Swelling of hand...not a fracture, so what is it?

Matth3w,

Do you have access to your x-rays and could you post them? And were you seen by an orthopedic surgeon (preferably a hand surgeon) or just seen at the TMC by one of the primary care docs (or one of the battalion PA's)?

The reason being, that the location you marked and the symptoms you describe, I would be very concerned that you may have a carpalmetacarpal joint (CMCJ) dislocation.

These are very hard to pick up on x-rays, if you are not specially trained to do so, and have a suspicion for it being there. These are often missed in the ER or by non orthopedic surgeons, and the patient is just told that they have bruised the hand.

Sometimes, the joint can dislocated and then go back into place (called a subluxation). So, the x-rays may not look too bad, or may even look normal.

But, when a patient states that it hurts when someone squeezes the hand, and they point to the region of the capitate and hamate, you have to worry that the metacarpal bases of the middle and ring fingers may have been dislocated.


Of course, it could still just be a bad contusion involving the intrinsic muscles of the hand (the ones deep down between the metacarpal bones), which can take a while to heal.


But, since you do not really know the mechanism of injury (but it occurred during a collision sport), it hurts over the CMCJ, it hurts when someone squeezes the hand but not when applying axial compression (making a fist), the x-rays are "normal" -- this all justifies being seen by a hand surgeon, just to be sure.

If you were just seen at the troop medical clinic, go back to sick call or whatever, and ask to be seen by an orthopedic surgeon.

If you have been seen by an orthopedic surgeon, who has done a very thorough hand exam and reviewed the x-rays, then you may have just a deep bruise. But, if it does not get better soon, ask to be seen again. You may have to have stress films taken, or for the hand to be looked at under the C-arm (fluoroscopy).

Again, subluxations of the CMCJ's are often missed, but can lead to traumatic arthritis down the road.


(By the way, you do know that Army Docs have exactly the same training as civilian doctors, that they are required to pass the same boards and exams. In fact, the percentage of Army Docs that are board certified in their specialty is higher than the civilian practice in the US. Uniformed physicians are just as good, if not better, than the civilian sector. Many are just in the military to pay off their meidcal school debts, others make a career of it. Now, don't get me started on TriCare, or is it Try-to-get-Care?)


Good luck.

"Preserve the Fighting Force!"

What us the treatment for the thing you describe?

Also, I was joking about the Army doctors. If I can get a copy of the XRay are you able to tell me if it is CMCJ or not???

It will take me WEEKS if not MONTHS to get seen by the ortho surgeon, so I'm hoping to get a second opinion long before that. Hell, I can't even get an appointment with a PA for several weeks.

Matth3w,

Depends upon how unstable the joint is.

First, if it is still slightly out of place, it is reduced (pressed back into joint). These can be very unstable, and just slip back out.

But, once the joint is congruent (like it should be), one of two things can be done. If it is stable, and does not just pop out of place when the pressure is release, it can usually be treated with immobilization. This is usually a short arm cast for about 4 weeks, followed by a removable OrthoPlast splint. And hand therapy is begun.

If it is unstable, then the joint is usually pinned. This requires a trip to the OR. The joint is held reduced and two or more smooth wires are placed to hold the joint in place. Then a cast is applied. The pins usually stay in around 6 weeks. Then they are removed in the clinic. After that the patient is placed in an OrthoPlast splint and therapy is started.


So, it usually takes a good hand exam to see if the joint is properly reduced and is stable. This may have to be done under the C-arm (real time x-rays) to see how the bones move (or don't move, preferably) during motion and stress.


Again, you may just have a really deep contusion of the instrinsic muscles, or just a sprain of the ligaments around the CMCJ, but if the discomfort doesn't get better (or you have a noticable click in the region), it should be checked out. Mainly, because it is easy to miss this injury if you are not used to looking at hand x-rays and the resulting traumatic arthritis from a nonreduced joint is pretty high.


Hope that is understandable. Good luck.

I am trying to have my wife stop by and pick up a copy of the xray on her way home from work, if she does that, can you look at them and tell?

Also, what would I do to create the clicking noise? rotating of the wrist, etc?

Matthew,

If your hand is really bothering you, go to the ER. Ask for the OOD (orthopedic officer of the day) to be contacted, so that you can be seen immediately or within a couple of days in the clinic.

In the large MedCen's, they have an orthopedic resident on call 24 hours a day, just for cases like this. In the smaller MedAC's, they can contact the orthopedic surgeon who is on call, to see if he/she wants to see you the same day, or in his/her clinic within a couple of days.


Again, if this is really bothering you, do not put it off. The orthopedic surgeons are there to take care of you. They would much rather take a look at your hand and it be just a sprain or contusion, than for a CMCJ injury to be missed.

If it is a really sharp pain when someone grasps your hand, the type that puts you on the floor, then there is probably something significant going on. If the pain is getting better, and only bothers you a little, then it is something that is probably healing and you may just need to give it a little more time. But, it's a call you are going to have to make.


Again, the surgeons are there to take care to you, the soldier. That is their only job. True, orthopedic surgeons are probably some of the busiest docs in the Army, because the soldier is a high performance athlete, and are always gettin' broken. But, that is why a lot of orthopedics surgeons stay in the Army. They like taking care of the soldiers.


