FAQ Category: Hand

It sounds like you may have arthritis at the trapezial-metacarpal (TM) joint (thumb-to-wrist connection) but no arthritis at the metacarpophalangeal (MCP) joint (large knuckle joint). Excess motion at the MCP joint is referred to as hyperextension). The medical term for these two problems is MCP joint hyperextension associated with TM arthrosis.

The dilemma in this problem is how to treat the arthritic TM joint and the hyperextended MCP while preserving thumb motion and function. A custom-made splint may help stabilize the joint but it will likely reduce your function (ability to use the hand). Pinch grip for holding keys will certainly be limited. The splint won’t change the underlying arthritis, joint deformity, or instability but it will protect the joints from further damage.

Recently a surgeon from Ohio State University Hand and Upper Extremity Center used a case report of a 58-year-old woman with a very similar problem to explore treatment options. In making a treatment plan, the surgeon looked at the current evidence. He found very few studies to guide him.

Most of the published papers were case series reporting the results of using one specific surgical technique. There were no studies comparing conservative (nonoperative) care like splinting with surgical treatment of MCP joint hyperextension. There were no studies comparing the different surgical techniques used for this problem.

He was able to see that most hand surgeons agree that when trapezial-metacarpal (TM) reconstruction surgery is done, the MCP hyperextension should be stabilized. The guideline is if there is more than 30-degrees of hyperextension of the MCP joint, then both problems should be surgically addressed at the same time.

If the MCP problem isn’t addressed, then the force and load is transferred to the reconstructed TM joint and that can cause some problems. But before we go too far down that road, the first step for you is to see an orthopedic surgeon, have an evaluation, and get a proper diagnosis. At that point, a treatment plan that is most appropriate for you can be determined.

There is some truth to that statement. Studies do show a high recurrence rate for this problem. Treatment isn’t curative. People with severe joint contractures seem to be more likely to “fail” treatment. They either don’t get the motion back they expected, don’t get the pain relief needed, or end up having more surgery.

No hard and fast rule exists as to when surgery is needed. But the sooner a contracture is treated, the better the results of a return to full function. Many patients are instructed to keep an eye on the disease and return for follow-up once their “tabletop test” shows light between their hand and the table.

The tabletop test is done by putting your hand flat on a table. If you can see sunlight between your hand and the table, it’s time to start to considering treatment for the condition. Surgery is usually recommended when the MCP joint (at the knuckle) of the finger reaches 30 degrees of flexion. When patients have severe problems and require surgery at a younger age, the problem often comes back later in life.

Studies show that patients with more severe disease (especially affecting the proximal interphalangeal (PIP) joints) have a higher risk of disease recurrence. In fact, for all treatment approaches (surgical and nonsurgical), the metacarpophalangeal (MCP) joints are easier to treat with better outcomes and fewer cases of recurrence. As many as half of all patients who have surgery report return of flexion contractures within five years of surgery. Patients with PIP contractures seem to have the highest recurrence rates.

There are complications of treatment to consider as well. Complications of this surgery can include permanent nerve damage, joint pain and stiffness, hematoma (pocket of blood), infections, and poor wound healing.

Patients who have the newer, less invasive injection treatment to dissolve the contractures report problems, too. Most of these are minor side effects. There are very few major or long-term complications with this new treatment.

During the control trials conducted with patients, most people had a local skin reaction (swelling, redness, skin tears, itching or stinging) where the injection went into the skin. A small number of more serious problems developed in a few patients including skin infection, tendon rupture, finger deformity, complex regional pain syndrome (pain and stiffness), and hives that had to be treated with medication.

Treatment does not always fully restore range-of-motion and function but it usually increases the ability to extend (straighten) the affected fingers. And that may be enough for some patients to pursue some kind of treatment. A hand surgeon who specializes in this type of problem may be able to give you a better idea of what might work best for your particular case based on the severity of the problem.

Two orthopedic hand surgeons from the University of Rochester Medical Center in Rochester, New York may have the answer for you. They take a look at the disease itself, the current treatment, and what we know about results for the various treatment approaches. They also point out where more information could help provide better outcomes.

As you know from having this condition, 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’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 joints 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.

Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The patient loses the ability to extend (straighten) the fingers.Motion limitations can make it impossible to reach into a pocket or shake hands. Placing the hand flat on the table may become a problem.

There are two types of treatment for Dupuytren’s contracture: nonsurgical and surgical. The best course of treatment is determined by how far the contractures have advanced. Palmar Fascia Removal (palmar fasciectomy) or release of the diseased cords still remains the standard way to treat advanced Dupuytren’s contracture.

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

The surgeons at the University of Rochester were treating a 66-year-old man with this condition. He could no longer straighten his fingers and was having trouble with daily activities. They took a look at the current evidence. Based on studies published in high quality medical journals, they found that studies using the newer less invasive treatment approaches are limited. Studies comparing the results of one technique to another are needed.

For example, collagenase injections you asked about and another newer (less invasive) treatment called percutaneous needle fasciotomy were evaluated. They found these methods of treatment are being used without much data to say which one works better or if either one works well at all.

Early studies show a good success rate (77 per cent) in reducing MCP contractures using this injection treatment. Almost all of the patients (92 per cent) were 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 (44 per cent) of the patients with PIP contractures had regained full motion of the affected joint. The long-term results and recurrence rates with enzyme fasciotomy are unknown at this time.

The authors made a list of what they think is needed for future research including:

You may be describing a condition called Dupuytren disease, a fairly common disorder of the fingers. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women. 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.

Genetics and gender play significant roles. This condition is seven times more common in men than women. It is more common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry. Researchers agree that genes are not a direct cause of this disease, but predispose someone to this condition. If you have a family member (especially a sibling) with this problem, you are at least three times more likely to develop the problem yourself.

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 (called contractures). Dupuytren’s contracture usually affects only the ring and little finger.

The fact that you can no longer place your open hand flat on the table is an important clue. This is called the table top sign. A positive table top sign points to Dupuytren disease. But there are other possible causes of what you are describing. For example, trigger finger can lock the tendon and keep the finger from moving.

It is best to see a hand specialist in order to get a proper diagnosis and treatment. Most hand conditions respond better with early intervention. Waiting until the symptoms are severe increases the risk of a poor result.

Dupuytren disease of the hand has been around for hundreds of years. In fact, there is some research to suggest it was present back in the days of Vikings. Despite how long we have had to figure out the problem, modern medicine is still struggling to understand and effectively treat the condition. There is no cure and recurrence over time with treatment is likely.

Scientists haven’t found a specific gene responsible for Dupuytren disease. DNA technology has made it possible to identify quite a few genes involved in regulating the collagen fibers. Some genes are kept from doing their job of breaking down collagen, while others that normally build up collagen are increased.

There are other risk factors including age, trauma, infection, alcohol use, diabetes, and smoking. What these risk factors have in common is narrowing of the small blood vessels in the hand. With narrowing of the microvessels comes a loss of blood supply, release of free radicals, and the formation of the wrong kind of collagen tissue. Free radicals are unstable atoms that have an unpaired electron. They cause tissue and DNA damage by robbing other atoms for electrons, thus forming a chain reaction of more free radicals.

Understanding the cellular events that occur in Dupuytren disease has led to the development of more nonsurgical means of treatment. Surgeons can now perform a procedure called percutaneous fasciotomy (also known as a needle aponeurotomy). A needle is slipped in through the skin and used to cut the contracted cord.

Afterwards, the patient sees a hand therapist who uses splinting and motion exercises to help the patient maintain finger motion. This approach is more successful if used early on. Recurrence rates are high in patients with more severe disease.

Another newer treatment approach to this problem is the injection of collagenase into the diseased cords. Collagenase contains enzymes that go to work breaking down the collagen tissue. The procedure can be done in the physician’s office and does not require anesthesia.

The injections can be repeated up to three times over a 30-day period of time. Recurrence rates are unknown at this time but with long-term studies, this information will eventually become available and help guide treatment. Complications reported so far include swelling, bruising, pain, and skin problems. Less often, tendon rupture or complex regional pain syndrome develops.

Surgery is still the treatment of choice for moderate-to-severe contractures and in the case of recurrence. As with any surgical procedure, there is always the risk of complications. Wound infection or delays in healing are the most common. But nerve damage and blood vessel injury are also possible. Recurrence after surgery is as high as 50 per cent.

