Download Paronychia:

1st part: Fatima Mirza Hammad
2nd part: Naeema Abdulla Ali
Mallet finger •
Trigger finger •
Hand Deformities
Boutonniere deformity •
Swan neck deformity •
Acute
infections of
the hand
Paronychia •
Whitlow(Felon) •
Tendon sheath infection •
Fascial spaces infection •
De Quervain's
disease
Carpal Tunnel
Syndrome


Injury of the extensor
digitorum tendon of the
fingers at the distal
interphalangeal (DIP) joint.
Results from hyperflexion
of the extensor digitorum
tendon
1st : Commonly an athletic or work related
injury.
Occurs when a ball (basketball, or volleyball),
while being caught, hits an outstretched
finger and jams it.
2nd : Other common mechanisms of injury
include forcefully tucking in a bedspread or
slipcover or pushing off a sock with extended
fingers.
With or without fracture.
1. Mallet splint for 6 to 8 weeks
2. Extension block by k-wire for 4
weeks, (when there is involvement
of more than one third of the base
of the distal phalanx).
This allows the tendon to reattach.
If the finger is bent during these
weeks the healing process must
start all over again.

A surgical pin acts like an
internal cast to keep the
DIP joint from moving so
the tendon can heal.

The pin is removed after
6 to 8 weeks


A type of stenosing
tenosynovitis
narrowing of the
sheath that surrounds
the tendon in the
affected finger, or a
nodule forms on the
tendon.
teno

The tendon can NO
longer slide freely
through its sheath.

Affected digits may
become painful to
straighten once bent

May make a soft crackling
sound when moved.

It props back suddenly
when straightened

It is called trigger finger
because when the finger
unlocks, it pops back
suddenly, as if releasing a
trigger on a gun.
Trigger finger is usually
idiopathic.
Injection of the tendon sheath
with a corticosteroid is
effective over weeks to months
in more than half of patients.
Surgery: cut the sheath that is
restricting the tendon.
Recurrency is rare
Flexion deformity of
the PIP joint, due to
interruption of the
central slip of the
extensor tendon (part
that insert extensor tendon to
the middle phalanx)
Hyperflexion at the
PIP joint with
hyperextension at
the DIP.


Makes it difficult or
impossible to extend the
proximal interphalangeal
(PIP) joint actively.
Passive extension of the PIP
joint is easy.



