Hand Conditions
Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) presents with a range of symptoms including pain, pins and needles, and numbness affecting usually the thumb, index, middle and part of the ring finger. In more severe cases it can cause weakness in the hand. Symptoms may be worse at night.
CTS is caused by pressure on one of the important nerves (median nerve) which runs from the forearm into the hand. The carpal tunnel is a space bordered by some of the wrist bones, at the floor and two sides, with a ligament forming the roof of the tunnel. In this tunnel, runs the nerve and 9 flexor tendons to the thumb and fingers.
There are multiple causes for carpal tunnel syndrome and usually no specific cause is determined. In the early stage, symptom relief from temporary splints or an injection can be beneficial. When these fail, or more advanced symptoms develop, surgery can be beneficial and in the vast majority of cases leads to an improvement in symptoms.
Image of hands in a patient with carpal tunnel syndrome on the left side (right on image). The arrow denotes the muscle wasting seen at the base of the thumb area often seen in severe cases
Trigger finger and thumb
Trigger finger and thumb is a very common condition. It is caused by rubbing of the tendon next to the pulley at the base of the finger or thumb. The pulley is a structure, like a tunnel-that covers the tendon and prevents the tendon from coming away ("bow-stringing") from the bone when the finger flexes to make a fist. The condition can occur spontaneously or can result from inflammation in the tendon with subsequent swelling.
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Trigger finger presents with pain in the base of the digit and can cause clicking with movement, or locking of the finger. Occasionally this needs to be prised open with the other hand or can becomes permanently fixed in a flexed position.
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Mild trigger finger may revolve spontaneously with rest and painkillers. In cases where symptoms persist or worsen, steroid injections can cause full resolution. In cases where these treatments have failed, then a simple local anaesthetic operation can be curative
De Quervain's Tenosynovitis
De Quervain's tenosynovitis (DQT) is a condition involving inflammation of two of the main tendons which control thumb movement. These tendons are covered with a thick sheath. Inflammation to these tendons can cause pain felt on the radial border (thumb-side) of the wrist. It often occurs as a gradual onset. It can be attributed to activities involving side-to-side movements of the wrist and may be seen in mothers with continual lifting of their babies.
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DQT often resolves with rest and cessation of provoking activities. A resting splint can be helpful as can be a steroid injection. In cases that fail to settle, surgery to release the tendons from their tight sheath can be beneficial.
Dupuytren's disease
Dupuytren's disease is a progressive condition causing thickening of the connective tissue ('fascia') underlying the skin in the hand. The disease usually starts as thickening in the palm and progressively involves the fingers (often ring, little then spreading towards the thumb). As the disease progresses, contractors can occur and the fingers flex. This can cause functional issues as the fingers struggle to open and may get in the way. The condition is usually not painful.
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Dupuytren's disease tends to be a genetic disorder and therefore is often found within families. There can be other associations to the development of the disease.
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Mild Dupuytren's disease can be observed in it's early stages. If the disease progresses then surgery can be useful to release and take out some of the diseased tissue which often improves the position of the finger significantly. The disease can recur even after surgery. In cases with significant involvement of the skin in the fingers, or in cases of recurrence, excision of the involved skin and skin grafting (using skin from the wrist or forearm on the same side) may be necessary.
Basal thumb arthritis
Arthritis at the base of the thumb (1st carpometacarpal joint) is the most common symptomatic arthritic joint in the hand. Arthritis in this joint is usually from gradual wear-and-tear but can occur after injury, such as fracture. In advanced cases it can cause a compensatory 'Z' deformity involving the joint further away (the metacarpophalangeal joint of the thumb).
Patients usually present with pain at the base of the thumb and the thumb-side (radial-side) of the wrist. Discomfort and weakness on pinching and gripping activities are common.
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In the early stages, simple painkillers, a resting splint, and activity modification can help. Some patients get excellent (but usually temporary) relief from a steroid injection.
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In more advanced cases, or after failure of non-operative treatment, surgery can be useful. This often involves excision of one of the arthritic bones, together with tendon suspension procedure to support the thumb from dropping into the gap from where the bone was removed. Other options may include a fusion procedure, denervation, or arthroplasty (replacement).
Radiograph (a) showing a patient with basal thumb osteoarthritis. Note the narrowed gap between the trapezium (white star) and the adjacent bones. Post-operative radiograph following a trapeziectomy and suspensoplasty (b) showing a gap (white star) where the bone has been excised.
Arthritis in the small joints of the hand
Arthritis can affect the small joints of the fingers leading to pain and stiffness. Arthritis at the DIP (end) joints can cause pain, swelling and deformity. A simple fusion procedure, where the joint is opened, clean and fused with a simple screw that lies within the bones can be effective. PIP joints (the next joint away from the knuckle) can be fused or replaced depending on a number of factors, such as which finger, type of arthritis, type of work or activity the patient performs. For replacements, a number of different materials exist including silastic (silicone), metal-on-plastic, and pyrocarbon. The type of replacement recommended will be discussed at consultation.
Pre-operative radiograph (a) showing a patient with arthritis in the knuckles (metacarpophalangeal joints of the hand). Post-operative radiograph (b) following pyrocarbon replacement of the index finger joint.