The hand, which through a complex anatomophysiology has a multitude of functions, is particularly vulnerable. All pathophysiological manifestations may express: osteoarthritis, vascular, neurological, infectious, tumor, autoimmune, etc. But that handsome body willingly allows unveil the doctor: Most diagnoses based on clinical examination.
The hand osteoarthritis affects more specifically the thumb TMC joint (or rhizarthrosis) and other finger distal interphalangeal (DIP) and proximal (IPP) producing Heberden’s nodes and Bouchard. It occurs most often in women in perimenopause. Even if there is a genetic predisposition, it is significantly enhanced by mechanical stresses.
Rhizarthrosis is suspected in pain the radial side of the hand at the base of the thenar. It occurs when gripping, disabling daily actions.
Sometimes it is only a mistake, the patient loose objects.
On examination, pain is awakened by the pressure of the anatomical snuffbox. The evolution is marked by wasting of the external muscles of the thenar and the installation of a strain: thumb adduction in the palm, closing the first interosseous space and hyperextension of the metacarpophalangeal (MCP) providing the appearance inch in Z.
The X-ray shows a more or less pronounced: a pinch of trapézométacarpien spaced, subchondral osteosclerosis, marginal osteophytes, bone geodes and a subluxation of the first metacarpal.
It can also reveal scaphotrapézienne osteoarthritis often associated. However, there is no parallelism and clinicopathological some very destructive arthritis are not symptomatic.
Treatment is primarily medical, obtaining indolence. Simple analgesics are prescribed as first line: paracetamol, dextropropoxyphene, codeine, tramadol.
Nonsteroidal anti-inflammatory drugs (NSAIDs) per os will be reserved for particularly painful forms and prescribed short curing 5 to 7 days; topical application, they can also be effective. The use of slow action antiarthrosic (diacerhein and chondroitin sulfate) sometimes brings relief.
Finally, intra-articular injections under radiographic control (prednisolone acetate 0.5 to 1 ml, without exceeding 3-4 injections per year) have a good analgesic effect.
The benefit of viscosupplementation by hyaluronic acid to be confirmed. It must involve a splint worn at night or during periods of rest which helps to fight against the strain and pain.
Surgery is reserved for very incapacitating forms.
Currently, three types of interventions can be envisaged: arthrodesis, trapeziectomy with or without silicone implant and joint replacement.
Osteoarthritis of IPD and PPIs:
The pain of osteoarthritis of the IPD and concomitant PPI is often the appearance of Heberden’s nodes and Bouchard.The IPD of achieving the second and third fingers is the most common. The pain may be permanent functional impairment affects all handicrafts; disfigurement is often a concern.
On examination, we can see signs of inflammation. The evolution is to a deformation in flexion and ulnar deviation of the third phalanx. The presence of mucoid cyst on the dorsal surface of the joint is not uncommon.
The radiograph is not essential to the diagnosis.
It shows the narrowing of the joint space and osteophytes. Some forms very erosive lead to a build appearance phalanges with disappearance of the epiphysis. Sometimes very very destructive inflammatory or presentations can evoke an inflammatory or metabolic arthritis. Examination of other joints, skin and nails, radiographs and biology (erythrocyte sedimentation rate, C-reactive protein, FAN [anti-nuclear factor], Latex, Waaler-Rose, anti-CCP [cyclic peptide citrullinated], uric acid) to refute the hypothesis of rheumatoid arthritis, psoriatic arthritis, a chondrocalcinosis or a drop.
Medical treatment is superimposed on that of the thumb osteoarthritis. Surgery is reserved for severe destructive forms. The excision of nodules is of no interest; arthroplasty can sometimes be considered.
PATHOLOGY TENDONS, the fascia, AND CYSTS:
Tendon pathology is frequent hand because of the many tendons, especially long and thin, and their mechanical stress.
Tendinopathy De Quervain:
Tendinopathy De Quervain is suspected in pain sitting next to the radial apophysis, which may radiate to the back of the thumb or the outer edge of the forearm. It corresponds to tenosynovitis of the tendons long abductor and short extensor of the thumb passing this place in a common sheath. It is an overuse condition.
On examination, there may be swelling of the outer edge of the wrist; Pain awakened by extending active abduction of-thumb or passive ulnar deviation of the wrist, thumb adduction.
No further examination is needed to diagnosis; ultrasound would show the hypoechoic thickening of the tendon sheaths.
