FAQ Category: Hand

As you well know, musicians often spend quite a bit of time in awkward positions. The pianist may get in the habit of slouching or hunching over the keyboard. Some piano music requires the pianist to stretche the fingers beyond theirn normal range to reach more keys. Holding both hands over the keyboard using the fingers, wrists, forearms, and upper arms repetitively during long hours of practice can lead to problems eventually.

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

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

You may be experiencing symptoms associated with a condition called thoracic outlet syndrome (TOS). TOS involves the compression of nerves and blood vessels in the neck area. Muscles that contract fiercely and repeatedly can clamp down on these soft tissues and cut off circulation to the muscles. This same type of compression puts pressure on the nerves causing numbness, tingling, and sharp pains. Poor posture can be a big factor but obesity and being female are other possible risk factors.

Technical retraining helps the musician identify, recognize, and stop using postural and motor patterns that have contributed to the problem. Usually, a hand therapist (physical or occupational therapist) is the expert who addresses these problems. Reducing the number of hours played, paying attention (and correcting) posture, and use of pain relievers can be tried, too.

Alignment and posture can be addressed. In some cases, the instrument can be modified to unload pressure and reduce fatigue and compression. With the piano, the piano itself isn’t changed but the seating may be altered. Sometimes just practicing for shorter periods of throughout the day and taking more frequent breaks is enough to allow for healing and recovery.

The therapist will work with the patient as he or she plays the instrument and provide technical retraining.Stretching, range-of-motion exercise, and strengthening are important aspects of conservative care. In the case of thoracic outlet that does not respond to conservative care, surgery may be needed. No musician likes to hear that word but sometimes something as simple as shaving a rough edge of a bone or removing a rib may be all that’s needed.

Dystonia, motor dystonia, and focal dystonia are all similar terms to describe a condition of cramping just like “writer’s cramp.” Muscles of the fingers and hands contract and don’t let go causing twisting and abnormal positioning that prevents the musician from playing his or her instrument.

This condition affects pianists, violinists, and woodwind (e.g., flute, clarinet, saxophone) players most often. There may be a genetic predisposition to the condition but in most cases involving musicians there is an element of repetitive overuse. Stiffness, cramping, and involuntary movements seem to come on slowly at first.

These symptoms often only occur while playing the instrument. The symptoms disappear when the person is at rest. This phenomenon can make it appear as though there is an emotional or psychologic cause (i.e., the person doesn’t really want to play), but this is not the case most times.

With retraining and sometimes a little medical help (e.g., Botox injections, anticholingergic medications), a more normal motor pattern can be re-established. Deep brain stimulation is a newer treatment for this problem that is under investigation. Since there may be excessive excitability in some areas of the brain, this approach may provide another safe and effective treatment option.

Don’t beat yourselves up for applying a little home therapy first. It’s a natural response to what may have seemed like a small injury. But as you have discovered, traumatic cuts can lead to infection affecting the flexor tendon sheath (lining) of the fingers.

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

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

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

Not all four signs have to be present to point to a flexor sheath infection. The two most common findings are tenderness along the sheath and pain with passive extension. It sounds like your husband may indeed have these two symptoms. Patients with other causes of similar symptoms will not have the Kanavel signs associated with flexor tendon infections.

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

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

There is the potential for loss of a finger, which is why early and quick diagnosis and treatment are required. Even without the more serious complications, up to one-fourth of all patients with flexor tendon sheath infections lose their ability to straighten the affected finger. You are in the right place now to get the treatment your husband needs. Take it one step at a time!

Despite the small size of a finger infection, the medical consequences can be extreme. Anyone presenting with a red, tender or painful, swollen finger following trauma should be evaluated carefully. Treatment may begin with nonoperative care but must be quickly replaced with surgery if results are not seen within the first 24 to 48 hours.

Since you are receiving hand therapy and having trouble straightening your finger, it sounds like you may have been initially treated for a flexor tendon sheath infection. Complications are always a possibility after any traumatic injury but especially after one that leads to a flexor tendon sheath infection.

Adhesions, joint capsular thickening, and destruction of the tendon pulley system by the infection can leave you with a permanently stiff finger. Even without the more serious complications, up to one-fourth of all patients with flexor tendon sheath infections lose their ability to straighten the affected finger.

Hand therapy to maximize finger motion is a good idea. Even with therapy and carrying out your home program every day faithfully, there is still a chance you might not regain your full finger motion. Studies show that anyone with diabetes is at increased risk for this type of infection and possibly a less than favorable result. Other risk factors include age over 43, kidney or peripheral vascular disease, loss of blood supply to the area, and multiple bacteria present at the same time.

