Hand Surgical Procedures

Carpal Tunnel Syndrome (CTS)

Introduction

Carpal Tunnel Syndrome is a common condition that affects the hand and wrist. It occurs when the Median Nerve in the wrist is compressed. Nerves carry messages between our brains, spinal cord, and body parts. The Median Nerve carries signals for sensation and muscle movement. When the Median Nerve is compressed or entrapped, it cannot function properly. This syndrome has received much attention in the last few years because of suggestions that it may be linked with jobs that require repeated use of the hands. In actual fact, little proof of this exists.

Carpal Tunnel Syndrome is more common in women and people between the ages of 30 and 60 years old. It is the most common nerve entrapment syndrome and affects up to 10% of the population. Individuals with Carpal Tunnel Syndrome may feel numbness, pain, and a “tingly” sensation in their fingers, wrists, and arms. They may have difficulty performing grasping and gripping activities because of discomfort or weakness.

Anatomy

The Median Nerve passes from the arm, through the wrist, and into our fingers. At the center of the wrist joint, the Median nerve goes through a passageway called the Carpal Tunnel. Our wrist bones form the bottom of the Carpal Tunnel. The Transverse Carpal Ligament covers the top. Ligaments are strong bands of tissues that connect bones together. In addition to the Median Nerve, the Carpal Tunnel also contains many tendons. These tendons attach to the muscles that allow our fingers to bend or flex.

The Median Nerve supplies the sense of feeling to our thumb, index finger, middle finger, and half of the ring finger. It also sends messages to the Thenar Muscles that move the thumb. We use the Thenar Muscles when we position our thumb to grasp and hold objects. When compressed in the Carpal Tunnel, the Median Nerve sends faulty messages as it travels into the hand and fingers.

Causes

Carpal Tunnel Syndrome develops when the tissues and tendons in the Carpal Tunnel swell and make the area within the tunnel smaller. This can happen in association with other medical conditions, such as hypothyroidism and diabetes. The increased pressure within the tunnel causes the Median Nerve to become compressed. The pressure disrupts the way the nerve works and causes the symptoms of Carpal Tunnel Syndrome. Usually, the exact cause of carpal tunnel syndrome is unknown.

Rheumatoid arthritis, joint dislocation, and fractures can cause the space in the tunnel to narrow. Some women develop Carpal Tunnel Syndrome because of swelling from fluid retention caused by hormonal changes. This may occur during pregnancy, premenstrual syndrome, or menopause.

Symptoms

The primary symptoms of Carpal Tunnel Syndrome are pain, numbness, and tingling. The numbness and tingling is typically present in the thumb, index, middle, and half of the ring finger. Some people describe the pain as a deep ache or burning. Your pain may radiate into your arms. Your thumb may feel weak and clumsy. You may have difficulty grasping items, and you may drop things. Your symptoms may be more pronounced at night, when you perform certain activities, or in cold temperatures.

Diagnosis

Your doctor can diagnose Carpal Tunnel Syndrome by conducting a medical examination, reviewing your medical history, and asking you about your activities and symptoms. During the physical exam, your doctor will check your wrist and hand for sensation and perform a thorough hand examination.

Your doctor may ask you to perform a couple of simple tests to determine if there is pressure on the Median Nerve. For the Phalen’s Test, you will firmly flex your wrist for 60 seconds. The test is positive if you feel numbness, tingling, or weakness. To test for the Tinel’s Sign, your doctor will tap on the Median Nerve at the wrist. The test is positive if you feel tingling or numbness in the distribution of the median nerve. Lab tests may be ordered if your doctor suspects a medical condition that is associated with Carpal Tunnel Syndrome. Your doctor may take an X-ray to identify arthritis or fractures. 

In some cases, physicians use nerve conduction studies to measure how well the Median Nerve works and to help specify the site of compression. Physicians commonly use a test called a Nerve Conduction Velocity (NCV) test. During the study, a nerve is stimulated in one place and the amount of time it takes for the message or impulse to travel to a second place is measured. Your doctor will place sticky patches with electrodes on your skin that covers the Median Nerve. The NCV may feel uncomfortable, but only during the time that the test is conducted.

An Electromyography (EMG) test is often done at the same time as the NCV test. An EMG measures the impulses in the muscles to identify poor nerve input. Healthy muscles need impulses to perform movements. Your doctor will place fine needles through your skin and into the muscles that the Median Nerve controls. Your doctor will be able to determine the amount of impulses conducted when you contract your muscles. The EMG may be uncomfortable, and your muscles may remain a bit sore following the test.

Treatment

The symptoms of Carpal Tunnel Syndrome can often be relieved without surgery. Some medical conditions associated with Carpal Tunnel Syndrome can be treated. Some cases respond to treatments that relieve pain and provide rest. Your doctor may recommend that you wear a splint at night to support your wrist in a neutral position.

 Splints may also be worn during activities that aggravate your symptoms to position the wrist properly and provide wrist support. Your doctor may suggest over-the-counter anti-inflammatory medication to help reduce your pain and swelling. Sometimes doctors choose to inject corticosteroid medication, an anti-inflammatory medication, to provide symptom relief.  

Surgery

Surgery is recommended when non-surgical options do not work or if the condition becomes worse. There are a few types of outpatient surgery to remove pressure on the Median Nerve. Your doctor will help you decide which option is best for you.

