Camptodactyly is a fixed flexion deformity at the PIP joint
of the little finger. The condition is an autosomal dominant trait involving
permanent flexion of the little finger. Camptodactyly may also be bilateral
affecting multiple digits. Unilateral 1/3 of the time and bilateral 2/3 of the
time. Camptodactyly occurs in less than 1% of the population, and it may be
associated with several congenital syndromes. Camptodactyly may be caused by
abnormal lumbricals and flexor digitorum superficialis insertion. Severe
camptodactyly may cause difficulty in grasping objects. Clinodactyly is
congenital curvature of the digit in the radioulnar plane. Treatment should be
done early with splinting, passive stretching, and physical therapy. Surgery
may be needed if the deformity is flexible, the patient may need tenotomy or
tendon transfer. If the deformity is severe and fixed, the patient may need
osteotomy or arthrodesis.
Female athlete triad is a condition that affects female
athletes such as gymnasts, dancers, or athletes with weight classifications
such as body builders. It is a syndrome in which amenorrhoea, osteoporosis, and
insufficient caloric intake affects certain groups of athletes. Each component
of the female athlete triad can occur from mild to severe. Not all components
need to be present, but if one component is found, the doctor should check for
the others. If you find a healthy, young female with stress fractures, ask
about her eating habits. The physician should examine the relationship between
the different components of the triad. The athlete will try to restrict their
diet in order to maintain lower body fat, and that may cause an imbalance of
energy (low caloric intake). This restriction of the athlete’s caloric intake
will lead to negative energy balance. Amenorrhoea results from energy
imbalance. Insufficient caloric intake is the most common cause of amenorrhoea
in female athletes, and it may or may not be associated with eating disorders.
Eating disorders can affect the brain’s regulation of the ovaries. This may
cause an absence of the menstrual cycle (amenorrhoea). It occurs in about 65%
of athletes such as runners and ballet dancers. There are two types of
amenorrhoea: primary and secondary. Primary amenorrhoea occurs when menstrual
cycles never start. Secondary amenorrhoea occurs when there is no menses for 6
months or absence of 3 or more consecutive menstrual cycles. Osteoporosis will
lead to bone fragility and often manifest as stress fractures. 90% of bone
mineral content occurs by the end of adolescence. The first step in treatment
is recognition of the disorder. Treatment includes prevention, correction of
the energy deficit, increase dietary calcium and vitamin D, maintaining bone
mass, resume normal menstrual function, and reduce training intensity. The
patient will need a multidisciplinary team including an athletic trainer, a
nutritionist, a psychologist, and a physician. Female patient with a history of
stress fracture should undergo a workup. This includes obtaining a menstrual
cycle history, nutritional consult, bone density, and psychological consult for
eating disorder.
Transient osteoporosis of the femoral head is not an
osteonecrosis of the femoral head. In transient osteoporosis, the symptoms are
usually more than the x-ray findings. It usually affects pregnant women, and it
also affects men during the 5th decade of life. On x-ray, you
probably will not find much. You may find osteopenia. The signal changes will
involve the femoral head and extend into the neck, and may include the
trochanteric area. In transient osteoporosis, there is no double density which
is seen in the MRI patients with osteonecrosis. Transient osteoporosis is not a
tumor, it is not an osteonecrosis, and it does not need surgery. Osteonecrosis
may be bilateral in about 80% of patients. Check the other hip even if the
patient is asymptomatic. Early diagnosis and treatment may improve the chances
for success of a head preserving surgical procedure, such as core decompression
or bone grafting. In late stages of osteonecrosis, the femoral head collapses and
cannot be saved. For the patient to have a good outcome, the femoral head will
need to be replaced at this late stage. MRI is usually the study of choice,
especially when the patient has persistent hip pain and the radiographs are
negative and the diagnosis of osteonecrosis of the femoral head is suspected,
especially if the patient has risk factors. On the T1 MRI, there will be a well-defined
band of low signal intensity usually within the superior anterior portion of
the femoral head. Decreased signal from the ischemic marrow, and there is a
single band-like area of low signal intensity (crescent sign). The crescent
sign represents the reactive interface between the necrotic and reparative
zone. The single line density demarcates the normal from the ischemic bone.
Double line sign is seen in T2 images. The subcortical lesion on T2 shows two
lines: low signal intensity line and high signal intensity line. The lesion
will show a high signal intensity inner border with a low signal intensity
peripheral rim (double line). The high signal intensity represents hyper
vascular granulation tissue. The size of the lesion is the most important
factor in determining the development of symptoms and the progression of the
disease. The best prognosis occurs in a small lesion with sclerotic margins.
