Dr. Budoff's Blog

Proximal Interphalangeal (PIP) Joint Replacement

August 2nd, 2011

The proximal interphalangeal joint is the middle joint of the finger. Injuries to the proximal interphalangeal joint often lead to arthritis. The treatment of proximal interphalangeal joint arthritis starts with buddy taping of the finger to its neighboring digit and a steroid injection into the proximal interphalangeal joint. If significant proximal interphalangeal joint pain continues then the options for treatment are usually either fusion or replacement.

The proximal interphalangeal joint of the index finger is best fused. The index finger is used for pinch. When the index finger opposes the thumb to create power during pinch, this creates a significant sideways stress on the proximal interphalangeal joint. Current proximal interphalangeal joint replacements simply cannot handle this sideways stress, and will become unstable. On the other hand, fusion leads to a stiff but pain-free and stable platform for pinching. The loss of proximal interphalangeal joint motion is not a significant problem for the index finger.

Because the middle, ring and small fingers are used for grasp, motion of the proximal interphalangeal joint of these digits is important. For that reason, proximal interphalangeal joint replacement may be considered. As for most joint replacements, they have less problems as the patient’s age increases. The reason for this is because joint replacements have a limited ‘life expectancy’, and do not last as long in younger, higher demand individuals. Having said that, the newer joint replacements may be better suited for younger, higher demand individuals, within reason.

Proximal interphalangeal joint replacement is performed as an outpatient surgery. The newer metal and polyethylene (a fancy plastic) replacements usually work better than the pyrocarbon implants that were popular a few years back. An example of the newer (SR-PIP) joint implant can be seen at www.totalsmallbone.com/us/products/hand/sr_pip.php4

After proximal interphalangeal joint replacement, motion is started within a few days after surgery with hand therapy. Ultimate motion is about 50% of normal, about 60°. It is unclear how long the newer proximal interphalangeal joint replacements will last.

Unfortunately, these newer unlinked proximal interphalangeal joint replacements are not appropriate for patients with advanced rheumatoid arthritis. Rheumatoid arthritis is a much rarer inflammatory condition than the typical osteoarthritis (wear and tear) that is much more common. If you’re not sure what type of arthritis you have, unless a rheumatologist (arthritis expert) has formally diagnosed you with rheumatoid arthritis, you most probably have simple osteoarthritis or a similar condition. People with rheumatoid arthritis have poor ligaments. Because of this, unlinked replacements, such as the SR-PIP, will become unstable. In cases of rheumatoid arthritis, one-piece linked silastic (a type of rubbery plastic) replacements provide some intrinsic stability and are better options. The post-operative therapy is the same. In cases of rheumatoid arthritis, motion is limited more by the conditions of the finger’s tendons than the joint replacement itself.

So if you are suffering with proximal interphalangeal joint arthritis, there are now better treatment options than were previously available. Most patients are very happy with the pain relief and function afforded by these newer implants.

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Proximal Interphalangeal (PIP) Joint Injuries

July 29th, 2011

The proximal interphalangeal joint is the middle joint of your finger. It is an unforgiving joint when injured, and often becomes extremely stiff. What most people don’t realize is that the bones of the fingers heal extremely quickly, and if this joint suffers a severe injury it can become irreparable within only 2-3 weeks. That’s a good reason to see a hand surgeon quickly following a proximal interphalangeal joint injury.

If the proximal interphalangeal joint becomes dislocated, without a fracture, these are almost always stable injuries. Splinting them is often counterproductive, because it leads to stiffness. This stiffness can become severe enough within 3-4 weeks so that nothing short of a surgical release will allow motion to regained. However, if motion is begun early an almost normal joint can be regained, with full function.

An unfortunate, but common enough scenario is that there is a proximal interphalangeal joint fracture-subluxation. That means that a critical part of the joint is broken (fractured), which allows the joint to sublux (partially dislocate). This leads to pain and stiffness. If not treated, arthritis often ensues within 6-12 months, or sooner. Even after optimal treatment, the joint will never be the same. The joint will always be thick, may have tenderness and ache sometimes (like when the weather changes) and will never regain full motion.

