Elbow Pain / Injury
There are several causes of elbow pain. The most common cause is tendon inflammation, or tendonitis from overuse and repetitive use. Tennis elbow and Golfer’s elbow are two forms of elbow tendonitis that cause pain on the outer and inner bony prominences of the elbow. Pain inside the elbow can be caused by arthritis. Elbow arthritis can be genetic or result after a fracture or injury. Overtime, the cartilage wears down and bone spurs develop. This causes elbow pain inside the joint with stiffness and loss of motion. Another cause of elbow pain is cubital tunnel syndrome. This involves a pinched nerve that causes sensitivity over the nerve on the inner side of the elbow and can lead to numbness and weakness in the hand. Elbow pain after a trauma should be seen urgently to rule out a fracture. Throwing athletes with chronic elbow pain or pain after a new injury should be seen by an elbow specialist to rule out a serious ligament injury.
Finger Stiffness or Locking
Stiff fingers can be caused from a variety of conditions. One of the most common causes is a “trigger finger” which is essentially a tendonitis of the flexor tendons. A trigger finger typically causes the affected finger to lock, or trigger, but can also cause pain and swelling. Stiff fingers with swollen joints can also occur with long standing “wear and tear” osteoarthritis or after an injury to the finger. Some medical condition such as rheumatoid arthritis can also lead to swelling and stiffness in the fingers. Dupuytren’s contracture is another condition that can lead to stiff fingers. It involves the development of abnormal cords of tissue in the palm of the hand which over time can cause the fingers to curl and lose their motion.
Hand Mass / Ganglion Cyst
The hand is a common part of the body to develop little bumps or masses. The most common are ganglion cysts that develop in the wrist or the fingers. They are usually small collections of fluid that only require treatment when they cause pain or loss of function. There are other masses of the hand that can affect the tendons of the fingers or even grow in the palm. Although the majority of these hand masses are benign, patients with a mass, bump, or cyst should seek medical attention from a hand surgeon for a definitive diagnosis.
Hand Numbness / Tingling
There are several conditions that affect the nerves of the upper extremity which can result in abnormal sensation in the hand and fingers. When a nerve is pinched or “compressed”, the nerve becomes irritated resulting in numbness and tingling of the hand. Some patients report burning pain that can awaken them from sleep or cramping when they use their hands. One of the most common is carpal tunnel syndrome which is caused by a pinched nerve at the wrist.
Another is cubital tunnel syndrome which is caused by a pinched nerve at the elbow. Numbness and tingling in the hand and upper extremity can be caused by a problem in the neck or even medical conditions such as diabetes. Thus, it is important to see your medical doctor or orthopaedic surgeon promptly for proper diagnosis and treatment.
Hand / Wrist Injury
A new injury, such as a fall onto an outstretched hand, typically results in immediate hand and wrist pain that is accompanied by swelling and bruising. In some cases, deformity of the wrist or fingers may also be present which can indicate a severe fracture or dislocation. Two of the most common fractures seen in the wrist are distal radius fractures and scaphoid fractures. Depending on the severity of the injury, immediate attention may be necessary. X-rays and sometimes CT scans are needed to rule out a "fracture." If a fracture is ruled out, there still may be a serious soft tissue injury that requires treatment by a hand surgeon. Ligament injuries can range from minor wrist sprains to complete ruptures that require surgery. Hand injuries involving a laceration should be seen urgently because of the risk of infection. Lacerations can also lead to tendon injuries that require surgery.
Hand / Wrist Pain
“Chronic” or long standing hand and wrist pain can be caused by a variety of conditions. One of the most common is arthritis. These patients usually have a slower onset of pain that can be accompanied by stiffness and swelling. Another cause of hand and wrist pain is tendonitis. This can affect the fingers as well as the wrist and is usually the result of overuse or repetitive activities (DeQuervain’s tenosynovitis, trigger fingers). Sometimes gout or even infections can occur in the hand and wrist. This can cause severe pain and swelling and requires urgent medical attention and sometimes surgery. Nerve compression such as carpal tunnel syndrome can also cause pain and burning in the palm and fingers.
Patients with severe pain or deformity from a new injury should be seen urgently to rule out a fracture or serious injury to a ligament or tendon in the wrist and hand.
Carpal Tunnel Syndrome
Carpal tunnel syndrome is a frequent cause of hand numbness, pain, and weakness. It usually presents over months to years, but can also come on suddenly from an injury or over-exertion from repetitive activities such as painting, weeding or typing. Driving a vehicle, reading a newspaper, or other repetitive activities commonly produce the symptoms. Several occupations which require repetitive use of the hands are quite prone to this condition, such as keyboarding, hair dressing, or the use of vibrating power tools. The pain is typically at night and may radiate from the hand all the way to the shoulder. Patients frequently are awaken with the pain in the early morning and find the hand is tingling or asleep. They may get relief by shaking the hands or dangling them over the side of the bed. The numbness involves the first 3 1/2 fingers including the thumb. Patients often complain about clumsiness in the hands or dropping things.
