The abductor pollicis longus tendon and the extensor pollicis brevis are located in the first dorsal extensor compartment of the wrist. These two extensor tendons are involved in movement of the thumb and glide through the tendon sheath in this compartment. Overuse can result in inflammation around these tendons. This in turn increases friction in the compartment, restricts movement and causes pain.

The symptoms of De Quervain's Tenosynovitis are pain and swelling in the wrist and the base of the thumb, which is worsened by motion. This pain and swelling restricts the motion of the thumb and wrist, resulting in a diminished ability to grasp and pinch objects. This gradual pain and tenderness may get worse and travel up the arm.

An exam called the Finkelstein test helps confirm the diagnosis of De Quervain's Tenosynovitis. An ultrasound study and confirm inflammation in the compartment as well as the presence of an anatomic variant that can predispose to the condition.

The treatment options for De Quervain's Tenosynovitis can involve splinting, occupational therapy, injections, or surgery. Immobilizing the thumb with a splint, using antiinflammatories, and activity modification are first lines of treatment. Corticosteroid injections into the tendon sheath help reduce swelling and are more effective than splinting. If these non-operative treatment options fail to relieve symptoms, a surgical release may be considered. During this operation, the tendon sheath is divided to make more space for the tendons and allow them to glide more easily within the compartment. The release is often completed under local anesthesia in the office via a small incision.

These fractures result from trauma, such as a fall. Higher energy mechanisms are also possible, such as motor vehicle accidents or falls from significant height. In all cases, the deforming forces are focused at the wrist and this leads to a break of the distal radius and often also the tip of the ulna which is called the ulnar styloid.

Distal radius fractures cause pain, tenderness, bruising and swelling at the wrist. If the fracture is displaced, there may be a visible deformity of the wrist. Numbness can occur if there is pressure on the median nerve, which is called acute carpal tunnel syndrome.

The injured forearm is assessed from the elbow to the wrist. Range of motion is typically diminished, in conjunction with bruising and swelling. Xrays are critical to make the diagnosis and guide treatment. Occasionally a CT scan is ordered. Minimally displaced fractures can be braced or casted. Displaced fractures may require surgery which entails realigning the fractured bone, and placing a plate and screws to stabilize the fracture while it heals. Open fractures (with a break in the skin) almost always require surgical intervention.

The development of a Dupuytren contracture is multifactorial. Risk factors include:

-Genetics: Northern European descent, family predisposition
-Age: often above 50
-Lifestyle: smoking and use of alcohol
-Sex: male predisposition
-Diabetes
-Trauma: in some patients a distinct trauma may precipitate the development of this condition. On occasion, a surgical intervention on the patient’s hand can precipitate the development of a contracture.

The first sign of Dupuytren's disease is the formation of nodules, cords and pitting under the surface of the palm skin. A Dupuytren's contracture may gradually develop, drawing the fingers into the palm and restricting their motion. The nodules and cords are usually, but not always, painless.

The physical examination usually allows the clinician to make the diagnosis. The involved parts of the hand are carefully inspected, including joint position and presence of any contractures. The condition is only treated if there is evidence of joint contractures, and less commonly if the nodules are prominent enough to be bothersome. Nonsurgical options include steroid or XiaflexⓇ injections. Operative procedures include needle release (percutaneous needle aponeurotomy), limited open release (fasciotomy), and excision (fasciectomy).

A personalized approach:

Depending on the severity of the condition, quality of the overlying skin, and prior attempted interventions, additional measures can be considered. These include but are not limited to:
-use of skin grafts
-use of artificial skin / skin substitutes
-use of flaps, either pedicled or free
-use of dynamic external fixators such as Digit Widget ®

No two patients with Dupuytren contractures are the same. Dr. Dowlatshahi will try to offer his opinion as to the options in your particular case.

The extensor carpi radialis brevis (ECRB) is an extensor tendon that extends the wrist and originates at the lateral epicondyle, tennis elbow usually involves changes in this tendon. This tendon undergoes degenerative changes called tendinosis and exhibits microtears located at the site of attachment to the lateral epicondyle at the elbow.

Pain associated with this condition often initiates near the lateral epicondyle and gradually radiates along the forearm. This pain can have a burning quality and can be present during activities as well as sleep. Patients with this condition may suffer from a loss of grip strength due to pain.

