Carpal tunnel syndrome is a compressive neuropathy affecting the median nerve. Compressive neuropathy is characterized by a progressive injury to a nerve caused by pressure—either constant or intermittent—typically from surrounding soft tissues like muscles, ligaments and tendons. The median nerve relays nerve impulses from the hand and wrist along the arm, and it is commonly compressed at the carpal tunnel, which is formed at the wrist by the transverse carpal ligament. When this happens, the outer covering of the nerve, called the myelin sheath, is injured due to a lack of blood flow, reducing the nerves’ ability to conduct signals. Small nerve fibers, such as those that conduct light touch and temperature, are affected by compression of the median nerve first. If carpal tunnel syndrome progresses, the larger fibers, like those that conduct impulses to muscles, can be affected as well. Unfortunately, this condition is progressive: if left untreated, carpal tunnel syndrome will result in increased damage to the nerve until it no longer functions.

The most common symptoms of carpal tunnel syndrome are numbness and tingling in digits innervated by the median nerve—the thumb, index, long and half of the ring finger. This numbness and tingling may be especially present at night time, and can very often wake you up. Some patients also complain of weakness, loss of dexterity, and repeated instances of dropping objects. Pain can be present, but it is not always there; some people who suffer from carpal tunnel never experience pain outside of the discomfort of numbness and tingling.

Carpal tunnel syndrome is the most common hand-related problem we treat. Despite it’s mythical status, the age-old idea that carpal tunnel syndrome is caused by typing has been disproven. Carpal tunnel syndrome is more accurately described as a disorder of aging. As we get older, our tissues become less compliant and therefore are less able to tolerate transient swelling (tendonitis) which can be aggravated by wrist position while sleeping.  Sleeping with your wrists bent can cause irritation and swelling of the nerve, which will in turn increase the daytime symptoms of carpal tunnel syndrome. Furthermore, people with comorbidities like diabetes, thyroid disorders, rheumatoid arthritis and obesity are prone to carpal tunnel syndrome. Carpal tunnel syndrome can also present as a swelling-related complication of pregnancy, although it is relatively rare.

There are a number of treatment options available to you, depending on how your carpal tunnel syndrome is graded. Mild carpal tunnel syndrome is often treated with nighttime splinting and reassessment at a later date to ensure there has been no progression of symptoms. Moderate and severe carpal tunnel syndrome often requires surgical intervention, known as carpal tunnel release (CTR). Unfortunately, there are many studies showing there is no significant benefit from steroid injections, therapy, ultrasound, or any other non-operative treatment for patients with moderate to severe carpal tunnel syndrome. We recently published an article in the Journal of Hand Surgery showing that those with moderate carpal tunnel syndrome have superior outcomes at any given time tested after surgery when compared to patients with severe carpal tunnel syndrome. This study also showed that if a patient has moderate carpal tunnel syndrome and has surgery the outcome is predictable, while those with severe carpal tunnel syndrome have a more unpredictable outcome.

https://asht.org/sites/asht/files/docs/2022/Carpal%20Tunnel%202022.pdf
https://www.assh.org/handcare/condition/carpal-tunnel-syndrome
https://orthoinfo.aaos.org/en/diseases–conditions/carpal-tunnel-syndrome/

Carpal Tunnel Syndrome

Medial epicondylitis “Golfer’s Elbow” is a tendinosis (degeneration, not inflammation) of the tendon insertion at the elbow of the muscles that flex the wrist and pronate the forearm (turn the hand palm down). It is a very common condition, but not anywhere near as common at lateral epicondylitis or tennis elbow.

The most common symptoms of medial epicondylitis are a pain at the inside of the elbow when gripping, lifting or swinging a racket or stick for sport. This is what gives the condition its moniker. In addition, almost all patients will have pain at the bump on the inside of the elbow (medial epicondyle of the humerus).

The age range is similar to those with lateral epicondylitis at 35-65 years of age.  While tennis elbow is usually not caused by tennis, golfers’ elbow can in fact be caused by golf, especially if one’s swing needs “some work.” Other causes of the condition can be overuse with any type of lifting exercise, improper weight lifting (straight bar biceps curls), or sudden pulling with the wrist flexed. Patients often experience pain inside the elbow with use or activity.

It is important to remember that the condition is a result of tendon degeneration, not inflammation. For this reason, traditional anti-inflammatory medications do not work. These include NSAIDs and steroid injections. There are no definitive studies telling us what treatment works best.  In addition, most all treatments work the same as doing nothing. Therefore, we generally set patients up with a trial of physical therapy. Eccentric exercises and aggressive soft tissue mobilization set up by a trained therapist with a home program will usually decrease symptoms and allow the patient to return to sport. However, there is no need to wait for healing to return to sports or work either. We believe that if a patient will do the exercises before their activity, they will be able to perform better and without pain. The program should be incorporated as part of the warm-up. In rare cases, patients may need surgical treatment. The surgery is simple–but will require post-operative immobilization for 10-14 days followed by a supervised therapy regimen.

https://www.assh.org/handcare/condition/golf-injuries
https://orthoinfo.aaos.org/en/staying-healthy/golf-injury-prevention/

Golfer’s Elbow

The scaphoid is the most commonly injured of the carpal bones. We have eight total carpal bones set in two rows. The scaphoid ‘bridges’ both rows of bones, which is why it is commonly fractured in a fall.

First, the scaphoid bone can suffer a non-displaced fracture that does not show up on routine x-rays. The bone itself is in the shape of a twisted peanut, making visualization difficult.  This may lull patients into a false sense of security of thinking the bone isn’t broken just because initial x-rays were read as ‘normal’. However, a non-displaced fracture can easily transition into a displaced fracture if not detected and immobilized. Second, the blood supply to the scaphoid comes from the distal or hand side–this means the blood supply comes through the bone, not into the bone. Therefore, the blood supply is disrupted if the bone is broken, which can cause the bone to heal properly and, in some cases, even die.

Most scaphoid fractures occur in males, with an average age of 25. Up to 61% of scaphoid fractures occur during a sporting event. Furthermore, because of the nature of those typically injured, they can often present weeks or months following the injury with an unhealed fracture.

