Search for tag: "hand"

Interviewer: You don't realize how much you really use and depend on your thumb until you can't use it anymore because it hurts so badly. And if you're suffering from thumb pain, it can have a drastic impact on your quality of life. Luckily, if you have thumb pain from thumb arthritis, there are some excellent nonsurgical and also surgical options to relieve the pain and get functionality back.

Dr. Brittany Garcia is a hand surgeon and an expert on thumb arthritis. And today, she's going to talk us through both the nonsurgical options to give you some relief from your thumb arthritis and also the surgical options and their effectiveness.

So let's start out here. If somebody has thumb pain, is it a good idea to go see their family doctor or a general practitioner first, or go to a specialist like yourself?

Dr. Garcia: First up is primary care physician because they have a lot of non-operative options that they can offer patients. So, usually, when you present to your primary care, most people will take some X-rays and then they'll be able to parse out, "Are there arthritic changes on your X-rays that we think are probably causing your pain? Or is this something else like the trigger finger, or carpal tunnel, or things like that?"

And then primary care can start with some of the non-operative options, such as splinting, activity modifications, referring to a hand therapist who can work on a home exercise program to strengthen the muscles around the joint.

I like to think of strengthening, which is a really good option, similar to an ACL. So if you've got weak quads and hamstrings and calf, you're probably more at risk of developing ACL tear. Well, similar to the base of the thumb. It seems silly, but you've got lots of small little muscles that attach around the base of the thumb, and strengthening those muscles likely offloads the forces and supports the joint in general.

Interviewer: Let's talk about some of those non-operative treatments first. So are there any downsides to any of those, or is it always kind of a best practice to start with the non-operative stuff first?

Dr. Garcia: Definitely best practice to start with non-operative treatment. And by doing non-operative therapies and trying those first, you don't necessarily drastically change what we're going to do surgically. So it's not like you're losing time or making the surgery much more complicated for us by trying these things first.

And certainly, for some people, while non-operative options don't necessarily take away the arthritis, and we know that, many of them can help quiet the arthritis.

And so the things that come to mind that are most common that we do is bracing, where we do a hand-based brace for the thumb to kind of support it from loading consistently in those types of movements that cause it to be painful. It's basically a rest thing. So if it hurts, then you rest it.

The other things that are commonly used are anti-inflammatory medications, as long as you don't have any other medical problems that would prohibit you from having them, such as kidney disease or issues with your stomach. But anti-inflammatories can be really helpful, both those that you take by mouth, as well as some topical anti-inflammatories.

I like to sell it to you straight. I'm not going to say this is a magical topical cream that's going make you feel 100% better, or take away your arthritis, or anything like that. But the goal with non-operative therapy is really to try to make you more comfortable to be able to do your normal activities of daily living, as well as your hobbies and things that you want to do without having pain that's limiting you.

Interviewer: When you do splinting to help relieve the pain, I thought I had read somewhere that that could relieve pain, but it could also cause weakness, which would be a concern to somebody who does use their hands for a living. Is that true?

Dr. Garcia: That's always a catch-22. Usually, my prescription, when I'm doing splinting with a patient, is I will try to have them wear that splint full time for about six to eight weeks to see if we can calm it down. So that includes daytime and nighttime with the exceptions of taking it off for showering and washing hands and hygiene and things like that.

Theoretically, there's a risk that, because you're not using those muscles, you get some weakening of that muscle. But I think if you can calm down the pain, then you're probably going to increase your function and gain that use back and bulk, so to speak, those muscles back up.

And the other thing is when you're having so much pain, you're probably not using it normally anyway. So there's probably some degree of deconditioning that people get just by having the pain and doing the splinting. But I think if you can get the pain under control by immobilizing that joint, then likely you bounce that back quite well.

And then the other thing I didn't mention, which is a nice non-operative option, is corticosteroid injections or steroid injections, which is commonly used in musculoskeletal conditions to help calm down the inflammation around the joint. So I sort of think of those as you're taking a dose of . . . it's sort of like putting ibuprofen right inside the joint to calm down inflammation.

"Itis," which is the end part of arthritis, is inflammation, so really this is an inflammatory process that's caused by the joint being overworked or overloaded. So putting steroid in that area can help calm down that inflammation and give people some pretty good relief.

Interviewer: Are there any downsides to the steroid injections?

Dr. Garcia: I like to use steroid injections for people who respond well to them and get a fairly long-lasting effect. It's really hard to predict exactly who's going to respond to them or who's not. And even if you've had an injection in the knee or the shoulder and it hasn't worked as well, it doesn't necessarily mean that it's not going to work in your hand. I've definitely had patients who've had injections in other places that haven't worked that well, and it's worked really well in the hand.

Interviewer: For surgical treatments, talk me through what considerations you have there. I think there are two different types of surgery, or is there just really kind of one that you tend to use most of the time? Help me understand that.

Dr. Garcia: There have actually been lots of different ways described to take care of arthritis here. Basically, they all culminate on taking out the trapezium bone, which is a small, little bone in the wrist that makes up the joint at the base of the thumb. And this is where most of your arthritis at the base of your thumb typically goes. So regardless of which type of procedure people choose to do, usually it all begins with taking out the trapezium.

And then there are a number of things that can be done to sort of stabilize or support the base of the thumb after you've taken out that little bone. That bone typically supports your metacarpal bone, which is the longer finger bone. It sits on that little bone.

So most people will take out the trapezium and then you can do a number of tendon-type procedures to support the base of the thumb. I like to do something called the suture suspensionplasty, which is where you take two of the tendons that are nearby and you suture them together underneath the metacarpal bone, which sort of acts as a soft tissue hammock or supportive structure for the base of the thumb now that that little arthritic bone is out. But people do a number of different iterations of that particular procedure.

Interviewer: And then after you get that procedure done, the goal is to reduce pain and improve functionality. How successful is that procedure at doing those two things?

Dr. Garcia: This CMC arthroplasty, which is what we call our surgery for this condition, is something that takes a long time to recover from, but people typically are very happy once they get recovered. So usually it involves some sort of immobilization like casting or splinting for about three months, exercises with our hand-specific occupational therapist to get the thumb back in good working condition and strong and get the range of motion back.

So people are sore for three to six months, but once they . . . They're slowly getting better, and once they get to kind of their maximum, I guess, potential of recovery, people are typically really happy with this surgery.

Interviewer: And that treatment, that pain relief will last for a while? The mobility will last for a while?