The physical cause of carpal tunnel syndrome is a pressure phenomenon that occurs on the palm side of the hand and wrist. There is tunnel, or tube, in the wrist which contains many flexor tendons and the “median nerve” which gives feeling to the fingers noted above. The problem begins with the liner of the tendons, which swell from overuse, causing pressure on the nerve. As the pressure rises in the confined tube, it begins to choke the nerve, bringing on the symptoms. It is also seen in several medical disorders such as diabetes and low thyroid function. Pregnancy can frequently cause carpal tunnel syndrome, but it usually improves after delivery. However, some patients may have the symptoms recur later in life.
Cubital Tunnel Syndrome
Similar to carpal tunnel syndrome, “cubital tunnel syndrome” is a result of abnormal compression of a nerve. The ulnar nerve is one of the main nerves going to the hand, providing sensation to the small finger (pinky) and half of the ring finger. It also innervates some of the most important muscles of the hand that are involved in fine motor skills. As the nerve travels down the arm towards the hand, it crosses the elbow on the inner side behind a part of the humerus bone called the medial epicondyle (“the funny bone”). There are ligaments that hold the nerve in its place on the inner side of the elbow, this forms the cubital tunnel. The cubital tunnel is a common spot for compression of the ulnar nerve. Sometimes the otherwise normal structures in this area place excessive pressure on the nerve and irritate it. Other times, blunt trauma to the elbow or repetitive motions can irritate the nerve. When the ulnar nerve becomes irritated, patients sense numbness and tingling in the small and ring fingers. This can happen during activities or even during sleep. Some patients experience elbow pain over the nerve as if they just “hit their funny bone”. In more severe cases, the little muscles of the hand are affected leading to clumsiness, weakness, and loss of dexterity. It is crucial to be evaluated when symptoms first arise because over time, if ignored, the nerve damage can become permanent.
De Quervain’s Tenosynovitis
De Quervain's tenosynovitis is a form of wrist tendonitis. It occurs over the thumb side of the wrist, where the radius bone is most prominent. It is typically the result of repetitive activity with certain wrist motions that cause the tendons to inflame. For example, mothers with toddlers are commonly affected because of the motion involved with repeatedly picking up a child. Over time, the tendon inflammation leads to tenderness over a short distance at this location. A specific test ("Finklestein") is diagnostic: the thumb is placed within a closed fist and the fist is moved toward the little finger side of the hand (as when swinging a hammer). In patients with De Quervain's tenosynovitis, the tension applied to the inflamed tendons can be intensely painful.
Dupuytren’s contracture is a progression condition affecting the hand. It starts as a thickening in the palm, which is usually painless, and can progress to thick fibrous cords that cause the finger to bend down into the palm. The disease is most commonly seen in older males of Northern European descent. It is also more common in smokers and patients with diabetes. If left untreated, hand function can significantly decrease if the contractures become severe.
While the exact cause of Dupuytren’s disease is unknown, many characteristics of the disease are well understood. The disease occurs when collagen, a connective tissue found throughout the body in skin, muscle, tendons and bones, begins to proliferate. Patients will usually first notice a lump, or nodule, in the palm. The nodule may be painful in its early stages, but this pain will almost always go away in 2 to 4 months. The collage can continue to proliferate into thick bands, called cords, which connect the nodules and begin to draw the fingers into the palm. The course of the disease in any given individual can be quite varied. In general, the younger the age of onset, the more aggressive the disease tends to be.
Like all joints of the body, the elbow is a mobile part of the skeletal system and is thus susceptible to arthritis. The ends of the bones are normally covered by smooth cartilage that allows fluid, pain free motion. Arthritis is a general term that is used to describe degeneration of a joint. In its most mild form, arthritis refers to inflammation with minimal loss of cartilage. In more advanced forms, full loss of cartilage can result in “bone-on-bone” arthritis with loss of motion and severe pain. Like other joints, elbow arthritis can result from trauma such as fractures (post-traumatic) or normal wear and tear (osteoarthritis). Some people are predisposed to inflammatory conditions, such as rheumatoid arthritis, that lead to generalized arthritis throughout the body including the elbow.
In the early stages of arthritis, patients may experience some discomfort but most are asymptomatic. In the later stages, pain becomes more common and patients will frequently notice that they can no longer fully straighten/extend their elbow. This is usually the result of bone spurs. Other patients will have locking and popping which can be the result of loose bodies in the elbow, or floating pieces of cartilage and bone. An orthopaedic surgeon can diagnose elbow arthritis on physical exam. X-rays are frequently used to grade the amount of cartilage loss as well as to look for bone spurs and loose bodies. In some cases, an MRI or CT scan may be needed.
