Upper Body Frequently Asked Questions

Anatomy of the Shoulder

The two main bones of the shoulder are the humerus and the scapula (shoulder blade). The joint cavity is cushioned by articular cartilage covering the head of the humerus and face of the glenoid. The scapula extends up and around the shoulder joint at the rear to form a roof called the acromion, and around the shoulder joint at the front to form the coracoid process.

The end of the scapula, called the glenoid, meets the head of the humerus to form a glenohumeral cavity that acts as a flexible ball-and-socket joint. The joint is stabilized by a ring of fibrous cartilage surrounding the glenoid called the labrum.

Ligaments connect the bones of the shoulder, and tendons join the bones to surrounding muscles. The biceps tendon attaches the biceps muscle to the shoulder and helps to stabilize the joint. Four short muscles originate on the scapula and pass around the shoulder where their tendons fuse together to form the rotator cuff.

All of these components of your shoulder, along with the muscles of your upper body, work together to manage the stress your shoulder receives as you extend, flex, lift and throw.

What Is the Rotator Cuff in the Shoulder?

The rotator cuff is a group of flat tendons which fuse together and surround the front, back, and top of the shoulder joint like a cuff on a shirt sleeve. These tendons are connected individually to short, but very important, muscles that originate from the scapula. When the muscles contract, they pull on the rotator cuff tendon, causing the shoulder to rotate upward, inward, or outward, hence the name "rotator cuff."

What Is Impingement Syndrome?

The uppermost tendon of the rotator cuff, the supraspinatus tendon, passes beneath the bone on the top of the shoulder, called the acromion. In some people, the space between the undersurface of the acromion and the top of the humeral head is quite narrow. The rotator cuff tendon and the adherent bursa, or lubricating tissue, can therefore be pinched when the arm is raised into a forward position. With repetitive impingement, the tendons and bursa can become inflamed and swollen and cause the painful situation known as "chronic impingement syndrome."

How Does Impingement Syndrome Relate to Rotator Cuff Disease?

When the rotator cuff tendon and its overlying bursa become inflamed and swollen with impingement syndrome, the tendon may begin to break down near its attachment on the humerus bone. With continued impingement, the tendon is progressively damaged, and finally, may tear completely away from the bone.

Why Do Some People Develop Impingement and Rotator Cuff Disease When Others Do Not?

There are many factors that may predispose one person to impingement and rotator cuff problems. The most common is the shape and thickness of the acromion (the bone forming the roof of the shoulder). If the acromion has a bone spur on the front edge, it is more likely to impinge on the rotator cuff when the arm is elevated forward. Activities which involve forward elevation of the arm may put an individual at higher risk for rotator cuff injury. Sometimes the muscles of the shoulder may become imbalanced by injury or atrophy, and imbalance can cause the shoulder to move forward with certain activities which again may cause impingement.

Other Than Impingement, What Else Can Cause Rotator Cuff Damage?

In young, athletic individuals, injury to the rotator cuff can occur with repetitive throwing, overhead racquet sports, or swimming. This type of injury results from repetitive stretching of the rotator cuff during the follow-through phase of the activity. The tear that occurs is not caused by impingement, but more by a joint imbalance. This may be associated with looseness in the front of the shoulder caused by a weakness in the supporting ligaments.

What Kind of Symptoms Does a Patient Have When the Rotator Cuff Is Injured?

The most common complaint is aching located in the top and front of the shoulder, or on the outer side of the upper arm (deltoid area). The pain is usually increased when the arm is lifted to the overhead position. Frequently, the pain seems to be worse at night, and often interrupts sleep. Depending on the severity of the injury, there may also be weakness in the arm and with some complete rotator cuff tears the arm cannot be lifted in the forward or outward direction at all.

How Is the Diagnosis of Rotator Cuff Disease Proven?

The diagnosis of rotator cuff tendon disease includes a careful history taken and reviewed by the physician, an x-ray to visualize the anatomy of the bones of the shoulder, specifically looking for acromial spur, and a physical examination. Atrophy may be present, along with weakness, if the rotator cuff tendons are injured, and special impingement tests can suggest that impingement syndrome is involved. An MRI (magnetic resonance imaging) scan frequently gives the final proof of the status of the rotator cuff tendon. Although none of these tests is guaranteed accurate, most rotator cuff injuries can be diagnosed using this combination of exams.

