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Your Hand Problem

Arthritis - Base of the Thumb

Description
A joint is where bones connect and move. Arthritis is thinning of the cartilage, which is the smooth covering of the joint. The body reacts to loss of the joint surface by forming bone spurs (osteophytes).

Arthritis at the base of the thumb is a genetic predisposition: like graying and thinning of the hair, it comes with age and it shows up earlier in some families. Unlike thinning of the hair, women tend to get thumb arthritis sooner than men do.

Signs and Symptoms
Patients with arthritis of the base of the thumb report pain and weakness with pinching and grasping. For instance, opening jars, turning doorknobs or keys, and writing are often painful.

Diagnosis
The diagnosis is made by talking with you and examining you. The appearance of the thumb can change with the development of bone spurs and stretching of soft tissues (ligaments) (see Figure 2). A grinding sensation may also be present at the joint (see Figure 3). X-rays are not necessary to make the diagnosis, but they can help you understand the disease and they can help when surgery is being considered.

Treatment
As with other aspects of aging, we adapt to thumb arthritis and treatment is often unnecessary. Options for treatment include non-surgical methods and surgery. Treatments without surgery range from ice/heat, pain medicines, splinting, and injections.

Surgery consists of removing the joint either by removing a bone or connecting the bones together. There are options for moving one of your tendons to secure or cushion the bone, and each hand surgeon has a different opinion on whether this is helpful (see Figure 4). After surgery, a splint or cast is worn for several weeks.

Carpal Tunnel Syndrome

Description
Carpal tunnel syndrome is essentially a pinched nerve in the wrist. There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand (Figure 1). Carpal tunnel syndrome happens when swelling in this tunnel puts pressure on the nerve.

Causes
Pressure on the nerve can happen several ways, including:

  • Swelling of the lining of the flexor tendons, called tenosynovitis
  • Joint dislocations
  • Fractures
  • Arthritis
  • Fluid build-up during pregnancy
The scenarios listed above can narrow the carpal tunnel or cause swelling in the tunnel. Thyroid conditions, rheumatoid arthritis and diabetes can also be associated with carpal tunnel syndrome. Ultimately, there can be many causes of this condition.

Signs and Symptoms
Symptoms of this condition can include:
  • Pain
  • Numbness
  • Tingling
  • Weak grip
  • Occasional clumsiness
  • Tendency to drop things
The numbness or tingling most often takes place in the thumb, index, middle and ring fingers. The symptoms usually are felt during the night but may also be noticed during daily activities such as driving or reading a newspaper. In bad cases, sensation and strength may be permanently lost.

How your doctor will diagnose Carpal Tunnel
A detailed history including medical conditions, how the hands have been used, and any prior injuries is important in diagnosing carpal tunnel syndrome. An x-ray may be taken to check for arthritis or a fracture. In some cases, laboratory tests may be done. Electrodiagnostic studies are also a possibility to confirm the diagnosis and check for other possible nerve problems.

Treatment
Symptoms may often be relieved without surgery. Some treatment options are:
  • Changing patterns of hand use (helps reduce pressure on the nerve)
  • Keeping the wrist splinted in a straight position (helps reduce pressure on the nerve)
  • Wearing wrist splints at night (helps relieve symptoms that may prevent sleep)
  • Steroid injections into the carpal tunnel (helps reduce swelling around the nerve)
When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms the top of the tunnel on the palm side of the hand (Figure 2). Following surgery, soreness around the cut area may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. Recovery may take several months. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.

Cubital Tunnel Syndrome

Description
Cubital Tunnel Syndrome is a condition that involves pressure or stretching of the ulnar nerve (also known as the "funny bone" nerve), which can cause numbness or tingling in the ring and small fingers, pain in the forearm, and/or weakness in the hand. The ulnar nerve (Figure 1) runs in a groove on the inner side of the elbow.

