FAQ Category: Hand

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!

You might be referring to a finger infection called paronychia. The common staphylococcus aureus bacteria is the most likely culprit. Moist skin (especially with cracked openings around the nails) from hands in water constantly gives bacteria a nice cozy place to live and breed more bacteria.

Dishwashers who don’t use rubber gloves are certainly at risk. So are swimmers and bartenders, people who bite their nails, and those who get frequent manicures. The first symptom is a red, swollen area under the nail fold. The nail fold is where the skin meets the nail and folds under slightly.

A pocket of pus (abscess) may form next. Pain develops that gets the person’s attention. Early treatment with antibiotics and draining the area are usually all that is required to take care of the problem. But if the hands are still exposed to water, the infection can return and become more difficult to treat. Surgery may be needed at that point.

The best thing to do as a new dishwasher on the job is get yourself a good pair of rubber gloves and wear them consistently. Don’t share them with anyone even if it means taking them home with you at the end of the day.

If you notice any of the symptoms mentioned, see your physician right away. An early diagnosis and quick response with treatment can make all the difference between an acute (one time) problem and something that becomes chronic and plagues you for a long time.

Modern microsurgery makes it possible to reattach severed fingers with good-to-excellent results most of the time. After reattaching the amputated finger, it is usually clear within a day or two if the replantation is going to be successful. Nursing and medical staff check frequently to see if skin color, temperature, and circulation are normal.

Sometimes a problem called venous congestion can develop. Blood clots form in the veins making it impossible for blood to the replantation to return to the heart. Without proper blood circulation to and from the finger, the reattached (replanted) tissue starts to die.

For mild problems, a quick and easy way to reduce the amount of blood pooling and remove the blood clot is with the application of leeches. Just as you might imagine, the leeches suck the pooled blood out from under the skin. But leeches aren’t enough when there are blood clots forming, skin inflammation with blisters, and/or necrosis (dying tissue).

There are other ways to surgically handle this situation. The surgeon usually chooses the least invasive method (leeches first if possible), then assesses the patient’s individual factors in order to decide the next step (if a next step is needed).

It sounds like you may be referring to a newly developed method for restoring blood flow to an amputated finger that has been reattached or replanted. It’s called a proximally based cross-finger flap.

In this procedure, the surgeon takes the top layer of skin and blood vessels from the finger next to the amputated one (the donor finger) and transfer it to cover the area where the replanted finger is connected back to the affected finger. The donor flap consists of skin, tissue just under the skin, and veins. The tendon is left untouched.

The donor flap is sewn loosely without tension to the replanted finger. The flap of skin is not cut away from the donor finger. Instead, it forms what looks like a bridge between the two fingers. The stripped donor site is covered with a layer of skin called a skin graft. When the replanted finger has a restored supply of blood, the graft can be removed.

This method may work best when there is venous congestion (blood pooling at the surgical site). It is also used when there is not enough skin to cover and reconnect the amputated finger or it’s clear that the replantation is in trouble because of venous congestion. The cross-finger flap is best applied within 48-hours of the original replant surgery.

Dupuytrens disease is a disorder that affects the palm side of the hand. It most often affects the ring or little finger, sometimes both, and often in both hands. This is where a type of connective tissue, called fascia that surrounds and separates the tendons and muscles of the hand is involved. Just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle.

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. Dupuytrens contractures usually only affect the ring and little finger.

Treatment for this problem has always been surgery. Heating and manually stretching the tight tissues doesn’t solve the problem. Cutting the hand open and releasing the tight cords has been the only effective treatment. Now, with the recent FDA approval of a new injectable drug (Xiaflex), the cord can be treated conservatively (nonsurgical approach).

By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the surgeon can manually pull the fingers straight and rupture the cord. That sounds dramatic — it’s not! The treatment is safe and effective.

There are a few possible (minor) side effects but 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 (redness, skin tears, itching or stinging) where the injection went into the skin.

During the testing phases and research trials, a small number of more serious problems developed. Only a few patients were effected. Complications reported included tendon rupture, finger deformity, and hives that had to be treated with medication.

Treatment with injected collagen (called enzymatic fasciotomy) may eventually replace surgery. But further study is needed to assess the long-term effects, especially recurrence rates. Until then, surgical release of the cords will likely remain the gold standard.

Dupuytrens disease is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is genetic in nature, meaning it runs in families.