Hand and Wrist Arthritis
Patients with wear-and-tear osteoarthritis of the hand and wrist often come in to the office with complaints of pain, swelling, and stiffness in these joints. The pain can range in severity from mild to severe, and can be described in many ways, including “burning,” “throbbing,” and “aching.” Arthritis in general can be the result of a traumatic injury, but more commonly is due to increased stresses and wear on the joints in the hand and wrist over time such that factors of older age and family history play a large role. Most often patients will note that their pain is made worse during activities and made better by rest. While other problems in the hand and wrist such as tendonitis may also show similar symptoms, arthritis is often the confirmed diagnosis by taking an X-ray in the location corresponding to the patient’s site of pain. The X-rays can show a decreased space between two bones at the joint. This indicates that the cartilage, or soft tissue covering of the joint, is wearing down. Interestingly, the amount of pain described by the patient does not always correlate to the amount of joint destruction seen on the plain X-rays. Therefore, it is very important to address the patient’s symptoms first and foremost. Over time and if left untreated, arthritis in the hand and wrist joints can lead to a progressive loss of motion with continued pain and even a gross deformity of the hand or wrist. This can lead to continued loss of function in the extremity and further loss of strength. The pain can ultimately affect the quality of the patient’s life, specifically affecting his or her ability to perform activities of daily living secondary to the discomfort.
The most common joints in the hand affected by wear and tear arthritis are the small joints at the tips of the fingers followed by the base of the thumb joint. Repetitive use and inherent hypermobility at these joints, respectively, helps contribute to these issues. This is more often seen in the female population. We are not sure exactly the reason for this, but research suggests that hormonal differences may play a part. Specifically, the small joints at the ends of the fingers called the distal interphalangeal (DIP) joints can be associated with cysts over the base of the nail on the back surface of the affected finger. These mucous cysts can not only become painful, but often times the skin is so thin at this location that skin breakdown with the possibility of an infection and subsequent difficulty with closure of this skin may become an issue. The growth of the nail itself may also be altered. With respect to the thumb, arthritis at the base can lead to changes in the adjacent joints closer to the finger. A “zig-zag” deformity may be noted, and if nonoperative management ultimately fails, both joints would likely need to be addressed in order to surgically treat the problem. At the wrist, arthritis is often secondary to a previous fracture or ligament injury that may have occurred even several years prior to the patient having symptoms. A not uncommon presentation is a patient who recalls “spraining” his wrist a long time ago. The pain from this initial injury got better but then a recent, sometimes innocent, traumatic event takes place prompting evaluation by an orthopaedic surgeon. X-rays obtained at the wrist would then confirm the diagnosis.
Hand Mass / Ganglion Cyst
There are various “lumps and bumps” that occur in the hand and wrist. The most common is a ganglion cyst. Depending on the location of the cyst, a different name is given to that cyst (“mucous cyst,” “dorsal ganglion cyst,” “volar ganglion cyst," and “volar retinacular ganglion cyst”). The common denominator in each of these is that each represents a “hernia” of sorts—a weak spot—arising from a deeper structure, typically a joint or tendon sheath. These cysts are balloon-like, not solid, and filled with fluid so they frequently increase and decrease in size over time. This virtually confirms the diagnosis. If a patient presents with a typical history and physical exam, very little is necessary for further evaluation. Sometimes an X-ray is taken if another diagnosis is suspected. For instance, arthritis in a joint can lead cyst formation, etc.
Mucous cysts arise from the end joint in the digits of the hand (closest to the fingertip or end of the thumb). They occur only on the nail side of the joint (opposite the palm surface). The involved joint typically has some degree of arthritis. The overlying skin can be so thin that the cyst may spontaneously drain a gelatinous fluid, especially if it’s traumatized accidentally or intentionally (don’t try this at home as serious consequences such as an infection can arise). Mucous cysts range in size from just a couple of millimeters to as much as a centimeter.
Dorsal Carpal Ganglions
Dorsal ganglion cysts historically called a “Bible bump,” arise from the central back of the wrist joint, opposite the palm. Despite lore to the contrary, they should not be slammed with a Bible as a form of self-treatment. These ganglions give patients aching discomfort, especially with extension of the wrist, as when pushing off a chair when arising or pushing open a swinging door. They can occasionally be so small and deep as to be very difficult or impossible to see. In these cases, an MRI may be helpful in making the diagnosis.
Volar Carpal Ganglions
Volar ganglion cysts arise on the palm side of the wrist, usually in the region of the radial artery pulse. They arise from the wrist joint on the thumb side. They can arise deep to, or even wrap around, the radial artery. Volar ganglion cysts also can be tender and cause discomfort with certain wrist motions.
Volar Retinacular Cysts
Volar retinacular ganglion cysts arise from the flexor tendon sheath of the digits. They can occur anywhere from the transverse creases of the palm to the end creases of the fingers and thumb. They typically are small, firm, and mobile. Many patients report that it feels almost as if there is a BB in the hand. They can be painful, or at least bothersome, when patients grip and grasp objects such as a steering wheel or briefcase.
The second most common fracture (broken bone) around the wrist is the scaphoid bone, also known as the navicular. This may be a difficult fracture to diagnosis and treat. If the wrist hurts following a fall and the X-rays are normal, a cast is applied with follow-up films at 2-3 weeks to see if a fracture is truly present. If suspicion is high, an MRI scan can make the diagnosis even sooner.
