30 Wrist and hand

DAVID J. WARWICK Wrist The wrist connects the radius and ulna to the metacarpals. It should provide a stable, mobile, pain !ree plat!orm on which the hand can !unction. It comprises ei"ht bones # scaphoid, trape$ium, trape$ioid, capitate, hamate, tri%uetral, pisi!orm and lunate. A comple& s'stem o! intrinsic and e&trinsic li"aments maintains the ali"nment o! these bones and coordinates their movement, whilst the lon" !le&or and e&tensor tendons contract across them. (and The hand is a ver' intricate tool with which the individual can receive in!ormation !rom the outside world and then act upon it. It must be supple, sensate, pain !ree and coordinated. There are several t'pes o! "rip. The thumb acts as a post a"ainst which the inde& !in"er moves !or !ine pinch )pic*in" up a pin+. The little and rin" !in"ers curl into the palm to provide power "rip )holdin" a hammer+. The thumb moves to the side o! the inde& !in"er !or *e' "rip and to the tips o! the inde& and middle !in"ers !or chuc* "rip )holdin" a pen+. All o! the !in"ers curl !or hoo* "rip )holdin" a suitcase+.

Assessment A care!ul histor' and e&amination is as important !or the wrist and hand as an'where else. (istor' , -eneral # Is the patient le!t or ri"ht handed. /ccupation, hobbies and ambitions. (ow do the s'mptoms inter!ere with these. , 0ain # What is the site o! the pain, what ma*es it better or worse, how lon" has it been present, does it !luctuate. , 1unction # Is the "rip wea*. Are there problems with !ine motor tas*s, such as doin" up buttons, or coarse tas*s, such as openin" a 2ar. Are there clic*s or clun*s. , 3ensation # 4oss o! sensation. Tin"lin". Which part o! the hand. , In2ur' # The e&act nature o! the in2ur'5 a cut )sharp, blunt, dirt'.+, a crush, a !all )how !ar.+, a bite, a punch, an avulsion. , -eneral health # Diabetes. 3mo*in". 3teroids. Cardiac or respirator' problems which ma' in!luence the choice o! anaesthetic. 6&amination , In the in2ured patient, are there Airwa', 7reathin" or Circulation problems which should ta*e priorit'. , 3*in # Are there cuts or bruises. Is there s*in loss, and i! so are tendons or bone e&posed. Are there previous sur"ical or traumatic scars. Are there si"ns o! in!ection. , 7ones # Is there de!ormit' or tenderness. The precise o! tenderness can be dia"nostic, !or e&ample a tender lunate with Kienboc*8s disease or a tender anatomical snu!!bo& with a scaphoid !racture. , Joints # Is there de!ormit' or tenderness. 4i"ament stabilit' should be tested b' stabilisin" the pro&imal bone and "entl' stressin" the distal. The active and passive ran"e o! movement in each 2oint should be established. A similar restriction in both

active and passive movement ma' be caused b' pain or 2oint sti!!ness. A discrepanc' ma' be due to tendon rupture, tendon adhesions or a nerve pals'. , Tendons # 0assive tenodesis is a use!ul screenin" test5 the hand is rela&ed and the wrist is moved into !le&ion and then e&tension b' the e&aminer. As the wrist e&tends, the !in"ers should curl into a neat cascade, and as the wrist is !le&ed the !in"ers should open. The !unction o! each individual tendon is established. 1le&or di"itorum pro !undus is tested in each !in"er b' supportin" the pro&imal interphalan"eal 2oint and middle phalan& then as*in" the patient to !le& the distal interphalan"eal 2oint. 1le&or di"itorum super!icialis is tested with the e&aminer holdin" the other three !in"ers strai"ht and as*in" the patient to !le& the pro&imal interphalan"eal 2oint o! the remainin" !in"er. 6&tensor di"itorum communis is tested b' as*in" the patient to !ull' e&tend the metacarpophalan"eal 2oints )interphalan"eal 2oint e&tension is a !unction o! the intrinsic muscles+. , 9erves # The nerves suppl'in" the hand can be %uic*l' chec*ed. I! there is a cut in the palm or !in"er, the di"ital nerves should be tested b' chec*in" sensation on each side o! the !in"er tip. Two point discrimination is use!ul in partial nerve lesions or recoverin" nerves: two pron"s o! a paper clip are spread and the patient as*ed to sa' whether one or two points can be !elt. 9ormal discrimination in the !in"er tips is about ; mm. Tinel8s percussion si"n # tappin" on a nerve and causin" <tin"lin"8# is present at the site o! nerve compression, a neuroma or at the advancin" tip o! a recoverin" nerve. In the unconscious patient or 'oun" child, the plastic pen test is help!ul. I! the nerve is normal then the side o! a pen brushed "entl' across the s*in will stic* because o! the intact suppl' to sweat "lands: i! the nerve is divided, the pen will brush o!! smoothl'. 6&aminin" the nerves o! the hand 9erve Altered sensation Wea*ness, wastin" Anterior 9il 1le&or pollicis lon"us, !le&or interosseous di"itorum pro!undus )1D0+ to inde& 0osterior 9il 6&tensors o! wrist and interosseous metacarpophalan"eal 2oint =edian Thenar eminence, palmar 1le&or carpi radialis, side o! thumb, inde&, pronator teres, lon" !in"er middle and radial hal! o! !le&ors )e&cept 1/0 to rin" rin" !in"er and little+, abductor pollicis brevis, opponens pollicis >lnar >lnar side o! hand, palmar 1le&orcarpi ulnaris, 1/0 to side o! little !in"er and rin" and little !in"er, ulnar hal! o! rin" !in"er adductor pollicis, interossei, h'pothenar eminence, 1roment8s si"n 3uper!icial Anatomical snu!!bo& 9il radial , Circulation # A white or blue !in"ertip su""ests circulation problems. I! the !in"er nail is compressed and then released, the circulation should return in less than ? seconds. I! not, this su""ests either s'stemic h'potension or loss o! the local blood suppl'. With the Allen test, one can tell whether both radial and ulnar arteries are intact. 7oth are compressed b' the e&aminer8s !in"ers, the patient s%uee$es his or her hand to e&press the blood and then rela&es. The hand will be white. The e&aminer

