Patient Education Category : Conditions & Injuries

Wrist Fractures

DESCRIPTION

A wrist fracture is a medical term for a broken wrist. The wrist is made up of eight small bones which connect with the two long forearm bones called the radius and ulna. Although a broken wrist can happen in any of these 10 bones, by far the most common bone to break is the radius. This is called a distal radius fracture by hand surgeons.

Some wrist fractures are stable. “Non-displaced” breaks, in which the bones do not move out of place initially, can be stable. Some “displaced” breaks (which need to be put back into the right place, called “reduction” or “setting”) also can be stable enough to treat in a cast or splint. Other fractures are unstable. In unstable fractures, even if the bones are put back into position and a cast is placed, the bone pieces tend to move or shift into a bad position before they solidly heal. This can make the wrist appear crooked.

Some fractures are more severe than others. Fractures that break apart the smooth joint surface or fractures that shatter into many pieces (comminuted fractures) may make the bone unstable. These severe types of fractures often require surgery to restore and hold their alignment. An open fracture occurs when a fragment of bone breaks and is forced out through the skin. This can cause an increased risk of infection in the bone.

CAUSES

A wrist fracture occurs from an injury such as falling down onto an outstretched hand. Severe trauma such as car accidents, motorcycle accidents or falls from a ladder cause more severe injuries. Weak bones (for example, in osteoporosis) tend to break more easily.

SIGNS AND SYMPTOMS

When the wrist is broken, there is pain and swelling. It can be hard to move or use the hand and wrist. Some people can still move or use the hand or wrist even if there is a broken bone. Swelling or a bone out of place can make the wrist appear deformed. There is often pain right around the break and with finger movement. Sometimes the fingers tingle or feel numb at the tips.

Diagnosis

Your hand surgeon will do a physical examination and obtain x-rays to see if there is a broken bone. Sometimes, tests such as a CT scan or MRI scan may be needed to get better detail of the fracture fragments and other injuries. Ligaments (the soft tissues that hold the bones together), tendons, muscles and nerves may also be injured when the wrist is broken. These injuries may need to be treated also.

TREATMENT

Treatment depends on many factors, including:

  • Type of fracture, whether it is displaced, unstable or open
  • Your age, job, hobbies, activity level, and whether it is your “dominant” hand
  • Your overall general health
  • Presence of other injuries

A padded splint might be worn at first in order to align the bones and support the wrist to provide some relief from the initial pain. If the fracture is not too unstable, a cast may be used to hold a fracture that has been set. Other fractures may benefit from surgery to put the broken bones back together and hold them in correct place.

Fractures may be fixed with many devices. Pins, screws, plates, rods or external fixation can all be used. A small camera might be used to help visualize the joint from the inside. Sometimes the bone is so severely crushed that there is a gap in the bone once it has been realigned. In these cases, a bone graft may be added to help the healing process. Your hand surgeon will discuss the options that are best for your healing and recovery.

Recovery

During recovery, it is very important to keep your fingers moving to keep them from getting stiff. Your hand surgeon will have you start moving your wrist at the right time for your fracture. Hand therapy is often helpful to recover motion, strength and function.

Recovery time varies and depends on a lot of factors. It is not unusual for recovery to take months. Even then, some patients may have stiffness or aching. Severe wrist fractures can result in arthritis in the joint. Occasionally, additional treatment or surgery is needed.

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Trigger Finger

DESCRIPTION

Stenosing tenosynovitis is a condition commonly known as “trigger finger.” It is sometimes also called “trigger thumb.” The tendons that bend the fingers glide easily with the help of pulleys. These pulleys hold the tendons close to the bone. This is similar to how a line is held on a fishing rod. Trigger finger occurs when the pulley becomes too thick, so the tendon cannot glide easily through it.

CAUSES

Trigger fingers are more common with certain medical conditions such as rheumatoid arthritis, gout and diabetes. Repeated and strong gripping may lead to the condition. In most cases, the cause of the trigger finger is not known.

