Writer’s Cramp

Writer's cramp is a focal dystonia of the fingers, hand, and/or forearm. Symptoms usually appear when a person is trying to do a task that requires fine motor movements, such as writing or playing a musical instrument. Clumsiness and painful tightness in the hand

and forearm occur during writing or playing, and abnormal tension

and strange posturing of hand develops.  

It has a strong psycological over lay. A patient hearing of the complaints of the patient  & reassuring him of recovery helps him a great deal. Tranqulizers  & anti oxydents give relief.

Local Botulinum toxin injection produces temporary relief.

Retraining and learning new techniques help some patients. But the outlook is poor  in some cases and may lead to the end of musical careers.

Transient Synovitis Or “Irritable Hip”

Transient synovitis of hip usually affects children below the age of 5 years, caused by a fall, un noticd trauma or unaccustomed physical exercise.The child limps, may have slight rise of temperature & be irritable. Affected children are not acutely ill and can

move the hip, but with some degree of stiffness. An effusion may

be seen on ultrasound images and the condition is usually self -

limiting. They respond to non  steroidal anti  inflammatory drugs well.

These children should not be allowed to bear weight on the affected limb for 2-3 wks. as they run the risk of avascular necrosis (AVN)of femoral head later in life.

Septic Arthritis Hip

Septic Arthritis of Hip is relatively uncommon condition in children, but it should be suspected in a child who is ill, toxic and unable to walk. Movement of the affected joint is not possible because of pain. Diagnosis is confirmed by raised white cell count and erythrocyte sedimentation rate(ESR) and perhaps by effusion on ultrasound images. No test is perfectly sensitive or specific, so expert clinical judgement is required.

Urgent surgical drainage should be done to save the hip joint from destruction or to reduce the risk of late osteoarthritis.

Diagnosis may be particularly difficult in neonates.

Staphylococcus aureus  is the usual infective organism.

Patient will need long term antibiotic  therapy.            

Weight bearing should be avided until complete recovery.

Rheumatoid Arthritis

Rheumatoid Arthritis is a self limiting condition. But, by the time it leaves, the patient is crippled due to deformities & contractures & is demoralised.  Medicines help in controlling the pain & inflammation. Physiotherapy maintains join mobility, prevents contractures & deformities & helps in locomotion.

Anyway it may be tried:

Acetaminophen 250 mg TDS X 5 days

Bio D3 Max  1 tab OD X 10 days

Keep your moral up.

God bless you.

Commonly used drugs in rheumatoid Arthritis are

1.    HCQS (IPCA lab)200/300/400mg tabs OD/ BD

2.    FOLITRAX tabs (IPCA lab) methotraxate  2.5,/5.0,/ 7.5,/ 10.0,/ 15.0, mg tabs. Weekly dose

3.    SAAZ tabs (IPCA lab) 500/1000mg tabs.OD

4.     LEFNO lefunomide (IPCA lab)20.0,10.0mg tabs.ODdose.

These are all effective but toxic drugs. They should be taken under close medical supervision. Their doses need to be monitored from time to time. They can cause bone marrow depression & affect other organs adversely. LFT , KFT  & other investigative procedures may have to be under taken repeatedly.

Many of the anti Rheumatoid drugs (DMRD) have teratogenic effect i.e. they affect the unborn baby adversely. You must discuss it with your treating doctor in detail.

Raynaud’s Phenomenon

It results from severe vasospasm in response to

a temperature change, causes marked and typically sharply demarcated pallor of one or more digits. As circulation recovers, the digit becomes blue (cyanotic) and then bright red because of rebound

hyperaemia — the triphasic response. Raynaud ’s is commoner in

females than males. In young women the condition is often a harm less nuisance, requiring warm gloves and sometimes vasodilators.

Its onset for the first time in older people warrants investigation.

