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Pain after Trapeziectomy (Page 3)

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September 21st, 2012
Experienced User
Hi Nightworker and DawnB1974 and all - wondering how you are progressing these past weeks? Hoping all is improving for you.
Kind regards,
anyalternative
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replied September 24th, 2012
Experienced User
Hi Gaelic,

A question, if I may please? I keep intending to ask my OT, but forget...

I have no idea at what stage of recovery it is anticipated that one should be able to use a knife and fork, as opposed to just managing with non dominant, left hand? I'm at nine weeks and not able to use both.

I'd appreciate if you could comment as to whether this is normal, or am I particularly slow in this aspect?

Many thanks in advance,
anyalternative
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replied September 24th, 2012
Especially eHealthy
anyalternative,

If memory serves me correctly, you are about 9 weeks out from surgery, but you only got your cast off a little over three weeks ago, is that correct?

Coordinated use of both hands is a difficult action. And, the use of a knife and fork is actually a pretty difficult maneuver. When cutting something firm, like meat, you actually have to put quite a bit or pressure on the hands and the thumb in particular.

The pinching action is particularly difficult for patients after an LRTI (or other basal thumb procedure).

While some patients regain function fairly quickly (within 6 weeks after the cast is removed), it is more common for patients to take several months.

Most patients who have an LRTI done have pretty weak hands by the time they decide to have the procedure done. Because of the pain in the base of the thumb, they do not use their hands a lot, so the hand muscles become weak.

So, after surgery, they not only have to rehab from the surgery, but also build the muscles back up to what would be considered "normal" for their age. They sort of start rehab "in the hole".


Thus, as long as you are progressing in your rehab, you should not be too concerned. You may have some plateaus in your rehab occasionally, don’t get too worried about that either, it happens. Again, as long as you are just plugging along, you are okay. I have seen patients take as much as 18 months till they were at a point where they felt they had recovered.

Keep working. Your function will come around.

Good luck.
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replied September 24th, 2012
Experienced User
Hi Gaelic,

Thank you so much for your quick and informative response and you are very accurate with the calendar!
I did have the LRTI on 23rd July and the cast removed on 29th August.
It helps enormously to know what to expect at various stages and you have defined this so well!
(I had been thinking that I should at the very least be able to butter my toast with my right (operated and dominant), hand, but there you go - I won't expect that any time this week...
Hmmm - I've certainly lost so much muscle. I have what looks like 'a hole' in the palm of my hand, in place of lost muscle, (can count/feel my ligaments).
Working on ROM at present which is apparently OK.
There's lots of stiffness in my thumb, which has much swelling at the tip, increased by the splint I imagine as it subsides a little during the times I'm not wearing it.

Again, thank you Gaelic, for all the help and encouragement you provide.
So appreciated!

Cheers!
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replied September 28th, 2012
I can't start to tell any of you how helpful and supportive I've found this Forum to be.
I'm now 11 weeks post Trapeziectomy procedure and can honestly say that each week that passes seems to register a lot of improvement. I never anticipated what a long time it would take to get back to some form of normality with my non-dominant hand!
I am waiting to have surgery on my dominant hand, - Trapeziectomy, fusion of the upper (PIP?) thumb joint and a silactic replacement for my middle finger!! This terrifies me but I have to go ahead with thoughts of the future consequences of not having it done before it is too late. I am 62 and don't want to spend the next 20 years, God willing, suffering as I do at the moment.
Has anybody had all three procedures at once?
I adore needlework and want to be sure that I will be able to continue with my hobbies once everything is done.
Also, I am in need of knee surgery, which means that I have to get both hands fixed to use crutches. I am about to ask my GP if I should have this done next as I am already needing a walking aid!
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replied September 28th, 2012
Especially eHealthy
Mabs19A,

It is a lot of surgery to have all three procedures done at once, but it is not uncommon for hand surgeons to do all three at once.


It is actually quite common to address the arthritis at the base of the thumb (in the CMCJ) and to fuse the MCPJ at the same time. In fact, that is the standard of care if the patient has an unstable MCPJ with hyperextension.


The replacement of the joint in the middle finger can be done at the same time, as long as you can do range of motion of the finger, while you are immobilized for the thumb surgery. Which should be possible, since the fingers are free in a thumb spica cast/splint. In a interphalangeal joint or metacarpalphalangeal joint replacement, early range of motion is very important, or the finger will get really stiff (so the surgery would have been done for nothing; as replacements are done so that motion can be maintained).

Needle work is actually very good therapy for post hand surgery!!

