News Category: Hand

It’s clear that Dupuytren’s Disease (DD) has a genetic base but scientists don’t know much beyond that. In this study researchers try to find the DNA sequence to explain DD.

DD causes thick scar tissue to form in the palm of the hand pulling the fingers into a flexed position. The patient with DD is unable to straighten the affected fingers. This is called a flexion contracture.

DNA microarray technology was used to look at DNA in three groups of patients. One group had DD. Tissue samples were taken from the contracted tissue. The second group of tissue samples came from patients with carpal tunnel syndrome. Normal, healthy tissue (control samples) were also taken from the DD group.

The technology used helped find genes present in the DD tissues that were not found in the other two tissue samples. Seven such genes were found but only one (MafB) can cause the overgrowth of tissue. MafB was then examined more closely.

The authors found more than four times the normal amount of MafB in the DD tissue samples. This is described as an upgraded expression of the MafB gene. There was no MafB found in any of the control or carpal tunnel tissues.

Future studies are needed to understand the role of MafB in DD. Finding the exact cause of the problem could help researchers find a cure for this disabling condition.

Scientists are looking for a genetic model to explain Dupuytren’s Disease (DD). DD is a benign condition. It causes thick, scar tissue to form in the palm of the hand. One or more fingers are pulled into flexion. It’s a common problem in northern European white populations.

In this study adults from northwestern England were recruited. Each one had surgery for DD. Family members were part of the study. Each one filled out a survey. Questions were asked about work history, smoking, and use of alcohol. Special note was made of anyone with liver disease, diabetes, high cholesterol, or epilepsy.

Computer software was used to analyze family history, risk factors, and patterns of disease among siblings. The authors report the following results:

In this study scientists and mechanical engineers at the University of Illinois looked at the Neuflex finger joint replacement. They measured changes in patterns of motion in the finger joints before and after the implant was put in.

Joint implants must be tested and studied before use in humans. This type of research is done on cadavers (human hands saved after death for use in studies). In the lab, the Neuflex MCP arthroplasty implant was used in the index, middle, and ring fingers of several cadaver hands. The MCP or metacarpophalangeal joints form the joints we usually call “knuckles” on the back of the hand.

The Neuflex MCPs are designed with a slight amount of flexion. This position helps mimic the normal MCP joint during rest when the hand tends to remain in a slight fist. The scientist who first designed this implant believed the constant stress of being straight would cause implant failure.

Joint and tendon motion along with joint forces were measured for all three joints in each finger. These measures were compared to unoperated fingers. The pattern of motion with the Neuflex MCP implant was similar but not exactly the same as the unoperated side.

There was more flexion in the fingertip and middle finger joints compared to the unoperated side. There was slightly less total flexion at the MCP joints. Overall, total motion was the same.The authors think the changes observed occur because the Neuflex implant is already slightly bent.

The results of this study show that the Neuflex MCP implant does restore normal motion. Cadaver studies don’t give any idea how long the implants and normal motion last over a long period of time. Human studies are needed for that.

Many school students take shop class or automotive or industrial arts. Injuries can occur, especially with table saws and other dangerous equipment. This report takes a look at a series of cases (15) involving trauma to the wrist or hand in shop class. The authors want to bring this risky activity to our attention and help prevent future injuries.

Table saws caused more than half of the injuries. Band saws, drill presses, routers, and planers were also ways students injured themselves. Amputation, tendon injury, and cutting a nerve or blood vessel were the most common accidents. Boys were affected in 14 of the 15 cases. This may reflect the fact that more boys than girls take shop class. Everyone needed some medical care. Some students needed one or more operations.

This is the first study of shop class injuries reported. To prevent long-term disability in young people teachers must instruct and insist on the use of safety measures. The authors question whether power saws should even be allowed in high schools. Trauma can be minimized with care by a hand surgeon trained in microvascular surgery.

In this review article hand surgeons from the University of Colorado Health Sciences Center in Denver discuss what causes trigger finger and what to do about it. Both conservative care and surgery are explained in detail. What to expect and types of problems that can occur are also presented.

Usually trigger finger is a mechanical problem. It can be caused by a tendon that’s too large for the pulley mechanism it slides through. Or sometimes the outer covering over the tendon is too tight. The tendon can’t slide and glide normally.

