Anatomy of the Hand and Wrist
The hand is composed of many small bones called carpals,
metacarpals and phalanges. The two bones of the lower arm — the
radius and the ulna — meet at the hand to form the wrist.
The median and ulnar nerves are the major nerves of the hand,
running the length of the arm to transmit electrical impulses to and
from the brain to create movement and sensation.
Carpal Tunnel Syndrome
What is Carpal Tunnel Syndrome (CTS)?
CTS is a compression neuropathy, i.e. a pinching of the median nerve
within the wrist. The carpal tunnel is a bony canal within the palm side
aspect of the wrist that allows for the passage of the median nerve
to the hand. Pinching or compression of this nerve by the transverse
carpal ligament sets into motion a progressively crippling disorder which
eventually results in wrist pain, numbness and tingling in the hand, pain
consisting of a "pins and needles" feeling at night, weakness in grip and a
feeling of incoordination.
Who Gets CTS?
This disabling syndrome occurs more often in women than men, by a ratio
of thee to one, usually between the ages of 30 and 50 years. Also, CTS
is seen more frequently in people who tend to do forceful repetitive types
of work, such as grocery store checkers, assembly line workers, meat
packers, typist, accountants, writers, etc. Most patients generally visit their doctor with these complaints, and
the diagnosis is confirmed after physical examination and appropriate nerve testing.
How is CTS Treated?
Treatment for CTS depends upon the stage of the disease. In the early stage, the syndrome can be reversible
and is most often treated with appropriate modification in activities, a removable wrist brace, and antiinflammatory
medicines. In moderate stages of the disorder, especially if the numbness and pain continues
in the wrist and hand, a cortisone injection into the carpal tunnel can be extremely beneficial. Surgical
intervention in CTS is only indicated in those patients in whom non-operative treatment has failed to eliminate
their symptoms. In patients with advanced disease, and especially in those who have profound weakness or
muscle atrophy, surgical intervention should be done early. CTS should not be left untreated because it can
eventually cause permanent nerve damage.
Triangular Fibrocartilage Complex
This is a cartilage similar to the cartilage in the knee that is often torn and does not have an adequate blood
supply to it. The reason it is causing discomfort is usually there is a flap of tissue that is flapping back and
forth and causes irritation of the joint.
For this problem there are three modes of treatment - no treatment, conservative, and surgical.
Conservative treatment would consist of resting the wrist in a wrist brace or a cortisone injection. Usually antiinflammatory
medications and physical therapy is not beneficial.
If there is persistent pain despite conservative treatment, arthroscopic surgery with debridement of the tear to
give the tear smooth edges is usually very successful. This can be performed under local anesthesia on an
outpatient basis with two or three small incisions on the wrist. Occasionally, the cartilage can be repaired.
Thumb (CMC Joint) Arthritis
This is the most common location for arthritis in the hand is due to wear and tear with use of the thumb
throughout the patient's years.
There is no cure for arthritis but there is treatment falling into three categories; no treatment, conservative,
and surgery. Surgery as the last resort, when conservative treatment has failed, consists of a joint
replacement using the patient's normal body tissues and involves excising the arthritic bone and replacing
it with a tendon taken from the wrist which is rolled up into a ball and used as a spacer and a portion of it
is used to reconstruct the ligament. This is done through a small incision at the base of the thumb and a
smaller incision at the base of the wrist to harvest the tendon used for the graft. It is an outpatient procedure
performed under axillary block where only the arm goes to sleep. The patient is immobilized in a splint for two
weeks, then a thumb spica cast for two weeks and then uses a removable custom made splint for two months
while they are undergoing therapy for their thumb. The first month is to regain range of motion and the second
month to regain strength. This concludes a three-month postoperative rehabilitation protocol. Patients have a
very good success rate with this surgery.
Before surgery is considered, conservative treatment is attempted which is aimed at alleviating the symptoms
of arthritis. This consists of use of a splint, possible anti-inflammatory medications, possible icing, and
occasionally a cortisone injection which usually give good but temporary relief.
