News Category: Hand

Studies show that taking antibiotics in preparation for hip replacement, surgery for hip fracture fixation, and breast reconstruction really does help reduce the risk of infection. But if you are having elective hand surgery to remove a tumor, cyst, or ganglion; to treat carpal tunnel syndrome, or to transfer a nerve — do you really need those preventive antibiotics? Especially now that we know the overuse of antibiotics has caused some equally serious problems.

That’s the topic of this retrospective study from the Department of Plastic and Reconstructive Surgery at Johns Hopkins University in Baltimore, Maryland. A retrospective study means the researchers looked at the medical records of patients who had already been treated in the past. By asking the computer to find all cases of hand surgery, they were able to identify 8,850 patients who had hand surgery between the year 2000 and 2008.

Then they compared the outcomes of two groups of patients: those who received prophylactic (preventive) antibiotics and those who did not. Of the 8,850 patients, one-third were given prophylactic antibiotics. The remaining two-thirds had the same type of surgery but they did not receive prophylactic antibiotics.

Patients were followed closely after surgery to determine whether or not a superficial skin infection (SSI) developed. They received a telephone call 10 days after surgery and were checked by the surgeon within the first two weeks. Only infections that occurred during the first 30-days after surgery were counted. Abscesses of stitches used to close incisions were not included as part of a post-operative skin infection.

In all 8,850 patients, there was an overall superficial skin infection (SSI) rate of 0.35 per cent. That’s a very low rate of SSI. And the rate wasn’t different between the two groups. That suggests the use of prophylactic antibiotics for routine hand surgery isn’t really needed. Late infections (those that develop a month or more after surgery) were not a part of this study. This type of infection is related more to poor wound care.

But just to be sure, the authors did a subanalysis to see if patients with certain risk factors for infection were less likely to develop an infection if they did get the “just-in-case” (prophylactic) antibiotic.

An analysis of data collected on the patients showed three risk factors linked with developing a skin infection. These three things included diabetes, procedure length (the longer time in surgery, the greater the risk of infection), and tobacco use (cigarette smokers were at increased risk). But the big news is that patients with these risk factors do NOT reduce their risk of a skin infection by taking a preventive antibiotic.

The natural conclusion is that prophylactic antibiotics are not needed by anyone when having simple, elective hand surgery. This guideline extends to include even those who have a known increase in risk of infection following surgery. The rate of postoperative skin infection is very low already. Taking an antibiotic does not lower that rate at all.

Previous studies have shown a consistent link between diabetes and smoking with delayed wound healing. Open wounds that don’t heal well are at increased risk for superficial skin infection. Changing lifestyle factors such as smoking cessation, losing weight, and getting the diabetes under good control are more likely to have a positive impact on outcome of hand surgery as it relates to infections.

The authors of the study offer a couple of things to think about related to their study. First of all, the number of people in each of the subgroups who did develop an infection (men, women, people with diabetes, people who were obese) was very small. A study with larger numbers may show a greater statistical significance of taking antibiotics versus not taking antibiotics.

And secondly, there was probably surgeon bias in selecting patients to be put on prophylactic antibiotics. Older adults, especially those who have diabetes, may have been targeted by surgeons for the use of preventive antibiotic use. The authors suggest future studies are needed to sort through all of the variables before routinely suggesting discontinuation of prophylactic antibiotics with elective hand surgery.

You’ve probably heard of BOTOX treatment for the movie stars trying to puff up their lips or hide wrinkles and other signs of aging. Maybe you’ve even considered having it done yourself. In this report we find out about the use of BOTOX (BOTOX stands for botulinum neurotoxin) for another condition that doesn’t have anything to do with your looks but affects hand function: Raynaud phenomenon.

What is Raynaud phenomenon? 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 what we refer to as Raynaud phenomenon.

Patients with Raynaud phenomenon 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 this condition varies from patient-to-patient. Sometimes physical therapy, acupuncture, and medications help. Creams applied to the skin to open the blood vessels can be used. Patients with this problem are encouraged to avoid cold conditions and stop using tobacco products. 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 works because it removes the nerve control that is causing the arteries to go into spasm. This is the treatment recommended most often for patients with Raynaud and ulcers that don’t heal. The result can be relief from pain and freedom from having to wear gloves.

Now BOTOX injections might be a less invasive and more effective treatment than surgery that disrupts blood vessels. It still works by turning off pain messages sent along tiny nerves in the hands but without having to cut the blood vessels or nerves directly. How well does it work? Who can have this treatment? How long does the pain relief last? These are a few of the questions answered in this article.

The information presented is based on small studies involving a few patients. There aren’t large studies available yet. The use of BOTOX for this problem is still considered “off-label” and experimental. Off label means the drug is used for something other than what it was intended for. The Food and Drug Administration (FDA) has not approved the use of BOTOX for Raynaud phenomenon.

The treatment is effective though and that’s why it’s used for patients who have not responded well to other conservative measures and who have now developed finger ulcers. The risk of gangrene and amputation is too high to just let the problem go untreated. BOTOX works because it delivers a toxin to the body fluid around the nerves and blood vessels.

Except for some local pain where the needle is inserted, this treatment has very few (if any) negative side effects. Injections can be repeated every four-to-six months (that’s about how long the effects last). Painful symptoms are decreased or gone and hand function is much better. But the effects may not last or provide a long-term (permanent) solution. The long-term effects of BOTOX injections for Raynaud phenomenon have not been investigated or reported yet either.

There are some patients who may not be good candidates for this type of approach for their Raynaud condition. For example, if they have tried BOTOX before and didn’t tolerate it well or got no results, then a second series of injections isn’t likely to help either. If the disease is too far progressed and there’s no hope the blood vessels can be repaired, then BOTOX may not be a good idea.

Patients considering BOTOX injections for Raynaud phenomenon should be warned of possible adverse effects of this treatment. Skin infections, inability for the skin to cool itself by sweating (called anhydrosis), and muscle paralysis contributing to hand weakness have been reported.

For many patients hampered by Raynaud phenomenon, a minimally invasive treatment approach may be a welcome option. With good pain control providing improved hand function, BOTOX may be worth taking the chance of potential side effects.

Every surgeon must know the details of the anatomy in the area being operated on. But sometimes the body throws a ringer that can surprise even the most experienced surgeons. That’s the case in this report of a 70-year-old woman with carpal tunnel syndrome.

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.

This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do. And that is the situation with this patient.

When the surgeons made the surgical incision to treat the symptoms of carpal tunnel syndrome in the woman featured in this report, they found an extra muscle and tendon causing the problem. Any unusual or extra anatomical changes in the body are referred to as anomalous. In this case, it was a muscle called the palmaris profundus.

Studies show that only one out of 100 cases of carpal tunnel syndrome is ever caused by anomalous muscles. And only one out of 1600 people ever have the palmaris profundus muscle. So you can see this particular cause of carpal tunnel is very rare and worth reporting.

The woman’s symptoms were clearly from compression of the median nerve with numbness and tingling of the affected hand and fingers during the day. At night she would wake up with pain and numbness in the fingers, hand, and forearm. When the symptoms started interfering with daytime activities, she went to the physician for help.

At first, they tried conservative (nonoperative) care, which is the standard treatment procedure. She took antiinflammatory medications and had steroid injections into the carpal tunnel to reduce any swelling that might be present. When those things didn’t work, they did some additional testing. X-rays were normal but nerve conduction tests were abnormal.

When nerve conduction tests show an increased delay in signals along the nerve, the surgeon has a green light to perform a procedure to release the nerve from whatever is putting pressure on it. Many times the band of connective tissue that goes across the flexor tendons (called the flexor retinaculum) is cut and that takes care of the problem.