As to your knee, it is usually recommended that you finish your hand surgeries or delay them until you are over the knee surgery. But, remember, unless you have balance problems for some reason, you should not be on crutches/walker for very long after a knee replacement. The replacement is done to get you up and moving about as soon as possible.

Good luck.
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replied September 28th, 2012
Especially eHealthy
Anyalternative and DawnB1974,

Mabs19A is another member of the "recently done base of thumb surgery" club.

She is having a lot of the same questions and problems that you are having.

Hopefully, the three of you are doing well and progressing in your therapy.
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replied September 28th, 2012
Experienced User
Hi Mabs19A,

Welcome to the forum; it's my life-line of support - wonderful resource with Gaelic providing answers and reassurance etc -I'm pleased you are finding the same.

I'm sorry you are having to undergo further, and more extensive surgery on the other hand, plus knee surgery for good measure!
Gaelic is the best person to advise on the sequence and what's involved, etc.

You are twelve weeks out from your trapeziectomy which puts you two and half weeks ahead of my LRTI.
It's very brave to be contemplating the other hand's operation soon, (I'm presuming you had the LRTI), because as you say, it is amazing how long it takes to recover 'normality' of use following this surgery.
How encouraging though, that you are noticing improvement on a weekly basis!
Overall, I would say that I am noticing similar.
Sometimes, have some pain in the proximal phalanx and also in the base of the palm of the hand, but this is probably normal.

Personally, I wouldn't have my other CMC joint operated on before I was absolutely sure I'd be able to put the entire work-load on to my healing/healed hand.
I hope you continue your improvement as quickly as possible and that you are able to tolerate some analgesia in the interim of waiting the next surgery?

Good luck with your decision! I'd be interested to know how you are faring.

And, please keep in contact and don't hesitate to ask of anything - it's a great coping mechanism!

Cheers,
anyalternative
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replied September 30th, 2012
Experienced User
Gaelic & Mabs19A
P.S.
Mabs19A - just noticed you have made some references on previous pages to 'strange' wrist pain at the 10-11 week mark - I went looking to see whether anybody has reported pain in the base of the palm/thumb, as I've had it quite severely the past four or so days and have begun taking analgesia for it!
This, I haven't had to resort to very often so it has me concerned. I don't know whether I'm over-doing my exercises or not?
We are, as I mentioned in previous post, at similar time-frame, 'though you're about a week more advanced than I.
Mabs, is your wrist pain actually in the wrist or further into the hand/thumb base?
I am taking my thumb across to the little finger at this stage, in accordance with my OT/hand therapist's advice. Hoping this isn't de-stabilising/adversely affecting the 'replacement'?
Any advice/explanation would be most appreciated.
Kind regards,
anyalternative
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replied September 30th, 2012
Especially eHealthy
anyalternative,

By this time, your tissues have healed enough to withstand any active motion you can do (using your muscles to move your thumb). Excessive passive motion, to the point of causing significant pain, could cause tearing of newly healed tissues.

Thus, hand surgeons will usually allow you to do all the active motion that you want and can do. If this is just not getting patients back to where they should be, then a therapist may be allowed to do some judicious passive motion. But, usually a patient will not allow a therapist to push too hard, enough to cause tearing of the tissues.

Some discomfort is fine, in terms of stretching. There is no way to rehab without having some of the stretching that goes with regaining range of motion, but sharp, intense, sudden pain should be avoided.


The base of the thumb is actually at the wrist joint. The trapezium is one of the wrist carpal bones. So, and LRTI is actually both a thumb and a wrist surgery. Many patients who have base of thumb procedures done will complain of “wrist” pain. The wrist is a very complex structure, made up of eight carpal bone, plus the metacarpals and the ends of the forearm bones. There are a multitude of ligaments and joint capsules, besides all of the tendons which go across the wrist. So, there are a lot of structures which can get “out of whack” around the wrist, after a major reconstruction.

If the discomfort in the wrist is becoming a problem to doing rehab, then your hand surgeon should be contacted.

Good luck.
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replied October 1st, 2012
Experienced User
Many thanks Gaelic,

Reasssuring to know I can't do damage to the 'tendon graft' or its capsule - sorry, not sure what one calls that 'cemented tendon' which replaced the trapezium?

I'm possibly over-doing the stretching and thus causing this pain as OT is very happy with my ROM and states my progress is good. She doesn't need to assist as she advises each new manoeuvre; I do exert myself.
I find I need to do the stretching several repetitions and as many times per day, in order to maintain that newly gained flexibility. I marvel at each new advancement and don't want to lose that 'gain'

Sharp, quite breath-catching pain presents in the phalanx oft times, as I return my thumb after stretching to reach the fingers, but my OT is aware of this. I think this must be normal during rehab?

