaneously. Other causes include bacterial infection (sometimes following penetrating injury) and gout.
- Elbow movements are usually not limited. Look for overlying cellulitis, wounds, and systemic symptoms, and check for fever (these suggest infection).
- Consider aspiration of the bursa under aseptic conditions— immediate microscopy for crystals or bacteria may confirm gout or bacterial infection. Aspirate using a small needle at a shallow angle, and try to aspirate the bursa completely.
- Non-infective bursitis: Provide analgesia and NSAID, and rest the arm in a broad arm sling. Consider compression and intermittent ice application. Symptoms should resolve with rest over a period of weeks. Rarely, persistent symptoms require surgical excision of the olecranon bursa.
- Gout bursitis: Treat as for non- infective bursitis. Arrange follow- up through the patient’s GP.
- Infective bursitis: If there is evidence of an underlying infection, treat with rest and NSAID and start antibiotics (e.g. flucloxacillin or clarithromycin). Occasionally, infection requires referral to the orthopaedic surgeon for surgical drainage.
- Olecranon bursa haematoma: A history of blunt trauma to the olecranon, followed rapidly by ‘golf ball- sized’ swelling over the olecranon, but with a full range of elbow movement (and no evidence of fracture), implies a haematoma in the olecranon bursa. Treat conservatively— attempts at drainage may result in secondary infection.
Nerve compression
- Ulnar nerve entrapment at the elbow (‘cubital tunnel syndrome’) is the second most common upper limb nerve entrapment (median nerve compression in carpal tunnel syndrome is the most common). Symptoms include flexor digitorum profundus weakness, numbness in ulnar half of ring and little fingers and paresthesias. Refer these chronic conditions back to the GP.
- Acute radial nerve palsy above the elbow presents with sudden wrist drop, following a history of compression (e.g. crutch use, falling asleep with the arm over the back of a chair). The underlying injury is usually a neurapraxia, which has the potential to recover completely, given time, with conservative measures. It is crucial to ensure that flexion contractures do not develop in the meantime— provide a removable wrist splint; advise regular passive wrist exercises, and refer for physiotherapy and follow- up to ensure recovery.
Osteochondritis dissecans
- This can affect the elbow and cause locking of the elbow joint.
- X- rays may reveal a defect and/ or loose body.
- Refer to the orthopaedic team.
Arm
Injuries to the biceps and brachialis
- Inflammation of the biceps and/or brachialis at the site of attachment at the elbow can cause persistent symptoms— treat with rest and NSAID.
- The biceps brachii can rupture either at its long head in the bicipital groove or near the elbow insertion:
- Distal ruptures are sometimes treated conservatively, but some benefit from repair— arrange orthopaedic review to consider this.
- The long head of the biceps can rupture at its proximal insertion after lifting or pulling. This may follow little force (and with little pain) in the elderly. Look for the
ruptured biceps muscle as a characteristic abnormal shape and low biceps bulge above the elbow on attempted elbow flexion against resistance. Treat with initial analgesia and support in a sling, followed by later exercises. Surgical repair is rarely indicated.
Shoulder
The extreme mobility of the shoulder is at the expense of stability which relies heavily on the rotator cuff. The rotator cuff comprises the supraspinatus (initiates abduction), infraspinatus and teres minor (externally rotate), and subscapularis (internally rotates). The rotator cuff may be injured acutely or damaged from a chronic degenerative process (e.g. impingement syndromes or RA).
Impingement syndromes
- The acromion process may compress or ‘impinge’ on the underlying subacromial bursa and rotator cuff during repetitive or strenuous shoulder use. The supraspinatus and its tendon are most commonly affected.
- Minor impingement is associated with inflammation, pain, and loss of function and is reversible with treatment. Rotator cuff tendonitis is more chronic and can lead to degeneration or tearing of the cuff. Although rotator cuff tendonitis and degenerative tears usually occur in later life, acute tears can occur in younger patients.
