Common Problems
of the Wrist and Hand

Below is a list of common problems of the wrist and hand. The brief treatment descriptions are meant only as introduction. Our highly-qualified physicians will be able to discuss in further detail your condition and treatment options.

Broken Bones - Scaphoid

Introduction

One of the more common bones to break around the wrist is the scaphoid (sometimes called the navicular). The scaphoid is one of the first bones of the base of the hand (carpal bones) and sits on the end of one of the two forearm bones called the radius. Its location between the forearm and the hand combined with its narrow-waisted, peanut shape make it particularly vulnerable to breaking when the wrist is forcibly bent back. It is a common injury in sports (like football) but can be broken anytime a person falls onto an outstretched hand.


The main symptoms of a scaphoid fracture are pain and swelling around the wrist. People often think that if they can still move their wrist after an injury that no bones are broken. This is not the case with scaphoids. Scaphoid fractures are often diagnosed late due to the fact that the pain is not always severe, the swelling is not dramatic, and the bruising is often minimal or absent. If there is anything to suggest a serious injury, the wrist should be evaluated by a qualified health care professional including the use of x-ray to examine the bone. Even x-rays are not 100% accurate in revealing the fracture, especially in the first week of injury. For that reason, repeat x-rays (and occasionally an MRI or CT scan) are often obtained 7-10 days after the injury in suspicious cases.

Treatment

The initial treatment in known or suspected fractures is immobilization with a splint, elevation to reduce swelling, and ice for comfort if necessary. An evaluation by a hand surgeon is preferably done within 7-10 days of the initial injury. The treatment can then be tailored to the specific pattern, location and severity of the break. The majority of scaphoid fractures can be treated with immobilization alone, typically in a fiberglass cast for 6-12 weeks. This is often followed by the use of a removable brace to allow motion exercises. Therapy is sometimes required to regain motion and strength.


In certain cases, especially when the pieces of the bone are clearly separated, surgery is considered. This typically involves realigning the broken ends of the bone and holding them together using a metal implant such as a screw. This can be done safely in an outpatient setting.

 

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People often think that if they can still move their wrist after an injury that no bones are broken.

Broken Bones - Scaphoid

Figure: a screw or pins are placed to stabilize the fracture

Photos used with permission from www.assh.org

Carpal Tunnel Syndrome

Introduction

Carpal Tunnel Syndrome (CTS) is condition where a nerve is compressed as it enters the hand near the base of the palm. When the nerve gets compressed, people experience a variety of symptoms including numbness, tingling, pain and weakness of the hand. The symptoms are often brought on by repetitive or prolonged hand activity. Frequently, people with CTS will notice that their hand gets numb or painful at night, causing them to wake up. Some will notice numbness when they first wake up in the morning. In more advanced cases, some degree of numbness or tingling may be present constantly.

 

The particular nerve involved is called the median nerve. It provides the feeling to the thumb, index, middle and ring fingers as well as the signal to move many of the muscles of the thumb. The median nerve (along with the tendons that make the fingers and thumb bend) enters the hand near the base of the palm through what is known at the carpal tunnel. The floor of the tunnel is made up of the bones at the base of the hand (carpal bones) that form a "U" shaped arch. The roof of the tunnel is a thick ligament that spans from one side of the "U" to the other.

 

The exact cause of CTS is not known, but ultimately comes down to a balance between the size of the tunnel versus the thickness of the structures passing through the tunnel. When the tissues are too thick (from inflammation of the finger tendons, for example), the tunnel becomes too tight and the nerve gets squeezed. CTS tends to be slightly more common in women, more common as we get older, and very common in certain diseases such as diabetes.

Treatment

For patients with mild symptoms (occasional numbness without major impact on function), simply reducing repetitive activity or taking more frequent breaks to rest and stretch may be enough to keep things under control. Anti-inflammatory medications might be helpful to settle down a short-term flare up. If the night-time numbness is the main issue, wrist braces worn while sleeping can often keep people comfortable. Braces (available at your local pharmacy) can counteract the additional kinking and compression of the nerve that commonly occurs when the wrists are bent while sleeping. If a person has CTS for a short-term reason (pregnancy is a common example), steroid ("cortisone") injections are sometimes considered. Even in pregnancy, a steroid injection can safely decrease the swelling of the tissues in the tunnel until the body gets back to normal.