What Is the Initial Treatment for Rotator Cuff Disease and Impingement?

If minor impingement or rotator cuff tendinitis is diagnosed, a period of rest coupled with medicines taken by mouth, and physical therapy will frequently decrease the inflammation and restore the tone to the atrophied muscles. Activities causing the pain should be slowly resumed only when the pain is gone. Sometimes a cortisone injection into the bursal space above the rotator cuff tendon is helpful to relieve swelling and inflammation. Application of ice to the tender area three or four times a day for 15 minutes is also helpful.

What Is the Second Line of Treatment if the Rotator Cuff Pain and Weakness Persist?

If there is a thickened acromion or acromial bone spur causing impingement, it can be removed with a burr using arthroscopic visualization. This procedure can often be performed on an outpatient basis, and at the same time, any minor damage and fraying to the rotator cuff tendon and scarred bursal tissue can be removed. Often this will completely cure the impingement and prevent progressive rotator cuff injury.

If the Rotator Cuff Is Already Torn, What Are the Options?

When the tendon of the rotator cuff has a complete tear, the tendon often must be repaired using surgical techniques. The choice of surgery, of course, depends on the severity of the symptoms, the health of the patient, and the functional requirements for that shoulder. In young working individuals, repair of the tendon is most often suggested. In some older individuals who do not require significant overhead lifting ability, surgical repair may not be as important. If chronic pain and disability are present at any age, consideration for repair of the rotator cuff should be given.

What Will Happen if the Rotator Cuff Is Not Repaired?

In some situations, the bursa overlying the rotator cuff may form a patch to close the defect in the tendon. Although this is not true tendon healing, it may decrease the pain to an acceptable level. If the tendon edges become fragmented and severely worn, and the muscle contracts and atrophies, repair at that point may not be possible. Sometimes in this situation, the only beneficial surgical procedure would be an arthroscopic operation to remove bone spurs and fragments of torn tissue that catch when the arm is rotated. This certainly will not restore normal power or strength to the shoulder, but often will relieve pain.

How Is a Major Injury to the Rotator Cuff Tendon Repaired Surgically?

The arthroscope is extremely helpful when repairing rotator cuff tendons, but sometimes it is necessary to add a "mini-open" procedure if the tendon is completely torn. Using the arthroscope at the beginning of the case allows visualization of the interior of the joint to facilitate trimming and removal of fragments of torn cuff tendon and biceps tendon. The next step utilizes the arthroscope to visualize the spur and thickened ligament beneath the acromial bone, while they are removed with miniature cutting and grinding instruments. If it is necessary to suture a rotator cuff tear which has pulled off the bone, a two-inch incision can be made directly over the tear that has been visualized and localized using the arthroscope. The deltoid muscle fibers can be spread apart so that strong stitches can attach the rotator cuff tendon back to the bone. If the tear is minimally retracted, small suture screw anchors may be used arthroscopically or open.

How Is My Shoulder Treated After Surgery?

In a minor operation for impingement, the shoulder is placed in a simple sling. If a full thickness tear of the rotator cuff was present and repaired, then the shoulder will be supported by an UltraSling or a SCOI postoperative brace. The brace is very helpful because it will allow exercise of the elbow, wrist, and hand at all times, and places the arm in a position that promotes better blood circulation and relieves stress on the repaired rotator cuff tissues. In addition, the shoulder can be exercised in the brace much easier than when it is at the side in an immobilizer.

What Is the Rehabilitation Program After Rotator Cuff Surgery?

Depending on the type of surgery performed, the program will allow a period of time for healing of the soft tissues followed by time to regain range of motion and then strengthen the shoulder muscles, but particularly the rotator cuff. In minor tendinitis and impingement syndrome, the program takes approximately two to three months. If the rotator cuff tendon has been completely torn, it may take six months or more before the atrophied muscles can resume their function and the range of motion of the arm is restored. Frequently, pain relief is much quicker and return to daily activities is often possible by two to three months.

How Successful Is Rotator Cuff Surgery?

