Localised Hand Pain: De Quervains tenosynovitis; Trigger finger; Carpal tunnel syndrome; Duputren’s contracture Flashcards
Describe what is meant by De Quervain’s tenosynovitis [1]
Which tendons does it most commonly affect? [2]
De Quervain’s tenosynovitis is a condition where there is swelling and inflammation of the tendon sheaths in the wrist. It is a type of repetitive strain injury
It primarily affects two tendons:
Abductor pollicis longus (APL) tendon
Extensor pollicis brevis (EPB) tendon
Describe the presentation of DQT [3]
Pain at the base of the thumb, which can extend to the forearm
Pain exacerbation during thumb abduction, gripping, or ulnar movement of the wrist
Tenderness of the anatomical snuffbox
What is meant by mummy thumb in DQT? [1]
One notable cause of bilateral De Quervain’s tenosynovitis is in new parents repetitively lifting newborn babies in a way that stresses the tendons of the thumb. For this reason, it is sometimes referred to as “mummy thumb”.
Name and describe the test used for DQT [1]
Finkelstein’s test:
- Finkelstein’s test involves the patient making a fist with their thumb inside their fingers.
- Then, the wrist is adducted (ulnar deviation), causing strain on the APL and EPB tendons.
- If this movement causes pain at the radial aspect of the wrist, the test is positive, indicating De Quervain’s tenosynovitis.
Mangement for DQT?
Non-operative:
First line:
- NSAIDS, rest and immobilisation
Second line:
- steroid injection
Operative:
- surgical release of 1st dorsal compartment (radial based incision proximal to the wrist)
Define trigger finger [1]
What is trigger finger AKA? [1]
It is also known as stenosing tenosynovitis.
Describe the pathophysiology of trigger finger [2]
Normal physiology:
- Flexor tendons of fingers pass through sheaths along the length of the fingers
Trigger finger:
- Get thickening of tendon or tightening of the sheath
- Means when flexed / extended it causes pain, stiffness or catching
- This spefically happens at the first annular pulley (A1) at the metacarpophalangeal (MCP) joint.
Clinical presentation of trigger finger? [3]
Presentation:
- Is painful and tender (usually around the MCP joint on the palm-side of the hand)
- swelling around MCP joint
* Does not move smoothly
* Makes a popping or clicking sound - hallmark feature
* Gets stuck in a flexed position
Which patient populations have a higher chance of getting trigger finger? [4]
DMT1
RA
gout
carpal tunnel syndrome
Non-operative and operative treatment of trigger finger?
Non-operative:
First line:
- splinting, activity modification, NSAIDs
Second line:
- Steroid injections
Operative:
- Surgery to release the A1 pulley - either percutaneous release or open release
Define Dupuytren’s contracture [1]
Describe the pathophysiology [2]
Dupuytren’s contracture is a condition where the fascia of the hand becomes thickened and tight, leading to finger contractures.
Pathophysiology:
* The palmar fascia of the hand forms a triangle of strong connective tissue on the palm.
- the fascia of the hands becomes thicker and tighter and develops nodules as a result of excessive collagen deposition
- Cords of dense connective tissue can extend into the fingers, pulling the fingers into flexion and restricting their ability to extend (contracture).
Describe the presentation of Dupuytren’s contracture [3]
- First sign: hard nodules on the palm.
- Skin thickening and pitting
- Finger pulled into flexion
- Most commonly the ring finger affected
Describe a test used to assess for DC [1]
Table-top test:
- The patient tries to position their hands flat on a table. If the hand cannot rest completely flat, the test is positive,
At what stage do you consider surgical treatment for DC? [1]
consider surgical treatment of Dupuytren’s contracture:
- metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table (positive table top test)
What are the three options for surgery for DC? [3]
Needle fasciotomy
- (also known as needle aponeurotomy) involves inserting a needle through the skin to divide and loosen the cord that is causing the contracture.
Limited fasciectomy:
- involves removing the abnormal fascia and cord to release the contracture.
Dermofasciectomy:
- involves removing the abnormal fascia and cord, as well as the associated skin. A skin graft is used to replace the removed skin.
Carpal tunnel syndrome:
Describe the basic anatomy relevent to this pathology [3]
Anatomy
* The flexor retinaculum is a fibrous band that wraps across the front (palmar side) of the wrist.
* Between the carpal bones and the flexor retinaculum is a passageway from the forearm and the hand called the carpal tunnel
- The median nerve and the flexor tendons of the forearm travel through the carpal tunnel.
The median nerve supplies the motor function to the three thenar muscles. These muscles make up the muscular bulge at the base of the thumb that is responsible for thumb movements.
Which muscles are these? [3]
Which movements do they cause? [3]
Abductor pollicis brevis (thumb abduction)
Opponens pollicis (thumb opposition – reaching across the palm to touch the tips of the fingers)
Flexor pollicis brevis (thumb flexion)
NB: The other muscle that controls thumb movement is the adductor pollicis (thumb adduction). However, this is innervated by the ulnar nerve. Whether this is classed as one of the thenar muscles depends on where you look.
