wrist and hand

Wrist and Hand

Symptoms:- Pain swelling. deformity. loss of function
signs :- Look. feel. move. grip strength. neurological assessment.

Painful hand 

Refereed pain :- neck, shoulder, mediastinum. Joint disorders:- RA, OA. Periarticular disorders: - carpal tunnel, tenosynovitis, infection.

Hand congenital deformitiesHand and foot are common site of congenital deformities of musculoskeletal system.

1- failure of formation2- failure of differentiation. e.g. syndactyly3-focal defect. e.g..polydactyly.4- overgrowth. Giant finger.5- generalized malformation. Marfan’s syndrome ( spider hand’s ), achondroplasia (trident hand)

Wrist malformations. RADIAL CLUB HAND The infant is born with the wrist in marked radial deviation. There is absence of the whole or part of the radius, and usually also the thumb. ulnar club hand.

The carpus is deviated forwards, leaving the ulnar head projecting on the back of the wrist. Deformity is seldom marked before the age of 10 years. function is usually excellent. in the worst cases the deformity may have to be corrected by Osteotomy
Madelung's deformity


Acquired deformitiesit may result from skin, subcutaneous tissues, muscles, tendon, joint, bone ,or neurological diseases
Skin contractures: Scar of burn or wound cause hand deformities. It should prevented by proper treatment and when established surgical treatment indicated. Bone lesion: malunited fractures may cause hand deformity.


Muscles contractures.
1- Ischemic contracture of the forearm. Finger flexed and only extend when the wrist flexed (Volkmann’s).2- Shortening of the intrinsic muscles. There is flexion of MPJ & extension of IPJ. It result from spasticity of intrinsic muscles or contracture of intrinsic muscles by infection or trauma.Both causes can be treated surgically-

After the metacarpophalangeal joints, the wrist is the most common site of rheumatoid arthritis. Pain, swelling and tenderness may at first be localized to the joints or to the tendon sheaths. In late cases the wrist and fingers are deformed and unstable.
Rheumatoid arthritis of Wrist and hand


Ulnar deviation of the fingers and subluxation of the Mp joints in RA. Swan-neck deformityboutonniere deformities Mallet’s finger : result from injury to the extensor tendon of terminal phalanx.Mallet’s thumb: Rupture of extensor pollicis longus: result from RA,or Colle’s fracture.Drop finger: result from rupture of extensor tendon proximal to MPJ.

X ray

The characteristic features are osteoporosis and periarticular bony erosions.

Narrowing joint space.

Treatment
Management in the early stage consists of splintage. local injection of corticosteroids. Combined with systemic treatment. At late stage surgery of different type according to stage and deformity. ( synovectomies, excision of head of ulna, soft tissues reconstruction, arthrodesis or arthroplasty in advance cases).

KIENBOCK'S DISEASE

The lunate bone develop a patchy avascular necrosis. A predisposing factor of Kienbock’s disease : may be relative shortening of the ulna . which could result in excessive stress being applied to the lunate where it is squeezed between the distal surface of the (over­long) radius and the second row of carpal bones.The patient, usually a young adult, Complains of ache and stiffness, Tenderness is localized to the centre of the wrist on the dorsum, wrist extension may be limited.


Imaging
Typical x-ray signs are increased density and fragmentation in the lunate. The earliest signs of osteonecrosis can be detected only by MRI. later osteoarthritis of the wrist.

Treatment

During the early stage, while the shape of the lunate is more or less normal, shortening osteotomy of the distal end of the radius may reduce pressure on the bone and thereby protect it from collapsing. In late cases, partial wrist arthrodesis may be the only option.


DeQuervain’s disease (stenosing tenosynovitis)Tenovaginitis ( tenosynovitis) Inflammation and thickening of tendon sheath of the first dorsal compartment ( extensor pollicis brevis and abductor pollicis longus) due to overuse, is usually seen in women between the ages of 30 and 50 years. There may be a history of unaccustomed activity.

Clinical features

The condition is common in women aged 30-50,who complain of pain in radial side of the wrist. There may be a swelling along the course of the thumb tendons, it may be hard and thick. Cripitus during thumb movement may palpable. Tenderness is most acute at the tip of the radial styloid.

The pathognomonic sign : Abduction of the thumb against resistance and passive adduction of the thumb across the palm are both painful.

Treatment

In early cases, symptoms can be relieved by avoid predisposing overuse, rest , and NSAID .Sometimes combined with splintage of the wrist. IF symptoms persist a local corticosteroid injection into the tendon sheath. In resistant cases Operation, which consists of slitting the thickened tendon sheath. Care should be taken to prevent injury to the dorsal sensory branches of the radial nerve, which may cause intractable pain.

Trigger finger (Stenosing tenosynovitis) Intermittent 'deformity'. usually of the ring , thumb or middle finger. A flexor tendon may become trapped at the entrance to the sheath; on forced extension it passes the constriction with snap (triggering). The usual cause is thickening of tendon sheath following trauma or overuse or RA.

