Diseases

Hands become infected more frequently as it is one of the commonly injured parts of our body. Hand infections, if left untreated or treated improperly can cause disabilities such as stiffness, contracture, weakness, and loss of tissues (skin, nerve and bone) that persist even after the infection resolves. Therefore, prompt treatment of hand infections is important.

Infections of the hand include:

Paronychia

Paronychia is an infection of the nail fold or cuticle area present around the fingernail. Paronychia may be acute or chronic infection. Acute paronychia is a bacterial infection and causes pain, redness, and swelling around the nail. It is caused by superficial trauma that may occur during nail biting or finger sucking. It can be treated with antibiotics and if pus forms, it needs to be drained. Chronic paronychia is a result of fungal infection and it causes milder symptoms such as mild pain, redness or swelling, with little or no pus. It occurs most commonly in people whose hands are often wet or are immunocompromised. The treatment for chronic paronychia consists of avoiding constant exposure to moisture and application of topical steroid and antifungal ointments.

Felon

Felon is a serious infection of the fatty tissues of finger tips which results in throbbing pain. It is caused due to direct entry of bacteria during a penetrating injury or by spread of infection from untreated paronychia. If there is an abscess, surgical drainage is done following which antibiotics will be prescribed.

Herpetic Whitlow

Herpetic whitlow is a herpes simplex virus infection of the fingers. It is more common in healthcare workers whose hands are exposed to the patient’s saliva which may carry the virus. Herpetic whitlow presents small, swollen, painful blisters. Conservative treatment for herpetic whitlow involves application of a dry gauze dressing to the affected finger to avoid spread of infection.

Septic arthritis/osteomyelitis

Septic arthritis is a severe infection of the joint caused by a wound or a draining cyst. The bacterial infection may cause destruction of the joint by eroding away the joint cartilage. Surgical drainage should be done as soon as possible because the condition may get complicated if the infection spreads to the bone causing osteomyelitis.

Deep space infections

Deep fascial spaces are the potential spaces in between the different structures of the hand. These spaces tend to get infected through penetrating wounds or spread of infection from blood. Deep space infections may occur in the thumb, the palm or in the area between the bases of fingers. Treatment for deep space infections includes antibiotic therapy, pain relieving medications, and surgical drainage.

Tendon sheath infection

Tendon sheath infection is the infection of the flexor tendon which occurs because of a small laceration or penetrating wound on the finger, near a joint. It causes severe stiffness of the finger accompanied by redness, swelling and pain. This condition may also lead to destruction and rupture of the tendon. Therefore, it demands the immediate surgical drainage.

Atypical mycobacterial infections

Atypical mycobacterial infections are tendon sheath infections caused by an atypical mycobacterium. These infections cause stiffness and swelling without much pain and redness. Antibiotic treatment is given for several months following which surgical removal of the infected tendon sheath may be done.

Infections from bite wounds

Infections from animal or human bite are associated with bacteria such as Streptococcus and Staphylococcus, Eikenella corrodens (human bite injuries) and Pasteurella multocida (dog and cat bite injuries). These wounds are given initial treatment and left open to allow the infection to drain out. Surgical trimming of infected or crushed tissue may be done.

Kienbock's disease is a condition in which the lunate, one of the small bones of the wrist loses its blood supply leading to death of the bone. This results in pain, stiffness, and degenerative changes in the wrist joint.

The exact aetiology of Kienbock's disease is unknown. Symptoms of Kienbock's disease include

• painful and swollen wrist with decreased motion
• reduced grip strength
• difficulty or pain in turning the hand upward and
• tenderness in the area over the back of wrist near the lunate bone

Kienbock's disease can be diagnosed by reviewing your medical history and by performing a thorough physical examination of your hand and wrist. Your doctor may also order an MRI and X-rays to confirm the diagnosis.

Treatment depends upon the severity and stage of the disease. In the very early and less severe stage, treatment may involve anti-inflammatory medications or immobilisation. Your doctor may recommend surgery if the pain is not relieved with the conservative treatment. The aim of surgery is to restore the blood supply to the lunate and may involve the following:

• Revascularisation involves insertion of a vascularised graft into the lunate bone.
• Joint levelling refers to lengthening or shortening of the forearm bones (ulna and radius).
• Fusion: Wrist arthrodesis, also called wrist fusion is a procedure in which the wrist joint is stabilised or immobilised by fusing the forearm bone (radius) with the small bones of the wrist.

