Articular pathologies and Surgery of the Hand



1. Epicondylitis (elbow of the tennis player)



The epicondylitis é the inflammation of tendini and some muscles of the forearm that s'inseriscono on the situated bony prominenza on the lateral depositor of the elbow (epicondilo you see figure). Beyond to this more frequently hit muscular insertion on the epicondilo from the inflammatory process, short supinatore muscle, posterior interosseo nerve, ring-like legamento etc can be been involved also other surrounding anatomical structures () can be the origin of the pain on the lateral depositor of the elbow.

The hit subjects more

Not only the tennis players suffer from this pathology known for the note as “elbow of the tennista” for a wrong execution of the athletic gesture or for I use it of a raquet with grip and/or tuning how much can be been involved also other sportswomen, like the golfisti (because of the impact with tappetino on the field practical), the fencers or quite the common ones died them that they work to the computer.

The epicondylitis however is not appanage only the sportswomen. Generally the persons hit from the disease carry out working activities that impose the use frequent and extended of instruments like the hammer or the screwdriver, instruments that imply continue movements of the wrist and the elbow. The repetitive raising of objects, not necessarily heavy, with the surface to palmare of the hand turned towards the bottom, can trigger the disease.
Not to neglect also the eventuality of a lesion directed on this anatomical region that can determine a trauma with consequent damage to cargo of the muscular insertion and trigger the annoying symptoms of the epicondylitis. Wrap more of hit age turns out to be that one between the 30 and 50 years.




Not always easy, especially in the cronicizzate shapes, beyond to traditional examinations (Rx, Echo, EMG) the RMN can turn out useful, or better still a ARTRO-RMN SCAN in order to evidence is the periarticolari structures that endoarticolari, putting in particular evidence the thickening of the woven ones of the menisco omero-radial talora compressed from the adjacent articular structures.



Rest to articulate and complete abstention and/or drastic reduction of the activities that provoke the pain in combination to:

In the serious cases, when the pain limits the working activity, a local infiltration of cortisone can resolve the pain completely.


The surgical treatment turns out necessary only in the event the pain persists for along time (6-12 months) in spite of the medical and physical therapy. The surgical treatment can be executed in artroscopia cioé penetrating in the articulation with small surgical instruments in degree is to remove the menisco omero-radial that of disinserire from the inside of the articulation muscles epicondilode, sometimes associated to one superselective arthrotomy.

The post-operative riabilitativo treatment consists in a short period of followed rest from exercises of muscular potenziamento. The complete recovery of usual demands 2-3 months.


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2. The “flick” finger

The “finger to release” é an inflammatory disease that hits the tendini flessori of the fingers. The thin membrane that it encircles such tendini has the function to inside guarantee the optimal sliding of a channel that can be thickened in the zone of greater friction works them in structures, called pulegge of reflection, that they concur with the tendini of flettere the fingers to level of the digital articulations them (you see fig. To).

In case a portion of the tendini is thickened for an inflammatory process, these slides inside with hard work of the channel and, sometimes, “they jam”, jamming to level of the beginning of the same channel. The sliding of the tendini initially happens exactly to hard work provoking pain and crackle feeling or can be verified the classic “release” (sees figure b). With the flesso-extension of the fingers this “difficult” passage repeats migliaia of times in the course of the day creating the bases of the chronic inflammation that triggers the progressive already ingrossati increase of volume of the tendini, creating therefore a vicious circle that perpetual the inflammatory process.

Fig. To: Normal anatomy of the digital channel them with the tendini flessori, the sinoviale membrane and the pulegge.


Fig. B: the block of the sliding caused from the thickening of tendini flessori to the income of the digital channel them.

Affected people

l “finger to release” appears most times spontaneously, without appearing cause. Sometimes it can be secondary to traumi of the hand or appears in combination to diseases like diabetes, gotta, morbo of Dupuytren, reumatoide arthritis, the primary arthrosis of the hand. The hit age more turns out to be between the 40 and 60 years. The disease can hit also the children in the first months of life, usually to level of the 1° metatarso of the inch that remains blocked in bending.


  • The finger to release preferibilmente hits the inch, the mean and the ring finger but sometimes also the index and the mignolo.

