FAQ Category: Hand

The boutonniere deformity affects the extensor tendon(s) of the finger so they no longer work properly. The injured area of the tendon is called the central slip. Damage occurs where the extensor tendon attaches to the middle phalanx (bone) of the finger.

Tightening of the tendon from injury or scarring can lead to a permanently crooked finger. The proximal interphalangeal (PIP or middle joint of the finger) gets stuck in a flexed (bent) position. At the same time, the distal interphalangeal (DIP) joint (moves the tip of the finger) is pulled up into too much extension (hyperextension).

The PIP joint may not straighten out completely under its own power. The finger can usually be straightened easily with help from the other hand. Eventually, the imbalance leads to the typical shape of the finger with a boutonniere deformity (tip of the finger extended too much, middle knuckle stuck in flexion). Sounds like that is your situation.

If conservative care has not helped (splinting, exercises), then surgery may be an option. We say ‘maybe’ because
loss of motion, stiffness, and the inability to use the finger in a normal way are often long-term problems even with surgery.

A hand surgeon is the best one to assess your finger/hand and see if you are a good candidate for surgery. There is some evidence that for fingers that won’t extend (straighten) but the loss is less than 30-degrees, the tendon can be cut. If the lag is more than 30-degrees, another surgery may be needed to repair the central slip and restore normal tension. Again, the surgeon will make a determination as to which procedure will be most helpful for you after completing an examination of the area.

It sounds like you may have a finger deformity referred to as Boutonniere’s. Just as you describe, the tip of the finger is hyperextended and the middle joint is stuck in flexion. Some people can passively straighten the finger out (by using the other hand to pull the finger straight). But a permanent contracture (joint is stuck) may be present, in which case you can no longer change the position of the joints.

Tightening of the extensor tendon from injury or scarring can lead to a permanently crooked finger. The boutonniere deformity affects the extensor tendon of the finger so it no longer works properly. The injured area of the tendon is called the central slip. Damage occurs where the extensor tendon attaches to the middle phalanx (bone) of the finger.

By now, after 20 years, it’s likely that the tendon has scarred down and is stuck in place (called a contracture). Even after all this time, the first consideration may still be for conservative (nonoperative) care with splinting, range-of-motion exercises, and strengthening exercises.

Many hand surgeons will try six weeks of splinting with the spring-type splint and exercise to see if the deformity lessens to a tolerable limit before considering surgery. This is desirable before surgery to stretch out a joint contracture before repairing or reconstructing the extensor tendon.

If it is just a matter of cosmetics (appearance), surgery may not help. If loss of motion has resulted in loss of function and disability, then surgery deserves a closer look. The surgeon can reattach the central slip and reconstruct the rest of the damaged soft tissue structures. Surgical procedures that can be used include lateral band reconstruction, central slip reattachment, central slip reconstruction, extensor tenotomy, or tendon and transverse retinacular reconstruction.

Each of these procedures has its own advantages, disadvantages, and indications (when to use each one). Some patients may need more than one operation. This concept is referred to as staged reconstruction. Decisions around what surgery to do and when to do it focus on how long ago the injury occurred, how much capsular (joint) stiffness is present, and the severity of the extensor lag (finger doesn’t straighten all the way).

To satisfy your own concerns, it may be well worth your time and effort to seek out an opinion from a hand surgeon who can best advise you. Boutonniere deformities are notorious for not responding quickly or easily, so just go prepared for any possibility. Perhaps you’ll be pleasantly surprised if splinting and exercise is all that’s needed!

In a recently published article, orthopedic surgeon Marco Rizzo, MD from the Mayo Clinic (Rochester, Minnesota) provides an update on what can be done for anyone with joint arthritis of the hands. There are two basic choices: conservative (nonoperative) care and surgery.

Conservative care consists of three options: splinting to protect the joint and give it a rest, medications, and steroid injections. Usually splints are worn during activities and removed during rest periods. Daily exercises are performed with the splints off. Some physicians advise their patients to just wear the splints at night as they do seem to help prevent deformities from developing.

