CHAPTER 12: HAND - ARTHRITIS, DUPUYTREN'S, TUMOURS Flashcards
0
Q
What is osteoarthritis?
What is the incidence and pathogenesis?
A
OA = degenerative arthritis
- 10% of adults over 50 have some OA
- X-ray evidence in almost everyone over 60
PATHOGENESIS
- Destruction of articular cartilage
- Sclerotic periarticular bone, +/- areas of porosity (cysts)
Mild synovitis and inflammatory joint effusions
- Idiopathic / after joint injury → joint instability, joint surgery, inflammatory joint disease
1
Q
What is arthritis?
How is it classified?
A
Arthritis = joint disease associated with inflammation
Degenerative Arthritis
- Erosive arthritis → Osteoarthritis
Inflammatory Arthritis
- Rheumatoid arthritis
- Psoriatic arthritis
- Gout
- Pseudogout
- Systemic lupus erythematosus (SLE)
Infective Arthritis
- Septic arthritis
2
Q
How is osteoarthritis classified?
A
Swanson Classification (JHS 1985) JSECS! I Joint narrowing II + Subchondral sclerosis, hypertrophic nodes III + Erosions IV + Cyst formation, deviation V + Dislocation or subluxation
3
Q
What are the clinical features of OA?
A
- Most upper limb = DIPJ and basal joints of thumbs
- Pain, stiffness, ↓ movement
- Bony swelling (osteophytes), effusions, tenderness
- DIPJ bony swellings = Heberden’s nodes
- PIPJ = Bouchard’s nodes
4
Q
What are the typical features on X ray?
A
- Narrow joint space
- Sclerosis
- Cyst formation within the bone underlying the joint
- Periarticular osteophytes
5
Q
What is the treatment for OA?
A
Non Op → activity modification, splint, NSAIDs, Intra-articular steroids, Physio
Surgery - for
pain/stiffness/deformity/cosmesis
DIPJ → fusion
CMCJ → Arthrodesis/ Trapeziectomy, Osteotomy of base of 1st MC, Ligament reconstruction. (Trap can be replaced by nothing, implant, rolled FCR, or PL)
Arthrodesis e.g. index finger:
- MCP 25deg
- PIPJ 40deg
- DIPJ 15deg max
Techniques:
- 90/90 box wires
- Lister loop
- Tension band wiring (around x2 k-wires)
- Parallel K-Wires
Arthroplasty (next slide)
6
Q
What are the risks of finger joint replacements?
A
Infection – 1%
Pain – This usually settles over the first week and is usually moderate.
Stiffness – Often the joint that is being replaced is very stiff. If this is the case the resultant movement after the operation will be limited. This is the most common complication in small joint replacements.
Swelling – The finger will remain swollen for 3 to 6 months
Nerve injury – Localised numbness around the wound may occur. It usually resolves with time.
Dislocation – This is a risk in the short term, before the tissues tighten. The risk is low, but if it does occur, a short anaesthetic is required to relocate the joint.
Loosening – This is the long term complication of the joint replacement and is almost inevitable. Once the joint is loose, it may become painful and swollen again. At that stage the majority of patients would have their replacement converted to a fusion. Hopefully though there have been many years of benefit!
7
Q
What types of arthroplasty do you know?
A
Soft tissue and Perichondrial arthroplasty:
- Cartilage graft with/without silicone spacer
- Tupper arthroplasty MCPJ - volar plate into joint
- Volar plate arthroplasty for PIPJ - a different op to Tupper
Replacement Arthroplasty
- Pyrolytic Carbon - good for high demand hands i.e. OA as opposed to RA £800 each
- Swanson silastic spacer - low demand hands as wear out - £80 each. Good for MCP and PIP
- Neuflex - silicone implants with special hinges, less strain on implant, fingers are in more anatomical position
1 = unconstrained - complications: subluxation, dislocation, loosening, implant fracture and joint stiffness
2 + 3 = constrained hinge: loosening, fracture. Neuflex’s centre of rotation is more volar
8
Q
How does psoriatic arthropathy present? What xray findings are there?
A
10% of pts with psoriasis
Clinically → DIPJs or whole finger (sausage finger)
X-ray → Joint surface erosions, Concave cup deformity of the distal phalanx surface and convex pencil deformity of the middle phalanx (pencil in cup deformity)
9
Q
What is gout and pseudo gout?
A
♂>♀ 8:1
Gout → intra- and periarticular deposits of needle shaped crystals of monosodium urate monohydrate → inflammatory arthritis.
Pseudogout → Calcium pyrophosphate deposits.
Hyperuricaemia – Primary or Secondary
Primary → ↑ intake (red wine and meat), enzyme abnormality, ↓ excretion
Secondary → Diuretics (esp. thiazides), Myeloproliferative disorders.
10
Q
How does gout present and what is the treatment?
A
Clinical Presentation
Acute gout → painful synovitis, red, inflamed, 90% self limiting, 60% affect 1st MTPJ, also wrists and fingers. Main DD = infection.
Chronic gout → tophi - sc nodules w crystals, may ulcerate through skin, erosive arthritis.
Diagnosis
- MUM crystals on polarised light microscopy (negative birefringence)
- High uric acid levels are NOT diagnostic
- X-ray → large punched out erosions away from the joint margin, soft tissue swelling.
Treatment
Acute → high dose NSAIDs, Colchicine
Chronic → Low purine diets, xanthine oxidase inhibitor → allopurinol, uricosuric drugs such as probenecid.
11
Q
what is RA? Incidence and aetiology?
A
RhA is inflammation / expansile / invasive - 3 phases -
1. Proliferative
2. Destructive
3. Reparative (burnt out)
Originates in synovium (joints and tendons)
2% of population worldwide
♀>♂ 3:1
90% some hand involvement, 10% significant
? due to autoimmune reaction to agent within synovial tissue → interacts with IgG and IgM antibodies → synovial inflammation.
