Wrist/Hand

Carpal tunnel syndrome results from pressure on the MEDIAN NERVE at the wrist. People usually note NUMBNESS in the finger tips, NUMBNESS OR ACHING PAIN that awakens then from sleep, a sense of CLUMBSYNESS with use of the hand, or more rarely PAIN in the palmar aspect of the wrist and or forearm. Although there is a common misconception that it is related to computer use, it is most frequently associated with obesity, diabetes, aging and genetic predisposition. It is also frequently seen during pregnancy. Later people note WEAKNESS in the hands as the muscles in the thumb weaken, then atrophy from lack of nerve input.

What is it?

The medical term for the wrist bones is the carpal bones. The carpal bones form three sides of a tunnel that is roofed by the transverse carpal ligament which is a very thick unyielding band of tissue. If the synovium, or lining on the tendons, thickens then the nerve becomes pinched at the carpal tunnel. The reason for the increased symptoms at night is that most people sleep with their wrists bent which causes further pressure on the nerve.

The best test for carpal tunnel syndrome is a EMG/NCV (electromyelogram/nerve conduction study). By testing the way the nerve carries a standardized electrical impulse we can test how well it is functioning. The EMG/NCV can help determine if you have carpal tunnel syndrome or pressure on the nerve elsewhere (neck, shoulder) or some other condition such as diabetic neuropathy.

Treatment options

Treatment often begins with splinting the wrists at night to keep them from being bent during sleep. Anti-inflamatory medications (NSAIDS) can reduce the swelling and help relieve the pressure. Various therapy regimens have been utilized and can be helpful but long term studies are tending to show they do not permanently resolve the problem. Likewise steroid injections have been very popular but long term studies are now suggesting they do not resolve the condition though they often provide temporary benefit. Surgery involves releasing the tight band across the top of the tunnel (the transverse carpal ligament) which usually permanently releases the pressure on the nerve. If the nerve has been compressed for too long release of the band can fail to improve nerve function.

Surgery is performed on an out-patient basis. The procedure takes about 15 minutes. Following surgery the wrist may be splinted for 2 weeks for comfort but the thumb and fingers can be used for light activities.

The bones of the hand consist of the METACARPALS and PHALANGES. Many types of injuries can cause fractures of these bones. Even small amounts of movement between the ends of the broken bones(referred to as displacement) can severely affect hand function. Additionally the tendons that move the joints of the hand lie next to the bones and healing of the fractures can lead to scarring of the tendons and loss of motion.

How are they treated?

Fractures where the bone is not out of position are usually treated by immobilization in a splint or a cast depending on the specific injury. Fractures where the bone fragments (pieces of the bone) have moved out of position usually require surgery and therapy to limit scarring of the tendons and preserve the motion of the fingers.

Ganglion cysts are fluid filled sacks that arise from the tissue (synovium) that lines the joints and tendons. Ganglion cysts are very common in the wrist and can be found at any age. Most often they appear for no known reason in the wrist area and are not felt to be related to “overuse”.

Ganglion cysts can also form in the joints of the fingers but are most often related to arthritic changes when seen at this location.

Ganglion cysts are also frequently found on the lining of the flexor tendons and present as tender bumps on the palm of the hand.

Ganglion cysts do not cause cancer, arthritis or any other more serious condition. They frequently cause pain when pressure is applied to the area of the cyst. It is important to obtain an Xray to be certain that the cyst is not arising because of underlying arthritis as this changes the treatment options.

What is it?

Ganglion cysts are an abnormal sack or cyst lined by the tissue (synovium) which creates the fluid that lubricates the joints and tendons. The fluid contains protein and over time the protein accumulates in the sack resulting in a thick fluid that resembles clear jelly.

Treatment options

Treatment choices include doing nothing unless the cyst is resulting in discomfort. Aspiration sucking out the fluid with a syringe) and injection of steroid medication can cause the cyst to resolve but this is rarely a successful treatment and most ganclion cyst rapidly reform following this treatment. Surgical removal of ganglion cysts usually results in permanent resolution.

