Kienböck’s Disease

Kienbock’s disease is caused by a loss of blood supply to the lunate. The lunate is one of eight small bones that make up the “carpal bones” in the wrist.

The carpal area is made up of two rows of bones: the proximal row (the one closer to the forearm) and the distal row (the one closer to the fingers). The lunate bone lies in the center of the proximal row. It is next to the scaphoid bone, which spans the two rows.

What Causes Kienbock’s Disease?

There is probably no single cause. Kienbock’s diease seems to develop due to several factors including:

• Blood supply (arteries)
• Blood drainage (veins)
• Skeletal variations (shorter length of the ulna and the shape of the lunate bone itself)
• Disease like gout, sickle cell anemia, and cerebral palsy
• Trauma, either a single event or repeated significant trauma

How is Kienbock’s Disease Diagnosed?

Most patients with Kienbock’s diease experience wrist pain and tenderness directly over the lunate bone. Dr. Patel can diagnose the disease by evaluating your history, and performing a physical evaluation, with x-rays.

In some cases special tests are needed to confirm the diagnosis. An MRI is the most reliable way to study to assess the blood supply of the lunate. A specialized CT scan or a bone scan may also be used.

How Does Kienbock’s Disease Progress?

Progression is varied and unpredicatable. It may be diagnosed in the early stage, when you may only experience pain and swelling, but with normal x-rays. Changes in the lunate become more apparent as the disease progresses.

As it progresses, the lunate develops small fractures and collapses. The mechanics of the wrist change, putting abnormal stress and wear on the joints within the wrist. Be aware that not every case progresses through all stages to the severely arthritic end-stage.

Treatment Options for Kienbock’s Disease

Treatment depends on the stage and severity of the disease. Observation and immobilization may be sufficient in the early stages. For more advanced stages, surgery may be considered to reduce the load on the lunate bone by lengthening, shortening or fusing various bones in the forearm or wrist. Bone grafting or removal of the diseased lunate is sometimes performed. If the disease is very advanced, a compete wrist fusion may be necessary.

Hand therapy, while it does not change the course of the disease, can minimize the disability from the problem. Treatment is designed to relieve pain and restore function.

Dr. Patel will advise you of which treatment is most appropriate. Call (770) 333-7888 to schedule your appointment with Atlanta Hand Specialist today.

Hand Tumors

A tumor, sometimes referred to as a mass, is any abnormal lump or bump. The term doesn’t necessarily mean the mass is malignant or is a cancer. In fact, the vast majority of hand tumors are benign or non-cancerous.

A hand tumor can occur on the skin (like a mole or wart), underneath the skin in the soft tissue, or even in the bone.

Common Types of Hand Tumors

A ganglion cyst is the most common type of tumor in the hand or wrist. It is a benign sac of gelatinous fluid that forms off a joint or tendon sheath. Cysts most often occur in the wrist but can appear around the finger joints.  Ganglion cysts form when a portion of the joint capsule or tendon sheath begins ballooning out and becomes filled with the fluid that lubricates the joint or tendon.

A giant cell tumor of tendon sheath is the second most common type of hand tumor. These tumors, unlike the fluid-filled ganglion cysts, are solid masses. They can develop anywhere near a tendon sheath. They are benign, slow-growing masses that spread through the soft tissue underneath the skin. These tumors are not cancer.

An epidermal inclusion cyst is another common type of tumor. It is also benign and forms underneath the skin. Epidermal inclusion cysts originate from the under-surface of the skin where there may have been a cut or puncture.  When skin cells, which create a protective waxy substance called keratin, get trapped under the surface, they continue to make keratin, which gets trapped under the surface of the skin. Overtime the keratin and the dead skin cells create a cyst.

Other less common types of hand tumors include lipomas (fatty tumors), neuromas, nerve sheath tumors, fibromas, and glomus tumors, among others.  Almost all are benign.

Hand Cancer

Cancer in the hand is very rare. Skin cancers like squamous cell carcinoma, basal cell carcinoma or melanoma are the most common. Other cancers, which are very rare, include sarcomas of the soft tissue or bone.

Evaluation and Treatment of Hand Tumors

Your hand doctor will perform a physical exam and evaluate your medical history to determine which type of tumor you have. He may also take x-rays of the growth if there is concern about bony involvement or to evaluate the soft tissue.

Surgical excision of the tumor is typically the treatment with the lowest re-occurrence rate.  It also allows your doctor to analyze the tumor and determine its type. Surgery is often performed on an outpatient basis and may not require general anesthetic. If your hand doctor believes the tumor is a ganglion cyst, he may try to aspirate or inject the cyst if you perfect to forgo surgery.

