FAQ Category: Hand

Your question is amazingly timely since there has been a recent study reporting on the use of a new splint that might be helpful. This is based on a single case report for use with a stiff, unmoving proximal interphalangeal (PIP) joint. But the results were dramatic and the reported benefits of the split far outweigh any disadvantages.

Here’s a brief summary of the case. A 49-year-old man involved in an all-terrain-vehicle accident suffered multiple injuries to the head, face, and fingers (including finger fractures). He also fractured his femur (thigh bone). By the time his finger fractures were healed (seven weeks later), he was left with a stiff PIP joint of the middle and ring fingers of his dominant (right) hand.

The splint used was a flexible, roll-on splint made of silicone. It was easy to get on and off and fairly comfortable so the patient was compliant in wearing it six to 10 hours a day. It did cause some swelling and discomfort at night, so it was only worn during the daytime hours. However, because he could bend the other joints, hand function was not severely limited.

And best of all, in 12 weeks’ time, the patient experienced significant improvements! He reported a decrease in pain and the therapists documented greatly improved motion, pinch and grip strength, and hand/upper extremity function.

A patent has been granted to the authors of this study (and makers of the splint). It comes in five sizes and has trim marks where the edges can be lopped off to fit the patient. A small opening in the tip of the splint makes it possible to visually inspect the patient’s skin for adequate circulation (color and temperature). For more information, you can email the lead author at the University of Pittsburgh Centers for Rehab Services: Ronit Wollstein, MD at wollsteinr@upmc.edu.

You may be referring to a recent case report published by a group of occupational therapists. They were treating one patient with proximal interphalangeal (PIP) joint contractures of the middle and ring fingers of his dominant (right) hand. The pain and stiffness in those joints were holdovers from immobilization for finger fractures following an ATV accident.

The authors designed the splint themselves and are in the process of further study in hopes of developing it for commercial use. They have been awarded a provisional patent. The splint is designed to stretch the joint by applying a dynamic, low-load over a long period of time. And the results? Excellent recovery after daily wearing for six hours over a period of three months.

The hand therapists treating this individual describe many advantages in using this new splint with only a few potential downfalls. Some of the benefits included:

Studies show that chronic injuries (repaired more than 30 days later) have the highest rate of postoperative complications. It’s easier for the surgeon to find the end of the torn tendon, pull it back to the bone where it belongs, and reattach it if the procedure is done before scar tissue and contracture (stiffness) occurs at the tendon/muscle interface.

A recent study of this matter conducted in Florida might provide you with some helpful information for your situation. Surgeons from four large orthopedic centers combined their research efforts to create a large patient data base. A total of 178 medical files of patients were reviewed. Each patient had a distal biceps tendon surgical repair. Only those patients who had a fracture, elbow dislocation, or traumatic laceration (cut) to the biceps were excluded from the study.

Information collected from the patient charts included age, sex (male or female), time between injury and surgery, surgical technique used, and post-operative complications. Anyone who had surgery 30 or more days after the injury was considered to have a chronic injury. Those patients who had surgical repair in the first 29 days after injury were labeled acute.

The problems that developed after surgery were divided into two categories: minor and major. Analysis of the information collected showed that slightly more than one-third (36 per cent) of all patients experienced some problems after surgery. Most of these were minor and temporary. Numbness from nerve injury and skin infections were the most common minor complications.

Major complications occurred much less often (eight per cent of the total) and included more serious nerve injury, painful heterotropic ossification, and rerupture. Heterotropic ossification refers to the formation of bone tissue in the tendon and muscle causing stiffness, loss of motion, and pain. Most of the reruptures were caused by trauma because of patients who did not follow the surgeon’s instructions.

Although there were five different surgeons who did the surgeries, there were no significant differences in results from one to another. The number of complications was the same no matter what surgical approach or technique was used. Patients with chronic injuries had slightly higher rates of postoperative problems.

