Wrist/Arm Injuries And Disorders

Introduction
Ganglion Cysts
Carpal Tunnel Syndrome
Tendonitis of the Wrist
"Wear and Tear" Arthritis of the Hand
Dupuytren's Contracture
Trigger Finger
Common Hand Injuries
Radial Tunnel Syndrome
Deformities
Infections

Ganglion cysts are the most common mass or lump in the hand. They are most common on the back of the wrist. These non-cancerous, fluid-filled cysts arise from the ligaments, joint linings, or tendon sheaths when they are irritated or inflamed. They may disappear or change size quickly. Many ganglion cysts do not require treatment. However, if the cyst is painful, interferes with function or the patient does not like the appearance, your orthopaedic surgeon can remove the fluid with a needle (aspiration) or remove it surgically.

DeQuervain's stenosing tenosynovitis is an irritation and swelling of the sheath or tunnel which surrounds the thumb tendons as they pass from the wrist to the thumb. Pain when grasping or pinching and tenderness over the tunnel are the most common symptoms. Sometimes a lump or thickening can be felt in this area. If the hand is made into a fist with the thumb "tucked in" and bent towards the little finger, the pain gets worse (Finkelstein test). Tendonitis may be caused by overuse and also can be seen in association with pregnancy or inflammatory arthritis such as rheumatoid disease. If treated early, many cases improve with short periods of rest in a splint, followed by stretching exercises designed to get the tendons gliding. Injection with steroids and/or taking anti-inflammatory medications. More severe cases or those that do not respond to other treatment may require surgery. Modification of the activities which caused the symptoms initially also may be required.

Common symptoms of carpal tunnel syndrome are numbness and tingling in the hand, especially at night; pain with prolonged gripping such as holding a steering wheel; or clumsiness in handling objects. Sometimes the pain can go all the way up to the shoulder. These symptoms are caused by pressure on the median nerve as it enters the hand through a tunnel in the wrist. The tendons that bend your fingers and thumb also travel in this tunnel. Mild cases can be treated with a splint or brace to rest the wrist. Steroid injections into the carpal canal to decrease swelling may be used in addition to splinting. Those cases that do not respond to nonsurgical treatment and those that are diagnosed late often require surgery. This is generally done in an outpatient setting under local anesthesia.

Wear and tear arthritis is very common at the base of the thumb. Pain localized to the base of the thumb, particularly with use, is a very common early symptom. Early disease can be treated with anti-inflammatory medication, steroid injections into the joint, or splinting. As the wear and deformity progress, surgery is frequently required. There are many procedures to relieve pain and improve function. Heberden nodes are "bumps" which occur at the last joint of the finger or thumb due to wear and tear arthritis (osteoarthritis). As the joints deteriorate, small bone spurs form over the back of the joints and make them appear "lumpy." Since most Heberden nodes are not painful and seldom interfere with function, no specific treatment is usually required. Patients with pain can be treated with anti-inflammatory medications. All patients should continue moving their hands; disuse frequently results in stiffness.

Dupuytren's contracture is a hereditary thickening of the tough tissue called fascia that lies just below the skin of your palm. This condition may vary from small lumps or bands to very thick bands which may eventually pull the fingers into the palm. Dupuytren's disease is familial, and may be associated with cigarette smoking, vascular disease, epilepsy, and diabetes. The mainstay of treatment is surgical and is recommended if there is progressive contracture drawing the fingers into the hand. Sometimes a steriod injection will be used in a painful nodule. Small nodules or lumps in the palm do not need treatment until they are very large and interfere with hand function. Even with successful surgical removal, the bands may reappear or occur in other fingers. Since most Heberden nodes are not painful and seldom interfere with function, no specific treatment is usually required. Patients with pain can be treated with anti-inflammatory medications. All patients should continue moving their hands; disuse frequently results in stiffness.

Trigger finger is an irritation of the digital sheath which surrounds the flexor tendons. When the tendon sheath becomes thickened or swollen hand, it pinches the tendon and prevents it from gliding smoothly. In some cases the tendon catches and then suddenly releases as though a "trigger" were released. Sometimes the swelling can be treated with rest, activity modification, oral anti-inflammatories, or steroid injections. The tendon sheath will then return to its normal, pain-free condition. More severe cases may require surgery to release the tendon. This can be done as an outpatient procedure. Normal activity can be resumed as pain allows.

