Wrist & Hand

An extraordinary collection of 29 bones and joints, 17 muscles, and 48 nerves in this one small space. Because it is made up of so many parts, many different things can get hurt.

Trigger Finger (Stenosing Flexor Tenosynovitis)

The tendons that bend or flex the fingers pass from the forearm into the palm, and out to the fingers. These tendons pass through a series of tunnels, or pulleys, that hold the tendon down along the bones. This prevents ‘bowstringing’, of the tendon, much like the metal eyelets on a fishing rod prevent bowstringing of the fishing line. If the tendon becomes swollen, it can catch, or get stuck as it tries to pass through a pulley (like a knot in the fishing line).

Common Causes

This is typically an ‘overuse’ injury, due to repetitive or frequent squeezing, gripping, or similar activities. Frequently seen Monday morning after a weekend of heavy pruning and gardening.

Symptoms

Pain in the fingers. There is often a sensation of catching, or ‘triggering’ of the involved digit. The finger may actually lock down into the palm, or lock out straight. Symptoms are usually worse in the morning, and improve during the day.

Physical Findings

Tenderness along the flexor tendon sheath, especially at the A1 pulley in the palm. A nodule may be felt moving under the pulley, with finger motion. Locking or catching is classic.

Workup

Most cases are straightforward. X-rays may be useful to rule out other injuries or disease, such as arthritis.

Non-Operative Treatment

A trial of a corticosteroid injection into the flexor tendon sheath, and anti-inflammatory medication is often very effective.

Surgical Treatment

A tendon sheath incision, or release of the involved pulley is curative.

Injury Comment

At least half of the cases can be cured non-operatively. A tendon sheath incision is performed under local anesthesia, often in an office setting, with a tiny incision.

Scaphoid Fracture

The scaphoid is a small, ‘bean shaped’ bone in the thumb side of the wrist. It is frequently broken, and is often a serious problem.

Common Causes

Usually a fall on the outstretched arm.

Symptoms

Pain in the wrist, usually at the base of the thumb (‘snuff-box’). Pain is worsened with gripping or squeezing.

Physical Findings

Tenderness directly over the broken scaphoid. There is often swelling in the wrist, and pain with range of motion.

Workup

X-rays will usually show a fracture, especially if the pieces of the bone have moved (displaced fracture). Rarely, additional imaging studies such as a Bone Scan or CT scan is needed.

Non-Operative Treatment

For non-displaced fractures (when the broken pieces of bone are in the right position), cast immobilization will usually work.

Surgical Treatment

All displaced fractures, and certain non-displaced fractures need to be fixed, usually with a small screw or pin.

Injury Comment

The scaphoid has a relatively poor blood supply, and these troublesome fractures often heal very slowly, or not at all. If the broken bone does not heal, or heals in a bad position, serious long-term damage to the wrist results, including post-traumatic arthritis.

Thumb Arthritis / Basal Joint Arthritis

The joint at the base of the thumb (carpometacarpal joint) is like a saddle, and allows a lot of motion of the thumb at that joint. If the cartilage coating the ends of the bones wears out, bone starts to rub against bone, and arthritis results.

Common Causes

Generally a ‘wear and tear’ phenomenon, with a genetic or family predisposition. More common in women. May be a late result of earlier trauma.

Symptoms

Pain deep in the base of the thumb, relieved with rest, and worsened with pinching, squeezing, and gripping activities. Opening jars, door handles, and turning keys are problematic.

Physical Findings

Tenderness at the carpometacarpal joint of the thumb. There may be deformity present, and loss of motion.

Workup

History, physical examination, and x-rays are usually diagnostic.

Non-Operative Treatment

Splinting, anti-inflammatory medication, and rest may reduce symptoms. A corticosteroid injection can provide relief for a while, but will not repair the joint. Thumb splints are effective, but poorly tolerated due to restriction of thumb motion. Physical therapy is contraindicated, as it tends to irritate things.

Surgical Treatment

A joint replacement, or thumb basal joint arthroplasty.

Injury Comment

Most patients can be managed non-operatively, but surgical reconstruction is very effective for pain relief, strength, and motion. About four weeks of casting are required after surgery, and up to several months of hand therapy.

Skier’s Thumb / Gamekeeper’s Thumb

The bones of the webspace of the thumb are held stable by strong ligaments on either side of the thumb. Occasionally the ulnar collateral ligament, the ligament between the thumb and index finger, tears.

