Hands/Upper Limb/ Tendinopathies (UL + LL) [week 5] Flashcards
Mucous cyst
> Outpouching of synovial fluid from DIPjt OA
> i.e. a ganglion at the DIPJt is known as a mucous cyst
> May be painful
> May fluctuate/discharge
> May deform nail, cause ridging
> Due to underlying OA (usually)
Joints are trying to lubricate themselves more to move –> nowhere for extra fluid to go –> mucous cyst
Can be excised if particularly bad
- may need to remove osteophytes too.
Ganglion
- what is it?
- common sites?
- management
- danger with solar ganglion
Outpouchings of synovial cavity
- common in wrist
Fibrous outer lining; Filled with synovial fluid
These fluctuate (get bigger and smaller)
Usually painless, tight feeling
Resolve with time
Volar (palmar) or dorsal wrist ganglion. DIPJ, Foot, ankle
Transilluminates
May be underlying joint damage
Commonest hand swelling
Management
- Benign neglect
- Aspiration: looks like gel in the syringe.
- Excision (if painful)
- Volar ganglions can be quite close to the radial artery –> be careful with aspiration.
Trigger Finger
- common site?
- pathology?
- examination
- management
Tendons run within the flexor tendon sheath
Any swelling on tendon leads to irritation –> more swelling and gets caught on edge of A1 pulley
i.e.
Stenosing tenosynovitis –> Fibrocartilagenous metaplasia –> Nodule FDS tendon affecting A1 pulley
Nodule catches of A1 causing triggering.
Tenderness / palmar pain
Can bend finger but cannot extend it and it suddenly gives.
Common site: A1 pulley (MC head)
Examination
- demo triggering
- tender over A1 pulley
- feel nodule pass beneath pulley
- distinguish from Dupuytren’s
Management
Conservative
- resolves spontaneously
- splint to prevent flexion
Tendon sheath injection
- steroidd + LA
- curative
- up to 3 times
Surgery
- under GA or LA
- divide A1 pulley
dividing any other pulley would severely affect finger movement
DeQuervain’s tenosynovitis
Specific test
Swollen tendon at base of thumb - locally tender. First extensor compartment
Spontaneous
PAINFUL
Swollen/red
Pain over radial styloid process
Extensor Pollicis Brevis and the Abductor Pollicis Longus tendons
Extensor tendons located in extensor compartments of hand.
Finkelstein’s test
Ix
- USS, XR rule out carbo-metacarpal OA
Management
- NSAIDs
- Splint
- rest
- steroid injection
- surgery - decompression (release both tendons in compartment - incision of the tunnel)
Gamer’s thumb
Dupuytren’s contracture
- is it to do with tendons?
- what do fibroblasts change into?
Thickening and contracture of subnormal Palmar fascia –> fixed flexion deformity of fingers.
Metaplasia of aponeurotic fibres.
Fibroblasts –> myofibroblasts (contractile)
Commonly middle and ring fingers
NOT tendons.
> Painless
Gradual progression
O/E
Feel cords
MCP/PIP joint involvement
Table top test
Genetics DM Alcohol/cirrhosis smoking epilepsy/ anti epilepsy meds
Common in Scandinavians/Scotland/Northern europe
Management
Conservative
- stretches
- activity modification
Surgery
- segmental fasciotomy
- fasciectomy
- dermofasciectomy
- amputation
Newer treatments
- collagenase injection: early dupuytren’s
- percutaneous needle fasciotomy
High rate of recurrence
May require a skin graft if there is skin involvement (the fascia may have fused to skin)
Dupuytren’s diathesis
Acute onset of Dupuytren’s contracture
Aggressive - in women, younger men, affects more of the fingers and progresses more rapidly
Contractures of feet - Lederhosen’s
Contractures of penis - Peyronie’s
Peyronie’s contracture
Dupuytrens of the penis
Zig zag incisions
You do not want to make an incision across a flexor crease
Paronychia
- common in?
Infection within the nail fold.
Painful
Red
Swollen
–> Pus
Can spread under the eponychium.
