Hand Deformities, Fractures, and palsy

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Hand Deformities, Fractures, and palsy

• By Adnan AL-Maaitah

Medical ppt
http//hastaneciyiz.blogspot.com
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NOTE

• The following subjects are NOT mentioned in the
  guidelines
• Dupuytren contracture (slides 28-31)
• Hand fractures (32-45)
• Hand palsy (46-57)
• Sry, but I got the guidelines after finishing the
  seminar ?

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Hand Deformities

• Mallet deformity
• Trigger Finger
• Boutonniere Deformity
• Swan Neck deformity
• Dupuytren contracture

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Mallet Finger

• Aka baseball finger
• Deformity in which the fingertip is curled in and
  cannot straighten itself
• Due to injury to extensor digitorium tendons at
  DIPJ

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(No Transcript)
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Mallet Finger/Causes

• Forced flexion of the finger when finger is
  extended
• . Sport Injury Finger struck by volleyball,
  basketball or baseball when it is in extension
• . Other common mechanisms of injury include
  forcefully tucking in a bedspread or slipcover or
  pushing off a sock with extended fingers.

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Mallet Finger/Presentation

• After DIPJ forced flexion inability to actively
  extend the distal joint, intact full passive
  extension
• Often injury is painless or nearly painless
• Dorsum of joint may be slightly tender and
  swollen
• Order X-ray to make sure there are no fractures

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Despite active extension effort, the distal
interphalangeal joint of the index finger rests
in flexion, characteristic of a mallet finger
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This x-ray depicts a large, dorsal-lip avulsion
fracture from the distal phalanx, a bony mallet
injury.
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Mallet Finger/Managment

• Mallet finger splint (6-10 weeks)
• Surgery
• In case of volar sublaxation of distal phalanx or
  avulsion fracture
• K-wire (Kirschner wire)

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Anteroposterior radiographic view of finger after
4 weeks. The longitudinal K-wire is blocking the
distal interphalangeal joint from flexion to
protect the repair
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Trigger Finger

• Trigger finger is the popular name of stenosing
  tenosynovitis, a painful condition in which a
  finger or thumb locks when it is bent (flexed) or
  straightened (extended).

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Trigger Tension

• Due to narrowing of the sheath that surrounds the
  tendon in the affected finger, or a nodule forms
  on the tendon.
• Trigger finger is often an overuse injury because
  of repetitive or frequent movement of the fingers
  (ex. hobbies as playing a musical instrument or
  crocheting)
• Trigger finger may also result from trauma or
  accident
• It is called trigger finger because when the
  finger unlocks, it pops back suddenly, as if
  releasing a trigger on a gun.

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Trigger Tension

• Clinical Picture
• Affected digits may become painful to straighten
  once bent
• May make a soft crackling sound when moved.
• It props back suddenly when straightened
• Symptoms are usually worse in the morning and
  improve during the day
• Treatment
• local steroid injections and splinting (weeks
  to months)
• Surgery cut the sheath that is restricting the
  tendon.

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Trigger Tension
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Introduction of the needle into the tendon sheath
at 45 to the palm for injection treatment.
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Boutonniere Deformity

• Aka Buttonhole Deformity
• Hyperflexion at the PIP joint with hyperextension
  at the DIP
• Passive extension of the PIP joint is easy.

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Boutonniere Deformity
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Boutonniere Deformity

• Flexion deformity of the PIP joint, due to
  interruption of the central slip of the extensor
  tendon
• 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.

Central Slip
Lateral Band
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(No Transcript)
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Boutonniere Deformity

• The 3 main etiologies
• RA and other inflammatory arthritides (most
  often)
• mechanical trauma
• burns and infections
• An X-ray should be done to detect avulsion
  fractures

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Boutonniere Deformity

• BD in patients with RA can be classified into 1
  of the following 3 stages, which serve as a guide
  to the appropriate management
• Stage I (mild) is the earliest stage and is the
  result of PIP joint synovitis with mild extensor
  lag that still can be corrected passively. The
  metacarpophalangeal (MP) joint usually is normal,
  and the DIP may or may not be hyperextended.
• Stage II (moderate) is characterized by 30-40 of
  flexion contracture at the PIP joint and
  hyperextension of the MP joint as a compensatory
  mechanism. The finger has increased functional
  loss. Early passive extension still is possible.
  With time, soft-tissue contractures develop, and
  passive extension becomes restricted.
• Stage III (severe) begins when the PIP joint can
  no longer be extended passively. Radiographs
  demonstrate destruction of the joint surfaces

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Boutonniere Deformity

• Treatment
• Splinting 4 weeks minimal (6 weeks preferable)
• safety-pin splint (lt40 degree)
• Dynamic spring splints (gt 40)
• Surgery When the deformity is the result of a
  dislocation of the PIP joint
• Surgery carries a relatively high risk of FAILURE
  to achieve completely normal functioning
  extension mechanism of the finger.