Proximal interphalangeal joint fracture-subluxations are difficult injuries to treat early, and late treatment is even more problematic. The priorities for early treatment of proximal interphalangeal joint fracture-subluxation are 1) Reduce the joint subluxation so that the joint is located. Failure to do this essentially guarantees early arthritis, 2) Obtain joint motion. Otherwise, the joint becomes extremely stiff, 3) And this priority is, by far, the least important of these three goals: try to reduce the joint fragments. Please note that this is not always possible, and that many people can do well without the joint fragments reduced, as long as the first two goals are met.

The fracture part of these injuries is often highly comminuted, meaning that it is made up of many very small fragments than cannot be reduced (placed back into good position) by opening the fracture directly. Relying only on open surgery to reduce these fractures often has a high rate of stiffness and suboptimal results.

The best treatment of an acute (<1-2 week old) proximal interphalangeal joint fracture-subluxation to accomplish at least the first two goals is a ‘dynamic external fixator’. This is a device constructed of wires and rubber bands in the operating room. The one that I prefer was invented by my late friend, Joe Slade, MD. Many comment that it looks somewhat like a radio antennae coming out of the finger. While that is true, it’s the best technique that I have found for treating early proximal interphalangeal joint fracture-subluxations. While no surgery, especially for severe injuries such as these, works 100% of the time, this one consistently reduces the joint and allows for early motion (with the help of post-operative hand therapy, which is extremely important). A small open incision often allows for reduction of the joint fragments.

Slade dynamic external-fixators usually need to be worn for 6 weeks. And they need to be taken care of. It is extremely important that the patient be responsible in looking after these. These require protective splints over them all the time except bathing or performing motion exercises to prevent them from catching on clothes, surrounding people or objects. The wires cannot be allowed to get bent. Extra rubber bands need to always be carried in case one breaks. Follow-up X-rays are taken every week to start, then every two weeks. Therapy sessions must be attended and ‘homework’ performed to regain motion. The fixators are removed in the office, usually after 6 weeks. This does not hurt very much, and is nothing to worry about.

If the proximal interphalangeal joint fracture-subluxation is not seen within 1-2 weeks, the Slade dynamic external fixator can often be used, but now the joint often has to be opened to clean out scar tissue and allow the joint to reduce. This creates more scar and the ultimate result is often not as good. After 4-6 weeks, the proximal interphalangeal joint fracture-subluxation cannot be fixed, and needs to be reconstructed (replaced).

The best reconstruction, in most cases, is a hemi-hamate arthroplasty. This involves removing a portion of the hamate (a wrist bone) with its cartilage and using it to replace the destroyed proximal interphalangeal joint surface through an open incision. While it probably works better than the other options for proximal interphalangeal joint fracture-subluxations presenting late, the joint often becomes stiff, and the results are not nearly as good as for early injuries treated by the Slade dynamic external fixator. Remember that scar has formed before the surgery, and the original joint surfaces are now destroyed. Some amount of arthritis is often present by this time.

Once significant arthritis has occurred, treatment options are limited to joint replacement or fusion. Both of these are salvage options. Newer options for joint replacement work better, but no artificial joint can ever be as good as your natural joint. Therefore, it’s best to get these injuries treated early to have the best chance at a good result.

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Hamate Hook (Hamulus) Fractures

June 16th, 2011

Fractures of the Hook of the Hamate (also called the “Hamulus”) occur mainly in people who play racket or batting sports, such as tennis, golf or baseball. Hamate hook fractures lead to pain in the base of the palm on the small finger’s side.

