Hand

Question 1

dupuytren’s contracture

Answer 1

proliferative connective tissue disorder where the palmar fascia undergoes hyperplasia (thickens) with normal fascial bands forming nodules and cords progressing to contractures at MCP and PIP joints

Question 2

pathology of dupuytren’s contracture

Answer 2

proliferation of myofibroblast cells and then production of abnormal collagen (type III rather than type I)

Question 3

properties of myofibroblasts

Answer 3

contractile

Question 4

features of dupuytren’s contracture

Answer 4

skin may be adherent to the diseased fascia and puckered

Question 5

is dupuytren’s contracture more common in males or females

Answer 5

males (10:1)

Question 6

causes of dupuytren’s contracture

Answer 6

familial (AuD)

feature of alcoholic cirrhosis and as a side effect of phenytoin therapy (anticonvulsant)

more common in diabetics

Question 7

phenytoin mechanism and adverse effects

Answer 7

• An antifolate drugs that can cause folate deficiency resulting in macrocytic anaemia. A symptom of this is tiredness
• Duputyren’s contracture
• Gingival hypertrophy
• Morbilliform rash/acne

Question 8

screening test for dupuytren’s contracture to see if patients will benefit from surgical treatment

Answer 8

Hueston table top test - >30 degrees fixed flexion deformity at MCPJs required to be a candidate for surgery

Question 9

Peyronie’s disease

Answer 9

• fibromatosis that can occur with dupuytren’s contracture - penis is bent due to fibrous tissue accumulation (as plaques) in the soft tissue of the penis

Question 10

Ledderhose disease

Answer 10

fibromatosis that can occur with dupuytren’s contracture

Question 11

how much contracture can be tolerated in the joints of hand in dupuytren’s contracture

Answer 11

up to 30 at MCP

PIPJ readily stiffens and any contracture here is usually an indication for surgery

surgery also offered if contractures are interfering with function

Question 12

what does surgery of dupuytren’s contracture usually involve

Answer 12

removal of all diseased tissue - fasciectomy

divison of cords - fasciotomy

recurrence can occur particularly in YP

severe contractures can be treated with amputation

Question 13

trigger finger

Answer 13

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.

movement of finger can produce a clicking sensation and can lock in flexed position

negative cycle of swelling and irritation of tendon

Question 14

clinical features of trigger finger

Answer 14

clicking sensation

at first finger is locked in flexed position, then gives way suddenly to extension

at later stage, it can only be extended forcibly (painful)

on examination, one can feel the nodule pass beneath the pulley and it is tender over A1

Question 15

which fingers and pulley are most commonly affected by trigger finger

Answer 15

middle and ring

A1 pulley - metacarpal neck

Question 16

how is trigger finger treated

Answer 16

• conservative - most cases resolve spontaeously, can splint to prevent flexion
• injection of steroid around the tendon within the sheath - up to 3 injections
• surgery in recurrent/persistent cases - incision of pulley, A1 is the only pulley that can be sacrificed, the others would cause bow stringing

Question 17

ganglion cyst

Answer 17

common mucinous filled cyst that is an outpouching of synovial cavity

can cause localised pain or irritation, cosmetically undesirable

common in the hand due to high concentration of synovial joint

Question 18

what is a ganglion cyst in the popliteal fossa called

Answer 18

baker’s cyst - seen in OA

Question 19

what should the ganglion cysts do in light

Answer 19

transilluminate

Question 20

removal of ganglion cyst

Answer 20

usually resolve with time

needle aspiration may be attempted - risk of recurrence 50%

surgical excision if it causes local discomfort

Question 21

aspects for surgical removal of gangalion cyst

Answer 21

• may wish to be removed for cosmetic reasons - the patient may be swapping a cyst for a scar - which is cosmetically more acceptable?
• scar may remain tender

Question 22

is the historical technique of hitting it with a bible advised

Answer 22

nope

Question 23

giant cell tumour of tendon sheath

Answer 23

usually found on palmar surface, especially PIP joints of index and middle fingers

may cause pain

can envelop digital artery or nerve and erode the bone

Question 24

giant cell tumour of tendon sheath histologically

Answer 24

giant multinucleated cells and haemosiderin (pigmented - brown appearance)

Question 25

what is a giant cell tumour of tendon sheath knwon as when it is in a synovial joint

Answer 25

pigmented villonodular synovitis

Question 26

treatment of giant cell tumour of tendon sheath

Answer 26

excision is recommended to prevent local spread and treat symptoms

recurrence 10-20%

Question 27

mucous cyst

Answer 27

outpouching of fluid from DIP joint OA

• the joint is trying to lubricate itself but there is nowhere for the fluid to go

CF: painful, discharge. appearance flucctuates and they can cause ridging of the nail deformity

Treatment: usually left alone, can be excised

Question 28

DeQuervains Tenosynovitis

Answer 28

inflammation of tendons at the side of the wrist and at the base of the thumb

Question 29

clinical features of DeQuervains Tenosynovitis

Answer 29

spontaneous

pain, swollen, red

Finklestein’s test

Question 30

what tendons are involved in DeQuervains Tenosynovitis

Answer 30

extensor pollicus brevis and abductor pollicus longus

Question 31

treatment of DeQuervains Tenosynovitis

Answer 31

NSAIDs

splint

rest

steroid

decompression surgery

Question 32

paronychia

Answer 32

an infection within the nail fold, that often occurs in children and is associated with nail biting

there can be a resultant pus collection

treatment is elevation, antibiotics and incision and drainage if it hasnt cleared in a few days

Question 33

flexor tendon sheath infection

Answer 33

SURGICAL EMERGENCY - an infection within the sheath that can track up the palm and forearm

extremely painful, and there is limited extension due to the pain

may be tracking lymphangitis

management is washing out the tendon sheath

Question 34

SLAC

Answer 34

sacpholunate advanced collapse

condition of progressive instability causing advanced arthritis due to untreated chronic dissociation between scaphoid and lunate

can occur if one falls onto outstretched hand