Non-displaced scaphoid fractures can be treated in a cast. A non-displaced fracture will have less than 1mm of a ‘step-off’ or gap at the fracture site and is usually found in younger children.  Any complete fracture will need operative fixation. In minimally displaced fractures, this is done with a screw, but sometimes bone grafting is needed because the fracture is comminuted or in multiple pieces.

https://asht.org/sites/asht/files/docs/2022/Scaphoid%20Fracture%202022.pdf
https://www.assh.org/handcare/condition/scaphoid-fracture
https://orthoinfo.aaos.org/en/diseases–conditions/scaphoid-fracture-of-the-wrist/

Scaphoid Fractures

Arthritis describes joint destruction and is broken down into three types: osteoarthritis, inflammatory arthritis and post-traumatic arthritis. The most common form is Osteoarthritis (OA), which is when the smooth layer of cartilage breaks down and does not heal. Inflammatory arthritis, which is less common than OA, is an autoimmune attack on the cells that line the joints and tendons (synovial cells). Post-Traumatic arthritis is also called “wear and tear arthritis” as it occurs when persistent joint irregularities and joints remain unstable or loose and cause a loss of their cartilage. 

Surprisingly, the most common symptom of arthritis in the fingers is a painless swelling at the distal interphalangeal joint or the end knuckle of the finger. It is very common to get osteoarthritis in this joint. It usually doesn’t hurt, but it can limit motion. Arthritis will first cause swelling and loss of motion, but pain can arise as the joint spaces become narrowed or irregular.  Sometimes arthritis can give rise to mucinous cysts in this joint, a common side effect.

Osteoarthritis is by far the most common type of arthritis in the hands and fingers. For some reason, it is more common in women than in men. Some people can get osteoarthritis at a very young age (20-30) whiles others may live into their 90s with no arthritis.

Activity modification, anti-inflammatory medication, and splinting can help individuals who have minor arthritis. However, there is nothing to prevent or slow the progression of osteoarthritis or post-traumatic arthritis. If an individual has inflammatory arthritis, treatment by a rheumatologist is warranted, as some patients can benefit from disease-modifying medications. Surgical treatment is reserved for those with continued pain. Surgical treatment for finger arthritis will not increase motion or function; it will only decrease pain. Surgical intervention for finger arthritis is mostly dependent on the location of the arthritic joint.

Finger Arthritis

The flexor tendons are the long tendons that run from the mid-forearm to the fingertip; each finger has two flexor tendons, and the thumb has one. The muscles that connect to these tendons originate in the forearm even though their action is in the hand. Their actions are complex, and their injuries to them are devastating.

The most common flexor tendon injury mechanism is a laceration from a sharp object like a knife, saw, or glass. You can also rupture a tendon when grabbing something or trying to tackle an opponent, hence the common name for an avulsion injury: “jersey finger.”  Frequently, an avulsion injury is thought to be a “sprain” as the finger hurts and swells but can still partially flex.

Researchers have published thousands of papers about the operative repair of flexor tendons, and surgeons have trialed numerous methods and implants. Today, the preferred method for repairing lacerations is multiple sutures crossing the gap (the area where the tendon is lacerated). Unfortunately, the treatment of choice for avulsions is less clear; if possible, surgeons fix the tendon to the bone with added sutures. Physical therapy with a Certified Hand Therapist (CHT) is mandatory for anyone recovering from a flexor tendon injury. Often, patients will be sent to see a hand therapist before surgery.

https://asht.org/sites/asht/files/docs/2022/Flexor%20Tendon%20Injury%202022.pdf
https://www.assh.org/handcare/condition/flexor-tendon-injury
https://orthoinfo.aaos.org/en/diseases–conditions/flexor-tendon-injuries/

Flexor Tendon Injuries

The triceps is a tripinnate muscle, meaning it is made up of three parts–the long, medial, and lateral heads. It extends the elbow and allows the arm to be held in place in space. The triceps originates on the humerus and runs down the upper arm where it attaches to the olecranon process of the ulna. The triceps tendon can get tendonitis or suffer a frank rupture. Both can look similar. Furthermore, a rupture is often not ‘complete’ and can confuse the diagnosis.

Inflammation of the triceps as it inserts on the olecranon tip, which causes pain on the tip of the elbow and weakness. This inflammation is likely not an inflammatory state, but rather a degenerative one (like tennis elbow and golfer’s elbow).

Most often, males that participate in vigorous activity suffer from triceps tendon injuries. Common injury mechanisms include weight lifting, football, or heavy manual labor.  It is typically caused by an eccentric load on an outstretched arm.

Loss of extension strength of the elbow is helpful for diagnosis but is not always present. Often, the triceps is incompletely ruptured, and some extension is possible. An MRI or ultrasound will make a definitive diagnosis. In those individuals with less than a 50% rupture in children and the non-athlete, we can treat a rupture using physical therapy with excellent results. However, those with significant ruptures or athletes are generally treated with surgical repair.

Triceps Tendons Injuries

The distal radius is the end (distal) portion of the forearm bone (radius). It connects to the carpal bones at the wrist and runs parallel to the ulna, which is the other bone of the forearm. The radius transmits up to 80% of the forces across the wrist to the forearm. In traumatic injuries, the distal radius breaks close to or at its joint with the carpal bones of the wrist. These fractures most often occur as the result of a fall on an outstretched wrist. It is the most common type of fracture in the arm.

Many distal radius fractures are dorsally displaced due to the nature of the injury (a fall on an outstretched hand). They can be extra-articular—meaning the joint is not involved—or intra-articular, meaning the fractures spread into the wrist joint.  Intra-articular fractures have a worse prognosis as they involve fractures of multiple bones, not just the radius. After a fall, there will often be swelling, pain, and limited motion in the affected wrist. In extreme cases, there can be an obvious, or visible, deformity in the wrist.

Distal radius fractures are very common in two subsets of patients: children and the middle-aged. They are the most common arm fracture in kids, as they spend a great deal of time at play, which can lead to falls. These fractures are typically non-displaced, or ‘greenstick,’ fractures. At the other end of the age spectrum, middle-aged patients, particularly those with moderate osteoporosis, commonly experience these fractures as the result of falls brought on by instability in gait and balance. Of course, anyone who participates in activities capable of generating enough force to break bones—think contact sports, roller or ice skating, cycling, etc.—can experience a distal radius fracture.