The pain for which I've begun taking analgesia, is present right along the base of my hand (palm side), and into the the base of the thumb but not into the wrist itself. Perhaps it's of normal muscular or tendon origin - it's a deep ache.
I mention it because I wasn't expecting to be in sudden need of analgesia at this stage when I've managed without, earlier.

Again, so many thanks Gaelic,

Kind regards
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replied October 5th, 2012
Hi there nightworker here.
I posted the other night Wed.but seems to have disappeared. Just letting you know how things are going for me.Saw hand surgeon 28th Sept. who was pleased with results,still having discomfort in fingers and wrist occasional pain base of thumb,surgeon states it will take another 3mths for things to get back to normality. So cheers everyone,take care you'll get there.
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replied October 6th, 2012
Experienced User
Hi nightworker,
So, so pleased to read your good and encouraging news!
Have been wondering how you were going, esp with your wrist and fingers.
Take care; the next three months should fly now you're through the worst of it.
Kindest regards,
anyalternative
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replied October 14th, 2012
Experienced User
Hi Gaelic,
I'm hoping you can help with this query?
I'm at 12 weeks post my LRTI. My fingers and thumb still become puffy, with my index finger and thumb being the worst affected.
The past week my index finger is slightly curling inwards with redness (?bruising) in each crease of the underside of the finger.
Plus, with exercising, ie,taking my thumb across my palm to reach other fingers, the action automatically causes the index finger to bend further forward. Should I be concerned about this or is this too, another aspect of no concern and which will rectify itself?
So wish I could write that all is improving!
I am not due to see my surgeon for two and a half weeks.
Many thanks in anticipation,
Kind regards!
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replied October 14th, 2012
Especially eHealthy
anyalternative,

The swelling is not uncommon, but you should not really be developing any redness or bruising.

It may be that you are doing a little too much, but you do not want to stop all activities. It is important to maintain as much range of motion as possible. But, strength activites (like twisting lids, using keys, and the like) may be a little much for you at this point.


LRTI and procedures like it do a lot of trauma to the tissues around the wrist and forearm. And, it takes a long time for this trauma to sort itself out. Tissue will become strong enough physiologically to withstand the stress to begin rehab at about six weeks post-op, but this does not mean that the tissues are completely healed by any means.

So, maintain your range of motion but try not to do anything too heavy till you see your surgeon.

Good luck.
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replied October 14th, 2012
Experienced User
Many thanks Gaelic.

I commenced driving about ten days ago as my OT said I was ready.
I'm using my non-operated hand to do all ignition and key work, and ensuring I don't grip too tightly, esp with index finger, and only driving about five to six kms per day when necessary.
Maybe this is still too much; I personally had the feeling that driving was quite demanding, and I didn't drive for four or five days, even after being given the go-ahead...

Could bruising in those index finger creases cause it to bend inwards at each joint?
The middle crease of that finger has never lost redness, but it wasn't curling/bending.
The palm of the hand, which is very hollow, and the forearm which was covered by the cast, have not lost their bruised appearance to date.

Again, so many thanks, Gaelic.
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replied October 14th, 2012
Especially eHealthy
I am not really sure what you mean by bending inwards. If it is flexing towards the palm, that can be due to tightness in the intrinsic muscles of the hand.

But, if the finger is deviating to the radial or ulnar aspects (side ways), that is not really normal at any time.

It this is the case, it should be checked out by your surgeon. And, if it is deviating quite a bit, you may need to buddy tape the index finger to the middle finger, to act as a splint.


As to the color changes in the extremity, it is not uncommon for patients to take a long time to get the vascular condition back to "normal". A lot of lymphatic channels and small veins are disrupted during surgery. These are have to be regrown across and through the area of trauma (surgery). This causes shunting of the fluids to other vessels, which usually cannot handle the increased load very well. So, the patient can develop swelling and venous stasis to a certain degree.

This is why it is recommended that patients use compression gloves and elevate the hand whenever possible, if they have these problems. They will gradually to away, but it takes time.

Again, this is why we tell patients it may take up to 18 months to "get over" an LRTI procedure.

Good luck.
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replied October 15th, 2012
Experienced User
Your information always helps! Thank you so much!

Now, I had written a lengthy reply, but it disappeared, so I'm sorry this one will be brief.

Sorry re the confusion of fingers flexing.
Both my index fingers deviate a little to ulnar aspects; suspected this was normal arthritis?

But the flexion of this index finger to which I referred, is towards the palm.