If seen soon after injury, Hamate Hook fractures are placed in a below-elbow cast for 6 weeks. Unfortunately, even with cast immobilization, only half of these fractures heal. When a fracture fails to heal it is called a ‘nonunion’. Hamate hook nonunions often continue to cause pain. Fortunately, the pain can be effectively relieved by simply removing the fractured bone fragment. While the ulnar nerve, the major nerve to the hand, wraps around the hamate’s hook, in the hands of a skilled hand surgeon the complication rate from this surgery is low. The wrist is splinted for just a few days to facilitate wound healing, and activities may be resumed as tolerated. Many well-known professional athletes have had this procedure performed and returned to their usual high level of competitive performance.

Sometimes the hamate hook nonunion does not cause pain. However, most surgeons still recommend excising the hamate’s broken hook because the flexor tendons to the small finger rub against it. The sharp edge of the hamate hook’s fractured end can damage the flexor tendon to the small finger, which leads to significant hand dysfunction and is a much tougher problem to treat. If a patient understands the risk of tendon injury, and is willing to accept it, then he or she can elect to leave an asymptomatic nonunion untreated.

So whether the hook of the hamate heals in a cast or not, it can be effectively and treated by a skilled hand surgeon with excellent long-term results. Simple removal of the fractured or non-united hook usually returns even professional athletes to their former level of performance.

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Stiff Fingers

May 26th, 2011

Stiff fingers may occur following injuries to the hand or wrist. The first-line treatment for this is hand therapy, often using splints with springs or rubber bands on them to stretch out the digits. If therapy fails and the finger stiffness is decreasing hand function, a surgical solution can be considered.

Surgical release is often very effective for stiff fingers, especially to regain flexion/bending. The surgical release is performed in the morning. Therapy begins that afternoon. The therapy is intensive, often 5 days/week for a month, then 4 days/week for a month, then 3 days/week for a month. The surgery is not very painful. The therapy can be painful and it’s often a good idea to take a pain pill before therapy if someone else can drive you there. Most people who work with the therapist and do their homework (ie. performing motion exercises several times a day, every day, on their own) regain excellent finger flexion and excellent hand function.

Obtaining finger extension is also possible, although not as predictable. The proximal interphalangeal (PIP) joint is the joint most commonly ‘stuck’ in flexion. Open surgery is not very effective for regaining PIP joint extension. To regain PIP joint extension, the best way is probably by using a ‘digit widget’. The digit widget is a device that is attached to the middle finger bone by a minor surgery. This surgery doesn’t hurt much at all. The digit widget attaches to a rubber band, which is attached to a removable Velcro glove that goes over the hand. This rubber band places an extension force on the PIP joint 24 hours a day. Therapy is not very intensive, but is performed roughly once a week, in order to check the digit widget’s position and often supplement it with splinting of the adjacent metacarpophalangeal joint (MPJ). The digit widget is left in place for 6 weeks and then removed in the office (which also doesn’t hurt very much). Night splints are worn for 6 months to minimize the chance of recurrence. The digit widget is usually very effective. If you’re interested, you can look up the digit widget on the internet at http://www.handbiolab.com/products/digit-widget/

For all surgical releases, results are best if only one finger is involved. If more than one finger is involved, then the time and attention of therapy is divided, and results may not be as good for each individual digit.

So if you have a stiff finger that is causing hand dysfunction and therapy isn’t working, you should be aware that effective surgical options exist. The surgeries are not very painful. However, the post-operative therapy is very intensive, and time must be set aside in your schedule to attend therapy for the releases to be effective. Hand therapy is a necessary and integral part of the treatment, as is ‘home work’, involving performing motion exercises on your own. As with most surgeries, motivated patients do best.

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Distal Radius Osteotomy

April 5th, 2011

Many wrist fractures heal in ‘suboptimal’ position, either because they were not surgically fixed or because the surgical fixation did not turn out well. When a wrist fracture heals in poor position (called a ‘malunion’) it can lead to deformity, pain, stiffness, weakness, and dysfunction, especially in active individuals. If the malunion includes a malalignment inside of the wrist joint, this usually leads to arthritis.