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.
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
Distal phalanx
1.Traumatic injury
2.Inflammatory
conditions (like
rheumatoid arthritis)
3.Severe burn
4.Dupuytren's contracture
(thickening of the palmar
fascia, producing a flexion
deformity of a finger)
1st Mild extension lag, passively correctable
2nd Moderate extension lag, passively
correctable
3rd Mild flexion contracture
4th Advanced flexion contracture
An X-ray should be done to detect avulsion fractures
(avulsion fracture occurs when the tendon
pulls off a piece of the bone as a result of
physical trauma)
A: Conservative Treatment:
Splinting of the PIP joint for 6 week
Splinting and a rigorous exercise
program may even work when
the injury is quite old.
B: Surgery :
When the deformity is the result
of a dislocation of the PIP joint
Surgery may be required to
reconstruct and rebalance the
extension mechanism.
Surgery carries a relatively high
risk of FAILURE to achieve
completely normal functioning
extension mechanism of the
finger.
- the PIP joint is hyper
extended .
- DIP joint is flexed.
volar plate becomes weakened and
stretched by RA , direct truma!
PIP joint becomes loose and begins to
easily bend back into hyperextension
extensor tendon gets out of balance
allows the DIP joint to get pulled
downward into flexion
swan neck deformity occurs
- Symptoms :
- swelling and pain due to inflammation
from injury or disease (RA)
- Signs :
Swan-neck !!
- the PIP joint is hyper extended .
- DIP joint is flexed.
- Diagnosis :
- clinical diagnosis
- X-ray is done to evaluate the joints (RA) and look for fractures. .
1) A special
splint may be
used to keep the
PIP joint lined
up, protect the
joint from
hyperextending,
and still allow
the PIP joint to
bend
2) Swan neck deformity
with a stiff PIP joint
sometimes requires
replacement of the PIP
joint, called arthroplasty
3) If past treatments, including surgery, do not stop
inflammation or deformity in the PIP joint, fusion of
the PIP joint may be recommended. The PIP joint is
usually fused in a bent position, between 25 and 45
degrees.
Fusing the two joint surfaces together eases pain,
makes the joint stable, and helps prevent additional
joint deformity.
Infections in the hand are dictated by
fascial boundaries within the hand, so
they can be classified as follows:
1.Under nail fold (paronychia).
2.Pulp space infections (whitlow).
3.Other subcutaneous infections.
4.Infections of the tendon sheaths
(Tenosynovitis).
5.Infections of the deep fascial
spaces.
Infection of the perionychium (also called eponychium), which is
the epidermis bordering the nail.
It results in swelling, erythema, and pain at the base of the
fingernail and later pus.
Acute paronychia is usually the result of
localized trauma to the skin surrounding
the nail plate.
Infection begins with a break in the skin of
the nail fold and spreads to the subungual
(underneath a fingernail or a toenail) space
causing severe pain.
The responsible organisms in acute
paronychia are usually Staphylococcus
aureus and Streptococcus pyogenes.
other: Pseudomonas ,Candida ,Gram -ve
bacilli.
Early cases may be treated with soaks and
antibiotics with
the hand elevated.
If there is no rapid improvement and pus is
seen or suspected, The cuticle (the dead skin at
the base of a fingernail or toenail ) should be
raised and the pus evacuated.
In some cases, the proximal half of the nail is
removed.
This procedure can be done under general or
regional anesthesia, but remember that local
anesthetics must never be used in the presence
of infection because it helps spread the
infection.
♣ Infection of the distal
pulp or phalanx pad of the
fingertip.
♣ It is usually caused by
inoculation of bacteria into
the fingertip through a
penetrating trauma.
♣ The most commonly
affected digits are the
thumb and index finger.
♣. Rapid onset of severe,
throbbing pain - with
associated redness and
swelling of the fingertip.
♣. The pain is usually
MORE intense than that
caused by paronychia.
♠. In the early stages , a felon may be amenable to
treatment with:
♥. elevation
♥. oral antibiotics
♥. warm water or saline soaks.
♠. If there is pus so drainage.
♠. Potential complications of a felon and felon
drainage include:
♥ neuroma
♥ unstable finger pad.
♠. It is a small laceration or puncture wound occurs over the
middle of a finger, especially near a joint on the palmar side, an
infection of the flexor tendon can occur.
♠. These can often cause severe stiffness, even destruction and
rupture of the tendon.
♠. These present acutely with:
♣.stiffness of the finger in a slightly bent posture
♣. diffuse swelling and redness of the finger
♣. tenderness on the palmar side of the finger,
and severe aggravation of pain with attempts to
straighten the finger.
♣.The flexor tendons of the hand are enclosed in distinct
synovial sheaths.
♣.The flexor tendon sheaths of the index, middle, and ring
fingers extend from the distal phalanges to the distal palmar
crease.
♣.The sheath encompassing the fifth finger extends from its
distal phalanx to the mid-palm, where it expands across the
palm to form the ulnar bursa.
♣. The thumb flexor sheath begins at the terminal phalanx and
extends to the volar (palmar) wrist crease, where it
communicates with the radial bursa.
♣. uniform, symmetric digit swelling.
♣. excessive tenderness along the entire course of the
flexor tendon sheath.
♣. at rest, digit is held in partial flexion.
♣. pain along the tendon sheath with passive digit
extension.
♠. It is dangerous and must be recognized early to prevent:
♣. tendon necrosis
♣. adhesion formation
♣.spread of infection to the deep fascial spaces.
♠. The synovial sheaths are poorly vascularized, but are rich in
nutritious synovial fluid. This combination provides an ideal
environment for bacterial growth.
♠. Once inoculated, infection spreads rapidly through the sheath.
Appreciable pain along the tendon sheath with
passive extension of the digit is often the first
clinical sign of this hand infection.
In the early stage:
may respond to non-operative treatment that includes :
♠. Splinting
♠. elevation
♠. intravenous antibiotics.
Rings should be removed from the affected finger and other fingers
of the hand as soon as possible.
- If there is no improvement within 12 to 24 hours, surgical
intervention is warranted.
Early surgical treatment
should be considered if the patient is
immunocompromised or has diabetes.
Surgical treatment involves proximal and distal tendon
exposure, and careful insertion of a catheter or feeding
tube into the tendon sheath with copious intra-operative
irrigation.
Postoperatively, the catheter may be left in place for 24
hours to allow for further low-flow irrigation.
•Infection
from web space or from infected tendon sheath or
from recent penetrating trauma to the hand may lead to
infection of the deep fascial spaces of the palm.
•Patient
presents with pain of the whole hand and with
movements of fingers and edema.
•Treatment:
♠. IV antibiotic.
♠. Drainage.

