Hand Problems

Question 1

Who gets Dupuytrens?

Answer 1

15-64s M:F = 8:1
75+ M:F = 2:1

Disease develops earlier in males

Associations made to; diabetes, alcohol, tobacco, HIV, epilepsy

Question 2

How is Dupuytrens inherited?

Answer 2

Autosomal dominant with variable penetrance

Sporadic in 30% of cases

Onset may be sex-linked, almost exclusively white races

Question 3

What is the pathology of Dupuytren’s disease?

Answer 3

Myofibroblast; intracellular contractile elements, regulated by growth factors and produce collagen

Question 4

What is the effect of Dupuytrens?

Answer 4

Functional problems, usually not painful

Loss of finger extension; active or passive

Hand in pocket, gripping things, washing face difficult

Question 5

What is the treatment for Dupuytrens?

Answer 5

Non operative

• observe
• splints don’t work
• radiotherapy

Operative

• partial fasciectomy
• dermo-fasciectomy
• arthrodesis
• amputation

Percutaneous needle fasciotomy
Collagenase

Question 6

Describe partial fasciectomy

Answer 6

Dupuytrens procedure

Most common procedure in UK

Good correction can be achieved

Wounds take 3-4weeks to heal

Stiffness requires physio, can’t be cured

Recurrence 50% at 5 years

Question 7

Describe dermo-fasciectomy

Answer 7

Dupuytrens procedure

More radical than partia faasciectomy

Removal skin may reduce reccurence rates but requires intensive physio

Question 8

Describe percutaneous needle fasciotomy

Answer 8

Dupuytrens procedure

Quick, no wounds

Return to normal activity 2-3 days and doesn’t prevent traditional surgery in future

Higher recurrence (?50% at 3 years)

Can be repeated but risk of nerve injury

Question 9

What is the anatomy of trigger finger?

Answer 9

2 tendons to each finger

Tendons run in sheath

Thickening in sheath = pulley which keeps tendon close to bone

Swelling in tendon catches on pulley

Question 10

Who gets trigger finger?

Answer 10

Women more than men

40s-60s

Ring > thumb > middle

Associated with; RA, DM, gout

Question 11

How is trigger finger diagnosed?

Answer 11

History

Clicking sensation with movement of finger

lump in palm under pulley

may have to use other hand to ‘unlock’

Clicking may progress to ‘locking’

Question 12

Describe treatment of trigger finger

Answer 12

Non-operative

• splintage
• steroid

Operative

• percutaenous release
• open surgery

Question 13

Describe the presentation of De Quervain’s tenovaginitis

Answer 13

Several weeks pain localised to radial side wrist

Aggravated by thumb movement

May have (had) localised swelling

Localised tenderness over tunnel

Question 14

Who gets De Quervain’s Tenovaginitis

Answer 14

M:F = 1:6

50s to 60s

Increased in post-partum and lactating females

Question 15

Where is the problem in De Quervain’s tenovaginitis?

Answer 15

1st dorsal extensor compartment

Fibro-osseous tunnel at distal radius

Thickening localised segment

30% 1st compartment divided by septum

Question 16

What tests can be done for De Quervain’s Tenovaginitis?

Answer 16

Finklestein’s test

Resisted thumb extension

Question 17

Describe treatment of De Quervain’s tenovaginitis

Answer 17

Non-operative

• splints
• steroid injection

operative
- decompression

Question 18

Describe ganglion anatomy

Answer 18

A myxoid degeneration from joint synovia (a lump)

Arise from joint capsule, tendon sheath or ligament

Question 19

Who gets ganglia?

Answer 19

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

Question 20

Describe the diagnosis of ganglia

Answer 20

Present with lump; firm, non-tender

Change in size, smooth

Occasionally lobulated, normally not fixated to underlying tissues

NEVER fixed to skin

Question 21

Describe treatment of ganglia

Answer 21

Non-operative

• reassure and observe
• aspirate

Operative

• excision
• including “root”

Question 22

How does OA of base of thumb present?

Answer 22

Pain
Stiffness
Swelling
Deformity
Loss of function

Question 23

Who gets base of thumb OA?

Answer 23

Common

1 in 3 women

pain opening jars/pinching

Dorsal subuxation, metacarpal adduction, MCPJ hyperextension

Look for STT OA

Question 24

How is OA base of thumb treated?

Answer 24

Non-operativee

• lifestyle modification
• NSAIDs
• Splint
• Steroid injection

Operative

• trapeziectomy
• fusion
• replacement

Question 25

Describe trapeziectomy

Answer 25

Used to treat base of thumb OA

“gold standard”

Good pain relief, moderate pinch group

+/- interposition flap or ligament reconstruction