INTRODUCTION

Carpal tunnel syndrome (CTS) is a condition caused by increased pressure on the median nerve at the wrist. There is a space in the wrist called the carpal tunnel, where the median nerve and multiple tendons pass from the forearm into the hand.  Carpal tunnel syndrome happens when swelling in this tunnel pinches, or compresses, the nerve.

LEGEND: Schematic drawing of the carpal tunnel and its contents. The median nerve is the yellowed colored structure.

 

CAUSES AND RISK FACTORS

• Chronic illnesses such ashypothyroidism, rheumatoid arthritis and diabetes.
• Repetitive hand and/or wrist movements, especially if the wrist is bent so that the hands are lower than the wrists.
• Pregnancy

SYMPTOMS

 

·         Pain

·         Numbness

·         Tingling

·         Weakness with grip

·         Tendency to drop things

·         Poor sleep due waking up at night due to pain and tingling in the hand

·         In severe cases, thinning of the muscles in the palm

 

The numbness and tingling often happens in the thumb, index, middle, and ring fingers. This may vary between individual patients. 

LEGEND: In patients with Carpal Tunnel Syndrome(CTS) 3 ½ finger and half the palm have decreased sensation

DIAGNOSIS

A thorough physical examination and discussion of the patient’s medical history, including current and past conditions, prior injuries and symptoms, will help diagnose carpal tunnel syndrome.

Depending on the examination of the patient’s hands, additional diagnostic tests may be needed to confirm the presence and extent of carpal tunnel syndrome. These include:

• Electrodiagnostic nerve studies (EMG)
• Laboratory tests
• X-rays

TREATMENT

Non surgical treatments

• Avoiding activities that cause numbness and pain
• Rest for longer periods of time between activities that cause numbness and pain
• Ice wrist area
• Anti-inflammatory medications such as ibuprofen
• Wearing a wrist splint
• Corticosteroid injections into the carpal tunnel

Surgery

When symptoms are severe or do not improve, surgery may be the next step. Pressure on the median nerve is decreased with surgical release of the ligament over the carpal tunnel. In the operation, the surgeon makes an incision from the middle of the palm to the wrist. He or she will then cut the tissue that’s pressing on the nerve, in order to release the pressure. A large dressing and splint are used after surgery to restrict motion and promote healing. The scar will gradually fade and become barely visible.

LEGEND: Incision for carpal tunnel

LEGEND: Drawing of carpal tunnel decompression

LEGEND: Decompressed carpal tunnel, opened ligament, exposed median nerve

RESULTS

The results of the surgery will depend in part on how long the condition has existed and how much damage has been done to the nerve. For that reason, it’s a good idea to see a doctor early if you think you may have carpal tunnel syndrome.

INTRODUCTION

Cubital tunnel syndrome is a condition caused by increased pressure on or stretch of the ulnar nerve that passes behind the elbow (also causes the “funny bone” sensation). People commonly notice it when sleeping or when holding the phone—any activity where the elbow is in a bent position for long period of time.

ANATOMY

There is a bump of bone on the inner portion of the elbow (medial epicondyle) under which the ulnar nerve passes. At this site, the ulnar nerve lies directly next to the bone and is susceptible to pressure. When the pressure on the nerve becomes great enough to disturb the way the nerve works, then numbness, tingling, and pain may be felt in the elbow, forearm, hand, and/or fingers.

 

CAUSES

Pressure on the ulnar nerve at the elbow can develop in several ways :

• Compressive force: arm leaned against a table on the inner part of the elbow, thicker connective tissue over the nerve, or muscle structure variations over the nerve at the elbow
• Traction or stretching: holding the elbow in a bent position for a long time, or following trauma
• Friction: an unstable ulnar nerve at the elbow clicks back and forth over the bony bump (medial epicondyle) with repetitive elbow flexion

 

SYMPTOMS

Cubital tunnel syndrome symptoms usually include pain, numbness, and/or tingling. The numbness or tingling most often occurs in the ring and little fingers. The symptoms are usually felt when there is pressure on the nerve, such as sitting with the elbow on an arm rest, or with repetitive elbow bending and straightening.