  • PAIN to the simple digital movement them that it turns out anomalous, sometimes is possible to perceive the typical “release” without the effective perception of the pain to level of the prossimale interfalangea articulation of the fingers or the interfalangea of the inch, therefore in a center they to the real center of the problem tos be distant.

  • The “release” comes perceived of usual to the mattino to the awakening when the fingers appear flesse in the palm and the patient is forced to complete a discreet effort in order to execute the extension of the finger. Sometimes the patient must resort to the hand healthy in order to unblock and to extend the same finger. With proceeding of the day the symptomatology gradually is attenuated in order then to ripresentarsi the mattino successive.

The palpazione in the region to palmare can be talora painful and often it reveals the presence of a nodule that moves during the movements of the finger. In an advanced stage the finger can turn out blocked in extension or bending because of a simple inflammatory process of the sinoviale woven one that it encircles you stretch some and that it comes called “tenosynovitis”. In this case sometimes the movement of the finger happens with a crackle, but without the “true release” and just.

The radiografico examination is necessary in order to exclude that they can it are to you bony causes to the “block” of the sliding of the tendini. A ecografico examination can reveal in is made begins them the simple tenosynovitis.



  • Nocturnal tutor of position;

  • Cycles of fisioterapia;

  • Local infiltrations of mucopolisaccaridi to low molecular weight and amino acids lubricated to you and arnica;

  • Exceptionally infiltrations made up of cortisone;

  • Anti-inflammatory medical therapy (FANS or Cox-2).

In it makes begins them some of these remedies can find a justification but in it makes advances, when the episodes of “block” take place every morning and also during the day and the painful symptomatology the surgical treatment becomes ingravescente.


Surgical treatment

The most effective E' and concurs than to resolve the problem immediately avoiding the progressive damage of the tendini. The treatment consists in the sbrigliamento of tendini through the recording of the prossimale portion of the digital channel them, practically of 1° the pulley (Fig. c). The participation is amazingly express and hard little minuteren, come executed in local anesthesia and the patient can immediately move the fingers after the participation. Sometimes can become necessary for some days uses it of one metallic stick in order to recover the complete extension of the finger.

Fig. 3: Liberation of the tendini through recording of 1° the pulley


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3. The cysts of the wrist


The cysts of the wrist or “sinoviale ganglion”, are neoformazioni much common to dorsal level dell and to palmare of the wrist (see figures).


< TO < B< C



The gangliari cysts originate with a thin one peduncolo from the deep articulations of the wrist (Fig. c). The cause that determines the appearance of the cysts is today disowned.



Initially to their appearance the cysts can be painful, in order then subsequently to become asymptomatic at rest, generating eventual pain only in occasion of an intense and protratto use of the hand. The volume of the gangliari cysts can vary in the time and for reasons it probably connects you to the metabolism and to the feeding in fact they can talora regrediire completely for recidivare later on.



Essentially clinical the diagnosis I found myself on the center and the morphologic characteristics and of consistency of the neoformazione. The surgeon of the hand can think opportune to advise a radiografico examination of the wrist and the hand in order to evidence eventual concomitant problematic osteo-articular. Sometimes, a ecografico examination in the smaller cysts or the cysts not still obvious can be thought clinical necessary (cysts hidden) but suspected on the base of one painful symptomatology to level of the wrist.



  • Incruenta if the cysts do not provoke limitation works them and/or pain and is based on the simple clinical control of the neoformazione;

  • aspiration with needle of the liquid: in case the cysts turned out painful and limiting in the accomplishment of sport the working activities or or it was quite not accepted from the same patient;

  • armed polsiera that prevents the movement temporary to articulate of the wrist, being allowed however the development of the daily manual activities and of the working activities to read.

In failure case it must take in consideration the surgical treatment.


Surgical treatment

executed in general or plessica anesthesia (peripheral anesthesia to the base of the limb) and it usually demands a shelter of a day. The participation resolves to do to completely remove the cysts with its peduncolo. This can demand sometimes the removal of one portion of the cap to articulate of the wrist. In such case it can become necessary, after the participation, I use it of one polsiera armed to carry for approximately two weeks.

