CARPAL TUNNEL SYNDROME
Carpal tunnel syndrome is a frequent cause of hand numbness, pain, and weakness. It usually presents over months to years, but can also come on suddenly from an injury or over-exertion from repetitive activities such as painting, weeding or typing. Driving a vehicle, reading a newspaper, or other repetitive activities commonly produce the symptoms. Several occupations which require repetitive use of the hands are quite prone to this condition, such as keyboarding, hair dressing, or the use of vibrating power tools. The pain is typically at night and may radiate from the hand all the way to the shoulder. Patients frequently are awaken with the pain in the early morning and find the hand is tingling or asleep. They may get relief by shaking the hands or dangling them over the side of the bed. The numbness involves the first 3 1/2 fingers including the thumb. Patients often complain about clumsiness in the hands or dropping things.
The physical cause of carpal tunnel syndrome is a pressure phenomenon that occurs on the palm side of the hand and wrist. There is tunnel, or tube, in the wrist which contains many flexor tendons and the “median nerve” which gives feeling to the fingers noted above. The problem begins with the liner of the tendons, which swell from overuse, causing pressure on the nerve. As the pressure rises in the confined tube, it begins to choke the nerve, bringing on the symptoms. It is also seen in several medical disorders such as diabetes and low thyroid function. Pregnancy can frequently cause carpal tunnel syndrome, but it usually improves after delivery. However, some patients may have the symptoms recur later in life.
CUBITAL TUNNEL SYNDROME
Similar to carpal tunnel syndrome, “cubital tunnel syndrome” is a result of abnormal compression of a nerve. The ulnar nerve is one of the main nerves going to the hand, providing sensation to the small finger (pinky) and half of the ring finger. It also innervates some of the most important muscles of the hand that are involved in fine motor skills. As the nerve travels down the arm towards the hand, it crosses the elbow on the inner side behind a part of the humerus bone called the medial epicondyle (“the funny bone”). There are ligaments that hold the nerve in its place on the inner side of the elbow, this forms the cubital tunnel. The cubital tunnel is a common spot for compression of the ulnar nerve. Sometimes the otherwise normal structures in this area place excessive pressure on the nerve and irritate it. Other times, blunt trauma to the elbow or repetitive motions can irritate the nerve. When the ulnar nerve becomes irritated, patients sense numbness and tingling in the small and ring fingers. This can happen during activities or even during sleep. Some patients experience elbow pain over the nerve as if they just “hit their funny bone”. In more severe cases, the little muscles of the hand are affected leading to clumsiness, weakness, and loss of dexterity. It is crucial to be evaluated when symptoms first arise because over time, if ignored, the nerve damage can become permanent.
DE QUERVAIN’S TENDONITIS
De Quervain's Tendonitis is a form of wrist tendonitis. It occurs over the thumb side of the wrist, where the radius bone is most prominent. It is typically the result of repetitive activity with certain wrist motions that cause the tendons to inflame. For example, mothers with toddlers are commonly affected because of the motion involved with repeatedly picking up a child. Over time, the tendon inflammation leads to tenderness over a short distance at this location. A specific test ("Finklestein") is diagnostic: the thumb is placed within a closed fist and the fist is moved toward the little finger side of the hand (as when swinging a hammer). In patients with De Quervain's tendonitis, the tension applied to the inflamed tendons can be intensely painful.
Dupuytren’s contracture is a progression condition affecting the hand. It starts as a thickening in the palm, which is usually painless, and can progress to thick fibrous cords that cause the finger to bend down into the palm. The disease is most commonly seen in older males of Northern European descent. It is also more common in smokers and patients with diabetes. If left untreated, hand function can significantly decrease if the contractures become severe.
