FAQ Category: Hand

Some medical conditions aren’t easily diagnosed with an X-ray, CT scan, or MRI. Carpal tunnel syndrome (CTS) is one of those problems. Sometimes it’s caused by a medical condition such as a tumor, hormone imbalance, liver disease, or diabetes.

Once the doctor has ruled out a medical cause, it’s time to look at posture, nerves, or muscles as the possible cause. Again, problems with these variables don’t show up on imaging studies. Nerves can be tested using nerve conduction studies. Muscles can be tested with electromyography. Both of these tests can be uncomfortable and expensive.

In general, the rising costs of health care have pushed researchers to find ways to predict who’s at risk for CTS. The next step is to reduce the risk by eliminating as many of the risk factors as possible.

A second step involves using a clinical prediction rule (CPR). Researchers help doctors find out which tests used in the clinic are the most reliable and accurate. There may be a CPR for each disease, illness, and condition. There may be one best test or a group of tests that give an accurate prediction.

You may have endured a variety of tests because a clear CPR for CTS isn’t available yet. The first study on this topic was reported this year (2005). More studies will be done to verify the results.

You may be describing a test used to look for carpal tunnel syndrome (CTS) called the flick sign. This test is done by shaking the hands as if shaking down a thermometer. It’s positive for CTS if the symptoms go away after shaking or flicking the hands. The flick sign is a highly sensitive and specific test for CTS.

The most common symptoms of carpal tunnel syndrome are pain, numbness, and tingling in the thumbs and first two fingers. Numbness in all fingers can also occur. Symptoms are usually worse at night and often wake patients up from a sound sleep.

Age (over 45 years old) and body size (obesity) are risk factors for CTS. CTS is also a common problem associated with other conditions such as pregnancy, diabetes, and thyroid problems. It may be a good idea to have your doctor take a look at you. Sometimes early diagnosis can help take care of the problem quickly and easily.

Surgery is done most often when the skin is broken open and the bone is sticking out. This is called an open fracture. Closed injuries can be treated surgically or nonsurgically.

The type of fracture you’re describing is called a mallet fracture. A small piece of bone breaks away from the last joint in the finger. The extensor tendon attaches there and is also torn.

Without this tendon, the finger doesn’t extend or straighten all the way. It stays in a bent position even when you try to straighten it. This is called extensor lag.

Studies have shown much higher rates of problems when closed mallet fractures are treated surgically. They seem to do better with a splinting program. Patients report they are painfree and able to resume all their former activities.

The carpal tunnel is an opening in the wrist bones that allows the nerves to the hands to pass from the forearm through the wrist. There’s a band of fibrous tissue called the retinaculum across the carpal tunnel at the base of the wrist. Carpal tunnel release takes the pressure off the median nerve by cutting through the retinaculum.

An incomplete decompression can occur in one of three ways. First, the retinaculum may not be cut through completely. The cut may not go all the way from the bottom at the base of the wrist to the top near the palm.

Second the cut may go from bottom to top but doesn’t cut through the full thickness of the retinaculum. This leaves a thinner but fully intact retinaculum in place.

Third, the retinaculum can be cut completely but scar tissue forms as the body tries to repair the damage. Fibrous scarring fills in the spot, once again putting pressure on the nerve.

The knifelight is a special instrument that allows the surgeon to cut the flexor retinaculum without actually seeing it. The retinaculum is a band of tissue that crosses the wrist. This fibrous band can put pressure on the carpal tunnel causing mild to severe symptoms of carpal tunnel syndrome.

A carpal tunnel release involves cutting the retinaculum in half from bottom to top. Usually an incision must be made to open the wrist so the surgeon can see the retinaculum fully. With a mini-open incision, the bottom edge of the retinaculum shows and the knifelight is used the finish the cut.

With the operating room lights off, the knifelight lights up the middle of the palm when the retinaculum is cut all the way through. Operation and recovery time are shorter with this method.

Carpal tunnel release has come a long way in a short time. Many surgeons have moved away from the long, open incision to an endoscopic approach. In this method, a special tool is inserted underneath the skin. The operation is done using special imaging that allows the surgeon to see what’s going on.