The shoulder is functionally a “ball and socket” joint. The socket is called the glenoid and the ball is the top part of the arm bone called the humerus. Like other joints in the body, the shoulder is susceptible to arthritis. As arthritis progresses, the normal smooth cartilage on the ends of the bones is worn down and the joint begins to degenerate. This causes inflammation and the formation of bone spurs. Patients with shoulder arthritis experience a gradual increase in pain, decreased range of motion, and progressive loss of function. Patients also report crackling noises in the worn joint.
The shoulder is functionally a “ball and socket” joint. The socket is called the glenoid and the ball is the top part of the arm bone called the humerus. Like other joints in the body, the shoulder is susceptible to arthritis. As arthritis progresses, the normal smooth cartilage on the ends of the bones is worn down and the joint begins to degenerate. This causes inflammation and the formation of bone spurs. Patients with shoulder arthritis experience a gradual increase in pain, decreased range of motion, and progressive loss of function. Patients also report and crackling noises in the worn joint.
Like other joints in the body, shoulder arthritis can result from trauma such as fractures which is known as post-traumatic arthritis. Other patients may develop shoulder arthritis because of normal wear and tear on the joint. This form of arthritis is called osteoarthritis and may be more common in people with a positive family history. Lastly, some patients are predisposed to inflammatory conditions, such as rheumatoid arthritis, that can lead to arthritis throughout the body including the shoulder.
Any cut deep enough to injure the finger can very likely cause the underlying tendon to also be cut. If the laceration is on the back of the hand, then the extensor tendon which allows the finger to straighten is at risk, and, conversely, if the injury is on the palm of the hand, then the flexor tendon controlling the ability of the finger to bend may also be cut. Most often, these injuries are first evaluated at an emergency department or at an urgent care facility. Once bleeding is controlled, the physician may be able to directly visualize the cut tendon ends through the wound in some cases, but other times a lack of motion at the finger is the only clue to a tendon laceration. The skin may be loosely closed and the finger splinted, with instructions to be evaluated by a surgeon.
Tennis Elbow (Lateral Epicondylitis) & Golfer’s Elbow (Medial Epicondylitis)
Tennis elbow or “lateral epicondylitis” is one of the most common causes of elbow pain and soreness. The condition is a tendonitis that frequently results from overuse or repetitive activities, although it can also occur after a traumatic injury. There is a group of muscles that originate from the outside of the elbow (lateral) and attach to the top of the wrist. These muscles help stabilize and extend the wrist during normal hand function. Tendons anchor muscles to bones and during certain repetitive motions, these tendons are overly stressed. With time, this can degenerate and weaken the tendons causing tendon inflammation, or tendonitis. This ultimately results in elbow pain. Lateral epicondylitis can be associated with tennis but it is certainly not limited to athletic activity. The pain is frequently experienced during grasping/gripping or lifting things away from the body. It is one of the most common diagnoses seen by orthopaedic surgeons in adult patients.
Golfer’s elbow or “medial epicondylitis” is also a very common cause of elbow pain. Similar to tennis elbow, medial epicondylitis is a tendonitis but it involves the tendons that are anchored on the inner part of the elbow (medial). These tendons attach to muscles that are responsible for flexing the wrist and fingers. During repetitive use, the tendons also can become inflamed which ultimately leads to elbow pain on the inner side of the elbow. Similar to tennis elbow, golfer’s elbow can occur after an array of physical activities and is certainly not limited to athletes.
Trigger finger, officially called "stenosing flexor tenosynovitis", is a form of tendonitis. It results in a catching ("triggering") of the mid-joint of the fingers (or end joint of the thumb) with attempted motion of the affected digit. Swelling of the flexor tendon lining occurs, for various reasons, at the entrance to the tendon sheath (just beyond the transverse palm creases). The difficulty, or even inability, of the flexor tendon to move in and out of the tendon sheath with digital motion results in the sensation of locking, or "triggering". The locking is typically worse in the morning and may lessen as the day progresses. Many patients develop finger swelling as well as pain in the palm at the base of the finger. The mechanical locking of the finger in combination with the pain can make this quite a disabling condition.
Broken bones and cracks seen around the wrist are called wrist fractures. The most common type involve the distal radius (the far end of the forearm). This occurs most frequently during a fall on the hand and produces pain, swelling and in some cases marked deformity. It is seen in all age groups, but most commonly in older patients when the bones are brittle from osteoporosis. Active, healthy children can also get these fractures because of the soft nature of the bones near the growth centers of the wrist. Fractures that go through the skin are called open fractures. These require immediate attention and antibiotics to lessen the chance of an infection. The diagnosis of a fracture is usually made with a simple X-ray. In some cases it may not be seen right away and may be picked up on an MRI. Your physician may in fact order a CT scan to better define the fracture through a 3-D image. This is not always necessary and is used more in pre-surgical planning of difficult fractures.