 

If symptoms are not adequately controlled with the above treatments, consideration is sometimes made for surgery. Although many surgical techniques exist, they all aim to divide the roof of the tunnel to create more space. The roof of the tunnel does eventually heal back together, but in a more relaxed position similar to loosening the laces of a tight shoe. The surgery is a very safe and is typically done as an outpatient procedure that does not require general anesthesia. For most people, the surgery only needs to be done once.

 

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2nd leading cause of missed work*

Carpal Tunnel Syndrome

*According to a 2007 report from the Bureau of Labor Statistics, carpal tunnel syndrome was associated with the second longest average time away from work (28 days) among the major disabling diseases and illnesses in all private industries.

Dupuytrens

Introduction

Dupuytren’s disease is a genetically-based condition that typically affects people of northern European ancestry over the age of fifty. The condition causes a gradual thickening and contracting of the tissue of the palm and fingers, resulting in restriction of full extension.


The palm of the hand and fingers has a special layer of tissue just underneath the skin and fat known as the palmar fascia. The fascia provides extra stability needed for grasp. This layer is not present on the back of the hand, where the skin and fat are soft and loose. In Dupuytren’s disease, the fascia slowly begins to thicken and contract, often over the top of the ring and small fingers. Initially, the only noticeable effect may be some thickening and lumpiness in the palm. Eventually, the contraction may progress to where it is difficult to fully straighten the fingers. Although initially the thickened areas may be tender, the condition is often painless. When the contracture becomes significant enough to warrant attention, difficulty with simple activities such as glove wear and placing the hand in a pant pocket become noticeable.

Treatment

In mild cases, where there is no significant restriction of motion, simple observation is usually the treatment of choice. There is no known way to halt the process either by medication, stretching exercise or bracing. The rate of progression is extremely variable from case to case. Some individuals may not require any intervention in their lifetime while others may have multiple procedures starting at an early age. As a general rule, if someone can still place their entire palm flat against a table, no intervention is usually required.


When the impact on hand function becomes unacceptable, active treatment is considered. The method of treatment is individually tailored depending on the location and severity of the contracture and the person’s functional needs. Most treatments involve some form dividing, removing or dissolving the thickened tissue to untether the affected digits. This is typically done is an outpatient setting, often followed by therapy to restore motion and minimize recurrence.

 

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Treatment is individually tailored depending on location and severity.

Carpal Tunnel Syndrome

Figure: Table top test.

Photos used with permission from www.assh.org

Finger Sprains and Dislocations

Introduction

Sprains and dislocations of the finger joints are one of the most common injuries to the hand. The most frequently injured joint is the proximal interphalangeal joint (PIP joint), which is the second closest joint to the fingertip. From a simple “jammed” finger playing basketball to a sudden fall from tripping on the sidewalk, the PIP joint can get bent backwards (hyperextended) causing injury to the supporting structures.


Like most of the joints of the fingers, the PIP joint has three main supporting structures. On each side of the joint there are strong bands of tissue known as the collateral ligaments. These keep the joint from bending sideways. On the palm side of the joint, there is a thick band of tissue known as the volar plate. This keeps the joint from being able to hyperextend. You can test these stabilizers on your own uninjured fingers and feel the resistance to movement. When a joint is forcibly hyperextended, such as when a basketball unexpectedly hits the fingertip, the stabilizers are stretched and sometimes even torn. This injury to the stabilizers and the subsequent pain, swelling and stiffness are what we refer to as a sprain. When the stabilizers are torn completely and the bones of the joint separate and become misaligned, we refer to this as a dislocation.

 

Judging the severity of a sprain or dislocation is difficult, and any suspicious injury should be evaluated by a qualified health care provider. Not all sprains and dislocations, even when properly realigned, heal normally with simple rest and time.