SIGNS AND SYMPTOMS

Trigger finger may start with discomfort felt at the base of the finger or thumb, where the finger joins the palm. This area is often sensitive to pressure. You might feel a lump there. Other symptoms may include:

  • Pain
  • Popping
  • Catching feeling
  • Limited finger movement

TREATMENT

The goal of treatment in trigger finger is to eliminate the swelling and catching/locking, allowing full, painless movement of the finger or thumb.

Common treatments include, but are not limited to:

  • Night splints
  • Anti-inflammatory medication
  • Changing your activity
  • Steroid injection

If non-surgical treatments do not relieve the symptoms, surgery may be recommended. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. The clicking or popping goes away first. Finger motion can return quickly, or there can be some stiffness after surgery. Occasionally, hand therapy is required after surgery to regain better use.

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Tennis Elbow – Lateral Epicondylitis

DESCRIPTION

Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons anchor the muscle to bone. The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist. With lateral epicondylitis, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.

CAUSES

Overuse – The cause can be both non-work and work related. An activity that places stress on the tendon attachments, through stress on the extensor muscle-tendon unit, increases the strain on the tendon. These stresses can be from holding too large a racquet grip or from “repetitive” gripping and grasping activities, i.e. meat-cutting, plumbing, painting, weaving, etc.

Trauma – A direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon.

Who gets tennis elbow/lateral epicondylitis?

The most common age group that this condition affects is between 30 to 50 years old, but it may occur in younger and older age groups, and in both men and women.

SIGNS AND SYMPTOMS

Pain is the primary reason for patients to seek medical evaluation. The pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle. This area becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.

TREATMENT

Conservative (non-surgical)

Activity modification – Initially, the activity causing the condition should be limited. Limiting the aggravating activity, not total rest, is recommended. Modifying grips or techniques, such as use of a different size racket and/or use of 2-handed backhands in tennis, may relieve the problem.

Medication – anti-inflammatory medications may help alleviate the pain.

Brace – a tennis elbow brace, a band worn over the muscle of the forearm, just below the elbow, can reduce the tension on the tendon and allow it to heal.

Physical Therapy – may be helpful, providing stretching and/or strengthening exercises. Modalities such as ultrasound or heat treatments may be helpful.

Steroid injections – A steroid is a strong anti-inflammatory medication that can be injected into the area. No more than (3) injections should be given.

Shockwave treatment – A new type of treatment, available in the office setting, has shown some success in 50–60% of patients. This is a shock wave delivered to the affected area around the elbow, which can be used as a last resort prior to the consideration of surgery.

Surgery

Surgery is only considered when the pain is incapacitating and has not responded to conservative care, and symptoms have lasted more than six months. Surgery involves removing the diseased, degenerated tendon tissue. Two surgical approaches are available; traditional open surgery (incision), and arthroscopy—a procedure performed with instruments inserted into the joint through small incisions. Both options are performed in the outpatient setting.

Recovery

Recovery from surgery includes physical therapy to regain motion of the arm. A strengthening program will be necessary in order to return to prior activities. Recovery can be expected to take 4–6 months.

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Rheumatoid Arthritis

DESCRIPTION

Rheumatoid arthritis is just one type of arthritis out of many. Patients with rheumatoid arthritis often wake up with stiff and swollen joints. Early on, many patients feel tired. While this condition can affect many parts of the body, two thirds of patients with rheumatoid arthritis have wrist and hand problems. Often, the joints feel hot and look red. Rheumatoid arthritis is most common in the wrist and knuckles. It typically happens in both hands.

Three other common types of arthritis include:

  • Wear and tear arthritis (osteoarthritis)
  • Gouty arthritis
  • Psoriatic arthritis

CAUSES

Rheumatoid arthritis affects the cells that lubricate and line joints. These tissues become swollen. They end up stretching supporting structures of the joints such as ligaments and tendons. As the support structures stretch out, the joints become deformed and unstable. The joint cartilage and bone wear away. Often the joints feel hot and look red. Rheumatoid arthritis is most common in the wrist and knuckles (Figure 1). It typically happens in both hands.