Later on the patient can gradually begin to mobilize the wrist. After the surgical participation some patients can complain for a sure period of time one light dolenzia and one modica tumefazione to level of the surgical scar. Such he disturbs concur however the resumption of the working activity. He can take place itself, in the 20-30% of the cases, the possibility of one recidiva of the time cysts artrogena at a distance variable.


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4. The tenosynovitis of De Quervain

Draft of an inflammation that takes the name from the Swiss surgeon who described it that he is involved the girdle that covers two of the tendini (abducent along and short drafter of the inch) that they come from the forearm and arrives you to the wrist pass inside of a girdle mails to the base of the inch and that they concur the movement of the inch.

The inflammation makes to increase the thickness and shrinks the opening of the girdle. That on hand reduces the space for the sliding of the tendini, than therefore they develop excessive friction to contact of the same girdle.


In red dark, you stretch of it short drafter clearly, in red its muscle.
In dark yellow, you stretch some abducent along, in clear yellow its muscle.
In green, the thickened and narrow girdle.



It hits persons who execute repetitive violent movements or much with the wrist or in subjects defedati from the nutrizionale point of view. For this he is frequent in the musicians, in the getlteman given over to the sewing and the embroidery, in who it uses a lot mouse or the keyboard of the computer and in the mothers, species in the last period of breast-feeding, when to raise the child it represents an intense and impegnativo effort. In effects, to the age of De Quervain, this it was known like the disease of the nannies and the ricamatrici.


Discreet possibility exists one to prevent the appearance of the disease, as an example avoiding to carry out for hours and hours the same type of movement, using correct positions and distributing the job, when possible, on the two hands.


  • PAIN in correspondence of the margin of the long wrist and the dorsal part of the inch;

  • sometimes the pain is diffused towards the forearm and gets worse in the movements of taken, like in opening a jar, to strizzare a cloth, or to turn one key;

  • other symptoms can be the rigonfiamento of the girdle that is of hard consistency: many patients in fact believe that this thickening has had to the appearance of “an ossicle that before not was”;

  • rather frequent it is the formicolio to the back of the inch provoked from the irritation of a small nervous branch that passes over the thickened girdle.



The diagnosis is based on the description of the symptoms, that they are much characteristic.

SIGN OF FINKELSTEIN: draft of a test a lot used that it is executed making to inside tighten the inch of the other fingers sluices to fist and at the same time asking the patient to tilt the wrist in the opposite direction to that one of the inch. This maneuver provokes an intense pain in the center in which the girdle it is narrow.


An echography can be useful, while the x-ray is useless, since not extension some alteration.


Therapy incruenta

In it is made begins them the treatment it is conservativo and it consists in the temporary suspension of the responsible manual activities of the mechanical stimulus to level of the channel.

Profit technical the contentivo handwraps or the application of a position tutor that immobilizes the wrist and leaves of the inch concurring however great part of the daily manual activities. Talora a cycle of therapy with drugs antiinflammatoryren can mitigate the disturbance.


Which arnica and echinacea and/or non-steroidei (FANS or Cox-2) to a fisioterapia cycle can also come employ natural anti-inflammatory drugs in combination to you.


Fisiokinesiterapia, exacta to the tekarterapia, to try even if often sortiscono do not turn out hope to you to you. E' possible moreover to practice an infiltration of cortisone directly in the channel of the tendini inflames to you. The treatments conserved list to you to you resolve the painful symptomatology in 70% of the patients.


Surgical therapy of the advance shapes

Qaundo the pain is intense and/or persistent or if it disturbs do not resolve with drugs and the tutor, it becomes indicated the surgical treatment.

The participation, that it comes carried out with the anesthesia of all the limb and in Day Hospital, has one duration of approximately 15 minuteren.

The operation consists in opening the tendinea girdle that is narrow, therefore to eliminate the friction between girdle and tendini.

After the participation the hand and the inch come immobilize in one chalk stick or rigid untutore to you for 10-12 days. Passed this time they come removes the points to you and a short program of riabilitazione of the hand is begun.

