Evaluation of Disorders of the Hands and Wrists

Transcription

1 Evaluation of Disorders of the Hands and Wrists

2 Case 27 yo female with 6 month history of right forearm and hand pain Works as secretary, symptoms are interfering with her job duties Complains that she is dropping objects and right hand feels weak

3 Carpal Tunnel Syndrome Ulnar nerve distribution Median nerve distribution Carpal Bones Median Nerve

4 Carpal Tunnel Syndrome Findings: Tinel s Sign Phalen s Sign

5 Case 27 yo female 6 mo hx of bilateral thumb pain Has worked for the past year on a factory assembly line Symptoms are interfering with her job performance

6 De Quervain s Tenosynovitis Pain and tenderness in the area about the radial styloid that is worsened with movement Due to inflammation of the abductor pollicis longus or extensor pollicis brevis Often due to overuse (repetitive grasping with the thumb against resistance)

7 De Quervain s Tenosynovitis -Finklestein Test-

8 Case 37 yo male carpenter 6 mo history of wrist swelling

9 Ganglion Cyst Cystic mass that arises in the proximity of the joint capsule or tendon sheath Associated with repetitive strain, trauma, or inflammatory arthritis Most commonly arises on the dorsal aspect of the wrist Usually asymptomatic

10 Case 56 yo male PMH: DM Progressive loss of range of motion of 3 rd & 4 th fingers

11 Dupytren s Contracture Thickening and shortening of the palmar fascia of the hand May be unilateral or bilateral Results in flexion contractures of the fingers

12 Case 29 yo female Professional musician CC: Intermittant locking up of fingers

13 Trigger Finger Inflammatory process of the flexor tendon sheath Associated with repetitive trauma, RA, diabetes Causes pain and catching with flexion

14 Case 73 yo female with a 10 year history of gradually progressive pain in her hands. Pain is most severe in her fingers and the base of her thumbs. Her hands are stiff when she first gets up in the morning. She has trouble opening jars and has been doing less knitting because of her pain.

15 Distribution of Pain and Disease Association DIP: OA, Psoriatic, Reiter s PIP: OA, RA, SLE, Psoriatic MCP: RA, Pseudogout, Hemochromatosis 1st CMC:OA DeQuervain s tenosynovitis Wrist: RA, Pseudogout, ganglion cyst, carpal tunnel syndrome

16 Physical Exam

17 Osteoarthritis- Physical Exam Bony hypertrophy (heberden s and bouchard s nodes) Crepitus Minimal heat or effusion Bouchard s Node Heberden s Node

18 Osteoarthritis (OA) Most common arthropathy of adults Noninflammatory condition Degeneration and loss of cartilage Site: DIPs, PIPs, 1st CMC, hips, knees, cervical spine, and lumbar spine

19 Case 37 yo female with a 6 month history of pain and swelling in her hands She has worked for the last year on an assembly line in a local factory Her symptoms are worse in the morning and get better as the day goes on

20 Physical Exam

21 Rheumatoid Arthritis (RA) Chronic, progressive, symmetric arthritis Small joints of the hands and feet (MCPs, PIPs, wrists, and MTPs) Prolonged morning stiffness (>30-60 minutes) 75-85% are RF positive

22 RA-Physical Findings Warmth Erythema Synovitis Nodules Loss of function Deformity Swan-neck Boutonniere Swanneck Ulnar drift Boutonniere

23 Rheumatoid Nodules

24 RA Ulnar deviation, MCP joint subluxation, rheumatoid nodules

25 Case 60 yo male with a 2 day history of pain and swelling in his left wrist He doesn t recall any recent trauma. He has had similar but less severe episodes in other joints in the past.

26 Physical Exam

27 Synovial Fluid Analysis Axis

28 Radiographs Soft tissue alterations Effusion, swelling, calcification Articular malalignment Joint space loss Changes in cortical bone Fracture, erosions, osteophytes, periosteal reaction

29 OA-Radiographic Features Loss of joint space Osteophytes Subchondral sclerosis DIP

30 RA-Radiologic Findings Soft tissue swelling Juxtaarticular osteopenia Erosions Loss of cartilage

31 Radiographic Features of Erosions RA Gout - Punched-out marginal erosions with sclerotic borders

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33 Findings in Scleroderma Calcinosis Cutis Raynauds Phenomenon Digital Pitting Scars

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35 Systemic Sclerosis Edematous Phase Acrosclerosis and Terminal Digit Resorp

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37 Gout with DIP Involvement

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39 SLE: Jacoud s arthropathy

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41 SLE: Interarticular Dermatitis Dermatomyositis: Gottron s Papules

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43 Psoriatic Arthritis Nail Dystrophy Nail Pitting Sausage swelling, Rash, & DIP Swelling

44 Nailfold Capillary Exam Normal Systemic Sclerosis Juvenile Dermatomyositis Adult Dermatomyositis