Xiaflex (pronounced Zy-a-flex) is the brand name for collagenase, an injectable medication used to treat Dupuytren’s disease (pronounced doop-a-trens). Dupuytren’s disease can cause abnormal thickening of the tissue just beneath the skin. It most commonly affects the palm and can extend into the fingers. Firm pits, bumps and cords can develop and cause the fingers to bend into the palm.
The thickened tissue is made up of collagen. There are many types of collagen in the body, but there is a prevalence of collagen type III in Dupuytren’s. Xiaflex is an enzyme that specifically breaks up collagen type III.
Here is a video demonstrating a cord that is injected and what is done afterwards to straighten the finger.
The wrist has several definitions, but generally, when one refers to a wrist fracture, they are referring to the end of the radius (also referred to as the distal radius). It is one of the bones in the forearm and is the most commonly broken bone of the wrist. However, the wrist can also technically include the other forearm bone, the ulna, as well as the eight small bones in the hand.
A break and a fracture are the same. It is the pattern of the fracture that determines the severity of it.
Simple fractures refer to ones where there may be 1 or 2 large bone pieces that are well aligned and stable. Hairline fractures fall into this category.
Displaced fractures refer to ones that are crooked. Sometimes the crooked fractures can be reduced, meaning they can be pushed back into place. After this is done, you are placed in a cast to hold the position. However, the fracture can be unstable, meaning that even in a cast, they may shift and become crooked again. Not all crooked fractures need surgery though. Some amount of crookedness on x-rays may not translate to any functional deficit in your activities of daily living.
Intra-articular fractures refer to fractures that go into the wrist joint. Sometimes there is just a crack in the joint, but sometimes it can become wide or it can shift so the joint becomes uneven. These types of fractures are harder to reduce and oftentimes need surgery. Also, the more uneven the joint is, the greater risk you have for developing arthritis in your wrist at a later time. This could cause pain.
Comminuted fractures refer to ones that have many many pieces. Comminuted fractures may be intra-articular and displaced as well, so these are very severe fractures.
Not all wrist fractures need surgery. Treatment is dependent on many factors, not just the xray. Factors such as age, activity level, hobbies, occupation, hand dominance, prior injuries or wrist arthritis, and other medical problems are very important when considering treatment and should come up in discussion with your surgeon.
Vascular disorders are problems with arteries and veins. Arteries are the pipes that bring blood from the heart to the fingers. When you feel your pulse in the wrist, you are feeling the radial artery. On the other side of the wrist is the ulnar artery, which is harder to feel. The ulnar and radial artery connect in the palm into two arches that continue towards the fingers. Each finger has two branches, the radial digital branch and the ulnar digital branch. When you cut your finger, if the bleeding pulsates, you likely cut into the artery. You can damage one digital artery to the finger, but if you damage both, the blood flow to the finger can be severely compromised.
Veins are the pipes that return the used blood back to the heart and lungs. When you get blood drawn or an IV placed in your hand, it is usually placed in a vein.
Vascular disorders are relatively uncommon in the upper extremities. They can cause problems such as pain, open wounds, or even loss of body parts.
The ulnar nerve is one of the three main nerves in your arm. It travels from your neck, past the inside of your elbow, and then down into your hand. It can be pinched anywhere along this course, but most commonly, at the elbow. When you hit the "funny bone" in your elbow, you are actually hitting the ulnar nerve, not a bone.
Excess pressure on the nerve can cause numbness or pain in your elbow, hand, wrist, or fingers. The nerve gives feeling to the little finger and half of the ring finger. It also supplies the little muscles in the hand that are responsible for finger dexterity as well as a few muscles in the forearm that help with grip.
Compression of the nerve at the elbow is called Cubital Tunnel Syndrome. Many things can cause compression here:
Bending your elbow repeatedly
Putting pressure on your elbow, such as leaning on the table
Prior fracture/dislocations or arthritis in the elbow
To reduce compression at the elbow, make sure not to keep your elbow bent for too long. If you tend to sleep on a bent elbow, wrapping the elbow loosely with a thick towel will help to remind you not to bend it. Try not to rest your elbows on anything. If you have armrests on your chart, remove them. Avoid leaning on your elbows at the table and don't rest your elbow on an open window while driving.
If numbness becomes constant or you are noticing clumsiness in your hands, consultation with a hand surgeon would be indicated. Treatments include anti-inflammatory medications, splints, steroid injections, therapy and in severe cases, or cases that do not improve with the above treatment, surgery.
Trigger finger is caused when the tendons that bend your finger gets stuck in a tunnel in the palm of your hand. This tunnel, also known as a pulley, can become too thick, making it difficult for the tendons to pass through. The tendons can sometimes get stuck in the tunnel, making it difficult to straighten the finger. There may also be symptoms of pain, popping or catching. Sometimes the popping will feel like it is in the joint but it is actually the tendon going through the tunnel. Causes of triggering include arthritis, gout, diabetes, trauma, and oftentimes, no clear cause at all.
Treatment involves trying to reduce swelling around the tendon and pulley. Wearing a finger splint or taking an oral anti-inflammatory medication may sometimes help. A steroid injection is often effective as well. However, if symptoms return after several injections, surgery may be recommended. With surgery, the pulley is opened so that there is more room for the tendon to move. Recurrence is rare after surgery.
Steroid injections are commonly used to treat a variety of inflammatory conditions of the upper extremity.
These injections typically contain a mixture of a synthetic cortisone and a local anesthetic such as lidocaine. Cortisone is a steroid normally produced by the body and is a powerful anti-inflammatory. These anti-inflammatory steroids are very different from the anabolic steroids that have been abused by some athletes for body-building and performance enhancement.
