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A number of different disorders may affect the hands, including ganglia, deformities, disorders related to nerves or blood vessels, injuries, and infections. Some other including fractures, osteoarthritis, tendinitis and tenosynovitis, de Quervain's syndrome.

 

 

 

 

 

 

 

 

 

 

Dupuytren's Contracture   (Palmar Fibromatosis)

 

Dupuytren's contracture (palmar fibromatosis) is a progressive tightening of the bands of fibrous tissue (called fascia) inside the palms, causing a curling in of the fingers that eventually can result in a claw like hand.

 

  • Dupuytren's contracture develops in people who are genetically predisposed.

  • Treatment involves injection of a corticosteroid into a tender nodule or, if the hand is already scarred, surgery to correct contracted (clawed) fingers.

 

 

 

 

 

 

 

 

 

 

Dupuytren's contracture is a common hereditary disorder that occurs particularly in men, especially after age 45. However, having the abnormal gene does not guarantee that someone will have the disorder. About 5% of people in the United States have Dupuytren's contracture. The disorder affects both hands in 50% of people. When only one hand is affected, the right hand is involved twice as often as the left.

 

 

 

 

 

 

 

 

 

 

 

 

Dupuytren's contracture is more common among people with diabetes, alcoholism, or epilepsy. The disorder is occasionally associated with other disorders, including thickening of fibrous tissue above the knuckles (Garrod's pads), shrinking of fascia inside the penis that leads to deviated and painful erections (penile fibromatosis [Peyronie's disease), and nodules on the soles of the feet (plantar fibromatosis). However, the precise mechanism that causes the fascia of the palm to thicken and curl in is unknown.

 

The first symptom is usually a tender nodule in the palm (most often at the third or fourth finger). The nodule may initially cause discomfort but gradually becomes painless. Gradually, the fingers begin to curl. Eventually, the curling worsens, and the hand can become arched (claw like). The doctor makes the diagnosis by examining the hand.

Surgery is usually needed when the hand cannot be placed flat on a table or when the fingers curl so much that hand function is limited. Surgery to remove the diseased fascia is difficult, because the fascia surrounds nerves, blood vessels, and tendons.

 

Dupuytren's contracture may recur after surgery if removal of the fascia is incomplete. The disorder also may recur spontaneously, especially in people who have developed the disorder at a young age; those who have family members affected by the disorder; and those who have Garrod's pads, Peyronie's disease, or nodules on the soles of the feet.

 

I know also provide a Xiapex Injection service for early Dupuytrens

Trigger Finger

 

In trigger finger (flexor digital tenosynovitis), a finger becomes locked in a bent position. The finger locks when one of the tendons that flex the finger becomes inflamed and swollen. Normally, the tendon moves smoothly in and out of its surrounding sheath as the finger straightens and bends. In trigger finger, the inflamed tendon can move out of the sheath as the finger bends. However, when the tendon is very swollen, it cannot easily move back in as the finger straightens, and therefore the finger locks.

 

 

 

 

 

 

 

 

 

Trigger finger can result from repetitive use of the hands (as may occur from using heavy gardening shears) or from inflammation (as occurs in rheumatoid arthritis). To straighten the finger, a person must force the swollen area into the sheath causing a popping sensation similar to that felt when pulling a trigger. Splinting, moist heat, and non steroidal anti-inflammatory drugs (NSAIDs) can help in mild cases. Sometimes a corticosteroid and a local anesthetic are injected into the tendon sheath. Surgery is commonly needed to treat chronic trigger finger. 

Carpal Tunnel Syndrome

 

Carpal tunnel syndrome is a painful compression of the median nerve as it passes through the wrist

  • The side of the hand near the thumb can tingle and become numb.

  • Symptoms can usually be relieved by use of a splint or injection of a corticosteroid.

    Carpal tunnel syndrome results from compression of the median

Carpal tunnel syndrome results from compression of the median nerve, which is located at the palm side of the wrist (an area called the carpal tunnel). The median nerve serves the thumb side of the hand. The compression results when swelling or bands of fibrous tissue form for a variety of reasons on the palm side of the wrist.

 

Carpal tunnel syndrome is common especially among women aged 30 to 50 years—and may affect one or both hands. At slightly increased risk are people whose work requires repeated forceful movements with the wrist extended, such as using a screwdriver. Another potential factor is use of a computer keyboard that is not positioned properly. Prolonged exposure to vibrations (for example, by using certain tools) has also been claimed to cause carpal tunnel syndrome. Pregnant women and people who have diabetes, an under active thyroid gland, gout, or rheumatoid arthritis are at increased risk of developing carpal tunnel syndrome. However, most cases develop for unknown reasons.

