Hand: Overuse & Degenerative Conditions

See also Wrist: Overuse & Degenerative Conditions for the wrist equivalents of these conditions.

Trigger finger (flexor tenosynovitis)

A nodule on a flexor tendon catches at the A1 pulley, causing the finger to lock/“trigger”. Thumb and ring finger most often affected; ~2.6% lifetime prevalence, peak in the 40s–50s.

• Associations: diabetes, gout, rheumatoid arthritis, hypothyroidism, amyloidosis.
• Features: the finger catches in flexion and may need to be manually extended (± a painful pop); usually progressive.
• Examination: tenderness ± a palpable nodule at the A1 pulley (distal palm).
• Management: corticosteroid injection is first-line (effective in ~70%, less so in the thumb and in diabetics); a night splint is an option; surgical A1 pulley release for refractory or recurrent cases.

Dupuytren’s disease

Fibroproliferative disease of the palmar fascia, depositing collagen as nodules and cords that progressively flex the fingers (ring and little fingers most often). Male:female ~8:1; associations include family history, Northern-European ancestry, diabetes, alcohol, and antiepileptics.

• Features: usually painless (can ache early); the main problem is the functional flexion contracture. Palpable palmar nodules/cords, skin pitting/ tethering.
• Assessment: Hueston’s tabletop test (can’t lay the palm flat); document the degree of contracture to track progression.
• Treatment (for functional contracture): needle aponeurotomy (higher recurrence), collagenase injection (less recurrence, cost/availability variable in Australia), or surgery (partial fasciectomy/dermofasciectomy — lowest recurrence, longer recovery). Radiotherapy may slow early disease.

Hand osteoarthritis

Often part of generalised OA affecting multiple joint sites — see Hip & Generalised Osteoarthritis.

Osteoarthritis of the hand classically affects the DIP joints (Heberden’s nodes), PIP joints (Bouchard’s nodes), and the first CMC (basal thumb) joint.

• Features: progressive joint pain, stiffness and deformity; bony swellings (osteophytes) at the finger joints; basal thumb OA causes pain at the base of the thumb with pinch/grip and a “squaring” appearance.
• Investigations: clinical; X-ray if needed.
• Management: Per the RACGP OA guideline: education, exercise and joint protection first; topical NSAIDs and analgesia; a thumb splint and hand therapy for basal thumb OA; intra-articular corticosteroid for the CMC joint. Surgery (trapeziectomy for refractory basal thumb OA) has a long recovery (~3 months of restricted thumb use).

The RACGP guideline is written for the knee and hip, so it is applied here by analogy. Its transferable points: exercise is a strong recommendation, low-dose oral NSAIDs for short periods with monitoring are recommended for some people, corticosteroid injection is for short-term relief with care over repeated injections, and oral or transdermal opioids and glucosamine/chondroitin should not be offered.

Ganglion cyst (digital)

A different presentation of the same condition covered on the Wrist page (most ganglia are dorsal/volar wrist) — here arising from the digital flexor tendon sheath, or as a mucous cyst near the DIP joint.

• Same diagnosis/management principles as the wrist form (transillumination, observation first, aspiration has high recurrence, surgery for persistent symptoms not cosmesis).
• Mucous cyst causing nail-bed deformity should be excised (and sent for histology) — the only reliable way to exclude a rarer alternative diagnosis.