then releases one arter': i! the hand does not <pin* up8, that arter' is occluded or divided. The test is repeated !or the other side. Investi"ation , 0lain radio"raphs # The standard views are a posteroanteriorand true lateral. /bli%ue views are help!ul particularl' !or intra articular !ractures and scaphoid !ractures. 3pecial views, !or e&ample stress views !or ulnar collateral li"ament in2uries o! the thumb or a clenched !ist view !or carpal instabilit', are sometimes needed. , =a"netic resonance ima"in" )=RI+ # This can detect, !or e&ample, Kienb@c*8s disease be!ore it is apparent on plain radio"raphs and "ives some indication o! the vascularit' o! a scaphoid !racture. , Isotope bone scannin" # In di!!icult cases this helps b' disclosin" the in!lammation that accompanies undisclosed !ractures or bone lesions such as osteoid osteoma. , Wrist arthroscop' # This can dia"nose tears o! the trian"ular !ibrocartila"e comple& )T1CC+, carpal instabilit' and arthritis. 3ome T1CC tears are treatable arthroscopicall'. , 6lectroph'siolo"' # 1or a clinicall' obvious carpal tunnel s'ndrome these ma' not be re%uired: !or less clear neurolo"ical s'mptoms these tests detect i! and where there is nerve compression. 7asic principles o! treatment Certain principles must be !ollowed when treatin" conditions o! the hand and wrist. Avoidin" swellin" and sti!!ness The hand swells !ollowin" in2ur', sur"er' or in!ection )1i". AB.C+: as it swells it tends to !all into a position with the wrist !le&ed, the metacarpophalan"eal 2oints e&tended and the interphalan"eal 2oints !le&ed. This position becomes permanent as the collateral li"aments shrin* and the oedematous tissues !ibrose. The hand then cannot !unction properl'. To avoid this, one must obe' the !ollowin" three principles. C.6levation. The hand must be elevated in a hi"h slin" or roller towel )1i". AB.?+, care bein" ta*en that the venous draina"e is not occluded b' too much elbow !le&ion. ?.3plinta"e. The wrist should be splinted initiall' in the position o! sa!et' # the <6dinbur"h8 position described b' James )1i". AB.A+. Dressin"s must not be too ti"ht. A.=ovement. As man' 2oints as possible o! the wrist and hand should be moved as earl' as possible. Rehabilitation should be planned so that the !ewest possible 2oints and tendons are immobilised. Anaesthesia =an' procedures on the wrist and hand can be per!ormed usin" local anaesthesia either pro&imall' )scalene bloc*, a&illar' bloc*+ or more distall' )7ier8s bloc*, wrist bloc*, di"ital nerve bloc* or tendon sheath bloc*+. In "eneral, i! a tourni%uet is used !or more than about ?B minutes it becomes uncom!ortable and so a pro&imal bloc* or "eneral anaesthetic is pre!erred. 1or a di"ital nerve bloc*, local anaesthetic is introduced into the palm at the level o! the distal palmar crease: this is pre!erable to surroundin" the base o! the !in"er with a potentiall' occlusive <rin" bloc*8. An alternative is to instill about C ml o! ? per cent li"nocaine beneath the !le&or tendon sheath. This ta*es a little more time to wor* than a di"ital nerve bloc*, but lasts !or lon"er and is e%uall' e!!ective. Tourni%uet A bloodless !ield is essential !or accurate sur"er'. A well padded tourni%uet above the elbow, in!lated to DE mm(" pressure over the s'stolic blood pressure, is usuall' satis!actor'. The time should not e&ceed ? hours. An 6smarch banda"e or a rubber

