Hands
Carpal tunnel syndrome
Carpal tunnel syndrome (CTS) is a condition where the median nerve is compressed where it passes through a short tunnel at the wrist. The tunnel contains the tendons that bend the fingers and thumb as well as the nerve (see diagram). CTS commonly affects women in middle age but can occur at any age in either sex. CTS can occur with pregnancy, diabetes, thyroid problems, rheumatoid arthritis and other less common conditions, but most sufferers have none of these. CTS may be associated with swelling in the tunnel which may be caused by inflammation of the tendons, a fracture of the wrist, wrist arthritis and other less common conditions. In most cases, the cause is not identifiable.
What are the symptoms?
The main symptom is altered feeling in the hand, affecting the thumb index, middle and ring fingers; it is unusual for the little finger to be involved. Many people describe the altered feeling as tingling. Tingling is often worse at night or first thing in the morning. It may be provoked by activities that involve gripping an object, for example a mobile telephone or newspaper, especially if the hand is elevated. In the early stages the symptoms of tingling intermittent and sensation will return to normal. If the condition worsens, the altered feeling may become continuous, with numbness in the fingers and thumb together with weakness and wasting of the muscles at the base of the thumb. Sufferers often described a feeling of clumsiness and drop objects easily. CTS may be associated with pain in the wrist and forearm. In some cases, nerve conduction tests are needed to confirm the diagnosis. Blood tests and x-rays are sometimes required.
What is the treatment?
Non-surgical treatments include the use of splints, especially at night, and steroid injection into the carpal tunnel. CTS occurring in pregnancy often resolves after the baby is born. Surgery is frequently required. The operation involves opening the roof of the tunnel to reduce the pressure on the nerve. The most common method involves an incision over the tunnel at the wrist, opening the roof under direct vision. The surgery is usually performed under a local anaesthetic. The outcome is usually a satisfactory resolution of the symptoms. Night pain and tingling usually disappear within a few days. In severe cases, improvement of constant numbness and muscle weakness may be slow or incomplete. It generally takes about three months to regain full strength and a fully comfortable scar.
Cubital tunnel syndrome
Cubital tunnel syndrome is compression or irritation of the ulnar nerve in a tunnel on the inside of the elbow. The ulnar nerve provides sensation to the little finger and part of the ring finger, and power to small muscles in the hand.
What are the causes?
Most cases arise without an obvious cause, sometimes the tunnel can be narrowed by arthritis of the elbow joint.
What are the symptoms?
Numbness or tingling of the little and ring fingers are usually the earliest symptom. It is frequently intermittent, but may later become constant. Often the symptoms can be provoked by leaning on the elbow or holding the elbow in a bent position. Sleeping with the elbow bent can also aggravate the symptoms. In the later stages, the numbness is constant and the hand becomes weak.
What is the treatment?
Avoid or modify any activity that aggrevates the nerve. Eg avoid leaning on the inside of the elbows or wear protective pads. Excessive bending of the elbow at night can be minimised by a folded towel wrapped around the elbow, or by a splint provided by a therapist. These manoeuvres may be curative in early cases. Surgery to decompress the nerve is required in severe cases, or in those that do not respond to the non-surgical treatments above. Surgery frequently improves the numbness, but its chief objective is to prevent the progressive muscle weakness and wasting that tends to occur in severe untreated cases. Several operations are used, including simple opening of the roof of the tunnel (decompression) or moving the nerve into a new location at the front of the elbow.
What is the outcome?
The outcome depends upon the severity of the compression being treated. Numbness frequently improves, though the improvement may be slow. Surgery generally prevents worsening of the muscle weakness, but improvements in muscle strength are often slow and incomplete. In the mild cases you can expect there to be full resolution of symptoms in most cases.
Ganglions
Ganglion cysts are the commonest type of swelling in the hand and wrist. They contain a thick clear fluid and can arise a variety of structures but there are four common locations in the hand and wrist - in the middle of the back of the wrist, on the front of the wrist at the base of the thumb, at the base of a finger on the palmar side, and on the back of an end joint of a finger. Normaly the diagnosis is obvious but occasionally Xrays or scans may be required to hlp with diagnosis and planning treatment. Ganglions can often be left alone but Mr Platt will discuss the pros and cons of treatment at the time of consultation
Mucous Cysts
A mucous cyst is a type of ganglion that occurs at the end joint of a finger. It can cause a groove in the nail and may sometimes leak a stick fluid.
Dupuytren's contracture
Dupuytren’s disease (also referred to as Dupuytren's contracture) is a common condition that usually arises in middle age or later and is more common in men than women. Firm nodules appear in the ligaments just beneath the skin of the palm of the hand, and in some cases they extend to form cords that can prevent the finger straightening completely. The nodules and cords may be associated with small pits in the skin. Nodules over the back of the finger knuckles (Garrod's knuckle pads) and lumps on the soles of the feet are seen in some people with Dupuytren's disease.
What are the symptoms?