New medications are available that target the immune system and stop the inflammatory processes linked with arthritis. Patients with inflammatory arthritis and especially rheumatoid arthritis get the most benefit from these drugs.

The physician will often prescribe one drug to start. If it is not effective or doesn’t work as well as expected, a combination of drugs may be used. It can take a while before finding just the right mix of medications that work best for each patient. Patience and persistence are the keys to success here.

Nonsteroidal antiinflammatories (NSAIDs) are still used for all types of arthritis (even osteoarthritis, which doesn’t have a strong inflammatory component). NSAIDs help improve pain and function but they do have some potentially serious adverse side effects (GI, kidney, liver damage). There is also a new topical agent (diclofenac) that works well for the hands and is less likely to cause systemic problems.

Steroid injections are easy to give and provide immediate relief from pain. Having the freedom from pain can give you a new lease on life. Improved function follows but the effects wear off and aren’t long-lasting. If there’s more than one finger involved, then splinting and systemic medications are a better choice.

When it comes to surgery, there are two main surgical choices: joint replacement and fusion. It’s more difficult to replace the thumb joint, so fusion is more common there. But silicone implants have worked well for the fingers and are an acceptable choice for all the other metacarpophalangeal (MCP) joints. If there is too much bone loss and deformity, surgery may not be as effective as patients hoped for. On the other hand, even some pain relief and improved motion can help aid function and hygiene.

For joint replacement, there are many types of joint implants available. The surgeon makes his or her decision on which implant to use based on the type of arthritis, amount of bone, and condition of the surrounding soft tissues. Patients with rheumatoid arthritis typically don’t get the same excellent outcomes as patients with osteoarthritis but they are still happy with improved results.

When selecting joint implants, the patient’s goals and lifestyle are also taken into consideration. The silicone implants still remain the top choice but newer carbon and metal-plastic are gaining in popularity. Patients must have good bone stock to benefit from the newer-generation implants. The carbon and metal-plastic implants are less likely to fracture compared with the more fracture-prone silicone implants.

Metacarpophalangeal (MCP) joint arthritis is a common problem. One that can be very disabling but when diagnosed early, conservative care can be very helpful in treating symptoms and even preventing progression of disease. Newer drugs on the market have made this possible. Splinting seems to be effective but studies are needed to really prove this point. And for those patients who need surgery, joint implant procedures have improved steadily over the years.

Pain, swelling, and loss of motion at the base of the thumb describe symptoms of carpometacarpal osteoarthritis (CMC OA) otherwise known as thumb arthritis. Just try and get along on a single day without being able to use your thumb. Everything from picking up a carton of milk to taking the handbrake off in the car can become impossible.

Over time, the thumb becomes weaker and weaker. With loss of normal strength, the thumb loses its anatomic alignment. Deformity and disability develop. Pretty soon even simple tasks such as picking up a piece of paper or turning a doorknob become impossible. That’s when surgery becomes a viable option.

Because so many older adults develop arthritis at the base of the thumb with severe symptoms, surgeons have developed a variety of ways to surgically treat the problem. At last count, there were at least eight different procedures that could be used to treat thumb osteoarthritis. Joint replacement is one of them.

The first joint replacement (called arthroplasty) for the base of the thumb was developed in the early 1960s so you can see there’s been about 50 years of research on this procedure. At first, there were many complications such as dislocations, fractures, and inflammation as the body reacted to the implant. Patients didn’t get the pain relief or improved motion they had expected.

Since that time, studies show that patients recover faster when they get a joint replacement rather than having reconstructive surgery. Better strength, better motion, and better function are reported when joint replacement is compared with removing the trapezium bone and filling in the hole with a soft tissue graft.

There are stil some potential problems with joint implants for the thumb. The joint prosthesis can come loose, shift, or sink down into the bone. Some patients experience a reaction as the body views the implant as a foreign object and mount an immune defense against it. Any of these complications can spell disaster for the outcomes. To combat these issues, improvements have been made in implant materials and design in the last few years.

