Osteoarthritis of the Fingers Heberden’s Nodes

Osteoarthritis is a degenerative condition of the cartilage. There is no clear etiology identified for osteoarthritis. Osteoarthritis is not related to tumor, inflammation, infection, gout, or trauma. Osteoarthritis is different from rheumatoid arthritis which is an inflammatory condition. The distal interphalangeal joint (DIP) is the joint that is most often involved with osteoarthritis. The trapeziometacarpal joint (TM) is the second most involved joint with osteoarthritis. When the trapeziometacarpal joint is involved, it causes pain with weak pinch and grip. Osteoarthritis of the fingers involves the following: DIP (Heberden’s Nodes). Heberden’s nodes are bony swellings (osteophytes) that can develop in the distal interphalangeal joints (DIP) due to the effects of osteoarthritis on these joints. Heberden’s nodes are a sign of osteoarthritis caused by osteophytes formation (bony outgrowth) of the articular cartilage in response to repeated microtrauma at the joint. Heberden’s nodes are more common in women than in men. PIP (Bouchard’s nodes) are also associated with osteoarthritis, and they are similar bony growths which develop in the proximal interphalangeal (PIP) joints. Bouchard’s nodes, like Heberden’s nodes, may or may not be painful. Swollen, hard, and painful finger joints (Heberden’s and Bouchard’s nodes) is the classical signs of DIP and PIP joint osteoarthritis. A mucous cyst is a small, fluid-filled sacs that form between the DIP joint of the finger and the bottom of the fingernail are another sign of osteoarthritis. The best treatment for the mucous cyst is surgical excision of the cyst and removal of the underlying osteophyte to decrease the risk of recurrence.

SLAP Tear Diagnosis & Treatment

 A SLAP tear is a tear that occurs where the biceps tendon inserts into the superior labrum. A SLAP tear is different from a Bankart lesion. A Bankart lesion is a lesion of the anterior inferior labrum, and it usually occurs with shoulder dislocation. SLAP tear is not common and can be hard to diagnose. Symptoms include pain deep within the shoulder or in back of the shoulder, pain when throwing a ball with decrease in velocity and the feeling of having a dead arm after pitching, pain with overhead activity which mimics impingement syndrome, and SLAP tear typically affects throwing athletes. When the biceps tendon is involved, pain may also be located at the front of the shoulder. SLAP tear can be an isolated lesion or it can be associated with internal impingement, articular sided cuff tear, or associated with instability. For clinical examination diagnosis of SLAP tear, usually the O’Brien test is the most commonly used test. Multiple tests are usually used (anterior slide test, clunk test, etc.). MRI with contrast is usually helpful. To perform the O’Brien’s test, the patient is standing or sitting with the arm at 90 degrees of flexion, 10 degrees of adduction, and full internal rotation with the forearm pronated. Do internal rotation of the arm with pronated forearm. The examiner applies pressure to the forearm and instructs the patient to resist the applied downward force. Pain at the shoulder joint suggests a SLAP lesion. Decrease in pain of the shoulder joint on supination of the arm is suggestive of a SLAP tear. Decrease in pain on supination of the arm. A normal labrum is seen on coronal MRI, and the normal superior labrum will show a black signal. The superior labrum is completely dark and triangular. A bright signal within superior labrum indicates a SLAP tear. Type II is the most common type. Type III is a bucket handle tear. White area with dye inside highlights the area of the tear. Treatment includes physical therapy, anti-inflammatory medication, injections, and surgery when conservative treatment fails. Surgery can be labral debridement for minor tearing and fraying. Biceps tenodesis is becoming popular; it is a procedure that cuts the biceps tendon where it attaches to the labrum and reinserts it in another area, usually in front of the shoulder. Biceps tenotomy is a procedure that cuts the biceps tendon from the glenoid and lets it fly. Releasing the long head of the biceps tendon from its attachment allowing it to fall into the upper arm out of the shoulder joint. Biceps tenotomy is probably suitable for some elderly patients. The patient may get a Popeye deformity and cramping of the upper arm. SLAP repair is a procedure which uses sutures to anchor the torn labrum to the glenoid. It is usually done for athletes and patients under the age of 40 years old.

