FAQ Category: Hand

Whether from sports-related activities, work injuries, car accidents, or falls, hand fractures can cause significant pain and disability. But most patients can expect that, in time, they can return to normal motion and use of the involved hand.

An accurate and timely diagnosis is always the first step. With careful review of the patient’s history (including the mechanism of injury), physical examination, and good quality X-rays, most hand fractures can be identified and a plan of care developed. It sounds like you are well past this phase. The main stumbling block in this process is making sure that all other injuries (especially soft tissue damage of nerves, tendons, and ligaments) are recognized and adequately treated.

Special attention must be paid to intraarticular fractures (fractures that extend into the joint). This type of fracture is often accompanied by damage/rupture of the ligaments needed for joint stability.

Fortunately, the hand is versatile, resilient, and forgiving making it possible to treat hand fractures without surgery. Conservative (nonoperative) care consisting of short-term immobilization in a splint or cast is acceptable for many people. In some cases, a particular position of the hand and wrist is necessary to limit specific motions.

But in selected cases, surgery will aid and assist healing and recovery. And this is evidently where you find yourself. Complications are to be expected with stiffness being the most common (and most difficult to treat) problem encountered. Infection around pins, screws, and wires used to hold the bones together during healing is another potential problem. The choice of hardware and the amount of skin tension on the wires are risk factors for infection that can be managed by the surgeon.

Postoperative care is just as important as the surgery itself. Ask your surgeon for a referral to a hand therapist (usually a physical or occupational therapist). The therapist will tailor your rehab program to meet the specific needs for the type of job you have. The surgeon and the therapist will be the best ones to advise you as to expectations (how long will it take and expected recovery).

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. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women.

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.

The contracture spreads to the joints of the finger, which can become permanently immobilized. Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. The MCP joints are what we usually refer to as the “knuckles.” As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The PIP joints are the middle joints between the knuckles and the interphalangeal (IP) joints (at the tips of the fingers).

Traditionally, treatment has been surgical release of the affected tissue. But more recently, collagenase injections have had some reportedly excellent results. This new treatment is getting close scrutiny because there is no known “cure” for Dupuytren’s disease and the proximal interphalangeal (PIP) joint does not respond well to treatment. When just the metacarpophalangeal (MCP) joints are primarily involved, treatment has been quite successful.

But with the PIP joints, treatment in the past has not been as successful. This may be because contractures of the PIP joints also affect the collateral ligaments (on each side of the finger joint), the volar plate, and cause adhesions inside the joint. The volar plate is actually a very thick ligament that prevents hyperextension of the joint. This ligamentous structure also reinforces the joint capsule and gives the joint greater stability.

In a recent study, surgeons from the Philadelphia Hand Center at Thomas Jefferson Medical College reported on the effect of a three-part therapy treatment. Patients enrolled included 19 men and two women ranging in age from 37 to 80 years old. All had one or more proximal interphalangeal (PIP) joints stuck in flexion of at least 40 degrees or more. Twenty-two proximal interphalangeal (PIP) joints received one standard collagenase injection followed by manual cord rupture (performed by the surgeon).

Then they were treated by a hand therapist. The hand therapy consisted of wearing a custom-made splint (dorsal hand-based extension orthosis) at night and special exercises delivered and supervised by the therapist but also performed by the patient throughout the day at home. For day use, the hand orthosis was replaced by a smaller, finger splint to hold the PIP joint in full extension (straight).

Results measured by change in finger motion were impressive. Patients went from having severe flexion contractures (range of 40 to 80 degrees) down to zero for some patients (a range from zero to 55 degrees among all 22 fingers). A contracture means the finger is stuck and cannot move. A flexion contracture gives us the clinical picture that the patient’s finger is bent by the amount of degrees mentioned and cannot straighten.

In viewing the results of this treatment compared to other studies utilizing surgery and postoperative splinting, there was an 88 per cent improvement in the patients who received this protocol of collagenase injection, manipulation, splinting, and exercises. This compared to a 44 per cent improvement with surgical intervention and splinting for the same problem.

Most hand therapists are willing to work with patients who have fixed means, no insurance, or other reasons why direct treatment isn’t always possible. With splinting, a home exercise program, and careful supervision by the hand therapist, you may be able to get by with fewer visits. But it is not advised to skip hand therapy altogether. Dupuytren contractures are notorious for coming back. The cost of additional therapy to avoid surgery may be worth the extra out-of-pocket expense.

You may be interested in the results of a study recently reported by a group of surgeons at the Philadelphia Hand Center at Thomas Jefferson Medical College. In this study, surgeons from the report on the effect of a three-part therapy treatment for severe Dupuytren disease.

Patients enrolled included 19 men and two women ranging in age from 37 to 80 years old. All had one or more proximal interphalangeal (PIP or middle) joints stuck in flexion of at least 40 degrees or more. Twenty-two proximal interphalangeal (PIP) joints received one standard collagenase injection followed by manual cord rupture (performed by the surgeon).

Then they were treated by a hand therapist. The hand therapy consisted of wearing a custom-made splint (dorsal hand-based extension orthosis) at night and special exercises delivered and supervised by the therapist but also performed by the patient throughout the day at home. For day use, the hand orthosis was replaced by a smaller, finger splint to hold the PIP joint in full extension (straight).

Results measured by change in finger motion were impressive. Patients went from having severe flexion contractures (range of 40 to 80 degrees) down to zero for some patients (a range from zero to 55 degrees among all 22 fingers). A contracture means the finger is stuck and cannot move. A flexion contracture gives us the clinical picture that the patient’s finger is bent by the amount of degrees mentioned and cannot straighten.

