THE HAND

Presented by : Rumondang Naibaho, Claudia M.F. Kurube Otto Parandangi, Syukri La Ranti Faqi Nurdiansyah Tutor : dr. Teuku Nanta dr. Jecky Chandra

 Symptoms

Clinical Assesment On The Hand

Sign Look: posture, Pain: localized or colour, hair, scarred, refered wasting, deformity, Deformity: suddenly lump or slowly Swelling: localized or Feel: temperature, texture, pulse, many joints tenderness simultantly Move: active and Loss of functions: passive movements handling tools, holding glass,etc Sensory symptoms and motor weaknes: neurolgical deficit

Examination
a)

b)
c) d)

e)
f) g) h) i)

Resting position Full flexion Full extension Power grip Finger abduction Pinch grip Pin prick Light touch Stereognosis

Finger and Thumb Movements

Congenital Variations
Hand and foot are much the commonest sites of congenital variations in the musculoskeletal system Cause:

Inherited genetic defect Chromosome disorder Viral infection, radiation, drug administration during first 2 month of

There are seven groups clinical disorder Early recogniton and definitive treatment as soon as feasible and preferable before the age of 3 years. Psycological support is important

ACQUIRED DEFORMITIES

INTRODUCTION
Deformity of the hand may be result from disorder of the skin, subcutaneous tissue, muscle, tendons, joints, bones of neuromuscular function

ACQUIRED DEFORMITIES
SKIN CONTRACTURE MUSCLE CONTRACTURE TENDON LESSION JOINT DISORDER BONE DISORDER NEUROMUSCULAR DISORDER

SKIN CONTRACTURE

MUSCLE CONTRACTURE
Volkmanns Ischemic Contracture Shortening Of The Intrinsic Muscle

TENDON LESSION

D
C A. MALLET FINGER B. RUPTURED EXTENSOR POLLICIS LONGUS C. SWAN NECK DEFORMITY E

D. BOUTONIERE DEFORMITY E. DROPPED FINGER

JOINT DISORDER
JUVENILLE CHRONIC ARTHRITS SYSTEMIC LUPUS ERYTHEMATOUS TRAUMA

NEUROMUSCULAR DISORDER

PERIPHERAL NERVE LESION

DUPUYTRENS CONTRACTURE

INTRODUCTION
DUPUYTRENS CONTRACTURE is a nodular hypertrophy and contracture of the superficial palmar fascia. It is inhereted as an autosomal dominant trait More common in male, increase with age, at an early stage means aggressive disease.

PATHOLOGY
Proliferation of myofibroblasts in fibrous tissue within the palmar fascia and fascial bands within the fingers contract flexion deformities of the MCP and PIP joints. Fibrous attachments to the skin lead to puckering. The digital nerve is displaced or enveloped, but not invaded, by fibrous tissue.

CLINICAL FEATURES
The palm is puckered, nodular and thick Pain flexion deformities

TREATMENT

Operation

STENOSING TENOVAGINITIS (TRIGGER FINGER)

INTRODUCTION
A flexor tendon may become trapped at the entrance to its sheath. On forced extension it passes the constriction with a snap (triggering). The usual cause is thickening of the fibrous tendon sheath ( often following local trauma or unaccustomed activity).

CLINICAL FEATURES
The patient notices that the finger clicks as he or she bends it, when the hand is unclenched, the affected finger remains bent at the PIP joint, but with further effort it suddenly straightens with a snap. A tender nodule can be felt in front of the MCP joint.

TREATMENT
Early cases injection of methylprednisolone carefully placed into the tendon sheath. Refractory cases need operation.

RHEUMATOID ARTHRITIS

INTRODUCTION

The hand, more than any other region, is where rheumatoid arthritis carves its story Rheumatoid arthritis consist of 3 stage: o Stage 1 synovitis of joints and of tendon sheaths. o Stage 2 joint & tendon erosions prepare the ground for mechanical derangement. o Stage 3 joint instability & tendon ruptur cause progressive deformity and loss of function.

CLINICAL FEATURES
STAGE 1 Stiffness, painfull,swelling of the fingers, the MCP joints, the PIP joints or the wrist. Carpal tunnel compression STAGE 2 slight radial deviation of the wrist and ulnar deviation of the fingers correctable swan-necking STAGE 3 Deformities are the rule

rheumatoid nodules

Symmetric
Swelling of tendon sheaths a drop finger or mallet thumb (from extensor tendon rupture)

weakness

The joints are tender and crepitus

Joint mobility and grip strength are diminished.

An isolated boutonniere

RADIOLOGY IMAGING
Stage 1: the x-rays show only soft tissue swelling and osteoporosis around the joints. Stage 2: joint space narrowing and small periarticular erosions appear; these are commonest at the metacarpophalangeal joints and in the styloid process of the ulna. Stage 3: Joint deformity and dislocation are common.

TREATMENT
Stage 1 : treatment is directed essentially at controlling the systemic disease and the local synovitis. Stage 2 : to prevent deformity. synovectomy followed by physiotherapy Stage 3 :deformity is combined with articular destruction. soft tissue correction alone will not suffice.

OSTEOARTHRITIS

Osteoarthritis
80% of people over the age of 65 have radiological signs of osteoarthritis in one or more joints of the hand, include DIP, PIP, MCP, and Carpo-metacarpal joints, most of them are asymptomatic.

OA IN DISTAL INTERPHALANGEAL JOINTS

It often starts with pain in one or two fingers; the distal joints become swollen and tender, usually spreading to all the fingers of both hands. (Heberdens nodes)

OA IN PROXIMAL INTERPHALANGEAL JOINTS

Not infrequently some of the PIP joints are involved (Bouchards nodes). The joints are swollen and tend to deviate ulnarwards due to mechanical pressure in daily activities.

TREATMENT
Treatment is usually symptomatic Non-operative Analgesic Appropriate rest Operative

RAYNAUDS DISEASE

RAYNAUDS DISEASE
Raynauds syndrome is produced by a vasospastic disorder which affects mainly the hands and fingers. precipitated by cold; the fingers go pale and icy, then dusky blue (or cyanotic) and finally red. Between attacks the hands look normal.

RAYNAUDS DISEASE

Raynauds phenomenon is the term applied when these changes are associated with an underlying disease such as scleroderma or arteriosclerosis.

Treatment : The hands must be kept warm. Calcium channel blockade, iloprost infusions or digital sympathectomy (surgical removal of the sympathetic plexus around the digital arteries)

ACUTE INFECTIONS OF THE HAND

Acute Infections Of The Hand

Infection of the hand is frequently limited to one of general compartments Usually the cause is a staphylococcus which has been implanted by fairly trivial injury. The response to infection is an acute inflammatory reaction with oedema, suppuration and increased tissue tension.

Clinical features
History of trauma (a superficial abrasion, laceration or penetrating wound) Painfull, swollen, fevers Examination: the finger or hand red and swollen, exquisitely ten over the site of tension, examined for lymphangitis and swollen gland, sign of septicaemia. X-Ray: Osteomyelitis or septic

(a) Acute nail-fold infection (paronychia) (b) Chronic paronychia (c) Pulp-space infection (felon or whitlow) of the thumb due to a prick-injury on the patients own denture

(a) Septic arthritis of the terminal interphalangeal (b) Infected insect bite.

Principles of treatment
Rest, splintage and elevation

Antibiotics

Drainase

Rehabilitation

The position of the immobilization

This position in which the ligaments are at their longest and splintage is least likely to result in stiffness

Thank You