Summer Sideliners

Common summer injuries of the hand, wrist and elbow

As we hike, bike, raft and climb our way through summer adventure, mishaps are bound to happen.  Some of the most common we see include wrist fractures, tennis elbow syndrome and cuts and lacerations to the hand.

Recognizing and treating mishaps that may occur while maximizing these brief few summer months can make a difference in how ready we are for all that awaits us in the fall.

Wrist Fractures

The wrist is susceptible to injury, often used as a first line of defense to break a fall, shield us from impact and soften a blow.  The wrist is comprised of eight small carpal bones, two forearm bones (radius and ulna) and four articulations or joints – which allow the wrist to bend and straighten, move from side-to-side and twist with a broad range of motion.  A force to the hand and wrist may result in a fracture of any one or several of these bones.  While a fracture to one of the smaller carpal bones may only be visible on x-ray, more common distal radius fractures are usually evident – crooked or deformed in appearance.  A wrist fracture may cause pain and swelling and should be immediately addressed.

Tennis Elbow Syndrome (Lateral Epicondylitis)

Though named for the sport frequently causing the condition in tennis players, Tennis Elbow Syndrome is in fact most often caused by everyday activity and diagnosed in those who have never played tennis.  Affecting the outside (lateral) portion of the elbow, tennis elbow syndrome is considered an “overuse” condition.  It is the result of strain placed on the muscles and tendons that attach to the bone.  Also caused by trauma, tennis elbow syndrome can cause pain with gripping, lifting and grasping.

Cuts and Lacerations

Cuts and lacerations to the hand are very common during the summer months as our hands are integral in most outdoor activity and projects. Tendon lacerations are also often the result of trauma to the hand or fingers.  Tendon lacerations may affect either the flexor or extensor tendons.  These types of lacerations often also result in other deep structure damage and require surgical repair.  The cut ends of a tendon must be brought back together in order for the cells inside the tendon to begin the healing/repair process.  Preventing infection in an open wound is also a primary concern with these types of injuries.


Platelet Rich Plasma Procedure, Among the Latest in Less Invasive Hand & Upper Extremity Treatment Options

While research efforts continue to assess the benefits of platelet-rich plasma (PRP) in the treatment of some orthopedic injuries and conditions, the clinical results for many, including some high-profile athletes such as Tiger Woods and Pittsburgh Steelers, Troy Polamalu and Hines Ward, are proving favorable.

PRP therapy is thought to accelerate healing by using the patient’s own “platelet rich plasma” and growth factors.  A small amount of a patient’s blood is taken and rotated in a centrifuge to separate red blood cells from platelets.  The concentrated platelets are then re-injected into the affected area – releasing growth factors that are believed to help the tissue recover more quickly.  The procedure is performed on elbows, shoulders, knees, hips and feet.

Initially PRP therapy was used to help athletes recover more quickly from an injury, accelerating recovery of arthroscopic cartilage and ligament repair.  Today, PRP injection therapy is used for some chronic tennis elbow and golfer’s elbow cases, as well as other cases of tendinitis.  The growth factors and stem cells that concentrated levels of the patient’s platelets activate not only promote more rapid healing but are also found to reduce pain and osteoarthritic symptoms and inflammation.

Tennis Elbow and Golfer’s Elbow

“Overuse conditions” affecting the muscles and tendons of the forearm where they attach at the outside of the elbow, tennis elbow (also known as lateral epicondylitis), or inside of the elbow and forearm as in golfer’s elbow (medial epicondylitis), are generally first addressed with conservative treatment – rest/activity modification, bracing, non steroidal anti inflammatory medication (NSAIDs).  Traditionally, patients continuing to suffer from chronic tennis elbow despite conservative treatment are recommended for surgery to address the affected tendons.  While arthroscopy has made surgical intervention less invasive, PRP therapy offers a non surgical option for chronic tennis elbow sufferers – providing relief for the pain and tenderness associated with the condition.

The Procedure

PRP therapy is a simple in office procedure and does not require a separate visit.  Patients opting for the therapy simply request it during their examination.  Results are usually evident within just a few days.