tube e&san"uinator are e!!ective, but should be avoided !or tumour or in!ection cases lest the patholo"' is spread s'stemicall'. In the !in"er, a tourni%uet can be made b' placin" a sterile "love on the patient, snippin" o!! the tip and then rollin" the "love down to the base o! the !in"er. Incisions Incisions which cross a !le&ion crease ma' produce an uncom!ortable and restrictive contracture. There!ore, sur"ical incisions should be planned to cut across !le&or creases at FEB or to lie in neutral areas, such as the midlateral line o! the !in"er. An alternative is to close a strai"ht incision across a !le&or crease with a G plast' )1i". AB.F+. 3plints 3plints can broadl' be described as restin", static or d'namic)1i". AB.E+. Restin" splints are used to immobilise the hand when there is active in!lammation, !or e&ample a!ter in2ur', a!ter sur"er' or durin" a !lare up o! rheumatoid arthritis or in!ection. 3tatic splints can be used continuousl')e.". !or a !racture until healed+, seriall' )e.". "raduall' chan"in" the an"le o! a splint to overcome a 2oint contracture+ or periodicall' )e.". a wrist e&tension splint at ni"ht to reduce s'mptoms o! carpal tunnel s'ndrome+. D'namic splints allow movement o! one "roup o! tendons but not the anta"onist, !or e&ample to protect either the !le&or tendons or e&tensor tendons a!ter repair. In2uries Vascular in2uries Vessel division A partial in2ur' o! an arter' will not contract and seal itsel! so it continues to bleed. 7leedin" should be controlled with pressure # it is dan"erous to use a tourni%uet )which can be !or"otten+ or to clip the vessel blindl' )which spoils the chance !or repair and can dama"e the nearb' nerve+. Compartment s'ndrome 1ollowin" crush in2uries and !ractures o! the !orearm or hand, or prolon"ed ischaemia !rom vessel dama"e, tourni%uet or ti"ht dressin"s, a compartment s'ndrome can develop. The pressure within the !ascial compartments )super!icial !le&or, deep !le&or, e&tensor, interossei, thenar and h'pothenar+ rises and occludes the microcirculation which supplies the muscles and nerves. The s'mptoms are pain, tin"lin", cold: the si"ns are ti"htness, tenderness and swellin" o! the muscles, and pain on passive stretchin" o! the muscles in the compartment. The main vessels will not necessaril' he occluded as their closin" pressure is "reater than the pressure re%uired to cut o!! the microcirculation. An' cast and dressin"s should be released and, i! this does not relieve the ischaemia, then a sur"ical !asciotom' should be per!ormed. =easurement o! the compartment pressures can help in a !ew cases, but should not dela' !asciotom' i! the clinical picture is clear. 1ractures 3caphoid This bone is !ractured b' a !all on the outstretched hand. The !racture is easil' overloo*ed # it causes little de!ormit' or pain and does not alwa's show clearl' on plain radio"raphs. (owever, it is notorious !or two reasons # it ma' not unite )par ticularl' in the relativel' avascular pro&imal pole+ or it ma' present later with intercarpal collapse and osteoarthritis. I! there is doubt about the dia"nosis, the wrist is best immobilised and radio"raphs repeated ? wee*s later. I! there is still doubt,

isotope bone scannin" or =RI scannin" will con!irm the dia"nosis. 0laster immobilisation is needed !or at least H wee*s: dela'ed union )e.". i! not healed b' about A months+ ma' merit bone "ra!t and internal !i&ation )1i". AB.;+. 3ome unstable displaced !ractures probabl' need earl' internal !i&ation. Distal radius This is commonl' in2ured. There are broadl' three "roups o! !racture. , Children. >suall' a 3alter (arris t'pe ? ph'seal in2ur', with the distal ulna sometimes !ractured as well. =anipulation and plaster !i&ation !or a !ew wee*s is usuall' ade%uate. 0ercutaneous Kirschner wires are sometimes needed !or unstable in2uries. , Ioun" adults. >suall' a hi"h ener"' in2ur', with several intra articular !ra"ments. 0er!ect anatomical reduction is most li*el' to "ive the best result: this ma' need a selection o! techni%ues, includin" bone "ra!t, percutaneous wires, internal !i&ation and distraction with an e&ternal !i&ator. , /lder adults. T'picall' throu"h osteoporotic bone in a postmenopausal !emale a!ter a !airl' minor !all. This is the classic Colles8 !racture. The distal !ra"ment is tilted dorsall' and radiall': the radius is shortened because o! impaction. Reduction is easil' achieved b' manipulation under re"ional anaesthesia or haematoma bloc*, but slippa"e is common and percutaneous wires ma' be chosen !or some. =etacarpals and phalan"es , 1i!th metacarpal nec*5 usuall' caused b' a punch )hence <7o&er8s !racture8+. >p to ;BB o! !le&ion at the !racture sitecan be accepted because o! the spare h'pere&tension in the !i!th metacarpophalan"eal 2oint and because the little !in"er8s !unction is to !le& # a loss o! e&tension is not !unctionall' too important. It is treated with elevation and splinta"e !or a !ew da's and then "entle mobilisation. 3ur"er' is rarel' re%uired. The <dropped *nuc*le8 de!ormit' is permanent. , =etacarpal sha!t !ractures5 most metacarpal !ractures are stable and undis placed, and need a restin" splint !or C#? wee*s !ollowed b' care!ul mobilisation. I! spiral, the !in"er rotates )no lon"er points to the scaphoid tubercle alon" with the other !in"ers when !le&ed into the palm+: i! an"ulated the prominent metacarpal head can be uncom!ortable when "rippin". There!ore some metacarpal !ractures need manipulation and !i&ation with plates or percutaneous Kirschner wires. , 0halan"eal !ractures5 whatever the !racture and its mana"ement, the !in"ers must be moved within a !ew da's o! in2ur' to avoid sti!!ness. =ost phalan"eal !ractures are undisplaced or can be manipulated under local anaesthetic into a stable, anatomical position. The hand is splinted and elevated !or a !ew da's then the !ractured !in"er is strapped to a nei"hbourin" !in"er and mobilised. I! the !racture is displaced and unstable, or i! the 2oint sur!ace is disrupted, accurate reduction and !i&ation is needed. Ri"id !i&ation with miniplates and screws allows earl' mobilisation which prevents sti!!ness, but un!ortunatel' the so!t tissue dissection re%uired parado&icall' can cause sti!!ness. There!ore, percutaneous wires are "enerall' pre!erred unless open sur"er' is needed !or reduction. 4i"aments Carpal instabilit' 9o tendons attach to the scaphoid, lunate or tri%uetral. These bones are called the <intercalated se"ment8, and their position and stabilit' are controlled b' the stout li"aments interconnectin" them. Dama"e to these li"aments, usuall' a!ter a !all on the outstretched hand, causes the bones to rotate abnormall' in relation to each other )1i". AB.D+. I! the scapholunate li"ament is ruptured, the lunate tilts dorsall' and the

