Trigger fingers

Expert, Textpert, joking smoker don’t you think the joker laughs at you.

“I am the Walrus” by the Beatles

Carpal tunnel syndrome is the most common hand condition that hand surgeons treat, but a problem known as the “trigger finger” probably runs a close second.  The trigger finger is a condition where the tendons that bend the finger get stuck.  The finger can bend down (this is called flexion) but when you try and straighten the finger up the finger has to be pushed up, sometimes with a pop or catch.  The problem occurs because the tendon which bends the finger runs through a sheath which begins  in the base of the hand.  Usually the tendon or it’s lining gets thick and that causes the tendon to get stuck.  In some people the sheath gets too thick, which cause the sheath to be too narrow to allow the tendon to glide.  In some people both things probably occur.  Since the tendon is actually getting stuck in the palm of the hand, this is the area that is usually the most tender.  However the joint that gets stuck is the first joint of the finger known as the proximal interphalangeal joint.   Sometimes it takes some time to convince people that the tendon is actually catching in their hand and that’s there’s nothing actually wrong with the joint.

Trigger fingers can occur in almost any age group, but the highest incidence is seen in middle aged women who are usually otherwise healthy.  Plenty of men get trigger fingers as well, but women have the problem 2-3 times more frequently.  Sometimes more than one finger may catch, and it can occur in both hands.  For some reason I often see patients who get the same trigger finger in both hands and I really have no explanation for that.  Other patients will have swelling in their finger and tenderness over their tendon sheath without actually locking.  This is probably the same problem as the trigger finger but in an earlier stage.

Trigger fingers can be seen in patients who have carpal tunnel syndrome as well.  Patients who are predisposed to have carpal tunnel syndrome, such as patients with diabetes and thyroid disease, also seem to have an increased incidence of trigger finger.  The thumb is the most common digit to trigger although any finger may develop trigger finger.

Most people try some form of non-surgical treatment for this problem.  Sometimes the problem just goes away.  If the finger is still locking after 4 to 6 weeks then it probably won’t get better on it’s own.  I’ve had patients try splinting their finger out straight to keep it from bending, especially when they sleep since the trigger seems to be worse in the morning.  Medicines such as NSAID’s (advil and aleve) don’t seem to have much affect on the problem.  If the triggering is causing problems such as pain or is interfering with activities, then most of my patients try at least one cortisone shot.  The shot is placed into the tendon sheath and seems to both shrink the tendon and enlarge the pulley to allow the tendon to glide without catching.  Although the results are variable I think that usually at least 65-70% of patients will have their trigger finger go away with a single injection.  A second injection can be done if the first one wears off but any further injections don’t seem to do much good.  The injections hurt for a short period of time and can sometimes cause the finger to temporarily go numb because of the local anesthetic that is injected along with the cortisone, but other than that it is very rare to have any complications from the injections.  Patients with diabetes have to keep a close eye on their blood sugar because the cortisone can send the levels of pretty high for several days in some patients.

If the shots don’t work then surgery is an effective way of getting rid of the problem.  The surgery can be done with a local anesthetic or with sedation, and consists of making a small incision over the sheath where the tendon is catching.  A small portion of the sheath is then opened to allow the tendon to glide.  If there is a lot of swollen tissue around the tendon this can be removed at surgery as well.  The whole procedure usually only takes about 5 minutes.  The biggest risks of surgery are for the finger to re-lock or for an infection to recur, and fortunately both of those complications are rare.

If the trigger finger is only an annoyance nothing has to be done.  No damage will occur from leaving the problem untreated.  If you are having problems then a cortisone shot will often relieve the problem, and if that doesn’t work a simple surgery can often take care of the problem once and for all.

Tennis Elbow: And I don’t even play tennis!

