Ganglion of the Wrist

Ganglion (Cyst) of the Wrist 

A wrist ganglion can appear on the A, back (dorsum) of the hand or B, on the underside.
Ganglion cysts arise from the capsule of a joint or the sheath of a tendon. They can be found at different places on the wrist. A ganglion cyst that grows on the top of the wrist is called a dorsal ganglion. Others are found on the underside of the wrist between the thumb and your pulse point, at the end joint of a finger, or at the base of a finger. Most of the time, these are harmless and will often disappear in time.

Cause 

A ganglion cyst contains a thick, clear, mucus-like fluid similar to the fluid found in the joint. No one knows what triggers the formation of a ganglion. Women are more likely to be affected than men. Ganglia are common among gymnasts, who repeatedly apply stress to the wrist.



Symptoms

Wrist ganglion. 

Because the fluid-filled sac puts pressure on the nerves that pass through the joint, some ganglion cysts may be painful. Large ganglia, even if they are not painful, are unattractive. Smaller ganglions that remain hidden under the skin (occult ganglions) may be quite painful.

A ganglion grows out of a joint, like a balloon on a stalk. It rises out of the connective tissues between bones and muscles. Inside the balloon is a thick, slippery fluid similar to the fluid in your joints. Usually, the more active the wrist, the larger the cyst becomes. With rest, the lump generally decreases in size.


Diagnosis 

Your doctor may ask you how long you have had the ganglion, whether it changes in size, and whether it is painful. Pressure may be applied to identify any tenderness. A penlight may be held up to the cyst to see whether light shines through. X-rays may be taken to rule out other conditions, such as arthritis or a bone tumor. Sometimes, an MRI or ultrasound is needed to find a ganglion cyst that is not visible.



Treatment 

Initial treatment is not surgical.

• Observation.
Because the ganglion is not cancerous and may disappear in time, just
waiting and watching may be enough to make sure that no unusual changes occur.
• Immobilization.
Activity often causes the ganglion to increase in size. This is because
activity increases pressure on nerves, causing pain. A wrist brace or splint may relieve symptoms, letting the ganglion decrease in size. As pain decreases, your doctor may prescribe exercises to strengthen the wrist and improve range of motion.
• Aspiration.
If the ganglion causes a great deal of pain or severely limits activities, the
fluid may be drained from it. This procedure is called "aspiration." The area around the ganglion cyst is numbed and the cyst is punctured with a needle so that the fluid drains away.

Nonsurgical treatment leaves the outer shell and the stalk of the ganglion intact, so it may reform and reappear.

The ganglion cyst can be removed through outpatient surgery, but this is no guarantee that the cyst will not grow again. Surgery may also include removing part of the involved joint capsule or tendon sheath. There may be some tenderness, discomfort, and swelling after surgery. Normal activities usually may be resumed two to six weeks after surgery.

Frozen Shoulder

Frozen shoulder is characterized by pain and loss of motion or stiffness in the shoulder. It affects about two percent of the general population. Frozen shoulder most commonly affects patients between the ages of 40 and 60 years, with no clear predisposition based on sex, arm dominance, or occupation.

Cause 

Anatomy of the shoulder, showing the ligaments and bones.

The causes of frozen shoulder are not fully understood. The process involves thickening and contracture of the capsule surrounding the shoulder joint.

Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10 percent to 20 percent of these individuals. Other medical problems associated with increased risk of frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease or surgery.

Frozen shoulder can develop after a shoulder is immobilized for a period of time. Attempts to prevent frozen shoulder include early motion of the shoulder after it has been injured.

Symptoms 

Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. The pain is usually located over the outer shoulder area and sometimes the upper arm.


The hallmark of the disorder is restricted motion or stiffness in the shoulder. The affected individual cannot move the shoulder normally. Motion is also limited when someone else attempts to move the shoulder for the patient.

Some physicians have described the normal course of a frozen shoulder as having three stages:

• Stage one: In the "freezing" stage, the patient develops a slow onset of pain. As the pain worsens, the shoulder loses motion. This stage may last from six weeks to nine months.
• Stage two: The "frozen" stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four months to nine months.
• Stage three: The final stage is the "thawing," during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.