The positive results of this study are important for two reasons. First, there is no known “cure” for Dupuytren disease and second, the proximal interphalangeal (PIP) joint does not respond well to treatment. When the metacarpophalangeal (MCP) joints are primarily involved, treatment has been quite successful.

But with the PIP joints, treatment in the past has not been as successful. This may be because contractures of the PIP joints also affect the collateral ligaments (on each side of the finger joint), the volar plate, and cause adhesions inside the joint. The volar plate is actually a very thick ligament that prevents hyperextension of the joint. This ligamentous structure also reinforces the joint capsule and gives the joint greater stability.

In viewing the results of this treatment compared to other studies utilizing surgery and postoperative splinting, there was an 88 per cent improvement in the patients who received this protocol of collagenase injection, manipulation, splinting, and exercises. This compared to a 44 per cent improvement with surgical intervention and splinting for the same problem.

Despite these good results, the authors warn that problems can develop using collagenase injections. The enzymes in the injection can eat away and dissolve more than just the contracted tissue. Tendons and tendon pulleys may be adversely affected by these effects. The use of only one collagenase injection followed by carefully supervised hand therapy may have made the difference in success rates observed in this group of patients.

Given this information, a one-on-one discussion with your surgeon about the pros and cons of each treatment for your hand may be the next step.

Serious injuries like tendon injuries often require treatment by an experienced hand surgeon. Surgeons know how complex and delicate the anatomic structures of the hand are. They understand the need for very careful surgical technique when repairing, reconstructing, transferring, or grafting a tendon.

There are many potential complexities of surgery for tendon transfers. Tendon transfer refers to taking one tendon and moving it to function in place of another. This is done most often when a tendon has been injured, the nerve to the tendon has been damaged, or as in your case, there is a defect of the tendon from rheumatoid arthritis. But tendon transfers are not as simple as they sound.

For example, sometimes a tendon originates (or begins) in a slightly different place than expected. Most tendons start from an attachment directly to the bone. But in some cases, the insertion point could be a ligament instead of the bone. Or the origination could be from the soft tissue over the bone.

If even a single tendon slip is taken from the wrong tendon, it can affect the movement and strength of the finger and/or hand. Likewise, if the surgeon chooses a weaker tendon for a transfer to a stronger tendon that has been injured, the result can be a significant loss of hand function.

The extensor indicis proprius (EIP) of the index finger has many connections to the extensor digitorum communis (EDC). EDC is the main tendon that extends all the fingers. The connection between these two tendons must be carefully cut to avoid losing the benefit of the EIP as a tendon transfer.

There are also thin bands of tissue that connect the extensor digitorum communis (EDC) tendons. These are called the juncturae tendinum. The full function of the juncturae tendinum is not completely understood but it is clear that the anatomy can be quite different from one person to another. Even rare anomalies (differences or variations) of the juncturae tendinum anatomy are important for the hand surgeon to be aware of.

Knowing how many and what kind of anatomical differences that can occur from patient to patient is essential when planning hand surgery. Knowing the anatomic and functional variations of the extensor tendons affects decisions surgeons make before and during tendon transfers. You will most likely want to find someone to do the surgery who has knowlege and understanding of the unique and very complex hand anatomy.

Like others who have relied on a family member with arthritis to predict an upcoming storm, you know there may be some kind of link between change in weather and joints. But what is that relationship? Is it real or imagined? Scientists have been studying this phenomenon for a while.

In a recent study from Brazil, the influence of air pressure, temperature, humidity, and moisture (precipitation) was evaluated on pain, joint stiffness, and function of the hands in patients with osteoarthritis (OA). These measures of weather are referred to as meteorological variables.

They did the study including 32 patients with known hand osteoarthritis (OA). Each patient filled out a survey answering questions about their hands. They did not know the study was about the influence of weather on hand arthritis. They answered questions like, How much pain (or stiffness) have you had in your hands? They completed the same survey three times a week throughout the months of July (summer) and November (winter).

In Brazil where this study was done, July has the lowest average temperature and higher relative humidity than any other month. November has the highest temperatures with low atmospheric pressure and humidity. Those features make these two months the most logical ones to select for a study on weather and arthritis affecting the hands.

After each patient completed the surveys, they compared the patient responses about pain, stiffness, and function against meteorological (weather) records. The patients ranged in ages from 45 to 77 with half being younger than 60 years of age. There were men and women included from all levels of income. Some were underweight while others were overweight. In other words, the patients included came in all sizes, shapes, and backgrounds.

The two weather factors that had the greatest effect on hand arthritis were temperature and humidity. In fact, there was a significant relationship between temperatures the day before and the day after changes in hand pain. Some patients (but not all) were affected by atmospheric pressure. The effect was most noticeable on hand function.

But the most interesting finding was that not everyone was affected in the same way. As you might expect, the lower the temperature, the more pain and stiffness with decreased function was experienced. But this wasn’t true for everyone or even the majority of patients. And remember, they did not know the study was about the influence of weather on their arthritic hands.

Some patients had improved symptoms when the temperature went up while others felt worse. It was the same with changes in humidity and atmospheric pressure. There were both positive and negative correlations between weather elements and arthritic effects.

It appears that weather does have a correlation with symptoms associated with hand arthritis. But individual sensitivity is very different from one person to the next and cannot be predicted. More study is needed before the exact relationship between weather and hand arthritis can be fully understood.

