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COPYRIGHT © by Michaelidou Maria
Dr. Maria Michailidou
BLUE FINGERS
Essentials of Diagnosis
An exaggerated response to cold temperatures that results in transient digital ischemia. Classified clinically into primary or secondary forms. Complications of digital tissue ischemia may occur in patients with secondary RP, leading to recurrent digital ulcerations, rapid deep tissue necrosis, and amputation. Avoidance of cold temperatures is crucial to the management of RP. The entire body must be kept comfortably warm. Medications are indicated if there are signs of critical tissue ischemia (eg, digital ulcers) or if the quality of life of the patient is so affected that normal function is restricted.
General Considerations
When humans are exposed to cold temperatures, the body will sacrifice the viability of peripheral tissues by shifting blood flow from the skin and other organs to maintain a stable core body temperature. A unique circulatory system exists in the skin, especially in the hands, feet, and areas of the face that include both thermoregulatory and nutritional blood vessels. In these areas of the body, local blood flow is regulated by a complex interaction of neural signals, cellular mediators, and circulating vasoactive molecules. Temperature responses are principally mediated through the sympathetic nervous system by rapidly altering blood flow through arteriovenous shunts in the skin. During hot weather, these shunts open (vasodilate), allowing heat to dissipate. In cool weather, the shunts constrict, shifting blood centrally and helping maintain a stable core body temperature.
Raynaud phenomenon (RP) is an exaggerated response to cold temperatures that results in transient digital ischemia. The vasoconstriction of digital arteries, precapillary arterioles, and cutaneous arteriovenous shunts leads to a sharp demarcation of skin pallor or cyanosis of the digits (. This ischemic phase is followed by recovery of blood flow that appears as cutaneous erythema, secondary to rapid reperfusion of the digits.
RP is classified clinically into primary or secondary forms. Primary RP occurs in the absence of any associated disease or definable cause. In fact, most experts think that the primary form is merely an exaggeration of normal physiologic responses to cold environmental temperatures or emotional stress or both, rather than a disease. Secondary RP is associated with an underlying pathologic condition or disease that alters regional blood flow by damaging blood vessels, interfering with neural control of the circulation, or changing either the physical properties of the blood or the levels of circulating mediators that regulate the digital and cutaneous circulation. Although there are a large number of suspected causes of secondary RP, the primary care physician will most commonly encounter RP associated with a rheumatic or connective tissue disease, such as scleroderma, systemic lupus erythematosus (SLE), Sjögren syndrome, or dermatomyositis.
Clinical Findings
Symptoms and Signs
RP results from an exaggerated vascular response to cold temperatures or stress.
This vascular constriction leads to color changes visible on the skin. The fingers
are the most commonly affected, although attacks also occur in the toes and occasionally
on areas of the face. A typical RP attack is characterized by the sudden onset of
cold digits associated with a demarcation of skin pallor (white attack) or cyanosis
(blue attack). After rewarming, the skin blushes from reperfusion, resulting in the
erythema secondary to rebound of blood flow. Although many people in the general
population (~ 30%) are "sensitive to the cold," a true RP attack is defined clinically
by a history of both cold sensitivity and associated color changes of the skin (pallor
or cyanosis or both) limited to the digits. RP attacks typically begin in a single
finger and then spread to other digits of the same or both hands. The index, middle,
and ring fingers are the most commonly involved digits. Primary RP occurs in the
absence of a definable cause for the attacks. It is most common in otherwise healthy
females with an age of onset between 15 and 30 years. A history that another first-
The most common causes of secondary RP are scleroderma, SLE, and other connective tissue disorders ( Patients with secondary RP generally have more severe RP, often accompanied by pain, which may herald an episode of serious digital ischemia, fingertip ulceration, and tissue loss. Tissue ischemia and digital ulceration may result
Treatment
Preventive Strategies
Avoidance of cold temperatures is crucial to the management of RP. Although the importance
