° Question 1 of 10 ¥ B © A.63 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. What is the underlying diagnosis? Radial nerve injury Ulnar nerve injury Psychosomatic illness Wrist arthritis 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. @ | | Improve 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 cirthosis 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. Carpal 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, procedure achieved by division of the flexor retinaculum. Non - surgical options include splinting and bracing, Miscellaneous hand lumps Osler's nodes Bouchard's nodes Heberde'ns nodes Ganglion Osler’s nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes. Hard, bony outgrowths or gelatinous cysts on the proximal 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. ‘Typically develop in middle age, beginning either with a chronic 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. It typically affects the DIP joint. ‘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 Its slightly more viscous. When the cysts are troublesome they may be excised Blea@W:+ #2. Tr & @ @ Save my notes ‘Search ‘Search textbook ‘Q Google search on “Hand diseases’ Suggest lnk + Suggest media° Question 2 of 10 ¥ Bp © ‘A 42 year old skier falls and impacts his hand on his ski pole. On examination, he is tender in the anatomical snuffbox and on bimanual palpation. X-rays with scaphoid views show no evidence of fracture. What is the most appropriate course of action? Admission and surgical debridement Application of tubigrip bandage and fracture clinic review Admission for open reduction and fixation Discharge with reassurance {A fracture may still be present and should be immobilised until repeat imaging can be performed. If clinical suspicion persists then subsequent imaging should be with MRI scanning or CT if MRI Is contra-indicated. wo @ | Improve Scaphoid fractures * * Incidence of scaphoid fractures in UK ranges from 12.4 per 100,000 to 29 per 100,000 * Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) + Forms floor of anatomical snuffbox * Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third) + Aseries of 4 scaphoid radiographs should be undertaken (PA, pronated oblique, Ziter view and lateral view). The Ziter view is a PA view with the wrist in ulnar deviation and beam angulated at 20 degrees + Sensitivity of scaphold radiographs in 1st week of injury Is 80% + Immobilization of scaphoid fractures difficult * Repeat imaging should be done at 10 days. MRI should be done in cases of diagnostic uncertainty Classification of scaphoid fractures Scaphoid tubercle Distal pole Waist Proximal pole Management Undisplaced fractures of the waist of the scaphoid and most distal pole fractures can be‘managed in a cast for 6 weeks with high rates of union, Displaced scaphold waist fractures (more than 1-2mm) should be viewed as unstable and surgically fixed. Al proximal pole fractures should be fixed surgically. Complications + Non union of scaphoid ‘+ Avascular necrosis of the scaphoid ‘+ Scapholunate disruption and wrist collapse + Degenerative changes of the adjacent joint Reference Berber O et al. Fractures of the scaphold. BMJ 2020 (369): 414-416. [save ots Search Search textbook B ‘Q Google search on *Scaphoid fractures" Suggest lnk ‘FSuggest media Dashboard wervanrxona 4448200604006 éQe Question 3 of 10 v p Oo ‘A 62 year old lady presents with a non tender lump overiying 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. What is the nature of the lesion? Oslers nodes Bouchards nodes Osteosarcoma Infective collection Heberdens nodes may produce swelling of the distal interphalangeal joint with deviation of the finger tip. | @ | Improve 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 cirthosis 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. Carpal 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. They nodes are the result of the deposition of immune complexes. Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal nodes 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. Heberde'ns Typically develop in middle age, beginning elther with a chronic swelling of the nodes 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. It typically affects the DIP joint. 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 itis slightly more viscous. When the cysts are troublesome they may be excised Save my notes Search Search textbook B Q Google search on "Hand diseases" + Suggest nk Suggest mediaVW Question 4.09 10 bl a 7 ‘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. What is the diagnosis? Heberdens nodes a Bouchards nodes @ Malignant fibrous histiocytoma Osteoclastoma e 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. sé | | Improve 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 cirthosis and alcoholism. However, many cases are idiopathic. * Treatment is surgical and involves fasclectomy. However, the condition may recur and ‘many surgical therapies are associated with risk of neurovascular damage to the digital nerves and arteries. Carpal 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 nodes Bouchard's nodes Heberde'ns nodes Ganglion Save my notes Search Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes. Hard, bony outgrowths or gelatinous cysts on the proximal 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. Typically develop in middle age, beginning