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Carpal Tunnel Syndrome

Richard A. Bernstein, MD

Carpal tunnel syndrome is an extremely common disorder affecting the hand, present in approximately 1 in 100 people. It is a condition characterized by numbness and tingling in the fingers. Pain can extend to the elbow, shoulder or neck and can occur any time, either in the day or night. People oftentimes complain of awakening from their sleep and oftentimes shake their hands to try to restore sensibility. Symptoms often occur during the day when one talks on the telephone, holds a book or newspaper. Many people awaken in the morning with their hands numb and tingling and it will take some time before the symptoms diminish.

What Is Carpal Tunnel Syndrome?

To understand carpal tunnel syndrome, one needs to learn about the basic structures occurring at the wrist and hand level. The basic supporting structures are the bones of the wrist, which include the forearm bones, the wrist bones, medically known as the carpal bones, and the bones of the hand. The flexor tendons are the structures that extend from the muscles to the fingers like the strings of a marionette. They allow us to perform the multiple activities during the day. There are three main nerves to the hand to control the muscles and tendons known as motor nerves and it gives us the ability to feel, which the sensory nerves are. The nerve involved with carpal tunnel is known as the median nerve which generally gives sensation of the thumb, index, long and ring fingers. There is also a small branch of the nerve that goes the muscles base of the thumb.

The median nerve involved with carpal tunnel syndrome runs with the tendons in the area appropriately called the carpal tunnel. The bones of the wrist cover this tunnel on three sides and on the palm side, there is a thick ligament called the transverse carpal ligament that forms the roof of the tunnel. It is within this tunnel that pressure builds up that can cause the classic symptoms of numbness and tingling.

Causes of of Carpal Tunnel Syndrome

Idiopathic: Many cases of carpal tunnel have no known cause and are thought to be anatomic abnormalities that make an individual at risk.

Overuse: There is some information to suggest that overuse of the fingers or wrist or certain positions, for extended periods of time, can contribute to pressure on the nerve.

Injuries: An injury to the wrist involving bleeding, such as with a fracture, can cause increased pressure within the tunnel leading to symptoms either early or late in the course after a fracture or dislocation.

Medical Conditions: Pregnancy, diabetes and thyroid problems are all known causes of carpal tunnel syndrome.

Understanding Carpal Tunnel Syndrome

In many cases the long-term consequences of numbness and tingling can be prevented through simple modifications. Altering the way one does certain activities, whether be at work, home or at recreation, can significantly improve and sometimes eliminate the symptoms of numbness and tingling.

Medical Interventions

Oftentimes wearing a proper splint, time or over the counter medications can significantly help.

Prescription medication known as anti-inflammatories can oftentimes help relieve the swelling. An injection of Cortisone can be helpful either temporarily or permanently to improve and eliminate the symptoms associated with this condition. Sometimes, physical therapy can be helpful.

Scientific studies have not today shown any predictable benefit from vitamins, though there have been anecdotal reports that vitamin B6 is helpful, though studies are not conclusive.

How to Diagnose Carpal Tunnel Syndrome

An early, thorough approach is very beneficial to diagnose, treat and prevent ongoing symptoms of carpal tunnel syndrome; one is history. It is very important to obtain a thorough history of other medical conditions, injuries and the characteristics of the condition. It is helpful to write down certain information that you can pass on to the doctor at the time of the examination.

Physical Examination

A thorough examination of the area is very helpful to either rule in or rule out the diagnosis. Most patients do not have textbook-like symptoms and it is important for you and me to look at the characteristics and the physical examination findings.

Three commonly used maneuvers are a Tinel's test, tap over the nerve,
the second is the Phalen's maneuver, which is performed by flexing the wrist and seeing if this causes characteristic numbness, and the third is termed a forearm compression test where wrist pressure is placed over the nerve to determine the distribution of tingling.

Copyright © 2010, TOG All rights reserved.
Revised 12/17/10
Updated 12/3/2015

Choosing a Hand Surgeon

Choosing the right doctor is a very important and, at times, a complex problem. There is no one right way to choose a doctor, but here are some things you should consider.

Academic qualifications

The first thing to consider is the doctor's academic qualifications: is he or she board certified in hand surgery? The highest certification that a doctor can have in hand surgery is called the Certificate of Added Qualifications in Hand Surgery. Most hand surgeons who have such a certification will list it in their yellow pages add; if not, call the office and ask. Do not be afraid to ask questions when you are choosing a doctor: it is your hand, after all! If the office does not want to answer questions about the doctor's qualifications, you do not want to go to that doctor. Dr. Bernstein has such a certification.

Practice type

Does the doctor do only hand surgery, or is hand surgery something they only do occasionally or in addition to other types of surgery? You can usually find this out by asking the office receptionist. Another good way to find out how important hand surgery is to the doctor is to look at their yellow pages ad: if they have a small ad in hand surgery, but a very large ad in another specialty, such as plastic surgery, you can probably guess which area of medicine is more important to them.

Dr. Bernstein limits his practice to only hand and upper extremity surgery, and he does this full-time. This is documented on the website, www.togct.com, as well as on his stationery and his business card. His ad only appears under hand surgery (actually, the yellow pages has "Hand Surgery" under "Surgery, Hand") and orthopedics (his original board certification); both specify that he limits his practice to hand surgery. He does not do general orthopedics, plastic surgery, or general surgery.

Is the doctor in your insurance plan?

You probably want to stay within your insurance plan, since it will be more expensive to see a doctor outside of your plan. However, depending on how serious your problem is, or how important your hand is to your work or recreation, you may consider seeing someone outside your plan, at least for an initial consultation.

Dr. Bernstein participates in a variety of health plans. If your insurance plan is not accepted, call our billing office to get an estimate of how much it might cost to go out of your plan.

Does the doctor within your plan have any financial incentives to limit your treatment?

Many patients don't realize that many plans pay financial incentives to their participating doctors to limit the treatment that they offer to their patients, such as restricting referrals only to same-plan doctors. This is the "managed" part of "managed care." There are other, more subtle ways that managed care may affect your hand problem. Dr. Bernstein does not participate in any plans that pay financial incentives to limit patient care.

How long will you have to wait in the doctor's office?

An interesting and insightful question when you are selecting a doctor is to ask the receptionist what the average wait is for the doctor. If they don't know, it means that they haven't studied this part of their practice and you might wonder if they consider your time important. If they say the average wait is an hour or more, you know that they don't respect their patients or consider their time important.

We think that your time is just as important as ours. We have kept track of the time patients wait in our office for several years, and the average time is less than 15 minutes.

How long will you have to wait to get an appointment?

Many patients are finding that they cannot get a timely appointment, even for an urgent matter such as a fracture.

Our office policy is that any patient with a new fracture will be seen in the office the next day we are in, whether or not there is an appointment opening. Obviously, emergencies cannot be scheduled or be put off until it conveniently fits into the doctor's schedule, and we hope our other patients understand the emergent nature of our work and minimize the wait unless it was absolutely necessary.

We hope that these suggestions will help you in deciding if you would like to make an appointment with our office.

Cortisone Injections

A steroid injection can be recommended for your condition. Steroid injections are generally a safe, reliable method of decreasing the inflammation and pain of an affected area. Steroid or Cortisone is a powerful anti-inflammatory drug similar to natural substance produced by your body. When injected into the affected area, irritation and inflammation can be reduced and healing promoted both short, bur more importantly, long term. A misconception is that the injection is simply for temporary pain relief; our goal is long term relief and combined with the other recommendations, will hopefully cure the condition.

A steroid preparation is mixed with a short and sometimes long-acting local Novocain-type anesthetic (Marcaine), which may bring immediate relief to your symptoms and last 6-8 hours. Cortisone itself takes 7-10 days to have its full effect. Therefore, it may take time before your symptoms start to respond.

There is a great difference between injected Cortisone and taking Cortisone by mouth as a pill. Local injections of Cortisone, in general, do not have any side effects on the body, staying locally in the area injected.

Diabetics may see a transient rise in their blood sugar; therefore if you have diabetes, monitor your blood sugars and if it changes, please let us or your diabetes doctor know.

Side effects are rare. One third of patients get discomfort the night of the injection that usually subsides by the next day. Some people can get thinning of the skin or change of pigmentation, these occur in less than 5% of our patients. You can only have a certain number of cortisone injections; generally no more than three in one area over your lifetime. Infections are extremely rare after an injection; even though the area will be prepared sterilely it can occur; if there is any concern please contact our office.

DeQuervain’s Tendinitis

Richard A. Bernstein, MD

DeQuervains-Tendinitis-Figure-1.jpg

DeQuervain’s tendinitis is a condition brought on by irritation or swelling of the tendons found along the thumb side of the wrist (Figure 1). The irritation causes the compartment (lining) around the tendon to swell, changing the shape of the compartment; this makes it difficult for the tendons to move as they should. The swelling can cause pain and tenderness along the thumb side of the wrist, usually noticed when forming a fist, grasping or gripping things, or turning the wrist. The pain is usually described by patients as a very sharp, stabbing pain. It is not subtle.

What Causes It?

The cause of DeQuervain’s tendinitis is an irritation of the tendons at the base of the thumb. For example, awkward hand positions required by a new mother in caring for an infant are a common cause of this condition.

