Pathologies of the Hand

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Pathologies of the Hand

• 1st part Fatima Mirza Hammad
• 2nd part Naeema Abdulla Ali

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Pathologies of the Hand
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Hand Deformities
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(1) Mallet finger

• Injury of the extensor digitorum tendon of the
  fingers at the distal interphalangeal (DIP)
  joint.
• Results from hyperflexion of the extensor
  digitorum tendon

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Mechanisms Of Injury

• 1st Commonly an athletic or work related
  injury.
• Occurs when a ball (basketball, or volleyball),
  while being caught, hits an outstretched finger
  and jams it.
• 2nd Other common mechanisms of injury include
  forcefully tucking in a bedspread or slipcover or
  pushing off a sock with extended fingers.
• With or without fracture.

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Management options

• 1. Mallet splint for 6 to 8 weeks
• 2. Extension block by k-wire for 4 weeks, (when
  there is involvement of more than one third of
  the base of the distal phalanx).
• This allows the tendon to reattach.
• If the finger is bent during these weeks the
  healing process must start all over again.

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3.Surgical Fixation of DIP joint

• A surgical pin acts like an internal cast to keep
  the DIP joint from moving so the tendon can heal.
  
• The pin is removed after 6 to 8 weeks

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(2) Trigger finger

• A type of stenosing tenosynovitis
• narrowing of the sheath that surrounds the tendon
  in the affected finger, or a nodule forms on the
  tendon.
• The tendon can NO longer slide freely through its
  sheath.

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Clinical picture

• Affected digits may become painful to straighten
  once bent
• May make a soft crackling sound when moved.
• It props back suddenly when straightened
• It is called trigger finger because when the
  finger unlocks, it pops back suddenly, as if
  releasing a trigger on a gun.

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Treatment

• Trigger finger is usually idiopathic.
• Injection of the tendon sheath with a
  corticosteroid is effective over weeks to months
  in more than half of patients.
• Surgery cut the sheath that is restricting the
  tendon.
• Recurrency is rare

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(3) Boutonniere deformity

• Flexion deformity of the PIP joint, due to
  interruption of the central slip of the extensor
  tendon (part that insert extensor tendon to the
  middle phalanx)
• Hyperflexion at the PIP joint with hyperextension
  at the DIP.

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• Makes it difficult or impossible to extend the
  proximal interphalangeal (PIP) joint actively.
• Passive extension of the PIP joint is easy.

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• The lateral bands separate
• The head of the proximal phalanx pops through the
  gap like a finger through a button hole
• The DIP joint is drawn into hyperextension.

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• The lateral bands separate
• The head of the proximal phalanx pops through the
  gap like a finger through a button hole
• The DIP joint is drawn into hyperextension.

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Central slip
Lateral band
Distal phalanx
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Causes of Boutonniere deformity

• 1.Traumatic injury
• 2.Inflammatory conditions (like rheumatoid
  arthritis)
• 3.Severe burn
• 4.Dupuytren's contracture (thickening of the
  palmar fascia, producing a flexion deformity of a
  finger)

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Stages of Boutonniere deformity

• 1st Mild extension lag, passively correctable
• 2nd Moderate extension lag, passively correctable
  
• 3rd Mild flexion contracture
• 4th Advanced flexion contracture

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• An X-ray should be done to detect avulsion
  fractures (avulsion fracture occurs when the
  tendon pulls off a piece of the bone as a result
  of physical trauma)

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Treatment

• A Conservative Treatment
• Splinting of the PIP joint for 6 week
• Splinting and a rigorous exercise program may
  even work when the injury is quite old.

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B Surgery

• When the deformity is the result of a dislocation
  of the PIP joint
• Surgery may be required to reconstruct and
  rebalance the extension mechanism.
• Surgery carries a relatively high risk of FAILURE
  to achieve completely normal functioning
  extension mechanism of the finger.

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(4) Swan-Neck deformity
- the PIP joint is hyper extended . - DIP
joint is flexed.
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In the PIP joint the strongest ligament is the
volar plate. This ligament connects the proximal
phalanx to the middle phalanx on the palm side of
the joint. The ligament tightens as the joint is
straightened and keeps the PIP joint from bending
back too far (hyperextending). Swan neck
deformity can occur when the volar plate loosens
from disease or in jury.
Oriantation of the cause
volar plate becomes weakened and stretched by RA
, direct truma! PIP joint becomes loose and
begins to easily bend back into
hyperextension extensor tendon gets out of
balance allows the DIP joint to get pulled
downward into flexion
swan neck deformity occurs
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S\S and Diagnosis
- Symptoms - swelling and pain due to
inflammation from injury or disease (RA) -
Signs Swan-neck !! - the PIP joint is
hyper extended . - DIP joint is flexed.
- Diagnosis - clinical diagnosis -
X-ray is done to evaluate the joints (RA) and
look for fractures. .
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Treatment

• 1) A special splint may be used to keep the PIP
  joint lined up, protect the joint from
  hyperextending, and still allow the PIP joint to
  bend

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• 2) Swan neck deformity with a stiff PIP joint
  sometimes requires replacement of the PIP joint,
  called arthroplasty

3) If past treatments, including surgery, do not
stop inflammation or deformity in the PIP joint,
fusion of the PIP joint may be recommended. The
PIP joint is usually fused in a bent position,
between 25 and 45 degrees. Fusing the two joint
surfaces together eases pain, makes the joint
stable, and helps prevent additional joint
deformity.
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Acute infections of the hand
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• Infections in the hand are dictated by fascial
  boundaries within the hand, so they can be
  classified as follows
• 1.Under nail fold (paronychia).
• 2.Pulp space infections (whitlow).
• 3.Other subcutaneous infections.
• 4.Infections of the tendon sheaths
  (Tenosynovitis).
• 5.Infections of the deep fascial spaces.