You may have developed something called a fistula. A fistula is an abnormal channel or passageway between two places that normally do not connect. In the case of a hand injury like you describe, the tract could be from the lining around a tendon out through an opening you see in the skin. The opening between these two places allows synovial fluid from inside the lining of the tendon to escape through a hole in the palm.

This is a rare problem but one that other patients report causes a frothy fluid to drain from an opening called the sinus in the palm. The skin around the sinus may soften and start to break down causing the skin to develop a maceration. Pain, loss of motion, and decreased strength may occur.

Treatment for the problem may be conservative (nonoperative) with antibiotics and immobilization in a splint. But if the fistula does not heal and the problem continues, then surgery may be needed.

The surgeon may have to remove the entire tract that forms the fistula including the skin around the fistula’s opening. A skin graft to cover the opening may be needed for successful wound closure. Just removing the fistula and closing the opening does not work. The quality of the macerated skin around the opening does not allow that area to be used. Complete healing of the fistula requires fresh, undamaged skin.

Your problem may be more simple than what we just described. The first and best thing to do is see a hand surgeon. A proper evaluation and diagnosis are the most important parts of getting treatment started. Even though the opening is only pinprick size, it’s best to get this looked at sooner than later — especially before a deep (unseen) infection develops.

Fistulas of the palm are very rare so we are relying on the report of a hand surgeon from the Southern Illinois Hand Center who treated 15 patients with this type of problem. All had either an injury to the palm or surgery with incision for trigger finger and steroid injections as the reason(s) or cause(s) allowing the problem to develop.

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

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

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

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

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

Eventually the scar tenderness went away. Thickening of the scar was still present but expected to slowly resolve over time. A hand therapist may be able to do some scar mobilization to aid in the process. If the problem does not resolve (or at least seem to be slowly getting better), see your surgeon again for a follow-up evaluation and suggestions.

There are some potential complications with wrist fractures that can cause serious problems later. This is true even with nondisplaced fractures. One of those complications is a rupture of the extensor pollicis longus (EPL tendon). This tendon helps move both the tip of the thumb and the wrist, so damage to it can impair function of the hand.

There are reports of how often this tendon rupture occurs after radial wrist fractures. Up to five per cent of patients with a radial wrist fracture later develop an EPL tendon rupture. X-rays can be used to look at the angle and height of the radial bone as well as the alignment of the wrist joint

But X-rays do not show much if anything about the soft tissues around the break. And that’s where CT scans come into play. When the force that breaks a bone is not enough to rip or tear the soft tissues around the bone, complications like the tendon rupture can occur later. This is because the tendon is held tightly against the bone. The fracture results in swelling, bleeding into the area, and the formation of a bone callus as healing takes place.

All of these events decrease the space around the tendon and put pressure on the tendon. The EPL tendon in particular doesn’t have a very good blood supply to its own tendon sheath (outer protective covering). Anything that disrupts this area can reduce blood flow and nutrition causing avascular necrosis. Avascular necrosis means death of the tissue due to loss of blood. The end result is rupture of the tendon.

More advanced imaging studies like CT scans help identify other problems that are either developing or already present. The surgeon treating your mother may have had an inkling that something else was going on — either from the type of injury or from the clinical presentation.

You can always ask for an explanation for a procedure (either before it is done or even afterwards). Preventing complications and/or treating them early on is possible with the information CT scans provide. And that could prevent a lot of suffering for some patients with unknown soft tissue damage.

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

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

Grip and pinch strength are especially affected by this problem. But it doesn’t come just from holding and playing cards. Degenerative arthritis is a condition in which a joint wears out, usually slowly over a period of many years.

Injury to a joint, such as a bad sprain or fracture, can cause damage to the articular cartilage. An injury to any joint of the thumb, even if it does not injure the articular (joint) cartilage directly, can alter how the joint works. These injuries can change the way the joint moves. The injury may increase the forces on the articular cartilage surfaces. This is similar to any mechanical device or machinery. If the mechanism is out of balance, it tends to wear out faster.

Women are three time more likely than men to develop arthritis of the CMC joint. There are several reasons for this. Women have higher amounts of certain hormones that are linked with joint laxity (looseness). There are also some anatomic differences in the joint surfaces between men and women. Increased joint motion from laxity combined with differences in the shape and surface of the bones add to the risk of thumb arthritis in women.

