HAND CONDITIONS

Hand is a very important part

of the body. Disorders
affecting the hand could
lead to loss of hand
function in various forms
and degrees.
Thumb itself accounts for
over 40 percent function
of the hand. It is
imperative that the
problems affecting the
hand should be diagnosed
and managed correctly.
 CONGENIAL ANOMALIES OF
THE HAND
1. Polydactyly – It is a duplication of one or more
digits and may require amputation for cosmetic
purposes
 Polydactyly
Polydactyly can occur by itself, typically as a
manifestation of autosomal dominant mutations,
or in conjunction with a syndrome of congenital
anomalies.
- Can be associated with Trisomy 13, Meckel
and Trisomy 21.
Trisomy 13 - Occurs when extra DNA from
chromosome 13 appears in some or all of the
body's cells.
 Meckel-Gruber Syndrome
Meckel-Gruber syndrome is a lethal, rare,
autosomal recessive condition mapped to 6
different loci in chromosomes 17q21-24 (MKS1),
11q13 (MKS2), 8q21.3-q22.1 (MKS3), 12q21.31-
q21.33 (MKS4), 16q12.2 (MKS5), and 4p15.3
(MKS6).
The triad of occipital encephalocele, large
polycystic kidneys, and polydactyly.
 CONGENIAL ANOMALIES OF
THE HAND
2. Syndactyly – This is fusion of digits and usually
occurs between the middle and ring fingers and
is 3 times more common in males. The fusion
may only be in the skin or all the structures. In
the latter case, surgery is done early at 18 months
age and in the less severe former case, surgery is
done after 5 years.
Syndactyly
 Syndactyly
Complete Simple Syndactyly - Adjacent
fingers which are joined out to the tips, but have
separate bones (and usually separate
fingernails).

Complete Complex Syndactyly - Adjacent

fingers which are completely joined, and have
bones fused together.
 Syndactyly
Syndactyly does not generally pose any health
risk, but if the thumb is joined, or if the fingers are
joined out toward their tips, they will grow in a
progressively worsening bend over time.
Surgical treatment is more likely to result in a
satisfactory outcome if surgery is done in the first
few years of life to give the child the most ability to
adapt and accommodate to the changes in their
hand.
 Phocomelia
Complete absence of a middle or intercalary
segment of a limb. The causes of phocomelia syndrome
can be divided into genetic inheritance and
thalidomide exposure. In the case of genetic
inheritance, it is usually transmitted to the offspring
through autosomal recessive trait specifically carried
by chromosome 8.
Thalidomide was first introduced into the market
in the year 1957 as a drug prescribed as a sedative,
although it also claimed to treat bouts of anxiety, and
insomnia. Furthermore, it has also been found useful to
alleviate symptoms of morning sickness especially in
the first trimester of pregnancy.
Phocomelia
 General Symptoms of
Phocomelia Syndrome
1. Growth retardation
2. Mental deficits
3. Defects on the eyes
4. Defects on the nose
5. Defects on the ears
6. Underdeveloped limbs
7. Short bones in the arms
8. Absent arm bones
9. Absent thigh bones
Severe Symptoms of Phocomelia
1. Skull fissure and brain projection also called as
encephalocele
2. Hydrocephalus or the accumulation of fluid in the
skull
3. Uterus is of abnormal shape
4. Blood clotting is inefficient secondary to low levels
of platelet in the blood
5. Malformations of body organs such as the heart
and the kidney
6. Shortened neck
7. Abnormalities in the urethra
 Thalidomide Syndromes
1. Facial palsies
2. Abnormalities of the ear, eye, leading to limited
visual functions as well as hearing
3. Disorders of the gastrointestinal and the
genitourinary tracts
4. Undeveloped lungs or missing lungs
5. Distorted digestive tract, heart, and kidney
 TENDON INJURIES
Either flexor or extensor tendons of the hand
can be injured when the patient sustains hand
injuries by a sharp cutting object. Flexor tendons
are more commonly injured than the extensors.
 Wrist Flexors
The main wrist flexors are the flexor carpi radialis
and flexor carpi ulnaris. They together bring about
palmar flexion of the wrist in the midline. If the flexor
carpi radialis is cut, wrist deviates medially towards
the intact flexor carpi ulnaris and laterally towards
intact flexor carpi radialis if flexor carpi ulnaris is cut.
 Finger Flexors
Flexion of the proximal IPJ of the fingers is
brought about mainly by the FDS and since the
FDP crosses this joint, it also aids FDS but FDP
is solely responsible for the flexion of the distal
IPJ. Both FDS and FDP could be injured, singly
or together.
 Test to Diagnose Flexor
Tendon Injuries
FDP: Instruct the patient to actively flex the distal IPJ
while you stabilize the proximal IPJ. If he/she can
flex it, there is no injury to the FDP tendon.
 Test to Diagnose Flexor
Tendon Injuries
FDS: Hold the two adjacent fingers in complete
extension. This anchors the FDP tendon in the
extended position and prevents it from flexing the
proximal IPJ. If he/she can do it, FDS is intact.
 Test to Diagnose Flexor
Tendon Injuries
FDS and FDP: Stabilize the metacarpophalangeal
joint and instruct the patient to flex the finger. If he
or she cannot flex either the distal IPJ or the
proximal IPJ, both the tendons are cut.
Flexor Zones of the Hand
It is extremely important to know the zones of injury
with regard to flexor tendon injuries of the hand and
wrist. There are five zones.

