SCAPHOID PSEUDARTHROSIS

Scaphoid is one of the 8 bones present in the wrist. The 8 small bones are aligned in 2 rows. scaphoid bone takes care of coordination of mobility between the two rows.

Scaphoid fracture may result from falling down onto the hand while the arm is wide open. This is the bone that is mostly exposed to fracture amongst the wrist bones. Scaphoid structuring and vascularity is quite interesting. It has a 3D variable form similar to beans. Circulation of the part that is proximate to the wrist is weak due to blood build-up of the bone and vascular structure. The vein structures that enable blood build-up following the fracture may be damaged, so circulation of part of the bone breaks down (avascular necrosis), resisting the joining.

Nonunion is a condition of lack of joining in 6 months after the fracture happens. Problems of nonunion that take more than usual is called delayed nonunion. Nonunion affects wrist functions, and the balance between the two rows composed of the wrist bones is interrupted. Two parts of the scaphoid act independently, which leads to wrist mechanical problems that increases arthritis in the wrist.

No-union is observed in cases that do not recover for a long time after being plastered or in the post-operative period. Some patients of scaphoid fracture may not be aware that fracture occurred and it did not union. The fracture is identified only when they apply to a physician for complaints of wrist pain. These patients have a wrist trauma history for part of their life as they have neglected it. Direct x-ray, computerized tomography and MRI are beneficial to diagnosis.

In the absence of a specific arthritis, objective of the treatment is to ensure joint union. Circulatory breakdown of fracture part of the bone towards the wrist that is called avascular necrosis is influential for making the treatment decision. In treatment, fractured fragment ends are refreshed by fixing them with screw or chords after putting a bone graft in between. In case of circulatory break down on the fractured part of the upper bone, vascular bone transplantation is performed, trying to union the fracture and feed the bone.

If arthritis has already started in the wrist, there is no need to put further efforts to union the scaphoid. The objective here is to resume the wrist in an indolent and functional manner. Depending on the degree of wrist arthritis, one should, first of all, decide which of the surrounding joints are to be protected. Radial stiloidectomy (removal of part of arthritic radius), proximal row carpectomy (removal of upper row of wrist), limited filling up of wrist and scaphoid sub-pol removal and total wrist filling up for very common arthritis are planned.

Source: scaphoid pseudarthrosis

SCAPHOID FRACTURES

The wrist has 8 small bones (carpal bones).Wrist bones are aligned in two rows. Scaphoid, one of the said 8 bones, connects the two rows to one another therefore it is mostly exposed to trauma and fractures. Fractures often result from falling down on the wide open hand. It is often very painful during the first trauma. The pain goes away gradually in subsequent days. Cyanosis is very rare. No specific deformity or swelling is observed in some patients. For this reason one should be careful about the diagnosis and pay particular attention to the scaphoid during the radiological examination of the area. Some patients apply to a physician for a diagnosis months and even years after the fracture. The scaphoid fracture may not be visible on all graphies on the first day. In suspicious cases, the fracture should be put into a plaster and another graphy should be performed again on the 10th day. If there are still suspicions, an MRI or computerized tomography should be performed.

If the fracture is not dislocated, mobility is restricted with the help of a brace including the forearm, hand and finger. Recovery period may take 6 to 19 weeks especially in a brace. The reason for such a long-lasting recovery is that different parts of the scaphoid builds up blood and part of it builds up blood relatively less. Fracture interrupts with the functionality of vascular structures that enable blood build-up, reducing the build-up of some parts of the bone. To this effect, surgical intervention is more preferable for scaphoid fractures especially in parts close to the forearm. Surgery is the most suitable method for dislocated fractures. In surgical treatment, screws and pins are used for stabilizing the fracture. In some cases, bone grafts needs to be collected from other parts of the body and used in these areas. Stabilization with screws may be advised for non-dislocated fractures due to long period of bracing.

No-union due to bone-specific circulation problems, osteolysis due to malnutrition and articular deformity can be observed. In such cases, a surgical operation is advised to the patients

Source: scaphoid fractures

RHEUMATOID ARTHRITIS

Rheumatoid arthritis is an autoimmune ( type of diseases in which the immune system fights against the body’s own tissues) disease in which inflammation occurs on symmetric joints, including the hand and foot joints, and swelling, pain and causing resulted damage in joints in time.

Rheumatoid arthritis can be diagnosed with various symptoms. The main cause is still unknown. Genetic tendency and many other factors may create (triggers) the autoimmune reaction. The disease occurs by 1% in public and occurs 2 or 3 times more frequently in females when compared to males. It usually arises in between the ages of 25-50, which, however, may also occur in the other ages. With treatment, the disease may recede in some patients. Out of four people’s, the symptoms of three people may decrease. However, gradual functional loss (loss of mobility) may develop in every single person out of ten after all. In this disease, the autoimmune system tends toward tissues covering the surface of joints. The bonds of cartilage, bone and joints erode in time and joints degrade on different levels consequently.

Rheumatoid arthritis can suddenly appear more than only one joint at the same time with swelling, pain and inflammation. It mostly starts with silence but affects various joints. If a joint with stiffness occurs on either left or right side of the body, then an inflammation appears on the same joint oppositely. It is typical that it starts with the small joints like fingers, toes, wrist, elbow and ankle. Joints with inflammation have frequent stiffness and pain after waking up or a long time of immobility. Some patients may feel tired and weak in the afternoon. The affected joints may have deformations by getting larger. Contractures develop in some joints and stay in a certain position that can’t be opened. Fingers deviate towards the little finger. Carpal tunnel syndrome may occur on the swelled wrist. Cysts that may occur behind the knee, when burst, can cause swelling and pain on feet. In the 30-40 % of patients, generally in locations near the affected joints, nodules arise under the skin (figure 1). Rheumatoid arthritis, with a mild fever, may also cause inflammations named vasculitis within the vessels. Thus, nerve injury and foot ulcers can be seen. As a consequence of the inflammation of pleura, pericarditic or scar formation may lead to a painful lung, difficult respiration and to the disorder of heart’s function.

