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Animal Bites

Each year millions of people in the United States—most of them children—are bitten by animals. Most animal bites are from dogs; cat bites are second most common. However, the risk of infection from a cat bite is much higher than that from a dog bite. Most bites occur on the fingers of the dominant hand, but children may also be bitten about the head and neck area.

A major concern about an animal bite is the possibility of rabies. Because most pets in the U.S. are vaccinated, most cases of rabies result from the bite of a wild animal such as a skunk, bat or raccoon. However, in other countries, dog bites are the most common source of rabies. If you are bitten by a dog outside the U.S., consult a doctor immediately.

Signs and symptoms

In some cases, the bite will not break the skin but may cause damage to underlying tendons and joints. If the skin is broken, there is the additional possibility of infection as well as injury to tendons and nerves. Dogs have powerful jaws and can cause crushing injuries to bone, muscles, tendons, ligaments and nerves.

Signs of an infection include:

• Warmth around the wound
• Swelling
• Pain
• A pus discharge
• Redness around the puncture wound

Signs of damage to tendons or nerves include:

• An inability to bend or straighten the finger
• A loss of sensation over the tip of the finger

First aid

1. Don’t put the bitten area in your mouth! You will just be adding the bacteria in your mouth to that already in the wound.
2. If the wound is superficial, wash the area thoroughly. Use soap and water or an antiseptic such as hydrogen peroxide or alcohol. Apply an antibiotic ointment and cover with a non-stick bandage. Watch the area carefully to see if there are signs of damaged nerves or tendons. Some bruising may develop, but the wound should heal within a week to 10 days. If it does not, or if you see signs of infection or damage to nerves and tendons, seek medical help.
3. If there is bleeding, apply direct pressure with a clean dry cloth. Elevate the area. Do not clean a wound that is actively bleeding. Cover the wound with a clean sterile dressing and always seek medical help.
4. If the wound is to the face and/or head and neck area, seek medical help immediately.
5. Contact your physician to see whether additional treatment is needed.
6. Report the incident to your public health department. They may ask your assistance in locating the animal so that it can be confined and observed for symptoms of rabies.

Medical assistance

Tell your doctor how you got the bite. Your physician will wash the wound area thoroughly and check for signs of nerve or tendon damage. The doctor may examine your arm to see if there are signs of a spreading infection. Your physician will probably leave the wound open (without stitches), unless you have a facial wound. You may need to get X-rays and a blood test. You may also need to get a tetanus shot and a prescription for antibiotics. If the tendons or nerves have been injured, you may need to see a specialist for additional treatment.

More about rabies

Rabies is a disease that affects only mammals (such as raccoons, bats, dogs, horses, and humans). It is caused by a virus that attacks the nervous system. Without treatment, it is 100 percent fatal. Rabies develops in two stages. During the first stage, which can last up to 10 days, the individual may have a headache, fever, decreased appetite, vomiting and general malaise, along with pain, itching, and tingling at the wound site. Symptoms of stage two include difficulty in swallowing, agitation, disorientation, paralysis, and coma. At this point, there is no known, effective treatment.

If rabies is identified early, a series of highly effective vaccinations can be administered. That’s why it’s important to capture and observe the animal that bit you. If the animal cannot be captured, but must be killed, the head should be kept intact so the brain can be examined for signs of rabies.

Preventing animal bites

Follow these recommendations to prevent animal bites and rabies.

1. Do not try to separate fighting animals.
2. Avoid animals that appear sick or act strangely. Call animal control.
3. Leave animals, even pets or other animals you know, alone when they are eating or sleeping.
4. Keep pets on a leash when out in public.
5. Never leave a young child alone with a pet. Don’t allow children to tease an animal by waving sticks, throwing stones, or pulling a tail.
6. Be sure your pet is vaccinated.
7. Do not approach or play with any kind of wild animal. Teach children not to pet strange animals, even pets on a leash, without asking permission of the owner first.

Arthritis of the Hand

Arthritis can affect any joint in the body, but it is most visible when it strikes the hands and fingers. Each hand has 27 bones plus the two bones of the forearm that help define the wrist. Joints are created whenever two or more bones come together, so there is plenty of potential for arthritic problems in the hand.

Arthritis of the hand can be both painful and disabling. The most common forms of arthritis in the hand are osteoarthritis and rheumatoid arthritis.

Osteoarthritis of the hand

Osteoarthritis is a degenerative joint disease in which the cushioning cartilage that covers the bone surfaces at joints begins to wear out. It may be caused by simple "wear and tear" on joints, or it may develop after an injury to a joint. In the hand, osteoarthritis most often develops in three sites:

• at the base of the thumb, where the thumb and wrist come together (the trapezio-metacarpal joint)
• at the middle joint of a finger (the proximal interphalangeal or PIP joint)
• at the finger tip (the distal interphalangeal or DIP joint)

Rheumatoid arthritis of the hand

Rheumatoid arthritis affects the cells that line and normally lubricate the joints (synovial tissue). It is a systemic condition, which means that it affects multiple joints, usually on both sides of the body. The joint lining (synovium) becomes inflamed and swollen. The swollen tissue may stretch the surrounding ligaments, which are connective tissues that hold bones together, resulting in deformity and instability. The inflammation may also spread to the tendons, which are the connective tissues that link muscles and bones. This can result in tears (ruptures) in the tendons. Rheumatoid arthritis of the hand is most common in the wrist and finger knuckles (the metacarpophalangeal or MP joints).

Signs and symptoms

Stiffness, swelling, loss of motion, and pain are symptoms common to both osteoarthritis and rheumatoid arthritis in the hand. With osteoarthritis, bony nodules may develop at the middle joints of one or more fingers (Bouchard’s nodes) and at the finger tip (Heberden’s nodes). The joints become enlarged and the fingers crooked. In rheumatoid arthritis, some joints may be more swollen than others. There is often a sausage-shaped (fusiform) swelling of the finger. Other symptoms of rheumatoid arthritis of the hand include:

• a soft, lumpy mass over the back of the hand
• a creaking sound (crepitus) during movement
• a shift in the position of the fingers as they drift away from the direction of the thumb
• inflammation of the finger tendons, resulting in a permanent bending (Boutonnière) deformity
• a "swan’s neck" deformity caused by hyperextension (sway-back) at the middle joint of the finger associated with a bent fingertip

Diagnosis and treatment

Your doctor will examine you and ask whether you have similar symptoms in other joints. X-rays will show certain characteristics of arthritis, such as a narrowing of the joint space, the formation of cysts or bony outgrowths (osteophytes or "nodes") and the development of hard (sclerotic) areas of bone. If your doctor suspects rheumatoid arthritis, he or she may request blood or other lab tests to confirm the diagnosis.

Treatment is designed to relieve pain and restore function. Treatment decisions are based on the type of arthritis you have, its progression and its impact on your life. Anti-inflammatory medications such as aspirin or ibuprofen may help reduce swelling and relieve pain; prescription medications or steroid (cortisone) injections may be recommended. Your physician may refer you to a physical or occupational therapist because changing the way you do things with your hands may help relieve pain and pressure.

Osteoarthritis treatments

If you have osteoarthritis, your physician may recommend a period of rest. You may also be advised to wear finger or wrist splints at night and for selected activities. Surgery is usually not advised unless these treatments fail. Several surgical options are available:

• Surgery may be used to drain or remove the cysts associated with the nodes and to remove excess bone growth.
• Joint fusion (stiffening the problem joint) may be used to correct deformities that interfere with functioning or that are cosmetically unacceptable.
• A joint replacement may be advised.

Rheumatoid arthritis treatments

If you have rheumatoid arthritis in your hands, medications can help decrease inflammation, relieve pain and retard the progress of the disease. Rest, controlled exercise, and wearing finger or wrist splints may also be part of your treatment program. Several disease-modifying treatments are now available. These include cortisone injections, antimalarial drugs, methotrexate, cyclosporine, gold and some other drugs that help suppress the body’s immune system to reduce the inflammation. Adaptive devices may help you cope with the activities of daily living.

Rheumatoid arthritis often affects the connective tissues (tendons) as well as the joints. The tendons that become inflamed may rupture. If this happens, you may be unable to bend or straighten your fingers or to grip properly. In certain cases, specific preventive surgery may be recommended. Preventive surgery options include removing nodules, releasing pressure on tendons by removing the inflamed tissue, and strengthening the tendons. If a tendon rupture occurs, an orthopaedic hand surgeon may be able to repair it with a tendon "transfer" or graft. Unfortunately, there is no cure for rheumatoid arthritis. However, surgical procedures can often help correct deformities, relieve pain, and improve function. These options include joint replacements, joint fusion and, in some cases, removing damaged bone.

Arthritis of the Thumb

Arthritis is a condition that irritates or destroys a joint. Although there are several types of arthritis, the one that most often affects the joint at the base of the thumb (the basal joint) is osteoarthritis (degenerative or "wear-and-tear" arthritis).

Osteoarthritis occurs when the smooth cartilage that covers the ends of the bones begins to wear away. Cartilage enables the bones to glide easily in the joint; without it, bones rub against each other, causing friction and damage to the bones and the joint.

The joint at the base of the thumb, near the wrist and at the fleshy part of the thumb, enables the thumb to swivel, pivot, and pinch so that you can grip things in your hand. Arthritis of the base of the thumb is more common in women than in men, and usually occurs after age 40. Prior fractures or other injuries to the joint may increase the likelihood of developing this condition.

Symptoms

• Pain with activities that involve gripping or pinching, such as turning a key, opening a door, or snapping your fingers.
• Swelling and tenderness at the base of the thumb.
• An aching discomfort after prolonged use.
• Loss of strength in gripping or pinching activities.
• An enlarged, "out-of-joint" appearance.
• Development of a bony prominence or bump over the joint.
• Limited motion.

Diagnosis

Your physician will ask you about your symptoms, any prior injury, pain patterns, or activities that aggravate the condition. The physical examination may show tenderness or swelling at the base of the thumb. One of the tests used during the examination involves holding the joint firmly while moving the thumb. If pain or a gritty feeling results, or if a grinding sound (crepitus) can be heard, the bones are rubbing directly against each other. An X-ray may show deterioration of the joint as well as any bone spurs or calcium deposits that have developed.

Many people with arthritis at the base of the thumb also have symptoms of carpal tunnel syndrome, so your physician may check for that as well.

Treatment

In its early stages, arthritis at the base of the thumb will respond to nonsurgical treatment.

• Ice the joint for five to fifteen minutes several times a day.
• Take an anti-inflammatory medication such as aspirin or ibuprofen to help reduce inflammation and swelling
• Wear a supportive splint to limit the movement of the thumb, and allow the joint to rest and heal. The splint may protect both the wrist and the thumb. It may be worn overnight or intermittently during the day.

Because arthritis is a progressive, degenerative disease, the condition may worsen over time. The next phase in treatment involves a steroid solution injection into the joint. This will usually provide relief for several months. However, these injections cannot be repeated indefinitely.

Surgical Options

When conservative treatment is no longer effective, surgery is an option. The operation can be performed on an outpatient basis, and several different procedures can be used. One option involves fusing the bones of the joint together. This, however, will limit movement. Another option is to remove part of the joint and reconstruct it using either a tendon graft or an artificial substance. You and your physician will discuss the options and select the one that is best for you.

