SYNDACTYLY - joined together

Syndactyly, or "webbed fingers," is caused by the failure of the fingers to separate during embryological development. It is the most common congenital anomaly of the hand, with an occurrence of 1 per 2000 births. Hereditary causes has been suggested, with up to 40% of patients having a positive family history of syndactily.

Syndactyly can also be associated with a variety of other syndromes, some of them rare - for example in the patient below with Apert Syndrome.

Syndactyly in an infant - part of a larger problem - the Apert Syndrome

Syndactyly is most commonly seen in the middle and ring fingers; it can be classified as simple when it involves soft tissues only and complex when it involves the bone or nail of adjacent fingers. It can also be classified as complete or incomplete depending on the degree of soft tissue union between the fingers.

Timing of separation of the digits depends on the fingers affected. If the affected digits grow at unequal lengths (for example the little and ring fingers) then separation should ideally be done within the first few months of life as the tethering of the skin will cause the fingers to deviate and cause contractures.

Ring and mddle finger syndactyly usually does not pose functional problems, as in the case of the older child below. In this case, it is a simple, complete syndactyly of the ring and middle fingers. Since both fingers grow at equal lengths, surgery to separate the fingers can be delayed later in life.

- the BomohTulang -

DE QUERVAIN's TENOSYNOVITIS - Pain at the side of the wrist

Wrist pain has multiple causes and can be localized to various areas around the wrist; one of the common ones being pain at the side of the wrist near the base of the thumb. This can be attributed to De Quervains tenosynovitis

De Quervain's tenosynovitis refers to inflammation of tendons together with their enclosing sheath on the side of the wrist at the base of the thumb. These tendons, the extensor pollicis brevis and the abductor pollicis longus tendons, help move the thumb a certain way - to extend and to abduct the thumb (hence their names). On their way to the thumb, the tendons passes through a tunnel (the extensor retinaculum) which helps hold the tendons in place. Much like trigger finger, irritation of the tendon causes the lining (synovium) around the tendon to swell, which makes it difficult for the tendons to move and glide into the tunnel. However, unlike trigger finger, there is no 'catching' sensation - just pain at the side of the wrist during certain positions of the hand.

Patients with De Quervain's frequently complain of pain with certain movements of the wrist, for example when pouring tea from a teapot, using a watering can and lifting the grocery bags during shopping. These particular wrist movements will cause a strain on the said tendons - leading to the wrist pain.

The pain can be replicated by bending your thumb inwards into your palm and making a fist - this is the basis of the eponymous Finkelsteins test. (if you can read Thai, here's a DIY video of the test :P)
Here's a picture of the test - it can be quite painful for the patients to perform so I would proceed slowly if I were to conduct the examination.

Patients are commonly women aged 30 to 50, and frequently mothers of infants. Indeed sometimes when the patients of a child bearing age sees me in the clinic for the problem, my usual interview question would include "have you recently had a baby?" Apparently picking up and carrying of the baby puts the wrist in an awkward position, putting strain to the tendon, and hormonal changes in the tissues further aggravates this situation.

Other conditions that may mimic this would include basal thumb arthritis or the intersection syndrome (most commonly confused with)

Treatment is basically conservative. A period of splinting would help to rest the inflamed tissue; there are smaller splints now which are more comfortable to wear, do ask your therapist about it. Non-steroidal anti-inflammatory medications (NSAIDs), ultrasound therapy and ice all help to relieve the inflammation. These conservative means are all that is needed for the majority of patients

Steroid injection directly into the sheath can be given for more severe cases, although there is a risk of discolouration of the skin at the injection site.

Failed conservative management would necessitate a surgical release of the constricting sheath of the tendon ( the 1st dorsal compartment ). This could be done on an outpatient basis, ideally under general anaesthesia.



- the Bomoh Tulang -

references:

Treatment of de Quervain's disease:role of conservative management.

 Journal of Hand Surgery - British Volume. 26(3):258-60, 2001 Jun.

	Ilyas AM "de Quervain Tenosynovitis of the Wrist" J. Am. Acad. Ortho. Surg., December 2007; 15: 757 - 764.