The physical examination is particularly important. A thorough elbow examination is performed to rule out other potential causes of pain in this area such as a radial nerve compression, arthritis, and ligamentous injury to the elbow. Imaging such as x rays, ultrasound, MRI are occasionally used, depending on the case.

Wear and tear during aging leads to progressive degeneration of the cartilage layer at the CMC joint. Trauma of the joint can predispose to arthritis, e.g. a history of fracture. Some patients have significant joint laxity that predisposes them to arthritis. Genetic predisposition can play a varying role.

Symptoms include pain and swelling at the base of the thumb, worsened after prolonged use. Loss of range of motion and reduced grip and pinch strength can result. The deformity at the base of the thumb can lead to changes in the biomechanics of the other thumb joints (called zig zag deformity). A “bump” is often seen near the CMC joint and represents growth of additional bone called “bone spurs” or “osteophytes”

Diagnosis:
The physical examination is the first step, and is supplemented with xrays of the thumb to show the extent of the degenerative changes. Specific maneuvers performed during the physical exam include the CMC grind test, looking tenderness over the CMC joint, crepitus with motion, and examining for joint laxity. Overall range of motion of the thumb is assessed, as well as pinch and grip strength. The position of the other joints of the thumb is also examined, since these may affect the choice of treatment.

Furthermore, other conditions can mimic CMC arthritis. Other joints nearby such as the triscaphe / STT joint can lead to similar symptoms. DeQuervain tendinitis also can be confused with thumb arthritis. Occasionally, laxity of the CMC joint can present with similar symptoms as arthritis. Lastly, some patients with carpal tunnel syndrome can experience cramping in the thumb (thenar muscle). These conditions need to be differentiated.

Treatment:
Almost always begins with conservative measures, including splinting, hand therapy, activity modification, and use of antiinflammatories (topical or oral). The next step is a steroid injection. This is often done under ultrasound guidance which is more precise and less painful.

Although the injections provide relief and can be repeated, some patients may be candidates for surgery which involves cleaning out and reconstructing the arthritic joint. Several operations have been described.

Dr. Dowlatshahi offers the following procedures:
-CMC joint denervation.
-arthroscopic (keyhole) hemi-trapeziectomy, and soft tissue interposition.
-trapeziectomy with or without interposition.
-trapeziectomy with ligament reconstruction.
-stabilization of the CMC joint.
-LRTI (Ligament Reconstruction with Tendon Interposition).

Dr. Dowlatshahi will discuss his specific recommendations with you during your visit.

The flexor tendons are involved in bending the fingers into the palm. They travel through a tendon sheath, where they glide freely during finger movement. The tendon sheath is reinforced along its length by several pulleys. Thickening of the sheath or tendons can lead to impaired tendon gliding and increased friction. This condition is often thought to be the result of repetitive use, including forceful flexion, and is increasingly common in patients with diabetes and rheumatoid arthritis, but commonly occurs in healthy patients.

Symptoms include a locking and catching sensation with movement of the fingers, pain when flexing or extending the finger, and occasionally the formation of a nodule at the base of the digit in the palm. In more advanced cases, the affected finger can become permanently locked in a flexed (bent) or extended (straight) position.

The most important diagnostic feature is the physical exam. Usually, no imaging modalities are required. Commonly there is tenderness to touch at the A1 pulley, and occasionally a nodule. The finger can catch with motion, and can even be locked in a flexed or extended position.

An ultrasound can be performed in the office to identify associated ganglion cysts and confirm a buildup of inflammatory tissue (tenosynovitis) as well as thickening of the A1 pulley.

The treatment usually begins with an injection. Alternatively, ice, antiinflammatories (topical or oral) and splinting may be attempted. The injection is usually effective, and can be repeated. The more definitive treatment is surgery, whereby the A1 pulley is released.

These fractures usually result from blunt force or torsional trauma. Higher energy mechanisms are also possible, such as injuries from gunshots, nailguns, and crush injuries. Fractures of the 5th metacarpal neck and carpometacarpal fracture dislocations can also occur when the patient punches a hard object.

Metacarpal fractures cause pain, tenderness, and swelling over the affected metacarpal. If the fracture is displaced, there may be a visible deformity such as angulation or malrotation called scissoring. Characteristic bruising in the palm can also be seen.

