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common injuries - wrist & hand

Scaphoid Fracture

Description
The scaphoid is a small, 'bean shaped' bone in the thumb side of the wrist. It is frequently broken, and is often a serious problem.
Common Causes
Usually a fall on the outstretched arm.
Symptoms
Pain in the wrist, usually at the base of the thumb ('snuff-box'). Pain is worsened with gripping or squeezing.
Physical Findings
Tenderness directly over the broken scaphoid. There is often swelling in the wrist, and pain with range of motion.
Workup
X-rays will usually show a fracture, especially if the pieces of the bone have moved (displaced fracture). Rarely, additional imaging studies such as a Bone Scan or CT scan is needed.
Bone Scan(hide)

A bone scan is a study that looks at relative blood flow to parts of the body. A small amount of a patient's blood is withdrawn, and a short acting radioactive isotope is attached to the red blood cells. The 'radioactive' blood is then reinjected back into the body. The patient lays on a table, which is really a big geiger counter. Wherever the blood flows in the body will show up on the scan. It just so happens that the skeleton has a tremendous amount of blood flow through it, compared to the rest of the body. Therefore, a bone scan will provide a picture of blood flow through the skeleton. Certain conditions cause a relative increase in local blood flow, such as a fracture, infection, or tumor. A bone scan is very sensitive at detecting this. By the way, the radioactive isotope is very weak, short-acting, and not very dangerous. It is expensive, however.

CT Scans(hide)

CT scans (CAT scans, Computed Axial Tomography) are another form of specialized x-rays. They look a lot like a MR scan, and you also have to lie still on a table with the CT scanner over you. The CT scan will also provide detailed pictures of slices of your body, but it works best on bones, and works relatively poorly for soft tissues. The CT scan is useful to look for fractures or other bony injuries, when the plain x-ray is difficult to interpret.

Non-Operative Treatment
For non-displaced fractures (when the broken pieces of bone are in the right position), cast immobilization will usually work.
Surgical Treatment
All displaced fractures, and certain non-displaced fractures need to be fixed, usually with a small screw or pin.
Comments
The scaphoid has a relatively poor blood supply, and these troublesome fractures often heal very slowly, or not at all. If the broken bone does not heal, or heals in a bad position, serious long-term damage to the wrist results, including post-traumatic arthritis.

Carpal Tunnel Syndrome

Description
Carpal Tunnel Syndrome (CTS) is due to pressure on a specific nerve, the Median nerve, as it enters the wrist and palm from the forearm. The nerve and the tendons to the fingers all pass through a tunnel of fixed size (the carpal tunnel). If there is a significant increase in pressure inside the tunnel, then the nerve may become compressed and injured.
Common Causes
Repetitive hand activities, unusual prolonged wrist flexion or extension, frequent gripping or squeezing, exposure to vibratory or pneumatic equipment. Certain medical conditions, including pregnancy, thyroid disease, and diabetes have an increased incidence of this injury.
Symptoms
Numbness, tingling, or pain in the hand; generally involving the thumb, index, and middle finger. May radiate up the arm to the shoulder. Waking at night with the hand asleep, or 'shaking out' the hand is common. Dropping of objects and weakness in advanced cases.
Physical Findings
Positive provocative testing on physical examination. Atrophy of the thumb muscles, and sensory loss in advanced cases.
Workup
The diagnosis is primarily based on history and physical examination. Electrodiagnostic studies are occasionally indicated, especially in confusing or difficult cases.
Electrodiagnostic Studies(hide)

Key words: electrodiagnostic, NCV, EMG, nerve conduction, electromyography

Electrodiagnostic studies refer to two different tests that examine the health of muscles and nerves.

Nerve Conduction Velocities (NCV) test how well a nerve can conduct an electrical signal, much like a wire conducts electricity. By giving a nerve a small stimulation, and then measuring how long it takes to conduct that signal to another point, the physician can calculate the speed of nerve conduction. If a nerve is injured or compressed, the speed of conduction may be impaired. NCVs can also help localize where a nerve is injured or compressed.

Electromyography (EMG) involves testing the health of individual muscles. By giving a specific muscle a small electrical stimulation, the physician can measure how the muscle behaves electrically. This is useful to detect any damage to a muscle, or to determine if there is long-term nerve damage to that muscle.

Both of these types of studies are generally performed by a specialist, either a Neurologist or Physiatrist. There is occasionally some discomfort with these tests, although they are not excruciating! As with any test, there are several limitations with these studies; they often give helpful information, but need to be interpreted only with a good clinical examination.

