Orthopedics 5th year, 5th lecture (Dr. Ariwan)

Orthopedic Hand Orthopedic Hand ProblemsProblems

Congenital anomaliesCongenital anomalies Central longitudinal deficiency Central longitudinal deficiency

((Lobster Claw HandLobster Claw Hand).). Syndactyly (Syndactyly (Congenital webbingCongenital webbing).). Polydactyly (Polydactyly (Extra digitExtra digit).). Overgrowth (Overgrowth (MacrodactylyMacrodactyly).).

Acquired deformitiesAcquired deformities Mallet fingerMallet fingerThe terminal phalanx is in flexion, cannot be extended The terminal phalanx is in flexion, cannot be extended actively but only passively.actively but only passively.Causes:Causes:Direct trauma or wound causing tendon rupture.Direct trauma or wound causing tendon rupture.Indirect trauma when the tip is forcibly bends during Indirect trauma when the tip is forcibly bends during active extension causing rupture or avulsion of bone active extension causing rupture or avulsion of bone chip.chip.Treatment:Treatment:Conservative:Conservative: Acute injury or delay for several weeks Acute injury or delay for several weeks by splintage in extension for by splintage in extension for 8 8 weeks. (Even with weeks. (Even with fracture)fracture)Operative:Operative: Old lesions, marked deformity, impaired Old lesions, marked deformity, impaired function, joint mobile function, joint mobile tendon reconstruction or fusion.tendon reconstruction or fusion.

Boutonniere Deformity Boutonniere Deformity (Button Hole)(Button Hole)

Hyperextension of the DIP joint with flexion Hyperextension of the DIP joint with flexion of the PIP joint.of the PIP joint.

Cases:Cases: Avulsion or rupture of central slip of Avulsion or rupture of central slip of

extensor expansion (RA, penetrating injury).extensor expansion (RA, penetrating injury). Dislocations of the lateral slips.Dislocations of the lateral slips.

Treatment:Treatment: According to the cause According to the cause Conservative:Conservative: splintage in corrected splintage in corrected

position.position. Operative:Operative: If avulsion or rupture in open If avulsion or rupture in open

wound early repair or late tendon wound early repair or late tendon reconstruction reconstruction

Swan Neck DeformitySwan Neck Deformity

Hyperextension of the PIP and flexion of Hyperextension of the PIP and flexion of the DIP joint.the DIP joint.

Usually seen in rheumatoid arthritis.Usually seen in rheumatoid arthritis. Treatment:Treatment: ConservativeConservative: Splintage.: Splintage. Operative:Operative: Intrinsic release or flexor Intrinsic release or flexor

digitorum superficials tenodeses.digitorum superficials tenodeses.

Trigger Finger (Stenosing Trigger Finger (Stenosing Tenovaginits)Tenovaginits)

Stenoses at the opening of fibrous flexor sheath of Stenoses at the opening of fibrous flexor sheath of flexor tendons.flexor tendons.

Usually affect the thumb in children, ring finger in Usually affect the thumb in children, ring finger in adults or any other finger.adults or any other finger.

Common in RA and gout.Common in RA and gout.Clinical featuresClinical features:: Clicking during finger bending.Clicking during finger bending. During unclenching finger remain flexed at the PIP During unclenching finger remain flexed at the PIP

& suddenly straighten with a snap.& suddenly straighten with a snap. Tender nodule in front of the MP joint (mouth of the Tender nodule in front of the MP joint (mouth of the

sheath).sheath).

TreatmentTreatment:: ConservativeConservative: Early by careful injection : Early by careful injection

of methylprednisolone into the tendon of methylprednisolone into the tendon sheath.sheath.

OperativeOperative: Is the definite treatment; : Is the definite treatment; transverse incision distal to the distal transverse incision distal to the distal palmar crease, longitudinal incision in palmar crease, longitudinal incision in the mouth of fibrous sheath release the mouth of fibrous sheath release the tendon.the tendon.

In babies surgery needed after age In babies surgery needed after age of one year.of one year.

