News Category: Hand

In this report, hand surgeons from the University of Florida use a case study to demonstrate a new test for fractures of the hamate bone in the hand. The hamate bone is one of the many small bones in the wrist. It lines up with the base of the fourth (ring) and fifth (baby) fingers.

On the palmar side of the hand and wrist, the hamate bone has a projection of bone. This bit of bone is referred to as the hook of the hamate. There are many ligaments, muscles, and tendons that either attach directly to the hook of the hamate or sling around it like a pulley.

The anatomy is significant because with so many different soft tissues affecting the hamate bone, it is at risk for injury. When does this happen most often? When a baseball player, golfer, or racquet sports player of any kind swings the bat, golf club, or racquet held in the hands.

While swinging the bat, club, or racquet, the hand and wrist move into a position of ulnar deviation (movement toward the small finger). The forearm, wrist, and hand move from a position of pronation (palm down) to supination (palm up). Direct pressure and shearing forces are applied to the hook of the hamate. It’s actually a wonder the hook of the hamate doesn’t break off more often.

In the case of this professional baseball player, there was a severe, sharp pain at the time of the fracture. This happened as the bat connected with the ball. The patient was unable to keep playing despite trying to do so. He continued to have a painful wrist. The severe pain subsided to a feeling of tenderness over the hamate bone when pressed.

It was three months before an accurate diagnosis was made. Why so long? This isn’t an easy injury to diagnose. It requires understanding of the clinical picture (history of injury and exam) that goes with hook of the hamate fractures.

Regular X-rays don’t show a problem. The special carpal tunnel view must be taken with the forearm, wrist and hand in a position of slight (30-degrees) supination. This test position puts the hand midway between a thumbs-up position and fully turned palm up. The best test for confirming a diagnosis of hook of the hamate fracture is a CT scan.

And now the authors introduce a clinical test they call the hook of the hamate pull test or HHPT to add to the surgeons’ testing tools. Here’s how it’s done: the patient’s hand is placed palm up. The wrist is placed in a fully ulnar deviated position (wrist tilted away from the thumb). The proper test position is essential to getting accurate test results.

The small and ring fingers are flexed or bent as the examiner applies pressure to the pads of the tips of those two fingers (as if trying to straighten the fingers). The test position loads the flexor profundus tendons of the two fingers. Those two tendons come alongside the hook of the hamate. When they contract, they push (displace) the broken hook off to the side. The result is a reproduction of the severe, sharp pain at the wrist where the hamate is located.

In all the cases tested, the pull test was always positive when there was a true hook of the hamate fracture. The test is not considered positive when generalized wrist pain occurs — only when the severe, sharp pain from the original injury is reproduced. A CT scan can confirm the diagnosis.

Treatment is surgery to remove the broken fragment of bone. Without surgery, the fractured hook can shift away from the hamate and become displaced. The jagged edges of the bone can cut through nearby tendons and ligaments. The result can be chronic pain, loss of motion, weakness, and eventual disability.

The professional baseball player in this case study was 26-years old and had a full career ahead of him. Without the proper diagnosis and treatment, he may have lost his chance to continue playing. As it was, he was benched for three extra months that might not have been necessary if the correct diagnosis had been made early on.

But all’s well that ends well — he was able to return to full participation with no further problems. The authors offer this information and the test they developed to all sports physicians, hand surgeons, and physical therapists. Anyone working with athletes who are using any kind of implement (club or bat) to swing and strike a ball with enough force to fracture the hook of the hamate will want to know about the pull test.

Benign tumors may not spread and cause death but they can create significant problems just the same. Tumors of the hand (the focus of this article) can wrap themselves around nerves, cut off blood supply, and cause fractures. Undiagnosed and untreated, they can invade surrounding soft tissues and eat away at the bone causing significant loss of motion, deformity, and disability.

Although benign tumors of the hand are fairly common, there are no large studies comparing one treatment to another. Therefore, today’s modern treatment is largely based on the hand surgeon’s experience and what little information can be gleaned from case studies published in medical journals.

That’s why these two hand surgeons combined their knowledge and expertise in presenting an up-to-date review on benign tumors of the bone and soft tissues of the hand. They base their recommendations on studies that are available and on their own experiences. The authors point out the fact that many tumors in the hand are treated based on similar tumors in other parts of the body, not necessarily from experience or evidence with hand tumors.

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

The authors discuss each one of these benign tumors, their clinical presentation, diagnosis, and treatment. The diagnosis is made when patients observe an odd lump under the skin or hard bump on the bone. Concern about what this might be brings them into see the doctor. Pain, swelling, and local tenderness are the most common symptoms (when symptoms are present).

X-rays or other diagnostic imaging tests (CT scan, MRI) and biopsy help make the diagnosis. Many times, it’s quite obvious that the problem is a benign tumor of the hand so biopsy isn’t necessary.

Conservative (nonoperative) care may be possible for some tumors. Aspirin for pain management seems to work well for osteoid osteomas (benign bone tumors). Radiofrequency ablation (a heat treatment) has been tried for other tumors of this type elsewhere in the body.

A few studies have been published with mixed results of radiofrequency ablation with hand tumors. The structures of the hand are so small, it’s easy to damage the small bones of the hand, as well as the tiny nerves, and blood vessels.

But many tumors must be carefully removed, a procedure called surgical excision. If a large amount of bone is removed, bone replacement called grafting may be needed to fill in the hole. When the cartilage is involved, the surgeon does everything possible to preserve the joint surface.

If bone fracture has already occurred (and that’s why the patient was diagnosed), treatment involves removing the tumor as well as healing the fracture. Lipomas (fatty tumors) and Schwannomas (tumor along a nerve) may be treated with simple observation (a “wait-and-see” approach). If and when the tumors cause symptoms, then it may be necessary to perform surgery to remove it.

In all cases, benign tumors can come back (recur) or even convert to a malignant tumor. Aneurysmal bone cysts are the most likely to recur. Young people whose bones are still growing seem to have the most trouble with these lesions coming back and growing fast. In extreme cases, it is necessary to remove the hand to stop the tumor.

Giant cell tumors of the bone are particularly tricky because this is one benign bone tumor that can metastasize (spread). The lungs are the most likely place tumor cells will travel to first. Anyone diagnosed with giant cell tumor of the bone should have a chest X-ray done right away to see if metastasis has already occurred.

Whatever type of lesion is present and regardless of successful treatment, patients must be followed carefully and observed for any signs of recurrence or conversion. Surgeons who understand the different types of benign hand tumors will be able to provide the most appropriate treatment aimed at reducing symptoms and preserving anatomy and function.

If you had a tumor of the hand, what would you like to know about the diagnostic process and treatment plan? In this article, a hand surgeon from the well-known and respected Sloan-Kettering Cancer Center brings us up-to-date on the topic of malignant and metastatic tumors of the hand.

The information on diagnosis, staging, and treatment modalities is important for all health care professionals because few people with finger problems would think to go to a cancer center to have it checked out.

And for the most part, the affected individuals would be right in their thinking. Malignant hand tumors are indeed rare. Most lumps, bumps, and tumors of the fingers turn out to be benign ganglions, giant cell tumors of the tendon sheath, or lipomas (fatty tumors).

By the nature of being “benign”, these growths don’t spread and don’t cause life-threatening problems like malignant and metastatic growths. Malignant soft tissue sarcomas affecting the bone include chondrosarcoma, osteogenic sarcoma, and Ewing’s sarcoma.

Any of these tumors can occur first in the bone and then metastasize elsewhere but in fact, it is much more likely that the primary (main) tumor is somewhere else and these new tumors are metastatic (spread from their original location) to the bones of the fingers.

When people develop swollen, red, painful fingers, they don’t head on in to the nearest cancer clinic. Instead, they show up at their primary care physician’s office or the local walk-in medical clinic. A patient history and physical exam will be performed but it’s really the diagnostic testing that will supply an answer to what is going on.

First, standard X-rays are taken. Then CT scans and MRIs may be ordered. If necessary, a PET scan (PET stands for Positron Emission Tomography) of the upper body may help show tumors in the chest or other areas other than the hand/fingers. PET scans also help sort out benign from malignant tumors.

