Orthopaedic Hand Problems Flashcards
Dupuytren’s disease: presentation
LITTLE + RING FINGER = CURLS IN
* Usually NOT PAINFUL * LOSS of FUNCTION = cannot put hands in pocket, grip things, wash face etc. ○ LOSS of FINGER EXTENSION - ACTIVELY + PASSIVELY
LUMP in HAND, ASYMPTOMATIC THICKENED CORD, SKIN DIMPLING as myofibroblasts adhere to skin, MCP CONTRACTURE, PIP CONTRACTURE, DIP CONTRACTURE, THUMB on RADIAL SIDE
Dupuytren’s disease: pathology
- MYOFIBROBLASTS have their own INTRACELLULAR CONTRACTILE ELEMENTS - they’re REGULATED by GROWTH FACTORS + PRODUCE COLLAGEN
- In Dupuytren’s disease, INCREASING ACTIVITY + GROWTH of MYOFIBROBLASTS = production of COLLAGEN = leading to INCREASED CONTRACTILITY of THICK PALMAR FASCIA
Dupuytren’s disease: management
NON-OPERATIVE: OBSERVE, RT, no splints (essentially nothing if pt. can lay hand float on table)
OPERATIVE: PARTIAL FASCIECTOMY - mainly, DERMO-FASCIECTOMY, ARTHRODESIS, AMPUTATION, PERCUTANEOUS NEEDLE FASCIOTOMY - mainly, COLLAGENASE
Dupuytren’s disease: dupuytren’s diathesis (severe form of condition)
• EARLY ONSET DISEASE
• BILATERAL DISEASE
• FHx
ECTOPIC DISEASE (can occur in dorsum of hand, foot)
Dupuytren’s disease: dupuytren’s diathesis (severe form of condition)
- EARLY ONSET DISEASE
- BILATERAL DISEASE
- FHx
- ECTOPIC DISEASE (can occur in dorsum of hand, foot)
Trigger finger: presentation
• ASK PT. TO MAKE A FIST + THEN STRAIGHTEN FINGERS - TRIGGER FINGER IS STUCK UNTIL SLIGHT PRESSURE IS APPLIED TO IT & IT POPS BACK
○ May BECOME STUCK LATER (diff. bwtn this and dupuytren's is that hx of popping finger out of stuck position) • RING > THUMB > MIDDLE DIAGNOSIS: * PT. Hx * CLICKING SENSATION w/ DIGIT MOVEMENT * LUMP in PALM UNDER PULLEY+ may have to USE OTHER HAND TO UNLOCK * CLICKING MAY PROGRESSING TO LOCKING
Trigger finger: pathophysiology
• EACH FINGER has 2 TENDONS - these RUN IN A SHEATH
○ SHEATH has THICKENINGS = PULLEYS - they keep the TENDON CLOSE to the BONE ○ IF THERE'S A SWELLING IN A TENDON IT CAN CATCH ON A PULLEY + BECOME STUCK IN THE TUNNEL THROUGH IT
Trigger finger: management
Non-operative - splints, steroid injection
Operative - percutaneous release, open surgery
Trigger finger: epidemiology
- W > M
* 40-60YRS
Trigger finger: aetiology/risk factors
- REPETITIVE USE OF HAND?/WEAR & TEAR
- LOCAL TRAUMA
• ASS.: (1st 2 more likely to need surgical decompression)
* RHEUMATOID ARTHRITIS - thickening of tendon * DM - does not respond well to conservative management * GOUT
De quervain’s tenovaginitis: aetiology/risk factors
- INCREASED In POST-PARTUM & LACTATING FEMALES
- ACTIVITIES w/ FREQ. THUMB ABDUCTION + ULNAR DEVIATION + GRIPPING + ROTATING WRIST - REPETITIVE HAND/WRIST MOVEMENT
- DIRECT INJURY to WRIST/TENDON = SCAR TISSUE can RESTRICT TENDON MOVEMENT
- INFLAMMATORY ARTHRITIS e.g. RHEUMATOID ARTHRITIS
WASHERWOMAN’S SPRAIN
De quervain’s tenovaginitis: presentation
- PAIN = for SEVERAL WEEKS + LOCALISED to RADIAL SIDE of WRIST + AGGRAVATED by THUMB MOVEMENT, GRIPPING or ROTATING WRIST
- May have LOCALISED SWELLING = on RADIAL STYLOID, FEELS like BONE (but it’s just a hardening of the sheath)
- LOCALISED TENDERNESS OVER TUNNEL
- DIFFICULTY MOVING THUMB & WRIST when involving GRASPING/PINCHING
De quervain’s tenovaginitis: pathology
- THUMB HAS 2 TENDONS ATTACHING to ITS BASE = has a TENDON SHEATH OVERLYING IT