Dupuytren's contractureDupuytren's contractureNodular hypertrophy and contracture of the Nodular hypertrophy and contracture of the

superficial palmer fascia (Palmar Aponeuroses).superficial palmer fascia (Palmar Aponeuroses). PathologyPathology::Proliferation of myofibroblasts in the palmer Proliferation of myofibroblasts in the palmer

aponeuroses contractions of fibrous aponeuroses contractions of fibrous bands in the fingers, flexion of the MP&PIP bands in the fingers, flexion of the MP&PIP joints.joints.

Fibrous attachment to the skin, skin puckering.Fibrous attachment to the skin, skin puckering. Associations:Associations:

Epileptics on phenyton therapy.Epileptics on phenyton therapy. DM & smoking.DM & smoking. Alcoholic cirrhoses.Alcoholic cirrhoses. AIDS.AIDS. Pulmonary TB.Pulmonary TB.

Clinical featuresClinical features:: Middle age, ♂>♀.Middle age, ♂>♀. Autosomal dominant in Anglo-Saxon descent.Autosomal dominant in Anglo-Saxon descent. Nodular thickening of the palm gradually Nodular thickening of the palm gradually

extends to the fingers.extends to the fingers. It's often bilateral (one more than the other).It's often bilateral (one more than the other). RingRing and/or the and/or the Little Little finger are flexed in finger are flexed in

the MP&PIP joints.the MP&PIP joints. The sole of the foot may be affected.The sole of the foot may be affected.

TreatmentTreatment Early:Early: Daily physiotherapy and splintage to Daily physiotherapy and splintage to

correct the fingers.correct the fingers. Late:Late: Resistant deforming lesion: Resistant deforming lesion: Subcutaneous fasciotomySubcutaneous fasciotomy : risk of : risk of

neurovascular injury and recurrence.neurovascular injury and recurrence. Open fasciectomyOpen fasciectomy: Z- plasty to the skin & : Z- plasty to the skin &

complete excision of the thickened complete excision of the thickened aponeuroses; postoperative splintage and aponeuroses; postoperative splintage and physiotherapy.physiotherapy.

Closure may need skin flap or partial Closure may need skin flap or partial thickness skin graft.thickness skin graft.

Acute Infections of the Acute Infections of the HandHand Common orthopedic hand problem, common in Common orthopedic hand problem, common in

young manual workers, diabetic, immune young manual workers, diabetic, immune compromised patients.compromised patients.

Usually limited to one of the closed compartments Usually limited to one of the closed compartments (nail fold, pulp space, tendon sheath, deep fascial (nail fold, pulp space, tendon sheath, deep fascial spaces…..).spaces…..).

Pathology:Pathology: Acute Acute pyogenicpyogenic inflammatory reaction. inflammatory reaction. Usual pathogen is Usual pathogen is staphylococcus aureusstaphylococcus aureus, 10% , 10%

unusual organisms.unusual organisms. Inflammation edema suppuration Inflammation edema suppuration

increase tissue tension in closed space increase tissue tension in closed space ischemia and tissue necrosesischemia and tissue necroses..

If neglected infection spread to other If neglected infection spread to other compartments stiff hand.compartments stiff hand.

Lymphangits lymphadenitis Lymphangits lymphadenitis Septicemia.Septicemia.

Clinical featureClinical feature:: History of trauma (abrasion, laceration, History of trauma (abrasion, laceration,

penetration….).penetration….). Pain (throbbing) and swelling after few Pain (throbbing) and swelling after few

hours or days.hours or days. Ill health & fever.Ill health & fever. Ask about DM, drug abuse, Ask about DM, drug abuse,

immunosuppression.immunosuppression. Examination:Examination:

Swelling of finger or hand (dorsum).Swelling of finger or hand (dorsum). Severe local tenderness.Severe local tenderness. Limited active finger flexion.Limited active finger flexion. Lymphangits & lymphadenitis.Lymphangits & lymphadenitis. Signs of septicemia.Signs of septicemia.

InvestigationsInvestigations CBP& ESR.CBP& ESR. Blood culture.Blood culture. X-ray:X-ray:

Early: foreign body.Early: foreign body. Late: osteomyelits, septic arthritis.Late: osteomyelits, septic arthritis. Pus for gram stains & culture Pus for gram stains & culture

sensitivity.sensitivity.