I hadn't heard of compression gloves and will buy (at pharmacy, I suspect), tomorrow. The neoprene splint causes the fluid from the thumb to accumulate at the first joint (looks like a tyre!) I haven't been told to not wear this splint, but from all I read, it is best to not over-use so have left it off for prolonged periods, wearing it when I leave the house and for some activities.

I hope it doesn't take 18 months - I'm hoping for a minimum of 80 to 90% recovery by six months as I need to work.

Again, much gratitude, Gaelic.
Kind regards.
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replied October 15th, 2012
Especially eHealthy
anyalternative,

Most patients do not take that long, but a few do. And, it is not that they are totally laid up for 17 months, then get better in the last month. Most of the time, the majority of function is regained long before that and it is just the little "polishing off" and “tweaking of junction” that takes the last several months.


Ulnar deviation can occur from degeneration of the MCPJ (metacarpophalaneal joint), often seen in arthritis such as RA. Most of the time all of the fingers tend to drift, but it can start with just one. This is actually called ulnar drift. The flexion of the fingers is probably from some tightness of the intrinsic muscles in the hand.

If the neoprene splint leaves parts of the hand open, the edema will tend to be pushed to those areas. This is why a compression glove is good to work on getting all of the edema out. Jobst makes very nice compression garments, but there are many other companies which do also (not advocating one brand over another). If you cannot find any at your local pharmacy, you can probably find one off the internet. If that fails, ask your therapist.

Also, be sure to massage your fingers and hand to reduce the edema. Starting at the tips of the fingers, massage and kneed the soft tissues proximally, pushing the fluid towards the body. This is usually easier if you warm the tissues up some beforehand.

Good luck.
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replied October 16th, 2012
Experienced User
Many thanks, for all this information, Gaelic.

Searched places for compression gloves, today!
Can have them delivered to our city, but was told they cost AU$75.00.
May have to just concentrate on the massage. The left hand thumb is becoming so 'unhappy' with all effort that's been demanded of it. LOL.

Kindest regards.
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replied October 16th, 2012
Especially eHealthy
Yes, anything "medical" seems to be expensive. Most insurance companies will cover the cost if you have a prescription for it. You could ask your hand therapist about one.

The massage is very good for getting the edema out, and it feels good.

Hang in there.
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replied October 17th, 2012
Hi anyalternative.
If its any consolation to you Ihad my op 18th June which is 4mths ago and although my surgeon is pleased with the results of the op.I still have stiff fingers and pain inmy wrist and base of thumb.I also have swelling at base of thumb but hopefully this will resolve in time.I wear my thumb spica for driving,at night and on computer.Hope this re-assures you in some way. Take care,Nightworker.
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replied October 17th, 2012
Experienced User
Hi Nightworker,
Many thanks for being in touch and the reassurance that what I'm experiencing is a part of the recovery process.
We do have same and similar symptoms and it was interesting to read you also, still have the swelling at the baes of the thumb. Yet, as you say, your surgeon is pleased with the results.
May I ask, are you able to write as yet?
I could write a couple of words a week or two ago; this week it's too painful.
An undulating road to recovery, perhaps?
Again, so many thanks. I appreciate your feedback, and hope you can say soon, that you are very much improved.
Take care,
anyalternative
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replied October 17th, 2012
Especially eHealthy
anyalternative,

As to writing: unfortunately, most of us do not use our writing instruments correctly, if you ask any of the "old" school teachers. Many of us try to strangulate the instrument as our first mistake. If your fingers blanch at all, you are putting too much pressure on the pen.

The second mistake, is that we use our fingers to actually move the pen. Back in the days when script writing was taught in primary school, the pupils were taught to use the shoulder and the whole upper extremity to write. The fingers and wrist were held still.

I am telling my age now, but I can remember the exercises of loosening up for the day’s writing by making circles or “O’s” of varying sizes, but never moving the fingers. Sitting there erect, a straight back, level shoulders, with the forearm properly supported on the desk top. Once this mechanism is learned, it is actually very easy on the hands when a person has to write for an extended amount of time. You never get hand cramps or fatigue.

Now, this was designed for script, flowing type of writing. I, unfortunately, have reverted back to first grade, as I print everything nowadays (so people have no problems reading my writing). But, even printing can be done with this mechanism. However, if you have to do very small, detailed work, as with certain drawings, then the fingers usually have to be used for that.


The third problem is that we use too small caliber of writing instruments. We need to stay with the kindergarten size crayons. If you notice, most of the very nice writing instruments (such as Mont Blanc) are pretty good size around. It is much easier on the hands, if you use the large caliber pens. If you have a favorite pen, but it is small (like a lot of the Cross pens are), you can get rubber or foam tubes to place on the pen. You can get them at any office supply store.


