News Category: Hand

What’s the real underlying cause of carpal tunnel syndrome? Is it genetics? Repetitive workload? Sudden change in temperature? Pregnancy? Low thyroid function? These are just a few of the potential risk factors for CTS.

In this study, a search of the published literature on CTS is performed. The authors were looking for scientific evidence to find out which risk factors linked to CTS are the strongest.

They used the Bradford Hill criteria to evaluate scientific data on the causes of CTS. Quality and strength of the data was evaluated for 117 articles. They were searching for a direct causal link between structural or genetic risk factors, biologic factors, and environmental or occupational risk factor and CTS. Other potential risk factors such as age, race, and gender were also reviewed.

After analyzing all the data, the authors reported the following:

Carpal tunnel syndrome (CTS) continues to cause pain, numbness, and weakness of the wrist, hand, and fingers for many people each year. Surgery may be needed but patients must be chosen carefully. A positive, successful result is the goal.

Research is ongoing trying to predict who will have a good surgical result. Surgeons try to spare patients surgery if it’s clear that operative treatment is not likely to succeed. For example, we know that numbness doesn’t go away after carpal tunnel release when there is advanced nerve damage to begin with.

And patients who have normal nerve function don’t really need surgery. They can get relief from painful symptoms with conservative care. For all the rest who may be good candidates for surgery, psychologic factors must be considered.

In this study, the effect of depression on outcomes after carpal tunnel surgery is examined. Surveys were sent to 200 patients with CTS who had open release surgery with one surgeon. All patients had positive electrodiagnostic tests to confirm CTS.

Questions were asked about satisfaction, pain anxiety, depression, and coping skills. Other factors evaluated included marital status, education level, and type of job. Cases involving worker’s compensation or litigation were also noted.

It turns out that depression was a predictor of decreased satisfaction after surgery. Patients who saw themselves as disabled had higher levels of depression and pain catastrophizing (thinking the worst will happen). Patients with more severe disease were more likely to be dissatisfied. They saw themselves as disabled after surgery.

The results of this study confirm that surgeons should consider the important of psychologic factors in patient satisfaction before doing carpal tunnel release. Permanent nerve damage is not changed by the operation. Patients will be disappointed and unhappy when muscle atrophy, weakness, and numbness are still present after surgery.

Many of the patients who delay seeking medical help until nerve damage is severe are also less likely to cope well and accept their limitations. The surgeon is advised to clearly explain the limitations of surgery in cases of advance nerve damage.

In this review article, surgeons from the Netherlands bring us up-to-date on the treatment of traumatic thumb dislocations. Dislocation of the carpometacarpal (CMC) joint (base of the thumb at the wrist) is very rare.

The thick, strong joint capsule protects the joint from dislocation. Instead, the base of the metacarpal (thumb) bone breaks off first — before the joint can dislocate. This injury is called an avulsion fracture.

The CMC joint is very complex. It has been called the saddle joint. The surface of the bones fit together like a saddle on a horse’s back. This configuration gives the thumb a wide range of movements, including thumb opposition. Four strong ligaments around the joint stabilize and hold everything tightly together.

The best treatment for a thumb CMC dislocation is still widely debated. The extent of ligamentous damage may dictate whether or not surgery is needed. Sometimes putting the joint back in place and using a simple cast is all that’s needed. This is called a closed reduction with casting.

Closed reduction is possible in an acute injury when the joint remains stable. Instability may require using a wire or pin to hold the joint together. In other cases, reconstruction of the torn ligaments is needed to restore thumb motion and function. Tendon graft or tendon transfer may be used to replace the ruptured ligament.

For a chronically dislocated CMC joint, more extensive surgery may be required. An open incision is made, the joint is lined up and held in place with wires. Torn ligaments are repaired or replaced. A cast is placed on the hand and wrist to immobilize the area.

The authors conclude that the literature (studies done so far) do not support the use of aggressive treatment. Open reduction with ligament reconstruction is not always the first choice of treatment. Each patient must be evaluated for joint stability (or instability) when deciding on the best course of action.