Non-displaced distal radius fractures can be treated in a cast until swelling and pain have subsided. For an adult, a non-displaced distal radius fracture will heal over the course of six to ten weeks. Over the course of healing, frequent x-rays are taken to ensure there has been no significant displacement of the bone as it is healing. A fracture brace can also be used in place of a splint. Displaced distal radius fractures in children are most often externally reduced and casted. Sometimes the reduction needs to be held in place with an external pin. In either case, the reduction is done under sedation to ensure the patient does not feel pain during the procedure. Displaced distal radius fractures in adults are usually treated with open reduction and internal fixation. This is most often accomplished with a plate placed on the palm side of the forearm. With stable plate fixation, patients can often go into a removable brace two to four weeks after surgery.

https://asht.org/sites/asht/files/docs/2022/Distal%20Radius%20Fracture%202022.pdf
https://orthoinfo.aaos.org/en/diseases–conditions/distal-radius-fractures-broken-wrist/

Distal Radius Fracture

In general, arthritis describes joint destruction. Arthritis can be broken down into three broad types. Osteoarthritis (OA), which is the most common form, is when the smooth layer of cartilage breaks down and does not heal. Much less common than OA, inflammatory arthritis is an autoimmune attack on the cells that line the joints and tendons (synovial cells). Post-Traumatic arthritis is also called “wear and tear arthritis” as it occurs when persistent joint irregularities and joints remain unstable or loose and cause a loss of their cartilage.

The first symptom is typically a loss of motion, especially in extension. Patients report that they can’t “get their elbow out.” Pain at the end of flexion can also occur. Swelling, instability, and mechanical symptoms can also occur as the condition progresses. Numbness in the pinky and weakness in the hand can occur from compression of the ulnar nerve at the elbow.

Comprehensive arthritis care, NSAIDS, glucosamine, and elbow sleeves can all help the pain. Steroid injections can also help with the pain. However, none of these interventions will halt the progression of arthritis. Surgical therapies include arthroscopic or open capsule release and removal of loose bodies and heterotopic bone. They are aimed at increasing motion and decreasing symptoms. If these do not help, the ultimate surgical treatment for elbow arthritis is a total elbow replacement.

Elbow Arthritis

Dupuytren’s is not actually a disease, but rather it is a disorder. It is a benign (non-cancerous) proliferation of tissue in the hands that may cause a contracture. This contracture and proliferation starts in the palmar fascia. This tissue in Dupuytren's is made up of a disproportionate amount of type III collagen. Type III collagen is the collagen in wound healing and has contractile properties. The condition in inherited, occurring mostly in white people of northern European descent. It has been called the “Viking Disease” for this reason.

Dupuytren’s usually starts with a painless bump. Often, those affected notice a lump or a “pucker” of the skin in the palm. With time, these lumps may grow or proliferate causing a contracture. Dupuytren’s does not hurt unless one tries to stretch out a contracture. As contractures worsen, patients complain of the inability to place their hands in certain positions.

The most common patient with Dupuytren’s is a white male in the sixth decade of life. It can occur, however, as early as the third decade in women. There is a strong genetic basis for Dupuytren’s. Some people get Dupuytren’s at an early age. When presenting young, Dupuytren’s tends to be aggressive.

Many times, patients are told that they do not require surgery. A painless bump or a ‘cord’ does not need intervention if it does not cause a contracture. Indications for intervention are a contracture of the metacarpophalangeal joint (knuckle) of 40° or any contracture of the proximal interphalangeal joint (the first joint of the finger). Surgery or enzyme injection can treat the contracture. Nothing will "cure" a patient of Dupuytren’s. The decision for which type of treatment will be made depending on the level of the contracture and the severity of the contracture.

Xiaflex: Xiaflex is a clostridium toxin. It cleaves type III collagen and works well to disrupt cords and can help to straighten fingers in those with Dupuytren’s contracture. It is a surgical procedure. Early reports have shown it to be about equal long-term in safety and recurrence to surgical treatment. More recent reports have shown it to be less effective long-term and have higher complications than surgical treatment and needle aponeurotomy. However, we no longer use Xiaflex due to its complications and expense.

Aponeurotomy: Aponeurotomy is a procedure done in the office. Under local anesthesia, a small needle is used to break up the cords. This allows the finger to straighten. This is used in minor cases and cases primarily with an MP contracture. A splint is worn for three weeks at night. Sometimes this does not achieve full correction.

Surgery for Dupuytren's: Intervention is indicated when one can’t use the hand appropriately and if the PIP joint is affected. Surgery is performed as an outpatient. Many times, patients will require therapy after surgery. Surgical outcomes are affected by the degree of contracture and the length of time the contracture has been present. Surgical correction of a 90° PIP contracture averages 45° residual contracture long term. This is the reason for intervention before the contracture is severe.

https://asht.org/sites/asht/files/docs/2022/Dupuytren%20Disease%202022.pdf
https://www.assh.org/handcare/condition/dupuytrens-contracture
https://orthoinfo.aaos.org/en/diseases–conditions/dupuytrens-disease/

Dupuytren’s Contracture

The triangular fibrocartilaginous complex (TFCC) is a soft tissue structure located on the small (pinky) finger side of the wrist. It is the primary stabilizer of the wrist in pronation and supination (rotation). It also cushions and supports the small bones of the wrist, especially while the hand is gripping. An injury to the TFCC can cause chronic wrist pain, but, fortunately, successful treatment does not depend on the chronicity of the injury, so patients with long-standing pain can often get better.

TFCC tears cause pain on the “ulnar side” of the wrist, the side opposite the thumb. It sits directly on top of the ulna bone, the small bone in the forearm. The radius rotates around the ulna when you pronate (palm down) or supinate (palm up) the hand. The most common symptom of a TFCC tear is pain and weakness at end range supination, with grip, and when bearing weight on the affected arm. There also can be numbness and tingling radiating toward the small finger.

Outcomes for the nonsurgical acute casting of TFCC tears is excellent. Unfortunately, the only patients who are typically seen early enough for this type of treatment are high-level athletes. Surgical treatment for traumatic tears is generally better than degenerative tears. As in most orthopaedic injuries, younger patients do better than older patients. The good news is that it doesn’t matter how long a TFCC has been injured; surgery has been performed on patients who have had tears for more than eight years with excellent results.

https://asht.org/sites/asht/files/docs/2022/TFCC%202022.pdf
https://www.assh.org/handcare/condition/tfcc-tear

TFCC Tears

De Quervain syndrome is a tendonitis of the first dorsal extensor compartment sheath, which is located at the wrist. It is a very common cause of wrist and thumb pain.  In this condition, the tendons that move the thumb become swollen and inflamed and have difficulty gliding through the first dorsal compartment. This constriction, in turn, leads to even more inflammation, further progressing the condition.

