History

The symptoms of arterial insufficiency include: intermittent claudication; rest pain; acute ischaemic pain of the limb; acute onset of weakness; ulceration and gangrene; and Raynaud’s phenomenon.

Examination

2 Palpation

The leg with arterial ischaemia is cool, a sign that is emphasised by comparison with the other side. Skin temperature is best appreciated by palpation using the sensitive thin skin over the dorsum of the middle phalanges (Fig 6.1). Diminished capillary return is present if more than two seconds is taken for colour to return after finger pressure is applied to the big toe.

Figure 6.1 Temperature change detected by applying the thin skin of the dorsal surface of the fingers to the lesions

The peripheral pulses in the affected limb are diminished or absent. The dorsalis pedis artery runs from a point midway between the malleoli to the space between the first and second metatarsal bones and is just lateral to the extensor hallucis longus on the forefoot. The dorsalis pedis may be absent in 5–10% of the population and its place may be taken by a branch of the peroneal artery. The pulse will then be felt more laterally. The posterior tibial artery is found in the soft tissue groove below and behind the medial malleolus, halfway between it and the Achilles tendon. The popliteal pulse is the most difficult to find and is best palpated in the lower popliteal fossa with the knee passively flexed. Beware that an easily felt popliteal pulse is often a sign of a pathologically enlarged popliteal artery. The femoral pulse is usually easily palpable in the groin at the midinguinal point (Fig 6.2). The effects of exercise on the appearance of the limb and on distal pulses should be assessed. In moderately severe disease, palpable pulses may disappear on exercise. It is also important to remember the surface landmarks for the various pulses in situations of ‘extremis’ when pulses may be very weak. The abdominal aorta and iliac vessels should also be examined.

Figure 6.2 The midinguinal point

A: lies halfway between the anterior superior iliac spine (1) and symphysis pubis (2) the deep inguinal ring; B: lies above the midpoint of the inguinal ligament which attaches to the pubic tubercle (3); C: common femoral artery; D: common femoral vein; E: saphenous opening; F: great saphenous vein

History

Symptoms of presentation of venous disease include varicose veins, swelling and oedema, pain on standing, ulceration and superficial venous thrombophlebitis.

Examination

History

Symptoms of neurological disease include paralysis, anaesthesia (to pain, light touch and temperature) and paraesthesia.

Examination

The aim on examination is to detect the site of a neurological lesion by evaluating disordered function. Neurological examination of the limbs commences with inspection and proceeds to assessment of motor nerve function, sensory nerve function and reflex functions. Assessment of gait and of other coordinated movements is an important component of the examination.

History

Symptoms of musculoskeletal disorders include joint pain, swelling (bony, joint and muscle swellings), locking or instability and deformity.

Examination

Each musculoskeletal segment, that is, the site of the presenting problem (e.g. shoulder pain) is examined fully (as described in that section) before moving on to complete the examination, which always follows the sequence: look, feel, measure, move. It is summarised below.

2 Palpation

There is a temptation to commence this part of the process by poking the painful area — something best avoided until closer to the end of the examination. Signs of heat, tenderness, swelling or oedema are noted by a hand laid gently onto the affected limb segment. Any localised swelling is noted and its physical characteristics recorded. In the supine patient, one leg may appear to be shorter than the other (apparent shortening — measured from the malleolus to a fixed point on the trunk such as the umbilicus). True shortening of the limb is established by comparing the distance on both sides from the tip of the medial malleolus to a fixed point on the bony pelvis — the anterior superior iliac spine. Accurate measurement of true shortening requires that the joints of both limbs be in an identical position, with the pelvis square to the sagittal plane and both iliac spines at right angles to the line of the spine (Fig 6.3). A fixed abduction or adduction deformity of one limb can cause apparent lengthening or shortening of that side — true shortening is checked after placing the opposite limb in a similar position of abduction or adduction. True shortening is often due to hip disease. The level can be simply and rapidly demonstrated by the disparity in span shown on bilateral palpation of the hip joint — placing the thumb on the anterior superior iliac spine and the middle finger on the greater trochanter and measuring by eye any disparity in distance between these digits on each side.

Figure 6.3 Apparent and true shortening

A: adduction deformity of the left leg. The legs are kept in line by pelvic tilt and the leg is apparently short (measured from umbilicus); B: when the pelvis is set square and the legs are matched for position the difference in length disappears; C: true shortening of the left leg (measured from ASIS) at hip or femoral neck. Measured with pelvis square and legs matched for position.

1 Callus formation

The most common cause of a bony tumour is exuberant callus formation at a fracture site. In most cases there is a history of injury, but sometimes a palpable callus is felt to develop after some weeks of pain from a spontaneous fracture. It is the latter group where diagnosis may be a problem. The most common sites are rib after paroxysmal coughing, second metatarsal bone after a long walk (‘March fracture’) and the upper end of the tibia (‘Recruit’s fracture’). Examination reveals a relatively nontender fusiform enlargement of the bone. The diagnosis is, as a rule, made easily on X-ray.

Myositis ossificans. Patients with myositis ossificans usually present with a painful bony swelling dating from an episode of definite trauma. However, the marked calcification and sometimes ossification of muscle may be confusing. The muscles most often affected are the brachialis and the quadriceps femoris after severe injuries of the distal arm and thigh. The ossification occurs in the bulk of the muscle and is fixed to the underlying bone. Unlike malignant processes the condition becomes less symptomatic with new bone becoming better defined.

Traumatic subperiosteal haematomas may also calcify. This diagnosis usually presents no difficulty as the swelling is localised and the X-ray shows normal dense bone with increase in thickness of the cortex alone.

2 Acute osteomyelitis

Most cases of acute osteomyelitis occur during or before adolescence. The presentation is typical of an acute inflammatory condition — in adults it is often in the setting of immunosuppression. The precise anatomical site of the lesion may be difficult to determine, but on examination a hot, tender, oedematous swelling is usually found at the end of a long bone, particularly about the knee. The organisms usually lodge in the metaphysis of the bone. There is associated systemic toxicity. The differential diagnosis is from cellulitis of soft tissue, an acute inflammatory noninfective joint lesion and, if the condition is less acute in its onset, osteosarcoma. Diagnosis is more difficult if the patient presents during the chronic phase of the disease.

The causative organism is usually one of the Gram-positive cocci such as Staphylococcus aureus or Streptococcus pyogenes. Haemophilus is becoming less common with recent advances in immunisation. Gram-negative organisms such as Escherichia coli and Pseudomonas aeruginosa must also be considered at the extremes of age, the immunosuppressed and when clinical response to treatment is not as expected. A subacute or chronic abscess (Brodie’s abscess) usually also involves the end of a long bone and manifests as a mildly tender, palpable bony thickening. As well as osteogenic sarcoma, tuberculosis must also be excluded.

X-rays show a central area of rarefaction, surrounding sclerosis of bone and deposition of subperiosteal new bone. Within about two weeks of the onset of acute osteomyelitis, an area of sclerotic dead bone (sequestrum) will appear in the central area of rarefaction (Fig 6.5). However, X-rays may not show any abnormal features in the first few days of the disease process.

Figure 6.5 Bone infection commonly starts in the metaphysis below the epiphyseal plate

A: the plate acts as a barrier to spread into the joint; B: spread through the cortex forms a subperiosteal abscess; C: stripping of the periosteum interrupts the blood supply to the cortex, which forms a sequestrum; the sequestrum froms a nidus for chronic ostemyelitis

3 Osteosarcoma

Most cases of osteosarcoma (osteogenic sarcoma) occur before the age of 25 years. Occasionally osteosarcoma occurs in the aged patient as a complication of Paget’s disease of bone. Osteosarcomas may also arise in bone that has been irradiated for other reasons. A painful bony lump is the predominant symptom. The onset is usually gradual, with a progressive increase in pain, a variable degree of swelling, local heat, venous engorgement and tenderness. Most sarcomas develop in the medullary cavity near the metaphysis of a major long bone; half lie in the region of the knee. A history of previous trauma may be given, that is, either incidental to the underlying process or has precipitated a pathological fracture. Palpation usually reveals a swelling close to the knee without detectable joint disease and with free joint movement.

The tumour felt is frequently much larger than the changes in bone demonstrable on X-ray. The interpretation of the X-ray can be difficult as the findings are variable depending upon the amount of osteolysis or osteosclerosis within the tumour. There is a loss of the normal bone trabecular pattern in the area of concern, combined with destruction of the cortical wall and elevation of the periosteum and extension into the surrounding soft tissues. A radiographic sign termed a Codman’s triangle is often associated with this tumour. It is a triangular area of subperiosteal new bone formation near the cortical margin of the tumour. Bony spicules are laid down perpendicular to the normal surface and may produce a sun-ray or ‘sunburst’ appearance. There is often a large soft tissue component, which is evident on the imaging. In some instances there may be little or no bony reaction, only irregular lysis of the cortex of the bone. The histological picture can also be indefinite and experienced assessment is essential. It may be difficult to make a diagnosis from an inflammatory cause, even with histology.

4 Giant cell tumour of bone

Giant cell tumours occur mostly around the knee joint and sometimes at the lower end of the radius. Most present with pain and swelling in patients between the ages of 25 and 50 years. A mass in bone may sometimes be the sole symptom. The tumour is usually easily palpable. In advanced cases, the outer bony shell of the tumour becomes so thin that eggshell crackling can be detected. It is an aggressive, locally recurrent tumour with low metastatic potential. In about half the cases the clinical behaviour of the tumour is benign, in about a third there is local aggressive behaviour and the remainder are frankly malignant with early metastasis. About 80% appear in the long bones after skeletal maturity and 75% occur around the knee joint. It usually affects the bone in the region of the epiphysis. On X-ray, an asymmetrically located osteolytic focus is seen within the bone, with expansion of the cortex and cortical erosion. Roughly spherical, foam-like areas can be seen in the cancellous bone in the distal metaphysis. Differential diagnosis on X-ray is from simple bone cysts. In simple bone cysts the age of onset is earlier and the bone expansion and destruction is much less marked.