For now, it looks like short-term results for joint replacement are better than for removing the trapezium bone and/or reconstructing the joint. What we don’t have yet are long-term results of joint replacement for the thumb using the newer implant design and surgical techniques. More studies are needed to really find out what works best over time for the problem of thumb arthritis. Experts in this area have called for better ways to measure results, especially related to hand function.

The decision to reconstruct the carpometacarpal (CMC) joint versus replacement can be a difficult one. There are always pros and cons to every surgical procedure. And each patient is unique in his or her presentation, goals, and expectations.

We recommend a frank conversation with your hand surgeon about these points. We can offer some information from a recent well-done systematic review that might help inform you when deciding what specific questions to ask your surgeon about your own situation.

In this review, hand surgeons tally up the results of studies in this area published from 1966 to 2009. The surgical procedures included 1) removing the trapezium bone (trapeziectomy) and filling in the hole with a spacer or rolled up piece of ligament (interposition), 2) same procedure using a piece of tendon instead of ligament, 3) removal of the trapezium and ligament reconstruction, 4) just ligament reconstruction, or 5) trapeziectomy with both ligament reconstruction and tendon interposition.

There were other surgical procedures as well such as an arthrodesis (joint fusion), joint replacement, or osteotomy. An osteotomy is the removal of a wedge-shaped piece of bone to help realign the entire bone and joint. Once the piece of bone is taken out, the remaining two edges of bone shift toward each other and change the structural alignment.

After reviewing results of studies for each surgical procedure, the following conclusions were made:

The development of osteoarthritis is complex and multifactorial (i.e., there are many risk factors involved). It is safe to say that for as much as we do know about this disease, there is much more we do not understand about it. Scientists are actively exploring who gets osteoarthritis, why and how it develops, and what can be done to prevent (or treat) it.

All aspects of the joint and surrounding soft tissue are affected. These structures support and stabilize the joint and include the cartilage, first layer of bone (called the subchondral bone), ligaments, and tendons. Any injury, damage, shift, or change in these structures can also change the biomechanics, force, and load on a joint. And any of these events can become the first step in the cascade that eventually leads to arthritis.

What exactly are those changes and the chain of events? It might be helpful to look at this first by describing what is seen on X-rays and in the clinic. Early arthritic changes show up on X-rays as a slight narrowing of the joint space. This phase is referred to as the stationary non-erosive stage. The joint remains intact and stable.

The next phase is the destructive erosive phase. Here there is swelling and break down of the cartilage and subchondral layer. The tendons that attach to the bone start to thicken and degenerate. Inflammation of the joint fluid (synovitis) develops and creates an inflammatory phase (not unlike what happens with rheumatoid arthritis).

After the destruction, the joint tries to recover and remodel the damaged area. But all that happens is the formation of osteophytes (bone spurs), cysts, scar tissue, a thickened cartilage, and other bumps on the finger bones called Heberden’s nodes.

As you have discovered, osteophytes (bone spurs) are one of the earliest things to show up on X-rays to suggest osteoarthritis is developing. These bumps form where the bone and cartilage meet. Often, the location of the bone spurs is right where the ligament attaches to the bone.

This finding has prompted experts who understand anatomy to suggest perhaps a ligament problem comes first. And as stated already: any injury, damage, shift, or change in the ligaments can also change the biomechanics, force, and load on a joint and the first step in the cascade that eventually leads to arthritis.

Osteoarthritis of the joints of the hand has both a nonerosive and an erosive stage with inflammation, destruction, and remodeling observed. This understanding has led to the development of scoring methods to help describe the process. Physicians rely on grading joint damage using one (or more) of the scoring systems currently available when making the diagnosis of osteoarthritis.

Various ways to assign a level of severity have been developed. Three of the most common scoring systems rely on X-rays to grade osteoarthritis. These are the Kellgren and Lawrence method, the Kallmann method, and the Verbruggen method.

The Kellgren and Lawrence grading system has four levels (one through four). Grade 1 is the normal joint. Up to one osteophyte (bone spur) can be seen around that joint and still be considered “normal”. Grade two is assigned to the joint that has two osteophytes in separate places on the same joint. There are some slight changes in the bone under the joint but no deformities and no changes in the joint space.

