What Surgeons Need to Know About Mallet Thumb

In three short pages, surgeons can obtain a quick, but thorough review of a condition known as mallet thumb. This evidence-based continuing education activity provides updated information on indications for the treatment of mallet thumb (both surgical and nonsurgical approaches), methods of splinting, and expected results from treatment. All information comes from the most current available literature on mallet thumb injuries.

A mallet injury affects the distal interphalangeal or DIP joint of the finger (or more rarely, the interphalangeal joint of the thumb). This joint is commonly injured during sporting activities such as baseball. If the tip of the finger or thumb is struck with the ball, the tendon that attaches to the small bone underneath can be injured. Untreated, this can cause the end of the finger to fail to straighten completely, a condition called mallet finger or mallet thumb.

Using the case of a 20-year-old woman with mallet thumb from a softball injury, the authors of this continuing education tool aid surgeons in providing best possible care for their patients with similar injuries. When faced with such a problem, the question is always, What is the preferred treatment?

The patient presented with a nontender but swollen thumb that she could no longer fully extend at the tip. The examiner could straighten the thumb fully (passively). X-rays were normal with no sign of fracture, dislocation, or other bony damage. The injury occurred three weeks before the surgeon evaluated the patient. The mechanism of injury was the typical failure to catch a speeding baseball that struck the end of the thumb instead.

A review of the literature and current evidence reveals no consensus on the most effective or recommended treatment. And the evidence presented is based on published case reports like this one. In general, closed injuries that do not require surgery are splinted. Open injuries are repaired surgically possibly using K-wire fixation of the interphalangeal joint of the thumb. When present, ruptured (avulsed) tendons of the thumb are reattached or reconstructed.

MRIs can be used to see how far an avulsed tendon has retracted (pulled away from the bone). The space between the end of the tendon and the place on the bone where it belongs is called a tendon gap. If the tendon hasn’t retracted too much, it can be stretched and pulled back to the insertion point and then reattached (repaired). If the tendon gap is too great, then a tendon graft may be needed (reconstruction). But there is no cut off point to determine when the gap requires repair versus reconstruction.

The type of splint to use for the nonoperative approach remains unknown as well. How long to use splinting (duration) for best results is also unknown. The most common time period for splint wear is four to six weeks when the injury is acute (occurred within the last two weeks). Results reported from different case series varied depending on whether the injury was open or closed and in the case of closed injuries — how much time had passed between injury and evaluation/treatment.

According to some studies, the earlier the treatment, the better the outcome. Closed injuries often results in better interphalangeal joint extension. Patients do not always get all of their normal motion (full thumb extension) back. In the case of this patient, a custom-made thumb spica splint was worn full-time for six weeks. Then she wore a nighttime splint for another four weeks. Four months after injury, she had full thumb motion and was satisfied with the results.

The authors note that evidence to support standardized treatment protocols are lacking because thumb mallet injuries are so rare. More multicenter studies are needed determine if and when nonsurgical treatment is best, what type of splinting to use, how long to use splinting, and when to attempt repair versus reconstruction based on tendon gapping. In addition, surgeons need evidence-based guidance to determine type of post-operative care and when to recommend formal hand therapy.

Important Tips for Nail Gun Removal From the Hand

There is evidence that with increased housing construction and remodeling going on after the recession during the mid-2000s, nail gun injuries to the hand have also gone up. It is estimated that half of all nail gun injuries affect the hands and fingers. Up to 14 per cent of those accidents occur during carpentry projects at home (compared with just less than four per cent among worker compensation claims). So safety at home is an important issue.

Once the individual has driven a nail with a nail gun into the hand, careful evaluation by the hand surgeon is required. Treatment can range from simple wound care to major microvascular surgery. The decision on how to manage the case depends on multiple factors. One important aspect of treatment is to avoid further tissue damage.

The following are some tips and guidelines presented by hand surgeons from the Mayo Clinic in Rochester, Minnesota when dealing with nail gun injuries to the hand:

  • Beware that fabric from shirt sleeves or gloves can be drawn into the wound during the accident/incident.
  • Watch out for additional injuries to the nerves, tendons, joints, and bone. This occurs in up to one-third of all cases.
  • X-rays are a must to look for fractures; X-rays will also help show the presence of clothing or other foreign bodies that were driven into the hand.
  • Some nail cartridges have “barbs” that will require extra special care when removing the nail. Sometimes the barbs are not always visible on X-rays. When barbs are present, additional soft tissue damage can be done by pulling the nail out rather than pushing it the rest of the way through.
  • Always conduct a thorough neurologic evaluation before numbing the area for treatment.
  • Antibiotics are standard and tetanus immunization should be updated when necessary.

    The wound must be cleaned within the zone of injury and damage repaired. Sometimes this can be done in one procedure. But when there is extensive contamination, a series of surgeries is required. In all cases, infection (and preventing infection) is a number one concern.

    The authors provide surgeons with specific information on techniques for nail extraction. Patient photos at the time of admission and interoperative photos are provided with a description of how-to remove the nail and any item it may still be attached to (often a piece of board). When to perform exploratory surgery and when to extract the nail during a surgical procedure are discussed in detail. How to handle contaminated nails that have entered the bone is an additional feature of this article.

    The authors end by reminding surgeons of the need for patient safety education. It may seem like common sense that a first injury would be a wake-up call to use protective gear but many patients have more than one episode of nail gun injuries to the hand. Gloves, goggles, and helmets are advised. The National Institute for Occupational Safety and Health (NIOSH) has a nail gun safety guide for construction contractors that can be just as informative for the do-it-yourself home owner.

  • Successful Treatment for Severe Dupuytren Contracture

    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. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women.

    The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened.

    The contracture spreads to the joints of the finger, which can become permanently immobilized. Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. The MCP joints are what we usually refer to as the “knuckles.” As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The PIP joints are the middle joints between the knuckles and the interphalangeal (IP) joints (at the tips of the fingers).

    In this study, surgeons from the Philadelphia Hand Center at Thomas Jefferson Medical College report on the effect of a three-part therapy treatment. Patients enrolled included 19 men and two women ranging in age from 37 to 80 years old. All had one or more proximal interphalangeal (PIP) joints stuck in flexion of at least 40 degrees or more. Twenty-two proximal interphalangeal (PIP) joints received one standard collagenase injection followed by manual cord rupture (performed by the surgeon).

    Then they were treated by a hand therapist. The hand therapy consisted of wearing a custom-made splint (dorsal hand-based extension orthosis) at night and special exercises delivered and supervised by the therapist but also performed by the patient throughout the day at home. For day use, the hand orthosis was replaced by a smaller, finger splint to hold the PIP joint in full extension (straight).

    Results measured by change in finger motion were impressive. Patients went from having severe flexion contractures (range of 40 to 80 degrees) down to zero for some patients (a range from zero to 55 degrees among all 22 fingers). A contracture means the finger is stuck and cannot move. A flexion contracture gives us the clinical picture that the patient’s finger is bent by the amount of degrees mentioned and cannot straighten.

    The positive results of this study are important for two reasons. First, there is no known “cure” for Dupuytren’s disease and second, the proximal interphalangeal (PIP) joint does not respond well to treatment. When the metacarpophalangeal (MCP) joints are primarily involved, treatment has been quite successful.