We don’t know your circumstances (e.g., whether the injury was acute or chronic, extent of the injury, your level of compliance after surgery) but these could be factors in your results. Based on the study we mentioned, there’s no evidence that the surgeon’s level of experience or expertise contributed in a negative way to the results of surgery.

Surgeons do everything they can to prevent problems or complications from developing after surgery of any kind. In the case of distal biceps tendon ruptures, if it looks like the procedure is too risky due to the possibility of damage to nearby blood vessels and nerves, then the surgeon might advise the patient to avoid surgery and treat the problem conservatively.

Since you have already had the surgery, the best approach is to follow your surgeon’s advice carefully. With time and sometimes additional surgery and/or a rehab program supervised by a hand therapist, patients do regain function. Many cases of nerve damage are temporary with full recovery possible.

As your granddaughter indicated, the treatment of carpal tunnel syndrome has changed quite a bit from 25 years ago. This information comes from a new study done by the American Society for the Surgery of the Hand (ASSH). They sent email questionnaires to all of their members (a total of 1,463) and compared the answers to the same questions sent out 25 years ago.

The goal of the study was to see how clinical practice has changed in the last 25 years. That is a little bit longer than the time you’ve been away from practice but should still give you the general idea of what’s going on.

One of the major changes in the way CTS is managed today is the increased use of conservative (nonoperative) care over a longer period of time. Surgery is still a treatment choice, but it takes a back seat to activity modification, antiinflammatory medications, hand therapy with a physical or occupational therapist, splinting, and possibly steroid injections.

If after a lengthy period of time (at least three months), there has been no (or minimal) change in symptoms, then surgery to release pressure on the median nerve may be advised. Surgery today is more likely to be done without an open incision using an endoscope. Choice of anesthesia has shifted from regional blocks to local anesthesia with sedation.

Today’s surgeon is less likely to use sutures deep within the carpal tunnel and less likely to inject corticosteroids into the tunnel during surgery. Only about one-third of the surgeons prescribe antibiotics before surgery to prevent infection.

Current clinical practice guidelines recommend electrodiagnostic tests before doing carpal tunnel surgery. This test confirms that the median nerve is compromised and that the problem is indeed coming from pressure (or compression) on the nerve in the carpal tunnel.

As you know, this is important because carpal tunnel symptoms can develop with pressure on the nerve anywhere from the neck down to the wrist. Releasing soft tissue structures in the wrist will not alleviate the symptoms if the problem is really coming from above (e.g., the neck or elbow).

After surgery, fewer surgeons apply a splint to the patient’s arm. In fact, half as many practice this approach compared with 25 years ago. The surgeons surveyed this time indicated that their expected outcomes are for patients to experience pain relief fully with gradual return of normal sensation, movement, and strength.

One of the biggest changes observed from 25 years ago to the present time is a narrower gap in treatment practices and opinions on the management of this problem. This finding may be as a result of The American Academy of Orthopaedic Surgeons’ published guidelines on the treatment of carpal tunnel syndrome. These guidelines reflect current research evidence and may have influenced many of today’s practicing hand surgeons who are treating carpal tunnel syndrome.

There is nothing that says you can’t go to both for an evaluation and their recommendations and then decide. If you get two completely separate suggestions, you can see a third surgeon for some additional input. Although carpal tunnel surgery is fairly simple as surgical procedures go, it is still your wrist and hand and it is still surgery. No one will fault you for being cautious in your decision-making.

We can tell you some of the changes that have occurred over the past 25 years in the management of carpal tunnel syndrome. That might help you evaluate any advice or recommendations you receive. This information comes from a study done by sending an email survey to the members of the American Society for the Surgery of the Hand (ASSH).

One of the major changes in the way CTS is managed today is the increased use of conservative (nonoperative) care over a longer period of time. Surgery is still a treatment choice, but it takes a back seat to activity modification, antiinflammatory medications, hand therapy with a physical or occupational therapist, splinting, and possibly steroid injections.