Treatment

If a PIP joint is merely sprained, rest, icing and a brief period of splinting are often recommended as initial treatment. When comfort allows, movement of the joint is encouraged to try to counter the stiffening that occurs as the body tries to healed the damaged tissue. Taping of the injured finger to the neighboring uninjured finger (buddy taping) is often done to allow movement with some degree of protection. Caution with high risk activities such as sports is usually needed for at least a few weeks to allow the injured ligaments to heal and re-stabilize the joint. Hand therapy is sometimes required to help regain motion and strength.

 

If a PIP joint is dislocated, urgent realignment of the joint is required. Although some people are able to successfully realign their own finger with a quick tug, evaluation by a health care provider including the use of x-ray should be considered for all dislocations. Subtle misalignments and even broken bones may be impossible to detect by simple inspection. If a simple dislocation is officially confirmed and realignment of the joint has been achieved, the injury is usually treated similar to a sprain. Because the soft-tissue injury to the joint is more severe, a greater degree of swelling and stiffness is expected as well as a longer period of recovery.

 

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Not all sprains and dislocations, even when properly realigned, heal normally with simple rest and time.

Ganglion Cysts

Introduction

Ganglion cysts are common fluid filled lumps that form next to joints or tendons. Although they often feel firm like a solid object, they are actually filled with the thick fluid that lubricates the associated joint or tendon. Ganglions are not really tumors and do not generally damage the surrounding tissues. Most of the problems associated with ganglions are related to the pressure they apply on their surroundings and the associated discomfort.

 

Although they can occur almost anywhere, certain locations in the upper extremity are extremely common. Around the back or palm side of the wrist, grape-sized cysts are common to see in children and young adults. On the palm side of the fingers, small, BB-sized cysts can sometimes form on tunnel that covers the tendons that bend the fingers (the flexor tendon sheath). These are generally located at the near end of the sheath where the finger attaches to the hand. A specific variety of ganglion cyst, sometimes referred to as a mucous or myxoid cyst, is commonly found around the tip joints of the fingers and thumb. These small cysts are almost always associated with underlying arthritis and are rare to see in people under the age of 40.

 

Outside of the cysts associated with arthritis or a specific tendonitis, the exact cause for most ganglion cysts is unknown. Anything that causes increased fluid production around a joint or tendon (such as over-activity) may result in formation of a cyst or enlargement of an existing cyst. Likewise, when activity is reduced, cyst size often decreases.

Treatment

Treatment decisions are often based on the location, size and discomfort of a given cyst. Small cysts with minimal pain are often left alone. Bracing or splinting the affected area may temporarily decrease the size of the cyst and reduce pain. "Old school" methods of cyst treatment such as striking them with a heavy book are generally not recommended due to their potential for local injury and the high recurrence rate. Draining the cyst with a needle and syringe (aspiration) is sometimes used to give people quick relief from the pressure-related pain. Although relatively simple to perform, the recurrence rate is quite high, mostly because the shell of the cyst is still present and connected to the joint or tendon.

 

When a ganglion is causing significant discomfort and has not responded to simple measures, surgery is often considered. Most ganglion cysts can be removed in a safe, outpatient surgery that does not require general anesthesia. Although varying by location, most ganglions have a recurrence rate of 10-15% after surgery (85-90% permanent removal).

 

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85%–90% success rate for surgically removed ganglion cysts*

Carpal Tunnel Syndrome

Figure: Cross-section of wrist showing stalk (or root) of ganglion.

Photos used with permission from www.assh.org

Infections

Introduction

Like virtually every part of the human body, the hand is vulnerable to infections. The physical barrier of our skin combined with the constant defensive action of our immune system allow us to live in harmony with the billions of bacteria that exist in and around us. On occasion, the defenses can be broken down and bacteria are able to invade and multiply in unwanted areas The two most common paths to infection are by direct entry through a wound in the skin or by traveling through the blood stream, delivering bacteria from one location to another.