The choice is between accepting the poor wrist position for life or having the bone ‘rebroken’ and fixed (or refixed, as the case may be) in a better position. This is called an osteotomy. As with many other things, if an osteotomy is going to be performed, it is better to perform it early rather than late. Early on, the original fracture line may be visible and it may be possible to reopen up the original fracture, which allows the wrist bone to be put into a fully normal position, or close to it. Once the fracture has healed and remodeled, this is no longer possible, and an approximation needs to be made. Performing the osteotomy early on is crucial if the malunion goes inside the joint, as surgery inside of a joint requires precision if the joint is to be made perfectly smooth again.

Once the osteotomy is made, it is then fixed with a plate in better position, just as a fresh distal radius fracture is plated. In order to ‘fill in the gaps’ in the bone created by the repositioning, bone graft is often needed for filler. Traditionally, this has been taken from the ‘hip’ (iliac crest), but it’s much less painful to take it from around the elbow. Bone taken from the body is much better for this purpose than bone taken from a cadaver, or synthetic bone, which are usually good enough for fresh fractures. Taking bone from around the elbow is not usually very painful, and rarely causes any problems.

After surgery, the wrist is immobilized for 1-2 weeks, depending primarily on the quality of the bone fixed. Then therapy is begun to regain motion. A splint is used as needed for 6 weeks.

Most patients who undergo osteotomy of a wrist fracture that has healed in poor position are extremely happy. This is a common, outpatient procedure, and should be considered in any active patient who is having problems from a wrist fracture that has healed in poor position.

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Flexor Carpi Radialis (FCR) Tendinitis

March 31st, 2011

The flexor carpi radialis (FCR) is one of the tendons that helps flex the wrist. It is located on the palmar surface of the wrist, near the base of the thumb. Overuse, such as occurs with repetitive lifting with the palm up, may lead to FCR tendinitis. This is similar to DeQuervain’s tendinitis in that it’s often caused by a space problem.

Like the tendons involved in DeQuervain’s syndrome, the FCR tendon runs in a sheath. Overuse can lead to swelling within that sheath, leading to compression/pinching of the FCR tendon. This leads to tendon pain,usually located about an inch above your wrist. This pain is often increased by lifting with your palm up and by grip, both of which stress the tendon.

Treatment starts with activity modification, lifting with the palm down when necessary, a splint that is worn during periods of heavy activity and a steroid injection to decrease inflammation and swelling. If that fails, then the FCR’s tunnel (sheath) can be surgically released. This is a simple, outpatient procedure that takes only 5-10 minutes. It can be performed under local anesthesia. Like the DeQuervain’s release, it is highly effective.

After surgery, keep the wound clean and dry for 3 days. Then you can shower and get it wet, but try not to submerge it under water for 10 days. Also try to avoid heavy activities for a week or two. Once released, the FCR tendon starts to heal. How long it takes to feel better depends on how much damage it had before it was released and how much the FCR tendon gets to rest following surgery.

In summary, wrist pain due to FCR tendinitis is fairly common and very treatable.

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EPL Rupture

March 8th, 2011

The EPL (extensor pollicis longus) tendon extends your thumb. Following a wrist fracture, or sometimes due to arthritis and bone spur formation, the EPL tendon can rupture. In cases of arthritis, the EPL tendon rubs can rub across a bone spur until it abrades and fails. In cases of fracture, the swelling cuts off the EPL tendon’s blood supply so that it ruptures after a few weeks or months.

When the EPL tendon ruptures the thumb can’t extend and the thumb can’t be brought out of the palm. The thumb gets in the way of using the hand, which makes many activities very difficult to perform. Fortunately, this is a very treatable problem using a ‘tendon transfer’.