After surgery, you will have to wear a cast for several weeks. A rehabilitation program, often involving a physical therapist, helps you regain movement and strength in the hand. You may feel some discomfort during the initial stages of the rehabilitation program, but this will diminish over time. Full recovery from surgery takes several months. Most patients are able to resume normal activities and are quite satisfied with the results.

Arthritis of the Wrist

Arthritis affects millions of people in the United States. Often, arthritis strikes at the weightbearing joints of the body, such as the knees and the shoulders. But a significant number of people suffer from arthritis in their wrists and hands that make it difficult for them to perform the activities of daily living.

Although there are hundreds of kinds of arthritis, most wrist pain is caused by just two types:

• Osteoarthritis (OA) is a progressive condition that destroys the smooth articular cartilage covering the ends of bones. The bare bones rub against each other, resulting in pain, stiffness and weakness. OA can develop due to normal "wear-and-tear" on the wrist or as a result of a traumatic injury to the forearm, wrist or ligaments.
• Rheumatoid arthritis (RA) is a systemic inflammatory disease that affects the joint linings and destroys bones, tissues, and joints. Rheumatoid arthritis often starts in smaller joints, like those found in the hand and wrist, and is symmetrical, meaning that it usually affects the same joint on both sides of the body.

Signs and symptoms

• OA of the wrist joint manifests with swelling, pain, limited motion and weakness. These symptoms are usually limited to the wrist joint itself.
• RA of the wrist joint usually manifests will swelling, tenderness, limited motion and decreased grip strength. In addition, hand function may be impaired and there may be pain in the knuckle joints (metacarpophalangeal or MP joints).
• Joint swelling may also put pressure on the nerves that travel through the wrist. This can cause a lesion to develop (compression neuropathy) or lead to carpal tunnel syndrome.

Diagnosis and treatment

Six bones make up the wrist joint: the two bones of the lower arm (the radius and the ulna) and four wrist bones (the carpals). Your physician will use a combination of physical examination, patient history, and tests to diagnose arthritis of the wrist. X-rays can help distinguish among various forms of arthritis. Some, but not all, forms of RA can be confirmed by a laboratory blood test.

In general, early treatment is nonsurgical and designed to help relieve pain and swelling. Several therapies can be used to treat arthritis, including:

• Modifying your activities.
• Immobilizing the wrist for a short time in a splint.
• Taking anti-inflammatory medications such as aspirin or ibuprofen.
• Following a prescribed exercise program.
• Getting a steroid injection into the joint.

Your physician may prescribe other therapies, depending on the type of arthritis you have. For example, additional therapies for patients with rheumatoid arthritis include antimalarial drugs, antimetabolites, gold, immunosuppresive drugs (both non-steroidal and corticosteroids) and newer genetically-engineered medications.

When such conservative methods are no longer effective, or if hand function decreases, surgery is an option. The goal of surgery is to relieve pain; depending on the type of surgery, joint function may also be affected. Surgical options include removing the arthritic bones, joint fusion (making the joint solid and preventing any movement at the wrist) and joint replacement. You and your physician should discuss the options and select the one that is best for you.

Baseball Finger

Every year, when the baseball season gets underway, doctors start seeing cases of "baseball finger." This condition, which is also called "mallet finger," is often caused when a ball hits the tip of your finger, bending it down.

Fingers can bend down (toward the palm of your hand) only about 35 to 40 degrees. The force of a batted ball can push the finger beyond that limit and tear the tendon that controls muscle movement in the finger. The force may even be great enough to pull tiny pieces of bone away as well. When the tendon is detached, the tip of the finger cannot be straightened out and it hangs down abnormally.

This is initially a very painful injury, and the top of the finger near the fingernail will be tender, slightly swollen and red. If it happens to you, stop playing. Immediately apply ice, and elevate your hand above the level of your heart. Contact a doctor who may request an X-ray to see if there is any damage to the bone. Sometimes, if the finger joints are jammed against each other, cartilage damage results. The joint may also be dislocated.

The finger will have to be immobilized in a splint for several weeks. This ensures that the tendon is correctly positioned for proper healing. There may be an additional problem if there is also an open wound along with the tendon tear. The open wound creates a risk of infection in the hand. In these cases, surgery may be necessary.

Baseball finger can also be a problem for children because it may involve injury to the cartilage that controls bone growth. This type of injury requires careful evaluation and treatment so that the finger does not become stunted or deformed.

Boutonnière Deformity

If you jam your finger while playing volleyball or basketball, you might notice that it takes on an odd appearance. The middle joint bends down and the fingertip end joint bends back. This is the characteristic shape of a boutonnière deformity, an injury to the tendons that straighten the fingers. About one-third of all people with rheumatoid arthritis also have fingers with boutonnière deformities.

Several tendons work together to straighten the finger. The tendons run along the side and top of the finger. The tendon on the top attaches to the middle bone of the finger (the central slip of tendon). A forceful blow to the bent finger or a cut on the top of the finger can sever the central slip from its attachment to the bone. The tear looks like a buttonhole ("boutonnière" in French); in some cases, the bone can actually pop through the opening.

Boutonnière deformity usually means that there is no way for a person to fully straighten the finger. Unless this injury is treated promptly, the deformity may progress, resulting in permanent deformity and impaired functioning.

Signs and symptoms

• Inability to straighten the finger at the middle joint and bend the fingertip.
• Swelling and pain on the top of the middle joint of the finger.

Diagnosis and treatment

Because a boutonnière deformity is only one of several injuries that result from a "jammed finger," you should consult a doctor for an appropriate diagnosis and treatment. Your doctor will examine your fingers and hand. He or she will ask you to straighten the affected finger and bend your fingertip. X-rays may be recommended to detect any broken bones attached to the central slip of tendon.

For the tendon or bone to heal properly, your doctor will apply a splint to straighten the finger at the middle joint. This keeps the ends of the tendon from separating as they heal. It is important to keep wearing the splint for the recommended length of time, usually six weeks. Your physician may also recommend stretching exercises for the fingertip. After the immobilization period, you may still have to wear the splint at night, and your physician will recommend exercises to improve strength and flexibility in your fingers. If you participate in sports, you may have to wear protective splinting or taping for several weeks after the splint is removed.

People with boutonnière deformity caused by arthritis may be treated with oral medications or corticosteroid injections as well as splinting.

Surgical options

Boutonnière deformity must be treated early to retain full range of motion in the finger. However, surgery is an option when the deformity results from rheumatoid arthritis, when the tendon is severed, when a large bone fragment is displaced or when the condition does not respond to splinting. Surgery can reduce pain and improve functioning, but it may not be able to fully correct the condition and make the finger look normal.

Carpal Tunnel Syndrome

What is carpal tunnel syndrome?

Do you often feel a numbness or tingling in your hand, especially at night? Maybe you experience clumsiness in handling objects and sometimes you feel a pain that goes up the arm to as high as the shoulder. These may be the symptoms of carpal tunnel syndrome.

The median nerve travels from the forearm into your hand through a "tunnel" in your wrist. The bottom and sides of this tunnel are formed by wrist bones and the top of the tunnel is covered by a strong band of connective tissue called a ligament. This tunnel also contains nine tendons that connect muscles to bones and bend your fingers and thumb. These tendons are covered with a lubricating membrane called synovium which may enlarge and swell under some circumstances. If the swelling is sufficient it may cause the median nerve to be pressed up against this strong ligament which may result in numbness, tingling in your hand, clumsiness or pain described above.

How is it diagnosed?

Your doctor may diagnose this condition by the following symptoms and signs:

• numbness and tingling in the hands, especially when these symptoms occur at night and after use of the hands
• decreased feeling in your thumb, index, and long finger
• the presence in your hand of an electric-like shock or tingling (like hitting your "funny bone") when your doctor taps over the course of the median nerve at the wrist
• the reproduction of your symptoms by holding your wrists in a bent down position for one minute

In some cases your doctor may recommend a special test called a nerve conduction study. This test, done by a specialist, determines the severity of the pressure on the median nerve and may aid your orthopaedic surgeon in making a diagnosis and forming a treatment plan.

How is it treated?

Mild cases may be treated by applying a brace or splint which is usually worn at night and keeps your wrist from bending. Resting your wrist allows the swollen and inflamed synovial membranes to shrink; this relieves the pressure on the nerve. These swollen membranes may also be reduced in size by medications taken by mouth called non-steroidal anti-inflammatories. In more severe cases, your doctor may advise a cortisone injection into the carpal tunnel. This medicine spreads around the swollen synovial membranes surrounding the tendons and shrinks them, and, in turn, relieves the pressure on the median nerve. The dosage of cortisone is small and when used in this manner it usually has no harmful side effects. The effectiveness of non-surgical treatment is often dependent on early diagnosis and treatment.

In those patients who do not gain relief from these non-surgical measures it may be necessary to perform surgery. The site of the operation is made pain-free by local anesthesia injected either into the wrist and hand or higher up in the arm. This may be done by your orthopaedic surgeon or an anesthesia doctor. The surgery itself is called a "release" - cutting the ligament that forms the roof of the carpal tunnel to relieve the pressure on the median nerve. The surgery is usually performed in an outpatient facility and you are generally not required to stay over night.

Your doctor can explain to you the likelihood of non-surgical or surgical treatment based on your own individual circumstances.

What causes it?

Anything that causes swelling, thickening or irritation of the synovial membranes around the tendons in the carpal tunnel can result in pressure on the median nerve.

Some common causes and associated conditions are:

• repetitive and forceful grasping with the hands
• repetitive bending of the wrist
• broken or dislocated bones in the wrist which produce swelling• arthritis, especially the rheumatoid type
• thyroid gland imbalance
• sugar diabetes
• hormonal changes associated with menopause
• pregnancy

Although any of the above may be present, most cases have no known cause.

After surgery

After surgery, your symptoms may be relieved immediately or in a short period of time. Tenderness at the incision site may persist until healing is complete. Numbness may remain for a period of time, particularly in older persons or in more severe cases. It may be several weeks before you can return to your normal level of physical activities; for some, it will be several months. You will probably be given hand exercises to do to rebuild circulation, muscle strength and joint flexibility in your hand and wrist.

Your orthopaedist is a medical doctor with extensive training in the diagnosis and nonsurgical and surgical treatment of the musculoskeletal system, including bones, joints, ligaments, tendons, muscles and nerves. This brochure has been prepared by the American Academy of Orthopaedic Surgeons and is intended to contain current information on the subject from recognized authorities. However, it does not represent official policy of the Academy and its text should not be construed as excluding other acceptable viewpoints.

Common Hand Problems

No matter what your age or occupation your hands are always working. Since your hands are so important any abnormality can be a cause for concern. Many common hand problems that interfere with your daily activities can be diagnosed and treated by your orthopaedic surgeon.

Ganglion Cysts

Ganglion cysts are the most common mass or lump in the hand. They are most common on the back of the wrist. These non-cancerous, fluid-filled cysts arise from the ligaments, joint linings, or tendon sheaths when they are irritated or inflamed. They may disappear or change size quickly.

