FAQ Category: Hand

Reattaching fingers traumatically amputated is called replantation. This type of procedure is possible but not always available where patients in need of it live. It requires a highly skilled surgeon trained in microsurgery. The right surgical equipment is also needed.

The nerves and vessels are repaired with special surgical instruments. While the patient is sedated, the bone ends are shortened to remove tension on the repaired blood vessels. The finger or toe is put in place and the bone is stabilized with wires or a plate and screws. Then any tendon repairs are done.

Replantation of an amputated part is best done within four to six hours after the injury. However, success has been reported up to 24 hours after the injury if the amputated part has been cooled and protected.

Replantation is possible when the fingers or toes are in a condition that would allow restoration of the blood and nerve supply. Children are especially good candidates for replantation surgery. They have a greater potential for healing and regenerating tissue.

Under the right conditions, the long-term prognosis for the restoration of use in the finger or toe is very good.

A boutonnière deformity affects the fingers or thumb of the hand. It is the most common deformity associated with rheumatoid arthritis but it can be caused by other conditions.

This type of deformity occurs when disease or injury causes the middle joint of the finger or the base of the thumb to become flexed (bent). The end of the finger or thumb is pulled up into too much extension (hyperextension). In the thumb, the position looks like an exaggerated hitchhiker’s thumb.

Prolonged inflammation in the joints from rheumatoid arthritis damages the lining aroudn the joint called the synovium. Over time the joint capsule starts to stretch and the extensor tendon slips out of place.

Weakness and an imbalance of forces results in the deformity. If it’s not corrected, the patient may lose the ability to even passively correct the joint position. Function is affected, especially the pinch grip.

Early intervention may be able to prevent such serious deformities. But by the time a boutonnière deformity occurs, surgery is usually needed. The type of surgery depends on the condition of the ligaments, tendons, and joints.

The surgeon may be able to repair any soft tissues that are torn or ruptured. Sometimes joint fusion is required. In other cases, joint replacement is advised.

A recent study showed that patient report of symptoms and the results of electrodiagnostic testing does provide different information. Sometimes patients have ongoing symptoms but no changes in nerve function. These people may benefit more from conservative care than surgery.

In other cases, the median nerve gets pinched or compressed as it goes through the circle of bones in the wrist (the carpal tunnel). Testing will be able to demonstrate the need for surgery.

There’s been some suggestion that psychologic factors are important in chronic pain problems. Patients who are depressed, anxious, or dissatisfied at work have more intense, longer lasting symptoms. Surgery won’t necessarily change the picture. A job change or even retirement may be much more effective.

Experts advise physicians (especially surgeons) to use patient report of symptoms and function along with electrodiagnostic results when deciding to do surgery. If your physician suggested nerve conduction velocity tests, it’s likely a very necessary step in the decision process.

Carpal tunnel syndrome is the most common nerve compression problem of the wrist and hand. Even so, diagnosing CTS accurately can be a challenge. There’s no single test that is 100 per cent sure.

Many doctors think that reviewing the patient’s symptoms is enough to make the diagnosis. Others disagree and suggest that electrodiagnostic testing is needed to confirm the diagnosis — especially before surgically releasing the soft tissues around the nerve.

A middle-of-the-road approach is often to treat the symptoms conservatively for up to six months and then decide. A hand therapist (usually a physical or occupational therapist) can teach you how to use your hands and wrists in such a way as to take pressure off the nerve that’s getting pinched.

Nerve and tendon gliding exercises can help restore free motion of the nerve inside the carpal tunnel. The carpal tunnel is an opening or space formed by the circle of bones in the wrist. The nerve passes through these bones on the way from the elbow to the fingers.

If you don’t get better and especially if you get worse, further testing can be done. Electrodiagnostic tests check to see if the nerve is functioning properly. Is it passing along messages and how fast is it going? Slowed or absent responses suggests the need for surgery to release the nerve.

If you haven’t already seen an orthopedic or hand surgeon, then your first step is to make an appointment. An examination and history will help the physician evaluate you. Special clinical tests can be done in the office to look at motion, strength, and assess nerve irritation. The surgeon will be able to advise you about what treatment is best and what to expect.

Studies show a significant decrease in grip strength after carpal tunnel surgery, especially when compared to the unoperated side. Most patients have about 80 per cent of their preoperative grip strength after the operation.

There are three types of grip strength: hand grip, thumb key grip, and tip pinch. Hand grip is measured by squeezing a grip tester called a dynamometer held against the palm in the hand between the fingers and thumb.

The thumb key grip is measured with the same position used to hold a key between the thumb and index finger. The tip pinch measures pinch strength between the pads of the thumb and index finger. This position would be as if you were holding a dollar bill between the pads of your thumb and first finger.

