Week 4 - E - Dupuytren's contracture, trigger finger, Osteoarthritis/Rheumatoid of hand, Ganglon cyst, Giant cell tumour Flashcards
A multitude of pathologies affect the hand and presentation to orthopaedics due to such conditions are common. A carefully history and examination is required to separate the conditions. Treatment choice is based upon the underlying pathology and the functional effect of the symptoms.
What is Dupuytren’s contracture?
Duputytren’s contracture is a proliferative connective tissue disorder where specialised palmar fascia undergoes hyperplasia with normal fascial bands forming nodules and cords progressing to contracture
What joints are typically affected by Dupuytren’s contracture? Which fingers are most commonly affected? Is Dupuytren’s contracture painful?
It is typically the MCP and PIP joints that are affected by Dupuytren’s contracture with the painless formation of nodules and cords
Contractures most commonly affect the ring and little fingers
What is thought to be the pathogenesis causing dupuytren’s contracture?
Dupuytrens contracture is thought to arise due to proliferation of myofibroblast cells and the production of abnormal collagen (type 3 rather than type 1)
Which sex is most commonly affected by Dupuytren’s? What percentage of cases are bilateral? What are the risk factors? Which drug is it a side effect of?
Males are much more commonly affected (10:1) an 50% of cases are bilateral
Risk factors include
* Familial (inherited in an autosomal dominant fashion)
* Feature of alcholoic liver cirrhosis
* Side effect of phenytoin therapy
* More common in diabetics
There is no cure for Dupuytren’s contracture and mild contractures may be tolerated however your fingers can be straightened if it’s severe. What are the indications for surgery in Dupuytren’s contraction?
* Up to 30 degree of contracture can be tolerated at the MCP before considering surgery
* PIPJ involvement is an indication for surgery
* If contracture interfere with functioning, this is an indication for surgery
What are the two surgical options for the treatment of Dupuytren’s contracture?
Surgery involves
* Removal of the diseased tissue - fasciectomy
* or Division of the cords - fasciotomy
Recurrence common particular in the young
What is trigger finger and what causes it?
Trigger finger is a condition where one of your fingers is stuck in a locked, position (flexed posiition)
It occurs usually after tendonitis of a flexor tendon results in a nodular enlargement of the affected tendon which can catch causing locking of the finger
Annular (A1-A5) and cruciform (C0-C3) ligaments of the tendon sheath lie over the flexor tendons of the index finger of the hands. Behind which pulley is it common for a nodule that arises on a flexor tendon to get stuck behind causing trigger finger? How does the nodule end up getting stuck proximal to this pulley?
The nodule usually arises distal to the A1 pulley
Movement of the finger then produces a clicking sound as the nodule passes underneath the pulley and then gets stuck proximal to the A1 pulley locking the finger from extending
What symptoms does the patient typically complain of in trigger finger?
Patient typically complains of a clicking sensation as the nodule catches underneath the pulley
The sensation may be painful and the finger may lock in extension
The patient may have to forcibly manipulate the finger to regain extension and this also usually causes pain
Which fingers are most commonly involved in Dupuytrens’ contracture? Which fingers are most commonly involved in trigger finger?
In Dupuytren’’s contracture, most commonly the ring and little finger are involved
In trigger finger, most commonly the middle and ring finger are involved
What is the management of trigger finger in most cases?
In most cases injection of steroid around the tendon within the sheath will relieve symptoms.
What is the management of trigger finger should recurrent and persistent cases occur?
Surgery involving incision of the A1 pulley to allow the tendon to move can be tried in recurrent and persistent cases
Due to the system of other pulleys, division of the A1 pulley does not affect function.
Wear and tear arthritis in the small joints of the hand can be troublesome for patients particularly when performing intricate tasks. 80% of over 60s will have radiological evidence of OA in the hands but only a minority complaining of symptoms. What is the name for when OA affects the DIP and PIP joints?
OA affecting the DIP joints - Heberden’s nodes
OA affecting the PIP joints - Bouchard’s nodes
These joints will become swollen and painful
Are Heberden’s or Bouchard’s nodes more commonly seen in postmenopasual woman?
Hebderens nodes (DIP) are very commonly seen in postmenopausal woman
What may be required for treatment of interphalngeal joint involvement in OA if it is unable to be managed conservatively?
Arthrodesis may be required - fusion of the joint or
Arthroplasty may be required - total joint replacement however re-operation rates are high
Rarely OA can affect the metocarpalphalageal (MCPs) joints but there is usually specific cause for this. What are typical histories that may lead to OA of the MCP joints?
Previous injury
Occupational stress
Gout or infection
Surgical treatment is possible for arthritis at MCPs
What is the most commonly affected carpo-metacarpal joint? What can help treat an acute flare up? How can chronic pain here be treated?
Most commonly affected caprometacarpal joint is the 1st - the trapeziometacarpal joint at the base of the thumb
What can help treat an acute flare up of 1st carpometacarpal joint OA? How can chronic pain here be treated?
Intra-articular steroid injection can help an acute flare up
Excision athroplasty (trapeziectomy) or arthrodesis can cure chronic pain
The joints between the scaphoid, trapeziuma nd trapezoid (STT joint) can be affected by primary OA. How may this be treated for severe symptoms?
Selected fusion of the scaphoid, trapezium, trapezoid joint or wrist fusion may be used for severe symptoms
The hands are the site where rheumatoid arthritis seems to cause the greatest number of problems and is most visible Patients with longstanding disease will eventually develop deformed, painful and occasionally malfunctioning hands. Which joints tend to be spared in the hands by RA? - in contrast with OA and psoriatic arthritis
The distal interphalangeal joints (DIPs) tend to be spared in RA (therefore no Heberden’s nodes) in contrast with OA and psoriatic arthritis
Describe the natural history of disease in the hands in rheumatoid arthritis * It can be thought of as occurring in three stages
* Synovitis and tenosynovitis - inflammation of the synovial lining of the joints and the tendon sheath
* Erosions of the joints - inflammatory pannus denudes (strips) the joints of articular cartilage
* Joint instability and (extensor) tendon rupture - follows progressive destruction of bony and soft tissue structure in the hand
Thankfully the end stages of RA are becoming less and less common due to the introduction of modern disease modifying anti‐rheumatic drugs (DMARDs). Nonetheless, there is still a significant population of people who will exhibit hand deformities as a result of the disease. What are the different deformities of the hand that can be easily identified on clinical examination in rheumatoid arthritis?
Volar metacarpophalngeal joint (MCPJ) subluxation
Ulnar deviation of MCPJ
Swan neck deformity
Boutonniere deformity
Z-shaped thumb
Describe swan neck deformity
Describe Boutonniere deformity
Describe Z-shaped thumb
- Swan neck deformity - hyperextension at PIPJ with flexion at DIPJ
- Boutonniere deformity - flexion at PIPJ with hyperextension at DIPJ
- Z-shaped thumb - fixed flexion of MCP joint and hyperextension of interphalngeal joint
What treatment pay prevent extensor tendon to the wrist or fingers rupturing in rheumatoid arthritis?
Tenosynovectomy (excision of the synovial tendon sheath) may prevent extensor tendon rupture in rheumatoid
