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