    But with the PIP joints, treatment in the past has not been as successful. This may be because contractures of the PIP joints also affect the collateral ligaments (on each side of the finger joint), the volar plate, and cause adhesions inside the joint. The volar plate is actually a very thick ligament that prevents hyperextension of the joint. This ligamentous structure also reinforces the joint capsule and gives the joint greater stability.

    In viewing the results of this treatment compared to other studies utilizing surgery and postoperative splinting, there was an 88 per cent improvement in the patients who received this protocol of collagenase injection, manipulation, splinting, and exercises. This compared to a 44 per cent improvement with surgical intervention and splinting for the same problem.

    Despite these good results, the authors warn that problems can develop using collagenase injections. The enzymes in the injection can eat away and dissolve more than just the contracted tissue. Tendons and tendon pulleys may be adversely affected by these effects. The use of only one collagenase injection followed by carefully supervised hand therapy may have made the difference in success rates observed in this group of patients.

    More study is needed to clearly identify the mechanism by which collagenase injections work. Topics for future study include: 1) the best way to deliver the injection (i.e., with or without ultrasound guidance), 2) the number of injections needed for optimal results, 3) the length of time for hand therapy to continue, and 4) whether or not this treatment protocol will prevent contracture recurrence.

    Consensus on Diagnosis and Treatment of Scaphoid Fractures

    Hand surgeons from Columbia University Medical Center in New York City wrote up a case study illustrating the difficulties of defining and diagnosing scaphoid fractures of the wrist. They were asked for a second opinion by a 31-year-old man who had fallen and injured his right wrist.

    The patient was advised to have surgery for a diagnosis of a slightly displaced scaphoid fracture. But after doing some research on the Internet, he sought out a second opinion because he saw some information that suggested cast immobilization may be all that he needed.

    The scaphoid bone of the wrist is located on the thumbside of the hand just below the radius bone of the forearm. Because the bones of the wrist are wedged together, any displacement or shift in the position of one bone changes the anatomic alignment of the wrist. Pain, loss of motion, and loss of function are common symptoms that must be addressed.

    It is known that a scaphoid bone that is fractured and displaced will not heal without proper re-alignment. And there is consensus (general agreement) that the best way to accomplish this is through open surgery. The fracture is reduced (bone ends put back together) and the bone is replaced where it belongs anatomically. Fixation is used (e.g., screws) to hold it all together until healing occurs.

    There is also consensus that a nondisplaced scaphoid fracture does not require surgery but can heal with cast immobilization. Screw fixation can also be helpful in these cases. But the real question is how to accurately diagnose scaphoid fracture displacement. This must be done in order to determine the best treatment approach.

    There is no consensus on a definition of a nondisplaced scaphoid fracture. That may be why this patient received the first diagnosis of a “slightly” displaced scaphoid fracture. There can be a slight change in the angle of the scaphoid bone after fracture. Does that qualify for a diagnosis of displacement?

    Some experts have defined scaphoid displacement by measuring the angle between the scaphoid and lunate bones. The lunate is another bone in the first row of wrist bones just below the forearm. It rests next to the scaphoid bone so a change in the angle or gap between these two bones would signal a true displacement. But once again, there is no common agreement as to the degree of angle or amount of gap that qualifies for displacement versus nondisplacement.

    Some surgeons avoid the dilemma of labelling the problem as displaced or nondisplaced by using the terms stable and unstable to describe the fracture. In some studies, CT scans were added to traditional X-rays in hopes of increasing the accuracy of diagnosis. But cadaver studies showed diagnosis of scaphoid displacement using CT scans was inaccurate more often than not.

    The authors concluded that all of this wrangling about terminology (separation, angulation, translation, slight displacement, minimally displaced, instability, fracture mobility) points to the need for future research to create a consensus definition of scaphoid fracture displacement. They propose that a minimally displaced fracture is still displaced and should not be labelled as nondisplaced.

    In the case of this patient seeking their (second) opinion, they recommended conservative treatment with cast immobilization. The criteria they used was based on current consensus that a less than one millimeter separation with no translation and no angulation can be treated without surgical fixation.

    Long-Term Results of Pyrolytic Carbon Implants for Finger Joint Replacement

    Take a moment to look at the knuckles of your hand. The main bumps across the back of your hand are the metacarpophalangeal or MCP joints. Now try moving your fingers or hand without using those MCPs (knuckles) and you’ll see why they are important to everyday life and function. For people with osteoarthritis (OA) of the MCPs, pain, stiffness, and deformity can lead to disability and loss of function. Quality of life is affected as the individual is unable to participate in work, play, or daily activities.

    Fortunately, this condition (osteoarthritis of the MCPs) is uncommon. Treatment begins conservatively with hand therapy, medications to control pain and inflammation, and sometimes steroid injections. Surgery is a last resort type of option but consists of joint replacement. In this report, one surgeon reports the results of 11 patients who had an implant made of pyrolytic carbon placed in the index or middle finger MCP joint.

    The implant is made by burning and separating hydrocarbon gas to make it chemically stable. The process makes the material biologically compatible (acceptable to the body). Pyrolytic carbon implants have been around and in use for finger joint replacements for 20 years or more. But the use of these devices for osteoarthritis (OA) of the metacarpophalangeal (MCP) joints has been limited. In fact, there is very little data reported on the results (especially long-term outcomes) for this condition. That’s what makes this study so important.

    All patients received the implant from one single surgeon. They were followed for at least two full years. Results were measured using pain, motion, function, and patient satisfaction. Assessment tools included the Michigan Hand Questionnaire and the Quick Disabilities of the Arm, Shoulder, and Hand survey. X-rays were used to look for implant loosening, fracture, movement, subsidence (sinking down into the bone), or failure of any kind.

    The surgeon reports that motion was significantly improved from before surgery to after. Grip strength was better than before surgery but less than the other hand. Pain was mild (rated as a one on a scale from zero to 10) if there was any pain at all. And 10 of the 11 patients were fully satisfied with the results.

    There were a few problems reported along the way. Two of the patients noticed clicking and squeaking when they moved the finger. There were no other symptoms accompanying the noises (e.g., no pain, no swelling, no tenderness). The one patient who was unhappy with the results had joint stiffness, constant pain, and squeaking for no apparent reason. She ended up having a joint fusion (arthrodesis) seven months later. In general, there was no sign of implant failure for any of the patients. Everyone had a little subsidence (implant sinking down) but this did not continue to get worse and presented no problems.

    In summary, long-term results of surgical placement of pyrolytic carbon implants in the metacarpophalangeal (MCP) joints of the hand are positive. Symptoms improve, satisfaction is high, and the implants hold up well. Patients are able to get back to work and/or daily activities requiring the full use of the fingers and hands.

    Pyrolytic carbon implants are a good solution to problems caused by osteoarthritis that are not corrected or improved with conservative care. Good alignment of the fingers is possible with these implants when the patient has healthy, undamaged soft tissues and ligaments. Without good soft tissue structures (e.g., with patients who have rheumatoid arthritis), this type of unconstrained implant (produces less stress where the implant meets the bone) cannot be used.

