News Category: Hand

Double Crush Syndrome (DCS) is described as compression of a peripheral nerve at more than one site. Scientists have theorized that compression at one site can be asymptomatic, but cause increase risk of impairment at another anatomic site, thus the double crush of the nerve. When the nerve is disrupted at both sites it can result in a change in nerve function nutrient flow at the axonal level and increase the chance that distal nerve axons also become compressed and often symptomatic.

Since being identified in 1973, there has been a lot of controversy surrounding the pathophysiology of double crush syndrome (DCS). There is no way to confirm objectively that the symptoms attributed to DCS are due to injury at two distinct sites and often the patients diagnosed with DCS have multiple comorbidities, other symptoms, and disability. Often the result of diagnosing an individual with DCS is encouragement to seek out surgical repair that may not be the most effective treatment, particularly when multiple comorbidities and disability coexist. Even with the surrounding controversy, it is important to identify that Double Crush Syndrome is a possibility and that a patient’s symptoms may not be related to only one site of nerve compression, multiple sites or even a systemic neuropathy can also be at play.

Many studies have attempted to identify the physiology, the risk factors and the frequency of DCS in the general population. The results have varied so significantly that it is difficult to define how common it is and which populations may be at greater risk. There is some consensus that there is an increased risk of nerve compression injury after systemic illness, such as diabetes, hereditary neuropathy, uremic neuropathy, hyperthyroidism, vitamin deficiency and chronic alcoholism. Researchers have found for possible mechanisms for DCS, the most common being a disruption in axonal nutrient flow due to the compression injury. Other reasons may be an immune response inflammation of the dorsal root ganglion portion of the nerve, an ion channel regulation issue, or a potential neuroma.

The most common diagnosis of DCS is with patients who are unsatisfied with a Carpal Tunnel release procedure. Researchers identified characteristics that differ between those with DCS compared to Carpal Tunnel Syndrome (CTS) alone and have found that in comparison to patients with only CTS, patients with DCS have greater incidence of radiating pain closer to the neck and shoulder, more parathesias and less numbness, decreased grip strength. Some of the classic tests for CTS, including Phalens and Tinnels, were also less frequently positive in those with DCS. It is important that the testing physician be able to identify these subtle differences that distinguish double crush syndrome from carpal tunnel syndrome, as it will allow for more appropriate treatment referral.

Double crush syndrome can also take place in the lower extremity, however there is less research available investigating the occurrence and risk factors for DCS in the legs. In general, the physiology of DCS can take place in any nerve. Examples of DCS in the lumbar nerve roots and associated peripheral nerve have been describes, as have injuries to the sciatic nerve and peripheral nerves. Trauma seems to be a large risk factor for DCS in the lower extremity, including acetabular Fractures of the Hip, posterior hip-dislocation-precautions/topic/45″ class=”alinks-link” title=”Hip Dislocation”>hip dislocation, and lumbar compression. DCS is also associated with ankle injuries resulting in tarsal tunnel syndrome where the posterior tibial nerve is compressed under the flexor retinaculum.

Treatment for double crush syndrome should be initiated with conservative measures that focus on distinct management of each individual lesion. This may include oral steroids, steroid injections, NSAIDs, relative rest to avoid irritating movements and positions, and physical therapy. It is important for the patient to understand that the treatment will involve both the area of pain and the secondary lesion contributing to symptoms, for example treating both the neck and the arm when dealing with carpal tunnel syndrome. If conservative measures fail, surgical consideration can be taken and may include cervical spine decompression and peripheral nerve decompression. This will include procedures such as cervical discectomy, fusion, total disc replacement, posterior laminoforaminotomy, 1st rib resection, or resection of a muscle. The decision as to where to focus surgical efforts first will depend on severity of symptoms and compression at each site. It is imperative that management, surgical or conservative, should focus first on accurate diagnosis and then treatment of all contributing elements.

History has shown that injuries located in zone II of the hand, classified between the distal palmar crease and the flexor digitorum superficialis (FDS) insertion, have been particularly challenging to repair. This is due to the fact that tendon gliding must be restored within a tight sheath while minimizing the adhesions in surrounding tissues. At one point surgery in this area was deemed “no man’s land”. However, there have been remarkable advances in the understanding of healing characteristics, both mechanically and histologically of tendons. Over time, there has been a shift toward surgical repair of finger flexor tendon injuries, including in the area or zone II. While injuries to the flexor tendons are relatively rare among acute hand injuries (less than one percent) there has been extensive research into the injury and subsequent repair.

The FDS and the flexor digitorum profundus FDP originate from the elbow and proximal ulna and interosseous membrane respectively. The muscles divide into tendons in the mid forearm and travel through the carpal tunnel toward each of the fingers. In zone II the FDS tendon splits with each slip traveling laterally and dorsally to the FDP tendon. The FDS slips attach separately along the palmar aspect of the middle phalanx bone while the FDP tendons further attach along the base of the last or distal phalanx. The finger possesses a series of flexor pulleys that allow for maximal mechanical efficiency of the flexor system. Tendon healing occurs through a combined extrinsic cellular response and intrinsic ability that the flexor tendons posses to heal themselves after injury. It has been shown that early mobilization of a repaired tendon shifts the healing process to an intrinsic mechanism to allow for collagen to be laid down in a pattern that closely replicates the native tendon and results in diminished amount of adhesions forming.

Evaluation of the patient with a flexor tendon injury should include a thorough history and physical examination to identify the type and extent of the injury. This should also include a neurovascular examination to identify if there was additionally any injury to the nerves or blood supply to the area. Within zone II, the FDP tendon is the more commonly injured of the two tendons. With a FDP repair, recent studies have suggested that there be partial excision of up to 50 per cent into the A2 pulley and complete division of the A4 pulley to allow for increased tendon gliding. Whereas, traditionally, many surgeons would have deemed these pulley inviolable. There have been many suture configurations described, the author of this review stresses that the treating surgeon us a technique that allows for properly coapted repair in the absence of gapping and minimal trauma to the tendon edges. It was also recommended that at least four core suture strands are used in surgical repair to minimize the risk of rupture. The senior author of this review paper’s preferred technique is a modified Kessler suture configuration that adds a separate cross-locked cruciate technique especially if there is an increased risk for adhesions anticipated. Mechanical testing demonstrated that ideal placement of the core suture was seven to ten mm from the repair site. Gapping or elongation of the repair site must be avoided as they can affect the strength of the repaired tendon thus the use of peripheral suture in addition to the core suture are important. The peripheral suture both minimizes the bulk of the repair and can help prevent elongation of the tendon or gapping. Whether to pursue repairing a FDS tendon in zone II depends on the exact location of the injury. If warranted, to limit bulk of the repaired tendon under the A2 pulley, surgeons will excise one of the slips of the FDS and repair the other to allow for improved gliding of the repaired tendons.

