The Hand and Wrist Institute

The median nerve courses with the brachial artery across the anterior aspect of the elbow and dives between the two heads of the pronator teres muscle giving muscle function to this muscle. It then goes beneath the origin of the flexor digitorum sublimis (FDS) muscle giving rise to the anterior interosseous nerve (AIN). The AIN gives muscle function to the FPL (thumb flexor), the FDP to index and middle (flexes last joint), and the pronator quadratus. The median nerve supplies the FCR, Palmaris Longus, FDS in the forearm then goes to the hand giving sensation to the T, I, M, and 1/2 R and gives muscle function to the thenar muscles and the lumbrical muscles to the I and M. There are two major points of compression. The first is between the two heads of the Pronator Teres (Pronator Syndrome) where the median nerve is involved, and the second is at the area beneath the origin of the FDS with involvement of the AIN (Anterior Interosseous Nerve Compression Syndrome).

What are causes of pronator syndrome?

Fascial bands, anomalous muscles, and trauma are the most common causes of these syndromes. Repetitive use of the hand, wrist and elbow can lead to swelling in these areas causing nerve compression.

What are the symptoms of pronator syndrome?

Pronator Syndrome (P.S.):

Slow onset of aching pain at proximal forearm or elbow at volar surface; may have a precipitating event; nocturnal pain uncommon; increased with activity particularly pronation (rotation of forearm with palm in a downward direction); numbness and tingling of T, I, M, and 1/2 of R; weakness with dexterity such as buttoning clothes or picking up of small objects

Anterior Interosseous Nerve Compression Syndrome (AINCS):

Sudden onset of pain at proximal volar forearm followed by motor weakness or paralysis (absent thumb, index, and middle distal joint flexion); may have pain at volar wrist area

How to diagnose pronator syndrome:

In addition to symptoms as listed above, the examination will reveal:

Swelling at proximal, volar forearm
Tenderness at point of compression
Pressure applied at point of compression reproduces symptoms
Tinels’ sign (thumping tissue over area causes shocks or tingling (paresthesias) within the hand (P.S.)
Sensation diminished to the T, I, M, 1/2 R (P.S.)
Muscle weakness: FPL, FDP (I, M), Pronator Quadratus only if AINCS; may involve all muscles supplied by median nerve (including AIN muscles) if P.S.

Additonal tests are helpful:

X-rays of elbow and forearm: To rule out underlying joint or bone abnormality
Electrodiagnostic tests (NCV/EMG): Can be helpful particularly to pick up loss of muscle function in certain muscles in severe cases; slowing of NCV at the elbow can help diagnose P.S.

What is the non-surgical treatment of pronator syndrome?

Pronator Syndrome:

Conservative initially if no weakness of muscles with limiting repetitive movement, NSAID (i.e. Advil) by or steroids, and therapy.

Anterior Interosseous Nerve Compression Syndrome:

If this is secondary to trauma (i.e. elbow dislocation) then observation for 6-8 weeks may allow return of function without surgery.

What is the surgical treatment of pronator syndrome?

Pronator Syndrome:

If conservative treatment fails or if weakness or paralysis is present, then decompression is necessary to minimize irreversible muscle weakness.

Anterior Interosseous Nerve Compression Syndrome:

If no trauma, then aggressive treatment with surgical decompression is recommended, as the risks of surgery are much less than the chance of irreversible motor weakness if left untreated for several months.

Surgical recovery:

Patients return 8-10 days after surgery for suture removal; their long arm splint is changed at that time; 2 weeks later the splint is removed and they are sent to therapy for a removeable splint that is worn for 2 weeks at night and when not exercising; therapy is started and lasts ~ 6-8 weeks depending on the severity.

How can Dr. Knight help your pronator syndrome?

Dr. Knight knows that pronator syndrome can be difficult to diagnose. With his years of experience in the treatment of peripheral nerve problems, he will take a careful history and perform a detailed examination to confirm the diagnosis. He will then begin conservative treatment. If necessary through minimally invasive techniques, he may need to relieve pressure on the nerve. No matter what the treatment needed Dr. Knight will return you to your active pain free lifestyle as quickly as possible.

Appointment

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Hours of Operation

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Dr. Knights Hours of Operation:

DAY	LOCATION	HOURS
Monday	Beverly Hills	8:30am-4:30pm
Tuesday	Marina del Rey	12:00pm-4:00pm
Wednesday	Beverly Hills	8:30am-4:30pm
Thursday	West Hills	8:30am-10:30am
Thursday	Downtown LA	12:00pm-3pm
Friday	Beverly Hills	8:30am-4:30pm

Location and times are subject to change without notice.