    A Review of the Complex, Delicate Anatomy of the Hand

    It might surprise you to know that the hand is the most commonly injured part of the body. Serious injuries like tendon injuries require treatment by an experienced hand surgeon. Surgeons know how complex and delicate the anatomic structures of the hand are. They understand the need for very careful surgical technique when repairing, reconstructing, transferring, or grafting a tendon.

    In this article, the extensor tendons of the hand are featured. The authors review the anatomy of each one and discuss the complexities of surgery for tendon transfers. Included in the discussion are the following tendons: extensor digitorum communis, extensor indicis proprius, extensor digiti minimi, extensor proprius indicis, extensor digitorum brevis manus, extensor pollicus brevis, extensor pollicis longus, and extensor medii proprius.

    Tendon transfer refers to taking one tendon and moving it to function in place of another. This is done most often when a tendon has been injured, the nerve to the tendon has been damaged, or there is a defect of the tendon from rheumatoid arthritis. But tendon transfers (or using tendon as a graft) are not as simple as they sound.

    For example, sometimes a tendon originates (or begins) in a slightly different place than expected. Most tendons start from an attachment directly to the bone. But in some cases, the insertion point could be a ligament instead of the bone. Or the origination could be from the soft tissue over the bone.

    If even a single tendon slip is taken from the wrong tendon, it can affect the movement and strength of the finger and/or hand. Likewise, if the surgeon chooses a weaker tendon for a transfer to a stronger tendon that has been injured, the result can be a significant loss of hand function.

    In yet another example, the authors point how the extensor indicis proprius (EIP) has many connections to the extensor digitorum communis (EDC). EDC is the main tendon that extends all the fingers. The connection between these two tendons must be carefully cut to avoid losing the benefit of the EIP as a tendon transfer.

    There are also thin bands of tissue that connect the extensor digitorum communis (EDC) tendons. These are called the juncturae tendinum. The full function of the juncturae tendinum is not completely understood but it is clear that the anatomy can be quite different from one person to another. The authors provide a detailed description of this anatomic structure and description of what is known so far about how it works. Even rare anomalies (differences or variations) of the juncturae tendinum anatomy are important for the hand surgeon to be aware of.

    In summary, this review article featuring the extensor tendons of the hand will benefit any surgeon who is evaluating a patient with a hand injury. Knowing how many and what kind of anatomical differences that can occur from patient to patient is essential when planning hand surgery. Known anatomic and functional variations of the extensor tendons are described and discussed keeping in mind how these may affect decisions before and during tendon transfers.

    Is It True That Weather Affects Arthritis?

    If you have ever relied on a family member with arthritis to predict an upcoming storm, you know there must be some kind of link between change in weather and joints. In this study from Brazil, the influence of air pressure, temperature, humidity, and moisture (precipitation) is evaluated on pain, joint stiffness, and function of the hands in patients with osteoarthritis (OA). These measures of weather are referred to as meteorological variables.

    They did the study including 32 patients with known hand osteoarthritis (OA). Each patient filled out a survey answering questions about their hands. They did not know the study was about the influence of weather on hand arthritis. They answered questions like, How much pain (or stiffness) have you had in your hands? They completed the same survey three times a week throughout the months of July (summer) and November (winter).

    In Brazil where this study was done, July has the lowest average temperature and higher relative humidity than any other month. November has the highest temperatures with low atmospheric pressure and humidity. Those features make these two months the most logical ones to select for a study on weather and arthritis affecting the hands.

    After each patient completed the surveys, they compared the patient responses about pain, stiffness, and function against meteorological (weather) records. The patients ranged in ages from 45 to 77 with half being younger than 60 years of age. There were men and women included from all levels of income. Some were underweight while others were overweight. In other words, the patients included came in all sizes, shapes, and backgrounds.

    The two weather factors that had the greatest effect on hand arthritis were temperature and humidity. In fact, there was a significant relationship between temperatures the day before and the day after changes in hand pain. Some patients (but not all) were affected by atmospheric pressure. The effect was most noticeable on hand function.

    But the most interesting finding was that not everyone was affected in the same way. As you might expect, the lower the temperature, the more pain and stiffness with decreased function was experienced. But this wasn’t true for everyone or even the majority of patients. And remember, they did not know the study was about the influence of weather on their arthritic hands.

    Some patients had improved symptoms when the temperature went up while others felt worse. It was the same with changes in humidity and atmospheric pressure. There were both positive and negative correlations between weather elements and arthritic effects. The question then becomes how to explain the variations in responses to weather?

    The authors point out that whereas it is possible to measure changes in weather very specifically and accurately, patient perceptions of pain, stiffness, and function are subjective. Depending on mood, individual sensitivities, and what may be going on in the person’s life, ratings of pain, stiffness, and function could be over or under estimated. And the influence of medications being taken by the patients should be considered.

    In summary, this study shows that weather does have a correlation with symptoms associated with hand arthritis. But individual sensitivity is very different from one person to the next and cannot be predicted. The authors suggest further study is needed before the exact relationship between weather and hand arthritis can be fully understood.

    Carpal Tunnel Syndrome and Neck Arthritis: Linked or Coincidence?

    What do neck pain and carpal tunnel syndrome (CTS) have in common? They could be coming from damage, injury, or compression of the same spinal nerve root. In fact, compression in one region has been shown to increase the likelihood of damage at another location along the nerve. And as this review shows, a nerve in the wrist is actually more susceptible to problems when there is compression in the neck.

    Although the link between cervical spine arthritis and carpal tunnel syndrome has been proven, the exact mechanism by which this comes about remains unknown. The condition is referred to as double crush syndrome (DCS). Many experts have suggested various different ways in which this syndrome develops.

    It could have to do with the damaged nerve’s ability to transport information further down. Perhaps there is a loss of blood supply. Or maybe the initial nerve damage leaves it stiff and no longer elastic enough to transmit messages along its length. Sometimes, another condition such as diabetes or thyroid disease is the missing link. But again, the exact mechanism by which carpal tunnel syndrome follows the initial neck pain remains a mystery.

    Physicians have found that electrodiagnostic testing is the most valid and reliable way to document nerve impairment linked with carpal tunnel syndrome. The same type of testing is not as reliable for documenting a double crush syndrome. Commonly used tests (e.g., Phalen’s, Tinel’s) that point to carpal tunnel syndrome and are confirmed with electrodiagnostic tests cannot be used reliably to diagnose a double crush syndrome.

    Without a clear mechanism of development of the double crush syndrome, treatment cannot be as specific as possible. Up until now, researchers have paid attention to types of treatment applied and then looked back to see which patients improved. By working backwards in this way, it may be possible to understand the mechanism underlying the loss of nerve function in more than one place along the nerve.

    But the problem is a bit more complex than it seems. Some studies show that patients with just carpal tunnel syndrome have better results after carpal tunnel release surgery compared with individuals who have the double crush syndrome. This would lead one to think it is necessary to have surgery at both sites of the nerve compression (neck and wrist).

    Yet other patients with double crush syndrome who have cervical decompressive surgery (without carpal tunnel release) have equally good results. Those results would suggest the need for cervical decompression before (or even alone without) carpal tunnel release.

    Not everyone agrees but some experts in this area suggest the following when faced with the dilemma of treating a double crush syndrome. First, look at symptoms, results of clinical exams, and perform electrodiagnostic testing. Second, correlate all results together and keep the big picture in mind. Third, when there is a double crush syndrome present, perform the least invasive surgical procedure first.

