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About Orthopaedic Surgery

Hand and Wrist

Anatomy | Carpal Tunnel Syndrome
Arthritis of the Base of the Thumb | Wrist Ganglions
De Quervain's Disease | Depuytren's Contracture | Trigger Finger

Anatomy
Wrist --- nine small carpal bones connected by ligaments, which move against the distal radius.

Hand --- multiple tubular bones which are moved by flexor and extensor tendons and innervated by the median, ulnar, and radial nerves. top

Carpal Tunnel Syndrome
Compression of the median nerve as it passes through the wrist, or carpal tunnel syndrome, can be the cause of numbness, pain, and/or weakness in the hand. Pain is often most problematic at night. The numbness is usually brought on or increased by hand use, such as driving, talking on the telephone, writing and keyboard use. It is usually in the thumb, index, long and ring fingers, which is the sensory area of the median nerve, but may be in only one or two of these, and may even be interpreted by the patient as being in the whole hand. Often, there is a problem dropping things, particularly small objects, due to inability to feel things in the hand well. If atrophy, or shrinkage, of muscles in the hand is present, weakness can result.

The carpal tunnel is the area of the wrist which is made up of the wrist bones on the sides and floor of the tunnel and the transverse carpal ligament, which connects the wrist bones on either side, on the ceiling, as viewed with the palm up. The median nerve goes through this tunnel as it enters the hand from the wrist, accompanied by the tendons which flex the fingers and thumb. Compression of the nerve is usually caused by a decrease in the available space for the nerve. This most often is due to swelling of the linings of the tendons, but other causes include fractures of the wrist bones, thickening of the transverse carpal ligament, especially in older patients, arthritis of the wrist joint, and generalized swelling from pregnancy or hypothyroidism. Rarely, tumors of the nerve can cause decrease in its function.

While carpal tunnel syndrome can be found in patients from all walks of life and may occur for no apparent reason, there does seem to be an increased incidence in people who use their hands in occupations or other activities which require repetitive gripping and motion of the fingers and wrist. Although certain occupations are clearly more likely to be associated with carpal tunnel syndrome, it is rarely possible to state with certainty that a particular patient has it because of his or her occupation.

Pregnancy can cause carpal tunnel syndrome due to the swelling that occurs, but the numbness usually resolves after delivery.

Diagnosis is made by considering the patient's symptoms, the physical examination, and, often, electrical diagnostic tests. Decreased sensation in one or more fingers innervated by the median nerve is often found. If atrophy of the muscles controlling the thumb is seen, the patient frequently will be unable to touch his thumb effectively to his fingers. Flexion of the wrist or pressure over the nerve usually causes numbness in at least part of the median nerve innervated fingers, and there may be tingling in the same area by tapping over the nerve at the wrist. The nerve conduction tests usually, but not always, show slowing of the speed of the nerve impulses (decreased conduction velocity) and prolongation of the time the nerve takes to function (increased distal motor or sensory latency).

Initially, treatment consists of splinting the wrist to prevent excessive motion during the day and to prevent problematic wrist positions at night, and decrease in the stresses on the wrist and hand by improving the workplace or home environment. For keyboard users, using a wrist support and positioning the height of the keyboard so that the wrist is not held in flexion or extension; optimally, with the arms at the side, the forearms should be parallel to the floor.

Injections of steroids into the carpal tunnel can be helpful for at least a short time in patients who have not have their symptoms very long and who are not elderly. A favorable response to the injection helps make the diagnosis and is associated with improved results from surgery, if and when it is needed. Vitamin B-6 has been shown to be helpful in some patients. Anti-inflammatory medications are not very effective.

In patients whose symptoms do not improve sufficiently with the above measures, and in those whose nerve function is significantly affected by the compression, surgical release of the transverse carpal ligament (Carpal Tunnel Release) may be required. The traditional method is to cut through the skin of the palm over the carpal tunnel and, then, through the ligament, thereby allowing the ligament to expand and to heal as a longer ligament. There have been techniques developed which use either an arthroscopic approach or specially designed instruments which minimize the size of the incision in the skin, thereby speeding recovery of strong, painless grip. There is a minimal increase in the risk of deep nerve, vessel, or tendon injury associated with some of these techniques. The physicians at Northern Rockies Orthopaedic Specialists use either open or arthroscopic techniques, depending on the patient's needs and desires.

Following surgery, the hand will have varying degrees of swelling and soreness, particularly over the sides of the carpal tunnel where the ends of the cut ligament now resides. The pain of the nerve compression usually subsides rapidly, but the numbness, though usually rapidly improved, may take several weeks to resolve, even longer in older patients. There is a small chance of recurrence of symptoms after a few years. There is a higher chance of failure after carpal tunnel release in patients who have a job related carpal tunnel syndrome, especially if they return to the job that incited the problem. top

Arthritis of the Base of the Thumb (Trapezio-metacarpal Arthritis)
Pain at the base of the thumb can be caused by arthritis of the joint between the thumb metacarpal and the trapezium bone on which it moves. If the joint becomes roughened and the joint cartilage narrowed, resulting in inflammation there, the patient will notice pain with pinch and grasp. This arthritis occurs more often in females in the fifth decade or older, and usually is caused by osteoarthritis, but may be due to rheumatoid arthritis or injury to the joint. Degenerative arthritis will often be painful for a variable period of time, only to lead ultimately to decreased pain but progressive deformity of the thumb. The deformity results from the thumb metacarpal becoming drawn into the palm and the joint between the metacarpal and the first phalanx extending to compensate for the limited thumb motion. This leads to permanent stretching of the ligaments which prevent excessive extension of this joint, resulting in a zigzag deformity of the thumb.

