Causes and Treatment of Hammertoes

A hammertoe is a deformity of either the second, third, or fourth toe. The toe becomes curled at the middle joint, resembling a hammer. Hammertoes can be classified as flexible (able to be easily straightened) or fixed (unable to be straightened). You may notice skin irritation or calluses where shoes rub the top of the toe.

What causes hammertoe?

The most common cause of hammertoe is wearing improper footwear, particularly shoes that are too tight in the toe box. Tight shoes force the toe to stay in a bent position. This causes the muscles to tighten and the tendons to shorten. When left in this position for extended periods of time, the toe muscles can no longer straighten appropriately. High heels can also cause hammertoe because they push your toes forward and crowd them in the toe box. Other causes of hammertoe include trauma, abnormal foot mechanics due to nerve and/or muscle damage from diabetes, arthritis, and stroke.

What is the treatment for hammertoe?

The first line of treatment includes lifestyle changes and conservative remedies when possible. Wearing proper footwear and low-heeled shoes with a deep toe box help. Also, you should choose a shoe made of flexible material with a half-inch space between your longest toe and the inside of the tip of the shoe. Additionally, there are exercises you can do to strengthen your toe muscles, like picking up marbles with your toes.

There are many cushions, straps, and non-medicated pads to relieve your toe symptoms, and your orthopedic foot and ankle surgeon can advise you on which of these suit your individual problem. Talk with your doctor before you attempt self-treatment to be sure that you are choosing the right measure.

Can surgery help my hammertoe?

Surgery is indicated for fixed hammertoe deformities that are painful. Surgery typically involves removing the middle joint of the toe (where the deformity exists) and fusing the toe into a straight position. Sometimes the tendon that pulls the toe up must be lengthened if it prevents complete correction of the deformity. Your orthopedic foot and ankle surgeon will discuss the appropriate procedure for your hammertoe condition. Surgery is typically done on an outpatient basis and can be done with local anesthetic if desired.

Common Wrist Sports Injuries

As an orthopedic specialist, I see wrist injuries more commonly among people who participate in sporting activities, such as gymnastics, contact sports, skiing, skateboarding, snowboarding, and racquet sports. Below I will explain the four common mechanisms of injury, the common wrist sports injuries, and how these injuries are treated.

The wrist allows you to properly position your hand, representing arguably one the most complicated joints in the body. There are 15 bones and 27 articular surfaces in the wrist, not to mention its elaborate system of muscles, tendons and ligaments. Ligament injury is quite common among athletes, as the repetitive action of the wrist puts athletes at risk for injury. Wrist sprains result from a torn or partially torn ligament, and wrist strains are the result of a torn or partially torn tendon. The most common wrist fractures among athletes include: distal radius fractures and scaphoid fractures.

The Four Mechanisms of Wrist Injury

Throwing – With throwing injuries, there is an overuse of the wrist. These are common in baseball players, tennis athletes, and racquet ball participants.

Weight-bearing – I see many weight-bearing injuries among those who participate in gymnastics, weightlifting, and cheer-leading.

Twisting – With a twisting injury, the wrist suffers from a rapid rotation that disrupts the stability of the wrist. I see this type of injury a lot with radical skateboarders and snowboarders.

Impact – More common in football athletes, I treat impact injuries that result from either a direct impact or a fall onto an outstretched hand.

Wrist Sprains

The most common wrist injury among athletes is a sprain of the wrist. This often is an injury to one of the ligaments – the connective tissue that attaches one bone to another. Most sprains occur when the wrist is forcefully bent during a fall on an outstretched hand. Wrist sprains can be mild or severe, and I grade them based on the degree of injury. A grade 1 sprain indicates a stretched ligament without apparent tearing. A grade 2 sprain, however, involves partial tearing of a ligament. With a grade 3 sprain indicates ligaments are completely torn.

Distal Radius Fracture

The most common fracture is called a “distal radius fracture.” A distal radius fracture is a break that occurs at the wrist end of the radius bone. These breaks are common among athletes and can be mistaken for sprains. Wrist fractures often occur during a fall onto an outstretched hand. With fractures of the wrist, the break can occur in four ways: intra-articular, extra-articular, open, or comminuted (in many parts). Many can be treated with casting alone, though some require surgery.

Scaphoid Wrist Fracture

The scaphoid bone is one of the smaller bones of the wrist, but it is one that commonly breaks during sporting injuries. This bone is located on the thumb side of the wrist, and can be difficult to treat due to its tenuous blood supply. As with most wrist injuries, a break to the scaphoid bone typically occurs from falling onto an outstretched hand. Treatment usually requires casting if not displaced, or surgery if displaced.

