FAQ Category: Hand

There is plenty of research evidence to support the benefits of surgery to release the soft tissues around the affected (median) nerve in the general adult population. But no one has really studied the results of surgical release in the older adult group.

The procedure can be done in one of two ways: with an open incision or with a minimally invasive approach and very small incision. The advantages to the older adult of endoscopic carpal tunnel release for carpal tunnel syndrome are many: less pain after the surgery, return of hand function faster, and improve grip and pinch strength more quickly than with open incision surgery. The two disadvantages of endoscopic release are: 1) possibility of nicking the nerves and blood vessels in the carpal tunnel and 2) the potential for an incomplete release.

There is evidence from studies that before surgery, the majority of patients report constant numbness as the primary symptom. Numbness is the most typical symptom associated with carpal tunnel syndrome. True pain may be present in a small percentage of sufferers but in many cases, the numbness is so severe that it is interpreted as pain. Many patients are treated conservatively (splinting, steroid injection) before trying surgery. Some are able to get partial relief from their symptoms but not enough to avoid surgery.

Those patients who report “pain” before surgery are able to get relief from their pain following the carpal tunnel release procedure. Numbness before surgery (especially noticeable at night) can also be eliminated with carpal tunnel release surgery.

According to one recent study, the procedure is considered a success in older adults and (older) age was not a factor linked with poor results. The findings of this study are very encouraging for older adults like your mother who are affected by carpal tunnel syndrome.

Two physicians from the Raleigh Hand Center (North Carolina) recently published an article reviewing current evidence on one alternative treatment for hand osteoarthritis. Their focus is on recent evidence concerning the use of glucosamine and chondroitin sulfate as an alternative treatment for hand osteoarthritis.

Most of today’s modern treatment of hand osteoarthritis does center around pain relievers and nonsteroidal antiinflammatory drugs (NSAIDs). But it’s clear that these medications have limited results and the risk of unpleasant side effects. That often leads the sufferer looking for solutions elsewhere.

Glucosamine and chondroitin sulfate are two alternative products touted by many as “safe and effective” in the treatment of joint arthritis. But what’s the evidence for (or against) these supplements? Can anyone take them? Should you take them?

Glucosamine and chondroitin sulfate are natural substances normally found in the articular cartilage. Articular cartilage lines the joints and makes for smooth sliding and gliding action while protecting the joint. When the joint has enough of these components, water within the collagen provides resistance to compression. Chondroitin and glucosamine also help keep the cartilage slippery smooth and elastic.

No one knows for sure how taking glucosamine and chondroitin by mouth as oral supplements helps the joints. But studies do show that the products are absorbed in the gut and show up in the joints. These products are not prescription drugs so they are not regulated by the Food and Drug Administration (FDA). Anyone can purchase them over-the-counter as a nutraceutical (nutritional supplement).

Most of the studies done so far have been focused on hips and knees. Whether or not the same results can occur taking these supplements for hand arthritis remains unknown. Taking a look at the current studies published, the authors pointed out that results are often inconsistent, treatment effects are exaggerated, and the length of time to achieve a benefit is months (three to six at least).

A review of studies sponsored by the National Institutes of Health (NIH) highlight the following observations: results may depend on how severe the arthritic damage is to the joints and whether the person takes one or the other supplement (or both together). All studies report potential adverse effects, which are infrequent, mild and consist of diarrhea, upset stomach, and/or nausea.

Overall, it seems the use of glucosamine and chondroitin is safe with the potential to reduce painful symptoms and thus improve hand function. Long-term use (months to years) seems to be necessary (if the patient can afford it). All evidence points to a positive benefit in the use of these nutraceuticals for osteoarthritis. They are certainly safer than currently prescribed medications for pain control. However, studies specific to the hand are needed to confirm the findings reported for hip and knee osteoarthritis.

Glucosamine and chondroitin sulfate are two alternative products used by many arthritis sufferers. Glucosamine and chondroitin sulfate are natural substances normally found in the articular cartilage. Articular cartilage lines the joints and makes for smooth sliding and gliding action while protecting the joint. When the joint has enough of these components, water within the collagen provides resistance to compression. Chondroitin and glucosamine also help keep the cartilage slippery smooth and elastic.

No one knows for sure how taking glucosamine and chondroitin by mouth as oral supplements helps the joints. But studies do show that the products are absorbed in the gut and show up in the joints. These products are not prescription drugs so they are not regulated by the Food and Drug Administration (FDA). Anyone can purchase them over-the-counter as a nutraceutical (nutritional supplement).

As you have discovered from your Internet search, most of the studies done so far have been focused on hips and knees. Whether or not the same results can occur taking these supplements for hand arthritis remains unknown. Taking a look at the current studies published, results are often inconsistent, treatment effects are exaggerated, and the length of time to achieve a benefit is months (three to six at least).