Treatment of arthritis of the thumb basilar joint may require only anti-inflammatory medication. If this is not successful, the joint may be injected with synthetic cortisone, splinted, or surgically replaced or fused.

Fusion of the trapezio-metacarpal joint is done by removing the joint surfaces from both bones and allowing the bones to heal together, much as a fracture heals. It results in diminished, but functional, motion in the thumb.

Replacement of the joint can preserve motion provide good pain relief. This is most often done by removal of the trapezium and its replacement by a rolled up piece of tendon taken from the wrist, and using the remaining tendon to reconstruct the joint ligaments, which have been stretched out. Following either fusion or arthroplasty, the hand is immobilized for six to eight weeks until stability is accomplished. top

Wrist Ganglions
A ganglion is a cyst which is filled with the lubricating fluid which normally is found inside joints or the linings of tendons. They most frequently are found in the wrist, particularly the top of the wrist. These wrist ganglions usually originate from the ligaments between two wrist bones, the scaphoid and the lunate, for unknown reasons. They often cause no symptoms, other than the bump under the skin which can be quite noticeable. Some, however, may be painful. They frequently will vary in size from time to time, and, in children, may spontaneously resolve.

If the symptoms or size cause problems for a patient, and if conservative measures, such as splinting or aspiration (rarely helpful) don't cure the ganglion, it may be surgically excised. The surgery requires the complete removal of the ganglion, along with its "stalk," which arises from the wrist ligaments. Although this can be done arthroscopically, the small scar from an open excision of the ganglion is not objectionable, and open excision is usually done. Recurrence is uncommon. top

De Quervain's Disease
Inflammation of the tendons which make the thumb straighten out, or extend, into the hitchhiking position causes pain at the wrist just short of the base of the thumb. These tendons pass through a tunnel made up a shallow depression in the radius (forearm bone) just above the base of the thumb, and are contained in this depression by a ligament, which can become thickened, tender, and painful with wrist motion. The cause is not known, but repetitive use of the hand and wrist can be contributory. The diagnosis is made by the characteristic tenderness over the tendon compartment, with pain worsened by bending the wrist to the little finger side while grasping the thumb with the fingers (Finklestein's Test). If splinting and injections are not successful in decreasing symptoms, surgical release of the constricting tendon compartment may be needed, with care taken to avoid injury to the sensory branch of the radial nerve, which courses over the compartment. top

Dupuytren's Contracture
Thickening of the tissue under the skin of the palm and the fingers, particularly the ring and little fingers, can result in the formation of small bumps or cords called Dupuytren's Disease. If the cords shorten, they will draw the affected fingers into a bent posture which cannot be overcome, and the disease is then called Dupuytren's Contracture. This disease is limited to people of northern European descent, more frequently seen in men, and in those past the age of sixty. If it occurs in younger people, the disease is more aggressive and more prone to recur after surgical excision. There is a slightly higher incidence of Dupuytren's Contracture in alcoholics, people with epilepsy, and in people with the disease in other family members.

There is no conservative care known to be effective for the contracture. Cortisone injections into the nodules and cords are occasionally effective. The definitive treatment is surgical removal of the thickened tissue, a procedure known as subtotal palmar fasciectomy. This procedure involves elevation of the skin from the diseased cords in the palm and finger, carefully separating the nerves, blood vessels, and tendons from them, and removing the diseased tissue.

Following surgery, the hand is placed in a dressing with a splint to hold the fingers straight. Return of motion can be slow. There is a tendency for the fingers to again be drawn down into flexion by the scar tissue, so the hand is often splinted in the post operative period. In patients with aggressive disease, the cords may recur, requiring repeat surgical removal of the cords, or even skin grafting following removal of the affected skin.

In order for the result to be optimal, surgery is best performed after contracture of the fingers develops, but before the middle joint of the fingers develop fixed contractures. top

Trigger Finger
Inflammation of the tendons which flex the fingers or thumb can lead to painful catching or locking of the finger as the thickened ligament in the distal palm traps the tendon as it tries to pass beneath it. The cause of trigger finger is unknown, but it is known that diabetics have a very high incidence of it, often in multiple fingers.

Treatment initially consists of injections into the tendon sheath, especially in patients who are not diabetic. In those who fail this treatment, and in patients whose fingers lock in flexion or extension, surgical release of the ligament trapping the tendon is performed, usually under local anesthesia, so that it can be demonstrated that the problem is corrected. top

NOTE: The information on this site is informational only and is not intended to be medical advice. NO ANSWERS TO MEDICAL QUESTIONS WILL BE GIVEN BY E-MAIL OR OTHER CORRESPONDENCE. Contact your physician for advice about specific medical conditions.

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