Causes
There are a few causes of this ulnar nerve problem. These include:

  • Pressure: The nerve has little padding over it. Direct pressure (like leaning the arm on an arm rest) can press the nerve, causing the arm and hand — especially the ring and small fingers — to "fall asleep."
  • Stretching: Keeping the elbow bent for a long time can stretch the nerve behind the elbow. This can happen during sleep.
  • Anatomy: Sometimes, the ulnar nerve does not stay in its place and snaps back and forth over a bony bump as the elbow is moved. Repeated snapping can irritate the nerve. Sometimes, the soft tissues over the nerve become thicker or there is an "extra" muscle over the nerve that can keep it from working correctly.
Signs and Symptoms
Cubital tunnel syndrome can cause pain, loss of sensation, tingling and/or weakness. "Pins and needles" usually are felt in the ring and small fingers. These symptoms are often felt when the elbow is bent for a long period of time, such as while holding a phone or while sleeping. Some people feel weak or clumsy.

Diagnosis
Your doctor can learn much by asking you about your symptoms and examining you. S/he might test you for other medical problems like diabetes or thyroid disease. Sometimes, nerve testing (EMG/NCS) may be needed to see how much the nerve and muscle are being affected. This test also checks for other problems such as a pinched nerve in the neck, which can cause similar symptoms.

Treatment
The first treatment is to avoid actions that cause symptoms. Wrapping a pillow or towel loosely around the elbow or wearing a splint at night to keep the elbow from bending can help. Avoiding leaning on the "funny bone" can also help. A hand therapist can help you find ways to avoid pressure on the nerve.

Sometimes, surgery may be needed to relieve the pressure on the nerve. This can involve releasing the nerve, moving the nerve to the front of the elbow, and/or removing a part of the bone. Your surgeon will talk to you about options.

Therapy is sometimes needed after surgery, and the time it takes to recover can vary. Numbness and tingling may improve quickly or slowly. It may take many months for recovery after surgery. Cubital tunnel symptoms may not totally go away after surgery, especially if symptoms are severe.

de Quervain Syndrome

Description
Patients with de Quervain syndrome have painful tendons on the thumb side of the wrist. Tendons are the ropes that the muscle uses to pull the bone. You can see them on the back of your hand when you straighten your fingers. In de Quervain syndrome, the tunnel (the first extensor compartment; see Figure 1A-B) where the tendons run narrows due to the thickening of the soft tissues that make up the tunnel. Hand and thumb motion cause pain, especially with forceful grasping or twisting.

Causes
Doctors are not sure what causes de Quervain syndrome. Patients often describe a feeling of inflammation, but studies have shown that the process is not inflammatory. People of all ages get it. When new mothers develop de Quervain syndrome, it typically appears 4 to 6 weeks after delivery. The old theory that it was caused by wringing out cloth diapers has been replaced by concerns about holding the baby, but changes in hormones and swelling seem more probable.

Treatment
Treatments that can relieve symptoms include:

  • A splint that stops you from moving your thumb and wrist.
  • Tylenol or aspirin type medications (e.g., ibuprofen).
Treatments that attempt to change the course of the disease include:
  • A cortisone-type of steroid injection into the tendon compartment. It has not been clearly established that these injections change the course of the disease and response to the injection varies.
  • Surgery to open the tunnel and make more room for the tendons.
Figure 1A: The first dorsal compartment. There are six compartments on the dorsal, or back, side of the wrist. The first and third compartments house tendons that control the thumb.
Figure 1B: A drawing of the first dorsal compartment.
Figure 2A and B: Pain with this motion (a hammering motion with the thumb in the fist) is characteristic of de Quervain syndrome.

Dupuytren's Contracture

Description
Dupuytren's contracture is an abnormal thickening of the tissue just beneath the skin. This thickening occurs in the palm and can extend into the fingers. Firm pits, bumps and cords (thick lines) can develop and cause the fingers to bend into the palm (Figures 1 and 2). This condition may also be known as Dupuytren's Disease. Occasionally, the disease will cause thickening on top of the knuckles or cause lumps and cords on the soles of the feet (plantar fibromatosis).