Again, every case is unique. In the young, healthy person with a minor rotator cuff impingement, surgery is predictably successful. As the injury becomes more severe, such as with a large bone spur and fragmentation of the tendon, then a perfect result cannot be expected. Since it is necessary to trim back the unhealthy tendon before reattaching it to the bone, a decreased range of motion of the shoulder will often result. Despite this, pain relief and return of strength are usually well worth the minor decreased mobility. The final outcome often depends on the willingness and ability of an individual patient to work on their postoperative physical therapy program.3

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Shoulder Instability

Shoulder instability represents a spectrum of disorders, the successful management of which requires a correct diagnosis and treatment. The boundaries of this spectrum are represented by a subluxation event (a partial dislocation which spontaneously reduces), to a complete dislocation which often requires anesthesia to reduce the shoulder. The majority of instabilities are traumatic in nature and the ball of the shoulder is unstable toward the front of the shoulder. It is this type of shoulder instability which we will concentrate on here.

In order for a shoulder to dislocate, the very important and delicate balance of soft tissues (ligaments, capsule and tendons) around the shoulder must become damaged. These damaged tissues often don't heal properly and the shoulder can develop recurrent dislocations and/or pain with certain types of activities.

The older a patient is at the time of initial injury the lower the chances are for developing recurrent instability. Patients under the age of 20 with traumatic dislocations have a substantially higher rate of recurrence (greater than 90%).

It is for this reason we have become more aggressive in recent years in recommending early repair for this group of patients. We believe early repair reduces the likelihood of further injuring the shoulder with additional episodes of dislocation.

The treatment for recurrent shoulder instability is usually surgical. This surgery is aimed at repairing the damaged capsule and ligaments directly. This procedure can be done arthroscopically as an outpatient. The surgery is performed with a miniature lighted telescope and small instruments introduced into the shoulder joint through hollow cannulas. Advanced miniature anchors with suture attached are inserted precisely into the socket of the shoulder, and the torn ligaments are reattached to the socket. Complete healing from this procedure takes approximately 4-6 months.

Calcium Deposits in the Shoulder

Calcium deposits around the shoulder are a fairly common occurrence. Frequently they do not cause problems, but if they increase in size or become inflamed, then very severe pain may result. This collection of questions and answers is intended to explain this common shoulder problem and describe the methods we recommend for treatment in different situations.

What Is the Cause of Calcium Deposits Around the Shoulder?

In most situations, there is no known cause for calcium deposits. Many people ask if their diet should be changed to reduce calcium intake. This should never be used as a form of treatment, since a normal balanced diet with a calcium supplement up to 1000mg a day is healthy in a normal patient, particularly senior citizens and post-menopausal females.

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Who Most Commonly Gets Calcium Deposits?

Calcium deposits occur most frequently in females between 35 and 65 years of age, but may occur in males as well.

Do All Calcium Deposits Cause Problems?

Many calcium deposits are present for years without causing any symptoms. Only when the deposit becomes large enough to pinch between the bones when the shoulder is elevated, does it cause pain. Sometimes smaller deposits cause pain if they become acutely inflamed, especially when the calcium salts leak from the lesion into the sensitive bursal tissues.

Does a Calcium Deposit Damage My Shoulder?

Some calcium deposits can cause erosion with the destruction of a portion of the rotator cuff tendon. Most calcium deposits remain on the outside of the rotator cuff tendon in the bursa and only cause problems because of their pain and catching.

Is the Calcium Deposit Hard Like a Rock?

Most early calcium deposits are very soft like toothpaste, but sometimes after being present for a long period of time, they do dry up and become chalk-like, sometimes even turning to bone.

What Is the Best Treatment for a Calcium Deposit?

When a calcium deposit becomes acutely inflamed, either because it ruptures and leaks calcium salts into the bursa, or because it pinches the bursa or rotator cuff, the symptoms can be quite severe. The acute inflammation can be treated with localized ice packs and rest in a sling, but oral anti-inflammatory medications are also helpful. A cortisone injection directly into the area of the calcium deposit may give relief within a few hours, when without it the acute severe pain may last for several days.

Do Calcium Deposits Need Removal?

If a patient has two or three recurrent episodes of painful symptoms in the shoulder, or if the calcium deposit appears on x-ray to be enlarging, then it may be appropriate to consider arthroscopic surgery to remove it.

