1 st part: Fatima Mirza Hammad 2 nd part: Naeema Abdulla Ali

Hand Deformities Mallet finger Trigger finger Boutonniere deformity Swan neck deformity Acute infections of the hand Paronychia Whitlow(Felon) Tendon sheath infection Fascial spaces infection De Quervain's disease Carpal Tunnel Syndrome

(1) Mallet finger  Injury of the extensor digitorum tendon of the fingers at the distal interphalangeal (DIP) joint.  Results from hyperflexion of the extensor digitorum tendon

1 st : Commonly an athletic or work related injury. Occurs when a ball (basketball, or volleyball), while being caught, hits an outstretched finger and jams it. 2 nd : Other common mechanisms of injury include forcefully tucking in a bedspread or slipcover or pushing off a sock with extended fingers. With or without fracture.

Management options 1. Mallet splint for 6 to 8 weeks 2. Extension block by k-wire for 4 weeks, (when there is involvement of more than one third of the base of the distal phalanx). This allows the tendon to reattach. If the finger is bent during these weeks the healing process must start all over again.

3.Surgical: Fixation of DIP joint  A surgical pin acts like an internal cast to keep the DIP joint from moving so the tendon can heal.  The pin is removed after 6 to 8 weeks

(2) Trigger finger  A type of stenosing tenosynovitis  narrowing of the sheath that surrounds the tendon in the affected finger, or a nodule forms on the tendon.  The tendon can NO longer slide freely through its sheath. teno

 Affected digits may become painful to straighten once bent  May make a soft crackling sound when moved.  It props back suddenly when straightened  It is called trigger finger because when the finger unlocks, it pops back suddenly, as if releasing a trigger on a gun.

Treatment Trigger finger is usually idiopathic. Injection of the tendon sheath with a corticosteroid is effective over weeks to months in more than half of patients. Surgery: cut the sheath that is restricting the tendon. Recurrency is rare

(3) Boutonniere deformity (3) Boutonniere deformity Flexion deformity of the PIP joint, due to interruption of the central slip of the extensor tendon (part that insert extensor tendon to the middle phalanx) Hyperflexion at the PIP joint with hyperextension at the DIP.

 Makes it difficult or impossible to extend the proximal interphalangeal (PIP) joint actively.  Passive extension of the PIP joint is easy.

 The lateral bands separate  The head of the proximal phalanx pops through the gap like a finger through a button hole  The DIP joint is drawn into hyperextension.

The lateral bands separate The head of the proximal phalanx pops through the gap like a finger through a button hole The DIP joint is drawn into hyperextension.

Lateral band Central slip Distal phalanx

Causes of Boutonniere deformity 1.Traumatic injury 2.Inflammatory conditions (like rheumatoid arthritis) 3.Severe burn 4.Dupuytren's contracture (thickening of the palmar fascia, producing a flexion deformity of a finger)

Stages of Boutonniere deformity 1 st Mild extension lag, passively correctable 2 nd Moderate extension lag, passively correctable 3 rd Mild flexion contracture 4 th Advanced flexion contracture

An X-ray should be done to detect avulsion fractures ( avulsion fracture occurs when the tendon pulls off a piece of the bone as a result of physical trauma)

Treatment A: Conservative Treatment: Splinting of the PIP joint for 6 week Splinting and a rigorous exercise program may even work when the injury is quite old.

When the deformity is the result of a dislocation of the PIP joint Surgery may be required to reconstruct and rebalance the extension mechanism. Surgery carries a relatively high risk of FAILURE to achieve completely normal functioning extension mechanism of the finger. B: Surgery :

- the PIP joint is hyper extended. - DIP joint is flexed.

In the PIP joint the strongest ligament is the volar plate. This ligament connects the proximal phalanx to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the PIP joint from bending back too far (hyperextending). Swan neck deformity can occur when the volar plate loosens from disease or in jury. volar plate becomes weakened and stretched by RA, direct truma! PIP joint becomes loose and begins to easily bend back into hyperextension extensor tendon gets out of balance allows the DIP joint to get pulled downward into flexion swan neck deformity occurs

- Symptoms : - swelling and pain due to inflammation from injury or disease (RA) - Signs : Swan-neck !! - the PIP joint is hyper extended. - DIP joint is flexed. - Diagnosis : - clinical diagnosis - X-ray is done to evaluate the joints (RA) and look for fractures..

