Orthopaedic problems of the hand

Question 1

What are some examples of orthopaedic hand conditions?

Answer 1

Dupuytren's
Trigger finger
De Quervain's tenovangitis
Nerve entrapment - carpal/cubital tunnel syndrome
Ganglion
Osteoarthritis base of thumb

Question 2

Who is most likely to get Dupuytrens?

Answer 2

M:F = 8:1 in 15-64a
M:F = 2:1 in over 75s
Disease develops earlier in males

Question 3

What is the aetiology of Dupuytrens?

Answer 3

Sporadic in 30% of cases
Onset may be sex linked
Almost exclusively white races
Autosomal dominant

Question 4

What are risk factors for developing dupuytrens?

Answer 4

Diabetes
Alcoholism
Tobacco
HIV
Epilepsy

Question 5

What is the pathology of Dupuytrens?

Answer 5

There is an increase in the number of myofibroblasts which leads to thickening of the palmar fascia

Question 6

What are functional problems in patients with Dupuytrens?

Answer 6

Usually no pain
Loss of extension - can be active or passive
Difficulty putting hand into pocket
Difficulty gripping things
Difficulty with face washing

Question 7

What are non-operative options for treatment of Dupuytrens?

Answer 7

Wait and observe

Radiotherapy

Question 8

What are operative options for Dupuytrens?

Answer 8

Partial fasciectomy
Dermo-fasciectomy
Arthrodesis
Amputation
Percutaneous needle Fasciotomy
Collagenase

Question 9

Can Dupuytrens be completely fixed in a patient?

Answer 9

Not completely, it is recurrent

Question 10

What is usually done to treat Dupuytrens?

Answer 10

Partial fasciectomy

Question 11

What is the rate of recurrence in Dupuytrens treated with partial fasciectomy?

Answer 11

50% at 5 years

Question 12

What is dermo-fasciectomy?

Answer 12

Skin is removed - thought to reduce recurrence rates but requires intensive physiotherapy

Question 13

What is percutaneous needle fasciotomy?

Answer 13

A needle is put through the skin and the bevel is used to saw through some fibres of the fascia to increase ability of movement

Question 14

What are advantages and disadvantages of percutaneous needle fasciotomy?

Answer 14

Advantages - quick, no wounds, return to normal activities within 3 days, can be repeated
Disadvantages - Higher recurrence - 50% at 3 years, Risk of nerve injury

Question 15

What is the pathology of trigger finger?

Answer 15

Swelling in the tendon running to the finger causes it to catch on a pulley in the tendon sheath

Question 16

Who is most likely to get trigger finger?

Answer 16

Women>Men
40s-60s
Ring finger>thumb>middle finger
Associated with rheumatoid arthritis, Diabetes Mellitus, and gout

Question 17

How is trigger finger diagnosed?

Answer 17

Patient history
Clicking sensation with movement of the digit
Lump in the palm under the pulley
May have to use the other hand to unlock the finger
Clicking may progress to locking
Palpable lump over A1 pulley/feel triggering

Question 18

What are non-operative treatment options for trigger finger?

Answer 18

Splintage

Steroids

Question 19

What are operative treatment options for trigger finger?

Answer 19

Percutaneous release

Open surgery

Question 20

What is De Quervain’s syndrome?

Answer 20

Inflammation of the tendons at the base of the thumb leading to the sheath thickening, causing pain at the base of the thumb

Question 21

What is the history of a patient with De Quervain’s syndrome?

Answer 21

Several weeks of pain localised to the radial side of the wrist
Aggravated by thumb movement
May see localised swelling
Localised tenderness over tunnel

Question 22

Who is most likely to get DeQuervain’s syndrome?

Answer 22

M:F = 1:6
50-60y
Increased prevalence in post partum and lactating females
Activities with frequent thumb abduction

Question 23

What is the pathology of De Quervain’s syndrome?

Answer 23

1st dorsal extensor compartment - fibro-osseus tunnel at the distal radius with thickening of the localised segment

Question 24

What can be used to make a diagnosis of De Quervain’s syndrome?

Answer 24

Examination of thumb joints, base for osteoarthritis
Finklestein’s test
Resisted thumb extension

Question 25

What options are available for treatment of De Quervain’s?

Answer 25

Non-operative - Splints, Steroid injection

Operative - Decompression

Question 26

What is a ganglion?

Answer 26

A lump - myxoid degeneration from joint synovia which arises from joint capsule, tendon sheath or ligament

Question 27

Where are you most likely to see ganglia?

Answer 27

Dorsal 3 times more than volar
May be associated with recurrent wrist injury
Twice as common in female
20-40y

Question 28

How is a ganglia diagnosed?

Answer 28

Presents with a lump
Firm, non tender
Change in size
Smooth
Occasionally lobulated
Normally not fixed to umderlying tissues
Never fixed to skin

Question 29

How can ganglia be treated?

Answer 29

Reassure and observe
Aspiration
Excision including the root

Question 30

What are symptoms of Osteoarthritis?

Answer 30

Pain
Stiffness
Swelling
Deformity
Loss of function

Question 31

What are non-operative options for treatment of Osteoarthritis of the base of the thumb?

Answer 31

Life style modifications
NSAIDs
Splint
Steroid injection

Question 32

What are operative options for treatment of Osteoarthritis of the base of the thumb?

Answer 32

Trapeziectomy
Fusion
Replacement

Question 33

What is the gold standard for treatment of osteoarthritis of the base of the thumb?

Answer 33

Trapeziectomy