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 TENDONITIS
The treatment of De Qeurvain’s tendonitis 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 post-pone 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 post-pone 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 decreases 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 non-operative 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 – 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 – 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 three to six months.
OPEN / ENDOSCOPIC CARPAL TUNNEL RELEASE
Non-operative 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 non-operative 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 three to six 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.