A second new method is the limited-open method. A vertical incision is still made in the palm. This allows the surgeon to see the entire retinaculum, which is cut. The retinaculum is a fibrous band of tissue across the carpal tunnel. Cutting the retinaculum takes the pressure off the median nerve.

The tiny sideways cut you saw is from the mini-open technique. A large enough opening is made to let the surgeon see the edge of the retinaculum. Then a special knifelight is used to cut the rest. Studies are being done to find out which method is best.

You may have two completely separate problems going on here. Or you may be having some wrist instability from the carpal tunnel release (CTR). Most of the bones in the wrist are held together by ligaments and fibrous connective tissue. When the band of tissue across the wrist is cut for a CTR, it can cause instability.

As it’s been three months since your surgery, it might be a good idea to make a follow-up appointment with the surgeon. It could be just a postural problem in the way you hold and use your wrist. Or you may just need a strengthening program for your wrist. Early intervention is always advised for the best results.

Sports! A mallet finger fracture of the tip of any finger usually occurs during a sporting activity. It’s so common in baseball it is often called baseball finger.

The cause is usually catching a ball wrong. The tip of the finger is forced suddenly into flexion. The extensor tendon and a small piece of bone pull away from the joint. Without
the tendon to extend the tip of the finger, it stays in a bent position. The finger looks like a mallet, thus the name.

Bumps or prominences on joints are common after injury to the joint, tendon, or ligament to the joint. The body will overcompensate for loss of bone or soft tissue by producing extra bone or tissue.

In the case of a finger fracture a process called bone remodeling takes place. First new bone cells develop at the fracture site. Then a bone bridge across the two broken pieces occurs. Then the body goes back and “remodels” the lump of bone at the site. It removes some (not all) of the extra bone it formed in the first place.

On the outside this can look like a bump. The same kind of appearance can occur when a ligament or tendon is torn and isn’t repaired. The end of the torn tissue pulls back into a ball that looks like a bump on the outside.

Arthritis is possible after joint injuries of this kind. A baseline X-ray may be a good idea to show the condition of the joint now. Future X-rays can show any changes that occur. This kind of information can help guide treatment now and later.

“Double jointed” is a term used to describe people who are very flexible. They really only have one joint but the motion at that joint is more than what most people have.”Double jointed” is a term used to describe people who are very flexible. They really only have one joint but the motion at that joint is more than what most people have.

You may have seen people in the circus or on TV who can support their body weight on their hands while wrapping their legs over their shoulders. Or contortionists who can get
their entire body into a two foot square box. These people have hypermobile joints. They are often very thin, so the muscle bulk doesn’t limit motion when the legs or arms are bent.

The contractile tissue around the joint is also loose or lax so the joint has more “give” or motion. You may have just one hypermobile joint. But many people who can touch the thumb to the forearm have generalized hypermobility throughout the body. They can also
touch the palms to the floor with the knees straight.

There are special tests that can be done to measure the nerve’s ability to send messages. These are called nerve conduction velocity (NCV) tests.

The tests aren’t usually advised when symptoms first come on. They are expensive and can be somewhat uncomfortable. Other tests can be done by a physician, physical, or occupational therapist to gain information about nerve function.

It’s likely that pressure on the nerves as they pass through the wrist is causing these symptoms. You can help by avoiding prolonged gripping on the bike handlebars.

If you are leaning forward over the bars, sit up and take periodic breaks. Roll your shoulders back and down. Take a deep breath and exhale to release tension. Shake your hands out every so often.

You can also wear biker’s gloves to help absorb some of the pressure. Don’t wait to see a doctor if the symptoms persist. Pressure on the nerve for too long can cause permanent damage. Early intervention is best for a good result.

Biker’s palsy occurs as a result of a firm grip on bicycle handlebars for hours to
days and longer. There are two nerves affected most often: ulnar and median. Both these
nerves pass through the wrist to the hand.

Prolonged pressure can cause numbness, tingling, and weakness. Nerve involvement of this
kind is called neuropathy.

A similar problem can occur in motorcylists as well as anyone handling high-power tools
that vibrate like a jackhammer.