Other tests may be ordered depending on what type of tumor is present (or what the physician is suspicious of). For example, soft tissue sarcomas (a malignant tumor affecting bone or surrounding soft tissue structures) will require a sentinel lymph node biopsy.

For this test, a dye is injected into the tissue around the tumor. The dye flows through the lymph system to the lymph nodes. The surgeon removes lymph nodes near the tumor and sends them to the lab where they are examined for the presence of any dye. A positive sentinel node suggests tumor cells have reached the lymph nodes and traveled beyond (a process called metastasis).

The results of this test help physicians stage the cancer, which in turn, helps determine treatment. Staging tells us how far advanced the disease is and helps determine the prognosis. Early diagnosis and treatment is always advised and often linked with better long-term outcomes.

Treatment for malignant hand tumors consists of surgery, chemotherapy, and/or radiation therapy (also known as “radiotherapy”). The surgeon must be careful to remove the entire tumor without cutting into it. This technique is referred to as getting “clear margins”.

Once the tumor is removed, it is sent to the lab where the pathologist identifies the exact type of tumor and “stages” it. The absence of clear margins requires an additional surgery to remove the rest of the tumor cells.

The process of disrupting the margins and conducting a second surgery contributes to a poorer prognosis than if clear margins are obtained the first time. But tumors don’t have dotted lines around them to show the surgeon where to cut so getting clear margins isn’t as easy as it sounds. The practice of performing a wide excision (cutting a large area around the tumor) is often used to avoid missing clear margins.

With hand surgery, the area is small and it could be devastating to lose a large amount of tissue and still preserve normal hand/finger function. Surgeons do everything they can to balance the need to remove tumor tissue (and enough tissue so that the tumor doesn’t grow back) with the impact on local tissues. The surgeon tries to preserve tissue and avoid partial hand amputations whenever possible.

Radiotherapy may be used before surgery to shrink the size of the tumor as much as possible before operating to remove it. Not all tumors will require radiation and in some cases, radiation is given after the tumor has been removed.

Postoperative radiation is most common when the margins between the tumor and normal tissue are very narrow. Postoperative radiation is also indicated when the tumor is large and/or pressing on other vital structures.

Radiation has many negative side effects so it must be used carefully whenever it is administered. Fortunately, technology has improved a great deal in this area and special machines make it possible to deliver radiation directly to the site of the tumor without radiating the surrounding tissue at the same time.

Chemotherapy can help to reduce the risk of tumor cells growing in that area again (a process referred to as cancer recurrence. The administration of cytotoxic drugs (another name for chemotherapy) kills all fast growing cells (not just cancer cells). That means chemotherapy can also impact cancer that has metastasized or moved from the original (primary) site.

Although radiotherapy and chemotherapy help prevent local recurrence and even eliminate some metastasis, these treatments do not improve patient survival. Most of the time, the cancer cells have traveled to the hand from some other primary (first) site such as the lung, breast, or kidney. Treatment is a matter of minimizing the effects of the tumor on the hand (e.g., preventing fractures and amputations).

In conclusion, malignant tumors of the hand are rare. That’s good news for anyone with cancer that can metastasize. For anyone with a painful, red, and swollen finger that looks like an infected hangnail, special care must be taken to make a proper differential diagnosis. Anyone with a past medical history of cancer of any kind but especially breast, lung, and kidney must be examined carefully before beginning any kind of local treatment.

Physicians often rely on visible changes in the skin and joints to identify and diagnose problems like Dupuytren’s disease. Dupuytren’s disease (also known as Dupuytren’s contracture) is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands.

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

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. This condition is seven times more common in men than women. It is more common in men of Scandinavian, Irish, or Eastern European ancestry. 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.

Your doctor can tell if you have a Dupuytren’s contracture by looking at and feeling the palm of your hand and your fingers. Usually, special tests are unnecessary. Abnormal fascia will feel thick. Cords and small nodules in the fascia may be felt as small knots or thick bands under the skin. These nodules usually form first in the palm of the hand.

Bumps or nodules on the backs of the hands (dorsum or dorsal side) are also linked with this condition. Various terms have been used to describe these changes. Two of the most common descriptors include knuckle pads and dorsal nodules. The medical term for knuckle pads is dorsal cutaneous pads (DCPs). The medical term for the nodules is dorsal Dupuytren’s nodules (DDN).

The pads are described as thickening, sclerosis, and loss of skin elasticity. The nodules are solid tumor-like masses over the back of the finger joints (knuckles). Some physicians think these two features (pads and nodules) are the same thing. Other experts believe the two are separate symptoms. They may not both be a sign of Dupuytren’s.

This study was done in order to see if there is a difference between these two entities and to find out if both are part of the Dupuytren’s condition. Two groups of adults were compared. The first group had a known diagnosis of Dupuytren’s. The second (control) group were considered normal, healthy individuals without Dupuytren’s.

Two hand surgeons examined the hands of all 100 participants looking for any signs of pads or nodules as defined above. They recorded how many skin lesions each person had and the location as well as what the skin changes looked like. Background on each participant was also collected such as age, family medical history, ancestry and ethnicity, and occupation or type of current employment. The surgeons also examined each person’s feet to look for similar symptoms.

After examining all the lesions and data collected, the surgeons found that knuckle pads and nodules are, indeed, two separate skin changes. Visibly, the pads are more like little cushions. The nodules look and feel like hard knots. And the nodules were more likely to be part of the Dupuytren’s disease.

More people in the control (normal) group (without Dupuytren’s) had knuckle pads — probably as a reaction to work or trauma or maybe as part of some type of skin condition. The control group did not have any nodules. And a closer examination of the nodules from people with Dupuytren’s showed that the tissue inside the nodules was exactly the same as the more common nodules found on the palmar side of the hand.

Several observations were made from this study. First, although people with Dupuytren’s can have both dorsal cutaneous (knuckle) pads and dorsal nodules, people in the control group (normal, healthy adults) only had the knuckle pads (no nodules). Joints and fingers affected differ between pads and nodules. Knuckle pads seem to affect multiple fingers. Nodules appear at single sites and usually affect the index or small finger.

The authors concluded that 1) knuckle pads and dorsal nodules are two separate things, 2) the knuckle pads are not a sign of Dupuytren’s, and 3) these two entities (pads and nodules) when found on the hands should be considered as different from one another. They advise further studies to continue examining differences between knuckle pads and nodules and a clearer understanding of why these develop.

There is some suspicion (and proof) that patients on Workers’ Compensation with injuries incur more costs in the course of their treatment. Are they taking advantage of the system? Or is the system the problem?

Studies that seem to verify the increased utilization of health care services and thus increased costs associated with Workers’ Compensation usually include all types of medical problems. That approach can skew results and generate conclusions that might not fit all circumstances.

In this study, the authors just look at patients with one type of problem: upper extremity disorders (shoulder, arm, and hand). They chose this particular area of work-related injuries because it is the most common Workers’ Compensation claim. They compared various aspects of patient care (diagnostic testing, treatment, wait between diagnosis and surgery, number of doctor visits) between patients on Workers’ Compensation and patients covered by standard health insurance.

A closer look at the specific diagnoses between these two groups showed some very similar patterns. The number of sprains/strains and cases of tendinitis was about the same. The Worker’s Compensation group tended to have more traumatic injuries (fractures).

Carpal tunnel syndrome was equally represented in both groups. Cubital tunnel syndrome (ulnar nerve compression along the inside of the elbow) was far more common in the Workers’ Comp group. Arthritis was a more common diagnosis in the standard insurance group.

The biggest difference between the two groups was the type of work performed. Not too surprising, there were more manual laborers in the Workers’ Compensation group and more unemployed, retired, and desk job workers in the standard insurance group. Age and gender were also different between the groups: patients in the Workers’ Comp group were younger and more likely to be male.

But despite those differences, it turns out the way in which patients are treated in the Workers’ Comp group has more to do with the system than the patient. What do we mean by that?

Well, patients in the standard insurance group could have surgery right away when it was recommended by the surgeon. Workers’ Compensation patients had to wait until all the paperwork was completed. This included letters of request and justification being filed and accepted. Often a second opinion was required adding to the total cost and delaying recommended treatment.

