Hand, Thumb, and Finger Conditions

Dupuytren's Contracture | Thumb Collateral Ligament Injury | Paronychia | Jammed Finger | References

Dupuytren's Contracture

Definition: Dupuytren's contracture is a condition in which the fascia of the palm thickens and shortens, leading to flexion contractures of the fingers, most commonly the ring and little fingers.

Aetiology: The exact cause is unknown, but it is believed to involve a combination of genetic, environmental, and lifestyle factors. It is more common in individuals of Northern European descent and may be associated with conditions such as diabetes and alcoholism.

Pathophysiology: The condition is characterised by the proliferation of myofibroblasts and the production of type III collagen in the palmar fascia, leading to nodule formation and thickened cords that cause the fingers to bend towards the palm.

Risk Factors: Family history, male gender, age over 40, diabetes, excessive alcohol consumption, and smoking.

Signs and Symptoms:

• Thickened nodules or cords in the palm, particularly over the fourth and fifth metacarpal bones.
• Flexion contractures of the fingers, making it difficult to fully extend the affected digits.
• Painless progression in the early stages, but may become painful as the contracture worsens.
• Difficulty performing tasks that require a full range of finger motion.

Investigations:

• Clinical Diagnosis: Based on history and physical examination, including the tabletop test (inability to lay the hand flat on a surface).
• Imaging: Ultrasound or MRI may be used in atypical cases to assess the extent of fascial involvement.

Management:

• Primary Care: Observation in mild cases with no functional impairment, patient education about the progressive nature of the condition, and referral to a hand specialist if contractures worsen.
• Specialist Care: Options include needle aponeurotomy, collagenase injections, or surgical fasciectomy for more severe cases. Postoperative physiotherapy is essential for regaining function.

Thumb Collateral Ligament Injury (Gamekeeper's Thumb, Skier's Thumb)

Definition: Thumb collateral ligament injury involves damage to the ulnar collateral ligament (UCL) of the thumb, commonly referred to as Gamekeeper's thumb or Skier's thumb. It results from a forceful abduction or hyperextension of the thumb.

Aetiology: Skier's thumb typically occurs due to acute trauma, such as a fall onto an outstretched hand while gripping a ski pole. Gamekeeper's thumb is a chronic condition seen in individuals who repetitively apply pressure to the thumb in a similar manner.

Pathophysiology: The UCL stabilises the thumb during pinching and gripping activities. Injury to the UCL leads to instability of the thumb's metacarpophalangeal (MCP) joint, resulting in pain, weakness, and difficulty gripping.

Risk Factors: Participation in sports or activities that involve gripping and a sudden force applied to the thumb, such as skiing or playing contact sports.

Signs and Symptoms:

• Pain and swelling on the ulnar side of the thumb, particularly around the MCP joint.
• Weakness in grip strength, especially during pinching or holding objects.
• Instability or a "loose" feeling in the thumb.
• Bruising and tenderness over the injured ligament.

Investigations:

• Clinical Diagnosis: Based on history and physical examination, including valgus stress testing of the thumb. Radiographs may be used to rule out associated fractures.
• MRI or Ultrasound: May be used to confirm the diagnosis and assess the extent of ligament damage.

Management:

• Primary Care: Immobilisation of the thumb in a thumb spica splint or cast for 4-6 weeks, NSAIDs for pain relief, and referral to a hand specialist for further evaluation if instability persists.
• Specialist Care: Surgical repair of the UCL may be necessary for complete tears or chronic instability. Postoperative physiotherapy is important to restore strength and function.

Paronychia

Definition: Paronychia is an infection of the skin surrounding the fingernail, typically caused by bacteria (acute paronychia) or fungi (chronic paronychia).

Aetiology: Acute paronychia is often caused by Staphylococcus aureus following minor trauma, such as nail-biting or manicures. Chronic paronychia is usually associated with Candida species and is more common in individuals with prolonged exposure to moisture.

Pathophysiology: Trauma to the nail fold allows pathogens to invade, leading to inflammation and infection. In chronic cases, repeated inflammation and infection can lead to thickening and retraction of the nail fold.

Risk Factors: Nail-biting, manicures, prolonged exposure to water, diabetes, and immunosuppression.

Signs and Symptoms:

• Redness, swelling, and tenderness around the nail fold.
• Pus formation, which may drain spontaneously in acute paronychia.
• Thickening of the nail fold and discolouration of the nail in chronic cases.
• Painful, throbbing sensation in the affected area.

Investigations:

• Clinical Diagnosis: Based on history and physical examination. In chronic cases, nail clippings or swabs may be taken for fungal culture.
• Imaging: Rarely needed, but may be considered if osteomyelitis (bone infection) is suspected.

Management:

• Primary Care: Warm soaks to relieve pain, topical or oral antibiotics for bacterial infection, and antifungal agents for chronic paronychia. Incision and drainage may be necessary if an abscess is present.
• Specialist Care: Referral to dermatology or surgery for persistent or complicated cases. Nail removal may be considered in severe cases of chronic paronychia.

Jammed Finger

Definition: A jammed finger occurs when the tip of a finger is forcefully compressed or hyperextended, causing injury to the ligaments, tendons, or bones within the finger joint.

Aetiology: Typically caused by a direct blow to the tip of the finger, often during sports or accidents, leading to hyperextension or compression of the finger joint.

Pathophysiology: The injury can result in damage to the ligaments (sprain), tendons, or even small fractures within the finger. The severity of the injury can vary from mild ligament sprains to more severe injuries involving fractures or dislocations.

Risk Factors: Participation in contact sports, activities that involve catching or hitting a ball, and previous finger injuries.

Signs and Symptoms:

• Pain and swelling around the affected joint.
• Bruising or discolouration of the finger.
• Stiffness and difficulty moving the finger.
• In more severe cases, visible deformity or dislocation of the joint.

Investigations:

• Clinical Diagnosis: Based on history and physical examination. The joint may be tender, swollen, and painful to move.
• X-rays: Indicated if there is suspicion of a fracture or dislocation to assess the extent of the injury.

Management:

• Primary Care: Immediate application of ice to reduce swelling, buddy taping the injured finger to an adjacent finger for support, and use of NSAIDs for pain relief. Rest and avoidance of activities that could aggravate the injury are recommended.
• Specialist Care: Referral to orthopaedics or a hand specialist may be required if there is a fracture, dislocation, or significant ligament injury. Surgical intervention may be necessary for severe cases.

References

1. NHS (2024) Hand and Finger Injuries: Diagnosis and Management. Available at: https://www.nhs.uk/conditions/hand-injuries/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Hand Conditions: Assessment and Management. Available at: https://cks.nice.org.uk/topics/hand-conditions/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Management of Hand and Finger Conditions. Available at: https://www.bmj.com/content/350/bmj.h4600 (Accessed: 24 June 2024).
4. American Academy of Orthopaedic Surgeons (2024) Thumb and Finger Injuries: Causes, Symptoms, and Treatments. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/thumb-and-finger-injuries/ (Accessed: 24 June 2024).

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