In this case, when the flexor retinaculum was cut, the surgeon could see the palmaris longus tendon (a muscle/tendon unit that is normally present in 90 per cent of all people). It was pressing on the nerve. When they moved up the palmaris longus tendon aside, they found the anomalous (extra) palmaris profundus.

They removed the palmaris profundus but before they cut into it, they checked to make sure it wasn’t producing any movement or providing any function to the hand. By pulling gently on the palmaris profundus, they could see there was nothing happening (no movement of the fingers or hand).

The patient recovered completely with no residual symptoms. Four years later at the last follow-up, she was still symptom-free. The authors of this report provide a detailed description of the unusual anatomy for any other surgeons who may run into this problem.

They know from other studies that when present, the anatomy of the palmaris profundus varies from patient-to-patient. A report like this will help surgeons understand the potential for unusual anatomic anomalies as the cause of carpal tunnel syndrome.

A complete understanding of the normal anatomy is essential for recognizing when something is amiss. Knowing the course of the median nerve will also prevent any accidental cuts or damage to the nerve during carpal tunnel surgery.

This report is from microsurgeons from China. They treated 10 patients with finger amputations. After reattaching the fingers, it was clear within a day or two that the replantation the blood that was at the surgical site was pooling, a process called venous congestion. Without proper blood circulation to and from the finger, the reattached (replanted) tissue was dying.

The authors used a newly developed method for restoring blood flow to an amputated finger that has been reattached or replanted. It’s called a proximally based cross-finger flap.

In this procedure, the hand surgeon takes the top layer of skin and blood vessels from the finger next to the amputated one (the donor finger) and transfer it to cover the area where the replanted finger is connected back to the affected finger. The donor flap consists of skin, tissue just under the skin, and veins. The tendon is left untouched.

The donor flap is sewn loosely without tension to the replanted finger. The flap of skin is not cut away from the donor finger. Instead, it forms what looks like a bridge between the two fingers. The stripped donor site is covered with a layer of skin called a skin graft. When the replanted finger has a restored supply of blood, the graft can be removed.

This method of proximally based cross-finger flap isn’t the only way to handle venous congestion in a newly replanted finger. In mild cases, leeches can actually be applied to the skin. Just as you might imagine, the leeches suck the pooled blood out from under the skin. But leeches aren’t enough when there are blood clots forming, skin inflammation with blisters, and/or necrosis (dying tissue).

The authors note that there are other ways to surgically handle this situation. But they suggest this method may work best when there is venous congestion, not enough skin to cover and reconnect the amputated finger, and it’s clear that the replantation is in trouble. The cross-finger flap is best applied within 48-hours of the original replant surgery.

Based on this study, it looks like the cross-finger flap is easy to apply (takes less than 90 minutes in the operating room) and quite successful. Microsurgeons performing finger replantations may want to consider this approach if and when venous congestion develops.

Results in this study were very good with return of blood flow, full range-of-motion, and a return to preinjury function. Only one of the 10 patients in this study had a failed surgery and that was because the original injury was a crush injury. One patient did not like how it looked and three people reported ongoing pain when the study ended two years later.

People who have rheumatoid arthritis of the hands often develop a finger deformity referred to as a Boutonniere deformity. The name comes from a French word for “button hole”. We will explain that further after we describe the deformity.

When the affected finger is viewed from the side, it has a zig-zag appearance. That’s because the joint of the middle knuckle of the finger (called the proximal interphalangeal or PIP joint) is permanently bent toward the palm while the tip of the finger (as the distal interphalangeal or DIP joint) is bent back or hyperextended.

This flexion deformity of the middle joint (the proximal interphalangeal or PIP joint) occurs when the central slip of the extensor tendon separates. The head of the proximal phalanx (middle finger) bone literally pops through the gap. It’s like a finger through a button hole and thus the name boutonniere.

The tip of the finger is then drawn into hyperextension because the two slips of the extensor tendon on either side of the separated central tendon are stretched by the head of the proximal phalanx. The two peripheral slips attach to the distal phalanx (finger tip bone), while the proximal slip is inserted into the middle phalanx. This deformity makes it difficult or impossible to extend the proximal interphalangeal (PIP) joint and bend the finger tip.

You can imagine how difficult it is to perform daily activities that require flexibility of the fingers. Try picking anything up with your fingers stuck in a Boutonniere position. Better yet, try using a key to unlock a door or turn a door knob. You will probably have to put anything down you are carrying and use two hands together.

What can be done about this problem? Treatment depends on how severe the deformity is, how much motion there is at each joint, and whether or not the joint can be passively straightened. Fingers that can be stretched or moved back to their normal resting position may benefit from hand therapy and splinting.

But fingers that are in a Boutonniere position and can’t be moved to a normal position are considered contracted. Surgery becomes the only option at that point. The surgical choices include synovectomy, tenotomy, or reconstruction of the extensor tendon. If the deformity is severe, then a joint fusion (called arthrodesis) or joint replacement (arthroplasty) may be required. These two procedures are referred to as salvage surgery).

Surgeons use a special classification system to decide just how severe is the deformity and therefore which surgical procedure to choose. There are three stages of Boutonniere deformity. Stage one (mild) is correctable with passive motion. The joint surface is normal without any signs of joint damage or degeneration.

Stage two Boutonniere deformity is considered moderate in severity. The joints can be partially returned to their normal anatomic position (neutral). And the articular (joint) surface remains unchanged. In the early phase of stage two deformity, it may still be possible to convert to a stage one deformity with conservative (nonoperative) care.

Stage three is defined by a fixed contracture (does not correct with passive motion) and the joint surface is damaged to the point of destruction. This is the stage that most often requires surgical intervention.

Stages one and two may still respond to hand therapy, splinting, and/or steroid injection of the joint. If stage one and stage two deformities fail to respond to conservative care, then surgery may be recommended for them, too.

When choosing the surgical technique for each patient, the surgeon takes into consideration the condition of the most affected joint, the adjacent joints, the skin, joint motion, and overall hand function.

One of the most commonly used approaches is to make an incision over the proximal interphalangeal (PIP) joint and remove the extra piece of central tendon where it has separated. The tendon is reattached where it can function best. The surgeon also corrects the tendon pull on the distal phalanx (tip of the finger).

Every effort is made to restore as much normal motion as possible to the two joints affected. Studies show that results of surgery are best when the procedures are done before the deformities become fixed contractures. But when all else fails and the finger is stuck and nonfunctional, it may be necessary to proceed to a joint fusion or replacement. Silicone implants are recommended by most surgeons who perform these replacement procedures.

Patients facing surgery for boutonniere deformities should be aware of a couple things. First, no matter what type of surgery is done, there is often a residual deformity called extensor lag at the tip of the finger. That means when the patient tries to extend or straighten the tip of the finger, it now moves but it doesn’t straighten all the way. Instead there is still a small amount of flexion at the finger tip.

And even if the patient has had hand therapy before surgery, further rehabilitation will be necessary after surgery. Once again, the hand therapist will use splinting, exercises, and specific therapeutic activities to help patients regain lost motion and maximize function. Patients usually wear splints 24/7 for at least four weeks to protect the healing tendon. A special splint for night time use may be prescribed for another four to eight weeks. Overall results vary but most patients can expect a good or satisfactory result.

What do children at day cares and prison inmates have in common with homeless people? These are groups of people who are at increased risk of MRSA (pronounced mersa). MRSA stands for methicillin-resistant staphylococcus aureus. MRSA is a staph bacterium that cannot be killed easily by antibiotics and especially not by a class of penicillin known as methicillin.