Some patients may notice weakness while pinching, occasional clumsiness, and/or a tendency to drop things. In severe cases, sensation may be lost and the muscles in the hand may lose bulk and strength

DIAGNOSIS

A thorough physical examination and discussion of the patient’s medical history, including current and past conditions, prior injuries and symptoms, will help diagnose cubital tunnel syndrome.

A test called electromyography (EMG) and/or nerve conduction study (NCS) may be done to confirm the diagnosis of cubital tunnel syndrome and stage its severity. This test also checks for other possible nerve problems, such as a pinched nerve in the neck, which may cause similar symptoms.

X-rays of the elbow with cubital tunnel view is required to assess the bones and joint

TREATMENT

Symptoms may sometimes be relieved without surgery, particularly if the EMG/NCS testing shows that the pressure on the nerve is minimal.

Changing the patterns of elbow use may significantly reduce the pressure on the nerve. Avoiding putting your elbow on hard surfaces may help, or wearing an elbow pad over the ulnar nerve may help.

Keeping the elbow straight at night with a splint also may help. A session with a therapist to learn ways to avoid pressure on the nerve may be needed.

When symptoms are severe or do not improve, surgery may be needed to relieve the pressure on the nerve.

Several operations are used, including simple opening of the roof of the tunnel (decompression), moving the nerve into a new location at the front of the elbow (transposition) and widening the tunnel by removing some of its bony floor (medial epicondylectomy). Your surgeon can advise on the technique most appropriate to your problem.

LEGEND: Exploration of ulnar nerve, decompression and neurolysis

LEGEND: Transposition of the decompressed ulnar nerve above the “funny bone” to minimize tension to the nerve

LEGEND: Coverage of the of the decompressed ulnar nerve above the “funny bone” with soft tissue for extra protection

RRECOVERY

Following surgery, the recovery will depend on the type of surgery that was performed. Kinesiotherapy may be necessary. The numbness and tingling may improve quickly or slowly, and it may take several months for the strength in the hand and wrist to improve. Cubital tunnel symptoms may not completely resolve after surgery, especially in severe cases.

INTRODUCTION

De Quervain tenosynovitis is a condition that causes pain and swelling at the base of the thumb and the thumb side of the wrist. In de Quervain tenosynovitis, swelling and thickening of the soft tissues around the thumb tendons cause pain with common activities, particularly with picking up or grasping objects.

RISK FACTORS FOR DE QUERVAIN’S

• Repetitive activities with thumb and wrist, such as wringing out clothes, hammering, skiing, knitting
• Lifting heavy objects
• Chronic illnesses such asrheumatoid arthritis and diabetes
• Pregnancy

SYMPTOMS

• Wrist pain on the thumb side
• Thumb and wrist pain with twisting or grasping
• Swelling on the thumb side of the wrist
• Crackling or popping sound with movement of thumb

TREATMENT

Treatment will depend on the severity of symptoms, which may be relieved without surgery. 

There are several non-surgical treatment options that may help relieve symptoms. These include:

• Anti-inflammatory medications such as ibuprofen
• Brace wear to stabilize and provide support for the wrist and thumb
• Cortisone injections to reduce pain and swelling
• Limiting activities that cause pain and swelling

Surgery

When symptoms are severe or do not improve, surgery may be the next step. The procedure involves dividing the tissues overlying the thumb tendons to allow them to glide better. 

LEGEND: Schematic drawing of inflamed and swelled tendon, passing with difficulty through the first dorsal canal

LEGEND: Photo of the released (opened) ligament (pink tissue) with the underneath tendon (white) freed to slide

INTRODUCTION

Dupuytren’s contracture is a disorder of the skin and underlying tissue on the palm side of the hand. It is created  due to abnormal thickening and tightening of the normally elastic tissue beneath the skin of the palm and fingers. This tissue is called fascia. The fascia contains strands of fibers, like cords, that run from the palm upward into the fingers. In Dupuytren’s contracture, these cords tighten, or contract, causing the fingers to curl forward. In severe cases, it can lead to crippling hand deformities.

CAUSES OF DUPUYTREN’S CONTRACTURE

The cause of Dupuytren’s contracture, also called Dupuytren’s disease, is unknown, but certain biochemical factors that affect the palm’s connective tissue may be involved. Injuries and overuse of the hand do not play a role. Tendons are not affected.