Some patients may decide to do nothing and live with the tumor if it’s benign. However, the tumors can grow over time. Your doctor will discuss the risks and benefits of removing the tumor during your appointment.

Call (770) 333-7888 to make your appointment with Atlanta Hand Specialist today at one of our multiple metro Atlanta offices.

Hand Infections

Urgency of Treatment

Early and aggressive treatment of a hand infection is essential. Failure to treat a hand infection can cause serious problems that may persist after the infection has cleared including stiffness, loss of strength, and loss of tissue such as skin, nerve or bone.

Some types of infection can be treated with antibiotics, rest and soaking. However, many infections can cause serious problems, even after a day or two, if not treated with antibiotics, surgical drainage, and removal of the infected tissues.

Drainage or pus is sent for laboratory testing to determine the type of bacteria causing the infection and the appropriate antibiotic for treatment.

Types of Hand Infections and Treatment Options

Paronychia

A paronychia is an infection of the cuticle area around the fingernail. Acute paronychia is caused by bacteria and results in redness, swelling, pain, and later on, pus. Early cases can be treated with soaking and antibiotics, but if pus is seen or suspected, drainage is required.

Chronic paronychia is caused by fungus. The cuticle area becomes mildly red and swollen, with little or no drainage and mild tenderness. People whose hands are frequently wet are prone to this infection. It can be treated with special medications and reduction or elimination of constant exposure to moisture. On occasion, surgery is necessary to remove the infected tissue.

Felon

A felon is a more serious, and usually more painful, throbbing infection. It occurs in the closed space of the fatty tissues of the finger tip and pulp. This usually requires surgical drainage and antibiotics. If not treated early, deconstruction of the soft tissues and even bone and occur.

Herpetic Whitlow

Herpetic whitlow is a viral infection of the hand, usually on the fingers, which is caused by a herpes virus. This is more common in healthcare workers whose hands are exposed to the saliva of patients carrying herpes. It is characterized by small, swollen, painful blood-tinged blisters, and sometimes numbness. It is typically treated conservatively and resolves itself in several weeks without many after-effects.

Septic Arthritis/Osteomyelitis

A wound in or near a joint, or a drainage cyst from an arthritic joint can cause severe infection for the joint. This is known as septic arthritis. Within in a few days, the joint can be destroyed by the bacteria eroding the cartilage surface of the joint. Surgical drainage is required, in addition to antibiotics.

Delayed treatment can result in the infection of the bone, a complication called osteomyelitis. It typically requires one or more operations to remove the infected issue and may require weeks of intravenous antibiotics.

Deep Space Infections

The spaces in between the different layers of structures in the hand can become infected, even from a small puncture wound. It may affect the thumb area (thenar space), the palm (deep palmar space) or even the web area between the bases of fingers (collar-button or web space abscess). Treatment involves surgical drainage, as the infection has the potential to spread to other areas, even to the wrist and forearm.

Tendon Sheath Infection

An infection in the flexor tendon can occur due to a small laceration or puncture wound over the middle of a finger, especially near a joint on the palm side. It can cause severe stiffness, even destruction and rupture of the tendon. These symptoms present acutely with stiffness of the finger in a slightly bent posture, diffuse swelling and redness of the finger, tenderness on the palm side of the finger, and severe aggravation of pain with attempts to straighten the finger. This infection requires immediate surgical drainage of the tendon sheath and antibiotics.

Atypical Mycobacterial Infections

In rare instances, a tendon sheath infection can be caused by an “atypical mycobacterium. The infection develops gradually and is often associated with swelling and stiffness without much pain or redness. It is treated with special antibiotics for several months. Surgical removal of the infected lining of the tendons is sometimes necessary. Many patients experience residual stiffness despite treatment.

Mycobacterium marinum is a common form of infection. It usually develops from
puncture wounds from fish spines, or contamination of a simple wound or abrasion from stagnant water (in nature or from aquariums). Identification of the cause can be difficult.

Patients with impaired immune systems (AIDS patients, cancer patients) are more susceptible to atypical mycobacterial infections.

Infections From Bite Wounds

Infections from bites (from humans or animals) are associated with several bacteria.

Although Streptococcus and Staphylococcus can be involved (driven in from the skin by a tooth), other organisms common to the mouth may be present and typically require other or additional antibiotics.

Eikenella corrodens is often seen with human bite injuries. Pasteurella multocida is seen with dog and especially cat bite wounds.