Symptoms of Significant Wrist Injuries

  • Pain at the time of injury
  • Swelling
  • Bruising or discoloration
  • Difficulty moving the wrist
  • A “popping” or tearing sensation during the trauma
  • Warmth and tenderness of the skin

Treatment for Wrist Injuries

Treatment really depends on the type of injury you have. For mild sprains, I generally recommend the “RICE” method and over-the-counter pain relievers, like Tylenol or Motrin.

RICE

R – Rest the wrist for around 48 hours.
I – Ice the injured area to reduce swelling (use a pack wrapped in a towel).
C – Compress the wrist with an elastic ACE wrap.
E – Elevate the injury above heart level.

Nonsurgical Treatment

Simple Sprain –With mild to moderate wrist sprains, you will need to wear a splint for 1 to 3 weeks. This keeps the wrist immobilized while it heals. If you develop stiffness, I can teach you some stretching exercises to allow you to regain full range of motion of your wrist.

Simple Fracture –If your broken bone is in good position, I can treat it by applying a fiberglass or plaster cast. This is done so that the healing wrist bone remains protected from further injury while it heals. You may have to wear the cast for up to 6 weeks, depending on your injury.

Closed Reduction –If the alignment is out of place, I may need to “reduce” the bone and re-position the bone fragments. A “reduction” is the medical term for this process, and because I will not be operating on your wrist, the procedure is called a “closed reduction”. After I put the bone in proper position, I will apply a splint or cast for you to wear for 4 to 6 weeks. Depending on the nature of the injury, I will take X-rays at weekly intervals for around 3 to 6 weeks. After a 6 week period, I may recommend physical therapy for you to help improve your wrist strength and mobility.

Surgical Treatment

Complex Fracture –For those fractures that require surgery, I follow one simple rule – put the broken pieces back into position and prevent them from moving out of place while they heal. I offer several treatment procedures for distal radius fractures and scaphoid fractures, and the choice depends on your age, your athletic activity, and your injury. As with most wrist surgeries, I may order hand therapy and rehabilitation exercises following the repair. It may take as long as 6 to 8 weeks for a complex fracture to heal.

Open Reduction –To perform wrist surgery, I usually make an incision directly over the area of the broken bones and re-align them in a process called “open reduction”. It is considered “open” because I have to surgically correct the fracture. It may be necessary for me to insert pins, plate and screws to hold the bones in place. As with other surgical procedures, I may require you to undergo hand therapy after your cast or splint is removed. Keep in mind, and open reduction surgical procedure takes a while to heal, but with proper physical therapy and rehabilitation, you will regain strength and full function of the wrist.

Switching to Anterior Approach for THR

I initially looked at switching to the anterior approach (going into the hip from the front rather than the side or back of the hip) because the PAs (physician assistants), nurses, and physical therapists in my hospital all told me that they felt that the patients who had anterior approaches were having significantly less pain and were able to rehabilitate faster.

I have a partner who was one of the first people in the Seattle area to do anterior approach THR and the hospital staff could watch the difference in how the patients recovered after their surgery.

Anterior Approach

Finally one day I asked our head PA how she would want her total hip done and she said definitely by the anterior approach. At that point I knew I had to learn more about it and whether it was reasonable for a surgeon that has always done THR through a posterior approach to change to a dramatically different technique and still be confident that my patients would benefit.

I first observed the technique in the operating room and then studied the anatomy of the anterior approach. The first obvious benefit is that the approach to the hip from the front is anatomically easy and does not involve cutting any major structures to get to the hip. You simply spread the interval between two muscles and you are down onto the hip capsule.

When you go in from the back you have to divide the gluteus maximus (butt) muscle and split part of the ilio-tibial band on the side of the hip and then cut several small tendons off the back of the hip.

The thing that stops a lot of surgeons from doing this approach is that it is so different from what they are used to. The other thing that stops them is the special technique that is necessary to place the stem into the femur (upper thigh bone). When you approach the hip from the back, it is fairly easy to place the stem of the implant into the femur.

From the anterior approach most surgeons use a special table called a fracture table that allows you to position the leg in a very specific way. In my case, all of the operating room staff and my assistants were used to doing this approach and that made my job a lot easier.

Once I decided that I wanted to learn this technique, I went to a lab where you can practice on cadavers. I was surprised at how easy the approach was and how well I could get good exposure of the socket and the femur to do the surgery. Once I had the exposure, the actual placement of the implants was exactly what I had been doing from the posterior approach.

I have now been doing all of my hips using the anterior approach, and although the first few that I did made me a little anxious, after about 10 hips I knew that I would never go back. For me to switch, I had to feel that it was an advantage to my patients and that I could do as good or better job implanting the components. I have definitely found both to be true.

I have found that my patients have less pain and are ready to leave the hospital sooner. After an anterior hip there are no hip position precautions like there are after a posterior approach. This means no pillows between the legs and you can bend over as far as you want.

