The cause of Dupuytren contracture, which is common particularly among white populations of Celtic origin, is not known. It occurs in one of three types (acute, subacute, and chronic), predominately in men over 50 who have been in sedentary occupations, and is bilateral in about half of cases. There is a hereditary influence, and the incidence is higher among idiopathic epileptics, diabetics, alcoholics, and patients with chronic illnesses. The contracture may develop in people who do not work and (in laborers) in the hand that does the least work, so that it is not considered work related. It is frequently found in the plantar fascia of the instep and occasionally in the penis (Peyronie disease).
Dupuytren contracture manifests itself most commonly in the palm by thickening, which may be nodular, and therefore mistaken for a callosity, or may be cord-like, and therefore mistaken for a tendon abnormality because it passes into the digits and restricts their extension. This process typically involves the longitudinal and vertical components of the fascia but at times seems to exist apart from anatomically distinct fascia. The skin may fuse with the underlying fascia and become raised and hard, or it may be greatly shrunken and sometimes drawn into a deeply puckered crevasse. The disorder invades the palm at the expense of fat but is never adherent to vessels, nerves, or musculotendinous structures (though it may be adherent to flexor tendon sheaths). It has an unpredictable rate of progression, but the earlier it starts in life, the more destructive and recurrent it is apt to be.
Dupuytren fasciitis may involve any digit or web space, but it affects predominantly the ring and small fingers. In long-standing cases, the fingers may be drawn tightly into the palm, resulting in secondary contracture of joint capsule and ligaments, flexor sheaths, and atrophic muscles.
The most recent addition for the treatment of Dupuytren contracture is enzyme (collagenase) injection. Based on early studies, it appears that this treatment works best on MCP contractures rather than PIP contractures in patients with a well-defined cord. This treatment does require two office visits, one for the injection and a follow-up visit to manipulate and rupture the cord.
Surgery is indicated when the disorder has progressed sufficiently, especially when it causes more than 30 degrees of flexion at the MCP joint or any flexion contracture of the PIP joint. The patient must be warned about the increasing technical difficulty with progressive flexion and adduction contractures and the potential for recurrence after surgery. Fasciectomy is the surgical procedure that gives the best long-term results. In selected cases where only the longitudinal pretendinous fascial band is involved and the skin moves freely over it, subcutaneous fasciotomy done through a small longitudinal incision may release a contracture quite well with only a few days of postoperative disability. In the occasional case with acute and rapid onset of a tender nodule, local triamcinolone may be used for subjective and even objective relief.
Depending on the amount of cutaneous shrinkage, skin grafts may be required for wound closure after fasciectomy. The overlying dermis has been implicated as an inductive mechanism in this process. Thus, skin grafting may diminish the recurrence rate in severe cases. The hopelessly contracted little finger must sometimes be amputated.
Motion should be started within 3-5 days after surgery. Dynamic splints and postoperative injection of corticosteroids into joints and the zone of surgery may help the well-motivated patient.
The potential complications of surgery are wound breakdown (loss of skin flaps), hematoma, fibrosis and stiffness, digital nerve injury, recurrence of contractures and digital ischemia secondary to digital artery injury. Reflex sympathetic dystrophy, a painful, debilitating neurologic disorder of the hand, can occur after surgery and must be treated aggressively. In general, the functional reward for the patient is great at any age.
KE: An evidence-based approach to Dupuytren’s contracture. Plast Reconstr Surg 2010;126:2210.
SS, Hentz: The treatment of Dupuytren disease. J Hand Surg 2011;36:936.
et al.: Advances in the management of Dupuytren disease: collagenase
. Hand Clin
DEGENERATIVE & RHEUMATOID ARTHRITIS
Arthritis of the hand is divided into two categories. Degenerative changes are usually due to some trauma resulting in damage to the bone or cartilage or to the supporting ligamentous structures. The increased wear to the joint results in inflammation and damage to the cartilage or underlying bone followed by reactive new bone formation (spurs). The wrists, hips, and knees are most commonly affected. Rheumatoid arthritis is a systemic disease characterized by synovial inflammation. The diseased synovium destroys adjacent tendons and joints in a specific way, leading to characteristic deformities in the hand.
