Theme: Hand disorders

A. de Quervain's tenosynovitis
B. Dupuytren's contracture
C. Bouchard's nodes
D. Ganglion
E. Carpal tunnel syndrome
F. Radial nerve injury
G. Ulnar nerve injury
H. Heberden's nodes
I. Tendon sheath infection

Please select the most likely diagnosis to account for the scenario given. Each option
may be used once, more than once or not at all.

1. A 49 -year-old male presents with discomfort in the fingers of his left hand. On
examination the ring and little fingers of his left hand are flexed and unable to
extend completely. He is able to make a fist with the hand. Palpation reveals
thickened nodules on the medial half of the palm.

Dupuytren's contracture

Discomfort of the hand is not uncommon in Dupuytrens contracture, true pain

is unusual. The disease most commonly affects the ring and little fingers.

2. A 62 year old man presents after his wife commented on the unusual shape of
his fingers. On examination he has a hard swelling adjacent to the distal
interphalangeal joint of his right hand with lateral deviation of the finger tip.
There is no sensory disturbance and the swelling is not tender

Heberden's nodes

These are bony outgrowths that occur in the distal interphalangeal joint in
association with osteoarthritis. They may skew the finger tip sideways.
Bouchards nodes are similar but occur in association with the proximal
interphalangeal joint.

3. A 57 year - old lady presents with a three month history of pins and needles in
the fingers of the right hand, particularly at night. On examination, there is
some loss of the sensation over the palmar aspect of the lateral three fingers and
wasting of the thenar eminence.
 Carpal tunnel syndrome

Carpal tunnel syndrome commonly produces pain at night as the wrists are
flexed during sleep. Compromise of the median nerve may produce wasting of
the thenar eminence muscles.

Hand diseases

Dupuytrens contracture

 Fixed flexion contracture of the hand where the fingers bend towards the palm
and cannot be fully extended.
 Caused by underlying contractures of the palmar aponeurosis . The ring finger
and little finger are the fingers most commonly affected. The middle finger
may be affected in advanced cases, but the index finger and the thumb are
nearly always spared.
 Progresses slowly and is usually painless. In patients with this condition, the
tissues under the skin on the palm of the hand thicken and shorten so that the
tendons connected to the fingers cannot move freely. The palmar aponeurosis
becomes hyperplastic and undergoes contracture.
 Commonest in males over 40 years of age.
 Association with liver cirrhosis and alcoholism. However, many cases are
idiopathic.
 Treatment is surgical and involves fasciectomy. However, the condition may
recur and many surgical therapies are associated with risk of neurovascular
damage to the digital nerves and arteries.

Carpel tunnel syndrome

 Idiopathic median neuropathy at the carpal tunnel.

 Characterised by altered sensation of the lateral 3 fingers.
 The condition is commoner in females and is associated with other connective
tissue disorders such as rheumatoid disease. It may also occur following
trauma to the distal radius.
 Symptoms occur mainly at night in early stages of the condition.
 Examination may demonstrate wasting of the muscles of the thenar eminence
and symptoms may be reproduced by Tinels test (compression of the contents
of the carpal tunnel).
 Formal diagnosis is usually made by electrophysiological studies.
 Treatment is by surgical decompression of the carpal tunnel, a procedure
achieved by division of the flexor retinaculum. Non - surgical options include
splinting and bracing.

Miscellaneous hand lumps

Osler's Osler's nodes are painful, red, raised lesions found on the hands and feet.
nodes They are the result of the deposition of immune complexes.
Bouchards Hard, bony outgrowths or gelatinous cysts on the proximal
nodes interphalangeal joints (the middle joints of fingers or toes.) They are a
sign of osteoarthritis, and are caused by formation of calcific spurs of the
articular cartilage.
Heberdens Typically develop in middle age, beginning either with a chronic
nodes swelling of the affected joints or the sudden painful onset of redness,
numbness, and loss of manual dexterity. This initial inflammation and
pain eventually subsides, and the patient is left with a permanent bony
outgrowth that often skews the fingertip sideways.
Ganglion Swelling in association with a tendon sheath commonly near a joint.
They are common lesions in the wrist and hand. Usually they are
asymptomatic and cause little in the way of functional compromise.
They are fluid filled although the fluid is similar to synovial fluid it is
slightly more viscous. When the cysts are troublesome they may be
excised.
Theme: Hand disorders

A. Malignant fibrous histiocytoma

B. Oslers nodes
C. Heberdens nodes
D. Bouchards nodes
E. Carpal tunnel syndrome
F. Complex regional pain syndrome
G. Osteoclastoma
H. Osteosarcoma
I. Ganglion

Please select the most likely diagnosis for the lesion described. Each option may be
used once, more than once or not at all.

