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

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

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

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

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