1) A special splint may be used to keep the PIP joint lined up, protect the joint from hyperextending, and still allow the PIP joint to bend

2) Swan neck deformity with a stiff PIP joint sometimes requires replacement of the PIP joint, called arthroplasty 3) If past treatments, including surgery, do not stop inflammation or deformity in the PIP joint, fusion of the PIP joint may be recommended. The PIP joint is usually fused in a bent position, between 25 and 45 degrees. Fusing the two joint surfaces together eases pain, makes the joint stable, and helps prevent additional joint deformity.

Infections in the hand are dictated by fascial boundaries within the hand, so they can be classified as follows: 1.Under nail fold (paronychia). 2.Pulp space infections (whitlow). 3.Other subcutaneous infections. 4.Infections of the tendon sheaths (Tenosynovitis). 5.Infections of the deep fascial spaces.

(1) Paronychia: (1) Paronychia: Infection of the perionychium (also called eponychium), which is the epidermis bordering the nail. It results in swelling, erythema, and pain at the base of the fingernail and later pus.

Acute paronychia is usually the result of localized trauma to the skin surrounding the nail plate. Infection begins with a break in the skin of the nail fold and spreads to the subungual (underneath a fingernail or a toenail) space causing severe pain. The responsible organisms in acute paronychia are usually Staphylococcus aureus and Streptococcus pyogenes. other: Pseudomonas,Candida,Gram -ve bacilli.

Early cases may be treated with soaks and antibiotics with the hand elevated. If there is no rapid improvement and pus is seen or suspected, The cuticle (the dead skin at the base of a fingernail or toenail ) should be raised and the pus evacuated. In some cases, the proximal half of the nail is removed. This procedure can be done under general or regional anesthesia, but remember that local anesthetics must never be used in the presence of infection because it helps spread the infection.

(2) Whitlow(Felon): ♣ Infection of the distal pulp or phalanx pad of the fingertip. ♣ It is usually caused by inoculation of bacteria into the fingertip through a penetrating trauma. ♣ The most commonly affected digits are the thumb and index finger.

♣. Rapid onset of severe, throbbing pain - with associated redness and swelling of the fingertip. ♣. The pain is usually MORE intense than that caused by paronychia.

♠. In the early stages, a felon may be amenable to treatment with: ♥. elevation ♥. oral antibiotics ♥. warm water or saline soaks. ♠. If there is pus so drainage. ♠. Potential complications of a felon and felon drainage include: ♥ neuroma ♥ unstable finger pad.

(3) Tendon sheath infection: (pyogenic flexor tenosynovitis): ♠. It is a small laceration or puncture wound occurs over the middle of a finger, especially near a joint on the palmar side, an infection of the flexor tendon can occur. ♠. These can often cause severe stiffness, even destruction and rupture of the tendon. ♠. These present acutely with: ♣.stiffness of the finger in a slightly bent posture ♣. diffuse swelling and redness of the finger ♣. tenderness on the palmar side of the finger, and severe aggravation of pain with attempts to straighten the finger.

Anatomy: ♣.The flexor tendons of the hand are enclosed in distinct synovial sheaths. ♣.The flexor tendon sheaths of the index, middle, and ring fingers extend from the distal phalanges to the distal palmar crease. ♣.The sheath encompassing the fifth finger extends from its distal phalanx to the mid-palm, where it expands across the palm to form the ulnar bursa. ♣. The thumb flexor sheath begins at the terminal phalanx and extends to the volar (palmar) wrist crease, where it communicates with the radial bursa.

♣. uniform, symmetric digit swelling. ♣. excessive tenderness along the entire course of the flexor tendon sheath. ♣. at rest, digit is held in partial flexion. ♣. pain along the tendon sheath with passive digit extension.

It is dangerous and must be recognized early to prevent: ♠. It is dangerous and must be recognized early to prevent: ♣. tendon necrosis ♣. adhesion formation ♣.spread of infection to the deep fascial spaces. ♠. The synovial sheaths are poorly vascularized, but are rich in nutritious synovial fluid. This combination provides an ideal environment for bacterial growth. ♠. Once inoculated, infection spreads rapidly through the sheath.

Appreciable pain along the tendon sheath with passive extension of the digit is often the first clinical sign of this hand infection.

Treatment: In the early stage: may respond to non-operative treatment that includes : ♠. Splinting ♠. elevation ♠. intravenous antibiotics. Rings should be removed from the affected finger and other fingers of the hand as soon as possible. - If there is no improvement within 12 to 24 hours, surgical intervention is warranted.

Early surgical treatment should be considered if the patient is immunocompromised or has diabetes. Surgical treatment involves proximal and distal tendon exposure, and careful insertion of a catheter or feeding tube into the tendon sheath with copious intra-operative irrigation. Postoperatively, the catheter may be left in place for 24 hours to allow for further low-flow irrigation.