Diagnosis 

A doctor can diagnose frozen shoulder based on the patient's symptoms and a physical examination.

X-rays or MRI (magnetic resonance imaging) studies are sometimes used to rule out other causes of shoulder stiffness and pain, such as a rotator cuff tear.

Treatment 

Frozen shoulder will generally get better on its own. However, this takes some time, occasionally up to two to three years. Treatment is aimed at pain control and restoring motion.


Nonsurgical Treatment 

Pain control can be achieved with anti-inflammatory medications. These can include pills taken by mouth, such as ibuprofen, or by injection, such as corticosteroids.


Physical therapy is used to restore motion. This may be under the direct supervision of a physical therapist or via a home program. Therapy includes stretching or range-of-motion exercises for the shoulder. Sometimes, heat is used to help decrease pain. Examples of some of the exercises that might be recommended can be seen in the following figures.

If these methods fail, nerve blocks are sometimes used to limit pain and allow more aggressive physical therapy.


More than 90 percent of patients improve with these relatively simple treatments. Usually, the pain resolves and motion improves. However, in some cases, even after several years the motion does not return completely and a small amount of stiffness remains.


Surgical Treatment 

Surgical intervention is considered when there is no improvement in pain or shoulder motion after an appropriate course of physical therapy and anti-inflammatory medications. When more invasive measures are considered, the patient must always consider that most individuals will get better if given sufficient time and that surgery always has risk involved.

Surgical intervention is aimed at stretching or releasing the contracted joint capsule of the shoulder. The most common methods include manipulation under anesthesia and shoulder arthroscopy:

Manipulation under anesthesia involves putting the patient to sleep and forcing the shoulder to move. This process causes the capsule to stretch or tear.

With shoulder arthroscopy, the surgeon makes several small incisions around the shoulder. A small camera and instruments are inserted through the incisions. These instruments are used to cut through the tight portions of the joint capsule.

Often, manipulation and arthroscopy are used together in combination to obtain maximum results. Most patients have very good results with these procedures.

After surgery, physical therapy is important to maintain the motion that was achieved with surgery. Recovery time varies, from six weeks to three months.

Flexible Flatfoot

Flexible Flatfoot in Children 

Flexible flatfoot is a condition in which the arch of the foot shrinks or disappears upon standing. Upon sitting or when the child is on tiptoes, the arch reappears. Parents and other family members often worry needlessly that an abnormally low or absent arch in a child's foot will lead to permanent deformities or disabilities. Most children eventually outgrow flexible flatfoot without any problems. The condition usually is painless and does not interfere with walking or sports participation.

Flexible flatfoot, showing the absence of an arch when standing.

Symptoms 

A flexible flatfoot has normal muscle function and good joint mobility and is considered to be a variation of normal. As the child grows and walks on it, the foot's soft tissues tighten, shaping its arch gradually. Flexible flatfoot often continues until the child is at least age 5 years or older. If flexible flatfoot continues into adolescence, the child may experience aching pain along the
bottom of the foot. A doctor should be consulted if the child's flatfeet cause pain.


Diagnosis 

To make the diagnosis, the doctor will examine the child to rule out other types of flatfeet that may require treatment. These include flexible flatfoot with a tight heel cord, or rigid flatfoot, which is a more serious condition.

The doctor will look for patterns of wear on the child's everyday shoes. Tell the doctor if anyone else in the family is flatfooted, as this may be an inherited condition. It is important to know about any known neurological or muscular disease in the child.

The arch disappears when standing (left) and reappears when the child is on tiptoes (right).

The doctor may ask the child to sit, stand, raise the toes while standing, and stand on tiptoe. He or she will probably examine the child's heel cord (Achilles tendon) for tightness and may check the bottom of the foot for calluses.

Treatment 

Nonsurgical Treatment 

Treatment for flexible flatfoot is required only if the child is experiencing symptoms of discomfort from the condition.

If the child has activity-related pain or tiredness in the foot/ankle or leg, the doctor may recommend stretching exercises for the heel cord.

A child at age 3 years (left) with flexible flatfoot. The same child at age 15 years (right) has a normal arch despite having received no treatment.