So, if you try these three things (don’t strangulate the pen, don’t use your fingers, and use a large caliber pen), you will probably find that writing is much easier to do. And, if you do use the proper technique (not using the fingers), writing can actually be done in wrist splints and short arm casts, even the thumb spica ones. (You don't know how many kids have tried to get out of homework when they were in casts; of course, that didn't fly.)

Good luck.
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replied October 18th, 2012
Experienced User
Thanks Gaelic, this makes so much sense - a little practise with the "O's", demonstrates the difference, so yes, I understand what you are saying.
I'll be trying to adopt all these techniques as 'writing' had become so difficult, it was a principal reason for having the surgery.

Kindest regards.
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replied October 19th, 2012
Hi there!
Funny you mentioned writing,this is one thing i am having problems with,don,t know how i'm going to write all my xmas cards.I'm hoping thing improve before I have to start.Have read Gaelics suggestion seems a bit complicated for me! Take care,Nightworker.
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replied October 19th, 2012
Especially eHealthy
nightworker,

Actually, it is really very easy once you get into the habit. But, as with anything, it is hard to break old habits and start new ones.

Just using a larger caliber pen usually helps a lot.

Not stranguling the pen, relaxing while holding the pen will take the pressure off significantly.

Not using your fingers will take some practice, but it is well worth not hurting to try it.

Good luck.
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replied October 20th, 2012
Experienced User
Hi Nightworker,
It's going to be one Christmas card at a time, for me, as it is still painful at the base of the thumb and palm of hand, even whilst adopting these techniques. We must have very similar post-op problems?
I hope it's not too long before this aspect resolves for us?
Take care,
anyalternative
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replied October 20th, 2012
Especially eHealthy
anyalternative and nightworker,

If the problem with the writing is mainly from having to grip the pen (which you have to do with any method, just remember to not strangle the pen), we have made a little device for some of our patients to use.

It does take a therapist who is good at making things with OrthoPlast (the plastic moldable splinting material so often used in hand surgery). It is basically a little splint-like thing that slips over the thumb and index finger, while they are in the writing position, which holds the pen. This is also used a lot in spinal cord injury and stroke patients (who do not have the muscle power to hold a pen).

You slip on this little device, load up the pen, and away you go. You do have to use the shoulder muscles (the old fashioned way of writing) as the fingers are bascially only there for the splint to to be placed upon.


Of course, the hand therapists will say that writing you Christmas cards will be good therapy, and thus reluctant to make one. But, some (who like to tinker around with making appliances) are happy to make one for you. It is something to look into if you are still having a lot of problems.

Good luck. Keep working hard.
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replied October 21st, 2012
Experienced User
Many thanks Gaelic; this is very helpful information which, if needed, I'll follow through.
I am practising, but it does somewhat stress the thoracic back in my case, but I suspect this is just a matter of adjustment? My technique obviously needs improvement. LOL I'm sure things get better!

Meant to mention: My OT/hand therapist, gave me a 'sort of compression stocking' about two inches long, for the swelling in my thumb, and a roll of Coban to wrap the index finger for the swelling/bruising and tendency to flex towards palm at each crease - an improvised measure for the problems which the compression glove would have solved.
These are proving helpful.

Again thanks for your advice and help,
Kindest regards.
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replied October 21st, 2012
Experienced User
Hi Nightworker,

As above, I'm practising with the writing.
My words are quite larger than my pre-op writing.
How are you going with it?
We could just type a letter and pop it in our Christmas cards, I guess?

Gaelic, you didn't see this! Smile

Kindest regards,
anyalternative
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replied October 21st, 2012
Hi guys!
Was in town to-day and bought pens with triangular shaped rubber grips,which feel quite good so will try practicing writing using Gaelics method. Will let you know how it goes! Cheers Nightworker.
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replied October 25th, 2012
Experienced User
Hi Nightworker!

Hope these rubber grips are just the thing for your writing skills. I'll be trying to find some also! Do hope things are improving for you; such a lengthy process. Good luck and keep improving!