De Quervain’s is a common overuse tendonitis. It can happen in anyone that performs repetitive activity. It is also common during or after pregnancy—which is why it is also sometimes called “mommy thumb.” Most often, however, the cause is unknown.

The vast majority of the time, a simple injection followed by a period of rest will alleviate De Quervain’s syndrome. We generally use a simple brace over a three to four-week period following the injection. If the injection is unsuccessful in alleviating symptoms, a simple surgical procedure may be required. This is done on an outpatient basis and even can be done under local anesthesia in the office.

https://www.assh.org/handcare/condition/dequervains-tenosynovitis
https://orthoinfo.aaos.org/en/diseases–conditions/de-quervains-tendinosis/

De Quervain’s Syndrome

The radial head is the most proximal portion of the radius bone and is located on the outside or lateral aspect of the elbow. It is made up mostly of cartilage and acts as a secondary stabilizer to elbow stress.

Radial head fractures almost always result from a fall on an outstretched arm, when the forces impact the radial head and cause injury. Often there is an associated ligamentous injury. The worse the radial head fracture is, the more likely there is to be a ligament injury as well.

They can occur in kids as well as adults. Most commonly, they occur in postmenopausal women after a routine fall due to osteoporosis. Radial head fractures also happen with high energy falls (ice, stairs, ladders), where they often have other fractures or ligament injuries associated with them.

Radial head fractures are treated non-operatively or operatively. Individuals with a non-displaced fracture with NO BLOCK to motion or MECHANICAL symptoms can be treated in a sling. There is often a ligament injury associated with the fracture, so a slow increase in activity is required. Individuals with a block to motion or an articular step-off are treated surgically. If there are only one or two fragments to the fracture, it is reduced and fixed with screws. Often, the fracture is in too many pieces to ensure healing. In this case, it will be replaced with a metal end cap. This metal cap is called a radial head arthroplasty.

https://asht.org/sites/asht/files/docs/2022/Radial%20Head%20Fracture%202022.pdf

Radial Head Fractures

Lateral epicondylitis “Tennis Elbow” is an age-related pain phenomenon that exists at the lateral side of the elbow. The wrist extensor muscle, called the extensor carpi radialis brevis (ECRB), inserts on the lateral epicondyle of the elbow. This muscle stabilizes the wrist in extension and more importantly gives it the strength and stability necessary for a “power grip.” It is thought that degeneration or tearing of the tendon, either acutely or over time, at the attachment to the elbow bone is the cause of symptoms of lateral epicondylitis. However, the exact pathophysiology of symptoms is unknown.

One of the classic symptoms of lateral epicondylitis is pain with pressure on the bony prominence of the elbow. Lateral elbow pain with power grip and pain with wrist extension are also hallmarks of lateral epicondylitis. There is often pain with passive wrist flexion as well.

One of the most common questions we hear regarding lateral epicondylitis is “I don’t play tennis, why do I have tennis elbow?” You have to keep in mind that this nickname is just that, a nickname; the condition is by no means limited to people who play tennis! Lateral epicondylitis is most common in individuals between the ages of 35-65 years old, regardless of their activity level. Sometimes a patient will report a sudden increase in pain, or it can be a more insidious onset. Furthermore, lateral epicondylitis is thought to be an overuse injury, but the actual pathogenesis is not fully understood.

Even in the evidence-based literature, there are hundreds of papers studying different treatment modalities for lateral epicondylitis, but almost all treatment results are equal to placebo (in essence, doing nothing). This includes bracing; injections of blood, platelets, or bone marrow; shock wave treatment; ultrasound-guided methods, etc. We do know that steroid injections into the elbow are worse than doing nothing and anti-inflammatory medications won’t work because lateral epicondylitis is not an inflammatory condition.

https://asht.org/sites/asht/files/docs/2022/Tennis%20Elbow%202022.pdf
https://www.assh.org/handcare/condition/tennis-elbow-lateral-epicondylitis

Tennis Elbow

What is Thumb Ulnar Collateral Ligament Injuries?

The thumb metacarpophalangeal joint contains two important ligaments: the ulnar collateral ligament, which is on the pinky side of the thumb, and the radial collateral ligament, which is on the free side of the thumb. These collateral ligaments are critical for the stability of the thumb and for pinch and grip activities of daily living. The ulnar collateral ligament to the thumb is a complex ligament, comprised of the UCL proper and the accessory UCL. Together, they stabilize the thumb for pinch and grip activities; without this ligament, you would have very little pinch or grip strength and very poor overall dexterity.

UCL injuries were originally called “gamekeepers’ thumb,” although a more apt name would be “skiers’ thumb” because skiing is one of the most common mechanisms of injury. However, any blow to the inside of the thumb can cause the ligament to tear. It can also be weakened over time by the degenerative aging process. There is also a serious complication of UCL injuries known as a Stener lesion, in which the ulnar collateral ligament is torn, displaced and ultimately caught between the muscle that moves the thumb and the thumb bone. If this happens, there is no chance for healing, even if the tear is caught acutely and casted immediately. The ligament simply can’t get itself back into place if it is stuck beneath the muscle.

Partial tears and minimally displaced tears can be treated in a cast, which is worn for four weeks followed by a removable splint until motion and stability are returned. Complete tears that are displaced are treated surgically. This procedure requires your surgeon to surgically reattach the ligament. Most everyone can get back to the same level of function after surgery, even those who have been injured chronically. Oftentimes, patients will present with instability long after an injury. Fortunately, these injuries can usually be treated by mobilizing the ligaments and performing a primary repair; sometimes, a graft is used. In any case, these patients usually have good success. If a UCL injury is not treated, the metacarpophalangeal joint will become arthritic due to prolonged instability. Once the joint is arthritic, the only treatment is an arthrodesis or fusion of the joint. An arthrodesis is well tolerated in this joint, but a reconstruction of the UCL is obviously a much better treatment option.

https://asht.org/sites/asht/files/docs/2022/UCL%20Thumb%202022.pdf

Thumb Ulnar Collateral Ligament Injuries

The extensor tendons run along the back of the hand and wrist and extend the fingers. These are tendons you see on the back of your hand when you flex your fingers. The muscles for the extensor tendons attach in the forearm and go through tight compartments and pulleys on the back of the wrist before inserting on the finger.  The index and small finger have two tendons, the long and ring fingers only have one extensor tendon, and the thumb has two extensors, but they attach at different joints.