Dr. Garcia: Yeah, the goal is for that to kind of be one and done for people, that they get the surgery and then most people don't need any sort of revision surgeries or other procedures down the line for it. It typically takes care of it for the duration of their life, which is the goal of it.

Interviewer: And you've removed a bone, so is there going to be from a mobility standpoint anything different? Or when you go in and you make the other adjustments, it usually takes care of that?

Dr. Garcia: When we put the sort of supporting stuff at the base of the thumb, typically, people have pretty good motion. Obviously, after you come out of your splint or your cast after surgery, everybody is stiff. And any surgery around an area will make you stiff, particularly in the hand. But it doesn't necessarily take away motion.

Certainly, we have other options for different types of arthritis in your hand where we're actually fusing joints, and those are types of procedures we're definitely . . . you're very clear preoperatively with patients that they're going to lose motion at the joint that you're operating on. This is not one of those where we're talking to them about drastically decreasing motion.

Usually, people are using their thumb better because it no longer hurts. And so once we get them through that initial therapy period of getting the swelling down and the stiffness from surgery down, people's motion comes back pretty good.

And then the other thing I wanted to bring up, because we see it not infrequently, is carpal tunnel. People who have arthritis at the base of the thumb, we see in about 30% of patients, they also have carpal tunnel symptoms when they present to clinic. So that's always something that we're looking for at the same time because we don't want to miss that and not release their carpal tunnel if it's surgically something that makes sense based on their exam.

So any time they're coming to clinic, we're always teasing out, "Is your pain due to arthritis at your thumb? Is it due to the carpal tunnel? Is it due to both? And how much is contributing to what's going on?"

Interviewer: Oh, so you can get both of those done kind of at the same time.

Dr. Garcia: Exactly.

Interviewer: Dr. Garcia, that is some great information. I hope that it helps some people find some relief from their thumb pain and thumb arthritis. Before we go, though, do you have a takeaway, something we should take away from the conversation today?

Dr. Garcia: The most important thing is to know that we've got lots of options, both non-operative stuff that works really well and can get many people through without needing surgery, and then we have a good surgical option. It's just important to know that with the surgical option, there's a reasonable amount of recovery that goes along with it.

Interviewer: So if you've been on social media lately and follow any of those pimple popper videos or whatever, you may have heard of a ganglion cyst. It is a small bump that usually shows up on the hands or the joints. And online, they'll tell you to pierce it with a needle or hit it with a big old book. We're going to find out if that's the right way to treat these big old cysts.

Joining us today is Dr. Brad Rockwell. He is a professor of plastic surgery and he works with hands.

Now, Dr. Rockwell, when it comes to a ganglion cyst, what is it?

Dr. Rockwell: All of our joints have fluid inside that's somewhat similar to oil to keep the bones moving freely. And around the joint, there's a skin layer that keeps the fluid inside the joint. If that skin layer gets a little weak spot, it can form a bubble and the normal fluid that's in the joint can enter that bubble. It stretches out that skin lining and then the bubble can get bigger and bigger. And eventually, that bubble can work its way up to be visible beneath the skin. And that's a ganglion.

Interviewer: So it's not just when you see pimple popper videos or whatever online it's oil or it's trapped dermatological fluid. This is something that your joints need to function correctly.

Dr. Rockwell: Yes. It's just normal structures that have moved outside of the joint and usually form under the skin. But they still have an attachment to the joint.

Interviewer: Oh, wow. Okay. And do they only show up on the hands, or can they show up in any joint?

Dr. Rockwell: They can show up in any joint. There are some that are more common. Palm side of the wrist, the back of the wrist, or the end joint in the finger are common spots. But the back of the knee is another common spot where orthopedists would treat ganglions.

Interviewer: Now, is there anything in particular that causes them? Any cofactors or anything, or are some people just more predisposed to having these, some activities that they do?

Dr. Rockwell: Most of the joints, we don't know. They may, to some degree, be arthritis-related, but most of the ones in the hand at the wrist don't have a specific arthritic etiology. At the end joint on the finger, there's a definite arthritic etiology. There's, in general, a bone spur that's there. The bone spur rubs on that skin inside joint layer and weakens it and allows the bubble to form, which becomes the ganglion.

Interviewer: Now, is there a way to, say, identify that it is a kind of ganglion cyst or it's one of these joint fluids, not something else that you should probably not be popping anyway?

Dr. Rockwell: Most times a doctor could look and tell. In general, where a ganglion is there is not something else comparable that would be in the same spot.

For a patient, they may notice that it increases and decreases in size. It is normal joint fluid that's beneath a stretched-out joint lining skin layer. Occasionally, that lining that contains the fluid can weaken and develop a little hole and the fluid may escape from the ganglion, and then the fullness will go away. The fluid escapes under the skin and gets resorbed. There are no symptoms associated with that.

So if someone notices a mass over the joint that gets bigger and then gets smaller and gets bigger, that's going to be a ganglion.

Interviewer: All right. So we now know what these things are, where they come from. Now, I've seen some pretty gnarly videos on the internet. Why or why not should someone pop them or hit them with a book?

Dr. Rockwell: Well, deflating a ganglion in the end is a good treatment. There's a medically appropriate way to do it. Popping it at home or hitting it with a book to try to rupture that skin layer may accomplish the same endpoint, but the body won't necessarily see it as a friendly way to treat the ganglion.

So, in the office, rather than popping it, we will put a little needle into it and drain the fluid. So put some lidocaine in the skin to numb the skin, clean the skin well, and then put a needle in and drain the fluid out. And about 20% of the time, that will be successful in treating the ganglion.

Eighty percent of the time, unfortunately, the fluid will recur. And then it can be drained again, although most likely if it recurred once, it will recur again. If it recurs once, surgery is the best option to resect the ganglion down to the level of the joint.

Interviewer: What are some of the potential dangers of, say, doing it at home by yourself? It's not just a big pimple on the back. This is something that's connected to your joints.

Dr. Rockwell: Yes, exactly. It's a fluid-filled cavity that has a connection to the joint. So if it's popped at home and an infection develops in the ganglion, the infection has a very short direct route into the joint. And an infected joint would be a horrible outcome from ganglion treatment.

Interviewer: Geez. So say someone finds themselves with a ganglion cyst. They now know, "Hey, don't treat it at home." What kind of doctor should they be going to? Is this something that you go to a primary care physician, an InstaCare, a dermatologist?

