Orthopaedic Problems of the Hand

Question 1

What populations are most commonly affected by Dupuytren’s?

Answer 1

Disease of northern Europe
Males more than females
In 15-64, M:F = 8:1
Over 65 2:1

Question 2

What are the risk factors for Dupuytren’s disease?

Answer 2

Genetic (autosomal dominant condition)
Sex linked
Almost exclusively white populations
Associations have been made with diabetes, alcohol, tobacco, HIV and epilepsy

Question 3

What are the characteristics of Dupuytren’s?

Answer 3

Not normally painful, but serious functional consequences
Loss of finger extension both actively and passively
Onset is gradual and is often tender in early stages
Commonly presents as one or more lump in the hand that join together into a cord over time

Question 4

Describe the pathological processes behind Dupuytren’s contracture

Answer 4

Dupuytrens involves thickening and contracture of the normal fascia of the hand. This progresses due to intracellular contractile elements that are regulated by growth factors, resulting in the production of collagen and formation of a myofibroblast.

Question 5

What are the treatment options for Dupuytren’s?

Answer 5

Very limited non-surgical treatment
Partial fasciectomy first line
Can also help:
Dermo-fasciectomy
Arthodesis
Amputation 
Percutaneous needle fasciectomy
Collagenase injections

Question 6

What are the pros and cons of a percutaneous needle fasciectomy?

Answer 6

Pros- quick and non-invasive

Cons- higher recurrence rate and chance of nerve injury

Question 7

What is the pathological cause of trigger finger?

Answer 7

Swelling of the tendon causes it to get caught on pulley inside finger

Question 8

What is the characteristic sign of trigger finger?

Answer 8

Someone who can make a fist, but when they open the fist they cannot initially extend a finger, which then pops extended

Question 9

What populations are most affected by trigger finger?

Answer 9

More common in females than males
Aged 40-60
Associations have been made with gout, rheumatoid arthritis, diabetes and trauma

Question 10

What fingers are most commonly affected by trigger finger?

Answer 10

From most to least common:
Ring finger
Thumb
Long finger

Question 11

How would you examine trigger finger clinically?

Answer 11

Palpation of A1 pulley

Feeling a lump or triggering around pulley

Question 12

What are the possible treatments of trigger finger?

Answer 12

Majority treated with intraarticular steroids
Non-operatively:
-Splintage 
-Steroids
Operatively:
-Percutaneous release
-Open surgery

Question 13

What are the symptoms of DeQuervain’s syndrome?

Answer 13

Several week history of pain localised to radial side of wrist that is aggravated by thumb movement
Can also be localised swelling with tenderness over carpal tunnel

Question 14

In what populations is DeQuervain’s most common?

Answer 14

Aged 50-60
M:F = 1:6
Increased incidence in post-partum and lactating females

Question 15

What part of the hand is affected by DeQuervain’s?

Answer 15

1st dorsal extensor compartment, specifically fibro-osseous tunnel at distal radius

Question 16

How is DeQuervain’s examined clinically?

Answer 16

Examination of thumb joint to exclude base of thumb arthritis
Finkelstein’s test (clenched fist and ulnar deviation)
Resisted thumb extension

Question 17

How is DeQuervain’s syndrome treated?

Answer 17

Non-surgical:
-Splintage
-Intraarticular steroid injection
Surgical:
-Surgical decompression

Question 18

How do ganglion develop pathologically?

Answer 18

Formed from outpouching of synovial fluid that results in lump in hand. Water is reabsorbed and so fluid retained is thick, viscous substance

Question 19

What populations are more commonly affected by ganglions?

Answer 19

Females (2:1)
Wide age range affected, peaking at 20-40
Dorsal more common than volar
Can be associated with recurrent injury around wrist

Question 20

What are the characteristics of ganglion?

Answer 20

Firm, non-tender lumps that present with a change in size, are smooth and can be lobulated
They are normally not fixed to underlying structures and never fixed to skin

Question 21

How is a ganglion treated?

Answer 21

Self-limiting and usually resolves spontaneously
Non-operative treatment is reassurance, observation and aspiration
Operative treatment is excision

Question 22

What are the characteristics of base of thumb osteoarthritis?

Answer 22

Pain
Swelling
Stiffness
Deformity
Loss of function
Begins as pain when opening jars or pinching
Affects 1 in 3 females at some point in life

Question 23

What are the treatment options for base of thumb osteoarthritis?

Answer 23

Non-operative treatments:
-Lifestyle modifications
-NSAIDs
-Splinting
-Steroid injection
Operative treatments:
-Trapeziectomy (first line)
-Fusion
-Thumb joint replacement

Question 24

What are the features of Dupuytren’s diathesis?

Answer 24

Early onset, bilateral disease
Family history
Ectopic disease can also occur (most commonly feet and penis)