This is the first study to compare two ways to predict symptom severity and function in patients with carpal tunnel syndrome (CTS). Ultrasound (also known as sonography) and electrophysiologic testing were compared. This type of information may help surgeons and patients decide when surgery is the recommended treatment of choice.

Ultrasound can be used to assess the structure of the median nerve. Pressure on the median nerve as it enters, passes through, and exits the carpal tunnel causes this syndrome. The carpal tunnel is an opening in the wrist formed by the arrangement of the bones and soft tissues. Ultrasound shows a cross-sectional area of the nerve. The amount of swelling present can be viewed this way.

The second type of testing was electrophysiologic measurements. The median nerve has both sensory (feeling) and motor (movement) function. This type of testing measures the presence and speed of nerve conduction along the nerve pathway.

Which is the better way to predict how severe the symptoms will be and functional status? The results of this study suggest electrophysiologic testing is more helpful than sonography. Testing the sensory nerve predicts symptom severity. Testing the motor nerve was a better predictor of function.

Flattening of the median nerve observed by ultrasound had some value. Swelling of the median nerve at the carpal tunnel entrance was present in cases of carpal tunnel syndrome of unknown cause. This type of CTS is called idiopathic.

The authors conclude that sonography may have some value in diagnosing idiopathic CTS. Electrophysiologic testing may be a better predictor of symptom severity and hand function. More studies are needed comparing CTS patients with mild to severe pain, numbness, tingling, and weakness of the wrist and hands.

The joint at the base of the thumb is called the thumb carpometacarpal (CMC) joint. It is a common site of osteoarthritis (OA) in the hand. The unique anatomy of this joint allows a wide range of movements.

Thick ligaments around the CMC keep it from moving too far and dislocating. Nine muscles surround the thumb CMC joint. These muscles work together to create a balance between stability and motion needed for movements such as thumb opposition and pinch.

Because CMC arthritis is so common, many older adults seek treatment for this problem. An accurate diagnosis is important in planning treatment. In this article, anatomy, diagnosis, and treatment are reviewed and updated for this condition.

X-rays are used to classify or stage thumb CMC arthritis. In stage I disease, the joint space is still normal. No changes are seen yet in the articular(joint) cartilage. In stage II disease, the joint space is starting to narrow. There is minimal damage to the joint or change in the joint contours (shape).

Stage III thumb CMC arthritis has noticeable narrowing of the joint space. There may be bone spurs, cysts, and sclerosis (hardening of the tissues). The joint begins to dislocate partially called subluxation. By the time stage IV occurs, the joint space has deteriorated. Complete dislocation is not uncommon.

Treatment is based more on the severity of patient symptoms than on the stage of disease. Conservative care with splinting, hand therapy, and steroid injection(s) are the first line of care. Surgery to preserve the joint may be needed in the earlier stages of this disease. Joint fusion or replacement is more likely in later stages.

The authors provide an in-depth review of surgical options. These include reconstruction, osteotomy, arthroscopy, arthrodesis (fusion), and arthroplasty (replacement). Osteotomy is the removal and repositioning of a wedge-shaped piece of bone. This procedure restores the anatomy and prevents dislocation.

Arthroscopy is used to look inside the joint and see what’s going on. The surgeon can scrape the joint clean and/or remove any debris. Any rough spots in the synovium (lining of the joint) can be smoothed out. Heat can be used during arthroscopy to shrink (tighten up) the capsule.

Fusion is used to stabilize the joint when pain relief and strength are needed on-the-job. Younger adults in high-demand occupations may choose this treatment option. Rehab and recovery does involve a long period (three months) in a cast. Loss of motion in the joint may prevent some motions such as getting the hand flat or into a pocket.

Joint replacement of the CMC has not worked well so far. The implant wears out quickly because of the shear and compression forces across the joint. Researchers are working to find ways to improve the results.

For now, the standard surgical procedure for thumb CMC arthritis is to remove the trapezium bone. A folded piece of tendon is placed in the hole left by the bone removal. This operation is called ligament reconstruction and tendon interposition (LRTI).

The authors provide guidelines for the use of each of these treatment methods. Patient age, occupation, and severity of symptoms are used to guide the decision. The same criteria are used to identify the best surgical procedure to choose. Possible complications of each operation are also taken into consideration.

