Steroid injections can be used to treat some problems in the arm and hand. These can include trigger fingers, tendonitis, carpal tunnel syndrome, arthritis, tennis elbow and rotator cuff tendonitis. These injections usually contain cortisone and a numbing medicine.
The olecranon (oh-LEH-cruh-nahn) is the pointy bone at the tip of the elbow. The bursa is the thin sac of fluid that lies between this boney tip and the skin. It helps the skin slide over the bone smoothly. Normally, this sac has only a tiny bit of fluid inside of it and lays flat. However, the bursa can become irritated or inflamed and fill with extra fluid (see Figure 1). When this happens, a painful swelling develops at the back of the elbow. This swelling is olecranon bursitis.
Hand bones are called metacarpals. The finger bones are called phalanges. The metacarpophalangeal joint (MP joint), or knuckle, is where the finger bones meet the hand bones. At the MP joints, the fingers can move in multiple directions. They can bend, straighten, spread apart and move together. MP joints are important for both pinching and gripping.
The shoulder (Figure 1) is a ball and socket joint that allows a wide range of movement. Because it is composed of several key structures such as tendons, cartilage and bone, the shoulder can be affected by a variety of conditions.
Gout and pseudogout are two types of arthritis that result in sore joints. With these types of arthritis, crystals form in the joint, causing irritation that is sometimes also present in the tendons near the joint. Joints can become swollen, painful, and red (Figure 1).
Ganglion cysts are very common lumps within the hand and wrist that occur adjacent to joints or tendons. The most common locations are the top of the wrist (see Figure 1), the palm side of the wrist, the base of the finger on the palm side, and the top of the end joint of the finger (see Figure 2). The ganglion cyst often resembles a water balloon on a stalk (see Figure 3), and is filled with clear fluid or gel.
The cause of these cysts is unknown although they may form in the presence of joint or tendon irritation or mechanical changes. They occur in patients of all ages.
These cysts may change in size or even disappear completely, and they may or may not be painful. These cysts are not cancerous and will not spread to other areas.
The diagnosis is usually based on the location of the lump and its appearance. Ganglion cysts are usually oval or round and may be soft or firm. Cysts at the base of the finger on the palm side are typically very firm, pea-sized nodules that are tender to applied pressure, such as when gripping. Light will often pass through these lumps (trans- illumination), and this can assist in the diagnosis. Your physician may request x-rays in order to look for evidence of problems in ad-jacent joints. Cysts at the far joint of the finger frequently have an arthritic bone spur—which is a small bony bump or projection—associated with them, the overlying skin may become thin, and there may be a lengthwise groove in the fingernail just beyond the cyst.
Ultrasound or other advanced imaging such as magnetic resonance imaging (MRI) may be helpful in confirming the diagnosis. There are different types of growths that can occur around the and wrist, and additional imaging is sometimes required.
Treatment can often be non-surgical. In many cases, these cysts can simply be observed, especially if they are painless, as they frequently disappear spontaneously. If the cyst becomes painful, limits activity, or is otherwise unacceptable, several treatment options are available.
The use of splints and anti-inflammatory medication can be prescribed in order to decrease pain associated with activities.
An aspiration can be performed to remove the fluid from the cyst and decompress it. This requires placing a needle into the cyst, which can be performed in most office settings. Aspiration is a very simple procedure, but recurrence of the cyst is common. If non-surgical options fail to provide relief or if the cyst recurs, surgical alternatives are available.
Surgery involves removing the cyst along with a portion of the joint capsule or tendon sheath (see Figure 3). In the case of wrist ganglion cysts, both traditional open and arthroscopic techniques usually yield good results. Surgical treatment is generally successful although cysts may recur. Your surgeon will discuss the best treatment options for you.
Orthopedic Sports Medicine Center of Oregon is located in Downtown Portland Oregon. Dr. Dominic Patillo, one of our Board-Certified Orthopedic Surgeons, specializes in hand surgery. His practice focuses on the treatment of both simple and complex hand and upper extremity conditions as well as general orthopaedic trauma. He is experienced with modern microsurgical techniques including nerve and vessel reconstruction.
Common problems treated include:
Other problems treated can include arthritis, nerve and tendon injuries, and congenital limb differences (birth defects).
If you have pain in your fingers, hand, wrist or arm, or if you have other upper-extremity related concerns, please consult our hand specialist Dr. Dominic Patillo for a consultation.
The biceps muscle is in the front of your arm (see Figure 1). It bends your elbow and twists your forearm to turn your palm upward. The biceps tendon connects the biceps muscle to your radius bone, which is one of the forearm bones. Such maneuverability may lead to distal biceps tendon problems.