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Dynamic spring extension splint
Bunnell Safety Pin Finger Splint
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Swan-Neck deformity

• -the PIP joint is hyper extended . DIP joint is
  flexed.
• Cause
• Volar plate becomes weak -gt hyperextension of
  PIPJ -gt flextion of DIFJ
• Due to injury or inflammation (RA)

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Swan-Neck deformity
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Swan-Neck deformity

• Swelling and pain due to inflammation from injury
  or disease (RA)
• X-ray is done to evaluate the joints (RA) and
  look for fractures.
• Treatment
• A boutonnière deformity caused by an extensor
  tendon injury can usually be corrected with a
  splint (Murphy Ring Splints) that keeps the
  middle joint fully extended for 6 weeks
• When splinting is ineffective, surgery may be
  needed.

MURPHY RING SPLINTS
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Dupuytren contracture

• Pathologic condition of the hand in which the
  fascia of the palm are shortened and thickened
• Common in south europe

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Dupuytren contracture
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Dupuytren contracture

• Dupuytren's contracture is more common among
  people with diabetes, alcoholism, or epilepsy
• The disorder affects both hands in 50 of people
• The disorder is occasionally associated with
  other disorders
• Garrod's pads thickening of fibrous tissue above
  the knuckles
• Penile fibromatosis shrinking of fascia inside
  the penis that leads to deviated and painful
  erections
• Plantar fibromatosis nodules on the soles of the
  feet

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Dupuytren contracture

• Symptoms
• The first symptom is usually a tender nodule in
  the palm
• Gradually, the fingers begin to curl.
• Eventually, the curling worsens, and the hand can
  become arched (clawlike)
• Treatment
• Surgery to correct contracted (clawed) fingers

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Hand Fractures
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Hand Fractures/Hx

• Hand trauma, industrial
• Hand dominance
• Hand injured
• Mechanism of injury
• Clean/dirty environment
• Position of the hand
• Thermal, electric or chemical injury
• Wearing jewelry on finger, removed
• In assault
• Hand open or fist clenched
• Lacerations (tendon injury)
• Contact with mouth, teeth
• Years since last tetanus immunization (esp. in
  lacerations and abrasions)

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Hand Fractures/ P/E

• Hand examination
• Compare with uninjured
• Signs of inflammation, abrasions, erosions
• Abnormal position (esp. fingers) rotational
  deformity
• Location of injury
• Capillary refill
• Neurology radian, median and ulnar nerve

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With fingers flexed at the metacarpophalangeal
and proximal interphalangeal joints and extended
at the distal interphalangeal joints, fingers
should all point toward the scaphoid bone
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Examination of the patient's hand with the
fingers flexed may clearly reveal a rotational
deformity
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Hand Fractures

• Imaging
• X-ray AP, lateral and oblique view
• MRI, CT, Bone scan seldom needed
• ED care
• Pain management, reduction, splinting, referral
• Primary concern is preservation of function
• Except for distal phalanx fracture, all pts.
  Should be referred to a hand surgeon

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Boxers Fracture

• A break in one or more metacarpal bones, usually
  the fourth or the fifth, caused by punching a
  hard object. Such a fracture is often distal,
  angulated, and impacted
• Finger shorten posteriorly

Fourth and fifth metacarpal fractures, oblique
view
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Scaphoid Fracture

• Epidemiology
• common in young men not common in children or
  in patients beyond middle age
• Mechanism
• FOOSH resulting most commonly in a transverse
  fracture through the waist (middle) of the
  scaphoid

Scaphoid fracture in the middle third or waist
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Scaphoid Fracture

