FAQ Category: Hand

Requiring scientific evidence to support work-related health claims has become a central issue in the last few years. As a result, more and more studies are underway evaluating the cause of conditions such as carpal tunnel syndrome (CTS).

According to a recent investigation, genetic factors ranked the highest as possible links to CTS. The anatomic structure of the wrist and increased body mass index (BMI) are the strongest risk factors.

There isn’t enough evidence to link CTS with occupational factors such as repetitive hand use, exposure to vibration, and activities requiring high-force grip. Hand position and stressful manual work have also been investigated with similar results.

At this point in time, all evidence points to CTS as a structural, genetic, biologic problem. Environmental and occupational factors play only a minor role in this condition. Typing and computer use have not been directly linked with CTS.

Vibration as a cause of work-related problems is divided into two types: whole-body vibration (WBV) and hand-arm vibration (HAV). Truck, bus, and boat drivers, helicopter operators, heavy equipment operators, miners, and others are at increased risk for WBV.

Vibration-induced white finger disease is the most common example of an occupational injury caused by vibration of the hands. This condition occurs secondary to the use of hand tools such as power saws, grinders, sanders, pneumatic drills, jackhammers. The same is true for other equipment used in construction, foundry work, machining, and mining.

Vibration has not been conclusively linked with carpal tunnel syndrome (CTS). The fact that not all workers using jackhammers develop CTS is a signal that something else is an precipitating factor. There may be other more important ergonomic factors present.

Studies show the highest evidence supports genetic and biologic factors as the most important risk factors for CTS. Structure of the wrist bones, tendons, and capral tunnel space formed by these structures may be the real cause. This may help explain why some people are more susceptible to CTS than others.

Preventing work-associated CTS may be possible but this has not been proven yet. Tools can be modified to reduce some of the dangerous levels of vibration. Grip kits provide grips that can be applied easily to any type of tool. Dampening products made of sorbethane reduce shock and vibration.

Steroid injection for trigger finger is a common and effective treatment for trigger finger (or thumb). A solution of steroid (antiinflammatory drug) and numbing agent such as lidocaine is injected into and around the tendon sheath. Swelling of the tendon sheath is reduced so that the tendon can glide through the covering smoothly.

Studies show that just one inection can resolve trigger finger for about half the patients. It may take a bit of time for the medication to be effective. So be patient with the process. Most patients find optimal results in about two to three months.

Some patients combine injection with hand therapy. Others have a repeat injection. Second or third injections are about half as effective as the first injection. If the trigger finger isn’t helped by an injection or if it comes back after injection, then surgery to release the tendon sheath and pulley ligament holding the sheath in place may be needed.

It’s not clear yet which method (or comination of treatments) works best. More research is needed in this area.

Trigger finger (or thumb) is usually the result of a thickening in the tendon that forms a nodule, or knob. The pulley ligament around the tendon may thicken as well. The constant irritation from the tendon repeatedly sliding through the pulley causes the tendon to swell in this area and create a nodule.

When tendons that bend or flex the finger become enlarged, the affected individual is unable to extend his/her finger. The finger(s) affected may become painful to straighten. A crackling or popping sound is heard when the finger is moved. When the finger unlocks, it pops back suddenly. It mimics the action of releasing a trigger on a gun, which is how it got its name.

Triggering can occur as a result of rheumatoid arthritis, partial tendon lacerations, and repeated trauma from gripping power tools. Long hours grasping a steering wheel can also cause tendon triggering. People with diabetes may be at increased risk for trigger finger as well.

The reason for this connection isn’t entirely clear. Most likely it’s the result of multiple factors. Changes in connective tissue lead to thickening of the tendon sheath. This probably occurs as a result of damage to the blood vessels and nerves, accumulation of collagen in the skin and soft tissues, and attachment of sugars to proteins. These are all part of the diabetic process.

You may have a type of carpal tunnel syndrome (CTS) called idiopathic, which means unknown cause. In many cases, CTS is the result of repetitive hand and wrist motions. Working at a computer keyboard, playing a musical instrument, or doing handwork as you suggested are commonly linked with CTS.