As a result, patients in the Workers’ Compensation group also had a higher number of doctor visits at a higher total cost. In the end, Workers’ Compensation patients were more likely to have surgery. This may be explained by the fact that these workers are trying to get back to work as soon as possible. It has also been suggested that the way surgeons are reimbursed by some state Workers’ Compensation programs may influence who has surgery and how soon that surgery takes place.

The fact that patients on Workers’ Compensation are in effect “on paid leave” has been suggested in the past as an explanation for why they take longer to recover from injuries and accidents. This concept is referred to as a moral hazard — they are paid to stay in the sick role and they don’t have to pay for their care so there is no incentive to get well.

Some experts suggest that moral hazard is the reason Workers’ Compensation patients have more doctor visits, higher rates of surgery, and longer waits between diagnosis and treatment. But, at least from this study on individual clinical data, the authors suggest it’s more a result of how the system is run than how the patient uses the system.

Besides the additional paperwork required, they point out that it’s the surgeon who decides what tests to order. And some of those tests are probably ordered because the surgeon knows Workers’ Compensation requires them for reimbursement. So Workers’ Comp patients can’t really be faulted for higher costs associated with more doctor visits.

In summary, a look at the bigger picture surrounding Workers’ Compensation claims and the costs associated with treating patients on Workers’ Compensation suggests that their policies and regulations may be what are driving higher costs. Greater utilization of health care services required by state laws or attorneys may not be the patient’s fault.

Taking a look at a particular segment of patients (just upper extremity problems) has helped highlight some of the differences between patients under standard insurance and those covered by Workers’ Compensation. The results of this study provide a jumping off point for future research looking for ways to reduce costs associated with state run Workers’ Compensation programs.

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

The regularly accepted treatment for Dupuytren’s has been surgery. But there is a high recurrence rate (the problem comes back) and there is always the risk of complications from surgery. Researchers are looking for alternate noninvasive ways to treat this problem. In this report, two new treatment options are presented. The first is collagenase injection. The second is a minimally invasive procedure called percutaneous aponeurotomy.

Let’s take a look at each one of these treatment techniques separately. First, collagenase injection: collagenase is an enzyme that can be injected directly into the problem area. If you remember the little Pac-men in commercials for laundry detergent or the game Pac-man, you know that enzymes break down substances like dirt. In this case, they are being used to break down the collagen fibers that cause the tendon thickening.

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

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

Uh-oh. There’s that word “complication”. But don’t panic yet — these potential side effects of the treatment seem to be short-lived. For most patients, they go away within one-to-three weeks. Physicians refer to these adverse effects as self-limiting. The most common problems include swelling of the fingers, bruising at the injection site, swollen glands, and skin itching. Although 85 per cent of the patients tested developed antibodies against the collagenase, these symptoms were not considered allergic responses.

Are collagenase injections going to replace surgery for Dupuytren’s disease? Not yet — short-term results are good but the long-term benefits are still unknown. And if patients end up with a recurrence of the disease, no one knows if having collagenase injections first will affect the success of surgery later. More studies are needed before we have some answers to these kinds of questions.

Now, what about that second potential treatment of percutaneous aponeurotomy? What is that and how well does it work? Percutaneous means the procedure is performed through the skin without an open incision. After numbing the skin, the surgeon passes a small needle through the skin to the tight cords and makes several cuts. Cuts are made until the finger can be moved by the surgeon through its full range-of-motion.

Just like with the collagenase injection treatment, percutaneous aponeurotomy seems to work best on the metacarpophalangeal joints (MCPs). When these joints are affected, it’s possible to get 100 per cent improvement. Likewise, patients with milder disease (smaller contractures) have the best results.

Anytime a surgeon is cutting through tissue, it’s possible to develop nerve damage or even rupture of the tendon. Fortunately, these complications are rare. The most common complications reported with percutaneous aponeurotomy are skin fissures and numbness of the finger. Both of these problems are also self-limiting and go away in time.

The biggest disappointment with percutaneous aponeurotomy is the high recurrence rate (65 per cent). Open surgery has a lower recurrence rate but the percutaneous method may still be preferred when the patient is older, less active, or has small contractures that don’t require open surgery.

Studies comparing these two new treatment options for Dupuytren’s disease were not reported by these authors. The promising results of these two less invasive procedures will ensure that future studies will be done. Long-term follow-up for patients already enrolled in current studies will also be pursued. Having safe and effective (and less invasive) surgical procedures for Dupuytren’s disease could speed up recovery and eliminate the need for a formal rehab program.

Turn your hand thumb up toward the ceiling. Place your thumb inside your palm and close your fingers around it. Now bend the wrist down toward the floor. This test is called the Finkelstein test. If you have severe wrist pain with this test, you may have a condition called de Quervain’s tendonitis (also referred to as de Quervain’s tenosynovitis).

But you could also have arthritis of the joint at the base of the thumb, wrist arthritis, or another condition called intersection syndrome. As the authors of this study show, the Finkelstein test (as it was just described to you) can identify a wrist problem on the radial (thumb) side. But it doesn’t necessarily prove the patient has de Quervain’s. They propose an alternate way to perform the test that is more reliable and less painful for the patient.

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

This tunnel is lined with a slippery coating called tenosynovium. The tenosynovium is a slippery covering that allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon is called tenosynovitis.

Three changes occur in the tendons (as observed during surgery for this problem): thickening of the tendon sheath, enlargement of the tendons, and thickening of tenosynovium. In de Quervain’s tenosynovitis, the inflammation constricts the movement of the tendons within the tunnel.

The Finkelstein test has been described and taught to trainees (orthopedic surgeons, physical therapists, occupational therapists, athletic trainers) several different ways. The most common is the one you tried on yourself. But the test can be very painful and isn’t as specific as needed for an accurate diagnosis.

Over the past 10 years, the authors of this article have tested a staged test maneuver to diagnose de Quervain’s. They report the staged test is easier on the patient and a reliable diagnostic test. The test is done like so: place your hand on the edge of a table (or arm rest on a chair) with the wrist supported but the hand off the edge of the supporting surface. Now tilt your hand down toward the floor.

When someone else is examining you, that examiner will then gently grasp your hand and passively (without your help) move the wrist a little farther in the downward direction. The final step is for the examiner to press down on your thumb (moving it toward your palm). Neither one of these last two steps is performed if you (or the patient) has pain with the first step.

The staged Finkelstein test as described here causes a stretch to the inflamed tendons. As the affected tendons are forced to move through the constricted area and over the bone underneath, pain is produced. The authors advocate stopping the test at the first point of pain. Placing additional traction on the wrist and/or thumb isn’t necessary. There’s no need to cause the person severe, intense pain if the test is positive on the first step.

Pictures of the test along with descriptions are provided to give surgeons a better understanding of this staged version of the Finkelstein test. The authors hope to spread the word to all who are learning this test so that it is performed the same way by everyone. Consistency in using this approach will aid in carrying out research that can be compared from one study to another with the added benefit of reducing discomfort to the patient.

In this article, hand surgeons from the Upper Extremity Center of Atlanta Georgia offer a detailed review and update on peripheral nerve injuries of the arm. Their specific focus is tendon transfer treatment for muscles that lose power as a result of the injury. Although age was not specifically stated in the discussion, the patient photos were all of children.

There are three major nerves to the muscles of the arm: the radial nerve, ulnar nerve, and median nerve. There can be a high nerve injury (above the elbow) or low nerve injury (below the elbow).

An injury to any of these nerves produces a predictable loss of hand and/or arm function depending on which muscles have been affected. Whether it is a high or low nerve injury also determines what muscle function has been lost or altered.

If the nerve has not been completely cut and if the damage done is not too severe, it can regenerate. This process of reinnervation and recovery is very slow. Often, it is a wait-and-see proposition. By watching for signs of muscle function, surgeons can gauge how long the patient must wait for complete recovery and whether or not surgery is needed.

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

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

Tendon transfers can be delayed by weeks to months (up to 18 months). If a tendon transfer is not done right away, an external splint is applied and worn as directed. When it is clear that recovery is not possible, then surgery is performed. Nerve recovery may be spontaneous as a result of the normal, natural healing process. Or it can be helped along by surgery to repair damage to the nerve.