Patients with degenerative arthritis complain of pain, aching, and stiffness in the area of the affected joint. Progression of the problem leads to immobility of the joint that affects the entire hand. Radiographic studies demonstrate joint narrowing and periosteal thickening early in the problem, progressing to bone spurs, loss of the articular surface, and bone destruction later. Patients with rheumatoid arthritis often present with very severe deformities without pain. Nodules around the olecranon and dorsum of the hand are often found. Both flexor and extensor tendons at the wrist can be inflamed, limiting tendon movement and resulting in rupture of the tendon. Involvement of the tendons and ligaments at the digits and MCP joints results in ulnar deviation of the digits, MCP joint destruction and dislocation, and swan-neck and boutonnière deformities. Destruction of the wrist joint is also common.
Arthritis is common among older patients and usually treated by primary care physicians and rheumatologists with anti-inflammatory medications and modification of the patient’s activities. In most cases, it is only when symptoms greatly hinder the patient’s lifestyle that they are referred to a hand surgeon. Physical therapy, splints, and medications are often no longer effective for these patients.
Surgical treatment of painful joints includes replacement with a prosthetic joint and partial or full fusion. Prosthetic joints of metal or Silastic permit near-normal movement but can become unstable and dislocate or degenerate over time. For a durable solution to the problem, fusion of the joint is recommended. Motion is severely limited, but pain relief is complete. There are more therapeutic options for the wrist, such as replacement, local fusion of only the affected carpal bone, or complete excision of the proximal row of carpal bones, leaving motion and stability to the distal carpal bones and ligaments.
Therapy for synovial inflammation in rheumatoid disease includes excision of the synovium to increase tendon excursion and prevent rupture, repair of ruptured tendons, and excision of painful nodules. Tendon-balancing procedures can help ulnar deviation of the MCP joints and improve joint movement. The most important concept of treating patients with rheumatoid hand disease is that often the patients have adapted well to their functional deficits. Correcting a physical deformity in a well-compensated patient may actually result in more problems for that patient.
et al.: Proximal interphalangeal joint replacement in patients with arthritis of the hand: a meta-analysis. J Bone Joint Surg Br 2012;94:1305.
KC: A systemic review of total wrist arthroplasty compared with total wrist arthrodesis for rheumatoid arthritis. Plast Reconstr Surg 2008;122:813.
TD: The rheumatoid thumb. Hand Clin 2008;24:307.
KC: Reconstruction of the rheumatoid hand. Clin Plast Surg 2011;38:713.
BR: Tendon reconstruction of the rheumatoid hand. Hand Clin 2011;27:105.
SCLERODERMA & LUPUS ERYTHEMATOSUS
These systemic diseases of unknown cause have distinctive—though not necessarily pathognomonic—manifestations in the hands.
Scleroderma initially produces joint stiffness, hyperhidrosis, and Raynaud phenomenon. Unchecked, it leads to marked tautness of skin and rigidity of joints with associated osteoporosis (even atrophy and ultimate resorption of the distal phalanges) and soft tissue calcifications.
Lupus erythematosus, which may be initiated or aggravated by certain drugs, foreign proteins, or psychic states, often causes polyarthritis indistinguishable from that of rheumatoid arthritis. It does not usually lead to similar joint destruction. Vasospasm in both lupus and scleroderma can cause severe ischemia of the hand and digits and may require therapy to prevent gangrene.
Gout is a metabolic disorder of uric acid metabolism that affects about 1% of the population; approximately 50% of patients with gout have cheiragra (gouty hands).
The diagnosis is suggested by a rapid onset of severe pain and inflammatory signs about the joints and musculotendinous structure, simulating a phlegmonous infectious cellulitis with marked induration (most dramatically seen about the elbow). The usual duration of an attack is 5-10 days. The serum uric acid is elevated in 75% of cases. Gout may coexist with rheumatoid disease. The diagnosis is confirmed by identification of uric acid crystals in joint fluid or tissue biopsy.