There are some medical reasons for CTS. These can include tumors, diabetes, lupus, gout, rheumatoid arthritis, or kidney failure. Other causes of CTS include thyroid problems, nerve entrapment, or vitamin B deficiency. Some medications can also cause damage to the nerves resulting in CTS.

It’s best to see a physician who can assess your symptoms more accurately. Testing to identify the location and cause of the nerve compression may be needed. Ultrasound can show any swelling of the median nerve as it passes through the entrance or exit of the carpal tunnel.

X-rays and other imaging such as CT scan or MRIs may be used to rule out fractures, tumors, or other space occupying lesions. Lab tests may be ordered to look for rheumatoid arthritis, diabetes, or hypothyroidism as a possible cause.

Sometimes the condition is treated to see if the symptoms will go away. The cause of the problem may be identified this way. For example, CTS associated with vitamin deficiency may go away with vitamin supplementation. Hand therapy to restore nerve and tendon gliding, stretch the connective tissue around the nerve, and reduce swelling in the carpal tunnel may be helpful.

If a physician hasn’t evaluated you, this may be your first step. Proper diagnosis is needed before the best treatment can be applied.

Carpal tunnel syndrome occurs when the median nerve is compressed or flattened as it travels through a tunnel formed by the bones of the wrist. Pressure in the form of mechanical compression also causes a loss of blood supply to the nerve. This loss of oxygen and nutrients is called ischemia.

The longer the pressure and ischemia are present, the more likely it is that symptoms will develop. Symptoms vary because the nerve has both sensory and motor function. Compromise of nerve function results in painful burning, numbness, and tingling. Impaired motor function is linked with muscle weakness and atrophy.

The specific symptoms and symptom severity depend on which fibers of the nerve are affected most. Electrodiagnostic tests such as nerve conduction velocity (NCV) or electromyography (EMG) can be done to find out where the nerve is affected. This type of testing can help determine when surgery might be needed.

When it comes to carpal tunnel syndrome, most hand surgeons tell their patients to be patient. Six weeks to six months of conservative (nonoperative) care is advised first. Antiinflammatory and/or pain relieving drugs may be prescribed. Referral to a physical or occupational therapist is a good idea.

A hand therapist will examine you and use treatment to alter the soft tissue structures around the nerve. Releasing the nerve and/or taking pressure off the affected nerve(s) can go a long way in reducing pain, numbness, and tingling that can be very disabling.

Special nerve mobilization techniques developed in the last 10 years are often very helpful. Stretching and gliding exercises restore full motion of the nerve. This is especially helpful if it has been bound down by adhesions or other connective tissue.

Two groups of patients are not usually good candidates for carpal tunnel release. The first show signs of advanced nerve damage. Muscle wasting called atrophy and weakness are present. Loss of sensation in the fingers and hand also signal more severe nerve damage. Surgery isn’t likely to change these symptoms.

The second group has pain but normal electrodiagnostic tests. This group is most likely to obtain relief from their symptoms with conservative care. Studies show that other factors can also affect the outcomes of carpal tunnel release. These include depression, litigation, and psychosocial factors.

If any of these situations describes you, consider a course of conservative care and discuss your concerns with your surgeon. Give yourself time to sort through all the factors and try some nonsurgical options. If you do have surgery, many surgeons commonly use newer, less invasive methods. There are fewer side effects and good relief of painful symptoms. Patient satisfaction with the results is very good.

Wrist pain can be difficult to diagnose. X-rays will show fractures, which could be a cause of wrist pain. Ligamentous tears can cause enough instability to cause pain but not enough to always show up on X-rays. Depending on which ligament is affected, specific tests done by the physician may be able to show what’s wrong.

If a fracture is not present and nothing shows up on X-rays, MRIs may be ordered. Again, this type of imaging study doesn’t always reveal ligamentous damage. Fraying of the ligament and/or deformity of the ligament can create enough wrist instability to be very painful.

