Week 4 - E - Dupuytren's contracture, trigger finger, Osteoarthritis/Rheumatoid of hand, Ganglon cyst, Giant cell tumour

Question 1

A multitude of pathologies affect the hand and presentation to orthopaedics due to such conditions are common. A carefully history and examination is required to separate the conditions. Treatment choice is based upon the underlying pathology and the functional effect of the symptoms.

What is Dupuytren’s contracture?

Answer 1

Duputytren’s contracture is a proliferative connective tissue disorder where specialised palmar fascia undergoes hyperplasia with normal fascial bands forming nodules and cords progressing to contracture

Question 2

What joints are typically affected by Dupuytren’s contracture? Which fingers are most commonly affected? Is Dupuytren’s contracture painful?

Answer 2

It is typically the MCP and PIP joints that are affected by Dupuytren’s contracture with the painless formation of nodules and cords

Contractures most commonly affect the ring and little fingers

Question 3

What is thought to be the pathogenesis causing dupuytren’s contracture?

Answer 3

Dupuytrens contracture is thought to arise due to proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1)

Question 4

Which sex is most commonly affected by Dupuytren’s? What percentage of cases are bilateral? What are the risk factors? Which drug is it a side effect of?

Answer 4

Males are much more commonly affected (10:1) an 50% of cases are bilateral

Risk factors include

* Familial (inherited in an autosomal dominant fashion)

* Feature of alcholoic liver cirrhosis

* Side effect of phenytoin therapy

* More common in diabetics

Question 5

There is no cure for Dupuytren’s contracture and mild contractures may be tolerated however your fingers can be straightened if it’s severe. What are the indications for surgery in Dupuytren’s contraction?

Answer 5

* Up to 30 degree of contracture can be tolerated at the MCP before considering surgery

* PIPJ involvement is an indication for surgery

* If contracture interfere with functioning, this is an indication for surgery

Question 6

What are the two surgical options for the treatment of Dupuytren’s contracture?

Answer 6

Surgery involves

* Removal of the diseased tissue - fasciectomy

* or Division of the cords - fasciotomy

Recurrence common particular in the young

Question 7

What is trigger finger and what causes it?

Answer 7

Trigger finger is a condition where one of your fingers is stuck in a locked, position (flexed posiition)

It occurs usually after tendonitis of a flexor tendon results in a nodular enlargement of the affected tendon which can catch causing locking of the finger

Question 8

Annular (A1-A5) and cruciform (C0-C3) ligaments of the tendon sheath lie over the flexor tendons of the index finger of the hands. Behind which pulley is it common for a nodule that arises on a flexor tendon to get stuck behind causing trigger finger? How does the nodule end up getting stuck proximal to this pulley?

Answer 8

The nodule usually arises distal to the A1 pulley

Movement of the finger then produces a clicking sound as the nodule passes underneath the pulley and then gets stuck proximal to the A1 pulley locking the finger from extending

Question 9

What symptoms does the patient typically complain of in trigger finger?

Answer 9

Patient typically complains of a clicking sensation as the nodule catches underneath the pulley

The sensation may be painful and the finger may lock in extension

The patient may have to forcibly manipulate the finger to regain extension and this also usually causes pain

Question 10

Which fingers are most commonly involved in Dupuytrens’ contracture? Which fingers are most commonly involved in trigger finger?

Answer 10

In Dupuytren’’s contracture, most commonly the ring and little finger are involved

In trigger finger, most commonly the middle and ring finger are involved

Question 11

What is the management of trigger finger in most cases?

Answer 11

In most cases injection of steroid around the tendon within the sheath will relieve symptoms.

Question 12

What is the management of trigger finger should recurrent and persistent cases occur?

Answer 12

Surgery involving incision of the A1 pulley to allow the tendon to move can be tried in recurrent and persistent cases

Due to the system of other pulleys, division of the A1 pulley does not affect function.

Question 13

Wear and tear arthritis in the small joints of the hand can be troublesome for patients particularly when performing intricate tasks. 80% of over 60s will have radiological evidence of OA in the hands but only a minority complaining of symptoms. What is the name for when OA affects the DIP and PIP joints?

Answer 13

OA affecting the DIP joints - Heberden’s nodes

OA affecting the PIP joints - Bouchard’s nodes

These joints will become swollen and painful

Question 14

Are Heberden’s or Bouchard’s nodes more commonly seen in postmenopasual woman?

Answer 14

Hebderens nodes (DIP) are very commonly seen in postmenopausal woman

Question 15

What may be required for treatment of interphalngeal joint involvement in OA if it is unable to be managed conservatively?

Answer 15

Arthrodesis may be required - fusion of the joint or

Arthroplasty may be required - total joint replacement however re-operation rates are high

Question 16

Rarely OA can affect the metocarpalphalageal (MCPs) joints but there is usually specific cause for this. What are typical histories that may lead to OA of the MCP joints?

Answer 16

Previous injury

Occupational stress

Gout or infection

Surgical treatment is possible for arthritis at MCPs

Question 17

What is the most commonly affected carpo-metacarpal joint? What can help treat an acute flare up? How can chronic pain here be treated?

