Dr. Budoff's Blog

Swan-Neck Deformity of the Thumb

January 3rd, 2012

Swan-Neck deformity of the thumb occurs when the thumb’s metacarpophalangeal (MP) joint (the joint where the thumb attaches to the hand) hyperextends too much. The ligament that usually prevents this is called the ‘volar plate’. Some people are born with loose (‘double’) joints; these joints are usually loose because of lax volar plates. Other people tear the volar plate during an injury. However, probably the most common cause of volar plate laxity / thumb MP joint instability / swan-neck deformity is basilar thumb arthritis. The basilar thumb joint is where most of thumb’s motion should occur. When the basilar joint becomes stiff and/or subluxed (partially out of joint) from arthritis, it can no longer move normally. The thumb’s stress of reaching around large objects, such as bottles or cans, is then transferred to the MP joint. In order for the thumb to grasp these objectsm the MP joint has to stretch into extension to compensate for the fact that the basilar joint is not moving well. Over time, the MP joint’s volar plate stretches out, leading to hyperextension laxity.

Regardless of why the MP joint’s volar plate is lax or injured, this problem is often curable by a simple, predictable outpatient surgery called a volar capsulodesis. The volar capsulodesis involves repairing or shortening the volar plate by placing a suture anchor (a device that looks like a harpoon-head with stitches attached) into the thumb’s metacarpal bone (the large bone of the thumb). The volar plate is then tied down to the metacarpal bone in a shortened position. After surgery, a cast is worn for 3-4 weeks. Computer use and typing is possible immediately, but heavy gripping and pinching should not be performed for 3-4 months after surgery.

If a basilar joint reconstruction (ie. LRTI; please see the Basilar Thumb Joint Arthritis section of the website) is being performed and the thumb’s MP joint has 30˚ of hyperextension or more, the volar capsulodesis must be performed at the same time. If the volar capsulodesis is not performed, the MP joint’s collapse into extension with gripping and pinching places high stresses on the LRTI reconstruction, leading it a higher chance of instability, with loss of grip and pinch strength. The MP joint volar capsulodesis is performed at the same time as the LRTI, doesn’t hurt much, and doesn’t lead to any extra time in a cast.

So, if your MP joint has a swan-neck deformity or weakness due to laxity of the volar plate, it can be well-treated with a simple, quick outpatient procedure.

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Luno-Triquetral Ligament Injuries

December 27th, 2011

Now that Kobe Bryant suffered a luno-triquetral ligament injury in his wrist, many people are interested in this problem. The luno-triquetral ligament keeps two of the wrist’s small bones, the lunate and the triquetrum, aligned and connected to each other so that they move together in a normal, synchronous fashion during wrist motion. Luno-triquetral ligament injuries can cause significant pain and can lead to arthritis, but are not as dangerous as the more common scapho-lunate ligament injuries (please see my previous blog on scapho-lunate ligament injuries). Luno-triquetral ligament injuries are also usually better tolerated than are scapho-lunate ligament injuries, causing less pain and disability.

Similar to scapho-lunate ligament injuries, luno-triquetral ligament injuries can occur from either repetitive overuse or from trauma, such as a fall onto the outstretched hand or a twisting injury, often due to power tools. Luno-triquetral ligament injuries can lead to pain on the back (dorsum) of the wrist that is worse with activities, especially when putting pressure onto the extended wrist, such as when doing a push-up, getting up off of the floor, getting out of a pool, or opening a door. They also can cause pain with forearm rotation, such as when using tools, turning a doorknob, etc.

The diagnosis of luno-triquetral ligament injuries is suspected based on a physical examination performed by a hand surgeon. Tenderness over the luno-triquetral ligament and pain about the ligament when extending the wrist makes one suspicious of a luno-triquetral ligament injury. The hand surgeon will perform various maneuvers to determine whether or not the lunate and triquetral bones are moving together correctly.

MRI is not very accurate for diagnosing luno-triquetral ligament injuries, even if intra-articular dye is added to the study (ie. an MR arthrogram). The best way to diagnose luno-triquetral ligament injuries is by arthroscopy. However, MRIs are usually performed before arthroscopic surgery to rule out other problems outside the joint that the arthroscope can’t see, such as occult ganglion cysts, avascular necrosis or interrupted blood supply of the lunate, etc.