What Is Involved in Arthroscopic Surgery to Remove Calcium?

The surgery is done in the outpatient department under a general anesthesia. There is no pain at all during the operation and afterwards a mild aching sensation is usually present for a few days until the skin puncture sites heal. If the calcium erodes a hole in the rotator cuff, then a decompression is necessary (removing a portion of the overhanging bone arthroscopically) and this will cause a little more discomfort for a few days.

Will Calcification Return Once It Is Removed?

It is incredibly rare for a calcification return in the same shoulder once it has been removed.

Can There Be Any Permanent Damage Caused by Calcification?

Yes. A long term calcification may cause pressure on the rotator cuff tendon which can damage portions of the tendon permanently.

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The AC (Acromioclavicular) Joint

What Is the AC Joint in the Shoulder?

The top of the wing bone or scapula is the acromion. The joint formed where the acromion connects to the collar bone or clavicle is the AC joint. Usually there is a protuberance or bump in this area, which can be quite large in some people normally. This joint, like most joints in the body, has a cartilage disk or meniscus inside and the ends of the bones are covered with cartilage. The joint is held together by a capsule, and the clavicle is held in the proper position by two heavy ligaments called coracoclavicular ligaments.

How Is the AC Joint Usually Injured?

The AC joint is injured most often when one falls directly on the point of the shoulder. The trauma will separate the acromion away from the clavicle, causing a sprain or a true AC joint dislocation. In a mild injury, the ligaments which support the AC joint are simply stretched (Grade I), but with more severe injury, the ligaments can partially tear (Grade II) or completely tear (Grade III). In the most severe injury, the end of the clavicle protrudes beneath the skin and is visible as a prominent bump.

How Is an AC Joint Separation Diagnosed?

Most often the clinical exam will demonstrate tenderness or bruising around the top of the shoulder near the AC joint, and the suspected diagnosis can be confirmed using an x-ray, which compares the injured side with the patient's other joint.

What Is the Proper Treatment for a Sprained AC Joint?

When a joint is first sprained, conservative treatment is certainly the best. Applying ice directly to the point of the shoulder is helpful to inhibit swelling and relieve pain. The arm can be supported with a sling which also relieves some of the weight from the shoulder. Gentle motion of the arm can be allowed to prevent stiffness, and exercise putty is very helpful to improve function of the elbow, wrist, and hand, but any attempts at vigorous shoulder mobilization early on will probably lead to more swelling and pain.

How Long Does It Take for a Shoulder Separation to Heal?

Depending on how severe the injury is, it may heal adequately in two to three weeks. In severe cases, the shoulder may not heal without surgery.

What Is the Proper Treatment for a Sprained AC Joint?

Usually surgery is reserved for those cases where there is residual pain or unacceptable deformity in the joint after several months of conservative treatment. The pain can occur with direct pressure on the joint, such as with straps from underwear or work clothing. Sometimes there will be catching, clicking, or pain with overhead activities, such as lifting, throwing, or reaching. Finally, in some people with very thin skin and very little muscular and soft tissue padding above their shoulders, the prominent clavicle after the separation may be considered unattractive, since the shoulder can appear to be unbalanced.

Are There Other Causes of AC Joint Pain and Disability?

Arthritis can occur as an isolated event in the AC joint, causing stiffness, aching, and sometimes swelling. Another condition called DCO, or distal clavicle osteolysis, gives a similar picture, usually in young people who lift heavy weights. This is called "Weightlifter's Shoulder."

What Type of Surgery Can Repair AC Joint Problems?

The simplest type of surgery for AC joint injury involves resection or removal of the end of the clavicle using arthroscopic (mini-surgical) techniques (called a Mumford procedure). If the joint becomes painful because of DCO (weightlifter's shoulder) or arthritis, or the separation is only minor, this technique can be very satisfactory. When the joint is severely displaced, then a more complex procedure is needed to restore the position of the clavicle. Usually this operation, called a Weaver-Dunn procedure, is done using a two-inch incision over the joint. The end of the clavicle is removed, and ligament is transferred from the underside of the acromion into the cut end of the clavicle to replace the ligaments torn during the dislocation. Soon an arthroscopic procedure should be available to restore the position of the joint, but at this point, only open surgery techniques are available.