In this report, hand surgeons from the Naval Medical Center in San Diego review the current state of hand infections in the United States. They discuss the microbiology of microbes that can cause infection, outline risk factors, and present a summary on a dozen conditions caused by infection. The anatomic area of focus is the hand and arm.

We’ve already told you three groups at increased risk for MRSA and other infections. Other groups at risk include individuals with diabetes, anyone who is immunocompromised, and anyone on long-term antibiotics for any reason.

People who are immunocompromised include organ transplant recipients, anyone with an autoimmune disease (e.g., multiple sclerosis, lupus, ALS). Patients in the intensive care unit, anyone who has had a recent surgery, and patients in close quarters with other patients already infected with MRSA are also at increased risk.

Infections affecting the finger include paronychia (bacterial or fungal infection under the nail fold), felons (e.g., abscess in the nail pulp), herpetic whitlow (infection with herpes virus), and pyogenic flexor tenosynovitis (bacterial infection of the flexor tendon sheath).

Each of these finger infections has its own clinical presentation to help differentiate it from the others. Physicians look at the location and signs and symptoms when making a diagnosis. Swelling, throbbing pain, redness of the skin are common with many of these conditions. So the patient’s history becomes a key feature in the diagnosis.

Different groups are at increased risk for each type of infection. For example, chronic paronychia develops most often in swimmers, dishwashers, and bartenders. These are folks who have their hands in water quite often and have moist skin — a perfect breeding ground for fungus.

Thumb sucking, nail biting, and contact with body secretions (by dentists, nurses, anesthesiologists, and other health care professionals) can transmit herpes viruses. Human or animal bites (especially cat bites) and clenched fist injuries can cause serious wounds that can be infected with one or more of over 40 bacterial strains. Some of these strains are resistant to many different antibiotics. This type of resistance creates an even greater challenge to treatment.

Finger infections can spread to the hand and up the arm. There are natural protective boundaries built into the hand in the form of connective tissue. These boundaries help contain the infection in one area or space. But some infections such as cellulitis spread up the arm via the blood system.

Joints can become infected causing a condition called septic arthritis. The damage done to the joint can be very serious. Bacteria release their own personal arsenal of toxins and enzymes that can destroy joint cartilage and lead to bone infections (osteomyelitis).

One of the worst types of complications from infections is a condition called necrotizing fasciitis. Without proper treatment immediately, necrotizing fasciitis (a flesh eating bacteria) can devour the body and cause death. What can be done to prevent all this tissue damage, loss of function, and in some cases, loss of life?

The first line of treatment is antibiotics. Often a broad-spectrum, more general antibiotic is prescribed until the specific type of bacteria can be identified with a lab culture. Once the offending organism is known, the patient can be switched to an antibiotic known to specifically kill those bacteria.

Severe infections may require hospitalization and surgical intervention. The surgeon may have to make an incision and drain the pus then scrape away any dead or infected tissue. This procedure is called debridement and may have to be repeated more than once until the infection is completely cleared up. Intravenous (IV) antibiotics are usually given while the person is in the hospital and may continue for several weeks to months after discharge.

Sometimes an irrigation drainage system must be put in the hand or forearm. This device bathes the tissues with a saline solution to keep bacteria from forming. In severe cases of septic arthritis, it may be necessary to fuse the joint, replace the joint, or (worse case scenario) amputate the infected finger(s).

Anyone interested in the types of hand infections seen most often in the United States will find this article comprehensive and helpful. Specific details about the surgical treatment of a dozen different types of infections affecting the fingers, hand, and arm are reviewed and discussed. With more and more cases of MRSA and other infections of the hand on the rise, this information is very timely.

If surgery is done for carpal tunnel syndrome, how can we tell if it worked? The more obvious answer is whether or not the patient’s symptoms (usually wrist/hand pain, numbness and tingling) improve.

Standardized research can rely on just asking the patient to rate his or her pain from zero to 10 or zero to 100. Two tools currently in clinical use to measure the results of treatment for carpal tunnel syndrome. The first is the 6-item carpal tunnel symptoms scale (referred to as CTS-6). The second is the 2-item palmar pain scale.

The CTS-6 measures change in symptoms after surgery, while the 2-item text is a measure of pain caused by the surgery. A study carried out by Swedish researchers was designed to assess how effective these two tests are in measuring symptoms related to carpal tunnel syndrome (CTS) and surgery for carpal tunnel surgery.

This particular group of researchers were the ones who developed the 6-item CTS symptoms scale in the first place back in 2009. It is a more streamlined and valid test than the previously used 11-item CTS severity scale. Since then, they followed 447 patients and measured the outcomes of surgical treatment for CTS.

Everyone in the study had an open incision approach (rather than minimally invasive) surgery. Almost everyone had the surgery under local anesthetic. Prior to surgery, they had all tried using a wrist splint without success.

There was no attempt to try hand therapy before surgery and no formal rehab program after surgery. Patients were given some exercises to do after surgery and advised to slowly increase their activities until able to resume all previous functions.

As predicted by the study authors, both tools were valid and reliable. The CTS-6 score reflected greater satisfaction after surgery in the patients who had the greatest pain relief and return of function. And as you might have expected, the longer patients were away from the surgery date, the less pain they reported on the 2-item palmar pain scale.

Results of these tests were also compared with the QuickDASH, another tool available to measure before and after results of carpal tunnel syndrome. They found that the QuickDASH is a better measure of disability. So comparing the QuickDASH to either the CTS-6 or the 2-item palmar pain scale was a bit like comparing apples to oranges (both fruit but not the same thing at all).

There was some speculation as to why some patients did not improve with surgery. It was suggested that some may have been given the wrong diagnosis (and therefore the wrong treatment). Problems in other parts of the arm (shoulder, elbow) may have been the real underlying cause of symptoms.

Others may have been clouded in their judgment by their perception — they actually had experienced measurable improvement in symptoms. But they got used to the gradual change and remained unsatisfied with any amount of pain no matter what amount of recovery had already been experienced.

In summary, the 6-item CTS symptoms scale is very responsive to change in CTS symptoms after surgery. Since the 6-item tool is faster than the previously 11-item scale, it is advised to make use of the shorter, yet still reliable tool.

Further analysis of the data collected from the 2-item palmar pain scale showed that maximum pain relief occurs between six and 13 months. There is some pain relief between three and six months post-op but the bulk of improvements comes a little later.

Almost 400 years have passed by since Dupuytrens disease of the hand was first described by a Swiss physician. Since that time, surgery has been the only successful treatment. That may all change with the recent FDA approval of Xiaflex, an injectable drug designed to weaken the diseased tissue.

Dupuytrens disease is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is genetic in nature, meaning it runs in families.

The palm side of the hand is affected. This is where a type of connective tissue, called fascia that surrounds and separates the tendons and muscles of the hand is involved. Just under the palm is the palmar fascia, a thin sheet of connective tissue shaped somewhat like a triangle.

This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers.

These bands continue into the fingers where they wrap around the joints and bones. Dupuytrens disease causes tightening called contracture. When the palmar fascia tightens, the fingers curl into a bent position and stay there.

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. Dupuytrens contractures usually only affect the ring and little finger.

Heating and manually stretching the tight tissues doesn’t solve the problem. Cutting the hand open and releasing the tight cords has been the only effective treatment. Now, according to this report, there is a nonsurgical approach to this problem.

By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken. Then the surgeon can manually pull the fingers straight and rupture the cord. That sounds dramatic — it’s not! The treatment is safe and effective.

