Hand & Wrist

Arthritis
Osteoarthritis, a degenerative joint disease, occurs when the cushioning cartilage that covers the bone surfaces at the joints begins to wear out. It may be caused by simple “wear and tear” on joints, or it may develop after an injury to a joint. It is most often seen where the thumb and wrist meet, at the joint closest to the fingertip, or at the middle joint of a finger. It may also develop in the wrist

Cause:
The cause of primary arthritis is not known. Secondary arthritis is sometimes the long-term result of joint injuries, mechanical trauma, or preexisting lesions. Sometimes arthritis develops as the result of an infection in a joint.

When arthritis occurs due to disease, the onset of symptoms is gradual and the cartilage decreases slowly. The two most common forms of arthritis from disease are osteoarthritis and rheumatoid arthritis. Osteoarthritis is much more common and generally affects older people. It appears in a predictable pattern in certain joints.

Rheumatoid arthritis has other system-wide symptoms and may be passed from parent to child. When arthritis is due to trauma, the cartilage is damaged. People of any age can be affected.

Prevention:
About one out of every five people in the United States has at least one joint with signs or symptoms of arthritis, and half of those are under age 50. The number of people with arthritis in the hand and wrist is unknown. Arthritis typically results from either disease or trauma.

Fractures – particularly those that damage the joint surface – and dislocations are the most common injuries that lead to arthritis. An injured joint is about seven times more likely to become arthritic, even if the injury is properly treated. Arthritis does not have to result in a painful or sedentary life. It is important to seek help early so that treatment can begin and so returning to doing what matters most is possible.

Treatment:
Conservative treatment is the first step to relieve pain and restore function. Anti-inflammatory or other analgesics, periods of rest, and/or the use of finger or wrist splints are options. When rigid splints are too restrictive, soft sleeves may be used. The heat of warm wax or paraffin baths might help. With severe swelling, ice may be beneficial. Most importantly, maintain motion in the fingers. Hand therapy may be indicated. A cortisone injection often provides relief of symptoms, but is not a cure.

When there is too much pain or too little function surgery may be necessary. There are two types of surgery: joint fusion and joint reconstruction. Three factors affect which surgery is best for the patient: the joints involved, the person’s activities, and his/her needs. In a joint fusion, the arthritic surface is removed and the bones on each side of the joint are fused together to eliminate motion. In a joint reconstruction, the degenerated joint surface is removed, eliminating the rough, irregular bone-to-bone contact that causes pain and restricts motion. Options for replacement depend on the joint involved and include tissue from the patient’s own body, such as a rolled-up tendon, or artificial implants.

Carpal tunnel syndrome(CTS)
Carpal tunnel syndrome (CTS) is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. The carpal tunnel is where the median nerve and nine tendons pass from the forearm into the hand. When pressure in this tunnel builds up the nerve causes pain.

Cause:
Usually the cause is unknown. Pressure on the nerve can occur in several ways: keeping the wrist bent for long periods of time; swelling of the lining of the flexor tendons; and narrowing of the tunnel through joint dislocations, fractures, and arthritis. Fluid retention during pregnancy may cause symptoms of carpal tunnel syndrome, which often go away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes also can be associated with carpal tunnel syndrome.

Prevention:
There are no proven strategies to prevent carpal tunnel syndrome, but to protect the hands from a variety of ailments, take the following precautions: reduce force and relax grip, give the hands and wrists a break every 15-20 minutes by gently stretching and bending them, avoid bending the wrist all the way up or down, improve posture, and keep the hands warm. It is much better to take these preventative steps while pain-free, instead of waiting for major dysfunction.

Treatment:
Symptoms may often be relieved without surgery. Identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position, may relieve pressure on the nerve. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. A steroid injection into the carpal tunnel may help relieve the symptoms by reducing swelling around the nerve.

When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. By cutting the ligament that forms on top of the tunnel on the palm side of the hand, pressure on the nerve is decreased. Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. In severe cases, carpal tunnel symptoms may not go away completely after surgery.

deQuervain's tendonitis
This condition is brought on by irritation or inflammation of the wrist tendons at the base of the thumb. The inflammation causes the sheath around the tendon to swell, making thumb and wrist movement painful when grasping or holding objects.

