What does zone II mean in reference to my hand?

The hand was broken down into a classification scheme based on the flexor tendon along five anatomic zones. Zone II occurs between the distal crease of the palm and the middle crease in the finger.

I am a farmer who works with heavy machinery on a daily basis.  I often wonder about what I should do if my hand ever gets caught in the equipment.  Say my finger is cut off.  What would be the best action to take?

Depending on the type of equipment involved there are several things you need to pay attention to regarding safety features and protective gear that you should wear.  If you do happen to have a finger amputation, the best course of action would be to apply pressure to the stump with clean gauze and rinse the amputated finger in warm water and place in a baggy submerged in ice and report to the closest hospital. That being said, prevention should be foremost in your mind.

I have been diagnosed with a trigger finger. What are my treatment choices?

The most conservative treatment is a simple cortisone injection into the affected tendon. This anti-inflammatory can sometime provide enough to allow the tendon to release and remodel. If the cortisone injection does not work, surgical options are your next choice. There are two surgical options, an open A1 pulley release or a percutaneous A1 trigger release. An open trigger release is considered the gold standard as it has a high success rate with little complications. It involves creating an incision to openly release the affected tendon. Percutaneous trigger release is another option that is becoming increasingly more popular in recent years with proponents claiming that it is a much simpler procedure that often results in a less painful and faster recovery. It involves using a hypodermic needle or specially desigen scalpel to release the affected tendon without an open incision. Percutaneous release can be done in a office setting, thus minimizing cost.

There is strong research with large sample sizes investigating open repairs, whereas the research is relatively meager investigating percutaneous repairs. Looking at the studies that have compared the two methods, those undergoing percutaneous repair reported post-operative pain lasting only about three days compared to almost six days for open repair. Return to work was four days for the percutaneous repair compared to seven and a half days for the open repair. According to these comparative studies, there was no difference between the two groups with regards to failure or complication rate.

Overall, percutaneous repair for trigger finger is promising in being both highly effective and economical, though strong research is currently lacking. As new techniques, such as ultrasound guided releases, and new equipment, such as specially designed scalpels, are introduced, randomized trials comparing these methods are warranted. If you are uninsured or worried about cost, a percutaneous repair may be in your best interest. It is best to discuss with your surgeon which method he or she is most accustomed to performing.

I have opted to have a surgical repair for my trigger finger. I tried a cortisone injection that failed. What are my risks?

There are two options for surgical repair of a trigger finger, open release and percutaneous release, both of which present with their own possible adverse effects.

The research investigating effectiveness and complications associated with open A1 pulley release surgery treating trigger finger indicates success rates varying from a 60 per cent to 100 per cent rate of symptom resolution. Adverse effects with open trigger finger release may include infection, nerve injury, slow range of motion recovery or bowstringing. Research has looked at the rate of adverse effects with findings ranging from less than one per cent to five per cent. One study identified adverse effects occurring in 30 per cent of patients, but this particular study included swelling and pain as adverse effects.

Research investigating percutaneous A1 pulley release is meager compared to the research investigating open A1 pulley release for trigger finger. Excluding the research of percutaneous release on thumbs, which is a procedure much more difficult to perform, and excluding cadaver studies, the success rates vary from 91 per cent 100 per cent. Complications of percutaneous release may include risk of incomplete release, superficial tendon abrasions, and neurovascular damage. Risk of these complications ranged from zero percent to 60 percent, with the 60 per cent being primarily superficial tendon abrasions.

Comparing outcomes of open versus percutaneous A1 pulley release surgery shows that those undergoing percutaneous repair reported post-operative pain lasting only three days compared to almost six days for open repair. Return to work was four days for the percutaneous repair compared to seven and a half days for the open repair. According to these comparative studies, there was no difference between the two groups with regards to failure or complication rate.

I have developed a pretty bad case of intrinsic contracture following a stroke several months ago. My surgeon is suggesting that I need a distal intrinsic release. Are there other options?

