Hand & Upper Limb
When a problem takes place in the hand, care must be given to all the different types of tissues that make function of the hand possible.
The field of hand surgery deals with both surgical and non-surgical treatment of conditions and problems that may take place in the hand or upper extremity (from the tip of the hand to the shoulder).
Many conditions occur in the upper extremity that can be treated by a hand surgeon, including:
- immediate care of a hand, wrist or arm injury
- treatment and reconstruction of old injuries
- congenital problems
- arthritis of the hand
- new growths
- nerve compression syndromes
- swelling of tendons
Why Visit a Hand Surgeon?
A qualified hand surgeon is specially trained to diagnose your hand condition and to recommend appropriate treatment options.
Not every visit to a hand surgeon results in hand surgery. Hand surgeons often recommend non-surgical treatment options to assist you. Sometimes, they may refer you to a hand therapist for more treatment.
Hand surgeons are specialists in hand care. If you have pain in your fingers, hand, wrist or arm, or have other upper-extremity related concerns, you may want to consult a hand surgeon.
Stress tendonitis on the lateral epicondyle. Tennis elbow is an inflammation around the bony knob on the outer side of the elbow. It occurs when the tissue that attaches muscle to the bone becomes irritated. The bony knob is called the lateral epicondyle. The most common symptom of tennis elbow is pain on the outer side of the elbow and down the forearm. You may have pain all the time or only when you lift things. The elbow may also swell, get red, or feel warm to the touch. Your treatment will depend on how inflamed your tendon is and may include rest and medication, exercises and therapy, anti-inflammatory injections and surgery.
Carpal Tunnel Syndrome
Carpal tunnel syndrome is a condition brought on by increased pressure or 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. 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. There may be a combination of causes.
Symptoms can 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. Anti-inflammatory medication taken by mouth or injected into the carpal tunnel may help relieve the carpal tunnel symptoms.
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 which forms the roof (top) of the tunnel on the palm side of the hand. 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
Dupuytren’s disease is an abnormal thickening of the fascia (the tissue between the skin and the tendons in the palm) that may limit movement of one or more fingers. In some patients, a cord forms beneath the skin that stretches from the palm into the fingers. The cord can cause the fingers to bend into the palm so they cannot be fully straightened. Sometimes, the disease will cause thickening over the knuckles of the finger. It can also occur in the soles of the feet.
The cause of Dupuytren’s is unknown and there is no permanent cure. The disease is usually painless. This is a non-cancerous condition. Dupuytren’s disease mostly affects white people with ancestors from Northern Europe. It occurs more often in men than in women, and usually starts after age 40. In many cases, the disease runs in families.
Dupuytren’s disease occurs slowly. It is usually noticed as a small lump or pit in the palm. This tends to occur near the crease of the hand that is closest to the base of the ring and little fingers. With time, a cord may develop between the palm and the fingers. The disease is usually noticed when the palm cannot be placed flat on an even surface, such as a table top.
There is no permanent cure for Dupuytren’s disease. Surgery can relieve the bending of the fingers into the palm, but the condition can return with time. The goal of surgery for Dupuytren’s disease is to restore the use of the fingers. Your doctor should advise you on whether surgery is recommended in your case.
Peripheral Nerve Disorders
Nerves are the “electrical wiring” system in all people that carry messages from the brain to the rest of the body. A nerve is like an electrical cable wrapped in insulation. A ring of tissue forms a cover to protect the nerve, just like the insulation surrounding an electrical cable. Nerves are fragile and can be damaged by pressure, stretching, or cutting. Injury to a nerve can stop signals to and from the brain causing muscles not to work correctly, and you may lose feeling in the injured area. When a nerve is cut, both the nerve and the insulation are broken. Pressure or stretching injuries can cause the fibres carrying the information to break and stop the nerve from working, without damaging the cover.