In mild cases, when the luno-triquetral ligament is ‘sprained’ and not significantly torn, immobilization using a splint or a cast, a steroid injection and avoiding loading the extended wrist (see the above activities that do this) for an extended period of time (often over a year) may be enough to quiet things down. Weight-lifting and push-ups can be performed in a splint that keeps the wrist in neutral position. As an aside, although most people perform the bench press and other weight-lifting exercises with the bar pressing their wrist back into extension, this is poor form, and may lead to wrist problems.

If non-operative management fails to provide sufficient pain relief, the next step is to confirm the diagnosis and to visualize the degree of luno-triquetral ligament instability. This is done arthroscopically. Wrist arthroscopy is a minimally invasive out-patient procedure that involves minimal down-time. After confirming the luno-triquetral ligament injury, the unstable torn ends of the ligament are debrided (shaved down) and an absorbable screw is placed between the lunate and triquetrum. This screw often provides stability and pain relief. A cast is worn for 6 weeks after surgery. This arthroscopic treatment has approximately an 80% success rate. As for scapho-lunate ligament injuries, there is a 20% failure rate for all surgical treatments of luno-triquetral ligament injuries.

Some people have long ulna bones that push against the triquetrum, causing luno-triquetral ligament injuries. In these cases, the ulnar bone may need to be shortened to take the stress off of the luno-triquetral joint. Shortening the ulna also tightens up the other ligaments around the luno-triquetral joint, providing further stability and symptom relief. The success rate of ulnar shortening is 81-84% and, in fact, many believe that ulnar shortening is the best long-term answer for luno-triquetral ligament injuries. In order to tighten up the ligaments about the luno-triquetral joint, the ulnar shortening has to be performed in the middle of the ulna bone, in its shaft. This is an outpatient procedure that involves removing a few millimeters of bone from the center of the ulnar shaft. A plate is placed to protect the ulna while it heals, which takes approximately 3 months. A cast is worn for the first 6 weeks, and then a removeable brace is used until the bone is fully healed. The main drawback to this procedure is that sometimes the ulna takes over 3 months to heal. Often, a bone stimulator is used to speed up the healing process. A bone stimulator is a painless device applied 20 minutes a day the operative area. Most activities, including many sports, can be restarted without the bone fully healed on x-ray.

If the luno-triquetral ligament injury is very severe because the secondary, back-up ligaments around it have also torn, or if the luno-triquetral ligament injury has already led to arthritis, the wrist is treated with a luno-capitate partial wrist fusion, the same procedure used to treat wrist arthritis (please see the Wrist Arthritis section of my website). Lunocapitate fusion is an outpatient procedure that involves fusing the lunate and the capitate together. The triquetrum and the scaphoid are both removed. A cast is worn for approximately 6 weeks and then therapy is begun. This is a predictable procedure that works very well for advanced wrist problems, including arthritis.

The good news about luno-triquetral ligament injuries is that they are usually not as serious as scapho-lunate ligament injuries. An injection and immobilization is often all that is needed. However, if problems persist, there are a number of outpatient surgeries that can provide relief.

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Retinacular Cysts

December 15th, 2011

Tender masses that appear in the base of a finger near the palm are usually retinacular cysts. Retinacular cysts are simply ganglion cysts that come from the flexor tendon sheath of the finger. Retinacular cysts may appear rather quickly and can lead to pain when gripping objects. Fortunately, they are benign and easily treated.

The first treatment is by aspiration with a needle. This removes the fluid from the center of the cyst. If the cyst’s walls are thin, the cyst will disappear. If the walls of the cyst are thick, a smaller, less tender mass may still be palpable. If the aspiration doesn’t change the cyst at all, then the mass is probably not a cyst, and an MRI and possible surgical excision should be considered.

Aspiration is usually successful in treating retinacular cysts. However, as for ganglion cysts elsewhere, once a cyst recurs, further aspirations will probably not be effective treatment. If a retinacular cyst returns following a successful aspiration, then the options are to live with it or have it removed surgically.

