Hand Flashcards
dupuytren’s contracture
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
pathology of dupuytren’s contracture
proliferation of myofibroblast cells and then production of abnormal collagen (type III rather than type I)
properties of myofibroblasts
contractile
features of dupuytren’s contracture
skin may be adherent to the diseased fascia and puckered
is dupuytren’s contracture more common in males or females
males (10:1)
causes of dupuytren’s contracture
familial (AuD)
feature of alcoholic cirrhosis and as a side effect of phenytoin therapy (anticonvulsant)
more common in diabetics
phenytoin mechanism and adverse effects
- 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
screening test for dupuytren’s contracture to see if patients will benefit from surgical treatment
Hueston table top test - >30 degrees fixed flexion deformity at MCPJs required to be a candidate for surgery
Peyronie’s disease
- 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
Ledderhose disease
fibromatosis that can occur with dupuytren’s contracture
how much contracture can be tolerated in the joints of hand in dupuytren’s contracture
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
what does surgery of dupuytren’s contracture usually involve
removal of all diseased tissue - fasciectomy
divison of cords - fasciotomy
recurrence can occur particularly in YP
severe contractures can be treated with amputation
trigger finger
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
clinical features of trigger finger
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
which fingers and pulley are most commonly affected by trigger finger
middle and ring
A1 pulley - metacarpal neck
how is trigger finger treated
- 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
ganglion cyst
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
what is a ganglion cyst in the popliteal fossa called
baker’s cyst - seen in OA
what should the ganglion cysts do in light
transilluminate
removal of ganglion cyst
usually resolve with time
needle aspiration may be attempted - risk of recurrence 50%
surgical excision if it causes local discomfort
aspects for surgical removal of gangalion cyst
- 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
is the historical technique of hitting it with a bible advised
nope
giant cell tumour of tendon sheath
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
giant cell tumour of tendon sheath histologically
giant multinucleated cells and haemosiderin (pigmented - brown appearance)
what is a giant cell tumour of tendon sheath knwon as when it is in a synovial joint
pigmented villonodular synovitis
treatment of giant cell tumour of tendon sheath
excision is recommended to prevent local spread and treat symptoms
recurrence 10-20%
mucous cyst
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
DeQuervains Tenosynovitis
inflammation of tendons at the side of the wrist and at the base of the thumb
clinical features of DeQuervains Tenosynovitis
spontaneous
pain, swollen, red
Finklestein’s test
what tendons are involved in DeQuervains Tenosynovitis
extensor pollicus brevis and abductor pollicus longus
treatment of DeQuervains Tenosynovitis
NSAIDs
splint
rest
steroid
decompression surgery
paronychia
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
flexor tendon sheath infection
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
SLAC
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