There is agreement that early treatment yields better results. Recurrence rates and spread of Dupuytren disease are more likely in moderate-to-severe disease. Even though you have had this problem for a couple of years, it is not too late to have treatment and with possibly better results than if you wait even longer. Bring this problem to your physician’s attention and see what can be done about it now before any more time goes by and the condition worsens.

Conservative (nonoperative) care with splinting, activity modification, and strengthening exercises may be helpful. They are at least worth a good try. But if after three to six months, you do not experience significant improvement, then surgery may be your best option.

The first area to address with surgery is the painful, arthritic trapezial-metacarpal (TM) joint. Most hand surgeons agree that when trapezial-metacarpal (TM) reconstruction surgery is done, the MCP hyperextension should also be stabilized. The guideline is if there is more than 30-degrees of hyperextension of the MCP joint, then both problems should be surgically treated at the same time.

If the MCP problem isn’t fixed, then the force and load is transferred to the reconstructed TM joint and that can cause some problems. Stabilization procedures for the MCP include using pins to hold the joint while the TM reconstruction heals, release of the muscle (extensor pollicis brevis) affecting the MCP, fusion of the joint, and capsular release of the palmar side of the joint.

There aren’t a lot of studies focused on the treatment of this problem. Limited evidence available suggest that temporary pinning of the MCP joint when there is less than a 30-degree hyperextension deformity does no good. In small studies, one year after the procedure, patients have no improvement in the hyperextension deformity.

Performing a tenotomy (tendon release and reattaching the tendon end to a different area of bone) has some benefit for most patients. Fusion of the joint doesn’t always work. Recurrence of the excess motion is possible.

Releasing the joint capsule on the palmar side of the thumb seems to have the best results. This procedure is called a volar capsulodesis. In three separate small case series of 10 to 13 patients, there were excellent results with no recurrence the majority of the patients. Excellent results mean pain was reduced and the patients had good pinch grip function.

When there isn’t enough evidence to really give surgeons a definite treatment guideline or protocol, they take the information from studies available and combine it with logic and common sense to form a treatment plan. In cases like yours, preserving thumb motion is usually the number one priority. Treating the MCP hyperextension is important to prevent risk of TM reconstructive failure. The volar capsulodesis may be the best option to reduce MCP deformity and improve MCP joint alignment.

But even with the positives associated with the volar capsulodesis procedure, there are no long-term studies to show what happens down the road. Further research is needed to show if treating the MCP is helpful or a waste of time and money.

Your surgeon is really the best one to advise you. Understanding the anatomy is a good starting point! Information like this from other studies may help you now to discuss the best treatment plan for you.

People with diabetes do have a tendency to develop problems with the incision site after surgery. They are four times more likely to have a failure of the wound to close properly. The suture line (where the stitches hold the skin together) is more likely to develop thickening tissue called suture granulomas. Removing the sutures without tearing the skin can become a real problem.

Diabetes is also a known risk factor for skin infections. So is smoking. Experts think that the delay in wound closure caused by the effects of diabetes is the real problem. Until the wound is closed, the area is susceptible to bacteria entering and causing infection.

A recent study from the Department of Plastic and Reconstructive Surgery at Johns Hopkins University in Baltimore, Maryland may offer you some helpful information. The researchers looked at the medical records of 8,850 patients who had hand surgery between the year 2000 and 2008.

They compared the outcomes of two groups of patients. The first group received prophylactic (preventive) antibiotics. Of the 8,850 patients, one-third were in this group. The second group (the remaining two-thirds) had the same type of surgery but they did not receive prophylactic antibiotics.

Patients were followed closely after surgery to determine whether or not a superficial skin infection (SSI) developed. In all 8,850 patients, there was an overall superficial skin infection (SSI) rate of 0.35 per cent. That’s a very low rate of SSI.

And the rate wasn’t different between the two groups. That suggests the use of prophylactic antibiotics for routine hand surgery isn’t really needed. Late infections (those that develop a month or more after surgery) were not a part of this study. This type of infection is related more to poor wound care.