Adults with increased body mass index (BMI) are also at risk for CMC arthritis. There are two possible reasons for this relationship. First, increased mechanical loading seems to occur at the CMC joint in obese adults. This is true even though the thumb is not a weight-bearing joint. Over time, increased load translates into wear and tear on the joint.

Second, patients with a higher body mass index also have elevated levels of lipids (fats), hormones, and insulin-like growth factor around the joint. Local biochemical changes from these hormones may speed up joint degeneration.

The more risk factors present in a single individual, the greater the likelihood of developing arthritis of the thumb, fingers, and hand. Playing cards or other repetitive activities or activities requiring hand grip are just a tiny component in the overall picture.

Management of the type of thumb deformity you describe (caused by arthritis) can be a complex challenge. Decision making between surgeon and patient becomes a collaborative process. The goal of surgery is to stabilize the joint and possibly bring the thumb into a more functional position. Both function and appearance can be improved. But which surgery to choose remains an unknown. Without evidence to show what works best, the choice of surgery is left up to the surgeon.

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

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

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

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

This is one problem you may not find complete agreement on. Each of the three surgeons you have consulted has given you the best advice he or she has based on clinical and surgical experience. You may have to work through this problem slowly until you find the choice that seems best for you.

Almost any type of splint or cast is going to be uncomfortable and somewhat inconvenient. The idea of immobilization is usually to give the arm a rest so the injured soft tissues can heal. Taking load and stress off the area helps prevent microtrauma that could delay recovery.

Preventing motion of the forearm, wrist, and hand certainly does restrict activity. And some devices are more restrictive than others. For example, a recent study showed when comparing casts to splints a definite difference in the amount of forearm motion that is allowed.

A long arm cast that includes the wrist and elbow is able to prevent forearm rotations (turning the palm up and down) better than any other method. Other immobilizers such as a short arm cast or removable splints reduced the amount of forearm rotation by about 60 per cent but did not eliminate these motions.

The short arm splint allowed the most amount of forearm rotation (more than half the normal range-of-motion). Splints also come in different ways — some are prefabricated and one-size-fits-all, whereas others are custom-made to mold to the individual perfectly.

There may be a better type of prefabricated (off-the-shelf) splint that would work better for you than the one you have. Or it’s possible you will just need to put up with the discomfort and inconvenience long enough to foster healing. It’s possible the nurse practitioner who saw you and knows the condition of your arm/hand may have some practical suggestions. A phone call to the clinic may help you sort out what your options are.

Carpal tunnel syndrome (CTS) is a fairly common problem in adults, affecting people of all ages from young to old. Symptoms of wrist and hand pain, weakness, numbness, and/or tingling can be annoying and even very disabling.

Many people are helped by conservative means with antiinflammatory medications, splinting, and hand therapy. But for those whose symptoms just don’t go away, surgery is needed to release the soft tissues that cross over the carpal tunnel and put pressure on the nerve.

In up to 20 per cent of those patients, the symptoms are unchanged or only slightly less. A little more hand therapy combined with antiinflammatory meds and special exercises and the problem is solved — for most of those patients. But in about five per cent of all cases, a second revision surgery is required.

Studies have found that whereas those electrodiagnostic tests are very useful to confirm the diagnosis of nerve compression, they are less helpful after surgery. The tests include nerve conduction velocity (measuring speed of signals along the nerve) and electromyography (checking to see if the nerve signals are reaching the muscles).

As your surgeon has pointed out, these tests are not useful with patients who have recurrent carpal tunnel syndrome. Studies show electrical changes can continue even after a successful primary carpal tunnel release. So the tests don’t offer additional useful or valuable information when facing the decision of a second surgery.

There has been some suggestion of trying steroid injection into the carpal tunnel before doing a second surgery. The hope is to find a way to predict who will have a successful response to surgery before doing the procedure. At least one study showed the steroid injection can aid in screening patients for surgery. But by itself, it isn’t completely reliable. The surgeon’s evaluation combined with a test injection offers more valuable predictive information and may be used instead of repeating electrodiagnostic tests.

You are not alone in facing this dilemma. One out of every five patients who has a carpal tunnel release reports that symptoms of pain, weakness, numbness, and/or tingling are still present years later. A second operation might be helpful.

In fact, about five per cent of the patients who are left with residual symptoms do end up having a second or revision surgery. And studies show that the second surgery is not always successful — statistics show the revision carpal tunnel release is less likely to help if the first surgery was not a success.