Nerve Injuries

By Nabil A Ebraheim MD & Paige Chapman MD

Nerves originate from the spine. They provide sensation to the skin and allow motor power and function to the muscles. When nerves are injured, many structures are affected. Medial winging of the scapula usually occurs due to long thoracic nerve injury. The axillary nerve can be injured during dislocation of the shoulder joint. Anterior interosseous nerve injury can occur due to fractures and dislocations around the elbow. The O.K. Sign is a test for anterior interosseous nerve injury with a positive test being that the patient cannot bend the IP of the thumb or the DIP of the index finger. The O.K. sign is used to check for paralysis of the anterior interosseous nerve due to entrapment or compression injury. Patient with paralysis of the anterior interosseous nerve will be unable to make the O.K. Sign. Posterior interosseous nerve injury can occur secondary to Monteggia fractures, and the patient cannot extend the fingers. The patient will have wrist extension, but will not have finger extension. In normal radial nerve function, the patient will be able to extend the wrist and extend the fingers and the thumb. When you have a radial nerve injury, which usually occurs due to fractures of the humerus (especially the distal third of humeral shaft), the patient will have wrist drop, and the patient will also be unable to extend the fingers and the thumb. Compression of the median nerve usually occurs in carpal tunnel syndrome. The patient will have tingling, numbness, and pain of the area indicated by the diagram. It is usually the area of the thumb and index finger. Multiple provocative tests are used to diagnose carpal tunnel syndrome such as Compression test, Tinel’s test, and Phalen’s test, in addition to the typical distribution of the area of the symptoms. Tinel’s test is positive when you tap on the nerve, which will worsen the tingling in the fingers. Thenar atrophy could indicate a severe condition of carpal tunnel syndrome due to lack of motor innervation from the median nerve. When carpal tunnel syndrome is not improved by conservative treatment and splinting, corticosteroid injection may be tried. If the injection is successful, it indicates that surgery for carpal tunnel release will be successful, as compression of the median nerve in the carpal tunnel is likely the cause of their symptoms.  Surgery of carpal tunnel release can be open or endoscopic. A skin incision is made over the carpal tunnel on the volar wrist, the transverse carpal ligament is opened, and the median nerve is released. Cubital tunnel syndrome occurs due to compression of the ulnar nerve at the elbow. With ulnar nerve injury, the patient cannot cross the fingers or abduct the fingers. In ulnar nerve injury, Froment’s test is usually positive. This test is performed by pinching a piece of paper between the thumb and the index finger, the thumb IP joint will flex if the adductor pollicis muscle is weak due to the ulnar nerve injury. The adductor pollicis muscle is innervated by the ulnar nerve. There will be numbness and tingling in the ulnar half of the ring finger and the entire little finger. Cubital tunnel syndrome is usually treated by ulnar nerve release around the elbow or less commonly by transposition of the nerve. Claw hand deformity is a symptom of a lower ulnar nerve entrapment or injury. The injury is below the elbow and typically causes flexion and clawing of the 4th and 5th fingers due to unopposed ulnar FDP action. The femoral nerve supplies the quadriceps muscles which extends the knee. Injury to the femoral nerve will result in a weak quadriceps muscle and the patient will be unable to extend the knee. The differential diagnosis will be quadriceps or patellar tendon tear. The sciatic nerve is divided into two branches: common peroneal nerve and posterior tibial nerve. Injury to the common peroneal nerve will result in a foot drop. Posterior tibial nerve injury or compression usually occurs in tarsal tunnel syndrome. This will result in pain and numbness in the plantar aspect of the foot.

Technique of Vaccination in the Arm

By Nabil A Ebraheim MD & Paige Chapman MD

How do we do the technique of injection or vaccination in the arm? Know where the landmark for injection is located, for the deltoid injection it would be the middle third of the deltoid muscle about 2.5 to 5 cm below the acromion. Give the vaccine to the nondominant arm as there can be some soreness for a couple days afterwards. Sterilize the skin using alcohol swabs. Use the needle that is between 1- 1 1/2 inches in length (20-25-gauge needle). Pull the skin 2-3 cm away from the injection site with your nondominant hand. Pull the skin to one side and then insert the needle at a 90-degree angle (do not advance the needle deep to touch the bone). Inject the medication once you are in the muscle belly. Withdraw the needle. Release the skin. This Z track technique allows the injection tract to seal as the skin is released. It reduces pain, minimizes skin irritation and inflammation, and prevents leakage of the medication into the subcutaneous tissue (reduces local irritation). The new guidelines are that squeezing the muscle from front to back is not necessary and the Z track technique is helpful. Wearing gloves is optional and aspiration may not be necessary. Aspiration may be painful and in reality, no large vessels are present in the vicinity of the proper site of injection. The posterior circumflex humeral artery arises from the axillary artery and runs with the axillary nerve through the deltoid region. It is rare to injure that artery during deltoid injection, because the injection is usually superficial and not deep. The posterior circumflex humeral artery is deep and is close to the bone. Do not inject deep to the bone. Vaccination is safe and complications from vaccination are extremely rare. The most common complication is SIRVA, shoulder injury related to vaccine administration. It can happen if the vaccination is given too high or too deep. SIRVA occurs due to injection of the vaccine into the shoulder joint capsule rather than the deltoid muscle. If the injection is given too high, then the injection can go into the shoulder joint capsule. SIRVA is connected to injection of the vaccine into the shoulder joint, the shoulder joint capsule, or the rotator cuff. SIRVA usually can occur even if the vaccine is administered properly. The patient may have predisposition to this reaction (meaning this is how the patient’s body reacts to vaccination). It presents itself in the form of pain, inflammation, swelling, decreased range of motion. The condition is usually temporary (heals after a few months). The symptoms of SIRVA usually begin within 48 hours of vaccine administration, and they do not improve with simple analgesic medications. These patients usually visit their doctors for many months because of chronic shoulder pain and are usually diagnosed with bursitis, tendonitis, rotator cuff tears, or adhesive capsulitis. Refreshing the knowledge of the proper landmarks and injection technique is important and also increases awareness of identifying patients who are showing signs of SIRVA. This can help to treat the patient early.