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(1) Paronychia

• Infection of the perionychium (also called
  eponychium), which is the epidermis bordering the
  nail.
• It results in swelling, erythema, and pain at the
  base of the fingernail and later pus.

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Mechanism Of Injery \ Cause

• Acute paronychia is usually the result of
  localized trauma to the skin surrounding the nail
  plate.
• Infection begins with a break in the skin of the
  nail fold and spreads to the subungual
  (underneath a fingernail or a toenail) space
  causing severe pain.
• The responsible organisms in acute paronychia are
  usually Staphylococcus aureus and Streptococcus
  pyogenes.
• other   Pseudomonas ,Candida ,Gram -ve bacilli.

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Treatment
Early cases may be treated with soaks and
antibiotics with the hand elevated. If there is
no rapid improvement and pus is seen or
suspected, The cuticle (the dead skin at the base
of a fingernail or toenail ) should be raised and
the pus evacuated. In some cases, the proximal
half of the nail is removed. This procedure can
be done under general or regional anesthesia, but
remember that local anesthetics must never be
used in the presence of infection because it
helps spread the infection.
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(2) Whitlow(Felon)

• ? Infection of the distal pulp or phalanx pad of
  the fingertip.
• ? It is usually caused by inoculation of bacteria
  into the fingertip through a penetrating trauma.
• ? The most commonly affected digits are the thumb
  and index finger.

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Clinical presentation

• ?. Rapid onset of severe, throbbing pain - with
  associated redness and swelling of the fingertip.
• ?. The pain is usually MORE intense than that
  caused by paronychia.

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Treatment (similar to paronychia)

• ?. In the early stages , a felon may be amenable
  to treatment with
• ?. elevation
• ?. oral antibiotics
• ?. warm water or saline
  soaks.
• ?. If there is pus so drainage.
• ?. Potential complications of a felon and felon
  drainage include
• ? neuroma
• ? unstable finger pad.

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(3) Tendon sheath infection(pyogenic flexor
tenosynovitis)

• ?. It is a small laceration or puncture wound
  occurs over the middle of a finger, especially
  near a joint on the palmar side, an infection of
  the flexor tendon can occur.
• ?. These can often cause severe stiffness, even
  destruction and rupture of the tendon.
• ?. These present acutely with
• ?.stiffness of the finger in a
  slightly bent posture
• ?. diffuse swelling and redness of
  the finger
• ?. tenderness on the palmar side
  of the finger,
• and severe aggravation of
  pain with attempts to
• straighten the finger.

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Anatomy

• ?.The flexor tendons of the hand are enclosed in
  distinct synovial sheaths.
• ?.The flexor tendon sheaths of the index, middle,
  and ring fingers extend from the distal phalanges
  to the distal palmar crease.
• ?.The sheath encompassing the fifth finger
  extends from its distal phalanx to the mid-palm,
  where it expands across the palm to form the
  ulnar bursa.
• ?. The thumb flexor sheath begins at the terminal
  phalanx and extends to the volar (palmar) wrist
  crease, where it communicates with the radial
  bursa.

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Patients with tendon-sheath infection present
with the four cardinal signs

• ?. uniform, symmetric digit swelling.
• ?. excessive tenderness along the entire course
  of the flexor tendon sheath.
• ?. at rest, digit is held in partial flexion.
• ?. pain along the tendon sheath with passive
  digit extension.

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• ?. It is dangerous and must be recognized early
  to prevent
• ?. tendon necrosis
• ?. adhesion formation
• ?.spread of infection to the deep fascial
  spaces.
• ?. The synovial sheaths are poorly vascularized,
  but are rich in nutritious synovial fluid. This
  combination provides an ideal environment for
  bacterial growth.
• ?. Once inoculated, infection spreads rapidly
  through the sheath.

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• Appreciable pain along the tendon sheath with
  passive extension of the digit is often the first
  clinical sign of this hand infection.

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Treatment

• In the early stage
• may respond to non-operative treatment that
  includes
• ?. Splinting
• ?. elevation
• ?. intravenous antibiotics.
• Rings should be removed from the affected finger
  and other fingers of the hand as soon as
  possible.
• - If there is no improvement within 12 to 24
  hours, surgical intervention is warranted.