In addition, many patients with DeQuervain’s have more than the normal number of tendons in this compartment. The figures below are cross-sections of the forearm at the level of the base of the thumb. The figure on the left is the normal situation. The green line represents the ligament that helps to hold the two thumb tendons (shown in brown) down to the radius (the main bone of the forearm).  There are usually two tendons. In patients with DeQuervain’s (figure on the right), it is not uncommon to find more than two tendons. If there are more than two tendons, it is common for there to be a septum (Latin for "wall") between some of the tendons (shown as a thin vertical green line in the figure on the right). It is thought that the patients who develop DeQuervain’s have a combination of unusual anatomy plus unusual repetitive use of the thumb, but this is not proven.

DeQuervains-Tendinitis-Figure-2a.jpgDeQuervains-Tendinitis-Figure-2b.jpg

Signs and Symptoms

DeQuervains-Tendinitis-Figure-3.jpgPain over the thumb side of the wrist is the main symptom. The pain may appear either gradually or suddenly. It is felt in the wrist and can travel up the forearm. The pain is usually worse with use of the hand and thumb, especially when extending the thumb (the "hitch-hikers" position). Swelling over the thumb side of the wrist is noticed and may be accompanied by a fluid-filled cyst in this region.

There may be an occasional catching, grating, or snapping when moving the thumb. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger, although this is rare.

Diagnosis

A Finkelstein's Test is generally performed. In this test, the patient makes a fist with the fingers over the thumb (i.e., the thumb is in the palm, under the fingers). The wrist is then bent in the direction of the little finger (Figure 2). This test can be quite painful for the person with DeQuervain’s tendinitis. Tenderness directly over the tendons on the thumb-side of the wrist is the most common finding.

Treatment

DeQuervains-Tendinitis-Figure-4.jpgThe goal is to relieve the pain caused by the irritation and swelling. The condition can be treated by a splint, but it is not very effective, it works only because you cannot use your thumb (and who can afford to give up the use of their thumb?), and usually returns as soon as the splint is discontinued. One of the most effective treatments is a cortisone injection. This injection is usually effective in about 90% of cases.

When symptoms are severe or do not improve, I may recommend surgery. The surgery opens the compartment (covering) to make more room for the irritated tendons (Figure 3). It is done on an out-patient basis. Patients can usually use the hand lightly right after surgery and most patients have normal use within about a month.

Copyright © 2010, TOG All rights reserved.
Revised 12/17/10

Distal Radius Fracture

Richard A. Bernstein, MD

Distal radius fractures are some of the most common fractures (the medical term for "broken bone"). The radius is the forearm bone on the thumb side (in the x - ray above, it is t he one on the right). Distal radius fractures are generally caused by a fall on an outstretched hand. The fracture is almost always within an inch of the wrist joint, and may extend into the joint. The radius above is fractured at this location: about one inch from the wrist joint.

Distal-Radius-Fractures-1.jpg

Fracture types can be described as "extra - articular" (which means the fracture line does not extend into the joint) or "intra - articular" ( which means the fracture line does extend into the joint; this is the more serious type of fracture). They can also be described as "comminuted" (which means the bone is broken into several or many small pieces) or not comminuted. The most serious type of fracture is the comminuted, intra - articular fracture.

The treatment options are quite varied, depending on the exact nature of your fracture, your age, and your activity level. The treatment options include a cast, internal fixation with a plate, percutane ous pin fixation, external fixation, or a combination of these modalities. It is an area of very vigorous research which I have been actively involved in distal radius research since 1993. The treatments, both surgical and non - surgical, have changed greatl y in the last few years. There are so many new ways to treat this fracture that it is difficult for most surgeons to keep up with all the new developments in this area. Here are some examples of the kinds of treatment that are available:

Distal-Radius-Fractures-2.jpg

This is an example of an internal fixation plate.

Distal-Radius-Fractures-4.jpgThis is an external fixator, which is used to treat fractures that are too unstable for a cast. You can shower and use your hand gently with the external fixator in place.

Treatment of Distal Radius Fractures

The treatment decision is very com plex. As noted above, the factors that are important are the exact nature of your fracture, your age, and your activity level. The nature of the fracture relates to the current alignment of your bones (what position they are in) and whether or not that ali gnment is acceptable. If it is acceptable, then you will probably get a cast. If it is not acceptable, I may need to reduce the fracture (put the bones in a better position). Sometimes the fracture is of the sort that can be pushed into place without surge ry (called a "closed reduction"), and sometimes the fracture needs surgery to push the bones into place (called an "open reduction", because the skin needs to be "opened" for surgery). Usually, if the broken bones need surgery (in medical terms, the fractu re needs open reduction), some kind of metal implant will be needed to hold the bones in the proper place while they heal. Most of the time, the metal implant (often called a "plate", but it does not look like a dinner plate! See the photo at the top for a n example of a plate) needs to be placed on the bones. As you can see, the treatment decision is very complex.

What Can I Expect While It is Healing?

This is a great and simple question, but the answer is not simple. It depends on many factors: the nature of your fracture, its treatment, your response to treatment, your age, and your activity level, amo ng many other factors. But it is an important question, and needs to be answered. Most patients need narcotic pain medication for only a few (less than 5) days, or never. Many times, just prescription - strength, non - narcotic medication is all that is needed.

If you have a cast, it is usually on for six weeks, then hand therapy is started. If you have internal fixation, you get a splint for three days and then hand therapy starts to get your wrist joint moving. No splint is usually needed three days after surgery. Casts must be kept dry (use a plastic bag while showering), and surgical incisions need to be kept dry only for five days. No matter what kind treatment you get, you should be actively exercising your fingers, elbow, and shoulder, so they don't get stiff. I will decide, based on your exact fracture, when you can start strengthening exercises; until then, just work on motion.

Distal-Radius-Fractures-3.jpg

What Can I Expect After It Has Healed?

Everyone wants to know, "Can I return to all my former activities?" This also is a great and simple question, but without a simple answer. Everyone has some stiffness in their wrist after treatment (remember, you fell on your hand hard enough to break the bone, so the joint and all the soft tissues around it are mad at you!). This is why almost everyone is referred to hand therapy as soon as your broken bone can tolerate it safely.

Everyone wants to know, "How much will it hurt?" Most patients will need to take some pain medication for a few days (see above), and some may need it for 10 or s o days. Few patients need any pain medication other than aspirin, Tylenol, or Motrin after 10 days. Almost everyone will have some discomfort in their wrist as it heals over a period of three to six months. If you do not develop arthritis, you will not have pain after this. You will still experience some minor discomfort for a year or so.

Almost everyone ends up with some stiffness that is permanent; how much depends on our injury, your age, if you already have some stiffness and arthritis, and how hard you work in hand therapy. The forearm motion that is usually the stiffest is turning your palm up (called "supination") in the position as if you were trying to hold some water in your cupped hand. There is also some limitation in flexion and extension, which are the motions bending your hand toward your palm or toward the back side of your hand.

Most patients return to normal recreation and work activities, and most do not have permanent pain. The most limiting fracture type is a comminuted, intra - articular fracture, and these patients will have the greatest amount of stiffness, may have pain, and are at risk for developing arthritis. Extra - articular fractures usually do not develop arthritis.

The amount of stiffness is largely what determines what activities you can return to. Most patients, who are active playing non - contact and non - impact sports such as bike riding, swimming, etc., can return to those activities, starting at about 3 months after the fracture. Most patients who are active playing contact spo rts or sports that involve impact, such as tennis, golf, baseball, football, etc, can return to those activities, starting at about 4 months. Most patients who do heavy labor, such as carpentry, plumbing, etc, can return to work at 2 months with restrictio ns, and regular work without restrictions at 4 months. Most patients who do lighter labor such as painting, or office work activities such as handwriting, keyboards, telephone, etc, can return to work at 1 to 2 months. I do not allow people to do activitie s where they are at risk for falling for about four months. These are only general guidelines so you have some idea of what to expect, and your specific restrictions will be determined by your individual circumstances.

Dr. Bernstein has a particular intere st in distal radius fractures. He has spoken at many national as well as international courses exclusively on distal radius fractures. He is actively involved with developing newer methods of distal radius fracture treatment and with teaching surgeons fro m around the world about how to treat distal radius fractures.

Copyright © 2010, TOG All rights reserved.
Revised 11/13/2015
Updated 11/13/2015

Dupuytren’s Disease

Richard A. Bernstein, MD

dupuytren’s-disease.png.jpgDupuytren's disease is a condition that affects the palm of the hand, forming contracted cords. It is more common in men and found most commonly in people with a Celtic genetic background (Irish, Scottish, Scandinavian, Northern European), although it is found in people of many different ancestries. It affects the connective tissue in the palm known as palmar fascia (normal tissues are shown in the illustration at the right), which is the tissue that helps stabilize the palm skin. The palmar fascia starts near the wrist, divides into bands (known as “pre-tendinous” bands) as it goes to the fingers.

It can then split into two bands that attach to the natatory ligament and into the sides of the fingers.

Dupuytren’s contracture is a fairly common condition that occurs when the connective tissue under the skin (specifically, the pre-tendinous bands of the palmar fascia) begins to thicken and shorten. As the tissue tightens, it may pull the fingers down towards the palm of the hand. In some individuals, the condition may progress until the involved fingers become disabled.

Who is at risk?

People of northern European descent. There is a strong genetic component to Dupuytren’s contracture, although not all patients are of northern European descent.