Traumatic injuries or lacerations can easily injure extensor tendons because they are so close to the skin. They can also rupture as a result of excessive swelling from a fracture or rheumatological condition.

Extensor tendon injuries are usually easier to treat than flexor tendon injuries, and they have better postoperative results. Acute lacerations are treated with a primary repair, and ruptures are typically treated by transferring one of the extra tendons to the injured one. The long thumb extensor tendon is the most common site of rupture. In this case, we take the extra index finger tendon and transfer it to the thumb. In addition to occupational therapy, it is crucial to have a therapist make a custom splint for the patient that accounts for their individual level of injury to increase the chance of optimal outcomes. We often send the patient to the therapist before surgery to get acquainted with the process and to make a splint.

https://asht.org/sites/asht/files/docs/2022/Extensor%20Tendon%20Injury%202022.pdf
https://www.assh.org/handcare/condition/extensor-tendon-injury

Extensor Tendon Injuries

Radial Tunnel Syndrome, also known as radial neuritis, is a confusing and challenging condition affecting the terminal branch of the radial nerve in the arm, the posterior interosseous nerve.  It is often misdiagnosed as lateral epicondylitis (tennis elbow) due to the prevalence of that condition. However, this condition is a constriction or irritation of the posterior interosseous nerve in the proximal, lateral arm.

Pain in the proximal lateral forearm is the most common symptom of radial tunnel syndrome. There is usually not numbness associated with the condition.  Radial tunnel syndrome can occur at the same time as lateral epicondylitis, making the diagnosis more confusing. However, the pain is more distal, or toward the hand, than tennis elbow. There is pain with grip, activities and fine control of the fingers. We do not know definitively what causes radial tunnel syndrome, but we believe the posterior interosseous nerve is compressed at the proximal border of the supinator muscle.  This muscle has a thick, fibrous tendon-like border that the nerve must travel under, and as the band becomes thicker and therefore less compliant, it can cause constriction of the nerve. Some less common causes are ganglion cysts in the elbow and vascular malformations.

Patients are usually 35-65 years of age, and men and women are affected equally.  Radial tunnel syndrome can occur in tennis players and in golfers.  It also happens in those with true overuse conditions with repetitive wrist motion, especially rotation.

Generally, physical therapy works most of the time to treat radial tunnel syndrome.  Aggressive massage of the area combined with specific exercises will cure radial neuritis most of the time. Surgery is reserved for patients who do not get better with therapy or those with significant weakness, which is a sign of a much more severe compression.  Surgery consists of exploration of the nerve and release of the proximal supinator muscle. Some patients will get a temporary worsening of the weakness with surgery, but this almost always recovers.

Radial Tunnel Syndrome

Little Leaguer’s elbow is an injury to the growth plate on the inside of the elbow, which is known as the medial epicondyle. Growth plates are areas of long bones that are comprised of cartilage, the same soft tissue that makes up your nose and ears. This soft tissue is what ultimately allows for the longitudinal growth of bones as they develop and grow. Unfortunately, because it is made up of cartilage, the growth plate is the weakest part of a growing bone. In Little Leaguer’s elbow, stress to the medial elbow, or medial epicondylar growth plate, can cause injury.

The most common symptom of Little Leaguer’s elbow is elbow pain with a loss of velocity. The injury usually develops during an accelerated period of growth. Longer arms mean more torque, which, coupled with a weaker growth plate, can lead to damage. Therefore, any symptom of pain in a young thrower should result in cessation of pitching and rest. If the pain persists, then an evaluation by a trained orthopedic surgeon should be the next step.

Of course, to have an injury at the growth plate, one must be growing, so this injury typically occurs in young individuals who are rapidly developing. Overuse is thought to be the most common underlying cause of the injury; to that end, year-round baseball, playing for multiple teams, and not tracking pitch counts are the most common offenders. Most kids with this problem already know they are pitching and throwing too much, so they will often downplay their activity level. Once an individual stops growing, their growth plates close and are finally comprised of solid bone.  At this point, excess stress on the medial elbow will cause ligament damage known as a ‘Tommy John’ injury.   The most common age for Little Leaguer’s elbow is between 10-14 years old because most boys’ growth plates usually close by age 14, and they typically are not able to throw with enough velocity to cause an injury before age 10.

One word: education. With a better understanding of the pathology of this condition, we can stop the offending activities before they can cause injuries.  Pitch counts, rest, rotating pitchers, and regular evaluation of throwing mechanics are critical. However, it is essential to know that even if you do everything right, a young boy can still develop Little Leaguer’s elbow. Once a diagnosis of Little Leaguer’s elbow is made, we will generally cast the elbow because it is tough to keep a preteen boy from throwing. We have found that the most effective way to enforce rest is with a long arm cast. Return to play is usually six to eight weeks, but can be longer. After the resolution of symptoms, coaches and trainers should initiate a throwing program as the player slowly returns to sport. Once the player has returned to sport, the constant evaluation of throwing mechanics is essential to ensure that the injury does not persist.

Little Leaguer’s Elbow

A bursa is a fluid-filled sac that can be found in areas of the body that require the skin or tendons to glide. Common sites include the elbow (olecranon), the knee (patellar) and the shoulder (rotator cuff). Olecranon bursitis is the inflammation of the olecranon bursa. It is generally referred to as any swelling on the posterior elbow.

There are three primary causes of olecranon bursitis: trauma, inflammation, and infection. If the elbow is injured and there is bleeding in the bursa, olecranon bursitis can occur. Prolonged pressure from a traumatic event can also have the same effect. Second, patients with gout, rheumatoid arthritis or other inflammatory conditions can inflame the bursa and cause olecranon bursitis. Finally, an infection of the bursa will cause the sac to fill with fluid.

