New Procedures Revolutionize Treatment of Dupuytren’s Disease

Helping Hands New Procedures Revolutionize Treatment of Dupuytren’s Disease BY DAN CHASE

July 2011

From left, Drs. Jeffrey Wint, Bruce Wintman, and Richard Martin at the Hand Center of Western Massachusetts. Helping Hands New Procedures Revolutionize Treatment of Dupuytren’s Disease BY DAN CHASE It has been called many names, from the ‘Viking Disease,’ due to its prevalence among people of Northern European ancestry, to palmar fibromatosis. But to most patients and doctors, it is named for the French surgeon Baron Guillaume Dupuytren, who described an early treatment for the condition. Dupuytren’s disease is a contraction of the fingers due to abnormal thickening of tissue. At the Hand Center of Western Massachusetts in Springfield, Drs. Richard Martin, Jeffrey Wint, and Bruce Wintman told HCN that the treatment of the disease has just been given a big helping hand. Two of them, in fact, in the form of new procedures that do nothing short of transform the way patients are given relief. To get a better understanding of the mysteries of Dupuytren’s, which doesn’t have any specifically known causes — only a series of predispositions in patients — Wintman described the symptoms. “There are different types of tissue in the hand,” he explained. “There’s skin, muscle, bone, and also a tissue that strands throughout the soft parts to give it form, called the fascia. In Dupuytren’s, your body makes a little bit too much of it, and an abnormal type of it at that. “As a result,” he continued, “you start to get nodules in the palm into the fingers, and sometimes these can coalesce into a cord of tissue that can actually curl the finger down. That cord can be so thick that you can’t actually straighten it out on your own, even though the joints are normal and tendons are working. That abnormal fascial cord is flexing the fingers down. And that’s what patients complain about, that inability to straighten out those fingers.” There is no pain particular to the abnormal fascia, but the lack of mobility can lead to problems with work and quality of life. “It can become so cumbersome, and for some people can become so severe,” Wint added, “that we’ve had some patients say, ‘if you can’t do anything for it, cut the hand off. I just can’t do anything with it.’ That’s the extreme, though. Here, we tend to see anything from simple nodules to cords.” Historically, the treatment for Dupuytren’s involved an open surgical procedure to remove the abnormal tissue, a process which also involves several months of physical therapy to restore mobility in the hand. However, new developments in the treatment of this condition have severed that downtime to the extent that a patient can have one of two new procedures — done in the office and not the surgical theater — and have immediate results with little aftereffect. “In some cases,” Wintman said, “a patient can have one of these procedures during the week and be golfing by the weekend.” This month, HCN sat down with the doctors of the Hand Center to find out what these new processes are, and how they are giving an important helping hand to the treatment of a life-altering condition. General Contractor Dupuytren’s is, as mentioned, a bit of a mystery, for there are no proven causes. But doctors say there are certain risk factors, including geographic ethnicity, age (over 40), a history of alcohol use, and, perhaps most importantly, those with a family history of the condition. While the disease is most commonly seen in men, it is not uncommon for women to contract it. When the first signs of Dupuytren’s are noticed, the tendency is not to take immediate action, Martin said. “If you get a little nodule, a little bump, there’s not a lot that needs to be done,” he explained. “However, when that becomes a cord, that’s the time when most people feel the need to do something about it. In years past, traditionally we would wait on treatment until it became a significant problem for the individual.” Wintman said the “flat-table test” is a point of entry for his patients. “It’s usually not a pain situation whereby someone will want to seek treatment, but rather a lifestyle condition,” he explained. “If you can’t lay your hand flat on the table, then you may wish to proceed with treatment.” For many years, what happened next was a pretty straightforward surgical process. If the nodule or cord was not contracting the fingers, nothing would be done, but the affected areas were kept under observation to monitor any marked development. If the progress contracted the fingers significantly, the hand would be incised, and the abnormal tissue cord removed. Wint said that this was a straightforward surgical procedure. “The problem isn’t taking that cord out,” he explained. “That’s fairly easy to do. After an hour of surgery you can remove it. The problem is what happens to the hand afterwards. If it’s used to being bent, then the skin may be inefficient — it’s used to being pulled down. The tendons may not be springy right away, and the joints may want