The hand The hand Examination of the hand:Examination of the hand:

History:History:

1- pain: felt in the palm & finger joint, if poorly defined may be referred from the 1- pain: felt in the palm & finger joint, if poorly defined may be referred from the neck or mediastinum.neck or mediastinum.

2- deformity: may appear sudden due to tendon rupture or slow due to bone or 2- deformity: may appear sudden due to tendon rupture or slow due to bone or joint pathology.joint pathology.

3- swelling: could be localized or diffuse in many joints.3- swelling: could be localized or diffuse in many joints.

4- loss of function. 4- loss of function.

5- sensory and motor symptoms give clue to neurological disorder. 5- sensory and motor symptoms give clue to neurological disorder.

Examination:Examination:

A)- look: resting posture, scar, color changes, dry or moist, hairy or smooth, A)- look: resting posture, scar, color changes, dry or moist, hairy or smooth, wasting, deformity, lump or swelling should be localized to the subcut. tissue, wasting, deformity, lump or swelling should be localized to the subcut. tissue, tendon, joint or bone. nail for atrophy in psoriasis. tendon, joint or bone. nail for atrophy in psoriasis.

B)- feel: temperature, skin texture, pulse, nodule or swelling, tenderness. B)- feel: temperature, skin texture, pulse, nodule or swelling, tenderness.

C)- move: C)- move:

1- active movement, 11- active movement, 1stst, by ask the patient to fully flex of all fingers, if there is , by ask the patient to fully flex of all fingers, if there is lagging finger will be obvious then examine movement at each individual joint 1lagging finger will be obvious then examine movement at each individual joint 1stst, , the MPJ. then the IPJ. of each finger.the MPJ. then the IPJ. of each finger.

2- passive movement, noting the range of movement at each joint. 2- passive movement, noting the range of movement at each joint.

3- examination of individual muscle:3- examination of individual muscle:

a- flexor digitorum profundus: ask the patient to flex the DIPJ. while immobilize the PIPJ. a- flexor digitorum profundus: ask the patient to flex the DIPJ. while immobilize the PIPJ. in extention.in extention.

b- flexor digitorum superficialis: because of the mass action maneuver of the FDP. ask b- flexor digitorum superficialis: because of the mass action maneuver of the FDP. ask the patient to flex the finger to be examined while holding the other fingers the patient to flex the finger to be examined while holding the other fingers extended.extended.

c- intrinsic muscles of the hand: “lumbricals and interossie”, cause flexion of MPJ. and c- intrinsic muscles of the hand: “lumbricals and interossie”, cause flexion of MPJ. and extention of IPJ. “ duck bill position” the interossei also cause fingers abduction and extention of IPJ. “ duck bill position” the interossei also cause fingers abduction and adduction.adduction.

d- the thumb 5 movements, extension; side way movement in the plane of the palm, d- the thumb 5 movements, extension; side way movement in the plane of the palm, abduction; up ward movement perpendicular to the plane of the palm, adduction; abduction; up ward movement perpendicular to the plane of the palm, adduction; press against the palm, flexion; side way movement toward the palm in the plane of press against the palm, flexion; side way movement toward the palm in the plane of the palm, opposition; touch the tip of the fingers.the palm, opposition; touch the tip of the fingers.

4- Grip strength: by squeeze partially inflated sphygmomanometer cuff normally 4- Grip strength: by squeeze partially inflated sphygmomanometer cuff normally pressure of 150 mmHg. Can be achieved easily. pressure of 150 mmHg. Can be achieved easily.

5- neurological assessment: power, reflexes, sensation, two point discrimination, cold & 5- neurological assessment: power, reflexes, sensation, two point discrimination, cold & heat sensation, & steriognosis. heat sensation, & steriognosis.

6- functional test: a) precision grip: pick up pin.6- functional test: a) precision grip: pick up pin.

b)- pinch grip: holding newspaper.b)- pinch grip: holding newspaper.

c)- side way pinch: holding a key. c)- side way pinch: holding a key.

d)- chuck grip: holding pen.d)- chuck grip: holding pen.

e)- hook grip: holding bag handle. e)- hook grip: holding bag handle.

f)- span grip: holding glass.f)- span grip: holding glass.

g)- power grip: gripping hammer handle. g)- power grip: gripping hammer handle.