Over time, the biceps tendon can weaken. This is called tendonosis. Tendonosis of the biceps tendon can be painless or it can cause dull or sharp pain in the area of the tendon just past the elbow in the forearm. Tendonosis can lead to tendon tears or tendon rupture. Not all pain in the area of the elbow is caused by biceps tendon problems. There can be other causes for pain in this area.
Biceps tendon tear or rupture can also cause weakness. This can happen without any warning. It often occurs when lifting heavy objects such as furniture. Weightlifters are more likely to experience this injury when doing “negatives,” which is done while holding a weight and extending the arm at the elbow.
A biceps tendon rupture usually occurs when the tendon tears away from the forearm bones (See Figure 2). This may be felt as a “pop” in the front of the elbow and can be painful. Often, but not always, people feel continued pain, swelling, bruising and warmth in the elbow. Sometimes, people feel a relief from pain that was present before. Muscle spasms in the biceps muscle are common when this happens. Symptoms usually get better over a few weeks. Also, sometimes the muscle can pull up in the arm toward the shoulder. This results in a muscle with a larger-than-normal appearance.
The elbow will usually continue to work after a biceps tendon rupture. This is because there are other muscles that can do part of the job of the biceps muscle. You may experience weakness when flexing the elbow. Most of the weakness after a biceps tendon rupture occurs when twisting your forearm to turn the palm upward, or in supination. You may experience fatigue with repetitive motions if your tendon is not repaired.
There are many medical problems that can make people more likely to have tendon ruptures. Chronic steroid use, whether for medical purposes or when used to gain muscle, is one of the most common reasons for this to happen.
Tendon rupture is most common in men over age 30, but can happen in women too.
If the biceps tendon tears completely, it will not grow back to the bone. You must seek care immediately if this occurs since surgery is an option and surgery is best done soon after the injury. If too much time passes, the tendon may not be repairable.
Your surgeon may choose to use imaging, such as an MRI or ultrasound. This can help to diagnose your tear or to plan for surgery. X-rays are often used at the initial visit. X-rays do not show the tendon well, but can be helpful in looking for other causes of elbow pain.
Surgery is not absolutely required for a biceps tendon rupture, but your doctor may suggest it. If your arm is working well after the rupture, you may choose not to have surgery. If you choose to avoid surgery then you should expect permanent weakness and an arm that becomes more easily fatigued.
Surgery is done to reattach the tendon to the bone or to a nearby muscle. There are many different ways surgeons can reattach tendons to bone. Figure 3 shows a repair of the biceps tendon. After surgery, you will require rehabilitation and time to heal. Often, people are able to resume even heavy activities after surgery and rehabilitation.
Figure 2A – Illustration of an acute rupture of the biceps tendon
Figure 2B – Image of an acute rupture of the biceps tendon
Figure 3A – Repair of the biceps tendon
Orthopedic Sports Medicine Center of Oregon is located in Downtown Portland Oregon. Dr. Dominic Patillo, one of our Board-Certified Orthopedic Surgeons, specializes in hand surgery. His practice focuses on the treatment of both simple and complex hand and upper extremity conditions as well as general orthopaedic trauma. He is experienced with modern microsurgical techniques including nerve and vessel reconstruction.
Common problems treated include:
Other problems treated can include arthritis, nerve and tendon injuries, and congenital limb differences (birth defects).
If you have pain in your fingers, hand, wrist or arm, or if you have other upper-extremity related concerns, please consult our hand specialist Dr. Dominic Patillo for a consultation.
Kienböck’s disease is a condition where the blood supply to one of the small bones in the wrist, the lunate, is interrupted. Bone is living tissue that requires a regular supply of blood for nourishment. If the blood supply to a bone stops, the bone can die. This is called osteonecrosis.
Damage to the lunate causes a painful, stiff wrist and, over time, can lead to arthritis.
Normal skeletal anatomy of the hand. The lunate is one of the small bones in the wrist.
Reproduced and modified with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.
The cause of Kienböck’s disease is not known. Many people with Kienböck’s disease think they have a sprained wrist at first. They may have experienced some form of trauma to the wrist, such as a fall. This type of trauma can disrupt the blood flow to the lunate.
Some things may put you more at risk for the disease. For example, most people have two vessels that supply blood to the lunate, but in some people there is only one source. This may slow the blood flow to the bone. In addition, if the two bones of the forearm (the radius and ulna) are different lengths, extra pressure can be put on the lunate during some wrist motions. Over time, this extra stress on the bone may lead to Kienböck’s disease.
The most common symptoms of Kienböck’s disease include:
Kienböck’s disease is a condition that progresses slowly, and many people do not decide to see a doctor until they have lived with symptoms for several months, perhaps longer.
During your first appointment, your doctor will discuss your symptoms and medical history, then examine your hand and wrist. In its early stages, Kienböck’s disease may be difficult for your doctor to diagnose because the symptoms are so similar to those of a sprained wrist. Imaging tests, such as x-rays and magnetic resonance imaging (MRI) scans, are used to confirm a diagnosis of Kienböck’s disease.
