Upper Limb - hand

Question 1

What is Dupuytren’s contracture?

Answer 1

Fixed flexion contracture of the fingers, where
(1) The fingers bend towards the palm

(2) cannot be fully extended

(3) is caused by contractures of the palmar aponeurosis
(triangle in the middle of the hand/ palm)

Question 2

Which fingers are most commonly affected in Dupuytren’s contracture?

Answer 2

1. The ring finger and little finger are most commonly affected
2. The middle finger may be involved in advanced cases, but the index finger and thumb are nearly always spared

Question 3

What is the primary cause of Dupuytren’s contracture?

Answer 3

Contracture of the palmar aponeurosis due to excessive proliferation of myofibroblasts and altered collagen composition

= leading to thickening and shortening of the fascia

Question 4

What is the most common age group affected by Dupuytren’s contracture?

Answer 4

males over 40 years of age

Question 5

How does Dupuytren’s contracture typically present?

Answer 5

It usually presents as a
1. painless
2. gradual progression
3. starting with a palmar nodule or pit

4. followed by flexion contracture
5. commonly affecting the 4th and 5th fingers

Question 6

What is the “table-top test” used for in Dupuytren’s contracture?

Answer 6

Checks for the inability to flatten the palm against a surface, which is due to the contractures in the metacarpophalangeal joints

Question 7

What is the most common form of surgical management for Dupuytren’s contracture?

Answer 7

Needle fasciotomy is used for single-band contractures, while limited fasciectomy involves the removal of the thickened bands

For severe cases, dermo fasciectomy with grafting may be performed

Question 8

What type of collagen is primarily involved in Dupuytren’s contracture?

Answer 8

collagen type III

Question 9

A 55-year old man presents to his GP complaining that he is unable to straighten his right ring finger. It bothers him whenever he tries to put on his gardening gloves as his finger tends to get caught. There is no associated pain or numbness and no history of trauma. He has a past medical history of type 2 diabetes controlled with metformin

On examination, his right ring finger was held at approximately 45 degrees of flexion at the metacarpophalangeal joint with a painless cord-like structure palpable on the palmar surface of the hand. The GP suspects this is a Dupuytren’s contracture

What is the earliest sign seen in the development of Dupuytren’s contracture?

Answer 9

Palmar nodule

Question 10

What is a Boxer’s fracture?

Answer 10

Fracture of the 5th metacarpal neck

= caused by striking a hard object with a clenched fist

Question 11

What is the common cause of a Boxer’s fracture?

Answer 11

It is commonly caused by punching a wall or another hard object with a clenched fist

Question 12

What are the main symptoms of a Boxer’s fracture?

Answer 12

1. dorsal hand pain
2. swelling
3. possible deformity of the hand

Question 13

Which fingers are most commonly affected by a Boxer’s fracture?

Answer 13

The 4th or 5th metacarpals are most commonly affected

Question 14

What signs are typically seen in a Boxer’s fracture?

Answer 14

1. Minimal displacement
2. no rotation
3. anterior displacement of the distal part of the fracture

= leading to shortening of the affected finger

Question 15

What is the main management approach for a Boxer’s fracture?

Answer 15

ulnar gutter splint

Question 16

What does the ‘buddy strap’ do in Boxer’s fracture management?

Answer 16

To bind the injured finger to the adjacent finger for support and stability

Question 17

A 19-year-old male presents to the emergency department with pain in his left hand after punching a wall with his bare fist. On examination, he is in pain. The skin appears mildly bruised but he has normal sensation and pulses

A radiograph confirms the presence of an undisplaced, non-comminuted Boxer’s fracture

What is the first-line definitive treatment?

Answer 17

Ulnar gutter splint

Question 18

A 25-year-old man presents to the emergency department with pain and swelling in his hand after punching a wall. Physical examination reveals tenderness and deformity over the fifth metacarpal. An X-ray confirms an isolated, non-angulated fifth metacarpal fracture with articular involvement

Given the most likely diagnosis, what is the most appropriate treatment?

Answer 18

Surgical intervention because theres articular involvement

Question 19

What are the common symptoms of Bennett’s fracture?

Answer 19

acute pain at the base of the thumb

Question 20

What is the most common cause of Bennett’s fracture?

Answer 20

It is usually caused by an axial force applied to the thumb in flexion
= eg, fist fights

Question 21

What is a Bennett’s fracture?