To help surgeons evaluate patients in possible need of tendon transfers, the authors provide detailed instructions in examination techniques. Understanding the anatomy (location of nerves and the muscles they supply) and what to expect in recovery is essential. This knowledge aids in making the decision about timing of tendon transfers as well.

Once it is clear that surgery is needed, the surgical technique for each procedure (for all three nerves) is described. The authors provide many step-by-step color photos of the harvesting and suturing methods for each nerve injury. Placement of the tendon attachment and how to judge the right amount of tension using wrist (thumb or finger) motion are described.

Other factors the surgeon must take into consideration when planning and carrying out a tendon transfer are 1) what’s needed to restore joint motion to all the joints of the affected finger(s), 2) what the thumb, finger, hand, or wrist will look like after recovery, and 3) whether or not the patient will be able to perform functional activities like grip a key, open a door, or pick up a heavy object.

Surgeons can benefit from the experiences of the authors as the authors describe techniques that work well, methods that have failed for them, and what they consider “good alternatives” among the various procedures possible.

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

Osteoarthritis of the thumb can be a very debilitating problem. Without a good, strong, stable thumb, it is difficult to hold a key and turn it in the door or open a jar. Pain and limited motion can make even simple motions like picking up a penny impossible. When conservative (nonoperative) care fails to provide relief from symptoms, the hand surgeon considers the need for surgery.

What can be done for this problem? There are many different types of surgical procedures used for thumb basal joint arthritis. One individual approach has not been found to be the best for everyone. Just as the name suggests, the basal joint is located at the base of the thumb where the thumb meets the wrist. It is the joint that allows you to stick your thumb out as if hitch hiking or touch the pad of the thumb to each finger.

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

In the case of this study, 48 patients were treated with a trapeziectomy, interposition of tissue, and soft tissue reconstruction. Interposition refers to using a piece of tendon or ligament folded up to fit into the empty space left by the bone removal. The technique is simple to do, gives the patient relief from the painful symptoms, and restores thumb motion and strength.

The authors (two hand surgeons from well known medical facilities) gave a detailed description and step-by-step drawings of the technique. A piece of the abductor pollicis longus (APL) tendon was woven around the other soft tissues and used to support the tissue placed in the defect left by the trapeziectomy. Before the incision was closed, joint stability was tested. If the joint was not stable when the thumb was moved from side-to-side, the sutures were removed and the slip of tendon used to hold everything together was tightened up.

A full rehab program was followed after surgery. Gentle but active finger motion was started right away. The thumb, hand, wrist, and forearm were placed in a plaster splint then in a short-arm cast (thumb included) a few days later. All of this was done to support and protect the healing surgical site. After six weeks, all protective devices were removed and the patient began gentle active motion and light activities (e.g., brushing teeth, combing hair, picking up objects that are easy-to-lift and hold).

Results of this particular surgical procedure were assessed using before and after measurements of grip and pinch strength. Thumb motion, pain intensity, and space ratio (as seen on x-rays) were also used to gauge outcomes. Patients also rated their satisfaction level from before to after surgery. The surgeons kept track of any complications and reported on these as well.

What were the results? All but four of the 48 patients had good-to-excellent pain relief. Only two of the 48 were not satisfied with the results. Grip and pinch strength improved for everyone. Movement of the thumb away from the hand did not change in a measurable way

What were the complications? Twenty per cent (20%) of the patients had some type of problem either related to the anesthesia or to the hand itself. Most of these were single events (meaning only one patient was reported for each complication). Complications included numbness, infection, persistent pain, and adhesions (scarring). Some of the problems could be treated with antibiotics. Others required an additional surgery.

And how did this technique compare to other (different) surgical procedures performed for the same problem? The authors report results are equal to those reported in other studies using different techniques. The reason they like this technique is because it is easy, doesn’t require drilling holes in the bones, and uses only one tendon to support the reconstruction.

Some of the complications that occur with other surgical procedures are eliminated (e.g., no drilling or wires used means fewer infections). The short-term use of splinting and casting also means fewer problems with adhesions and loss of motion. Patients regain motion, strength, and function faster, too.

Long-term results are not yet available so it remains to be seen if these positive short-term results will last. There isn’t one particular repair method that is known to work best for persistently painful basal joint arthritis. Surgeons are left to try and find a method that works well for everyone. This one may not be superior to all other methods, but it is equal and does present some positive benefits to consider.

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

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

Community-acquired MRSA (CA-MRSA) is a methicillin-resistant staph infection that occurs in healthy people. These folks are not in the hospital, are not on dialysis, and except for this new infection, are otherwise in good health. The bad news is that studies have shown this type of superbug didn’t spread from the hospital to the community. It’s a different bacteria with a different genetic makeup compared with the hospital-based MRSA.

The good news is that community-acquired MRSA infections can still be treated using antibiotics. That’s good news, indeed, for the many patients who develop hand infections severe enough to require surgery. In order to better understand what’s going on, who is at risk, and why, the authors of this study conducted a retrospective chart review. That means they took a look at their medical records and identified all patients who had been treated for hand infections.

There were just over 100 patients who came to the level one trauma unit at the New Jersey Medical School in Newark, New Jersey. The specific time period selected for review was the seven-year period between 2002 and 2009. All patients included had a hand infection that was treated surgically with a procedure called debridement. The surgeon removes any pus and dead tissue to make way for a healthy healing response.

When they tested the infection to find out what type of bacteria was present, one-third of the group had community-acquired MRSA. The rest of the group had a wide variety of different types of bacteria. Some patients had multiple organisms present in the soft tissues of the hand. The next logical question was: Why? What put this particular group of patients at risk for CA-MRSA?

Taking a look at all the data gathered on age, medical history, sex (male or female), type of hand injury, where the people live, lab values, and so on, there was one distinct risk factor. And that was the intravenous use of illicit drugs. And there was a peak in the number of such cases between 2005 and 2006.

The authors suspect the drop in number of infections related to intravenous drug use after 2006 might be the result of educational efforts at that time by the National Institute on Drug Abuse (NIDA). Campaigns aimed at teens and young adults may have led to some changes in behavior with less drug use/abuse.

Recommendations as a result of this study are three-fold:
1. Antibiotics are advised for anyone with a hand infection. Once the culture comes back from the lab, the best antibiotic to best combat the specific bacteria present can be chosen.
2. For patients who have been using intravenous (illicit) drugs, MRSA specific antibiotics should be started immediately until lab results are available. Then the medication can be changed if needed.
3. More studies must be conducted to confirm these recommendations and to find ways to prevent the further spread of community-acquired MRSA.

The authors point out several things about their own study that should be kept in mind when reviewing their results and recommendations. First, the patients they saw might not be the same as patients affected in other facilities or even other areas of the country. As a level-one trauma center in a large city, their patients might be very different from those patients treated in a different setting (e.g., small rural hospital or clinic).

Not all patients seen in this trauma center who came with hand injuries were included in the study. Anyone seen by a plastic surgeon (instead of by the orthopedic surgeon) was not included in the hospital database. Since the orthopedic surgeons share emergency room coverage with the plastic surgeons, that means half the patients (those seen by the plastic surgeons) weren’t included. This type of situation can skew the results so further investigation is needed.

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

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

Undiagnosed and untreated, this type of hand infection can become chronic and even cause the loss of fingers or hand. That’s why this report is so important. Fish handlers and the physicians and surgeons who treat them must be aware of these deadly bacteria. Early diagnosis and aggressive (surgical) treatment may be needed to prevent the rapid spread of infection and damage to the tissues.

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

Without a history of trauma and with an otherwise healthy individual, misdiagnosis or delayed diagnosis is easy to occur, thus complicating matters. Whenever hand infections develop in fish handlers, the standard treatment is antibiotics. Using the right antibiotic specific to the underlying bacteria is important. Sometimes the antibiotic chosen just kills a portion of the bacteria. The patient feels better and symptoms improve but don’t go away. They go back to work only to develop worse symptoms days to weeks later.

Eventually, the right diagnosis is made but the delay could mean damage to the flexor tendon system of the hand. Excess scar tissue in the finger can extend into the hand. The pulley system that allows the tendons to glide and slide while moving the fingers into a flexed (bent) position get stuck. The final result can be a loss of hand function that could mean the end of a job for a fish handler.