Causes
The cause of Dupuytren's contracture is unknown. The problem is more common in men, people over age 40 and people of northern European descent. There is no proven evidence that hand injuries or specific jobs lead to a higher risk of developing Dupuytren's contracture.

Signs and Symptoms
Symptoms of Dupuytren's contracture usually include lumps and pits within the palm. The lumps are generally firm and stuck to the skin. Thick cords may develop from the palm into one or more fingers. The ring and small fingers are most commonly involved. These cords may cause bending of the fingers. In many cases, both hands are affected, but each hand can be affected differently.

The lumps can be uncomfortable in some people, but Dupuytren's contracture is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on a surface (Figure 3). As the fingers are drawn into the palm, it may be more difficult to wash hands, wear gloves, shake hands, and get hands into pockets. It is difficult to predict how the disease will progress. Some people have only small lumps or cords while others will develop severely bent fingers. The disease tends to be more severe if it occurs at an earlier age.

Treatment
In mild cases, especially if hand function is good, only observation is needed. A lump in the palm does not mean that treatment is required or that the disease will progress. For more severe cases, various treatment options are available to straighten the finger(s). These options may include needles, injectable medicine or surgery.

Your hand surgeon will discuss the most appropriate method based upon the stage and pattern of the disease and the joints involved. The goal of treatment is to improve finger motion and function; however, complete correction of the finger(s) may not always happen. Even with treatment, the disease may come back. Before treatment, the surgeon will discuss realistic goals and possible risks.

Splinting and hand therapy are often needed after treatment in order to maintain the improved finger function.

Figures 1 and 2: Advanced case of Dupuytren with pits, nodules and cords leading to bending of the finger into the palm
Figure 3: Table top test

Elbow Fractures

Description
Elbow fractures may result from a fall, a direct impact to the elbow, or a twisting injury to the arm. Sprains, strains or dislocations may occur at the same time as a fracture. X-rays are used to confirm if a fracture is present and if the bones are out of place. Sometimes a CT (Computed Tomography) scan might be needed to get further detail.

Causes
The different types of elbow fractures include:

Radial head and neck fractures (Figure 2)
Pain is usually worse with forearm rotation (turning the palm up and down). The treatment for this fracture depends on the number and size of the bone fragments. Complex fractures often require surgery to repair and stabilize the fragments or to remove or replace the radial head if there are too many bony pieces.

Olecranon fractures (see Figure 3)
These fractures are usually displaced and require surgery. The bone fragments are re-aligned and held together with pins and wires or plates and screws.

Fractures of the distal humerus (see Figure 4)
These fractures occur commonly in children and in the elderly. Nerve and/or artery injuries can be associated with these types of fractures and must be carefully evaluated by your doctor. These fractures usually require surgical repair with plates and/or screw, unless they are stable.

Signs and Symptoms
Pain, swelling, bruising and stiffness in and around the elbow may be signs of a possible fracture. A snap or pop at the time of injury may be felt or heard. Visible deformity might mean that the bones are out of place or that the elbow joint is dislocated. There may be numbness or weakness in the arm, wrist and hand.

Treatment
Fractures that are out of place or unstable are more likely to require surgery. A surgical procedure would replace and stabilize the fragments or remove bone fragments. Whenever a fracture is open (skin broken over the fracture), urgent surgery is needed to clean out the wound and bone to minimize the risk of infection.

Non-surgical treatment such as using a sling, cast or splint is typically used when the bones are at low risk of moving out of place or when the position of the bones is okay as is. Age is also an important factor when treating elbow fractures. Casts are used more frequently in children, as their risk of developing elbow stiffness is small; however, in an adult, elbow stiffness is much more likely. Rehabilitation directed by your doctor is often used to maximize motion and decrease the chance of getting elbow stiffness. This might include exercises, scar massage, ultrasound, heat, ice and splints that stretch the joint.