To distinguish Rheumatoid arthritis from other diseases causing arthritis is sometimes difficult. Patients with following four criteria are likely to have Rheumatoid arthritis.

• Morning stiffness lasts more than 1 hour. (continued at least for 6 weeks)
• Inflammation on 3 or more joints (continued at least for 6 weeks)
• Arthritis of joints on hand, wrist and fingers (continued at least for 6 weeks)
• The presence of rheumatoid factor in blood
• Typical changes on radiography

Laboratory tests, examination of joint fluids or sometimes biopsy may be required for diagnosis. The blood erythrocyte sedimentation rate increases in every 9 /10 patients. Most patients have mild anaemia and white blood cell number also rarely decreases. Most of patients with Rheumatoid arthritis have distinctive antibodies (rheumatoid factor) in their blood. However, an increase in the rheumatoid factor in all patients may not be determined or all patients with high rheumatoid factors may not have Rheumatoid arthritis. This could be still positive without being the disease (RA) for patients with chronic liver diseases and in some infections (for some people). A high rate of rheumatoid factor is connected with the degree of Rheumatoid arthritis.

The treatment is performed in a multi way. Besides pharmacological treatment to patients, training, suggestions for relaxation and exercising, special supportive tools that stop being dependent on one’s supervision and surgical treatments in advanced cases could be possible. The treatment serves for repressing the inflammation period, activating the patient, preventing the stiffness and pain and generally to reduce the complaints, but cannot finish the disease at all. As Rheumatoid arthritis, when not treated, may cause permanent functional loss, the treatment is required to be guided by a specialist doctor.

Poli-arthritis (rheumatism with more than one symptom) occurs in females with the age 20-60, which starts as bilateral and symmetrical and stiffens up wrist or matacarpophalangeal joints. Synovial inflammation deforms the joint progressively. Cartilage, joint capsule, ligaments are damaged progressively. Stiffening up the sinoviyal tissues of extensor and flexor tendons on hand and wrist level, rheumatoid synovitis causes the tendon of ruptures on long time view. Extensor tendons stiffen up more when compared to flexor tendons. Tendon ruptures mostly occur on the tendon which lifts the thumb up. Shape deformations happen on hand and wrist as a consequence of Rheumatoid arthritis.

For the swellings of rheumatoid joint that don’t respond to pharmacological treatment, synovectomy is applied to prevent the joint damage. Tenosynovectomy is applied to prevent the joint ruptures. In extreme joint damages, the joint could be completely removed and substituted with prosthesis applications (especially the trapezo-metacarpal joint and metacarpalphalangeal joint). To the joints (especially thumb metacarpofalangeal joint) that are unable to be applied prosthesis applications, the freezing process could be applied.

Source: rheumatoid arthritis

Hand Surgery Turkey: POLYDACTYLY

Hand Surgery Turkey: POLYDACTYLY: "Polydactyly is called presence of more fingers than the normal which is observed in the thumb, small finger or rarely middle fingers. It is ..."

POLYDACTYLY

Polydactyly is called presence of more fingers than the normal which is observed in the thumb, small finger or rarely middle fingers. It is frequently seen either in hand or in the foot (Figure 1). Polydactyly is one of frequent upper extremity abnormalities. Mostly we observe extra thumb and second, related with the fifth finger.

Polydactyly may be examined within two groups as complete developed excessive finger or less developed excessive finger (frequently as a skin extension).

Thumb polydactyly is observed in 8 of 100,000 live birth (Figure 2,3). Excess thumb is observed at every level of the finger, approximately 45% of cases is from the first joint and 15-20% from the second joint. Surgical treatment should be taken to the agenda when medical conditions are suitable after one year. As a treatment approach, weak and less functioned finger is removed. If the excess finger has some functions and movements even limited, tendons that provide to make them is transferred to the finger that will be protected. If no difference can be observed between double fingers, combining may be done by knitting bones of the two fingers in cases that the problem is especially in the end.

Small finger polydactyly may vary from only additional skin presence to double fifth finger.

The valid criteria for selection of the finger that will be excised is to protect the best developed finger same as the thumb polydactyly. To tie the skin extension part with a rope and to provide to fall by itself is a method which is very popular in the public. These small parts include vascular structures that are bounded to the hand. When they are tied up, circulation will be destroyed and they may cause infection development. Sometimes, they may cause bleeding that is not expected during auto-amputation. Therefore this method should not be applied.

Kaynak: polydactyly

PERIPHERAL NERVE PALSY

Nerves function to provide mobility and sensation on the hand and upper limb. Part of the nervous system located between the cranial cavity and spinal cord is called central nervous system; and the parts from which they branch into the entire body are called peripheral nervous system. Palsy is a condition wherein peripheral nerve functions break down for any reason; hence the muscles to which the nerve or group of nerves transmits electric signals do not function any more.

Upper limb has five primary peripheral nerves. Axillar nerve, which is one of them, transmits electric signals to the deltoid, enabling the arm to open to the side. Radial nerve enables that the elbow, wrist and all of the fingers extend. Musculocutaneous nerve borrows its fibers to the biceps muscles, so the elbow is bent. Median and ulnar nerves enable touch sensation of our hand and bending movement of the wrist and fingers. Should any of the peripheral nerves cease to function and the patients become unable to do the aforecited functions.

The most common reason for the nerve palsy is cuts following a trauma. Otherwise, nerve compression, obtuse traumas that do not result in any cuts, tumors, although very rarely, a set of various neurological disorders that retain systemic or isolated nerves may appear to be influential factors.

On concluding that the nerve cannot recover on its own (which might take a couple of months), it becomes final with the help of a test called EMG that measures muscular and nervous functions. After this, a treatment is planned depending on the level of the nervous cut, age and profession of the patient and date of nervous cut. Palsy due to nervous cuts is treated in early periods by repairing it under the microscope. If a lot of time has passed, the treatment is made via tendon transplantation as irrevocable myolysis appear (Detailed information about tendon transplantations has been provided in this chapter). Physiotherapy is a compulsory and complementary part of many disorders in the field of hand surgery before and after the operation.

