What’s New in Hand Surgery

“Anything you can do to help would be very…..helpful”

from Monty Python’s “The Search for the Holy Grail”

To be honest with you things tend to change very slowly in the field of hand surgery.  Most of the treatment I provide are not much different from what I learned during my hand fellowship almost 30 years ago.  In general this is not a bad thing since most of these treatments have stood the test of time and have been proven to be predictable and reliable.

However over the past several years several new treatments have become available that have changed the way I treat several conditions and perform surgery.  I’m excited about these changes and I wanted to share them with you so you can be aware of what’s new in hand surgery.

The most dramatic change has come in the treatment of Dupuytren’s disease.  I touched on this on an earlier post about Dupuytren’s and you can refer to that post for more information.  The change has come with the discovery of a medicine that can be injected into a cord and allow us to disrupt the cord and straighten the finger without surgery.  Before the creation of this medicine, called Xiaflex, surgery was usually the only option for treatment for a patient with Dupuytren’s who had a cord that was pulling their finger down and causing difficulty in using their hand.  The surgery was usually successful, but it was a long, difficult and demanding procedure both for the surgeon and the patient.  Recovery usually took several months, and there was a significant chance of damaging a nerve and causing numbness after the surgery.  With Xiaflex the entire process of disrupting the cord and straightening a finger is much easier on the patient and the recovery process is much shorter and simpler.  The results are similar to those seen with surgery.  I’ve taken care of patients who had surgery on one hand and then had xiaflex on another hand, and they are amazed at the difference and how much simpler that procedure is.  Xiaflex doesn’t work in every case, but overall I think it’s been a tremendous improvement in the care of the patients I see with Dupuytrens disease.

Another new and innovative treatment that has come about is the use of an ultrasound probe for the treatment of chronic tendonosis of the elbow, known as tennis elbow and golfers elbow.  I’ve discussed both conditions in previous blogs and you can refer back to those posts for more information.  These problems affect of lot of people as they reach their 40’s and 50’s and can affect people during a lot of activities they like to do.  Rest, exercises and an occasional cortisone injection can take care of most of these problems, but in some people the pain persists to the point that they need something more done.  In the past the only other option was to make an incision and surgically remove the damaged tendon tissue.  This surgery worked pretty well, but it usually took 3 to 4 months to recover and regain strength and use of the arm.  Some inventive physicians from the Mayo clinic theorized that you could use ultrasound to remove the damaged tendon tissue through a small puncture wound rather than a large incision.  They developed what is called the FAST procedure (F-focused A-aspiration of S-scar T-tissue).  A small ultrasound probe is placed through a tiny stab wound directly into the area of damaged tendon, which is seen and localized on an ultrasound machine similar to what people use to see unborn babies in the womb.  The entire procedure only takes a couple of minutes and can be done under local anesthesia.  I think the FAST procedure works very well, but doesn’t help every patient.  The open procedure may work a little better, but the FAST procedure usually results in a quicker recovery and much less down time.  It’s nice to have something to offer patients who have chronic elbow problems without having to resort to pretty big surgical procedure.

The third change has been in the improvement in the use of local anesthesia in hand surgery.  In the past we have been able to numb fingers very well, but it was difficult to use local anesthesia for many cases.  The hand bleeds very much, which means we have to use a tourniquet to control the bleeding.  A tourniquet is like a blood pressure cuff, and most people can’t stand it for more the 3 or 4 minutes before it becomes very uncomfortable.  However a hand surgeon in Canada figured out that , contrary to what was commonly thought, it was safe to use local anesthesia with epinephrine in the hand.  Epinephrine controls bleeding, and it allows the surgeon to operate on the hand and control the bleeding without the use of a tourniquet.  This has allowed me to do a number of procedures such as carpal tunnel release, trigger finger release and Dequervain’s surgery under local anesthesia.  A lot of patients choose this option and almost universally they enjoy the experience and have no problems with the surgery.  It’s nice for the patients to have options about not only their treatment but also about the way the treatment is done.

Dequervain’s Tendonitis: De ker what?