Grade three shows a definite narrowing of the joint space, moderate osteophytes, and the start of joint deformity at the ends of the bones. In a joint labeled grade four, there are large osteophytes, loss of joint space, bone sclerosis (hardening), deformity, and the formation of cysts.

The Kallmann system differs from the Kellgren and Lawrence scoring in that the changes observed (spurs, joint space, cysts, deformity, sclerosis) are given a score of zero (none or absent)or one (present). Some of the defining characteristics (e.g., joint space narrowing, osteophytes) can also be given a score of two for moderate changes and three (large or severe).

The third system (the Verbruggen assessment) was developed to help record smaller changes that take place quickly. Each of these systems has a slightly different way of assessing hand osteoarthritis. The tests give points that can be considered the “score”. The final score determines the “grade” that helps define whether your arthritic changes are mild, moderate, or severe.

Using all three systems together provides a way to assess specifics about changes in the individual lesions as well as the progression in phases of osteoarthritis. None of the systems are enough as stand-alone methods. The Verbruggen scoring method is less time consuming and might be the most reliable but further studies are needed to confirm this.

It sounds like you are experiencing some weakness in the muscles of the hand that affect your pinch grip. These are the same muscles (flexor pollicis longus of the thumb and flexor digitorum profundus of the index finger) that make it possible to form the “OK” sign.

An examination by a medical doctor would be a good place to start to find out what’s going on. You may have a temporary nerve dsyfunction. The most likely nerve involved is the anterior interosseous nerve. Anterior interosseous nerve (AIN) palsy is fairly uncommon. But what we do know about it suggests some unknown cause for a malfunction that seems to correct itself over time.

There may be a nerve entrapment from scar tissue, connective tissue, or other fibrotic tissue pressing on the nerve. The lining around the nerve called the nerve sheath may be affected. But the fact that in most cases, the nerve seems to recover suggests more than just pressure on the nerve from tight tissues around it.

Treatment is usually just a wait-and-see approach. The average amount of time required for nerve healing is about 12 months from the start of your symptoms. But before making any assumptions, get an accurate diagnosis and recommendations for treatment based on that.

It sounds like you may have a condition called anterior interosseous nerve palsy AIN stands for anterior interosseous nerve. It is the nerve that supplies the muscles of the hand/fingers (flexor pollicis longus and flexor digitorum profundus) that make it possible to form the “OK” sign with the thumb and index finger.

Considering how often we use the thumbs to hit the space bar, loss of anterior interosseous nerve function can be very disabling for someone making a living at the keyboard. The same is true for those who hunt and peck with just the index fingers. But if you are typing 150 (or more) words per minute, you probably are most likely using both hands together at the same time.

Research shows that spontaneous recovery is the norm for anterior interosseous nerve palsy. But healing takes time. Initial signs of recovery may be seen as early as six months after the first symptom appeared. The average time is closer to 12 months. And for those who are over 40, the expected time for full recovery is 18 months.

According to a recent review study on this topic, surgery is not recommended unless there is complete loss of nerve transmission due to some type of trauma, infection, or tumor.

Patients should be followed carefully and monitored for recovery. Some patients are advised to take Vitamin B12 to help enhance nerve function. Electrical stimulation therapy provided by a hand therapist may be of some benefit. Electrodiagnostic testing can be done to look for signs of recovery and then repeated every four to six weeks to observe the progression of improvement in nerve function.

We may not have a simple, direct answer to that question. As it turns out, osteoarthritis is a fairly complex disease and one that is not very well understood. Taking a look at risk factors may shed some light on the subject.

Let’s take the most obvious: overuse of the hands. You might think the way people use their hands at their jobs would make a difference. But researchers have not been able to clearly establish a link between occupation and arthritis. Cotton-pickers and industrial workers are at a disadvantage and are more likely to develop hand arthritis. But that’s as far as the evidence goes.

