Wrist and Hand Flashcards
What is Dupuytren’s contracture?
A Dupuytren’s contracture is a common condition* involving contraction of the longitudinal palmar fascia.
Typically starting as painless nodules, fibrous cords and flexion contractures develop at the MCP and interphalangeal joints, which can severely limiting digital movement and reduce patient quality of life.
Describe the pathophysiology of Dupuytren’s contracture?
The condition involves a fibroplastic hyperplasia and altered collagen matrix of the palmar fascia. This compositional change leads to a thickening and contraction of the palmar fascia.
The disease progresses in a predictable pattern, although the rate is variable:
Initial thickening of the palmar skin and underlying subcutaneous tissue, with loss of mobility of overlying skin
A firm painless nodule begins to form, becoming fixed to the skin and the deeper fascia, gradually increasing inside
A cord then develops, resembling a tendon, which begins to contract over months to years
Contraction of the cord pulls on the MCP and PIP joints, leading to progressive flexion deformity in the fingers
What are the clinical features of Dupuytren’s contracture?
Patients will present at varied stages of progression. Symptoms may therefore range from reduced range of motion and nodular deformity through to a complete loss of movement.
The ring and little finger are most commonly involved; however, the other digits may be involved. The condition is bilateral in 45% of cases*.
On examination, a thickened band (Fig. 2) or firm nodule adherent to the skin may be palpable. Skin blanching may occur on active extension of the affected digits. In advanced disease, the MCP and/or PIP joints of the affected digit may be in contracture.
Hueston’s test is a specific test that can be performed for such patients; if the patient is unable to lay their palm flat on a tabletop, this is a positive test.
How can we investigate Dupuytren’s contracture?
can curl finger but can’t stretch it (palmar cords)
painful nodules
Heuston’s table top test (ask pt to put hand flat on table.If can= no surgery.If can’t AND there is 20 degrees PIP joint, 30 degrees MCP joint AND/OR pain/functional deficit = surgery
What is the treatment for Dupuytren’s contracture?
Conservative Management
Patients are advised to undergo hand therapy*, keeping the hand active with multiple stretching exercises throughout the day.
Injectable collagenase clostridum histolyticum (CCM) is used by some clinicians in early disease, as data shows that for early stages of Dupuytren’s contracture its use is equivalent to surgery in functional outcomes (albeit with high recurrence rates)
*Both the use of radiotherapy or steroid injections are not routinely recommended for early Dupuytren’s disease.
Surgical Management
Surgical procedures for Dupuytren’s disease involve the excision of diseased fascia. Surgical management is typically indicated in those with functional impairment, MCP joint contracture >30 degrees, any PIP contracture, or rapidly progressive disease.
A fasciectomy performed under local/general anaesthetic is the most commonly used surgical procedure for Dupuytren’s disease. Various approaches to this are present, such as:
Regional fasciectomy, whereby the entire cord is removed (the most common approach)
Segmental fasciectomy, whereby only short segments of the cord are removed
Dermofasciectomy, whereby the cord and overlying skin are removed, to be followed by a skin graft
What is carpel tunnel syndrome?
Carpal tunnel syndrome (CTS) is a condition involving a compression of the median nerve within the carpal tunnel of the wrist, due to a raised pressure within this compartment.
space occupying lesion, synovitis- causes narrowing of carpal tunnel and compresses median
What is carpel tunnel syndrome caused by?
The main risk factors for developing carpal tunnel syndrome include female gender, increasing age, pregnancy, obesity, and previous injury to the wrist.
Carpal tunnel syndrome is as associated with other conditions, such as diabetes mellitus, rheumatoid arthritis, and hypothyroidism.
Individuals who have occupations involving repetitive hand or wrist movements (e.g. vibrating tools or assembly line work) are also potentially at increased risk of CTS.
What are the clinical features of carpel tunnel syndrome?
Patients with carpal tunnel syndrome typically complain of pain, numbness, and/or paraesthesia throughout the median nerve sensory distribution.
The palm is often spared, due to the palmar cutaneous branch of the median nerve branching proximal to the flexor retinaculum and passing over the carpal tunnel.
