The Wrist and the hand

1. The Wrist and the hand Dr BakhtyarBaram

2. Congenitalanomalies of the wrist and the hand • The most importantaim in the treatment is to gain the function of the hand. • In Embryo ,by 6 weeks the digital raysbegin to appear,afterthatmodellingof the limbs and the formation of joints and separate digits. Complitted by 8th week. • Mallformationmayoccureduringembryonicdevelopmentbecause of eitherdefective formation or incoomplete separation of mesenchymal components. • 2 in every 1000 has deformity. • It is important to gain the confidence of the family and rememberthat the childrenarelikely to be long term pt.s. • They must be given a diagnosis and idication of prognosis, reassurance about the future and long term plan.. • Examination in a childfriendlysettingmaybe in parent s lap. Toys. • May be part of alargesyndrome, or genetic problem.

3. Indications for operative treatment • Function, using it in everyday, howimportant. • Progression of deformity, • Appearance, self-confidence, the childwillhide it. • Pain, likeconstruction ring syndrome.

4. Failure of formation • Transverse arrest, maybe in proximalforearm, protheseswhenadult or fingers • Longitudinal arrest, • Radial dysplasiawhich is rare and it maybeapart of otherassosiateddisease. And the treatment if it is mild just learn the parrentsgentlestretching. Or surgicalsofttissuecorrection, attension must bepaid to the deformity of the elbow joint in the same time. • Ulnardysplasialmost same but surgerylitteldifferent. • Central dysplasia,vshapedcleft in the hand, maybeassosiated with one or more fingers.

5. Failureof differentiation • Syndactyly, conjoineddigits is the commonest type, maybe simple onlysofttissue or complex ,skin and bone, or completewhichaffecting the entire web or incompletewhichaffect part of the web. In central digigitsmayneednotreatmering but in the border digitslikethumb to index or littel to ring finger maycause progressive deformity and surgerywillbeindicated in the early age. • Camptodactyly, bent finger is a flexiondeformity of the pip joint usuallylittle finger. Splinting or surgerymaybeindicated. • Duplication, polydactyly or extradigit, common in the littel finger canbe removed easy in first 4 monthes, • Overgrowth, or macrodactyly, must bedistinguished from othercauseslike in neurofibromatosis, • Undergrothbrachydactyly, common,surgerylikeoppostion transfer.

6. Ganglioncysts • Verycommon, arises from leakage of synovial fluid from ajoint or atendon and contains a glairy , viscous fluid. • Back of the wrist is the commonest type, a painlessswelling or lump, welldefined and not move. Sometimescausingcompression on the nerves like on the deepbranch of ulnar nerve. • Normallynotreatment, but it is indicatedwhenthere is sign of compression or cosmotic • Recurrence is possibleafter the operation.

7. De quervain s disease • Caused by thickening of the firstextensorcompartmentsheath on the extensorpollicisbrevis and abductorpollicislongus. • Middel agedwomencomplain of pain on the radial side of the wrist ,theremaybehistory of hard or ubnormalactivity, ,there is tenderness on the radial stylodid and maybeswelling. • Finkelsteins sign is pathognomotic, hold the pt thumb in fullflexion and turn the wrist to adduction the pt feel sharppain and tenderness in thatarea. • DD is arthritis in the basis of thumb or scaphoid non union or intersectionsyndrome. • Treatment by localcortisoninjection, ,ultrasoun or splintagecanbeused • Or surgerywhich is slitting of the thckenedsheath, care must betaken to the dorsalsensorybranch of the radial nerve

8. Other cases of tenosynovitis or tenovaginitislike in intersectionsyndromewhich is pain and swelling over the tendons of ofextensorpollicisbrevis and abductorpollicislongusproximal to the site of de quervainsdisease.mostlyweight lifter and even rest og cortisoninjection or surgery in widening of secondcompartment. • Other types is in extensorcarpi radialis brevis at the commonextensorcompartment by trauma • In flexor region mostly in flexorcarpi radialis and ulnaris. • All of them has relation to the occupation and hardwork, need rest og antiinflammatorymedicine , cortisoninjecion, splintage or surgery.

9. osteoarthritis • In the wrist , normallyafter trauma or fracture or maybeafterrhumaticdiseases. Or lunatummalacia.normally all syptoms and signs of osteoarthritiscanbeseenlikepain and tenderness and limitedmovement and in x raysclerosing with narrowing of joint spaceosteophute and joint distruction.treatment is splintage , antiinflammotorymedicine , arthrodese or joint replacement • In the basis of the firstmetacarpal bone is commonespicallymiddelagedwomen or older , tenderness in the region with pain in movement , cortisonilocalinjection or tendoninterpositionsarthroplastic. • DIP joint OA, same, arthrodese is one of the goodtreatment. • Pisiform bone, tenderness TULNART AND VOLART SIDE ,removal of the bone withoutaffectingflexorcarpiulnaristendon.