A review of studies sponsored by the National Institutes of Health (NIH) highlight the following observations: results may depend on how severe the arthritic damage is to the joints and whether the person takes one or the other supplement (or both together). All studies report on potential adverse effects, which are infrequent, mild and consist of diarrhea, upset stomach, and/or nausea.

Overall, it seems the use of glucosamine and chondroitin is safe with the potential to reduce painful symptoms and thus improve hand function. Long-term use (months to years) seems to be necessary (if the patient can afford it). All evidence points to a positive benefit in the use of these nutraceuticals for osteoarthritis. They are certainly safer than currently prescribed medications for pain control. However, studies specific to the hand are needed to confirm the findings reported for hip and knee osteoarthritis.

Recently, three hand surgeons from well-known centers for reconstructive hand surgery presented a lecture on complications following dislocations of the proximal interphalangeal (PIP) joint. This is the joint you are describing. They offered some information about splinting that may be helpful.

First, understanding a little bit about the injury is important. Injuries to the joint in the middle joint of the finger (the proximal interphalangeal (PIP) joint) can be very problematic. When there has been a fracture and/or dislocation, every effort is made to prevent complications such as chronic swelling, stiffness, deformity, and loss of finger function. When the volar plate (restraining ligament) of the joint is damaged by the dislocation, redislocation can occur.

Damage to the cup-shaped joint along with injury to the ligaments can result in an unstable joint. The most successful treatment of these injuries involves limited immobilization with a finger splint and early motion of the finger. Keeping the gliding and sliding motion of the joint is very important — even more so than fixing the dislocation.

Conservative (nonoperative) care is advised when the dislocation is considered “stable”. Stability is determined by X-rays based on how much of the joint surface is damaged (fractured). The surgeon also looks at whether or not the joint partially or completely dislocates during motion. So your next step should be to have an orthopedic surgeon or hand surgeon examine and evaluate your finger.

The use of splinting during the early (acute) phase of healing could be helpful but must be used carefully. A balance is essential between maintaining the joint in a stable position while still allowing motion. The surgeon may recommend using a figure-of-eight splint to keep the finger in slight flexion (bent 10 degrees at the PIP joint). X-rays can be used to show that the joint stays in place while in the splint.

Buddy taping (taping the damaged finger to the finger next to it or between two fingers) is an acceptable alternative. Splinting or taping also immobilizes the distal interphalangeal (DIP) joint (tip of the finger). So it is necessary to take this into consideration in order to prevent stiffness of the finger. An unstable joint with severely damaged volar plate (restraining ligament) and any sign of redislocation is an indication that surgery is needed.

Dislocations of the proximal interphalangeal (PIP) joint (middle joint of the finger) can be complex and challenging. Treatment is not always straightforward, especially when there is a fracture involved. Decisions are made based on the extent of damage, percentage of joint surface that is involved if there was a fracture, and presence of joint instability. The surgeon must rely on clinical judgment evaluating each and every patient individually.

Damage to the cup-shaped joint along with injury to the ligaments can result in an unstable joint. The most successful treatment of these injuries involves limited immobilization with a finger splint and early motion of the finger. Keeping the gliding and sliding motion of the joint is very important — even more so than fixing the dislocation.

Every effort is made to prevent complications such as chronic swelling, stiffness, deformity, and loss of finger function. When the volar plate (restraining ligament) of the joint is damaged by the dislocation, redislocation can occur.

Conservative (nonoperative) care is advised when the dislocation is considered “stable”. Stability is determined by X-rays based on how much of the joint surface is damaged (fractured). The surgeon also looks at whether or not the joint partially or completely dislocates during motion.

The use of splinting during the early (acute) phase of healing is possible. A balance is essential between maintaining the joint in a stable position while still allowing motion. But any sign of redislocation while the finger is in the splint (or after splinting comes to an end) is an indication that surgery is needed.

Surgery is suggested when the joint is unstable, chronically dislocating, and/or if conservative care does not correct the contracture or deformity. The type of surgery performed is surgeon-determined and may include reconstruction of the cup-shaped contour of the joint, pinning the joint to block full extension (and thereby protect healing soft tissue structures), and/or fixation (internal or external) of the volar plate with mini-screws, pins, or wires.

There are advantages and disadvantages to each surgical procedure. The surgeon who is recommending surgery will likely be willing to explain why surgery is being considered. Any questions you may have should be voiced before the final decision is made. This will help you understand the surgeon’s decision-making process as well as offer insights and information about your son that might be important.

With the mallet deformity, the end of the finger is bent and cannot be straightened voluntarily. The distal interphalangeal (DIP) joint (tip of the finger) can be straightened easily with help from the other hand. If the DIP joint gets stuck in a bent position and the proximal interphalangeal (PIP) joint (middle knuckle) extends, the finger may develop a deformity that is shaped like a swan’s neck. This is what is meant by a swan neck deformity.