Congenital disorder of the hand:" classification”Congenital disorder of the hand:" classification”

1- failure of formation---------Transverse absence 1- failure of formation---------Transverse absence

----------Longitudinal absence-------Radial-------Radial club hand ----------Longitudinal absence-------Radial-------Radial club hand

--------Ulnar-------Ulnar club hand --------Ulnar-------Ulnar club hand

--------Central-----Central club hand--------Central-----Central club hand

2- failure of differentiation------------syndactyly, symphalagisim, camptodactyly, 2- failure of differentiation------------syndactyly, symphalagisim, camptodactyly, clinodactyly, flexed thumb, arthogryposis.clinodactyly, flexed thumb, arthogryposis.

3- duplication: polydactyly or extra digit-------------thumb duplication.3- duplication: polydactyly or extra digit-------------thumb duplication.

4- over growth--------------macro dactyly. 4- over growth--------------macro dactyly.

5- under growth------------thumb hypoplasia.5- under growth------------thumb hypoplasia.

6- constriction ring syndrome-----------------simple ring.6- constriction ring syndrome-----------------simple ring.

7- general skeletal abnormalities-----Marfan’s, Turner’s, Down’s--------etc. 7- general skeletal abnormalities-----Marfan’s, Turner’s, Down’s--------etc.

Radial club hand: Radial club hand:

There is partial or complete absence of the thumb or radius with the hand & wrist in There is partial or complete absence of the thumb or radius with the hand & wrist in marked radial deviation in some sever cases the humorous is fused to the ulna marked radial deviation in some sever cases the humorous is fused to the ulna associated anomaly should be sought. Especially in the heart & blood vessels. associated anomaly should be sought. Especially in the heart & blood vessels.

Treatment: by manipulation of the wrist & elbow since birth. By 6-12 month the wrist Treatment: by manipulation of the wrist & elbow since birth. By 6-12 month the wrist centralized on the ulna with soft tissue release, bone resected & position held by k centralized on the ulna with soft tissue release, bone resected & position held by k wire for several weeks. If the thumb is absent then the index finger should be wire for several weeks. If the thumb is absent then the index finger should be pollicised “ shortened & rotated to form anew thumb. pollicised “ shortened & rotated to form anew thumb.

Syndactyly: “Congenital webbing”Syndactyly: “Congenital webbing”

The most common congenital variation in the hand it may be simple “skin only” or The most common congenital variation in the hand it may be simple “skin only” or complex “skin & bone” or acrosyndactyly “ only the tips are joined”. complex “skin & bone” or acrosyndactyly “ only the tips are joined”.

Treatment: surgical separation with skin graft required, if more than 2 fingers are to be Treatment: surgical separation with skin graft required, if more than 2 fingers are to be divided it is wise to stage the procedure in case the blood vessels on each side of the divided it is wise to stage the procedure in case the blood vessels on each side of the digit are damaged. digit are damaged.

Camptodactyly:Camptodactyly: flexion deformity of the PIPJ. usually of the little finger.flexion deformity of the PIPJ. usually of the little finger.Clinodactyly:Clinodactyly: side way bent of the finger usually the little. side way bent of the finger usually the little.Duplication: “polydactyly or extra digit”Duplication: “polydactyly or extra digit” Nearly as common as syndactyly; extra little finger usually inherited & other variations Nearly as common as syndactyly; extra little finger usually inherited & other variations

may be present extra thumb is sporadic while extra central digit which the rarest of may be present extra thumb is sporadic while extra central digit which the rarest of the duplication usually associated with syndactyly & disorganization of the skeleton,the duplication usually associated with syndactyly & disorganization of the skeleton,

Treatment: extra skin tag, simply excised. Any thing more complex need meticulous Treatment: extra skin tag, simply excised. Any thing more complex need meticulous surgery.surgery.

Mallet finger:Mallet finger:Result from injury to the extensor tendon of the terminal phalanx may be due to direct Result from injury to the extensor tendon of the terminal phalanx may be due to direct

trauma or the tendon rupture when the finger top is forcibly bent during active trauma or the tendon rupture when the finger top is forcibly bent during active extension of finger as during trying to catch a ball, the terminal joint held flexed & extension of finger as during trying to catch a ball, the terminal joint held flexed & the patient cannot straighten it, but passive movement is normal, with the extensor the patient cannot straighten it, but passive movement is normal, with the extensor mechanism unbalanced the PIPJ. Hyperextend. mechanism unbalanced the PIPJ. Hyperextend.