There are a few possible (minor) side effects but very few major or long-term complications with this new treatment. During the control trials conducted with patients, most people had a local skin reaction (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 tendon rupture, finger deformity, and hives that had to be treated with medication.

Treatment of this type (called enzymatic fasciotomy) may eventually replace surgery. But further study is needed to assess the long-term effects, especially recurrence rates. Until then, surgical release of the cords will likely remain the gold standard.

The criteria for when to have surgery are joint contractures of 30 degrees or more, significant impaired function, and/or disease that is getting worse over time. There are several different surgical procedures possible. Each one has the same purpose — to release the cording and restore joint and finger motion.

The least invasive approach is called needle aponeurotomy. Under local anesthesia, the surgeon inserts a very thin needle under the skin. The sharp needle cuts a path through the cord, weakening it enough to stretch and extend or rupture it.

The advantage of this procedure is that it can be done on older adults who have other health issues that might make surgery under general anesthesia too risky. The disadvantage is a high recurrence rate and the potential for nerve injury, infection, and hematoma (pocket of blood) formation.

Future studies will be needed to compare final results for different treatments. Conservative care with Xiaflex (or other similar) injections must be compared to surgical treatment. The various surgical approaches should all be included as well.

For now, just developing a collagen enzyme injection and getting it on the market is a big step in moving from a surgical to nonsurgical approach to Dupuytrens disease. Cost considerations among the different treatment options will have to be considered along with the long-term effects and recurrence rates.

Fears that older age (65 or older) increases the risk of complications (including death) from finger replantation can be set aside. According to this study from Stanford University, the risk of serious blood clots leading to death after surgery to reattach a thumb or finger in the older age group is no different than in the younger crowd.

They determined this by reviewing the medical records of 616 patients across the U.S. who had this surgery done over a 10-year period of time. The data was taken from the Nationwide Inpatient Survey (NIS). Information collected at the time of hospital discharge is placed in this database and can be used by all researchers. No patient is identified, so it is confidential.

To give you a little perspective on this topic, compared to the 616 patients over the age of 65 who had a digit replantation, there were almost 15,000 of these procedures done in younger patients (under 65). In case you are puzzled over the meaning of the term digit replantation, it simply refers to the reattachment of a finger or thumb that has been accidentally cut off.

There were complications for patients in the older group. Blood clots, bleeding, pressure ulcers, and accidental cuts were reported. But the percentage of patients affected was less than one per cent (0.6 per cent). Death occurred in an even smaller number (0.04 per cent).

Age as a risk factor for death following digit replantation just wasn’t a factor. But that doesn’t mean that age should be ignored. Older adults who had a digit replantation were twice as likely to need a blood transfusion. Discharge to a nursing home rather than directly to the patient’s home was also more likely in the older age group.

Although this study did not analyze survival rates of the finger (or thumb), other studies have reported no difference based on age. Patients with diabetes or who smoke are at risk for less optimal outcomes compared with those without these risk factors.

Survival of the digit is one variable; function is something else. In other words, the patient may not lose the finger but he or she may not have good use (function) of the digit. Survival versus function was not studied in this study and may be the basis of future studies.

In summary, age (along with all other factors) should be taken into consideration when planning treatment for a finger or thumb amputation. But age should not be a reason to avoid replantation. Surgeons keep in mind the idea that “life comes before limb” (i.e., don’t put someone at risk of death to save a finger). The results of this study show that older adults can have both!

If you have ever experienced the aching forearm pain caused by pronator syndrome, then it’s likely you believe this condition to be a real and true problem. But some experts in the orthopedic world aren’t convinced.

Pronator syndrome is a nerve entrapment (pressure on the median nerve in the forearm). The median nerve traveling down the inside of the forearm can get pinched between two other soft tissue structures such as muscles, tendons, ligaments, or fascia (connective tissue).

The syndrome produces more than just forearm aching pain. Some patients also report numbness and tingling in the thumb and index finger. The symptoms are usually mild-to-moderate in intensity. Hand function may be impaired but disability from this problem is rare.

There are no tests to really confirm the diagnosis. Electrodiagnostic tests are typically used to confirm other nerve compression problems. The test provides positive proof when there’s a problem. But in the case of pronator syndrome, stimulating the nerve with an electrical impulse shows there’s a problem in nerve conduction for only one out of every 10 patients with symptoms of pronator syndrome.

Likewise, any of the other clinical tests performed by the surgeon (e.g., pronator compression test, pronation resistance, resisted elbow flexion, resisted motion of the middle finger) have inconsistent results at best.

Women in their 40s are the ones most likely to be seen with this condition. And because there are no objective measures and because surgery to decompress the nerve isn’t successful, there is a belief that what we are facing here isn’t a disease, but rather an illness.

When surgery does relieve the problem, it could be a placebo effect. So determining disease (true pathologic anatomy or physiology) from illness (physical symptoms caused by emotional or psychologic distress) can’t be cleared up by successful treatment.

Until the concept of pronator syndrome can be fully explored and explained, treatment will likely remain nonsurgical. Antiinflammatory medications and a few sessions with a hand therapist may be all that’s needed. The therapist will teach the patient how to modify activities to avoid contracting the pronator muscle and thereby keep pressure off the nerve.

Exercises to stretch the nerve and manual therapy to release fibrous tissue around the nerve may help. Any postural effects will be addressed. The therapist may conduct a review of the patient’s home and/or office work areas for possible contributing or aggravating factors.

Whether you believe the pronator syndrome exists or not, people affected by this condition are experiencing real symptoms. Future research is needed to get to the bottom of the problem — in other words, what’s really happening here and why, as well as what can be done about it?

For now in the opinion of hand experts, surgery is only recommended on rare occasions and then only after at least six months of nonoperative care first. Other supportive measures may include splinting, acupuncture, or pain medications.

Have you ever nearly cut the tip of your finger off and thought that was a close one? Some folks aren’t so lucky and face the decision of whether to accept the amputation or try for replantation of the finger tip. Hand surgeons say this is a challenging procedure with many pitfalls.

In this article, two hand surgeons from the Christine M. Kleinert Institute for Hand and Microsurgery in Louisville, Kentucky describe and illustrate this surgical procedure called distal finger replantation.

They suggest the procedure is not possible when the injury involves crushing or contamination. But for children, young women, musicians, or others who truly need the tip of the finger, distal finger replantation should be attempted.

What makes this procedure so technically challenging? You wouldn’t necessarily know it to look at the tip of the finger but the anatomy is incredibly complex. There are multiple pulleys that make it possible for the finger to bend.

A network of arteries, veins, ligaments, fascia (connective tissue), and an elaborate lymphatic (fluid drainage) system are all contained within the finger. All of the structures are tiny and their locations are not exactly the same from person-to-person.

Replantation calls for a microvascular surgeon who uses a high-power microscope to repair blood vessels. Unless blood vessels and nerves are matched up and reconnected properly, loss of sensation and temperature control can occur.

To aid surgeons in understanding tip recovery and restoration, detailed drawings of the finger and fingertip anatomy are provided. X-rays, photos of damaged fingers (before, during and after surgery), and drawings aid in demonstrating surgical techniques for replantation.

Special consideration must be given when the fingernail has been damaged. In children, the surgeon must assess whether the amputation injury has gone through the growth plate of the bone. Any joint damage must also be considered. Skin grafts may be needed if too much skin must be removed or has been destroyed by the injury.

There are many possible complications following distal finger replantation. Blood clots can form cutting off circulation to the healing area and/or traveling to the heart or brain. The reattached tip of the finger may not survive. There is a risk of infection but modern day antibiotics often prevent that from happening.