Treatment for mallet finger is usually nonsurgical. If there is no fracture, then the assumption is that the end of the tendon has been ruptured, allowing the end of the finger to droop. Usually continuous splinting for six weeks followed by six weeks of nighttime splinting will result in satisfactory healing and allow the finger to extend.

The key is continuous splinting for the first six weeks. The splint holds the tip of the finger (the distal interphalangeal or DIP joint) in full extension and allows the ends of the tendon to move as close together as possible. As healing occurs, scar formation repairs the tendon. If the splint is removed and the finger is allowed to bend, the process is disrupted and must start all over again. The splint must remain on at all times, even in the shower.

While a simple homemade splint will work, there are many splints that have been designed to make it easier to wear at all times. In some extreme cases where the patient has to use the hands to continue working (such as a surgeon), a metal pin can be placed inside the bone across the DIP joint to act as an internal splint and allow the person to continue to use the hand. The pin is removed at six weeks.

Splinting may even work when the injury is quite old. Most doctors will splint the finger for eight to 12 weeks to see if the drooping lessens to a tolerable amount before considering surgery.

Surgical treatment is reserved for unique cases. The first is when the result of nonsurgical treatment is intolerable. If the finger droops too much, the tip of the finger gets caught as you try to put your hand in a pocket. This can be quite a nuisance. If this occurs, the tendon can be repaired surgically, or the joint can be fixed in place. A surgical pin acts like an internal cast to keep the DIP joint from moving so the tendon can heal. The pin is removed after six to eight weeks.

If the damage cannot be repaired using pin fixation, finger joint fusion may be needed. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from rubbing on one another. Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity.

It sounds like you may be a young adult so conservative care without drastic surgical intervention (such as joint fusion) would be advised. There is also another surgical technique known as the Thompson procedure that might be helpful for patients who have chronic mallet finger.

The Thompson procedure uses a graft from the palmaris longus tendon. The graft tendon is split, spiraled under and over the middle bone of the finger, and then tied over the skin with an external button. The procedure makes it possible for motion of both the distal and proximal interphalangeal joints (DIP and PIP) to work together creating coordinated flexion and extension of the finger.

The biggest benefit of the Thompson procedure is that it corrects the extension lag of the tip of the finger (when you can’t fully extend the finger tip) while also addressing the swan neck deformity. And it does so without scarring the extensor tendon (which would restrict finger extension) or preventing flexion of the proximal interphalangeal (PIP) joint. The goal is to get smooth finger flexion and extension of both the DIP and the PIP joints.

Your best bet is to make an appointment with a hand surgeon and find out what might work for you. The information here will give you some understanding of the conservative (nonoperative) and surgical treatment options when discussing your situation with the surgeon.

It’s true that open incision carpal tunnel release is being replaced by the endoscopic (minimally invasive) approach. But open incision surgery is still in use and the jury is still out, so-to-speak, on the comparative results. Now for the first time, results of a long-term study on open incision carpal tunnel release have been published from Harvard Medical School in Boston, Massachusetts.

One (fellowship-trained) hand surgeon who had performed 211 open carpal tunnel releases contacted his patients 11 to 17 years after the procedure. Using a series of self-assessment surveys, symptoms, function, and patient satisfaction were measured.

Of course, in that amount of time, some patients had died and others could not be located. There were also 27 patients who did not want to be part of the study. But they found 113 people who participated in the study. The patients included adults of all ages from under fifty years of age to sixty and older. There were adults who were actively employed and working, retirees, and pre-and postmenopausal women.

They discovered that three-fourths of the group no longer had any carpal tunnel problems. Most of the problematic symptoms went away in the first year after the surgery. Almost 90 per cent (88 per cent to be exact) were very satisfied or completely satisfied with the results.

For the people who still had some symptoms of carpal tunnel syndrome, the most common symptom was hand weakness (e.g., grip and pinch strength, difficulty opening jars or holding a book). Daytime pain, numbness, and tingling were also reported by a few people.

Patients who had the most difficulty years later were those who also had diabetes, rheumatoid arthritis, osteoarthritis, or polyneuropathy. All of these conditions are linked with carpal tunnel syndrome. It is likely that the problems encountered with functional tasks was really related more to these comorbidities (other conditions) than the after-effects of carpal tunnel surgery.

Only two of the 113 patients had to have a second (repeat) surgery. And only a few patients had pain at night or tenderness along the (healed) incision line. Analysis of all the data did not show any particular pain patterns associated with age. But function was worse in the middle age group (ages 50 to 59). The reason(s) for the connection between middle ages and worse function were unknown. It’s possible that the older age group had worse function but accept their limitations and/or have fewer physical demands placed on them so the loss of function is not as noticeable.

This is one of the few long-term studies of results following open carpal tunnel release. As mentioned, more carpal tunnel surgeries are done endoscopically now with minimally invasive techniques. So it is possible that this will be one-of-a-kind study. But the results clearly show that excellent early improvements are maintained over the long-term with equally excellent reports of patient satisfaction and improved quality of life. Those patients (like yourself) who had the more invasive (open) incision approach may have a visible scar but the long-term results are excellent, possibly making that thin line worth it anyway.

