FAQ Category: Hand

Benign tumors of the hand are fairly common. They can affect the bone (e.g., osteoid osteoma, cysts, giant cell tumors), cartilage (e.g., osteochondroma, enchondroma, periosteal chondroma, fibromas), fat/connective tissue (e.g., lipomas, giant cell tumor of tendon sheath), nerves (e.g., Schwannoma, neurofibroma), and blood vessels (e.g., glomus tumor).

Many benign tumors of the hand recur or come back after being removed. In growing children, this can be a problem because of how fast and how large these tumors can become. Most benign hand tumors do not convert to a malignant type. The type most likely to metastasize (spread) are giant cell tumors of the bone.

Anyone who is diagnosed with this type of tumor will automatically have a chest X-ray and/or CT scan ordered. Metastasis to the lungs is the first place malignancy might be observed.

If you are at risk for conversion from a benign to malignant tumor, your physician will monitor you for any signs of malignancy. Fast growth of a lump or bump, the formation of new lumps/bumps, increasing pain, or any other suspicious signs and symptoms must be reported to your primary care physician or hand surgeon right away.

If you are wondering what your risk of recurrence or conversion may be, find out the exact diagnosis (type of tumor) and ask if it is likely to come back or metastasize. This information may give you peace of mind and/or direction for future follow-up.

You may be describing something that has been referred to by hand surgeons as knuckle pads. There is quite a bit of debate about these skin lesions. Some experts think they are the same as what others call nodules. What’s the difference?

Knuckle pads are soft areas of thickening with loss of skin elasticity over and around them. Nodules are firm or even hard and feel like knots. In either case, the lesions are painless and may be caused by separate things.

Knuckle pads like the kind you have may be more likely a result of trauma or reaction to repetitive hand movements linked with work or occupation. These pads may also develop after injury to the tendon as the soft tissues try to repair themselves.

Nodules are more often linked with specific hand diseases such as rheumatoid arthritis, osteoarthritis, and Dupuytren’s disease. It’s also possible that either of these skin changes may be an early sign of a more serious systemic disorder.

The best thing to do is have your physician take a look at them. You may only be creating a baseline (what they look like now) for comparison later should there be any changes that develop. But an initial “look-see” to rule out a treatable condition is always a good idea.

Dupuytren’s disease (also known as Dupuytren’s contracture) is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands.

Normally, we are able to control when we bend our fingers and how much. How much we flex our fingers determines how small an object we can hold and how tightly we can hold it. People lose this control as the disorder develops and the palmar fascia contracts, or tightens. This contracture is like extra scar tissue just under the skin. As the disorder progresses, the bending of the finger becomes more and more severe, which limits the motion of the finger.

And in some individuals, the nodules appear on the backs of the fingers. These are called dorsal cutaneous nodules. Dorsal just refers to the back of the hand, cutaneous means it affects the skin, and nodules tell us the lesion is a hard knot-like structure.

Examining these nodules under a microscope has shown that they have the same structure as the nodules that normally form on the palmar surface of the hand with Dupuytren’s. They are made up of dense fibrotic (scar) tissue.

Why do they develop on the backside of the hands? That remains a mystery. They may be a reaction to the tightening on the palmar side causing finger flexion and putting increased pressure across the back of the knuckles. They may be extensions of the palmar nodules that develop. Further study is needed to determine the exact cause and if anything specific should be done to treat or remove them.

You can administer first aid by gently cleaning the area with mild soap and warm water. Some people feel better if they apply an antibiotic ointment or cream to the skin but this may not be necessary. If at all possible, collect the spider in a jar for identification.

There are only two species in the United States that can cause bodily harm with their bites: the black widow spider (Lactrodectus) and the brown recluse or fiddleback spider (Loxosceles). “Fiddleback” refers to the violin shaped back of this spider.

The brown recluse is considered by some experts to be the most dangerous spider to humans. But in their defense, they do eat cockroaches, silverfish and other soft-bodied insects. Not all states even have this type of spider. They are most common in the western, central, and southern states.

The female black widow is commonly recognized by its black color, hour glass shape and red markings. Males are smaller, usually have yellow and red bands and spots over the back, and don’t bite. Although they live in warmer climates (and desert areas), they can be found in states with cooler temperatures.

The female black widow spider is probably the most venomous spider in North America. But it injects a very small amount of venom (poison) when it bites. Very few people actually die of spider bites.

The bite of the brown recluse or black widow can cause local effects (pain, redness of the skin, an open wound) or systemic effects. In a very small number of people, deep wounds can develop from infection. The result can be necrosis (tissue death).