of keeping the hands and feet warm is obvious, the whole body must be kept comfortably
warm. Thus, wearing several layers of loose fitting clothing, mittens, stockings,
and headwear in cold temperatures is very important. Damp windy weather or rapid
shifts in ambient temperature are more likely to precipitate RP attacks. Air-
Medications that have the potential to vasoconstrict the peripheral arteries should be avoided in patients with both primary and secondary RP. Sympathomimetic drugs (decongestants, diet pills, ephedra) and serotonin agonists such as sumatriptan should be avoided because they are vasoconstrictors and could aggravate RP. In addition, certain chemotherapeutic agents (bleomycin, cisplatin, carboplatin, and vinblastine) may cause vascular occlusion and trigger RP attacks. RP patients should avoid smoking because nicotine reduces cutaneous and digital blood flow. Nonselective blockers were once thought to be contraindicated, but new studies refute this finding. Clonidine and narcotics also vasoconstrict the cutaneous circulation and should be used with caution. A recent warning has noted potential vasospasm with concomitant administration of ergotamine tartrate plus caffeine, a migraine medication, and CYP3A4 inhibitors such as macrolide antibiotics and protease inhibitors.
Essentials Features
Pain is the most common symptom. An orthopedic consultation should be obtained early in the evaluation to rule out infection, tumor, or traumatic injury, which would require urgent treatment. Symptoms associated with shoulder pain may include numbness, weakness, instability, stiffness, redness, fevers, and weight loss.
General Considerations
Because of the many sources of shoulder pain, diagnosis is often challenging. A thorough
patient evaluation, including the interview, examination, and radiographic work-
Clinical Findings
History
The quality of the pain should be identified. Features of the pain that need to be addressed include the date of onset, history of trauma, character of the pain, associated symptoms, and all aggravating and relieving factors. Associated symptoms may include numbness, weakness, instability, stiffness, redness, fevers, and weight loss.
Pain is a subjective complaint but needs to be documented in an objective manner. Questions that should be answered include the presence of night pain (often indicates rotator cuff injury), analgesic requirements, degree of interference with work and activities of daily living, and an estimate of the amount of pain on a linear scale by the patient.
Physical Examination
The three basic steps of the physical examination include inspection, palpation, and range of motion.
Inspection
Scars provide information about trauma or previous surgery. Muscle wasting may be
due to an underlying neurologic condition or to disuse atrophy. Paracervical spasm
is common among patients with underlying cervical spine disease. Distal muscle wasting,
such as in the interossei of the hand, may be found in cervical nerve root disorders.
Deltoid wasting is best viewed over the anterior acromion and will produce a "squared-
Skin changes can aid in the diagnosis. Erythema, ecchymosis, or hair loss can indicate
an infection, hemorrhage (seen with proximal biceps ruptures or fractures), or reflex
sympathetic dystrophy. Deformities of the acromioclavicular (AC) joint may indicate
previous trauma or underlying arthritis (). Scapular winging is best assessed while
the patient performs a push-
Palpation
Sites that should be palpated during the physical examination include the AC and SC joints, the biceps tendon (in the bicipital groove), posterior joint line, and the rotator cuff at its insertion on the greater tuberosity. Deformities that may be tender along the course of the clavicle may be associated with an ununited fracture. Tenderness over the superior surface of the acromion may indicate an os acromiale with underlying impingement. The AC joint is best identified by following the clavicle and the spine of the scapula out laterally until they meet (). Arthritis of the SC and AC joints is usually associated with tenderness. The greater tuberosity may be tender in patients with a fracture or rotator cuff tendinitis or tear. The bicipital groove is identified between the greater and lesser tuberosities. It can be palpated in thin patients as the arm is gently externally and internally rotated. The groove faces directly anterior when the arm is in about 10 degrees of internal rotation. Tenderness in the bicipital groove usually indicates biceps tendinitis. Biceps tendinitis is seldom an isolated diagnosis and is usually associated with underlying rotator cuff injury. Glenohumeral joint arthritis may elicit posterior joint line tenderness.