Pressure on the nerves in the wrist and hand from gripping too long and too hard on the handlebars is a common problem in bicyclists.

Take a tip from the professionals like Lance Armstrong. Use biker’s gloves and padded handlebars. Both these items are available commercially at your local sporting goods or bicycle store.

Glove material is designed to absorb shock. You can do your part too by consciously avoiding a death grip on the handlebars. Take frequent breaks by opening and closing first one then the other hand.

Keep your shoulders away from your ears. Remember to breathe. This can reduce tension in the entire upper body.

Doctors do think there’s a link between these two problems. They both occur most often in postmenopausal women. There may be a hormonal connection. This may also just be a matter or anatomy.

The trapezium bone at the base of the thumb forms one side of the carpal tunnel. Other bones in the wrist and ligaments make up the rest of the borders for this oval-shaped tunnel. Tendons and the median nerve pass through the tunnel.

Arthritic changes of the bone such as bone spurs can protrude into the carpal tunnel. This narrows the space even more and puts pressure on the nerve. New imaging technology may help doctors study this problem more thoroughly in the future. At present, only several small studies have been done.

At the base of the thumb is a bone called the trapezium. This bone also forms one side of an open tunnel in the wrist called the carpal tunnel. This oval-shaped opening gives room for the median nerve and tendons to pass from the forearm to the hand.

Usually, during surgery for carpal tunnel syndrome, the doctor cuts the ligament that goes across the top of the tunnel. This ligament attaches to the trapezium. Then, the bone is taken out.

Removing the trapezium changes the shape and volume of the carpal tunnel. The tunnel becomes more circular or round in shape. This change in shape may open up a narrow carpal tunnel and take pressure off the nerve. Studies with MRI to confirm this are underway.

Wrestling is a common cause of injury to the thumb. Many times, the radial collateral ligament (RCL) at the base of the thumb is torn. When this happens, early treatment is best, but late treatment is successful.

If the ligament isn’t completely torn, cast immobilization for six weeks is advised. With a complete rupture, surgery to repair the tendon is often needed.

A study over 20 years of thumb injuries showed that even late treatment gives good results. The ligament and the sheath covering it are carefully pulled back to the bone and reattached. The joint is pinned in place during the healing process. Most patients regain motion and strength without pain.

The radial collateral ligament in the thumb holds the base of the thumb and the wrist together. Deciding how to best treat an injury of this type has several steps. The doctor listens to the patient’s symptoms and looks for any signs of wrist, thumb, or hand deformity. A bump at the base of the thumb is a sign of a torn ligament.

Range of motion and strength are measured. Strength includes grip and pinch strength and along with your ability to use the thumb for daily activities. This is called functional strength.

An X-ray is also taken. The X-ray is often the final deciding factor. If there is a bone chip visible or the joint is wider than normal, surgery is needed.</P

The radial collateral ligament (RCL) goes between the radial bone in the forearm and the capitate bone at the base of the thumb. In a small number of cases, pain at the base of the thumb persists after surgery. However, most patients are pain free and symptom free after this operation to repair the ligament.

Other residual symptoms can include a mild loss of strength. This involves pinching objects or pushing with the thumb. Some patients report aching after constant, heavy activity.

There are two kinds of arthritis: rheumatoid and degenerative. Both kinds can result in changes that lead to carpal tunnel syndrome. The carpal tunnel is an oval-shaped space in the wrist formed by bones and ligaments. The median nerve and tendons to the hand pass through this space.

Anything that narrows the space can put pressure on the nerve and cause painful symptoms. In the case of rheumatoid arthritis, swelling from inflammation can do this. With degenerative arthritis, the bones in the wrist can form bone spurs. These can protrude into the tunnel and press against the nerve.

A procedure to weave sections of nearby tendons through and around the bones of the thumb shows promise in delaying, and possibly preventing, thumb joint arthritis.

This form of surgery is best used when the main thumb joint is mildly loose but not yet arthritic. When arthritis is present other surgical procedures may be recommended. When these guidelines are used, ligament reconstruction surgery appears to keep the joint from eventually becoming arthritic. In a recent study, follow up X-rays taken as many as 17 years after this type of surgery showed no signs of thumb arthritis.