The hand and wrist are comprised of multiple small joints that work together to produce many intricate motions, from threading a needle to turning a key in a door. When joints become affected with arthritis, the activities of daily living can be very difficult. When a joint becomes arthritic, the cartilage has worn away and the joint can no longer function smoothly with the bones gliding easily over each other. Movement is painful and the range of motion is reduced.
The most common form of arthritis is osteoarthritis or wear and tear arthritis, which generally affects people over 50. Rheumatoid arthritis is a systemic form of the disease that causes significant joint inflammation that can damage cartilage and bone.
Traumatic arthritis can affect people of any age and may occur as a result of an injury or trauma to the joint. A joint that has sustained an injury is more likely to become arthritic, even if the injury has been properly treated. Fractures that damage the cartilage or joint surface and dislocations are the most common injuries that lead to arthritis.
Carpal tunnel syndrome is caused by compression of the median nerve at the base of the palm, where it passes near the wrist joint. This nerve provides sensation to the thumb and most parts of the fingers. It also affects the strength of the muscles at the base of the thumb. If compressed, the nerve may sustain serious damage.
Common symptoms of carpal tunnel syndrome include numbness and tingling in the hand, especially at night; pain while gripping or holding; and clumsiness in handling objects. The pain may even extend from the hand up into the shoulder.
Treatment for carpal tunnel syndrome may initially be treated with a splint or brace to allow the wrist to rest. Steroids injected into the carpal canal may also help decrease swelling. Cases that do not respond to non-surgical methods, or are diagnosed late, may eventually require surgery. This is usually done in an outpatient setting under local anesthesia.
Dupuytren’s (pronounced, “doo puh trenz”) contracture is a progressive hand condition that causes a thickening of the tissue that is just below the skin of the palm. An abnormal build-up of collagen thickens into a rope-like cord in the palm that slowly causes the fingers to curl to the point where they cannot be straightened. Often mistaken for arthritis or other conditions over time the tightening of the Dupuytren’s cord can significantly reduce your finger’s range of motion. The disease is hereditary and is also linked with cigarette smoking, vascular disease, epilepsy, and diabetes. If nodules or lumps are small, surgery is not needed. However if a cord forms, the affected fingers will develop a contraction effect that can interfere with proper hand function. Surgery may be recommended at this point.
Treatment with Xiaflex
Today there is a new FDA approved treatment with a medication called Xiaflex that is proving to be highly effective. Xiaflex is a prescription medication used to treat adults with Dupuytren’s contracture once a cord can be felt in the palm. Xiaflex is an injectable solution of enzymes (purified collagenase clostridium histoliticum) that is injected directly into the Dupuytren’s cord. The enzymes break down the cord which allows the finger to straighten again.
Approximately 24 hours after the injection the patient returns to the doctor who will carefully extend the injected finger to help release the cord. Up to three injections may be given into the cord of an affected joint. Only one finger (and one joint) may be injected per treatment. If desired another finger may be addressed at a minimum of 30 days later.
Studies indicate that the majority of patients achieve a reduction in their contracture; many achieving complete or near complete reduction. The treatment has been shown to be more effective in the metacarpophalangeal joints (the lowest finger joints to the palm) than in the proximal interphalangeal joints (the middle joints of fingers).
Xiaflex is not right for every patient. Ask your physician if this treatment is recommended in your case.
The most common fracture to the wrist occurs to the distal radius, the end of the larger of the two arm bones at the thumb-side of the wrist. Distal radius fractures usually happen about one inch from the end of the radius and most often occur in people over 60. The injury causes pain, swelling, bruising and can create a deformed appearance to the wrist.
Initial treatment usually includes icing, elevating the arm and anti-inflammatory medications to control pain and swelling. If the bone is properly aligned, a splint may be used for the first few days. A cast may be added a few days later, after the swelling has gone down. It may need to be changed after a couple of weeks once the swelling has diminished further.
