Common Conditions & Treatments

Carpal tunnel syndrome is a condition brought on by increased pressure on the median nerve at the wrist (in effect, a pinched nerve).

There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand. Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel, disturbing the way the nerve works.

Cause

Usually the cause is unknown. Pressure on the nerve can happen several ways: swelling of the lining of the flexor tendons (tenosynovitis); joint dislocations, fractures, and arthritis; or a frequent bend in the wrist for long periods.

Fluid retention during pregnancy can cause swelling in the tunnel, which often goes away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes also can be associated with carpal tunnel syndrome. There may be a combination of causes.

Signs & Symptoms

Carpal tunnel syndrome symptoms usually include pain, numbness, tingling, or a combination of the three. The numbness or tingling most often takes place in the thumb, index, middle, and ring fingers.

The symptoms are usually felt during the night but may also be noticed during daily activities such as driving or reading. Patients may sometimes notice a weaker grip, occasional clumsiness, and a tendency to drop things.

In severe cases, sensation may be permanently lost and the muscles at the base of the thumb slowly shrink (thenar atrophy), causing difficulty with pinch.

A detailed history including medical conditions, how the hands have been used, and whether there were any prior injuries is important. An x-ray may be taken to check for the other causes of the complaints such as arthritis or a fracture. In some cases, laboratory tests may be done if there is a suspected medical condition that is associated with carpal tunnel syndrome. Electrodiagnostic studies (NCV–nerve conduction velocities and EMG–electromyogram) may be done to confirm the diagnosis of carpal tunnel syndrome as well as to check for other possible nerve problems.

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 help reduce 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. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand. Incisions for this surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve.

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. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.

Arthritis—literally, "inflamed joint"—can affect any joint in the body, including the joints between the 29 bones of the wrist, hand, and fingers. Osteoarthritis is a degenerative joint disease in which the smooth cartilage that covers the bone surfaces at the joints either is injured or wears over time.

Cause

A normal joint is made of two smooth, cartilage-covered bone surfaces that fit together so that they glide when the bones move. Arthritis develops when the smooth surfaces wear out and they no longer fit together. Injury, infection, gout, psoriasis, and other conditions can also cause arthritis of the hand.

Signs & Symptoms

The three most common sites where arthritis happens in the hand are:

• At the base of the thumb, where the thumb and wrist come together (the trapeziometacarpal or basilar joint)
• At the joint closest to the fingertip (the distal interphalangeal or DIP joint)
• At the middle joint of a finger (the proximal interphalangeal or PIP joint)

All forms of hand arthritis can cause stiffness, swelling, pain, and deformity. Osteoarthritis sometimes causes bony nodules at the middle joint of the finger (Bouchard’s nodes) or at the end joint of the finger (Heberden’s nodes). Osteoarthritis at the basilar joint can cause swelling, a bump, and a deep, aching pain at the base of the thumb.  Weakness of grip and pinch can make it hard to open a jar or turn a key.

When making a diagnosis, your doctor will ask you about your hands and other joints. Explain how your symptoms affect what you do. Your doctor will check how your hands look and function.  X-rays of joints with osteoarthritis can show loss of normal joint space, "bone spurs," or other changes. 

Treatment

The goals of treatment are to relieve pain and restore function. Brief rest—either by changing activities or wearing a splint—can help. Soft, snug sleeves can help support a joint when rigid splints are too restrictive. Heat (paraffin paths and warm compresses) can soothe the joints and help keep them mobile. 

It is important to keep as much finger motion and function as possible. Hand therapists can teach joint protection exercises and activity modification. Anti-inflammatory medication or a steroid injection into the joint can decrease pain, but neither cures arthritis.

Surgery is considered when the non-surgical options have not helped. In most cases, you will tell your doctor when you are ready for surgery. The goal is to restore as much function as possible and to minimize your pain.

One type of surgery is joint fusion. The worn cartilage is removed and the bones on each side of the joint are fused together so that the joint will not move--but it will not hurt. Another choice is joint reconstruction, where the rough joint surface is removed and either replaced with your own soft tissue or with an implant.

The type of surgery depends on the joint(s) involved, your anatomy, and your activities. Your hand surgeon can help you decide which type of surgery is the best for you.

 

This content is adapted from the American Society for Surgery of the Hand website, developed by the ASSH Public Education Committee.

Stenosing tenosynovitis, commonly known as “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 through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. 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 constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb. When the tendon catches, it produces irritation and more swelling of the pulley. This causes a vicious cycle of triggering and thickening of the pulley. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend.

Causes

Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.

Signs & Symptoms

Trigger finger/thumb may start with discomfort at the base of the finger or thumb. This area is often tender to local pressure and prone to nodules.

When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints.

Treatment

The goal of treatment for trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon.

Wearing a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may also include a change in activities to reduce swelling or an injection of steroids into the area around the tendon and pulley.

If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely.

Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use.

 

This content is adapted from the American Society for Surgery of the Hand website, developed by the ASSH Public Education Committee.

 

Dupuytren's disease is an abnormal thickening of the tissue just beneath the skin known as fascia. This thickening occurs in the palm and can extend into the fingers. Firm pits, nodules, and cords may develop that can cause the fingers to bend into the palm, in which case it is described as Dupuytren contracture. 

Although the skin may become involved in the process, the deeper structures—such as the tendons—are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).

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.

Signs & Symptoms

Symptoms usually include lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Thick cords may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. These cords cause bending or contractures of the fingers. In many cases, both hands are affected, although the degree of involvement may vary.

The initial nodules may produce discomfort that usually resolves, but Dupuytren's disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop. As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets. Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

Treatment

In mild cases, especially if hand function is not affected, only observation is needed. For more severe cases, various treatment options are available in order to straighten the finger(s). These options may include collagenase injection, needle aponeurotomy or open surgery. Collagenase injection is a technique where a small amount of medicine is injected into the Dupuytren tissue, weakening it so that the finger can be manipulated manually to make it straighter. Needle aponeurotomy is a method where a needle is placed through the skin and used to cut the Dupuytren tissue. Both collagenase injection and needle aponeurotomy are office procedures. Your hand surgeon can describe these options in more detail, including potential risks and benefits, to help you decide what treatment method is best for you. 

Specific surgical considerations include the following:

• The presence of a lump in the palm does not mean that surgery is required or that the disease will progress.
• Correction of finger position is best accomplished with milder contractures or contractures that affect the base of the finger. Complete correction sometimes cannot be attained, especially of the middle and end joints in the finger.
• Skin grafts are sometimes required to cover open areas in the fingers if the skin is deficient.
• The nerves that provide feeling to the fingertips are often intertwined with the cords.
• Splinting and hand therapy are often required after surgery in order to maximize and maintain the improvement in finger position and function.

 

This content is adapted from the American Society for Surgery of the Hand website, developed by the ASSH Public Education Committee.