Hand problems

Question 1

What is Dupuytrens?

Answer 1

• An inherited disease of progressive fibrous tissue contracture of the palmar fascia.
• Condition in which one or more fingers become permanently bent in a flexed position

Question 2

Epidemiology of Dupuytrens?

Answer 2

• M : F = 8 : 1 in 15 – 64’s
• M : F = 2 : 1 in over 75’s
• Autosomal dominant – variable penetrance
• Almost always white race
• Onset may be sex linked

Question 3

What is the pathology of dupuytrens?

Answer 3

• Myofribroblast
  
  • Intracellular contractile elements
  • Regulated by growth factors
  • Production of collagen

Question 4

What functional issues arrise with Dupuytrens?

Answer 4

• Usually not painful
• Loss of finger extension – active or passive
• Hand in pocket
• Gripping things
• Washing face

Question 5

Non-operative treatment for Dupuytrens?

Answer 5

• Observe
• Splints don’t work
• Radiotherapy

Question 6

Operative treatment for Dupuytrens?

Answer 6

• Partial fasciectomy
• Dermo-fasciectomy
• Arthrodesis
• Amputation
• Percutaneous Needle Fasciotomy
• Collagenase

Question 7

Please explain pros/cons partial fasciectomy.

Answer 7

This procedure involves the excision of diseased Dupuytren’s tissue with the use of multiple 1 cm transverse incisions

• Most common procedure performed in UK
• Good correction can be achieved
• Wounds can take 2-3 weeks to heal
• Stiffness requires physiotherapy
• Can’t be cured
• Recurrence 50 % at 5 years

Question 8

Please explain pros/cons of dermo fasciectomy.

Answer 8

• More radical procedure
• Removal skin may reduce recurrence rates
• Requires intensive physiotherapy

Question 9

Elaborate on the pros and cons of Percutaneous Needle Fasciotomy.

Answer 9

• Quick
• No wounds
• Return to normal activities 2-3 days
• Does not prevent traditional surgery in future
• Higher recurrence (? 50% at 3 years)
• Can be repeated
• Risk of Nerve Injury

Question 10

What is trigger finger?

Answer 10

Trigger fingers is a common disorder characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain

Question 11

Pathogenesis of trigger finger?

Answer 11

• 2 tendons to each finger
• Tendons run in sheath
• Thickenings in sheath = pulley
• Keep tendon close to bone
• Swelling in tendon catches on pulley

Question 12

Who is likely to get trigger finger?

Answer 12

• 40-60s
• Women more than men
• Repetitive use of hand
• Trauma

Question 13

What are some diagnostic factors for trigger finger?

Answer 13

• Patient history
• Clicking sensation with movement of digit
• Lump in palm under pulley
• Clicking may progress to locking

Question 14

Tx for trigger finger?

Answer 14

Non-operative

• Splintage
• Steroids

Operative

• Percutaneous release
• Open surgery

Question 15

What is De Quervain’s Syndrome?

Answer 15

Tenosynovitis of the sheath or tunnel that surrounds two tendons that control movement of the thumb

Question 16

How is De Quervains diagnosed?

Answer 16

• Patient history
  
  • Several weeks pain localised to radial side of wrist
  • Aggravated by movement of the thumb
  • May have seen a localised swelling
  • Localised tenderness over tunnel

Question 17

Who get’s de querveins?

Answer 17

• M:F 1:6
• Age 50s - 60s
• Increased in post partum and lactating females
• Activities with frequent thumb abduction and ulnar deviation

Question 18

What do we need to examine when suspected de quervains?

Answer 18

• Examine thumb joints
• Consider base of thumb OA

Question 19

Tx for de quervains?

Answer 19

Non-operative

• Splints
• Steroid injection

Operative

• Decompression

Question 20

What is a ganglion? Where do they arrise?

Answer 20

A myxoid degeneration from joint synovia…‘Doctor, I have a lump’

Arise from joint capsule, tendon sheath or ligament

Question 21

Who gets ganglions?

Answer 21

• 70% of all discrete swellings in the hand and wrist
• More common in females (2:1)
• Wide age distribution (peak 20-40yrs)
• Dorsal > Volar (3:1)
• May be associated with recurrent injury around the wrist

Question 22

How do ganglions present?

Answer 22

• Present with lump
• Firm, non-tender
• Change in size
• Smooth
• Occasionally lobulated
• Normally not fixed to underlying tissues
• Never fixed to the skin

Question 23

Tx for ganglion?

Answer 23

Non-operative

• Reassure and observe
• Aspiration
• Hit it with a bible?

Operative

• Excision
• Including the root