My patients who have had one hip done through the posterior approach and one through the anterior approach tell me that not having to follow specific hip position precautions is one of the biggest positive differences that they noticed and they feel that it helped them recovery more quickly.

From my standpoint as a surgeon, I love the approach because I don’t have to cut any major structures to get to the hip, and also when it is done through the anterior approach it is easy to use fluoroscopy (real time x-ray) to check the position of the hip components while you are putting them in. This allows the cup position to be optimal and allows the surgeon to check the leg length to be sure it is the same as the other leg.

I am very happy that I was pushed to learn this new approach to THR. Total hip replacement surgery is one of the most rewarding surgeries that we do. No matter how it is done, as long as it is done well, patients have wonderful results. This is exactly why many surgeons don’t feel the need to change. They are doing an operation with excellent results and they don’t want to take a chance on having problems while learning a new way of doing it.

Fortunately for me, I was able to see a good surgeon and support staff doing this procedure and it convinced me to change.

My last thoughts for anyone reading this who is contemplating having their hip replaced is to know that the most important thing for a successful hip replacement is having a good surgeon and a hospital that does hip replacement surgery routinely. I do think the anterior approach has advantages over the posterior approach for both the patient and the surgeon and that’s why I switched.

Treatment of Cubital Tunnel Syndrome (Cell Phone Elbow)

Ulnar nerve entrapment at the elbow, also known as cubital tunnel syndrome is a condition where the ulnar nerve in your arm becomes irritated or compressed. This nerve is one of the three important arm nerves that travel from your neck all the way down into your hand. Constriction can occur in a number of places along this path, and depending on the site of irritation or compression, this pressure causes numbness, elbow pain, hand and wrist discomfort, or finger pain. When the ulnar nerve is compressed at the elbow, it is called, Cubital Tunnel Syndrome.   This condition is now also commonly called “cell phone elbow”.

Causes of Cubital Tunnel Syndrome

The ulnar nerve gives you feeling in your little finger and half of your ring finger. Additionally, it controls the muscles of the hand that allow you to pick stuff up and do other fine movements. It also controls bigger muscles of the forearm that allow you to grip objects.  The exact cause of cubital tunnel syndrome is not completely understood, but it is believed that the ulnar nerve is susceptible to compression at the elbow because it passes through a narrow space where there is not much tissue for protection.

Keeping your elbow bent for long periods of time (like when you hold a cell phone to your ear) may cause ulnar nerve irritation and symptoms.   Other common reasons for this condition include:

  • -A direct blow to the inside of the elbow or “hitting the funny bone”
  • -Fluid buildup in the elbow that leads to swelling and nerve compression
  • -Irritation when the nerve slides in and out of place with bending
  • -Pressure on the nerve from prolonged leaning on your elbow
  • -Sleeping with your elbow bent

Home Remedies for Cubital Tunnel Syndrome

The simplest thing you can do is to lay down your cell phone and avoid other activities that require you to bend your arm for long periods of time. Also, make sure your computer chair is not too low, and do not rest your elbow on the armrest a lot. Keep your elbow straight when sleeping, if possible, by wrapping a towel around your elbow region or wear an elbow pad backwards.

What the Doctor May Do at Your Visit

If the orthopedic specialist suspects you have cubital tunnel syndrome, he may order special X-rays to see if bony deformities are the cause of the problem.  Additionally, he may order electrical nerve conduction studies to determine how well your ulnar nerve is working and to identify exactly where the compression site is located.

Nonsurgical Treatment

Sometimes, non-steroidal anti-inflammatory medicines can alleviate your symptoms. The orthopedic specialist will want to decrease the swelling around the nerve with these medications. Also, he may inject a “steroid”, like cortisone around the ulnar nerve area of compression. It is not uncommon for the doctor to recommend a brace or splint for you to wear at night to keep your elbow straight. Finally, there are certain nerve gliding exercises that may help your nerve slide through the cubital tunnel so that symptoms can improve or resolve completely. These special exercises help keep the wrist and forearm from getting stiff and sore.

Surgical Treatment

For some people, nonsurgical measures are not enough to relieve the symptoms of cubital tunnel syndrome. In these cases, the orthopedic specialist recommends surgery to take the pressure off the ulnar nerve. Also, surgery is indicated for those who have severe nerve compression or muscle wasting due to the condition. The surgical procedures available include:

Endoscopic or Open Cubital Tunnel Release:  In this surgery, the ligament “roof” of the cubital tunnel is divided. This allows for an increased tunnel space and a decreased nerve pressure.   This procedure minimizes the dissection around the nerve and allows for the quickest recovery.  Dr. Weil is one of the only surgeons in the northwest performing Endoscopic Cubital Tunnel Ulnar Nerve Decompression surgery.  This method is the least invasive and allows for the fastest recovery of all ulnar nerve decompression surgeries.  Dr. Weil was highlighted on King 5 news Health Link for his treatment of cubital tunnel syndrome.