Unexpected… Pregnancy Related Hand & Wrist Problems, Part 3 (Trigger Finger)

This is the last part of a three-part series on unexpected hand and wrist conditions experienced during pregnancy.  We have focused in this series on three of the most common conditions expectant moms may experience, Carpal Tunnel Syndrome, de Quervain’s Tendonitis and Trigger Finger.

Last month we discussed deQuervain’s Tendonitis and the non invasive ways in which we address the condition – and prior to that Carpal Tunnel Syndrome.  In this last part of the series, we focus on Trigger Finger.

Any one of these conditions may be prompted in expectant moms as a result of the hormonal changes, increased blood flow and water retention and swelling in the body during pregnancy.

Trigger Finger is a disorder characterized by snapping and locking of the flexor tendon of the affected finger or thumb. The term Trigger Finger comes from the unlocking of the finger, in which case it pops back suddenly as if releasing a trigger.

Trigger Finger is the result of inflammation of tendons connecting muscles of the forearm to the finger and thumb bones.  This connection permits movement and bending. While in most cases the inflammation is the result of a repetitive or forceful use of the finger or thumb, medical conditions causing a change in tissues – such as pregnancy – may also prompt Trigger Finger.

One of the early symptoms of Trigger Finger is soreness at the base of the finger or thumb, followed by painful clicking or snapping when flexing or extending the affected finger.  Occasionally there may be swelling.  Periods of inactivity may make this worse, though eases with movement.  In more severe cases, the affected finger or thumb may lock in a flexed or extended position – and forced to straighten.  Joint stiffening may eventually occur.

Diagnosing and Treating Trigger Finger

Diagnosing Trigger Finger is done with a physical examination of the hand and assessment of the symptoms.

Treatment for Trigger Finger is generally conservative and may include:

  • Avoiding activity that aggravates the affected finger or thumb
  • Anti-inflammatory medication
  • A steroid injection into the tendon sheath

If conservative treatment is unable to resolve the condition, a minimally invasive surgical procedure to release the tendon sheath may be indicated.  Expectant women are advised to wait before considering surgical treatment as often times the condition is resolved following pregnancy – when the body resumes normal function.

Unexpected… Pregnancy Related Hand & Wrist Problems, Part 2

Last month we discussed several unexpected hand and wrist conditions associated with pregnancy – the first in a series of blogs on this subject.

We focused first on one of the most common pregnancy related hand and wrist conditions, Carpal Tunnel Syndrome – discussing the symptoms and common treatment options available to expectant moms.Pregnancy related hand conditions

This month we’re discussing another common hand and wrist condition women may experience during pregnancy and following childbirth, deQuervain’s Tendonitis.  Like Carpal Tunnel Syndrome, deQuervain’s can develop as a result of the musculoskeletal changes, hormonal fluctuations, pregnancy related fluid retention and nursing – all of which can place stresses on the tendons.

DeQuervain’s Tendonitis affects the tendons around the base of the thumb and results when these tendons become irritated – causing the lining around the tendon, known as synovium, to become inflamed.  Tendonitis actually means “swelling of the tendons.”  Tendons are responsible for attaching muscle to bone.

The main symptom of deQuervain’s Tendonitis is pain and tenderness along the thumb side of the wrist, which may radiate down the thumb or up the forearm when rotating the wrist, grasping things or gripping.  The swelling may also place pressure on nearby nerves, causing numbness in the thumb and index finger.  The pain may be gradual or arise suddenly.

DeQuervain’s Tendonitis is generally easily diagnosed in the physicians office after a physical examination and discussion of patient history.  Patients are then asked to perform a series of hand movements and discuss the level of discomfort and area of pain and tenderness.Parts of the hand and wrist affected by deQuervain's Tendonitis

Treating deQuervain’s Tendonitis
Treatment for deQuervain’s Tendonitis is generally nonsurgical and may include:

  • Resting the thumb and wrist with the support of a splint
  • Anti-inflammatory medication 
  • A steroid injection into the tendon compartment
Look for the final part of this series on Unexpected Pregnancy Related Hand & Wrist problems next month when we talk about Trigger Finger.