Many ganglion cysts do not require treatment. However, if the cyst is painful, interferes with function or the patient does not like the appearance, your orthopaedic surgeon can remove the fluid with a needle (aspiration) or remove it surgically.

Carpal Tunnel Syndrome

Common symptoms of carpal tunnel syndrome are numbness and tingling in the hand, especially at night; pain with prolonged gripping such as holding a steering wheel; or clumsiness in handling objects. Sometimes the pain can go all the way up to the shoulder.

These symptoms are caused by pressure on the median nerve as it enters the hand through a tunnel in the wrist. The tendons that bend your fingers and thumb also travel in this tunnel.

Mild cases can be treated with a splint or brace to rest the wrist. Steroid injections into the carpal canal to decrease swelling may be used in addition to splinting. Those cases that do not respond to nonsurgical treatment and those that are diagnosed late often require surgery. This is generally done in an outpatient setting under local anesthesia.

Tendonitis of the Wrist

DeQuervain's stenosing tenosynovitis is an irritation and swelling of the sheath or tunnel which surrounds the thumb tendons as they pass from the wrist to the thumb. Pain when grasping or pinching and tenderness over the tunnel are the most common symptoms. Sometimes a lump or thickening can be felt in this area. If the hand is made into a fist with the thumb "tucked in" and bent towards the little finger, the pain gets worse (Finkelstein test).

Tendonitis may be caused by overuse and also can be seen in association with pregnancy or inflammatory arthritis such as rheumatoid disease.

If treated early, many cases improve with short periods of rest in a splint, followed by stretching exercises designed to get the tendons gliding. Injection with steroids and/or taking anti-inflammatory medications. More severe cases or those that do not respond to other treatment may require surgery. Modification of the activities which caused the symptoms initially also may be required.

"Wear and Tear" Arthritis of the Hand

Wear and tear arthritis is very common at the base of the thumb. Pain localized to the base of the thumb, particularly with use, is a very common early symptom. Early disease can be treated with anti-inflammatory medication, steroid injections into the joint, or splinting.

As the wear and deformity progress, surgery is frequently required. There are many procedures to relieve pain and improve function.

Heberden nodes are "bumps" which occur at the last joint of the finger or thumb due to wear and tear arthritis (osteoarthritis). As the joints deteriorate, small bone spurs form over the back of the joints and make them appear "lumpy."

Since most Heberden nodes are not painful and seldom interfere with function, no specific treatment is usually required. Patients with pain can be treated with anti-inflammatory medications. All patients should continue moving their hands; disuse frequently results in stiffness.

Dupuytren's Contracture

Dupuytren's contracture is a hereditary thickening of the tough tissue called fascia that lies just below the skin of your palm. This condition may vary from small lumps or bands to very thick bands which may eventually pull the fingers into the palm.

Dupuytren's disease is familial, and may be associated with cigarette smoking, vascular disease, epilepsy, and diabetes.

The mainstay of treatment is surgical and is recommended if there is progressive contracture drawing the fingers into the hand. Sometimes a steriod injection will be used in a painful nodule. Small nodules or lumps in the palm do not need treatment until they are very large and interfere with hand function. Even with successful surgical removal, the bands may reappear or occur in other fingers.

Trigger Finger

Trigger finger is an irritation of the digital sheath which surrounds the flexor tendons. When the tendon sheath becomes thickened or swollen it pinches the tendon and prevents it from gliding smoothly. In some cases the tendon catches and then suddenly releases as though a "trigger" were released.

Sometimes the swelling can be treated with rest, activity modification, oral anti-inflammatories, or steroid injections. The tendon sheath will then return to its normal, pain-free condition. More severe cases may require surgery to release the tendon. This can be done as an outpatient procedure. Normal activity can be resumed as pain allows.

deQuervain's Tendinitis

What is it? deQuervain’s tendinitis is a condition brought on by irritation or swelling of the tendons found along the thumb side of the wrist (Figure 1). The irritation causes the compartment (lining) around the tendon to swell, changing the shape of the compartment; this makes it difficult for the tendons to move as they should. The swelling can cause pain and tenderness along the thumb side of the wrist, usually noticed when forming a fist, grasping or gripping things, or turning the wrist.

Signs and symptoms. Pain over the thumb side of the wrist is the main symptom. The pain may appear either gradually or suddenly. It is felt in the wrist and can travel up the forearm. The pain is usually worse with use of the hand and thumb, especially when forcefully grasping things or twisting the wrist. Swelling over the thumb side of the wrist is noticed and may be accompanied by a fluid-filled cyst in this region. There may be an occasional "catching" or "snapping" when moving the thumb. Because of the pain and swelling, it may be difficult to move the thumb and wrist, such as in pinching. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger.

Diagnosis. A Finkelstein test is generally performed. In this test, the patient makes a fist with the fingers over the thumb. The wrist is then bent in the direction of the little finger (Figure 2). This test can be quite painful for the person with deQuervain’s tendinitis. Tenderness directly over the tendons on the thumb side of the wrist is the most common finding, however.

Treatment. The goal is to relieve the pain caused by the irritation and swelling. In some cases, your doctor may recommend resting the thumb and wrist by wearing a splint. Anti-inflammatory medication taken by mouth or injected into that tendon compartment may help reduce the swelling and relieve the pain. In some cases, simply not doing the activities that cause pain and swelling may allow the symptoms to go away on their own. When symptoms are severe or do not improve, surgery may be recommended. The surgery opens the compartment (covering) to make more room for the irritated tendons (Figure 3). Normal use of the hand can usually be resumed once comfort and strength have returned. Your hand surgeon can advise you on the best treatment for your situation.

Dupuytren's Contracture

Many people find that as they age it becomes increasingly difficult to fully extend or stretch their fingers. In many cases, arthritis or some other joint disease may be to blame. But a condition in the palm of the hand may also cause the fingers to contract.

Dupuytren’s (pronounced du-pwe-trahns’) contracture is a fairly common condition that occurs when the connective tissue (fascia) under the skin begins to thicken and shorten. As the tissue tightens, it may pull the fingers down towards the palm of the hand. In some individuals, the condition may progress until the involved fingers become disabled.

Who is at risk?

• People of northern European descent. There is a genetic component to Dupuytren’s contracture.
• Men. The incidence of Dupuytren’s contracture is about seven times higher among men than among women.
• People of middle age. Most of the time, Dupuytren’s contracture doesn’t show up until after age 40. However, a very aggressive form may appear in teenagers and children.
• Diabetics, alcoholics and people taking anticonvulsant drugs for epilepsy.

Signs and symptoms

The first sign is a thickening (nodule) in the palm of the hand that most frequently develops near the base of the ring or little finger. The nodule, which can resemble a callus, is painless but may be tender to the touch. Gradually, other nodules may develop and extend a contracture across the first joint into the finger. The overlying skin begins to pucker, and rough cords of tissue extend into the finger. As the process continues, these cords tighten and pull the finger in toward the palm. The ring finger is usually affected first, followed by the little, long and index fingers. The problem is not pain, but the restriction of motion and the deformity it causes.

The progress of the disease is often sporadic and unpredictable. Exactly what triggers the formation of nodules and cords is unknown. As the disease progresses, the diseased tissue wraps itself around and between normal tissue.

Many people do not seek medical care until the contracture is well advanced. The only treatment for this condition is surgery, which is usually reserved for individuals who have developed deformity as a result of the progressive contracture. Because many nodules do not progress to contracture and because scar tissue from previous surgeries can make excision of recurrent nodules more difficult, surgical removal of isolated nodules is not indicated in most cases.

A good guideline for determining when to consider surgery is the "table top test." Try to place the palm of your hand completely flat on a hard surface. If you can’t, the contracture has progressed to a point where surgical intervention could be helpful.

Surgical Treatment

Several different surgical techniques can be used to remove the thickened fascia and correct the contracture. Your surgeon will select a technique based on his or her experience, training, and approach. The aim of the surgery is to release the contracture and improve hand function by removing the diseased tissue.

The results of surgery are usually good, and the fingers can return to normal extension after therapy. However, the disease can return even some years after the initial surgery. Dupuytren’s contracture usually does not recur beneath a skin graft, so this may be an option in especially aggressive forms of the disease.

After Surgery

It’s important to follow your doctor’s orders regarding therapy and treatment after surgery. You will probably have to wear a splint so that the fingers stay extended. The splint is usually worn full time immediately after the surgery and then only at night for several months. You will also have to do some active range-of-motion exercises so that the finger retains mobility and strength.

Fingertip Injures / Amputations

Your child accidentally slams a fingertip in a car door. Or you cut off the end of your finger while chopping vegetables. Or you lose the tops of several fingers trying to clear debris from a lawnmower or snowblower. Fingertip injuries are very common. Accidents can happen at work, play and in the home, crushing, tearing (lacerating) or cutting off (amputating) the tips of fingers and thumbs. The tips of longer fingers get injured more often because they are last to escape when you pull your hand out of harm’s way. You may have damage to skin and soft tissue, bone (distal phalanx) and/or nail and nailbed.

What to do

Always see a doctor right away if you injure the tip of a finger or thumb. Fingertips are rich with nerves and extremely sensitive. Without prompt and proper care, a fingertip injury can disrupt the complex function of your hand, resulting in permanent deformity and disability.

First aid:

• Elevate the injury and apply ice to reduce bleeding and swelling.
• Cover the fingertip wound with a dry, sterile dressing.
• Immobilize the affected hand and wrist with a short splint.

If a fingertip is completely cut-off:

• Gently cleanse the amputated part with water (preferably saline).
• Cover it in gauze wrap.
• Put it in a watertight bag.
• Place the bag on ice.
• Do not put the amputated part directly on ice. You could further damage it.

Take the amputated part with you to the emergency room.

Medical treatment

Doctors provide individualized treatment for a fingertip injury/amputation based on the angle and extent of the injury, as well as factors related to your health and lifestyle. Tell your doctor how and when the injury happened and:

• If the injury is on your dominant hand.
• What you do for a living and recreational activities.
• If you have other hand problems, osteoarthritis or systemic diseases (i.e., diabetes, rheumatoid arthritis).
• Whether your tetanus immunization is current.

The doctor will probably give you an injection (digital block anesthesia) to stop pain in the affected finger. Then he or she may irrigate the wound with a saline solution; inspect it for exposed bone, soft tissue loss and nail/nailbed injury; and clean (debride) it, removing dead (devitalized) tissue and foreign contaminants to reduce risk of infection. You may need X-rays to check for fractures. If blood has accumulated beneath the nail (subungual hematoma), your doctor may drain it by piercing through the fingernail. You may also need an antibiotic and/or tetanus shot.

Your doctor formulates a plan for treatment after completely assessing your injury. The goal is a painless fingertip that has durable and sensate skin. Your hand should be able to pinch, grip and perform other normal functions. If possible, your doctor may also try to maintain the finger’s length and appearance and preserve its fingernail.

Soft tissue injury with no exposed bone

Small wound: A small wound to a fingertip’s skin and fleshy tissue (pulp) may close on its own (healing by secondary intention). Your doctor may put a protective dressing over the wound, splint your hand and instruct you to change the bandage at regular intervals. After 48 hours, you may begin range-of-motion finger exercises. After about a week, you may start daily finger soaks in a warm water-peroxide solution. Complete healing usually takes 3-5 weeks. Then you may need a program of fingertip desensitization.