There are other options for treatment of intrinsic contracture, but your surgeon probably has a good reason to be suggesting this course of action. The most conservative treatment is a trial of Physical Therapy. This would probably focus on specific stretches and possibly casting. This therapy may also help address other issues associated with your stroke, and there could be other things also affecting the recovery of your use of your hand. If there is no change, or not enough change in about twelve months, to allow for neurologic recovery time, then surgery may be the next step. With this particular procedure there are different levels of resection depending on movement available in each individual, and will usually not require entire release of these muscles, which is a more conservative procedure.

My mother is having a lateral band mobilization for her hand next week and we are confused about what this means.

Lateral band mobilizations are performed when there is contracture of muscles that are inside the hand, the intrinsics, as well as other structures such as the joint itself or tendons coming from the forearm, the extrinsics. This means that if they released only the intrinsics there will still be contracture present, so they have to address both issues. Surgeons will usually perform three types of procedures to regain functional grip strength. The lateral band resection causes these ligaments to to the palm side of the fingers, allowing better flexion. There will also be release of the dorsal, back side, of the joint capsule, to allow more flexion at the PIP (middle finger joint). At times the joint in question can also be replaced. In addition the tendons that pull this same middle joint into extension will be released, again allowing less restriction into a grasping movement. Research has shown this procedure to allow good tip-to-tip pinch ability and better grasp following the surgery.

I was recently diagnosed with Dupuytren Disease affecting my pinky finger and was told that surgery was the best choice. What does surgery involve?

A typical surgery to correct the contracture caused by Dupuytren Disease begins with an incision along the affected finger. The surgeon will use this incision to excise or remove the fibrous bands and nodules causing the contracture. In some cases, a ligament or tendon sheath release or palmar capsule release is also necessary. After the contracture has been corrected, a z-plasty with or without skin graft is used to close the incision. After surgery, expect to wear a compressive bandage and thermoplastic splint for the first week. After the first week, the splint will be worn only at night for up to three months. Hand therapy begins shortly after surgery to help restore ROM and strength.

I just had surgery for Dupuytren Disease that caused a contracture of my index and ring finger. What are the chances that the contracture will return after surgery?

There are several possible outcomes resulting from surgical correction of Dupuytren’s Disease. You can regain your extension mobility and maintain it for years to come or you could lose a small amount of your range in the first several months after which your contracture is stable and no longer progressing. These are the majority of cases, in some studies reporting minimal to no return of contracture in greater than 80 percent of patients electing surgical repair of contracture. The minority of cases result in significant loss of range and return of contracture to close to preoperative state. This can occur in the first few months after surgery then the contracture becomes stable, or the contracture can continue to progress up to and beyond five years. A few risk factors have been identified that will predispose one to return to severe contracture, including level of disability as measured with PEM scores prior to surgery, length of disease prior to surgery, and time required in surgery to correct contracture.

I jammed my finger playing basketball a few weeks ago.  I’ve rested my finger since then but still am unable to straighten my fingertip all the way.  Should I seek medical treatment or is it just going to stay this way?

Recent review of the literature suggests that you should go ahead and seek medical treatment.  Even though it has been awhile since your injury you are still within the successful treatment time-frame.  Your physician will more than likely refer you to a physical therapist or hand specialist to splint your finger.

My grandmother has multiple fingertips that will not straighten all the way. She says that they do not bother her but they look stuck.  Should I take her to the doctor?  What could they do for her?

It seems you are describing mallet finger, a condition where the tendon that helps to straighten your fingertip ruptures.  Typically treatment is only sought if it becomes an aesthetic issue or interferes with your ability to do something.  In your Grandmother’s case it seems that she is not bothered by her fingers.

I had a flexor tendon repair two weeks ago.  My doctor has set me up with this futuristic looking contraption that lets me straighten my finger if I want and then bends it back to a resting position.  He didn’t give me much instruction other than to wear this thing.  Should I be doing something else for my finger?