The surgery is a quick outpatient procedure. The cyst is removed along with a section of the flexor tendon sheath from which it originated. The section of the sheath is removed in order to prevent recurrence, which is rare if this step is performed. This is similar to removing a section of joint capsule when excising ganglion cysts.

In conclusion, tender masses near the junction of a finger and the hand are often retinacular cysts, which are easily curable by experienced hand surgeons.

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Snapping Elbow (Plica)

December 9th, 2011

One of the most common causes of a snapping elbow is a plica. A plica is an inflamed part of the joint lining that catches in between the bones of the elbow with motion. A plica can be caused by anything that inflames the elbow, typically either an injury or overuse.

Although symptoms may vary, the snapping usually occurs when the elbow is bent approximately 90 degrees, with the palm of the hand facing away from the body. The popping usually hurts on the outside of the elbow and may be associated with swelling. Other conditions that may cause elbow popping include loose bodies from arthritis, trauma, or osteochondritis dissecans (OCD: see previous blog).

The diagnosis of a plica is best made on physical examination. A steroid injection placed into the elbow serves two purposes: 1) diagnostic: if an injection inside the joint decreases elbow pain, then the problem is located inside the elbow, 2) therapeutic: the anti-inflammatory effects of the plica can reduce its size, decreasing symptoms.

While MRIs are very good at detecting arthritis, they miss plicas 25% of the time, and cannot be relied upon to diagnose a plica.

If the pain recurs following an injection, the plica can usually be very well treated with an arthroscopic excision. This is an outpatient procedure that is not very painful. In order to maximize treatment results and minimize complications, this procedure should be performed only by experienced elbow arthroscopists. Please note that just because a surgeon performs many arthroscopies of the knee and shoulder, that does not mean that they are skilled elbow arthroscopists. This is a separate skill set and involves an understanding of elbow arthroscopy’s more complex anatomy. The plica needs to be removed in both the front and the back of the elbow.


Figure 1. Plica in Front of Elbow Figure 2. Shaving Front of Plica Figure 3. Front of Plica Removed
Figure 4. Plica in Back of Elbow Figure 5. Shaving Back of Plica Figure 6. Back of Plica Removed

Figure 1 shows the plica and inflammation (which looks like seaweed) at the front of the elbow. This inflamed tissue became entrapped between the bones of the joint with motion, leading to painful snapping. Figure 2 shows the motorized shaver used to remove the plica and its associated inflammation. Figure 3 shows the front of the elbow joint with the plica and its associated inflammation removed. Figure 4 shows the plica in the back of the joint. The plica needs to be removed in both the front and the back of the elbow in order to eliminate the symptoms. Figure 5 shows the motorized shaver used to remove the plica from the back of the elbow. Figure 6 shows the back of the elbow joint with the plica removed.

After surgery, the elbow should be kept clean and dry for 3 days. After 3 days the dressing can be removed and the elbow can get wet in a shower. Elbow motion is begun to regain full motion. Band-aids are applied to the arthroscopy portals and submersion under water is avoided until the stitches are removed at the first post-operative appointment at 2 weeks.

In conclusion, painful elbow snapping and popping is often due to an inflamed plica. Fortunately, plicas can be easily treated by arthroscopic excision.

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Flexor Carpi Ulnaris (FCU) Tendinosis

December 2nd, 2011

The flexor carpi ulnaris (FCU) tendon is on the palmar side of your wrist, above the small finger. It is one of the major tendons that flexes your wrist. Occasionally, overuse can cause damage to the FCU tendon. As opposed to the flexor carpi radialis (FCR) tendon, which runs in a sheath and can get ‘pinched’ by it (see previous blog on the FCR tendon), the FCU tendon has no sheath. FCU overuse leads to painful degeneration of the FCU tendon itself, similar to the tendon degeneration found in tennis elbow and painful rotator cuffs.

Initial treatment is usually a steroid injection and physical therapy. The strengthening exercises are easy and can be learned in 1-2 visits, and then performed every day at home. They should take no longer than 5 minutes each day. If the FCU pain doesn’t resolve after a few months, then a surgical option may be considered.

