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

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

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