Men. The incidence of Dupuytren’s contracture is about seven times higher among men than among women.

People of middle age. Most of the time, Dupuytren’s contracture doesn’t show up until after age 40. However, a very aggressive form may rarely appear in teenagers and children.

Signs and symptoms

The first sign is a thickening (nodule) in the palm of the hand that most frequently develops near the base of the ring or little finger. The nodule, which can resemble a callus, is painless but may be tender to the touch. Gradually, a thickened tissue of palmar fascia forms from the pre-tendinous band and becomes a cord. This may extend across a joint, causing a contracture as the cord shortens. The overlying skin begins to pucker, and cords of tissue extend into the finger. As the process continues, these cords tighten and pull the finger in toward the palm. The ring finger is usually affected first, followed by the little, long and index fingers. The problem is not pain, but the restriction of motion and the deformity it causes.

The progress of the disease is often sporadic and unpredictable. Exactly what triggers the formation of nodules and cords is unknown. As the disease progresses, the diseased tissue wraps itself around and between normal tissue. Many people do not seek medical care until the contracture is well advanced. Until recently, the only treatment for this condition is surgery, which is usually reserved for individuals who have developed deformity as a result of the progressive contracture. New nodules do not necessarily progress to contracture and because scar tissue from previous surgeries can make excision of recurrent nodules more difficult, surgical removal of isolated nodules is not indicated in most cases.

A good guideline for determining when to consider surgery is the "table top test." Try to place the palm of your hand completely flat on a hard surface. If you can’t, the contracture has progressed to a point where surgical intervention could be helpful. Dupuytren’s can also be associated with thickening of the knuckles on the back of the hand or thickening of the tissue on the sole of your foot. Men can rarely get a band of tissue in their penis, called Peyronie's, if so we can have you see a Urologist who specializes in that.

Unfortunately there are no splints, exercises, pills or simple “cortisone” injections that can improve the course of Dupuytrens. Many of these techniques have been tried without success. Xiaflex is an injection that was FDA approved in 2010. It is an enzyme based on the Clostridium bacteria. The medication has been studied and trialed, and has undergone numerous studies on its efficacy in treating certain cases of Dupuytren's. Xiaflex does not “get rid” of the Dupuytrens; it helps erode the cord so that the cord can be broken to correct the contracture. There are risks that include a flare reaction, tendon rupture, skin tear, nerve injury, and recurrence. The best contractures are bands at the MP joint and those with a centraI band. Bands and contractures that extend to the PIP joint also respond to Xiaflex, but not as successfully as an MP joint contracture. I have used Xiaflex extensively and have presented results at the American Society of Surgery of the Hand meeting and will be happy to discuss whether your Dupuytrens is a candidate for the medication. In my experience, when you are a candidate, the results have been gratifying and much easier for my patients to recuperate from than surgery.

Surgical Treatment

When surgery is needed, every case has subtle differences and we can discuss the techniques based on the extent of the contracture and disease. The aim of the surgery is to release the contracture and improve hand function by removing the diseased tissue. The results of surgery are usually good, and the fingers can return to good extension after therapy. You need to be dedicated to your post-operative therapy. Probably more than any other condition I treat with surgery; you need to be dedicated to wearing a splint, doing your exercises and working with a therapist. If you are not going to be able to wear the splints and exercise, it is not worth having the surgery. Some studies suggest night time splinting for 6 months after the surgery. However, the disease can return even some years after the initial surgery. Dupuytren’s contracture usually does not recur beneath a skin graft, so this may be an option in especially aggressive forms of the disease. There has also been a resurgence in another option based on a Scottish surgeon, termed the McCash technique. This involves intentionally leaving open part of the incision at surgery. By leaving it open it diminishes tension on the skin and decreases the chance of a blood clot (hematoma) developing under the skin. In severe contractures, this is a technique that I may discuss with you for in some cases it is a better option than putting a lot of tension on the skin. The skin heals on its own within 2-5 weeks depending upon the extent of the open area; the therapist and I will discuss how to care for your hand.

After Surgery

It’s important to keep the appointment for hand therapy after surgery. You will have to wear a splint so that the fingers stay extended during the day and at night. The splint is usually worn full time immediately after the surgery and then only at night for several months. You will also have to do some active range of motion exercises so that the finger retains mobility and strength.

dupuytrens-disease-incision.png.jpgThis is the incision of a Dupuytren’s patients about two weeks after surgery on the palm and fifth finger. Note how he can fully straighten out the finger.

Many patients ask about return to work activities after a Dupuytren's release. Everyone is different, but here are some guidelines. I encourage you to return to any activities that you want as soon as the dressing is off, as long as the hand remains clean and dry. Keyboarding, playing a musical instrument for instance are both great therapies to help restore hand function. These are only rough guidelines which will give you some idea of what to expect.


Copyright © 2010, TOG All rights reserved
Revised 11/13/2015
Updated 11/13/2015

Gamekeeper's Thumb

By Richard A. Bernstein, M.D.

Gamekeeper's Thumb, also called Skier's Thumb, is an injury to the thumb on the little finger side, at the second joint from the thumbnail (MP joint). The ligament can be either torn itself, or the ligament can be torn from the bone, usually pulling a small fragment of bone off with it, as illustrated below.

thumb.jpg

This is a view of the thumb from the top, looking straight down on the thumbnail. Note the broken fragment of bone from the middle phalanx. (Note: this x-ray has been modified to remove the sesamoid bones, which can be confused with fracture fragments.)

thumb2.jpg

This is a view of the thumb from the side. You cannot see the fracture fragment, since it is in the middle of the bone on this view. What you can see is that the joint is not parallel: the bones are closer to the right than to the left. (Again, the sesamoids have been removed.)

The Injury

Gamekeeper's thumb is clinical instability of the first MP joint caused by an insufficiency of the ulnar collateral ligament (UCL) in the MP of the thumb. Because the stability of the thumb is important for holding things between the thumb and the index finger, treatment is directed toward optimizing the healing of the ligament to restore its full function. Gamekeeper's thumb is a common injury. The incidence is increased in skiers, but it does not depend on the type of ski pole used.

Challenges in Establishing the Nature of the Injury

If the history (typically a fall that stressed the thumb) and the clinical exam (painful, swollen thumb MP joint, especially on the index finger side of the thumb) are suggestive of an injury, an x-ray should be taken. If the x-ray does not show a fracture (no gamekeeper's fracture), but the history and clinical exam show a sufficient injury, there still might be a gamekeeper's thumb (the kind with just a ligament injury), which is actually more serious. The reason is due to the anatomy of the thumb. The muscle on the index finger side of the thumb (adductor) has an expansion called the aponeurosis, which usually gets stuck between the ruptured ligament and its site of insertion at the base of the proximal phalanx, preventing the ligament ends from touching. This is called a Stener lesion and prevents the ligament from healing back together. This lesion also can be associated with the gamekeeper's fracture, but this can usually be seen on the x-ray, because the fracture fragment is several millimeters away from where is it supposed to be. The real challenge is to diagnose a gamekeeper's thumb due to a ligament injury, since the ligaments don't show up on the x-ray! At times, an MRI may be useful.

The best way to decide if the ligament is ruptured is to stress the joint. If the pain is enough to prevent a good stress examination, the joint may be anesthetized with a Lidocaine injection prior to stress testing. If the ligament is loose (called laxity) by about 35°, or if the injured thumb has more looseness (laxity) than the other thumb by 15° more, the collateral ligament is ruptured. Stress testing with the thumb slightly flexed tests the ligament itself. Stress testing with the thumb in the extended position is the best test for determining the competence of the lower part of the ligament, called the accessory collateral portion of the UCL. If laxity of the MCP joint is present in both the flexed and extended positions, complete UCL rupture should be suspected.

Treatment

Splinting or casting is appropriate for injured thumbs and the ligament is not loose or is only very slightly loose. These are called partial tears, that is, grade I or grade II tears, of the UCL. These tears usually involve an isolated rupture of the proper collateral ligament. Splinting or casting is also appropriate when there is a fracture, but the fragment of bone is displaced only a millimeter or two. The splint or case should immobilize the thumb for 4 weeks. With appropriate closed treatment, good to excellent results can be expected in 90% of such injuries. Surgery is needed when there is too much looseness of the ligament (it is probably ruptured and the Stener lesion will prevent it from healing) or if there is a fracture and the bone fragment is displaced. Without surgery, the joint will be floppy, will probably develop arthritis, and the thumb will not be able to oppose the index finger (useful for things like opening a door with a key!). Occasionally, significant ligamentous injury may occur without immediate gross instability, which can be masked by swelling and muscle spasm. At this point, a repeat examination can be performed after 1 week; and if swelling persists and motion has not been regained, surgical fixation may be considered.

What Happens If Surgery is not Performed?

Sometimes the injury is not diagnosed or the patient decides against surgery. This creates chronic instability of the thumb. This is difficult to treat. Just trying to repair the ligament late has limited success. Even surgical repair performed 6 weeks after the complete UCL rupture has limited success. Essentially, the longer a complete rupture of the UCL exists, the smaller the possibility of stability restoration with anatomic repair. Fractures may not be repairable. Ligament injuries need to be reconstructed.

What is the Surgery?

The surgical procedure involves a 1 inch incision, opening the muscle, and replacing the bone fragment or repairing or replacing the ligament. The thing to watch out for is the radial sensory nerve, which often has one to three small (

What is the Recovery?