The systemic symptoms are caused by the neurotoxic effects of the venom. Neurotoxins primarily target the nervous system. Systemic symptoms can include muscle cramping, sweating, nausea, vomiting, fever, chills, and dehydration. In less than one per cent of cases, the reaction can be severe enough to cause paralysis, respiratory arrest, and even death.

Most of the time, local treatment of the skin is all that’s required. A tetanus shot may be needed. Hospitalization is only necessary when there is a severe reaction with dehydration and/or compromise of the heart or lungs. Antibiotics are not used unless infection develops.

Antivenin (an antidote to the poison) is not given routinely because symptoms go away quickly (within several hours to several days). Although there is a specific antivenin for brown recluse spider bites, it is not available in the United States. There aren’t very many studies on the subject, but research evidence does not support the use of antivenin to prevent skin necrosis.

Keep a close watch on your son for the next few hours to days. If he starts to develop any systemic signs, call your doctor immediately.

The symptoms you described could be coming from a couple of different problems. The most likely is something called de Quervain’s tenosynovitis. But you could also have arthritis of the joint at the base of the thumb, wrist arthritis, or another condition called intersection syndrome.

De Quervain’s tenosynovitis is described as a thickening of the tendon sheath, enlargement of the tendons, and thickening of tenosynovium. The tenosynovium is a slippery covering that allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon is called tenosynovitis.

This condition affects two thumb tendons. These tendons are called the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). On their way to the thumb, the APL and EPB tendons travel side by side along the inside edge of the wrist. They pass through a tunnel near the end of the radius bone of the forearm. The tunnel helps hold the tendons in place, like the guide on a fishing pole.

A quick and easy way to see if you have de Quervain’s is to place your hand on the edge of a table (or arm rest on a chair) with the wrist supported but the hand off the edge of the supporting surface. Now tilt your hand down toward the floor.

When someone else is examining you, that examiner will then gently grasp your hand and passively (without your help) move the wrist a little farther in the downward direction. You can use your other hand to do this to yourself.

The final step is for the examiner to press down on your thumb (moving it toward your palm). Again, you can use your other hand to do this to your painful hand. Neither one of these last two steps is performed if you (or the patient) have pain with the first step.

There are other tests that can sort out de Quervain’s from arthritis. The best way to get an accurate diagnosis is to see your physician (either your primary care doctor or an orthopedic surgeon). Getting a diagnosis and treatment early on can help prevent this from becoming a chronic problem.

Dupuytren’s disease refers to the tightening of a thin sheet of fascia or connective tissue called the aponeurosis. In the hand, the aponeurosis is shaped somewhat like a triangle. It is located just under the palm and covers the tendons of the palm, holding them in place.

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 disease causes contractures to form. The palmar fascia tightens, causing the fingers to bend and get stuck, unable to straighten.

Collagenase is an enzyme that can be injected directly into the problem area. With Dupuytren’s disease, the involved soft tissues include If you remember the little Pac-men in commercials for laundry detergent or the game Pac-man, you know that enzymes break down substances like dirt. In this case, they are being used to break down the collagen fibers that cause the tendon thickening.

Studies done so far have used up to three injections, 30-days apart. Follow-up has shown that collagenase injections works best for patients who have the most problems at the metacarpophalangeal joints (MCPs). The MCP joints are what we more commonly refer to as the knuckles across the back of the hand. The injections have been used successfully for the proximal interphalangeal (PIP) joints but with less improvement of motion. The PIP joints are the joints in the middle of the fingers.

It looks like collagenase injections work best for mild-to-moderate Dupuytren’s disease. More severe cases improve but not by as much. Contractures (joint is stuck and can’t move any farther) of 50-degrees or more don’t seem to loosen up as much as contractures less than 50-degrees. Fingers that are contracted 40-degrees or less have the best results with more motion and fewer complications.

Having an allergic response to the treatment is one of those potential complications. But studies so far have reported swelling of the fingers, bruising at the injection site, swollen glands, and skin itching that are self-limiting. That means the symptoms go away in a relatively short period of time.

When tested, the majority (85 per cent) of patients studied showed that they had developed antibodies against the collagenase. These symptoms were not considered allergic responses.

If you have not already discussed your tendency to have allergic reactions when exposed to new substances, be sure and bring this up at your next meeting. Your surgeons will want to be prepared for any possible reactions and minimize any adverse effects of the treatment.