Gamekeeper's thumb is a rupture of the ligament on the palm side of the thumb, which is responsible for pinching movements. It usually results from a fall that jams the thumb backward onto a hard surface. This injury is so named because it used to be an occupational hazard of gamekeepers in England, who broke the necks of rabbits with their hands. Treatment usually consists of a splint, but surgery is sometimes necessary.

Rupture of the scapholunate ligament may result from falling on an outstretched hand. Pain is felt mostly on top of the wrist. Treatment consists of surgical repair of the ligament and pinning of the bones.

Scaphoid fractures are a common type of wrist fracture. Tenderness is felt in the wrist below the thumb. Untreated scaphoid fractures often do not heal, eventually leading to arthritis of the wrist. Treatment consists of a cast or surgery. The bone may take 3 to 4 months to heal.

Dislocations may occur at the joint at the base of the thumb or other fingers or at the middle joints of the fingers. Dislocations usually result when the thumb is bent too far out or the fingers are bent too far back. Surgery is often required to correct dislocations at the base of the thumb or fingers. Dislocations of the middle joints may be treated by taping the dislocated finger to an adjacent finger. It the ligament is badly torn, a splint is used, usually for 3 weeks.

Fractures of the hook of hamate may result from striking the ground with a stick or making a divot playing golf. The lower part of the palm below the little finger is tender. The hand is put in a cast for 4 to 6 weeks, but the fracture may not fully heal. If unhealed fracture causes pain, weakness, or numbness of the little finger, surgery to remove the unattached part of the bone may be necessary.

Sometimes doctors can diagnose a hand injury by examining the hand. A local anesthetic may be given before the examination, which otherwise might be too painful. However, x-rays may be needed to determine whether the joint is unstable and to detect fractures. Occasionally, computed tomography (CT) or magnetic resonance imaging (MRI) is needed. Often, an untreated injury can result in a permanent deformity of the hand. Therefore, an injured hand should be immobilized so that it can heal normally. A bandage, splint, or cast may be used, depending on the injury. Surgery is sometimes necessary if bones are out of position or a joint is unstable. Hand exercises are begun as soon as possible to prevent loss of function.

Mallet Finger
Mallet finger is a deformity in which the fingertip is curled in and cannot straighten itself.

This deformity usually results from injury, which either damages the tendon or tears the tendon from the bone. It can affect one or more fingers. A doctor can make the diagnosis by examining the finger. An x-ray is usually taken to be sure that there is no fracture. The usual treatment is placing a splint on the finger with the finger straightened. The tendon may take 6 to 8 weeks to heal. Mallet finger rarely requires surgery, unless a large fragment of bone has broken off or the joint is partially dislocated, even in the splint.

Swan-Neck Deformity
Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint.

The most common cause is rheumatoid arthritis. Other causes include untreated mallet finger, looseness (laxity) of the fibrous plate inside the hand at the base of the fingers or of the finger ligaments, muscle spasm affecting the hands, and a misalignment in the healing of a fracture of the middle bone of the finger. Closing the finger may become impossible; the deformity can therefore result in considerable disability.

True swan-neck deformity does not affect the thumb, which has one less joint than the other fingers. However, in a variant of swan-neck deformity, called duck-bill deformity, the top joint of the thumb is severely overstraightened with a bending in of the joint at the base of the thumb to form a 90° angle. If duck-bill deformity and swan-neck deformity of one or more fingers occur together, the ability to pinch can be seriously reduced.

A doctor makes the diagnosis by examining the hand and finger. Treatment is aimed at correcting the underlying cause when possible. Mild deformities may be treated with finger splints (ring splints), which correct the deformity while still allowing a person to use the hand. Problems with the ability to pinch can be greatly improved by surgically realigning the joints or by fusing the thumb or finger joints together (called interphalangeal arthrodesis) into positions that allow for optimal function.

Boutonnière Deformity
Boutonnière deformity (buttonhole deformity) is a deformity in which the middle finger joint is bent in a fixed position inward (toward the palm) and the outermost finger joint is bent excessively outward (away from the palm).

This disorder most often results from rheumatoid arthritis but can also occur from injury (deep cuts, joint dislocation, fractures) or osteoarthritis. People with rheumatoid arthritis can develop the disorder because they have long-standing inflammation of the middle joint of a finger. If the deformity is due to an injury, the injury usually occurs at the base of a tendon (called the middle phalanx extensor tendon). As a result, the middle joint (called the proximal interphalangeal joint) becomes "buttonholed" between the outer bands of the tendon that runs to the end of the finger. The deformity can, but need not, interfere with hand function. The doctor makes the diagnosis by examining the finger.

