1. Pain in the hands. Index Cases Lent term 2010

2. This 67 yr old man comes to you with gradually worsening hand pains. What do you see?

3. What condition do you think he has? What tests are available to aid your diagnosis? What treatments are available? What considerations would guide your treatment advice?

4. This and the following Xrays are typical of this condition. What changes are evident?

7. Another man in his 60’s is on the ward being treated following a GI bleed. What is the likely diagnosis of his hand problems?

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12. Why is it important to distinguish between different forms of arthritis? At present osteoarthritis cannot be effectively treated other than by supportive management including analgesia and joint replacement. Inflammatory arthritides, including rheumatoid, may respond well to ‘disease modifying anti-rheumatic drugs (DMARDs)’. They may also be associated with a number of other complications and conditions – as RA does not only affect the musculoskeletal system.

13. A 49yr old man slipped on ice and fell onto his left hand and arm. He comes to you for advice about his ‘bruised wrist’, though there is little bruising visible. You examine him and elicit acute tenderness in an area just distal to his wrist on the dorsal radial aspect. What is this area colloquially known as? What is your suspicion? How will you proceed?

14. (This is a right hand!) Bones of the carpus.

16. Scaphoid fractures. Classically from a ‘fall on the outstretched hand’. Tenderness in the ‘anatomical snuff box’. Easy to miss. Xrays may not reveal the fracture initially, in which case a cast may be applied ‘on suspicion’ until further confirmation is obtained; techniques for this include radioisotope scans, delayed (14d) Xray, CT or MRI scans. If fragments are displaced, internal fixation may be approprite. These fractures can be a problem owing to a rather tenuous blood supply to the bone. Avascular necrosis of the proximal fragment may result, with resulting arthritis a painful sequel.

17. Another case of hand pain. A 34 year old woman comes to see you. She complains of a 6 week history of gradually worsening pain and numbness affecting her right hand. Her symptoms are often worst on waking in the morning, and gradually settle – at least partially – later on, unless she is using her hand a lot. She is otherwise well, though somewhat overweight (BMI 28.5). Can you think of some other questions you need to ask?

18. Detail the precise distribution of symptoms. Does she work – if so, what does she do? Is she pregnant? Does she have diabetes, or is there a family history of it? Likewise thyroid disease. The answers to the above all prove negative, and her symptoms are quite well localised to her thumb, index and middle fingers, mainly on the palmar aspect. What do you think is the likely diagnosis? How might you go about confirming this? What treatments are available?

19. The carpal tunnel is tightly packed with tendons, blood vessels, and the median nerve.

20. Tinel sign, and Phalen’s test.

21. Nerve conduction studies may confirm the diagnosis.

22. A steroid injection into the carpal tunnel may give relief, but the definitive treatment is often surgical.

23. And finally…..

24. The lady in the preceding picture notes these changes intermittently, particularly if she goes out in the cold. Apart from the colour change, her fingers become painful and may turn blue. This condition is not common, but have you any ideas ? Why the colour changes? What is the final colour change, when she returns to the warm?

25. This condition is not common, but have you any ideas ? Raynaud’s phenomenon. Caused by vasospasm, it may be associated with a range of diseases – particularly connective tissue disorders, and exacerbated by smoking, caffeine, oestrogen. Why the colour changes? White because of reduced perfusion, then blue because of hypoxia (cyanosis).and finally deep flushed red as hyperperfusion returns. What is the final colour change, when she returns to the warm? See above.