 

The symptoms, due to the nerve compression, are odd sensations, numbness, tingling, and pain in the first three fingers on the thumb side of the hand. Occasionally, there is also pain and a burning or tingling sensation in the arm. The pain may be more severe while the person is sleeping because of the way the hand is positioned. With time, the muscles in the hand on the thumb side can weaken and shrink through lack of use (atrophy).

 

 

 

 

 

 

 

 

 

 

The diagnosis is made largely by examining the affected hand and wrist. I may first perform nerve conduction studies to be certain that the problem is carpal tunnel syndrome, particularly if surgery is considered.

 

Avoiding positions that overextend the wrist or put extra pressure on the median nerve, including such measures as adjusting the angle of a computer keyboard, sometimes provide some relief. Wearing wrist splints that hold the hand in a neutral position (especially at night) and taking mild analgesics often help. Treating underlying disorders (such as rheumatoid arthritis or an under active thyroid gland) can help to relieve symptoms.

Injections of a corticosteroid suspension into the carpal tunnel occasionally bring long-lasting relief. If pain is severe or if the muscle atrophies or weakens, surgery is the best way to relieve pressure on the median nerve. A surgeon can cut away the bands of fibrous tissue that place pressure on the nerve. 

Gamekeeper's thumb

It is a rupture of the ligament on the palm side of the thumb, which is responsible for pinching movements. It usually results from a fall that jams the thumb backward onto a hard surface. This injury is so named because it used to be an occupational hazard of gamekeepers in England who broke the necks of rabbits with their hands. Treatment usually consists of a splint, but surgery is sometimes necessary.

 

Rupture of the scapholunate ligament

It may result from falling on an outstretched hand. Pain is felt mostly on top of the wrist. Treatment consists of surgical repair of the ligament and pinning of the bones.

 

 

 

 

 

 

 

 

 

 

 

Scaphoid fractures  

What causes a scaphoid fracture?

A scaphoid fracture is almost always caused by a fall on the outstretched hand. We commonly try to break a fall by putting our hands out for protection. Landing on an outstretched hand makes hand and wrist injuries, including a fracture of the scaphoid bone, fairly common.

When a scaphoid fracture is recognized on the first X-ray, treatment begins immediately. But patients often assume that the injury is just a sprain, and they wait for it to heal on its own. In some cases, the wrist gets better. In many cases the bone fails to heal. The scaphoid fracture then develops into what surgeons call a nonunion.

A nonunion can occur in two ways. In a simple nonunion, the two pieces of bone fail to heal together. The second type of nonunion is much more serious. The lower half of the fractured bone loses its blood supply and actually dies. This condition is calledavascular necrosis (Avascular means no blood supply, and necrosis means dead.)

The scaphoid bone is at risk for avascular necrosis. Only one small artery enters the bone, at the end that is closest to the thumb. If the fracture tears the artery, the blood supply is lost. Avascular necrosis becomes easy to see on X-rays several months after the injury.

 

 

 

 

 

 

 

 

 

 

 

 

How will I know if I have a scaphoid fracture?

The symptoms of a fresh fracture of the scaphoid bone usually include pain in the wrist and tenderness in the area just below the thumb. You may also see swelling around the wrist. The swelling occurs because blood from the fractured bone fills the wrist joint. Thin people will see a bulging of the joint capsule. The joint capsule is the watertight sac that encloses the joint.

Symptoms of a nonunion of the scaphoid bone are more subtle. You may have pain when you use your wrist. However, the pain may be very minimal. It is fairly common for doctors to see a nonunion of the scaphoid bone on X-rays, but the patient can't remember an injury. These people probably suffered a wrist injury years ago that they thought was a simple sprain. Still, the most common symptom of a nonunion is a gradual increase in pain. Over several years the nonunion can lead to degenerative arthritis in the wrist joint.

 

Treatment.

If the fracture is identified immediately and is in good alignment, you will probably wear a cast for nine to 12 weeks. The cast will cover your forearm, wrist, and thumb. This is necessary to hold the scaphoid bone very still while it heals. Your doctor will take X-rays at least once a month to check the progress of the healing. Once your doctor is sure the fracture has healed, the cast will be removed. Even with this type of treatment, there is still a risk that the fracture may not heal well and will become a nonunion.

 

Nonunion

Some surgeons report good results doing surgery right away when a patient has had a recent, non displaced scaphoid fracture. Studies have shown that this method can help people get back to activity faster than wearing a cast for up to 12 weeks. The procedure involves inserting a screw through the scaphoid. The screw holds the scaphoid firmly until it heals. It will also require a bone graft.