Postoperative rehabilitation is a very important process of the flexor tendon repair. Like mentioned previously early mobilization enhances the strength of the repair site and decreases possible adhesions. It is the discretion of the surgeon to chose either early passive or early active motion protocol. It is recommended that range of motion exercises are not initiated until at minimum four days post surgery but not later than seven days post surgery. A systematic review of the literature demonstrated that both early passive and early active mobilization protocols deliver adequate motion. In the only randomized controlled trial that compared the two protocols it was found that patients who underwent an active place-and-hold protocol showed greater ROM, less flexion contractures and greater patient satisfaction. It was noted that it’s important for the surgeon to select a rehabilitation protocol that best matches the patients ability to comply with the protocol’s restrictions.

It is difficult to draw conclusions on the reported outcomes of flexor tendon repairs due to the heterogeneity of the the rehabilitation protocols and studies on flexor tendon repairs, the variability in reporting of the finger motion and the lack of use of patient-reported outcome measures. Patients with multiple finger involvement, have additional nerve injury and those who smoke were found to more likely have poor outcomes.

Animal bites are a fairly common and expensive injury in the United States, affecting about 1.5 per cent of the population and costing over $850 million annually to treat. Dog bites are most common, followed by cats, and humans. Because of the complexity of anatomical structures in our hands and because of the high risk of infection associated with bites, a seemingly small bite can quickly become a big deal.

Bite wounds are very prone to infection due to the high amount of bacteria present in mouths.  Each mammal presents a different prevalent strain of bacteria, each which can cause different problems. The type of wound caused by a bite also comes in to play.  For instance, a bite from a German Shepard may cause more trauma, but a cat bite can easily puncture to the bone, which could lead to easier spread of infection. Human bites are notorious for having a high rate of infection from all of the bacteria present in the human mouth.

Signs of infection can present up to 12 hours after a bite and include a reddening and warming of the skin, swelling, increasing pain and fever.  Evaluation should include personal history, lab tests for infection, x-rays, and a thorough assessment of the wound.  Treatment involves immediate antibiotics and a thorough wound cleansing to prevent further damage by infection. The amount of time between the bite and seeking treatment matters especially with hand injuries and the presence of infection.

Agricultural injuries to the upper limbs represent up to 70 per cent of all hospitalizations due to farm accidents, occurring mostly in males. Injuries are often debilitating and result in loss of limb or extensive correctional surgeries.  The cause of most accidents have been studied in detail and include lack of attention, complacency, hurriedness, carelessness, removal of safety shields, and not using machinery in the manner it was meant.  The size of the injury depends on the speed and force of the machinery involved, the amount of contact and struggle, and the type of release from the machine. Machines most frequently involved in upper limb farm accidents include tractors, augers, hay balers, combine harvesters and corn pickers. Often, limbs are pulled into a piece of rotary equipment on the machine resulting in complex injuries of soft tissues (nerves, blood vessels, tendons, muscles) and bone, if not complete amputations.  

Because most of the injuries are in rural settings and frequently involve amputation, proper management of amputations should be followed at the first medical clinic prior to transfer to a trauma center.  For instance, an amputated finger should be rinsed in clean water or warm saline mixture, wrapped loosely in gauze and placed in a plastic bag submerged in ice. The stump should be wrapped with gauze with compression and elevation to minimize bleeding. Because of the high amount of contamination from farm equipment, antibiotics should immediately be administered along with a tetanus booster.

Once the patient is in the operating room, the gauze is removed and surgeons have the difficult task of determining the next step:  to attempt to replant the appendage, reconstruct or amputate. This is based on the extent of the injury, available vasculature and nerve damage as well as the basic surgical principles of preventing infection, restoring greatest amount of function and best healing times.  Surgeons are best prepared to make this decision if they have knowledge of the type of farming equipment involved in association to the injury present as well as the risk of infection from this piece of equipment.

Because of the great amount of complexity associated with agricultural upper extremity injuries the optimum treatment is not straightforward. However, with the proper initial trauma treatment, transfer to a surgery center in a timely manner, and treatment by a surgeon familiar with the farm equipment involved outcomes can be more promising with a faster return to work at a greater level of function.

A recent review of all available research papers concluded that there is really not a straightforward recipe for rehabilitation when it comes to recovery from a flexor tendon repair but that the surgical repair techniques have improved.

Our hands’ intricate system of pulleys and tendons allows us the ability to perform very fine motor tasks such as writing or typing. Your finger flexor tendons control the bending motion that allows us to do these amazingly intricate tasks.

The finger flexor tendons attach onto each individual segment of your finger. Notice how you have three points along your finger that you can bend; your fist knuckle, your finger knuckle and finally the end of your fingertip.  Each of these knuckles is controlled by a separate muscle, which turns into a tendon and connects to your finger bone. Should any of these flexor tendons tear it becomes quite difficult, if not impossible, to perform the usual things we require of our hands without a second thought, unless the tendon is reattached to the bone. 

As it turns out, however, repair of the tendon is just the first step.  The tricky part to total recovery is in the rehabilitation of the finger. Following surgical reattachment of the tendon there are two problems that frequently occur. First, the repair itself can fail and the tendon can tear again.  Secondly, while the site of the repair itself needs to rest and rebuild, the remainder of the tendon is stagnant as well. As we all know, if you stay in a static position for a long time you tend to get stiff. The same is true for your tendon and actual adhesions or a binding down of the tendon can occur which causes a decrease in your strength and ability to bend your finger. The ideal rehabilitation recipe, or protocol, would account for both of these issues by allowing your finger to move without risking tearing the tendon again.