to reassume that bent position. So, someone who has a simple surgical removal to get rid of that cord needs to now go into a splint, sometimes full-time, up to a month, and into rehabilitation for three to six months after.” Recurrence rates are a fact of life for patients with Dupuytren’s, and even with full removal of the contracting cord, the abnormal tissue can return in several years’ time. Also, if the original surgery involved the removal of a nodule, there’s a risk of not excising enough tissue, which Wint said could cause the abnormal tissue to return with increased vigor. Handle with Care While open surgery had been the only means for patients suffering this condition to return functionality to their fingers and hands, science has come to their rescue. Two new procedures, as differentiated from surgery since they can be done in physicians’ offices, have come to the market within the last five years. One of these new techniques, a collagenase injection, was made available only one year ago. That drug is called Xiaflex, and Wintman explained the process. “You give a small shot of this enzyme in one area in the cord, and it eats through the collagen which the Dupuytren’s fascia is made from,” he said. “So it dissolves through the collagen, and then disrupts the cord at that one level. You come back the next day for manipulation, and the finger can go straight at that level after the manipulation.” The second process is called needle aponeurotomy (NA), and essentially is a micro-perforation of the cord. “We take a needle and actually make a series of puncture wounds along the length of the cord that’s keeping the finger bent down,” Martin said. “This breaks up the cord at various levels using the needle, almost like a tiny scalpel. The cord then actually breaks apart at these different levels. And then, the finger can straighten out. This doesn’t remove the tissue; you’re just breaking it up. “As a result,” he continued, “afterward there are just a series of exterior puncture wounds that need to heal, typically over the course of five to seven days. Patients go home with some Band-Aids and an ice pack, and they’re moving and using their hand right away. Typically they don’t need a splint, although we might give them one to reinforce the gains we’ve made. But that is rare.” Choosing between the new procedures comes down, ultimately, to dollars and sense: often an insurance carrier might cover one but not the other. Also, the NA can involve several affected areas in the hand on one visit, whereas the Xiaflex must be administered only in one area every 30 days. “So if someone comes in with three fingers affected, that’s a bit of a stretch,” Wintman said. “But some people want to try the medication over the four months.” However, he added, “a patient might have co-morbidities. They might be on a blood thinner, and you wouldn’t want to give them an injection of an enzyme that eats tissue, because there would be too much swelling. Some people may have skin issues and not want to be exposed.” But it can come down to a patient’s word-of-mouth referral to determine one over the other, Wint said. Around the Bend Sadly, science has not cured Dupuytren’s once and for all. The same recurrence rates for the abnormal tissues does still apply to these two new procedures, and, in fact, the time until reappearance of nodules and cords is often just a few years’ time. But, doctors agree, the ease with which both Xiaflex and NA can be administered should allay any fears of a return visit. But has science sounded the death knell for the surgical open procedure? “Well, it does reduce that frequency significantly,” Wint said. “Since that used to be the only solution, it was that or nothing. I had some people who, because of their work, really couldn’t take three to four months off. And you had to try to prepare people, also, because it could have even been longer.” Martin said there are patients who still say, “I want it out,” and that does mean surgery. And for a patient with a history of severe Dupuytren’s, or situations involving prior complex surgeries, the new procedures might not offer any assistance. “Their anatomy might be markedly distorted; they may have had skin grafts done elsewhere,” Wintman said. “Also, you can have contractures of the joints — the joint itself is scarred in. It’s not that you can feel a clearly defined cord anymore, but there might be scar tissue that keeps the fingers contracted. And, unfortunately, you really can’t do anything with that in the new procedures.” But one thing the two new techniques will hopefully bring about is a future whereby doctors don’t see such severe cases of Dupuytren’s. “As more and more people read about these procedures, or hear about them from friends, they’ll realize that the need for the surgery will be less and less,” Martin said. His colleagues nodded in agreement when Wintman said, “it’s incredibly satisfying for us, because when the patient leaves the office, they will have noticeable results. They walk in with a deficit, and they leave here with straight fingers.”