Standing beside the ocean, looking across the water

Everything is beautiful here but I still don’t feel like I oughta

from the song “Dancing the Night Away” by the Amazing Rhythm Aces

 

One of the most common conditions that involves inflammation, or swelling, in the hand and wrist is called “Dequervain’s Tendonitis”.  The names comes from a Swiss physician who first described the problem way back in 1895.  People pronounce this in various ways, most commonly something like De-kwer-vains.  The problem involves a group of tendons that help to move the thumb.  The tendons get irritated as they pass through a sheath that helps hold them close to the bone.   Most patients have pain with movement of their thumbs and swelling in their wrists on the side of the wrist near the thumb.  Most of the time the swollen area if very tender.  Some patients will get popping of their thumbs when they move their thumb because the tendons are so swollen they are popping as they pass in and out of their sheath.

As far as anatomy goes, there are 6 groups of tendons that pass through compartments in the wrist.  The tendons involved in Dequervain’s are in the first compartment so Dequervain’s is also known as first dorsal compartment tendonitis.  There are two tendons involved with the elegant names of the abductor pollicis longus and the extensor pollicis brevis.  The help move the thumb away from the other fingers and lift the thumb away from the palm.  Most people have one compartment for both tendons, but people who have Dequervain’s can have two seperate compartments, one for each tendon.

Most of the time there is no known cause and the symptoms seem to appear out of nowhere.  Some patients recall a minor injury, while others relate the problem to increased use and repetitive activity of the thumb and wrist.  In all likelihood the tendons get inflamed through some change in activity and then the repetitive use probably doesn’t allow the tendon to heal and rest.  In patients with two separate compartments, as mentioned above, I think the tendons just don’t have enough room to heal when they get irritated and inflamed.

It’s usually not too hard to diagnose the problem.  Patients usually have pain with movement of both the thumb and wrist, and most of the time there are very specific activities that aggravate the problem.  Swelling and tenderness over the first dorsal compartment is usually seen as well.  There is a specific test to help diagnose the problem which is known as Finklestein’s test.  The best way to describe how to do this test would be to bend you thumb into the palm, grab the thumb with your fingers, then make a motion like you are casting a fishing pole.  If you have Dequervain’s that test should reproduce the pain and discomfort that you are having.

Initial treatment usually consists of rest, ice, over the counter non-steroidals like Aleve or Advil and avoiding as much as possible the activities that aggravate the problem.  If these don’t work a brace that immobilized the thumb is a good idea.  I see a lot of patients who have braces the hold the wrist still but don’t do anything to the thumb and rarely do these help at all.  The thumb has to be pretty still for the brace to work, and the splints often are called thumb spica splints.

If these initial treatments don’t work and the symptoms persist and cause problems, then the next most reasonable options are cortisone injections or surgery.  I haven’t tried creams or rubs very much because most patients don’t seem to be helped by them, but it’s an option if the patient wants to avoid something invasive.

Cortisone shots work fairly well for Dequervain’s.  Probably 70% or more of the patients who receive an injection will get relief of their symptoms, often without any further problems.  If the shot works initially and then the symptoms recur then another injection is a reasonable way to go.  If the shots fail to work or quit working then surgery is an option.  The surgery involves opening up the sheath where the tendons are inflamed and cleaning out the inflamed tissue.  The surgery can be done as an outpatient under local anesthesia with or without sedation and is usually successful with few complications.

Dequervain’s tendonitis is a common condition that can be successfully treated without surgery, but surgery is an option if other treatments don’t work.

 

Dupuytren’s Disease: What do I do about it?

He’s old enough to know what’s right but young enough not to choose it.

from the song “New World Man” by Rush

Once a patient has been told they have Dupuytren’s disease the next question is what to do about it.  In general patients that develop cords will get a contracturewhich causes the finger to bend will need some form of treatment.  It’s usually best to wait until a contracture has progressed a little bit before considering treatment since mild contractures really don’t get in the way of hand function.  A joint usually has to contract about 30 to 40 degrees before it starts getting in the way and that’s the point that most patients start to think about getting something done.

