HAND AND FOOT

HAND
SURGICAL ANATOMY
Surgical Anatomy of the Hand
Flexor Retinaculum
_ It extends medially from pisiform and hook of hamate,
laterally to scaphoid tubercle and trapezium crest as a strong
fi brous band so as to bridge carpus to create a carpal tunnel.
_ Ulnar nerve and vessels, palmar cutaneous branches of
median and ulnar nerves, palmaris longus muscle are superfi
cial to the carpal tunnel.
_ Median nerve, tendons of fl exor digitorum superfi cialis,
profundus and pollicis longus, radial and ulnar bursa are
deep to fl exor retinaculum.
Palmar Aponeurosis
It is a thickened, modifi ed deep fascia in the palm with its apex
pointing proximally (as continuation of palmaris longus) and
base distally which in turn gets divided into four parts. They
extend over deep transverse ligament into lumbrical tunnel.
Blood Supply of the Hand
_ Superfi cial palmar arch is mainly formed by ulnar artery and
completed by superfi cial palmar branch of radial artery. It
gives four digital branches to medial three fi ngers.
_ Deep palmar arch is formed by radial artery and is completed
by deep branch of ulnar artery. It gives three palmar metacarpal
arteries which communicate with superfi cial palmar
arch. It also gives communicating, perforating branches to
dorsal metacarpal arteries.
Muscles of the Hand
_ Thenar muscles: Abductor pollicis brevis, fl exor pollicis
brevis, opponens pollicis and adductor pollicis.
_ Hypothenar muscles: Palmaris brevis, abductor digiti
minimi, fl exor digiti minimi and opponens digiti minimi.
_ Lumbricals are four in numbernamed from lateral to
medial.

_ Four palmar interossei.

_ Four dorsal interossei.
Nerve Supply
_ Abductor pollicis brevis, fl exor pollicis brevis, opponens
pollicis and 1st and 2nd lumbricals are supplied by median
nerve (5 muscles).
_ Rest of the muscles in hand are supplied by ulnar nerve
CHRONIC PARONYCHIA
It is commonly due to fungal infectiondue to candida infection
commonly.
Clinical Features
_ It is common in females.
_ Nail is diseased with ridges and pigmentation.
_ Itching in the nail bed.
_ Recurrent pain, discharge
_ Secondary bacterial infection may supervene.
Investigation
Culture of scrapings for fungus and other causative agents.
Treatment
_ Long-term antifungal therapylocal and systemic.
_ Antibiotics for secondary infection.
_ In severe cases removal of nail is required.
APICAL SUBUNGUAL INFECTION
_ It is infection of the space between subungual epithelium
and the periosteum.
_ It occurs after minor trauma or rarely after formation of
subungual haematoma.
_ Beneath the free edge of the nail, pus comes to the surface.
_ Excruciating tenderness with small visible pus under the tip
(summit) of the nail is the feature.
_ Drainage with V incision over the summit is the treatment
along with antibiotics.
_ Osteomyelitis is not common.
TERMINAL PULP SPACE INFECTION
(FELON)
_ It is the second most common hand infection (25%).
_ Index and thumb are commonly affected.
_ Usually by a minor injury like fi nger prick.
Surgical Anatomy
_ Terminal pulp space contains fat and is partitioned by septae
which is attached from periosteum of terminal phalanx to

skin.
_ Proximally deep fascia is attached to the periosteum distal
to the base of terminal phalanx, i.e. distal to the attachment
of fl exor tendon.
_ So, terminal space is a closed compartment, as the result
of which pressure increases when there is infection,
compressing terminal artery leading to thrombosis, resulting
in osteomyelitis of terminal phalanx.
Bacteria
_ Staphylococcusmost common.
_ Streptococcus, Gram-negative organisms.
Clinical Features
_ Pain, tenderness, swelling in the terminal phalanx.
_ Fever.
_ Tender axillary lymph nodes.
Often suppuration is severe, forming collar stud abscess
which eventually may burst.
HAND INJURIES
Classification
_ Tidy injuries: They are clean incised wounds and are usually
treated by primary suturing but depends on the tissues
involved like nerves, tendons and muscles.
_ Untidy injuries: They are lacerated wounds. Treated by
debridement and later by delayed primary or secondary
suturing.
_ Compartment injuries.
_ Degloving injuries
_ Indetermined injuries which could not be assessed.
Primary repair of tendons and nerves are of lesser priority
in untidy injuries. Priority is wound debridement/ wound
excision and early skin cover. Cut ends of nerves and tendons
are tagged with coloured stitches for future identifi cation
purpose.
Complications and morbidity of hand injuries
_ Infection
_ Osteomyelitis
_ Arthritis of joints
_ Stiffness
_ Loss of function due to disability

