Dupuytren’s contracture is a fairly common disorder of the fingers. It most often affects the ring or little finger, sometimes both, and often in both hands. Although the exact cause is unknown, it occurs most often in middle-aged, white men and is genetic in nature, meaning it runs in families. This condition is seven times more common in men than women. It is more common in men of Scandinavian, Irish, or Eastern European ancestry. Interestingly, the spread of the disease seems to follow the same pattern as the spread of Viking culture in ancient times. The disorder may occur suddenly but more commonly progresses slowly over a period of years. The disease usually doesn’t cause symptoms until after the age of 40.

This guide will help you understand:

• how Dupuytren’s contracture develops
• what the symptoms are
• how the disorder progresses, and how you can measure its progression
• what options for treatment are available
• what First Choice Physical Therapy’s approach treatment is

What part of the hand is affected?

The palm side of the hand contains many nerves, tendons, muscles, ligaments, and bones. This combination allows us to move the hand in many ways. The bones give our hand structure and form joints. Bones are attached to other bones by ligaments. Muscles allow us to bend and straighten our joints. Muscles are attached to bones by tendons. Nerves stimulate the muscles to bend and straighten.

Blood vessels carry needed oxygen, nutrients, and fuel to the muscles to allow them to work normally and heal when injured. Tendons and ligaments are connective tissue. Another type of connective tissue, called fascia, surrounds and separates the tendons and muscles of the hand.

Lying just under the skin of the palm is the palmar fascia; a thin sheet of connective tissue shaped somewhat like a triangle. This fascia covers the tendons of the palm of the hand and holds them in place. It also prevents the fingers from bending too far backward when pressure is placed against them. The fascia separates into thin bands of tissue at the fingers. These bands continue into the fingers where they wrap around the joints and bones. Dupuytren’s contracture forms when the palmar fascia tightens, causing the fingers to bend.

The condition often first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren’s contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.

Why do I have this problem?

No one knows exactly what causes Dupuytren’s contracture. The condition is rare in young people but becomes more common with age. When it appears at an early age, it usually progresses rapidly and is often very severe. The condition tends to progress more quickly in men than in women.

People who smoke have a greater risk of having Dupuytren’s contracture. Heavy smokers who abuse alcohol are even more at risk. Recently, scientists have found a connection with the disease among people who have diabetes. It has not been determined whether or not work tasks can put a person at risk or speed the progression of the disease.

What does Dupuytren’s contracture feel like?

Normally, we are able to control when we bend our fingers and how much. How much we flex our fingers determines how small an object we can hold and how tightly we can hold it. This control  is lost as the disorder develops and the palmar fascia contracts, or tightens. The contracture is like extra scar tissue just under the skin. As the disorder progresses, the bending of the finger becomes more and more severe, which limits the motion of the finger.

Without treatment, the contracture can become so severe that you cannot straighten your finger, and eventually you may not be able to use your hand effectively. Being that our fingers are slightly bent when our hand is relaxed, many people put up with the contracture for a long time. Patients with this condition usually eventually seek medical advice for cosmetic reasons or because they lose use of their hand. At times, the nodules can be very painful. For this reason many patients are worried that something serious is wrong with their hand.

How do health care providers identify the problem?

When you visit First Choice Physical Therapy, our Physical Therapist will ask you the history of your problem, such as how long you have had it, whether you’ve noticed it getting worse, and whether it has kept you from doing your daily activities. We will then examine your hand and fingers.

Our Physical Therapist can tell if you have a Dupuytren’s contracture by looking at and feeling the palm of your hand and your fingers. Usually, special tests are unnecessary. Abnormal fascia will feel thick. Cords and small nodules in the fascia may be felt as small knots or thick bands under the skin. These nodules usually form first in the palm of the hand. As the disorder progresses, nodules form along the finger. These nodules can be felt through the skin, and patients can usually feel them themselves. Depending on the stage of the disorder, your finger may have started to contract, or bend.

The amount you are able to bend your finger is called flexion. The amount you are able to straighten the finger is called extension. Both are measured in degrees. Normally, the fingers will straighten out completely. This is considered zero degrees of flexion (no contracture). As the contracture causes your finger to bend more and more, you will lose the ability to completely straighten out the affected finger. The loss of ability to straighten out your finger is also measured in degrees.

Measurements we take at follow-up visits to First Choice Physical Therapy will tell us how well our treatments are working or how fast the disorder is progressing. The progression of the disorder is unpredictable. Some patients have no problems for years, and then suddenly nodules will begin to grow and their finger will begin to contract.

Our Physical Therapist may also do the tabletop test. The tabletop test will show if you can flatten your palm and fingers on a flat surface. You can follow the progression of the disorder by doing the tabletop test yourself. Our Physical Therapist will tell you what to look for and when you should return for a follow-up visit.

What can be done for the condition?

There are two types of treatment for Dupuytren’s contracture: nonsurgical and surgical. The best course of treatment is determined by how far the contractures have advanced.

Nonsurgical Treatment

The nodules of Dupuytren’s contracture are almost always limited to the hand. If you receive regular examinations, you will know when to proceed with the next treatment step. Dupuytren’s contracture is a progressive disease, early treatment, determined by the stage of the disease, is important to release the contracture and to prevent disability in your hand. Treatment is determined based on the severity of the contracture.

Enzymatic FasciotomyOngoing research of this condition has resulted in a less invasive nonsurgical method of treatment called an enzymatic fasciotomy.  If it is the main knuckle of the finger (at the base of the finger) that is contracted, and there are only one or two cords involved, this procedure may be possible. For this treatment, a new injectable drug, Xiaflex, which is gaining popularity and approval for use around the world, is used. By injecting an enzyme directly into the cords formed by the disease, the tissue dissolves and starts to weaken, most often the patients are able to break apart the cord by themselves.

With the injection of this new drug generally patients return within 24 hours for a recheck. If the cord hasn’t broken apart, your physician may have to numb the finger and then stretch it to break apart the cord and regain full motion of the finger. This technique sounds dramatic, but it’s not! The treatment so far has been deemed to be safe and effective.

There are a few possible (minor) side effects but very few major or long-term complications with this new treatment. During the control trials conducted with patients, most people had a local skin reaction (redness, skin tears, itching or stinging) where the injection went into the skin. A small number of more serious problems developed in a few patients including tendon rupture, finger deformity, and hives that had to be treated with medication. Further studies are needed to assess the long-term effects of this new treatment, especially to determine any recurrence rates.

Injection of this drug may eventually replace surgery. Until then, surgical release of the cords and removing a portion of the fascia will likely remain the gold standard.

The ability of nonsurgical treatments to slow or actually reverse the contracture is not all that promising. The contracture usually requires surgery at some point.
In the early stages of this disorder, frequent examination and follow-up is recommended. In addition to your Physical Therapy treatments at First Choice Physical Therapy, your doctor may want to inject cortisone into the painful nodules. Cortisone can be effective at temporarily easing pain and inflammation.

Heat and stretching treatments given by our Physical Therapist may also be done to control pain and to try to slow the progression of the contracture. Our Physical Therapist may advise you to wear a splint that keeps the finger straight. This splint is usually worn at night. The combination of heat, stretching, and a finger splint seem to be the most effective non-surgical treatments for Dupuytren’s contracture.

Although recovery times among patients varies, as a general rule, you may be advised to

attend our Physical Therapy sessions a few visits per week for up to six weeks. After that, our Physical Therapist will instruct you to continue using the splint and do the stretches as part of a home program for several months.

