News Category: Hand

Who goes to the doctor and what do they go for? Insurance companies and managed care companies use this information to plan services. When it comes to orthopedic services, back pain tops the list of musculoskeletal problems. After that comes arthritis, traumatic injuries, and knee and shoulder problems.

Only about one in 10 patients is seen for a wrist or hand problem. The most common wrist or hand problems are fractures, carpal tunnel syndrome, tendonitis, and cysts. About half of those patients needed surgery.

These are the results of a study looking at how often members of a capitated insurance plan are treated for a specific body region. (Capitated means a single fee per person is paid to the doctor or clinic.) This type of plan is called a health maintenance organization (HMO). The same amount of money is paid to the HMO whether you see the doctor (or other health care provider) 100 times a month or not at all.

Researchers who conducted this study also looked at how gender and age are linked to services used by patients. They found use of services for arthritis increased as patients (especially women) got older, starting at age 35. Wrist and hand problems caused by trauma decreased with age after age 35. Men are more likely to be treated for injuries. Children from birth to 15 use orthopedic services the most for hand and wrist conditions.

Knowing how much demand there is for a type of service or doctor helps HMOs plan ahead. They can tell how many doctors they’ll need and what kind of training those doctors must have to work in the HMO. The information also helps doctors negotiate contracts and fee schedules with the HMO.

Doctors find that patients tend to fall into three groups. The first group are the optimists who are happy no matter how poor the results of their treatment. The second group are pessimists who report poor results even when the doctors think that things look good. In the third group, everything is “just right” — the results and the patient’s report match.

Hand surgery specialists at the University of Cincinnati find themselves in a different group altogether. They report the results of adults receiving new finger joints for severe rheumatoid arthritis. They see poor results and aren’t happy. It seems that joint implants don’t hold up in the long-run. Implant fracture, bone erosion, and shortening of the bones occur in almost all of the patients.

Each patient had all four metacarpophalangeal (MCP) joints replaced. The MCP joints are the knuckles at the base of the fingers. They stick out when you form a fist. At first motion is better and function is improved. But over time the motion gets worse, the fingers start to drift to the side, and the patient can’t use the hand for daily activities. Pain is present in about half the patients.

The good news is that treatment of rheumatoid arthritis has improved greatly with new drugs. These medications keep the arthritis from getting worse. The drugs are called disease-modifying anti-rheumatic drugs (DMARDs). With DMARDs, fewer patients end up needing joint replacements. Those who do have a better result than in the past.

The patients in this study were treated between 1980 and 1991. Today patients are healthier, and the MCP joint implants now outlive the patients. The authors think it’s still worth it to replace deformed and painful rheumatic joints that are limited in motion. The implants do offer some help when nothing else is available.

Are you troubled by carpal tunnel syndrome (CTS)? Are you thinking about having surgery to relieve the pain, numbness, and tingling? If you have CTS in both hands, should you have both wrists done at one time? Will you be able to manage simple things like dressing or using the bathroom? What about going back to work?

These are the kinds of questions doctors from the University of Utah asked 20 patients with CTS who had open surgery done on both wrists during the same operation.

Surprisingly, using the bathroom was considered one of the easier tasks. Opening jars was the most difficult. Driving, writing, dressing, and eating were hard. Holding a book, shopping, talking on the phone, and using a computer were easier tasks. Even so, 100 percent of the patients said they would do it the same way if they had to do it over.

The reason for having both wrists done at the same time? To decrease the total time disabled and to miss less overall time at work. Most patients were back to work in three weeks. Some returned as quickly as three days. Others were out a full six weeks.

The authors recognize that gripping and lifting activities are most difficult for
patients having carpal tunnel surgery. The patients seem to manage personal hygiene and are less likely to ask for help in this area. Having both wrists operated on at the same time for CTS is not advised for patients who live alone.

Lance Armstrong would probably agree with the saying that “an ounce of prevention is worth a pound of cure” — especially when that ounce is in the form of cycling gloves or a proper bike fit. Without these, bikers are prone to suffer a common problem called cyclist’s palsy.

