Hand, Wrist and Elbow

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Carpal tunnel syndrome (CTS) is a prevalent condition that affects the hand and wrist, leading to pain, numbness, and tingling sensations. It develops when the median nerve, responsible for controlling sensations and movements in the hand, becomes compressed as it passes through the carpal tunnel—a narrow passageway in the wrist. This compression can result in various symptoms, including weakness and discomfort in the affected hand, making daily activities challenging.

Common Causes

The primary cause of carpal tunnel syndrome is the compression of the median nerve in the carpal tunnel. Several factors can contribute to this compression, including repetitive hand movements, such as typing or using vibrating tools, which can irritate the tendons and cause swelling. Other risk factors include underlying health conditions like diabetes, rheumatoid arthritis, or thyroid dysfunction, as well as pregnancy, which can lead to fluid retention and increased pressure on the median nerve.

Carpal Tunnel Surgery

Carpal tunnel release surgery is a common treatment for severe cases of carpal tunnel syndrome that do not respond to conservative treatments. During the procedure, the surgeon makes an incision in the palm or wrist and cuts the ligament that forms the roof of the carpal tunnel, relieving pressure on the median nerve. This can be performed as an open surgery or arthroscopically, with smaller incisions and the use of a camera for visualisation. The goal of surgery is to alleviate symptoms, such as pain and numbness, and restore normal nerve function in the hand.

Recovery

After carpal tunnel surgery, patients typically experience some pain and discomfort, which can be managed with pain medications and ice packs. The hand may be wrapped in a bandage or splint to provide support and immobilisation during the initial healing phase. Physical therapy exercises may be prescribed to improve hand strength and flexibility gradually. Most patients can resume light activities within a few weeks but should avoid heavy lifting or strenuous activities for several weeks to allow for proper healing. Full recovery may take several months, during which time symptoms should gradually improve as the nerve regenerates and inflammation subsides. Regular follow-up appointments with the surgeon are essential to monitor progress and address any concerns.

Ganglions are the most common types of lumps found in the hand and wrist. These cysts are benign and do not develop into cancer. They contain a jelly-like substance and may vary in consistency, feeling soft, firm, or even hard.

Common Locations

1. Dorsal Wrist Ganglion: Located on the back of the wrist.
2. Volar Wrist Ganglion: Found on the palm side of the wrist.
3. Mucous Cyst: Appears near the tip of the finger around the nail.
4. Flexor Sheath Ganglion: Found around the tendons in the finger.

While the exact cause of ganglions is unclear, they may develop following an injury. Often, they do not cause any symptoms, but they can become painful when they press against nearby structures, particularly during strenuous activities or extreme movements.

Diagnosis

1. Ganglions are usually diagnosed based on their characteristic locations.
2. Plain X-rays may be taken to rule out bony abnormalities.
3. Ultrasound can help confirm the diagnosis and pinpoint the cyst's location and origin.
4. In some cases, deep-seated cysts may require an MRI.

Treatment

1. Treatment depends on the symptoms and location of the ganglion.
2. The main reasons to remove ganglions are for pain relief, functional improvement, and aesthetic concerns.
3. Ganglions may resolve on their own, so observation is a valid option if they are not causing symptoms.
4. Aspiration and injection have a 50% recurrence rate.
5. Surgical removal has a lower recurrence rate, ranging from 5-10%.
6. Surgery can be performed either openly or arthroscopically.
7. An old-fashioned method for treating dorsal wrist ganglions involves striking the cyst with a heavy book, traditionally a Bible, to "pop" the cyst.

A bending force applied to the tip of the finger can cause damage to the tendon that straightens the finger, leading to dysfunction. This may happen if the tendon itself is pulled away from the bone or if there's a fracture where the tendon attaches to the bone.

Mallet Fracture

This type of injury causes the tip of the finger to "sag" and, if left untreated, can lead to progressive worsening and potentially result in a more disabling condition known as "swan neck deformity" affecting the nearby joint.

Diagnosis

Initially, the diagnosis is based on clinical signs, particularly the loss of extension at the tip of the finger. An X-ray should be taken to determine whether there's a bone fracture and to ensure the joint is properly aligned.

Treatment

Most injuries of this type can be treated non-operatively with splinting. The duration of splinting varies depending on whether the injury involves only the tendon or includes a bone fracture.

1. Tendon Only:  Full-time splinting for 8 weeks, followed by night splinting for an additional 4 weeks.
2. Bone:  Full-time splinting for 6 weeks, followed by night splinting for an additional 4 weeks.

A comfortable fit is crucial for the splint, so custom-made splints are often the best choice. Adjustments can be made as the swelling decreases.

If the splint needs to be removed, the joint must be kept straight at all times. If the finger droops when the splint is off, the healing process must restart, and the clock is reset.

During the splinting period, other finger joints should be moved regularly to maintain their range of motion. As the splint is gradually removed, motion should be restored gradually to protect the tendon, especially in cases of tendon avulsions.

