Upper limb pain

Chapter 19 Upper limb pain



Case 19.1



1. Redness, swelling and pain are typical of inflammation and/or infection. What structure is likely to be infected?

Synovial flexor sheaths and surrounding soft tissue.


2. Will the infection spread quickly into the hand? Give reasons for your answer.

Not especially, as the synovial flexor sheath in the index finger is not continuous with the common synovial sheath in the hand itself. Refer to Figure 19.1.


3.
a If the infection had commenced in the thumb, what structure may have been rapidly infected?
image

Figure 19.1 Synovial sheaths of the hand


(Source: Drake R, Vogl A, Mitchell A. Gray’s Anatomy for Students [2nd edn]. Philadelphia: Churchill Livingstone; 2010: 760, Fig 7.98)


The common synovial sheath in the hand and then the wrist, due to the continuity of the sheath from the thumb. Refer to Figure 19.1.


b From which other digit would this happen?

Little finger.


4. What do the red streaks indicate?

Inflammation around lymphatic vessels — acute lymphangitis.


5. What are the lumps in the axilla?

Enlarged lymph nodes.


6. Describe the drainage of lymph from the index finger to the axilla.

See Figure 19.2.


image

Figure 19.2 Axillary group of lymph nodes (20–30)



Case 19.2



1. From the information given regarding the difficulties in function, name:
a the joints that may be involved

Radioulnar joints and the wrist joint.


b the movements that occur at these joints
• Radioulnar joints: pronation and supination.

• Wrist joint: flexion, extension, abduction and adduction of the hand.

2. Name the muscles attached to the lateral epicondyle. At which joints do they act?
• Supinator — proximal radio-ulnar joint.

• Anconeus — elbow joint.

• Extensor carpi radialis brevis (ECRB) — wrist and mid-carpal joints predominantly.

• Extensor digitorum (ED) — wrist, mid-carpal, metacarpophalangeal and interphalangeal joints of digits 2–5.

• Extensor digiti minimi (EDM) — wrist, mid-carpal, and metacarpophalangeal joints of digit 5.

• Extensor carpi ulnaris (ECU) — wrist and mid-carpal joints.

3. What is the most likely diagnosis?

Lateral epicondylitis (aka ‘tennis elbow’).


4. Describe how this disorder occurs.

Most commonly, this disorder results from excessive use of the wrist extensors or sustained power gripping. It often commences after a sudden increase in load.


5. Does this condition affect range of motion (ROM) at the elbow?

Generally not.


6. Is there a need for any imaging studies?

Not usually, although magnetic resonance imaging (MRI) or ultrasound may be useful if the diagnosis is uncertain.



Case 19.3



1. What do you observe in this photograph?
• Redness of the periphery of her palm and of the distal parts of her fingers.

• Swelling of her first metacarpophalangeal joint.

2. What is the name given to the redness on her hands? Name the causes of this sign.

Palmar erythema. Causes include:


• pregnancy

• use of the oral contraceptive pill

• rheumatoid arthritis

• hyperthyroidism

• chronic liver disease

• connective tissue disorders

• excessive heat, sunlight or cold.

3. Can you see any evidence in the photograph which would help you determine the cause of the redness in this particular individual?

Yes, the joint swelling. This would suggest that the cause of her palmar erythema is either rheumatoid arthritis or possibly a connective tissue disorder.


4. What other clinical features might she have or develop later?

If the diagnosis is rheumatoid arthritis:


• Onset was most likely insidious (although it may have been acute).

• She may have had transient arthralgia or myalgia prior to joint swelling.

• Spindle-shaped swellings of metacarpophalangeal and proximal interphalangeal joints are most common, and are described as ‘boggy’ in texture and tender to touch.

• Other joints that may be affected include: knees, wrists, elbows, ankles and cervical spine (this is the most commonly affected region of the spine with rheumatoid arthritis, however, it is a late manifestation of the disorder, and usually occurs in patients with advanced disease).

• Affected joints are painful and swollen; the overlying skin is warmer than normal.

• Muscle stiffness, atrophy and deformities often occur in later stages.

• The range of joint movements is restricted, and movement causes pain, especially at the extremes.

• Deformities include subluxation of joints, fixed flexion of digits, and medial deviation of the fingers (called ulnar deviation).

