Common conditions of the hand Flashcards
Dupuytren’s contractures:
- What is it?
- Who gets it?
- Is it common?
Dupuytren’s is a condition where 1 or more fingers are fixed in flexed position. It is caused by thickening and drawing in of the palmar fascia resulting in the affected finger bending toward the palm.
- It is autosomal dominant, tend to have a FH
- Almost exclusively seen in white populations
- M>F
- No cure but if severe your fingers can be straightened
- Associated with things like DM, smokers, HIV etc
Pathology of Dupuytren’s
- Myofibroblasts proliferate
- They produce excess collagen (dysregulation of growth factors)
- Which leads to contraction of the pre-tendinous bands in the hand, pulling the fingers into flexed position
What functional problems come about because of Dupuytren’s?
- Loss of finger extension – active or passive
- Struggle with every day tasks such as putting hand in pocket, gripping things, washing your face, getting dressed etc
How is Dupuytren’s contractures treated?
Usually just observe until it becomes severe. In severe cases the 2 key treatments are:
- Fasciectomy - A cut is made along your palm and finger so the surgeon can straighten it.
- Needle Fasciectomy - same idea but use a needle to cut
Re-contracture is an issue however as you can not remove all the fascia.
Describe fasciectomy treatment for Dupuytren’s
- Procedure where you open the skin, find the thickened bands and remove them if they are causing the problem
- Stiffness requires physiotherapy – early on in recovery
- Can’t be cured as you can’t remove all fascia so contracture may come back at later stage
How can you treat re-contracture after initial treatment for Dupuytren’s? (5)
There are other options if the contracture comes back after initial fasciectomy. These are:-
- Dermo-fasciectomy - remove skin from the palm and the underlying fascia and replace with skin graft. Requires intesinve physio.
- Arthrodesis/PIP joint fusion - removing the joint and making the two bones grow together to form one bone.
- Amputation - extreme
- Collagenase
- Radiotherapy – to slow down cellular activity that produces the excessive collagen
What is Percutaneous Needle Fasciotomy?
- A quick, inexpensive treatment used to treat mild to moderate Dupuytren’s contracture
- It involves the use of a needle to cut one or more fibrous bands (contractures)
- No wounds
- Small risk of nerve injury
What is collagenase?
- Substance that is injected into the band.
- It dissolves the collagen in the band
- May cause flexor tendor ruptures - where the tendon dissolves too
- Not used in Aberdeen
What is trigger finger?
- 2 flexor tendons to each finger.
- These tendons run in a sheath which is lined with synovium and they pass through a series of pulleys.
- In the case of trigger finger, one of these tendons becomes inflamed and the tendon, or the sheath surrounding it, can swell and thicken to the point that the tendon can no longer glide smoothly.
- The tendon catches and can “trigger” into a bent position i.e it gets stuck in this flexed position.
Presentation of trigger finger
- F>M, 40-60s
- Ring>thunb> middle
- Lump in palm under pulley – under metacarpal head
- Clicking sensation with movement of digit – bending fingers.
- ‘Clicking’ may progress to ‘locking’ – cannot be straightened
- May have to use other hand to ‘unlock’ finger when it jams.
How is trigger finger treated?
- Splintage can help as it limits the movement of the finger and holds it in a position that helps reduce swelling
- Steroid injection in and around the pulley decreases potential swelling
If these options don’t work then:
- Percutaneous release - needle
- Open surgery
What is the key difference between Dupuytren’s contracture and trigger finger?
Unlike a finger which is bent due to trigger finger, a finger bent by Dupuytren’s contracture is unable to straighten, even with help from the other hand.
What is De Quervain’s syndrome?
- It is a painful condition affecting the tendons on the thumb side of your wrist (1st dorsal extensor compartment)
- The external pollicis brevis and the abductor pollicis longus run together in a sheath.
- If these tendons become inflammed / swollen it can restrict their movement through the tendon sheath and can be very painful
How might someone present with De Quervain’s syndrome?
- Several weeks of pain localised to radial side of the wrist that is aggravated by movement of the thumb
- Most common cause = overuse of the thumb
- Age 50-60s
- F>M
Which 2 tests are done for De Quervain’s syndrome?
- Finklestein’s test - fold thumb into palm, put fingers over thumb. Then you bend your wrist toward your little finger. If this causes pain on the thumb side of your wrist, you likely have de Quervain’s.
- Thumb extension against resistance
What is retinaculum?
A band of thickened deep fascia around tendons that holds them in place.