5 Fibrosarcoma

Fibrosarcoma is a rare, malignant tumour of fibrous tissue, muscle or sometimes periosteum, which is often confused with a primary bone tumour. Fibrosarcoma occurs in middle age. A history of a lump is often of longstanding. Patients usually present because of slow growth of a lump in a limb muscle that interferes with muscle function. On examination the lesion can appear to be fixed to the bone. The consistency of the lump is firm, rather than hard. Eventually, fibrosarcoma forms a large and asymmetrical lesion, much larger than the X-ray findings, in contrast to many bone tumours. With the rarer periosteal fibrosarcoma there can be radiological evidence of periosteal elevation with developing erosion into the cortex. Pathological fracture is common (30%).

6 Chondrosarcoma

Chondrosarcoma occurs mainly during middle age — half of all chondrosarcomas occur in people over the age of 40. Presentation is a mass in the epiphyseal area of the major long bones and in flat bones such as the ilium. Most cartilaginous tumours are benign; however, when associated with rapid increases in growth and pain, one must be mindful of an underlying condrosarcoma rather than a benign cartilage lesion. X-ray reveals areas of mottled translucency in the epiphysis with a demarcating line of sclerotic bone around the tumour.

7 Metastatic carcinoma

Secondaries are a relatively uncommon cause of painful bony swelling. However, they are the most common bone tumour in patients over the age of 40. The major primary sites that commonly metastasise to bone include a lung, breast, prostate, kidney and thyroid. The vast majority of metastases in bone present with bone pain rather than swelling and a minority present with spontaneous fracture. Kidney and thyroid secondaries are the ones most likely to produce swelling as well as pain. The patient often has a past history of the primary tumour and its treatment, such as mastectomy for carcinoma of the breast. Sometimes symptoms of the primary tumour and its metastases may be synchronous. Approximately 10% of patients with cancer present with bony metastases as the first sign of disease. Some metastases, such as from the kidney, may be so vascular that they resemble an aneurysm. The common sites of metastasis are areas of bone marrow formation such as skull, clavicle, rib, vertebrae and upper femur and humerus. Local radiotherapy will often relieve bone pain. Lesions in long bones resulting in extensive cortical destruction and pain may often require an orthopaedic opinion regarding prophylactic surgery in order to prevent fracture.

8 Less common causes

Hydatid disease is an unusual cause of bone swelling that is almost impossible to treat successfully and may eventually require amputation.

Myeloma. The outstanding symptom is bone pain at multiple sites, without swelling. Occasionally myeloma will present as a lump in the bone. Focal lesions are seen on X-ray as circumscribed punched-out areas of rarefaction with minimal local sclerosis; only occasionally is there cortical expansion.

Osteomas occur in children and adolescents as longstanding, small, exquisitely tender tumours mainly affecting the femur and upper tibia. The pain sometimes precedes the appearance of radiographic changes. Nocturnal pain and pain relieved by salicylates are prominent and characteristic symptoms. On X-ray the lesion is densely sclerotic with a radiolucent centre. Treatment is by surgical removal. More recently advances in image-guided radiofrequency ablation have provided a less invasive means of effecting a cure.

Enchondromas may be solitary or multiple (Ollier’s disease). Presenting complaints include tender swellings of the bones of the hands and feet. They are rarely painful unless there has been a pathological fracture. They have been reported in most bones. On X-ray there may be multiple, mottled, translucent lesions with cortical expansion but not erosion. Treatment is by curettage often combined with bone grafting. Lesions in flat bones may be locally invasive in their behaviour.

Reticulum cell (Ewing’s) sarcoma presents as a painful, tender swelling of the shaft of a long bone in young adults or adolescents. However, it is prudent to remember that in approximately 20% of cases the lesion is found in the innominate bone. It is rarely found in individuals aged under five or over 30 years old. Later these lesions are associated with systemic toxicity. X-ray shows the characteristic ‘onion peel’ appearance of subperiosteal lamination in the mid-long bone. A soft tissue mass over the area involved indicates soft tissue involvement. In the past the outcomes of treatment were disappointing with low medium-term survival rates. However, the advent and advances in chemotherapy have improved the outlook. Treatment is usually radiotherapy and chemotherapy.

Chondromyxoid fibroma occurs in young adults, mainly in the metaphysis of long bones. The X-ray findings are not characteristic and treatment is by curettage after biopsy confirmation of the diagnosis.

Tuberculosis of the bone has an insidiously mild onset, with the development of painful bony swelling. Mild systemic toxicity and joint involvement are common, in contrast to tumours of bone. As tissue necrosis and caseation are common, abscess formation with spontaneous external drainage can lead to chronic sinus formation. If the joint is involved the synovium becomes thick and oedematous giving rise to an effusion. The pannus slowly destroys the articular cartilage with active bone erosion often also occurring at the edges of the joint leading to the characteristic, yet seldom seen, radiographic appearance of periarticular osteopenia. Diagnosis depends upon isolation of acid-fast bacilli from biopsy specimens. This often requires protracted culture in specific culture media. When the lesion is limited to the metaphysis of bone, it appears as single or multilocular cysts surrounded by sclerotic bone. Initial treatment is conservative, using antituberculous antibiotics.

Causes

Cause

Clinical features, diagnostic and treatment plans

Muscle swellings

1 Muscle rupture

Muscle rupture in youthful and adult patients is often due to sporting injuries. Spontaneous rupture of certain skeletal muscles, tendons and aponeurosis is also common after trivial or unnoticed strain. Degenerative wear and tear with age makes elder patients especially liable to spontaneous rupture during sport. Muscle rupture presents as a lump of bunched-up fibres that is emphasised by contraction.

Sometimes, with deeper muscles not accessible to palpation or with spontaneous tendon rupture distant from the muscle, patients present with muscle weakness or disability or a limp rather than with a lump. Biceps brachii (long head), Achilles tendon, supraspinatus (rotator cuff) and quadriceps femoris are common muscles involved. Affected characteristics of visible muscles are a tender hollow defect and deformity of the muscle at rest, with an indistinct edge adjacent to the lump. On contraction, the lump moves with the muscle and is made more prominent. Weakness and pain are present when muscle power is tested.

Ruptured long head of biceps brachii tendon. The patient is usually over 50 years; however, the injury may also occur in an athlete performing a large amount of weight training such as bench-press activities. Rupture in the older age group is usually secondary to degenerative weakness and the long head, with its complex intracapsular course over the humeral head, is particularly at risk. The patient may have felt something snap while lifting or flexing the elbow but may not have noted a precipitating event. The clinical picture is unmistakable (Fig 6.8). The belly of the muscle is distorted, looks lower than the other side, does not tighten properly on contraction and is round or semicircular in shape rather than fusiform and ovoid. Shoulder and elbow movements are free and painless — apart from evidence of degenerative joint disease or, occasionally, rheumatoid arthritis. In the younger athlete, sometimes pain may be reproduced by passive stretching of the biceps (Speed’s test) or resisted active contraction (Yergason’s test). While active treatment in either case is rarely required, there is an increasing tendency to repair proximal ruptures in the younger, high-performance athlete. Occasionally the biceps are avulsed from their distal (radial) insertion — this is usually a more acute and painful injury from lifting heavy weights and the muscle belly retracts to a higher position and sometimes requires repair to the bicipital tuberosity in order to preserve full motor power in the younger person.

Figure 6.8 Ruptured long head of biceps brachii

Ruptured Achilles tendon. This injury is common in middle-aged squash players. It classically occurs in athletes in their 30s and 40s. The sufferer feels acute pain in the lower calf or ankle and may fall to the ground thinking he has been struck by a squash racquet. The examination findings are almost diagnostic. There is a tender defect palpable in the muscle just above the insertion of the tendo achilles into the calcaneum, with a painful tender lump above it. Active flexion of the ankle is painful and limited. The patient should not be able to stand on his toes and the foot should be able to be passively hyperextended; however, the latter signs are seldom elicited due to pain. Local bruising is not uncommon.

Complete rupture is best treated by operative repair. This is associated with 27% lower re-rupture rate compared with non-operative means. Incomplete rupture or rupture in the older patient may be treated conservatively. In this case healing with elongation is not uncommon, giving signs of a firm ovoid lump in the tendo achilles, hyperextension of the foot and weakness of plantar flexion. However, it does avoid an 11% risk of complications such as infection and adhesions between the tendon and the skin.

Supraspinatus (rotator cuff) rupture. This can accompany shoulder injuries such as dislocation or lifting strains. A degenerative rotator cuff in patients over 45 years is more prone to rupture. Active abduction of the shoulder is impaired or not possible, despite an actively contracting deltoid. The shoulder hunches laterally on attempts by the patient to initiate abduction. If the arm is passively elevated through the painful arc, it can be maintained above the head by action of deltoid and the remaining muscles (see Ch 6.4). The treatment of this pathology should include treatment of the tendinopathy and treatment of the associated bony abnormalities. The lateral edge of the acromion may impinge on the rotator cuff during active abduction of the shoulder. Surgical repair of complete rupture is the standard in young patients. In older patients a corticosteroid injection into the subacromial space combined with an exercise program to strengthen the rotator cuff and the periscapular muscles may be all that is required. Surgery in older patients is mainly for the pain-relief associated with alleviating impingement rather than gains in muscle power.

Quadriceps femoris. Rupture classically occurs just above the patella at the junction of the vastus intermedius with its tendon, due to resisted extension strain. This usually occurs in older patients but may occasionally occur in weightlifters during their deeper squats. There is a tender defect and lump at this site — knee extension is weakened but not usually absent. Surgical repair is indicated for major ruptures.

Sternomastoid ‘tumour’. Tearing of sternomastoid muscle fibres can occur in infants, causing a sternomastoid muscle ‘tumour’ with muscle spasm and torticollis (wry neck). The wry neck is seldom visible at birth. Usually within a week or two the parents notice a lump at the lower end of the sternomastoid muscle with the head being held asymmetrically and persistently rotated to one side. As the child spends more time on the one side the face and occiput become more flattened on that side. Treatment is predominantly conservative, with gentle stretching exercises supervised by a paediatric physiotherapist. It is prudent to ask for an orthopaedic opinion in order to exclude congenital cervical vertebral anomalies. The syndrome can also occur in older children and adults. In older children inflammatory conditions of surrounding soft tissue structures, optical disorders and rotatory subluxation of the C1 vertebra on the C2 vertebra are the most common casues. In adults it is more commonly due to a nearby inflammatory lymph node swelling.