In time, typical tophi form, consisting of toothpaste-like infiltrates of urate crystals, arising in multilobulated form about soft tissue structures that have been invaded. X-rays show characteristic punched-out lesions at the margins of articular cartilage.
Prophylactic treatment of gouty arthritis consists of diet, colchicine, allopurinol (a urate-blocking agent) or probenecid (a uricosuric agent), and avoidance of stress. Colchicine, 0.6 mg/h with a glass of water for six to eight doses or to the point of gastrointestinal distress, is the time-honored means of interrupting an attack, but phenylbutazone, topical corticotropin gel, and systemic corticosteroids are also of value.
Surgical measures consist of drainage of abscessed tophi (seldom needed) and tophectomy. The latter procedure is more often of cosmetic rather than functional value. Tophectomy consists of removal of as much tophaceous material as can be fairly easily recovered. The surgeon should be careful not to destroy ligaments, tenoretinacular structures, nerves, and vessels in the process.
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et al.: Different surgical approaches to treat chronic tophaceous gout in the hand: our experience. Tech Hand Up Extrem Surg 2010;14:187.
E: Systemic sclerosis: bilateral improvement of Raynaud’s phenomenon with unilateral digital sympathectomy. Semin Arthritis Rheum 2010;40:137.
BURNS & FROSTBITE OF THE HAND
The hands are a common site of thermal (including frictional), electrical, chemical, and radiation burns. Function is imperiled in all instances by swelling and scar formation. Prompt measures to preserve existing function are often urgently required. Burns over other areas of the body may be more life threatening and require more urgent attention, but burns of the hand should never be neglected. Delay in therapy leads to irreversible impairment and deformity that are impossible to correct later.
As in other areas of the body, thermal burns are grouped into three degrees. Superficial (first-degree) burns are red and painful; partial-thickness (second-degree) burns develop blisters; and full-thickness (third-degree) burns are insensate and appear like leather or charred tissue. The prognosis and therapy depend on the location, depth, and extent of the burn.
All burns to the hand cause swelling of the tissues, and the need for elevation of the arm to relieve pain and prevent stiffness cannot be overemphasized. Tetanus immunization should be given. Cold compresses may help alleviate the pain in first-degree burns. Second-degree burns must be watched more carefully. Large blisters restricting motion are broken. Otherwise, since they are sterile, they should be left intact. Treatment with thrice-daily washing and silver sulfadiazine is usually adequate. Patients with third-degree burns or superficial burns that fail to heal and patients unable to care for their burns at home should be admitted to the hospital.
Deeper burns require close observation and more extensive treatment. In the first few hours after injury, circumferential or near-circumferential burns may cause ischemia in the extremity. Because evaluation of sensory function and capillary refill is nearly impossible in these limbs, escharotomies should be performed if compartment syndrome is suspected. If done correctly, escharotomies have few complications, since these burns usually require surgical debridement anyway. Incisions are placed to avoid exposure of neurovascular structures.
Partial-thickness burns heal spontaneously. Deeper burns on the dorsum of the hand are best treated with early excision of the eschar and placement of skin grafts to prevent contractures. Palmar burns are best left to heal spontaneously because skin grafts function very poorly in this area. Some hand surgeons believe that excision and grafting of superficial burns should be performed to prevent contractures. This is true if adequate therapy has not been available. In burn units with good rehabilitation services, surgeons are treating superficial second-degree burns without surgery and obtaining results as good as with skin grafting. Pigskin, cadaver homografts, or a number of commercially available biologic dressings can be used to cover the wounds temporarily, decreasing pain and keeping the wound moist until autologous skin grafts are placed.
Neglected burns of the hands result in contracture deformities that often require extensive surgery to restore function. Delayed healing and wound contractures often result in a claw hand with MCP hyperextension and fusion of the digits with loss of the web space (syndactyly). Burns on the volar surface leave flexion contractures. Some contractures can be treated with release and skin grafting of the tissue gap. Web space contractures and released contractures with exposed tendons or nerves must be covered with skin or muscle flaps. Web space release is done with skin flaps from the dorsum folded down to create the space. Large flaps can be obtained by attaching the hand to the groin, allowing the tissue to adhere and vascularize before cutting the flap away from the groin. Recently, free tissue transfer from other parts of the body using microsurgical techniques has allowed more extensive reconstruction of severely burned hands.