Fortunately, there is a quick, effective, minimally-invasive outpatient surgical option available that is not very painful. In fact, I published a study on this procedure in 2005.1 All patients who had this procedure performed had excellent pain relief. The degenerative part of the tendon is removed through a small incision and the remaining good part of the tendon repaired. A splint is worn for a few days after surgery, and then normal activities can be restarted, as tolerated.

So if the FCU tendon is causing pain, it can be effectively treated either nonoperatively, or with a small outpatient surgical procedure. Either way, this pain from overuse can usually be cured.

Reference 1: Flexor Carpi Ulnaris Tendinopathy, Budoff JE, Kraushaar BS, Ayala G, The Journal of Hand Surgery, Vol 30A(1):125-129, 2005.

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Metacarpophlangeal (MP) Joint Replacement

November 23rd, 2011

The metacarpophalangeal (MP) joint is the large joint where the finger attaches to the hand. Arthritis of the MP joint can lead to pain, swelling and stiffness. Nonoperative management includes a steroid injection or two, activity limitation and buddy taping the finger to its neighbor. In patients with rheumatoid arthritis, all of the MP joints can be involved, and the fingers can deviate away from the thumb, making it difficult to use the hand to pick up and pinch objects. Rheumatoid arthritis causes the fingers to angulate, sublux and/or dislocate because it is a systemic disease that destroys not only the joint, but also the ligaments that hold the joint in position.

Once rheumatoid arthritis causes the MP joint to dislocate, joint replacement should be strongly considered. The reason is because following the dislocation, the finger starts to drift up into the palm of the hand. This causes the soft tissues to shorten. Then, when MP joint replacement is finally performed, the finger cannot be brought out to length. At this point, in order place the new joint, a significant amount of bone needs to be removed from the metacarpal bone of the hand. So now the MP joint replacement can no longer be placed in the wide area at the end of the bone. It now must be placed in the narrow shaft of the bone (think of how a dog bone in wider on either end than in the middle). Placing an MP joint replacement in the narrow shaft doesn’t provide as much stability as the wider bone ends do, predisposing to complications.

If non-operative management fails, MP joint replacement is an effective surgical option. Patients without rheumatoid arthritis usually have good tendons and ligaments, and can therefore benefit from the newer total joint replacements now available. These newer MP joint replacements are made of metal and polyethylene (a very tough plastic-like material). Each side of the joint is resurfaced by a separate piece, for a total of two pieces. These replacements are made of the same materials that hip, knee and shoulder replacements are made out of, and are believed to last longer and provide better function than the older single-piece hinged silastic (a rubbery material) joint replacements.

If the ligaments have been compromised, which is almost always the case with rheumatoid arthritis, than the newer type of total joint replacement cannot be used, because there are no ligaments to stabilize the two separate pieces. The older hinged silastic replacement must be used, as these single-piece joint replacements provide their own stability to the joint. These silastic implansts work well, but will eventually break after a number of years. Having said that, good function often remains even after they break; broken silastic joints don’t necessarily have to be replaced.

Both types of replacement provide an average of about 50% of normal motion. However, that amount of MP joint motion is still very functional. Even though it’s not full motion, having 50% of pain-free motion is almost always better than having motion that causes pain, as when a joint hurts its function is usually significantly compromised.

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Scapho-Lunate Ligament Injuries

November 18th, 2011

Scapho-lunate (SL) ligament injuries are serious injuries to the wrist.  The scapho-lunate ligament connects two of the most important bones of the wrist together: the scaphoid and the lunate.  The scapho-lunate ligament keeps those small bones of the wrist moving together in a normal, synchronous fashion.  Tears of the scapho-lunate ligament can cause significant pain and usually lead to arthritis after 10-15 years, sometimes earlier.

Scapho-lunate ligament injuries can occur from either repetitive overuse or from trauma, such as a fall onto the outstretched hand.  Scapho-lunate ligament injuries lead to pain on the back (dorsum) of the wrist that is worse with activities, especially when putting pressure onto the extended wrist, such as when doing a push-up, getting up off of the floor, getting out of a pool, or opening a door.