Other studies are needed to sort out all the different variables that can affect a person’s response to weather. Medications they are taking, their mood, their overall health, and/or type of joint (or other soft tissue) diseases that are present may have an effect on what appear to be weather-related joint changes.

Neck pain, shoulder pain, thoracic outlet syndrome, carpal tunnel syndrome, and this diagnosis of neck pain and carpal tunnel syndrome (which together make up the double crush syndrome) are fairly common among bicyclists. In fact, in a recent study of just patients who were bicyclists, they found a high proportion of riders who had positive clinical tests for double crush syndrome.

The exact mechanism by which this condition develops remains uncertain. It is believed that the symptoms at the neck and wrist/hand come from damage, injury, or compression of the same spinal nerve root. In fact, compression in one region has been shown to increase the likelihood of damage at another location along the nerve. A nerve in the wrist is actually more susceptible to problems when there is compression in the neck.

Many experts have suggested various different ways in which this syndrome develops. It could have to do with the damaged nerve’s ability to transport information further down. Perhaps there is a loss of blood supply. Or maybe the initial nerve damage leaves it stiff and no longer elastic enough to transmit messages along its length. Sometimes, another condition such as diabetes or thyroid disease is the missing link. But again, the exact mechanism by which carpal tunnel syndrome follows the initial neck pain remains a mystery.

Physicians have found that electrodiagnostic testing is the most valid and reliable way to document nerve impairment linked with carpal tunnel syndrome. The same type of testing is not as reliable for documenting a double crush syndrome. Commonly used tests (e.g., Phalen’s, Tinel’s) that point to carpal tunnel syndrome and are confirmed with electrodiagnostic tests cannot be used reliably to diagnose a double crush syndrome.

Without a clear mechanism of development of the double crush syndrome, treatment cannot be as specific as possible. Up until now, researchers have paid attention to types of treatment applied and then looked back to see which patients improved. By working backwards in this way, it may be possible to understand the mechanism underlying the loss of nerve function in more than one place along the nerve.

But the problem is a bit more complex than it seems. Some studies show that patients with just carpal tunnel syndrome have better results after carpal tunnel release surgery compared with individuals who have the double crush syndrome. This would lead one to think it is necessary to have surgery at both sites of the nerve compression (neck and wrist).

Yet other patients with double crush syndrome who have cervical decompressive surgery (without carpal tunnel release) have equally good results. Those results would suggest the need for cervical decompression before (or even alone without) carpal tunnel release.

Not everyone agrees but some experts in this area suggest the following when faced with the dilemma of treating a double crush syndrome. First, the physician looks at symptoms, results of clinical exams, and performs electrodiagnostic testing. Second, all results are reviewed together with the big picture in mind. Third, when there is a double crush syndrome present, a surgeon will perform the least invasive surgical procedure first.

Then the patient’s symptoms are reassessed along with goals and expectations. The next step in the treatment plan is determined accordingly. The patient who continues to have pain and other nerve symptoms should be re-evaluated for a more proximal (closer to the neck) disorder of the nerve(s). If and when a clearer understanding of the mechanism underlying double crush syndrome is discovered, patient management can be re-visited. More appropriate and more consistently successful treatment can then be developed.

The implant is made by burning and separating hydrocarbon gas to make it chemically stable. The process makes the material biologically compatible (acceptable to the body). Pyrolytic carbon implants have been around and in use for finger joint replacements for 20 years or more. But the use of these devices for osteoarthritis (OA) of the metacarpophalangeal (MCP) joints has been limited. In fact, there is very little data reported on the results (especially long-term outcomes) for this condition.

A recent study from Washington University in St. Louis has some information that may be helpful. A single surgeon performed joint replacements for nine patients in 11 metacarpophalangeal (MCP) joints (index and middle fingers). The patients were followed for at least two full years.

Results were measured using pain, motion, function, and patient satisfaction. Assessment tools included the Michigan Hand Questionnaire and the Quick Disabilities of the Arm, Shoulder, and Hand survey. X-rays were used to look for implant loosening, fracture, movement, subsidence (sinking down into the bone), or failure of any kind.

The surgeon reported that motion was significantly improved from before surgery to after. Grip strength was better than before surgery but less than the other hand. Pain was mild (rated as a one on a scale from zero to 10) if there was any pain at all. And there was high satisfaction associated with 10 of the 11 fingers.

There were a few problems reported along the way. Two of the patients noticed clicking and squeaking when they moved the finger. There were no other symptoms accompanying the noises (e.g., no pain, no swelling, no tenderness). One patient who was unhappy with the results had joint stiffness, constant pain, and squeaking for no apparent reason. She ended up having a joint fusion (arthrodesis) seven months later. In general, there was no sign of implant failure for any of the patients. Everyone had a little subsidence (implant sinking down) but this did not continue to get worse and presented no problems.

Postoperative rehabilitation was initiated 10 to 14 days after surgery. Edema control was an important focus. A splint was provided to maintain the MCP joint in full extension for six weeks. Patients were instructed and encouraged to perform active motion of the other joints of the finger. After six weeks, the splint could be removed while patients performed light activities.

Three weeks after surgery, the patients were shown how to do short arc motion of the MCPs starting at 30-degrees. These exercises were repeated three or four times each day. MCP flexion was gradually increased by 10 degrees each week until full motion was restored.