The authors conclude by saying that the cosmetic effect of replantation is preferred by most people. Full function of the finger is not possible without the tip but this may not be as important for a manual laborer as for a musician. Amputation without replantation can lead to the development of painful neuromas (growth or tumor of nerve tissue).

There’s no doubt that improved medical treatment has reduced the number (and severity) of hand, finger, and thumb deformities caused by rheumatoid arthritis. But these and other problems still do crop up and may require surgical intervention.

In this article, the role of surgery in the management of rheumatoid arthritis affecting the hand is reviewed. Each area of the hand from the wrist to the finger tips is discussed. Treatment of specific deformities such as boutonniere or swan-neck of the fingers and thumb is highlighted. Tendon rupture, a common problem with rheumatoid arthritis is also reviewed.

As the author of this publication, Dr. Chung hopes to show that surgeons should be called in as consultants early in the management of rheumatoid arthritis. Rheumatologists treating this condition with medications such as the newer disease-modifying anti-rheumatic medications (DMARDs) should not view the need for surgery as a failure of medical treatment.

There are some patients who don’t respond to these medications but who could still benefit from surgical intervention to improve joint alignment, motion, and function. Coordinating treatment between the rheumatologist and the surgeon can be vital in providing the best possible outcomes for these patients.

What kind of surgery is available for hand conditions caused by rheumatoid arthritis? Let’s start with the wrist and work our way down to the thumb and finger tips. The wrist is affected in 70 per cent of all patients with rheumatoid arthritis of the hand.

Inflammation of the fluid inside the joint (a condition called synovitis) weakens the ligaments and other soft tissue support structures of the wrist. Without the support from these connective tissues, the bones of the wrist collapse. Dislocation of the wrist is the next step.

Surgery can be done to realign the bones and reduce pain (when present). Correcting alignment and minimizing deformities may help improve motion and function. Surgery doesn’t have to wait until the damage is done.

The surgeon can take action once evidence is seen that the wrist bones are migrating (shifting). Partial fusion of the wrist may prevent shifting of the bones, thus reducing the risk of hand and finger deformities. Total fusion may be needed to decrease pain and stabilize the wrist.

The health of the bones can impact surgical decisions. Weak, brittle, or insufficient bone stock can limit surgical options (e.g., making the use of an implant for joint replacement impossible). Studies are ongoing to find ways to improve wrist replacement surgery. Problems with implant loosening, fracture, and degeneration have resulted in new designs being developed.

Next, let’s look at surgical options for the metacarpophalangeal (MCP) joints (the big knuckles you see across the back of the hand when you form a fist). Synovitis associated with rheumatoid arthritis often causes a shift of the fingers off to the side called ulnar deviation or ulnar drift.

You can imagine how difficult it is to grasp objects, open doors or jars, get dressed, or pick up items when your fingers won’t straighten out. And that doesn’t even begin to address the cosmetic appearance that is so distressing to many patients. What can be done surgically for this problem?

Fusion of the metacarpophalangeal (MCP) or other finger joints doesn’t work — the loss of motion would only make daily functions even more difficult. Some surgeons are trying to remove the affected synovium (called a synovectomy) and transfer ligaments to hold the joints in place. The transfer procedure is called a cross-intrinsic transfer. It can be done if damage to the joints caused by the synovitis is not too great.

It is possible to replace the MCP joints. This joint replacement surgery is recommended when the joints sublux (partially dislocate) or completely dislocate. When enough joint damage has been done that the joints can’t recover or it’s too late for reconstructive surgery, then joint replacement may be the next step.

Long-term studies do show a high rate of implant breakage. The implants are made of silicone and they don’t seem to hold up as well as hoped for. Still, patients say the improved hand function in the short- and mid-term period is worth having the procedure done.

This brings us to the treatment of tendon ruptures so common among patients with rheumatoid arthritis. With the shifting position of bones, tendons can get caught between two bones or rub against bony edges shredding them until they break. Tendon weakening from synovitis also contributes to tendon ruptures with minor injuries or mechanical trauma.

Surgical treatment removes the problem causing the tendon rupture. The surgeon then repairs or reconstructs the damaged tendon. Sometimes a tendon can be sewn to another tendon so that movement of the intact tendon assists the torn tendon. In other cases, a tendon transfer can be done. With this procedure, one tendon is split and a portion of that tendon is moved over and attached where the ruptured tendon used to be.

In the final section, Dr. Chung addresses the problem of finger and thumb deformities. Any changes or problems in the wrist and hand will affect the fingers and thumb. Collapse of any bone above the digits (if untreated) will cause a zig-zag shift throughout the rest of the hand and fingers. Finger deformities are an even greater challenge than wrist and hand problems.

Surgical intervention will depend on the specific joint affected and whether or not the deformity is still flexible (finger joints can still be moved passively) versus “fixed” (joints are stuck in one position). The two main choices are soft tissue reconstruction (best for flexible deformities) and joint replacement (recommended for fixed deformities). Fusion of unstable joints presents a third option but this is a last resort effort.

When making treatment decisions regarding the thumb and fingers, the surgeon must take into account whether the problem is one of appearance or function. It’s important to avoid making function worse in order to improve the appearance. Many patients are more concerned about how their hands look and will sacrifice function for a more normal looking hand.

In summary, the author suggests there is a great need for research to really provide evidence that identifies which medical and/or surgical treatments of rheumatoid arthritis of the hand are most effective.

Until that is available, disagreements between these two specialties may hamper efforts to improve wrist and hand function. Dr. Chung presents a very clear argument for hand surgery to aid patients with rheumatoid arthritis maintain or regain hand function and improve quality of life. Communication between surgeons and rheumatologists may help educate the medical community of the need for an individual plan of coordinated care for each patient.

Jersey finger injury refers to the damage done to the tip of the ring finger when an athlete grabs the shirt (jersey) of another player while that player is pulling away. The hand grasping the jersey is closed in a fist. But the force of the player wearing the shirt pulls the tip of the ring finger into extension.

The result is a rupture of the tendon away from the bone. A piece of the bone may come with the tendon (still attached). This is called an avulsion injury. There can be a bone fracture along with the tendon rupture.

And although it sounds like this is an injury only an athlete can have, in fact, “jersey” finger injuries occur in nonathletes of all ages. Older adults with rheumatoid arthritis or other inflammatory joint conditions experience this injury as well. The same mechanism takes place: forceful extension of the tip of the finger when it is bent that causes the problem.

Any finger can be affected. The ring finger seems to be the most commonly injured digit because of its unique anatomy. It is the weakest of the fingers and least able to move by itself. The flexor digitorum profundus (or FDP) tendon pulls away from the bone more easily than any other finger tendon.

When the fingers are in a fisted position, the ring finger is actually just a tiny bit more forward than the other fingers. So it absorbs more of the force during a pull-away maneuver compared with the other fingers.

Treatment is based on a classification scheme. The injury can be described as a type I, II, III, IV, or V level of retraction. Retraction refers to how far back toward the palm the tendon has recoiled. Type I describes a flexor digitorum profundus tendon (FDP) that has pulled away from the bone and snapped all the way back to the palm.

Type II injury means the tendon has pulled away from the tip of the finger taking a tiny bit of bone with it but without retracting past the next bone. With a type III injury, the tendon has avulsed with a large bone fragment that has gotten caught or entrapped without moving.

Type IV level of retraction has a ruptured tendon with bone avulsion and retraction back toward the palm. And Type V is a ruptured tendon with bone avulsion. The bone where the tendon has pulled away is broken into tiny pieces (called a comminuted fracture). Type V injuries are further divided into Va and Vb. Type Va means the damage is outside the joint (extra-articular). Type Vb tells us there is intraarticular (inside the joint) damage.