Postoperatively, most patients will be casted and then a splint that but can be removed specialized exercises. Great care must be taken not to stress the repair! Three months after surgery, full activities can be resumed.

Chronic instability of the MCP joint can occur despite a good repair, especially if motion and return to play are resumed prematurely. This instability is difficult to treat and can lead to arthritic changes in the MCP joint, as well as a weak pinch grasp in the long term.

Stiffness of the MCP and IP joints is a common complication. This stiffness is usually not a functional problem, and it tends to improve with time.

Neuropraxia of the radial sensory nerve may occur, even if care is taken to isolate and protect the nerve. The neuropraxia usually resolves spontaneously.

Outcomes

Early diagnosis is the most important factor that determines the functional outcome. In thumbs with partial ligament injuries, nonsurgical treatment by means of immobilization yields a stable, painless thumb in most cases. In more than 90% of complete ruptures that are surgically treated within 3 weeks of the injury, a good-to-excellent result can be expected. Pain and stiffness can be expected to be mild or absent, and pinch and grip strength will be nearly normal. The rate of return to former activities, including recreational sports, is reported to be as high as 96%. The failure to diagnose this injury and the patient’s failure to seek medical treatment are the most common reasons for a poor outcome.

In complete tears, the failure rate of treatment with bracing and early motion is 50%. If a patient is unable to tolerate or refuses surgery, the use of a brace or thumb spica is the treatment of choice. However, full stability of the thumb is unlikely. The prognosis for all repairs and reconstructions undertaken more than 6 weeks after a complete UCL rupture is not as good as early treatment. However, good (but less than normal) motion can be obtained.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10
Updated 11/13/15

Ganglion

Richard A. Bernstein, MD

Mucous cyst is a term given to a ganglion cyst when it occurs overlying the last joint of the finger. The last joint of the finger is medically termed the distal interphalangeal joint(DIP) joint. Wear and tear arthritis, known as osteoarthritis can oftentimes affect this joint. Bumps can occur in this joint from the arthritis itself and it can often be felt as a bony enlargement.

Mucous-Cyst.jpgOn the other hand, a mucous cyst occurs when the arthritis irritates the joint and skin and forms a fluid-filled cyst. These are oftentimes bluish in coloration;sometimes, the overlying skin gets thin. The fluid within the cyst is joint fluid analogous to a ganglion cyst (ganglion).

The danger occurs if they rupture. Similarly I have seen patients picking at them with needles and they could become secondarily infected. Because the cyst is in continuity to the underlying joint, infections can extend to the joint or bone.Therefore, it is important not to pick these areas and if the skin breaks to call immediately.

Treatment option includes splinting, injections, or surgical removal. When the skin does become very thin, surgery is oftentimes recommended to try to get the area closed before an infection occurs. Recent studies confirmed by my experience show a relatively high success rate of cortisone.

It is not uncommon for the nail to develop some ridging within it and since the cyst irritates the tissue from which the nail grows.

Many times, the cysts will diminish on their own. My belief is that the cyst is caused by irritation from the bone spur to the skin causing the fluid production. If it comes to surgery, you cannot only remove the cyst, this has leads to a high recurrence rate. The important aspect of surgery is to remove any underlying bone spurs causing the irritation.

If surgery is the choice you make, I perform it on an outpatient basis under alocal anesthetic. The anesthesiologist is there to give you sedation if you want.The surgery generally involves a semicircular incision that gives me access to the cyst and joint. If the skin is thin, this incision allows me to move tissue around to gain coverage. After surgery the finger is splinted for a few weeks; the therapist will guide you through the early motion program. If you move it too soon, the skin over the joint will breakdown; the splinting and slow return of motion is to allow the skin to heal.

At the 3-5 week range the skin will often look quite red and angry looking. Since there is little fat and no muscle between the skin and bone, the area does become more inflamed than some at peak reaction. If you have any concerns about the wound call immediately.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10
Updated 11/13/2015

Innovations in Wrist Care (Distal Radius & Scaphoid Fx’s)

Richard A. Bernstein, MD

Fractures of the bones of the wrist, particularly the radius and the scaphoid remain common sources of injuries requiring fracture care. Though most fractures can be treated with splints or casts, there has been evolving treatment options which allow patients to return to activities much more quickly than they could in the past. There is increased awareness of osteoporosis, or thinning of the bone but despite advances in medical treatment “fragility” fractures commonly occur. On the other end of the spectrum, adolescents and young adults are particularly active with sports such as skiing, ice skating, gymnastics, and contact sports all of which put the wrist in jeopardy of an injury. Fortunately our bodies are incredibly resilient and most wrist injuries, typically represent a sprain that usually heals uneventfully. With significant trauma, fractures do commonly occur when significant force is placed across the wrist especially as the wrist is extended, or bent backwards.

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Distal Radius Fx

The most common fracture in the arm, and the second most common fracture in the body (second to spine fractures) is an injury of the bone in the distal forearm named the radius. Eponyms for this fracture include a Colles, Smith, and Barton’s fractures; each term describing a different fracture pattern. Usually, a patient falls on the outstretched arm causing displacement of the bone towards the back of the wrist. X-rays usually demonstrate the extent of the injury and if in good alignment or if it can be easily reduced, most fractures can be treated in a cast. However, often this necessitates six weeks or longer of cast treatment. Over the last 10 to 15 years there has been an evolution in treatment of fractures of the wrist using metallic plate and screws. Fracture fixation can usually be done in 30 to 45 minutes and typically a week after a surgery, I allow my patients to progress to a removable splint and start physical therapy. I was fortunate to have made the acquaintance of the pioneer in distal radius fractures, Dr. Jorge Orbay a number of years ago. By learning the technique, I was able to share the experience and surgical technique providing over twenty teaching sessions to orthopaedic and hand surgeons across the country on this innovative technique. Patients can shower when the dressing is removed and then start their hand rehabilitation. When compared to six weeks in a cast, early fracture fixation can help maintain the bone alignment and allow patients to return to work, sports, and activities much more quickly than they could with cast treatment.

The scaphoid bone is a canoe shaped bone that sits on the thumb side of the wrist. Similar to the radius fracture described previously, a scaphoid fracture typically occurs from a fall onto outstretched arm. This bone is more commonly injured in people 15 to 30 years old, men more than women and are often times passed off as a simple sprain. The difficulty with a scaphoid fracture is that often times the fracture cannot be visualized on initial x-rays and requires follow up X-rays or other advanced radiology as necessary. Because the fracture sometimes does not show up on initial x-rays, a scaphoid fracture can be missed; if that occurs, there is a very high risk that the bone neither heals and /or the wrist becomes arthritic. First and foremost an accurate diagnosis and a high level of clinical suspicion for this injury is necessary.

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Scaphoid

Once diagnosed, the traditional treatment is three months in a cast, six weeks in a cast above the elbow and six weeks with a cast below the elbow. This is double the time it typically takes for a fracture of the radius to heal, and therefore the long duration of casting immobilization can be problematic. For a scaphoid fracture, a so called “percutaneous” procedure can be done to insert a small metallic screw in the body of the scaphoid under a special television like x-ray called fluoroscopy. The technique involves a small incision and using a special camera, a pin, a guidewire, and a screw placed within the bone to provide fixation. With good bone quality and excellent fixation, patients can come out of the postoperative dressing in one to two weeks, be placed in a custom made splint and start early careful activities. Healing of the scaphoid, even with surgery can be tenuous and occasionally requirs a slower rehabilitation course, but surgery avoids the need for prolonged periods in a cast. Studies have shown greater than 95% healing with placement of a screw within the scaphoid bone.

We always want to look for the most conservative approaches to treat our patients; however oftentimes, it is important to understand the options available, and in the right scenario, surgery can expedite, facilitate, and improve the healing. Though no medical treatments are without risks, there are many options available and medical technology continues to advance and I would be happy to answer any question with regards to these or other injuries

Pediatric Forearm and Distal Radius Fractures

Richard A. Bernstein, MD

Forearm fractures in children are common and are managed differently than similar injuries in adults. Historically, the results of nonoperative treatment of adult forearm fractures have been poor, with reports of nonunion, malalignment, and stiffness due to the lengthy immobilization required for union. Currently, most adults with both-bone forearm fractures are treated by open reduction and internal fixation. In pediatric patients, treatment is primarily nonoperative because of uniformly rapid healing and the potential for remodeling of residual deformity.

Although the outcomes in children are usually good, treatment of individual patients and education of families can be challenging. Beyond the sometimes difficult mechanics of fracture reduction and maintenance, the clinician is faced with controversies regarding techniques of reduction, position of immobilization, and definition of an acceptable reduction.

The purpose of this article is to critically summarize available information and present treatment recommendations based on a literature review and the previous experience of the senior author (C.T.P.). The scope of this discussion will be limited to the more common entities, such as pediatric forearm and distal radius fractures, and will not include articular fractures, plastic deformation, and fracture-dislocations, such as Monteggia lesions.

Functional Anatomy

The ulna is a relatively straight bone around which the curved radius rotates during pronation and supination. The axis of rotation passes obliquely from the distal ulnar head to the proximal radial head. The two bones are stabilized distally and proximally by the triangular fibrocartilage complex and the annular ligament, respectively. Further stabilization is provided by the interosseous membrane, with oblique fibers passing distally from the radius to the ulna; these fibers are somewhat relaxed in supination and tighter in pronation.

