Swan-neck deformity

A swan-neck deformity, defined as proximal interphalangeal (PIP) joint hyperextension with concurrent distal interphalangeal (DIP) joint flexion, occurs in approximately 50% of patients with rheumatoid arthritis RA. However, swan-neck deformity is not unique to RA, because it may also be congenital or traumatic in nature.

It may also caused by:
# mallet finger (due to rupture of lateral slips at their junction with bone)
# cerebral palsy (due to muscle imbalance)
# congenital joint laxity

The pathophysiology of the swan-neck deformity begins with flexor synovitis, which increases the flexor pull on the MP joint. Constant efforts to extend the finger against this pull lead to stretching of the collateral ligaments and the volar plate at the PIP joint.

In a normal finger, intrinsic muscles (interosseous and lumbrical) insert into the lateral bands and serve as flexors of the MP joint and extensors of the PIP and DIP joints by being located volar to the MP joint axis and dorsal to the PIP and DIP joint axes.

In a rheumatoid finger, the lateral bands are constrained in their dorsal position, upsetting the flexor-extensor balance. In this position, the lateral bands increase the pull of the long extensor tendon's central slip, which attaches to the dorsal base of the middle phalanx. The increase of flexor profundus tension resulting from hyperextension of the PIP joint leads to a reciprocal flexion of the DIP joint. Progressive disease causes joint destruction and fixed contracture.

Facts about Pinguecula

A pinguecula is often referred to as a fatty degeneration of the conjunctival tissue, but it may also reflect deposits of lipids from serous exudate. The fine, nearly transparent collagen fibers of the conjunctiva degenerate and are replaced by ...........

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Deep venous thrombosis

Several different terms are used for the chronic symptoms that can occur after a deep vein thrombosis:
1. Venous stasis syndrome
2. Postthrombotic syndrome
3. Venous insufficiency syndrome
4. Postphlebitic syndrome

Symptoms:

* chronic leg swelling
* chronic (or waxing) pain
* diffuse aching
* leg heaviness
* leg tiredness
* leg cramping
* dark skin pigmentation (=postthrombotic pigmentation; figure)
* hardening of the skin
* skin dryness
* formation of varicose veins
* skin ulcer (stasis ulcer)

Complications of DVT:
- Pulmonary embolism (the most important) WATCH VIDEO
- Post thrombotic syndrome
- Limb ischaemia

Investigation:
* A blood test called a D-Dimer. This measures a substance which develops when a
blood clot breaks down. If this is negative it's unlikely that you have a DVT.
* A Doppler ultrasound. This is a test that uses sound waves to look at your
blood as it flows through your blood vessels. It's the best test to detect
blood clots above your knee.
* A venogram. In this test, a special dye is injected into your vein, which shows
up the vein on X-ray. This is the best way of showing clots below your knee.


Prevention:
There are a number of things you may be able to do to reduce your risk, such as stopping smoking if you smoke, or losing weight if you're overweight. Regular walking can help to improve the blood circulation in your legs and help to prevent another DVT from developing.

There is no good evidence that taking aspirin reduces your risk of developing DVT.

Treatment of DVT:
The treatment for deep venous thrombosis above the knee is anticoagulation, unless a contraindication exists (recent major surgery or abnormal reactions).Anticoagulation prevents further growth of the blood clot and prevents it from forming an embolus that can travel to the lung.

. Warfarin (Coumadin) is the drug of choice. It is begun immediately, but unfortunately it may take a week or more for the blood to be appropriately thinned. Therefore, low molecular weight heparin [enoxaparin (Lovenox)] is administered at the same time. It thins the blood via a different mechanism and is used as a bridge therapy until the warfarin has reached its therapeutic level.

The dosage of warfarin is monitored by blood tests measuring the prothrombin time or INR (international normalized ratio). For an uncomplicated deep vein thrombosis, the recommended length of therapy with warfarin is three to six months.

Some patients may have contraindications for warfarin therapy, for example a patient with bleeding in the brain, major trauma, or recent significant surgery. An alternative may be to place a filter in the inferior vena cava to prevent emboli from reaching the heart and lungs. These filters may be effective but also may be the source of new clot formation.

Compression stockings
These are also called graduated compression stockings.It eases pain and reduce swelling, and to prevent post-thrombotic syndrome. You may need to wear them for two years or more after having a DVT.

In rare cases, surgery may be needed if medicines do not work. Surgery may involve:

* Placement of a filter in the body's largest vein to prevent blood clots from
traveling to the lungs
* Removal of a large blood clot from the vein or injection of clot-busting
medicines.

Dupuytren's contracture Pic and shape of incision

The most commonly affected digits are the ulnar digits (ring and small fingers).

Dupuytren's contracture is a thickening of the fibrous tissue layer underneath the skin of the palm and fingers. Although painless, the thickening and tightening (contracture) of this fibrous tissue can cause the fingers to curl (flex).

It is more common in men than in women.

The cause of Dupuytren's contracture is not known. It is not caused by an injury or heavy hand use.

Symptoms:
Dupuytren's contracture symptoms usually occur very gradually.

1-Nodules. One or more small, tender lumps (nodules) form in the palm. Over time, the tenderness usually goes away.

2-Bands of tissue. The nodules may thicken and contract, forming tough bands of tissue under the skin.

3-Curled fingers. One or more fingers bend (flex) toward the palm. The ring and little fingers are most commonly affected, but any or all fingers can be involved. As the bend in the finger increases, it may be hard to straighten your finger. Grasping large objects and putting your hand in a pocket becomes difficult.

Treatment:
**Nonsurgical Treatment:

-Steroid injection. If a lump is painful, an injection of corticosteroid - a powerful anti-inflammatory medication - may help relieve the pain. In some cases, it may prevent the progression of contracture. Several injections may be needed for a lasting effect.

-Splints. Splinting does not prevent increased bend in the finger. Forceful stretching of the contracted finger will not help either, and may speed the progression of contracture.
The intralesional enzyme, collagenase clostridium histolyticum, was approved by the FDA in February 2010.

**Surgical Treatment:

Surgery is recommended when joint contracture exceeds 30°, or when nodules are painful and interfere with hand function.

Surgical procedure. Surgery for Dupuytren's contracture divides or removes the thickened bands to help restore finger motion. Sometimes the wound is left open and allowed to heal gradually. Skin grafting may be needed.

Acrocyanosis of the hands and feet commonly seen in newborns.


Acrocyanosis: Bluish discoloration of the extremities (the hands and feet). Acrocyanosis is typically symmetrical..................

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Angular stomatitis: can be treated at home!!

Angular stomatitis ( or angular cheilitis ) is the inflammation of the corners of the mouth (labial commissures) following a bacterial or a fungal infection.
This condition is more common in people who .................

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