70% rheumatoid factor +ve (IgG / IgM)
12
Q
How is RA hand disease classified?
A
Monoarthropathy → single joint Pauciarthropathy → 2-4 joints Polyarthropathy → over 4 joints or Monocyclic disease → one attack Polycyclic disease → recurrent attacks Progressive disease → chronic worsening disease
13
Q
What is the 1987 American College of Rheumatology classification
criteria for rheumatoid arthritis?
A
1-4 >6wks
- Morning stiffness of >1 hour most mornings
- Arthritis and soft-tissue swelling of >3 of 14 joints/joint groups
- Arthritis of hand joints
- Symmetric arthritis
- Subcutaneous nodules in specific places
- Rheumatoid factor at a level above the 95th percentile
- Radiological changes suggestive of joint erosion
At least four criteria have to be met for classification as RA.
14
Q
What are the 3 clinical stages of RA?
What changes are seen in the bones and cartilage?
A
- Proliferation → synovial swelling and pain
- Destruction → erosion of tendon, bone and joint
- Reparation → ↓ synovial activity and fibrosis – burn-out.
Bone Disease in RA
- Sclerotic
- Lytic
- Mutilans
Cartilage Destruction in RA
- Articular Lysosomes
- Free radicals from neutrophils - damage
- Inhibition of cartilage production
15
Q
What is the 2010 American College of Rheumatology/European League Against Rheumatism classification
criteria for rheumatoid arthritis?
A
Target population : Patients who
1) have at least 1 joint with definite clinical synovitis (swelling)
2) with the synovitis not better explained by another disease
Classification criteria for RA
Cutoff score for RA is 6/10
A. Joint involvement
1 large joint = 0
2 - 10 large joints = 1
1 - 3 small joints (with or without involvement of large joints) = 2
4 - 10 small joints (with or without involvement of large joints) = 3
>10 joints (at least 1 small joint) = 5
B. Serology (at least 1 test result is needed for classification)
Negative RF and negative ACPA = 0
Low-positive RF or low-positive ACPA = 2
High-positive RF or high-positive ACPA = 3
C. Acute-phase reactants (at least 1 test result is needed for classification)
Normal CRP and normal ESR = 0
Abnormal CRP or abnormal ESR = 1
D. Duration of symptoms
=6 weeks = 1
ACPA = anticitrullinated protein antibody
16
Q
What extra-articular manifestations of RA?
A
Eyes →
Iritis, Scleritis, uveitis,
Sjögren’s syndrome = dry eyes –keratoconjunctivitis sicca, xerostomia and RhA.
Nervous system →
Peripheral neuropathy , carpal tunnel + other nerve entrapment syndromes, cervical myelopathy, mono neuritis multiplex.
Haemopoietic syn →
Anaemia, Felty’s syn (RA, splenomegaly, neutropenia).
Heart → Pericarditis, myocarditis, pericardial effusions, valvular heart disease, conduction defects.
Lungs → Pleural effusions, nodules, fibrosing alveolitis, Caplan’s syndrome: RA + pneumoconiosis.
Kidneys→ Amyloidosis
Skin → vasculitic ulcers and rashes, pyoderma gangrenous,, pretibial lacerations Rh Nodules (20% of pts) esp. olecranon, thin skin due to steroids.
17
Q
How do RA patients present?
A
- Joint or systemic symptoms
- Upper limb joints → elbow, wrist, MCPJ and PIPJ.
- Numbness, paraesthesiae, weakness.
- Record time period over which symptoms have occurred.
- Degree of functional impairment
18
Q
What investigations are there for RA?
A
Blood → Rh factors, ACPA, CRP. X-ray → - Joint space widening (effusion) - then narrowing and ankylosis due to joint destruction. - Juxta-articular erosions, - Fusiform soft tissue swelling, - Periarticular bone cysts, - Generalised osteopenia.
19
Q
What is the conservative treatment of RA?
A
Aim: induce remission with no active joint inflammation and no erosive or functional deterioration.
MDT
GP, rheumatologist, hand surgeon, nurse specialist, physiotherapist, occupational therapist, dietitian, podiatrist, pharmacist, and social worker
Steroid injections, physio, splints, activity modification
20
Q
What is the medical treatment of RA?
A
Analgesics + Anti-inflammatories
- paracetamol, opiates
- NSAIDs
- COX-inhibitors (celecoxib, etoricoxib)
Corticosteroids
Non- biological DMARDS
- azathioprine, ciclosporin, d-penicillamine, hydroxychloroquine, leflunomide, methotrexate, mycophenolate mofetil (MMF), sulfasalazine
Biological DMARDS = cytokine modulators (used if patient resistant to methotrexate)
- Tumour necrosis factor (TNF) inhibitors: adalimumab (Humira), certolizumab pegol, Etanercept (Enbrel), golimumab, infliximab.
- Anti-interleukin-1 therapy: Anakinra (Kineret).
- T-cell co-stimulator modulator: abatacept.
- Anti-CD20 therapy: rituximab.
- Anti-interleukin-6 receptor therapy: tocilizumab.
21
Q
What are the indications for surgery?
A
- Pain
- Loss of function
- Disease progression (Prophylactic surgery to prevent future deformity)
- Cosmesis
Deformity without loss of function is not an indication for surgery
22
Q
NICE guidelines on referral for surgery
A
If failed non-surgical therapy:
- Persistent pain (from e.g. joint damage or other soft tissue cause).
- Worsening joint function.
- Progressive deformity.
- Persistent localised synovitis.
Refer people with complications for a specialist surgical opinion before damage or deformity becomes irreversible:
- Imminent or actual tendon rupture.
- Nerve entrapment (e.g. carpal tunnel syndrome).
- Any stress fracture.