Prior to the 1970’s, protocols called for a three-week period of total immobility because it was thought that repairs tended to fail during that time. Then two things changed in the mid 1970’s.  First, new evidence claimed that some motion–three to five millimeters (about the width of a thin wedding band), was actually beneficial for recovery because it prevented adhesions or binding down of the tendon.  Secondly, another team came up with a simple yet ingenious device that allowed patients to extend their finger themselves (since the extensor tendon on the back of the finger was fine) and a rubber band would pull the finger back to its resting position.  This allowed for active motion, or exercise of the healthy tendons on the back of the finger, and relaxation of the repaired tendon on the palm side.  

Authors of this systematic review analyzed the results of 34 different research papers to compare protocols for flexor tendon repair rehabilitation.  They looked at three trends: the difference in success rates between active motion (the patient moving their own finger) and passive motion (movement with the rubber band-like brace), the rate of tendon re-rupturing, and the overall trends in surgical repair. 

The outcome of the repairs were mixed with the overall failure rate (meaning decrease in motion following the protocol or another actual tendon rupture) being slightly better with the active protocols (11 per cent) than the passive protocols (13 per cent).  Breaking down these percentages makes it slightly more meaningful– for the active protocols five per cent of the failures were due to rupture and six per cent were due to decrease in motion; the passive protocols had a four per cent rupture rate and nine per cent due to a decrease in motion—but these data left the authors unable to conclude which protocol is actually better. 

Reviewing the research available left the authors still wondering what the best balance is between active and passive rehabilitation protocols following flexor tendon repair.  Luckily, they were able to conclude that during the past 25 years overall trend in tendon re-rupture rates after surgery is decreasing thanks to material advances and improved suturing techniques.  So until the perfect protocol is determined at least we know that the rupture rate is decreasing in part to surgical advancements.

The hand is a very intricate and complicated feature of the human body. There are many small structures, including tendons, ligaments and muscles that run through the hand and fingers. When these structures don’t move properly the result can be mild to severe disability from weakness of grip strength, inability to grasp objects and difficulty with general hygiene.

Intrinsic contracture is a diagnosis that specifically refers to small muscles with origin and insertion in the hand called interossei and lumbricals. There are seven interossei muscles, four on the dorsal or backside of the hand and three on the volar or palm side. There are four lumbricals, which originate from one of the long finger flexor tendons. These muscles course through the fingers to act as flexors of the MCP and extensors of the PIP. With this case these muscles become stiff and contracted causing imbalance in the forces that help us open and close our fingers. This results in stiffness, deformity and even dislocation of the fingers. In severe cases the resultant deformity is where the base of the finger (metacarpophalangeal or MCP joint) is flexed or bent while the middle finger joint (proximal interphalangeal or PIP joint) is extended or straight.

Intrinsic contractures can result from several causes. This can include trauma, spasticity, loss of blood supply, rheumatoid arthritis or even as a result of a medical procedure.

With a traumatic injury, such as a fracture, the primary problem is edema and immobilization, which can lead to adhesions and stiffening of the tendons and muscle bellies over the course of the recovery. Other injuries causing a fibrotic muscle can result from a loss of blood flow as with compartment syndrome or a vascular injury. Blood loss can also result from bandages or casts that are too tight, however this is less common today.

Spasticity is a condition where the neuron controlling the muscle is injured as with a stroke, traumatic brain injury or cerebral palsy. In this case there may be other contractures present as well.

Rheumatoid Arthritis is another common cause of intrinsic contracture. In these such cases the impaired muscle function can be the result of adhesions, muscle spasm from inflammation, or contraction due to decreased movement. Often in this population there are several factors including joint instability, and drifting of the fingers in the ulnar direction (towards the pinky finger).

Assessment and evaluation of these cases is based on the history of the injury as well as measurements for both active movements and passive movements of all the joints in the hand. This is important to distinguish between joint or muscle contracture. Often there will be testing of multi-joint motion to further evaluate the complicated balance of the many structures in the fingers and hand. There may also be radiographs to evaluate bony deformity, fracture, or joint instability. Testing for joint instability may also include laboratory testing for signs in the blood stream for rheumatic signals in cases with no obvious cause.

The most conservative and first line of management is nonsurgical. This will include proper care following trauma to reduce effects of swelling and immobilization. Quite often hand therapy protocols will be utilized to assist in reducing these effects and will usually include stretching and progressive splinting. With spastic patients, often optimizing their medications can improve on intrinsic function.

Surgeries are also common to treat intrinsic contractures, and there are many types that are chosen based on the specific case. Some of the many surgical options are to release tendons, release or partial release of the passive structures of the joints; or the procedures can be more complicated and include tendon repositioning, lengthening of the muscles, moving the location of the muscles, or even cutting off the nerve supply.

Dupuytren Disease is a flexion deformity of the proximal interphalangeal joints of the hand. It involves a gradual thickening of the tissue under the skin on the palm of the hand into a cord-like structure. The flexion deformity makes it very difficult to fully straighten the fingers. Though it typically affects the ring and pinky finger, all fingers can be affected. Surgical correction of the flexion contracture is a common procedure that can have varying results, short and long term.

The PIP joint can recontract following surgery either due to post-operative scarring, post-operative joint contracture, or a recurrent Dupuytren Disease. In order to better understand the recurrence rate of contracture, a group of 82 patients exhibiting contracture greater than 30 degrees were recruited to participate in a longitudinal study that followed their progress up periodically over a course of five years after surgery.

The surgical procedure involves excision of the fibrous bands and nodules and a ligament release if necessary, followed by z-plasty. Of the initial 82 patients, a total of 62 showed for follow-up. Of these 62, 49 per cent showed good improvement after surgery that was maintained five years, 32 per cent showed good initial improvement that worsened less than 20 degrees in three months then remained at this level for the five year follow up. Seven per cent of the patients showed immediate severe worsening greater than 20 degrees in the first three months then remained stable after this for the five year follow up. The final group of 12 per cent showed immediate worsening that progressed over the next five years. Four patterns of recontracture following surgical correction were thus identified.

