The dorsal wrist ganglion is most often confused with the carpal boss, so named by the French physician Foille. The carpal boss is an osteoarthritic spur that develops at the base of the second and/or third carpometacarpal joints. (figure 1) A firm, bony, nonmobile, tender mass is visible and palpable at the base of the carpometacarpal joints, especially
when the wrist is volar flexed. The lining of the joint thins out and small bone spurs form n the top of the hand leadingto a bone prominence. Tendon irritation can occur and a small cyst or ganglion may form as well.
figure 1 Right hand with carpal boss
Figure 2 Carpal Boss seen on Xray
Radiologically, the mass is best visualized with the hand in 30 to 40 degrees supination and
20 to 30 degrees ulnar deviation ("carpal boss view")( figure 2).
The boss is more common in women (2:1), in the right hand (2:1), and between the third and fourth decades. The mass may be asymptomatic, but the patient may complain of considerable pain and aching. A small ganglion is associated with the carpal boss in 30 percent of cases, adding to its confusion with the more common dorsal wrist ganglion.
Injection to the ganglion or to the cmc joint may be used to reduce pain and irritation. This may be combined with splinting and anti inflammatory medication and avoidance of trauma to the back of the hand\
If symptoms persist at times surgery may be offered. (figure 3) Surgery may involve the removal of the prominent bone, the excision of an associated ganglion or cyst and at times involves tenosynovectomy or tenolysis of adjacent affected tendons. What occurs during surgery may depend upon the preoperative findings as well as the surgical intra operative findings
Figure 3 Surgical Approach to carpal boss excision using a transverse incision
The most common complication is the persistence of a mass because of excision of the ganglion alone or inadequate excision of the osteophytes. Pain will persist unless all abnormal abutting surfaces have been excised. Dorsal wrist ganglions can present over the carpometacarpal joints and must be distinguished from the carpal boss with its own associated ganglion. Avoidance of injury to branches of the radial and ulnar sensory nerves is again stressed.
CONGENITAL LIMB DIFFERENCES Limb Differences.org is a web site for children and families with congenital limb differences.Information and support groups dealing with amputation, finger and hand abnormalities, fused fingers, absent fingers and hands, radial club hand, thumb pollicization and other topics. Lower extremity problems of the leg, and foot are also discussed
HAND ANATOMY An electronic listing of hand anatomy from e-hand
ORTHOGATE Orthogate is an Orthopedic web portal that enables internet searches on any orthopedic topic
According to the Consumer Product Safety Commission, national losses involving fireworks amount to 3 deaths and 10,527 injuries annually. Hand and finger injuries are the most common and account for 32 percent of all injuries. Head and eye injuries occur with about the same frequency, equaling 19 and 18 percent of total injuries.
BACKGROUND
A review of firework mishaps shows a variety of factors contribute to the typical mishap. Most pre-school age victims are injured by fireworks ignited by someone else, while older children who are injured are usually lighting the fireworks themselves. Children under age five are commonly hurt by rocket-type fireworks; small firecrackers and ground spinners injure the majority of children between the ages of 5 and 14. Most of the injuries associated with large, illegal firecrackers such as M-80's are to older teenagers or adults.
Hand Surgeons Agree:
Leave Fireworks to the Professionals
The American Society for Surgery of the Hand (ASSH) has urged the public to leave fireworks in the hands of the professionals.According to the U.S. Consumer Product Safety Commission, 38% of all reported fireworks-related injuries from June 22-July 22, 2001, were to fingers, hands, and arms. These injuries included burns, lacerations, fractures, and traumatic amputation.
Of the finger, hand, and arm injuries, the majority of injuries were caused from accidents involving firecrackers, bottle rockets, and sparklers— the three firework-types most often used in a backyard environment. Accidents involving firecrackers, bottle rockets, and hand-held sparklers totaled 57% of all firework injuries (source: American Pyrotechnic Association).
One solution that has been offered by the ASSH to individuals is to attend public fireworks displays, which are monitored for safety by a local fire department, rather than setting off fireworks near or around the home.
The following precautions should be taken when attending a public fireworks display:
Obey safety barriers and ushers.
Stay back a minimum of 500 feet from the launching site.