Zone II - It has been called “No

Man’s Land” or “No Man’s
Zone” because repair in this
zone is very difficult. This is a
critical area of pulleys. These
pulleys help in the tendon
movements. Primary repairs at
this level invariably fail due to
adhesions in the area of the
pulleys.
 Methods of Treatment
1. Primary repair – This is indicated in fresh,
clean-cut wounds. The tendons are primarily
sutured end-to-end, end-to-side or by various
special suturing technique.
 Methods of Treatment
2. Secondary repair – Necessary for severe hand
injury, contamination, skin loss, etc. After the
initial debridement, tendons are secondarily
repaired after 2 – 3 weeks.

3. Tendon transfers - Tendon transfer surgery is a

type of hand surgery that is performed in order to
improve lost hand function. A functioning tendon
is shifted from its original attachment to a new
one to restore the action that has been lost.
Tendon Transfer Surgery
During tendon transfer surgery, the origin of the
muscle is left in place; the nerve supply and blood
supply to the muscle is left in place. The tendon
insertion (attachment) onto bone is detached
and re-sewn into a different place. It can be
sewn into a different bone, or it can be sewn into
a different tendon. After its insertion has been
moved, when the muscle fires, it will produce a
different action, depending on where it has been
inserted.
Tendon Transfer Surgery
 Methods of Treatment
4. Tendon grafting – In the event of loss of tendons
due to crash injury, tendon grafting can be
considered. Donor tendons for grafting in order of
preference are the palmaris longus, the
plantaris, the long extensors of the toes.
 INFECTIONS OF THE HAND
Trivial infections like a scratch, prick, small punctured
wounds can cause hand infections. Staphylococcus
aureus (80%), Streptococcus pyogenes and
gram-negative bacilli are the famous trio who inflict
the infective unmitigated disaster in the hand. The
sequelae of these infections are edema, abscess,
necrosis, fibrosis and lastly contractions leading
to a grotesque, debilitating hand.
 PRINCIPLES OF TREATMENT
OF HAND INFECTIONS
1. Hand should be kept elevated to facilitate gravity
to drain and thereby prevent edema and swelling
2. Following treatment, the hand needs to be placed
in functional position for optimum results
3. Early and appropriate use of IV antibiotics
4. General or regional anesthesia is preferred over
local anesthesia because the latter help spread
infection.
Functional Position Hand
 HAND INFECTIONS
1. Paronychia
2. Apical Subungual Infection
3. Deep Pulp Infection (Felon)
4. Infection of the Web Spaces
5. Deep Palmar Abscess
6. Tenosynovitis
 Paronychia
This is an infection of the eponychium and could
be acute or chronic. Acute paronychia has the
distinction of being the most common infection
of the hand. Staphylococcus aureus is the main
culprit and it is usually due to a hangnail,
unsterile manicure instruments etc. The
infection normally begins at one corner, tracks
down to the opposite end via the eponychium or
nail.
Paronychia
Paronychia
Treatment of Paronychia
1. Antibiotics
2. Drainage
3. Nail avulsion
Apical Subungual Infection
The space between the distal phalanx and the
nail plate gets infected usually secondary to
pinprick. Treatment is antibiotic and drainage
of pus.
Deep Pulp Space Infection (Felon)
Next to acute
paronychia, this is the
most common hand
infection. It usually
follows a pinprick, with
the index finger and
thumb being the
commonly affected. A
felon is a deep space
infection or abscess of
the distal pulp of the
finger or thumb.
 Treatment
A. Antibiotics
B. Incision and drainage

