Hand and Wrist Problems Flashcards
what is dupuytren’s contracture
a proliferative connective tissue disorder where the specialised palmer fascia undergoes hyperplasia with normal fascial bands forming nodules and cord progressing to contractures at MCP and PIP joints
what is the pathophysiology of dupuytren’s contracture
proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1). The skin of the hand may be adherent to the disease fascia and puckered. Palpable nodules may be present
where does dupuytrens contracture mostly affect
ring and little fingers approx 1/2 cases bilateral
what causes dupuytrens contracture
males (10:1) familial (autosomal dominant) feature of alcohol cirrhosis side effect of phenytoin therapy diabetes can also occur with other fibromatoses including peyronies (effects penis) and ledderhose (affects feet)
what is involved in examination of dupuytrens contracture
feel cords MCP/PIP joint involvement = measure angles table-top test = can you put your hand flat on table
when would surgery be offered in dupuytrens contracture
mild contractures may be tolerated but surgical treatment can be offered if contractures are interfering with function. Up to 30o of contracture can be tolerated at MCP joint but the PIPJ readily stiffens and any contracture here is usually indication for surgery
what does surgery in dupuytrens contracture involve
either removal of all diseased tissue (fasciectomy) or division of cords (fasciotomy recurrence can occur severe contractures (finger in palm) may be most appropriately treated with amputation
what newer treatments are coming in for dupuytrens contracture
collagenase injection or percutaneous needle fasciotomy
what is trigger finger
tendonitis of a flexor tendon to a digit can result in nodular enlargement of affected tendon, usually distal to the fasical pulley over the metacarpal neck (the A1 pulley)
what fingers most commonly affected in trigger finger and what disease causes a risk of it
any finger but middle and ring most common diabetics at risk
what is symptoms of tigger finger
movement of finger produces a clicking sensation, as this nodule catches on and then passes through pulley this painful and finger lock in flexed position as nodule passes under pulley but cant go back through on extension
how to tell difference between trigger finger and dupuytrens
dupuytrens never opens in trigger finger it does even though patient may have to forcibly manipulate finger to regain extension
how is trigger finger treated
in most cases a steroid injection around tendon within sheath will work surgery can be offered in recurrent cases - incision of pulley to allow tendon to move freely (due to system of other pulleys, division of A1 does not affect function)
what do you call the stiffness and bony thickening seen in OA on DIP joints
heberden’s nodes DIP OA very common in post menopausal women
what do you call the bony swelling seen in OA of PIP joints
bouchards nodes
treatment options for OA in DIP joints
mild = removal of oteophytes and excision of any mucous cyst severe = arthrodesis may be performed
how is treatment options for OA in PIP joints
index finger = arthrodesis may be required to preserve pinch grip other fingers = replacement arthroplasty may be required however results are variable and reoperation rates high
rarely OA can affect MCP joints, what causes this
very specific cause eg previous injury, occupational stress, gout or infection
surgical treatment is possible for OA of MCP joint, what is it
MCP joint replacement may relieve pain and improve ROM but complications common (ulnar drift, extensor tendon subluxation)
the 1st carpo-metacarpal (trapziometacarpal joint) at base of thumb is commonly affected by OA, particularly in women, how is this treated
injection of steroid can help an acute flare up whilst excision arthroplasty (trapeziectomy) or fusion may cure chronic pain
what is the treatment of primary OA of the joints between the scaphoid, trapezium and trapezoid (STT) joint
selected fusion of these carpal bones or wrist fusion may be required for severe symptoms
what is treatment in OA of the radio-carpal joint of wrist which usually occurs as consequence of trauma (eg scaphoid non-union, carpal dislocation)
wirst arthroplasty or fusion
what are the three stages in which RA occurs in hands
1 = synovitis and tenosynovitis 2 = erosions of joints (as inflammatory pannus denudes joints of articular cartilage) 3 = joint instability and tendon rupture
what are the end stages of RA in hand (these arent really common anymore due to DMARDs)
volar MCPJ subluxation ulnae deviation swan neck deformity (hyperextension at PIPJ with flexion DIPJ) boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ) Z shaped thumb
what treatments are available for the complications of RA in hands
tenosynovectomy to prevent tendon rupture soft tissue release (lengthening) for contractures MCP replacement, PIP replacement or fusion and wrist replacement or fusion may be required resection of distal ulna may be required for DRUJ arthritis
what is a giant cell tumour of the tendon sheath
2nd most common soft tissue swelling of hand (after ganglions) that are usually on palmar surface especially around PIP joint of index and middle fingers
what do giant cell tumours of tendon sheath look like histologically
contain multinucleated giant cells and haemosiderin (which gives brown appearance)
what is consequence of giant cell tumour of tendon sheath
may or not cause pain, they can envelop the digital nerve or artery and can erode into bone
how is giant cell tumour of tendon sheath treated
excision usually recommended to prevent local spread and treat symptoms recurrence not uncommon (10-20%)
what is a mucous cyst
out pouching of synovial fluid from DIP joint OA
what do mucous cysts look like
what are symptoms of mucous cysts
typical appearance may be painful may fluctuate / discharge may deform nail and cause ridge
how are mucous cysts treated
may be left alone or excised
what are ganglions
out pouching of synovial cavity filled with synovial fluid therefore more common where there is high concentration of synovial joints eg wrist
other than wrist, where else can ganglions occur
foot and ankle as well as knee (bakers cyst)
what are symptoms of ganglion cyst
fluctuate in size, usually painless but may feel tight
how are ganglions treated
usually resolve with time sometimes aspirated with big bore needle but 50% chance of recurrence if do this. if reoccurs after this, can excise it but this rarely happens as by time of surgery it is gone. Aspiration / excision may damage radial nerve = damage determined by Alan test (old people used to hit them with bible - dont do this lol)
what is dequervains tenosynovitis
inflammation of the tendon sheath in wrist and lower thumb - first extensor compartment (ALP an EBP)
what are symptoms of dequervains tenosynovitis
spontaneous painful when using thumb swollen / red
how is dequervains tenosynovitis diagnosed
finklestein’s test (examiner grasping and ulnar deviating the hand when the person has their thumb held within their fist. If sharp pain occurs along the distal radius, de Quervain’s tenosynovitis is likely)
how is dequervains tenosynovitis
NSAIDs, splint and rest steroid injection in more severe cases failing that, surgical decompression
what is paronychia
infection within the nail fold which often occurs in children
what is risk factor for paronychia
nail biting
what are symptoms of paronychia
red, tenderness and swelling discolouration and thickening of nail plate cuticle pulls away from nail bed
how is paronychia treated
elevate antibiotics incise and drain collection
what is flexor tendon sheath infection
infection within sheath tracking up palm and arm - it is rare but a surgical emergency!!
what are symptoms of flexor tendon sheath infection
extremely painful even by slightest movement and limited extension due to pain may have tracking lymphangitis
how is flexor tendon sheath infection treated
elevate it and wash out tendon sheath