Arthritis of the thumb is a common problem in the older adult. Women are affected twice as often as men. Treatment is usually with conservative measures. But when pain and stiffness affect daily function, then surgery may be considered. Fusion or joint replacement are two possible choices. But removing the arthritic bone and replacing it with a piece of tendon may be a better choice.

In this study, two different reconstructive methods for basal (thumb) joint arthritis are compared. The main difference between the two operations is in how much bone is removed. In the first operation (ligament reconstruction tendon interposition (LRTI)), the entire trapezium bone at the base of the thumb is taken out. In the second procedure (trapeziometacarpal interposition arthroplasty (TMIA)), only enough bone to smooth the joint surface was removed.

LRTI is usually done on patients with the most severe arthritis (stage IV). Mild to moderate cases (stages II and III) are treated with TMIA. Results of the two operations were measured based on range of motion, grip and pinch strength, and function. Other measures included pain and/or tenderness, amount of medications taken for pain relief, and patient satisfaction.

The results showed no difference in motion or function between the two groups. This was true even for those patients in the LRTI group who experienced shortening of the thumb. Pinch strength did not seem to be linked with thumb shortening either.

Several patients in the TMIA group had to have a second operation later to convert the patient to a LRTI. The authors reported a high rate of revision surgeries for the TMIA group. They suggest this procedure is better suited for younger patients with a greater need for pinch strength. Both groups had equal satisfaction rates despite differences in outcomes.

Patients with stage II or III thumb joint arthritis may be able to benefit from either one of these two reconstructive surgeries. After examining the patient and looking carefully at the joint surfaces, the surgeon will decide between LRTI and TMIA. The TMIA limits how much thumb shortening can occur. But from the results of this study, it’s not clear that bone migration resulting in thumb shortening is a problem that affects function in any measurable way. For severe (stage IV) basal arthritis, LRTI is advised.

In this article, orthopedic hand surgeons from Brown University in Rhode Island review an uncommon hand condition called carpal boss. Carpal boss refers to a bony bump on the back of the hand between the index and middle fingers near the wrist. It is an extra growth of bone that forms before birth or as a result of degenerative arthritis.

It may be painful with swelling and aching where the bone sticks up. Bending the wrist shows the bump more clearly. Some patients report an injury. Others notice it develops after playing golf or racquet sports. Older adults and/or people who have jobs with repetitive tasks are also at increased risk for this problem.

Carpal boss is easily mistaken for a ganglion cyst or tumor. But it has a much harder consistency than cysts or tumors. Sometimes, a cyst or bursa forms over the bony bump making the diagnosis more challenging.

There are some clinical tests that can be done but they aren’t conclusive. These include the malalignment and stress tests. Both of these tests are described in detail. The test results are helpful but don’t make the final diagnosis. X-rays are really needed to confirm the diagnosis. In more complicated cases, advanced imaging such as MRIs, CT scans, or angiography may be needed.

Symptoms that don’t go away with hand therapy may require surgery. The extra bone can’t just be cut out or it will grow back. The surgeon must find all areas of sclerosis (hardening) around the bone and cartilage and remove them. This is called a wide wedge excision.

Care must be taken to remove only the necessary amount of bone to prevent destabilization of the wrist. Joint instability can be treated with a wrist fusion. This procedure may reduce the painful symptoms but can result in loss of motion and function.

More studies are needed to find the best treatment for carpal boss. Identifying who would benefit from surgery and reducing complications after surgery are important research goals.

Kienbock’s disease, a disorder that restricts blood flow to one of the small bones in the hand near the wrist, causes osteonecrosis, or bone death, to the bone. Doctors don’t know what causes Kienbock’s disease but there are some treatment options available.

In the early stages of the disease, doctors might reconstruct the bony area to bring blood to the bone, for example. The authors of this study were interested in evaluating the long-term outcome of a procedure called grafting, where vascularized bone (grown bone) from the pelvic area is used to graft to the affected bone in the hand.