Gaelic,
I'm beginning to think that not a lot has gone right in my case, with this op...
Firstly the cast problems - well they may be the cause of several other problems I have?
The red, raised area over radial ?bone which the GP treated as thrombophlebitis about 12th September, didn't heal at all. An ultrasound was done; the result hazy -inconclusive. It's very painful as I exercise, and it will be interesting to see what the surgeon says next week?
Swelling is very common with most of us, so of course, that's expected. However, OT gave me a compression glove yesterday to try to address that issue plus the bruising, which is so very evident all underside of hand, but excessive in the index finger.
I have been having lots of stiffness and pain in my fingers, the past two to three weeks. (Never had that at all pre-op)
I wore the golve last night, under the splint. Finger pain was mighty!
My fingers looked fairly normal,ie, without their swelling, so re-applied the glove, in the hope that if we rid the swelling and bruising, the finger stiffness and pain will disappear? I'll try it again tonight.
I haven't mentioned in previous posts that my hand (entire hand), has had a very pronounced (about 45 -50 degree) ulnar drift since the op. The OT said this was caused by the way the cast was set.
I'm not sure whether the glove aggravated my fingers because of a)the slant of my hand, or whether b)it was just a response that's expected as the fluid is moving.
I'm hoping it's the latter and that there is no other problem manifesting.
And re that ulnar drift, I was given a stretching exercise yesterday to try to lengthen the ulnar ligaments/tendons/muscles. (I saw a different OT in same clinic in the absence of my regular OT.)
Really sorry to be so prolific with all these 'negatives'.
My main queries:
Is it common to have this ulnar slant?
Would you care to comment on the fingers' pain, and perhaps the glove, please Gaelic?

Many thanks in anticipation.
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replied October 25th, 2012
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anyalternative,

I am so sorry that you are having so many difficulties after your surgery. That is really the pits, especially since you just want to get over this and get on with your usual activities.

I am glad that you were able to get a compressive glove. When they are properly fitted, they can really make a big difference in the diffuse edema that accumulates in the fingers and hand. Significant amounts of swelling can cause all sorts of problems, from problems getting wounds to heal to problems in regaining range of motion. But, if the glove is causing too much discomfort, to the point that you cannot sleep, you may have to only wear it for part of the night. Then, as the swelling gradually goes down, you can gradually increase the amount of time you can wear the glove. Also, continue with the massage, from the finger tips, up towards the hand and forearm.


As to the “red, raised area over radial ?bone which the GP treated as thrombophlebitis”, where exactly is that located? If it is over the radial styloid, you could be having inflammation within the first dorsal compartment, often called DeQuervain’s tenosynovitis. This compartment can really become inflammed; red, warm, boggy swelling, crepitus with motion of tendons running through the tunnel, and pain with motion. This compartment often gets quite a bit of manipulation during any surgery at the base of the thumb.

You might need to have your OT or surgeon check for this the next time you see him/her.


As to the ulnar drift, that is quite a bit of movement. When the thumb spica cast is applied, you do want to put it in “a little” ulnar deviation, but not the amount that you were placed in. That much deviation runs the risk of putting compression on the ulnar nerve, as it passes through Guyon’s canal at the base of the palm.

You really did have some problems with your casting. I am always hesitant to comment upon how surgeons have done specific things, because I was not there and do not have access to all of the information of the case, but, from just the information you have given, it seems that the surgeon was not really paying the attention to detail that he/she should have been doing. When a patient presents numerous times because the cast feels way too tight in the palm, that should be looked into. The patient should not just be patted on the head and told that everything is okay, when it is obviously not okay.

It is not uncommon for problems with the cast to cause significant and prolonged problems during the rehab period. You have to really impress this point upon young orthopedic cast technicians and orthopedic residents. The residents are always wanting to get to the exciting stuff - like doing surgery. But, rolling a proper cast is just as important as performing a proper surgery. Cast immobilization is just blown off by a lot of ortho residents as something that is “below them”, that can be done by the ortho techs. But, that is just not true. Placing a comfortable and proper cast takes just as much training and skill as doing a slick knee ‘scope. I had one mentor who always said that he could train a chimpanzee to do a knee ‘scope; but it takes a heck of a lot more intelligence and dexterity to be able to put on a slick PTB (patellar tendon bearing) cast or a hip spica for an infant with hip dysplagia.

So, again, sometimes just an improper cast placement can cause significant problems during rehab. But, that is water over the bridge or under the dam, or wherever the water goes. You have to focus on where you are at the present time and work with what you have.


Speak with your OT about what you can do to help with the ulnar drift. You may have to have some resting splints made for bedtime wear, that will gradually, over time, bring the hand back into the “normal” resting posture. Your OT can also give you some exercises to actively have to pull the hand back into a more neutral position.


Continue with your swelling reduction activities. Swelling is always a problem, which can cause further problems. Sort of like a cascade effect. Ask your OT about the possibility of you have DeQuervain’s (it is just a thought, since I cannot examine your hand). Ask about things to do to get the hand out of the ulnar drift.


Again, sorry you are having so many problems. But, you are continuing on like a trooper. Keep it up. Hang in there.