Treatment: acute mallet finger splinted with the DIPJ. extended 8 Wks. this treatment still Treatment: acute mallet finger splinted with the DIPJ. extended 8 Wks. this treatment still work if presentation is delayed for few weeks. Surgery is ill advised.work if presentation is delayed for few weeks. Surgery is ill advised.

Old mallet finger which cause marked deformity or impair hand function treated by Old mallet finger which cause marked deformity or impair hand function treated by arthrodesis of the DIPJ. arthrodesis of the DIPJ.

Dupuytren contracture: Dupuytren contracture: it is a nodular hypertrophy & contracture of palm aponeurosis, it is inherited as it is a nodular hypertrophy & contracture of palm aponeurosis, it is inherited as

autosomal dominant trait more common in people of European descent, more autosomal dominant trait more common in people of European descent, more common in male than female, prevalence increase with age there is high incidence in common in male than female, prevalence increase with age there is high incidence in epileptic, smoker, alcoholic cirrhosis, & pulmonary tuberculosis. epileptic, smoker, alcoholic cirrhosis, & pulmonary tuberculosis.

Pathology & clinical feature: there is proliferation of myofibroblast, fibrous tissue within Pathology & clinical feature: there is proliferation of myofibroblast, fibrous tissue within the palmer fascia & facial bands in the fingers contract cause flexion deformity at the the palmer fascia & facial bands in the fingers contract cause flexion deformity at the MPJ. & PIPJ. Fibrous attachments to the skin cause puckering of skin. Digital nerve MPJ. & PIPJ. Fibrous attachments to the skin cause puckering of skin. Digital nerve displaced but not involved by fibrous tissue. Usually involve the ring & little finger, displaced but not involved by fibrous tissue. Usually involve the ring & little finger, often both hands affected some time the dorsal knuckle become thick called Garod’s often both hands affected some time the dorsal knuckle become thick called Garod’s pads. Similar nodule may be seen in the sole of the feet called Ledderhose’s disease. pads. Similar nodule may be seen in the sole of the feet called Ledderhose’s disease. If associated with fibrosis of corpus cavernosum called Peyronie’s disease. If associated with fibrosis of corpus cavernosum called Peyronie’s disease.

Treatment: if deformity is nuisance or rapidly progressing or involve the PIPJ. then surgery is Treatment: if deformity is nuisance or rapidly progressing or involve the PIPJ. then surgery is indicated to reasonable but not completely correct the deformity by excising only the thick indicated to reasonable but not completely correct the deformity by excising only the thick pert of fascia, complete fasciactomy not necessary & may cause complicationpert of fascia, complete fasciactomy not necessary & may cause complication

Stenosing teno vaginitis: “trigger finger”Stenosing teno vaginitis: “trigger finger”

Follow local trauma or unaccustomed activity there will be thickening of the fibrous tendon Follow local trauma or unaccustomed activity there will be thickening of the fibrous tendon sheath cause a flexed tendon to become trapped at the entrance to it’s sheath but on sheath cause a flexed tendon to become trapped at the entrance to it’s sheath but on forced extension it pass the constriction with snap= trigger.forced extension it pass the constriction with snap= trigger.

Similar hold occur in rheumatoid teno synovitis, diabetes & people with gout.Similar hold occur in rheumatoid teno synovitis, diabetes & people with gout.

Clinical feature: any digit include the thumb may by affected but commonly affect the ring & Clinical feature: any digit include the thumb may by affected but commonly affect the ring & middle finger some time several digits are affected patient notice that the finger click as middle finger some time several digits are affected patient notice that the finger click as he bend it but when the hand unclenched the affected finger remain bent at the PIPJ. But he bend it but when the hand unclenched the affected finger remain bent at the PIPJ. But with further effort it suddenly straighten with snap, tender nodule may be felt in front of with further effort it suddenly straighten with snap, tender nodule may be felt in front of the MPJ.the MPJ.

Infantile trigger thumb: baby some time develop teno vaginitis of the thumb flexor sheath very Infantile trigger thumb: baby some time develop teno vaginitis of the thumb flexor sheath very occasionally the child grow up with the thumb permanently bent. occasionally the child grow up with the thumb permanently bent.

Treatment: early by injection of methylpridnisolon placed carefully into the tendon sheath. Treatment: early by injection of methylpridnisolon placed carefully into the tendon sheath. Refractory case treated by operation by incising the thick fibrous sheath until the tendon Refractory case treated by operation by incising the thick fibrous sheath until the tendon move freely. In rheumatoid arthritis flexor synovectomy preferred. move freely. In rheumatoid arthritis flexor synovectomy preferred.