A: A midlateral incision is preferred. B: A J-

shaped or hockey-stick incision. C: A through-
and-through incision. D,E: A volar transverse or
longitudinal incision.
Infection of the Web Spaces
Web spaces are the three triangular areas filled
with loose fat between the ends of the fingers.
Infection reaches these areas either through skin-
crack or a blister or through the lumbrical
canal from an abscess in the proximal volar space;
Also called collar button abscess or hourglass
abscess.
Infection of the Web Spaces
1. Antibiotics
2. Two incisions may be required for drainage, one
on the dorsal surface between the metacarpal
heads and the other on the palm distal to the
palmar crease. The web should be left unincised.

Incisions used for

decompression of a web
space infection. A: A curved
volar incision. B: A dorsal
longitudinal incision.
 Deep Palmar Abscess
This is rare and accounts for only 1% of all hand
infections.

This is the space lined by fascia and in between the

flexor tendons above and metacarpal bones
below
 Clinical Features of Deep
Palmar Abscess
1. Severe systemic reaction
2. Local pain, tenderness and loss of active
movements of the middle and ring fingers
3. Generalized gross swelling of the hand and
fingers which resemble an inflated rubber glove
also called frog hand.
4. In thenar abscess, thumb web is more swollen,
index finger is held flexed and active movements
of both the index and thumb is lost
5. With increase swelling, concavity of the palm
becomes flat and later convex before it bursts
open
 Diagnostic Test
In deep palmar abscess, passive stretching of
the metacarpophalangeal joint is painful while
that of IPJ is painless. In tenosynovitis of the
flexor tendons, the passive stretching of both the
MP and the IP joints are painful.
 Treatment of Palmar Abscess
1. Antibiotic
2. In the middle palmar space abscess, it is drained
by a central transverse incision at the level of the
distal palmar crease in line with the middle finger
extending ulna wards towards the hypothenar
eminence.
3. In the thenar space abscess, it is drained by a
curved incision in the thumb web parallel to the
border of the first dorsal interosseous muscle.
Incisions used for decompression of palmar (A–D), thenar (E,F), and
hypothenar space infections (G). A: A curvilinear longitudinal
approach. B: A transverse incision through the distal palmar crease.
C: A distal palmar incision approach through the lumbrical canal. D: A
combined transverse and longitudinal incision. E: A volar curvilinear
thenar crease incision. F: A dorsal first web space incision. G: A volar
longitudinal incision.
 Tenosynovitis
These are serious infections and are due to
infection of the fibrous sheaths and synovial
lining of the flexor tendons of the hand.

The causative organisms are usually due to

Staphylococcus aureus or Streptococcus
pyogenes. Penetrating injuries of the tendon
sheaths, extension of the infection from its terminal
pulp space are some of the common modes of
infection.
Clinical Features of Tenosynovitis
Pain, swelling and the affected finger is
motionless. Active or passive extensions of the
fingers are very painful. The classical local signs
include the swelling of the finger through its
entire length, flexion of the finger with marked
pain on extension and tenderness over the
sheath.
Tenosynovitis
 Treatment
1. Antibiotics
2. In the early stages of pus formation abscess
is drained by a transverse incision at the
distal palmar crease and the proximal edge
of the sheath is opened. The sheath is
opened distally through a midcarpal incision
over the middle phalanx. If the infection has
progressed far, a full midlateral incision may
be required.
Tenosynovitis
Tenosynovitis
 Kanavel’s Sign
This is a clinical sign found in patients with
infection of a flexor tendon sheath in the hand
(flexor tenosynovitis), a serious condition which
can cause rapid loss of function of the affected
finger. The sign is named after Allen B. Kanavel.
The sign consists of four components:
• the affected finger is held in slight flexion
• there is fusiform swelling over the affected tendon
• there is tenderness over the affected tendon.
• there is pain on passive extension of the affected
finger.
 De Quervain’s
Also called stenosing tenosynovitis of the first
dorsal compartment of the wrist involving the
abductor pollicis longus and extensor pollicis
brevis tendons.
 Etiology
Exact cause is not known. De Quervain’s disease is
commonly seen among women between 30 -50
years of age and may be due to repeated overuse of
the wrist.
Other names include Gamers’ thumb,
Washerwoman’s sprain, Radial styloid
tenosynovitis, Mother's wrist, Mommy thumb.
Jobs or hobbies that involve repetitive hand and
wrist motions like gardening, racquet sports overuse,
a direct trauma or injuries to the thumb, repetitive
grasping and certain inflammatory conditions, such as
rheumatoid arthritis, can all trigger the disease.
 Clinical Features
Pain and limitation of the movements of the
involved tendons are the presenting features. The
common sheath of the abductor pollicis longus
and extensor pollicis brevis tendons at the
wrist are involved. Tenderness can be elicited by
sudden ulnar deviation of the flexed hand with the
thumb tucked inside the palm. (Finkelstein’s Test)
 Finkelstein’s Test