Dr. Rockwell: So if it's in the hand, it should be a hand surgeon, and hand surgeons are either orthopedic-trained or plastic surgery-trained. If they're in other joints, most likely it would be an orthopedist.

Most of the other bigger joints in our body, the ganglion would be deeper under the skin or the patient may not actually know there is a ganglion there. But if they have arthritic trouble and are seeing a rheumatologist or an orthopedic surgeon for the arthritis, the doctor would recognize that the ganglion is there and then suggest appropriate treatment.

Interviewer: If you have carpal tunnel syndrome, it might seem like surgery is the only means of relief from your symptoms. But what about simple splinting? Could that be an effective, non-invasive alternative? Dr. Douglas Hutchinson is a hand surgeon. Does splinting work for carpal tunnel syndrome?

Dr. Hutchinson: You know, it's very effective actually, and splints alone are the mainstay of our treatment. And if a person can sleep at night and not wake up with numb fingers, they're going to feel a lot better, they're going to do better during the day, their hands are not going to hurt them, and/or go to sleep on them as much during the day as well, and they're going to get several years out of that type of treatment before they may get to the point where despite splinting they're still getting numbness, and that's when they probably should talk about surgery.

updated: November 23, 2020
originally published: March 28, 2018

Interviewer: Starting to get some wrist pain. Maybe it's carpal tunnel. Well, maybe not. Dr. Douglass Hutchinson, what is carpal tunnel syndrome, and what are the symptoms?

Dr. Hutchinson: Carpal tunnel syndrome is a common diagnosis, and, frankly it's commonly misdiagnosed. Carpal tunnel syndrome, primarily, is numbness in your fingers. Carpal tunnel syndrome is not primarily wrist pain, so if you have wrist pain, it's a different story. Carpal tunnel syndrome is numbness in most your fingers. Sometimes they feel as though it's all their fingers. Usually, it's the thumb, index, and third finger primarily. It usually comes at night because of the way we sleep, and that is part of the treatment right there is to change the way we sleep with our wrists bent.

Interviewer: So if you have numbness in your hand like that, visit your primary care provider for treatment options.

updated: January 8, 2021
originally published: March 6, 2019

Interviewer: Common ways that people cut themselves that lands them in the ER. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health Care. What are some of the ways that you see that people come into the ER that they've cut themselves that lands them in the ER? The whole point of this is to maybe make us all a little bit aware.

Dr. Madsen: Sure.

Interviewer: When we're doing one of these things that, you know, this is a common way that somebody could cut themselves.

Dr. Madsen: Yeah, it is, and we do see lots of lacerations. Probably when you think of the ER, you think of going there because you were cut at some point and maybe had to have stitches. One of the common ways I often see people cutting themselves is cooking. This is something where I oftentimes see people who work in restaurants, who cook on a regular basis and are slicing and cutting things up and they'll catch a finger.

That's the most common site. They'll sometimes cut off the end of the finger, just the tip of it, not through the bone but slice off a piece there or cut down through the fingernail and then it seems to stop once it hits the bone. That's not an uncommon thing I see just from rapid cutting and just getting their finger in the wrong spot and getting that knife right through it.

Interviewer: Yeah, restaurant workers. What about just regular people? Not quite as much?

Dr. Madsen: Oh, sure. We see it with regular people, too.

Interviewer: Yeah, sure.

Dr. Madsen: But I guess for me it's always a surprise when you see the restaurant worker where they're doing this all the time and then they cut themselves and they always say they feel stupid, but it happens quite often.

Interviewer: Okay, so kitchen accidents. Watch those kitchen knives.

Dr. Madsen: For sure.

Interviewer: Be careful.

Dr. Madsen: Watch the kitchen knives and watch your fingers when they're near the kitchen knives.

Interviewer: Because that's the common kitchen cut, is a bit of finger.

Dr. Madsen: Exactly.

Interviewer: More so than a [makes cutting noise].

Dr. Madsen: Oh, yeah, for sure. I usually don't see someone who sliced down through their hand. It's almost always on the finger.

Interviewer: Okay. All right, what's the second kind of most common cut that you might see?

Dr. Madsen: The next common cut I see is someone who falls. They either land on their elbow and that will split the elbow open causing a laceration there, or they hit their knee and slice their knee open, or sometimes they'll fall and hit their head.

These head injuries, when it hits the scalp, that's where you really see a lot of bleeding. A lot of times they'll just come in with all sorts of bandages or holding towels on their head and just saying, "I must have a huge laceration on my scalp because it's bleeding like crazy." We'll pull these towels off and it's maybe only an inch long.

Interviewer: Oh, no.

Dr. Madsen: But scalp lacerations bleed like crazy. That's the bottom line. That is probably the next most common thing I see.

Interviewer: So they look much worse than they really are?

Dr. Madsen: They really do.

Interviewer: Generally?

Dr. Madsen: I think they really scare people and it's something you've got to go to the ER for typically, or maybe an urgent care because you do have to have it repaired, but a lot of times it looks much worse than it actually is.

Interviewer: All right. So I guess I didn't even consider a cut caused by blunt trauma.

Dr. Madsen: Sure.

Interviewer: That's interesting.

Dr. Madsen: Not an uncommon thing.

Interviewer: What are some other common ways that you see people with cuts?

Dr. Madsen: So another common thing we see is power tools. I've got to throw this one in here because probably the biggest surprise for me when I started working in the ER was all of the table saw injuries I saw. It's funny because at the time I had this old table saw in my garage. I'm not an experienced woodworker, but I thought I'm going to pull that saw to make some stuff with it.

Within the first month I probably saw four people who came in who had had their fingers amputated, cut off, from table saws. So I immediately got rid of the table saw. These were experienced carpenters and woodworkers that just said, "You know, it just happened." As they were pushing the wood through this table saw it just jumped or whatever, it hit a knot and their finger jumped forward, just cut right through the finger. So household equipment, power tools, table saw injuries, we do see a lot of those.

Interviewer: Watch those sorts of things. You've got experienced people that are cutting their fingers. Is there anything you can do to avoid that?

Dr. Madsen: Well, there are certain techniques you can use. I know there actually are some power tools and table saws that, I don't know how they're designed to do it, but somehow it's able to sense if that saw hits flesh. I don't know how it knows this. It's pretty remarkable.

Interviewer: I know, I took a woodworking class and the guy said you could take a hot dog and go to run it through this blade and it would stop it without cutting that hot dog.