 The standard surgery for Carpal Tunnel Syndrome is called an Open Release. The surgeon will use a local or regional anesthetic to numb the hand area. For this procedure, the surgeon makes a two to three inch opening along the palm. This allows the surgeon access to the Transverse Carpal Ligament, the roof of the Carpal Tunnel. The surgeon makes an incision in the Transverse Carpal Ligament to open the tunnel and make it larger. By doing so, pressure is taken off of the median nerve. The surgery time for an Open Release is short, only about fifteen minutes

Recovery

Following surgery, your incision will be wrapped in a soft dressing. Your physician may recommend that you wear a splint to provide support and promote healing. You will be able to move your fingers immediately after surgery. You will need to avoid heavy grasping or pinching motions for about six weeks. Your doctor may recommend that you participate in occupational or physical therapy to gain strength, joint stability, and coordination. It may take several months for strength in the wrist and hand to return to normal.

 Recovery from Carpal Tunnel Surgery is individualized and depends on the extent of the condition and the type of surgery performed. Your doctor will tell you what to expect.

Prevention

There are several things that you can do that may help prevent the symptoms of Carpal Tunnel Syndrome. A general physical examination could identify medical conditions that are associated with Carpal Tunnel Syndrome. An early diagnosis may allow for optimal treatment.

Dupuytren’s Disease

Introduction

Dupuytren’s disease causes an abnormal thickening of the tissues located underneath the skin in the palm of the hand. As the tissue thickens it can form lumps and strong cords. The abnormal growth causes the fingers to bend in towards the palm of the hand.  Severe symptoms can cause contractures and loss of hand function. Dupuytren’s disease generally progresses slowly, but progression is unpredictable.

Anatomy

The palm of your hand contains ligaments and tendons.  Ligaments are strong bands of tissues that connect your bones together.  Tendons attach muscles to bone.  The tendons in the palm of your hand flex or bend your fingers inward.  Your ligaments and tendons are covered and kept in place by the palmar fascia, a thin sheet of connective tissue.  The palmar fascia is located just beneath your skin.

Causes

The cause of Dupuytren’s disease is unknown.  It may be associated with abnormal biochemical processes in the palmar fascia.  It is more common in people of Northern European descent.  It occurs more frequently in men than in women.  Dupuytren’s disease is rare among young people and more common in people over 40 years old.  If it occurs in young people, the condition tends to be very severe and quickly progressing.

Smoking and drinking alcohol increase the risk of Dupuytren’s disease.  Certain medical conditions are associated with an increased risk of Dupuytren’s disease.  Such conditions include diabetes, thyroid problems, epilepsy, pulmonary tuberculosis, and liver disease.

Symptoms

The onset of Dupuytren’s disease is very slow.  Both hands may be affected but usually one hand is more affected than the other.  You may notice a small tender lump in the palm of your hand.  The tenderness will go away as Dupuytren’s disease typically is not painful.  Over time, tough cords may form beneath your skin.  The thickened tissue may cause your fingers to bend inward toward your palm.  Your ring finger and little finger are affected most often.  You may have difficulty straightening your fingers. 

The progression of Dupuytren’s disease is unpredictable.  For some, the condition may consist of a lump or thickening of the tissue.  Other people may experience severe symptoms, including contractures and loss of hand function.

Diagnosis

Your doctor can diagnose Dupuytren’s disease by examining your hand.  You should tell your doctor about any symptoms and if they restrict the use of your hand.  Your doctor will look at and feel the skin on the palm of your hand for thickened tissue or nodules.  Your doctor will observe your finger positioning and test the movement of your finger joints.  You may be asked to perform the Table Top Test, in which you will attempt to place your open hand on a surface and flatten your palm and fingers out as far as you can.  This will be difficult in the presence of finger contractures.

Treatment

There is no way to stop the progression of Dupuytren’s disease.  Your doctor will monitor the progress of your disease.  Injections may help relieve the pain in a lump that has formed early in the disease process.  Surgery is recommended if the fingers become flexed enough to interfere with the functional use of your hand.

Injectable enzymes to dissolve the diseased tissue were FDA approved in 2010. The product is called Xiaflex. Studies and ongoing use of the enzyme have shown success in treating finger contractures caused by Dupuytrens Disease.

Surgery

The goal of surgery is to increase the movement of your fingers and restore their correct positions to improve hand functioning.  There are several different options for this.  Your surgeon may simply divide the thickened bands in a procedure called fasciotomy.  Your surgeon may remove the sheet of diseased palmar fascia in a procedure called fasciectomy.  In some cases, a skin graft may be necessary.

Recovery

Following surgery, you will participate in rehabilitation with a hand therapist who will instruct you in strengthening and stretching exercises.  You may receive therapy treatments to reduce swelling and ease pain.  Your hand therapist will provide you with a splint to position your hand and promote healing.

Surgery is not always a permanent solution for Dupuytren’s Disease.  The condition tends to gradually recur over time.

Complex Regional Pain Syndrome (CRPS) – Reflex Sympathetic Dystrophy (RSD)

Introduction

Complex regional pain syndrome (CRPS) is a type of chronic pain syndrome.  CRPS was formerly called reflex sympathetic dystrophy (RSD) and shoulder-hand syndrome.  CRPS causes severe burning pain and possible eventual deterioration of an affected arm or leg.  The cause of CRPS is unknown, but it can develop following an injury, stroke, or heart attack.  Prompt treatment is associated with the best outcomes.  If untreated, CPRS can cause irreversible extremity deterioration.