While the exact cause of Dupuytren’s disease is unknown, many characteristics of the disease are well understood. The disease occurs when collagen, a connective tissue found throughout the body in skin, muscle, tendons and bones, begins to proliferate. Patients will usually first notice a lump, or nodule, in the palm. The nodule may be painful in its early stages, but this pain will almost always go away in 2 to 4 months. The collage can continue to proliferate into thick bands, called cords, which connect the nodules and begin to draw the fingers into the palm. The course of the disease in any given individual can be quite varied. In general, the younger the age of onset, the more aggressive the disease tends to be.
Like all joints of the body, the elbow is a mobile part of the skeletal system and is thus susceptible to arthritis. The ends of the bones are normally covered by smooth cartilage that allows fluid, pain free motion. Arthritis is a general term that is used to describe degeneration of a joint. In its most mild form, arthritis refers to inflammation with minimal loss of cartilage. In more advanced forms, full loss of cartilage can result in “bone on bone” arthritis with loss of motion and severe pain. Like other joints, elbow arthritis can result from trauma such as fractures (post-traumatic) or normal wear and tear (osteoarthritis). Some people are predisposed to inflammatory conditions, such as rheumatoid arthritis, that lead to generalized arthritis throughout the body including the elbow.
In the early stages of arthritis, patients may experience some discomfort but most are asymptomatic. In the later stages, pain becomes more common and patients will frequently notice that they can no longer fully straighten/extend their elbow. This is usually the result of bone spurs. Other patients will have locking and popping which can be the result of loose bodies in the elbow, or floating pieces of cartilage and bone. An orthopaedic surgeon can diagnose elbow arthritis on physical exam. X-rays are frequently used to grade the amount of cartilage loss as well as to look for bone spurs and loose bodies. In some cases, an MRI or CT scan may be needed.
HAND AND WRIST ARTHRITIS
Patients with wear and tear osteoarthritis of the hand and wrist often come in to the office with complaints of pain, swelling, and stiffness in these joints. The pain can range in severity from mild to severe, and can be described in many ways, including “burning,” “throbbing,” and “aching.” Arthritis in general can be the result of a traumatic injury, but more commonly is due to increased stresses and wear on the joints in the hand and wrist over time such that factors of older age and family history play a large role. Most often patients will note that their pain is made worse during activities and made better by rest. While other problems in the hand and wrist such as tendonitis may also show similar symptoms, arthritis is often the confirmed diagnosis by taking an x-ray in the location corresponding to the patient’s site of pain. The x-rays can show a decreased space between two bones at the joint. This indicates that the cartilage, or soft tissue covering of the joint, is wearing down. Interestingly, the amount of pain described by the patient does not always correlate to the amount of joint destruction seen on the plain x-rays. Therefore, it is very important to address the patient’s symptoms first and foremost. Over time and if left untreated, arthritis in the hand and wrist joints can lead to a progressive loss of motion with continued pain and even a gross deformity of the hand or wrist. This can lead to continued loss of function in the extremity and further loss of strength. The pain can ultimately affect the quality of the patient’s life, specifically affecting his or her ability to perform activities of daily living secondary to the discomfort.
The most common joints in the hand affected by wear and tear arthritis are the small joints at the tips of the fingers followed by the base of the thumb joint. Repetitive use and inherent hypermobility at these joints, respectively, helps contribute to these issues. This is more often seen in the female population. We are not sure exactly the reason for this, but research suggests that hormonal differences may play a part. Specifically, the small joints at the ends of the fingers called the distal interphalangeal (DIP) joints can be associated with cysts over the base of the nail on the back surface of the affected finger. These mucous cysts can not only become painful, but often times the skin is so thin at this location that skin breakdown with the possibility of an infection and subsequent difficulty with closure of this skin may become an issue. The growth of the nail itself may also be altered. With respect to the thumb, arthritis at the base can lead to changes in the adjacent joints closer to the finger. A “zig-zag” deformity may be noted, and if non-operative management ultimately fails, both joints would likely need to be addressed in order to surgically treat the problem. At the wrist, arthritis is often secondary to a previous fracture or ligament injury that may have occurred even several years prior to the patient having symptoms. A not uncommon presentation is a patient who recalls “spraining” his wrist a long time ago. The pain from this initial injury got better but then a recent, sometimes innocent, traumatic event takes place prompting evaluation by an orthopaedic surgeon. X-rays obtained at the wrist would then confirm the diagnosis.