Cyclist’s palsy is caused by pressure on the ulnar or median nerves of the hand. The pressure can cause numbness, tingling, and weakness. Risk factors include ill-fitting or worn-out gloves, worn-out handlebar padding, and not changing hand position often enough. A poor seat position can also put too much body weight on the hands.

The purpose of this study was to find out how often cyclist’s palsy occurs. Twenty-five mountain and road bikers were included. Testing was done before and after a 600-kilometer bike ride.

Pinch strength and muscle strength was measured. Examiners looked for muscle wasting and tested for numbness and tingling at rest and with pressure. They also asked about the use of gloves, level of experience, and previous hand injuries.

The authors report very few symptoms of nerve compression before the ride. However, testing showed changes in sensation, strength, or both for many bikers. The level of experience and type of bike didn’t seem to make a difference.

According to these researchers, the best way to manage cyclist’s palsy is to prevent it. Everyone is at risk. When planning a long bike ride, wear padded cycling gloves and change hand position often. Make sure the seat position doesn’t throw your weight forward onto the handlebars.

The thumb joints are what help us pinch and grasp. Osteoarthritis (OA) in the joints of the thumb can be debilitating. OA of the thumb joints is fairly common. Still, doctors don’t understand exactly how the cartilage of the thumb joints wears down over time. Knowing cartilage wear patterns could help doctors more effectively diagnose and treat OA in the thumb.

These authors used cadavers (human bodies preserved for research) to study the way thumb cartilage wears down with age. The authors looked at the thumb joints in 100 cadavers. The joints were rated for stage of OA using visual exams and X-rays. Then the cartilage thickness was measured on the surface of the carpometacarpal (CMC) and trapezium joints.

Both joints showed more wear in the areas that bear the most force, as the authors expected. Cartilage in the CMC wore away primarily in the center of the joint. The trapezium joint showed wear along one edge. The authors say that this information could be used to develop exercises and therapy to shift the forces on the joints.

The authors also note that visual ratings of the stage of OA were generally higher than ratings done by X-ray. The authors say this means that X-rays may not be helpful in diagnosing OA in its early stages.

Workers who use large machines that press, cut, grind, or heat are at high risk for hand injuries. Some workers hurt their hands badly. Their hands and fingers can get cut off or crushed. Too often these workers become depressed and have a hard time going back to work.

These authors studied people after bad hand injuries. The goal was to find out how workers’ attitudes about what caused the accident affected their return to work. Over six months, all patients’ depression got better, and they were all physically to get back to work. However, many still had a hard time going back to their jobs. Over 60 percent went to a new department or went to work for another company.

Patients who blamed themselves for the accident were more likely to go back to work easily. The authors say that these patients felt some control in the situation, so they felt they would be able to avoid dangerous situations in the future. Patients who blamed co-workers, faulty machinery, or their employers had a harder time going back to work. These patients now saw their workplaces as dangerous.

This study did not try to understand whether injured workers were laying blame in the right places. Further research could help doctors, psychologists, and employers understand the mental state of workers who suffer traumatic hand injuries at work.

We hear a lot about hip and knee joint replacements. But smaller joints can be replaced, too. Surgery to replace joints in the fingers is most common with rheumatoid arthritis (RA). The metacarpophalangeal (MCP) joint is affected most often. The MCPs form the large knuckles on the back of the hand. The MCPs stick out when the hand is in a fist.

RA is a chronic inflammatory disease. It affects many organs and systems in the body, especially the musculoskeletal system. The lining of the joints becomes inflamed. Cartilage starts to soften, and joint damage occurs. Change in one joint affects how all the other joints in the hand line up. The soft tissues around the joints are affected, too. This sets up a vicious cycle.

Without normal muscle pull, increased and uneven forces cause still more damage and deformity. Ligaments stretch and weaken. The fingers and wrist start to drift away from their normal middle position. Painful deformity, joint dislocation, and joint destruction can lead to the need for joint replacement. This operation is not advised if a patient has certain skin conditions, poor bone condition, or vasculitis (inflammation of the blood vessels).