In baby wait until the child 1 year old because spontaneous recovery may occur.In baby wait until the child 1 year old because spontaneous recovery may occur.

Hand deformity in rheumatoid arthritis:Hand deformity in rheumatoid arthritis:

1- Boutonnière deformity:1- Boutonnière deformity:

Flexion deformity of the PIPJ. Due to interruption or stretching of the central slip of the Flexion deformity of the PIPJ. Due to interruption or stretching of the central slip of the extensor tendon where it insert into the base middle phalanx, the lateral slip separate & extensor tendon where it insert into the base middle phalanx, the lateral slip separate & the head of the proximal phalanx thrust through the gap like a button through a button the head of the proximal phalanx thrust through the gap like a button through a button hole, initially the deformity passively correctable later because the soft tissue contract hole, initially the deformity passively correctable later because the soft tissue contract result in fixed flexion of the PIPJ. & hyper extension of DIPJ. result in fixed flexion of the PIPJ. & hyper extension of DIPJ.

2- Swan neck deformity:2- Swan neck deformity:

The PIPJ. Hyper extended & the DIPJ. flexed, it occur due to imbalance of the extensor The PIPJ. Hyper extended & the DIPJ. flexed, it occur due to imbalance of the extensor versus flexor action at the PIPJ. & laxity of the palmer plate, the deformity can also versus flexor action at the PIPJ. & laxity of the palmer plate, the deformity can also caused by: 1-the PIPJ. extensor over act due to intrinsic muscle spasm or contracture. 2- caused by: 1-the PIPJ. extensor over act due to intrinsic muscle spasm or contracture. 2- after disruption of the distal extensor attachment. 3- follow volar subluxation of the MPJ. after disruption of the distal extensor attachment. 3- follow volar subluxation of the MPJ. 4- if the PIPJ. Flexor inadequate as in division of flexor superficialis attachment. 5- if the 4- if the PIPJ. Flexor inadequate as in division of flexor superficialis attachment. 5- if the palmer plate fail as in rheumatoid A., lax jointed individual or trauma. palmer plate fail as in rheumatoid A., lax jointed individual or trauma.

If the deformity allowed to persist secondary contracture of the intrinsic muscle & eventually If the deformity allowed to persist secondary contracture of the intrinsic muscle & eventually of the PIPJ. Make correction increasingly difficult & ultimately impossible of the PIPJ. Make correction increasingly difficult & ultimately impossible

3- 3- rupture of extensor policies longus at the wrist:rupture of extensor policies longus at the wrist: also occur follow Collies # the distal also occur follow Collies # the distal phalanx drop into flexion, it can be passively extended & there may still be weak active phalanx drop into flexion, it can be passively extended & there may still be weak active extension because of the thinner muscle insert into the extensor expansion. extension because of the thinner muscle insert into the extensor expansion.

4- 4- Dropped finger:Dropped finger: sudden loss of finger extension at the MPJ. Usually due to tendon rupture sudden loss of finger extension at the MPJ. Usually due to tendon rupture at the wrist treated by attaching the distal part of the ruptured tendon to adjacent at the wrist treated by attaching the distal part of the ruptured tendon to adjacent tendon extensor or by transfer.tendon extensor or by transfer.

5- 5- Z-collapse:Z-collapse: if one of two adjacent joints change direction then the overlying tendon pull if one of two adjacent joints change direction then the overlying tendon pull the other joint into opposite direction this in RA. typified by radial tilt of the wrist & ulnar the other joint into opposite direction this in RA. typified by radial tilt of the wrist & ulnar drift of the MPJ. Boutonniere deformity & swan neck deformity. drift of the MPJ. Boutonniere deformity & swan neck deformity.

Acute hand infections:Acute hand infections:

1- 1- nail fold infection “paronychia”nail fold infection “paronychia”

Infection under the nail fold is the commonest hand infection, seen most often in children or Infection under the nail fold is the commonest hand infection, seen most often in children or in older people after rough nail trimming, the edge of the nail fold become red & swollen in older people after rough nail trimming, the edge of the nail fold become red & swollen & increasingly tender, a tiny abscess may form in the nail fold if left un treated pus can & increasingly tender, a tiny abscess may form in the nail fold if left un treated pus can spread under the nail spread under the nail

Treatment: early by antibiotics alone may be effective, if pus present it must be released Treatment: early by antibiotics alone may be effective, if pus present it must be released

