The Hand

The Hand

1. Synovial Joints in hand

   • Radiocarpal
     • Type: Ellipsoid
   • Intercarpal
     • Type: Plane
   • Carpometacarpal
     • Thumb
       • Type: Saddle
     • Medial 4 fingers
       • Type: Ellipsoid
   • Metacarpophalangeal
     • Thumb
       • Type: Hinge
     • Medial 4 fingers
       • Type: Ellipsoid
   • Interphalangeal
     • Type: Hinge
   • Inflammation of joints
     • Arthritis of 3 or more joints
       • Rheumatoid Arthritis
         • Diagnostic criteria for 4 or more symptoms for a duration of 6 or more weeks
           • Morning Stiffness for more than 1 hr
             • due to an increase in inflammatory edema in the early morning
           • Rheumatoid nodules
           • RF +
           • Radiological erosions
         • autoimmune disease
         • Characteristic deformity
         • Histological Appearance
           • hyperplasia of synoviocytes
             • Papillary forms
         • Diagnosis
           • 1. Medical History
           • 2. Physical Examination
             • Look, Feel& Move
           • 3. Investigations
             • Diagnositic Lab tests
               • ESR
               • Latex test and rheumatoid factor
               • C-Reactive protein
         • Genetic, epigenetic and environmental factors
           • link with MHC class II gene; HLADR4 and HLA-DR1
         • Chronic Inflammation
           • accompanied by anemia.
         • Stages
           • Early
             • swelling
             • para articular effusion
             • osteoporosis
             • deossification
           • Late
             • destruction of cartilage
             • bone erosion
             • ankylosis
             • deformity
         • Radiograph of rheumatoid of arthritis hand
         • Complications
           • Peripheral Neuropathy
           • Infections
           • Eye problems
           • Vasculitis
           • secondary amyloidosis
         • occurs at twice the rate in women compared with men
         • Management
           • NSAIDs
             • inhibit cox enzyme
               • so Prostaglandins aren't produced
                 • Inflammation suppressed
               • types of cox enxyme
                 • cox 1
                   • present in all cells- constitutational
                 • cox 2
                   • present in inflammatory cells
             • analgasic, anti-inflammatory, antipyretic
             • GI & Renal side effects, hypersensitivity, CVD risk
           • DMARDs
             • Reduce progression of disease, joint damage & deformity
           • Physiotherapy
           • Intermittent Splinting
             • to rest and support weakened joint structures
             • to help decrease inflammation
             • to properly position joints
           • Biological therapies
             • TNF inhibitors
             • non-TNF biological therapy
           • Glucocorticoids
         • Pathogenesis
           • 1. Activation of CD4+ Helper-Tcell
           • 2. Th1/Th17 phenotype secrete IFN & IL-17
           • 3. Macrophages and secrete TNF
             • resulting in cartilage destruction via effects on chondrocytes
             • release matrix metalloproteinases
           • 4. B cell activation lead to release of Rheumatoid factors
           • 5. Recruit of neutrophils
         • HALLMARK: PANNUS FORMATION
     • Arthritis of hand joints
     • Symmetrical arthirits
   • Synovial fluid
     • secreted from the synovial membrane
     • Composition
       • Proteins, Hyaluronan, lubricin
     • Function
       • reduction of friction , shock absorption , nutrient and waste transportation

2. Anatomy of the hand

   • Bones
   • Ligaments
     • Anterior & Posterior radio-carpal ligaments
     • Radial Collateral Ligament
     • Ulnar Collateral Ligament
     • Intercarpal Ligament
   • Movements
     • Wrist
       • Ulnar & Radial deviation
       • Flexion &Extension
     • Fingers
       • flexion & extension
       • abduction & adduction
     • Thumb
       • opposition
   • Flexor retiniculum
     • a strong band that cover over the carpal groove, turing it into carpal tunnel
     • Passes deep to it:
       • Tendons of flexor digitorum (superficialis and Profundas)
       • Tendon of flexor pollicis longus
       • Tendon of flexor Carpi radialis
       • Flexor Synovial Shealths
         • Covered by
           • Fibrous sheath
             • Protects the tendons from pulling out
             • Keep tendons & its synovial sheaths in place
     • Superficial to it are:
       • Palmaris Longus tendon
   • Intrinsic Muscles
     • 20 muscles
       • 1st layer
         • thenar muscle
         • Hypothenar
       • 2nd layer
         • Opponens of thenar & hypothenar
       • 3rd layer
         • 4 Lumbricals
       • 4rth layer
         • Palmar Interossei
         • Dorsal Interossei

3. Blood Supply

   • superficial palmar arch
     • mainly by ulnar artery
   • deep palmar branch
     • mainly by radial artery

4. Nerve supply

   • Median Nerve
     • Cutaneous innervation
       • Lateral 2/3 of the palm + lateral 3 1/2 fingers + their nail beds
     • supply 3 thenar muscles + 1st & 2nd lumbricals
     • Its compression in carpal tunnes
       • Carpal Tunnel Syndrome
   • Ulnar Nerve
     • Cutaneous innervation
       • medial 2/3 of the palm & dorsum + medial 11/2 fingers
     • supplies all intrinsic muscles
       • except
   • Radial Nerve
     • Cutaneous innervation
       • lateral 2/3 of the dorsum of hand + lateral 3 1/2 fingers.

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