The palm side of the hand is affected. This is where a type of connective tissue, called fascia that surrounds and separates the tendons and muscles of the hand is involved. 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. Dupuytrens disease causes tightening called contracture. When the palmar fascia tightens, the fingers curl into a bent position and stay there.

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. Dupuytrens contractures usually only affect the ring and little finger.

Almost 400 years have passed by since Dupuytrens disease of the hand was first described by a Swiss physician. Since that time, surgery has been the only successful treatment. That may all change with the recent FDA approval of Xiaflex, an injectable drug designed to weaken the diseased tissue.

By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the surgeon can manually pull the fingers straight and rupture the cord. That sounds dramatic — it’s not! The treatment is safe and effective.

Treatment of this type (called enzymatic fasciotomy) may eventually replace surgery. But further study is needed to assess the long-term effects, especially recurrence rates. Until then, surgical release of the cords will likely remain the gold standard.

Check with your surgeon and find out what he or she thinks about the new injectable treatment for Dupuytrens. It’s possible this treatment technique is available in your area should you want to consider trying it.

Future studies will be needed to compare final results for different treatments. Conservative care with Xiaflex (or other similar) injections must be compared to surgical treatment. The various surgical approaches should all be included as well. Cost considerations among the different treatment options will have to be considered along with the long-term effects and recurrence rates.

Surgeons keep in mind the idea that “life comes before limb” (i.e., don’t put someone at risk of death to save a finger). The decision can be a difficult one and often has to be made quickly.

Age is taken into consideration along with general health, type of injury (as well as other injuries sustained at the time of the accident), and the functional needs of the patient. The desire to continue doing things like playing the piano or tying fishing flies may not come up at the time of the accident and injury. Shock, panic, and fear take center stage.

According to a recent study from the Department of Reconstructive Surgery at Stanford University (California), age is not a reason to rule out finger or thumb replantation. Older adults (over age 65) were not found to be at greater risk of death with replantation surgery.

Oh, to be sure, there were complications in this age group. Blood clots, bleeding, pressure ulcers, and accidental cuts were reported. But the percentage of patients affected was less than one per cent (0.6 per cent). Death occurred in an even smaller number (0.04 per cent). And some folks couldn’t be discharged to home and had to go to a nursing home. But overall, age should not be a reason to avoid replantation.

Fears that older age (65 or older) increases the risk of complications (including death) from finger replantation can be set aside. According to a recent study from Stanford University, the risk of serious blood clots leading to death after surgery to reattach a thumb or finger in the older age group is no different than in the younger crowd.

They determined this by reviewing the medical records of 616 patients across the U.S. who had this surgery done over a 10-year period of time. The data was taken from the Nationwide Inpatient Survey (NIS). Information collected at the time of hospital discharge is placed in this database and can be used by all researchers. No patient is identified, so it is confidential.

To give you a little perspective on this topic, compared to the 616 patients over the age of 65 who had a digit replantation, there were almost 15,000 of these procedures done in younger patients (under 65).

Age as a risk factor for death following digit replantation just wasn’t a factor. But that doesn’t mean that age should be ignored. Older adults who had a digit replantation were twice as likely to need a blood transfusion. Discharge to a nursing home rather than directly to the patient’s home was also more likely in the older age group.

Although this study did not analyze survival rates of the finger (or thumb), other studies have reported no difference based on age. Patients with diabetes or who smoke are at risk for less optimal outcomes compared with those without these risk factors. The effect of a past history of smoking on the success of finger replantation has not been studied. But the low rate of overall complications suggests this isn’t a big factor.

Survival of the digit is one variable; function is something else. In other words, the patient may not lose the finger but he or she may not have good use (function) of the digit. Survival versus function was not studied in this particular study and may be the basis of future studies.

On the positive side of things, surgery today has advanced to the point that replantation is possible with microsurgery. Rehabilitation under the guidance of a highly trained hand therapist has made it possible to regain function as well. With a team effort, your brother is likely to have a very good result.

You may be suffering from a condition referred to some as pronator syndrome. Pronator syndrome is a nerve entrapment (pressure on the median nerve in the forearm). The nerve can get pinched between two other soft tissue structures such as muscles, tendons, ligaments, or fascia (connective tissue). Besides forearm aching, it can also cause numbness of the thumb and index finger.