The pronator quadratus (distally) and pronator teres (inserting on the middle portion of the radius) actively pronate the forearm, while the biceps and supinator (proximal insertions) provide supination. The insertions of these four muscles can partially account for fragment position in complete fractures. In distal-third fractures, the proximal fragment will be in neutral to slight supination, and the weight of the hand combined with the pronator quadratus tends to pronate the distal fragment. In proximal-third fractures, the distal fragment is pronated, and the proximal fragment is supinated. Mid-shaft fractures tend to leave both fragments in a neutral position with the distal fragment slightly pronated and the proximal fragment slightly supinated.

Several anatomic differences distinguish pediatric forearms from those of adults. The pediatric radial and ulnar shafts are proportionately smaller, with narrow medullary canals, and the metaphysis contains more trabecular bone. In addition, the periosteum in children is much thicker than that in adults; this feature can both hinder and help in the management of pediatric fractures.

Normal Growth and Implications for Remodeling

The proximal and distal physes provide longitudinal growth, which contributes to remodeling after fracture healing. The distal radial and ulnar growth plates are responsible for 75% and 81% of the longitudinal growth of each bone, respectively. 1 This is consistent with the oft-made observation that distal forearm fractures have greater potential for remodeling than do more proximal fractures. 2-4 Additional remodeling can also be attributed to elevation of the thick osteogenic periosteum after fracture (Fig. 1). Intramembranous ossification by the periosteum will assist in rapid healing and subsequent remodeling of residual diaphyseal deformity. Normal Function and Treatment Objectives. The goal of treatment of forearm and distal radius injuries is to facilitate union of the fracture in a position that restores functional range of motion to the elbow and forearm. The predominant motions affected by malunion are pronation and supination, which are a function of skeletal length and axial and rotational alignment. Normal supination from neutral is 80 to 120 degrees; normal pronation from neutral is 50 to 80 degrees. 5 It is important to realize that .normal" motion may not be what is needed for normal function Biomechanical testing has revealed that common activities of daily living require 100 degrees of forearm rotation, equally split between pronation and supination. 6 Limited pronation is more easily compensated for by shoulder abduction. Secondary concerns include cosmetic alignment; however, acceptable reduction usually precludes gross malalignment. Ulnar alignment is the most important cosmetic determinant.

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Fig. I In completely displaced pediatric forearm fractures; the periosteum is tom and elevated. In cases of reversed fracture obliquity, it becomes difficult to reduce the bone end to end with longitudinal traction, as the periosteum tightens around the buttonholed proximal end. However, the elevated periosteum does provide a framework for rapid cortical remodeling as bone and cous form along the elevated margin.

Classification

Specific classification schemes have not been developed, but fractures are generally categorized according to location, amount of cortical disruption, displacement, angulation, and malrotation. As mentioned previously, we will not address articular fractures, physeal fractures, or fracture-dislocations in this article. Three main types of forearm fractures will be discussed: greenstick fractures, complete fractures, and distal radial metaphyseal fractures. Greenstick fractures are incomplete fractures with an intact cortex and periosteum on the concave surface. These are usually the result of excessive rotational force. Complete fractures of both bones of the forearm are classified by location as being in the proximal, middle, or distal third. Proper treatment depends on differentiating greenstick and complete fractures. Completely displaced distal metaphyseal fractures of the radius will be discussed separately because of the differences in reduction and outcome.

Mechanism of Injury

It is important to have a basic understanding of the forces leading to forearm fracture, as reductions are often performed in the direction opposite to that of the initial injury. Pediatric forearm fractures typically follow indirect trauma, such as a fall on an outstretched hand. Direct trauma may additionally account for open fractures, severely displaced fractures, and those in the proximal forearm.9 Evans described an indirect mechanism of axial compression force in varying directions and degrees of rotation, the latter accounting for different patterns of fragment angulation. The final degree of fragment displacement due to indirect trauma varies between greenstick and complete fractures, but the initial mechanism of injury is usually the same. In some cases, the force is not sufficient to completely displace the fracture, and therefore a greenstick fracture results. A greenstick fracture in one forearm bone may coexist with a complete fracture in the other.

Radiographically, greenstick fractures demonstrate angulation due to rotational deformity. 7,10 Fractures with apex-volar angulation are the result of an axial force applied with the forearm in supination; fractures with the less common apex-dorsal angulation are the result of an axial force applied in pronation. 10 Reducing a greenstick fracture usually involves rotation in the direction opposite to the deforming force. When indirect or direct trauma exceeds the resistance of the forearm, complete fractures of both bones will follow. In severe falls, the bones may initially angulate according to the rotation of the wrist.

However, when completely broken by either indirect or direct forces, the bones shorten, angulate, and rotate within the confines of the surrounding periosteum, interosseous membrane, and muscle attachments. Because the final positioning in complete fractures depends to some degree on the relationship of fracture location and the insertions of the pronating and supinating muscles, reduction is more complex than for simple greensick fractures.

Distal radius fractures usually follow a fall on an outstretched hand. The resultant angulation may also be accompanied by rotational deformity. Apex-volar angulation (the most common deformity) is accompanied by supination and apex-dorsal angulation with pronation. In our experience, solely ulnar fractures are less common, and probably result from direct trauma.

Patient Assessment and Radiographic Evaluation

The diagnosis of forearm fractures is usually self-evident from the history and the obvious deformity. Child abuse must always be considered in patients less than 3 years of age. Inspection and palpation should be carefully performed; occasionally, soft-tissue swelling will obscure gross malalignment. The wrist and elbow should be examined for swelling, tenderness, and unusual prominences that may signify a Monteggia or Galeazzi fracture. Cursory examination of the humerus and clavicle may detect fractures that have also resulted from a fall on an outstretched hand. Detailed neurovascular examination is necessary before and after reduction; median, ulnar, and posterior interosseous neurapraxias have been documented. Such deficits usually resolve with observation in 2 to 3 weeks.

Radiographic evaluation should include anteroposterior (AP) and lateral views of the forearm. If the elbow and wrist are not adequately visualized, corresponding views should be obtained to eliminate radial head dislocation, supracondylar fracture, and distal radioulnar joint injury. Forearm radiographs are examined to determine fracture pattern (complete or greenstick), location (proximal, middle, or distal third), displacement, angulation, and rotation.

Displacement and angulation are fairly easy to document on AP and lateral views. Although deformities can often be quantified and described on these standard views, it is important to remember that fracture angulation and displacement are always in a single plane, between those obtained on orthogonal radiographs. The magnitude of the deformity is at least as great as or greater than that seen on each view. Malrotation in complete fractures can be difficult to detect and assess, but can be suspected when the cortical, medullary, or bone diameters of both fragments are not equal. Malrotation can be gauged from deviations of normal orientation of proximal and distal bony prominences.

On a standard AP view, the radial tuberosity is seen in profile on the medial side, while the radial styloid and thumb are seen 180 degrees opposite on the lateral side. On this same view, ulnar styloid and coronoid process are not seen. Lateral views reveal the ulnar styloid pointing posterior and the coronoid process pointing directly anterior; the aforementioned radial prominences will not be seen. Another useful method for determining rotation of the proximal fragment utilizes the tuberosity view described by Evans. This technique allows a quantitative assessment of proximal fragment rotation. The distal fragment can then be manipulated and rotated into a corresponding position.

Anesthesia (edited)

In many centers, a large proportion of forearm and distal radius fractures are treated outside the surgical suite, requiring the treating surgeon to consider and administer appropriate anesthesia. Strict guidelines for conscious sedation have been established by the American Academy of Pediatries.14 A survey of orthopaedic surgeons completed in 1993 indicated that as many as one third of orthopaedic surgeons were not in compliance with these guidelines during fracture reduction. 15

The chosen method should be as safe as possible, induce the least trauma, including fracture reduction. As no one method completely meets these criteria, several different choices exist, each with its own advantages and disadvantages.

Options include quick reduction without anesthesia, hematoma block which involves an injection of the anesthetic in the area of the fracture or going to the hospital for either a block type or a general anesthetic. Intravenous sedation entails the potential for overdosage and cardiopulmonary depression.

Regional intravenous blocks have the advantages of rapid onset of effect, simple administration, and good muscle relaxation. Disadvantages include pain when the injured limb is exsanguinated by wrapping or elevation. Premature cuff deflation may lead to major neurologic and cardiac complications when high doses are used.

Use of general anesthesia relieves the surgeon of the burden of providing safe and effective anesthesia. This allows the surgeon to concentrate on reduction and stabilization unencumbered by the proximity of anxious parents. In addition, if several reduction attempts are required, general anesthesia provides total relaxation with minimal constraints. Furthermore, if reduction is inadequate or unstable, it easy to convert to operative stabilization.

Adequacy of Reduction and Results of Closed Treatment

Anatomic reduction is usually not required for pediatric forearm fractures due to the potential for growth and remodeling. However, the treating physician must be able to define reasonable residual malalignment by answering several important questions: What are the acceptable limits of displacement at healing, and to what degree do the deformities remodel over time? How is remodeling potential affected by variables such as age and location of the fracture? Does malalignment at healing and follow-up correlate with loss of motion? What degree of documented motion loss is associated with poor function and patient dissatisfaction?