Those rubber or foam tubes/triangles that you can place on your favorite writing instrument can be obtained at just about any place that sells pens and paper. All of the office supply stores carry several types and you can also find them at the discount stores (Walmart, Kmart, Target, etc, etc). Many of the art supply stores also carry them. So, you should not have too much trouble finding some.

Wishing you the best. Good luck.
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Users who thank Gaelic for this post: anyalternative 

replied October 25th, 2012
Experienced User
I can't tell you how appreciative I am, Gaelic, again, for all this detail and knowledge, and thanks also for your encouragement!

I'm amazed at how much you can determine the possibilities of complications just by reading - so impressed!

I had to google a little and, yes, the red swelling is exactly over the radial styloid. I'll be seeing both OT and the surgeon next week, and will ask about the De Quervain's possibility.
I'm now pleased I mentioned this ulnar drift also, as I don't want any more complications, now or down the track. I thought I'd complained enough and possibly bored everyone - LOL

I'll certainly keep up the massaging of the fingers and will be wearing the glove tonight. It's so good to know the effects of such swelling, and how responsible that factor alone can be, for many problems.

I have you to thank for recommending the compression glove, too!!!

I'll be touch to inform you of the outcomes,

Kindest regards!

P.S. I hope everyone can learn something from Gaelic's responses, as, there are not too many 'out there' who are as astute and lead us in the right direction.
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replied November 1st, 2012
Experienced User
Hi Gaelic,

You might recall, I mentioned the curling of the index finger towards the palm of the hand, (in mid October.)
The hand therapist has not been too worried about it.
Today, I asked the surgeon for his opinion on it during my routine 3/12 check-up. He looked at it and said that LRTI can trigger Dupytren's contracture in some people who have a family history of it! He said it may be that!
I was quite shocked with hearing this, so he indicated the hard 'lines' in my palm of hand as being another sign.
This shoched me further, as my OT told me some five or so weeks ago that these were just evident because I had lost muscle there!
Re a family history - There is absolutely no family history of this or any hand problems in the extensive family tree, and, with all living into their mid to late nighties, I think it's a fair trial.

Have you heard of this being a complication of an LRTI, please, Gaelic? I'm praying that this is a wrong 'possibility' (diagnosis)
Is there anything I can do to prevent the possible ???Dupytren's contracture from advancing? I haven't spoken to my OT since I learned this from the surgeon.

The ulnar drift is being addressed via exercises, and I'm told I may have had De Quervain's tenosynovitis, but "it seems to be settling..." so we are just watching and waiting.
This latter statement may in fact be true as the swelling and redness has subsided a little, perhaps.
Could this occur of its own accord, if it was De Quervan's?

OT has made a night-time splint for my left thumb as I will not be having surgery on it.

Again, many thanks in advance, Gaelic.

Kindest regards
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replied November 1st, 2012
Especially eHealthy
anyalternative,


Dupuytren’s Contracture (Dupy) is a condition where the palmar fascia becomes thickened and fibrotic. It will form cords of this thickened tissue, where the normal fascial bands had been previously. It can also form nodules along the flexor tendon sheaths. The contracture part comes in, when the cords become tighter and tighter, drawing the finger towards the palm. It used to be said, that when the patient could no longer put the palm of the hand flat on the table, it was time to do surgery.

The cause of Dupy is still not fully understood. It is much more common in men than women (something like 8 to 1). It is most commonly seen in men of Scandinavian descent (the Vikings). The age of onset in men is usually between 30 and 40 year of age. Rate of progression is very variable. It is rare to see Dupy in women before the age of 60. Women also usually have a milder course than men. It does run in families.

It is most commonly seen on the ulnar side of the hand. When there is involvement of the radial side of the palm, and especially in the first web space, conditions like diabetes are usually present. This may have something to do with the ischemia that can be produced in the tissues from the small vessel disease associated with diabetes.


Some research was done several years ago, which found that carpal tunnel release should not be done at the same time as Dupuytren’s fasciectomy. These studies showed that the rates of post-op complications were a lot higher, than if the procedures had been staged. However, more recent research has shown that the previous thoughts about doing them at the same time causing higher rates of complications was not substantiated.

Some surgeons have extrapolated from some of these research projects that some patients may excite their Dupy when hand surgery is performed on the same hand. There is some anecdotal evidence, but not much real hard data.


So, you sort of just have to go on a case by case basis.


When looking at the palm of the hand, if there is a lot of atrophy of the interosseous muscles and the lumbricals (also called the intrinsic muscles of the hand), the flexor tendons which run on the metacarpal shafts become very prominent. They can be easily palpated. However, the skin is not connected to the underlying tissues. You can move the skin over the flexor tendon sheaths (as much as the palmar skin will normally move).