Not everyone believes such a condition really exists. That’s because there are no tests that truly diagnose the problem. Pressure on the nerve is just as likely to reproduce the symptoms as not. Likewise with the other clinical tests at the surgeon’s disposal.

X-rays, MRIs, CT scans, and ultrasound images show nothing out of the ordinary. Electrodiagnostic tests normally used to test nerve lesions are normal nine times out of 10. That leaves some experts wondering if this is truly a disease or more likely an illness.

In fact, because women in their 40s are the ones most likely to be seen with this condition, the notion that this might be hormonal, emotional, or psychologic has been raised. And because surgery to decompress the nerve isn’t successful, there is a belief that what we are facing here isn’t a disease, but rather an illness.

When surgery does relieve the problem, it could be a placebo effect. So determining disease (true pathologic anatomy or physiology) from illness (physical symptoms caused by emotional or psychologic distress) can’t be cleared up by successful treatment.

Your surgeon’s advice is actually very good. Conservative care is the first line of treatment for this condition whether it is called “aching forearm” or “pronator syndrome.” Heat or cold along with pain relievers is the recommended approach for this problem.

Exercises prescribed by a hand therapist may help stretch the nerve. Manual therapy (a type of hands on approach) to release fibrous tissue around the nerve may help. Any postural effects will be addressed. The therapist may conduct a review of your home and/or office work areas for possible contributing or aggravating factors.

In the opinion of hand experts, surgery is only recommended rarely and then only after at least six months of nonoperative care first. Other supportive measures may include splinting, acupuncture, or pain medications.

Pronator syndrome is a nerve entrapment (pressure on the median nerve in the forearm). The nerve can get pinched between two other soft tissue structures such as muscles, tendons, ligaments, or fascia (connective tissue).

The syndrome produces more than just forearm aching pain. Like you, many patients also report numbness and tingling in the thumb and index finger. The symptoms are usually mild-to-moderate in intensity. Hand function may be impaired but disability from this problem is rare.

Recommended treatment is usually conservative (nonoperative) care. As far as seeking out a second opinion, there’s nothing wrong with that for any condition. Information gathering is an important step in determining the best way to treat a problem like pronator syndrome.

Some surgeons don’t believe pronator syndrome even exists. There are no clear cut diagnostic tests that prove a patient has this problem. The clinical and electrodiagnostic tests usually used with nerve compression just don’t yield consistent results from patient to patient.

Depending on how the surgeon who sees you next feels about the condition called pronator syndrome, you may get the same advice, you may not. Nonspecific forearm aching that isn’t easily reproduced with testing is a puzzling problem. Research is really needed to figure out what’s going on and find ways to address the underlying problem.

You may be experiencing a phenomenon called the response shift theory. Your measurements before and after treatment show a significant difference. But you are experiencing the change more slowly. As your symptoms improve, your internal measuring unit for change shifts.

Your judgment may have been clouded by your perception — you may have actually experienced measurable improvement in symptoms. But you got used to the gradual change. When change occured, you may not have recognized just how much improvement there was. In other words, you did not register the full amount of pain decrease no matter what amount of recovery had really been experienced.

This is not an uncommon shift in response to treatment. That’s why physicians, surgeons, and therapists use different tools to measure outcomes of treatment. Each tool has its own function and importance.

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. Another name for this medical condition is 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.

Treatment usually begins with conservative (nonoperative) care. This can include the use of anti-inflammatory medications, wearing a splint on the wrist and hand, modifying the way you perform certain activities, and some specific exercises to help the affected nerve move through the bone and soft tissues surrounding it.

You may work with a physical or occupational (hand) therapist. The main focus of treatment is to reduce or eliminate the cause of pressure in the carpal tunnel. Your therapist may check your workstation and the way you do your work tasks. Suggestions may be given about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems.

Surgery such as you are considering is only recommended if/when nonoperative care has failed to relieve your pain or other symptoms. Three to six months of conservative care is recommended before making this decision.

Studies show that the majority of patients do get significant relief from painful symptoms, numbness, and tingling. Patient satisfaction with results increases as pain decreases and normal function returns.

For those who do not get better, it may be a matter of a misdiagnosis or another (second) problem in the neck, shoulder, elbow, or wrist. When there is a true carpal tunnel syndrome, symptoms rarely get worse after surgery.