Refer urgently for:
- Suspected or proven septic arthritis (especially in a prosthetic joint).
- Any symptoms or signs that suggest cervical myelopathy.
23
Q
What are the principles of surgery?
A
- Best shot first
- Minimum intervention for maximal result
- Treat the patient, not the x-ray
- Midline, longitudinal incisions to allow repeat surgery
24
How should procedures be prioritised?
Flexors before MPs before Extensors
Start proximal then go distal - wrist is the key
Soutar's Winners 1979 - Groups
I
Thumb MPJ fusion
Extensor synovectomy + excision ulna head
II
Flexor tendon synovectomy
MP joint arthroplasty
III
PIP joint fusion
Wrist stabilisation
IV
Correction of swan-neck deformity
MP & PIPJ synovectomy
Thumb IPJ fusion
V
PIPJ arthroplasty
Boutonniere correction
25
What wrist deformities are noted in rheumatoid arthritis?
Carpal supination (ulnar side of wrist dropped)
Volar translocation
Ulnar translation
Radial rotation
Caput ulnae = prominent ulnar head
26
What is ulnar shift vs ulnar drift?
Ulnar drift = ulnar deviation + ulnar shift
Ulnar deviation = ulnar rotation of the PP in relation to MC head
- can be normal (index is always ulnar deviated unless 1st dorsal interosseus is actively abducting finger)
- becomes abnormal when it cannot be corrected
Ulnar shift = ulnar translation of PP in relation to MC head
- is always pathological
In RA the MCPJ also develops volar dislocation / subluxation
27
What is ulnar shift vs ulnar drift?
Ulnar drift = ulnar deviation + ulnar shift
Ulnar deviation = ulnar rotation of the PP in relation to MC head
- can be normal (index is always ulnar deviated unless 1st dorsal interosseus is actively abducting finger)
- becomes pathological when uncorrectable.
Ulnar shift = ulnar translation of PP in relation to MC head, causing joint incongruity and eventual subluxation.
- is always pathological.
In RA the MCPJ also develops volar dislocation / subluxation
28
How do you correct extensor tendon rupture?
- Tends to occur in ulnar to radial direction
EDM EDC EI (ECU is protected)
- Direct repair not normally possible
- Suture to adjacent tendon is best
- Both little and ring together → both to middle finger, or EIP to little and ring to middle.
- If all ruptured → FDS ring transferred from palm (Boyes transfer)
29
Describe the classic wrist deformity
Caput ulnae syndrome
- Volar subluxation of carpus
→ Volar subluxation of ECU + tendon swings around & acts more as flexor
- Supination of carpus
- Prominent ulnar (piano key sign)
- Dorsal swelling = synovial proliferation within ext compartments
Surgery
1. Synovectomy
- extensor tendons
- DRUJ
2. ECRL to ECU transfer to correct radial deviation and carpal supination.
3. Excision of distal ulna
- limited (Bowers)
- complete (Darrachs) + sling of extensor retinaculum can be used to support subluxed ECU tendon.
- segmental resection of distal ulna shaft and fusion of DRUJ (Sauve-Kapandji)
4. Wrist-Fusion
- radio-lunate (Chamay)
- radio-scaphoid
- total
- Intermetacarpal placement of Stanley pin (instead of through 3rd MC) to extend wrist for better grip, or
- Dorsal locking wrist plate (suitable for osteopenic bone).
30
What is Z deformity and why does it occur?
- When a joint adopts angulation in one direction, the next joint down/up adopts compensatory opposite angle
- Swan neck can be thought of as same in palmar/volar plane
31
How does flexor tenosynovitis present?
```
Pain on finger flexion
↓ range of finger movement
Trigger finger
Carpal tunnel syndrome
Crepitus on finger flexion
Synovial erosion → flexor tendon rupture.
```
Treatment → flexor synovectomy
- small nodules (rice bodies) may be found in flexor sheaths
- DO NOT RELEASE A1 PULLEY
32
How does flexor tenosynovitis present?
- Swelling proximal to wrist crease
- Pain on finger flexion
- ↓ active and passive ROM
- Trigger finger
- Carpal tunnel syndrome
- Crepitus on finger flexion
- Synovial invasion → flexor tendon rupture.
Treatment → flexor synovectomy
- small nodules (rice bodies) may be found in flexor sheaths
- DO NOT RELEASE A1 PULLEY
33
What is the commonest flexor tendon rupture and how do you treat it?
Mannerfelt lesion = FPL most common, attrition on scaphoid osteophytes.
- Reconstruction by direct repair / tendon graft / middle or ring FDS transfer or IPJ arthrodesis if joint is unstable or destroyed.
Fingers: rupture of
- FDP in palm → transfer distal stump to adjacent FDP.
- FDP in finger → arthrodese DIPJ + tenosynovectomy to preserve FDS.
- FDS → not usually noticed clinically → synovectomy to protect FDP.
- FDP + FDS → reconstruct FDP using FDS tendon graft.
34
What changes are observed at the MCPJs?
MCPJ synovitis → erodes through dorsal joint capsule → sagittal bands stretches & radial is thinnest therefore ulnar deviation + volar subluxation occurs.
Ulnar drift = ulnar deviation + ulnar shift
Factors for volar subluxation:
1. Weak or stretched dorsal extensor expansion
2. Dislocation of the extensors into valleys between MCs
3. Detached or stretched collaterals
Factors for ulnar drift are:
1. Thumb pressure on index from key pinch
2. Intrinsic tightness
3. Pull of abductor digiti minimi
4. Ulnar inclination of MC heads
5. Radial deviation of the wrist causing compensatory ulnar deviation of MCPJs by Z
mechanism.
6. Ulnar deviating forces of flexor tendons
35
What are the surgical options of MCPJ treatment?
1. Synovectomy
2. Synovectomy
+ intrinsic release,
+/- crossed intrinsic transfer,
+ extensor tendon stabilisation.