Source: peripheral nerve palsy

OSTEOARTHRITIS IN HAND

Osteorthritis is an ongoing joint disease and causes joint pain and stiffness characterized by degenerating on joint cartilage and adjacent bone tissue.

Osteoarthritis is one of the most frequent joint diseases. It is equally observed in men and women. But iy may appear in men in early ages.

Osteoarthritis possibly appear as a result of abnormal degeneration of cells that produces substances belong to the connective tissue. Findings such as bone pains, limitation of joint movements, easier injuring and breaking of bones are very common in patients with osteoarthritis.

When the disease progresses;

• Bone pains become significant
• joint movements are limited
• rattle sound called crepititation during joint movements and joint becomes not opened
• Projection may arise on the farthest joint on fingers, back pain
• stiffness on neck and on the lower vertebra
• numbness as a result of nerve compression of osteophytes
• weakness on arms and legs and similar neurological problems may occur.

As etiology is not lightened enough, it does not have a cause-oriented treatment. Nevertheless, the progress is not as severe as arthritis. Treatments such as exercise, physiotherapy, supportive tools, drug treatment and surgical intervention are applied if necessary. Osteoarthritis is mostly seen 1st carpormetacarpal joint in the hand. This disease is also called as risarthrosis. When hand functions start to be degenerated, surgical treatment may be discussed.

Source: osteoarthritis in hand

MALLET FINGER INJURY

It arises as a result of impacts to the farthest joint of the finger. The tendon (extensor tendon) which flattens the finger was injured in the area where it adheres to the bone on the farthest knot (distal phalanx). It is mostly observed after closed injuries that no cut is present on the finger.

When the patient was told to flatten his/her finger, she/he can not do this, the finger may be flatten by only with the other hand and the doctor who examines. (Figure 1)

In some cases it is observed that a small fracture accompanies the subject in direct X-rays. (Figure 2)

Ice application and non steroid anti inflammatory drugs will be useful for the pain in the early period (Figure 3). The patients without bone fractures may be treated with mallet finger brace which may be obtained from orthopaedic shops is applied for 2 months without taking off from the finger.

The decision that the patient may be followed by only the brace without any surgical intervention should be given by the doctor in this step.

Surgical intervention is required in cases with open injury and bone fracture. This intervention is performed with local anesthesia. Both fractured bone part and the injured tendon are repaired. By placing a wire which will keep the farthest two knots for approximately two months, the patient’s finger is fixed during this period.

Some of patients do not apply to a specialist by considering that it is only a problem of view. But some of untreated cases may become to a severe shape and movement problem that we call swan-neck deformity by shortening of injured tendon and moving to downward. Therefore, it is very important to get the concerned information from specialists and to have the recovery process under their follow-up.

Source: mallet finger injury

KIENBÖCK DISEASE

Kienböck disease may be defined as avascular necrosis (circulation disorder) of lunate bone in the wrist and wrist problems developed depending on it. Lunatum is one of the 8 small bones on the wrist. Lunate is in the middle of the wrist and forms the wrist joint with two small bones on the both sides of it (scaphoid and triquetrum), and also forms the joint with forearm bones (radius, ulna). Actually the bone looses its normal functions after collapsed circulation because of exactly undetermined reasons. Pain, movement limitation and calcification in the wrist may arise because of luantum looses its normal structure and its shape changes. It is mostly seen between 20-40 years. Rarely, it may be seen in both wrist.

Current variations may be the factor especially in the skeleton system (different length inequality of forearm bones; ulna, radius); and factors such as continuous exposure to recurrent trauma in the wrist is effective in the disease.

It arises with pain in the middle section of the wrist. Pain increase by lifting the middle finger up is characteristic. Gradually pain increase is seen in the wrist. Unless direct radiological finding is present in the early stage, deformity in the lunatum, collapse, sclerothic region formation and disjunction may appear. MR and computerized tomography are useful for diagnosis. Particularly if there is a suspicious in the early stage, MR imaging is important for early diagnosis.

Diagnosis of the disease is difficult in the early stage. It may be missed out unless it is not behaved careful. Pain and complaints increase after initiation of the disease. Most of the time, the disease is diagnosed after a long time.

Generally progress of the disease is slow and progressive. It is divided into 4 stages.

1. In the first stage, radiological examination is normal in general. MRI helps to diagnose. Lunatum starts to loose its circulation
2. Shape of luantum starts to be degenerated in the second stage.
3. Collapse has arisen in the third stage.
4. In the fourth stage, lunatum completely collapses and calcification starts in the wrist joint.

Stage of the disease, existence of length difference between arm bones and age of the patient are efficient in the treatment decision. Application of resting brace for a while is enough in very early stage. In advanced stages (stages 2-3), correction of the current length difference in forearm bones is useful. Besides correcting the mechanical problems, this also provides an increase in blood flow, thus an increase in bone circulation. If there is no difference in length, vascular bone transplantations should come to mind as a treatment option. In further stages, to change the direction of the load by fusing small bones may be provided. If the wrist joint was calcified, wrist freezing may be planned. Recently, treatment methods performed by camera system have become popular. Sometimes treatment decision may be difficult. Experience is important for decision mechanism. The patient should be informed about the treatment that will be applied. Sometimes the patient may need multiple operations. Pain moderates with most treatment, intensive physiotherapy is required for movement limitations.

Source: kienbock disease

INJURY OF NERVES

Nerves are the transmission systems that transmit signals incoming from the brain to various parts of the body and vice versa. Nerves are made up of thousands of fibers, which progress in cables coiled in protective sheat as groups inside the nerves. The system that bears the cabled transmission is surrounded by a protective insulant.

There are two types of nerves as motor nerves that function to transmit signals from brain to muscles and control the movements, and sensory nerves that function to transmit pain, pressure, temperature and such sensations from various parts of the body.