Okay, so what about age? Are we agreed that the older you get, the more likely it is you will develop arthritis? Well, yes, in a way age is related because the majority of people who have osteoarthritis of the hands are older (over 55). But as you pointed out, what about all the older folks who don’t have arthritis? There are plenty of adults up into their 80s and 90s who are arthritis-free (including your grandmother). How do we explain that?

Genetics. It seems the most recent scientific research has been able to put a finger on the contribution of genetics as a potential risk factor. Gene mutations have been identified that when present may explain the higher incidence of hand arthritis in some, but not all, people.

Hormones seem to play a role here, too. Postmenopausal women are more likely to see their arthritis get worse despite treatment. But even this risk factor is inconsistent because only certain joints (for example, the base of the thumb) are affected. If low estrogen levels are linked with arthritis, then why aren’t all the joints involved? Scientists are still scratching their heads over that one — they simply don’t know.

Racial/ethnic background and hand dominance are two final risk factors under investigation. So far, it looks like there may be something here as both being Caucasian (white) and favoring one hand over the other for most activities may lead to a greater risk of developing finger arthritis. Using one hand more than the other and ending up with arthritis is probably due to the added biomechanical load on the joints.

Why Caucasian Americans have much more hand arthritis of the proximal interphalangeal (PIP) joints compared with Chinese people is unknown. There may be genetic, lifestyle, joint mechanics, or other protective factors in the Chinese group that have not yet been identified.

It’s likely that there are some specific factors (more than one) that interact with each other in such a way that the final outcome is joint arthritis. Knowing how important the hand is for daily activities, especially self-care (grooming, toileting, preparing and eating food), research needs to continue placing an emphasis on unraveling the mysteries of this disease.

There are many avenues to explore from genetics to types of arthritis, risk factors, and joint changes. Prevention may eventually be possible and when that isn’t successful, then finding treatment techniques that work is next.

Right now, the middle joints of the fingers (called the proximal interphalangeal (PIPs) joints have the best long-term track record for success with implants. The implants are made of silicone (a type of rubber) or pyocarbon (a carbon-based material).

Both materials are flexible and durable enough to function in the fingers. But there have been some problems. Implant fracture and loosening head the list of reasons why implants fail.

There can be a settling of the implant down into the bone — a little bit of settling is okay and to be expected. But too much sinking and problems with joint instability develop.

Other problems that have been reported include squeaking, dislocating, and contractures (the joint gets stuck in one position and won’t move). Overall results of joint implants is quite good in terms of relief of painful symptoms and improvement in hand function. But much more work needs to be done to figure out why problems develop and how to prevent them.

Nerves to the arms and legs (down to the feet and hands) are referred to as peripheral nerves. They come out of the spinal cord and supply the limbs with sensation and motor function. Peripheral nerves can regenerate after an accident when they are cut. Crush injuries are less likely to recover.

All of the nerves that travel to the hand and fingers begin together at the shoulder: the radial nerve, the median nerve, and the ulnar nerve. These nerves carry signals from the brain to the muscles that move the arm, hand, fingers, and thumb. The nerves also carry signals back to the brain about sensations such as touch, pain, and temperature.

The ulnar nerve branches out to supply feeling to the little finger and half the ring finger. Branches of this nerve also supply the small muscles in the palm and the muscle that pulls the thumb toward the palm.

Studies show that nerve regeneration takes place slowly but steadily. The healing nerve grows back at a pace of about one to two millimeters each day. A nerve transected near the elbow will take much longer to heal and recover compared to the same nerve cut down close to the wrist. So the range of expected recovery can up to one year when the nerve is transected at the elbow.

You can figure this out for yourself if you know the approximate location of your nerve injury. Use a ruler with metric measurements and measure from the point of injury down to the tip of your ring finger (the furthest point innervated or supplied by that nerve). The total number of millimiters is the approximate number of days expected for complete recovery.

Of course, there are individual factors that might slow (or speed up) healing. Good nutrition aids healing and recovery. Poor nutrition, tobacco use, and excessive alcohol intake can slow recovery. Good general health is a plus. The presence of other chronic illnesses and diseases such as diabetes or heart disease can slow things down.