Strengthening was started eight to 10 weeks after surgery. The hand therapist started each patient off slowly and gently. About this time, the daytime splint was gradually phased out but the splint was still worn throughout the night for three to six months. The time lines for all of these separate treatment components were worked out for each patient between the therapist and the surgeon. You may want to provide a proposed treatment plan and consult with the surgeon for your two patients.

As you know, for people with osteoarthritis (OA) of the metacarpophalangeal (MCP) joints (the knuckles), pain, stiffness, and deformity can lead to disability and loss of function. Quality of life is affected as the individual is unable to participate in work, play, or daily activities.

Fortunately for most people, this condition (osteoarthritis of the MCPs) is uncommon. Just as you have experienced, treatment begins conservatively with hand therapy, medications to control pain and inflammation, and sometimes steroid injections. Surgery is a last resort type of option but consists of joint replacement. The use of implants for MCP joint replacement isn’t new (they’ve been around 20 years or more) but the number of studies reporting on long-term results is fairly low.

We know that motion is significantly improved from before surgery to after with this type of joint replacement. Grip strength is usually better than before surgery but often less than the other hand. Pain (when present) is reported as ‘mild’ (rated as a one on a scale from zero to 10). And even though the studies are small, the majority of patients are fully satisfied with the results.

There have some problems reported along the way. Clicking and squeaking may develop when the joint is moved. Joint stiffness, constant pain, and squeaking can occur for no apparent reason. X-rays show that most patients have a little subsidence (implant sinking down into the bone) but this does not continue to get worse and presents no particular problems.

In general, long-term results of surgical placement of carbon implants in the metacarpophalangeal (MCP) joints of the hand are positive. Symptoms improve, satisfaction is high, and the implants hold up well. Patients are able to get back to work and/or daily activities requiring the full use of the fingers and hands.

Reasons for less than satisfactory results or outright failure remain unclear and deserve further attention through future studies. In your case, you may want to seek a second opinion in case there is an identifiable cause and possible treatment for your continued symptoms.

You may want to start with our publication A Patient’s Guide to Hand Anatomy. You may find other Patient Guide topics of interest in the section on hand. We also recently reported on a review article just on the extensor tendons of the hand from The University of Illinois at Chicago Department of Orthopaedic Surgery. The extensor tendons are the ones that lift the fingers off the table when the hand is resting palm down (or pull the fingers back as your subway companion described it).

Although the review of hand extensors is for hand surgeons, the information would benefit anyone studying hand anatomy. Injuries of the hand are very common. Surgeons know how complex and delicate the anatomic structures of the hand are. They understand the need for very careful surgical technique when repairing, reconstructing, transferring, or grafting a tendon.

In the article just mentioned, there is a review the anatomy of each extensor tendon and discuss the complexities of surgery for tendon transfers. Included in the discussion are the following tendons: extensor digitorum communis, extensor indicis proprius, extensor digiti minimi, extensor proprius indicis, extensor digitorum brevis manus, extensor pollicus brevis, extensor pollicis longus, and extensor medii proprius.

Tendon transfer refers to taking one tendon and moving it to function in place of another. This is done most often when a tendon has been injured, the nerve to the tendon has been damaged, or there is a defect of the tendon from rheumatoid arthritis. But tendon transfers (or using tendon as a graft) are not as simple as they sound.

For example, sometimes a tendon originates (or begins) in a slightly different place than expected. Most tendons start from an attachment directly to the bone. But in some cases, the insertion point could be a ligament instead of the bone. Or the origination could be from the soft tissue over the bone.

If even a single tendon slip is taken from the wrong tendon, it can affect the movement and strength of the finger and/or hand. Likewise, if the surgeon chooses a weaker tendon for a transfer to a stronger tendon that has been injured, the result can be a significant loss of hand function. In yet another example, the authors point how the extensor indicis proprius (EIP) has many connections to the extensor digitorum communis (EDC). The connection between these two tendons must be carefully cut to avoid losing the benefit of the EIP as a tendon transfer.

There are also thin bands of tissue that connect the extensor digitorum communis (EDC) tendons. These are called the juncturae tendinum. The full function of the juncturae tendinum is not completely understood but it is clear that the anatomy can be quite different from one person to another. The authors provide a detailed description of this anatomic structure and description of what is known so far about how it works. Even rare anomalies (differences or variations) of the juncturae tendinum anatomy are important for the hand surgeon to be aware of.

So you can see even in just this brief review that there are many extensor tendons. They are an important part of the complex and delicate structure we call the hand. Without the fingers (and the movement they provide), performing even the simplest of daily activities can be difficult, if not impossible. And this is just one feature of the amazing hand!

A broken finger is not something trivial. Even though the individual bones that make up each finger are small, a fracture (and especially a fracture with dislocation) can result in a painful, unstable, nonfunctional finger. And the “middle” joint of the finger (called the proximal interphalangeal (PIP) joint is important because of the tendons that attach there allowing for finger motion.

Studies show that early treatment (within the first six weeks of injury) is advised for the best outcomes. Waiting too long (until the injury becomes “chronic”) is never a good idea. So, it sounds like you’ve crossed the first important hurdle: early evaluation and treatment.

Proximal interphalangeal (PIP) joint fracture-dislocation injuries are named according to the location of the damage. There is the dorsal fracture pattern, the volar fracture pattern, and the pilon injury. Treatment depends on what type of PIP fracture your wife has.