Arthroscopic exam may be needed to find the cause of the problem. The surgeon inserts a long, thin scope (needle) into the joint. A tiny TV camera on the end of the scope gives an inside view of the wrist. The surgeon can inspect the soft tissues, joint capsules, and bones using this method. In some cases, repair and/or reconstruction of the wrist can be done at the same time.

Bennett’s fracture is a break in the first metacarpal bone. This is the bone at the base of the thumb where it attaches to the wrist. This is called the carpometacarpal (CMC) joint. Bennett’s fracture is named after the physician (Edward Bennett, M.D.) who was the first one to describe it back in 1882.

Bennett’s fracture is the most common break in the thumb. It is actually a fracture and dislocation at the base of the joint of the thumb. The fracture occurs with trauma when the thumb is flexed in a fisted position. Fist fights frequently result in this type of injury.

Skaters who land on the partially flexed thumb have also been known to suffer a Bennett’s fracture. Treatment is usually surgical. The thumb is reduced or relocated in the joint. If any of the ligaments are ruptured, reconstruction is required to restore motion and function.

A stable, strong thumb is needed to accomplish the many movements of this joint. Opposition to the other fingers is the most complex, yet functional motion of the CMC joint. Many ligaments and muscles are involved with this joint and must be repaired in order to restore full function.

It’s true that pain by itself can increase anyone’s anxiety level. And relieving anxiety can often reduce pain by as much as 50 per cent. But pain anxiety is a little different idea than just anxiety caused by pain.

Pain anxiety is a combination of mental and psychologic anxiety, fear of pain, and escape and avoidance behaviors. There are some tests that help sort out pain versus pain anxiety. The Pain Anxiety Symptoms Scale (PASS) measures how often patients have negative thoughts related to their pain.

A subscale also measures the frequency of thoughts that bring on fearful responses. And the test brings out how often dread of negative results of pain occurs. Other measures include physical responses to pain such as increased heart rate, elevated blood pressure, and sweating. All of these are measures of pain anxiety.

Pain anxiety decreases a patient’s ability to cope effectively with pain. The person tends to catastrophize their symptoms. This means they think about the pain, focus on the pain, and magnify the pain. They sink into thoughts of helplessness and hopelessness.

Surgery is not usually advised for patients with pain anxiety. Their symptoms are not alleviated. They end up very dissatisfied with the results. A program of behavioral and psychologic counseling is a better choice at first. Once the psychologic factors are overcome, then the need for surgery can be reevaluated.

Arthritis of the thumb affects the carpometacarpal (CMC) joint most often. This is the joint at the base of your thumb. It allows a great deal of thumb motion in all directions. Pinching and gripping would not be possible without this joint.

Women are affected almost twice as often as men by CMC osteoarthritis (OA). There may be several reasons for this difference between the sexes. First, women have more joint laxity or looseness at this site. Hormones such as prolactin, relaxin, and estrogen are the most likely cause.

Second, there are subtle differences in the anatomy between men and women. The size and shape of the trapezium bone is different in women. The joint surface is smaller and flatter in women. The joint surfaces don’t always match up in women as well as they do in men. These differences seem to predispose the joint to early degenerative changes.

Female gender combined with other risk factors may contribute to a higher rate of CMC arthritis among women. For example, trauma resulting in ligament damage and instability may lead to joint changes that increase the risk of joint arthritis.

Not all the reasons for these differences are known yet. More research is needed to help identify risk factors and possibly find ways to prevent this disabling condition for everyone.

There are two basic ligament reconstructive procedures for basal thumb arthritis. The first is called the ligament reconstruction tendon interposition (LRTI). In this operation, the arthritic bone (trapezium) is removed from the base of the thumb. A tendon is harvested from nearby and rolled up to fit inside the hole left by the trapezium.

