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. 

Bad Thumb Arthritis – What Does It Look Like?

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The video below shows a patient’s thumb moving back and forth. As you’ll see, most of the range of motion is at the MP (metacarpophalangeal) joint. This is abnormal – in a normal thumb, the majority of the motion is through the CMC (carpometacarpal joint, at the base of the thumb).

When the CMC joint stiffens up from arthritis, the next joint toward the tip of the thumb gets hyperflexible to compensate.

Forearm Fractures In Kids – What Parents Need To Know

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Bones in children are different from bones in adults. They break differently and they respond differently to injury.

Some fractures occur both in adults and kids – some fractures occur only in children. Forearm fractures occur in both, with some important differences. This article will cover some of the basics of forearm fractures in kids.

The forearm is a unique structure which provides stability and mobility at the same time. The forearm is made up of two bones – the radius and the ulna. The bones can be broken at any point along the shaft of the bone – down by the wrist, at the middle of the bone’s shaft, or up by the elbow.

How the bones are broken

Fracture of both bones of the forearm may occur directly or indirectly by force.

Direct injuries happen when a child falls directly on the forearm, or something hits the forearm with a direct impact. This could be during a fall onto the sharp edge of a curb, or if a child is hit with a baseball bat or other blunt object.

Indirect injuries are much more common – they happen when a child puts her hand out to break her fall and the force from the fall travels up the forearm and breaks both bones.

How the diagnosis is made

Fractured forearms are usually pretty obvious when the doctor sees the patient. There’s usually a pronounced deformity that involves swelling or bruising of the forearm area. If the break is near the wrist or elbow, those areas may be swollen as well, and the child will refuse to move the joints around the fracture (even the fingers).

Xrays are a critical part of making the diagnosis of a forearm fracture. Other tests like CT scan and MRI are almost never necessary.

In children, bone fragments are usually not displaced (moved out of place) because the periosteum (covering over the bone) is thick and functions as an extra layer that contains the pieces of the fracture.

How forearm fractures are treated in children

In childhood, conservative treatment is usually successful. Most forearm fractures don’t need to be straightened out in surgery. A cast is the most common treatment. Sometimes the cast is put on after a week or two in a fiberglass or plaster splint.

Kids rarely need surgery. However, “surgery” needs to be defined here.

Surgery on kids’ fractures could be anything from simply pushing on the arm with the child asleep in the operating room, to making an incision over the bone and moving the pieces with bone clamps.

The most common surgery in kids’ forearm fractures is when the surgeon straightens the bones and puts a splint on the arm while the child is asleep. No pins, no incisions required.

The more the pieces are moved out of place and the older the child, the more likely it is that surgery will be necessary for correct healing.

Other reasons for taking a child to surgery for a broken forearm:

  • the bones are partially healed in the wrong position – a bad angle or not lined up at all
  • the surgeon or doctor in the ER tries to line up the pieces but they don’t line up well or won’t stay lined up after a week or so
  • pieces of the broken bones are highly displaced (moved out of place)
  • it’s a compound, or open fracture – pieces of the broken bones came through the skin

Complications from pediatric forearm fractures

Complications are rare. The most common problems involve stiffness and leftover deformity of the bones.

It’s common for the forearm to look crooked after the cast comes off. The younger the child, the faster and better the body straightens out deformities.

Usually, even if the bones aren’t perfectly straight on the xrays, the arm functions normally and the mild deformity doesn’t prevent the child from doing anything she wants to do.

Some parents don’t want any deformity at all and are more aggressive about wanting surgery – other parents are OK with most of the straightening happening after the cast comes off. This is why having an open discussion in the office is so important!

What restrictions are necessary during the healing of a forearm fracture?

The same restrictions apply whether treating an adult or a kid who has a fractured forearm:

  • no lifting
  • no weight bearing or pushing with the arm
  • keep fingers moving
  • light activities like writing and playing video games are fine

Sometimes the most frustrating part of recovery involves dealing with the cast – keeping it clean, dry, and comfortable.

How long is the recovery time from a forearm fracture?

Healing time depends on the severity of the forearm fracture. Fractures in children generally heal in 6 weeks.

The younger the child, the faster the bones heal. Past 4 years old, the process takes a full six weeks.

Declaring a fracture healed is a combination of

  • healing on the xray
  • lack of pain when the doctor pushes on the arm

After the bone has healed, the arm will be stiff for several days. This usually goes away with time without any physical therapy.

 

Fingertip Ganglion Cysts – Mucous Cysts

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picture of finger joint ganglionThe most common tumor in the finger is a ganglion cyst.

A ganglion cyst is simply a fluid-filled sac. It can be visible from the outside or buried deep underneath the skin.

Sometimes it causes symptoms like soreness and pain; other times patients have no idea it’s there.

What is a mucous cyst?

Ganglion cysts in the finger are often called “mucous cysts”, because of the mucous-like, or jelly-like clear fluid inside them.

