Hand Problems

Question 1

Who gets Dupuytren’s Disease?

Answer 1

8M>1F

White people

Question 2

Explain the inheritance pattern of Dupuytren’s Disease? [2]

Answer 2

Autosomal dominant with variable penetrance

Question 3

What conditions are associated with Dupuytren’s? [4]

Answer 3

Diabetes
Alcohol n Tobacco
HIV
Epilepsy - phenytoin rx

Question 4

Describe the pathology behind Dupuytren’s? [3]

Answer 4

Myofibroblasts make collagen which forms hard nodules along the palmar tendons of the fingers, pulling the finger into flexion

Question 5

How does Dupuytren’s present? [5]

Answer 5

First: hard nodules under palmar skin, bilateral
Then the fingers become permanently flexed (lose passive/active extension)
Usually not painful
Functional issues like problems washing their face or gripping things
Ectopic lesion on plantar fascia

Question 6

Which fingers are effected by Dupuytren’s? [3]

Which clinical test is used to investigate [1]

Answer 6

Mostly Ring Finger
Followed by Pinkie & Middle
Houston’s table top test

Question 7

How do we treat Dupuytren’s?
Non-operative [3]
Operative means [6]

Answer 7

Non-operative:
Watch and wait, splints but ineffective, radiotherapy

Partial Fasciectomy
Dermo-Fasciectomy
Arthrodesis
Amputation
- Percutaneous Needle Fasciotomy
- Collagenase

Question 8

Partial vs demo fasciectomy
Both followed by physiotherapy
Recurrence rate in partial?
Percutaneous needle fasciotomy vs fasciectomy
- 2 cons?
- recovery time?
Collagenese recurrence rate, 2 cons

Answer 8

Dermo fasciectomy - more radical than partial as overlying skin is removed too
Recurrence rate in partial is 50% in 5 years
Percutaneous needle fasciotomy - quick recovery within 2-3 days but higher recurrence and risk of nerve injury
Collagenase - 3 year recurrence 35%, $ and no control over where collagenase goes

Question 9

Who gets Trigger Finger and which fingers does it affect? [2]

Answer 9

F>M in 40-60s

Affects Ring > Thumb > Middle

Question 10

What is Trigger Finger?

Answer 10

Swollen flexor tendon catches the sheath it passes through making it difficult to flex

Question 11

What conditions are associated with trigger finger? [5]

Answer 11

RA
Diabetes
Gout
CTS
De Quervain's tenosynovitis

Question 12

How does Trigger Finger present? [3]

Answer 12

Clicking sensation on movement of the digit than can progress to “locking”

They may need the other hand to unlock the digit

May be a palpable lump under the sheath in the palm

Question 13

How can we treat Trigger Finger?
2 non-operative
2 operative

Answer 13

Splintage
Steroid Injection

Operatively:

• Percutaneous release
• Open surgery

Question 14

Define De-quervain’s Tenovaginitis?

Answer 14

Non-inflammatory thickening of the EPB & APL tendons along with their sheaths that causes:

• radial wrist pain aggravated by thumb movement
• +/- a localised swelling

Question 15

Epidemiology Dequervain’s Tenovaginitis? [2]

Causes [3]

Answer 15

Mostly women in 50-60s

Also Post-partum or lactating women

Causes:
Caused by repetitive overuse in activities with frequent thumb abduction and ulnar deviation
RA
Trauma - direct blow to thumb

Question 16

What tests can be used for De Quervain’s Tenosynovitis? [2]

Answer 16

Finklestein’s Test - Grasp the patients thumb and sharply ulnar deviate the hand looking for sharp pain along the distal radius

Question 17

How do we treat De Quervain’s Tenovaginitis? [4]

Answer 17

Splintage
Steroid Injection
Immobilisation with thumb splint (spica)
Operative Decompression

Question 18

What is ganglion?

Answer 18

Cyst arising from a joint capsule, tendon sheath or ligament

Question 19

Who gets ganglia? [2]

Where are most ganglia found on the hands?

Answer 19

More common females

Wide age ranges but peaks at 20-40yrs

Dorsal Surface

Question 20

How does a ganglia appear? [5]

Answer 20

As a smooth, firm, non-tender lump that changes in size

Its never fixed to skin and rarely to underlying structures

Question 21

How do we treat ganglia? [3]

Answer 21

• Aspiration
• “Family Bible” Technique

Operative Excision including root

Question 22

Epidemiology OA - common

Answer 22

1 in 3 women

Question 23

How does OA present in the thumb? [5]

One clinical finding on examination

Answer 23

Pain - pinching, night, use-related
Stiffness
Swelling
Deformity
Loss of function

• Crepitus

Question 24

What else should we check for in a patient with base of thumb OA? [1]

Answer 24

Scapho-Trapezoid-Trapezium (STT) OA

Question 25

How can we treat base of thumb OA non-operatively?

Non-Operative [4]

Answer 25

• Steroid injection
• Splint
• NSAIDs
• Lifestyle modifications eg exercise, weight loss

Question 26

What surgery can we offer for OA? [3]

Answer 26

Gold standard is Trapeziectomy
Joint Fusion
Joint replacement

Question 27

Metacarpal fracture
Ax
Presentation of rotational type # [3]

Answer 27

Ax: usually punch

Rotational # cause:

• rotation of fingers
• if cannot extend fingers, get them to flex
• rotation has occurred if all not pointing to scaphoid

Question 28

Metacarpal fracture Mx
Stable closed fracture [2]
Rotational or >2MCs

Answer 28

Stable closed #:

• splint or cast
• with wrist in partial extension, MCP in flexion and fingers in extension

Rotational or >2MCs:
- ORIF with plates or screws

Question 29

Infective flexor tenosynovitis

Ax [3]

Answer 29

Ax:

• staph aureus (although can incl. strep and gram -ves)
• causes infection of flexor tendon sheath
• which has spread from paronychia or felon

Question 30

What is paronychia or felon?

Infective flexor tenosynovitis Mx [3]

Answer 30

Paronychia - cellulitis around nail bed
Felon - abscess of pulp of distal finger

Mx:

• IV Abx
• Wash out in theatre
• Repeated washouts with post-op indwelling catheter

Question 31

Kanavel’s 4 signs

Answer 31

Characteristic of infective flexor tenovsynovitis

• Symmetrical swollen fingers
• Tenderness over flexor sheath
• Pain on passive exetension of fingers
• Neutral position in slight flexion