Electrical burns of the upper extremity may not appear extensive on initial inspection. The skin may be burned only in a very small area of the entry point of the current or by ignited clothing. The current tends to spare the skin but damage underlying muscles, vessels, and nerves. Often, the extent of dead tissue is not evident for several days.
Initial treatment is the same as for thermal burns. Since muscle damage may be extensive, it is important to prevent renal failure from myoglobinuria by maintaining a high output of alkaline urine. Arteriography, fluorescein injections, and radionuclide studies may help delineate the extent of necrosis. Examination of the patient in the operating room is still the most accurate method of assessing the extent of tissue damage. All obviously dead tissue should be removed during the initial evaluation. Two or three days later, the patient is reexamined in the operating room and any additional debris is removed. The wounds are closed when only clearly viable tissue remains.
Frostbite occurs most often in people under the influence of alcohol or with psychiatric illness. The lower extremity is affected more often than the upper. Freezing tissue causes cellular death and vascular thrombosis. Hypothermia of the entire body must first be treated. The frozen part should be quickly rewarmed by immersion in warm water (40°C). Elevation of the extremity minimizes edema. Skin wounds are treated like burns with silver sulfadiazine cream. The extent of necrosis may not be obvious for several weeks, and debridement or amputation should be delayed until demarcation of the injury occurs. Sympathectomy may help ameliorate the sequelae of frostbite, such as cold sensitivity and pain. Children with frostbite may develop premature closure of phalangeal epiphyses, which creates growth disturbances of the bone.
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et al.: Reconstruction of the burned hand. Plast Reconstr Surg 2011;127:752.
DH: Cold injury. Hand Clin 2009;25:481.
RL: Rehabilitation of the burned hand. Hand Clin 2009;25:529.
Only 2% of all masses in the hand are malignant lesions; the majority are benign neoplasms, cysts, or a myriad of other masses. Though the clinician must be ever vigilant to identify malignancy, a mass of the hand is highly likely to be benign—excisional biopsies are thus reserved for subcutaneous lesions that are rapidly growing or for skin lesions that may be carcinomas. Otherwise, masses can be observed over a period of time to determine that they are not growing. They may be removed for functional or cosmetic reasons.
Ganglions are formed by herniation of the synovial lining of joints or tendons into the surrounding soft tissue. These cysts are filled with a viscous fluid thought to be modified joint fluid. Trauma to the wrist or hand may cause extrusion of the synovium, but it is more likely that the ganglion was already present and that trauma to that area merely brought the lesion to the surgeon’s attention.
Ganglions can arise from any joint of the hand but most commonly appear on the dorsal wrist over the scapholunate ligament and the volar wrist near the radial artery. Tendon ganglions are most common on the flexor sheath at the metacarpal head (A1 pulley). Pain and tenderness are due to compression of adjacent nerves by the mass.
Ganglions have a typical appearance, and diagnosis is simple. If any doubt exists, aspiration with a large-bore needle of the viscous fluid confirms the diagnosis and occasionally cures the lesions. Injection of the empty sac with steroids and lidocaine may help to keep the mass from reappearing, but the majority recurs. Ganglions need not be treated unless they cause pain or interfere with hand function. Often, it is enough just to reassure the patient that the mass is benign.
Operative removal of ganglions should be done using loupe magnification and a tourniquet. The entire ganglion should be removed, including all attachments to the joint capsule and the underlying ligament, without injuring the surrounding structures. Prolonged splinting after removal of ganglions does not decrease recurrence rates but does cause hand stiffness. Unfortunately, despite careful surgical removal of the lesion, recurrence of ganglions is relatively common.