What Is the Postoperative Treatment and Rehabilitation?

Postoperatively, treatment depends on the type of surgery performed. Usually, when the Mumford procedure is performed using arthroscopic techniques, the arm can be treated with a sling. Bathing is allowed in three days' time, and elbow, wrist, and hand exercises are begun immediately. Lifting is limited for three weeks, but following that, progressive exercise and motion activities proceed as the symptoms allow.

When a Weaver-Dunn procedure (rebuilding of the torn ligaments) is needed, approximately two or three weeks is added to the immobilization time before motion exercises are begun. This time allows the ligament to heal. Otherwise, the exercise program is the same as that for the Mumford procedure above.

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The Biceps Tendon

What Is the Biceps Tendon?

The biceps tendon is a long cord-like structure which is located in the front of the shoulder. It originates from the top of the shoulder socket (the glenoid) and exits the joint through a bony trough (the biceps groove). Below the shoulder, this tendon becomes the long head of the biceps muscle. The short head of the biceps is a continuation of the conjoined tendon which originates from a bony hook (the coracoid) at the front of the shoulder blade. Thus the biceps muscle, which functions to bend the elbow and rotate the forearm, has two anchor points in the shoulder region.

Who Get Biceps Tendon Injuries?

In general, these injuries occur more frequently as we become older. As we age, our tendons lose their elasticity and slowly become stiffer and more "brittle." The blood supply which nourishes the tendon also diminishes with age. The "degenerative" processes may be more pronounced in sedentary individuals, but may be lessened with proper and regular exercise. The well-conditioned individual, however, is not immune from biceps tendon injuries as over-training can also harm an otherwise healthy tendon.

How Do Biceps Tendon Injuries Occur?

As mentioned above, age, inactivity, or over-activity can weaken a tendon which may lead to injury due to the decreased ability to endure repetitive motions and sudden loads. Because of its location, from a direct blow to the front of the shoulder, some individuals develop bone spurs in their biceps grooves or under the top of their shoulder blades (the acromion) which can lead to wear and tear of their tendons. A less frequent injury is a dislocation of the biceps tendon from its groove. This is usually seen in combination with a tear of the subscapularis tendon or the rotator cuff tendon which normally help hold the biceps tendon in it groove. The biceps tendon can also be injured at its attachment site on top of the glenoid. This usually involves an avulsion, where the tendon is pulled off the bone and rendered unstable.

What Happens to the Tendon When It Is Injured?

If the tendon or its sheath (which encases the tendon) is irritated, it becomes inflamed, resulting in pain and swelling. This condition is called "tendinitis." Mild injuries can also result in microscopic tearing of individual tendon fibers. As the severity of an injury increases, larger tears can occur to the point where the tendon is partially torn or even completely ruptured. If a rupture occurs, the long head will usually fall distally toward the elbow. Biceps muscle function usually remains nearly normal because of its dual attachment proximally.

How Are Biceps Tendon Injuries Treated?

Initially, rest, ice, and gentle anti-inflammatory medications are all that is usually needed. Sometimes an injection with a strong anti-inflammatory medication such as cortisone is needed to control the pain and swelling. Severe cases which fail to improve may require surgical treatment.

What Does Surgery Involve?

Surgical treatment depends on the nature and extent of damage to the tendon. If only a small portion of the tendon is damaged, a simple arthroscopic shaving (debridement) of the torn fibers may be all that is needed. If a significant portion is involved, a biceps tenodesis may need to be performed. This is done by arthroscopically removing the torn tendon stump from inside the shoulder joint and then, through a small skin incision, attaching the remaining tendon to the bone in the upper arm (humerus). If the biceps tendon is completely ruptured, causing the muscle to bulge in the upper arm, a tenodesis can be done only if the distal portion remains near the top of the shoulder. A tenodesis is not done if the tendon slides too far distally because doing so would require unacceptably large incisions. If the tendon has been partially avulsed from its origin on the top of the glenoid (SLAP lesion) it can be arthroscopically reattached using miniature screws and sutures.

What Is the Usual Course After Surgery?

