C. Noel Henley, MD

Hand and Upper Extremity Specialist

Mallet Finger Injury

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“my finger doesn’t work”
“my finger is bent”
“my finger won’t straighten”
“my finger is drooped”

These are several of the most common things I hear when patients come in with a mallet finger. 

A mallet finger is the name for a ruptured (torn) tendon at the tip of the finger. A tendon rupture is where a tendon rips off the bone where it’s normally attached. 

This can happen by jamming the finger, by cutting the tendon on top of the finger, or even with a lot of pressure on the fingertip, like if you’re trying to rub paint out of the carpet. 

It usually happens in people over 40 years old. Sometimes these injuries hurt, but not too bad at all. That’s why lots of people come into my office several weeks after the injury. 

Some mallet fingers cause a huge droop – 45 degrees or more. Others are more subtle and minor; just a small droop. But in every case, the patient can’t extend (straighten) the end joint of the finger. 

The extensor tendon normally attaches to the dorsal (top) side of the finger. When your extensor muscle fires, it pulls the tendon, which pulls the bone up into extension.

Your flexor tendon attaches on the volar (bottom) side of the fingertip, and is about 6 times stronger than the extensor on top, so the finger rests in flexion (bent) without the extensor on top to hold it straight. 

The extensor tendon isn’t like a solid piece of rubber or plastic that just completely snaps in half every time. It’s made of millions of tiny strands of collagen, kind of like the strands of a rope or a mop. These strands can pull apart completely, partially, or on one side of the tendon or the other. 

Splinting

When the tendon tears off the bone, the bone at the end of the finger – the distal phalanx – droops down. If the tendon fibers are to heal, the torn ends need to be brought back closer together. In a mallet finger, we do this by splinting the end joint (DIP joint) straight. 

Splinting is the least risky, most effective treatment option for these injuries. The best splints are made by a hand therapist out of thin, moldable plastic. 

But even more important than the splint material is the fact that the splint MUST be worn full time. If you remove the splint and let the finger droop ONE TIME, all the healing is torn apart, and you have to start over. 

The therapist can teach you some tricks of wearing the splint, but it’s safer not to remove the splint for a full SIX WEEKS. 

Even when you do what you’re supposed to do and the splint is made perfectly, EVERY mallet finger injury heals with a slight droop. It may be three degrees or 10 degrees, but it won’t be completely normally straight at the end of the process. 

Even surgery doesn’t make this better. Even if I put a pin inside the finger to hold it straight, you’ll still have a droop. 

There are some surgeries that can be done for mallet fingers that stay VERY drooped after six or eight weeks, but none of them are very predictable, and all have more risk than the average carpal tunnel or routine hand surgery. 

Another reason the splint doesn’t work well is if the constant splinting is started late – a week or more after the injury. There’s just too much scar tissue formed between the ends of the tendon for it to heal correctly. 

Surgery For Wrist Arthritis

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The most common type of wrist arthritis creates pain at the thumb, or radial side of the wrist. Pain can flare up and down, with good days and bad days. Sometimes a wrist brace, anti-inflammatory pills, heat or ice can help. Hand surgeons can help with occasional cortisone (steroid) shots in the joint. 

When all these treatments fail (or when you’re just sick of them), surgery is a good option. All these other treatments just deal with the symptoms. 

Surgery is the only way to get rid of the arthritis forever. 

Two surgeries exist for wrist arthritis: proximal row carpectomy (PRC) and partial wrist fusion, also known as four corner wrist fusion. 

Both surgeries stop the arthritis pain because the worst and most painful carpal bone, the scaphoid, is completely removed. Unfortunately, just taking out this bone isn’t good enough. Something else has to be done to prevent the rest of the wrist from becoming arthritic. 

In the PRC procedure, the scaphoid, lunate, and triquetrum bones are removed. These three bones form the “proximal carpal row”, basically a row of three bones close to the radius and ulna (where the forearm bones join with the tiny wrist bones). 

PROXIMAL ROW CARPECTOMY

This leaves a big space, obviously, but it’s filled in as the distal row of carpal bones sinks into the space, forming a new joint. This surgery takes about six weeks to recover from. You’re in a temporary splint for 10 days, then into a cast for 3 weeks. Then you start some gentle motion and maybe visit the hand therapist a few times. 