Large wound: If you let a larger fingertip wound heal itself, you may not get a durable fingertip. Therefore, your doctor may need to transplant a piece of skin from the palm of your hand or other donor sites (skin graft) to cover the injury. The donor site is surgically closed.

Exposed bone

If your injury exposes bone, there is probably not enough tissue available on the fingertip to surgically close it. Your doctor may need to shorten the bone, which generally does not hurt hand function. He or she may also need to transfer a piece of skin and underlying fat and blood vessels from a healthy part of your body to the injury site (reconstructive flap surgery). Depending upon the angle of injury or amputation, the flap may come from:

• The injured finger (triangular volar advancement flap).
• An uninjured finger (cross-finger flap).
• The palm of the hand (thenar flap).

Your doctor sews (sutures) the flap to the defect and surgically closes the donor site. A bulky dressing and splint supports your hand after surgery, with uninjured fingers left free to exercise. A second operation may be necessary in a few weeks to detach the flap from its origin. If the amputated part is large (includes the entire nail and dorsal skin), your doctor may discuss the pros and cons if replantation is right for you. This involves a long, complicated surgical procedure which may keep you hospitalized for several days.

Young children

Doctors treat fingertip amputations somewhat differently in children under age 6. After thoroughly cleaning and removing fat from an amputated fingertip, your doctor may suture it back on the finger (composite flap). Especially in children under age 2, a relatively normal looking fingertip may form, even if bone was exposed.

Outcome

In many cases, fingertip repair surgery can give you back a large degree of feeling and function. Infection, poor healing, loss of feeling or motion, blood clots and adverse reactions to anesthesia are all possible complications of surgery. You may have mild to severe pain and sensitivity to cold following treatment for a fingertip injury/amputation. Recovery may take months, and you will probably need hand therapy. This may include hand exercises to improve movement and strength, heat and massage therapy, electrical nerve stimulation, splinting, traction and special wrappings to control swelling.

Flexor Tendon Injures

Tendons are tissues that connect muscles to bone so that joints can bend or straighten. The flexor muscles that move your fingers and thumb are located in your forearm, above your wrist. Long tendons extend from the flexor muscles through the wrist and attach to the small bones of your fingers and thumb.

Anatomy

Each finger has two tendons; the thumb has one tendon. The tendons run along the palm side of the fingers and are very close to the surface of the skin, particularly where the skin folds as you bend your fingers. The longer tendon (flexor digitorum profundus or FDP) attaches to the last bone of the finger and bends the tip; the shorter tendon (flexor digitorum sublimis or FDS) bends the middle joint of the finger.

If you tear (rupture) or cut (sever) the tendon anywhere along its route—at the wrist, in the palm of the hand, or along the finger, you may be unable to bend your finger. If you injure the FDS tendon, you may still be able to bend the finger, but not completely, and bending the finger will be painful.

Tendons are stretched tightly as they connect the muscle to the bone. If the tendon tears, the end connected to the muscle will be pulled back in toward the palm. Because the tendon can’t heal unless the ends are touching, a severed tendon must be sewn back together again (a surgical repair).

Types of injuries

Most often the flexor tendons are damaged by a cut. Because the nerves to the fingers are also very close to the tendons, a cut may damage them as well, resulting in a feeling of numbness on one or both sides of the finger.

Athletic injuries are also common, usually in football, wrestling or rugby. One player grabs another’s jersey, and a finger—usually the ring finger—gets caught and pulled. This type of injury is so common, it even has a name: "jersey finger." You can also strain or rupture the tendon while rock climbing.

People with rheumatoid arthritis may experience a spontaneous rupture of the flexor tendons. You may notice that the finger no longer bends, but cannot recall when you lost the ability to bend it.

Signs and symptoms

• An inability to bend one or more joints of the finger
• Pain when you bend your finger
• An open injury, such as a cut, on the palm side of the hand, particularly in the joint area where the skin folds as the finger bends
• Mild swelling over the joint closest to your fingertip
• Tenderness along the finger on the palm side of the hand

Diagnosing your injury

See your physician whenever you injure your fingers, especially if you "jam" the finger and notice that you cannot bend or straighten the tip. For immediate first aid, apply ice and compression to slow the flow of blood to the damaged site.

Your doctor will ask you to bend and straighten the fingers and may apply resistance to test the strength of the fingers. Your doctor may also test the sensation and blood flow to your fingers to see if any nerves or blood vessels were also injured. You may need to get an X-ray to see if there is any damage to the bone; if you have an open wound, you may need a tetanus shot or antibiotics.

Treatment

Your doctor may first clean and treat any superficial wounds and put your hand in a splint. Flexor tendon injuries require surgical repair and it’s best to have the surgery as soon as possible after the injury. The hand surgeon will sew the tendon together using special stitches on both the inside and outside of the tendon. However, it can take up to two months before the repair is healed and strong enough to use your hand without protection. It may take another month or so before you can use your hand with any force.

In the meantime, you will need to wear a splint and see a physical therapist. The therapist will give you special exercises to perform. Follow your doctor’s and your therapist’s instructions carefully to ensure the best possible result.

Even after surgery, you may experience some stiffness in your finger. However, it will be considerably less than if you did not have the surgery.

Fracture of the Finger

You might think a broken finger is a minor injury, but without proper treatment it can cause major problems. The bones in a normal hand line up precisely, letting you perform many specialized functions like grasping a pen or manipulating small objects in your palm. When you fracture a finger bone, it can put your whole hand out of alignment. Without treatment, your broken finger might stay stiff and painful.

Signs of a fractured finger

• Swelling.
• Tenderness.
• Inability to move it completely.
• Deformity.

Diagnosis

If you think you broke your finger, tell your doctor right away exactly what happened and when. You have three bones (phalanges) in each finger and two in each thumb. Your doctor must determine not only which bone fractured, but also how it broke: straight across, in a spiral, into several pieces, or shattered completely. Your doctor may want to see how your fingers line up when you extend your hand or make a fist. Does any finger overlap its neighbor? Angle in the wrong direction? Look too short? Your doctor may X-ray both of your hands for comparison.

Treatment and rehabilitation

Your doctor will put your broken bone back into place, usually without surgery. Sometimes you need pins, screws or wire to hold it together, especially if you have a complicated injury. You’ll get a splint or cast to hold your finger straight and protect it from further injury while it heals. Sometimes your doctor may splint the fingers next to the fractured one for support. Your doctor will tell you how long to wear the splint – usually about three weeks. Sometimes you may need more X-rays as you heal so your doctor can check your progress.

Begin using your hand again as soon as your doctor determines it is okay to move your finger. Doing simple rehabilitation exercises each day will help reduce the finger’s stiffness and swelling. You may be required to see a physical therapist to assist you in these exercises.

Ganglions (cysts) of the Wrist

Finding a lump on your hand or wrist can be a frightening experience. But most of the time, these are harmless ganglion cysts that will often disappear in time.

Commonly, ganglion cysts grow on the top of the wrist (dorsal ganglions). But they can also be found on the underside of the wrist (between the thumb and your pulse point), at the end joint of a finger or at the base of a finger. A ganglion grows out of a joint, like a balloon on a stalk that rises out of the connective tissues between bones and muscles. Inside the balloon is a thick, slippery fluid similar to the fluid in your joints. Usually, the more active you are, the larger the lump becomes; when you rest, the lump decreases in size.

What causes ganglions

No one knows what triggers the formation of a ganglion. Women are more likely to be affected than men, and ganglions are common among gymnasts, who repeatedly apply stress to the wrist. Because the fluid-filled sac puts pressure on the nerves that pass through the joint, some ganglion cysts may be painful. Large ganglions, even if they are not painful, are unattractive. Smaller ganglions that remain hidden under the skin (occult ganglions) may be quite painful.

Examination and diagnosis

Your doctor may ask you how long you’ve had the ganglion, whether it changes in size and if it is painful. He or she may apply pressure to see if there is any tenderness, or hold a penlight up to the cyst to see if the light shines through. You will probably need to get an X-ray, so that the doctor can rule out conditions such as arthritis or a bone tumor. Sometimes, an MRI or ultrasound is needed to find a ganglion cyst hidden under the skin.

Treatment options

The first course of treatment is nonsurgical and conservative.

• Observation. Because the ganglion is not cancerous and may disappear in time, the physician may recommend just waiting and watching to make sure that no radical changes occur.
• Immobilization. Activity often causes the ganglion to increase in size, thus increasing the pressure on nerves and causing pain. Your physician may recommend that you wear a wrist brace or splint to relieve symptoms and allow the ganglion to decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
• Aspiration. If the ganglion causes significant pain or severely limits your activities, you may choose to have the doctor drain the fluids with a procedure called "aspiration." The doctor will numb the wrist and puncture the cyst with a needle to remove the fluid.

These treatments leave the outer shell and the stalk of the ganglion intact, so it may reform and reappear. Outpatient surgery can remove the ganglion, but is no guarantee that the cyst will not recur. Part of the involved joint capsule or tendon sheath may also be removed. This is of little concern, but afterwards you may feel some tenderness, discomfort and swelling. You should be able to resume normal activities in two to six weeks.

Hand Fractures

Have you ever been so frustrated that you wanted to slam your fist into a wall? If you do, you could break one of the bones in your hand (metacarpals). Fractures of the hand bones account for about one-third of all hand fractures. In fact, fractures of the fifth bone (the one that leads to your little finger) are commonly known as "boxer’s fractures."

The hand bones can break near the knuckle, mid-bone, or near the wrist. Signs and symptoms of a broken bone include:

• Swelling
• Tenderness
• Deformity
• Inability to move the finger
• Shortened finger
• Depressed knuckle
• Finger crosses over its neighbor when you make a partial fist

Diagnosis and Treatment

Your physician will request X-rays to identify the fracture location and type. The physical examination may include some range of motion tests and an assessment of sensation in the fingers to ensure that there is no damage to the nerves.

Most of the time, the physician can realign the bones by manipulating them without surgery. Then, a cast, splint or fracture-brace is applied to immobilize the bones and hold them in place. The cast will probably extend from the fingertips down past the wrist almost to the elbow to ensure that the hand bones remain fixed in place. Your physician will probably request a second set of X-rays about a week later to ensure that the bones remain in the proper position. You will usually have to wear the cast for three to four weeks, but you can probably begin gentle hand exercises after three weeks. Afterwards, the finger may be slightly shorter, but this should not affect your ability to use your hand and fingers.

Surgical options

Some hand fractures, such as those that break through the skin or result from a crushing accident, require surgery to stabilize and align the bones. The orthopaedic surgeon implants wires, screws or plates in the hand to hold the fracture in place. If the bone rotates while healing, loss of function could result.

After the bone has healed, the surgeon may remove the implants, or they may be left in the hand. Research to develop implants that are resorbed into the body is ongoing. Your physician may ask you to return frequently for check-ups to ensure that the joint doesn’t tighten (contract) during healing. You may experience some joint stiffness in your hand because of the long immobilization period. Your physician may prescribe exercises to help restore strength and range of motion or recommend that you see a physical therapist.

