What are Common Hand & Wrist Injuries?

 

Arthritis of the Hand

 

What Is Arthritis?

Arthritis literally means "inflamed joint." Normally a joint consists of two smooth, cartilage-covered bone surfaces that fit together as a matched set and that move smoothly against one other. Arthritis results when these smooth surfaces become irregular and don’t fit together well anymore and essentially “wear out.” Arthritis can affect any joint in the body, but it is most noticeable when it affects the hands and fingers. Each hand has 19 bones, plus 8 small bones and the two forearm bones that form the wrist. Arthritis of the hand can be both painful and disabling. The most common forms of arthritis in the hand are osteoarthritis, post-traumatic arthritis (after an injury), and rheumatoid arthritis. Other causes of arthritis of the hand are infection, gout, and psoriasis.

Osteoarthritis of the Hand

Osteoarthritis is a degenerative joint disease in which the cushioning cartilage that covers the bone surfaces at the joints begins to wear out. It may be caused by simple "wear and tear" on joints, or it may develop after an injury to a joint. In the hand, osteoarthritis most often develops in three sites (see Figure 1):

• at the base of the thumb, where the thumb and wrist come together (the trapezio-metacarpal, or basilar, joint).
• at the end joint closest to the finger tip (the distal interphalangeal or DIP joint).
• at the middle joint of a finger (the proximal interphalangeal or PIP joint).

It also often develops in the wrist.

Signs and Symptoms of Arthritis of the Hand

Stiffness, swelling, and pain are symptoms common to all forms of arthritis in the hand. With osteoarthritis, bony nodules may develop at the middle, or PIP, joint of the finger (Bouchard’s nodes), and at the end-joints, or DIP, of the finger (Heberden’s nodes) (see Figure 2). A deep, aching pain at the base of the thumb is typical of osteoarthritis of the basilar joint. Swelling and a bump at the base of the thumb where it joins the wrist may also be observed. Grip and pinch strength may be diminished, causing difficulty with activities such as opening jars or turning keys. Pain, swelling, stiffness, and diminished strength are also seen with osteoarthritis of the wrist.

How Is Osteoarthritis Diagnosed?

Your doctor will examine you and determine whether you have similar symptoms in other joints and assess the impact of the arthritis on your life and activities. The clinical appearance of the hands and fingers helps to diagnose the type of arthritis. X-rays will also show certain characteristics of osteoarthritis, such as narrowing of the joint space, the formation of bony outgrowths (osteophytes or “nodes”), and the development of dense, hard areas of bone along the joint margins.

Treatment for Osteoarthritis of the Hand

Treatment is designed to relieve pain and restore function. Anti-inflammatory or other analgesic medication may be of benefit in relieving pain. Brief periods of rest may help if the arthritis has flared up. You may also be advised to wear finger or wrist splints at night and for selected activities. Often soft sleeves may be of some benefit when the rigid splints are too restrictive, especially when the arthritis is affecting the joint at the base of your thumb. Heat modalities in the form of warm wax or paraffin baths might help, and when severe swelling is present, cold modalities may be of help. It is important to maintain motion in the fingers and use the hand as productively as possible. Hand therapy is often helpful with these exercises, splints, and modalities. A cortisone injection can often provide relief of symptoms, but does not cure the arthritis. Surgery is usually not advised unless these more conservative treatments fail.

Base of 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 to pinch with the fingers.

Who Gets Arthritis at the Base of the Thumb?

Arthritis at the base of the thumb is more common in women and usually starts after age 40. The cause of this form of arthritis is unknown in most cases. Past injuries to the joint, such as fractures or severe sprains, and generalized joint laxity may increase the chances of developing this form of arthritis at a younger age.

What Are the Symptoms and Signs of Arthritis at the Base of the Thumb?

The most common symptom of thumb basal joint arthritis is a deep, aching pain at the base of the thumb. The pain is often worsened with activities that involve pinch, including opening jars, turning door knobs or keys, and writing. As the disease progresses, patients may experience pain at rest and at night, and patients often note loss of pinch and grip strength. In severe cases, progressive destruction and mal-alignment of the joint occurs and a “bump” develops at the base of the thumb, which is caused by the thumb metacarpal moving out of position in relation to the trapezium. At this point, thumb motion becomes limited and the space between the thumb and index finger narrows, making pinch activities difficult. The next joint up may hyper-extend to compensate.

How Is the Diagnosis Made for Arthritis at the Base of the Thumb?