TENNIS ELBOW or LATERAL EPICONDYLITIS

Tennis Elbow: treatment (Lateral Epicondylitis)treatment

The Hand Center of Western Massachusetts Springfield

taken and modified from the American Academy of Orthopedic Surgery (AAOS) website

for additional information taken from ASSH website  to see our office website click here

	DescriptionTennis elbow is a degenerative condition of the tendon fibers that attach on the bony prominence (epicondyle) on the outside (lateral side) of the elbow. The tendons involved are responsible for anchoring the muscles that extend or lift the wrist and hand (see Figure 1). Risk Factors/Prevention Tennis elbow happens mostly in patients between the ages of 30 years to 50 years. It can occur in any age group. Tennis elbow can affect as many as half of athletes in racquet sports. However, most patients with tennis elbow are not active in racquet sports. Most of the time, there is not a specific traumatic injury before symptoms start. Many individuals with tennis elbow are involved in work or recreational activities that require repetitive and vigorous use of the forearm muscles (see Table 1). Some patients develop tennis elbow without any specific recognizable activity leading to symptoms. Symptoms Patients often complain of severe, burning pain on the outside part of the elbow. In most cases, the pain starts in a mild and slow fashion. It gradually worsens over weeks or months. The pain can be made worse by pressing on the outside part of the elbow or by gripping or lifting objects. Lifting even very light objects (such as a small book or a cup of coffee) can lead to significant discomfort. In more severe cases, pain can occur with simple motion of the elbow joint. Pain can radiate to the forearm. To diagnose tennis elbow, tell the doctor your complete medical history. He or she will perform a physical examination. The doctor may press directly on the bony prominence on the outside part of the elbow to see if it causes pain.   The doctor may also ask you to lift the wrist or fingers against pressure to see if that causes pain. X-rays may be necessary.  Xrays can reveal the presence of calcification or arthritis that may also affect the elbow joint. Rarely, MRI (magnetic resonance imaging) scans may be used to show changes in the tendon at the site of attachment onto the bone for acute high energy injuries Treatment Options In many cases  when there are fairly severe symptoms a simultaneous-three pronged approach,  (1) use of anti-inflammatories,  (2) orthotic bracing and  (3)injection  at the same time work more efficaciously and can save time in treatment and offers a more rapid resolution of symptoms. Sometimes, when conditions are right a more slow sequential treatment is offered. This takes longer but may be more suitable for those with minimal symptoms In most cases, nonoperative treatment should be tried before surgery. Pain relief is the main goal in the first phase of treatment. The doctor may tell you to stop any activities that cause symptoms. You may need to apply ice to the outside part of the elbow. You may need to take acetaminophen or an anti-inflammatory medication for pain relief. Orthotics can help diminish symptoms of tennis elbow. The doctor may want you to use counterforce braces and wrist splints. These can reduce symptoms by resting the muscles and tendons (see Figure 2). Symptoms should improve significantly within four weeks to six weeks. If not, the next step may be a corticosteroid injection around the outside of the elbow. This can be very helpful in reducing pain. Corticosteroids are relatively safe medications. Most of their side effects (i.e., further degeneration of the tendon and wasting of the fatty tissue below the skin) occur after multiple injections. Avoid repeated injections (more than two or three in a specific site).As noted above some patients symptoms are severe enough to warrant a simulateous-three pronged approach at the time of initial consultation. After pain is relieved, the next phase of treatment starts. Modifying activities can help make sure that symptoms do not come back. The doctor may want you to do physical therapy. This may include stretching and range of motion exercises and gradual strengthening of the affected muscles and tendons (see Figure 3). Physical therapy can help complete recovery and give you back a painless and normally functioning elbow.  In many cases however PT is not needed once pain has subsided.  Nonoperative treatment is successful in approximately 85 percent to 90 percent of patients with tennis elbow. Treatment Options: Surgical Surgery is considered only in patients who have incapacitating* pain that does not get better after  non-operative treatment. *The difficult question to answer is:  What is incapacitating pain?  Very often what affects one person may not be significant for another.  This is especially true for those engaged in athletics or jobs that require very specific motions or activities.  Thus the indications for surgery are relative in most and absolute in few. The surgical procedure involves removing diseased tendon tissue and reattaching normal tendon tissue to bone (see Figure 4). The procedure is an outpatient surgery; you do not need to stay in the hospital overnight. It can be performed under regional or general anesthesia. Technique for surgical treatment of lateral epicondylitis. A, Skin incision over the lateral epicondyle. B, Distal reflection of the extensor mechanism exposing the lateral compartment of the elbow. C, Excision of pathologic tissue from the underside of the extensor mechanism. D, Decortication of the lateral epicondyle. E, Drilling of two V-shaped tunnels within the lateral epicondyle. F, Reattachment of the extensor mechanism to the lateral epicondyle. G, Side-to-side repair of the extensor tendon mechanism.   *Note: steps E and F are not often needed except in cases where large *tears exist. Most commonly, the surgery is performed through a small incision over the bony prominence on the outside of the elbow. So far, no significant benefits have been found to using an arthroscopic method over the  traditional open incision. After surgery, the elbow is placed in a small brace and the patient is sent home. About one week later, the sutures and splint are removed. Then exercises are started to stretch the elbow and restore range of motion. Light, gradual strengthening exercises are started two months after surgery. The doctor will tell you when you can return to athletic activity. This is usually approximately four months to six months after surgery. Tennis elbow surgery is considered successful in approximately 90 percent of patients. Persistent pain can be from associated arthritis in the elbow, nerve compression, muscular fatigue or residual bone pain.  While most patients return to full activity after tennis elbow surgery, many still relate that there is aching pain that persists at times.  Overall, however, most are satisfied and have a significant improvement and much less pain than prior to surgery November 2004
	Author Information (Please note that although the original document has been modified  we wish to grant the original author from the AAOS credit.)

