Upper Limb - hand

Question 1

What is Dupuytren’s contracture?

Answer 1

Fixed flexion contracture of the fingers, where
(1) the fingers bend towards the palm
(2) cannot be fully extended
(3) is caused by contractures of the palmar aponeurosis

Question 2

Which fingers are most commonly affected in Dupuytren’s contracture?

Answer 2

1. The ring finger and little finger are most commonly affected
2. The middle finger may be involved in advanced cases, but the index finger and thumb are nearly always spared

Question 3

What is the primary cause of Dupuytren’s contracture?

Answer 3

Contracture of the palmar aponeurosis due to excessive proliferation of myofibroblasts and altered collagen composition

= leading to thickening and shortening of the fascia

Question 4

What is the most common age group affected by Dupuytren’s contracture?

Answer 4

males over 40 years of age

Question 5

How does Dupuytren’s contracture typically present?

Answer 5

It usually presents as a
1. painless
2. gradual progression
3. starting with a palmar nodule or pit 4. followed by flexion contracture
5. commonly affecting the 4th and 5th fingers

Question 6

What is the “table-top test” used for in Dupuytren’s contracture?

Answer 6

The table-top test checks for the inability to flatten the palm against a surface, which is due to the contractures in the metacarpophalangeal joints

Question 7

What is the most common form of surgical management for Dupuytren’s contracture?

Answer 7

Needle fasciotomy is used for single-band contractures, while limited fasciectomy involves the removal of the thickened bands

For severe cases, dermo fasciectomy with grafting may be performed

Question 8

What type of collagen is primarily involved in Dupuytren’s contracture?

Answer 8

collagen type III

Question 9

A 55-year old man presents to his GP complaining that he is unable to straighten his right ring finger. It bothers him whenever he tries to put on his gardening gloves as his finger tends to get caught. There is no associated pain or numbness and no history of trauma. He has a past medical history of type 2 diabetes controlled with metformin

On examination, his right ring finger was held at approximately 45 degrees of flexion at the metacarpophalangeal joint with a painless cord-like structure palpable on the palmar surface of the hand. The GP suspects this is a Dupuytren’s contracture

What is the earliest sign seen in the development of Dupuytren’s contracture?

Answer 9

Palmar nodule

Question 10

What is a Boxer’s fracture?

Answer 10

A Boxer’s fracture is a fracture of the 5th metacarpal neck, usually caused by striking a hard object with a clenched fist

Question 11

What is the common cause of a Boxer’s fracture?

Answer 11

It is commonly caused by punching a wall or another hard object with a clenched fist

Question 12

What are the main symptoms of a Boxer’s fracture?

Answer 12

The symptoms include
1. dorsal hand pain
2. swelling
3. possible deformity of the hand

Question 13

Which fingers are most commonly affected by a Boxer’s fracture?

Answer 13

The 4th or 5th metacarpals are most commonly affected

Question 14

What signs are typically seen in a Boxer’s fracture?

Answer 14

1. Minimal displacement
2. no rotation
3. anterior displacement of the distal part of the fracture

= leading to shortening of the affected finger

Question 15

What is the main management approach for a Boxer’s fracture?

Answer 15

early mobilisation and using a ‘buddy strap’ to stabilise the injured finger

Question 16

What does the ‘buddy strap’ do in Boxer’s fracture management?

Answer 16

The ‘buddy strap’ is used to bind the injured finger to the adjacent finger for support and stability

Question 17

A 19-year-old male presents to the emergency department with pain in his left hand after punching a wall with his bare fist. On examination, he is in pain. The skin appears mildly bruised but he has normal sensation and pulses

A radiograph confirms the presence of an undisplaced, non-comminuted Boxer’s fracture

What is the first-line definitive treatment?

Answer 17

Ulnar gutter splint

Question 18

A 25-year-old man presents to the emergency department with pain and swelling in his hand after punching a wall. Physical examination reveals tenderness and deformity over the fifth metacarpal. An X-ray confirms an isolated, non-angulated fifth metacarpal fracture with articular involvement

Given the most likely diagnosis, what is the most appropriate treatment?

Answer 18

Surgical intervention because theres articular involvement

Question 19

What are the common symptoms of Bennett’s fracture?

Answer 19

acute pain at the base of the thumb

Question 19

What is the most common cause of Bennett’s fracture?

Answer 19

It is usually caused by an axial force applied to the thumb in flexion
= eg, fist fights

Question 20

What is a Bennett’s fracture?

Answer 20

Fracture of the 1st metacarpal base caused by forced hyperabduction of the thumb

Intra-articular fracture at the base of the thumb metacarpal

Question 21

What is the pathophysiology of Bennett’s fracture?

Answer 21

The fracture may extend into the first carpometacarpal (CMC) joint

= causing instability and subluxation, which often requires surgical repair

Question 22

What happens to the volar beak ligament in Bennett’s fracture?

Answer 22

A small bony fragment often remains attached to the volar beak ligament of the CMC joint

Question 23

What is the common surgical treatment for Bennett’s fracture?

Answer 23

The thumb is surgically reduced onto the bony fragment and fixed, commonly with K wires

Question 24

What is Trigger Finger?

Answer 24

Trigger finger is a condition where the tendon becomes 'stuck' and cannot pass smoothly through the pulley, causing abnormal flexion of the digits

Question 25

What are the common associations with Trigger Finger?

Answer 25

often idiopathic, but is also associated with rheumatoid arthritis and diabetes mellitus

Question 26

In which fingers is the Trigger Finger most commonly seen?

Answer 26

thumb, middle, or ring fingers

Question 27

What are the initial symptoms of Trigger Finger?

Answer 27

Initially, there is (1) stiffness (2) snapping ('trigger') (3) when extending a flexed digit (4) a nodule may be felt at the base of the affected finger Pain over A1 pulley (MC head), may need other fingers to help extend or may not extend at all

Question 28

What is the first-line management for Trigger Finger?

Answer 28

steroid injections = a finger splint may be applied afterwards too

Question 29

When should surgery be considered for Trigger Finger?

Answer 29

not responded to steroids

Question 30

A 64-year-old woman who is known to have rheumatoid arthritis presents with pain in her right ring finger when she flexes it. On one occasion she reports it became 'stuck'. Clinical examination is unremarkable other than a palpable nodule at the base of the finger What is the most likely diagnosis?

Answer 30

Trigger finger

Question 31

How can you differentiate Trigger Finger from Dupuytren’s Contracture?

Answer 31

In Trigger Finger, when you pull the finger out, it will straighten. In Dupuytren’s Contracture, the finger will not straighten