The presence of bone marrow edema on the MRI is predictive of worsening of the
pain and future progression of the disease. Multifocal osteonecrosis is a
disease involving three or more sites such as the hip, the knee, the shoulder
and the ankle, occurs in about 3% of patients. A patient that presents with
osteonecrosis at a site other than the hip should undergo MRI of the hip to
rule out the asymptomatic lesion in the femoral head.
Osteoarthritis of the knee is the most common cause of
arthritis of the knee. The patient will complain of pain, swelling, stiffness,
and decreased range of motion of the knee. In arthritis, the cartilage of the
knee gets worn off. The meniscus which absorbs the shock, becomes degenerated
and tears. Which time, there will be more and more degeneration with wear and
tear on the knee joint. The joint space becomes narrower and narrower. When the
cushion of the cartilage is completely lost, the bone will rub against bone, causing
severe symptoms to the patient with severe pain, inability to walk, a lot of
swelling with the knee, and “giving way” (knee will be unstable). The x-ray
will show arthritis. When you ask the patient to stand or walk, the alignment
of the lower extremity is lost, and the patient may have varus or valgus
malalignment. With varus deformity, the bowing end of the leg occurs more with
medial osteoarthritis (common), and the patient will compensate for the
arthritis and pain in the knee by limping. The patient is trying to reduce the
weight being placed on the knee. The stance phase on the affected knee will be
shortened. The patient cannot take the pain any longer, so they are quick to
get the foot off the ground due to the painful knee. Arthritis can be mild,
moderate, or severe. To understand the arthritis, you need to know the anatomy
of the knee. Synovial fluid lubricates the knee joint. As you can see here at
the end of the femur and the tibia, there is hyaline articular cartilage which
is smooth and allows for smooth movement of the joint. There are no holes, no
fissures or cracks in the normal hyaline cartilage. For mild osteoarthritis of
the knee, the patient will have some discomfort, and the x-rays can appear
normal. The fabric of the articular cartilage breaks down. The process of wear
and tear, being overweight, and enzymes will affect the cartilage, and the
cartilage will break down (it is mild or minimal) which can be controlled by
nonsteroidal anti-inflammatory medication, weight loss and therapy. For
moderate osteoarthritis, there will be narrowing of the joint space on x-ray
due to degeneration of the cartilage. There will be cysts in the subchondral
space located underneath the cartilage, and there may be some osteophytes or
bony spurs. The joint will no longer be smooth (joint surface is roughened with
cracks and fissures). The patient’s pain will be worse with more swelling. This
is the time when the physician has a lot of options, but none of them are
optimal. You may try nonsteroidal anti-inflammatory medication or try weight
loss and exercises, steroid injection (viscosupplementation or hyaluronic acid
injections). Recently, long acting steroid injections is used. Other doctors
may try platelets and stem cells. None of the options are proven to be
successful. The only protocol that is proven to be successful is weight loss,
exercises, and nonsteroidal anti-inflammatory medication. For severe
osteoarthritis, the condition of the knee is bad. The joint space is severly
narrowed with total destruction of the cartilage. The knee is swollen and
painful with more osteophytes, and the bone is rubbing against the bone, and no
cartilage is left. There is no cushion and nothing to absorb the shock of the
weight, so the condition becomes very painful. The patient’s knee is like a car
that is running on its rim. Because the patient is walking on their own bone,
there will be decreased activity, and the patient will have an inferior quality
of life. Surgery is the best option for the patient and surgery is usually done
by a total knee replacement. Total knee replacement is like a house that has a
roof that leaked, you want to change the roof of the house. Total knee
replacement is the same thing. You need to fix the damaged roof of the house
and fix the destruction to the knee.
Infection of the finger is common, and it can vary in
severity. Serious infection of the fingers will require urgent surgical care.
Felon is a deep infection of the soft pad, or pulp, of the
fingertips. It is usually the result of a puncture wound. Swelling or pus is trapped
in the small compartments of the pulp or the tip of the finger. Symptoms
include unusual redness or swelling, firm swelling, throbbing pain at the tip
of the finger, or visible yellowish area of puss. If the infection goes
untreated, it may lead to severe symptoms such as skin necrosis, flexor
tenosynovitis, osteomyelitis, and arthritis of the distal interphalangeal
joint. Surgery is the usual treatment in the form of incision and drainage of
the felon. If there is no foreign body in the finger, you will do the midaxial
incision or the “J shaped” incision, and you will leave the wound open. If
there is a foreign body present, such as a splinter or a thorn, you will do the
volar longitudinal incision. Try to avoid doing the “fish mouth” incision; it will
lead to unstable finger pulp.
