de Quervain tenosynovitis

Tendons involved can be remembered by ALEB (ALL Exclusively Breastfeeding mothers!)

Abductor pollicis Longus and Extensor policis Brevis

Remember, it occurs commonly in new mothers due to the awkward way they support the baby's head with their hand e.g during breastfeeding. It can also be occupational (washer woman, carpenters, musicians, office workers)

The Finkelstein test is positive


© Cork Emergency Medicine 2013.



Low back pain; indications for imaging

Do imaging (initial: X ray, most accurate :MRI) if  there's:

point tenderness + compression symptoms


IV drug use (risk of epidural abscess) + compression symptoms


History of cancer with suspected metastases  + compression symptoms


Sciatica (disc herniation) + compression symptoms


Cauda Equina syndrome


Ankylosing spondylitis: (fused vertebrae)
young man with stiffness & low back pain worsened by rest! + Archilles tendon pain, AV block, Aortic insufficiency, uveitis, arthritis in other jts
(do Xray sacroiliac jt as initial test)




Cauda Equina syndrome is xterised by:

• Saddle anaesthesia
• Loss of sphincteric tone
• Incontinence
• leg weakness
• erectile dysfunction

Compression symptoms include:

• focal neurological deficit
• sensory loss
• hyperreflexia

(if suspected, give steroids immediately before investigation)

Pseudogout

looks like OA, involves large joints, wrists, but not DIP or PIP.

Calcium pyrophosphate deposition unlike uric acid in gout

Rhomboid shaped , +vely birefringent crystals unlike the needle shaped -vely birefringent crystals of gout

Suspect in patient with haemochromatosis or hyperparathyroidism

Arthritis

Osteoarthritis: Degenerative disease. Obese, athlete, weight bearing joints, DIP> PIP, Herbeden nodescrepitus, stiffness less than 15mins, normal labs, jt space narrowing, osteophytes, bone cysts, dense subchondral bone.

Rheumatoid arthritis: Autoimmune disease. Female, PIP, MCP, wrists,ankles, knees, morning stiffness longer than 30mins, nodules, systemic involvement, Baker cyst, Carpal tunnel syndrome,  anti-CCP (sensitive), raised ESR. Most common COD is CAD.

Gout: Metabolic. Male, sudden big toe swelling, pain and redness at night after binge drinking. Tophi, kidney stones, asymptomatic periods.

SLE: Autoimmune. Female. Other features of SLE, normal X ray, present in 90%


Reactive (Reiter's) arthritis: preceeded by an infection by chlamydia, Yersinia, shigella, salmonella or campylobacter. "Can't see, can't pee, can't climb a tree." Uveitis, non gonococcal urethritis, arthritis, archilles tendon pain, circinate balanitis, oral ulcers, nail changes etc Treat the preceeding infection + NSAIDS or Sulfasalazine if no response

Paediatric Hip joint pain

Slipped capital femoral epiphysis : Obese adolescent male, referred pain to knee usually present, loss of abduction and internal rotation of hip. Tmt: surgical pinning promptly to avoid avascular necrosis.

Legg-Calve-Perthes disease:  child 4-10yrs, male, avascular necrosis of femoral head, idiopathic. Tmt- splint or surgery

Septic arthritis:  Emergency. Acute onset, warm swollen jt, hematogenous spread following URTI, staph & strep,
hip is externally rotated, X ray usually normal,  wbc count is high, ESR is high.
Do USS guided aspiration- synovial fluid leucocyte >100,000 is definitely SA, do culture.
Tmt : drain immediately, empirical antibiotics nafcillin (or vancomycin ) + cephalosporin

Avascular necrosis in sickle cell anemia: African descent, history suggestive of SS

Transient synovitis:  male child 3-10yrs, following trauma or viral infection.

Exclude septic arthritis. if at least 3 of the following are present, do further workup.

Fever>39°C,
WBC >12,000,
ESR >40 ,
 Refusal to bear weight