The nodules of Dupuytren’s contracture are almost always limited to the hand. If you attend Physical Therapy regularly and follow our Physical Therapist’s advice, you may be able to slow the problems caused by this disorder. Dupuytren’s contracture, however, is known to progress, so surgery may be needed at some point to release the contracture and to prevent disability in your hand.

First Choice Physical Therapy provides services for Physical Therapy in Lynn Haven and Panama City Beach.

No hard and fast rule exists as to when surgery is needed. Surgery is usually recommended when the joint at the knuckle of the finger reaches 30 degrees of flexion. When patients have severe problems and require surgery at a younger age, the problem often comes back later in life. When the problem comes back or causes severe contractures, surgeons may decide to fuse the individual finger joints together. In the worst case, amputation of the finger may be needed if the contracture restricts the nerves or blood supply to the finger.

Surgery for the main knuckle of the finger (at the base of the finger) has better long-term results than when the joint in the middle of the finger is affected. A contracture is more likely to return after surgery for the middle joint.

Tissue Release

The goal of tissue release surgery is to release the fibrous attachments between the palmar fascia and the tissues around it, thereby releasing the contracture. Once released, finger movement should be restored to normal. If the problem is not severe, it may be possible to free the contracture simply by cutting the cord under the skin. If the palmar fascia is more involved and more than one finger is bent, your surgeon may take out a large portion of the sheet of fascia.

Palmar Fascia Removal (partial palmar fasciectomy)

This remains the gold standard of treatment for Dupuytren’s contracture. Removal of the diseased palmar fascia will usually give a very good result. The cure is often permanent but depends a great deal on the success of doing the Physical Therapy post surgically as prescribed. Removing the palmar fascia causes little ill effect, although the fingers may bend backward slightly more than normal. If you decide to have this surgery, it is pertinent that you commit to doing the therapy needed to make your surgery as successful as possible.

Removal of the entire palmar fascia (radical fasciectomy) requires extensive removal of involved and non-involved palmar and digital (finger) fascia. This approach may be required but it has higher complications rates without providing better success rates so it is no longer done commonly.

Needle Aponeurotomy

A less invasive procedure called a needle aponeurotomy (also referred to as a percutaneous fasciotomy) is available when the disease is at an early stage. Under local anesthesia, the surgeon inserts a very thin needle under the skin. The sharp needle cuts a path through the cord, weakening it enough to stretch and extend it, or rupture it.
The advantage of this procedure is that it can be done on older adults who have other health issues that might make surgery under general anesthesia too risky. The disadvantage is a high recurrence rate and the potential for nerve injury, infection, and hematoma (pocket of blood) formation.This procedure, however, has replaced the fasciectomy in many practices.

Skin Graft Method

A skin graft may be needed if the skin surface has contracted so much that the fingercannot relax as it should and the palm cannot be stretched out flat. Surgeons graft skin from the wrist, elbow, or groin. The skin is grafted into the area near the incision to give the finger extra mobility for movement.

Your hand will be bandaged with a well-padded dressing and a splint for support after surgery. As stated above, your Physical Therapy at First Choice Physical Therapy is a very important part of your recovery. Physical Therapy treatments after surgery can make the difference to a successful result. The treatments applied by our Physical Therapist may include a program of heat, soft tissue massage, and vigorous stretching, as well as a home program which includes similar exercises that you will be required to do on your own.  Your Physical Therapist will keep a close watch on how your recovery is going, and will take ongoing measurements to mark the progress of your recovery.

Generally Physical Therapy at First Choice Physical Therapy occurs without any issues, and full recovery occurs provided our advice is closely followed. If, however, your recovery is not progressing as your Physical Therapist feels it should, we will ask you to return to your surgeon for a follow-up visit to ensure there are no complications, which are impeding your recovery.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be solely in charge of doing your own exercises as part of an ongoing home program.

Arthritis of the Finger Joints

When you stop to think about how much you use your hands, it’s easy to see why the joints of the fingers are so important. Arthritis of the finger joints has many causes, and arthritic finger joints can make it hard to do daily activities due to pain and deformity. Unbearable pain or progressive deformity from arthritis may signal the need for surgical treatment.

This guide will help you understand:

• how arthritis of the finger joints develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

How do the finger joints normally work?

The bones in the palm of the hand are called metacarpals. One metacarpal connects to each finger and thumb. Small bone shafts called phalanges line up to form each finger and thumb.

The main knuckle joint is formed by the connection of the phalanges to the metacarpals. This joint is called the metacarpophalangeal joint (MCP joint). The MCP joint acts like a hinge when you bend and straighten your fingers and thumb.

The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint). The thumb only has one IP joint between the two thumb bones. The IP joints of the digits also work like hinge joints when you bend and straighten your hand.

The finger and thumb joints are covered on the ends with articular cartilage. This white, shiny material has a rubbery consistency. The function of articular cartilage is to absorb shock and provide an extremely smooth surface to facilitate motion. There is articular cartilage essentially everywhere that two bony surfaces move against one another, or articulate.

Articular Cartilage

Hand Anatomy Introduction

Causes

What causes arthritis?

Degenerative arthritis is a condition in which a joint wears out, or degenerates, usually slowly over a period of many years. Degenerative arthritis is usually called osteoarthritis. The term arthritis means joint inflammation (pain, redness, heat, and swelling). The term degenerative arthritis means inflammation of a joint due to wear and tear. You may also hear the term degenerative arthrosis used. Degenerative arthritis is usually called osteoarthritis.

Degenerative Arthritis

Injury to a joint, such as a bad sprain or fracture, can cause damage to the articular cartilage. An injury to any of the joints of the fingers, even if it does not injure the articular cartilage directly, can alter how the joint works. After a fracture, the bone fragments may heal in slightly different positions. This may make the joints line up differently. When an injury changes the way the joint lines up and moves, force can start to press against the surface of the articular cartilage. This is similar to how a machine that is out of balance wears out faster.

Articular Cartilage Damage

Over time, this imbalance in the joint can lead to damage to the articular surface. Since articular cartilage cannot heal itself very well, the damage adds up. Eventually, the joint can no longer compensate for the increasing damage, and symptoms begin. The damage in the joint starts well before the symptoms of arthritis appear.

Symptoms

What does arthritis feel like?

Pain is the main problem with arthritis. At first, the pain usually only causes problems when you begin an activity. Once the activity gets underway, the pain eases. But after resting for several minutes the pain and stiffness increase. When the arthritis condition worsens, pain may be felt even at rest. The sensitive joint may feel enlarged and warm to the touch from inflammation.

In rheumatoid arthritis, the fingers often become deformed as the disease progresses. The MCP joints of the fingers may actually begin to point sideways (towards the little finger). This is called ulnar drift. Ulnar drift can cause weakness and pain, making it difficult to use your hand for daily activities.

Ulnar Drift

Both rheumatoid arthritis and osteoarthritis can affect the IP joints of the fingers. The IP joints may begin to flex (bend) or hyperextend (over straighten), causing characteristic finger deformities. Swan neck deformity occurs when the middle finger joint (the PIP joint) becomes loose and hyperextended, while the DIP joint becomes flexed. When the PIP joint flexes and the DIP joint extends, a boutonniere deformity forms.

Swan Neck Deformity

Boutonniere Deformity

Both forms of arthritis can cause enlarged areas over the back of the PIP joints. These areas tend to be sore and swollen. They are known as Bouchard’s nodes.

Bouchard’s Nodes

Osteoarthritis causes similar enlargements over the DIP joints, called Heberden’s nodes.

Heberden’s Nodes

Diagnosis

How do health care providers identify arthritis?