Dupuytren's disease is a genetically inherited disorder that primarily involves the palmar aponeourosis and
its digital prolongations. The primary pathological change is in the fascial tissues of the palm, which results
in thickening, cord-like formation of contractile bands, and then eventual contractures at the level of the
interphalangeal joints. On occasion, it can be associated with other diseases such as diabetes, epilepsy or
Certain contributing factors increase the likelihood of significant progression. These include a strong family
history, early onset of disease, rather extensive bilateral involvement, and the presence of disease in other
areas such as the plantar regions of the feet. These contributing factors may lead to a more aggressive
course of the disease and possibly even an operation at an earlier age.
The disease appears to be slightly different in women than men, has a tendency to usually appear between
the ages of 40 and 60, is seen much more frequently in men than in women, has over a 65% chance of being
bilateral, and can involve other areas such as the foot, the dorsum of the hand, and other fibrous tissues.
It is a slowly progressive disorder that may have periods of temporary arrest, or even a rapid progression.
After the nodules have formed, the tendency is for these to coalesce into a cord, which will lead to a flexion
contracture at the MCP joints and the PIP joints. The disease can infiltrate the skin itself.
Initial treatment is always non-surgical. This would consist of continued observation for progression of the
problem. As the disease does not involve any pain, there is no reason for the excision of the nodules or cords
until contractures in digits have occurred. If a contracture becomes bothersome or a nodule becomes painful,
or if the contracture in the MCPJ exceeds 30 degrees or any involvement at the PIP joint occurs, we would
recommend surgical excision. This would consist of a palmar and digital fasciectomy utilizing an axillary block
anesthetic. A skin graft taken from the forearm is almost always used. Long-term results are usually quite
good. If contractures have developed at the MCPJ and PIP joint, they can usually be corrected to within half
of the preoperative level. Recurrence of the disease is possible, but this is usually not associated with further
contracture necessitating surgery.
De Quervain's Disease
The problem is a swelling of the tendon sheath around the tendons passing along the distal radial aspect of
the wrist. This sheath runs through a tight tunnel holding the tendon down to bone and this swollen sheath
passing through a tight tunnel results in significant pain. For this problem there are three modes of treatment,
not treatment, conservative treatment and surgery.
As a last resort, when conservative treatment has failed, surgical decompression of the tendon by opening up
the pulley can be performed as an outpatient procedure under local anesthesia with a small incision. This has
a good success rate.
Conservative treatment consists of modification of activities, use of a thumb brace and occasional icing and
then possible use of anti-inflammatory medications. If the pain still persists despite the above treatment a
cortisone injection can be helpful. No more than three cortisone injections are recommended per year in any
Volar Plate Avulsion Injury
This is a hyperextension injury that is essentially a ligamentous injury, although it may involve a portion of
bone avulsed off by a ligament. It usually involves a piece of bone avulsed off the base of the middle phalanx
by the volar plate, which is usually not significantly displaced and usually will heal without problem. It also
usually involves a collateral ligament tear which heals without problem but often heals with abundant scar
tissue leading to an appearance of chronic swelling on one side of the joint, which is permanent.
No more than a few days of immobilization is necessary and is important to work on obtaining full range of
motion of the joint. The middle joint of the fingers is the worst with regards to stiffness and early range of
motion is very important. Range of motion exercises may be explained to the patient or therapy with a hand
therapist may be necessary. "Buddy taping" of the fingers after the initial few days of immobilization is all that
is necessary for finger support. At first, "buddy taping" will be necessary all the time, gradually progressing to
"buddy taping" only with exertive or sporting activities with effected hand. If motion is begun early, full range
of motion can be expected. For those who have been immobilized longer, permanent stiffness may result.
Rarely, with severe stiffness, surgical release of the scarred tendons and joint capsule may be necessary.
Also rarely, instability may result which may require reconstructive surgery. Most patients do extremely well,
being able to progress to painless activity with full function, with minimal abnormal appearance.
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