scaphoid !le&es !orward: on the posteroanterior radio"raph the !le&ed scaphoid loo*s li*e a <rin"8 and the scapholunate "ap opens up. 6arl' repair and temporar' stabilisation with wires should be considered. Thumb ulnar collateral li"ament The ulnar collateral li"ament o! the thumb metacarpophalan"eal 2oint is crucial !or stable pinch. It can be torn when the thumb is wrenched radiall' )Js*ier8s thumb8+. A relativel' stable sprain is splinted !or about A wee*s: an unstable li"ament should be repaired: o!ten the adductor pollicis tendon is trapped between the torn li"ament and its insertion. The thumb ulnar collateral li"ament can also be stretched with chronic overuse )<"ame*eeper8s thumb8+. Trian"ular !ibrocartila"e comple& This important structure attaches the base o! the ulnar st'loid to the ulnar side o! the distal radius. It is continuous with the dorsal and palmar capsule o! the ulnar side o! the wrist. The T1CC stabilises the distal radioulnar 2oint. It can be torn, leadin" to instabilit' o! the distal radioulnar 2oint and ulnar sided wrist pain. The dia"nosis is con!irmed b' arthro"raph' or arthroscop', and some tears can be repaired. Dislocations 0eri lunate A !all on the outstretched hand can cause the lunate to dislocate !rom the surroundin" carpus, or !or the carpus to dislocate around the lunate. The scaphoid ma' also be !ractured. =edian nerve compression ma' result. The in2ur' is easil' missed on radio"raphs. 0rompt reduction should be supplemented b' li"ament repair and temporar' Kirschner wires. =etacarpophalan"eal 2oints These can be simple, which reduce easil', or comple&, which usuall' need open reduction throu"h a dorsal approach because the palmar plate )the thic*ened palmar capsule+ is wed"ed in the 2oint. 7ennett8s !racture dislocation This unstable intra articular !racture o! the thumb carpometacarpal 2oint is di!!icult to treat with plaster: closed reduction and percutaneous wire !i&ation !or E wee*s is more reliable. Interphalan"eal 2oints These are usuall' eas' to reduce and are stable. (owever, an associated !racture o! the cond'les, tendon avulsion, palmar plate avulsion or collateral li"ament tear ma' need speci!ic treatment. Tendons =allet !in"er 1orced !le&ion o! the distal interphalan"eal 2oint can rupture the insertion o! the lon" e&tensor tendon. There ma' be a bone !ra"ment. Closed reduction and splinta"e in !ull e&tension !or H wee*s is pre!erable to sur"er' which has a hi"h complication rate. 1le&or tendons 1le&or tendon in2uries have a poor reputation. 3ur"er' is particularl' demandin" in 7unnell8s <no man8s land8 # otherwise *nown as $one II # between the metacarpophalan"eal 2oint and distal interphalan"eal 2oint where both !le&or di"itorum super!icialis and !le&or di"itorum pro!undus run in an intricate, ti"ht !ibrous sheath )1i". AB.H+. The best outcome is probabl' with primar' repair b' an e&perienced sur"eon usin" special sutures under ma"ni!ication )1i". AB.K+. Rehabilitation must be meticulous to avoid either sti!!nessor rupture. Various splints and mobilisation protocols have been recommended. 6&tensor tendons

6&tensor tendon in2uries "enerall' have a better outcome than !le&or tendon in2uries. The' usuall' recover well with care!ul primar' suture and splinta"e !or about F wee*s. There are two sites where special care must be ta*en. , Cuts over the pro&imal interphalan"eal 2oint, i! untreated, can lead to a <boutonniere8 )buttonhole+ de!ormit' because the central slip no lon"er e&tends the pro&imal 2oint whilst the remainin" e&tensor mechanism h'pere&tends the distal 2oint and !le&es the .pro&imal 2oint. 6arl' repair and splinta"e is there!ore important. , Cuts over the metacarpophalan"eal 2oint, especiall' !ollowin" a punch, usuall' enter the 2oint and must be thorou"hl' cleaned. 1in"ertip in2uries The choice o! treatment depends on the t'pe o! in2ur', as well as the patient8s occupation, hobbies and cosmetic demands. =an' !in"ertip in2uries will heal when le!t alone beneath a semi permeable dressin". I! more than C cm? o! s*in is lost, a s*in "ra!t will speed up the overall time to healin". I! the pulp is lost and bone e&posed then man' techni%ues are available to cover the bone and maintain the len"th o! the !in"er. I! earl' return to manual wor* is important, then shortenin" throu"h the distal interphalan"eal 2oint is considered )<terminalisation8+. Care!ul attention to detail is important #trimmin" the cond'les, tailorin" well vascularised s*in !laps, bur'in" the nerve ends and completel' removin" the nail bed. I! len"th, sensation and appearance are important )particularl' in the thumb and inde& !in"er+ then a !lap ma' be pre!erred5 !or e&ample, a cross !in"er !lap or a V to I advancement !lap )1i". AB.CB+. Replantation With microsur"ical techni%ues, it is sometimes both possible andadvisable to replant amputated parts )1i". AB.CC+. Amputated parts should be wrapped in a sterile cloth soa*ed in sterile saline, and placed in a plastic ba" which is placed in water and crushed ice. Replantation is not alwa's advisable. The choice must alwa's be tailored to the individual in2ur' and the individual patient. A sin"le di"it replanted pro&imal to the super!icialis insertion is li*el' to become ver' sti!!, with imper!ect sensation and the prospect o! a considerable time o!! wor* a!ter the !irst, and o!ten subse%uent, sur"er'. Amputation is o!ten a better option. The thumb, in contrast, !unctions well enou"h even i! sti!!, and replantation should be considered. Replantation Indications5 , Thumb , 3in"le di"its in children , 3in"le di"its at distal interphalan"eal 2oint level , =ultiple di"its , (and, wrist, !orearm Relative contraindications5 , 3in"le di"its in adults , Crushed, man"led or avulsed parts , 0oor "eneral condition o! patient , 4on" warm ischaemic time In!ection 3i"ns include redness, tenderness, swellin" )o!ten more apparent on the bac* o! the hand+, l'mphan"itis # strea*s o! red runnin" up the arm # and l'mphadenopath' )epitrochlear or a&illar'+. =an' hand in!ections will settle within ?F#FH hours i!

