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Musculoskeletal MBCHB > Hand Conditions > Flashcards

Hand Conditions Flashcards

1
Q

What is the standard burn treatment?

A

(respiratory, manage infection, rehydrate, pain relief)

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2
Q

What is the burn treatment specific to hands?

A
  • Excise damaged skin and perform split skin grafts early
  • Aggressive mobilisation to prevent finger stiffness
  • Escharotomy - surgical release of eschar (thick, leathery, inelastic skin which can form after burns)
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3
Q

What is the initial treatment of severe mutilating injuries?

A
  • Preserve amputated parts in a moist gauze and then in ice
  • Early debridement
  • Establish stable bony support
  • Establish vascularity
  • Repair all tissues
  • Establish skin cover - grafts, flaps
  • Prevent/treat infection
  • Aggressive mobilisation
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4
Q

What is the further management of severe mutilating hand injuries?

A
  • Early involvement with Plastics
  • Will require microsurgery to repair nerves and vessels
  • Split skin grafts onto healthy tissue
  • Flaps to cover exposed bone
  • Formal amputation if unreconstructable or unable to re-establish nerve supply
  • In amputation, consider later use of prosthetics
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5
Q

What is Dupuytren’s contracture?

A

Superficial fibromatosis that starts in the hand

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6
Q

What is the aetiology of Dupuytren’s contracture?

A
  • Genetic predisposition
    • Autosomal dominant mutation with variable penetration
    • Common in northern Europe
    • Higher incidence in males
  • Environmental factors
    • Diabetes mellitus
    • Alcohol/cirrhosis
    • Smoking
    • Epilepsy/epileptic medication
    • Repetitive trauma or from an acute injury to the hand
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7
Q

What is the pathophysiology of Dupuytren’s contracture?

A
  • Excessive myofibroblast proliferation and altered collagen matrix composition leads to thickened and contracted palmar fascia
  • The thickening and contracture of the subdermal fascia leads to fixed flexion deformity of fingers (NOT associated with a tendon)
  • Bands are primarily collagen type III
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8
Q

What is the presentation of Dupuytren’s contracture?

A
  • Painless, gradual progression
  • Usually starts as palmar pit/nodule
  • Flexion contracture of affected fingers, 4th and 5th fingers are the most commonly involved
  • Dupuytren’s diathesis - severe form of Dupuytren’s involving little and ring fingers, Lederhosen’s (superficial fibromatosis of the foot) and Peyronie’s (superficial fibromatosis of the penis)
  • Palpate cords
  • MCP/PIP joint involvement - measure angles
  • Table-top test - inability to flatten the palm against the surface of a table due to the contractures in the metacarpophalangeal joints
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9
Q

What is the management of Dupuytren’s contracture?

A
  • Conservative - observation, stretches, activity modification
  • Surgery - needle fasciotomy (single band), limited fasciectomy (removal of the bands) dermofasciectomy + graft (removal of the band, adherent/contracted skin and covering graft)
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10
Q

What is the aetiology of interphalangeal joint dislocations?

A
  • Hyperextension injury; direct axial blow
  • Almost always dislocate posteriorly
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11
Q

What is the presentation of interphalangeal joint dislocation?

A

pain and deformity of the affected digit

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12
Q

What is the management of Interphalangeal joint dislocations?

A
  • PIP - closed reduction and buddy taping (or splinting)
  • DIP - closed reduction +/- splinting
  • Head of phalynx can button-hole through volar plate, causing volar plate entrapment which blocks reduction → open reduction required
  • If associated fracture renders the joint unstable, additional fixation/repair is required
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13
Q

What are the complications of interphalangeal joint dislocations?

A
  • Delayed presentation causes degeneration of the articular surface and profound stiffness of the finger
    • Impossible to reduce, may require fusion
  • Recurrent instability due to associated fracture
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14
Q

What is a Boxer’s fracture?

A

Fracture of the 5th metacarpal neck

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15
Q

What is the aetiology of a boxer’s fracture?

A

Usually caused by a clenched fist striking a hard object

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16
Q

What is the presentation of a boxer’s fracture?

A
  • Dorsal hand pain
  • Swelling
  • Possible deformity
  • Distal part of the fracture is displaced anteriorly, producing a shortening of the affected finger
  • Neurovascular exam
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17
Q

What are the investigations of a boxer’s fracture?

A

X-ray - AP, lateral, oblique

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18
Q

What is the management of a boxer’s fracture?

A
  • ‘Buddy strap’
  • Early mobilisation
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19
Q

What is Bennett’s fracture?

A

A fracture of the 1st metacarpal base, caused by forced hyperabduction of the thumb

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20
Q

What is the aetiology of a Bennett’s fracture?

A

Mostly caused by axial force applied to the thumb in flexion

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21
Q

What is the pathophysiology of a Bennett’s fracture?

A
  • Fracture can extend into the first carpometacarpal joint leading to instability and subluxation of the joint - often needs surgical repair
  • If missed, the articular cartilage of the CMC joint will degenerate → deformity, dysfunction and arthritis
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22
Q

What is the presentation of a Bennett’s fracture?

A
  • Acute pain at base of thumb
  • Swelling and ecchymosis
  • Tenderness to palpation at CMC joint
  • Pain with motion
23
Q

What are the investigations of a Bennett’s fracture?

A

X-ray - AP and lateral

24
Q

What is the management of a Bennett’s fracture?

A
  • Following the fracture, there tends to be a small bony fragment attached to the volar beak ligament (a ligament of the CMC joint)
  • The thumb is surgically reduced onto the bony fragment and fixed, commonly with K wires
25
Q

What is trigger finger?

