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Fifth stage
Surgery-Ortho
Lec-4
د
.
مثنى
3/1/2016
The hand
Congenital anomalies
Extra digits (polydactyly); eg duplication of the thumb, extra little finger.
Syndactyly; congenital webbing; simple (only skin) or complex (bone fusion).
Skin contractures
After cuts, burns, or surgical incisions.
Surgical incisions should be parallel or oblique to skin creases and never vertical to
avoid contractures.
Treated by Z-plasty or skin graft.
Superficial palmar fascia contracture
(Dupuytren’s contracture
)
Hypertrophy and contracture of the palmar aponeurosis.
Leads to puckering of the palmar skin and fixed flexion of the fingers.
Volkman’s ischemic contracture
Circulatory insufficiency at or below the elbow leads to forearm flexor muscle
contracure.
The end result of untreated compartment syndrome.
Mallet finger
Injury of the extensor tendon of the distal phalanx.
Cause: direct trauma or indirect as the distal phalanx is forcibly bent during active
extension.
The distal phalanx is flexed, and cannot be actively extended.
Treatment: splintage in extension for 8 weaks.
Stenosis tenovaginitis
(trigger finger)
Trapping of the flexor tendon sheath on entrance to its sheath.
On Forceful extension the tendon enters its sheath with a snap (triggering).
Cause: thickening of the sheath due to:
o Trauma.
o Rheumatoid tenosinovitis.
o Associated with DM and gout.
Clinical features
Ring and middle fingers are more affected.
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Triggering on forceful extension of the affected finger.
Tender nodule in front of the MPJ.
Treatment
Early; local injection of methyleprednisolone.
Late; division of the fibrous sheath.
Acute infections of the hand
Usually stphylococcus aureus.
Pathology: inflammation, edema, suppuration and increased tissue tension.
Closed compartments; (eg pulp space, tendon sheath) rise in pressure lead to tissue
necrosis.
Permanent Stiffness.
Lymphangitis, septicemia.
Clinical features
History of trauma (abrasion, laceration, or penetrating wound, animal or human bite).
Hand pain (throbbing), and swelling.
Patient ill and feverish.
History of trauma; eg plant thorn prick, local injection,…
Predisposing factors; DM, uremia…
On examination
Hand is red, swollen, exquisitely tender.
Movement restricted.
Lymphangitis and lymphadenopathy.
Septicemia.
N.B.: local signs are not typical in immunosuppressed patient.
X-ray
Foreign body.
Later osteomyelitis.
Pus for culture and sensitivity.
Differential diagnosis
Insect bite or sting.
Thorn prick (non-septic inflammatory reaction to a retained fragment).
Acute tendon rupture.
Acute gout.
Treatment
should be adequate without delay
1. Antibiotics:
Started soon after C/S.
Flucloxacillin or cephalosporines.
Fucidic acid added in osteomyelitis.
Metronidazole added in agricultural infections for anerobes.
Penicillines for bites.
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2. Rest, splintage and elevation
Admit to hospital.
Elevation.
Analgesia.
Splintage in position of safe immobilization.
3. Drainage
If signs of abscess; throbbing pain, marked tenderness, and toxemia.
Done under GA with tourniquet.
4. post operative rehabilitation
Started as soon as the acute inflammation settles.
Nail-fold infection (paronychia)
Commonest hand infection.
After rough nail trimming.
Treated by antibiotics.
Drainage if abscess is formed.
Pulp infection (felon)
Pulp space is a closed compartment.
Infection and abscess collection may cause tissue necrosis.
Usually caused by Staphylococcus aureus.
May spread to bone, joint or tendon.
Antibiotics and early drainage are essential.
Tendon sheath infection
(suppurative tenosynovitis)
Uncommon but dangerous.
Caused by Staphylococcus Aureus.
Digit is tender, swollen, held in slight flexion, and no movement is allowed.
Delayed diagnosis and drainage leads to rise in pressure and tendon necrosis.
Deep fascial plane infections
Thenar and mid-palmar space infection.
Swelling is more on the dorsum of the hand.