Non-traumatic hand problems in adults are extremely numerous and both diagnosis and management are challenging. Some of the most common conditions are discussed below. Even these fairly straightforward problems are unfortunately prone to misdiagnosis and injudicious surgery.
Ganglion
Trigger Finger
Carpal Tunnel Syndrome
Ulnar Nerve Entrapment
Arthritis of the thumb and fingers
Dupuytren’s contractures
Nerve Entrapment Syndromes
Tendonitis/ de Quervain’s
A Ganglion is a fluid collection that originates from a nearby joint or tendon. Most ganglia are pain free but can be associated with pain if the joint or tendon is inflamed or it causes pressure on other structures.
Simple ganglia can be left without treatment. In selected cases the ganglion can be aspirated and injected but there is a high recurrence rate.
In some younger patients with weight bearing on the wrist, pain and restriction of motion occurs that lasts for a few days or weeks. This may be due to an occult ganglion (not visible) associated with synovitis and is best diagnosed by examination and doing an ultrasound of the wrist. This condition is also called dorsal wrist impingement.
With larger ganglia and multilocular ganglia surgery is the preferred treatment method. Surgery is undertaken after excluding underlying pathology. The recurrence rate after surgery is approximately 5%.
Trigger Finger is a painful condition, where the finger clicks and gets stuck in the palm of the hand. This is due to the flexor tendons of the various fingers and/or the thumb getting stuck in their respective sheaths. They then snap into extension with a painful sensation. Injection into the tendon sheath as well as exclusion of various systemic conditions which may cause this condition is the first step in treatment. Unfortunately, many trigger digits do not resolve with non-surgical treatment. The tendon sheath is released through a small incision in the palm of the hand with rapid recovery and good outcome.
Nerve entrapment conditions in the hand and upper limb may involve any of the major nerves. The median nerve supplies most of the forearm muscles as well as the thumb muscles in the hand. The most common, but not the only site of median nerve entrapment is the carpal tunnel at the wrist.
Carpel Tunnel Syndrome is caused by nerve compression in the carpal tunnel at the wrist. This usually causes numbness and pain (often at night) in the thumb, index and middle fingers and may progress to thumb muscle weakness.
The most important first step in treating carpal tunnel syndrome is confirming the diagnosis. This is best done by examination of the hand.
Splinting: In recent onset carpal tunnel syndrome (less than 2 months) a trial of splinting can be considered.
Injection: In selected cases the patient may benefit from an injection of corticosteroid to reduce swelling and resolve the symptoms.
Surgery: Surgical treatment successful and the procedure should be performed before any major muscle weakness develops. We suggest that patients seek help within three months of onset of symptoms.
The surgery is minimally invasive and can be performed under local anaesthetic and sedation in many cases. The hand can be used from the following day onwards but will have to be kept dry until the sutures are removed. We will supply a glove and instructions after surgery.
Ulnar Nerve Entrapment
The ulnar nerve may be entrapped in several places along its course, the most common entrapment site is around the “funny-bone” on the inside of the elbow. This cubital tunnel syndrome usually begins with intermittent pain and/or pins and needles in the ring and little fingers of the hand. Initially this resolves when the elbow is straightened and “shaken out”. If symptoms persist for more than three months or there is weakness of the hand then the patient should be examined and treatment commenced.
The diagnosis of this condition is not always straightforward and even nerve conduction studies may show no abnormalities.
Once there is confirmation of a diagnosis and the site of compression then a nerve release should be considered before there is permanent damage to the nerve.
Arthritis of the various small joints of the hand is common and involvement of the basal joint of the thumb is frequently a sign that the patient is predisposed to developing “primary” osteoarthritis in the weight bearing joints. Diagnosis is made on clinical examination and may be confirmed with X-ray. Treatment involves initial no surgical management with anti inflammatory medications, joint injections and splints. If the symptoms become unbearable despite maximal conservative treatment, surgical solutions may have to be discussed. These include joint replacement as well as excision arthroplasties. The vast majority of patients do not require surgery at any stage. Other procedures which may become necessary are the excision of bone overgrowth (osteophytes) and associated cysts around the affected joints.
Arthritis of the basal joint of the thumb (carpo-metacarpal joint or CMCJ OA) is common condition that mainly affects women. This can become extremely disabling and results in pain, often when opening a tap or similar twisting action. In advanced arthritis it can result in stiffness and thumb deformity with loss of webspace and limited ability to grip larger objects such as a bottle or glass. Diagnosis is made on clinical examination and may be confirmed with X-ray. Management consists of splinting and local anesthetic as well as steroid injection. If the disease progresses, surgical management becomes an option. Various forms of excision arthroplasty with interposition of various materials can be considered. Our treatment is to excise the trapezium which is part of the arthritic joint and then to do a ligament reconstruction with a local tendon. In this way the joint has only natural tissue in it without a replacement metal or plastic object that is likely to wear and can lead to failure. We have been performing this type of procedure for more than 15 years with good success and quick recovery.
Dupuytrens Contracture is a condition which will cause your fingers to curl into the palm of your hand in advanced cases. Most people get a nodule or a dimple in the palm of the hand at the base of the finger. This often affects the little and ring fingers and mostly occurs in men. The fibrous tissue layer in the palm of the hand shortens over time and prevents various fingers from fully extending. It is often surprising how severe these contractures become before patients seek orthopaedic attention.
With Dupuytrens Contracture, once the hand can no longer be placed palm-downwards onto a flat surface, surgical management should be considered. Various minimally invasive techniques have been widely publicized. We feel that needle releases can only be done in selected patients and have a higher incidence of recurrence. Protein digestive enzyme injections are not available in South Africa. Standard open procedures to remove the tissue whilst the nerves can be visualized and protected, offer the safest and best results. It is important to note that the younger the patient, the more likely it is to recur, and it is therefore advised not to do the surgery too early.
Nerve Entrapment Syndromes
The Sciatic nerve may be entrapped by the piriformis as it runs around the muscle. Unusual anatomic arrangement of the sciatic nerve, which occurs in a significant percentage of the population may predispose patients to this condition. Pain usually radius radiates into the buttock and posterior thigh. A mass around the piriformis muscle me may be palpable and pain is reproduced with internal rotation of the extended hip.
A De Quervain’s Tenovaginitis is a condition where the first extensor compartment sheath becomes constricted and the resultant tendon friction results in painful inflammation around the radial side of the wrist. If initial conservative management is unsuccessful, surgical release may be required.