elevated, splinted and treated with a best "uess antibiotic. As soon as the si"ns o! in!lammation have settled, the hand must be dili"entl' mobilised. I! pus appears, it must be drained: the wound should be le!t open, antibiotics chan"ed accordin" to microbiolo"ical advice, and the hand splinted in the 6dinbur"h position and then mobilised as soon as the in!lammation settles. Acute paron'chia This is the most common in!ection o! the hand, o!ten caused b' careless nail trimmin" or pic*in" the s*in around the nail !old )1i". AB.C?+. A!ter an initial in!lammator' phase, pus is trapped beside the nail. The pus is released b' incision on to the nail !old and e&cision o! the outer %uarter o! the nail. Chronic paron'chia This appears over several wee*s )1i". AB.CA+. Rather than a conse%uence o! an acute paron'chia, it is usuall' a chronic !un"al in!ection in those with their hands constantl' immersed. =icroscopical e&amination o! the scrapin"s and special !un"al cultures will con!irm the dia"nosis. It ma' resolve i! the hands are *ept dr' and the nail !old is re"ularl' dressed with anti!un"al ointment. I! this !ails, the nail !old is laid open. 0ulp space /therwise *nown as a <!elon8, this causes severe pain in the !in"er pulp. 0us is trapped between the !ibrous septae which bind the specialised !in"ertip s*in to the underl'in" bone: the bone o! the terminal phalan& can also become in!ected leadin" to a se%uestrum. An abcess should be drained throu"h an obli%ue incision over the point o! "reatest tenderness. The di!!erential dia"nosis is a herpetic whitlow. This is caused b' herpes simple& virus and ma' be !ound, !or e&ample, in dental wor*ers. 3mall vesicles appear which then become crust'. 3ur"er' should not be per!ormed: it resolves itsel! over a !ew wee*s. 1le&or tendon sheath in!ection There is little spare space within the tendon sheath: an untreated in!ection rapidl' causes adhesions and even tendon necrosis, leadin" to a sti!!s useless !in"er. The classic si"ns, described b' Kanavel, are a swollen !in"erheld in !le&ion, with e&%uisite pain on passive e&tension and tenderness precisel' over the !le&or sheath. The usual or"anism is a 3taph'lococcusor a 3treptococcus. The tendon sheath should bepromptl' irri"ated with normal saline throu"h a !ine catheter passed into small incisions over the distal and pro&imal ends o! the sheath. The !in"er must be moved as soon as the si"ns o! in!lammation be"in to resolve. 7ites 3erious in!ection and subse%uent loss o! !unction can result !rom animal or human bites. (uman or"anisms include 6i*enella corridens: animal bites include 0asteurella multicodens. 3taph'lococci are common in both. These or"anisms are usuall' sensitive to broad spectrum antibiotics such as Au"mentin. Wounds should be e&plored under ade%uate anal"esia and a tourni%uet. A common in2ur' is over the *nuc*le when the opponent8s tooth penetrates the metacarpophalan"eal 2oint. The penetration ma' not be apparent because the !our la'ers )s*in, tendon and capsule and s'novium+ which are in2ured in !le&ionclose over when the *nuc*le is e&amined in e&tension. The wound must be e&cised, the 2oint thorou"hl' washed out, and the e&tensor tendon repaired and splinted. /ther in!ections ='cobacterial in!ections Tuberculosis in the hand ma' involve the tenos'novium, 2oints or bone. The most dramatic is a so called compound palmar "an"lion, with s'novial swellin" both

