Carpal tunnel syndrome:
Carpal tunnel syndrome (CTS) is one of the most common hand conditions. Carpal tunnel results from compression of the median nerve at the wrist. The median nerve provides sensation to the thumb, index, long and ½ of the ring finger and strength to the thumb.
Some people think repetitive use, use of a mouse or typing may cause carpal tunnel syndrome. While the work as a cause may be subject to debate, in our experience certain activities can certainly make symptoms worse. Attention to proper use of tools, keyboard position and ergonomics can go a long way to help live with your symptoms.
Carpal tunnel syndrome may be associated with conditions that cause swelling such as changes in fluid pills, rheumatoid arthritis or hypothyroidism. Finger numbness and hand weakness may also be signs of pinched nerve at the neck . In some cases, the nerve may be pinched at the neck and the wrist (double crush syndrome).
- Numbness or tingling in the thumb, index, long and ½ of the ring finger
- Night time awakening with numbness or pain, shaking the hand
- Numbness or pain with driving, holding the phone or newspaper
- Weakness of thumb, difficulty opening pop bottles
- Aching in the shoulder or arm
Carpal tunnel and wrist / thumb pain:
CTS does not typically cause wrist pain. Carpal tunnel may be caused by wrist arthritis, deformities or fractures. CTS can cause aching in the thumb. Thumb pain commonly results from arthritis at the base of the thumb. Your doctor will examine you and may obtain xrays to differentiate thumb pain related to CTS from arthritis.
Treatment of carpal tunnel syndrome:
There are 3 basic treatments for CTS: Splinting and observation, cortisone injection and surgery. Loss of strength in the thumb is a key factor to determine treatment. Numbness, tingling and pain typically respond to treatment with expectation of significant recovery. Loss of thumb strength and muscle may be permanent. As a result, when thumb muscle weakness and muscle loss occurs, surgery is typically indicated to prevent further permanent loss of function.
For patients with good strength, cock up splints may be prescribed. The splints support the wrist in a position to decrease pressure on the nerve. NSAID anti-inflammatory drugs or injection of steroid may also be considered to decrease symptoms. The goal of these treatments is to decrease the swelling and pressure on the nerve.
Carpal tunnel surgery directly decreases the pressure on the nerve. It is an outpatient procedure that may be done under local anesthesia or block. Pressure on the nerve is released by dividing the transverse carpal ligament overlying the nerve. Scar tissue surrounding the nerve is also released.
Absent marked weakness in the thumb and loss of muscle, most insurance companies require a trial of splinting for at least 3 weeks and nerve conduction studies prior to authorizing surgery.
What are the results?
Carpal tunnel release surgery is highly effective at relieving numbness and tingling for patients with normal nerves. Many patients experience immediate improvement of night time symptoms and numbness. Full healing of the nerve may take up to 18 months. Weakness of the thumb and muscle loss typically does not recover fully, and in some cases may not recover at all.
Individual expectations may vary based on severity and duration of the problem and other medical conditions. For patients with diabetes or neuropathy, results are less predictable. Your doctor will tell you what you should expect.
Does it come back?
Carpal tunnel release is a permanent solution to the problem for most patients. In a small percentage of patients, the problem can return.
When can I return to work?
Achilles tendinitis may be persistent and difficult to treat. Resolution of symptoms may take weeks to months. Treatment of the tendonitis is reducing inflammation and pain.
- NSAID anti-inflammatory medicines or oral steroids may be used to decrease inflammation.
- Physical therapy modalities including ultrasound and stretching
- Cast or boot immobilization may be used for some patients.
Preparing for your visit:
The doctor will ask you about your symptoms, perform an examination, and may obtain xrays. Your doctor will need to know how and when symptoms began. Many patients report “the whole hand goes numb.” When your hand goes numb, check to see if the little finger is involved, as the location of the numbness is a key to making the diagnosis. Be sure to report neck pain, prior surgeries, changes in fluid pills, low thyroid, diabetes, rheumatoid or psoriatic arthritis as these conditions may also cause CTS.