There are three main ligaments of the wrist. These are the SCAPHO-LUNATE LIGAMENT, the LUNO-TRIQUETRAL LIGAMENT and the TRIANGULAR FIBROCARTILAGE (TFCC).

The scapho-lunate ligament is a key ligament on the radial side of the wrist (thumb side). Injury of this ligament is usually the result of a fall onto the outstretched hand and causes RADIAL WRIST PAIN. Often the pain of the initial injury resolves and it seems the injury has healed. Unfortunately the ligament has not healed and the wrist bones begin to shift out of place leading to early onset of arthritis. By the time the wrist pain returns the arthritis is advanced and treatment options may be limited.

The luno-triquetral ligament is on the ulnar side (pinky finger side) of the wrist and causes ULNAR WRIST PAIN. Injury of this ligament can also cause the wrist bones to shift out of position but rarely causes arthritic changes.

The triangular fibrocartilage is a combination of ligament and cartilage on the ulnar side of the wrist. It can be torn in an acute injury such as a fall or worn out by repetitive activity. Injuries of the Triangular fibrocatilage are the most common cause of ULNAR WRIST PAIN.

What is it?

The diagram below shows the location of these three ligaments.

Treatment 

If there is pain or tenderness at the base of the thumb after a fall a fracture of the scaphoid should be suspected.  If initial x-rays do not show a fracture a MRI can be obtained or a cast may be applied for 2 weeks and then the wrist re-examined.  If the pain has resolved completely then a fracture is very unlikely.  If pain persists then casting for 8 weeks or an MRI need to be considered.

Non-displaced fractures of the scaphoid (with certain exceptions) will heal with casting about 95% of the time.  If the fracture is displaced, then surgery is required.  Some surgeons advocate surgery for all scaphoid fractures to shorten the time in a cast and reduce the chance of the fracture not healing.  Even with surgery the scaphoid may fail to heal and require additional procedures.

Tendons are the tissue that connect the muscle to the bone.  As the muscle contracts it pulls on the tendon which then pulls on the bone moving the joints.  Because of the frequency of lacerations involving the hand and the superficial location of the tendons of the hand, these specialized structures are often injured.  Injuries can involve the FLEXOR TENDONS (the tendons on the palm side that bend the fingers) or to the EXTENSOR TENDONS (the tendons on the back of the hand that straighten the fingers).  Sometimes the tendons may RUPTURE (break) without a laceration.  The most frequent of these injuries is at the last joint of the finger and is called a MALLET FINGER.

How are they treated?

Lacerations of the tendons require surgical repair followed by a very specific program of splinting and therapy to allow the tendon to heal but minimize the scar tissue formation.  Scar tissue always forms around a tendon and can limit its motion and hence the motion of the joint that it moves.  The therapy program maximizes the recovered motion.

Mallet finger injuries can most often be treated with a splinting program without surgery.

TRIGGER FINGER is a common cause of FINGER PAIN.   Many times the affected finger(s) also catch or click with motion.  Symptoms are often worst in the morning and may begin as morning STIFFNESS.  Trigger finger is very commonly associated with DIABETES but is also very common in non-diabetics.  While most common in older adults it can present in CHILDREN.  Treatment options include splinting, anti-inflamatories, cortisone injections or surgery.

What is it?

Trigger finger is caused initially by thickening of the first pulley holding the tendon in place.  (see diagram).  This then causes secondary inflammation and swelling of the tendon.  It is this thickening that causes the characteristic snapping of the finger as it moves back and forth.  Trigger finger is often associated with diabetes but is also associated with aging, obesity, forceful repetitive activity as well as other factors.

Treatment choices.

Options for treatment include splinting and oral anti-inflammatory medications (NSAIDS) although these are often ineffective.  Injections of steroid medications (such as depo-medrol) into the tendon sheath are curative about 60% of the time and generally produce 3 to 6 months of symptom relief in the other 40% of patients.   Surgical release of the pulley is highly effective and is usually performed as a local anesthetic procedure.  Many patients recover very quickly but some have residual pain, swelling and/or stiffness for several months.  Trigger digit does not generally resolve without treatment.