“Americans love a winner.  The very thought of losing is hateful”

George C. Scott as General George S. Patton in the movie “Patton”

Elbow pain is one of the most common and vexing problems I treat.  There are only a few causes of elbow pain, and none of them have a simple answer.  In addition elbow pain often affects relatively healthy people in their 40’s and 50’s, and they have a hard time reconciling the limits that these problems can cause on a healthy and active lifestyle.

The most common cause of elbow pain is usually called lateral epicondylitis, which is better know by it’s common name of “tennis elbow.”  The pain is located on the outside of the elbow and is usually centered on a bony prominence called the lateral epicondyle.  This is the bump that you feel on the outside of your elbow.  This area is the attachment point of the muscles that extend of lift up your wrist, and this is the area that’s involved in tennis elbow.  The underlying problem is a degeneration of a tendon attaches to the bone.  The simplest way to think about this is that the tendon starts to unravel with use and activity, and your body is having a hard time healing this area on it’s own.   The symptoms usually begin slowly when people notice a pulling type of discomfort on the outside of their arm with certain activities.  Lifting luggage or a coffee pot are two of the most common activities that people describe to me that cause them problems.  A small percentage of people, probably 5-10%, actually have pain when they play tennis.  In general this starts off as an aggravation but things can spiral and get worse to the point that the pain is noticeable with almost any use of the arm.  People rarely have pain at rest.

Most people try to rest their arm and perhaps take over the counter anti-inflammatory medications such as Aleve or Advil.  This works a lot of the time.  When the problem persists then patients will come to see me or their primary care physician for advice.  The main thing I tell people is that this indeed will pass, but it may take up to a year or longer.  For people engaged in active lifestyles modifying their activities for that length of time is not much of an option.  In addition, the pain can get bad enough that it restricts not only leisure activities but work as well.  So when it gets to this point, what can we do about it?

The first step in treatment is a good exercise program.  I have a series of exercises that I provide patients.  They involve stretches and some gentle strengthening exercises that try to strengthen the muscles that move your wrist.  The theory is that if you can strengthen the muscles that are involved in the problem, then there will be less stress on the muscle where it originates at the elbow.  I can relate to you first hand that the exercises do work since I have had problems with both tennis elbow and a similar problem called “golfer’s elbow” which occurs on the inside of the elbow.  Once I took the advice I give to my patients and started the exercise program my symptoms have almost completely gone away.

Elbow braces are also a good idea for most people.  These are usually called counterforce braces, and they generally are straps with a gel foam pad on them.  The pad is placed over the area of tenderness  on your forearm just past the elbow.  The thought is that the pad absorbs the stress before it gets to the tendon and decreases pain.  Again, from personal experience, I can say that these pads do a good job of decreasing pain with activity.

If these methods don’t work other options are available.  Many physicians will offer a steroid shot into the damaged tendon area to try and stimulate healing.  This is somewhat controversial, since some reports seem to show that the shots don’t really make too much of a difference.  In my experience the shots can help when the pain is very severe, but that the long term cure rate of the problem will be the same with or without the shot.  In other words, the shot can get you through a rough patch.

The last resort is surgery.  Traditionally a standard open surgery which consisted of removing the damaged tendon tissue has been the mainstay of treatment, and this is still, by far, the most common surgical treatment for tennis elbow.  The surgery works pretty well, and I would estimate that 85% or more of the patients who have the surgery get rid of the problem.  There is usually significant down time with open tennis elbow surgery, and it probably takes 3-4 months to completely recover.

Another option is a newer procedure known as the FAST procedure, or focused aspiration of scar tissue.  This was developed at the Mayo clinic using ultrasound technology developed for cataract surgery.  A small probe is inserted (using anesthesia) into the area of damaged tendon using an ultrasound machine to identify the injured area.   The probe then directs ultrasound directly into the tendon and can remove the damaged tissue.  In general the recovery is much shorter the surgery is much less invasive than the open procedure.  The technique is still new, and there aren’t a lot of reports on the effectiveness of the procedure.  I have been doing the FAST procedure for several years, and my experience is that is does work very well, but that there is a lot of variability in the outcomes people experience.  I will usually offer the FAST procedure for patients who want surgery with the warning that it probably doesn’t work quite as well as the open procedure.