Hand Surgery

What is it? Our hands serve many purposes. Hands help us eat, dress, write, earn a living, create art, and do many other activities. To do these tasks and activities, our hands require sensation and movement, such as joint motion, tendon gliding, and muscle contraction. When a problem takes place in the hand, care must be given to all the different types of tissues that make function of the hand possible. The field of hand surgery deals with both surgical and non-surgical treatment of conditions and problems that may take place in the hand or upper extremity (from the tip of the hand to the shoulder).

Many conditions occur in the upper extremity that can be treated by a hand surgeon. These conditions include immediate care of an injury, treatment and reconstruction of old injuries, congenital problems, arthritis, infection, and new growths and tumors. Hand surgeons also treat other problems such as nerve compression syndromes and swelling of tendons. Microsurgery is used for the reattachment of amputated parts and certain hand reconstructions. Some hand surgeons also take care of problems of the elbow and shoulder.

What are the qualifications of a hand surgeon? Hand surgery is part of the practice of general surgery, orthopaedic surgery, and plastic surgery. As surgical techniques in the upper extremity become more refined and complex, specialized training in upper extremity surgery continues to be very important. Training usually takes place during orthopaedic and plastic surgery residency or a fellowship. A fellowship is an additional period of study in surgery after a physician completes a multi-year residency. Surgeons may take an examination in hand surgery, which qualifies them to obtain a Certificate of Added Qualifications in Surgery of the Hand. our mission

What is hand therapy? When a problem takes place in the hand or upper extremity, making the hand work is the main goal. The objective of therapy is to provide exercises and activities designed to help return the hand to normal use. Therapy may be necessary after surgery and may be provided by your surgeon or a physical or occupational therapist with specialized training in rehabilitation of the upper extremity. Therapy sessions are important for recommending changes in the treatment program as well as keeping a record of progress being made. It is important that each patient understand his or her therapy program and practice it at home if maximum recovery is to be made. Achieving the best result following a hand injury or problem is a team effort of the patient, hand surgeon, and hand therapist.

Human Bites

Human bite wounds may not sound very dangerous, but they are. Human bite wounds contain very high concentrations of bacteria, so the risk of infection is high. Even though the wound may appear insignificant, an infection can lead to a severe joint infection. About one third of all hand infections result from human bite wounds. These infections can progress quickly and result in significant complications, so early treatment is necessary.

Bites can transmit the human immunodeficiency virus (HIV), as well as the hepatitis B virus and syphillis. Joint infections can lead to septic arthritis. Someone who has a human bite wound should get prompt first aid and see a doctor within 24 hours of the injury if the skin is broken.

Sometimes the wound is incurred directly (an actual bite). Other times, it is indirect (a clenched fist strikes a tooth, which breaks the skin on the hand). In a fight, a punch to the mouth can result in an indirect bite injury at the knuckle joint (MP or metacarpophalangeal joint), which can lead to a severe infection and possible destruction of the joint if it is not promptly treated.

Signs and symptoms

In some cases, the bite will not break the skin but may cause damage to underlying tendons and joints. If the skin is broken, there is the additional possibility of infection as well as injury to joints, tendons and nerves. An injury to the top of the hand can result in significant swelling within hours. Signs of an infection include:

• Warmth around the bite wound
• Swelling
• Pain
• A pus discharge

Signs of damage to tendons or nerves include:

• An inability to bend or straighten the finger
• A loss of sensation over the tip of the finger

First aid

1. Don’t put the bitten area in your mouth!
2. If there is no bleeding, wash the wound thoroughly. Use soap and water or an antiseptic such as hydrogen peroxide or alcohol. Apply an antibiotic ointment and cover with a non-stick bandage. Watch the area carefully to see if there are signs of damaged nerves or tendons. If you see any, seek medical help immediately.
3. If there is bleeding, apply direct pressure with a clean dry cloth. Elevate the area. Do not clean a wound that is actively bleeding. Cover the wound with a clean dressing and seek medical help. In these situations, early intervention (within 24 hours) is needed to prevent complications.

Medical assistance

Be sure to tell your doctor how you got the bite. Your physician will measure the wound, note its location, and check for signs of nerve or tendon damage. The doctor may examine your arm to see if there are signs of a spreading infection. You may need to get X-rays and a blood test. You may also need to get a tetanus shot and a prescription for antibiotics. You may also have to return in a day or two so that the physician can confirm that an infection has not developed. If the tendons or nerves have been injured, you may need to see a specialist for additional treatment.

Kienböck's Disease

Bone is living tissue that requires a regular supply of blood for nourishment. If the blood supply to a bone stops, the bone can die, a condition known as osteonecrosis. That’s what happens in Kienböck’s disease, which affects the lunate, one of the small bones of the hand near the wrist.

Signs and symptoms

The cause of Kienböck’s disease is unknown. Many people with Kienböck’s disease think they have a sprained wrist at first. They may have experienced some form of trauma to the wrist, such as a fall. This type of trauma can disrupt the blood flow to the lunate. In most people, two vessels supply blood to the lunate, but in some people there is only one source. This puts them at greater risk for developing the disease. As the disease progresses, other signs and symptoms are noted, including:

• A painful and sometimes swollen wrist
• Limited range of motion in the affected wrist (stiffness)
• Decreased grip strength in the hand
• Tenderness directly over the bone (on the top of the hand at about the middle of the wrist)
• Pain or difficulty in turning the hand upward

Progression

Kienböck’s disease follows a specific progressive pattern through four stages.

• Stage 1: Symptoms are similar to those of a wrist sprain. X-rays may be normal or show a line indicating a possible fracture. Magnetic resonance imaging (MRI) may also be helpful in making the diagnosis in this early stage.
• Stage 2: The lunate bone begins to harden. On an X-ray, it may appear brighter or whiter than the surrounding bones. These changes indicate that the bone is dying. Either an MRI or a computed tomography (CT) scan may be used to assess the condition of the bone. Recurrent pain, swelling and wrist tenderness are common.
• Stage 3: The dead bone begins to collapse and break into pieces. The surrounding bones may begin to shift position. Patients experience increasing pain, weakness in gripping, and limited motion.
• Stage 4: The surfaces of adjoining bones are affected, resulting in arthritis of the wrist.

Diagnosis and treatment

In its early stages, Kienböck’s disease may be difficult to diagnose because the symptoms are so similar to those of a sprained wrist. Even X-rays of the wrist may appear normal. At this point, the goal of treatment is to relieve the pressure on the lunate and help restore blood flow within the bone. Your physician may splint or cast your wrist for two to three weeks. Anti-inflammatory medications such as aspirin or ibuprofen will help relieve any pain and reduce swelling. If the pain continues, your physician may refer you to an orthopaedic or hand surgeon for further evaluation.

Surgical options

Although there is no cure, there are several surgical options for treating the more advanced stages of Kienböck’s disease. The right procedure for you will depend on several factors, including disease progression, your personal activity levels and goals and your surgeon’s experience with various procedures. Do not hesitate to discuss these options with your orthopaedic or hand surgeon and to ask why he or she is recommending a particular procedure.

In some cases, returning the blood supply to the bone (revascularization) may be possible. This procedure uses a bone graft from the inner bone of the lower arm. It may be combined with an external fixator, a metal device that helps relieve pressure on the lunate and preserve the spacing between bones.

If the bones of the lower arm are uneven in length, a joint leveling procedure may be recommended. Bones can be made longer with bone grafts, or shortened by removing a section of the bone. This reduces the compressive forces on the lunate and seems to halt progression of the disease. If the lunate is severely collapsed or fragmented, it can be removed. The two bones on either side of it are also removed. This procedure is called a proximal row carpectomy and will relieve pain while maintaining partial wrist motion.

Another way to ease pressure on the bone is to fuse several of the small bones of the hand together. However, this will not improve range of motion. If the disease has progressed to severe arthritis of the wrist, fusing the bones will reduce pain and help maintain function, although motion is limited.

Nerve Injury

What are nerves? Nerves are the "electrical wiring" system in all people that carry messages from the brain to the rest of the body. A nerve is like an electrical cable wrapped in insulation. A ring of tissue forms a cover to protect the nerve, just like the insulation surrounding an electrical cable (Figure 1).

Nerves serve as the "wires" of the body that carry information to and from the brain. Motor nerves carry messages from the brain to muscles to make the body move. Sensory nerves carry messages to the brain from different parts of the body to signal pain, pressure, and temperature. While the axon (nerve fiber) carries only one type of message, either motor or sensory, most nerves in the body are made up of both.

What happens when a nerve is injured? Nerves are fragile and can be damaged by pressure, stretching, or cutting. Injury to a nerve can stop signals to and from the brain causing muscles not to work properly, and you may lose feeling in the injured area. When a nerve is cut, both the nerve and the insulation are broken. Pressure or stretching injuries can cause the fibers carrying the information to break and stop the nerve from working, without damaging the cover.

When nerve fibers are cut, the end of the fiber farthest from the brain dies, while the insulation stays healthy. The end that is closest to the brain does not die, and after some time may begin to heal. If the insulation was not cut, new fibers may grow down the empty cover of the tissue until reaching a muscle or sensory receptor. If both the nerve and insulation have been cut and the nerve is not fixed, the growing nerve fibers may grow into a ball at the end of the cut, forming a nerve scar or neuroma. A neuroma can be painful and cause an electrical feeling when touched.

How is it treated? To fix a cut nerve, the insulation around both ends of the nerve are sewn together. The goal in fixing the nerve is to save the cover so that new fibers may heal and work again (Figure 2). If a wound is dirty or crushed, your physician may wait to fix the nerve until the skin has healed. If there is a space between the ends of the nerve, the doctor may need to take a piece of nerve (nerve graft) from another part of the body to fix the injured nerve. This may cause permanent loss of feeling in the area where the nerve graft was taken.

Once the nerve cover is fixed, the nerve generally begins to heal three or four weeks after the injury. Nerves usually grow one inch every month depending on the patient’s age and other factors. This means that with an injury to a nerve in the arm above the fingertips, it may take up to a year before feeling returns to the fingertips. The feeling of pins and needles in the fingertips is common during the recovery process. While this can be uncomfortable, it usually passes and is a sign of recovery.

What is my role in recovery and what kind of results can I expect? The patient must do several things to keep up muscle activity and feeling while waiting for the nerve to heal. Your doctor may recommend therapy to keep joints flexible. If the joints become stiff, they will not work even after muscles begin to work again. When a sensory nerve has been injured, the patient must be extra careful not to burn or cut fingers since there is no feeling in the affected area. After the nerve has recovered, the brain gets "lazy," and a procedure called sensory re-education may be needed to improve feeling to the hand or finger. Your doctor will recommend the appropriate therapy based on the nature of your injury.

Factors that may affect results after nerve repair include age, the type of wound and nerve, and location of the injury. While nerve injuries may create lasting problems for the patient, care by a physician and proper therapy help two out of three patients return to more normal use.