A non-infected bursa can be treated with the use of an elbow sleeve and, if necessary, an aspiration to remove excess fluid. Oftentimes, an aspiration is needed to diagnose infection or gout. A chronic bursa or one that has been infected before is usually treated with surgical excision. This requires patients to use a splint, followed by an elbow sleeve, for three to four weeks. In the case of an infected bursa, the infection must be controlled, which requires antibiotics and immobilization. In the case of a severe infection, this can require hospitalization and emergent surgery, combined with strong antibiotics.

https://www.assh.org/handcare/condition/olecranon-bursitis

Olecranon Bursitis

Cubital Tunnel Syndrome (CTS) is a compressive neuropathy of the ulnar nerve at the point behind the inside of the elbow where the nerve travels through the cubital tunnel. A compressive neuropathy is a progressive injury to a nerve caused by constant, unrelenting pressure; as the condition progresses, the outer covering of the nerve, which is called the myelin sheath, is injured due to a lack of blood flow. Small nerve fibers, those that conduct light touch and temperature, are affected first. Larger fibers, like those that conduct impulses to muscles, are affected later with chronic progression of the injury.

The most common presenting symptoms of cubital tunnel syndrome are numbness and tingling in the digits innervated by the ulnar nerve. These may be especially present at night time, often waking the sufferer up from sleep. Some people also complain of weakness, loss of dexterity, and a problem with consistently dropping objects.  Fine motor activities of the hand are also affected because the ulnar nerve controls all the small muscles of the hand. This can make typing and writing very difficult.

Cubital tunnel syndrome is often related to elbow position; to that end, sleeping with the elbow bent is the most likely culprit. Prolonged elbow flexion while typing or driving can also worsen symptoms. Like carpal tunnel syndrome, cubital tunnel syndrome often gets worse as individuals age and soft tissues become less compliant and less able to tolerate compression. Furthermore, people with diabetes, thyroid disorders, and obesity are more prone to compressive neuropathies. Finally, an estimated 10% of the population has a naturally subluxing ulnar nerve, which can be exacerbated by rapid elbow movements—like lifting weights, baseball, tennis—and this can cause symptom progression as well.

Mild cubital tunnel syndrome is treated with nighttime splinting and periodic reassessment to ensure there is no progression. The most reliable splint is an elbow pad or even a children’s knee pad worn backward so that the pad is anterior to the elbow. Either of these times, when worn while sleeping, can often relieve symptoms in mild compression on their own. However, in some cases, workplace and activity modification may also be required. Moderate and severe ulnar neuropathy is usually relegated to surgical treatment. One recent study done at Harvard demonstrated that severe ulnar neuropathy did improve with surgical treatment, but not to ultimately to normal levels. Therefore, surgical treatment before progression to severe disease is paramount. We treat patients surgically by releasing the nerve and placing it anterior to the elbow, allowing the nerve to be unaffected by the elbow position. Following surgery, patients are treated in a posterior elbow splint for two weeks. From week two to four they are relegated to limited activities but are encouraged to progress to activities as tolerated by four weeks post-op.

https://www.asht.org/sites/default/files/docs/2018/Cubital%20Tunnel%20Syndrome%202018.pdf
https://www.assh.org/handcare/condition/cubital-tunnel-syndrome

Cubital Tunnel Syndrome

What are the Types of Biceps Tendon Injuries at the Elbow?

The biceps tendon is a bipennate (two heads) tendon that attaches the biceps muscle to the radius in the forearm. Its main action is to supinate (forcefully rotate the palm up) and flex the elbow. Biceps tendonitis and complete biceps rupture are the two types of injuries. They are likely both part of the same disorder. The tendon insertion on the radius has a poor blood supply and therefore, may become injured through use or with age.

Inflammation, due to the body’s attempts at healing this tendon, can cause pain. Conversely, a frank rupture can occur. Sometimes there is a presenting period of pain in the anterior elbow before the tendon pops, but most of the time, it is just a sudden tear of the tendon.

Typically, weekend warriors get biceps ruptures. They are almost always male between the ages of 35-60. Steroids can also be implicated. Biceps tendonitis is less common or at least less diagnosed. These can be in men and women and present with anterior elbow pain, pain with lifting, and pain with gripping. There may or may not be an inciting injury.

A complete rupture is usually obvious if the tendon retracts up the arm. Often, a tight band of tissue in the arm prevents the tendon from retracting after the injury. There will be significant pain, swelling and often subcutaneous bleeding. An MRI is diagnostic. Tendonitis is diagnosed with a physical examination: pain with resisted supination, pain when pushing on the biceps tendon, and pain with resisted flexion. In addition,x-rays and MRIs are essential in making the diagnosis and ruling out other problems like radial nerve irritation.

Biceps ruptures are usually treated surgically. Non-surgical evaluations of patients show that not repairing a biceps tendon at the elbow can result in up to a 70% loss in supination strength and a 40% loss of elbow flexion strength. With the advent of new surgical techniques and hardware, surgeons can reattach the biceps through a drill hole in the bone with excellent results.

Chronic, long-standing biceps tendon ruptures can be treated surgically. While most orthopedic surgeons won’t treat a biceps tendon rupture after two to three weeks. We have treated patients as late as six years after injury. Ideally, we would treat patients earlier but sometimes they present late for a myriad of reasons. For chronic injuries, we use a tendon graft, either from the patient’s leg or more commonly from a tissue bank. The reason for surgical treatment late is continued pain or weakness. The cosmetic deformity may persist, but strength will improve.

Complications of surgical treatment increase with time from injury to surgery. This means time is of the essence for surgical treatment for acute ruptures.

https://orthoinfo.aaos.org/en/diseases--conditions/biceps-tendinitis/

Biceps Tendon Injuries

Trigger fingers are a very common orthopaedic condition of the hand. They are a result of the tendons of the finger swelling underneath the pulleys in the hand. Pulleys are soft tissue structures that help the tendons achieve a mechanical advantage with flexion of the fingers. They accomplish this by essentially holding the tendon against the finger; without the pulleys, our tendons would “bowstring” out of place with flexion and be very weak. The progression of a trigger finger generally unfolds as follows. The first pulley of the flexor tendon becomes stiff and less compliant, which causes the tendon to no longer fit under the pulley leading to swelling and irritation. Inflammation on the tendon can cause the tendon to get stuck as it travels underneath the pulley. This catching, or “triggering,” of the tendon is where the name comes from. Thus begins the cycle of triggering and swelling, which causes and worsens trigger fingers.

The most common symptoms of a trigger finger are pain and “catching” with movement through the range of motion of the fingers. Oftentimes, a painful lump in the palm can occur as well, marking the site of inflammation. However, catching of the finger does not have to be present for a patient to have a trigger finger. Pain with extension or gripping may be the only symptoms a patient experiences. In any case, symptoms are more common in the morning than throughout the rest of the day.