SIGNS AND SYMPTOMS

Stiffness, swelling and pain are common symptoms for all types of arthritis. There are some symptoms that are unique to rheumatoid arthritis. They are:

    • Firm bumps along fingers or the elbow
    • Soft lump on the back of the hand that moves as the fingers straighten
    • Abnormal bend or collapse of fingers
    • Sudden inability to straighten or bend a finger
    • A bent middle finger joint (Boutonniere deformity)
    • A bent end of the finger and over-extended middle joint (Swan-neck deformity)
    • Bones in the wrist that stick out

In addition, patients with rheumatoid arthritis often have problems with numbness and tingling in their hand (carpal tunnel syndrome). This is because the swelling of the tendons causes pressure on the nearby nerve.

How Rheumatoid Arthritis is Diagnosed

The diagnosis of rheumatoid arthritis is made based on an examination, x-rays and lab tests. Your doctor will ask questions about your symptoms and how the disease has affected your activities. Your physician will also ask whether other family members have had rheumatoid arthritis or symptoms similar to yours. There are several blood tests that are often ordered to confirm the diagnosis. MRI – a special imaging study – has also been used to help confirm the diagnosis.

TREATMENT

Treatment for rheumatoid arthritis aims to decrease swelling, relieve pain and maintain function. While there is no cure for this condition, medications are available that slow the progression of the disease. Treatment typically involves a team approach among the patient, physicians and therapists. A rheumatologist is often the physician that monitors and determines the best type of medicine for the patient.

Your hand therapist will provide instruction on how to use your hands in ways that help relieve pain and protect joints. Therapists also can provide exercises and splints to help you live a normal life.

Rheumatoid arthritis can be a progressive disease. In certain cases, preventive surgery may be recommended. Preventative surgery may include removing lumps, removing inflamed tissue, or removing bone spurs that may rub on tendons or ligaments.

There are several types of procedures to treat joints affected by rheumatoid arthritis. This can include removal of inflamed joint lining, joint replacements and joint fusions. The specific procedure(s) chosen depends on many factors. These factors include the particular joints involved, the degree of damage present, and the condition of surrounding joints.

One of the most important factors in deciding the most appropriate surgical procedure is the needs of the patient. There are often many ways to treat hand deformities from arthritis. Your hand surgeon can help you decide on the most appropriate treatment for you.

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Mallet Finger

DESCRIPTION

A mallet finger is a deformity of the finger caused when the tendon that straightens your finger (the extensor tendon) is damaged.

When a ball or other object strikes the tip of the finger or thumb and forcibly bends it, the force tears the tendon that straightens the finger. The force of the blow may even pull away a piece of bone along with the tendon. The tip of the finger or thumb no longer straightens. This condition is sometimes referred to as baseball finger.

SIGNS AND SYMPTOMS

In a mallet finger, the fingertip droops: it cannot straighten on its own power. The finger may be painful, swollen and bruised, especially if there is an associated fracture, but often the only finding is the inability to straighten the tip. Occasionally, blood collects beneath the nail. The nail can even become detached from beneath the skin fold at the base of the nail.

TREATMENT

Diagnosis

The diagnosis is evident by the appearance of the finger. Doctors will often order x-rays to see if a piece of bone pulled away and to make sure the joint is aligned.

Nonsurgical Treatment

The majority of mallet finger injuries can be treated without surgery. Ice should be applied immediately and the hand should be elevated (fingers toward the ceiling.) Medical attention should be sought within a week after injury. It is especially important to seek immediate attention if there is blood beneath the nail or if the nail is detached. This may be a sign of a nail bed laceration or an open (compound) fracture.