In the photo, the line of cutaneous recording of the surgical participation


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5. Dupuytren disease


The disease of Dupuytren consists in a thickening of wraps to palmare, that is of the interposed woven one between cute of the palm of the hand and the tendini flessori. Such thickening can give origin to a true and own stiff rope from the palm of the hand until to the fingers whom the movement of extension of a finger limits or more fingers rendering impossible the complete opening of the hand (Figure To)





In 80% of the cases, the M. of Dupuytren, regard the male sex, however it is dimostratata from clinical a sure familiar predisposition that can favorite and be aggravated from heavy unskilled labors, or from pathologies as antipeilettici diabetes, alcoholism, or drugs type “Gardenale”.

Considering that the disease unavoidablly progresses and is aggravated, how much the more will be taken part prematurely, much more it turns out to you will be better.


Hit subjects more from pathology

Patients of male sex. The disease usually rebels to the age of 40 years and often famous one familiar distribution. Some patients can introduce stricter shapes and in such case the age of insorgence is more premature and the localization diffused to both the hands and more very rarely to the feet.



The disease rebels much slow and progressive and manifest with the appearance of one small tumefazione d hard-elastic consistency that stretches to become a small nodule fibrous or, sometimes, of an area of cutaneous retraction in the palm of the hand. Such formations appear of usual in correspondence of the palmari pliche along the axis of 4° or 5° the finger.

Sure patients instead report only begin them sense of rigidity-annoyance localized in the palm of the hand with the compulsiva tendency of massaggiare the cute to palmare, to this clinical phase follow at a distance of time usual, the progressive appearance of the nodule and/or the cutaneous retraction. With passing of the time it is possible to find the formation of true and just a stiff fibrous cord to caorda of arc between the palm of the hand and the finger or the hit fingers. The patient moreover notices of the disease when she states that the palm of the hand cannot completely be supported to plate on one surface like that one of a table (figure B).


Such clinical picture can remain invariato for years and practically to arrest itself definitively or to get exausted itself momentarily for evolvere then progressively until the complete retraction of one or more fingers in the palm of the hand. In the serious cases the retraction of the fingers in the palm of the hand can interfere with the normal daily activities like washing the hands or the ace, wearing gloves or to thread the hands in the pockets.




Needle aided microsurgery treatment

Draft of one technical minium-invasive, consists in the multiple section of the aponeurotica sclerosis, thickened and retratta, executed with a agosonda based on following is made:

  • Local anesthesia;

  • Without shelter, in day-hospital;

  • Minium-invasive technique, without opening of the fingers and the palm of the hand: the needle cuts in subcutaneous wraps it to normally palmare retratta in various points and therefore allonge;

  • No time of cicatrization;

  • Minimal riabilitazione;

  • No suspension of the job;

  • Very rarely a nocturnal tutor will use itself.

This technique is, unfortunately, a lot often forgotten or not known from the specialists, for which too many sick ones they cannot benefit some.


Classic surgical treatment

  • General or native place-regional anesthesia of the arm;

  • Shelter hospital worker for 24~48 hours;

  • Wide opening, only or multiple, of the fingers and the palm of the hand for the removal of wraps to palmare thickened and retratta;

  • Cutaneous cicatrization of 2 weeks;

  • Riabilitazione of 1~2 months;

  • I use of nocturnal tutor for the operated fingers;

  • Suspension of the job of 1~2 months for the manual workers.

The treatment is surgical and consists in the removal of wraps to palmare and digital retratta them. The treatment comes executed in general or pelvic anesthesia (peripheral anesthesia to the base of the limb) and usually demands a shelter of a day. The isolated presence of a nodule does not constitute an indication to the participation, but it demands a periodic control from part of a Surgeon of the Hand. The distribution of the cutaneous manifestations can turn out useful to such care to mark on a representing design the palm of the hands begins them of the disease (Figure C).


The progressive retraction in bending of a finger to level of the metacarpofalagea articulation determines a limitation works them of the such hand to justify the surgical participation, considering also that, in a premature stage, the aponevrectomia turns out simpler. In it is made intermediate or advances, when the retraction in bending verification also to level of the prossimale interfalangea articulation being involved capsulo-legamentose structures, the complete removal of wraps to palmare and the recovery of the extension of the finger turns out more difficult and, sometimes, it can not happen completely. The cute of the surface to palmare over a long time span of the hand, remained retratta and often maceration center it demands, in some cases, the cutaneous plastic resource in order to concur the complete extension of the finger. At a distance variable of time from the participation it is possible, even if rare, to have one recidiva of the disease, that is reforming itself of a fibrous cord to level of the same digital beam operated them or in other centers of the palm of the hand.