The diagnosis of scapho-lunate ligament injuries is suspected based on a physical examination performed by a hand surgeon.  Tenderness over the scapho-lunate ligament and pain about the ligament when extending the wrist makes one suspicious of a scapho-lunate ligament injury.  The hand surgeon will perform a ‘scaphoid shift’ test, which attempts to determine whether or not the scaphoid and lunate bones are moving together correctly.  A negative test does not mean that the ligament is not affected, only that other supportive ligaments may be intact enough to prevent a shift under the low loads imposed during a physical examination.  On the other hand, a positive scaphoid shift test signifies a significant scapho-lunate ligament injury.

MRI is not very accurate for diagnosing scapho-lunate ligament injuries, even if intra-articular dye is added to the study (ie. an MR arthrogram).  The best way to diagnose scapho-lunate ligament injuries is by arthroscopy.  However, MRIs are usually performed before arthroscopic surgery to rule out other problems outside the joint that the arthroscope can’t see (occult ganglion cysts, avascular necrosis or interrupted blood supply of the lunate, etc).

In mild cases, where the scapho-lunate ligament is ‘sprained’ and not significantly torn, a splint, a steroid injection and avoiding loading the extended wrist (see the above activities that do this) for an extended period of time (well over a year) may be enough to quiet things down.  Weight-lifting and push-ups can be performed in a splint that keeps the wrist in neutral position.  As an aside, although most people perform the bench press and other weight-lifting exercises with the bar pressing their wrist back into extension, this is poor form, and may lead to wrist problems.

If non-operative management fails to provide sufficient pain relief, the next step is to confirm the diagnosis and to visualize the degree of scapho-lunate instability.  This is done arthroscopically.  Wrist arthroscopy is a quick, minimally invasive out-patient procedure that involves minimal down-time.  As above, an MRI is usually obtained before surgery, but because the MRI is not very accurate for problems inside the wrist joint, it is only used to rule out problems outside the wrist joint that the arthroscope can not see.

If the scapho-lunate ligament is intact and the scaphoid and lunate bones are stable, then the pain may be coming from ‘dorsal capsulitis’, a somewhat controversial inflammatory condition of the joint lining next to the scapho-lunate ligament  that can mimic a scapho-lunate ligament injury.  Dorsal capsulitis can be addressed arthroscopically by removing some of the joint capsule (the joint covering).  There is no harm incurred by removing this piece of joint capsule.  Following this arthroscopic procedure, there is no splinting and activities can slowly be restarted within a week following surgery.  If any other problems are found within the wrist joint, they can be addressed arthroscopically or noted for further discussion with the patient if they are too severe for arthroscopic management.

If the scapho-lunate ligament injury is due to a traumatic event that occurred within the past 3 months in a young patient, ligament repair can be considered.  Let me state now for the record that anything that is done to treat a scapho-lunate ligament injury has at least a 20% failure rate.  Period.  Sometimes more.  Scapho-lunate ligament injuries are still one of the big unsolved problems in hand and wrist surgery today.

A scapho-lunate ligament repair is performed through an open incision.  The scapho-lunate ligament is repaired back to the bone with a small anchor, which is looks a lot like the head of a harpoon.  It sticks into the bone and has stitches on it that hold the ligament back down against the bone.  The scapho-lunate ligament repair is protected by an absorbable screw between the scaphoid and the lunate.  The screw absorbs over time.  This eventually causes it break, with a disconcerting, but harmless, ‘pop’ a few months after surgery.  However, by the time it breaks it has already stabilized the scaphoid and lunate together enough that the ligament has healed, if it’s going to heal.

If there is no acute injury, or it’s been over 3 months following an injury, a scapho-lunate ligament repair will probably fail.  As a failed scapho-lunate ligament repair can lead to permanent stiffness, it’s not a surgery that I recommend if the odds of success are poor.  In this situation, which is the most common situation, if the symptoms are too much to live with reconstruction can be considered.  I also prefer reconstructions rather than scapho-lunate ligament repair in patients between the ages of 40-60 years, as stiffness following scapho-lunate ligament repair becomes more common in patients over 40.  Reconstruction techniques stabilize the wrist by other methods, such as using a tendon to tether the scaphoid, rather than relying on a scapho-lunate ligament repair.  There are many different reconstruction techniques described in the hand literature.  The reason that so many techniques have been described is that none of them work predictably.  Again, there is at least a 20% failure rate with any treatment of scapho-lunate ligament injury.