You are not alone in your concern about how your hands look. Many patients (men and women) with rheumatoid arthritis make this same comment. You may think there’s nothing you can do about this but experts in this field are taking a second look and offering some suggestions.

Understanding the underlying cause of the developing hand deformities helps guide treatment decisions. Inflammation of the fluid inside the joint (a condition called synovitis) weakens the ligaments and other soft tissue support structures of the wrist.

Without the support from these connective tissues, the bones of the wrist collapse. Dislocation of the wrist is the next step. Synovitis associated with rheumatoid arthritis often causes a shift of the fingers off to the side called ulnar deviation or ulnar drift.

Conservative care with splinting, range-of-motion, and activity modification are important aspects of management of this disease. Surgery can be done early to realign the bones and reduce pain (when present). Correcting alignment and minimizing deformities may help improve motion and function. Surgery doesn’t have to wait until the damage is done.

The surgeon can take action once evidence is seen that the wrist bones are migrating (shifting). Partial fusion of the wrist may prevent shifting of the bones, thus reducing the risk of hand and finger deformities. Total fusion may be needed to decrease pain and stabilize the wrist.

Fusion of the metacarpophalangeal (MCP) joints (the large knuckles across the back of your hand) doesn’t work — the loss of motion would only make daily functions even more difficult. Some surgeons are trying to remove the affected synovium (called a synovectomy) and transfer ligaments to hold the joints in place. The transfer procedure is called a cross-intrinsic transfer. It can be done if damage to the joints caused by the synovitis is not too great.

It is possible to replace the MCP joints. This joint replacement surgery is recommended when the joints sublux (partially dislocate) or completely dislocate. When enough joint damage has been done that the joints can’t recover or it’s too late for reconstructive surgery, then joint replacement may be the next step.

There are many ways to deal with drifting finger deformities associated with rheumatoid arthritis. But it takes a team of health care professionals including hand therapists, hand surgeons, and rheumatologists to find the best approach for each individual patient. You may want to seek the advice of others in these disciplines for further advice and counsel.

You are right that rheumatoid arthritis can be a very disabling and deforming condition — but it doesn’t have to be! With the coordinated efforts of a team of health care specialists, patients can often address problems early on and delay or prevent them from developing.

How can you do this? First, by making good use of the newer medications for rheumatoid arthritis called disease-modifying antirheumatic drugs (DMARDs) as prescribed by your rheumatologist. These drugs have been shown to slow down the destructive processes created by the inflammatory effects of rheumatoid arthritis.

Working with a hand therapist (occupational or physical therapist) to maintain joint motion, muscle strength, and function is important. The therapist will show you ways to protect your joints and preserve motion. Everything you do with your hands (whether at home, work, or play) can be modified to accomplish these goals.

Having a hand surgeon on your team keeping tabs on your situation can be a help as well. There’s no doubt that improved medical treatment has reduced the number (and severity) of hand, finger, and thumb deformities caused by rheumatoid arthritis. But these and other problems still do crop up and may require surgical intervention.

Surgery doesn’t have to wait until the damage is done. For example, surgery can be done to realign the bones and reduce pain (when present). Correcting alignment and minimizing deformities may help improve motion and function.

The surgeon can take action once evidence is seen that the wrist bones are migrating (shifting). Tendon transfers, partial fusion of the wrist, and removing some of the inflamed synovium (joint lining) may prevent shifting of the bones, thus reducing the risk of hand and finger deformities.

Let your team know of your interest in being as pro-active as possible in managing this disease. Don’t hesitate to bring a problem to their attention. It is better to address issues as they arise rather than trying to “make do” or “get through” until it is too late for the optimal (best) result.

Finger replantation (that’s what it’s called when the surgeon reattaches a finger or fingertip) has been possible since the 1960s. High-powered microscopes developed at that time (and since improved) have made it possible for surgeons to see tiny blood vessels and nerves.

Unless blood vessels and nerves are matched up and reconnected properly, loss of sensation and temperature control can occur. You wouldn’t necessarily know it to look at the tip of the finger but the anatomy is incredibly complex. There are multiple pulleys that make it possible for the finger to bend.

A network of arteries, veins, ligaments, fascia (connective tissue), and an elaborate lymphatic (fluid drainage) system are all contained within the finger. All of the structures are tiny and their locations are not exactly the same from person-to-person.

