News Category: Hand

Fractures of the long bones of the fingers (called metacarpals usually only require casting and immobilization for a short time to promote healing. But if the fracture is separated (called displacement), unstable, or incongruent (broken ends don’t line up correctly), then surgical fixation may be required.

Fixation refers to the use of Kirschner wires, condylar plates, or interfragmentary screws to hold broken bones together until healing takes place. The surgery may be done as an open or closed reduction and fixation. The goal is to restore normal bone alignment and joint function. Specific approaches depend on the location and severity of the fracture.

Metacarpal fractures can affect the metacarpal head, neck, or shaft. As the authors point out, there aren’t too many studies comparing the different ways to repair these fractures. That’s why they decided to review all the studies published in the last two years on this topic and summarize it by location of fracture.

Boxer’s fracture affecting the metacarpal bone of the little finger is the most common fracture of the metacarpal neck. As the name suggests, the “neck” is the area between the long shaft of the bone and the round knobby end (the “head”) that helps form the joint. With a neck fracture, the metacarpal head can poke out into the palm of the hand or rotate causing a deformity.

Typical treatment for Boxer’s (metacarpal neck) fracture is just immobilization (nonoperative approach). If surgical fixation is needed, Kirschner wires are used. After surgery, the hand is placed in a cast or splint for up to a week followed by the use of a special metacarpal brace that allows use of the hand. Recovery can take a few months or more. The wires aren’t removed for three months. Getting strength and motion back can take a bit longer.

Patients who have had surgery for this type of fracture report they do not like the looks of the scar. Patients who did not have surgery did not like the appearance of the hand (the fifth knuckle disappears without surgical repair). There is also a strange feeling in the hand reported when holding tools.

Fractures of the metacarpal shaft can also be repaired nonoperatively with immobilization. Like metacarpal neck fractures, fractures of the metacarpal shaft require surgery when there is malangulation, rotation, or loss of length of the bone. Type of fixation used depends on the size of the bone at the fracture site. Standard-sized screws may be too big or may reduce bone strength.

Kirschner wires can be used but sometimes they slip, twist or bend. Wires also tend to move or “migrate” causing a loss of reduction (the bone fracture separates more). The surgeon may choose to use more than one wire or to wrap the wire with stainless steel to help improve stability. Another option is the use of a “nail” (long pin) down through the inside of the bone shaft. This type of fixation is referred to as intramedullary nail fixation.

Two other types of fixation are reviewed and discussed. There is the interfragmentary screw and plate fixation and external fixation. The first type (interfragmentary) is used for long fractures of the shaft or spiral-shaped fractures around the shaft.

Interfragmentary screws are used with plates when there are many small fragments of bone, extensive soft tissue damage, and/or multiple fingers injured. Interfragmentary screw and plate fixation can also be used instead of wires. More recent studies have started looking at results based on strength of different screw and plate combinations as well as whether the plates are the locking or nonlocking kind.

And finally, external fixation (hardware is inserted through the skin and bone but located outside the finger). These devices are miniature in size and custom made. The advantage of this type of fixation is early motion while the fracture is still healing. Complications and results have not been reported yet with this type of fixation.

In summary, most metacarpal (finger) fractures can be treated without surgery. The surgeon realigns the bones and puts a cast on the patient’s hand. Surgery to reduce the fracture and hold it in place (fixation) may be needed when there is separation of the fractured bone or instability. According to the studies reviewed, there isn’t one single ideal fixation strategy. Each patient must be evaluated individually based on which finger is affected; type, location, and severity of fracture, and surgeon preferences.

Few structures of the human anatomy are as unique as the hand. The hand needs to be mobile in order to position the fingers and thumb. Adequate strength forms the basis for normal hand function. The hand also must be coordinated to perform fine motor tasks with precision. The structures that form and move the hand require proper alignment and control in order for normal hand function to occur.

Ligaments are an important feature in the hand. We take them for granted until an injury puts them out of commission. Then we realize just how important they are. Ligaments are tough bands of tissue that connect bones together. Two important structures, called collateral ligaments, are found on either side of each finger and thumb joint. The function of the collateral ligaments is to prevent abnormal sideways bending of each joint.

Other important ligamentous structures include the volar plates and flexor tendon pulleys. The volar plate is the strongest ligament in the fingers. This ligament connects the proximal phalanx (finger 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 proximal interphalangeal (PIP) joint from bending back too far (hyperextending). Finger deformities can occur when the volar plate loosens from disease or injury.

The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects.

In this special focus article on the hand and wrist, ligamentous injuries of the hand are reviewed. The authors performed a literature search for the last 18 months. Updated information on new treatment techniques is provided. Topics covered include: 1) thumb collateral ligament injury, 2) finger collateral ligament injuries, 3) volar plate injuries, 4) flexor pulley injuries, and 5) carpometacarpal (CMC) ligament.

Most of the time, only severe injuries will require surgery to repair or reconstruct torn or damaged soft tissue (ligamentous) structures described here. Conservative (nonoperative) care is more often the case. When making treatment decisions, the surgeon takes into consideration the patient’s age, severity of injury, and presence of other injuries (e.g., bone fractures, joint dislocations).

Nonoperative care for these ligamentous injuries is usually under the supervision of a hand therapist (occupational or physical therapist). Treatment is designed to reduce pain, restore motion, and improve function. The therapist may provide a custom-made (designed for each individual patient) splint when needed. Splinting has been shown to allow early active motion that protects the healing ligament while encouraging healing.

Surgery to repair or reconstruct the damaged soft tissues is advised when there is a partial or complete (avulsion) tear of the ligament away from the bone. Operative care is also required when the patient does not respond to conservative care and/or when joint instability persists.

New surgical techniques that have developed in the last few years include mini bone anchors. The authors review various types of these newer bone anchors (e.g., PushLock suture anchor) compared with conventional types of sutures used in these repairs. Sometimes ligaments tear so badly, they can’t be repaired. In such cases, a tendon may be used as a graft to lengthen the ligament enough to reattach it to the bone. If that fails, the joint controlled and stabilized by the ligament may have to be fused or replaced.

Volar plate injuries can be managed with good results when diagnosed early and treated by the hand therapist. But late recognition of these injuries may mean a poor prognosis without surgical intervention. The authors give a detailed description of current recommendations for surgical technique. This included a discussion of the type of incision to use, way to retract or pull back the connective tissue covering tendons, careful debridement or removal of scar tissue, sutures and fixation used, and postoperative care.

One other newer feature in treatment related to flexor pulley injuries is a pulley splint. This type of metal ring fits over the injured pulley and provides support during the two-week rest period needed for healing. Rock climbers and fastball pitchers experience this type of injury most often and can benefit from these new pulley splints.

In summary, this article brings surgeons up-to-date on the diagnosis and treatment of ligamentous injuries of the hand. Although conservative care is mentioned, the main focus is on surgical decisions and surgical techniques for each of the five types of injuries described.

Can a person who suffers from chronic neck, back, or leg pain have a successful surgery for carpal tunnel syndrome? This is the question addressed by hand surgeons from the Department of Plastic and Reconstructive Surgery at The Johns Hopkins University. They compared the results of surgical treatment between two groups of patients who had a carpal tunnel release.