My own personal philosophy when all treatments have a significant failure rate is to perform techniques with higher success rates that also have low complication rates.  At the current time, until better reconstructive options come along, I prefer to use the modified Brunelli reconstruction, which is performed on an outpatient basis.  This reconstruction uses a tendon to substitute for the loss of the scapho-lunate ligament.  Roughly 1/3 of the flexor carpi radialis (FCR) tendon is separated from the remaining 2/3 of the FCR tendon and pulled through a hole created in the scaphoid.  This is then tensioned over the scaphoid and lunate bones and tied down with an anchor to reconstruct a tether between the scaphoid.  A short arm cast is worn for approximately 5 weeks.

If a patient is 55-60 years or older, it may be better to just remove the scaphoid and perform a lunocapitate fusion, as detailed in the ‘Wrist Arthritis’ section of the website.  This outpatient procedure involves a cast for 6 weeks and provides motion similar to what an older patient could expect from a scapho-lunate ligament reconstruction.

I know that’s a lot of information, but scapho-lunate ligament injuries are a complex topic that is still without a predictable solution.  We have a good surgical option available, if needed, but no great treatments as of yet. However, if realistic goals are understood, most patients are quite happy with their surgical treatments.

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Finger Nail Injuries

November 3rd, 2011

Injuries to the finger nail are fairly common. While these often lead to some degree of nail deformity or change in the nail’s appearance, good treatment can often minimize the degree of damage.

If the finger nail gets crushed, bleeding may occur underneath it. If this bleeding doesn’t hurt, it doesn’t need to be drained. Your body will resorb it over time. However, if this is painful, the pressure that is leading to the pain may be injuring the underlying nail bed, the tissue that forms the nail and allows it to adhere to the finger. In this case, it should be drained by burning a hole through the nail to release the blood trapped beneath it. In an emergency room, cautery devices are usually available to do this. In a physician’s office, the usual technique is to heat up a paper clip with a cigarette lighter and then burn through the nail. This takes a few minutes, but is painless. Upon completing the hole through the nail, the blood underneath cools the paper clip and so the underlying nail bed is not burned. As no one in my office smokes (or at least, no one will admit to smoking) if you come into my office for this, it is helpful to bring a cigarette lighter with you.

If the nail has been avulsed (torn out from underneath the nail fold), it should usually be replaced underneath nail fold for 2 weeks to avoid scarring of the cuticle/nail fold to the nail bed, which can lead to a nail deformity. The nail is usually relocated in the office under a digital block, which numbs the finger. Part of the nail is removed to make it fit back easier and then the nail is replaced and held in position with steristrips (tape). The digit is splinted for two weeks, as bending the finger may cause the nail to pop out again. After 2 weeks have passed the nail can be allowed to grow out or fall out, depending on how badly it was avulsed.

In a child, nail avulsion is often associated with a fracture through the growth plate of the bone underneath the nail. These fractures are ‘open’, ie. exposed to the environment, and can become infected. These injuries should be washed out in an emergency room or office, antibiotics prescribed and the fracture fixed in the operating room within a few days. This is an outpatient procedure. Usually a pin is used to hold the fracture in place. The digit is splinted, usually for 3 weeks, and then the pin is removed in the office; this doesn’t hurt very much, and is nothing to be feared.

If the nail has been cut or damaged, then the underlying nail bed is often cut. Any underlying bony fracture should be fixed, often with pins as this bone is small, and the nail bed should be repaired to minimize the resulting nail deformity. As above, the nail, or a substitute, is placed underneath the nail fold for at least 2 weeks and can then be removed. A new nail should start growing. It will always have some degree of deformity, but good treatment usually minimizes any problems.

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Acromio-Clavicular (AC) Joint Injuries Subluxation Dislocation Instability

October 31st, 2011

The Acromio-Clavicular (AC) Joint is the small joint on top of the shoulder where the clavicle attaches. If the AC joint is hit head-on, such as when falling off a bike or tackling somebody without shoulder pads, the clavicle may detach, raise up and become noticeably ‘out of joint’. A dislocation occurs when no part of the clavicle remains touching the acromion bone that it normally sets into. A subluxation is a partial dislocation, meaning that the clavicle goes partially out of joint, with part of the clavicle still touching the acromion.