Reflex Sympathetic Dystrophy

What is it? Reflex sympathetic dystrophy, also known as RSD, is a condition of burning pain, stiffness, swelling, and discoloration of the hand. RSD includes other medical diagnoses such as casualgia, Sudeck’s atrophy, and shoulder-hand syndrome. RSD occurs from a disturbance in the sympathetic (unconscious) nervous system that controls the blood flow and sweat glands in the hand and arm. When the nervous system becomes overactive, burning pain is felt and swelling and warmth are left in the affected arm. If not treated, RSD can cause stiffness and loss of use of the affected part of the arm.

What causes it? In some cases, the cause of RSD is unknown. Often an injury can cause RSD, or the symptoms may appear after a surgery. Other causes include pressure on a nerve, infection, cancer, neck disorders, stroke, or heart attack. These conditions can cause pain, which sets off the sympathetic reflex causing RSD symptoms. Nerve injuries may change the way the nerve impulses are sent, causing a "short circuit" (Figure 2).

Signs and symptoms. The pain associated with reflex sympathetic dystrophy is often described as burning in nature. Swelling can cause painful joints and stiffness. RSD has three stages:

Stage I (acute) may last up to three months. During this stage the symptoms include pain and swelling, increased warmth in the affected part/limb, and excessive sweating. There may be faster-than-normal nail and hair growth and joint pain during movement of the affected area (Figure 1).

Stage II (dystrophic) can last three to 12 months. Swelling is more constant, skin wrinkles disappear, skin temperature becomes cooler, and fingernails become brittle. The pain is more widespread, stiffness increases, and the affected area becomes sensitive to touch.

Stage III (atrophic) occurs from one year on. The skin of the affected area is now pale, dry, tightly stretched, and shiny. The area is stiff, pain may decrease, and there is less hope of getting motion back.

Diagnosis. The diagnosis usually is made when at least three of the following symptoms are present: pain and tenderness, signs of changed blood flow (either increased or decreased), swelling with joint stiffness, or skin changes.

Treatment. Early diagnosis and treatment are important. Three forms of treatment may be combined: medication, physical therapy, and surgery. Medication taken by mouth can help decrease the symptoms. To reduce symptoms and provide long-term relief, local anesthetics may be injected into a nerve bundle at the base of the neck (stellate ganglion block). In some cases, a tourniquet is applied to the arm and medication can be injected into a vein along with an anesthetic. Your hand surgeon may recommend therapy by a hand, occupational or physical therapist, or physician. Therapy is important to regain function and reduce discomfort caused by RSD. Successful treatment depends on the patient’s full and active effort in therapy. Occasionally, surgery is performed in the later stages, but the results can be disappointing. Your physician can advise you on the best treatment for your situation.

Replantation

What is replantation?

Replantation refers to the surgical reattachment of a finger, hand, or arm that has been completely cut from a person’s body. The goal of replantation surgery is to give the patient back as much use of the injured area as possible. In some cases, replantation is not possible because the part is too damaged. If the lost part cannot be reattached, a patient may have to use a prosthesis (a device that substitutes for a missing part of the body). In some cases, a prosthesis may give a person without hands or arms the ability to function.

Replantation is usually recommended when the replanted part will work at least as well as a prosthesis. Generally, a missing hand would not be replanted knowing that it would not work, be painful, or get in the way of everyday life. Before surgery the doctor, if possible, will explain the procedure and how much use is likely to return following replantation. The patient or family member must decide whether that amount of use justifies the long and difficult operation, time in the hospital, and months or years of rehabilitation.

How is the procedure done?

There are a number of steps in the replantation process. First, damaged tissue is carefully removed. Then bone ends are trimmed before they are rejoined. This makes putting together the soft tissue on either side of the wound easier. Arteries, veins, nerves, muscles, and tendons are sewn back together (Figure 1). Areas without skin are covered with skin that has been taken from other areas of the body. Uncovered nerves, tendons, and joints may be covered by a free-tissue transfer, where a piece of tissue is removed from another part of the body, along with its artery and veins.

What kind of recovery can I expect?

The patient has the most important role in the recovery process. Smoking causes poor circulation and may cause loss of blood flow to the replanted part. Allowing the replanted part to hang below heart level may also cause poor circulation. Younger patients have a better chance of their nerves growing back, they may regain more feeling, and may regain more movement in the replanted part. Generally, the further down the arm the injury occurs, the better the return of use to the patient. Patients who have not injured the joint will get more movement back than those who have. A cleanly cut part usually works better after replantation than one that has been crushed or pulled off. Recovery of use depends on regrowth of two types of nerves: sensory nerves that let you feel, and motor nerves that tell your muscles to move. Nerves grow about an inch per month. The number of inches from the injury to the tip of a finger gives the minimum number of months after which the patient may be able to feel something with that fingertip. The replanted part never regains 100% of its original use. Most doctors consider 60% to 80% an excellent result. Cold weather can be uncomfortable and a frequent complaint even for those with excellent recovery.

What about therapy and rehabilitation?

Complete healing of the injury and surgical wounds is only the beginning of a long process of rehabilitation. Therapy and temporary bracing are important to the recovery process. From the beginning, braces are used to protect the newly repaired tendons and allow the patient to move the replanted part. Therapy with limited motion helps keep joints from getting stiff, muscles moving, and scar tissue to a minimum. Even after you have recovered fully, you may find that you cannot do everything you wish to do. Tailor-made devices may help many patients do special activities or hobbies. Talk to your physician or therapist to find out more about such devices. Many replant patients are able to return to the jobs they held before the injury. When this is not possible, patients can seek assistance in selecting a new type of work.

Are emotional problems common following replantation?

Replantation can affect your emotional life as well as your body. When your bandages are removed and you see the replanted part for the first time, you may feel shock, grief, anger, disbelief, or disappointment because the replanted part simply does not look like it did before. Worries about the look of a replanted part and how it will work are common. Talking about these feelings with your doctor often helps you come to terms with the outcome of the replantation. Your doctor may also ask a counselor to assist with this process. You may find it helpful to talk about it with someone and work through your feelings so you can move on with your life.

Will additional surgery be necessary?

Some patients who have fully recovered from replantation surgery may need surgery later to reach full usage of the part. Some of the most common procedures are:

• Tenolysis — frees tendons from scar tissue.
• Capsulotomy — releases stiff, locked joints.
• Tendon or muscle transfer — moves tendons or muscles to another spot so that they can work in an area that needs the tendon or muscle more.
• Nerve grafting — replaces a scarred nerve or a gap in the nerves to improve how the nerve works.
• Late amputation — removing the part later because it does not work or has become painful.

Stay in the flow of life. You have many great gifts. Even with the best medical care, you need to be strong during the course of recovery. Remember that quality of life is directly related to your attitude and expectations—not just regaining limb use.

Restoring Hand Function after Spinal Cord Injury

An injury to the upper part of the spinal cord can leave an individual with little or no sensation or movement in both the arms and the legs, a condition called tetraplegia (tet-rah-PLEE-gee-ah). A surgical technique called a tendon transfer can help restore function to arms and hands by giving working muscles different jobs. This can greatly enhance the quality of life for people with tetraplegia by enabling them to do many more tasks for themselves. The types of tendon transfer surgeries that can be performed depend on where the spinal cord injury occurred and which muscles are affected.

How it works

Tendons are the strong cords that connect muscle to bone. When a tendon crosses a joint, it helps transmit muscle action into joint movement. A tendon transfer repositions the tendons of a working muscle so that they take over the functions of a paralyzed muscle. This enables the working muscle to do what the paralyzed muscle can no longer do.

For example, in the upper arm, the triceps muscle is used to straighten the elbow. The larger deltoid muscle pulls the arm backwards and forwards away from the body. If the triceps muscle is paralyzed but the deltoid is still functional, surgeons can split the deltoid muscle and graft a portion of it to the triceps. This restores elbow function without greatly diminishing shoulder function.

Tendon transfers can help restore three critical capabilities necessary for self-care and increased independence:

• the ability to straighten (extend) and bend (flex) the elbow
• the ability to bend and straighten the wrist
• the ability to grip with the fingers and hand

Planning for a tendon transfer

Usually, a tendon transfer is not scheduled until about a year after injury. During the first months after the injury, rehabilitation focuses on retaining passive range of motion. These exercises help prevent shoulder stiffness and pain. As time progresses, strength and range of motion (both active and passive) must be evaluated frequently. Severe muscle contractures or muscle spasms may necessitate another type of surgery rather than a tendon transfer. Usually tendon transfer surgery is scheduled only after there is no more progress in function.

Before surgery is scheduled, several assessments must be made, including:

• identifying which muscles still work and measuring how well they work to determine whether they can be used in the transfer
• assessing the individual’s abilities to see which functions need to be restored
• matching available muscles with functional requirements
• determining if an additional procedure such as a joint fusion or electrical stimulation implant is needed to restore function
• verifying that the individual has a strong support system that can provide the care needed during rehabilitation after surgery
• assessing the individual’s motivation and commitment to the process
• determining which surgeries should be performed, when, and in what order

Elbow Extension

The ability to bend and straighten the elbow adds greatly to a person’s independence, so this is often the first surgery to be performed. In most cases, a portion of the deltoid muscle in the shoulder is used to provide elbow extension. The back (posterior) portion of the deltoid is brought down toward the elbow. Because the deltoid portion is not long enough to reach the attachment point in the lower arm, a graft is taken from an upper leg muscle (fascia lata) to provide the necessary length. In some cases, the biceps muscle in the upper arm is used instead of the deltoid muscle. After the surgery, the arm is immobilized in a slightly bent position for up to four weeks. When the cast is removed, a hinged brace is used to allow a gradual stretching and strengthening of the muscles. Initially, the brace is worn night and day, but as the individual gains the ability to fully extend the arm, the brace is worn only at night. Tendon transfer to achieve elbow extension is done on one arm at a time because the arm is totally immobilized during rehabilitation. This means that the person becomes even more dependent on others for the simple activities of daily living. However, the results are impressive. It can eliminate the need for many adaptive devices and enable the person with tetraplegia to propel a wheelchair, to move independently from bed to chair, to shift weight within a chair or bed and to reach up and outwards.

Key Pinch

Restoring key pinch enables the individual to grip items between the thumb and the hand. This greatly enhances the ability of the patient with tetraplegia to accomplish activities of daily living, such as writing or feeding themselves. In this surgery, one of the forearm muscles (brachioradialis) is grafted to the tendons that move the wrist and thumb. The surgeon may also stiffen the joint so that when the wrist is extended, the grip forms automatically.

These two surgeries significantly improve hand and arm function in many patients, providing them with much greater independence.

Electronic Implants

A relatively recent advance uses an electronic implant, similar to a pacemaker, to stimulate muscles. Tiny electrodes are attached to the functioning muscles of the arm and hand. The electrodes are connected to a control device implanted in the front of the chest. An external unit delivers the signals to initiate grasp and key pinch. This is an option when tendon transfers cannot be used.

Outcomes

Because tendon transfers use the patient’s own tissues, the risk of infection is lessened. However, the risk of developing a latex allergy is increased so precautions should be taken. The length of the surgery (approximately six hours) also increases the risk of postoperative respiratory problems.

In general, the results using tendon transfer surgery to restore arm and hand function after spinal cord injury are good. People with tetraplegia can often benefit from the increased self-confidence and independence they gain after tendon transfer surgery.