According to a study from Harvard Medical School, your experience may be fairly typical. In fact, many studies have been done on patients who have had open incision carpal tunnel release surgery. The results have shown that symptoms improve right away but it can take months for patients to recover strength and function. Some studies show that slightly more than half of all patients report a recurrence of hand pain, numbness, and tingling two years after surgery.

What happens 10 years later is the subject of the study from Harvard Medical School in Boston, Massachusetts. One (fellowship-trained) hand surgeon who had performed 211 open carpal tunnel releases contacted his patients 11 to 17 years after the procedure. Using a series of self-assessment surveys, symptoms, function, and patient satisfaction were measured.

The patients included adults of all ages from under fifty years of age to sixty and older. There were adults who were actively employed and working, retirees, and pre-and postmenopausal women. They discovered that three-fourths of the group no longer had any carpal tunnel problems. Most of the problematic symptoms went away in the first year after the surgery. Almost 90 per cent (88 per cent to be exact) were very satisfied or completely satisfied with the results.

For the people who still had some symptoms of carpal tunnel syndrome, the most common symptom was hand weakness (e.g., grip and pinch strength, difficulty opening jars or holding a book). Daytime pain, numbness, and tingling were also reported by a few people.

Patients who had the most difficulty years later were those who also had diabetes, rheumatoid arthritis, osteoarthritis, or polyneuropathy. All of these conditions are linked with carpal tunnel syndrome. It is likely that the problems encountered with functional tasks was really related more to these comorbidities (other conditions) than the after-effects of carpal tunnel surgery.

Only two of the patients had to have a second (repeat) surgery. And only a few patients had pain at night or tenderness along the (healed) incision line. Analysis of all the data did not show any particular pain patterns associated with age. But function was worse in the middle age group (ages 50 to 59). The reason(s) for the connection between middle ages and worse function were unknown. It’s possible that the older age group had worse function but accept their limitations and/or have fewer physical demands placed on them so the loss of function is not as noticeable.

This is one of the few long-term studies of results following open carpal tunnel release. As you mentioned, more carpal tunnel surgeries are done endoscopically now with minimally invasive techniques. But the results for patients who had open-incision carpal tunnel releases clearly show that excellent early improvements are maintained over the long-term with equally excellent reports of patient satisfaction and improved quality of life.

Successful nonsurgical treatment is based on restoring balance in the structures of the hand and fingers. The proximal interphalangeal or PIP joint must be supple (not stiff). This is the middle knuckle of each finger. Aligning the PIP joint and preventing hyperextension should help restore distal interphalangeal or DIP extension (straightening the tip of the finger).

You may benefit from a session or two with a hand therapist. This is either a physical or occupational therapist who will address the imbalances that have formed the swan neck deformity. Stretching, massage, and joint mobilization are used to try and restore finger alignment and function. Special forms of stretching may help reduce tightness in the intrinsic muscles of the hand and fingers. Strengthening exercises can help with alignment and function of the hand and fingers.

A special splint may be used to keep the PIP joint lined up, protect the joint from hyperextending, and still allow the PIP joint to bend. No one need know there is a problem with the newer styles shaped like jewelry. These rings are available in stainless steel, sterling silver, or gold. Your therapist will work with you to obtain and use your finger splint. Be sure and mention your need to keep the problem to yourself.

This conservative approach works best for mild cases of swan neck deformity in which the PIP joint is still supple (i.e., not stiff or “stuck” and unable to move). The goal of nonsurgical treatment is to get the finger joints, tendons, and muscles in balance. If nonsurgical treatment is going to be successful, you may see improvement in eight to 12 weeks.

You can find a more thorough discussion of swan neck deformity of the finger in our publication A Patient’s Guide to Swan Neck Deformity of the Finger. Swan neck deformity sounds elegant but as you have discovered, it can be very limiting.

To the rest of the world, it just looks like a crooked finger. The tip of the finger is bent at the distal interphalangeal (DIP) joint while the middle joint (proximal interphalangeal or PIP) is hyperextended. However, human anatomy is not simple and that description does not begin to tell you how complex a “crooked finger” can be.

In the proximal interphalangeal (PIP) joint, (that is the middle joint between the main knuckle and the tip of the finger), the strongest ligament is the volar plate. This ligament connects the proximal phalanx (bone closest to the palm) to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the PIP joint from bending back too far (hyperextending). Swan neck deformity can occur when the volar plate loosens from disease or injury.

Rheumatoid arthritis (RA) is the most common disease affecting the PIP joint. Chronic inflammation of the PIP joint puts a stretch on the volar plate. As the volar plate becomes weakened and stretched, the PIP joint becomes loose and begins to easily bend back into hyperextension. The extensor tendon gets out of balance, which allows the tip of the finger to get pulled downward into flexion. As the tip of the finger bends down and the PIP joint hyperextends, the swan neck deformity occurs.

