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MSK > Cortex- Upper limb: Hand > Flashcards

Cortex- Upper limb: Hand Flashcards

1
Q

What forms the carpal tunnel

A

carpal bones and flexor retinaculum

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2
Q

what passes through the carpal tunnel

A

median nerve and 9 flexor tendons (FDS & FDP to 4 digits + FPL) with their synovial covering

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3
Q

what results in synovial nerve compression

A

any swelling of the contents of the cubital fossa (felxor tendons and their syonvial coverings)

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4
Q

what can cause carpal tunnel syndrome

A

idiopathic (most cases)
secondary to- RA, fluid retention (pregnancy, diabetes, chronic renal failure, hypothyroidism), fractures (esp colles fracture)

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5
Q

what is myxoedema

A

swelling of the skin and underlying tissues giving a waxy consistency- seen in hypothyroidism

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6
Q

who gets carpal tunnel

A

women 8x more likely than men

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7
Q

how do patients with carpal tunnel present

A

parathesiae in the median nerve innervated digits (thumb and radial 2 1/2 digits) which is worse at night
loss of sensation
sometimes weakness of the thumb and clumbsiness in the areas of hand supplied by the median nerve

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8
Q

what is seen on examination of carpal tunnel syndrome

A

demonstrable loss of sensation and/ or muscle wasting of their thenar eminence (in chronic severe cases)

symptoms reproduced by doing tinels test (percussing over the median nerve) or phalens test (holding the wrists hyper-flexed which decreases space in carpal tunnel)

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9
Q

how can you confirm the diagnosis of carpal tunnel

A

nerve conduction studies- will show slowing of conduction across the wrist

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10
Q

what is the treatment for carpal tunnel syndrome

A

wrist splints at night to prevent flexion
injection of corticosteroid

surgery- carpal tunnel decompression (division of the transverse carpal ligament under local anaesthetic)

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11
Q

what is dupuytren’s contracture

A

proliferative connective tissue disorder
the specialised palmar fascia undergoes hyperplasia
normal fascial bands form nodules and cords
progresses to contractures at the MCP and PIP joints

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12
Q

describe the pathology of dupuytrens contracture

A

proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1)

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13
Q

describe the clinical signs of dupuytrens contracture

A

skin may be aderent to the disease fascia and puckered
palpable nodules may be present
contractures most commonly affect the ring and little fingers
50% have bilateral involvement

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14
Q

who gets dupuytrens contracture

A

men 10:1, high prevelance in northern european/ scandinavian descent
can be familial- autosomal dominant

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15
Q

what can dupuytrens occur secondary to

A

is a feature of alcoholic cirrhosis
side effect of phenytoin therapy
common in diabetics
fibromatoses- peyronies disease (affects penis) and plantar fibromatosis (ledderhose disease-affects the feet)

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16
Q

what is the treatment for dupuytrens contracture

A

mild ones can be tolerated
surgery if interfering with function - (fasciectomy- removal of all diseased tissue and fasciotomy- division of cords)
amputation if severe (finger in palm)

(30 degrees of contracture can be tolerated at the MCP joint but the PIPJ readily stiffens and any contracture here is an indication for surgery)

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17
Q

what is trigger finger

A

tendonitis of a flexor tendon to a digit
resulting in nodular enlargement of the affected tendon
usually distal to a fascial pulley over the metacarpal neck
(A1 pulley)

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18
Q

what causes the ‘trigger’ finger sign

A

movement of this finger produces a clicking sensation as this nodule catches on and then passes underneath the pulley
this might be painful
finger may lock in flexed position as the nodule cannot pass back under the pulley on extension

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19
Q

what fingers are most commonly affected in trigger finger

A

middle and ring

20
Q

what is the treatment for trigger finger

A

injection of steroid around the tendon within the sheath will relieve symptoms

surgery offered in recurrent and persistent cases (incision of the pulley to allow the tendon to move freely- divison of A1 pulley doesn’t affect function)

21
Q

what hand arthritis is common in post menopausal women

A

DIP OA

22
Q

what is seen clinically in DIP OA

A

DIPs will become painful, swollen and tender- fill eventually affect all fingers

stiffness and bony thickening (heberdens nodes)

associated dorsal ganglion cyst (mucous cyst) may be present

23
Q

how can OA be treated

A

mild to moderate- removal of osteophytes and excision of any mucous cysts

severe pain- arthrodesis

24
Q

what are bouchards nodes

A

bony swelling of the PIPs in OA

25
Q

what might be required to preserve pinch grip in PIP OA

A

index finger arthrodesis

26
Q

what is a possible surgery option for OA in the fingers

A

arthroplasty (variable results, extensor tendon subluxation)

27
Q

what can cause OA in the MCP joints

A

previous injury, occupational stress, gout or infection

28
Q

is surgery possible for OA at MCPs

A

yes- arthroplastys may relieve pain and improve ROM but complications (ulnar drift, extensor tendon subluxation)

29
Q

what is the trapziometacarpal joint

A

1st carpo-metacarpal joint (base of the thumb)

30
Q

why is the trapziometacarpal joint significant

A

commonly affected by OA, particularly in women

31
Q

what can treat trapziometacarpal joint OA

A

injection of steroid can help in an acute flare up

excision arthroplasty or fusion may cure chronic pain

32
Q

when does OA of the radio-carpal joint of the wrist occur

A

as a consequence of trauma

33
Q

why is RA in the hand so important

A

where it seems to cause the most problems and is most visible

34
Q

what will patients with long standing RA (without treatment) develop

A

deformed, painful and occasionally malfunctioning hands

35
Q

what joint does RA tend to spare

A

the DIPs

36
Q

what are the three stages of RA in the hands

A
  1. synovitis and tenosynovitis- inflammation within the joints and the tendon sheath leading 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 progressive destruction of bony and soft tissue structure, patients can progress to subluxation. chronic tenosynovitis predisposes to extensor tendon ruptures.
37
Q

name 5 deformities seen in end stage hand RA

A

volar MCPJ subluxation

ulnar deviation

swan neck deformity (hyperextension at PIPJ with flexion DIPJ)

boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ

z shaped thumb

38
Q

what surgery may prevent tendon rupture in RA

A

tenosynovectomy (excision of synovial tendon sheath)

39
Q

is surgery to fix rupture of extensor tendons to the wrist or fingers possible

A

not directly as diseased tendon will fail

tendon transfers or joint fusion may be required to preserve function

40
Q

what surgeries may be required in RA

A

soft tissue releases (lengthening) for contractures

MCP replacements, PIP replacements of fusions, wrist replacements or fusion may be required for severe arthritic change

41
Q

what are ganglion cysts

A

common mucinous filled cysts found adjacent to a tendon or synovial joint

42
Q

where are ganglion cysts common

A

DIPJ- mucous cyst, flexor tendon

wrist: dorsal or volar

foot, ankle, knee (bakers cyst)

43
Q

what are the symptoms of a ganglion cyst

A

localised pain or irritation

cosmetic displeasure

44
Q

what do ganglion cysts look/feel like

A

firm, smooth, rubbery, should transilluminate

45
Q

what is the treatment for a ganglion cyst

A

surgery for cosmesis not on NHS
surgical excision required if the swelling causes localised discomfort

needle aspiration may be attempted (recurrence common)

46
Q

what are the 2nd most common soft tissue swellings of the hand (ganglion cysts first)

A

giant cell tumour of the tendon sheath

47
Q

what is the histology of a giant cell tumour

A

contain multinucleated giant cells and haemosiderin (gives brown appearance)

MSK (71 decks)

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