One common example of direct entry is animal bites. Cat bites are a frequent cause for a trip to the emergency room. Cat teeth are sharp and narrow, delivering bacteria deep into the tissues where they begin to multiply. The small size of the punctures allows the wounds to close quickly, trapping the bacteria inside and potentially creating a pocket infection known as an abscess. It is not uncommon for a serious cat bite infection to require hospitalization, intravenous antibiotics, and even surgical opening (drainage) of the abscess.

Not all direct entry infections are from trauma. A very common finger infection occurs around the base of the fingernail. The normal bacteria that live on our skin can sometimes find entry between the nail and the skin and start to multiply. This type of infection, called a paronychia, usually causes pain, redness and swelling of the skin around the margins of the nail. In some cases, a small collection of pus can sometimes be seen under the skin or under the nail. Treatment typically includes drainage of the pus and a course of oral antibiotics.


Infections that arise by travel through the blood stream often occur unpredictably. An ordinarily healthy individual can show up in the emergency room with hot, swollen finger with no known wound or injury. In fact, in many cases the original source of the bacteria is never clearly identified.


Although everyone is potentially susceptible to infection, there are certain medical conditions that increase the risk. Diabetes and rheumatoid arthritis are examples where the immune system is compromised and infections are more common.

 

If a hand infection is suspected, the most import first step is to quickly seek evaluation by a qualified health care professional. Redness, swelling, warmth or red streaking in the neighboring area are all local warning signs of a potentially serious infection. Fever, chills and sweats are more general warning signs.

Treatment

Prompt evaluation, potentially including blood tests and cultures, is the best route to recovery with the fewest complications. One should not rely on topical antibiotic ointments since they have limited ability to penetrate under the skin. Antibiotics left over from other infections should never be used since they may or may not be directed at the type of bacteria that is currently the issue.

 

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The normal bacteria that live on our skin can sometimes find entry between the nail and the skin and start to multiply.

Carpal Tunnel Syndrome

Figure: Acute paronychia

Photos used with permission from www.assh.org

Mallet Finger

Introduction

A mallet finger is a common injury caused by the tearing of a tendon at the tip joint of the finger. When this particular tendon tears, the tip of the finger droops down into a flexed position, simulating the appearance of a small hammer (or mallet). It is a frequent sports injury when a ball unexpectedly strikes the tip of a finger, but can occur under any circumstance where the fingertip is forcibly flexed.

 

The joint closest to the tip of the finger is known as the distal interphalangeal joint (DIP joint). There are two tendons that control the movement, a flexor tendon on the palm side and an extensor tendon on the back side. If the tip of the finger is flexed past its normal limit, the extensor tendon will either tear or detach. Once the tendon is disconnected, the fingertip cannot be held straight without support. Under certain circumstances, the tendon will sometimes detach along with a small piece of bone. The only way to know if this has happened is by x-ray.

Treatment

The vast majority of mallet fingers can be treated with immobilization in a splint. Even when completely torn, the extensor tendon at this location does not retract away. The torn ends of the tendon can be brought back together by splinting the joint in full extension. Typically, over a period of 8-12 weeks the body lays down scar tissue to repair the tear. A physician, sometimes with the help of a hand therapist, chooses from a variety of splints to keep the DIP immobilized during healing. The key to proper healing is maintaining the splinted position without interruption, especially in the first six weeks. Allowing the joint to bend during this critical period causes the healing tissue to stretch or tear, prolonging the healing time and sometimes leading to persistent drooping.

 

In a minority of cases, simple splinting is not sufficient to keep the finger properly aligned. Surgery is occasionally considered to repair or tighten the torn tendon or to realign an associated bone fragment. This is done in an outpatient setting, usually without the need for general anesthesia.

 

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Once the tendon is disconnected, a fingertip cannot be held straight without support.

Carpal Tunnel Syndrome

Figure: Extensor Tendon Disruption

Photos used with permission from www.assh.org

Skier's Thumb (Ulnar collateral ligament tear)

Introduction

One of the most common injuries in the hand is a tear of one of the ligaments that supports the side of the thumb. Originally described in Scottish gamekeepers, who stretched out their ligaments holding down animals, its modern name now reflects a more common mechanism of injury, falling onto the hand while skiing.