In the past the most common treatment was excision of the cord by surgery.  While this sounds fairly simple, in reality I always found this to be one of the hardest surgeries I did.  The cord, although well defined, was often tightly connected to the skin so it required a great deal of skill and patience to remove the cord from the skin.  What was even more difficult, however, was the fact that the cords often wrapped around the nerves and arteries to the finger, and it was very difficult to free the cord from the nerves and arteries.  Although I’ve never cut a nerve during a Dupuytren’s surgery I think it is something that could happen even with a careful and skilled surgeon.  The care after surgery is also very difficult since the extensive surgery required to excise the cord caused a good deal of swelling.  Many patients require therapy and the recovery from the surgery often takes several months.  That being said, surgery is usually very successful in removing the dupuytren’s tissue and straightening out the finger.  Dupuytren’s can come back after surgery and the surgery for recurrent disease is even more difficult than the original surgery.

In order to avoid many of the difficulties of surgery several surgeons tried something a little less invasive.  Instead of removing the entire cord they began cutting the cord with a sharp needle under local anesthesia.  In medical terms this is known as a needle aponeurotomy.  Many hand surgeons utilize this technique and have good results with the procedure.  It can be done in the office under local anesthesia and is much less invasive than the surgery that is done to remove the cord.  In addition recovery is much quicker than with surgery.  Personally I have never done this procedure because of my fear of damaging a nerve or artery with the needle.  It also seems that the recurrence rate after needle aponeurotomy is pretty high, which is to be expected since the dupuytren’s tissue causing the cord is not removed.  I think this is a good choice for patients as long as the treating physician has a lot of experience with the technique.  Needle aponeurotomy makes me a little nervous so I don’t do it, but I understand the reasons people choose to have this done.

A third option has now been available for the past 6 years.  Several physicians worked to develop a drug which , when injected into the cord, could cause the cord to start to unravel and allow the cord to be separated, allowing the finger to be straightened.  The cords are made out of a material called collagen, and the medicine is a protein that eats up or lyses the collagen.  In medical terms the medicine is called a collagenase, and the medicine we used is known as Xiaflex.  Xiaflex was introduced in 2010 and this has been my first choice for the treatment of symptomatic cords since that time.  The medicine is first injected into the cord, and then at a point 24 to 72 hours after the injection the finger is straightened out, which causes the cord to tear and disrupt.  The Xiaflex continues to work even after the cord is straightened, so that in a lot of cases the dupuytren’s tissue eventually dissolves.  The results from Xiaflex treatment seem to be similar to surgery.  The biggest downside is the cost of the drug.  Most of the time insurance covers most of the cost but patients can be stuck with a significant bill.  My office has a lot of experience in dealing with Xiaflex so we can usually get a pretty good idea of the financial aspects involved in the treatment.

In summary, in the past surgery was about your only choice to remove dupuytren’s disease and straighten out a crooked finger.  Less invasive techniques such as needle aponuerotomy and collagenase injection (Xiaflex) have been developed so that patients now have a choice of treatments that they can discuss with their physician and decide which one suites them best.

 

Dupuytren’s Disease: What is it?

I’ve got vision and the rest of the world’s wearing bifocals.

Paul Newman as Butch Cassidy in “Butch Cassidy and the Sundance Kid”

One of the more interesting problems a hand surgeon encounters is a rather unusual condition know as Dupuytren’s disease.  This is a condition where the normal tissue in the palm of your hand becomes thicker and can sometimes progress and cause the fingers to pull down and contract.  Dupuytren’s disease usually starts as a nodule in the palm of the hand.  This can occur at the base of any finger, including the thumb.  In some cases the nodule can be painful and tender, but generally the pain and tenderness go away and the patient is left with a small painless knot in their hand.

Most patients are usually first seen by their primary care physicians for this problem.  Most of the time it’s not hard to diagnose the problem, but sometimes the nodule can be confused for a cyst in the hand, and cysts do occur in the same area.  However if you’re carefully examined a physician can usually tell the difference between a cyst and a dupuytren’s nodule. Patients are usually sent to a hand surgeon for evaluation and recommendations for treatment.

There is no single cause for Dupuytren’s disease.  Some patients will have family members who have had the problem, but the majority of the time patients don’t know or can’t remember any relatives who had the problem.  The disease does seem to be more closely associated with certain ethnic groups, although Dupuytrens’ has been seen in patients of all races and cultures.  The most common association is with people of Northern European descent, so much so that one of the names for Dupuytren’s disease is “Viking Disease”.  Trauma, either acute or repetitive, does not cause Dupuytren’s disease.  So most of the time the nodules just appear, seemingly out of nowhere.  The disease occurs in both men and women, but is much more common in men, probably by a ratio of 2:1 or higher.