Answer 21

Fracture of the 1st metacarpal base caused by forced hyperabduction of the thumb

= Is a Intra-articular fracture at the base of the thumb metacarpal

Question 22

What is the pathophysiology of Bennett’s fracture?

Answer 22

The fracture may extend into the first carpometacarpal (CMC) joint

= causing instability and subluxation, which often requires surgical repair

Question 23

What happens to the volar beak ligament in Bennett’s fracture?

Answer 23

A small bony fragment often remains attached to the volar beak ligament of the CMC joint

Question 24

Explain what the volar beak ligament is and how this relates to a Bennett fracture

Answer 24

(1) A strong ligament that connects the base of the 1st metacarpal to the trapezium bone. Also called the anterior oblique ligament.

(2) It stabilises the thumb carpometacarpal (CMC) joint = the base joint of the thumb

(3) A Bennett fracture occurs at the base of the 1st metacarpal, extending into the joint

(4) The volar beak ligament remains attached to the small volar fragment of the metacarpal. Meanwhile, the rest of the metacarpal is pulled dorsally and laterally by the abductor pollicis longus muscle

(5) In a Bennett’s fracture, the base of the 1st metacarpal bone breaks into two parts:

A. A small fragment that stays attached to the wrist bone (trapezium) because the volar beak ligament is still holding it in place

B. The rest of the metacarpal is pulled out of position by muscles

Question 25

What is the common surgical treatment for Bennett’s fracture?

Answer 25

The thumb is surgically reduced onto the bony fragment and fixed, commonly with K wires

Question 26

What is Trigger Finger?

Answer 26

Trigger finger is a condition where the tendon becomes 'stuck' and cannot pass smoothly through the pulley, causing abnormal flexion of the digits

Question 27

Explain what a "pulley" is regarding trigger finger

Answer 27

(1) In your fingers, the tendons that help you bend them (flexor tendons) run through a series of fibrous rings called pulleys (2) A1 pulley = The one most commonly involved in trigger finger. It's located in the palm, near the MCP joint (knuckle) (3) The tendon sheath or pulley (usually A1) becomes thickened or inflamed. The tendon can no longer glide smoothly. (4) This causes catching or locking of the finger in a bent position, like it's "triggering" (5) Pulley = a fibrous ring that guides the tendon along the bone

Question 28

What are the common associations with Trigger Finger?

Answer 28

often idiopathic, but is also associated with rheumatoid arthritis and diabetes mellitus

Question 29

In which fingers is the Trigger Finger most commonly seen?

Answer 29

thumb, middle, or ring fingers

Question 30

What are the initial symptoms of Trigger Finger?

Answer 30

Initially, there is (1) stiffness (2) snapping ('trigger') (3) when extending a flexed digit (4) a nodule may be felt at the base of the affected finger Pain over A1 pulley (MC head), may need other fingers to help extend or may not extend at all

Question 31

What is the first-line management for Trigger Finger?

Answer 31

steroid injections = a finger splint may be applied afterwards too

Question 32

When should surgery be considered for Trigger Finger?

Answer 32

not responded to steroids

Question 33

A 64-year-old woman who is known to have rheumatoid arthritis presents with pain in her right ring finger when she flexes it. On one occasion she reports it became 'stuck'. Clinical examination is unremarkable other than a palpable nodule at the base of the finger What is the most likely diagnosis?

Answer 33

Trigger finger

Question 34

How can you differentiate Trigger Finger from Dupuytren’s Contracture?

Answer 34

In Trigger Finger, when you pull the finger out, it will straighten. In Dupuytren’s Contracture, the finger will not straighten

Question 35

Main actions for the radial nerve

Answer 35

1. Extension of the elbow, wrist, fingers, and thumb

Question 36

Main actions for the median nerve

Answer 36

1. Thumb opposition, thumb abduction, thumb flexion (thenar muscles) 2. Flexion of the wrist, index, and middle fingers

Question 37

Main actions for the ulnar nerve

Answer 37

1. Finger abduction & adduction 2. Flexion of ring and little fingers 3. Thumb adduction (adductor pollicis)

Question 38

Main actions for the musculocutaneous nerve

Answer 38

1. Elbow flexion 2. Forearm supination

Question 39

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 can make a fist with his hand. Palpation reveals thickened nodules on the medial half of the palm

Answer 39

Discomfort of the hand is not uncommon in Dupuytrens contracture, true pain is unusual. The disease most commonly affects the ring and little fingers