November 07, 2012

Your Health Registers in Your Face (?)

A recent Danish study suggests that you may not need expensive cardiac testing to determine your risks of heart disease.  Just look in the mirror.

People who look old--with receding hairlines, bald heads, creases near their earlobes, or bumpy deposits on their eyelids--have a greater chance of developing heart disease than younger-looking people the same age.

"Looking old for your age marks poor cardiovascular health," said Anne Tybjaerg-Hansen of the University of Copenhagen in Denmark.

Tybjaerg-Hansen led a research study which documented the differences between biological and chronological age.

A small consolation: Wrinkles elsewhere on the face and gray hair seemed just ordinary consequences of aging and did not correlate with heart risks.

The research involved 11,000 Danish people and began in 1976. At the start, the participants were age 40 and older.

Researchers documented their appearance, tallying crow's-feet, wrinkles, and other signs of age.

In the next 35 years, 3,400 participants developed heart disease (clogged arteries) and 1,700 suffered a heart attack.

The risk of these problems increased with each additional sign of aging present at the start of the study. This was true at all ages and among men and women, even after taking into account other factors such as family history of heart disease.

Those with three to four of these aging signs--receding hairline at the temples, baldness at the crown of the head, earlobe creases, or yellowish fatty deposits around the eyelids--had a 57 percent greater risk for heart attack and a 39 percent greater risk for heart disease compared with people with none of these signs.

Having yellowish eyelid bumps, which could be signs of cholesterol buildup, conferred the most risk, researchers found. Baldness in men has been tied to heart risk before, possibly related to testosterone levels.

They could only guess why earlobe creases might raise risk.

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February 10, 2012

A Silver Lining for Patients with French-Made PIP Breast Implants

I have previously blogged about my concerns with silicone breast implants manufactured by Poly Implant Prothese (PIP).  A quick summary:  The French company PIP used industrial-grade silicone in breast implants (rather than medical-grade silicone), thereby increasing the risk of rupture and of complications.  PIP is not licensed to sell their devices in the USA, so no American women should have been harmed by this flagrant violation of good practices.  All of my own patients have received only Mentor (Johnson & Johnson) and Allergan (formally Inamed) devices, so they need not worry.

However, my practice is quite international, and I do see many patients whose implants were not placed in the USA.  In particular, many of my patients have had surgery in Mexico, where, unfortunately, PIP has been licensed to sell their products.

Fortunately, this affair seems to have a silver lining.  The Mentor Corporation has agreed to discount their (high-quality) replacement implants for any patients with PIP devices--with a $250 American Express Gift Card.

While I have not seen many PIP patients, I did want everyone to know that I am doing everything in my power to help these poor ladies.  I will continue to search out opportunities to assist them.

Please pass along this information to any of your friends who may have had breast surgery performed outside of the USA, and who may benefit from this valuable Mentor program.

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February 06, 2012

A Word About PIP/French Breast Implants

You may have read recently about safety concerns with French-made PIP silicone breast implants.  If you are one of my patients, thankfully, you are not part of this European debacle.

I am posting to reassure my patients that I do NOT use PIP implants.  If you are one of my patients, and if you have recently undergone breast augmentations or reconstructions, please rest assured that your implants were made either by Mentor or by Allergan--not by PIP.  Both Mentor and Allergan are headquartered in the USA, and neither is being scrutinized for quality or safety concerns.

So, you are OK!

How did we in the United States manage to miss the PIP (Poly Implant Prothese) controversy?  Please thank the United States government; as early as 2000, the FDA had raised concerns about the implants manufactured by PIP.  In 1996, PIP had started selling its pre-filled saline implants in the United States under a 510(k) accelerated review application that did not require the company to submit clinical trials as long as the implant was said to be "substantially equivalent" to those already on the market.  However, by 2000, the FDA required all breast implant manufacturers to submit a formal application (known as a "pre-market approval").  Three companies submitted applications - Inamed (now Allergan), Mentor (now a division of Johnson & Johnson), and PIP.  Two companies received approval:  Inamed (Allergan) and Mentor.  PIP did not.  PIP then stopped selling its pre-filled saline implants in the United States.  That is why, although over 30,000 pre-filled saline implants manufactured by PIP have been reported sold in the United States, none of the offending PIP silicone implants have ever been implanted in the United States.