Nerves can be damaged due to compression, pressure and cut-off. In case of stretching and pressure injuries, the structure of the protective layer surrounding the nerve is not interrupted, yet the transmission system breaks down due to fibers damages, hence the nervous system fails to function. In case of cut-off, not only the nerve fibers but also the surrounding protective layer is damaged. After damages, transmissions cannot be conveyed from brain to the muscles, hence they become dysfunctional or sensory transmissions received from different parts of the body cannot be transmitted to the brain.

Once the nerve fibers are damaged, the structure of the surrounding protective layer subsists. Part of the damaged nerve fibers up to upper transmission station die away and melt down, leaving the protective layer in the form of hollow tubes. Recovery period begins in a while. If the protective sheat is not damaged or the sheat is repaired, fibers continue to grow through the innards of hollow tubes and recovers up to the receptors of motor or sensory nerves. Nerves are the tissues that heal the most slowly in our body. If the protective sheat structure is not repaired, nerve endings that undergo a recovery period and grow on cannot find their way, hence cysts called neuroma are formed at the nerve ending. These cysts form painful electric signals when pressed on them.

If the nerves are fully cut, both nerve endings are identified for treatment and the surrounding protective sheat is repaired by way of thinnest stitches as possible (Fig. 1). Objective of the treatment is to ensure sustainability of the surrounding sheat structure and to enable the nerve fibers, which are now in a healing process, find their way up to the final transmission points. Nerve sheats should be treated carefully with the thinnest stitches as much as possible by way of microsurgery methods to avoid excessive scar tissue and pressure in the nerve healing area. Nerves thin down particularly on hand and finger levels and progress adjacent to vascular structures in general. When a damaged nerve is identified, the vascular damages are often identified in parallel. As very thin stitches are used, a 3-week plaster treatment is applied to protect the repaired area.

Nerve sheats are intended to be sewn back to their original place with the help of vascular structures upon nerves; however, hollow tubes do not often find their original place no matter how original the stitches are in terms of surgery. It is not possible for millions of fibrils to find their original place.

If the injury is very contaminated and is to be left open, nerves may not be sewn in the first surgical operation. In case of nervous defects, a nerve graft often collected from the leg is inserted in between to enable nervous sustainability.

It takes 3 to 4 weeks for nerve fiber to grow up against following the repairs. Fibrils usually progress 1 mm on average within the nerve tubes depending on the age of the patient, type of injury, smoking etc. For this purpose, sensory recovery may take up to 1 or 2 months and 6 or 8 months depending on the proximity of the injury to the target. During this time, the patient should be careful about finger tip injuries while touching warm objects and working. Activity of the muscles stimulated by the nerves should not be lost during the expected nerve recovery.

Source: injury of nerves

HAND TUMORS

The word meaning of tumor which has entered to the medical literature and the daily use is swelling. Abnormal swellings occurred in hand are called as hand tumor even they are benign or malign. Most of hand tumors are benign. Hand tumors may be as wart or mole, and masses sourced from soft tissue or the bone under the skin.

The most frequent mass in the hand is masses are ganglion cysts (Figure 1). These cysts are sacs that include gelatinous substance. They are usually seen in the wrist as well as they may be sourced from tendon sheaths and pulleys on fingers.

The tumour type that has the second frequency is tumour with giant cells. These masses are hard and can be lobule. It can occur anywhere, however, most frequently seen around the sheath of tendon. They are good behaved and have a slow development.

Another tumour that has frequent occurrence is epidermal inclusion cysts. They are good behaved and formed from under skin after cuts and injuries. Skin cells normally secrete a protective substance with dense firm that is called creatin. New cells are substituted with the dead ones due to environmental factors occur during skin exchange. If the skin cells stay under the skin (after cuts and skin damages), they start to produce creatin and reproduce as if skin exchange happens. Dead skin cells and creatin make a cystic form under the skin. Cyst gets larger with the increasing production of creatin and increasing number of dead cells, which is called inclusion cyst.

Lipoms (good behaved wens), noroms (neural end tumours), neural shealth tumours, fibromas, nail bed tumours (glomous tumours), hemangioms (tumours that occured due to the winding up of capillary) (figure. 2)

Masses connected with bone projecting that arise due to arthritis and trauma. Swellings due to foreign substance reaction may arise.

When the patients feel a mass in their hands, they are curious about whether it is benign or malign. Malign cancers of hand are rare. Most of them are benign. The most frequent malign tumors are skin cancers such as squamose cell carcinoma, basal cell carcinoma, melanoma. Other malign tumors are sarcomas of the bone and the soft tissue. Sarcomas diffuse rapidly. The most frequent metastasis is to lungs. Hand metastasis may be seen from other tumors of the body. Even though most of them are considered as benign, sample should be taken for pathological examination from all masses.

When masses in the hand are evaluated, examinations such as direct graphs and CT (computerized tomography) , MRI (magnetic resonance imaging) may be run. General procedure is to remove the mass totally if the tumor is not very big in size. Generally removal of the mass provides the sufficient treatment. Recurrence features of some masses in the hand are present. Therefore, regular recording of any tumor which is removed surgically and sending to pathological examination are very important for post operative follow-up.

Source: hand tumors

HAND INFECTIONS

Most of hand and finger infections occur from injuries that are neglected or insufficiently treated. There are compartments separated with various borders in the hand and fingers. Infection agents that reach to these areas through open injuries or foreign bodies causes localized or diffuse infections. Infection agents are mostly bacteria and rarely funguses or viruses. Most of these agents are on the skin of the healthy person’s hand and injuries, hand cracks, peeling, and degeneration of the skin continuity due to getting wet help these agents to be carried inside.

Panaris (nail side infection), paronychia (nail root infection) and felon (pulpa-finger touch surface infection) are most common soft tissue infections of fingers and the hand. (Figure 1.2)

Infections seen near the nail is frequently observed in persons who always have wet hands, having a recent manicure, biting nails and those who have short nail cutting habits. Finger infections are more frequent in diabetic patients. Besides, tenosynovitis (infection seen through tendon sheath) and abscess formed in various regions of the palm are other frequent soft tissue infections. Infections called osteomyelitis which is seen in hand bones generally develop on fracture basis together with open injuries.

