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PubMed1999

A narrative review on classification of pain conditions of the upper extremities.

Local and regional musculoskeletal discomfort and pain in the shoulder girdle or upper extremities are often reported, especially in the working population. In this review we describe the most important problems and factors when classifying musculotendinous pain in the upper extremities and shoulders. This includes an analysis of how four common diagnoses (wrist tenosynovitis, lateral epicondylitis, rotator-cuff tendinitis, myofascial pain syndrome) fulfil basic criteria of validity. It is evident that there are some serious problems regarding the validity of the current classification of the conditions. Clinical criteria are often poorly defined and the reliability insufficiently tested. The relationship to objective pathoanatomic or physiological findings seems inconsistent. Although magnetic resonance and ultrasonographic imaging are promising, they are still only preliminary methods for evaluation of tendon and connective tissue structures. The prognosis with and without treatment also seems heterogeneous and can vary between studies. A generally accepted terminology is lacking in the pathogenetically complex regional muscle pain conditions.

Acute Disease↗

PubMed2000

Sonographic analysis of the ankle in patients with psoriatic arthritis.

Foot involvement is very frequent in patients affected by psoriatic arthritis (PsA). However, evaluation of the painful foot can be problematic, because it is often difficult to distinguish between arthritis, tenosynovitis, and enthesopathy. Plain radiographs can show bone erosion or other features of joint involvement, but give little information about the soft tissues. We therefore studied foot involvement in 31 PsA patients using high resolution sonography, and compared the results with the findings on x-ray and clinical examination. Ultrasound revealed pathological findings in a large proportion of the patients, most of whom exhibited no clinical (pain or swelling) or radiological signs of foot involvement at the time of the study. Our data suggest that involvement of the tendons and entheses may be more frequent in PsA patients than has thus far been supposed, even in cases of not particularly aggressive disease, and that clinical evaluation tends to underestimate these manifestations.

Achilles Tendon↗

PubMed1982

Investigation of cumulative trauma disorders in a poultry processing plant.

Cumulative trauma disorders such as carpal tunnel syndrome and tenosynovitis can be caused, precipitated, or aggravated by repeated exertions with the hand. This paper describes a study in a poultry processing factory that proceeds from an analysis of health records to an analysis of work methods, postures and forces. Alternative work procedures and knife designs are recommended to reduce stressful work postures and forces.

Animals↗

PubMed1994

Fine-needle aspiration biopsy cytology of giant-cell tumor of tendon sheath.

Localized nodular tenosynovitis, better known as giant-cell tumor of tendon sheath (GCTTS), is a common neoplasm that has a peak incidence in the fourth to sixth decades of life. Few reports exist elucidating the cytologic features of this lesion obtained by fine-needle aspiration biopsy (FNAB). The authors describe five patients, aged 8-50 years, in whom GCTTS was diagnosed by FNAB cytology. In four of the patients, the lesion was excised, and the FNAB diagnosis of GCTTS was confirmed; surgical excision is pending in one patient. A diagnosis of malignancy was not suggested in any of the patients. The tumors were .7-5 cm in greatest dimension. In two patients, GCTTS affected the ankle; the hand was affected in the other three. Aspiration smears were cellular in four cases. All but one case contained several multinucleate osteoclast-type giant cells; in addition, binucleate cells were common. The nongiant cell population was dispersed principally as single cells that had a cytologic appearance mimicking histiocytes and osteoblasts. Anisonucleosis was minimal, and nuclear pleomorphism was distinctly absent in both single and multinucleate cells. Mitotic figures were infrequent, except in one case. The diagnosis of GCTTS can be made or at least strongly suggested using FNAB when the cytologic and clinical features are combined.

Adolescent↗

PubMed2003

Towards epidemiological criteria for soft-tissue disorders of the arm.

BACKGROUND: The lack of universally agreed criteria has hampered population studies of the prevalence and causation of soft-tissue disorders of the upper limb. OBJECTIVES: To establish core variables for classification of the commonest disorders seen in population samples. METHODS: Consecutive new cases seen in clinical practice in five different centres were evaluated with respect to 30 variables shown to have discriminatory value in univariate analysis. Multivariate analysis using logistic regression modelling was carried out with these as the independent variables and with the clinical diagnosis as the dependent variable. RESULTS: A total of 1382 cases of soft-tissue disorder were recorded and only those diagnostic groups with 50 or more cases were included. In multivariate logistic regression, significant variables positively discriminating for each disorder were identified for carpal tunnel syndrome (n = 56), lateral epicondylitis (n = 87), tenosynovitis (n = 63), shoulder tendonitis (n = 157), non-specific upper limb disorder (n = 458), fibromyalgia (n = 124) and inflammatory arthritis (n = 100), which was used for comparison purposes. Significant discrimination for each model was demonstrated by the construction of receiver operating characteristic (ROC) curves and appropriate area under the curve statistics. CONCLUSIONS: This approach to classification criteria is based on multivariate modelling rather than on a consensus statement. This includes the effects of negative as well as positive associations. Further work is required on both the reproducibility of the clinical signs and the application of the criteria to other datasets.

