Orthopaedic problems of the Hand Flashcards
what are some Elective Hand Conditions?
- Dupuytren’s Disease
- Trigger Finger
- De Quervain’s Tenovaginitis
- Nerve entrapments - Carpal Tunnel Syndrome, Cubital Tunnel Syndrome
- Ganglion
- OA Base of Thumb
what gender and age gets Dupuytrens?
- M : F = 8 : 1 in 15 – 64’s
- M : F = 2 : 1 in over 75’s
- Disease develops earlier in males
Who gets Dupuytrens and how is ti caused?
- Autosomal dominant – variable penetrance
- Sporadic in 30% of cases
- Onset may be sex linked
- Almost exclusively white races
- Few sporadic reports in other races
in Dupuytrens, Associations have been made to what?
- Diabetes
- Alcohol
- Tobacco
- HIV
- Epilepsy
Dupuytrens Diathesis - what are the different types?
- Early onset disease - Early onset is more aggressive with rapid progression
- Bilateral disease
- Family History
- Ectopic disease
what is the pathology of Dupuytrens?
- Myofibroblast
- Intracellular contractile elements
- Regulated by growth factors
- Production of collagen
Contractions of these bands that cause contraction and pull the finger into flexion
Knots of tissue form under the skin — eventually creating a thick cord that can pull one or more fingers into a bent position
what are functional problems caused by Dupuytrens?
- Usually not painful
- Loss of finger extension – active or passive
- Hand in pocket
- Gripping things
- Washing face
- Curse of the MacCrimmons
what Dupuytren’s Disease Treatment - non-operative?
- Observe
- Splints don’t work
- Radiotherapy
what Dupuytren’s Disease Treatment - operative?
- Partial fasciectomy - affected connective tissue is removed
- Dermo-fasciectomy
- Arthrodesis - surgical immobilization of a joint by fusion of the bones
- Amputation
- Percutaneous Needle Fasciotomy
- Collagenase
what is Partial Fasciectomy an dhow is it done??
- 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
Open skin and excise thicken bands that are causing problems
what is Dermo-Fasciectomy?
- More radical procedure
- Removal skin may reduce recurrence rates
- Requires intensive physiotherapy
Only do in early aggressive patients
Remove skin and underlying fascia
what is Percutaneous Needle Fasciotomy and how is it done?
- 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
whart is Collagenase?
Collagenases are enzymes that break the peptide bonds in collagen
Injected into band and dissolves the collagen in the band and allows the collagen to be straight
- Presented 3 year recurrence rate 34.8%
- 3 Flexor Tendon Ruptures!
- Cost
- Await longer term recurrence rates
what is the anatomy involved in trigger finger?
- 2 tendons to each finger
- Tendons run in sheath
- Thickenings in sheath = pulley
- Keep tendon close to bone
- Swelling in tendon catches on pulley
who gets trigger finger?
- Women more frequent than men
- 40s-60s
- Ring > Thumb > Middle
- Repetitive use of hand ?
- Local trauma
- Associations - RA, DM, Gout
how is the diagnosis of trigger finger made?
- 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’
- Palpable lump in palm over A1 pulley
- Feel the triggering around the A1-pulley
what is the treatment of trigger finger?
- Non-operative - Splintage, Steroid
- Operative - Percutaneous release, Open surgery
what is 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 would be in a history of a patient with De Quervain’s Syndrome?
- 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
who gets De Quervain’s Syndrome?
- M:F 1:6
- Age 50s - 60s
- Increased in post partum and lactating females
- Activities with frequent thumb abduction and ulnar deviation
- Washerwoman’s sprain – Gray’s anatomy
what should be examined in De Quervain’s Syndrome?
- Examine thumb joints
- Consider base of thumb OA - Look for tenderness over base of the thumb to make sure they don’t have OA
what tests can be done in De Quervain’s Syndrome?
- Finklestein’s Test - Fold thumb into palm and fold fingers over tour thumb, ulnar deviate your wrist, pulls on extensor abductor tendon and produces pain
- Resisted thumb extension - Allow patient to pull thumb in extension and they will feel pain
what is the treatment of De Quervain’s Syndrome?
- Non-operative - Splints, Steroid injection
- Operative - Decompression
what is ganglion?
- Ganglion - A myxoid degeneration from joint synovia…‘Doctor, I have a lump’
- Arise from joint capsule, tendon sheath or ligament
A ganglion cyst is a fluid-filled swelling that usually develops near a joint or tendon. The cyst can range from the size of a pea to the size of a golf ball
They’re made up of a thick, jelly-like fluid called synovial fluid, which surrounds joints and tendons to lubricate and cushion them during movement.
Ganglions can occur alongside any joint in the body, but are most common on the wrists (particularly the back of the wrist), hands and fingers.
who gets ganglia?
- 70% of all discrete swellings in the hand and wrist
- More common in females (2:1)
- Wide age distribution (peak 20-40yrs)
- Dorsal > Volar (3:1)
- May be associated with recurrent injury around the wrist
how is a diagnosis of 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 is the treatment of ganglia?
Non-operative:
- Reassure & Observe
- Aspiration
- Hit it with a bible!?
Operative:
- Excision
- Including ‘the root’
OA Base of Thumb causes what symptoms and signs?
- Pain
- Stiffness
- Swelling
- Deformity
- Loss of function
Base of Thumb OA - who gets it and when is it present?
- Common
- 1 in 3 women
- Pain opening jars / pinching
- Dorsal subuxation, metacarpal adduction, MCPJ hyperextension
- Look for STT OA
what is the treatment of OA Base of Thumb?
Non Operative:
- Life style modifications
- NSAIDS
- Splint
- Steroid Injection
Operative:
- Trapeziectomy
- Fusion
- Replacement (shown in picture)
what is a Trapeziectomy?
involves removing a small bone (one of eight which form the wrist) called the trapezium. This is situated at the base of the thumb. This provides more space for the thumb to move so that the arthritic bone surfaces are not rubbing together causing pain
- The “gold standard”
- Good pain relief
- Moderate pinch grip
- +/- interposition flap or ligament reconstruction