If after a lengthy period of time (at least three months), there has been no (or minimal) change in symptoms, then surgery to release pressure on the median nerve may be advised. Surgery today is more likely to be done without an open incision using an endoscope. Choice of anesthesia has shifted from regional blocks to local anesthesia with sedation.

Today’s surgeon is less likely to use sutures deep within the carpal tunnel and less likely to inject corticosteroids into the tunnel during surgery. Only about one-third of the surgeons prescribe antibiotics before surgery to prevent infection.

In keeping with current evidence and recommended clinical practice guidelines, 85 per cent of the group that responded order electrodiagnostic tests before doing surgery. This test confirms that the median nerve is compromised and that the problem is indeed coming from pressure (or compression) on the nerve in the carpal tunnel.

This is important because carpal tunnel symptoms can develop with pressure on the nerve anywhere from the neck down to the wrist. Releasing soft tissue structures in the wrist will not alleviate the symptoms if the problem is really coming from above (e.g., the neck or elbow).

After surgery, fewer surgeons apply a splint to the patient’s arm. In fact, half as many practice this approach compared with 25 years ago. The surgeons surveyed this time indicated that their expected outcomes are for patients to experience pain relief fully with gradual return of normal sensation, movement, and strength.

One of the biggest changes observed from 25 years ago to the present time is a narrower gap in treatment practices and opinions on the management of this problem. In other words, surgeons today are practicing more consistently in the same manner than in previous years. Hopefully, you won’t find much difference between surgeons consulted, thus making your decision easier.

It might surprise you to know that over six million American families have a pet bird. And as you have discovered (and probably knew all along), a bird bite can do some serious damage to those they bite — even causing bone fractures and amputation of fingers!

Infection from bird bites is probably the biggest concern. Birds carry many of the common bacteria we are exposed to in our environment such as E. coli, Samonella, and Staphylococcus. But they also can transmit to humans (through bites and scratches) Lactobacillus, Pasturella multocida, and Proteus.

Treatment in a hospital setting is your best insurance against complications or problems following a bite severe enough to take the tip of the finger off. The finger was probably irrigated and debrided (cleaned). An antiobiotic is always prescribed with such injuries. And lab tests will be done to follow-up, making sure no systemic infection develops.

Long-term studies reporting the results of treatment for bird bites are lacking in the medical literature. Early treatment in a healthy child usually results in good to excellent results. But domestic bird bites can be very serious and pose a real health threat. The best advice is for your niece to follow all of the physician’s recommendations and to go to the follow-up appointments.

Preventing infection and saving the finger are the priorities. Teaching children not to put their fingers into a bird cage is also a good idea. You might think that this experience would be enough to put an end to this kind of behavior (child) and response (bird). But it doesn’t always work out that way. Don’t take chances. If necessary, cover the bird’s cage whenever you have visitors (adults and children).

Like all domestic animals, birds come with a variety of interesting problems. Besides the mess that they can make and parasites they carry, as you have recently found out — they also bite! And those beaks are designed for crushing seeds and berries. So they can do some serious damage to those they bite. Infection can develop if the skin is broken because birds carry many of the common bacteria we are exposed to in our environment such as E. coli, Samonella, and Staphylococcus. But they also can transmit to humans (through bites and scratches) Lactobacillus, Pasturella multocida, and Proteus.

And those bites can be strong enough to break a finger bone or even amputate a finger! Bird owners, family members, and helpful friends don’t have to worry about getting rabies from a bird bite — domestic birds don’t carry rabies. And except for training the bird not to bite (good luck with that!), no further action (e.g., quarantine) is suggested after a bite.

Infection is a major concern after a bird bite severe enough to cut the skin open. All bites that break the skin should be irrigated and cleaned (debridement) in a
hospital or clinic setting; more severe injuries may require surgical debridement.