Resist the temptation to pick up firework debris when the display is over. The debris may still be hot, or in some cases, the debris might be “live” and could still explode.
Never give children hand-held sparklers. Sparklers cause 10% of all firework injuries (source: American Pyrotechnics Association)—and were associated with the most injuries to children under 5 years of age. (source: U.S. Consumer Product Safety Commission)
The American Society for Surgery of the Hand has joined an alliance to heighten awareness regarding the dangers of consumer fireworks. Please visit the National Fire Protection Association site for details on how to stay safe and hear directly from victims who have been injured.
According to a newly-released NFPA report, in 2006 fireworks caused an estimated 32,600 reported fires, including 1,700 total structure fires, 600 vehicle fires, and 30,300 outdoor and other fires.
“Bottle rockets aren’t the only things we don’t want to see soaring on Independence Day – we also don’t want to see the number of fires climbing,” said Massachusetts State Fire Marshal Stephen Coan who is featured in the PSA. “Nationally, there are typically more fires reported on Independence Day than on any other day of the year, and half of these fires are caused by fireworks. This puts civilians and firefighters at greater risk of death and injury and there is no excuse for it.”
Massachusetts is one of only five states that bans all consumer fireworks. The others are Delaware, New Jersey, New York and Rhode Island.
these photos from http://www.safetyworld.com/topics/hand_safety.htm?kc=Jfa11
these photos from http://www.safetyworld.com/topics/hand_safety.htm?kc=Jfa11
GENERAL POWER SAW TIPS
Never look away from your work when operating a power saw.
When beginning, let the saw reach full speed before cutting and support the work firmly so it won't shift.
If the saw stalls, switch off the power and unplug the tool before trying to restart it.
Stop working and turn off the power saw you are working with if distracted by something or someone
Never use your hands to clear the scraps from a sawing worktable. Instead, use a long stick
When working with metal, secure the metal materials with clamps or in a machinist's vise to keep it from moving.
TOOL SPECIFIC TIPS
Table Saws:
Adjust the table saw blade to project about 1/8 inch above the wood.
Make certain the work piece is out of contact with the blade when starting or stopping the saw.
Keep the body out of the way. Use a push stick when ripping narrow strips.
Lower the saw blade below the table top when work is finished.
Radial Arm Saws:
When cross-cutting wood, lay the stock solidly on the table and against the back guide. The saw blade should rotate downward as viewed by the operator. Pull the saw with one hand while the stock is held with the other hand.
Never reach across the line of cut.
When making miter cuts, secure the locking devices to prevent the saw from changing angles or digging in.
Return the saw to the rear position after completing a cut.
Band Saws:
Keep the saw blade set evenly and with the correct tension. Push the stock through the blade with the hands on both sides of the line of cut.
Hand-Held Circular Saws:
Do not work in wet areas unless standing on a dry surface and make certain the saw is properly grounded. Do not clamp or wedge the
guard in the open position. Keep your finger off the trigger when carrying the saw. Do not cut the power cord. Wait until the blade stops before laying down the
saw. When finished, unplug the saw and put it out of the reach of children.
Saber Saws:
Select the proper blade for the job. Make sure it is sharp, undamaged and securely tightened in place. Do not turn on the saw when the blade is in
contact with the work piece. Hold the saw firmly with one hand and steady the work with the other. Keep your hand and other objects clear of the blade.
http://siri.uvm.edu/ftp/ppt/hand safe/sld033.htm
Portable Circular Saw Safety Precautions
Always wear safety goggles or safety glasses with side shields complying with the current national standard and a full face shield when needed. Use a dust mask in dusty work conditions. Wear hearing protection during extended periods of operation.
Don't wear loose clothing, jewelry, or dangling objects, including long hair, that may catch in rotating parts or accessories
Don’t use a circular saw that is too heavy for you to easily control
Be sure the switch actuates properly. It should turn the tool on and return to the off position after release.
Use sharp blades. Dull blades cause binding, stalling and possible kickback,
Use the correct blade for the application. Check this carefully. Does it have the proper size and shape arbor hole? Is the speed marked on the blade at least as high as the no-load RPM on the saw's nameplate?