Trigger finger can also occur as a result of other conditions. Carpal tunnel and trigger finger often develop at the same time in the same patient. Endocrine and metabolic diseases can be the cause of both. Patients with systemic diseases like rheumatoid arthritis and diabetes have a higher risk of trigger finger.

Whatever the cause of trigger finger treatment is usually the same. First nonsteroidal antiinflammatory drugs (NSAIDs) are used. Splinting may help. Steroid injections are also common. Patients get long-term relief with one to three injections.

When all else fails the patient may want to think about having surgery. The surgeon makes a small incision in the palm of the hand. The pulley is cut. In most cases there aren’t any problems for the patient afterwards. The authors do review the complications that can occur with surgical treatment for this problem. Releasing the wrong pulley and nerve injury are uncommon but serious side effects of this operation.

Imagine being a quarterback on a Division I team and your finger is stuck in a flexed position. You can’t straighten your finger to release the ball. In this case report, doctors present the diagnosis and treatment of a 20-year-old football player with just sush a locked finger joint.

The metacarpophalangeal or MP joint is the large joint that forms what we call the “knuckle” on the back of the hand. A locked MP joint is fairly common in the index and middle fingers. In this case the patient was lifting weights when he felt a “pop” in his index finger. It was painful, and he could no longer extend the finger past 40 degrees. The surgeon was unable to unlock or reduce the joint without doing surgery.

Surgery was done to release the soft tissue around the joint. The joint was put back in place successfully. The first operation didn’t take care of the problem. The patient came back six months later with the same locked MP. A second operation opened the joint. The surgeon found a bony ridge on the joint that was catching a ligament inside the edge of the joint. The bone and ligament were both removed.

Two years later the patient had no symptoms and was able to return to play football as both a quarterback and a wide receiver. The authors present this case to show that not all locking fingers are caused by a single problem. Most patients have a locking MP from a condition called tenosynovitis (inflammation of the tendon sheath). This case was different.

Carpal tunnel syndrome (CTS) affects the median nerve as it goes through the bones of the wrist. The median nerve affects the sensation and strength of the thumb and first two fingers. It’s logical to assume thumb strength is less with CTS. Researchers from the Hand Research Laboratory at the University of Pittsburgh tested this theory out.

They measured thumb strength in 12 women with CTS and compared it to 12 women without CTS. The women in both groups were about the same age. All 24 women were right-handed. Strength was measured in all directions including flexion (thumb down), extension (thumb up), abduction (thumb away from hand), and adduction (thumb toward hand).

The authors report they did not find decreased thumb strength in motion controlled by the median nerve for patients with CTS. They actually had more weakness in directions controlled by the ulnar nerve. Direct weakness of nerve-specific muscles just wasn’t found.

The researchers offer some possible reasons for their findings:

In this study researchers at the University of Cincinnati followed 59 patients with Dupuytren’s nodules of the hand. Patients were seen for at least six years from the time symptoms started.

Dupuytren’s involves the fascia or connective tissue of the palm. An excess of abnormal connective tissue forms nodules in the palm. The base of the ring and little fingers are affected most often.

The authors review the course of the disease. Nodules form then develop into cords. Joint contractures form with loss of motion. As time goes on the condition usually gets worse and often affects both hands. A small number of patients do get better.

The authors found three major risk factors in how quickly Dupuytren’s progresses. These include disease before age 50, Northern European ethnicity, and a positive family history of Dupuytren’s.

The overall fate of most patients with Dupuytren’s is one of gradual progression. The earlier it develops in life, the faster it gets worse. Surgery to remove the nodules is not always advised. Often the nodules come back.

Surgeons are trying new ways to restore the trapeziometacarpal (TMC) joint at the base of the thumb in patients with osteoarthritis (OA). Pain and weakness from pain reduces pinch strength from this problem. Without a strong pinch, patients are limited in how they can use that hand.

In this pilot study, surgeons compared two ways to treat TMC OA. The first was a standard removal of the trapezium bone with a nearby tendon used to stabilize the joint. The operation is called a tendon arthroplasty. The tendon is actually rolled up into a ball and tucked into the space left by the missing bone. The second was the removal of the trapezium bone with a special T-shaped device put in the open space.