Anatomy

The sympathetic nervous system is a part of the complex system that regulates involuntary bodily functions.  These are bodily functions that run automatically and are necessary for life.  Your sympathetic nervous system speeds up your heart rate, constricts your blood vessels, sends blood to your vital organs, raises your blood pressure, raises your blood sugar level, and increases sweating.  It energizes your body for immediate action in response to an emergency or “flight or fight” situation.

Causes

The exact cause of CRPS is unknown.  Researchers suspect that changes in the sympathetic nervous system lead to poor regulation of blood flow, sensation, and temperature.  This contributes to problems involving the skin, nerves, blood vessels, bones, and muscles.  Another theory is that it may be related to an immune response.  CRPS can develop after an injury or infection in the arm or leg.  It can occur after heart attacks, cancer, nerve compression, and strokes. 

Symptoms

The symptoms of CRPS vary from person to person.  Severe burning pain, joint stiffness, and swelling are hallmark symptoms of CRPS.  It can affect an arm or leg.  Three stages characterize CRPS.  Not all people progress through all three of the stages.  Some people may stay in the first stage indefinitely, and others may skip a stage.

Stage I occurs at the onset of CRPS and can last about three months.  You may feel burning pain, stiffness, increased sweating, and warmth in your affected limb.  Your nails and hair may grow faster than usual.  Your skin may become dry, thin, and change color.

Stage II CRPS lasts from three to twelve months.  You may experience an increase in swelling.  Your skin may become cooler and more sensitive to touch.  Your pain may become more widespread.  Your joints and muscles may become stiffer.

Stage III occurs from one year on.  Changes in Stage III may be irreversible and permanent.  The pain may spread to your entire limb.  Your joints may be very stiff and very difficult to move.  You may experience muscle wasting and contractures.

Diagnosis

Early diagnosis of CRPS is important for the best treatment results.  Your doctor can diagnose CRPS by reviewing your medical history and conducting a physical examination.  You should tell your doctor about your symptoms and their progression.  Your doctor will examine your limb for skin changes, swelling, changes in blood flow, and loss of mobility.  Your doctor may order tests such as X-rays, bone scans, or nerve studies.  There is no test, however, that can diagnose specifically CRPS.

Treatment

To ensure the best outcome, it is important to start treatment as soon as possible.  Treatment for CRPS includes medications, rehabilitation therapy, injections and surgery.  There is no true cure for CRPS, but treatments in the early stages can prevent the disease from progressing, and cause them to regress.  Treatment goals during the advanced stages are aimed at symptom relief and improving function. 

Your doctor can prescribe medications to help ease your symptoms.  A combination of medications may be used including pain relievers, antidepressants, blood pressure medications, and steroids.  Injected pain relieving medications, spinal cord stimulation, and implanted medication delivery pumps may provide pain relief for longer periods of time.  Hand therapy can help ease your symptoms and regain function in your limb.

Surgery

Surgery is rarely indicated for CRPS.  For those cases in which the syndrome is caused by nerve injury or compression, surgery to resolve the problem can help relieve symptoms.

Recovery

CRPS that is treated in the early stages has the best outlook.  If treated early, CRPS can go into an inactive state and function is optimized.  If CRPS is not diagnosed and treated promptly, irreversible changes can occur in the involved extremity.

Prevention

There is no known prevention for CRPS.  Prompt treatment may prevent the progression of symptoms.

Congenital Hand Differences

Introduction

Congenital hand differences are abnormalities present at birth.  They occur before birth when an embryo is developing the upper extremity.  Congenital hand differences are caused by genetic, environmental, and unknown reasons.  A variety of hand conditions may occur. 

A hand surgeon and hand therapist should evaluate all babies born with a hand difference.  Some conditions do not need treatment.  For others, treatment during the first few years of life allows children to best adapt to their hands.  Treatments may include splinting, hand therapy, or surgery. 

Anatomy

Your upper limb (arm) develops before you are born.  An embryo develops an arm bud at four weeks.  The tip of the arm bud sends genetic signals to cells to direct limb formation.  The upper limb is formed when an embryo is between four to eight weeks old in the womb.  The arm develops first at the shoulder and progresses to the fingers.  The development of a limb is a complex process involving millions of steps guided by genetics, your inherited blueprint for growth.

Your upper extremity is composed of many bones that provide structure for your wrist and fingers.  The bones are connected with strong ligament tissues.  Tendons are strong fibers that attach your muscles to your bones and allow movement.  Your hand also contains nerves, blood vessels, and fat.  The skin that covers your hand protects it from the environment.

Causes

Congenital hand differences are abnormalities present at birth.  Congenital hand differences occur when an embryo is developing the upper limb.  Some conditions may develop due to genetic problems and passed from generation to generation.  Other congenital hand differences develop because of environmental factors or for no known reason.

Symptoms

There are several different types of congenital hand differences.  Variances can range from major to minor.  Some congenital hand differences are associated with other medical or genetic problems.  Congenital hand differences are categorized by type including failure of formation, failure of separation, duplication, undergrowth or overgrowth, and constriction band syndrome.