Wounds are usually not closed after treatment, allowing the infection to drain out. Surgical trimming of infected/crushed tissue is often required.

A rabies infection from an infected animal may be serious, even fatal. Treatment is determined by risk. Fortunately, the reported cases of rabies in humans are rare, and the incidence of rabies is small in domestic animals.

Call (770) 333-7888 to make an appointment with Atlanta Hand Specialist. We have offices in Douglasville, Smyrna, and Marietta.

Hand Fractures

What is a Fracture?

Simply put, a fracture is a broken bone. It may be simple, with bone pieces aligned and stable, or unstable, with the bones shifting or displaced. Some fractures occur in the shaft (main body) of the bone, while others occur along the joint surface. When the bone is fracture into many pieces, this is known as a comminuted fracture. An open, or compound, fracture occurs when a bone fragment breaks through the skin. There is some risk of infection in these cases.

Hand Fractures

Because your hand is made of many bones, hand fractures are common. Common signs of a fracture include:

• Pain
• Swelling
• Stiffness
• Decreased use of your hand

Some fractures result in an obvious deformity, such as a crooked finger, but many do not.
Due to the close relationship of bones to ligaments and tendons, your hand may be stiff and weak after the fracture heals. Fractures that involve surface joints can lead to early arthritis in the joint involved.

How Are Hand Fractures Treated?

Your hand doctor will perform a medical evaluation and take an X-ray to determine if your hand is fractured. Depending on the type of fracture, he will recommend one of several treatment methods.

If the fracture is not displaced, your hand doctor may use a splint or cast. This also protects a fracture that has been set. In some cases, a displaced fracture needs to be set and then held in place with wires or pins without making an incision (closed reduction and internal fixation).

Other fractures may need surgery to set the bone (open reduction). Once the bone fragments are set, they are held together with pins, plates, or screws. If the fracture disrupts the joint surface (articular fracture), it usually needs to be set more precisely to restore the joint surface as smooth as possible.

If a bone is missing or so severely crushed that it cannot be repaired, it may require a bone graft. This procedure involves taking bone from another part of the body to provide more stability. Once the fracture has enough stability, motion exercises may be started to try to avoid stiffness. Your surgeon will determine when the fracture is sufficiently stable.

What Results Can You Expect?

Perfect alignment of the bone on x-ray is not always necessary. You may develop a bony lump at the fracture site as the bone heals. This is known as a “fracture callus,” which functions as a “spot weld.” This is a normal healing process, and the lump should get smaller over time.

Problems with fracture healing include:

• Stiffness
• Shift in position
• Infection
• Slow healing or complete failure to heal

You can ease the chances of complications by carefully following your surgeon’s advice during the healing process and before returning to work or sports activities. Your doctor may recommend a hand therapy program with splints and exercises to speed and improve the recovery process.

Call (770) 333-7888 to make an appointment with Atlanta Hand Specialist. We have multiple offices throughout the metro Atlanta area.

Ganglion Cyst

Ganglion cysts are common lumps within the hand and wrist that develop adjacent to joints or tendons. The most common locations are:

• Top of the wrist
• Palm side of the wrist
• Base of the finger on the palm side
• Top of the end joint of the finger

The cyst often resembles a water balloon on a stalk, and is filled with clear fluid or gel. The cause is unknown, although they may form in the presence of joint or tendon irritation or mechanical changes. They can occur in patients of all ages.

Ganglion cysts may change in size or even disappear completely. They may or may not be painful. These cysts are not cancerous and will not spread to other areas.

How Are Ganglion Cysts Diagnosed?

Dr. Patel can usually diagnose a ganglion cyst based on the appearance and location of the bump. Ganglion cysts are usually oval or round and may be soft or very firm. Dr. Patel may also request x-rays in order to investigate problems in the adjacent joints. Cysts at the end joint of the finger frequently have an arthritic bone spur associated with them.

Ganglion Cysts Treatment Options

Treatment is often non-surgical. In many cases, cysts are simply observed, as they frequently disappear on their own.

If the cyst becomes painful, limits activity or is otherwise unacceptable, there are several treatment options including:

• Splints and anti-inflammatory medication to decrease pain
• Aspiration to remove the fluid and decompress the cyst
• Surgery to remove the cyst (if the above fail to provide relief or if the cyst recurs)

Surgery involves removing the cyst along with the portion of the joint capsule or tendon sheath. With wrist ganglion cysts, traditional and arthroscopic techniques may yield good results. Dr. Patel will discuss which treatment options are right for you during your appointment.