 

After Surgery

Depending on the type of surgery you have, you may be placed in a splint for up to 12 weeks after surgery. Your surgeon will X-ray the wrist several times after surgery to make sure that the bones are healing properly. Once the two halves of the scaphoid bone have healed, you can safely begin a rehabilitation program.

You may need physical or occupational therapy sessions for six to eight weeks after surgery. The first few treatments will focus on controlling the pain and swelling. You will work into doing exercises to help strengthen and stabilize the muscles around the wrist joint. Other exercises are used to improve fine motor control and dexterity of your hand. You'll be given tips on ways to do your activities while avoiding extra strain on the wrist joint.


 

DeQuervains Disease (First Dorsal Extensor compartment tenosynovitis)

 

Who does it affect? 
Usually adults, slightly more common in females

 

Why does it occur? 
The tendons on the back of the wrist travel through separate tunnels at the wrist joint level. These tunnels are to ensure that the tendons do not bowstring when the wrist is cocked back. The space inside the tunnel is limited and lubricated. If inflammation occurs in the tunnel then the tendons become irritated and cause pain and swelling inside the tunnel. DeQuervain's disease is inflammation of the tendons in the first compartment. This compartment is on the back of the wrist on the thumb side.

 

Symptoms 
Localised pain and swelling on the back of the wrist on the thumb side. This may be accompanied with a palpable and sometimes audible "creaking" sensation.

 

Clinical Examination 
Bending the thumb over into a flexed position reproduces the pain. This test can be positive in other conditions. This test is often called the Finklestein's test. In this short video you will see that I bend the thumb forwards trying to reproduce the DeQuervain's symptoms. Also during the examination, you will see that I compress the thumb along its length to see if there is any co-existing base of thumb arthritis.

 

Investigations 
Usually none, however an ultrasound scan can visualise the inflammation.

 

Non-operative treatment 
A steroid injection into the sheath may lubricate and also damp down the inflammation. Steroid injections can be repeated only once. Further attempts may damage the skin and dissolve fat and therefore surgery would be advised after one or two failed injections.

 

Operative treatment 
The surgery is a day case procedure usually under local anaesthetic and takes about 10 minutes. A tourniquet is used; which is like a blood pressure cuff around the upper arm that prevents blood from obscuring the surgeons view. It is quite tight, but well tolerated for up to 20 minutes.

The surgery is performed through a 2cm transverse skin crease incision

Local anaesthetic is infiltrated under the skin in line with the incision at the thumb side of the wrist. Once numb the skin is incised and then the underlying fat is retracted. Care is taken not to injure sensitive nerves and blood vessels. At the base of the wound is the extensor compartment sheath. This structure needs to be released to allow the tendon and its nodule to glide in and out without catching. Occasionally multiple small sub compartments need to be released. The skin is sutured and a bulky dressing is applied.

 

Post-operative rehabilitation 
The patient is fit to go home soon after the operation. The anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. Gently bend and straighten the fingers from day 1. My preference is to remove the dressing at 2 days. The wound is cleaned and redressed with a simple dressing. Avoid forced gripping or lifting heavy objects for 2-3 weeks. The sutures are removed at about 10 days. You should notice an improvement in symptoms within a few days but the final result may be realised at about 3 months.

 

Return to activities of daily living
It is my advice to keep the wound dry until the stitches are out at 10 days.

 

Return to driving:

The hand needs to have full control of the steering wheel and left hand the gear stick. It is probable advisable to delay returning to driving for at least 7 days or even once the sutures are removed.

 

Return to work:

Everyone has different work environments.

Returning to heavy manual labour should be prevented for approximately 4 - 6 weeks. Early return to heavy work may cause the tendons and nerve to scar into the released ligament. Please ask your surgeon for advice on this.

 

Complications
Overall greater than 95% are happy with the result. However complications can occur.

There are complications specific to DeQuervain's disease and also general complications associated with hand surgery.

 

General complications:

Infection (Less than 1%),

Neuroma (Less than 1% , a coiled painful nerve bundle),

Numbness,

Reflex Sympathetic Dystrophy - RSD (2% bad reaction to surgery with painful stiff hands- this can occur with any hand surgery from a minor procedure to a complex reconstruction.)

 

Specific complications:

Failure to completely resolve the symptoms (approximately 1% - this may be due to failure to completely release all the tendon sub sheaths. This should be rare but may be released again).

The nerves just under the skin are notoriously sensitive, if damaged a painful neuroma can develop. Extra care is taken with these nerves to keep this risk to a minimum.