Extensor Tendon Injuries

Description
Extensor tendons are just under the skin. They lie next to the bone on the back of the hands and fingers and straighten the wrist, fingers and thumb (Figure 1). They can be injured by a minor cut or jamming a finger, which may cause the thin tendons to rip from their attachment to bone. If not treated, it may be hard to straighten one or more joints.

Common Extensor Tendon Injuries

  • Mallet Finger refers to a drooping end-joint of a finger. This happens when an extensor tendon has been cut or torn from the bone (Figure 2). It is common when a ball or other object strikes the tip of the finger or thumb and forcibly bends it.
  • Boutonnière Deformity describes the bent-down (flexed) position of the middle joint of the finger. Boutonniere can happen from a cut or tear of the extensor tendon (Figure 3).
  • Cuts on the back of the hand can injure the extensor tendons. This can make it difficult to straighten your fingers.

Treatment Tears caused by jamming injuries are usually treated with splints. Splints hold the tendon in place and should be worn at all times until the tendon is healed. The tendon may take eight to twelve weeks to heal completely. Longer periods of splinting are sometimes needed. Your doctor will apply the splint in the correct place and give you directions on how long to wear it.

Other treatment may include stitches (for cuts in the tendon). Also, a pin may need to be placed through the bone across the joint as an internal splint. Surgery to free scar tissue is sometimes helpful in cases of severe motion loss.

After treatment, therapy may be necessary to improve motion. Consult your hand specialist for the best form of treatment.

Flexor Tendon Injuries

Description
The muscles that bend (flex) the fingers are called flexor muscles. These flexor muscles move the fingers through cord-like extensions called tendons, which connect the muscles to bone. The flexor muscles start at the elbow and forearm regions, turn into tendons just past the middle of the forearm, and attach to the bones of the fingers (see Figure 1). In the finger, the tendons pass through tunnels that keep them close to the bones, which helps them work better.

Causes
Deep cuts can injure the tendons and nearby nerves and blood vessels. An injury that looks simple on the outside can be much more complex on the inside.

When the tendon is cut, you cannot bend your finger (see Figure 2).

Treatment
A cut tendon cannot heal without surgery. Nearby nerves and blood vessels may need to be repaired as well. After surgery, the injured area will need to be moved to limit stiffness, but the repair must be protected (see Figure 3).

In most cases, exercise is done by having you move your fingers with your other hand, but you are not allowed to try to bend your finger on your own for about a month. You must wear a splint for at least a month after surgery. These exercises can be tricky and a hand therapist can help you. These exercises can vary among surgeons; your surgeon will direct your care.

Prognosis
There is scarring as the tendon heals, and most people do not regain normal motion. In some cases, if motion is less than expected after months of exercises, then your surgeon might offer you surgery to release scar tissue around the tendon.

Ganglion Cysts

Description
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 (see Figure 1), 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 (see Figure 2). The ganglion cyst often resembles a water balloon on a stalk (see Figure 3), and is filled with clear fluid or gel.

Causes
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.

Signs and Symptoms
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, (trans-illumination) and this can assist in the diagnosis. Your physician may request x rays in order to look for evidence of problems in adjacent joints. Cysts at the far joint of the finger frequently have an arthritic bone spur associated with them, the overlaying skin may become thin, and there may be a lengthwise groove in the fingernail just beyond the cyst.

Treatment
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 (see Figure 3). 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.

Figure 1: Ganglion top side (dorsum) wrist
Figure 2: Ganglion end joint of finger (mucous cyst)
Figure 3: Cross-section of wrist showing stalk (or root) of ganglion.

Hand Fractures

Description
The hand is made up of many bones that form its supporting framework. This frame acts as a point of attachment for the muscles that make the wrist and fingers move. A fracture occurs when enough force is applied to a bone to break it. When this happens, there is pain, swelling, and decreased use of the injured part. Many people think that a fracture is different from a break, but they are the same (see Figure 1). Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to displace or shift. Some fractures occur in the shaft (main body) of the bone, others break the joint surface. Comminuted fractures (bone is shattered into many pieces) usually occur from a high energy force and are often unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin. There is some risk of infection with compound fractures.