    Then reassess the patient’s symptoms, goals, and expectations and plan accordingly. The patient who continues to have pain and other nerve symptoms should be re-evaluated for a more proximal (closer to the neck) disorder of the nerve(s). If and when a clearer understanding of the mechanism underlying double crush syndrome is discovered, patient management can be re-visited. More appropriate and more consistently successful treatment can then be developed.

    Test and Treatment for Sesamoiditis

    True or false? Chronic sesamoiditis can be treated effectively with conservative (nonoperative) care. A sampling of the published studies on this condition suggests “no” — steroid injections, physical therapy, splints, and pain relievers do not relieve the painful symptoms of chronic sesamoiditis. But in this report of 18 patients, hand surgeons from Singapore present a differing opinion.

    Sesamoiditis refers to an inflammatory process affecting the sesamoid bones of the thumb. The sesamoid bones are two pea-sized bones embedded in the volar plate of the thumb. The volar plate is actually a very thick ligament that prevents hyperextension of the joint. The volar plate also reinforces the joint capsule and gives the joint greater stability.

    Even though they are small in size, the sesamoids play an important role in how the thumb moves. These tiny bones are part of the pulley system that allows for thumb movement. Two different tendons (adductor pollicis, flexor pollicis brevis) insert into each of these little bones. Together, these tendons across the sesamoid bones pull to create thumb adduction (moving the thumb toward the hand) and thumb flexion (bending the tip of the thumb).

    The sesamoid bones lift the tendons and their attached muscles away from the joint to increase the mechanical advantage needed for smooth thumb motion. If the sesamoids are injured or starting to degenerate, they can be a source of severe pain and disability.

    Normally, as the thumb bends, the sesamoid bones “track” or move up and down against the head of the thumb metacarpal (bone that forms the tip of the thumb). If the sesamoids do not track evenly on the center of the metacarpal head, the cartilage starts to wear unevenly and break down. That’s when inflammation develops around the sesamoid bones with eventual bone-on-bone pain from chronic sesamoiditis.

    The 18 patients studied in this case series were men and women between the ages of 17 and 57. One-third of the group had a history of trauma (e.g., direct crush of the sesamoid bones, fall onto the thumb).

    Everyone had a positive sesamoid provocation test (SPT). This test is done in two steps. First, the examiner holds the thumb in a flexed position and applies resistance to the patient’s effort to bend the tip of the thumb. Then the thumb is held in an extended position and resistance is applied to the tip of the thumb again. A positive test for sesamoiditis is no pain with the first test and much more pain when the second test is done. This test is helpful because most of the time, X-rays are normal.

    Treatment for these patients followed a flow-chart (called an algorithm) starting with one steroid injection into the sesamoid joints. Each patient was put on pain relievers and given a thumb splint for six weeks. The splint held the thumb joint in a neutral position but still allowed the tip of the thumb to move.

    Six weeks later, they were re-evaluated and treated further if pain continued. Mild pain was treated with activity modification and continued use of pain medications and splint as needed. Moderate (or more severe) pain was treated with a second steroid injection. If that didn’t help relieve the pain, then the sesamoid bones were surgically removed (in a procedure called sesamoidectomy).

    Follow-up with each patient showed these results: half the group was pain free after one steroid injection and five more patients achieved the same results after the second steroid injection. That’s a total of 13 out of 18 patients who were successfully treated with just steroid injections.

    Everyone else had the sesamoidectomy procedure. During the surgery, the hand surgeon could see significant degeneration in the metacarpal (thumb) bone that is above the sesamoids. One person in the group ended up having the thumb joint fused when all treatment failed to end his pain.

    The author concluded that surgery to remove the sesamoid bones and repair the muscle insertions isn’t always necessary for chronic sesamoiditis. Good to excellent results with pain free function of the thumb is possible with nonoperative care. They use the sesamoid provocation test (SPT) to confirm the diagnosis.

    The best candidates for this treatment approach are patients with no prior trauma to the thumb and who have sedentary (low-demand) jobs. Early diagnosis of the problem before it becomes chronic may also help create successful treatment with conservative care. They recommend surgery (sesamoidectomy) should always be considered a last resort after trying all other nonoperative approaches first.

    Treatment and Rehab Vital to Finger Fractures

    A broken finger is not something to ignore. Even though the individual bones that make up each finger are small, a fracture (and especially a fracture with dislocation) can result in a painful, unstable, nonfunctional finger. Studies show that early treatment (within the first six weeks of injury) is advised for the best outcomes. Waiting too long (until the injury becomes “chronic”) is never a good idea.

    Surgeons treating fracture injuries of the proximal interphalangeal (PIP) joints (the middle bone of the three bones of each finger) will find this review article helpful. Three types of fracture-dislocations of the PIP joint and goals of treatment are presented. Readers are given an anatomical understanding of the forces and mechanism of injury. Nonsurgical and surgical treatments are discussed along with some pointers on the rehabilitation process.

    Proximal interphalangeal (PIP) joint fracture-dislocation injuries are named according to the location of the damage. There is the dorsal fracture pattern, the volar fracture pattern, and the pilon injury. Drawings are provided to illustrate each one.

    In simple terms, a dorsal fracture occurs along the bottom (palm side) of the finger. The tendon that helps flex or bend the finger is torn away from the bone allowing the joint to dislocate. A volar fracture affects the top (back of the hand side) of the bone. In this case, the extensor tendon is torn (the one that straightens the finger) with joint dislocation. And a pilon fracture involves multiple fractures on both sides of the bone and ruptures of both the flexor and extensor tendons. With a pilon injury, the joint is very unstable.

    The authors provide an easy-to-read table to give the reader an overall view of each fracture classification. Range-of-motion, amount of joint involvement, and whether the fracture/dislocation is stable or unstable can be seen at a glance. The dividing point between a stable versus unstable fracture-dislocation is based on the amount of joint involvement.

    Less than one-third of the joint surface disruption will likely be a stable joint. More than half of the joint surface involvement is predictive of an unstable joint. Anyone with 30 to 50 per cent joint surface damage falls into the gray area (not as easy to predict stability). Of course, with a pilon injury, the entire joint is compromised and there’s no question it will be severely unstable.

    The goals of treatment are fairly simple and straightforward but not always so easy to achieve: realign the joint, restore range-of-motion, and return patient to full finger/hand function. The plan of care and treatment decisions depend on severity of injury and amount of tendon retraction (pulling away from the bone).

    Sometimes it is possible to treat these injuries (even when there is a fracture and dislocation) nonsurgically. This is possible when the fracture-dislocation is stable (not likely to separate or shift). You have probably seen someone with two (or sometimes three) fingers taped together. This is called buddy taping. It can be used for one to three weeks and has the advantage of allowing some early range-of-motion.

    A second approach to conservative (nonsurgical) care is the use of splinting. One type of block splinting is especially helpful when motion in one direction is okay but movement in the other direction is unstable (results in the bones shifting or the joint dislocating).

    But if and when the fracture-dislocation cannot be held stable with buddy taping or splinting, then surgery is necessary. The surgeon has a wide variety of surgical techniques to choose from. Sometimes the bone and joint can be realigned and held together with pins and/or wires without making an incision to open the finger. This is called closed reduction and pinning.