Your recovery so far is a helpful predictor as well. Attitude, personality traits, and response to pain are also predictors of healing. If you are still uncertain what to expect, don’t hesitate to check with your surgeon for the best estimate for you.

You may want to get an X-ray to make sure the thumb or wrist isn’t broken. Fist fights are notorious for causing fractures of the thumb, wrist, or hand. Keeping the hand still (not using the muscles) is advised until an X-ray can rule out (or rule in) a fracture.

If there is a broken bone, immobilization is essential. Fractured bones can become displaced (separated) when muscles and tendons pull on the fracture site where the tendons attach. That turns a simple fracture into a more complex one.

The orthopedic surgeon will probably take several X-ray views in order to get a close look at the trapeziometacarpal (TMC) joint. That’s a common area injured in fist fights. There’s a particular type of fracture called a Rolando fracture that affects this area. It’s a Y-shaped break that can cause misalignment of the joint surface.

Treatment beyond rest, ice, compression, and elevation (R.I.C.E.) may be needed. A cast or ever surgery may be necessary. Get in to see a doctor soon in order to know for sure and prevent unnecessary long-term complications.

Hand surgeons from Barcelona, Spain recently published a comprehensive review of Rolando fractures. They described the anatomy involved, reported how often these types of fractures occur, and who is most likely to experience such an injury. The pattern of fracture, mechanism of injury, and diagnosis were also included.

As you might guess with a label like Rolando fracture, this thumb injury was named after the surgeon from Italy who first described it back in 1910. Over 100 years later, the name has remained to refer to a particular Y-shaped break at the base of the thumb joint. The Y-shaped Rolando fracture affects the joint surface of the trapeziometacarpal (TMC) joint.

Of particular interest to you would be the authors’ review of treatment options for Rolando fractures with details of surgical procedures used. Surgeons can use an algorithm to guide treatment. An algorithm is a series of steps used to make a decision. In the case of Rolando fractures, the algorithm begins with the question of whether the fracture is displaced. If no, then a cast can be put on the hand, wrist, and forearm until the fracture heals (usually four to five weeks).

If yes (the fracture has separated), then the next decision point is made based on whether the two ends of the separated bone can be brought back together. The process of reducing the space between the two pieces of bone is called reduction. Reduction with less than a two millimeter gap is a good result. A wider gap than that would usually require surgery.

Fractures that are on the edge of this measurement can present a challenge. In cases like this, it may be helpful to look at other factors. For example, Rolando fractures that include many tiny fragments of bone (called comminuted) cannot be surgically reduced. It’s next to impossible to line up all the pieces of bone to recreate a smooth joint surface.

The surgeon does what he or she can to use traction (downward pull) to line up the trapeziometacarpal (TMC) joint. Then a cast is placed on the arm to protect the fractured site until healing takes place. Immobilization with a cast also makes sure the muscles and tendons don’t pull on the fracture site (further deforming the damaged area).

When adequate reduction is impossible with traction alone, then surgery is needed. Under the relaxing effects of anesthesia, the surgeon can pull the bones and realign them. Then wires, screws, or other hardware are used to hold everything together. If an incision is needed to gain access to the joint, the procedure is called open reduction and internal fixation (ORIF). If the operation can be done through the skin, it is referred to as a closed reduction and percutaneous fixation.

Some things to consider include post-operative complications. Damage to the small nerves and blood vessels is more likely when open reduction and fixation are done. Arthritic changes may develop no matter what you do. If you are at risk for post-traumatic arthritis no matter which choice you make, then the least invasive approach is advised.

Whenever possible, surgeons try to restore the natural contours of the joint. Studies done so far have shown that a two millimeter gap does not adversely affect the biomechanics of the thumb when the joint surface is intact. This final tidbit of evidence-based information may be the most helpful for you to discuss with your surgeon when making the final treatment decision. X-rays will help determine the condition of the joint to aid in this dilemma.