either with a chronic 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. It typically affects the DIP joint. ‘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 itis slightly more viscous. When the cysts are troublesome they may be excised, Tr @ @ @ Search textbook. ‘Q Google search on"Hand diseases" + Suggest lnk + suggest mediavy Question Sof 10 - = Zs ‘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 index finger of the right hand with lateral deviation of the finger tip. There is no sensory disturbance and the swelling Is not tender. Which pathological process underpins the underlying diagnosis? Rheumatold arthritis Q@ a = Infection with atypical organisms eQ Deposition of immune complexes Malignancy eo The description fits with Heberdens 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 affect the proximal interphalangeal joint. [« @ | improve 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. Carpal 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. They nodes are the result of the deposition of immune complexes. Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal nodes 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. Heberdeins Typically develop in middle age, beginning either with a chronic swelling of the nodes 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. It typically affects the DIP joint. 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 itis slightly more viscous. When the cysts are troublesome they may be excised, Bireu- = Tr &- @ © Save my notes Search Search textbook Go ‘Q Google search on "Hand diseases" Suggest lnk ‘Fuggest media°e Question 6 of 10 ¥ B o 82 year old male presents with discomfort in the fingers of his left hand. On examination, the ring and litle 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, What Is the most likely diagnosis? de Quervain's tenosynovitis, Tendon sheath infection Ganglion Heberden's nodes Discomfort of the hand is not uncommon in Dupuytren's contracture, true pain is unusual. The disease most commonly affects the ring and little fingers. [ot | | improve 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 Carpal 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 theumatoid 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 nodes Bouchard's nodes Heberde'ns nodes Ganglion Save my notes Search ‘Search textbook Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes. Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal Joints (the middie joints of fingers or toes.) They are a sign of osteoarthritis, ‘and are caused by formation of calcific spurs of the articular cartilage. Typically develop in middle age, beginning elther with a chronic 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. It typically affects the DIP joint. ‘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 itis slightly more viscous. When the cysts are troublesome they may be excised ‘Q Google search on Hand diseases’ “+ Suggest tink + uggest media° Question 7 of 10 x B 6 ‘43 year old man falls over landing on his left hand. Although there was anatomical snuffbox tenderness; no x-rays either at the time, or subsequently, have shown evidence of scaphoid fracture. He has been immobilised in a futura splint for two weeks and is now asymptomatic. What is the most appropriate course of action? Application of tubigrip bandage and fracture clinic review ‘Admission and surgical debridement Application of below elbow cast for 6 weeks This patient is at extremely low risk of having sustained a scaphold Injury and may be discharged. [2 [= [wor ] Scaphoid fractures * + Incidence of scaphoid fractures in UK ranges from 12.4 per 100,000 to 29 per 100,000 + Surface of scaphold Is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) ‘+ Forms floor of anatomical snuffoox + Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third) ‘+ Aseries of 4 scaphoid radiographs should be undertaken (PA, pronated oblique, Ziter view and lateral view). The Ziter view is a PA view with the wrist In ulnar deviation and beam angulated at 20 degrees * Sensitivity of scaphoid radiographs in 1st week of injury is 80% + Immobilization of scaphoid fractures difficult + Repeat imaging should be done at 10 days. MRI should be done in cases of diagnostic uncertainty Classification of scaphoid fractures Scaphoid tubercle Distal pole Waist Proximal pole Management Undisplaced fractures of the waist of the scaphoid and most distal pole fractures can be‘managed in a cast for 6 weeks with high rates of union. Displaced scaphoid waist fractures (more than 1-2mm) should be viewed as unstable and surgically fixed, All proximal pole fractures should be fixed surgically. Complications + Non union of scaphoid + Avascular necrosis of the scaphoid ‘+ Scapholunate disruption and wrist collapse + Degenerative changes of the adjacent joint Reference Berber 0 et al. Fractures of the scaphoid. BMJ 2020 (369): 414-416, Tr @y @ | Save my notes Search Search textbook GB ‘Q Google search on "Scaphoid fractures’ “+ Suggest lnk Suggest media Dashboard weeavousena tA 4204 244488 3oe Question 8 of 10 v 8 ° 13 year old boy falls onto an outstretched hand and is brought to the emergency department. He is examined by a doctor and a bony injury is cleared clinically. He re-presents a week later with ain in his hand. What is the most likely underlying injury? Fracture of the distal radius Dislocation of the lunate Rupture of