The diagnosis of arthritis of the finger joints begins with a history of the problem. When you visit First Choice Physical Therapy, our Physical Therapist will want details about any injuries that may have occurred to the hand. This information is important because it may suggest other reasons why the condition exists.

Following the history, we will do a physical examination of the hand and possibly other joints in the body. Our Physical Therapist will need to see how the motion of each joint has been affected.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

Treatment usually begins when the joint first becomes painful. This may only occur with heavy use and may simply require mild anti-inflammatory medications, such as aspirin or ibuprofen. Reducing the activity, or changing from occupations that require heavy repetitive hand and finger motions, may be necessary to help control the symptoms.

Our primary goal is to help you learn how to control symptoms and maximize the health of your hand and fingers. When you visit First Choice Physical Therapy in Lynn Haven and Panama City Beach, our Physical Therapist will instruct you in ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs.

We will then begin range-of-motion exercises for your finger after your pain eases, followed by a program of strengthening to improve your finger movement. Strengthening exercises for the arm and hand help steady the hand and protect the finger joints from shock and stress. Our therapist may also use dexterity and fine motor exercises to get your hand and fingers moving. We will go over tips on how you can get your tasks done with less strain on the joint.

Your Physical Therapist may recommend a custom finger brace or splint to support your finger joints. These devices are designed to help reduce pain, prevent deformity, or keep a finger deformity from getting worse.

Post-surgical Rehabilitation

Your hand will be bandaged with a well-padded dressing and a finger splint for support after surgery. Although time required for recovery varies among patients, you may need to attend our physical or occupational therapy sessions after surgery for up to eight weeks.

When you begin your First Choice Physical Therapy post-surgical Physical Therapy program, the first few treatments will be used to help control the pain and swelling after surgery. Some of the exercises that our Physical Therapist will have you do help strengthen and stabilize the muscles around the finger joint. We’ll recommend other exercises to improve the fine motor control and dexterity of your hand. Our Physical Therapist will also give you tips on ways to do your activities while avoiding extra strain on the finger joint.

At First Choice Physical Therapy, our goal is to help you keep your pain under control, improve your range of motion, and maximize strength and control in your finger. When your recovery is well under way, regular visits to our office will end. Our Physical Therapist will give you tips on keeping your symptoms controlled. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program.

Surgery

Fusion

A fusion (or arthrodesis) of any joint is designed to eliminate pain by allowing the bones that make up the joint to grow together, or fuse, into one solid bone. Fusions are used in many joints and were very common before the invention of artificial joints for the replacement of arthritic joints. Even today, joint fusions are still very commonly used in many different joints for treating the pain and potential deformity of arthritis. Fusions are more commonly used in the PIP or the DIP joints in the fingers. A fusion of these joints is far easier and more reliable than trying to save the motion by replacing the joint.

Artificial Joint Replacement

Artificial joints are available for the finger joints. These plastic or metal prostheses are used by some hand surgeons to replace the arthritic joint. The prosthesis forms a new hinge, giving the joint freedom of motion and pain relief. The procedure for putting in a new joint is called arthroplasty.

Arthritis of the Thumb

When you stop to think about how much you use your thumbs, it’s easy to see why the joint where the thumb attaches to the hand can suffer from wear and tear. This joint is designed to give the thumb its rather large range of motion, but the tradeoff is that the joint suffers a lot of stress over the years. This can lead to painful osteoarthritis of this joint that may require surgical treatment as the arthritis progresses.

This guide will help you understand:

• how arthritis of the thumb develops
• how it is diagnosed
• what can be done for the condition

Anatomy

Where is the CMC joint, and what does it do?

The CMC joint (an abbreviation for carpometacarpal joint) of the thumb is where the metacarpal bone of the thumb attaches to the trapezium bone of the wrist. This joint is sometimes referred to as the basal joint of the thumb. The CMC is the joint that allows you to move your thumb into your palm, a motion called opposition.

Carpometacarpal Joint

Trapezium Bone

Several ligaments hold the CMC joint together. These ligaments can be injured, such as when you sprain your thumb. The joint surfaces are covered with a material called articular cartilage. This material is the slick, spongy covering that allows one side of a joint to slide against the other joint surface easily.

Articular Cartilage

Causes

What causes arthritis of the thumb?

Arthritis is a condition in which a joint becomes inflamed (red, swollen, hot, and painful). Degenerative arthritis is a condition in which a joint wears out, usually slowly over a period of many years. Doctors sometimes also describe this same condition as degenerative arthrosis. It is also called osteoarthritis.

Degenerative Arthritis

Injury to a joint, such as a bad sprain or fracture, can cause damage to the articular cartilage. An injury to the CMC joint of the thumb, even if it does not injure the articular cartilage directly, can alter how the joint works. After a fracture of the thumb metacarpal, the bone fragments may heal in slightly different positions. The joints may then line up differently. This is also true when the ligaments around the CMC joint are damaged by a sprain. When an injury results in a change in the way the joint moves, the injury may increase the forces on the articular cartilage surfaces. This is similar to any mechanical device or machinery. If the mechanism is out of balance, it tends to wear out faster.

Over many years this imbalance in the joint mechanics can lead to damage on the articular surface. Since articular cartilage cannot heal itself very well, the damage adds up. Eventually, the joint is no longer able to compensate for the increasing damage, and it begins to hurt. Damage has occurred well before the pain begins.

Symptoms

What does arthritis of the thumb feel like?

Pain is the main problem with degenerative arthritis of any joint. This pain occurs at first only related to activity. Usually, once the activity gets underway there is not much pain, but after resting for several minutes the pain and stiffness increase. Later, when the condition worsens, pain may be present even at rest. The most noticeable problem with CMC joint arthritis is that it becomes difficult to grip anything. It causes a sharp pain at the base of the thumb in the thick part of the heel of the hand.

Base of Thumb

When the articular cartilage starts to wear off the joint surface, the joint may make a squeaking sound when moved. Doctors refer to this sound as crepitus. The joint often becomes stiff and begins to lose motion. Moving the thumb away from the palm may become difficult. This is referred to as a contracture.

Osteoarthritis may cause the CMC joint of the thumb to loosen and to bend back too far (hyperextension). If the middle thumb joint (MCP joint) becomes flexed and the furthest thumb joint also becomes hyperextended, the deformity is named a thumb swan neck deformity. A similar finger deformity sometimes occurs in people with finger arthritis.

Thumb Swan Neck Deformity

Diagnosis

When you visit First Choice Physical Therapy, our diagnosis of CMC joint arthritis of the thumb begins with our Physical Therapist taking a detailed history of the problem. Specifics about any injuries that may have occurred to the hand are important because they may suggest other reasons why the condition exists.

Following the history, our Physical Therapist will examine your hand and possibly other joints in your body. We will need to see how the motion of the CMC joint has been affected.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What can be done for CMC joint arthritis?

The treatment of degenerative arthritis of the CMC joint of the thumb can be divided into the nonsurgical means to control the symptoms and the surgical procedures that are available to treat the condition. Surgery is usually not considered until the symptoms have become impossible to control without it.

Non-surgical Rehabilitation

Treatment usually begins when the CMC joint first becomes painful. This may only occur with heavy use and may simply require mild anti-inflammatory medications, such as aspirin or ibuprofen. Ensure that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication. Reducing the activity, or changing from occupations that require heavy repetitive gripping with the hand, may be necessary to help control the symptoms.