Dupuytren's disease begins with nodules in the palm, often in line with the ring finger. The nodules are sometimes uncomfortable on pressure in the early stages, but the discomfort almost always improves over time. In about one affected person out of every three, the nodules extend to form cords that pull the finger towards the palm and prevent it straightening fully. Without treatment, one or more fingers may become fixed in a bent position. The web between thumb and index finger is sometimes narrowed. Contracture of fingers is usually slow, occurring over months and years rather than weeks.
What is the treatment?
There is no cure. Surgery can usually make bent fingers straighter, though not always fully straight; it cannot eradicate the disease. Over the longer term, Dupuytren's disease may reappear in operated digits or in previously uninvolved areas of the hand. But most patients who require surgery need only one operation during their lifetime. Injection of collagenase is helpful in some cases. Surgery is not needed if fingers can be straightened fully. It is likely to be helpful when it has become impossible to put the hand flat on a table, and should be discussed with a surgeon at this stage. The surgeon can advise on the type of operation best suited to the individual, and on its timing. The procedure maybe carried out under local, regional (injection of local anaesthetic at the shoulder) or general anaesthetic.
Surgical options are:
1. Fasciotomy. The contracted cord of Dupuytren’s disease is simply cut in the palm, in the finger or in both, using a small knife or a needle.
2. Segmental fasciectomy. Short segments of the cord are removed through one or more small incisions.
3. Regional fasciectomy. Through a single longer incision, the entire cord is removed.
4. Dermofasciectomy. The cord is removed together with the overlying skin and the skin is replaced with a graft taken usually from the upper arm. This procedure is usually undertaken for recurrent disease, or for extensive disease in a younger individual and helps prevent recurrence. After surgery, the hand may be fitted with a splint to be worn at night. Hand therapy is important in recovering movement and function, especially for more extensive surgery and skin grafts. The recovery is variable with regard to the degree of improvement achieved and the time to achieve the final position. The final outcome is dependent on many factors including the extent and behaviour of the disease itself and the type of surgery required.
Trigger finger
Trigger finger is a painful condition in which a finger or thumb clicks or locks as it is bent towards the palm. Thickening of the mouth of a tendon tunnel leads to roughness of the tendon surface, and the tendon then catches in the tunnel mouth. People with diabetes are especially prone to triggering. There is little evidence that it is caused by work activities, but the pain can certainly be aggravated by hand use at work, at home, in the garden or at sport.
What is the treatment?
Trigger finger and trigger thumb are not harmful, but can be a really painful nuisance. Some mild cases recover over a few weeks without treatment. The options for treatment are:
1. Avoiding activities that cause pain, if possible
2. Using a small splint to hold the finger or thumb straight at night. A splint can be fitted by a hand therapist, but even a lollipop stick held on with tape can be used as a temporary splint. Holding the finger straight at night keeps the roughened segment of tendon in the tunnel and makes it smoother.
3. Steroid injection relieves the pain and triggering in about 70% of cases, but the success rate is lower in people with diabetes. The risks of injection are small, but it very occasionally causes some thinning or colour change in the skin at the site of injection. Improvement may occur within a few days of injection, but may take several weeks. A second injection is sometimes helpful, but surgery may be needed if triggering persists.
4. Surgical decompression of the tendon tunnel under a local anaesthetic. Through a small incision the mouth of the tendon tunnel is opened by slitting its roof. The wound will require a small dressing for 10-14 days, but light use of the hand is possible from the day of surgery and active use of the digit will aid the recovery of movement. Pain relief is usually rapid. Although the scar may be red and tender for several weeks, it is seldom troublesome in the longer term. Recurrence of triggering after surgery is uncommon.
Hand arthritis
Osteoarthritis in the hand is a common cause of pain and disability. Many joints can be affected but one of the most common is the basal joint of the thumb. This universal joint at the base of the thumb often becomes arthritic as people get older.
What are the symptoms?
1. Pain at the base of the thumb, aggravated by thumb use
2. Tenderness if you press on the base of the thumb
3. Difficulty with tasks such as opening jars, turning a key in the lock etc
4. Stiffness of the thumb and some loss of ability to open the thumb away from the hand
5. In advanced cases, there is a bump at the base of the thumb and the middle thumb joint may hyperextend, giving a zigzag appearance
What is the treatment?
The options for treatment include:
1. Avoiding activities that cause pain, if possible
2. Pain killers
3. Using a splint to support the thumb and wrist. Rigid splints (metal or plastic) are effective but make thumb use difficult. A flexible neoprene rubber support is more practicable
4. Steroid injection improves pain in many cases, though the effect may wear off over time
5. Surgery is a last resort, as the symptoms often stabilise over the long term and can be controlled by the non-surgical treatments above. There are various operations that can be performed to treat this condition. Removal of the bone at the base of the thumb - trapeziumectomy is the most common.
Injections for arthritis
Mr Platt offers steroid injections for arthritis of the small joints in the hand.