Hand disorders

The hands are an extraordinary part of our body and allow us to perform multiple different activities of potentially incredible dexterity. Unfortunately, things can go wrong and there are a variety of conditions that can affect the hand. These may involve the joints, the bones and the surrounding soft tissues.

Trigger finger/ thumb

Trigger finger is a painful condition in which a finger or thumb clicks or locks as it is bent towards the palm.

Trigger finger

 

Cause:

Thickening of the mouth of a tendon tunnel leads to roughness of the tendon surface, and the tendon then catches in the tunnel mouth. People with insulin-dependent diabetes are especially prone to triggering, but most trigger digits occur in people without diabetes. Triggering occasionally appears to start after an injury such as a knock on the hand. 

Symptoms:

  1. Pain at the site of triggering in the palm (fingers) or on the palm surface of the thumb at the middle joint, usually in a person over the age of 40. 
  2. Tenderness if you press on the site of pain.
  3. Clicking of the digit during movement, or locking in a bent position, often worse on waking in the morning. The digit may need to be straightened with pressure from the opposite hand. 
  4. Stiffness, especially in trigger thumb where movement at the end joint is reduced. 

Treatment:

Trigger finger and trigger thumb are not harmful but can be a really painful nuisance. Some mild cases recover over a few weeks without treatment. The options for treatment are:

  1. Avoiding activities that cause pain, if possible
     
  2. Using a small splint to hold the finger or thumb straight at night. A splint can be fitted by a hand therapist, but even a lollipop stick held on with tape can be used as a temporary splint. Holding the finger straight at night keeps the roughened segment of tendon in the tunnel and makes it smoother. 
     
  3. Steroid injection relieves the pain and triggering in about 70% of cases, but the success rate is lower in people with diabetes. The risks of injection are small, but it very occasionally causes some thinning or colour change in the skin at the site of injection. Improvement may occur within a few days of injection, but may take several weeks. A second injection is sometimes helpful, but surgery may be needed if triggering persists.
     
  4. Percutaneous trigger finger release with a needle. Some surgeons prefer to release the tight mouth of the tunnel using a needle inserted under a local anesthetic injection, but others feel that open surgery is more effective. The needle method is not suitable for all cases and all digits. 
     
  5. Surgical decompression of the tendon tunnel. The anesthetic may be local (injected under the skin at the site of operation) regional (injected in the armpit to numb the entire arm) or a general anesthetic. The wound will require a small dressing for 10-14 days, but light use of the hand is possible from the day of surgery and active use of the digit will aid the recovery of movement. Pain relief is usually rapid. Although the scar may be red and tender for several weeks, it is seldom troublesome in the longer term. Recurrence of triggering after surgery is uncommon.

 

De Quervain's syndrome

De Quervain's syndrome is a painful condition that affects tendons where they run through a tunnel on the thumb side of the wrist.

Cause:
 

It appears without obvious cause in many cases. Mothers of small babies seem particularly prone to it, but whether this is due to hormonal changes after pregnancy or due to lifting the baby repeatedly is not known. There is little evidence that it is caused by work activities, but the pain can certainly be aggravated by hand use at work, at home, in the garden or at sport.

Symptoms:

1. Pain on the thumb side of the wrist, as shown in the diagram. Pain is aggravated especially by lifting the thumb, as in the hitchhiker position or when using scissors.

2. Tenderness if you press on the site of pain.

3. Swelling of the site of pain – compare it with same spot on the opposite wrist.

4. Clicking or snapping of the tendons occurs occasionally.

Treatment:
 
De Quervain’s syndrome is not harmful, but it can be a really painful nuisance. Some mild cases recover over a few weeks without treatment.

Treatment options are:

1. Avoiding activities that cause pain, if possible

2. Using a wrist/thumb splint, which can often be obtained from a sports shop or a physiotherapist. It needs to immobilize the thumb as well as the wrist.

3. Steroid injection relieves the pain in about 70% of cases. The risks of injection are small, but it very occasionally causes some thinning or colour change in the skin at the site of injection.

4. Surgical decompression of the tendon tunnel. The anesthetic may be local (injected under the skin at the site of operation), regional (injected in the armpit to numb the entire arm) or a general anesthetic.

Pain relief is usually rapid. The scar may be sore and unsightly for several weeks. Because the nerve branches were gently moved to see the tunnel, transient temporary numbness can occur on the back of the hand or thumb.

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a condition where the median nerve is compressed where it passes through a short tunnel at the wrist. The tunnel contains the tendons that bend the fingers and thumb as well as the nerve. CTS commonly affects women in middle age but can occur at any age in either sex. CTS can occur with pregnancy, diabetes, thyroid problems, rheumatoid arthritis and other less common conditions, but most sufferers have none of these. CTS may be associated with swelling in the tunnel which may be caused by inflammation of the tendons, a fracture of the wrist, wrist arthritis and other less common conditions. In most cases, the cause is not identifiable.

Symptoms:

The main symptom is altered feeling in the hand, affecting the thumb index, middle and ring fingers; it is unusual for the little finger to be involved. Many people describe the altered feeling as tingling. Tingling is often worse at night or first thing in the morning. In the early stages the symptoms of tingling intermittent and sensation will return to normal. If the condition worsens, the altered feeling may become continuous, with numbness in the fingers and thumb together with weakness and wasting of the muscles at the base of the thumb. Sufferers often described a feeling of clumsiness and drop objects easily. CTS may be associated with pain in the wrist and forearm.

In some cases, nerve conduction tests are needed to confirm the diagnosis. Blood tests and x-rays are sometimes required.

Treatment:

Non-surgical treatments include the use of splints, especially at night, and steroid injection into the carpal tunnel. CTS occurring in pregnancy often resolves after the baby is born.

Surgery is frequently required. The operation involves opening the roof of the tunnel to reduce the pressure on the nerve. The surgery may be performed under local anesthesia, regional anesthesia (injected at the shoulder to numb the entire arm) or general anesthesia. 

The outcome is usually a satisfactory resolution of the symptoms. Night pain and tingling usually disappear within a few days. In severe cases, improvement of constant numbness and muscle weakness may be slow or incomplete. It generally takes about three months to regain full strength.

 
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