Dr. Madsen: Yeah, it's amazing, but apparently you don't want to try the hot dog because if you do that, the way the mechanism works it just throws some steel right up into the blade and pretty much destroys the tool. Apparently, that's an option. I think there are other techniques where you're just not getting your hand close to . . . like, using a piece of wood or something to push that wood through rather than getting your hands right in there.

Interviewer: So three ways that people tend to cut themselves. Is there kind of a fourth category that you could lump in, two or three of the more minor ways?

Dr. Madsen: Yeah there are always knives. People who have pocket knives or maybe something where they're using their knife or some kind of tool to try and use it in a way maybe it shouldn't be used. Something slips or . . . you know I've got to tell you a personal story. I once made the mistake of trying to separate several frozen hamburgers using a butter knife. The butter knife slipped and went right into my hand.

Interviewer: A butter knife?

Dr. Madsen: Yeah, a butter knife. It was not good. I threw a little suture in that and tried to sew it up myself. It actually worked okay, but that's the kind of stuff we see, too. People with different household items, maybe screwdrivers, things like that, trying to use them in certain ways and something slips and cuts themselves.

Interviewer: Using them in a way that they weren't intended.

Dr. Madsen: Exactly.

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Dr. Miller: Hand trauma and the hand surgeon. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on the Scope.

Dr. Miller: Hi I'm Dr. Tom Miller and I'm here with Dr. Andrew Tyser. He is an orthopedic surgeon specializing in hand surgery and also microvascular surgery of the hand. Andy, talk to us a little bit about what types of hand trauma you see in your practice.

Dr. Tyser: Hand trauma is unfortunately a pretty common thing to happen to people. It turns out the hands are the way you interact with environment in many different walks of life, on the job, for play, and sometimes just randomly things that happen to your hands. In that case, sometimes the trauma can range from fairly common, simple fractures of the fingers to fairly severe, even loss of fingers and thumbs and things like that.

Dr. Miller: And you mostly see these in perhaps automotive accidents or industrial accidents.

Dr. Tyser: We do. I think most commonly for very severe hand trauma, for instance if you were to lose fingers or a hand, that's involving industrial type accidents, or people working with table saws in their own garage.

Dr. Miller: So if one is to lose a finger or even a thumb, which would be a catastrophic loss, you can re-attach those at times.

Dr. Tyser: We can, at times. It's for select indications as we say. So not every single person is a perfect candidate to have their finger put back on, depending on where it's cut off or the mechanism. However, that's the first consideration that we have here at the university is we try to put things back on when able.

Dr. Miller: Let's say that a patient or a person cuts off that finger by mistake using a table saw, while they're trying to build a table in their garage. What do they need to do? Do they need to put the finger on ice, I mean we see in the movies and all the TV shows about ER, what steps should they take if that thumb is to be saved or that finger is to be saved? What do you recommend?

Dr. Tyser: That's a great question. I think the first thing that patients in that situation should do is make sure that they have their bleeding controlled, either with a pressure dressing, or having even a little tourniquet on their finger because we don't want them to lose too much blood and compromise everything else.

The second thing is trying to find the parts. Sometimes if it happens with a table saw, it actually can kind of fly off into the saw dust or something like that, and we want them to find the part, and surprisingly, people will sometimes come to the emergency room without the part and then it's pretty hard to put it back on.

Dr. Miller: If they do find the part or the digit that has been amputated, what do they bring it to the emergency room in? Should they put it on ice or cool water, put it in a plastic bag, or does that even make a difference?

Dr. Tyser: Yeah, great question. We have a recommendation. We're not sure how much of a difference it makes. I think the main thing is finding the part and bringing it with you. But we typically tell people to put it in a soft kind of damp rag or gauze if you have it, and then put that inside of a plastic bag and then that bag inside of another plastic bag that has ice inside of it so to keep it cool.

Dr. Miller: What is the likelihood of success of reconnecting the amputation? Is there a time limit to that? Is, I suppose the type of trauma related to whether that's successful or not?

Dr. Tyser: Yeah, that's a great question and it's one we're commonly asked, and we tell them the same thing, which is please come as soon as you can. Ideally be within about eight hours to have the best results. I think the overall success rate really varies in the literature if you critically look at it. However, most recently with relatively large level-1 academic centers involved with the studies, it's about a 50:50 chance of making it work.

Dr. Miller: Now fortunately, these types of accidents, these amputation accidents are more rare than they were maybe 15 years ago.

Dr. Tyser: Yeah, I think that's true. It's something we talk about in hand surgery. It's kind of as a consequence of the loss of lot of industrial jobs in the United States unfortunately, and also a consequence of the increased occupational standards that we have in America. I think that in general that we see less amputations of fingers and hands and things like that.

Dr. Miller: Now that's not the only problem or injury that people have to their hands, crush injuries, degloving injuries, could you talk about those a little bit, and actually what would be the most common injury that you would see in a hand injury?

Dr. Tyser: We talked about table saws a little bit earlier and the table saw injury right around Christmas time in particular when people are making things for the family, unfortunately it's kind of a sad story when that happens. However, table saws typically don't actually cut off the finger completely. They just damage it pretty significantly.

That is very common. Using knives for cooking and other things when people accidentally slip and cut their fingers and many times can lacerate either tendons or nerves or arteries or all of the above. Those are common.

Dr. Miller: What do you see in automotive accidents?

Dr. Tyser: In automotive accidents, we call that more typically blunt trauma and that's typically fractures due to things like crushes or high-energy impacts.

Dr. Miller: Are those difficult to repair?

Dr. Tyser: They can be. They can be very complicated. At times it's not just the bones that are fractured but it's also the soft tissues that are injured around the bones and that can lead to need for not just one surgery but sometimes multiple, depending on the severity of the injury.

Dr. Miller: It sounds like if you have a hand trauma you need to get to an emergency department as quickly as possible and then obviously if you amputate a digit, you need to try to recover that digit, prepare it as you suggested, and then bring that to the emergency department in the hopes it could be reattached microscopically.

Dr. Tyser: Yeah, I think that's very accurate. And I think we have a very well-run trauma unit here at the University of Utah, staffed by hand surgeons who are very comfortable with all sorts of trauma and it's part of our job that we actually really enjoy restoring function to people's hands, if possible.

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Dr. Miller: Do you have a wrist fracture and what do you do about that if you have one? We're going to talk about that next on Scope Radio.