For more information and to confirm Dr. Knight’s availability call 310.574.0400

Burns of the hand

admin — Fri, 30 Jul 2010 20:28:07 +0000

What are burns of the hand?

The hand is extremely susceptible to burns because of its very function. Burns are often sustained as the result of cooking accidents, or industrial accidents, and while burns to the hand are often isolated, they can also be part of a larger, much more serious burn of the arms or sometimes even the whole body. Burns can be present in four different degrees, first degree being the least serious, causing redness but little blistering, all the way to fourth degree, wherein the burn extends far below the surface and can affect even tendons and bones.

What causes burns to the hand?

First degree burns are typified by sunburn, and this is often the case on the hands. They can also be caused by friction, or very isolated contact with dry or wet heat or chemicals. Second degree burns (among the more common for hands), are caused by direct exposure to open flame, boiling liquids or chemicals. Second degree burns can also be caused by sunburns, but this can be avoided with proper use of sunblock. Third degree burns are much more severe, and are usually the result of extended contact with flame, corrosive chemicals, immersion in boiling liquid, or electricity.

What are symptoms of burns to the hand?

First degree burns are typified by slight redness. Second degree burns show up as extreme redness and a large amount of blistering on the skin, as well as fluid suppuration. Third degree burns often greatly disfigure the hand, and the skin can appear cracked, leathery and black. The tissue death extends down to beyond the skin and fat to underlying nerves and tendons. The nerve receptors die in the most severe cases, so third degree burns often cause less pain than second or even first. Third degree burns can also cause a person to go into shock, typified by confusion, nausea and rapid breathing.

How to diagnose of burns to the hand

To assess the severity of a burn to the hand, the doctor will take a detailed history of the injury, and by learning the cause and associated symptoms, it will make it easier to determine the proper course of treatment.

Non-surgical treatment of burns to the hand

First degree burns can usually be treated with analgesic creams and pain medication, and seldom require more than a week to heal. Second degree burns may be treated in a variety of ways. Sometimes, the blisters are trimmed, but that is not always the case, and opened blisters require the application of topical creams such as Silvadene, and antibiotics. It is also helpful to splint the affected hand or arm to prevent the development of stiffness in the limb.

Surgical treatment of burns to the hand

Third degree burns often require that the affected skin be removed and replaced with grafted skin from either an unaffected part of the body or from a donor. After splinting for the healing process, intensive therapy is necessary to restore full movement and flexibility to the hand.

How can Dr. Knight help you with burns to the hand?

While minor burns to the hand can be an inconvenience, more sever burns can be debilitating and painful, and should be treated as soon and as thoroughly as possible, to avoid further complications. Dr. Knight has treated many burns in the course of his practice, and will work with you to develop the most comprehensive course of treatment to bring your hand back to proper function.

Boxer’s Fracture

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What is a Boxer’s fracture?

A Boxer’s fracture is a break that occurs in the neck of one of the five metacarpals, just below where the fingers meet the hand. It is most commonly associated with the fifth metacarpal, below the little finger (“pinky”). As the name indicates, this injury is most common among boxers or other people who engage in violent hand-to-hand sport.

What causes a Boxer’s fracture?

A Boxer’s fracture is caused, almost exclusively, when the closed fist strikes a very hard and unyielding object (such as a human skull). Because of the nature of the punches thrown in boxing, and the angle with which the hands impact the face and head, the pressure exerted on the metacarpal bones is not constant, and as a result, the bone beneath the smallest finger is often the one under the most pressure, so it is the most likely to break.

What are the symptoms of a Boxer’s fracture?

The most immediate symptoms of Boxer’s fracture are pain and swelling, as well as bruising, as with any fracture. Most telling, however, is the loss of prominence of the knuckle of the little finger, which will undoubtedly accompany the injury.

How to diagnose a Boxer’s fracture.

The best way to diagnose a Boxer’s fracture is through traditional X-ray technology, as with most fractures, which will allow the doctor to ascertain the severity of the break and the angle at which the bone has been fractured.

Non-surgical treatment of a Boxer’s fracture.

It is generally preferred to treat the Boxer’s fracture non-surgically, which entails placing the affected area in a splint or cast so that the bones will knit together properly. If this is not done in a timely fashion, there is a very real risk that the bones will not join at the proper angle, and use of the finger will be permanently reduced. Even though functionality will be almost entirely restored, there may be some loss of prominence in the knuckle, but this in no way effects the use of the finger.

Surgical treatment of a Boxer’s fracture.

In very rare cases, surgery is necessary to repair the fracture. It is only recommended in cases in which the angle of the broken bone surpasses 70 degrees, and this is rare enough that it is extremely unlikely that surgery will be necessary for you. The surgery consists of the doctor placing a several pins through both parts of the bone, right at the point of fracture, to hold them in place so that the bone heals properly.