If you don’t need surgery, your Physical Therapist at First Choice Physical Therapy will first work with you to obtain or create a special thumb brace or splint when needed. These devices are designed to help reduce pain, prevent deformity, or keep a thumb deformity from getting worse. A thumb stabilizer is a type of thumb splint that is often custom-made of heat-moldable plastic. It is designed to fit the forearm, wrist, and thumb. Our patients with CMC joint arthritis usually only wear the splint at night and when the joint is flared up. It should also be worn to protect the thumb during heavy or repeated hand and thumb activities.

Our primary therapeutic goal is to help you learn how to control symptoms and maximize the health of your thumb. Our Physical Therapist will teach you ways to calm pain and symptoms, which might include the use of rest, heat, or topical rubs.

We will begin instructing you in range-of-motion and stretching exercises to improve your thumb motion. Our program then advances to include strength exercises for the thumb and fingers. We use dexterity and fine motor exercises to get your hand and thumb moving smoothly. Your Physical Therapist will also go over tips on how you can get your tasks done with less strain on the joint.

Although the time required for recovery varies among patients, as a guideline, you may expect to progress to a home program within four to six weeks.

Post-surgical Rehabilitation

After surgery, your hand will be bandaged with a well-padded dressing and a thumb splint for support. When you begin your Physical Therapy program, the first few treatments are used to help control the pain and swelling after surgery.

Our Physical Therapist will have you begin doing exercises to help strengthen and stabilize the muscles around the thumb joint. We’ll use other exercises to improve the fine motor control and dexterity of your hand. Our Physical Therapist will also provide tips on ways to do your activities while avoiding extra strain on the thumb joint.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Physician Review

Your doctor may take X-rays to see how much the joint is damaged.

X-Rays

This test usually determines how bad the degenerative arthritis has become. How much articular cartilage remains in the joint can be estimated with the X-rays.

An injection of cortisone into the joint can give temporary relief. Cortisone is a very powerful anti-inflammatory medication. When injected into the joint itself, it can help relieve the pain. Pain relief is temporary and usually only lasts several weeks to months. There is a small risk of infection with any injection into the joint, and cortisone injections are no exception.

Cortisone Injection

Surgery

The surgical treatment for arthritis of the CMC joint includes several options. At one time, joint replacement with an artificial joint made with silicon was very popular. Problems with silicon implants in other parts of the body have led many surgeons to return to more traditional operations such as fusion and excision arthroplasty instead. Newer artificial joints are being developed, and in the future we may see more surgeons using them.

CMC Joint Fusion

A fusion, or arthrodesis, of any joint is designed to eliminate pain by allowing the bones that make up the joint to grow together, or fuse, into one solid bone. Fusions are used in many joints and were very common before the invention of artificial joints for the replacement of arthritic joints. Even today, joint fusions are still commonly used in many different joints for treating the pain of arthritis.

A fusion of the CMC joint of the thumb is done quite often in younger people who need a strong grip or pinch more than they need the fine motion of the thumb. People who use their hands for heavy work will probably prefer a fusion over an arthroplasty (described below).

Artificial Joint Replacement (Arthroplasty)

Artificial joints are available for the CMC joint. These plastic or metal prostheses are used by some hand surgeons to replace the joint. The prosthesis acts as a spacer to fill the gap created when the arthritic surfaces of the two bones that make up the CMC joint are removed.

Excision Arthroplasty

The traditional operation for treating CMC joint arthritis is excision arthroplasty. This method has been used for many years and has withstood the test of time. The purpose of excision arthroplasty is to remove the arthritic joint surfaces of the CMC joint and replace them with a cushion of material that will keep the bones separated. Most surgeons use a piece of tendon that has been rolled up and placed into the space created by removing the bone surfaces. During the healing phase after surgery, this tendon turns into tough scar tissue that forms a flexible connection between the bones, similar to a joint.

This operation is also combined with a reconstruction of the joint where tendons in the area are used to create a ligament sling between the metacarpal bone of the thumb and the carpal bone of the index finger. This helps hold the thumb in place and keeps the space between the bones from collapsing.

Boutonniere Deformity of the Finger

The tendons that allow each finger to straighten, the extensor tendons, at first appear to be relatively simple. But as the extensor tendon runs into the finger, it becomes a complex and elegantly balanced mechanism that allows very fine control of the motion of each joint of the finger. When this mechanism is damaged in certain areas, this balance can be destroyed. The result is a finger that doesn’t work properly. Over time, the imbalance can lead to contractures (tightening of the tendons) and other changes that result in a permanently crooked finger. The boutonniere deformity is one such problem that affects the extensor tendons of the finger.

This guide will help you understand:

• what parts of the finger are involved
• what causes the boutonniere deformity
• how the problem is treated
• what to expect from treatment

Anatomy

What parts of the finger are involved?

The extensor tendons begin as muscles that arise from the backside of the forearm bones. These muscles travel towards the hand, where they eventually connect to the extensor tendons before crossing over the back of the wrist joint. As they travel into the fingers, the extensor tendons become the extensor hood. The extensor hood flattens out to cover the top of the finger and sends out branches on each side that connect to the bones in the middle and end of the finger. When the extensor muscle contracts, it shortens and pulls on these attachments to straighten the finger.

Extensor Tendons

Small ligaments also connect the extensor hood with other tendons that travel into the finger to bend the finger. These connections help balance the motion of the finger so that all the joints of the finger work together, giving a smooth bending and straightening action. Problems arise when these ligaments become too tight or too loose.

Extensor Hood

The fingers are actually made up of three bones, called phalanges. The three phalanges in each finger are separated by two joints, called interphalangeal joints (IP joints). The joint near the end of the finger is called the distal IP joint (DIP joint). (Distal means further away.) The proximal IP joint (PIP joint), is the middle joint between the main knuckle and the DIP joint. (Proximal means closer in.) The IP joints of the fingers work like hinge joints when you bend and straighten your hand.

A boutonniere deformity occurs when disease or injury causes the PIP joint to become flexed (bent) and the DIP joint is pulled up into too much extension (hyperextension).

Causes

How does this condition occur?

The boutonniere deformity happens when the extensor tendon attachment to the middle phalanx is injured. This area is called the central slip. This tendon attachment may be injured in many ways. The central slip may simply be damaged when a cut occurs over the back of the middle finger joint (PIP joint). More commonly the central slip tears or pops off its attachment on the bone when the finger is jammed from the end, forcing the PIP joint to bend.

Central Slip

When a small amount of bone is pulled off with the tendon, doctors call it an avulsion fracture. The central slip can also be torn when the PIP joint is dislocated and the middle phalanx dislocates towards the palm.

Middle Phalanx Dislocates

Other conditions that affect the central slip can cause the boutonniere deformity. For example, prolonged inflammation in the PIP joint from rheumatoid arthritis stretches and eventually ruptures the central slip. A severe burn on the hand can damage the central slip. Another problem affecting the hand, called Dupuytren’s contracture, can weaken the central slip and produce the boutonniere deformity.

Related Document: First Choice Physical Therapy’s Guide to Dupuytren’s Contracture

The boutonniere deformity may not occur right away. It is the imbalance in the extensor hood that results from the torn tendon that eventually causes the deformity. Because the middle phalanx no longer is pulled by the central slip, the flexor tendon on the other side begins to bend the PIP joint without resistance. The lateral bands begin to slide down along the side of the finger where they continue to straighten the DIP joint. Eventually the finger becomes stiff in this position.

Symptoms

What do boutonniere deformities look and feel like?

Initially, the finger is painful and swollen around the PIP joint. The PIP joint may not straighten out completely under its own power. The finger can usually be straightened easily with help from the other hand. Eventually, the imbalance leads to the typical shape of the finger with a boutonniere deformity.