In simple terms, a dorsal fracture occurs along the bottom (palm side) of the finger. The tendon that helps flex or bend the finger is torn away from the bone allowing the joint to dislocate. A volar fracture affects the top (back of the hand side) of the bone. In this case, the extensor tendon is torn (the one that straightens the finger) with joint dislocation. And a pilon fracture involves multiple fractures on both sides of the bone and ruptures of both the flexor and extensor tendons. With a pilon injury, the joint is very unstable requiring surgery right away.

The goals of treatment are fairly simple and straightforward but not always so easy to achieve: realign the joint, restore range-of-motion, and return patient to full finger/hand function. The plan of care and treatment decisions depend on severity of injury and amount of tendon retraction (pulling away from the bone).

Sometimes it is possible to treat these injuries (even when there is a fracture and dislocation) nonsurgically. But if and when the fracture-dislocation cannot be held stable with taping or splinting, then surgery is necessary. It sounds like this is where your wife ended up.

The surgeon has a wide variety of surgical techniques to choose from. Sometimes the bone and joint can be realigned and held together with pins and/or wires without making an incision to open the finger. This is called closed reduction and pinning.

If closed reduction is not possible, then open incision may be needed to realign the bones and hold them together with hardware. This procedure is called open reduction and fixation (ORIF). ORIF is necessary when the surgeon must repair or reconstruct the torn tendons and/or when there is hinging at the fracture site. Hinging refers to motion that occurs between the two ends of the broken bone (rather than at the actual joint).

Pilon fractures can be treated with ORIF but sometimes require a special surgical treatment referred to as dynamic distraction and external fixation or DDEF. The joint is “distracted” or pulled apart and as many of the pieces of bone as possible are put back together. Then the surgeon applies a special device made of wires and rubber bands to achieve stability.

Now that you have been sent home with a referral to the hand center, your focus will be on rehabilitation, which is considered “vital” to the successful treatment of proximal interphalangeal joint fracture-dislocations. A hand therapist working with the surgeon will provide the treatment based on the type of fracture and surgery that was done.

Early passive range-of-motion is a key to recovery. Passive means the therapist (and eventually the patient) moves the joint. Motion is only allowed through the stable arc of motion. Too much movement too early can disrupt the healing bone and soft tissues.

Gradually, the therapist will advance the motion to active-assisted (patient is allowed to move the finger through partial range-of-motion with help). In the case of dynamic distraction and external fixation (DDEF), active motion can be started right away since everything is stabilized with hardware.

Your hand therapist will guide you and your wife through each phase of treatment. Finger joints are small but mighty. It can take a long time to heal and recover fully. It can take several months to work through stiffness, swelling, and loss of smooth motion before she regains full function. But with steady rehab and following the hand therapist and surgeon’s instructions, full recovery is possible.

You may be experiencing a problem known as sesamoiditis. But to know for sure (and to find out the best way to treat whatever is wrong), you will need an evaluation by your primary care physician or an orthopedic physician.

Sesamoiditis refers to an inflammatory process affecting the sesamoid bones of the thumb. The sesamoid bones are two pea-sized bones embedded in the volar plate of the thumb. The volar plate is actually a very thick ligament that prevents hyperextension of the joint. The volar plate also reinforces the joint capsule and gives the joint greater stability.

Even though they are small in size, the sesamoids play an important role in how the thumb moves. These tiny bones are part of the pulley system that allows for thumb movement. Two different tendons (adductor pollicis, flexor pollicis brevis) insert into each of these little bones. Together, these tendons across the sesamoid bones pull to create thumb adduction (moving the thumb toward the hand) and thumb flexion (bending the tip of the thumb).

The sesamoid bones lift the tendons and their attached muscles away from the joint to increase the mechanical advantage needed for smooth thumb motion. If the sesamoids are injured or starting to degenerate, they can be a source of severe pain and disability.

Normally, as the thumb bends, the sesamoid bones “track” or move up and down against the head of the thumb metacarpal (bone that forms the tip of the thumb). If the sesamoids do not track evenly on the center of the metacarpal head, the cartilage starts to wear unevenly and break down. That’s when inflammation develops around the sesamoid bones with eventual bone-on-bone pain from chronic sesamoiditis.

The physician will take your history and ask about current signs and symptoms. Sesamoiditis may be caused by previous trauma to the thumb but it can also be caused by wear and tear (more of a degenerative process). He or she will perform some clinical tests to evaluate the joints, tendons, ligaments, muscles, and other soft tissue structures. A positive sesamoid provocation test (SPT) will confirm if it is sesamoiditis.

This test is done in two steps. First, the examiner holds the thumb in a flexed position and applies resistance to the patient’s effort to bend the tip of the thumb. Then the thumb is held in an extended position and resistance is applied to the tip of the thumb again. A positive test for sesamoiditis is no pain with the first test and much more pain when the second test is done. This test is helpful because most of the time, X-rays are normal.

Once a proper diagnosis has been made, then the appropriate treatment can be prescribed. Most of the time, this is a nonoperative (conservative) approach. Over-the-counter pain relievers, splinting, and physical therapy are the most cormmon treatments for thumb problems like you are describing. Occasionally, steroid injections are needed and more rarely surgery may be advised. But don’t put it off because the earler problems are addressed, the more likely simple measures will take care of the symptoms.

Sesamoiditis is usually treated effectively with conservative (nonoperative) care. But when pain relievers, antiinflammatory medications, a thumb splint and hand therapy do not help, then steroid injection into the sesamoid joint is advised and can be very effective. But please know that a good period of conservative care (at least six weeks and more like three months) is recommended before injection therapy.