So the question comes up: is there some test or some way to predict who might benefit from a second surgery? Surgeons are studying this problem with a few good results. For example, some studies have been done to show that steroid injection into the carpal tunnel before the primary (first) surgery is a good predictor of symptom improvement after surgery. Could this same approach be used after a failed first surgery before considering a second (revision) release?

Surgeons conducted another study to check this idea out. They injected the wrists of 23 patients (for a total of 28 wrists because a couple of people had carpal tunnel in both wrists). The patients involved ranged in ages from 29 to 85 years.

Some of the patients had symptoms 40 years after the first surgery. Everyone was carefully evaluated before injection. The surgeons wanted to make sure the persistent symptoms were really coming from pressure on the median nerve as it passed through the wrist bones forming the carpal tunnel.

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

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

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

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

With this information in the back of your mind, it might be a good time to make an appointment with an orthopedic surgeon or hand surgeon for a new evaluation. Once the surgeon completes his or her exam, you may have a better idea of what’s next. If revision surgery is recommended, consider asking about this technique of screening using a pre-operative steroid injection.

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

Given your interest in comparisons, you may find the results of a recent study helpful. In this study, outcomes of various treatments for basal thumb arthritis were investigated and compared with current trends in the treatment of this condition.

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

Surgeons from all regions of the United States participated with a wide range of experience. Half had been practicing less than 15 years; half had been practicing more than 15 years. Younger surgeons were more likely to recommend conservative care while the more experienced surgeons opted for trapeziectomy or trapeziectomy with ligament reconstruction. Steroid injection was favored by most (89 per cent) of the group.

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

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

You may be experiencing basal thumb arthritis if by acting up you mean there is pain, stiffness, and decreased pinch strength. These are symptoms often associated with degenerative changes of the trapeziometacarpal (TM) joint.

The trapeziometacarpal (TM) joint is at the base of the thumb where the metacarpal bone of the thumb connects to the trapezium of the wrist. This joint is also referred to as the CMC joint (an abbreviation for carpometacarpal joint) of the thumb.

This is the joint that allows you to move your thumb into your palm, a motion called opposition. The TM or CMC joint is sometimes referred to as a universal joint because of the wide range of movements possible.

Treatment usually begins with conservative (nonoperative) care. This could include splinting, exercise, antiinflammatory medications, and steroid or hyaluronate injections. A recent survey of active surgeons from the American Society for Surgery of the Hand showed only a small number of surgeons (four per cent) used the more recent treatment of hyaluronate injections.

The use of hyaluronate for the thumb has not yet received approval from the FDA. Insurance doesn’t always cover this procedure and it costs more than steroid injections. Studies haven’t really shown a benefit of hyaluronate injection over steroid injection. These factors may explain why this treatment is not more popular.

Patients who fail conservative care as described may benefit from surgery. The simplest procedure is a trapeziectomy (removal of the trapezium bone). More advanced procedures include trapeziectomy with ligament reconstruction, arthrodesis (fusion), or arthroplasty (joint replacement).

But the first step for you is to get an accurate diagnosis. Your orthopedic surgeon can evaluate you and make recommendations based on clinical findings. X-rays may help identify the severity of changes in the joint. Your symptoms along with the objective clinical results will guide treatment.

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

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

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

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

Working in a meat packing plant may make it necessary to wear gloves over the finger splint. That is to keep the splint from catching on things creating another safety threat. The splint is something that can be made specifically for you given the type of movement you need at work. A hand therapist can modify an off-the-shelf splint or make a custom-made splint for you.

Sometimes just wearing the splint (during work and leisure hours) is enough to clear up the problem. Experts in the area of hand function and disease believe that resting the soft tissues of the finger give time for the trigger finger to resolve on its own. By changing the way the tendons pull around the joints, there is less inflammation and a chance for the tendon sheath to heal and recover fully.

But if conservative care doesn’t change anything for you (or not enough to make a difference at work), then surgery may be an option. The surgeon opens the pulley mechanism inside the finger that is keeping the tendon from sliding smoothly. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day.

The best thing to do is see an orthopedic or hand surgeon for an evaluation and treatment. The sooner you do this, the better your chances are for recovery without surgery. Even with surgery, the procedure is simple and the results effective.

Finger splints can be very helpful with trigger finger. They are meant to help reduce painful symptoms and stop the triggering effect. Splinting is a fairly inexpensive means of treatment. In some cases, cortisone injections are prescribed or a combination of injection with splinting is recommended.