The authors of this report review the anatomy of the finger joints and discuss the technique for MCP joint replacement. Results after surgery are also reviewed. With MCP implants, patients can expect better hand position and pain relief. Sometimes the fingers start to drift from the midline again. Most patients are happy with the results of the new joint because the hand looks and feels better.

Carpal tunnel release (CTR) has traditionally been “open” surgery, done through a long incision made in the hand and wrist. Open CTR has been proven to be a safe and effective procedure. Still, surgeons have recently begun using an endoscope to do CTR. The endoscope is a tube with a tiny camera on it. It allows the surgeon to watch the inside of the wrist on a TV screen. Endoscopic CTR requires only one or two very small incisions. The theory is that smaller incisions will cause fewer problems than the long incision.

Studies comparing the two types of surgery have not come to a clear conclusion about which method of surgery is best. These authors compared patients who got open CTR to patients who got endoscopic CTR. The patients were all evaluated for pain and hand function before surgery and again one, six, and 12 weeks after surgery.

The one difference found between groups was that the open CTR patients had a weaker grip both one and six weeks after surgery. However, by 12 weeks there was no difference in grip between the two groups. No one in either group had nerve or blood vessel problems, and they reported about the same relief from symptoms. Also, both groups returned to work at about the same time.

All the patients were contacted again at least two years after surgery. Patients who had endoscopic CTR rated their satisfaction with the surgery at an average of 85 percent, while the open CTR group rated their satisfaction at 93 percent. However, the researchers note that five percent of the endoscopic group needed another surgery, compared to none in the open group. The patients who needed further surgery were very unhappy with their CTR.

The authors conclude that both surgeries are safe and effective. However, they were concerned about the number of endoscopic CTR patients who needed a second surgery. In fact, the authors report that their medical center is doing fewer endoscopic CTR surgeries partly because of these results.

The authors also note that they used the traditional long incision for open CTR, although there is a new open technique that uses a short incision in the palm of the hand. Only further study will show how the open technique using a short incision compares to traditional and endoscopic CTR.

Doctors from the Mayo Clinic and the Naval Medical Center report good results after surgery for mallet fractures of the fingers. A mallet injury tears the extensor tendon from the tip of the finger. This tendon extends, or straightens, the fingertip.

A mallet fracture occurs when the tendon actually pops off a piece of bone from the end of the finger where the tendon attaches. Mallet injuries involving the tendon or bone can result in a permanently bent fingertip. A torn tendon may only require the use of a splint that keeps the finger straight, allowing the tendon to heal. Serious tendon tears and those involving a fracture usually need surgery.

This study examines a surgical method called extension block pinning. Doctors use wires and pins to put the bone back together and hold the joint in one position. It takes about 35 days for the bone to heal. The pins are taken out when an X-ray shows new bone bridging both sides of the fracture line. The fracture site must be pain-free and not tender. Exercises begin to regain range of motion after the pins are removed. A special splint is worn for two to three weeks to protect the joint.

The authors report that this surgery is a good treatment for large mallet fractures of the fingers. Risks and complications with other methods are reduced by using this approach. Patients showed quick healing with good range of motion.

Sometimes, trouble runs in twos, especially for some patients with arthritis at the base of the thumb. This thumb condition, called basal joint arthritis is often joined by carpal tunnel syndrome. There is a definite link between these two problems, but the cause is unknown.

Both diseases occur most often in postmenopausal women, which may help explain the link. Another possible cause is the size and shape of the carpal tunnel in the wrist. The carpal tunnel is an oval-shaped space formed by bones and ligaments. Tendons and the median nerve pass through this tunnel.

Anything that narrows the carpal tunnel can put pressure on the median nerve causing painful symptoms. Arthritic changes of the trapezium bone at the base of the thumb can be part of the problem. This bone forms one wall or border of the carpal tunnel. Bone spurs, points of bone projecting from this bone, may press into the carpal tunnel.

Surgery to correct this problem is usually in two-steps. First, the surgeon cuts the ligament that crosses the carpal tunnel. It attaches to the trapezium. Then, the trapezium is removed completely. This changes the position of the nerve and the shape of the tunnel. The carpal tunnel changes from an oval shape to a more round or circular shape.