Principles of treatmentPrinciples of treatment Superficial infection may change to serious deep one.Superficial infection may change to serious deep one.1.1. Antibiotics:Antibiotics: After pus specimen taken start After pus specimen taken start cloxacillinecloxacilline or or

cephalosporin.cephalosporin. If suspect If suspect anaerobesanaerobes (bite, agricultural inj.) add (bite, agricultural inj.) add

metronidazole.metronidazole. Later antibiotic changed according to culture result& Later antibiotic changed according to culture result&

continued till infection clearance.continued till infection clearance.2.2. Rest, splintage, elevation:Rest, splintage, elevation: Mild infection Sling.Mild infection Sling. Severe infection hospital admission+ Severe infection hospital admission+

elevation+ position of safe immobilization.elevation+ position of safe immobilization.3.3. Surgical drainage:Surgical drainage: If signs of abscess.If signs of abscess. If no response after 48 hours.If no response after 48 hours. Drain the abscess+ excise necrotic tissue+ leave the Drain the abscess+ excise necrotic tissue+ leave the

wound open+ inspect after 24 hours (closure).wound open+ inspect after 24 hours (closure).4.4. Rehabilitation:Rehabilitation: Once acute symptoms settled active physiotherapy + Once acute symptoms settled active physiotherapy +

intermittent splintage.intermittent splintage.

Nail Fold Infection Nail Fold Infection (Paronychia)(Paronychia)

Pyogenic infection under the nail fold, it's Pyogenic infection under the nail fold, it's the commonest type of hand infection.the commonest type of hand infection.

Clinical features:Clinical features: Common in children> adult.Common in children> adult. Nail fold edges become red, swollen, tender and later Nail fold edges become red, swollen, tender and later

abscess formation. abscess formation.

Treatment:Treatment: Early : antibiotics are curative.Early : antibiotics are curative. Late (abscess): drainage through incision parallel to Late (abscess): drainage through incision parallel to

the nail fold.the nail fold. If pus extend below the nail, partial nail excision.If pus extend below the nail, partial nail excision.

Pulp Infection (Felon)Pulp Infection (Felon)Pyogenic infection of the distal finger pad; Pyogenic infection of the distal finger pad;

intense pain &ischemia to the distal phalanx.intense pain &ischemia to the distal phalanx.Causes:Causes: Pricking by needle, thorn…. .Pricking by needle, thorn…. . Commonest organism is Commonest organism is staphylococcus staphylococcus

aureusaureus..

Clinical features:Clinical features: Intense throbbing pain at finger tip.Intense throbbing pain at finger tip. Red, swollen, acutely tender.Red, swollen, acutely tender.Treatment:Treatment:

Early: elevation + antibiotics.Early: elevation + antibiotics. Late: drainage over maximum tenderness, the wound Late: drainage over maximum tenderness, the wound

heal by secondary intension.heal by secondary intension. If neglected infection spread to bone, joint, If neglected infection spread to bone, joint,

tendon sheath.tendon sheath.

Deep Fascial Space Deep Fascial Space InfectionInfection

Pyogenic infection of the thenar and mid Pyogenic infection of the thenar and mid palmar fascial spaces.palmar fascial spaces.

Causes: Causes: Penetrating injury.Penetrating injury. Secondary spread from (web space, tendon Secondary spread from (web space, tendon

sheath…..).sheath…..).

Clinical features:Clinical features: Intense throbbing pain at the hand.Intense throbbing pain at the hand. Redness over the palm, intense swelling of the Redness over the palm, intense swelling of the

dorsum (inflated glove).dorsum (inflated glove). Intense tenderness, hand held immobile.Intense tenderness, hand held immobile. Lymphangits.Lymphangits. The patient is ill, feverish, and toxic.The patient is ill, feverish, and toxic.

TreatmentTreatment Antibiotics, elevation, splintage, analgesics.Antibiotics, elevation, splintage, analgesics. Surgical drainage (persistent fever, signs of Surgical drainage (persistent fever, signs of

abscess).abscess). Thenar space: curved incision radial to Thenar space: curved incision radial to

the thenar crease.the thenar crease. Hypothenar space: transverse incision Hypothenar space: transverse incision

proximal to the distal palmar crease.proximal to the distal palmar crease.

Leave the wound open, second look after Leave the wound open, second look after 24 hour then closure.24 hour then closure.

Never cross the creases at right Never cross the creases at right anglesangles