Rupture of other tendons. Spontaneous rupture of long tendons occurs in a variety of classic sites, usually on the basis of chronic attrition from occupational stress or local pathology. Presentation is with deformity and weakness rather than as a lump. Common tendons involved are: tendon of extensor pollicis longus at the wrist from excessive use (‘Kettle-drummer’s palsy’) or after Colles’ fracture; spontaneous rupture of extensor tendons of fingers in association with rheumatoid arthritis; and ‘boutonnière’ deformity from rupture of the central slip of extensor digitorum to the middle phalanx. Mallet finger (rupture of distal insertion of extensor digitorum) usually occurs as a hyperflexion sporting injury.

2 Intramuscular haematoma

This presents as a painful, tender, firm lump with indistinct edges within a muscle. It often follows an injury during a movement with the muscle under heavy load or after localised contusion. There is associated muscle pain and weakness. Common sites are the thigh, involving quadriceps femoris or hamstring muscles in footballers (‘cork leg’). Treatment is by a brief period of rest; local ice packs and compression, followed by active exercises (Ch 13).

Muscle haematoma in older patients can occur after a trivial strain or from nocturnal leg cramps causing a painful, indistinct calf muscle swelling exacerbated by movement. Absence of a history of previous injury can make the diagnosis difficult — sometimes an ecchymosis is visible and establishes the diagnosis.

Tearing of fibres in the anterior abdominal wall can mimic acute intra-abdominal injuries. All haematomas are more common in patients on anticoagulants.

Chronic haematomas. These form localised firm intramuscular lumps and may become osmotically encysted. If there is no history of injury, diagnosis from a malignant muscle tumour may be impossible without open operation and biopsy.

3 Muscle hernia

This is due to a localised defect in the overlying deep fascial envelope of the muscle. At rest no lump is usually visible, but on contraction a bulge of muscle protrudes through the fascia. These hernias are common in the lower leg over the anterior or lateral compartments and involve the tibalis anterior, extensor digitorum or the peronei. They may follow a known injury to the leg and a palpable defect is usually apparent when the muscle is relaxed. They require no treatment but can be confused with localised blowouts of varicose veins by the inexperienced observer.

4 Benign or malignant intramuscular neoplasms

Intramuscular lipomas. Lipomas are very common neoplasms and may be found within muscles and between muscle groups. They arise from normal fat and appear during adulthood. Physical signs are usually distinctive. The history is usually of a longstanding and clearly benign lump. Most lipomas are of the subcutaneous type and are well-circumscribed, ovoid masses that are movable. They are also commonly situated in relation to the large muscles of the back. Subfascial and intramuscular lipomas are firmer and more flattened than their subcutaneous counterparts, the edge is more difficult to define and the classic lobulated contour more difficult to detect. Occasionally the lump appears with an acute history after exertion, suggesting extrusion of the lipoma from between muscle groups.

Occasionally lipomas ramify widely and diffusely in tissue planes, especially between muscles (lipoma arborescens). Complete removal is difficult because the lesion extends into surrounding tissue planes and local recurrence is common. This is not a sign of malignancy but of incomplete initial removal. Intramuscular lipomas should be removed surgically to establish the benign nature of the diagnosis beyond doubt.

Fibromatosis. The fibromatoses comprise a group of localised hyperplasias of connective tissues that form nodules with scarring and fibrosis. They may be split into superficial fibromatoses and deep fibromatoses (desmoids — abdominal and extra-abdominal). The superficial category includes variants such as the palmar (Dupuytren’s) and plantar types. They tend to recur locally after removal and form a spectrum from benign conditions to locally malignant tumours. Dupuytren’s contracture is the most benign and well-known form, beginning as a slow-growing palmar nodule in subcutaneous tissue.

‘Desmoid’ tumour (Paget’s tumour). This is a less common form of locally aggressive tumour and usually occurs in the muscles of the anterior abdominal wall. It presents as a firm lump within the rectus muscle of the lower abdomen, often in multiparous women. It requires wide local excision to avoid recurrence (Ch 8.3).

Malignant muscle tumours (fibrosarcoma, rhabdomyosarcoma). Fibrosarcoma is the most common mesodermal tumour of muscle and presents as a painless intramuscular lump. Distal spread occurs late, the lump may be firm or soft and may be vascular and even demonstrate a soft bruit. It can be difficult to distinguish from a benign haematoma without biopsy. CT scanning and more recently MRI are helpful in the diagnosis and delineation of the extent of suspected tumour masses. The lesions are most common on the limbs and may be close to or attached to bone. Smaller tumours present as completely circumscribed and, as they enlarge, tend to become diffusely infiltrative. Other sarcomas such as rhabdomyosarcoma are more malignant and spread locally and systemically at an early stage. Removal of the tumour is necessary for local control. Treatment requires wide local excision after exploration and biopsy. As local spread tends to be within the muscle bundle, excision should encompass the whole muscle involved, from origin to insertion. Consideration needs to be given to excising the whole compartment in which the muscle is found. Chemotherapy and radiotherapy are often also required. Multimodal therapy involving limb salvage surgery combined with adjuvant chemotherapy and radiotherapy may provide survival rates comparable to amputation and chemotherapy, while preserving a functioning limb.

5 Less common causes

Myositis ossificans. Traumatic myositis ossificans occurs after severe soft tissue or bony injury with lifting and disruption of the periosteum at the site of attachment of muscles and ligaments to bone. Calcification and ossification occur within the soft tissue haematoma. Common sites are around the elbow and knee — within the brachialis, deltoid or quadriceps femoris after fractures and dislocations or tendinous avulsions. Patients present with hard, bony lumps, usually attached to bone at the site of tendinous insertions or in continuity with the callus of a fracture. Initially the swelling may have sharp edges and be painful and tender. Later the swelling’s edges become rounded, tenderness diminishes and the lump may regain a degree of mobility on the underlying bone. Joint stiffness is common, but there are no signs of inflammation. Differentiation from an intrinsic bony swelling can be difficult (Ch 6.2). With a primary swelling of bone, the muscles are usually more freely mobile over the lesion. In myositis, muscle function is impaired and the swelling is in continuity with the muscle.

A somewhat similar picture to traumatic myositis can occur with prolonged hypercalcaemia and is due to metastatic calcification. Rarely, in myotonia dystrophica congenita, widespread calcification occurs throughout muscle bellies.

Suppurative myositis (pyomyositis). This is an uncommon condition as normal muscle is resistant to bacterial infection because of good blood supply. It is most common in tropical countries. The quadriceps, iliopsoas and other large muscles are most commonly affected. Painful, fluctuant swellings occur acutely in muscles of limbs or trunk, with signs of local inflammation. Exploration reveals intramuscular abscesses that are often multiple. Culture may be sterile or reveal staphylococci or nonspecific organisms. The lesions may be seen in patients already ill and debilitated with tuberculosis, leprosy or other chronic infective conditions.

Cinchona bodies and other chronic reactions to intramuscular infections more commonly present as subcutaneous lumps. Injections of irritant materials or contaminated injection sites within the gluteal muscles or subcutaneous tissues of the buttocks are followed by chronic inflammatory granulomatous lumps or, occasionally, a chronic thick-walled abscess without overt signs of infection.

Common materials seen in migrant European men and women are quinine (cinchona) bodies and bismuth. Quinine tends to form round or ovoid lumps in subcutaneous fat or gluteal muscles, which are firm and nontender and often exhibit the sign of eggshell crackling on palpation.

Bismuth and other heavy metal injections tend to form deeper and less well defined intramuscular lumps.

X-rays show characteristic findings. Cinchona bodies show a thin rim of calcification in a round or ovoid buttock mass, bismuth shows as radiating converging radio-opaque lines in the line of muscle fibres. Treatment other than reassurance is rarely required.

1 Rotator cuff lesions

The tendons of the rotator cuff are separated by the subacromial bursa from the bony arch of the coracoid process and the undersurface of the acromion. The pathology of rotator cuff disease consists of three processes: degeneration; traumatic and inflammatory oedema; and bursitis. An insidious onset during middle age, with pain on lifting the arm, particularly in mid-abduction within a painful arc, suggests the presence of chronic supraspinatus tendinitis. The condition is predisposed to overuse and minor trauma, accompanied by degeneration and calcification in the tendon. The pain is often worse at night and is a dull pain felt in the shoulder and down the lateral side of the arm. Local tenderness extends along the edge of the acromion and anteriorly in the angle between the acromion and the coracoid process. Abduction is painful particularly between 60° and 120° of its arc — a ‘painful arc’ (Fig 6.10). The arc may be negotiated with less pain by a trick movement in which the shoulder is dropped while externally rotating the arm to allow the tendon to clear the coracoacromial arch. It is not uncommon to have a bony spur on the undersurface of the acromion. Acute intermittent or cyclical supraspinatus tendinitis also affects young adult females. Pain may increase to an agonising peak over hours, and then subside over the next few days. During the acute attack the arm is held immobile and is too painful to examine. Early calcification of the tendon can occur. In older patients, complete rotator cuff tears in the shoulder may suddenly occur on lifting, without the warning of longstanding shoulder symptoms. Pain is felt immediately and the patient is unable to abduct the arm despite an active deltoid. There may be partial recovery with a persistent painful arc of abduction or gradual development of a frozen shoulder or slow full recovery. Traumatic defects in the rotator cuff are often situated anteriorly, and instability and recurrent anterior dislocation of the shoulder may be associated with the rotator cuff lesion. Chronic cuff tears can predispose the shoulder to osteoarthritis with a humeral head that sits more superiorly than its normal relationship to the glenoid cavity — ‘cuff arthropathy’.

Figure 6.10 Anatomical basis of rotator cuff disorders

A: 1: inflamed subacromial bursa; 2: degeneration and calcification of the supraspinatus tendon; B: the painful arc of shoulder movement through 60° and 120° of shoulder abduction

2 ‘Frozen’ shoulder

Frozen shoulder may be primary or secondary in nature. The primary form has vague beginnings and a protracted natural history. It often starts with chronic night pain and a painful arc of abduction characteristic of chronic degenerative tendinitis. Sometimes a history of minor trauma is followed by increasing shoulder pain and tenderness with walking and when the patient lies on the involved shoulder. There are three phases with the first characterised by pain, the second by stiffness — which may last between three and 18 months — and the third by a gradual improvement as the pain subsides and the stiffness improves — ‘thawing’. During the initial period, as the pain lessens, the stiffness of the shoulder increases. Stiffness may progress to involve the hand and elbow; alternatively, any distal lesion of the hand or forearm causing prolonged immobility can lead to secondary shoulder stiffness (‘shoulder–hand syndrome’). Movements of the shoulder are limited in all directions; in severe cases the arm may be held internally rotated, with gross restriction of movement in all directions and muscle wasting. The secondary form may follow significant injuries to the shoulder including fractures and dislocations. Frozen shoulder may also be a part of a complex regional pain syndrome (previously termed reflex sympathetic dystrophy) as in patients after myocardial infarction and stroke.

