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Hand and Fingers

The hand is a sophisticated part of the body equipped with bones, joints, ligaments, muscles, nerves and arteries that allow for versatility of its functions.

Medical Conditions
Trigger Finger


Trigger finger is a painful condition caused by the inflammation of the flexor tendon sheath and subsequent entrapment of the flexor tendons at the level of the A1 pulley.

Symptoms

The symptoms of trigger finger are:

 - Finger clicking

 - Pain at distal palm

 - Finger becoming “locked” in flexed position


Physical exam

The diagnosis is typically made by the following characteristic presentation:

 - Tenderness to palpation over A1 pulley

 - A palpable bump may be present near the same location


Treatment

Initial management of trigger finger is conservative and involves night splinting, activity modification, and non-steroidal anti-inflammatory drugs for pain control. 

Injection of corticosteroids should be attempted before surgical intervention as it is very efficacious and is a best initial treatment for fingers. Operative treatment by release of A1 pulley is highly effective with low complication and recurrence rates.


Medical Conditions
Dupuytren's Disease

Dupuytren’s disease is a condition in which fibrous tissue grows in the palm of the hand and attaches to the tendon sheaths, pulling the fingers in toward the middle of the hand.

Treatment

Treatments are available for patients with severe symptoms.

Nonoperative treatments include:

 - Injection of Clostridium histolyticum collagenase (Xiaflex)

 -- causes lysis and rupture of cords

The treatment is more successful at MCP correction than PIP correction. PIP recurrence is more severe than MCP recurrence.

Most common complications include edema, tears in the skin around the injection site, pain, and contusion. Serious injury to the tendons of the hand is a rare side effect of this drug/procedure. Flexor tendon rupture or pulley rupture may occur. 

 - Needle aponeurotomy

Needle aponeurotomy is a minimally invasive procedure used to treat Dupuytren’s disease. It should be performed as first line of treatment, when patient is not a candidate for surgery. Indications include metacarpophalangeal (MCP) joint contracture greater than 30° and/or any proximal interphalangeal (PIP) joint contracture. 

Depending on the severity of of the disease, the procedure has a higher recurrence rate than surgery. 


Surgery has long been the most common form of treatment for Dupuytren’s disease. There are many variations to how surgery can be done and how extensive it needs to be. The advantage of surgical treatment is a lower recurrence rate than other treatment options. 


Traumatic Conditions 
Tendon Injuries
Extensor Tendons
Mallet Finger

Mallet finger is a common injury of the extensor tendon insertion causing an extension lag of the distal interphalangeal joint. It is frequently encountered in sports and usually occurs in the work environment. 

Treatment

Nonoperative:

 - Extension splinting of DIP joint for 6-8 weeks

Operative:

 - Close vs. open reduction of fracture

In case of persistent symptoms, deformity, and functional impairment following splinting and surgical management, arthrodesis is the primary salvage procedure used.

Traumatic Conditions 
BoutonniereDeformity

A boutonniere deformity is a central extensor tendon injury characterized by pathologic flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint.

Mechanism

Boutonniere deformity is generally caused by a forceful blow to the top (dorsal) side of a bent (flexed) middle joint of a finger.

It can also be caused by a cut on the top of the finger, which can sever the central tendon from its attachment to the bone. In some cases, the bone can actually pop through the opening.

Boutonniere deformities may also be caused by rheumatoid arthritis.

Treatment

Boutonniere deformity must be treated early to help patient retain the full range of motion in the finger.

Nonoperative:

Application of a splint to the finger at the middle joint to straighten it. It is important to wear the splint continuously for the recommended period of time -- usually six weeks. 

Operative:

 - Primary central band repair

 - Lateral band relocation

 - Terminal tendon tenotomy

Surgery can reduce pain and improve functioning, but it may not be able to fully correct the condition and make the finger look normal. It generally takes about 12 weeks to recover from these types of surgery, and you may have limited use of your affected hand during that period.

Flexor Tendon Lacerations
Flexor Tendon Injuries

Jersey Finger

A jersey finger is an injury to the flexor tendon. This is common injury which occurs in contact sports. With jersey finger, the pain is located on the distal area of the finger and the patient is unable to bend the tip of the finger atively. The finger involved will have rigidity when trying to make a fist.

Treatment

The treatment of choice is usually surgical:

 - Direct tendon repair or reinsertion

 -- acute injury (< 3 weeks)

 - ORIF fracture fragment

 - Two-stage flexor tendon grafting

 -- chronic injury (>3 months) with full PROM of the DIP joint

 - DIP arthrodesis

 -- chronic injury (>3 months) with chronic stiffness

If jersey finger is left untreated, it will have functional consequences on the whole hand. It can affect the grip strength and the capacity to handle objects.

Other Flexor Tendon Lacerations

Flexor tendon laceration can happen to anyone who sustains a penetrating injury to the hand, wrist or arm. Deep cuts to the hand are most common causes. Some conditions, such as rheumatoid arthritis, can weaken the tendons, making them more susceptible to spontaneous rupture. Athletes are also at higher risk for flexor tendon injury.

Treatments

The vast majority of tendon lacerations are surgical injuries to allow repair of the cut tendon(s). Splints, ice, and anti-inflammatories are used preoperatively for comfort and tissue healing.

Nonoperative:

 - Partial lacerations < 60% of tendon width

Partially torn tendons do not require surgery for good results. The same splinting and exercise programs that are used for surgery patients can be very effective for patients with partial tears. 

Operative:

 - Flexor tendon repair and controlled mobilization

 -- lacerations > 60% of tendon width

 - Flexor tendon reconstruction and immediate rehabilitation

 -- failed primary repair

 -- chronic untreated injuries

Tendon transfer to thumb (FDS 4 to thumb)

 - Chronic FPL rupture

It can take up to two months before the repair heals and the hand is strong enough to use without protection. It may take another month or so before the hand can be used with any force. 

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The Miami Institute for Joint Reconstruction
11801 sw 90th St, Suite 201 Miami, FL 3318
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3650 NW 82nd Ave #201, Doral, FL 33166

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