The joint spacer used in the second group was biodegradable. It works by giving the local tissue a place to lay down new healing tissue. This is called a scaffold for tissue ingrowth. The spacer slowly disintegrates as the new tissue is formed. Over time any pressure or load through the joint is transferred from the device to the newly forming joint capsule.

Results were measured by pain, strength, motion, and stability. All but one patient was followed for three years. Everyone was pain free and had equal motion after the operation. The main difference between the two groups was pinch strength. Patients with the biodegradable spacer had increased pinch strength compared to the tendon arthroplasty group.

The authors conclude that the use of a TMC spacer gives equal, if not better, results than tendon arthroplasty for TMC OA. It may be the treatment of choice for anyone with TMC joint pain and damage who needs good grip function and pinch strength.

Doctors at the Boston Medical Center have found a way to do two operations on the wrist and hand with one incision. They used a special L-shaped cut called the Wagner incision. In this operation, the trapezium bone can be removed and the transverse carpal ligament can be cut.

Now surgeons can treat thumb arthritis and carpal tunnel syndrome at the same time. This is important because patients often have both problems together. A single operation cuts down costs and time in recovery. There are fewer problems because the nerve inside the carpal tunnel isn’t disturbed. The single scar looks better too.

This study was done on four cadavers (upper limbs saved after death for study). The exact steps of the operation are described in detail for any interested surgeon. The authors say based on their results, the Wagner incision can be used to do a two-part operation in one-step safely.

Dupuytren’s disease causes a tightening of the fingers, called contractures. Dupuytren’s most often pulls the small and ring finger into flexion (towards the palm of the hand). Sometimes the middle finger gets a contracture, too. The authors of this report have done other studies showing improved hand function after surgery for Dupuytren’s. In this study they look at which joints are most responsible for improved hand function after surgery.

Thirty patients were tested before and after surgery. Angle of joint deformity was measured for two joints, the MCP and PIP joints. The MCP joints form the knuckles across the back of the hand. The PIP joints are the middle joints of each finger. All patients had contractures of one or more joints in one or more fingers.

All but one patient had improved MCP and PIP joints when checked six months and 12 months after surgery. Results showed that the more deformity present in the joints, the worse the hand function. Improving PIP motion has a greater effect on hand function than improving MCP motion.

The authors conclude that joint position does make a difference in hand function for patients with Dupuytren’s disease. Both the MCP and the PIP joints are important. But it is especially important that deformed PIP joints be corrected.

Computers are everywhere. And it will be a while before data entry is done by voice alone. Until then, keyboard design is important in reducing problems like neck pain, carpal tunnel syndrome, and wrist tendonitis. Do the new slanted, separated, and tilted keyboards help reduce these problems?

A physical therapist and an engineer at Marquette University in Milwaukee, Wisconsin, review the studies done so far to answer this question. Here’s what they found in their investigation:

In this article, a well-known physical therapist reviews the latest findings on carpal tunnel syndrome (CTS). Her focus is on nonsurgical treatment. She discusses the use of splinting, cortisone injections, and exercise.

The use of heat, laser, magnets, and yoga are also presented. Patients and therapists are told how to decide when surgery is the best option. Details are offered on what to expect after surgery.

Dr. Michlovitz reminds therapists that CTS can be caused by diseases such as diabetes, arthritis, and hypothyroidism. She points out that splinting should put the wrist in a neutral position. This is a fairly new finding after years of splinting the wrist in slight extension.

Patients with mild to moderate symptoms of CTS can do well with a program of splinting and exercises. The patient and therapist work together to find activities and positions the patient should avoid. This might include long periods of gripping or awkward positions of the wrist and hand.

Surgery is an option when symptoms are severe and don’t respond to therapy. Patients who have mild symptoms but with muscle loss and muscle weakness might also need to consider surgery.

Doctors at the Mayo Clinic in Jacksonville, Florida, report four cases of arthritis from ovarian cancer. In each case the women had their first symptoms in the hands. Swelling, stiffness, and pain were reported. Then the palms became red, and bumps or nodules formed. One woman also had carpal tunnel syndrome.

Diagnosis was delayed because the standard lab values were all normal. X-rays and MRIs were typical for arthritis. It wasn’t until the tumor was large enough to be found that a correct diagnosis was made and proper treatment started. Most cases of ovarian cancer were found at an average of nine months. In one case the patient had inflammatory muscle pain for five years before having hand symptoms.