Cubital Tunnel Syndrome
It is extremely important to be evaluated by a hand surgeon when patients experience hand numbness and tingling. Cubital tunnel syndrome can range in severity from occasional small finger (pinky) numbness to severe loss of hand function. A hand surgeon can diagnose cubital tunnel syndrome on physical exam but will typically order a nerve study to confirm the diagnosis. The elbow is the most common site for ulnar nerve compression but it can also be compressed in the neck or even at the level of the wrist (called “Guyon’s canal"). Less severe cases of cubital tunnel syndrome typically respond to a period of night splinting. Another common treatment is a soft elbow pad that protects the nerve from being bumped during daily activities. This allows the nerve inflammation to settle down and the symptoms resolve. If symptoms persist, or in more severe cases involving the motor function of the hand, surgery is necessary to take the pressure off of the nerve. This is called a cubital tunnel release. In some cases, the hand surgeon may move the nerve to the front of the elbow into a more secure location. This is called an “anterior transposition.” The surgery can be done under regional anesthesia in otherwise healthy patients and it is typically done as an outpatient. After the pressure is taken off of the nerve, the symptoms improve. Once again, it is crucial to be evaluated when symptoms first arise because over time, if ignored, the nerve damage can become permanent.
De Quervain’s Tenosynovitis
The treatment of De Quervain’s tenosynovitis almost always begins with conservative management. Many patients respond to a period of splinting in a wrist brace or even a cast. For patients with more intense pain or who fail splinting, a steroid (cortisone) shot can be curative. Sometimes stretching or even formal hand therapy can be helpful. For those patients with persistent or recurrent symptoms, surgical intervention is very predictably successful. The surgery is typically done under local anesthesia as an outpatient. It requires a small incision on the thumb side of the wrist. Most patients have a swift recovery. Some patients develop stiffness or scar sensitivity that improves with time.
Elbow arthroscopy is a minimally invasive approach to elbow surgery. Like arthroscopy in other joints, the surgeon uses small incisions to place a camera and other small instruments inside the joint. Elbow arthroscopy disrupts less soft tissues than traditional open surgery and can lead to less stiffness and a faster recovery.
For patients with arthritis, elbow arthroscopy can be used to remove loose bodies, shave down bone spurs, and clean up the liner of the joint. This frequently helps patients with pain and can allow them to regain motion. Arthroscopic treatment for elbow arthritis can also potentially eliminate or postpone the need for an elbow replacement.
For patients with tennis elbow or “lateral epicondylitis," elbow arthroscopy is a minimally invasive alternative to the open technique. Through two small incisions large enough to pass instruments the size of a pencil, the diseased tendon is “debrided” or cleaned out. The recovery is often accelerated allowing a faster return to work and sporting activities. Elbow arthroscopy is also frequently used to treat elbow problems in young athletes. Teenage athletes can develop small cartilage defects known as “OCDs” or “osteochondral defects." These defects may persist despite conservative measures. In these cases, elbow arthroscopy can be used to evaluate the joint and potentially drill the defect to stimulate new cartilage growth. This is known as a “microfracture."
In the early stages of arthritis, most patients can alleviate their symptoms with rest and by modifying their activities. Over-the-counter anti-inflammatory medication can also be very helpful if not contra-indicated by other medical conditions. An orthopaedic surgeon may also recommend a steroid injection. Steroids are very potent anti-inflammatories that are injected directly into the elbow joint. Decreasing the inflammation can alleviate pain and help maintain a functional range of motion. Steroid injections can serve an important role in the treatment of elbow arthritis but cannot be done more than a few times a year. If conservative treatment fails, surgery may be beneficial to patients who continue to have symptoms related to elbow arthritis.
Elbow arthroscopy is a minimally invasive approach to elbow surgery. Like arthroscopy in other joints, the surgeon uses small incisions to place a camera and other small instruments inside the joint. Elbow arthroscopy can be used to remove loose bodies, shave down bone spurs, and clean up the liner of the joint. This frequently helps patients with pain and can allow them to regain some motion. Elbow arthroscopy disrupts less soft tissues than traditional open surgery and can lead to less stiffness and a faster recovery. Arthroscopic treatment for elbow arthritis can also potentially eliminate or postpone the need for an elbow replacement.
When all else fails, elbow replacement may be necessary. This is used as a last resort and involves surgically removing the normal joint and replacing it with an artificial one. The surgery is typically reserved for older patients who have lower demands. It is not meant for athletes or heavy laborers because the artificial joint can be worn out. Nevertheless, it can be an excellent solution for the right patient that can lead to pain-free functional use.
Hand Mass / Ganglion Cyst
All hand masses should be evaluated to confirm the diagnosis. Most ganglion cysts are not painful and require no specific treatment other than watchful waiting. Over time these masses can either resolve or become minimally symptomatic requiring no specific orthopaedic intervention. Sometimes a mass might be aspirated with a needle, though the relief is usually short-term (Don’t try this at home!). If these masses persist beyond several months, if they are sufficiently bothersome to the patient, if there is a question about the diagnosis, or if other special circumstances apply, then surgical removal is appropriate. Operative treatment resolves the problem with a high degree of predictability. The surgery is typically done as an outpatient with local or regional anesthesia.
