Cortex - adult orthopaedics spine and upper limb (hand) 5

Question 1

What is Dupuytren’s contracture?

Answer 1

Connective tissue disorder where the specialized palmar fascia undergoes hyperplasia with normal fascial bands forming nodulesand cords progressing to contractures at the MCP and PIP joints.

Question 2

What disorder is shown ?

Answer 2

Dupuytrens contracture

Question 3

Describe the pathology of duputyrens contracture

Answer 3

• Involves proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1).
• Palpable nodules may be present

Question 4

What fingers are most commonly affected by duputyrens contracture ?

Answer 4

Most commonly affect the ring and little fingers.

Question 5

Describe the epidemiology of duputyrens contracture:

who is most commonly affected and its inheritance?

Answer 5

• Males (10:1)
• Can be familial (inherited in autosomal dominant manner)
• Can be seen in alcoholic cirrhosis and as a side effect of phenytoin therapy
• Can also occur with other fibromatoses including Peyronie’s disease, which affects the penis, and plantar fibromatosis affecting the feet (Ledderhose disease)

Question 6

What is a useful test used to determine if a patient with dupuyrten’s contracture may benefit from surgery or not ?

Answer 6

• Hueston Table Top Test - the patient is asked to place their palm flat on the table. Failure to be able to do so is due to fixed flexion contracture at the MCPJs and is a quick screening tool for whether patients may benefit from surgical management
• A fixed flexion deformity > 30 degrees will cause the patient to fail the test

Question 7

What is the treatmeant of duputyrens contracture ?

Answer 7

Mild contractors can be tolerated but

If interfering with function or affecting the PIPJ (this joint readily stiffens and cannot tolerate it) then surgery can be done

Question 8

What are the surgical options for duputyrens contracture ?

Answer 8

Either removal of all diseased tissue (fasciectomy) or division of cords (fasciotomy).

Question 9

The flexor tendons of the fingers are held close the the volar aspect of the phalangeal bones by what?

Answer 9

A system of annular (A) and cruciate (C) pulleys.

Question 10

What is trigger finger ?

Answer 10

Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck

Question 11

What are the signs/symptoms of trigger finger?

Answer 11

• Movement of the finger produces a clicking sensation, as this nodule catches on and then passes underneath the pulley.
• This can produce pain
• Finger may lock in a flexed position as the nodule passes under the pulley but can’t go back though on extension

Question 12

Which fingers are msot commonly affected by trigger finger ?

Answer 12

Middle and ring finger

Question 13

What is the treatment of trigger finger ?

Answer 13

1st line - NSAIDs and steroid injection

Question 14

OA commonly affects the hands and wrists - what are the signs/symptoms seen ?

Answer 14

• DIPs will become painful, swollen and tender eventually affecting all fingers. Stiffness and bony thickening can be seen readily on examination (Heberden’s nodes). An associated dorsal ganglion cyst (known as a mucous cyst) may be present.
• PIPs can also be affected with OA and bony swelling (Bouchard’s nodes)

Question 15

What is the treatment of OA of the hands and wrists ?

Answer 15

Mild to moderate OA may be treated with removal of osteophytes and excision of any mucous cyst.

For severe pain arthrodesis may be performed.

Question 16

What is the amin difference between OA and RA affecting the hands and wrists ?

Answer 16

RA spares the DIPs

Question 17

What are the main different deformities shown in the hands in patients with RA?

Answer 17

• Volar MCPJ subluxation
• Ulnar deviation
• Swan neck deformity (hyperextension at PIPJ with flesion DIPJ)
• Boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ)
• Z-shaped thumb

Question 18

What is the 3 main stages of RA in the hands ?

Answer 18

1. Synovitis and tenosynovitis – inflammation within the joints and the tendon sheath lead to swelling and pain in the affected structures.
2. Erosions of the joints – inflammatory pannus denudes the joints of articular cartilage
3. Joint instability and tendon rupture – following the progressive destruction of the bony and soft tissue structure in the hand patients can progress to subluxation and chronic tenosynovitis predisposes to extensor tendon ruptures.

Question 19

The mainstay of systemic RA treatment is DMARDs but what is the treatment of the hand complications seen in RA?

Answer 19

• Tenosynovectomy (excision of synovial tendon sheath) may prevent not repair tendon rupture
• If tendon rupture then Tendon transfers or joint fusions
• Soft tissue releases (lengthening) may be required for contractures
• MCP replacements, PIP replacements or fusions, wrist replacement or fusion may be required for severe arthritic change.

Question 20

What is a ganglion cyst ?

Answer 20

Mucinous filled cysts found adjacent to a tendon or synovial joint

Question 21

Where are ganglion cysts commonly found ?

Answer 21

• The hand (DIPJ) and wrist
• Foot and ankle
• Knee (bakers cyst)

Question 22

What symptoms can a ganglion cyst cause ?

Answer 22

Localised irritation and discomfort (may not though)

Question 23

What is the clinical feel/appearance of a ganglion cyst ?

Answer 23

Firm, smooth and rubbery and should transilluminate

Question 24

What is the treatment of ganglion cysts ?

Answer 24

• Needle aspiration but recurrence is very common (50-70%)
• Surgical excision may be required if the swelling causes localized discomfort.