If you have a nodule, there is a pretty decent chance that a contracture, or pulling down of the finger, will never occur.  The best estimate is that only 50% of people who develop a nodule, or bump, will ever go on to have a contracture that will bother them or require treatment.  There is no treatment that can affect the progression of the disease.  No medicine, diet, exercise or anything else will have any affect at all on this process.  The one thing that can make it worse is to operate on a nodule before it causes a contracture, since that can sometimes cause a progression of the disease and further problems.  I’ll talk about that more in my next post, when I’ll talk about the treatment of the disease.

Some factors do raise a red flag and indicate that a patient may develop a contracture that will cause problems and require treatment.  The most important is probably a strong family history of the disease.  If Dad or an uncle had a bad contracture, then the odds are pretty good that if you develop the disease then you will have a significant contracture as well.  Another bad sign would be if you have similar nodules elsewhere in your body.  The most common area is the bottom of the feet.  Also, some patients all develop tender areas on top of their fingers called “knuckle pads”, and if you have these that can be a sign that the disease may progress.  The third factor would be developing the problems at a younger age, younger in this case being below the age of 50.

My next blog will discuss the treatment of Dupuytren’s disease.  There have been some exciting advances in treatment and some new, non-surgical treatments are available that I will discuss in detail.

 

Mallet Finger

“He’s old enough to know what’s right but young enough not to chose it”

from the song “New World Man” by Rush

There are a number of seemingly minor hand injuries that can cause a lot of trouble, and the injury know as “mallet finger” is one of those.  This injury usually occurs during some very minor and normal activity, and people often then feel a tear or pop and realize they can’t straighten the end of their finger.  I’ve seen patients who did something as trivial as flicking an object and cause a mallet finger.

The injury occurs when the tendon that straightens the end of the finger either stretches or pulls away from the bone.  Since this is the only thing that can straighten the end of the finger the joint gets bent down and can’t be straightened.  The patient can push the finger up straight but it won’t stay there.  Many people intuitively know to try and splint their finger straight, but the problem is that this injury takes a long, long time to heal and requires a lot of patience by both the patient and the physician.

The tendon usually pulls off the bone, but every once in a while the tendon will pull off with a piece of bone.  The bone piece can be a small fleck or it can be very large, sometimes up to half the joint surface of the end of the joint.  The good news is that almost all of these injuries can be treated without surgery.  The bad news is that treatment often requires wearing a splint for a minimum of six weeks and often times the splint has to be worn even longer.

The key to treatment is to keep the finger completely straight during the time of treatment.  This means keeping the splint on all the time, 24/7 during the treatment.  This requires a lot of discipline because it’s easy to bend the finger when you wash or clean your hand.  However, if your finger bends during the treatment it will stretch out the tissue that is healing the tendon and the tendon will continue to drop down.  If a patient can’t, or won’t keep the splint on, then you can consider other options.  One is to go to surgery and place a pin across the joint.  This will hold the joint straight as long as the pin is in, and isn’t a bad option for people who can’t wear splints due to their work or their personal preference.  Pins work well, but they are not without their problems.  The pins can get infected, and if the patient isn’t careful and is very overactive the pin can break.  I offer pinning to patients that I think need them, but I always caution them about the possible complications.

Another problem with mallet fingers is that the patient can be very disciplined and faithful in their treatment and still have problems getting the tendon to heal.  I really don’t have a good explanation for this other than the fact that all of us heal differently and in some cases the tendon just won’t go back like it should.  Patients often ask me if I could repair the tendon, and the interesting thing is that the tendon actually stretches out rather than tearing.  So suturing or repairing the tendon usually causes a lot of scarring and stiffness so I usually don’t recommend this. Even under the best of circumstances it’s hard to get a perfect outcome.  Usually the finger will lack just a little bit from straightening up all the way, but usually after treatment the finger is much straighter than before and works pretty well.

Most mallet fingers that have a fracture can also be treated without surgery.  However sometimes a very large piece will pull off and surgery will be necessary to reattach the bone fragment and keep the joint in place.