Antibiotics should be prescribed when the wound is severe enough to warrant them. A broad spectrum antibiotic is advised to cover many different types of organisms. Follow-up lab work to evaluate blood for systemic infection is also recommended; how long after the injury follow-up should continue is unknown. More specific antibiotics can be prescribed if lab testing shows the presence of a particular bacteria or if patients do not respond to the first antibiotic.

If the skin was broken and you haven’t been evaluated and treated for this problem, we advise medical follow-up with your family physician.

Kienbock’s disease is very rare in children though there are some individual reports among teenagers. It is a condition in which one of the small bones of the wrist (the lunate) loses its blood supply and dies, causing pain, swelling, and stiffness with wrist motion.

In the late stages of the disease, the bone collapses, shifting the position of other bones in the wrist. This shifting eventually leads to degenerative changes and osteoarthritis in the joint. It is not a life-threatening condition but it can create some problems.

Bone sclerosis (hardening), fracture, collapse, and arthritis are just a few of the things that can happen with this disease. The patient suffers from pain, loss of motion, and loss of function sometimes leading to disability.

In adults with Kienböck disease, the natural history (what happens over time) is not fully known or understood. For example, some people have severe symptoms with mild disease labeled stage 1 disease. Others can have no symptoms despite severe (stage 4 disease). And it is possible to have many different combinations in between those two extremes.

Treatment can range from conservative (nonoperative) care to any one of a number of surgical procedures. But the results are usually pretty good with relief of the painful symptoms and restoration of near normal strength and function of the wrist and hand. Of course, since there are so few cases among children and teens, all we have to rely on are case studies.

But younger patients who have not reached full bone (skeletal) maturity actually have some advantages over older adults with this condition. The body is still producing new bone growth and this can aid in recovery. The prognosis for your grandson is likely very good but you will have a better idea of what to expect once the surgeon has fully evaluated him and started treatment. Please let us know how he does!

If you would like more information on Kienböck disease in general, you can read our Patient Guide to Kienböck Disease.

Kienböck disease is a condition in which one of the small bones of the wrist (the lunate) loses its blood supply and dies, causing pain and stiffness with wrist motion. In the late stages of the disease, the bone collapses, shifting the position of other bones in the wrist. This shifting eventually leads to degenerative changes and osteoarthritis in the joint.

It’s the progression of this disease that concerns physicians and why treatment is recommended in most cases. Surgical procedures are usually recommended based on staging of the disease. Staging of any disease is a way to classify the condition based on severity. In the case of Kienböck disease, X-rays are used to determine each stage. The following is a brief summary of the stages.

It sounds like you are benefitting from a newer feature in treatment related to flexor pulley injuries: a pulley splint. This type of metal ring fits over the injured pulley and provides support during the rest period needed for healing. Rock climbers and fastball pitchers experience this type of injury most often and can benefit from these new pulley splints.

To help you understand the splint’s intended purpose, a brief anatomy lesson may help. The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys.

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

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

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

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

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

Other important ligamentous structures include the volar plates and flexor tendon pulleys. You’ll really impress your daughter if you ask about volar plates and tendon pulleys. The volar plate is the strongest ligament in the fingers. This ligament connects the proximal phalanx (finger bone closest to the palm) to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the proximal interphalangeal (PIP) joint from bending back too far (hyperextending). Finger deformities can occur when the volar plate loosens from disease or injury.

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

Five of the most common ligament injuries affecting the hand and fingers include: 1) thumb collateral ligament injury, 2) finger collateral ligament injuries, 3) volar plate injuries, 4) flexor pulley injuries, and 5) carpometacarpal (CMC) ligament. You could pick one or two of these and ask her if she has treated any of these injuries this week.

It might also help you if you understand a little bit more about how treatment decisions are made since your daughter will be making this kind of decision every day of her practice. Most of the time, only severe injuries will require surgery to repair or reconstruct torn or damaged soft tissue (ligamentous) structures. Conservative (nonoperative) care is more often the case. When making treatment decisions, the surgeon takes into consideration the patient’s age, severity of injury, the presence of other injuries (e.g., bone fractures, joint dislocations), and how long ago the injury occurred.