Typical Shape of Finger

Diagnosis

When you visit First Choice Physical Therapy, our Physical Therapist will take a history and do a physical examination of your finger. Usually the diagnosis is evident just from the physical examination.

Some patients may be referred to a doctor for further testing. X-rays may be required to see if there is an associated avulsion fracture, since this may change the recommended treatment. No other tests are required normally.

Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

What can be done for a boutonniere deformity of the finger?

Treatment for boutonniere deformity depends on whether the injury to the central slip is recognized immediately or if the deformity has been present for a long time. When the injury is the result of a laceration of the finger, a surgeon will usually repair the tendon as well as suture the skin.

Non-surgical Rehabilitation

If the injury to the central slip results from a simple avulsion (tearing) of the tendon from the bone, your Physical Therapist at First Choice Physical Therapy may recommend splinting of the PIP joint for approximately six weeks to allow the bone to heal and prevent the boutonniere deformity from occurring. The splint does allow the DIP joint to move throughout this period and it can be exercised to prevent stiffness.

While a simple homemade splint will work, there are many special designs that make it easier to wear your splint at all times. There are also splints that have been designed to be similar to springs. These splints can be used to gently stretch out a contracture of the PIP joint over several weeks. The spring applies gentle pressure all the time, and the PIP joint slowly straightens.

A splint may also be needed to keep the DIP joint from hyperextending. Newer styles are shaped like jewelry rings and are available in stainless steel, sterling silver, or gold.

Splinting and a rigorous exercise program may even work when the condition has been present for some time. Often our Physical Therapists will try six weeks of splinting with the spring-type splint and exercise to see if the deformity lessens to a tolerable limit before considering referring you for surgical evaluation. This is desirable before surgery to stretch out a PIP contracture before repairing or reconstructing the extensor hood.

Although time required for recovery is different for each patient, if nonsurgical treatment is successful, you may see improvement in eight to 12 weeks. After wearing a finger splint for up to eight weeks, our Physical Therapist may have you continue wearing the splint at night for at least another month. It is important during this time that the joints on either side of the splint be moved. Your Physical Therapist can design a personalized exercise program to allow you to properly and safely exercise your finger.

Post-surgical Rehabilitation

You’ll wear a splint or brace after surgery. A protective finger splint holds the PIP joint straight and is typically used for at least three weeks after surgery. We may apply a dynamic splint to help gradually straighten the PIP joint, and our Physical Therapy or occupational therapy treatments usually start three to six weeks after your surgery.

Although the time needed for recovery varies among patients, it is likely that you will need to attend Physical Therapy sessions for three to four months, and you should expect full recovery to take up to six months.

Our first few Physical Therapy treatments will focus on controlling the pain and swelling from surgery. Then our Physical Therapist will begin gentle range-of-motion exercise. Strengthening exercises usually follow eight to 10 weeks after surgery. We’ll instruct you in ways to grip and support items in order to do your tasks safely and with the least amount of stress on your finger joint. As with any surgery, you need to avoid doing too much, too quickly.

Eventually, our Physical Therapist will have you begin doing exercises designed to get your hand and fingers working in ways that are similar to your work tasks and daily activities. We will help you find ways to do your tasks that don’t put too much stress on your finger joint. Before your Physical Therapy sessions end, our Physical Therapist will teach you a number of ways to avoid future problems.

Our goal is to help you keep your pain under control, improve your strength and range of motion, and regain your fine motor abilities with your hand and finger. When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will be in charge of doing your exercises as part of an ongoing home program.

Surgery

Surgery is required in some cases of boutonniere deformity. Best results occur when the PIP joint is limber, rather than stuck in a bent position. If the PIP joint is stuck in a bent position, surgeons usually wait before doing surgery to see if splinting will help stretch and straighten the PIP joint.

Joint Fixation

When the deformity is the result of a dislocation of the PIP joint, surgery may be required to repair the damaged structures and prevent the later development of a boutonniere deformity. A pin is usually placed through the PIP joint to fix the joint in place for up to three weeks. Patients wear a splint to protect the joint for another three weeks after surgery.

Soft Tissue Repair

In cases where the balance cannot be restored to a tolerable limit with splinting or by simply pinning the PIP joint, surgery may be required to reconstruct and rebalance the extensor hood. There are numerous types of operations that have been designed to try and rebalance the extensor hood. None is completely successful.

Surgery to repair the soft tissues that are contributing to a boutonniere deformity carries a relatively high risk of failure to achieve completely normal functioning of the extensor mechanism of the finger. All of the repair and reconstruction procedures are dependant on a well designed and rigorous exercise program following the surgery. A Physical Therapist or occupational therapist will work closely with you during your recovery.

Fusion

If past treatments, including surgery, do not stop inflammation or deformity in the joint, finger joint fusion may be recommended. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from moving. Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity.

Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

This article will help you understand:

• where the carpal tunnel is located
• how CTS develops
• what can be done for the condition

Anatomy

Where is the carpal tunnel, and what does it do?

The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on one side and the transverse carpal ligament on the other. (Ligaments connect bones together.) This opening forms the carpal tunnel.

The median nerve passes through the carpal tunnel into the hand. It gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb.

Median Nerve

The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips each of each finger on the same hand, a motion called opposition.

Opposition

The median nerve and flexor tendons pass through the carpel tunnel. The median nerve rests on top of the tendons, just below the transverse carpal ligament. The flexor tendons are important because they allow movement of the fingers, thumb, and hand, such as when grasping. The tendons are covered by a material called tenosynovium. The tenosynovium is a slippery covering that allows the tendons to glide next to each other as they are worked.

Causes

What causes CTS?

 

Any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel can lead to symptoms of CTS. For example, a traumatic wrist injury may cause swelling and extra pressure within the carpal tunnel. The area inside the tunnel can also be reduced after a wrist fracture or dislocation if the bone pushes into the tunnel.

Any condition that causes abnormal pressure in the tunnel can produce symptoms of CTS. Various types of arthritis can cause swelling and pressure in the carpal tunnel. Fractured wrist bones may later cause CTS if the healed fragments result in abnormal irritation on the flexor tendons.

Other conditions in the body can produce symptoms of CTS. Pregnancy can cause fluid to be retained, leading to extra pressure in the carpal tunnel. Diabetics may report symptoms of CTS, which may be from a problem in the nerve (called neuropathy) or from actual pressure on the median nerve. People with low thyroid function (called hypothyroidism) are more prone to problems of CTS.

The way people do their tasks can put them at more risk for problems of CTS. Some of these risks include:

• force
• posture
• wrist alignment
• repetition
• temperature
• vibration

One of these risks alone may not cause a problem. But doing a task that involves several factors may pose a greater risk. And the longer a person is exposed to one or more risks, the greater the possibility of having a problem with CTS. However, scientists believe that other factors such as smoking, obesity, and caffeine intake may actually be more important in determining whether a person is more likely to develop CTS.

In other instances, CTS can start when the tenosynovium thickens from irritation or inflammation. This thickening causes pressure to build inside the carpal tunnel. But the tunnel can’t stretch any larger in response to the added swelling, so the median nerve starts to squeeze against the transverse carpal ligament. If the pressure continues to build up, the nerve is eventually unable to function normally.