 

The thumb joint second closest to the tip is known as the metacarpophalangeal joint, or MP joint. On each side of the joint, there are thick bands of tissue known as the collateral ligaments that limit side to side motion. When the hand is used to break a fall (not just while skiing), the thumb is often pulled away from the fingers, severely stressing the ligament on the side closest to the index finger (referred to as the ulnar collateral ligament or UCL). The UCL can become partially torn, completely torn or detached with a fragment of bone. When the ligament is injured, people will typically experience pain, swelling and occasionally bruising around the MP joint.

 

The severity of a thumb ligament injury is very difficult to assess by appearance alone. If an injury is suspected, evaluation by a qualified health care professional possibly including x-rays or MRI (magnetic resonance imaging) is recommended.

Treatment

If the thumb ligament is found to be injured, initial treatment usually consists of immobilization with a splint, elevation to reduce swelling and icing for comfort if needed. An evaluation by a hand surgeon is preferably done within 7-10 days of the injury. Examination of the joint to test for stability, often combined with the x-rays or MRI, will help determine the severity of the injury. Careful attention is made to assess the location of the torn end of the ligament. In some cases, the ligament is flipped back and trapped under other tissues (Stener's lesion), potentially limiting its ability to heal properly.

 

Many UCL tears can be treated with simple immobilization alone. If the joint has no detectable looseness (laxity) under stress, casting or bracing of the thumb for 6-8 weeks should allow the ligament to heal and restore painless function.

 

If the joint feels loose or unstable under stress (especially when a Stener’s lesion is present), or if a bone fragment has been pulled off and is misaligned, surgery may be considered. In surgery, the ligament is typically stitched back together or anchored back to the bone. Any bone fragments would be realigned and stabilized as well. Surgery may involve the use of small metal implants on a temporary or permanent basis. Even with surgery, a period of immobilization is required similar to non-surgical treatment. The surgery can be done safely in an outpatient setting.

 

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Many UCL tears can be treated with simple immobilization alone.

Skier's Thumb

Figure: The ulnar collateral ligament (UCL) and the radial collateral ligament (RCL) help stabilize the thumb.

Photos used with permission from www.assh.org

Steroid injections

Introduction

Steroid, or “cortisone”, injections are a very common treatment for a wide range of painful or inflammatory conditions around the hand, wrist and elbow. Unlike pills, injected steroids deliver a high concentration of the medicine directly to the area of concern and minimize the side effects to the body as a whole.

 

The steroids that are used for injection are just one member of a large family of compounds known are hormones. The hormones produced naturally in the body regulate many biological functions such as growth, metabolism, inflammation and reaction to stress or injury. The synthetically produced steroids used for injections (e.g. betamethasone, triamcinolone) are in a group called glucocorticoids. Like their naturally occurring counterparts, this group has a number of functions including regulation of inflammation and the immune system. These the steroids should not be confused with anabolic steroids that have been misused for performance enhancement in sports. Anabolic steroids mimic the action of testosterone and are not generally used for musculoskeletal problems.

 

Two of the most common conditions treated by steroid injection are tendonitis and arthritis. In the wrist and hand, most of the tendons pass through tunnels (tendon sheathes) that keep them tracking properly as they move. When a tendon is injured or overused, it often becomes swollen, making it more difficult to glide through its narrow tunnel. This results in pain and limitation of motion. A steroid injection can quickly reduce the swelling and associated pain, sometimes on a permanent basis.

 

In arthritic conditions, the protective tissue at the ends of the bones (articular cartilage) is reduced or lost, allowing bone to bone contact within the joint. This triggers inflammation, with resulting pain, stiffness and swelling. A steroid injection in the joint can quickly reduce the inflammation, allowing resumption of activity with comfort. Although the effect is temporary, since the underlying cartilage loss remains, the benefits can often last for months at a time.