3. Replacement Arthroplasty
36
What are the steps in MCPJ arthroplasty?
Swanson
- 'a flexible hinge or a dynamic spacer'.
- Implant + capsule form new joint.
1. Skin incision – longitudinal
2. Through ulnar sagittal band, intrinsic release ulnarly
3. Sagittal arthrotomy
4. Excise MC head at metaphyseal flare (cutting block)
5. Synovectomy
6. Volar plate release from base of P1
7. Reaming, broach
8. Trials
9. Drill dorsoradial MC for collateral reattachment radially
10. Implant
11. Reef radial sagittal band, Centralise and Radialise Extensor
12. Close
37
What changes are observed in the PIPJ and what deformities result?
Synovial inflammation + proliferation → stretching of extensor mechanism → imbalance in extensor mechanism → swan neck or boutonnière deformity
38
What is a swan-neck deformity and what is the classification?
Hyperextension at PIPJ and flexion at DIPJ
Causes
- PIPJ volar plate rupture
- Attenuation of FDS (synovitis)
- Intrinsic tightness
- MCPJ subluxation
- Mallet deformity
Classification (Nalebuff 1989)
I PIPJ flexible in all positions
II PIPJ flexion limited in some positions
III PIPJ flexion limited in all positions
IV Stiff PIPJ with poor radiographic appearance
Surgery - depends on PIPJ mobility
1. PIPJ flexible in all positions (I) → silver ring splint limiting extension or flexor tendoesis (FDS sling detached proximally and anchored to hold PIPJ in some flexion)
2. PIPJ flexion limited (II+III) → intrinsic release, extensor tenolysis, capsulodesis or tenodesis.
3. Stiff PIPJ, joint destruction (IV) → arthroplasty or arthrodesis.
39
What is a Boutonniere deformity?
Flexed PIPJ and hyperextended DIPJ
Synovial proliferation → erosion just lateral to the central slips over the PIPJ → volar displacement of lateral bands from pull of TRL → flexor force on PIPJ → attrition of central slip.
Nalebuff and Millender’s classification.
• Type I: PIPJ extensor lag of 10∘–15∘, passively correctable.
∘ Night splinting with steroid injection.
∘ Dolphin or Fowler tenotomy.
– Lateral bands are divided distal to PIPJ to reduce abnormal flexion forces exerted by them on PIPJ.
– Tenotomy is done proximal to the oblique retinacular ligament insertion, which avoids a mallet deformity.
• Type II: PIPJ extensor lag of 30∘–40∘, passively correctable.
∘ Surgery to shorten central slip or centralise lateral bands.
• Type III: Fixed flexion deformity of PIPJ.
∘ Arthrodesis or rarely, Swanson-type arthroplasty.
40
What is Z deformity of the thumb? How is rheumatoid thumb classified?
• Z deformity of thumb: either boutonnière or swan neck deformity.
• Mechanisms underlying these deformities are analogous to those in finger:
∘ Thumb MCPJ≅finger PIPJ.
∘ Thumb IPJ≅finger DIPJ.
∘ Adductor pollicis and APB≅intrinsic lateral bands.
∘ EPB≅central slip.
Type I: Boutonnière (most common).
Type II: Mixed type I and type III – adducted boutonnière (rare).
Type III: Swan neck.
Type IV: Gamekeeper’s thumb – laxity of MCPJ UCL.
Type V: Swan neck without CMCJ adduction contracture.
41
What causes thumb CMCJ OA?
weakness of Beak Ligament (deep anterior oblique ligament – the ‘volar-plate’ of the thumb CMCJ
42
What are the treatment options for rheumatoid thumb?
Aimed at location of disease.
Types I, IV and V = predominant MCPJ disease.
– Arthrodesis.
Type III = predominantly CMCJ disease.
– Trapeziectomy or
– Hemiarthroplasty (resembles half a Swanson-type implant).
Operations
- Synovectomy
- Arthroplasty
- Arthrodesis
- Tendon repair, replacement or repositioning
- Arthroplasty MP and fuse IP
43
Thumb CMCJ OA classification
Eaton & Littler Classification
o 1 – Widening of joint, < 1/3 subluxation
o 2 – 1/3 subluxation, calcific deposits <2mm in diameter, Joint contours ok
o 3 - >1/3 subluxation, fragments >2mm, cysts, sclerosis, minor joint narrowing
o 4 – Advanced, Major subluxation, joint narrowing, sclerosis, osteophytes, STT involved too.
44
How is CMCJ OA managed?
Conservative – activity modification, NSAIDs, Splint, Steroids
Surgical
Arthrodesis – Muller 1949 (not if STT jt arthritic)
Arthroplasty – Paul Smith hemi-trapeziectomy & French ball/socket prosthesis
Denervation – Lorea 2002, Derby
Osteotomy of proximal thumb MC
Trapeziectomy – Harvey Gervis
- grip strength decreases, 12wk recovery
- Complications = 15% - mainly sensory nerve problems - sensory loss or neuroma
45
Explain the procedure of trapeziectomy and LRTI
Ligament Reconstruction with Tendon Interposition (Pelegrini and Burton 1986)
Technique
1. Dorsal incision over CMCJ
2. Expose radial artery - divide deep branch(es)
3. Longitudinal incision into CMCJ
4. Bisect trapezium into palmar (removed 1st) and dorsal fragments (saw / nibbler)
5. Watch for FCR
6. Remove osteophyte between 1st & 2nd MC
7. 2 incisions over FCR - proximal and distal to harvest radial side using traction sutures
8. Drill hole in base of 1st MC at 90deg to nail
9. Thread FCR through hole using a prolene/dental-wire loop
10. Double graft back on itself - suture together to recreate basal ligament of thumb - leave suture ends long for next step
11. Roll + stitch together remaining tendon push into cavity and tie into place
12. Repair capsule - v. important
46
What is the epidemiology and aetiology of STT arthritis?