    If closed reduction is not possible, then open incision may be needed to realign the bones and hold them together with hardware. This procedure is called open reduction and fixation (ORIF). ORIF is necessary when the surgeon must repair or reconstruct the torn tendons and/or when there is hinging at the fracture site. Hinging refers to motion that occurs between the two ends of the broken bone (rather than at the actual joint).

    Pilon fractures can be treated with ORIF but sometimes require a special surgical treatment referred to as dynamic distraction and external fixation or DDEF. The joint is “distracted” or pulled apart and as many of the pieces of bone as possible are put back together. Then the surgeon applies a special device made of wires and rubber bands to achieve stability. The authors comment that restoring normal joint structure and function may not be possible with either the ORIF or the DDEF.

    The final section of this review article is focused on rehabilitation, which is considered “vital” to the successful treatment of proximal interphalangeal joint fracture-dislocations. A hand therapist working with the surgeon will provide the treatment.

    Early passive range-of-motion is a key to recovery. Passive means the therapist (and eventually the patient) moves the joint. Motion is only allowed through the stable arc of motion. Too much movement too early can disrupt the healing bone and soft tissues.

    Gradually, the therapist will advance the motion to active-assisted (patient is allowed to move the finger through partial range-of-motion with help). In the case of dynamic distraction and external fixation (DDEF), active motion can be started right away since everything is stabilized with hardware.

    In summary, the results of treatment for fracture-dislocations of proximal interphalangeal (PIP) joints vary depending on the severity of the injury, stability, and approach (surgical versus nonsurgical). There is no set way to deal with these injuries that will always produce the best results. That’s why these surgeons put together this review article with as much information as is available through published studies and their own experience. Hand surgeons will find the detail and thoroughness of the article helpful.

    Results From Around the World Treating Dupuytren’s Contracture

    Thirty-seven hand surgeons from around the world worked together over a period of years to gather data on the long-term results of using collagenase (Xiaflex) injection for Dupuytren’s contracture. This report is a summary of their findings using recurrence rate as the main measuring stick for success/failure.

    Dupuytren’s contracture is a fairly common disorder of the fingers. The condition usually shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren’s contracture usually affects only the ring and little fingers. The contracture spreads to the joints of the finger, which can become permanently immobilized.

    The condition is noted to be secondary to an increase in fibroblast density a complex biochemical and cellular interaction. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.

    The areas affected most often are the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Flexion contractures usually develop at the metacarpophalangeal (MCP) joints first. The MCP joints are what we usually refer to as the “knuckles.” As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well. The PIP joints are the middle joints between the knuckles and the joints at the tips of the fingers.

    Nonsurgical and surgical treatments are to treat the contracture itself. This does not cure the disease. Dupuytren’s disease continues to slowly form the bands although it may be years before the contracture presents itself again. Conservative care with bracing and stretching of the fingers has not been proven to help in the long term progression of this condition.

    Surgery to remove the palmar fascia (palmar fasciotomy) is the “gold standard” in treatment for advanced (severe) contractures. But the development of a less invasive method of treatment called enzymatic fasciotomy is being used with mild to moderate cases. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the patient can stretch the fingers and break apart the cord himself/herself.

    There are a few possible (minor) side effects but very few major or long-term complications with this treatment. When the product was first being studied, there were reports of a local skin reaction (swelling, redness, skin tears, itching or stinging) where the injection went into the skin. A small number of more serious problems developed in a few patients including skin infection, tendon rupture, finger deformity, complex regional pain syndrome (pain and stiffness), and hives that had to be treated with medication.

    Early studies showed a good success rate in reducing MCP contractures using this injection treatment. Almost everyone treated this way was able to straighten the MCP joints with less than a 30-degree flexion contracture. Results were not quite as good for the PIP joints. Less than half of the patients with PIP contractures had regained full motion of the affected joint.

    This study of 1,080 joints treated with collagenase injection provided some good feedback. The long-term results (after three to five years) measured by recurrence rates with enzyme fasciotomy were not quite as good as responses in the short-term. For example, one-third of the MCP joints and two-thirds of the PIP joints that were corrected had a recurrence. And of the joints that were only partially corrected in the first study, half had a worsening in the years to follow.

    Recurrence was defined as a 20-degree (or more) flexion contracture (finger won’t straighten and remains flexed by at least 20-degrees). These are fingers that were able to straighten within five degrees of normal after the injection.

    Adverse effects of this injection treatment for Dupuytren’s contracture are minimal and in the long-term, nothing worse than recurrence occurs. This was true even when up to eight injections were used and bloodworm showed antibodies in response to the collagenase. No systemic allergic reactions occurred.

    The authors concluded that the treatment is safe and effective for mildly involved joints. Their study will continue on and collect further long-term information. The treatment is certainly worth a try if it can prevent patients from having surgery. Results are not as good with PIP joints but repeat injections or even surgery are always follow-up options.

    Can 300 Patients Be Wrong?

    Based on a retrospective (looking back) study of 300 patients with carpal tunnel syndrome, this study showed a direct link between the number of trigger fingers a person had and the risk of carpal tunnel syndrome. In fact, they found that patients with more than one trigger finger were three times more likely to develop carpal tunnel syndrome in the same hand as someone with only one trigger finger.

    Hand surgeons have noticed for a long time that many patients with trigger finger often had carpal tunnel syndrome first. They naturally wondered if there was a direct connection between trigger finger and carpal tunnel syndrome.

    And according to this study, 41 per cent of the patients with multiple trigger fingers also had carpal tunnel syndrome. Only 16 per cent with single trigger finger presentation had carpal tunnel syndrome. And as the number of trigger fingers increased (from one finger to four), the incidence of carpal tunnel also increased.

    Risk factors for carpal tunnel have been studied and written about. The most common risk factor for carpal tunnel syndrome is diabetes. Now we can add trigger finger to that list.

    Once the link between multiple digit trigger fingers was established, the authors turned their attention to the possible reasons for this connection. The carpal tunnel is created by the wrist bones forming an arch around the soft tissues of the wrist (e.g., around the ligaments, nerves, blood vessels, fascia, tendons).

    Anything that decreases the space in the tunnel for these soft tissues can put pressure on the median nerve resulting in wrist and hand pain, numbness, and tingling common symptoms of carpal tunnel syndrome. It may be that thickening of the synovium (fluid and lining around the tendons) that causes trigger finger is a contributing factor to carpal tunnel syndrome.

    Patients with trigger finger also have thickening of the fibrous cartilage around the pulley system that helps the flexor tendons move the fingers. This pathologic change in the anatomy may help explain why carpal tunnel syndrome follows the formation of trigger fingers.

    In conclusion, there is evidence that multiple trigger fingers increase the risk for and rate of carpal tunnel syndrome. Other studies have also linked carpal tunnel release surgery with trigger finger. More study is needed to understand the pathoanatomic relationship between trigger finger, carpal tunnel syndrome, and carpal tunnel release.

    Worldwide Results of Injection Therapy for Dupuytren Contracture

    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. It occurs most often in middle-aged, white men. This condition is seven times more common in men than women. Although more common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry researchers agree that genes are not a direct cause of this disease, but predisposes them to this condition.