Certain types of amputation injuries are easier to repair than others. The most likely type to be successful is the guillotine amputation of the fingertip. That’s a cut straight through the finger with no jagged edges and little tissue damage. This type of injury can be reconnected without a skin graft. The finger looks and functions normally after replantation.

Hand surgeons always advise bringing accidentally amputated body parts with you to the emergency room. Keep it as clean as possible. Wrap it in a clean cloth if one is available. The best plan is to practice safety at all times and avoid such injuries.

If possible and appropriate, ask other butchers for safety tips and their advice for preventing accidental amputation of fingers. It may be a difficult conversation, but it could also make a difference for your future in the butcher business.

Making the decision of whether to accept the amputation or try for replantation of the finger tip can be difficult. Hand surgeons say this is a challenging procedure with many pitfalls.

The hand surgeon will be the best person to advise you on this. Patient preference is certainly part of the decision. But surgeon expertise and the availability of a microvascular surgeon is important.

Experts in this area suggest the procedure is not possible when the injury involves crushing or contamination. But for children, young women, musicians, or others who truly need the tip of the finger, distal finger replantation should be attempted.

There are other factors to consider. For example, full function of the finger is not possible without the tip but this may not be as important for a manual laborer as for a musician.

Amputation without replantation can lead to the development of painful neuromas (growth or tumor of nerve tissue). The cosmetic effect of replantation is preferred by most people but at the moment it doesn’t sound like this is of prime importance to your husband.

Again, the surgeon will help you walk through this decision. After he or she examines your husband, your options will be clearer. Don’t be afraid to speak up and ask any questions you may have or think should be asked. This is especially important if you suspect your husband may not make the same decision if he was able to think clearly and not under the potential influence of blood loss and shock.

Compartment syndrome describes a condition in which fluid (swelling or blood) builds up inside one or more of the individual compartments of the arm. An electrical burn is one of many ways this problem can develop.

The “compartments” are easier to understand if you think of each group of muscles and tendons as being surrounded by a protective sheath or lining of connective tissue called fascia. There are individual compartments on the front and back of the upper arm, forearm, hand, and fingers.

In each compartment, the fascia fits closely to the outer layer of the soft tissue it surrounds — like a sleeve or envelope. The structures are lubricated with a glistening fluid that allows everything to slide and glide against each other. There isn’t a lot of give or room for increased volume of fluid from swelling or bleeding from an injury.

When an injury occurs that leads to swelling, the increased pressure inside the sleeve or envelope cuts off blood supply to the muscles. The muscle cells start to necrose or die. Left untreated, this necrosis can progress to the point of gangrene. That sounds pretty extreme. The good news is that with early diagnosis and treatment, results are usually good.

Treatment may begin with just taking pressure off the arm whenever and however possible (e.g., loosening bandages, splint, or cast if that’s the problem). Most of the time, early surgery is indicated.

The surgical procedure for this condition is called compartment decompression or fasciotomy. The surgeon slits open the skin and first layer of fascia called the epimysium. Once the upper layers of fascia have been released, the surgeon conducts a careful search of each compartment for any other areas of restriction.

The procedure does involve direct release of all layers of fascia involved and debridement (removal of any tissue that has died). In some cases, it may be necessary to release tight tissues from around nerves passing through the compartments.

The patient may need several surgeries to complete the decompression process. Skin grafts to cover the wound may be needed. Rehab to restore motion and function is the final step. We offer our best to you and your husband during this process and for your service to our country!

Infection with the mycobacterium known as mycobacterium tuberculosis (M. tuberculosis) usually affects the lungs but it can have extrapulmonary (outside the lungs) affects. Bone, joints, skin, and soft tissues are favorite targets. When the spine is affected, the condition is referred to as Potts disease.

In the case of the fingers, hand, and/or wrist infections, a previous history of tuberculosis has been reported. Older adults who had tuberculosis as children may still have the mycobacterium stored within their bodies. The body walled off the bacterium and kept it from affecting the person but did not get rid of the problem.

If the mycobacterium were not inactivated by direct contact with sunlight or destroyed by antibiotics, they can become reactivated. This reactivation process occurs most often in older adults whose immune systems have become weakened or compromised by age, inflammatory conditions such as arthritis, or some other chronic health problem (e.g., diabetes, autoimmune diseases).

And because the mycobacteria grow so slowly, tissue cultures don’t always show the problem for months (sometimes even years). Without an accurate identification of the underlying organism, treatment with antibiotics may not be effective until the specific drug (or combination of drugs) needed is used. By that time, significant damage can occur (such as you describe with your mother).