As you probably know by now, sesamoiditis refers to an inflammatory process affecting the sesamoid bones of the thumb. The sesamoid bones are two pea-sized bones embedded in the volar plate of the thumb. The volar plate is actually a very thick ligament that prevents hyperextension of the joint. The volar plate also reinforces the joint capsule and gives the joint greater stability.

Even though they are small in size, the sesamoids play an important role in how the thumb moves. These tiny bones are part of the pulley system that allows for thumb movement. Two different tendons (adductor pollicis, flexor pollicis brevis) insert into each of these little bones. Together, these tendons across the sesamoid bones pull to create thumb adduction (moving the thumb toward the hand) and thumb flexion (bending the tip of the thumb).

The sesamoid bones lift the tendons and their attached muscles away from the joint to increase the mechanical advantage needed for smooth thumb motion. If the sesamoids are injured or starting to degenerate, they can be a source of severe pain and disability.

Normally, as the thumb bends, the sesamoid bones “track” or move up and down against the head of the thumb metacarpal (bone that forms the tip of the thumb). If the sesamoids do not track evenly on the center of the metacarpal head, the cartilage starts to wear unevenly and break down. That’s when inflammation develops around the sesamoid bones with eventual bone-on-bone pain from chronic sesamoiditis.

If moderate (or more severe) pain persists after conservative treatment, then one or two steroid injections might do the trick. If that doesn’t help relieve the pain, then the sesamoid bones can be surgically removed (in a procedure called sesamoidectomy).

In a recent study on the treatment of sesamoiditis for a series of 18 patients, half the group was pain free after one steroid injection. Five more patients achieved the same results after the second steroid injection. That’s a total of 13 out of 18 patients who were successfully treated with just steroid injections.

Sesamoidectomy was reserved for patients with significant degeneration in the metacarpal (thumb) bone that is above the sesamoids. Good to excellent results with pain free function of the thumb is possible with nonoperative care. Multiple steroid injections can cause thinning of the soft tissues and is not advised.

Starting with one injection (if all other avenues of conservative care have been tried fully) is the next step. You may still have to use a thumb splint off and on when the thumb is painful and/or you have to use it excessively. A hand therapist can also show you how to modify some of your sewing activities to reduce pressure on that joint. A strengthening program might be helpful, too. Even though you use your hands and thumbs for your work, there may be some weakness associated with this problem that is causing further pain or discomfort.

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. As you have probably experienced first hand, 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 finger. The contracture spreads to the joints of the finger, which can become permanently immobilized. The areas 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.

Surgery to release the cords has long been the standard treatment for this condition. But more recent research has resulted in this less invasive, less expensive method of treatment called an enzymatic fasciotomy. This type of injection therapy may eventually replace surgery.

Patients must be carefully selected for this treatment approach. For example, it can be used if only one or two cords are involved. And it is most effective when used early while the disease is still very mild. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken.

Most often the patient or the surgeon is able to break apart the cord the next day if spontaneous disruption does not occur. Just actively moving the fingers and using the hand are often enough to accomplish this.

A recent study involving almost 600 patients (total of 879 joints) with Dupuytren contractures from the U.S., Australia, and Europe may be of interest to you. They each had at least one injection of Xiaflex (the enzyme injected into the finger). Finger motion was used as the primary measure of improvement. Patient satisfaction was a secondary measure of success.

As with other studies already published, Xiaflex was shown to be very successful with 92 per cent of the group either quite satisfied or very satisfied with the results. Although the researchers were prepared to inject up to three injections per site, only 11 per cent needed three injections.

Three-fourths of the group responded well with the first injection and maintained those results for the nine month period of follow-up of this study. Contractures affecting motion of the metacarpal phalangeal (MCP) joints seem to respond better than cords that cross the proximal interphalangeal (PIP) joints.

There were a few adverse reactions that pointed to the need to study the safety of this treatment more carefully. A few patients had a local skin reaction (rash and swelling) at the site of the injection. Two patients developed serious blood clots. But no one had any tendon ruptures and only four per cent of the group had a recurrence of the problem.

This study expands the data base (number of patients) with Dupuytren contracture successfully treated with Xiaflex. Two factors that point to the likelihood of success include treatment early on (first predictive factor) for less severe contractures (second predictive factor).

The conclusion of the study was that xiaflex injections for Dupuytren contractures are safe and effective, especially if the contracture is not severe and is treated early. Complications can occur (most often in severe contractures) and patients should be aware of these potential problems before treatment. Most adverse events after treatment are mild and go away in 10 to 14 days.

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. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women.

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 finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

The areas 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.

Surgery to release the cords has long been the standard treatment for this condition. But more recent research has resulted in a less invasive method of treatment called an enzymatic fasciotomy. It sounds like this is the type of injection therapy your drummer is thinking about having done.

By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Most often the patient or the surgeon is able to break apart the cord the next day if spontaneous disruption does not occur. Just actively moving the fingers and using the hand are often enough to accomplish this.

There are a few adverse reactions that can develop. Local skin reaction (rash and swelling) can occur at the site of the injection. Blood clots, tendon ruptures, infections, and nerve damage are some examples of problems that can develop afterwards as a result of the treatment.

Most adverse events after treatment are mild and go away in 10 to 14 days. Patients probably won’t need hand therapy after the injection treatment but may need to wear a splint at night for a few months.

You are correct that the use of this collagenase enzymatic product known as Xiaflex is a relatively new treatment for Dupuytren’s contracture. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the patient can stretch the fingers and break apart the cord himself/herself.