Unexpected… Pregnancy Related Hand & Wrist Problems

Pregnancy, while one of the most exciting times of a woman’s life, can also present a few physical challenges – affecting parts of the body new moms-to-be may not expect.

During pregnancy women are not only adjusting to changes in the body necessary to create new life, but also other less expected changes resulting from the musculoskeletal challenges and overall physical demands pregnancy places on body function.  These demands come from added weight of carrying the baby as well as the reallocation of nutrients from mom to baby, hormonal changes and pregnancy-related fluid retention.  

It is this type of physical impact to seemingly unrelated areas of the body like the hands, wrist and elbow that takes most expectant women by surprise.

While problems in these areas might be expected after the baby is born – as extended holding in unusual positions, feeding positions, pushing of strollers and other unusual hand and upper extremity movements place stress on the hands, wrist and elbow – there are actually a number of hand and upper extremity pregnancy-related conditions women may experience.

Such conditions include carpal tunnel syndrome, deQuervain’s tendonitis, trigger finger and general swelling and tingling in the hands and upper extremity.

This article is one in a series focusing on pregnancy related conditions, beginning with carpal tunnel syndrome, as it is one of the most common hand and wrist conditions affecting pregnant women.  While often categorized as a “repetitive stress” condition – which affects those performing a repetitive tasks resulting in irritation and inflammation – it is often also commonly associated with pregnancy.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is the compression of the median nerve passing through the narrow carpal tunnel of the wrist.  Increased fluid generated during pregnancy can cause the same inflammatory/compressive effect of repetitive stress generally associated with carpal tunnel syndrome. 

Carpal tunnel syndrome is most often experienced in the third trimester when fluid retention is at its highest.

Symptoms of carpal tunnel syndrome may include pain, tingling and numbness in one or both hands. It is traditionally addressed nonsurgically with behavior modification, rehabilitation exercises and bracing.  If bracing and activity modification do not alleviate the problem, a steroid injection may be given and usually resolves the problem within a day or two.  Patients infrequently will need surgery if the carpal tunnel syndrome is related to pregnancy.

Forearm Fractures

Understanding Pediatric and Adult Forearm Fractures

Forearm fractures are common upper extremity fractures in kids and adults alike, as they compose the part of the arm which is integral in everyday activities, sports and hobbies – and frequently utilized to slow the force of an impact or fall.

Fracture of one of the forearm bones

Forearm bones and illustration of a forearm fracture.

The forearm bones are known as the ulna and the radius.  They run parallel to one another and connect the wrist joint (distal end) to the elbow joint (proximal end).

A forearm fracture can affect one or both forearm bones.  In fact, the impact one forearm bone sustains often forces it into the other causing both to break.

When a forearm fracture occurs, the type of break is carefully assessed using both a physical examination and x-rays.  It is then identified as a fracture involving either the proximal, middle or distal “shaft.”

Some of the common types of forearm fractures include:

  • Radial Head Fractures
  • Olecranon Fractures
  • Distal Radius Fractures (wrist fracture)
  • Radial Shaft Fractures,
  • Ulnar Shaft Fractures
Both bone forearm fracture in a young football player

An x-ray of a both bone forearm fracture in an adolescent football player.

The fracture is identified based on a set of criteria and the location on the bone.  If both the radius and the ulna are affected, it is known as a “both bone forearm fracture.”

If the fracture does not pierce through the skin it is considered a simple or closed fracture.  One that pierces through the skin is considered a complex or open fracture.

Forearm Fractures in Children

Forearm fractures represent nearly half of all childhood fractures – most of those occurring at the distal, or wrist end of the radius. These fractures are classified by the area of the bone affected, whether it is stable or displaced, how clean the break and whether it is partial or complete across the bone.

The classifications include:

  • Torus fracture, also known as a “buckle” fracture.  It results when the top layer of bone on one side compresses upon a harsh impact.  It is considered a stable fracture.
  • Metaphyseal fracture.  This type of fracture affects the upper or lower shaft of the bone without affecting the growth plate.
  • Greenstick fracture.  This type of fracture extends through part of the bone, causing it to bend on the other side.
  • Galeazzi fracture.  This impact is often a displaced fracture disrupting the radius and also the wrist joint where the radius and ulna come together at the wrist.
  • Monteggia fracture.  This fracture usually involves the ulna shaft and disrupts the elbow joint where the radius dislocates requiring urgent care.
  • Growth plate fracture. This type of fracture occurs across the growth plate.