Failure of formation describes upper arms, forearms, wrists, hands, or fingers that do not form completely or at all.  Failure of separation includes finger webbing.  Finger webbing can involve only the skin or can include the finger bones, extra bones, or fingernails.  The two bones that make up the forearm, the ulna and radius can also be joined together.

Duplication is another type of congenital hand difference.  It most commonly involves an extra thumb or little finger, although duplication of any portion of the hand can occur.  Overgrowth or undergrowth causes a section of the hand or arm to be too large or too small.  This can affect joint structure and function.  Constriction band syndrome causes tight bands of tissue to form around the arm, forearm, wrist or fingers.  The constrictions can range from mild to severe.  Severe constrictions can result in the loss of a portion of the hand.

Diagnosis

A hand specialist should evaluate all babies born with a hand difference.  The doctor can diagnose a congenital hand difference by reviewing your child’s medical history and conducting an examination.  X-rays will identify the location and position of affected bones.  If necessary, your doctor may refer you to a geneticist or specialist for diagnosis and treatment of associated medical conditions.

Treatment

Treatment for congenital hand differences depends on the type and extent of the condition.  Some people may not require any treatment.  Splinting and hand therapy may be used to improve hand structure and function.  Hand therapists can recommend assistive devices to make everyday activities such as handwriting, grooming tasks, and feeding easier.

Surgery

Surgery can help severe hand differences.  Surgeons are able to separate webbed fingers and remove extra fingers.  The hand and fingers can be surgically reconstructed to improve function and appearance.  There are many methods that may be used and your hand surgeon will discuss the most appropriate options for your child with you.  As this type of surgery is specialized even within the realm of hand surgery, you may be referred to a hand specialist with expertise in congenital hand differences.

Recovery

Recovery from hand surgery may include splinting and hand therapy.  Surgery performed in the first few years of life provides children with the greatest opportunity to adapt to their reconstructed hand.  Hand therapy and possibly additional hand surgery may be necessary as a child grows and develops.

Prevention

There is no way to prevent congenital hand differences that occur during pregnancy.  It is important for babies with the condition to receive prompt diagnosis from a hand specialist and receive early treatment, if necessary.

Cubital Tunnel Syndrome – Ulnar Nerve Transposition (Elbow)

Introduction

Cubital Tunnel Syndrome is a condition caused by pressure on the ulnar nerve at the elbow.  Nerves carry messages between the brain, spinal cord, and body parts.  When a nerve is compressed, it cannot function properly.  Cubital Tunnel Syndrome is the second most common nerve entrapment syndrome, after Carpal Tunnel Syndrome.

The Ulnar Nerve carries signals for sensation in one half of our ring finger and our small finger and to our muscles that perform fine hand movements.  Individuals with Cubital Tunnel Syndrome have difficulty handling objects and performing gripping motions.  Individuals may feel pain, numbness, and a “tingly” sensation, similar to when the “funny bone” is hit.  When the” funny bone ” is hit, the odd feeling is actually caused by the Ulnar Nerve. 

Anatomy

The Ulnar Nerve runs from the side of our neck, down our arm, and to our fingers.  The elbow is the most common site for Ulnar Nerve compression. At the elbow joint, the Ulnar Nerve passes through a passageway, formed by muscle, ligament, and bone, called the Cubital Tunnel at the inside part of the elbow. If the Ulnar Nerve is compressed at the Cubital Tunnel, it will send faulty messages as it travels down the forearm into the hand and fingers The Ulnar Nerve supplies the sense of feeling to the outer half of our ring finger and our little finger. The Ulnar Nerve also sends messages to some of the muscles that move our hands and fingers. These muscles are called the Interossei and the Adductor Pollicis. The Interossei muscles in the hand work to move our fingers together and apart. When the fingers and thumb spread open, the Adductor Pollicis moves the thumb back towards the hand. These hand and finger movements are especially important for manipulating and holding objects.

Causes

Cubital Tunnel Syndrome can result from Ulnar Nerve compression. Its cause is unknown but several factors appear to contribute to it. Its most common cause appears to be from repeated elbow movements. The Flexor Carpi Ulnaris muscle can press on the Ulnar Nerve as it runs through the Cubital Tunnel. The Ulnar Nerve can also become irritated from pressure on the elbow. This can occur when the elbow is leaned on or pressed on for long periods of time. Elbow fractures, trauma, bone spurs, swelling, or cysts are additional factors that can cause Ulnar Nerve compression and lead to Cubital Tunnel Syndrome.

Symptoms

Cubital Tunnel Syndrome frequently causes numbness and tingling in the ring finger and little finger.  Your symptoms may come and go.  They may happen more often when your elbow is bent, such as at night when sleeping in one position.  You may experience poor finger coordination and a weak grip.  This may interfere with activities such as holding objects in your hand, using a keyboard, or playing an instrument.  If the Ulnar Nerve compression is not treated it can cause muscle deterioration and lead to permanent impairment.  You should always contact your physician if the symptoms of Ulnar Nerve compression last more than a few weeks and interfere with normal activity.

Diagnosis

You doctor will perform an examination and review your medical and activity history to make a diagnosis of Cubital Tunnel Syndrome.  Your physician will attempt to find where the Ulnar Nerve is compressed and will examine your forearm, elbow, hand strength and movement.  Your doctor may tap on your Ulnar Nerve in the cubital tunnel to see if it reacts and will test for sensation.  The examination may cause a bit of discomfort as the physician is looking for the cause of the symptoms.

