THE HAND DR BAKHTYAR BARAM

MALLET FINGER Results from injury to the extensor tendon of the terminal finger DIP joint The pt can not extend it active but passive no problem. X ray good to exclude fracture. In case of fracture more than 50% of the joint surface with dislocation operation is a good idea, But with operation or without it, need splintage of that joint from 6-8 weeks plus 4 weeks only in the night and the result is not always satisfactory. Some times need joint fusion.

DUPUYTREN´S CONTRACTURE This is anodular hypertrophy and contracture of the superficial palmar fascia (palmar aponeurosis) Is an autosomal dominant triat. Higher incidence in phenytoin user,DM, smoking, alcoholic cirrhosis, AIDS, TB. Pathology is proliferation of myofibroblasts which remain unclear why.. After that thickining of that fascia and flexion deformity MCP and PIP joints. Pt is ususally middel-aged complain of anodular thickining in the palm, they have pain but not the main feature. 60% have family history It may be seen in the soles of the feet but rare.

Operation is agood methode of treatment but it will not cure the disease and only partiially correct the deformity. The thickened part of the fascia will be removed. Or it can be done by needle fasciotomy. Fasciotomy done by Z-plasty. Care should be taken not to damage the nerve, the arteries and the tendons. Recurence is possible after the operation, rarely need skin- grafting

TRIGGER FINGER Aflexor tendon become trapped by thickining at the entrance to its sheath.on forced extension it passes the construction with a snap (triggerin). Most common with DM patients. Any digit may be affected, but thumb, ring and middel more commonly. Pt notices a click, and sometimes uses the other hand to extend the joint (pip) Atender nodule can be felt volar at MCP joint which is the site of the obstruction. Treatment even by injection of corticosteroid (recurrence may be) or operation release (tenovaginotomy) under LA.

RHUMATOIT ARTHRITIS The hand more than any other region, is where RA carves it´s history. The early stage is characterized by synovitis of the joints and tendon sheath. Stiffness and swelling of the fingers are early symptoms. Some times startes with CTS because of synovitis in the wrist. Examination may reveal swelling of the MCP and PIP joints, both hands is affeced, the joints are tender and may be felt crepitus on moving, joint mobility and grip strength are diminished. Later slight radial deviation of the wrist and ulnar deviation of the fingers. Correctable swan neck deformity(PIP joint is hyper extended and DIP joint flexed) or isolated boutoniiere deformity (flexion of PIP and extension of DIP) or drop finger or mallet. Later the deformities will be more established and characteristic that make very easy the diagnosis.

Weakness Rhumatoid nodules Z- collapse X-ray in start discren joint space narrowing, and small peri-articular erosions and later to total joint destruction with deformity. Treatment Essentially by controllling the systemic disease, prepare the pt to along term treatment. Local injection in the tender joinnts in small quantity. Treatment of CTS and synovectomy. Physiotherapy. Splintages espicially in the early stage to protction and pain treatment. And in late stages joint replacement or Silastic spacers or Arthrodesis. Many types of operation for every joint.

ACUTE INFECTIONS OF THE THE HAND Infection of the hand is frequently limited to the one of the several defined compartments, under the nail fold paronychia, pulpa space felon, and subcutaneous tissue or deep even in the tendon sheaths. Start with acute inflammatory reaction with oedema and suppuration and increased tissue tension. In negglected cases infection can spread from one compartment to another and may cause haematogenous spread to lymphangitis and septocaemia May cause stiff and useless hand. Normally history of trauma The hand or the finger will be painfull and swollen Pt feel ill and feverish. Predisposing factor like DM, immunosup. Druds or IV drug abuse.

With deep infection active flexion is not possible, the arm should be examined for injury and lymphangitis and swollen glands. X ray to detect foreign body. DD from insect bite, thorn prick, acute tendon rupture, and acute gout. Princips of treatment Antibiotic Rest, splintage and elevation Drainage Rehablitation. Many hand will respond to antibiotic in the first first hours, if there is signs of abscess, throbbing pain, marked tenderness and toxaemia, surgery is indicated. Drainage is important and washing throgh drainage in few days and observation.

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