Signs and Symptoms
Fractures often take place in the hand. A fracture may cause pain, stiffness, and loss of movement. Some fractures will cause an obvious deformity, such as a crooked finger, but many fractures do not. Because of the close relationship of bones to ligaments and tendons, the hand may be stiff and weak after the fracture heals. Fractures that injure joint surfaces may lead to early arthritis in those joints.

Treatment
Medical evaluation and x-rays are usually needed so that your doctor can tell if there is a fracture and to help determine the treatment. Depending upon the type of fracture, your hand surgeon may recommend one of several treatment methods.

A splint or cast may be used to treat a fracture that is not displaced, or to protect a fracture that has been set. Some displaced fractures may need to be set and then held in place with wires or pins without making an incision. This is called closed reduction and internal fixation.

Other fractures may need surgery to set the bone (open reduction). Once the bone fragments are set, they are held together with pins, plates, or screws (see Figure 2). Fractures that disrupt the joint surface (articular fractures) usually need to be set more precisely to restore the joint surface as smooth as possible. On occasion, bone may be missing or be so severely crushed that it cannot be repaired. In such cases, a bone graft may be necessary. In this procedure, bone is taken from another part of the body to help provide more stability. Sometimes bone graft substitutes may be used instead of taking bone from another part of the body.

Fractures that have been set may be held in place by an "external fixator," a set of metal bars outside the body attached to pins which are placed in the bone above and below the fracture site, in effect keeping it in traction until the bone heals.

Once the fracture has enough stability, motion exercises may be started to try to avoid stiffness. Your hand surgeon can determine when the fracture is sufficiently stable.

What types of results can I expect from surgery for hand fractures?
Perfect alignment of the bone on x-ray is not always necessary to get good function. A bony lump may appear at the fracture site as the bone heals and is known as a "fracture callus." This functions as a "spot weld." This is a normal healing process and the lump usually gets smaller over time. Problems with fracture healing include stiffness, shift in position, infection, slow healing, or complete failure to heal. Smoking has been shown to slow fracture healing. Fractures in children occasionally affect future growth of that bone (see the brochure/web page on Fractures in Children). You can lessen the chances of complication by carefully following your hand surgeon's advice during the healing process and before returning to work or sports activities. A hand therapy program with splints and exercises may be recommended by your physician to speed and improve the recovery process.

Figure 1: Examples of fractures in fingers.
Figure 2: Examples of plates, pins, and screws used to join fractures while they heal.

Mallet Finger

Description
A mallet finger is a deformity of the finger caused when the tendon that straightens your finger (the extensor tendon) is damaged.

When a ball or other object strikes the tip of the finger or thumb and forcibly bends it, the force tears the tendon that straightens the finger (see Figure 1a and 1b). The force of the blow may even pull away a piece of bone along with the tendon (see Figure 2). The tip of the finger or thumb no longer straightens. This condition is sometimes referred to as baseball finger.

Signs and Symptoms
In a mallet finger, the fingertip droops: it cannot straighten on its own power. The finger may be painful, swollen and bruised, especially if there is an associated fracture, but often the only finding is the inability to straighten the tip. Occasionally, blood collects beneath the nail. The nail can even become detached from beneath the skin fold at the base of the nail.

Diagnosis
The diagnosis is evident by the appearance of the finger. Doctors will often order x-rays to see if a piece of bone pulled away and to make sure the joint is aligned.

Nonsurgical Treatment
The majority of mallet finger injuries can be treated without surgery. Ice should be applied immediately and the hand should be elevated (fingers toward the ceiling.) Medical attention should be sought within a week after injury. It is especially important to seek immediate attention if there is blood beneath the nail or if the nail is detached. This may be a sign of a nail bed laceration or an open (compound) fracture.