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6. Syndrome of the Carpal Tunnel




The Carpal Tunnel Syndrome is a disease caused from the jam of the median nerve, that Carpale Tunnel inside crosses the wrist of a called channel. This nerve controls the sensibility of the inch, the index, the mean and of a part of the ring finger and the movements it correlates you to the sinergica activity of small muscles, it calls tenari muscles to you, it situates you to the base of the inch (figure To).

To      B



The Carpale tunnel is one circumscribed anatomical region and very defined of the base of the palm of the hand and circumscribed on three sides from boneses of carpo and on the fourth side from a legamento a lot often called Legamento Trasverso of the Carpo. The median nerve with to nine tendini flessori slides in this channel (Figure B).



The Syndrome of the carpale Tunnel is the result of the conflict works them that every time can be verified that produces an increase of pressure inside of the such channel to disturb to the element more weak person than this system, that is the median nerve. Most times the increase of pressure inside of the channel verification for an increase of volume of the membrane that covers the tendini flessori, called condition tenosynovitis, articular luxations, fractures of the wrist that can moreover determine one excessive pressure and a venetuale narrowing from the outside of the responsible channel in its turn of an ulterior increase of the present pressorio regimen inside of the same channel.


Hit subjects more

The syndrome of the Carpale Tunnel is one disease much frequent one. Working activities that involve repetitive movements of the fingers and the wrist can inside be the cause of the inflammation of the tendini flessori of the channel and therefore of the suffering of the median nerve. The persons who often work to the PC complain such symptoms and in such cases it is useful to resort to of the ortesi works them.


The women come frequently hit during the pregnancy because of the retention of liquids that inside determines an increase of volume of the channel. The symptoms often are resolved spontaneously with the term of the pregnancy. The women often come hit also in the period of the menopause. The appearance of the characteristic symptoms of the syndrome of the carpale Tunnel often happens in concomitanza with a gessato apparatus applied for one wrist fracture. Diabetic patients or dializza you or with diseases of the tiroide or reumatoide arthritis they can develop a Syndrome of the Carpale Tunnel, often caused just from a thickening of the membrane that covers the tendini flessori.



Formicolio of usual, more emphasized than night the much risvegliare patient and to force it to search one position of the wrist and the hand in order to reduce the annoyance. In the stages more it advances the loss to you of sensibility and the pain appears by day also in concomitanza with simple daily activities like guiding the automobile or reading a newspaper or to hold the cornetta of the telephone or in concomitanza with working activities that demand repeated movements of prensione;

Feeling of bruciore (or pain) to the first 3-4 fingers of the hand, often only to 3° and 4° the finger;

Often extended pain to the forearm, talora to the arm and more very rarely to the shoulder;

REDUCTION DELAL FORCE PRENSILE, with difficulty to seize some objects that can fall without warning from the hands;

LOSS OF THE TONE AND MUSCULAR VOLUME; the patients can notice also one “loss” of the musculature to the base of the inch (atrophy tenare). The symptoms can be present in both the hands, but usually they are gets worse on one side.



Beyond that on the base of the clinical history the diagnosis comes mail with the aid of a called examination Elettromiografia (EMG) that concurs the recording of the activity of muscles and the nerves. The examination, of the duration of 15 minuteren approximately, can turn out annoying than more painful generally less (than how much s'immagini) and usually is very tolerated from the patient who immediately after can resume the normal activities (job, guide, sport…). Other nerves can come estimated with the same examination so as to to be sure that the symptomatology reported from the patient is due only to the jam median nerve to the wrist and that is not instead the consequence of neurological problems it generalizes to you.


The RMN (artroscan) of the wrist is useful, therefore as the RXo of the wrist, especially if osteoarticolari problems to level of the wrist are suspected.


Surgical therapy

The symptomatology is of solvable usual surgical, however in the stages it begins them and light, it can incruentemente talora be resolved. The identification and the medical treatment of the eventual disease of base, the change of particular a working gestualità, the use of a rigid tutor (polsiera army, in order to guarantee a correct postura of the wrist in rest position during the working activity, can be revealed useful in order to reduce the jam on the median nerve.

