Orthopoedic Problems of the Hnad Flashcards
Who gets Dupuytren’s disease?
- Disease develops earlier and his more common in males
- M : F = 8 : 1 in 15 – 64s
- M : F = 2 : 1 in over 75s
What are the genetics of Dupuytren’s disease?
- Autosomal dominant - variable penetrance
- Sporadic in 30% of cases
- Onset may be sex-linked
- Almost exclusively white races
- Fewer sporadic reports in other cases
Dupuytren’s is related to which diseases/risk factors?
- Diabetes
- HIV
- Epilepsy
- Alcohol
- Tobacco
What are the features of Dupuytren’s?
- Early onset disease - tends to more aggressive
- Bilateral disease
- Family history
- Ectopic disease - such as fibrous conditions in the foot
What is the pathology of Dupuytren’s?
- Myofibroblast
- Intracellular contractile elements
- Regulated by growth factors
- Overproduction of collagen
- Pretendinous bands thicken and contract pulling fingers permanently into flexion
What are the functional problems caused by Dupuytren’s?
- Usually not painful - only painful in early stages
- Loss of finger extension - active or passive
- Hand in pocket
- Gripping things
- Washing face
What are the non-operative treatments of Dupuytren’s?
- Observe
- Radiotherapy
- Splints do not work!
What are the operative treatments of Dupuytren’s?
- Partial fasciectomy
- Dermo-fasciectomy
- Arthrodesis - artificial joint ossification
- Amputation
- Percutaneous needle fasciotomy
- Collagenase
What is a partial fasciectomy and how effective is it?
- Open skin and excise thickened bands
- Wounds take 2-3 weeks to heal
- Stiffness requires physiotherapy
- Can’t be cured
- recurrence 50% ar 5 years
What is a dermo-fasciectomy and how effective is it?
- More radical procedure
- Carried out in more early aggressive disease
- Removal of skin may reduce recurrence rates
- Requires intensive physiotherapy
What is a percutaneous need fasciotomy and how effective is it?
- Band is cut
- Quick
- No wounds
- Recovery 2-3 days
- Does not prevent traditional surgery in future
- Higher recurrence - up to 50% at 3 years
- Can be repeated
- Risk of nerve injury
What is collagenase treatment and how effective is it?
- Injected and dissolves collagen in the band
- Presented 3 year recurrence rate 34.8%
- Flexor Tendon Ruptures risk
- Cost
- Await longer term recurrence rates
- Not used in Aberdeen as benefit not seen over needle fasciotomy
Who gets trigger finger?
- More common in women
- 40s-60s
- Ring > Thumb > Middle
- Repetitive use of hand ?
- Local trauma
- Associations - RA, DM, Gout
What is the pathology of trigger finger?
- 2 tendons to each finger
- Tendons run in sheath
- Thickenings in sheath known as pulleys - keep tendon close to bone (like line in a rod)
- Swelling in tendon catches on pulley in trigger finger
How is trigger finger diagnose?
- Patient history
- Pain at level of distal palmer crease
- Clicking sensation with movement of digit
- Lump in palm under pulley
- May have to use other hand to unlock the finger
- Clicking may progress to locking
What are the specific features of trigger finger in the hand?
- Palpable lump in palm over A1 pulley
* Feel the triggering around the A1 pulley (when flexing and extending the finger)
What are the non-operative treatments of trigger finger?
- Splintage
- Steroid
- Works in 50%
What are the operative treatments of trigger finger?
- Percutaneous release (usually release of A1 pulley)
* Open surgery
What is De Quervain’s tenovaginitis?
- Takes place in the 1st dorsal extensor compartment
- Fibro-osseous tunnel at the distal radius
- There is thickening of the localised segment
- 30% 1st compartment divided by septum
RETINACULUM
How does DQT present?
- 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 suffers from DQT?
- More common in females
- 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
How is DQT diagnoses?
- Examine thumb joints - consider base of thumb OA
- Perform Finklestein’s Test
- Perform resisted thumb extension
What are the non-operative treatments of DQT?
- Splints
- Steroid injection
- Settles 50%
What is the operative treatment of DQT?
•Decompression - open retinaculum and divided compartments if the are present
What is a ganglion?
- A myxoid degeneration from joint synovia
- Arise from joint capsule, tendon sheath or ligament
- Fluid concentrates - become firm
How common are ganglia?
•70% of all discrete swellings in the hand and wrist
Who gets ganglia?
- 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
What are the signs of ganglia?
- 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 non-operative treatments of ganglia?
- Reassure & Observe - they can be resilient
- Aspiration (and inject steroid)
- Hit it with a bible!?
What are the operative treatments of ganglia?
•Excision (including ‘the root’)
How does base of thumb OA present?
- Pain at base of the thumb
- Pain may be worse at night after a busy day
- Stiffness
- Swelling
- Deformity
- Loss of function
Who gets base of thumb OA?
- Common - most common OA in the body
- 1 in 3 women
- Pain opening jars/pinching
- Dorsal subuxation, metacarpal adduction, MCPJ hyperextension
- Look for STT OA
What are the non-operative treatments of base of thumb OA?
- Life style modifications
- NSAIDS
- Splint - limit movement, limit pain
- Steroid Injection
What are the operative treatments of base of thumb OA?
- Trapeziectomy - take away part of the joint leaving fibrous space
- Fusion
- Replacement
What is a trapeziectomy?
•The “gold standard”
•Good pain relief
•Moderate pinch grip
+/- interposition flap or ligament reconstruction