Approach in infections is to try to prevent the presence of germs by antibiotic use; to drain if abcessing is present and to provide local cleaning by frequent medical dressing. In some cases intravenous antibiotic use should be required by hospitalizing. If prevention is not taken and right approach is not performed on time for infections which seem to be simple, they may leave severe sequelae.

Source: hand infections

HAND FRACTURES

The hand has a support structure which forms from many bones and allows complex functions. Muscles that provide finger and wrist movements are tied to some parts of this support structure. Fractures due to excess forces on bones may form. When the fracture occurs, some compliant arise such as pain, swelling, bruising, deformity, using disability of the damaged region. As fractures may be not disintegrated, they may be disintegrated to form multiple and deformed. Some fractures are on the body of the bone and some of them extends from end part of the bone into the joint. Treatment of the fractures that reach into the joint is more difficult. Joint movement limitation occurs in general. Fragmental fractures occur after high energy traumas in general. Infection risk is present in fractures together with open injury.

Usually the disease is diagnosed after patient examination and X-ray imaging. As hand has a complex structures, experience is important in fracture evaluation. Computerized tomographic examination may be performed in detection of treatment method in some fractures.

It may be used for treatment of fractures that brace or plaster do not dislocated. Some fractures are fixed with wires by taking the ends face to face under scopy imaging which allows us to make radiological examinations under anesthesia.

If open injury is present for fractures that can not be taken face to face, the skin is opened and parts are taken face to face. The fracture is fixed by using plaque, screw and wires. (Figures 1-2-3)

If the fracture extends to the joint surface, the joint surface should be carefully corrected and fixed. If the fracture is excessively fragmental or bone defect is present, bone parts taken from other parts of the body may be placed in the fractured area. Elbow and hip may be used as bone graft. Taking bone graft doesn't give permanent damage to patients; undesired situation is rarely seen except inflammation and recovery problems that may occur after every surgery.

If the lesion is contaminated and the fracture is fragmental, the fracture is fixed with bars (external fixator) which are applied from outside of the body on pins that is applied to bone from upper and lower level. In intraarticular multiple fractures, pins applied over the bar are alienated from each other and fracture parts to them may be taken close to the original place (ligamotaxis). Fracture knitting period varies according to the place and shape of the fracture. Joint movements after the fracture may be limited. Therefore, physical treatment should be started as soon as possible after the bone knitting is completed.

HAND BURNS

Burn injury literally stands for tissue damage due to dying of skin cells when the skin meets a hot object. Burn severity is determined with the temperature and contact time. If a hot object is contacted for a while, complete layer injury of the skin may arise, even subcutaneous tissue may be injured due to the burn. (Figure 1)

Burns are not always with hot. Burns sometime arise with chemical substances as well.

Burn degrees are as;

1. First Degree (superficial) ; only rash without bulla is present.
2. Second Degree; partial skin injury is seen. Bullas are present.
3. Third Degree; complete layer skin injury is present. The skin is white and rigid.
4. Fourth Degree; is the burn type that deeper tissues, chorda, nerve, joint etc. tissues are affected.

After the burn, hand should be immediately removed from the hot material and should be cleaned under the cold water. Dry ice should never contact the skin directly. It should be applied on the skin after covering a material such as a cloth.

The main purposes are to stop the pain and to try to prevent problems that may arise due to loss of protective layer of the skin. Germ protective ointment and creams that provide regional anesthesia are mixed and applied over the injured area. The pain may be extensive for the first days. When effect of ointments, especially anesthetic one, passes away, the mixture may be applied over and over. If the injury surface covers an important part of the body, the patient should be followed up in the hospital, because fluid losses and infection risk that may threaten the life may arise with the burn. If the burn is only in the hand, medical dressing follow-ups are made in general.

1. First Degree burn recovers within a short time with ointment application following the cold application.
2. In second degree burn, fluids in the bulla is cleaned additionally. Bracing may me performed for the further skin stretching. In cases where protective layer of the skin is destroyed, mixing germ protective ointments and pain decreasing ointments and application by dressing is suitable.
3. Third degree burn is the burn of complete skin layers. Long term dressing follow-up is performed after removal of the dead tissues. Medical dressing period varies according to the burn degree and the recovery situation. Bracing is done to prevent tacking and expulsion that may occur during the recovery. After subcutaneous tissue becomes suitable, transplantation of skin to the places where skin loss is present is provided with surgery. Relaxing is performed with various surgical techniques for tacking and expulsions that may develop after the recovery (Figure 2.3).
   
   
   
   

Generally hand burn treatment is problematic. Because of skin recovery problems after the burn and hands expulsions require a long term treatment period with patience. Physiotherapy is useful as well as bracing to not have expulsions in

Source: hand burns

FLEXOR TENDON INJURIES

Muscles that provide fingers to bent inside are called flexor muscles. They are connected to finger bones with structures which exits from the current muscles in the forearm and look like chords and called tendons. Flexor muscles start from the elbow and forearm and extends to finger ends by converting into tendons in the middle of the arm (Figure 1). Flexor tendons in the finger passes inside of tunnels called pulleys. Pulleys prevent tendons to move away from the bone by forming tunnels on tendon and they provide active operation of joints.

Flexor tendon injuries may arise after deep cuts of the forearm, wrist, hand and fingers.

Flexor tendons are very close with vessel-nerve structures anatomically. Therefore, in palmar side injuries of the hand, injury is frequently together with vessel, nerve injuries as well as flexor tendons. When tendon injury is occurred, tendon ends move away from each other due to muscle traction. Tendon ends may not be found in the cut area immediately. When flexor tendon cut arises, the patient can not bend his/her finger. If the tendon is not completely cut, bending may be possible by the patient. Generally pain accompanies to this situation. If incomplete tendon cuts are not treated, tendon may be broken away from the cut region.