Epidermal cysts are rests of epidermis located in the subcutaneous tissue. Many are thought to be due to traumatic disruption of epidermal cells into the soft tissue (inclusion cyst). The cells proliferate just as skin does and form a cyst filled with creamy keratin, the remains of dead epidermal cells that usually desquamate from the skin. Infected cysts become inflamed and form abscesses. Removal of the entire cyst wall is required to prevent abscess formation.
Pyogenic granuloma may form in any chronic wound. Histologically, it consists of vascular tissue identical to granulation tissue. Just as for hypertrophic granulation tissue elsewhere on the body, excision or cautery of the material flush to skin level allows epidermis to migrate over the wound.
Giant cell tumors are benign, multilobulated, solid masses found on the lateral aspects of the finger. They are often attached to the tendon sheath. The mass may be quite complex and extend throughout the adjacent nerves, vessels, tendons, and ligaments. The entire lesion should be removed, but recurrence is relatively common.
The most common bone tumors are enchondromas. Multiple enchondromas (Ollier disease) are associated with other skeletal deformities. The lesion appears on x-ray as thinned cortical bone with speckled calcifications. Fractures through the tumors usually do not heal spontaneously. The tumor should be removed with a curette. Bone graft taken from the distal radius is used to fill the gap if needed.
A carpal boss is due to abnormal bone formation at the base of the second or third metacarpal bones and presents as a hard mass on the dorsum of the hand. The excess growth of bone can be removed if symptomatic.
Glomus tumors are composed of blood vessels and unmyelinated nerves of a heat-regulating arteriovenous malformation. They are usually found in the fingertip or under the fingernail and can be extremely painful. Local excision of the tumor is curative. Occasionally, when the tumor is large and disrupts the nail matrix, a split-thickness nail graft from another digit is needed to reconstruct the defect.
The most common malignant tumor of the hand is squamous cell carcinoma, though basal cell carcinomas and melanomas also occur. Subungual melanomas are often difficult to diagnose because they are difficult to examine. These tumors should be treated just the same as elsewhere on the body. Particular care should be taken to examine for spread of tumor in the lymphatic drainage at the supratrochlear and axillary nodes.
Other tumors include lipomas, fibromas, hemangiomas, arteriovenous malformations, neurofibromas, sarcomas, and various skin lesions. These tumors act no differently in the hand than elsewhere in the body. However, because of the close proximity of the nervous and vascular structures within the small spaces of the hand, these tumors cause compressive signs and symptoms sooner. CT scans or MRI help delineate the extent of soft tissue tumors and may help in preoperative planning.
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A: Indeterminate soft-tissue tumors of the hand and wrist: a review based on a clinical series of 39 cases. Skeletal Radiol 2011;40:977.
Crush Injuries & Amputations
Advances in microvascular surgery have greatly increased our ability to treat complex hand injuries. Mangled and amputated digits, hands, as well as entire upper extremities have been replanted or repaired. Complex nerve repairs, microvascular free tissue transfers of muscle flaps, and toe-to-hand reconstructions have made it possible to restore more function to severely injured hands. The end result must be a sensate, painless, and useful extremity. Patients who undergo multiple surgical procedures and prolonged rehabilitation with only marginal results would have benefited from early amputation. A surgeon with extensive experience can best assess the patient’s injuries, occupational requirements, and psychosocial needs to determine if salvage is worthwhile.
Complex hand injuries often result from improper use or malfunction of machinery. Heavy machinery in the workplace or motorized cutting tools at home, such as rotary saws, are often cited as the mechanism of injury. Sharply amputated or partially devascularized parts are most likely to be saved. Severe crushing or avulsion of the part produces wider nerve and vessel injury. The extent of this type of damage is difficult to determine and often impossible to repair.
The decision to try to salvage a damaged part must be individualized to each situation, but some general principles apply. The thumb is crucial to hand function, and all efforts are made to save the entire digit or as much length as possible. When multiple digits or half of the hand is damaged or amputated, a greater effort is made to repair the part. Children can recover function in badly damaged extremities far better than adults can, and any amputated parts in children should be replanted. Replantation of the entire arm at the elbow and above is controversial. The usefulness of these replanted limbs is limited by the slow nerve regeneration, and some hand surgeons believe that amputations in these cases result in better function.