Common Causes

Nowadays, a fall on the outstretched thumb is the most common injury, seen especially in skiers. In previous times, the gameskeeper could injure his thumb while breaking the neck of the poor animals that were caught on the Master’s hunt.

Symptoms

Initially, there is pain and swelling at the base of the thumb, and pain using the thumb for pinching and gripping. Later on, the primary complaint may be that of thumb weakness or instability with pinching, opening jars, car door handles, etc.

Physical Findings

Tenderness along the ulnar collateral ligament. Instability and discomfort with stress testing of the ligament.

Workup

X-rays are required to rule out a fracture. Selective stress testing, under x-ray or real-time fluoroscopy may be valuable.

Non-Operative Treatment

Casting the wrist and thumb for several weeks.

Surgical Treatment

Repair of the torn ligament, with reattachment to the bone.

Injury Comment

There is controversy regarding surgery versus casting for acute ulnar collateral ligament tears. Sometimes, when the ligament tears off of the bone, it may fold back on itself or get caught under some other tissue. Thus the torn end of the ligament may not be next to the area of the bone that it was torn from. If this happens, the ligament will not heal, and chronic instability will result. There are arguments both for and against early repair of this torn ligament, and should be discussed with your doctor.

Flexor Tendon Injuries

The joint at the base of the thumb (carpal-metacarpal joint) is like a saddle, and allows a lot of motion of the thumb at that joint. If the cartilage coating the ends of the bones wears out, bone starts to rub against bone, and arthritis results.

Common Causes

Generally a ‘wear and tear’ phenomenon, with a genetic or family predisposition. More common in women. May be a late result of earlier trauma.

Symptoms

Pain deep in the base of the thumb, relieved with rest, and worsened with pinching, squeezing, and gripping activities. Opening jars, door handles, and turning keys are problematic.

Physical Findings

Tenderness at the carpal-metacarpal joint of the thumb. There may be deformity present, and loss of motion.

Workup

History, physical examination, and x-rays are usually diagnostic.

Non-Operative Treatment

Splinting, anti-inflammatory medication, and rest may reduce symptoms. A corticosteroid injection can provide relief for a while, but will not repair the joint. Thumb splints are effective, but poorly tolerated due to restriction of thumb motion. Physical therapy is contraindicated, as it tends to irritate things.

Surgical Treatment

A joint replacement, or thumb basal joint arthroplasty.

Injury Comment

Most patients can be managed non-operatively, but surgical reconstruction is very effective for pain relief, strength, and motion. About four weeks of casting are required after surgery, and up to several months of hand therapy.

DeQuervain’s Stenosing Tenosynovitis

The tendons that straighten the fingers and thumb travel on the back of the wrist, and are held down to the wrist by a series of tunnels, or pulleys. When the tendons that straighten the thumb become swollen and inflamed as they pass through one of the tunnels, it becomes painful to use the thumb. Repeated use of the thumb only causes more swelling and inflammation of these tendons.

Common Causes

Repeated use of the hands and thumb, especially pinching, gripping or squeezing. Gardening, knitting, keyboarding etc.

Symptoms

Pain in the wrist, with use of the thumb.

Physical Findings

Tenderness, and occasional swelling along the thumb extensor tendons. A positive Finklestein’s test.

Workup

History and physical exam is usually sufficient. Occasionally, x-rays are obtained to rule out other causes of pain, such as arthritis.

Non-Operative Treatment

Splinting, anti-inflammatory medication, and a trial of a corticosteroid injection into the tendon sheath.

Surgical Treatment

Release of the band, or part of the tunnel that is causing constriction of the tendons.

Injury Comment

Non-operative treatment is usually successful. Surgical release is generally curative, and can be performed with local anesthesia, often in an office setting.

Ganglion Cysts

A ganglion, or cyst, is a collection of fluid that builds up on either the back or the front of the wrist. Usually it is an ‘outpouching’ of the wrist capsule, forming a bump or lump on the wrist.

Common Causes

There may be a history of trauma, such as a fall, or a direct blow. Often there is no known cause or history of injury.

Symptoms

There is usually a lump, or mass on one side of the wrist. It may be painful or painless, and may change size or come and go.

