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Question 1-3 of 6

Theme: Hand disorders

A. de Quervain's tenosynovitis
B. Dupuytren's contracture
C. Bouchard's nodes
D. Ganglion
E. Carpal tunnel syndrome
F. Radial nerve injury
G. Ulnar nerve injury
H. Heberden's nodes
I. Tendon sheath infection

Please select the most likely diagnosis to account for the scenario given. Each option may be used once, more than once or not at all.

1. 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 is able to make a fist with the hand. Palpation reveals thickened nodules on the medial half of
the palm.

Dupuytren's contracture

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

2. A 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.

You answered Ganglion

The correct answer is Heberden's 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.

3. A 57 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.

You answered Radial nerve injury

The correct answer is Carpal tunnel syndrome

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.

Next question

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

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eMRCS 19/07/2015

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.

Carpel 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 are the result of the deposition of immune
nodes complexes.

Bouchards Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a
nodes sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.

Heberdens Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of
nodes 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 it is slightly more viscous. When the cysts are troublesome they may be excised.

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Question 4-6 of 6

Theme: Hand disorders

A. Malignant fibrous histiocytoma

B. Oslers nodes
C. Heberdens nodes
D. Bouchards nodes
E. Carpal tunnel syndrome
F. Complex regional pain syndrome
G. Osteoclastoma
H. Osteosarcoma
I. Ganglion

Please select the most likely diagnosis for the lesion described. Each option may be used once, more than once or not at all.

4. A 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.

You answered Bouchards nodes

The correct answer is Oslers nodes

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.

5. A 62 year old lady presents with an non tender lump overlying 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.

You answered Bouchards nodes

The correct answer is Heberdens nodes

Heberdens nodes may produce swelling of the distal interphalangeal joint with deviation of the finger tip.

6. 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.

You answered Malignant fibrous histiocytoma

The correct answer is Ganglion

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.

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.

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eMRCS 19/07/2015

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.

Carpel 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 are the result of the deposition of immune
nodes complexes.

Bouchards Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a
nodes sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.

Heberdens Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of
nodes 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 it is slightly more viscous. When the cysts are troublesome they may be excised.

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Overall score: 16.7%

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