There are many different types of splints/casts for mallet fingers. The goal is to keep the fingertip straight until the tendon heals. Most of the time, a splint will be worn full-time for eight weeks (see Figure 3). Over the next three to four weeks, most patients gradually begin to wear the splint less frequently. The finger usually regains acceptable function and appearance with this treatment. Nevertheless, it is not unusual to lack some extension at the conclusion of treatment. Your surgeon or hand therapist will instruct you about how to wear the splint and will also show you exercises to maintain motion in the middle joint (the proximal interphalangeal joint) so your finger does not become stiff. Once your mallet finger has healed, your surgeon or hand therapist will teach you exercises to regain motion in the fingertip.

In children, mallet finger injuries may involve the cartilage that controls bone growth. The doctor must carefully evaluate and treat this injury in children so that the finger does not become stunted or deformed.

Surgical Treatment
Surgical repair may be considered when mallet finger injuries have large bone fragments or joint mal-alignment. In these cases, pins, wires or even small screws are used to secure the bone fragment and realign the joint (see Figure 4). Surgery may also be considered if splint wear is not feasible or if non-surgical treatment is not successful in restoring adequate finger extension. Surgical treatment of the damaged tendon can include tightening the stretched tendon tissue, using tendon grafts or even fusing the joint straight. Your surgeon will advise you on the best technique in your situation.

Tennis Elbow - Lateral Epicondylitis

Description
Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons anchor the muscle to bone. The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist (see Figure 1). With lateral epicondylitis, there is degeneration of the tendon's attachment, weakening the anchor site and placing greater stress on the area. This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.

Causes
Overuse – The cause can be both non-work and work related. An activity that places stress on the tendon attachments, through stress on the extensor muscle-tendon unit, increases the strain on the tendon. These stresses can be from holding too large a racquet grip or from "repetitive" gripping and grasping activities, i.e. meat-cutting, plumbing, painting, weaving, etc.

Trauma – A direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon.

Who gets tennis elbow/lateral epicondylitis?
The most common age group that this condition affects is between 30 to 50 years old, but it may occur in younger and older age groups, and in both men and women.

Pain is the primary reason for patients to seek medical evaluation. The pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle. This area becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.

Conservative (non-surgical)

  • Activity modification – Initially, the activity causing the condition should be limited. Limiting the aggravating activity, not total rest, is recommended. Modifying grips or techniques, such as use of a different size racket and/or use of 2-handed backhands in tennis, may relieve the problem.
  • Medication – anti-inflammatory medications may help alleviate the pain.
  • Brace – a tennis elbow brace, a band worn over the muscle of the forearm, just below the elbow, can reduce the tension on the tendon and allow it to heal.
  • Physical Therapy - may be helpful, providing stretching and/or strengthening exercises. Modalities such as ultrasound or heat treatments may be helpful.
  • Steroid injections – A steroid is a strong anti-inflammatory medication that can be injected into the area. No more than (3) injections should be given.
  • Shockwave treatment – A new type of treatment, available in the office setting, has shown some success in 50–60% of patients. This is a shock wave delivered to the affected area around the elbow, which can be used as a last resort prior to the consideration of surgery.
Surgery
Surgery is only considered when the pain is incapacitating and has not responded to conservative care, and symptoms have lasted more than six months. Surgery involves removing the diseased, degenerated tendon tissue. Two surgical approaches are available; traditional open surgery (incision), and arthroscopy—a procedure performed with instruments inserted into the joint through small incisions. Both options are performed in the outpatient setting.

Recovery
Recovery from surgery includes physical therapy to regain motion of the arm. A strengthening program will be necessary in order to return to prior activities. Recovery can be expected to take 4–6 months.

Figure 1: The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist.