- Examination of the shoulder:
- Examine both shoulders for comparison with the patient sitting relaxed.
- Look for deformity of the clavicle or sternoclavicular joint, AC joint deformity, wasting of the deltoid muscle (axillary nerve damage), a step in the deltoid contour, or a gap below the acromion (subluxation or dislocation).
- Feel for tenderness over the sternoclavicular joint, clavicle, AC joint, subacromial area, rotator cuff insertion, and biceps tendon insertion.
- Move the shoulder gently in all directions to test passive movements. Test the strength of active movements.
- Examine for crepitus on movement, restriction, pain (note any painful arc), and weakness of particular movements.
- Test sensation over the badge area (upper outer arm) supplied by the axillary nerve.
- Examine the cervical spine when shoulder examination does not reveal a cause for symptoms.
- In suspected impingement syndromes, consider
- Neer’s impingement test: fully abducting the straight arm will recreate symptoms.
- Hawkin’s impingement test: hold the arm at 90° abduction and 90° elbow flexion. Rotating the arm across the body will recreate symptoms.
- LA injection of 10 mL of 1% plain lidocaine into the subacromial bursa (approach just under acromion process from behind) should help the pain but will not affect the strength or range of movement, allowing assessment. Adding hydrocortisone, methylprednisolone, or triamcinolone to LA injection is useful for a first presentation of acute impingement. Note that symptoms may increase briefly after steroid injection. Repeated injection can precipitate tendon rupture.
Subacromial bursitis
- This is an early form of impingement in younger patients. It follows unaccustomed activity or exercise.
- Look for a painful arc of 60– 100° abduction, with dull, aching pain worse on activity.
- The differential diagnosis includes gout, sepsis, or RA.
- Treat with analgesia, NSAID, and ice. LA injection will improve pain and movement, and help confirm the diagnosis. Consider steroid injection if first presentation.
Rotator cuff tendonitis/ tendinopathy
- Usually a longer history and chronic pain (± sleep disturbance) in patients aged 25– 40y.
- Examine for tenderness and crepitus over humeral insertions of the rotator cuff and decreased active and passive shoulder movements.
- X- ray may show osteophytes or subacromial calcification.
- LA injection may decrease pain but usually does not increase the strength or range of movement. Treat as for subacromial bursitis. In more severe cases, consider formal physiotherapy and orthopaedic referral.
Calcific tendonitis
- A poorly understood process of calcium deposition and resorption within the rotator cuff tendon. Commoner in women. May be related to degenerative change or follow minor trauma. Most common site is within supraspinatus 1– 2 cm proximal to humeral insertion.
- Acute pain (occurs during periods of calcium resorption, granulation, and healing) often starts at rest, worsens on movement and at night.
- Examine for tenderness at the rotator cuff insertion. There may be crepitus, painful limitation of movement or a painful arc.
- The calcium deposits may be evident on X- ray.
- Most episodes spontaneously resolve in 1– 2 weeks. Treat with analgesia, NSAID, and ice. Immobilise briefly in a broad arm sling, but start gentle exercises once symptoms allow. Arrange orthopaedic follow-up— steroid injection and/or physiotherapy and, rarely, surgical treatment may be required.
Adhesive capsulitis
- A misleading term, since it is caused by generalised contracture of the shoulder capsule, not adhesions. Causes include immobilisation, injury, or diabetes.
- More common in women and rare in those <40y or >70y.
- Insidious onset results in diffuse, aching pain (worse at night) and restricted active and passive shoulder movements. The cuff is usually not tender.
- X- rays exclude posterior dislocation.
- Refer to orthopaedics for MUA, arthroscopy, and capsulotomy.
Other causes of shoulder pain
These include:
- referred pain from degenerative cervical spine
- C5/ 6 disc prolapse
- brachial plexus neuritis
- axillary vein thrombosis
- IHD
- suprascapular nerve compression
- Pancoast’s syndrome
- cervical rib
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