2- Pulp space infection: “felon”2- Pulp space infection: “felon”

Is usually caused by prick injury, the most common organism is staph aureus. The distal finger Is usually caused by prick injury, the most common organism is staph aureus. The distal finger pad is essentially a closed facial compartment filled with compact fat & subdivided by pad is essentially a closed facial compartment filled with compact fat & subdivided by radiating fibrous septa. A rise in the pressure within the pulp space cause intense pain & if un radiating fibrous septa. A rise in the pressure within the pulp space cause intense pain & if un relived may threaten the terminal branches of the digital artery which supply most of the relived may threaten the terminal branches of the digital artery which supply most of the terminal phalanx.terminal phalanx.

Treatment: early by antibiotics & elevation of the hand, once abscess has formed the pus must Treatment: early by antibiotics & elevation of the hand, once abscess has formed the pus must be released be released

3- 3- herpetic whitlow: herpetic whitlow:

Herpes simplex virus may inter the finger tip possibly by auto inoculation from the patient own Herpes simplex virus may inter the finger tip possibly by auto inoculation from the patient own mouth or genitalia or by cross infection during dental surgery. Small vesicle form on the mouth or genitalia or by cross infection during dental surgery. Small vesicle form on the finger tip then coalesce & ulcerate, the condition is self limiting & usually subside after about finger tip then coalesce & ulcerate, the condition is self limiting & usually subside after about 10 days but may recur acyclovir may be effective in the early stages.10 days but may recur acyclovir may be effective in the early stages.

4- Tendon sheath infection: “supurative teno synovitis” 4- Tendon sheath infection: “supurative teno synovitis”

The tendon sheath is a closed compartment extending from the distal palmer crease to the DIPJ. The tendon sheath is a closed compartment extending from the distal palmer crease to the DIPJ. In the thumb & little finger the sheaths are coextensive with the radial & ulnar bursa, which In the thumb & little finger the sheaths are coextensive with the radial & ulnar bursa, which envelope the flexor tendon, in the proximal part of the palm & across the wrist these bursas envelope the flexor tendon, in the proximal part of the palm & across the wrist these bursas also communicate with the parona’s space in the lower forearm. also communicate with the parona’s space in the lower forearm.

Pyogenic teno synovitis is uncommon but dangerous, it usually follow penetrating injury; the Pyogenic teno synovitis is uncommon but dangerous, it usually follow penetrating injury; the commonest organism is staph aureus but strepto cocus & gram –ve. organism also commonest organism is staph aureus but strepto cocus & gram –ve. organism also encountered. encountered.

Clinical features: the affected digit is painful & swollen it usually hold slightly flexed very tender Clinical features: the affected digit is painful & swollen it usually hold slightly flexed very tender & the patient will not move it or permit it to be moved, delayed diagnosis result in & the patient will not move it or permit it to be moved, delayed diagnosis result in progressive rise in pressure within the sheath & a consequent risk of vascular occlusion & progressive rise in pressure within the sheath & a consequent risk of vascular occlusion & tendon necrosis, in neglected case infection may spread proximally within the radial or ulnar tendon necrosis, in neglected case infection may spread proximally within the radial or ulnar bursa or from one to the other “horse shoe abscess” it can also spread proximal to the flexor bursa or from one to the other “horse shoe abscess” it can also spread proximal to the flexor compartment at the wrist & in to the parona’s space in the forearm occasionally result in compartment at the wrist & in to the parona’s space in the forearm occasionally result in median n. compression. median n. compression.

Treatment: started as soon as the diagnosis is suspected; by elevation, splint & iv. Treatment: started as soon as the diagnosis is suspected; by elevation, splint & iv. Antibiotics, ideally broad spectrum penicillin or systemic cephalosporin. If there is no Antibiotics, ideally broad spectrum penicillin or systemic cephalosporin. If there is no improvement after 24 hours surgical drainage essential by 2 incision proximal & improvement after 24 hours surgical drainage essential by 2 incision proximal & distal using fine catheter, the sheath is irrigated from proximal to distal. Post distal using fine catheter, the sheath is irrigated from proximal to distal. Post operatively the hand dressed & splinted in position of safe immobilization, catheter operatively the hand dressed & splinted in position of safe immobilization, catheter removed after 2 days & splint remain for 2 wks. Interrupted by change dressing & removed after 2 days & splint remain for 2 wks. Interrupted by change dressing & physiotherapy. physiotherapy.