Chronic pain was defined by pain lasting more than three months. The two groups included one (chronic pain) group who had taken narcotic pain medications for pain in some other part of the body besides the hand/wrist. The second (control) group had carpal tunnel syndrome but without chronic pain and without taking pain medications.

Everyone was evaluated before and after surgery for pain, hand/wrist function, and satisfaction with treatment. Follow-up occurred at regular intervals after surgery for a full year. Despite the surgeons’ concern that chronic pain patients would not recover well after carpal tunnel surgery, there were no differences between the two groups at the end of the study.

That may sound like the surgeons pre-judge patients just because they report chronic pain. But research does show that people who are in chronic pain process pain messages differently from people who don’t have daily pain. And many physicians have treated patients who don’t seem to want to get better or who don’t seem to respond to anything except narcotic medications.

There are other concerns as well. For example, it is difficult to accurately evaluate and diagnose patients who are in chronic pain. Performing carpal tunnel surgery on someone who doesn’t have a true carpal tunnel syndrome could lead to poor outcomes. It’s difficult to know when a patient is magnifying symptoms or even making up the problem for the attention. Typically, such patients don’t respond to treatment no matter what approach is taken.

But as this study clearly showed, patients who have surgery for carpal tunnel syndrome (CTS) who also have chronic (nonhand) pain elsewhere in the body do quite well. In fact, they do just as well as patients having CTS surgery who don’t have chronic pain and who aren’t taking narcotic pain meds.

The authors say that despite concerns about poor coping skills, drug-seeking behaviors, addiction to narcotics, or mental illness among chronic pain patients, this group of patients should not be denied surgical treatment for hand/wrist pain from carpal tunnel syndrome (CTS).

There is no evidence to support the idea that they won’t benefit from the same treatment offered to patients with CTS who don’t have chronic pain and who aren’t taking narcotics. And as this study showed, the benefit of pain relief and return of hand function outweighs the possible risks of further drug addiction.

They do suggest some strategies for pain management among chronic pain patients having carpal tunnel surgery. First, only the primary care physician (or pain specialist) should be in charge of prescribing and supervising pain meds for chronic pain patients. The surgeon will give the necessary pain meds the day of the surgery and the day after surgery. But after that, any further medications must be under the care and coordination of the primary/pain physician. The overall plan should be discussed with all concerned including the patient, surgeon, primary care physician, and pain specialist if one is involved.

Most people with Dupuytren disease don’t complain of pain. They are bothered much more by the loss of finger motion, especially extension (straightening the affected fingers). But sometimes the nodules that form are painful.

Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. The condition is noted to be secondary to an increase in fibroblast density, a complex biochemical and cellular interaction. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.

Surgeons wondering why this condition becomes painful for some patients decided to investigate further. They also evaluated whether surgery would help (or make worse) painful symptoms in 10 patients.

Cords and nodules present as part of the condition were dissected (cut apart and removed) and then examined under a microscope. The tissue samples all contained some type of nerve tissue. Some had tiny nerve branches in or across the fibrous tissue. Other patients had nerve fibers embedded inside the nodules. Three patients had actual neuromas (bundle of nerves grown together where they don’t belong).

Based on these findings, the surgeons suggested that nerve compression is the cause of painful Dupuytren disease. The fact that all patients were painfree after surgical removal of the tissue supports this theory.

They suggest early sugery for anyone with painful Dupuytren disease even if finger motion is fine. All tissue removed should be examined by a pathologist who will look for the presence of nerve tissue embedded within or crossing the fibrous cords. Correlating pain patterns with results of surgical removal (as was done in this small study) may help direct future treatment recommendations.

When you think about it, musicians often spend quite a bit of time in awkward positions. The flute player (flautist) has to hold that instrument up and to the side for hours. The violinist tucks the violin under the chin with the head and neck twisted. The pianist stretches the fingers to reach more keys. They hold both hands over the keyboard using the fingers, wrists, forearms, and upper arms repetitively during long hours of practice.

Preparing for a concert often involves increasing the number of hours practicing and rehearsing. Some muscles contract and hold without a break. Joints open and close over and over and over. Inevitably injuries occur for many musicians. Pain, stiffness, cramping, spasm, numbness, swelling, clicking and popping, and tremors are just a few of the more common symptoms experienced.

Sometimes the very thing that makes it possible for a musician to play well is the contributing factor to their injury. For example, joint hypermobility from lax ligaments gives joints greater flexibility. But without strong muscles to stabilize that joint, pain, fatigue, and spasm can develop. Loss of finger or hand dexterity can be devastating to the musical performer.

What can be done to aid these folks? The first step is to make an accurate diagnosis. The most common problems are considered first: overuse syndrome, thoracic outlet syndrome, and focal dystonia. Nerve compression and even bone fractures can be part of the picture.

Overuse syndrome is just as it sounds — muscles, tendons, and joints are repeatedly contracted, flexed, rotated, and so on during intense periods of practice. Pain in the hands, the wrists, and forearms are most common. The lining around tendons and muscles can become inflamed. But depending on the instrument being played, any area can be affected.

Thoracic outlet syndrome involves the compression of nerves and blood vessels in the neck area. Muscles that contract fiercely and repeatedly can clamp down on these soft tissues and cut off circulation to the muscles. This same type of compression puts pressure on the nerves causing numbness, tingling, and sharp pains. Here again, poor posture can be a big factor but obesity and being female are other possible risk factors.

Loss of strength or the ability to move and control the fingers signal the possibility of a nerve entrapment syndrome such as carpal tunnel syndrome. This is considered first when the symptoms only occur during practice and performance and are not present at rest. Muscle cramping called “focal dystonia” much like “writer’s cramp” can occur when certain muscles remain contracted for long periods of time. Pianist and violinists are affected by this problem the most.

Second, the simple application of a common sense approach can help. Reducing the number of hours played, paying attention (and correcting) posture, and use of pain relievers can be tried. A visit (or several sessions) with a physical therapist can be very helpful.

Alignment and posture can be addressed. Instruments can be modified to unload pressure and reduce fatigue and compression. Sometimes just practicing for shorter periods of throughout the day and taking more frequent breaks is enough to allow for healing and recovery. Stretching, range-of-motion exercise, and strengthening are important aspects of conservative care. The therapist will work with the patient as he or she plays the instrument and provide technical retraining. Abnormal motor patterns will be identified and corrected.

In the case of thoracic outlet that does not respond to conservative care, surgery may be needed. No musician likes to hear that word but sometimes something as simple as shaving a rough edge of a bone or removing a rib may be all that’s needed. Other treatment techniques such as deep brain stimulation and the use of Botox injections have been tried for a diagnosis of dystonia.

Many musicians try to apply self-treatment but without a complete understanding of the anatomic and physiologic factors, they may not be successful in changing the symptoms. Waiting too long to get the necessary help needed can delay recovery. Musicians need to be educated as to the importance of getting help sooner than later. This simple approach can prevent the end of a musician’s career and return them to a full schedule of practice and play.

Traumatic puncture wounds can lead to infection affecting the flexor tendon sheath (lining) of the fingers. It may seem like a small problem but it can lead to permanent stiffness of the affected finger(s) and palm. In worse case scenarios, amputation is even a possibility.

Quick and accurate diagnosis is needed to avoid such devastating consequences of this problem. In this article, hand surgeons from the University of North Carolina in Chapel Hill provide a detailed review of flexor tendon sheath infections of the hand. The intent is to help physicians respond appropriately to this injury.