A second operation is the trapeziometacarpal interposition arthroplasty (TMIA). Only part of the trapezium is removed. Then, part of the flexor carpi radialis tendon is used to reconstruct the thumb. Some of the same tendon is also placed inside the spot where the piece of bone has been taken out.

By taking out the whole bone, LRTI comes with a slight risk that the thumb will shorten as the bones move up toward the hand. This process is called proximal migration of the thumb. The idea behind the TMIA is to reduce this risk by leaving a portion of the bone in place.

And in fact, studies show that there’s a good chance of proximal migration in those patients who have had a LRTI compared with a TMIA. However, it doesn’t appear that the shortening has any functional significance. There is a decrease in pinch strength after this operation but it’s the same amount with either the LRTI or the
TMIA.

Loss of function after thumb reconstruction is to be expected. This is true no matter how the operation is done. With time and a good hand therapy program, your father should be able to get back to his woodcarving. It may even be an excellent form of therapy!

It sounds like you might be describing basal or carpometacarpal (CMC) thumb joint arthritis. The first step is to get an accurate diagnosis. See your primary care physician or an orthopedic surgeon.

The doctor will rely on you to describe when it hurts and where it hurts. Pay attention over the next few days of all your symptoms so you can report them. An x-ray may be taken but doesn’t always show joint damage during the early phases (stage I). Joint narrowing, bone spur formation, and bone cysts are among some of the changes that begin to occur in stages III and IV.

Conservative care is usually advised first. Your doctor may recommend pain relievers and/or antiinflammatory drugs. A referral to the hand therapist is a good idea. The therapist (occupational or physical) will test and measure your grip and pinch strength, range of motion, and function.

A program of exercises to improve motion, restore strength, and increase function will be prescribed. Sometimes a resting splint is fabricated. This can be worn at night or during the day when you are engaged in a quiet activity such as reading or watching television. A functional splint may be made for you. This can be worn during activities to protect the joint from excess strain and load.

Surgery is a possibility but only if you have moderate-to-severe problems and you’ve tried at least six months of nonoperative care first. Surgery can involve fusion of the joint in a functional position. You’ll have pain relief but loss of motion. You may not be able to open your hand all the way.

Ligament reconstruction is another choice. Part or all of the trapezium bone at the base of the thumb is scraped smooth or removed. A nearby tendon is harvested and placed in the empty hole from the missing trapezium. Many patients are very happy with the results of this operation. They get pain relief and function is preserved.

A claw hand is given that name because the fingers of the hand begin to bend and the hand looks like an animal claw. People can be born with this deformity, or it can happen later in life.

When it happens later on in life, the nerves in the fingers are damaged and the tendons of the fingers begin to contract and pull the fingers towards the palm of the hand.

Whether your son has surgery for the claw hand is a decision you have to make with his doctor. You don’t say how old your son is, but he may want to have some say in this as well.

Discuss with the doctor the pros and cons of the surgery. Listening to people who have had the surgery is a good idea, but it shouldn’t be the reason behind your decision. To get more informed, the doctor can describe the surgery and the recovery period for you.

You can ask about whether the doctor immobilizes the hand for four weeks before therapy begins or if therapy begins right away – those are two different approaches that doctors can take. Ask how many of these repairs the doctor has done, talk about the type of therapy that will follow and who will be doing the therapy.

It is always a good idea to go in with a list of questions so you don’t forget something that you feel is important.

Trigger finger is also known as stenosing tenosynovitis. It is a narrowing of the space in which the tendon slides and glides. The tendon sheath or lining around the tendon becomes swollen or forms scar tissue or a nodule for some reason.

When the tendon can’t move smoothly inside the sheath, a trigger finger may develop. The finger gets stuck in a flexed or bent position. When it is straightened out, the finger pops back like a trigger on a gun.

Any finger can be affected. Usually the thumb, middle, or ring fingers are involved. In most cases, the etiology (cause) is unknown. This is referred to as idiopathic.

Sometimes a specific etiology can be identified. This could be a soft tissue or bone tumor, arthritis, bone spur, or scar tissue from a previous injury. Trauma as a cause is possible if damage to the tendon results in scarring or the formation of a fibrous nodule.

