Wrist and hand

Question 1

What is Dupuytren’s contracture?

Answer 1

Progressive, painless fibrotic thickening of the palmar fascia with the skin puckering and tethering.

Question 2

Describe the clinical features of Dupuytren’s contracture

Answer 2

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

Question 3

Name 3 risk factors for Dupuytren’s contracture

Answer 3

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

Question 4

Name 2 differential diagnoses for Dupuytren’s contracture

Answer 4

Callus
Ganglion
Skin contracture
Trigger finger
Ulnar nerve palsy

Question 5

Outline the management of Dupuytren’s contracture

Answer 5

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

Question 6

What is a ganglion cyst?

Answer 6

A smooth fluid-filled swelling associated with a joint capsule or tendon sheath.

Question 7

Describe the treatment options for ganglion cysts

Answer 7

May disappear spontaneously or with local pressure.
Aspiration via wide-bore needle
Surgical dissection

Question 8

Define De Quervain’s tenosynovitis

Answer 8

Stenosing tenosynovitis of the abductor policies longus and extensor policies brevis tendons as they cross the distal radial styloid.

Question 9

Describe the clinical features of De Quervain’s tenosynovitis

Answer 9

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

Question 10

Outline the management options for De Quervain’s tenosynovitis

Answer 10

Rest, thumb splint, ice
NSAIDs
Hydrocortisone injection
Decompression of tendons sheath

Question 11

What is trigger finger?

Answer 11

Entrapment of a flexor tendon nodule at the sheath, preventing smooth gliding. On forced extension, the nodule passes the constriction with a snap.

Question 12

Describe the clinical features of trigger finger

Answer 12

Most commonly affects ring and middle fingers
Sudden extension of finger after initial locking
Tender nodule palpable in front of affected sheath

Question 13

What are the treatment options for trigger finger?

Answer 13

Simple immobilisation
Steroid injection
Percutaneous trigger finger release

Question 14

Define Volkmann’s ischaemic contracture

Answer 14

Permanent flexion deformity due to muscle necrosis and fibrosis after ischaemic injury.

Question 15

What hand deformities are seen with osteoarthritis

Answer 15

Bouchard’s nodes (PIP)
Heberden’s nodes (DIP)
Squaring of the thumb base

Question 16

What hand deformities are seen with rheumatoid arthritis

Answer 16

Z thumb
Ulnar deviation of MCPJ
Swan-neck: DIP hyperflexion, PIP hyperextension
Boutonniere: DIP hyperextension, PIP hyperflexion

Rheumatoid nodules

Question 17

Define mallet finger

Answer 17

Flexion deformity of distal phalanx, with normal passive movement. Due to injury to extensor tendon of distal phalanx.

Question 18

What is the treatment for mallet finger?

Answer 18

Distal phalanx hyperextension splint for 6-8 weeks

Question 19

Define carpal tunnel syndrome

Answer 19

Compression of the median nerve as it passes under hte flexor retinaculum

Question 20

Describe the clinical features of carpal tunnel syndrome

Answer 20

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

Question 21

Explain the pattern of sensory deficit with carpal tunnel syndrome

Answer 21

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

Question 22

List 3 risk factors for carpal tunnel syndrome

Answer 22

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

Question 23

Describe 2 tests used to assess carpal tunnel syndrome

Answer 23

Phalen’s test: hyperflexion of wrist for 1 minute

Tinel’s test: tapping over the carpal tunnel

Question 24

What is the treatment for carpal tunnel syndrome?

Answer 24

Treat any treatable associated diseases
Rest, activity modification
Wrist splints: esp at night
Carpal injection
Carpal tunnel release