Tendons in your fingers connect the finger bones to finger muscles and help bend and straighten the finger at the joint when the muscles contract. Boutonnière deformity is a condition in which a tendon injury to the middle joint of the finger results in the inability to straighten the affected finger.

Boutonnière deformity can occur because of forceful trauma to the top of the middle joint when bent, laceration to the middle joint or from arthritis. Symptoms associated with this deformity may appear immediately or after a few weeks and may include swelling, pain and restricted movement. In severe cases, a fragment of the bone may be displaced from its original position.

The condition can be diagnosed by physical examination of the hand, and an X-ray may be recommended to confirm diagnosis.

Boutonnière deformity can be treated both surgically and non-surgically.

Non-surgical treatments include:

• Application of a splint to the middle joint of the affected finger to straighten it and allow the tendon to heal
• Exercises to improve the flexibility and strength of your fingers
• Protecting your finger by taping it or using protective splints
• Use of oral medications or corticosteroid injections

Surgery is performed when the injury is caused due to rheumatoid arthritis, the tendon is severed, presence of bone displacement, or if non-surgical treatments fail to provide relief. Surgical treatments improve the functioning of the finger but may not always correct the appearance depending on how soon surgery is initiated.

Arthrogryposis refers to group of non-progressive congenital disorders causing multiple joint contractures (deformities). The word congenital means that the deformities are present at birth that is they have occurred before birth.

A contracture is the limitation of movement of a specific joint. The condition is also referred to as arthrogryposis multiplex congenital (AMC).

Types of Arthrogryposis

There are four types of arthrogryposis:

• Amyoplasia
• Distal arthrogryposis
• Classic arthrogryposis
• Syndromic arthrogryposis

Amyoplasia- Amyoplasia is a congenital disorder characterized by generalized lack of muscle formation and development, with multiple joint contractures of arms and legs. It is the most common type of arthrogryposis. Infants with this disorder may have symmetric limb involvement and replacement of skeletal muscle with dense fibrous tissue and fat. The condition occurs once in every 10,000 live births.

Distal arthrogryposis - This disorder is characterized by joint contractures affecting the hands and feet with limited range of motion.

Classic arthrogryposis - The condition usually affects affect hands, wrists, elbows, shoulders, hips, feet, knees including the back and jaw thus resulting in muscle weakness and limited range of motion.

Syndromic arthrogryposis - This type of condition is characterized by involvement of internal organs, muscle and joints. Internal organ involvement results in breathing problems, problems in feeding, speech disorders and rarely mental retardation.

Causes and Risk factors

The major cause of amyoplasia is impaired foetal movements. Limitation of joint movements before birth leads to joint contractures due to the development of extra connective tissue around the joint. This connective tissue makes the joint stiff and limits its movements.

Causes of decreased foetal movements include:

• Neurologic defects including defects of the spine such spina bifida
• Muscle abnormalities such as myotonic dystrophy and myasthenia gravis
• Maternal infections such as German measles (rubella) during pregnancy
• Exposure to teratogens such as drugs, alcohol or phenytoin during pregnancy can harm the foetus
• Lack of amniotic fluid due to underproduction of fluid by the foetal kidneys or chronic leakage of fluid from the uterus can cause reduced space for the foetus to move around freely

Symptoms

Although joint contractures and associated symptoms vary from child to child, several characteristics are common and include the following:

• All the four limbs are involved

Upper extremity-

Shoulder – shoulders are sloped and rotated internally

Elbow – elbow is extended with a weak biceps resulting in loss of muscle mass giving a tapering appearance to the upper extremities

Wrist - wrists are flexed. This flexion deformity of the wrist is a typical characteristic appearance of amyoplasia.

Hand -Fingers are flexed and rigid.

Lower extremity

Hip - contractures of the hip including flexion, abduction and external rotation are common. Unilateral or bilateral dislocation of the hip may occur.

Knee- Flexion and extension contractures of the knee are seen. Subluxation or dislocation of the knee joint may occur.

Foot and Ankle - deformity of the feet such as club foot may be observed. Club foot is a congenital abnormality in which one or both feet are twisted in an abnormal position.

• Spine - scoliosis, abnormal curvature of the spine may occur
• Other abnormalities include cardiac and respiratory problems, genital problems, small immobile jaws, and cleft palate and skin defects.