Trigger Finger

Description
Stenosing tenosynovitis is a condition commonly known as "trigger finger." It is sometimes also called "trigger thumb." The tendons that bend the fingers glide easily with the help of pulleys. These pulleys hold the tendons close to the bone. This is similar to how a line is held on a fishing rod (Figure 1). Trigger finger occurs when the pulley becomes too thick, so the tendon cannot glide easily through it (Figure 2).

Causes
Trigger fingers are more common with certain medical conditions such as rheumatoid arthritis, gout and diabetes. Repeated and strong gripping may lead to the condition. In most cases, the cause of the trigger finger is not known.

Signs and Symptoms
Trigger finger may start with discomfort felt at the base of the finger or thumb, where the finger joins the palm. This area is often sensitive to pressure. You might feel a lump there. Other symptoms may include:

  • Pain
  • Popping
  • Catching feeling
  • Limited finger movement
Treatment
The goal of treatment in trigger finger is to eliminate the swelling and catching/locking, allowing full, painless movement of the finger or thumb.

Common treatments include, but are not limited to:
  • Night splints
  • Anti-inflammatory medication
  • Changing your activity
  • Steroid injection
If non-surgical treatments do not relieve the symptoms, surgery may be recommended. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. The clicking or popping goes away first. Finger motion can return quickly, or there can be some stiffness after surgery. Occasionally, hand therapy is required after surgery to regain better use.

Figure 1: The pulley and tendon in a finger, gliding normally.
Figure 2: If the pulley becomes too thick, the tendon cannot glide through it.

Wrist Fractures

Description
A wrist fracture is a medical term for a broken wrist. The wrist is made up of eight small bones which connect with the two long forearm bones called the radius and ulna. Although a broken wrist can happen in any of these 10 bones, by far the most common bone to break is the radius. This is called a distal radius fracture by hand surgeons (Figure 1).

Some wrist fractures are stable. "Non-displaced" breaks, in which the bones do not move out of place initially, can be stable. Some "displaced" breaks (which need to be put back into the right place, called "reduction" or "setting") also can be stable enough to treat in a cast or splint. Other fractures are unstable. In unstable fractures, even if the bones are put back into position and a cast is placed, the bone pieces tend to move or shift into a bad position before they solidly heal. This can make the wrist appear crooked.

Some fractures are more severe than others. Fractures that break apart the smooth joint surface or fractures that shatter into many pieces (comminuted fractures) may make the bone unstable. These severe types of fractures often require surgery to restore and hold their alignment. An open fracture occurs when a fragment of bone breaks and is forced out through the skin. This can cause an increased risk of infection in the bone.

Causes
A wrist fracture occurs from an injury such as falling down onto an outstretched hand. Severe trauma such as car accidents, motorcycle accidents or falls from a ladder cause more severe injuries. Weak bones (for example, in osteoporosis) tend to break more easily.

Signs and Symptoms
When the wrist is broken, there is pain and swelling. It can be hard to move or use the hand and wrist. Some people can still move or use the hand or wrist even if there is a broken bone. Swelling or a bone out of place can make the wrist appear deformed. There is often pain right around the break and with finger movement. Sometimes the fingers tingle or feel numb at the tips.

Diagnosis
Your hand surgeon will do a physical examination and obtain x-rays to see if there is a broken bone. Sometimes, tests such as a CT scan or MRI scan may be needed to get better detail of the fracture fragments and other injuries. Ligaments (the soft tissues that hold the bones together), tendons, muscles and nerves may also be injured when the wrist is broken. These injuries may need to be treated also.

Treatment
Treatment depends on many factors, including:

  • Type of fracture, whether it is displaced, unstable or open
  • Your age, job, hobbies, activity level, and whether it is your "dominant" hand
  • Your overall general health
  • Presence of other injuries
A padded splint might be worn at first in order to align the bones and support the wrist to provide some relief from the initial pain. If the fracture is not too unstable, a cast may be used to hold a fracture that has been set. Other fractures may benefit from surgery to put the broken bones back together and hold them in correct place.