As you probably know, Dupuytren’s disease is a condition where the tissue just under the skin in the palm of your hand becomes thick and shrinks, pulling very tight. In some cases, this causes lumping or unevenness of the palm of the hand and in others, it can cause a significant flexion contracture, making the hand look as if it is permanently holding on to something.

The regularly accepted treatment for Dupuytren’s has been surgery. It sounds like you’ve already been down that path. A new treatment called percutaneous aponeurotomy has been developed and studied. Early results using this technique for Dupuytren’s disease have been very promising.

Percutaneous means the procedure is performed through the skin without an open incision. After numbing the skin, the surgeon passes a small needle through the skin to the tight cords and makes several cuts. Cuts are made until the finger can be moved by the surgeon through its full range-of-motion.

The need for formal hand therapy is reportedly less following percutaneous aponeurotomy. The therapist may evaluate you, give you a home program to follow, and recheck you several weeks later. If you develop significant problems with motion, don’t get your motion back, or have persistent weakness, then a formal rehab program may be needed.

The timing of tendon transplants is a matter of considerable debate. Early transfers (done within the first weeks after injury) create what is called an internal splint. An internal splint works much like and external splint (one that is strapped on around the arm). Whether an internal or external spling, the effect is to hold the arm in place so the tendons and ligaments don’t get overstretched or the joints contracted (so tight it can’t move fully).

Nerve recovery may be spontaneous as a result of the normal, natural healing process. Or it can be helped along by surgery to repair damage to the nerve. Until it’s clear what’s going on, tendon transfers can be delayed — sometimes by weeks to months (up to 18 months).

When it’s clear that the nerve to an individual muscle isn’t going to recover, then surgery is done to transfer a tendon to take over the function of the muscle no longer innervated by the damaged nerve. The surgeon can’t take any tendon. It must be one powerful enough to accomplish the task needed. The donor tendon must also move like the tendon it is replacing in order to provide the function needed.

Understanding the anatomy (location of nerves and the muscles they supply) and what to expect in recovery is essential. This knowledge aids in making the decision about timing of tendon transfers as well.

And although the surgeon’s role is very important, it is important to recognize the value and benefit of a multidisciplinary (team) approach. That team is made up of the patient, parents (if the patient is a child), nurses, therapists, and electrodiagnosticians (nerve testing). Everyone’s contribution to the patient’s care is a valued part of patient care, recovery, and rehabilitation.

Staph infection (staphylococcus aureus being the most common type) affecting the hand can develop as a result of trauma. Records kept by trauma units and emergency departments in hospitals report wood splinters and metal pieces getting embedded in the hand as the most frequent way an opening into the hand leaves the body at risk for a staph infection.

There are other means by which bacteria can get introduced into the bloodstream, soft tissues, and joints. Human bites, insect bites, and intravenous (illicit) drug use are three other mechanisms of wound development. There are cases of spontaneous infection without any known event beforehand.

If antibiotics will work, then your son may have what is referred to as a community-acquired methicillin resistant stapholococcus aureus (CA-MRSA) infection. The really worrisome type of infection is just called MRSA. This type of staph infection is resistant to all antibiotics. It is multidrug resistant.

Older adults are at the greatest risk of developing staph infections that are multidrug resistant. They have weak or compromised immune systems. They may be catheterized or on dialysis. Health problems such as diabetes may increase the risk of infection.

Once your son has had the surgery to debride (clean out the infection) the wound and gets back on his feet, it may be possible to identify what led up to the infection in the first place. It could be any one of the risk factors identified for community-acquired MRSA. But it could remain unknown.

The overuse of antibiotics has led to bacteria that have become resistant to the effects of antibiotics. You may have heard of this problem. The term superbugs has been used to describe staphylococcus aureus (“staph”) bacteria that are no longer killed off by drugs. The infection that can develop is called methicillin-resistant S. aureus or MRSA (pronounced Mer’-suh).

The number of cases of MRSA continues to rise steadily. The biggest group of patients affected are those in the hospital, nursing homes, or other extended care facilities. Patients on dialysis or who have a weak immune system are also at increased risk for MRSA. But there’s another twist to this story. Now there is community-acquired MRSA or CA-MRSA infections.

Community-acquired MRSA (CA-MRSA) is a methicillin-resistant staph infection that occurs in healthy people. These folks are not in the hospital, they are not on dialysis, and except for this new infection, they are otherwise in good health.

There’s good news and bad news about this type of bacteria. The bad news is that studies have shown this type of superbug didn’t spread from the hospital to the community. It’s a different bacteria with a different genetic makeup compared with the hospital-based MRSA. The good news is that community-acquired MRSA infections can still be treated using antibiotics.