Trigger fingers are common in men and women over the age of 35. Patients with one trigger finger are at increased risk of developing another trigger finger and also at increased risk for developing carpal tunnel syndrome.  Trigger fingers can also be associated with certain comorbidities like diabetes and rheumatoid arthritis and are very common in people whose occupations or hobbies cause irritation of the flexor tendons.

Unfortunately, studies have shown that trigger fingers often do not respond to non-surgical interventions like splints, non-steroidal anti-inflammatory drugs (NSAIDs), and physical therapy. However, a single steroid injection may be curative in 50-75% of cases, but this intervention is less effective in patients that have more than one finger affected, or are experiencing a recurrence following a previous injection. Surgical treatment, known as a trigger finger release, is a definitive treatment and is required if someone has failed an injection, has rheumatoid arthritis or has insulin-dependent diabetes.  Surgery is done under local anesthesia to ensure the complete release and requires a surgeon to release the pulley that is causing irritation of the tendon. This release allows the tendon to once again move freely underneath the pulley, ending the cycle of catching and swelling.

https://asht.org/sites/asht/files/docs/2022/Trigger%20Finger%202022.pdf
https://www.assh.org/handcare/condition/trigger-finger
https://orthoinfo.aaos.org/en/diseases–conditions/trigger-finger/

Trigger Finger

A mucous cyst is an “outpouching” of the last joint of the finger, which is called the distal interphalangeal joint.

It can cause joint swelling and pain, and most often occurs in conjunction with arthritis. A mucous cyst can also cause nailbed deformities and can get infected if the skin becomes thin and breaks open. If there is a groove or ridge in the nail, bacteria can get underneath it and cause an infection there as well.

Many individuals with arthritis of the hand get mucous cysts. They most commonly occur in women over the age of 45, because women get hand arthritis more frequently and severely than men.

Mucous cysts are generally treated surgically. The procedure, which can be done under local anesthesia, requires that half of the joint be exposed, and arthritic spurs removed. Sometimes, a flap of adjacent skin is rotated over the area of bad skin. Unfortunately, the cysts can recur; if they do, and pain is present, sometimes a fusion of the last joint of the finger is required. After surgery, we generally send patients to a hand therapist one time. Patients should not bend the end of the finger postoperatively as this will cause stress on the wound. The therapist can make a splint holding the end of the finger still until the skin is healed, which takes roughly two to three weeks.

Digital Mucinous Cyst

A mallet finger is a disruption of the terminal extensor tendon at the tip of the finger, where the tendon attaches to the bone. It can be either the result of a tendon avulsion (ripping off the bone) or a fracture of the bone (mallet fracture).

Pain and swelling are the most common symptoms of a mallet finger. Oftentimes, patients think they “jammed” their finger.  The finger will also have limited extension at the tip and sometimes it will droop.

Although it is also known as “baseball finger,” this injury can happen to anyone when an unyielding object (like a ball) strikes the tip of a finger or thumb and forces it to bend further than it is intended to go.

Any mallet finger with a tendon avulsion seen within a month of injury can be treated non-operatively. For this, we use a mallet splint made by a hand therapist; off-the-shelf splints do not work. Mallet splints made by a hand therapist are non-removable, but patients can play sports, shower, and swim in them. They will be worn for six weeks. Patients that cannot tolerate splinting can opt for a pin to be placed in the finger holding the joint in extension.

https://asht.org/sites/asht/files/docs/2022/Mallet-Finger%202022.pdf
https://www.assh.org/handcare/condition/mallet-finger
https://orthoinfo.aaos.org/en/diseases–conditions/mallet-finger-baseball-finger/

Mallet Finger

Thumb arthritis, also known as basal joint arthritis, is the degeneration of the thumb joint at the base of the thumb metacarpal. Thumb arthritis is usually found in the trapezium/metacarpal joint (TMC), but it can be present in the joint below the TMC as well. It is the second most common form of arthritis in the hand, surpassed only by arthritis in the last joint of each finger.

The most common symptom of thumb arthritis is pain at the junction of the thumb and the wrist, which is exacerbated by pinching, or flexing, those bones together. Many times there is deformity of the wrist, including loss of the web space between the thumb and index finger. Swelling and stiffness of the joint are also common symptoms of basal joint arthritis.

Basal joint arthritis of the thumb is extremely common. It usually occurs in women over the age of 45, or men over the age of 60. It can be isolated to the thumb alone or be present alongside other hand and/or wrist arthritis. Often, patients will present with a family history of arthritis. While the condition itself is not work-related, doing any job will be hard with thumb arthritis. While osteoarthritis is the biggest culprit, there are other conditions such as inflammatory arthritis that can affect the base of the thumb and cause the deterioration of that joint. In rare cases, an old fracture can lead to thumb arthritis.

Treating thumb arthritis is about controlling pain. Thumb arthritis has usually progressed for years before anyone seeks treatment. There is no prevention or preventative treatment for arthritis. In addition, there is no benefit to early surgical intervention. Initial treatments consist of bracing and periodic steroid injections. No exercise program has been shown to slow the progression of thumb arthritis. When bracing and steroid injections no longer help, surgical treatment can be very successful. The patient makes the decision to operate. The trapezium is removed, and a tendon is usually placed in the space that once held the trapezium. The deformity is usually corrected at the time of surgery. If a patient has a significant “Z” deformity, they may require a fusion or a stabilization of the joint above is required.

https://www.assh.org/handcare/condition/thumb-arthritis
https://orthoinfo.aaos.org/en/diseases–conditions/arthritis-of-the-thumb/

Thumb Arthritis

A boutonniere injury describes damage to the attachment/insertion point of the extensor tendon of the middle phalanx, which straightens the middle finger. The word boutonniere means “buttonhole,” which describes how the joint will “buttonhole” through the tendon when you have a deformity like this. It’s a classic injury pattern that is often initially missed by treating physicians. In a boutonniere deformity, the central extensor tendon is no longer properly attached at its normal insertion point on the middle phalanx. When this happens, the tendons that extend the last joint on the finger, which are known as lateral bands, will slide down and any attempt to extend the finger will make the proximal interphalangeal joint flex and the distal interphalangeal joint extend. If left untreated, this can ultimately progress to a classic fixed or permanent boutonniere deformity.

