Hand Conditions Flashcards
What is the standard burn treatment?
(respiratory, manage infection, rehydrate, pain relief)
What is the burn treatment specific to hands?
- 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)
What is the initial treatment of severe mutilating injuries?
- 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
What is the further management of severe mutilating hand injuries?
- 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
What is Dupuytren’s contracture?
Superficial fibromatosis that starts in the hand
What is the aetiology of Dupuytren’s contracture?
- 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
What is the pathophysiology of Dupuytren’s contracture?
- 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
What is the presentation of Dupuytren’s contracture?
- 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
What is the management of Dupuytren’s contracture?
- 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)
What is the aetiology of interphalangeal joint dislocations?
- Hyperextension injury; direct axial blow
- Almost always dislocate posteriorly
What is the presentation of interphalangeal joint dislocation?
pain and deformity of the affected digit
What is the management of Interphalangeal joint dislocations?
- 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
What are the complications of interphalangeal joint dislocations?
- 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
What is a Boxer’s fracture?
Fracture of the 5th metacarpal neck
What is the aetiology of a boxer’s fracture?
Usually caused by a clenched fist striking a hard object
What is the presentation of a boxer’s fracture?
- Dorsal hand pain
- Swelling
- Possible deformity
- Distal part of the fracture is displaced anteriorly, producing a shortening of the affected finger
- Neurovascular exam
What are the investigations of a boxer’s fracture?
X-ray - AP, lateral, oblique
What is the management of a boxer’s fracture?
- ‘Buddy strap’
- Early mobilisation
What is Bennett’s fracture?
A fracture of the 1st metacarpal base, caused by forced hyperabduction of the thumb
What is the aetiology of a Bennett’s fracture?
Mostly caused by axial force applied to the thumb in flexion
What is the pathophysiology of a Bennett’s fracture?
- 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
What is the presentation of a Bennett’s fracture?
- Acute pain at base of thumb
- Swelling and ecchymosis
- Tenderness to palpation at CMC joint
- Pain with motion
What are the investigations of a Bennett’s fracture?
X-ray - AP and lateral
What is the management of a Bennett’s fracture?
- 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
What is trigger finger?
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
What is the aetiology of Trigger finger?
- More common in females
- Typically age 50+ (but can occur at any age)
- More common in diabetics
What is the pathophysiology of Trigger finger?
- 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
What is the presentation of trigger finger?
- 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
What is the management of trigger finger?
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
What is paronychia?
Infection within the nail fold
What is the aetiology of paronychia?
- Often in children/YAs
- Associated with nail biting
What is the presentation of paronychia?
- Inflammation and redness around the fingertip
- May result in pus collection
What is the management of paronychia?
- Elevate
- Antibiotics
- Incise and drain pus collection
What is a subungual haematoma?
- 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)
What are the categories of nailbed injuries?
- 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
What is the management of nailbed injuries?
- 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
What are flexor tendon sheath infections?
Infection within tendon sheath, tracking up palm + arm
What is the aetiology of flexor tendon sheath infections?
- Can occur from direct penetrating trauma e.g. knife wound
- Haematogenous spread e.g. from dental infection
What is the presentation of flexor tendon sheath infections?
- Extremely painful
- Limited extension (including passive) due to pain
What are the investigations for flexor tendon sheath infections?
- 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
What is the management of flexor tendon sheath infections?
- Elevation and high dose antibiotics
- Emergency surgery - washout tendon sheath, opening up A1 and A5 pulleys
What is the aetiology of flexor tendon injuries?
Commonly result from volar lacerations
How are flexor tendon injuries classified?
- 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
What is the presentation of a flexor tendon injury?
Loss of active flexion strength or motion of the involved digits
What are the investigations for flexor tendon injuries?
- X-ray to assess for associated fracture
- US - to assess suspected lacerations
What is the management of flexor tendon injuries?
- Conservative - wound care, early ROM
- Surgical - flexor tendon repair/reconstruction/transfer
What is mallet finger?
An avulsion of the extensor tendon from the distal phalynx resulting in inability to actively extend the DIPJ (flexion deformity)
What is the aetiology of Mallet finger?
Caused by an object hitting the tip of the finger or thumb; the force of the blow tears the extensor tendon
What is the presentation of Mallet finger?
- Tenderness/bruising
- No resisted finger extension on examination
What is the management of mallet finger?
- 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 +)
What is the aetiology of extensor pollicus longus rupture?
- Can occur with RA: autoimmune attack on synovium → tendon degeneration → rupture
- Can also occur secondary to Colles fracture
What is the presentation of extensor pollicus longus rupture?
Substantial loss of function - can’t extend thumb at MCP/IPJ
What is the management of extensor pollicis longus rupture?
- If caught during proceeding synovitis from RA, a synovectomy can help prevent rupture
- Once rupture has occurred, a tendon transfer is required (EIP)