Hi, I'm Dr. Tom Miller and I'm here with Dr. Andrew Tyser and he is an orthopedic surgeon specializing in hand care and hand surgery. Welcome.

Dr. Tyser: Thanks, Tom.

Dr. Miller: How would somebody know if they might have a wrist fracture versus a sprain of the wrist? What are the common ways that we get wrist fractures?

Dr. Tyser: That's a great question. I think it's important to know that wrist fractures in general are very common as are wrist sprains. Many times they're caused by similar mechanisms. Lots of times people have a simple fall from ground level, sometimes slipping on the ice, sometimes falling off a bike. And the first question is, this hurts, is it broken or not?

Dr. Miller: How would you know? Is it swollen? Is it red? Is it just not mobile?

Dr. Tyser: Sometimes it's really obvious. The wrist may look like it's not straight. In that case it's pretty obviously going to be a wrist fracture. However, in many cases the wrist looks pretty normal, maybe a little bit swollen and it's not as clear.

Usually in that case, if the pain subsides over the next few days, it's typically considered a wrist fracture. But if the pain is not getting better and persists and the swelling gets worse, difficult use to the hand, etc., many times an X-ray is warranted to determine if it is a wrist fracture or not.

Dr. Miller: Now there are many bones in the hand and sometimes if you have a fracture it may not be quite obvious and I think that's one of the things you were saying. So maybe for those who wonder if it's fractured they should just have that checked out.

Dr. Tyser: And we see that quite a bit in our clinic as well as in the emergency room or urgent care centers. I think ruling out a fracture is sometimes just as important as diagnosing one. The X-ray is a fairly simple, quick, easy thing to do and will tell us usually one way or the other if you have a fracture or not.

Dr. Miller: And there are certain parts of the wrist that become fractured, the back, the front, one of the particular bones.

Dr. Tyser: I think the most common fracture that we see as hand surgeons and hand specialists, is a fracture of what's called the distal radius. It seems to be a commonly fractured area of all ages. There are a couple of other smaller bones in the wrist that also sometimes get broken, but they're a little bit less common.

Dr. Miller: Is the distal radius closer to the thumb or the little finger? Where is that?

Dr. Tyser: Right where your wrist bends. It's on the thumb side of the wrist and about an inch or so right before your wrist bends. That's the typical area that breaks.

Dr. Miller: And how would you get that fracture? Would you fall on an outstretched hand?

Dr. Tyser: Exactly. Falling on an outstretched hand pretty hard typically. Sometimes people that are skiing or participating in other sports that take a hard fall unexpectedly have that fracture.

Dr. Miller: If you've fallen on your wrist and you think it may just be a strain, is there anything you should be doing between the time you decide that you need to see the doctor? That is, could you ice it? Could you take ibuprofen or aspirin? What would you recommend?

Dr. Tyser: That's a great question and I think I would typically do the normal things that we recommend for many relatively minor injuries to the wrist, that is ice, elevation, resting it, and observing it and keeping a close eye on it. If you are overly concerned, usually your body will tell you if things are getting better or not. If it's not, that may be a good time to get evaluated.

Dr. Miller: And what if you don't go and have this diagnosed as a fracture? What is the long term consequence of that? Obviously for people who have long bone fractures they can't do anything until the fracture is healed. But wrist fractures you might go on for awhile with a swollen wrist and use it, not as much as you're used to. But eventually that could create problems.

Dr. Tyser: I think typically for people that do have a wrist fracture who initially don't realize it, they'll come to realize that within the first few days, within a week I would say. And so the long-term chances of missing it, the long term consequences of missing it aren't too common to see because people do not wait that long to actually go get it evaluated.

Dr. Miller: So you're a hand surgeon, a specialist? How do the patients make their way to you after they're diagnosed with a fracture? Or should they? Or can these fractures be handled by a general practitioner?

Dr. Tyser: That's a great question. I think more and more hand specialists are the ones that are managing fractures about the hand, including the wrist. Many times the sequence of events is patients suspects they have a wrist fracture, they're evaluated in either an emergency room or urgent care center. X-rays are taken and sure enough unfortunately they have a wrist fracture. At that point, they typically have either a reduction of the fracture, meaning putting the bone back in place and setting it and a splint placed. Or if it's not a bad fracture sometimes just a splint placed and are advised to follow up with an orthopedic hand doctor.

Dr. Miller: How long before a wrist fracture heals typically?

Dr. Tyser: About six weeks. And many of these fractures are able to be treated with conservative measures, such as casting or even splinting. However, there is a fairly significant subset of them do require surgery and in this same sense as far as time goes, it's about a six week recovery also, as far as the bones healing.

Dr. Miller: If you're in an area where a general orthopedic surgeon is available but they don't have a hand surgeon, I don't imagine that some places have access to hand surgeons, is it a good idea to proceed to see a hand surgeon at some point? What is your thought about that?

Dr. Tyser: That's a great question. I think it really depends on the community and also the training of the person taking care of the fracture. Many general orthopedic surgeons are more than qualified to take care of the routine, distal radius and other wrist fractures. However, for more complicated ones, fractures and dislocations at the same time or those involving other small bones of the wrist, many times we see that those are more traditionally taken care of by hand surgeons.

Dr. Miller: So to summarize, it sounds like if you have a fall and your wrist really hurts or is immobile or the pain lasts and the swelling is lasting longer than three days, you probably ought to have that checked out, have an X-ray. And if there is a fracture, you'd advise them to see an orthopedic hand surgeon.

Dr. Tyser: I would and I think that's a good summary of the recommendations.

updated: May 18, 2018
originally published: April 3, 2016

Dr. Miller: Trigger finger. Can you uncock that? How are we going to figure that out? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on the Scope. Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Angela Wang. She's a professor of Orthopedics here at the University of Utah and she specializes in hand care and hand surgery.

Angela, what is trigger finger and how do you know if you have it?

Dr. Wang: Trigger finger is a very common condition. We see it in patients who come in with pain in their finger and popping. Usually, they'll notice that they make a fist and then the finger gets stuck and it's painful. Sometimes they have to unstick it under their own power. Sometimes it's even as bad that they have to use their other fingers to pry it open.

The symptoms of the pain and the finger popping are caused by a little swelling of the flexor tendon in the palm. So that's the tendon that bends your finger and then it goes underneath a tight area in the palm. So then when there's a little bit of swelling in the tendon, that area is tight and it's getting stuck.