If discomfort continues, the doctor may recommend shoe inserts. Soft-, firm-, and hard-molded arch supports may relieve the child's foot pain and fatigue in many cases. They can also extend the life of his or her shoes, which may otherwise wear unevenly. Sometimes a doctor may prescribe physical therapy or casting if your child has flexible flatfoot with tight heel cords.


Surgical Treatment 

Occasionally, surgical treatment will be necessary for an adolescent with persistent pain. A small number of flexible flatfeet become rigid instead of correcting with growth. These cases may need further medical evaluation.

Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a condition where the bones of the hip are abnormally shaped. Because they do not fit together perfectly, the hip bones rub against each other and cause damage to the joint.

Anatomy 

The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The ball is the femoral head, which is the upper end of the femur (thighbone).

A slippery tissue called articular cartilage covers the surface of the ball and the socket. It creates a smooth, low friction surface that helps the bones glide easily across each other.

The acetabulum is ringed by strong fibrocartilage called the labrum. The labrum forms a gasket around the socket, creating a tight seal and helping to provide stability to the joint.

In a healthy hip, the femoral head fits perfectly into the acetabulum.

Description 

In FAI, bone spurs develop around the femoral head and/or along the acetabulum. The bone overgrowth causes the hip bones to hit against each other, rather than to move smoothly. Over time, this can result in the tearing of the labrum and breakdown of articular cartilage (osteoarthritis).


Types of FAI 

There are three types of FAI: pincer, cam, and combined impingement.

Pincer. This type of impingement occurs because extra bone extends out over the normal rim of the acetabulum. The labrum can be crushed under the prominent rim of the acetabulum.

Cam. In cam impingement the femoral head is not round and cannot rotate smoothly inside the acetabulum. A bump forms on the edge of the femoral head that grinds the cartilage inside the acetabulum.

Combined. Combined impingement just means that both the pincer and cam types are present.
(Left) Pincer impingement. (Right) Cam impingement.



How FAI Progresses 

It is not known how many people may have FAI. Some people may live long, active lives with FAI and never have problems. When symptoms develop, however, it usually indicates that there is damage to the cartilage or labrum and the disease is likely to progress. Symptoms may include pain, stiffness, and limping.



Cause 

FAI occurs because the hip bones do not form normally during the childhood growing years. It is the deformity of a cam bone spur, pincer bone spur, or both, that leads to joint damage and pain. When the hip bones are shaped abnormally, there is little that can be done to prevent FAI.

Because athletically active people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active. However, exercise does not cause FAI.



Symptoms 

People with FAI usually have pain in the groin area, although the pain sometimes may be more toward the outside of the hip. Sharp stabbing pain may occur with turning, twisting, and squatting, but sometimes, it is just a dull ache.


Home Remedies 

When symptoms first occur, it is helpful to try and identify an activity or something you may have done that could have caused the pain. Sometimes, you can just back off on your activities, let your hip rest, and see if the pain will settle down. Over-the-counter anti-inflammatory medicines (ibuprofen, naproxen) may help.


If your symptoms persist, you will need to see a doctor to determine the exact cause of your pain and provide treatment options. The longer painful symptoms go untreated, the more damage FAI can cause in the hip.


Doctor Examination 

During your first appointment, your doctor will discuss your general health and your hip symptoms. He or she will also examine your hip.


Impingement Test 

As part of the physical examination, your doctor will likely conduct the impingement test. For this test, your doctor will bring your knee up towards your chest and then rotate it inward towards your opposite shoulder. If this recreates your hip pain, the test result is positive for impingement.


Imaging Tests 

Your doctor may order imaging tests to help determine whether you have FAI.

X-rays. These provide good images of bone, and will show whether your hip has abnormally shaped bones of FAI. X-rays can also show signs of arthritis.

Computed tomography (CT) scans. More detailed than a plain x-ray, CT scans help your doctor see the exact abnormal shape of your hip.

Magnetic resonance imaging (MRI) scans. These studies can create better images of soft tissue. They will help your doctor find damage to the labrum and articular cartilage. Injecting dye into the joint during the MRI may make the damage show up more clearly. Your doctor may also inject a numbing medicine into the joint as a diagnostic test. If the numbing medicine provides temporary pain relief, it confirms that FAI is the problem.