The doctor will examine you, and may obtain xrays of your hand, wrist and neck. Nerve conduction studies may be ordered to confirm the diagnosis, and evaluate for other nerve problems in the arm and neck. If you have had nerve studies, neck studies (MRI, xray, CT) please bring reports and copies of the studies with you to your appointment. The doctor will need to review these studies, and the hospitals do not send them to the office. If the studies are not available for review, your diagnosis may be delayed.
Medications and lab tests may be relevant to your problem as well. The doctor will need an accurate and complete list of medication name and dose. Bring all your medications in their original container so we may verify your medications. If you have had recent blood tests, particularly thyroid function, arthritis blood tests, diabetes blood tests (hemoglobin A1C) or kidney function tests, please bring a copy for the doctor to review.
Checklist for your visit:
- Date of onset ( when did the problem start
- Which fingers are involved
- History of neck problems or neck surgery
- Complete list of medications, bring bottles of all medications
- Prior nerve studies: Copies of reports in hand
- Prior Neck xrays, MRI, CT or other study: Copies of report and disc in hand
- Recent lab tests: Thyroid functions, arthritis blood tests, kidney functions: copies of tests in hand
Base of thumb arthritis:
The base of the thumb is one of the most common joints in the body to be affected by arthritis. The early stages are characterized by pain with grip or moving or grasping with the thumb. Stiffness, swelling and loss of motion follow in later stages. It may become difficult to move the thumb away from the hand to hold a glass. The pain can interfere with pinch and grip.
In early phases, symptoms may respond to use of NSAID anti-inflammatory meidcations, and decreased gripping activity with the hand. Thumb splints may be prescribed by the doctor. In later stages, cortisone injection may give relief. Fusion of the joint or interposition may be considered when conservative measures fail. Fusion involves removal of the joint and fixation of the joint to permanently stiffen the joint. Interposition involves removal of the joint and then placement of a tendon between the bones, or fastening the base of the thumb to an adjacent bone. Fusion provides the most stability. Interposition retains a bit more movement at the basilar thumb joint. Your doctor will discuss what approach is best for you.
Ganglion cysts are bumps that come up over the wrist. The cyst is a sac filled with fluid that is pushed out of the joint. The cyst typically forms by tissue pushing through a weakness in the ligaments of the wrist. Many cysts may not cause symptoms. They may become bigger and smaller over time. The appearance of the cyst may bother some patients. When they become large, the mass of the cyst may interfere with activity or wearing a watch or jewelry. Cysts on the underside of the wrist are typically in close proximity to the radial artery, the pulse you can feel below your thumb.
Treatment of ganglion cysts:
BIBLE: Historically, there are reports of smashing cysts with the good book. This treatment is no longer recommended, either by clergy or the doctors.
Observation: If cysts are small and causing minimal symptoms, they may be left alone.
Aspiration:: If cysts are larger, unsightly or interfering with function, the doctor may numb the skin over the cyst and draw the jelly like fluid out of the cyst and inject it with cortisone. In more than 50% of cases, the cyst may return.
Surgery: The cyst may be surgically removed. This procedure is typically done as an outpatient at the hospital. Typically a block is used, so you do not need to go to sleep. Unfortunately for 10-20% of patients, the cyst can return or another cyst may form in near proximity to the cyst that was removed. Cysts should not be lanced or operated in less controlled circumstances to prevent injury to surrounding blood vessels and nerves. Due to the large number of skin nerves in the hand, scars from surgical excision may also be tender.
Dequervain’s tendonitis is an inflammation of the tendions that bring the thumb into the “hitchhiker” position. Tenderenss extends from the place shown in the diagram, often extending up the arm along the tendons shown. IN some cases, tender nodules may form over the bone of the wrist. Symptoms include localized pain and swelling, and pain with moving the thumb into the hitchhiker position, or with forced bending of the thumb into the palm.
- Observation / NSAID anti- inflammatory medications and rest. Local ice or warm heat and modification of activity.
- Injection: Cortisone injection may help about 50-60% of patients. In some cases 2 injections may be required.