Dr. Miller: Now, is any one finger more common than the other to be affected by this trigger finger problem?

Dr. Wang: Actually, the ring finger is the most commonly affected finger. Dr. Miller: And why is that?

Dr. Wang: We're not sure, exactly, but your ring finger is more involved than your other fingers when you're making a tight grip, so that may be the reason why it tends to get stuck more. Dr. Miller: So who do we see trigger fingers in, young people, old people, men or women? Who gets it?

Dr. Wang: Actually, everybody gets it. When we see it in very young children it tends to be a slightly different condition. It's called a congenital trigger finger and that's a little more rare. That mostly involves the thumb. But the vast majority of people we see it in are older people, more common in diabetic people, but it can definitely happen for no particular reason.

Dr. Miller: Is your type of job related to developing trigger finger?

Dr. Wang: It might.

Dr. Miller: Someone who works on an assembly line or works with their hands frequently.

Dr. Wang: It might be. We haven't been able to conclusively prove that, but it would be reasonable to say that if you had to do a lot of tight squeezing or something like that that it might lead to a trigger finger. We also see it sometimes in conditions like pregnancy, where the fluids in your body are shifting so you can have some swelling.

Dr. Miller: Is it dangerous?

Dr. Wang: No, no, and it's easily fixed. If you see us anytime, early or late, we can take care of it.

Dr. Miller: And how do you take care of it? Do you operate on it? Do you inject it? Do you provide physical therapy?

Dr. Wang: All of those are viable options. Some people who really want to be very minimalistic in their approach can even splint it. Something as easy as splinting and immobilization of the finger can sometimes decrease the inflammation enough that the trigger finger will go away.

Oftentimes we do inject it, a little bit of cortisone and numbing medicine together and that is very effective. And then eventually, if it keeps coming back or the injection doesn't work well, we do a small surgery to release it. Dr. Miller: So if you have trigger finger in one hand, is it more likely that you'll have it in the other hand? And the second question is, after you repair it can it come back again?

Dr. Wang: Just because you have it in one hand does not necessarily mean that you'll get it in another hand, although we do see it in multiple digits in both hands sometimes. Sometimes the injection will completely cure it and sometimes it will just be a temporary cure. The surgery, however, is a permanent cure.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Dr. Miller: Are there surgical solutions for your painful hand arthritis? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Doug Hutchinson. He's a Professor of Orthopedic Surgery here at the University of Utah. Doug, I have a lot of patients that come to see me with arthritis in their hands as they get older. They're asking me from time to time if there are any surgical solutions for their pain.

Dr. Hutchinson: Everyone gets arthritis in the hand at some point in time as long as we last long enough. Most arthritis in the hand is something that people live with and I think that's appropriate. Surgery is not going to solve everything that comes down the road, but there's no question that some people have certain fingers that get arthritic changes that hurt them on a daily basis and really get in their way of doing certain things in the kitchen, doing certain things in the garden, doing certain sports activities, and those we probably in some situations can help a lot.

Dr. Miller: How do we do that?

Dr. Hutchinson: For example, in the fingers the most common place to get arthritis is near the tips in the last joint, called the distal interphalangeal joint, right underneath your nail. Some people get cysts that grow out of those that become a problem on the nail and they're painful. Those can be taken care of if we get rid of some of the arthritis there.

Primarily, if the joint of the finger is stiff and painful and has arthritis on x-ray, which is common, one of the things we'll do the most commonly is fuse that joint. That just means putting a screw across the one bone into the other bone and making that joint effectively go away. You can't bend it at the end, but it stays straight the whole time.

Dr. Miller: And that eliminates the pain?

Dr. Hutchinson: That totally eliminates the pain, and the other joints still make you use your hand very well. Functionally, you're normal without that last joint working.

Dr. Miller: Are there any particular joints in the hand that are more amenable to surgery than others?

Dr. Hutchinson: Yeah, other than the DIP joint of the fingers, which is the last joint near the nail, the base of the thumb, which is all the way back closer to your wrist. Some people even think that they have wrist pain but in fact it's the base of the thumb that's hurting them. Typically a patient will really have a hard time with certain grips. They won't want to shake hands as much. They really hate the fact that they can't open a jar at home. They've got to give it to their wife or their husband to figure that out. It's generally a thumb pain problem that is really, in the world of humans the thumb is overwhelmed by what we do with our hands, and there are more forces put through our thumb joint than was originally intended.

Dr. Miller: Do you perform a similar stabilizing surgery where you put a pin or screw in the joint?

Dr. Hutchinson: Yeah. For a thumb arthritis, the most common solution is to remove a bone at the base of the thumb, which means the two ends of the bone that were grinding on each other causing pain, now one of them is gone. There's no longer a bone grinding on a bone. The word arthritis means "arth" which is joint, and "itis" which is inflammation. I tell my patients that if you don't have an "arth" you can't have arthritis. The getting rid of the "arth" is either a fusion, like we do in the distal joint of the finger, or a resection of the bone which means it can still move very well as opposed to a fusion. The pain is gone and we use a tendon to help stabilize the joint.

Dr. Miller: Would you recommend conservative therapy prior to considering surgery for either a distal interphalangeal arthritis or base of the thumb arthritis?

Dr. Hutchinson: Yes. We always recommend conservative care first, and most times that usually works for a lot of people for a good bit of time. A thumb arthritis, the mainstay for treatment is to get them a splint. The splint is something no one wants on their hand and no one wants on their thumb in particular, but it's worn at night when no one theoretically is using their thumb in the middle of the night. It allows the thumb to rest. That may make it better during the day when you take the splint off and use your thumb for normal activities.

We always want them to avoid certain activities. You don't want to open a can with a hand crank if you have thumb arthritis. You want to go out and buy an automatic can opener. That's something our hand therapists insist on. They think that should be done; at age 20 we should all get automatic can openers.

Dr. Miller: In your opinion, what would be the best conservative therapy? What do you advise patients to take?

Dr. Hutchinson: We generally tell them to wear a splint during the night that's fairly rigid that holds their thumb. We give them a strap type of a splint that's easy to wear during the day that they can wear when they want. When they don't want to they can not wear it at all. It sometimes helps when they're gripping things and gives them a little bit more support and decreases their pain.