What can be done to prevent such devastating results? Awareness is the key here. Physicians and surgeons must know about the possibility of this rare infection. Before assuming the problem is mycobacterium marinum, the possibility of mycobacterium abscessus should be considered as the real cause of the initial symptoms. This is especially true whenever a fish handler comes in with complaints of hand or finger symptoms.

Early surgery to open up the hand, drains the infection, clean the area out, and provide the most effective antibiotics are essential to a good outcome for these patients. Hand therapy after surgery is needed to prevent stiffness and assure smooth return of full finger motion and hand function. Antibiotic treatment may continue for up to a year (or longer). No one really knows how long medication is needed to prevent a relapse. Future studies may address this question.

Experts in hand surgery from Harvard Medical School say it is not necessary to routinely send all ganglion cyst specimens removed from the wrist to the lab. The practice of examining all tissue surgically removed is well-established. But the results of this study suggest the chances that a ganglion cyst being something more serious (like a cancerous tumor) are nil.

How can they be so sure? They examined 424 cysts removed from the hands (wrists, thumbs, fingers) of patients from ages three up to age 90. Three separate diagnoses were made and compared before and after surgery. There was the preoperative clinical diagnosis, the surgical diagnosis, and the postoperative pathologic diagnosis.

The clinical diagnosis is what the surgeon thinks is wrong with the patient before surgery is done. This opinion is based on the patient’s history and physical exam (tests, measures, observations) conducted in the surgeon’s office.

The surgical diagnosis takes place in the operating room as the surgeon examines the tissue removed. A telltale sign that a cyst is a benign ganglion is the presence of a clear, jelly-like fluid inside the cyst.

The final and most accurate diagnosis is the pathologic diagnosis. The pathologic diagnosis is made by the pathologist, a specially trained medical doctor who examines the tissue under a microscope and confirms what it is. Looking at the individual cells of the cyst while performing what’s called a histopathologic exam, the pathologist is able to give the patient and surgeon the true diagnosis.

In this study, the before and after results (diagnoses) were labeled as concordant, discrepant, or discordant. Concordant means the surgeon’s clinical diagnosis was the same as the pathologist’s postoperative diagnosis. Discrepant means the two diagnoses were different but treatment was the same. And discordant describes a difference between surgeon and pathologist diagnosis that required a change in treatment from what was originally planned based on the clinical diagnosis.

Discrepancies occurred when the cyst turned out to be fibrous tissue that wasn’t a ganglion cyst but also wasn’t a tumor. Removal was all that was required, which is what was done anyway. There was one case of a benign tumor involving the blood vessels. Again, removal was the treatment of choice. There were a total of five out of the 424 cases where the clinical diagnosis differed from the pathologic diagnosis. And in all five cases, the surgeon recognized the tissue as nonganglionic at the time of removal.

In the end, there were no cases of a discordant (inaccurate or wrong) diagnosis. Given the costs of the pathologist consultation fee, lab costs, and postage for mailing the results, the costs of over 400 pathologic tests could have been saved. And that was just at one hospital.

The results of this study support the mounting evidence that 25 to 40 per cent of all lab tests aren’t needed. Surgeons and pathologists have questioned the need for routine lab testing of body parts removed. This includes tissue such as the appendix, tonsils, gallbladders, hernias, and intervertebral discs. They have even questioned the need to test arthritic bone removed when joint replacements are done. But in some cases, there’s a state law in place requiring it, the patients expect it, or there is a concern about lawsuits.

The authors concluded that the surgeon’s physical exam of the patient and problem area along with inspection during surgery are enough to make an accurate diagnosis of ganglion cyst in the wrist and hand. Patients, hospitals, and insurance companies can save the cost of this routine lab test. Surgeons who are suspicious that something’s not quite right can always send the tissue to the lab for evaluation.

Recommendations like this have already been made and put into place in Europe. With more attention being paid to reducing health care costs, we can expect to see similar changes made in the U.S. policy. Surgeons will be allowed (and even encouraged) to limit pathologic testing when there is limited or no need/benefit for the test.

Using your hand every day, you may not realize how intricate the extensor mechanism is, the part of the hand that allows you to extend your hand and fingers. In your forearm, the extrinsic extensor tendons are either superficial or deep muscular. The superficial group is divided into several other types of extensors. These many extensors feed through several compartments to get into the hand to allow extension.

The first dorsal compartment holds two tendons (the abductor pollicis longus and extensor pollicis brevis) and many injuries are common to this area. The second tunnel or compartment has two more tendons (the extensor carpi radialis longus, and brevis), the third tunnel one tendon (the extensor pollicis longus), and the fourth tunnel, two more tendons (the extensor indicis proprius, EIP, and extensor digititorum communis, EDC). This compartment also houses the posterior interosseous nerve. A fifth tunnel houses a tendon that rests above the distal radial ulnar joint (the extensor digiti minimi, EDM), and the last tunnel holds the last tendon (the extensor carpi ulnaris).

The further the tendons go through the compartments or tunnels, the higher they move to the surface of the hand and the more they flatten out. These changes can make the tendons vulnerable to injury. As the tendons go through the hand to the fingers, the more complex the system becomes and they wind around, allowing you the ability to extend your fingers and hand. By understanding the detail of the extensor mechanisms, doctors are better able to recognize and diagnose injuries to an extensor tendon.

When first inspecting an extensor injury in the hand or wrist, doctors should closely investigate for the size and location, and determine the underlying injury. To do this, the extensor mechanism is divided into nine zones, so the injuries may be classified. Those zones with odd numbers are found directly over joints while the even number ones are over bone. Zone 1 starts at the tip of the fingers and zone 9, the forearm.

As the doctor inspects the arm and hand, the normal resting cascade is one of the first things checked. This is how the fingers natural flex from the index (pointing) finger to the little finger. Each finger is tested individually. If a tendon injury is suspected, there is a good chance there is more injury, because it seems that rarely is only one tendon damaged. At this point, an x-ray is usually indicated.

Zone I injuries involve the distal interphalangeal joint (DIP). A common injury, a mallet finger, is an injury of the DIP, the joint on the fingers closest to the tip, or the most distal part of the finger. This is usually caused by forced flexion (bending) and is classified into one of four types:

I: closed
II: open
III: open with skin loss and tendon affected
IV: involves large mallet fractures

Usually, type I is treated with a splint and the other types with surgery. But, if there are other injuries involved, other treatment options may be necessary. One analysis of previous studies looking at various treatment methods and outcomes, done by researchers Handoll and Vaghela, found only four studies in 2004 that were usable and no studies in 2005 to 2008. Therefore, there are still not a lot of usable data to determine the best way to treat mallet finger.

When looking at surgery for stage II and above mallet fingers, the different procedures are controversial among some surgeons. Here, too, there are not a lot of data available. In general, however, primary repair is often using a variety of suture (stitches) techniques, using K wires for stabilization or suture anchors.

Zone II injuries are usually due to lacerations or cut wounds and affect the DIP joint as well. If the tendon isn’t completely cut through or injured, surgery may not be needed and the tendon can be repaired with a short course of splinting, but only if more than half the tendon is intact, and there is no indication of extensor lag, or drooping at the joint.

If the tendon has been cut through, surgery is required, which will most often be followed by splinting, as long as the DIP joint is extended as it should.

Zone III injuries affect the proximal interphalangeal joint (PIP) joint, the one at the middle of your finger. Doctors use the Elson test, which checks for the rigidity of the DIP joint while trying to bend the PIP joint. This can tell the doctor if there may be a central slip injury. Splinting when such an injury is suspected is usually recommended, to prevent further damage. As with zone I injuries, treatment depends on if the injury is open or closed, and how much damage has occurred. Unfortunately, no one particular splint has been found to be better than any other with this joint, unlike the mallet finger. If surgery is needed, splinting will be done for a set period of time during recovery, but some surgeons have been concerned about patients not using the joint for between four to six weeks, resulting in stiffness. One surgeon, Evans, has been experimenting with shorter splint times of about three weeks and results are promising.

