Orthopaedic Problems of the Hand

Question 1

What elective hand conditions are there?

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 is the epideminiology of Dupuytren’s?

Answer 2

• M:F 8:1 (15-64s)
• M:F 2:1 (75+)

Disease develops earlier in males

Question 3

What is the aetiology of Dupuytren’s?

Answer 3

Autosomal dominant of variable penetrance

• Sporadic in 30% of cases
• Onset may be sex linked
• Almost exclusively white races
• Few sporadic reports in other races

Question 4

What is Dupuytren’s associated with?

Answer 4

• Diabetes
• Alcohol
• Tobacco
• HIV
• Epilepsy

Question 5

What are the features of Dupuytren’s diatheses?

Answer 5

• Early onset disease
• Bilateral disease
• Family history
• Ectopic disease

Question 6

What is the pathophysiology of Dupuytren’s?

Answer 6

Myofibroblast

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

Question 7

What functional problems does Dupuytren’s present?

Answer 7

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

Question 8

What are the treatment option for Dupuytren’s?

Answer 8

Non-operative

• Observe
• Splints don’t work
• Radiotherapy

Operative

• Partial fasciectomy
• Dermo-fasciectomy
• Arthrodesis
• Amputation
• Percutaneous needle fasciotomy
• Collagenase

Question 9

What are the features of a partial fascieotomy?

Answer 9

• 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 10

What are the features of a dermo-fasciotomy?

Answer 10

• More radical than partial fasciotomy
• Removal of skin may reduce recurrence rates
• Requires intensive physiotherapy

Question 11

What are the features of a percutaneous needle fasciotomy?

Answer 11

-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 12

What is the anatomy behind trigger finger?

Answer 12

• 2 tendons to each finger
• Tendons run in sheath
• Thickenings in the sheath are called pulleys
• Pulleys keep tendons close to the bone
• Swelling in tendon catches on the pulleys

Question 13

Who gets trigger finger?

Answer 13

• F>M
• 40s-60s
• Ring > Thumb > Middle
• Repetitive use of hand ?
• Local trauma
• Associations: RA, DM, Gout

Question 14

How is trigger finger diagnosed?

Answer 14

• Patient History
• Clicking sensation with movement of digit
• Lump in palm under pulley
• May have to use other hand to ‘unlock’
• ‘Clicking’ may progress to ‘locking’

Question 15

What are the treatment options for trigger finger?

Answer 15

Non-operative

• Splintage
• Steroids

Operative

• Percutaneous release
• Open surgery

Question 16

What history may a patient with de Quervain’s syndrome present with?

Answer 16

• 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

What is the epidemiology of de Quervain’s syndrome?

Answer 17

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

Question 18

What is the pathophysiology of de Quervain’s syndrome?

Answer 18

• 1st dorsal extensor compartment
• Fibro-osseous tunnel at the distal radius
• Thickening of localised segment
• 30% 1st compartment divided by septum

Question 19

What examination should be done in Quervain’s syndrome?

Answer 19

• Examine thumb joints and consider base of thumb OA
• Finklestein’s test
• Resisted thumb extension

Question 20

What are the treatment options for de Quervain’s syndrome?

Answer 20

Non-operative

• Splints
• Steroid injection

Operative
-Decompression

Question 21

What is the anatomy of a ganglion?

Answer 21

• A myxoid degeneration from joint synovia

- Arise from joint capsule, tendon sheath or ligament

Question 22

Who gets ganglia?

Answer 22

• F:M 2:1
• Peak 20-40 years
• Account for 70% of discrete swelling of the hand and wrist
• Dorsal> volar 3:1

Question 23

What may ganglia be associated with?

Answer 23

Recurrent injury around the wrist

Question 24

How is a diagnosis of hand/wrist ganglia made?

Answer 24

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

Question 25

What are the treatment options for ganglia?

Answer 25

Non-operative - Reassure and observe - Aspiration - Hit with a book Operative -Excision (including the root)

Question 26

How does OA of the base of the thumb present?

Answer 26

- Pain - Stiffness - Swelling - Deformity - Loss of function

Question 27

Who is affected by base of the thumb OA?

Answer 27

- Common condition affecting 1 in 3 women | - They have difficulty opening jars and pinching

Question 28

What should you look for in base of the thumb OA?

Answer 28

STT OA

Question 29

What are the treatment options for base of the thumb OA?

Answer 29

Non Operative - Life style modifications - NSAIDS - Splint - Steroid Injection Operative - Trapeziectomy - Fusion - Replacement

Question 30

What is the gold standard treatment for base of the thumb OA?

Answer 30

Trapeziectomy as it gives good pain relief and moderate pinch grip (+/- interposition flap or ligament reconstruction)