ORTHOPEDIC
The HandCongenital anomalies• Extra digits (polydactyly); eg duplication of thethumb, extra little finger.• Syndactyly; congenital webbing; simple (onlyskin) or complex (bone fusion).
Skin contractures• After cuts, burns, or surgical incisions.• Surgical incisions should be parallel or obliqueto skin creases and never vertical to avoidcontractures.• Treated by Z-plasty or skin graft.
Superficial palmar fascia contracture(Dupuytren’s contracture)• Hypertrophy and contracture of the palmaraponeurosis.• Leads to puckering of the palmar skin andfixed flexion of the fingers.
Volkman’s ischemic contracture• Circulatory insufficiency at or below the elbowleads to forearm flexor muscle contracure.• The end result of untreated compartmentsyndrome.
Mallet finger• Injury of the extensor tendon of the distalphalanx.• Cause: direct trauma or indirect as the distalphalanx is forcibly bent during activeextension.• The distal phalanx is flexed, and cannot beactively extended.• Treatment: splintage in extension for 8 weaks.
Stenosis tenovaginitis(trigger finger)• Trapping of the flexor tendon on entrance toits sheath.• On Forceful extension the tendon enters itssheath with a snap (triggering).• Cause: thickening of the sheath due to:– Trauma.– Rheumatoid tenosinovitis.– Associated with DM and gout.
Clinical features• Ring and middle fingers are more affected.• Triggering on forceful extension of theaffected 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 staphylococcus aureus.• Pathology: inflammation, edema, suppurationand increased tissue tension.• Closed compartments; (eg pulp space, tendonsheath) rise in pressure lead to tissue necrosis.• Permanent Stiffness.• Lymphangitis, septicemia.Clinical features• History of trauma (abrasion, laceration, orpenetrating wound, animal or human bite).• Hand pain (throbbing), and swelling.• Patient ill and feverish.• History of trauma; eg plant thorn prick, localinjection,…• 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 inimmunosuppressed patient.• And extremes of age.X-ray• Foreign body.• Later osteomyelitis.• Pus for culture and sensitivity.Differential diagnosis• Insect bite or sting.• Thorn prick (non-septic inflammatory reactionto a retained fragment).• Acute tendon rupture.• Acute gout.Treatmentshould be adequate without delay1. Antibiotics:– Started soon after C/S.– Flucloxacillin or cephalosporines.– Fucidic acid added in osteomyelitis.– Metronidazole added in agricultural infectionsfor anerobes.– Penicillines for bites.2-Rest, splintage and elevation• Admit to hospital.• Elevation.• Analgesia.• Splintage in position of safe immobilization.
3-Drainage• If signs of abscess; throbbing pain, markedtenderness, and toxemia.• Done under GA with tourniquet.4- post operative rehabilitation• Started as soon as the acute inflammationsettles.
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 causetissue 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 inpressure and tendon necrosis.
Deep fascial plane infections• Thenar and mid-palmar space infection.• Swelling is more on the dorsum of the hand.