DUPUYTRENS CONTRACTURE
It refers to localised thickening of palmar aponeurosis and
later formation of nodules with severe permanent changes
in metacarpophalangeal and proximal interphalangeal joints.
Terminal interphalangeal joint is not involved as palmar
aponeurosis does not extend to terminal phalanx. It is common
in males (10:1).
_ It starts in ring and little fi ngers, with fl exion of ring and
little fi ngers. Later involving all fi ngers.
_ There is thickening and nodule formation in the palm with
adherent skin.
_ It is often familial and bilateral 45%.
_ Pads (of fat) develop in knuckles and are called as Garrods
pads (in proximal IP joints).
Conditions often associated with:
_ Plantar fasciitis 5%Ledderhoses disease
_ Mediastinal and retroperitoneal fi brosis
_ Peyronies disease of penis 3%
_ Nodules in the face and ear
_ Pellegrini-Stiedas disease
Aetiology
_ Repeated minor trauma, use of vibrating tools.
_ Cirrhosis, alcoholism, smoking,
_ Epileptics on treatment with phenytoin sodium.
_ Diabetics, pulmonary tuberculosis, AIDS.
_ Other metabolic conditions.
_ Familialautosomal dominant.
Galezia triad
_ Dupuytrens contracture
_ Retroperitoneal fi brosis
_ Peyronies disease of penis
Complications
_ Restriction of hand function and so disability.
_ Arthritis of MCP and proximal IP joints.
TREATMENT
Haemostasis.
_ Use of tourniquet.
_ Wound debridement and cleaning.

_ Antibiotics and antitetanus treatment (toxoid and antitetanus

globulin).
_ Primary suturing if it is a incised wound or delayed primary
suturing if there is odema.
_ Skin grafting or fl aps for skin loss.
_ Tendon suturing or tendon graft for tendon injuries.
_ Rest and elevation of the affected parts.
_ Management of fractures by splint, wiring.
In hand
Dos Donts
Do examine hand carefully Do not incise every infected digit
Do think of other diagnosis Do not make puncture incisions or over pads
Do wait for abscess to localise Do not injure the digital nerves or vessels
Do place adequate length and depth of incisions Do not place incisions crossing
the crease line
Do immobilise, elevate the hand Do not close human bites or lacerated wounds
Do give antibiotics and proper dressings Do not forget to send pus for culture
and sensitivity.

FOOT
SURGICAL ANATOMY
Foot contains 7 tarsal bones, 5 metatarsals, 14 phalanges (total
26 bones). Two sesamoid bones of 1st metatarsal bone are
common. There are 4 layers of muscles in foot. Ligaments,
muscles, joints, maintain the stability of foot complex. Blood
supply is by anterior tibial, posterior tibial and peroneal
arteries.
Nerve supply is by saphenous, sural, posterior tibial, superfi cial
and deep peroneal nerves.
PLANTAR FASCIITIS (Policemans Heel)
It occurs due to friction or tear of the ossifi ed posterior
insertion
of the plantar fascia which is common in people who stand or
walk for long-time.
Treatment
Analgesics, rest, steroid injections to the site.

INGROWING TOE NAIL (Onychocryptosis)

_ It is also called as embedded toe nail.
_ It is due to curling of the side of nail inwards, causing it
to form a lateral spike resulting in repeated irritation and
infection of overhanging tissues in the nail fold.
Causes
_ Tight shoes.
_ Improper cutting of nails (very short and convex).
Clinical Features
_ It is common in great toe and is often bilateral.
_ Both medial and lateral sides of the toe can be involved.
_ Recurrent attacks of acute and subacute paronychia
occurs.
_ Pain, tenderness, swelling of margins of the toe, often along
with granulation tissue and foul smelling discharge.
Treatment
_ Regular dressing and packing.
_ Antibiotics. Discharge is sent for culture and sensitivity.
_ Nails should be cut concavely or straight without leaving
lateral spikes towards soft tissues.
HALLUX VALGUS
_ Here great toe is deviated laterally at fi rst
metatarsophalangeal
joint. There is outward deviation of great toe with
medial deviation of fi rst metatarsal head.
_ It may be due to persistent lateral force or occasionally
hereditary.
_ Condition is often bilateral.
_ It is common in females.
_ Thick walled bursa (bunion) over medial aspect of the head
of the fi rst metatarsal bone is common.
_ Undue prominence of head of fi rst metatarsal bone is typical
often forming an exostosis at this point. Osteoarthritis of 1st
metatarsophalangeal joint can occur.
_ Lateral deviation of proximal phalanx over 2nd toe causing
crowding of the toes.
_ Initially it is painless; but eventually pain and tenderness
develops with infection of bunion and splaying of forefoot.

_ X ray shoes deviation with often osteoarthritis of the

metatarsophalangeal
joint.