There are many different types of splints/casts for mallet fingers. The goal is to keep the fingertip straight until the tendon heals. Most of the time, a splint will be worn full-time for eight weeks. Over the next three to four weeks, most patients gradually begin to wear the splint less frequently. The finger usually regains acceptable function and appearance with this treatment. Nevertheless, it is not unusual to lack some extension at the conclusion of treatment. Your surgeon or hand therapist will instruct you about how to wear the splint and will also show you exercises to maintain motion in the middle joint (the proximal interphalangeal joint) so your finger does not become stiff. Once your mallet finger has healed, your surgeon or hand therapist will teach you exercises to regain motion in the fingertip.

In children, mallet finger injuries may involve the cartilage that controls bone growth. The doctor must carefully evaluate and treat this injury in children so that the finger does not become stunted or deformed.

Surgical Treatment

Surgical repair may be considered when mallet finger injuries have large bone fragments or joint mal-alignment. In these cases, pins, wires or even small screws are used to secure the bone fragment and realign the joint. Surgery may also be considered if splint wear is not feasible or if non-surgical treatment is not successful in restoring adequate finger extension. Surgical treatment of the damaged tendon can include tightening the stretched tendon tissue, using tendon grafts or even fusing the joint straight. Your surgeon will advise you on the best technique in your situation.

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Jammed Finger

DESCRIPTION

Jammed fingers are common in sports but may also occur during regular daily activities. Even if the injured finger looks normal and can move normally, it may require medical treatment. The anatomy of the finger joint is complex, and several types of injuries can result in permanent problems if they are left undiagnosed or untreated.

CAUSES

Jammed fingers occur when the tip of the finger is compressed towards the hand. As the finger is compressed, the ligaments supporting the joints are stretched or “sprained.” Ligaments are soft tissues that hold bone to bone. The greater the force, the more severe the sprain. If the force is strong enough, the ligaments can tear completely.

Other injuries that may occur from more violent forces include torn tendons, fractures (broken bones) and dislocations.

SIGNS AND SYMPTOMS

A jammed finger may result in pain and the inability to bend, straighten or grip with the finger.

TREATMENT

Your doctor will need to know how and when the injury occurred. Physical examination is performed to check finger position, movement, pain and swelling. X-rays are usually taken. On occasion, other studies may be needed, such as an MRI or CT scan.

Jammed fingers may be treated without or with surgery, depending on how severe the injury is. Some injuries can be treated with a splint and/or buddy strapping to the neighboring normal finger. These treatments are often performed along with the care of a hand therapist. Some severe injuries require surgery. In any case, even with simple sprains, the finger may be swollen for up to a full year. You and your hand specialist will determine the best approach for your individual situation. Successful outcomes depend on the combined efforts of the specialist, therapist and you.

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Hand Tumors and Wrist Tumors

DESCRIPTION

Any abnormal lump or bump in the hand or wrist is considered a tumor. The term “tumor” does not necessarily mean it is malignant or that it is a cancer. In fact, most hand and wrist tumors are benign (not cancer).

Tumors can occur on the skin, such as a mole or a wart, or underneath the skin in the soft tissue or even the bone. Because there are so many types of tissue in the hand (e.g. skin, fat, ligaments, tendons, nerves, blood vessels, bone, etc.), there are many types of tumors that can occur. Only a few of them are seen commonly.

CAUSES

Common Types of Wrist Hand Tumors

  • Ganglion Cysts : This is the most common tumor in the hand and wrist. Ganglion cysts are seen frequently in the wrist but can occur at the base of the fingers or around the finger joints. The cyst is typically filled with fluid, and it will feel very firm. There are several treatment options for a ganglion cyst, including observation (doing nothing), aspiration (puncturing with a needle) or surgically removing it.
  • Giant cell tumor of the tendon sheath : This is the second most common hand tumor. Unlike the fluid-filled ganglion cyst, these tumors are solid. They are benign (not cancer) and slow-growing.
  • Epidermal inclusion cyst : This tumor is benign and forms just underneath the skin where there may have been a cut or puncture. The cyst is filled with keratin, a soft, waxy material.