Flexor tendon repair protocols tend to be very specific to the type of surgical repair and tendon rupture.  Surgeons typically have an exact idea of what motions they want to restrict and when it is appropriate to advance.  You might, however, ask your surgeon for a referral to a hand specialist for closer monitoring of your rehabilitation.  This can either be a physical therapist or an occupational therapist

Mother is 82-years-old and loves to knit and crochet. She has made over 100 blankets for our local hospice. But she has terrible carpal tunnel syndrome and wants to have surgery. What are the risks and how do other people come out of this surgery? She’s pretty healthy otherwise but slowing down.

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.

I was turned down flat for carpal tunnel surgery because of my age (87 years old). I am hale and hearty except for this terrible numbness in my left hand. I expect to live another 20 years and I do NOT want to live like this. How can I convince my doc to approve this procedure? I think it’s because I’m on Medicare and old enough to be his grandfather that I’m getting this kind of treatment.

The question of whether older adults can benefit from carpal tunnel release surgery has been studied with mixed results. Older adults (65 years old and older) seem to have a greater chance of developing carpal tunnel syndrome and with more severe symptoms. So finding an answer to the question is very important for a large portion of our population.

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.

One recent study looked at the surgical results for 78 adults (ages 65 to 93) who had carpal tunnel surgery. Each individual was carefully evaluated before surgery to make sure the diagnosis was correct. The most reliable test for carpal tunnel syndrome is a nerve conduction study. Only patients whose carpal tunnel syndrome was confirmed with nerve conduction studies were included. The surgery done was an endoscopic (minimally invasive) carpal tunnel release.

Patient charts were reviewed, data collected, and statistics analyzed. The kinds of information viewed included demographic data (e.g., age, gender, smoking status, health status, previous surgeries), clinical presentation (e.g., symptoms and physical findings), and patient satisfaction (e.g., very satisfied, satisfied, neutral, dissatisfied). Each patient filled out several surveys (questionnaires) answering questions about pain, numbness, sleep, and daily function.

Before surgery, two-thirds of the group reported 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 of the patients were treated conservatively (splinting, steroid injection) before trying surgery. They were able to get some relief from their symptoms but not enough to avoid surgery.

Those patients who did report “pain” before surgery (70 of the 78) were able to get relief from their pain following the carpal tunnel release procedure. Almost everyone (94 per cent) who had numbness before surgery (especially noticeable at night) was no longer bothered by this symptom.

In terms of the level of satisfaction, three-fourths of the group was satisfied or very satisfied. About 10 per cent classified themselves in the middle (not satisfied and not dissatisfied) — more neutral. About 12 per cent indicated that they were dissatisfied. Overall, the procedure was considered a success in older adults and (older) age was not a factor linked with results.

The findings of this study are very encouraging for older adults who are affected by carpal tunnel syndrome. Surgery to release the soft tissues around the affected nerve can be done endoscopically (small incision). The advantages to the older adult of endoscopic carpal tunnel release for carpal tunnel syndrome are many: less pain after the surgery, regain function faster, 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. Given the severity of symptoms in the older adult and the few complications reported in this study, surgeons may be more likely to recommend this procedure now for patients 65 and older.

The authors also make note of the fact that other studies have come to the opposite conclusion (i.e., finding that older age is a predictor of poor outcomes). However, the other studies often did not follow patients past 60 days. In this study, patients were re-evaluated six months after surgery. Some of the results seem to even out with more time. They suggest that studies of open incision versus closed (endoscopic) procedures for this age group should be done to compare results and over a longer period of time (up to two years).

In the meantime, you may want to present your physician with this information and request a re-evaluation of your situation. If all else fails, you can always ask for a second opinion from another physician. There may be some circumstances unique to your situation that would prevent you from having surgery. It would be important to be aware of this information for your peace of mind in accepting a second recommendation withholding surgery.

Are antibiotics always required when someone gets in a fight and cuts the hand on another person’s teeth? This happened to my brother over the weekend. He turned 21 (legal drinking age here) and of course, went out partying. He ended up in a fight and two knuckles bashed in and bleeding. We took him to the emergency department and they hooked him up to IV antibiotics immediately. I was just wondering if so much treatment is really needed. Couldn’t they just clean up the area and give him a prescription? Mom is going to be livid and I know she will question what happened.