Carpal Boss of the WRIST and HAND

  

Carpal Boss

  

Clinical Characteristics

The dorsal wrist ganglion is most often confused with the carpal boss, so named by the French physician Foille.  The carpal boss is an osteoarthritic spur that develops at the base of the second and/or third carpometacarpal joints. (figure 1) A firm, bony, nonmobile, tender mass is visible and palpable at the base of the carpometacarpal joints, especially when the wrist is volar flexed.

Radiologically, the mass is best visualized with the hand in 30 to 40 degrees supination and  

 20 to 30 degrees ulnar deviation ("carpal boss view")( figure 3).

figure1

The boss is more common in women (2:1), in the right hand (2:1), and between the third and fourth decades.  The mass may be asymptomatic, but the patient may complain of considerable pain and aching.  A small ganglion is associated with  the carpal boss in 30 percent of cases, adding to its confusion with the more common dorsal wrist ganglion. 

Injection to the ganglion or to the cmc joint may  be used to reduce pain and irritation.  This may be combined with splinting and anti inflammatory medication and avoidance of trauma to the back of the hand\

If symptoms persist at times surgery may be offered. (figure 2) Surgery may involve the removal of the prominent bone, the excision of an associated ganglion or cyst and at times involves tenosynovectomy or tenolysis of adjacent affected tendons.  What occurs during surgery may depend upon the preoperative findings as well as the surgical intra operative findings

figure 2

The most common complication is the persistence of a mass because of excision of the ganglion alone or inadequate excision of the osteophytes.  Pain will persist unless all abnormal abutting surfaces have been excised.  Dorsal wrist ganglions can present over the carpometacarpal joints and must be distinguished from the carpal boss with its own associated ganglion.  Avoidance of injury to branches of the radial and ulnar sensory nerves is again stressed.            

figure 3

Helping Hands New Procedures Revolutionize Treatment of Dupuytren’s Disease BY DAN CHASE