Symptoms of paronychia include swelling, redness, puss
formation, and pain in the soft tissue around the nail plate. Treatment is
antibiotics if the infection is caught early. Surgery is the usual treatment.
Incision and drainage with or without partial nail removal for subungual
abscess.
Herpetic Whitlow is a painful infection caused by the herpes
simplex virus that usually affects the fingers or the thumb. It is seen in
dentists, respiratory therapists, anesthesiologists, and toddlers (children who
suck their thumb). Symptoms include swelling, tenderness, redness, fever,
swollen lymph nodes, burning pain, and vesicle formation on the finger. It can
be grouped together with inflammation and redness at the base of the finger.
The fluid in the vesicle is usually clear (not purulent). The infection is
self-limiting. Conservative treatments include antiviral treatments applied to
the skin (acyclovir). Antibiotics are not used unless secondary infection is
present. Do not do surgery, surgery can make the situation worse.
Flexor tenosynovitis is a relatively common infection of the
hand usually caused by Staphylococcus aureus. It usually occurs due to prior
penetrating trauma and infection. The index, middle, and ring fingers are most
commonly affected. Symptoms include painful swelling of the finger that hurts
worse with motion. Flexor tenosynovitis has Kanavel’s four cardinal signs:
uniform swelling of the entire finger (fusiform swelling, finger looks like a
sausage), the finger is flexed, intense pain when attempting to straighten the
finger (occurs early), tenderness along the course of the tendon sheath (most
important sign). If the infection is caught early, treat with IV antibiotics.
If the infection is severe, do early open drainage of the infection to avoid
skin loss, tendon necrosis, and osteomyelitis. Surgical incisions used to drain
the flexor sheath infection. Use a midaxial or Bruner incision. Use two small
incisions, one proximally at A1 pulley and one distally at A5 pulley. Use an
angiocath for irrigation. Give culture specific IV antibiotics. Infection may
spread from the tendon into the deep palmar space or into the Parona’s space in
the forearm. The little finger communicates with the ulnar bursa. The thumb
communicates with the radial bursa. The radial and ulnar bursa communicate
proximal to the carpal tunnel. Infection may travel from the little finger into
the ulnar bursa to the Parona’s space. Infection can also travel from the thumb
into the radial bursa to the Parona’s space. Infection may cause “horse shoe”
tenosynovitis. Infection travels from the thumb through the radial bursa to the
ulnar bursa infecting the little finger. May need combination of incisions for
drainage.
The most common joint affected by gout is the first
metatarsophalangeal joint. The most common joint affected by pseudogout is the
knee joint. Gout and pseudogout both show a sudden onset of pain, redness, and
swelling typically affecting a single joint in 80% of the cases. Gout and
pseudogout are similar problems with different causes. Gout is caused by the
buildup of uric acid and the deposit of uric acid crystals inside a joint. The
best test to diagnose gout is with a joint fluid analysis. Gout crystals are
needle shaped and negatively bifringent. When placed under polarized light,
they will be yellow. 90% of patients suffering from gout are men between the
ages of 40-60 years old. Uric acid buildup in the body occurs by two main
mechanisms: excessive urate production and diminished urate clearance. Uric
acid is produced from the breakdown of proteins inside the body and from the
proteins of food that is eaten. Gout symptoms and signs include joint pain,
swelling and arthritis. Patients with gout have periarticular erosions along
with the formation of uric acid soft tissue masses in and around the joint
which can be seen on x-ray. Soft tissue tophus deposition with periarticular
erosions “punch-out” lesions. The tophi occurs due to deposition of uric acid
crystals. The tophus aspirate may look like tooth paste. The sudden attack of
gout can be brought on by anything that increases the level of uric acid in the
blood such as: dehydration, increased consumption of alcohol, eating large
amounts of meat or seafood, or trauma/surgery. Other risk factors for gout are
obesity, hypertension, and diuretics. Red meats, seafood, liquor, beer, all
increase the risk of gout. Vegetables, wine, dairy products, and total proteins
do not increase the risk of gout. Aspiration and analysis of the joint fluid is
the best method for diagnosis. Elevate uric acid is not diagnostic. 80% of
people with elevated uric acid will not get a gouty attack. There are blood
tests such as white blood cell count, C-reactive protein, sedimentation rate,
and uric acid level that are helpful in supporting the diagnosis if elevated,
but if these levels are normal, it cannot definitively rule out gout or
pseudogout. Every time you aspirate a joint and you get synovial fluid, you
need to analyze it for cell count differential, find out if you have crystals
or not and send the fluid for culture and sensitivity if you suspect infection.