However, certain things may make you more likely to develop Dupuytren’s contracture. They include:

• Drinking a lot of alcohol, although most people with the disease do not have alcoholism
• Diabetes
• Seizures, such as those seen in people with epilepsy
• Smoking

The condition usually runs in families, which means it is inherited. You are also more likely to develop this condition if you have a Northern European (English, Irish, Scottish, French, Dutch) or Scandinavian (Swedish, Norwegian, Finnish) background.

SYMPTOMS

The first symptom for many patients is one or more lumps (nodules) under the skin in the palm of the hand. The lump may feel tender and sore at first, but this discomfort eventually goes away.

The nodules cause tough bands of tissue to form under the skin in the palm. These inflexible bands cause the fingers to bend, or “curl,” forward toward the wrist. As this curling gets worse, it becomes difficult, if not impossible, to straighten the fingers.

The pinkie and ring fingers are most often affected, appearing clenched. Both hands are usually involved, although one may have worse symptoms than the other.

Interestingly, a Dupuytren’s contracture is sometimes associated with inflammation and thickening of the fascia tissue in a similar manner of the sole of the foot. This condition is called Ledderhose disease, or plantar fascial fibromatosis, and is sometimes associated with plantar fasciitis. It can sometimes be felt as a nodule or group of nodules in the middle of the sole of the foot.

Very rarely, a Dupuytren’s contracture occurs in association with an uncommon scarring condition of the penis called Peyronie’s disease.

DIAGNOSIS

The surgeon will examine your hands, wrists, and fingers. Diagnosis of Dupuytren’s contracture typically involves feeling the palm areas to check for nodules and recording how many nodules are found. Your doctor will likely ask you to try to place your hands flat on a table.

Tests may also be done to:

• See how well you can grasp items with your hands.
• See how well you can pinch items with your fingers.
• Measure the feeling in your thumbs and fingers.
• Determine your range of motion in your fingers, to see if you can straighten them all the way.

INDICATIONS FOR TREATMENT

• You have one or more lumps in your palm, whether or not it is painful.
• You have difficulty straightening your fingers.
• You have difficulty grasping objects.
• You cannot place your hand flat on a table or place your hand in your pocket

TREATMENT

Treatment for Dupuytren’s contracture is usually only required if the condition affects the function of your hand. Many cases are mild and don’t need to be treated.

Non-surgical treatments

These are generally most effective if used before the condition becomes severe.

a.   Collagenase clostridium histolyticum

Collagenase clostridium histolyticum is a medicine that can be injected into cords in the palm of your hand. The medicine contains special proteins that can weaken the cords.

After having the injection, you’ll be monitored for around half an hour and then you can go home. You return to your doctor 24 hours later and they’ll straighten your bent finger and stretch it out for 10 to 20 seconds. This breaks the cord and should help to increase the range of movement in your bent finger.

If the first injection isn’t effective, you can have up to three injections in the same cord, with one month between each injection.

b. Needle fasciotomy

A needle fasciotomy is also known as a needle aponeurotomy or a percutaneous needle fasciotomy (percutaneous means “performed through the skin”).

It’s usually performed as an outpatient procedure, meaning you won’t need to be admitted to hospital. You’ll be given a local anaesthetic to numb your hand without making you lose consciousness.

During the procedure, a sharp blade or a very fine needle will be inserted into the fibrous bands in the palm of your hand or your fingers. The blade or needle will be used to divide the cord under your skin.

By dividing the thickened tissue, your surgeon will release the tightness in your hand that’s forcing your finger to bend.

However, the rate of recurrence for Dupuytren’s contracture is very high: as many as 60% of people who have a needle fasciotomy experience Dupuytren’s contracture again within three to five years.

Surgical treatments

a.   Open fasciotomy

An open fasciotomy is sometimes used to treat more severe cases of Dupuytren’s contracture. The procedure is more effective in the long term than a needle fasciotomy, but it’s also a more extensive operation and carries some additional risks (see below).

Like a needle fasciotomy, an open fasciotomy will be carried out as an outpatient procedure under local anaesthetic. The surgeon will make an incision in the skin of your hand, so they can gain access to the connective tissue underneath. They’ll then cut the thickened connective tissue to divide it up, allowing you to straighten your fingers.