This tendinopathy should not be confused with the “ouch crackling” wrist. This is called an inflammation of the bursa located between the tendons of the radial and the long abductor of the thumb. The pain is accompanied found four fingers through crackling swelling over the radial styloid and is triggered by the movements of the wrist flexionextension.
The analgesics and NSAIDs are often disappointing. Laying up a wrist splint may be associated with one or two peritendinous infiltration of prednisolone acetate.
The rebels forms, exceptional, entrusted to the surgeon.
The trigger finger flexor tenosynovitis is.
It is the expression of a conflict between the tendon and its sheath digital, at the first refl ection pulley located on the palmar surface of the MCP. It particularly affects the 1st, 3rd and 4th fingers. It results in bending blocks of PPI, often painful, sometimes requiring the help of the other hand to put the finger extension.
On examination, one can find a painful nodule in the palmar surface of the MCP. Most often isolated, it is more common during inflammatory rheumatic or diabetic.
Its treatment involves one or two peritendinous infiltration of prednisolone acetate next to the MCP. Exceptionally, the surgical incision of the fiber channel is required.
Dupuytren’s contracture is a retractile fibrosis
of the palmar fascia, etiology
The patients presenting with palmar nodules, sometimes painful, causing a retraction of the MCP and PIP joints.Occurring between 40 and 50 years, male dominance is clear.
Involvement is bilateral in over half the cases, especially affecting the 4th and 5th fingers. There is certainly a genetic predisposition and certain predisposing factors: the intense and repetitive manual work, diabetes, alcohol and barbiturates or treatments isoniazid.
There are four clinical forms: the palmar nodular form pure to be monitored; palmodigitale the form with extension deficit localized to the MCP which recovers completely after treatment; digital form with extension deficit on PPI whose postoperative recovery is uncertain; palmodigitale the form (MCP and IPP). This condition, in strictly clinical diagnosis is frequently associated with other fibromatosis: the pads of phalanges, Ledderhose disease and Peyronie’s disease.
The “table” test is a good indicator therapeutic.
The palm flat on the table, the patient must take off the fingers of the horizontal plane with the contralateral hand.When this is not possible, consider treatment.
There is no medical treatment.
The needle aponeurotomy is now a common alternative to surgical aponévrectomie.
Cysts of the hand are common affections related degeneration of the capsule, they develop near the joints or tendon sheaths and contain a mucoid type of substance.
Synovial cysts are most often located on the dorsal surface of the wrist (next to the scapholunate joint) in young women.
This is a round formation, which can be painful during movement, closes and rénitente, low mobility, protruding during flexion of the wrist. Developed on the palmar surface, they can be responsible compression of the median or ulnar nerve.
No further examination is needed to diagnosis, radiography is almost always normal.
The therapeutic abstention, after reassuring the patient, is the rule. If there is a functional impairment, or for aesthetic concerns, we can make a paracentesis followed by infiltration of prednisolone acetate. Unfortunately, relapse is not uncommon. So when there is neurological or compression, surgical removal is possible.
Mucoid cysts preferentially sit on the dorsal surface of the IPD, willingly satellites underlying osteoarthritis. The discomfort is usually aesthetic than functional. Their processing is identical to that of other cysts.
by tunnel syndrome refers to the compression of a peripheral nerve by anatomical structures neighborhood, altering its function sensory and / or motor.
Carpal tunnel syndrome:
This is the most common. It corresponds to a compression of the median nerve in the carpal tunnel.
The latter is limited behind by the anterior surface of the carpal bones and forth by the flexor carpi; the nerve travels there in the company of finger flexor tendons. Just before entering, it gives rise to sensory branch innervating the ulnar border of the palm. Then he is responsible for the sensitivity of the palmar aspect of the first three fingers and the radial edge of the fourth, the dorsal surface of the 2nd and 3rd phalanges of the 2nd and 3rd fingers and the radial edge of the 4th. Its main function is driving the pollicidigital clip and opposition of the thumb.
The diagnosis is suggested by pain, especially nocturnal, hand occurring in women over 40 years. It may also be paresthesia or fingers bloating, prompting the patient to shake the hand to relieve himself. The achievement, gradual onset, is often bilateral, asymmetrical, partial, involving only the thumb and forefinger.
The research objective neurological examination a median nerve compression and locates his wrist. The superficial hypoesthesia pulp is first isolated and then may be associated with atrophy of the thenar muscles and external deficit of the opposition of the thumb that demonstrate a severe neurological impairment. The compression is confirmed by the wrist carpal tunnel percussion (Tinel’s sign) and hyperflexion of the wrist (Phalen sign) that trigger paresthesias.The main differential diagnoses are: cervical radiculopathy C6 or C7, thoracic outlet syndrome, cervical spinal cord compression.