3 Bicipital tendinitis and rupture

Tendinitis of the long head of the biceps muscle occurs in athletes, particularly those who repeatedly move their arm at the shoulder. Pain is felt on abduction and external rotation of the shoulder with precise localisation of tenderness to the bicipital groove. In older patients chronic bicipital tendonitis is often associated with cuff tears. The proximal biceps tendon may also completely rupture through a degenerated section of tendon. In these cases, function usually returns to near normal after the initial acute pain. On examination, the distorted belly of the long head of the biceps can sometimes be mistaken for a muscle tumour (Ch 6.3).

4 Osteoarthritis of the acromioclavicular joint

Mono-articular osteoarthritis usually follows a previous injury. The joint feels thick and tender and pain is most marked during the final 60° of abduction. The range of shoulder movement is not significantly diminished. A good provocative test is the crossed adduction in which the arm is adducted towards the other shoulder. The pain may be relieved after an intra-articular injection of local anaesthetic — not uncommonly used to confirm the site of the origin of the pain.

5 Referred pain

Occasionally pain may be referred from disease extrinsic to the shoulder. Cervical spondylosis is the most common cause of referred shoulder pain. The pain is referred from the base of the neck, over the shoulder and down the arm and may be associated with neurological signs in the arm and hand. Movements of the cervical spine in these patients will reproduce the shoulder pain while shoulder movements are usually full and painless. Visceral diseases such as angina pectoris, diaphragmatic pleurisy, pericarditis and oesophageal disorders may sometimes present with shoulder pain. Pancoast’s tumour of the lung apex is usually associated with shoulder pain. In most cases of referred pain the patient can reach behind the back with the arm in full adduction or from over the shoulder with the arm in full abduction (the back scratch test).

Any old shoulder injury, particularly fractured surgical neck of the humerus in middle-aged patients, can cause later diminution in shoulder function with pain and stiffness.

6 Less common causes

Attacks of gout are rare in the shoulder. Osteoarthritis in the shoulder usually follows an identifiable cause such as a previous injury; primary generalised osteoarthritis usually spares the shoulder. Rheumatoid arthritis only rarely affects the shoulder joint in the first instance.

1 Carpal tunnel syndrome

Carpal tunnel syndrome is due to compression of the median nerve beneath the flexor retinaculum at the wrist. The syndrome is a common complication of fluid retention so occurs with cyclical oedema in women at the menopause and during pregnancy. Carpal tunnel syndrome may be the presenting symptom of rheumatoid arthritis.

Symptoms consist of burning pain and paraesthesia in the median nerve distribution, felt mostly at night. The pain is due to ischaemia of the median nerve. Pain is usually felt in one or all of the radial three and half digits and often radiates to the elbow or even to the shoulder. There are few early physical signs. In late cases, wasting of the thenar muscles occurs with impaired sensation over the area of median nerve. The median nerve cutaneous innervation is to the volar aspect of the thumb, index, middle and the radial half of the ring fingers and the radial side of the palm. It also innervates the distal aspect of the dorsum of the thumb, index and middle finger, back to at least the distal interphalangeal joint. The sensation to the palm is often spared as the cutaneous branch to this area arises proximal to the carpal tunnel. Carpal tunnel syndrome can follow wrist fractures or dislocations, particularly those involving the scaphoid. It is only rarely due to a lesion of the nerve itself, such as a neurofibroma. Symptoms, whatever the primary cause, relate to entrapment of the nerve within a too-tight carpal tunnel and can be cured by relieving the compression. Tapping over the flexor retinaculum (Tinel’s test) may produce identical symptoms. The clinical picture, particularly the history, is usually classic. Sometimes the differentiation from nerve root compression due to cervical osteoarthrosis can be difficult. Electromyography and nerve conduction studies may then be necessary to confirm the diagnosis.

Ulnar nerve compression is less common and may occur either as the nerve passes behind the medial epicondyle (the cubital tunnel) or in its passage from the pisiform bone to the hook of the hamate (Guyon’s canal).

2 Tennis elbow

Tennis elbow, also called baseball elbow, is localised pain due usually to a tendinitis at the origin of the extensor muscles from the lateral epicondyle of the humerus (Fig 6.11). The condition is characterised by precise local tenderness over the dorsal radial head below the epicondyle. Most cases will settle with activity modification and nonsteroidal anti-inflammatory medications. An injection of local corticosteoid or autologous blood at the site of the tenderness is sometimes required. For recalcitrant cases surgical excision of the origin of extensor carpi radialis brevis with decortication of the lateral epicondyle may be required. Tenderness at the origin of the flexor muscles from the medial epicondyle on the other side of the elbow has been called golfers’ elbow. The point of maximal tenderness is usually anterior to the medial epicondyle. The pain can usually be reproduced with flexion of the wrist and pronation of the forearm against resistance. Management is also along conservative lines. Surgery is rarely required. Both conditions can follow repetitive actions such as hammering, sawing and sanding and are frequently related to occupation as well as to sport.

Figure 6.11 Tennis elbow

A: the site of tenderness is over the extensor tendons just anterior to the lateral epicondyle

3 De Quervain’s tenosynovitis

De Quervain’s disease is a stenosing tenosynovitis of the extensor pollicis brevis and abductor pollicis longus causing pain and tenderness proximal to the radial styloid process (Fig 6.12). Clinical features are as outlined in Chapter 6.2.

Figure 6.12 De Quervain’s tenosynovitis

Thickening in the sheath of abductor pollicis longus and extensor pollicis brevis (A) where they cross the styloid process of the radius (B)

4 Repetitive strain injury

Repetitive strain injury (RSI) is a chronic, poorly localised, painful condition of the forearm. It occurs in occupations where repetitive movements are necessary, such as typing and machine and processing work. The chronic pain may radiate to the neck and elsewhere in the body in a varying pattern and is associated with cold extremities (that look normal) and may radiate to the other arm. Sleep deprivation is a common complaint. The condition has no defined pathology and no constant physical signs are demonstrable — it embraces a group of functional disorders. Prognosis often depends upon expectations of compensation. Its incidence has fallen dramatically since it ceased to be a valid cause for a compensation claim.

1 Ganglion

These are the most common chronic lumps affecting hands or fingers. They are slow growing and patients usually present because of concern with appearance rather than pain. A number of varieties are specific to the hand.

Small localised wrist ganglia. The dorsal ganglion is the most common, located over the dorsal carpus near the proximal tubercle of the capitate, lying to the radial aspect of the midline on the dorsum of the wrist (Fig 6.13). This often arises from the dorsal wrist joint and effective management involves excision of the stalk of the ganglion and repair of the defect in the dorsal wrist capsule.

Figure 6.13 Dorsal wrist ganglion

A: sectional view; B: surface view of a ganglion presenting between slips of the extensor digitorum longus

A ventral ganglion is also common and is invariably also on the radial side, arising from the fibrous sheath of the flexor carpi radialis tendon and in close proximity to the radial artery.

Small localised ganglia of palm and fingers (‘sesamoid’ ganglia). These ganglia arise from the lateral volar aspects of the fibrous flexor tendon sheath of the metacarpophalangeal joints of the thumb or fingers — usually opposite the metacarpal head. The small firm tense nodule can be confused with the sesamoid bones that lie on the volar aspects of the metacarpophalangeal joints cradling the flexor tendon (Fig 6.14).

Figure 6.14 Ganglion

1: sesamoid ganglia on the lateral palmar aspect of the metacarpophalangeal joints arising from the fibrous flexor tendon sheath; 2: sesamoid bones lie medially in relation to the volar aspect of the thumb

Ganglia of the fibrous flexor tendon sheath may also occur more distally, at the sides of the shaft of the proximal phalanx, causing a small tender firm lump.

Mucous (synovial) cysts of the fingers: These give classic clinical features and present as subcutaneous cystic lumps over the dorsum of the distal phalanx in or near the midline. These often occur in the setting of arthritis and one must beware that there may be a skin deficit to fill subsequent to their excision.

Extensive compound palmar and dorsal ganglia involving flexor and extensor tendon sheaths. These present as bilobed ganglia with fluctuation across the wrist. They may be associated with the chronic synovitis of rheumatoid arthritis.

Ganglia should be excised if symptomatic. Excision of a focal ganglion must include a complete excision of the lining of the ganglion and repair of any associated capsular defect to minimise risk of recurrence.

2 Synovioma of tendon sheath (benign giant-cell tumour, xanthoma)

These lesions are benign solid neoplasms of tendon sheaths and are virtually confined to the hand. They present as progressive, but slow-growing, firm lumps related to the tendon sheaths of fingers or thumb, usually on the proximal volar surface. They are thus often difficult to distinguish clinically from ganglia. Pain is not usually a marked feature although discomfort occurs with finger movement or gripping. The firm, solid, lobulated mass spreads into tissue planes around the tendon sheath and adjacent joints. They can cause absorption of bone and joint surfaces (usually metacarpal head or proximal phalanx) by compression rather than infiltration and may encircle the bone. They occur in adults of all ages and require surgical excision with an adequate margin because the risk of local recurrence from incomplete excision is high. On exploration, synoviomas are greyish-white lobulated lumps, showing yellow or red areas on the cut surface. On histology, characteristic multinucleated giant cells and foamy macrophages are seen, which are responsible for the yellow colour and the alternative name of xanthoma.

Xanthomas around other joints (e.g. knee and elbow) can be associated, as can linear streaks in the palmar creases and xanthomas around the eyes. Multiple xanthomas should raise suspicion of hypercholesterolaemia or diabetes and a family history should be sought.