So if you have tennis elbow, don’t get discouraged.  You have a lot of company out there.  Try the simple things first and this too will pass.  If not, there are options available to get rid of your pain.

Do I have to be put to sleep? A surgeon’s view of anesthesia for hand surgery

It’s better to burn out than it is to rust.

Neil Young from the song “Hey hey, My my”

One of the great aspects of being a hand surgeon is the fact that almost all the surgeries that I do can be done as an outpatient.  In fact I’m finding that I can safely do more procedures in the office as well.   One of the main factors that determines where a surgery can be done is the anesthesia that is required.  Patients have a healthy fear of being “put to sleep” and we have found that a great number hand surgeries can be done with local anesthesia.  What I would like to talk about in this post is the different types of anesthesia that hand surgeons use and the various types of operations that can be done under the different types of anesthesia.  I’ll start with the most complicated and move to the simpler methods of anesthesia.

General anesthesia, or being “put to sleep” is commonly used for longer and more involved surgeries.  There has been a number of great improvements in the types of medications used for general anesthesia so that patients seem to have fewer problems from general anesthesia.  Two of the most common side effects of general anesthesia are drowsiness and nausea and the newer medications have decreased the incidence of these complications.  In addition many general anesthesia cases can be done with a device called an LMA (laryngeal mask airway) which avoids placing an breathing tube  (endotracheal tube) into the trachea.  This can avoid problems with throat irritation after general anesthesia.  In my practice I do most major elbow surgeries under general anesthesia, and major surgeries around the hand and wrist that I expect will take longer than an hour or so I will do under general anesthesia as well.

Sometimes patients choose to have their entire arm “numbed up”.  These are called “blocks” and the goal is to numb all the nerves to the arm and hand.  The nerves can be blocked in the armpit or above the collar bone.  This type of anesthesia is commonly done for shoulder surgery, but I don’t use it too often in the hand and wrist areas.  The blocks probably work only about 75% of the time, and most people who need this level of anesthesia choose to go ahead and have general anesthesia.

Many of the surgeries I do are done with local anesthesia.  Some patients choose to be sedated, and the medical term for the sedation is MAC, or monitored anesthesia care.  In many cases some of the same medicines that are used for general anesthesia are used in the MAC but in lower doses than are used for general anesthesia.  Most patients have the sensation that they are completely “out”.  The purpose of the anesthesia is to avoid the pain of the injection of the local anesthetic and also to help control pain that can arise from the use of a tourniquet during hand surgery.

I have an increasing number of patients who choose to have their surgery done with local anesthesia only.  If the surgery is being done on a finger then it is relatively easy to numb the entire finger and use a small finger tourniquet to do a number of different types of surgeries.   I do a number of surgeries in my office using this technique,  the most common one is to remove small cysts from fingers. Also there has been a recent upswing in the number of patients using local anesthesia for surgeries such as carpal tunnel releases or a procedure called a trigger finger release.  Studies have shown that it is safe to use local anesthesia in the hand that has epinephrine in it.  Epinephrine can greatly decrease bleeding and allow some surgeries to be done without a tourniquet.  There’s some discomfort when the shot goes in, but once the incision is numb then the patient doesn’t feel any pain or discomfort during the procedure.  This is a great way to go if you want to avoid any chance of having problems with nausea or sedation.

If you’re planning on having hand surgery certainly ask about the anesthesia options available.  Every surgeon has different ideas but most surgeons should be open to using a number of different types of anesthesia to suit your needs.

 

Lumps and bumps: What’s this on my hand doc? The ganglion cyst.