There are other less common types of tumors seen in the hand, including lipomas (fatty tumors), neuromas (nerve tumors), nerve sheath tumors, fibromas and glomus tumors, among others. Almost all are benign.

Other Causes of Lumps, Bumps and Masses

Foreign bodies, such as a splinter, can cause reactions that form bumps in the hand. Dupuytren’s Contracture may cause firm bumps in the hand, which are often confused with tumors. Finally, blood vessel growths can also be confused with other tumors.

How Your Doctor Will Diagnose

A physical exam and review of your medical history by a hand surgeon can help to determine the type of hand or wrist tumor you may have. X-rays might be taken to evaluate the bones, joints and possibly the soft tissue. Further studies such as ultrasound, CT, MRI or bone scans may be done to help narrow down the diagnosis. Needle biopsy or incisional biopsy (cutting out a small sample of the tumor) may be considered if the surgeon wants to confirm the diagnosis before recommending treatment.

TREATMENT

Typically, the most successful treatment is removing the tumor with surgery. This allows a pathologist to analyze it and to determine the type of tumor. Often, surgery is done on an outpatient basis.

Some patients may choose to do nothing and simply live with the tumor once they learn that it is non-cancerous. However, if the tumor changes (e.g. skin discoloration, pain, increased size) or if it causes other problems such as numbness or pain from pressure on a nearby nerve, then re-evaluation by a hand surgeon is recommended. You and your hand surgeon can choose the best treatment plan.

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Hand Therapy

DESCRIPTION

Hand Therapy is a type of rehabilitation performed by an occupational or physical therapist with patients that suffer from conditions affecting the hands and upper extremities. Therapy enables patients to hasten their return to a productive lifestyle.

Patients who are candidates for hand therapy may have been affected by an accident or trauma leaving them with wounds, scars, burns, injured tendons or nerves, fractures, or even amputations of the fingers, hands or arms. Others include patients who suffer from conditions such as carpal tunnel syndrome and tennis elbow, as well as from chronic problems such as arthritis or a neurologic condition (i.e. stroke).

What Does Hand Therapy Provide?

  • Treatments without an operation
  • Help with recent or long-lasting pain
  • Help to reduce sensitivity from nerve problems
  • Learning to feel again after a nerve injury
  • Learning home exercise programs to help with movement and strength
  • How to make splints to help prevent or improve stiffness
  • Learning to complete everyday activities with special tools
  • Help getting back to work

If surgery is needed, hand therapists can also help with a patient’s recovery. This may include assistance with helping wounds heal, preventing infection, scar management and reducing swelling.

Getting Back to Work

Hand therapists are able to talk with employers about preventing problems for workers with hand or arm symptoms. They may recommend changes at your place of work or different ways of doing your job to help ensure a healthy style of work.

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Hand Fractures

DESCRIPTION

The hand is made up of many bones that form its supporting framework. This frame acts as a point of attachment for the muscles that make the wrist and fingers move. A fracture occurs when enough force is applied to a bone to break it. When this happens, there is pain, swelling, and decreased use of the injured part. Many people think that a fracture is different from a break, but they are the same. Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to displace or shift. Some fractures occur in the shaft (main body) of the bone, others break the joint surface. Comminuted fractures (bone is shattered into many pieces) usually occur from a high energy force and are often unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin. There is some risk of infection with compound fractures.

SIGNS AND SYMPTOMS

Fractures often take place in the hand. A fracture may cause pain, stiffness, and loss of movement. Some fractures will cause an obvious deformity, such as a crooked finger, but many fractures do not. Because of the close relationship of bones to ligaments and tendons, the hand may be stiff and weak after the fracture heals. Fractures that injure joint surfaces may lead to early arthritis in those joints

TREATMENT

Medical evaluation and x-rays are usually needed so that your doctor can tell if there is a fracture and to help determine the treatment. Depending upon the type of fracture, your hand surgeon may recommend one of several treatment methods.