For more serious fractures, surgery may be required to correct the alignment of the bone. Sometimes a cast alone can be used, or it may be necessary to insert metal pins, a plate and screws.
A fracture may also occur to the scaphoid bone, a small bone in the thumb-side of the wrist. A fracture of the scaphoid is a common sports injury and is usually a result of a fall toward an outstretched arm.
Treatment depends on the location of the break. Fractures at the end of the bone, close to the thumb, usually heal in a few weeks when placed in a cast. If the scaphoid is broken in the middle of the bone or closer to the forearm, healing can be more difficult, requiring a long-arm cast or surgery.
When the scaphoid is broken at the waist or proximal pole, surgery may also be recommended. Screws and wires are used to stabilize the bone so that is can heals. After surgery, the wrist may be put into a cast, however even with surgery these fractures can be difficult to heal.
Ganglion cysts are a non-cancerous mass or lump the usually occur in the back or front of the wrist or in the fingers. They are fluid-filled capsules that arise from joint linings or tendon sheaths. They may arise from underlying joint injury or arthritis. They are benign, often painless and many do not require treatment. However, if the cyst is painful or interferes with normal function, it may be made smaller by removing the fluid with a needle (aspiration), or removed surgically.
Injuries to the hand are common in athletes because the hands frequently absorb impact during sports activity. Sports-related injuries may involve the supporting ligaments, tendons or bones.
Skiers are susceptible to an injury known as skier’s thumb, a tear of the ulnar collateral ligament in the large joint of the thumb. This can happen when the skier falls and the ski pole handle forces the thumb to bend away from the fingers. The same injury can occur in other sports players whose hands are often used to break a fall.
Treatment for sports-related tears
Many common ligament injuries are treated non-surgically, A few will require surgery to restore stable ligament function.
If the thumb ligament is completely torn, surgery may be necessary. Sometimes, as the ligament tears, it pulls a bone fragment away from the base of the bone. The fragment may need to be removed or replaced to its correct position. Patients commonly need to wear a short-arm cast or a splint to protect the thumb ligament for a period of time following surgery.
DeQuervain’s tendinitis is characterized by pain and swelling of the thumb-side of the wrist. Recurrent irritation of the tendon and its sheath make it difficult and painful for the tendons to function normally.
Pain that occurs when grasping or pinching and tenderness over the wrist, are the most common symptoms of tendonitis. Sometimes a lump can be felt in this area.
Wrist tendinitis (inflammation of the tendons) may be caused by overuse and also can be seen in association with pregnancy or rheumatoid arthritis.
Treatment for tendinitis
Tendinitis symptoms may improve with short periods of rest in a splint and by stretching exercises designed to get the tendons gliding again. Resting the tendon often allows the inflammation to decrease. Avoiding or modifying the activities that led to the onset of symptoms may be necessary.
Icing wrist tendinitis can help decrease inflammation and also stimulate blood flow to the area affected area. Nonsteroidal anti-inflammatory medications may help control pain, and decrease inflammation and swelling of the soft-tissues. A steroid injection can frequently cure the condition. More severe cases may require surgery. The operation entails opens the covering that surrounds the tendons to create more room for the irritated tendons. Afterward, physical therapy is usually prescribed to restore normal use of the hand.
Illustration reproduced with permission from Fischer S, (interim ed): Your Orthopaedic Connection. Rosemont, IL, American Academy of Orthopaedic Surgeons. Available at http://orthoinfo.aaos.org.org/.
The tendon that bends the finger passes through a tube-like tendon sheath. If the tendon and sheath become irritated and enlarged from repetitive gripping action, inflammation may occur making it difficult for the tendon to pass through the sheath. The condition is called trigger finger because the tendon catches and then suddenly releases, as if clicking a “trigger.”
Discomfort and swelling may be treated with rest, activity modification, anti-inflammatory medication, or steroid injections. If the tendon does not return to normal, a minor surgery may be necessary.