HAND MASS / GANGLION CYST
There are various “lumps and bumps” that occur in the hand and wrist. The most common is a ganglion cyst. Depending on the location of the cyst, a different name is given to that cyst (“mucous cyst”, “dorsal ganglion cyst”, “volar ganglion cyst”, and “volar retinacular ganglion cyst”). The common denominator in each of these is that each represents a “hernia” of sorts- a weak spot- arising from a deeper structure, typically a joint or tendon sheath. These cysts are balloon-like, not solid, and filled with fluid so they frequently increase and decrease in size over time. This virtually confirms the diagnosis. If a patient presents with a typical history and physical exam, very little is necessary for further evaluation. Sometimes an x-ray is taken if another diagnosis is suspected. For instance, arthritis in a joint can lead cyst formation, etc.
Mucous cysts arise from the end joint in the digits of the hand (closest to the fingertip or end of the thumb). They occur only on the nail side of the joint (opposite the palm surface). The involved joint typically has some degree of arthritis. The overlying skin can be so thin that the cyst may spontaneously drain a gelatinous fluid, especially if it’s traumatized accidentally or intentionally (don’t try this at home as serious consequences such as an infection can arise). Mucous cysts range in size from just a couple of millimeters to as much as a centimeter.
Dorsal Carpal Ganglions
Dorsal ganglion cysts historically called a “Bible bump”, arise from the central back of the wrist joint, opposite the palm. Despite lore to the contrary, they should not be slammed with a Bible as a form of self-treatment. These ganglions give patients aching discomfort, especially with extension of the wrist, as when pushing off a chair when arising or pushing open a swinging door. They can occasionally be so small and deep as to be very difficult or impossible to see. In these cases, an MRI may be helpful in making the diagnosis.
Volar Carpal Ganglions
Volar ganglion cysts arise on the palm side of the wrist, usually in the region of the radial artery pulse. They arise from the wrist joint on the thumb side. They can arise deep to, or even wrap around, the radial artery. Volar ganglion cysts also can be tender and cause discomfort with certain wrist motions.
Volar Retinacular Cysts
Volar retinacular ganglion cysts arise from the flexor tendon sheath of the digits. They can occur anywhere from the transverse creases of the palm to the end creases of the fingers and thumb. They typically are small, firm, and mobile. Many patients report that it feels almost as if there is a BB in the hand. They can be painful, or at least bothersome, when patients grip and grasp objects such as a steering wheel or briefcase.
The second most common fracture (broken bone) around the wrist is the scaphoid bone, also known as the navicular. This may be a difficult fracture to diagnosis and treat. If the wrist hurts following a fall and the x-rays are normal, a cast is applied with follow-up films at 2-3 weeks to see if a fracture is truly present. If suspicion is high, an MRI scan can make the diagnosis even sooner.
The shoulder is functionally a “ball and socket” joint. The socket is called the glenoid and the ball is the top part of the arm bone called the humerus. Like other joints in the body, the shoulder is susceptible to arthritis. As arthritis progresses, the normal smooth cartilage on the ends of the bones is worn down and the joint begins to degenerate. This causes inflammation and the formation of bone spurs. Patients with shoulder arthritis experience a gradual increase in pain, decreased range of motion, and progressive loss of function. Patients also report crackling noises in the worn joint.
The shoulder is functionally a “ball and socket” joint. The socket is called the glenoid and the ball is the top part of the arm bone called the humerus. Like other joints in the body, the shoulder is susceptible to arthritis. As arthritis progresses, the normal smooth cartilage on the ends of the bones is worn down and the joint begins to degenerate. This causes inflammation and the formation of bone spurs. Patients with shoulder arthritis experience a gradual increase in pain, decreased range of motion, and progressive loss of function. Patients also report and crackling noises in the worn joint.