Patients with complex hand injuries should be immediately referred to a regional center with the staff and facilities to manage the problems. Occasionally, in the rush to transfer patients with these very obvious injuries, intra-abdominal, neurologic, and other less obvious injuries have been overlooked. The entire patient must be evaluated and stabilized prior to transfer. A clean, moist dressing should be placed on the wound and the extremity elevated. The amputated part is wrapped in a plastic bag and placed in ice water. The amputated part should never be frozen.
The accepting hand surgeon evaluates the patient’s overall condition, potential for rehabilitation, and personal wishes before coming to a decision. To revascularize or replant a part, the patient must be taken urgently to the operating room. Ischemia over 6 hours is often associated with failure of revascularization, but—depending on the metabolic needs of the constituent tissues—extremities that have undergone periods of ischemia longer than this can be successfully replanted.
Bone must first be stabilized with Kirschner wires or metal plates before vascular repairs are performed. Arterial and venous repairs are done with microscopic magnification, and the ischemic tissue is reperfused. Failure of a replanted part is more often due to venous outflow problems than arterial inflow. Systemic and local anticoagulants help to maintain perfusion but are not always needed. Leeches placed on the part release a potent local anticoagulant and can decrease venous congestion. Nerve and tendon repairs must also be performed. When there is inadequate local soft tissue to cover the repaired structures, muscle or skin flaps from a distant site must be transferred using microsurgical methods to the area. Although these operations are not life threatening, blood loss can be extensive and transfusions are sometimes required.
Secondary procedures to free tendon adhesions, reduce bulky flaps, and transfer tendons in motor nerve injuries may need to be done. Reconstruction of unsuccessful replantations is being done more often. The original method using toes to reconstruct thumbs has also been used to make fingers. These reconstructions give patients the ability to grasp objects. Because these digits are sensate, they can even perform fine movement tasks not possible with prosthetic devices. Patients with loss only of the thumb are better treated with transfer of the index finger to the thumb position (pollicization).
Partial or total loss of a single digit is less critical. Hand function is better without a stiff or painful digit. When a decision is made to amputate a digit, care must be taken to leave a painless stump with good sensate soft tissue coverage. The flexor tendon must not be sutured to the extensor tendon for soft tissue coverage, since this will cause the tendons to pull each other rather than move the joint. Local flaps to cover the stump are preferred to skin grafts or cross-finger flaps, since they usually provide better sensation. A short amputation stump on the long or ring finger is often bothersome because small objects such as coins tend to fall out of the palm, and a ray amputation eliminates the problem. For cosmetic purposes, ray amputations are far less noticeable than partial amputations. The loss of hand breadth with a ray amputation can decrease grip strength, however.
The loss of part of all of the hand can be compensated both functionally and cosmetically by a variety of prostheses. Their use involves careful adaptation to the requirements of the patient, who must receive appropriate training to ensure success.
INJECTION INJURIES OF THE HAND
High-pressure devices used in industry to apply material such as air, grease, paint, and oil cause a unique hand injury. The typical case is injection of the material into the index finger of the nondominant hand of a factory worker. A pinpoint injection site may be the only external evidence of injury, and the hand appears discolored or pale, or swollen due to the injected material.
The examination should include a careful hand evaluation and an x-ray to demonstrate the distribution of material or gas in the hand. All such cases require continued, unrelenting scrutiny, even if the part seems completely normal. If there is any evidence of retained foreign material, swelling, or ischemia, early surgical exploration is advocated to release the tourniquet effect of the skin and fascia and to remove as much of the material as possible without injuring healthy tissue. Prophylactic antisludging agents (dextran 40), corticosteroids, and antibiotics may help.
Often, the pressure forces the material to spread along the tendon sheaths throughout the hand and even into the forearm. Expansion of the foreign material in a closed space and the chemical irritation cause congestion, inflammation, vascular thrombosis, and gangrene. The injected material is difficult to remove completely, and a foreign-body response leads to fibrosis so extensive that it often destroys the function of the hand.
E Davis, Chung
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