Endoscopic therapy

In cases it selects, we execute with succeeding also the technique to you for via endoscopy, that small recording consists in practicing one on the depositor to palmare de wrist through which comes inside introduced of the carpale tunnel a probe to fiber optics that concurs to visualize the legamento trasverso and, at the same time, sezionar decompressing it the nerve.

The duration of the participation is short and comes of usual executed in local anesthesia and regimen of day-hospital therefore that the patient will be able to return to the own room the same day. The patient must begin immediately to move the fingers.

The resumption of manual activities to read like dressing themselves, eating and the personal hygiene happen within one week from the participation.

I use suit of the operated hand happens in the 4-6 turn weeks. The surgical treatment determines of usual the immediate passing of the formicolio nocturnal. It can residuare, however, for some weeks or, sometimes, also for months a dolenza localized to level of the scar to palmare that it can appear reddened and hardened. Such it disturbs are assigns to you however to resolve itself spontaneously also at a distance of a year. In the serious cases, when the jam of the nerve lasts from much time, the surgical treatment can not resolve the symptomatology completely.


Contenitiva Polsiera

The use of one polsiera armed also with night can, sometimes, resolve the formicolio that it disturbs the sleep.

Medical Tetapia

Also medical therapy (FANS or Cox-2 and Gabapentin) antiinflammatory somministrata for oral way or an infiltration of cortisone directly in the carpale Tunnel can, sometimes, resolve the symptomatology. If the symptomatology does not improve the surgical treatment it turns out necessary and it has the scope to create more space in the carpale Tunnel being reduced therefore the jam on the nerve. The treatment consists in one small recording of the cute of the palm of the hand and in the successive recording of the legamento trasverso of carpo (Figure C).





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7. Lesions of the flexor tendinis


The muscles that flettono or close the fingers are found to level of the forearm and flessori muscles are called. Such muscles are in a position to flettere the fingers thanks to cordiformi structures calls tendini that they become part to the falangi.

The inch possesses along flessore muscle that through along you stretch some becomes part to the falange tos be distant them. The other fingers have two flessori muscles ognuna, the superficial flessore muscle and deep the flessore muscle. You stretch some of the superficial flessore muscle one becomes part to the falange intermediate and she has the task to fold the finger to level of 2° the articulation of every finger, while that one of the deep flessore becomes part to the falange tos be distant them and has the task to fold also 3° the articulation of every finger.

To level of the fingers the tendini they passes in a digital channel that it turns out constituted deeply from a sinoviale membrane that encircles both the tendini and of it it favors the mutual sliding and more superficialally from ciamati fibrous thickenings pulegge of reflection cha they have the task to maintain the tendini to contact with the bony plan during the bending of the falangi.

A deep cut to level of the wrist, the palm or the fingers can interest tendini flessori and also the important nervous and vascular structures. The lesion can appear practically initially simple but to be much complex. When ransom, you stretch some it is behaved as elastic and a two extremity goes away one from the other. Since the greater part of the lesions from cut happens while the fingers are flesse, the cut tendinee extremities goes away ulteriorly when the finger comes straightened for the clinical examination. To second of the center of the lesion we can have the section of a solo you stretch some and the finger can partially maintain the ability to flettersi. If the lesion happens more neighbor to the base of the finger can have the section of both the tendini and the finger completely loses the ability to flettersi. At last the lesion from cut puo sezionare only partially you stretch some and the finger can maintain the ability subsequently to flettersi but to lose it for one secondary breach.



For all these reasons are not unfortunately infrequent that a tendinea lesion comes or not riconosciuita or underrated when the examination of the wound from cut comes made in hurried and inadequate way. We at last remember the subcutaneous breaches from tendinea avulsion to level of its insertion tos be distant them that they are involved often sure disciplines sport like rugby or the climb, lesions that ill-fatedly pass initially inossevate. The interested finger more is the ring finger. The lesivo mechanism consists in a forced extension while the flessore muscle strongly is contracted sometimes and that determines the avulsion of stretches of it and its retraction also to level of the palm. Also such lesion goes ready recognized because you stretch some must be recovered and be made to slide through the intact digital channel them within at least 7-10 days. Beyond such period you stretch some degenerates and swell and it will not be more possible to make it to slide in its channel and reinserir it in the bone.