Currently, there are data that show up to five years of follow up following this type of graft surgery, but these researchers wanted to know the longer 10-year outcome. In order to do this, the researchers found 18 patients with Kienbock’s disease stage 3 who had undergone this surgery. None of the patients had received any other type of treatment for this disorder. X-rays taken before the surgery showed no signs of osteoarthritis.

The patients were all assessed before and after surgery by x-ray and for their active range of motion and ability to use their hand. Pain was assessed using the Visual Analog Scale (VAS). Patients rate their pain on the VAS from zero to 100, with 100 being the most severe possible. The patients’ function after the surgery was measured using the DASH questionnaire, from zero to 100, with 100 being the worst outcome.

At five years after the surgery, 16 patients’ hands had responded to the graft but two had not. Their grafts had fractured and were no longer in place. The x-rays of the 16 successful wrists showed that the bones had integrated successfully at five years and at 10 years as well. Their range of motion and grip strength remained better at 10 years than they had been before the surgery.

Pain, as assessed by the VAS, decreased from between 35 and 85 points to 0 to 15 points at the five-year follow up. At 13-year follow up, pain was reported at 0 to 19 points. The researchers found that one patient did experience mild pain at the final follow up, despite having no pain at five years.

In reviewing the findings from the two patients whose grafts did not succeed, the researchers found that there was statistical worsening of active range-of-motion and strength between the five-year follow up and the final follow up.

Complications only occurred in two patients (infection).

The authors concluded that study findings showed the good functional, radiologic, and subjective outcome of this grafting technique. The authors wrote, “This graft has been found to be strong enough to carry the applied loads for a long period of time.” They suggest that the grafting is a reasonable treatment option for patients with Kienbock’s disease stage 3.

Standard management following a tendon transfer for management of claw deformity of the hand is to immobilize the wrist and metacarpophalangeal (MCP), or knuckles, that are in the middle of each finger. A cast is put on for four weeks and then there is another four weeks of “re-education” of the hand to strengthen it for use. One of the problems observed with the immobilization is the stiffness that results and this may delay return of function.

The author of this study showed in an earlier study that not immobilizing the flexor digitorum superficialis, the tendon that help you point your finger, and used active immobilization instead, provided a 40 percent reduction in time needed for rehabilitation. This study was undertaken to see if the same could be said for the claw deformity correction.

Thirty-one patients (32 hands with claw deformity total) had the surgery followed by active immobilization (group A) and researchers looked back at the records of 32 hands that underwent standard immobilization (group B) to use as the control/comparison group.

The patients were a mean age of 27 years in group A and 31 years in group B. In group A, the patients had experienced hand paralysis for a mean of 5.5 years and in group B, 4.2 years.

Following the surgery, both groups followed the same protocols with the exception of immobilization. On Day 2 following surgery, the patients in group A began active mobilization, which was only begun at Week 4 in group B. The patients in group A were encouraged to do active bending of the hand and opening and closing of the fist. Joint blocks were provided at various angles during the rehabilitation period to prevent overstretching of the hand.

After introduction of transfer strengthening to the hand for group A, they began occupational therapy at Week 3 following surgery. A splint was used at night for three months. As the patients were discharged fro therapy, they were able to perform daily activities, such as dressing and grooming.

Follow-up was monthly for three months following surgery and then every three months for a year. If patient recovery was satisfactory, they were permitted to return to sedentary work at eight weeks following surgery and they were permitted unrestricted activities at 12 weeks.

To assess the effectiveness of the non-immobilizing procedure, the researchers looked for tendon transfer pullout, comparisons with the control group, and the angle at which the fingers open. The researchers found that there were no incidences of transfer pullout in any patient in group A and, in terms of physical comparisons with patients in group B, the hands in group A healed faster and required shorter immobilization for many patients (39 percent shorter).

There are some drawbacks to this study, which include that there was no way to compare claw correction outcome and because the groupings were done according to criteria for “good, fair,” and “poor,” the wide range has limited accuracy. Another issue was the use of a prospective trial (group A) to compare with a retrospective trial (group B). This limited the ability to ensure that the same surgical techniques, positioning, etc, were the same in all patients.