Thumb key grip is affected by carpal tunnel surgery. Thumb tip pinch may not decrease at all. The stronger your grip strength before surgery, the stronger it will be after surgery. Men and younger patients tend to have stronger grip in general before and after carpal tunnel surgery.

You should expect to regain your full grip strength within six to 12 weeks after surgery. You may have to do some rehab exercises if grip strength remains less than it should be or if you are kept from doing work or job tasks.

Many surgeons have switched from the open-incision method to the endoscopic approach. Instead of a four-inch long cut, the surgeon makes an incision just big enough to insert a small, fiber-optic TV camera called an endoscope.

The endoscope is placed through this portal or opening and into the carpal tunnel. The surgeon passes all instruments through this portal. This displays a view inside the wrist up on a video screen. The surgeon uses this visual tool to help complete the operation.

Although the endoscopic method is less invasive, the final outcomes of these two approaches is the same. Studies have failed to show one operation works better than the other.

Short-term results may be better with endoscopic surgery. With less bleeding and a smaller scar, you may be able to resume work activities sooner than with the open-incision method.

Studies show that in up to half of all cases of trigger thumb in children, the problem goes away on its own. The length of time before this happens can vary. Most experts suggest a six- to 12-month waiting and watching period.

When treated with splinting or surgery, the results are very good. Almost every child is cured meaning the thumb stays in a normal position, and there’s no snapping or locking of the joint.

It’s not advised to wait too long. Older children (age three and older) are not as likely to see improvement with splinting and/or surgery. A simple splint to hold the joint in neutral position can be worn for several weeks to several months with good results. Switching to a splint for just nighttime wear is a good maintenance plan.

There’s been quite a bit of debate over this question. Open incision carpal tunnel release (OCTR) has been around for 40 years. Endoscopic release has about a 10 year history.

In both operations, the transverse carpal ligament is cut and released. The goal is to take pressure off the median nerve in the wrist. With an open incision, there is a two to three inch cut made. Using the endoscopic approach, the surgeon uses a special tool called an endoscope. A very small incision is made and the endoscope is inserted under the skin.

Even with such a head start, there are only half as many studies on the open CTR compared to the endoscopic CTR. The ECTR has become very popular with surgeons. The rate of complications between the two methods is about the same now. When the ECTR was first developed nerve problems were a major complication.

At this point, it doesn’t appear that one method is better than the other. Patient preference and surgeon’s choice seem to be the main deciding factors. Problems such as nerve or tendon damage are still possible with either technique.

Neurapraxia is the loss of nerve function resulting in tingling, numbness and weakness and the hand and fingers. It is usually caused by compression of the nerve.

Injury to the nerve during carpal tunnel surgery can result in paralysis. But the nerve doesn’t die or degenerate so the condition is transient or temporary. There can be rapid and complete recovery of function.

The most common complications of carpal tunnel release include nerve, tendon, or blood vessel injury. Cutting any of these structures can occur during CTR with problems afterward. This doesn’t happen very often anymore (less than one per cent) because of all the improvements in surgical technique.

Problems of this type were more common in the mid 1990’s when a new method of operation was first introduced called endoscopic carpal tunnel release (ECTR). Instead of cutting the wrist open, the surgeon inserts a special tool called an endoscope under the skin into the carpal tunnel area.

Improved equipment, technique and experience brought the complication rate for ECTR down equal to the rate for open CTR.

Amputation for disabling flexion contractures has been suggested. A flexion contracture is the name of the deformity that occurs when the joint can’t straighten out fully. When the middle joint of the finger is flexed, grasping large objects, putting on gloves, or even shaking hands becomes an impossible task.

It’s not likely that a hand surgeon would amputate your finger without a fair trial of therapy or conservative care first. A hand therapist will teach you how to do exercises to get the nerves and tendons gliding smoothly.

Passive and active range of motion exercises might help, too. If there are adhesions or scar tissue holding the joint in place, the therapist can try using deep heat and manual therapy to release the soft tissues.

Splinting and even serial casting might be used over a period of weeks to months. If after at least six months of active therapy (with your cooperation) you have not gained motion, then a fusion or even amputation may be considered.

If there are no problems with circulation or blood loss to the area, fusion may be the best first step. If fusing the joint in an extended position doesn’t alleviate your problem, then amputation is the last step considered.

Taping one finger (or toe) to another is called buddy taping and is a common treatment for ligament tears alongside the joint. These ligaments are called collateral ligaments.

Buddy taping helps ensure proper healing and return of normal function. The good finger actually works like a splint for the injured digit. The patient is advised to keep the buddy tape on for three to six weeks depending on whether the finger is sprained or broken.