Call (770) 333-7888 to schedule your appointment at Atlanta Hand Specialist. We have offices in Smyrna, Douglasville, and Marietta.

Flexor Tendon Injuries

What Are Flexor Tendons?

Flexor tendons are cord-like extensions that connect the flexor muscles to the bone, and allow these muscles to bend or flex the finger.

The flexor muscles start from the elbow and forearm regions, turn into the tendons just past the middle of the forearm, and attach into the bones of the fingers. In the finger, the tendon passes through fibrous rings (pulleys), which guide the tendons and keep them near the bone. This enables the tendons to move the joint much more effectively.

Flexor Tendon Injuries

Deep cuts on the palm side of the wrist, hand or fingers may injure the flexor tendons and the nearby nerves and blood vessels. The injury may appear minor, but is more complex on the inside. If a tendon is cut, it acts like a rubber band, with its cut ends pulling away from each other. A tendon that has not been cut completely through may allow the finger to bend, but will cause pain or catching and might eventually tear all the way through. When a tendon is completely cut through, the finger joint can’t bend on its own.

Treating Flexor Tendon Injuries

Since the cut ends of a tendon usually separate after an injury, it will likely not heal without surgery.

Your doctor will advise you on how soon surgery is needed after the tendon is cut. There are many ways to repair the cut tendon, and certain types of cuts need a specific type of repair. It’s important to preserve certain pulleys in the finger, and there is little space between the tendon and the pulley in which to perform a repair.

After surgery, the injured area can either be protected from movement or started on a very specific limited-movement program for several weeks, depending on the type of cut. Your surgeon may also prescribe hand therapy after surgery. After four to six weeks, you should be allowed to move your finger slowly and without resistance.

If you believe you’ve suffered a flexor tendon injury, call Atlanta Hand Specialist at (770) 333-7888 to make an appointment with a dedicated hand doctor at Atlanta Hand Specialist in metro Atlanta.

Fingertip Injuries

Fingertip Injuries

Fingertip injuries include any injury to the skin, bone, nail, nail bed, tendon, or the pulp of the padded area of the fingertip.

The skin of the palm side of the fingertip has many more nerve endings than most other parts of the body. These nerve endings enable fine sensation, but can be damaged. When this specialized skin is injured, exact replacement is difficult.

Evaluating an Injury

How the injury occurred as well as any medical problems are important factors in determining treatment. Your hand doctor will examine the extent of the tissue injury and its size. He or she will also assess sensation and circulation of the finger tip.

Your doctor may check the mobility of the tip, as injuries can occur to the tendons that bend or straighten the fingertip. An X-ray may be necessary to see if the bone has been injured.

Fingertip Injury Treatment

Severe crush or avulsion injuries may completely remove some or all of the tissue at the fingertip. If just skin is removed and the defect is less than a centimeter in diameter, you may simply treat these injuries with dressing changes.

If there is a little bit of bone exposed at the tip, your doctor may trim it back slightly and treat it with a dressing, too.

For larger skin defects, skin grafting may be recommended. Your doctor can obtain smaller grafts from the little finger side of the hand. Larger grafts may be harvested from the forearm or groin.

Call (770) 333-7888 to schedule an appointment with a dedicated hand doctor at Atlanta Hand Specialist. We have multiple locations throughout metro Atlanta.

Extensor Tendon Injuries

What Are Extensor Tendons?

Located on the back of the hand and fingers, the Extensor tendons allow you to straighten your fingers and thumb. These tendons are attached to muscles in your forearm. The tendons become flat and thin as they continue into your fingers, and are then joined by smaller tendons from the muscles in the hand. It is these small-muscle tendons that allow delicate finger motions and coordination.

Extensor Tendon Injuries

The extensor tendons lie just below the skin, directly on the bone, on the back of the hands and fingers. Due to their location, they are easily injured, even by a minor cut. Jamming a finger may tear these thin tendons away from the bone. After this type of injury, you may have trouble straightening one or more joints. Treatment is necessary to return use to the tendon.

Common Types of Extensor Tendon Injuries:

• Mallet finger, or the droop of the end of the joint where an extensor tendons has been cut or separated from the bone
• Boutonniere deformity, or the bent-down (flexed) position of the middle joint of the finger from a cut or tear of the extensor tendon
• Lacerations or cuts on the back of the hand

Extensor Tendon Injury Treatment

A cut that splits the tendon may require stitches, but tears caused by jamming injuries are usually treated with splints. The splint prevents the healing ends of the tendon from pulling apart, and should be worn at all times until the tendon has fully healed.