When a tendon ruptures because of abrasion or lack of blood supply, a large area of the tendon is damaged, not just a small piece, as would happen if the tendon were, for example, cut by a knife. And when a large area of the tendon is damaged , it can’t simply be repaired, because the tendon would now be too short. So we use a nearby tendon to substitute for the damaged tendon. This is known as a ‘tendon transfer’, where we essentially ‘rob from Peter to pay Paul’. In this example, the index finger has two tendons that extend it, so one of these can be used as a ‘spare part’ and transferred to the stump of the EPL tendon on the thumb.

This is a relatively quick outpatient procedure that is not very painful at all. It does, however, require a fair amount of hand therapy afterwards. A special dynamic splint (with a rubber band to take the stress off of the repaired tendon during thumb extension) needs to be worn for 4 weeks. After 4 weeks the hand can be used for light activities, with full activities usually allowed after 3 months. A night splint is worn for 3 months. Athletics can be resumed after 4 months.

While the thumb doesn’t move totally normally following this tendon transfer (perfection is an elusive goal), the situation is almost always greatly improved and patients are usually very happy because they can now extend their thumb and get it out of their palm. This allows them to use their hand again.

So, if your EPL ruptures and you can’t use your hand effectively because your thumb gets in the way, know that this is a not uncommon problem with an effective solution.

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Boxer’s Fracture

March 1st, 2011

Boxer’s fracture refers to a fracture (break) of the 5th metacarpal, that is the hand bone connected to the small finger. It often happens from punching a solid object, hence its name. This injury leads to pain and swelling over the broken bone.

The vast majority of boxer’s fractures can be treated without surgery. I prefer to splint these for 3 weeks and then allow motion. It is very important that the hand is splinted in the correct position. ER splints and many other splints hold the hand in positions where significant stiffness will occur. This stiffness can be so profound that it takes a surgery to improve it, whereas the original fracture would not have required a surgery without the administered ‘treatment’. Hand surgeons will splint the hand in the correct position while the fracture heals.

Some fractures will do better with a ‘closed reduction’, where the fracture is ‘set’. This involves numbing the broken bone and moving it into a better position. The hand is then splinted for 3 weeks, as above. Fractures can only be ‘set’ during the first 5-7 days, so it is important to see a hand surgeon quickly. After that, the fractures alignment is either accepted (most common) or corrected surgically (uncommon).

Most boxer’s fractures will leave a cosmetic deformity, ie. a ‘dropped knuckle’. This means that when you make a fist the knuckle of the broken bone will be less prominent. In the vast majority of cases, this deformity is cosmetic only, and normal function will ensue.

Uncommonly, a boxer’s fracture is so angulated or rotated that surgery is required. The fracture is placed into a good position and held there with either pins or a plate. I prefer to plate most of these and then obtain early motion to regain function as quickly as possible.

Regardless of how these are treated, it may be a couple of months before pain resolves and function returns to normal. It’s a function of the individual’s healing capacity and pain tolerance.

To summarize: if your hand swells and has pain after striking a solid object, it should be evaluated by a hand specialist during the first week in order to preserve all treatment options and obtain the best result. Most boxer’s fractures don’t require surgery, and do very well with non-operative management.

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Intersection Syndrome

February 15th, 2011

Intersection syndrome leads to pain, swelling and occasionally ‘squeaking’ on the back (dorsum) of the wrist. The pain is worse with gripping or lifting. Intersection syndrome is usually due to overuse from activities that require repetitive wrist extension, such as raking leaves, shoveling, rowing, weight lifting or skiing.

Similar to DeQuervain’s tendinitis, intersection syndrome is due to a space problem, that is too much stuff in too little space. The tendons of your wrist travel through tunnels. When you overuse them, swelling enters the tunnels. In cases of intersection syndrome, the tendons become compressed in the tunnel next door to the tunnel that causes DeQuervain’s tendinitis.

Treatment of intersection syndrome starts with avoiding lifting with the palm down, which stresses the involved tendons; lifting with the palm up causes less pain. A splint and a steroid injection are also used to decrease swelling and inflammation about the wrist.