flexor pollicis longus tendon Bennett's fracture Scaphoid fractures in children are rare, will usually involve the distal pole and are easily missed. The initial clinical examination (and sometimes x-rays) may be normal and repeated clinical examination and imaging is advised for this reason. Whilst the other injuries may be sustained from a fall onto an outstretched hand they are less likely to be overlooked on clinical examination. In the case of a Bennetts fracture, the injury mechanism is less compatible with this type of injury. @ | | Improve Scaphoid fractures * * Incidence of scaphoid fractures in UK ranges from 12.4 per 100,000 to 29 per 100,000 * Surface of scaphold is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) * Forms floor of anatomical snuffbox * Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal third) * A series of 4 scaphoid radiographs should be undertaken (PA, pronated oblique, Ziter view and lateral view). The Ziter view is a PA view with the wrist in ulnar deviation and beam angulated at 20 degrees + Sensitivity of scaphoid radiographs in 1st week of injury is 80% + Immobilization of scaphoid fractures difficult ‘+ Repeat imaging should be done at 10 days. MRI should be done in cases of diagnostic uncertainty Classification of scaphoid fractures Scaphoid tubercle Distal pole Waist Proximal poleManagement Undisplaced fractures of the waist of the scaphoid and most distal pole fractures can be managed in a cast for 6 weeks with high rates of union. Displaced scaphoid waist fractures (more than 1-2mrm) should be viewed as unstable and surgically fixed. All proximal pole fractures should be fixed surgically. Complications ‘+ Non union of scaphoid ‘+ Avascular necrosis of the scaphoid ‘+ Scapholunate disruption and wrist collapse * Degenerative changes of the adjacent joint Reference Berber O et al. Fractures of the scaphoid. 8MJ 2020 (369): 414-416. Reve f° Tr & Boe Save my notes ‘Search exch erbook oO Q Google search on "Scaphoid fractures’ # Suggest nk suggest media Dashboard CK OKSVw Question 9 of 10 + e wy ‘A.17 year old boy 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. What is the nature of the lesion? Osteosarcoma Malignant fibrous histiocytoma Bouchards nodes Oslers nodes 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. | | imorove | 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 cltrhosis and alcoholism. However, many cases are idiopathic. ‘+ Treatment is surgical and involves fasciectomy. However, the condition may recur and ‘many surgical therapies ate associated with risk of neurovascular damage to the digital nerves and arteries Carpal 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. They nodes are the result of the deposition of immune complexes. Bouchard's Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal nodes 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. Heberde’ns Typically develop in middle age, beginning either with a chronic swelling of the nodes 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. It typically affects the DIP joint. 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 itis slightly more viscous. When the cysts are troublesome they may be excised Search Search textbook. o ‘Q Google search on "Hand diseases" + Suggest lnk Suggest media°o Question 10 of 10, ¥ 5 © ‘A25 year old man is diagnosed as having an undisplaced fracture of the proximal pole of the scaphoid, What is the best course of action? immobilisation in future splint for 5 weeks ‘Arrange an MRI scan Immobllisation in plaster cast for 4 weeks Initial immbolisation in plaster cast for 2 weeks with check radiographs at that stage It is generally accepted that proximal pole fractures of the scaphoid should be surgically fixed as non union rates of up to 34% can be seen when cast immobilization alone is attempted. vt | | imorove | Scaphoid fractures * ‘+ Incidence of scaphold fractures In UK ranges from 12.4 per 100,000 to 29 per 100,000 ‘+ Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply) ‘+ Forms floor of anatomical snuffbox ‘+ Risk of fracture associated with fall onto outstretched hand (tubercle, walst, or proximal third) + Aseries of 4 scaphoid radiographs should be undertaken (PA, pronated oblique, Ziter view and lateral view), The Ziter view is a PA view with the wrist in ulnar deviation and beam. angulated at 20 degrees ‘+ Sensitivity of scaphoid radiographs in 1st week of injury is 80% + Immobilization of scaphoid fractures difficult ‘+ Repeat imaging should be done at 10 days. MRI should be done in cases of diagnostic uncertainty Classification of scaphoid fractures Scaphoid tubercle Distal pole Waist Proximal pole Management Undisplaced fractures of the walst of the scaphoid and most distal pole fractures can be ‘managed in a cast for 6 weeks with high rates of union. Displaced scaphoid waist fractures (more than 1-2mm) should be viewed as unstable and surgically fixed.All proximal pole fractures should be fixed surgically. Complications + Non union of scaphoid * Avascular necrosis of the scaphoid * Scapholunate disruption and wrist collapse + Degenerative changes of the adjacent joint Reference Berber 0 et al. Fractures of the scaphoid. BMJ 2020 (369): 414-416. Blea we Tr & @ @ Save my notes ‘Seaman CanscanerEMRCS 2021 EDITED BY OMER KAMAL AHMED A SUDANESE MEDICAL OFFICER AT ALGAZIRA CENTER FOT ORTHOPEDIC AND TRAUMA coobLugKV\ER K AHMET Wit tery tl