A

Inhibition of smooth tendon gliding due to mechanical impingement at the level of the A1 pulley that causes progressive pain, clicking catching and locking of the affected finger

26
Q

What is the aetiology of Trigger finger?

A
  • More common in females
  • Typically age 50+ (but can occur at any age)
  • More common in diabetics
27
Q

What is the pathophysiology of Trigger finger?

A
  • Tendons run within flexor tendon sheath
  • Stenosing tenosynovitis (tendon swelling) → irritation → fibrocartilaginous metaplasia (more swelling) → nodule on FDS tendon
  • The nodule results in the loss of smooth gliding of the finger flexor tendons under the annular pully, so finger gets locked in flexed position
28
Q

What is the presentation of trigger finger?

A
  • Pain over A1 pulley (MC head)
  • Sticking of finger, usually in flexion
    • May need other hand to extend
    • May not be able to extend at all
  • Demonstrate triggering
  • Tenderness over A1 pulley
  • Feel nodule pass beneath pulley
  • Distinguish between Dupuytren’s
29
Q

What is the management of trigger finger?

A

Conservative

  • Often resolves spontaneously
  • Splint to prevent flexion

Tendon sheath injection

  • Steroid + LA
  • Often curative
  • May be repeated 2x

Surgical release

  • Division of the A1 pulley under general or local anaesthetic
30
Q

What is paronychia?

A

Infection within the nail fold

31
Q

What is the aetiology of paronychia?

A
  • Often in children/YAs
  • Associated with nail biting
32
Q

What is the presentation of paronychia?

A
  • Inflammation and redness around the fingertip
  • May result in pus collection
33
Q

What is the management of paronychia?

A
  • Elevate
  • Antibiotics
  • Incise and drain pus collection
34
Q

What is a subungual haematoma?

A
  • Haematoma under the nail plate
  • If pressure causing pain - trephine
    • Small hole pierced in the thick collagen of the nail plate which allows the haematoma under pressure to drain
    • Pressure and associated pain will disappear instantly
  • Nail may eventually fall off (will grow back)
35
Q

What are the categories of nailbed injuries?

A
  • Type 1 - soft tissue only
  • Type 2 - soft tissue and nail
  • Type 3 - soft tissue and nail and bone
  • Type 4 - proximal 1/3 of phalanx
  • Type 5 - proximal to DIP
36
Q

What is the management of nailbed injuries?

A
  • Keep nail if possible - splint, maintains nail fold
  • Level 1 and 2 - dressing only
  • Level 3 - repair nail bed and stabilise bone
  • Level 4 - repair nail bed and stabilise bone, if there is <5mm of nail bed remaining → ablate
  • If fingertip not available, terminalise the finger or perform a V-Y flap
37
Q

What are flexor tendon sheath infections?

A

Infection within tendon sheath, tracking up palm + arm

38
Q

What is the aetiology of flexor tendon sheath infections?

A
  • Can occur from direct penetrating trauma e.g. knife wound
  • Haematogenous spread e.g. from dental infection
39
Q

What is the presentation of flexor tendon sheath infections?

A
  • Extremely painful
  • Limited extension (including passive) due to pain
40
Q

What are the investigations for flexor tendon sheath infections?

A
  • Kanavel’s cardinal signs:
    • Affected finger held in fixed flexion
    • Fusiform swelling over finger
    • Painful to percuss over sheath
    • Painful on passive extension
  • X-rays
  • Culture of drainage/surgical sample
41
Q

What is the management of flexor tendon sheath infections?

A
  • Elevation and high dose antibiotics
  • Emergency surgery - washout tendon sheath, opening up A1 and A5 pulleys
42
Q

What is the aetiology of flexor tendon injuries?

A

Commonly result from volar lacerations

43
Q

How are flexor tendon injuries classified?

A
  • Classified by the zone of injury
  • Zone II (no mans land) - zone from FDS insertion (just distal to PIP joint) to the A1 pulley
    • These injuries are very difficult to treat
44
Q

What is the presentation of a flexor tendon injury?

A

Loss of active flexion strength or motion of the involved digits

45
Q

What are the investigations for flexor tendon injuries?

A
  • X-ray to assess for associated fracture
  • US - to assess suspected lacerations
46
Q

What is the management of flexor tendon injuries?

A
  • Conservative - wound care, early ROM
  • Surgical - flexor tendon repair/reconstruction/transfer
47
Q

What is mallet finger?

A

An avulsion of the extensor tendon from the distal phalynx resulting in inability to actively extend the DIPJ (flexion deformity)

48
Q

What is the aetiology of Mallet finger?

A

Caused by an object hitting the tip of the finger or thumb; the force of the blow tears the extensor tendon

49
Q

What is the presentation of Mallet finger?

A
  • Tenderness/bruising
  • No resisted finger extension on examination
50
Q

What is the management of mallet finger?

A
  • Mallet splint for 6 weeks (24/7) if joint is congruent
  • If joint is not congruent (large displaced avulsion fracture) reduce the joint and fixate with K wires or screws
    • Non-congruent joints will be predisposed to secondary OA
  • Dermatotenodesis in chronic cases (3 months +)
51
Q

What is the aetiology of extensor pollicus longus rupture?

A
  • Can occur with RA: autoimmune attack on synovium → tendon degeneration → rupture
  • Can also occur secondary to Colles fracture
52
Q

What is the presentation of extensor pollicus longus rupture?

A

Substantial loss of function - can’t extend thumb at MCP/IPJ

53
Q

What is the management of extensor pollicis longus rupture?

A
  • If caught during proceeding synovitis from RA, a synovectomy can help prevent rupture
  • Once rupture has occurred, a tendon transfer is required (EIP)

Musculoskeletal MBCHB (21 decks)

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