But just to be sure, the authors did a subanalysis to see if patients with certain risk factors for infection were less likely to develop an infection if they did get the “just-in-case” (prophylactic) antibiotic.

An analysis of data collected on the patients showed three risk factors linked with developing a skin infection. These three things included diabetes, procedure length (the longer time in surgery, the greater the risk of infection), and tobacco use (cigarette smokers were at increased risk). But the big news is that patients with these risk factors do NOT reduce their risk of a skin infection by taking a preventive antibiotic.

The natural conclusion is that prophylactic antibiotics are not needed by anyone when having simple, elective hand surgery. This guideline extends to include even those who have a known increase in risk of infection following surgery (including diabetes). The rate of postoperative skin infection is very low already. Taking an antibiotic does not lower that rate at all.

More study is needed in this area before surgeons will be able to say antibiotics are never helpful before elective surgery like carpal tunnel surgery. Your surgeon may have some specific reasons why he or she thinks you would benefit from this course of action.

This is a good question. Usually patients are given a sheet of instructions following any surgery with information on what to watch out for and when to call your surgeon. Infection is certainly one of the things patients must self-monitor.

The earliest sign of infection is redness around the wound. Any yellow or green discharge from the area is a red flag and should be examined by a health care professional. Fever, swelling, and hot, hot skin are additional signs and symptoms of local skin infection. The presence of any of these (and especially if you have two or more symptoms) warrants at least a phone call to your surgeon or a visit to a local walk-in clinic.

Even minor superficial (surface) skin infections can lead to a delay in healing, delay in rehab, and delay in return to normal daily activities and/or work. Deep or major infections can have even more serious side effects such as scarring, systemic (blood) sepsis (infection), and even death from toxic shock syndrome.

It is well known that people with diabetes, who smoke, and/or who have multiple comorbidities (other major health problems) are at increased risk of infection after surgery. If the description of infection here or the risk factors associated with infection describe you, seek medical attention immediately. Early discovery and treatment of a superficial skin infection can save you much grief later if left untended.

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist. This creates a medical condition known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

Determining who will go back to work after carpal tunnel surgery is the focus of a recent study from France. Looking at factors that might predict why or why not patients return to work was a second area of interest. Studying patterns of return to work and factors associated with return to work might help patients like yourself who are planning to have carpal tunnel surgery.

By comparing demographics with return to work status, the authors were able to analyze the data for predictive or prognostic factors. All participants were adults between the ages of 20 and 59 years. It turns out there were quite a few factors that affected return to work status.

The various obstacles included other musculoskeletal disorders requiring surgery, unfavorable work environment, blue collar work status, and belief that the problem was work-related. Number of days before returning to work (referred to as duration of sick leave) was also linked with these risk factors plus one more: dissatisfaction with results of surgery.

Other studies have shown that workers employed in jobs requiring repetitive or intensive hand work and manual labor are most likely to have longer return to work times following carpal tunnel surgery. In fact, sick leave in industries with a high rate of carpal tunnel syndrome is rarely less than six months following surgery for carpal tunnel syndrome.

The authors concluded there is a relationship between medical, surgical, and occupational factors and return to work status for workers with carpal tunnel syndrome. Predicting who will be able to return to work (and how soon) after carpal tunnel surgery is not simple or straightforward. With so many potential risk factors and most cases involving more than one factor, makes predicting return to work a challenge.

More research to find the “best” or most predictive factors are needed to complete the information gathered by this study. The role of sickness payment or workers compensation cannot be underestimated and deserves further investigation and study as well.

According to a recent study looking at factors predicting return to work after carpal tunnel surgery, this is a complex and multifactorial problem. Patients who are least likely to return to work are those who have other musculoskeletal problems requiring surgery, worker compensation cases, unfavorable work environment, blue collar work status, and belief that the problem was work-related.

Number of days before returning to work (referred to as duration of sick leave) were also linked with these risk factors plus one more: dissatisfaction with results of surgery. Dissatisfaction with surgery is a difficult factor to analyze and understand because it inovlves patient expectations and actual results.