By the time an accurate diagnosis was made, the women had joint contractures of the hands. This means the joints could no longer straighten and the women couldn’t open their hands fully. Hand pain improved with treatment of the cancer. Joint motion didn’t change for three of the four women. In one case, the cancer spread to the lungs. Despite treatment, she died.

Ovarian cancer is the fifth leading cause of cancer deaths for women in the United States. Reliable screening tests haven’t been found yet. The authors suggest that any women with sudden symptoms of hand arthritis or changes in the palms should be checked for cancer.

The Place: Finland. The Time: Between 1978 and 1980. The People: 8,000 Finns, age 30 or older.

Doctors offered each person in this pool of 8000 subjects a complete physical exam. Then everyone was followed for up to 17 years. Researchers use studies like this to look at many health issues. This study measured the number of cases of thumb arthritis and looked for risk factors.

Subjects with a history or symptoms of muscle or bone disease were given a special X-ray of the hand. A test of function was given to assess overall disability. The authors found that women who smoked were more likely to have arthritis of the carpometacarpal joint (CMC). The CMC joint is at the base of the thumb. Obesity was directly linked to thumb OA in both men and women. In fact, overweight subjects were twice as likely to have thumb OA compared to people the same age with normal weight.

The authors conclude that OA of the CMC joint is common in Finland. Obesity is the number one risk factor. It affects the body as a whole and the thumb joint in particular.

Does surgery for severe carpal tunnel disease improve pain and other symptoms in people over the age of 70? Doctors at the University of Rochester in New York asked this question in a recent study.

Pain, grip strength, and function were measured in 14 hands before and after surgery. The operation involved an open incision and carpal tunnel release (CTR). Local anesthesia was used.

The researchers found no change in grip strength before and after the operation. However, the patients were happy with the results. They had less pain and more function. These results were seen as early as six months after surgery. There was more improvement in symptom severity and ability to use 12 months after the surgery.

There’s been some debate about CTR for severe disease in older adults. As this study shows, taking pressure off the median nerve in the wrist does help. Patients are satisfied with the results even though they don’t get back their full strength.

In this study, no one needed any more hand surgery for this problem. The authors say that complete recovery is more likely when surgery is done early. Patients should be warned that a delay could mean some symptoms will remain after surgery, and that grip strength may not change.

Doctors in Japan report two cases of a very rare thumb condition. In this condition, one thumb tendon on the back of the hand is missing, and another tendon is in its place. Both patients in this study had wrist pain on the thumb side of the wrist. The pain was made worse by moving the thumb.

A diagnosis could be made based on pain, swelling, and a positive Finkelstein’s test. Finkelstein’s test is done by making a fist with the thumb wrapped inside the fingers. The wrist is then tilted down toward the floor. Painful symptoms on the thumb side of the wrist suggests a tendonitis of two tendons in the wrist. These tendons are the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). The condition is called de Quervain’s disease.

In the first case, treatment for de Quervain’s with cortisone injections didn’t change the patient’s symptoms. During surgery the doctors found that the EPB was missing. In its place was the extensor pollicis longus (EPL) tendon. The EPL is usually on the index finger side of the thumb. It attaches to the back of the last knuckle of the thumb. Contracting the EPL straightens the tip of the thumb. The doctors pulled on the tendon, and found it did indeed pull the tip of the thumb back.

The second case was another patient diagnosed with de Quervain’s disease. The diagnosis was made based on the painful symptoms along the thumb side of the wrist. Again cortisone injections didn’t relieve the pain. When the patient could no longer extend her thumb, surgery was done. The doctors remembered the first case and looked closely at this patient’s anatomy.

They found that the EPB was missing. Again, the EPL took the place of the EPB in the wrist. The EPL was tightly bound down by the lining (tendon sheath) around it. The surgeons released the tendon sheath. Immediately, the patient had complete relief from her symptoms.

The authors report that it’s possible to have what looks like tendonitis of the EPB when it’s really the EPL. This happens when the EPB is missing and the EPL is in its place instead. The doctor can avoid making the wrong diagnosis. Swelling and tenderness are located further up the wrist and more toward the center than in de Quervain’s disease.