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Treatment
Early surgical treatment should be considered
if the patient is immunocompromised or has
diabetes. Surgical treatment involves proximal
and distal tendon exposure, and careful insertion
of a catheter or feeding tube into the tendon
sheath with copious intra-operative
irrigation. Postoperatively, the catheter may be
left in place for 24 hours to allow for further
low-flow irrigation.
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(4) Fascial spaces infection

• Infection from web space or from infected tendon
  sheath or from recent penetrating trauma to the
  hand may lead to infection of the deep fascial
  spaces of the palm.
• Patient presents with pain of the whole hand and
  with movements of fingers and edema.
• Treatment
• ?. IV antibiotic.
• ?. Drainage.

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Carpal Tunnel Syndrome
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Carpal Tunnel Syndrome

• The carpal tunnel is a bony canal within the
  palm side aspect of the wrist that allows for the
  passage of the median nerve to the hand.

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Carpal Tunnel Syndrome

• Carpal Tunnel Syndrome (CTS) is a compressive
  neuropathy, i.e. it pinch's the median nerve
  within the wrist.

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Causes of CTS

• ? Systemic diseases
• ? Hyper\ hypothyroidism
• ? Rheumatoid arthritis
• ? DM
• ? Amyloidosis
• ? Forceful or repetitive movement of the
  fingers and hand, wrist injuries or swelling of
  the tendon sheath can decrease the space
  available in the carpal tunnel.
• ? Pregnancy and menopause
• ? Smoking and obesity can each increase the
  risk of developing symptoms.

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Clinical features of CTS

• Its 8 times more common in women than men (age
  40-50 years).
• ? Pain
• waken in the early morning hours
• With ? burning pain
• ? tingling
• ? numbness
• May be relieved by
• ? Hanging the arm over the
• side of the bed.
• ? shaking the arm
• Little pain during the day
• may develop in the arm and the shoulder
• there also could be swelling in the hand,
• increases at night

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Clinical features of CTS

• ? Parasthesia.
• ? A sense of weakness in the hands and a
  tendency to drop objects, loss of gripping
  strength.
• ? In late cases, there is wasting of the thenar
  muscles and weakness of thumb abduction.

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Examination
Tinel sign Tap over median nerve at wrist
crease gtgtgt electric or tingling sensation
Thumb abduction Abductor pollicis brevis
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Examination
Phalen maneuver Holding the wrist fully
palmarflexed for 1 mingt Paresthesia.ltltpositive
Wrist compression test (Durkan's test) pressure
over the median nerve proximal to the wrist,
appearance of symptoms within 30 seconds
positive
Durkan test is more sensitive than tinels sign
and phalen maneuver
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INVESTIGATION

• ?. Nerve conduction study (NCS).
• Two electrodes are taped to the skin. A small
  shock is passed through the median nerve to see
  if electrical impulses are slowed in the carpal
  tunnel.
• ?. Electromyogram (EMG).
• This test can help determine if muscle damage
  has occurred.

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Treatment
? Splinters - Prevent wrist flexion and pain
appearance during sleep. - Preferable during
pregnancy.
? Corticosteroid injection into the carpal canal.
? Open surgical division of the transverse carpal
ligament (flexor retinaculum)
? Arthroscopic carpal tunnel release.
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De Quervain's disease

• It is a painful tenosynovitis due to relative
  narrowness of the common tendon sheath that
  surrounds 2 tendons of the thumb.
• The swollen tendons and their coverings cause
  friction within the narrow tunnel, or sheath,
  through which they pass.

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De Quervain's disease (cont.)

• Most common in women aged 30-50 yrs
• de Quervain's affects women 8 to 10 times more
  often than men.
• The result is pain on the thumb side of the wrist
  joint.
• The tendons usually involved are those of
  extensor pollicis brevis and abductor pollicis
  longus.

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Causes of De Quervain's

• ?. The most common cause is chronic overuse of
  the wrist.
• ?. Direct injury to the wrist or tendon scar
  tissue can restrict movement of the tendons.
• ?. Inflammatory arthritis (such as rheumatoid
  arthritis).
• ?. Gardening, racquet sports may aggravate the
  condition.

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Clinical features

• ?. Pain on the radial side of the wrist
• Patient can point to the painful area (at the
  very tip of radial styloid)
• ?. Swelling along the course of the thumb tendons
• ?. Positive Finkelsteins test
• Hold the patients hand with the thumb tucked
  in inside the fist, then turn the wrist sharply
  toward the ulnar side. Pain over the radial side
  is a positive sign.

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Treatment

• ?. Splint that includes wrist and thumb.
• (24 hours a day for 4 to 6 weeks to immobilize
  the affected area. )
• ?. Avoid any activities that aggravate the
  condition.
• ?. Anti-inflammatory medication (such as naproxen
  or ibuprofen).
• ?. If symptoms continue, inject the area with
  cortisone to decrease pain and swelling.
• ?. Resistant cases, need surgery

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• ?. Surgery for de Quervain's disease is an
  outpatient procedure done under local anesthesia.
• ?. Surgical release of the tight sheath
  eliminates the friction.
• ?. Upon recovery, an exercise program is done to
  strengthen thumb and wrist.
• ?. Recovery times vary, depending on age,
  general health, and duration of symptoms.
• ?. In cases that have developed gradually, the
  disease is usually more resistant.