Range of Motion
Range of motion of the shoulder can be assessed in the upright or supine positions. Active motion should always be compared with the contralateral side and documented. Passive motion only needs to be noted when active motion is incomplete. The motion of the opposite shoulder should also be documented. Because of the global nature of shoulder motion, a multitude of motions can be assessed. However, these various motions make documentation difficult. Therefore, the Society of the American Shoulder and Elbow Surgeons recommends recording the following four arcs of motion:
1. Total elevation 2. External rotation at side 3. External rotation in 90 degrees of abduction 4. Internal rotation
The Society has agreed that this list represents a standard protocol that is simple and reproducible. Total elevation represents a more functional measurement than forward flexion or abduction. With total elevation, the patient is allowed to find the most comfortable position in between the coronal and sagittal planes. Internal rotation is checked by having the patient scratch his or her back to the highest achievable point. The point where the patient's thumb touches is recorded (ie, the gluteus, L4, or T7).
Muscle strength should be assessed throughout all of the documented ranges of motion. Decreased strength may be found in a patient with a rotator cuff tear, brachial plexus lesion, or cervical disc disease. Sensory testing should also be performed, along with evaluation of reflexes, to assess for central or peripheral nerve involvement.
KNEE PAIN
General Considerations
Knee pain may result from trauma, overuse, internal derangement, osteoarthritis,
or inflammatory arthritis. In addition, pain about the knee may be due to vascular
or neurologic conditions. Hip disease may also refer pain to the knee, distal thigh,
or both. The initial evaluation of a patient with knee pain should provide sufficient
information to determine whether the pain is the result of intra-
Initial Clinical Assessment
Essential Features
Conditions such as septic arthritis or vascular occlusion may require acute intervention. Knee pain may be referred from ipsilateral hip disease or may be due to a neurologic condition resulting from degenerative arthritis of the lumbosacral spine, lumbar disc herniation, or spinal stenosis.
History
The significant features of the history should include the onset and history of the pain as well as any prior history of similar problems in the knee or other joints. A history of trauma, whether recent or remote, should be noted. The nature of the onset of pain, including the location of the pain, whether the pain began suddenly, or whether symptoms began gradually and insidiously should be determined. The examiner should seek information about the response of pain to activity; whether the pain is constant or intermittent; and whether it is present only with weight bearing, at rest, or both. The history should elicit information about whether activities such as negotiating stairs or inclines, weather changes, rest, or position exacerbate the symptoms and whether rest, moving about, stretching, or other factors may relieve them. Specific questions to determine whether the onset of symptoms may have been associated with any specific activity or change in activity, such as recreational exercise, physically demanding work, or hobbies, may be helpful.
A history of swelling as well as its location should be sought. A history of stiffness, locking, catching, snapping, grinding, and crepitus should be obtained (. Locking symptoms must be further characterized as either true mechanical locking or nonmechanical locking due to apprehension or reluctance to move the knee because of pain or anticipation of pain. Similarly, symptoms of giving way should also be further investigated to determine whether they are the result of mechanical instability, weakness, or possible neurologic problems. A history of change in sensation, low back pain, radicular symptoms, feelings of leg weakness or heaviness, muscle cramps, and claudication may alert the examiner to the possibility of neurologic or vascular problems. Fevers, chills, or a history of infection elsewhere should also be noted.
A more comprehensive past medical history may be required in selected cases. A history of prior glucocorticoid use or alcohol abuse should alert the examiner to the possibility of avascular necrosis of the hip, which may initially present with thigh pain, knee pain, or both. Diabetes, systemic glucocorticoid use, HIV, and other conditions that may compromise immune function should similarly raise the clinician's index of suspicion to the possibility of septic arthritis.