(Fracture classifications source:  American Academy of Orthopaedic Surgeons)

Fractures in children are different from those in adults, because their bones are still growing.  As a result, they have more cartilage and collagen resulting in a more “pliable” bone less subject to a break – or one less severe as an adult might sustain with the same impact.  In fact, many fractures in children may be so subtle they are difficult to detect on an x-ray and require an orthopedic specialist to assess.  A fracture in a child heals rapidly.  So, it is important that it is addressed quickly and properly set before it heals in improper alignment – causing other long term problems.

Also unique in children is the impact a fracture could have on their growth plates.  Depending on the extent of a fracture, the growth and function of the child’s limb could be negatively impacted as a result.

Adult Forearm Fractures

The same fracture classifications applied to those in children, with the exception of growth plate and greenstick fractures, apply to those in adults.  The adult bone is less “pliable” than that of a child’s and has a higher tensile strength, which can result in a more serious break.

Adults suffering from osteoporosis are particularly subject to breaks from an impact or activity seemingly unlikely to inflict such damage.


Fracture treatment depends on the severity of the break and any other soft tissue damage that may have occurred as a result.  The right treatment will depend on the fracture, age and lifestyle of the patient – and may be nonsurgical or surgical with internal fixation.

All treatment includes hand therapy for the best results and most rapid return to activity.

Playing with an Injury

When is it Okay to Return to Play?

As fall sports heat up, we begin to see a lot of injuries.  The first question players ask after we confirm their injury is, “how soon before I can play again?

Whether it’s a junior high schooler, college athlete or professional player, this question is asked with the same passion and underlying conviction to do whatever it takes to get back in as soon as possible.  This is their sport and their heart is all in – despite the injured limb and challenge it now presents.

Kinkaid Team Captain and outside linebacker, Harris Green, not slowed by forearm fracture

As an orthopedic physician who wants to ensure the best outcome in their recovery and a team doctor who understands this drive distinct in athletes, it’s important to develop the right treatment plan – some of which might entail permission for immediate return to play.

Green back in the game as fracture heals

While this may seem counterintuitive, certain hand and upper extremity fractures once stabilized and placed in a cast are fine for an immediate resumption of play.  This is particularly true of the younger athlete.  Some of the types of fractures allowing athletes to return quickly back to the game despite their cast or splint include certain finger and distal radius fractures and ligament sprains.

While the position on a team will impact the enthusiasm in our recommendation to allow such return to play – linemen with the capability to restrict their hands in a cast verses a receiver or running back more fully engaging their injured limb – many are as capable to play their position with their injury as they were before.

The type of injury is also a determination – stabilized fractures are more likely to be considered for immediate return to play than ligament or tendon tears.

Now, there are some risks for further damage if the injured limb is hit in such a way and the inflexibility of the cast places other vulnerabilities on the uncasted portion of the limb.  Other risks include refracture, retear of a tendon or displacement of a fracture.

But, the only way to truly avoid further injury is to sit out of the game until the injury is completely healed. And this is rarely an option for an athlete.

So, we ensure that our patients know everything upfront.  And we give them the tools to keep their injured limb as strong as possible – regardless of the decision they make.   Continuing to keep the injured limb strong by exercising the muscles and joints around the injury, in conjunction with cardiovascular exercise for overall physical well-being….is key.  We remain very involved and ready to make any readjustments we need to the treatment.

Basal Joint Arthritis (Arthritis of the Thumb)

Basal joint arthritis (also known as Basilar Joint arthritis) affects the base of the thumb, known as the basal joint or carpometacarpal (CMC) joint.  It is, in fact, the range of motion permitted by this joint that most distinctly separates the hand movement of humans within the animal kingdom – as it’s function and wide range of motion is unlike any other.

Bones which comprise the basal joint of the thumb.

The basal joint, or the CMC joint, is an interesting joint consisting of the small bone of thewrist known as the trapezium and the first (metacarpal) bone of the thumb.  This joint allows the thumb to reach a unique range of motion – permitting not only up and down movement but also the ability to span across the palm and achieve a “pinching” position.

