Patient Education

Boutonniere Deformity

Richard A. Bernstein, M.D.

boutonniere-deformity.pngA boutonniere deformity is a complex imbalance between the flexor and extensor mechanisms of the finger. As you can see from the photo above, the middle joint of the finger is flexed too much (PIP hyperflexion) and the distal joint is slightly extended beyond neutral (DIP hyperextension).

The problem with Boutonniere deformities is that most patients neglect them as a "sprained finger". The specific difference between a sprain and a Boutonniere injury is the latter is associated with a rupture of the tendon that extends the middle, PIP joint.

With the tendon rupture the first thing to happen is that you cannot actively extend the finger. One of the classic findings is the ability to passively extend the joint, but a loss of active extension. Furthermore you can find tenderness over the back of the joint.

boutonniere-deformity-diagram.pngOn the positive side, surgery is usually not needed in most cases. On the other side, the treatment is full time splinting of the joint keeping the finger completely straight at the PIP joint but encouraging flexion of the tip joint. This helps mobilize the tendon to facilitate healing.

The splint needs to be worn 24/7 often for approximately 6 weeks. Our goal is a full restoration of motion, but honestly most patients do lose a permanent motion of the finger. By participating in the splinting and formal therapy program, we can usually minimize the functional loss.

Copyright © 2010, TOG
All rights reserved. Revised 12-9-10

Carpal Tunnel Syndrome

Richard A. Bernstein, MD

Carpal tunnel syndrome is an extremely common disorder affecting the hand, present in approximately 1 in 100 people. It is a condition characterized by numbness and tingling in the fingers. Pain can extend to the elbow, shoulder or neck and can occur any time, either in the day or night. People oftentimes complain of awakening from their sleep and oftentimes shake their hands to try to restore sensibility. Symptoms often occur during the day when one talks on the telephone, holds a book or newspaper. Many people awaken in the morning with their hands numb and tingling and it will take some time before the symptoms diminish.

What Is Carpal Tunnel Syndrome?

To understand carpal tunnel syndrome, one needs to learn about the basic structures occurring at the wrist and hand level. The basic supporting structures are the bones of the wrist, which include the forearm bones, the wrist bones, medically known as the carpal bones, and the bones of the hand. The flexor tendons are the structures that extend from the muscles to the fingers like the strings of a marionette. They allow us to perform the multiple activities during the day. There are three main nerves to the hand to control the muscles and tendons known as motor nerves and it gives us the ability to feel, which the sensory nerves are. The nerve involved with carpal tunnel is known as the median nerve which generally gives sensation of the thumb, index, long and ring fingers. There is also a small branch of the nerve that goes the muscles base of the thumb.

The median nerve involved with carpal tunnel syndrome runs with the tendons in the area appropriately called the carpal tunnel. The bones of the wrist cover this tunnel on three sides and on the palm side, there is a thick ligament called the transverse carpal ligament that forms the roof of the tunnel. It is within this tunnel that pressure builds up that can cause the classic symptoms of numbness and tingling.

Causes of of Carpal Tunnel Syndrome

Idiopathic: Many cases of carpal tunnel have no known cause and are thought to be anatomic abnormalities that make an individual at risk.

Overuse: There is some information to suggest that overuse of the fingers or wrist or certain positions, for extended periods of time, can contribute to pressure on the nerve.

Injuries: An injury to the wrist involving bleeding, such as with a fracture, can cause increased pressure within the tunnel leading to symptoms either early or late in the course after a fracture or dislocation.

Medical Conditions: Pregnancy, diabetes and thyroid problems are all known causes of carpal tunnel syndrome.

Understanding Carpal Tunnel Syndrome

In many cases the long-term consequences of numbness and tingling can be prevented through simple modifications. Altering the way one does certain activities, whether be at work, home or at recreation, can significantly improve and sometimes eliminate the symptoms of numbness and tingling.

Medical Interventions

Oftentimes wearing a proper splint, time or over the counter medications can significantly help.

Prescription medication known as anti-inflammatories can oftentimes help relieve the swelling. An injection of Cortisone can be helpful either temporarily or permanently to improve and eliminate the symptoms associated with this condition. Sometimes, physical therapy can be helpful.

Scientific studies have not today shown any predictable benefit from vitamins, though there have been anecdotal reports that vitamin B6 is helpful, though studies are not conclusive.

How to Diagnose Carpal Tunnel Syndrome

An early, thorough approach is very beneficial to diagnose, treat and prevent ongoing symptoms of carpal tunnel syndrome; one is history. It is very important to obtain a thorough history of other medical conditions, injuries and the characteristics of the condition. It is helpful to write down certain information that you can pass on to the doctor at the time of the examination.

Physical Examination

A thorough examination of the area is very helpful to either rule in or rule out the diagnosis. Most patients do not have textbook-like symptoms and it is important for you and me to look at the characteristics and the physical examination findings.

Three commonly used maneuvers are a Tinel's test, tap over the nerve,
the second is the Phalen's maneuver, which is performed by flexing the wrist and seeing if this causes characteristic numbness, and the third is termed a forearm compression test where wrist pressure is placed over the nerve to determine the distribution of tingling.

 Wide awake surgery video


Copyright © 2010, TOG All rights reserved.
Revised 12/17/10
Updated 12/3/2015

Choosing a Hand Surgeon

Choosing the right doctor is a very important and, at times, a complex problem. There is no one right way to choose a doctor, but here are some things you should consider.

Academic qualifications

The first thing to consider is the doctor's academic qualifications: is he or she board certified in hand surgery? The highest certification that a doctor can have in hand surgery is called the Certificate of Added Qualifications in Hand Surgery. Most hand surgeons who have such a certification will list it in their yellow pages add; if not, call the office and ask. Do not be afraid to ask questions when you are choosing a doctor: it is your hand, after all! If the office does not want to answer questions about the doctor's qualifications, you do not want to go to that doctor. Dr. Bernstein has such a certification.

Practice type

Does the doctor do only hand surgery, or is hand surgery something they only do occasionally or in addition to other types of surgery? You can usually find this out by asking the office receptionist. Another good way to find out how important hand surgery is to the doctor is to look at their yellow pages ad: if they have a small ad in hand surgery, but a very large ad in another specialty, such as plastic surgery, you can probably guess which area of medicine is more important to them.

Dr. Bernstein limits his practice to only hand and upper extremity surgery, and he does this full-time. This is documented on the website,, as well as on his stationery and his business card. His ad only appears under hand surgery (actually, the yellow pages has "Hand Surgery" under "Surgery, Hand") and orthopedics (his original board certification); both specify that he limits his practice to hand surgery. He does not do general orthopedics, plastic surgery, or general surgery.

Is the doctor in your insurance plan?

You probably want to stay within your insurance plan, since it will be more expensive to see a doctor outside of your plan. However, depending on how serious your problem is, or how important your hand is to your work or recreation, you may consider seeing someone outside your plan, at least for an initial consultation.

Dr. Bernstein participates in a variety of health plans. If your insurance plan is not accepted, call our billing office to get an estimate of how much it might cost to go out of your plan.

Does the doctor within your plan have any financial incentives to limit your treatment?

Many patients don't realize that many plans pay financial incentives to their participating doctors to limit the treatment that they offer to their patients, such as restricting referrals only to same-plan doctors. This is the "managed" part of "managed care." There are other, more subtle ways that managed care may affect your hand problem. Dr. Bernstein does not participate in any plans that pay financial incentives to limit patient care.

How long will you have to wait in the doctor's office?

An interesting and insightful question when you are selecting a doctor is to ask the receptionist what the average wait is for the doctor. If they don't know, it means that they haven't studied this part of their practice and you might wonder if they consider your time important. If they say the average wait is an hour or more, you know that they don't respect their patients or consider their time important.

We think that your time is just as important as ours. We have kept track of the time patients wait in our office for several years, and the average time is less than 15 minutes.

How long will you have to wait to get an appointment?

Many patients are finding that they cannot get a timely appointment, even for an urgent matter such as a fracture.

Our office policy is that any patient with a new fracture will be seen in the office the next day we are in, whether or not there is an appointment opening. Obviously, emergencies cannot be scheduled or be put off until it conveniently fits into the doctor's schedule, and we hope our other patients understand the emergent nature of our work and minimize the wait unless it was absolutely necessary.

We hope that these suggestions will help you in deciding if you would like to make an appointment with our office.

CMC Arthritis/ Basal Joint Arthritis

Richard A. Bernstein, MD


Patients with osteoarthritis of the hand (photo at left from David Nelson, M.D. and at right from Atlas of Rheumatology)

Osteoarthritis is a disease affecting the joints. It is very treatable. It is rarely deforming or crippling, although it can be painful if not treated. Osteoarthritis is very common and affects almost everybody as they get older. The older you get, the more likely you are to have it, and around eight out of ten people over the age of 50 are affected. In the hand, it typically affects the base of the thumb first (see the image above and the x-ray at right), then the finger joints. Women are affected more than men.


Osteoarthritis can be thought of as "wear and tear" arthritis. It is not the same as rheumatoid arthritis, which is an autoimmune disease that is very deforming and can be crippling. Osteoarthritis does not deform the hands in the way that rheumatoid arthritis does. What are the symptoms of osteoarthritis?

The hallmarks of osteoarthritis are joint stiffness, swelling, and pain. This often improves with light activity, but is usually worse again after forceful gripping or pinching, or after a period of rest.

Who gets osteoarthritis?

Many people think osteoarthritis should come from a long history of hard work, but hard labor does not seem to be very related. Osteoarthritis can be due to trauma such as an old fracture, but it is usually just due to the effects of aging coupled with some hereditary contribution.

How is osteoarthritis diagnosed?

The diagnosis is made by listening to the patient and by examining the patient. Most patients will have a history of slowing increasing pain, stiffness, and swelling over a period of years. Sometimes there is a fairly sudden onset of symptoms, usually associated with a single episode of trauma (typically a fall) or a period of overuse (weeding the garden, say, or packing to move). An x-ray examination confirms the diagnosis. Often there will be no correlation between the amount of pain and the severity of the arthritis as shown by the x-ray.

What does the x-ray show?

The x-ray typically shows some joint space narrowing, that is, the white shape of the bones are closer together than they normally are (see the x-ray above). The bone along the joint is usually whiter (called "sclerosis") and may have little points of bone growing out (called "osteophytes"). There may be holes in the bone (called "cysts") and the bones may be starting to slide out of alignment (called "subluxation"). I will review your x-rays with you and explain exactly what I see.


How is osteoarthritis treated?

My treatment includes:

· Diagnosis

· Patient education 
Activity modification


Hand therapy 
Anti-inflammatory medication 
Steroid injection 

Patient Education

I believe that the key part of treating osteoarthritis is patient education. Once you understand what is going on, you can take charge of managing the condition. Osteoarthritis cannot be made to go away; getting younger is the only thing that will do that (we are working on it!). Osteoarthritis is not "cured", but managed, and most patients with osteoarthritis doing well and did not require surgical treatment.

For arthritis of the base of the thumb, known as basal joint arthritis or carpometacarpal (CMC) arthritis is very common. It is thought to affect approximately 75% of people in their lifetime, and women are 6 times more common than men to become symptomatic in this area. The basal joint of the thumb serves as the pillar to support the thumb. Because of the importance of the thumb in pinch and prehension (grasp), it can become symptomatic and painful with gripping and use. Fortunately, studies have shown that approximately 75% of people can improve with nonoperative measures.

Activity Modification

The next step after patient education is activity modification. Learn what activities exacerbate your pain, and see if you can avoid them. For instance, opening tight jar lids puts a great strain on your thumb base joint. Get a plastic sheet from me when you see me, or ask someone else to open jars. If you have faucets that are leaky or stiff, replace the gasket or grease the threads. Look at the activities throughout your day and identify which ones cause you pain.

Along with activity modification, there are a number of patient-directed therapies which can help. Pain can be relieved by applying heat to stiff and painful joints for 20 minutes up to three times a day.


The first medication that you should try is acetaminophen (Tylenol). It will not upset your stomach and will help to offset the pain of minor arthritis. Most patients have tried this long before they have seen their doctor, and still need something more, so I will not dwell on this.

The next class of medications that should be tried are called non-steroidal antiinflammatory drugs, or NSAID's.

These can very useful. These drugs block the enzyme (cyclo-oxygenase) that creates the pain but You should check with your primary care physician to make sure that these medications are safe for you.

Steroid Injections

Steroid injections can be very helpful to calm down a very painful joint. These are not the systemic steroids that cause road rage, osteonecrosis, and all the other bad things you have heard about steroids. These are highly localized treatments of steroids, which are a class of substances that your own body makes to calm down unwanted or excessive inflammation. I am allergic to pain, and presume that you are, too. There are debate amongst hand surgeons regarding the usefulness of steroid injections for the thumb. Once study compared cortisone to placebo, interestingly, both groups of patients had improvement of the pain but there is not statistically significant difference in both groups. In my personal experience, I have seen many patients improve with a cortisone injection and that is something that we can discuss in the office.


Surgery is reserved for last. It is for patients whose osteoarthritis is so bad that they cannot manage their disease with activity modification, antiinflammatory medication, and steroid injections. Indications for surgery generally involve patients who are so uncomfortable with their arthritis that they cannot do the things in life that they want to do. Life is too short to give up all the things you like to do. If you have tried all of the above steps, and still have more pain and more limitations than you want to live with, talk to me about surgery.

When surgery is needed, there are two procedures that I offer. The first procedure goes by the abbreviation LRTI, that stands for ligament reconstruction tendon interposition arthroplasty. The procedure was invented and popularized in the 1970s, has stood the test of time and is still utilized by most hand surgeons. The procedure involves removing the arthritic portion of the joint and reconstruction using a slip of a tendon from the forearm. Scientific studies have shown that there is not any statistically significant loss of strength to the wrist by harvesting the tendon, and the procedure has worked very, very well in long term studies. The second option is prosthetic arthroplasty. Artificial hips and artificial knees have worked well for decades. A prosthetic replacement of the thumb joint has been difficult to create. However a colleague of mine in 2014 released a cobalt chrome prosthetic joint replacement for the base of the thumb. The results are early, but seem to obtain better strength long-term compared to the LR TI procedure, however at this point we only have a few years of results on this implant and long term studies are pending.

Copyright © 2010, TOG All rights reserved.
Revised 5/17

Cortisone Injections

A steroid injection can be recommended for your condition. Steroid injections are generally a safe, reliable method of decreasing the inflammation and pain of an affected area. Steroid or Cortisone is a powerful anti-inflammatory drug similar to natural substance produced by your body. When injected into the affected area, irritation and inflammation can be reduced and healing promoted both short, bur more importantly, long term. A misconception is that the injection is simply for temporary pain relief; our goal is long term relief and combined with the other recommendations, will hopefully cure the condition.

A steroid preparation is mixed with a short and sometimes long-acting local Novocain-type anesthetic (Marcaine), which may bring immediate relief to your symptoms and last 6-8 hours. Cortisone itself takes 7-10 days to have its full effect. Therefore, it may take time before your symptoms start to respond.

There is a great difference between injected Cortisone and taking Cortisone by mouth as a pill. Local injections of Cortisone, in general, do not have any side effects on the body, staying locally in the area injected.

Diabetics may see a transient rise in their blood sugar; therefore if you have diabetes, monitor your blood sugars and if it changes, please let us or your diabetes doctor know.

Side effects are rare. One third of patients get discomfort the night of the injection that usually subsides by the next day. Some people can get thinning of the skin or change of pigmentation, these occur in less than 5% of our patients. You can only have a certain number of cortisone injections; generally no more than three in one area over your lifetime. Infections are extremely rare after an injection; even though the area will be prepared sterilely it can occur; if there is any concern please contact our office.

Crushed Finger

Richard A. Bernstein, MD

The fingertip is a highly specialized structure, with many specialized features. It has a lot of nerves, as I am sure you are more aware of than you would like! The illustration below shows many of the important structures of the fingertip.


The fingernail itself, the thing that you cut with a fingernail clipper, is called the nail plate. Underneath the nail plate is the nail bed, the mostly pink tissue you can see under the nail. It has several regions. The proximal (this is a medical term that is good to understand, it means that part closer to the heart; the opposite direction is called distal) part of the nail plate is called the germinal matrix. This is the part of the nail bed that originates the nail plate.

When you look at your fingertip, part of the germinal matrix can be seen through the nail plate: it is the white moon-shaped area. The name for this is the lunula. That is, the lunula is the visible part of the germinal matrix. The majority of the germinal matrix is not visible, and it is located under the proximal nail fold, or eponychium. The cells of the dorsal roof in the eponychium are responsible for placing the shine on your nail plate.

The hyponychium is a specialized structure under the nail plate at the distal end. Its purpose is to help prevent dirt and bacteria from entering under the nail into the nail bed. It is backed by specialized capillaries (small arteries) and lymphatics that also help to prevent the invasion of bacteria or fungus under the nail plate.

The fingertip is also an organ of temperature regulation: if you are hot, special valves open up to allow increase blood flow to your fingertips. If you are cold, these valves shut off (this explains why your fingertips get so cold in cold weather!) The fingertip is a very specialized structure!

Fingertip Crush Injuries

There are many kinds of fingertip injuries, from crushed fingertips (hit with a hammer, smashed in the car door, and other things that are just too painful to think about!) to cuts all the way to various levels of amputation. This page will The nail bed can bleed, which creates a collection of blood (called a hematoma) under the nail plate. This is called a subungual hematoma. They can be very painful, and sometimes need to be drained. This usually dramatically decreases the pain of a fingertip injury. Fractures of the fingertip, usually of the type called a tuft fracture, usually heal well if given a chance to rest. A splint and rest is all that is needed.

If the nail's germinal matrix is crushed or otherwise injured, the nail plate may separate from the germinal matrix. This is usually not a problem. What will happen is a new nail plate will form, and it will eventually push off the old nail plate. You don't need to do anything, just protect the old nail plate from ripping off (it even sounds painful!) by covering it with a band aid. Trim off whatever you can trim easily, so there will be less to catch. Give it time. It usually takes about three months for the new nail to come in completely.

A crushed fingertip will always be swollen and painful. Keep your hand elevated and take both an anti-inflammatory (such as aspirin or Motrin, if you can take such medication) and Tylenol. These work in different ways and it is a case of 1 + 1 = 3. Ice will be very helpful for the first day or three. Be sure to take both an anti-inflammatory and Tylenol.

The fingertip will usually stay a little bit swollen permanently, but it should not interfere with function. It will take longer than you think is reasonable, about six to twelve months, for the swelling to go down as much as it will.