Is the blade guard working? Check for proper operation before each cut. Check often to ensure that guards return to their normal position quickly. If a guard seems slow to return or hangs up, repair or adjust it immediately. Never defeat the guard to expose the blade by, for example tying it back or removing it.
Before starting a circular saw, be sure the power cord and extension cord are out of the blade path and are long enough to freely complete the cut. Keep aware of the cord location. A sudden jerk or puling on the cord can cause loss of control of the saw.
For maximum control, hold the saw firmly with both hands after securing the work piece. Clamp work pieces. Check frequently to be sure clamps remain secure.
Avoid cutting small pieces that cant be properly secured and material on which the saw show can't properly rest.
When you start the saw, allow the blade to reach full speed before contacting the workplace.
When making a partial cut, or if power is interrupted, release the trigger immediately and don't remove the saw until the blade has come to a complete stop.
Portable Circular Saws
www.cdc.gov/niosh/nasd/docs/oa05000.html
All portable, power-driven circular saws having a blade diameter greater than two inches must be equipped with guards. The upper guard must cover the saw to the
depth of the teeth. The lower guard must also cover the saw to the depth of the teeth, except for the minimum arc required to allow proper retraction and contact
with the work. When the tool is withdrawn from the work, the lower guard must automatically and instantly return to the covering position.
Switches and Controls
www.cdc.gov/niosh/nasd/docs/oa05000.html
All hand-held powered circular saws having a blade diameter greater than two inches must be equipped with a constant pressure switch or control that will shut off
the power when the pressure is released.
Miter Box Saws and Chop Saws
http://siri.uvm.edu/ftp/ppt/handsafe/sld040.htm
Stay alert to keeping hands and fingers away from the blades path as it has a downward cutting motion
Be sure all guards are in place and working. If a guard seems slow to return to its normal position adjust or repair it immediately
Use only recommended size and RPM rated blades
When installing or changing a blade, be sure the blade and related washers and fasteners are correctly positioned and secured on the saw arbor
Cuts and amputations. Make sure the saw blade is not touching anything before you turn on a saw.
Do not drop-start a chainsaw. To start a saw with a starter cord, put one foot on the back handle, put
one hand on the top handle to keep the blade off the surface, and use the other hand to pull the cord.
OSHA says a circular saw must have a guard above and below the base plate. Keep the blade guard and
other safety devices on the saw. Make sure the blade guard goes back to the fully guarded position
after you cut.
Hold a saw with both hands. Do not use your leg to prop up a saw. To prevent kickback, hold your
forward arm straight and do not cut above chest height.
After you turn off a saw, hold it away from you until the blade stops turning. Do not prop the saw on
your leg while the blade slows down. Turn off a saw before you carry it anywhere.
1. University of Maine Cooperative Extension Power Tool Safety: Choose the correct tool for the job. Power Tool Safety Bulletin #2329 by Dawna L. Cyr, Farm Safety Project Assistant, and Steven B. Johnson, PhD
Rosemont, IL; May 4, 2005— The American Society for Surgery of the Hand (ASSH) recommends that individuals take the proper precautions to prevent hand-related injuries while tending to Spring projects. Each year, thousands of people suffer maiming or amputations of their fingers or hands due to improper handling of power saws.
In a 2001 study, the Consumer Product Safety Commission (CPSC) found that over 50,000 people were treated in U.S. hospital emergency rooms for injuries associated with table saws, band saws, miter saws, or redial arm saws in the calendar year. Contact with the saw blade was the major hazard to power saw operators, followed by being hit by stock or cutting material. An injury sustained from a power saw could quickly and suddenly have devastating consequences involving severe lacerations and fractures. Nerve, tendon, vascular injury and amputation are possible as well. Fingertip injuries are the most common with the thumb being the most commonly injured digit. It has been determined that a circular table saw can sever a human forearm 6 centimeters in diameter in just 40 - 60 milliseconds depending upon the feeding power of the saw.
”Power saw injuries are usually very serious, often requiring delicate surgery followed by weeks or even months of rehabilitation,” said Jeffrey C. Wint, MD of the American Society for Surgery of the Hand. “"Even with treatment an injury may result in permanent changes to the function of the injured hand and upper extremity."