1% over 30s, 10% of post menopausals
Most are asymptomatic. Minority need surgery
Kinematics - joint is also imp for radial/ulnar dev as well as flexion/ext
?poor Capito-trapezium lig.
47
How is it managed?
Non-surgical
1. Splint - Futuro is v good
2. NSAIDs
Surgical
1. Trapeziectomy - if assoc with CMCJ arthritis
2. Excision arthroplasty
3. lnterposition arthroplasty (Vivian Lees)
4. Denervation - better for prox row pain
5. STT Arthrodesis with bone graft - For isolated STT-OA. Rough up dorsum - not whole joint otherwise get collapse
48
What are the complications of STT arthrodesis?
Pain for at least 15 weeks
Non-union
Pin problems
Altered kinematics
49
What is the difference between intrinsic tightness and extrinsic tightness?
Bunnell-Littler test
- hold the MP joint in maximum extension and passively flex the PIP joints
- now hold MP joints in flexion and passively flex the PIP joints.
If the PIP joint can be passively flexed more when the MP joints are flexed than they can when the MP joints are in extension = tightness in intrinsic muscles.
Extrinsic Tightness test
- do the same test in both positions
- results are opposite.
If you can passively flex the PIP joint more when the MP joint is extended then you can when the MP joint is flexed = extrinsic tightness.
50
Define Dupuytren's disease
Benign fibroproliferative disease of the hand characterised by contraction of palmar and/or digital fascia.
- 1831 Guillame Dupuytren
51
What is Dupuytren's diathesis?
It describes a more aggressive form of the disease
1. Family history
2. Bilateral disease
3. Ectopic lesions
- penile fibromatosis 2-4% (Peyronie’s disease)
- plantar fibromatosis 5-20%(Ledderhose disease)
- Garrod's pads 2-44%
4. Male
5. Early age at onset
(6. Radial disease)
52
What is the epidemiology?
What is the pathogenesis?
- 1-3% of population of N Europe and USA
- Rare in Far East and Africa
- ↑ incidence with age
- M > F until age 70 (M=F)
- Strong hereditary disposition (AD, variable penetrance)
- trauma may hasten onset of DD in predisposed individuals
- ? more common in DM, ETOH, smoking (microangiopathy, local tissue ischaemia, free radical release) or epilepsy
Early stages → large number of fibroblasts in palmar fascia. → transform to myofibroblasts (smooth muscle fibres) → contraction.
Type III collagen early get Type I later.
53
Describe the normal anatomy of the palmar fascia
3 layers of palmar aponeurosis
1. Superficial → longitudinal fibres
2. Intermediate → transverse fibres of Skoog
3. Deep → vertical fibres of Juvara and Lejueu encircles flexor sheaths and binds the fascia to the deep transverse ligaments and metacarpals
Distally the longitudinal fibres split into 3 layers and insert into
1. Superficially → dermis
2. Middle → Spiral band of Gosset (dorsal to NVBs) → lateral digital sheet
3. Deeply → middle phalanx and flexor sheath
54
What structures contribute to Dupuytren's disease and contracture?
1. Pretendinous cord = superficial longitudinal layer contracture (MCPJ contractures)
2. Central cord = continuation of pretendinous cord into finger
3. Lateral cord = contracture of the lateral dig sheet
4. ADM Cord = ulnar side of the little finger
5. Retrovascular cord = dorsal to NVB, volar to Cleland’s
6. Natatory cord = limits abduction at MCPJ (webspace contractures)
7. Superficial layer of pretendinous cords (skin pitting)
8. Spiral cord (causes PIPJ & MCPJ contracture). Made up of:
1. Pretendinous band
2. Spiral band
3. Lateral dig sheet
4. Grayson’s ligament
- are actually straight! it contracts and causes NVB to spiral around it (medially and superficially)
55
What features in history and examination
| are important in determining management?
History
- disease progression (rapid)
- ADLs (affected)
- Dupuytren's diathesis
Examination
- extent of disease - skin & joint involvement
- Heuston's tabletop test
- tender palmar nodules
Historically when MCPJ contracture >30 or any degree of PIPJ contracture, surgical intervention is indicated. No evidence this must be followed
56
What other structures are important in understanding Dupuytrens?
Spiral Band = normal condensation of fascia from longitudinal bands → natatory ligament
Natatory Ligament = passes transversely across web space
Lateral digital sheet = vertical condensations of fascia along finger outside NVB
Grayson’s ligaments = proximal and middle phalanx → skin VOLAR to the NV bundles
Cleland’s ligaments → DORSAL (ClelanD = Dorsal) (no disease)
57
What are the clinical features?
- palmar skin changes (pits, nodules)
- thickening of the palmar fascia and cord like structures from palm into the digits.
- flexion and/or adduction contracture of MCPJs PIPJ DIPJ
- ring finger most commonly affected, then little, middle, index, thumb.
58
Classify Dupuytren's disease
Dias and Braybrook 2006
Mild
- No functional problems
- No contracture.
- Mild MCPJ contracture only (30)
- Reassure, observe
Moderate
- Notable functional problems
or moderate MCPJ contracture (30 - 60).
- Moderate PIPJ contracture (less than 30).
- First web contracture
- Needle fasciotomy if appropriately trained; for MCPJ contracture
- Possibly collagenase
- Refer for surgery – limited fasciectomy
Severe
- Severe contracture of both MCPJ (60+) and PIPJ (30+).
- limited fasciectomy
- dermofasciectomy
59
How is Dupuytren's contracture graded?