In the partial wrist fusion surgery, after the scaphoid bone is removed, instead of taking out more bones, I fuse together four of the remaining carpal bones: the lunate, triquetrum, capitate, and hamate. A fusion means forcing the bones to grow together into a solid, stable mass of bone. 

PARTIAL WRIST FUSION

A wrist fusion requires hardware – this could be anything from simple stainless steel wires to special staples, to a small plate and screws. Most of the time I use a plate and screws. The fused bones take about six weeks to heal solid. During that time, you’re in a cast with your fingers free, but can’t lift or grip anything. You may need some therapy afterwards to get the wrist moving again. 

A “total” wrist fusion means the wrist never bends again. That’s different than the “partial” wrist fusion I’m talking about here. 

Deciding which is best

PRC versus partial wrist fusion is controversial. Most of the research that tries to study which one is better tells us that they’re equal. Both are pretty good at stopping pain. Both options let patients function very well after surgery. 

My advice is to have the least complicated surgery that stops the pain. For most people, that’s a PRC. No hardware to worry about; no fusion to heal, and a slightly faster recovery time. 

The advantage of a partial wrist fusion is mostly theoretical, in my opinion. It leaves more of your natural anatomy in place than a PRC. But with higher risk of complication (the fusion not healing or having to take hardware out later). Some surgeons believe that a PRC weakens the grip, but there’s no good science to tell us that for sure. 

Surgery For Thumb Arthritis

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Many operations have been designed over the last 100 years to treat this type of arthritis. They all have one thing in common: removing a bone called the trapezium, which is covered with arthritis.

LRTI Surgery

Taking out the trapezium leaves a hole, an empty space with bones, tendon, and muscle all around it. Most of the videos on YouTube show the surgeon taking a tendon from the forearm (usually the FCR – flexor carpi radialis), rolling it up, and putting it in this space to form a cushion for the remaining bones. This is commonly known as an “LRTI” thumb surgery, which stands for ligament reconstruction tendon interposition.

I used to do this operation as well, but after a few years found a simpler way to accomplish the same thing, save the FCR tendon, and with lower risk of complications for patients.

In the current version of this surgery, which I’ve used since about 2011, I only work through the original incision. No extra tendon is harvested or rolled up.

Steps of the Operation

In this drawing, I show the internal anatomy of the thumb from a side view – as if you just rested the back of your left hand on the table in front of you and looked at the thumb from the side, pointing your fingers to your right.

The thumb has three bones. Naming them from the tip toward the wrist, they’re called distal phalanx, proximal phalanx, and metacarpal.

The metacarpal base joins up with the trapezium – that’s where the worst thumb arthritis is in most people. This is where most people see a big bony lump at the base of their thumb. The next bone back towards the wrist is the scaphoid (skay-foid) bone.

I make the incision directly over the trapezium bone, on the top side of the thumb. When I take out the trapezium, as mentioned above, the space that’s left is between the thumb metacarpal bone and the scaphoid bone.

Visualize the space as a room with a ceiling and floor. Strung across the ceiling, or top of the incision (top of the thumb) is a large tendon called the APL (abductor pollicis longus). Deep in the “floor” of the space (toward the palm side of your thumb) is another large tendon called the FCR (mentioned above – same one).

The next step in the surgery is to “pinch” those two tendons closer together with a strong suture. This forms a cushion where the metacarpal can glide smoothly when everything is healed up. It also pulls the base of the metacarpal down from its “kicked up” position (reducing the big bony lump most people have).

This is the part that has to heal for a solid four weeks after the surgery. That’s why you can’t use your thumb for a month afterwards.

Recovery From Thumb Arthritis Surgery

The surgery takes about 45 minutes from start to finish. Afterwards you’re in a bulky, well-padded dressing and splint from the tip of the thumb all the way up the forearm for ten days. Your elbow and all other fingers are free.

After ten days, you come back to the office and get sutures out, then you’re fitted for a custom thumb splint, which will protect the surgery for another two and a half weeks. Then you’ll finally start getting the thumb loosened up by doing therapy exercises – mostly at home.

Most patients are pinching and gripping by three months on average. Some move faster, some move slower. You should be free of the splint by six weeks after surgery.

For a detailed description of the recovery process and how to prepare for it, click here. This was written by one of my patients who thoughtfully took notes on her experience.

What Is This Bump On My Finger?

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Finding a bump on your hand that wasn’t there before can be scary, especially when you don’t know what it is. Thankfully, these bumps, or tumors, are almost never malignant (cancer), although they may not be particularly pleasant. Here’s some information on some of the most common hand tumors.