Common in children
Nail biters
--- Management - elevate - abx - incise and drain
Flexor tendon sheath infection
SURGICUAL EMERGENCY
Infection within sheath
Tracking up palm + arm
Extremely painful.
Limited extension (inc. passive extension) due to pain
May have tracking lymphangitis - check axilla, or groin (if infection in the foot)
Risk of tendon adhesion.
Management
Wash out the tendon sheath
Incision at tip and further down - drain it.
History of a swelling
Examination of a swelling
> Duration
Pain
- dull, chronic –> ?cancer
- sharp?
> Change in size - growing - fluctuating > Hx of injury > Solitary or multiple
O/E
> Site > Size > Definition - well/ill defined > Consistency > Surface - smooth/irreg? > Mobile or fixed -- to skin or deep tissues > Temperature > Transilluminable - solid or cystic > Pulsatility > Overlying skin changes > lymphadenopathy
Consistency - Hard = forehead, Firm = cartilage of nose, Soft = lips
Benign soft tissue swelling - on examination
> Smaller size (<5cm) > Fluctuation in size > Cystic/fluid filled > Well defined > Soft/ fatty
Potential malignant soft tissue swellings - O/E
>5cm Rapid growth Solid Ill defined Irregular surface Systemic upset Lymphadenopathy
Soft tissue swellings - Investigations
> Ultrasound
- solid or cystic
> MRI (GOLD STANDARD)
- Better anatomic def
- – tissue type
- – relationship to nerves and vessels
- good at diagnosing benign lesions
- can identify aggressive/worrying features
–> BIOPSY
MRI - soft tissue swellings worrying features
- > 5cm
- Deep location
- Heterogeneity / necrosis
- Bone or neuromuscular involvement
- crossing any boundaries?
- Gadolinium enhancement
- malignant tend to enhance more
- Enlarged lymph nodes
Lipoma
In the Subcut fat (can occur in muscle)
Fatty consistency
Painless
Can be large
Entirely benign
(Tethered to the skin)
Giant Cell Tumour (GCT)
- where do they originate
- pigmented? which iron complex is found?
- management
> Arise from synovium tendon sheath or joint
> can occur in knees, toes, hands
> PIGMENTED and HAEMOSIDERIN
Management
> Excise if painful
radiotherapy may help
can become malignant
Pigmented Villonodular Synovitis (PVNS)
- types
- arise from
- Management
Similar to Giant Cell Tumours
Tumours from synovium.
Nodular and diffuse types
Commonest in knee, can affect other large joints
–>Joint destruction and arthritis
Management
synovectomy
may require knee replacement
recurrence of 15%
Baker’s Cyst
- should you excise or leave alone? why?
Cyst in popliteal fossa
Arises from egress synovial fluid through one way valve to semimembranosis brush or medial gastrocnemius bursa
In adults – usually intrartiuclar pathology/arthritis
Children – resolve
High recurrence if excised.
Bursitis
- common places
- why shouldn’t you aspirate it?
Bursae normally prevent friction
Can become INFLAMED.
Painful.
Commonly:
- olecranon
- prepatellar
- infra patellar
- 1st metatarsal head (bunion)
Arthroscopic bursectomy
DO NOT ASPIRATE. FORMS A SINUS
Implantation Dermoid
Penetrating trauma –> epithelial cells into subcutaneous tissue
Reactive cyst forms with pseudo capsule
Greyish fluid
Epidermoid (Sebaceous cyst)
- where can they NOT occur
- blackhead in the middle is known as?
Common
Can occur anywhere (apart from palms and soles)
Epidermal cells find their way into subcutaneous tissue
Epidermoid cells lining cyst secrete keratin
PUNCTUM (dead blackhead) which tethers cyst to epidermis - little black spot in the middle of the cyst.
Abscess
> May arise from cellulitis, infected wound, epidermoid cyst, blocked sweat gland, injection site
> Painful
> Fluctuant
> Once abscess is formed, must be incised and drained.
> May erupt/discharge itself.
Heterotropic Ossification (or Myositis ossificans)
- NSAID which can help? (Indo-?)
- Management
Formation of bone in the wrong places.