So, if you think your hand is really hurt, get it taken care of.

Good luck.

I agree with you, but that's unfortunately not how it always works in the Army. They want you to make an appointment with your PA, which can take a week or two, then get a referral, which can take another 48-96 hours to hit the system, then an appointment with an ortho. Total process can easily take a month or more, I know first hand because it took me 10 weeks to finally see someone about my back to determine I had a pinched nerve and bulging discs.

Sorry to keep repeating the same question over and over, but are you able to tell from my xray if I post it????

Sorry for my shorter replies, I'm having a hard time reading the computer screen because I just had PRK surgery done on Tuesday.

I forgot to mention that the pain is SOMEWHAT better than when I first got the injury. Plus I can still play hockey with it, it just hurts doing certain movements.

Matth3w,

It could be that you sprained the ligaments around the CMCJ, without having a frank dislocation. In that case, with time, the ligaments will heal down. Just like an ankle sprain.


So, it is sort of a judgement call, as it is for the physicians.

If you press straight down, right where you have the red circle drawn, and you feel a click, that can mean that the metacarpal base is out of place and you have pushed it back into place. Or if you have a feeling that the bones in that area shift just a little when someone squeezes your hand, that could also mean that the joint is unstable.


If you feel that the injury is significant enough, have someone take a look at it soon. You are the one who is going to have to live with this hand the rest of your life. Orthopedic surgeons would much rather have a patient come and make sure it is nothing serious, than to have to try to reconstruct or fix something later down the road, when it is much more difficult and not as satisfying.

Good luck.

I'm REALLY trying to be patient because you're obviously taking your personal time to try to help me, but I asked you like ten times if YOU can read the xrays if I post them to determine whether or not it's the issue described and for some reason you keep ignoring the question.

Matth3w,

Sure, I can take a look at the films. I would need to have at least three views of the hand; an AP (anterior-posterior), lateral, and oblique film. These are usually the standard set that are taken for any hand injury.

But, even if they are normal, that does not rule out a subluxation of the joint.

If the patient still has significant pain at the CMCJ and the x-rays are normal, then usually the surgeon will do stress films under a C-arm. This way the hand can be moved around, while looking at it under the x-ray, to see if the bones are stable. Usually, the surgeon will also press on the joint to see if he/she can get it to sublux or pop out of joint.

If there is still a concern, a CT scan of the hand would be obtained.


But, if you have the x-rays, I can take a look at what you have.

You were posting so fast there, that you stuck a post in on me while I was typing, and didn't get a chance to read it, before submitting my post. Sorry about that.

Good luck. Hang in there.

Do you have access to eLite? The doc gave me the disc with the files to open in this eLite program but I can't open them because the program keeps freezing.

Do you have access to eLite? The doc gave me the disc with the files to open in this eLite program but I can't open them because the program keeps freezing.

Nm I got it:

http://img862.imageshack.us/img862/9451/52 035496.png

Matth3w,

Yes, that's been a problem with that program. What I usually had to do was call the radiology department and have one of the young soldiers who works as a radiology tech there tell me what to do.

It is possible to open them, but sometimes there were a few tricks that had to be done, and I'm not that literate on the computer.

But, you should be able to just call the radiology department, or go by there, and they should be able to help you. They have to help outside providers all the time, when we send patients out to see a civilian physician.

Let me know if you still have problems and I can see if I can do anything else. But, the radiology department that burned the disc is the best place to start. I really miss the old x-rays films. But, this is progress.


Good luck.

I tried to post a picture (I loaded it up in that program and then took a screen shot) but now it says my post is being reviewed by the community. So when they allow it to go through you will have a link to the scans.

I tried to post a picture (I loaded it up in that program and then took a screen shot) but now it says my post is being reviewed by the community. So when they allow it to go through you will have a link to the scans.

Matth3w,

Yes, that's policy here, for any outside links and links to picture (they don't want inappropiate pictures posted). Thanks, I will check back every so often to see if it is up.

G

Matthew,

I took a look at your x-rays.

Unfortunately, the lateral is not a true lateral, it's more of an oblique.

It looks like the CMCJ are all in the correct locations, none of them appear to be subluxed or dislocated. But, again, the lateral is not the best shot, so it is hard to see the 4th CMCJ.

The joint between the hamate and capitate looks a little funny on the AP view (the one with the pen in it). It may just be the overlapping shadows, but if that is where you are really tender, I would look at it under the c-arm, just to be sure. And if there was any concern, I'd get a quick CT scan through that joint.


So, over all they look pretty good.


If you feel that your pain is getting better, you can probably just let mother nature take her course. But, if you are having trouble doing push-ups or PT, and need a Profile, you might consider going to sick call so that the OOD can be called. You should be able to be seen acutely for a possible fracture. What would they do if you had a broken leg, make you wait a month to be seen? That's silly. But, anyways...I know, it's the military.

Again, I don't see anything grossly out of place. You may have a chip off of the capitate, on the hamate side, but further x-rays would probably have to be done to confirm this or rule it out.


Sorry that I can't be anymore definitive than this. Just wish I could do a quick look at it under the C-arm. But, that's life.


Good luck. Hope your hand is feeling better.