Despite the drawbacks, the author recommends future trials examining all the aspects involved to see if the findings are replicated.

A rare case is reported here of a trigger finger linked to an infection from Mycobacterium kansasii. A 38-year old woman in good health cut her finger while cutting vegetables. She washed it off with tap water. It seemed to heal just fine.

Later she noticed tenderness along the palmar side of her middle finger. A trigger finger developed causing her to seek medical attention. A trigger finger occurs when the tendon can’t slide smoothly through the tendon sheath (lining around it).

Trigger finger is also known as stenosing tenosynovitis. Tenosynovitis refers to swelling of the tendon sheath. Stenosis means a narrowing of the space for the tendon.

The tendon makes a cracking sound when the finger is moved. It gets stuck in a flexed position and then makes a popping sound when the finger unlocks, as if releasing the trigger on a gun.

A diagnosis of stenosing tenosynovitis was made based on her clinical presentation. She was treated with two steroid injections into the tendon sheath. Triggering, stiffness, and pain persisted.

Surgery was done to release the A1 pulley of the middle finger. The pulley is part of the tendon mechanism that allows for smooth and controlled movement through the sheath. At the time of the operation, the surgeon did not see any sign of scarring, infection, or swelling of the tendon.

Two weeks after the surgery, there was still pain and stiffness with limited motion. A hand therapist treated her. Her motion improved but the pain and tenderness remained. A third steroid injection was tried without success. This was followed by another surgery.

At the time of the second operation, the tendon sheath was thickened and full of synovial fluid. Further testing showed inflammation, dead tissue, and a positive culture for Mycobacterium kansasii.

The problem finally cleared up with antibiotics. The patient had full and pain free motion. The surgeon could not be sure if the infection came from the tap water used to rinse the wound originally or from a contaminated needle during the steroid injection. Once the proper diagnosis and treatment were given, no further treatment was needed.

This article offers a review of the epidemiology, pathology, and signs and symptoms of gout. Epidemiology refers to patient characteristics such as age, gender, and incidence of a disease or condition. Management of hand and wrist gout (a more uncommon form of gout) is also included.

It appears that the number of cases of gout may be increasing. This is thought to be related to the fact that people are living longer. As we age, cartilage and synovium degenerate. This leaves the joints more susceptible to gout because of these arthritic changes.

Improved medical management may help offset chronic symptoms and damage from this condition. A team of specialists is helpful in getting the best results. The physician provides supervised drug therapy and focuses on preventing complications of the disease.

The physical therapist teaches the patient how to prevent loss of motion and function, especially during flare-ups. Splinting, exercises, and other rehab tools may be used. Nutrition, diet, and education about lifestyle factors are important parts of the management program.

For example, there is a known link between alcohol and gout. Patients are advised to limit alcohol intake, especially beer but also liquor. Drinking small amounts of wine does not seem to increase the risk.

Certain food can also increase the uric levels associated with gout and should be avoided. These include meat and seafood. Dairy products and purine-rich vegetables such as peas, spinach, and cauliflower help reduce the risk of gouty attacks.

The wrist and hand are sites of gout in older adults. Postmenopausal women taking diuretics (water pills) seem to be affected most often. Tophus deposits along tendons of the wrist, hand, and finger tendons may require surgical treatment.

Tophus (tophi is plural) is the deposit of crystallized monosodium urate. A pocket of these crystals can put pressure on the nerves and cause painful inflammation of the joints. Surgery to remove the tophi and wash out the crystals may help improve tendon gliding.

In some cases, part of the tendon may have to be removed. The surgeon does everything possible to avoid this step. If it is necessary, then tendon grafting, tendon transfers, and joint fusion may be required. Amputation of the finger is considered only when uncontrolled pain and infection prevents healing.

The authors say that gout of the wrist and hand is relatively uncommon. Advanced cases can cause severe loss of hand function. Today’s improved management has resulted in better outcomes for patients affected by this disease.

This study presents the results of 11 patients treated with a tendon transfer for rupture of the extensor pollicis longus (EPL). The EPL is a tendon that extends (straightens) the thumb. The rupture was caused by a wrist fracture.

