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

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The lecture has been given on Feb. 23rd, 2011 by Dr. Ariwan.

The lecture has been given on Feb. 23rd, 2011 by Dr. Ariwan.

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

    • Orthopedic Hand Problems
    • Congenital anomalies
      • Central longitudinal deficiency ( Lobster Claw Hand ).
      • Syndactyly ( Congenital webbing ).
      • Polydactyly ( Extra digit ).
      • Overgrowth ( Macrodactyly ).
    • Acquired deformities
      • Mallet finger
      • The terminal phalanx is in flexion, cannot be extended actively but only passively.
      • Causes:
      • Direct trauma or wound causing tendon rupture.
      • Indirect trauma when the tip is forcibly bends during active extension causing rupture or avulsion of bone chip.
      • Treatment:
      • Conservative: Acute injury or delay for several weeks by splintage in extension for 8 weeks. (Even with fracture)
      • Operative: Old lesions, marked deformity, impaired function, joint mobile
      • tendon reconstruction or fusion.
    • Boutonniere Deformity (Button Hole)
      • Hyperextension of the DIP joint with flexion of the PIP joint.
      • Cases:
      • Avulsion or rupture of central slip of extensor expansion (RA, penetrating injury).
      • Dislocations of the lateral slips.
      • Treatment: According to the cause
      • Conservative: splintage in corrected position.
      • Operative: If avulsion or rupture in open wound early repair or late tendon reconstruction
    • Swan Neck Deformity
      • Hyperextension of the PIP and flexion of the DIP joint.
      • Usually seen in rheumatoid arthritis.
      • Treatment:
      • Conservative : Splintage.
      • Operative: Intrinsic release or flexor digitorum superficials tenodeses.
    • Trigger Finger (Stenosing Tenovaginits)
      • Stenoses at the opening of fibrous flexor sheath of flexor tendons.
      • Usually affect the thumb in children, ring finger in adults or any other finger.
      • Common in RA and gout.
      • Clinical features :
      • Clicking during finger bending.
      • During unclenching finger remain flexed at the PIP & suddenly straighten with a snap.
      • Tender nodule in front of the MP joint (mouth of the sheath).
      • Treatment :
      • Conservative : Early by careful injection of methylprednisolone into the tendon sheath.
      • Operative : Is the definite treatment; transverse incision distal to the distal palmar crease, longitudinal incision in the mouth of fibrous sheath release the tendon.
      • In babies surgery needed after age of one year.
    • Dupuytren's contracture
      • Nodular hypertrophy and contracture of the superficial palmer fascia (Palmar Aponeuroses).
      • Pathology :
      • Proliferation of myofibroblasts in the palmer aponeuroses contractions of fibrous bands in the fingers, flexion of the MP&PIP joints.
      • Fibrous attachment to the skin, skin puckering.
      • Associations:
        • Epileptics on phenyton therapy.
        • DM & smoking.
        • Alcoholic cirrhoses.
        • AIDS.
        • Pulmonary TB.
    • Clinical features:
      • Middle age, ♂>♀.
      • Autosomal dominant in Anglo-Saxon descent.
      • Nodular thickening of the palm gradually extends to the fingers.
      • It's often bilateral (one more than the other).
      • Ring and/or the Little finger are flexed in the MP&PIP joints.
      • The sole of the foot may be affected.
    • Treatment
      • Early: Daily physiotherapy and splintage to correct the fingers.
      • Late: Resistant deforming lesion:
      • Subcutaneous fasciotomy : risk of neurovascular injury and recurrence.
      • Open fasciectomy : Z- plasty to the skin & complete excision of the thickened aponeuroses; postoperative splintage and physiotherapy.
      • Closure may need skin flap or partial thickness skin graft.
    • Acute Infections of the Hand
      • Common orthopedic hand problem, common in young manual workers, diabetic, immune compromised patients.
      • Usually limited to one of the closed compartments (nail fold, pulp space, tendon sheath, deep fascial spaces…..).
      • Pathology:
      • Acute pyogenic inflammatory reaction.
      • Usual pathogen is staphylococcus aureus , 10% unusual organisms.
      • Inflammation edema suppuration increase tissue tension in closed space ischemia and tissue necroses .
      • If neglected infection spread to other compartments stiff hand.
      • Lymphangits lymphadenitis Septicemia.
    • Clinical feature:
        • History of trauma (abrasion, laceration, penetration….).
        • Pain (throbbing) and swelling after few hours or days.
        • Ill health & fever.
        • Ask about DM, drug abuse, immunosuppression.
        • Examination:
          • Swelling of finger or hand (dorsum).
          • Severe local tenderness.
          • Limited active finger flexion.
          • Lymphangits & lymphadenitis.
          • Signs of septicemia.
    • Investigations
            • CBP& ESR.
            • Blood culture.
            • X-ray:
      • Early: foreign body.
      • Late: osteomyelits, septic arthritis.
      • Pus for gram stains & culture sensitivity.
    • Principles of treatment
      • Superficial infection may change to serious deep one.
      • Antibiotics:
      • After pus specimen taken start cloxacilline or cephalosporin.
      • If suspect anaerobes (bite, agricultural inj.) add metronidazole.
      • Later antibiotic changed according to culture result& continued till infection clearance.
      • Rest, splintage, elevation:
      • Mild infection Sling.
      • Severe infection hospital admission+ elevation+ position of safe immobilization.
      • Surgical drainage:
      • If signs of abscess.
      • If no response after 48 hours.
      • Drain the abscess+ excise necrotic tissue+ leave the wound open+ inspect after 24 hours (closure).
      • Rehabilitation:
      • Once acute symptoms settled active physiotherapy + intermittent splintage.
    • Nail Fold Infection (Paronychia)
      • Pyogenic infection under the nail fold, it's the commonest type of hand infection.
      • Clinical features:
      • Common in children> adult.
      • Nail fold edges become red, swollen, tender and later abscess formation.
      • Treatment:
      • Early : antibiotics are curative.
      • Late (abscess): drainage through incision parallel to the nail fold.
      • If pus extend below the nail, partial nail excision.
    • Pulp Infection (Felon)
      • Pyogenic infection of the distal finger pad; intense pain &ischemia to the distal phalanx.
      • Causes:
      • Pricking by needle, thorn…. .
      • Commonest organism is staphylococcus aureus .
      • Clinical features:
      • Intense throbbing pain at finger tip.
      • Red, swollen, acutely tender.
      • Treatment:
        • Early: elevation + antibiotics.
        • Late: drainage over maximum tenderness, the wound heal by secondary intension.
      • If neglected infection spread to bone, joint, tendon sheath.
    • Deep Fascial Space Infection
      • Pyogenic infection of the thenar and mid palmar fascial spaces.
      • Causes:
      • Penetrating injury.
      • Secondary spread from (web space, tendon sheath…..).
      • Clinical features:
      • Intense throbbing pain at the hand.
      • Redness over the palm, intense swelling of the dorsum (inflated glove).
      • Intense tenderness, hand held immobile.
      • Lymphangits.
      • The patient is ill, feverish, and toxic.
    • Treatment
        • Antibiotics, elevation, splintage, analgesics.
        • Surgical drainage (persistent fever, signs of abscess).
      • Thenar space: curved incision radial to the thenar crease.
      • Hypothenar space: transverse incision proximal to the distal palmar crease.
      • Leave the wound open, second look after 24 hour then closure.
      • Never cross the creases at right angles