Orthopaedic Problems of the Hand Flashcards
Who gets Duputytren’s?
More males in 15-64 - 8:1
Then 2:1 when over 75
Disease develops earlier in males
What are factors which contribute to Dupuytren’s?
Autosomal dominant - variable penetrance
Sporadic in 30%
Onset may be sex linked
Almost exclusively white races
What diseases are associated to Dupuytren’s?
Diabetes, alcohol, tobacco, HIV and Epilepsy
What is dupuytren’s diathesis?
Early onset
Bilateral disease
FH
Ectopic disease
Describe the pathology of Dupuytren’s
Myofibroblasts
Intracellular contractile elements - peritendinous bands an palmar aponeurosis
Regulated by growth factors
Production of collagen
What are the functional problems caused by Dupuytren’s disease?
Usually not painful
Loss of finger extension - active or passive
Difficulties in hand in pocket
Gripping problems
Washing face
What is non-operative treatment for Dupuytren’s?
Observe, splints and RT
What are the operative treatment for Dupuytren’s/
Partial and Dermo-fasciectomy
Arthrodesis
Amputation
Percutaneous needle fasciotomy and collagenase
Describe partial fasciectomy
Excise the thickened bands causing problems - most common procedure in UK
Good correction achieved
Wound 2-3 weeks to heal
Stiffness require physio
Can’t be cured
What is the recurrence rate after partial fasciectomy?
50% at 5 years
Describe dermo-fasciectomy
More radical procedure
Early more progressive disease
Remove skin and underlying fascia - removing recurrence
Needs intensive physio after
What are the positives and negatives for percutaneous needle fasciotomy?
Quick, no wounds, return to normal activities after 2-3days, can be repeated
Risk of nerve injury and can have higher recurrence
Does not prevent traditional surgery in future
Describe collagenase for treatment of Dupuytren’s
Injected into band and dissolves collagen
Recurrence rate is 34% in 3 years
Risk of 3 flexor tendon rupture
Cost
What is trigger finger?
Sensation a patient feels due to abnormality in flexor tendon
Describe the anatomy of trigger finger anatomy
2 tendons to each finger
Tendon run in sheath - thickening in sheath are called pulleys
Keep tendon close to bone
Swelling in tendon catches on pulley
Who gets trigger finger?
Women are more frequent - 40-60 year age group
Common in ring finger > thumb > middle
Can be from repetitive use of hand and local trauma
What diseases are associated to trigger finger?
Rheumatoid arthritis, DM and gout
How is trigger finger diagnosed?
Patient history
Clicking sensation when moving digit, lump in palm under pulley, may need other hand to unlock and clicking can go to locking
What can be felt in examination of trigger finger?
Palpable lump in palm over A1 pulley
Feel the triggering around the A1 pulley
What is the non-operative treatment for trigger finger?
Splint age and steroids injections around A1 pulley
What is the operative treatment for trigger finger?
Percutaneous release (A1 pulley released) and open surgery
Describe De Quervain’s syndrome
Occurs in 1st dorsal extensor compartment
Fibro-osseous tunnel at distal radius
Thickening of localised segment
30% of patients - 1st compartment divided by septum
What is the patient history for De Quervain’s syndrome?
Several weeks pain localised to radial side of wrist
Aggravated by movement of thumb
May seen a localised swelling
Localised tenderness over tunnel
Who gets De Quervain’s syndrome?
Male : Female 1:6
Age 50-60
Increased in post partum and lactating females
Activities with frequent thumb abduction and ulnar deviation
Washerwomen’s sprain
What is looked for in examination of De Quervain’s syndrome?
Examine thumb joints - consider base of thumb tenderness for OA
Finklestein’s test (fold thumb into palm, close finger over and ulnar deviate wrist and produces pain) and resisted thumb extension - provide resistance with finger onto patient thumb and pain will be localised over radial styloid
What is the non-operative treatment for De Quervain’s syndrome?
Splints and steroid injection
What is the operative treatment for De Quervain’s syndrome?
Decompression - decompress tendon by opening retinaculum that is holding it down
What are 2 nerve entrapment conditions?
Carpal tunnel syndrome
Cubital tunnel syndrome
Describe ganglion anatomy
A myxoid degeneration from joint synovia - lump
Arise from joint capsule, tendon sheath or ligament as outpouchings - fluid within is concentrated making it firm
Who gets ganglia?
More common in females
Wide age distribution - peak 20-40
More dorsal than volar
May be associated with recurrent injury around the wrist
How does the patient present with ganglia?
Presents with lump, firm, non-tender, change in size, smooth, occasionally lobulated, normally not fixed and never fixed to skin
What is the non-operative treatment for ganglia?
Reassure and observe
Aspiration
What is the operative treatment for ganglia?
Excision including the root
What is the commonest OA of the body?
Base of thumb
What is the symptoms of OA base of thumb?
Pain, stiffness, swelling, deformity and loss of function
pain worse on activity and at night after a busy day
Describe base of thumb OA
Common, 1 in 3 women, pain opening jars/ pinching
Dorsal subluxation, metacarpal adduction and MCPJ hyperextension
Look for SST OA
What is the non-operative treatment of OA base of thumb?
Life style modification, NSAIDS, splint and steroid injection
What is the operative treatment for OA base of thumb?
Trapeziectomy - take away part of joint (trapezium) leaving fibrous space, fusion and replacement
Describe trapeziectomy
Gold standard for OA base of thumb
Good pain relief
Moderate pinch grip
Possible interposition flap or ligament reconstruction