Gripping objects and picking things up becomes very difficult when this deformity is present. The main goal of treatment is to prevent the joint from becoming fixed or “stuck” in extension and no longer able to bend. Conservative care is tried first. A physical or occupational therapist addresses the imbalances that have formed the swan neck deformity. Stretching, massage, and joint mobilization are used to try and restore finger alignment and function.

A special splint may be used to keep the PIP joint lined up, protect the joint from hyperextending, and still allow the PIP joint to bend. This approach works best for mild cases of swan neck deformity in which the PIP joint is supple. Many hand surgeons recommend at least six weeks with the splint and exercise to improve PIP joint mobility before performing surgery.

There are several different ways to approch this problem surgically. Which one to choose is determined by the surgeon based on his or her experience and preference, and based on a number of different factors specific to the patient.

Some of the decisions about which method to use depend on how much joint stiffness is present in the proximal interphalangeal (PIP) joint. Earlier deformities may be more supple (not as stiff as the more advanced or severe cases) and have not been studied as much so evidence for outcomes remains limited. Joint replacement or fusion are additional possible surgical alternatives if repair or reconstruction fails.

Routine hand therapy following surgical release of Dupuytren contractures usually includes the fabrication of a finger extension orthosis or splint for each patient. This customized splint may affect each joint of the hand differently resulting in some stiffness when the splint if first removed.

A review of studies focused on maintaining finger motion after surgery for Duyputren contracture(s) suggests that stiffness, pain, and slow recovery of function after surgical release is possible but not typical.

In fact, what is most surprising is that up to half of all patients lose significant amounts of finger extension after surgery with or without the splint. It’s possible that wearing the splints for a longer period of time may be helpful. Perhaps the use of night positioning during the formation of new scar tissue requires longer time to change tissue length.

It is also possible that the type of splint makes a difference. A different design may provide more optimal joint motion. Since there are three joints in each finger, it is possible that the joints respond differently from one another in the type of splinting being used.

And since not all patients develop recurring contractures, there may be other factors at play here. Further research is needed to determine predictive factors (e.g., who is most likely to develop contractures again, who will get stiff with splinting) that can then be used to identify patients who should be splinted after surgery (and for how long).

This is a good question and one that hand therapists are actively researching. With the new push for evidence-based outcomes, investigations are ongoing comparing different treatment approaches for various hand conditions including contractures caused by Dupuytren disease.

Dupuytren contracture is a fairly common disorder of the fingers. In this condition, the fascia (connective tissue) of the hand is transformed into shortened cords. The first symptom is often a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger.

More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. This contracture is like extra scar tissue just under the skin. As the disorder progresses, finger becomes more and more bent (the contracture), which limits the motion of the finger. Dupuytren’s contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

Without treatment, the contracture can become so severe that the affected finger(s) cannot be straightened. Eventually loss of motion leads to loss of hand function, including grip strength. Surgery is often required when the contractures are severe.

Removal or release of the diseased tissue can be done surgically with a procedure called palmar fasciectomy. Bracing and stretching of the fingers alone has not been proven to help in the long term progression of this condition. And according to the results of a recent study from New Zealand, night splinting after surgery may not be any more effective than not splinting.

The hand therapists randomly divided patients with Dupuytren contracture who had surgical release into two groups. The patients in one group received a custom-made night extension orthosis along with hand therapy. The second group just had hand therapy (no splint).

Both groups were treated for three months. Results were measured and compared for the two groups using finger extension, finger flexion, grip strength, and hand function as the final outcomes. Motion measurements were taken before surgery, at the first visit with the hand therapist after surgery, six weeks after surgery, and one last time three months after surgery.

They found out that splinting did not improve results following surgical release for this condition. The practice of routinely holding fingers in an extended position at night did not prevent loss of motion — at least not after three months’ time. Contracture recurrence is common (more than half of all patients experience this problem) and wearing a night splint didn’t seem to help.

It’s possible that wearing the splints for a longer period of time may be helpful. Perhaps the use of night positioning during the formation of new scar tissue requires longer time to change tissue length. It is also possible that the type of splint makes a difference. A different design may provide more optimal joint motion. Since there are three joints in each finger, it is possible that the joints respond differently from one another in the type of splinting used in this study.

The study did not include a group of patients who did not receive hand therapy since this is a form of withholding available treatment and is not considered ethical. So, we don’t have studies to show what would happen without the hand therapy. And it is not clear based on just this one study that the routine use of hand splinting after contracture release can be eliminated.

If your surgeon advises hand therapy and splinting, you should be able to work out a payment agreement with the therapist. A program that has more emphasis on a home program (you do more of the work) may also reduce the total cost of your rehab. Be sure and talk with both the surgeon and the therapist before surgery to see what is possible.

