Clinical conditions of the hand

Question 1

What are the functional needs for a hand?

Answer 1

• Sensation
• Mobility
• Strength

Question 2

What are the common conditions of the hand?

Answer 2

• Carpal tunnel syndrome
• Ulnar nerve compression
• Dupuytren’s disease
• Rupture of the ulnar collateral ligament of the thumb
• Osteoarthritis
• Rheumatoid arthritis

Question 3

What is carpal tunnel syndrome?

Answer 3

• Pressure on the median nerve at the wrist
• Alteration in median nerve function due to pressure on the nerve in the tunnel where it enters the hand
• May lead to permanent loss of nerve function

Question 4

Describe the relationships within the carpal tunnel

Answer 4

• Ulnar n. and artery (Guyon Canal)
• Median n.
• Tendon of flexor carpi radialis
• Division of flexor retinaculum

Question 5

What are the associated risk factors of carpal tunnel syndrome?

Answer 5

-Gender: more common in women
-Age
-White race
-Diameter of carpal tunnel
-Obesity
-Hormonal (fluid retention)
=Hypothyroidism
=Menopause
=Diabetes
=Contraceptive pill

Question 6

What are the signs, symptoms and investigations for carpal tunnel syndrome?

Answer 6

Symptoms:
-Paraesthesia (tingling in nerve distribution)
-Nocturnal symptoms**
-Provocative features*
=Wrist flexion, hand elevation, Phalen’s test
-Relieving features*
=Shaking hand, running under cold tap
Signs:
-Hypoaesthesia (diminished sensation)
-Muscle wasting***
Investigations:
-Neurophysiology (measuring speed of conduction in nerve)
ADVANCED LOSS OF MEDIAN NERVE FUNCTION

Question 7

What is the treatment for carpal tunnel syndrome?

Answer 7

-Night splint
-Inject
-Operation
=Open
=Endoscopic
(open release of the flexor retinaculum- nerve still has to recover)

Question 8

What is Ulnar Nerve Dysfunction?

Answer 8

Usually due to irritation/compression at the elbow

Question 9

What occurs in ulnar nerve dysfunction?

Answer 9

• It is exposed to direct pressure over the medial epicondyle
• It is stretched when the elbow flexes
• When the elbow flexes it is compressed beneath the fibrous band between the two heads of FCU
• When the elbow flexes it may sublux medially

Question 10

Describe the presentation of ulnar nerve dysfunction

Answer 10

• Paraesthesia (tingling)
• Hypoaesthesia (numbness)
• Weakness of grip
• Paralysis of affected muscles
• “Clawing” of hand
• Froment’s sign (flexed thumb)

Question 11

What is the treatment for ulnar nerve dysfunction?

Answer 11

• Release of compression at elbow

- Occasionally transposition to front of elbow

Question 12

What is Dupuytren’s Disease?

Answer 12

Thickening and contracture of the palmar and digital fascia of unknown cause
-Variable patterns

Question 13

Describe Dupuytren’s disease

Answer 13

• Cord-like contractures in the bands of the longitudinal fibres of the palmar and digital fascia
• A cellular process involving myofibroblasts
• Collagen is abnormal
• Normally type I but in DD type III predominates
• The cause/s are unknown but there are some associated factors

Question 14

What are the causes associated with in Dupuytren’s disease?

Answer 14

-Genetic influences
=Familial
=Racial
-Systemic disease
=Diabetes
=Cirrhosis of liver
-Trauma
=Site of injury
More common in men

Question 15

What is the treatment ladder for Dupuytren’s disease?

Answer 15

• Amputation
• Dermofasciectomy
• Fasciectomy
• Fasciotomy
• Advice

Question 16

What advice can be given for Dupuytren’s disease?

Answer 16

-No contracture (surgery unnecessary)
-Contracture (indications for surgery)
=Getting in the way
=Interfering with function
=Patient wants operation

Question 17

Which joints are easier to be corrected in Dupuytren’s disease?

Answer 17

-MCPJ contractures can usually be corrected (no capsular contracture)= metacarpophalangeal joint
-PIPJ contractures may be difficult (established capsular contracture)
= proximal interphalangeal joint

Question 18

What is Fasciotomy?

Answer 18

Division of cords either by surgical release or injection of collagenase

Question 19

What is Fasciectomy?

Answer 19

Excision of fascia

Question 20

Describe rupture of the ulnar collateral ligament of the thumb

Answer 20

Hill end thumb (matting)
Pull thumb back
Cannot grip

Question 21

What is the treatment for rupture of the ulnar collateral ligament of the thumb ?

Answer 21

• Repair the ligament

- It may have flipped out from beneath the adductor pollicis tendon

Question 22

Describe OA in the trapeziometacarpal joint

Answer 22

• Double saddle joint
• Laxity may cause abnormal wear at edges of joint because of incongruity
• Common in middle-aged women
• Various treatments- most can be controlled without operation (analgesics, rest, spontaneous improvement)

Question 23

Describe the trapeziometacarpal joint

Answer 23

(a) Neutral position
(b) Pommels fitted edge to edge (adducted position 1st MC)
(c) Cantles fitted edge to edge (abducted position 1st MC)
(d) Flexion with medial rotation, extension with lateral rotation

Question 24

What is the treatment for OA in the trapeziometacarpal joint?

Answer 24

-Rest
-Analgesia
-Surgery
=Excision of trapezium
=Joint replacement

Question 25

Describe the pathology of RA

Answer 25

• Synovial proliferation (cause unknown) but now preventable by early drug treatment
• Destruction of articular cartilage → loss of movement
• Tendon invasion → rupture
• Ligamentous stretching → instability

Question 26

What can RA lead to in the joints of the hand?

Answer 26

• Wrist synovitis

- Flexor tendon rupture

Question 27

What are the common problems in metacarpophalangeal joints?

Answer 27

-Subluxation and/or ulnar drift

=MCPJ replacements if there is loss of 3-point grip