If tendon ends are not exposed surgically, recovery is not provided. If repair of tendon cuts delays, length of the tendon shorten due to muscle traction and tendon exposing may not be possible. To protect tunnels called pulley that tendons pass in is very important for tendons to perform its functions after the recovery. Vessel-nerve structures which are very close to tendons should be repaired with microsurgerical methods during the surgery. 3-4 weeks of bracing is made to protect sutured structures after the surgical intervention. Movement is not provided just after the plaster is removed. During tendon recovery, cohesion arises to surrounding tissues. Early physical therapy may start with plaster or physical therapy should be given after the plaster. Generally professional physiotherapy is required after flexor tendon injuries. If providing movements are insufficient even after the physiotherapy, cohesion around the tendon should be opened and physiotherapy should start immediately. Early term physiotherapy is important. If physiotherapy does not start on time, to gain movements will be difficult.

Source: flexor tendon injuries

FINGER AND EXTREMITY AMPUTATIONS

Amputations are divided into two groups as total and partial amputations. The organ (finger, hand or arm) is completely separated from the body in total amputations and the amputated part shall be immediately sutured to its place as all vessels are severed. Continuity of the organ with the body continues in partial amputations and only a part is cut. If vessels are stable, as vitality of the damaged part continues, transportation of the patient to the hospital is less important than those with total amputations. The most important factor for success of the surgical treatment is to transmit the patient and the part to the facility as soon as possible in both circumstances. Replantation is called to suture the severed organ on its place. To suture the organ on it place is not possible in all circumstances. General condition of the patient, status of the severed part, transportation period of the patient to a health facility, current technical options are factors that are effective to perform the procedure.

The priority in severe injuries that damages other systems of the patient such as in traffic accidents is to focus on the vital risk. If there is a vital risk in the patient or replantation may cause a vital risk, this procedure should not be done.

If the damage is much in the severed organ due to contusion or fragmentation, replantation may not be performed. The rate of success in amputations with sharp cutters such as knife, chopper is higher than amputations by pulling due to compression under press or tripping.

Additional conditions such as smoking, diabetes, heart diseases, blood pressure diseases effects the treatment adversely. Also, success may be less in old patients than young and middle age patients.

Severed part should be sutured on its place within 2 hours in ideal conditions. When amputation level reaches to the finger tip, this period may increase up to 6-12 hours, if amputated part is stored in suitable conditions. As specified above, the patient should be immediately transported to the hospital. As the amputation level approaches to the end, due to small vessels to be sutured; quality of the technical equipment and experience in microsurgery become more important. On the other hand, functional results are better when the severed part is treated properly in end level amputations.

Replantation and after period requires perseverance both for the patient and the surgeon. While a replantation procedure may last for 2-14 hours according to the severance level, if severed part is more than one (4-5 fingers or severance of both arms) this period may increase. Recovery period also may vary between 2 months and 2 years according to the level of severance. Also further operations may be required to provide function after the severed part is kept alive.

It should be remembered that, replantation process may not be performed in every health centre. Patients should apply to a microsurgery centre where special microsurgery tools and operation microscope exists with a microsurgery and hand surgery specialist. Unfortunately, such centers are not many either in Istanbul or in Turkey.

EXTENSOR TENDON INJURIES

Extensor tendons take place on the upper surface of the hand. They play role in lifting the hand and fingers. Extensor tendons are chorda extensions of forearm muscles extending to the fingers. Tendons in the finger tapers and flattens. Besides chorda extensions staring from muscles of the palm (lumbrical and interosseos) also participates to the extensor mechanism which lifts the fingers. (Figure 1.2)

They play important role in finger movements and coordination.

Extensor tendons are just under the skin. Therefore, extensor mechanism injury may arise even with small cuts. After traumas such as compression and crashing, disconnection of thin tendons by dissevering from bone connection points (mallet finger, boutoniere deformity) may be observed. Fingers up-lifting is not performed after extensor mechanism injuries. Surgical treatment may gain old functions in extensor tendon injuries.

Treatment of extensor mechanism cut or disintegration is provided by sewing the cut or disintegrated area. For injuries which is close to finger joints, joints should be fixed by a wire to protect continuity of sutured thin tendon structure. Because of natural features of the extensor tendon, 5 weeks of brace treatment is required for relaxing and not having debility for lifting the finger up.

In cases that extensor mechanisms separate from connection of the extensor mechanism after compression and crushing (mallet finger, boutoniere deformity), re-connection of the tendon from disintegration place is provided by methods such as bracing, finger ring application, using three point braces. Patient compliance is very important in these treatment methods. Another treatment option is to fix by threading pin from bones and joints.

CONGENITAL ARM PARALYSIS (Congenital brachial plexus injuries)

The five big nerves which are extension of the spine, combines with each other with different ways after exits from neck vertebras on side of the neck and under the scapula and forms a nerve web called brachial plexus. Nerve branches which exits from the brachial plexus are responsible either movements of a part of back and chest, arm, forearm and hand or sense of these body parts.

Congenital arm paralysis are those arisen in the brachial plexus due to various reasons before or after the birth. It is mostly unilateral. Symptoms may change according to the severity of the nerve damage. If the baby moves one arm less than the other or if the baby can not move one arm, if the effected hand can’t be made fist, the difference between arms, if one arm is softer than the other, if objects are always clutched by one arm in bigger babies, if the baby can’t take his hand to his mouth; these findings point out brachial plexus damage.

Surgery may be required in about 10% of babies who were effected by brachial plexus injury and the above mentioned problems. But babies born with arm paralysis should be under the control of a team including surgical and physiotherapy of brachial plexus injuries whether surgical treatment is required. First, it should be set forth that if the current paralysis sourced from central nervous system or a problem in the brachial plexus.