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

Hopefully, this little primer will give you enough information to get you started. Once you get your daughter talking about her work, you may not have to say much else or ask any further questions until the next phone call! Good luck and let us know if you need more conversational “ammunition.”

Like many physicians, yours may wonder if a person who suffers from chronic neck, back, leg pain, or other nonhand pain have a successful surgery for carpal tunnel syndrome? That may sound like surgeons pre-judge patients just because they report chronic pain.

But research does show that people who are in chronic pain process pain messages differently from people who don’t have daily pain. And many physicians have treated patients who don’t seem to want to get better or who don’t seem to respond to anything except narcotic medications.

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

A recent study by hand surgeons from the Department of Plastic and Reconstructive Surgery at The Johns Hopkins University has shed some light on this subject. They compared the results of surgical treatment between two groups of patients who had a carpal tunnel release.

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

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

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

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

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

This is a very reasonable question and a concern raised by surgeons as well. The goal of carpal tunnel release surgery is to provide relief from painful (and other) symptoms. If doing the surgery will make things worse overall, then it’s time to consider the risks versus the benefits.

We have some information from a recent study at The Johns Hopkins University that might help you. They compared the results of surgical treatment between two groups of patients who had a carpal tunnel release.

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

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

As this study showed, the benefit of pain relief and return of hand function outweighed the possible risks of further drug addiction. The surgeons did suggest some strategies for pain management among chronic pain patients having carpal tunnel surgery. These may be of interest and help to you in your present decision-making process.

First, only the primary care physician (or pain specialist) should be in charge of prescribing and supervising your pain meds. The surgeon will give the necessary pain meds the day of the surgery and the day after surgery. But after that, any further medications must be under the care and coordination of your primary/pain physician. The overall plan should be discussed with all concerned including you, your surgeon, your primary care physician, and the pain specialist if one is involved.

It sounds like you may have some broken (fractured) fingers (metacarpal bones) but of course, you will have to wait for the attending physician to give you exact diagnosis and full details. Fractures of the metacarpals can affect the head, neck, or shaft of the bone.

The type of splint you are wearing (clam-digger) puts the wrist in a slightly extended (cocked up) position. This splint also holds the metacarpophalangeal (MCP) joints (big knuckles of the hand) in 90-degrees of flexion (bent). The rest of the fingers are straight. The clam-digger splint is usually used for metacarpal shaft (long portion of the finger bone) fractures.

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

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

Your description of a cage around the outside of the finger suggests a surgical method referred to as external fixation. External fixation (hardware is inserted through the skin and bone but located outside the finger). These devices are miniature in size and custom made. The advantage of this type of fixation is early motion while the fracture is still healing.

The use of external fixation for the little finger suggests the possibility of a Boxer’s fracture. This type of fracture affects the metacarpal bone of the little finger. It is the most common fracture of the metacarpal neck. As the name suggests, the “neck” is the area between the long shaft of the bone and the round knobby end (the “head”) that helps form the joint. With a neck fracture, the metacarpal head can poke out into the palm of the hand or rotate causing a deformity. That’s why it is carefully reduced (put back in its anatomic position) and held in place with hardware.

The full mystery of what happened to you might not be revealed. But you should be able to at least find out what type of injuries you have, what’s been done so far to treat them, and what to expect next.

Dupuytren’s contracture forms when the palmar fascia begins to thicken and tighten, causing the fingers to bend. The palmar fascia lies under the skin on the palm of the hands and fingers. This fascia is a thin sheet of connective tissue shaped somewhat like a triangle. It covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against the front of the fingers. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones.

The Dupuytren condition 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.