Several pieces of information are crucial when examining a swollen, painful and tender, hot, and red finger. The first is a good knowledge of finger anatomy, especially of the flexor sheath system of the hand. Studies show there can be quite a bit of variation in the location and configuration of this area from one person to another. There are layers of connective tissue, a pulley system to bend the fingers, the blood vessels, and synovial fluid and the space for synovial fluid. The synovial system is key to providing smooth movement.

Second, the physician must be familiar with all possible causes of these same symptoms. Treatment and the speed at which surgery is considered depends on recognizing a true tendon sheath infection from other diagnoses. The differential diagnosis includes septic arthritis, tenosynovitis, herpetic whitlow, cellulitis, gout, pseudogout, and other hand infections.

Third, knowledge of the four Kanavel signs (named after Dr. Kanavel in 1933 that point to a flexor sheath infection is essential. These include: 1) symmetric (even) swelling of the entire finger, 2) extreme tenderness along the length of the tendon sheath, 3) finger in a slightly bent position, and 4) pain with any attempt by the physician to straighten the finger (passive extension).

Not all four signs have to be present to point to a flexor sheath infection. The two most common findings are tenderness along the sheath and pain with passive extension. Patients with other causes of similar symptoms do not have the Kanavel signs associated with flexor tendon infections.

The fourth important item for surgeons to understand when dealing with a potential flexor tendon sheath infection is the nature of bacteria, infection, and matching the most appropriate antibiotic with the bacteria present. Antibiotics are necessary and patients are put on a broad-spectrum antibiotic (one that will kill many different “bugs”) until special tests called cultures are done to identify the specific bacteria present. Then the patient can be switched to a more specific antibiotic.

And finally, the physician must know what are the treatment options. Conservative (nonoperative) care with intravenous antibiotics, splinting, and elevation must show significant improvement within 48 hours. If there’s been no improvement or the patient gets worse, then surgery to irrigate (clean out) and decompress (take pressure off) the tissue may be necessary.

The authors describe their own and others’ surgical techniques including open and closed tendon sheath irrigation and continuous closed irrigation. Pros and cons of each from patient and surgeon point-of-view are offered. For example, closed technique is less painful and makes it possible for the patient to begin the necessary hand therapy sooner.

Complications are always a possibility after any traumatic injury but especially after one that leads to a flexor tendon sheath infection. Adhesions, joint capsular thickening, and destruction of the tendon pulley system by the infection can leave the patient with a permanently stiff finger. Skin infection can destroy enough skin that a skin graft is needed. Deep infection or infection that spreads can cause loss of tissue requiring amputation of the finger.

The potential for loss of a finger is why early and quick diagnosis and treatment are required. Even without the more serious complications, up to one-fourth of all patients with flexor tendon sheath infections lose their ability to straighten the affected finger. Anyone with diabetes is at increased risk for this type of infection. Other risk factors include age over 43, kidney or peripheral vascular disease, loss of blood supply to the area, and multiple bacteria present at the same time.

In summary, despite the small size of a finger infection, the medical consequences can be extreme. Anyone presenting with a red, tender or painful, swollen finger following trauma should be evaluated carefully. The four cardinal signs of Kanavel must be tested to rule out other potential causes. Treatment may begin with nonoperative care but must be quickly replaced with surgery if results are not seen within the first 24 to 48 hours. Physicians can find specifics of evaluation, treatment, surgical techniques, and complications for the problem of finger flexor infections in this detailed and comprehensive article.

Fractures of the fingers that don’t involve the joint are called extraarticular phalangeal fractures. The term phalanges refers to the finger bones. Of the three bones in each of the fingers, the phalanges closest to the hand is the proximal phalange. Extraarticular fractures of the proximal phalanges are the topic of this article.

Treatment for nondisplaced phalangeal fractures is usually with cast immobilization. The cast places the large knuckles (metacarpal phalangeal joints) in a bent position to tighten the tendons and protect the healing fractures. Because it is a forearm cast (goes from hand to just below the elbow), the patient’s wrist is also immobilized. The result is a stiff wrist when the fracture(s) are finally healed.

To accomplish the same fracture stabilization without involving the wrist, a special cast called the Lucerne cast or LuCa for short was devised. This cast still holds the large knuckles in a bent position but now the wrist is free to move. The LuCa just covers the hand and stops below the wrist.

In this study, surgeons from four different hospitals in Switzerland compared the use of the standard forearm cast with the LuCa on 66 patients. In this patient group, one to three fingers on one hand were fractured (little finger fractured most often). Patients ranged in age from 16 to 93 years old and fractured the finger(s) in sports injuries or falls.

The patients were randomly assigned to one of the two treatment groups. All patients were instructed to move the fingers as far as the cast would allow (full flexion, partial extension) during the four weeks of immobilization. Fractured fingers were taped to the uninjured finger next to it or to fingers on both sides if possible. A special tubular finger bandage was used.

Results were measured and compared with X-rays and range-of-motion measurements of the fingers and wrist. Follow-up was for at least three months. Patients were also given the opportunity to rate their satisfaction with the results on a scale from zero (dissatisfied) to 10 (completely satisfied).

The authors report that everyone had equal results when viewed at the end of the three month follow-up. The only difference was better wrist motion in the LuCa group when the cast first came off. About one third of the group was referred to a hand therapist for various reasons. With or without hand therapy, everyone else caught up by the end of the follow-up period. The conclusion is that for well-reduced finger fractures affecting the proximal phalanges, a modified cast that does not include the wrist can be used.

A couple of events occurred during the study that should be noted. First, about one-third of the total group was referred to a hand therapist. This was done at the discretion of the surgeon. Referral was not based on any specific criteria consistently applied to each patient.

Second, three patients treated with the LuCa ended up having surgery within the first two weeks when X-rays showed the fracture reduction wasn’t holding. And third, two of the patients in the forearm cast group developed a condition known as complex regional pain syndrome or CRPS. Loss of wrist motion may have contributed to that complication, possibly supporting the LuCa as the better option.

In summary, it is possible to treat extraarticular fractures of the proximal phalangeal (finger bones) conservatively without surgery. Nonoperative care with cast immobilization allows free wrist motion and good results. The advantage of being able to use the wrist increases patient satisfaction and may prevent some other complications. There is a risk that the fracture site may separate and thus require surgery but whether that happened in this study because of the LuCa or for some other reasons remains unknown.

In this report, a hand surgeon from the Southern Illinois Hand Center recaps his experience treating a rare fistula in the palm of 15 patients. All had either an injury to the palm or surgery with incision for trigger finger and steroid injections as the reason(s) or cause(s) allowing the problem to develop.

A fistula is an abnormal channel or passageway between two places that normally do not connect. In the case of these patients, the tract was from the lining around a tendon out through an opening in the skin. The opening between these two places allowed synovial fluid from inside the lining of the tendon to escape through a hole in the palm.

Patients with this problem had a frothy fluid draining from an opening called the sinus in the palm. The skin around the sinus was soft and breaking down described as a maceration. Pain, loss of motion, and decreased strength were also noted.

Treatment for the problem had been conservative (nonoperative) with antibiotics and immobilization in a splint. But the fistula did not heal and the problem continued. When these patients were referred to the Hand Center, they were tested for infection. No one had any infection.

