Cumulative Trauma Disorders

Cumulative Trauma Disorders

• No man’s land in flexor tendon → Zone 2

• Infertility workup → WHO grade 2 is most common

• BE FAN VEIN

• Patellar clunk syndrome

HLA associations

HLAs	Diseases
DQ1	• Pemphigus Vulgaris
DQ7	• BP variant
DQ2 / DQ8	• Celiac disease • Seal with DQ ()
DR2	• Good Pasteur’s (GBS) • Narcolepsy (DQB1:06:02) • Multiple sclerosis (B16, DR2) • 2nd - Good doctor () - have MS () - always sleeps ()
DR3	• Chronic active hepatitis • Dermatitis herpetiformis • SLE • Sjogren’s • T 1 DM
DR4	• Rheumatoid arthritis • Pemphigus vulgaris (DQ1, DR4)
DR5	• Hashimoto’s thyroiditis (DR3, DR5)
B27	• Ankylosing spondylitis • Reactive arthritis • Psoriatic arthritis
B35	• De Quervain's thyroiditis
B47	• CAH
B51	• Behcet’s disease
B57	• Abacavir hypersensitivity (B*57:01)

Shoulder Joint

Anatomy:

• Ball & socket joint.

• Supported by rotator cuff muscles & glenoid labrum.

Rotator Cuff Muscles:

1. Supraspinatus: In supraspinous fossa.

2. Infraspinatus: In infraspinous fossa.

3. Teres minor.

4. Subscapularis:
• In subscapular fossa,
• known as "forgotten tendon" of rotator cuff.

• Mnemonic:
• SITS
• Teres ne minor (Teres minor) aytt Rotate cheyth Sub () akkan 2 spine (supra, infra) venam

Impingement/Painful Arc Syndrome:

Description:

• Impingement of
• supraspinatus tendon +/-
• subacromial bursa

• in a narrow subacromial space upon abduction.

Evaluation:

• Maximum pain between 60°-120° (mid-abduction pain).

Provocative Tests:

Hawkin's impingement test.

Neer's impingement test.

• Mnemonic: Hawk (Hawkins) vann thollil irunn, shoulder neeradich (Neers)

Lady between 2 majors

• Intertubercular groove

• Pec major → Adduction and IR + Flexion

• Latissimus Dorsi → Adduction and IR + Extension
• Climbing muscle

• Teres major → Adduction and IR

• Mneumonic:
• Lady between 2 majors → LML → Addupichitt Internally (Add + IR) rotate cheyyan nokkum

SIT Muscles

• Greater tubercle has three prominences
• provide Insertion to ‘SIT’ muscles

• Initial abduction (0-15 degrees)
1. Supraspinatus

• External rotation
2. Infraspinatus
3. Teres minor

• Function
• Adduction?? and External Rotation

• When sitting (SIT muscle except Supraspinatus) in Lap → Addupich (Add) Externally (ER) rotate cheyyanam

Winging of scapula

Feature	Spinal Accessory Nerve (CN XI)	Long Thoracic Nerve	Dorsal Scapular Nerve
Muscle Innervated	Trapezius, Sternocleidomastoid	Serratus anterior	Rhomboids, Levator scapulae
Mechanism of Injury	Surgery in posterior triangle of neck	Sports injury, mastectomy	Rare; trauma or stretch injury
Main Deficit	Dropped shoulder, weak abduction, weak shrugging of shoulder	Winging scapula, can't lift arm above head	Winging scapula, esp. on slow lowering
Winging Increases When	Arm abducted at shoulder level	Wall push-up, head tilt	Slow lowering of raised arm

Adduction and IR

• MLM +

• Subscapularis

• ”Mneumonic: Sabu (Subscapularis) nte Wife 2 major (MLM) nte kude kidannu (Add+ IR)

Abduction of the Shoulder Joint

• 0–15°: Supraspinatus

• 15–90°: Middle fibers of deltoid

• 90–180°:
• Trapezius, serratus anterior
• Sar (Serratus anterior) trapped (Trapezius) us and said Hands up (overhead abduction)

Rotator Cuff Tear:

• Most Common Tendon Tear:
• Supraspinatus > Achilles tendon.

Causes:

• Degeneration (Most Common):
• In elderly patients.

• Trauma:
• In young patients.

Evaluation

Treatment:

• Avoid painful & overhead activities.

• Physiotherapy.

• NSAIDs (Nonsteroidal Anti-Inflammatory Drugs).

• Steroid injections.

• Arthroscopic tendon repair.

Popeye sign

• Rupture of Long Head of Biceps Tendon:
• Proximal rupture leads to distal migration of muscle belly

Elbow Joint

Tennis Elbow (Lateral Epicondylitis)

• (Most Common):

• Pathology:
• Inflammation of the
• common extensor origin
• lateral epicondyle

Earliest Affected Muscle:

• Extensor carpi radialis brevis > longus.

• Mnemonic: Go in car for tennis and golf

Cozen's test

• Extend wrist against resistance,

• causing pain at lateral condyle.

• Mnemonic: Make amma cozy

Golfer's Elbow (Medial Epicondylitis):

• Pathology:
• Inflammation of the
• common flexor origin
• medial epicondyle

• Earliest Affected Muscle:
• Flexor carpi radialis.