If they get to the point where it's worse, we'll often inject them which helps them for two to three months at a time and really makes their pain go away, again, can delay the surgery if they want to have the surgery. Some people come back to me every six months and say, "Give me another injection. I don't want that surgery. I ain't got time for that. Let me just have three, five, six months of peace, please."

Dr. Miller: What is the durability of the surgery? Is it long-lasting?

Dr. Hutchinson: Yes. The surgery for base of the thumb arthritis is actually one of the best we have in our armamentarium. It works well in most any surgeon's hands. There are different procedures that can be done, all of which work about the same or as well as the others. I would caution a patient that it takes three months of being good and wearing a splint, and therefore it's a longer rehabilitation than they would like.

Other than that being a negative, the rest of it is positive. They maintain their motion. They actually increase their grip strength a little bit. Their pain is effectively 100% resolved at that particular joint. Again, a person with a lot of arthritis in their hand is not going to get the rest of their arthritis to go away, but that one is usually the one that is causing the most problem.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: May 16, 2019
originally published: January 19, 2016

Dr. Miller: What is carpal tunnel syndrome? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope. Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Doug Hutchinson. He's a Professor of Orthopedic Surgery here at the University of Utah. Doug, what is carpal tunnel syndrome? What is that?

Dr. Hutchinson: Tom, carpal tunnel syndrome is a common diagnosis, and frankly, it's commonly missed diagnosed in the lay public. Carpal tunnel syndrome primarily is numbness in your fingers. Carpal tunnel syndrome is not primarily wrist pain. That's the first misconception I'd like to solve. So if you have wrist pain, it's a different story. If you primarily have numbness, sometimes it comes with pain, but mostly it's numbness.

Dr. Miller: What causes that numbness?

Dr. Hutchinson: What's happening is the median nerve, with is a main nerve that goes into your hand through your wrist, goes through a tight tunnel where all the tendons for your fingers are also located, and basically our assumption is that the space is so limited that if you use your tendons a lot, which we all do over the course of years, there will be a little bit of a buildup of tissue in there, and maybe a little bit of inflammation, though it's not much, but enough to make it so that the nerve feels claustrophobic, if you will, and pressured. Therefore, pressure on a nerve creates numbness where that nerve is going or coming from, and in this case that nerve is coming from those fingers.

So carpal tunnel syndrome is numbness in most of your fingers. Sometimes they feel as though it's all their fingers. Usually it's the thumb, index and third finger primarily. It usually comes at night because of the way we sleep on our wrists, and that is part of the treatment right there, is to change the way we sleep with our wrists bent. Dr. Miller: Now, are some people at greater risk of developing carpal tunnel than others?

Dr. Hutchinson: The common person who has carpal tunnel is 40s, 50s, 60s, and a little bit more often in a female than in a male. There's a lot of history of whether these come from repetitive activities and computers, and probably the bias and my answer is it doesn't. It's primarily genetic. It's primarily something that you were going to get anyhow even if you lived in rubber room your entire life and didn't do anything with your hands. It's just something that eventually can happen to some people because the nerve's in a tight spot in the wrist, and certain movements and certain positions will make that nerve a little bit unhappy over time and it will want a little bit of a bigger house.

Dr. Miller: Does it usually occur in the dominant hand or in both hands?

Dr. Hutchinson: Usually it's in the dominant hand first, but it usually occurs in both hands eventually.

Dr. Miller: Now, I heard that it's more common in pregnant women. Is that true?

Dr. Hutchinson: Pregnant women are very common, and anybody else who has major fluid changes, etc., and even can come in some women around their periods because of that type of change. Post-menopausal women are clearly the most common when it comes in. So yeah, there are changes that can occur. Some people will have something like a ganglion cyst that will actually put pressure in that area, and that can cause carpal tunnel syndrome. But usually it's idiopathic, and that means that there's no real cause for it, it just is happening to them.

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Dr. Miller: Your primary care doctor is referring you for treatment of carpal tunnel to a specialist. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, I'm here today with Dr. Doug Hutchinson. Doug, tell us what happens when you receive a referral for carpal tunnel syndrome and I send you a patient that I think has carpal tunnel. What are the next steps?

Dr. Hutchinson: Well, of course, you're always right, so I wouldn't have to worry about any diagnostic situations at that point in time.

Dr. Miller: That's what my wife always tells me.

Dr. Hutchinson: Yes. In general, the story is that a patient will come to us and say, "I've got numbness and Dr. Miller: thinks I have carpal tunnel syndrome," and we'll talk to them merrily because what they tell us is happening to them is more important than anything else. Their history is the most important thing. We'll do a few physical exam maneuvers that will confirm our suspicions.

And if they're a typical patient who is complaining of numbness more than pain and who is 40 or 50 and not 20, then we're going to pretty much be able to diagnose this as carpal tunnel syndrome in our office without any further studies, without any need for electrical studies or other things that have been routinely done for this problem.

Dr. Miller: Which patients might need electro-diagnostic studies?

Dr. Hutchinson: In my opinion, those that need it are those that things don't fit, the nerve doesn't seem like it's the right distribution in the hand, they don't wake up at night with numbness, a splint doesn't help them, they think it's work related. Things like that are a little bit different than the normal and those are ones that we might want a little bit more information to make sure we're not missing something else.

A patient with a lot of neck pain as well as having carpal tunnel syndrome could easily have a compression of the nerve somewhere else, like in the neck, and it would be obviously smart to know the difference between this coming from the neck or from in the wrist since wrist surgery won't help the neck problem.

Dr. Miller: Let's say you agree with the diagnosis of carpal tunnel. How effective is conservative therapy using splints and other treatments?

Dr. Hutchinson: It's very effective, actually, and splints alone are the mainstay of our treatment and if a person can sleep at night and not wake up with numb fingers, they're going to feel a lot better, they're going to do better during the day, their hands are not going to hurt them and/or go to sleep on them as much during the day as well.

And they're going to get several years out of that type of treatment before they may get to the point where, despite splinting, they're still getting numbness and that's when they probably should talk about surgery.

Dr. Miller: Are there any other conservative measures aside from splinting? Are there any exercises?

Dr. Hutchinson: For the most part, in my opinion, there are not a lot of exercises that can help. Taking a vitamin B complex can be helpful for any nerve issues and that may benefit some people and again, it's probably going to delay things. It may delay things upwards of a year or two if you can get a little bit of symptom relief.

