The Hand Patient

TheHandPatient
A Selection
of GaseStudies
for OuickReference
Havinghad the pleasureto teach and train students for many years,andthe privilegeofhaving patients referred to
me by ex-student General Practitioners,one realizesthat medical school training can only impart but a general
overview of knowledge.lt is impossibleand unfair to expect of any medical student to "know it all".
For this reason continuing medical education,or Continuing ProfessionalDevelopment (CPD) as it is now known
in South Africa, is imperative.
This post-graduatetraining should however, be presented in such a way that the busy practitioner readily has
accessto the relevant information in a succinct form and in an understandablejargon.
Communication between the referring doctor and the specialistshould not only include information regarding
that particular patient, but should also contain some informative detail on the pathology and management.
This continuing education is part of the responsibilitiesof a consultant specialist.
It is sincerelyhoped that this edited collection of selectedcasereports will promote a well-informedcommunication
between the practitioner and his/her "hand patient".
Mennen,U.
MBChB,FRCS(Glasg),FRCS(Edin),FCS(SA) Orth., MMed (Orth), MD (Ort) Pret
Head:DepartmentHand-and Microsurgery,
MEDUNSA
DeOuervain
Tenosynovitis
Stenosing
+ cm by * cm on the radialstyloid.With
percussionshe has localtendernessas
R E : Y O U RP A T I E N TW I T H P A I N l N
w e l l a s p i n s a n d n e e d l e si n t h e r a d i a l
T H E T H U M B A N D H A R D N O D U L E nerve distributionover the thumb and
O N T H E R A D I A LS I D EO F T H E W R I S T the first web space.This is the type of
painwhich she experiencesduring her
Thank you for the referral of Ms D Q,
daily activities. The pain is further
24 yearold right handeddata processor enhancedbygently pressingon the hard
who has been complainingof a painful nodule and requestingthe patient to
right thumb, inability to extend the
flex and extend her thumb. One could
thumb and a hard nodule on the radial c l e a r l y f e e l c r e p i t u s o f t h e t e n d o n s
side of her right wrist for the last 6
which run throughthe little nodule,i.e.
m o n t h s . T h i s c o n d i t i o n s t a r t e d t h e a b d u c t o r p o l l i c i sl o n g u sa n d t h e
s p o n t a n e o u s l yw i t h n o h i s t o r y o f
extensor pollicisbrevis.One could also
i n j u r y o r o v e r u s e . l t i m p i n g e so n h e r
feel the unevenness
ofthe tendon as it
work when she uses the keyboard moves in and out of the tunnel.
a n d h a s d i f f i c u l t y i n l i f t i n g h e a v y Clutchingthe thumb in the palm by the
o b j e c t s s u c h a s f i l e s . T h i n g st e n d t o
other fingers and gently forcing the
fall out of her hand.
wrist in ulnar deviation causesacute
pain. (Finkelsteintest).
On examination Ms Q shows no
neurovascularabnormalities in both
S i n c e t h e d i a g n o s i si s q u i t e c l e a r
local
hands. On
inspection,she has a
special investigations are not
definite tender hard swelling of about
necessary.
Dear Colleague
The diagnosis is a De Quervain's
stenosing tenosynovitis of the
a b d u c t o r p o l l i c i sl o n g u sa n d t h e
extensor pollicisbrevistendons.
The management
should be
conservativeinitially.SinceMs Q has
a clear synovitisin the tunnel,a local
injection with a steroid preparation
suchas Celestone/Soluspan
anda long
actinglocalanaestheticsuchas Macain
injected into the tunnel without
infiltrationof the tendons,wouldoften
clear the problem. One should also
support the thumb with a firm crepe
bandagefor about a week. Additional
non-steroidalanti-inflammatorydrugs
for 5 to 7 days may augment the
conservativemanagement.Shouldthe
i n j e c t i o n b e u n s u c c e s s f u ol ,n e m a y
considera second injection.This
should however,be done very carefully
lest the cortisone is injectedinto the
tendon.This may cause a future rup-
ture of the tendon. lf conservative
managementis not successfula surgical
r e l e a s ei s i n d i c a t e d . A 2 c m o b l i q u e
incisionis made carefullythrough the
skin only, taking great care not to
damagethe delicatesuperficialbranches
ofthe radialnerve. Shouldone ofthese
branchesbe injured,neuromaformation
is inevitable with very painful
c o n s e q u e n c e s .T h e s e b r a n c h e s a r e
carefullypushedasideuntil the nodule
and the APL and EPBtendons are
identified. The nodule is excisedand
the tunnelreleased.Invariably
one finds
many more than the two tendons.
Thesetendons may often run in at least
two tunnels. The variation should
carefully be explored and noted. The
great
skin is carefullyclosedagain,taking
care not to involvethe superficialradial
nervebranches.A volar splintis applied
supportingthe thumb in abductionfor
five daysonly.The patient is encouraged
to use the thumb after removalof the
s p l i n t . A s c a r m a s s a g ei s s t r o n g l y
advisedto preventadhesions.
injectionswith or without additional
non-steroidalanti-inflammatory drugs
a n d s p l i n t i n gf o r a f e w d a y s . O n e
o c c a s i o n a l l ys e e s a y o u n g n u r s i n g
mother with the samecondition.This
c l a s s i c a l ldy e s c r i b e da c a u s ef o r D e
Q u e r v a i n ' s d i s e a s ei s d u e t o t h e
DISCUSSION:
abductedposition of the thumb while
the mother supports the head of the
De Quervain stenosingtenosynovitis n u r s i n g b a b y . A g a i n c o n s e r v a t i v e
u s u a l l yo c c u r s i n t h e y o u n g f e m a l e . managementshould usuallysufficein
H o w e v e r , o n e f i n d s i t a s a n a c u t e the situation.The deferentialdiagnosis
occurringcondition in peoplewho are s h o u l d e x c l u d e s c a p h o i dp a t h o l o g y ,
not accustomedto a DIY job, such as scapho-radialosteo-arthritis,scaphoidt i l i n g t h e k i t c h e n f l o o r o v e r t h e trapezium-trapezoid(STT) osteow e e k e n d . T h e o v e r e x t e n d e d a n d arthrosis,osteo-arthrosisof the first
overused thumb presents with acute c a r p o - m e t a c a r p a lj o i n t s , a n d e v e n
teno-synovitis
without
the
scapho-lunateand lunate pathology.
characteristicnodule at the entrance Shouldtheseconditionsbe susDected,
of the tunnel. These patients usually plainradiographsof both handsshould
r e s p o n d v e r y w e l l t o c o r t i s o n e revealthe diagnosis.
De Quervain StenosingTenosynovitis
Thetenderandhardnoduleon the radialsideof the radiusstyloidprocessis usuallyindicative
of a cartilaginous
tunnelentrance.Surgicalexcisionaswell asa synovectomy
of the tendonsis indicated.Alwaysexplorefor
morethanone tunnel.