What are hand tumors?

A hand tumor is an abnormal bump or lump on the hand. The word “tumor” just means “swelling”.

They can vary in size from nigh unnoticeable to much bigger, and can be discolored or painful. A tumor on the skin may appear as a mole or a wart. A tumor on the bone may not appear at all. However, it can still be extremely painful. Luckily, only 1-2% of hand tumors are malignant, so while the bump on your hand may be painful, it probably isn’t cancerous.

The three most common hand tumors are ganglion cysts, epidermal inclusion cysts, and giant cell tumors of the tendon sheath.

Ganglion Cysts

A ganglion cyst is the most common type of hand tumor. These cysts most often occur at the top of the wrist, the palm side of the wrist, the base of the finger, and on top of the end joint of the finger, near the finger nail. From the outside, they look like bubbles underneath the skin.

It is unknown what causes ganglion cysts. They appear in patients of all ages equally. There is some speculation that they form due to tendon irritation. Ganglion cysts may grow or shrink in size, or even disappear completely. They may also hurt, but that is not always the case. They may be soft or hard, and may allow light to pass through them, which aids in diagnosis.

Epidermal Inclusion Cysts

An epidermal inclusion cyst (EIC) is a type of hand tumor that resides on or just beneath the skin. They are generally caused by some kind of trauma to the skin, and usually appear on the palm. This trauma can include cuts and puncture wounds, as well as some kinds of piercing. Men are more commonly affected, and while anyone can get an EIC, they are more often seen during middle age. An important thing to note is that while EICs can be caused by trauma to the skin, they may also develop without this factor.

An EIC is formed when the epidermis is pushed into the dermis, creating a cyst (a sac full of fluid). These can range in size from 5 millimeters to a centimeter. They may be raised above the skin and red. Thankfully, EICs are generally not painful or itchy. They are firm to the touch and usually easy to see.

Giant Cell Tumors of the Tendon Sheath

A giant cell tumor of the tendon sheath (GCTTS) is a type of tumor that can be found on the hand or in other joints, especially in the feet. It is generally painless, and is seen more often in women than in men, usually between the ages of 30-50. It is unsure why exactly a GCTTS develops, although it has been theorized that this is due to trauma or infection, to name a couple of ideas. They are, however, most likely linked to degenerative joint disease, also known as arthritis. The GCTTS is firm to the touch and grows slowly in size. Unlike ganglion cysts, you cannot shine a light through the tumor.

Diagnosing Rheumatoid Arthritis

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What is Rheumatoid Arthritis?

Rheumatoid arthritis is one of the most common forms of arthritis in the hand, along with osteoarthritis. While osteoarthritis occurs through wear and tear, rheumatoid arthritis is an autoimmune disease. This type of disease occurs when the body falsely identifies a naturally occurring protein within the body as being foreign, and attempts to get rid of it. In the case of rheumatoid arthritis, the body targets a protein within the synovial lining of a joint. This lining secretes fluid that is essential to lubricate and cushion the joint. When the synovial lining is injured, it can allow inflammatory cells into the joint and bone. These wear away at the cartilage and bone. Rheumatoid arthritis can affect any joint, and can occur in any age group.

Rheumatoid arthritis is thought to be caused in part by genetics. Researchers haven’t yet determined what genes are influential in the passing on of this disease. Another probable factor is the existence of certain outside conditions that trigger an immune response that “turns on” the arthritis. Hormones may also play a role, as 70% of those affected are women.

How is Rheumatoid Arthritis Diagnosed?

Your physician will first go over your medical history, and possibly the medical history of your immediate family. This should be followed by questions about your symptoms (when they started, how they have progressed, etc), what sort of treatment you’ve had, and other relevant information. You will then be given a physical exam. Stressing the affected joints should cause slight discomfort, which will confirm the location of the problem. The physician will also look for other signs, such as swelling and limited motion in the joints, as well as lumps or nodules under the skin.

After the examination, you may be sent to get diagnostic tests done, such as x-rays and blood tests. X-rays can check for bone damage and cartilage loss, while blood tests are done to look for levels of antibodies and inflammation known to be present with rheumatoid arthritis, along with proteins called rheumatoid factor. These are present in 80% of people with rheumatoid arthritis. They target and attack healthy tissue in the body. The physician may also take a fluid sample to rule out other conditions such as gout or lupus that can cause some of the same symptoms.