Antibiotics are given prophylactically to prevent infection in almost all cases of what is referred to as acute fight bite. The only two exceptions are: 1) patients with minimal superficial wounds (skin is not broken) and 2) those individuals who come for care 72 hours or more after the injury and have no signs of infection.

With up to 50 different types of bacteria in the human mouth, the concern for infection is very real. The physician may also surgically debride the wound (open the hand down to the bone/joint and clean out any microbes present).

Without knowing what may happen in those early hours after the contact with someone’s tooth, a wide-spectrum antibiotic is given. This type of medication covers most of the common bacteria (Staphylococcus, Streptococcus, Corynebacterium, Eikenella corrodens). Anyone with clinical signs of infection (fever; red, swollen, tender or painful skin/joint) will likely receive additional medications including intravenous antibiotics.

Even a small skin opening from such an injury can allow bacteria to enter the body. The joint can become infected to the point that finger amputation is the end-result. Not all complications from infection following an acute fight bite of the hand are as drastic as finger amputation. But loss of motion, decreased grip strength, tenosynovitis, osteomyelitis, and septic arthritis occur in up to one-third of all cases.

You did the right thing to get your brother medical care right away. The risk of amputation from infection increases dramatically with longer delays between injury and care.

Last night I witnessed a bar fight (my first ever). I tried to get the guy (a friend) who did the punching (to protect me) to go to the hospital for what looked like a bad wound on his knuckles. He must have cut his hand on the other guy’s teeth. He refused to go and today I’m worried about broken bones, infection, I don’t know what! What do you advise?

Acute fight bites that result in broken skin from contact with someone else’s tooth/teeth have a high potential for infection and more dire consequences. It is advised that he get medical evaluation and treatment as soon as possible.

Even a small skin opening from such an injury can allow bacteria to enter the body. The joint can become infected to the point that finger amputation is the end-result. Not all complications from infection following an acute fight bite of the hand are as drastic as finger amputation. But loss of motion, decreased grip strength, tenosynovitis, osteomyelitis, and septic arthritis occur in up to one-third of all cases. With up to 50 different types of bacteria in the human mouth, the concern for infection is very real.

Antibiotics are given prophylactically to prevent infection in almost all cases. The only two exceptions are: 1) patients with minimal superficial wounds (skin is not broken) and 2) those individuals who come for care 72 hours or more after the injury and have no signs of infection. The physician may also surgically debride the wound (open the hand down to the bone/joint and clean out any microbes present).

Without knowing what may happen in those early hours after the contact with someone’s tooth, a wide-spectrum antibiotic is given. Anyone with clinical signs of infection (fever; red, swollen, tender or painful skin/joint) should receive additional medications including intravenous antibiotics.

The biggest concern is for patients who do not seek care immediately and wait up to a week before getting treatment. The risk of amputation from infection increases dramatically with longer delays between injury and care. Patients whose tetanus shots are out-of-date and who have not had hepatitis vaccinations (or for whom hepatitis B status is unknown) will require additional treatment.

I’ve heard that smoking is a cause for the pain I have with carpal tunnel syndrome. I would be willing to try quitting smoking if I thought it would really stop the pain in my hands. Is there any kind of test I could have that would show me ‘yes’ or ‘no’ smoking would help?

There are several things you may need to know about smoking and carpal tunnel syndrome. Of course, even without the carpal tunnel, the long-term consequences of tobacco use are well documented and potentially serious. In the interest of your overall health and well-being, it is always advised to stop smoking. Most likely, you already know this but it is important enough to bear repeating.

Second, pain is not considered a classic sign of carpal tunnel syndrome. Sometimes people have such severe numbness that they consider the symptom “painful”. A clear and accurate diagnosis of carpal tunnel syndrome can be made through a combination of health history, clinical tests, and nerve conduction (electrophysiologic) studies. The nerve conduction studies are especially important to confirm the diagnosis.

