COMMON HAND & WRIST CONDITIONS
There are many conditions that can afflict the hand and wrist. Below are just a few of the possibilities. A proper diagnosis is impossible over the internet. Please click here to schedule an in person appointment with Dr. Butzen so that we can discuss your symptoms and develop a plan to get you feeling 100% again.
Carpal Tunnel Syndrome
Carpal tunnel syndrome is a group of symptoms (tingling, numbness, weakness, or pain) in the fingers or hand. These symptoms occur when there is pressure on a nerve (median nerve) within the wrist (carpal tunnel). Carpal tunnel syndrome can occur acutely or over many years of repetitive motions. Initial treatment is with anti-inflammatories and night-time bracing, and an Electromyogram (EMG, a nerve test) can help confirm the diagnosis.
Definitive treatment of carpal tunnel syndrome is with surgical release of the carpal tunnel to release the compression on the nerve. Endoscopic release is a new technique, which releases the carpal tunnel from below, which results in faster return to work, faster recovery of strength, and less pain, with no increase in risks. For more complicated cases, a mini-open release can be performed, with direct visualization of the nerve structures. Doctor Butzen has been performing both endoscopic and mini-open carpal tunnel releases since 2009.
Wrist Fractures / Scaphoid Fractures
The most common fracture to the wrist occurs to the distal radius, the end of the larger of the two arm bones at the thumb-side of the wrist. This is usually the result of a fall onto the outstretched hand (FOOSH). The injury causes pain, swelling, bruising and sometimes a “dinner fork” deformity. Initial treatment is to minimize discomfort and swelling, and includes icing, elevation, and anti-inflammatories.
If the bone is properly aligned, it can be treated by immobilization in a splint or cast until healed.
If the bone has significant deformity or a pattern of fracture fragment instability, surgery may be indicated, which is to reduce the fracture to the anatomic alignment and hold it until healed. There are many techniques to achieve this, such as a plate and screws, smooth pins, or external fixture, each with its advantages and disadvantages.
A fracture may also occur to the scaphoid bone, one of the 8 small bones of the wrist. Like the radius fractures, this can be caused by a FOOSH (Fall On OutStretched Hand). Sometimes it is difficult to identify this fracture on X-rays, and so clinical impression is important. This bone has a tenuous blood supply, so care must be taken to carefully assess this bone for fracture and healing. Treatment depends on the location and severity of the fracture, but may be treated with casting or surgical fixation with a screw. Use of screw fixation has been shown to return people to their full activities faster, with less wrist stiffness, and more reliable healing.
Arthritis in the joint at the base of the thumb is common, and the cause is multifactorial: increased use of the thumb for grip and pinch, the shape of the joint surfaces, and the genetic makeup of the supporting ligaments of this joint all play a role. Initial treatment for this condition is with rest, bracing, and anti-inflammatories. Cortisone injections in this joint is a controversial topic, but can give some relief.
The definitive treatment is surgical replacement of this joint. There are many different techniques to treat this, and each technique can provide good pain relief and function of the thumb. Doctor Butzen has developed a technique that allows for equivalent symptom relief compared to the other techniques, but without the sacrifice of a functioning tendon, and earlier removal from immobilization, with an increase in the resulting range of motion of the thumb, which increases the overall functional result.
Thumb Sprains - Skier’s Thumb
Skier’s thumb is the acute injury to the inside ligament of the thumb metacarpophalangeal (middle) joint, from an extreme bending motion. This is common with skiing during a fall, as the ski pole has significant leverage and easily bends the thumb. If this is a chronic injury, it is called Gamekeeper’s thumb. Evaluation by an experienced physician is important because diagnosing this injury early may prevent the need for surgical intervention. Initial treatment is with rest, splinting and anti-inflammatories. If the ligament fails to heal, or there is significant weakness in the ligament, surgery may be indicated for repair (acute injury) or reconstruction/replacement (chronic injury).
Ganglion cysts are a non-cancerous mass or lump the usually occur in the back or front of the wrist or in the fingers. They are fluid-filled capsules that arise from joint linings or tendon sheaths. They may arise from underlying joint injury or arthritis. They are benign, often painless and many do not require treatment. However, if the cyst is painful or interferes with normal function, it may be made smaller by removing the fluid with a needle (aspiration), or removed surgically.
Fingers are easily injured from everyday activities, and finger injuries are some of the most common traumatic injuries seen in an emergency room. Injuries may range from simple bruises or contusions to broken bones and dislocations of the joints.
The tendon that bends the finger passes through a tube-like tendon sheath. If the tendon and sheath become irritated and enlarged from repetitive gripping action, inflammation may occur making it difficult for the tendon to pass through the sheath. The condition is called trigger finger because the tendon catches and then suddenly releases, as if clicking a “trigger.”
Discomfort and swelling may be treated with rest, activity modification, anti-inflammatory medication, or steroid injections. If the tendon does not return to normal, a minor surgery may be necessary.
De Quervain's tenosynovitis is a painful condition affecting the tendons on the thumb side of your wrist. Similar to trigger finger, this is due to swelling in the tendon and friction as it passes through the tendon sheath there. Symptoms include pain with thumb extension, and is common in new parents holding their baby, and with texting. Initial treatment is with rest, anti-inflammatories, bracing, and cortisone injections. Surgical release of the tendon sheath is performed for failure of the initial treatments to improve the symptoms.