In Dupuytren’s, the fibrous tissue is very invasive, infiltrating into the skin, subQ tissue, and throughout the fascial planes of the palm. The skin becomes very tight and immobile. There is a classic “pit” or dimple in the skin over the palmar creases. This is not seen in cases of just loss of muscle. The cords in Dupy go in line with the fingers. There are some transverse cords in the webspaces. Sometimes, patients will have nodules in the palm.

So, it is usually pretty easy to tell the difference between atrophy with prominent flexor tendon sheaths, and a case of Dupuytren’s.


Unfortunately, if this is Dupy, there is not a whole lot that you can do about it. Some surgeons and therapists recommend trying to maintain range of motion as much as possible. Night splinting as been tried, with variable success. Hand lotions and massage may help the skin for mild cases.


As to the DeQuervain’s, it is possible for it to go away on its own. It is just an inflammatory condition, which often resolves with rest and time. Use of NSAIDs can make the condition better. But, again, some patients just get better with time and rest.


So, hang in there. You have a lot going on in your hand. Try to maintain range of motion. That’s most important. You can always build strength a little latter. Speak with your therapist about the different conditions. He/she should be able to show you how the different conditions look, and which ones you fit into.


Good luck. Wishing you the best.
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replied November 1st, 2012
Experienced User
Hi Gaelic,

Thank you again foor your quick resonse and your helpful information!

I will have to quiz my OT re whether it looks like muscle atrophy or Dupytren's. I hope she can differentiate as she did say some weeks ago that it was muscle loss that caused these longitudinal tendons or sheaths? to be prominant.
But the surgeon, as I showed him my index finger's flexion at the DIP and PIP joints and the puckering look of the finger and associated redness at the joints on palmar side, plus these cords, said very casually, that it looked like Dupytren's.
Yet you say:
"So, it is usually pretty easy to tell the difference between atrophy with prominent flexor tendon sheaths, and a case of Dupuytren's." I have to wonder why their comments differ so?

I cannot flatten my palm to table, and presume this is a normal response to surgery plus the fact that the hand was so cupped in a tight cast. My OT made the comment two weeks ago that I'll never be able to do that.
As to moving the palmar skin - I have to admit I cannot tell if it moves as I attempt this test.

I did some googling and read that needle aponeurotomy can be helpful sometimes for Dupy. ??

I hope I have not acquired that from this surgery. If it wasn't for the index finger's state, I would be feeling more positive that it's only muscle atrophy.

Many thanks again, Gaelic. I don't know where I'd be without this forum, your knowledge and help.

Kindest regards
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replied November 2nd, 2012
Especially eHealthy
anyalternative,

Dupy has a very particular look. Once you have seen it several times, it sort of just becomes; oh, yea, that's Dupuytren's.

The skin in your palm is normally not very mobile (so you can turn jar lids without the skin turning around), but in Dupy, the skin is very fibrotic and tough. Where the cords are, there is no movement of the skin at all. Many patients will have a little pit at the palmar crease, and this is almost pathognomonic for Dupy. The cords in Dupy go out into the finger(s), and cause the finger to bend in towards the palm. Depending upon the type of cord, the flexion will occur at the PIPJ or MCJP (or both). Usually, the DIPJ is not involved, but can be in rare cases.


Usually, loss of your intrinsic musculature of the hand, will not cause your finger(s) to flex down. And, it will be a generalized involvement of the whole hand. One finger flexor tendons would not be more prominent than others. And, to have so much wasting that your flexor tendons become prominent would be a lot of wasting. Even in patients with cachexia, they usually do not lose that much tissue in the palms of their hands.

Needle fasciectomy is basically reserved for cases of Dupy that has one prominent cord that is responsible for the flexion. This is a “blind” procedure, so the nerves and arteries can be at high risk (even more than they are with an open procedure). Usually, most patients have much more involvement, with the fibrosis infiltrating thoughout most of the tissues in the hand. The hand surgeon has to decide on the best treatment, after a very thorough examination of the hand and fingers.

Hopefully, this is not Dupy. Not all “scarring“ or fibrosis is Dupy, though that is the most common cause. Have your therapist take a look at your hand again. No matter what she thinks this is, have her explain the different structures in the hand and how they are being involved. Hand anatomy is very complex and difficult to understand. It is always easier to understand when someone actually shows you things, rather than trying to explain it with words (picture worth a thousand words, a model is worth a million).

Hang in there. Good luck.
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