Symptoms are typically worse during night and symptoms can often be temporarily relieved by hanging the affected arm over the side of the bed or by shaking it back and forth.
On examination there are often no visible findings during early stages of CTS. However, sensory symptoms can be reproduced by either percussing over the median nerve (Tinel’s Test) or holding the wrist in full flexion for one minute (Phalen’s Test).
In the later stages of carpal tunnel syndrome, there may be weakness of thumb abduction (due to denervation atrophy of the thenar muscles) and / or wasting of the thenar eminence
What examination tests are used for CTS?
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
Nerve conduction studies: prolongation of the action potential
To rule out DDx: A) Bloods- Diabetes, Vitamin B12 B) Scans- MRI C- spine
What is the treatment for CTS?
Carpal tunnel syndrome can be treated conservatively initially with a wrist splint (commonly worn at night), which can relieve some of the symptoms by preventing wrist flexion. Hand therapy can also be prescribed.
Corticosteroids injections can be trialled. They are administered directly into carpal tunnel to reduce swelling and in turn symptoms. Some clinicians may also trials NSAIDs in an attempt to further reduce swelling, however there is limited evidence to support their routine use.
Surgical Treatment
Surgical treatment is undertaken in symptomatic patient, where previous treatments (splints and hand therapy) have not been successful.
Carpal tunnel release surgery (Fig. 4) decompresses the carpal tunnel, involving cutting through the flexor retinaculum, in turn reducing the pressure on the median nerve. This can be done under local anaesthetic and is performed as a day case.
What is a Ganglionic cyst?
Ganglionic cysts are non-cancerous soft tissue lumps that occur along any joint or tendon. They arise from degeneration within the joint capsule or tendon sheath of the joint, subsequently becoming filled with synovial fluid
How do we identify a ganglionic cyst?
A ganglionic cyst typically presents as a smooth spherical painless lump adjacent to the joint affected (Fig. 2). It may have appeared suddenly or grown over time. In some cases, the cyst may have subsided initially, to then reappear at a later date.
On examination, the lump will be soft and will transilluminate, however may mechanically restrict the full range of motion in the affected joint.
If the cyst exerts any pressure upon an adjacent nerve(s), the patient may present with localised paresthesia, pain, or motor weakness.
How do we investigate and manage a ganglionic cyst?
Most ganglion cysts are diagnosed clinically. A plain film radiograph may assist in ruling out osteoarthritis or bone malignancies as differentials, as ganglions cannot be visualised via X-ray.
In uncertain cases, imaging via ultrasound or MRI can be done in order to assess the shape, size, and depth of the cyst. Due to their high sensitivity, such imaging may also pick up incidental cysts that have not yet grown large enough to be symptomatic.
A ganglionic cyst can be aspirated for temporary symptomatic relief (however there is a high rate of recurrence) and any fluid extracted can be sent off for microscopy +/- cytology if required.
If the cyst does not cause any pain, the usual recommended treatment is to simply monitor, as cysts often disappear spontaneously without further intervention.
If the cyst causes pain or severely limits range of movement, there are two main interventions that can be performed:
Aspiration +/- steroid injection*, although this is associated with infection and high rate of recurrence.
*There is only limited evidence demonstrating a clear benefit of steroid injections in ganglion.
Cyst excision, removing the cyst capsule along with a portion of the associated tendon sheath (recurrence is less than with aspiration, but still possible)
Often reserved for symptomatic cases with recurrence following aspiration.
What is De Quervain’s tenosynovitis?
De Quervain’s tenosynovitis is inflammation of the tendons within the first extensor compartment of the wrist, resulting in wrist pain and swelling.
sheath containing the extensor pollicis brevis and abductor pollicis longus tendons (Dorsal compartment on radial side) is inflamed. Females aged 30 - 50 years old.
What are the risk factors for De Quervain’s tenosynovitis?
The main risk factors for developing De Quervain’s tenosynovitis include:
Age – most common between 30 and 50 years
Female gender
Pregnancy