In problems that upper nerve roots are involved, shoulder and elbow movements are absent or insufficient. Usually hand movements are complete. If the baby can not take his hand to his mouth in the sitting position in 6-9. months; surgery is considered. (Figure 1)

In another frequent form of the injury, hand sense and movement is insufficient. The child doesn’t respond to stimulus that will give pain to his hand. Shoulder and elbow movements are absent or insufficient. A slight ptosis on the eyelid in the same side of the problem may be observed and the pupil may be smaller according to the other side. Surgery may be thought for patients whom this table doesn’t progress positively from the 3rd month. (Figure 1, 2)

The important is which of these five nerve roots were damaged with which levels in operations performed in this period. A nerve transplant from less used nerves in the daily life may be required for spine level damaged nerve roots. For lower level injuries, nerves taken from legs are used by making a bridge between deficit area. If necessity is thought for nerve operations, it should be applied before one year. Nerves which are taken from the leg are sensory nerves that is not related with movement. Scars in the area that nerves are taken should be ignored for arm functions that will be gained.

One of the most important points that should be remembered related with either brachial plexus surgery or other nerve operations is that operation results will be taken after a long while. The nerve progresses about 1 mm for every day to the finger tip starting from the repaired point by budding. Therefore, a long time between 6 months and 2 years until nerve buds reach to muscles. The patients should be followed with physiotherapy for a long period before and after the surgery.

After it is convinced that nerve recovery is completed, other operating muscles may be transferred instead of non operating muscles in the arm and bone correction operations may be performed if necessary. If these operations are needed, the preferred period is 3. and 5. ages and preschool period. Compatibility of the child for braces that will be used after the operation and physiotherapy process that will be performed increases the success positively.

The thing that is aimed to be obtained after a difficult treatment protocol is to form a helper extremity to the other firm extremity by providing the maximum function that will be able to be provided (a recovery with 100% and complete function should not be waited). But even this may be possible with operations that will be performed within appropriate periods, a compatible follow-up between the patient-family-doctor and physiotherapy process and a big patience.

Source: congenital arm paralysis

BUTTENHOLE (BOUTONNIERE) DEFORMITY

It is the deformity that the middle joint of the finger can not be flatten. It is usually arisen after a trauma. Flattening the finger is provided with a very complex mechanism. While a tendon which goes to the middle line on the finger flattens lower and middle knots (proximal and middle phalanx), tendons which come from both side of the finger flatten the end knot (distal phalanx). In button hole deformity, the middle tendon is injured on proximal phalanx where near to the middle joint.

Diagnosis is very easy with typical view. It may be seen in rheumatic diseases besides traumas.

Professional help is necessary. The first approach in closed injury should be physiotherapy. Requirement of surgery may be disappeared with suitable splinting by a control of a physiotherapist. (Figure 1)

Surgical treatment comes to agenda in cases that only physiotherapy is insufficient. Generally to sew the ruptured tendon on end to end is not possible. There are various repair techniques by using stable side tendons after the middle finer joint of the patient is softened enough with physiotherapy. But long term physiotherapy is sine qua non even tough surgical treatment is applied.

Source: buttenhole deformity

Boxer's fracture (distal tip fracture on the fifth metacarpal)

It’s the fracture that occurs at the neck of the bones which form the knuckles of the hand. It almost always occurs as a result of an impact of a clenched fist to a hard object.

In the suspected cases, it’s useful to apply some ice and to raise the arm above the heart until the patient has arrived at the doctor’s. It is diagnosed with the pain, swelling after the trauma and with the determination of the fracture on direct radiography (figure 1).

The treatment is to realign the fracture by hand and to apply hard casts. However, in some cases the fracture has multiple parts and cannot be realigned by hand (or can’t keep its position after realignment). In these cases, the multiple fracture parts may need to be splinted using strings. (figure 2,3)

Open or closed technique is chosen according to the position of the fracture. Operation is performed using axillaries or ulnar nerve complex. The patient doesn’t need to be under anaesthesia completely and discharged from hospital on the same day. If the fracture is recovered following 4-6 weeks, the hard casts and strings then can be removed. A physiotherapy counselling or support is very useful following this period.

Source: Boxer's fracture

ARM PARALYSIS SEEN IN ADULTS

(TRAUMATIC BRACHIAL PLEXUS INJURIES)

Branches of five nerve roots which exits from neck vertebras control movement and sense of all upper extremity by forming a web (Figure 1).

Nerves give the electrical stimulus to our muscles that provide our movements. When nerves are out of function, movement is impossible in muscles that they give electric.

Arm paralysis of adults arise after motorcycle accidents, other traffic accidents, falling from high and forearm wounding. In closed injuries the patient is followed up for three months and some tests are run. In cases that nerve structural integrity is not damaged but regression arises, transmission losses are expected to regress at most within three months. Accompanying tissue injuries such as bone fractures, vessel injuries that may occur in the trauma area are examined and treated. Advanced radiological tests (MRI, Myelo CT) that will help to show whether the nerve is damaged and if it is, the level of injury; and tests that shows nerve transmission and if the muscles take stimulus or not lighten the differential diagnosis.

As in all nerve injuries, operations that will be performed immediately after the diagnosis provides more successful results. Nerves grow by extending 1 mm rate daily from the repair area to downwards. While waiting function from shoulder and elbow muscles is possible, muscles that provide detailed hand movements are the farthest aims. Reason for this is muscles that nerves will give electric turns into the connective tissue slowly and looses their contraction features irreversible. If requirement for nerve operations is considered, it should applied before one year. In this term, how many nerve roots are damaged and their damage levels are important. For nerve roots that are damaged on spine level, transplantation from nerves that we use less may be required. In lower level injuries that nerve roots are visualized, nerves taken from legs are used by making bridge between the deficient region. Nerves taken from the leg are sensory nerves that do not cause any movement failure. Scars of the area that they are taken should be ignored for arm functions.

One of the most important points that the patient and patient relatives should remember related with either brachial plexus or other nerve operations is operations results will be taken after a long time. The purpose after this difficult treatment protocol that may last for years is to form a helper extremity that helps to the stable extremity by providing the maximum function in the arm and the hand (one hundred percent recovery and providing all functions should never be waited). But even this is possible with surgeries that will be performed in a long term, with a complying follow-up between the patient and the doctor and physiotherapy process and a big patience.