Treatment 

Nonsurgical Treatment 

Activity changes. Your doctor may first recommend simply changing your daily routine and avoiding activities that cause symptoms.

Non-steroidal anti-inflammatory medications. Drugs like ibuprofen can be provided in a prescription-strength form to help reduce pain and inflammation.


Physical therapy. Specific exercises can improve the range of motion in your hip and strengthen the muscles that support the joint. This can relieve some stress on the injured labrum or cartilage.


Surgical Treatment 

If tests show joint damage caused by FAI and your pain is not relieved by nonsurgical treatment, your doctor may recommend surgery.

Many FAI problems can be treated with arthroscopic surgery. Arthroscopic procedures are done with small incisions and thin instruments. The surgeon uses a small camera, called an arthroscope, to view inside the hip.

During arthroscopy, your doctor can repair or clean out any damage to the labrum and articular cartilage. He or she can correct the FAI by trimming the bony rim of the acetabulum and also shaving down the bump on the femoral head. Some severe cases may require an open operation with a larger incision to accomplish this.


(Left) During arthroscopy, your surgeon inserts an arthroscope through a small incision about the size of a buttonhole. (Right) Other instruments are
inserted through separate incisions to treat the problem.


Long-Term Outcomes 

Surgery can successfully reduce symptoms caused by impingement. Correcting the impingement can prevent future damage to the hip joint. However, not all of the damage can be completely fixed by surgery, especially if treatment has been put off and the damage is severe. It is possible that more problems may develop in the future.

While there is a small chance that surgery might not help, it is currently the best way to treat painful FAI.

Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE) is an unusual disorder of the adolescent hip. It is not rare. For reasons that are not well understood, the ball at the upper end of the femur (thigh bone) slips off in a backward direction. This is due to weakness of the growth plate. Most often, it develops during periods of accelerated growth, shortly after the onset of puberty.

The patient's left hip (arrow) shows that a slight shift of the head of the femur occurred through the growth plate.


The condition is diagnosed based on a careful history, physical examination, observation of the gait/walking pattern, and X-rays of the hip. The X-rays help confirm the diagnosis by demonstrating that the upper end of the thigh bone does not line up with the portion called the femoral neck.


Risk Factors 

The cause of SCFE is unknown. It occurs two to three times more often in males than females. A large number of patients are overweight for their height. In most cases, slipping of the epiphysis is a slow and gradual process. However, it may occur suddenly and be associated with a minor fall or trauma. Symptomatic SCFE, treated early and well, allows for good long-term hip function.

Symptoms 

The typical patient has a history of several weeks or months of hip or knee pain and an intermittent limp. The appearance of the adolescent is characteristic. He or she walks with a limp. In certain severe cases, the adolescent will be unable to bear any weight on the affected leg. The affected leg is usually turned outward in comparison to the normal leg. The affected leg may also appear to be shorter.



Diagnosis 

The physical examination will show that the hip does not have full and normal range of motion. There is often a loss of complete hip flexion and ability to fully rotate the hip inward. Because of inflammation in the hip, there is often pain at the extremes of motion and involuntary muscle guarding and spasm.



Treatment 

The goal of treatment, which requires surgery, is to prevent any additional slipping of the femoral head until the growth plate closes. If the head is allowed to slip farther, hip motion could be limited. Premature osteoarthritis could develop. Treatment should be immediate. In most cases, treatment begins within 24 to 48 hours.

Early diagnosis of SCFE provides the best chance to achieve the treatment goal of stabilizing the hip.
A screw is inserted to prevent any further slip of the femoral head through the growth plate.
Fixing the femoral head with pins or screws has been the treatment of choice for decades.
Depending on the severity of he child's condition, the surgeon will recommend one of three surgical options.

• Placing a single screw into the thighbone and femoral epiphysis.
• Reducing the displacement and placing one or two screws into the femoral head.
• Removing the abnormal growth plate and inserting screws to aid in preventing    any further displacement.