The standard operation for this injury is to use the extensor indicis proprius (EIP) tendon. The tendon is transferred from its normal location to replace the function of the EPL.

There are some disadvantages of using the EIP. So the surgeon tried using the accessory abductor pollicis longus (AAPL) instead. Accessory means extra. The abductor pollicis longus has an extra slip of tendon. It can be used (transferred) without affecting the function of the APL.

Not all people have this tendon. It is present in about 85 to 95 per cent of the general public. Results of this new method to repair the torn tendon were measured based on pain and function. Patient satisfaction was also measured.

A testing tool called the Geldmacher score was used to assess overall thumb motion. Any difficulty lifting the thumb off the table with the palm flat is a sign of donor site morbidity. This means the donor tendon lost some strength after the accessory slip was used.

This group of patients had a good outcome. Thumb motion compared favorably with results from other studies using different tendons for this repair. Thumb abduction (moving the thumb away from the palm) was better using the AAPL compared with other tendon transfers.

The authors conclude the AAPL can be used successfully to restore function of the ruptured EPL. This new surgical technique has many advantages over other tendon transfers for this injury.

In this article, orthopedic surgeons from Northwestern Memorial Hospital in Chicago give us an update on carpal tunnel syndrome (CTS). They review the diagnosis, causes, and treatment of this condition. Results of new surgical methods are compared to the standard operation.

CTS remains a fairly common problem. Anything that can put pressure on the median nerve as it passes through the bones of the wrist (carpal tunnel) can cause CTS. Symptoms commonly include wrist and hand pain, numbness, and tingling. Weakness and muscle atrophy (wasting) can also occur.

The authors provide drawings of the most common, as well as unlikely, patterns of symptoms associated with CTS. They review the anatomy of the wrist bones and soft tissues, including the median nerve.

Normal pressure within the carpal tunnel is around 2.5 mm Hg. Symptoms of CTS occur when the pressure rises to 20 mm Hg. Symptoms get much worse when the pressure is 30 mm Hg or more.

No one knows for sure yet why so many people develop CTS. Trauma, shape of the wrist, tumors, and some systemic conditions are listed. Repetitive use has always been blamed for many cases of CTS. But it’s also true that just as often, people doing the same job for the same amount of time don’t develop CTS. Why the difference? We still don’t know.

Treatment depends on many factors such as how long the CTS has been present. If the cause is identified, then treatment may be centered on the specific problem (for example, taking vitamin B supplements for CTS caused by vitamin B deficiency).

Conservative (nonsurgical) care is usually tried first. This might include physical therapy, splinting, and/or antiinflammatory drugs. Surgery is advised when all other forms of treatment have failed or in the case of trauma or infection.

Surgery is done to release the transverse carpal ligament (TCL). The TCL stretches across the median nerve. Cutting it takes the pressure off the nerve. This operation can be done with an open incision or with a closed approach using an endoscope.

Endoscopic carpal tunnel release uses a thin, narrow tool that slips under the skin and into the carpal tunnel. Then the TCL is cut in half. The tool can be slipped back out with less risk of soft tissue or nerve injury. Results are the same between these two methods when patients are examined three months later.

The author say that more studies are still needed to better understand CTS. The result could mean more effective, less invasive treatments. Understanding the causes of CTS may help us find ways to prevent it as well.

The joint at the base of the thumb is called the carpometacarpal joint (CMC). This is the joint where the thumb attaches to the wrist. It is also a common site of osteoarthritis (OA), especially among postmenopausal women.

In this article, two hand surgeons from the NYU Hospital for Joint Diseases review the anatomy and biomechanics of this joint. They also present two specific surgical techniques used to stabilize the joint.

The operations discussed include the volar ligament reconstruction (VLR) and the LRTI arthroplasty. LRTI stands for ligament reconstruction with tendon interposition.

The basic idea behind surgery is to remove part or all of the arthritic bone. The empty space where the bone was located must be filled in with tendon or other soft tissue material. Step-by-step instructions are provided for both operations. Detailed drawings are also included.

Surgery is done when conservative care has failed to reduce painful symptoms or to improve function. The type of surgery selected depends on how progressed the disease is. Stage I disease has not affected the joint capsule yet. This may be the ideal time to have surgery.