When pressure builds on the median nerve, the blood supply to the outer covering of the nerve slows down and may even be cut off. The medical term for this is ischemia. At first, only the outside covering of the nerve is affected. But if the pressure keeps building up, the inside of the nerve will start to become thickened. New cells (called fibroblasts) form within the nerve and create scar tissue. This is thought to produce the feelings of pain and numbness in the hand. If pressure is taken off right away, the symptoms will go away quickly. Pressure that isn’t eased right away can slow or even stop the chances for recovery.

Symptoms

What does CTS feel like?

One of the first symptoms of CTS is gradual tingling and numbness in the areas supplied by the median nerve. This is typically followed by dull, vague pain where the nerve gives sensation in the hand. The hand may begin to feel like it’s asleep, especially in the early morning hours after a night’s rest.

Sometimes pain may even spread up the arm to the shoulder. If the condition progresses, the thenar muscles of the thumb can weaken, causing the hand to be clumsy when picking up a glass or cup. If the pressure keeps building in the carpal tunnel, the thenar muscles may begin to shrink (atrophy).

Atrophy

Touching the pad of the thumb to the tips of the other fingers becomes difficult, making it hard to grasp items such as a steering wheel, newspaper, or telephone.

Diagnosis

How do health care providers identify the condition?

When you visit First Choice Physical Therapy, our Physical Therapist in Lynn Haven and Panama City Beach begins the evaluation by obtaining a history of the problem, followed by a thorough physical examination. Your description of the symptoms and the physical examination are the most important parts in the diagnosis of CTS. Commonly, patients will complain first of waking in the middle of the night with pain and a feeling that the whole hand is asleep.

Careful investigation usually shows that the little finger is unaffected. This can be a key piece of information to make the diagnosis. If you awaken with your hand asleep, pinch your little finger to see if it is numb also, and be sure to tell our Physical Therapist if it is or isn’t. Other complaints include numbness while using the hand for gripping activities, such as sweeping, hammering, or driving.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

When you begin your Physical Therapy in Lynn Haven and Panama City Beach, our Physical Therapist will recommend that you change or stop the activities that are causing your symptoms if at all possible. Avoid repetitive hand motions, heavy grasping, holding onto vibrating tools, and positioning or working with your wrist bent down and out. If you smoke, talk to your doctor about ways to help you quit. Lose weight if you are overweight. Reduce your caffeine intake.

Our Physical Therapist will often have you wear a wrist brace. This sometimes decreases the symptoms in the early stages of CTS. A brace keeps the wrist in a resting position, not bent back or bent down too far. When the wrist is in this position, the carpal tunnel is as big as it can be, so the nerve has as much room as possible inside the carpal tunnel. A brace can be especially helpful for easing the numbness and pain felt at night because it can keep your hand from curling under as you sleep. The wrist brace can also be worn during the day to calm symptoms and rest the tissues in the carpal tunnel.

The main focus of our treatment is to reduce or eliminate the cause of pressure in the carpal tunnel. Our Physical Therapist may check your workstation and the way you do your work tasks. We may provide suggestions about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems. Our Physical Therapist may also begin treatments to reduce inflammation and to encourage normal gliding of the tendons and median nerve within the carpal tunnel.

Although time required for recovery is different for every patient, as a general rule, you may see improvement in four to six weeks. We may ask you to continue wearing your wrist splint at night to control symptoms and keep your wrist from curling under as you sleep. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and vibration in the hand.

Post-surgical Rehabilitation

It generally takes longer to recover after open carpal tunnel release. Pain and symptoms usually begin to improve, but you may have tenderness in the area of the incision for several months after surgery.

Patients who wait too long to seek medical advice sometimes have difficulty adjusting after surgery. Poor coping skills in the presence of persistent pain and numbness may result in disappointment or dissatisfaction with the results of surgery. Recovery may take longer than expected when nerve damage is severe. In some cases, symptoms are not entirely alleviated.

When the stitches are removed, you may begin your Physical Therapist program. Our treatments are used at first to ease pain and inflammation. Our Physical Therapist may apply gentle massage to the incision to help reduce sensitivity in and around the incision and limit scar tissue from building up. We will show you some special exercises that you can do to encourage normal gliding of the tendons and median nerve within the carpal tunnel.

As you progress, our therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand, wrist, and arm. We use other exercises to improve fine motor control and dexterity of the hand. Our Physical Therapist will also work with you to help you do your daily and work activities safely and with the least amount of strain on your wrist and hand.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Physician Review

If your symptoms started after a traumatic wrist injury, your doctor may order X-rays to check for a fractured bone.

If more information is needed to make the diagnosis, electrical studies of the nerves in the wrist may be requested by your doctor. Several tests are available to see how well the median nerve is functioning, including nerve conduction velocity (NCV) test. This test measures how fast nerve impulses move through the nerve.

Anti-inflammatory medications may also help control the swelling and reduce symptoms of CTS. Ensure that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication. These include common over-the-counter medications such as ibuprofen and aspirin. Oral steroid medication may also offer some relief. In some studies, high doses of vitamin B-6 have been shown to help in decreasing CTS symptoms. Some types of exercises have also shown to help prevent or at least control the symptoms of CTS.

If these simple measures fail to control your symptoms, an injection of cortisone into the carpal tunnel may be suggested. This medication is used to reduce the swelling in the tunnel and may give temporary relief of symptoms.

A cortisone injection may help ease symptoms and can aid your doctor in making a diagnosis. If you don’t get even temporary relief from the injection, it could indicate that some other problem is causing your symptoms. When your symptoms do go away after the injection, it’s likely they are coming from a problem within the carpal tunnel. Some doctors feel this is a signal that a surgical release of the transverse carpal ligament would have a positive result.

Surgery

If all attempts to control your symptoms fail, surgery may be suggested to reduce the pressure on the median nerve. Surgery may not be advised if there is advanced nerve damage. Persistent pain and numbness may not go away with surgery. If you have muscle atrophy and weakness and/or loss of sensation, you may not be a good candidate for surgery.

And surgery may not be advised if electrodiagnostic studies show normal results. In such cases, patients seeking pain relief will be advised to continue with conservative (nonoperative) care.

When surgery is needed, several different surgical procedures have been designed to relieve pressure on the median nerve. By releasing the pressure on the nerve, the blood supply to the nerve improves, and most people get relief of their symptoms. However, if the nerve pressure has been going on a long time, the median nerve may have thickened and scarred to the point that recovery after surgery is much slower.

The standard surgery for CTS is called open release. Open surgical procedures use a small skin incision. In open release for CTS, an incision as small as one inch can be made down the front of the wrist and palm. By creating an open incision, the surgeon is able to see the wrist structures and to carefully do the operation. The surgeon cuts the transverse carpal ligament in order to take pressure off the median nerve.

After dividing the transverse carpal ligament, the surgeon stitches just the skin together and leaves the loose ends of the transverse carpal ligament separated. The loose ends are left apart to keep pressure off the median nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue.

Dividing Transverse Carpal Ligament

Endoscopic Release

Some surgeons are using a newer procedure called endoscopic carpal tunnel release. The surgeon merely nicks the skin in order to make one or two small openings for inserting the endoscope. An endoscope is a thin, fiber-optic TV camera that allows the surgeon to see inside the carpal tunnel as the transverse carpal ligament is carefully released.

Upon inserting the endoscope, the surgeon can see the wrist structures on a TV screen. A special knife is used to cut only the transverse carpal ligament. The palmar fascia and the skin over the wrist are not disturbed.

As in open release, the loose ends of the transverse carpal ligament are left apart after endoscopic release to keep pressure off the median nerve. The gap eventually fills in with scar tissue.

