The hand

Dupuytrens contracture 1 1 0 Vibration syndromes 1 i 0 Tendon and tendon sheath lesions 1 1 1 Rheumatoid arthritis 1 1 2

Osteoarthritis of the interphalangea joints 1 1 3

Carpometacarpal joint of the thumb 113

Tumours in the hand 1 1 3 Infections in the hand 1 14 Inspection 115-123 Movements T 19-123 Vibration syndromes 123 Assessing hand circulation 1 23 Tendon injuries 123-124 Infections 124-125 Assessing hand function 1 25-1 26 Pathology 126-127

Note that the separation of conditions into those affecting the wrist and those affecting the hand has been done for convenience, and that in many cases examination of both regions is necessary.

dupuytren's contracture _

In this condition there is nodular thickening and a contracture of the palmar fascia. The palm of the hand is affected first, followed at a later stage by the fingers. The ring finger is most frequently involved, followed by the little and middle fingers. The index and even the thumb may be affected. In some cases there is corresponding thickening of the plantar fascia. The progressive flexion of the affected fingers interferes with the function of the hand and may be so severe that the fingernails dig into the palm. The condition mainly affects men over the age of 40. There is a definite genetic predisposition in 60-70% of cases, and in some cases there may be an association with epilepsy, diabetes or alcoholic cirrhosis. There is a distinct geographical distribution: it is rare in Africa, India and China. Below the age of 40, and in either sex, its onset may be precipitated by trauma. Under these circumstances it may pursue a particularly rapid course.

As far as treatment is concerned, a waiting policy may be pursued if the condition is confined to the palms. When the fingers are affected surgical treatment is usually advised, but this is complicated by a number of factors. If the fingers have been held in a flexed position for a long time, secondary changes in the interphalangeal joints may prevent finger extension even after the involved tissue has been removed. In the case of the little finger, amputation in these circumstances may be the best line of treatment. The digital nerve sheaths may blend with the fascia so that dissection is tedious and difficult; involvement of the skin may necessitate Z-plasties or other plastic procedures; and the patient's age and general health may be adverse factors. In most cases wide excision of the affected fascia is advised. When this is not possible, improvement in function, often lasting for some years, may follow simple division of the contracted fascia in the palm.

vibration syndromes__

Prolonged exposure to high-frequency vibration (such as may be experienced from the use of jack hammers or handheld buffing, riveting and caulking machines) may affect bone, nerves and blood vessels. Bone is rarely affected to a significant degree, but new bone formation and hairline fractures (which are slow to heal) are sometimes seen. Involvement of the peripheral nerves may lead to pain and paraesthesia, numbness, tremor, loss of fine touch sensation, proprioception and discrimination. There may be muscle denervation and weakness involving especially the small muscles of the hand. In the case of the peripheral blood vessels there is disturbance of their autonomic control, and the arterioles of the hand become hypersensitive to cold and vibration. In the typical case there are attacks in which one or more fingers turn white on exposure to cold ('episodic blanching'), with reactive hyperaemia on warming; and there is usually associated discomfort and clumsiness of the hand during attacks. As the condition progresses more fingers become involved, incidents occur both in summer and in winter, and hand function becomes permanently disturbed. The hand becomes weak and clumsy, and with impaired sensation and proprioception the patient has difficulty in dressing (e.g. doing up buttons and shoelaces), handling small objects (e.g. coins, nuts and screws), and carrying out many other tasks (e.g. tying fishing hooks). The differential diagnosis includes Raynaud's disease, cervical rib and the costoclavicular syndrome, cervical spondylosis, and sensitivity to p-blockers.

There are a number of classifications of the stages of the condition, and the long-established Taylor-Pelmear scale is still widely used (Table 7.1). Well established cases are recognized as one of the prescribed diseases under the Social Security Act, and the qualifying criteria are clearly stated. (The condition must occur throughout the year, involve at least three fingers of one hand (with the middle and/or proximal phalanges being affected), and be due to exposure to vibrating tools.) No treatment is effective, but deterioration may be slowed or prevented by avoiding further exposure to vibration.

Table 7.1 The Taylor-Pelmear Scale

Stage

Condition of digits

Work and social interference

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