Other studies have shown that workers employed in jobs requiring repetitive or intensive hand work and manual labor are most likely to have longer return to work times following carpal tunnel surgery. In fact, sick leave in industries with a high rate of carpal tunnel syndrome is rarely less than six months following surgery for carpal tunnel syndrome.

It seems there is a relationship between medical, surgical, and occupational factors and return to work status for workers with carpal tunnel syndrome. Predicting who will be able to return to work (and how soon) after carpal tunnel surgery is not simple or straightforward. With so many potential risk factors and most cases involving more than one factor, makes predicting return to work a challenge.

Adding age-related factors and facing the decision to retire (or possibly change jobs) muddies the waters a bit more. There isn’t one best way to predict who will go back to work, when, or why/why not. This is a

Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the palm side of the ring or little finger, sometimes both, and often in both hands.

Just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle. This fascia 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 them. 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. Dupuytren’s contracture transforms the fascia into shortened cords.

As a result, a thick nodule (knob) or a short cord in the palm of the hand slowly forms, 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 condition occurs most often in middle-aged, white men. The disease usually doesn’t cause symptoms until after the age of 40. This condition is seven times more common in men than women. Although more common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry researchers agree that genes are not a direct cause of this disease, but predisposes them to this condition.

Symptoms may be mild at first and only affect one joint of one finger. Over time, other joints and other fingers may be affected. Patients report difficulty putting the affected hand in a pocket and difficulty picking up or holding small objects like coins or keys.

It can become impossible to pick up a coffee mug or hold the dog’s leash with more than the thumb and first two fingers. Even things you might take for granted otherwise become difficult: plumping up a pillow at night, using toilet paper to wipe yourself, putting on face cream.

There’s no real evidence or consensus on when is the best time to treat this problem. The recurrence rate is high (between 30 and 60 per cent). Studies are needed to compare no treatment versus early treatment versus late treatment with the various different treatment options (conservative and surgical).

Patients who have a hand condition called Dupuytren’s contracture have three basic treatment choices. They can have an open partial fasciotomy (removal of the tissue), needle aponeurotomy (destruction of the connective tissue), or collagenase injection (needle injection of enzymes that break down the tissue.

Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the palm side of the ring or little finger, sometimes both, and often in both hands. Just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle.

This fascia 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 them. 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. Dupuytren’s contracture transforms the fascia into shortened cords.

As a result, a thick nodule (knob) or a short cord in the palm of the hand slowly forms, 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 best treatment choice may depend on the patient. For example, open partial fasciectomy has been the standard treatment approach for a long time. But studies show that the recurrence rate is 30 per cent in severe disease and complications (e.g., wound infection, nerve damage) are common.

Needle aponeurotomy is an alternative treatment but the recurrence rate is even higher (60 per cent) than for open partial fasciectomy. The collagenase injections are fairly new and gaining in popularity but we don’t have studies yet to show how the results compare. Right now, the injections are used most often for single digit/single joint problems.

According to a recent study using cost-analysis to evaluate these three treatment approaches, health economics suggests using collagenase injection as the first-line of treatment. If the problem comes back, open partial fasciectomy could be tried. But there’s nothing to say needle collagenase in the treatment of any recurrence wouldn’t be just as effective. Future studies are needed to sort this out.

BOTOX injections have been used in small studies for the treatment of Raynaud phenomenon. It may turn out to be a less invasive and more effective treatment than surgery for this condition. It works by turning off pain messages sent along tiny nerves in the hands but without having to cut the blood vessels or nerves directly.

The use of BOTOX for this problem is still considered “off-label” and experimental. Off label means the drug is used for something other than what it was intended for. The Food and Drug Administration (FDA) has not approved the use of BOTOX for Raynaud phenomenon.

The treatment is effective though and that’s why it’s used for patients who have not responded well to other conservative measures and/or who have now developed finger ulcers. The risk of gangrene and amputation is too high to just let the problem go untreated. BOTOX works because it delivers a toxin to the body fluid around the nerves and blood vessels.

Except for some local pain where the needle is inserted, this treatment has very few (if any) negative side effects. Injections can be repeated every four-to-six months (that’s about how long the effects last). Painful symptoms are decreased or gone and hand function is much better. But the effects may not last or provide a long-term (permanent) solution. The long-term effects of BOTOX injections for Raynaud phenomenon have not been investigated or reported yet either.