We suspect this last piece of information explains why the health care staff working with your father mentioned the “good news” linked with CA-MRSA.

Post-operative recovery depends somewhat on a number of different things. For example, your overall physical health can affect how quickly you recover or whether you have complications. People who smoke, have diabetes, high blood pressure, or circulation problems tend to have more problems after any surgical procedure.

The complexity of the surgical procedure can be a risk factor for complications. Sometimes the surgeon has to drill holes through the bone. That can increase the risk of bone fracture and infection.

In a recent study of 48 patients who had a similar surgery, twenty per cent (20%) had some type of problem either related to the anesthesia or to the hand itself. Most of these were single events (meaning only one patient was reported for each complication).

Complications included numbness, infection, persistent pain, and adhesions (scarring). Some of the problems could be treated with antibiotics. Others required an additional surgery.

The rehab program following surgery usually consists of gentle but active finger motion right away. The thumb, hand, wrist, and forearm are often placed in a plaster splint for a few days. Then the splint is removed and a short-arm cast (thumb included) is put on.

All of this is done to support and protect the healing surgical site. After six weeks, all protective devices are removed and gentle active motion and light activities (e.g., brushing teeth, combing hair, picking up objects that are easy-to-lift and hold) can begin.

The entire rehab process takes three to four months. By that time, you should be able to do all your normal activities without any problems.

Osteoarthritis of the thumb can be a very debilitating problem. Without a good, strong, stable thumb, it is difficult to hold a key and turn it in the door or open a jar. Pain and limited motion can make even simple motions like picking up a penny impossible.

Thumb arthritis usually affects the basal joint. Just as the name suggests, the basal joint is located at the base of the thumb where the thumb meets the wrist. It is the joint that allows you to stick your thumb out as if hitch hiking or touch the pad of the thumb to each finger.

The first line of treatment is usually antiinflammatory drugs and hand therapy. The hand therapist will show you how to use your hands in ways that reduces the stress on the joint. When conservative (nonoperative) care fails to provide relief from symptoms, the hand surgeon considers the need for surgery.

There are many different types of surgical procedures used One individual approach has not been found to be the best for everyone. One simple procedure is called a trapeziectomy (removal of the trapezium).

The trapezium is a rectangular-shaped bone in the wrist. It is located right where the thumb meets the wrist. Taking the bone out (a procedure called trapeziectomy) removes the source of the pain, but something must fill the hole in order to stabilize the joint.

Trapeziectomy can be done along with interposition of tissue and soft tissue reconstruction. Interposition refers to using a piece of tendon or ligament folded up to fit into the empty space left by the bone removal. The technique is simple to do, gives the patient relief from the painful symptoms, and restores thumb motion and strength.

Men and women who handle fish (fresh or frozen) with their bare hands are at risk for hand infections. Usually, the type of bacteria present is mycobacterium marinum. Exposure to this type of bacteria (leading to hand
infection) is common with exposure to fish. There is a less common (actually rare) bacteria among fish handlers that can also cause infection and even death of the affected soft tissues.

Early diagnosis and aggressive treatment may be needed to prevent the rapid spread of infection and damage to the tissues caused by mycobacterium abscessus. Surgery is done to open up the hand, drain the infection, clean the area out, and provide the most effective antibiotics. Together, this combination of treatment is essential to a good outcome for these patients.

Hand therapy after surgery is needed to prevent stiffness and assure smooth return of full finger motion and hand function. The therapist (either a physical or occupational therapist) may provide a special gutter splint to help maintain finger range-of-motion. The splint helps prevent the loss of finger extension (and subsequent curling of the fingers into flexion). Without full finger motion, hand function can be severely affected.

Since your job probably involves fine dexterity of the hands (and also keeps your hands in a flexed position much of the time), hand therapy is an excellent idea. Your surgeon and your therapist will be able to advise you about specific dates for returning to work. Following your home program may help ensure a faster recovery.

Every job has its ups and downs. Men and women who handle fish (fresh or frozen) with their bare hands are at risk for hand infections. Fish, shrimp, and other seafood products have sharp fins or claws that can cause small cuts in the fingers or palms of the hand. The tiny opening is big enough for bacteria to enter and cause damage to the tendons and tendon sheaths (covering around tendons).

Usually, the type of bacteria present is mycobacterium marinum. Exposure to this type of bacteria (leading to hand infection) is common with exposure to fish. A less common (rare) bacterium among fish handlers that can also cause infection and even death of the affected soft tissues has been reported.