It is uniformly agreed that post-traumatic angular deformities in children have variable remodeling potential; however, it has not been consistently proved that deformities characterized by rotational malalignment will also remodel. Many studies have documented better radiographic remodeling of distal fracture and fractures in patients less than 9 or 10 years of age. It is important to realize that fracture location and age may not be independent variables. Creasman et al 22 documented better results in distal fractures; however, their patients were on average 3 years younger than patients with proximal fractures. Whether anatomic alignment correlates with final range of motion is controversial. Fuller and McCullough4 demonstrated a positive relationship with residual angulation and eventual range of motion. However, there are certainly examples of excessive malunion with good motion.

Conversely, cases of "anatomic" healing with documented motion loss have been reported. Carey et al 24 reported the follow-up data on 33 patients with bothbone forearm fractures and demonstrated average angulation of 12 degrees in patients aged 6 to 10 years and 9 degrees in patients aged 11 to 15 years. While almost all patients in the former group had full motion, those in the latter group had a small loss of rotation averaging 20 to 30 degrees. This disparity suggests that factors other than alignment may affect range of motion. Perhaps motion loss in such cases is due to contracture of the interosseous membrane from the injury and/or immobilization.

However, it is clear from in vitro studies that fracture malrotation proportionally decreases forearm rotation.27 Published discrepancies between residual angular deformity and final forearm rotation may be due to inability to accurately document and record radiographic malrotation. Finally, what is the subjective outcome in pediatric patients with fractures of both forearm bones, and does residual deformity or motion loss correlate with decreased function? Although several authors have demonstrated decreased remodeling potential in proximal fractures, Holdsworth and Sloan found that only 3 of 51 proximal forearm malunions showed marked loss of function, with a mean attendant loss of 65 degrees of forearm rotation. Studies of documented malunions demonstrate that good function can be obtained in all patients with motion loss up to 50 degrees, and that more symptomatic losses of 90 degrees can be partially compensated for with shoulder abduction. Other authors have demonstrated little functional loss with decreases in forearm rotation of 35 to 40 degrees. Higgstrom et al 3 found that some patients with a limitation of 60 degrees or less in the range of pronation and supination appeared to be unaware of their incapacity. In addition, it is conceivable that patients with initially unsatisfactory motion may have improvement with time. Although differing definitions of acceptable alignment have been delineated in the literature, many patients with residual deformity have good functional results.

Our recommendations are based on previous studies of malunion in children with relatively good function. In fractures at any level in children less than 9 years of age, we accept complete displacement, 15 degrees of angulation, and 45 degrees of malrotation. In children 9 years of age and older, we continue to accept bayonet apposition but only 30 degrees of malrotation; acceptable angulation is 10 degrees in proximal fractures and 15 degrees in more distal fractures. In distal radial metaphyseal fractures, we accept complete displacement and up to 20 degrees of angulation. In cases of completely displaced and slightly angulated distal radius fractures, it is important to inform the family that cosmetic deformity may be noted initially after fracture healing; however, remodeling can be expected to improve the appearance as long as 2 years of growth remains.

Reduction and Casting Greenstick Fractures

Historically, incomplete fractures were treated by completing the fracture and then manipulating the bones into an acceptable position. This approach has the theoretical advantage of increasing the size of the fracture callus and decreasing the risk of refracture. Currently, it is recognized that residual angulation is a result of malrotation and that the fracture should be reduced by rotating in the direction opposite to the deforming force. Traction and manipulation of the apex while rotating will often assist in the reduction. Most greenstick fractures are supination injuries with apex-volar angulation, which can be reduced with varying degrees of pronation. It can be difficult to remember whether to pronate or supinate the hand. Most fractures can be reduced by rotating the palm toward the deformity. Fractures with apex-volar angulation are a result of axial load in supination; there- fore, the palm should be rotated volarly (pronation). Fractures with apexdorsal angulation are a result of pronation force; therefore, the palm should be rotated dorsally (supination). It is not uncommon to see a greenstick fracture of one bone and a complete fracture of the other. in these cases, we use the same principles of reduction by rotation.

After reduction, the forearm should be immobilized in the same position that reduced the fracture. Studies have documented 10% to 16% rates of redisplacement when greenstick fractures were not adequately rotated in the cast. Complete Fractures Complete both-bone forearm fractures are reduced with a combination of sustained traction and manipulation. The fingers are taped to prevent sores and placed in fingertraps with the elbow at 90 degrees of flexion. Countertraction is provided by 10 to 15 lb of weight suspended from a sling over the distal humerus. The fracture and soft tissues are slowly brought out to length for 10 to 15 minutes, and the arm is allowed to find its own rotation.12 End-toend apposition is then attempted with deformity exaggeration and direct manipulation. If attempts to achieve bone apposition are unsuccessful, complete overriding of fracture fragments is accepted as long as rotation and angulation are reduced (Fig. 2). Fracture alignment in traction is assessed with fluoroscopy or plain radiography. If alignment is adequate, the distal part of the long arm cast is applied and molded while the arm is still in traction. Residual malrotation is addressed before cast application by rotating the forearm. It was traditionally taught that the hand should be casted in a position dictated by the relationship of fracture location with the insertions of the pronators and supinators. This principle is used to direct distal forearm positioning when residual malrotation is present. Because most displaced both-bone fractures are in the middle region, the hand is placed in a neutral or slightly supinated position, which usually accommodates rotation and angulation. Pronation is rarely employed for complete fractures and may result in a functional loss of supination due to soft-tissue contracture.

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Figure 2A

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Figure 2B

forearm-radiographs-2c.jpgfull-range-forearm-2c.jpgFigure 2C

Fig. 2A, Displaced midshaft fracture of the radius and ulna in a girl aged 9 years I month. 2B, The fracture was reduced in neutral position. Bayonet apposition with minimal angulation and no rotational malalignment was accepted. The fracture united in this position. 2C, Radiographs obtained 6 years later demonstrate complete remodeling. Clinical examination demonstrated full range of motion in pronation and supination.

Distal Radius Fractures

Distal radius fractures are reduced with a combination of traction, angulation, and rotation of the palm in the direction of the angulation. In the case of completely displaced and bayoneted fractures, sustained longitudinal traction is used with fingertraps, as previously described. After the fracture has been brought out to length, deformity exaggeration and rotation may produce end-to-end contact. It may be difficult to obtain apposition, as torn periosteum tightens around the buttonholed proximal fragments (Fig. 1). In these cases, it is acceptable to leave the fragments overlapped as long as rotation and angulation are reduced (Fig. 3). Typically, these fractures are immobilized in casts. Sugar-tong splinting is another form of immobilization commonly used immediately after reduction. If this method is selected, it is important to tighten the splint or convert to a cast when the initial swelling resolves in 2 or 3 days; high rates of reangulation in distal radius fractures have been reported. Distal radius fractures without ulnar fracture are immobilized in a lesser degree of pronation or supination depending on the apex direction. As these fractures are the result of an angulatory force as well as rotation, the position of the wrist is less critical. There is some suggestion that distal radius fractures are more stable in supination because of the action of the brachioradialis.

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Fig. 3A, Distal radius fracture and intact ulna in an 8-year-old girl. Preliminary reduction failed to reduce bayonet apposition. B, After initial immobilization in a sugar-tong splint, a change was made to a long arm fiberglass cast. Early callus formation is noted along the dorsally elevated periosteum. C, Continued remodeling was noted 3 months after fracture. D, The fracture was almost completely remodeled 2 years after injury.

All fractures are eventually placed in either fiberglass or plaster long arm casts with the elbow at 90 degrees. Plaster may be easier to mold, but fiberglass permits better radiographic visualization. Casts are molded with anterior and posterior pressure applied over the interosseous membrane (Fig. 4, A). This tends to separate the bones and increase stability in the cast, and a straight ulnar border is produced. Medial and lateral molding above the humeral condyles will prevent the cast from sliding distally and angulating the fracture after swelling resolves (Fig. 4, B). Meticulous casting is critical as several studies have documented reangulation in approximately 8% to 14% of cases. 11,12,28,29 Some have blamed poor casting technique,11,28 while others have attributed the reangulation to residual rotational malalignment.7,12,30 Forearm AP and lateral radiographs are taken after reduction and immobilization, and improvements of residual angulation can then be corrected by wedging the cast. 23

After adequate reduction and immobilization, patients typically return for a followup radiograph 1 to 2 weeks after injury. Several studies have documented reangulation during the first 2 weeks. If reangulation is documented, cast removal and re-reduction under general anesthesia are recommended. Good results of re-reduction have been documented if performed within a few weeks of the initial fracture. If no reangulation is appreciated, the cast is continued for 6 to 8 weeks or until there is radiographic evidence of healing. Patients cannot participate in contact sports for 4 to 6 months, but all other activities are permitted. Refractures are uncommon; when they do occur, it is usually within several months of cast removal.

Scaphoid Fracture Treatment - Conservative and Surgical

Richard A. Bernstein, MD

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Left: an x-ray of the wrist showing a scaphoid fracture.

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Right: diagram of the wrist showing the position of the scaphoid.