The appearance of the thumb and the location of the pain are usually very helpful in identifying this condition. Applying longitudinal pressure along the thumb and twisting or grinding the basal joint is also helpful in reproducing symptoms. Although X-rays help confirm the diagnosis, symptom severity often does not correlate directly with the joint’s appearance on the X-ray.

What Are the Treatment Options for Arthritis at the Base of the Thumb?

Less severe thumb arthritis will usually respond to non-surgical care. Pain medication, topical agents, splinting, and limited use of corticosteroid injections may help alleviate pain. A hand therapist might provide a variety of rigid and non-rigid splints to support the thumb during activities.

Carpal Tunnel Syndrome

What Is 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. 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.

What Causes Carpal Tunnel Syndrome?

Usually the cause is unknown. Pressure on the nerve can happen several ways: swelling of the lining of the flexor tendons, called tenosynovitis; joint dislocations, fractures, and arthritis can narrow the tunnel; and keeping the wrist bent for long periods of time. Fluid retention during pregnancy can cause swelling in the tunnel and symptoms of carpal tunnel syndrome, which often go away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes also can be associated with carpal tunnel syndrome. There may be a combination of causes.

Signs and Symptoms of Carpal Tunnel Syndrome

Carpal tunnel syndrome symptoms usually include pain, numbness, tingling, or a combination of the three. The numbness or tingling most often takes place in the thumb, index, middle, and ring fingers. The symptoms usually are felt during the night but also may be noticed during daily activities such as driving or reading a newspaper. Patients may sometimes notice a weaker grip, occasional clumsiness, and a tendency to drop things. In severe cases, sensation may be permanently lost and the muscles at the base of the thumb slowly shrink (thenaratrophy), causing difficulty with pinch.

Diagnosis of Carpal Tunnel Syndrome

A detailed history including medical conditions, how the hands have been used, and whether there were any prior injuries is important. An X-ray may be taken to check for the other causes of the complaints such as arthritis or a fracture. In some cases, laboratory tests may be done if there is a suspected medical condition that is associated with CTS. A nerve conduction study (NCV) and/or electromyogram (EMG) may be done to confirm the diagnosis of carpal tunnel syndrome as well as to check for other possible nerve problems.

Treatment of Carpal Tunnel Syndrome

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. When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve.

Cubital Tunnel Syndrome

What Is Cubital Tunnel Syndrome?

Cubital tunnel syndrome is a condition brought on by increased pressure on the ulnar nerve at the elbow. There is a bump of bone on the inner portion of the elbow (medial epicondyle) under which the ulnar nerve passes. This site is commonly called the “funny bone”. At this site, the ulnar nerve lies directly next to the bone and is susceptible to pressure. When the pressure on the nerve becomes great enough to disturb the way the nerve works, then numbness, tingling, and pain may be felt in the elbow, forearm, hand, and/or fingers.

What Causes Cubital Tunnel Syndrome?

Pressure on the ulnar nerve at the elbow can develop in several ways. The nerve is positioned right next to the bone and has very little padding over it, so pressure on this can put pressure on the nerve. For example, if you lean your arm against a table on the inner part of the elbow, your arm may fall asleep and be painful from sustained pressure on the ulnar nerve. If this occurs repetitively, the numbness and pain may be more persistent. In some patients, the ulnar nerve at the elbow clicks back and forth over the bony bump (medial epicondyle) as the elbow is bent and straightened. If this occurs repetitively, the nerve may be significantly irritated. Additionally, pressure on the ulnar nerve can occur from holding the elbow in a bent position for a long time, which stretches the nerve across the medial epicondyle. Such sustained bending of the elbow may tend to occur during sleep. Sometimes the connective tissue over the nerve becomes thicker, or there may be variations of the muscle structure over the nerve at the elbow that cause pressure on the nerve. Cubital tunnel syndrome occurs when the pressure on the nerve is significant enough, and sustained enough, to disturb the way the ulnar nerve works.

Signs and Symptoms of Cubital Tunnel Syndrome

Cubital tunnel syndrome symptoms usually include pain, numbness, and/or tingling. The numbness or tingling most often occurs in the ring and little fingers. The symptoms are usually felt when there is pressure on the nerve, such as sitting with the elbow on an arm rest, or with repetitive elbow bending and straightening. Often symptoms will be felt when the elbow is held in a bent position for a period of time, such as when holding the phone, or while sleeping. Some patients may notice weakness while pinching, occasional clumsiness, and/or a tendency to drop things. In severe cases, sensation may be lost and the muscles in the hand may lose bulk and strength.