When planning the type of surgery to perform, the surgeon evaluates how far back the tendon has retracted, how much bone damage is present, and if the joint is involved. For example, full retraction of the tendon often means the pulley system that holds the tendon in place has also been disrupted. When the force of the injury is enough to strip the tendon from the bone carrying the pulley mechanism along with it, then the blood supply is also affected.

Besides considering the classification type of jersey injury, the surgeon must also consider how long ago the finger was damaged. The longer the time between the trauma and the treatment, the more likely it is that fibrosis and scar tissue has set in. Pre-operative X-rays and MRIs are helpful in showing the surgeon the extent of the damage and where the retracted tendon is located.

There is limited evidence from high quality studies to guide surgeons as to the very best surgical procedure to use for jersey finger injuries. Sometimes it is possible to reattach the tendon to the bone. In other cases, the tendon must be threaded back where it belongs.

If the tendon has to be pulled from the palm all the way forward to the tip of the finger, then it must be secured to hold it in place. The surgeon can choose between a button repair, anchor repair, locking sutures, or multiple strand sutures. The goals of surgical treatment are 1) to avoid a gap between where the tendon should be attached and where it can be attached and 2) provide a strong enough repair to withstand normal load on the finger.

Even with the best results, patients should expect some loss of motion. The tip of the affected finger may be permanently bent or flexed. Stiffness of the joint at the tip of the finger is common. Restoring full range-of-motion requires an aggressive hand therapy program and a motivated patient. Complications such as infection, too much stretching on the repaired tendon, or rupture of the repair can limit results as well.

Medicine has taken a decided turn toward demanding evidence that the intended treatment is really what’s going to work for the patient and the condition or problem. In this case review, two hand surgeons from Vanderbilt Orthopaedic Institute in Nashville, Tennessee present a 30-year-old patient with a jammed and deformed index finger. They ask the question: how should this be treated? And then they offer their opinion about treatment options and the evidence they base their recommendations on.

The problem they are dealing with is one many orthopedic surgeons treat called a boutonniere deformity. The boutonniere deformity affects the extensor tendon(s) of the finger so they no longer work properly. The injured area of the tendon is called the central slip. Damage occurs where the extensor tendon attaches to the middle phalanx (bone) of the finger.

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

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

So, back to the question about how to treat this problem? The surgeon has two choices. The first consideration is for conservative (nonoperative) care with splinting, range-of-motion exercises, and strengthening exercises. Many hand surgeons will try six weeks of splinting with the spring-type splint and exercise to see if the deformity lessens to a tolerable limit before considering surgery. This is desirable before surgery to stretch out a PIP contracture before repairing or reconstructing the extensor tendon.

Even with conservative care, surgery is required in some cases of boutonniere deformity. If it is just a matter of cosmetics (appearance), surgery may not help. If loss of motion has resulted in loss of function and disability, then surgery deserves a closer look.

Best results occur when the PIP joint is limber, rather than stuck in a bent position. If the PIP joint is stuck in a bent position, surgeons usually wait before doing surgery to see if splinting will help stretch and straighten the PIP joint. Splint immobilization may help restore full finger extension. In this position, the central slip may heal. But if it doesn’t, then here’s where the next dilemma presents itself: what type of surgery works best?

The surgeon can reattach the central slip and reconstruct the rest of the damaged soft tissue structures. Surgical procedures that can be used include lateral band reconstruction, central slip reattachment, central slip reconstruction, extensor tenotomy, or tendon and transverse retinacular reconstruction.

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

The authors offer other hand surgeons these opinions from their own experience and based on collected evidence in previously published articles and studies:

In many of the classic cartoons, the wicked witch is portrayed as an old crone with bony, crooked, and deformed fingers. We don’t feel sorry for her appearance at all — or for the pain she might be suffering with what looks like arthritis of the hands.

But if you are that arthritis sufferer (young or old), you might feel differently. Pain, disfigurement, and disability of the hands is more than unsightly — it’s a major stumbling block in accomplishing everyday tasks like picking up a piece of mail, opening a jar of pickles, or even taking care of business in the bathroom.

In this article, orthopedic surgeon Marco Rizzo, MD from the Mayo Clinic (Rochester, Minnesota) offers us an update on what can be done for anyone with joint arthritis of the hands. In particular, he focuses on the metacarpophalangeal (MCP) joints. The MCP joints are what we more commonly refer to as the “knuckles” across the back of the hand (prominent when making a fist).

Without treatment, considerable destruction and cartilage loss occur in the joint. The MCP joints in all the fingers and the thumb can develop these types of changes with both osteoarthritis (OA) as well as rheumatoid arthritis (RA). And after an injury or trauma to the fingers or hand, another type of arthritis called posttraumatic arthritis can occur.

With all types of arthritis, the symptoms are similar. There are more inflammatory symptoms with rheumatoid arthritis and more deformity. The fingers start to drift to one side. Tendons tighten up pulling on the bones until the fingers curl and twist — just like the witch in the cartoons. Poor dear! What’s worse is that as the joint cartilage is destroyed and the soft tissues lose power, the bone starts to disintegrate as well.

What can be done for this condition? There are two basic choices: conservative (nonoperative) care and surgery. Let’s see what Dr. Rizzo recommends for each. Conservative care consists of three options: splinting to protect the joint and give it a rest, medications, and steroid injections.

Some patients have worried that wearing splints might cause them to lose motion in the end. But there’s no evidence that splints contribute to joint stiffness or muscle contractures. Usually splints are worn during activities and removed during rest periods. Daily exercises are performed with the splints off. Some physicians advise their patients to just wear the splints at night as they do seem to help prevent deformities from developing.

The biggest change in nonoperative care in the last 10 years has come from new medications that target the immune system and stop the inflammatory processes linked with arthritis. Patients with inflammatory arthritis and especially rheumatoid arthritis get the most benefit from these drugs.

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

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

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

What about surgery? Surgeons and rheumatologists don’t always agree on surgery as an important option for the treatment of hand arthritis. Researchers put it to a test and did a study asking patients after surgery for their opinions. Based on surveys and patient-report, they found there were fewer deformities than in patients who did not have surgery. Grip and pinch strength weren’t better in the surgical group but all other outcomes were superior.

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

Dr. Rizzo provides an in-depth description, discussion, and analysis of the various types of joint implants available. The surgeon makes his or her decision on which implant to use based on the type of arthritis, amount of bone, and condition of the surrounding soft tissues. Patients with rheumatoid arthritis typically don’t get the same excellent outcomes as patients with osteoarthritis but they are still happy with improved results.

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

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

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

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

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

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

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

Studies are evaluated by design and quality. Strength of evidence is gauged from poor to good. Studies with the lowest level of evidence are usually case reports or series of cases with no control group. Studies with the highest level of evidence are randomized controlled trials with large numbers of people in the experimental and the control groups. A meta-analysis like this one that only includes randomized controlled trials yields the best level of evidence to guide treatment.

The authors provide a detailed table of information obtained from the studies reviewed. Authors, level of evidence, number of patients in each group, type of procedure, and results are recorded. It’s easy to see from this layout that patients and results weren’t always assessed in the same way from study to study. Sometimes patient satisfaction was the main measure. Most of the time, joint motion, strength, and function were the key areas assessing outcomes.

Other measures included revision rates (need for further surgery), number and type of complications after surgery, speed of recovery, ability to perform specific job tasks (including light to heavy work), and results of biopsy exams (looking for signs of foreign body reaction and incorporation of implants into the bone).