“When you have eliminated the impossible whatever remains, however improbable, must be the truth”

Sherlock Holmes from The Sign of Four by Sir Arthur Conan Doyle

Lumps and bumps, masses and growths in the hand, are one of the most common reasons patients come to see hand surgeons.  Fortunately malignant ,or cancerous, lesions in the hand and wrist are very, very rare, so much so that a hand surgeon may go through his entire career and never treat a malignant lesion.  A good hand surgeon is always on the lookout for malignant tumors, but the vast majority of hand lesions are benign growths that can be either observed or removed without too many problems.

By far and away the most common hand tumor is a growth called a ganglion cyst.  Ganglions are fluid filled cysts that usually arise from joints or from other areas such as the sheaths of tendons.  No one has any idea how these lesions arise.  A fair number of them will come and go seemingly as they please.  A great number of people live with these lesions and they never cause them trouble.  I have a couple of ganglions on my fingers, and when I show them to patients who have them most people choose to live with them rather than to have them removed.

What is a ganglion like?  It’s usually a solid lesion that you can move around a bit.  You can usually feel around the mass and get the feeling that the mass is separated from the surrounding tissues.  If you shine a light through it the light will usually pass through, or trans-illuminate the lesion.  The cysts have a fairly thin wall and inside they contain a viscous fluid that looks more like hair gel than anything else I can come up with.  They can grow to some degree, but I’ve not seen a ganglion in the hand or wrist that got as big as a ping pong ball.  Ganglions can grow up around the other structures in the hand, but only very rarely do they cause a problem.  My sense is that ganglions are like balloons, in that they can only grow and fill up to a certain size.

There are four common locations for ganglions in the hand and wrist, although they can occur in other locations.  I’ll talk about each location separately.

The most common location is on the back of the wrist.  Ganglions can start as very small growths, the size of a pea, that arise from the wrist joint and grow bigger and become more noticeable.  Some people get pain in the back of their wrist from the ganglion, especially when they’re doing things like a push up.  About 30% of ganglions go away on their own.  An option for treatment, especially on the back of the wrist, is to pop the cyst with a needle after numbing the skin over the cyst.  You can draw out the jelly inside the cyst, and this gets rid of 50-60% of the ganglions.  The last option is surgery, which can result in some stiffness in the wrist.  Even with surgery I would estimate 2-3% of ganglions recur.

The second most common site is on the bottom of the wrist near where your pulse is.  These arise from the wrist joint as well.  These cysts will grow up towards the radial artery, which is your pulse, but they will never choke off or constrict the artery.  Because the artery is so close to these cysts I’m not very fond of trying to aspirate these cysts.  I usually recommend either living with the cyst or have it removed with surgery if it’s bothering you.  The surgery is a little harder than taking those out on the back of the wrist because of the location of the artery, but the cyst can be safely removed in an operating room.

The most common location in the fingers is just in front on the nail.  These small cysts arise from the last joint of the finger called the distal inter-phalangeal joint, or DIPJ.  A lot of patients have some underlying arthritis at the joint.  The skin is really thin over this joint, and sometimes these cysts can grow and actually pop through the skin.  I’ve patients try to pop these on their own, as well as some physicians, and I don’t seem to have much luck trying to pop, or aspirate them.  Again I advise folks to live with the cyst or have it taken out.  I remove almost all of these in my office under local anesthesia and most of the patients do very well.  Like ganglions in other locations, these can recur after surgery.

The last spot that ganglions occur is in the palm of the hand at the base of the finger.  These ganglions arise from a tendon sheath rather than a joint, and they are usually very firm and not as mobile as ganglions in other locations.  I have a couple of these in my right hand that have been there for years and not caused me any problems.  In some people the cyst can get tender and cause problems grasping objects so they want something done about it.  You can occasionally succeed in popping the cyst with a needle after numbing the skin with local anesthetic or you can have the cyst removed with surgery.

If you have a ganglion there is no harm in living with it.  They won’t grow and cause problems by wrapping themselves around nerves or tendons.  In most cases you can pop, or aspirate the cyst, which has around a 50/50 chance of working or you can have the cyst removed with surgery.  2-3% of cysts can come back after surgery.