Hand Problems Flashcards
What are ganglions?
Fluid filled cysts, found adjacent to a tendon or synovial joint (outpourings of a synovial cavity)
When can ganglions/mucous cysts be removed? What is the rate of recurrence?
If they are causing pain- 50% chance of recurrence
When can ganglions not be removed?
For cosmetic reasons
If a patient wants a ganglion removed for cosmetic reasons, what should you inform them?
It will leave a scar, which may be just as cosmetically unacceptable. It may also remain tender which can be worse than the cyst in the first place.
What is a mucous cyst?
A ganglion at the flexor tendon of the DIP joint, often associated with OA
What are some symptoms of a mucous cyst?
May be painful, produce discharge, deform the nail
Will the size of a mucous cyst remain constant?
No, it will fluctuate
How would you describe what a ganglion feels like?
Smooth, rubbery, firm and should transilluminate
What kind of lumps will transilluminate?
Fluid filled
What are mucous cysts filled with? What are ganglions filled with?
Mucus cysts = mucous, ganglions = synovial fluid
What side of the wrist are ganglion cysts seen at?
Both, can be dorsal or volar
Is there normally treatment for a ganglion?
No, they usually resolve with time and do not require treatment
What type of ganglion shouldn’t be excised? Why?
Volar wrist ganglion cysts: close association with the radial artery
What type of tendons can be affected by trigger finger? What tendon is mostly affected?
Flexor tendons, especially flexor digitorum superficialis
What happens in trigger finger?
There is swelling of the tendon and tendon sheath, until the tendon gets caught on the edge of the A1 pulley
Where will there be pain in trigger finger?
Over the A1 pulley at the metacarpal head
In trigger finger, the finger will be stuck in what position? Why?
Stuck in flexion because the nodule passes below the pulley but then can’t get back through on extension
How can the affected finger in trigger finger be extended?
Using the other hand to pull it which can be painful, or over time it will suddenly ping into extension
Will all patients with trigger finger be able to extend their finger?
No
Movement of the finger in trigger finger causes what? Why?
A clicking sensation as the nodule catches onto and then passes under the pulley
Who does trigger finger affect?
Anyone at any age, even kids
What is the conservative management for trigger finger?
It often resolves spontaneously, in the meantime you can give a splint to prevent flexion, and up to 3 tendon sheath injections which are often curative
What is the downside of using a splint in trigger finger?
Can cause stiffening
What is the surgical management of trigger finger? When is this used?
Division of the A1 pulley to allow the tendon to move freely. Only used in recurrent/persistent cases.
DeQuervain’s tenosynovitis affects where?
The first extensor compartment, containing abductor policies longs and extensor pollicis brevis
What causes DeQuervain’s tenosynovitis? Where does it cause pain?
Usually a repetitive strain injury causing pain over the radial styloid process at the wrist
Who does DeQuervain’s tenosynovitis occur in? What conditions is it related to?
Mostly women aged 30-50, associated with pregnancy and RA
What tests and investigations are used for DeQuervain’s tenosynovitis?
Finklestein’s test, US, x-ray
Describe a presentation of DeQuervain’s tenosynovitis?
Spontaneous and painful, red and swollen
Describe the Fincklestein’s test?
Get the patient to make a fist and then press down on the base of the thumb- this will elicit a lot of pain
What are the treatment options for DeQuervain’s tenosynovitis?
NSAIDs, splinting, rest, steroid injections, decompression surgery
What is Dupuytren’s contracture?
Connective tissue disorder where the palmar fascia undergoes hyperplasia. Normal fascial bands then form nodules and cords.
Dupuytren’s causes contractures where? What deformity does this result in?
Contractures at the MCP and PIP joints, resulting in a fixed flexion deformity
What is the underlying pathology of Dupuytren’s contracture?
Proliferation of myofibroblast cells rather than fibroblasts and the production of abnormal collagen- type 3 rather than type 1
Which fingers do contractures in Dupuytren’s most commonly affect?
Little and ring fingers (though can affect any)
How common is it for Dupuytren’s to be bilateral?
Half of cases
Describe the onset of Dupuytren’s?
Painless, gradual progression which usually begins as a palmar pit/nodule
What are some factors which can be related to Dupuytren’s?
Genetics, diabetes, alcohol/cirrhosis, smoking, phenytoin therapy (epilepsy), fibromatosis
What is a clinical sign which is a fairly strong indicator of Dupuytren’s?
The patient cannot put their hand flat on a table
Who is Dupuytren’s most common in?
Older men (10:1)
Diathesis is a severe type of Dupuytren’s. Who is a more severe type more common in?
Young people, and those with fibromatosis elsewhere
What are some conservative management options for Dupuytren’s?
Stretches, activity modification, splintage
What two surgeries are mostly used for Dupuytren’s?
Fasciectomy (removal of diseased fascia) or fasciotomy (division of cords)
What are some outcomes to be aware of following surgery for Dupuytren’s?
A lot of therapy and rehab to get it moving again, and chance of recurrence (especially younger patients)
If Dupuytren’s is familial, how is it inherited? Where are descendents commonly from?
Autosomal dominant, high prevalence in North Europe/Scandinavia
Up to 30% of Dupuytren’s contractors at which joint can be tolerated?
MCP
Dupuytren’s at which joint is usually an indicator for surgery? Why?
PIP- readily stiffens
What is paronychia?
Infection within the nail fold
Paronychia usually occurs in who? Why?
Children, due to nail biting
What can paronychia result in?
Formation of pus, may affect the growth of the nail
What are some management options for paronychia?
Elevation, antibiotics, incision and drainage
Flexor tendon sheath infection is what? Is it associated with trauma or injury?
An emergency! Not necessarily associated with trauma or injury.
Why is flexor tendon sheath infection an emergency?
It can track up the palm and arm
What are some signs and symptoms of flexor tendon sheath infection?
Extreme pain, limited extension, tracking lymph node involvement
How is a flexor tendon sheath infection treated? What can occur if not treated?
Make an incision at the top and bottom and wash it out. If this is not done it can cause permanent disability.
