In Canada, most of the hand surgery and medical management of hand health problems is performed by plastic surgeons. Hand health problems include most of the problems for which people go to Emergency Departments. This includes infection, animal bites, burns, wounds of any kind, broken bones or any other problems seen daily in any Emergency Department. The more simple hand problems are managed by the Emergency room physicians. The more complex hand problems are generally referred to plastic surgeons.
Most broken bones of the hand heal with casting for a period of 2-4 weeks. However, some fractures will require surgery to better align the broken fragments. This is especially true if the break occurs into a joint where arthritis is more likely to occur if the broken fragments are not properly lined up.
Stenosing tenosynovitis, commonly known as “trigger finger” or “trigger thumb”, involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys.
Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb. When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend.
What causes it?
Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.
Signs & Symptoms
Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb, where they join the palm. This area is often tender to local pressure. A nodule may sometimes be found in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints.
The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. The wearing of a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may also include changing activities to reduce swelling. An injection of steroid into the area around the tendon and pulley is often effective in relieving the trigger finger/thumb.
If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use.
Dupuytren’s disease is an abnormal thickening of the fascia (the tissue just beneath the skin of the palm). It often starts with firm lumps in the palm. In some patients, firm cords will develop beneath the skin, stretching from the palm into the fingers. Gradually, these cords may cause the fingers to bend into the palm. Although the skin may become involved in the process, the deeper structures (such as the tendons) are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).
What causes it?
The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.
Symptoms & Signs
Symptoms of Dupuytren’s disease usually include a small lump or series of lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Gradually a cord may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. In many cases, both hands are affected, although the degree of involvement may vary. The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful.
The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop. As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets. Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.
Treatment & Options
In some cases, only observation is needed for nodules and cords that are not contracted. Patients with more advanced contractures may require surgery in order to improve function. Various surgical techniques are available in order to correct finger position. Your treating surgeon will discuss the method most appropriate for your condition based upon the stage of the disease and the joints involved (see Figure 4). The goal of surgery is to improve finger position and thereby hand function. Despite surgery, the disease process may recur and the fingers may begin to bend into the palm once again. Before surgery, your treating surgeon will discuss realistic goals and results.
Specific surgical considerations:
• The presence of a lump in the palm does not mean that surgery is required or that the disease will progress.
• Correction of finger position is best accomplished with milder contractures and contractures that affect the base of the finger. Complete correction sometimes can not be attained, especially of the middle and end joints in the finger.
• Skin grafts are sometimes required to cover open areas in the fingers if the skin is deficient.
• The nerves that provide feeling to the fingertips are often intertwined with the cords.
• Splinting and hand therapy are often required after surgery in order to maximize and maintain the improvement in finger position and function.
de Quervain’s Tendonitis Syndrome
First dorsal compartment tendonitis, more commonly known as de Quervain’s tendonitis or tenosynovitis after the Swiss surgeon Fritz de Quervain, is a condition brought on by irritation or inflammation of the wrist tendons at the base of the thumb. The inflammation causes the compartment (a tunnel or a sheath) around the tendon to swell and enlarge, making thumb and wrist movement painful. Making a fist, grasping or holding.
What causes it?
The cause of de Quervain’s tendonitis is an irritation of the tendons at the base of the thumb, usually caused by taking up a new, repetitive activity. New mothers are especially prone to this type of tendonitis: caring for an infant often creates awkward hand positioning, and hormonal fluctuations associated with pregnancy and nursing further contribute to its occurrence. A wrist fracture can also predispose a patient to de Quervain’s tendonitis, because of increased stresses across the tendons.
Symptoms & Signs
Pain over the thumb-side of the wrist is the main symptom. The pain may appear either gradually or suddenly, and pain is located at the first dorsal compartment (see Figure 1, 1A) at the wrist. Pain may radiate down the thumb or up the forearm. Hand and thumb motion increases pain, especially with forceful grasping or twisting. Swelling over the base of the thumb may include a fluid-filled cyst in this region. There may be an occasional “catching” or “snapping” when moving the thumb. Because of the pain and swelling, motion such as pinching may be difficult. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger.
Tenderness directly over the tendons on the thumb-side of the wrist is the most common finding. A test is generally performed in which the patient makes a fist with the fingers clasped over the thumb. The wrist is then bent in the direction of the little finger. This maneuver can be quite painful for the person with de Quervain’s tendonitis.
The goal is to relieve the pain caused by the irritation and swelling. Your doctor may recommend resting the thumb and wrist by wearing a splint. Oral anti-inflammatory medication may be recommended. A cortisone-type of steroid may be injected into the tendon compartment as another treatment option. Each of these non-operative treatments help reduce the swelling, which typically relieves pain over time. In some cases, simply stopping the aggravating activities may allow the symptoms to go away on their own.
When symptoms are severe or do not improve, surgery may be recommended. The surgery opens the compartment to make more room for the inflamed tendons, which breaks the vicious cycle where the tight space causes more inflammation. Normal use of the hand can usually be resumed once comfort and strength have returned.
Your hand surgeon will advise the best treatment for your situation.
What are they?
Ganglion cysts are very common lumps within the hand and wrist that occur adjacent to joints or tendons. The most common locations are the top of the wrist, the palm side of the wrist, the base of the finger on the palm side, and the top of the end joint of the finger. The ganglion cyst often resembles a water balloon on a stalk, and is filled with clear fluid or gel. The cause of these cysts is unknown although they may form in the presence of joint or tendon irritation or mechanical changes. They occur in patients of all ages.
These cysts may change in size or even disappear completely, and they may or may not be painful. These cysts are not cancerous and will not spread to other areas.
How are they diagnosed?
The diagnosis is usually based on the location of the lump and its appearance. They are usually oval or round and may be soft or very firm. Cysts at the base of the finger on the palm side are typically very firm, pea sized nodules that are tender to applied pressure, such as when gripping. Light will often pass through these lumps, (transillumination) and this can assist in the diagnosis. Your physician may request x-rays in order to investigate problems in adjacent joints. Cysts at the end joint of the finger frequently have an arthritic bone spur associated with them.
Treatment can often be non-surgical. In many cases, these cysts can simply be observed, especially if they are painless, as they frequently disappear spontaneously. If the cyst becomes painful, limits activity, or is otherwise unacceptable, several treatment options are available. The use of splints and anti-inflammatory medication can be prescribed in order to decrease pain associated with activities. An aspiration can be performed to remove the fluid from the cyst and decompress it.
This requires placing a needle into the cyst, which can be performed in most office settings. Aspiration is a very simple procedure, but recurrence of the cyst is common. If non-surgical options fail to provide relief or if the cyst recurs, surgical alternatives are available. Surgery involves removing the cyst along with a portion of the joint capsule or tendon sheath. In the case of wrist ganglion cysts, both traditional open and arthroscopic techniques usually yield good results. Surgical treatment is generally successful although cysts may recur. Your surgeon will discuss the best treatment options for you.
Carpal Tunnel Syndrome is a very common hand problem affecting up to 3% of Canadians. With this condition, there is usually numbness of the thumb, index, long finger and half of the ring finger. The numbness often begins in the night and may respond to splinting the wrist straight while sleeping. However, it may progress to daytime numbness and sometimes associated pain. Carpal Tunnel Syndrome is explained by a lack of room for the median nerve in the carpal tunnel of the hand. Surgery has a greater than 90% success rate for this problem and usually requires a 4-8 week absence from work.