Evaluation (Reverse Cozen's test):

• Flex wrist against resistance,

• causing pain at medial condyle.

Treatment

• (Both Tennis and Golfer's Elbow):
• Activity modification.
• Counterforce brace:
• Prevents movement from reaching the muscle origin.



• NSAIDs.
• Physiotherapy.
• Steroids.
• Debridement.

Hand & Wrist Joints

De Quervain's Disease:

• Description:
• Stenosing tenosynovitis and
• inflammation of the
• abductor pollicis longus and
• extensor pollicis brevis tendons
• in the 1st dorsal compartment of the wrist.

• Causes:
• Overuse,
• Rheumatoid arthritis.

• Clinical Profile:
• Females > males,
• pain over radial styloid.

• Mnemonic: DEF → de quervain, Eichhoff, finklestein

Evaluation:

Finkelstein's Test.

Eichhoff's Test.

Suppurative tenosynovitis

 

• M/c Staph Aureus

• Kanavel sign
• ⇒ Pain on passive extension

• Fusiform swelling

• Resembles sausage

• Tenderness along sheath

• Finger held in flexion

Dupuytren's Contracture:

• Pathology:
• abnormal cord-like fibrosis of palmar aponeurosis
• contracture of finger.

• Etiology (Most Common):
• Idiopathic (Most Common).
• Diabetes mellitus.
• Alcoholism (Liver failure).
• Repetitive trauma

Clinical Profile:

• Males > Females

• Most Common Involved finger:
• Ring finger,

• Most Common Involved joint:
• Metacarpophalangeal (MCP) joint.

Ectopic Types (in other parts of the body):

Peyronie's disease (Penis).

Ledderhose disease (Soles of Feet).

Trigger Finger:

• Pathophysiology:
• Trauma → stenosis of A-1 pulley at MCP joint
• obstruction of flexor tendon passing through it
• difficulty in opening the finger
• finger suddenly opens on forceful extension.

• Etiology (Most Common):
• Trauma (Most Common).
• Rheumatoid arthritis.
• Help diff b/w ring finger and dupyutren
• Diabetes mellitus.

Clinical Profile:

• Females > males,

• Most Common Involved finger:
• Ring finger,

• Most Common Involved tendon:
• Flexor Digitorum Profundus (FDP).

Gamekeeper's Thumb/Skier's Thumb:

Pathology:

• Hyperabduction of the thumb

• tear/avulsion of the ulnar collateral ligament (UCL)
• at the 1st MCP joint.

• If Adductor pollicis entrapped → Steiner’s lesion ⇒ Surgical Rx

• Rx: Thumb spica splint

• Mnemonic: Game keep () cheyyan vangiyapo → Ullinnu collateral (Ulnar collateral) kodukkanam

Bowler's Thumb:

• Pathology:
• Neuroma of the ulnar digital nerve of the thumb
• due to perineural fibrosis.

• Mnemonic: Bowl () → Also game → Ullinnu ulla Nerve () povum

Bursitis

Description:

• Inflammation of bursae due to overuse → swelling, redness, pain.

Types:

• Housemaid's knee (Prepatellar bursitis).

• Clergyman's knee (Infrapatellar bursitis).

• Student's elbow
• Olecranon bursitis

• Haglund's/Pump bump deformity
• Mulholland hump
• Calcaneal spur
• Retrocalcaneal bursitis
• Calcification of bursa forms a bony bump behind the ankle.
• Mnemonic: Kalnte Bacilund → Haglund, Kalnte backil Mullu kond

NOTE

Pseudohypoparathyroid/ Albright Hereditary Osteodystrophy (AHO)

• Maternal

• Type 1 A → AD
• GNAS Mediated

• Mimic secondary Hyper PTH

• Mother → Lie to child (pseudo)

• PTH is high but cannot act

• (Same Pic as CKD, but Normal ALP)

• Psudo pseudo
• knuckle knuckle dimple dimple

• NOTE: If only short 4th Metacarpal
• Turner

PseudopseudohypoPTH

• Paternal

• AD

• Everything is normal

• Father → Lie to child and mother (pseudo pseudo) → but everything will be normal

Madelung

• Distal radial abn

• Seen in Turner’s syndrome

• Radius is not formed

• Radio carpal coalation doesnt take place

ㅤ	Williams syndrome	Marfan syndrome
Mutations	Elastin Mutation	Fibrillin Mutation
Leads to	Supravalvular aortic stenosis	Dilatation of aortic root ↳ Rupture → Death

ㅤ	ㅤ
Supravalvular AS	• Vitamin D toxicity • William syndrome
Supravalvular PS	• Noonan syndrome

ㅤ	Seen in
GNAS	• Mccune Albright • Cardiac Myxoma
GNAS 1	• Pseudohypoparathyroid/ Albright Hereditary Osteodystrophy
GNAQ	• Sturge Weber (Sporadic)

Thoracic Outlet Syndrome (TOS)

https://www.notion.so/Thoracic-Outlet-Syndrome-2180a7eb0c7780e4bc80db075ae40852?source=copy_link#2180a7eb0c7780e59888d4332f52e8c5