Grading
• Tubiana Grading of Total Passive Extension Deficit
1. 0-45°
2. 45-90°
3. 90-135°
4. >135°
• Mikkleson 1976
1. Nodule or band, no contracture
2. 1-45° total contracture (adding up all joints)
3. 45-90°
4. 90-135°
5. >135°
60
Conservative and outpatient procedures
1. Intralesional triamcinolone injection to painful nodules
- 50% recurrence in 1-3yrs (Ketchum 2000)
2. Collagenase (clostridial)
- direct injection into cords and nodules
- Hurst 2009 NEJM - now completed Phase III of Level 1 multicentre study - significant improvement at 90 days (?any better than NF)
- inject D1, straighten D2
- only licensed for MCPJ not PIPJ contracture
- £1200 per injection
- Trials - Derby, Southampton
3. Percutaneous fasciotomy (Foucher 2003)
- NICE approved, but risks = risk of NVB damage esp border digits, tendon injury, CRPS, infection, recurrence 65%
61
What is the evidence behind collagenase injections?
Collagenase Option for Reduction of Dupuytren’s Trials.
Evidence for the efficacy of Xiapex® comes from two pivotal, double-blind, placebo-controlled RCTs of identical design (CORD-1 and CORD-2) Hurst 2009, Gilpin 2010.
- All patients had >20° contracture.
- Primary end point = reduction of contracture to ≤5°, 30 days after last injection.
• CORD-1 included 203 patients and demonstrated efficacy of 64% compared to 7% with placebo. 39% reached primary end point with 1 injection. Mean = 2.17 injections.
• CORD 2 had 45 patients (more PIPJ disease in this cohort).
- 44% reached primary end point vs 5% with placebo.
• CORDLESS Trial: 3yr follow-up.
- 623/1080 treated reached primary end point (1st study).
- Of the 623 successfully treated, 35% recurred (meaning 20°+ recurrence or medical intervention required)
- 7% of the 623 required surgery or other medical intervention.
62
Tell me about Collagenase
Xiapex (Pfizer) = Collagenase
- 2 enzymes derived from Clostridium histolyticum.
- Used for treatment of Dupuytren's contracture in an outpatient setting, by a suitably trained hospital specialist.
- In patients with two or fewer palpable cords per hand and where needle fasciotomy is not appropriate.
Costs £650 / vial.
On average 1.7 treatments per patient.
Not cost effective if >2 injections (+4 OPD visits) required per patient c.f. limited fasciectomy as day case.
63
Tell me about the safety and efficacy of Xiapex
Adverse effects
- peripheral oedema, contusion, injection site pain, tenderness, swelling at the injection site, localised itching, injection site haemorrhage and lymphadenopathy.
Serious adverse reactions
- tendon rupture
Contraindicated
- hypersensitivity to active ingredient or excipients
- anticoagulants in the previous 7 days
- tetracyclines in the previous 14 days
No dosage adjustments necessary in elderly, renal or hepatic impairment
In clinical trials, Xiapex®▼ produced better results when used in patients with less severe baseline contractions and when used in metacarpophalangeal (MCP) rather proximal interphalangeal (PIP) joints
64
What is the evidence for needle and open fasciectomy and Collagenase injections?
Systematic review comparing open fasciectomy, needle fasciectomy and collagenase injections
- All treatments are associated with a high recurrence rate and complications.
(A) Needle fasciectomy (50 - 58% with mean f/u 3-5 years)
(B) Open fasciectomy (12 - 39%, 1.5 to 7.3 years mean f/u)
(C) Collagenase injections (10 - 31%, 4mths-4yrs mean f/u)
65
What are the indications for surgery?
- Functional deficit
- Flexion of MCPJ > 20-30°
- Any contracture of IPJs, Pickford says 20°
- BSSH says MCPJ 30-60, PIPJ 30
- Painful nodules
- Rapidly progressive disease
- Strong family history of aggressive disease
66
What types of surgery are available?
Fasciotomy
- Simple division of the cords
- Open vs. Needle
- 80-90% recurrence in 2 years
- new results 63% at 3yrs, 83% at 5yrs
Fasciectomy
(a) Regional → excise diseased fascia → keep transverse fibres
(b) Limited → (Hueston 1961) 40% recurrence at 4yrs
(c) Limited regional → diseased fascia to single ray
(d) Segmental → piece only
(e) Radical → all palmar and digital fascia removed. Not popular anymore as recurrence rate = LF
3. Dermofasciectomy
Excision of fascia and overlying skin + skin graft or open (MCCash 1964)
SG - reduce disease recurrence but not extension (Bayat and McGrouther 2006)
4. Arthrodesis
5. Amputation
Esp recurrent disease (on little finger = 1%)
67
What is important to cover in consent?
- 40% recurrence
- Not curative
- Nerve damage (2-4%)
- Arterial damage (2-4%)
- Incomplete correction of deformity
- Stiffness
- Swelling
- Delayed healing (23%)
- Infection (2%)
- Cold intolerance
- Painful scar (18%)
- CRPS (5%)
- Further surgery
- If recurrent disease - vascular compromise, amputation
68
What types of incisions do you know of?
Longitudinal Incision
- Straight line with Zs → Skoog
- Zigzag → Brunner
- Multiple VY → Palmen
Transverse Incision - > 1 ray
- Transverse with finger extensions → Skoog
- Open palm → McCash
Skin excision
- Dermofasciectomy (aggressive or recurrent) → FTG
69
What is the postoperative management?
```
Elevation
Rehab A, B, C
Splints immediately
Physio
Dynamic splintage in some cases
Palmar based static night extension splint for up to 3-6 months
```
70
How do you perform PIPJ release?
Fascial contracture → Joint contracture
Release contracture by:
1. MUA to release adhesions – gently lean on joint with MCPJ flexed
2. Flexor sheath - transverse incision at C1, just distal to vincular branches
3. Check rein ligaments (fibrous condensations between volar plate and proximal phalanx).
4. Accessory collateral ligament release
5. Volar capsulotomy
(HD says 1-3-4-2)
Testing central slip – flex wrist and stress MCPJ – PIPJ extends – Smith, Ross 1994
Treat central slip attenuation
Splint, hand therapy, K wire.