When to Refer to a Specialist
Patients with a septic knee should be referred urgently to an orthopedist to evaluate the need for surgical drainage. Patients with fractures or bone tumor should also be referred to an orthopedist.
Patients in whom avascular necrosis of bone or a systemic rheumatic disease such as rheumatoid arthritis is suspected should be referred to a rheumatologist for treatment.
Referral to a specialist is also warranted if the cause of knee pain eludes diagnosis or fails to respond appropriately to initial therapy.
Morning stiffness is a type of joint stiffness, a general term used to describe difficulty moving your arms, legs, and other parts of your body. Stiffness is often described as a tight, rigid feeling in the joints. Stiffness caused by RA can occur at any time, but it is most common after waking in the morning and following other times of prolonged inactivity (for example, after sitting for a while). In addition, stiffness is usually worse during RA “flares” — temporary periods when RA is very active. Stiffness can occur in any joint of the body, although the joints most commonly affected are the hands, feet, hips, knees, and spine. In RA, morning stiffness typically lasts more than one hour. Because it lasts so long, it can make it difficult to carry out simple morning routines such as dressing, eating, and showering.
Ιn RA, pain and stiffness are brought on by an overactive immune system that mistakenly attacks the joints, inflaming the thin layer of cells that surround them (called the synovium, or joint lining) and causing the joint fluid to thicken. As a result, the joint becomes swollen, painful, and increasingly difficult to move.
If this immune-
Sometimes RA medicines are used alone and other times in combination with one another. Your doctor — preferably a rheumatologist, a physician who specializes in treating rheumatic conditions such as RA — is best able to help you decide which RA medicines are appropriate for you. When you speak with your rheumatologist, be sure to ask about potential side effects of your medicines, how best to take them, any interactions they may have with other medicines, and how long it will take before they are effective. Knowing you must take a medicine for two weeks before your symptoms improve can help you feel more confident about the medicine and stick with it even if it doesn’t seem to be working at first.
Introduction: the Patient with Hand, Wrist
Pain in the hand, wrist, and elbow usually falls into three broad categories: neurologic, musculoskeletal, and vascular. A careful history often distinguishes among these categories. However, patients may be unable to accurately describe their symptoms. For example, a patient may refer to numbness or the lack of sensation as "painful" rather than conveying the perception of numbness. A disorder in the hand may produce pain referred proximally to the elbow, the axilla, or the neck. Conversely, disease in the cervical spine and proximal nerve roots can produce pain in the distal upper extremity. A full physical and neurologic examination of both upper extremities is therefore important to help isolate the cause of symptoms. Often, the history and examination are sufficient to establish a diagnosis. In selected cases, however, diagnostic tests such as radiographs, nerve conduction tests and electromyography, computed tomography scans, and magnetic resonance imaging (MRI) are needed to confirm the diagnosis.
Neurologic Causes of Pain
Pain due to peripheral nerve dysfunction can present with varying symptoms, ranging from pure sensory dysfunction to pure motor paralysis or a combination of both. Most commonly, the dysfunction is due to external compression. As peripheral nerves travel from the vertebral foramina to their end organs, they pass through several anatomic sites where compression can occur. Compression produces localized ischemia of the nerve and interferes with the axonal transport of metabolic products. The level of compression determines the clinical symptoms. Proximal compression of a nerve root as it exits the vertebral bodies will produce symptoms in a dermatome distribution, whereas distal nerve compression will produce symptoms in the defined region of the specific nerves. Peripheral neuropathies, in contrast, tend to manifest in multiple limbs and are more global within each limb. After the physical examination, the next step in the evaluation should be an electrodiagnostic examination. Nerve conduction studies reveal the level and severity of compression. Electromyography reveals whether the compression has led to denervation of muscle.