After the surgery has finished, the cut on your hand is sealed with stitches and a dressing is applied. The recovery time for an open fasciotomy is slightly longer than that of a needle fasciotomy, because the wound will need time to heal.

b.   Fasciectomy

A fasciectomy involves removing the thickened connective tissue. There are three variations of the procedure:

• regional fasciectomy – where the affected connective tissue is removed through a single, larger incision; this is the most commonly used type of surgery for Dupuytren’s contracture
• segmental fasciectomy – where one or more small cuts are made in the skin, through which small segments of connective tissue are removed
• dermofasciectomy – where the affected connective tissue is removed, along with the overlying skin (which may also be affected by the disease) and the wound is sealed with a skin graft (where healthy skin is removed from another part of the body and used to cover the area of skin loss in your hand)

A fasciectomy is usually carried out under general anaesthetic. This means you’ll be unconscious throughout the procedure and unable to feel pain. In some cases, regional anaesthetic may be used. This is where local anaesthetic is injected into the nerves near your neck, to numb your whole arm, but you remain conscious.

A fasciectomy is a more extensive operation than a fasciotomy, so the risk of complications is slightly higher, at around 5% (see below). However, the results are longer-lasting. For example, the rate of recurrence of Dupuytren’s contracture following dermofasciectomy may be as low as 8%.

LEGEND: Schematic drawing of different incisions used to remove the involved fascia

LEGEND: Duputren’s contracture affecting both the little and the fourth finger of the left hand

LEGEND: Planning of incisions

LEGEND: Excision of involved thickened fascia (fasciectomy)

LEGEND: Closed incsions

LEGEND: Postoperative photo of the right hand. The same patient had the same operation done (fasciectomy) three months before the operation of the left hand

 

RISKS OF SURGERY

• splitting the skin with the needle during a needle fasciotomy
• damage to the nerves supplying sensation to your fingertips – the nerves can be repaired, but it’s unlikely the fingers will recover their full sensation
• joint stiffness – this can be helped with hand therapy (see recovering from Dupuytren’s contracture for more information)
• wound failure – the wound or graft failing to heal (more likely to occur if you smoke)
• infection of the wound – usually treated with antibiotics
• haematoma – a blood-filled swelling that forms as the wound heals, usually in the palm; it can be drained to reduce the swelling
• scarring
• complex regional pain syndrome – a rare complication that causes the hand to become painful, stiff and swollen after surgery; it usually resolves within a few months, although it can sometimes be permanent

INTRODUCTION

Extensor tendons run just underneath the skin along the back of the hands and wrists. They control the hand’s ability to straighten the fingers and wrists. A mallet finger injury happens when a finger is jammed, causing an extensor tendon to rupture at the base of the finger joint. Other extensor tendon injuries commonly occur from cuts to the back of the hand. 

SYMPTOMS

Common signs and symptoms of extensor tendon and mallet finger injuries include:

• Inability to straighten the fingers or extend the wrist
• Pain and swelling in fingertip
• Recent trauma or laceration to the hand
• Drooping of the end joint of the finger

LEGEND: Injury to the extensor tendon of the middle finger. Inability to straighten the finger

DIAGNOSIS

Whether it takes place in an emergency room or office visit, a thorough physical examination and discussion of the patient’s medical history and symptoms will help diagnose extensor tendon and mallet finger injuries. A hand surgeon will test the tendons to ascertain their integrity and decide if a repair is needed. 

Additional imaging may also be needed to confirm the presence and extent of the injury:

• X-rays may be taken if the injury was caused by glass or if damage to a joint is suspected or if fractures are present
• Occasionally, ultrasound or MR scans are needed to give more information about the tendon.

TREATMENT

Tendon repair. 

Most cut tendons need surgical repair, although partly cut tendons can heal well with splintage or with gentle exercise in some cases. The repair may be performed under local anesthetic, general anesthetic or regional anesthetic (injection of local anesthetic at the shoulder).   The wound is enlarged so that the cut ends of the tendon can be found and held together with stitches.   At the end of the operation the hand and forearm are immobilised in a plaster splint that is placed over the bandages, in order to protect the repair.

Hand therapy. 

