Hand Conditions and Injury Flashcards
What is a mucous cyst?
Out-pouching of the DIP joint synovial fluid
Found in OA
What symptoms do mucous cysts usually have for the patient?
- painful
- sometimes there is discharge
- deform nail, causing ridge
How is a mucous cyst usually treated?
may be left alone
OR in some cases = excision
How is a ganglion cyst defined?
- Outpouchings of synovial cavity
- Filled with synovial fluid
=> more common where high concentration of synovial joints eg. wrist
What symptoms can a ganglion cyst cause?
- Fluctuate (not always there)
- painless
- may feel tight
- Usually resolve with time
How are ganglions managed?
- Left alone
- aspirated (difficult as fluid inside is so viscous)
- excision if causing difficulty to patient
(e. g. keeps catching it on clothes etc)
Tendons in the fingers run within what?
The Flexor tendon sheath
What can finger tendon swelling lead to?
Trigger Finger (catches in flexion)
swollen tendon gets caught on A1 pulley
What is the function of pulleys in the fingers?
Anchor tendons to bones for more effective fine movement
Explain the different stages of Trigger Finger
Early: Finger sticks in flexion but can spring back to extension after period of time
Middle: Pt needs to use their other hand to extend the finger
Late: Patient cannot extend the finger at all
What methods of examination can confirm a suspected trigger finger?
demonstrate triggering
tender over A1 pulley
feel nodule pass beneath pulley
How is Trigger Finger treated?
Often resolves spontaneously
=> splint to prevent flexion
Tendon sheath inj.
- steroid + Local anaesthetic - often curative - may be repeated up to 3x
Surgery
- under General or Local Anaesthetic - divide A1 pulley (not A2 or 4 as these are the most important)
What hand condition is characterised by a painful, red and swollen thumb that has come on spontaneously?
De Quervains Tenosynovitis
What examination can be used to test for De Quervains?
Finklestein’s test
How is De Quervains managed?
First:
- NSAIDS
- splint
- rest
Next:
- steroid injection
Finally:
- surgical decompression
What group of people are particularly likely to get De Quervains?
Pregnant women
What condition thickens and contracts the subdermal fascia leading to a fixed flexion deformity of the fingers?
Dupuytrens Contracture
How do Dupuytren’s contractures usually begin?
Usually starts as palmar pit/nodule
What can predispose to Dupuytren’s Contracture?
- genetics (?Viking)
- Diabetes Mellitus
- alcohol/cirrhosis
- smoking
- epilepsy/anti-epileptic medication
- ?trauma
What examination is most useful in determining a Dupuytrens contracture?
Table top test
If patient cant extend fingers far enough their hand will not be flat on the table
How is Dupuytren’s contracture usually treated conservatively?
- stretches
- activity modification
What surgical treatments are available for a Dupuytrens Contracture?
- non-segmental/ segmental fasciectomy
- dermofasciectomy (skin graft)
- amputation if severe (past PIP)
- percutaneous needle fasciotomy
(release that can be repeated)
What is a Paronychia?
- infection within nail fold
- May result in pus collection
- often in children
What action is a large risk for paronychia formation?
Nail biting
How are paronychias usually treated?
- elevate (as with any infection)
- antibiotics
- incise and drain collection
How does an infection within the tendon sheath usually present?
Tracking up palm + arm
Extremely painful
limited extension (including passive), due to pain
May have tracking lymphangitis
How is a tendon sheath infection usually treated?
wash out tendon sheath
surgical emergency
What part of a hand history is the most important?
- dominant hand
- PMHx
- DM
- arthritis
- cardio-resp (for GA factors)
- Occupation
- Hobbies/sports
If there is a history of trauma what points of the history are most important?
- crush/ sharp/ burn
- gloves/protective items worn?
- timing of injury - especially if partial/complete amputation
- Degloving (skin seperation)
- Estimate level of energy
What should you look for when examining a hand injury?
Wound Nails Deformity Swelling Point of tenderness Movement Neurological
When inspecting a hand injury wound, what is important to look for?
Where How long How deep Clean/dirty Skin loss Obvious structures in wound e.g. bone/tendon/foreign bodies/dirt/grit
What is the name given to a collection of blood under the nail bed and nail plate?
Subungual haematoma
How is a subungual haematoma treated?
If pressure causing pain => Trephine
- Needle through nail plate and bed to relieve pressure and blood
What is the drawback of relieving the pressure in a subungual haematoma?
Nail may eventually fall off
BUT will grow back
How are nail and nail bed injuries classified, and what does each class affect?
Type 1- Soft tissue only Type 2- Soft tissue + nail Type 3- Soft tissue + nail + bone Type 4- Proximal ⅓ of phalanx Type 5- proximal to DIP Joint
How is each level of nail/nailbed injury treated?
Level 1 + 2- dressing only
Level 3- repair nail bed + stabilise bone
Level 4- as above unless <5mm of nail bed ➞ ablate
If tip of finger = not available, terminalise or V-Y flap
What is a Boxers fracture?
Fracture of the 5th Metacarpal near the MCP joint
How is a Boxers Fracture treated?
Buddy Strap (to adj. finger) Early mobilisation
An avulsion fracture of the DIP joint is given what name?
Mallet Finger
How would a Mallet fracture present on examination?
resisted finger extension
tenderness/bruising
How is Mallet Finger treated?
Constant mallet splint for 6 weeks
Occasionally fix large displaced avulsion fragment using wire
Dermatotenodesis (chronic cases)
How is a PIP joint dislocation treated acutely?
pull to reduce
buddy strap
delayed presentation may not reduce => bone fusion
Where is a Bennetts Fracture usually found?
At 1st MCP joint
How is the hand divided into sections when discussing tendon injury?
I - distal to FDS tendon II - No mans land III - Lumbrical Origin IV - Carpal Tunnel V - Muscle Tendon Junction
What are the basic principles for a patient presenting with an extensive and mutilating injury to the hand?
- Preserve amputated parts on ice
- Early debridement
- Establish stable bony support
- Establish vascularity
- Repair all tissues- nerves, tendons
- Establish skin grafts/flaps
- Prevent/treat infection
- Aggressive mobilisation
Why is a zig-zag incision used to surgically repair a dupuytrens contracture?
A straight incision would heal as a scar which is difficult and painful to flex
Zig-zag scar allows movement with less pain
What is considered the “Standard Burns Treatment”
respiratory
infection
dehydration
pain relief
What treatments are specifically used for burns in the hands?
- Excise damaged skin
- perform split skin grafts early
- Aggressive mobilisation to prevent finger stiffness
- Escharotomy (releasing burnt skin)
What is Eschar?
Thick, leathery, inelastic skin which can form after burns
May require surgical release to allow movement