The surgeon decided to remove the entire tract forming the fistula including the skin around the fistula’s opening. A skin graft to cover the opening was required. Just removing the fistula and closing the opening does not work. The quality of the macerated skin around the opening did not allow it to be used. Complete healing of the fistula required fresh, undamaged skin.

And, in fact, all 15 patients had complete closure of the wound with this treatment approach. No one had a recurrence of the problem. Everyone regained full pinch and grip strength, normal sensation, and full motion. The only postoperative problems were temporary tenderness over the scar in one patient. That one person developed a thicker scar in the palm than the other patients. This particular patient had already had two previous surgeries (both simple fistula closures), which may have been contributing factors to the scarring.

The author advises other surgeons and physicians (especially emergency department personnel dealing with these kinds of issues) to perform this type of complete tract removal if and when a fistula develops in the hand. Conservative care can be tried but is not likely to take care of the problem. Based on his experience, a simple excision will also not provide adequate closure.

The base of the thumb (where it joins the wrist) is a common spot for arthritis that can be very disabling. This joint is called the thumb basilar or carpometacarpal joint. Arthritis of the thumb makes it difficult to pick up objects, open doors, turn a key in a lock, get dressed, and many other daily activities we often take for granted.

More than half of all women in their 70s and older will experience this type of problem. Collapse of the basilar thumb joint will cause a zigzag shift throughout the rest of the thumb. As part of the zigzag shift, the metacarpophalangeal (MCP) joint becomes hyperextended. The MCP joint is the large knuckle at the base of your thumb.

The pain, loss of motion, and weakness that occur as a result of this deformity can make the simplest task impossible. What can be done to treat thumb basilar joint arthritis and in particular, the resulting MCP hyperextension deformity? That is the question many hand surgeons face as they try to help patients with this difficult problem.

A review of the literature shows many different surgical approaches. But no one single procedure has risen above the others as being superior. There are ligament and tendon transfers, fusions, pinning procedures, bone removal, and capsulodesis. This last technique involves shifting the metacarpal attachment of the volar plate. The volar plate is a very thick ligament that prevents hyperextension from occurring.

The goal of surgery is to stabilize the MCP joint and possibly bring the thumb into a more functional position. Both function and appearance can be improved. But which surgery to choose remains an unknown. Without evidence to show what works best, the choice of surgery is left up to the surgeon.

Results seem to vary depending on severity of deformity, presence of joint instability, and surgical approach taken. Some patients regain full use of the thumb. Others have an improved cosmetic result but no change in their ability to use the thumb.

Some studies show that unless the MCP deformity is at least 30 degrees or more, no change can be expected with surgery to correct the problem. For patients with degenerative joint disease and an unstable joint that won’t realign, joint fusion may be the only reasonable choice.

Experts agree there is a need for future studies to compare results of different treatment options. Research is needed to show if there is even a need for surgery at all. The question needs to be answered whether surgery improves function enough to make it worth it. And of course, which procedure is the most effective must be determined.

Imagine you have carpal tunnel syndrome that has not responded well to conservative (nonoperative) treatment. After having surgery to release the carpal tunnel but you didn’t get the results you had hope for. Instead, the pain remains in your wrist and hand. The numbness and tingling in your thumb and first two fingers is enough to drive you crazy some days. You ask yourself: is it worth it to have a second surgery? If it didn’t work the first time, how can you be sure the procedure will be successful if repeated?

These are the questions surgeons and patients face in about five per cent of carpal tunnel release cases. Some studies have been done to show that steroid injection into the carpal tunnel before the primary (first) surgery is a good predictor of symptom improvement after surgery. Could this same approach be used after a failed first surgery before considering a second (revision) release?

The surgeons who conducted this study injected the wrists of 23 patients (for a total of 28 wrists because a couple of people had carpal tunnel in both wrists). The patients involved ranged in ages from 29 to 85 years. Some of the patients had symptoms 40 years after the first surgery.

Everyone was carefully evaluated before injection. The surgeons wanted to make sure the persistent symptoms were really coming from pressure on the median nerve as it passed through the wrist bones forming the carpal tunnel.

A single injection of cortisone into the carpal tunnel space was given to each patient. Results were recorded based on whether or not the symptoms were relieved or eliminated. Then the second carpal tunnel release was performed. Patients were followed for six months after the second surgery. They were re-evaluated at regular intervals during that time.

Measures of success included symptom improvement and patient satisfaction. A positive report of patient satisfaction was defined as being willing to have the second surgery again if they had to do it all over again. Patients who had enough symptom relief were more likely to say the gains received by a second surgery were enough to be satisfied that a second surgery was worth it.

In this group of 23 patients (28 wrists), 23 wrists had complete pain and symptom relief. Five patients were unchanged after the revision surgery. Three of the patients who did NOT have any change in symptoms DID have symptom relief (or improvement) with the steroid injection.

After analyzing all the data, the researchers concluded that the steroid injection by itself wasn’t statistically significant enough to predict surgical success. The surgeon’s evaluation of the patient (history and clinical observations/tests) alone was not able to predict the results either. But when combined together (results of injection with the results of the surgeon’s evaluation), they concluded that this approach could serve as a good screening tool.

They also pointed out that electrodiagnostic tests of nerve conduction velocity and muscle function (electromyography) are not useful with patients who have recurrent carpal tunnel syndrome. Studies show electrical changes can continue even after a successful primary carpal tunnel release.

The information gained in this study is important because carpal tunnel surgery isn’t always successful. And that leaves the patient and surgeon trying to figure out what to do next. No one wants to have another surgery without some hope or assurance that it will work.

Studies show that failure rates after revision carpal tunnel release can be as high as 40 per cent. Up to 80 per cent of patients report improvement after a second surgery but say there are still some symptoms present.

Having a preoperative test of this kind that can be used to help screen for success is a start. The authors suggest further studies using more than one injection before revision surgery to see if that approach may be even more successful — possibly even eliminating the need for a second surgery.

There is nothing more annoying than having your finger lock up on you and not being able to open your hand. Your hand gets stuck inside pants pockets. You can’t reach into your pocket and pull out your wallet. Even taking care of business in the bathroom can become a challenge.

Trigger finger is a condition affecting the movement of the tendons as they move the finger(s) toward or away from the palm of the hand. In the early stages of this condition, there is pain, swelling, and a clicking sensation when moving the affected finger. But as the problem gets worse, the finger can get stuck or locked in a bent or straight position.

Treatment most often begins with conservative (nonoperative) care. Usually patients are put on antiinflammatory medications and given a splint. The finger splint is meant to help reduce symptoms. It is a fairly inexpensive means of treatment. In some cases, cortisone injections are prescribed or a combination of injection with splinting is recommended.

There are many different types of finger splints available. Some block movement of the metacarpophalangeal (MCP) joint closest to the palm. Others block movement of the tip of the finger (the distal interphalangeal (DIP) joint). Some splints are custom made (designed and molded specifically to each patient) while others are premade. Ready made splints are taken off the shelf with more of a one-size-fits-all approach.

In this study, hand therapists from the University of Toronto Hand Program compare two different types of finger splints in the treatment of trigger finger. Thirty (30) people with trigger finger participated in the study. The purpose of the study was two-fold. First, to find out if splinting for trigger finger is even helpful. And second, to see if one type of splint works better than another.