The hand therapist will usually replace the plaster splint with a light plastic splint and start a protected exercise program within a few days of the operation. The therapy program after tendon repair is crucial and at least as important as the operation itself, so it is vital to follow the instructions of the therapist closely.   The objective is to keep the tendon moving gently to prevent it sticking to the surrounding tissues but to avoid breaking the repair.  

The splint is usually worn for between three and six weeks, depending on the injury, after which a gradual return to hand use is allowed.  However, the tendon does not regain its full strength until three months after the repair and the movement may improve slowly for up to six months.

LEGEND: Postoperative splinting

REHABILITATION

Occupational and physical therapists under the direction of a trained hand therapist are involved immediately after surgery to speed up the rehabilitation. The ultimate goal of therapy and rehabilitation is the restoration and optimization of wrist and finger function, renewed independence and improved overall quality of life.

OUTCOMES OF EXTENSOR TENDONS INJURIES

Repair of cleanly cut extensor tendons generally results in a functional finger but does not always provide full movement.  The result may be less good if the injury involved crushing, loss of skin or damage to bones and joints.

Problems that can occur include:

• The repair breaks.  It usually happens early on as the tendon is at its softest at this stage of healing. The patient may feel a “ping” as the repair snaps or simply notices that the finger isn’t moving in the way it has been. If you are concerned that your tendon repair has broken you should contact the surgical or therapy team immediately.
• The tendon sticks to its surroundings.   More hand therapy may help.  In some cases, an operation to release the tendon from the scar tissue (tenolysis) may improve the movement, but full movement may not be regained.

INTRODUCTION

Flexor tendons run from the forearm to the ends of the fingers across the palm side of the hand. They control the ability to bend fingers down to the palm (for example to make a fist, grip, or pinch objects).  When these tendons are cut or injured, it can be impossible to bend.

The flexor tendons allow you to bend your fingers.

DESCRIPTION OF THE INJURY

A torn or cut tendon in the forearm, at the wrist, in the palm, or along the finger will make it impossible to bend one or more joints in a finger.

Because flexor tendons are very close to the surface of the skin, a deep cut will most likely hit a flexor tendon. In these cases, the tendon is often cut into two pieces.

Like a rubber band, tendons are under tension as they connect the muscle to the bone. If a tendon is torn or cut, the ends of the tendon will pull far apart, making it impossible for the tendon to heal on its own.

Because the nerves to the fingers are also very close to the tendons, a cut may damage them, as well. This will result in numbness on one or both sides of the finger. If blood vessels are also cut, the finger may have no blood supply. This requires immediate surgery.

Occasionally, flexor tendons may be partially cut or torn. With a partial tendon tear, it may still be possible to bend your finger, but not completely. These types of tears can be difficult to diagnose.

RISK FACTORS FOR GLEXOR TENDON INJURIES

• Cuts to the arm, hand or fingers
• Sports activities, such as football, wrestling, rugby and rock climbing.
• Chronic illness such asrheumatoid arthritis where muscles are weakened and more likely to tear. This can happen without warning or injury — a person may simply notice that his or her finger no longer bends, but cannot recall how it could have happened.

SYMPTOMS

• Difficulty bending one or more fingers
• Numbness on one or both sides of the finger, which indicates damage to the nerve
• Pain when your finger is bent
• Loss of blood flow to the finger when the blood vessel is cut (which would lead to white or purple discoloration of the finger). This requires immediate surgery.
• An open injury, such as a cut, on the palm side of your hand, often where the skin folds as the finger bends

DIAGNOSIS

Whether it takes place in an emergency room or office visit, a thorough physical examination and discussion of the patient’s medical history and symptoms will help diagnose flexor tendon injuries.

TREATMENT

 Splinting

Certified hand therapists can custom fit a splint which, depending on the severity of the injury, may be used without surgery, or following surgery to allow the tendon to repair to fully heal.  At your first hand therapy appointment, your therapist will remove your post-op dressing and make a custom splint. This splint will be worn full-time for six weeks.

 Surgery

Tendons will not heal unless the two ends are closely touching. The only effective treatment for a flexor tendon injury is to surgically repair the tendon(s) by sewing the cut ends together. Your hand surgeon will locate the ends of the tendon and stitch them back together. If the nerve has also been cut, it will be repaired at the same time. After treatment, hand therapy (provided by certified hand occupational therapists) is very important to improve motion and maximize functional recovery of the hand. Surgery is usually performed within 7 to 10 days after an injury. In general, the sooner surgery is performed, the better recovery will be. If your injury is restricting blood flow to your hand or finger, your doctor will schedule an immediate surgery.