X-rays are necessary to confirm the diagnosis and make sure that a clavicle fracture isn’t present. Unless the AC joint injury occurs in a young manual laborer or an overhead athlete, it’s often best to wait for at least 3 months before considering any surgical reconstruction of the AC joint ligaments that hold the AC joint in place, even in a professional (non-overhead) athlete. The pain will usually subside faster and people usually return to sports quicker without surgery, even to collision sports such as football or rugby. The arm is placed in a sling for a couple of weeks to let the inflammation subside, and then range of motion exercises are begun, either at home or under the direction of a therapist. At 6 weeks, strengthening of the rotator cuff and muscles about the shoulder blade, which may also be affected by the injury, can begin.

The vast majority of people with AC joint injuries can be treated without surgery. The exceptions are when the clavicle is extremely high riding, if the clavicle has been forced backward through its restraining fascia (a sheet of stabilizing tissue), or forced downward under a bone called the coracoid (which is incredibly rare). Although these circumstances are uncommon, they do occur, and are a good reason to have any shoulder injury evaluated by a shoulder or upper extremity specialist.

If non-operative management fails to provide significant pain relief after 3 months, it’s usually because the AC joint ligaments didn’t heal on their own and the end of the clavicle remains unstable. This may lead to persistent pain with shoulder motion. Often, the end of the clavicle is so unstable that it can be moved around with a couple of fingers. In these cases, surgical stabilization may be considered.

There are many surgical stabilizations described to treat AC joint instability. All work fairly well, although some work better than others. However, none of them recreate a totally normal AC joint. I prefer to use a cadaveric hamstring tendon (semi-tendinosis allograft) to recreate the torn ligaments. This is an outpatient procedure. The clavicle is reduced back to its natural place and held there with a ligament reconstruction that includes the cadaveric hamstring tendon to add more strength. However, there is almost always some degree of stretch following surgery. While the clavicle usually raises up a little, it is usually stable enough so that it no longer hurts and full activities can be performed. To prevent the surgical reconstruction from stretching out too much, it is necessary to protect the shoulder until enough scar forms to provide strength. To protect the reconstruction, a sling is worn for 6 weeks with only limited motion allowed until then. Fortunately, despite this immobilization, the shoulder doesn’t usually get very stiff as the surgery is entirely outside of the shoulder joint. Overall, most people do very well following this surgery, and can return to their usual work and sporting activities by 4-6 months.

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Extensor Tendon Subluxation / Boxer’s Knuckle

October 25th, 2011

Subluxation or snapping of the tendons on the back of the hand can occur for different reasons. It’s often due to a trauma, such as punching a hard object. That’s why some refer to this injury as ‘Boxer’s Knuckle’. It can also happen when a ball or other object strikes the finger, or from a generalized condition, such as rheumatoid arthritis. The middle finger is the most commonly affected.

When the injured finger is moved the tendon on the back of the hand snaps back and forth. This is an annoying, sometimes painful problem that can greatly affect hand function. If it’s due to an injury that happened no more than 2 weeks previously, a minimally restrictive brace can be tried. This can take two forms: one is a pen-like cylindrical object under the base of the affected digit, on top of the other fingers. This keeps the injured finger’s MP (metacarpophalangeal) joint, the big joint that connects the finger to the hand, from fully flexing. The other type of brace fits into the palm of the hand and also prevents the affected finger’s MP joint from fully flexing.

However, if the tendon subluxation has been going on for over two weeks, or if it’s due to a systemic problem, bracing will probably not work. In these cases, the extensor tendon subluxation is either accepted or treated surgically. Surgically, a strip of the subluxating extensor tendon is used to reconstruct the torn ligament (the sagittal band) that normally keeps the tendon stable. This is an outpatient procedure that is not very painful. It does, however, leave a scar on the back of the hand. After surgery, one of the two braces mentioned above is worn for 4 weeks. The hand can be used, but full MP joint flexion should be avoided for 4 weeks, except under the supervision of a hand therapist.

So if extensor tendon subluxation is causing problems, please know that there is a very simple, effective, and reliable cure for it.

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