The other main thing we use is an injection of cortisone. An injection of cortisone, most of us feel, is not going to ever cure carpal tunnel syndrome but it could last even all the way up to a year of symptom free, so I use that a lot to get people to where they want to be for their surgery.

For example, if they're a big skier, they want to wait until ski season's over, that's a reasonably good thing to do. If they're going to go on vacation and they don't want to wake up every night with their hands numb, that helps them do that.

And the other major person for that is a pregnant female who will eventually not be pregnant. And therefore if we can make their symptoms diminish while they're in their third trimester then when they deliver the baby usually their hands get better and they won't need surgery. Some question about whether they'll need surgery in 10 years from now or not, but they don't need it right then which is not when they want it anyhow.

Dr. Miller: When conservative methods are ineffective, how effective is surgery?

Dr. Hutchinson: Surgery for carpal tunnel syndrome is, in my opinion, probably the best surgery on the planet.

Dr. Miller: No doubt.

Dr. Hutchinson: It makes more people happy and few people, very few people are unhappy. Every surgery has risks and every surgery doesn't work some of the time. This surgery is simple, fast, easy to get over, and many, 99% or so, of the patients are not just happy, they're ecstatic. They think it's the easiest and greatest thing they ever did from a surgical standpoint, and they wonder why the heck they waited with a splint on the last month or the last year or whatever of their lives. They feel as though they should have gone ahead and done it sooner.

Dr. Miller: Is there any new special technique that you use surgically now?

Dr. Hutchinson: There really isn't much new there for the last 20 years, we've been doing an endoscopic carpal tunnel release, which is decreasing the size of the scar. The truth is, when I was in training the scar was about four times the size of what it is now anyhow. So we've learned to get smaller scars, not spend much time; it takes about nine minutes to do a carpal tunnel release. The patient can be completely awake during that time.

We do most of our carpal tunnels with them, more or less, in a procedure room, not even in the operating room anymore because they can avoid the anesthesia hangover, they can avoid changing clothes, getting an IV. They can even avoid not having to eat something the night before. Some of my patients will come in with their cup of coffee in the morning, get their carpal tunnel done, and pick up their coffee and go back to work.

Dr. Miller: So is that surgery effective long-term? Does it recur?

Dr. Hutchinson: It's really effective mostly long-term and, on a rare situation, someone will need another redo carpal tunnel release down the road.

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Interviewer: You come back from the slopes, and your thumb is hurting really, really badly. Is it something you should worry about or not? We'll find out next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. David Rothberg is an orthopedic surgeon at the University of Utah Hospital. We're going to talk about something called "skier's thumb" right now. So you go for a day of skiing, you come back, your thumb hurts. Do you have skier's thumb or not? How do you even know? First of all, what is skier's thumb?

Dr. Rothberg: Skier's thumb is a relatively common injury of the upper extremity suffered when someone falls on a pole. So the most common scenario is with a grip-fitted poles, you fall, and the pole is forced into the palm as you place your hand down to slow your fall.

People know when they have it because the actual ligament that's hurt is your ulnar collateral ligament on your thumb, and it supports your thumb as a post. So when you pinch with your forefinger and your thumb . . .

Interviewer: Kind of making the "OK" symbol except for against the side of your thumb . . .

Dr. Rothberg:That's putting pressure on that collateral ligament.

Interviewer: Okay.

Dr. Rothberg: If you think about all the daily tasks we do with grip strength and manipulating objects with your hand, it's really common that we use your thumb as a post. So the quickest and dirtiest way to figure this out is to use your thumb as a post. Press your forefinger against the side of your thumb and see if it hurts at the large knuckle at the base of your palm, or your MCP joint.

Interviewer: So it refers pain down, because you're touching at the very top part of the thumb, and it's kind of coming down, the base of the nail almost, off to the side.

Dr. Rothberg: Right, and you're going to feel that.

Interviewer: Okay. And if you feel that, is it for sure that you've got skier's thumb?

Dr. Rothberg: It may not be for sure, because like all ligament injuries, it can really come with a grade of injury, from a sprain, which the vast majorities will be, to complete tears, to fractures of the insertion of the ligament.

Interviewer: So if you're feeling pain, should you go see somebody right away? Is it important that you see somebody or should you just kind of wait and see if it goes away?

Dr. Rothberg: I think, in the very beginning, if this is something that gets better very quickly, then you're probably safe. But if you have a persistent pain lasting more than a day or two, and it's causing dysfunction, it's worthwhile to get checked out by an orthopedic hand surgeon.

They're most commonly going to take an X-ray to rule out that scenario where there may be fracture associated with it. The reason that you want to take care of this is it can lead to a chronic instability of that joint, meaning that you're no longer able to fully use your thumb as a post because of non-healing of the ligament.

So the typical course of treatment is in a non-operative setting, which is the vast majority, is a brace. That brace is going to hold your thumb in a position that protects it from being used as a post or really straining or stressing that ligament as it attaches at the MCP joint.

Interviewer: So it sounds like kind of a big deal, because it could hinder your usage of that for the rest of your life if you don't have something done to it, and it's simple. It's a brace.

Dr. Rothberg: That's exactly right. When chronically injured, then it becomes something kind of interesting historically. It's called a "gamekeeper's thumb," and that referred to when people who farmed chickens they would break the neck of the chicken over their thumb, and it could lead to repetitive stress on the ligament, that then loosened it and then caused chronic disability.

So that's the worry when you don't take care of this skier's thumb is that it becomes a chronic instability that causes pain and dysfunction.

Interviewer: How long does it take for this to recover at this point, after you get the brace?

Dr. Rothberg: Typically, people are in the brace from four to six weeks, and then depending on the range of motion and tasks that they have in their daily life, they may start some hand therapy. Motion tends to help with the healing process. All in all, people can be back to activities around the six week mark.

Interviewer: So just for perspective, not something to be taken lightly. Not to go, "Aw, it's just my thumb. I won't worry about it."

Dr. Rothberg: That's very true, and I think it's a real common one that people get and take lightly, and then are presenting to us later with problems.

Interviewer: Then it's too late. Is it too late at that point? I guess that's a good question. What if three years down the road, I come in? Is it too late to fix that problem?

Dr. Rothberg: It isn't necessarily too late, depending on whether you've developed any arthritis in the joint because of instability. Certainly, there are late reconstructions, where we can reconstruct the ligament to give you stability. In most people, this tends to be something they pick up and don't really miss, because it does cause quite a bit of dysfunction. But getting it looked at sooner is always better than later.

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