Hand & Wrist Arthritis
We first treat patients with symptomatic hand and wrist pain from arthritis with conservative management. This may include oral anti-inflammatory medications such as NSAIDs, splinting of the affected joint(s), as well as injections of steroid medication directly into the joint space (i.e., the site of the problem). It is important to note that these medications and injections are treating the symptoms of arthritis (ie, the inflammatory process) and NOT reversing the arthritic process itself. Sometimes occupational therapy with a hand therapist can be very helpful to show patients how to use their hands and wrists in ways that will decrease the stresses on their painful arthritic joints, thus protecting them.
The painful cysts that can develop at the ends of the finger joints caused by underlying arthritis can be surgically excised when conservative measures fail. This surgery often includes shaving down the bone spur at the arthritic joint. While this does not reverse the arthritis itself, the cyst often does not recur. When the arthritis in the small finger joints becomes painful enough and all other treatment options have been exhausted, the best surgical choice to relieve the patient of pain is fusion of the joints. Since often these painful joints have limited motion to start with, then a very good option is to eliminate the motion entirely by placing screws or wires across the joint in order to fuse it. Reliable relief of pain at these fused joints has been documented in our orthopaedic literature.
With respect to treating thumb arthritis that has not responded to nonoperative measures, there are several surgical options. These are only used as a last resort because the different operations available are not without risk and should not be considered without a thorough discussion between the patient and the surgeon. Although each type of surgery for arthritis of the thumb joint has subtle differences, the common principle is that some portion of the arthritic joint is removed and excised. Removing all or part of the arthritic joint leaves the joint potentially both unstable and weak. Therefore, in the space previously occupied by the arthritis, the bone can be "replaced" with a spacer that may be a biocompatible implant, or, more likely, the patient's own tissue. This is called a carpo-metacarpal joint arthroplasty or "CMC arthroplasty." Often times a tendon taken from the patients arm can be re-routed around the thumb joint to both stabilize it and act as the new joint surface. Reliably, the pain the patient had from the arthritis is improved within the first few weeks after the operation in most patients. However, the intricate nature of the joint and surgery to treat it requires immobilization for several weeks in a splint and/or a cast. This is followed by a course of hand therapy which focuses on motion and strengthening over the next several months. Most patients need to get comfortable with their thumb after the operation. This process may take up to 4 to 6 months after surgery, but sometimes it can be even longer.
Finally, failed conservative treatment of wrist arthritis leads to surgical treatment options. Unlike primary hip and knee arthritis, which when treated surgically can truly involve the replacement of the arthritic joint surface with metal and plastic, the wrist joint sees a different load and thus replacement is often not the best option. While total wrist replacements do exist, they are usually reserved for the elderly, low-demand, rheumatoid arthritis patient and not someone with wear and tear degenerative arthritis who wants to maintain an active lifestyle. Like in the finger joints, fusion becomes a very reliable option to patients with intractable pain and a decreased quality of life secondary to their wrist arthritis. The wrist can be either partially or completely fused depending on which part of the wrist is affected by the disease. This can be done with the use of plates, screws, and pins, or some combination thereof. Fusion will eliminate about half or even all of the flexion and extension of the wrist depending on whether it is a partial or a complete fusion. Surgery for wrist fusion can require up to 6 to 8 weeks of immobilization, followed by hand therapy focused on regaining strength. Patients who undergo this procedure are often very happy with the outcome because although they lose the little remaining motion they had prior to surgery, the pain relief they get by the joint being fused allows them to use the extremity in a functional way with improved strength.
Lateral & Medial Epicondylitis (Tennis / Golfers Elbow)
The treatment for both lateral and medial epicondylitis typically begins with conservative measures. First and foremost is identifying the motions that aggravate the condition and may have caused it. This is called activity modification. Whether it's a sport, household chore, or work related activity, the idea is to avoid elbow and wrist motions that continue to inflame the tendons. If rest fails to alleviate the symptoms, physical therapy may be prescribed. Through a series of stretching, strengthening, and other modalities such as ultrasound, a course of therapy can help cure the tendonitis and teach the patient how to prevent it from recurring. The treating physician may also recommend over the counter anti-inflammatory medication unless contra-indicated by other medical problems.
Another form of nonsurgical treatment for tennis elbow and golfer's elbow is steroid injections. The steroid is injected into the affected area and acts as a very potent anti-inflammatory. This can help relieve the pain and swelling. It also helps patients tolerate the physical therapy. These conservative measures are very effective in treating the majority of patients. Surgery is only considered if the pain has lasted for months and if the patient has failed other treatments. The surgery is typically done as an outpatient. It involves removing the damaged, degenerated part of the tendon which is the source of the pain. This can be done by either an open surgical technique or less invasive techniques such as elbow arthroscopy and radiofrequency microtenotomy. Proper rehabilitation is crucial to the recovery process. The initial phases of the recovery involve regaining arm motion which is then followed by a strengthening program. Physical therapy is often part of the rehabilitation. Return to prior activities can take 3 to 6 months.