Cause:
It is usually caused by taking up a new, repetitive activity. New mothers are especially prone to this type of tendonitis, because caring for an infant often creates awkward hand positioning. Hormonal fluctuations associated with pregnancy and nursing exacerbate the situation. A wrist fracture can also predispose a person to deQuervain’s tendonitis, as a result of increased stresses across the tendons.

Prevention:
Keeping the body strong and flexible is a key to prevention. Avoid prolonged repetitive stressful movements, and take frequent breaks at work if this type of activity is required.

Treatment:
The goal is to relieve the pain through non-operative treatment, including resting the thumb and wrist, by wearing a splint. Oral anti-inflammatory medication may be helpful. A cortisone-type of steroid may be injected into the tendon sheath. These are all intended to reduce the swelling, which typically relieves pain over time. In some cases, simply stopping the aggravating activities may allow the symptoms to go away on their own.

When symptoms are severe or do not improve, surgery may be recommended. The surgery opens the sheath to make more room for the inflamed tendons, which breaks the vicious cycle where the tight space causes more inflammation. Normal use of the hand can usually be resumed once comfort and strength have returned.

Broken wrist (Distal radius fracture)
When someone falls on an outstretched hand, the result may be a broken wrist. It can also happen in a car accident, a bike accident, a skiing accident, and similar situations. A broken wrist usually causes pain and swelling.

Cause:
Many wrist fractures in people over 60 are due to osteoporosis (decreased density of the bones). Fractures can happen in healthy bones if the trauma is severe enough (for example, a car accident or a fall off a bike).

Prevention:
The best prevention is to maintain good bone health. Older patients who have problems keeping their balance need special attention to prevent falls. Wrist guards worn on the forearms may help to prevent some fractures.

Treatment:
There are many treatment choices, depending on the nature of the fracture, and the age and activity level of the person and the xray alignment of the fracture. If the bone is in a good position a physician may apply a cast until the bone heals. If the alignment of the bone is not good and could limit the use of the arm, surgery may be recommended. This may be done without making an incision. After the bone is properly aligned, a splint or cast may be placed on the arm to hold the bone in place. The cast is removed four to six weeks after the surgery. At that point, physical therapy often helps improve wrist motion and function.

If the position of the bone is not acceptable for the future function of the arm, a different operation may be necessary. The bone may be held in a corrected position with metla pins, a plate and screws, an external fixator, or any combination of these techniques.

Dupuytren’s contracture
Dupuytren’s disease, an abnormal thickening of the fascia (the tissue just beneath the skin of the palm), often starts with firm lumps in the palm. In some patients, firm cords will develop beneath the skin, stretching from the palm into the fingers and gradually causing the fingers to bend into the palm.

Cause:
The cause of Dupuytren’s disease is unknown, but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.

Prevention:
This condition becomes more common after the age of 40, and men are affected more often than women. Risk factors include alcoholism, epilepsy, pulmonary tuberculosis, diabetes and liver disease.

Treatment:
Only observation is needed for nodules and cords that are not contracted. The presence of a lump in the palm does not mean that surgery is required or that the disease will progress.

Patients with more advanced contractures may require surgery to improve function. Various surgical techniques are available depending on the stage of the disease and the joints involved. The goal of surgery is to improve finger position and thereby hand function. Despite surgery, the disease may recur with the fingers bending into the palm again. Before surgery, the treating surgeon will discuss realistic goals and results.

Ganglion cysts of the wrist
Ganglion cysts are very common lumps within the hand and wrist that occur adjacent to joints or tendons. They can often be found at the top of the wrist, the palm side of the wrist, the base of the finger on the palm side, and the top of the end joint of the finger. The ganglion cyst is filled with clear fluid or gel.

Cause:
The cause of these cysts is unknown. They may form in the presence of joint or tendon irritation or mechanical changes. These cysts may change in size or even disappear completely, and they may or may not be painful. Ganglion cysts contain a thick, clear, mucus-like fluid similar to the fluid found in the joint. They are not cancerous and do not spread to other areas.

Prevention:
There is no known specific cause for ganglions, but often there has been an injury before the appearance of the cyst. Women are more likely to be affected than men. Ganglia are common among gymnasts, who repeatedly apply stress to the wrist.

Treatment:
In many cases, these cysts can simply be observed, especially if they are painless. If the cyst becomes painful, limits activity, or is cosmetically unacceptable, splints and anti-inflammatory medication may be prescribed to decrease pain. An aspiration (inserting a needle into the cyst) can remove fluid from and decompress the cyst.