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

In this article, hand surgeons from the Walter Reed National Military Medical Center in Washington, D.C. offer us a review of rare, but potentially disabling hand infections. They focus on two infections of the wrist, hand, or fingers: osteomyelitis and septic arthritis. Causes, type of bacteria involved, patient symptoms, diagnosis, and treatment are summarized for each condition. Complications with and without treatment are also presented.

Osteomyelitis is an infection of the bone or bone marrow that can affect the hand. The most common infecting bacteria are staph, strep, and e coli. Undiagnosed, delayed diagnosis, or untreated, any of these infectious agents can cause destruction of the joint. Loss of motion, impaired function, and eventual arthritis with pain, stiffness, and disability can occur. The disease process can get so bad, a person can lose the affected hand.

How does a person get osteomyelitis of the hand or wrist? There are three main mechanisms: 1) puncture wounds (e.g., human bites, thorns, fractures, and surgery), 2) spread from infection of nearby soft tissues, and 3) spread through the blood system from any other infection in the body.

The immune system sets up an inflammatory response and tries to wall off the infection. In the healthy child or adult, this reaction may be enough to take care of the problem. But malnutrition, smoking, medications that suppress the immune system, and cancer or other health problems can put the patient at a disadvantage for self-healing.

In the case of one particular bacteria (methicillin resistant Staphylococcus aureus or MRSA, pronounced “mersa”), even healthy people can be affected. Tissue invasion and severe bone destruction can occur quickly. That’s why early diagnosis and immediate treatment is recommended for hand infections of this type.

How does the hand surgeon know a patient has an osteomyelitis-linked hand infection? There are usually visual signs (swelling, redness, warmth) and pain. The patient may have a fever with chills and fatigue. These flu-like symptoms are a red flag of systemic (system-wide) infection. Blood tests and imaging studies possibly including X-rays, bone scans, PET scans, MRIs, and other more advanced imaging aid in making the diagnosis.

Once it’s clear what the surgeon is dealing with, then treatment begins. Antibiotics may be all that’s needed if the problem is identified and caught early. But most of the time, surgery is needed to debride (clean out) the area. This surgical procedure is followed by a course of antibiotics as well.

It may be necessary to perform more than one debridement, a process called serial debridement. Serial debridement is done until the affected area is clear of infection. The whole process can take six weeks or more. If the infection has occurred around an implant (e.g., joint replacement or hardware used to repair a fracture), the implant may have to be removed before debridement and antibiotics can be successful.

Even with successful treatment of osteomyelitis, there can be long-term results of the disease process. For one thing, the infection can come back. Pain and stiffness may persist for months to years. Deformity from bone destruction and fractures can result in loss of hand strength and function.

Infection that never goes away fully can eventually become cancerous. As mentioned, amputation may be required for chronic, unresolved cases. In fact, half of all fingers with osteomyelitis end up being amputated. So you can see why early diagnosis and intervention are extremely important with osteomyelitis of the wrist, hand, and fingers.

Now, what about septic arthritis, the second point of focus of this article? The difference between osteomyelitis and septic arthritis is location. Remember, osteomyelitis is a bacterial infection of the bone or bone marrow. Septic arthritis is an overgrowth of the same bacteria only in the joint instead of in the bone.

Causes of septic arthritis of the wrist and hand are similar to osteomyelitis of the same areas: trauma (knife wound, human bites, or face punch with puncture by the teeth) and spread from some other nearby location. Staph infections are the most common cause of septic arthritis but joint infections can also be caused by a bacteria called pseudomonas.

Patient factors that increase the risk of septic arthritis include: rheumatoid arthritis, alcohol abuse, diabetes, steroid therapy, injection drug abuse, and chronic kidney or liver failure. As with osteomyelitis, when the immune system gets word that there is a bacterial infection of the joint, it launches an immediate anti-inflammatory response. If unsuccessful, septic arthritis can eat its way through the joint to the bone then causing osteomyelitis (of the bone next to the septic joint).

How can such extreme complications be avoided? You should seek medical help right away after any type of trauma that results in joint pain, swelling, redness, fever, chills, or other systemic (flu-like) symptoms. Lab values, X-rays and other imaging studies, and examination of the joint fluid help the physician make an accurate diagnosis.

Even with early detection, septic arthritis is considered a surgical emergency. It is not treated first with antibiotics. Intravenous antibiotics will be part of the treatment after surgery. The joint is surgically debrided and irrigated (washed out repeatedly). Any area of dead tissue, abscess, or pus is removed. This type of surgery does involve cutting into the cartilage surrounding the joint to gain access to the inside of the joint. The surgeon must be careful to avoid cutting nearby nerves and blood vessels.

The authors conclude by saying that the effects of osteomyelitis and septic arthritis of the wrist, hand, or fingers can be severe. Even with treatment, stiffness and loss of motion can lead to significant disability. Chronic, unresolved infection may result in bone (osteomyelitis) or joint (septic arthritis) destruction requiring amputation.

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

Osteoarthritis (OA) can affect any joint in the body. Most people associate OA with hip, knee, and spine (back) pain. But it can also affect the fingers of the hand, right down to the very tip of the fingers. The joint that allows finger tip motion is called the distal interphalangeal (DIP) joint.

In this article, experts who understand and treat hand osteoarthritis (OA) discuss the two main types of OA that affect the hand. They summarize what is known about normal distal interphalangeal (DIP) joint anatomy. A description of the four phases of osteoarthritis progression in the DIP is provided along with drawings, photos, and X-rays to help us understand this process.

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

Some of the more common risk factors being studied are age, genetics, sex (male versus female), race/ethnicity, hand dominance, and occupation. When it comes to osteoarthritis of the distal interphalangeal (DIP) joint, studies have shown a possible link to each one of these factors.

But the people who are affected don’t all have the same risk factors and are not in the same age range. So it’s a bit of a puzzle how demographics, environment, genetics, and joint mechanics interact to result in this final outcome we call osteoarthritis.

Aside from patient factors, scientists are examining the pathogenesis of osteoarthritis. Pathogenesis refers to the steps that take place as a normal joint is altered and becomes an arthritic joint.

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

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

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

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

Although we can describe what happens, it’s still unclear what starts the process, what keeps it going, and why it happens. Where do the first signals come from — the cartilage? The joint surface? The ligaments around the joint? There are theories but no firm knowledge about this.

While scientists continue to try and unravel all the details of the pathogenesis of osteoarthritis, the authors suggest finding better ways to detect those changes. Various ways to assign a level of severity have also been developed. Three of the most common scoring systems rely on X-rays to grade osteoarthritis. These are the Kellgren and Lawrence method, the Kallmann method, and the Verbruggen method.

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

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

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

Each of these systems has a slightly different way of assessing hand osteoarthritis. The third system (the Verbruggen assessment) was developed to help record smaller changes that take place quickly.

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

In summary, osteoarthritis of the distal interphalangeal (DIP) joints of the hand has both a nonerosive and an erosive stage with inflammation, destruction, and remodeling observed. This understanding has led to the development of scoring methods to help describe the process. Until knowledge of the disease process is complete, physicians must rely on grading joint damage using one (or more) of the scoring systems currently available.

Sometimes orthopedic surgeons have to be like Sherlock Holmes, the fictional detective written about by Sir Arthur Conan Doyle back in the 1800s. Patients come in with all types of pain and symptoms. The diagnosis isn’t always obvious at first.

