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Swan-Neck Deformity of the Thumb

Tuesday, 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

Tuesday, 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

Thursday, 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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Flexor Carpi Ulnaris (FCU) Tendinosis

Friday, 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

Wednesday, 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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Finger Nail Injuries

Thursday, 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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Extensor Tendon Subluxation / Boxer’s Knuckle

Tuesday, 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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Forearm Fractures

Thursday, October 20th, 2011

The forearm consists of two bones, the radius and the ulna. Forearm fractures are usually signicant injuries that lead to pain, stiffness and deformity. If the forearm bones are broken in an adult, surgical fixation is usually required. The best way to fix forearm fractures in an adult is with strong plates and screws. This is an outpatient procedure and is very effective. If the bones are in more than two pieces, bone graft may be required. Bone graft can be obtained through a small incision over the wrist or the elbow, and usually does not add any significant pain to the operative experience. This is different than it used to be when surgeons routinely harvested iliac crest bone graft from the area above the hip; this was more painful, especially using older, more invasive techniques.

Forearm fractures should be fixed in a timely fashion, within 2-3 weeks of the injury. If the forearm bones are allowed to remain in a displaced position (ie. bent or shortened) for a long period of time, scarring can increase the difficulty and complication rate of the surgery and decrease final motion, especially forearm rotation.

Following surgery, if the bone quality is good, early motion can usually be started after 4-5 days. It is very important to regain forearm rotation, as that is the most common motion that is lost.

In children, forearm fractures can often be treated without surgery. However, if the broken fragments of bone are too angled (bent) or shortened, surgery may be required. In older children, 10 years of age or greater, a small plate that avoids the physis (growth plate) may be placed. Unlike in adults, children are usually casted. That is because the smaller plates used in children are weaker than those used in adults, and need protection until the fracture is healed, which usually takes 6 weeks. Children do not usually become as stiff as adults.

If skillfully fixed, forearm fractures usually do very well. An orthopaedic hand or upper extremity specialist is usually the most experienced in treating these fractures.

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Metacarpophalangeal Joint (MPJ) and Proximal Interphalangeal (PIP) Joint Arthroscopy

Wednesday, August 17th, 2011

The metacarpophalangeal joint (MPJ) is the large joint where the finger connects to the hand. The proximal interphalangeal (PIP) joint is the middle joint of the finger. If pain occurs at these joints, initial treatment consists of buddy-taping the finger to its neighbor and an injection. If the injection works, but wears off, the injection can be repeated.

If pain persists after two injections, it is often because a ligament has been partially torn and the torn part is folded into the joint. This can irritate and inflame the joint, similar to irritation due to a pebble in a shoe.

These cases respond extremely well to arthroscopic debridement. The torn part of the ligament is shaved out and the pain relief is usually significant. If the underlying cause is found to be early arthritis, that will be revealed and appropriate management discussed (please see previous blogs).

Both metacarpophalangeal joint arthroscopy and proximal interphalangeal joint arthroscopy are minimally-invasive procedures performed on an outpatient basis. The ‘stab wounds’ are small and pain is usually minimal. Early motion is encouraged. Stiffness is uncommon, and the need for post-operative hand therapy is often short. The wounds only need to be kept dry for 3 days, and then showering is permitted. Heavy use and power grip are best avoided for a week or two.

In short, both metacarpophalangeal joint arthroscopy and proximal interphalangeal joint arthroscopy are minimally-invasive procedures that are helpful to both diagnose and treat many disorders of the metacarpophalangeal joints and proximal interphalangeal joints that have failed appropriate non-operative management.

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Proximal Interphalangeal (PIP) Joint Replacement

Tuesday, August 2nd, 2011

The proximal interphalangeal joint is the middle joint of the finger. Injuries to the proximal interphalangeal joint often lead to arthritis. The treatment of proximal interphalangeal joint arthritis starts with buddy taping of the finger to its neighboring digit and a steroid injection into the proximal interphalangeal joint. If significant proximal interphalangeal joint pain continues then the options for treatment are usually either fusion or replacement.

The proximal interphalangeal joint of the index finger is best fused. The index finger is used for pinch. When the index finger opposes the thumb to create power during pinch, this creates a significant sideways stress on the proximal interphalangeal joint. Current proximal interphalangeal joint replacements simply cannot handle this sideways stress, and will become unstable. On the other hand, fusion leads to a stiff but pain-free and stable platform for pinching. The loss of proximal interphalangeal joint motion is not a significant problem for the index finger.

Because the middle, ring and small fingers are used for grasp, motion of the proximal interphalangeal joint of these digits is important. For that reason, proximal interphalangeal joint replacement may be considered. As for most joint replacements, they have less problems as the patient’s age increases. The reason for this is because joint replacements have a limited ‘life expectancy’, and do not last as long in younger, higher demand individuals. Having said that, the newer joint replacements may be better suited for younger, higher demand individuals, within reason.

Proximal interphalangeal joint replacement is performed as an outpatient surgery. The newer metal and polyethylene (a fancy plastic) replacements usually work better than the pyrocarbon implants that were popular a few years back. An example of the newer (SR-PIP) joint implant can be seen at www.totalsmallbone.com/us/products/hand/sr_pip.php4

After proximal interphalangeal joint replacement, motion is started within a few days after surgery with hand therapy. Ultimate motion is about 50% of normal, about 60°. It is unclear how long the newer proximal interphalangeal joint replacements will last.

Unfortunately, these newer unlinked proximal interphalangeal joint replacements are not appropriate for patients with advanced rheumatoid arthritis. Rheumatoid arthritis is a much rarer inflammatory condition than the typical osteoarthritis (wear and tear) that is much more common. If you’re not sure what type of arthritis you have, unless a rheumatologist (arthritis expert) has formally diagnosed you with rheumatoid arthritis, you most probably have simple osteoarthritis or a similar condition. People with rheumatoid arthritis have poor ligaments. Because of this, unlinked replacements, such as the SR-PIP, will become unstable. In cases of rheumatoid arthritis, one-piece linked silastic (a type of rubbery plastic) replacements provide some intrinsic stability and are better options. The post-operative therapy is the same. In cases of rheumatoid arthritis, motion is limited more by the conditions of the finger’s tendons than the joint replacement itself.

So if you are suffering with proximal interphalangeal joint arthritis, there are now better treatment options than were previously available. Most patients are very happy with the pain relief and function afforded by these newer implants.

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