If non-surgical options do not provide relief or if the cyst recurs, surgical alternatives are available to remove the cyst and a portion of the joint capsule or tendon sheath. Surgical treatment is generally successful although cysts may recur.

Hand fractures
Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to shift. Some fractures occur in the shaft (main body) of the bone, while others break the joint surface. Fractures where the bone is shattered into many pieces usually result from a high energy force and are usually unstable. A compound or open fracture occurs when a bone fragment breaks through the skin. There is some risk of infection with compound fractures.

Cause:
A fracture occurs when enough force is applied to a bone to break it. When this happens, there is pain, swelling, and decreased use of the injured part.

Prevention:
Avoid situations where a fracture to the hand could occur.

Treatment:
Medical evaluation and x-rays are usually needed to identify a fracture and help determine the treatment. Depending upon the type of fracture, several treatment methods are possible. A splint or cast may be used to treat a stable fracture, or to protect a fracture that has been set. Some displaced fractures may need to be set and then held in place with wires or pins without making an incision. This is called closed reduction and percutaneous fixation.

Other fractures may need surgery to set the bone (open reduction), which will be held together with pins, plates, or screws. Fractures that disrupt the joint surface (articular fractures) usually need to be set more precisely to make the joint surface as smooth as possible. On occasion, bone may not be able to be repaired. In such cases, a bone graft may be necessary. In this procedure, bone is taken from another part of the body.

Fractures that have been set may be held in place by an “external fixator,” a set of metal bars outside the body attached to pins, which are placed in the bone above and below the fracture site, in effect keeping it in traction until the bone heals.

Once the fracture has enough stability, motion exercises will help avoid stiffness.

Scaphoid fracture
The scaphoid bone is unique because it spans two rows of the wrist’s carpal bones. One row is closer to the forearm (proximal row) and the other closer to the hand (distal row). Because of its position, the scaphoid bone is at extra risk during injury, which accounts for it being the most commonly fractured carpal bone.

Cause:
Fracture of the scaphoid bone occurs most frequently from a fall onto an outstretched hand. It is common for people who have fractured this bone to not be aware of the injury until months or years after the event. Though there is initial pain, it may decrease after days or weeks. Bruising is rare, and swelling may be minimal. Since there is no deformity, many people with this injury mistakenly assume that they have just sprained their wrist, leading to a delay in seeking evaluation.

Prevention:
The best way to avoid a scaphoid fracture is to use proper protective gear whenever possible. Wrist guards are particularly useful during sports such as rollerblading, snowboarding and other contact sports.

Treatment:
A simple, nondisplaced fracture may be treated with cast immobilization. X-rays are repeated over several weeks or months, so the physician can watch for healing. It usually takes at least 10 to 12 weeks for the scaphoid to heal itself. If it does not heal, surgery is usually recommended. For displaced fractures, as well as some nondisplaced fractures, surgery is performed initially to improve the bone’s ability to heal and to minimize the time spent in a cast. With surgery, the bone is fixed in place with a screw. Sometimes a bone graft may also be used. A cast is frequently used to immobilize the scaphoid after surgery.

Trigger finger
Trigger finger or trigger thumb involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel for the tendons, much like the guides for a line on a fishing rod. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys.

Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricts the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a knot or swelling of its lining. One may experience pain, popping, or a catching feeling in the finger or thumb. Sometimes the finger becomes stuck or locked, making it hard to straighten or bend.

Cause:
Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm or base of the finger may be a factor, but in most cases there is not a clear cause.

Prevention:
Overuse of the tendon may result in trigger finger. If pain occurs when doing activities like using a computer, playing a musical instrument, or crocheting, rest the finger.

Treatment:
The goal of treatment is to eliminate the catching or locking, allowing full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced. Using a splint or taking an oral anti-inflammatory medication may help. Treatment may also include changing activities to reduce swelling. An injection of steroid is often effective in relieving the trigger finger/thumb.

If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This outpatient surgery opens the pulley at the base of the finger, so the tendon can glide more freely. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can be resumed when comfortable. Some patients may feel tenderness, discomfort, and have swelling around the surgery area. Occasionally, hand therapy is required after surgery to improve function.