Keep your dressing dry. Moisture will promote a bacterial infection. Use a plastic bag when you shower. If you get it wet, you will need to change the dressing.

If there is a fracture, most but not all times, it will heal. Occasionally tissue known as fibrous tissue will bridge the gap, especially with breaks towards the very tip of the finger. Usually this is not a problem since the fibrous tissue should provide enough stability to the finger. Over years, sometimes this fibrous tissue will turn to bone.

I hope that this information helps you understand and take care of your fingertip crush, and supplements the explanation I gave you in the office.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10/ updated 1/28/16


DeQuervain’s Tendinitis

Richard A. Bernstein, MD


DeQuervain’s tendinitis is a condition brought on by irritation or swelling of the tendons found along the thumb side of the wrist (Figure 1). The irritation causes the compartment (lining) around the tendon to swell, changing the shape of the compartment; this makes it difficult for the tendons to move as they should. The swelling can cause pain and tenderness along the thumb side of the wrist, usually noticed when forming a fist, grasping or gripping things, or turning the wrist. The pain is usually described by patients as a very sharp, stabbing pain. It is not subtle.

What Causes It?

The cause of DeQuervain’s tendinitis is an irritation of the tendons at the base of the thumb. For example, awkward hand positions required by a new mother in caring for an infant are a common cause of this condition.

In addition, many patients with DeQuervain’s have more than the normal number of tendons in this compartment. The figures below are cross-sections of the forearm at the level of the base of the thumb. The figure on the left is the normal situation. The green line represents the ligament that helps to hold the two thumb tendons (shown in brown) down to the radius (the main bone of the forearm).  There are usually two tendons. In patients with DeQuervain’s (figure on the right), it is not uncommon to find more than two tendons. If there are more than two tendons, it is common for there to be a septum (Latin for "wall") between some of the tendons (shown as a thin vertical green line in the figure on the right). It is thought that the patients who develop DeQuervain’s have a combination of unusual anatomy plus unusual repetitive use of the thumb, but this is not proven.


Signs and Symptoms

DeQuervains-Tendinitis-Figure-3.jpgPain over the thumb side of the wrist is the main symptom. The pain may appear either gradually or suddenly. It is felt in the wrist and can travel up the forearm. The pain is usually worse with use of the hand and thumb, especially when extending the thumb (the "hitch-hikers" position). Swelling over the thumb side of the wrist is noticed and may be accompanied by a fluid-filled cyst in this region.

There may be an occasional catching, grating, or snapping when moving the thumb. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger, although this is rare.


A Finkelstein's Test is generally performed. In this test, the patient makes a fist with the fingers over the thumb (i.e., the thumb is in the palm, under the fingers). The wrist is then bent in the direction of the little finger (Figure 2). This test can be quite painful for the person with DeQuervain’s tendinitis. Tenderness directly over the tendons on the thumb-side of the wrist is the most common finding.


DeQuervains-Tendinitis-Figure-4.jpgThe goal is to relieve the pain caused by the irritation and swelling. The condition can be treated by a splint, but it is not very effective, it works only because you cannot use your thumb (and who can afford to give up the use of their thumb?), and usually returns as soon as the splint is discontinued. One of the most effective treatments is a cortisone injection. This injection is usually effective in about 90% of cases.

When symptoms are severe or do not improve, I may recommend surgery. The surgery opens the compartment (covering) to make more room for the irritated tendons (Figure 3). It is done on an out-patient basis. Patients can usually use the hand lightly right after surgery and most patients have normal use within about a month.

Copyright © 2010, TOG All rights reserved.
Revised 12/17/10

Diabetes and Hand Pain

Richard A. Bernstein, MD

The effect of diabetes goes beyond problems with blood sugar: diabetes may also be affecting your hands. There are four hand problems that occur in patients with diabetes, many of which can be easily addressed and treated.

Carpal tunnel syndrome is not only a problem in assembly workers or people who spend their days on computers. Diabetes also puts you at risk for developing this problem. Carpal tunnel syndrome involves pressure on one of the three major nerves coming down to the arm, specifically to the thumb, index, and long fingers. Numbness and tingling are common symptoms as well as pain that oftentimes awakens people from sleep. Many people develop symptoms while driving a car or reading a book or newspaper. Some- times it is simply numbness, other times pain can develop with an aching sensation. People will commonly try to shake their hands to restore sensation. Splints and therapy can help diminish the symptoms of carpal tunnel compression and despite what people hear, surgery is often not needed for this condition.

There have been some reports of good success with the so-called cold laser. Th is ultrasound-like wand has been used in Europe and one study was done at a large car assembly plant showing that it can help diminish the pain and discomfort of carpal tunnel.

Second, pain, clicking and the sense of locking of one’s finger is medically known as a trigger finger. This condition is also more common in patients with diabetes and sometimes will cause a painful locking of the finger, especially when getting up in the morning.

Rather than locking, some people develop a less severe example of trigger finger pain. Tendonitis, is an inflammation of the tendons. It usually affects the tendons which allow us to bend our fingers. Similar to carpal tunnel syndrome, splints, medication, therapy, and sometimes a Cortisone injection can eliminate this. Ninety percent of patients with a trigger finger can be cured without surgery.

A third condition that can get confused with a trigger finger is a process called Dupuytren’s contracture, which is a benign non-cancerous condition, initially described by a French surgeon. It begins with thickening of the skin in the palm, usually along the ring finger. When it progesses, the finger bends down and it cannot be straightened out. Unlike a trigger finger where there is pain with motion, and the finger can be straightened with pressure, Duputren’s involves a pain -free nodule where the skin actually contracts and shortens. The two conditions can sometimes be confusing: Dupuytren’s will commonly run in families and is more common in people whose ancestors come from Northern Europe. Men are more commonly affected than women.

Lastly, one of the unfortunate side effects of diabetes is a peripheral neuropathy. Symptoms include tingling in all fingers which is different from the distribution in carpal tunnel syndrome. A doctor can help differentiate a peripheral neuropathy from symptoms of carpal tunnel syndrome. The former will often involve both hands and both feet, in a distribution starting from the ends of the toes or fingers coming more towards the central part of the body. If you are developing progressive numbness or tingling or pain in your fingers, let your doctor know, for these conditions, are treatable and can help your hand function. Though diabetes is a difficult condition, many of the consequences of the disease, especially those involving the hands can be treated and most cured.

© 2008 The Orthopaedic Group, LLC

Not to be reproduced without the express permission of the author 

Distal Radius Fracture

Richard A. Bernstein, MD

Distal radius fractures are some of the most common fractures (the medical term for "broken bone"). The radius is the bone in the forearm on the thumb side (in the x - ray below, it is the one on the right). Distal radius fractures are generally caused by a fall on an outstretched hand. The fracture is almost always within an inch of the wrist joint, and may extend into the joint. The radius above is fractured at this location: about one inch from the wrist joint.


Fracture types can be described as "extra - articular" (which means the fracture line does not extend into the joint) or "intra - articular" ( which means the fracture line does extend into the joint; this is the more serious type of fracture). They can also be described as "comminuted" (which means the bone is broken into several or many small pieces) or not comminuted. The most serious type of fracture is the comminuted, intra - articular fracture.

The treatment options are quite varied, depending on the exact nature of your fracture, your age, and your activity level. The treatment options include a cast, internal fixation with a plate, percutaneous pin fixation, external fixation, or a combination of these modalities. It is an area of very vigorous research which I have been actively involved in distal radius research since 1993. The treatments, both surgical and non - surgical, have changed greatly in the last few years. 

Treatment of Distal Radius Fractures

The treatment decision is very complex. As noted above, the factors that are important are the exact nature of your fracture, your age, and your activity level. The nature of the fracture relates to the current alignment of your bones (what position they are in) and whether or not that alignment is acceptable. If it is acceptable, then you will probably get a cast. If it is not acceptable, I may need to reduce the fracture (put the bones in a better position). Sometimes the fracture is of the sort that can be pushed into place without surgery (called a "closed reduction"), and sometimes the fracture needs surgery to push the bones into place (called an "open reduction", because the skin needs to be "opened" for surgery). Usually, if the broken bones need surgery (in medical terms, the fracture needs open reduction), some kind of metal implant will be needed to hold the bones in the proper place while they heal. Most of the time, the metal implant (often called a "plate", but it does not look like a dinner plate!) 

What Can I Expect While It is Healing?

This is a great and simple question, but the answer is not simple. It depends on many factors: the nature of your fracture, its treatment, your response to treatment, your age, and your activity level, among many other factors. But it is an important question, and needs to be answered. Most patients need narcotic pain medication for only a few (less than 5) days, or never. Many times, just prescription - strength, non - narcotic medication is all that is needed.

If you have a cast, it is usually on for six weeks, then hand therapy is started. If you have internal fixation surgery, you get a splint for five days and then hand therapy starts to get your wrist joint moving. No splint is usually needed three days after surgery. Casts must be kept dry (use a plastic bag while showering), and surgical incisions need to be kept dry only for five days. No matter what kind treatment you get, you should be actively exercising your fingers, elbow, and shoulder, so they don't get stiff. I will decide, based on your exact fracture, when you can start strengthening exercises; until then, just work on motion.


What Can I Expect After It Has Healed?

Everyone wants to know, "Can I return to all my former activities?" This also is a great and simple question, but without a simple answer. Everyone has some stiffness in their wrist after treatment (remember, you fell on your hand hard enough to break the bone, so the joint and all the soft tissues around it are mad at you!). This is why almost everyone is referred to hand therapy as soon as your broken bone can tolerate it safely.

Everyone wants to know, "How much will it hurt?" Most patients will need to take some pain medication for a few days (see above), and some may need it for 10 or so days. Few patients need any pain medication other than aspirin, Tylenol, or Motrin after 10 days. Almost everyone will have some discomfort in their wrist as it heals over a period of three to six months. If you do not develop arthritis, you will not have pain after this. You will still experience some minor discomfort for a year or so.

Almost everyone ends up with some stiffness that is permanent; how much depends on your injury, your age, if you already have some stiffness and arthritis, and how hard you work in hand therapy. The forearm motion that is usually the stiffest is turning your palm up (called "supination") in the position as if you were trying to hold some water in your cupped hand. There is also some limitation in flexion and extension, which are the motions bending your hand toward your palm or toward the back side of your hand.

Most patients return to normal recreation and work activities, and most do not have permanent pain. The most limiting fracture type is a comminuted, intra - articular fracture, and these patients will have the greatest amount of stiffness, may have pain, and are at risk for developing arthritis. Extra - articular fractures usually do not develop arthritis.

The amount of stiffness is largely what determines what activities you can return to. Most patients, who are active playing non - contact and non - impact sports such as bike riding, swimming, etc., can return to those activities, starting at about 3 months after the fracture. Most patients who are active playing contact sports or sports that involve impact, such as tennis, golf, baseball, football, etc, can return to those activities, starting at about 4 months. Most patients who do heavy labor, such as carpentry, plumbing, etc, can return to work at 2 months with restrictions, and regular work without restrictions at 4 months. Most patients who do lighter labor such as painting, or office work activities such as handwriting, keyboards, telephone, etc, can return to work at 1 to 2 months. I do not allow people to do activities where they are at risk for falling for about four months. These are only general guidelines so you have some idea of what to expect, and your specific restrictions will be determined by your individual circumstances.

Dr. Bernstein has a particular interest in distal radius fractures. He has spoken at many national as well as international courses exclusively on distal radius fractures. He is actively involved with developing newer methods of distal radius fracture treatment and with teaching surgeons from around the world about how to treat distal radius fractures.

Dr. Bernstein's lectures and presentation of treating wrist fractures (distal radius fractures)

Current Concepts in Treating Comminuted Distal Radius Fractures, DaVinci Learning Center, Miami, FL.


Treatment of Distal Radius Fractures, Glens Falls, NY

Treatment of Distal Radius Fractures, Providence, RI

Treatment of Distal Radius Fractures, AAOS, San Diego, CA

Treatment of Distal Radius Fractures, Baltimore, MD

Treatment of Distal Radius Fractures, Boston, MA

Treatment of Distal Radius Fractures, AAOS Learning Center, Chicago, IL

Treatment of Distal Radius Fractures, Key Largo, Florida

Treatment of Distal Radius Fractures, Evolution or Revolution, Orthopaedic Grand Rounds, Dartmouth Medical School, Hanover, NH

Treatment of Distal Radius Fracture and Small Bone Fixation of the Hand, Vail, CO

Treatment of Distal Radius Fracture using the Dorsal Nail Plate, Combined American and Japanese Societies for Surgery of the Hand Meeting, Honolulu, HI

Treatment of Distal Radius Fracture using the DVR Volar Fixed Angle PlatedCombined American and Japanese Societies for Surgery of the Hand Meeting, Honolulu, HI

Treatment of Distal Radius Fractures, Evolution or Revolution, Maine Orthopaedic Society Annual Meeting, Sugarbush, ME

Current Techniques in Radius Fracture Fixation, Doral Country Club, Miami, FL

Copyright © 2010, TOG All rights reserved.
Revised 11/13/2015
Updated 11/13/2015

Updated 09/14/2017

Dupuytren’s Disease

Richard A. Bernstein, MD

dupuytren’s-disease.png.jpgDupuytren's disease is a condition that affects the palm of the hand, forming contracted cords. It is more common in men and found most commonly in people with a Celtic genetic background (Irish, Scottish, Scandinavian, Northern European), although it is found in people of many different ancestries. It affects the connective tissue in the palm known as palmar fascia (normal tissues are shown in the illustration at the right), which is the tissue that helps stabilize the palm skin. The palmar fascia starts near the wrist, divides into bands (known as “pre-tendinous” bands) as it goes to the fingers.

It can then split into two bands that attach to the natatory ligament and into the sides of the fingers.

Dupuytren’s contracture is a fairly common condition that occurs when the connective tissue under the skin (specifically, the pre-tendinous bands of the palmar fascia) begins to thicken and shorten. As the tissue tightens, it may pull the fingers down towards the palm of the hand. In some individuals, the condition may progress until the involved fingers become disabled.

Who is at risk?

People of northern European descent. There is a strong genetic component to Dupuytren’s contracture, although not all patients are of northern European descent.

Men. The incidence of Dupuytren’s contracture is about seven times higher among men than among women.

People of middle age. Most of the time, Dupuytren’s contracture doesn’t show up until after age 40. However, a very aggressive form may rarely appear in teenagers and children.

Signs and symptoms

The first sign is a thickening (nodule) in the palm of the hand that most frequently develops near the base of the ring or little finger. The nodule, which can resemble a callus, is painless but may be tender to the touch. Gradually, a thickened tissue of palmar fascia forms from the pre-tendinous band and becomes a cord. This may extend across a joint, causing a contracture as the cord shortens. The overlying skin begins to pucker, and cords of tissue extend into the finger. As the process continues, these cords tighten and pull the finger in toward the palm. The ring finger is usually affected first, followed by the little, long and index fingers. The problem is not pain, but the restriction of motion and the deformity it causes.

The progress of the disease is often sporadic and unpredictable. Exactly what triggers the formation of nodules and cords is unknown. As the disease progresses, the diseased tissue wraps itself around and between normal tissue. Many people do not seek medical care until the contracture is well advanced. Until recently, the only treatment for this condition is surgery, which is usually reserved for individuals who have developed deformity as a result of the progressive contracture. New nodules do not necessarily progress to contracture and because scar tissue from previous surgeries can make excision of recurrent nodules more difficult, surgical removal of isolated nodules is not indicated in most cases.

A good guideline for determining when to consider surgery is the "table top test." Try to place the palm of your hand completely flat on a hard surface. If you can’t, the contracture has progressed to a point where surgical intervention could be helpful. Dupuytren’s can also be associated with thickening of the knuckles on the back of the hand or thickening of the tissue on the sole of your foot. Men can rarely get a band of tissue in their penis, called Peyronie's, if so we can have you see a Urologist who specializes in that.

Unfortunately there are no splints, exercises, pills or simple “cortisone” injections that can improve the course of Dupuytrens. Many of these techniques have been tried without success. Xiaflex is an injection that was FDA approved in 2010. It is an enzyme based on the Clostridium bacteria. The medication has been studied and trialed, and has undergone numerous studies on its efficacy in treating certain cases of Dupuytren's. Xiaflex does not “get rid” of the Dupuytrens; it helps erode the cord so that the cord can be broken to correct the contracture. There are risks that include a flare reaction, tendon rupture, skin tear, nerve injury, and recurrence. The best contractures are bands at the MP joint and those with a centraI band. Bands and contractures that extend to the PIP joint also respond to Xiaflex, but not as successfully as an MP joint contracture. I have used Xiaflex extensively and have presented results at the American Society of Surgery of the Hand meeting and will be happy to discuss whether your Dupuytrens is a candidate for the medication. In my experience, when you are a candidate, the results have been gratifying and much easier for my patients to recuperate from than surgery.

Surgical Treatment

When surgery is needed, every case has subtle differences and we can discuss the techniques based on the extent of the contracture and disease. The aim of the surgery is to release the contracture and improve hand function by removing the diseased tissue. The results of surgery are usually good, and the fingers can return to good extension after therapy. You need to be dedicated to your post-operative therapy. Probably more than any other condition I treat with surgery; you need to be dedicated to wearing a splint, doing your exercises and working with a therapist. If you are not going to be able to wear the splints and exercise, it is not worth having the surgery. Some studies suggest night time splinting for 6 months after the surgery. However, the disease can return even some years after the initial surgery. Dupuytren’s contracture usually does not recur beneath a skin graft, so this may be an option in especially aggressive forms of the disease. There has also been a resurgence in another option based on a Scottish surgeon, termed the McCash technique. This involves intentionally leaving open part of the incision at surgery. By leaving it open it diminishes tension on the skin and decreases the chance of a blood clot (hematoma) developing under the skin. In severe contractures, this is a technique that I may discuss with you for in some cases it is a better option than putting a lot of tension on the skin. The skin heals on its own within 2-5 weeks depending upon the extent of the open area; the therapist and I will discuss how to care for your hand.

After Surgery

It’s important to keep the appointment for hand therapy after surgery. You will have to wear a splint so that the fingers stay extended during the day and at night. The splint is usually worn full time immediately after the surgery and then only at night for several months. You will also have to do some active range of motion exercises so that the finger retains mobility and strength.

dupuytrens-disease-incision.png.jpgThis is the incision of a Dupuytren’s patients about two weeks after surgery on the palm and fifth finger. Note how he can fully straighten out the finger.