If a patient has a mallet finger that’s occurred in the past, you can still try a splint up to 2 or 3 months after the original injury.  There are some surgeries that can be done on an old mallet finger to rebalance the finger and get the tendon to straighten, but they are very hard to pull off and get a good result.  The bottom line is that it’s best to be treated as soon as possible after the injury.  Most patients will have a good outcome, although not perfect, outcome from their mallet finger, but the treatment requires a lot of patience and discipline from the patient.

Golfer’s elbow. And I don’t play golf!

“If you give up and lose your head you neither win nor live, and that’s just the way it is”

The Outlaw Josey Wales

Elbow pain and soreness is very common.  It seems to hit active and healthy people when they turn 40.  They symptoms usually start out as a pulling or discomfort in the arm but things can worsen to the point that routine activities can be difficult or almost impossible to do.  I’ve talked about tennis elbow, or tendinopathy  on the outside or lateral part of the elbow, and now I’d like to discuss it’s counterpart on the inside , or medial part of the elbow commonly called “golfers elbow”.  Tennis elbow is much more common than golfer’s elbow, but golfer’s elbow is a significant problem for the patients who get it.

Tennis elbow is usually called “lateral epicondylitis”, and golfer’s elbow is known as “medial epicondylitis”.  These terms are somewhat misleading.  In medical terms the four letters “itis” at the end of the word imply a form of inflammation, where tissues are irritated from a variety of causes.  In both tennis and golfer’s elbow the tendon tissues are really not inflamed, but instead seem to be degenerated.  The best thought at this time is that the tendons become damaged and your body is unable to heal the damaged tissue.

In golfer’s elbow the pain is usually located right on the bone on the inside of your elbow.  Several tendons attach here and they usually get irritated right at the point where they attach to the bone.  People have pain with grasping and activities that cause the wrist to bend down.  Golfers usually get pain right at impact when they hit the ball.  I can speak from personal experience that the pain can get pretty bad and cause you to have to lay off from golf and other aggravating activities for a period of time to rest the elbow.

In general I recommend conservative, non – surgical treatment for the problem.  Eventually the body can usually heal the damaged tendon if we just give it enough time.  Unfortunately a lot of people don’t want to wait or limit their activities long enough to let the problem heal, so there are some other things we can try.  Elbow stretches and light strengthening exercise can be very effective in decreasing pain.  Sometimes topical ointments such as compounding rubs with different types of medications in them can help as well.  Cortisone shots for the treatment of this problem are controversial.  I’ve looked at a lot of articles on this and had the personal experience of having cortisone shots into both sides of my right elbow, and I’ve come to the conclusion that cortisone probably won’t “cure” the problem any faster than exercises or rest, but the shot can sure get you through a rough past if you’re almost incapacitated from the problem.  If you’re a golfer then there are several things you can do to help prevent or treat the problem.  I think enemy #1 are the mats that many golf courses have you hit off on practice ranges during the winter.  Although the mats have some give they’re pretty hard underneath and I think the really stress the inside of your elbow.  I usually won’t hit more than 5 or 6 shots off a mat at any one time.  Another idea is to look at your shafts.  Graphite shafts have less stiffness and stress your arms less than steel.  It might be worth a look to see if changing shafts could help your arms.  Higher level players are reluctant to use graphite in their irons, but there are newer composite iron shafts of graphite and steel that seem to perform as well as pure steel shafts and may be an option.  Several tour pros have gone to the composite shafts so they are gaining in popularity.  Other people have suggested increasing your grip size, since this can theoretically decrease the amount of grip you place on the club and decrease the stress on your elbows.

If everything fails you can think about surgery.  Most surgeons would recommend waiting at least 6 months before considering surgery.  An open procedure where the damaged tendon tissue is directly removed is the most common treatment, but I have also used an ultrasound guided excision through a small incision.  This is known as the FAST procedure (F-focused A-aspiration of S-scar T-tissue).  I’ve done many more FAST procedures on tennis elbow than I have on golfer’s elbow, but I think it’s something to consider because of the potential for a quicker recovery.

The best advice to to try exercises and waiting this out as well as possibly modifying your equipment if you’re a golfer.  If that doesn’t help then injections and surgery are a reasonable thing to consider.

 

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.