July 2011

From left, Drs. Jeffrey Wint, Bruce Wintman, and Richard Martin at the Hand Center of Western Massachusetts. Helping Hands New Procedures Revolutionize Treatment of Dupuytren’s Disease BY DAN CHASE It has been called many names, from the ‘Viking Disease,’ due to its prevalence among people of Northern European ancestry, to palmar fibromatosis. But to most patients and doctors, it is named for the French surgeon Baron Guillaume Dupuytren, who described an early treatment for the condition. Dupuytren’s disease is a contraction of the fingers due to abnormal thickening of tissue. At the Hand Center of Western Massachusetts in Springfield, Drs. Richard Martin, Jeffrey Wint, and Bruce Wintman told HCN that the treatment of the disease has just been given a big helping hand. Two of them, in fact, in the form of new procedures that do nothing short of transform the way patients are given relief. To get a better understanding of the mysteries of Dupuytren’s, which doesn’t have any specifically known causes — only a series of predispositions in patients — Wintman described the symptoms. “There are different types of tissue in the hand,” he explained. “There’s skin, muscle, bone, and also a tissue that strands throughout the soft parts to give it form, called the fascia. In Dupuytren’s, your body makes a little bit too much of it, and an abnormal type of it at that. “As a result,” he continued, “you start to get nodules in the palm into the fingers, and sometimes these can coalesce into a cord of tissue that can actually curl the finger down. That cord can be so thick that you can’t actually straighten it out on your own, even though the joints are normal and tendons are working. That abnormal fascial cord is flexing the fingers down. And that’s what patients complain about, that inability to straighten out those fingers.” There is no pain particular to the abnormal fascia, but the lack of mobility can lead to problems with work and quality of life. “It can become so cumbersome, and for some people can become so severe,” Wint added, “that we’ve had some patients say, ‘if you can’t do anything for it, cut the hand off. I just can’t do anything with it.’ That’s the extreme, though. Here, we tend to see anything from simple nodules to cords.” Historically, the treatment for Dupuytren’s involved an open surgical procedure to remove the abnormal tissue, a process which also involves several months of physical therapy to restore mobility in the hand. However, new developments in the treatment of this condition have severed that downtime to the extent that a patient can have one of two new procedures — done in the office and not the surgical theater — and have immediate results with little aftereffect. “In some cases,” Wintman said, “a patient can have one of these procedures during the week and be golfing by the weekend.” This month, HCN sat down with the doctors of the Hand Center to find out what these new processes are, and how they are giving an important helping hand to the treatment of a life-altering condition. General Contractor Dupuytren’s is, as mentioned, a bit of a mystery, for there are no proven causes. But doctors say there are certain risk factors, including geographic ethnicity, age (over 40), a history of alcohol use, and, perhaps most importantly, those with a family history of the condition. While the disease is most commonly seen in men, it is not uncommon for women to contract it. When the first signs of Dupuytren’s are noticed, the tendency is not to take immediate action, Martin said. “If you get a little nodule, a little bump, there’s not a lot that needs to be done,” he explained. “However, when that becomes a cord, that’s the time when most people feel the need to do something about it. In years past, traditionally we would wait on treatment until it became a significant problem for the individual.” Wintman said the “flat-table test” is a point of entry for his patients. “It’s usually not a pain situation whereby someone will want to seek treatment, but rather a lifestyle condition,” he explained. “If you can’t lay your hand flat on the table, then you may wish to proceed with treatment.” For many years, what happened next was a pretty straightforward surgical process. If the nodule or cord was not contracting the fingers, nothing would be done, but the affected areas were kept under observation to monitor any marked development. If the progress contracted the fingers significantly, the hand would be incised, and the abnormal tissue cord removed. Wint said that this was a straightforward surgical procedure. “The problem isn’t taking that cord out,” he explained. “That’s fairly easy to do. After an hour of surgery you can remove it. The problem is what happens to the hand afterwards. If it’s used to being bent, then the skin may be inefficient — it’s used to being pulled down. The tendons may not be springy right away, and the joints may want to reassume that bent position. So, someone who has a simple surgical removal to get rid of that cord needs to now go into a splint, sometimes full-time, up to a month, and into rehabilitation for three to six months after.” Recurrence rates are a fact of life for patients with Dupuytren’s, and even with full removal of the contracting cord, the abnormal tissue can return in several years’ time. Also, if the original surgery involved the removal of a nodule, there’s a risk of not excising enough tissue, which Wint said could cause the abnormal tissue to return with increased vigor. Handle with Care While open surgery had been the only means for patients suffering this condition to return functionality to their fingers and hands, science has come to their rescue. Two new procedures, as differentiated from surgery since they can be done in physicians’ offices, have come to the market within the last five years. One of these new techniques, a collagenase injection, was made available only one year ago. That drug is called Xiaflex, and Wintman explained the process. “You give a small shot of this enzyme in one area in the cord, and it eats through the collagen which the Dupuytren’s fascia is made from,” he said. “So it dissolves through the collagen, and then disrupts the cord at that one level. You come back the next day for manipulation, and the finger can go straight at that level after the manipulation.” The second process is called needle aponeurotomy (NA), and essentially is a micro-perforation of the cord. “We take a needle and actually make a series of puncture wounds along the length of the cord that’s keeping the finger bent down,” Martin said. “This breaks up the cord at various levels using the needle, almost like a tiny scalpel. The cord then actually breaks apart at these different levels. And then, the finger can straighten out. This doesn’t remove the tissue; you’re just breaking it up. “As a result,” he continued, “afterward there are just a series of exterior puncture wounds that need to heal, typically over the course of five to seven days. Patients go home with some Band-Aids and an ice pack, and they’re moving and using their hand right away. Typically they don’t need a splint, although we might give them one to reinforce the gains we’ve made. But that is rare.” Choosing between the new procedures comes down, ultimately, to dollars and sense: often an insurance carrier might cover one but not the other. Also, the NA can involve several affected areas in the hand on one visit, whereas the Xiaflex must be administered only in one area every 30 days. “So if someone comes in with three fingers affected, that’s a bit of a stretch,” Wintman said. “But some people want to try the medication over the four months.” However, he added, “a patient might have co-morbidities. They might be on a blood thinner, and you wouldn’t want to give them an injection of an enzyme that eats tissue, because there would be too much swelling. Some people may have skin issues and not want to be exposed.” But it can come down to a patient’s word-of-mouth referral to determine one over the other, Wint said. Around the Bend Sadly, science has not cured Dupuytren’s once and for all. The same recurrence rates for the abnormal tissues does still apply to these two new procedures, and, in fact, the time until reappearance of nodules and cords is often just a few years’ time. But, doctors agree, the ease with which both Xiaflex and NA can be administered should allay any fears of a return visit. But has science sounded the death knell for the surgical open procedure? “Well, it does reduce that frequency significantly,” Wint said. “Since that used to be the only solution, it was that or nothing. I had some people who, because of their work, really couldn’t take three to four months off. And you had to try to prepare people, also, because it could have even been longer.” Martin said there are patients who still say, “I want it out,” and that does mean surgery. And for a patient with a history of severe Dupuytren’s, or situations involving prior complex surgeries, the new procedures might not offer any assistance. “Their anatomy might be markedly distorted; they may have had skin grafts done elsewhere,” Wintman said. “Also, you can have contractures of the joints — the joint itself is scarred in. It’s not that you can feel a clearly defined cord anymore, but there might be scar tissue that keeps the fingers contracted. And, unfortunately, you really can’t do anything with that in the new procedures.” But one thing the two new techniques will hopefully bring about is a future whereby doctors don’t see such severe cases of Dupuytren’s. “As more and more people read about these procedures, or hear about them from friends, they’ll realize that the need for the surgery will be less and less,” Martin said. His colleagues nodded in agreement when Wintman said, “it’s incredibly satisfying for us, because when the patient leaves the office, they will have noticeable results. They walk in with a deficit, and they leave here with straight fingers.”