Buddy taping is often used to allow early motion in a joint. It’s used instead of a cast or splint because of the ease of use. It can be removed for bathing and put back on right away.

Your postoperative course may depend on the type of surgery you had. Your recovery time is shorter if the surgeon was able to repair the injury arthroscopically. Healing time for an open incision operation is often longer.

With arthroscopy, the surgeon makes one or two puncture holes and inserts a long thin needle. This is the scope. A tiny TV camera on the end of the needle allows the surgeon to look at a video screen and see inside the joint.

The joint is distracted and the bone fragment found and viewed on screen. Sometimes another special type of X-ray called fluoroscopy is also used. Fluoroscopy and arthroscopy used together help the surgeon make sure the bone fragment is lined up and reattached properly. A K-wire or pin is used to hold the piece of bone in place.

The short arm cast you’re wearing is usually put on about one week after the surgery. The pin can be removed around week five after the operation. At that time, a hand therapist will give you a removable splint to use during volleyball and other strenuous activities.

You may need an exercise program to regain strength and motion. If you follow your surgeon’s directions carefully, you should be able to rejoin the volleyball team around eight weeks post-operatively.

Tendon rupture after surgery to repair a tendon problem certainly can happen. This happens in about four to six per cent of cases. Surgeons don’t always know why it happens. Sometimes it’s poor surgical technique or too aggressive therapy afterwards. Many times it’s because the patient doesn’t follow the surgeon’s directions.

For example, the patient who removes the splint, lifts heavy objects, and/or tries to make a strong grip to lift or hold things is at increased risk for tendon rupture. The tendon is especially vulnerable to reinjury between days six and 18. Reports of tendon rupture have been made as late as six or seven weeks after the operation.

The best way to have a good post-operative result is to follow your surgeon’s advice carefully. Ask questions if you don’t understand the directions given for use of the splint or how to do the exercises. In the case of tendon repairs, motion is lotion. Early movement of the wrist and hand gives the best results.

The first step is to find the cause for the loss of motion. It could be skin or joint contracture or tendon adhesion. Each of these problems has its own treatment. In both cases, the patient loses active motion but with adhesions or scarring, there is usually some active motion left. With joint contracture, the joint is stiff and stuck and doesn’t move past a certain point (if at all).

Imaging studies may be needed to identify the cause of the joint motion problems. MRIs or ultrasound help show if the loss of motion is from tendon re-rupture versus adhesions.

Once it’s clear what the problem is, then hand therapy with an occupational or physical therapist is advised. Splinting and exercise are the focus of treatment for these problems. If there’s no progress or very little change, then a second surgery may be needed.

If there are adhesions keeping the tendon from gliding, then the surgeon performs a tenolysis. Scar tissue around the tendon is carefully cleaned out. The tendon is released inside the sheath so that it will slide and glide again freely. The patient is sedated but awake enough to actively move the hand during the surgery. This is the only way the surgeon can tell that the tendons are gliding properly for normal motion.

If there is a joint contracture, then the method of splinting must be reviewed and changed if needed. Finger “buddy” taping (one finger is taped to another to move together) and active-assisted exercises are performed. If conservative care doesn’t help, then surgery may be needed to release the joint.

If there’s a hand surgeon in your area, make an appointment for a consult. A physical exam and testing will be done to find out the severity of joint damage. This will help guide the physician in making recommendations.

You may be a candidate for conservative care with medications and hand therapy. A physical or occupational therapist may be able to help you manage your symptoms without surgery. You’ll learn safe ways to lift, pinch, pull, and use your hands in general. The therapist may give you some exercises to restore motion and improve strength. Splinting may help with the symptoms as well.

If conservative treatment fails, then surgery may be the next option. There are several operations that can be done. Removing the trapezium, the arthritic bone at the base of the thumb may be necessary.

A special procedure called ligament reconstruction with tendon interposition (LRTI) may be done. In this operation, a tendon is split in half. One half is rolled up and used to fill in the space where the bone was taken out. The other half is used like a ligament to stabilize the joint. LRTI has been shown to be a very good way to restore a stable thumb that can then be used for daily tasks without pain.

Attempts have been made to replace the joint with an implant. Silicone and titanium implants have been used with mixed results. Silicone implants fell out of favor because of implant instability. Wear and tear caused silicone synovitis. Titanium has been used but with a high failure rate. Until better implant design is successful, the LRTI remains the surgery of choice for this condition.

Hand and finger positions when playing the piano are actually quite different from using a computer keyboard. The piano keyboard is three times as big as the computer keyboard.

Pianists actually move their arms and hands much more than typists. Computer operators use different repetitive motions and keystrokes than pianists. On the computer keyboard, you will rarely stretch the thumb and little finger apart to reach the keys. But for some people, stretching an octave plus a chord on the piano stretches the hand maximally.