Fractures may be fixed with many devices. Pins, screws, plates, rods or external fixation can all be used (Figure 2). A small camera might be used to help visualize the joint from the inside. Sometimes the bone is so severely crushed that there is a gap in the bone once it has been realigned. In these cases, a bone graft may be added to help the healing process. Your hand surgeon will discuss the options that are best for your healing and recovery.

Recovery
During recovery, it is very important to keep your fingers moving to keep them from getting stiff. Your hand surgeon will have you start moving your wrist at the right time for your fracture. Hand therapy is often helpful to recover motion, strength and function.

Recovery time varies and depends on a lot of factors. It is not unusual for recovery to take months. Even then, some patients may have stiffness or aching. Severe wrist fractures can result in arthritis in the joint. Occasionally, additional treatment or surgery is needed.

Figure 1: Wrist bones shown with a non-displaced fracture of the radius.
Figure 2: Radius fracture shown stabilized with external fixation and plate and screws.

Wrist Sprains

Description
A sprain is an injury to a ligament. Ligaments are the connective tissues that connect bones to bones; they could be thought of as tape that holds the bones together at a joint (see Figure 1).
The most common ligament to be injured in the wrist is the scapho-lunate ligament (see Figure 2). It is the ligament between two of the small bones in the wrist, the scaphoid bone and the lunate bone. There are many other ligaments in the wrist, but they are less frequently injured. Sprains can have a wide range of severity; minor sprains may have minimal stretch of the ligaments, and more severe sprains may represent complete tears of the ligament(s). Another common ligament injured is the TFCC (triangular fibrocartilage complex).

Causes
Wrist sprains are common when a person falls. The wrist is usually bent backwards when the hand hits the ground.

Signs and Symptoms
After injury, the wrist will usually swell and may show bruising. It is usually painful to move.

Diagnosis
Initially your doctor will examine your wrist to see where it hurts and to check how it moves. X-rays are taken to make sure there are no broken bones or dislocated joints (see Figure 3). Occasionally other studies, such as Magnetic Resonance Imaging (MRI), may be performed.

Treatment
Treatment may range from wearing a splint or cast to surgery. Surgery may consist of arthroscopic (with an internal camera) or open surgery. Arthroscopic surgery is performed through small (3-4 millimeter) incisions in the skin. A camera and other special instruments are placed inside the wrist to confirm the diagnosis and potentially treat the ligament injury. Some injuries require open surgery, where an incision is made to repair the ligament. A variety of repair methods exist, which could include metal pins, screws, and other specialized devices. Patients are usually placed in a splint or cast that may need to remain on for several weeks after surgery. Your doctor will determine the best course of treatment.

Chronic Injuries
The term "chronic" refers to an old injury of greater than several months to years. If there is no or minimal cartilage damage, the ligament may be reconstructed. If there is moderate to severe cartilage damage (arthritis), symptoms may include pain, stiffness, and swelling. Chronic injuries may first be treated with splinting and non-steroidal anti-inflammatory medicines, and later with cortisone injections. If these treatments fail, surgery may be an option. Various types of procedures are possible, including a partial wrist fusion, removal of arthritic bones ("proximal row carpectomy"), wrist replacement, or complete wrist fusion. Your doctor will determine the best course of treatment.

Associated Injuries
Occasionally fractures occur along with this type of sprain.These may require additional procedures to repair the fracture with metal pins, screws, or plates. Cartilage damage may also be present, which does not show up on the x-ray.

Future Treatments
The optimum treatment for these injuries is not always clear. There is much research underway searching for better methods to treat these serious injuries.They include stronger and more precise ligament reconstructions using either local tissues (tendons) or distant tissues (ligaments from the hand or foot).

Prognosis
Despite optimal treatment, these sprains occasionally result in residual long term pain, stiffness, and swelling. The wrist is a complex group of bones, cartilage, and ligaments that are in a delicate balance for precise movements. Injury can upset this balance and damage previously well-tuned moving parts.




Content provided by the American Society for Surgery of the Hand

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