71
What are top differentials for soft tissue tumours of the hand?
Ganglion
Giant cell tumour of tendon sheath
Glomus tumour
72
What is the differential diagnosis for a lump in the wrist?
· Ganglion
· Extensor tenosynovitis in rheumatoid disease
· Dorsal wrist pain of unknown aetiology due to occult wrist ganglia
· Radial artery aneurysm over volar wrist
· Malignant soft tissue tumour
· CMC boss
· EDMB
73
What symptoms occur?
How do they present?
How would you investigate the lump?
asymptomatic
dull ache, pain
```
Westbrook (2000)
38%- cosmetic concerns only
28% - concerned re: cancer
26% - pain
8% - restricted hand function / altered sensation
```
Most diagnoses don't require Ix
If in doubt - USS, MRI
74
What is a ganglion?
| What is the aetiology and pathogenesis?
- Most common soft tissue tumour of hand (50 - 70% of all)
- ♀>♂ 3:1
- 70% between 20 and 40
- Post trauma in 10%
- 50% recur if incompletely excised. 20% recur if complete
• Mucin-filled cysts, usually attached to adjacent joint capsule, tendon or tendon sheath.
• Cyst wall comprises compressed collagen fibres without epithelial or synovial lining.
Mucoid degeneration v production of hyaluronic acid lubricant by cells at the synovial/capsule interface secondary to minor trauma.
1. Herniation of joint capsule (Volkmann 1872) → but wrong lining
2. Ligament strain resulting in mucoid degeneration (Ledderhose, 1893).
3. Embryological remnants of synovial tissues in the joint capsule
75
Where do they commonly occur?
1. Dorsal wrist (60-70%) - scapholunate lig (b/t EPL & EDC), dorsal wrist capsule
2. Volar wrist (20-30%) - radioscaphoid/scapholunate interval, scaphotrapezial-trapezoid joint (radial to FCR), or metacarpotrapezial joint
3. Flexor sheath (10%) (volar retinacular ganglia)
4. Mucous cysts → ganglia of DIPJ
5. Less common → at PIPJ, extensors, Guyon’s, carpal tunnel, within bone (interosseous ganglion)
76
How do you classify ganglia according to severity of symptoms?
o Mild - reassure
Asymptomatic lump
o Moderate - reassure / observe
Symptomatic lump; long duration of symptoms
Occult ganglia
Cancer- phobia
o Severe - surgery
Severe pain with restriction of activities of daily living; concern re diagnosis
77
What are the non-surgical treatments for ganglia?
- >40% spontaneously resolve in 6 years (Dias 2007, Burke 2003), if asymptomatic can reassure and not treat
- Sclerosant therapy
- Aspiration - single asp, recurrence rate = 90%, 3 asp = 15%
- Intralesional steroid
- Pressure
78
How do you excise wrist ganglia?
Excision of dorsal wrist ganglion
- Transverse incision over SLL.
- Retract EPL and EDC and mobilise the pedicle to joint capsule,
- Capsule incised and ganglion excised tangentially off the SLL.
Excision of volar wrist ganglion
- Perform pre-op Allen’s test (may be very close to radial artery)
- Longitudinal or transverse incision
- Pedicle dissected around the artery
- Excised at origin
79
How do flexor sheath ganglia present and how do you excise them?
- Firm tender nodule prox digital crease, middle finger most common
- From A1 pulley, do not move with tendon
Treatment
- Needle rupture and steroid
- Open exploration and excise with piece of A1 pulley
80
What are the risks of surgery on ganglia?
recurrence - up to 40%
persistence of pain - 27% (Clay)
neuroma
infection, scar etc
• No difference demonstrated between conservative and surgical management in terms of
pain, stiffness or weakness.
81
How do mucous cysts present and how do you excise them?
- DIPJ, longitudinal groove in nail due to pressure on germinal matrix
- Later swelling occurs
- +/- Heberden’s Nodes and OA changes on x-ray
Treatment
- L shaped / curved incision over cyst
- Cyst mobilised and traced, excised with part of joint capsule
- Preserve EDC and germinal matrix
- Local flap or graft may be needed to close defect
82
Name some benign bone and cartilage tumours of the hand
1. Osteoid Osteoma – young, night pain, relieved by aspirin
2. Enchondroma
3. Osteochondroma - protrusion capped with cartilage
4. Chondromyxoid Fibroma - recurrence a problem so need en-bloc excision
5. Osteoblastoma - Similar to osteoid osteoma but larger
6. Simple (Unicameral) Bone Cyst - in 10% of cadaveric wrists
7. Aneurysmal Bone cysts - expansile and erosive
8. Giant Cell Tumours of bone - more aggressive than soft tissue GCT
9. Chondroblastoma - lytic lesion
83
What is a GCT of flexor sheath aka?
- aka pigmented villonodular synovitis
- 2nd most common soft tissue tumour of hand
- Arise from synovium
- Benign but locally invasive
- Painless mass on palmar surface of fingers, hand or wrist.
- Grey/yellow–brown and multi-loculated
- Treat by local excision → high recurrence (Multilobular 15-20%, Solitary 5-10%)
84
What is a glomus tumour?
- Glomus = AV anastomosis involved in thermoregulation
- under nails / in finger pulps
- Presentation
1 Paroxysmal pain
2 Pinpoint tenderness
3 Cold hypersensitivity.
- Resemble small haemangioma
- If in nail bed → ridging
- Love’s Sign → one exquisitely painful spot on palpation
- Hildreth’s Sign → ↓ pain on exsanguination
- MRI: enhanced by gadolinium
- Treatment → excision
85
Name some malignant bone and cartilage tumours of the hand
Rare
1. Chondrosarcoma - usually secondary to multiple enchondromatosis
2. Osteosarcoma
3. Ewing’s - Pyrexia, pain, raised ESR. Onion skin on x-ray
4. Metastases - only 1% metastasise to hand
86
What is an enchondroma?