These cysts are filled with joint fluid that has partially thickened. The jelly looks a lot like hair gel when it squishes out of the cyst in surgery!

The most common location for these is in the middle finger. They usually don’t happen in patients younger than 45 or 50 years old.

This type of arthritis is more common in women than men, and usually doesn’t happen before age 40. Fractures and other trauma to the thumb joint may put you at risk for developing arthritis in the future.

What’s inside the cyst?

The fluid inside the cyst is joint fluid. Every joint produces this fluid normally. In arthritis, the worn-out joint produces more fluid than usual. The fluid builds up and eventually forces its way through the joint lining and through the tendon fibers on top of the finger. This forms a cyst that you can see underneath the skin.

Sometimes the skin has a normal thickness, and you just see the bulge of the cyst below the skin.

Other times the cyst puts so much pressure on the skin that the skin thins out and becomes translucent – you can almost see through the skin at that point!

These cysts can be tiny or huge – they can have a single chamber, or multiple lobes and chambers.

Where do mucous cysts come from?

The cysts almost always come from a mildly arthritic joint. In other words, the joint may not be worn out enough to be painful, like most people think arthritis would be. But the joint is worn out enough to make more fluid than normal.

I always take an xray of the finger when I see one of these cysts. Sometimes the xray will show big bone spurs and other signs of arthritis. Most of the time, though, the xray appears almost normal; just a little extra narrowing of the joint more than normal.

Can they go away on their own?

Sometimes they pop on their own – other times they last for years.

Usually, they go up and down in size with activity.

Some of my patients are adventurous and try to puncture them on their own before they come and see me. It’s amazing how often they come back, despite the multiple self-surgery attempts.

Nail deformity and fingertip ganglion cysts

Many patients see a deformity or groove in the nail along with the cyst.

This happens because the tissues that grow a nail are very close to the cyst. The cyst pushes on these tissues, called the nail bed, and the nail can’t grow normally. Grooves in the nail usually resolve completely once the cyst is removed in surgery.

How are fingertip ganglion cysts treated?

In almost every situation, it’s safe to leave these cysts alone. There’s no medical reason to take them out.

However – if the cyst has ruptured on its own, or the patient has repetitively punctured the cyst with a needle, trying to get rid of it, I recommend surgery.

Since the ruptured cyst comes from the joint, a hole in the cyst and in the skin provides a direct path for bacteria to get from the skin down into the joint and even into the bone.

It’s rare to see an infected joint from one of these ruptured cysts, but it is possible, and not worth the risk.

Pain is another reason patients want these removed. But I always caution them that the pain could be coming from the arthritis in the joint and not the cyst itself. Getting rid of the cyst may not take their pain away.

The surgery involves opening up the skin over the cyst and cutting out a small window in the joint lining. I then scrape the edges of the joint where the cyst comes from. I try to find the root of the cyst and destroy it so it can’t come back.

Surgery is done as an outpatient, under local anesthesia plus a little sedation through an IV. You wear a tiny finger splint on the tip of the finger for about 10 days until the stitches come out. It’s safe to take the splint off for showering and typing during that time. After 10 days, you can use the finger as much as you want for normal activities.

Can mucous cysts come back after surgery?

There’s always a theoretical possibility of the cyst coming back. I’ve seen two come back in 8 years of doing hand surgery, so it’s rare. Since the arthritis is still there after the surgery, the cyst can come back. The only way to permanently remove the arthritis is to fuse the joint, which is a pretty radical step for most patients with a mucous cyst.

What Is Tennis Elbow?

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What is tennis elbow?

Tennis elbow is also called lateral epicondylitis (inflammation on the outside part of the elbow). This is a painful condition that involves a tendon on the outside part of your elbow.

A tendon starts from bone, turns into muscle, then back to tendon and reattaches to bone at the other end of the muscle.

The tendon involved in tennis elbow is called the ECRB (extensor carpi radialis brevis). Scroll down this page to see a video showing you exactly where this tendon is.

Tennis elbow is a wear and tear degenerative (chronic, age related) tear of the origin of this ECRB tendon.

Tennis elbow pain can occur with lots of different activities like gripping, lifting (light or heavy weight), twisting and even pinching. Golf and tennis can make it worse, but most patients with this condition don’t even play sports regularly.

What causes tennis elbow?

Overuse

The cause can be both non-work and work related. An activity that places stress on the tendon attachments, increases the stress and strain on the tendon, pulling on this degenerated, abnormal tissue. This creates a pain response in the body.

These stresses can be from holding too large a racquet grip or from “repetitive” gripping and grasping activities, i.e. meat-cutting, plumbing, painting, weaving, etc.

Trauma

A direct blow to the elbow may result in tearing and swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon – imagine a huge muscle pulling and contracting so hard that some of the fibers attached to bone start to tear away!

One theory is that the degeneration was happening already, then the traumatic event “turned on” the pain of the tendon problem.