3 Dupuytren’s disease

This condition starts as a firm nodule in the subcutaneous tissues of the palmar aponeurosis just proximal to the base of the ring or little finger. As the lesion progresses, signs of skin attachment develop with skin fixation, pitting or dimpling over the lump. Skin sinuses due to fibrosis may progress to skin fistulas. Joint contractures are a later manifestation and progress is often very slow over many years.

Knuckle pads (subcutaneous thickenings over the closed metacarpophalangeal joints) may accompany Dupuytren’s disease.

Histology of nodules shows an exuberant fibromatosis that can be mistaken for a low-grade fibrosarcoma unless the characteristic site and clinical picture are known. Nodules are best merely observed, surgery is not usually necessary as symptoms are minor.

There is an aggressive form of Dupuytren’s contracture (Dupuytren’s diathesis) that begins at an early age with a strong family history, knuckle pads, plantar fibromatosis (Ledderhose’s disease) and penile fibromatosis (Peyronie’s disease). In this form of the disease, progression, despite surgery, is the rule.

4 Traumatically induced lesions

Implantation dermoid. These characteristic small, firm, painful nodules are palpable just beneath the skin of the finger pulps or palm. They are the most common tumour in the distal phalanx. They are sensitive to palpation and usually blanch on pressure. An overlying discoloured spot on the skin or small scar may tether the cyst to overlying skin. They have long natural histories and consist of whorled fibrous tissue surrounding a squamous epithelial-lined cyst that contains keratin. They are due to implantation of dermal elements and are often occupation related. They are effectively treated with surgical excision.

Foreign body granuloma. A firm solid subcutaneous lump can develop months or years after a penetrating injury with a retained foreign body (e.g. glass, wood, metal). The history of the injury may often have been forgotten. X-ray may clarify the diagnosis by revealing a radio-opaque foreign body. Ultrasonic examination may be required for organic matter. Lesions should be excised. Tetanus prophylaxis prior to excision is vital.

Traumatic false aneurysms of the radial artery can develop after arterial puncture for blood gas analysis or after a penetrating injury.

Ulnar hammer syndrome. This gives an intriguing clinical syndrome in men using the ulnar and palmar surfaces of the hand as a hammer in their jobs — workers such as motor mechanics and repairers are most often affected. The repetitive trauma to the ball of the hypothenar eminence can damage the deep branch of the ulnar artery near the hook of the hamate, causing a false aneurysm. Symptoms are usually of the pulsating painful swelling associated with paraesthesia in the ulnar nerve distribution. Distal ischaemia of the ulnar digits is rare. The lesion should be excised, taking care to avoid the ulnar nerve and its branches. An Allen test, to ensure that there is an adequate collateral circulation to the hand, is important prior to the surgical excision.

5 Nodules associated with joint disease

These are common, especially in association with osteoarthritis. They rarely require treatment on their own account, but patients often present with the nodule as an independent problem.

Heberden’s nodes. These firm fibrous nodules on each side of the dorsum of the terminal interphalangeal joints are associated with osteoarthritis. They require no treatment. Differentiation from the less common mucous (synovial) cyst of the finger, which is over the dorsum of the distal phalanx in or close to the midline, should be easy.

Bouchard’s nodes. These are fibrous thickenings of the proximal interphalangeal joints seen in rheumatoid arthritis. Subcutaneous rheumatoid nodules may be seen on the dorsum of hand and wrist and present as firm discrete lobulated subcutaneous fibrous nodules, also common around the forearm and elbow.

Gouty tophi. In longstanding gouty arthritis, tophaceous deposits are often present in the hand. These cause firm nodules stretching the overlying skin with the yellowish–white colour of the tophaceous deposit shining through the skin. They are common on the lateral dorsal aspects of interphalangeal joints and may discharge through the skin. Occasionally they require surgical enucleation. X-rays usually show classic gouty arthritis.

6 Less common causes

Glomus tumour. Glomus tumour is among the rarest of hand tumours. These small vascular subcutaneous nodules are reddish-brown in colour and are most common on the limbs. They can cause severe, excruciating pain and are exquisitely tender to pressure. They are often so small that they will escape detection on cursory examination and symptoms may be thought fabricated and histrionic. A common site is a reddish-brown subungual nodule, which is dramatically cured by removal of the nail and enucleation. The characteristic triad of severe pain, point tenderness and cold sensitivity should be sought. It must be differentiated clinically and histologically from the less painful subungual melanoma that requires radical excision by finger amputation.

Lipoma. Lipomas are uncommon in the hand — only 10–20% of upper limb lipomas occur in the hand and wrist area. The most frequent site is the thenar eminence. Those under the thick palmar skin are flatter and firmer than at other sites and usually need excisional biopsy for diagnosis. Confined beneath the flexor retinaculum, they may spread along fascial planes between tendons (lipoma arborescens) and can cause symptoms of nerve compression. Lipoma arborescens and neurofibroma of the median nerve each present as vague swellings of the palm with carpal tunnel syndrome symptoms. They are very rare causes, but important, as surgical treatment is conservative, requiring just flexor retinaculum division and, in the case of the lipoma, very conservative excision with extreme care to avoid injury to the median nerve. MRI examination of the wrist and carpus if often useful in delineating the underlying pathology.

1 Congenital contractures

Congenital deformities should be recognisable on inspection, but a practised eye is required to pick up even such seemingly obvious lesions as polydactyly.

Syndactyly (web fingers). Two or more digits are united by a web that may be thin and incomplete in some instances or involve the full thickness of the fingers in others. Simple (cutaneous) syndactyly refers to cases with no underlying bony fusion, whereas complex (osseous) syndactyly indicates underlying bony fusion. Incomplete syndactyly refers to cases where the web began to recede but stopped short of the normal level and complete syndactyly indicates that the entire web is absent to the tips of the fingers. Syndactyly is often an isolated anomaly; however, it is prudent to be aware that it may be sometimes linked to chromosomal and craniofacial conditions.

Polydactyly (supernumerary digits). This is characterised by the presence of extra digits or toes. Syndactyly and polydactyly have a familial tendency. Polydactyly often has a genetic link. The extra digit in the hand may be radial, central or ulnar in its position. Radial polydactyly may be a duplication of the distal phalanx, the middle and distal phalanges or the proximal, middle or distal phalanges. A triphalangeal thumb, an uncommon variant of this condition where the thumb appears as a fifth finger is rare but important to identify as it may be linked with cardiac pathology and pancytopenia. Central polydactyly is less common; however, one must be aware that it often has an autosomal inheritance pattern. Ulnar polydactyly is common and may present as a floating digit (autosomal dominant in African-American patients) or may have skeletal attachment.

Congenital contracture of the little finger. This is common and should be instantly recognisable on inspection as distinct from the deformities of Dupuytren’s contracture or of nerve lesions. The little finger alone — usually on both sides — is involved, with a congenital fixed flexion deformity at the interphalangeal joints. The finger is often also curved inwards (camptodactyly, clinodactyly — bent finger). Disability is usually mild and functional adaptation of the hand is usually complete. The deformity is often familial.

2 Wound contractures

Skin contractures due to secondary scarring of wounds across skin creases, and especially after deep burns, are common causes of deformity. They have a characteristic history and appearance. Surgery may be required in order to improve function; however, there is a tendency for recurrence.

3 Dupuytren’s contracture

Dupuytren’s contracture involves a thickening and shortening of the palmar aponeurosis and adjacent subcutaneous tissues. The aponeurosis lies deep to the subcutaneous tissues of the hand and superficial to the flexor tendons. Nodular thickenings in the palmar fascia progress to longitudinal bands that result in flexion contractures of the fingers. The condition may have a familial predisposition. It is also not uncommon in patients with cirrhosis of the liver and in epileptics receiving phenytoin. An association is also described with chronic illness and immobility of the hand, diabetes and pulmonary tuberculosis. Progression may be affected by local trauma and by occupation but these latter effects are probably minor. Dupuytren’s disease begins as a firm nodule in the palm, usually at the base of the ring finger and often many years before the development of a contracture. Men are more often affected than women and the development of severe contracture is uncommon in patients under 45 years of age. The earlier the lesion starts in life, the more aggressive the condition is and the more likely it is to recur after treatment. All digits may be affected, most commonly the ring finger, followed by the little, middle and index fingers. Thumb involvement is much less common. The palmar nodule becomes attached to the skin and causes puckering, dimpling, pits and sinuses of the surface.

As the disease progresses, continuing fibrosis and infiltration involve the subcutaneous tissues and palmar aponeurosis. Diverging bands run from the palm in the region of the flexor retinaculum to the volar aspects of the digits and extend across the metacarpophalangeal joint and proximal interphalangeal joint to the middle phalanx. The terminal interphalangeal joint is usually not involved. The effect of the disease on the end joint of the finger depends upon the degree to which the finger is rolled into the palm by contracture at the metacarpophalangeal and proximal interphalangeal joints. The deformity can cause flexion of the metacarpophalangeal and proximal interphalangeal joints to a right angle; the distal and intermediate phalanges remain in line and forced against the palm (Fig 6.18). Less commonly the terminal interphalangeal joint is flexed and the affected finger is rolled tightly into the palm with flexion of all joints. All degrees of contracture of the metacarpophalangeal and proximal interphalangeal joints occur; the firm subcutaneous fascial bands causing the deformities are easily palpable and often attached to overlying skin. The deformity is unaffected by movements of the wrist joint and there is no sensory disturbance. The contracted fingers impair the grip and make it difficult to let objects go, and also get caught up in pockets.

Figure 6.18 Dupuytren’s contracture

4 Ischaemic muscle contracture (Volkmann’s)

Volkmann’s ischaemic contracture follows ischaemic fibrosis involving the long flexor muscles of the forearm and gives a disabling and characteristic claw-like deformity of the fingers and wrist. The usual causes of muscle ischaemia are injury to the brachial artery from supracondylar fractures of the humerus or to its branches from fractures of both bones of the forearm or from an excessively tight arm plaster or occasionally after arterial embolism. Prevention of the complication requires adequate treatment of these conditions and effective management of incipient ischaemia from any cause. The major sign of incipient ischaemia of the long flexor muscles of the forearm is extreme pain on attempted finger extension. This should alert the clinician to the danger of ischaemic contracture; it demands immediate diagnosis and relief. The muscle ischaemia involves muscles within the flexor compartment of the forearm, often with secondary involvement of nerves due to ischaemic neuritis. The skin and subcutaneous tissues are not involved and the fingers are paraesthetic but not ischaemic. Muscle ischaemia leads to permanent damage and ultimately fibrosis if ischaemia is not relieved within six to 12 hours. The infarcted muscles undergo progressive fibrotic contracture that particularly affects the long finger flexors and, to a variable degree, the wrist flexors.