Many patients ask about return to work activities after a Dupuytren's release. Everyone is different, but here are some guidelines. I encourage you to return to any activities that you want as soon as the dressing is off, as long as the hand remains clean and dry. Keyboarding, playing a musical instrument for instance are both great therapies to help restore hand function. These are only rough guidelines which will give you some idea of what to expect.

Copyright © 2010, TOG All rights reserved
Revised 11/13/2015
Updated 11/13/2015

Finger Fracture

Richard A. Bernstein, MD

Fractures can occur anywhere in the finger and usually respond well to splinting or casting. The important thing about fractures of the finger is how the injury can ultimately affect motion and strength. These injuries can oftentimes lead to stiffness and a permanent loss of motion if not addressed; even with the best of care, loss of motion is not uncommon.


A commonly asked question is the difference between a fracture, break, and crack of the bone. All terms are identical; though occasionally there is the misconception that a crack is simple. What you need to understand is the location and degree of stability of the injury, but for all three terms, the bone is broken and needs to be recognized.

The other two confusing terms are comminuted and compound. Comminuted refers to multiple fragments which are therefore inherently less stable. A compound fracture is also knows as an open fracture. This means that there is a cut overlying the break or the bone has punctured the skin. A compound fracture has a higher chance of infection.

It is important to differentiate fractures that go into the joint from those that do not. When a break goes into a joint, there is a higher chance of arthritis developing if the joint does not remain clean and smooth. Other breaks can sometimes occur in areas where the fracture will block motion and these also need to be addressed differently. Fractures that go into the joint have less tolerance for displacement and may need surgery.

For stable fractures, (the clarification of which you should ask in the office), casting or splinting is usually the method that we choose. The key is understanding the instructions about when you can start moving the fingers and hand and when you should stay still. I use the example of a seesaw between immobilization and motion. The longer we immobilize a break, the more stable it will be but also more stiff. On the other side of the seesaw is motion; the earlier we move it, the better the motion may be, but there may be greater difficulty with healing. Therefore, we need to balance the seesaw to gauge between motion and stability.

When fractures need to be fixed, there are different options of pins, screws, and plates. Not one method is applicable for all fractures. Based on their location, size, instability, there are different options available that you should discuss with me.

Copyright © 2010, TOG All rights reserved.
Revised 12/17/10, updated 1/28/2016

Fingernail Fungus Infections

Richard A. Bernstein, MD

Nail fungus infection is a condition called onychomycosis ("onycho" refers to the nail, and "mycosis" means fungus). It is fairly common, with about 12 million Americans being affected. We all have a variety of microorganisms, including bacteria and fungi, growing in and on our bodies. Some of these are absolutely essential to our health (for instance, the bacteria in our intestines that assist in digestion). Others may cause illness (infection) whenever they invade us, or only if they multiply rapidly and out of control. Fungal infections are caused by fungi, which are microscopic plants.

We all have fungus growing on our skin, particularly on our feet, where the condition is called "athlete's foot." Fungus loves the growth conditions of damp, moist, and lots of food, and the skin of our feet is the perfect location (the "food" is the dead skin cells that are sloughed off by the millions every day). Other common fungal infections include mold-like fungi (dermatophytes, causing tinea infections) and yeast-like fungi (such as Candida). Tinea infections include jock itch, ringworm, and tinea capitis. Candida (yeast is the spore form of fungus) infections include diaper rash, oral thrush, cutaneous candidiasis, and some cases of genital rashes. The fungus is usually not a problem, since our immune system fights back and the fungus stays on the outside of our bodies. Fungus is a problem when there is a breakdown in our defenses.

The fingertip is a highly specialized structure, with many specialized features.


The illustration above shows the anatomy of the fingertip. There are also additional specialized tissues just around the nail, in order to help fight nail fungus infections. In terms of evolution, this should make sense. Originally, nails were claws, and animals would get dirt forced under and around their claws as they dug, fought, etc. The nail area developed many specialized defenses against the invasion of bacteria and fungus.

Nail bed infections usually start when there is some breakdown in the body's defenses, such as an immune system illness, fingertip crush, nail fold laceration, etc. The fungus may get a start because of a bacterial infection.

The fungus, typically caused by a species of Trichophyton fungus, feeds on keratin, the protective outer layer of nails, hair and skin. If the fungus gets some advantage over our fingertip defenses, it may start growing on the keratin of the skin under the nail plate (the part that you trim with a fingernail clipper). There is a buildup of organic waste material and the body can react with over-production of keratin, both of which forces the nail to separate from the nail bed. This causes the typical yellow color under the nail and partial nail separation. It can also result in the thickened, distorted nail plate. Sometimes, the soft tissues around the nail will be just a bit red and tender.

Eventually, the entire nail separates, resulting in partially destroyed, yellow nail.


Once fungus gets into the nails, it is very difficult to treat, but if you are persistent you can beat it. My choice is to treat it with topical ointments, but I want to review the alternatives so you understand why this is my choice. Some kind of treatment is necessary, as it will not go away by itself, so don't just ignore it.

Fungal infections of finger nails can be treated by taking pills called griseofulvin. The pills must be taken for six months to one year and have side effects. These include headaches, nausea, and rare reversible liver damage or blood disorders. You can not drink alcohol if you are taking griseofulvin. A course of treatment costs approximately $350 and has a 50-70% chance of curing the condition.

A new medication, terbinafine, is now available for the treatment of toe and finger nail fungal infections. Terbinafine is taken once a day for 6 to 12 weeks. This medication has fewer side effects than griseofulvin, but there still is the possibility of side effects. A 12 week course of treatment costs $500 and has a 50-70% chance of curing the condition.

So what do I recommend? I suggest that you try topical ointment. It is slower; takes more work on your part, and needs to be done over a very long period of time (six months to a year) and may need to be done periodically in the future.

Lotrimin cream is available without a prescription at your local drug store, or I can write you a prescription. Clean your fingernails (and toenails, too, if you want) every day. Don't push up the cuticle and do not wear false nails. Do not clean the nail area with solvents (fingernail polish remover, for instance). Rub some of the Lotrimin into the nail area, especially under the nail plate. Squoosh it around (do you mind if I make up a word?) so that it gets under the nail as far as possible. It can't help fight the fungus under the nail if you don't get it in there!

If we can make the environment hostile enough for the fungus, our body's natural ability to heal itself and fight off the fungus will win the day. Don't be discouraged if you don't see instant results: you won't. It will take a few months before you see much of a change.

In severe cases, removal of the hard part of the nail, called the nail plate does three things. First the nail itself is almost a foreign body; anti inflammatory cells cannot get into the dead area of the nail so by removing it, you allow the bodies resources to get to the live tissue. Second, it allows a more thorough exposure of the anti-fungal cream to the area. Third, a nail fungus likes a moist environment and removing the nails, prevents water and moisture from getting trapped beneath the nail.

Copyright © 2010, TOG All rights reserved.
Revised 12/20/10/ updated 1/28/2016

Gamekeeper's Thumb

By Richard A. Bernstein, M.D.

Gamekeeper's Thumb, also called Skier's Thumb, is an injury to the thumb on the little finger side, at the second joint from the thumbnail (MP joint). The ligament can be either torn itself, or the ligament can be torn from the bone, usually pulling a small fragment of bone off with it, as illustrated below.


This is a view of the thumb from the top, looking straight down on the thumbnail. Note the broken fragment of bone from the middle phalanx. (Note: this x-ray has been modified to remove the sesamoid bones, which can be confused with fracture fragments.)


This is a view of the thumb from the side. You cannot see the fracture fragment, since it is in the middle of the bone on this view. What you can see is that the joint is not parallel: the bones are closer to the right than to the left. (Again, the sesamoids have been removed.)

The Injury

Gamekeeper's thumb is clinical instability of the first MP joint caused by an insufficiency of the ulnar collateral ligament (UCL) in the MP of the thumb. Because the stability of the thumb is important for holding things between the thumb and the index finger, treatment is directed toward optimizing the healing of the ligament to restore its full function. Gamekeeper's thumb is a common injury. The incidence is increased in skiers, but it does not depend on the type of ski pole used.

Challenges in Establishing the Nature of the Injury

If the history (typically a fall that stressed the thumb) and the clinical exam (painful, swollen thumb MP joint, especially on the index finger side of the thumb) are suggestive of an injury, an x-ray should be taken. If the x-ray does not show a fracture (no gamekeeper's fracture), but the history and clinical exam show a sufficient injury, there still might be a gamekeeper's thumb (the kind with just a ligament injury), which is actually more serious. The reason is due to the anatomy of the thumb. The muscle on the index finger side of the thumb (adductor) has an expansion called the aponeurosis, which usually gets stuck between the ruptured ligament and its site of insertion at the base of the proximal phalanx, preventing the ligament ends from touching. This is called a Stener lesion and prevents the ligament from healing back together. This lesion also can be associated with the gamekeeper's fracture, but this can usually be seen on the x-ray, because the fracture fragment is several millimeters away from where is it supposed to be. The real challenge is to diagnose a gamekeeper's thumb due to a ligament injury, since the ligaments don't show up on the x-ray! At times, an MRI may be useful.

The best way to decide if the ligament is ruptured is to stress the joint. If the pain is enough to prevent a good stress examination, the joint may be anesthetized with a Lidocaine injection prior to stress testing. If the ligament is loose (called laxity) by about 35°, or if the injured thumb has more looseness (laxity) than the other thumb by 15° more, the collateral ligament is ruptured. Stress testing with the thumb slightly flexed tests the ligament itself. Stress testing with the thumb in the extended position is the best test for determining the competence of the lower part of the ligament, called the accessory collateral portion of the UCL. If laxity of the MCP joint is present in both the flexed and extended positions, complete UCL rupture should be suspected.


Splinting or casting is appropriate for injured thumbs and the ligament is not loose or is only very slightly loose. These are called partial tears, that is, grade I or grade II tears, of the UCL. These tears usually involve an isolated rupture of the proper collateral ligament. Splinting or casting is also appropriate when there is a fracture, but the fragment of bone is displaced only a millimeter or two. The splint or case should immobilize the thumb for 4 weeks. With appropriate closed treatment, good to excellent results can be expected in 90% of such injuries. Surgery is needed when there is too much looseness of the ligament (it is probably ruptured and the Stener lesion will prevent it from healing) or if there is a fracture and the bone fragment is displaced. Without surgery, the joint will be floppy, will probably develop arthritis, and the thumb will not be able to oppose the index finger (useful for things like opening a door with a key!). Occasionally, significant ligamentous injury may occur without immediate gross instability, which can be masked by swelling and muscle spasm. At this point, a repeat examination can be performed after 1 week; and if swelling persists and motion has not been regained, surgical fixation may be considered.

What Happens If Surgery is not Performed?

Sometimes the injury is not diagnosed or the patient decides against surgery. This creates chronic instability of the thumb. This is difficult to treat. Just trying to repair the ligament late has limited success. Even surgical repair performed 6 weeks after the complete UCL rupture has limited success. Essentially, the longer a complete rupture of the UCL exists, the smaller the possibility of stability restoration with anatomic repair. Fractures may not be repairable. Ligament injuries need to be reconstructed.

What is the Surgery?

The surgical procedure involves a 1 inch incision, opening the muscle, and replacing the bone fragment or repairing or replacing the ligament. The thing to watch out for is the radial sensory nerve, which often has one to three small (

What is the Recovery?

Postoperatively, most patients will be casted and then a splint that but can be removed specialized exercises. Great care must be taken not to stress the repair! Three months after surgery, full activities can be resumed.

Chronic instability of the MCP joint can occur despite a good repair, especially if motion and return to play are resumed prematurely. This instability is difficult to treat and can lead to arthritic changes in the MCP joint, as well as a weak pinch grasp in the long term.

Stiffness of the MCP and IP joints is a common complication. This stiffness is usually not a functional problem, and it tends to improve with time.

Neuropraxia of the radial sensory nerve may occur, even if care is taken to isolate and protect the nerve. The neuropraxia usually resolves spontaneously.


Early diagnosis is the most important factor that determines the functional outcome. In thumbs with partial ligament injuries, nonsurgical treatment by means of immobilization yields a stable, painless thumb in most cases. In more than 90% of complete ruptures that are surgically treated within 3 weeks of the injury, a good-to-excellent result can be expected. Pain and stiffness can be expected to be mild or absent, and pinch and grip strength will be nearly normal. The rate of return to former activities, including recreational sports, is reported to be as high as 96%. The failure to diagnose this injury and the patient’s failure to seek medical treatment are the most common reasons for a poor outcome.

In complete tears, the failure rate of treatment with bracing and early motion is 50%. If a patient is unable to tolerate or refuses surgery, the use of a brace or thumb spica is the treatment of choice. However, full stability of the thumb is unlikely. The prognosis for all repairs and reconstructions undertaken more than 6 weeks after a complete UCL rupture is not as good as early treatment. However, good (but less than normal) motion can be obtained.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10
Updated 11/13/15


Richard A. Bernstein, MD

Mucous cyst is a term given to a ganglion cyst when it occurs overlying the last joint of the finger. The last joint of the finger is medically termed the distal interphalangeal joint(DIP) joint. Wear and tear arthritis, known as osteoarthritis can oftentimes affect this joint. Bumps can occur in this joint from the arthritis itself and it can often be felt as a bony enlargement.

Mucous-Cyst.jpgOn the other hand, a mucous cyst occurs when the arthritis irritates the joint and skin and forms a fluid-filled cyst. These are oftentimes bluish in coloration;sometimes, the overlying skin gets thin. The fluid within the cyst is joint fluid analogous to a ganglion cyst (ganglion).

The danger occurs if they rupture. Similarly I have seen patients picking at them with needles and they could become secondarily infected. Because the cyst is in continuity to the underlying joint, infections can extend to the joint or bone.Therefore, it is important not to pick these areas and if the skin breaks to call immediately.

Treatment option includes splinting, injections, or surgical removal. When the skin does become very thin, surgery is oftentimes recommended to try to get the area closed before an infection occurs. Recent studies confirmed by my experience show a relatively high success rate of cortisone.

It is not uncommon for the nail to develop some ridging within it and since the cyst irritates the tissue from which the nail grows.

Many times, the cysts will diminish on their own. My belief is that the cyst is caused by irritation from the bone spur to the skin causing the fluid production. If it comes to surgery, you cannot only remove the cyst, this has leads to a high recurrence rate. The important aspect of surgery is to remove any underlying bone spurs causing the irritation.

If surgery is the choice you make, I perform it on an outpatient basis under alocal anesthetic. The anesthesiologist is there to give you sedation if you want.The surgery generally involves a semicircular incision that gives me access to the cyst and joint. If the skin is thin, this incision allows me to move tissue around to gain coverage. After surgery the finger is splinted for a few weeks; the therapist will guide you through the early motion program. If you move it too soon, the skin over the joint will breakdown; the splinting and slow return of motion is to allow the skin to heal.

At the 3-5 week range the skin will often look quite red and angry looking. Since there is little fat and no muscle between the skin and bone, the area does become more inflamed than some at peak reaction. If you have any concerns about the wound call immediately.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10
Updated 11/13/2015

Glucosamine and Chondroitin

Richard A. Bernstein, MD

Chondroitin and Glucosamine are not drugs

First of all, legally neither of these are drugs, they are "nutritional supplements." The reason I put the quotes around them is that the companies that market them want you to think that they are drugs and market them as cures or treatments for arthritis. One of the companies actually sent me some prescription pads for their product, even though it is not a prescription substance! I find this lack of intellectual honesty disturbing and makes me, and some other physicians I have discussed this with, question everything else that the manufacturers do: how they promote their products, the "research" that they sponsor, etc. Let me make it clear: they are actually not drugs and are not regulated by the FDA: they have not been tested for safety or efficacy, and their production is not regulated by Good Manufacturing Practices (GMP), which is a set of guidelines from the FDA to ensure quality. Legally they are "nutritional supplements," and as an unintended side effect of the FDA Modernization Act of 1997, companies are allowed to market them with fewer controls than previously.

What are they chemically?

Chondroitin is derived from the cartilage of the tracheas (windpipes) of cows and Glucosamine is derived from crushed crab shells. Their chemical makeup resembles cartilage molecules, and their manufacturers claim that they help worn cartilage. Medical specialists and researchers are skeptical, but the manufacturers of these substances have been successful in building their market up to over $700 million in 1999 despite a lack of good evidence that they work. They may work, and the manufacturers can show you testimonials that they do, but there is as yet a lack of good scientific evidence that they work. And the lack of evidence is not for a lack of trying.

The Confounding "Snake Oil" Factor

Chondroitin and Glucosamine may be of some use, and there is some evidence that it may be chondroprotective (that is, it might not only stop arthritis pain but also stop the progression of arthritis, which would be an important first). The problem has been the confounding factor of the "snake oil salesman" approach of many of the companies that sell the products or people who stand to personally gain from their promotion. Rather than taking the normal and accepted route for a new drug, which is through the FDA, they have tried to promote their product (and make money) by selling their products as "nutriceuticals" (a madeup name combining "nutrition" and "pharmaceutical") direct to the public, making some rather unscientific claims. This makes it harder to see the truth underlying the hype. Science does not progress well with self-promotion, and this has created a lot of smoke rather than heat from this particular fire.

What is the evidence for them helping arthritis?

There was a review article in the March 15, 2000, issue of the Journal of the American Medical Association, which examined the evidence for the effectiveness of Glucosamine and Chondroitin. The authors of the study searched the published and unpublished literature, and even went so far as to ask the manufacturers of Glucosamine and Chondroitin for their data. The results of the study were that:

"Trials of Glucosamine and Chondroitin preparations for OA symptoms demonstrate moderate to large effects, but quality issues and likely publication bias suggest that these effects are exaggerated (emphasis mine). Nevertheless, some degree of efficacy appears probable for these preparations." The authors found that most of the studies had been paid for by the manufacturers, and that the degree of support for the effectiveness of Chondroitin and Glucosamine was closely linked to the quality of the study: if the study was poorly designed and paid for by the manufacturer, it was more likely to justify the sales of the supplements. You make your own conclusions.

An accompanying editorial concluded:

"As with many nutriceuticals that currently are widely touted as beneficial for common but difficult-to-treat disorders, the promotional enthusiasm often far surpasses the scientific evidence supporting clinical use (emphasis mine). Until high-quality studies, such as the National Institutes of Health study, are completed, work such as [the meta-analysis] is the best hope for providing physicians with information necessary to advise their patients about the risks and benefits of these therapies."