Zone IV injuries are similar to zone II but closer to the wrist. They are most often due to lacerations and, at this level, the tendon is flat and wraps around the bone, so injuries are usually partial. It is vital that the doctor check the tendon thoroughly, checking if there is any weakness to the PIP. If the PIP can extend and flex normally, then nonsurgical treatment is usually acceptable. On the other hand, any sign of loss of flexion is usually an indicator that surgery is needed to repair the tendon.

Zone V injuries occur over the metacarpophalangeal joint (MCP), the middle knuckle of your fingers, and this is the most common spot for extensor mechanism injuries. One of the more common injuries is the so-called fight bite, which is the result of a punch to another’s mouth. Treatment of this type of injury may be different from a non-bite injury because of the potential of infection from a bite injury. A bite injury can become easily infected and this can destroy the tissue, requiring surgery to remove the dead tissue and to clean out the area. Both the bite and non-bite injuries are divided into one of three categories:

Type 1: a bruise without a break in the skin
Type 2: displacement of the joint but not complete dislocation
Type 3: dislocation of the tendon

Which treatment is recommended depends on the type of injury and how long ago the injury was sustained. If the injury is acute, less than six weeks, splinting may be the recommended treatment, and this has been reported to be fairly successful for the long (middle) and ring fingers that don’t have any other issues, such as rheumatoid arthritis. An eight-week splinting is good for displacements of 25 degrees to 35 degrees. If the splinting doesn’t work or if the injury is chronic, then surgery may be needed.

Zone VI injuries occur over the metacarpals, which are the bones in your hand. These injuries have a better prognosis than the ones in the fingers because there aren’t usually associated joint injuries, which allows for better healing. These injuries, however, are not always obvious as the patients may still be able to extend their hand and fingers.

Zone VII injuries occur just below the metacarpals in the extensor retinaculum. This structure consists of fibers that connect the smaller bone of your forearm radius, with the longer bone, the ulna. This must be opened to be able to see if there is damage inside. If there is an acute injury, a repair can be done, but if the injury is chronic, having been present for a while, this is difficult to treat. Grafting or a tendon transfer may be needed here.

Zone VIII and Zone IX injuries are at the forearm level and can be difficult to repair because of a lack of tissue that can be used to make the surgical repair. Repairs can be made though, if there is enough tissue. Another issue that doctors must look for in this type of injury, is nerve damage because of the location of the nerves in the wrist/forearm area.

Rehabilitation after any of these types of injuries depends on the severity and location of the injury and repair. Most often, the extensors were supported with splinting after surgery but researchers, Newport and colleagues, found there was only a 64 percent success rate and some left over difficulty with bending the joint with this type of rehabilitation. Researchers are looking at shorter splinting times and the results have been promising. Mowlavi and colleagues found that there was a better total active motion and grip strength after eight months, but at six months, the patients were no different than patients who had longer splinting times.

An issue to take into account with early mobilization is the possibility of complications, such as tendon rupture or lag, but this shorter splinting time may be appropriate for highly motivated patients.

The authors conclude the article by pointing out that extensor injuries are often not considered to be taken as seriously as flexor injuries and the damage is often underestimated. Therefore, more research needs to be done to ensure doctors know what to look for and how best to treat it, to prevent long-term complications or disability.

It is quite likely that the most common injuries to the hand and wrist are those affecting the tendons. And, although they are common and have been known about for a long time, there are still disagreements and uncertainty as to how to treat some of them. In earlier days, it was thought that tendon injuries were caused by inflammation and this is why they were given their names: tendonitis, tenosynovitis, and tendovaginitis – with itis meaning inflammation. However, this isn’t always the case. The author of this article reviews evaluation and management of common tendon disorders and discussed in recent medical literature to clear up some misconceptions.

Although many injuries are caused by traumas (falls, for example) most tendon disorders in the hand and wrist are idiopathic, which means they are of unknown cause. Some people are at higher risk of tendon-related disorders, such as those with diabetes.

Many have made a connection between tendon disorders and workplace activities, but this isn’t always the case and can be controversial. Eighteen papers focusing on this connection and, upon review, there wasn’t much data to support a general work and tenosynovitis connection. That being said, there are some factors that can help identify people who may be at higher risk of developing tendon disorders and these include people who are over 40 years old, have a body mass index of over 30, already have complaints of shoulder or neck problems, have a history of carpal tunnel syndrome, or have jobs that require higher shoulder posture.

When looking at the affected tendons of patients who have trigger finger or de Quervain’s disease, there is no inflammation seen on the tendon and there seems to be more of a breakdown of the pulley system in the tendon system that causes the problem. In de Quervain’s disease, researchers also found that the tissue is denser, up to five times as much as the tendons of people who do not have the disease.

Two researchers, Hueston and Wilson, once described the tendon as it moves over certain points and becoming damaged is “akin to that seen when a large, braided thread is passed through the slightly smaller eye of a needle.” Another disorder, chondroid metaplasia also doesn’t have inflammation, but an invasion of other tissue that causes the original tissue to become hardened.

Other tendon disorders haven’t been studied as widely as those just mentioned. For some, there have been inflammations, both acute and chronic, noted. But, the question is did the inflammation cause the problem or did the problem cause the inflammation?

Because of the lack of usefulness in calling tendon disorders with an “itis,” indicating inflammation, there is a movement to begin using the term tendinopathy, which would indicate a degeneration or using the suffix -osis to indicate and abnormal state or condition.These suggestions have not yet taken off.

Treatment with corticosteroid injections is the usual first-line treatment for tendon disorders in the hand and wrist. The treatment has been fairly successful, but there have not been many studies to back this up.

Mucous cysts are abnormal sac-like bumps filled with fluid. They are benign (noncancerous), but they may become annoying to the patient because of how they look or they may cause pain. Currently, treatment of these mucous cysts may be surgical or nonsurgical. Removing the cyst surgically may not always relieve the pain if there is any arthritis in the joint just below the cyst. In this case, the suggested treatment is usually joint arthrodesis, or fusion of the joint. If this isn’t done, a new cyst will likely form.

Injecting steroids is a nonsurgical way of treating a mucous cyst. One researcher, Epstein, followed six patients for between one to nine months following a steroid injection into the cysts. All six recurred. Another researcher, Goldman, followed 41 patients after injecting their cysts with corticosteroids and he found that 68 percent recurred. In yet another study, 80 patients were followed for a minimum of two years after having multiple punctures to their cysts and steroid injection. There was a 40 percent recurrence. Eight patients had repeat injections and five had recurrence again. Two of the 80 patients developed infections that were treated with oral antibiotics.

Surgical procedures include excising or removing the cyst, or draining it. A skin graft could be needed to cover the area, but is not always necessary. If there are osteocyte formations (small bits of bone), surgical treatment may include debriding (removing dead tissue) in the joint. In one study of 25 patients who underwent excision, led by Crawford, seven patients had recurrence of the cyst. Another researcher, Dodge, followed 18 patients for about 7.5 years after excision of not only the cysts but any osteophytes that were obviously present. He found that five patients had recurrence.

More involved surgery, in which the surgeon deliberately goes into the knuckle to remove osteophyte formations, may be necessary in some cases. A study of 54 patients followed for a minimum of two years, by Rizzo, found that there were no recurrences and in 25 of 31 fingers that had nail ridging, the ridging went away. There were no reports of joint instability or deformities, but three patients did develop infection. Two were treated with oral antibiotics but one needed surgery to clean out the joint. Eighty-six patients who had cysts excised along with osteophytes were followed by researcher Fritz. He applied rotation flaps on 58 of the 86 fingers. After about 2.6 years, three of the 86 patients had recurrence. Fifteen patients had limited range of motion and extension. One patient developed an infection, two developed septic arthritis, which required arthrodesis. Fifteen of the 25 patients who had nail deformities saw them resolve, but four patients who did not have a nail deformity before surgery developed one after.

In another study, by Kasdan, 113 cysts were removed along with osteophyte debridement. Two patients had cysts return and two developed infections. Forty of the 46 nails with deformities were corrected.