  

Mallet Finger
  

Who does it affect?
Anyone

 

Why does it occur?
When a finger is forcibly stubbed the end finger joint (distal interphalangeal joint) bends forwards quite suddenly. This causes the tendon on the back of the finger that straightens the end joint to pull off the bone. Usually it pulls off without a piece of bone but sometimes it can pull of a fragment.

Symptoms
Sudden inability to fully straighten the end finger joint and the joint is held in a bent position.

 

Clinical Examination
Your doctor will ask you to try and straighten your end finger joint. You will not be able to do this, no matter how hard you try.

 

 

 

 

 

 

 

 

Investigations
An x-ray is required to see whether the tendon has pulled off a piece of bone. This will dictate treatment.

 

Non-operative treatment
The vast majority of mallet finger injuries do not need an operation. If an x-ray reveals the tendon has pulled off a large fragment of bone with it we recommend surgery. If the x-ray is all clear and show the tendon has just pulled away without a fragment of bone a non operative approach will yield satisfactory results in most patients. A splint is applied to the front of the finger (pulp side) to straighten the joint. It is worn for 6-8 weeks constantly. It can be removed for washing, but it is vital the finger is held straight at the end finger joint by a helper; otherwise the healing tendon will become undone. The splints can be off the shelf stack splints, but often my patients prefer a custom made splint by my hand therapist

 

Operative treatment
When the x-ray reveals a large bone fragment has pulled off with the tendon an operation may be required.

The surgery is a day case procedure usually under local anaesthetic and takes about 10 minutes. The surgery can be performed using fine wires that hold the bone fragments back in place. The wires can be inserted percutaneously through small1mm stab incisions. The wires are left in place for 4 to 6 weeks and are removed in the clinic with little discomfort.

 

Complications
Overall greater than 95% are happy with the result. However complications can occur. If a splint is worn the skin may become irritated. This requires regular washing but care to keep the fingerstraight whilst doing this. This may be a recurrence of the dropped finger or what is called a swan neck deformity. This deformity is the mallet appearance of the end finger joint combined with a bending backwards of the middle knuckle joint the proximal interphalangeal joint (PIPJ). On side profile it has the appearance of a swan's neck. There are surgical options to improve both these complications

 

Wrist Fusion
 

A wrist fusion can be a very effective operation for controlling pain in an arthritic wrist. Arthritis can arise as a consequence of a number of conditions, including trauma, generalised wear and tear arthritis, inflammatory arthritis, such as those caused by rheumatoid arthritis or psoriasis.

Arthritis is a disease process whose end product is destruction of the articular cartilage of the joints. The articular cartilage is the slippery substance found at the end of bones. These allow the two bones in a joint to move with each other without any friction. In arthritis the cartilage is destroyed and the bone is exposed, and rubs against the opposite exposed bone surfaces, causing significant pain.

 

Why does it occur?
Arthritis can occur in a wrist as a consequence of a fracture that may have gone into the joint and healed with a step, causing localised wear and tear. Arthritis can occur as a generalised wear and tear process, with increasing age. Arthritis can occur as a consequence of inflammatory joint disease such as rheumatoid arthritis or psoriatic arthritis.

 

Symptoms
Patients often complain of pain and a decreased range of movement in the wrist. Painful actions include lifting and bending the wrist. These can be quite painful. Restricted range of movements can affect patients, with inability to perform common day-to-day tasks.

 

Clinical examination
Generally speaking the arthritic wrist is swollen and has a restricted range of movement.

 

Investigations
Plain x-rays often confirm the diagnosis, but further imaging such as a CT scan or MRI scan may visualise the joint space more carefully.

 

Non-operative treatment
Options could include splintage, to keep the wrist still, or x-ray guided cortico-steroid injections.

 

 

 

 

 

 

 

 

 

 

 

 

Operative treatment for wrist arthritis
There are two main types of fixation for wrist fusions. The first is a contoured plate that is held across the back of the wrist joint, with screws into the bone to secure fixation. The surgeon will carefully remove the remaining articular cartilage from the wrist joint to allow the bone to completely solidify underneath the plate. The second type of fixation is a pin that is passed across the wrist joint (usually down through the middle knuckle joint). This second type of fixation is often performed for patients with rheumatoid arthritis.

 

 

Limited fusion is carried out in SNAC and SLAC wrist

How I do Limited Fusion

IP fusion in arthritis and joint replacement carried out in Rheumatoid Patients

I use the Lavander Medical system I have had great success with these procedures.