There is enough suggestive evidence, however, that the National Institutes of Health have granted a $6.7 million research grant to the University of Utah to conduct a prospective, randomized, double-blind study of 1000 patients with osteoarthritis.

What do I recommend for my patients?

Of course, the most natural remedy for hip and knee (but not hand) arthritis is to lose weight and have a moderate exercise program. All of the known side effects of this approach are good ones. But then no manufacturer will make any money from you, either. The best approach to hand arthritis is to identify the activities that cause you pain (probably firm pinching, tight jar lids, faucet handles that are stiff or need a lot of force to prevent them from dripping, gripping your pencil tightly, etc.) and to avoid them (have someone else open the jar, fix the faucet gasket, don't grip the pencil tightly, etc). Acetaminophen (the ingredient in Tylenol) is generally safe when taken as directed and does not hurt your stomach. It can give you relief from minor arthritis pain. If your pain is more than you want to tolerate despite the above measures, discuss with me the possibility of taking an anti-inflammatory.

Until good, scientific, prospective randomized studies are done to show, demonstrate and prove that these medications are both safe and effective; I will not either support or refute their use. I try to base my approach to my patients based on science and evidence, and until we get that, I think, as the saying goes, "The jury is still out."

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10/ updated group name 1/28/2016

Growth Plate Injuries

Richard A. Bernstein, MD

The Growth Plate

Our skeleton is a marvelous thing. It grows as we grow! And it does this without shutting down or closing for remodeling. A great thing, or we would be in real trouble!

The skeleton grows due to the presence of a region of the bone called (surprise!)the growth plate. The medical term for this is the physis (adjective form is physeal), and I mention it only so you can understand the term if you run into it and so that you can understand the names of the other parts of the bone.

Here are the parts of a growing bone. The example is of a wrist, partly because about 50% of growth plate injures are at the wrist and partly because that is themost likely growth plate injury my patients will have. In this x-ray, the wrist bonesare at the top and the forearm bones at the bottom; the radius is the bone on the right, it is the one on the thumb side of the hand:


The epiphysis is the end of the bone, with the cartilage that makes up your joint("epi" means "upon", so an epiphysis is the part of the bone that is on the physis).The physis is the growth plate, the part of the bone that has the cells that allows the bone to grow longer. The metaphysis is the broad region of bone right next to the physis. The diaphysis is the narrow center part of the bone.

The growth plate is made up of a special kind of cartilage called (surprise!)growth plate cartilage.

Growth Plate Injuries

Growth plate injuries occur in children, up until about age 16 for girls and 18 for boys. The growth plate is the weakest area of the growing bone, weaker than the metaphysis or the diaphysis, and weaker than the ligaments of the adjacent joint.In a growing child, a serious injury to a joint is more likely to damage a growth plate than the ligaments that stabilize the joint. Interestingly, each age bracket has a different response to a similar injury of falling on the outstretched arm: little children get a fracture (break) to the bone that only bends it ("greenstickfracture"), older grammar school children get a growth plate injury, young adults will often get a fracture into the joint or a wrist dislocation, and an elderly personwill fracture through the metaphysis. An injury that might cause a sprain in an adult may cause a growth plate injury in a child.

Growth Plate

Injuries are Fractures

Growth plate injuries are actually a broken bone, which is the same thing as a fracture. They represent about 15 percent of all childhood fractures. They occur twice as often in boys as in girls, with the greatest incidence among 14- to 16-year-old boys and 11- to 13-year-old girls. Older girls experience these fractures less often because their growth plates stop growing and change into solid bone at an earlier age than boys. Boys have a higher rate of fractures due to their more aggressive form of play. In my practice, if you exclude the fractures in girls from falling off horses, boys outnumber the girls probably 4 to1! And all of my"high volume" patients (4 or more fractures) are boys.

Classification of Growth Plate Injuries (Fractures)

The fractures of the growth plate are classified according to the system of Drs. Salter and Harris. This diagram is from their text Disorders and Injuries of the Musculoskeletal System, 3rd Edition. Robert B. Salter, Baltimore, Williams and Wilkins, 1999, and is from the National Institutes of Health website, which has permission to use this image. I added the red color, to show where the fracture is in each case.

the-salter0harris-classification-of-growth-plate-inuries.jpgI mention this classification system because you will almost certainly hear about it. Unfortunately, it does not actually tell us much about how the fracture should be treated or what the outcome will be.

Complications of Growth Plate Injuries (Fractures)

The main concern about growth plate injuries is that the growing cells can be injured by the fall, which must have been rather forceful, or the growth plate would not have broken. (Most falls don't result in a fracture, do they?) They can also be injured by the doctor, when he or she is trying to help correct the problem by straightening out the broken bone, which is why we try to do it very, very gently. Almost all of growth plate injuries of the forearm heal without any problem(the main problem occurs in knee and hip growth plate injuries, which fact you should bear in mind when you are reading generalized statistics about growth plate injuries). The challenge is that we cannot see the growing cells on the x-ray(see the photo at the top, and note that the growing cartilage cells are within the physis, which is the clear section between the epiphysis and the metaphysis) and we cannot tell if they are injured enough to stop growing or not. Even CT scans and MRI's cannot tell if they are injured enough to stop growing. The only way to tell is to treat the fracture gently and watch how the bone grows by taking x-rays over a period of about 12 months. The diagnosis is always made with the 20-20 of hindsight (what the doctors call a "retrospective diagnosis".)

The incidence of growth plate closure (what happens if the growing cells are injured enough to stop growing) is very rare. A well-respected, published paper cites a rate of 1 case in 547 distal radius (forearm) fractures (Davis and Green,Forearm Fractures in Children, 1976); Dr. David Green is the author of the most respected hand surgery textbook. The rate of growth plate closure varies with the amount of trauma that the forearm was subjected to, among other factors, many of which are still undefined.

The reason I am bringing this up, even though growth plate injuries are very rare,is that if the growth plate is injured enough and it closes, the bone does not grow properly. It can stop growing entirely, which may not be a problem in an older child. It can stop growing only on one side, which in children with a large amount of growth left can cause the bone to grow crooked. These problems are even more rare than growth plate injuries (that is, most growth plate injuries heal without any problems), and usually is not even noticed by the patient. In one long-term study of growth plate injures (157 fractures followed for an average of25 years, a remarkable study, indeed), only 7 had shortening or angulation of the radius, and only 2 were noticed by the patients, and only 3 needed surgery(Cannata, et al. Physeal Fractures of the Distal Radius and Ulna: Long-Term Prognosis, 2003). The majority of the growth plate injuries resulting in bone growth problems had very special kinds of injuries, such an open fractures (bone sticking out of the skin or similar "compound" fractures) that got infected, injuries in which the growth plate of both the radius and the ulna were present, or other rather unusual kinds of injuries. Growth plate injuries and growth disturbances are very rare in the typical, simple fall on an outstretched arm. I recommend follow-up x-rays just to be sure there is NO growth plate and bone abnormalities present, not because I expect them to be present.

How Are Growth Plate Injuries (Fractures) Treated?

In general, we like to straighten out (reduce) fractures, which includes growth plate injuries. We straighten them out (reduce them) as gently as possible. The mild deformity left after a growth plate fracture almost always remodels and growth plate injuries resulting in closure are rare. If your child has sustained a growth plate injury, we will discuss it when you are in the office and will take xrays over time (sometimes over a period of a year) to see how the bone is doing.Remember, growth plate injuries that do not heal properly are rare. If the accident was caused by something like a simple fall on an outstretched arm, in Dr. Green's study, only 1 in 547 forearm fractures resulted in a growth disturbance.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10 / updated 1/28/2016

Innovations in Wrist Care (Distal Radius & Scaphoid Fx’s)

Richard A. Bernstein, MD

Fractures of the bones of the wrist, particularly the radius and the scaphoid remain common sources of injuries requiring fracture care. Though most fractures can be treated with splints or casts, there has been evolving treatment options which allow patients to return to activities much more quickly than they could in the past. There is increased awareness of osteoporosis, or thinning of the bone but despite advances in medical treatment “fragility” fractures commonly occur. On the other end of the spectrum, adolescents and young adults are particularly active with sports such as skiing, ice skating, gymnastics, and contact sports all of which put the wrist in jeopardy of an injury. Fortunately our bodies are incredibly resilient and most wrist injuries, typically represent a sprain that usually heals uneventfully. With significant trauma, fractures do commonly occur when significant force is placed across the wrist especially as the wrist is extended, or bent backwards.


Distal Radius Fx

The most common fracture in the arm, and the second most common fracture in the body (second to spine fractures) is an injury of the bone in the distal forearm named the radius. Eponyms for this fracture include a Colles, Smith, and Barton’s fractures; each term describing a different fracture pattern. Usually, a patient falls on the outstretched arm causing displacement of the bone towards the back of the wrist. X-rays usually demonstrate the extent of the injury and if in good alignment or if it can be easily reduced, most fractures can be treated in a cast. However, often this necessitates six weeks or longer of cast treatment. Over the last 10 to 15 years there has been an evolution in treatment of fractures of the wrist using metallic plate and screws. Fracture fixation can usually be done in 30 to 45 minutes and typically a week after a surgery, I allow my patients to progress to a removable splint and start physical therapy. I was fortunate to have made the acquaintance of the pioneer in distal radius fractures, Dr. Jorge Orbay a number of years ago. By learning the technique, I was able to share the experience and surgical technique providing over twenty teaching sessions to orthopaedic and hand surgeons across the country on this innovative technique. Patients can shower when the dressing is removed and then start their hand rehabilitation. When compared to six weeks in a cast, early fracture fixation can help maintain the bone alignment and allow patients to return to work, sports, and activities much more quickly than they could with cast treatment.

The scaphoid bone is a canoe shaped bone that sits on the thumb side of the wrist. Similar to the radius fracture described previously, a scaphoid fracture typically occurs from a fall onto outstretched arm. This bone is more commonly injured in people 15 to 30 years old, men more than women and are often times passed off as a simple sprain. The difficulty with a scaphoid fracture is that often times the fracture cannot be visualized on initial x-rays and requires follow up X-rays or other advanced radiology as necessary. Because the fracture sometimes does not show up on initial x-rays, a scaphoid fracture can be missed; if that occurs, there is a very high risk that the bone neither heals and /or the wrist becomes arthritic. First and foremost an accurate diagnosis and a high level of clinical suspicion for this injury is necessary.



Once diagnosed, the traditional treatment is three months in a cast, six weeks in a cast above the elbow and six weeks with a cast below the elbow. This is double the time it typically takes for a fracture of the radius to heal, and therefore the long duration of casting immobilization can be problematic. For a scaphoid fracture, a so called “percutaneous” procedure can be done to insert a small metallic screw in the body of the scaphoid under a special television like x-ray called fluoroscopy. The technique involves a small incision and using a special camera, a pin, a guidewire, and a screw placed within the bone to provide fixation. With good bone quality and excellent fixation, patients can come out of the postoperative dressing in one to two weeks, be placed in a custom made splint and start early careful activities. Healing of the scaphoid, even with surgery can be tenuous and occasionally requirs a slower rehabilitation course, but surgery avoids the need for prolonged periods in a cast. Studies have shown greater than 95% healing with placement of a screw within the scaphoid bone.

We always want to look for the most conservative approaches to treat our patients; however oftentimes, it is important to understand the options available, and in the right scenario, surgery can expedite, facilitate, and improve the healing. Though no medical treatments are without risks, there are many options available and medical technology continues to advance and I would be happy to answer any question with regards to these or other injuries

Intersection Syndrome

Richard A. Bernstein, MD

An intersection syndrome is a relatively rare overuse tendinitis affecting the wrist. The pain and swelling occur on the back of the forearm near the wrist joint and on the side b y the thumb. Oftentimes, one can see swelling in this area; with wrist or finger motion, oftentimes, it will be a Velcro - like sensation in the back of the wrist. The inflammation occurs at the so-called intersection area between tendons that go to the wrist and thumb. Where these tendons crossover at the back of the wrist, there is a point of inflammation in the coverings of the tendon that will give this type of sensation. Fortunately, most cases do respond to a course of splinting and therapy.

Topical applications such as a modality called iontophoresis by a certified hand therapist can usually eliminate this pain. Therapy is best done as an adjunct with rest and splinting.

Occasionally, this condition will be seen in conjunction with de Quervain’s tenosynovitis. Occasionally, a Cortisone injection can also be helpful to treat this condition; surgery is rarely needed.

Copyright © 2010, TOG All rights reserved.

Kienböck's Disease

Richard A. Bernstein, MD

Kienböck disease is a condition in which a one of the small bones of the hand in the wrist called the lunatedies. We don't know what causes it. Bone is a living tissue that grows an d changes, and it requires a regular supply of blood for nourishment. If the blood supply to a bone stops, the bone can die, a condition known as osteonecrosis.

Kienböck's disease is osteonecrosis of the lunate. It usually affects the dominant wrist of me n aged 20 - 40 years, but can effect women, but usually later than in men. The true natural history (what happens if we do not treat it) of this condition is not well understood. Not only do we not know what causes it, we do not know why some get better by themselves and some get worse. We don't even know how many have minimal symptoms and get better by themselves, as doctors usually only see a patient after the symptoms are pretty bad. As you can imagine, this has hampered the determination of the ideal treatment. In addition, as with many conditions that affect the wrist, the patient's pain does not necessarily correlate well with the radiographic appearance: some people with almost normal x - rays hurt a lot, some with bad x-rays hardly hurt at all. (Note: the little "ö" is used because the disease was first described by a Viennese radiologist named Robert Kienböck, and that is how his name is spelled in English. Just thought you might want to know.)

Signs and symptoms

Many people with Kienböck’s disease thin k they have a sprained wrist at first. They may have experienced some form of trauma to the wrist, such as a fall. This type of trauma can disrupt the blood flow to the lunate. In most people, two vessels supply blood to the lunate, but in some people there is only one source. Our best guess is that this puts them at greater risk for developing the disease (but as you can understand, we can't do an experiment and prove this!) As the disease progresses, other signs and symptoms may start, including:

  • A painful and sometimes swollen wrist
  • Limited range of motion in the affected wrist (stiffness)
  • Decreased grip strength in the hand
  • Tenderness directly over the lunate (on the top of the hand at about the middle of the wrist )
  • Pain or difficulty in turning the hand upward

However, as you can see, these things also can occur with many other things, so they are not very specific.

Stages of Disease

Kienböck’s disease follows a specific progressive pattern through five stages.

Stage 0: Symptoms are similar to th ose of a wrist sprain. X - rays are normal, magnetic resonance imaging (MRI) is normal. (We only know this stage retrospectively, that is, later down the road, when more symptoms occur and more x - rays or MRI's are done.)

Stage I: Symptoms are similar to tho se of a wrist sprain. X - rays may be normal or show a line indicating a possible fracture. Magnetic resonance imaging (MRI) may also be helpful in making the diagnosis in this early stage.

Stage II: The lunate bone begins to harden. On an X - ray, it may ap pear brighter or whiter than the surrounding bones. These changes indicate that the bone is dying. Either an MRI or a computed tomography (CT) scan may be used to assess the condition of the bone. Recurrent pain, swelling and wrist tenderness are common.

Stage III: The dead bone begins to collapse and break into pieces. The surrounding bones may begin to shift position. Patients experience increasing pain, weakness in gripping, and limited motion. Stage III is broken down into IIIa (no fixed scaphoid rota tion) and IIIb (fixed scaphoid rotation).

Stage IV: The surfaces of adjoining bones are affected, resulting in arthritis of the wrist.


Diagnosis is usually based on a suggestive history and physical exam, then x - rays or MRI. In its early stag es, Kienböck ’ s disease may be difficult to diagnose because the symptoms are so similar to those of a sprained wrist. Even X - rays of the wrist may appear normal.


Treatment is not well - defined, because the natural history (see above) is not well known. However, this is what has worked best:

Medical therapy: Treatment is primarily directed by the level of symptoms. The primary methods of non-operative treatment are immobilization and anti-inflammatory medications. Because our best understanding of the disease is that it is related to loss of blood supply to the lunate, and because we know some patients can be cured if we can just avoid trauma and collapse, this is our first choice in the earlier stages. Younger patients tend to have a better ability to re-establish blood flow to various areas, so in a very young patient, we almost always start with this approach, especially if the disease is early, in hopes of allowing revascularization of the lunate and prevention of disease progression.

Surgical therapy: Surgery is reserved for more advanced disease. Although there is no cure, there are several surgical options for treating the more advanced stages of Kienböck’s disease. The number of options is a bit confusing, so hang in there. The right procedure for you will depend on several factors, including disease progression, your personal activity levels and goals and my experience with various procedures. We will need to discuss this several times. The two most important pieces of information are the stage of your disease and the presence or absence of ulnar variance (the length of the ulna to the length of the radius).

Directly comparing the results of different techniques is difficult because most studies have a fairly small number of patients and short follow - up. However, our experience is that many of the techniques result in very similar rates of good outcomes.

Operative treatment can be classified broadly into six categories, including: (1) joint - leveling procedures; (2) intercarpal fusions; (3) salvage procedures; and (4) others.

Joint - leveling procedures

If the bones of the lower arm are uneven in length, a "joint leveling" procedure (shortening the longer bone or lengthening the shorter bone) has been done. Bones can be made longer with bone grafts, or shortened by removing a section of the bone. This reduces the compressive forces on the lunate and seems to halt progression of the disease. Forces on the lunate, caused by using the hand forcefully, are thought to flatten down the lunate, advancing the stage of the disease. This collapsing force can be reduced by 70% with an appropriate radial shortening or ulnar lengthening. Currently, radial shortening with a 3.5 - mm metal plate is preferred over ulnar lengthening, as there is a lower complication rate and similar good outcomes. In patients with neutral or positive ulnar variance, shortening the radius is a poor idea. In this clinical situation, radial wedge osteotomies designed to decrease the radial inclination have been proposed. If the lunate is severely collapsed or fragmented, it can be removed. The two bones on either side of it are also removed. This procedure is called a proximal row carpectomy and will relieve pain while maintaining partial wrist motion.

Intercarpal fusions

Another way to ease pressure on the lunate is to remove some of the wrist bone joints and make them grow together into one or more bigger bones. This is called a fusion. If you make all of the bones grow together, it is called a complete fusion. Usually, we only do some of the bones; this is called a partial fusion. However, this approach may or may not improve range of motion, depending on whether the fusion is complete or partial, and on the stage of the disease, and on the amount of motion you started with. If the disease has progressed to severe arthritis of the wrist, fusing the bones will reduce pain and help maintain function, although motion is limited. A variety of intercarpal fusions for the treatment of Kienböck disease have been used. The goal is to red uce forces on the lunate, crushing it down, and, in procedures that involve the scaphoid , to correct and maintain proper scaphoid position.