The ultimate goal is to diagnose a boutonniere injury before it progresses to a full-blown deformity. In the beginning stages of a boutonniere injury, patients will experience pain over the PIP joint at the insertion site of the tendon. There will also be little to no extension of the middle phalanx and pain and resistance to flexion of the distal joint. While diagnosing a boutonniere injury, your orthoapedic surgeon will need to take x-rays to ensure there is no bony injury.

Anyone can get a boutonniere injury. They are caused by any type of blow to the finger; in some cases, they can also be associated with a laceration or cut. However, boutonniere injuries are most common in sports like basketball, football, and volleyball. Most patients describe the mechanism of injury as a sensation of “jamming” their finger.

Ideally, a boutonniere injury will be diagnosed within 3-4 weeks of the initial injury. If this happens, it is possible for the injury to be treated with splinting and hand therapy. You will be placed in an extension splint for 3-4 weeks, followed by a relative motion splint until the damage is healed. However, you cannot play sports in these braces, so it is important for you to rest and recuperate your injury while it is healing. If your boutonniere injury is chronic or has progressed to a permanent deformity, then surgical reconstruction will likely be required. However, surgical reconstruction is not as reliable as early treatment with hand therapy-directed splinting, so early diagnosis is critically important to achieving the best outcomes.

https://asht.org/sites/asht/files/docs/2022/Boutonniere%20Deformity%202022.pdf
https://www.assh.org/handcare/condition/boutonniere-deformity
https://orthoinfo.aaos.org/en/diseases–conditions/boutonniere-deformity/

Boutonniere Injuries

The biceps is located at the front of the upper arm. There are three biceps tendons. Two attach to the shoulder and one attaches to the elbow. The tendons function in the motion of both the elbow and the shoulder.

Biceps tendon tears can occur when the tendons are overused and exposed to repeated stress. This can cause a tendon to fray, and thus eventually tear. Tendons can also tear when there is an injury to this part of the arm, such as oddly moving or twisting the elbow or shoulder, or falling on an outstretched hand.

Bicep tendon tears can occur at either the shoulder or the elbow, and tears can be complete or partial. When a complete tear occurs, the tendon has torn away from the bone.

Sudden, severe pain in the upper part of the arm or at the elbow is the most obvious symptom of a biceps tendon tear. Additionally, a popping sound or sensation may be experienced when the tendon tears. Other signs of a biceps tendon tear include:

The appearance of a bruise on the upper arm

Difficulty rotating your forearm with the elbow bent

A change in the contour of the front of the arm

There are several causes and risk factors associated with a biceps tendon tear.

There are two main causes, which include:

Trauma – lifting an extremely heavy object that overpowers the muscle, or falling on an outstretched hand.

Overuse – Overuse wears down and frays the tendon, eventually leading to a tear. This occurs gradually, over time, and tends to occur naturally with age. Sports that involve repetitive throwing increase the possibility of a tear due to overuse. 

The following increases the risk of tearing the biceps tendon:

Age – It is more common in older people, as their biceps tendon has had more wear and tear

Heavy overhead activities – Lifting heavy objects over the head, such a s in weightlifting, can cause excess wear and tear on the tendon

Overuse of the shoulder – Overusing the shoulder in sports increases the risk of this condition. Swimmers, throwing athletes and tennis players often tear their biceps tendon

Corticosteroid medications – This can cause muscle and tendon weakness

Initially, your doctor will take a full medical history and conduct a physical examination. A physical examination is typically only effective for a complete rupture, as the deformity of the arm muscle is obvious. Your doctor may also ask you to bend your arm and tighten your biceps muscle. If you experience pain while doing so, this could indicate a partial rupture.

An MRI scan may also be ordered to diagnose a partial or complete rupture. X-rays may be useful to rule out other problems that is causing elbow and shoulder pain, although X-rays do not provide images of soft tissues, such as the biceps tendon.

Both non-surgical and surgical treatment methods are used for biceps tendon ruptures. Tears at the elbow most often require surgery, especially in active individuals. Because there are two attachments to the shoulder, a tear in the shoulder area if often well tolerated and can be treated without surgery.

Administration of nonsteroidal anti-inflammatory medications

Surgery is not always necessary for partial tears but may be recommended for very active adults. For complete tears, surgery by an orthopaedic surgeon is often necessary depending on the location. It is imperative to seek an early evaluation as surgery should be performed within two weeks for best results.

Recovery time varies from person to person. After surgery, you will wear a brace for four to six weeks. Rehab begins within the first 3 weeks and involves physical therapy and exercise. It’s also important to listen to the aftercare instructions provided by your doctor to prevent secondary injury.

Once a bicep is torn, it, unfortunately, will not reattach itself to the bone and heal on its own. There are, however, a variety of treatment options available depending on the severity of your injury and whether it was a partial or complete tear.

Some bicep tendon tears will limit your range of motion and may cause pain. Many treatments for this condition involve rest, ice, the use of over-the-counter medications, prescription medications, and avoiding activities that might aggravate or worsen the injury.

There are two primary causes of bicep tendon tears: trauma and overuse. The risks of tearing one of your three biceps tendons increase with overuse of your shoulder (common for pitchers, tennis players, and swimmers, as well as in certain careers), heavy overhead activities (common among athletes who lift weights, for instance), age, and the use of corticosteroid medications, which are known to cause weakness in muscles and tendons.

Preventing bicep tendon tears is a multi-stage process that isn’t always foolproof, but there are things you can do to minimize your risks. These include strengthening your back to minimize strain on your biceps and avoiding repetitive overhead lifting activities. A thorough warm-up before participating in physical activities involving the use of your biceps is also imperative to prevent tears.

If you are lifting weights, practice using the “mixed grip” technique to reduce your risk of a bicep tear. A mixed grip has your palms facing in opposite directions: one facing toward your body and one facing away.

Biceps Tendon Tears

Andrews Institute Ambulatory Surgery Center - Gulf Breeze, FL

Baptist Hospital Pensacola - Pensacola, FL

Dr. Alex Coleman is a board certified and fellowship-trained orthopaedic surgeon specializing in hand, wrist, and elbow reconstruction, as well as microvascular surgery and limb salvage. His practice encompasses the full spectrum of hand and wrist conditions from the simple to the complex, utilizing a broad range of non-surgical treatment regimens, and, when necessary, the latest surgical techniques. His scholarly interests include biomechanical engineering and the design and manufacture of specialized surgical instruments.

Doctor of Medicine (M.D.) The Medical University of South Carolina Charleston, SC

Dr. Alex Coleman

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