Symptoms of hand infection due to mycobacterium abscessus are very similar to symptoms caused by the more common mycobacterium marinum. Symptoms include pain, swelling, and redness of the skin over the area affected. Fish handlers often ignore the symptoms. They may keep on working for months before seeking medical help. They may not be able to identify a single traumatic event that could have caused the problem. And they are in good health otherwise.

You may not have done anything different from other fish handlers. If your immune system was compromised (weakened) for any reason, you could have been at increased risk for hand infection. Previous trauma to the affected area may put you at risk for infection. Use of contaminated needles (e.g., to inject drugs) is another risk factor for this type of infection. But, there may not be a known cause in some fish handlers.

The extensor tendon is what works to allow you to extend your hand and fingers. Without them working properly, you would not be able to flatten you hand out or point your fingers. There are many ways the extensor tendons can become damaged, and if they are not treated properly, you could be left with a long-term inability to use your fingers to their fullest potential.

Trigger finger is a common tendon disorder of the hand. The flexor tendon pulls and causes your finger to fold or bend to the point that it locks. In most cases of trigger finger, it is idiopathic, which means that doctors don’t know why it happened, there is no known cause.

Injecting a corticosteroid to treat a trigger finger is the usual and most commonly accepted treatment. For many people, the one injection is all they need. However, not everyone responds the same way, as you can see with your husband. A second injection has a lower success rate than the first one, and there is no proof that a third injection is of any use.

Because the trigger finger returned so quickly after the second injection, his doctor likely feels that a third injection just won’t help. That is probably why he suggested surgery, which has a very high success rate.

A mucous cysts on the finger, just below the cuticle, is not uncommon. It is a sac-like structure that is filled with fluid and it can cause the finger nail to become indented. It can also cause pain, particularly if there is arthritis or osteophyte formation (small bone pieces) in the joint.

There are ways to treat the cysts without surgery, such as with steroid injections, but they are not always successful and the cyst may come back. Surgery is more reliable in terms of long-term results, but all surgery has its risks, such as infection.

Whether your mother should take the risk or not is a discussion she should have with her doctor, who knows her medical history. Second opinions are also possible and if your mother has questions or doubts, then she should consider consulting with another physician.

Mucous cysts on the fingers can be merely annoying or they can be painful. They are not cancerous or dangerous, so having one doesn’t really do much to your hand or health, except the affected fingernail may become bent or deformed.

If you are not concerned with the cyst and it is not bothering you by causing pain or limiting your range of motion, then discuss with this your doctor to explain why you are refusing surgery. Ultimately, it is your decision.

The best advice we can offer is to follow the instructions your surgeon gives you as closely as possible. He or she knows what exactly was done and how much load, stress, and pressure the healing tissue can handle.

At the same time, it might be helpful if you had a little background information about flexor tendon injuries. For example, back in the 1970s, hand surgeons discovered that early motion after flexor tendon repairs yielded better results. Putting the hand in a splint that blocked some motions but allowed others was better than no motion at all. Those early studies supported the idea that motion is lotion.

Since that time, research has continued in the area of hand therapy. Hand rehab programs have expanded to include all kinds of different ideas for post-op positioning, motion, and exercise. So you can expect your husband to be treated by a hand therapist early on after surgery.

Some interesting findings from a recent study might be helpful, too. In the study, the use of a passive motion program was compared with early active motion therapy. The authors believe this is the first study published comparing these two hand therapy techniques.

Passive motion refers to the fact that someone else other than the patient (in this case, a hand therapist) is moving the affected fingers. Active motion means the patient is moving the finger by himself.

The results were striking. Patients in the early motion group had significantly better outcomes. They had much more motion, fewer (and less severe) joint contractures, and better dexterity (e.g., picking up small objects, using fingers to manipulate objects). Not surprising, the early motion group with the better results were also much happier with the progress they made after surgery.

Patients treated by a certified (specially trained) hand therapist also had better outcomes. There were some negative predictive factors to take note of. A negative risk factor means that when either of these factors were present, the patients were more likely to have worse results.

In this study, cigarette smokers, patients with more than one finger laceration, and those with nerve injuries seemed to have the worst results. There’s not much someone can do to change the injury once it has happened.

So your husband’s two finger involvement increase his risk of complications. But if he smokes or uses tobacco, he would do well to reduce his tobacco use (eliminate it if possible during the healing and recovery phase). Good nutrition is also essential. And, of course, as mentioned — follow the surgeon and the therapist’s directions carefully.