Hot Topics in Hand

Healio spoke with Steven S. Shin, MD, executive vice chair of the department of orthopedic surgery at Cedars-Sinai Health System, about the challenges of treating pain in the hand, recent innovations in pain management of the hand and more.

“We feel with our hands, and there’s tons of little nerve endings that pulse through our fingers, as well as in other places,” Shin said, adding that injury to these nerve endings “can be painful.”

Challenges of pain management in hand

Shin explained that in addition to challenges posed by the many nerves in the hand and wrist, “for some patients, the propensity to make scar tissue is high, and those are challenging patients.”

“The hand [and] wrist – especially the fingers – they don’t tolerate scar tissue well. So, [it] can be painful to try to break scar tissue, to gain their motion and their function,” he said.

Shin noted that while there are several options for pain management for conditions of the hand and wrist, a “multimodal” approach can be used. For instance, anti-inflammation medications and gels can help provide relief when patients are using a brace or a splinter cast.

Cortisone injections, according to Shin, may also be helpful, but he stressed that physicians “should be careful not to use many of them, because they can cause degeneration or weakness of the tissues in that area.”

Shin said he often works with pain management clinicians “who are experts in using different kinds of modalities, whether it’s medication or injections or other types of modalities to decrease their pain.”

He said that as hand surgeons often “see patients with complex regional pain syndrome as a result an injury or surgery, [which] can be challenging, so we are thankful to have pain management specialists manage the pain for that patient.”

Recent innovations

One innovative option, Shin said, is ketamine infusion therapy.

“Ketamine is a drug that’s been around for a long time,” he said, adding that it is still used as a sedative among children.

“One can consider ketamine infusion therapy for the right patient, so that’s another kind of interesting treatment modality that I’m looking forward to seeing the outcomes of,” he said.

Targeted muscle reinnervation (TMR), Shin said, is undergoing research and “seeing some good outcomes clinically.”

Shin said this is used among patients who have undergone an amputation and formed a neuroma at the end of the nerves at the site of amputation.

“What you can do now is remove the neuroma and then attach that nerve through a muscle, perhaps [one] that wasn’t even functioning there or maybe even if it was functioning, you can do some microsurgery and insert that nerve into the muscle. The nerve can supply that muscle, and it’s existing, and you don’t have that neuroma information anymore.”

He noted that this procedure also helps patients who have prothesis, as the muscle that nerves are attached to during TMR, which may not have previously had a function, can help support the prosthesis.

“So that’s an exciting, innovative area of research that they’re seeing great clinical outcomes with right now,” Shin said. “I look forward to seeing research on that in the future.”

Disclosure:

Shin reports being a consultant to and receiving royalties from Arthrex.