Your doctor may use imaging tests to identify structural factors, such as bone spurs or arthritis, which may contribute to nerve compression.  These tests can include X-rays, Computed Tomography (CT scans), or Magnetic Resonance Imaging (MRI).  An X-ray uses a camera to take a picture of the elbow area to show the bone’s condition.  CT scans take pictures in layers, so it produces images in the form of slices that make up the elbow, like the slices that make up a loaf of bread.  MRI scans provide a very detailed view of the elbow complex.  Like the other imaging tests, the MRI equipment focuses on the area to be examined and takes pictures.  All of these imaging tests are painless and require that you remain very still.

In some cases, the physician may use nerve conduction studies to measure how well the Ulnar Nerve works and to help specify the site of compression.  Electromyography (EMG) is usually performed with nerve conduction studies.  This test examines the nerve’s input into the muscles.  The test may feel uncomfortable, but only during the actual test then resolves quickly.

Treatment

Most cases of Cubital Tunnel Syndrome respond to non-surgical treatments.  Treatment typically includes activity restriction, rest, and pain relief.  You should avoid repetitive elbow movements and avoid leaning or putting pressure on the elbow.  In other words, you should refrain from the movements and postures that cause discomfort.  You should take frequent breaks to rest when performing such movements.  Elbow splints may be worn to keep your arm straight, especially while sleeping.  Anti-inflammatory medications may provide pain relief.

Some physicians prescribe occupational or physical therapy.  The occupational or physical therapists focus on gentle exercises to help the Ulnar Nerve slide through the Cubital Tunnel.  The exercises may help keep the forearm and wrist muscles healthy while preventing joints from becoming stiff.

Surgery

Your doctor may recommend surgery for you if you do not receive relief from non-surgical treatments.  Surgery can remove pressure from the Ulnar Nerve and prevent further damage. Your surgeon may also recommend surgery if you have muscle wasting. 

The surgery may be done as an outpatient procedure or may require an overnight stay at the hospital.  You may be sedated for surgery or remain alert with a regional anesthesia that blocks the feeling in your arm.

The surgeon has various options for relieving the pressure on the Ulnar Nerve.  In one procedure, the “roof” is removed from the Cubital Tunnel.  This method is called simple decompression.  The most common surgical procedure is called an Anterior Transposition of the Ulnar Nerve.  In this procedure, the surgeon makes an incision at the elbow and moves the Ulnar Nerve from behind the elbow to a new place in front of the elbow.  If the Ulnar Nerve is relocated under the skin and fat but on top of the muscle, the procedure is called a Subcutaneous Transposition of the Ulnar Nerve.  When the Ulnar Nerve is placed under the muscle it is called a Submuscular Transposition of the Ulnar Nerve. 

The surgeon considers many factors when selecting which method to use and will discuss the appropriateness of each with you.

Following surgery, a splint is typically worn on the elbow for a few weeks.  Individuals who receive a Submuscular Transposition of the Ulnar Nerve may need to wear a splint for a longer time, from three to six weeks.  Occupational or physical therapy is recommended to regain strength and motion in the arm.

Recovery

If you require surgery for Cubital Tunnel Syndrome it may take several months to recover, but generally you can achieve good results.  Individuals with muscle or nerve damage may take a longer time to recover.  Nerves take a long time to heal.  Nerves regenerate at about one millimeter a day. For individuals with severe nerve or muscle damage, complete healing may not be possible, and they may have some symptoms even after surgery.

Ganglion Cysts – Wrist/Hand Lumps and Bumps

Introduction

Ganglion Cysts are a common condition.  They are not harmful or cancerous, although they may cause some people discomfort.  Ganglion Cysts usually appear as bumps on the back of the hand and at either side of the wrist.  They are also called “Bible Cysts” because in the past, treatment included hitting them with a Bible or a large book.  Today, of course that practice is no longer accepted.  Instead, individuals with Ganglion Cysts have several professional treatment options from which to choose. 

Anatomy

Our wrist complex contains many joints.  The joints are composed of several bones in the hand and two bones in the forearm.  The wrist joints function to position our hands and fingers for movement.

The bones in our hands are covered with smooth cartilage connected with ligaments.  Ligaments are firm tissues that provide support and enable us to position our hands for finger movements.  The ligaments are lined with a Synovial Membrane.  The Synovial Membrane secretes a thick liquid called Synovial Fluid.  The Synovial Fluid acts as a cushion and lubricant between the joints, allowing us to perform smooth and painless motions. 

Ganglion Cysts arise from the fluid filled areas on the ligaments or between the bones.  The cyst is a round sac-like structure filled with Synovial Fluid.  The fluid is harmless and not cancerous.  The fluid can become thick over time, making the cyst feel firm and spongy.  It is common for cysts to grow larger, but they will not spread to other parts of your body. 

Ganglion Cysts occur most frequently on the back of the hand and wrist.  These cysts, called “Dorsal Wrist Ganglions,” are the most common type of cyst.  Ganglion Cysts occasionally develop on the palm side of the wrist near the thumb and on the fingertips, just below the cuticle.  Ganglion Cysts can appear on the lower extremities as well.  They may form on the outside of the knee or ankle and on the top of the foot.