MRI (magnetic resonance imaging) can be used to measure the size or volume of the carpal tunnel. Doctors use the image to see if the operation opened up the narrow tunnel. Researchers are exploring whether or not changing the shape of the carpal tunnel is enough to get rid of pain and other symptoms.

Several small studies have been done. More studies with larger numbers of patients are needed to help answer questions about how much surgery is needed and exactly what steps are needed. The information will also help solve the puzzle of why it is common for patients with basal joint arthritis to also have carpal tunnel syndrome.

Thumb injuries are sometimes the result of a bad fall. More often, they are caused by a football, wrestling, or other athletic injury. Injuries at work also account for some thumb injuries.

When the radial collateral ligament (RCL) is torn, medical treatment is needed. This ligament goes between the radial bone of the forearm and the small bone at the base of the thumb (scaphoid). Without the RCL, pain and weakness occur. The patient typically has trouble grasping and lifting objects. Pinch strength is also affected.

Doctors don’t have a “best” treatment for everyone with a torn RCL. Some use casting to hold the joint until healing takes place. Others suggest surgery to repair the tear. Treatment choices vary widely if the injury goes a long time without treatment.

One doctor did a study over a 20-year period of 45 patients with RCL injuries. The torn ligament and its covering were carefully pulled toward its normal attachment and held in place with sutures. A cast was put on the arm for six weeks.

The results of this study showed that repair of a torn radial collateral ligament may be all that’s needed. Even late cases can be treated with this method. The author of this study concludes that using extra soft tissue to reinforce the site of injury isn’t needed. A simpler repair gives long-term stability with relief of pain.

The hamate is a small bone in the wrist. It is one of eight carpal bones and is located on the inside edge of the wrist.
(the edge on the opposite side from the thumb).

The hamate has a hook (called the hamulus) where it connects with the ulna bone in the forearm. This hook is sometimes broken in athletes who use rackets, clubs, or bats. It can be a hard injury to diagnose. The pain of a broken hamulus is much like the pain from an injury to the wrist ligaments or muscles.

A broken hamulus most often doesn’t heal well. Pain often remains, and gripping can be difficult. Usually the pain is caused by a break that has not fully healed, called a nonunion. A nonunion is usually treated by surgically removing the hamulus.

These doctors believe that in some cases the pain is caused by a partial union. In a partial union, the break heals well enough so that it looks healed on X-rays. However, it still causes pain and problems gripping.

The authors write about eight patients who seemed to have a partial union of the hamulus. All eight were injured while playing golf or baseball. After several weeks of other diagnoses, it was found that they had fractures of the hook of the hamate. The break looked as if it had healed, but pain continued. A special type of X-ray called a CT (computed tomograpy) scan was used to help in the diagnosis. CT scans are very useful when doctors need to see if there are problems with bones. In this case, the CT scan did show faint evidence of a partial union. The doctors finally removed the hamulus. Within an average of eight weeks, all the athletes were pain-free and back to their sports. Grip measurements showed that they had gotten their strength back.

The authors recommend that doctors should always use CT scans when looking for problems with the hamate. They also suggest that doctors should suspect injury to the hamulus when golfers, baseball players, or tennis players have problems with grip strength and pain in the wrist.

Dupuytren’s disease happens when the tissues in the palm of the hand shorten. The tissues eventually get so tight that they pull the ring and pinky finger down so they can’t fully straighten. For the most part, surgery has been one of the only successful ways to correct Dupuytren’s disease. Unfortunately, the problem commonly returns after surgery. The surgery process, to many people, is time-consuming and painful, and there is a long time before they get back normal use of the hand.

Researchers are doing clinical trials of an enzyme called collagenase to treat Dupuytren’s disease. Collagenase is injected into the contracted joint, where it breaks down the tight tissue. A day after the injection, a doctor can more easily stretch the fingers, causing the tight cord of tissue to rupture. This allows the fingers to regain movement and straighten out. A splint is usually then worn for four months to keep the fingers stretched out.