The finger or thumb click as the patient flex it, when the hand open the affected finger remain bent but with further effort it suddenly straightens with snap. A tender nodule can be felt in front of the affected sheath. Caused by thickening of the fibrous tendon sheath or due to a bulky Tenosynovitis. TREATMENT Early cases cured may be cured rest and local injection of steroid placed at entrance of the tendon sheath. If symptom persist the fibrous sheath is incised surgically, allowing the tendon to move freely.


Ganglion
It arises from cystic degeneration in the joint capsule or tendon sheath, the distended cyst contains a glairy fluid . The patient, often a young adult, presents with a painless lump, usually on the back of the wrist, and to less degree in volar side. Occasionally there is a slight ache. The lump is well defined, cystic and not tender. It may be attached to one of the tendons.

Treatment

The ganglion often disappears after some months, so there should be no haste about treatment. If the lesion continues to be troublesome, it can be aspirated. if it recurs, excision is justified, but the patient should be told that there is a 30 per cent risk of recurrence, even after careful surgery .

CARPAL TUNNEL SYNDROME

This is the commonest and best known of all the nerve entrapment syndromes. In the normal carpal tunnel there is barely room for all the tendons and the median nerve . Any swelling in this canal is likely result in compression and ischaemia of the nerve. Common in women at the menopause, in rheumatoid arthritis, in pregnancy and in myxoedema.

Clinical features

The usual age group is 40-50 years The history is most helpful in making the diagnosis. Pain and paraesthesia occur in the distribution of the median nerve in the hand. Night after night the patient is woken with burning. Patients tend to seek relief by hanging the arm over the side of the bed or shaking the arm.

helpful test (Tinels sign) : sensory symptoms can often be reproduced by percussing over the median nerve.phalen’s test : Holding the wrist fully flexed for a minute or two .

In late cases there is wasting of the thenar muscles. weakness of thumb abduction and sensory impairment in the median nerve territory. Electrodiagnostic tests. which show slowing of nerve conduction across the wrist.

Treatment

Light splints that prevent wrist flexion can help those with night pain or with pregnancy-related symptoms. Steroid injection into the carpal canal when surgery contraindicated, provides temporary relief . Open surgical division of the transverse carpal ligament usually provides a quick and simple cure. Endoscopic carpal tunnel release offers an alternative.

DUPUYTREN'S CONTRACTURE

nodular hypertrophy and contracture of the palmer aponeurosis. It is familial. It is more common in Anglo-Saxon, diabetic, aids ,epileptic treated by phenytoin.Clinical features: middle aged man complain of a nodular thickening in the palm extend to ring and little finger. One hand usually affected more than other. It produce flexion contracture of MPJ &PIPJ. Similar node may be seen in sole of foot.Dupuytren’s contracture should differentiated from contractures result from skin scar or tendon lesions.Surgical treatment through Z -plasty incision is the treatment, followed by physiotherapy and splintage.

Acute infections of the hand

Infection of The hand is frequently limited or one of several well-defined compartments: Nail fold (paronychia). The pulp space (whitlow). Subcutaneous tissues elsewhere. A tendon sheath. One of the deep fascial spaces or a joint. usually the cause is a Staphylococcus which has been implanted by trivial or unobserved injury.

Pathology and Clinical features

Acute inflammation and suppuration in small closed compartments (e.g. The pulp space or tendon sheath) may cause an increase in pressure to levels at which the local blood supply is threatened, In neglected cases tissue necrosis is an immanent risk. Even if this does not occur, the patient may end up with a stiff and useless hand unless the infection is rapidly control. Usually there is a history of trauma like thorn prick , but it may have been so trivial as to pass unnoticed. The patient may feel ill, feverish and the pain becomes throbbing. obvious redness and tension in the tissues, tenderness over the site of infection, Finger movements may be markedly restricted.

Principles of treatment

1- AntibioticsAs soon as the diagnosis is made and specimens have been taken for microbiological investigation, antibiotic treatment is started - usually with, flucloxacillin and, in severe cases, with fusidic acid, or a cephalosporin as well. This may later be changed when bacterial sensitivity is known.2 – Rest , Analgesics and elevationIn a mild case the hand is rested in a sling. In a severe case the arm is elevated while the patient is kept in hospital under observation. Analgesics are given for pain.

3- Drainage

If there are signs of an abscess (throbbing pain, marked tenderness and toxaemia). the pus should drained. A tourniquet and either general or regional block anaesthesia are essential. The incision should be made at the site of maximal tenderness, but never across a skin crease. Necrotic tissue is excised and the area thoroughly washed and cleansed. The wound is either left open and then covered with dressings. A pus specimen is sent for microbiological investigation

4- Splintage and physiotherapy

splint should be applied always with the joints in the position of function. Early active exercises.

Paronychia

Pulp-space infection (felon)

Tendon-sheath infection

Deep fascial space infection

Human bites

M . O . (including anaerobes) are encountered, the commonest being Staphylococcus aureus, Streptococcus group . such wounds should be assumed to be infected. Surgery to clean the infected tissue. Antibiotic .