Jersey finger injury refers to the damage done to the tip of the ring finger when an athlete grabs the shirt (jersey) of another player while that player is pulling away. The hand grasping the jersey is closed in a fist. But the force of the player wearing the shirt pulls the tip of the ring finger into extension.

The result is a rupture of the tendon away from the bone. A piece of the bone may come with the tendon (still attached). This is called an avulsion injury. There can be a bone fracture along with the tendon rupture.

And although it sounds like this is an injury only an athlete can have, in fact, “jersey” finger injuries occur in nonathletes of all ages. Older adults with rheumatoid arthritis or other inflammatory joint conditions experience this injury as well. The same mechanism takes place: forceful extension of the tip of the finger when it is bent that causes the problem.

Any finger can be affected. The ring finger seems to be the most commonly injured digit because of its unique anatomy. It is the weakest of the fingers and least able to move by itself. The flexor digitorum profundus (or FDP) tendon pulls away from the bone more easily than any other finger tendon.

When the fingers are in a fisted position, the ring finger is actually just a tiny bit more forward than the other fingers. So it absorbs more of the force during a pull-away maneuver compared with the other fingers.

Your father could have been doing something as simple as picking up a heavy bag of groceries with his fingertips or opening a car door while losing his balance backwards. There are any number of ways an older adult can manage to get a “jersey finger” injury without coming in contact with someone else’s shirt. But it makes an exciting story and gains him a little extra attention, so smile and enjoy the moment.

Jersey finger injury refers to the damage done to the tip of the ring finger when an athlete grabs the shirt (jersey) of another player while that player is pulling away. The hand grasping the jersey is closed in a fist. But the force of the player wearing the shirt pulls the tip of the ring finger into extension.

The result is a rupture of the tendon away from the bone. A piece of the bone may come with the tendon (still attached). This is called an avulsion injury. There can be a bone fracture along with the tendon rupture.

And although it sounds like this is an injury only an athlete can have, in fact, “jersey” finger injuries occur in nonathletes of all ages. Older adults with rheumatoid arthritis or other inflammatory joint conditions experience this injury as well. The same mechanism takes place: forceful extension of the tip of the finger when it is bent that causes the problem.

Treatment is based on a classification scheme. The injury can be described as a type I, II, III, IV, or V level of retraction. Retraction refers to how far back toward the palm the tendon has recoiled. Type I describes a flexor digitorum profundus tendon (FDP) that has pulled away from the bone and snapped all the way back to the palm.

Type II injury means the tendon has pulled away from the tip of the finger taking a tiny bit of bone with it but without retracting past the next bone. With a type III injury, the tendon has avulsed with a large bone fragment that has gotten caught or entrapped without moving.

Type IV level of retraction has a ruptured tendon with bone avulsion and retraction back toward the palm. And Type V is a ruptured tendon with bone avulsion. The bone where the tendon has pulled away is broken into tiny pieces (called a comminuted fracture). Type V injuries are further divided into Va and Vb. Type Va means the damage is outside the joint (extra-articular). Type Vb tells us there is intraarticular (inside the joint) damage.

When planning the type of surgery to perform, the surgeon evaluates how far back the tendon has retracted, how much bone damage is present, and if the joint is involved. Besides considering the classification type of jersey injury, the surgeon must also consider how long ago the finger was damaged.

The longer the time between the trauma and the treatment, the more likely it is that fibrosis and scar tissue has set in. Pre-operative X-rays and MRIs are helpful in showing the surgeon the extent of the damage and where the retracted tendon is located.

Sometimes it is possible to reattach the tendon to the bone. In other cases, the tendon must be threaded back where it belongs. If the tendon has to be pulled from the palm all the way forward to the tip of the finger, then it must be secured to hold it in place.

The goals of surgical treatment are 1) to avoid a gap between where the tendon should be attached and where it can be attached and 2) provide a strong enough repair to withstand normal load on the finger.

Even with the best results, patients should expect some loss of motion. The tip of the affected finger may be permanently bent or flexed. Stiffness of the joint at the tip of the finger is common.

Restoring full range-of-motion requires an aggressive hand therapy program and a motivated patient. Complications such as infection, too much stretching on the repaired tendon, or rupture of the repair can limit results as well.