This is also positive in Ist carpometacarpal arthritis

and arthritis of the radiocarpal and intercarpal joints
 Treatment
1. Conservative – Rest, NSAIDs, local infiltration of
hydrocortisone, wrist immobilization
2. Surgery – Division of the appropriate retinaculum if
conservative measures fail
- Transverse incision with release on dorsal side of
1st compartment to prevent volar subluxation of the
tendon
Reason’s for Failure of Conservative
Treatment in de Quervain’s Disease
1. Anomalous tendons
2. Multiple slips of abductor pollicis longus tendon
3. Multiple subcompartments within the first wrist
compartment which is seen in 75% of the cases.
Trigger Fingers and Thumb
Stenosing tenosynovitis, in which the sheath of
the flexor tendon thickens to entrap the tendon.

It is locking of the finger in a position of flexion,

that occurs at the retinaculae of the flexor tendons
of the fingers and thumb in the palm. These are
common in women. Congenital trigger fingers are
seen in 25% of the cases and may present as late
as 2 years of age.
Trigger Fingers and Thumb

The A1 pulley is thickened and fibrosed

Trigger Fingers and Thumb
Treatment of Trigger Finger
1. Splinting of the finger
2. NSAIDs
3. Steroid injection
4. Surgical excision of A1 pulley
Treatment of Trigger Finger
Carpal Tunnel Syndrome
ANATOMY: The carpal tunnel is a narrow, tunnel-
like structure in the wrist. The bottom and sides of
this tunnel are formed by wrist (carpal) bones.
The top of the tunnel is covered by a strong band
of connective tissue called the transverse carpal
ligament. The median nerve travels from the
forearm into the hand through this tunnel in the
wrist
Carpal Tunnel Syndrome
Carpal tunnel syndrome occurs when the tissues
surrounding the flexor tendons in the wrist swell
and put pressure on the median nerve. These
tissues are called the synovium. The synovium
lubricates the tendons and makes it easier to move
the fingers.
This swelling of the synovium narrows the
confined space of the carpal tunnel, and over
time, crowds the nerve.
Carpal Tunnel Syndrome
 Causes of CTS
P - Pregnancy
R - Rheumatoid Arthritis (and other forms of
arthritis)
A - Acromegaly
G - Glucose (Diabetes)
M - Mechanical (Fractures, anomalous
muscles etc)
A - Amyloid
T - Thyroid (Under-activity)
I - Infection
C - Crystals (Gout and Pseudogout)
 Clinical Test
Phalen’s Test – 80% specificity
 Clinical Test
Tourniquet Test
BP cuff is applied proximal to the elbow and
inflated higher than the patient’s systolic
blood pressure. Specific in 65% of the cases
only.
 Clinical Test
Tinel's sign is a way to detect irritated nerves. It is
performed by lightly tapping (percussing) over the
nerve to elicit a sensation of tingling or "pins and
needles” in the distribution of the nerve. Seen only
in 45% of cases.
 Clinical Test
Durkan's test is a medical procedure to diagnose
a patient with carpal tunnel syndrome. It is a new
variation of Tinel's sign that was proposed by JA
Durkan in 1991; Also called Median Nerve
Compression Test.
 Treatment
1. NSAIDs
2. Steroid injection
3. Splinting
4. Surgery – Division of the flexor retinaculum
and transverse carpal ligament and is
indicated for failed non-operative
management, thenar atrophy and sensory
loss
Treatment
 Chow’s Technique
Endoscopic release of the carpal ligament.
It is a reliable alternative for the open
procedure.
END