There are times when the joint needs to be debrided but there the cyst will not be removed. A study of 20 cysts, by Gingrass, looked at the cysts that were left intact after the osteophytes were debrided. There were no recurrences during the three-year follow-up. Eighteen fingernails were no longer deformed and two had only slight deformations after surgery.

When a patient with thinned skin has mucous cyst on the finger, treatment is controversial. Some surgeons feel that the cyst and skin should be removed and replaced with a graft. However, research is showing that thin skin can heal, so this may not be necessary.

The author of this article presents a 62-year-old woman who complained about a bump that appeared nine months earlier, which was just below her cuticle, on the finger. It caused a groove in her nail, as well. X-rays showed that the patient had mild osteoarthritis, with some osteocyte formation but she had good range of motion in the joint. In this case, the author did not suggest surgery, saving this in case nonsurgical treatment failed. He recommends aspirating the cyst, asking the patient to return if the cyst occurs. The reasoning allows the patient to consider the ramifications of surgery. He also does not suggest using steroids due to the recurrence rate.

If the patient were to return with a recurrence of the cyst, then surgery would be recommended, although pain relief can’t be guaranteed.

Back in the 1970s, hand surgeons discovered that early motion after flexor tendon repairs yielded better results. Putting the hand in a splint that blocked some motions but allowed others was better than no motion at all. Those early studies supported the idea that motion is lotion.

Since that time, research has continued in the area of hand therapy. Hand rehab programs have expanded to include all kinds of different ideas for post-op positioning, motion, and exercise. In this study, the use of a passive motion program was compared with early active motion therapy. The authors believe this is the first study published comparing these two hand therapy techniques.

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

The major concern following tendon repair surgery is re-rupture of the healing tendon. At the moment surgery is completed, the only thing holding the damaged tendon together is the sutures. It takes time for the tendon to heal across the tear. There’s always been a fear that too much movement too soon would tear the newly forming tissue.

On the other hand, without some movement, scar tissue forms. Adhesions within and around the tendon create loss of motion and stiff joints. The tendon stops gliding smoothly. The end result can be joint contractures — joints that can’t move beyond a certain point in the range.

Hand therapists carried out the motion therapy. Specific programs were used for the passive motion rehabilitation program (e.g., Duran and Kleinert programs). Patients in the passive motion group wore a special protective rubber-band traction splint in between sessions with the hand therapist.

Patients in the active motion group wore a special hinged splint that held the fingers in flexion but still allowed wrist extension. This splint was used during the motion exercises to allow for the right kind of motion yet still prevent some movements. In between exercise sessions, the active motion group wore a special blocking splint. The design of the splint was to keep the wrist and fingers in a position of flexion (bent) and prevent extension (straightening).

The researchers took several steps to help keep things even between the groups and make comparisons more meaningful. Everyone had the same tendon repair (zone-II flexor repair using a four-strand suture). The young (less than 15 years old) and the old (more than 75 years old) were not included because of age-related complications that often develop. To keep it simple, anyone with other hand injuries (e.g., crush injury, fracture, blood vessel injury) was excluded as well.

The results were measured using finger joint range-of-motion, dexterity tests, and ratings of patient satisfaction. A well-known and valid questionnaire called the Disabilities of the Arm, Shoulder, and Hand (DASH) was given to each patient as a self-reported measure of function and symptoms.

In addition, factors known to affect the results of tendon injuries and repairs were also compared between the two groups. This included things like whether or not the patient was a cigarette smoker, age, which hand was injured versus which hand was the dominant hand, number of fingers injured, and type of injury.

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

It was also the case that patients with more than one finger injured had worse outcomes. The patients with multiple-digit injuries had less motion and worse contractures compared with single-digit injuries in both groups. Patient satisfaction with results was higher among the patients with single-finger injuries.

Analysis of the data collected showed two additional negative risk factors: smoking and nerve injury. A negative risk factor means that when either of these factors were present, the patients were more likely to have worse results. On the positive side, patients treated by a certified (specially trained) hand therapist had better outcomes.

The authors concluded that early motion after flexor tendon surgical repair is a good thing. Under the supervision of a hand therapist, results are better than when the finger is kept immobilized or only passively moved.

Patients should be advised that results can be affected by certain (negative) risk factors such as tobacco use, the presence of nerve injuries, and when more than one finger is involved. There is always the risk of tendon re-rupture as a possible complication but surgeons and therapist do everything possible to keep this from happening. Patients are also asked to stop smoking to aid in their own recovery.

One final note: in this study, most of the re-ruptures affected the little finger. The authors advise NOT using the early active motion program for patients with flexor tendon ruptures of the little finger. The tendon fibers in that particular finger are just too few to handle the force of motion in the early phases of recovery.

Stenosing tenosynovitis, or trigger finger, is fairly common among adults. The name is taken from the position of the hand and fingers that result, like that of getting ready to pull a gun trigger. Unfortunately, treatment for trigger finger doesn’t guarantee that it won’t come back and many people find themselves with the problem again later on. The authors of this article present a case study of a woman who had a trigger finger five years previously and returned with symptoms of another in the same finger of the opposite hand. She wants advice as to how to proceed with treatment – injection or surgery?

Usual first-line treatment for idiopathic trigger finger, a trigger finger of unknown cause, is injection with a corticosteroid. In this case, the patient developed non-insulin dependent diabetes, usually called Type 2 diabetes, since her first experience with trigger finger and people with diabetes may need a different type of steroid and injection procedure than those without diabetes.

There have been cases reported of patients with trigger fingers who were treated successfully with splinting alone of their affected finger, for six to nine weeks. Most did well if the symptoms were mild and had not been present for a long time. However, there are not many studies that combine splinting with steroids. Studies that look at steroid injections alone report about a 57 percent effectiveness rate. One study, done by Rhoades and colleagues found that if the patient experienced pain and symptoms for more than four months, they were not likely to respond well to steroid injections. Other researchers, led by Newport, found that people with only one affected finger and who had symptoms for less than six months, did respond better to one steroid injection. In yet another study, Rozental and colleagues found that younger patients who had more than one affected finger and a history of other issues involving the tendons in the arms and hands were more likely to need a second injection or surgery.

The researchers for this study were only able to find one study, by Ring and colleagues, who studied two types of injection: triamcinolone and dexamethasone. In Ring’s study, the first medication worked more quickly than the second, but the effects only lasted as long as did the second medication’s injection. Other researchers looked into where the injection was given. Kazuki and colleagues injected another type of medication, betamethasone, along with a numbing agent lidocaine, together. In 74 percent of the cases, the symptoms were relieved and after one injection, 50 percent had another occurrence of trigger finger. In another study by Taras and colleagues, the researchers tested the type and location of injection using a dye to identify the delivery site. The goal was to inject intrasheath, into the target area, but in 17 percent of the cases, the medication went subcutaneous, or under the skin. However, the researchers found that there weren’t any differences in patient outcome whether the medication was intersheath or subcutaneous. Other researchers looked at mid-axial, into the finger and compared this to injection through the palm of the hand. There was more pain and recurrence rates in those who received injections through the palm.

Further studies of treating trigger finger was done among people who have diabetes. Researcher Baumgarten and colleagues investigated the use of corticosteroids in both type 1 (insulin dependent) and type 2 diabetes. The patients who received the corticosteroid had about the same level of success as those who received a placebo injection. Yet, only 40 percent of the patients with diabetes went on to have surgery.

Injecting with triamcinolone and lidocaine together resulted in a success rate of 41 percent in a study done by Rozental, and having type 2 diabetes did not have any effect on the outcomes. However, six study patients had type 1 diabetes and none of them had relief from the injection and went on to have surgery. Finally, another study had reports of 41 percent and 72 percent success rates in people with type 1 and type 2 diabetes, respectively.

Taking these studies and their findings into account, the authors write that “in patients without diabetes, up to 2 corticosteroid injections work more than half the time, but the recurrence rate is uncertain.” However, many studies are too short and for adequate assessment of treatment success, studies should follow patients for at least one full year.

In terms of the patient presented in this case study, the authors state that they would advise the patient that there is a 60 percent success rate with the injection if she has not had the symptoms for too long. The fact that she is not dependent on insulin is an advantage, leads to better success rates that if she had been on insulin. However, if she had been insulin-dependent, then the authors would advise the patient that surgery is a viable option, particularly if she was looking for quick and predictable results.