Scaphocapitate (SC) fusion has been used by some surgeons. Biomechanically, this fusion has been shown to reduce co mpressive forces at the radiolunate joint by about 10%. Some surgeons prefer this fusion because it requires only one fusion site and is technically easier to perform.

What to do if all else fails

Salvage procedures are what we call the surgeries that are used when all else fails. One procedure that has worked rather well, despite how destructive it sounds: cut out three of the little bones of the wrist (scaphoid, lunate, and triquetrum.) This is called a proximal row carpectomy (PRC). It has been shown t o provide relatively good results in Kienböck disease by a several very good friends of mine. Our experience with a PRC is also supported by the fact that it works well for other wrist problems, so we have more experience with this surgical approach than w ith many of the others, which are only used for the relatively rare condition of Kienbock's. Complete wrist fusion (arthrodesis) is the final option for patients with global wrist degeneration. Arthrodesis can be achieved successfully following a failed PR C. It always works to stop the pain, and although the patient cannot do wrist flexion and extension, they usually have increased function in their wrist because the pain is gone.

Copyright © 2010, TOG All rights reserved.

Mallet Finger

Richard A. Bernstein, MD

mallet-finger.jpgMallet finger is a condition caused by disruption of the tendon (extensor mechanism) of the finger joint at the base of the fingernail. The joint involved is known as the DIP joint (Distal interphalangeal joint). The tendon that extends the tip of the finger can be disrupted in two ways, either the tendon or the bone where the tendon inserts. If the problem is in the tendon, it is called a tendinous mallet finger. If the problem is caused by a fracture, then it is called a bony mallet fracture. The Anatomy section can show the tendon injury area.

The problem with a mallet deformity is that many patients neglect them as a "sprained finger". The specific difference between a sprain and a mallet finger is the latter is associated with a rupture of the tendon that extends the tip or DIP joint. With the tendon rupture the first thing to happen is that you cannot actively extend the finger. One of the classic findings is the ability to passively extend the joint, but a loss of active extension. Furthermore, you can find tenderness over the back of the joint.

On the positive side, surgery is not needed and has shown in some cases to afford a worse result. On the negative side, the treatment is full time splinting, keeping the finger completely straight at the DIP joint but encouraging flexion of the remainder of the finger. This helps maintain flexibility of the other joints.

On the negative side, the splint needs to be worn 24/7 often for 6 weeks; if you take the splint off, the clock resets for another 6 weeks. There are many splints on the market, but I have found the best way is an aluminum splint to keep the tip joint straight. Specifically, the tip of the finger should be kept straight but to allow free PIP and MP motions. The splint can be changed by the therapist, but the finger needs to be maintained in an extended position. If the finger drops to a flexed position, the clock "resets" for another six weeks. With this protocol, 70% of people heal with six weeks of immobilization, and approximately 25% more heal with 6 more weeks of immobilization; surgery is an option but in most cases is not necessary. Unfortunately, most people do permanently lose some motion, but functionally, it is not usually problematic.

If any skin irritation occurs, call our office immediately so we can check the finger. We will also have the therapist check the finger, splint and skin to assure that no problem occurs. Our goal is a full restoration of motion, but honestly most patients do lose some motion permanently. By participating in the splint and therapy program, we can usually maximize function.

Once we start motion

It is very important that you understand the concept of PROGRESSIVE MOBILIZATION once you are released to begin moving the finger. This generally begins 6 weeks after full time splinting. We want to SLOWLY start motion and SLOWLY increase the motion, not go for broke right away. The first week, just remove your splint and wiggle the joint a little, about 10 degrees. Do this about five times a day, wearing the splint the rest of the time except for some periods while you are at rest, such as watching TV. Wear it at night. The second week, double the motion to about 20 degrees, and take the splint off a bit more, but wear it while sleeping, and while active (when you might bump your finger). The third week you can move it more and wear the splint less, even taking it off at night. Wear it when you are active. The fourth week, you can move it a lot and keep the splint off except when you are active. After that week, you can take it off all the time, but avoid trauma for several more months and use it during strenuous activities.

BEWARE: if you develop a lag (cannot fully straighten the finger), put the splint back on and stop the movement exercises. Give me a call. I expect about a 5 degree lag in most cases, but it should not increase with time. If so, it may mean that you are stretching out the healing tendon. I want to talk to you and probably will need to see you to assess the situation.

This program of gradually increasing motion helps to strengthen the tendon as it limbers up the joint, which will be quite stiff from our treatment. Most patients recover a great, functional range of motion with only a slight lag.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10

Mucous Cysts

Richard A. Bernstein, MD

mucous-cyst-diagram.jpgMucous cyst is a term given to a ganglion cyst when it occurs overlying the last joint of the finger. The last joint of the finger is medically termed the distal interphalangeal joint (DIP) joint. Wear and tear arthritis, known as osteoarthritis can oftentimes affect this joint. Bumps can occur in this joint from the arthritis itself and it can often be felt as a bony enlargement.

On the other hand, a mucous cyst occurs when the arthritis irritates the joint and skin and forms a fluid-filled cyst. These are oftentimes bluish in coloration; sometimes, the overlying skin gets thin. The fluid within the cyst is joint fluid analogous to a ganglion cyst (ganglion).

The danger occurs if they rup

ture. Similarly I have seen patients picking at them with needles and they could become secondarily infected. Because the cyst is in continuity to the underlying joint, infections can extend to the joint or bone. Therefore, it is important not to pick these areas and if the skin breaks to call immediately.

Treatment option includes splinting, injections, or surgical removal. When the skin does become very thin, surgery is oftentimes recommended to try to get the area closed before an infection occurs. Recent studies confirmed by my experience show a relatively high success rate of cortisone.

It is not uncommon for the nail to develop some ridging within it and since the cyst irritates the tissue from which the nail grows.

Many times, the cysts will diminish on their own. My belief is that the cyst is caused by irritation from the bone spur to the skin causing the fluid production. If it comes to surgery, you cannot only remove the cyst, this has leads to a high recurrence rate. The important aspect of surgery is to remove any underlying bone spurs causing the irritation.

If surgery is the choice you make, I perform it on an outpatient basis under a local anesthetic. The anesthesiologist is there to give you sedation if you want. The surgery generally involves a semicircular incision that gives me access to the cyst and joint. If the skin is thin, this incision allows me to move tissue around to gain coverage. After surgery the finger is splinted for a few weeks; the therapist will guide you through the early motion program. If you move it too soon, the skin over the joint will breakdown; the splinting and slow return of motion is to allow the skin to heal.

At the 3-5 week range the skin will often look quite red and angry looking. Since there is little fat and no muscle between the skin and bone, the area does become more inflamed than some at peak reaction. If you have any concerns about the wound call immediately.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10

Pediatric Forearm and Distal Radius Fractures

Richard A. Bernstein, MD

Forearm fractures in children are common and are managed differently than similar injuries in adults. Historically, the results of nonoperative treatment of adult forearm fractures have been poor, with reports of nonunion, malalignment, and stiffness due to the lengthy immobilization required for union. Currently, most adults with both-bone forearm fractures are treated by open reduction and internal fixation. In pediatric patients, treatment is primarily nonoperative because of uniformly rapid healing and the potential for remodeling of residual deformity.

Although the outcomes in children are usually good, treatment of individual patients and education of families can be challenging. Beyond the sometimes difficult mechanics of fracture reduction and maintenance, the clinician is faced with controversies regarding techniques of reduction, position of immobilization, and definition of an acceptable reduction.

The purpose of this article is to critically summarize available information and present treatment recommendations based on a literature review and the previous experience of the senior author (C.T.P.). The scope of this discussion will be limited to the more common entities, such as pediatric forearm and distal radius fractures, and will not include articular fractures, plastic deformation, and fracture-dislocations, such as Monteggia lesions.

Functional Anatomy

The ulna is a relatively straight bone around which the curved radius rotates during pronation and supination. The axis of rotation passes obliquely from the distal ulnar head to the proximal radial head. The two bones are stabilized distally and proximally by the triangular fibrocartilage complex and the annular ligament, respectively. Further stabilization is provided by the interosseous membrane, with oblique fibers passing distally from the radius to the ulna; these fibers are somewhat relaxed in supination and tighter in pronation.

The pronator quadratus (distally) and pronator teres (inserting on the middle portion of the radius) actively pronate the forearm, while the biceps and supinator (proximal insertions) provide supination. The insertions of these four muscles can partially account for fragment position in complete fractures. In distal-third fractures, the proximal fragment will be in neutral to slight supination, and the weight of the hand combined with the pronator quadratus tends to pronate the distal fragment. In proximal-third fractures, the distal fragment is pronated, and the proximal fragment is supinated. Mid-shaft fractures tend to leave both fragments in a neutral position with the distal fragment slightly pronated and the proximal fragment slightly supinated.

Several anatomic differences distinguish pediatric forearms from those of adults. The pediatric radial and ulnar shafts are proportionately smaller, with narrow medullary canals, and the metaphysis contains more trabecular bone. In addition, the periosteum in children is much thicker than that in adults; this feature can both hinder and help in the management of pediatric fractures.

Normal Growth and Implications for Remodeling

The proximal and distal physes provide longitudinal growth, which contributes to remodeling after fracture healing. The distal radial and ulnar growth plates are responsible for 75% and 81% of the longitudinal growth of each bone, respectively. 1 This is consistent with the oft-made observation that distal forearm fractures have greater potential for remodeling than do more proximal fractures. 2-4 Additional remodeling can also be attributed to elevation of the thick osteogenic periosteum after fracture (Fig. 1). Intramembranous ossification by the periosteum will assist in rapid healing and subsequent remodeling of residual diaphyseal deformity. Normal Function and Treatment Objectives. The goal of treatment of forearm and distal radius injuries is to facilitate union of the fracture in a position that restores functional range of motion to the elbow and forearm. The predominant motions affected by malunion are pronation and supination, which are a function of skeletal length and axial and rotational alignment. Normal supination from neutral is 80 to 120 degrees; normal pronation from neutral is 50 to 80 degrees. 5 It is important to realize that .normal" motion may not be what is needed for normal function Biomechanical testing has revealed that common activities of daily living require 100 degrees of forearm rotation, equally split between pronation and supination. 6 Limited pronation is more easily compensated for by shoulder abduction. Secondary concerns include cosmetic alignment; however, acceptable reduction usually precludes gross malalignment. Ulnar alignment is the most important cosmetic determinant.


Fig. I In completely displaced pediatric forearm fractures; the periosteum is tom and elevated. In cases of reversed fracture obliquity, it becomes difficult to reduce the bone end to end with longitudinal traction, as the periosteum tightens around the buttonholed proximal end. However, the elevated periosteum does provide a framework for rapid cortical remodeling as bone and cous form along the elevated margin.


Specific classification schemes have not been developed, but fractures are generally categorized according to location, amount of cortical disruption, displacement, angulation, and malrotation. As mentioned previously, we will not address articular fractures, physeal fractures, or fracture-dislocations in this article. Three main types of forearm fractures will be discussed: greenstick fractures, complete fractures, and distal radial metaphyseal fractures. Greenstick fractures are incomplete fractures with an intact cortex and periosteum on the concave surface. These are usually the result of excessive rotational force. Complete fractures of both bones of the forearm are classified by location as being in the proximal, middle, or distal third. Proper treatment depends on differentiating greenstick and complete fractures. Completely displaced distal metaphyseal fractures of the radius will be discussed separately because of the differences in reduction and outcome.

Mechanism of Injury

It is important to have a basic understanding of the forces leading to forearm fracture, as reductions are often performed in the direction opposite to that of the initial injury. Pediatric forearm fractures typically follow indirect trauma, such as a fall on an outstretched hand. Direct trauma may additionally account for open fractures, severely displaced fractures, and those in the proximal forearm.9 Evans described an indirect mechanism of axial compression force in varying directions and degrees of rotation, the latter accounting for different patterns of fragment angulation. The final degree of fragment displacement due to indirect trauma varies between greenstick and complete fractures, but the initial mechanism of injury is usually the same. In some cases, the force is not sufficient to completely displace the fracture, and therefore a greenstick fracture results. A greenstick fracture in one forearm bone may coexist with a complete fracture in the other.

Radiographically, greenstick fractures demonstrate angulation due to rotational deformity. 7,10 Fractures with apex-volar angulation are the result of an axial force applied with the forearm in supination; fractures with the less common apex-dorsal angulation are the result of an axial force applied in pronation. 10 Reducing a greenstick fracture usually involves rotation in the direction opposite to the deforming force. When indirect or direct trauma exceeds the resistance of the forearm, complete fractures of both bones will follow. In severe falls, the bones may initially angulate according to the rotation of the wrist.

However, when completely broken by either indirect or direct forces, the bones shorten, angulate, and rotate within the confines of the surrounding periosteum, interosseous membrane, and muscle attachments. Because the final positioning in complete fractures depends to some degree on the relationship of fracture location and the insertions of the pronating and supinating muscles, reduction is more complex than for simple greensick fractures.

Distal radius fractures usually follow a fall on an outstretched hand. The resultant angulation may also be accompanied by rotational deformity. Apex-volar angulation (the most common deformity) is accompanied by supination and apex-dorsal angulation with pronation. In our experience, solely ulnar fractures are less common, and probably result from direct trauma.

Patient Assessment and Radiographic Evaluation

The diagnosis of forearm fractures is usually self-evident from the history and the obvious deformity. Child abuse must always be considered in patients less than 3 years of age. Inspection and palpation should be carefully performed; occasionally, soft-tissue swelling will obscure gross malalignment. The wrist and elbow should be examined for swelling, tenderness, and unusual prominences that may signify a Monteggia or Galeazzi fracture. Cursory examination of the humerus and clavicle may detect fractures that have also resulted from a fall on an outstretched hand. Detailed neurovascular examination is necessary before and after reduction; median, ulnar, and posterior interosseous neurapraxias have been documented. Such deficits usually resolve with observation in 2 to 3 weeks.

Radiographic evaluation should include anteroposterior (AP) and lateral views of the forearm. If the elbow and wrist are not adequately visualized, corresponding views should be obtained to eliminate radial head dislocation, supracondylar fracture, and distal radioulnar joint injury. Forearm radiographs are examined to determine fracture pattern (complete or greenstick), location (proximal, middle, or distal third), displacement, angulation, and rotation.

Displacement and angulation are fairly easy to document on AP and lateral views. Although deformities can often be quantified and described on these standard views, it is important to remember that fracture angulation and displacement are always in a single plane, between those obtained on orthogonal radiographs. The magnitude of the deformity is at least as great as or greater than that seen on each view. Malrotation in complete fractures can be difficult to detect and assess, but can be suspected when the cortical, medullary, or bone diameters of both fragments are not equal. Malrotation can be gauged from deviations of normal orientation of proximal and distal bony prominences.

On a standard AP view, the radial tuberosity is seen in profile on the medial side, while the radial styloid and thumb are seen 180 degrees opposite on the lateral side. On this same view, ulnar styloid and coronoid process are not seen. Lateral views reveal the ulnar styloid pointing posterior and the coronoid process pointing directly anterior; the aforementioned radial prominences will not be seen. Another useful method for determining rotation of the proximal fragment utilizes the tuberosity view described by Evans. This technique allows a quantitative assessment of proximal fragment rotation. The distal fragment can then be manipulated and rotated into a corresponding position.

Anesthesia (edited)

In many centers, a large proportion of forearm and distal radius fractures are treated outside the surgical suite, requiring the treating surgeon to consider and administer appropriate anesthesia. Strict guidelines for conscious sedation have been established by the American Academy of Pediatries.14 A survey of orthopaedic surgeons completed in 1993 indicated that as many as one third of orthopaedic surgeons were not in compliance with these guidelines during fracture reduction. 15

The chosen method should be as safe as possible, induce the least trauma, including fracture reduction. As no one method completely meets these criteria, several different choices exist, each with its own advantages and disadvantages.

Options include quick reduction without anesthesia, hematoma block which involves an injection of the anesthetic in the area of the fracture or going to the hospital for either a block type or a general anesthetic. Intravenous sedation entails the potential for overdosage and cardiopulmonary depression.

Regional intravenous blocks have the advantages of rapid onset of effect, simple administration, and good muscle relaxation. Disadvantages include pain when the injured limb is exsanguinated by wrapping or elevation. Premature cuff deflation may lead to major neurologic and cardiac complications when high doses are used.

Use of general anesthesia relieves the surgeon of the burden of providing safe and effective anesthesia. This allows the surgeon to concentrate on reduction and stabilization unencumbered by the proximity of anxious parents. In addition, if several reduction attempts are required, general anesthesia provides total relaxation with minimal constraints. Furthermore, if reduction is inadequate or unstable, it easy to convert to operative stabilization.

Adequacy of Reduction and Results of Closed Treatment

Anatomic reduction is usually not required for pediatric forearm fractures due to the potential for growth and remodeling. However, the treating physician must be able to define reasonable residual malalignment by answering several important questions: What are the acceptable limits of displacement at healing, and to what degree do the deformities remodel over time? How is remodeling potential affected by variables such as age and location of the fracture? Does malalignment at healing and follow-up correlate with loss of motion? What degree of documented motion loss is associated with poor function and patient dissatisfaction?

It is uniformly agreed that post-traumatic angular deformities in children have variable remodeling potential; however, it has not been consistently proved that deformities characterized by rotational malalignment will also remodel. Many studies have documented better radiographic remodeling of distal fracture and fractures in patients less than 9 or 10 years of age. It is important to realize that fracture location and age may not be independent variables. Creasman et al 22 documented better results in distal fractures; however, their patients were on average 3 years younger than patients with proximal fractures. Whether anatomic alignment correlates with final range of motion is controversial. Fuller and McCullough4 demonstrated a positive relationship with residual angulation and eventual range of motion. However, there are certainly examples of excessive malunion with good motion.

Conversely, cases of "anatomic" healing with documented motion loss have been reported. Carey et al 24 reported the follow-up data on 33 patients with bothbone forearm fractures and demonstrated average angulation of 12 degrees in patients aged 6 to 10 years and 9 degrees in patients aged 11 to 15 years. While almost all patients in the former group had full motion, those in the latter group had a small loss of rotation averaging 20 to 30 degrees. This disparity suggests that factors other than alignment may affect range of motion. Perhaps motion loss in such cases is due to contracture of the interosseous membrane from the injury and/or immobilization.