Diagnosis

Your physician will diagnose the condition based on the following factors:

• Family History : Your physician will review your family history to ascertain whether the disease has affected any family members, including second degree and third-degree relatives. Your doctor may also review about the previous miscarriages.
• Pregnancy History: Your physician will ask if there was maternal fever, injury, exposure to alcohol or drugs, presence of fibroids or tumours, severe hypoxia during pregnancy.
• Delivery History- Your doctor will ask about the presentation of the foetus at the time of birth (head-first or feet- first) and the difficulty level during delivery due to fixed joints.
• Physical Examination: Your doctor will perform a careful physical examination of the joints.
• Photographs : photographs may be taken to document the extent of the deformities, which can be used as a reference to track your progress during treatment.
• Radiographs : radiographs are used to evaluate skeletal and joint abnormalities.
• Ultrasonography, CT scan and MRI may be used to evaluate the abnormalities of the central nervous system and the muscle mass.
• Pre-natal ultrasonography can be done to know the foetal movement's position and the amount of amniotic fluid.
• Additional tests, including blood test , muscle biopsy and other imaging studies help to confirm the diagnosis.

Muscle biopsy is done to differentiate neuropathic and myopathic disorders. It is a procedure in which a piece of muscle tissue is removed and examined under the microscope. Amyoplasia shows fatty and fibrous replacement of the tissues.

Treatment

There is no complete cure for arthrogryposis, however starting vigorous physical therapy as early as possible helps to stretch contractures and strengthen the weak muscles. This improves joint motion and avoids muscle atrophy.

Physical therapy- Physical therapy improves muscle strength and function thus increasing the range of motion of affected joints.

Splinting- Splinting along with physical therapy may help to improve joint motion. Splinting after the surgery may be indicated to maintain full range of motion.

Surgical intervention is often necessary and should be performed at early age of 3 to 12 months. The goal of surgery is to eliminate pain, improve mobility and halt progression of condition.

Surgery may be indicated to correct the various joint deformities occurring in conjunction with arthrogryposis.

Complex regional pain syndrome (CRPS) is a chronic pain condition characterised by severe pain, swelling and changes in the skin. It usually affects the arms, hands, legs or feet. It is also known as reflex sympathetic dystrophy or causalgia. It usually begins after trauma such as an injury to the tissue, bone or nerves of your limb.

Causes

The exact cause of CRPS is not known, however certain theories suggest that in some cases the sympathetic nervous system plays an important role in sustaining the pain. It may also be caused by triggering the immune response, which can result in inflammatory symptoms of redness, warmth, and swelling in the affected area.

There are two forms of CRPS based on different causes: CRPS I is triggered by a soft tissue injury, where nerve damage is not the primary cause;

Whereas, CRPS II is triggered by damage to a nerve.

Symptoms

The main symptom of CRPS is intense, burning pain that feels much worse than the injury and continues long after the injury has healed. Your skin colour may change to red, blue or white. The skin over the affected area may become tender, thin or shiny and sensitive to hot or cold temperatures. You may also have muscle spasms, joint stiffness, and severe limited mobility in the affected area.

Diagnosis

Diagnosis of complex regional pain syndrome is based on your medical history and physical examination. The best way to diagnose and treat CRPS is through a sympathetic block of the affected nerve plexus. The injected anaesthetic should numb the affected extremity. Pain relief and improved temperature of the extremity is a positive diagnostic test for CRPS.

Treatment Options

Treatment is aimed at relieving painful symptoms so that people can resume their normal lives. The following treatment options are often used:

Physical therapy to help decrease pain and improve range of motion and strength. Medications including pain relievers, corticosteroids, bone-loss medications, antidepressants and anticonvulsants. Cognitive behavioural therapy or psychotherapy can also be useful in helping you cope better with the pain. Sympathetic nerve blocks: A nerve block is an injection of local anaesthetics into a group of nerves around the spinal column to provide relief from the pain and discomfort. Intrathecal drug pump: In this technique a external pump and implanted catheters may be used to administer pain-relieving medication into the spinal fluid to provide relief. Spinal cord stimulation: This involves placement of stimulating electrodes next to the spinal cord. A small electrical current delivered to the spinal cord provides a pleasant tingling sensation to the painful area. Surgical sympathectomy: It is a surgical technique that destroys the nerves involved in CRPS.