Hands Flashcards
Carpal tunnel syndrome
The carpal tunnel of the wrist is formed by the carpal bones and the flexor retinaculum.
The median nerve passes through the carpal tunnel along with 9 flexor tendons (FDS & FDP to 4 digits + FPL) with their synovial covering.
Any swelling within the confines of the carpal tunnel may result in median nerve compression.
Whilst the flexor tendons are not particularly susceptible to pressure, nerves are highly sensitive to this problem.
Carpal tunnel syndrome risk factors
may be idiopathic (most cases)
can occur secondary to many conditions including rheumatoid arthritis (synovitis > less space) and conditions resulting in fluid retention – pregnancy, diabetes, chronic renal failure, hypothyroidism (myxoedema).
can also be a consequence of fractures around the wrist
(especially a Colles fracture)
With pregnancy the symptoms usually subside after childbirth
Women are affected up to 8 times more than men.
Carpal tunnel syndrome symptoms
present with parathesiae in the median nerve innervated digits (thumb and radial 2½ fingers) which is usually worse at night, loss of sensation and sometimes weakness of the thumb or clumsiness in the areas of the hand supplied by the median nerve
Carpal tunnel syndrome investigation
On examination there may be demonstrable loss of sensation and/or muscle wasting of the thenar eminence (with chronic sever cases).
Symptoms can be reproduced by performing Tinel’s test
(percussing over the median nerve) or
Phalen’s test, holding the wrists hyper‐flexed
(which decreases space in the carpal tunnel)
Nerve conduction studies confirm the diagnosis with slowing of conduction across the wrist.
Carpal tunnel syndrome treatment
Non-operative: treatment includes the use of wrist splints at night to prevent flexion.
Injection of corticosteroid can also be used.
Surgical treatment: Carpal tunnel decompression involves division of the transverse carpal ligament under local anaesthetic
(one of the most commonly performed surgical procedures).
It is usually a highly successful operation, although there is risk of damage to the median nerve or one of it’s smaller branches.
Dupuytren’s contracture
This is a proliferative connective tissue disorder where the specialized palmar fascia undergoes hyperplasia with normal fascial bands forming nodules and cords progressing to contractures at the MCP and PIP joints.
Dupytrens pathology
Pathology involves proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1).
The skin of the hand may be adherent to the disease fascia and puckered.
Palpable nodules may be present. Contractures most commonly affect the ring and little fingers.
Approximately half of cases have bilateral involvement.
Dupytrens risk factors
Males are much more commonly affected (by around 10:1), it can be familial (inherited in an autosomal dominant pattern) and has a high prevalence in those of Northern European / Scandinavian descent.
Dupytrens can also be seen as a feature of alcoholic cirrhosis and as a side effect of phenytoin therapy.
It is also more common in diabetics.
Peyronie’s disease, which affects the penis,
plantar fibromatosis affecting the feet (Ledderhose disease).
Young patients and patients with fibromatosis elsewhere tend to have more aggressive forms of the disease.
Dupytrens treatment
Mild contractures may be tolerated but surgical treatment can be offered if contractures are interfering with function.
Up to 30° of contracture can be tolerated at the MCP joint and but the PIPJ readily stiffens and any contracture here is usually an indication for surgery.
Surgery involves either removal of all diseased tissue (fasciectomy) or division of cords (fasciotomy).
Recurrence can occur particularly in the younger patient.
Severe contractures (finger in palm) may be most appropriately treated with amputation.
Trigger finger
Tendonitis of a flexor tendon to a digit can result in nodular enlargement of the affected tendon, usually distal to a fascial pulley over the metacarpal neck (the A1 pulley).
Trigger finger symptoms
Movement of the finger produces a clicking sensation, as this nodule catches on and then passes underneath the pulley.
sensation may be painful and the finger may lock in a flexed position as the nodule passes under the pulley but can’t go back though on extension.
may have to forcibly manipulate the finger to regain extension, usually with pain.
Any finger can be affected but the middle and ring are those most commonly affected.
Trigger finger treatment
most cases injection of steroid around the tendon within the sheath will relieve symptoms.
surgery can be offered in recurrent and persistent cases.
Surgery involves incision of the pulley to allow the tendon to move freely.
Due to the system of other pulleys, division of the A1 pulley does not affect function.
Osteoarthritis (Hand & Wrist)
Wear and tear arthritis in the small joints of the hand can be troublesome for patients particularly when performing intricate tasks.
80% of over 60s will have radiological evidence of OA in the hands but only a minority complaining of symptoms.
Distal interphalangeal joints (DIP) OA is very common in postmenopausal women.
Osteoarthritis (Hand & Wrist) DIPs
DIPs will become painful, swollen and tender eventually affecting all fingers.
Stiffness and bony thickening can be seen readily on examination (Heberden’s nodes).