A splint or cast may be used to treat a fracture that is not displaced, or to protect a fracture that has been set. Some displaced fractures may need to be set and then held in place with wires or pins without making an incision. This is called closed reduction and internal fixation.

Other fractures may need surgery to set the bone (open reduction). Once the bone fragments are set, they are held together with pins, plates, or screws. Fractures that disrupt the joint surface (articular fractures) usually need to be set more precisely to restore the joint surface as smooth as possible. On occasion, bone may be missing or be so severely crushed that it cannot be repaired. In such cases, a bone graft may be necessary. In this procedure, bone is taken from another part of the body to help provide more stability. Sometimes bone graft substitutes may be used instead of taking bone from another part of the body.

Fractures that have been set may be held in place by an “external fixator,” a set of metal bars outside the body attached to pins which are placed in the bone above and below the fracture site, in effect keeping it in traction until the bone heals.

Once the fracture has enough stability, motion exercises may be started to try to avoid stiffness. Your hand surgeon can determine when the fracture is sufficiently stable.

What types of results can I expect from surgery for hand fractures?
Perfect alignment of the bone on x-ray is not always necessary to get good function. A bony lump may appear at the fracture site as the bone heals and is known as a “fracture callus.” This functions as a “spot weld.” This is a normal healing process and the lump usually gets smaller over time. Problems with fracture healing include stiffness, shift in position, infection, slow healing, or complete failure to heal. Smoking has been shown to slow fracture healing. Fractures in children occasionally affect future growth of that bone (see the brochure/web page on Fractures in Children). You can lessen the chances of complication by carefully following your hand surgeon’s advice during the healing process and before returning to work or sports activities. A hand therapy program with splints and exercises may be recommended by your physician to speed and improve the recovery process.

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Ganglion Cysts

DESCRIPTION

Ganglion cysts are very common lumps within the hand and wrist that occur adjacent to joints or tendons. The most common locations are the top of the wrist, the palm side of the wrist, the base of the finger on the palm side, and the top of the end joint of the finger . The ganglion cyst often resembles a water balloon on a stalk (see Figure 3), and is filled with clear fluid or gel.

CAUSES

The cause of these cysts is unknown although they may form in the presence of joint or tendon irritation or mechanical changes. They occur in patients of all ages.

These cysts may change in size or even disappear completely, and they may or may not be painful. These cysts are not cancerous and will not spread to other areas.

SIGNS AND SYMPTOMS

The diagnosis is usually based on the location of the lump and its appearance. They are usually oval or round and may be soft or very firm. Cysts at the base of the finger on the palm side are typically very firm, pea sized nodules that are tender to applied pressure, such as when gripping. Light will often pass through these lumps, (trans-illumination) and this can assist in the diagnosis. Your physician may request x rays in order to look for evidence of problems in adjacent joints. Cysts at the far joint of the finger frequently have an arthritic bone spur associated with them, the overlaying skin may become thin, and there may be a lengthwise groove in the fingernail just beyond the cyst.

TREATMENT

Treatment can often be non-surgical. In many cases, these cysts can simply be observed, especially if they are painless, as they frequently disappear spontaneously. If the cyst becomes painful, limits activity, or is otherwise unacceptable, several treatment options are available. The use of splints and anti-inflammatory medication can be prescribed in order to decrease pain associated with activities. An aspiration can be performed to remove the fluid from the cyst and decompress it. This requires placing a needle into the cyst, which can be performed in most office settings. Aspiration is a very simple procedure, but recurrence of the cyst is common. If non-surgical options fail to provide relief or if the cyst recurs, surgical alternatives are available. Surgery involves removing the cyst along with a portion of the joint capsule or tendon sheath (see Figure 3). In the case of wrist ganglion cysts, both traditional open and arthroscopic techniques usually yield good results. Surgical treatment is generally successful although cysts may recur. Your surgeon will discuss the best treatment options for you.

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