Early studies showed a good success rate in reducing contractures affecting the metacarpophalangeal (MCP) joints using this injection treatment. The MCP joints are what we usually refer to as the “knuckles.” Almost everyone treated this way has been able to straighten the MCP joints with less than a 30-degree flexion contracture. Results have not been quite as good for the PIP joints. Less than half of the patients with PIP contractures regained full motion of the affected joint.

Some of the first long-term studies have started to release the results of their data analysis. Thirty-seven hand surgeons from around the world have worked together over a period of years to gather information on the long-term results of using collagenase injection for Dupuytren’s contracture.

They recently published a report summarizing their findings using recurrence rate as the main measuring stick for success/failure. Of the 1,080 joints treated with collagenase injection, the long-term results (after three to five years) measured by recurrence rates with enzyme fasciotomy were not quite as good as responses in the short-term.

For example, one-third of the MCP joints and two-thirds of the proximal interphalangeal (PIP) joints that were corrected had a recurrence. And of the joints that were only partially corrected in the first study, half had a worsening in the years to follow.

Recurrence was defined as a 20-degree (or more) flexion contracture (finger won’t straighten and remains flexed by at least 20-degrees). These are fingers that were able to straighten within five degrees of normal after the injection.

Adverse effects of this injection treatment for Dupuytren’s contracture are minimal and in the long-term, nothing worse than recurrence occurs. This was true even when up to eight injections were used and bloodworm showed antibodies in response to the collagenase. No systemic allergic reactions occurred.

The authors concluded that the treatment is safe and effective for mildly involved joints. Their study will continue on and collect further long-term information. The treatment is certainly worth a try if it can prevent patients from having surgery. Results are not as good with PIP joints but repeat injections or even surgery are always follow-up options.

It sounds like you have been treated with collagenase enzymatic injection for Dupuytren’s contracture. This type of hand problem is a fairly common disorder of the fingers. The condition usually 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 areas affected most often are the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. The MCP joints are what we usually refer to as the “knuckles.” As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The PIP joints are the middle joints you mentioned.

The development of this less invasive method of treatment called enzymatic fasciotomy is being used with mild to moderate cases. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the patient can stretch the fingers and break apart the cord himself/herself. Many (but not all) patients are able to avoid surgery with this treatment.

Early studies showed a good success rate in reducing MCP contractures using this injection treatment. Almost everyone treated this way was able to straighten the MCP joints with less than a 30-degree flexion contracture. Results were not quite as good for the PIP joints. Less than half of the patients with PIP contractures had regained full motion of the affected joint.

A recent study involving 37 surgeons around the world and 1,080 joints treated with collagenase injection has given us some good feedback. The long-term results (after three to five years) measured by recurrence rates with enzyme fasciotomy were not quite as good as responses in the short-term. For example, one-third of the MCP joints and two-thirds of the PIP joints that were corrected had a recurrence. And of the joints that were only partially corrected in the first study, half had a worsening in the years to follow.

Recurrence was defined as a 20-degree (or more) flexion contracture (finger won’t straighten and remains flexed by at least 20-degrees). These are fingers that were able to straighten within five degrees of normal after the injection.

Adverse effects of this injection treatment for Dupuytren’s contracture are minimal and in the long-term, nothing worse than recurrence occurs. This was true even when up to eight injections were used and bloodworm showed antibodies in response to the collagenase. No systemic allergic reactions occurred.

The authors concluded that the treatment is safe and effective for mildly involved joints. Their study will continue on and collect further long-term information. The treatment is certainly worth a try if it can prevent patients from having surgery. Results are not as good with PIP joints but you still have the option of a series of repeat injections (or even surgery if that fails).

A recent study of 300 patients treated for trigger finger and carpal tunnel syndrome was done looking for a direct link between the two. In fact, they found that patients with more than one trigger finger were three times more likely to develop carpal tunnel syndrome in the same hand as someone with only one trigger finger.

Though you didn’t ask specifically about trigger finger, the study is important in answering your question. They also looked at other factors that might be linked with carpal tunnel syndrome. Age, sex (male versus female), and tobacco use were evaluated as possible risk factors. Rheumatoid arthritis, gout, and the presence or absence of thumb osteoarthritis were also examined.

The most common risk factor for carpal tunnel syndrome was diabetes. And now according to this list, we can add trigger finger to that list. But these other variables (gout, tobacco use, age, sex, and thumb arthritis) were not found to be statistically significant.

Knowing the anatomy of the carpal tunnel is helpful when looking at other hand problems that might come before or after carpal tunnel as a part of the whole picture. The carpal tunnel is created by the wrist bones forming an arch around the soft tissues of the wrist (e.g., around the ligaments, nerves, blood vessels, fascia, tendons).

Anything that decreases the space in the tunnel for these soft tissues can put pressure on the median nerve resulting in wrist and hand pain, numbness, and tingling common symptoms of carpal tunnel syndrome. It may be that thickening of the synovium (fluid and lining around the tendons) that causes trigger finger is a contributing factor to carpal tunnel syndrome.

Patients with trigger finger also have thickening of the fibrous cartilage around the pulley system that helps the flexor tendons move the fingers. This pathologic change in the anatomy may help explain why carpal tunnel syndrome follows the formation of trigger fingers. More study is really needed to understand the full implications of the anatomy and pathology that leads to combined hand conditions such as osteoarthritis of the thumb, trigger finger, and carpal tunnel syndrome.