Dupuytren’s contracture is a genetic progressive hand condition that causes a thickening of the tissue that is just below the skin of the palm. This can lead to contraction of this tissue and loss of the ability to extend the fingers. Surgery, or injection with a collagenase medication (Xiaflex) may be necessary to restore hand function.
Hand Tendon Injuries
The flexor tendons are located on the palm-side of the fingers and attach the flexor muscles to the finger bones, enabling the finger to be flexed into the palm for grasping and gripping. Extensor tendons are on the top side of fingers and help the digits to straighten, grasp and let go of objects. Laceration to any of these tendons resulting from an injury caused by a knife or glass can cause pain, loss of function and damage to surrounding tissue. The injury can partially sever the tendons, in which fingers can still move, or completely cut the flexor or extensor tendons, causing total loss of mobility in affected fingers for a given direction of motion (bending vs. straightening). Due to complications with finger lacerations, and urgency for rapid surgical repair in almost all cases, it is critical to have a careful evaluation by a physician specializing in conditions of the hand right away to receive the best possible treatment.
Nerves are the network of “wires” that carry messages from the brain to the rest of the body. Motor nerves carry messages from the brain to muscles to make the body move, and sensory nerves carry messages from the skin and joints to the brain. Injuries to nerves happen with blunt or sharp trauma, compression, or stretch, resulting in nerve dysfunction (numbness, weakness). There are a severities of these injuries, too, with different prognoses depending on the severity. Evaluation by an experienced surgeon is recommended early following the injury. Surgery may be necessary for severe injuries that fail to improve with a period of observation. Doctor Butzen has undergone additional training in microscopic surgery, which may be necessary for these injuries.
As the terminal extension of the fingers and hand, the fingertips are the portions of the upper extremity through which we touch, feel, write, grip, and pinch. With touch-screen devices, our dependence on our fingertips for everyday living continues to increase.
One third of all traumatic injuries affect the hands; the fingertips are the most frequently injured portion of the hand. An estimated 6 million emergency room visits and 12 million office visits for hand injuries occur each year. Annually, hand injuries account for approximately 90 million days of restricted work activity and 16 million days of missed work. The yearly cost of hand injuries to American society is approximately 10 billion dollars.
Successful treatment of fingertip injuries depends on many considerations, including patient age, sex, and occupation, and the anatomy of the fingertip defect. An algorithm to the treatment of fingertip injuries is reviewed below to assist in the management of these injuries.
A mallet finger (Baseball finger) is a deformity of the finger caused when the tendon that straightens your finger (the extensor tendon) is damaged, resulting the in the inability to extend the finger at the furthest joint. This is usually cause by an impact to the tip of the finger, with immediate deformity. X-rays are helpful to identify a small fracture of the bone of the fingertip. Splinting is usually indicated for this injury, though surgery may be necessary, depending on the injury characteristics.
Injuries to the nail are often associated with damage to other structures that are in the same location. These include fractures of the bone (distal phalanx), and/or cuts of the nailbed, fingertip skin (pulp), tendons that straighten or bend the fingertip, and nerve endings.
Any abnormal lump or bump, or “mass," is considered a tumor. The vast majority of hand or wrist tumors are benign or non-cancerous. Because there are so many tissue types in the hand (e.g. skin, fat, ligaments, tendons, nerves, blood vessels, bone, etc) there are many types of tumors that can occur there. Common tumors include ganglion cysts, giant cell tumor of tendon sheath, epidermoid cysts, and hemangiomas. A careful history and physical exam performed by a hand surgeon can help to determine the type of hand or wrist tumor, though frequently it is indeterminate or not easily identified. Studies such as X-rays, CT, MRI, or bone scan may be done to help narrow down the diagnosis. Recommendations for treatment are based on the presumed tumor type and preferences of the patient, and can include observation, local office treatments, or surgical excision.
Kienböck’s disease, or avascular necrosis (AVN) of the lunate, is the loss of blood supply to the lunate bone, leading to death and eventually the collapse of the bone. Damage to the lunate can lead to pain, stiffness, and in late stages, arthritis of the wrist. This disease is most common in men between the ages of 20 and 40 and rarely affects both wrists. Treatment ranges from immobilization and anti-inflammatories to surgery, depending on the severity and stage of the disease.
The hand and wrist are comprised of multiple small joints that work together to produce many intricate motions, from threading a needle to turning a key in a door. When joints become affected with arthritis, the activities of daily living can be very difficult. When a joint becomes arthritic, the cartilage has worn away and the joint can no longer function smoothly with the bones gliding easily over each other. Movement is painful and the range of motion is reduced.
The most common form of arthritis is osteoarthritis or wear and tear arthritis, which generally affects people over 50. Rheumatoid arthritis is a systemic form of the disease that causes significant joint inflammation that can damage cartilage and bone.
Traumatic arthritis can affect people of any age and may occur as a result of an injury or trauma to the joint. A joint that has sustained an injury is more likely to become arthritic, even if the injury has been properly treated. Fractures that damage the cartilage or joint surface and dislocations are the most common injuries that lead to arthritis.