    The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren’s contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

    The areas affected most often are the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The MCP joints are what we usually refer to as the knuckles. The PIP joints are the middle joints between the knuckles (MCPs) and the joints at the tips of the fingers (distal interphalangeal joints). As the disease spreads from the palm down to the fingers, the proximal interphalangeal (PIP) joints start to be affected as well.

    Surgery to release the cords has long been the standard treatment for this condition. But more recent research has resulted in a less invasive method of treatment called an enzymatic fasciotomy. This approach can be used if only one or two cords are involved. This type of injection therapy may eventually replace surgery.

    Researchers in the United States, Australia, and Europe have joined together to study the effectiveness and safety of injection therapy with a product known as collagenase clostridium histolyticum (CCH or Xiaflex). By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken.

    Most often the patient or the surgeon is able to break apart the cord the next day if spontaneous disruption does not occur. Just actively moving the fingers and using the hand are often enough to accomplish this. Almost 600 patients (total of 879 joints) were evaluated using this type of treatment. Finger motion was used as the primary measure of improvement. Patient satisfaction was a secondary measure of success.

    As with other studies already published, Xiaflex was shown to be very successful with 92 per cent of the group either quite satisfied or very satisfied with the results. Although the researchers were prepared to inject up to three injections per site, only 11 per cent needed three injections.

    Three-fourths of the group responded well with the first injection and maintained those results for the nine month period of follow-up of this study. Contractures affecting motion of the metacarpal phalangeal (MCP) joints seem to respond better than cords that cross the proximal interphalangeal (PIP) joints.

    There were a few adverse reactions that pointed to the need to study the safety of this treatment more carefully. A few patients had a local skin reaction (rash and swelling) at the site of the injection. Two patients developed serious blood clots. But no one had any tendon ruptures and only four per cent of the group had a recurrence of the problem.

    This study expands the data base (number of patients) with Dupuytren contracture successfully treated with Xiaflex. Two factors that point to the likelihood of success include treatment early on (first predictive factor) for less severe contractures (second predictive factor).

    In summary, xiaflex injections for Dupuytren contractures are less expensive and less invasive than surgery. It is considered safe and effective, especially if the contracture is not severe and is treated early. Complications can occur (most often in severe contractures) and patients should be aware of these potential problems before treatment. Most adverse events after treatment are mild and go away in 10 to 14 days. Patients probably won’t need hand therapy after the injection treatment but may need to wear a splint at night for a few months.

    Evaluation and Treatment Flowchart for Skier’s Thumb

    You may have seen a flowchart meant to help someone make an important or difficult decision. Physicians use this same idea when examining patients and determining the best treatment approach. For example, they might think “if this symptom is present, then I will order this test — or if the patient reports this is how he or she got hurt, then my treatment will be XYZ.” That type of decision-making process is referred to as a flowchart or algorithm.

    In this review article, hand surgeons from Mayo Clinic in Rochester, Minnesota report on an algorithm they use to evaluate and treat skier’s thumb (also known as gamekeeper’s thumb). The names skier’s thumb and gamekeeper’s thumb refer to the same injury: tear or rupture of the ulnar collateral ligament (UCL) of the thumb.

    In the case of skier’s thumb (obviously the result of a skiing accident), the UCL is damaged when a sudden force is placed on the thumb. Usually this occurs when the hand is wrapped around a ski pole and the pole comes to a sudden stop but the skier does not.

    With gamekeeper’s thumb, a repetitive force is placed on the thumb over and over again. This name was actually applied many years ago when Scottish gamekeeper’s killed wounded rabbits and other small game by breaking their necks. The repetitive force against the web space between the thumb and index finger eventually damaged the UCL.

    The evaluation and treatment algorithm presented here starts with a suspected UCL injury. The next step is a physical exam and X-rays. The X-rays may show some obvious damage such as joint laxity (looseness) or bone fracture. That result would require different follow-up than if the X-rays are suspicious but not clear. Unclear or “equivocal” findings require further testing such as stress X-rays, ultrasound, or MRIs.

    Once the surgeon is able to make an accurate diagnosis, then the algorithm can be used again to determine the best treatment for each patient. For example, a complete rupture of the ulnar collateral ligament would mean surgery to repair the damage.

    An incomplete rupture could possibly be treated with a splint on the thumb and hand. Such a splint would immobilize the joint for six weeks. Following treatment of any sort, hand therapy to rehabilitate the thumb would be the last step. Once motion, strength, and function were returned, the patient would be discharged from further treatment.

    Of course, in many cases, the algorithm isn’t really that simple. There are different approaches to take when performing the surgical repair or reconstruction. Which way to go depends in part on how old the injury is. Acute (early) injuries will be surgically repaired differently than chronic (old) injuries.

    Sometimes acute injuries treated conservatively (without surgery) can become chronic problems. Later those chronic problems require surgery and that’s another decision tree (algorithm). Whenever possible (for acute and chronic injuries), the surgeon tries to perform a primary anatomic repair (i.e., put the ligament back where it belongs. That isn’t always possible, especially if the ligament ruptured and snapped way back away from the bone where it attached. Over time, the torn soft tissue tightens up so it can’t be pulled back to its insertion site on the bone.

    More complex ligamentous procedures involve tendon transfers or tendon grafts to actually reconstruct the torn ligament. This more involved surgery may be the only way to regain strength and stability of the joint. The goals of any surgery for UCL rupture are to reduce pain, improve motion, and restore function.

    Living with a thumb that can’t pinch with enough strength to pick up objects isn’t a life or death situation but it does result in some potentially disabling problems. The final decision for someone who has had reconstructive surgery is what to do if it fails. This is usually a case of someone with a chronically painful thumb. It either repeatedly dislocates, is too weak to pick up even small objects or touch the tip of the little finger, or have severe arthritic changes in the joint.

    What does the decision tree suggest for this person? Thumb joint replacements are not possible so joint fusion (called arthrodesis) may be the only and final option. Another algorithm pops up now as the surgeon decides whether to fuse the joint using Kirschner wires, tension-band wiring, and/or bone grafting.

    Algorithms go full circle in that the treatment choices are based on results of past treatment approaches. Good results using one method over another create changes in the flowchart. Optimal outcomes usually occur when a proper diagnosis is made and treatment is provided early on (before additional problems develop or the condition becomes chronic).

    Surgeons More Conservative in Treatment of Carpal Tunnel Syndrome Compared to 25 Years Ago

    According to a new survey of hand surgeons, the treatment of carpal tunnel syndrome has changed quite a bit from 25 years ago. This new study was done by the American Society for the Surgery of the Hand (ASSH). They sent email questionnaires to all of their members (a total of 1,463) and compared the answers to the same questions sent out 25 years ago.

    The goal of the study was to see how clinical practice has changed in the last 25 years. No attempt was made to assess results from then to now with these new changes. That might be a good subject for future studies. Just knowing how practice has changed in the management of this condition is useful information for now.

    Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

    One of the major changes in the way CTS is managed today is the increased use of conservative (nonoperative) care over a longer period of time. Surgery is still a treatment choice, but it takes a back seat to activity modification, antiinflammatory medications, hand therapy with a physical or occupational therapist, splinting, and possibly steroid injections.