Non-Operative Treatment
Night-time wrist splints, anti-inflammatory medication, and avoidance or modification of the aggravating activity is helpful in early cases. A trial of a single corticosteroid injection is of value for both diagnosis and treatment.
Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
Carpal Tunnel Release. This can be done either as an open procedure, or as an Endoscopic Carpal Tunnel Release, with only a tiny incision under local anesthesia.
Comments

The goal of all treatment options for this injury is to take the pressure off of the nerve, and allowing it to heal on its own.

This is much like taking a 'pot-bound' plant, and repotting it in a larger pot. The goal of surgery is to prevent progression, and allow for the nerve to recover. Prolonged compression of a nerve may cause permanent damage. Think of a garden hose after your car has parked on it for a very long time.

For more detailed information: Click here!

Wrist Sprains / Wrist Ligament Injuries

Description
The wrist is a collection of eight small bones that connect the forearm bones (radius and ulna) to the bones of the hand (metacarpals). These small bones have a complex series of ligaments that control smooth wrist movement. Any injury to these ligaments may cause abnormal motion between some of the bones of the wrist.
Ligaments(hide)

Ligaments are the strong tissues that connect a bone to another bone. Ligaments are very important in joint stability, by holding the bones in a joint together.

Excessive tension on a ligament will cause injury, also known as a sprain: A grade 1 sprain is a stretch injury to the ligament, without damage to its structure. These injuries typically heal rather quickly, with little long-term problems. A grade 2 sprain involves microscopic damage to the ligament, but the ligament remains structurally intact. These painful injuries will usually heal well, but often the joint needs to be supported while the ligament heals, up to 6 or 8 weeks. A grade 3 sprain involves actual disruption of the ligament, and may render a joint unstable. Depending on the location of the injury, the ligament may or may not heal on its own, and surgery to repair the ligament may be necessary for these injuries.

Common Causes
Usually trauma, such as a fall on a flexed or extended wrist. A direct blow to the wrist may injure ligaments.
Symptoms
Pain, swelling, or weakness in the wrist. There can occasionally be a sense of 'popping' or 'slipping' inside the wrist. Symptoms are generally worse with activity, such as gripping, squeezing, and lifting.
Physical Findings
Tenderness over specific wrist ligaments. Swelling, loss of motion, and weakness. Certain special tests are suggestive of specific ligament injuries.
Workup
History, physical examination, and x-rays are required. Specialized x-rays, including stress x-rays or real-time motion studies are often obtained. An injection of local anesthetic into the area is helpful in confirming the diagnosis. Rarely, an MR scan or arthrogram is obtained. The high error rate of these tests in this injury makes them of limited value. The definitive diagnostic tool is a wrist arthroscopy.
MR scans(hide)

MR scans (MRI, Magnetic Resonance Imaging) are a valuable way to visualize the soft tissues in the body, such as tendons, ligaments, muscles, and other organs. The MR scan uses a magnetic field, not radiation. Basically, you lie still on a flat table, with the MR tube over the body part, in a magnetic field. A computer is able to analyze the data (how fast hydrogen atoms change their spin direction!) and provide exquisitely detailed pictures of slices of your body. It is painless and safe, but people with significant claustrophobia may require some sedation. It is not cheap: about a thousand dollars per scan. It is also not perfect, and one must be careful not to rely too heavily on the MR scan. It does a poor job with bones and cartilage.

Arthrogram(hide)

An arthrogram is a study where a special dye is injected into a joint. This dye shows up on x-ray, and an x-ray of the joint while the dye is being injected can reveal information about soft tissues such as muscles and ligaments, even if they aren't seen directly. Typically, an arthrogram is positive when dye is seen traveling into an area it shouldn't normally go to, implying a tear of another structure. Arthrograms have generally been replaced by MR. Although they are a lot cheaper that MR scans they are invasive and fairly uncomfortable. There are other limitations with Arthrograms: just because the dye doesn't cross into an area, doesn't mean its not torn anyway. Think of the one-way valve on an inflatable pool toy.

What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Non-Operative Treatment
Splinting or casting for several weeks will allow partial ligament tears to heal.
Surgical Treatment
An arthroscopy will confirm the diagnosis. Many ligament injuries can be treated entirely arthroscopically, but open ligament repairs or other reconstructive procedures are occasionally required.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments
While most wrist sprains heal uneventfully, early recognition of more severe injuries will help to prevent the often devastating complications of this injury.