Kienböck’s disease progresses through four stages of severity. If you are diagnosed with Kienböck’s disease, your doctor will plan your treatment based on several factors, most importantly, the stage of your progression.
During the first stage of the disease, the symptoms are similar to those of a wrist sprain. Although the blood supply to the lunate has been disrupted, x-rays may still appear normal or suggest a possible fracture. An MRI scan can better detect blood flow and is helpful in making the diagnosis in this early stage.
Stage 1. An x-ray of a patient’s wrist during Stage I shows no deterioration of the lunate bone.
Reproduced with permission from Allan CH, Joshi A, Lichtman DM: Kienböck’s disease: diagnosis and treatment. J Am Acad Orthop Surg 2001; 9 : 128-136.
The most common symptoms during this stage are wrist pain, swelling, and tenderness.
Stage 2. (Left) This illustration shows that the lunate has hardened with more than one fracture line. (Right) The lunate is brighter than the surrounding bones, which indicates that the bone is dying.
Reproduced and adapted with permission from Allan CH, Joshi A, Lichtman DM: Kienböck’s disease: diagnosis and treatment. J Am Acad Orthop Surg 2001; 9 : 128-136.
In Stage 3, the dead lunate bone begins to collapse and break into pieces. As the bone begins to break apart, the surrounding bones may begin to shift position.
During this stage, patients typically experience increasing pain, weakness in gripping, and limited wrist motion.
Stage 3. Both the illustration and x-ray image show that the lunate has begun to collapse and several bones in the wrist have shifted out of position.
Reproduced and adapted with permission from Allan CH, Joshi A, Lichtman DM: Kienböck’s disease: diagnosis and treatment. J Am Acad Orthop Surg 2001; 9 : 128-136.
If the condition progresses to Stage 4, the surfaces of the bones surrounding the lunate also deteriorate, and the wrist may become arthritic.
Stage 4. (Left) This illustration shows damage to several bones in the wrist. (Right) This CT scan also shows deterioration in the bones of the wrist.
Reproduced and adapted with permission from Allan CH, Joshi A, Lichtman DM: Kienböck’s disease: diagnosis and treatment. J Am Acad Orthop Surg 2001; 9 : 128-136.
Although there is no complete cure for Kienböck’s disease, there are several nonsurgical and surgical options for treating it. The goals of treatment are to relieve the pressure on the lunate and to try to restore blood flow within the bone.
In the very early stage of the disease, pain and swelling may be managed with anti-inflammatory medications, such as aspirin or ibuprofen. Immobilizing your wrist for a period of time can help relieve pressure on the lunate, and your doctor may recommend splinting or casting for 2 to 3 weeks.
It is important to monitor any changes in your symptoms during the early stage of Kienböck’s disease. If the pain is not relieved with simple treatments or it returns, your doctor may recommend surgery.
There are several surgical options for treating Kienböck’s disease. The choice of procedure will depend on several factors, in particular how far the disease has progressed. Additional factors to consider are the patient’s activity level, personal goals, and the surgeon’s experience with the procedures.
Revascularization. In some cases, it may be possible to return the blood supply to the lunate bone. This procedure is called revascularization. It is more successful during early phases of the disease — stages 1 and 2 — before the lunate has significantly deteriorated.
Revascularization involves removing a portion of bone with attached blood vessels from another bone — most often a forearm bone (radius) or an adjacent bone in the hand. This piece of bone with its blood supply is called a vascularized graft. It is inserted into the lunate bone.
To help the bones stay in place during healing, an external fixator may be temporarily applied. This is a metal device that is attached to the outside of the wrist with pins that insert into the bones. It can relieve pressure on the lunate while the graft is healing and restoring a blood supply.
Joint leveling. If the two bones of the lower arm are not the same length, a joint leveling procedure may be recommended. Bones can be made longer using bone grafts or shortened by removing a section of the bone. This leveling procedure reduces the forces that compress the lunate and often stops the progression of the disease.
Proximal row carpectomy. If the lunate is severely collapsed or broken into pieces, it can be removed. In this procedure, the two bones on either side of the lunate are also removed. This procedure, called a proximal row carpectomy, will relieve pain while maintaining partial wrist motion.
(Left) The three wrist bones that are removed in a proximal row carpectomy, are shaded here. (Right) An x-ray image of a wrist after a proximal row carpectomy.
Fusion. To ease pressure on the lunate, nearby wrist bones can be fused together to make one, solid bone. A fusion can be partial, in which just some of the bones are fused together. This procedure relieves pain and retains some wrist motion.
If the disease has progressed to severe arthritis of the wrist, fusing all of the bones of the wrist to the radius will relieve pain and and improve hand function. Although all wrist motion is eliminated in a complete fusion, forearm rotation is preserved.
