Conditions of Hand and Wrist

Question 1

What is Dupuytren’s contracture

Answer 1

A progressive, painless fibrotic thickening of the palmar fascia with skin puckering and tethering.
Ring and little fingers mostly affected - loss of finger extension (difficulty gripping
Often bilateral and symmetrical.
As disease progresses, may be MCP flexion
If IP joints are affected, hand can be very disabled
Disease develops earlier in males

Question 2

Causes / associations of Dupuytren’s

Answer 2

Genetic (AD) - mostly white race
Smoking and Alcohol
Epilepsy, Diabetes, HIV
Peyronie’s disease, Knuckle pads

Question 3

What is Dupuytren’s diathesis

Answer 3

More aggressive Dupuytren’s disease - usually involves more than one of Dupuytren’s family (Dupuytren’s, Knuckle pads, Ledderhose, Peyronie’s, Frozen shoulder)

• earlier onset
• more progressive
• Strong FH
• more recurrence

Question 4

Treatment of Dupuytren’s

Answer 4

Fasciectomy (partial or dermo)
Collagenase injection
Percutaneous Needle Injection

Question 5

What is trigger finger

Answer 5

A disproportion of the tendon to its sheath giving a fixed flexion deformity where full extension of the finger cannot be achieved. The nodule moves with the flexor tendon on extension, but becomes jammed on the proximal side of the pulley and has to be flicked straight, producing triggering.

• if aided by other hand, a click may be felt
• ring and middle fingers most affected (thumb in children)

Question 6

What is trigger finger associated with

Answer 6

RA
DM
Gout

Question 7

Who is most affected by trigger finger

Answer 7

Women

40-60 age

Question 8

Causes of trigger finger

Answer 8

Repetitive use of hand

Trauma

Question 9

Treatment of trigger finger

Answer 9

Steroid injection into region of nodule, but not nodule itself (if not child, renal failure or DM)

Surgery - percutaneous release or open

Question 10

What is De Quervain’s Disease (stenosing tenovaginosis)

Answer 10

Pain over the radial styloid process and thickening of the Abductor Pollicis Longus and Extensor Pollicis Brevis tendons (1st dorsal extensor compartment)

Question 11

Clinical presentation of De Quervain’s

Answer 11

Pain over lateral wrist aggravated by thumb movement (i.e. lifting a teapot)
Swelling over wrist
FEMALES
Age 50-60

Question 12

Diagnosis of De Quervain’s

Answer 12

Examine thumb joint - consider OA of base of thumb but DQ tends to be more proximal

Finklestein’s Test - pain is elicited by sharply pulling on the relaxed thumb to cause ulnar deviation

Resisted thumb extension

Question 13

Cause of De Quervain

Answer 13

Unknown but exacerbated by activities with frequent thumb abduction and ulnar deviation (i.e. wringing clothes - Washerwoman’s sprain)

Increased in postpartum and lactating females

Question 14

Treatment of De Quervain’s

Answer 14

1st

• NSAIDs
• Steroid (hydrocortisone) injection around tendons in their sheath

2nd
- Decompression of tendons by splitting tendon sheaths

Question 15

What is a ganglion

Answer 15

Smooth cyst from the degeneration of joint synovial, containing jelly-like fluid in communication with tendon sheaths or joint capsules

Question 16

Diagnosis of ganglion

Answer 16

FEMALES
May be associated with recurrent wrist trauma
Firm, Non-Tender, Smooth lump
Changed in size
Normally not fixed to underlying tissue and never fixed to skin

Question 17

Treatment of ganglion

Answer 17

May disappear spontaneously so treatment usually not needed unless causing pain or pressure (i.e. on median or ulnar nerve in wrist or large popliteal nerve in knee)

• Local pressure may disperse it (BIBLE BASH)
• Aspiration
• Surgical Excision - less recurrence, painful scars, neuromuscular damage (esp. in volar wrist ganglia)

Question 18

Presentation of OA of the thumb

Answer 18

Pain, Stiffness, Swelling, Deformity
Loss of function - i.e. painful opening jars / pinching)
Dorsal subluxation, Metacarpal Adduction and Hyperextension

Question 19

Treatment of OA of base of thumb

Answer 19

1. Trapeziectomy - lowest complication rate, good pain relief
   Arthrodesis - may be best for patients who value pain relief and reliable strength more than mobility (i.e. young manual workers)
   Reconstruction

Question 20

Non-op treatment of base of thumb

Answer 20

Thumb exercises
NSAIDs
Splints
Steroid injections