Guyon’s Canal Syndrome

Guyon’s canal syndrome is an entrapment of the ulnar nerve as it passes through a tunnel in the wrist called Guyon’s canal. This problem is similar to carpal tunnel syndrome but involves a completely different nerve. Sometimes both conditions can cause a problem in the same hand.

This guide will help you understand:

• how Guyon’s canal syndrome develops
• how doctors diagnose the condition
• what can be done to treat the problem

Anatomy

Where is the ulnar nerve, and what does it do?

The ulnar nerve actually starts at the side of the neck, where the individual nerve roots exit the spine through small openings between the vertebrae. The nerve roots then join together to form three main nerves that travel down the arm to the hand, one of which is the ulnar nerve.

Nerve Roots

After leaving the side of the neck, the ulnar nerve travels through the armpit and down the arm to the hand and fingers. As it crosses the wrist, the ulnar nerve and ulnar artery run through the tunnel known as Guyon’s canal.

Guyon’s Canal

This tunnel is formed by two bones (the pisiform and hamate) and the ligament that connects them. After passing through the canal, the ulnar nerve branches out to supply feeling to the little finger and half the ring finger. Branches of this nerve also supply the small muscles in the palm and the muscle that pulls the thumb toward the palm.

Tunnel Formed by Two Bones

 

The hamate bone forms one side of Guyon’s canal. This bone has a small hook-shaped spur that sticks out to provide an attachment for several wrist ligaments. Known as the hook of hamate, this small bone can break off and press against the ulnar nerve within Guyon’s canal.

Causes

Why do I have this problem?

Guyon’s canal syndrome has several causes. Overuse of the wrist from heavy gripping, twisting, and repeated wrist and hand motions can cause symptoms. Working with the hand bent down and outward can squeeze the nerve inside Guyon’s canal.

Constant pressure on the palm of the hand can produce symptoms. This is common in cyclists and weight lifters from the pressure of gripping. It can also happen after running a jackhammer or when using crutches.

Pressure or irritation of the ulnar nerve can cause symptoms of Guyon’s canal syndrome. A traumatic wrist injury may cause swelling and extra pressure on the ulnar nerve within the canal. Arthritis in the wrist bones and joints may eventually irritate and compress the ulnar nerve. In rare cases, the ulnar artery that travels right beside the nerve may be damaged and form a blood clot. The symptoms caused by the clot mimic Guyon’s canal syndrome. The lack of blood supply to the ulnar nerve is believed to cause the symptoms.

As mentioned earlier, a fractured hamate bone in the wrist can pinch the nerve inside Guyon’s canal. This bone is sometimes fractured when golfers club the ground instead of the golf ball and when baseball players are batting.

Fractured Hamate Bone

Symptoms

What does Guyon’s canal syndrome feel like?

Symptoms usually begin with a feeling of pins and needles in the ring and little fingers, which is often noticed in the early morning when first awakening. This may progress to a burning pain in the wrist and hand followed by decreased sensation in the ring and little fingers. The hand may become clumsy when the muscles controlled by the ulnar nerve become weak. Weakness can affect the small muscles in the palm of the hand and the muscle that pulls the thumb into the palm. Gradual weakness in these muscles makes it hard to spread your fingers and pinch with your thumb.

This syndrome is much less common than carpal tunnel syndrome (CTS), yet both conditions can occur at the same time. The numbness caused by these two syndromes affects the hand in different locations. When the median nerve is compressed in CTS, pain and numbness spread into the thumb, index finger, middle finger, and half of the ring finger. Compression of the ulnar nerve in Guyon’s canal syndrome usually causes numbness in the pinky and half of the ring finger.

Diagnosis

When you visit First Choice Physical Therapy, diagnosis of Guyon’s canal syndrome begins with a careful history and physical examination by our Physical Therapist. Compression can occur at several areas along the ulnar nerve, and we will test to find exactly where the nerve is being affected.

Some patients may be referred to a doctor for further diagnosis. Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

When you begin your Physical Therapy program, our Physical Therapist will recommend that you change or stop the activities that might be causing your symptoms if at all possible. Avoid repetitive hand motions, heavy grasping, resting your palm against hard surfaces, and positioning or working with your wrist bent down and out.

We may have you wear a wrist brace to decrease the symptoms in the early stages of Guyon’s canal syndrome. A brace keeps the wrist in a resting position (neither bent back nor bent down too far). It can be especially helpful for easing the numbness and pain felt at night because it can keep your hand from curling under as you sleep. The wrist brace can also be worn during the day to calm symptoms and rest the tissues within the canal.

We may also recommend anti-inflammatory medications. Common over-the-counter medications, such as ibuprofen and aspirin, can also help control the symptoms of Guyon’s canal syndrome.

The main focus of your First Choice Physical Therapy treatment is to reduce or eliminate the cause of pressure on the ulnar nerve. Our Physical Therapist may check your workstation and the way you do your work tasks. We will provide suggestions about the use of healthy body alignment and wrist positions, helpful exercises, and tips on how to prevent future problems.

Although the rate of recovery is different for each patient, if nonsurgical treatment is successful, you may see improvement in four to six weeks. We may recommend that you continue wearing your wrist splint at night to control symptoms and keep your wrist from curling under as you sleep. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and pressure on the palm of the hand.

Post-surgical Rehabilitation

Your hand will be wrapped in a bulky dressing  following surgery. When you begin your recovery, our Physical Therapist will advise you to take time during the day to support your arm with your hand elevated above the level of your heart. We will encourage you to move your fingers and thumb occasionally during the day. Keep the dressing on your hand until you return to the surgeon. Avoid getting the stitches wet. Your stitches will probably be removed 10 to 14 days after surgery.

Pain and numbness generally begin to improve after surgery, but you may have tenderness in the area of the incision for several months.

Although each patient recovers at a different rate, you will probably need to attend our occupational or Physical Therapy sessions for six to eight weeks, and you should expect full recovery to take several months. We will start by having you begin doing active hand movements and range-of-motion exercises. Our Physical Therapistss also use ice packs, soft-tissue massage, and hands-on stretching to help with your range of motion. When your stitches are removed, we may suggest that you start carefully strengthening your hand by squeezing and stretching special putty.

As you progress, our Physical Therapist will give you exercises to help strengthen and stabilize the muscles and joints in the hand. We use other exercises to improve fine motor control and dexterity. Some of the exercises you’ll do are designed get your hand working in ways that are similar to your work tasks and sport activities.

Our Physical Therapist will help you find ways to do your tasks that don’t put too much stress on your hand and wrist. Before your Physical Therapy sessions end, your Physical Therapist will teach you a number of ways to avoid future problems.

When your recovery is well under way, regular visits to First Choice Physical Therapy will end. Although we will continue to be a resource, you will eventually be in charge of doing your exercises as part of an ongoing home program.

Physician Review

If it is unclear on physical examination where the nerve is being squeezed, electrical studies may be ordered to try to find the area of compression.

Nerve conduction velocity (NCV) is a test  that measures how fast nerve impulses travel along the nerve.

Your doctor might want this test to be done to help pinpoint your problem. Special tests may be required to study the nerve.

The NCV is sometimes combined with an electromyogram (EMG). The EMG is done by testing the muscles of the forearm that are controlled by the ulnar nerve to determine if they are working properly.

If the test shows a problem with the muscle, the nerve that goes to the muscle might not be working correctly.

This is similar to checking whether the wiring in a lamp is working.

If the light still doesn’t work after you’ve put in a new bulb, you can begin to tell if there’s a problem in the wiring.

If your symptoms started after a traumatic wrist injury, X-rays may be needed to check for a fractured or dislocated bone.