Like other joints in the body, shoulder arthritis can result from trauma such as fractures which is known as post-traumatic arthritis. Other patients may develop shoulder arthritis because of normal wear and tear on the joint. This form of arthritis is called osteoarthritis and may be more common in people with a positive family history. Lastly, some patients are predisposed to inflammatory conditions, such as rheumatoid arthritis, that can lead to arthritis throughout the body including the shoulder.
Any cut deep enough to injure the finger can very likely cause the underlying tendon to also be cut. If the laceration is on the back of the hand, then the extensor tendon which allows the finger to straighten is at risk, and, conversely, if the injury is on the palm of the hand, then the flexor tendon controlling the ability of the finger to bend may also be cut. Most often, these injuries are first evaluated at an emergency department or at an urgent care facility. Once bleeding is controlled, the physician may be able to directly visualize the cut tendon ends through the wound in some cases, but other times a lack of motion at the finger is the only clue to a tendon laceration. The skin may be loosely closed and the finger splinted, with instructions to be evaluated by a surgeon.
TENNIS ELBOW (LATERAL EPICONDYLITIS) & GOLFER’S ELBOW (MEDIAL EPICONDYLITIS))
Tennis Elbow or “lateral epicondylitis” is one of the most common causes of elbow pain and soreness. The condition is a tendonitis that frequently results from overuse or repetitive activities, although it can also occur after a traumatic injury. There is a group of muscles that originate from the outside of the elbow (lateral) and attach to the top of the wrist. These muscles help stabilize and extend the wrist during normal hand function. Tendons anchor muscles to bones and during certain repetitive motions, these tendons are overly stressed. With time, this can degenerate and weaken the tendons causing tendon inflammation, or tendonitis. This ultimately results in elbow pain. Lateral epicondylitis can be associated with tennis but it is certainly not limited to athletic activity. The pain is frequently experienced during grasping/gripping or lifting things away from the body. It is one of the most common diagnoses seen by orthopaedic surgeons in adult patients.
Golfer’s Elbow or “medial epicondylitis” is also a very common cause of elbow pain. Similar to tennis elbow, medial epicondylitis is a tendonitis but it involves the tendons that are anchored on the inner part of the elbow (medial). These tendons attach to muscles that are responsible for flexing the wrist and fingers. During repetitive use, the tendons also can become inflamed which ultimately leads to elbow pain on the inner side of the elbow. Similar to tennis elbow, golfer’s elbow can occur after an array of physical activities and is certainly not limited to athletes.
Trigger finger, officially called "stenosing flexor tenosynovitis", is a form of tendonitis. It results in a catching ("triggering") of the mid-joint of the fingers (or end joint of the thumb) with attempted motion of the affected digit. Swelling of the flexor tendon lining occurs, for various reasons, at the entrance to the tendon sheath (just beyond the transverse palm creases). The difficulty, or even inability, of the flexor tendon to move in and out of the tendon sheath with digital motion results in the sensation of locking, or "triggering". The locking is typically worse in the morning and may lessen as the day progresses. Many patients develop finger swelling as well as pain in the palm at the base of the finger. The mechanical locking of the finger in combination with the pain can make this quite a disabling condition.
Broken bones and cracks seen around the wrist are called wrist fractures. The most common type involve the distal radius (the far end of the forearm). This occurs most frequently during a fall on the hand and produces pain, swelling and in some cases marked deformity. It is seen in all age groups, but most commonly in older patients when the bones are brittle from osteoporosis. Active, healthy children can also get these fractures because of the soft nature of the bones near the growth centers of the wrist. Fractures that go through the skin are called open fractures. These require immediate attention and antibiotics to lessen the chance of an infection. The diagnosis of a fracture is usually made with a simple X-ray. In some cases it may not be seen right away and may be picked up on an MRI. Your physician may in fact order a CT scan to better define the fracture through a 3-D image. This not always necessary and is used more in pre-surgical planning of difficult fractures.