The injections worked within a month for up to 90% of them. There were no serious side effects, even for people who needed more than one injection. Further clinical trials are planned. If all goes well, doctors may soon have a successful nonsurgical treatment for Dupuytren’s disease.

Some musicians face a terrible problem. Their hand cramps, making it impossible to play their instrument. This can happen to any musician, on any type of instrument. Piano, guitar, oboe, and flute players have often reported this problem.

“Writer’s cramp” or “occupational hand cramp” is known in the medical world as focal hand dystonia. There’s no particular treatment that works for more than just a short time. This can leave professional musicians out of a job.

A new treatment has been tried in Germany. It’s called sensory motor retuning. It works best with string players. Wind players haven’t had the same success. The musician works with a physical therapist who combines the use of a special splint with exercises.

The splint is placed on the hand and fingers that try to make up for the dystonic finger. It holds the fingers in a resting position and doesn’t let them move. The dystonic or “stuck” finger(s) must move through a series of exercises. These are done in 10-minute blocks of time. Five sets are done in an hour, once each day. Then the musician goes back to playing normally.

In all cases of string players, normal motion without cramping was restored. However, none of the wind players got better with this program. There are several possible reasons for this. The exact cause is unknown and will be the subject of more research.

There’s new hope for musicians who play the guitar or piano and also suffer from hand cramping. Sensory motor retuning can be used with good results. It’s not certain how long these exercises should be done, but the musicians who used them in this study are showing good results on a long-term basis.

Two tendons run through a tunnel, or compartment, along the thumb-side of the wrist. These are the extensor pollicis brevis (EPB) and the abductor pollicis longus (APL).

Inflammation in these tendons is called de Quervain’s disease. It seems to occur most often when the two tendons are separated by a piece of tissue called a septum. This means each tendon has its own space, or compartment.

There isn’t a single treatment known to be effective in all cases of de Quervain’s. Sometimes a steroid injection into the tendon tunnel helps. However, the doctor must know if there is a separate space for each tendon when giving this injection. In other cases, surgery is to release the tissue between the tendons is needed.

Doctors think that the patients who have a separate compartment for each tendon do better with surgery. Finding a test that will show which patients have the septum would be helpful. A group of doctors tested for this by resisting thumb motion. First the thumb was kept from outward movement. Then resistance was given as the thumb moved straight out from the palm.

This test was counted as “positive” when the patient had more pain with the thumb straight out away from the hand. There was less or no pain with downward motion away from the palm. This test is called the EPB entrapment test.

Patients with a positive EPB entrapment test are more likely to have a septum within the tunnel than those with a negative result. Knowing about this extra compartment can help direct the doctor’s treatment. When the septum is present, it must be fully released to allow for pain-free thumb motion.

The fingers each have three separate joints to give the hand its arc of motion when bending and straightening. Each joint has a specific name. The joint in the middle is called the proximal interphalangeal joint, or PIP joint.

Loss of motion in the PIP joint can cause real problems doing daily activities. If more than one finger is involved, the patient can lose the ability to flex or extend the fingers. Sometimes, both motions are restricted. When the joint is “stuck” and can’t bend or straighten, it’s called a contracture.

Treatment for problem joints includes therapy with an occupational or physical therapist. Surgery may be needed if therapy doesn’t get the desired results. Surgery isn’t always helpful. For this reason, doctors would like to be able to tell which patients will do well with surgery. They want to avoid doing surgery on patients who won’t get better.

A study from the Curtis National Hand Center in Baltimore, Maryland, has given some advice about which patients should consider surgery. Patients with PIP contractures do well with surgery if they are younger than 28 years and have a simple diagnosis. “Simple” problems include breaks, dislocations, cuts, and injuries to the ligaments. More serious or “complex” problems include patients with poor circulation, crush injuries, or severe pain patterns.

Careful selection of patients with PIP contractures can help create a good result after surgery. Younger patients with more motion and fewer serious finger problems do best with surgery to release the contracture.

What’s in a handshake? It depends on who’s asking. Physical and occupational therapists measure handgrip strength to find out many things. It gives practical information about the muscles, nerves, bones, and joints. The strength of a handgrip tells the therapist if the patient needs help with daily activities.

