Hand problems Flashcards
Epidemiology of dupuytrens?
> Age 15-64 - M:F = 8:1
Age >75 - M-F = 2:1
> Disease develops earlier in men > Autosomal dominant, varied penetrance > Sporadic in 30% cases > White race almost exclusively > Associative factors (Diabetes, alcohol, tobacco, HIV, Epilepsy)
Associations with Dupuytren’s?
> Diabetes > Alcohol > Tobacco > HIV > Epilepsy
Which race is more likely to get Dupuytren’s?
White
Which sex is more likely to get Dupuytren’s?
Male
> Age 15-64 - M:F = 8:1
> Age >75 - M-F = 2:1
Dupuytren’s diathesis?
> Early onset disease
Bilateral disease
Family History
Ectopic disease
Dupuytren’s pathology?
Myofibroblast:
> Intracellular contractile elements
> Regulated by growth factors
> Production of collagen
Dupuytren’s - functional problems?
> Usually not painful > Loss of finger extension – active or passive > Hand in pocket > Gripping things > Washing face
Dupuytren’s - treatment options?
Non-operative
> Observe
> Splints don’t work
> Radiotherapy
Operative > Partial fasciectomy > Dermo-fasciectomy > Arthrodesis > Amputation
> Percutaneous Needle Fasciotomy
Collagenase
Dupuytren’s - non-operative treatment options?
Non-operative
> Observe
> Splints don’t work
> Radiotherapy
Dupuytren’s - operative treatment options?
Operative > Partial fasciectomy > Dermo-fasciectomy > Arthrodesis > Amputation
> Percutaneous Needle Fasciotomy
Collagenase
What is the most common procedure performed in the UK?
Partial fasciectomy
How long does it take for the wound to heal in partial fasciotomy?
2-3 weeks
Why is physiotherapy required in Dupuytren’s?
For stiffness
Can Dupuytren’s be cured?
No
What is the reoccurrence rates of Dupuytren’s after partial fasciectomy?
50% at 5 years
What is the advantage and disadvantages of dermo-fasciotomy in Dupuytrens?
Advantage:
> Removal skin may reduce reoccurrence
Disadvantages:
>More radical procedure
> Requires intensive physiotherapy
What is the advantage and disadvantages of percutaneous needle fasciotomy in Dupuytrens?
Advantages: > Quick > No wounds > Return to normal activities 2-3 days > Can be repeated > Does not prevent traditional surgery in future
Disadvantages:
> Higher recurrence
(? 50% at 3 years)
> Risk of Nerve Injury
What is the advantage and disadvantages collagenase in Dupuytrens?
> Presented 3 year recurrence rate 34.8%
3 Flexor Tendon Ruptures!
Cost
Await longer term recurrence rates
How many tendons to each finger?
Two tendons to each finger
What is the significance of the tendons of the fingers running within a sheath
> Keep tendon close to bone
Thickens in sheath = pulley
Swelling in tendon catches on pulley
Epidemiology of trigger finger?
> Women more frequent than men > 40s-60s > Ring > Thumb > Middle > Repetitive use of hand > Local trauma > Associations (RA, DM, Gout)
Epidemiology of trigger finger - sex?
Women
Epidemiology of trigger finger - Age?
40-60s
Epidemiology of trigger finger - associations?
RA, DM, Gout
Diagnosis of trigger finger?
> Patient History > Clicking sensation with movement of digit > Lump in palm under pulley > May have to use other hand to ‘unlock’ > ‘Clicking’ may progress to ‘locking’
Where is a lump palpable in trigger finger?
In the palm over A1 pulley
Where is the triggering palpable in trigger finger?
Around the A1 pulley
Trigger finger - treatment?
Non-operative
> Splintage
> Steroid
Operative
> Percutaneous release
> Open surgery
De Quervain’s syndrome - patient history?
> Several weeks pain localised to radial side of wrist
> Aggravated by movement of the thumb
> May have seen a localised swelling
> Localised tenderness over tunnel
De Quervain’s syndrome - epidemiology?
> M:F 1:6
Age 50s - 60s
> Increased in post partum and lactating females
> Activities with frequent thumb abduction and ulnar deviation
> Washerwoman’s sprain – Gray’s anatomy
De Quervain’s syndrome - epidemiology, sex?
Female
> M:F = 1:6
De Quervain’s syndrome - epidemiology, when increased in women?
> Increased in post partum and lactating females
De Quervain’s syndrome - epidemiology, which activities?
> Activities with frequent thumb abduction and ulnar deviation
De Quervain’s syndrome - diagnosis?
> Examine thumb joint = Consider base of thumb OA
Finklestein’s Test
Resisted thumb extension
De Quervain’s syndrome - management?
Non-operative:
> Splints
> Steroid injection
Operative:
> Decompression
What is a ganglion?
> A myxoid degeneration from join synovial joint, “A lump”
> Arise from joint capsule, tendon sheath or ligament
Ganglion - epidemiology?
> 70% of all discrete swellings in the hand and wrist
> More common in females (2:1)
> Wide age distribution (peak 20-40yrs)
> Dorsal > Volar (3:1)
> May be associated with recurrent injury around the wrist
Ganglion - epidemiology,, sex?
Females (2:1)
Ganglion - epidemiology, age?
Age 20-40 yrs peak
Ganglion - epidemiology, site (Dorsal vs. Volvar)?
Dorsal > Volvar (3:1)
Ganglion - Diagnosis?
Present with lump:
> Firm, non-tender
> Change in size
> Smooth
> Occasionally lobulated
> Normally not fixed to underlying tissues
> Never fixed to the skin
Ganglion - treatment?
Non-operative
> Reassure & Observe
> Aspiration
> Hit it with a bible!? Old-school
Operative
> Excision
> Including ‘the root’
OA base of thumb - Clinical presentation?
> Pain (Opening jars) > Stiffness > Swelling > Deformity > Loss of function
Issues surrounding OA base of thumb?
Dorsal subuxation, metacarpal adduction, MCPJ hyperextension
How many woman affected by OA base of thumb?
1 in 3
OA base of thumb - treatment?
Non Operative > Life style modifications > NSAIDS > Splint > Steroid Injection
Operative
> Trapeziectomy
> Fusion
> Replacement
OA base of thumb - treatment, non-operative?
Non Operative > Life style modifications > NSAIDS > Splint > Steroid Injection
OA base of thumb - treatment, operative?
Operative
> Trapeziectomy = “Gold standard”
> Fusion
> Replacement
OA base of thumb - treatment, gold standard operative?
Trapeziectomy
Trapeziectomy?
> Gold standard surgical treatment of OA base of thumb
> Good pain relied
> Moderate pinch grip:
- +/- interposition flap
or
- ligament reconstruction