Complications 

There are several potential complications associated with a slipped capital femoral epiphysis. The most common are avascular necrosis (AVN) of the femoral head and chondrolysis.

Avascular necrosis means that the blood supply to the femoral head has been permanently altered by the femoral head slipping. There is no way to identify children at risk for avascular necrosis or to prevent this complication. Evidence of avascular necrosis may not be seen on X-rays for as long as 6 to 24 months following surgery.
Chondrolysis, or loss of articular cartilage of the hip joint, is a major complication of SCFE. It may cause the hip to stiffen with a permanent loss of motion, flexion contracture, and pain. The loss of motion may be a result of an inflammation in the hip joint. This is still not fully understood by surgeons. Aggressive physical therapy and anti-inflammatory medications may be prescribed for this rare complication. There may be some return of motion.



Care After Surgery 

Most likely, the child will be admitted to the hospital by a pediatric orthopaedist. Surgery is usually performed within 24 to 48 hours. After surgery, the child will be on crutches for weeks to months. A physical therapist will demonstrate how to use crutches. The doctor will give you specific instruction about your child's weight-bearing status and activity restrictions. Follow the instructions closely.

It is important that your child be followed closely for 18 to 24 months after surgery. After the immediate postoperative period, X-rays every 3 to 4 months are needed to ensure that the abnormal growth plate has fused.

Your child may be restricted from certain sports and activities during this time of recuperation. This helps to minimize the chance of further complications. The fusion must be mature enough to prevent further slippage. Then, vigorous physical activities can begin.

Elbow (Olecranon) Bursitis

Description 

The bursa is a slippery sac between the loose skin and the bones of the elbow. It is located at the tip of the elbow. The bursa allows the skin to move freely over the underlying bone. Normally, the bursa is flat. If it becomes irritated or inflamed, a condition known as bursitis develops.

Cause 

Elbow bursitis can occur for a number of reasons.

• Trauma: A hard blow to the tip of the elbow could cause the bursa to produce    excess fluid and swell.
• Prolonged Pressure: Leaning on the tip of the elbow for long periods of time on    hard surfaces, such as a tabletop, may cause the bursa to swell. Typically, this    type of bursitis would develop over several months.
• Infection: If the tip of the elbow has an injury that breaks the skin, such as an    insect bite or a scrape, bacteria may get inside the bursa and cause an infection.    The infected bursa produces fluid, redness, and swelling. If the infection goes    untreated, the fluid may turn to pus.
• Medical Conditions: Certain conditions such as rheumatoid arthritis and gout are
   associated with development of elbow bursitis.


Symptoms 

Swelling is often the first symptom. The skin on the back of the elbow is loose, which means that a small amount of swelling may not be noticed right away. As the swelling continues, the bursa grows. This causes pain as the bursa is stretched, because the bursa contains nerve endings. The swelling may grow large enough to restrict motion of the elbow.

If the bursitis is infected, the skin becomes red and warm. If the infection is not treated right away, it may spread to other parts of the arm or move into the bloodstream. This can cause serious illness.


Diagnosis 

An X-ray may be taken to look for a foreign body or a bone spur. Bone spurs are often found on the tip of the bone of the elbow in patients who repeatedly have elbow bursitis.


Treatment 

Nonsurgical Treatment 

Elbow bursitis due to infection. 

If the doctor suspects that bursitis is due to an infection, he or she may remove fluid (aspirate) from the swollen area. This is commonly performed as an office procedure. Fluid removal helps relieve symptoms and gives the doctor a sample that can be looked at in a laboratory to identify if any bacteria are growing. This also lets the doctor know if a specific antibiotic is needed to fight the infection.

Often, the doctor may prescribe antibiotics before the exact bacterium can be identified. This is done to prevent infection from progressing. The antibiotic that the doctor uses at this point will cover a number of possible infections.

If the bursitis is not from an infection, it is treated through a number of options. The elbow is elevated and ice is applied. An elbow pad may be used to cushion the elbow. Direct pressure to the swollen elbow should be avoided. Oral medications such as ibuprofen or other antiinflammatories may also be used.