Studies done so far have not conclusively and consistently linked smoking with carpal tunnel syndrome. Although it appears there is some kind of association between the two things, the exact relationship remains unclear. For example, it is possible that depression is the underlying reason why people smoke (to self-soothe). Likewise, chronic pain may be the reason people smoke (or increase their use of tobacco). Other studies have linked pain intensity with smoking.

Smokers seem to get more relief from surgery to decompress the nerve (take pressure off the nerve) compared with nonsmokers. This finding suggests some link between carpal tunnel syndrome and smoking. But again, the exact mechanism between the two is unknown.

There are many helpful tools available now to assist people in stopping smoking. Talk with your physician or the local health department and find out what is available to you. With or without painful symptoms from carpal tunnel syndrome, smoking cessation is clearly beneficial and in your best interest.

I have a definite case of carpal tunnel syndrome. Would wearing a splint be helpful? I’d rather not have the surgery recommended.

There is sufficient evidence now to show that positive nerve conduction (electrophysiologic) tests are a reliable diagnostic tool for CTS. It is recommended that treatment should not be determined until a clear and accurate diagnosis has been made.

If you have, indeed, been clearly diagnosed with carpal tunnel syndrome (based on history, clinical tests, and nerve conduction studies), then the evidence points to the need for decompression surgery.

There are a small number of people (about one per cent) who do respond well to wrist splinting as the only course of treatment. So, there is no problem with trying this as your first option. A second approach that has been used with some success is injection therapy with corticosteroids. And a third option is hand therapy with an occupational or physical therapist.

Surgery today for carpal tunnel syndrome is minimally invasive and provides beneficial results quickly. The recovery time is faster, too compared with previous methods of open incision surgery. Today’s modern surgical tools and techniques makes this kind of surgery successful in cases of true carpal tunnel syndrome.

If carpal tunnel surgery didn’t work the first time, is there any point in doing it again?

Symptoms after carpal tunnel surgery must be evaluated carefully to determine whether this is a case of persisting symptoms (they never went away with the surgery), recurrent symptoms (the symptoms went away but came back later), or new symptoms (a different problem). Treatment will be planned according to the findings.

For example, there could be scar tissue that has built up around the median nerve and nearby soft tissues contributing to the problem. A short course of conservative (nonoperative) care might help restore the natural sliding and gliding of the nerve necessary for normal function. But sometimes only surgery to release these compressive tissues will restore full blood supply to the area and thereby alleviate the painful symptoms.

A recent study by researchers from the Division of Plastic and Reconstructive Surgery (Washington University in St. Louis School of Medicine) may have some information to help you in making your decision about revision surgery.

They took a look back at patients (all adults) who had a first carpal tunnel surgery before 2001. Each one was evaluated and placed in one of three groups. The groups included patients who had carpal tunnel symptoms that continued after the first surgery (group one), recurrent (group two: symptoms went away after surgery but then came back), or group three: new symptoms developed.

Medical records for each patient were reviewed and analyzed looking at a variety of information and factors. For example, they paid attention to the surgeon’s notes during the revision procedure. Two areas of interest from the notes were: 1) how the revision procedure was done and 2) what the surgeon found at the time of the surgery.

Information about the patients (e.g., age, work status, use of pain medications, results of electrodiagnostic tests) was collected and compared among the three groups. Clinical measures of grip and pinch strength were also measured, reported, and compared. Pain level and quality of life were also assessed. The authors provided all of this information for each group in a table for anyone interested in the exact details.

When trying to find some differences among the three groups, the only significant factors were diabetes and longer time between first and second surgeries. These two variables were specific to the group with recurrent symptoms. New symptoms occurred more often in people who had an unintended nerve injury during the first surgery.

Clinically, everyone in all three groups did get pain relief with the revision surgery. Grip and pinch strength improved for the persistent and new group (as symptoms resolved) but not for the recurrent group. Overall, the long-term results were positive for all groups. This is good news for patients like you who are facing the possibility of a second surgery for carpal tunnel syndrome when the first procedure was less than successful.