It’s also true with most computer keyboards that the pressure needed to strike a key is far less than the pressure needed to depress a piano key to make a sound. The computer keyboard operator uses about the same amount of pressure on each key every time. The pianist is more likely to strike with power and force to produce the sound required by the music.

Finally, wrist motion is different between the two activities. On the piano, the player may have to tilt or rotate the wrist more and more often compared to using a computer. There’s also greater risk of injury or overuse on the piano for players with smaller hand size or hand span.

Pianists are at risk for overuse syndromes most often affecting the forearms, wrists, and hands. Some pianists also suffer with neck, shoulder, and upper arm problems. Many different conditions have been diagnosed and described in association with piano playing. It seems that music requiring fast and forceful finger movements puts musicians at the greatest risk.

Studies using computer and video systems to track hand motion have helped identify some of the problems pianists experience. Researchers have found that music with trills or arpeggios played with speed or endurance can cause many problems.

Rest is always the best treatment but most serious pianists don’t feel they have the ability to take time off from practice or performance. Choosing less difficult music for awhile may be one way to rest the soft tissues.

Without special equipment to analyze your arm and hand movements, you can still do several things on your own. Set up a video camera to record yourself playing. Ask your piano instructor to watch a short amount of the video with you. Look for anything that might help you reduce the muscular stress in the upper extremity.

A physical therapist or hand therapist (sometimes a physical therapist, sometimes an occupational therapist) may be able to help you identify a motor control problem. The muscles may be firing too soon, too late, or too long for the motion required. the therapist may be able to show you ways to change how you play without negatively affecting your playing.

Comparing symptoms before and after a treatment is one simple way to see the results. This could be a change in symptoms (better or worse) such as pain or numbness. Decreased weakness seen as improved strength may be a meaninful change.

Each person will have his or her own standard of improvement. For example, one patient may want and need to be able to lift a coffee pot and pour coffee without spilling. Another patient may say that getting a good night’s sleep is what counts.

A meaningful change from the patient’s point-of-view may not be the same as what society or the physician would say. Society might see the patient’s ability to go back to work sooner as the important change. The physician may say there were no complications and that’s what counts.

Researchers often use patient surveys of questions before and after treatment to calculate the minimal clinically important difference (MCID). The MCID is a measure of success and guides treatment. If the MCID shows a benefit from treatment, then it’s possible no further treatment is needed. If not, then further treatment may be needed. The patient and doctor decide this together.

There are many ways to treat carpal tunnel syndrome (CTS) including conservative care and surgical intervention. Conservative care may include vitamin B, splinting, antiinflammatories, and nerve and tendon gliding exercises.

Steroid injections may be used when these methods have not changed the patient’s symptoms. Patients who don’t want to have surgery may choose this treatment option. A small amount of numbing agent mixed with a steroid is injected into the carpal tunnel.

Results of studies using steroid injections for CTS have been mixed. About half the patients get relief from symptoms and the other half do not. Researchers aren’t sure why this happens. Studies are ongoing to try and find factors that would predict who gets better and who doesn’t. Then doctors could select patients for steroid injection based on these factors.

For many patients, steroid injections give only temporary relief. If the needle giving the injection accidentally punctures the nerve, the patient can be left with permanent nerve injury. Studies comparing steroid injection to surgery show that patients have better short-term results with the injection. Long-term results (six months or more) show equal results.

For patients who can’t have surgery due to other health concerns, steroid injection may be a good option. Patients who want to avoid surgery for any reason can usually have one to three injections safely. They may not get better, but if there are no complications, they won’t be any worse.

Dupuytren’s is a disease of unknown cause with thickening of the palmar fascia in the hand. Cords or bands of tissue form pulling the affected finger(s) into a flexed position. Surgery to release the tissue is the most successful treatment method.

There are several ways to do the surgery. The most common is a limited fasciectomy (LF). Limited fasciectomy is a partial removal of the fascia. The procedure is usually done under a general anesthesia. Only the diseased fascia is taken out.

As you’ve described your surgery, it sounds like you’re having a fasciotomy. In this operation the surgeon cuts the bands to relieve tension or pressure. Small incisions in the palm allow the surgeon to pass special tools under the skin to do this. The patient is awake but the hand is numb.

The cords or bands of tissue don’t have any sensation or nerve endings for pain. Cutting these isn’t painful at all. However, the nerves in the hand will respond if the surgeon comes too close with the needle. You may feel a strong electric-current sensation at the tip of the finger. Let the surgeon know right away if you feel this. He or she can redirect or move the needle away from the nerve and avoid causing any damage.