• Clinical Features
• pain on wrist movement
• tenderness in scaphoid region (anatomical "snuff
  box")
• usually undisplaced
• Investigations
• x-ray (AP/lat/scaphoid views with wrist exended
  and ulnar deviation)
• /- bone scan and CT scan
• Note a fracture may not be radiologically
  evident up to 2 weeks after acute injury, so if a
  patient complains of wrist pain and has
  anatomical snuff box tenderness but a negative
  x-ray, treat them as if they have a scaphoid
  fracture and repeat x-ray 2 weeks later to rule
  out a fracture
• Treatment
• Undisplaced cast
• Displaced open (or percutaneous) screw fixation

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Colles and Smith Fracture

• Colles Fracture
• Due to FOOSH
• gt 40 yrs, female (esp. osteoperosis)
• Fx fragment upward-dorsal angulation (fork-like
  appearance)
• Smith Fracture
• Aka reverse Colles fracture
• Falling on the back of a flexed hand
• Fx fragment volar (palmar) displacment

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Colles Fracture
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Smith Fracture
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Both Bones Fracture (Radius Ulna)

• FOOSH, direct blow
• Internal fixation by plates and screws
• Complications
• Compartment syndrome
• malunion

Anteroposterior radiograph of a displaced,
midshaft both-bone forearm fracture in an
adolescent with a transitional growth plate
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Hand Palsy
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Ulnar nerve palsy

• This occurs due to nerve compression at the elbow
  (cubital tunnel) or at the wrist (Guyon's canal)
  (Ulnar canal)
• Muscle weakness and atrophy predominate the
  clinical presentation

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Ulnar nerve palsy/Causes

• Cubital Tunnel Syndrome
• Frequent bending of the elbow
• Leaning on the elbow, resting it on an elbow, 
  rest during a long distance drive  or running
  machinery may cause repetitive pressure and
  irritation on the nerve.
• A direct hit on the cubital tunnel may damage the
  ulnar nerve

• Guyon's Canal Syndrome
• A cyst within the canal.
• Clotting of the ulnar artery.
• Fracture of the hamate bone.
• Arthritis of the wrist bones

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Ulnar nerve palsy/Causes

• Symptoms signs
• numbness and tingling in the ring and little
  finger and the sides and back of the hand. At
  Guyon's Canal, sensory supply to the skin of the
  back of the hand is spared.
• The hand may become weaker resulting in trouble
  opening bottles or jars
• Clawing may occur in the ring and little fingers
•  Froment's test by asking the patient to hold a
  piece of paper between their thumb and index
  finger (hence checking adductor pollicis). In a
  patient with Ulnar nerve palsy the
  interphalangeal joint of the thumb will flex to
  compensate
• Treatment
• Nonsurgical therapy elbow or wrist splints to
  limit mobility in addition to an
  anti-inflammatory drug such as ibuprofen.
• Surgical decompression maybe required in some
  cases

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Froment's test
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Radial nerve palsy

• Aka
• wrist drop
• Saturday night palsy

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• Causes
• Caused by excessive compression of the radial
  nerve against a hard surface in individuals
  insensitized by the intake of alcohol or
  sedatives
• Broken humerus
• lead poisoning 
• Stab wounds to the chest at or below the
  clavicle. Damage the posterior cord of the
  brachial plexus
• Symptoms
• Wrist drop
• Occasionally, the back of the hand may lose
  feeling

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Wrist Drop
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Erbs Palsy

• Aka
• Waiter's tip deformity
• Erb-Duchenne Palsy

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Erbs Palsy

• Due to brachial plexus damage, by excessive
  lateral neck flexion away from sholder
• Forceps delivery
• Falling on the neck
• Leads to loss of the lateral rotators of the
  shoulder, arm flexors, and hand extensor muscles.
• The position of the limb, under such conditions,
  is characteristic
• the arm hangs by the side and is rotated
  medially
• the forearm is extended and pronated.
• The hand is flexed
• The arm cannot be raised from the side all power
  of flexion of the elbow is lost, as is also
  supination of the forearm

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Erbs Palsy

• The three most common treatments from Erb's Palsy
  are
• Nerve transfers (usually from the opposite leg),
  
• Sub Scapularis releases
• and Latissimus Dorsi Tendon Transfers.
• Although range of motion is recovered in many
  children under one year in age, individuals who
  have not yet healed after this point will rarely
  gain full function in their arm and may develop
  arthritis

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THE END !!!!!
Medical ppt
http//hastaneciyiz.blogspot.com