The tendinea relief

The tendini they are constituted from alive cells and woven connecting. If the tendinee extremities are brought back to contact taking part surgical, the guarigione has beginning inside of stretches of it thanks to the cellular member and outside of you stretch of it thanks to the connettivale member. The recovery of the tendinee extremities is not however always simple. Often it must record a part of the digital channel them with the relative ones pulegge, woven that they come been involved to they time in the repair process.
All this woven production of connettivale outside of you stretch some can involve which is the more frequent complicanza of the surgical treatment of the tendinee lesions, the adhesion of tendini from each other and to the digital channel them, that it provokes to a block of the sliding and a deficit of active movement of the finger. To this it can be only obviated with particular a riabilitativo outline that the patient must carefully execute in the post-operative one.


The other complicanza is instead the yielding of sutura or tendinea repair, and also in this case that happens if the riabilitativo outline equally is not corrected. Practically in post operating and based on the type of lesion and executed repair the area center of the lesion it will come or protect from every movement or will come granted a particular outline riabilitativo. Ta l and outline concur with the finger or the fingers center of the lesion an active movement in extension and liabilities in bending so that a sliding of the tendini happens without some resistance to level of sutura tendinea in order at least 4-6 weeks.



After which it will come granted to the patient to begin weak people active movements in bending without resistance reminding that the complete process of guarigione usually demands approximately 3 months. In the greater part of the cases a complete recovery of the movement will not be had however also because the cicatriziale adhesion is from considering a part of the normal process of tendinea guarigione.
If however the aderenziale process is excessive to the point that the bending and the ectification of the finger turn out difficult in spite of the riabilitativo outline an ulterior surgical participation has been executed correctly will be necessary, called “tenolisi technically”, with the scope to eliminate the peripheral adhesions to sutura tendinea. Also such participation will be followed from a precise riabilitativo outline.


And' important to emphasize that through controls clinicians it only draws near the terapista or the same surgeon to you will be in a position to understanding if the patient is executing the riabilitazione correctly. In the inveterate tendinee lesions dealt not correctly or recognized sometimes the cicatriziale process is not such that it becomes necessary to clean up the sliding channel completely and to replace you stretch some or both the tendini with a tendineo graft captured from the same hand or others you leave of the body. Also in this case the patient will be subordinate to a particular riabilitativo outline.


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8. The arthrosis of the hand


Which thing is?

Most frequent between the diseases of the articulations it is sure the Arthrosis, disease characterized from the slow and progressive degeneration of the cartilage to articulate. The hand comes hit from the arthrosis in some characteristic centers that are, in frequency order, the interfalangee articulations tos be distant them, the prossimali interfalangee articulations and the articulation trapeze-metacarpale, to the base of the inch. Very rarely they come hit the metacarpofalangee articulations or the wrists.


From what it is caused?

It comes defined commonly osteoartrosi primary because of usual the cause is not characterized any. Sometimes it comes defined secondary because he turns out consequent or to traumi or working activity characterized from repeated gestures or to articular infections. The arthrosis can be manifested moreover associate to other reumatiche, often confused diseases with the osteoartrosi primary, like as an example the psoriasica arthropathy or the reumatoide arthritis. The arthrosis of the hand progresses with the age of the patient. Signs radiograph to us typical of the arthrosis of the hands can be found in 8O% of the population beyond the 65 years of age; to of under of the 45 years it appears with equal frequency in the male and feminine sex while beyond 5O the years they mainly turn out hit the women.



The light symptoms appear gradually and are of usual and not correlabili to the signs it radiographs to us characterizes to you from the narrowing of the space to articulate and from the formation of osteofiti or bony appuntimenti. Only 1O% of the population introduce symptoms like pain, rigidity to articulate and loss of function of such intensity to demand the participation of the doctor.



The conservativo treatment, beyond to the occasional somministrazione of anti-inflammatory (FANS or Cox-2), can comprise cortico infiltrations steroids, cycles of fisioterapia like paraffin baths, ultraplays or ionoforesi and I use it of position tutors to carry above all during is made acute of the inflammation. In rare cases and for particular clinical manifestations the surgical participation only becomes necessary.