Open / Endoscopic Carpal Tunnel Release
Nonoperative treatment of carpal tunnel syndrome begins with using a wrist splint at night. Over-the counter anti-inflammatory medications and vitamin B6 sometimes help. If endocrine disorders are present, they should be addressed by your primary medical doctor. A cortisone injection into the tunnel can give temporary relief, but it is not curative. Hand therapy has been used with limited success and is not thought to be cost effective. Acupuncture and laser light therapy may make it feel better, but do not remove the damaging pressure on the nerve. Delay in treatment may lead to permanent nerve damage.
Surgery is indicated for those who have failed conservative treatment. It is usually done as an out-patient under local anesthesia with sedation and has minimal risks. Excellent results can be achieved by cutting the side wall of the tube which releases the pressure on the nerve. This can be done through a small open incision in the palm or "endoscopically," which is a minimally invasive technique using a fiber optic camera through a 1/2 inch incision at the wrist (also known as an "Endoscopic Carpal Tunnel Release"). The results seem to be the same after 6 months, but the return to function and work may be quicker with the endoscopic technique. Surgical failure with either technique is highest in those who already have permanent nerve damage. After successful carpal tunnel release, recurrence rates are noted to be 3-5% regardless of the technique, and may be revised by only the open technique.
If you suspect that you might have carpal tunnel syndrome, you should have it assessed by an orthopaedic surgeon. A clinical exam and nerve testing are usually required to confirm the disease. Consult your physician or hand surgeon for appropriate evaluation and treatment. The Bone & Joint Center does approximately 1,000 carpal tunnel releases a year.
The scaphoid bone is very slow to heal because of its poor blood supply and may go on to a non-union even if it is appropriately treated for up to 16 weeks. Displaced fractures require early internal screw fixation to correct the alignment. Non-unions often require open reduction internal fixation (surgery) with a screw and the transfer of a vascularized piece of bone from the nearby radius to promote healing. This in fact requires lifting a piece of living bone with the blood vessels still attached to it and rotating it around the "vascular stalk" which keeps the transported bone alive in its new place in the scaphoid. The graft helps promote healing.
Assessment of the healing can be done with an X-ray or even more accurately with a CT Scan. Some cases of non-displaced scaphoid fractures have a very poor prognosis. These are cases where the break is at the near end of the bone where the blood supply is the poorest. Early fixation with a screw place through a minimal incision and over a guide wire may be indicated to prevent a more difficult fix down the line.
Scaphoid fractures, if left untreated usually go on to a non-union and develop severe wrist arthritis which is usually painful down the line. Once this occurs, fixing the fracture is no longer appropriate. The arthritis can be treated with removal of the damaged scaphoid and partial fusion of the surrounding bones. Or, in some cases with severe arthritis, complete fusion may be required to eliminate the pain.
Once again, your hand surgeon will advise you through this decision making process. Given your specific condition and findings we will advise you of the best course of action.
Shoulder Arthritis & Total Shoulder Replacement
An orthopaedic surgeon can diagnose shoulder arthritis on physical exam. X-rays are very helpful in assessing the amount of joint destruction and the formation of bone spurs. In the early stages of treatment, anti-inflammatories can be very helpful, if not contra-indicated by other medical conditions. As the arthritis progresses, the physician may also recommend a steroid injection. Steroids are very potent anti-inflammatories that are injected directly into the shoulder. Decreasing the inflammation can alleviate pain and help maintain a functional range of motion. Steroid injections can serve an important role in the treatment of shoulder arthritis and can potentially postpone the necessity of joint replacement surgery. However, they should only be done a few times a year.
When nonoperative treatment fails, shoulder replacement surgery is considered. There are different types of shoulder replacements depending on the amount of arthritis and the age of the patient. In younger, higher demand patients, shoulder resurfacing surgery may be an option. This is a less invasive approach that requires less surgical resection of bone. After surgery, patients have few restrictions in terms of work and sports. In more advanced cases of shoulder arthritis, a full shoulder replacement may be indicated with an artificial ball and socket. This can provide excellent pain relief and allow patients to return to most prior activities. The rehabilitation typically requires the assistance of a physical therapist to regain range of motion. Patient function continues to improve 3 to 6 months after surgery.
A reverse total shoulder replacement is an option for patients who suffer from shoulder arthritis and a concomitant rotator cuff tear. These patients typically have pain but have also lost significant function because of the rotator cuff tear. The “reverse” artificial shoulder changes the anatomical relationship between the ball and socket. It is a surgery that can help patients by effectively treating their pain as well as restoring their arm function. However, patients with a reverse total shoulder replacement have specific limitations after surgery so it is reserved for older patients with lower demands.
The Treatment of Dupuytren’s Contracture
Although there are several ways to treat the contractures, there is no known way to prevent or slow their development. Stretching and splinting has not been shown to be effective in preventing contracture of the hand due to Dupuytren's disease.
Previously, the only effective way to treat the disease was surgical removal of the excess collagen. This requires the surgeon to make cuts in the skin over the cords and nodules and to dissect them away from the surrounding nerves, blood vessels, and tendons. Following surgery, most patients attend hand therapy to soften and stretch out the surgical scars and to regain their hand motion. Despite all of this, the disease is often progressive, and can reappear in the original location (recurrence of the disease) or elsewhere in the hand (extension of the disease).