An inexperienced operator is more likely to be injured with a power saw than with other tools. These injuries are likely to be more severe than with other tool injuries. While tool design may be responsible for some power saw injuries a primary source of injury comes from failure to properly use the equipment and exercise sound safety principles.
To prevent hand injuries, the ASSH suggests the following safety tips when using a power saw:
• Never look away from your work.
• Never use your hands to clear the scraps from a sawing worktable, instead, use a long stick.
• Do not wear loose clothing or jewelry around the wrists.
• Keep your finger off the trigger when carrying a portable power saw.
• Use the correct blade for the application.
• Use sharp blades. Dull blades cause binding, stalling and possible kickback.
• When starting, let the saw reach full speed before cutting and support the work firmly so it will not shift.
• If the saw stalls, switch off the power and unplug the tool before trying to restart it.
• When working with metal, secure the metal materials with clamps or in a machinist’s vise to keep it from moving.
• Check for proper blade guard operation before each cut.
• When starting or stopping the saw, make sure the work is not touching the blade.
• Lower a table saw blade below the table top when finished.
• Keep a clear head, concentrate, and DO NOT DRINK ALCOHOL before using a power saw!
Whether removing tree branches, building a deck or working on another Spring project, use caution when operating a power saw. If you are injured seek prompt medical attention. Delay in treatment can lead to a higher risk of infection or tissue loss. The damage done to a finger, hand or any site often exceeds what may be initially apparent due to the force of these types of injuries. Make the safety tips presented here common knowledge and practice in your home and workplace. Know your equipment and its limits
taken from contents of ASSH press release of 5/4/05 at www.assh.org for www.handctr.com and www.safehand.org
What are scaphoid fractures?
The scaphoid bone is one of the eight small bones that make up the “carpal bones” of the wrist. There are two rows of bones, one closer to the forearm (proximal row) and the other closer to the hand (distal row). The scaphoid bone is unique in that it links the two rows together (see Figure 1). This puts it at extra risk for injury, which accounts for it being the most commonly fractured carpal bone. How do scaphoid fractures occur?
Fractures of the scaphoid occur most commonly from a fall on the outstretched hand. Usually it hurts at first, but the pain may improve quickly, over the course of days or weeks. Bruising is rare, and there is usually no visible deformity and only minimal swelling. Since there is no deformity, many people with this injury mistakenly assume that they have just sprained their wrist, leading to a delay in seeking evaluation. It is common for people who have fractured this bone to not become aware of it until months or years after the event. Diagnosis of scaphoid fractures
Scaphoid fractures are most commonly diagnosed by x-rays of the wrist. However, when the fracture is not displaced, x-rays taken early (first week) may appear negative. A non-displaced scaphoid fracture could thus be incorrectly diagnosed as a “sprain.” Therefore a patient who has significant tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist, or “snuffbox”) should be suspected of having a scaphoid fracture and be splinted (see Figure 2). An X-ray a couple of weeks later may then more clearly reveal the fracture. In questionable cases, MRI scan, CT scan, or bone scan may be used to help diagnose an acute scaphoid fracture. CT scan and/or MRI are also used to assess fracture displacement and configuration. Until a definitive diagnosis is made, the patient should remain splinted to prevent movement of a possible fracture. Treatment of scaphoid fractures
If the fracture is non-displaced, it can be treated by immobilization in a cast that usually covers the forearm, hand, and thumb, and sometimes includes the elbow for the first phase of immobilization. Healing time in a cast can range from 6- 10 weeks and even longer. This is because the blood supply to the bone is variable and can be disrupted by the fracture, impairing bony healing. Part of the bone might even die after fracture due to loss of its blood supply, particularly in the proximal third of the bone, the part closest to the forearm. If the fracture is in this zone, or if it is at all displaced, surgery is more likely to be recommended. With surgery, a screw or pins are inserted to stabilize the fracture, sometimes with a bone graft to help heal the bone (see Figure 3a,3b). Surgery to place a screw may also be recommended in non-displaced cases to avoid prolonged casting. Complications of scaphoid fractures Non-union: If a scaphoid fracture goes unrecognized, it often will not heal. Sometimes, even with treatment, it may not heal because of poor blood supply(seeFigure 3c). Over time, the abnormal motion and collapse of the bone fragments may lead to mal-alignment within the wrist and subsequent arthritis. If caught before arthritis has developed, surgery may be performed to try to get the scaphoid to heal.