Physical Findings

The swelling, or lump is generally diagnostic. There may be tenderness, or loss of wrist motion.

Workup

The mass must be differentiated from other causes of swelling, such as a benign tumor, ruptured tendon, or other condition. X-rays are of limited value. An aspiration of the contents of the cyst is usually diagnostic.

Non-Operative Treatment

A trial of an aspiration of the cyst contents, along with a corticosteroid injection and a compressive dressing for a short period of time may resolve the cyst in up to one half of cases. Repeated aspirations are generally not very successful.

Surgical Treatment

Excision of the cyst. This may be done with an open surgical procedure, or recently, we have begun excising the cysts arthroscopically.

Injury Comment

Arthroscopic cyst excision seems to provide superior results, with faster healing, and less stiffness and scarring. There is a low, but not insignificant recurrence rate for open cyst excision. We do not yet know what the recurrence rate will be for arthroscopic cyst excision.

Wrist Sprains / Wrist Ligament Injuries

The wrist is a collection of eight small bones that connect the forearm bones (radius and ulna) to the bones of the hand (metacarpals). These small bones have a complex series of ligaments that control smooth wrist movement. Any injury to these ligaments may cause abnormal motion between some of the bones of the wrist.

Common Causes

Usually trauma, such as a fall on a flexed or extended wrist. A direct blow to the wrist may injure ligaments.

Symptoms

Pain, swelling, or weakness in the wrist. There can occasionally be a sense of ‘popping’ or ‘slipping’ inside the wrist. Symptoms are generally worse with activity, such as gripping, squeezing, and lifting.

Physical Findings

Tenderness over specific wrist ligaments. Swelling, loss of motion, and weakness. Certain special tests are suggestive of specific ligament injuries.

Workup

History, physical examination, and x-rays are required. Specialized x-rays, including stress x-rays or real-time motion studies are often obtained. An injection of local anesthetic into the area is helpful in confirming the diagnosis. Rarely, an MR scan or arthrogram is obtained. The high error rate of these tests in this injury makes them of limited value. The definitive diagnostic tool is a wrist arthroscopy.

Non-Operative Treatment

Splinting or casting for several weeks will allow partial ligament tears to heal.

Surgical Treatment

An arthroscopy will confirm the diagnosis. Many ligament injuries can be treated entirely arthroscopically, but open ligament repairs or other reconstructive procedures are occasionally required.

Injury Comment

While most wrist sprains heal uneventfully, early recognition of more severe injuries will help to prevent the often devastating complications of this injury.

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome (CTS) is due to pressure on a specific nerve, the Median nerve, as it enters the wrist and palm from the forearm. The nerve and the tendons to the fingers all pass through a tunnel of fixed size (the carpal tunnel). If there is a significant increase in pressure inside the tunnel, then the nerve may become compressed and injured.

Common Causes

Repetitive hand activities, unusual prolonged wrist flexion or extension, frequent gripping or squeezing, exposure to vibratory or pneumatic equipment. Certain medical conditions, including pregnancy, thyroid disease, and diabetes have an increased incidence of this injury.

Symptoms

Numbness, tingling, or pain in the hand; generally involving the thumb, index, and middle finger. May radiate up the arm to the shoulder. Waking at night with the hand asleep, or ‘shaking out’ the hand is common. Dropping of objects and weakness in advanced cases.

Physical Findings

Positive provocative testing on physical examination. Atrophy of the thumb muscles, and sensory loss in advanced cases.

Workup

The diagnosis is primarily based on history and physical examination. Electrodiagnostic studies are occasionally indicated, especially in confusing or difficult cases.

Non-Operative Treatment

Night-time wrist splints, anti-inflammatory medication, and avoidance or modification of the aggravating activity is helpful in early cases. A trial of a single corticosteroid injection is of value for both diagnosis and treatment.

Surgical Treatment

Carpal Tunnel Release. This can be done either as an open procedure, or as an Endoscopic Carpal Tunnel Release, with only a tiny incision under local anesthesia.

Injury Comment

The goal of all treatment options for this injury is to take the pressure off of the nerve, and allowing it to heal on its own.
This is much like taking a ‘pot-bound’ plant, and repotting it in a larger pot. The goal of surgery is to prevent progression, and allow for the nerve to recover. Prolonged compression of a nerve may cause permanent damage. Think of a garden hose after your car has parked on it for a very long time.