There is a difference between the degeneration process (which happens in everyone as they age) and the pain process, which doesn’t happen in everyone.

Who gets tennis elbow/lateral epicondylitis?

The most common age group for tennis elbow is between 30 to 50 years old, but it may occur in younger and older age groups, and in both men and women.

Signs and symptoms of tennis elbow/lateral epicondylitis

Pain is the primary reason for patients to come to the doctor.

The pain is located over the outside part of the elbow, over the bony part of the elbow called the lateral epicondyle.

This area becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. This is because the tendon and muscle (ECRB, mentioned above) are attached to both the elbow and the wrist.

The video below shows you exactly where tennis elbow is in the arm.

Sometimes patients are very stiff and painful in the morning. Trying to straigten out the elbow all the way causes pain.

Treatment for tennis elbow

Conservative (non-surgical)

Activity modification – Initially, the activity causing the condition should be limited. Limiting the aggravating activity, not total rest, is recommended. Modifying grips or techniques, such as use of a different size racket and/or use of 2-handed backhands in tennis, may relieve the problem.

A big no-no is lifting palm down – train yourself to lift with the forearm turned palm up. This reduces stress and strain on the ECRB tendon.

Medication – anti-inflammatory medications may help alleviate the pain.

Topical versions of these medications are available and are less harsh on your stomach – ask us in the office if prescribing one is appropriate.

Brace – a tennis elbow brace, a band worn over the muscle of the forearm, just below the elbow, can reduce the tension on the tendon and allow it to heal.

Physical Therapy – may be helpful, providing stretching and/or strengthening exercises. Modalities such as ultrasound or heat treatments may be helpful.

Steroid injections – A steroid is a strong anti-inflammatory medication that can be injected into the area. No more than three injections should be given total.

PRP Injection

PRP, or protein-rich plasma, is a concentrated part of your own blood.

Injecting this solution of growth factors and other immune proteins into the painful degenerated tendon can help jumpstart healing and is often more effective than steroid shots.

Ultrasound

Tenex is the brand name of a probe used to treat painful tennis elbow. This is done with local anesthetic, using ultrasound to let the doctor see the abnormal tendon in the elbow. A good step to take between non-surgical treatments and the final, larger surgery. One of our doctors at Ozark does this procedure.

Surgery

Surgery is only considered when the pain is incapacitating and has not responded to non-surgical options, and symptoms have lasted more than six months.

Imagine yourself saying, “I’m sick and tired of trying this stuff that hasn’t worked”! – that’s about the right time to think about surgery.

Surgery involves removing the diseased, degenerated tendon tissue. This surgery is performed in the outpatient setting.

Recovery

Recovery from surgery includes physical therapy to regain motion and strength of the arm. Full recovery can take 4–6 months but normal daily activities are possible at around 6-8 weeks.

Another Tennis Elbow Video from the ASSH (American Society for Surgery of the Hand):

Do You Have An Allergy Or A Reaction?

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A common source of confusion and worry among patients is the subject of allergies. I’m not talking about sneezing and runny nose symptoms from lots of pollen in the air – I’m talking about allergies to medications.

You know when a doctor or nurse asks, “are you allergic to anything?” – how would you answer that question?

Many people just start giving a long list of anything they’ve ever touched, tasted, breathed, or looked at funny, and didn’t enjoy it.

I’ve seen anything from Peaches to Penicillin to Mayonnaise on a “drug allergies” list. Some folks are allergic to dyes, cleaning solutions, and latex.

What happens if you have lots of allergies?

Most of the time it’s wise for nurses and doctors to take patients seriously and write all of these down. Problems arise when someone has a list of 20-30 “allergies” that start to interfere with the actual caring for the patient’s needs.

For example, if someone is truly allergic to latex, that means that any latex that touches the skin can cause them to stop breathing if the reaction is bad enough. All the products, bandages, tubing, and equipment must be checked and changed in the operating room before a patient goes to surgery. However, if a person is just “sensitive” to latex or has a mild reaction to it, that’s totally different and may change what type of equipment can be used. Latex-free options are not always the same and are often inferior to products containing latex.

Only about 10% of people who say they’re allergic to penicillin are also allergic to the most common antibiotic given in surgery, which is a relative of penicillin but not technically the same thing. Often some doctors won’t give the common drug if someone says they’re truly allergic to penicillin.

The difference between allergies and reactions

A true allergy to a medication involves swelling, trouble breathing, usually along with hives or a widespread skin reaction. This can be life threatening and is called an anaphylactic (anna-fuh-lack-tik) reaction.

Simple “reactions” to medications are much more common – rash, itching, nausea, diarrhea, are examples. These are not life-threatening and for some patients are easily treated with anti-itching or anti-nausea medications taken at the same time.

So the next time a nurse or doctor asks about allergies to medications, you can help by classifying them a little better, which helps you get better care. One big tip here: write them down ahead of time (like, now) so you can just hand the information to the staff when the time is right.

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