A boutonnière deformity caused by an extensor tendon injury can usually be corrected with a splint that keeps the middle joint fully extended for 6 weeks. When splinting is ineffective, or when buttonhole deformity is due to rheumatoid arthritis, surgery may be needed.

Infections Caused By Bites
The most common cause is injury to the knuckles by the teeth from a punch to the mouth. Animal bites are also common causes. Wound contamination by a number of types of bacteria can result from human and animal bites. All bite injuries are potentially dangerous and can cause significant infection. The injured area should be cleaned surgically, with the wound left open. Antibiotics should be given to prevent joint infection (septic arthritis), which can otherwise lead to permanent destruction of the knuckle joints. Bacteria in human and animal bites are resistant to many antibiotics but are generally sensitive to ampicillin and penicillin.

Felon
A felon is infection of the soft tissue (pulp) at the fingertip.

An infection of the fingertip can lead to an abscess, which creates pressure and death of nearby tissues. The fingertip becomes very swollen and firm with intense throbbing pain. The doctor makes the diagnosis by examining the affected finger. If a felon is not treated promptly, the underlying bone, joint, or tendons may become infected. Minor felons may be treated with warm soaks several times a day to increase blood flow. An antibiotic is usually needed. Treatment may require prompt surgical drainage of the abscess as well.

Herpetic Whitlow
Herpetic whitlow is a viral infection of the fingertip.

Herpes simplex virus may cause an intense, painful skin infection. The fingertip is sore and swollen but is not as firm as in a felon. The appearance of tiny fluid-filled blebs (vesicles) on the fingers is diagnostic. A herpetic whitlow is often mistaken for a felon. The disorder eventually goes away on its own. Surgery is not needed.

Paronychia
Paronychia is infection of the cuticle.

This very common hand infection can be caused by an injury to the nail and cuticle, nail biting, or aggressive manipulation of the cuticle during a manicure. Paronychia can be caused by many different bacteria, including Pseudomonas and Proteus. The cuticle and tissue at the margin of the nail become red, swollen, and intensely painful. If left untreated, an abscess will develop and can spread to the fingertip (leading to a felon) or to the bone.

The doctor makes the diagnosis by examining the affected finger. In its earliest stage, paronychia may be treated with oral antibiotics and frequent warm soaks to increase the blood flow. If an abscess develops, it must be surgically drained.

Hand Abscess
A hand abscess is an accumulation of pus affecting the hand, usually caused by a bacterial infection.

Abscesses in the hands are fairly common and usually result from injury. An abscess in the soft pad at the tip of a finger nearly always results from a minor injury, such as a splinter or needle prick. Severe pain, warmth, and redness develop over the abscess, often with swelling of nearby lymph nodes in the arm. Infection of the bone underneath the abscess may cause more pain.

Abscesses may occur around the tendons that run along the inside of the fingers. This type of abscess is caused by an injury that penetrates one of the creases on the palm side of a finger. Infection and pus form around the tendon and rapidly destroy tissue. The gliding mechanism of the tendon becomes damaged, so the finger can barely move. Symptoms include swelling and inflammation of the finger, tenderness over the tendon sheath, and extreme pain when trying to move the finger. Swollen lymph nodes near the abscess are common. Fever is also common.

An abscess may occur in any part of the palm and spread between the metacarpal bones (the hand bones between the wrist and fingers). Such an infection may occur after the skin is ripped or the hand is punctured by something sharp. Palm abscesses (also called collar-button abscesses) may develop from an infected callus. Palm abscesses begin as intense throbbing pain with swelling and severe tenderness to touch.

Treatment involves surgically draining the pus. Laboratory cultures of the pus are carried out to determine which antibiotic is best for treatment (usually a cephalosporin).

Infection of the Tendon Sheath
An infection of the flexor tendon sheath is characterized by pain and swelling, with tenderness along the length of the tendon sheath and pain when straightening the finger. Pus may spread inside the hand to form a horseshoe-shaped abscess. Surgical drainage of the abscess is required. Antibiotic therapy is also required (the choice depending on the results of laboratory cultures of the pus).