- CHRONIC WRIST OVERUSE/REPEATED MOVEMENT can cause TENDON SHEATH TO BECOME IRRITATED = RESULTING in THICKENING + SWELLING = RESTRICTS MOVEMENT of TENDONS RUNNING THROUGH IT (connecting to base of thumb)
De quervain’s tenovaginitis: investigations/diagnosis
- Hx + EXAMINATION = EXAMINE THUMB JOINTS - consider base of thumb osteoarthritis as it has a similar presentation
- FINKLESTEIN’S TEST - EXAMINER GRASPS THUMB + SHARPLY ULNAR DEVIATES HAND (sharp pain along distal radius = diagnostic)
- RESISTED THUMB EXTENSION = CLINICALLY DONE AS ABOVE IS NORMALLY PAINFUL
De quervain’s tenovaginitis: management
Non-operative - rest involved joints, splints, steroid injection
Operative - decompression
De quervain’s tenovaginitis: epidemiology
- M : F = 1 : 6
* 50-60YRS
Carpal tunnel syndrome: investigations
- NERVE CONDUCTION STUDIES can be helpful in complex/mixed symptoms + for monitoring responses to surgery
- USS/MRI - lesion identification
Carpal tunnel syndrome: presentation
SYMPTOMS:
• COMMONEST CAUSE of HAND PAIN at NIGHT
SIGNS: MEDIAN NN. DISTRIBUTION
• TINGLING/PAIN felt in THUMB, INDEX, MIDDLE FINGERS
* WHEN PAIN is at its WORST - PT. FLICKS/SHAKES WRIST to BRING ABOUT RELIEF * PAIN esp. COMMON at NIGHT + AFTER REPETITIVE ACTIONS - AFFECTED PT. may experience CLUMSINESS * WASTED THENAR EMINENCE + REDUCED SENSATION over LATERAL 3.5 DIGITS (thumb to lateral half of ring finger) * LATERAL PALMAR SENSATION SPARED * PHALEN'S TEST = HOLDING WRIST HYPERFLEXED for 1 MIN REPRODUCES SYMPTOMS
Carpal tunnel syndrome: pathology
• COMPRESSION of MEDIAN NERVE as it PASSES UNDER FLEXOR RETINACULUM
Carpal tunnel syndrome: associations
- HYPOTHYROIDISM
- PREGNANCY
- GOUT + PSEUDOGOUT
- DM, OBESITY
- HF
- ACROMEGALY
- RA
- PRE-MENSTRUAL STATE
- AMYLOIDOSIS
Ganglion: presentation
• BENIGN LUMP in HAND (70% of all discrete swellings in hand & wrist)
○ FIRM + NON-TENDER ○ CHANGE in SIZE ○ SMOOTH ○ Occasionally LOBULATED ○ Normally NOT FIXED to UNDERLYING TISSUES + NEVER FIXED to SKIN ○ RED FLAGS = HARD, CRAGGY, STICK TO UNDERLYING TISSUES • DORSAL > VOLAR (3 : 1)
Ganglion: pathophysiology
- GANGLION = MYXOID DEGENERATION from JOINT SYNOVIA
- ARISE from JOINT CAPSULE/TENDON SHEATH/LIGAMENT○ WEAKNESS in JOINT CAPSULE/TENDON = causes OUTPOUCHING of SYNOVIAL FLUID - FLUID ABSORBED & PROTEIN LEFT BEHIND - LOOKS LIKE CLEAR THICK JELLY
Ganglion: management
Non-operative - reassure + observe (mainly), aspiration
Operative - excision
Ganglion: epidemiology
- M : F = 1 : 2
* WIDE AGE DISTRIBUTION = PEAK ~ 20-40YRS
Ganglion: aetiology/risk factors
• May be ASS. W/ RECURRENT INJURY ~ WRIST
OA of thumb base: management
Non-operative - lifestyle modifications, NSAIDs, splint, steroid injection
Operative - trapeziectomy, fusion, replacement
OA of thumb base: management
Non-operative - lifestyle modifications, NSAIDs, splint, steroid injection
Operative - trapeziectomy, fusion, replacement
look for scaphotrapeziotrazeidal OA
OA of thumb base: presentation
- PAIN = OPENING JARS/PINCHING
- SWELLING
- STIFFNESS
- DEFORMITY = STARTS to SUBLUX into Z-SHAPE○ DORSAL SUBLUXATION, METACARPAL ADDUCTION, MCPJ HYPEREXTENSION
○ Base of thumb looks like it’s squaring off
OA of thumb base: pathophysiology
• THUMB JOINT (SYNOVIAL SADDLE) = LARGE RANGE of MOVEMENT ∴ UNSTABLE JOINT = DEPENDS on LIGAMENTS
OA of thumb base: epidemiology
- COMMON
* 1/3 WOMEN
