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Hand Deformities, Fractures, and palsy

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Hand Deformities, Fractures, and palsy By Adnan AL-Maaitah http://hastaneciyiz.blogspot.com Medical ppt – PowerPoint PPT presentation

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Title: Hand Deformities, Fractures, and palsy


1
Hand Deformities, Fractures, and palsy
  • By Adnan AL-Maaitah

Medical ppt
http//hastaneciyiz.blogspot.com
2
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 ?

3
Hand Deformities
  • Mallet deformity
  • Trigger Finger
  • Boutonniere Deformity
  • Swan Neck deformity
  • Dupuytren contracture

4
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

5
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6
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.

7
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

8
Despite active extension effort, the distal
interphalangeal joint of the index finger rests
in flexion, characteristic of a mallet finger
9
This x-ray depicts a large, dorsal-lip avulsion
fracture from the distal phalanx, a bony mallet
injury.
10
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)

11
Anteroposterior radiographic view of finger after
4 weeks. The longitudinal K-wire is blocking the
distal interphalangeal joint from flexion to
protect the repair
12
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).

13
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.

14
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.

15
Trigger Tension
16
Introduction of the needle into the tendon sheath
at 45 to the palm for injection treatment.
17
Boutonniere Deformity
  • Aka Buttonhole Deformity
  • Hyperflexion at the PIP joint with hyperextension
    at the DIP
  • Passive extension of the PIP joint is easy.

18
Boutonniere Deformity
19
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
20
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21
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

22
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

23
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.

24
Dynamic spring extension splint
Bunnell Safety Pin Finger Splint
25
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)

26
Swan-Neck deformity
27
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
28
Dupuytren contracture
  • Pathologic condition of the hand in which the
    fascia of the palm are shortened and thickened
  • Common in south europe

29
Dupuytren contracture
30
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

31
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

32
Hand Fractures
33
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)

34
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

35
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
36
Examination of the patient's hand with the
fingers flexed may clearly reveal a rotational
deformity
37
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

38
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
39
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
40
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

41
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

42
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43
Colles Fracture
44
Smith Fracture
45
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
46
Hand Palsy
47
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

48
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

49
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

50
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51
Froment's test
52
Radial nerve palsy
  • Aka
  • wrist drop
  • Saturday night palsy

53
  • 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

54
Wrist Drop
55
Erbs Palsy
  • Aka
  • Waiter's tip deformity
  • Erb-Duchenne Palsy

56
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

57
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

58
THE END !!!!!
Medical ppt
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