Orthopaedic Problems of the Hand Flashcards
What elective hand conditions are there?
- Dupuytren’s Disease
- Trigger Finger
- De Quervain’s Tenovaginitis
- Nerve entrapments (Carpal Tunnel Syndrome, Cubital Tunnel Syndrome)
- Ganglion
- OA Base of Thumb
What is the epideminiology of Dupuytren’s?
- M:F 8:1 (15-64s)
- M:F 2:1 (75+)
Disease develops earlier in males
What is the aetiology of Dupuytren’s?
Autosomal dominant of variable penetrance
- Sporadic in 30% of cases
- Onset may be sex linked
- Almost exclusively white races
- Few sporadic reports in other races
What is Dupuytren’s associated with?
- Diabetes
- Alcohol
- Tobacco
- HIV
- Epilepsy
What are the features of Dupuytren’s diatheses?
- Early onset disease
- Bilateral disease
- Family history
- Ectopic disease
What is the pathophysiology of Dupuytren’s?
Myofibroblast
- Intracellular contractile elements
- Regulated by growth factors
- Production of collagen
What functional problems does Dupuytren’s present?
- Usually not painful
- Loss of finger extension (active or passive)
- Hand in pocket
- Gripping things
- Washing face
What are the treatment option for Dupuytren’s?
Non-operative
- Observe
- Splints don’t work
- Radiotherapy
Operative
- Partial fasciectomy
- Dermo-fasciectomy
- Arthrodesis
- Amputation
- Percutaneous needle fasciotomy
- Collagenase
What are the features of a partial fascieotomy?
- Most common procedure performed in UK
- Good correction can be achieved
- Wounds can take 2-3 weeks to heal
- Stiffness requires physiotherapy
- Can’t be cured
- Recurrence 50 % at 5 years
What are the features of a dermo-fasciotomy?
- More radical than partial fasciotomy
- Removal of skin may reduce recurrence rates
- Requires intensive physiotherapy
What are the features of a percutaneous needle fasciotomy?
-Quick
-No wounds
-Return to normal activities 2-3 days
-Does not prevent traditional surgery in future
-Higher recurrence
(? 50% at 3 years)
-Can be repeated
-Risk of Nerve Injury
What is the anatomy behind trigger finger?
- 2 tendons to each finger
- Tendons run in sheath
- Thickenings in the sheath are called pulleys
- Pulleys keep tendons close to the bone
- Swelling in tendon catches on the pulleys
Who gets trigger finger?
- F>M
- 40s-60s
- Ring > Thumb > Middle
- Repetitive use of hand ?
- Local trauma
- Associations: RA, DM, Gout
How is trigger finger diagnosed?
- Patient History
- Clicking sensation with movement of digit
- Lump in palm under pulley
- May have to use other hand to ‘unlock’
- ‘Clicking’ may progress to ‘locking’
What are the treatment options for trigger finger?
Non-operative
- Splintage
- Steroids
Operative
- Percutaneous release
- Open surgery
What history may a patient with de Quervain’s syndrome present with?
- Several weeks pain localised to radial side of wrist
- Aggravated by movement of the thumb
- May have seen a localised swelling
- Localised tenderness over tunnel
What is the epidemiology of de Quervain’s syndrome?
- M:F 1:6
- 50s to 60s
- Increased in post partum and lactating females
- Activities with frequent thumb abduction and ulnar deviation
What is the pathophysiology of de Quervain’s syndrome?
- 1st dorsal extensor compartment
- Fibro-osseous tunnel at the distal radius
- Thickening of localised segment
- 30% 1st compartment divided by septum
What examination should be done in Quervain’s syndrome?
- Examine thumb joints and consider base of thumb OA
- Finklestein’s test
- Resisted thumb extension
What are the treatment options for de Quervain’s syndrome?
Non-operative
- Splints
- Steroid injection
Operative
-Decompression
What is the anatomy of a ganglion?
- A myxoid degeneration from joint synovia
- Arise from joint capsule, tendon sheath or ligament
Who gets ganglia?
- F:M 2:1
- Peak 20-40 years
- Account for 70% of discrete swelling of the hand and wrist
- Dorsal> volar 3:1
What may ganglia be associated with?
Recurrent injury around the wrist
How is a diagnosis of hand/wrist ganglia made?
- Present with lump
- Firm, non-tender
- Change in size
- Smooth
- Occasionally lobulated
- Normally not fixed to underlying tissues
- Never fixed to the skin
What are the treatment options for ganglia?
Non-operative
- Reassure and observe
- Aspiration
- Hit with a book
Operative
-Excision (including the root)
How does OA of the base of the thumb present?
- Pain
- Stiffness
- Swelling
- Deformity
- Loss of function
Who is affected by base of the thumb OA?
- Common condition affecting 1 in 3 women
- They have difficulty opening jars and pinching
What should you look for in base of the thumb OA?
STT OA
What are the treatment options for base of the thumb OA?
Non Operative
- Life style modifications
- NSAIDS
- Splint
- Steroid Injection
Operative
- Trapeziectomy
- Fusion
- Replacement
What is the gold standard treatment for base of the thumb OA?
Trapeziectomy as it gives good pain relief and moderate pinch grip (+/- interposition flap or ligament reconstruction)