Adolescent↗

PubMed1997

Mycobacterium marinum infection causing septic arthritis and osteomyelitis.

A 48-yr-old female on immunosuppressive therapy for fibrosing alveolitis and polymyositis developed a septic arthritis of the left middle finger proximal interphalangeal joint, tenosynovitis of the left palm and osteomyelitis of the right hindfoot due to infection with Mycobacterium marinum. Such widespread and severe bone and joint involvement has not been described previously with this organism.

Anti-Bacterial Agents↗

PubMed2000

Diffuse-type giant cell tumor: clinicopathologic and immunohistochemical analysis of 50 cases with extraarticular disease.

The clinical and pathologic features of 50 cases of diffuse-type tenosynovial giant cell tumor (D-TGCT), also known as extraarticular pigmented villonodular tenosynovitis (PVNTS), are presented. Patients' ages ranged from 4 to 76 years (median, 41 yrs), with a slight female predominance (28 women, 22 men). By definition, all lesions presented as predominant soft tissue masses, with or without an associated articular component. Tumor sites included the wrist (9 cases), knee (8 cases), thigh and foot (6 cases each), finger (5 cases), ankle (3 cases), hand, elbow, toes, buttock, paravertebral region (2 cases each), lower leg, sacrococcygeal area, and retroperitoneum; 27 cases were described as entirely extraarticular. Tumors showed infiltrative margins and, in most cases, a sheet-like growth pattern. Striking variation in the number of osteoclast-like giant cells, foamy cells, amount of hemosiderin, and in the degree of stromal hyalinization were responsible for a wide morphologic spectrum. In addition to the predominant histiocyte-like cells, we identified in most cases a subpopulation of large dendritic, desmin-positive cells showing characteristic, but potentially misleading, cytologic features, including abundant eosinophilic cytoplasm, large vesicular nuclei, paranuclear eosinophilic inclusions, and occasional nuclear inclusions. Follow-up information was available for 24 patients, with a duration ranging from 6 months to 30 years (mean, 55 mos). Local recurrence occurred in eight cases (33%), between 4 months and 6 months after surgery (median, 15 mos) and was repeated in five cases; recurrence did not appear to correlate with morphologic parameters. Six cases showed atypical histologic features and four of these contained areas of sarcomatous change. Among the latter, one of three cases with available follow up developed pulmonary metastases and died after 35 months. In addition, one histologically benign lesion gave rise, after two local recurrences, to inguinal and iliac lymph node metastases. Despite this exceedingly uncommon event, we think most cases of D-TGCT are best regarded as benign but locally aggressive neoplasms with significant recurrent potential and should be treated, when possible, by wide excision. Atypical features such as increased mitotic activity, necrosis, spindling of the mononucleate cells, and cytologic atypia are not indicative of malignancy when present individually. This study also confirms the existence of malignant tenosynovial giant cell tumors, some of which are characterized by aggressive behavior.

Adolescent↗

PubMed1991

Atypical mycobacterium soft-tissue infection of the dorsal radial wrist: a possible complication of steroid injection for de Quervain's disease.

Corticosteroid injection into the first dorsal compartment for acute de Quervain's tenosynovitis is an accepted form of therapy. Potential side effects include soft-tissue atrophy, tendon attrition, postinjection neuritis of the superficial radial nerve, systemic reactions, and infection. We present a patient with a Mycobacterium chelonei infection localized to the soft tissue overlying the first dorsal compartment, occurring 3 years after a triamcinolone injection into this area. Histological examination with the polarizing microscope revealed persistent steroid granules in the involved tissue. Successful treatment consisted of complete excision of the involved skin and subcutaneous tissue followed by delayed closure. Systemic antibiotics were not used.

Adult↗

PubMed2003

Musculoskeletal ultrasound: an alternative imaging modality for sports-related injuries.

Advanced technology and increasing clinical experience have established sonography as a reliable imaging modality for sports-related injuries. Tears of muscles and tendons, tendinosis, and tenosynovitis are promptly diagnosed using ultrasound. Dynamic assessment of joints can be performed, allowing diagnoses of conditions that may remain undetected when evaluated with conventional magnetic resonance imaging. Sonography provides expeditious image guidance for procedures such as drainage of fluid collections and cysts. This article reviews the applications of sonography to sports-related injuries in which its diagnostic performance may be comparable to magnetic resonance imaging.

