HAND/WRIST

Your hand and wrist contain several joints, muscles, tendons, and ligaments. Our orthopedic surgeons are specialty-trained in hand and wrist conditions and can diagnose and treat your hand and wrist condition to help you regain your mobility.

CONDITIONS WE TREAT

THUMB ARTHRITIS

In a normal joint, cartilage covers the ends of the bones and allows them to move smoothly and painlessly against one another. In osteoarthritis (or degenerative arthritis), the cartilage layer wears out, resulting in direct contact between the bones. In the hand, the second most common joint to develop osteoarthritis is the joint at the base of the thumb. The thumb basal joint, also known as the carpometacarpal (CMC) joint, is a specialized saddle-shaped joint that is formed by a small wrist bone (trapezium) and the first of the three bones in the thumb (metacarpal). The specialized shape of this joint allows the thumb its wide range of movement—up and down, across the palm, and the ability of the patient to pinch with the fingers.

TREATMENT OPTIONS

Less severe thumb arthritis will usually respond to non-surgical care. Pain medication, topical agents, splinting, activity modification, and limited use of corticosteroid injections may help alleviate pain due to wear and tear. A hand physical therapist might provide a variety of rigid and non-rigid splints to support the thumb during activities. Physical therapy is an excellent option for treating thumb arthritis of the joint, helping improve range of motion. A physical therapist will provide you with exercises to perform at home to improve your hand, finger, and joints, and will help alleviate the impacts of arthritis and osteoarthritis.

Patients with advanced arthritis of the thumb (rheumatoid arthritis) or who do not respond to non-surgical treatment may be candidates for surgical reconstruction. A variety of surgical techniques are available that can successfully reduce or eliminate pain and improve thumb position and function. Common surgical procedures include removal of the arthritic bone and joint reconstruction (joint arthroplasty), bone fusion or realignment techniques, and sometimes arthroscopic procedures in select cases. A consultation with your treating surgeon in Bethesda can help decide the best options for you when suffering from thumb, finger, wrist, joint, hand pain, and other conditions.

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. In effect, it is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. 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 (see Figure 1). Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel and puts pressure on the nerve. When the pressure from the swelling becomes great enough to disturb the way the nerve works, numbness, tingling, and pain may be felt in the hand and fingers.

TREATMENT OPTIONS

Symptoms may often be relieved without surgery. Identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position may help reduce pressure on the nerve. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. A steroid injection into the carpal tunnel may help relieve the symptoms by reducing swelling around the nerve.

SURGERY

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 roof (top) of the tunnel on the palm side of the hand (see Figure 3). Incisions for this surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve. Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.

DE QUERVAIN'S TENDONITIS

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 (see Figure 1, 1A). 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 objects—often infants—are common painful movements with de Quervain’s tendonitis.

TREATMENT OPTIONS

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.

SURGERY

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.

DUPUYTREN'S DISEASE

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 (see Figure 1). Gradually, these cords may cause the fingers to bend into the palm (see Figure 2). 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).

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.

SURGERY

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

GANGLION CYSTS

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. The ganglion cyst often resembles a water balloon on a stalk (see Figure 2), 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. 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.

TREATMENT OPTIONS

Treatment can often be non-surgical. In many cases, these cysts can simply be observed, especially if they are painless. If the cyst becomes painful, limits activity, or is cosmetically unacceptable, other 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. 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 may yield good results. Surgical treatment is generally successful although cysts may recur. Your surgeon will discuss the best treatment options for you.

TRIGGER FINGER

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 (see Figure 2). The catching or triggering action is distinctive, as seen in this brief video clip of a ring trigger finger: video demonstration (may take up to two minutes to load). 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.

TREATMENT OPTIONS

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.

SURGERY

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.