MALLET FINGER (baseball finger)

MALLET FINGER (BASEBALL FINGER)

A mallet finger occurs when the extensor tendon at the tip of a finger ruptures. The rupture of this tendon can involve the tendon alone, be associated with a small bone fragment or fracture or can be associated with a fracture that requires significant care.

The force applied to the finger can come from something as simple as tucking in a bed sheet or can come from a direct blow to the end of a finger. Mallet finger has also been known as baseball finger.

A mallet finger often begins with pain at the distal joint of the finger.  At times there is an immediate loss of motion while at other times the finger seems to stay straight for a while and only later starts to lose its ability to be extended actively at the tip.  At times there is an injuries are typically closed in that the skin and nail is intact but at times there is an injury to the skin or nail bed as well. In severe cases the injury is associated with an open injury to the joint or bone, a so called open or compound fracture.

In adults the injury can involve the joint surface.  In children it can involves the growth plate or physis.

The diagnosis is often made based upon the type of injury and the appearance of the finger.  The fingertip will droop down and there is a loss of active motion.  Often the finger can be passively pushed up to straighten it but the independent active motion to extend the digit at the tip has been lost

Mallet finger.

X-rays are often taken to further delineate the injury and see how much if any bone, joint or growth plate is involved

Treatment depends largely upon the extent the soft tissue and underlying boney injury.

Tendon rupture without bone injury

Most of these mallet finger injuries can be treated with splinting.  The splint can be applied in a variety of ways depending upon the injury.  Typically the split is left in place full time for six to eight weeks with a time for part time splinting after that depending upon what daily activity is done by the patient with a typical part time period of 3 – 4 weeks.  In some situations pinning of the joint is used rather than a splint

Tendon rupture with a small bone fragment

These injuries typically are treated like non-boney injuries

Types of splints used to treat mallet finger. A, Dorsal aluminum splint. B, Commercial splint.

Reproduced with permission from Culver JE Jr: Office management of athletic injuries of the hand and wrist. Instr Course Lect 1989;38:473-482.

Tendon rupture with a large bone fragment involving the joint.

These injuries may respond to splinting and splinting is often used however a small bump may always be present a t the joint.  At times if the doctor feels that that the bone fragment is large enough and the joint may be unstable surgery may be offered.  During surgery pins or small screws may be used and the joint itself may be pinned to prevent motion during the healing process.

Above: X-rays showing fracture at the insertion of the extensor tendon. In the first image on the left the fragment is displaced.  This will heal with a bump but will be able to be treated with a splint.  IN the image on the right the joint has subluxed.  This will  need to have surgical repair.

In adults with severe open injury more immediate surgery may also be offered

Children

In children the doctor needs to differentiate between these injuries that require reduction or realignment of the bone without surgery and those who may have a portion of the nail bed significantly torn or retained within the fracture site or growth plate.  Often children will not have a tendon injury but a fracture through the physis which appears to be a mallet injury.  X-rays often will reveal this.

Mallet deformity from a fracture across the growth plate in a child is different than the adult fracture or tendon avulsion

Late or Delayed Treatment in adults

Delayed treatment of mallet finger deformity may consist of splinting initially and at times surgical methods are offered to correct chronic deformities and other associated joint and tendon problems that may accompany the chronic situation

Results

Most mallet fingers heal well, although often there is a slight loss of full extension. The slight extension loss typically has no effect on hand of finger function, but if left untreated it can cause other issues to occur in the finger due to tendon imbalance. While treatment of a closed mallet finger is not an acute emergency, the improper, partial or untreated injury can lead to further problems such as a swan neck deformity.

 Swan neck deformity from tendon imbalance and laxity at the proximal joint.

 

Athletics

While there may be special circumstances where a professional athletes plays with a splint in place for mallet finger for the child or recreational athlete, or even most professional or collegiate level athletes this is not typically recommended.

