Orthopaedic Problems of the Hand Flashcards
What is the M:F incidence of Dupuytren’s disease in 15-64s?
M:F
8:1
What is the M:F incidence of Dupuytren’s disease in over 75s?
M:F
2:1
What are the genetic features of Dupuytren’s disease?
Disease develops earlier in males
Autosomal dominant with variable penetrance
Sporadic in 30% of cases
Onset may be sex-linked
What races are affected by Dupuytren’s disease?
Almost exclusively white races
What are some of the conditions/causes linked to Dupuytren’s disease?
Diabetes mellitus Excess alcohol Tobacco smoking HIV Epilepsy
What is the presentation of Dupuytren’s diathesis?
Early onset disease
Bilateral disease
Family history
Ectopic disease
What is Dupuytren’s diathesis an indication of?
Severity and strong genetic predisposition
What is the pathology of Dupuytren’s diathesis?
Myofibroblast
Thickening and contracture of palmar fascia
Intracellular contractile element, regulated by growth factors, produces collagen
What are the symptoms and signs of Dupuytren’s contracture?
Usually not painful
Loss of finger extension - active or passive
May see skin pits
MCP/PIP joint contracture
Table-top test - can they get their hand flat on the table, if not, this may be indicative of necessary treatment
Most commonly affects little and ring fingers
Radial disease means they are more likely to have rapid recurrence
What is the non-operative treatment of Dupuytren’s?
Observe
Splints don’t work
Radiotherapy (less common in UK)
What is the operative treatment of Dupuytren’s?
Mainstay of treatment in the UK
Partial fasciectomy - remove thickened fascia
Dermo-fasciectomy - remove fascia and skin then replace with skin graft, most extensive operation but least recurrence
Arthrodesis
Amputation
Percutaneous needle fasciotomy
Collagenase
NB - Dupuytren’s can be treated but not cured
What are the features of a partial fasciectomy?
Most common procedure in the UK Good correction can be achieved Wounds take 2-3 weeks to heal Stiffness requires physiotherapy Recurrence 50% at 5 years
What are the features of dermo-fasciectomy?
More radical, generally done for recurrence
Removal of skin may reduce the recurrence rate
Requires intensive physiotherapy
What are the features of percutaneous needle fasciotomy?
Quick No wounds Return to normal activities in 2-3 days Does not prevent traditional surgery in the future Higher recurrence - 50% at 3 years Can be repeated Risk of nerve injury
What are the features of collagenase treatment?
Presented 3 year recurrence rate 34.8%
3 flexor tendon ruptures/300 patients in trials
Expensive
Longer-term recurrence rates currently unknown
What is trigger finger?
There are 2 tendons to each finger which run in sheaths
Thickenings in the sheath result in a ‘pulley’ which keeps the tendon close to bone
Swelling in tendon catches on this pulley, causing fingers to catch/lock when bent
Can usually be straightened with encouragement
When is trigger finger more likely?
Women > men
40-60s
Ring > thumb > middle
Repetitive use of hand - degenerative changes
Local trauma
Association with rheumatoid arthritis, diabetes and gout
How is trigger finger diagnosed/what are the signs and symptoms?
Patient history
Clicking sensation with movement of digit
Lump in palm under pulley
May have to use the other hand to unlock the stuck finger
Clicking may progress to locking
If a palpable lump is felt in palm over A1 puller, will feel triggering around this area
NB - Dupuytren’s is more slowly progressive
What is the treatment of trigger finger?
Non-operative
- splintage
- steroid injection
Operative
- percutaneous release
- open surgery
What are the signs and symptoms of De Quervain’s Tenovaginitis?
Several weeks of pain localised to the radial side of the wrist
Aggravated by movement of the thumb
May have localised swelling
Localised tenderness over tunnel
When is De Quervain’s tenovaginitis more common?
M>F, M:F 1:6
Age 50-60
Increased in postpartum and lactating females
Activities with frequent thumb abduction and ulnar deviation
What is the pathology of De Quervain’s tenovaginitis?
1st dorsal extensor compartment
Fibro-osseous tunnel at the distal radius
Thickening of localised segment
30% 1st compartment is divided by septum
What tests can be done for De Quervain’s tenovaginitis?
Finklestein’s test - put thumb in clenched fist then ulnar deviate the hand
Resisted thumb extension - more sensitive
What is the treatment of De Quervain’s tenovaginitis?
Non-operative
- splints
- steroid injection, risk of depigmentation and thinning
Operative
- decompression
- be aware of dorsal sensory branch of radial nerve
What are the nerve entrapments in the hand?
Carpal tunnel syndrome
Cubital tunnel syndrome
What are the signs and symptoms of osteoarthritis in the base of the thumb?
Pain Stiffness Swelling Deformity Loss of function Pain opening jars/pinching Dorsal subluxation Metacarpal adduction ACPJ hyperextension Look for STT osteoarthritis
What is the treatment of osteoarthritis of the thumb?
Non-operative
- lifestyle modification
- NSAIDs
- splint
- steroid injection
Operative
- trapeziectomy
- fusion
- replacement
What are the features of trapeziectomy?
Gold standard treatment for OA of thumb
Good pain relief
Moderate pinch grip +/- interposition flap or ligament reconstruction
What is a ganglion?
Myxoid degeneration from joint synovia (cyst containing thick, clear substance) that arises from joint capsule, tendon sheath or ligament
70% of all discrete swellings in hand and wrist
When are ganglions most common?
More common in females 2:1 males
Wide age distribution peak 20-40 years
What are the signs and symptoms of a ganglion?
Lump - firm, non-tender, change in size, smooth, occasionally lobulated
Normally not fixed to underlying tissues and never fixed to the skin
What is the treatment of a ganglion?
Non-operative
- reassure and observe
- aspiration, about 60% recurrence, can be repeated
Operative
- excision, including the root, 30-40% recurrence