 

Like most medications, steroid injections do have potential side effects. The most common is a temporary flare of pain directly in the site of injection. Though uncomfortable, it predictably resolves over a period of a few days. Less common side effects include lightening of the skin color or thinning of the fat at the site of injection. These effects are not dangerous, and will often reverse over time. Extremely rare complications include infection and tendon ruptures.

 

Some common misunderstandings exist regarding steroid injections. One popular myth is that a person can only receive three injections in one location in their lifetime. Although the frequency of injections is often kept to three or less a year, there is no specific lifetime limit. Injections are often stopped after three attempts because they are no longer effective, not due to safety concerns. Another common myth is that steroid injections cause arthritis. Although increased activity due to pain relief may play some role, the worsening of arthritis is largely due to the natural progression of the disease rather than to steroid exposure.

 

Steroid injections are a safe and effective treatment alternative for a variety of painful conditions. You can have a detailed discussion with your hand surgeon or other health care professional to determine whether or not it is right for you.

 

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Injected steroids minimize the side effects to the body as a whole.

Carpal Tunnel Syndrome

Figure: Steroid injection sites

Photos used with permission from www.assh.org

Thumb base arthritis

Introduction

The thumb base is a common joint to be affected by arthritis. The joint experiences significant stress with any activity that requires pinching or grip. Any deterioration of the joint can lead to pain, swelling and weakness of the thumb.

 

The two main bones that comprise the base are the thumb metacarpal bone and the small bone that it sits on called the trapezium. The joint between these two bones is known at the carpometacarpal or CMC joint. Normally, the two surfaces where the bones meet are covered with a special tissue called articular cartilage. The cartilage allows the two bones to touch and glide on each other with minimal friction during movement and pinch. In osteoarthritis, the most common type of arthritis affecting the thumb base, the cartilage degenerates over time. Ultimately, the underlying bone is exposed and direct bone to bone contact occurs with activity. Since the bones are no longer smooth and cushioned, pain and inflammation result. People will often notice that their joint has become enlarged, warm and tender. There is often achiness with rest and episodes of sharp pain with pinch and grasp.

Treatment

For mild cases, where the pain is only with activity and the discomfort is tolerable, simple rest, icing and anti-inflammatory medications may be enough to get a flare up to settle down. Joint specific dietary supplements (e.g. chondroitin and glucosamine) might be slightly better than placebo for pain relief, but have not been proven to rebuild or restore damaged cartilage. In more persistent cases, bracing of the thumb base may be helpful. Off-the-shelf braces are available at your local pharmacy, but a brace fabricated or fitted by a hand therapist may provide a better fit with less bulk and restriction.


When non-invasive measures are not effective, a steroid (cortisone) injection can be quite helpful. A small injection of medication into the CMC joint can quickly get a flare up to calm down, often for months at a time. Steroid injections do not cure the underlying arthritis, but can often allow people to manage their discomfort and continue to lead active lifestyles.


When conservative measures are not effective, surgical reconstruction of the thumb base may be considered. Unlike the hip and knee, arthritis surgery for the thumb base does not usually involve the use of artificial implants. During surgery, the arthritic section of the joint (usually the trapezium) is removed and the joint is stabilized using neighboring soft tissues (often the flexor carpi radialis tendon). The surgery is typically done as an outpatient procedure.

 

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A brace fabricated or fitted by a hand therapist may provide a better fit with less bulk and restriction.

Carpal Tunnel Syndrome

Figure: Thumb Basal Joint

Photos used with permission from www.assh.org

Trigger Fingers

Introduction

Triggering is a very common condition that affects the tendons that bend (flex) the fingers and the thumb. The tendons get stuck as they try to pull, causing a clicking or catching sensation with bending of the joints. In more advanced cases, the affected digit will actually get stuck in a flexed position.