Most mallet finger injuries are treated with splinting, which is what it sounds like you have already tried quite faithfully. Surgery is reserved for those patients who still have the mallet finger deformity (tip of the finger remains bent and cannot be straightened voluntarily) several months after splint immobilization.

There are several different ways to address the problem surgically. Most take care of the ruptured and scarred end of the tendon where it was torn away from the distal interphalangeal (DIP) joint.

Some of the procedures include plication (surgical tucking) of the distended tendon, repair with a tendon graft, threading a strip of the lateral band into the bone at the tip of the finger, and central slip tenotomy (splitting the tendon to adjust the tension on the bone).

There is also a technique known as the Thompson procedure, which addresses the need to reconstruct the spiral oblique retinacular ligament (SORL). This makes it possible for motion of both the distal and proximal interphalangeal joints (DIP and PIP) to work together creating coordinated flexion and extension of the finger.

The Thompson procedure uses a graft from the palmaris longus tendon. The graft tendon is split, spiraled under and over the middle bone of the finger, and then tied over the skin with an external button. A major benefit of the Thompson procedure is that it corrects the extension lag of the tip of the finger (when you can’t fully extend the finger tip) while also addressing a bend in the middle joint (proximal interphalangeal (PIP) joint).

If splinting was unsuccessful for you, make a follow-up appointment with your surgeon and let him or her know your desire to continue treatment. Loss of function is one reason to pursue additional treatment but appearance is also important.

Getting a finger smashed in the car door (or other similar crush injuries) is a fairly common injury and can be very problematic. The best way to treat these injuries is a matter of opinion and conjecture. Deformity and loss of finger function can be very serious consequences of this injury.

Without proper treatment, more problems and complications can develop. Blood trapped under the nail bed known as a subungual hematoma can prevent normal healing. Other injuries that occur at the same time (e.g., fractures, fingertip amputation, nail matrix laceration) must be treated as well.

There was a recent article in The Journal of Hand Surgery written by hand surgeons from Vanderbilt University Medical Center in Nashville, Tennessee that may be helpful. They addressed the complexities and controversies in the treatment of nail bed injuries. They focused primarily on nail plate injuries and what to do about them. The nail plate covers the nail matrix, which is divided into two matrices: germinal and sterile.

The nail matrix (also known as matrix unguis) is formed by these two layers of cells at the base of the fingernail (or toenail). This tissue consists of rapidly dividing skin cells that soon fill with the protein keratin. The matrix of finger nails consists of the most rapidly dividing skin cells in the body. The matrix is involved in growth and position of the nail plate.

A crush injury such as you described compresses the nail matrix between the nail plate and the bone. Damage to the nail bed can lead to the formation of scar tissue and misalignment of matrices and nail plate. However, in the acute phase (right now immediately after the injury), the more immediate problem is the subungual hematoma.

A decision-formula for determining whether or not to remove the nail and repair the nail bed when there is a subungual hematoma has not been developed. Most surgeons depend on their own experience and expertise in making treatment decisions regarding these hematomas. Some surgeons make the decision based on how much of the nail bed (e.g., more than 25 to 50 per cent) is compromised by the hematoma.

Others suggest that removing a circular piece of the nail (the procedure you mentioned called trephination) to take pressure off the nail bed is all that’s needed. Surgical removal of the nail and nail bed repair is advised by some experts in the case of bone fracture along with more than 50 per cent of the nail bed affected by a hematoma. The nail plate is removed, the nail bed is examined for deep cuts, the area is debrided (cleansed), and any lacerations (cuts) are repaired with sutures.

Studies where only trephination was performed for subungual hematoma (with or without fracture) report equally good results as when surgery is done. This type of minimal approach (i.e., trephination) aids in preventing infection and post-injury nail abnormalities. One other consideration is the cost of each treatment. Trephination can be done at one-tenth the cost of the more involved surgery.

The authors point out the need for further research to provide evidence-based treatment protocols for nail bed crush injuries. All indications are (from currently available studies) that trephination works well even for subungual hematomas with fracture. More involved surgery may only be needed when the bone fracture is unstable or when the nail matrix is trapped or embedded in the nail matrix. Trephination is also a cost savings!

It sounds like your partner may have an injury known as a mallet thumb. A mallet injury usually affects the distal interphalangeal or DIP joint of the finger. More rarely, the interphalangeal joint of the thumb is involved.

This joint is commonly injured during sporting activities such as baseball but evidently, calf roping is another way to end up with a mallet thumb. If the tip of the finger or thumb is struck enough force, the tendon that attaches to the small bone underneath can be injured. Untreated, this can cause the end of the thumb to fail to straighten completely, a condition called mallet thumb.

A review of the literature and current evidence reveals no consensus on the most effective or recommended treatment. And the evidence presented is based on published case reports. In general, closed injuries that do not require surgery are splinted. Open injuries are repaired surgically possibly using K-wire fixation of the interphalangeal joint of the thumb. When present, ruptured (avulsed) tendons of the thumb are reattached or reconstructed.