Fractures of the scaphoid, a bone in your wrist, are not to be taken lightly. This is the only bone of the body that I know of that has an entire book written about how hard it is to diagnose and treat scaphoid fractures, and what to do when a fracture does not heal! Most of the time, a broken bone is obvious. The area around the break may be painful, swollen or deformed. But sometimes a bone can break without your realizing it. That ’ s can happen to the scaphoid (pronounced "skaf'-oyd"). Some doctors call this bone the "navicular", but this is an older, out of favor term. Many people with a fractured scaphoid think they have a sprained wrist instead of a broken bone because there is no obvious deformity and very little swelling. If you’ve fallen and think you’ve sprained your wrist, call Dr. Bernstein for an appointment as soon as possible. Rest your wrist until you get seen.

The scaphoid bone is located on the thumb side of your wrist, close to the lower arm bones (see the diagram and x - ray at the top of the page). It is shaped like a cashew, which makes it hard to visualize on the x - ray.

The reason scaphoid fractures have a hard time healing is due to the anatomy of the blood supply to the bone. The blood supply is what keeps the bone alive and allows it to heal. Most of the bone is covered with cartilage, the smooth shiny material that forms the joints and allows the bones to move. Blood vessels cannot enter through the cartilage; they enter only through the bone. Since the scaphoid is mostly covered in cartilage, there is a limited area for the arteries to enter the bone. In the scaphoid, the blood supply to the bone enters from the distal end, that is, the end toward your fingers. This can be a problem for healing, since most fractures occur in the middle or lower portion of the bone. The blood supply to the proximal fragment, that is, the piece that is toward your elbow, may not have any blood supply. Without a blood supply, the bone cannot heal and that fragment may die.

Who Gets Scaphoid Fractures?

Scaphoid fractures account for about 60 percent of all wrist (carpal) fractures. They usually occur in men between ages 20 and 40 years, and are less common in children or in older adults. The break usually occurs during a fall on the outstretched hand. It ’ s a common injury in sports and motor vehicle accidents. The angle at which the hand hits the ground determines the injury. The following is a very rough "rule of thumb": If the wrist is bent at a 90 - degree angle or greater, the scaphoid bone will break; if the angle is less than 90 degrees, the lower arm bone (radius) will break.

Signs and Symptoms

  • Pain and tenderness on the thumb side of the wrist.
  • Motion (gripping) may be painful.
  • May be some swelling on back and thumb side of wrist.
  • Pain may subside, and then return as a deep, dull aching.
  • Marked tenderness to pressure on the "anatomical snuffbox," (a triangular-shaped area on the side of the hand between two tendons that lead to the thumb.)

Diagnosis

The diagnosis is based on a history of trauma to the wrist (usually a fall or accident), a clinical exam that shows tenderness in the region of the scaphoid and a painful Watson test (a maneuver in which the wrist is moved back and forth, with the examiner's thumb on your scaphoid; it is just slightly painful), and x - rays that show a fracture. Sometimes, the x - ray does not show a fracture. In some cases other X - rays are needed to diagnosis the problem. Usually, with a supportive history and clinical exam, the diagnosis will be made of a probable scaphoid fracture.

Treatment

Treatment is determined by the fracture site, the degree of displacement , any associated injuries, and the patient's occupation and desires.

Cast Treatment: Many scaphoid fractures are treated with immobilization in a cast that immobilizes the elbow, wrist, and thumb, for six weeks, and then only the wrist and thumb for an additional six weeks. Healing time, however, can range from six weeks for fractures in the top portion (toward the fingers) to six months or longer for fractures in the lower portion (toward the wrist). The cast must be checked regularly to make sure that it fits properly and prevents movement. After the cast is removed, a rehabilitation program helps restore range of motion and strength.

scaphoid-fractures-3.jpgSurgical Treatment: Some fractures are displaced by 1 mm or so. These usually need surgical treatment. Scaphoid fractures that are accompanied by other injuries, usually a distal radius fracture, also need surgery. Also, with newer techniques, the risks of surgery are reasonably low that some patients choose surgery, because it usually means the patient does not need to we are a cast at all, just a splint. Over the last few years through a limited approach we can address scaphoid fractures and avoid cast immobilization. Via a small incision, I can introduce a screw into the scaphoid and minimize the time in a cast. As with any surgery there are risks with this procedure, there is still no guarantee that the scaphoid will heal and there are risks to the wrist and tendons. The pros and cons are something that we can talk about in the office.

Not all scaphoid fractures will heal properly. The usual causes are delay in treatment or too short a time in a cast that is too short. Smoking also interferes with bone healing. However, the scaphoid is rather famous for not healing, even when everything is done properly. Surgery is usually recommended when the scaphoid fails to heal (non - union). Surgery for non - union is successful in approximately 75 percent of cases.

Sometimes a bone graft is used to promote healing. There are two types of bone grafts. One is using your own bone, often times from the radius bone of the forearm. This can bring in new bone cells to help fill the gap. The other type of bone grafting is taking a segment of bone from the radius and moving it to the scaphoid attached to a microscopic blood vessel. There are certain times to do one or the other that we can discuss in the office.

Scaphoid fractures often take a long time to heal. Any delay in getting treatment increases the risk of poor healing and the probability of more problems later. An untreated scaphoid fracture can lead to severe arthritis and eventually require surgery to fuse or replace the joint.

Copyright © 2010, TOG All rights reserved.
Revised 4/1/11

Tendon Lacerations

Richard A. Bernstein, MD

What is a tendon?

Tendons are tissues that connect muscles to bone, allowing the force of the muscles to move the joints. A ligament is different, connecting a bone to a bone; its cells are different from the cells of a tendon, so there are other differences besides just what it connects to what. The muscles that move your fingers and thumb are located in your forearm, above your wrist. Long tendons extend from the muscles through the wrist and attach to the small bones of your fingers and thumb. The muscles and tendons that flex your fingers (make a fist) are called flexor muscles and flexor tendons. The ones that open your fist are called extensors. There are many important differences between flexor tendon injuries and extensor tendon injuries.

tendon-lacerations-open-hand.jpg

The white, cord-like structures are the tendons in your wrist that move your fingers.

Anatomy

There are two flexor tendons in each finger, the flexor digitorum superficialis (Latin for finger flexor that is closer to the surface, or superficial), also called the FDS, and the flexor digitorum profundus (Latin for the finger flexor that is deep). The FDP attaches to the last bone of the finger and bends the tip. The FDS bends the middle joint of the finger. They have a very specialized blood supply. Since they move back and forth, they are not connected to the rest of the hand The white, cord-like structures are the tendons in your wrist that move your fingers. except at certain places, such as the muscle where they come from, the bone where they go, and a specialized structure called the vinculum (Latin for chain or fetter, i.e., something that holds something down). The thumb has one tendon. See the pictures below.

The flexor tendons run along the palm side of the fingers and are very close to the surface of the skin, particularly where the skin folds as you bend your fingers. The extensor tendons run along the back side (not the palm side) of your fingers and are also very close to the skin.

If you tear (rupture) or cut (sever) the tendon anywhere along its route—at the wrist, in the palm of the hand, or along the finger, you may be unable to bend your finger. If you injure the FDS tendon, you may still be able to bend the finger, but not completely, and bending the finger will be painful.

Tendons are stretched tightly as they connect the muscle to the bone. If the tendon tears, the end connected to the muscle will be pulled back in toward the palm. Because the tendon can’t heal unless the ends are touching, a severed tendon must be sewn back together again (a surgical repair).

tendon-lacerations-open-fingers.jpgThis illustration shows the flexor tendon pulley system (labeled A1 to 5 and C1 to 3). The tendons are below the pulleys, and can be seen in the smaller cross section to the upper left.

two-flexor-tendons.jpg

This illustrates the two flexor tendons, the FDP and FDS, as well as their blood supply that comes through the long and short vincula.

Types of injuries

Most often the flexor tendons are damaged by a cut. Because the nerves to the fingers are also very close to the tendons, a cut may damage them as well, resulting in a feeling of numbness on one or both sides of the finger.

Athletic injuries are also common, usually in football, wrestling or rugby. One player grabs another’s jersey and a finger—usually the ring finger—gets caught and pulled. This type of injury is so common, it even has a name: "jersey finger." You can also strain or rupture the tendon while rock climbing.

People with rheumatoid arthritis may experience a spontaneous rupture of the flexor tendons. You may notice that the finger no longer bends, but cannot recall when you lost the ability to bend it.

Signs and symptoms of a cut tendon

  • An inability to bend one or more joints of the finger
  • Pain when you bend your finger
  • An open injury, such as a cut, on the palm side of the hand, particularly in the joint area where the skin folds as the finger bends
  • Mild swelling over the joint closest to your fingertip
  • Tenderness along the finger on the palm side of the hand
  • Diagnosing your injury

Give me a call if you injure your fingers, especially if you cut your finger or "jam" it and notice that you cannot bend or straighten the tip. For immediate first aid, apply ice and compression to slow the flow of blood to the damaged site.

In the office, I will ask you to bend and straighten the fingers and may apply resistance to test the strength of the fingers. I may also test the sensation and blood flow to your fingers to see if any nerves or blood vessels were also injured. You may need to get an x-ray to see if there is any damage to the bone; if you have an open wound, you may need a tetanus shot or antibiotics.

Treatment

I may first clean and treat any superficial wounds and put your hand in a splint. Flexor tendon injuries require surgical repair and it’s best to have the surgery soon after the injury. I will sew the tendon together using special stitches on both the inside and outside of the tendon. It can take up to 3 months before the repair is healed and strong enough to use your hand without protection. It may take another month or so before you can use your hand with any force.