- Surgery: Surgery involves releasing the tissue over the tendons responsible for the inflammation. This surgery is done as an outpatient at the hospital under block anesthesia.
Trigger finger results from inflammation of the tendon that bends the fingers or thumb, and the tough fibrous tunnel that guides the tendon. Triggering refers to the symptom where the finger locks down, and then with increasing pressure, snaps open. There usually tenderness over the tendon at the base of the finger over the inflamed tendon. Symptoms are worse in the morning for many patients. Also patients with trigger finger are prone to have multiple fingers with the problem over the years.
- Splinting, observation: Mild cases may respond to taping a popsicle stick to the finger to keep it straight. Splinting is typically only required at night. Modify activity to decrease heavy gripping. In some cases, use of NSAID anti-inflammatory medications may help.
- ,Injection: The doctor can inject cortisone into the area around the tendon do decrease inflammation. Typically 1 or 2 injections are tried before considering surgery. Injections help more than 50% of patients on a temporary or permanent basis.
- Surgery: Release of the fibrous tunnel around the tendons at the base of the finger results in permanent resolution of the problem for the vast majority of patients. The procedure can be done as an outpatient under local anesthesia.
Dupytren’s disease causes cords to form in the palm. Over the years, the cords may become more prominent and begin to pull the fingers to the palm. Dupytren’s may also affect the soles of the feet and the penis. The ring and small finger are most commly affected. The contractures are caused by abnomality of copper related bonds in the connective tissue of the hand.
Some may confuse rigid locking of a severe trigger finger with Dupytrens. The conditions can usually be differentiated on clinical exam.
Dupytren’s cords must be differentiated from heavy scarring that may follow cuts to the hand. Fingers are left alone until moderate contracture of the joints occurs. When loss of mobility reaches a moderate level, the cords are surgically excised. The cords are typically intertwined with the small nerves of the hand. Excision of the cords requires careful dissection of the small nerves and blood vessels in the hand. The best results are typically obtained when the cords are completely excised. This can be a fairly major operation. In some cases, after the finger is released, skin may be insufficient to completely close the wound. Contracture to the joints on the finger are typically more resistant to treatment than the jont where the finger joints the hand. Healing typically takes 6 to 8 weeks. In some cases, therapy and splinting may be required to restore and preserve motion following surgery. In some cases, the cords may return even after radical excision of the tissue. The surgery is performed at the hospital as an outpatient. For severe cases, the procedure may take 2 or more hours. Nerve and vessel dissection may be performed with maginification, or in some cases with the operating microscope.
Injection: Over the past few years, an enzyme may be injected to digest the cord. The following day, the finger is manipulated to rupture the cord. While Dr. Branson has been certified to perform these injections, we do not currently perform injection treatment of Dupytrens at OCV.
Mallet Finger / Baseball finger:
Mallet finger is a drooping of the joint at the base of the finger nail that is caused by injury to the tendon on top of the finger that straightens the finger tip, or the bone that that tendon attaches to . This injury may be caused by relatively minor trauma. In sports, the injury is commonly cuased by a ball striking the finger tip of a straight finger.
These injuries may disrupt the joint. Left untreated, the tendon injury may imbalance the tendons that straighten the finger, resulting in a swan neck deformity, where the middle joint of the finger hyperextends (bends backward) with continued droop of the joint at the base of the finger nail.
Treatment depends on whether the injury involves the tendon alone, or the bone at the base of the finger tip bone.
Isolated tendon injuries and fractures that are small may be treated with splinting. Splints must be worn constantly for 8-12 weeks. If splints are repeatedly removed, droop of the joint will be permanent. An alternative to an external splint is surgical insertion of a pin across the joint to keep the joint in position to promote healing.
For fractures involving a significant portion of the joint surface, surgical reduction of the fracture is the preferred option. If the fracture is large, the joint will come out of position (sublux) due to disruption of the joint surface. In these cases, reduction of the fracture and pinning of the fracture and joint or excision of the bone fragment may be performed. IF the fragment is excised, the tendon is advanced to decrease loss of stability of the joint or development of secondary deformities of the finger.