• Non-articular symptoms/signs include:
image appearance of ‘rheumatoid nodules’ (sub-cutaneous, hard swellings)

image leg ulcers

image fever

image tachycardia.

• There is a tendency for rheumatoid arthritis to become quiescent after remaining active for months or years. In most cases there is permanent impairment of joint function. In certain joints, especially in the knees, degenerative changes are often superimposed upon the previous rheumatoid condition, and lead to increasingly severe disability even though the original rheumatoid affection is no longer active.

Complications may include:


• Articular complications:
image ongoing synovitis of the upper cervical zygapophyseal joints produces loosening and destruction of the transverse ligaments with subsequent atlanto-axial subluxation

image zygapophyseal joint involvement leading to intersegmental instability and possible spinal cord compromise.

• Extra-articular complications:
image Pleural involvement is the most common. Pulmonary manifestations rarely compromises respiratory status. Bronchial disease is also common. Interstitial lung disease is seen more frequently in men. Symptoms of this condition include dyspnoea and a non-productive cough.

image Pericarditis.

image Rheumatoid vasculitis: one of the most serious complications of rheumatoid arthritis. Cutaneous, neurological, pulmonary, and gastrointestinal involvement comprise the spectrum of vasculitis.

image Ophthalmologic: complications in patients with rheumatoid arthritis include corneal involvement. Keratoconjunctivitis sicca or dry eyes is the most common eye complaint in rheumatoid arthritis patients. This manifestation of Sjögrens syndrome can cause corneal scarring and decreased visual acuity if ulcers and infections are allowed to develop. Scleritis can cause pain, thinning of the sclera and ultimately perforation and blindness.

image Secondary amyloidosis: this is a rare complication of rheumatoid arthritis.

image Felty’s syndrome: classified as a classic triad of rheumatoid arthritis, splenomegaly, and granulocytopaenia. Many rheumatoid arthritis patients have rheumatoid nodules and other extra-articular manifestations of their disease such as vasculitis. Some patients with this syndrome suffer recurrent bacterial infections.

For more information, refer to the further reading section at the end of this chapter.



Case 19.4



1. Using only the information provided in Vicky’s history, list your differential diagnoses for her hand symptoms. Justify your answer.





















Possible diagnosis Justification
DDx 1: carpal tunnel syndrome (carpal tunnel syndrome)
• Job: repetitive motion — keyboarding and mouse work

• Pain and paresthesia greater at night

• Median nerve distribution

• Clumsiness

• Symptoms increased with wrist flexion

• Use of birth control pills

• Gender: more common in females
DDx 2: thoracic outlet syndrome
• Increased night pain and

• paresthesia

• Clumsiness

• Neck pain and tightness
DDx 3: cervical disc herniation with radiculopathy
• Pain in C6 and C7 dermatomes

• Weakness: dropping items

• Neck pain and stiffness
DDx 4: pronator teres syndrome
• History of repetitive motion

• Median nerve distribution
DDx 5: polyneuropathy
• Pain and paresthesia in extremities

• Bilateral presentation

2. Why was Vicki asked about the following:
a quality of the pain

The nature of the pain helps to narrow the differential diagnosis. Neuropathic pain is often described as shooting and burning and may be associated with numbness and tingling. Neuropathic pain may suggest compression of a peripheral nerve resulting in a peripheral neuropathy. Ischaemic pain is associated with decreased blood flow to an area and can be excruciating. Ischaemic pain may also be associated with swelling in the hands.


b exacerbating and relieving factors

Vocational factors are commonly related to peripheral compression neuropathies. Carpal tunnel is frequently associated with extensive computer work or activities involving gripping or vibration. Thoracic outlet syndrome may be exacerbated by overhead work. Carpal tunnel syndrome and thoracic outlet syndrome are both commonly exacerbated during sleeping, with the pain relieved when the patients wakes and shakes the hands. This shaking of the hands is known as the ‘flick sign’.


c timing of the pain and paresthaesia

An evaluation of the timing of the symptoms can help refine the differential diagnoses. For example, symptoms of carpal tunnel syndrome and thoracic outlet syndrome are frequently worse at night and commonly awaken the patient.

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Upper limb pain

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