Ganglion Cysts

Description
A ganglion, or cyst, is a collection of fluid that builds up on either the back or the front of the wrist. Usually it is an 'outpouching' of the wrist capsule, forming a bump or lump on the wrist.
Common Causes
There may be a history of trauma, such as a fall, or a direct blow. Often there is no known cause or history of injury.
Symptoms
There is usually a lump, or mass on one side of the wrist. It may be painful or painless, and may change size or come and go.
Physical Findings
The swelling, or lump is generally diagnostic. There may be tenderness, or loss of wrist motion.
Workup
The mass must be differentiated from other causes of swelling, such as a benign tumor, ruptured tendon, or other condition. X-rays are of limited value. An aspiration of the contents of the cyst is usually diagnostic.
Non-Operative Treatment
A trial of an aspiration of the cyst contents, along with a corticosteroid injection and a compressive dressing for a short period of time may resolve the cyst in up to one half of cases. Repeated aspirations are generally not very successful.
Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
Excision of the cyst. This may be done with an open surgical procedure, or recently, we have begun excising the cysts arthroscopically.
What is Arthroscopy?(hide)

The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)

With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.

During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.

There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.

There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.

Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.

Comments
Arthroscopic cyst excision seems to provide superior results, with faster healing, and less stiffness and scarring. There is a low, but not insignificant recurrence rate for open cyst excision. We do not yet know what the recurrence rate will be for arthroscopic cyst excision.

DeQuervain's Stenosing Tenosynovitis

Description
The tendons that straighten the fingers and thumb travel on the back of the wrist, and are held down to the wrist by a series of tunnels, or pulleys. When the tendons that straighten the thumb become swollen and inflamed as they pass through one of the tunnels, it becomes painful to use the thumb. Repeated use of the thumb only causes more swelling and inflammation of these tendons.
Common Causes
Repeated use of the hands and thumb, especially pinching, gripping or squeezing. Gardening, knitting, keyboarding etc.
Symptoms
Pain in the wrist, with use of the thumb,
Physical Findings
Tenderness, and occasional swelling along the thumb extensor tendons. A positive Finklestein's test.
Workup
History and physical exam is usually sufficient. Occasionally, x-rays are obtained to rule out other causes of pain, such as arthritis.
Non-Operative Treatment
Splinting, anti-inflammatory medication, and a trial of a corticosteroid injection into the tendon sheath.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
Release of the band, or part of the tunnel that is causing constriction of the tendons.
Comments

Non-operative treatment is usually successful. Surgical release is generally curative, and can be performed with local anesthesia, often in an office setting.

For more detailed information: Click here!

Trigger Finger (Stenosing Flexor Tenosynovitis)

Description
The tendons the bend or flex the fingers pass from the forearm into the palm, and out to the fingers. These tendons pass through a series of tunnels, or pulleys, that hold the tendon down along the bones. This prevents 'bowstringing', of the tendon, much like the metal eyelets on a fishing rod prevent bowstringing of the fishing line. If the tendon becomes swollen, it can catch, or get stuck as it tries to pass through a pulley (like a knot in the fishing line).
Tendons(hide)

Tendons are the strong whitish tissues that attach muscles to bones. All muscles cross a joint, and when the muscle contracts, the joint moves. If the muscle is overloaded beyond its normal strength, the tendon may begin to tear, causing a strain. These may range from a mild strain, which heals quickly, to a complete tendon rupture. Since the normal elasticity of the muscle causes the torn tendon to pull away from the bone, the tendon end does not remain near its normal attachment. This means that most complete tendon ruptures will not heal normally, and thus many complete tendon ruptures require surgical repair.

Common Causes
This is typically an 'overuse' injury, due to repetitive or frequent squeezing, gripping, or similar activities. Frequently seen Monday morning after a weekend of heavy pruning and gardening.
Symptoms
Pain in the fingers. There is often a sensation of catching, or 'triggering' of the involved digit. The finger may actually lock down into the palm, or lock out straight. Symptoms are usually worse in the morning, and improve during the day.
Physical Findings
Tenderness along the flexor tendon sheath, especially at the A1 pulley in the palm. A nodule may be felt moving under the pulley, with finger motion. Locking or catching is classic.
Workup
Most cases are straightforward. X-rays may be useful to rule out other injuries or disease, such as arthritis.
Non-Operative Treatment
A trial of a corticosteroid injection into the flexor tendon sheath, and anti-inflammatory medication is often very effective.
Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Surgical Treatment
A tendon sheath incision, or release of the involved pulley is curative.
Comments

At least half of the cases can be cured non-operatively. A tendon sheath incision is performed under local anesthesia, often in an office setting, with a tiny incision.