In a fusion, the bones of the wrist are held together with a plate, screws, and pins.
Kienböck’s disease varies considerably in its severity, as well as its rate of progression. Each patient’s response to treatment depends on the degree of damage to the lunate and surrounding wrist bones. Some patients may require more than one procedure if the disease continues to progress.
In summary, patients with Kienböck’s disease should not expect to ever return to normal wrist function after any treatment. However, treatment gives the greatest opportunity for long-term preservation of function and pain relief.
Orthopedic Sports Medicine Center of Oregon is located in Downtown Portland Oregon. Dr. Dominic Patillo, one of our Board-Certified Orthopedic Surgeons, specializes in hand surgery. His practice focuses on the treatment of both simple and complex hand and upper extremity conditions as well as general orthopaedic trauma. He is experienced with modern microsurgical techniques including nerve and vessel reconstruction.
Common problems treated include:
Other problems treated can include arthritis, nerve and tendon injuries, and congenital limb differences (birth defects).
If you have pain in your fingers, hand, wrist or arm, or if you have other upper-extremity related concerns, please consult our hand specialist Dr. Dominic Patillo for a consultation.
A mallet finger is a deformity of the finger caused when the tendon that straightens your finger (the extensor tendon) is damaged.
When a ball or other object strikes the tip of the finger or thumb and forcibly bends it, the force tears the tendon that straightens the finger (see Figure 1a and 1b). The force of the blow may even pull away a piece of bone along with the tendon (see Figure 2). The tip of the finger or thumb no longer straightens. This condition is sometimes referred to as baseball finger.
In a mallet finger, the fingertip droops: it cannot straighten on its own power. The finger may be painful, swollen and bruised, especially if there is an associated fracture, but often the only finding is the inability to straighten the tip. Occasionally, blood collects beneath the nail. The nail can even become detached from beneath the skin fold at the base of the nail.
The diagnosis is evident by the appearance of the finger. Doctors will often order x-rays to see if a piece of bone pulled away and to make sure the joint is aligned.
The majority of mallet finger injuries can be treated without surgery. Ice should be applied immediately and the hand should be elevated (fingers toward the ceiling.) Medical attention should be sought within a week after injury. It is especially important to seek immediate attention if there is blood beneath the nail or if the nail is detached. This may be a sign of a nail bed laceration or an open (compound) fracture.
There are many different types of splints/casts for mallet fingers. The goal is to keep the fingertip straight until the tendon heals. Most of the time, a splint will be worn full-time for eight weeks (see Figure 3). Over the next three to four weeks, most patients gradually begin to wear the splint less frequently. The finger usually regains acceptable function and appearance with this treatment. Nevertheless, it is not unusual to lack some extension at the conclusion of treatment. Your surgeon or hand therapist will instruct you about how to wear the splint and will also show you exercises to maintain motion in the middle joint (the proximal interphalangeal joint) so your finger does not become stiff. Once your mallet finger has healed, your surgeon or hand therapist will teach you exercises to regain motion in the fingertip.
In children, mallet finger injuries may involve the cartilage that controls bone growth. The doctor must carefully evaluate and treat this injury in children so that the finger does not become stunted or deformed.
Surgical repair may be considered when mallet finger injuries have large bone fragments or joint mal-alignment. In these cases, pins, wires or even small screws are used to secure the bone fragment and realign the joint (see Figure 4). Surgery may also be considered if splint wear is not feasible or if non-surgical treatment is not successful in restoring adequate finger extension. Surgical treatment of the damaged tendon can include tightening the stretched tendon tissue, using tendon grafts or even fusing the joint straight. Your surgeon will advise you on the best technique in your situation.
Orthopedic Sports Medicine Center of Oregon is located in Downtown Portland Oregon. Dr. Dominic Patillo, one of our Board-Certified Orthopedic Surgeons, specializes in hand surgery. His practice focuses on the treatment of both simple and complex hand and upper extremity conditions as well as general orthopaedic trauma. He is experienced with modern microsurgical techniques including nerve and vessel reconstruction.
Common problems treated include:
Other problems treated can include arthritis, nerve and tendon injuries, and congenital limb differences (birth defects).
If you have pain in your fingers, hand, wrist or arm, or if you have other upper-extremity related concerns, please consult our hand specialist Dr. Dominic Patillo for a consultation.
Arthritis— which literally means “inflamed joint” — can affect any joint in the body, including the joints between the 29 bones of the wrist, hand, and fingers. Arthritis of the hand can hurt and keep you from being able to do what you want or need to do. The most common forms of arthritis in the hand are osteoarthritis, post-traumatic arthritis (after an injury), and rheumatoid arthritis. Osteoarthritis is a degenerative joint disease in which the smooth cartilage that covers the bone surfaces at the joints either is injured or wears over time.