    If after a lengthy period of time (at least three months), there has been no (or minimal) change in symptoms, then surgery to release pressure on the median nerve may be advised. Surgery today is more likely to be done without an open incision using an endoscope. Choice of anesthesia has shifted from regional blocks to local anesthesia with sedation.

    Today’s surgeon is less likely to use sutures deep within the carpal tunnel and less likely to inject corticosteroids into the tunnel during surgery. Only about one-third of the surgeons prescribe antibiotics before surgery to prevent infection.

    In keeping with current evidence and recommended clinical practice guidelines, 85 per cent of the group that responded order electrodiagnostic tests before doing surgery. This test confirms that the median nerve is compromised and that the problem is indeed coming from pressure (or compression) on the nerve in the carpal tunnel.

    This is important because carpal tunnel symptoms can develop with pressure on the nerve anywhere from the neck down to the wrist. Releasing soft tissue structures in the wrist will not alleviate the symptoms if the problem is really coming from above (e.g., the neck or elbow).

    After surgery, fewer surgeons apply a splint to the patient’s arm. In fact, half as many practice this approach compared with 25 years ago. The surgeons surveyed this time indicated that their expected outcomes are for patients to experience pain relief fully with gradual return of normal sensation, movement, and strength.

    One of the biggest changes observed from 25 years ago to the present time is a narrower gap in treatment practices and opinions on the management of this problem. Although the authors do not say so, this finding may be as a result of The American Academy of Orthopaedic Surgeons’ published guidelines on the treatment of carpal tunnel syndrome. These guidelines reflect current research evidence and may have influenced many of today’s practicing hand surgeons who are treating carpal tunnel syndrome.

    New Roll-On Splint for Stiff Finger Tip

    The fingers bend and straighten because of three separate joints. The middle joint called the proximal interphalangeal joint (PIP) is the focus of this case study. A previous ATV accident left this 49-year-old with a very stiff PIP. The problem described was stiffness of the PIP causing pain and preventing finger pinch, grip, and overall function.

    The solution was a new roll-on splint for the PIP. The splint is designed to stretch the joint by applying a dynamic, low-load over a long period of time. And the results? Excellent recovery after daily wearing for six hours over a period of three months.

    The hand therapists treating this individual describe many advantages in using this new splint with only a few potential downfalls. Some of the benefits included:

  • Easy to get on and off the finger: flexible material allows the patient to just roll it on and off the finger.
  • Easy to keep the finger clean and avoid any skin breakdown with long-term use.
  • Spreads the load evenly over the finger.
  • Designed to cover just the middle (PIP) finger joint, leaving the other two joints free to move. In other words, the splint does not interfere with daytime use of the hand and fingers during daily activities.
  • Useful for older adults who need the use of their hands and arms to push up out of a chair or walk with assistive devices such as a cane or walker.
  • Has an opening at the end to allow for visual inspection of the tip of the finger (this makes it possible to see if circulation to the end of the finger is okay; something a regular splint or cast would not allow).
  • Light-weight and not bulky so it doesn’t catch on clothing or weigh the finger down causing fatigue.
  • Available in 5 different sizes for variations in finger size from patient-to-patient; most patients need at least two different sizes to adjust for daily fluctuations in swelling and stiffness.
  • Considered a dynamic splint because it allows the person to bend the finger against the splint while getting help extending (straightening) the finger.

    And as the results showed, these many features of this little finger splint made it possible for the patient to wear it faithfully. The result was a significant and measurable increase in motion and strength with a decrease in pain, swelling, and stiffness.

    Were there any disadvantages to the roll-on PIP splint? A few — but very few — and easy to work around. First, the splint is made of silicone material, which is known to cause allergic reactions in some people. That was not the case for this patient. And second, it was too uncomfortable to wear at night so wear-time was limited to daytime hours when the person might need the finger more for daily activities.

    The hand therapists who worked with this patient were very favorably impressed with the roll-on splint. They suggest it is a simple yet effective treatment for challenging cases of proximal interphalangeal (PIP) joint stiffness. Of course, with only one patient involved in the study, there is a need for more research with a broader range of patients. Other studies comparing results of this roll-on splint with other finger splints used for the same problem would also be helpful. Concern about possible allergic reaction will require careful monitoring with this particular splint.

  • Kienböck Disease: 100 Years Later

    Over 100 years ago, Dr. Robert Kienböck, an Austrian radiologist described (and named after himself) a breakdown of the lunate wrist bone. Now known as Kienböck disease, we still don’t know really what causes it or how to best treat it.

    Kienböck disease is a condition in which one of the small bones of the wrist (the lunate) loses its blood supply and dies, causing pain and stiffness with wrist motion. In the late stages of the disease, the bone collapses, shifting the position of other bones in the wrist. This shifting eventually leads to degenerative changes and osteoarthritis in the joint.

    Bone sclerosis (hardening), fracture, collapse, and arthritis are just a few of the things that can happen with this disease. The patient suffers from pain, swelling, loss of motion, and loss of function sometimes leading to disability. Treatment can range from conservative (nonoperative) care to any one of a number of surgical procedures.

    In this article, hand surgeons from the Division of Hand Surgery at the Rothman Institute in Philadelphia concentrate on surgical procedures based on staging of the disease. Staging of any disease is a way to classify the patient’s condition based on severity. In the case of Kienböck disease, X-rays are used to determine each patient’s stage. The following is a brief summary of the stages.

  • Stage 1: There is normal bone density without sclerosis; possible fracture lines;
    decreased signal throughout the bone is seen on MRI.

  • Stage 2: Sclerosis throughout the lunate bone can be seen on X-rays; fracture lines
    often present but bone is not collapsed and joint is not narrowed.

  • Stage 3: The lunate bone has collapsed causing narrowing of the joint surface; this
    stage is divided into two parts. Part A: lunate has collapsed but without loss of joint alignment. Part B: There is lunate collapse plus other bones around the lunate have now shifted causing changes in wrist alignment.

  • Stage 4: Lunate collapse and arthritis of the wrist.

    The authors are clear in pointing out that X-ray findings and staging direct treatment but not without consideration for the patient’s symptoms. Some people can have severe symptoms with Stage 1 disease. Others can have no symptoms despite Stage 4 disease. And every possible combination can occur between those two extremes.

    Most of the time, Stage 1 disease is treated conservatively with splinting or some other kind of immobilization. This gives the wrist a rest and the bone a chance to heal. If the patient develops Stage 2 or even Stage 3A disease, the focus of treatment is to restore blood supply to the bone and prevent the disease from getting worse.

    In these cases, the surgeon has several options to choose from including the old tried and true “traditional” approaches as well as some new treatment procedures. Some of the more traditional methods include pinning the bone in place, taking a piece of bone out of the radius (forearm bone) to help take pressure off the wrist, or shortening one of the other wrist bones to unload the lunate.

    One of the newer procedures involves bone grafting (e.g., pedicled bone graft or vascularized bone transfer). This approach amounts to taking bone that still has a good blood supply and using it to help create new and improved circulation to the defected area in the wrist. There are limited long-term studies showing the results of these procedures but early results show no further bone collapse or disease progression.

    The surgeon may need to level the joint by removing from (shortening) or adding to (lengthening) bone from the forearm that makes up part of the wrist. The authors review when to use each procedure (and when NOT to use them!). They base their recommendations off the results of other studies’ reports of complications, successes, and safety concerns.