Compression of the Median Nerve at the Wrist (Carpal Tunnel Syndrome)
Essentials of Diagnosis
Paresthesias of the volar aspect of the thumb, index and long fingers, and radial
side of the ring fingers. Positive Phalen maneuver or Tinel sign at the wrist. Thenar
atrophy and weakened pinch with long-
General Considerations
Carpal tunnel syndrome, the most common nerve entrapment in the upper extremity, occurs most often in the fourth to the sixth decades of life and affects more women than men. Most cases are idiopathic. There may be an association with activities that produce repetitive motion of the wrist, such as keyboarding. Idiopathic carpal tunnel syndrome is frequently associated with the inflammation of the tenosynovium of the nine tendons within the carpal tunnel. Synovitis of the wrist (due to rheumatoid arthritis or any other inflammatory arthritis of the wrist) can result in the compression of the median nerve, as the space within the carpal tunnel is limited. Pregnancy, diabetes, and hypothyroidism can also be associated with carpal tunnel syndrome. Rare causes may include amyloidosis and acromegaly. Occasionally, compression of the median nerve is due to a giant cell tumor, lipoma, or ganglion cyst in the carpal tunnel.
Clinical Findings
Symptoms and Signs
Symptoms include burning in the volar thumb, index and long fingers, and the radial side of the ring fingers. Dysesthesias may be felt along the volar surface of the forearm as well. Shaking or flicking the hand can sometimes relieve the pain; this is called the "flick test." Patients may say that lowering the hand or gravity dependency helps with the pain or that the hand feels cold, perceiving vascular insufficiency as the cause. Symptoms are commonly nocturnal but also can occur during the day, especially when the wrist is hyperflexed or hyperextended, such as during driving or typing.
There is usually decreased sensation in digits innervated by the median nerve (thumb,
index and long fingers, and radial side of the ring fingers). With long-
Imaging Studies and Special Tests
Imaging studies are not necessary unless a compressing tumor or mass is suspected, in which case an MRI should be ordered. If the diagnosis is in doubt or if symptoms persist despite conservative management (see following Treatment section), electrodiagnostic testing should be performed.
Neurologic Causes of Pain
Pain due to peripheral nerve dysfunction can present with varying symptoms, ranging from pure sensory dysfunction to pure motor paralysis or a combination of both. Most commonly, the dysfunction is due to external compression. As peripheral nerves travel from the vertebral foramina to their end organs, they pass through several anatomic sites where compression can occur. Compression produces localized ischemia of the nerve and interferes with the axonal transport of metabolic products. The level of compression determines the clinical symptoms. Proximal compression of a nerve root as it exits the vertebral bodies will produce symptoms in a dermatome distribution, whereas distal nerve compression will produce symptoms in the defined region of the specific nerves. Peripheral neuropathies, in contrast, tend to manifest in multiple limbs and are more global within each limb. After the physical examination, the next step in the evaluation should be an electrodiagnostic examination. Nerve conduction studies reveal the level and severity of compression. Electromyography reveals whether the compression has led to denervation of muscle.
Compression of the Median Nerve at the Wrist (Carpal Tunnel Syndrome)
Essentials of Diagnosis
Paresthesias of the volar aspect of the thumb, index and long fingers, and radial
side of the ring fingers. Positive Phalen maneuver or Tinel sign at the wrist. Thenar
atrophy and weakened pinch with long-
General Considerations
Carpal tunnel syndrome, the most common nerve entrapment in the upper extremity, occurs most often in the fourth to the sixth decades of life and affects more women than men. Most cases are idiopathic. There may be an association with activities that produce repetitive motion of the wrist, such as keyboarding. Idiopathic carpal tunnel syndrome is frequently associated with the inflammation of the tenosynovium of the nine tendons within the carpal tunnel. Synovitis of the wrist (due to rheumatoid arthritis or any other inflammatory arthritis of the wrist) can result in the compression of the median nerve, as the space within the carpal tunnel is limited. Pregnancy, diabetes, and hypothyroidism can also be associated with carpal tunnel syndrome. Rare causes may include amyloidosis and acromegaly. Occasionally, compression of the median nerve is due to a giant cell tumor, lipoma, or ganglion cyst in the carpal tunnel.
