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Garrard's pads

Writing competition runner-up Dr Ahmed Zahid comes face-to-face with a clinical condition that even Google can’t detect 

‘I’ve got Garrard’s pads,’ he exclaimed with a certain ring of pride in his voice. The patient in question was a stocky chap in his 50s who looked like one of those hairy bikers from TV. With sideburns many an Elvis impersonator would have killed for, he looked at me, perhaps expecting a congratulatory response.

His sister thrust a piece of paper onto the table in front of me, adding ‘yes, we went to see the rheumatology clinic and that’s what they said he has’.

I paused. Touch-typing the spelling she had given me for Garrard’s pads, I used my GP Notebook tab on my web browser, which helpfully responded with my most-visited page: the all-too frequent ‘Sorry but GP Notebook was unable to find any pages to match your query. We recommend you use the following sites to search’.

So I turned to the wise oracle that is Google. Looking up from my screen at the hairy biker, I said: ‘So you were told you have brake pads for a car?’ The Garrard 301/401 brake pad is on sale for only £5.99 on eBay. Fantastic, I thought. And it was in stock too. Wise old Google – ever so helpful. ‘Would you like another one?’ I asked.

Hairy biker and his sister burst out laughing. ‘Must use some outside-the-box thinking here,’ I thought, scratching the occipitoparietal junction of my own noggin.

I tried using the search term ‘Garrard pad joint’ and this time Google became contextually aware and threw up
a Medscape reference entitled ‘Knuckle Pads’.

Now I was getting somewhere.

Knuckle pads, also known as Garrod’s pads, are benign papules, nodules or plaques found on the dorsal aspects of the metacarpophalangeal joints as well as the interphalangeal joint. The lay term knuckle pad is a bit of a misnomer, since most are reported over the proximal interphalangeal joints.

Pad pedigree

Archibald Garrod, a turn-of-the-century English physician, first described them in 1893 in the medical literature, although they have been observed since the Renaissance era. Among other examples, Michelangelo’s statue of David, in Florence, sports knuckle pads, as does his statue of Moses, in Rome. Violinists and cellists are prone to Garrod’s pads too.

Often occurring in relation to repetitive trauma, they can have a familial basis or be idiopathic, and they are four times as common in those who have a Dupuytren’s contracture. Hairy biker did indeed have both.

The treatment section from Medscape was helpful, albeit preceded by the sentence ‘neither medical nor surgical treatments for knuckle pads are very effective’. The GP Notebook entry stated ‘all forms of treatment have met with little success’.

Hairy biker had been coming to me for months, querying gouty tophi, warts and all other manner of differentials. Finally, stumped, I had arranged for him to be seen by our local musculoskeletal service. This at least got him a label to use – hence the misspelt scrawl on the piece of paper and the great pride in his voice.

‘This is what I would suggest,’ I said. ‘Continue with the splint you have been provided with and let’s see how you get on’. I did ask him to stop playing the violin too. He laughed with me.

The conversation moved on towards his cardiac rehabilitation and peripheral artery disease. Finally, here was
a symptomatic pad I could more comfortably discuss.

And as I grabbed my pen to sign his repeat prescription, I noticed something I had long forgotten about. I had a little Garrod’s pad of my very own – right where the pen rests against the middle

Dr Ahmed Zahid is a GP in Swinton, Manchester.

Pulse asked for talented GP writers to send us stories to inspire and amuse their colleagues, and we were bowled over by the quality of the entries submitted.

Nearly 30 GPs took the time to put pen to paper – or finger to keyboard – and entries varied from amusing tales from consultations to clinical dilemmas or political ideas about general practice or the NHS in general.

Click here to read the winner and all the runners up.

Readers' comments (1)

  • Mohammed Morad

    Dear editor
    As I can see the term has been misspelled and that could be the reason for being an unable to get good search results.
    Knuckle pads were described in the NEJM and could be with success retrieved by use of Pubmed and even Google if spelled Garrod's pads.
    As stated in the paper can be familial and these days we have found a family with the condition and genetic testing is undergoing.
    In our patients the lesions are on hands but very prominent on knees while almost all of them have overweight, metabolic syndrome and dyslipidemia.
    More on that to follow.

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