In looking at patient demographics and surgical procedure, a few trends were identified. The progressive recontracture group constituting 12 per cent of the patients had higher disability scores, longer duration of disease and required longer surgical time. These characteristics can be used to help determine success rates of surgical correction for Dupuytren Disease.

Trigger finger occurs when a finger gets stuck in a flexed or bent position then releases into a straight position with a snap-like motion. Caused by the narrowing of the sheath that surrounds the tendon in the affected finger, the treatment often ends up being surgical. An open trigger release is considered the gold standard as it has a high success rate with little complications. It involves creating an incision to openly release the affected tendon.

Percutaneous trigger release is another option that is becoming increasingly more popular in recent years with proponents claiming that it is a much simpler procedure that often results in a less painful and faster recovery. It involves using a hypodermic needle or specially designed scalpel to release the affected tendon without an open incision. Percutaneous release can be done in an office setting, thus minimizing cost.

The research investigating effectiveness and complications associated with open A1 pulley release surgery treating trigger finger indicates success rates varying from a 60 per cent to 100 per cent rate of symptom resolution. Adverse effects with open trigger finger release may include infection, nerve injury, slow range of motion recovery or bowstringing. Research has looked at the rate of adverse effects with findings ranging from less than one per cent to five per cent. One study identified adverse effects occurring in 30 per cent of patients, but this particular study included swelling and pain as adverse effects.

Percutaneous A1 pulley release has also been the subject of research investigating effectiveness and rate of complication, though the research is not as strong as with A1 pulley release. Excluding the research of percutaneous release on thumbs, which is a procedure much more difficult to perform, and excluding cadaver studies, the success rates vary from 91 per cent 100 per cent. Complications of percutaneous release may include risk of incomplete release, superficial tendon abrasions, and neurovascular damage. Risk of these complications ranged from zero percent to 60 per cent, with the 60 per cent being primarily superficial tendon abrasions.

Comparing outcomes of open versus percutaneous A1 pulley release surgery shows that those undergoing percutaneous repair reported post-operative pain lasting only three days compared to almost six days for open repair. Return to work was four days for the percutaneous repair compared to seven and a half days for the open repair. According to these comparative studies, there was no difference between the two groups with regards to failure or complication rate.

Overall, percutaneous repair for trigger finger is promising in being both highly effective and economical, though strong research is lacking. As new techniques, such as ultrasound guided releases, and new equipment, such as specially designed scalpels, are introduced, randomized trials comparing these methods are warranted.

Mallet finger typically occurs with jamming your finger, like hitting a basketball with a straight finger, forcing it to bend when not expected.  If the tendon that attaches near the base of your fingernail is unable to withstand this sudden force, it avulses or rips out of the bone creating a droopy fingertip.  Unless this tendon is reattached somehow, you will never be able to straighten the tip of your finger again. Typically, this does not interfere with your ability to do things.  People seek treatment because they are more concerned about how their finger looks.  A small percentage of mallet finger injuries can progress to a swan neck deformity where the tip of your finger is stuck pointing down and the middle knuckle is hyperextended in the opposite direction. This does interfere with finger function and treatment is typically necessary.

Treatment options for mallet finger vary depending on the length of time after injury that the droopy finger shows up (its not always immediate).  Treatment is deemed successful if there is little or no extensor tendon lag, meaning you are able to straighten your finger fully.  

The most conservative treatment option is long term splinting.  This involves wearing a specially made finger brace that holds your finger in a neutral position in hopes that the tendon will reattach via scar tissue.  This can be anywhere from six to 14 weeks.  Most patients see acceptable success with splinting alone, their finger tip may be not quite straight but less noticeably bent, and do not seek further treatment.
 
Surgery is the next step if splinting does not work.  However, recent review of the literature suggests that despite many different applications of surgical procedures, results are relatively no better than splinting alone.  

Not everyone with carpal tunnel syndrome (CTS) experiences wrist or hand pain as a symptom. In fact, many people with CTS have numbness as the main problem. But that numbness can be so severe that it is interpreted by the brain as “pain”. In this study, researchers explored the possible factors linked with carpal tunnel syndrome pain.

The study involved 275 adults (ages 22 to 87) who were formally diagnosed with carpal tunnel syndrome (CTS) using history, nerve conduction studies, and clinical tests. Everyone was carefully assessed based on demographic factors such as tobacco use (smoking), body mass index (BMI), past medical history, and occupation. Age, hand dominance, use of tools that vibrate, and other health concerns were also noted.

Evidence from studies done so far support the understanding that carpal tunnel syndrome (CTS) usually presents with numbness, weakness, and atrophy of the muscles of the hand. There is no evidence that pain as a symptom is linked with (or will predict) positive results with nerve conduction studies.

There is sufficient evidence now to show that positive nerve conduction tests are a reliable diagnostic tool for CTS. Finding a symptom or other clinical test that might correlate with nerve conduction testing would be very helpful in predicting who might be experiencing CTS. This information could lead more quickly to an accurate diagnosis of CTS.

The researchers who conducted this study had two other questions (besides whether pain is a factor predicting carpal tunnel syndrome). They wanted to know if a specific questionnaire known as the Short Form-McGill pain questionnaire (SF-MPQ) would be a helpful tool for predicting CTS based on pain as a symptom. They also wanted to know if pain at the time of diagnosis was a factor in the later outcomes (results after one year).

Here are a few of the study findings:

What happens to patients who have a first carpal tunnel surgery that isn’t entirely successful and then need a second (revision) procedure? Do they get better after the second surgery? How long do the results last? These are questions asked by researchers from the Division of Plastic and Reconstructive Surgery (Washington University in St. Louis School of Medicine). They conducted a retrospective study (taking a look back) of their patients over a 10 year period of time.

The patients were all adults who had their first carpal tunnel surgery before 2001. Each one was evaluated and placed in one of three groups. The groups included patients who had carpal tunnel symptoms that continued after the first surgery (group one), recurrent (group two: symptoms went away after surgery but then came back), or group three: new symptoms developed.