A simple sling is all that is needed for the first few weeks after surgery. Immediate use of the hand is encouraged, but only for very light objects. Four to six weeks of healing is required before a gradual return to moderate or heavy lifting. Desk work and light-duty can usually be resumed within the first week or two. Return to heavy labor usually takes 2 to 4 months.

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Elbow

The elbow is a hinge joint made up of the humerus, ulna and radius.

The unique positioning and interaction of the bones in the joint allows for a small amount of rotation as well as hinge action. This rotation is easily noticed during activities such as hand-to-mouth eating motions.

The primary stability of the elbow is provided by the ulnar collateral ligament, on the medial (inner) side of the elbow. However, one of the most common injuries to the elbow occurs on the lateral, or outer, side of the elbow -- it is called Lateral Epicondylitis, or Tennis Elbow.

What is Tennis Elbow (Lateral Epicondylitis)?

Tennis elbow, or lateral epicondylitis, is one of the most common elbow problems seen by an orthopedic surgeon.

It is actually a tendinitis of the muscle called the extensor carpi radialis brevis which attaches to the lateral epicondyle of the humerus. It may be caused by a sudden injury or by repetitive use of the arm.

Many doctors feel that micro tears in the tendon lead to a hyper-vascular phenomenon resulting in pain. The pain is usually worse with strong gripping with the elbow in an extended position, as in a tennis back hand stroke, but this problem can occur in golf and other sports as well as with repetitive use of tools.

Before surgery is considered a trial of at least six months of conservative treatment is indicated and may consist of a properly placed forearm brace and modification of elbow activities, anti-inflammatory medication and physical therapy. If the above treatment is not helpful, a cortisone injection can be beneficial but no more than three injections are recommended in any one location in a year.

Conservative treatment is in two phases and after Phase I (Pain relief) has been successful, Phase II (Prevention of recurrence) is equally as important and involves stretching and then later strengthening exercises, so the micro tears will not occur in the future.

When conservative treatment has failed, then surgery is indicated. Many procedures have been described. Procedures as simple as percutaneous release of the tendon off of the bone have been described and more recently arthroscopic procedures or other procedures involving the joint and resection of a ligament as well have been described.

The most popular procedure today is a simple excision of diseased tissue from within the tendon, shaving down the bone and re-attachment of the tendon. This can be performed as an outpatient procedure with regional anesthesia (where only the arm goes to sleep) and through a relatively small incision of approximately 3” long. 85-90% of patients with this technique are typically able to perform full activities without pain after a recuperation of two to three months. Approximately 10-12% of patients have improvement but with some pain during aggressive activities and only 2-3% of patients have no improvement.

What is Golfer's Elbow (Medial Epicondylitis)?

Medial epicondylitis is inflammation of the tendon attachment of the flexor pronator muscles in the forearm. Usually this begins as microscopic tears in the tissue which leads to an inflammatory or hypervascular process. This occurs when stiff, underused tendons are suddenly overused or this may occur from an acute injury. The treatment includes three treatment options, no treatment, conservative and surgery.

Surgery is a last resort and involves cleaning up the tendon from diseased tissue, shaving down the bone and re-attachment of the tendon. This is necessary in 10-15% of the patients. Conservative treatment is in two phases, Phase I is to get rid of the pain and Phase II is to prevent it from coming back with stretching and strengthening exercises. To reduce the pain, using the elbow in a flexed position and the use of an elbow strap counterforce brace is usually the first line of treatment. If the patient has persistent symptoms a cortisone injection may be considered. No more than three injections are recommended per year and if the patient still has persistent symptoms despite conservative treatment, surgery is considered.

What is Cubital Tunnel Syndrome?

Cubital tunnel syndrome is a pinched nerve at the elbow commonly known as the "funny bone". This might be caused by trauma or repetitive use of the elbow and may be caused by continuous use of the elbow in a flexed position. This causes the nerve to become stretched and irritated as opposed to when the arm is extended and the nerve is in a relaxed position. The diagnosis can be confirmed with electrodiagnostic testing including nerve conduction velocity and the electromyogram. Nerve conduction velocity studies, the speed of the nerve across the elbow, will be slowed when there is nerve compression and electromyogram studies, the innervation of the muscles, might be affected by the pinched nerve.