Patients were randomly assigned to one of the two splint groups. One group had the metacarpophalangeal (MCP) joint blocking splint. This splint wraps around the MCP joint and extends down two-thirds of the way across the palm below the affected finger. It also forms a ring around the proximal phalanx (middle bone of the finger).

The second type of splint was a distal interphalangeal (DIP) blocking splint that wrapped around the tip of the finger. There were three different types of DIP blocking splints to choose from. The hand therapist selected the one that best suited each patient in this group. Patient comfort was a key feature in the selection process.

They wore the splints as much as possible 24/7 (24 hours of each day, every day) for six weeks. Then they were allowed to keep wearing the splint or gradually lessen the amount of time on the finger until stopping its use altogether.

Results were measured by comparing range-of-motion, grip strength, frequency of triggering, and function. These measures were taken before treatment began and again one week, three weeks, and six weeks after the start of splinting. Patients were asked to comment on the level of difficulty in performing daily activities while wearing the splint. They also rated the splint as either comfortable or uncomfortable.

Results showed better responses to the metacarpophalangeal (MCP) joint blocking splint. Three-fourths of the patients wearing the MCP splint reported positive results. This was compared with only 50 per cent effectiveness in the group using the distal interphalangeal (DIP) joint splint.

In both groups, patients with diabetes or carpal tunnel syndrome were more likely to experience failure (no improvement in triggering). All patients also noticed increased stiffness and decreased grip strength after wearing their splints. Once they stopped wearing their splints, these symptoms went away.

In terms of function, everyone noted that it was awkward when trying to use the hand or work with the finger splint on. It took longer to get things done. Some patients reported the edges of the MCP splint were digging into their skin. In the DIP splinting group, there were instances where the splint would slip off the finger too easily.

On the plus side, once the finger splint was removed or discontinued in use, the benefits (reduced triggering, less pain) remained for the full six weeks. Many patients experienced continued improvements that were maintained for a full year. Some patients continued wearing the splint after the six-week study period but most had abandoned its use by the end of 12-weeks.

Experts in the area of hand function and disease believe that resting the soft tissues of the finger give time for the trigger finger to resolve on its own. By changing the way the tendons pull around the joints, there is less inflammation and a chance for the tendon sheath to heal and recover fully.

The authors of this study conclude that the more comfortable MCP joint splint may be the best way to begin treatment for trigger finger. Factors to consider in selecting the best choice for each patient include symptoms, required work-related activities, and preferred leisure-time activities.

If the patient does not get enough pain relief using this splint, then the more restrictive DIP joint splint can be used instead. The hand therapist is advised to keep an eye on joint stiffness for these patients.

The results of this study from the Hand and Upper Extremity Department at Massachusetts General Hospital in Boston may be of interest to anyone with carpal tunnel syndrome. They took a look at type of work (desk versus manual labor) and its relation to return-to-work.

The patients in the study had a small open incision surgery under local anesthesia to release pressure on the median nerve (the usual cause of carpal tunnel syndrome). Desk workers were able to return-to-work sooner than manual laborers. Forceful use of the hand in manual laborers was the likely reason nondesk workers experienced more time off from work and more work restrictions when they did return.

But the study was able to also show that individual patient beliefs, expectations, and psychologic factors played an important part, too. Patients who expected to take no time off and get back to work right away did, indeed, take fewer days off and returned-to-work sooner than those who were anxious, fearful, and who expected a slow recovery time.

Younger patients who expected less time off were the first to return-to-work full-time and without restrictions. The conclusion of this was that early return-to-work after carpal tunnel surgery can be predicted by patient attitude and expectations.

Surgeons can aid patients by offering preoperative counseling to influence the patient’s expectations and perspective toward quick recovery and speedy return to full work duty. Patients should be told there may be a few days of discomfort but that return-to-work for the desk worker is safe.

Manual laborers can expect a slower time to return-to-work (up to one month minimum). They should avoid activities that place force on the hand and wrist. More work restrictions may also be recommended for the manual worker.

In this study, outcomes of various treatments for basal thumb arthritis are investigated and compared with current trends in the treatment of this condition. Basal thumb arthritis refers to pain, stiffness, and decreased pinch strength associated with degenerative changes of the trapeziometacarpal (TM) joint.

The trapeziometacarpal (TM) joint is at the base of the thumb where the metacarpal bone of the thumb connects to the trapezium of the wrist. This joint is also referred to as the CMC joint (an abbreviation for carpometacarpal joint) of the thumb. This is the joint that allows you to move your thumb into your palm, a motion called opposition. The TM or CMC joint is sometimes referred to as a universal joint because of the wide range of movements possible.

Treatment usually begins with conservative (nonoperative) care. This could include splinting, exercise, antiinflammatory medications, and steroid or hyaluronate injections. Patients who fail conservative care may benefit from surgery. The simplest procedure is a trapeziectomy (removal of the trapezium bone). More advanced procedures include trapeziectomy with ligament reconstruction, arthrodesis (fusion), or arthroplasty (joint replacement).

In order to find out how hand surgeons are currently treating this condition, the authors sent an on-line survey to active members of the American Society for Surgery of the Hand. They asked questions about conservative care, preferred methods of treatment for patients who failed conservative care, and most common surgical procedures used. Demographic information about the surgeon was also collected (e.g., geographical location, number of years in practice).

They received a response rate of 50 per cent. Surgeons from all regions of the United States participated with a wide range of experience. Half had been practicing less than 15 years; half had been practicing more than 15 years.

Younger surgeons were more likely to recommend conservative care while the more experienced surgeons opted for trapeziectomy or trapeziectomy with ligament reconstruction. Steroid injection was favored by most (89 per cent) of the group.

Only a small number of surgeons (four per cent) used the more recent treatment of hyaluronate injections, which have not yet received approval from the FDA for the trapeziometacarpal joint. Insurance doesn’t always cover this procedure and it costs more than steroid injection. Studies haven’t really shown a benefit of hyaluronate injection over steroid injection. These factors may explain why this treatment is not more popular.

In general, surgery (and more involved procedures) was reserved for patients with more advanced cases of arthritis. There appears to be a trend toward returning to the simpler trapeziectomy procedure by many hand surgeons. Studies seem to show similar good results for all types of surgery. However, there is evidence that more advanced surgeries do not yield better outcomes than simple trapeziectomy. And those procedures involving ligament reconstruction have higher rates of complications.

The use of trapeziectomy with ligament reconstruction instead of a simple trapeziectomy is not supported by the evidence. The authors suggest the need for more research with larger studies to compare outcomes for the surgical treatment of trapeziometacarpal arthritis. Such data would give hand surgeons better direction when choosing treatment for their patients.

Two orthopedic hand surgeons from the University of Rochester Medical Center in Rochester, New York use the example of a 66-year-old man with Dupuytren contracture to look at directions for future research. By asking what is the best treatment for this patient, the authors identified areas where more study is needed. They take a look at the disease itself, the current treatment, and point out where more information could help provide better outcomes.

Dupuytren’s contracture is a fairly common disorder of the fingers. The condition commonly first shows up as 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. Dupuytren’s contracture usually affects only the ring and little fingers. The contracture spreads to the joints of the finger, which can become permanently immobilized.

The joints affected most often are the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The MCP joints are what we usually refer to as the “knuckles.” The PIP joints are the middle joints between the knuckles and the joints at the tips of the fingers.

Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The patient loses the ability to extend (straighten) the fingers. For the patient in this case study, the motion limitations made it impossible to reach into his pocket or shake hands. Placing the hand flat on the table was no longer possible.

There are two types of treatment for Dupuytren’s contracture: nonsurgical and surgical. The best course of treatment is determined by how far the contractures have advanced. Palmar Fascia Removal (palmar fasciectomy) or release of the diseased cords still remains the standard way to treat advanced Dupuytren’s contracture.

Bracing and stretching of the fingers alone have not been proven to help in the long term progression of this condition. Nonsurgical and surgical treatments are to treat the contracture itself. This does not cure the disease. Dupuytren’s disease continues to slowly form the bands making recurrence a common problem, although it may be years before the contracture presents itself again.

In trying to decide the best way to treat this particular patient, the surgeons involved in his care took a look at the current evidence. Based on studies published in high quality medical journals, they found that studies using the newer less invasive treatment approaches are limited. Studies comparing the results of one technique to another are needed.

For example, collagenase injections and percutaneous needle fasciotomy are two of the newer (less invasive) methods of treatment used without much data to say which one works better or if either one works well at all. Some surgeons are using external fixation devices to stretch the hand out before doing surgery. At this point, we don’t know if that is a good idea or not.

The authors made a list of what they think is needed for future research including:

Reviewing 26 studies involving a total of 1500 patients still doesn’t answer the question: What factors predict the outcome of surgery for cubital tunnel syndrome? Six of the most commonly used prognostic factors were evaluated. These included age, duration of symptoms, severity of preoperative status, results of preoperative electrodiagnostic testing, type of surgery, and Workers’ Compensation status.

Cubital tunnel syndrome is a condition that affects the ulnar nerve where it crosses the inside edge of the elbow. The symptoms are very similar to the pain that comes from hitting your funny bone. When you hit your funny bone, you are actually hitting the ulnar nerve on the inside of the elbow. There, the nerve runs through a passage called the cubital tunnel. When this area becomes irritated from injury or pressure, it can lead to cubital tunnel syndrome.

The ulnar nerve actually starts at the side of the neck, where the individual nerve roots leave the spine. The nerve roots exit through small openings between the vertebrae. These openings are called neural foramina. The nerve roots join together to form three main nerves that travel down the arm to the hand. One of these nerves is the ulnar nerve.

The ulnar nerve passes through the cubital tunnel just behind the inside edge of the elbow. The tunnel is formed by muscle, ligament, and bone. You may be able to feel it if you straighten your arm out and rub the groove on the inside edge of your elbow.

The ulnar nerve passes through the cubital tunnel and winds its way down the forearm and into the hand. It supplies feeling to the little finger and half the ring finger. It works the muscle that pulls the thumb into the palm of the hand, and it controls the small muscles (intrinsics) of the hand.

But when pressure on the nerve is severe enough, constant pain, numbness, and electric shock sensations make it difficult to perform daily tasks at home and at work. The problem is usually treated conservatively with nonoperative care. Anti-inflammatory medications may help control the symptoms. The early symptoms of cubital tunnel syndrome usually lessen if you just stop whatever is causing the symptoms. This is called activity modification.

If the symptoms do not go away, even with changes in activities and nonsurgical treatments, then surgery may be advised to stop damage to the ulnar nerve. The goal of surgery is to release the pressure on the ulnar nerve where it passes through the cubital tunnel.

The surgical approach reviewed in this study is called ulnar nerve transposition. In this procedure, the surgeon forms a completely new tunnel from the flexor muscles of the forearm. The ulnar nerve is then moved (transposed) out of the cubital tunnel and placed in the new tunnel.

It’s a delicate operation that can have variable results. It would be helpful to have some way to evaluate patients before surgery for potential factors that might cause postoperative pain and disability. Having what we call predictive or prognostic factors might help surgeons choose patients more careful (and specifically) for this procedure and/or change the way patients are treated.

But the results of these studies showed no clear trend and conflicting results when focusing on these six potential predictive factors. The authors of this review say that the reasons for the lack of convincing or consistent evidence may not have to do with the factors themselves. It’s more likely that the study design and general low-quality of the studies were the real problem areas. Many times there just weren’t enough patients in the studies to create significant statistical data.

They concluded that future prognostic (high-quality) studies are definitely needed. One step researchers could take is to use the same disease-specific outcome measure that is reliable. Research to find such a tool should be the first step. Studies with large numbers of patients would also be helpful. And research that doesn’t rely on retrospective design (patients have to recall or remember events over a long period of time) is preferred.

New understanding of Dupuytren disease is changing the way the condition is treated. Surgery is less common now. Injections to dissolve the cords formed by this condition are becoming a preferred treatment. In this article, two hand surgeons from the Boston area review the causes, treatment, complications of treatment, and prognosis for this problem.

Dupuytren disease is a fairly common disorder of the fingers. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women. With this condition there is an increase in fibroblast density, a complex biochemical and cellular interaction.

The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40. There is no cure for the disease and even with treatment recurrence and spread are common.

A brief review of anatomy will help explain what happens. Lying just under the palm of the hand is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. Dupuytren disease transforms the fascia into shortened cords.

The condition commonly first shows up as 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 (called contractures). 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.

Most people who develop this condition wonder, “Why me?” There isn’t a quick and easy answer to this question but there are some hints along the way. Genetics and gender play significant roles. This condition is seven times more common in men than women.

It is common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry. Researchers agree that genes are not a direct cause of this disease, but predispose people to this condition. If you have a sibling (brother or sister) with this problem, you are at least three times more likely to develop the problem yourself.

Scientists haven’t found a specific gene responsible for Dupuytren disease. DNA technology has made it possible to identify quite a few genes involved in regulating the collagen fibers. Some genes are kept from doing their job of breaking down collagen, while others that normally build up collagen are increased.

There are other risk factors including age, trauma, infection, alcohol use, diabetes, and smoking. What these risk factors have in common is narrowing of the small blood vessels in the hand. With narrowing of the microvessels comes a loss of blood supply, release of free radicals, and the formation of the wrong kind of collagen tissue. Free radicals are unstable atoms that have an unpaired electron. They cause tissue and DNA damage by robbing other atoms for electrons, thus forming a chain reaction of more free radicals.

Understanding the cellular events that occur in Dupuytren disease has led to the development of more nonsurgical means of treatment. Surgeons can now perform a procedure called percutaneous fasciotomy (also known as a needle aponeurotomy). A needle is slipped in through the skin and used to cut the contracted cord.

Afterwards, the patient sees a hand therapist who uses splinting and motion exercises to help the patient maintain finger motion. This approach is more successful if used early on. Recurrence rates are high in patients with more severe disease.

Another newer treatment approach to this problem is the injection of collagenase into the diseased cords. Collagenase contains enzymes that go to work breaking down the collagen tissue. The procedure can be done in the physician’s office and does not require anesthesia.

The injections can be repeated up to three times over a 30-day period of time. Recurrence rates are unknown at this time but with long-term studies, this information will eventually become available and help guide treatment. Complications reported so far include swelling, bruising, pain, and skin problems. Less often, tendon rupture or complex regional pain syndrome develops.