Scaphoid (wrist bone) Fracture

Most of the time, a broken bone is obvious. The area around the break may be painful, swollen or deformed. But sometimes a bone can break without your realizing it. That’s usually what happens to the scaphoid (skaf'-oyd) bone in your wrist. Many people with a fractured scaphoid think they have a sprained wrist instead of a broken bone because there is no obvious deformity and very little swelling.

The scaphoid bone is located on the thumb side of your wrist, close to the lower arm bones. It is shaped like a cashew nut. The blood supply to the bone enters from the top, but most fractures occur in the middle or lower portion of the bone. This presents a problem because the blood supply cannot reach the injury to encourage rapid, adequate healing.

Who’s at risk?

Scaphoid fractures account for about 60 percent of all wrist (carpal) fractures. They usually occur in men between ages 20 and 40 years, and are less common in children or in older adults. The break usually occurs during a fall on the outstretched wrist. It’s a common injury in sports and motor vehicle accidents. The angle at which the wrist hits the ground determines the injury. If the wrist is bent at a 90-degree angle or greater, the scaphoid bone will break; if the angle is less than 90 degrees, the lower arm bone (radius) will break.

Signs and symptoms

• Pain and tenderness on the thumb side of the wrist.
• Motion (gripping) may be painful.
• May be some swelling on back and thumb side of wrist.
• Pain may subside, then return as a deep, dull aching.
• Marked tenderness to pressure on the "anatomical snuffbox," a triangular-shaped area on the side of the hand between two tendons that lead to the thumb.

Diagnosis

If you’ve fallen and think you’ve sprained your wrist, see your doctor as soon as possible. Your physician will ask you to describe what happened, examine your hand and wrist, and order X-rays of the area. Unless the fracture is displaced (the bone ends no longer touch each other), it may be difficult to see a scaphoid fracture on the first set of X-rays. Even if the initial X-rays do not show a scaphoid fracture, your physician may immobilize your wrist in a cast or splint for a week or so.

A bone scan taken two or three days after the injury can confirm the diagnosis. Or your physician may request a second set of X-rays after a week to ten days. Other diagnostic imaging tests that may be used include magnetic resonance imaging (MRI) and computed tomography (CT) scan.

Treatment

Treatment is determined by the fracture site, the degree of displacement, and any associated injuries. Most scaphoid fractures are treated with immobilization in either a cast that covers the lower arm, the wrist and the thumb or one that covers the full arm, wrist and thumb. Healing time can range from six weeks for fractures in the top portion to six months for fractures in the lower portion. The cast must be checked regularly to make sure that it fits properly and prevents movement. After the cast is removed, a rehabilitation program helps restore range of motion and strength.

Even with immediate cast immobilization, however, not all scaphoid fractures will heal properly. Surgical bone graft placement with internal fixation is usually recommended when the scaphoid fails to heal (non-union). This is successful in approximately 75 percent of cases.

Surgery is also required if the fracture is displaced or if there are other injuries. During the operation, the surgeon will align the bone and stabilize it with screws or pins. Sometimes a bone graft is used to promote healing.

Scaphoid fractures often take a long time to heal. Any delay in getting a diagnosis increases the risk of poor healing and the probability of more problems later. An untreated scaphoid fracture can lead to severe arthritis and eventually require surgery to fuse or replace the joint.

Sprained Thumb

When people start to fall, they usually extend their arm to reduce the force of the impact when they hit the ground. If you try to break your fall on the palm of your hand or take a spill on the slopes with your hand strapped to a ski pole, your thumb may be injured. The main ligament (ulnar collateral), which supports pinch and grasp activities, may be torn (sprained). The ligament helps your hand to function properly, acting like a hinge to keep your thumb joint (metacarpophalangeal) stable.

When you have a sprained thumb, you lose some or all of your ability to grasp items between your thumb and index finger. It may or may not hurt right away. Other signs include bruising, tenderness and swelling. To make sure your injury won’t cause long-term weakness, pain and instability, see your doctor for evaluation and treatment.

Partial and complete tears

Your thumb ligament may have a partial or complete tear. Your doctor will probably move your thumb joint to test its stability and take X-rays to make sure you don’t also have a broken bone. You may also get a stress X-ray showing what the joint looks like when your ligament is tested. If it hurts to do this, a shot of local anesthetic may help. Your doctor will probably also X-ray your uninjured thumb to compare it.

If you have a partial tear, your doctor will probably immobilize your thumb joint with a splint or other bandage until it heals. You wear the splint for about three weeks straight, then start taking it off to do flexion and extension exercises with your thumb. Put the splint back on for protection when you are not doing the exercises. Keep doing this for another two or three weeks until your thumb’s swelling and tenderness are gone. You may also put ice on your injury twice a day for 2-3 days after the fall.

If your thumb ligament is completely torn, you may need surgery. Fragments of bone that sometimes get pulled away when your ligament tears may be removed or put back in their correct positions. After surgery, you’ll probably need to wear a short-arm cast or a splint to protect your thumb ligament for six to eight weeks while it heals.

Thumb Fractures

A broken thumb is a serious problem because it affects your ability to grasp items in your hand and can increase the risk of arthritis later in life.

Anatomy
The thumb has two finger bones connected to a hand bone. The first finger bone (distal phalange) extends from the tip of the thumb to the knuckle. The second finger bone (proximal phalange) extends from the knuckle to the webbing between the thumb and the first finger. There, it connects with the hand bone (first metacarpal), which extends from the webbing down to the wrist.

Although a break can occur in any of these bones, the most serious breaks happen near the joints, particularly at the base of the thumb near the wrist. These fractures have specific names, depending on the type of break. The Bennett and Rolando fractures are breaks at the base of the thumb, involving the joint between the thumb metacarpal and a specific wrist bone. Fractures that involve the joints are always more difficult to treat and are at increased risk of an unfavorable outcome.

How it happens
Thumb fractures are usually caused by direct stress, such as when you fall or when a ball catches and pulls the thumb back. Some fractures may be caused indirectly, from twisting or muscle contractions. People who play contact sports such as wrestling, hockey or football; skiers; and people with a history of bone disease or calcium deficiency are especially at risk.

The risk of a thumb fracture can be lessened by using protective taping, padding or other equipment and by developing strength in your hands through exercise and proper nutrition.

Symptoms of a fracture

• Severe pain at the fracture site
• Swelling
• Limited or no ability to move the thumb
• Extreme tenderness
• A misshapen or deformed look to the thumb
• Numbness or coldness in the thumb

Treatment options
See a doctor as soon as possible. Without immediate treatment, the joint will be unstable and you will be unable to grip or pinch properly. Continued swelling may make it more difficult to align the bones properly. Delayed treatment will make the fracture much more difficult to treat and can lead to a poor outcome. Use a padded splint to prevent the bone from moving further out of alignment is encouraged prior to definitive treatment.

The physician will examine the injury, take your medical history and have X-rays taken of the injury. You may need surgery, depending on the location of the fracture and the amount of movement between the broken pieces of bone. If there is little movement (displacement) or if the break is located in the middle (shaft) of the bone, an orthopaedist may be able to use a specially designed cast (spica cast) to hold the bone fragments in place. You will have to wear the cast for at least four to six weeks, and your doctor may request regular X-rays to ensure that the bone hasn’t slipped out of alignment.

Often, Bennett and other more severe fractures of the thumb require surgical treatment. The hand surgeon may use one of several operative fixation techniques to restore boney anatomy and hold the bones in place while they heal. These techniques include the use of wire, pins, plates and screws as internal fixation. Another technique uses pins in bone that exit the skin and are attached to an external fixation device You will likely be required to wear a cast or splint for two to six weeks after surgery. When the cast is removed, your physician may recommend hand therapy to restore movement. It can take three months or more to regain full use of the hand, depending on the severity of the injury.

Complications and outcomes
If the bones remain in a stable position, thumb fractures generally heal well. There is a possibility of infection and tenderness around the surgical site and around the pins, if external fixation is used. As with all joint injuries, there is an increased tendency to develop arthritis, which can limit motion and reduce strength in the thumb.

To help restore motion, soak your hand in warm water and move your thumb in a circular direction. Try to touch your little finger with your thumb. To help restore strength, get a spring-type hand squeezer and use it regularly.

Trigger Finger

"Trigger finger" sounds like a malady that might affect gunslingers or hunters. In fact, this common condition results in a finger bent as if to pull a trigger. People over 40 years of age with a history of diabetes or rheumatoid arthritis are especially at risk to develop this condition.

How it develops

Although the exact cause of trigger finger is unknown, the progression of the condition is well documented. Trigger finger involves the tendons and pulleys in the hand that bend the finger. The tendons connect the muscles of the forearm with the bones of the fingers. Each tendon is covered by a slick lining or sheath. When you bend your fingers, the tendons glide back and forth, guided by a restraining pulley or yoke.

When the tendon sheath becomes inflamed, it swells and may develop a knot or thickening in the tendon. The knot passes through the pulley as the finger bends, but gets stuck as the finger straightens. This causes further irritation and results in a vicious circle of irritation, swelling, catching and more irritation until finally, the finger locks in a bent position.

Diagnosis

No X-rays are needed to diagnose trigger finger. Your doctor will examine your hand and fingers, and use the findings to make the diagnosis. The finger may be swollen and there may be a bump, or nodule, over the joint in the palm of the hand. The finger may be stiff and painful. Although it may seem that the problem is in the knuckles, it is actually at the joint nearest the palm of the hand.

Treatment

Treatment aims to reduce swelling and eliminate catching. Initial treatment is usually conservative, involving rest, splinting the extended finger, and taking aspirin or ibuprofen to reduce swelling and ease pain.

If symptoms persist, your physician may administer a steroid injection in the tendon sheath. Although there may be some short-term discomfort from the injection, it can relieve the pain and locking for several months.

People with diabetes and rheumatoid arthritis will probably require surgery to release the tendon. The surgery is done on an outpatient basis and can restore active motion immediately. However, hand therapy may be needed to regain better use of the finger(s).

Ulnar Tunnel Syndrome

Most people are familiar with carpal tunnel syndrome, which can cause numbness and tingling in the hand. A similar condition, called ulnar tunnel syndrome, can cause numbness and tingling that is confined to your little finger and the outside of your ring finger. Unlike carpal tunnel syndrome, however, ulnar tunnel syndrome is not usually caused by repetitive motions.

The ulnar nerve is one of three major nerves that provide sensation and motor function to the hand. It runs down the inside of your forearm to the heel of your hand. Then it branches out across the palm and into the little and ring fingers. Excessive pressure on this nerve can result in a loss of feeling and/or muscle weakness in the hand.

Signs and symptoms

You may or may not have pain in your hand, but you will probably experience weakness and increasing numbness, particularly on the little finger side of the hand. You may experience sensory or motor changes or both, depending on the location of the pressure point. Symptoms develop gradually and can lead to difficulties in opening jars, holding objects, or coordinating your fingers while typing or playing a musical instrument.