Medical records for each patient were reviewed and analyzed looking at a variety of information and factors. For example, they paid attention to the surgeon’s notes during the revision procedure. Two areas of interest from the notes were: 1) how the revision procedure was done and 2) what the surgeon found at the time of the surgery.

Information about the patients (e.g., age, work status, use of pain medications, results of electrodiagnostic tests) was collected and compared among the three groups. Clinical measures of grip and pinch strength were also measured, reported, and compared. Pain level and quality of life were also assessed. The authors provided all of this information for each group in a table for anyone interested in the exact details.

The groups divided up as follows: 42 per cent of the patients were in group one (persistent symptoms), 20 per cent had recurrent symptoms, and 37 per cent were in the new symptom group. When trying to find some differences among the three groups, the only significant factors were diabetes and longer time between first and second surgeries. These two variables were specific to the group with recurrent symptoms. New symptoms occurred more often in people who had an unintended nerve injury during the first surgery.

Clinically, everyone in all three groups did get pain relief with the revision surgery. Pain is not a key symptom in primary (first) episodes of carpal tunnel syndrome. Instead, numbness seems to be more common. The presence of scar tissue around the median nerve and nearby soft tissue structures may explain the pain feature. Loss of blood supply to those areas because of scar tissue pressing and blocking the nerve may be part of the picture. The senior surgeon on this project recommends entering the carpal tunnel away from the nerve to reduce the risk of complications from the second surgery.

Grip and pinch strength improved for the persistent and new group (as symptoms resolved) but not for the recurrent group. Those patients who used pain medication were more likely to experience no change (or even pain that got worse) after the second surgery. Overall, the long-term results were positive for all groups. This is good news for patients facing a second surgery for carpal tunnel syndrome when the first procedure was less than successful.

When should antibiotics be given after a bite (tooth punctured the skin) from punching someone in the mouth? What are the exceptions to the guidelines on prophylactic (preventive) antibiotics? What are the potential complications for such bites? How often do they happen? Can they be prevented?

These are just some of the questions posed in this educational article for emergency department (and other) physicians treated acute fight bites. To help answer these questions, the case of a 26-year-old man with a laceration (cut) on the back of his hand is presented. He came to the emergency department a few hours after a bar fight. The cut was his only injury as X-rays showed there was no fracture or other lesions observed on the radiograph.

Now the emergency physician must decide on the best plan-of-care to manage this acute fight bite injury. All of the questions posed above must be considered. Even a small skin opening from such an injury can allow bacteria to enter the body. The joint can become infected to the point that finger amputation is the end-result.

Not all complications from infection following an acute fight bite of the hand are as drastic as finger amputation. But loss of motion, decreased grip strength, tenosynovitis, osteomyelitis, and septic arthritis occur in up to one-third of all cases. With up to 50 different types of bacteria in the human mouth, the concern for infection is very real.

Antibiotics are given prophylactically to prevent infection in almost all cases. The only two exceptions are: 1) patients with minimal superficial wounds (skin is not broken) and 2) those individuals who come for care 72 hours or more after the injury and have no signs of infection. The physician may also surgically debride the wound (open the hand down to the bone/joint and clean out any microbes present).

Without knowing what may happen in those early hours after the contact with someone’s tooth, a wide-spectrum antibiotic is given. This type of medication covers most of the common bacteria (Staphylococcus, Streptococcus, Corynebacterium, Eikenella corrodens). Anyone with clinical signs of infection (fever; red, swollen, tender or painful skin/joint) should receive additional medications including intravenous antibiotics.

The biggest concern is for patients who do not seek care immediately and wait up to a week before getting treatment. The risk of amputation from infection increases dramatically with longer delays between injury and care. Patients whose tetanus shots are out-of-date and who have not had hepatitis vaccinations (or for whom hepatitis B status is unknown) will require additional treatment.

Research in the area of acute fight bites is limited by a number of factors. First, many individuals in this situation do not seek medical care. They are often young men who do not have insurance or money to pay for treatment. Second, the only data really available is for those people who do seek medical treatment because of a problem. Information on how often these injuries occur without infection (with self-healing) is virtually unknown.

In summary, current concepts for acute fight bites based on available evidence are presented in this article. The authors propose future studies to help physicians recognize risk factors for serious consequences of fight bites (e.g., osteomyelitis, septic arthritis, amputation). A way to evaluate joint involvement would also be helpful in planning treatment.

Older adults (65 years old and older) seem to have a greater chance of developing carpal tunnel syndrome and with more severe symptoms. There is plenty of research evidence to support the benefits of surgery to release the soft tissues around the affected (median) nerve in the general adult population. But no one has really studied the results of surgical release in the older adult group.

This study looked at the surgical results for 78 adults (ages 65 to 93) who had carpal tunnel surgery. Each individual was carefully evaluated before surgery to make sure the diagnosis was correct. The most reliable test for carpal tunnel syndrome is a nerve conduction study. Only patients whose carpal tunnel syndrome was confirmed with nerve conduction studies were included. The surgery done was an endoscopic (minimally invasive) carpal tunnel release.

Patient charts were reviewed, data collected, and statistics analyzed. The kinds of information viewed included demographic data (e.g., age, gender, smoking status, health status, previous surgeries), clinical presentation (e.g., symptoms and physical findings), and patient satisfaction (e.g., very satisfied, satisfied, neutral, dissatisfied). Each patient filled out several surveys (questionnaires) answering questions about pain, numbness, sleep, and daily function.

Before surgery, two-thirds of the group reported constant numbness as the primary symptom. Numbness is the most typical symptom associated with carpal tunnel syndrome. True pain may be present in a small percentage of sufferers but in many cases, the numbness is so severe that it is interpreted as pain. Many of the patients were treated conservatively (splinting, steroid injection) before trying surgery. They were able to get some relief from their symptoms but not enough to avoid surgery.

Those patients who did report “pain” before surgery (70 of the 78) were able to get relief from their pain following the carpal tunnel release procedure. Almost everyone (94 per cent) who had numbness before surgery (especially noticeable at night) was no longer bothered by this symptom.