Causes

Overall, Ganglion Cysts occur more often in women.  The cause of Ganglion Cysts is unknown.  One theory suggests that trauma or stress at the wrist joints may cause degeneration and the formation of cysts.  This may occur in individuals who participate in activities that are strenuous to the hand, such as gymnastics or meat cutting.  According to this theory, prior wrist injuries that are re-injured may be susceptible to Ganglion Cyst development.

The second, most likely theory is that the Ganglion Cysts form because of structural flaws in the joint tissues.  The cyst may develop when Synovial Fluid collects between the joints.  As the fluid builds up, it may create a bulge where the tissues weaken.

Symptoms

Ganglion Cysts can be so small that they are not noticeable underneath the skin.  They can also become large, over one inch in diameter.  It is very common for the cysts to increase in size.  They may also come and go or disappear forever.  The unattractive appearance of these cysts is what often leads patients to seek treatment for them.

Some cysts are painless, but the majority causes some degree of discomfort.  The pain is usually continuous and may become worse with activity.  You may experience a tingling sensation, considerable pain, or numbness if the cyst is pressing on a nerve.

Diagnosis

You should have your physician evaluate a suspected Ganglion Cyst but it is not a medical emergency.  Your doctor can diagnose a Ganglion Cyst by performing an examination and talking to you about your symptoms.  Your doctor will feel your cysts and ask you about their degree of tenderness.

Sometimes doctors use needle aspiration to confirm the diagnosis of a Ganglion Cyst.  This simple procedure involves numbing the area and then using a syringe and needle to draw fluid from the cyst.  The fluid is examined to confirm the diagnosis and rule out any other condition.

In some cases, physicians use imaging tests, such as ultrasound or Magnetic Resonance Imaging (MRI) scans, to determine more information about the cyst.  An ultrasound uses sound waves to create an image when a device is gently placed on your skin.  A MRI scan provides a very detailed view of the cyst and surrounding structures.  The MRI scan requires that you remain very still while the pictures are taken.  Both tests are painless.  The tests are helpful to determine if a cyst is fluid-filled or solid.  The images can also identify if an artery or blood vessel is causing the bump.

Treatment

Some Ganglion Cysts require no treatment and disappear on their own.  Your doctor may recommend that you wear a wrist splint.  This can help relieve pain caused by activity and promote healing. 

Physicians may also use needle aspiration to treat Ganglion Cysts.  Your doctor will numb your wrist area for the procedure and remove the fluid from the cyst using a needle and syringe.  The site is injected with an anti-inflammatory steroid medication to reduce swelling.  Your wrist will be splinted following the procedure to promote healing.  Not long after the procedure, your doctor will prescribe exercises to mobilize the joints.  Needle Aspiration is a fairly successful treatment, although some individuals may need to have it repeated a few times.

Surgery

Outpatient surgery is recommended if the Ganglion Cyst is painful, causes numbness or tingling, and interferes with functional movement.  In some cases patients want the cysts removed because of their unattractive appearance. 

Your surgeon will numb the area before removing the cyst.  Following the surgery, you will wear a splint on your wrist for a few days.  Your doctor may recommend occupational or physical therapy to mobilize and strengthen the joints.

Recovery

Recovery from surgery differs from individual to individual, depending on the size of the cyst and the extent of the surgery.  Recovery typically takes from about two to six weeks.  In a few cases the cysts may return.  However, the majority of people experience successful results with surgery.

Flexor Tendon Injuries (Hand)

Introduction

A flexor tendon injury occurs when the tendon is cut or ruptures.  The flexor tendons attached at the palm side of your fingers and thumbs.  They allow your finger and thumb joints to bend, grasp items, and perform fine coordinated movements.  The muscles that control these tendons are in the forearm.  Lacerations, other trauma, and rheumatoid arthritis are the primary causes of flexor tendon injuries.

Flexor tendon injuries can cause loss of movement, pain, and swelling.  Flexor tendon injuries require surgical repair.  Splinting and hand therapy rehabilitation usually follow surgical treatment.

Anatomy

Your hand is composed of many bones that provide structure for your wrist and fingers.  Your fingers and thumbs are made up of bones called phalanges.  The bones are connected with strong ligament tissues.  Tendons are strong fibers that attach your muscles to your bones and allow movement.  Your hand also contains nerves, blood vessels, and fat.

Your flexor tendons begin in your forearm and continue to the palm side of your fingers and thumb.  Each finger has two flexor tendons and your thumb has one.  They are located just underneath the skin.  Sheaths thickened in areas by fibrous pulleys guide the flexor tendons and keep them close to your phalanges during motion.  The flexor tendons allow your fingers and thumbs to bend, grasp items, and perform fine coordinated movements.  The nerves in your fingers (digital nerves) travel parallel and along both sides of the flexor tendons.

Causes

Deep cuts are the main cause of flexor tendon injuries.  They may also occur during sports, such as football, wrestling, rugby, and rock climbing.  Rheumatoid arthritis can cause flexor tendons to rupture.  The outward injury often appears simple, but is usually complex when involving the tendons and possibly the nerves.

Symptoms

A flexor tendon injury can cause your finger joints to feel painful and swollen.  It may be difficult or impossible for you to move your finger.  You may not be able to bend your finger joints.  Nerves are located very close to the flexor tendon.  If the nerves are injured, your finger may feel numb.