pro&imal and distal to the transverse carpal li"ament. The dia"nosis is con!irmed b' biops'. Treatment is b' s'novectom' and prolon"ed dru" treatment. 0ilonidal sinus A hair implanted in the palm or web space can cause a c'st with recurrent in!ection )1i". AB.CF+. The c'st should be e&cised. /r! Transmitted b' sheep, this virus causes red papules which become reddish blue and then "re' nodules. The condition resolves a!ter a !ew wee*s. 0almar space in!ections 0us can collect deep to the palmar !ascia either side o! the septum runnin" down to the third metacarpal. The whole hand is swollen and the palm intensel' tender. The in!ection is drained throu"h a lon"itudinal incision, "reat care bein" ta*en to avoid dama"e to the tendons, nerves and blood vessels. Web space in!ections 0us can collect in the potential space surroundin" the lumbrical muscles as the' pass !rom the palm, across the deep transverse metacarpal li"ament into the e&tensor mechanism. The swellin" in the web space tends to spread the ad2acent !in"ers apart. The pus is drained throu"h a lon"itudinal incision over the web space, ta*in" care not to dama"e the nearb' neurovascular bundles. Arthritis Rheumatoid arthritis Rheumatoid arthritis is a disease which a!!ects man' s'stems and man' 2oints. It can devastate the wrist and hand. The s'novitis destro's li"aments, tendons and 2oints, producin" pain, de!ormit' and loss o! !unction. Gi" $a" collapse is t'pical o! rheumatoid arthritis # as one 2oint de!orms in one direction, the ne&t de!orms in the opposite )e.". boutonniere, swan nec*, ulnar dri!t o! metacarpophalan"eal 2oints with radial dri!t o! wrist+. As the 2oints de!orm, the tendons overl'in" them "ain a "reater mechanical advanta"e, leadin" to "reater de!ormit'. 3imple activities o! dail' livin", such as thumb pinch and openin" 2ars, stress the wea*ened li"aments and produce worsenin" de!ormit' )particularl' ulnar dri!t at the metacarpophalan"eal 2oints+. Assessment 1or the hand to !unction well, it must be placed accuratel' and !irml' in place # the elbow, shoulder and wrist must be care!ull' assessed as well. (istor'. What are the patient8s social circumstance, mobilit', occupation and "eneral health. These all in!luence the treatment that is o!!ered. Which particular 2oints concern the patient. What is the patient8s problem with these 2oints #pain, instabilit', wea*ness, sti!!ness, appearance. Are there s'mptoms elsewhere, particularl' the shoulder and elbow. What speci!ic !unctional problems are there. 6&amination. Does the patient have a t'pical pattern o! de!ormit'. Are the 2oints stable or unstable. Is there s'novitis in the 2oints or tendons. What is the active and passive ran"eo! movement o! each 2oint. Are these movements pain!ul. Are the tendons intact. Are the muscles wea*. Is there a median nerve pals' )!rom s'novitis in the carpal tunnel+ or a radial or ulnar nerve pals' )much rarer, !rom s'novitis around the elbow+. 0inch "rip and power "rip. De!ormities in rheumatoid arthritis Wrist5 , Radial deviation , Carpal supination , 0rominent, unstable ulnar head

, 6&tensor tenos'novitis =etacarpophalan"eal 2oints5 , 1le&ion , >lnar deviation , 3ublu&ation, dislocation 1in"ers5 , 3wan nec* , 7outonniere , 6&tensor tendon rupture , 1le&or tendon rupture , 1le&or s'novitis ,Con"enital de!ormities T'pe 1ailure o! !ormation

6&ample 4on"itudinal absence radial )radial club hand+, lon"itudinal absence ulnar )ulnar club hand+, lon"itudinal absence central )lobster claw hand+ 1ailure o! di!!erentiation 3'ndact'l' )!in"ers 2oined b' s*in and sometimes bone+ Duplication Thumb duplication /ver"rowth =acrodact'l' >nder"rowth Thumb h'poplasia Constriction rin" s'ndrome 3imple rin"s -eneralised s*eletal abnormalities =ar!an8s, Turner8s, Down8s, etc. 9onoperative treatment Rheumatoid arthritis is best mana"ed with a team comprisin" the patient, ph'sician, ph'siotherapist, occupational therapist, social wor*er and sur"eon. Dru"s can reduce s'mptoms and slow pro"ression. Restin" splints are help!ul durin" !lare ups. Appliances can help with tas*s such as turnin" on taps or openin" 2ars, which would otherwise strain and dama"e the la& li"aments. 3tatic splints stabilise and protect la& 2oints and improve !unction. 3ur"er' The hand can never be made normal but man' patients bene!it !rom care!ull' planned sur"er'. 3ur"er' must be tailored !or each patient. In "eneral, the shoulders, elbow and wrist should be treated be!ore the hand, and reliable operations )e.". thumb or wrist !usion+ should be underta*en be!ore more uncertain operations )e.". so!t tissue reconstruction+. There are !our indications !or sur"er'5 , pain: , prevention o! pro"ression: , improvin" !unction: , improvin" appearance. 3'novectom'o! the wrist 2oint, metacarpophalan"eal 2oints and interphalan"eal 2oints should be considered i! medical treatment has !ailed to control pain, with minimal 2oint dama"e on radio"raphs. 3'novectom' o! the !le&or tendons ma' be needed i! the patient has !le&or tendon rupture, poor active !in"er !le&ion, tri""er !in"er or carpal tunnel s'ndrome. 3'novectom' o! the e&tensor tendons )o!ten with e&cision o! the distal ulna+ removes unsi"htl' swellin" and reduces the ris* o! rupture.