A partial palmar fasciectomy remains the “gold standard” surgical procedure, although at earlier stages of this disease a less invasive surgical procedure called a needle aponeurectomy may be done. One reason to have surgery done sooner than later is when the condition is painful.

Most people with Dupuytren disease don’t complain of pain. They are bothered much more by the loss of finger motion, especially extension (straightening the affected fingers). But sometimes the nodules that form are painful. A recent study showed that tiny nerve fibers in or across the fibrous tissue is the likely cause of painful symptoms. Early surgery to remove the nodules and nerve tissue within the fibrous tissue does put a stop to the pain.

Another reason to consider surgery is the loss of finger extension that can forms. The goal of surgery is to remove the diseased fascia, allowing the finger to straighten out again. By removing the tight cords and fascia, the tension on the finger is released. Once the fibrous tissue is removed, the skin is sewn together with fine stitches. Surgical treatment does not stop or cure this disease process, so recurrence is possible.

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

What you have discovered is correct — most people with Dupuytren disease don’t complain of pain. They are bothered much more by the loss of finger motion, especially extension (straightening the affected fingers). But sometimes the nodules that form are painful.

We can answer your question by referring to a study done in Switzerland. Surgeons there were wondering why this condition becomes painful for some patients. So they decided to investigate further. They also evaluated whether surgery would help (or make worse) painful symptoms in 10 patients.

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

Based on these findings, the surgeons suggested that nerve compression is the cause of painful Dupuytren disease. The fact that all patients were painfree after surgical removal of the tissue supports this theory. remains a mystery. More studies are needed to find out the exact cause why these 10 patients (and you) developed nerve branches inside the nodules and cords. Clearly, it is a problem that affects some, but not all, people with Dupuytren disease.

Dupuytren’s contracture is a fairly common disorder of the fingers. The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

Successful treatment usually requires invasive procedures such as steroid injections or surgical release of the fascia. There are known advantages and disadvantages for each approach. For example, percutaneous needle aponeurotomy (PNA) has few complications and a quick recovery time. Patients report little pain and improved hand function. But the recurrence rate is high. This procedure may be what you had that you refer to as “needle stripping”.

The procedure involves slipping a surgical needle under the skin and making multiple incisions along the fascia to divide the cord up. Soft tissue release is done until the patient’s finger can be fully straightened.

Surgery to slice the palm open and remove the diseased tissue has a lower recurrence rate compared with percutaneous needle aponeurotomy (PNA). But the open incision technique called dermofasciectomy leaves scars. Not everyone is a good candidate for dermofasciectomy. Older age and other health problems can prevent surgery from being an option.

Without a one-best-treatment approach, surgeons continue to look for ways to obtain patient satisfaction and low recurrence rate. In a recent study, one surgeon compared two different treatments for Dupuytren disease. One group of patients just had percutaneous needle aponeurotomy (PNA).

The second group had the PNA procedure followed immediately by injection of triamcinolone acetonide (TA). TA injections were repeated six weeks and three months after the first injection. TA injection is a type of steroid (antiinflammatory). The injections were placed right into the contracted (tight) cords caused by the Dupuytren disease.

Results were measured by comparing finger motion (extension) before and after treatment. Overall joint motion was better in the group who received the combined PNA procedure and TA injection. The joint most affected (in a positive or beneficial way) by this combined approach was the proximal interphalangeal (PIP) joint. The PIP joint is the middle knuckle of the finger.

Although this study only presented short-term results, there is limited evidence that TA injections may have the ability to provide long-term correction of joint contracture. Results were promising enough after six months to encourage further study using TA injections for Dupuytren contractures. This treatment may be something you will want to discuss with your surgeon as the next step to your painful, limited finger motion.

Studies have gone back and forth on the best way to prevent recurrence of the nodules that form with Dupuytren contracture. Reported recurrence rates are as high as 50 per cent. Successful treatment usually requires invasive procedures such as steroid injections or surgical release of the fascia.