In terms of the level of satisfaction, three-fourths of the group was satisfied or very satisfied. About 10 per cent classified themselves in the middle (not satisfied and not dissatisfied) — more neutral. About 12 per cent indicated that they were dissatisfied. Overall, the procedure was considered a success in older adults and (older) age was not a factor linked with results.

The findings of this study are very encouraging for older adults affected by carpal tunnel syndrome. Surgery to release the soft tissues around the affected nerve can be done endoscopically (small incision). The advantages to the older adult of endoscopic carpal tunnel release for carpal tunnel syndrome are many: less pain after the surgery, regain function faster, improve grip and pinch strength more quickly than with open incision surgery.

The two disadvantages of endoscopic release are: 1) possibility of nicking the nerves and blood vessels in the carpal tunnel and 2) the potential for an incomplete release. Given the severity of symptoms in the older adult and the few complications reported in this study, surgeons may be more likely to recommend this procedure now for patients 65 and older.

The authors also make note of the fact that other studies have come to the opposite conclusion (i.e., finding that older age is a predictor of poor outcomes). However, the other studies often did not follow patients past 60 days. In this study, patients were re-evaluated six months after surgery. Some of the results seem to even out with more time. They suggest that studies of open incision versus closed (endoscopic) procedures for this age group should be done to compare results and over a longer period of time (up to two years).

If you are one of the many people who suffer from painful, degenerative arthritis of the hands, you may find the information in this article helpful. Two physicians from the Raleigh Hand Center (North Carolina) bring us up-to-date information on alternative treatment for this condition. Their focus is on recent evidence concerning the use of glucosamine and chondroitin sulfate in the treatment of hand osteoarthritis.

Most of today’s modern treatment of hand osteoarthritis centers around pain relievers and nonsteroidal antiinflammatory drugs (NSAIDs). But it’s clear that these medications have limited results and lots of potential unpleasant side effects. That often leads the sufferer looking for solutions elsewhere.

Glucosamine and chondroitin sulfate are two alternative products touted by many as “safe and effective” in the treatment of joint arthritis. But what’s the evidence for (or against) these supplements? Can anyone take them? Should everyone take them?

Glucosamine and chondroitin sulfate are natural substances normally found in the articular cartilage. Articular cartilage lines the joints and makes for smooth sliding and gliding action while protecting the joint. When the joint has enough of these components, water within the collagen provides resistance to compression. Chondroitin and glucosamine also help keep the cartilage slippery smooth and elastic.

No one knows for sure how taking glucosamine and chondroitin by mouth as oral supplements helps the joints. But studies do show that the products are absorbed in the gut and show up in the joints. These products are not prescription drugs so they are not regulated by the Food and Drug Administration (FDA). Anyone can purchase them over-the-counter as a nutraceutical (nutritional supplement).

Most of the studies done so far have been focused on hips and knees. Whether or not the same results can occur taking these supplements for hand arthritis remains unknown. Taking a look at the current studies published, the authors point out that results are often inconsistent, treatment effects are exaggerated, and the length of time to achieve a benefit is months (three to six at least).

A review of studies sponsored by the National Institutes of Health (NIH) highlight the following observations: results may depend on how severe the arthritic damage is to the joints and whether the person takes one or the other supplement (or both together). All studies report potential adverse effects, which are infrequent, mild and consist of diarrhea, upset stomach, and/or nausea.

Overall, it seems the use of glucosamine and chondroitin is safe with the potential to reduce painful symptoms and thus improve hand function. Long-term use (months to years) seems to be necessary (if the patient can afford it). All evidence points to a positive benefit in the use of these nutraceuticals for osteoarthritis. They are certainly safer than currently prescribed medications for pain control. However, studies specific to the hand are needed to confirm the findings reported for hip and knee osteoarthritis.

Getting a finger smashed in the car door (or other similar crush injuries) is a fairly common injury and can be very problematic. The best way to treat these injuries is a matter of opinion and conjecture. Deformity and loss of finger function can be very serious consequences of this injury.

Without proper treatment, more problems and complications can develop. Blood trapped under the nail bed known as a subungual hematoma can prevent normal healing. Other injuries that occur at the same time (e.g., fractures, fingertip amputation, nail matrix laceration) must be treated as well.

In this article, hand surgeons from Vanderbilt University Medical Center in Nashville, Tennessee address the complexities and controversies in the treatment of nail bed injuries. They focus primarily on nail plate injuries and what to do about them. The nail plate covers the nail matrix, which is divided into two matrices: germinal and sterile.

The nail matrix (also known as matrix unguis) is formed by these two layers of cells at the base of the fingernail (or toenail). This tissue consists of rapidly dividing skin cells that soon fill with the protein keratin. The matrix of finger nails consists of the most rapidly dividing skin cells in the body. The matrix is involved in growth and position of the nail plate.

A crush injury (however it is caused) compresses the nail matrix between the nail plate and the bone. Damage to the nail bed can lead to the formation of scar tissue and misalignment of matrices and nail plate. However, in the acute phase (immediately after the injury), the more immediate problem is the subungual hematoma.

A decision-formula for determining whether or not to remove the nail and repair the nail bed when there is a subungual hematoma has not been developed. Most surgeons depend on their own experience and expertise in making treatment decisions regarding these hematomas. Some surgeons make the decision based on how much of the nail bed (e.g., more than 25 to 50 per cent) is compromised by the hematoma.

Others suggest that removing a circular piece of the nail (a procedure called trephination) to take pressure off the nail bed is all that’s needed. Surgical removal of the nail and nail bed repair is advised by some experts in the case of bone fracture along with more than 50 per cent of the nail bed affected by a hematoma. The nail plate is removed, the nail bed is examined for deep cuts, the area is debrided, and any lacerations (cuts) are repaired with sutures.

Studies where only trephination was performed for subungual hematoma (with or without fracture) report equally good results as when surgery is done. This type of minimal approach (i.e., trephination) aids in preventing infection and post-injury nail abnormalities. One other consideration is the cost of each treatment. Trephination can be done at one-tenth the cost of the more involved surgery.

The lack of evidence-based (or even consensus of best practice) is due to the fact that studies are few and far between. Patients cannot be put in control groups (no treatment) or even randomized into different treatment groups for ethical reasons. The various possibilities (e.g., subungual hematoma with or without laceration, hematoma with or without fracture) also adds another dimension to the research design.