Ulnar Nerve Anterior Transposition:  With this procedure, the nerve is moved from the cubital tunnel and placed in front of that region. Ulnar nerve anterior transposition allows the nerve to lie under the skin and fat but on the muscle, within the muscle, or under the muscle. Placement will depend on your particular problem and the surgeon’s choice.

Medical Epicondylectomy:  One great option to release the ulnar nerve is to remove part of a bony section called the medial epicondyle. This technique prevents the nerve from becoming caught on one of the bony ridges so that it can adequately stretch with bending motions.

Surgical Recovery

If you must undergo a surgical procedure, the orthopedic specialist may put you in a splint following the surgery. For the endoscopic technique no splint is required, for the transposition technique, you may have to wear it as long as 6 weeks. Also, your doctor may recommend that go to physical therapy to learn exercises that will help you regain strength and motion in your arm.

Common Forearm Fractures in Children

Fractures of the forearm in children can occur near the wrist (at the distal bone end), in the middle of the bone, or near the elbow (at the proximal bone end). The two forearm bones are the radius and the ulna. A child’s bones are at risk for growth plate fractures because these sections are made of cartilage. Fortunately, children’s bones heal faster than adults’.

Forearm fractures make up around 50 percent of all childhood fractures, and the majority of these involve the wrist-end of the radius bone. Most forearm fractures in children occur from a fall onto an outstretched arm.

Types of Childhood Forearm Fractures

The main categories of fractures are non-displaced or displaced fractures and closed or open fractures. Displaced fractures involve the bone snapping into two or more parts and these parts do not line up. A non-displaced fracture is one in which the bones break but are still in anatomic position.

These fractures require a procedure to re-align the bones. A closed fracture is where the bone breaks but does not protrude through the skin. An open fracture, however, involves the bone breaking through the skin.

Torus Fracture

A torus fracture, is also called a “buckle” fracture, results in the top layer of the bone on one side compressing and buckling away from the growth plate. This is a stable fracture, with the broken segments not separated or displaced. These breaks hurt but do not cuase a deformity.

Metaphyseal Fracture

With a metaphyseal fracture, the break is across the upper or lower portion of the bone shaft. With this type of injury, the growth plate is not affected.

Greenstick Fracture

A greenstick fracture runs through a portion of the bone, causing it to bend on the other side. This term came about because doctors described this fracture like a green stick breaks. These types of injuries occur only in children, as adult bones won’t break in this manner.

Galeazzi Fracture

The Galeazzi fracture affects the radius and the ulna bones. These types of injuries are usually displaced with dislocation of the ulna at the wrist area.

Monteggia Fracture

With a Monteggia fracture, both forearm bones are affected. The ulna breaks and the top and the radius dislocates. This is a severe injury that requires immediate urgent care.

Growth Plate Fracture

Growth plate fractures, also called physeal fractures, occur at or across the growth plate, typically in the area where the radius attaches with the wrist. This area heals well, with less than 5 percent having complications.

Symptoms

Symptoms really depend on the type of fracture, but most fractures cause severe pain and numbness of the hand and forearm. Sometimes, the fracture causes a bent appearance of the forearm. Other symptoms include swelling, bruising, and inability to rotate or turn the arm.

Treatment

Treatment depends on the degree of displacement and the specific type of fracture. The severity of a fracture depends on the location and the amount of damage done to the tissue and bone. A minor fracture could heal within a few weeks, whereas a serious fracture could take months to heal.

Treatment also depends on the age of the child, the degree of deformity, and the stability of the break. The goal of treatment to a fracture involving the growth plate is restoration of normal alignment with minimal trauma.

Nonsurgical Treatment

Many fractures of the forearm in children can be treated without surgery. Casts and immobilizing devices protect the bones while they heal. Sometimes it is necessary for the orthopedic specialist to manipulate the bones into proper alignment, a process called reduction.

Surgical Treatment

Surgery to realign the bones and secure them in place is necessary if the skin is broken, if the fracture is unstable, if bone segments have been displaced, and if the bones cannot be manipulated to realign through reduction. Once the surgeon aligns the bone segments, he may use metal implants, pins, or a cast to hold these in place.

Long-Term Outcome

Once your child’s cast comes off, the wrist joint or elbow joint may be stiff for a few weeks. This will resolve without the need for physical therapy in most cases. Your child’s healing bones will be temporarily weak following immobilization, so you should not allow rough play, climbing, or contact sports for 3 to 4 weeks after the cast comes off.