AS YOU CAN SEE AN EPONYM SUCH AS BASEBALL FINGER CAN BE MISLEADING

Needle Aponeurotomy and Xiaflex are on Facebook

Dupuytren's Disease updates Needle Aponeurotomy and Xiaflex are on Facebook

Dupuytren's Disease updates Needle Aponeurotomy and Xiaflex are on Facebook

Dupuytren's Disease New Treatment Updates: Xiaflex and Needle Aponeurotomy

Needle Aponeurotomy and Xiaflex update from the Hand Center of Western MA

What are the treatment options for Dupuytren's disease?

In mild cases especially if hand function is not affected, only observation is needed.
 For more severe cases various  techniques are available in order to straighten the finger(s). Your treating surgeon will discuss the method most appropriate for your condition based upon the stage of the disease and the joints involved. The goal of any treatment is to improve finger position and thereby hand function. Despite  treatment the disease process may recur. Before treatment, your doctor should discuss realistic goals and results.
Types of treatment may include Needle Aponeurotomy, Partial or Complete Fasciectomy, and limited release as well as on Collagenase injections or cortisone injection in a nodule.  The rationale behind each treatment depends upon the treating physician and the patient.
Surgical Fasciectomy  (Partial or Complete) uses open incisions and the cords and nodules are removed
Incisonal Aponeurotomy or Fasciotomy uses small incisions  or portals and the cords are released or perforated
Needle Aponeurotomy  (NA) or Percutaneous Aponeurotomy (PA) or Percutanoeous Needle Fasciotomy (PNF)Needle aponeurotomy uses a small gauge needle or a microblade as a cutting device to sever the abnormal cords of tissue in the palm and digits which cause the fingers to flex down.  The tissue is not removed it is essentially perforated or cut in multiple places along the palm  to release the contracture (see figure 3) Incisional aponeurotomy fasciotomy is done in some instances.
Collagenase Injection (Xiaflex)
Collagenase is an enzyme that digest collagen a structural protein in tissues.  Xiafllex is a collagenase derived  from the bacteria Clostridium Histolyticum.  Xiaflex is a mixture of several types of collagenase, titrated to achieve digestion of  tissue or cords that are present in the hands  of those who have Dupuytren's disease. (Figure 4)
Corticosteroid Injection (cortisone shot)
When a steroid or cortisone injection  is given to the palm, in a nodule or small cord  it will often soften the cord. There are studies that state that this may limit progression of the disease While there have been no large scale prospective double blinded studies or dose dependent studies many surgeons now will attempt to inject a nodule or soft cord that is not ready for surgery in an attempt to treat it.

IMPORTANT considerations:

1. The presence of a lump in the palm does not mean that surgery  or treatment is required or that the disease will progress.
2. Correction of finger position is best accomplished with milder contractures and contractures that affect the base of the finger. Complete correction sometimes can not be attained, especially of the middle and end joints in the finger. no matter what method is used.
3. Skin grafts are sometimes required to cover open areas in the fingers if the skin is deficient during open fasciectomy or open removal of cord tissue..
4. The nerves that provide feeling to the fingertips are often intertwined with the cords and may be affected by any treatment
5. Splinting and hand therapy are often required after surgery  or other treatment procedures in order to maximize and maintain the improvement in finger position and function.
6. All treatments for Dupuytren's may involve the risk of tendon, nerve, joint, skin: injury, infection, and stiffness. as well other conditions that may negatively affect the result.

WATER PROOF CAST?

QUESTIONS AND ANSWERS from the HAND CENTER OF WESTERN MASSACHUSETTS

CAN I HAVE A WATERPROOF CAST?
WHAT ARE MY OPTIONS?

   

With certain fractures

A water proof cast may be an option.

IF YOU WANT A WATER PROOF CAST AND THE DOCTOR STATES YOU CAN HAVE ONE

----IT IS YOUR DECISION

Most insurance companies DO NOT see fit to reimburse our office for the significant extra cost for the materials used in preparing a waterproof cast.

BE AWARE that there is an additional charge for a waterproof cast payable at the time of service.

This charge may change with the cast size but there is a minimal starting charge.

If you think about it…if you have to come back in because you soaked your cast and it can’t dry, or if your cast gets so dirty that its an issue for you, you will need to pay another co-pay and the insurance company  or you pay for another cast.. SO for many it makes good sense to either do a good job protecting their cast from the outset or getting a waterproof cast right away. -----IT IS YOUR DECISION!

 

You can have a non-waterproof cast and protect it.  Non waterproof casts cannot get routinely wet or washed.  If it gets wet by accident typically we tell you to let the cast air dry or use a hairdryer on a cool setting.  But the cast is not designed to get wet repeatedly. NOTHING IS WRONG WITH THIS OPTION. IT’S WHAT MOST PEOPLE HAVE DONE AND CONTINUE TO DO

A non waterproof cast and a plastic newspaper bag, bread bag, or a grocery bag can work well too. WE DO NOT ROUTINELY CHANGE a cast if it just gets some water on it.