Treatment is determined based on the severity of the contracture. The best course of treatment is determined by how far the contractures have advanced. There are two types of treatment for Dupuytren contracture: nonsurgical and surgical.

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

There is a minimally invasive method of treatment called an enzymatic fasciotomy available now. An enzyme in the form of a drug (Xiaflex) is injected directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the cords can be broken apart. This is used if only the metacarpophalangeal (MCP) joint (largest knuckle closest to the palm) is contracted, and there are only one or two cords involved.

Percutaneous needle aponeurotomy (PNA) is another type of treatment that involves slipping a surgical needle under the skin and making multiple cuts along the fascia to divide the cord up. Soft tissue release is done until the patient’s finger can be fully straightened.

Another approach is called palmar fascia removal or palmar fasciectomy. Surgery to slice the palm open and remove the diseased tissue has a lower recurrence rate compared with percutaneous needle aponeurotomy (PNA). But the open incision technique called dermofasciectomy leaves scars. Not everyone is a good candidate for dermofasciectomy. Older age and other health problems can prevent surgery from being an option.

Your surgeon is really the best one to advise you what to do next. Having some knowledge of the various options may help you in finding the best choice for you now that you’ve had some initial treatment and have experienced your first recurrence of the condition.

There is some evidence that some patients with diabetes and trigger fingers have more trouble keeping tight control on their blood glucose (sugar) when injected with steroids. And since hand problems like trigger finger are common with diabetes, this information is important to pay attention to.

The effect of steroid injections is to reduce inflammation, which would also reduce (and possibly eliminate) pain and the nodules that form around the tendons. A recent study was done in Malaysia to compare treatment of trigger finger with injectable steroids versus injectable nonsteroidal antiinflammatory medication. Two groups of patients were compared: those with diabetes and those without diabetes.

They did find that although the early results (after three weeks) were better with the steroid injections, the later results (after three months) were the same between the two groups. These two types of injections have different ways in which they work but they do both provide the same pain relief and decrease in inflammation.

Patients with diabetes who develop trigger fingers can be treated effectively with injections that don’t affect glucose (blood sugar) levels. They get the same benefit as with steroid injections (that do affect blood sugars) — just at a slightly slower rate. In other words, steroids work faster but changes with NSAIDs catch up by the end of 90 days.

Trigger finger is a condition affecting the movement of the flexor tendons as they bend the fingers toward the palm of the hand. This movement is called flexion. Triggering is caused by a mismatch between the size of the tendon with its covering or lining (called the tendon sheath) and the pulley system the tendon and its sheath glide through.

The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium.

The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule. This inflammation and swelling of the tendon sheath or the pulley leads to pinching of the tendon. The tendon fibers start to bunch up causing a nodule to form.

Symptoms of trigger finger include pain and a funny clicking sensation when the finger is bent. The clicking sensation occurs when the nodule moves through the tunnel formed by the pulley ligaments. With the finger straight, the nodule is at the far edge of the surrounding ligament.

When the finger is flexed, the nodule passes under the ligament and causes the clicking sensation. If the nodule becomes too large it may pass under the ligament, but it gets stuck at the near edge. The nodule cannot move back through the tunnel, and the finger is locked in the flexed trigger position. Pain occurs when the finger is bent and straightened. Tenderness occurs over the area of the nodule.

People with diabetes often develop hand problems because of the effect of elevated sugar in the blood (elevated blood glucose). Glucose deposits along the tendons and ligaments result in loss of flexibility and rigidity.

Flexor tenosynovitis (also called chronic stenosing tenosynovitis) is one of those problems seen more commonly in persons with diabetes. Tenosynovitis is caused by accumulation of fibrous tissue in the tendon sheath and can cause aching, nodularity along the flexor tendons, and contracture.

Trigger finger can occur in flexion or extension with tenosynovitis and may be associated with crepitus or pain. In the population with diabetes, tenosynovitis is found predominantly in women and affects the thumb, middle, and ring fingers most often.