Athletic Injuries↗

PubMed1998

Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature.

Tendonitis is a common diagnosis in sports medicine. The traditional view of tendonitis is a tendon injury resulting from repetitive mechanical load with a subsequent inflammatory response. The English literature from 1966 to the present on the etiology, diagnosis, and treatment of tendonitis was evaluated. There is some scientific support in the literature for the diagnosis of tenosynovitis and tendinosis as a pathologic entity. Actual inflammation of tendon tissue consistent with tendonitis has not been seen clearly in patho-anatomic studies. Conclusive evidence confirming that repetitive mechanical load is a major etiologic factor could not be found. Similarly, strength deficits, inflexibility, and improper equipment have not been studied in a controlled prospective manner. Other factors such as age and tendon vascularity have been consistently correlated with these injuries although their overall importance remains difficult to assess. There are no controlled studies on treatment through physical therapy aimed at flexibility and/or strengthening. Treatment with anti-inflammatory drugs has been studied extensively. However, only nine of 32 studies are prospective and placebo controlled. Some pain relief was found in five of the nine controlled studies, but healing of the tendon problem was not studied in these short follow-up studies. Twenty-three studies on steroid injections were found. Eight were prospective and placebo controlled studies, with three showing beneficial effects of the injection at follow-up. It was concluded that much of the pathology and etiology of tendonitis remains unclear. The possibility must be considered that current treatment methods may not significantly affect the natural history.

Anti-Inflammatory Agents, Non-Steroidal↗

PubMed1998

Phonophoresis versus ultrasound in the treatment of common musculoskeletal conditions.

PURPOSE: The purpose of this study was to determine whether the pain response after phonophoresis (PH) differs from the pain response after ultrasound (US) alone. METHODS: Forty-nine subjects with soft tissue injuries including epicondylitis, tendinitis, and tenosynovitis were randomly assigned (double blinded technique) to PH or US treatment groups. Both groups received 8 min of continuous US at 1.5 w x cm(-2), three times per week for 3 wk. For the PH group a gel containing 0.05% fluocinonide was used as a coupling agent. An identical gel absent the steroid was used for the US group. Subjects indicated their pain level by marking on a visual analog scale (VAS) at the start of treatment and at the end of weeks 1, 2, and 3. Pressure algometry was used to note tolerance to direct pressure over the target tissue. ANOVA for repeated measures was used to analyze data. RESULTS: At the end of 3 wk of treatment, both groups combined showed a significant decrease in pain level and an increase in pressure tolerance (P < 0.05), but there were no differences between groups from the onset of treatment to the end of week 3 (VAS: US 5.5-1.9, PH 5.0-2.0; algometry (involved limb): US 4.7 lb-7.1 lb, PH 5.1 lb-6.6 lb). CONCLUSIONS: We conclude that US results in decreased pain and increased pressure tolerance in these selected soft tissue injuries. The addition of PH with fluocinonide does not augment the benefits of US used alone.

Adult↗

PubMed1975

Carpal tunnel syndrome caused by hand injuries.

Although carpal tunnel syndrome associated with injury to the wrist is common, it is possible to overlook symptoms of median nerve compression caused by an ascending tenosynovitis secondary to trauma distal to the wrist. One should look for these symptoms in such patients who complain of pain and weakness of the hand, and release the carpal tunnel if nerve compression is suspected.

Carpal Tunnel Syndrome↗

PubMed1995

Association of Wartenberg's syndrome and De Quervain's disease: a series of 26 cases.

We report on a series of 25 patients (26 cases) presenting an association of Wartenberg's radial neuritis and De Quervain's tenosynovitis. In all patients the diagnosis was made on clinical grounds. In group 1, conservative treatment of Wartenberg's syndrome was used in 16 patients (associated with surgical release of the first extensor compartment in 5 patients). Of the 14 patients available for follow-up at an average of 15 months, 9 (64 percent) were excellent and good results. In group 2 (11 patients, with 1 failure of conservative treatment), surgical treatment addressed both conditions. Neurolysis has to be performed at the classic proximal site of entrapment (constant excellent and good results), for the 2 cases of neurolysis at the styloid level gave fair results. It is particularly important to identify an associated Wartenberg's syndrome before performing a release of the first dorsal compartment to avoid incomplete relief or even aggravation of neuritis, exposing the surgeon to litigation.

Adult↗

PubMed2000

Management of hand and upper-extremity infections in heart transplant recipients.

