Rheumatology Notes

Hand and Wrist Problems.

Tendon Problems:
Flexor tensoynovitis tendon sheath inflammation causes stiffness and pain in the fingers, worse in the morning. Palpate for thickening of the tendon sheaths in the palms (rub). Local injection of steroids to treat. Trigger finger development of tendon nodules, these can be palpated. Causes pain and/or fixed flexion. Hence trigger finger. Local steroid injection to treat. Dupuytrens contracture painless fixed flexion deformity, little and ring fingers. Caused by thickening of the palmar aponeurosis. Hand surgery if the fixed flexion is disabling.

Carpal Tunnel Syndrome:

Very common, associated specifically with hand pain at night. Caused by compression of the medial nerve as it travels through the carpal tunnel. Causes pain, numbness, pins and needles classically in the distribution of the median nerve. Treated with a splint for mild symptoms and local steroids for severe.

Nodal Osteoarthritis:
Either acute or insidious onset, acute phase presents with pain, swelling and redness. Accompanied by bony swellings called Henerdens nodes if they are in the distal interphalangeal joints, and Bouchards nodes in the proximal interphalangeal joints are affected. Conservative treatment, reassurance that pain will settle.

Systemic Disorders:
Inflammatory Arthritis The hand is commonly associated with rheumatoid, and inflammatory arthritis associated with psoriasis. Classically: symmetrical involvement of the proximal interphalangeal and metacarpal phalangeal joints suggests rheumatoid arthritis, whereas dactylics is associated with seronegative arthritis. Acute Gout Sodium urate crystals induced synovitis of the wrist or finger joints. Treated with non-steroidal anti inflammatries. Raynauds Phenomenon undue vasospastic response of digital arteries to col. Finger develop pallour, then cyanosis, then painful redness due to hyperaemia. Often first noted in young women, can also be associated with scleroderma, SLE and rheumatoid arthritis. Vasodilators may be used. Diabetic Stiff Hand diabetics may develop a stiff hand and positive prayer sign. Characterised by tight, shiny skin.

Scaphoid Bone Fracture:

Caused by a fall onto an outstretched arm with the wrist in dorsiflexion. Pain swelling and tenderness in the anatomical snuff box. Treatment by immobilisation.

Neck, Shoulder and Upper Arm Problems.

Rotator Cuff
Impingement on the rotator cuff is caused by instability or osteophytes. Initially this forms tendinosis, with pain through a limited range of movements. This can lead to a tear. patient will present with pain, especially when trying to perform overhead activities.

Frozen Shoulder
An acute inflammatory process results in synovitis, fibroplasias and then capsular contracture. Treatment is aimed at controlling pain.