There is medical treatment available for trigger finger. Steroid injection, hand therapy, and sometimes, surgery can be helpful. See a hand surgeon or orthopedic surgeon if symptoms persist or cause decreased function.

Infections affecting the soft tissues can be very difficult to pinpoint. Studies show that the average time between the start of symptoms and an accurate diagnosis for this problem is one year.

There isn’t a single reason for this delay. Sometimes the patient has other problems that are more pressing, and the primary focus isn’t on the finger. In other cases, there is a compromised immune system due to other illness or disease. This can lead to delays in diagnosis.

Most of the time, the cause of trigger finger is idiopathic or unknown. In rare cases, infection is the underlying cause. A series of cases have been reported caused by mycobacterium infections in AIDS patients. Patients who have had a series of steroid injections into the joints have also been reported with infection leading to joint and tendon problems.

Gout affects the joints and is a disease caused by a problem with uric acid metabolism. Sometimes this condition is referred to as metabolic arthritis.

In this condition, there is an elevated amount of uric acid in the blood. Uric acid crystals form and get deposited on joint surfaces, tendons and surrounding soft tissues.

An inflammatory reaction of these tissues occurs. The deposits often increase in size. They can form tracks through the skin and out to the surface. A chalky white material may ooze from the skin. Sometimes the affected individual can squeeze a liquid or pasty substance out of the area.

The feet (especially the big toe) are affected most often. But the fingers and hands can also develop gout. The location of gout in the peripheral joints may be because the temperature of the hands and feet is lower than the rest of the body. And the urate crystals tend to form at lower temperatures.

Symptoms of gout in the hands and wrist are more likely in people who have chronic gout. But the incidence of symptoms in the hands and fingers is less likely now with improved medical care. The tips of the fingers are involved most often. Experts think this is related to arthritic changes seen in the distal interphalangeal (DIP) joints.

Gout can rupture tendons so early treatment is advised. Medical management with drug therapy is the first step. Nonsteroidal antiinflammatory drugs (NSAIDs) are the first line of medications. Rest, elevation, and ice are helpful during acute attacks.

You’ll want to check with your hand surgeon about a timeline from surgery to rehab to full recovery and return to work. Tendon transfers are usually done as an outpatient. This means you’ll likely be in and out of surgery and home on the same day.

Patients are usually placed in a splint that includes the thumb after surgery. The surgeon wants your hand and thumb in a position that will put just the right amount of tension on the tendon. This is important for tendon healing during the first three weeks.

It will be very important to follow your surgeon’s instructions carefully. A rehab program will begin according to the surgeon’s plan. A hand therapist will focus on helping you regain strength and motion.

Things should go smoothly for you. Scarring called fibrosis can affect tendon gliding and sliding. The amount of tendon motion is called the excursion rate. With a good result, your excursion rate will be close to normal.

This motion is important since you will be using your hands for gripping and pulling while roofing. Tendon healing and rehab take time. You can expect to be off work for at least 12 weeks, but again, check with your surgeon for his or her expected return to work date.

Rehab of hand injuries can be long and difficult. This is especially true for a musician who needs very fine movements. If you ruptured a tendon, a tendon transfer may be needed.

The surgeon may use one of several possible tendons in the hand to restore motion and function. For example, transfer of the extensor indicis proprius (EIP) is common to repair a ruptured extensor pollicis longus (EPL). However, using the (EIP) may decrease the strength of extension in the index finger.

This means you may be unable to lift the index finger away from the oboe. The problem is called an extensor lag. Patients can lose up to half their extensor motion after receiving an EIP transfer.

It’s best to let your surgeon know of your need for finger dexterity and strength. Other tendons can be used that may suit your needs more closely.

A recent study reported using the accessory abductor pollicis longus (AAPL) instead of the standard EIP showed good results with very few problems. This new method of tendon transfer may be a treatment option for you.