Hand orthopedics

Dr.Abdirahman Adan
 Function of the hand
Picking
Holding,
Pressing,
Grip.

Qualities of hand:
flexibility, strength,
sensitivity, coordination.
History
Age
Occupation
Left or right hand
Ask about sensation and
weakness.
 Examination
•  Look: Deformity, scars, nodules.
•  Feel: Sensation of digits - both sides with light
touch and two point discrimination, Tinel´s
test.
•  Move: Tendon functions. Superficial and deep
flexors and extensors.
•  Circulation: Capillary refill time, Allen test.
Allen test
•  Hand elevated in fist
•  Press ulnar and radial artery to occlude them
•  Fist opened
•  Release one of the arteries
•  Positive(normal), if hand becomes pink in 7
seconds
 Investigations
•  Plain radiograph: Ap and lateral (wrist), AP and oblique
(hand)
•  Electrophysiology to confirm nerve compression
•  MRI
•  bone scan reveals higher vascularity
 Congenital anomalies
•  Radial club hand
•  Radial head dislocation
•  Extra / accessory digits
•  Syndactyly
•  Clinodactyly
•  Camptodactyly
•  Trigger thumb
 Radial club hand
•  Short or absent radius
•  Associated with other malformations
•  Different stages severity
•  Treatment: splinting, physiotherapy, surgical
stabilization, forearm lengthening
Accessory digit
•  = Polydactyly.
•  Treatment: excision/amputation
 Syndactyly
•  Failure of separation of
digits.
•  Treatment: surgical
separation.
Clinodactyly
• Abnormal angulation of digit in the
radioulnal plane.
• In progressive deformity or functional
problems: surgical treatment.
 Camptodactyly
•  Fixed flexion deformity of PIP
joint
•  Usually the 5. digit
•  Treatment: splinting and
physiotherapy.
Surgery rarely indicated.
Tendon disorders
Trigger finger
De Quervain´s disease
Boutonniere deformity
Swan neck deformity
 Trigger finger
• Flexor tendon sheath thickening
• Can be congenital (thumb) or acquired
• Tendon can not move freely – triggering
•  Sign: painful extension.
•  Treatment: steroid injection to sheath,
surgical release (congenital at 1 year of age).
 De Quervain´s disease
Most common cause of radial wrist pain
Overuse of abductor pollicis longus(APL) and extensor pollicis
brevis(EPB).
Symptoms: pain in moving wrist and thumb
Signs: dorsoradial wrist pain and tenderness,
positive Finkelstein´s test (pain when thumb in flexion, wrist in ulnar
deviation)
Treatment: NSAID, splinting, steroid injection, surgical release
Finkelstein´s test
 Boutonniere deformity
•  PIP flexion and DIP joint hyperextension.
•  Injury to superficial extensor insertion.
•  Deep extensor tendon unable to function normally.
•  Common in rheumatoid arthritis.
 Swan neck deformity
•  Hyperextension of PIP and flexion of DIP joints.
•  Disruption of volar plate of PIP joint.
•  Deep extensor unable to function normally.
•  Common in rheumatoid arthritis.
 Ganglion cyst
 Definition:
Fluid-filled synovial lining that protrudes between carpal bones or from
a tendon sheath; most commonly carpal in origin
most common soft tissue tumour of hand and wrist (60% of masses)
Symptom: discomfort or pain
Treatment:
– No treatment: small, without symptom.
– Aspiration
–  Surgical removal of whole ganglion with attachment to joint or tendon
sheath
 Dupuytren´s contracture
•  Fibroblastic hyperplasia.
•  Autosomal dominant inheritance.
•  Signs: Nodules and cords of the palm,
flexion contractures of digits.
•  Progressive deformity.
•  Functional problems: surgical excision.
Kienböck´s disease
•  Cause: ischemia and microtrauma of lunate.
•  Associated with ulnar shortening.
•  Symptoms: wrist pain and weakness.
•  X-ray and MRI
•  Stages: Sclerosis, collapse, arthritis.
•  Treatment: wrist splint , analgesia, radial shortening,
wrist fusion
Carpal Tunnel Syndrome
Definition
• median nerve compression at the level of the flexor retinuculum as
opposed to pronator teres Sydrome(most common entrapment neuropathy)
Causes:
median nerve entrapment at wrist
 primary cause is idiopathic
secondary causes: space occupying lesions (tumours, hypertrophic
synovial tissue, fracture callus, and osteophytes), metabolic and
physiological
repetitive trauma, especially forced wrist flexion
Clinical Features
sensory loss in median nerve distribution
classically, patient awakened at night with numb/painful hand,
relieved by shaking/dangling/rubbing
decreased light touch and 2-point discrimination, especially
fingertips
advanced cases: thenar wasting/weakness
± Tinel’s sign (tingling sensation on percussion of nerve)
± Phalen’s sign (wrist flexion induces symptoms)
Treatments:
•medical: NSAIDs, local corticosteroids injection, oral corticosteroids
•surgical decompression: transverse carpal ligament incision to decompress
median nerve
•avoid repetitive wrist and hand motion, wrist splints and night time
 Hand infections
•  Paronychia
– Pus beside the nail
– Treatment: Surgical release
• 
Pulp space (felon)
Definition:
– subcutaneous abscess in the fingertip that commonly occurs
following severe
paronychia or a puncture wound into the pad of digit,
•May lead to osteomyelitis
Treatments:
•elevation, warm soaks, cloxacillin 500 mg PO q6h (if in early
stage);
•if obvious abscess then I&D and PO cloxacillin
 Hand infections
Flexor tendon sheath infection
acute suppurative tenosynovitis commonly caused by a penetrating injury
and can lead to tendon necrosis and rupture if not treated
– Swollen finger in flexion, extension is painful.
– Tenderness in tendon sheath.
– Adhesions lead to stiff, useless finger.
– Treatment: early incision drainage and irrigation followed by
early motion.
Web space infection
– Between metacarpals, treat with incision drainage.
 Arthritis
•  Rheumatoid arthritis: morning stiffness, deformities, synovitis
affecting tendons
•  Osteoarthritis: primary or secondary (after trauma or infection)
•  Management:
Conservative: Analgesia, splints, less activity, corticosteroid injections

Operative: Arthrodesis
Radiographic Evolution of the Rheumatoid Hand
Earliest sign:
erosion of the ulnar styloid.
Progression:
chracterized by symmetrical joint space narrowing and erosions of
the carpal bones, MCP and PIP (with DIP relatively spared).
Late stage:
Swan neck and Boutonniere deformities
 General treatment principles in hand orthopedics

Avoid swelling and stiffness by:

•  Elevation – reduces swelling
•  Splint to a position of safety – avoid contracture

–  Wrist 30 degrees extension, MCP 60 degrees flexion, PIP

and DIP extension
•  Movement. Mobilize joints as quickly as possible, avoid
stiffness.
Thank you