In the most severe case the deformity is unmistakable and involves all digits and the whole hand. The wrist is usually held moderately flexed. The metacarpophalangeal joints are in neutral position or extended due to tension of the long extensors and the proximal and interphalangeal joints are grossly flexed (Fig 6.19). Varying degrees of ischaemic neuritis may accompany the contracture. Most often, regeneration of affected nerves occurs so that muscle function of the small muscles of the hand is maintained and sensation of the fingers is present. The deformity and its effects are thus very different from that produced by a claw hand due to a neurologic deficit. It is also soon obvious on examination that the deformity is associated with contracture of the long flexor muscles of the fingers: extension of the wrist worsens the finger deformity and flexion of the wrist diminishes it. The source of proximal ischaemia will be apparent on questioning or examination. The most common findings are an old fracture of the elbow or forearm or a proximal source of vascular embolus.

Figure 6.19 Volkmann’s contracture

A: moderate flexion of the wrist with gross flexion of the interphalangeal joints; the metacarpophalangeal joints are in the neutral position or slightly extended; B: the thumb is partly spared in this case

Fibrous contracture of the small muscles of the hand can also occur, secondary to ischaemia or to rheumatoid arthritis, or to the hypertonicity found in cerebral palsy. The deformity resulting from fibrous shortening of the interossei and lumbricals is very typical and results in metacarpophalangeal flexion of the joints of the fingers and thumb, interphalangeal joint extension and adduction of the thumb. This position is called the ‘intrinsic plus’ hand (Fig 6.20). Minor degrees of contracture of the short muscles are diagnosed by passive hyperextension of the metacarpophalangeal joints; the interphalangeal joints will not be capable of passive flexion in this position, as it stretches the intrinsic muscles of the fingers and thus the dorsal capsules of the distal joints.

Figure 6.20 The ‘intrinsic plus’ hand

The ‘intrinsic plus’ hand results from fibrous contracture or hypertonicity of the small muscles of the hand. Flexion of the metacarpophalangeal joints, interphalangeal joint extension and adduction of the thumb.

5 Tendon disorders

Trigger finger (stenosing flexor tenosynovitis) is a very characteristic condition in which the finger becomes locked in full flexion. Forced active or passive extension is associated with a sudden click and release (Fig 6.21).

Figure 6.21 Trigger finger from stenosing tenosynovitis of the flexor tendon

The finger becomes locked in flexion. Forced extension leads to a sudden click and release.

Mallet finger (Fig 6.22) is a flexion deformity of the distal interphalangeal joint caused most commonly by a hyperflexion injury of the finger tip while catching a ball, resulting in rupture of the extensor tendon slip to the base of the distal phalanx. Sometimes the injury is associated with avulsion of a small flake of bone from the dorsal aspect of the base of the distal phalanx. Occasionally, division of the tendon occurs from a penetrating wound. For closed injuries, early treatment by splinting in the hyperextended position can result in healing without final disability or deformity, particularly when a bony fracture is present. However, healing of the tendon is often accompanied by lengthening and deformity, with failure of complete extension on straightening the finger. Passive extension confirms that the deformity is not due to joint stiffness but to tendon weakness (drop finger). The condition may also follow invasion of the extensor tendon and its insertion by rheumatoid inflammatory tissue, in which case other deformities of rheumatoid arthritis are usually obvious. Treatment is usually immobilisation of the distal joint in a hyperextended position in a ‘mallet splint’. Should the piece of bone be large or include a significant segment of articular surface, then surgical repair may be warranted.

Figure 6.22 Mallet finger

A: extensor tendon avulsion; B: avulsion of bone fragment, tendon intact

Boutonnière deformity. This is a flexion deformity of the proximal interphalangeal joint due to traumatic division, rupture or stretching of the central slip of the extensor tendon expansion where it inserts into the base of the middle phalanx. The lateral slips separate and dislocate around the sides of the flexed joint and the head of the proximal phalanx protrudes through the gap, as though through a button-hole. Eventually there is hyperextension of the distal interphalangeal joint and fixed flexion of the proximal interphalangeal joint giving a typical deformity (Fig 6.23).

Figure 6.23 Boutonnière deformity

A: normal tendon B: ruptured central slip; C: established deformity

Swan neck deformity is the reverse of the boutonnière deformity. The proximal interphalangeal joint is hyperextended and the distal interphalangeal joint is flexed. The swan neck deformity can be seen in normal hands and is secondary to an imbalance between extensor and flexor tendon action. It is a common deformity in rheumatoid arthritis (Fig 6.24) and is often associated in this disease with other deformities and fibrotic contacture of the interossei and lumbrical muscles. Testing for intrinsic muscle contracture and isolated sublimis action (Ch 5.2), and observing if stabilising the metacarpophalangeal joint corrects the deformity, will usually indicate the cause.

Figure 6.24 Swan neck deformity

6 Deformities due to arthritis

Osteoarthritis affects particularly the distal interphalangeal joints and wrist joint. Heberden’s nodes are hard or firm nodules over the dorsum of the distal interphalangeal joints. Radial or ulnar deviation of the distal phalanx may also be present. The index finger is most often affected. Adventitious bursae occasionally develop between the skin and the Heberden’s nodules.

Rheumatoid arthritis. This usually has its most disabling effects on the hands. The disease commonly begins with pain, stiffness and swelling of the fingers. The joints mainly involved are the metacarpophalangeal joints and proximal interphalangeal joints (different to the distal pattern of osteoarthritis). Synovial thickening and associated muscle wasting give the fingers and hands a spindle-shaped deformity. Rheumatoid granulomatous nodules develop in the subcutaneous tissue, usually over bony prominences and within tendon sheaths. Thickening of the dorsal ligaments of the proximal interphalangeal joints causes Bouchard’s nodules. Progressive disease causes the typical deformity of the ‘intrinsic plus’ hand: with thickened deformed wrists and metacarpophalangeal joints, ulnar deviation of the hand and fingers and a Z-deformity of the thumb. Progressive flexion deformity at the metacarpophalangeal joints can progress to subluxation. Hyperextension of the interphalangeal joints, tendon erosion and rupture, swan neck deformity, boutonniere and mallet finger deformities are all common (Fig 6.25).

Figure 6.25 Rheumatoid hand

1: ‘swan neck’ finger deformity; 2: mallet finger; 3: flexion contracture of M-P joint; 4: Z-thumb deformity; 5: muscle wasting; 6: synovial thickening; 7: thickening of the dorsal ligaments of the proximal interphalangeal joints; 8: ulnar deviation of fingers

Gout. Gouty arthritis affecting the hand can cause severe deformities that can occasionally be difficult to distinguish from rheumatoid arthritis. Gouty arthritis produces tophaceous deposits (a toothpaste-like yellow material containing infiltrates of uric acid crystals). Tophi are maximal at terminal interphalangeal joints but can affect proximal interphalangeal joints and metacarpophalangeal joints as well. Tophi are also responsible for subcutaneous deposits at elbow and ear. The yellowish colour of the uric acid deposits is usually visible through the skin. The degree of muscle wasting and systemic illness is rarely as severe as with rheumatoid arthritis.

7 Deformities due to neurological lesions

Peripheral nerve lesions. These give classic hand deformities (Ch 5.3).

Radial or posterior interosseous nerve deformity gives wrist and finger drop. Sensory loss with radial nerve palsy is usually minor and confined to the anatomical snuff box. Extension of the wrist joint, of the metacarpophalangeal joints of all digits and of the terminal interphalangeal joint of the thumb are all paralysed. Power grasp is impaired as there is an inability to stabilise the wrist in neutral or extension. Furthermore, as the fingers and thumb are unable to be spread sufficiently during prehension there is an inability to open the palm to grasp objects. In a posterior interosseous nerve palsy, the extensor cari radialis longus and brevis tendons and the brachioradialis tendons are still functioning, thus preserving wrist extension, albeit in radial deviation.

Ulnar nerve palsy gives the classic deformity of ulnar claw hand. The characteristic posture enables this to be easily distinguished from the other claw deformities. Only the little and ring fingers are clawed, unless the ulnar nerve supplies all the lumbrical muscles. Sensation is lost over the ulnar side of the hand and over the little finger and the ulnar side of the ring finger. The claw deformity of an ulnar claw hand involves hyperextension at the metacarpophalangeal joints and flexion of the other finger joints (Fig 6.26).

Figure 6.26 Claw hand due to ulnar nerve palsy

As the metacarpophalageal joints hyperextend due to the lack of hand intrinsic function, full extension of the proximal interphalangeal joints is not possible. Wasting of the small muscles of the hand is present, apart from the short abductor and flexor of the thumb. Functional impairment is significant. With grasping there must be a coordinated action of the long and short flexors in the forearm and hand such that flexion proceeds from the metacarpophalangeal joints to the interphalabgeal joints. With a loss of the interossei and lumbricals there is an inability to selectively initiate flexion at the metacarpophalangeal joint. As such, the remaining long flexor tendons — flexor digitorum superficialis and profundus — curl the fingers into the palm with the metacarpophalangeal joints being activated towards the end of this motion. The arc of finger motion is therefore significantly shortened and large objects are unable to be grasped. Stability of pinch is also affected, as demonstrated using the Froment test — the interphalangeal joint of the thumb flexes to increase the mechanical advantage of the extensor pollicis longus and compensate for the weakened or missing action of the adductor pollicis.

Klumpke’s paralysis. This is an eponymous name attached to a palsy of the lower roots of the brachial plexus (C8 and T1). This gives a complete claw hand due to paralysis of all intrinsic muscles of the hand. It follows brachial plexus injury due to birth trauma or motor vehicle accident. All digits are clawed with hyperextension of the metacarpophalangeal joints; the thumb drifts in line with the other digits. Sensation of the hand is normal but is lost in the axilla and inner arm from the first thoracic nerve root lesion. A combined median and ulnar nerve palsy due to slashed wrist will give a similar picture, but sensory loss will, in that instance, be confined to the hand.

Motor neurone disease and other neurological conditions (syringomyelia, leprosy) can also give claw hand deformities (Box 6.1).