How can Dr. Knight help you with a Boxer’s fracture?

By assessing the damage using x-rays, and then treating the injury appropriately with splinting and casting (or surgery in extreme circumstances), Dr. Knight will be able to restore full functionality to your injured hand.

Boutonniere Deformity

admin — Fri, 30 Jul 2010 20:28:07 +0000

What is a Boutonniere Deformity?

Boutonniere deformity is a deformity in which the middle joint of the finger (known as the PIP, or Proximal Inter-Phalangeal joint) is permanently bent towards the hand, while the outermost joint, or DIP (Distal Inter-Phalangeal joint) is bent away from the hand. This happens as a result of a tear in the tendon sheet along the top of the PIP joint. The tendon can no longer effectively extend the PIP joint and then over compensates by over extending the DIP joint.

What causes Boutonniere Deformity?

Boutonniere Deformity is most often caused by an injury, typically a hard blow to the outstretched finger or “jamming”, but can also occur as a result of rheumatoid arthritis.

What are symptoms of Boutonniere Deformity?

As mentioned, Boutonniere finger presents as a very distinct malformation, so it is relatively easy to diagnose once it has become apparent. It does not, however, immediately present, and may take as long as one to three weeks before the finger begins to show signs of the malformation. Even before the finger takes on the characteristic form, the problem may be indicated by swelling and pain in the joints of the affected finger.

How to Diagnose Boutonniere Deformity.

Because of the characteristic presentation of the deformity, the doctor will no doubt be able to ascertain quickly the nature of the problem, but, depending on the cause of the injury, there may be various related issues. If the Boutonniere Finger is the result of Rheumatoid arthritis, then treatment is relatively straightforward, but if it is the result of an injury, the doctor must take care to ascertain if any more damage has been done to the surrounding hand. If any bones are broken, or additional tendons damaged, it may indicate a larger problem.

Non-surgical treatment of Boutonniere Deformity.

The most common non-surgical treatment for Boutonniere Deformity is for the injured patient to wear a special splint on the affected finger. This splint is designed specifically to hold the bent and injured finger in proper position, so that the tendon will heal correctly, without any gaps or additional tearing. This splint will also help strengthen the joint as it heals. The length of time can vary, but generally, the finger should be immobilized in the splint from 3 to 6 weeks. In addition, even after the splint is removed, you may still be advised to wear it at night, to further strengthen the joint. Once the splint is removed, a regimen of exercise and therapy are recommended, in order to restore the joint to its original flexibility and return it to full use.

Surgical treatment of Boutonniere Deformity.

Generally, a nonsurgical treatment is preferred, but may not be possible in certain circumstances. These cases include the severing of the tendon, displacement of bone or fragmentation, as well as if the deformity is a result of rheumatoid arthritis, or if splinting the finger proves ineffectual. If necessary, Dr. Knight will perform a minimally invasive procedure along the top of the finger, reattaching the tendon to its original position, as well as moving the bone back into place and stitching any tears that may have occurred in the tendon prior to diagnosis.

How can Dr. Knight help you with Boutonniere Deformity?

After confirming that you do, in fact, suffer from Boutonniere Deformity, it is important that you receive treatment as soon as possible, because if left untreated, this deformity can severely affect your manual dexterity. Once diagnosed, Dr. Knight will treat you as soon as possible in order to allay any complications that might arise, and to restore you to full mobility and dexterity, so that you can return to your life and work.

Biceps Tendon Rupture

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What is a Biceps Tendon Rupture?

The biceps muscle is the muscle on the front side of your upper arm, and is partially responsible for bending the elbow and rotating the forearm. The Biceps Tendon is the tendon that attaches the biceps muscle to both the shoulder and the elbow, and when this tendon tears or is injured it can have grave consequences for arm mobility and strength.

What causes a Biceps Tendon Rupture?

Tears of the Biceps Tendon at the elbow most commonly occur when the elbow is forcibly straightened against the effort of the muscles and tendons. This type of injury is common among people who lift heavy loads for a living, but can occur in anyone else who happens to be lifting a heavy object, as well.

What are symptoms of a Biceps Tendon Rupture?

Because of the sudden nature of the injury, a tear in the Biceps Tendon at the elbow is characterized by sudden, intense pain at the elbow, as well as vivid and highly visible bruising at the site of injury. One of the most marked features is that the muscle, because it is no longer attached to the radius bone at the elbow, will recoil within the arm, and form a lump in the arm resembling a “ Popeye” muscle appearance. There will also be weakness in bending or flexing the elbow, as well as difficulty twisting the forearm into a palm up position with a bent elbow.