TRIGGER FINGER - your finger is catching

Trigger finger (stenosing tenosynovitis),  is one of the common causes of pain and dysfunction in the hand.
The initial symptom is of a painless "click" in the hand on moving the fingers which might eventually progress into a locked finger. The finger might be locked in flexion, whereby a forceful extension of the finger is required to unlock the finger , causing a feeling of "triggering" at the base of the finger (the metacarpo-phalangeal joint). Patients may or may not notice a lump or knot in the palm of the hand, again typically at the base of finger.

The problem occurs when there is a constriction where the finger flexor tendon enters the tendon sheath at the base of the finger. It is caused either by a thickening (hypertrophy) of the tendon sheath, or a nodular swelling of the tendon itself just proximal to the sheath. Either way, the basic problem lies in the discrepancy between the size of the tendon nodule and the thickened tendon sheath. This means that the tendon can no longer slide easily through it and it becomes harder to bend or straighten the affected finger or thumb as a result. 

Trigger finger occurs two or three times more frequently in women than in men and has a peak incidence of around 40- 60 years of age (the demographics sounds similar to carpal tunnel syndrome... ) The ring finger is the most frequently involved, followed by thumb and ring finger.Frequently one finds that multiple fingers are affected and bilateral hand involvements are not uncommon.

As many as 85% of trigger finger can be successfully treated non-operatively. These include activity modification, splinting, anti-inflammatory drugs (NSAIDs) and steroid injections.

Steroid injection around the flexor sheath can be an effective treatment, and in my experience, for the patients with mild triggering and short duration of symptoms, one can expect a complete resolution of symptoms.

Surgical release of trigger finger is reserved for patients not responding to conservative management, the chronically locked finger, long duration of symptoms, and multiple digit involvement. As with most of my minor hand surgery cases, this can be done as a daycare procedure under local anaesthesia and takes about 15 minutes. However, in instances where multiple fingers need to be operated upon, general anaesthesia may be a more comfortable option.

Similar to carpal tunnel release, a small incision about 1cm is made at the base of the affected finger and the constricting sheath is then cut open longitudinally under direct vision. Care is taken to ensure that the nerves running alongside the tendon is not disturbed, and this can only be done if the surrounding structures are well visualized; this is the reason that I am not in favour of percutaneous release of trigger finger, although the proponents say that it is a reasonably safe option.

A surgical loupe is frequently needed to identify the structures

Incision at the base of the finger

the constricting sheath (A1 pulley) is visualized and divided

sutured up

Trigger finger in infants or children almost always involves the thumb and could be a different entity from the adult type. Most authors recommend observation as children below 6 months can have spontaneous resolution of symptoms ( I know, because my nephew had the same problem - it resolved spontaneously!). Surgery, as with adults, could be considered if symptoms persist.

- the BomohTulang - 

References: 

Trigger digits: diagnosis and treatment.   J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):246-52.

Trigger digits: principles, management, and complications. J Hand Surg Am. 2006 Jan;31(1):135-46.

The Natural History of Pediatric Trigger Thumb. The Journal of Bone and Joint Surgery-American Volume

Issue: Volume 90-A(5), May 2008, pp 980-985

Core Knowledge in Orthopaedics: Hand, Elbow, and Shoulder. Trumble, Budoff, Cornwall. Mosby 2005

Surgery for CARPAL TUNNEL SYNDROME

Continuing from the previous post, lets talk a bit about SURGERY for CARPAL TUNNEL SYNDROME.

Surgery entails cutting or transecting the transverse carpal ligaments that overlies the median nerve and can be done as an outpatient basis or a day care procedure in the OT.

The surgery itself can be accomplished in two ways:

The traditional approach is by open carpal tunnel surgery, whereby a longitudinal skin incision is made in the wrist and the carpal ligament cut to relieve the pressure on the median nerve. Incisions generally have become smaller over the years, and the so-called "mini" 2cm skin incision have become the standard length now.