The carpal tunnel is a bony canal within the palm side
aspect of the wrist that allows for the passage of the
median nerve to the hand.
Carpal Tunnel Syndrome

Carpal Tunnel Syndrome
(CTS) is a compressive
neuropathy, i.e. it pinch's
the median nerve within
the wrist.
♠ Systemic diseases:
♣ Hyper\ hypothyroidism
♣ Rheumatoid arthritis
♣ DM
♣ Amyloidosis
♠ Forceful or repetitive movement of the fingers
and hand, wrist injuries or swelling of the tendon sheath
can decrease the space available in the carpal tunnel.
♠ Pregnancy and menopause
♠ Smoking and obesity can each increase the risk of
developing symptoms.
Its 8 times more common in women than men (age 40-50
years).
♠ Pain:
# waken in the early morning hours
With: ♣ burning pain
♣ tingling
♣ numbness
May be relieved by:
♣ Hanging the arm over the
side of the bed.
♣ shaking the arm
# Little pain during the day
# may develop in the arm and the shoulder
# there also could be swelling in the hand,
increases at night
♠ Parasthesia.
♠ A sense of weakness in the
hands and a tendency to drop
objects, loss of gripping strength.
♠ In late cases, there is wasting
of the thenar muscles and
weakness of thumb abduction.
Examination:
Thumb abduction
Abductor pollicis
brevis
Tinel sign : Tap over
median nerve at wrist
crease >>> electric
or tingling sensation
Examination:
Phalen maneuver:
Wrist compression test (Durkan's test):
Holding the wrist fully
pressure over the median nerve proximal to
palmarflexed for 1 min>
the wrist, appearance of symptoms within
Paresthesia.<<positive
30 seconds = positive
Durkan test is more sensitive than tinel’s sign and phalen maneuver
♣. Nerve conduction study (NCS).
Two electrodes are taped to the skin. A small
shock is passed through the median nerve to see if
electrical impulses are slowed in the carpal tunnel.
♣. Electromyogram (EMG).
This test can help determine if muscle
damage has occurred.
♣ Splinters
- Prevent wrist flexion and pain appearance during sleep.
- Preferable during pregnancy.
♣ Corticosteroid injection into the carpal canal.
♣ Open surgical division of the transverse carpal ligament
(flexor retinaculum)
♣ Arthroscopic carpal tunnel release.

It is a painful tenosynovitis due
to relative narrowness of the
common tendon sheath that
surrounds 2 tendons of the
thumb.

The swollen tendons and their
coverings cause friction within
the narrow tunnel, or sheath,
through which they pass.

Most common in women aged 30-50 yrs

de Quervain's affects women 8 to 10 times
more often than men.

The result is pain on the thumb side of the
wrist joint.

The tendons usually involved are those of
extensor pollicis brevis and abductor pollicis
longus.
♣. The most common cause
is chronic overuse of the
wrist.
♣. Direct injury to the wrist
or tendon; scar tissue
can restrict movement of
the tendons.
♣. Inflammatory arthritis
(such as rheumatoid
arthritis).
♣. Gardening, racquet
sports may aggravate the
condition.
♣. Pain on the radial side of the
wrist
Patient can point to the painful
area (at the very tip of radial
styloid)
♣. Swelling along the course of
the thumb tendons
♣. Positive Finkelstein’s test:
Hold the patient’s hand with
the thumb tucked in inside the
fist, then turn the wrist sharply
toward the ulnar side. Pain over
the radial side is a positive
sign.
♣. Splint that includes wrist and thumb.
(24 hours a day for 4 to 6 weeks to immobilize
the affected area. )
♣. Avoid any activities that aggravate the condition.
♣. Anti-inflammatory medication (such as naproxen
or ibuprofen).
♣. If symptoms continue, inject the area with
cortisone to decrease pain and swelling.
♣. Resistant cases, need surgery
♣. Surgery for de Quervain's disease is an outpatient
procedure done under local anesthesia.
♣. Surgical release of the tight sheath eliminates the
friction.
♣. Upon recovery, an exercise program is done to
strengthen thumb and wrist.
♣. Recovery times vary, depending on age, general
health, and duration of symptoms.
♣. In cases that have developed gradually, the disease
is usually more resistant.