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Common Conditions of the Hand
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CARPAL TUNNEL SYNDROME
The “carpal tunnel” is a narrow bony passage in the wrist formed by the bones of the wrist (carpal bones) on the bottom and the transverse carpal ligament on the top. An important nerve (median nerve) and nine tendons that allow the wrist to flex, or move downward, pass through this small area. Carpal tunnel syndrome (CTS) occurs when the median nerve, the softest structure in the tunnel, becomes compressed against the transverse carpal ligament. The median nerve is responsible both for the ability to fire the nine tendons to flex the wrist and for sensation in certain fingers in the hand.
A person can be predisposed to CTS by having any condition that might decrease the space in the carpal tunnel and cause pressure on the median nerve. Some examples of such conditions are:
CTS as been linked to occupations or activities that require repetitive use of the hands, but it can develop regardless of the type of work or activities that an individual does.
Common signs and symptoms of CTS are aching in the wrist and base of thumb that might extend to the forearm near the elbow or even to the shoulder. Numbness and tingling in certain fingers the median nerve affects often occurs in some combination and is usually made worse with repetitive use of the wrist or hand for extended periods. Symptoms might awaken patients at night. Weakness, reported as frequent dropping of objects or problems twisting off jars and lids are also common complaints.
Treatment of CTS is best if sought before permanent loss of sensation, weakness, or atrophy occurs. Modifications at work with seat adjustments, keyboard and forearm supports and being conscious to avoid holding the hand in a flexed position for prolonged periods of time can be helpful in preventing CTS from worsening. Other conservative treatment options include wrist splints worn at night and during repetitive use activities and a course of anti-inflammatory medication(s). In addition, TS might resolve if any underlying disorder is corrected/controlled. CTS related to pregnancy should subside after delivery. Corticosteroid injections are an option for patients who have pain more than numbness or tingling, but there is a risk of injuring the median nerve and so are not done frequently. When conservative management methods fail, or there is weakness, atrophy, or persistent loss of sensation, surgery is recommended. “Carpal tunnel release” is an operation that releases the transverse carpal ligament in the carpal tunnel and provides more room for the flexor tendons and median nerve. TRIGGER FINGER
Trigger finger is a disorder of the tendons that allow the fingers to bend towards the palm, called the flexor tendons. Each of these tendons is directed by a number of “pulleys” along the course of the finger to keep the tendons (and finger) straight and not bow-stringed. Sometimes the pulley closest to the palm can become inflamed, thickened, and irritated so that the tendons have a difficult time passing through smoothly, causing locking, a catching sensation (“triggering”), and pain as the finger is bent and straightened. Trigger finger without an obvious predisposition occurs most commonly in middle-aged women, but other conditions such as diabetes, rheumatoid arthritis, carpal tunnel syndrome, and DeQuervain’s stenosing tenosynovitis can predispose a patient to the development of trigger finger.
Diagnosis of trigger finger is usually made with a careful history and physical examination. X-rays or other tests are rarely needed unless there are other conditions that must be excluded.
Treatment depends on the extent that the trigger finger is affecting daily function. Permanent contracture (bending) of the finger or stiffness when the finger is straightened may develop if trigger finger is left untreated. A short course of anti-inflammatory medications can be tried, but surgery is usually considered to release the tightened pulley and to allow the tendon to more freely move. DE QUERVAIN’S STENOSING TENOSYNOVITIS
DeQuervain’s disorder is a condition where inflammation occurs in the sheath around the tendons that run from the forearm & wrist to the thumb. It is most commonly seen in middle-aged women and is precipitated by overuse of the thumb. The tendon sheath becomes thickened from the inflammation and causes constriction of the tendons that are involved in moving the thumb.
Diagnosis of DeQuervain’s disorder is usually made with a careful history and physical examination. The physician may move your wrist and hand in a number of positions to determine the source of the problem. X-rays may be taken to rule out fracture, arthritis, or a bony abnormality that might be causing problems with the tendons gliding as the thumb moves.
Treatment of DeQuervain’s disorder initially involves the use of a splint that immobilizes the wrist and thumb, called a "thumb spica splint." Taking anti-inflammatory medications on a regular basis can help settle down the inflammation and relieve some of the associated pain. A maximum of three corticosteroid injections may be tried over a period of time, although if the first injection is unsuccessful, further injections are not usually merited. Surgery to release the thickened tendons is an effective option if conservative management fails and is done as a same day procedure. GANGLION CYSTS & MASSES IN THE HAND
There are many kinds of masses or tumors that can occur in the wrist and/ or hand. Almost all such occurrences are non-cancerous (benign). Ganglion cysts are the most common type of mass on the hand or wrist seen in the orthopedic setting.