The key is in the tip of the thumb. Since the EPL straightens the tip, any problems with this movement can alert the doctor. If a patient has painful symptoms like de Quervain’s disease but can’t straighten the tip of the thumb, the problem isn’t de Quervain’s. In such cases the problem is more likely tendonitis of the EPL and not the EPB.

Statistics from 1996 indicate that workers in Ontario, Canada, are commonly affected by carpal tunnel syndrome (CTS). Nearly 1,000 of the three million workers covered by worker’s compensation had CTS that was severe enough for them to miss work. Most of the patients worked on assembly lines or did fabrication work. Other jobs included clerical (office), food processing, construction, and retail. A small number of bus drivers, mechanics, and janitors were also included.

Researchers reviewed the medical charts of these patients. They looked for factors that affected treatment. They also looked for treatment that worked and the cost of work-related CTS. Workers also got a survey four years after their CTS case was opened. Questions were asked about their symptoms, severity of symptoms, and daily activities. They were also asked about recreation and when they went back to work.

The authors found that only 14 percent of patients were symptom-free. Most of the workers still had pain or numbness or both. Almost half had severe pain. More than half had moderate to very severe numbness. About one-fourth of the workers reported moderate to severe problems with daily activities. Nearly half had trouble playing an instrument, doing crafts or hobbies, or joining in sports. More than one-third couldn’t go back to their job or work at all because of the CTS.

Office workers were more likely to return to work (RTW). Assembly or food processing workers were less likely to report RTW. Workers who’d had arm and hand problems in the past were also less likely to RTW. The same was true for workers with diabetes or arthritis.

The authors point out that about one of every 70 workers has CTS severe enough to miss work. Workers who miss work because of CTS are usually in their early 40s. This compares to late 50s when CTS occurs in the general population. It appears that most workers keep working with early symptoms of CTS before filing a worker’s compensation claim. Those who ended up having surgery generally had a better result.

The cost of work-related CTS in Ontario is high ($8,330 for CTS in one wrist, and $15,450 for CTS in both wrists). The largest expense is for lost time benefits. Other costs included drugs, doctor visits, medical tests, and surgery.

These researchers report that a large number of Canadian workers suffer pain and loss of work and money from CTS. They were unable to say which factors had a direct cause and effect. More study is needed to answer many questions that still remain about work-related CTS.

Osteoarthritis (OA) at the base of the thumb can be very disabling. Pain and decreased motion result in loss of function. Even the simplest task can become impossible. In this study doctors at Washington University in St. Louis looked at the use of steroid injection and splinting for this problem.

Researchers used a single injection of a steroid drug into the basal thumb joint of 30 patients. A special thumb splint was worn for three weeks after the injection. Patient’s pain, strength, and function were measured at six weeks, 12 weeks, 12 months, and 18 months after the treatment.

The authors report that the best results occurred in patients with mild thumb OA. The more severe the OA, the less likely patients would get pain relief that lasted. With decreased pain, there was increased strength and improved function. Anyone who didn’t get better from the injection by six weeks didn’t improve later.

This study shows good results in early thumb OA by combining a single steroid injection with splinting. Surgery may be a better treatment option if X-rays already show bone spurs or narrowing of the joint space.

People with diabetes often have carpal tunnel syndrome (CTS). CTS can occur as a result of pressure on the median nerve as it passes through the bones in the wrist. The nerve can also get stuck inside its protective covering and no longer glide as it should. This is called nerve entrapment. CTS from nerve entrapment can cause pain, numbness, and tingling in the wrists, hands, and fingers.

The treatment for CTS may involve an operation, called carpal tunnel release, to get pressure off the nerve. Some studies show that patients with diabetes and CTS don’t have as good a result after release surgery as patients with CTS who don’t have diabetes.

To test this idea, doctors in Italy compared two groups of patients with CTS. Group one (24 patients) had CTS and diabetes. Group two (72 patients) only had CTS. Symptoms, pain level, strength, and function were measured one month and six months after the operation.

The authors report relief from pain and symptoms right away in almost all the patients in both groups. All but two patients went back to work within a month of the carpal tunnel release. Patients in both groups continued to improve up to six months after the operation.

Unlike other studies, these researchers conclude there is no difference in results between CTS patients with and without diabetes. In other words, diabetes isn’t a risk factor for a poor result after carpal tunnel surgery. This means diabetes should not keep a patient who needs it from having carpal tunnel surgery.