Hand and Wrist

Our CPOSM doctors are specialized in the treat of hand and wrist problems and can help determine if wrist surgery is required or if other appropriate modification in activities are appropriate.

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

Carpal Tunnel Syndrome (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 and tendons 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 and weakness.

Who Gets CTS?
This disabling syndrome occurs more often in women than men, by a ratio of 3 to 1. 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, typists, accountants, writers, etc. Most patients generally visit their doctor with these complaints, and the diagnosis is confirmed after physical examination and appropriate nerve testing.

Treatment
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, anti-inflammatory medicines and stretching exercises. 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.

A common treatment of Carpal Tunnel Syndrome is a Carpal Tunnel Release. This surgery can be done endoscopically or open. The endoscopic surgery is the procedure of choice in our office.

 

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. Therefore, the tear usually does not heal adequately. 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.

Treatment

Conservative treatment would consist of resting the wrist in a wrist brace, a cortisone injection, anti-inflammatory medications or physical therapy.

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 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. It is more common in women with its onset after menopause. It is frequently genetic in origin. However, it can be caused by injury.

Treatment

There is no cure for arthritis but there is treatment falling into three categories; no treatment, conservative, and orthopedic surgery.

Conservative treatment is aimed at alleviating the symptoms of arthritis. This consists of use of a splint, possible anti-inflammatory medications, possible icing, physical therapy and cortisone injections which usually give good but temporary relief.

Surgery -- as the last resort, when conservative treatment has failed -- consists of a joint arthroplasty 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. It is an outpatient procedure. The patient is immobilized in a splint for one week, then a thumb spica cast for four 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. Artificial joint implants are expensive and have not proven to be a better treatment alternative.

 

Dupuytren's Disease

Dupuytren's disease is a genetically inherited disorder which primarily involves the palmar fascia and its digital prolongations of the palm of the hand.

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 metacarpal phalangeal and interphalangeal joints. On occasion, it can be associated with other diseases such as diabetes, epilepsy, or alcoholism.

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 and knuckles of the fingers. These contributing factors may lead to a more aggressive course of the disease and possibly even an operation at an earlier age.

The disease is seen much more frequently in men than in women and has a tendency to usually appear between the ages of 40 and 60.

Dupuytren's disease has over a 65% chance of being bilateral. It is a progressive disorder which 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 skin itself can be infiltrated by the disease.

Treatment

Initial treatment is always non-surgical. This would consist of continued observation for progression of the problem. As the disease rarely involves 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.

Long term results are good. Recurrence is possible and may require subsequent further surgery. The little finger is most problematic.

Other treatment modalities include cortisone injection of contracted bands, “needling” of the bands and an enzyme injection of collagenase to disrupt the bands. These procedures are frequently temporary with recurrence anticipated.

 

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. The swollen tendons run through a tight tunnel resulting in significant pain. For this problem there are three modes of treatment, no treatment, conservative treatment and surgery.

Treatment

Conservative treatment consists of modification of activities, use of a thumb brace and occasional icing and use of anti-inflammatory medications. If the pain still persists despite the above treatment a cortisone injection can be helpful. No more than two cortisone injections are recommended in any one location.

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 an excellent success rate.

PIP Joint Finger Strain (Jammed Finger)

Collateral ligaments stabilize the PIP joints to the finger. They are frequently injured with sporting activities. The so-called “jammed finger.” The ligament may be partially or completely torn. The hallmark of this injury is a swollen, painful joint with restricted range of motion. It frequently takes six months before the soft tissue injury stabilizes. The joint will always be larger secondary to the scar from the healed torn ligament.

Treatment

Primary treatment: ice the affected finger. Splint the finger for no more than 7-10 days. Then buddy tape the finger to an adjacent finger and start early active range of motion. Buddy tape is useful for 6-12 weeks. Usually an x-ray is taken to make sure there is not an associated fracture which might require a different treatment program.

If joint stiffness persists after six weeks, then hand therapy is indicated. Surgery is rarely necessary.

 

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