Surgery

Surgery is not typically required unless the joint becomes unstable and dislocates, usually due to a significant fracture fragment. In simple cases, surgical outcomes may not be as favourable as non-operative treatment.

Trigger finger occurs when a finger or thumb flexor tendon gets stuck, causing a "pop" or locking sensation when bending the digit. Sometimes the finger locks in a bent position and needs to be manually straightened. This can lead to contracture of the finger joints.

Cause

The flexor tendon passes through a tight tunnel that helps guide finger movement and keeps the tendon close to the joint it moves. Trigger finger arises from increased pressure from repeated gripping, which causes the tunnel edge to thicken or the tendon to swell.

Location

Trigger finger is most common in middle-aged women and can involve multiple fingers. In cases with multiple affected digits, the thumb is most commonly involved, followed by the ring, long, little, and index fingers. This condition is often linked with diabetes, gout, renal disease, rheumatoid arthritis, and other rheumatic diseases, resulting in a less favorable prognosis.

Patients typically report a history of catching or locking of the digit during bending, sometimes accompanied by pain in the palm. Symptoms often worsen in the morning, with the finger sometimes locked in a bent position upon waking up but improving throughout the day. Severe cases may show noticeable catching and contracture of the finger joint.

Non-Surgical Treatment

Most cases of trigger finger can be treated non-surgically using steroid injections, which have a low complication rate and are successful in up to 75% of cases, depending on the chronicity of the condition. Diabetic patients may experience a temporary increase in blood glucose levels. Splinting can also be considered and is effective in about 50-60% of cases.

Operative Treatment

Trigger finger is not inherently dangerous. The decision to proceed with surgery depends on the severity of symptoms and how much they interfere with daily life. Surgery may prevent permanent stiffness if the finger is stuck in a bent position.

Surgical Procedure

The goal of the surgical procedure is to "release" the tight tunnel so the tendon can move freely without catching. This is typically an outpatient procedure performed under local anesthesia. The surgery involves making a small incision in the palm and releasing the tunnel to create more space for the tendon to move.

Wrist and hand fractures, particularly those involving the radius, are common injuries and often result from falls or accidents. The radius is the larger of the two forearm bones located just before the wrist joint. These fractures tend to occur in two main age groups:

- Young Adults: Typically caused by high-energy incidents such as sports injuries or motor vehicle accidents.

- Older Adults: Often the result of low-energy falls, such as a fall onto an outstretched hand.

These injuries are frequently referred to as Colles fractures.

Treatment Options

Treatment for wrist fractures varies based on the severity of the injury and the patient's needs, ranging from simple immobilisation with a cast to surgical stabilisation.

Non-Operative Treatment: 

Involves immobilisation in a cast for approximately 6 weeks. Regular X-rays are used to monitor the healing process, especially if there was initial displacement.

Operative Stabilisation:

More severe fractures may require surgery, commonly involving the use of plates and screws to stabilize the bone. After surgery, the dressing is removed after 2 weeks and the patient is fitted with a removable brace.

The choice of treatment often relies on regular X-rays to assess the fracture, and in some cases, a CT scan may be performed to provide better 3D visualisation, particularly when the joint is involved.

Rehabilitation

The goal of treatment is to reduce disability and restore motion and strength. However, even with the best care, some patients may not regain full function. Full recovery of strength and motion can take up to 6 months.

Patients are often referred to hand therapy for range-of-motion exercises and rehabilitation. This therapy helps facilitate recovery and improve function.

While it's rare for these fractures not to heal, the recovery process can take time, and following the prescribed rehabilitation is key to regaining as much function as possible.

De Quervain's tenosynovitis is a condition affecting the tendons on the thumb side of the wrist. It occurs when the tendons, specifically the extensor pollicis brevis and abductor pollicis longus, become inflamed and irritated within their sheaths. This leads to pain, tenderness, and sometimes swelling around the base of the thumb, particularly when moving the thumb or making a fist.

Common Causes

The condition often results from repetitive hand and wrist movements, such as gripping, twisting, or lifting. It is common among people who engage in activities that involve frequent thumb use, such as texting, typing, playing racquet sports, or lifting heavy objects. Pregnant women and new mothers may also be at risk due to the additional strain of caring for a baby.

Treatment Options

Non-surgical treatment options for De Quervain's tenosynovitis typically begin with rest, immobilization with a splint, and anti-inflammatory medications. Physical therapy and corticosteroid injections may also help alleviate symptoms. If these methods do not provide relief, or if the condition is severe, surgery may be considered.

Surgery and Post-Surgery Rehabilitation

Surgery involves releasing the tight sheath around the tendons to allow them to move freely and reduce irritation. This is usually an outpatient procedure performed under local anesthesia. After surgery, the wrist may be immobilized in a splint for a short period to promote healing. Post-surgery rehabilitation includes exercises to gradually restore movement, strength, and function to the wrist and thumb. Physical therapy can help guide the recovery process and ensure optimal outcomes. Most patients experience significant improvement in symptoms and regain full use of their wrist and thumb after recovery.