Wrist and hand Flashcards
What is Dupuytren’s contracture?
Progressive, painless fibrotic thickening of the palmar fascia with the skin puckering and tethering.
Describe the clinical features of Dupuytren’s contracture
Mainly affects the ring and little fingers
Often bilateral (45%) and symmetrical
1. Pitting and thickening of palmar skin and SC tissue
2. Nodule forms: firm, painless, fixed
3. Cord develops and begins to contract over months/years
MCP joint flexion
Involvement of interphalangeal joints: disabling
Name 3 risk factors for Dupuytren’s contracture
Increasing age
North European descent
Positive family history
Smoking (3:1)
Alcoholic liver disease
HIV or cancer
Diabetes mellitus (20%)
Occupational exposure to hand-transmitted vibration
Epilepsy/anticonvulsant drugs: e.g. Phenytoin
Peyronie’s disease (rare): penile fibromatosis
Name 2 differential diagnoses for Dupuytren’s contracture
Callus Ganglion Skin contracture Trigger finger Ulnar nerve palsy
Outline the management of Dupuytren’s contracture
Surgery offered for significantly compromised hand function or positive Hueston table-top test.
Non-surgical: injectable collagenase, radiotherapy
Closed fasciotomy
Fasciectomy
Post-op splintage and physiotherapy
What is a ganglion cyst?
A smooth fluid-filled swelling associated with a joint capsule or tendon sheath.
Describe the treatment options for ganglion cysts
May disappear spontaneously or with local pressure.
Aspiration via wide-bore needle
Surgical dissection
Define De Quervain’s tenosynovitis
Stenosing tenosynovitis of the abductor policies longus and extensor policies brevis tendons as they cross the distal radial styloid.
Describe the clinical features of De Quervain’s tenosynovitis
Pain on radial side of wrist
Tenderness over radial styloid process
Abduction of thumb against resistance is painful
Finkelstein’s test: with thumb flexed across palm, pain on wrist flexion and ulnar deviation
Outline the management options for De Quervain’s tenosynovitis
Rest, thumb splint, ice
NSAIDs
Hydrocortisone injection
Decompression of tendons sheath
What is trigger finger?
Entrapment of a flexor tendon nodule at the sheath, preventing smooth gliding. On forced extension, the nodule passes the constriction with a snap.
Describe the clinical features of trigger finger
Most commonly affects ring and middle fingers
Sudden extension of finger after initial locking
Tender nodule palpable in front of affected sheath
What are the treatment options for trigger finger?
Simple immobilisation
Steroid injection
Percutaneous trigger finger release
Define Volkmann’s ischaemic contracture
Permanent flexion deformity due to muscle necrosis and fibrosis after ischaemic injury.
What hand deformities are seen with osteoarthritis
Bouchard’s nodes (PIP)
Heberden’s nodes (DIP)
Squaring of the thumb base
What hand deformities are seen with rheumatoid arthritis
Z thumb
Ulnar deviation of MCPJ
Swan-neck: DIP hyperflexion, PIP hyperextension
Boutonniere: DIP hyperextension, PIP hyperflexion
Rheumatoid nodules
Define mallet finger
Flexion deformity of distal phalanx, with normal passive movement. Due to injury to extensor tendon of distal phalanx.
What is the treatment for mallet finger?
Distal phalanx hyperextension splint for 6-8 weeks
Define carpal tunnel syndrome
Compression of the median nerve as it passes under hte flexor retinaculum
Describe the clinical features of carpal tunnel syndrome
Affects the median nerve distribution of the hand
Pain or paraesthesia: typically localised to median innervated fingers, but may involve entire hand or radiate into the forearm
Common at night and after repetitive movement
Relieved by hanging arm or shaking*
Late: clumsiness and weakness
Wasting of thenar eminence
Sensory deficit of lateral 3.5 digits
Sparing of lateral palmar sensation
Explain the pattern of sensory deficit with carpal tunnel syndrome
Sensory deficit in lateral 3.5 digits: median nerve
Sparing of lateral palmar sensation: palmar cutaneous branch of median nerve does not travel within tunnel
List 3 risk factors for carpal tunnel syndrome
Occupation/activities Genetic: FHx, wrist anatomy Post-Colles' fracture, wrist injury Diabetes, obesity Menopause or pregnancy Rheumatoid arthritis Acromegaly Thyroid: myxoedema Amyloidosis Gout and CPPD
Describe 2 tests used to assess carpal tunnel syndrome
Phalen’s test: hyperflexion of wrist for 1 minute
Tinel’s test: tapping over the carpal tunnel
What is the treatment for carpal tunnel syndrome?
Treat any treatable associated diseases Rest, activity modification Wrist splints: esp at night Carpal injection Carpal tunnel release
