Orthopaedic Problems of the Hand Flashcards
Epidemiology of Dupuytrens Disease
It is much more common in males in early life but it soon starts to become prominent in females later in life.
Risk factors of dupuytrens disease
autosomal dominant and sporadic in 30% of cases. The onset may be sex linked and is almost exclusively white races (there are few sporadic cases in other races). Other risk factors include diabetes, alcohol, tobacco, HIV, epilepsy.
Dubuytrens Diathesis
early onset, bilateral, family history and ectopic disease (the feet, the penis). This suggests recurrence and poor response to treatment.
Pathology of Dupuytrens
The pathology is the thickening and tightening of the palmar fascia due to proliferation of the myofibroblast by increasing the production of collagen type 3. It is very similar to premature scar tissue.
Function problems in Dupuytrens
- They are unable to extend finger
- Usually not painful
- Hand in pocket
- Difficulty in gripping things
- Difficulty in washing face
Signs of dupuytrens
An early sign of dypetruns is palmar disease and palmar nodules but they start to form a line down the palm. There may be skin pits due to the pulling of skin down due to the contraction of the fascia. As it progresses the will be contracture.
Table top test - if they can get their hand flat on the desk no surgery is required
Treatment of Dupuytrens
Partial fasciectomy (50% recurrence after 5 years)
Dermo-fasciectomy
Arthrodesis
Amputation
Percutaneous needle fasciotomy (risk of nerve injury and 50% recurrence at 3 years)
Collagenase injection - dissolves fascia. This has a three year recurrence rate of 34/38%
Pathology of Trigger finger
When the tendon is swollen (A2 and 4) on pulleys sticks.
Trigger Finger
The digit sticks in the fully flexed position and must be straightened with the other hand. It is due to lack of free running of the flexor tendon through the tunnel at the base of the digit. May be palpable lump over the A1 pulley.
Risk factors for trigger finger
Diabetes and RA
Treatment of trigger finger
Steroid injection
Splintage
Percutaneous release
De Quervains Disease
Result of myxoid degeneration of the wall of the tunnel in the extensor retinaculum containing the tendons of extensor pollicus longus and abductor pollicis longus causing it to become thickened. There is usually pain felt on the radial border of the wrist, especially when moving the thumb.
Finklesteins Test
Inducing pain by deviating the hand into ulnar deviation with the thumb held across the palm.
Treatment of De Quervains Disease
Steroids injection
surgical release of the tunnel.
risk factors for De Quervains disease
Females
Increased occurance in post partum and lactating females
Risks of steroid injection
De-pigmentation
Bruising
Ganglion
Myxoid degeneration from joint synovia and it arises from the joint capsule, tendon sheath and ligament. usually occurs on the dorsal surface
Presentation of ganglion
Firm, non-tender lump which changes in size. It is not fixed to any of the underlying tissues.
Treatment of ganglion
Reassure and observe, aspiration, excision
Most common site for OA in the hand
The trapezio-metacarpal joint of the thumb.
Presentation of OA of the thumb
Pain (opening jars and pinching), stiffness, swelling, deformity and loss of function.
Dorsal Subluxation
X-ray findings of OA of the base of the thumb
Sclerosis, large joint space, cysts and osteocytes
Treatment of OA of the base of the thumb
NSAIDs, splints, steroid injection, trapeziectomy (removal of the trapezium bone, however there can be reduction in pinch strength), fusion, replacement