4. A 42 year old lady who has systemic lupus erythematosus presents to the clinic
with a 5 day history of a painful purple lesion on her index finger. On
examination she has a tender red lesion on the index finger.

Oslers nodes

Osler nodes are normally described as tender, purple/red raised lesions with a
pale centre. These lesions occur as a result of immune complex deposition.
These occur most often in association with endocarditis. However, other causes
include SLE, gonorrhoea, typhoid and haemolytic anaemia.
5. A 62 year old lady presents with an non tender lump overlying the distal
interphalangeal joint of the index finger. On examination she has a hard, non
tender lump overlying the joint and deviation of the tip of the finger.

Heberdens nodes

Heberdens nodes may produce swelling of the distal interphalangeal joint with
deviation of the finger tip.

6. A 17 year old body is brought to the clinic by his mother who is concerned
about a lesion that has developed on the dorsal surface of his left hand. On
examination he has a soft fluctuant swelling on the dorsal aspect of the hand, it
is most obvious on making a fist.

Ganglion

Ganglions commonly occur in the hand and are usually associated with
tendons. They are typically soft and fluctuant. They do not require removal
unless they are atypical or causing symptoms.

Hand diseases

Dupuytrens contracture

 Fixed flexion contracture of the hand where the fingers bend towards the palm
and cannot be fully extended.
 Caused by underlying contractures of the palmar aponeurosis . The ring finger
and little finger are the fingers most commonly affected. The middle finger
may be affected in advanced cases, but the index finger and the thumb are
nearly always spared.
 Progresses slowly and is usually painless. In patients with this condition, the
tissues under the skin on the palm of the hand thicken and shorten so that the
tendons connected to the fingers cannot move freely. The palmar aponeurosis
becomes hyperplastic and undergoes contracture.
 Commonest in males over 40 years of age.
 Association with liver cirrhosis and alcoholism. However, many cases are
idiopathic.
 Treatment is surgical and involves fasciectomy. However, the condition may
recur and many surgical therapies are associated with risk of neurovascular
damage to the digital nerves and arteries.

Carpel tunnel syndrome

  Idiopathic median neuropathy at the carpal tunnel.
 Characterised by altered sensation of the lateral 3 fingers.
 The condition is commoner in females and is associated with other connective
tissue disorders such as rheumatoid disease. It may also occur following
trauma to the distal radius.
 Symptoms occur mainly at night in early stages of the condition.
 Examination may demonstrate wasting of the muscles of the thenar eminence
and symptoms may be reproduced by Tinels test (compression of the contents
of the carpal tunnel).
 Formal diagnosis is usually made by electrophysiological studies.
 Treatment is by surgical decompression of the carpal tunnel, a procedure
achieved by division of the flexor retinaculum. Non - surgical options include
splinting and bracing.

Miscellaneous hand lumps

Osler's Osler's nodes are painful, red, raised lesions found on the hands and feet.
nodes They are the result of the deposition of immune complexes.
Bouchards Hard, bony outgrowths or gelatinous cysts on the proximal
nodes interphalangeal joints (the middle joints of fingers or toes.) They are a
sign of osteoarthritis, and are caused by formation of calcific spurs of the
articular cartilage.
Heberdens Typically develop in middle age, beginning either with a chronic
nodes swelling of the affected joints or the sudden painful onset of redness,
numbness, and loss of manual dexterity. This initial inflammation and
pain eventually subsides, and the patient is left with a permanent bony
outgrowth that often skews the fingertip sideways.
Ganglion Swelling in association with a tendon sheath commonly near a joint.
They are common lesions in the wrist and hand. Usually they are
asymptomatic and cause little in the way of functional compromise.
They are fluid filled although the fluid is similar to synovial fluid it is
slightly more viscous. When the cysts are troublesome they may be
excised.