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Hand Examination (Deformities (RA ((Swan neck, Z-thumb, Ulnar deviation @…

- - - - Swan neck
      - Z-thumb
      - Ulnar deviation @ the MCPs
      - MCP volar subluxation
      - Boutonniere’s
- - - - Calcinosis and tophi
      - Ulceration
      - Ganglia
- - - - Ledderhose disease
        
        Fibrosis of plantar aponeurosis
        
        5% c¯ dupuytren’s
      - Retroperitoneal fibrosis
  - - - Fasciotomy
      - Partial fasciectomy
        
        Z-plasty to lengthen wound
        
        Post-op physio
        
        Can damage ulnar nerve
        
        Often recurs
      - Dermofasciectomy + full-thickness skin grafting
        Lowest risk of recurrence
      - Arthrodesis and amputation
- - - - Tingling / pain in thumb, index and middle fingers
      - Pain worse @ night or after repetitive actions
      - Relieved by shaking / flicking hand
  - - - Scar formation: high risk for hypertrophic or keloid
      - Scar tenderness: up to 40%
      - Nerve injury
        Palmar cutaneous branch of the median nerve
        Motor branch to the thenar muscles
      - Failure to relieve symptoms
  - - - Compression of the anterior interosseous branch
        by the deep head of pronator teres
      - Muscle weakness only
        
        Pronator quadratus
        
        FPL
        
        Radial half of FDP
- - - - Ulnar deviation @ the MCPs
      - Boutonniere deformity
      - Swan neck deformity
      - Z thumb
      - MCP volar subluxation
- - - - Early morning stiffness
      - Pain
      - Swelling
  - - - FBC: ↓Hb, ↓PMN
      - ↑ESR and ↑CRP
      - Immune: RF, anti-CCP, ANA, HLA-DR3/4
    - - Soft tissue swelling
      - Periarticular osteopenia
      - Loss of joint space
      - Periarticular erosions
      - Deformity
  - - - Analgesia
      - Steroids: IM, PO or intra-articular
      - DMARDS
      - Biologicals
      - Other: CV risk, prevention of PUD and osteoporosis
    - - Carpal tunnel decompression
      - Tendon repairs and transfers
      - Ulna stylectomy
      - Arthroplasty
- - - - Thumb CMC
      - PIPJs
      - DIPJs
- - - - Hypothenar eminence
      - Dorsal interossei
- - - - Avoid repetitive flexion-extension of elbow
        
        Avoid prolonged elbow flexion
      - Night splinting of elbow in extension
    - - Ulnar nerve decompression
      - Medial epicondylectomy
- - - - Loss of MCP extension
      - Preserved PIPJ extension: lumbricals
- - - - Just below brachial plexus
      - Compression: crutches
    - - Occur at spiral groove
      - Mid-shaft humerus #, Saturday night palsy
    - - Occur at elbow
      - Only involve posterior interosseous nerve so sensation
        preserved
      - Local wounds, # or dislocation