If swelling and pain do not respond to these measures, the doctor may recommend removing fluid from the bursa and inject a corticosteroid medication into the bursa. The steroid medication is an anti-inflammatory drug that is stronger than the medication that can be taken without a prescription.



Surgical Treatment 

If the bursa is infected and it does not improve with antibiotics or by removing fluid from the elbow, surgery may be needed. This is an inpatient procedure.

If elbow bursitis is not a result of infection, surgery may still be needed if nonsurgical treatments don't work. Surgery to remove the bursa is usually performed as an outpatient procedure. The surgery does not disturb any muscle, ligament, or joint structure.


Rehabilitation 

Physical therapy after surgery is not always needed. Postoperative casting or prolonged immobilization is not typically required.

Developmental Dislocation

Developmental Dislocation (Dysplasia) of the Hip (DDH) 

Developmental dysplasia (dislocation) of the hip (DDH) is an abnormal formation of the hip joint in which the ball on top of the thighbone (femur) is not held firmly in the socket. In some instances, the ligaments of the hip joint may be loose and stretched.

The degree of hip looseness, or instability, varies in DDH. In some children, the thighbone is simply loose in the socket at birth. In other children, the bone is completely out of the socket. In still other children, the looseness worsens as the child grows and becomes more active.

In a normal hip, the head of the femur is firmly inside the hip socket. In some cases of DDH, the thighbone is completely out of the hip socket.

Pediatricians screen for DDH at a newborn's first examination and at every well-baby checkup thereafter. When the condition is detected at birth, it can usually be corrected. But if the hip is not dislocated at birth, the condition may not be noticed until the child begins walking. At this time, treatment is more complicated and uncertain.

Left untreated, DDH can lead to pain and osteoarthritis by early adulthood. It may produce a difference in leg length or a "duck-like" gait and decreased agility. If treated successfully (and the earlier the better), children regain normal hip joint function. However, even with appropriate treatment, especially in children 2 years or older, hip deformity and osteoarthritis may develop later in life.

Cause 

DDH tends to run in families. It can be present in either hip and in any individual. It usually affects the left hip and is predominant in:

• Girls
• First-born children
• Babies born in the breech position (especially with feet up by the shoulders).

The American Academy of Pediatrics now recommends ultrasound DDH screening of all female breech babies.

Symptoms 

Some babies born with a dislocated hip will show no outward signs.

Contact a pediatrician if your baby has:

• Legs of different lengths
• Uneven skin folds on the thigh
• Less mobility or flexibility on one side
• Limping, toe walking, or a waddling, duck-like gait


Doctor Examination 

In addition to visual clues, the doctor will use careful physical examination tests to check for DDH, such as listening and feeling for "clunks" as the hip is manipulated. For older infants and children, X-rays of the hip may be taken.



Nonsurgical Treatment 

Treatment methods depend on the child's age.

Newborns 

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH.

Newborns are placed in a Pavlik harness for 1 to 2 months to treat DDH. The baby is placed in a soft positioning device, a Pavlik harness, for 1 to 2 months to keep the thighbone in the socket. This will help tighten the ligaments around the hip joint and promote normal hip socket formation.



1 to 6 months 

The baby's thighbone is repositioned in the socket using a harness or similar device. The method is usually successful. But if it is not, the doctor may have to anesthetize the baby and move the thighbone into proper position, and then put the baby into a body cast (spica).


Surgical Treatment 


6 months to 2 years 

The child is placed under anesthesia, and the thigh bone is manipulated into the proper position in the socket. Open surgery is sometimes necessary. Afterwards, the child is placed into a body cast (spica) to maintain the hip position.


Older than 2 years 

Deformities may worsen, making open surgery necessary to realign the hip. Afterwards, the child is placed into a body cast (spica) to maintain the hip in the socket.

In many children with DDH, a body cast and/or brace is required to keep the hip bone in the joint during healing. X-rays and other regular follow-up monitoring are needed after DDH treatment until the child's growth is complete.


Complications 

Complications of treatment may include a delay in walking if the child was placed in a body cast. The Pavlik harness and other positioning devices may cause skin irritation, and a difference in leg length may remain. Growth disturbances of the upper thigh rarely occur.