The injured hand is assessed. Range of motion is typically diminished, in conjunction with bruising and swelling. X Rays are critical to make the diagnosis and help guide treatment.

This condition is caused by an ulna which is longer than the neighboring radius bone. The ulna then impinges on the wrist/carpal bones and leads to pain, swelling and discomfort, especially then the wrist is in pronation (palm down) and extension. The cause of the relatively long ulnar can be a prior wrist fracture, or congenital.

Pain in the ulnar side of the wrist (pinky side), possible swelling. Most often, the pain happens with activity, especially if the wrist is pronated (palm down) and extended, e.g. during push-ups.

The diagnosis is often made clinically, together with xrays of the wrist. An MRI is particularly helpful in confirming the diagnosis since changes along the small wrist bones can be visible. Also, the long ulna impacting against the wrist bones often leads to a tear in the TFCC which is a ligament / disc in the wrist joint, similar to the meniscus of the knee.

In the hand and upper extremity, soft tissue defects can result from various causes, including trauma, infection and cancer, among many others. On occasion, a surgical incision doesn’t heal well, or if there is infection or hematoma, an open wound will result that will require intervention. Dr. Dowlatshahi has extensive experience with soft tissue reconstruction of the hand and will often get referrals from other hand surgical colleagues to assist when the need arises.

Open wounds can be painful, especially if in sensitive areas such as the fingertips or palm. They can drain quite a bit and require frequent bandage changes. If infection sets in, the drainage can increase and become purulent, and there can be an increase in swelling and redness, called cellulitis. If the infection enters the lymphatic system, a red streak can appear along the forearm which is called “lymphangitis”.

Physical examination is paramount. Other important measures are taking a culture to identify any bacterial organisms. Xrays can assess whether there is any bony involvement, such as underlying fracture from trauma, or infection involving bone. A biopsy is important to consider if a form of cancer is suspected. Advanced imaging such as CT scan or MRI can help address any further bone or soft tissue involvement and help with operative planning.

Wear and tear during aging leads to progressive degeneration of the cartilage layer at the interphalangeal joint. Trauma of the joint can predispose to arthritis, e.g. a history of fracture. Genetic predisposition can play a varying role.

Symptoms include pain and swelling of the affected joint, worse after prolonged use. Loss of range of motion and reduced grip and pinch strength can result. Often, the affected joint is visibly deformed: there can be unusual angulation of the joint, or a visible “bump” which represents growth of additional bone called “bone spurs” or “osteophytes”. Ganglion cysts can also arise from such arthritic joints which are commonly called “mucous” cysts. These can also cause a ridge in the nail plate.

The physical examination is the first step, and is supplemented with xrays of the affected joint to show the extent of the degenerative changes. Overall range of motion of the joint is assessed, as well as pinch and grip strength. The position of the other joints of the affected digit is also examined, since this may affect the choice of treatment. Ultrasound can be used to help differentiate between bone spurs and ganglion cysts.

These fractures usually result from blunt force or torsional trauma. Higher energy mechanisms are also possible, such as injuries from gunshots, nail guns, and crush injuries.

Finger fractures cause pain, tenderness, and swelling over the affected digit. If the fracture is displaced, there may be a visible deformity such as angulation or malrotation called scissoring.

The injured hand is assessed. Range of motion is typically diminished, in conjunction with bruising and swelling. X Rays are critical to make the diagnosis and help guide treatment.

High energy mechanism, such as fall from significant height, motor vehicle accident, motorcycle crash, industrial accident.

Pain and swelling are common. Numbness in the median nerve distribution is a sign of associated acute carpal tunnel syndrome which represents a surgical emergency.

Physical examination and plain radiographs. Occasionally, a CT scan helps guide treatment, especially if associated fractures are present.

Trauma, arthritis, posttraumatic arthritis, intraarticular fracture malunions, inflammatory conditions such as rheumatoid arthritis.

Pain is the primary reason to consider a joint denervation procedure.

The history is critical in understanding to what degree the involved joint is causing symptoms. In terms of imaging, depending on the affected joint, an xray, MRI, and/or CT scan may be helpful in establishing a plan of action. A series of anesthetic injections can be considered in order to simulate a denervation procedure, depending on the joint involved.