Orthopedics 5th year, 5th lecture (Dr. Ariwan)
Upcoming SlideShare
Loading in...5

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



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

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



Total Views
Views on SlideShare
Embed Views



1 Embed 1

http://www.slashdocs.com 1



Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
Post Comment
Edit your comment

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