LEGEND: Incisions for flexor tendon repair

However, tendon repair surgery does not have to be performed as an emergency. It’s often best to let the wound ‘settle down’ for a few days before reopening it surgically. Tendon lacerations are optimally repaired within 2 weeks.

If the flexor tendon isn’t repaired within two weeks, the narrowed tunnel pinches the repaired tendon, making it more likely that the tendon will get stuck in the tunnel after surgery. Because of this, and the fact that there is more scar formation after two weeks, it becomes more difficult to regain motion after tendon repair, and increases the chance that a second surgery will be required after 3-4 months to regain motion. While surgical repair is still helpful after 4 weeks, the chances of stiffness and the necessity of a second surgery to regain motion are even greater.

If the injury has happened many days or weeks prior to the initial consultation, then the flexor tendon reconstruction is done in two stages, mainly because the proximal part of the cut tendon has retracted towards the palm. During the first stage a silicone rod is placed where the tendon gap is, in order to form a spacious canal. Then a few weeks later a tendon graft is sutured between the two cut ends of the injured tendon. In some cases, an additional surgery to remove scar tissue around the tendon is required to improve motion to the affected finger(s). 

Because flexor tendons can only live for so long before they are no longer repairable, people who wait too long to see if the finger “heals on its own” often miss their chance to get it repaired. Then they need even more complex reconstructions to improve finger function, or need to live their life with a weak finger that doesn’t fully bend and a permanent loss of grip strength.

LEGEND: Injured flexor tendon of the middle finger from a knife cut. The patient is unable to flex the tendon

LEGEND: Exploration of the middle finger and retrieval of the proximal part of the tendon and primary repair

HAND THERAPY AND REHABILITATION

Certified Hand Therapists work closely with doctors to create a customized therapy and rehabilitation program to restore function. Your therapist will also instruct you in a very strict home exercise program, teach you scar management techniques, and help you progress through the post-operative rehabilitation protocol ordered by your hand surgeon. Most people need 1-2 hand therapy appointments per week for 8-12 weeks.

LEGEND: After surgery, a splint is applied to limit movement and help the tendon heal.

 COMPLICATIONS

·        The repair breaks:

It usually happens early on as the tendon is at its softest at this stage of healing. The patient may feel a “ping” as the repair snaps or simply notices that the finger isn’t bending in the way it has been.

·        The tendon sticks to its surroundings and does not slide in its tunnel:

Scarring of the tendon repair is a normal part of the healing process. But in some cases, the scarring can make bending and straightening of the finger very difficult. More hand therapy may help. If therapy fails to improve motion, an operation to release the tendon from the scar tissue (tenolysis) may improve the movement, but full movement may not be regained.

INTRODUCTION

Any abnormal lump or bump, or “mass”, is considered a tumor. The term “tumor” does not necessarily mean it is malignant or that it is a cancer. In fact, the vast majority of hand and wrist tumors are benign or non-cancerous. Any lump or bump in your hand or wrist is a tumor regardless of what causes it.

GANGLION CYSTS

The most common tumor in the hand and wrist is a ganglion cyst. It is frequently found at the wrist but can occur at the base of the fingers or around the finger joints. The cyst is filled with a clear gelatin-like fluid. It may change in size, and it is noncancerous.  Most ganglion cysts appear and disappear on their own without treatment. Some cysts may become painful or tender, interfere with normal hand function, or have an objectionable appearance.

Risk factors

Although the majority of patients with ganglion cysts are adults between 15 and 40 years old, anyone can get one. There is no known cause for ganglion cysts, but there are several factors that have been linked to their occurrence:

• Injury to the wrist or finger joint
• Inflammation or irritation in the tendons or joints
• Repetitive activities that use the wrists and fingers
• Chronic illness, such asarthritis

Symptoms

Common signs and symptoms of ganglion cysts include:

• Round mass on wrist or finger joint, which may be firm or soft to the touch
• Thinned skin or a grove along the fingernail may occur with cysts at the end joint of the finger

Treatment

Initial treatment of ganglion cysts is often non-surgical. The cysts can be monitored, and may disappear on their own. 