An associated dorsal ganglion cyst (known as a mucous cyst) may be present.
Mild to moderate OA may be treated with removal of osteophytes and excision of any mucous cyst.
For severe pain arthrodesis may be performed.
Osteoarthritis (Hand & Wrist) PIPs
can also be affected with OA and bony swelling (Bouchard’s nodes).
For the index finger arthrodesis may be required to preserve pinch grip.
For other fingers replacement arthroplasty may be required however results are variable and re‐ operation rates are high.
Osteoarthritis (Hand & Wrist) MCPs
Rarely OA can affect the metocarpalphalageal (MCPs) joints but there is usually specific cause for this.
For example: previous injury, occupational stress, gout or infection.
Surgical treatment is possible for arthritis at the MCPs. MCP joint replacements are available which may relieve pain and improve ROM however complications are not uncommon (ulnar drift, extensor tendon subluxation).
Osteoarthritis (Hand & Wrist) 1st carpo‐metacarpal joint (trapziometacarpal joint)
base of the thumb metacarpal is commonly affected by OA, particularly in women with up to 1/3 of women over 40 having radiographic signs present.
Injection of steroid can help an acute “flare up” whilst excision arthroplasty (trapeziectomy) or fusion may cure chronic pain.
Rheumatoid arthritis (Hands)
hands are the site where rheumatoid arthritis (RA) seems to cause the greatest number of problems and is most visible.
patients with longstanding disease will eventually develop deformed, painful and occasionally malfunctioning hands
RA tends to spare the DIPs (in contrast with OA and psoriatic arthritis).
Rheumatoid arthritis (Hands)- 3 stages
Synovitis and tenosynovitis – inflammation within the joints and the tendon sheath lead to swelling and pain in the affected structures.
Erosions of the joints – inflammatory pannus denudes the joints of articular cartilage
Joint instability and tendon rupture – following the progressive destruction of the bony and soft tissue structure in the hand patients can progress to subluxation and chronic tenosynovitis predisposes to extensor tendon ruptures.
Thankfully the end stages of RA are becoming less and less common due to the introduction of modern disease modifying anti‐rheumatic drugs (DMARDs). Nonetheless, there is still a significant population of people who will exhibit hand deformities as a result of the disease.
Rheumatoid arthritis (Hands) clinical examination deformities
Volar MCPJ subluxation
Ulnar deviation
Swan neck deformity (hyperextension at PIPJ with flesion DIPJ)
Boutonniere deformity (flexion at PIPJ with hyperextension at DIPJ)
Z-shaped thumb
Rheumatoid arthritis (Hands) treatment/ management
Tenosynovectomy (excision of synovial tendon sheath) may prevent tendon rupture.
When extensor tendons to the wrist or fingers rupture direct surgical repair is not possible as repair of the diseased tendon will fail.
Tendon transfers or joint fusions may be required to preserve function.
Soft tissue releases (lengthening) may be required for contractures whilst MCP replacements, PIP replacements or fusions, wrist replacement or fusion may be required for severe arthritic change.
A multidisciplinary approach is required for the management of RA with rheumatologists, orthopaedic surgeons, physiotherapists, occupational therapists and orthotists all having a role in improving symptoms and maintaining function.
Ganglion cyst
These are common mucinous filled cysts found adjacent to a tendon or synovial joint.
They are common in the hand (DIPJ – mucous cyst, flexor tendon) and wrist (dorsal or volar).
They can also occur in the foot and ankle as well as the knee (Baker’s cyst).
Ganglion cyst symptoms & removal
can cause localized pain or irritation but many patients may wish to have them to be removed for cosmetic reasons, which isn’t strictly possible on the NHS.
caution should also be exercised in these cases ,as the patient is swapping a cyst for a scar, which may not be any more cosmetically acceptable to them.
scars sometimes remain tender and in these instances, the patient may feel themselves worse off after surgery than they were before.
Ganglion cyst other treatment
cysts are firm, smooth and rubbery and should transilluminate.
Needle aspiration may be attempted (watch volar ganglion à radial artery) but recurrence is common after this treatment (50‐ 70%).
Surgical excision may be required if the swelling causes localized discomfort.
The historic treatment of striking the wrist with a heavy book (“bible technique”) to burst the swelling is not advised.
Giant cell tumour of the tendon sheath
second most common soft tissue swellings of the hand (after ganglions).
on the palmar surface especially around the PIP joint of the index and middle fingers and are typically well circumscribed but can be diffuse.
may or may not cause pain, they can envelop the digital nerve or artery and they can erode into bone.
contain multinucleate giant cells and haemosiderin (which gives their brown appearance).
Excision is usually recommended to prevent local spread and to treat symtoms.
Recurrence is not uncommon (10‐20%).