Diagnosis

Your physician may examine your hand to see if there are any signs of muscle shrinkage (atrophy) or weakness. To test sensory involvement, he or she may tap a finger over the nerve to see if this produces a tingling sensation (Tinel sign). When you spread your fingers apart, the doctor will look for signs of muscle weakness or dry skin in the spaces between your fingers. Your doctor may prescribe anerve conduction study to see if the nerve is working properly. A computed tomography scan or a magnetic resonance image (MRI) may be useful in identifying whether a cyst or other growth is putting pressure on the nerve. X-rays can show if you’ve fractured a bone that is now pressing on the nerve. The ulnar nerve also passes through a narrow tunnel at the elbow. Pressure at that point can cause similar symptoms in your hand. So your physician may examine that area as well.

Treatment

Treatment depends on what’s causing the pressure on the nerve. If pressure results from the way you rest your wrist when typing, a change in position or the addition of some padding may help. Your doctor may prescribe anti-inflammatory medications such as aspirin or ibuprofen to help alleviate your symptoms, and may recommend that you wear a wrist splint for a time. However, most cases of ulnar tunnel syndrome are caused by a growth in the wrist and must be treated with surgery to remove the growth. An experienced hand surgeon can remove cysts, scar tissue, or other causes of compression on an outpatient basis. Once the pressure point is removed, you’ll notice an improvement in sensation with a decrease in the numbness and tingling. But it will take several months for the nerve to regrow and heal completely. Your surgeon will make recommendations for postoperative rehabilitation and exercises.

 

Wrist Arthroscopy

Arthroscopy (ar-THROS-ka-pea) is an outpatient surgical procedure used by orthopaedic surgeons to diagnose and treat problems inside a joint. The surgeon makes small incisions, less than half an inch long, and inserts a pencil-sized instrument called an arthroscope. The arthroscope contains a small lens, a miniature camera and a lighting system. This projects three-dimensional images of the joint on a television monitor, enabling the surgeon to look directly inside the joint and identify the trouble. Tiny probes, forceps, knives and shavers can then be used to correct many problems at the same time.

Arthroscopy has been used for several years to treat conditions in large joints such as the knee and the shoulder. As cameras and instruments became smaller and more refined, arthroscopy was applied to other joints, including the wrist. The wrist is a complex joint, with eight small bones and many connecting ligaments. Arthroscopy enables the surgeon to see the anatomic parts and their movements and to make a more accurate diagnosis.

Diagnostic arthroscopy

Diagnostic arthroscopy may be used if the cause of your wrist pain cannot be identified or if wrist pain continues for several months despite nonsurgical treatment. Before surgery, your doctor will do:

• A physical examination that focuses on your hand and wrist. Your doctor will also ask about your medical history.
• Provocative tests that involve moving your hand in ways that reproduce the pain.
• Imaging studies, such as X-rays of your hand and wrist. In some cases, additional imaging studies may be needed. These can include an MRI (magnetic resonance image) or an arthrogram, in which a contrast agent is injected into the joint before the image is taken.

Usually, regional anesthesia is used during arthroscopic surgery. This numbs your arm and hand. You may also be given a sedative to further relax you and enable you to doze through the surgery. Two or more small incisions (portals) are made on the back of the wrist, through which the arthroscope and instruments are inserted. After the surgery, the incisions are closed with a small stitch and a dressing is applied. Sometimes a splint may also be used.

Arthroscopic surgical treatment

Several conditions can be treated using arthroscopic surgery, including chronic wrist pain, wrist fractures, ganglion cysts and tears in the ligaments or the triangular fibrocartilage complex (TFCC). Wrist arthroscopy may also be used to smooth the bone surfaces and remove inflamed tissue. Arthroscopy can also be used to surgically treat carpal tunnel syndrome, but in that diagnosis, the arthroscope is not inserted into the wrist joint itself.

• Chronic wrist pain: Arthroscopic exploratory surgery may be used to diagnose the cause of chronic wrist pain when other tests are inconclusive. Often, there may be areas of inflammation, cartilage damage, or other findings after a wrist injury. In some cases, after the diagnosis is made, the condition can be treated arthroscopically as well.
• Wrist fractures: Doctors can remove small fragments and fracture debris, align the broken pieces of bone, and stabilize them by using pins, wires, or screws.
• Ganglion cysts: These cysts commonly grow from a stalk between two of the wrist bones. During an arthroscopic procedure, the surgeon can remove the stalk, which may also reduce recurrence of the cysts.
• Ligament/TFCC tears: Ligaments are fibrous bands of connective tissue that link or hinge bones. They provide stability and support to the joints. The TFCC is a cushioning structure within the wrist. A fall on an outstretched hand can tear ligaments, the TFCC or both, resulting in pain with movement or a clicking sensation. During arthroscopic surgery, the surgeon can trim or repair the tears.
• Carpal tunnel release: Carpal tunnel syndrome is characterized by numbness or tingling in the hand, and sometimes with pain up the arm. It is caused by pressure on a nerve that passes through the carpal tunnel, which is formed by the wrist bones and a thick tissue roof. Pressure can build up within the tunnel for many reasons, including irritation and swelling of the tissue (synovium) that covers the tendons. If the syndrome does not respond to conservative treatment, your doctor may recommend surgery to cut the ligament roof and enlarge the tunnel, thus reducing pressure on the nerve and relieving symptoms. This can sometimes be done using an arthroscope.

After surgery, you will need to keep your wrist elevated for the first two or three days and keep your bandage clean and dry. You can ice your wrist to help keep swelling down. Your doctor and/or your physical therapist will teach you exercises to help maintain motion and rebuild your strength. Analgesic medications will help relieve any postoperative pain, which is usually mild.

Complications

Complications during or after arthroscopic wrist surgery are unusual, but may include infection, nerve injuries, excessive swelling or bleeding, scarring or tendon tearing. An experienced surgeon, particularly one who specializes in treating the hand, can reduce the likelihood of complications.

Summary

Arthroscopic surgery is a valuable diagnostic and treatment tool. It is minimally invasive, and patients generally experience fewer problems and a more rapid recovery than with open surgery. Because it is an outpatient procedure, most patients are home several hours after surgery.

Wrist Joint Replacement

Most people are familiar with joint replacement surgery for the hip, knee, and shoulder joints. Joint replacement surgery in the wrist is less common but can be an option if you have painful arthritis that does not respond to other treatments.

Anatomy of the wrist

The wrist is a more complicated joint than the hip or the knee. At the base of the hand are two rows of bones, with four bones in each row. These are called the carpals. The long thin bones of the hand radiate out from one row of carpals toward the fingers and thumb. The two bones of the lower arm (radius and ulna) form a joint with the other row of carpals. All the bone ends are covered with a slick, elastic tissue called cartilage, which enables the bones to move smoothly against each other. However, if the cartilage is worn away or damaged by injury, infection or disease, the bones will rub against each other causing pain. During any total joint replacement, the worn-out bone ends are removed and replaced by an artificial joint (prosthesis).

Reasons for wrist replacement surgery

The typical candidate for wrist replacement surgery has severe arthritis but does not need to use the wrist to meet heavy demands in daily use. The primary reasons for wrist replacement surgery are to relieve pain and to maintain function in the wrist and hand.

• Osteoarthritis, the most common form of arthritis, results from a gradual wearing away of the cartilage covering on bones.
• Rheumatoid arthritis is a chronic inflammatory disease of the joints that results in pain, stiffness and swelling. Rheumatoid arthritis usually affects several joints on both the right and left sides of the body.

Both forms of arthritis may affect the strength of your fingers and hand, making it difficult for you to grip or pinch. In some cases, fusing the wrist bones together will reduce or eliminate pain and improve grip strength. However, if the bones are fused together, you will not be able to bend the wrist. Wrist replacement surgery may enable you to retain or recover wrist movements and improve your ability to perform daily living activities, especially if you also have arthritis in the elbow and shoulder.

Implant design

Wrist implants are made of the same kind of materials used for hip and knee joint replacements. There are several different designs. Most have two components and are made of metal; a high quality plastic called polyethylene is used as a spacer between the two components. Newer implant designs try to replicate the anatomy of the wrist.

The piece that attaches to the lower arm (radius bone component) fits into the bone of the lower arm. The top of this component has a curve that matches to the wrist part. The piece that attaches to the hand (carpal component) may have one long stem and one or two shorter stems that insert into the hand bones, or use small screws. The surface of this component is flat. The plastic spacer comes in different sizes so it can be matched to your hand. It is normally flat on one side and rounded on the other. This design enables it to fit into the carpal component while it rocks on the radial component, creating a more natural wrist motion.

Implant insertion

A wrist joint replacement can be done as an outpatient procedure, unlike a hip or knee replacement. Wrist replacement surgery is often combined with other procedures to correct deformities or disorders in the tendons, nerves, and small joints of the fingers and thumb.

The incision is made on the back of the wrist. The damaged ends of the lower arm bones are removed and the first row of carpal bones may also be removed. The radial component of the prosthesis is inserted into the center of the radius bone on the outside of the lower arm. It is held in place with bone cement. Depending on the component design, the carpal component is then inserted into the center hand bone (third metacarpal) or screwed into the remaining row of carpal bones. Bone cement may be used to hold the component in place. The carpal bones may be linked or fused together to better secure this component.

An appropriately sized spacer is used between the metal components.

After your surgery

You will have to wear a cast for the first several weeks. When the cast is removed, you will have to wear a protective splint for the next six to eight weeks. Although pain relief is immediate, you will have to do gradual exercises for several weeks to restore movement and, eventually, to increase power and endurance. Wrist arthroplasty can improve motion to about 50 percent of normal.

The physical demands that you place on the wrist prosthesis will have an effect on how long the implant lasts. You will not be able to use a hammer often or pneumatic tools. You may only be able to lift a limited amount of weight. A fall on the outstretched hand may break the prosthesis, just as it might fracture a normal wrist. So you will want to avoid activities such as roller sports that could result in a fall.

Although there have been significant advances in wrist prostheses, the implant may loosen or fail due to wear or deformation. In these cases, additional surgery may be necessary. On average, a wrist replacement can be expected to last 10 to 15 years with careful use. As with all implants, long-term follow-up is advised. Generally, you should see your hand surgeon every year or two years so that x-rays can be taken and used to identify any developing conditions or problems.

Wrist Sprains

 

When you fall forward, your natural response is to put your hands out in front to catch yourself. As you land on your palm, your wrist bends backwards, which can stretch and perhaps tear the ligaments that connect bone to bone within the joint. The resulting injury is a sprain.

Signs and symptoms

Signs and symptoms of a wrist sprain may vary in intensity and location, depending on the degree of injury. Indications of a wrist sprain include:

• Swelling in the wrist
• Pain at the time of the injury
• Persistent pain when you move the wrist
• Bruising or discoloration of the skin
• Tenderness at the injury site
• A feeling of popping or tearing inside the wrist
• A warm or feverish feeling to the skin

Degrees of injury

Wrist sprains are graded, depending on the degree of injury to the tissues.

• Grade 1 or mild sprains occur when the ligaments are stretched, but not torn.
• Grade 2 or moderate sprains occur when some of the ligaments are torn. Grade 2 sprains may involve some loss of function.
• Grade 3 or severe sprains occur when there is a complete tear all the way through the ligament. These are significant inj