Answer 17

Most commonly affected caprometacarpal joint is the 1st - the trapeziometacarpal joint at the base of the thumb

Question 18

What can help treat an acute flare up of 1st carpometacarpal joint OA? How can chronic pain here be treated?

Answer 18

Intra-articular steroid injection can help an acute flare up

Excision athroplasty (trapeziectomy) or arthrodesis can cure chronic pain

Question 19

The joints between the scaphoid, trapeziuma nd trapezoid (STT joint) can be affected by primary OA. How may this be treated for severe symptoms?

Answer 19

Selected fusion of the scaphoid, trapezium, trapezoid joint or wrist fusion may be used for severe symptoms

Question 20

The hands are the site where rheumatoid arthritis seems to cause the greatest number of problems and is most visible Patients with longstanding disease will eventually develop deformed, painful and occasionally malfunctioning hands. Which joints tend to be spared in the hands by RA? - in contrast with OA and psoriatic arthritis

Answer 20

The distal interphalangeal joints (DIPs) tend to be spared in RA (therefore no Heberden’s nodes) in contrast with OA and psoriatic arthritis

Question 21

Describe the natural history of disease in the hands in rheumatoid arthritis * It can be thought of as occurring in three stages

Answer 21

* Synovitis and tenosynovitis - inflammation of the synovial lining of the joints and the tendon sheath

* Erosions of the joints - inflammatory pannus denudes (strips) the joints of articular cartilage

* Joint instability and (extensor) tendon rupture - follows progressive destruction of bony and soft tissue structure in the hand

Question 22

Thankfully the end stages of RA are becoming less and less common due to the introduction of modern disease modifying anti‐rheumatic drugs (DMARDs). Nonetheless, there is still a significant population of people who will exhibit hand deformities as a result of the disease. What are the different deformities of the hand that can be easily identified on clinical examination in rheumatoid arthritis?

Answer 22

Volar metacarpophalngeal joint (MCPJ) subluxation

Ulnar deviation of MCPJ

Swan neck deformity

Boutonniere deformity

Z-shaped thumb

Question 23

Describe swan neck deformity

Describe Boutonniere deformity

Describe Z-shaped thumb

Answer 23

• Swan neck deformity - hyperextension at PIPJ with flexion at DIPJ
• Boutonniere deformity - flexion at PIPJ with hyperextension at DIPJ
• Z-shaped thumb - fixed flexion of MCP joint and hyperextension of interphalngeal joint

Question 24

What treatment pay prevent extensor tendon to the wrist or fingers rupturing in rheumatoid arthritis?

Answer 24

Tenosynovectomy (excision of the synovial tendon sheath) may prevent extensor tendon rupture in rheumatoid

Question 25

What is a ganglion cyst?

Answer 25

A ganglion cyst is a small mucinous filled sac of fluid that occurs around a synovial joint or around a synovial tendon sheath

Question 26

Which area of the body are ganglion cysts common in?

Answer 26

They are common in the hand - DIPJ (mucous cyst, flexor tendon) and wrist (dorsal or volar) (most common)

They can also occur in the foot, and ankle as well as the knee (Baker’s cyst)

Question 27

How would you describe a ganglion cyst on examination? What test can be done to make sure it is a ganglion cyst?

Answer 27

Ganglion cysts are well defined, may be quite firm and will transilluminate when a transillumination test is carried out (shining a light on it)

They can cause localised pain

Question 28

What may cause the development of a ganglion cyst?

Answer 28

They may form as a result of herniation or out-pouching of a weak portion of joint capsule or tendon

Weakness can be developmental or as a result of underlying joints damage/arthritis

Question 29

What are the treatment options for a ganglion cyst?

Answer 29

Needle aspiration may be attempted (watch volar ganglion aspiration due to radial artery)

Surgical excision if the swelling causes localised discomfort

Question 30

The second most common soft tissue swellings of the hand after ganglion cysts are the giant cell tumour of the tendon sheath What is the giant cell tumour of the tendon sheath? Why can it also be known as giant cell synovium?

Answer 30

Giant cell tumour of the tendon sheath is a rare benign tumour which can develop on the tendon sheaths around the body

A tendon sheath is a layer of membrane around a tendon known as synovium hence the name giant cell synovium

Question 31

What does the giant cell tumour of the tendon sheath feel like and which tendon sheath is normally affected?

Answer 31

Giant cell tumour of the tendon sheath feels like a small firm swelling which is typically well circumscribed

It is most commonly around the PIP joint of the index and middle fingers

Question 32

How does the giant tumour of tendon sheath appear both macroscopically and histologically?

Answer 32

Macroscopically, the giant cell tumour of tendon sheath is a pigmented lesions

Histologically, they contain multinucleated giant cells and haemosiderin (gives it its brown colour)

Question 33

What is the recommended treatment of a giant cell tumour of the tendon sheath?

Answer 33

Recommended treatment is usually excision to prevent local spread and treat symptoms

Recurrence is not uncommon