How is Rheumatoid Arthritis Treated?

Current treatments for rheumatoid arthritis aim to treat symptoms such as swelling and pain, and allow the joints to function properly again. There is no known cure for rheumatoid arthritis at the present time.

There are both surgical and non-surgical treatments for rheumatoid arthritis. Non-surgical treatments may be better for when the disease has not yet begun to progress, while surgical treatments can help after the arthritis has taken a toll on the joints.

Non-Surgical Treatments

Cases that are mild and stable can be treated with painkillers and anti-inflammatory drugs, such as ibuprofen. Current research suggests that the disease is best treated immediately after its development, before problems such as erosion can occur. This treatment uses disease modifying drugs, such as methotrexate. Steroid injections into the joint or tendon can also be very helpful. Another alternative is splinting. While this will not stop deformity and erosion, it can help ease pain and increase function.

Surgical Treatments

Surgery can be extremely helpful for people with rheumatoid arthritis. For smaller joints within the hand and wrist, you might consider fusion (joining the bones of the joint together). For larger joints, such as hips and knees, replacement is usually a better option. Inflamed tendons may also require surgical treatment to keep from rupturing. If the tendon has already ruptured, there are several treatments that can replace the tendon or bridge the gap left behind.

Avoiding Tennis Elbow

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What Is Tennis Elbow?

Tennis elbow, also called lateral epicondylitis, is a condition involving the tendons that attach to the outside bone of the elbow. It is very painful, and caused by overuse of the joint. It was given its name because tennis, along with many other sports and activities, can cause this condition. Tennis elbow is an inflammation of the tendon. As it progresses, it weakens the tendon, leading to weakness and pain. This is especially noticeable while doing any activities that require the affected muscle, such as lifting, gripping, or playing tennis.

Your elbow is made of three bones: the humerus in your upper arm, and the radius and ulna in your forearm. The end of the humerus has bony bumps called epicondyles. The bump on the outside is called the lateral epicondyle. Lateral epicondylitis (tennis elbow) involves the tendons called extensors in the forearm that attach to the lateral epicondyle.

What Causes Tennis Elbow?

There are three main factors in the development of tennis elbow: overuse, activities, and age.

Overuse

Tennis elbow is often caused due to overuse and damage of one particular muscle. The extensor carpi radialis brevis (ECRB) helps to stabilize the wrist while the elbow is being held straight. When the ECRB is used too much, it can be damaged. Microscopic tears can form in the tendon where it attaches to the lateral epicondyle. This leads to inflammation and pain.

Activities

The type of activities you do also has an impact on whether you are at risk of developing tennis elbow. This condition is more common in athletes, but it is not limited to people who play tennis. The activities that lead to tennis elbow can be work related or recreational. Jobs such as painting, plumbing, and carpentry all have higher risk levels for getting tennis elbow, because of the amount of repetitive motion in the forearm.

Age

Most people who develop tennis elbow are between the ages of 30 and 50. However, people both older and younger are also at risk if they have other risk factors, such as playing tennis incorrectly or doing a job that calls for repetitive forearm motion. The condition equally impacts men and women.

How to Avoid Tennis Elbow

Lee_Valley_Golf_CourseOne of the most important ways to prevent tennis elbow is to build up the strength in your arms, upper back, and shoulder. Remember to stretch these areas frequently, to keep them flexible and to avoid straining your elbow. Try not to move your arm in the same way repeatedly. Switch arms while playing sports such as tennis or golf, if you can. There may be a trainer who can teach you how to use alternate moves to reduce strain on your elbow.

Make sure the equipment you use in sports and at work is the correct size for you. Using equipment that is made for someone bigger can put a lot of tension on your elbow.

Here are some tennis-specific things you can do to avoid tennis elbow:

  • Work with a professional player to develop the correct hitting technique, which will remove stress from your joints
  • Consider using a two-handed backhand instead of a one-handed backhand if it’s causing you pain
  • Use a racket grip that is soft enough to provide a cushioning effect
  • Don’t grip the racket too tightly and relax your grip between points

Make sure to stretch before and after playing a game or doing any other repetitive activity.

The worst activity you can do

The most aggravating activity you can do is palm down lifting (lifting straight up in a pronated position). Think of reaching far out in front of your body to lift up a heavy plastic grocery bag with a gallon of milk inside.

Instead, turn your hand palm up when lifting, and lift heavy weight close to your body, not out away from it.