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Skier's Thumb / Gamekeeper's Thumb

Description
The bones of the thumb at the thumb webspace are held stable by strong ligaments on either side of the thumb. Occasionally the ligament on the inside (pinky side) of the thumb- the ulnar collateral ligament- tears.
Ligaments(hide)

Ligaments are the strong tissues that connect a bone to another bone. Ligaments are very important in joint stability, by holding the bones in a joint together.

Excessive tension on a ligament will cause injury, also known as a sprain: A grade 1 sprain is a stretch injury to the ligament, without damage to its structure. These injuries typically heal rather quickly, with little long-term problems. A grade 2 sprain involves microscopic damage to the ligament, but the ligament remains structurally intact. These painful injuries will usually heal well, but often the joint needs to be supported while the ligament heals, up to 6 or 8 weeks. A grade 3 sprain involves actual disruption of the ligament, and may render a joint unstable. Depending on the location of the injury, the ligament may or may not heal on its own, and surgery to repair the ligament may be necessary for these injuries.

Common Causes
Nowadays, a fall on the outstretched thumb is the most common injury, seen especially in skiers. In previous times, the gameskeeper could injure his thumb while breaking the neck of the poor animals that were caught on the Master's hunt.
Symptoms
Initially, there is pain and swelling at the base of the thumb, and pain using the thumb for pinching and gripping. Later on, the primary complaint may be that of thumb weakness or instability with pinching, opening jars, car door handles, etc.
Physical Findings
Tenderness along the ulnar collateral ligament. Instability and discomfort with stress testing of the ligament.
Workup
X-rays are required to rule out a fracture. Selective stress testing, under x-ray or real-time fluoroscopy may be valuable.
Fluoroscopy(hide)

Fluoroscopy is a form of x-ray. It is like an x-ray movie, where the body's bones can be visualized in real time. It is very valuable when looking for abnormalities that show up only during activity or motion, or when a joint is stressed. Flouroscans use extremely low doses of radiation, and are quite safe.

Non-Operative Treatment
Casting the wrist and thumb for several weeks.
Surgical Treatment
Repair of the torn ligament, with reattachment to the bone.
Comments
There is controversy regarding surgery versus casting for acute ulnar collateral ligament tears. Sometimes, when the ligament tears off of the bone, it may fold back on itself or get caught under some other tissue. Thus the torn end of the ligament may not be next to the area of the bone that it was torn from. If this happens, the ligament will not heal, and chronic instability will result. There are arguments both for and against early repair of this torn ligament, and should be discussed with your doctor.

Thumb Arthritis / Basal Joint Arthritis

Description
The joint at the base of the thumb (carpal-metacarpal joint) is like a saddle, and allows a lot of motion of the thumb at that joint. If the cartilage coating the ends of the bones wears out, bone starts to rub against bone, and arthritis results.
Common Causes
Generally a 'wear and tear' phenomenon, with a genetic or family predisposition. More common in women. May be a late result of earlier trauma.
Symptoms
Pain deep in the base of the thumb, relieved with rest, and worsened with pinching, squeezing, and gripping activities. Opening jars, door handles, and turning keys are problematic.
Physical Findings
Tenderness at the carpal-metacarpal joint of the thumb. There may be deformity present, and loss of motion.
Workup
History, physical examination, and x-rays are usually diagnostic.
Non-Operative Treatment
Splinting, anti-inflammatory medication, and rest may reduce symptoms. A corticosteroid injection can provide relief for a while, but will not repair the joint. Thumb splints are effective, but poorly tolerated due to restriction of thumb motion. Physical therapy is contraindicated, as it tends to irritate things.
Anti-Inflammatory Medication(hide)

Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.

Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.

All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.

Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.

Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.

Corticosteroids ("cortisone")(hide)

Key words: cortisone, corticosteroid, Medrol

Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.

Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.

This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.

Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.

Surgical Treatment
A joint replacement, or thumb basal joint arthroplasty.
Comments
Most patients can be managed non-operatively, but surgical reconstruction is very effective for pain relief, strength, and motion. About four weeks of casting are required after surgery, and up to several months of hand therapy.