If your brother has not been seen by a physician, then the first step is an immediate medical appointment. For this type of injury and infection, self-care at home is not advised as it may not be enough. Antibiotics may be needed and if there is infection in the joint, surgery may even be needed.

If he is already under the care of a physician, then proper follow-up is important. He must go to any scheduled appointments. Any change in symptoms (worsening) or new symptoms (flu-like with fever, chills, fatigue) must be reported to the doctor right away.

Patients with infections of the wrist, hand, or fingers from trauma may develop either osteomyelitis (bone infection) or septic arthritis (joint infection). Undiagnosed, delayed diagnosis, or untreated, any of these infectious agents can cause destruction of the joint. Loss of motion, impaired function, and eventual arthritis with pain, stiffness, and disability can occur. The disease process can get so bad, a person can lose the affected hand.

But even when caught quickly, there is still a risk of poor outcomes, especially for patients who abuse tobacco and/or alcohol. Likewise, patients with other health problems are at increased risk for long-term problems. Patients must be advised of these possible complications right from the start to avoid an unhappy surprise if/when treatment is not as successful as hoped for.

That all sounds like a lot of bad news. Recovery with all parts intact is possible. Again, the key is early and consistent medical care. Your most important role may be as a supportive family member who helps get your brother to his doctor appointments. It will be up to him to follow his doctor’s counsel and advice.

Without a proper diagnosis, it would be hard to say what kind of treatment is advised. The first step is to see your physician and at least get a baseline examination. Based on your history of any hand trauma, personal or family history of cancer, and type of work or recreational activities, the physician will take it the next step.

Physical examination and testing of the forearm, hand, and fingers will guide the physician in ordering further tests (e.g., blood work, X-rays). You may be referred to a specialist such as a hand surgeon.

Most lumps and bumps in the hand are benign tumors affecting the bone or nearby soft tissues. Soft tissue involvement can include the muscles, tendons, fat, nerves, blood vessels, cartilage, joint, or synovium.

Benign doesn’t necessarily mean “harmless”. It means the tumor won’t spread to other vital structures. But it can get larger and put pressure on nearby structures. The end result can be loss of motion, strength, and function. Deformity and disability are even possible.

That’s why we take you back to the beginning and repeat the idea that an early medical evaluation is important. Early diagnosis and intervention are said to yield the best results. You may still end up in a medical “wait-and-see” situation but under the watchful eye and care of your physician, you’ll know when something more is needed.

You are quite right! When people develop swollen, red, painful fingers, they don’t usually head on in to the nearest cancer clinic. Instead, the tendency is to apply a home remedy and see if it clears up on its own.

If the person shows up at their primary care physician’s office or the local walk-in medical clinic, the same home therapy may be prescribed. Since local problems like you described in the hand aren’t usually cancerous tumors, it’s easy to miss the diagnosis.

But a careful patient history (especially a personal history of cancer) and a physical exam should be performed. Blood may be drawn and sent to the lab. If there is reason to be suspicious, the attending medical personnel will order X-rays or even other more advanced imaging studies to help determine what’s going on.

Any time a group of symptoms like swelling, redness, pain, tenderness, and/or warmth appear at a local site (finger, hand) and don’t go away with standard care, then it’s definitely time for a more thorough exam.

Treatment for malignant hand tumors consists of surgery, chemotherapy, and/or radiation therapy (also known as “radiotherapy”). This is very different than soaking it. The surgeon must be careful to remove the entire tumor without cutting into it. This technique is referred to as getting “clear margins”.

Once the tumor is removed, it is sent to the lab where the pathologist identifies the exact type of tumor and “stages” it. Staging tells us how far advanced the disease is and helps determine the prognosis. Early diagnosis and treatment is always advised and often linked with better long-term outcomes. Thanks for the reminder!

Sentinel lymph node biopsy is a test reserved for patients who may have cancer that has traveled outside the confines of the tumor. Even though you describe your primary problem as a red and swollen index finger, it sounds like your surgeon or primary care physician is trying to rule out cancer as a possible cause.