Surgery is still the treatment of choice for moderate-to-severe contractures and in the case of recurrence. As with any surgical procedure, there is always the risk of complications. Wound infection or delays in healing are the most common. But nerve damage and blood vessel injury are also possible. As mentioned, recurrence after surgery is as high as 50 per cent.

Every effort is made with postoperative hand rehab to prevent failure. The hand therapist helps manage scar tissue, restore motion, and maintain flexibility. Regardless of the treatment approach used, regaining full motion and function of the hand while preventing stiffness is the end-goal.

Medicine is moving more and more toward evidence-based practice, but research hasn’t caught up in all areas. There are still times when good old common sense and a little logic go a long way. One hand surgeon from Ohio State University Hand and Upper Extremity Center use this case report to demonstrate this point.

The patient was a 58-year-old woman with long-standing pain at the base of her thumb (where the thumb meets the wrist). She also had hyperextension (excessive backward motion) of the metacarpophalangeal (MCP) joint. The thumb MCP joint if the large knuckle you see when you tuck your thumb inside your palm.

X-rays showed considerable arthritis at the trapezial-metacarpal (TM) joint (thumb-to-wrist connection) but no arthritis at the metacarpophalangeal (MCP) joint (large knuckle joint). The dilemma in this case is how to treat the arthritic TM joint and the hyperextended MCP while preserving thumb motion and function. By the way, the diagnosis for these two problems was MCP joint hyperextension associated with TM arthrosis.

In making a treatment plan, the surgeon looked at the current evidence. He found very few studies to guide him. Most of the published papers were case series reporting the results of using one specific surgical technique. There were no studies comparing conservative (nonoperative) care with surgical treatment of MCP joint hyperextension. There were no studies comparing the different surgical techniques used for this problem.

He was able to see that most hand surgeons agree that when trapezial-metacarpal (TM) reconstruction surgery is done, the MCP hyperextension should be stabilized. The guideline is if there is more than 30-degrees of hyperextension of the MCP joint, then both problems should be surgically addressed at the same time.

If the MCP problem isn’t addressed, then the force and load is transferred to the reconstructed TM joint and that can cause some problems. Stabilization procedures for the MCP include using pins to hold the joint while the TM reconstruction heals, release of the muscle (extensor pollicis brevis) affecting the MCP, fusion of the joint, and capsular release of the palmar side of the joint.

The limited evidence available showed the surgeon that temporary pinning of the MCP joint when there was less than a 30-degree hyperextension deformity did no good. Performing a tenotomy (tendon release and reattaching the tendon end to a different area of bone) has some benefit for most patients. Fusion of the joint doesn’t always work. Recurrence of the excess motion is possible.

Releasing the joint capsule on the palmar side of the thumb seems to have the best results. This procedure is called a volar capsulodesis. In three separate small case series of 10 to 13 patients, there were excellent results with no recurrence the majority of the patients. Excellent results mean pain was reduced and the patients had good pinch grip function.

Armed with the information from these studies, this surgeon used logic and common sense to form his treatment plan. Preserving thumb motion was the number one priority. Treating the MCP hyperextension was deemed important to prevent risk of TM reconstructive failure. The volar capsulodesis was done to reduce MCP deformity and improve MCP joint alignment.

The patient was told ahead of time all of the surgeon’s concerns, the pros and cons of the surgery, and what to expect. In the short-term (one to two years), the patient would probably have the benefit of a more normal functioning MCP joint. In the long-run, the surgeon could not predict what effect the MCP surgery would have on the trapezial-metacarpal (TM) reconstruction. In the worst case scenario, the patient could always have a joint fusion if this plan fails.

The surgeon uses this patient case to point out the deficiencies in research regarding the problem of MCP joint hyperextension in patients with arthritic TM joints. Even with the positives associated with the volar capsulodesis procedure, there are no long-term studies to show what happens down the road. Further research is needed to show if treating the MCP is helpful or a waste of time and money.

When you stop to think about how much you use your thumbs, it’s easy to see why the joint where the thumb attaches to the hand can suffer from wear and tear. This joint is called the carpometacarpal or CMC joint. The CMC is the joint that allows you to move your thumb into your palm, a motion called opposition. The CMC joint is sometimes referred to as a “universal joint” because of the wide range of movements possible.

The place where the CMC joint of the thumb attaches to the wrist is at the trapezium bone. This joint is sometimes referred to as the basal joint of the thumb. The CMC or basal thumb joint suffers a lot of stress over the years. This can lead to painful osteoarthritis of this joint that may require surgical treatment as the arthritis progresses.

One of the more successful surgical procedures for CMC joint arthrosis is to remove the trapezium bone completely, a procedure referred to as a trapeziectomy. Taking a bone out of the wrist does leave a space or hole. Surgeons usually put something in that hole to keep the bones from shifting. They may use a tendon graft from the patient or a synthetic (manmade) spacer made of silicone rubber, gelfoam, animal donor tissue, or zirconia.

In this brief review, two hand surgeons from Columbia University in New York City provide an update on the use of nonautogenous spacers. Nonautogenous means the material used was not taken from the patient but rather from a tissue bank (a biologic material) or from one of several synthetic products available.

Nonautogenous products have the distinct advantage of no donor site pain, infection, or other problems that can occur from harvesting the patient’s own tissue. Using a nonautogenous source (either synthetic or biologic materials) also reduces surgical time.

But what about the results? How well do they work? Is there an advantage of one type of nonautogenous material over the others? By reviewing the results of studies published in this area, the authors provide surgeons with some data and some guidelines.

Let’s take a look at the nonautogenous biologic materials studied. The use of pig skin to fill in the gap (a product called porcine dermal collagen xenograft) often creates an immune reaction as the body recognizes pig skin as foreign (decidedly not human). Efforts to continue researching pig graft as a potential spacer have been dropped.

A human-based product called Graft-Jacket has had some good success. This material is taken from cadavers (human bodies preserved after death for study) and treated in a way to prevent an immune response. This approach works well but there are concerns that there could be disease transmission from the cadaver to the patient. It is also possible that in time the body will find a way to get rid of this tissue.

Surgeons comparing the use of interspacers versus removal of the bone without filling in the gap made a surprising discovery. They found the results were just as good (and often even better) if they just left the gap unfilled. There was less risk of infection, inflammation, and no risk of graft material moving out of the space or spreading disease to the patient.

It is possible that inserting something into the void left by removing the trapezium just isn’t necessary. If this is the case, it would be a cost savings with no risk of foreign body reaction. The authors suggest further studies are needed to take a closer look at this phenomenon. Studies comparing autogenous with nonautogenous grafts would be helpful along with efforts to compare these two approaches with no interspace filling.

Determining who will go back to work after carpal tunnel surgery is the focus of this study from France. Looking at factors that might predict why or why not patients return to work was a second area of interest. Studying patterns of return to work and factors associated with return to work might help surgeons counsel and advise patients who are planning to have carpal tunnel surgery.

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist. This creates a medical condition known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

The study was conducted through mail surveys of patients who were working at the time of the carpal tunnel surgery. Demographic information was collected including age, sex (male or female), and presence of other health problems.

Number of years at the same job, worker’s compensation status, and satisfaction/dissatisfaction with work were also recorded. They also looked at the time between surgery and return to work and whether or not work tasks were modified for the individual workers. Any work restrictions present after return to work were also noted.