    Stage 3B and Stage 4 require a different approach because the lunate bone has collapsed and sometimes the other bones have shifted as a result of the collapse. Choices of surgical treatment for Stage 3B disease include arthrodesis (bone fusion), osteotomy (partial bone removal), or complete excision (removal) of the lunate with soft tissue put in its place (called interposition arthroplasty).

    Removing all of the bones in the first row of the wrist (called carpectomy) may be done when the Stage 3 disease process is more severe. But studies show this isn’t an ideal solution as patients often end up having the wrist fused. It is not recommended for anyone under the age of 35.

    Stage 4 disease is considered past the point of being able to restore or reconstruct the bone, joint space, or alignment. Arthritis has permanently altered the joint so that treatment is considered more of a salvage approach. In other words, the surgeon does what he or she can to save as much as possible without further destroying the wrist. The hope is to ease the patient’s pain and prevent further progression of disease. In some cases, the nerves to the wrist have to be cut to achieve pain control.

    In summary, the authors do a very fine job giving us a broad perspective of Kienböck disease over the last 100 years. They review what we know about causes, anatomy, natural history, and current treatment. X-rays, MRIs, and tables are also provided that summarize stages and treatment of this condition.

  • Bird Bites are a Real Health Threat

    Would it surprise you to know that over six million American families have a pet bird? And like all domestic animals, birds come with a variety of interesting problems. Besides the mess that they can make and parasites they carry, they also bite! And those beaks are designed for crushing seeds and berries. So they can do some serious damage to those they bite — even causing bone fractures and amputation of fingers!

    In this article, bird bites and their treatment are discussed. Infection from bird bites is a big concern. Birds carry many of the common bacteria we are exposed to in our environment such as E. coli, Samonella, and Staphylococcus. But they also can transmit to humans (through bites and scratches) Lactobacillus, Pasturella multocida, and Proteus.

    Infection is a major concern after a bird bite severe enough to cut the skin open. Without direct evidence from studies to guide treatment, the following suggestions are made:

  • All bites that break the skin should be irrigated and cleaned (debridement) in a hospital or clinic setting; more severe injuries may require surgical debridement.
  • Antibiotics should be prescribed when the wound is severe enough to warrant them. A broad spectrum antibiotic is advised to cover many different types of organisms.
  • Follow-up lab work to evaluate blood for systemic infection is also recommended; how long after the injury follow-up should continue is unknown.
  • More specific antibiotics can be prescribed if lab testing shows the presence of a particular bacteria or if patients do not respond to the first antibiotic.

    Bird owners and family members don’t have to worry about getting rabies from a bird bite — domestic birds don’t carry rabies. And except for training the bird not to bite, no further action (e.g., quarantine) is suggested after a bite. Of course, advising family members (especially children) not to stick their fingers in the cage toward the bird might be a good idea, too.

  • Reducing the Risk of Dupuytren Recurrence

    Studies have gone back and forth on the best way to prevent recurrence of the nodules that form with Dupuytren contracture. Reported recurrence rates are as high as 50 per cent.

    Dupuytren’s contracture is a fairly common disorder of the fingers. The condition commonly first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

    This condition is seven times more common in men than women. Although more common in men of Scottish, Scandinavian, Irish, or Eastern European ancestry researchers agree that genes are not a direct cause of this disease, but predisposes them to this condition. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.

    Successful treatment usually requires invasive procedures such as steroid injections or surgical release of the fascia. There are known advantages and disadvantages for each approach. For example, percutaneous needle aponeurotomy (PNA) has few complications and a quick recovery time. Patients report little pain and improved hand function. But the recurrence rate is high.

    The procedure involves slipping a surgical needle under the skin and making multiple incisions along the fascia to divide the cord up. Soft tissue release is done until the patient’s finger can be fully straightened.

    Surgery to slice the palm open and remove the diseased tissue has a lower recurrence rate compared with percutaneous needle aponeurotomy (PNA). But the open incision technique called dermofasciectomy leaves scars. Not everyone is a good candidate for dermofasciectomy. Older age and other health problems can prevent surgery from being an option.

    Without a one-best-treatment approach, surgeons continue to look for ways to obtain patient satisfaction and low recurrence rate. In this study, one surgeon compared two different treatments for Dupuytren disease. One group of patients just had percutaneous needle aponeurotomy (PNA).

    The second group had the PNA procedure followed immediately by injection of triamcinolone acetonide (TA). TA injections were repeated six weeks and three months after the first injection. TA injection is a type of steroid (antiinflammatory). The injections were placed right into the contracted (tight) cords caused by the Dupuytren disease.

    Results were measured by comparing finger motion (extension) before and after treatment. Overall joint motion was better in the group who received the combined PNA procedure and TA injection. The joint most affected (in a positive or beneficial way) by this combined approach was the proximal interphalangeal (PIP) joint. The PIP joint is the middle knuckle of the finger.

    Although this study only presents short-term results, there is limited evidence that TA injections may have the ability to provide long-term correction of joint contracture. Results were promising enough after six months to encourage further study using TA injections for Dupuytren contractures. The authors mention the need to assess patient satisfaction as an outcome in all future treatment selections and studies.

    Safe Injections for Trigger Finger in Patients with Diabetes

    Trigger finger is a condition affecting the movement of the flexor tendons as they bend the fingers toward the palm of the hand. This movement is called flexion. Triggering is caused by a mismatch between the size of the tendon with its covering or lining (called the tendon sheath) and the pulley system the tendon and its sheath glide through.

    The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to run in along the bone. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium.

    The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create the nodule. This inflammation and swelling of the tendon sheath or the pulley leads to pinching of the tendon. The tendon fibers start to bunch up causing a nodule to form.

    Symptoms of trigger finger include pain and a funny clicking sensation when the finger is bent. The clicking sensation occurs when the nodule moves through the tunnel formed by the pulley ligaments. With the finger straight, the nodule is at the far edge of the surrounding ligament.

    When the finger is flexed, the nodule passes under the ligament and causes the clicking sensation. If the nodule becomes too large it may pass under the ligament, but it gets stuck at the near edge. The nodule cannot move back through the tunnel, and the finger is locked in the flexed trigger position. Pain occurs when the finger is bent and straightened. Tenderness occurs over the area of the nodule.

    There are a variety of ways to treat this problem depending on how long it has been present and how severe the problem is. In this study, two specific injection treatments are compared for a particular population group. The two treatment approaches are nonsteroidal antiinflammatory (NSAID) injection and steroid injection. Two groups of patients were included: 50 patients with type 1 or type 2 diabetes mellitus and 50 patients without diabetes.

    The reason the researchers focused on the use of injections for trigger finger in people with diabetes is because steroid injections can affect blood sugar control. The goal of this study was to see if a nonsteroidal antiinflammatory injection would have just as good of results as a steroid injection without affecting blood sugars.

    And in fact, they did find that although the early results (after three weeks) were better with the steroid injections, the later results (after three months) were the same. These two types of injections have different ways in which they work but they do both provide the same pain relief and decrease in inflammation.

    In summary, patients with diabetes who develop trigger fingers can be treated effectively with injections that don’t affect glucose (blood sugar) levels. They get the same benefit as with steroid injections (that do affect blood sugars) — just at a slightly slower rate.