Box 6.1

The causes of ‘claw hand’ deformities

Ulnar palsy, combined ulnar and median nerve palsy

Brachial plexus lesion (lower trunk)

Spinal cord lesions: syringomyelia, poliomyelitis, motor neurone disease — amyotrophic lateral sclerosis

Volkmann’s ischaemic contracture

Advanced rheumatoid arthritis (‘intrinsic plus’hand)

Dupuytren’s contracture

1 Congenital contractures

Treatment is surgical with the exception of congenital contracture of the little finger.

2 Scar contractures

Established contractures are treated by excision of scar tissue or release incisions with skin grafting or Z-plasty. Insensitivity of areas of palmar surface skin can be treated by transposing flaps of skin with an intact nerve supply to the defective site as local or island flaps.

3 Dupuytren’s contracture

Operation is only indicated for deformity and not for subcutaneous nodules without contracture. Surgery is usually indicated when the patient complains of functional impediment and fails Hueston’s tabletop test — placing the palm and fingers flat on a tabletop and being unable to simultaneously place the palm and fingers flat on the tabletop. This usually translates to a metacarpophalangeal contracture of at least 30°. The usual operation is a limited excision of the fascia sufficient to reduce the contracture through one or more palm or finger incisions. Z-plasties are often used in reconstruction to prevent contracture. Skin grafting is sometimes necessary where the bands involve large areas of skin. Amputation is indicated for a severe contraction of the little or ring finger with associated fixed-joint capsule contracture. Division of localised bands by subcutaneous tenotomy is only occasionally possible — surgery must preserve the digital sensory nerves. Care must be taken during surgery as the cords often displace the neurovascular bundle medially and superficially, particularly at the level of the first transverse finger crease. At present the treatment of this disorder is surgical with the aim of alleviating the flexion deformties by removing the fibrous cords while preserving the neurovascular structures.

4 Ischaemic contracture

Volkmann’s ischaemic contracture may require tendon transfer or, in less severe cases, distal transfer of the origin of the flexor muscles. It may be necessary to supplement this procedure with nerve grafting.

5 Tendon lesions

Surgical treatment of trigger finger is curative. An early mallet finger deformity usually just requires splinting. Boutonnière and swan neck deformity are commonly associated with other changes of rheumatoid arthritis but, in an isolated lesion, splinting may be successful.

6 Arthritis

In the early stages splinting may help to reduce pain, improve mobility and reduce loss of function when combined with systemic treatment (e.g. aspirin and corticosteroids). In more advanced disease it is important to be sure that the operative procedures planned will improve function. Surgical procedures are complicated and include synovectomy, tightening of capsular structures, tendon release and tenoplasty, arthrodesis and joint replacement. Gout is treated by dietary management, colchicine (for acute attacks) and long-term allopurinol, a urate-blocking agent. Surgical measures include drainage of infected tophi.

7 Neurological lesions

Treatment of neurologically induced deformities of the hand may involve tenolysis or tendon transfer, arthroplasty or arthrodesis.

1 Infected recent wounds

Wound infection often follows inappropriate primary repair of lacerations and is usually the result of errors of inadequate debridement. Wounds that are seen more than 24 hours after injury should be treated initially with antiseptic dressings rather than closure. Delayed closure can be performed, if required, after the swelling has settled down. With established infection it is necessary first to lay open the wound after suture removal. The open wound is treated by the repeated application of moist porous dressings. More recently, negative pressure dressings, often termed ‘vacc dressings’, have eliminated the requirements for numerous daily dressing changes. Final healing may require secondary closure. Skin grafting is necessary when there has been skin loss or major skin retraction.

2 Subcutaneous infections

Subcutaneous infections are particularly common with the fingers (Fig 6.27).

Figure 6.27 Finger infection

1: nail fold suppuration (paronychia); 2: pulp space suppurative necrosis; 3: eponychium — cuticle; 4: pulp space with fascial septa

Pulp-space infection. Subcutaneous infections of pulp (Whitlow) and web spaces, nail bed, palmar compartments and thenar and hypothenar eminences, are initially treated similarly — with antibiotics and splinting and careful review to identify any developing abscess that requires drainage. If the abscess has not involved the skin, a short incision is made at the point of maximum tenderness — if possible, parallel to the nearest skin crease. If the abscess is carefully cleaned by curettage and any slough is excised, healing will be rapid. Exposure is usually best by a direct approach, combined with careful removal of infected material and antibiotic treatment.

The distal finger pulp is divided into a number of tiny compartments by strong fibrous septa that traverse from the skin to the periosteum. Because of these septa, a pulp space abscess — felon — presents with severe and immediate pain, due to the increase in pressure within the pulp, with early evidence of subcutaneous necrosis. Incision should be combined with excision of slough and treatment with antibiotics (Fig 6.28). Be aware that the felon may extend into the periosteum and around the nail bed.

Figure 6.28 Pulp-space infection (Whitlow)

Direct incision, adequate excision of slough and antibiotic treatment have reduced the need for older methods of extensive incision and irrigation.

Paronychia. The management of acute paronychia with pus formation depends upon the extent and direction of spread. In early cases, only elevation of the nail fold is required to facilitate drainage. With subungual extension of pus, a small vertical incision alongside the nail or removal of the nail in part or whole may be necessary (Fig 6.29). Staphylococcus aureus is the most common bacterial source in acute infections; however, recent studies have identified a 25% incidence of anaerobic infections. In chronic paronychia, candida albicans is the causative agent in 70–90% of cases.

Figure 6.29 Paronychia

A: raising the eponychium to release pus is sufficient in most cases; B: more severe infections require incision of the cuticle and removal of some or all of the nail

Hair follicle infections usually appear on the dorsal aspect of the hand. Folliculitis has pus formation within a hair follicle with infection limited to the dermis. A furuncle is an infection of a number of hair follicles within a confined area and a carbuncle is an abscess involving a number of adjacent hair follicles where the infection has penetrated the dermis and formed a subcutaneous abscess. A dorsal abscess is treated by excising the slough, preserving as much viable skin as possible and treating with antibiotics. The treatment of a carbuncle must also include the excision of the abscess and its fibrous septa. Firm bandaging after cleaning out the cavity will result in rapid obliteration of the space. The causative agent is usually a staphylococcal species; however, with lesions below the waist coliforms and anaerobes should also be considered. Diabetes must be excluded in all hand infections. Attention to hygiene is important if recurrence is to be prevented.

3 Deep infections

Palmar space infection. Most abscesses in the palm or over the thenar eminence lie between the skin and the fascia overlying the muscles and tendons. Most of these infections point early and are best treated by early drainage with excision of slough. However, there are deeper spaces in the palm that may become infected — the thenar, midpalmar and hypothenar spaces. These infections lie between the fascia covering the metacarpals and their associated muscles and the fascia dorsal to the flexor tendons (Fig 6.30). On examination, these deep infections tend to flatten or obliterate the palmar cavity and also produce swelling of the dorsum of the hand. Extension of the fingers may cause severe pain suggestive of tendon sheath infection. Incision into the subcutaneous space is usually made parallel to the nearest skin crease and then into the subfascial space by bluntly separating the fibres of the aponeurosis. Debridement is then performed under direct vision.

Figure 6.30 Surface markings

A: thenar fascial space; B: midpalmar fascial space

Tendon sheath infection. Kanavel described four signs of suppurative flexor tenosynovitis: tenderness over the flexor tendon sheath; a flexed posture of the digit; fusiform swelling of the digit; and pain on passive extension of the digit. The most common organism is Staphylococcus aureus and surgical drainage if usually required. Prolonged use of antibiotics may be a factor in the development of persistent, low-grade, poorly localised infection around the tendons. Pain on passive extension of the finger, if persistent, suggests the need for exploration. Irrigation of the sheath with an antibiotic solution infused through a fine, supple, nonreactive thin tubing inserted at points of incision may control infection in cases with established suppurative tenosynovitis.

Acute suppurative arthritis may develop from a neglected — and often apparently trivial –wound to the dorsal aspect of the joint. The knuckles are common sites where penetrating tooth wounds can become infected. Human, feline and canine bites often cause severe spreading infections after apparently trivial wounds and response to treatment may be slow. Human bites commonly transmit Eikenella corrodens and animal bites Pasteurella multocida. If the bite is limited to soft tissue, the treatment is conservative with antibiotics and the immobilisation of the hand in plaster, with elevation in a sling. Any suspicion of joint involvement should include surgical exploration of the wound, debridement and lavage. In some cases the original wound may need to be enlarged to improve drainage. In advanced cases, drainage should be combined with removal of sequestra, necrotic tissue and curettage of infected bone and cartilage as required.

Careful rehabilitation is crucial to the full recovery of hand function after infection. The hand is splinted initially in the position of function. Once the infection has been controlled and healing is in progress, graduated finger movement and exercises are begun. In this way, tendon and joint adhesion formation can be minimised and late stiffness of the hand prevented. Contractures may not develop for weeks or months after injury and infection and are especially common in cases where massive scarring is associated with delayed treatment and healing. Infections in wounds crossing the flexor joint creases are especially likely to be complicated by skin contracture. Prevention may require early skin grafting, especially when significant skin loss exists.

1 Subungual haematoma and melanoma

Melanoma must be considered in all patients presenting with a dark spot beneath the nail. A history of trauma does not automatically exclude melanoma. A haematoma is usually reddish-brown with sharp edges. A melanoma forms a dark brown or bluish-black discolouration of the nail bed with indistinct edges. The lesion of melanoma has mass to it and may elevate the nail. There may also be streaks of pigment in the nail plate. Eventually ulceration and bleeding of the nail bed occurs with erosion of overlying nail. Some tumours are amelanotic, forming red friable subungual plaques or papules. In contrast to melanoma, haematomas move distally with nail growth and are often accompanied by a depressed line and ridge (Beau’s line) in the overlying nail. When there is any doubt, the lesion should be treated as a melanoma, by biopsy excision after removal of the overlying nail.

A pyogenic granuloma adjacent to the nail fold may be difficult to diffentiate from amelanotic malignant melanoma. Pyogenic granulomas at this site are usually secondary to ingrown toenail, so the history and appearance is usually typical. When the diagnosis is not obvious, biopsy is necessary.