There are some patients who may not be good candidates for this type of approach for their Raynaud condition. For example, if they have tried BOTOX before and didn’t tolerate it well or got no results, then a second series of injections isn’t likely to help either. If the disease is too far progressed and there’s no hope the blood vessels can be repaired, then BOTOX may not be a good idea.

Patients considering BOTOX injections for Raynaud phenomenon should be warned of possible adverse effects of this treatment. Skin infections, inability for the skin to cool itself by sweating (called anhydrosis), and muscle paralysis contributing to hand weakness have been reported.

For many patients hampered by Raynaud phenomenon, a minimally invasive treatment approach may be a welcome option. With good pain control providing improved hand function, BOTOX may be worth taking the chance of potential side effects.

BOTOX (BOTOX stands for botulinum neurotoxin) has been used as an off-label way to treat Raynaud phenomenon. Off label means the drug is used for something other than what it was intended for. BOTOX as a treatment for Raynaud phenomenon is still considered experimental. The Food and Drug Administration (FDA) has not approved the use of BOTOX for this condition.

For those who do not know, the condition we refer to as Raynaud phenomenon occurs when the small blood vessels of the hands tighten up and close off. The blood supply to the fingers gets cut off. These spasms come and go in response to cold temperature or strong emotion.

Patients with Raynaud phenomenon commonly suffer from pain and loss of function. Sometimes they can’t even reach inside a refrigerator without gloves to protect their fingers. The loss of blood to the fingertips can cause ulcers to form. Patients who depend on their hands for work may be forced to change jobs.

Treatment for this condition varies from patient-to-patient. Sometimes physical therapy, acupuncture, and medications help. Creams applied to the skin to open the blood vessels can be used. Patients with this problem are encouraged to avoid cold conditions and stop using tobacco products. In cases that don’t respond to these methods, surgery may be needed.

Cutting the nerve to the arteries that bring blood to the area may be an option. The outermost layer of the blood vessel is stripped away. This works because it removes the nerve control that is causing the arteries to go into spasm. This is the treatment recommended most often for patients with Raynaud and ulcers that don’t heal. The result can be relief from pain and freedom from having to wear gloves.

Now BOTOX injections might be a less invasive and more effective treatment than surgery that disrupts blood vessels. It still works by turning off pain messages sent along tiny nerves in the hands but without having to cut the blood vessels or nerves directly.

There aren’t large studies available yet. But based on the results of smaller studies, the treatment appears effective. That’s why it’s used for patients who have not responded well to other conservative measures. The long-term effects of BOTOX injections for Raynaud phenomenon have not been investigated or reported yet either.

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

The most common cause of narrowing in the carpal tunnel is a thickening of the flexor tenosynovium. This is the lining around the tendon that contains fluid to help the tendons slide and glide easily. When the connective tissue gets thick and dried out, the tendon gets stuck and pulls or presses on the nerve. The result can be the characteristic numbness and tingling of the fingers and hand.

Unusual anatomy or alterations in the normal anatomy can be another cause of carpal tunnel syndrome. It doesn’t happen very often — estimated at one in 100 cases. There could be a narrow passageway at the wrist because of the shape, structure, or alignment of the carpal bones.

There could be a missing protective covering of fascia over the carpal tunnel. Pressure from the contracting muscles and tendons could then compress the nerve more easily. There is also a transverse carpal ligament that crosses over the carpal tunnel. This, too, can become thickened and apply pressure to the nerve.

When there is an extra tendon, it usually has something to do with a tendon normally present in about 90 per cent of all humans. That’s the palmaris longus tendon. Sometimes this tendon is absent and another tendon is present instead (the palmaris profundus).

In some people, both the palmaris longus and the palmaris profundus are present. Pressure from either (or both) of these tendons can cause carpal tunnel syndrome. Only one out of 1600 people have the palmaris profundus muscle. So you can see this particular cause of carpal tunnel is very rare.

There have been reports of the palmaris profundus being encased inside the sheath or lining that covers and protects the median nerve. With this abnormal arrangement, any time the muscle/tendon unit contracts, it puts pressure on the nerve.