Avascular necrosis: A portion of the scaphoid may die because of lack of blood supply, leading to collapse of the bone and later arthritis. Fractures in the proximal one third of the bone, the part closest to the forearm, are more vulnerable to this complication. Again, if arthritis has not developed, surgery to try to stabilize the fracture and restore circulation to the bone may be attempted. (see.Figure 4)
Post-traumatic arthritis: If arthritis has already developed, salvage-type procedures may be considered, such as removal of degenerated bone or partial or complete fusion of the wrist joint.
Figure 1: The scaphoid bone is unique in that it spans the two rows of wrist bones making it more prone to injury from a fall in full extension
Figure 2: Significant tenderness directly over the scaphoid bone (which is located in the hollow at the thumb side of the wrist).
Figure 3a,3b: A screw or pins are placed to stabilize the fracture.
Figure 3c. The scaphoid has a varialbe pattern of blood supply that may predispose it to AVN and delayed healing
Figure 4. An MRI may be used to diagnose Avascular Necrosis (AVN) after a scaphoid fracture has not healed
Congenital Hand Differences
What are congenital hand
differences?
Babies born with hands that are different than
the normal hand have a congenital hand
difference.
What causes
congenital hand differences?
The upper limb is formed between four and eight
weeks after the sperm and egg unite to form an
embryo. The embryo develops an arm bud at four
weeks. The tip of the arm bud sends messages to
each cell as the upper limb forms. Millions of
steps are followed to form a normal arm. Failure
of any of these steps to occur can result in a
congenital hand difference. Research continues
into further understanding of this embryonic
process. Some congenital hand differences may
occur due to a genetic cause. Many congenital
hand differences just occur without an apparent
cause.
What are different types of
congenital hand differences?
One in twenty children is born with some
difference from normal, either major or minor.
The different groups of congenital hand
differences include missing parts of the arm
(failure of formation), webbed or fused parts of
the hand (failures of separation), extra parts
present in the hand (duplication), undergrowth
or overgrowth of parts of the hand, or
constriction band syndrome.
What are common congenital
hand differences?
The most common congenital hand difference in
the Caucasian population is webbed fingers (syndactyly
- see Figure 1).
The most common congenital hand difference in
the black population is an extra, sixth digit on
the little finger side (post-axial polydactyly -
see Figure 2). The
most common congenital hand difference in the
Asian population is an extra thumb (thumb
polydactyly - see
Figure 3).
Which congenital hand
difference does my child have?
Because there are so many different congenital
hand differences, it is important that your
child be evaluated by a hand surgery specialist
to help determine if any treatment is needed.
Some congenital hand differences are associated
with genetic disorders or other medical
problems. Your hand specialist may request
further genetic evaluation by a geneticist, or
may request further medical testing by your
pediatrician or family physician.
How do parents feel if their
child has congenital hand differences?
Immediately after the birth of a child with a a
congenital abnormality, the patents may feel
shock, anger and guilt. These are normal
emotions. All the dreams of a perfect baby did
not take place. Each family member must cope
with their feelings. Rarely is there anything
parents or doctors could have done differently.
Your newborn doesn’t realize that he or she
is different. The baby has all the normal needs
of any newborn. The way the baby has formed is
normal for him or her, without pain and without
a sense of loss. Talk to your physician about
support groups or professional help.
Can congenital hand
differences be treated?
All babies born with congenital hand differences
should be evaluated by a hand specialist to make
an individual assessment of the type. Depending
on the type of congenital hand difference,
treatment may be recommended. For example,
webbed fingers are surgically separated. Extra
digits can be surgically removed with
reconstruction of the remaining digit if
necessary. Hand function can be improved if the
functions of thumb pinch or finger grasp is
compromised. Some congenital hand differences
may need therapy to help improve hand function. In some cases, no intervention is
necessary.
Figure 1: Syndactyly between long
and ring fingers
Figure 2: Polydactyly, with an
extra little finger
Figure 3: Thumb polydactyly,
with duplication of the thumb
Amputation.pdf
AnimalBite.pdf
MPJoint.pdf
CarpalTunnel.pdf