MRIs can be used to see if there is a tendon avulsion and how far the torn tendon has retracted (pulled away from the bone). The space between the end of the tendon and the place on the bone where it belongs is called a tendon gap. If the tendon hasn’t retracted too much, it can be stretched and pulled back to the insertion point and then reattached (repaired). If the tendon gap is too great, then a tendon graft may be needed (reconstruction).

It may be possible for your friend to avoid surgery with the use of a splint and some hand therapy. The most common time period for splint wear is four to six weeks when the injury is acute (occurred within the last two weeks). Treatment (and results) really depend on how much time has passed between injury and evaluation/treatment.

According to some studies, the earlier the treatment, the better the outcome. Closed injuries often results in better interphalangeal joint extension. Patients do not always get all of their normal motion (full thumb extension) back. A special (custom-made) thumb splint might be helpful but first, an examination by a hand surgeon or sports physician is really required. Encourage your roping partner to seek medical help and evaluation (preferrably sooner rather than later).

In a continuing education publication from The Journal of Hand Surgery (June 2013), you can obtain a quick, but thorough review of this condition known as mallet thumb. This evidence-based continuing education activity provides updated information on indications for the treatment of mallet thumb (both surgical and nonsurgical approaches), methods of splinting, and expected results from treatment. All information comes from the most current available literature on mallet thumb injuries.

A mallet injury affects the distal interphalangeal or DIP joint of the finger (or more rarely, the interphalangeal joint of the thumb). This joint is commonly injured during sporting activities such as baseball. If the tip of the finger or thumb is struck with the ball, the tendon that attaches to the small bone underneath can be injured. Untreated, this can cause the end of the finger to fail to straighten completely, a condition called mallet finger or mallet thumb.

Using the case of a 20-year-old woman with mallet thumb from a softball injury, the authors of this continuing education tool aid health care providers in offering best possible care for their patients with similar injuries. When faced with such a problem, the question is always, What is the preferred treatment?

The patient presented with a nontender but swollen thumb that she could no longer fully extend at the tip. The examiner could straighten the thumb fully (passively). X-rays were normal with no sign of fracture, dislocation, or other bony damage. The injury occurred three weeks before the patient was evaluated. The mechanism of injury was the typical failure to catch a speeding baseball that struck the end of the thumb instead.

A review of the literature and current evidence reveals no consensus on the most effective or recommended treatment. And the evidence presented is based on published case reports like this one. In general, closed injuries that do not require surgery are splinted. Open injuries are repaired surgically possibly using K-wire fixation of the interphalangeal joint of the thumb. When present, ruptured (avulsed) tendons of the thumb are reattached or reconstructed.

MRIs can be used to see how far an avulsed tendon has retracted (pulled away from the bone). The space between the end of the tendon and the place on the bone where it belongs is the tendon gap. If the tendon hasn’t retracted too much, it can be stretched and pulled back to the insertion point and then reattached (repaired). If the tendon gap is too great, then a tendon graft may be needed (reconstruction). But there is no cut off point to determine when the gap requires repair versus reconstruction.

The type of splint to use for the nonoperative approach remains unknown as well. How long to use splinting (duration) for best results is also unknown. The most common time period for splint wear is four to six weeks when the injury is acute (occurred within the last two weeks). Results reported from different case series varied depending on whether the injury was open or closed and in the case of closed injuries — how much time had passed between injury and evaluation/treatment.

According to some studies, the earlier the treatment, the better the outcome. Closed injuries often results in better interphalangeal joint extension. Patients do not always get all of their normal motion (full thumb extension) back. In the case of this patient, a custom-made thumb spica splint was worn full-time for six weeks. Then she wore a nighttime splint for another four weeks. Four months after injury, she had full thumb motion and was satisfied with the results.

The authors note that evidence to support standardized treatment protocols are lacking because thumb mallet injuries are so rare. More multicenter studies are needed determine if and when nonsurgical treatment is best, what type of splinting to use, how long to use splinting, and when to attempt repair versus reconstruction based on tendon gapping. In addition, surgeons need evidence-based guidance to determine type of post-operative care and when to recommend formal hand therapy.

Information is limited but we hope this helped. You may also want to read our Patient Guide to Mallet Finger Injuries. Although it is specific to mallet fingers, the information can be applied to mallet thumb as well.

Penetrating trauma to the hand from nail gun injuries are on the rise due to increasing numbers of housing starts and, of course, home remodeling. But only 3.9 per cent of these injuries are attributed to industrial (worker compensation) injuries. The majority occur in residential carpentry.

Roofing companies are usually careful to provide safety instruction for new employees. One would expect even more so for young workers just starting out. But there are cases (in one study, seven per cent of the group) where the worker has more than one nail gun injury. So it is not a given that experience with these kinds of tools equals prevention.