A ganglion cyst forms when a sheath around a tendon or a capsule around a joint tears and allows an excess of the normal lubricating fluids in that area to enter a cavity (or cyst) but do not allow the fluid to leave. Ganglia usually occur in people ages 15 to 40 years old, but a special type of ganglia (called mucous cysts) are more common in older women aged 40 to 70 in relation to arthritis in the finger joints.
Ganglion cysts are usually well defined, smooth masses that can be found anywhere on the wrist or hand, but are most commonly seen on the backside or palm side of the wrist, or at the base of the finger. Cysts on the backside of the hand are usually more visible than those on the palm side of the hand. An important difference from other masses or tumors is that ganglia will change sizes according to periods of increased use of the wrist and hand. Ganglion cysts are usually non-tender to touch, but they can cause pain with movement as they rub on other structures. Rarely, a cyst can compress important nerves in the wrist/ hand and can cause weakness or changes in sensation in the hand and fingers. Mucous cysts at the tips of fingers often have a history of breaking open, draining clear gelatinous fluid, and healing, but can form an ulcer, infection, or become painful around the fingernail.
Diagnosis of ganglion cysts is usually made with a careful history and physical examination alone, but x-rays of the wrist and hand might be taken to confirm that the mass does not involve the bones. With mucous-type ganglion cysts associated with arthritis, arthritic changes and bone spurs might be seen around the affected finger.
Ganglion cysts can resolve spontaneously, but this is unpredictable from patient to patient. Immobilizing the area might decrease the size of the cyst temporarily, but does not offer a permanent solution. Aspiration or rupture of the cysts are not recommended because of the risk of introducing an infection and/ or of damaging adjacent structures such as arteries or nerves. If a cyst is painful or bothersome, surgical excision is usually indicated and this is usually a simple, same-day surgical procedure. The most common complication of surgery is a 10% recurrence rate. MALLET FINGER
Any injury to the fingers can cause pain and swelling in the affected area. In addition, mallet finger usually produces an obvious deformity such that the finger is bent at the affected joint. Because the tendon that works to straighten the finger is disrupted, the finger often cannot be straightened on its own. Diagnosis of mallet finger involves a careful history and physical examination as well as x-rays to determine if there are any associated fractures in the fingers. Treatment of mallet finger involves wearing a splint that keeps the affected finger straightened for a number of weeks. Continuous use of this splint is critical for the recommended amount of time -- if the splint is worn only occasionally or if its use is discontinued early, the finger will not be as mobile and the deformity will persist. DUPETRYN’S CONTRACTURE
Dupetryn’s disease causes the fingers to pull into the palm of the hand, called a “contracture”. This contracture is progressive, starting with bending at the metacarpophalangeal joint and gradually the proximal interphalangeal joint over time. It is most commonly seen in the ring and little fingers. Patients may also notice nodules in “distal palmar crease”, the crease that connects the palm with the affected finger. The condition is not usually painful and sensation is not usually affected, but the ability to straighten the affected finger(s) becomes limited, making normal activities such as putting your hand into your pocket, putting on a glove, or grasping for objects difficult and frustrating.
Diagnosis of this problem is essentially made with a history and physical examination. Your physician may want to verify that the contracture is not coming from a tendon disruption or bony abnormality such as a fracture, and thus other tests may be done to rule out these things. Definitive treatment for this problem involves surgery to release the thickened bands and contractures. Conservative treatment such as splinting and physical therapy may slow the progression of the disease but will not correct the problem.
Arthritis in the thumb often occurs in the carpometacarpal joint, called the “CMC” joint. CMC arthritis usually develops as a result of previous fracture or dislocation to the joint or as a result of a long-standing genetic predisposition in which case the way the joint exists over time subject it to instability and degenerative change.
Your physician may want to rule out other disorders that cause pain the hand or forearm, including arthritis or fracture, tendonitis, or impingement of nerves.
Treatment for CMC arthritis is usually conservative and can involve splinting of the thumb, the use of regularly scheduled anti-inflammatory medications, and/ or injections of cortisone into the joint. |
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