This type of arthritis of the thumb results when the cartilage, which cushions the meeting point of the bones comprising the joint, deteriorates.  In the absence of sufficient cartilage, the bones are allowed to rub together during movement – causing pain at the base of the thumb and in severe cases deformity as the thumb collapses into the palm.

Pain may hinder many daily activities when the basal joint is irritated during such activities as turning knobs, opening lids, and writing.

It is one of the most common forms of arthritis of the hand, and it is thought that those suffering from a previous fracture or dislocation which affected the joint may be at higher risk for developing basal joint arthritis. Those suffering from osteoarthritis may also suffer from this type of arthritis.

Diagnosing Basal Joint Arthritis

The first steps in diagnosing this type of arthritis may include a physical examination, a discussion of patient history, and review of the pain and limitations experienced. A grind test and an X-ray may also be used to help confirm the diagnosis.

Treating Basal Joint Arthritis

There are a number of nonsurgical treatments for less severe cases of basilar joint arthritis, including:

  • Hand Therapy, which includes: therapeutic hand splints to support the thumb and wrist during rest; posture modification exercises to reduce joint irritation during certain activities; and massage, heat and ice therapy.
  • Non steroidal anti inflammatory medications (NSAIDS) – ibuprofen, aspirin, naprosyn.
  • Injection therapy – such as steroid, viscosupplementation, etc.

More severe cases of basal joint arthritis may require joint reconstruction or other surgical intervention to restore joint stability.

Learn more about this type of arthritis and other conditions affecting the hand, wrist and elbow.





XIAFLEX® Injection Therapy for Dupuytren’s Contracture

Dupuytren’s Contracture is a condition that affects the hands – and while the exact cause is unclear, there are a number of factors that can increase an individual’s risk.

The condition causes the tightening of fibrous tissue in the palm of the hand – between the skin of the palm and underlying flexor tendons of the fingers.  As the condition progresses, these rope like cords contract and begin to pull one or more fingers inward towards the palm making everyday activities more challenging.

While the exact cause of Dupuytren’s is unclear, risk factors include a genetic predisposition and those suffering from other diseases such as diabetes, cirrhosis and epilepsy.  Though, many sufferers are affected by none of the above.

Symptoms of this condition develop gradually and may go unnoticed.  Patients may first develop a tender lump in the palm of the hand, though associated pain may eventually subside. The condition is generally diagnosed upon physical examination.  Signs of Dupuytren’s include the inability to completely flatten the hand (palm down) on a flat surface, dimples in the palm and puckering over lumps in the palm may be evident.  In more advanced cases, fingers may be curled inward and difficult to straighten.

When Dupuytren’s Contracture is mild to moderate no surgical intervention is required.  Though in advanced cases, it may be necessary to surgically remove the fibrous cords which are pulling the fingers inward.

Until recently, traditional open surgery was the only option available to address the tightening, movement restricting cords to restore normal hand function.

While the innovative and less invasive needle aponeurotomy reduced for many over the past few years the need for more invasive traditional surgical intervention, another even less invasive procedure is gaining attention and showing much promise.

XIAFLEX® injection therapy is a new treatment for Dupuytren’s Contracture, which is an FDA-approved injectable collagenase (extracted from clostridium histolyticum).  Injected directly into the cords, XIAFLEX works to dissolve them – breaking down the fibrous tissue.  The injection takes just five minutes in the office.  Over the next 24 hours, the treatment works to dissolve the contracted cord.  Patients then return to the office the following day and the cord is “released” in a simple procedure.  A “popping” sound is often heard as the finger is pushed open and the cord is released.

Rehabilitation and specialized hand therapy, also known as occupational therapy, can help patients restore hand function following a Dupuytren’s Contracture procedure.

Learn more about Dupuytren’s Contracture, Injection Therapy and other common hand injuries and conditions.


Pitcher’s Elbow


Today’s youth sports are more demanding than ever.  Seasons are longer and the practice and game schedule is intense.  Though with proper training and the ability to understand what pain may be signaling, a career ending injury can be avoided.

