Hand + Wrist

Question 1

What is a mucus cyst?
Where is it found?
Which condition is it associated with?
Symptoms?
benign or malignant?
Which structure can it impact on?
Management?

Answer 1

This is an outpouching of synovial fluid from DIPJ osteoarthritis
May be painful
Benign
Can deform the nail, causing a ridge
Either left alone or removed by surgical excision

Question 2

Ganglion
What is this?
Where are they more common and why?
What are they filled with?
What are they in communication with?
Symptoms?
Natural history?
Management options?
Consequences?

Answer 2

These are outpouchings of synovial cavity - therefore more common where high concentration of synovial joints e.g. wrist.
They are filled with a clear jelly like substance which is just concentrated synovial fluid. They are in communication with the joint capsule or tendon sheath.
Usually painless, but may feel tight – due to stretching of the capsule.
Usually resolves with time, so try and leave it alone.
Local pressure can disperse them
Aspiration
Excision
Problems include painful scars, neurovascular damage, especially in palmar wrist ganglia.

Question 3

Trigger finger
What is the pathophysiology?
Symptoms?

Answer 3

Swelling of the tendon sheath, along with nodule formation on the tendon proximal to the A1 pulley, prevents the tendon gliding smoothly and instead “catches”, causing the finger to lock in flexion.
The patient gets pain over the A1 pulley (MC head); “Triggering” = sticking of finger (usually in flexion), which then suddenly gives (extension). May need other hand to extend, or may not be able to extend at all.

Question 4

How do you differentiate between trigger finger and dupuytren’s contracture?

Answer 4

Trigger finger is sore and doesn’t have the thick skin that you get with Dupuytren’s, although they can sometimes coexist.

Question 5

What are the different management options for trigger finger?

Answer 5

Conservative
- Often resolves spontaneously
- Splint to prevent flexion
Tendon sheath injection – at the base of the finger
- Steroid + LA
- Often curative
- May be repeated up to 3x
Surgery
- Under GA or LA
- Divide A1 pulley (no others- why not?) – quite like undoing the cuff on your shirt

Question 6

DeQuervain’s tenosynovitis
What is this?
When is pain worst?

Answer 6

This is stenosing tenosynovitis (thickening and tightening) of the 1st extensor compartment (there are six total), which contains the abductor pollicis longus and the extensor pollicis brevis, as they cross the distal radial styloid
Pain is worst when these tendons are stretched e.g. lifting a teapot.

Question 7

DeQuervians tenosynovitis
Symptoms?
Special test?
Management?

Answer 7

Symptoms
- Spontaneous
- Painful!
- Swollen/red	Finklestein’s test – put thumb in hand, make fist and ulnar deviate
Management 
- NSAIDS
- Splint + rest 
- Rest
- Steroid injection
- Surgery - decompression

Question 8

Dupuytren’s conracture
What is this?
Which fingers are most commonly affected?
Which conditions is it associated with?

Answer 8

This is progressive, painless fibrotic thickening and contracture of subdermal fascia leading to fixed flexion deformity of fingers. Can affect any finger – most commonly ring or little.
Associated with diabetes, epilepsy medication, liver disease (?alcohol).

Question 9

Dupuytren’s contracture
Symptoms?
What should examination involve?

Answer 9

Symptoms
- Painless, gradual progression
- Usually starts as palmar pit/nodule
Examination
- Feel cords
- Try and extend finger – feel and try and fine the causative cord – differentiate between MCP (usually gets full correction) and PIP (not as likely to heal)
- MCP/PIP joint involvement - measure angles
- Table-top test – can you put your hand flat down on the table

Question 10

What are some options for surgical management of Dupuytren’s?

Answer 10

Segmental fasciectomy – remove about a 1cm segment of the cord
Fasciectomy – remove all of the cord; this is the most typical operation
Dermofasciectomy – remove all of the cord and the skin overlying it

Question 11

Paronychia
What is this?
Who often gets it?
Management?

Answer 11

This is infection causing painful cellulitis in and around a nail fold.
Often in children as they tend to bite their fingers.
Management
- Elevate – important for any cellulitis or limb infection
- Antibiotics may help in the early stages
- Incise and drain collection

Question 12

Flexor tendon sheath infection
What is important about this?
Symptoms?
What is done in theatre?

Answer 12

Rare, but important- surgical emergency – because where the two flexor tendons run in the flexor tendon sheath is very susceptible to stiffness and so patient can lose movement in the finger.
Infection within sheath, tracking up palm + arm.
Symptoms
- Extremely painful
- Limited extension (including passive), due to pain
- May have tracking lymphangitis
Wash out tendon sheath