Post-operative rehabilitation
If a plate fixation is used and the fixation is solid often no post-operative immobilisation is required, and patients are advised to move their fingers as soon as possible. Swelling is common after such a surgery and it is advisable to highly elevate the hand for the first few weeks after surgery. If a pin fixation has been used then often this is supplemented with plaster of Paris for four to six weeks until the underlying bones have solidly united.

 

Return to activities of daily living
These, generally speaking, can be well tolerated with a plate fixation within the first two to three weeks. Heavy loading activities should be avoided until the bone has completely solidified.

 

Complications
The main risk is that of non-union, whereby the bone ends fail to completely grow over. This will cause the metalwork eventually to fail and the procedure may need to be repeated. Other risks include infection (less than 1%), damaging blood vessels/nerves (less than 1%), and tendon injury (less than 1%). As with all hand surgery a regional pain syndrome can occur, and this is reported to be in the region of 2% to 5% following this type of surgery.

 

 

 

 

 

 

 

 

 

 

 

Wrist Ganglions


Other common names 
Dorsal wrist ganglion ( back of the wrist)

Volar wrist ganglion ( front of the wrist)

 

Who does it affect? 
Anyone

 

Why does it occur? 
It is a fluid filled sac, that occurs on the back of the wrist (dorsal) or volar (front). The fluid is clear and quite thick. They are thought to be related to changes in the lining of the joint, but not related to arthritis. Occasionally they communicate with the joint and / or a ligament in the joint.

 

Symptoms 
A painless lump that comes and goes in size. The outline is quite smooth and may feel tense like a small ball or balloon (cystic).

 

Clinical Examination 
A ganglion has quite typical features both in its location and appearance. With the lights turned down and a pen torch is shone through the lump, it transilluminates.

 

 

 

Investigations 
Usually none. In unusual situations an ultrasound scan will be helpful.

 

Non-operative treatment 
Ganglions can be aspirated under local anaesthetic. A needle is then introduced into the lump and the fluid sucked away. I then perform multiple wall perforations to help prevent their reoccurrence. A small pressure bandage is applied for a few days afterwards. Here is a short video clip of a ganglion being aspirated (drained). You will see Mike Hayton infiltrating local anaesthetic under the skin, prior to the aspiration. At the end of the video you will see him squeeze the fluid out onto the back of his glove..

 

Operative treatment 
If the lump has reappeared 6 weeks after aspiration I usually recommend surgery. The surgery is a day case procedure usually under local anaesthetic and takes about 20 minutes. A tourniquet is used; which is like a blood pressure cuff around the upper arm that prevents blood from obscuring the surgeons view. It is quite tight, but well tolerated for up to 20 minutes.

Local anaesthetic is infiltrated under the skin in line with the incision over the lump. Once numb the skin is incised and then the underlying fat is retracted. Care is taken not to injure nerves and blood vessels. At the base of the wound is the ganglion wall. The ganglion is dissected taking care not to puncture it. The base of the ganglion is identified and excised. The photograph below shows a typical ganglion and also the clear jelly like fluid it contains after I have punctured it. The skin is sutured and a bulky dressing is applied.

 

Post-operative rehabilitation 
The patient is fit to go home soon after the operation. The anaesthetic will wear off after approximately 6 hours. Simple analgesia usually controls the pain and should be started before the anaesthetic has worn off. The hand should be elevated as much as possible for the first 5 days to prevent the hand and fingers swelling. Gently bend and straighten the fingers from day 1. My preference is to remove the dressing at 2 days. The wound is cleaned and redressed with a simple dressing. The sutures are removed at about 10 days.

 

Return to activities of daily living
It is my advice to keep the wound dry until the stitches are out at 10 days.

 

Return to driving:

The hand needs to have full control of the steering wheel and left hand the gear stick. It is probably advisable to delay returning to driving for at least 7 days or even when the stitches are removed.

 

Return to work:

Everyone has different work environments. Return to heavy manual labour should be prevented for approximately 4 - 6 weeks. Early return to heavy work may cause tendons ands nerves to scar into the released ligament. Please ask your surgeon for advice on this.

 

Complications
Overall, greater than 95% are happy with the result. However complications can occur.

There are complications specific to Wrist Ganglion surgery and also general complications associated with hand surgery.

 

General complications:

Infection (Less than 1%),

Neuroma (Less than 1%, a coiled painful nerve bundle),

Numbness,

Reflex Sympathetic Dystrophy - RSD (2% bad reaction to surgery with painful stiff hands - this can occur with any hand surgery from a minor procedure to a complex reconstruction.)

 

Specific complications:

Recurrence: This is reported between 10 and 40%. We are not sure whether it is the same ganglion recurring or simply another one forming nearby.