If the cyst becomes painful or limits activity, there are various treatment options:

• Splint to immobilize the wrist or finger
• Anti-inflammatory medications such as ibuprofen
• Aspiration or decompression of the cyst with a needle to drain fluid
• Surgical removal of the cyst

LEGEND: Preoperative photo of ganglion cysts of the dorsum of the hand

LEGEND: Excised ganglion cyst. Note the gel filled material

GIANT CELL TUMORS

The 2nd most common hand tumor is a giant cell tumor of tendon sheath. Unlike the fluid-filled ganglion cyst, these tumors are solid. They occur anywhere near a tendon sheath (outer lining layer that supports the tendon) and are benign (non-cancerous) and are slow-growing. They may be caused by trauma to the tendon sheath that stimulates abnormal growth.

LEGEND: Giant Cell tumor of the fourth (ring finger)

EPIDERMAL INCLUSION CYST

Another common tumor is an epidermal inclusion cyst. It is also benign and forms just underneath the skin, originating from the undersurface of the skin where there may have been a cut or puncture. Skin cells normally produce a protective waxy substance called keratin. When skin cells get trapped under the surface, such as with a skin puncture, they continue to grow and make keratin, forming the cyst. The cyst is like a sac with a fibrous outer lining and is filled with a soft, cheese-like material, the keratin.

OTHER SOFT TISSUE TUMORS

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

LEGEND: Lipoma of the hand. Above, MRI depiction of the lipoma (white mass). Below, removal of the lipoma

BONE TUMORS

Bone spurs can form, from arthritis or trauma, which feel like hard tumors.

The most common bone tumor is exostosis. It is a benign bone growth that appears during growth and is produced by a cartilage cap. Its most common location is the metaphyses of long bones.

LEGEND: Bone tumor (arrow) of the Enchondroma type

SKIN CANCERS OF THE HAND

Cancer in the hand is extremely rare. The most common cancers that originate in the hand are skin cancers, such as squamous cell carcinoma, basal cell carcinoma, or melanoma. Other cancers are very rare but include sarcomas of the soft tissue or bone. It is also possible for cancer to spread to the hand or wrist from somewhere else in the body, such as the lung or breast. This is called metastatic cancer. As with any cancer, a biopsy is usually required to make a definitive diagnosis.

LEGEND: Squamous Cell carcinoma of the hand in an immunocompromised patient with a renal transplant

 CAUSES HAND TUMORS

Hand benign tumors may have different causes.

As previously said, the giant cell tumors of the tendon sheath may follow trauma. This is also the case for many types of tumors of the hand.

Epidermal inclusion cysts, another common type of tumor of the hand, develop following a finger injury, and skin cells that would normally be out of the body, are retained under the skin, and still secrete keratin thereby forming the cyst.

Tumors can also occur in response to a foreign body, such as when a splinter causes the development of a mass under the skin.

SYMPTOMS OF HAND TUMORS

Most hand tumors are visible to the eye on the surface of the skin. If the tumor has formed beneath the skin on the bone or near a nerve, it may not be visible, but will oftentimes be painful.

While the majority of hand tumors are benign, it is always a possibility that the tumor could be cancerous, which is why you should not hesitate to see a doctor if you suspect that you have a tumor in your hand or wrist.

DIAGNOSIS OF HAND TUMORS

A careful history and physical exam help to determine the type of hand or wrist tumor. X-rays might be taken to evaluate the bones, joints, and possibly the soft tissue. Further studies such as CT, MRI, or bone scan may be done to help narrow down the diagnosis

TREATMENT OF HAND TUMORS

Recommendations for treatment are based on the experience of the hand surgeon and preferences of the patient.

Typically, definitive treatment with the lowest recurrence rate involves surgical excision of the tumor. Removing the tumor also allows a pathologist to analyze it and to determine what type it is with reasonable certainty. Needle biopsy or incisional biopsy (cutting out a small sample of the tumor) may be considered if the surgeon wants to confirm the diagnosis before recommending definitive treatment. Often, surgery is done under a local or regional anesthesia (numbing the extremity or area) and on an outpatient basis. Risks and benefits should be discussed with the surgeon. Most hand and wrist tumors can be cured with surgery.