The local anesthetic dissolves the steroid and numbs up the area of the injection, diminishing discomfort during the procedure.
There are several available synthetic cortisones that all have similar mechanisms although they vary in strength and duration of action (short versus long-acting). No single preparation has been found to be superior to others so the choice of medication is left up to the individual provider.
The injection should take effect within a few days and the benefits can last for many weeks. The exact timing, however, varies from patient to patient. For some conditions, one injection can be sufficient to completely get rid of the inflammation and pain while for more severe cases, several injections may be required. Most patients respond well to injections although a small subset may not experience any relief of symptoms.
There is no set rule as to how many injections a person can get. Many providers use three injections as a rule of thumb although, in some cases, more frequent injections may be helpful. Your response to the first injection is very important in determining whether to proceed with re-injection: If the first injection doesn’t work or wears off quickly it may not be worthwhile repeating. Many providers limit the number of injections because repeated cortisone may cause damage to tendons and/or cartilage.
If an injection is done for a condition that is aggravated by use (e.g. tendinitis, arthritis), it is also important to learn how to properly use that body part to ensure recurrence does not happen. Oftentimes, cortisone will mask the pain, but the underlying cause of the pain is still there. If this is due to arthritis, it is important to practice joint protection so further injury to the joint is not done. If the cause of pain is due to repetitive stress, continuing to repeat the stress may lead to worsening pain once the injection wears off.
The most common side effect of a cortisone injection is known as a flare reaction. This is thought to happen when the steroid crystallizes after being injected, leading to pain lasting one or two days after the injection. This pain can be worse than the initial discomfort for which the injection was given. Cortisone flares resolve spontaneously over a few days and can be treated with ice, an anti-inflammatory medication such as Ibuprofen and rest of the affected body part.
Another common side effect, especially in patients with darker skin, involves skin discoloration at the injection site. The skin becomes locally lighter in color and sometimes thinner. Although this can improve, the whitening of the skin can sometimes be permanent.
One of the more serious complications from these injections is an infection, especially if the injection was given into a joint. Fortunately infections are rare and can usually be prevented by carefully cleaning the skin before performing the injection. Very rarely, some patients may experience allergic reactions to the steroid or local anesthetic in the injection.
Diabetics may often notice a transient increase in their blood glucose in the days following an injection. Cortisone injections are usually safe during the last trimester of pregnancy and while breast-feeding. However, checking with your obstetrician would be advised prior to proceeding.
A second R post in light of Jimmy Fallon's recent finger injury...
Ring avulsion injuries are a rare injury that can cause severe damage to the finger.
There are three classes of injury.
Class I: Skin and soft tissue are damaged, but repairable with good recovery of the finger.
Class II: Blood vessels and nerves are damaged, oftentimes requiring special grafts to repair them. Overall outcome is good, although sensation to the finger may not be perfect.
Class III: Tendons and bone are damaged, so severely that amputation is often advised. Attempts at reconstruction, even if successful in saving the finger, often leave a finger that does not move or function well due to post-surgical scarring and swelling.
Common causes of ring avulsion injuries: jumping a fence, dunking a basketball, falling in the shower. The ring will get caught on the fence, basketball hoop, shower bar, and pull on the finger forcefully. Best way to prevent the injury: remove rings with sports or any activity where the ring may catch on the edge of an object.
A repetitive strain injury (RSI) is often used as an umbrella term to describe pain in the upper extremity associated with repetitive tasks. However, many times, there are no objective findings of injury (e.g. swelling, bruising). What is usually common in these "injuries" is postural deterioration due to improper ergonomics and poor movement patterns (sitting hunched over at a desk for many hours). Many patients who present with wrist and forearm pain that develops after keyboarding will have poor posture and weak posterior musculature. That is, their shoulder stabilizers will be very weak as will their core. There may or may not be associated pain in the shoulder or back. Upper Crossed Syndrome is another term that has been used to describe the postural dysfunction that can lead to RSI.
Treatment for RSI includes therapy that focuses on the body as a whole, not just the areas of pain. Proper ergonomics, frequent breaks and positional changes, and a well-balanced stretching and exercise program as guided by an occupational therapist or functional movement specialist are all an integral part of treatment.
de Quervain syndrome is caused by swelling along the tendons on the thumb side of the wrist. These tendons are attached to muscles in your forearm. When the muscle contracts, the tendons will pull the bones that they are attached to. In deQuervain syndrome, the tendons that are affected are attached to the thumb bones and are responsible for moving the thumb away from the hand.
In de Quervain syndrome, the tendons run in a tunnel called the first extensor compartment. This tunnel will become narrow due to thickening of the soft tissues that make up the tunnel. This will limit the movement of the tendon, leading to pain with hand and thumb motion, especially with forceful grasping or twisting. The syndrome can often be seen in new mothers and is referred to as "mommy thumb." It is thought to be caused by hand positioning when breast feeding and lifting the baby as well as possibly hormonal changes and fluid shifts.
Treatment includes wearing a brace that keeps you from moving your thumb and your wrist. Anti-inflammatory medications and hand therapy can also help. Cortisone injections may help to reduce swelling. Surgery can also be done to open up the tunnel and make more room for the tendons.
The phalanges are the bones that make up the fingers of the hand. There are 14 phalanges in each hand. Three phalanges are present in each finger and two in the thumb. The phalanges are named according to whether they are proximal (closer to the hand), intermediate/middle or distal (towards the tip), and according to the finger they are in. The thumb does not possess a middle phalanx.
The proximal phalanges join with the metacarpals (long bones in the hand) at the metacarpophalangeal joint. The space between the proximal and intermediate and intermediate and distal phalanges are called interphalangeal joints.