Clinical Findings
Symptoms and Signs
Symptoms include burning in the volar thumb, index and long fingers, and the radial side of the ring fingers. Dysesthesias may be felt along the volar surface of the forearm as well. Shaking or flicking the hand can sometimes relieve the pain; this is called the "flick test." Patients may say that lowering the hand or gravity dependency helps with the pain or that the hand feels cold, perceiving vascular insufficiency as the cause. Symptoms are commonly nocturnal but also can occur during the day, especially when the wrist is hyperflexed or hyperextended, such as during driving or typing.
There is usually decreased sensation in digits innervated by the median nerve (thumb,
index and long fingers, and radial side of the ring fingers). With long-
Osseous Causes of Pain
Hand and wrist pain can be due also to the underlying skeletal structures. Usually,
the most common cause of pain among middle-
Basilar Thumb Osteoarthritis (First Carpometacarpal Joint Osteoarthritis)
Essentials of Diagnosis
Pain at the base of the thumb made worse by pinching activity. Pain and crepitance with passive rotation and compression of the first carpometacarpal (CMC) joint. Degenerative changes of the first carpometacarpal joint on radiographs.
The base of the thumb is the area in the hand most commonly affected by osteoarthritis. The thumb is a long lever, and the power of the thumb pinch can be more than 30 pounds. Pinch power at the tip of the thumb is amplified 25 times at the base of the thumb, because of the long lever arm (ie, up to 750 pounds of force).
Clinical Findings
Physical examination findings include pain and crepitance on passive rotation and compression of the first CMC joint. This is referred to as the "grind test." Radiographs usually show degenerative changes involving the first CMC joint. DeQuervain tendinitis must be ruled out because the two entities have similar symptoms.
have surgery.
If symptoms persist after 2–3 months of splinting, NSAIDs, and perhaps steroid injections, surgical intervention is indicated to avoid permanent damage to the median nerve and the muscles that it innervates. Surgical release can be done by either an open procedure or endoscopically.
Compression of the Ulnar Nerve at the Wrist in the Guyon Canal
Essentials of Diagnosis
Paresthesias of the volar aspect of the ring finger and small finger. Absence of numbness on the dorsal ulnar aspect of the hand.
Clinical Findings
Symptoms and Signs
Numbness that occurs primarily in the volar aspect of the small and ring fingers, with or without weakness in the hypothenar muscles, is most likely due to compression of the ulnar nerve in the Guyon canal at the base of the hypothenar region. The Guyon canal is triangular in dimension. The roof is defined by the volar palmar fascia. The lateral wall is formed by the hook of the hamate and the insertion of the transverse carpal ligament. The medial wall is formed by the pisiform bone. It is through this small space that the ulnar nerve and the ulnar artery pass from the forearm to the hand. The lack of numbness on the dorsal ulnar aspect of the hand isolates the compression to the wrist rather than to the elbow. This is because the dorsal ulnar sensory nerve separates from the main trunk of the ulnar nerve 9 cm proximal to the Guyon canal. Therefore, dorsal ulnar sensation is not affected by ulnar nerve compression within the Guyon canal. Lipomas and ganglion cysts in the canal can cause ulnar nerve compression. Manual labor with repeated trauma to the hypothenar region can lead to scar adhesions of the ulnar nerve or the development of an ulnar artery pseudoaneurysm causing ulnar nerve compression (the hypothenar hammer syndrome).
Special Tests
Electrodiagnostic studies may show slowing of the ulnar nerve conduction across the canal but are often normal. The diagnosis is based on the clinical presentation and normal ulnar nerve conduction velocity at the elbow through the cubital tunnel. If hypothenar hammer syndrome is suspected, an upper extremity vascular Doppler examination and an arteriogram should be ordered.