Orthopaedic Problems of the Hand

Question 1

What are some common conditions of the hand?

Answer 1

• Dupuytren’s disease
• Trigger finger
• De Quervain’s tenovaginitis
• Nerve entrapments
  
  • Carpal tunnel syndrome
  • Cubital tunnel syndrome
• Ganglion
• OA base of thumb

Question 2

What sex and ethnicity does Dupuytren’s disease affect more?

Answer 2

Males > females

Almost exclusively white

Question 3

Are there any genetic factors to Dupuytren’s disease?

Answer 3

Autosomal dominant

Question 4

What are some risk factors for Dupuytren’s disease?

Answer 4

• Diabetes
• Alcohol
• Tobacco
• HIV
• Epilepsy
• Genetics

Question 5

Describe the pathology of Dupuytren’s disease?

Answer 5

• Contraction of pretendinous bands and palmar aponeurosis (fascia) causes disease
• Myofibroblast
  
  • Intracellular contractile elements
  • Regulated by growth factors
  • Production of collagen

Question 6

What are some functional problems of dupuytren’s disease?

Answer 6

• Usually not painful
• Loss of finger extension
• Problems gripping things, putting hands in pockets or washing face

Question 7

What is the treatment of dupuytren’s disease?

Answer 7

• Non operative
  
  • Observe
  • Splints don’t work
  • Radiotherapy
• Operative
  
  • Partial fasciotomy
    
    • Most common procedure in UK
    • Doesn’t get rid of all fascia
    • Recurrence 50% at 5 years
  • Dermo-fasciectomy
    
    • More radical procedure, gets rid of all fascia and removes some skin
    • Requires intensive physiotherapy
  • Arthrodesis
  • Amputation
  • Percutaneous needle fasciotomy
    
    • Quick and no wounds
    • Higher reoccurrence rate
    • Risk of nerve injury
  • Collagenase
    
    • Dissolves collagen in the band
    • Major problem is the flexor tendon may rupture
    • Expensive procedure

Question 8

What causes trigger finger?

Answer 8

• 2 tendons to each finger that sits in sheath
• Thickenings in sheaths known as pulley, keep tendon close to bone
• Swelling in tendon catches the pulley

Question 9

What age group and sex is more affected by trigger finger?

Answer 9

• Woman more than men
• 40-60 years

Question 10

Which fingers does trigger finger affect most commonly?

Answer 10

ring>thumb>middle

Question 11

Describe the clinical features of trigger finger?

Answer 11

• Patient history
  
  • Clicking sensation, may progress to locking
• Examination
  
  • Palpable lump over A1 pulley

Question 12

What is the treatment of trigger finger?

Answer 12

• Non operative
  
  • Splintage
  • Steroid
• Operative
  
  • Percutaneous release
  • Open surgery

Question 13

What does De Quervain’s Tenovaginitis occur due to?

Answer 13

Occurs in 1^st dorsal extensor compartment due to thickening of localised segment

Question 14

What is the presentation of de quervain’s tenovaginitis?

Answer 14

• Pain
  
  • Localised to radial side of wrist
  • Aggravated by movement of thumb
• Localised swelling
• Tenderness over tunnel

Question 15

What sex and age group is most affected by de quervain’s tenovaginitis?

Answer 15

• Females more than males
• 50-60 years

Question 16

How is de quervain’s tenovaginitis diagnosed?

Answer 16

• Examination of joints
• Finkelstein’s test
• Resisted thumb extension

Question 17

What is the treatment of de quervain’s tenovaginitis?

Answer 17

• Non operative
  
  • Splints
  • Steroid injection
• Operative
  
  • Decompression

Question 18

What is a ganglion?

Answer 18

Ganglion = a myxoid degeneration from joint synovial

Question 19

What can a ganglion arise from?

Answer 19

Arise from joint capsule, tendon sheath or ligaments

Question 20

What age group and sex are most affected by ganglion?

Answer 20

• More common in females
• 20-40 years

Question 21

What are the clinical features of ganglion?

Answer 21

• Present with lump
• Firm, non-tender
• Change in size
• Smooth
• Normally not fixed to underlying tissues and never fixed to skin

Question 22

What is the treatment of ganglion?

Answer 22

• Non operative
  
  • Reassure and observe
  • Aspiration
• Operative
  
  • Excision
    
    • Make sure also excise the ‘root’

Question 23

What does OA stand for?

Answer 23

Osteoarthritis

Question 24

What is the presentation of osteoarthritis of base of thumb?

Answer 24

• Pain
  
  • At base of thumb
  • Worse on activity
• Stiffness
• Swelling
• Deformity
• Loss of function

Question 25

Which sex does OA of the base of thumb affect more?

Answer 25

Females \> males

Question 26

What is the treatment of OA of the base of the thumb?

Answer 26

* Non-operative * Life style modifications * NSAIDs * Splint * Steroid injection * Operative * Trapeziectomy * Gold standard * Good pain relief * Fusion * Replacement