INTRODUCTION

There are many nerves that run between the shoulder and the fingertips in the area of the body known as the upper extremity. These nerves are responsible for carrying messages from the brain to parts along the arm for movement, feeling and reflexes. The nerves in the upper extremity leave the central nervous system through several areas in the neck, and form a complex structure called the brachial plexus. The nerves are larger in diameter near the neck, and eventually divide to form smaller branches in the upper arm, forearm and hand.

Injuries to the upper extremity occasionally cause trauma to nerves, which can interfere with the various functions of the arm and hand. Occasionally, the nerve is bruised, and may heal on its own in time. However, if a nerve is cut or crushed, it may need surgical treatment in order to help improve or restore function to the hand or arm. Sometimes, certain illnesses can affect nerves and cause similar symptoms in the upper extremity.

The goal of the therapy is to relieve symptoms of the nerve injury and perform nerve reconstruction as soon as possible with minimal impact on the patient’s quality of life.

SYMPTOMS

• Loss of sensation in the upper arm, forearm, and/or hand. Each nerve supplies different areas of sensation in the upper extremity. The pattern of numbness can help guide the surgeon to the specific injured nerve(s).
• Loss of function in the upper arm, forearm, and/or hand. The muscles in the upper extremity are supplied by different nerves. The muscles that do not function properly help guide the surgeon to the specific injured nerve(s).
• Wrist drop or inability to extend the wrist
• Decreased muscle tone in the upper arm, forearm, and/or hand
• Changes in sweating patterns of the upper arm, forearm, and/or hand

DIAGNOSIS

• Undergo a physical examination and provide a complete medical history, including information about previous surgical procedures, past and present medical conditions, and any current medications or herbal supplements.
• Discuss possible options for treatment of the condition, including whether surgery is recommended. If surgery is recommended, patients will discuss the surgical procedure in detail, including the possible risks and complications of the procedure, recovery and rehabilitation period, and the probable outcome in terms of function and appearance.

In addition to an initial consultation appointment, additional diagnostic tests may be ordered. These include:

• Electrodiagnostic nerve studies (EMG)
• X-ray: Images used to determine if fractures are present
• CT Scan, MRI, or ultrasound (US) for more detailed imaging

SURGICAL TREATMENT

The goal of surgery is to improve function of the affected area in the upper extremity.

If the nerve is thought to be repairable, surgical treatment may consist of:

• Nerve decompression
• Nerve repair
• Nerve graft
• Nerve transfer

If nerve repair is not an option, a tendon transfer may be recommended.  Tendon transfers borrow extra tendons from other parts of the hand or forearm to perform a function that is lost due to the nerve injury.  The tendon chosen so the patient does not have loss of function with use of the donor tendon. 

LEGEND: Transected (cut) median nerve

LEGEND: Nerve repaired with sutures

INTRODUCTION

Trigger finger is a condition that involves the pulleys and flexor tendons in the hand that bend the fingers. The flexor tendons are “ropes” that connect the muscles to the fingertips. The pulleys are “tunnels” that the tendons travel through. Sometimes the pulley gets thick, or the tendon develops a knot, both of which make it difficult for the tendon to glide within the pulley.

CAUSES

In most cases there is not a clear cause of trigger finger, but it can be associated with medical conditions such as diabetes and rheumatoid arthritis. Trigger finger is more common in women than men, and in people 40 to 60 years old.

SYMPTOMS

• Pain and tenderness in the palm at the base of the finger
• Popping or catching of the finger
• Finger stuck or locked when bent towards palm

TREATMENT

1. Non-surgical treatments include:

• Anti-inflammatory medications such as ibuprofen
• Cortisone injections to reduce pain and swelling

1. Surgical treatment

If non-surgical treatment does not work, surgery may be recommended. The procedure will open the pulley to allow better tendon gliding and to relieve the catching of the finger. 

LEGEND: Schmematic explanation of trigger finger.

Left side: before surgery the inflamed tendon cannot pass through the thickened A1 pulley

Right side: after surgical release of A1 pulley the tendon slides freely

LEGEND: Intra-operative Photo of released A1 Pulley, the tendon is freed