Grip strength is measured in some sports. It’s required in some places before entering work as a police officer, fire fighter, or soldier. The device used to measure grip strength is called a dynamometer. There are several different types of dynamometers. One is a bulb that is squeezed. A dial attached shows the pounds of force used. The most commonly used one is handheld with an adjustable handle. It can be placed in five different grip positions.

Therapists and doctors who use the grip dynamometer would like to know if there is an optimal grip span. Is this grip span related to the patient’s hand size? If it is, should the adjustable grip bar be set according to the hand size?

Doctors in Spain set out to answer these questions. They especially wanted to know which position on the grip dynamometer gives the hand the strongest measurement. They found the best grip span for both men and women. It’s different for each hand. They also discovered that hand size makes a difference for women when choosing a grip setting. This wasn’t true for men.

When measuring grip strength, the standard dynamometer can be set in one place for men. In women, the hand size must be measured first before deciding which grip span to use. A simple formula is used to make this decision.

For most people, the hands and fingers are an important part of everyday life. Daily activities require the use of finger strength and coordination. Some jobs really depend on the strength of the fingers and hands to complete work tasks.

Grip strength has been measured and studied closely. Matching a worker’s strength with the strength needed for job tasks is important. Static measures for grip and pinch strength are commonly used. This means the strength is tested in one position without moving the wrist or arm.

But what about jobs that require a certain amount of grip strength while moving? Does changing the wrist position change finger and hand strength? It makes sense that a different wrist position would change the force of each finger.

A study has been done using nine healthy adult men. All the men were right-handed. Their grip strength was measured while moving the wrist through its full range of motion. The wrist moved forward and back in flexion and extension. Motion also included side to side movement called radial and ulnar deviation.

A special device was used to measure the force (strength) of each individual finger. The strength of the fingers does depend on the position of the wrist. In general, the fingers are strongest when the wrist is extended and moved toward the ring finger. Strength didn’t seem to vary or fluctuate much in this position. The fingers did show differences in strength when the wrist was bent.

Fingers work together to share the workload when the hand is gripping an object. To get the best grip with the strongest force, extend the wrist back and angle the wrist out slightly. Avoid extreme wrist positions.

Carpal tunnel release (CTR) is a surgery done for carpal tunnel syndrome. It relieves pressure on the median nerve where it passes through the carpal tunnel of the wrist. This surgery relieves pain, but it often causes a weak grip.

Doctors are not sure why. They think it could be because the transverse carpal ligament (TCL) is cut during CTR. This is the ligament that connects across the base of the palm, forming one part of the carpal tunnel.

These doctors tested this theory of the cause of weak grip after CTR. They measured the grip strength of patients undergoing CTR right before surgery, right after surgery, and then over the next five weeks. Grip strength was found to be the same right before and after surgery. Once week later, grip was much weaker. By the fifth week, grip strength was back to its pre-surgery level.

The results mean that cutting the TCL is not the cause of weak grip after this surgery. The authors suggest that other factors such as pain, bleeding, or swelling, may be what make it hard for patients to “get a grip” after CTR surgery.

When the small blood vessels of the hands tighten up and close off, the blood supply can get cut off to the fingers. These spasms come and go in response to cold temperature or strong emotion. This condition is called Raynaud’s disease. When this problem occurs as a result of another disease, it’s called Raynaud’s phenomenon.

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

Treatment for Raynaud’s varies from patient to patient. Sometimes physical therapy, acupuncture, and drugs help. Creams applied to the skin to open the blood vessels can be used. In cases that don’t respond to these methods, surgery may be needed.

Cutting the nerve to the arteries that bring blood to the area may be an option. The outermost layer of the blood vessel is stripped away. This layer is called the adventitia. This works because it removes the nerve control that is causing the arteries to go into spasm.

There is help for patients with Raynaud’s and ulcers that don’t heal. The arteries just above the wrist can be stripped of their outer covering and the nerves to these vessels cut. The result can be relief from pain and freedom from having to wear gloves. Researchers suggest that this operation is best for patients with finger ulcers from Raynaud’s disease that don’t heal.