Diagnosis

Your doctor can diagnose a flexor tendon injury by reviewing your medical history and examining your wrist, hand and fingers.  You should tell your doctor if you sustained an injury.  Your doctor will carefully move your finger joints.  Your doctor will test the sensation and blood flow to your fingers.  X-rays can identify bone injuries. 

Treatment

Flexor tendon injuries do not heal well without surgical repair.  When a flexor tendon separates, the two pieces pull away from each other, making it impossible for the tendon to heal without surgery.

Surgery

There are many ways to surgically repair flexor tendons.  Certain types of injuries need specific types of surgery.  Your hand surgeon will stitch the ends of the tendon together and repair damaged nerves, blood vessels, or bones.  A splint will immobilize your hand to allow the flexor tendon to heal after surgery.

Recovery

Hand therapy rehabilitation and continued splinting follow flexor tendon repair surgery.  Hand therapy will help you regain strength, flexibility, motion, and functional use of your hand.  Recovery from flexor tendon surgery is very individualized and rarely is full normal motion regained.  Therapy protocols vary and will depend on the nature of your injury and repair.  Splint protection is generally required for six weeks. Healing continues for three months after repair.  Your doctor will let you know what to expect.

Extensor Tendon Injuries (Hand)

Introduction

An extensor tendon injury occurs when the tendon is torn, cut or otherwise detached.  The extensor tendons attach to the back of your fingers and thumbs.  They allow your fingers and thumbs to straighten and perform fine coordinated movements.  Extensor tendon injuries can result from trauma, burns, or arthritis.

Extensor tendon injuries cause loss of movement, pain, and swelling.  Some extensor tendon injuries are treated with splinting and hand therapy.  Surgery may be necessary in cases of tendon separation, fracture, or malalignment.

Anatomy

Your hand is composed of many bones that provide structure for your wrist and fingers.  Your fingers and thumbs are made up of bones called phalanges.  The bones are connected with strong ligament tissues.  Tendons are strong fibers that attach your muscles to your bones and allow movement.  Your hand also contains nerves, blood vessels, and fat.  The skin that covers your hand protects it from the environment.

Your extensor tendons begin in your forearm and continue to the back side of your fingers and thumb.  As the extensor tendons reach your fingers, they become flat and thin.  They are located just underneath the skin.  The extensor tendons are attached to your phalanges via a complex system.  The extensor tendons allow your fingers and thumbs to straighten and perform fine coordinated movements.  

Causes

Arthritis, burns, and injuries, such as cuts or jammed fingers, can cause extensor tendon injury.  Boutonniere deformities and mallet finger injuries are specific types of extensor tendon injuries.  An extensor tendon may be partially or completely cut.  It can remain intact but pull a piece of bone away from where it attaches on the phalanx.  This is called an avulsion fracture.

Symptoms

An extensor tendon injury can cause your finger or hand to feel painful and swollen.  It may be difficult or impossible for you to extend your finger. 

Diagnosis

Your doctor can diagnose an extensor tendon injury by reviewing your medical history and examining your hand.  X-rays can identify an avulsion fracture or joint malalignment.

Treatment

Many factors affect the seriousness of an extensor tendon injury such as associated fractures, infection, the degree of tendon separation, and if the tendon was cut or torn.  Treatment is individualized and your doctor will discuss your options with you.  Nonsurgical treatments for extensor tendon injuries include splinting and hand therapy.

Splinting positions your finger to allow the extensor tendon to heal.  It is important not to remove the finger splint at anytime, even while you shower.  If the finger splint is removed, even for the shortest amount of time, the treatment is disrupted and the process must start all over.  You will wear your splint for several weeks full-time, followed by a part-time splint schedule.  A dynamic splint may be used to allow movement while protecting the healing tendon.

Surgery

Surgery is necessary for many extensor tendon injuries.  The ends of separated extensor tendons can be stitched together.  In rare cases, the extensor tendon may be tightened or repaired with a graft.

Recovery

Splinting and surgical treatments are usually followed by hand therapy.  A hand therapist will show you exercises to stretch and strengthen your joints.  The other joints in your fingers may become stiff and benefit from hand therapy as well.  It can take an extensor tendon injury several months to recover from completely.  Healing is an individualized process.  Your doctor will let you know what to expect.

What is ulnar nerve compression?

The ulnar nerve goes round the back of the inner side of your elbow. It then goes through a tight tunnel between the forearm muscles and the hand. If these tunnels become too tight, it can cause pressure on the nerve, usually resulting in numbness in your ring and little fingers.

Ulnar nerve compression.

What are the benefits of surgery?

The aim is to prevent further damage to the nerve. If you have the operation early enough, the numbness in your hand may get better.

Are there any alternatives to surgery?

If your symptoms are mild and happen mostly at night, a splint to hold your elbow straight while you are in bed often helps.

What does the operation involve?

Various anaesthetic techniques are possible. The operation usually takes 30 to 45 minutes.

Your surgeon will make a cut over the back of the inner side of your elbow. They will cut any tight tissue that is compressing the nerve.

Your surgeon may need to remove a piece of bone, or move the nerve so that it lies in front of your elbow.

How can I prepare myself for the operation?

If you smoke, stopping smoking now may reduce your risk of developing complications and will improve your long-term health.