Hand and upper-extremity infections are routinely managed by antibiotics, immobilization, and limited incision and drainage. However, in immunocompromised patients, these infections may be more aggressive and they may require more emergent treatment. The authors performed a retrospective review of the Stanford University Medical Center experience with hand and upper-extremity infections in 911 cardiac transplant recipients over the past 30 years. Thirteen heart transplant recipients were treated for infections of the hand and upper extremity on an inpatient basis. Ten patients (77 percent) required operative debridement, and three (23 percent) required more than one operative procedure. Nine patients (69 percent) had bacterial infections, six (46 percent) had fungal infections [four of these patients (31 percent) had both bacterial and fungal infections], one (7.7 percent) had a mycobacterial infection, and one (7.7 percent) was not cultured. Hand and upper-extremity infections in transplant recipients frequently resulted in deep-space infections, tenosynovitis, and osteomyelitis. The authors believe such infections represent a surgical emergency, requiring immediate evaluation by hand surgeons and early, aggressive treatment.

Adult↗

PubMed1992

Archery-related injuries of the hand, forearm, and elbow.

The five patients reported herein had various archery-related injuries of the upper extremities. Acute injuries included arrow laceration of a digital nerve and artery, contusion of forearm skin and subcutaneous tissue, and compression neuropathy of digital nerves from the bowstring. Chronic injuries included bilateral medial epicondylitis and median nerve compression at the wrist, de Quervain's tenosynovitis, and median nerve compression at the elbow. Essential measures for archery safety include use of archery protective gear, use of a light-weight bow, conditioning of the forearm flexor muscles, and modifications in drawing the bowstring.

Adult↗

PubMed2000

Flexor tendon entrapment of the digits (trigger finger and trigger thumb).

Flexor tendon entrapment of the digits is a disorder characterized by snapping or locking of the thumb or fingers (with or without pain). Most cases are secondary to thickening of the digit's A1 pulley, but other pathogeneses include tendon abnormalities at the level of the carpal tunnel, thickening of other pulleys, and abnormalities of the metacarpal-phalangeal joint. Its historical name, stenosing tenosynovitis of the digits, is inappropriate because histological studies document a lack of inflammation. Flexor tendon entrapment of the digits is a relatively common, uncomplicated, and non-controversial musculotendinous disorder of the distal upper extremity. The purpose of this invited review is to summarize information from the medical literature on aspects of this condition likely to be of interest and relevant to occupational medicine practitioners. Topics covered include normal anatomy and kinesiology, history, clinical observations related to diagnosis, pathology, pathophysiology, clinical observations on etiology, descriptive epidemiology, epidemiological studies, and case management. Models for the pathogenesis of flexor tendon entrapment of the digits are proposed, and opportunities for future research are presented.

Fingers↗

PubMed2005

Management of human and animal bite wounds: an overview.

Serious infections can result from wounds that are caused by bites from animals and humans. Organisms recovered from bite wounds generally originate from the oral cavity of the biting animal, as well as from the patient's skin flora. Anaerobes have been isolated from animal and human bite wound infections, especially those associated with abscess formation. In addition to local wound infections, common complications, such as lymphangitis, septic arthritis, tenosynovitis, and osteomyelitis, and uncommon complications, such as endocarditis, meningitis, brain abscess, and sepsis, may occur. Wound management includes proper local care and, when needed, antimicrobial therapy.

Animals↗

PubMed1993

Hand abnormalities are strongly associated with the duration of diabetes mellitus.

OBJECTIVES: To study the prevalence of hand abnormalities in diabetic patients and to evaluate associations between the hand abnormalities and diabetic variables, ergonomic factors and smoking habits. DESIGN: Cross-sectional study of 100 patients selected at random. Setting. Out-patient clinic, Department of Internal Medicine, Orebro Medical Centre Hospital in Sweden. MAIN OUTCOME MEASURES: Presence and extent of carpal tunnel syndrome (CTS), Dupuytren's contracture (DC), flexor tenosynovitis (FTS), and limited joint mobility (LJM). Duration of diabetes, metabolic control, chronic diabetic complications, blood pressure, ergonomic factors and smoking habits. RESULTS: Carpal tunnel syndrome, DC, FTS and LJM were each present in about 20% of the patients. Hand abnormalities were observed in 50 patients and more than one abnormality was found in 26 of the patients. The hand abnormalities were associated with the duration of diabetes but not with the metabolic control or with other diabetic complications. However, the diabetic complications were associated with bad metabolic control and with the duration of diabetes. Hand abnormalities correlated with heavy manual work but not with smoking habits. Twenty-five of the 50 patients with hand syndromes were disabled to such an extent that surgery was recommended. CONCLUSION: The prevalence of hand abnormalities in diabetic patients is high and increases with the duration of diabetes. In many cases patients with hand abnormalities can be helped by surgery.

Adult↗