(4) Fascial spaces infection: Infection from web space or from infected tendon sheath or from recent penetrating trauma to the hand may lead to infection of the deep fascial spaces of the palm. Patient presents with pain of the whole hand and with movements of fingers and edema. Treatment: Treatment: ♠. IV antibiotic. ♠. Drainage.

 The carpal tunnel is a bony canal within the palm side aspect of the wrist that allows for the passage of the median nerve to the hand.

Carpal Tunnel Syndrome  Carpal Tunnel Syndrome (CTS) is a compressive neuropathy, i.e. it pinch's the median nerve within the wrist.

♠ Systemic diseases: ♣ Hyper\ hypothyroidism ♣ Rheumatoid arthritis ♣ DM ♣ Amyloidosis ♠ Forceful or repetitive movement of the fingers and hand, wrist injuries or swelling of the tendon sheath can decrease the space available in the carpal tunnel. ♠ Pregnancy and menopause ♠ Smoking and obesity can each increase the risk of developing symptoms.

Its 8 times more common in women than men (age years). ♠ Pain: # waken in the early morning hours With: ♣ burning pain ♣ tingling ♣ numbness May be relieved by: ♣ Hanging the arm over the side of the bed. ♣ shaking the arm # Little pain during the day # may develop in the arm and the shoulder # there also could be swelling in the hand, increases at night

♠ Parasthesia. ♠ A sense of weakness in the hands and a tendency to drop objects, loss of gripping strength. ♠ In late cases, there is wasting of the thenar muscles and weakness of thumb abduction.

Tinel sign : Tap over median nerve at wrist crease >>> electric or tingling sensation Examination: Thumb abduction Abductor pollicis brevis Thumb abduction Abductor pollicis brevis

Examination: Phalen maneuver: Holding the wrist fully palmarflexed for 1 min> Paresthesia.<<positive Wrist compression test (Durkan's test): pressure over the median nerve proximal to the wrist, appearance of symptoms within 30 seconds = positive Durkan test is more sensitive than tinel’s sign and phalen maneuver

♣. Nerve conduction study (NCS). Two electrodes are taped to the skin. A small shock is passed through the median nerve to see if electrical impulses are slowed in the carpal tunnel. ♣. Electromyogram (EMG). This test can help determine if muscle damage has occurred.

♣ Splinters - Prevent wrist flexion and pain appearance during sleep. - Preferable during pregnancy. ♣ Open surgical division of the transverse carpal ligament (flexor retinaculum) ♣ Corticosteroid injection into the carpal canal. ♣ Arthroscopic carpal tunnel release.

De Quervain's disease  It is a painful tenosynovitis due to relative narrowness of the common tendon sheath that surrounds 2 tendons of the thumb.  The swollen tendons and their coverings cause friction within the narrow tunnel, or sheath, through which they pass.

De Quervain's disease (cont.)  Most common in women aged yrs  de Quervain's affects women 8 to 10 times more often than men.  The result is pain on the thumb side of the wrist joint.  The tendons usually involved are those of extensor pollicis brevis and abductor pollicis longus.

Causes of De Quervain's ♣. The most common cause is chronic overuse of the wrist. ♣. Direct injury to the wrist or tendon; scar tissue can restrict movement of the tendons. ♣. Inflammatory arthritis (such as rheumatoid arthritis). ♣. Gardening, racquet sports may aggravate the condition.

Clinical features ♣. Pain on the radial side of the wrist Patient can point to the painful area (at the very tip of radial styloid) ♣. Swelling along the course of the thumb tendons ♣. Positive Finkelstein’s test: Hold the patient’s hand with the thumb tucked in inside the fist, then turn the wrist sharply toward the ulnar side. Pain over the radial side is a positive sign.

Treatment ♣. Splint that includes wrist and thumb. (24 hours a day for 4 to 6 weeks to immobilize the affected area. ) ♣. Avoid any activities that aggravate the condition. ♣. Anti-inflammatory medication (such as naproxen or ibuprofen). ♣. If symptoms continue, inject the area with cortisone to decrease pain and swelling. ♣. Resistant cases, need surgery

♣. Surgery for de Quervain's disease is an outpatient procedure done under local anesthesia. ♣. Surgical release of the tight sheath eliminates the friction. ♣. Upon recovery, an exercise program is done to strengthen thumb and wrist. ♣. Recovery times vary, depending on age, general health, and duration of symptoms. ♣. In cases that have developed gradually, the disease is usually more resistant.