Take the patient featured in this article for example. She was a 36-year-old woman without significant pain or discomfort. But suddenly her handwriting started to get worse and worse. She didn’t have any numbness or tingling to suggest a nerve problem. The usual suspect (ulnar nerve) tested okay.

By systematically checking each one of the muscles in the forearm and wrist, the surgeon was able to find the clues needed to identify the anterior interosseous nerve (AIN) as the culprit. Because the patient could not make the “OK” sign with the thumb and first (index) finger, the surgeon knew the anterior interosseous nerve was compressed or pinched.

Once a diagnosis has been made, the next question in the mystery is what to do about it? Anterior interosseous nerve palsy or syndrome is a fairly uncommon problem. There isn’t a lot of research to help the surgeon know what treatment is best. And with fairly mild nerve compression like this, it could get better on its own.

So the next question is: how long can the patient wait to see if recovery occurs before having surgery? And finally, will surgery really fix the problem? When surgeons are faced with these kinds of questions, they can search the medical literature for evidence to favor one approach over another.

The two surgeons involved in this case did just that. They found quite a few studies with small numbers of patients (six to 20) and compiled their results. There was agreement that full recovery occurs in about 12 to 18 months. Younger patients (those who started developing anterior interosseous palsy before age 40) recovered faster.

Some patients were treated with vitamin B12 and electrical stimulation therapy performed by a hand therapist (physical or occupational therapist). The patients receiving this type of nonoperative care were tested every month with electromyography< (EMGs). EMG results give some idea of the status of the muscles and allow the surgeon (and patient) to know when there are early signs of recovery.

Some studies showed that untreated, a few patients went on to develop paralysis and disability from unresolved nerve compression. Recovery is more likely when the nerve compression is partial or incomplete. Compression severe enough to cut the nerve off completely is less likely to recover and more likely to need surgery.

When surgical care is required, the surgeon attempts to remove pressure from the nerve. This procedure is called decompression. Any scar tissue, fibrosis, or connective tissue that may have formed around the nerve is carefully stripped away. The process of cutting the nerve sheath (protective covering around the nerve) lengthwise is called neurolysis.

There are some confusing issues that are difficult to sort out regarding anterior interosseous syndrome. For one thing, the nerve does seem to recover spontaneously without surgical intervention, whereas other similar nerves in the forearm and wrist (e.g., ulnar, median, radial nerves) do not naturally heal.

Comparing results of natural healing versus surgical intervention is difficult when the cause of anterior interosseous syndrome could be from trauma versus an unknown cause. Maybe one type of nerve compression responds differently than another. Studies have not been done to compare the two.

Based on the evidence that anterior interosseous nerve palsy has a natural history of spontaneous recovery, and the fact that this particular patient came to them after only three months of symptoms, the surgeons followed the wait-and-see approach. They checked on her every few months to see how she was doing. In the end, surgery was not needed.

The authors suggest that perhaps the patients who develop anterior interosseous nerve palsy don’t really have a compression neuropathy. Since most of them seem to get better on their own with time, it’s possible there is a temporary nerve dysfunction of some type. If that’s the case, then surgery could make things worse instead of better.

Unless there is complete loss of nerve transmission due to some type of trauma, infection, or tumor, surgical treatment is not advised. Patients should be followed carefully and monitored for recovery. Electrodiagnostic testing can be done to look for signs of recovery and then repeated every four to six weeks to observe the progression of improvement in nerve function.

Whether or not treatment is helpful during the recovery phase (e.g., with vitamin B, electrical stimulation, or other methods) was not investigated or reviewed in this report. Future studies are needed to compare various nonsurgical approaches to find the best healing modality.

Perhaps the body’s own innate ability to heal is all that’s needed to foster recovery.
If that is true, we might say this deduction is obvious or to quote Sherlock Holmes who often said to his friend Dr. Watson, “It’s elementary, my dear Watson”.

If we asked you which joints are affected most often by osteoarthritis (OA), what would you say: hips? knees? shoulders?

While those joints are indeed affected, two-thirds of all women over the age of 55 have X-ray evidence of osteoarthritis of the hand. And just slightly more than half (55 per cent) of the men in the same age group have clearly visible arthritic changes in at least one joint of the hand.

There are three major finger joints: the knuckles across the fist or metacarpal phalangeal joints (MCPs), the middle joints (proximal interphalangeal joints or PIPs), and the tips (also known as the distal interphalangeal joints or DIPs).

In this article, the focus is on the proximal interphalangeal joints (PIPs) starting with the incidence of osteoarthritis (OA) and the main risk factors. Four types of OA are mentioned: no erosive, erosive, posttraumatic, and primary.

A description is provided of what happens to the cartilage, bone, and soft tissues of the affected joints for the nonerosive and erosive types of OA. And finally, treatment ideas (both general and specific) are offered for these two types of arthritis at the proximal interphalangeal (PIPs) joints.

We’ve mentioned how often osteoarthritis affects the joints of the fingers. Let’s take a look at who is at risk. You might think the way people use their hands at their jobs would make a difference. But researchers have not been able to clearly establish a link between occupation and arthritis. Cotton-pickers and industrial workers are at a disadvantage and are more likely to develop hand arthritis. But that’s as far as the evidence goes.

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

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

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

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

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

Treatment for most conditions like arthritis is based on what is causing the problem as well as what is happening inside the joint. Researchers are having trouble here, too. It appears that the biologic cascade of steps that lead to osteoarthritis are much more complex than was ever imagined. It’s not just a matter of overuse and repetitive motion causing wear and tear on the joint surface.

Even being able to tell whether a person has inflammatory versus erosive arthritis is difficult. And it’s possible to have inflammatory arthritis that is erosive! Studies looking at immune pathways have been able to identify signaling molecules and degradative enzymes that are part of the process.

They are also taking a look at the chondrocytes (cartilage cells) more closely because it seems that they have a major role in the process. Somewhere along the line, the chondrocytes start to break down. The bone under the cartilage called subchondral bone compensates by stiffening up. But it’s possible the stiffer bone only leads to increased (or abnormal) biomechanical forces on the joint.

So there are more questions than answers and more unknowns than knowns in the search for understanding of osteoarthritis. If you are experiencing hand pain that you think might be caused by osteoarthritis, don’t let this lack of clear understanding of the disease process lead you to adopt a wait-and-see attitude.

Early diagnosis to detect small joint changes and treatment are still two important keys in maintaining motion, strength, and function of the hand(s). The orthopedic surgeon has at his or her disposal a wide range of imaging tools (e.g., X-rays, ultrasound, thermography, MRIs, bone scans) to help evaluate the painful joints.

Conservative (nonoperative) care begins with antiinflammatory drugs. Uncontrolled or severe joint damage may only be resolved with surgery to replace the joint, a procedure referred to as arthroplasty. In rare cases (and usually only because there is some specific reason), joint fusion may be performed.

Joint implants for the proximal interphalangeal (PIP) joint are usually made of silicone or pyrocarbon. They work well to reduce pain and improve motion but the implants have a bad reputation for breaking, settling into the bone, squeaking, loosening, and dislocating.

The authors conclude by saying that overall, treatment for finger and hand osteoarthritis is still fairly limited. Until more is known about the various causes, risk factors, and pathogenesis of the disease, treatment will remain dependent on medications that ease the symptoms but don’t change the disease process and surgery with all of its potential complications.

Knowing how important the hand is for daily activities, especially self-care (grooming, toileting, preparing and eating food), research needs to continue placing an emphasis on unraveling the mysteries of this disease. There are many avenues to explore from genetics to types of arthritis, risk factors, and joint changes. Prevention may eventually be possible and when that isn’t successful, then finding treatment techniques that work is next.