Blunt trauma –> intramuscular haematoma –> calcifies
Hard to the touch
Painless (usually)
Can be confused with osteosarcoma on MRI.
—
Management
Can be excised once bone has matured
Indomathacin can help (NSAID)
Angiosarcoma
Fibrosarcoma and Malignant fibrous histiocytoma
Liposarcoma
Rhabdomyosarcoma
Synovial sarcoma
Definitions
Angiosarcoma - blood vessel malignant cancer
Fibrosarcoma and Malignant fibrous histiocytoma - malignancy of fibrous tissue
Liposarcoma - malignancy of fat tissue (deep tissue rather than subcut)
Rhabdomyosarcoma - skeletal muscle malignancy
Synovial sarcoma - malignancy of synovium joint or tendon sheath
Soft tissue swellings - when should biopsies be performed?
If nature of lesion is indeterminate on clinical assessment and MRI
Treatment of malignant lesion
Wide local excision
Radiotherapy (neo-adjuvant or adjuvant)
Large lesion may greatly reduce function of limb.
Amputation w/neurovascular involvement
Hand Injury history - what to consider
Examintion
> Handedness
PMHx
Occupation
Hobbies/sports
Description of injury
- crush, sharp, burn
- gloves, protection? (fabric in wound?)
- timing of injury?
- degloving
- level of energy estimate
Symptoms
- pain
- weakness
- sensory
Morbidity is mostly associated with the soft tissues.
Examination
- wound itself
- nails
- deformity
- swelling
- point of tenderness
- movement
- movement
- neurological
Hand wound examination
Where is it How long/deep Clean/dirty (farm injury, grease) Skin loss Obvious structures in wound - bone - tendon - foreign bodies - dirt / grit
In crush injuries, are we more worried about the bones or soft tissue?
Soft tissue.
Subungual Haematoma
- if causing pain, best course of action is
Collection of blood underneath the fingernail or toenail
Nail may eventually fall off and grow back.
If pressure is causing pain –> trephination (hot needle/paper clip to pierce nail and relieve the pressure)
Nail /nailbed injuries
- Types of injury (5 types)
Keep nail if possible
- act as a splint to maintain nail fold
- protects nail matrix during healing process.
Repair the nail bed
Types: 1 - Soft tissue (ST) only 2 - ST + nail 3 - ST + nail + bone 4 - Proximal half of phalanx 5 - proximal to DIPjt
Amputation of fingerTIP - levels
Level 1 involved only skin.
Level II involves both skin and bone.
Level III involves some loss of nailbed.
Level IV involves the germinal matrix and often some of the nail fold.
Level V involves the insertion of the tendon.
Each amputation level has unique implications for treatment and outcome
Level 1 & 2 - dressing only
Level 3 - repair nail bed + stabilise bone
Level 4 - as 3, unless <5mm of nail bed –> ablate
If tip not available, terminalise, or V-Y flap
Terminalisati
Fingertip terminalisation
Shortening the bone so that the soft tissue can cover it properly and heal
How many phalanges are in the thumb?
2
Proximal and distal
Only one Interphalangeal joint
Treatment for hand fractures
- What is key to recovery?
Stable fractures - can splint
Unstable fracture- surgery, straighten. Plates, screws, wires.
Stabilise the joints
GET THE JOINTS MOVING
MOVEMENT IS THE BEST THING FOR THEM
Boxer’s fracture
Minimal displacement
Fracture of metacarpal neck
No rotation
Index/middle finger commonly
More distal
“Buddy strap” and early mobilisation
Rotational deformity of fingers
Bend fingers in both hands to compare
Can occur after fracture of metacarpals.
Mallet Finger
A mallet finger is an extensor tendon injury at the DIPjt
Inability to extend the finger tip without pushing it.
Pain and bruising at the back side of the DIPjt
Typically this occurs when a ball hits an outstretched finger and jams it.
This results in either a tear of the tendon or the tendon pulling off a bit of bone (Avulsion fracture)
Mallet splint for 6 weeks 24/7
If large displaced avulsion fragment - surgery, wire inserted
Dermatotenodesis in chronic cases