VLR is the best way to stabilize the joint at this stage. LRTI is another ligament reconstruction technique. It was developed to overcome the tendency of the thumb to shift toward the hole left by the bone removal.

These operations have been shown to help improve grip strength and function. Pain relief isn’t always as much as hoped for or as expected. Long-term results show that two-thirds of all patients have pain or discomfort five to 15 years later.

In this article, Dr. Paul W. Brown, the author of the text The Hand: Primary Care of Common Problems reviews common hand injuries. He presents the what, when, and where of management for tendon and nerve injuries. Wounds, fractures, and ligament tears are also discussed.

Most hand injuries can be grouped according to severity: minor, moderate, and complex. Most minor and moderate injuries can be treated in the doctor’s office. More complex problems requiring X-rays and/or surgery must be seen in the emergency department.

Dr. Brown points out that knowing the what of an injury is important. For example, what happened and what kind of force was involved in the injury? Special tests are provided to help the physician identify specific finger tendon injuries.

Asking when it happened helps establish a time line. Management of an old injury is different from the treatment for something that just happened.

And finally, knowing where the injury occurred may help direct treatment. A household wound is very different from one that occurred in a barnyard or at an industrial site.

Some injuries don’t look serious but really are. The hand may look normal even with ruptured tendons, fractures, and cut arteries. X-rays first and then a careful exam help guide the examiner.

Management of minor injuries such as bruises, contusions, and mild sprains can be easily treated at home or in the office. Likewise, simple cuts, abrasions, and mild burns can be handled in the same way. More involved injuries, open wounds, deep cuts, and amputation</i. (loss of fingers or hand) may require surgery.

In this case report, surgeons from the Naval Medical Center in San Diego, California present the result of surgical treatment for ulnar tunnel syndrome (UTS).

A 29-year old woman presented with UTS after an 80-mile bike ride. UTS is the compression of the ulnar nerve in the wrist and hand at the base of the little finger side of the hand. Prolonged pressure on the hand at that site can put enough pressure on the nerve to cause UTS.

Symptoms range from pain and numbness to tingling, weakness, and muscle atrophy. This woman had all of these symptoms along with decreased sensation int he ring and little fingers. Conservative care did not help. She had surgery to release the pressure on the nerve.

The surgeons reported that the ulnar nerve was flattened and narrowed. There was no other damage to the ulnar nerve tunnel. There were no other tumors, hematomas, or lesions in the area.

Her symptoms gradually went away. Strength and motion improved. By the end of 10 weeks post-operatively, she was back to normal. Even the tenderness around her incision was gone.

Most cases of UTS resolve with conservative care using splinting, rest, and avoiding activities that caused the problem in the first place. But surgeons should be aware that in some cases, ulnar tunnel release might be needed.

With more people involved in long-distance biking events, UTS may be something surgeons see more often in the near future. They should know that surgery is an acceptable treatment if conservative care fails. Results can be 100 per cent successful.

Many people suffer from the painful symptoms, numbness, and tingling of carpal tunnel syndrome (CTS). Diagnosing the problem isn’t always easy. There isn’t one simple test that can be done to diagnose CTS.

In this article, various tests used to diagnose CTS are reviewed. The pros and cons of each test are discussed. These include nerve conduction tests, Semmes Weinstein monofilament tests, and somatosensory evoked potentials (SSEP). Imaging studies such as ultrasound or MRI can also be helpful.

In CTS, the median nerve to the wrist and hand is compressed most often. But in some patients, testing shows changes in the other nerves in the forearm and wrist. And sometimes the tests are normal until major damage is done to the median nerve.

Doctors rely most often on clinical tests. These are referred to as provocative maneuvers. The patient’s hand and wrist are placed in a position that puts pressure on the nerve. In a positive test, the position brings on the symptoms.

Experts aren’t even sure yet what causes CTS. The risk factors are well known. For example, obesity, diabetes, aging, and pregnancy increase the risk of CTS. But how do these things actually cause CTS? Some studies show increased pressure inside the canal where the nerve passes. Others suggest reduced blood flow to the nerve causes damage.