When nerve fibres are cut, the end of the fibre farthest from the brain dies, while the insulation stays healthy. The end that is closest to the brain does not die, and after some time may begin to heal. If the insulation was not cut, new fibres may grow down the empty cover of the tissue until reaching a muscle or sensory receptor. If both the nerve and insulation have been cut and the nerve is not fixed, the growing nerve fibres may grow into a ball at the end of the cut, forming a nerve scar or neuroma. A neuroma can be painful and cause an electrical feeling when touched.
To fix a cut nerve, the insulation around both ends of the nerve are sewn together. The goal in fixing the nerve is to save the cover so that new fibres may heal and work again. If a wound is dirty or crushed, your physician may wait to fix the nerve until the skin has healed. If there is a space between the ends of the nerve, the doctor may need to take a piece of nerve (nerve graft) from another part of the body to fix the injured nerve. This may cause permanent loss of feeling in the area where the nerve graft was taken.
Once the nerve cover is fixed, the nerve generally begins to heal three or four weeks after the injury. Nerves usually grow one inch every month depending on the patient’s age and other factors. This means that with an injury to a nerve in the arm above the fingertips, it may take up to a year before feeling returns to the fingertips. The feeling of pins and needles in the fingertips is common during the recovery process. While this can be uncomfortable, it usually passes and is a sign of recovery.
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 form a tunnel under which the tendons must glide. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding inside the pulleys.
Trigger finger/thumb happens when the tendon develops a nodule (knot) or swelling of its lining. When the tendon swells, it must squeeze through the opening of the tunnel (flexor sheath) which causes pain, popping, or a catching feeling in the finger or thumb. 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 (locked) and is hard to straighten or bend.
Causes for this condition are not always clear. The medical conditions of rheumatoid arthritis, gout, and diabetes may be associated with trigger finger/thumb symptoms. Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb. A thickening may be found in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the top knuckle of the thumb.
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 anti-inflammatory medication by mouth or an injection into the area around the tendon may be recommended to reduce swelling. Treatment may also include changing activities to reduce swelling.
If non-surgical forms of treatment do not improve symptoms, surgery may be recommended. The goal of surgery is to open the first pulley so the tendon will 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.
Ganglion cysts are very common masses (lumps) that sometimes grow in the hand and wrist. The cysts are generally found on the top of the wrist, on the palm side of the wrist, the end joint of a finger (mucous cysts), and at the base of a finger. Ganglion cysts usually come from nearby joints or tendon sheaths. There is no specific cause. These cysts can be painful, especially when they first appear or with constant or strenuous use of the hand. Ganglions often change in size and may disappear completely. These cysts are not malignant (cancerous).
The diagnosis of a ganglion cyst is usually based on where the cyst is and what it looks like. Your hand surgeon may recommend X-rays to rule out problems in nearby joints.
Treatment of ganglion cysts may be simply watching for any changes. However, if the cyst is painful, limits activity, or its appearance is unacceptable to the patient, other treatment may be recommended. Treatment may include removing fluid from the cyst with a needle and/or the wearing of a splint to keep the hand or wrist from moving. If these nonsurgical treatments fail, surgery to remove the cyst may be recommended by your hand surgeon.
The goal of surgery is to remove the source of the cyst. This may require removal of a portion of the joint capsule or tendon sheath next to the ganglion. If the ganglion is removed from the wrist a splint may be recommended following surgery. Some patients may feel tenderness, discomfort, and swelling at the site of their surgery a little longer than others, but full activity can be resumed once comfort permits. While surgery offers the best success in removing ganglions, these cysts may return.
* Source: American Society for Surgery of the Hand; Hand Diagram: Australian Orthopaedic Association
Please remember that medical information provided by Brisbane Orthopaedic and Sports Medicine Centre, in the absence of a visit with a physician, must be considered as an educational service only. The information contained in this web site should not be relied upon as a medical consultation. This web site is not designed to replace a physician's independent judgement about the appropriateness or risks of a procedure for a given patient.