Unfortunately, PIP did not self-critique upon its expulsion from the American market.  It never addressed its quality issues.  PIP has been using a cheaper industrial-grade silicone in their silicone gel breast implants, rather than medical-grade silicone.  When this information came to light, PIP was finally shut down altogether.

But damage has been done.  These cheap PIP silicone implants are much more prone to rupture and leakage than normal.  Many European health commissions have recommended PIP implant removal (and replacement with new, safe implants from either Mentor or Allergan) as a precautionary measure.  While there appears to be no evidence of a cancer link due to these implants, we can never be sure.

I would like to reiterate that the implants that I use in my practice, made by Allergan or Mentor, are FDA-approved, and have an excellent track record.  However, I do frequently see patients whose breast surgery was done in Mexico and elsewhere.  IF YOUR IMPLANTS WERE PLACED AT A FACILITY NOT IN THE UNITED STATES, PLEASE CHECK TO SEE WHETHER YOU HAVE PIP-BRAND SILICONE IMPLANTS.  If you do have them, please come and talk to me about an implant exchange.  This is very important.  Your health may depend upon it.

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January 08, 2012

Hand Surgery #7: Tennis Elbow

Tennis elbow is a painful disorder of the side of the elbow.  The medical name is lateral epicondylitis, but both names are incorrect!

  • Tennis elbow is not more common in tennis players,
  • and lateral epicondylitis is not an -itis (an inflammatory condition) but is instead a degenerative problem....



The medical name for tennis elbow, lateral epicondylitis, explains much about the anatomy.

  • Lateral means "on the side," and refers to the area of the elbow away from the body.
  • The humerus is the large upper arm bone, between the shoulder and the elbow.
  • At its distal end, the humerus has rounded bony protrusions on both sides of the elbow that are called epicondyles.
  • The lateral epicondyle, then, is the outer prominence of the humerus at the elbow.
  • The muscles that extend the wrist and fingers mainly originate from the lateral epicondyle.


Pathology - Tennis Elbow

Tennis elbow is a degenerative or traumatic tear of the extensor tendon origins at their attachment to the lateral epicondyle bone.  This causes pain on the outside of the elbow. When the injury does not heal normally, it becomes a chronic condition. It is NOT an inflammatory condition.



Tennis Elbow is often caused by repeated straining of the muscles of the forearm that extend the wrist and fingers.

  • Activities that involve repeated twisting or extension of the wrist during work or hobbies may strain the muscle attachment at the bone on the outside of the elbow.
  • In addition, carrying or pulling a heavy load with the elbow extended and the palm towards the floor may also cause a tear in the tendon origins.
  • In rare instances, a direct blow to the elbow may cause this condition.

Most often, tennis elbow reflects an aging process occurring around or after age 40, when repair capability diminishes.

I usually try to rule out other possible causes of pain in this area. Frequently, I order X-rays to make sure that there is no arthritis of the elbow and no shoulder problems.  I will also examine you carefully to be certain that there is no pressure on the radial nerve in the region of the elbow, which is called radial runnel syndrome.


Signs and Symptoms

Examination of the affected elbow will usually reveal tenderness and discomfort when pressure is applied to this area. In the early stages, pain may only be experienced with sudden, forceful activities involving grasping, pulling, or carrying objects with the elbow extended.



  • Conservative treatment:
    • avoidance of activities that provoke further symptoms
    • wearing a splint to hold the wrist in extension
    • use of a counter-force brace to provide localized pressure on the extensor forearm muscles and to give support to the area
    • a therapy program for strengthening the muscles of the forearm
    • Non-operative recoveries usually take 6-12 months.
  • I rarely recommend surgery for tennis elbow--only when symptoms are particularly severe and/or longstanding....
    • outpatient
    • small incision on the outside of the elbow
    • remove degenerative tissue
    • possibly, release the origins of the extensor muscles
    • possibly, remove a small portion of the lateral epicondyle



Following surgery, the wrist and elbow may be immobilized by the use of a bulky dressing or splint for 2 to 6 weeks. Range of motion exercises are prescribed on an individual basis, followed by exercises designed to strengthen the muscles of this region. Depending on the patient's progress with strengthening, unrestricted use of the arm is usually possible at 3 months following surgery.

It may be necessary to alter daily activities, especially avoiding those activities involving repeated or prolonged grasping with the elbow straight, high force pulling, or carrying of objects with the palm down. If work activities demand these types of motion, it may be necessary to change the way these tasks are performed.

When playing racquet sports, careful consideration should be given to proper grip size, the composite of the racquet, as well as the size of the racquet's "sweet spot." Continuation of the prescribed flexibility and strengthening exercises is also important in preventing recurrence of injury.

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January 03, 2012

Hand Surgery #6: Dupuytren's Contracture

In 1831, French surgeon Baron Guillaume Dupuytren first described a spontaneous, "deep scarring" disorder of the palmar surfaces of the hands and fingers....



The skin of the palmar surfaces of the hands and fingers is special.  Like the skin of the soles of the feet, this skin...

  • lacks hair
  • is thick and tough
  • is very sensitive
  • has grooves and whorls (fingerprints) to help with gripping

This special glabrous skin is supported by an underlying network of tough palmar fascia.


Pathology - Dupuytren's Disease

In Dupuytren's Disease, for unknown reasons, parts of the supporting palmar fascia become progressively thickened. This frequently distorts the overlying skin, leading to nodules and/or pits.  The fascia can even pull longitudinally to limit the extension of a finger at the various knuckles.

The course of Dupuytren's Disease is unpredictable, but there are some consistent truths....

  • The process is not malignant.
  • The disease may progress slowly, or it may have periods of temporary arrest followed by rapid progression.
  • Involvement of the feet may be associated in 15-20% of cases. Other body parts (such as the penis) may also be affected.
  • Bilaterality is common.
  • Flexion contractures usually occur at either of the first two finger joints.
  • Flexor tendons are never involved in this process.
  • Skin may be involved by the infiltration of dermal layers.
  • Recurrence is frequent, particularly at the proximal interphalangeal joints.
  • This condition is not painful, except for tenderness in the area of skin infiltration or during an inflammatory phase.



Dupuytren’s contracture is a condition commonly found in northern European countries, such as Scandinavia and Russia. There is a strong familial tendency to develop Dupuytren’s Disease, and some have proposed that the condition is a result of a single dominant gene.  Men are much more commonly affected than women.


Signs and Symptoms


  • The most common evidence of the disease is a “lump” or nodule in the palm near the flexion crease, most often located at the base of the ring or small finger.
  • This lump or nodule may also occur at the base of the thumb.
  • Although the appearance of these nodules in the finger usually occurs within the course of the disease, these nodules may be evident as the very first symptom.


  • Another sign or symptom of Dupuytren’s contracture is known as a dermal pit.
  • The pit may be single or multiple, and appears as a small, local, deep indentation of the skin.
  • This may be the first finding, it may come later, or the pit may never appear at all.
  • The pit usually is located in the palm but also can be found in the fingers.
  • This indentation occurs due to a contraction of the connective tissue fibers from the palmar fascia to the skin. The skin is drawn down to form the pit.


  • The cord is a longitudinal fibrous band, which extends from the palm into the finger(s).
  • It most often appears with a nodule, but it can be separate.
  • It may appear as a single or multiple bands.
  • The cord or band creates a flexion contracture at the finger joints as it crosses the joints; or, in other words, the cord pulls the finger into a bent position.
  • Once the contracture has started, the process may proceed (either slowly or rapidly) to a severe deformity of one or several fingers.
  • Even if only one or two fingers are involved, this condition may become so advanced that daily activities are awkward.
  • Which fingers are affected most often?
    1. Ring finger
    2. Small finger
    3. Middle finger
    4. Thumb
    5. The index finger is seldom involved.



  • Conservative treatment:
    • Traditionally, I was not enthusiastic about non-operative treatments....
      • Of course, non-surgical treatments do have less recuperation time, less discomfort, and quicker resumptions of normal activity.
      • However, because less invasive treatments do not actually remove the diseased tissue, deformities are usually not completely corrected.
      • Moreover, recurrence rates are invariably much higher than with a more traditional surgery.
    • The classic, non-surgical treatment was a needle aponeurotomy.
      • A very fine hypodermic needle divides the cord in multiple locations, allowing the finger to be immediately extended.
      • Typically, patients wear band-aids for about 24 hours and resume their normal activities within a few days, without the need for any formal post-operative splinting or therapy
    • The newest option is a non-operative technique called a collagenase injection.
      • This is relatively new, and I am excited about its possibilities.  However, I have very little experience with this intervention.
      • It is an office-based procedure where a mixture of enzymes is placed into the diseased tissue. The enzymes work by dissolving the fibrous cord causing the contracture. Once the enzyme has had time to weaken the cord, typically by the following day, the finger is manipulated so that the cord will rupture and the finger can be straightened.
      • Typical side effects may include bruising, swelling, and soreness at the injection site. No formal therapy is required, although a hand-based splint is prescribed for night use. Most patients resume normal use of their hand within two weeks.
  • The mainstay for the treatment of Dupuytren's Disease is surgery, called a sub-total palmar fasciectomy....
    • The aim of surgery in Dupuytren’s contracture is to regain maximum hand function, rather than totally cure the disease. If there is no present deformity and no loss of hand function, surgery may be delayed until significant deformity has developed. Therefore, the small palmar nodule rarely requires surgery unless it is sufficiently tender as to interfere with activities.
    • A progressive contracture is regarded as an indicator for surgery and is best demonstrated when the hand can no longer be placed flat on a table top (Hueston's table top test). At this stage, there is sufficient deformity to demonstrate that hand function will eventually be threatened.
    • A flexion deformity at the first finger joint (MCP) is usually correctable with surgery. A deformity at the second finger joint (PIP) is not always fully correctable, and sometimes can reoccur.
    • Sub-total palmar fasciectomy is the surgical removal of the taut, retracted palmar fascia from the palm and afflicted finger(s). The amount of time spent during the operation depends on the amount of involvement, but surgery generally requires one to three hours. Surgery is usually performed under a general anesthetic.
    • A zigzag incision is made in the palm of the hand and may be extended into the finger(s). Because it is extremely important to protect the nerves and blood vessels of the palm and fingers, meticulous dissection by the surgeon is necessary.
    • Because of the type of incision, numerous stitches are required for adequate closure of the wound. Drains may be inserted to provide maximum drainage from the hand, and are usually removed the first or second day after surgery. On some occasions, I elect to leave part of the surgical wound open in order to prevent complications. In this instance, the incision heals naturally and stitches are not required.
    • Following surgery, the hand is wrapped and immobilized in a large “boxing glove” type bulky compressive dressing, which is generally removed three to five days following surgery. The surgical wounds may be slow to heal and may occasionally gap open during the rehabilitation process. The physicians and therapists will monitor this closely in order to balance the program of wound care, exercise, and splinting.



Post-operative therapy appointments will be made for periodic checks on the healing progress. The hand therapist provides the patient with a specific exercise program. Discomfort with early therapy is not uncommon, but this improves with time. Several months of therapy may be required to regain joint mobility. Some residual inability to fully extend the involved fingers is common.

Skin incisions may remain large and somewhat tender for several months, but will gradually improve. Splinting the involved fingers to prevent the recurrence of contractures may be necessary (usually at night) for as long as 6-9 months following surgery. The goal of surgery is to remove the diseased tissue and to prevent additional contractures. Full return of finger function is not always possible and, in some cases, the deformity may reoccur.

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December 30, 2011

Hand Surgery #5: Ganglion Cysts

The most common tumor of the hand is not a cancer.  It's a ganglion cyst....



Bones meet at joints.  Joints are lubricated by synovial fluid.  Escape of the fluid is prevented by a joint capsule.

Likewise, tendons are lubricated and nourished by synovial fluid from their surrounding tenosynovium.


Pathology - The Ganglion Cyst

If some of that synovial fluid escapes from a joint or tendon sheath, it stimulates an encompassing scar.  The resulting fluid-filled sac is a ganglion cyst.

Gangions are common, and they are benign (meaning that they are not cancer).

A ganglion can arise from almost any joint or tendon sheath in the wrist and hand, but they are most common at the back of the wrist, on the front of the wrist below the thumb, along the palmar surfaces of the proximal fingers, and at the last knuckles of the fingers (the distal interphalangeal joints, which are just proximal to the nails; ganglion cysts at the distal interphalangeal joints are sometimes erroneously referred to as mucous cysts).



The exact cause of ganglions remains uncertain. Why does the fluid leak in the first place?  The most popular theory is that ganglions form after trauma or degeneration of the capsule around the joint or tendon sheath.


Signs and Symptoms

Ganglion cysts can frequently be diagnosed simply by their location and shape. They are usually not adherent to the overlying skin and are firmly attached to the underlying joint or tendon sheath. X-rays are sometimes helpful in diagnosing ganglion cysts, particularly about the distal interphalangeal joint, where associated degenerative arthritis is often found. As other lesions can produce swelling in the same sites as ganglions, a 100% accurate diagnosis cannot be provided without aspiration or excision of the mass.

Ganglions may limit motion in the adjacent joints, or produce discomfort from compression or distention of local soft tissues. Particularly large ganglions can be cosmetically unpleasant. Ganglion cysts of the distal interphalangeal joint may produce grooving or ridging of the fingernails. Ganglion cysts arising from the flexor tendon sheath at the base of the finger may produce pain when grasping. On rare occasions, ganglion cysts (particularly those associated with the wrist) may cause changes in the bone.



  • Conservative treatment:
    • Ganglion cysts often change in size and may even disappear spontaneously. For this reason, if the ganglion is asymptomatic, it may be best to simply observe the mass for a period of time. Ganglions about the wrist may respond well to a temporary period of immobilization.
    • Aspiration of a ganglion may diagnose the lesion and may temporarily or permanently treat the condition. This consists of first numbing the area with a local anesthetic, and then inserting a needle to withdraw the clear, jelly-like fluid from the ganglion sac. A compressive dressing or splint may be applied following aspiration. Aspiration is extremely useful in minimizing symptoms when surgery is not desired. Recurrence of the ganglion can be expected in >50% of cases following aspiration.
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • small incision over the ganglion cyst
    • The cyst is carefully freed from the surrounding structures.
    • Care is taken to identify its site of origin, and to excise a small portion of the joint capsule or tendon sheath from which it has arisen.
    • In the treatment of a "mucous cyst" at the distal interphalangeal joint,I remove the osteophytes (bony spurs) that may be associated with the origin of this type of ganglion.



Following ganglion cyst removal, a bulky compressive dressing is applied. Within 1-2 weeks, exercises are initiated to prevent the development of stiffness. Usual recovery time following surgery for ganglion cysts ranges from 2-3 weeks for small ganglions of the finger, and 6-8 weeks for ganglions involving the wrist.

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December 27, 2011

Hand Surgery #4: De Quervain's Stenosing Tenosynovitis

While trigger fingers involve inflamed flexor tendons (which bring the fingers into the fist) in their digital sheaths, de Quervain's stenosing tenosynovitis refers to inflamed extensor tendons of the thumb (which help you to hitch hike) as they traverse the back of the wrist.

Once called washer woman's sprain, this painful inflammation of the thumb side of the wrist now bears the name of the Swiss surgeon Fritz de Quervain, who wrote about this condition in 1895.  Stenosing refers to the narrowing of an opening or passageway in the body. Tenosynovitis refers to inflammation of the outer covering of the tendons that bend and extend any finger or thumb.



Passing over the back (or dorsal surface) of the wrist are the tendons for muscles that extend and straighten the fingers and thumb, and lift the hand at the wrist. These tendons run through 6 lubricated tunnels (compartments) under a thick fibrous layer called the extensor retinaculum.

The 1st dorsal compartment lies over the bony bump at the base of the thumb. Through it, pass the tendons for the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) muscles. Both of these muscles help spread and extend the thumb away from the rest of the hand.


Pathology - De Quervain's Stenosing Tenosynovitis

De Quervain's stenosing tenosynovitis is a painful inflammation of the tendons in the first dorsal compartment of the wrist. The lubricating synovial sheath lining this compartment thickens and swells, giving the enclosed tendons less room to move, and produces extra synovial fluid. A painful cyst may also form.



This inflammation may be caused by anything that changes the shape of the compartment or causes swelling or thickening of the tendons.  De Quervain's occurs most often in individuals between the ages of 30 and 50. Women are afflicted with this condition 8-10 times more often than men. People who engage in activities requiring sideways motion of the wrist while gripping with the thumb--as in hammering, skiing, and some assembly line jobs--may be predisposed to developing this disorder.


Signs and Symptoms

Pain over the thumb side of the wrist is the primary symptom. This condition may occur "overnight" or very gradually, and it may radiate pain into the thumb and up the forearm. It is worse with the use of the hand and thumb, especially with any forceful grasping, pinching, or twisting. Swelling over the thumb side of the wrist may be present, as well as some "snapping" when the thumb is moved. Because of the pain and swelling, there may be some decreased thumb motion.

Besides pain and swelling over the first dorsal compartment, having a positive Finkelstein's Test is a good indication the patient has this problem. In this test, the patient makes a fist with his or her thumb placed under the fingers. Then, the patient bends the wrist away from the thumb and towards the little finger side of the hand. This test is mildly painful to many of us, but to someone with de Quervain's stenosing tenosynovitis, it is very painful.



  • Conservative treatment:
    • avoidance of activities that may provoke further symptoms
    • wearing a thumb spica splint to restrict movement of the wrist and thumb
    • a cortisone injection into the 1st dorsal compartment to decrease swelling
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • small incision over the back of the wrist, at the base of the thumb
    • cut (release) the ligaments forming the roof and interior walls of the 1st dorsal compartment
    • The pressure on the APL and EPB tendons is relieved.
    • The whole surgery takes less than 30 minutes.



A bulky post-operative dressing is worn for 1-2 weeks.  Then, an exercise program for the thumb and wrist is started. It usually takes several weeks for a full recovery.

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December 22, 2011

Hand Surgery #3: Trigger Finger

A carpal tunnel release is the most common hand surgery that I perform.  The second most common is a trigger finger release.

A trigger finger (or trigger thumb) involves painful snapping or locking of the fingers or thumb. The medical name for this condition is stenosing tenosynovitis. Stenosing refers to the narrowing of an opening or passageway in the body. Tenosynovitis refers to inflammation of the outer covering of the tendons that bend and extend the fingers and thumb.



  • The tendons are tough, fibrous cords that connect the muscles of the forearm to the bones of the fingers and thumb.
    • This muscle and tendon system enables one to bend the fingers inward when making a fist, and extend them out straight.
  • The tendons glide through a protective covering called the tendon sheath.
    • The sheath is like a tunnel.
    • It is lined with a thin membrane called synovium. The synovial lining helps reduce friction as the tendons glide through the tendon sheath.
    • Areas of dense fibrous tissue called annular bands or pulleys are also part of the tendon sheath.


Pathology - The Trigger Finger

A trigger finger (or trigger thumb) is often caused by inflammation of the synovial sheath surrounding the tendons. It may also result from enlargement of the tendon itself, or narrowing of the first annular band (A1 pulley).

When inflamed, the normally thin covering of the sheath may be thickened to several times its normal size. This reduces the amount of space through which the tendons are able to pass. The tendon is no longer able to glide freely through the sheath, and the tendon itself may swell up in a balloon-like mass at the point where it tries to pass through the tunnel.

Upon forceful bending of the finger or thumb, the enlarged portion of the tendon is dragged through the constricted opening. This motion is often accompanied by a painful snap, and the finger or thumb may be locked in a bent position. Straightening the finger or thumb may require using the non-affected hand to actually pull the finger back into an extended position, causing another painful snap as the swollen portion of the tendon passes back through the sheath.



The exact cause of trigger finger or thumb is not always readily apparent. In many cases, however, this condition may be the result of repeated strain of this area due to work or hobby activities. Tasks that require repetitive grasping or the prolonged use of tools (scissors, screwdrivers, etc.) which press firmly on the tendon sheath at the base of the finger or thumb may irritate the tendons and result in thickening of the tendons themselves or the tendon sheath. Symptoms of trigger finger may also be associated with conditions such as...

  • rheumatoid arthritis
  • gout
  • diabetes


Signs and Symptoms

One of the first symptoms may be discomfort in the area of the palm directly beneath the affected finger or thumb. This region marks the entrance of the tendon sheath (the A1-pulley area).

As the disease progresses, patients notice painful snapping sensations during finger motion.  If the disorder is not treated, the finger or thumb may actually become locked in a bent position (or less often, in an extended position).

This joint may appear to jump or lock, but the true problem is found in the tendon sheath. It is here that the smooth gliding of the tendon becomes obstructed.


  • Conservative treatment is worthwhile, unless the finger or thumb is in an unmovable locked position:
    • avoidance of activities that provoke triggering
    • oral anti-inflammatory pain medications
    • a cortisone injection into the tendon sheath to decrease inflammation
  • When conservative treatment fails, or when the finger or thumb remains in a locked position, I usually recommend surgery....
    • outpatient
    • small incision in the palm at the base of the finger or thumb
    • cut (release) the first annular band of the tendon sheath
    • The constriction of the tendon is relieved.
    • If the surgery is done under local anesthesia without heavy sedation, I usually ask the patient to actively move the tendon during the surgery to confirm that the triggering has resolved.
    • The whole surgery takes less than 20 minutes.
  • In rare cases, such as in patients with rheumatoid arthritis, the surgery may be more extensive.  A portion of the tendon or the synovial covering may require removal.



Following surgery, a light dressing is applied to protect the incision yet allow for motion of the finger or thumb. The dressing is removed 10-14 days following surgery. Activities requiring normal use of the affected hand may be restricted depending on your specific activity level.

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December 19, 2011

Hand Surgery #2: Cubital Tunnel Syndrome

Carpal tunnel syndrome is, far and away, the most common nerve compression disorder of the upper extremity.  The second most common is cubital tunnel syndrome....



The cubital tunnel is...

  • a passageway between...
    • the bony prominence of the inside elbow (medial epicondyle)
    • the tip of the elbow (olecranon process).
  • The roof of this tunnel is formed by a firm tissue called fascia.

Through this passageway travels the ulnar nerve as it crosses behind the elbow. After exiting the tunnel, the ulnar nerve passes between the two origins of the flexor carpi ulnaris muscle.

The ulnar nerve...

  • provides sensation to the little finger and half of the ring finger
  • innervates several muscles in the forearm
  • controls many of the small muscles in the hand responsible for coordinating finger motion and pinch


Pathology - The Cubital Tunnel Syndrome

Cubital tunnel syndrome is caused by increased pressure in the cubital tunnel resulting in compression of the ulnar nerve. When the ulnar nerve is pushed up against the fascia or bones, blood flow to the nerve is restricted, causing a sensation often described as "pins and needles" to the small and ring fingers. In severe or chronic cases, numbness can be constant.



There are many ways in which the ulnar nerve may be injured or compressed in the cubital tunnel:

  • Either a severe, direct impact to the inner aspect of the elbow or chronic pressure to this area (such as supporting the arm by resting on the elbow) may produce swelling and inflammation within the cubital tunnel irritating the ulnar nerve. Over time, this may lead to the formation of scar tissue in and about the ulnar nerve.
  • The fascial covering of the cubital tunnel may lose its ability to stabilize the ulnar nerve with elbow motion. The nerve then becomes exposed to repetitive trauma as it slides in and out of its normal position.
  • Injury to the bones of the elbow joint may produce changes in the alignment or carrying angle of the joint. This may place tension on the ulnar nerve or narrow the size of the cubital tunnel.
  • As the floor of the cubital tunnel is formed by the elbow joint, arthritis may produce swelling or enlargement of the joint which in turn narrows the cubital tunnel compressing the ulnar nerve.
  • Tumors such as ganglion cysts or anomalous structures such as an extra muscle may compromise the space available for the ulnar nerve within the cubital tunnel.


Signs and Symptoms

Most cubital tunnel syndrome victims report intermittent numbness or tingling in the ring and little fingers.  These symptoms may occur with prolonged flexion of the elbow or resting against the elbow. There may be an associated aching discomfort along the inner forearm or elbow. If nerve damage persists, there is loss of sensation in the ring and little fingers.

Eventually there is loss of strength in the muscles supplied by the ulnar nerve.  Patients usually note a loss of pinch and grip strength.  There may be difficulty crossing the index finger and middle fingers. Severe cases will reveal loss of muscle bulk or wasting over the little finger aspect of the palm and along the back of the first web space or base of the index finger.

Other conditions resembling cubital tunnel syndrome include compression of the nerves in the neck and shoulder area, or compression of the ulnar nerve in the wrist. These conditions can often be excluded by physical examination; however, it may be necessary to obtain special x-rays, vascular tests, or nerve testing to help with the diagnosis.



  • Conservative treatment:
    • avoidance of activities that may provoke further symptoms, such as minimizing elbow flexion
    • wearing a splint at night to restrict elbow flexion
    • during the day, wearing an elbow pad
    • oral anti-inflammatory medications
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • incision on the inner elbow
    • cut (release) the fascia forming the roof of the tunnel
    • possibly move the nerve out of the cubital tunnel to the front of the elbow
    • The pressure on the ulnar nerve is relieved.



Following surgery, the arm is immobilized in a long-arm bulky dressing with a plaster splint.

Elevation and finger motion is important to prevent swelling during the post-operative period. The splint is usually removed at 10 to 14 days after surgery to permit suture or staple removal. Additional elbow immobilization may be required up to 3 weeks following surgery. Once therapy is started at the elbow, splinting between exercises is sometimes helpful for comfort and protection until normal motion has been restored. Strengthening of the extremity begins 4 to 8 weeks after surgery depending upon the procedure performed.

Recovery from cubital tunnel surgery requires 2 to 3 months before resuming unrestricted use of the extremity. Several months may be required before the maximum benefits of surgery are achieved. In severe cases with loss of sensation and muscle wasting, complete recovery may not be possible. With proper diagnosis and appropriate treatment, progression of this condition may be prevented.

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December 13, 2011

Hand Surgery #1: Carpal Tunnel Syndrome

Many people are surprised to learn that plastic surgeons are trained to evaluate and to treat hand disorders.  Around the USA, about 1/3 of all the hand surgery is performed by plastic surgeons.

So, for the next few blog posts, I will forego discussions of Botox, facelifts, and tummy tucks, and will instead focus on common hand problems, such as carpal tunnel syndrome....



The carpal tunnel is the passageway in the wrist formed by...

  • 8 carpal (wrist) bones, which make up the floor and sides of the tunnel
  • the transverse carpal ligament, which is a strong ligament stretching across the roof of the tunnel

Inside the carpal tunnel are...

  • 9 flexor tendons, which flex (bend down) your fingers and thumb
  • the median nerve, a cord about the size of a pencil containing thousands of nerve fibers supplying sensation (feeling) to your thumb, index and middle fingers, and half of the ring finger


Pathology - The Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by increased pressure in the carpal tunnel resulting in compression of the median nerve. When the median nerve is pushed up against the ligament, blood flow to the nerve is restricted, causing a sensation often described as "pins and needles" to the fingers. In severe or chronic cases, numbness can be constant.



Carpal tunnel syndrome can be caused by a variety of problems. Certain medical conditions that may lead to compression of the median nerve include:

  • Inflammation or swelling about the tendons
  • Fluid retention
  • Wrist fractures and dislocations
  • Crushing injuries to the wrist
  • Rheumatoid/degenerative arthritis
  • Diabetes
  • Tumors and tumor-like conditions
  • Hypothyroidism
  • Pregnancy

There is considerable debate as to whether specific work activities may lead to carpal tunnel syndrome. Certain occupational activities which involve repeated flexing of the fingers or wrist, or prolonged use of vibrating tools may contribute to the development of carpal tunnel syndrome.

Determining whether or not carpal tunnel syndrome is a work-related condition can be very difficult. Each case must be considered individually and must be based on documentation of specific work-related activities which may contribute to this condition.

Non-work related activities of daily living and leisure may also provoke symptoms of carpal tunnel syndrome. Lawn mowing, long distance driving, or hobbies such as knitting or wood carving are activities which involve prolonged or repetitive grasping and wrist flexion and may elicit symptoms of carpal tunnel syndrome.


Signs and Symptoms

Numbness, burning, or tingling of one or more of the fingers (excluding the little finger) is the most common symptom of carpal tunnel syndrome. This numbness can happen at any time; often these symptoms occur at night and may awaken the individual from sleep. Partial relief can sometimes be gained by shaking, massaging, or elevating the hands. At times, the numbness may extend up the arm, into the elbow, and as far up as the shoulder and neck.

A decrease in sensation or feeling may result in clumsiness and weakness of the affected hand. Patients may find themselves dropping objects and less capable of performing tasks requiring gripping or pinching strength.

On the palm side of the hand, just below the thumb, is a bulging pad of muscle called the thenar muscle group. Some of these muscles are controlled by the median nerve. With advanced carpal tunnel syndrome, this muscle group may begin to waste away, giving a flattened appearance to the palm when compared to the other hand.



  • Conservative treatment:
    • avoidance of activities that may provoke further symptoms
    • wearing a splint to restrict movement of the wrist
    • a cortisone injection into the carpal tunnel to decrease swelling
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • small incision on the palm of the hand
    • cut (release) the ligament forming the roof of the tunnel
    • The pressure on the median nerve is relieved.
    • The whole surgery takes less than 30 minutes.



With the blood flow to the median nerve restored, the symptoms of burning and tingling are usually relieved soon after surgery. Patients can expect soreness from the incision for 4 – 6 weeks and discomfort from deep pressure for as long as several months. Improvements in strength and sensation depend on the extent of the nerve damage prior to treatment. Normal grip strength may not return for several months following surgery. The natural healing process and regeneration of nerve fibers will occur throughout the following six months to a year.

Formal physical therapy is not usually required.  However, in certain instances, I recommend a program of hand therapy to regain strength, reduce discomfort, and increase range of motion to the fingers and hand.

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