Orthopaedic problems of the hand

dupuytrens affects who most likely

M>F 15-64s

M>F over 75s

northern european descent

what is dupuytren’s disease

thickening of the palmar fascia

autosomal dominant - variable penetrance

associations of dupuytrens disease

diabetes

alcohol

tobacco

HIV

epilepsy

dupuytrens diathesis

more aggressive dupuytren’s

•Early onset disease

•Bilateral disease

•Family History

•Ectopic disease

functional problems of dupuytrens disease

•Usually not painful

•Loss of finger extension – active or passive

•Hand in pocket

•Gripping things

•Washing face

dupuytren’s disease treatment

non operative:

•Observe

•Radiotherapy

operative:

•Partial fasciectomy

•Dermo-fasciectomy

•Arthrodesis

•Amputation

•Percutaneous Needle Fasciotomy

•Collagenase

what treatment doesn’t work for dupuytrens

splints

what is percutaneous needle fasciotomy better for in duputren’s disease

metacarpophalangeal joint

-risk of nerve injury

myofibroblasts - dupuytren’s contracture

myofibroblast

-found in nodules

•Intracellular contractile elements (actin & myosin)

•Regulated by growth factors

•Production of collagen

-found in high concentrations within the active, "nodular" phase of the disease

-key contractile cells driving the development of Dupuytren's contracture, particularly within the proliferative nodules grant increased contractile strength.

trigger finger anatomy

•2 tendons to each finger

•Tendons run in sheath

•Thickenings in sheath = pulley

•Keep tendon close to bone

•Swelling in tendon catches on pulley

who gets trigger finger

women > men

40s-60s

those who use their hand repetitively

which finger more affected in trigger finger

ring > thumb > middle

associations of trigger finger

rheumatoid arthritis

diabetes mellitus

gout

diagnosis of trigger finger

•Clicking sensation with movement of digit

‘Clicking’ may progress to ‘locking’

•May have to use other hand to ‘unlock’

•Palpable lump in palm over first annular (A1) pulley

•Feel the triggering around the A1-pulley

trigger finger treatment

non operative:

splintage

corticosteroid injections

operative:

percutaneous release

open surgery

De Quervain’s Tenosynovitis

•1st dorsal extensor compartment

•Fibro-osseous tunnel at the distal radius

•Thickening of localised segment

•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

who’s affected more in de quervain’s syndrome

women > men

50s-60s

•Increased in post partum and lactating females

•Activities with frequent thumb abduction and ulnar deviation

where should you examine in de quervain’s syndrome

thumb joints

-consider base of thumb osteoarthritis

finklestein’s test

resisted thumb extension

treatment of de quervain’s syndrome

non operative:

•Splints

•Steroid injection

operative:

decompression of the first doral compartment

carpal tunnel syndrome

nerve entrapment of median nerve

cubital tunnel syndrome

nerve entrapment of ulnar nerve

treatment for nerve entrpaments

splint

steroid injections

release flexor retinaculum (carpal tunnel syndrome)

release flexor carpi ulnaris fascia (cubital tunnel syndrome)

what study can you do for nerve entrapments

nerve conduction studies

ganglion

fluid filled lump under the skin

arises from joint capsule, tendon sheath or ligament

where is ganglia mostly found

in the hand and wrist

posterior hand > front of hand

who is most likely to get ganglia

females

20-40yrs

may be associated with recurrent injury around wrist

diagnosis of ganglia

•Present with lump

•Firm, non-tender

•Change in size

•Smooth

•Occasionally lobulated (small rounded sections)

•Normally fixed to underlying tissues

•Never fixed to the skin

treatment of ganglia

•Non-operative

•Reassure & Observe

•Aspiration

•Operative

•Excision - Requires removing the ganglion along with its "root" or attachment to the joint capsule to prevent recurrence.

osteoarthritis base of the thumb

•Pain

•Stiffness

•Swelling

•Deformity

•Loss of function

•Pain opening jars / pinching

•Dorsal subluxation, metacarpal adduction, MCPJ hyperextension

•Look for Scaphoid Trapezium or Trapezoid OA

treatment of osteoarthritis at base of thumb

Non Operative

•Life style modifications

•NSAIDS

•Splint

•Steroid Injection

Operative

•Trapeziectomy

•Fusion

•Replacement

gold standard for base of thumb osteoarthritis

trapeziectomy

-good pain relief

-moderate pinch grip

+- interposition flap or ligament reconstruction