The electromyogram is not essential to the diagnosis. It will be realized if there is a clinical uncertainty or surgical treatment is considered. The most sensitive electrical anomaly is a slowing of nerve conduction velocity of the median nerve, sensory and motor, wrist. The appearance of a major increase in motor latency is a surgical indication.
This syndrome is idiopathic more than two times out of three. Secondary forms are found in rheumatoid arthritis, diabetes, hypothyroidism, pregnancy, acromegaly, and amylose (primitive myeloma or hemodialysis). The carpal tunnel syndrome is the List of occupational diseases.
The medical treatment is when the sensory disturbances remain isolated. Wearing a wrist splint rest of the night frequently enough t. infiltrations can be added y (up to three) Carpal tunnel with a corticosteroid derivative.
However, recurrence is not uncommon.
Surgery should be considered with the waning of medical treatment if failure or recurrence, and immediately if there are clinical or electromyographic arguments of severe disease. Feasible to open or endoscopic sky, it consists of an incision of the carpal ligament and the medial neurolysis possibly associated with tenosynovectomy flexor.
Ulnar tunnel syndrome:
The ulnar nerve in Guyon’s canal, head pain and paresthesias of the ulnar side of the hand, is much less common.
Algodystrophy is a regional pain syndrome characterized by vasomotor disturbances.
The hand is edematous, cyanotic, seat of sweating. Pain, type of allodynia and hyperalgesia, is increased by movement and often a source of significant functional impairment.
Occurring at any age, it may be accompanied by a breach of the shoulder (adhesive capsulitis type) while realizing the shoulder-hand syndrome. The triggers are: upper limb trauma (fracture or sprain); orthopedic surgery; central neurological disorders (stroke, brain tumor, hemiplegia); chest diseases (cardiovascular or lung); Unexpected rehabilitation and medications (phenobarbital, isoniazid).
Bone scintigraphy with technetium, very demonstrative, reveals bone uptake of carp, overflowing fingers and forearm.
The x-ray later shows how a speckled demineralization, extended to several bones. Rarely in young patients, bone scan shows instead a decreased uptake.
class of painkillers I, II or III, are often insufficient. calcitonin injections subcutaneously, 5 times per week for 4 weeks are effective. To improve tolerance, they can be made in the evening after dinner, in combination with an antiemetic.
Meanwhile, a gentle rehabilitation, or infiltration of the carpal tunnel is expected.
Refractory shapes can be intravenous block buflomedil (Fonzylane®) or infusions of pamidronate (Aredia®).
Hand, particularly exposed to skin wounds, is readily prone to infections by direct inoculation. Staphylococcus aureus is the first officer; the β-hemolytic streptococcal infection can be necrotizing.
It begins with an erythematous and painful lesion around the nail, and progresses to readily overcome swelling pulp purulent blister. The pain is so insomniante, is accompanying fever, lymphangitis and regional lymphadenopathy.
At the initial stage, the treatment is based on pluriquotidiens antiseptic baths (Hexomédine® transcutaneous, for example) and a staphylococcal antibiotics per os (synergistin, oxacillin). However, if evolution is not really favorable in 48 hours, or if the patient is seen immediately at the stage of collection, the surgical drainage is immediately necessary. Indeed, always fear an evolution towards a phlegmon of the sheaths of the flexor or phalangeal osteoarthritis.
Nonsteroidal anti-inflammatory drugs are cons-indicated because they can promote the expansion of deep infection.Tetanus prophylaxis is essential.
Cellulitis synovial sheaths:
This is a diagnostic and therapeutic emergency because it can be complicated by necrosis of tendons. The infectious gateway is often local and obvious. It must be mentioned when there is pain on palpation of the proximal synovial cul-de-sac, away from the front door, and a volar edema. The finger is then contracture analgesic. Surgical exploration is necessary.
It is an infection by inoculation of Pasteurella multocida, small gram-negative bacilli, on the occasion of a bite or a cat or dog scratches. Within less than eight hours occurs edematous and extremely painful erythematous lesion; the small wound is often oozing. Antibiotic doxycycline, amoxicillin or fluoroquinolone for 8 to 10 days is indicated.
It is the most common painful vascular disease (see Raynaud’s phenomenon).