We are still far from finding the gold standard for diagnosing CTS. It may be that different tests will work for different patients based on the underlying cause(s) of the condition. For now, CTS is a clinical diagnosis based on the presentation of classic symptoms. The authors suggest this is unlikely to change until the exact mechanism of CTS is found.

In this single case report, hand surgeons describe a false aneurysm in a 38-year-old woman after a hand injury. The diagnosis was delayed because of symptoms of carpal tunnel syndrome (CTS) present at the time. The surgeons found out later the numbness and tingling from CTS was caused by a large mass of blood from the aneurysm stretching the nerve to the fingers.

An aneurysm is a bulge in the blood vessel caused by a weakness in the vessel wall. As the bulge gets larger, the wall gets thinner and can burst. A false aneurysm refers to blood leaking between two layers of the blood vessel wall. False aneurysms are often caused by trauma that punctures the artery.

The patient was initially treated at a local hospital. On two separate occasions, blood pooled in her palm and was removed. The injury was cleaned each time but the mass kept coming back. Her symptoms of pain and finger numbness got worse. Finger range of motion was decreased due to pain.

An MRA (magnetic resonance angiography) was done and showed the false aneurysm in her palm. Surgery to remove the mass showed that it extended into the carpal tunnel area putting pressure on the median nerve.

After surgery, the patient needed wound care and hand therapy. By the end of six months, she was pain free and her fingers were back to normal. Range of motion, strength, and sensation were all restored at the end of one year after surgery.

The authors comment that false aneurysms are very rare in the hand. It’s easy to misdiagnose this problem. This is the only reported case of a false aneurysm complicated by carpal tunnel syndrome.

Surgeons from the University of Michigan report an isolated case of a tendon in the hand being cut by a stream of water from a pressure washer. In this case, a 43-year-old man suffered a tendon injury of the thumb from the force of a high-pressure water spray.

He was using a home unit pressure washer to clean the outside of his house. As he was coming down the ladder, the spray wand directed the stream of water across his left hand. The thin stream of water with a pressure of 2300 psi made a cut across the base of his thumb.

The extensor pollicis longus tendon was sliced in half by the spray. Water was forced up into his forearm through the opening in his skin. Surgery was needed to repair the tendon. The surgeon reported a clean cut of the tendon. A branch of the radial nerve was also cut.

This case shows the power of home unit pressure washers. Likewise, industrial water guns can put out a stream of water strong enough to cause serious injuries. The mechanical action and the force of the spray is enough to puncture the skin and cut a tendon.

The authors suggest with the increased home use of power equipment like pressure washers, there will likely be more injuries expected.

What is the best treatment for trigger finger? How well do injections of steroids work? Is it better to just have surgery? These are the questions researchers at Vanderbilt University School of Medicine sort out by reviewing the medical literature on the subject of treatment for trigger finger.

Trigger finger is a condition in which a tendon gets stuck and no longer glides smoothly through its tunnel. Usually it’s caused by a thickening of the protective sheath or cover around the tendon. The finger gets locked in a position of flexion or extension. The person with trigger finger reports pain and swelling to go along with the locked position.

Only studies with the highest level of evidence were included in this review. Random controlled trials (RCTs) using steroid injections as the main treatment were included. Only adults were studied. Follow-up of treatment outcomes were required.

Analysis of the data collected showed that women between the ages of 52 and 62 are most likely to develop trigger finger. These results confirm the results of previous studies. Fingers are affected 77 per cent of the time. The thumb is involved in about one-fourth of all cases.

One cortisone injection relieved symptoms in 47 to 87 per cent of the patients. But in one-quarter of those patients, the symptoms came back within a year’s time. The authors suggest that cortisone may be helpful in the short-term but doesn’t provide any long-term benefits.

Similar studies report an 89 to 100 per cent success rate with surgery. It may be that cortisone injection shouldn’t be considered the first step in treatment. Although injection is effective in slightly more than half the patients, surgery has a much better track record for long-term success.

On the other hand, a single steroid injection is inexpensive and gives relief to a large number of people, therefore avoiding surgery.