It might be difficult to differentiate an acute gouty attach from acute septic
arthritis. Patients with an acute gouty arthritis may not have an elevated
serum uric acid level. A patient with acute gouty arthritis may present with
symptoms and a clinical picture that is similar to septic arthritis. Aspirate
the joint fluid, and the joint fluid will look like pus, but it could be gout.
You will take the fluid and examine it under the microscope (you will find
needle shaped, intracellular crystals, and you will think that it is gout). The
cell count of the aspirate may be high (may be 50,000-60,000) and the
neutrophils may also be high (may be 80%). The incidence of gout and associated
septic arthritis of a joint is low (about 1.5%). The incidence of septic
arthritis will increase to 11% or more if the cell count is more than 50,000.
We aspirate the joint (aspirate will look cloudy, like pus). We look for
crystals and if there is crystals, then it is gout, but the presence of uric
acid crystals does not exclude septic arthritis. We look at the cell count
(will be high, 50,000 or more). The neutrophil count may be 80% or more (we
think there is an infection in addition to gout or maybe gout alone). We need
to culture the fluid. After we aspirate the fluid and send the fluid for culture,
then we give the patient empiric intravenous antibiotics pending the culture
result. Remember that gout and septic arthritis can occur together, but the
incidence is low. The incidence will increase significantly if the cell count
is more than 50,000. Pseudogout or chondrocalcinosis is the deposition of
calcium pyrophosphate dihydrate crystals in the hyaline cartilage or
fibrocartilage (CPPD). Pseudogout is a metabolic disease where calcium
pyrophosphate dehydrate crystals (CPPD) are formed within the joint space.
Pseudogout most often affects the knee, occurs more in older patients, and is a
calcification of fibrocartilage (chondrocalcinosis). Pseudogout crystals are
rhomboid shaped and positively birefringent. Crystals will be blue when placed
under polarized light. Associated conditions include hyperparathyroidism,
rheumatoid arthritis, and gout. Aspirate to see if it is pseudogout or
infection, because you do not want to inject the knee with steroids when there
is an infection. You need to look for the rhomboid crystals of pseudogout.
X-rays in pseudogout will show thin calcification in the articular cartilage or
menisci. Calcifications of the synovium, tendon, and ligaments can also occur.
Acute gout can be treated with indomethacin or colchicine if the patient cannot
tolerate NSAIDs. Colchicine inhibits the inflammatory mediators and is
indicated if the patient cannot tolerate indomethacin. Chronic gout can be
treated with allopurinol to prevent buildup of uric acid. Allopurinol is a
xanthine oxidase inhibitor. Pseudogout is treated with NSAIDs and
intraarticular injections.
The knee bursa is a small, fluid filled sac located between
the front of the patella (knee cap) and the overlying skin. The bursa allows
the knee cap to slide freely underneath the skin as we bend and straighten the
knee. This is an inflamed bursa over the top of the knee cap. When the bursa
becomes inflamed, it is called bursitis, which causes pain, swelling,
tenderness and a lump in the area on the top of the knee cap. It may be
difficult to kneel down and put the knee the floor due to the tenderness and
swelling. Types of knee bursitis include suprapatellar, prepatellar (most
common), and infrapatellar. Knee bursitis can be caused by trauma such as a
direct injury or a fall into the knee which damages the bursa with the
development of sudden large swelling. Knee bursitis can also be caused by
occupational kneeling. Bursitis is chronic and develops slowly as seen in
carpet layers, tilers, and wrestlers. Infection can cause knee bursitis as well.
Inspect the bursa for any breaks in the skin leading to infection. Red, hot,
painful, and swollen bursa is a sign of possible infection. Wrestlers may have
abrasions of the knee, and this can lead to knee bursitis that may be infected.
Inflammation of the bursa can also cause knee bursitis. Treatment of knee
bursitis includes anti-inflammatory medications, ice therapy, aspiration, or
surgery. Do aspiration if infection is suspected or confirmed. Aspirate first
before you give antibiotics and send the fluid for culture and crystals.
Surgery is debridement and excision of the bursa may be needed. Protective
covering should be placed around the knee while avoiding activities that
aggravate the condition.