Particular pictures


The osteoartrosi erosive consist in acute inflammatory varying of the osteoartrosi primary and also hit of usual the women in menopause being able to begin also in 3° and 4° the decade. In this case the articulations more hit, also in asymmetric way, are the interfalangee to be distant them of the fingers. The debut can be also much painful to level of one single articulation. The osteoartrosi erosive, with the exception of the osteoartrosi primary, determine one fast and massive destruction of the cartilage to articulate and the bone provoking, in the arc of some years, marked axial shunting lines. The base of the last one falange of the fingers appears of increased usual and dancing causing one clean limitation of the prensione. Also in the osteoartrosi erosive the treatment in is made begins them is sintomatico and consists in the use of small digital tutors them in is made acute of the inflammation. When the instability picture to articulate limits the total function of the single hand the surgical treatment, based of usual on the artrodesi or “fusion” of the articulations hit, it can be a useful treatment.


The nodules of Eberden are painful rigonfiamenti situate to you on the dorsal face of the interfalangee articulations to be distant them of the fingers. They are the sign more obvious than arthrosis of the hand and they are manifested more frequently approximately 1O times in the woman who in the man. These nodules are developed initially in way graduate them, without pain and of usual they only hit a finger for time. To the fine all the fingers can introduce the nodules of Eberden and confer to the hand a homogenous knotted aspect (Fig. 1).


< Nodules of Eberden        < Cysts mucosae


Very rarely the development of the nodules turns out more express with reddening and pain in particular after extended use of the hand. Sometimes the manifestations and the symptoms are therefore acute to simulate an infection. Of usual after some months the flush and the tumefazione, recedono spontaneously, leaving to of over of the dorsal face of these small articulations one thickened and not painful callosity. The rigonfiamento to articulate turns out caused from a thickening of the soft woven ones beyond that from one proliferation of cartilage to level of the bony insertion of the cap, the legamenti and the tendini. This progressive increase of the articulation can succeed in to determine a lateral shunting line or in bending of the falange they tos be distant. Very rarely a surgical treatment is indicated. Only the in a marked manner turned aside painful articulations and justify the surgical treatment that consists in the artrodesi that is the “fusion” to articulate that it restores the necessary stability to one good taken.


The cysts mucosae or mucoidi are generally associated formations to the arthrosis of the small articulations to be distant them of the fingers or the inch. They are small peduncolate cysts that contain sinoviale liquid and the articulation and the base of the nail are developed between. One thinks that these cysts always are associated to dorsal osteofita.


The cysts turn out of hard consistency to the palpazione and because of their progressive increase of volume the cute that it covers to them can become much thin one, nearly transparent. Left in center can determine a dystrophy of the nail that is of usual one of the causes that push the patient from the doctor. An other problem consists in the fact that cute that it covers the cysts can become more and more thin with the risk to ulcerarsi determining an infection of the articulation. Of cysts in the event mucoide in evolution, above all if much painful one, the surgical treatment of escissione of the cysts with its peduncolo and the osteofita small is sure the ideal treatment.

The nodules of Bouchard represent the clinical manifestation of the arthrosis to level of the prossimali interfalangee articulations. The debut is much slow one and usually characterized from dolenzia articulating to the movements and rigidity early riser. In extension is made begins them the radiografico examination some interest not to articulate and the treatment must be sintomatico and to comprise drugs antiinflammatoryren and tutors of position in particular in is made acute of the sinoviale inflammation. With passing of the osteofiti time but the formation of to the margins of the articulation nodules of Bouchard exactly confer to the finger a fusiform aspect with typical the nodosità lateral calls. In the cases more it is left over to you can be arrived to the shunting line of the axis of the hit finger, of usual in direction to ulnare because of the direction of the force applied on every finger during the prensione with the inch. Often the nodules of Heberden and the nodules of Bouchard coexist in more fingers of the same hand causing however an impediment works them inferior to what us it could be waited for from the radiografico aspect. In it makes advances, characterized beyond that from the axial shunting line of the finger also from limitation of the movement and above all from pain, the treatment is surgical and consists here also in the artrodesi of the articulation hit (generally indicated for 2° and 3° the finger that must sopportare greater sollicitations) or in the protesica substitution of the articulation.



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