There is a rare, benign tumor of the bone that can occur in the finger causing deformities and loss of motion. It’s called osteochondroma. Benign means the tumor isn’t cancerous and won’t travel elsewhere in the body causing harm. But it’s not benign in the sense that the loss of motion can affect hand function. And the deformity can lead to painful, limiting osteoarthritis.

This report on a series of 10 patients with a single osteochondroma of a finger helps point out the need for early surgery. The patients ranged in ages from three to 36 but the majority of them were older children and young teens (ages 10 – 15). Any finger can be affected by this condition. In this group, it was mostly the ring and long fingers.

Each person had just one finger affected and one joint of that finger. Since the joint was involved, the diagnosis for each patient was solitary intra-articular osteochondroma. It is possible to have the same problem without affecting the joint but that wasn’t the case for any of these patients. In all cases either the middle bone (middle phalanx) of the finger was affected or the tip of the finger (distal phalanx).

Pain isn’t a big feature of intra-articular osteochondroma. Loss of motion is more often the problem as the tumor blocks movement or causes the bone to shift. Changes in bone and joint alignment eventually result in finger deformity. As in the case of one patient who waited 20 years to seek treatment, the deformity can be severe enough to lead to arthritis where the joint surfaces no longer line up evenly.

Surgical treatment consists of removing the tumor, a procedure called excision. If there were any soft tissue problems, the surgeon corrected them at the same time. In several patients, a second procedure called osteotomy was necessary.

An osteotomy is used to correct angular deformities. For example, if the bone has shifted or tilted too far to one side, an osteotomy is done to realign the bones and joint. This is done by cutting a wedge- or pie-shaped piece of bone from one side of the bone and allowing the two edges of the bone to collapse back toward each other. The result is a straightening of the bone and a shift of forces on the joint from one side more to the middle with a more even distribution of joint contact.

Results were very good for most of the 10 patients. The one adult who waited so long was not able to get full motion back but his finger motion and hand function were much improved from before surgery. Removing the mass enabled the finger to move past where the tumor was blocking motion.

Solitary intraarticular osteochondroma is a fairly rare problem. At least one other study has been published with results similar to this one. The results of both studies confirm that early surgery is important to prevent deformity and early arthritis. When the tumor is allowed to grow unchecked, it can create problems with bone and joint alignment. Restoring normal appearance and function without delay should be the goals right from the start.

The basal thumb joint, the joint at the base of the thumb, allows you to pivot and swivel your thumb at will. However, for people with arthritis affecting that joint, such movements can be very painful, if movement is possible at all. There are surgeries that may help reconstruct the joint, which include removing tissue from the joint or implanting silicone, but just as they have some advantages, they have some disadvantages as well.

In the 1970s, experimentation began with a joint replacement for the basal thumb joint. They were a ball-and-socket prosthesis similar to hip and shoulder implants. As well as having several designs, some were cemented while others were uncemented. And, between the cemented and uncemented, loosening of the implant was the most common complication, particularly among the uncemented implants.

Since the introduction of the ball-and-socket implants, researchers developed a newer model that better replicated the original joint and had a more “saddle-like” appearance. The authors of this article evaluated the effectiveness of the Avanta SR TMC prosthesis, one of these newer implants, looking at the range of motion, strength, and functioning, as well as any complaints of pain and implant loosening.

Thirteen patients had 15 basal thumb implants. Eleven of the 13 had a diagnosis of idiopathic osteoarthritis, “wear-and-tear” arthritis of unknown cause, and two had posttraumatic osteoarthritis. The average follow-up after surgery was 36 months and the average age of the patients was 58 years, ranging from 47 to 68 years. Eight of the implants were placed in the patients’ dominant hand and two of these patients had a second surgery in the other hand six months after the first surgery.

Researchers measured, both before and after surgery, range of thumb motion angle, grip and pinch strength, pain, and function. Pain was assessed with the sequential occupational dexterity assessment (SODA) and Michigan Hand Outcomes Questionnaire (MHQ). With the SODA assessment, the patients rated how much pain they experienced while doing every day tasks, such as opening jars, writing, and using utensils. The MHQ raged how much pain was present while at rest, as well as hand function, work-related activities, aesthetics (how the hand looks), and overall satisfaction. When assessing function in one hand, the researchers asked the patients to perform a 9-hole peg test. X-rays from both before and after surgery were evaluated for the angle of the thumb and spaces in the joint.

After gathering the data, the researchers found, according to the SODA scores, the patients reported a significant decrease in pain, although the MHQ findings were not as significant. There was not much improvement in the affected hand alone, as seen by the 9-hole peg test, meaning the time it took to take the pegs out of the board and put them back was not faster after surgery than it was before. However, when using SODA and MHQ to evaluate hand function, there was a significant improvement in the ability to do daily activities. Although, in general, most patients were satisfied with the outcome, there were no significant changes in their function at work and the aesthetics of the hand.

According to x-ray examination, the researchers found that the angles of the joint were within 10 degrees of the ideal position (90 degrees) and that there had been no shortening in the joints and, in seven cases, there was lengthening of the space. There were no signs of loosening within the implant.

One patient, who had minimal pain after the surgery, fell on the operated hand seven months after. This fall resulted in more pain and limited use of the thumb. She did not seek medical help until nine months after the fall, where x-rays showed that there was an old fracture at the base of the thumb that had not been there before the surgery. Surgery was done to replace the implant, however it became infected and further surgery was needed. The only other reported complication was one other patient who had a nerve injury that occurred during the surgery.

The authors concluded that this particular implant, the Avanta SR TMC, is provided significant improvement both in function when both hands were used and in pain relief, but did not provide a significant change in range of motion or strength when the hand was used alone. The prosthesis was found to be sound at follow-up, with no loosening noted.

Trigger finger is a condition that occurs when a finger or thumb is caught in a bent position. In severe cases, it may become locked in that position. If you can straighten the digit, it may straighten with a sharp snap. The bending occurs because the rings, or pulleys at the base of the finger, which surround the tendons, become thick and put pressure on the tendon, making it difficult for the tendon to slide back and forth, bending and extending the finger. The catching or snapping feeling comes as the tendon catches on the rings.

Trigger finger is fairly common and if surgery is needed, the surgeon releases the A1 pulley. The minor procedure is said to have a low complication rate but there has not been a lot of research done into the procedure or its complications. The few studies that have been done show complication rates of between 11 percent to 43 percent, with the majority of them being minor, such as scar pain and tenderness, a bit of difficulty extending the finger, redness (treated with antibiotics), and a recurrence of the condition. However, some major complications have also been reported and these include bowstringing of the flexor (bending) tendon, nerve damage, and infection that does not clear up with antibiotics. The authors of this article investigated the reported complications associated with this procedure.

Researchers reviewed the records of 43 patients (25 women) who had undergone surgery to release their trigger finger. Their ages ranged from 34 to 85 years, with the average being 61.5 years. Among the 43 patients, 78 open trigger release procedures were performed. The patients were followed, on average, for 16 months, although one was followed for as long as 126 months. All surgeries were performed by the same surgeon, the senior author of this article.

Upon review, the researchers found that there were 27 minor complications in 22 digits as a result of their first procedure (primary release). This comes in at 28 percent (22 procedures out of 78). Ten cases were decreased range of motion in the affected digit, four of scar tenderness, nine of swelling and pain, and four of redness and/or infection. None of the complications lasted any longer than six months.

There were two major complications reported after the primary procedure, giving a complication rate of only three percent (two out of 78). One, a fistula (tunnel) inside the joint, stopped the would from healing, despite antibiotics and dressing changes. Surgery was needed to correct the problem and healing then occurred. The second complication was arthrofibrosis, thickening of tissue in the joint. This was managed by applying a cast for three weeks, followed by three weeks of active range of motion exercises and medications. Although the wound had healed, the patient was left with a lower degree of correction, losing 30 degrees in extending the finger and only able to bend it to 85 degrees.

The authors concluded that although the minor complications, usually wound complications or difficulty with some range of motion, was a bit high, the major complication rate was low. Therefore, surgeons should advise their patients of the possibilities before performing the procedure.