Mucous cysts of the fingers usually cause a subcutaneous lump proximal to the nail on the dorsal surface of the finger. Deformities in nail growth are commonly associated. If the cyst affects the nail bed alone, it will present as a subungual tumour and will require nail removal and biopsy.

Pigmented naevi of the nail bed are occasionally seen in Asians. The appearance of the lesion is that of a dense longitudinal pigmented band; its occurrence in Europeans is rare and biopsy is required.

2 Ingrown toenail

Ingrown toenail is the most common surgical condition affecting the nail and is classically located along the lateral edges of the great toenail. It represents an imbalance between the soft tissues of the nail fold and the growing nail edge. It is exacerbated by faulty nailtrimming, by constricting shoes and by poor hygiene. The pressure exerted by the shoe’s toebox pushes the great toe towards the second toe, resulting in pressure on the lateral aspect of the nail where it abuts the second toe, with the shoe itself exerting pressure on the medial aspect of the nail. A skin breach, due to the sharp edge of an improperly cut nail, is followed by infection and by succulent oedema and a poorly draining abscess. The resultant exuberant granulation tissue of the nail fold causes further imbedding of the edge of the nail and a vicious circle ensues. In the established case the nail acts as a foreign body preventing healing. The condition is most common in adolescent boys. Poorly fitting shoes and repeated trauma to the big toe, as in playing football, exacerbate the problem. The tendency for the nail to be ingrown may occasionally be due to a congenital excessively curved nail or a subungual exostosis producing doming of the nail plate. Heaping and rolling over of the nail fold on the nail also contributes. Ingrown toe nail is uncommon in adults but may follow injury or deformity of the nail bed.

3 Paronychia

Paronychia is an acute or chronic inflammatory condition of the lateral nail fold. Fingernails are more commonly affected than toenails. The condition is seen most frequently in those with constantly wet hands, such as dishwashers. Diabetes is a common predisposing factor. The condition is also common in patients with chronic fungal or yeast infections of the nail. Hypertrophy of the nail fold and rigidity of the nail leads to pressure necrosis and ulceration of the nail fold with secondary bacterial infection and abscess formation. The condition is often triggered by formation of a hang nail after lateral paring of the nail or trimming of the cuticle (eponychium). Paronychia is also more common in patients with Raynaud’s phenomenon.

4 Periungual warts

Warts of the nail fold and eponychium present particular difficulties in treatment and are often painful and subject to inadvertent injury. The warts may be confluent or isolated papules. Typical warts are also seen elsewhere on the hand in most cases.

5 Less common conditions

These include onychogryposis, subungual exotosis and glomus tumour.

Onychogryposis is a heaped and clawed appearance of the nail resembling a ram’s horn. The condition can be precipitated after repeated injury to the end of the toenail sufficient to interfere with the sliding growth of the nail on the nail bed, especially with sporting trauma and in people going barefoot. Onychogryphosis is, however, most commonly seen as an incidental finding in the elderly patient. The aetiology is unknown but may be a combination of lack of nail care and the presence of a fungal infection. Arterial ischaemia is not commonly a major problem in these patients but may contribute and should always be checked.

A subungual exostosis on the dorsal surface of the distal phalynx can contribute to disordered nail growth or to ingrowing toenail. The deformity is usually obvious and confirmed by X-ray.

A glomus tumour is an angioneuromyoma (a benign hamartoma). Presentation is with an exquisitely tender, small purple–red spot beneath the nail. The symptoms are characteristically markedly severe in relation to the physical findings.

1 Subungual haematoma and melanoma

Excisional biopsy and histological confirmation is essential before amputation of the finger or toe.

2 Ingrown toenail

All patients with an ingrown toenail should be instructed on correct foot and nail care. The patient is advised to wear correctly fitting shoes and to cut the end of the nail squarely, not at the sides, so that the nail can grow out from the nail fold (Fig 6.32). In the meantime the patient must attend to foot hygiene, including foot baths, avoiding the use of nylon socks and frequent changes of clean cotton or wool socks, and placing cotton wool beneath the nail edge to assist separation of the edge from the nail fold. Thinning the central portion of the nail with a nail file or razor blade makes the edge more pliant and easier to lift away from the nail fold.

Figure 6.32 Correct (A) and incorrect (B) trimming of toenails

Antibiotics are only indicated for associated cellulitis. In such instances drainage may be a matter of urgency, especially when the patient is diabetic.

Persistent or recurrent ingrown toenail requires surgical treatment. Avulsion of the nail may be indicated for severe purulent infection, especially when both sides of the nail are involved, and gives very effective drainage. Recurrence occurs on regrowth of the nail in about 30% of patients. Elective surgical treatment involves removal of the offending section of the nail and nail bed (wedge resection) so that regrowth and recurrence will not occur. The operation can be performed under a digital nerve block (Fig 6.33) or under general anaesthesia. Before the procedure is performed, the circulation to the foot must be checked — circulatory problems must be identified in older patients and problems prevented by alternative plans of management.

Figure 6.33 Digital nerve block

Adrenaline must not be added to local anaesthetic for a digital block.

In a simple wedge resection the affected side of the nail is excised and the underlying nail bed surgically removed and curetted, taking particular care to remove the entire lateral extension of the nail bed (the key to success). Zadik’s operation (originally described by Quenu in 1887) is a more radical procedure done for severe and recurrent disease. Two lateral incisions in the eponychium are extended proximally from the edges of the nail fold to allow the raising of a wide flap of skin and also distally along the nail fold so that granulation tissue can be excised. The entire proximal nail bed is excised so that regrowth of the nail does not occur. The exposed nail bed keratinises and becomes less sensitive, forming a ‘pseudo-nail’ with time (Fig 6.34). Incomplete excision may lead to dysmorphic regeneration of the nail and further symptoms.

Figure 6.34 Surgical treatment for ingrown toenail

A: wedge excision procedure. The lateral third of the nail is avulsed. The nail bed is either excised, curetted or ablated with local phenol; B: Zadik’s operation — the entire nail and nail bed, and the lateral nail folds, are excised.

3 Paronychia

This is treated initially by antiseptic-soaked dressings, elevation of the nail fold to drain pus, and antibiotics. Many abscesses can be drained satisfactorily through the point of necrotic fluctuant skin overlying the abscess. Occasionally the nail must be avulsed to establish free drainage of a subungual abscess. Careful avoidance of moisture and injury to the affected area is the most important element in the treatment of chronic paronychia. Diagnosis of chronic fungal paronychia is by culture of scrapings on Sabouraud’s medium. Treatment by local antifungal creams is helpful, but curative treatment may require several months of oral griseofulvin therapy.

4 Periungual warts

These are difficult to treat, especially if the wart extends under the nail plate. Available treatments include topical agents such as podophyllin and salicylic acid. The sclerosant action may be localised by painting around the wart with nail polish during treatment. Simple methods such as these are always first lines of treatment. Recurrent lesions require cryodestruction (liquid nitrogen), surgical curettage or electrocautery.

5 Less common causes

Onychogryposis. In young patients, limitation of repeated trauma must be achieved if recurrence is to be prevented after removal of the nail. Repeated trimming of the nail usually requires the use of heavy cutters. This is the preferred form of treatment in older patients where there is always concern for the adequacy of the peripheral circulation. A nail bed obliterative procedure is the only absolute cure.

1 Osteoarthritis

In the majority of patients over 60 years of age with osteoarthritis, no specific risk factors are apparent. In young adults, osteoarthritis is more often a sequelae of traumatic dislocation, slipped upper femoral epiphysis, Perthes’ disease, infection, rheumatoid arthritis or osteonecrosis. Pain is felt in the front of the hip or groin and may radiate down the inside of the thigh to the knee. It occurs with weight-bearing activities. At first the pain is more severe early in the day or when movement follows a period of rest. Later the pain is constant. It may even disturb sleep — particularly in those who turn regularly during sleep. Initally stiffness may manifest itself on rising by difficulty putting on socks and doing up shoe laces. On examination of the patient with moderate to severe disease, the affected leg lies in external rotation and adduction so that it appears to be shorter than the other leg (Fig 6.37). Some degree of flexion deformity can often be demonstrated by Thomas’ test. The greater trochanter can be felt higher and a little posterior on the affected side. Internal rotation, adduction and extension are the first movements to be decreased on examination.

Figure 6.37 Osteoarthritis of the right hip joint

The characteristic deformity is true shortening with external rotation of the lower limb. Flexion deformity may also be present.

2 Extrinsic causes of referred hip pain

As a general rule in these conditions, a full range of painless hip movement is present. The longstanding intermittent pain of lumbar spinal disc disease is often referred to the buttock or lateral aspect of the thigh. On examination, tender areas may be demonstrable in the back and buttocks and lumbar spine movements are limited and painful while hip movements are free. Neurological examination may show objective evidence of past disc prolapse and nerve compression, such as an absent ankle jerk. The pain of sacroiliac arthritis spreads diffusely over the buttock and may simulate hip pain. Sacroiliac arthralgia is characterised by local pain and tenderness over the sacroiliac joints. Sacroiliac arthralgia may herald the onset of ankylosing spondylitis. Chronic salpingitis may also simulate hip pain. The hip symptoms arise because of irritation of the obturator nerve and the hip muscles that have their origin within the pelvis. Pain in the hip related to vascular disease is brought on by exercise and relieved by rest. Evidence of peripheral arterial insufficiency will be present. Signs of ischaemia not present at rest may be induced by exercise.

Meralgia paraesthetica is a nerve entrapment syndrome causing pain over the lateral aspect of the hip and thigh in the distribution of the lateral cutaneous nerve of the thigh.

Referred pain should always be considered when full investigation of hip pain still leaves the diagnosis in doubt. Clinical and X-ray examination of the hip joint is found to be normal in these cases.

3 Less common causes

Less common causes include inflammatory conditions such as rheumatoid arthritis and Reiter’s disease, and paediatric conditions that lead to an altered surface geometry to the femoral head including slipped upper femoral epiphysis, Perthes’ disease and osteonecrosis. Osteonecrosis may be posttraumatic in those with previous fracture or dislocation of the hip joint, due to the intake of high-dose steroids or excessive alcohol or due to disorders of metabolism that somehow interfere with the blood supply to the femoral head. Most of these diseases affect younger patients. Occasionally tuberculosis and septic arthritis involve the hip joint.