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

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

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

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

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

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

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

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

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

The authors of this study concluded that the more comfortable MCP joint splint may be the best way to begin treatment for trigger finger. This does require seeing a hand therapist who can evaluate you and design a custom-made splint just for you. Factors the therapist must consider in selecting the best choice for each patient include symptoms, required work-related activities, and preferred leisure-time activities.

If you do not get enough pain relief using this splint, then the more restrictive DIP joint splint can be used instead. The hand therapist will keep an eye on joint stiffness and make necessary adjustments to make sure you are comfortable and able to use the hand effectively.

You raise an interesting point that has been recently studied. Surgeons at the Hand and Upper Extremity Department at Massachusetts General Hospital in Boston may be of interest to anyone with carpal tunnel syndrome. They took a look at type of work (desk versus manual labor) and its relation to return-to-work.

The patients in the study had a small open incision surgery under local anesthesia to release pressure on the median nerve (the usual cause of carpal tunnel syndrome). Desk workers were able to return-to-work sooner than manual laborers.

Forceful use of the hand in manual laborers was the likely reason nondesk workers experienced more time off from work and more work restrictions when they did return. This is probably the answer to your question.

In general, manual laborers can expect a slower time to return-to-work (up to one month minimum). They are advised to avoid activities that place force on the hand and wrist during wound healing. More work restrictions may also be recommended for the manual worker.

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

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

There is some evidence that mental health status and patient expectations are important factors. Patients who are anxious, depressed, or who catastrophize situations (see things in a negative perspective) are more likely to experience delays in recovery and return-to-work.

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

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

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

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

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

Using your thumbs for hand work like crocheting and knitting, can cause the joint where the thumb attaches to the hand to suffer from wear and tear. This joint is called the carpometacarpal or CMC joint. The CMC is the joint that allows you to move your thumb in all sorts of directions while using a crochet hook or knitting needle. The CMC joint is sometimes referred to as a “universal joint” because of the wide range of movements possible.

The place where the CMC joint of the thumb attaches to the wrist is at the trapezium bone. This joint is sometimes referred to as the basal joint of the thumb. The CMC or basal thumb joint suffers a lot of stress over the years. This can lead to the painful osteoarthritis of this joint that you are experiencing.

One of the more successful surgical procedures for CMC joint arthrosis is to remove the trapezium bone completely, a procedure referred to as a trapeziectomy. Taking a bone out of the wrist does leave a space or hole. Surgeons usually put something in that hole to keep the bones from shifting. As you have mentioned, there are several choices. The surgeon may use a tendon graft harvested from you or a synthetic (manmade) spacer.

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

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

But what about the results? How well do they work? Is there an advantage of one type of nonautogenous material over the others? By reviewing the results of studies published in this area, the authors may help answer your question

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

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

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

Until those studies provide us with the evidence we need to direct and guide treatment, we must rely on the individual surgeon’s experience and expertise. Ask her to review all the pros and cons of each choice with you and offer her opinion. This may help you make the final decision together.

You aren’t the first to think of this idea! Gore-Tex is a porous form of a chemical known as polytetrafluoroethylene (a member of the Teflon family). It has a micro-structure characterized by nodes interconnected by fibrils, which makes it ideal as an intervention device such as a bone spacer.

In fact, since its first patent in 1976, Gore-Tex has been developed into many industrial and medical products. One of those products was called a “Regenerative Membrane” used as an aid in tissue engineering. This particular product had some problems and has been taken off the market.

Gore-Tex was actually used in the mid-1990s to fill in the gap left when the trapezium bone was removed for 34 patients (a procedure referred to as a trapeziectomy). In 80 per cent of those patients, bone destruction occurred. As a result of this study, the use of Gore-Tex for thumb interposition was recommended against.

Gore-Tex continues to be used in other medical products as synthetic vascular grafts, stent-grafts, surgical meshes for hernia repair, and sutures for use in surgery. Further research may be able to improve on the use of Gore-Tex grafts for thumb trapeziectomy.

However, it is possible that inserting something into the void left by removing the trapezium just isn’t necessary. If this is the case, it would be a cost savings with no risk of foreign body reaction. This conclusion was made by surgeons comparing the use of interspacers versus removal of the bone without filling in the gap.

They made the surprising discovery that results were just as good (and often even better) if they just left the gap unfilled. There was less risk of infection, inflammation, and no risk of graft material moving out of the space or spreading disease to the patient.

Further studies are needed to take a closer look at this phenomenon. Studies comparing different types of grafts would be helpful along with efforts to compare filling the gap with no interspace filling.