This man has quite severe Dupuytren's contracture causing this fixed flexion deformity. He was referred for orthopaedic assessment. In more severe cases like this, the surgery is harder and the problem may recur. Cases should ideally be referred much earlier, for example at the stage when the finger can no longer be flat on a surface. In these cases, needle fasciotomy is a much easier procedure and may give very good results. Recently, radiotherapy has also been used for this condition.
This elderly man was very distressed by the loss of his wife. Soon after, his skin began to slough off. There was no history of other skin disease, or other symptoms affecting his skin. He was given some emollient cream. It was felt that his skin condition was due to stress, and it settled quite quickly.
This lesion grew rapidly at the base of this 37-year-old woman's thumb. It looked rather alarming and she was convinced that it was a cancer. There was no obvious cause. In fact it was perfectly benign and was surgically removed. The diagnosis was confirmed on histology. No further action was required.
This woman was concerned about the appearance of her nails. Although very regular, the dark pigmentation was slightly alarming. She was referred to a dermatologist who diagnosed benign longitudinal melanonychia. No action was required.
This elderly woman had experienced problems with her circulation all her life. This photograph was taken in relatively mild weather, illustrating the degree of sensitivity of her vasculature. She has taken great care to try to reduce the vasospasm, including practical measures such as always putting on thermal gloves while still indoors. Investigation has failed to identify any of the numerous possible causes and she has simply learned to live with it. Extreme cases may be much more severe, even leading to necrosis of the distal parts of the fingers.
This young woman has had severe rheumatoid disease for many years. It is tragic that a patient in her thirties has been so severely affected when early diagnosis and aggressive treatment can now prevent most of the joint destruction that she has. She has had multiple complex operations on her hands and feet, all of which are affected. She continues on DMARDs and anti-inflammatories.
This elderly woman has a complex medical history including hypertension, AF and heart failure. She has had gout for many years. She has multiple tophi (Latin for 'stone'), such as the one seen here. These tophi are essentially collections of uric acid crystals. She has flare-ups of her gout periodically, possibly aggravated by her diuretic treatment, which she has been unable to do without. She is on allopurinol, the dose of which has now been titrated to try to prevent further problems.
Lunate bone cyst
This 28-year-old woman complained of stiffness in her left wrist that led to significant problems for her at the stables where she worked. Plain X-ray was unhelpful and subsequent investigation with MRI scanning eventually revealed that she had a benign bone cyst in her lunate bone. There was no simple treatment option so a surgical approach was required. It was curetted and filled with bone graft from the distal radius. Following significant physiotherapy, the range of movement improved considerably.
- Contributed by Dr Philip Marazzi, a GP in Horsley, Surrey