 

All of the finger and thumb flexor tendons travel down tunnels (tendon sheaths) that guide them down the digits into the palm. Normally, just the right amount of room exists in the tunnel to allow the tendons the glide smoothly. If the tendon becomes swollen, in reaction to overuse for example, it sticks or catches in the tunnel as it tries to glide. This catch often makes the joint of the affected digit feel as if it were popping or clicking. If the tunnel is really tight, the tendon will get trapped, and cause the digit to get stuck in flexed (or occasionally extended) position. People often have their worst triggering first thing in the morning, but symptoms can occur at any time. The irritated area can become quite painful and tender, especially on the palm side of the digit near its base.

 

Triggering is often caused by overactivity, such as repetitive gripping. Individuals with certain diseases such as diabetes have a predisposition for triggering.

Treatment

For a mild case of triggering, simply decreasing activity (avoiding repetitive gripping, for example) may be all that is required. Anti-inflammatory medications may also be helpful to ease the discomfort. Temporary splinting of the affected digit may help if reduction of activity for the hand overall is not possible.

 

Steroid (cortisone) injections are a very effective treatment, especially when given 3-6 months from the start of symptoms. One or two injections can often cure the triggering and get people back to normal. Injections are often used in diabetics as well, but statistically the cure rate is lower.

 

If conservative measures are not working, surgery may be recommended. The goal of surgery is to open the tight portion of the tendon sheath to allow smooth gliding of the tendon. The tight section is usually the near end of the tunnel, close to where the finger or thumb attaches to the hand. The surgery is a safe, outpatient procedure that does not require general anesthesia and is often done in an office operating room setting. The beneficial results of the surgery are usually permanent.

 

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Procedures are typically done safely in an outpatient setting.

Carpal Tunnel Syndrome

Figure: Abnormal anatomy showing tendon catching thick, tight pulley. Sometimes the tendon will be locally enlarged and thicker.

Photos used with permission from www.assh.org

Wrist Sprains

Introduction

Although the wrist appears simple from the outside, the inside of the joint is a complex interconnection of ligament, bones, cartilage, and tendons. When someone sustains impact to their wrist, any one or a combination of those structures can get damaged, resulting in pain and loss of function.

 

The most common mechanism of injury is a fall onto an outstretched hand, causing the wrist to be forcibly bent backwards (hyperextended). When this occurs, the ligaments (direct bone to bone connections) are stretched and sometimes torn. Similarly, the small bones of the base of the hand (the carpal bones) can actually be broken by the leverage of the force from the hand and forearm.

 

There are two types of cartilage in the wrist. The articular cartilage is the smooth, shiny covering on the bone that allows two bones touch with minimal friction. Fibrocartilage is a fibrous, thicker material that sits between certain bones acting like a cushion or bumper. Either type of cartilage can be scuffed or torn when compression and shearing occur in the wrist with impact.

 

Tendons connect muscle to bone, allowing the muscles to move and control our joints. In a fall, the muscles and tendons tighten by reflex to brace for the impact. Under this kind of load, the tendons can be strained and sometimes torn. This is especially true in areas where the tendons make a change of direction (common near the wrist).

Treatment

The severity of a wrist sprain is very difficult to assess just by inspection alone. The degree of a pain, swelling and bruising may not be very different between a mild sprain where soft tissues have been merely stretched versus a severe injury where ligaments are completely torn or carpal bones may be broken. If a wrist injury looks suspicious at all, prompt evaluation by a qualified health care professional is recommended. A careful examination of the wrist, often combined with imaging studies such as x-ray and MRI (magnetic resonance imaging), will sort out which structures have been injured and how severely. The initial treatment, regardless of severity, is typically immobilization with a splint, elevation to reduce swelling and icing for comfort.

 

Ultimately, an evaluation by an experienced hand surgeon will lead to a specific treatment plan. Many sprains can be treated with immobilization alone, often in some type of removable brace. For some injuries; especially if serious soft tissue or bone damage has been identified, surgery may be considered. The goal of surgery is usually to repair, remove or replace the damaged structures. These procedures are typically done safely in an outpatient setting.

 

 

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The wrist is a complex interconnection of ligament, bones, cartilage, and tendons

Carpal Tunnel Syndrome

Figure: Ligaments of wrist

Photos used with permission from www.assh.org