6&cision o! the distal end o! the ulna, o!ten with reconstruction o! the associated e&tensor tendon ruptures, reliabl' improves pain and !unction, and prevents e&tensor tendon rupture. Replacemento! the wrist with silicone or metal#pol'eth'lene implants carries a hi"h ris* o! !ailure. Replacement o! the metacarpophalan"eal 2oints helps pain and appearance, and the implants can last !or a considerable time: the e&tensor tendons, collateral li"aments and intrinsic tendons all need care!ul reconstruction to overcome ulnar deviation. Replacement o! the pro&imal interphalan"eal 2oint can maintain some movement but there is an appreciable !ailure rate. 1usiono! the radiocarpal 2oint "ives a pain !ree, stable plat!orm !or the hand. An intramedullar' pin with bone "ra!t usuall' su!!ices. 1usion o! the thumb metacarpophalan"eal 2oint and the !in"er distal interphalan"eal 2oints can considerabl' improve !unction b' providin" stabilit' and removin" pain. Tendon reconstruction is sometimes necessar'. A ruptured e&tensor pollicis lon"us is treated e!!ectivel' with an e&tensor indicis trans!er. A ruptured !le&or pollicis lon"us is most reliabl' treated, i! the patient8s s'mptoms need it b' thumb interphalan"eal 2oint !usion. =ultiple tendon ruptures on the dorsum o! the wrist are mana"ed with side to side suture to intact tendons, tendon trans!er or a tendon "ra!t. 3wan nec* de!ormit' )1i". AB.CE+ is caused b' imbalance o! the !le&or and e&tensor tendons over the !in"er, sublu&ation o! the metacarpophalan"eal 2oint, ti"htness o! the intrinsic muscles and !ailure o! the palmar plate o! the pro&imal interphalan"eal 2oint. It ma' need splinta"e, manipulation, tenodesis, intrinsic muscle release, lateral band release or even !usion dependin" on the cause and severit'. /steoarthritis Wrist The radiocarpal 2oint ma' develop osteoarthritis a!ter an intra articular !racture or in!ection: it can develop without an obvious cause. I! splinta"e, anal"esics and modi!ication o! activit' !ail, then !usion o! the wrist at about ?Bde"ree e&tension with a dorsal plate and bone "ra!t will "ive a stable, pain !ree wrist. Arthritis ma' develop around the scaphoid a!ter a scaphoid !racture or a scapholunate li"ament rupture. I! simple measures !ail, then bone e&cision, a limited !usion or total wrist !usion ma' be needed. The pisotri%uetral 2oint can develop osteoarthritis. There is !ocal tenderness over the 2oint and ABde"ree supination radio"raphs show the patholo"' )1i". AB.C;+. I! rest, splinta"e and a steroid in2ection !ail, pisi!orm e&cision is help!ul. (and /steoarthritis o! the hand is most commonl' part o! a predisposition to "eneralised osteoarthritis, particularl' in late middle a"ed !emales. In!re%uentl' it !ollows 2oint in2ur' or in!ection. The pro&imal interphalan"eal 2oints ma' be involved )7ouchard8s nodes+, the distal interphalan"eal 2oints )(eberden8s nodes+ or the carpometacarpal 2oint o! the thumb. The metacarpophalan"eal 2oints and !in"er carpometacarpal 2oints are rarel' involved. The s'mptoms do not correlate well with the radio"raphs. /ccasionall' sur"er' is needed. 1usion o! the distal interphalan"eal 2oint removes pain and "ives "ood !unction. The pro&imal interphalan"eal 2oint can be !used, but the loss o! !le&ion is a si"ni!icant hindrance: the alternative o! replacement with silastic is unreliable. The basal 2oint o! the thumb usuall' responds to anal"esics, steroid in2ections and splinta"e. 6&cision o! the trape$ium helps the pain but the thumb is wea*ened. 1illin" the space with a rolled up len"th o! palmaris lon"us, or suspendin" the base o! the !irst metacarpal with a slin" made !rom part o! the !le&or carpi radialis tendon, ma' improve stabilit' o! the thumb. /ther !orms o! arthritis