The authors point out the need for further research to provide evidence-based treatment protocols for nail bed crush injuries. All indications are (from currently available studies) that trephination works well even for subungual hematomas with fracture. More involved surgery may only be needed when the bone fracture is unstable or when the nail matrix is trapped or embedded in the nail matrix. Trephination is also a cost savings!

In this investigation, hand therapists from New Zealand study the effect of hand splinting at night (night extension orthoses) after surgery to release Dupuytren contracture. They asked the questions: are these splints helping? Does everyone need to be splinted after surgery? Is it possible the splints actually delay the return of finger motion, strength, and function?

Dupuytren contracture is a fairly common disorder of the fingers. In this condition, the fascia (connective tissue) of the hand is transformed into shortened cords. The patient first notices a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger.

More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. 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. Dupuytren’s contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

Without treatment, the contracture can become so severe that the affected finger(s) cannot be straightened. Eventually loss of motion leads to loss of hand function, including grip strength. Because our fingers are slightly bent when our hand is relaxed, many people put up with the contracture for a long time. Patients with this condition usually seek medical advice for cosmetic reasons or the loss of use of their hand. The condition usually isn’t painful, but the nodules can be sensitive to touch.

Surgery is often required when the contractures are severe. Removal of the palmar fascia (palmar fasciectomy) or release of the diseased cords is a common way to treat advanced Dupuytren contracture. Bracing and stretching of the fingers alone has not been proven to help in the long term progression of this condition. And now, according to the results of this study, night splinting after surgery may not be any more effective than not splinting.

The hand therapists randomly divided patients with Dupuytren contracture who had surgical release into two groups. The patients in one group received a custom-made night extension orthosis along with hand therapy. The second group just had hand therapy (no splint).

Both groups were treated for three months. Results were measured and compared for the two groups using finger extension, finger flexion, grip strength, and hand function as the final outcomes. Motion measurements were taken of each individual finger joint and for total combined finger motion (referred to as total active extension and composite flexion). Measurements were taken before surgery, at the first visit with the hand therapist after surgery, six weeks after surgery, and one last time three months after surgery.

They found out that splinting did not improve results following surgical release for this condition. The practice of routinely holding fingers in an extended position at night did not prevent loss of motion — at least not after three months’ time. Contracture recurrence is common (more than half of all patients experience this problem) and wearing a night splint doesn’t seem to help.

It’s possible that wearing the splints for a longer period of time may be helpful. Perhaps the use of night positioning during the formation of new scar tissue requires longer time to change tissue length. It is also possible that the type of splint makes a difference. A different design may provide more optimal joint motion. Since there are three joints in each finger, it is possible that the joints respond differently from one another in the type of splinting used in this study.

And since not all patients developed recurring contractures, there may be other factors at play here. Further research is needed to determine predictive factors (who is most likely to develop contractures again) that can be used to identify patients who should be splinted after surgery (and for how long).

Many studies have been done on patients who have had open incision carpal tunnel release surgery. The results have shown that symptoms improve right away but it can take months for patients to recover strength and function. And slightly more than half of all patients report a recurrence of hand pain, numbness, and tingling two years after surgery.

If that’s the case then what happens 10 years later? That is the subject of this study from Harvard Medical School in Boston, Massachusetts. One (fellowship-trained) hand surgeon who had performed 211 open carpal tunnel releases contacted his patients 11 to 17 years after the procedure. Using a series of self-assessment surveys, symptoms, function, and patient satisfaction were measured.

Of course, in that amount of time, some patients had died and others could not be located. There were also 27 patients who did not want to be part of the study. But they found 113 people who participated in the study. The patients included adults of all ages from under fifty years of age to sixty and older. There were adults who were actively employed and working, retirees, and pre-and postmenopausal women.

They discovered that three-fourths of the group no longer had any carpal tunnel problems. Most of the problematic symptoms went away in the first year after the surgery. Almost 90 per cent (88 per cent to be exact) were very satisfied or completely satisfied with the results.

For the people who still had some symptoms of carpal tunnel syndrome, the most common symptom was hand weakness (e.g., grip and pinch strength, difficulty opening jars or holding a book). Daytime pain, numbness, and tingling were also reported by a few people.

Patients who had the most difficulty years later were those who also had diabetes, rheumatoid arthritis, osteoarthritis, or polyneuropathy. All of these conditions are linked with carpal tunnel syndrome. It is likely that the problems encountered with functional tasks was really related more to these comorbidities (other conditions) than the after-effects of carpal tunnel surgery.

Only two of the 113 patients had to have a second (repeat) surgery. And only a few patients had pain at night or tenderness along the (healed) incision line. Analysis of all the data did not show any particular pain patterns associated with age. But function was worse in the middle age group (ages 50 to 59). The reason(s) for the connection between middle ages and worse function were unknown. It’s possible that the older age group had worse function but accept their limitations and/or have fewer physical demands placed on them so the loss of function is not as noticeable.

This is one of the few long-term studies of results following open carpal tunnel release. More carpal tunnel surgeries are done endoscopically now with minimally invasive techniques. So it is possible that this will be one-of-a-kind study. But the results clearly show that excellent early improvements are maintained over the long-term with equally excellent reports of patient satisfaction and improved quality of life.

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

In this study from Japan, surgeons use a particular surgical approach known as the Thompson procedure developed in 1978 by Dr. J. S. Thompson. Seven adults ranging in age from 25 to 71 had a chronic mallet finger that was not resolved with a previous surgery. They ended up with both the mallet position as well as a swan neck deformity.

With the mallet deformity, the end of the finger is bent and cannot be straightened voluntarily. The DIP joint can be straightened easily with help from the other hand. If the DIP joint gets stuck in a bent position and the proximal interphalangeal (PIP) joint (middle knuckle) extends, the finger may develop a deformity that is shaped like a swan’s neck. This is what is meant by a swan neck deformity.