If these treatments don’t work, or if they work but the intersection syndrome recurs, a surgical release is very effective. This release decompresses the tendons and allows them to heal. How long it takes to feel better is often dependent on how damaged the tendon was by the tunnel’s constriction. This is an outpatient procedure. The adjacent tunnel, that leads to DeQuervain’s tendinitis is often released at the same time, as these conditions may coexist.

After surgery, please keep the wound clean and dry for four days. Bathing is safer than showering. Wrap a towel around the dressing in case any water gets in, then place a plastic bag over your hand and secure it tightly with rubber bands. After 4 days you can remove your dressings and the splint and get your incision wet in the shower. Blot it dry. There are no stitches to remove (they’re buried and absorbable). There are little pieces of tape over your wound. The longer they stay, the nicer the final wound may look. They’ll fall off when they’re ready. Please don’t submerge your incision under water (like swimming, or putting your hand under water while doing dishes) for 10 days after surgery.

Try to avoid heavy lifting and gripping while the tendon is trying to heal. Otherwise, computer use and typing are fine immediately after surgery.

In conclusion, intersection syndrome is a very treatable overuse syndrome that causes pain, swelling and occasionally ‘squeaking’ on the back of the wrist. The earlier treatment starts, the better people do so, as usual, get any medical issues addressed in a timely fashion.

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The 1st Metacarpal Osteotomy for Basilar (Basal) Thumb Pain in Young Adults

January 24th, 2011
First metacarpal osteotomy with fixation.

First metacarpal osteotomy with fixation. The straight pin is removed after 5 weeks.




Arthritis commonly affects the base of the thumb. Older patients, or those with more advanced arthritis, are well-treated by the LRTI procedure, which is well-covered in this website. While the LRTI is extremely effective, it may be more surgery than a younger patient with less-advanced arthritis requires.

If nonoperative management, including activity modification, a splint and an injection fail to provide acceptable pain relief, younger patients may desire surgical treatment.

The first metacarpal osteotomy is a simple procedure that provides predictable pain relief for young adults with less-advanced basilar thumb arthritis. First metacarpal osteotomy involves cutting the first metacarpal (the long bone of your thumb) and extending it 30°. It is then fixed in its new position with 2 wires, one that stays inside and one that protrudes through the skin and is removed after five weeks (which doesn’t hurt much at all). After surgery, a cast is worn for five weeks. Throughout this time it is important to move the tip of the thumb at least 3 times a day to prevent the thumb’s tendons from scarring down.

This surgery has passed the test of time and is very effective. It transfers stress from the arthritic areas of the basilar joint to areas of the basilar joint that are still normal, or have only mild arthritis. This decreases the stresses going through the most arthritic areas of the basilar joint, decreasing pain. The first metacarpal osteotomy does not remove any arthritis already present. Therefore, activities that are very stressful on the thumb (massage, forceful use of certain tools, etc) often have to be avoided indefinitely. Many people often have one activity that they have to ‘give up’. Following first metacarpal osteotomy, any given stress on the basilar joint will lead to less pain. Another way to say this is that more stress can be placed on the thumb before pain occurs. Any arthritis present will still continue to progress, but probably at a slower pace. Therefore, this surgery probably helps to delay the need for future surgery. The first metacarpal osteotomy will not be effective in cases of more advanced arthritis because, in advanced cases, there’s no remaining normal joint to ‘off-load’ stresses onto.

Because the thumb’s metacarpal bone is extended, thumb flexion will be decreased a little, but this is rarely a problem. Close inspection of the thumb will detect a slight angle to it, but this is rarely noticed unless actually looked for, ie. the angulation is not usually ‘obvious’. There is some, but usually not a lot, of hand therapy required once the cast is removed. A removable splint is then used as needed.

In summary, basilar thumb pain can usually be successfully treated in young patients without advanced arthritis by a first metacarpal osteotomy, an outpatient procedure that ‘burns no bridges’ and still allows for an LRTI, or any other needed procedure, to be performed in the future.

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