However, it is clear from in vitro studies that fracture malrotation proportionally decreases forearm rotation.27 Published discrepancies between residual angular deformity and final forearm rotation may be due to inability to accurately document and record radiographic malrotation. Finally, what is the subjective outcome in pediatric patients with fractures of both forearm bones, and does residual deformity or motion loss correlate with decreased function? Although several authors have demonstrated decreased remodeling potential in proximal fractures, Holdsworth and Sloan found that only 3 of 51 proximal forearm malunions showed marked loss of function, with a mean attendant loss of 65 degrees of forearm rotation. Studies of documented malunions demonstrate that good function can be obtained in all patients with motion loss up to 50 degrees, and that more symptomatic losses of 90 degrees can be partially compensated for with shoulder abduction. Other authors have demonstrated little functional loss with decreases in forearm rotation of 35 to 40 degrees. Higgstrom et al 3 found that some patients with a limitation of 60 degrees or less in the range of pronation and supination appeared to be unaware of their incapacity. In addition, it is conceivable that patients with initially unsatisfactory motion may have improvement with time. Although differing definitions of acceptable alignment have been delineated in the literature, many patients with residual deformity have good functional results.

Our recommendations are based on previous studies of malunion in children with relatively good function. In fractures at any level in children less than 9 years of age, we accept complete displacement, 15 degrees of angulation, and 45 degrees of malrotation. In children 9 years of age and older, we continue to accept bayonet apposition but only 30 degrees of malrotation; acceptable angulation is 10 degrees in proximal fractures and 15 degrees in more distal fractures. In distal radial metaphyseal fractures, we accept complete displacement and up to 20 degrees of angulation. In cases of completely displaced and slightly angulated distal radius fractures, it is important to inform the family that cosmetic deformity may be noted initially after fracture healing; however, remodeling can be expected to improve the appearance as long as 2 years of growth remains.

Reduction and Casting Greenstick Fractures

Historically, incomplete fractures were treated by completing the fracture and then manipulating the bones into an acceptable position. This approach has the theoretical advantage of increasing the size of the fracture callus and decreasing the risk of refracture. Currently, it is recognized that residual angulation is a result of malrotation and that the fracture should be reduced by rotating in the direction opposite to the deforming force. Traction and manipulation of the apex while rotating will often assist in the reduction. Most greenstick fractures are supination injuries with apex-volar angulation, which can be reduced with varying degrees of pronation. It can be difficult to remember whether to pronate or supinate the hand. Most fractures can be reduced by rotating the palm toward the deformity. Fractures with apex-volar angulation are a result of axial load in supination; there- fore, the palm should be rotated volarly (pronation). Fractures with apexdorsal angulation are a result of pronation force; therefore, the palm should be rotated dorsally (supination). It is not uncommon to see a greenstick fracture of one bone and a complete fracture of the other. in these cases, we use the same principles of reduction by rotation.

After reduction, the forearm should be immobilized in the same position that reduced the fracture. Studies have documented 10% to 16% rates of redisplacement when greenstick fractures were not adequately rotated in the cast. Complete Fractures Complete both-bone forearm fractures are reduced with a combination of sustained traction and manipulation. The fingers are taped to prevent sores and placed in fingertraps with the elbow at 90 degrees of flexion. Countertraction is provided by 10 to 15 lb of weight suspended from a sling over the distal humerus. The fracture and soft tissues are slowly brought out to length for 10 to 15 minutes, and the arm is allowed to find its own rotation.12 End-toend apposition is then attempted with deformity exaggeration and direct manipulation. If attempts to achieve bone apposition are unsuccessful, complete overriding of fracture fragments is accepted as long as rotation and angulation are reduced (Fig. 2). Fracture alignment in traction is assessed with fluoroscopy or plain radiography. If alignment is adequate, the distal part of the long arm cast is applied and molded while the arm is still in traction. Residual malrotation is addressed before cast application by rotating the forearm. It was traditionally taught that the hand should be casted in a position dictated by the relationship of fracture location with the insertions of the pronators and supinators. This principle is used to direct distal forearm positioning when residual malrotation is present. Because most displaced both-bone fractures are in the middle region, the hand is placed in a neutral or slightly supinated position, which usually accommodates rotation and angulation. Pronation is rarely employed for complete fractures and may result in a functional loss of supination due to soft-tissue contracture.


Figure 2A


Figure 2B

forearm-radiographs-2c.jpgfull-range-forearm-2c.jpgFigure 2C

Fig. 2A, Displaced midshaft fracture of the radius and ulna in a girl aged 9 years I month. 2B, The fracture was reduced in neutral position. Bayonet apposition with minimal angulation and no rotational malalignment was accepted. The fracture united in this position. 2C, Radiographs obtained 6 years later demonstrate complete remodeling. Clinical examination demonstrated full range of motion in pronation and supination.

Distal Radius Fractures

Distal radius fractures are reduced with a combination of traction, angulation, and rotation of the palm in the direction of the angulation. In the case of completely displaced and bayoneted fractures, sustained longitudinal traction is used with fingertraps, as previously described. After the fracture has been brought out to length, deformity exaggeration and rotation may produce end-to-end contact. It may be difficult to obtain apposition, as torn periosteum tightens around the buttonholed proximal fragments (Fig. 1). In these cases, it is acceptable to leave the fragments overlapped as long as rotation and angulation are reduced (Fig. 3). Typically, these fractures are immobilized in casts. Sugar-tong splinting is another form of immobilization commonly used immediately after reduction. If this method is selected, it is important to tighten the splint or convert to a cast when the initial swelling resolves in 2 or 3 days; high rates of reangulation in distal radius fractures have been reported. Distal radius fractures without ulnar fracture are immobilized in a lesser degree of pronation or supination depending on the apex direction. As these fractures are the result of an angulatory force as well as rotation, the position of the wrist is less critical. There is some suggestion that distal radius fractures are more stable in supination because of the action of the brachioradialis.


Fig. 3A, Distal radius fracture and intact ulna in an 8-year-old girl. Preliminary reduction failed to reduce bayonet apposition. B, After initial immobilization in a sugar-tong splint, a change was made to a long arm fiberglass cast. Early callus formation is noted along the dorsally elevated periosteum. C, Continued remodeling was noted 3 months after fracture. D, The fracture was almost completely remodeled 2 years after injury.

All fractures are eventually placed in either fiberglass or plaster long arm casts with the elbow at 90 degrees. Plaster may be easier to mold, but fiberglass permits better radiographic visualization. Casts are molded with anterior and posterior pressure applied over the interosseous membrane (Fig. 4, A). This tends to separate the bones and increase stability in the cast, and a straight ulnar border is produced. Medial and lateral molding above the humeral condyles will prevent the cast from sliding distally and angulating the fracture after swelling resolves (Fig. 4, B). Meticulous casting is critical as several studies have documented reangulation in approximately 8% to 14% of cases. 11,12,28,29 Some have blamed poor casting technique,11,28 while others have attributed the reangulation to residual rotational malalignment.7,12,30 Forearm AP and lateral radiographs are taken after reduction and immobilization, and improvements of residual angulation can then be corrected by wedging the cast. 23

After adequate reduction and immobilization, patients typically return for a followup radiograph 1 to 2 weeks after injury. Several studies have documented reangulation during the first 2 weeks. If reangulation is documented, cast removal and re-reduction under general anesthesia are recommended. Good results of re-reduction have been documented if performed within a few weeks of the initial fracture. If no reangulation is appreciated, the cast is continued for 6 to 8 weeks or until there is radiographic evidence of healing. Patients cannot participate in contact sports for 4 to 6 months, but all other activities are permitted. Refractures are uncommon; when they do occur, it is usually within several months of cast removal.

Reflex Sympathetic Dystrophy

Richard A. Bernstein, MD

Reflex sympathetic dystrophy (RSD), currently better named Complex Regional Pain Syndrome (CRPS), is a syndrome (collection of symptoms) that is characterized by burning pain (can vary from mild to severe), stiffness in the affected joints of the extremity, swelling, discoloration, skin changes (thinness, shininess, excessive sweating, hair changes), bone changes (osteoporosis), and extreme sensitivity to light touch. The severity of the symptoms can also vary widely, from just a little vasomotor changes (variation in the color of the skin from moment to moment, due to constriction of blood vessels) to rather disabling pain and almost complete joint stiffness, resulting in a useless hand or foot (the usual affected parts of the body). The rest of this discussion will only deal with CRPS of the hand and upper extremity; since this is the only part of the body I treat and have experience with. The disorder is unique in that it simultaneously affects the nerves, skin, muscles, blood vessels, and bones. One good aspect of CRPS is that the problem is self-limited (will eventually resolve by itself), although treatment can help hasten the resolution and decrease the permanent effects of it (primarily stiffness).

CRPS has been called many things in the past (RSD, casualgia, Sudeck’s atrophy, and shoulder-hand syndrome). Causalgia was first documented in the 19th century by physicians concerned about pain Civil War veterans continued to experience after their wounds from high-velocity impacts such as those from bullets or shrapnel had healed. Doctors often called it "hot pain," after its primary symptom. Complex Regional Pain Syndrome, or CRPS, is a better term because research has shown that it is more complex than just a reflex in the sympathetic nervous system. It is due to a perception of pain and other noxious input to the brain that is sustained long after the initial insult to the body has ceased. Research and clinical evidence indicates that the original injury probably occurs due to an injury to the sympathetic nervous system. (The sympathetic nervous system controls the automatic processes of the body, such as heart rate, blood flow, the stomach and intestines, and sweat glands, among other things.) When the nervous system becomes overactive, burning pain is felt and swelling and warmth are left in the affected arm. If not treated, CRPS can cause stiffness and loss of use of the affected part of the arm.

CRPS-with-reddened-joints.jpgFigure 1
On the right, the swollen, painful hand of
early CRPS with reddened joints.

What causes CRPS?

This is a much more complex question than you may realize, and it is an area of vigorous research that is targeted and supported by the National Institutes of Health. In some cases, the cause of CRPS is unknown. Why any one particular injury will result in CRPS and another similar injury to the same patient did not, is not clear. Why one particular surgery will result in CRPS, when hundreds of seemingly identical surgeries in other patients did not, is unknown. To say that CRPS developed "after" a surgery also does not answer the question of "what caused the CRPS?" "After" does not mean "because of" (for those of you interested in Logic, this is the "post hoc, ergo propter hoc" falacy), nor does it tell us anything of the mechanism of its causation.

Often an injury such as a fracture or a laceration can cause CRPS, or the symptoms may appear after a surgery. The onset of symptoms is not immediate, and may lag about 3 weeks or so from the event that we think probably caused it, so identifying the cause can be difficult to impossible. Other causes include pressure on a nerve, infection, cancer, neck disorders, stroke, or heart attack. We think that the common event in all of these conditions is a painful injury, probably involving a nerve. It is theorized that these damaged nerves send inappropriate signals to the brain, interfering with normal information about sensations, temperature, and blood flow. The incidence of CRPS does not seem to be more common after large injuries, and can follow even relatively minor injuries that do not obviously involve a nerve.

Until recently, doctors thought that CRPS always involved a problem in the sympathetic nervous system (as I noted above, the sympathetic nervous system controls the automatic processes of the body, such as heart rate, blood flow, the stomach and intestines, and sweat glands, among other things.) They also thought that the problem involved a reflex arc, from the injured part to the spine and back to the arm. This is where the term "Reflex Sympathetic Dystrophy" came from. (The "dystrophy" part came from the muscle atrophy that developed in untreated arms.) Research has shown that, while this may explain some cases, it does not explain all, or possibly even most, cases.

If SMP does not explain the pain in most patients with CRPS, what is the cause of the pain? Experts agree that there are problems in the peripheral nervous system (the nerves in the body) and the central nervous system (the brain and spinal cord) of patients with CRPS, but the details are not known. There are other factors that could be involved in the development of CRPS because they directly affect the activity of the nervous system, muscles and bones. Examples of these factors are emotional issues or stress (see section below on personality types) and not using a painful body part. One thing we know for certain: many pathological processes are at work, the condition affects more than one organ system in the extremity, and that pain is the predominant symptom experienced by the patient. This is why the term "Complex Regional Pain Syndrome" is a better name than "Reflex Sympathetic Dystrophy". RSD, however, is such a well established and widely-used term, it will not disappear from the medical vocabulary.

We now know much more about the sympathetic reflex, and this sort of pain is now called "sympathetically maintained pain", or SMP, and is found in other conditions as well. The only way a doctor can find out if a patient has SMP is to do a sympathetic nerve block. (Sympathetic nerve blocks are injections of a numbing drug, called a local anesthetic, into different sites in the body). A person suffering from CRPS can be said to have SMP only if he or she has good pain relief from a sympathetic block.

Signs and symptoms

The symptoms of CRPS usually occur near the site of an injury and include: burning pain, muscle spasms, local swelling, increased sweating, joint tenderness or stiffness, restricted or painful movement, and changes in the nails and skin. One visible sign of CRPS near the site of injury is warm, shiny red skin that later becomes cool and bluish. The pain that patients report is out of proportion to the severity of the injury and gets worse, rather than better, over time. It is frequently characterized as a burning, aching, searing pain, which may initially be localized to the site of injury or the area covered by an injured nerve but spreads over time, sometimes involving an entire limb. Pain is continuous and may be heightened by emotional stress. Moving or touching the limb is often intolerable. If untreated, the joints may become stiff. As you can imagine, there can be significant psychological effects of CRPS, due to the severe and chronic nature of the pain and disability.

The symptoms of CRPS vary in severity and duration, with the majority of cases being very mild, with more stiffness and tenderness than would be expected after an injury such as a distal radius fracture. However, some rare cases can be severe. There are usually three stages associated with CRPS, and each stage is marked by progressive changes in the skin, nails, muscles, joints, ligaments, and bones.

The pain associated with reflex sympathetic dystrophy is often described as burning in nature. Swelling can cause painful joints and stiffness. The color of the skin can vary from reddish to purplish to pale, varies with the stage of the disease, and can vary by the minute.

short-circuit-in-the-nervous-system.jpgFigure 2
This diagram shows how a nerve injury may cause a “short circuit” in the nervous system resulting in sympathetic overactivity in the hand with burning pain, swelling, and increased sweating.

Stage I (acute) usually starts after a delay of three or four weeks and lasts up to about three months. During this stage the symptoms include pain (usually described as a burning pain, which can be severe) and swelling, increased warmth in the affected part/limb, and excessive sweating. There may be fasterthan- normal nail and hair growth and joint pain during movement of the affected area (Figure 2). An unusual aspect of CRPS is how it can affect the muscles that control the diameter of skin blood vessels. The innervation of the muscles is probably the reason for the condition, and the nerve impulses to the blood vessels can rapidly vary, with the result that the skin color can vary from pale to red or bluish in a matter of a minute or so. This is called vasomotor instability.

Stage II (dystrophic) can last three to six or twelve months. The pain is often increased and can be more widespread. The hand or arm can be more sensitive to touch. Swelling is more constant, skin wrinkles disappear, skin temperature becomes cooler, and fingernails become brittle

Stage III (atrophic) occurs from one year on. The skin of the affected area is now pale, dry, tightly stretched, and shiny. The area is stiff, pain may decrease, and there is less hope of getting motion back.

It should be noted that recent research has challenged the concept of CRPS progressing through stages (see the official journal of the International Association for the Study of Pain, Pain, Vol 95, No.s 1-2, January 2002, page 119-124, Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome?" These authors found in a study of 113 patients that symptoms were stable and did not progress through 3 stages, but that the IASP's two sub-types did exist. More research is ongoing. For now, there is some utility in the concept of stages, but you should be aware that it may not be the best description of the disease.

Who gets CRPS?

Anyone who has an injury or surgery (either elective or for an injury) can develop CRPS. However, there do seem to be certain things which may increase the incidence of CRPS. It is more common with injuries to nerves or injuries that are very painful (probably involving an unrecognized nerve injury), often between the ages of 40 and 60. It affects both men and women, but is most frequently seen in women. It affects all personality types, but seems to be more common in Type B (passive) personalities than in Type A (active) personalities, although this categorization of people's psychological makeup is rather crude and may not be of much value. My professional experience supports this general concept; however, I have had two very strong Type A patients who have gotten severe CRPS. Investigators estimate that two to five percent of those with peripheral nerve injury may develop CRPS.


The diagnosis usually is made when at least three of the following symptoms are present: pain and tenderness, signs of changed blood flow (either increased or decreased), swelling with joint stiffness, or skin changes. The prognosis is good if the CRPS is diagnosed early and treated aggressively. The confusing nature of the condition and it causes as well as its variable presentation often leads to a delayed diagnosis. It is not easy to either diagnose or treat. Many physicians do not have the patience to deal with the complexity of the condition, the patient, and the treatment.


Early diagnosis and treatment are important. Three forms of treatment may be combined: medication, physical therapy, and surgery. Medication taken by mouth can help decrease the symptoms. To reduce symptoms and provide long term relief, local anesthetics may be injected into a nerve bundle at the base of the neck (stellate ganglion block). In some cases, a tourniquet is applied to the arm and medication can be injected into a vein along with an anesthetic. Your hand surgeon may recommend therapy by a hand, occupational or physical therapist, or physician. Therapy is important to regain function and reduce discomfort caused by RSD.

Successful treatment depends upon the patient’s full and active effort in therapy. Occasionally surgery is performed in the later stages, but the results can be disappointing. This is certainly a case where good patient education and teamwork between the doctor, the patient, and the certified hand therapist is important in obtaining good results.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10


Scaphoid Fracture Treatment - Conservative and Surgical

Richard A. Bernstein, MD


Left: an x-ray of the wrist showing a scaphoid fracture.


Right: diagram of the wrist showing the position of the scaphoid.

Fractures of the scaphoid, a bone in your wrist, are not to be taken lightly. This is the only bone of the body that I know of that has an entire book written about how hard it is to diagnose and treat scaphoid fractures, and what to do when a fracture does not heal! Most of the time, a broken bone is obvious. The area around the break may be painful, swollen or deformed. But sometimes a bone can break without your realizing it. That ’ s can happen to the scaphoid (pronounced "skaf'-oyd"). Some doctors call this bone the "navicular", but this is an older, out of favor term. Many people with a fractured scaphoid think they have a sprained wrist instead of a broken bone because there is no obvious deformity and very little swelling. If you’ve fallen and think you’ve sprained your wrist, call Dr. Bernstein for an appointment as soon as possible. Rest your wrist until you get seen.