Source: arm paralysis seen in adults

ANESTHESIA IN HAND SURGERY

Decreasing risks of anesthesia of patients during and after the operation and efficient pain killing as the main purposes has become effective in development of anesthesia alternatives. Local, regional and general anesthesia techniques may be used in hand surgery anesthesia. The technique is decided by evaluating operation area, health status, psychological status of the patient.

Local Anesthesia

Local Anesthesia is performed via drugs administrated subcutaneously for narcotizing small areas (finger, small skin cuts etc.). With this method, patient relaxation is provided through intravenous relaxing drugs. It is simple, easy to apply and less risky method. It is the best method for managing the pain in small surgical procedures. The patient may be discharged just after the operation. The patient may eat and drink water after the surgery with this technique.

Regional Anesthesia

Regional anesthesia aims to stop motor and sensory functions temporary by drugs administrated to locations close to main nerves. Wider areas are narcotized according to local anesthesia. Generally nerve passing ways are detected by ultrasound or nerve stimulator. This anesthesia type should be applied in operation room conditions. Intravenous relaxing (sedative) drugs may be administrated at the same time to relax the patient. By this method, early term pains are prevented as well as narcotizing the arm during the surgery. The patient does not take risks of general anesthesia with this method. The patient may eat and drink water just after the surgery. The patient may be informed by the surgeon and the anesthesia team in suitable situations during the surgery. If the patient wants to sleep during the procedure, sedative drugs may be administrated. Besides, continuous pain killing may be provided by putting a catheter on the narcotized area even to help to increase the blood circulation on the finger or to kill the pain for patients with circulation loss in the finger. Method application is comfortable and short. The patient does not feel discomfort while the method is applied. Regional anesthesia paralysis the extremity between 6-8 hours as showing personal differences. The patient is hospitalized until the patient feels his/her hand. Complications are seen very rarely. Insufficient level of anesthesia, pain and bruising in the needle area and fornication may be observed rarely. The anesthetist controls whether the pain is stopped and if there is a problem in areas where arm should re-narcotized. Supraclavicular block, axillary block, interscalenous block, infraclavicular block, elbow level ulnar block, wrist block are among the methods used in regional anesthesia.

General Anesthesia

The operation is done after the patient is intubated with this method. 5-8 hours of hunger period is required before the surgery. Risks are relatively more than regional anesthesia. It is generally used in children and adult patients who has a bad psychological situation and/or will have multiple operation. Postoperative pains of the patient are stopped by other analgesic methods and drugs. Eating and drinking water are not allowed for 4 hours as it may cause some complications after the surgery. .

Source: anesthesia in hand surgery

ACRONYX

Acronyx is a condition wherein the nail deviates from its normal direction and is embedded into the surrounding dermal tissue. Sharp pains and future infections may affect daily life and even psychological condition of the patient.

Weaning inappropriate and tight shoes and cutting nails in an incorrect manner are the most common reason for acronyx, but also certain generic factors may trigger it.

Contrary to what is generally assumes, the treatment does not involve removal of the nail as the problem does not stem from the nail itself but the nail fold that is a constituent of the nail and is placed underneath it. For this reason, the problem subsisting on the nail folder should be corrected surgically.

Source: acronyx

1. CALCIFICATION ON THUMB BASE (OSTHEOARTHRITIS OF CMC-1 JOINT)

Smooth surfaced cartilage covers both ends of bones. This cartilage structure provides bones to slide in the joint easily during the movement. Osteoarthritis arises by wearing and surface damaging of this cartilage. Hand osteoarthiritis is generally observed in the joint on thumb base. There is a joint which provides the thumb turning on its axis, pinch move and supporting other fingers on the basis of the thumb. We can clutch and take in our hands by virtue of this joint. After deformation of this joint, pain arises during thumb use in hand functions. Arthritis which affects the thumb base is observed more frequent in women than men and after the age of 40. Joint injury and fracture history increase the possibility of arthritis.

Pain during movements such as clutching and pinching; swelling and sensibility in the thumb base; feeling of pain and discomfort after long finger use; loss of force in clutching and pinching movements; enlarged joint view which resembles joint dislocation; limited joint movement may be detected.

Sensibility and swelling may exist in the thumb base during physical examination (figure 1). One of tests that is used during the physical examination is to move the thumb while holding the joint on the thumb base fixed. During this test, if there is sense of grit presence or sound of friction, bone rubbing is suspected.

Deformation of the joint in the direct graphy, spur like bulges in the bone and calcium residues may be observed.(Figure 2)

Thumb base arthritis may response to other treatments except the surgery in the beginning term. Cold application may be performed with ice for 5-15 minutes on the joint for several times. Taking anti inflammatory drugs such as asprine or ibuprofen helps to reduce the inflammation and the swelling. Using supportive brace enables joint resting and recovery by limiting the joint movement. Brace may protect either the thumb or the wrist. It may be used intermittently during the day or only in the night. (Figure 3)

As arthritis is a progressive disease, it may get worse in time. Intraarticular steroid injection may be done in progressive joint damages. Generally comfort is provided for a couple of months after this application. But injections are rarely repeated continuously during the disease. In cases of which non-surgical procedures are not useful, surgery is considered. There are many different surgical procedure. Surgical operation may be applied as ambulatory without need of hospitalization. One of surgical procedures is bone combining in the joint that limits the joint movement. Another option is to remove damaged part of the joint and restructuring by tissue transplantation or artificial substances from sinew (tendon). The best surgical option which is used frequently is the process known as 1. carpometacarpal arthroplasty, removal of arthritic bones from the are and placing sinews by changing their direction as to act like a buffer between the thumb and the wrist. This procedure provides comfort in articular movement as well as decreasing the pain compliant.

Plaster is applied for a couple of weeks after the surgery. Generally a rehabilitation program that involves a physical treatment specialist helps you to gain force and movement of your hand back. You may feel difficulty and discomfort at the beginning of the program, but these complaints decrease in time. Complete recovery takes a couple of months after the surgery.

Source: 1. Calcification on thumb base