Cast covers can be purchased at surgical supply stores or online

Commercial waterproof cast covers at www.drycorp.com with online prices

Short arm covers at $35.95 – $37.95

Long arm covers at $35.95 – $39.95

You can also go to a surgical supply store. Local storesin Western Massachusetts include:

Agawam medical supply 413 789 1100

Footit Surgical-West Springfield 413-733-7843

Mass Surgical supply-Holyoke 413-532-1401

Prices from a recent round of phone calls ranged from 32-40 dollars

There are other cast covers out there too such as seal tight which we were quoted as $33.99

Other covers such as ARMRX are in the 8-12 dollar range but these are thinner and some of our patients have come back and told us that these were no better than the plastic bag and tape method

.  To swim and more successfully  keep dry we have found you need to use a more expensive type. But your cast may still get too wet if it leaks/tears no matter what you pay for the cover.  In general a plastic bag and tape does not work for swimming.

-----IT IS YOUR DECISION

With a waterproof cast you can WASH YOUR ARM with water and squirt liquid soap down the cast and RINSE IT OUT.

WITH A SHOWER/SWIM cover or bag you cannot wash your cast/arm

The text of the mmodified HAND OUT WE USE IN OUR OFFICE FOR 3M™ Scotchcast™Wet or Dry Cast Padding  is below:

A new cast is awkward. You probably feel limited in what you can do with it. Luckily, your physician has fitted you with different kind of cast, constructed of the most innovative casting materials available, and designed with your comfort in mind. Your cast is made of a synthetic water-repellent padding material (3M™ Scotchcast™Wet or Dry Cast Padding), and a fiberglass outer shell designed so that you may get your cast wet, if your physician allows. The outer part is fiberglass which means that the cast is light, strong and water resistant. The combination of these materials allows you to shower or bathe without having to wrap the cast in a waterproof cast cover, if you follow the cast care instructions listed below. You must carefully follow your physician’s instructions if your cast treatment is to be successful. The following are general guidelines only. These guidelines should not be a substitute for your physician’s advice

Cast Care —Wet Use

• If your physician permits you to get your cast wet, you must allow the cast and your skin to dry thoroughly before getting the cast wet again.

• If you experience maceration (i.e., softened, white or wrinkled skin), skin irritation, heat rash or pain, do not get the cast wet.

• Drying time for casts will vary. In some cases, weather conditions, perspiration will prevent the cast from drying completely. Most casts will feel comfortably dry in one to three hours. If your cast feels wet longer, stop getting the cast wet.

• Parents or guardians of young children should monitor the condition of the cast and skin under the cast after the child has gotten the cast wet. If the cast is not drying, do not allow the child to get the cast wet again.

• If a blow dryer is used to aid in drying your cast, use only on a cool setting.

• Gravity causes the water to drain from the cast. If your cast is wet, it is important to position your cast so that water will drain out. .  Hang your arm downward and drain from end of cast.  The material will not absorb water and it will drain to the lowest point. If the cast will not drain, or you cannot position yourself to drain the cast do not get the cast wet again.

• Avoid swimming in natural bodies of water (lakes, rivers or oceans). Waterborne parasites or contaminants entering your cast may cause skin irritation or other problems.

• Ensure that you rinse out the cast thoroughly with clean water after swimming, showering or bathing.

• For your safety when swimming, deep water should be avoided.

General Cast Care —Wet or Dry Use

• Move your fingers frequently to prevent swelling and joint stiffness.

• If your cast becomes soiled on the outside, clean it with a damp cloth and a small amount of mild detergent.

• Do NOT stuff cotton or toilet tissue under your cast, since it may fall into the cast, or decrease your circulation and cause serious medical problems. Do not pull out the cast padding.

• Do NOT break off rough edges or trim your cast before consulting your physician. (Rough edges can be reduced with light filing with a nail file.)

• Do NOT expose the inside of your cast to dirt,

sand or powder.

• Do NOT scratch under your cast with anything. This may break the skin and cause infection.

• Do NOT remove your cast yourself.

Although an old invention, casts are still the most common way of treating broken bones and several other injuries. A key to the effectiveness of you cast is good cast care.

Contact your physician if you

experience any of the following:

• If your cast feels too snug or tight. NOTE: swelling around the injury is common and can cause a cast to feel tight for the first 48 hours.

• If your cast does not dry.

• If you have continued coldness or discoloration of your casted limb.

• Any pain, numbness or continued tingling of your casted fingers or toes.

• If your skin becomes red, raw or emits a bad odor.

• If your cast has cracks, soft spots or becomes loose.

www.handctr.com