hand

orthopedics
د.عادل الهنداوي the hand

clinical assessment:
*symptoms: pain? can be localized, diffuse or referred from the neck, shoulder or mediastinum.
deformity? can be sudden(tendon rupture) or slow.
swelling? ra causes swelling of pipj while oa of dipj.
sensory &motor deficit &loss of function.
*signs: ask which is the dominant hand &examine both sides.
look at … posture, wasting, deformity, lump, nails & skin for scar, color, dry.
feel the… skin for temperature &texture, pulse, tenderness & lump: related to subcut. tissue, tendon, joint or bone.
move … active mvt? finger flexion &opposition. passive mvt? of each joint.grip strength & pinch grip.
*neurological examination & *functional tests.

congenital variations: are 7 groups
1-failure of formation: either:
transverse failure: at any level(often at forearm& finger).
longitudinal failure: either:
radial? radial club hand
ulnar? ulnar club hand or
central? cleft hand.
2-failure of differentiation:
syndactyly(congenital webbing): is the commonest of all congenital variations of the hand. it may be simple(skin only) or complex (skin &bone). ?? surgical finger separation (plus skin graft).
if >2 fingers to be divided, it is wise to stage the procedure.
camptodactyly: flexion deformity of pipj usually of little finger. often bilateral, inherited but appears at 10yr. no ?.
clinodactyly: sideway bending often of little finger. no ?.
3-duplication:
polydactyly (extra digits): is common. extra little finger > common than extra thumb while extra central finger is rare.
? of extra skin tag is simple excision, if more needs fine surgery.
4- overgrowth: (giant finger) is often stiff &ugly. ??
surgical reduction by excision of excess bone &soft tissue.

5- undergrowth: the commonest is hypoplastic thumb.
6-constriction band: causes distal edema. ?: multiple z-plasties.
7-generalized skeletal abnormalities e.g. marfan s syndrome(spider hand), achondropinglasia(trident hand) &down s syndrome(short broad).


acquired deformities:
1-skin? skin contracture from wound or burn.
2-subcutaneous tissue? dupuytren s contracture.
3-muscle ?ischemic contracture of: long flexors (volkmann s) & of intrinsic muscle(intrinsic-plus).
4-tendon? mallet finger, rupture of epl, droping finger, boutonniere &swan-neck deformity.
5-joint? ra, oa, gout &trauma.
6-bone? infection, tb, tumor &malunited #.
7-neuromuscular disorders?
spastic palsy like cerebral palsy, head injury or stroke cause intrinsic- plus hand.
flaccid palsy like poliomyelitis or peripheral nerve injury causes intrinsic-minus hand.

dupuytren s contracture: is a nodular hypertrophy & contracture of palmar aponeurosis(superficial palmar fascia). it is an autosomal dominant trait especially in europeans. it is > common in males, dm, tb, aids, epileptics taking phenytoin, smokers &alcoholics.
pathology: there is proliferation of myofibroblasts lading
fibrous tissue within palmar fascia, contraction of which
causes flexion deformity of mpj &pipj &puckering of skin.
plantar aponeurosis may also be affected.

cf: a middle-aged man complains of rather painless nodule often in both palms. then the palm become puckered, nodular &thick. late subcutaneous cords extend to the little &ring fingers causing flexion at mpj &pipj.
?: 1-open fasciectomy for severe deformity: excision of thick fascia &cords? exercise &night splint for several months.
2-percutaneous needle fasciotomy (=percut. needle aponeurotomy) for early stages.
3- radiotherapy used early may? recurrence.
recurrence is common.




mallet finger: the dipj is flexed &can be extended passively but not actively because of injury to the extensor tendon at its insertion to distal phalanx by direct trauma or indirect force: forced flexion of actively extended dipj like catching a ball
?? splint in extension for 8weeks. surgery may be indicated.

dropingped finger: sudden loss of finger extension at mpj due to tendon rupture at the wrist in ra. ?? direct repair or suture to adjacent finger extensor.

ruptured extensor pollicis longus: following colle s # or in ra results in flexion of thumb distal phalanx. ?? tendon transfer using extensor indicis.
boutonniere deformity(le buttonhole): flexion of pipj & hyperextension of dipj due to trauma or ra causing rupture of central slip? separation of lateral slips? head of proximal phalanx passes through the gap like a button through its hole. ?? 6weeks splint or direct repair of central slip.
swan-neck deformity: hyperextension of pipj &flexion of dipj due to trauma or ra. ?: if correctable deformity: soft tissue operation if fixed? arthrodesis.

stenosing tenovaginitis(trigger finger): is common in middle age.
usually caused by trauma, overuse or ra? thickening of fibrous tendon sheath? interfere with free tendon movement in its sheath.

cf: often the ring or middle finger is affected: the patient feels a click during flexion when open his hand, the affected finger remains flexed but with force it extends with snap.
o/e: tender nodule felt in front of mpj.
?? early: local steroid injection if fail? surgical division of 1st annular pulley(a1).
infantile trigger thumb: often recovers spontaneously within months.


hand infections: are common, often caused by
staphylococci implanted by penetrating wound?acute inflam. with increasing edema? suppuration & tissue tension? decrease in the
blood flow? tissue necrosis & possible spread to nearby compartment or blood stream.
cf: swelling, redness, tenderness. in superficial infection, finger mvt is
free in deep infection, it is painful. look for lymphangitis&lymphadenitis.
x-ray: early may show foreign body.
later: om, septic arthritis or bone necrosis.
??1-ab: flucloxacillin or cephalosporin for bone infection add fusidic acid for plant prick add metranidazole.
2-splint &elevation: rest the hand in a splint in the position of safety &elevate it in an arm sling or if severe use overhead sling.
3-drainage: early, within 48 hrs, ab may be enough. if abscess
develops it should be drained &left open for 2nd look. 4-exercise.

nail-fold infection(paronychia): infection under nail fold is the commonest hand infection. the fold is swollen, red &tender then collects pus which may spread under the nail. ?? ab &pus drainage.
chronic paronychia may be due to fungal infection.

pulp infection(felon): often caused by prick injury?swollen, red &tender finger tip pulp with throbbing pain. ?? ab, elevation &abscess drainage. if ? is delayed, infection may spread to bone, joint or tendon sheath.
other subcutaneous infections: anywhere in the hand.
tendon sheath infection(suppurative tenosynovitis): is uncommon but dangerous. often caused by penetrating injury-? swollen, painful, very tender finger which is held in slightflexion &never allow mvt. if diagnosis is delayed? risk of tendon necrosis or spread of infection proximally.
?? hand elevation &splint + i.v. ab if no response within 24 hrs? drainage by proximal &distal incisions with frequent saline irrigation by fine catheter.
deep fascial space infection: infection of thenar & mid-palmar spaces may come from a wound or spread from web space infection or suppurative tenosynovitis.
cf: pain, tenderness, palm swelling is mild but extensive on the dorsum the hand is held still refusing any mvt.
?? i.v. ab, splint, elevation &drainage.
septic arthritis: of mpj or ipj may come from penetrating
wound or from blood stream. cf: the joint is painful, swollen, red with limited mvt. ?? i.v. ab, splint, drainage &leave wound open. continue oral ab for 2-4 weeks.