They carry a cutanéovasculaire acrosyndrome, Benin, induced by cold. This is maculopapular purple cupboards, purpuric willingly, often itchy and painful.
Affecting the young woman, they sit on the dorsal surface of the 2nd and 3rd phalanges. Their evolution is seasonal.
Treatment is primarily preventive (protection against cold), the use of nifedipine is exceptional.
It is a paroxysmal vascular peripheral vascular disease.
The condition is characterized by painful crises, type burns interesting hands (and sometimes the feet), accompanied by a rash and evolving over a few minutes or hours. Crises are readily triggered by heat or effort. Most often idiopathic, then it concerns the aged man. It may be secondary to a myeloproliferative disorder.
If Aspirin is effective in secondary forms, the primitive forms are resistant to any treatment.
These are diagnostic and therapeutic emergencies.
The pulp is the seat of a dark closet that gives way to an ulcer. The causes are multiple, covering all vasculitis and joining those of the secondary Raynaud’s phenomenon, scleroderma, lupus syndrome or antiphospholipid primitive, Buerger’s disease; essential thrombocythaemia, embolism of cholesterol crystals, complication of the use of vibrating tools, derivatives of ergot, beta blockers, vincristine, bleomycin.
Processing, in parallel to that of the underlying disease, based on calcium channel blockers (nifedipine or nicardipine), derivatives of prostacyclin and heparin.
The fracture of the uncinate process of the hamate is more frequently a stress fracture by repeated impact of a handle, a violent trauma fracture.
It will be discussed in athletes (tennis, golf, baseball) who suffers at the proximal ulnar side of the hand, and whose grip strength is diminished. On examination the pain woke up to the pressure of the proximal region of the thenar, and thwarted flexion 4th and 5th fingers.
The radiograph of the wrist supination 45 °, or the scanner in “prayer position” objective fracture.
OSTEONECROSIS OF SEMI-MOON:
Kienböch the disease should be considered in pain on the dorsum of the wrist, occurring in a young man. The lunate, located in the middle of the first row of the carpus, is almost entirely covered with cartilage and has only two small vascular holes.
The initial pain is often reported minor trauma. Then, it tends to become permanent, particularly exacerbated by the extension of the hand. It can be accompanied by a decrease in grip strength.
Clinical examination is poor, but accurate. Pain is awakened by the pressure of the “dimple crucifixion” at the base of the third metacarpal.
Radiography allows diagnosis by showing a heterogeneous bone matrix and deformed bones, according to the seniority of necrosis.
The disease progresses to osteoarthritis. MRI may be helpful to clarify the injury.
Medical treatment involves painkillers and rest by joint brace wrist. When functional impairment is significant, consider surgery. There are different techniques to get the indolence and avoid carpal collapse.
Osteoarticular inflammatory autoimmune or metabolic damage affecting willingly hand. They are easily raised when the lesions are bilateral or concerns other joints.
It is responsible for arthritis of the radiocarpal, MCP and IPP. The land (young woman) and the long morning stiffness must be able to evoke in its initial phase.
Confirmation of the diagnosis is based on immunology (FAN, Latex, Waaler-Rose, anti-CCP) and radiography (bone subchondral erosions).
It is located typically in IPD but also to IPP (finger sausage). Skin involvement and nail disorder may initially help to guide the diagnosis.
She willingly gives acute inflammatory manifestations radiocarpal and thumb column in a subject over 50 years.
Radiography research calcium border of the triangular fibrocartilage or scaphotrapézienne arthropathy.
It never manifests itself in isolation by hand. Tophi and arthropathy concern MCP, PPI and RPI.
We’re getting into a rare pathology.
The primary or secondary malignant bone tumors are exceptional hand.
This is the most common benign tumor. Developing the knuckles, she may be responsible for pain when gripping or pathological fracture.
The radiograph showed metaphyseal gap eroding the medial cortex. Surgical filling is indicated if the tumor is symptomatic.
Two other benign tumors characterized by their painful presentation, deserve mention.
This is a bone tumor consists of a nidus (osteoid tissue hypervascular) surrounded by osteosclerosis. He willingly meeting in young men, revealed by a very localized pain, spontaneous upsurge at night and relieved by aspirin.
Bone scintigraphy can guide the diagnosis will be confirmed by MRI.
It is a subungual glomus tumor neuromyoartériel.
Pain is characteristic: lively, intense, caused by the slightest pressure of the nail or thermal variation. The MRI allows the highlight.
The treatment of these tumors is surgical excision