-outcan easil' be mista*en !or a septic arthritis in the wrist or !in"er 2oints. The dia"nosis is con!irmed b' measurin" the serum urate and e&aminin" the 2oint aspirate under a microscope. In more chronic !orms, tophi are seen beneath the s*in and bone can be eroded. -out can also cause tenos'novitis leadin" to tri""er !in"er or carpal tunnel s'ndrome. 0soriasiso!ten involves the 2oints o! the hand and wrist. The nails are pitted and bone ma' resorb. Dupu'tren8s contracture The condition is inherited as an autosomal dominant trait and is more common in males, with a"e, smo*in", pulmonar' tuberculosis, epileps', ac%uired immunode!icienc' s'ndrome )AID3+ and alcoholic cirrhosis. It is usuall' !ound in those o! An"lo 3a&on descent. ='o!ibroblasts in the palmar !ascia proli!erate and contract. Initiall', there is a nodular swellin" in the palm. The overl'in" s*in then puc*ers. Cords runnin" into the !in"ers contract causin" a !le&ion de!ormit' o! the metacarpophalan"eal and pro&imal interphalan"eal 2oints. The s*in over the bac* o! the pro&imal interphalan"eal 2oints ma' thic*en )-arrod8s *nuc*le pads # 1i". AB.CD+ and a !ew patients ma' have thic*enin" in the penis )0e'ronie8s disease+ or on the sole o! the !oot )4edderhose8s disease+. 3ur"er' is advised i! the de!ormit' is a nuisance or i! the de!ormit' is rapidl' pro"ressin", especiall' at the pro&imal interphalan"eal 2oint where it soon becomes irreversible. Durin" sur"er', care must be ta*en to avoid the neurovascular bundles. G plasties can provide e&tra s*in but occasionall' !ull thic*ness s*in "ra!ts are needed. The palm wound can be le!t open # it will heal rapidl' with dressin"s. 3ur"er' is not curative and recurrence is ver' common. Tendon disorders Tri""er !in"er 1or reasons which are o!ten obscure, the openin" o! the !le&or tendon sheath )the Al pulle'+ thic*ens and snares the tendon which ma' secondaril' develop a small nodule. When the pro&imal interphalan"eal 2oint is !le&ed it loc*s and then snaps into e&tension. This o!ten starts onl' on awa*enin", and then "raduall' occurs more !re%uentl' durin" the da'. I! it does not resolve with a steroid in2ection into the sheath, then release o! the pulle' at the level o! the metacarpophalan"eal 2oint )distal palmar crease+ is success!ul, watchin" !or the neurovascular bundle. In in!ants, the thumb can tri""er: this o!ten resolves spontaneousl' b' the a"e o! C 'ear, but i! not sur"er' is needed, bein" aware that in the thumb the di"ital nerves run close to the midline )not the midlateral line as the' run in the !in"ers+. In rheumatoid arthritis, the tri""erin" is caused either b' s'novitis or b' a nodule in the tendon. 3'novectom', and i! necessar' e&cision o! a slip o! !le&or di"itorum super!icialis, is sa!er than division o! the pulle' # the latter can worsen the tendenc' to ulnar dri!t o! the metacarpophalan"eal 2oints. De Luervain8s disease The e&tensor pollicis brevis tendon and abductor pollicis lon"us tendon run in a compartment beneath the e&tensor retinaculum. This compartment can constrict the tendons, causin" pain at the base o! the thumb. >suall' occurrin" spontaneousl' in middle a"ed women, it is also associated with late pre"nanc' and overuse. 1in*elstein8s test is positive there is pain over the radial side o! the wrist when the patient8s thumb is "rasped and the hand is %uic*l' abducted ulnarward. 3plinta"e, nonsteroidal anti in!lammator' medication, steroid in2ection and ultrasound ma' help. 3ur"ical decompression is o!ten re%uired, avoidin" the super!icial radial nerve )lest a

ver' troublesome neuroma occurs+ and rememberin" that there are o!ten e&tra septae and slips o! tendon # the condition will persist i! these are overloo*ed. Carpal tunnel s'ndrome This is common. The t'pical patient awa*ens with pain!ul tin"lin" over the radial side o! the hand: there is o!ten loss o! !ine de&terit' because o! wea*ness o! the abductor pollicis brevis muscle and altered sensation over the thumb, inde& and middle !in"ertips. /n e&amination, Tinel8s percussion si"n is positive over the carpal tunnel and 0halen8s test ma' be positive )tin"lin" in the hand when the wrist is !ull' !le&ed+. In advanced cases, the thenar eminence is wasted. The dia"nosis, i! not certain clinicall', is con!irmed with electroph'siolo"'. Treatment includes splintin" the wrist in e&tension at ni"ht, in2ectin" steroid into the carpal canal and sur"ical release o! the transverse carpal li"ament. Kienboc*8sdisease The aetiolo"' is unclear, but probabl' involves both ischaemia and microtrauma in the lunate, causin" sclerosis initiall', then collapse and !inall' arthritis. =an' patients have a relativel' short ulna )<ne"ative ulnar variance8+. 0atients complain o! pain and wea*ness in the wrist. Ver' earl', bone scan or =RI can detect disease be!ore it shows on plain radio"raphs. Treatment is initiall' conservative, with splinta"e, avoidance o! activit' and simple anal"esics. 3ur"ical shortenin" o! the radius reduces the compressive !orces across the lunate and ma' help those with earl' disease. In advanced cases with pain!ul osteoarthritis around the lunate, radiocarpal !usion is the most reliable treatment. -an"lion c'sts These are the most common swellin"s in the hand. 0atients present with concern about the lump and occasionall' with pain. The swellin" is smooth, well de!ined, !luctuant and transilluminable. A !ew resolve with aspiration or compression )<hittin" with the !amil' bible8+. 3ur"er' should be meticulous otherwise recurrence is li*el'. -an"lia around the wrist should be traced down to their source, usuall' the scapholu nate li"ament and sometimes the scapho trape$io trape$ioid 2oint. (istolo"' shows a compressed colla"en sheath !illed with a mucoid substance. Con"enital di!!erences These a!!ect about one in EBB babies )1i". AB.CH+. 3ome have a clear "enetic cause, while others ma' !ollow an intrauterine insult durin" the second month o! pre"nanc' when the limb buds are !ormin". These need care!ul mana"ement o! both child and parent: sur"er' is challen"in" and the patients are best re!erred to a specialist. 1urther readin" American 3ociet' !or 3ur"er' o! the (and )CKK;+ (and 3ur"er' >pdate, American Academ' o! /rthopaedic 3ur"eons, Rosemount I4. 7rand, 0.W and (ollister, A. )CKKA+ Clinical =echanics o! the (and, ?nd edn, =dsb', 3t 4ouis, =/. 1latt, A.6. )CKKE+ The Care o! the Arthritic (and, Eth edn, L=0, 3t 4ouis. -reen, D.0. )ed.+ )CKKH+ /perative (and 3ur"er', Ard edn, Churchill 4ivin"stone, 9ew Ior*.

4ister, -.D. )CKKA+ The (and # Dia"nosis and Indications, Ard edn, Churchill 4ivin"stone, 6dinbur