Whether or not this could happen on the other hand is uncertain. There are no studies to document how often this problem occurs bilaterally (on both sides). For a better understanding of your own condition, you can ask the surgeon for a copy of the surgical notes. Reading the details of the procedure may give you a better idea of the exact difference(s) in your anatomy. Or you can just ask the surgeon to give you the particulars of your case at your final follow-up appointment.

Carpal tunnel syndrome (CTS) can develop at any age in adulthood. CTS is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment or compressive neuropathy.

This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

Any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel can lead to symptoms of CTS. The carpal tunnel cannot expand so any condition that causes abnormal pressure in the tunnel can produce symptoms of CTS. And any increase in pressure within the carpal tunnel can reduce blood flow to the nerve, leading to loss of nerve function.

Various types of arthritis can cause swelling and pressure in the carpal tunnel. The way people do their tasks can put them at risk for problems of CTS. Some of these risks include force, posture, wrist alignment, repetition, temperature, and vibration.

In other instances, CTS can start when the tenosynovium (lining around the tendons in the carpal tunnel) thickens from irritation or inflammation. This thickening causes pressure to build inside the carpal tunnel. But the tunnel can’t stretch any larger in response to the added swelling, so the median nerve starts to squeeze against the transverse carpal ligament. If the pressure continues to build up, the nerve is eventually unable to function normally.

A traumatic wrist injury may cause swelling and extra pressure within the carpal tunnel. The area inside the tunnel can also be reduced after a wrist fracture or dislocation if the bone pushes into the tunnel. Fractured wrist bones may later cause CTS if the healed fragments result in abnormal irritation on the flexor tendons.

Other conditions in the body can produce symptoms of CTS. Any condition that can cause fluid to be retained can lead to extra pressure in the carpal tunnel. People with medical problems such as diabetes low thyroid function (called hypothyroidism), or tumors or cysts are more prone to problems of CTS.

You will need a thorough examination to find out what might be causing your carpal tunnel symptoms. There could be more than one cause, which is why it is finally becoming symptomatic. Your physician will work with you to get to the bottom of the problem.

Treatment for Boutonniere finger deformities depends on how severe the deformity is, how much motion there is at each joint, and whether or not the joint can be passively straightened. Fingers that can be stretched or moved back to their normal resting position may benefit from hand therapy and splinting.

But fingers that are in a Boutonniere position and can’t be moved to a normal position are considered contracted. Surgery becomes the only option at that point. The surgical choices include synovectomy, tenotomy, or reconstruction of the extensor tendon.

If the deformity is severe, then a joint fusion (called arthrodesis) or joint replacement (arthroplasty) may be required. These two procedures are referred to as salvage surgery).

Surgeons use a special classification system to decide just how severe is the deformity and therefore which surgical procedure to choose. There are three stages of Boutonniere deformity. Stage one (mild) is correctable with passive motion. The joint surface is normal without any signs of joint damage or degeneration.

Stage two Boutonniere deformity is considered moderate in severity. The joints can be partially returned to their normal anatomic position (neutral). And the articular (joint) surface remains unchanged. In the early phase of stage two deformity, it may still be possible to convert to a stage one deformity with conservative (nonoperative) care.

Stage three is defined by a fixed contracture (does not correct with passive motion) and the joint surface is damaged to the point of destruction. This is the stage that most often requires surgical intervention.

Stages one and two may still respond to hand therapy, splinting, and/or steroid injection of the joint. If stage one and stage two deformities fail to respond to conservative care, then surgery may be recommended for them, too.

When choosing the surgical technique for each patient, the surgeon takes into consideration the condition of the most affected joint, the adjacent joints, the skin, joint motion, and overall hand function. Every effort is made to restore as much normal motion as possible to the joints affected.

Finger joint replacements have been around for quite a while but the design and materials are still in need of some improving. It’s a small joint that gets a lot of use so the implants get a real workout.

It’s not uncommon for patients who have finger joint replacements to develop complications. Joint stiffening, implant loosening, squeaking, dislocations, and fractures are just a few of the problems reported by patients.