Raynaud ’s may also be part of a systemic autoimmune disorder

(rheumatoid arthritis, systemic lupus erythematosus, or systemic

sclerosis), and it occasionally leads to necrosis. When associated with rheumatoid disease, Raynaud’s can be extremely severe and requires specialist referral. It can also occur in people who use vibrating tools. Roughly two out of  three patients with primary Raynaud ’s phenomenon have spontaneous resolution of their symptoms (Spencer - Green, 1998).

Mallet Finger

This is a flexion deformity affecting the distal interphalangeal joint

of the finger and is due to either distal extensor tendon rupture or

avulsion with a bony fragment after traumatic forced flexion of the

extended finger tip. The resultant weakness is often painless and

presents with an inability to actively extend the fingertip.

Non traumatic mallet finger occurs more often in diabetics.

Treatment is usually by splinting the distal interphalangeal joint in extension

Surgery is rarely required.

Ganglion

A ganglion is a cystic swelling in continuity with a joint capsule or tendon sheath. It is a degenerative disorder  arising from the joint capsule. It is filled with clear, viscous fluid. Ganglia are common on the dorsum of  wrist.

They are often painless and resolve spontaneously

Often, only reassurance of the patient is required.

Wrist splints relieve the pain.

Aspiration and injection are rarely effective.

surgical excision is best avoided as recurrance rate after surgery is quite high.

De Quervain’s Disease

It is a painful condition of wrist.Pain is at the lower end of the wrist at the root of the thumb.Wrist movements become painful  particularly when rotation with fore is required eg. Opening & closing of a water tap or squeezing or wringing of clothes.

There may be swelling at the lower end of radius which is painful to touch.

Some times it appears during third trimester of pregnancy , but settles down of its own after delivery.

De Quervain’s stenosing tenosynovitis affects the tendon sheath of

abductor pollicis longus and extensor pollicis brevis at the radial

styloid process.  

 Tenderness & swelling  at the wrist are suggestive, but Finkelstein’s test   diagnostic. ( Ask the patient to close wrist with thumb in palm,give a sudden ulner jerk to the wrist,patient stands up with pain)

  Crepitus or a tendon nodulemay cause triggering.

Management   — Rest is essential, with avoidance

of thumb extension and pinching. Immobilization splints help, but are

are inconvenient.

Anti inflamatory drugs along with antioxidents gives relief.

Physiotherapy including wax bath, US. IFT & remideal exercises help.

Injection of steroid with local anesthetic give immidiate relief.It is better avoided,as the long term effects of steroids are not desirable.

Rarely surgical release of the tendons may have to under taken.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is characterised by pain, burning / tingling sensation, numbness at the wrist, palm, thumb, index, middle & adjoining half of ring finger. It is caused by entrapment of the median nerve in a tunnel, called Carpal tunnel. Entrapment is caused by the inflammation of the synovial sheath covering flexor tendons at the wrist.

Pain, tingling and numbness in fingers are typically present on waking up or can wake the patient.

The fingers feel swollen and intense aching is felt in the forearm.

The symptoms may appear when the patient holds a newspaper

Or the steering wheel of a car or holding objects in kitchen. Permanent numbness and wasting of the thinnear eminence cause clumsiness of movements. It may lead to depression.

Sometimes it is seen in the third trimester of pregnancy which settles down of its own after delivery.

Tests and investigations — tapping the median nerve in

The carpal tunnel or holding the wrist in forced

Flexion may provoke symptoms.

 Weakness of grip of hand is also suggestive of the condition.

 The carpal tunnel syndrome can be confirmed by US, MRI & CT scan. But they are usually not needed.

Management and injection technique — A splint worn on the wrist

at night relieves or reduces the symptoms of carpal tunnel syndrome.

This is diagnostic and may be curative.

Anti inflammatory & neurotropic drugs help in recovery.

 A corticosteroid injection into the carpal tunnel may also be considered,

This often helps rapidly, although recurrence is common.

Surgical decompression of the median nerve is usually a permanent solution.