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Palmar Nodules
453 Plays6 months ago
Miranda and Josh talk about differentiating the various types of palmar nodules in the hand
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Transcript
Introduction to Hand Therapy Academy
00:00:05
Speaker
Hi, I'm Josh McDonald. And I'm Miranda Materi, and we are Hand Therapy Academy.
Exploring Clinical Tests for Palmar Nodules
00:00:10
Speaker
So in a recent article of Journal of Hand Surgery, I came across an article at the very back end of things kind of buried at the tail end of it. It was all about this quick little clinical test that I thought was kind of an interesting, quirky-like tidbit that could be useful in your practice.
Understanding Common Palmar Nodules
00:00:27
Speaker
So it was all about how to identify a nodule in the palm around the distal palmar crease area to identify what type of nodule it was based on movement of MCP and PIP. That's really interesting. So when you're talking about common palmar nodules, I always think of dupa trends, trigger finger.
00:00:46
Speaker
Um, and then you believe you mentioned one more. It was, um, ganglion. Yeah.
Identifying Nodule Types Through Joint Movement
00:00:51
Speaker
A ganglion cyst nodule, which when I think ganglion cysts, obviously I think about the scaphoid folder dorsal, but ganglion cysts can exist a lot of other places. And so this talked about, Hey, if it's over that around the distal polymer crease, same general area, there's this little clinical test you can do to give an idea of which one it is.
00:01:07
Speaker
Right. And then how do you know? So when Josh was like talking to me about this article, I was like, okay, well, how am I going to know? How would I typically run through and see which one it was? Because I'm like, well, I think I know, but I wanted to hear what you had to say. So what, how are you determining what the difference
00:01:25
Speaker
Yeah, so this article talked about palpating the nodule and then moving first just PIP with MCP blocked, then just MCP with PIP blocked.
The Role of Active Movement in Diagnosing Nodules
00:01:36
Speaker
And if the nodule moves with PIP only motion, it's trigger finger because it is on the sheath. And when you move PIP, it's FDS traveling and that nodule is attached to the sheath.
00:01:49
Speaker
if it moves with just MCP movement and PIP maintained in extension, then it's a ganglion nodule because that is kind of bonded to the volar plate and sheath of, excuse me, not the sheath, but the volar plate and the pulley of the MCP. So because it's bonded to that, when the NCP moves, the ganglion nodule also moves.
00:02:15
Speaker
If MCP movement and PIP movement, neither one of them cause movement of that nodule, then it's dupatrins. Right. I think that definitely makes sense. Now, when you're talking about movement, are you talking about active movement or passive movements? They talked about active. So you have the patient do active MCP flexion with nothing else moving. Active PIP with nothing else movement. So just active. Yeah. OK.
Reflecting on Ultrasound Methods for Nodule Identification
00:02:41
Speaker
That makes sense.
00:02:42
Speaker
I would imagine that if you did the PIP passively, that nodule on a trigger finger sheath of the tendon might not actually travel if it's caught. The slack would maybe not make it move, but that active pull through would make it move.
00:02:55
Speaker
Yeah, definitely. I was a little bit more accurate of a test, I would think. And before you read this, what were you doing to determine them? I think that's a helpful pointer. So when I look back, I was like, well, I sometimes would be on my ultrasound machine, and sometimes I would think, well, I think it's a trigger finger, but then they'd go to the surgeon, and they'd be like, no, it's a cyst.
00:03:15
Speaker
Yeah, yeah, so honestly,
Diagnosing Palmar Nodules: Clinical Insights
00:03:17
Speaker
the dupatrins, I'm usually looking for that classic, more like a longitudinal presentation, and not like a longitudinal band cord, but I'm more looking at like, hey, it's this longer connection of the fascial tissue that stretches across the hand.
00:03:34
Speaker
That's the more obvious presentation and then a little bit of flexion contracture and that tension on the fashion more of like a visual presentation almost have like a little bit of a pitting right it doesn't seem like it's it seems like it's kind of through more of the layers as opposed to just.
00:03:48
Speaker
one layer. Yeah. Yeah. So kind of on either sides, radial ulnar sides of it, you get that pitting. Yeah. For trigger finger, I'm looking as much at like clinical presentation of movement as their pain with it, which I suppose pain could be present in the others. And is it actively triggering? If I can palpate it like catching and slipping and sliding while they're doing that movement, that's an indication.
Case Study: Misdiagnosis and Discovery of a Ganglion
00:04:13
Speaker
And then the ganglion, honestly, I didn't really have a great clinical assessment for that one. So I think this really kind of fills that gap for me. Yeah, I think me too. I was thinking cause you can't really, like when they're small in there, you can't like really, you know, I feel like a ganglion is pretty obvious when it's like prominent on the dorsal aspect of the wrist, but we don't really think of how we have ganglions in different areas and in different joint spaces, right? So they can come up from any like synovial joint space.
00:04:40
Speaker
And sometimes we don't even know they're there because they don't like protrude through the superficial layers.
00:04:46
Speaker
Yeah. And so sometimes too, a trigger finger nodule could be very small, maybe palpable, but then you start questioning, am I feeling like bony prominences of the head of the metacarpal? Is that, but if I can do that PIP movement without so much range of motion, it's going to trigger, right? I want to keep them from going so far, it's going to trigger, but I may still be able to like get an idea of blocking those other joints if it's going to present with movement in one, but not the other.
00:05:12
Speaker
And what was interesting, this is probably been like a year ago now, I had a patient that had a percutaneous trigger finger release. So they just took the sharp, the beveled edge of the needle and released the A1 pulley. And she still wasn't getting better and wasn't happy with her recovery. And I was thinking like, well, maybe they didn't fully release the pulley. So maybe it was something like that since it was done percutaneous. But the doctor went back in and explored and she had a ganglion.
The Value of Reading Journal Articles in Hand Therapy
00:05:41
Speaker
Interesting. So that's another, I think, thing to think about when you have someone that's had a release, maybe she did have a little bit of trigger finger, but then also there was assist and it wasn't identified because the release was percutaneous. Yeah. And maybe
00:05:57
Speaker
the presence of one or the other might not have been that bad, but because both were there, it was, yeah, coincidentally interesting to think about. Yeah. So we have all kinds of clinical tests, all kinds of different things we can do for provocative movers. Just thought that was an interesting one that, um, you know, it, it pays to kind of sift through some of those journal articles that we get that come mailed to your house. You get it, you set it aside, maybe a carry it to work a couple of times and it make its little vacation trip out of your house before actually read it ever. But you know, if you get some time at a lunch break or,
00:06:25
Speaker
you're sitting and watching tv flip through those you may find some really useful tidbits and things out of those articles that you get those journals you get to your house yeah that's really true and then sometimes i flip through and be like oh dr so you know dr summer is in here gosh that's really cool ask girl texter and tell her congratulations i think there's a lot of cool things that can come by reading them
00:06:43
Speaker
Yeah, so hopefully that's helpful. You can use it in your practice when patients are coming in with one of those diagnoses.
Engagement with Hand Therapy Academy
00:06:49
Speaker
But otherwise, if you have any questions or we can help you with anything, reach out to us on our social media platforms, Hand Therapy Academy, or email info at handtherapyacademy.com.