Early reports after the type of interphalangeal (IP) joint replacements you are thinking about said, ‘Yes! Good results!” But the authors of a recent long-term study reported differently. In that study, one surgeon replaced 31 IP joints in the hands of 17 patients and then followed them for at least two years. Most were followed for an average of four years (or more).

Results were measured using pain, finger joint motion, finger and hand function, and X-ray findings. X-rays were used to look at alignment of the implants including subsidence (sinking of the implant down into the bone) and implant failure (fracture, dislocation). Activities of daily living and patient satisfaction were also assessed as important outcome measures.

What they found was that like the results reported from other studies, in the early months, patients experienced significant improvements in pain, motion, and function. But over time, significant problems developed.

Pain persisted. Complications occurred that required additional surgeries. For example, there were five joint dislocations, one fracture, and 11 complaints of finger squeaking. Some joints just wouldn’t move at all while in others the implant loosened creating an unstable joint. In quite a few cases, the implant shifted and moved until it had migrated right out of the bone!

The surgeon performing the study attributed these complications to the particular type of implant he was using (a pyrolytic carbon resurfacing joint replacement). When he tallied up all the problems and saw how unhappy his patients were with the results, he stopped using this particular type of implant.

The material (pyrolytic carbon) is supposed to wear well and last a long time. It has the added advantage of stimulating bone growth, which is important to help the body create a stable implantation. But as the results of this study show, the benefits didn’t last.

Silicone implants may have a better track record. It might be best to talk with your rheumatologist and the hand surgeon who would do the surgery. Express your concerns based on what you’ve been told by other patients. See what they have to say about your particular situation.

Each patient is different and those differences can sometimes account for better (or worse) outcomes. Find out what you can expect and what factors you might have that would predict a good (or possibly poor) result. It’s not always a good idea to base everything on the reports of one or two patients — but what they had to say is worth investigating before making any final decisions for yourself.

Anyone who has suffered the long-term effects of arthritis knows how pain can result in loss of motion and function. The quality of life can really suffer over the loss of a normal, healthy finger joint!

Joint replacement is possible now for all three joints of the four fingers (index, middle, ring, pinkie). Those joints are made up of the metacarpal phalangeal (MCP or the large knuckle), the proximal interphalangeal joint (PIP), and the distal interphalangeal joint (DIP). The proximal interphalangeal joint is the joint in the middle of the finger between the knuckle and the tip of the finger.

But as with all joint replacements, problems can develop. If the implant isn’t in good alignment, it can slip out of place causing dislocation and even fracture. Sometimes the implants sink down into the bone, a process referred to as subsidence.

Squeaking has also been reported by some patients. In fact, it is the third most common complication (after implant loosening and finger stiffening). Implants made of pyrolytic carbon tend to squeak more than silicone joint replacements. And as you have discovered, the squeak can be loud enough to be heard by others.

The best thing to do is let your surgeon take a look and see if he or she can offer any solutions. But beware there’s probably not much that can be done about the problem short of removing and replacing the implant with a different type of joint replacement. Removing the implant and fusing the finger is an option but this approach results in no motion and therefore loss of function for pinching and gripping objects.

According to experts at the Division of Hand and Microvascular Surgery, Division of Infectious Diseases, and Department of Internal Medicine at the Naval Medical Center in San Diego, California, infections that develop from bites can be very serious.

You might be surprised to find that human bites top the list for dangerous wounds. Human bite wounds can be infected with one or more of 40 bacterial strains. Many of these bacteria are on the skin surface and don’t represent much of a problem.

But an open wound from a bite leaves an entrance for the bacteria to move in. And the bite itself can drive bacteria into the finger, hand, or other body part. Common complications with human bite wounds include skin and soft tissue infection, bone fractures, and bone infection (called osteomyelitis).

Animal bites from cats and dogs can cause significant problems, too. Infection is much more common after cat bites. But as you suggest, dogs are able to chomp down and pull, thus tearing skin, soft tissues, tendons, and even muscles.

Cat teeth are more like thin, sharp needles. The skin breaks are small and heal quickly but that allows bacteria to get trapped inside the skin. The bacteria move into deeper tissues and can cause some serious delayed infections. As the old saying goes, Dogs rule. Cats drool. Avoid bites from either species!