One of the more common overuse sports injuries we see affects the elbow and is known as Pitcher’s Elbow.

Throwing a baseball, particularly repeatedly as a pitcher does, puts a tremendous amount of stress on the inside of the elbow.  This stress is concentrated on a ligament known as the ulnar collateral ligament (UCL).

Lateral Collateral Ligament / Ulnar Collateral Ligament

When there is pain on the inside of the elbow it may mean that the ligament has either been stretched or has micro-tears.  The goal is to avoid throwing to the point of such pain, as it may indicate that the damage is already done!

There are many factors that can lead to the injury of a young player’s elbow ligament.  The main problem is throwing too much.  Often times this player is young, talented and needed in much of the game in order for the team to win.  The player then gets “overplayed,” until the elbow pain prevents further throwing.  The team must then find another pitcher and the cycle repeats.

Below are some suggestions that will hopefully help young pitchers – enabling them to mature and develop their full potential before an injury cuts their season short:

1. Pitch Count

The definitive pitch count guideline generally adopted comes from the 1996 American Sports Medicine Institute (ASMI) study.  This guideline includes maximum pitches per day, and days of rest between pitching.  Below are websites that include more information on this.

2. All Season Baseball

As our youth become more competitive, they begin to play year round.  This includes spring…..and now also summer and fall.  The elbow never gets a chance to rest and re-strengthen.  Ideally, the young athlete would pursue a different sport during the off-season – engaging different muscles, ligaments and tendons.  If baseball is the only sport, the pitcher must limit the amount of pitching during the off-season and work on some of the other influencing factors listed below.

 3. Pitching Mechanics

The mechanics of pitching are often left to the weekend warrior coach.  It may be worthwhile to find a professional pitching coach who can not only see the subtle corrections that need to be made, but also find a way to help the player make these adjustments as they throw at ever increasing velocity.  Consider that the player is developing as he gets older.  This means that the lessons from last year may no longer apply.  Players are not only getting taller, but developing more muscle.  This will impact their pitching mechanics.  A player should be re-evaluated every year or two.

 4. The Shoulder

Pitching is a rotation sport!  The windup starts in the body and gets transmitted to the hand via the shoulder and elbow.  If the shoulder is weak, the elbow must compensate.  This leads to injury.  It is important to strengthen the shoulder, chest and back in order to support this movement.  Specifically, it is important to strengthen the shoulder muscles that rotate the shoulder called the rotator cuff.  It is also important to strengthen the muscles that control the shoulder blade (scapula).  Young players have open growth plates in their bones, and injury to these growth plates are avoided by keeping the weight low.  The goal is not to build bulk but rather to build strength and stamina.  Weight training is best done in the off-season.   Smaller muscles like the rotator cuff can be exercised two or three times per week.  More than three times a week will weaken and not strengthen these muscles.  Finally, it is important to stretch the shoulder joint, especially the posterior capsule.  This is done by bringing the arm across the body and feeling the stretch on the back of the shoulder.

5. Fatigue

There is a difference between strength and fatigue.  As the game progresses, the muscles become fatigued.  The player, in their effort to maintain speed, start to use other muscles and change their throwing mechanics.  This then leads to increased strain on the elbow and ultimately to injury.  This may be avoided by strengthening the upper muscles in the off-season and by watching the pitch count during the season.

6. Addressing an already painful elbow

Pain in the elbow could indicate that the elbow is injured.  The first step is to stop playing baseball and seek the assessment of an orthopedic specialist.

–  Once pain is resolved and the tenderness is completely gone, initiate a strengthening program focusing on muscles of the chest, back and shoulders

– After the strengthening program is well on its way, the player should seek an evaluation by a professional pitching coach.

-Gradually the player will increase pitching distance and speed – with particular focus on proper mechanics

– After completing these steps, players can return to the regular season.

Typically, once a player has elbow pain they generally require about six months to complete the steps above.  Since the pain often occurs at the start or middle of a pitching season, this usually means that they will lose out on the remainder of that season.  Though, this is preferable to permanently damaging the arm and eliminating any chance of playing another season.

Helpful Websites:   (pitch count regulation)