Yes! A recent study of 300 patients with carpal tunnel syndrome showed a direct link between the number of trigger fingers a person had and the risk of carpal tunnel syndrome. In fact, they found that patients with more than one trigger finger were three times more likely to develop carpal tunnel syndrome in the same hand as someone with only one trigger finger. With three trigger fingers AND carpal tunnel syndrome, it is likely that you have something going on to explain both.

Hand surgeons have noticed for a long time that many patients with trigger finger often had carpal tunnel syndrome first. They naturally wondered if there was a direct connection between trigger finger and carpal tunnel syndrome.

And according to this study, 41 per cent of the patients with multiple trigger fingers also had carpal tunnel syndrome. Only 16 per cent with single trigger finger presentation had carpal tunnel syndrome. And as the number of trigger fingers increased (from one finger to four), the incidence of carpal tunnel also increased.

Once the link between multiple digit trigger fingers was established, the authors turned their attention to the possible reasons for this connection. The carpal tunnel is created by the wrist bones forming an arch around the soft tissues of the wrist (e.g., around the ligaments, nerves, blood vessels, fascia, tendons).

Anything that decreases the space in the tunnel for these soft tissues can put pressure on the median nerve resulting in wrist and hand pain, numbness, and tingling common symptoms of carpal tunnel syndrome. It may be that thickening of the synovium (fluid and lining around the tendons) that causes trigger finger is a contributing factor to carpal tunnel syndrome.

Patients with trigger finger also have thickening of the fibrous cartilage around the pulley system that helps the flexor tendons move the fingers. This pathologic change in the anatomy may help explain why carpal tunnel syndrome follows the formation of trigger fingers. But the exact relationship has not been completely uncovered just yet. More study is needed to understand the pathoanatomic relationship between trigger finger and carpal tunnel syndrome.

You may have seen a flowchart meant to help someone make an important or difficult decision. Physicians use this same idea when examining patients and determining the best treatment approach. For example, they might think “if this symptom is present, then I will order this test — or if the patient reports this is how he or she got hurt, then my treatment will be XYZ.” That type of decision-making process is referred to as a flowchart or algorithm.

In a recent article, hand surgeons from Mayo Clinic in Rochester, Minnesota reported on the algorithm they use to evaluate and treat skier’s thumb. Skier’s thumb refers to a tear or rupture of the ulnar collateral ligament (UCL) of the thumb.

The UCL is damaged when a sudden force is placed on the thumb. Usually this occurs when the hand is wrapped around a ski pole and the pole comes to a sudden stop but the skier does not.

The evaluation and treatment algorithm starts with a suspected UCL injury. The next step is a physical exam and X-rays. The X-rays may show some obvious damage such as joint laxity (looseness) or bone fracture. That result would require different follow-up than if the X-rays are suspicious but not clear. Unclear or “equivocal” findings require further testing such as stress X-rays, ultrasound, or MRIs.

Once the surgeon is able to make an accurate diagnosis, then the algorithm can be used again to determine the best treatment for each patient. For example, a complete rupture of the ulnar collateral ligament would mean surgery to repair the damage.

An incomplete rupture could possibly be treated with a splint on the thumb and hand. Such a splint would immobilize the joint for six weeks. Following treatment of any sort, hand therapy to rehabilitate the thumb would be the last step. Once motion, strength, and function were returned, the patient would be discharged from further treatment.

Of course, in many cases, the algorithm isn’t really that simple. There are different approaches to take when performing the surgical repair or reconstruction. Which way to go depends in part on how old the injury is. Acute (early) injuries will be surgically repaired differently than chronic (old) injuries.

Sometimes acute injuries treated conservatively (without surgery) can become chronic problems. Later those chronic problems require surgery and that’s another decision tree (algorithm). Whenever possible (for acute and chronic injuries), the surgeon tries to perform a primary anatomic repair (i.e., put the ligament back where it belongs. That isn’t always possible, especially if the ligament ruptured and snapped way back away from the bone where it should attach. Over time, the torn soft tissue tightens up so it can’t be pulled back to its insertion site on the bone.

More complex ligamentous procedures involve tendon transfers or tendon grafts to actually reconstruct the torn ligament. This more involved surgery may be the only way to regain strength and stability of the joint. The goals of any surgery for UCL rupture are to reduce pain, improve motion, and restore function.

Algorithms go full circle in that the treatment choices are based on results of past treatment approaches. Good results using one method over another create changes in the flowchart. Optimal outcomes usually occur when a proper diagnosis is made and treatment is provided early on (before additional problems develop or the condition becomes chronic).

Most likely, your daughter’s injuries were severe enough to disrupt the ligament requiring surgical repair. She may have been given several different options and decided to choose this one.

Skier’s thumb (also known as gamekeeper’s thumb). The names skier’s thumb and gamekeeper’s thumb refer to the same injury: tear or rupture of the ulnar collateral ligament (UCL) of the thumb.

In the case of skier’s thumb (obviously the result of a skiing accident), the UCL is damaged when a sudden force is placed on the thumb. Usually this occurs when the hand is wrapped around a ski pole and the pole comes to a sudden stop but the skier does not.

With gamekeeper’s thumb, a repetitive force is placed on the thumb over and over again. This name was actually applied many years ago when Scottish gamekeeper’s killed wounded rabbits and other small game by breaking their necks. The repetitive force against the web space between the thumb and index finger eventually damaged the UCL.

As the description of gamekeeper’s thumb suggests, this isn’t a common cause of UCL rupture any more. But skiing accidents do still occur and this one is one of the most common hand injuries caused by a skiing accident.