Other tests may be ordered depending on what type of tumor is present (or what the physician is suspicious of). Soft tissue sarcomas (a malignant tumor affecting bone or surrounding soft tissue structures) will require a sentinel lymph node biopsy.

For this test, a dye is injected into the tissue around the tumor. The dye flows through the lymph system to the lymph nodes. The surgeon removes lymph nodes near the tumor and sends them to the lab where they are examined for the presence of any dye. A positive sentinel node suggests tumor cells have reached the lymph nodes and traveled beyond (a process called metastasis).

The results of this test help physicians stage the cancer, which in turn, helps determine treatment. Staging tells us how far advanced the disease is and helps determine the prognosis. Early diagnosis and treatment is always advised and often linked with better long-term outcomes.

Another potential test for problems like this is the use of a PET scan (PET stands for Positron Emission Tomography). A scan of the upper body may help show tumors in the chest or other areas other than the hand/fingers. PET scans also help sort out benign from malignant tumors.

You are more likely to undergo tests of this nature if there is a previous history of cancer anywhere else in the body. The most likely primary (original or first) sites of cancer that can spread or metastasize to the bones (and bones of the hand) are lung, breast, and kidney cancer.

If this doesn’t seem to fit your family history or personal situation, don’t hesitate to ask your surgeon for his or her reasons behind the node biopsy.

Hand surgeons from the University of Florida have recently published a case study to demonstrate a new test for fractures of the hamate bone in the hand. For those readers who don’t know, the hamate bone is one of the many small bones in the wrist. It lines up with the base of the fourth (ring) and fifth (baby) fingers.

On the palmar side of the hand and wrist, the hamate bone has a projection of bone. This bit of bone is referred to as the hook of the hamate. There are many ligaments, muscles, and tendons that either attach directly to the hook of the hamate or sling around it like a pulley.

The anatomy is significant because with so many different soft tissues affecting the hamate bone, it is at risk for injury. When does this happen most often? When a baseball player, golfer, or racquet sports player of any kind swings the bat, golf club, or racquet held in the hands.

While swinging the bat, club, or racquet, the hand and wrist move into a position of ulnar deviation (movement toward the small finger). The forearm, wrist, and hand move from a position of pronation (palm down) to supination (palm up). Direct pressure and shearing forces are applied to the hook of the hamate. It’s actually a wonder the hook of the hamate doesn’t break off more often.

The surgeons introduced a clinical test they call the hook of the hamate pull test or HHPT to help diagnose these problems. Here’s how it’s done: the patient’s hand is placed palm up. The wrist is placed in a fully ulnar deviated position (wrist tilted away from the thumb). The proper test position is essential to getting accurate test results.

The small and ring fingers are flexed or bent as the examiner applies pressure to the pads of the tips of those two fingers (as if trying to straighten the fingers). The test position loads the flexor profundus tendons of the two fingers. Those two tendons come alongside the hook of the hamate. When they contract, they push (displace) the broken hook off to the side. The result is a reproduction of the severe, sharp pain at the wrist where the hamate is located.

In all the cases tested, the pull test was always positive when there was a true hook of the hamate fracture. The test is not considered positive when generalized wrist pain occurs — only when the severe, sharp pain from the original injury is reproduced. A CT scan can confirm the diagnosis.

The joint that moves the tip of the finger is called the distal interphalangeal (DIP) joint. It is at risk for injuries like this — especially among athletes like baseball players who are catching balls pitched or thrown at fast speeds. But injuries like these can occur at home or in the workplace, too.

The proper medical term for this type of finger fractures is a mallet finger fracture. Many times, a mallet finger fracture can and will heal on its own. If the bone is not displaced (separated or shifted apart), straightening it out and putting it in a splint will allow it to heal in the correct alignment.

But if there is a bone fragment that has pulled away from the main finger bone (called a phalanx, then surgery may be needed to repair the bone. That’s when surgery may be needed. The surgeon realigns the two bones, using wires, pins, or screws to hold it in place until it heals.

It’s important to make sure you have seen a surgeon before attempting to self-treat. An accurate diagnosis and plan of care appropriate to the problem will save you from problems in the long run.