For this problem there are three modes of treatment; no treatment, conservative, and surgical. Unfortunately with conservative treatment, only splinting with the arm in an extended position has been found to be helpful. Night time splinting is achieved with a custom made long arm splint that the patient will wear at night time and as often as possible during the day. Unfortunately it is cumbersome to keep the arm out straight all the time and therefore this is usually used only at night.

If the patient has persistent complaints despite conservative treatment surgery would be recommended. There are three types of procedures, one is to cut the medial epicondyle which is the bone pinching the nerve or the other two operations are to actually move the nerve out of the cubital tunnel either above or below the muscles of the forearm. This can be performed as an outpatient procedure with an axillary block where only the arm is put to sleep and it has a high success rate.

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Hand & Wrist

The hand is composed of many small bones called carpals, metacarpals and phalanges. The two bones of the lower arm -- the radius and the ulna -- meet at the hand to form the wrist.

The Median and Ulnar nerves are the major nerves of the hand, running the length of the arm to transmit electrical impulses to and from the brain to create movement and sensation.

What is Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome (CTS) is a compression neuropathy, i.e. a pinching of the median nerve within the wrist. The carpal tunnel is a bony canal within the palm side aspect of the wrist that allows for the passage of the median nerve to the hand.

Pinching or compression of this nerve by the transverse carpal ligament sets into motion a progressively crippling disorder which eventually results in wrist pain, numbness and tingling in the hand, pain consisting of a “pins and needles” feeling at night, weakness in grip and a feeling of incoordination.

Who Gets CTS?

This disabling syndrome occurs more often in women than men, by a ratio of 3 to 1, usually between the ages of 30 and 50 years. Also, CTS is seen more frequently in people who tend to do forceful repetitive types of work, such as grocery store checkers, assembly line workers, meat packers, typist, accountants, writers, etc. Most patients generally visit their doctor with these complaints, and the diagnosis is confirmed after physical examination and appropriate nerve testing.

How is CTS Treated?

Treatment for CTS depends upon the stage of the disease. In the early stage, the syndrome can be reversible and is most often treated with appropriate modification in activities, a removable wrist brace, and anti-inflammatory medicines. In moderate stages of the disorder, especially if the numbness and pain continues in the wrist and hand, a cortisone injection into the carpal tunnel can be extremely beneficial. Surgical intervention in CTS is only indicated in those patients in whom non-operative treatment has failed to eliminate their symptoms. In patients with advanced disease, and especially in those who have profound weakness or muscle atrophy, surgical intervention should be done early. CTS should not be left untreated because it can eventually cause permanent nerve damage.

What is Triangular Fibrocartilage Complex?

This is a cartilage similar to the cartilage in the knee that is often torn and does not have an adequate blood supply to it. The reason it is causing discomfort is usually there is a flap of tissue that is flapping back and forth and causes irritation of the joint.

For this problem there are three modes of treatment; no treatment, conservative, and surgical.

Conservative treatment would consist of resting the wrist in a wrist brace or a cortisone injection. Usually anti-inflammatory medications and physical therapy is not beneficial.

If there is persistent pain despite conservative treatment, arthroscopic surgery with debridement of the tear to give the tear smooth edges is usually very successful. This can be performed under local anesthesia on an outpatient basis with two or three small incisions on the wrist. Occasionally, the cartilage can be repaired.

What is Thumb (CMC Joint) Arthritis?

This is the most common location for arthritis in the hand is due to wear and tear with use of the thumb throughout the patient's years.

There is no cure for arthritis but there is treatment falling into three categories; no treatment, conservative, and surgery.

Surgery -- as the last resort, when conservative treatment has failed -- consists of a joint replacement using the patient's normal body tissues and involves excising the arthritic bone and replacing it with a tendon taken from the wrist which is rolled up into a ball and used as a spacer and a portion of it is used to reconstruct the ligament. This is done through a small incision at the base of the thumb and a smaller incision at the base of the wrist to harvest the tendon used for the graft. It is an outpatient procedure performed under axillary block where only the arm goes to sleep. The patient is immobilized in a splint for two weeks, then a thumb spica cast for two weeks and then uses a removable custom made splint for two months while they are undergoing therapy for their thumb.

The first month is to regain range of motion and the second month to regain strength. This concludes a three month postoperative rehabilitation protocol. Patients have a very good success rate with this surgery.