The scaphoid bone is located on the thumb side of your wrist, close to the lower arm bones (see the diagram and x - ray at the top of the page). It is shaped like a cashew, which makes it hard to visualize on the x - ray.

The reason scaphoid fractures have a hard time healing is due to the anatomy of the blood supply to the bone. The blood supply is what keeps the bone alive and allows it to heal. Most of the bone is covered with cartilage, the smooth shiny material that forms the joints and allows the bones to move. Blood vessels cannot enter through the cartilage; they enter only through the bone. Since the scaphoid is mostly covered in cartilage, there is a limited area for the arteries to enter the bone. In the scaphoid, the blood supply to the bone enters from the distal end, that is, the end toward your fingers. This can be a problem for healing, since most fractures occur in the middle or lower portion of the bone. The blood supply to the proximal fragment, that is, the piece that is toward your elbow, may not have any blood supply. Without a blood supply, the bone cannot heal and that fragment may die.

Who Gets Scaphoid Fractures?

Scaphoid fractures account for about 60 percent of all wrist (carpal) fractures. They usually occur in men between ages 20 and 40 years, and are less common in children or in older adults. The break usually occurs during a fall on the outstretched hand. It ’ s a common injury in sports and motor vehicle accidents. The angle at which the hand hits the ground determines the injury. The following is a very rough "rule of thumb": If the wrist is bent at a 90 - degree angle or greater, the scaphoid bone will break; if the angle is less than 90 degrees, the lower arm bone (radius) will break.

Signs and Symptoms

  • Pain and tenderness on the thumb side of the wrist.
  • Motion (gripping) may be painful.
  • May be some swelling on back and thumb side of wrist.
  • Pain may subside, and then return as a deep, dull aching.
  • Marked tenderness to pressure on the "anatomical snuffbox," (a triangular-shaped area on the side of the hand between two tendons that lead to the thumb.)


The diagnosis is based on a history of trauma to the wrist (usually a fall or accident), a clinical exam that shows tenderness in the region of the scaphoid and a painful Watson test (a maneuver in which the wrist is moved back and forth, with the examiner's thumb on your scaphoid; it is just slightly painful), and x - rays that show a fracture. Sometimes, the x - ray does not show a fracture. In some cases other X - rays are needed to diagnosis the problem. Usually, with a supportive history and clinical exam, the diagnosis will be made of a probable scaphoid fracture.


Treatment is determined by the fracture site, the degree of displacement , any associated injuries, and the patient's occupation and desires.

Cast Treatment: Many scaphoid fractures are treated with immobilization in a cast that immobilizes the elbow, wrist, and thumb, for six weeks, and then only the wrist and thumb for an additional six weeks. Healing time, however, can range from six weeks for fractures in the top portion (toward the fingers) to six months or longer for fractures in the lower portion (toward the wrist). The cast must be checked regularly to make sure that it fits properly and prevents movement. After the cast is removed, a rehabilitation program helps restore range of motion and strength.

scaphoid-fractures-3.jpgSurgical Treatment: Some fractures are displaced by 1 mm or so. These usually need surgical treatment. Scaphoid fractures that are accompanied by other injuries, usually a distal radius fracture, also need surgery. Also, with newer techniques, the risks of surgery are reasonably low that some patients choose surgery, because it usually means the patient does not need to we are a cast at all, just a splint. Over the last few years through a limited approach we can address scaphoid fractures and avoid cast immobilization. Via a small incision, I can introduce a screw into the scaphoid and minimize the time in a cast. As with any surgery there are risks with this procedure, there is still no guarantee that the scaphoid will heal and there are risks to the wrist and tendons. The pros and cons are something that we can talk about in the office.

Not all scaphoid fractures will heal properly. The usual causes are delay in treatment or too short a time in a cast that is too short. Smoking also interferes with bone healing. However, the scaphoid is rather famous for not healing, even when everything is done properly. Surgery is usually recommended when the scaphoid fails to heal (non - union). Surgery for non - union is successful in approximately 75 percent of cases.

Sometimes a bone graft is used to promote healing. There are two types of bone grafts. One is using your own bone, often times from the radius bone of the forearm. This can bring in new bone cells to help fill the gap. The other type of bone grafting is taking a segment of bone from the radius and moving it to the scaphoid attached to a microscopic blood vessel. There are certain times to do one or the other that we can discuss in the office.

Scaphoid fractures often take a long time to heal. Any delay in getting treatment increases the risk of poor healing and the probability of more problems later. An untreated scaphoid fracture can lead to severe arthritis and eventually require surgery to fuse or replace the joint.

Copyright © 2010, TOG All rights reserved.
Revised 4/1/11

Tendon Lacerations

Richard A. Bernstein, MD

What is a tendon?

Tendons are tissues that connect muscles to bone, allowing the force of the muscles to move the joints. A ligament is different, connecting a bone to a bone; its cells are different from the cells of a tendon, so there are other differences besides just what it connects to what. The muscles that move your fingers and thumb are located in your forearm, above your wrist. Long tendons extend from the muscles through the wrist and attach to the small bones of your fingers and thumb. The muscles and tendons that flex your fingers (make a fist) are called flexor muscles and flexor tendons. The ones that open your fist are called extensors. There are many important differences between flexor tendon injuries and extensor tendon injuries.


The white, cord-like structures are the tendons in your wrist that move your fingers.


There are two flexor tendons in each finger, the flexor digitorum superficialis (Latin for finger flexor that is closer to the surface, or superficial), also called the FDS, and the flexor digitorum profundus (Latin for the finger flexor that is deep). The FDP attaches to the last bone of the finger and bends the tip. The FDS bends the middle joint of the finger. They have a very specialized blood supply. Since they move back and forth, they are not connected to the rest of the hand The white, cord-like structures are the tendons in your wrist that move your fingers. except at certain places, such as the muscle where they come from, the bone where they go, and a specialized structure called the vinculum (Latin for chain or fetter, i.e., something that holds something down). The thumb has one tendon. See the pictures below.

The flexor tendons run along the palm side of the fingers and are very close to the surface of the skin, particularly where the skin folds as you bend your fingers. The extensor tendons run along the back side (not the palm side) of your fingers and are also very close to the skin.

If you tear (rupture) or cut (sever) the tendon anywhere along its route—at the wrist, in the palm of the hand, or along the finger, you may be unable to bend your finger. If you injure the FDS tendon, you may still be able to bend the finger, but not completely, and bending the finger will be painful.

Tendons are stretched tightly as they connect the muscle to the bone. If the tendon tears, the end connected to the muscle will be pulled back in toward the palm. Because the tendon can’t heal unless the ends are touching, a severed tendon must be sewn back together again (a surgical repair).

tendon-lacerations-open-fingers.jpgThis illustration shows the flexor tendon pulley system (labeled A1 to 5 and C1 to 3). The tendons are below the pulleys, and can be seen in the smaller cross section to the upper left.


This illustrates the two flexor tendons, the FDP and FDS, as well as their blood supply that comes through the long and short vincula.

Types of injuries

Most often the flexor tendons are damaged by a cut. Because the nerves to the fingers are also very close to the tendons, a cut may damage them as well, resulting in a feeling of numbness on one or both sides of the finger.

Athletic injuries are also common, usually in football, wrestling or rugby. One player grabs another’s jersey and a finger—usually the ring finger—gets caught and pulled. This type of injury is so common, it even has a name: "jersey finger." You can also strain or rupture the tendon while rock climbing.

People with rheumatoid arthritis may experience a spontaneous rupture of the flexor tendons. You may notice that the finger no longer bends, but cannot recall when you lost the ability to bend it.

Signs and symptoms of a cut tendon

  • An inability to bend one or more joints of the finger
  • Pain when you bend your finger
  • An open injury, such as a cut, on the palm side of the hand, particularly in the joint area where the skin folds as the finger bends
  • Mild swelling over the joint closest to your fingertip
  • Tenderness along the finger on the palm side of the hand
  • Diagnosing your injury

Give me a call if you injure your fingers, especially if you cut your finger or "jam" it and notice that you cannot bend or straighten the tip. For immediate first aid, apply ice and compression to slow the flow of blood to the damaged site.

In the office, I will ask you to bend and straighten the fingers and may apply resistance to test the strength of the fingers. I may also test the sensation and blood flow to your fingers to see if any nerves or blood vessels were also injured. You may need to get an x-ray to see if there is any damage to the bone; if you have an open wound, you may need a tetanus shot or antibiotics.


I may first clean and treat any superficial wounds and put your hand in a splint. Flexor tendon injuries require surgical repair and it’s best to have the surgery soon after the injury. I will sew the tendon together using special stitches on both the inside and outside of the tendon. It can take up to 3 months before the repair is healed and strong enough to use your hand without protection. It may take another month or so before you can use your hand with any force.

In the meantime, you will need to wear a splint and see a certified hand therapist. The therapist will give you special exercises to perform. Follow my instructions and that of the therapist carefully to ensure the best possible result. This means both preventing adhesions, which will bind the tendon down and prevent you from moving your finger, and a tendon repair rupture, which is the worst of all, since you are back to square one.


The results after surgery depend on many factors: the location and nature of your injury, the delay between injury and first seeing a doctor, the difficulty of the repair and the skill of the surgeon, and (very importantly) how well you cooperate with post-operative hand therapy. You will experience some stiffness in your finger, but it will improve over a period of two years, and you can dramatically decrease the stiffness by working on range of motion exercises that will be given to you by the hand therapist. You will almost certainly have use of your hand, and probably you have a very good chance of nearly normal use of your hand. The results depend on many variables. I will discuss your particular case with you at the time of the first visit, after the surgery, and as you progress through your rehabilitation.

Copyright © 2010, TOG All rights reserved.

Revised 12/21/10

Tennis Elbow

Richard A. Bernstein, MD

Tennis elbow is a terrible name! The reason is it a terrible name is that is it wrong in both words! It usually is not from tennis and the problem is not what you do with your elbow! Although the pain is at the elbow, the problem is what you do with your wrist and fingers. Its medical name is "lateral epicondylitis", which is more correct but still misleading. Patient education is probably more important in tennis elbow than in almost any other condition I treat. If you don't teach yourself about your condition, you will probably continue to injure yourself. If you learn about the condition, modify how you use your arm and hand, about 92% of people can avoid surgery. Let's go!

What is tennis elbow?

Tennis elbow is a type of painful tendinitis. More precisely, lateral epicondylitis is due to a tear and resulting inflammation (that is why the name ends in "-itis", which means inflammation) of the collagen fibers that attach the forearm extensor muscles to the outside of the elbow (which called the lateral [or outside] epicondyle [or end of the bone]). This is diagrammed in the illustration below. The extensor muscles extend (lift) the wrist and hand. The muscles also have to contract when you make a firm grip, in order to extend the wrist and allow you to close your fingers forcefully. (Just try to make a firm grip when you are fully flexing your wrist!) The muscle which is usually the most irritated is the extensor carpi radialis brevis. This name is just Latin that means "the short muscle that extends the wrist". It is the middle muscle in the diagram below. The collagen fibers that connect the muscle to the bone are a combination of tendinous fibers and some specialized fibers called Sharpie's fibers (both are shown in green in the diagram below). In the elbow, the common origin is well-developed and looks like a flat strap of

This is a view of the outside (lateral side) of your elbow, with your hand to the right. The common extensor muscles are in brown and the common origin in green.

Forceful muscle contractions in the common wrist extensors may result in pain where the se fibers attach to the bone on the outside of the elbow or along the muscles in the forearm. Pain is usually aggravated by any forceful gripping and lifting with the hand in certain positions (palm down, called pronation). Pain is usually more noticeable during or after stressful use of the arm. There may be swelling on the side of the elbow, but this is usually minimal. In severe cases, lifting and grasping even light things may be painful.

The name "tennis elbow" came from the fact that beginners who take up tennis or other acquet sports sometimes develop this problem from improper playing technique. The condition arises in beginners, who think a backhand is a wrist motion. Experts know that shoulder muscles are larger and stronger than wrist muscles, so they use shoulder muscles for a backhand. Medial epicondylitis or “golfers elbow” is a similar condition that occurs on the inside of the elbow. The condition is quite common in our late 30s and early 40s.

What causes tennis elbow?

Although tennis elbow can arise for no obvious reason, the most common situation in which tennis elbow develops is following unaccustomed strenuous activity involving the arm and hand. This could be activities such as using a screwdriver to place a few dozen screws, or scrubbing a floor vigorously. It also commonly develops in people who are increasing their level of activity in work or recreation that requires wrist extension and/or firm grip.

The area of the common origin is hard and pushes against the side of the bone. It does not stretch or easily accommodate swelling, and if irritated by sudden overuse, pressure may build up and cut off the blood supply to the middle of the tendon. The tendon wraps around an area where the bone sticks out, and pressure between this bone and the hard outer layer of tendon may squeeze the inner parts of the tendon like a nutcracker. This can be very painful!

Once the fibers in the common extensor origin are torn, the fibers of origin may not be able to heal unless you rest them, or may heal very slowly over many months if you do not rest them long enough. This slow healing may have to do with decreased circulation in the common extensor tendon, but also because the area is stretched and twisted by normal movement of the elbow, making it hard for irritated areas to rest. If you do not change how you are using your wrist and hand, you continue to injure the common extensor tendon.

Tennis elbow is usually a chronic problem. Patients do not know why their elbow is hurting, so they continue to injure themselves, overusing the extensor muscles of the forearm and tearing the common origin. This sets up a vicious circle of tearing the fibers, some healing (tendinous tissues like Sharpie's fibers heal by scarring), and then repeat tearing before the healing has had a chance, and further scarring.

What can you do to help?

The most important thing to do is first, learn why and how the elbow is being reinjured.

You must completely stop activities that cause the pain, such as heavy lifting with the palm facing down, firm gripping, or repetitive or resistive wrist extension. No other treatment will be helpful if you the area is continually reinjured and stop the vicious circle of tearing and healing and tearing again before the healing scar can mature and accept that load, nothing else (pills, splints, exercises) will work!

Ice for five to fifteen minutes at a time on the area which is most swollen and tender. After the acute stage has resolved, healing (scar formation) has had a chance to take place, and the scar has matured to the point that it can take some pulling by the muscles; you can start to slowly and gently resume activities.

It is very important that you not overuse your arm while the healing is taking place. If it still hurts, even a little, you are overdoing it! The only way to break the cycle is to rest your arm until the vicious circle is broken.

Sometimes a band wrapped around the forearm near the elbow (tennis elbow strap) can be used to protect the injured muscles as they are healing. Anti-inflammatory medication can be taken by mouth. In severe or long-lasting episodes, an injection of steroids into the area may relieve the discomfort. There is some controversy about cortisone for tennis elbow. We should discuss this in the office, though I do find an injection can help many people. The therapist will teach exercises that stretch and strengthen the muscles to help prevent the condition from returning. Some patients respond to additional treatment through therapy. As the condition improves, there is usually a slow return to normal activities. Recurrence of this condition is common.

Exercises should not be performed until the area is no longer swollen and tender. If, during the course of strengthening the muscles, you experience tenderness and/or pain, STOP! You are starting the vicious circle all over again. Rest until you can do the exercises without pain. Lateral epicondylitis is often a nagging or chronic condition sometimes requiring many months for healing to occur.

If nonsurgical forms of treatment do not eliminate the pain of this condition, surgery may be recommended. I need to discuss with you the surgical treatments for lateral epicondylitis and the possible outcomes.

Injection of blood

The problem in tennis elbow is a lack of adequate healing. An injection of your own blood can help.

What can a therapist do to help?

The most important thing a therapist can do is to help to teach you about the anatomy of the area and the mechanism of injury. They can help identify aggravating activities and suggest to you alternative postures. They can provide a forearm strap or wrist brace to help protect the irritated area. They can instruct you in a home program of massage, heat, ice and other treatments aimed at making the area more comfortable. Once you have let the scar tissue mature, they can supervise a set of progressive exercises designed to gradually strengthen and recondition the irritated muscles. Remember, however, even if the therapist has given you exercises to do, STOP if you experience the pain returning.

Copyright © 2010, TOG All rights reserved. Revised 12/21/10

The Benefits of Orthopaedic Ultrasound

By Richard A. Bernstein, M.D

Over the last few years, the use of musculoskeletal ultrasound has gained increased popularity.  Ultrasound has been used for decades in many aspects of healthcare for its noninvasive nature and avoidance of exposure to ionized radiation.  Though the bony architecture is not visualized in detail, ultrasound provides incredible insight into the soft tissue structures of the musculoskeletal system.  Historically, musculoskeletal ultrasound has been primarily utilized by radiologists due to equipment costs.  As the technology evolved portable ultrasound has become a cost effective tool in Orthopaedic practice. Noninvasive musculoskeletal ultrasound allows a quick and immediate visualization of soft tissues.


In-office ultrasound allows visualization of partial and full-thickness rotator cuff tears, examination for calcific deposits within the shoulder and also allows for greater accuracy in injecting the specific areas around the shoulder.  Anatomic landmarks were relied on for years to inject the acromioclavicular joint, subacromial space and glenohumeral joints.  However, the advent of musculoskeletal ultrasound helps increase the reliability and accuracy of these injections.  Anatomic visualization of the rotator cuff may now also be done in the office setting.  It does not preclude the use of magnetic resonance imaging (MRI) for labral or other rotator cuff pathology, but ultrasound is a painless inexpensive test, now at our disposal.


Similar to the shoulder, the use of ultrasound aids in the diagnosis of both medial and lateral epicondylitis and cubital tunnel syndrome.  The accuracy of intra-articular aspirations and injections has improved utilizing ultrasound technology.

Hand and Wrist

One of the greatest advantages of in-office ultrasound is the evaluation of hand and wrist soft tissue abnormalities.  The subcutaneous position of these abnormalities allows relatively easy access for diagnostic assessment.  Aneurysms and ganglia may be differentiated by color Doppler ultrasound. For example, a mass that is fluid filled may be a ganglia, whereas a solid mass may be a tumor. Most foreign bodies are non-radiopaque, but diagnostic ultrasound allows the visualization of small foreign bodies buried in the subcutaneous tissue. 

Ultrasound-Machine-for-Bernstein-article-wrist.pngThe differential diagnosis of radial wrist pain includes basal joint arthritis or deQuervains tenosynovitis of the first dorsal compartment.  Identifying the diagnosis clinically may be challenging. However, ultrasound of the first dorsal compartment may show tenosynovial inflammation and thickening of the first dorsal compartment which guides the differential diagnosis.  Thickening or enlargement of the first dorsal compartment may also be easily visualized on ultrasound. In an inflamed wrist, the addition of ultrasound may guide a corticosteroid injection into an inflamed sheath and improve its efficacy.