Dr. Patel will apply the splint in the correct place, and give you directions on how long you should wear it. He may also place a pin through the bone across the joint as an internal splint.

Call (770) 333-7888 to schedule an appointment with Dr. Patel. Atlanta Hand Specialist has offices in Smyrna, Douglasville, and Marietta.

Dupuytren’s Disease (Viking’s Disease)

Dupuytren’s disease, also called Viking’s disease, is an abnormal thickening of the fascia (the tissue just beneath the skin of the palm).

It often starts with firm lumps in the palm, with some patients developing firm cords beneath the skin that stretch from the palm into the fingers. Gradually, these cords may cause the fingers to bend into the palm.

Although skin may become involved in the process, deeper structures such as the tendons are not. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).

What Causes Dupuytren’s Disease?

The cause is unknown but may be associated with certain biochemical factors within the involved fascia. Dupuytren’s disease is more common in men over age 40 and in people of northern European descent. There is also no evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.

Signs and Symptoms

Symptoms usually include a small lump or series of lumps and pits within the palm. The lumps are generally firm and adherent to the skin.

A cord may develop gradually, which will extend from the palm into one or more fingers (the ring and little fingers are most commonly affected. Although the cords may be mistaken for tendons, they actually lie between the skin and tendons. In many cases, both hands are affected, although the degree of involvement may vary.

While the initial nodules may produce discomfort, Dupuytren’s disease is not typically painful.

You may first notice it due to difficulty placing your hand flat on an even surface. As your fingers are drawn into the palm, you may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets.

The progression of the disease is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

Treatment for Dupuytren’s Disease

In some cases, Dr. Patel may simply observe the nodules and cords that contracted.

If you have more advanced contractures, you may require surgery to improve function. There are various surgical techniques that can correct finger position. Dr. Patel will discuss which method is most appropriate for you based on the stage of the disease and joints involved.

Surgery should help improve finger position, and thereby hand function. Even after surgery, the disease may reoccur, and the fingers may begin to bend into the palm once again.

Call Atlanta Hand Specialist at (770) 333-7888 to make an appointment with Dr. Patel. We have offices in Smyrna, Douglasville, and Marietta.

de Quervain’s Tendonitis or Wrist Tendonitis

de Quervain’s tendonitis (first dorsal compartment tendonitis) is brought on by irritation or inflammation of the wrist tendons at the base of the thumb. This inflammation causes the compartment (a tunnel or a sheath) around the tendon to swell and enlarge, making thumb and wrist movement painful. Making a fist, grasping, or holding objects often causes pain.

What Causes de Quervain’s Tendonitis?

This condition is usually caused by taking up new, repetitive activity.

New mothers are especially prone to this type of tendonitis because caring for an infant often creates awkward hand positioning. Hormonal fluctuations associated with pregnancy and nursing further contribute to its occurrence.

A wrist fracture may also predispose you to de Quervain’s tendonitis because of increased stresses across the tendons.

Signs and Symptoms of Wrist Tendonitis

The main symptom is pain over the thumb-side of the wrist. It may appear gradually or suddenly, and is located at the first dorsal compartment at the wrist. The pain may radiate down the thumb or up the forearm, with hand and thumb motion increasing pain (especially with forceful grasping or twisting).

You may experience swelling over the base of the thumb which can include a fluid-filled cyst in this region. There may be an occasional “catching” or “snapping” when you move your thumb.

Because of the pain and swelling, motion such as pinching may be difficult. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger.

Diagnosis of Wrist Tendonitis

You will be asked to make a fist with your fingers clasped over your thumb. This involves bending your wrist in the direction of your little finger, making the maneuver quite painful if you have de Quervain’s tendonitis.

Wrist Tendonitis Treatment

The goal of wrist tendonitis treatment is to relieve the pain caused by the irritation and swelling. Options may include:

• Resting the thumb and wrist by wearing a splint.
• Taking an oral anti-inflammatory
• Cortisone-type of steroid injections in into the tendon compartment

Each of these non-operative treatments helps reduce the swelling, which typically relieves pain over time. In some cases, simply stopping the aggravating activities may allow the symptoms to go away on their own.

If symptoms are severe or do not improve, surgery may be recommended to open the compartment to make more room for the inflamed tendons, which breaks the vicious cycle of the tight space causing more inflammation. You can resume normal use of your hand once comfort and strength have returned.

Call Atlanta Hand Specialist at (770) 333-7888 to make an appointment for wrist tendonitis treatment at any one of our multiple metro Atlanta locations.