Surgery takes about 20 minutes and can be done under  local anaesthesia although my preference is to do it under general anaesthesia, unless there are contraindications.

Torniquet applied to prevent bleeding

Local anaesthesia injected

Checking for the landmarks

Incision over the wrist

Incision deepened

The carpal ligament is cut

The underlying median nerve could be seen

Wound washed and closed 

Post operatively, the patient will feel relief from the night pain, as early as the day after surgery. Numbness of the fingers will take a bit more time to disappear, as is wasting of the hand muscles which will be the last to recover.

Sutures are usually taken off at two weeks and patients are advised not to lift heavy objects or to grip tightly for the next 4-6 weeks. There might be some weakness of the hand grip but this will also recover over time.

Another, more minimally invasive method would be through the endoscopic method. A small incision is made at the wrist and a small camera, together with a knife, introduced into the wound to see the carpal tunnel. The ligament is then cut below the skin by the knife. Proponents of this technique claim shorter recovery time and less post operative pain. The downside is the complexity of the procedure as it necessitates more (expensive) equipment and has a steeper learning curve on the part of the surgeon.

- the BOMOH TULANG -

Numbness in your hand - CARPAL TUNNEL SYNDROME?

Do you have numbness in your hands? Worse in the early hours of the morning, painful too? pain wakes you up at night? Or, do you notice that sometimes your hands get all clumsy and you start dropping things, like a coffee cup for instance?

Well, you have come to the right place. Today let's talk  a bit about CARPAL TUNNEL SYNDROME, a condition that affects between 1 to 10% of the population.

Lets start with the textbook description:

CARPAL TUNNEL SYNDROME (CTS) , by definition, is a syndrome characterized by pain, tingling, and numb sensations in your hand, typically involving the lateral (radial) 3 ½ digits (ie the thumb, index and middle fingers) caused by compression of the median nerve at the wrist, by whatever reasons. 

 

Shaking the hands to make it better

Patients usually complain of numbness and tingling at night that wakes them up;  they often find that they have to shake their hands to make it better. They can also experience numbness  when driving, reading the newspaper or a book, when typing on a keyboard, or any activity that requires the hands to be kept flexed for a period of time. Sometimes they can also have referred pain radiating to the forearm and arm, in which case the condition could be misdiagnosed by other health care professionals.




Where is the CARPAL TUNNEL?


The carpal tunnel is located at the wrist; the concave bottom part is created by the bony structures of your small bones of the wrist (the carpal bones), and tunnel completed on the top by a non-yielding structure called the transverse carpal ligament. Traversing the crowded tunnel are the tendons that go to your fingers and the median nerve, which supplies sensation to the thumb, index finger, middle finger, and the radial side (thumb side) of the ring finger

What causes CARPAL TUNNEL SYNDROME?

 Carpal tunnel syndrome is due to median nerve compression within the carpal tunnel, as increased pressure causes decreased blood flow to the nerve.  This increased pressure comes from swelling (edema) of the tissues surrounding the tendons called the synovium. This swelling may be due to injury to the synovium from overuse, trauma, or other causes such as metabolic disturbances (endocrine disorders, pregnancy, menopause). Increased pressure in the tunnel could also be due to anything that decreases the volume available in the tunnel, such as a lipoma or neuroma.

Having said that, do keep in mind that most of the time no cause could be found.


How does the doctor know I have CARPAL TUNNEL SYNDROME?

Well, as per the usual way, through questioning and thorough clinical examination.
A variety of special tests involving the wrist could be performed ie the Tinel's test and Phalen's test.

Additional tests such as X rays, MRI and nerve conduction tests could be called upon to make the diagnosis or rule out other conditions

What happens next

Usually once a firm diagnosis is made, the doctor could start the patient on a trial of conservative measures, typically lasting a month or two, and best results are obtained with early onset of symptoms. These might include:

• Activity modification
• Splinting - to rest the joint, and keep it in a neutral position
• Addressing the primary cause of CTS - treating hypothroidism for example
• Oral medications - NSAIDS and oral steroids
• injections into the carpal tunnel

 
Well, I have I tried all that, and it still doesnt seem to work..

Failed conservative treatment indicates that the patient is a candidate for the next step: SURGERY.
Surgery is also indicated for worsening symptoms and evidence of atrophy of the small muscles of the hand.
There are various techniques in doing surgery on the carpal tunnel , which i will discuss in the next entry.

Till then,

-The BomohTulang -

NB: there a literally tons of info on the net about CTS, so I have compiled some links which i think could be useful:

The  American Academy of Orthopedic Surgeons (AAOS) has an article about CTS here

Additionally, you can download the American Society for Surgery of the Hand (ASSH) brochure on CTS here (PDF file)

Closer to home, the Arthritis Foundation Malaysia (AFM) has an article on CTS here

GANGLION CYST - swelling in the wrist

Patients frequently present to the clinic with a lump at the wrist, with or without associated pain. These masses are usually round, smooth, and soft to firm with pressure.
The usual diagnosis would be a GANGLION CYST.

 

 

Ganglia cyst are among the most common cause of focal masses in the hand. They are thought to arise from the joint synovium or the sheaths of the tendons transversing the joint. The cause of the cysts remain unclear although it has been hypothesized that occupational trauma plays a part.

As described above, they usually do not cause pain, although when they get bigger, the cyst might press onto the structures around the wrist joint, such as an overlying nerve or tendon. They could also catch onto clothing or watch straps giving rise to discomfort. Lastly, they could just be a nuisance from a cosmetic point of view - in which case the patient usually request for excision.

Can you leave it alone?

Yes you can, and as I have explained, if they do not cause any pain, it really is a harmless swelling. In addition, if the swelling is small, there just might be a chance that the swelling would disappear.
However, some patients would insist that the lump be removed (for various reason - large swelling, pain, disfiguring, etc) in which case the options are:

Aspiration of the cyst.

This can be done as an office procedure. A local anaesthetic is usually administered around the lump and the lump aspirated with a large bore needle. Some practitioners would instil steroid into the remaining cavity to prevent recurrence. The success rate of this procedure is about 60%. (ie 1/3 of patients will have recurrence)

Surgical excision

The procedure of choice, in my opinion, as the success rate goes up to 90% (ie only 1 in 10 surgeries will have a recurrence). This can be done as a day procedure in the OT. Although some doctors can do it under local anaesthesia, the preferred method would be under general anaesthesia or a regional block at the minimum. The reason being that the root of the ganglion is usually deep seated and to get access to the deeper structures under local anaesthesia will cause much discomfort to the patient, not to mention unsettling to the operating surgeon.

 

  

   

Post surgery.

There might be some discomfort and swelling around the area operated. I usually close the skin with an absorbable suture so that no removal of the sutures need be done and it leaves a nicer scar.

Sometimes, with a larger lump, some ligaments of the wrist needs to be retracted and have to repaired. In this case, the patient will be required to use a resting wrist splint for a short period of time.

STACK THEM UP - The Mallet finger splint

A finger has a mallet finger deformity when the distal phalanx droops down, with the patient unable to actively extend the joint.

It is also known as the baseball finger, in which the ball hits the distal phalanx and forcibly flexes the joint. This will usually result in an avulsion of the attachment of extensor tendon to the distal phalanx, usually accompanied with a flake of bone. 

It can be an open (ie with a wound  - in which case the tendon is cut) or closed (ie no wound - implying an avulsion injury) injury.

For closed injuries, the usual treatment is non-surgical. The patient will need to use a splint -  a so-called STACK splint, to keep the joint in extension (or hyperextension even) so as to allow the avulsed flake of bone to heal and to prevent stretching of the tendon.

a custom made Stack splint made by the Occupational therapy dept

another Stack splint. bought off the shelf. nice.

One needs to use the splint diligently for 6 to 8 weeks to allow adequate time for healing. There is a chance of relapse if the splint is taken out for an extended period of time. At the end of the treatment period, one might find that the finger may be stiff in which case physiotherapy might help.


 - the BomohTulang -