By comparing demographics with return to work status, the authors were able to analyze the data for predictive or prognostic factors. All participants were adults between the ages of 20 and 59 years. It turns out there were quite a few factors that affected return to work status.

The various obstacles included other musculoskeletal disorders requiring surgery, unfavorable work environment, blue collar work status, and belief that the problem was work-related. Number of days before returning to work (referred to as duration of sick leave) were also linked with these risk factors plus one more: dissatisfaction with results of surgery.

Other studies have shown that workers employed in jobs requiring repetitive or intensive hand work and manual labor are most likely to have longer return to work times following carpal tunnel surgery. In fact, sick leave in industries with a high rate of carpal tunnel syndrome is rarely less than six months following surgery for carpal tunnel syndrome.

The authors conclude there is a relationship between medical, surgical, and occupational factors and return to work status for workers with carpal tunnel syndrome. Predicting who will be able to return to work (and how soon) after carpal tunnel surgery is not simple or straightforward. With so many potential risk factors and most cases involving more than one factor, makes predicting return to work a challenge.

More research to find the “best” or most predictive factors are needed to complete the information gathered by this study. The role of sickness payment or workers compensation cannot be underestimated and deserves further investigation and study as well. Will You Return to Work After Carpal Tunnel Surgery?

Determining who will go back to work after carpal tunnel surgery is the focus of this study from France. Looking at factors that might predict why or why not patients return to work was a second area of interest. Studying patterns of return to work and factors associated with return to work might help surgeons counsel and advise patients who are planning to have carpal tunnel surgery.

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist. This creates a medical condition known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

The study was conducted through mail surveys of patients who were working at the time of the carpal tunnel surgery. Demographic information was collected including age, sex (male or female), and presence of other health problems.

Number of years at the same job, worker’s compensation status, and satisfaction/dissatisfaction with work were also recorded. They also looked at the time between surgery and return to work and whether or not work tasks were modified for the individual workers. Any work restrictions present after return to work were also noted.

By comparing demographics with return to work status, the authors were able to analyze the data for predictive or prognostic factors. All participants were adults between the ages of 20 and 59 years. It turns out there were quite a few factors that affected return to work status.

The various obstacles included other musculoskeletal disorders requiring surgery, unfavorable work environment, blue collar work status, and belief that the problem was work-related. Number of days before returning to work (referred to as duration of sick leave) were also linked with these risk factors plus one more: dissatisfaction with results of surgery.

Other studies have shown that workers employed in jobs requiring repetitive or intensive hand work and manual labor are most likely to have longer return to work times following carpal tunnel surgery. In fact, sick leave in industries with a high rate of carpal tunnel syndrome is rarely less than six months following surgery for carpal tunnel syndrome.

The authors conclude there is a relationship between medical, surgical, and occupational factors and return to work status for workers with carpal tunnel syndrome. Predicting who will be able to return to work (and how soon) after carpal tunnel surgery is not simple or straightforward. With so many potential risk factors and most cases involving more than one factor, makes predicting return to work a challenge.

More research to find the “best” or most predictive factors are needed to complete the information gathered by this study. The role of sickness payment or workers compensation cannot be underestimated and deserves further investigation and study as well.

Patients who have a hand condition called Dupuytren’s contracture have three basic treatment choices. They can have an open partial fasciotomy (removal of the tissue), needle aponeurotomy (destruction of the connective tissue), or collagenase injection (needle injection of enzymes that break down the tissue.

Along with those three choices come some disappointing results — recurrence of the problem. Let’s take a look at what the problem is and then come back to this point. Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the palm side of the ring or little finger, sometimes both, and often in both hands.

Just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren’s contracture transforms the fascia into shortened cords.

As a result, a thick nodule (knob) or a short cord in the palm of the hand slowly forms, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. 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.

The condition occurs most often in middle-aged, white men. The disease usually doesn’t cause symptoms until after the age of 40. This condition is seven times more common in men than women. Although more common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry researchers agree that genes are not a direct cause of this disease, but predisposes them to this condition.

Now what about the recurrence rate with each of the three treatments described? Well, studies show a 30 to 40 per cent return of the contracture with open partial fasciectomy. Since this is the treatment used most often for all levels of involvement (mild to severe) the result is less than satisfactory for one out of every three patients. And there are some serious complications with this technique including wound healing problems and loss of hand function due to nerve damage.

Let’s take a look next at the recurrence rate with needle aponeurotomy. More than 60 per cent (almost two-thirds) of the patients with severe Dupuytren’s who are treated with this approach experience a return of the problem.

That leaves the newest treatment (collagenase injection). This treatment method seems to have the best results (up to 100 per cent effective) but it is mostly used for single finger/single joint contractures. More studies are needed to really get a handle on how well collagenase injections are working and if it is cost-effective.

That’s where this study comes in. They took a look at varying rates of disease recurrence with each of these treatment methods and compared the costs. A specific measure called quality-adjusted life years (QALY) was used in the cost-effective analysis. The QALY is a number value used to measure the quality of life or in measuring the opposite, it gives a number value to represent the burden of ill-health or disease.

The QALY is based on the number of years of life that would be added by the intervention. Health care researchers can use this measure to assess a monetary value on treatment methods such as the three used for Dupuytren’s contracture. Studies like this help determine the best way to divide up healthcare resources.

There is one downside to using this type of cost-effective analysis. Perfect health is hard, if not impossible, to define. Some people believe that there are health problems worse than death. The measure as it stands now doesn’t allow for negative values. The lowest value is zero and that value is given only to death. And the QALY system doesn’t take into account the effect of a patient’s health on others (e.g., partner, spouse, or other family members).

But having said that, let’s look at what the QALY results do tell us from this study at least. The authors asked a total of 50 adults (men and women) between the ages of 50 and 80 to participate. None of these people had a hand problem of any kind (including Dupuytren’s).

They were asked to speculate how they would feel about certain limitations in hand function if they had Dupuytren’s (e.g., if they were unable to put their hand in a pocket, pick up a package, grasp a coin or key). The study involved analyzing the QALYs gained with treatment versus no treatment for each study participant. A cost value was given to each one. Recurrence and complication rates (as determined by other studies) were factored in as well.

Using this approach, the open partial fasciectomy (most commonly used treatment currently) was not cost-effective. This was true even if the procedure was 100 per cent successful with no complications. Needle aponeurotomy was cost-effective but only when it was 100 per cent successful. Collagenase injection was the most cost-effective but only if the price was less than $945.

The authors concluded that by using QALY to measure treatment success with Dupuytren’s contracture, health economics suggests using collagenase injection as the first-line of treatment. If the problem comes back, open partial fasciectomy could be tried. But there’s nothing to say needle collagenase in the treatment of any recurrence wouldn’t be just as effective. Future studies are needed to sort this out.

Information from QALY studies helps health care providers form policies, make treatment decisions, evaluate results, and direct insurance companies as to which procedures to cover. Cost data should only be one method of analysis.

Other factors such as individual patient characteristics, surgeon’s assessment of severity, joints affected, and need for hand therapy afterwards can alter the final treatment decision. This study only reflects the fees charged using Medicare costs and may not reflect treatment everywhere outside of the Medicare system.

The authors suggest this is just one model to use when comparing treatment effectiveness for Dupuytren’s. There are other models and other considerations that should be addressed in future health economic studies of hand surgery.