The Thompson procedure uses a graft from the palmaris longus tendon. The graft tendon is split, spiraled under and over the middle bone of the finger, and then tied over the skin with an external button. The procedure reconstructs the spiral oblique retinacular ligament (SORL). This makes it possible for motion of both the distal and proximal interphalangeal joints (DIP and PIP) to work together creating coordinated flexion and extension of the finger.

The authors say that the biggest benefit of the Thompson procedure is that it corrects the extension lag of the tip of the finger (patient can’t fully extend the finger tip) while also addressing the swan neck deformity. And it does so without scarring the extensor tendon (which would restrict finger extension) or preventing flexion of the proximal interphalangeal (PIP) joint. The goal is to get smooth finger flexion and extension of both the DIP and the PIP joints.

In these seven cases, the Thompson procedure proved to be successful in restoring full, smooth active motion of the affected finger in six of the seven patients. Failure to fully extend the tip of the finger (called extensor lag) was resolved for six people. The seventh patient had improved motion but not a complete “cure.” The reasons for this included a seven year delay between injury and surgical repair and injury to the end of the torn tendon.

An important point from this study is the fact that patients who had previous (failed) surgeries all benefitted from the Thompson technique. The authors also commented that appropriate graft tension is essential to avoiding problems or complications after surgery.

They applied enough tension to the graft before buttoning it down so that the proximal interphalangeal (PIP) joint was in a neutral position with the distal interphalangeal (DIP) joint in five degrees of flexion. With one of the seven patients, the graft tension was adjusted with both joints in a neutral position. The result was a buttonhole deformity (obvious inward indentation or “dimple” along the side of the finger where the graft is tied).

In summary, the purpose of this study was to report on results of using the Thompson procedure in seven cases of chronic mallet finger deformity. The Thompson procedure is safe and effective. It is recommended in cases of severe extensor lag (30 degree or more) of the distal interphalangeal (DIP) joint and for patients who have had an unsuccessful prior surgery for mallet finger.

The authors also point out that patients with a rigid swan neck deformity, contracture of the DIP joint, or DIP joint deformity caused by bone fracture and joint dislocation are NOT good candidates for the Thompson procedure.

This article from the Hand Unit at the Bristol Royal Infirmary (United Kingdom) uses the case of a 42-year-old woman with an early swan neck deformity (SND) to review the evidence for current surgical procedures to correct the problem. Since there is no clear consensus on which one is the best, surgeons must use available studies to make the most appropriate decision for each patient.

What is a swan neck deformity? Sounds elegant but in fact, it can be very limiting. Basically, it is a crooked finger. The tip of the finger is bent at the distal interphalangeal (DIP) joint while the middle joint (proximal interphalangeal or PIP) is hyperextended. To see what this looks like, see our publication Swan Neck Deformity of the Finger. Human anatomy is not simple and that description does not begin to tell you how complex a “crooked finger” can be.

In the proximal interphalangeal (PIP) joint, (that is the middle joint between the main knuckle and the tip of the finger), the strongest ligament is the volar plate. This ligament connects the proximal phalanx (bone closest to the palm) to the middle phalanx on the palm side of the joint. The ligament tightens as the joint is straightened and keeps the PIP joint from bending back too far (hyperextending). Swan neck deformity can occur when the volar plate loosens from disease or injury.

Rheumatoid arthritis (RA) is the most common disease affecting the PIP joint. Chronic inflammation of the PIP joint puts a stretch on the volar plate. As the volar plate becomes weakened and stretched, the PIP joint becomes loose and begins to easily bend back into hyperextension. The extensor tendon gets out of balance, which allows the tip of the finger to get pulled downward into flexion. As the tip of the finger bends down and the PIP joint hyperextends, the swan neck deformity occurs.

Gripping objects and picking things up becomes very difficult when this deformity is present. Conservative care (often with splinting) is tried first but if it is unsuccessful (as in the case of this patient), then surgery may be needed. But that brings us back to the question of which surgical procedure works best to prevent a fixed-extension deformity?

There are four basic surgical choices: 1) Dermodesis, 2) Flexor Tendon Tenodesis, 3) Retinacular Ligament Reconstruction, and 4) Lateral Band Tenodesis/Translocation. Each technique has benefits and drawbacks. Some are easier to perform than others. Some seem to work better than others for certain individuals. Currently, there are no large studies comparing one method to another and most studies are very small in size.

The authors describe each one in detail outlining when it is most appropriate and how the technique has been modified by different surgeons over time. Some of the decisions about which method to use depend on how much joint stiffness is present in the proximal interphalangeal (PIP) joint. Earlier deformities may be more supple (not as stiff as the more advanced or severe cases) and have not been studied as much so evidence for outcomes remains limited.

Future research is needed to compare newer methods of volar ligament repair (attaching to the bone versus soft tissue fixation). Long-term follow-up to report on late failures is also needed. Patient satisfaction (not just surgeon satisfaction) should always be taken into account when measuring results. Appearance, range-of-motion, grip strength, and hand function are all important outcomes to the patients. Degree of deformity correction may be the surgeon’s primary measure of success.

Three hand surgeons from well-known centers for reconstructive hand surgery presented a lecture on complications following dislocations of the proximal interphalangeal (PIP) joint. The lecture was given at the 2013 annual meeting of the American Academy of Orthopaedic Surgeons. This article is a written record of that instructional lecture.

The proximal interphalangeal (PIP) joint is the middle joint of the finger. Dislocations of this joint can be very problematic. Every effort is made to prevent complications such as chronic swelling, stiffness, deformity, and loss of finger function. When the volar plate (restraining ligament) of the joint is damaged by the dislocation, redislocation can occur.

Damage to the cup-shaped joint along with injury to the ligaments can result in an unstable joint. The most successful treatment of these injuries involves limited immobilization with a finger splint and early motion of the finger. Keeping the gliding and sliding motion of the joint is very important — even more so than fixing the dislocation.

Conservative (nonoperative) care is advised when the dislocation is considered “stable”. Stability is determined by X-rays based on how much of the joint surface is damaged (fractured). The surgeon also looks at whether or not the joint partially or completely dislocates during motion.

The use of splinting during the early (acute) phase of healing is controversial. A balance is essential between maintaining the joint in a stable position while still allowing motion. These hand surgeons recommended the following: