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January 2012

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....

 

Anatomy

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.

 

Causes

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.

 

Treatment

  • 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

 

Recovery

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....

 

Anatomy

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.

 


Causes

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

Nodules:

  • 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.

Pits:

  • 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.

Cords:

  • 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.

 

Treatment

  • 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.

 

Recovery

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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