- An area of abnormal hyaline cartilage formation within bone
- Slow growing, benign, most common primary bone tumour
- Phalanges or metacarpals
- Present usually as path # in young adults
X-ray → central radiolucent area, thinning and expansion of bony cortex, speckled calcification in radiolucent area, stippled appearance
Treatment → curette +/- bone graft
Pathological fracture with enchondroma - fix and get fracture healed first then remove tumour
Olliers disease = Multiple enchondromas
Larger and assoc with skeletal deformity
Can → chondrosarcomas (biopsy if sudden change)
Maffucci’s syndrome = Multiple enchondromas + vascular anomalies
87
What is an osteochondroma?
| What is an osteoid osteoma?
Osteochondroma
- Benign, bony tumours with hyaline cartilage cap esp. in radius and ulna
- Risk of malignant change very low
- Indication for surgery → functional impairment
Osteoid Osteoma
- Benign bone forming tumours in 2nd - 3rd decades.
- Night pain relieved by aspirin
- X-ray changes subtle so diagnosis difficult.
- lesion
88
What is a dermatofibroma?
- Common, small tumours (1.5-2cm), involving skin esp. extremity
- Containing fibrous tissue and histiocytic cells
- Benign, usu solitary, may be multiple.
- Nodular mass with variable pigmentation (skin: red → red/brown → dark brown → black) => DD inc MM
- If large DD = dermatofibrosarcoma protuberans + fibrosarcoma
- Rx marginal excision
- Recurrence rare with complete excision
89
What is a simple bone cyst?
| What is an aneurysmal bone cyst?
Simple Bone cyst
- Benign cystic, common in distal radius
- Treatment options → aspirate + steroids, curettage
Aneurysmal Bone Cyst
- Rare tumours occur in 20s and 30s
- Benign but locally invasive, prone to local recurrence after excision
- Treatment → En bloc resection
90
What is nodular fasciitis?
- Self limiting benign fibroblastic lesion (occasionally big + through skin)
- Irregular, firm, Sub cut lump (often ↓3cm)
- may involve fascia and muscle.
- More common in forearm, sometimes firm lump in hand
- Rapid growth
- Half are painful
- ♀=♂ young adults
- Histology = Rich cellularity ω regular fibroblasts, few mitosis w/o atypical mitoses
- Loosely textured ‘feathery ‘appearance classic
- MRI more signal than muscle on T1 and brighter than fat on T2
- Diff for sarcoma, fibrosarcoma, malig fibrous histiocytoma and synovial sarcoma
- Rx marginal excision, rarely recurs
91
What are the differential diagnosis of a dropped finger(s)?
1. Extensor tendon rupture
– Loss of tenodesis effect on passive movement of wrist.
2. Ulnar subluxation of extensor tendon over MCPJs
– Due to attrition of radial sagittal band.
– Displacement of extensor tendons volar to MCPJ axis makes initiation of extension impossible.
– However, if MCPJ is passively extended, patient will be able to maintain extension.
3. MCPJ dislocation
– Not usually passively correctable.
4. PIN compression
– Compressed by rheumatoid synovitis at radiohumeral joint.
– Loss of finger and thumb extension but preserved tenodesis.
92
What is psoriatic arthritis?
seronegative oligoarthritis found in 10% of patients with psoriasis.
• Develops between age 35 and 55; no sex predilection.
93
What are the radiological findings and treatment for psoriatic arthropathy?
XRay
∘ Asymmetric joint surface erosions.
∘ Erosion of distal phalanx tuft (acro-osteolysis).
∘ ‘Pencil-in-cup’ deformity:
– Concave ‘cup’ deformity of distal phalanx articular surface.
– Convex ‘pencil’ deformity of middle phalanx.
Treatment
- DMARDs, NSAIDs, biologic agents and intra-articular steroid injections
- Surgery may be indicated for salvage:
∘ Arthrodesis
∘ Arthroplasty
∘ Bone grafts to lengthen digits in arthritis mutilans.
94
What are the clinical findings of psoriatic arthropathy?
∘ RF negative.
∘ Involvement of DIPJs (10%).
∘ Acute attacks affecting entire finger – dactylitis or sausage finger (35%).
∘ Arthritis mutilans
95
What joint changes are associated with SLE?
- systemic autoimmune disorder
- no erosive arthritis
- deformities similar to RA, due to ligamentous laxity.
- associated with Raynaud's phenomenon
- 5:100,000 population, F:M 9:1
Treatment
- NSAIDs, antimalarials, immunosuppressants, biologic agents and corticosteroids.
- Surgical: arthrodesis > arthroplasty as main problem is soft tissue laxity.
96
What is gout?
• Inflammatory arthritis characterised by self-limiting, excruciatingly painful acute attacks.
• M:F = 4:1
• Intra- and periarticular deposition of needle-shaped monosodium urate (MSU)
crystals initiate an inflammatory arthritis.
• Recurrent attacks cause cumulative joint damage, instability and tendon ruptures.
97
What are the causes of gout?
Hyperuricaemia is a risk factor for gout, but patients can have normal uric acid levels.
Primary hyperuricaemia causes:
∘ Decreased renal clearance of uric acid
∘ Rare inborn errors of metabolism.
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• Secondary hyperuricaemia causes:
∘ Diuretics (particularly thiazides)
∘ Myeloproliferative disorders
∘ Cytotoxic drugs
∘ Alcohol.
∘ Excessive dietary purine intake and diets high in fructose.
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• Surgery occasionally indicated for unstable joints or symptomatic tophi.