Superficial traumatic hand lacerations may affect the integrity of underlying tendons. Ultrasound may visualize the intact or lacerated flexor tendons thereby eliminating a need for surgical wound exploration. Foreign bodies may also be readily visualized in the office setting and thereby avoid expensive and time consuming testing.

Ultrasound-Machine-for-Bernstein-article.pngAnother advantage of diagnostic ultrasound is in the diagnosis of carpal tunnel syndrome.  Ultrasound allows for visualization of the median nerve in the wrist. Multiple studies have demonstrated that a median nerve cross sectional area greater than 10mm is consistent with carpal compression.  In hopes of avoiding useful though invasive, neuro-diagnostic testing, a faster painless noninvasive ultrasound may give significant information regarding the diagnosis of an entrapment neuropathy at the wrist.  Furthermore, aspiration and injection of the smaller joints of the hand and wrist are far more accurate with ultrasound guidance. This minimizes patient discomfort.

The rheumatology literature has also reported the beneficial use of ultrasound to identify early inflammatory arthritis. A patient may present with one inflamed finger joint but be found to have inflammatory synovitis of multiple digits by ultrasound, thereby warranting further serologic investigation.

In summary, the utility of musculoskeletal ultrasound is an incredible advantage to the physician and it is an even more important benefit to the patient as it allows for a definitive diagnosis and more effective, less painful treatment.

Trigger Finger

What is trigger finger or trigger thumb?

Trigger finger and trigger thumb are some most common conditions I treat. It is due to a swollen part of the tendon at the base of the digit. It can cause a painful popping and clicking in the finger or thumb as the patient flexes or extends the digit. It is very common for this to occur just when you wake up in the morning. If the condition is not treated, it will commonly worsen to the point that you cannot fully straighten the finger (or sometimes cannot flex, although that is less common). The painful popping and clicking is called "triggering" (this is where the name comes from) and the inability to fully straighten is called "locking". To better understand how this happens, look at the illustration below.


The Palm of the Hand

This is a view of the palm side of the hand. The tendons, shown in white, pass into the finger inside a tendon sheath. This sheath functions to keep the synovial fluid (the "tendon oil") around the tendon. The synovial fluid lubricates the tendon as it moves back and forth in the finger. The beginning of the sheath is called the A1 pulley. Note the digital (finger) artery and nerve. They are very close to the pullies. The illustration below shows an enlarged view of the pulley system.


Enlarged View of the Pulley System

This illustration shows the tendon sheath, and shows how it has some thicker regions that are divided into regions. The A1 region is the one that gets involved in trigger finger. There is a similar division, but much simpler, in the thumb.

The purpose of the pullies is to keep the tendons close to the bone (see the smaller illustration above, to the left). As the finger bends (flexes), the pullies prevent the tendons from sagging away from the bone.

In trigger finger, there is some swelling of the tendon, due to a variety of factors, mostly processes of aging. The swollen part of the tendon "pops" under the A1 pulley, causing the finger to "pop" or not bend smoothly. Often the patient thinks it is the joint that is popping, but it is the tendon that moves that joint that is popping.

What causes trigger finger?

We do not know exactly what causes trigger finger, but we do know some things. The tendon is subjected to significant forces at the A1 pulley, which is where trigger finger occurs. Trigger fingers show changes in the substance of both the tendon and the pulley called "fibrocartilaginous metaplasia", which means that some of the cells change into cells that have the characteristics of cartilage cells such as those found in intervertebral disks. The cells show an increase in both the size of the cells and the number of cells. The smooth gliding layer of the tendon and the pulley change, with fraying and disintegration of the surface. We do not see these high forces or cellular changes in other areas of the flexor tendons, therefore we feel that these changes must be related to the disease called trigger finger. (Trigger Digits: Diagnosis and Treatment, by Miguel J. Saldana, MD; Journal of the AOS, July/August, 2001, pages 246-252)

What are the symptoms of trigger finger?

The hallmarks of trigger finger is painful popping of the digit and pain in the palm at the A1 pulley level. The popping is usually worse in the morning when you first get up, but as the problem progresses, it can pop all the time. When it is really bad, the bump in the tendon cannot pass under the pulley and the finger is "locked", that is, it cannot straighten (or bend, if it is stuck out straight).

Who gets trigger finger?

Many people think trigger finger should come from a long history of hard work, but hard labor does not seem to be related. It can come from an episode of overuse, but is usually not associated with any period of heavy use. It usually comes on gradually, and typically comes in our 40's, 50's, and 60's. It is about two to three times more common in women than in men, and the fourth finger is the most often involved. It is common for patients to get it in more than one finger. If they do, it is often either the same finger in both hands, or two adjacent fingers. I have only had one patient who had it in all 10 fingers, and he was a 60 year old who played handball. I think if you are 60 and go around whacking things with your palm, you should expect to get problems! Most patients will get it in only one or two fingers.

How is trigger finger diagnosed?

The diagnosis is made by listening to the patient and by examining the patient. Most patients will have a history of painful clicking and popping, without any history of trauma. There will be a painful nodule in the palm, exactly at the A1 pulley location.

How is trigger finger treated?

Making the diagnosis is usually quite simple. The next step is very important: patient education. The third step in my general treatment regimen for all hand problems is activity modification. This step does not really apply much to trigger finger. It is usually not due to overuse. The fourth step in my general treatment regimen for all hand problems is anti-inflammatory medication. This usually does not help in the treatment of trigger fingers. It is not strictly an inflammatory condition, since the changes are not just the changes of inflammation, but of fibrocartilaginous metaplasis (see section above for explanation).

The fifth stepis splints. While they will work as long as you wear the splints, you will not be able to do anything with your hand. If the trigger digit was minimally symptomatic and you happened to do something that made you hand swell, a temporary splint may help. What is easy and can help is to tape the finger at night. By placing a one inch piece of tape lightly around the joint helps to comfortably splint the finger in extension and avoids a common problem of a painfully locked finger in the morning. Once up, remove the tape and start some normal use; some stiffness in the morning is common. The sixth step in my general treatment regimen for all hand problems is hand therapy. While I use a lot of hand therapy in my practice, there is only a little that hand therapy can offer this condition.

The seventh step in my general treatment regimen for all hand problems is steroid injection, and this is a great way to treat trigger fingers. I presented a study at the American Society for Surgery of the Hand showing that one injection was curative (through 2 years of follow up) in 75% of cases, and a two injections in 90%, pretty good odds. It is not a good idea, in general, to give more than 2 injections in any one location in the body, as it can cause some collagen degeneration. You can have 2 in each involved finger.

The final step is surgery. About 10% of trigger fingers go on to surgery. The longer you waited to come see me, the greater the chance that you will need surgery. It is out-patient surgery (that is, you don't stay overnight in the hospital). You don't even have to eat the hospital food!

Surgical Risks

What can go wrong?

Fortunately, most surgical procedures have a very low complication rate and a very good rate of success. However, the results of surgery cannot be guaranteed; complications can occur despite the best of intentions. Though I cannot list every possible problem, I will highlight the most common complications.

  • Anesthesia
  • Infection
  • Nerve or tendon injury
  • Stiffness


What type of anesthesia do I use?

I recommend that most surgery be done under a local type of anesthesia. In many cases I will administer the local anesthetic myself which is a combination of a short and long acting Novocain-like anesthetic. Most of the time, the anesthesiologists will be there to comfort you and provide the level of sleepiness that you desire. You can be as awake or as sleepy as you wish; my preference, to minimize any postoperative side effects is for you to be awake so we can talk through the surgery. Some very small cases will be done with the local anesthetic only. For surgeries requiring more medication, the anesthesiologist can do what is referred to as a regional block to numb a larger portion of the arm. Occasionally for the more complex surgeries, you will require a general anesthetic. People may react to the medications given and they can rarely affect your heart, lungs or other organs, which is why I try to use the least invasive anesthetics.

What about bleeding?

For virtually all the surgeries I do, excessive bleeding is usually prevented by a medical tourniquet. This is a blood pressure type cuff applied to your arm at the time of surgery. By wrapping the arm with a rubber bandage, the blood is removed and the blood pressure cuff is inflated to minimize blood loss and allow me to best visualize the anatomy of your arm.


Do infections occur with hand surgery?

Fortunately infections are rare and usually occur in less than 1% of cases. If you have no significant allergies, I will have the anesthesiologist administer an intravenous dose of an antibiotic, usually one known as Cefazolin. This is in the category known as Cephalosporins that cover most of the common skin bacteria. Despite sterility and antibiotics, infections may occur. If you have any concerns for infection after surgery, please call my office. Infections may require hospitalization, further surgery and intravenous antibiotics.

Nerve and Tendon Injuries

Nothing else can happen, right?

Fortunately rare, but unfortunately these injuries may cause a significant complication. Nerves, tendons and blood vessels run close to each other in the intricate anatomy of the hand. I do most of my surgeries wearing magnified glasses to define these structures but injuries may occur that could require further surgery or may lead to permanent problems with hand function.


I am a firm believer in hand therapy by individuals trained in this capacity. After most surgeries, we will have you see the therapist to not only work with you, but to teach you what to do on your own to maximize your result. Complex regional pain syndromes are rare and serious conditions.

After Surgery

What should I expect after surgery?

You will leave the operating room in a very large bulky dressing which serves two purposes. First it helps control the swelling. Second, because of the tourniquet that I described above, the bandage helps provide compression to minimize bleeding, sort of like holding pressure on a bloody nose. What ever is out of the dressing you can move but keep the dressing in place. If you have any concern that it is too tight, the fingers change color, you cannot feel your hand or you have unexpected pain or fevers call my office at any time (203-865-6784).

Will it be painful?

I usually use a long acting Novocain-like medication called Bupivicain. This can block the pain for six to eight hours after many surgeries. You will also be given a prescription for pain medication to help the discomfort. Most of these contain Tylenol so do not take Tylenol at the same time, but you can alternate Tylenol with the prescription medication at 4 hour intervals. Anti-inflammatories like Ibuprofen can be taken at the same time, as long as you have no medical contraindication to these types of medications. However, if your surgery was for a fracture or fusion, studies have shown that anti-inflammatories do interfere with bone healing so I suggest avoiding them in this situation.

Can I smoke cigarettes?

As a physician, my request for all my patients is to stop cigarette smoking period, based on its bad health effects. Before surgery, cigarette smoking affects the lungs and increases your complication rate with anesthetics. Post operatively, cigarette smoking significantly affects healing, so if you smoke, use your surgery as a good reason to stop.

When will I return to the office?

When you leave the operating room, there will generally be two appointment cards, one for the therapist and one for me. For many surgeries you will see the therapist first who will remove the dressing, splint you if appropriate, and start you on an exercise program. They will work with you and explain what you should do on your own.

When do the sutures come out?

Depending upon the surgery, it is usually 7 to 10 days after the procedure. Generally, I do not using absorbable sutures except in young children, since the scarring is worse than with sutures that we remove. We try to make all your appointments in the office next convenient for you. However, because of the timing for suture removal, this one appointment might be in a different office.

When can I get it wet?

Keep the wound clean and dry until after the sutures are removed.

Therapy and Rehabilitation

The Therapist will continue to work with you to maximize your result after surgery. The goal is to return your hand to its best possible function, maximal strength and range of motion, and return the fine motor skills of your hand. Both the therapists and I will supervise you during this period; some people need more visits, some less and the frequency of visits will diminish as you are exercising on your own and your hand function returns.

 Wide awake surgery video


Copyright © 2010, TOG All rights reserved.
Revised 12/21/10

Wide-Awake Hand Surgery

By Richard A. Bernstein, M.D

A recent advance in the operative care of patients undergoing hand surgery is the use of wide-awake local anesthesia. The popularity and efficacy can best be attributed to Dr. Donald Lalonde, a Canadian hand surgeon, who has reported on over 1400 hand surgery cases performed with wide-awake anesthesia.  The local anesthetic is administered 30 to 45 minutes before the surgery, which allows the anesthetic to take the best effect.  By giving the medication time to work, the procedure can be comfortably performed with the patient being wide awake.  Avoiding intravenous medications minimizes postoperative nausea, vomiting, sore throat, shivering, possible damage to teeth or eyes, postoperative confusion, and some of the rare complications from intravenous sedation.  Furthermore, patients on anticoagulants or blood thinners such as Coumadin, Plavix, or aspirin can maintain and continue their anticoagulant medication up to, and through surgery.  Fragile diabetic patients, who worry about changes in their blood glucose levels and insulin, can actually eat and drink the morning of surgery.

The local anesthetic is a combination of epinephrine and lidocaine, the latter of which has been used for years in all aspects of medicine.  Historically, there was a belief that epinephrine should not be used in hand surgery.  This myth has been scientifically disproven, and studies demonstrate that epinephrine can be safely used in the hand and digits. 

Epinephrine diminishes bleeding and potentiates the effect of the lidocaine allowing the medication to last longer.  Consequently, anticoagulated patients benefit since epinephrine helps control bleeding by causing vasoconstriction.  By buffering lidocaine with a solution called sodium bicarbonate, the discomfort from the injectate is lessened significantly; it is believed that much of the pain from a lidocaine injection is based on its low pH value.  By adding bicarbonate, the pH is neutralized making the administration of the anesthetic more comfortable. 

The risks during surgery are lessened when the procedure is done under a local anesthetic, without intravenous sedation. This minimizes the extent of necessary preoperative evaluations and testing making it more convenient and less costly. Elderly patients or those with multiple medical problems are potentially at risk with sedating medications and/or general anesthesia.   

Procedures I typically perform with a wide-awake anesthesia technique are carpal tunnel surgery, trigger finger release, flexor and extensor tendon repair, de Quervain’s tenosynovectomy and mucous cyst and ganglion excisions.

A review from the United Kingdom reported 99% of patients experienced a high satisfaction rate.  By injecting the anesthetic medications slowly, most patients in general tolerate it well.  Wide-awake anesthesia is not appropriate for everyone, nor is it applicable for every surgical procedure.  It is an advance in surgical technique that is a new option available to our patients.

Finally, with larger deductibles and copayments, the cost can be significantly less, patients to not require complex medical clearance and testing, they spend significantly less time in the recovery room and usually go home immediately after surgery.

 Wide awake surgery video

Wrist Arthroscopy

Richard A. Bernstein, MD

Wrist arthroscopy is an outpatient surgical procedure used to diagnose and treat problems inside the wrist. I will make small three or four incisions, usually less than a half - inch long, and insert an instrument called an arthroscope, which is smaller than the diameter of a pencil. The arthroscope contains a small lens, a miniature camera and a lighting system, enabling me to look directly inside the joint. Tiny probes, forceps, knives and shavers can then be inserted into the wrist and may be able to be used to correct some problems. I also have some nifty instruments for suturing inside the joint!

Wrist anatomy

The wrist is a complex joint, with eight small bones and many connecting ligaments. Arthroscopy enables me to see the anatomic parts more easily than with an open incision. I can see the movement of the bones, test the tightness of the ligaments, look for cartilage damage, and make a more accurate diagnosis than I can from MRI o r other imaging modalities (x - ray, arthrogram).


Diagnostic arthroscopy

Diagnostic arthroscopy may be used if the cause of your wrist p ain cannot be identified or if wrist pain continues for several months despite nonsurgical treatment. Before surgery, I will perform:

  • A physical examination that focuses on your hand and wrist.
  • Provocative tests that involve moving your hand in ways that reproduce the pain.
  • Differential Lidocaine injections, to help localize the source of the pain.
  • Imaging studies, such as X-rays of your hand and wrist.

Arthroscopic exploratory surgery may be used to confirm my diagnosis of a ligament tear or a triangular fibrocartilage (TFCC) tear. Ligaments are fibrous bands of connective tissue that link bones, helping to control the motion of our joints and providing stability and support. The TFCC is a fibrocartilaginous cushioning structure within the wrist, made of material very much like the meniscus of the knee. Most people have heard of "torn cartilage in the knee"; this usually refers to the meniscus. The meniscus is a piece of fibrocartilage that cushions the thigh bone from the leg bone. The TFCC similarly cushions the wrist especially along its outside portion. A fall on an outstretched hand can tear ligaments, the TFCC or both, resulting in pain with movement or a clicking sensation. In some cases, after the diagnosis is made, the condition can be treated arthroscopically as well.

Arthroscopic surgical treatment

Arthroscopy of the wrist is generally considered the "gold standard" to diagnose wrist conditions. Though physical exam, regular X - rays and certain more sophisticated X - rays can be useful, many times these tests are not definitive and surgical examination via arthroscopy is helpful for an accurate diagnosis.

Several conditions can be treated using arthroscopic surgery, including tears in the ligaments or the triangular fibrocartilage complex, synovitis (inflammation) and cysts. Often, there may be areas of inflammation, cartilage damage, or other findings after a wrist injury.

During arthroscopic surgery, I can trim or repair the tears. Wrist arthroscopy may also be used to smooth the bone surface s and remove inflamed tissue. Based on the findings at the time of arthoscopy, the post-operative regimen can change. Generally speaking debridement or cleaning up tears allows an earlier restoration of motion. If the ligament or cartilage (TFCC) requir es repair, this generally requires immobilization in a cast and then a splint for a period of time, depending upon the specifics. The specifics we will discuss after surgery.

Arthroscopy and limited incision surgery is also available to treat fractures of the scaphoid bone of the wrist. Limited approaches to the scaphoid fracture can often times get you out of a cast sooner than you would otherwise.

Arthroscopic surgery in general

Usually, general anesthesia is used during arthroscopic surgery. After the surgery, the incisions are each closed with a small stitch and a dressing and splint is applied.

After surgery, you will need to keep your wrist elevated and keep your bandage clean and dry. You can ice your wrist to help keep swelling down. I will give yo u a prescription for specialized hand therapy. The hand therapist will teach you exercises to help maintain motion and rebuild your strength. Analgesic medications will help relieve any postoperative pain, which is usually mild.


Complication s during or after arthroscopic wrist surgery are unusual, but may include infection, nerve injuries, excessive swelling or bleeding, scarring or tendon tearing. An experienced surgeon, particularly one who specializes in treating the hand, can reduce the likelihood of complications.


Arthroscopic surgery is a valuable diagnostic and therapeutic (treatment) tool. It is minimally invasive, and patients generally experience fewer problems and a more rapid recovery than with open surgery. Because it is an outpatient procedure, most patients are home several hours after surgery.

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Revised 12/21/10