Diagnosis of Cubital Tunnel Syndrome

Your physician will assess the pattern and distribution of your symptoms, and examine for muscle weakness, irritability of the nerve to tapping and/or bending of the elbow, and changes in sensation. Other medical conditions may need to be evaluated such as thyroid disease or diabetes. A test called electromyography (EMG) and/or nerve conduction study (NCS) may be done to confirm the diagnosis of cubital tunnel syndrome and stage its severity. This test also checks for other possible nerve problems, such as a pinched nerve in the neck, which may cause similar symptoms.

Treatment of Cubital Tunnel Syndrome

Symptoms may sometimes be relieved without surgery, particularly if the EMG/NCS testing shows that the pressure on the nerve is minimal. Changing the patterns of elbow use may significantly reduce the pressure on the nerve. Avoiding putting your elbow on hard surfaces may help, or wearing an elbow pad over the ulnar nerve and "funny bone" may help. Keeping the elbow straight at night with a splint also may help. A session with a therapist to learn ways to avoid pressure on the nerve may be needed. When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve.

 

de Quervain’s Thumb Tendonitis

What is 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. 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.

What Causes de Quervain's Tendonitis?

The cause of de Quervain’s tendonitis is an irritation of the tendons at the base of the thumb, usually caused by taking up a new, repetitive activity. New mothers are especially prone to this type of tendonitis: caring for an infant often creates awkward hand positioning, and hormonal fluctuations associated with pregnancy and nursing further contribute to its occurrence. A wrist fracture can also predispose a patient to de Quervain’s tendonitis, because of increased stresses across the tendons.

Signs and Symptoms of de Quervain's Tendonitis

Pain over the thumb-side of the wrist is the main symptom. The pain may appear either gradually or suddenly, and pain is located at the first dorsal compartment at the wrist. Pain may radiate down the thumb or up the forearm. Hand and thumb motion increases pain, especially with forceful grasping or twisting. Swelling over the base of the thumb may include a fluid-filled cyst in this region. There may be an occasional “catching” or “snapping” when moving the thumb. Because of the pain and swelling, motion such as pinching may be difficult. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger.

Diagnosis of de Quervain's Tendonitis

Tenderness directly over the tendons on the thumb-side of the wrist is the most common finding. A test is generally performed in which the patient makes a fist with the fingers clasped over the thumb. The wrist is then bent in the direction of the little finger. This maneuver can be quite painful for the person with de Quervain’s tendonitis.

Treatment of de Quervain's Tendonitis

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. When symptoms are severe or do not improve, surgery may be recommended.

 

Distal Radius Fracture (Colles Fracture)

Description

When someone falls on their outstretched hand, they sometimes get a "broken wrist." The bone that is usually broken is called the radius. It is the larger bone on the upper side of the photograph above. The end toward the wrist is called the distal end. The medical term for "broken bone" is fracture. Therefore, the medical term for the most common type of "broken wrist" is a distal radius fracture (that is, the larger forearm bone is broken near the wrist).

This kind of fracture is very common. In fact, the radius is the most commonly broken bone in the arm. The break usually happens when you fall and land on your outstretched hands. It can also happen in a car accident, a bike accident, a skiing accident, and similar situations. Sometimes, the other forearm bone (the ulna) is also broken. When this happens, it is called a distal ulna fracture.

This fracture was first described by an Irish surgeon and anatomist, Abraham Colles, in 1814; hence the name, "Colles' " fracture.

A broken wrist usually causes pain and swelling, and frequently causes a deformity, causing the wrist to look bent. See your doctor for a diagnosis. The doctor will take an X-ray of the wrist. The fracture is almost always about 1 inch from the end of the bone. If the fracture extends into the joint, it is called an intra-articular fracture; if it does not, it is called an extra-articular fracture. ("Articular" means "joint.") If the fractured bone breaks the skin, it is called an open fracture. If the bone is broken into more than two pieces, it is called a comminuted fracture. A fracture is more difficult to treat if it is intra-articular, open or comminuted.

Dupuytren’s Disease

What Is 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. Gradually, these cords may cause the fingers to bend into the palm. 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)

What Causes Dupuytren's Disease?

The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.

What Are the Symptoms and Signs of Dupuytren's Disease?

Symptoms of Dupuytren’s disease usually include a small lump or series of lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Gradually a cord may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. In many cases, both hands are affected, although the degree of involvement may vary.

The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop. As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets. Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

What Are the Treatment Options for Dupuytren's Disease?

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.

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. 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.

 

If you are suffering from hand or wrist pain, please contact our office immediately to schedule an evaluation.

 

Dallas Orthopedics Institute
 9330 Poppy Drive
Dallas , TX 75218