A newer procedure, needle aponeurotomy, uses the tip of a needle to make small cuts in the cords to weaken them. The contracted finger is then straightened, tearing the weakened cord. This procedure has the advantage of not requiring long complex incisions and faster recovery time. Because the disease is progressive, however, the contractures can still recur following needle aponeurotomy.
The newest treatment option for Dupuytren's disease is an injectable collagenase, approved by the FDA in 2010. Medication which actually dissolves a section of the Dupuytren's cord is injected into hand in the office or outpatient surgery center. Over the next 24 hours, the medication breaks down the cord and weakens it. The following day, the patient returns and the finger is straightened, rupturing the weakened cord. The finger is then splinted in extension and motion is started in a few days. Patients continue to wear a splint at night for several months to keep the finger straight. While this new treatment is very promising, there is a chance of complications and recurrence of the contracture, as there is with all procedures to treat Dupuytren's disease.
Trigger Finger Release
The treatment of trigger fingers begins with conservative measures whenever possible. If the finger triggers or "catches" only occasionally with no pain, watchful waiting may be considered. As the tendonitis settles down, the symptoms may resolve with time. Unfortunately, many patients develop more consistent triggering that is painful. For over half of these patients, one steroid (cortisone) injection can be curative. If the symptoms return, particularly in non-diabetics, a second injection can be tried. For patients who fail conservative treatment, surgery may be necessary. However, it is typically done as an outpatient under local anesthesia with sedation. It does require a small incision in the palm but the recovery is typically fast. Some patients may persist to have stiffness and sensitivity after surgery that may benefit from hand therapy.
Like the knee, shoulder, and hip, there are many wrist problems that can be evaluated and treated with arthroscopy. The difference is the size. A smaller arthroscope (usually 2.5 mm instead of 4 mm) and smaller instruments are used. Two or three small incisions, called portals, are made on the back of the wrist to introduce the arthroscope and the instruments into the wrist joint.
A wrist arthroscope allows the hand surgeon to visualize the ligaments and cartilage within the wrist joint. Often, there are partial tears with remnants of the torn tissue getting caught or pinching in the joint. This is especially true with the tissue on the back of the wrist, which can get pinched with activities such as pushups or yoga. Removing this inflamed tissue arthroscopically can eliminate the pain in the wrist and allow the patient to return to many activities.
Another common wrist injury is a tear in the Triangular Fibro-Cartilage Complex (TFCC) which is the ligament that holds the two forearm bones together at the wrist. This condition leads to pain on the back of the wrist on the ulnar (small finger) side of the wrist. The TFCC can be debrided or repaired arthroscopically much better than it can be repaired using a regular incision.
As previously discussed, the most common type of wrist fracture involves the end or "distal" part of the radius bone. The treatment of distal radius fractures depends on the age of the patient and the amount of fracture deformity (also known as displacement). Non-displaced fractures are treated with casting but should be watched every few weeks with an X-ray to make certain they do not displace. Those fractures which are displaced usually require a reduction (manually "setting" of the fracture) before the cast is applied. This can be done in the office or the operating room depending on several factors. Displaced fractures with a shift or separation into the joint surface or shortening frequently require a surgical incision. This is done to correct the displacement and to apply pins or plates and screws into the bone to hold the alignment until healing occurs. This is usually done to lessen the risk developing arthritis with its associated long term pain and stiffness. Surgery is not without additional risks and will be advised only if necessary by your surgeon.
Nutrition & Exercise
Proper nutrition and exercise; approved by your physician, can be vital factors in hand and upper extremity injury prevention.
Occupational therapy, "OT," is similar to physical therapy by definition, but different in concept. Both types of rehabilitation help people regain the skills and movement necessary for functioning independently, but the majority of occupational therapists treat hand-and-upper-extremity injuries. This therapy can be a vital tool for you to prevent injuries to the hand and upper extremity.
For more information on Hand and Upper Extremity Prevention, contact our office or make sure to check out at our magazine, “Bone and Joint Review,” for articles relating to this topic. Additionally, there is valuable information available in regards to hand safety on the American Society for Surgery of the Hand’s website.
Why choose The Bone & Joint Center?
Our shoulder surgeons at The Bone & Joint Center have completed additional training specifically in the shoulder. With this advanced training, our shoulder surgeons have the experience and expertise to assess, diagnose, and treat your shoulder injury or condition individually to your needs.
To consult with a shoulder surgeon at The Bone & Joint Center, please request an appointment online or call (518) 489-2666.
Orthopaedic Urgent Care
HURT TODAY? TREATED TODAY!
Injuries occur when you least expect them. That’s why our doctors are proud to offer same-day orthopaedic care and treatments at our Albany office for those who suffer from acute injuries and conditions. At our Orthopaedic Urgent Care, we have extended clinic hours staffed with highly skilled medical professionals who will put your needs first.