Before surgery is considered, conservative treatment is attempted which is aimed at alleviating the symptoms of arthritis. This consists of use of a splint, possible anti-inflammatory medications, possible icing, and occasionally a cortisone injection which usually give good but temporary relief.

What is Dupuytren's Disease?

Dupuytren's disease is a genetically inherited disorder which primarily involves the palmar aponeourosis and its digital prolongations.

The primary pathological change is in the fascial tissues of the palm which results in thickening, cord-like formation of contractile bands, and then eventual contractures at the level of the interphalangeal joints. On occasion, it can be associated with other diseases such as diabetes, epilepsy, or alcoholism.

Certain contributing factors increase the likelihood of significant progression. These include a strong family history, early onset of disease, rather extensive bilateral involvement, and the presence of disease in other areas such as the plantar regions of the feet. These contributing factors may lead to a more aggressive course of the disease and possibly even an operation at an earlier age.

The disease is seen much more frequently in men than in women and has a tendency to usually appear between the ages of 40 and 60.

Dupuytren's disease has over a 65% chance of being bilateral, and can involve other areas such as the foot, the dorsum of the hand, and other fibrous tissues. It is a slowly progressive disorder which may have periods of temporary arrest, or even a rapid progression. After the nodules have formed, the tendency is for these to coalesce into a cord, which will lead to a flexion contracture at the MCP joints and the PIP joints. The skin itself can be infiltrated by the disease.

Initial treatment is always non-surgical. This would consist of continued observation for progression of the problem. As the disease does not involve any pain, there is no reason for the excision of the nodules or cords until contractures in digits have occurred. If a contracture becomes bothersome or a nodule becomes painful, or if the contracture in the MCPJ exceeds 30 degrees or any involvement at the PIP joint occurs, we would recommend surgical excision. This would consist of a palmar and digital fasciectomy utilizing an axillary block anesthetic. A skin graft taken from the forearm is almost always used. Long term results are usually quite good. If contractures have developed at the MCPJ and PIP joint, they can usually be corrected to within half of the preoperative level. Recurrence of the disease is possible, but this is usually not associated with further contracture necessitating surgery.

What is De Quervain's Disease?

The problem is a swelling of the tendon sheath around the tendons passing along the distal radial aspect of the wrist. This sheath runs through a tight tunnel holding the tendon down to bone and this swollen sheath passing through a tight tunnel results in significant pain. For this problem there are three modes of treatment, not treatment, conservative treatment and surgery.

As a last resort, when conservative treatment has failed, surgical decompression of the tendon by opening up the pulley can be performed as an outpatient procedure under local anesthesia with a small incision. This has a good success rate.

Conservative treatment consists of modification of activities, use of a thumb brace and occasional icing and then possible use of anti-inflammatory medications. If the pain still persists despite the above treatment a cortisone injection can be helpful. No more than three cortisone injections are recommended per year in any one location.

What is Volar Plate Avulsion Injury?

This is a hyperextension injury which is essentially a ligamentous injury although it may involve a portion of bone avulsed off by a ligament. It usually involves a piece of bone avulsed off the base of the middle phalanx by the volar plate which is usually not significantly displaced and usually will heal without problem. It also usually involves a collateral ligament tear which heals without problem but often heals with abundant scar tissue leading to an appearance of chronic swelling on one side of the joint, which is permanent.

No more than a few days of immobilization is necessary and is important to work on obtaining full range of motion of the joint. The middle joint of the fingers is the worst with regards to stiffness and early range of motion is very important. Range of motion exercises may be explained to the patient or therapy with a hand therapist may be necessary.

"Buddy taping" of the fingers after the initial few days of immobilization is all that is necessary for finger support. At first, "buddy taping" will be necessary all the time, gradually progressing to "buddy taping" only with exertive or sporting activities with effected hand.

If motion is begun early, full range of motion can be expected. For those who have been immobilized longer, permanent stiffness may result. Rarely, with severe stiffness, surgical release of the scarred tendons and joint capsule may be necessary, also rarely, instability may result which may require reconstructive surgery. Most patients do extremely well, being able to progress to painless activity with full function, with minimal abnormal appearance.

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