Gloves, goggles, and helmets are advised. The National Institute for Occupational Safety and Health (NIOSH) has a nail gun safety guide for construction contractors that can be just as informative for the do-it-yourself home owner. This publication is available on-line at https://www.osha.gov/Publications/NailgunFinal_508_02_optimized.pdf.

You can also access additional preventive information by typing into your search engine: nail gun safety. There are even some “how-to” instructional videos available. You will find those using the same search. Encourage your son to read the safety guide and watch at least one of the videos.

Once the individual has driven a nail with a nail gun into the hand, careful evaluation by the hand surgeon is required. Treatment can range from simple wound care to major microvascular surgery. The decision on how to manage the case depends on multiple factors. One important aspect of treatment is to avoid further tissue damage.

The wound must be cleaned within the zone of injury and damage repaired. Sometimes this can be done in one procedure. But when there is extensive contamination, a series of surgeries is required. In all cases, infection (and preventing infection) is a number one concern.

There are many factors to consider when determining the best treatment approach in cases like this. For example, fabric from shirt sleeves or gloves can be drawn into the wound during the
accident/incident, so the surgeon will have to look for that. X-rays are a must to look for fractures. X-rays will also help show the presence of clothing or other foreign bodies that were driven into the hand.

The surgeon will also examine your nephew for any additional injuries to the nerves, tendons, joints, and bone. This occurs in up to one-third of all cases. Some nail cartridges have “barbs” that will require extra special care when removing the nail. Sometimes the barbs are not always visible on X-rays. When barbs are present, additional soft tissue damage can be done by pulling the nail out rather than pushing it the rest of the way through. Antibiotics are standard and tetanus immunization should be updated when necessary.

With a board still attached to the hand, it’s likely that exploratory surgery to extract the nail during a surgical procedure will be necessary. However, when the surgeon finishes his or her examination, he or she will most likely let you know what treatment is advised.

Nail plate injuries that also affect the nail matrix can be complicated. The nail plate covers the nail matrix, which is divided into two matrices: germinal and sterile. The nail matrix (also known as matrix unguis) is formed by these two layers of cells at the base of the fingernail (or toenail).

This tissue consists of rapidly dividing skin cells that soon fill with the protein keratin. The matrix of finger nails consists of the most rapidly dividing skin cells in the body. The matrix is involved in growth and position of the nail plate.

A crush injury (however it is caused) compresses the nail matrix between the nail plate and the bone. Damage to the nail bed can lead to the formation of scar tissue and misalignment of matrices and nail plate. However, in the acute phase (immediately after the injury), the more immediate problem is the subungual hematoma. Healing may not occur until and unless that hematoma is removed, which it sounds like you have had this procedure done.

Because injury affects the growing nail plate, growth is slowed considerably. Infection and scar formation can slow nail plate growth even more. During the first three weeks after injury, growth is very stunted. Then for the next six weeks, you should experience a period of very rapid growth and recovery.

Eventually the nail plate is fully restored (usually two to four months after the injury). After that normal growth returns. Complications such as bone fracture (especially if the fracture site is unstable) can further delay recovery.

According to orthopedic experts at the George Washington University Medical Center in Washington, D.C., the solution may lie somewhere in-between. In a recently published update on the treatment of hand fractures, they suggested that many (if not most) hand fractures are adequately cared for by emergency room physicians, general orthopedic surgeons, and primary care physicians.

They would certainly agree that some type of medical care is necessary and highly recommended. An accurate and timely diagnosis is always the first step. With careful review of the patient’s history (including the mechanism of injury), physical examination, and good quality X-rays, most hand fractures can be identified and a plan of care developed. The main stumbling block in this process is making sure that all other injuries (especially soft tissue damage of nerves, tendons, and ligaments) are recognized.

Most often, surgery is not needed. Conservative (nonoperative) care consisting of short-term immobilization in a splint or cast. In some cases, a particular position of the hand and wrist is necessary to limit specific motions. And there is a danger of permanent stiffness, pressure sores, and loss of motion with prolonged immobilization. Movement of all uninvolved parts of the upper extremity is important and patients should be advised when and how to keep moving.

Special attention must be paid to intraarticular fractures (fractures that extend into the joint). This type of fracture is often accompanied by damage/rupture of the ligaments needed for joint stability. Complications are to be expected with stiffness being the most common (and most difficult to treat) problem encountered.

Fortunately, the hand is versatile, resilient, and forgiving making it possible to treat hand fractures without surgery. But in selected cases, surgery will aid and assist healing and recovery. With the right treatment, your husband can expect that, in time, it will be possible to return to normal motion and use of the involved hand.

Holding a fracture together with a popsicle stick is similar to some splinting used. But this approach must still be done under the supervision of a health care provider. One who can make sure problems and complications don’t develop and that the proper treatment is given in the right time frame to avoid more problems.