How to diagnose a Biceps Tendon Rupture

As with any trauma, the doctor will start by taking a medical history, to establish the past use of the injured area and determine the cause of the injury. After this, there will be a physical examination of the injury, which will indicate the severity and scope of the trauma. Typically, imaging tests, such as X-rays and MRI scans, will be ordered in order to rule out any fracture of the elbow or other bones, as well as rupture of the biceps tendon away from its insertion.

Non-surgical treatment of a Biceps Tendon Rupture

By their nature, tendons do not reattach themselves to bone without medical intervention, so the only instances in which surgery would not be advisable were if the injured party were elderly, truly inactive, or because of health concerns. If you choose to forgo surgery, the only thing to do is intense rehabilitation, to train the remaining tendons and muscles to compensate for the lack of the Biceps Tendon.

Surgical treatment of a Biceps Tendon Rupture

The surgical repair of a Biceps Tendon tear is relatively straightforward, but there are a few different ways to do it. Some doctors choose to attach the tendon to the bone with sutures that pass through holes drilled in the bone, while others secure them using suture anchors in the bone. Another method, which Dr. Knight uses, involves anchoring the tendon to the bone through one small minimally invasive incision with a biosorbable device that inserted into the bone and causes much less irritation during the healing process.

How can Dr. Knight help you with a Biceps Tendon Rupture?

As mentioned, Dr. Knight uses a novel method that avoids the necessity of metal anchors, which is, in the long term, much better for the healing process. It is important that you are able to return to your life and work just as before your injury, and Dr. Knight will make sure that that happens.

Basal Thumb Arthritis

admin — Fri, 30 Jul 2010 20:28:07 +0000

What is Basal Thumb Arthritis?

Basilar thumb arthritis is a type of osteoarthritis that affects the joint at the base of the thumb, where the trapezium bone meets the thumbs first metacarpal, also known as the TMC or Trapezio-MetaCarpal joint. As a result of the arthritis, the cartilage that covers the ends of each bone at the point of friction wears away, causing the bones to rub against one another with no buffer, which leads to a great deal of pain.

What causes Basal Thumb Arthritis?

The particular joint affected by basal thumb arthritis is one that is subjected to a great deal of wear and tear over the course of your life as it is very mobile as a saddle joint. So even if you do not suffer from osteoarthritis of other joints, it is possible to have it affect only the TMC joint. While general wear and tear of the joint is the immediate cause of the arthritis, the factors that lead to an individual having a likelihood of arthritic development are unknown. It is suspected that a variety of factors play a role such as weight, heredity, possible prior injury, or employment that requires constant heavy use of the joint.

What are symptoms of Basal Thumb Arthritis?

Symptoms of basal thumb arthritis include pain and swelling of the TMC joint, decreased range of motion, weakening of the pinch strength of the hand, and sometimes a bone protuberance at the base of the thumb. Depending on the severity of the arthritic development, the pain and swelling may vary in intensity, but can often be debilitating.

How to diagnose Basal Thumb Arthritis.

Physical examination and X-rays are the best way to determine if you have basal thumb arthritis, but in some cases more complex imaging such as CT scans or MRI scans may be advisable to determine the severity of the arthritis.

Non-surgical treatment of Basal Thumb Arthritis.

The main concern in treatment of this type of arthritis is to reduce pain, minimize the disability and improve joint mobility. This may be achieved by splinting the joint, either full-time or just at night, depending on the severity of the pain. Over-the-counter NSAIDs can also aid in reduction of the inflammation and reduction of pain. Cortico-steroids may also be beneficial in pain management. It may also be beneficial for you to modify the activity you perform that puts strain on the joint, so as to avoid increasing the pain and inflammation.

Surgical treatment of Basal Thumb Arthritis.

As in most conditions, surgery is always a last resort, but if you are experiencing pain while at rest, or while doing daily activities, and of course if conservative, non-surgical treatment proves ineffective, surgery is the only option. While there are several surgical procedures that may be performed for this condition, the most common is a Trapezial resection arthroplasty. In this surgery, the trapezium bone is removed entirely and replaced with a cushion made from your body’s own tendon tissue, so that it will most likely not be rejected by your immune system. In some cases, it is necessary for the doctor to hold the bones in place with a steel pin while they heal, but this is not universal. You may also undergo a joint fusion, in which the affected bones are fused together, which greatly reduces the swelling and pain, but also reduces the flexibility of the joint, making some tasks more difficult or even impossible.

How can Dr. Knight help you with Basal Thumb Arthritis?

Basal thumb arthritis can be extremely painful, and Dr. Knight’s primary concern is to relieve you of this pain, as well as the accompanying inflammation, so that you can return to your life and work and continue to go about your daily routine with little or no change in behavior.