In the meantime, you will need to wear a splint and see a certified hand therapist. The therapist will give you special exercises to perform. Follow my instructions and that of the therapist carefully to ensure the best possible result. This means both preventing adhesions, which will bind the tendon down and prevent you from moving your finger, and a tendon repair rupture, which is the worst of all, since you are back to square one.

Results

The results after surgery depend on many factors: the location and nature of your injury, the delay between injury and first seeing a doctor, the difficulty of the repair and the skill of the surgeon, and (very importantly) how well you cooperate with post-operative hand therapy. You will experience some stiffness in your finger, but it will improve over a period of two years, and you can dramatically decrease the stiffness by working on range of motion exercises that will be given to you by the hand therapist. You will almost certainly have use of your hand, and probably you have a very good chance of nearly normal use of your hand. The results depend on many variables. I will discuss your particular case with you at the time of the first visit, after the surgery, and as you progress through your rehabilitation.

Copyright © 2010, TOG All rights reserved.

Revised 12/21/10

The Benefits of Orthopaedic Ultrasound

By Richard A. Bernstein, M.D

Over the last few years, the use of musculoskeletal ultrasound has gained increased popularity.  Ultrasound has been used for decades in many aspects of healthcare for its noninvasive nature and avoidance of exposure to ionized radiation.  Though the bony architecture is not visualized in detail, ultrasound provides incredible insight into the soft tissue structures of the musculoskeletal system.  Historically, musculoskeletal ultrasound has been primarily utilized by radiologists due to equipment costs.  As the technology evolved portable ultrasound has become a cost effective tool in Orthopaedic practice. Noninvasive musculoskeletal ultrasound allows a quick and immediate visualization of soft tissues.

Shoulder

In-office ultrasound allows visualization of partial and full-thickness rotator cuff tears, examination for calcific deposits within the shoulder and also allows for greater accuracy in injecting the specific areas around the shoulder.  Anatomic landmarks were relied on for years to inject the acromioclavicular joint, subacromial space and glenohumeral joints.  However, the advent of musculoskeletal ultrasound helps increase the reliability and accuracy of these injections.  Anatomic visualization of the rotator cuff may now also be done in the office setting.  It does not preclude the use of magnetic resonance imaging (MRI) for labral or other rotator cuff pathology, but ultrasound is a painless inexpensive test, now at our disposal.

Ultrasound-process-applying-gel-to-elbow-for-bernstein-article-(2).pngElbow

Similar to the shoulder, the use of ultrasound aids in the diagnosis of both medial and lateral epicondylitis and cubital tunnel syndrome.  The accuracy of intra-articular aspirations and injections has improved utilizing ultrasound technology.

Hand and Wrist

One of the greatest advantages of in-office ultrasound is the evaluation of hand and wrist soft tissue abnormalities.  The subcutaneous position of these abnormalities allows relatively easy access for diagnostic assessment.  Aneurysms and ganglia may be differentiated by color Doppler ultrasound. For example, a mass that is fluid filled may be a ganglia, whereas a solid mass may be a tumor. Most foreign bodies are non-radiopaque, but diagnostic ultrasound allows the visualization of small foreign bodies buried in the subcutaneous tissue. 

Ultrasound-Machine-for-Bernstein-article-wrist.pngThe differential diagnosis of radial wrist pain includes basal joint arthritis or deQuervains tenosynovitis of the first dorsal compartment.  Identifying the diagnosis clinically may be challenging. However, ultrasound of the first dorsal compartment may show tenosynovial inflammation and thickening of the first dorsal compartment which guides the differential diagnosis.  Thickening or enlargement of the first dorsal compartment may also be easily visualized on ultrasound. In an inflamed wrist, the addition of ultrasound may guide a corticosteroid injection into an inflamed sheath and improve its efficacy.

Superficial traumatic hand lacerations may affect the integrity of underlying tendons. Ultrasound may visualize the intact or lacerated flexor tendons thereby eliminating a need for surgical wound exploration. Foreign bodies may also be readily visualized in the office setting and thereby avoid expensive and time consuming testing.

Ultrasound-Machine-for-Bernstein-article.pngAnother advantage of diagnostic ultrasound is in the diagnosis of carpal tunnel syndrome.  Ultrasound allows for visualization of the median nerve in the wrist. Multiple studies have demonstrated that a median nerve cross sectional area greater than 10mm is consistent with carpal compression.  In hopes of avoiding useful though invasive, neuro-diagnostic testing, a faster painless noninvasive ultrasound may give significant information regarding the diagnosis of an entrapment neuropathy at the wrist.  Furthermore, aspiration and injection of the smaller joints of the hand and wrist are far more accurate with ultrasound guidance. This minimizes patient discomfort.

The rheumatology literature has also reported the beneficial use of ultrasound to identify early inflammatory arthritis. A patient may present with one inflamed finger joint but be found to have inflammatory synovitis of multiple digits by ultrasound, thereby warranting further serologic investigation.

In summary, the utility of musculoskeletal ultrasound is an incredible advantage to the physician and it is an even more important benefit to the patient as it allows for a definitive diagnosis and more effective, less painful treatment.

Wrist Arthroscopy

Richard A. Bernstein, MD

Wrist arthroscopy is an outpatient surgical procedure used to diagnose and treat problems inside the wrist. I will make small three or four incisions, usually less than a half - inch long, and insert an instrument called an arthroscope, which is smaller than the diameter of a pencil. The arthroscope contains a small lens, a miniature camera and a lighting system, enabling me to look directly inside the joint. Tiny probes, forceps, knives and shavers can then be inserted into the wrist and may be able to be used to correct some problems. I also have some nifty instruments for suturing inside the joint!

Wrist anatomy

The wrist is a complex joint, with eight small bones and many connecting ligaments. Arthroscopy enables me to see the anatomic parts more easily than with an open incision. I can see the movement of the bones, test the tightness of the ligaments, look for cartilage damage, and make a more accurate diagnosis than I can from MRI o r other imaging modalities (x - ray, arthrogram).

Wrist-Arthroscopy.jpg

Diagnostic arthroscopy

Diagnostic arthroscopy may be used if the cause of your wrist p ain cannot be identified or if wrist pain continues for several months despite nonsurgical treatment. Before surgery, I will perform:

  • A physical examination that focuses on your hand and wrist.
  • Provocative tests that involve moving your hand in ways that reproduce the pain.
  • Differential Lidocaine injections, to help localize the source of the pain.
  • Imaging studies, such as X-rays of your hand and wrist.

Arthroscopic exploratory surgery may be used to confirm my diagnosis of a ligament tear or a triangular fibrocartilage (TFCC) tear. Ligaments are fibrous bands of connective tissue that link bones, helping to control the motion of our joints and providing stability and support. The TFCC is a fibrocartilaginous cushioning structure within the wrist, made of material very much like the meniscus of the knee. Most people have heard of "torn cartilage in the knee"; this usually refers to the meniscus. The meniscus is a piece of fibrocartilage that cushions the thigh bone from the leg bone. The TFCC similarly cushions the wrist especially along its outside portion. A fall on an outstretched hand can tear ligaments, the TFCC or both, resulting in pain with movement or a clicking sensation. In some cases, after the diagnosis is made, the condition can be treated arthroscopically as well.

Arthroscopic surgical treatment

Arthroscopy of the wrist is generally considered the "gold standard" to diagnose wrist conditions. Though physical exam, regular X - rays and certain more sophisticated X - rays can be useful, many times these tests are not definitive and surgical examination via arthroscopy is helpful for an accurate diagnosis.

Several conditions can be treated using arthroscopic surgery, including tears in the ligaments or the triangular fibrocartilage complex, synovitis (inflammation) and cysts. Often, there may be areas of inflammation, cartilage damage, or other findings after a wrist injury.

During arthroscopic surgery, I can trim or repair the tears. Wrist arthroscopy may also be used to smooth the bone surface s and remove inflamed tissue. Based on the findings at the time of arthoscopy, the post-operative regimen can change. Generally speaking debridement or cleaning up tears allows an earlier restoration of motion. If the ligament or cartilage (TFCC) requir es repair, this generally requires immobilization in a cast and then a splint for a period of time, depending upon the specifics. The specifics we will discuss after surgery.

Arthroscopy and limited incision surgery is also available to treat fractures of the scaphoid bone of the wrist. Limited approaches to the scaphoid fracture can often times get you out of a cast sooner than you would otherwise.

Arthroscopic surgery in general

Usually, general anesthesia is used during arthroscopic surgery. After the surgery, the incisions are each closed with a small stitch and a dressing and splint is applied.

After surgery, you will need to keep your wrist elevated and keep your bandage clean and dry. You can ice your wrist to help keep swelling down. I will give yo u a prescription for specialized hand therapy. The hand therapist will teach you exercises to help maintain motion and rebuild your strength. Analgesic medications will help relieve any postoperative pain, which is usually mild.

Complications

Complication s during or after arthroscopic wrist surgery are unusual, but may include infection, nerve injuries, excessive swelling or bleeding, scarring or tendon tearing. An experienced surgeon, particularly one who specializes in treating the hand, can reduce the likelihood of complications.

Summary

Arthroscopic surgery is a valuable diagnostic and therapeutic (treatment) tool. It is minimally invasive, and patients generally experience fewer problems and a more rapid recovery than with open surgery. Because it is an outpatient procedure, most patients are home several hours after surgery.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10