Try to maintain a healthy weight. You have a higher risk of developing complications if you are overweight.

Regular exercise should help to prepare you for the operation, help you to recover and improve your long-term health. Before you start exercising, ask the healthcare team or your GP for advice.

If you have not had the coronavirus (COVID-19) vaccine, you may be at an increased risk of serious illness related to COVID-19 while you recover. Speak to your doctor or healthcare team if you would like to have the vaccine.

What complications can happen?

General complications of any operation

• bleeding
• unsightly scarring of your skin
• infection of the surgical site (wound)
• allergic reaction to the equipment, materials or medication
• chest infection

Specific complications of this operation

• continued numbness in your ring and little fingers
• return of numbness caused by scar tissue that forms
• numbness in a patch of skin just below the tip of your elbow
• tenderness of the scar
• severe pain, stiffness and loss of use of your arm

Consequences of this procedure

• pain

How soon will I recover?

You should be able to go home the same day.

You may be told to rest your arm in a sling for a few days. It is important to gently exercise your fingers, elbow and shoulder to prevent stiffness.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask the healthcare team or your GP for advice.

Your symptoms may continue to improve for up to 18 months.

Summary

Ulnar nerve compression causes numbness in your ring and little fingers. An ulnar nerve release may improve your symptoms and should prevent permanent nerve damage.

Trigger Finger and Trigger Thumb

Introduction

Trigger Finger and Trigger Thumb, medically termed Stenosing Tenosynovitis, are common hand conditions.  This condition occurs when the tendons in the thumb and fingers do not glide smoothly.  Tendons are strong tissues that connect our muscles to our bones.  Trigger Finger and Trigger Thumb causes the tendons to catch or get stuck when the fingers or thumb bend.  This condition makes it difficult to straighten the fingers and thumb back out. It can also cause pain, discomfort, and swelling.  Trigger Finger can occur in one or more fingers or the thumb at the same time, or it may occur in different fingers with or without thumb involvement at different times.

Anatomy

We have tendons that attach to our thumb and finger bones.  The tendons pass through a tunnel, called a tendon sheath, and connect to the muscles from our forearm.  These muscles allow our fingers and thumb to straighten or extend, such as when our hand is placed flat on a table.

Normally, our tendons glide smoothly through the tendon sheath allowing for smooth and easy movements.  However, tendons can have difficulty fitting through the tendon sheath if they are swollen or develop a nodule, a small round mass.  The tendon sheath may also swell from irritation, creating a smaller opening for the tendons to fit through.  When the tendon gets stuck in the tendon sheath it can cause pain, swelling, and a popping or catching feeling.  Your finger or thumb may become stuck in one position and may be difficult to bend or straighten.

Causes

The cause of Trigger Finger and Trigger Thumb is not always clear.  The condition is more common among women than men.  It occurs most often in individuals between the ages of 40 and 60 years old. Trigger Finger and Trigger Thumb develop more frequently in people with certain medical conditions, such as diabetes, rheumatoid arthritis, autoimmune disease, and gout.  Additionally, some individuals may be born with a nodule on their tendon. In some cases, repetitive gripping, such as holding tools, can cause the tendons to become irritated.

Symptoms

The symptoms of Trigger Finger and Trigger Thumb usually begin with pain and discomfort at the base of the finger or thumb.  You may also feel pain in the palm of your hand. The area may be swollen and you may feel a small lump.

You will have difficulty bending and straightening your fingers or thumb.  It may feel like they catch or get stuck when you try to move them.  The stiffness and catching may be worse when you first wake up in the morning or after periods of inactivity.  Your fingers or thumb may loosen up with movement.  Your pain may increase when your finger or thumb becomes free. In severe cases, the fingers or thumb can become stuck and unable to move.

Diagnosis

Your doctor can diagnose Trigger Finger or Trigger Thumb by examining your hand. Your doctor will ask you about your symptoms and level of pain.  Your doctor will feel for any clicking or popping during movement and note any restricted movement.  A locked finger or thumb typically leads to diagnoses of Trigger Finger or Trigger Thumb.

Treatment

For people with mild symptoms, rest and pain relief may relieve symptoms.  Your doctor may recommend that you wear a splint for support and to promote healing.  Your doctor may suggest over-the-counter pain medication to reduce discomfort and swelling. In some cases, physicians choose to inject an anti-inflammatory cortisone medication into the site.

Surgery

Surgery is recommended when other treatments have failed or if the thumb or finger is stuck in a bent position.  There are a couple of surgical options, and your doctor will help you decide which is best for you.  One surgery is performed on an outpatient basis.  Your surgeon will numb the area and make a small opening on the palm side of your hand.  Your surgeon will make an incision in the tendon sheath.  This will create a larger tunnel for the tendons to fit through and enable them to glide easily.

Another option is a procedure that can take place in your doctor’s office.  In some cases, the tendon sheath can be safely opened with the tip of a needle.  This will also create a larger tunnel for your tendons to move through with ease.

Recovery

Recovery is individualized and dependent on the extent of the condition and the type of surgery performed.  Your doctor will be able to tell you what to expect.  You will be able to move your fingers or thumb immediately following surgery.  You may experience discomfort or swelling for a short period.  A few individuals may require hand therapy to help regain movement, but most people achieve a full recovery in just a few weeks.