Surgery

If all attempts to control your symptoms fail, surgery may be suggested to reduce the pressure on the ulnar nerve.

The surgery can be done using a general anesthetic (one that puts you to sleep) or a regional anesthetic.

A regional anesthetic blocks the nerves going to only a portion of the body. Injection of medications similar to lidocaine are used to block the nerves for several hours.

This type of anesthesia could be an axillary block (only the arm is asleep) or a wrist block (only the hand is asleep).

The surgery can also be performed by simply injecting lidocaine around the area of the incision.

Once you have anesthesia, your surgeon will make sure the skin of your palm is free of infection by cleaning the skin with a germ-killing solution.

A small incision is made in the palm of the hand over the spot where the nerve goes through the canal.

The incision makes it possible for the surgeon to see the ligament that crosses over the top of the ulnar nerve.

This ligament forms the roof over the top of Guyon’s canal.

Once in view, this ligament is reduced by using a scalpel or scissors.

 

Ligament is Reduced

Care is taken to make sure that the ulnar nerve is out of the way and protected. By cutting the ligament, pressure is taken off the ulnar nerve.

Upon releasing the ligament, the surgeon sutures just the skin together and leaves the loose ends of the ligament separated. The loose ends are left apart to keep pressure off the ulnar nerve. Eventually, the gap between the two ends of the ligament fills in with scar tissue. This surgery can usually be done as an outpatient procedure, meaning you can leave the hospital the same day.

Mallet Finger Injuries

When you think about how much we use our hands, it’s not hard to understand why injuries to the fingers are common. Most of these injuries heal without significant problems. One such injury is an injury to the distal interphalangeal, or DIP, joint of the finger. This joint is commonly injured during sporting activities such as baseball. If the tip of the finger is struck with the ball, the tendon that attaches to the small bone underneath can be injured. Untreated, this can cause the end of the finger to fail to straighten completely, a condition called mallet finger.

This article will help you understand:

• what parts make up the DIP finger joint
• what types of injuries affect this joint
• how the injury is treated
• what to expect from treatment

Anatomy

What parts of the finger are involved?

The finger joints work like hinges when the fingers bend and straighten. The main knuckle joint is the metacarpophalangeal joint (MCP joint). It is formed by the connection of the metacarpal bone in the palm of the hand with the first finger bone, or proximal phalanx. Each finger has three phalanges, or small bones, separated by two interphalangeal joints (IP joints). The one closest to the MCP joint (knuckle) is called the proximal IP joint (PIP joint). The joint near the end of the finger is called the distal IP joint (DIP joint).

Finger Joints

 

The extensor tendon is attached to the base of the distal phalanx. When it tightens, the DIP joint straightens. Another tendon, the flexor tendon, is attached to the palm of the finger. When it pulls, the DIP joint bends.

Extensor Tendon

Causes

How do these injuries of the DIP joint occur?

A mallet finger results when the extensor tendon is cut or torn from the attachment on the bone. Sometimes, a small fragment of bone may be pulled, or avulsed, from the distal phalanx. The result is the same in both cases: the end of the finger droops down and cannot be straightened.

Symptoms

What do mallet finger injuries look and feel like?

Initially, the finger is painful and swollen around the DIP joint. The end of the finger is bent and cannot be straightened voluntarily. The DIP joint can be straightened easily with help from the other hand. If the DIP joint gets stuck in a bent position and the PIP joint (middle knuckle) extends, the finger may develop a deformity that is shaped like a swan’s neck. This is called a swan neck deformity.

Swan Neck Deformity

Diagnosis

What tests will my health care provider do?

When you visit First Choice Physical Therapy, our Physical Therapist will take a history and do a physical examination. Usually the diagnosis of mallet finger is clearly evident from the physical exam.

Some patients may be referred to a doctor for further diagnosis. X-rays may be required to see if there is an associated avulsion fracture since this may change the recommended treatment. No other tests are normally required.

Once your diagnostic examination is complete, the Physical Therapists at First Choice Physical Therapy have treatment options that will help speed your recovery, so that you can more quickly return to your active lifestyle.

Our Treatment

Non-surgical Rehabilitation

 

Treatment for mallet finger is usually nonsurgical. If there is no fracture, then the assumption is that the end of the tendon has been ruptured, allowing the end of the finger to droop.

When you begin your Physical Therapy program, our Physical Therapist may recommend continuous splinting for approximately six weeks followed by six weeks of nighttime splinting.

Usually this will result in satisfactory healing and allow the finger to extend.

The key is continuous splinting for the first six weeks.

The splint holds the DIP joint in full extension and allows the ends of the tendon to move as close together as possible.

As healing occurs, scar formation repairs the tendon.

If the splint is removed and the finger is allowed to bend, the process is disrupted and must start all over again. The splint must remain on at all times, even in the shower.

While a simple homemade splint will work, your Physical Therapist can provide you with a recommendation for the type that will be most beneficial to your recovery. There are many splints that have been designed to make it easier to wear at all times. In some extreme cases where the patient has to use the hands to continue working (such as a surgeon), a metal pin can be placed inside the bone across the DIP joint to act as an internal splint allowing the patient to continue to use the hand. The pin is removed at six weeks.

Splinting may even work when the injury is quite old. In this case, we will usually splint the finger for about eight to 12 weeks to see if the drooping lessens to a tolerable amount before considering surgery.

When the injury is new, we may recommend that the DIP joint be splinted nonstop in full extension for six to eight weeks. A mallet finger that is up to three months old may require splinting in full extension for eight to 12 weeks. The splint is then worn for shorter periods that include nighttime splinting for six more weeks.

Skin problems are common with prolonged splinting. We advise that you monitor the skin under your splint to avoid skin breakdown. If problems arise, our Physical Therapist may recommend new or different splint. Nearby joints may be stiff after keeping the finger splinted for this length of time. Your Physical Therapist can design a program of Physical Therapy and exercise to assist in finger range of motion and to reduce joint stiffness.

Post-surgical Rehabilitation

Rehabilitation after surgery for mallet finger focuses mainly on keeping the other joints mobile and preventing stiffness from disuse. Our Physical Therapy and occupational therapists can teach you home exercises to make sure your other joints do not become stiff. After the surgical pin has been removed, we may gradually introduce exercises to strengthen the finger and increase flexibility.

At First Choice Physical Therapy, our goal is to help speed your recovery so that you can more quickly return to your everyday activities. When your recovery is well under way, regular visits to our office will end. We will continue to be a resource, but you will be in charge of doing your exercises as part of an ongoing home program..

Surgery

DIP Fixation

Surgical treatment is reserved for unique cases.

The first is when the result of nonsurgical treatment is intolerable.

If the finger droops too much, the tip of the finger gets caught as you try to put your hand in a pocket.

This can be quite a nuisance. If this occurs, the tendon can be repaired surgically, or the joint can be fixed in place.

A surgical pin acts like an internal cast to keep the DIP joint from moving so the tendon can heal.

The pin is removed after six to eight weeks.

Fracture Pinning

The other case is when there is a fracture associated with the mallet finger.

If the fracture involves enough of the joint, it may need to be repaired.

This may require pinning the fracture. If the damage is too severe, it may require fusing the joint in a fixed position.

Pinning the Fracture

Finger Joint Fusion

If the damage cannot be repaired using pin fixation, finger joint fusion may be needed. Joint fusion is a procedure that binds the two joint surfaces of the finger together, keeping them from rubbing on one another. Fusing the two joint surfaces together eases pain, makes the joint stable, and prevents additional joint deformity.