Hand conditions

Basal thumb arthritis is a very common condition mainly affecting middle aged women but also men who perform manual tasks. It presents with pain at the base of the thumb and difficultywith everyday tasks such as opening tight jar lids, pain on wringing out a cloth and difficulty holding objects such as a kettle.

The condition is confirmed by expert examination – pain and crepitus on grinding or axially loading the thumb. As the disease progresses the hand can adopt a characteristic appearance as the basal thumb joint gradually subluxes and the thumb adducts with secondary compensatory hyperextension at the metacarpophalangeal joint resulting in a Z thumb deformity in advanced cases.

XRs will usually confirm the diagnosis. Occasionally, the XRs will show that the at the joint below (the scaphotrapeziotrapezoidal joint,STTJ ) is also arthritic.

Treatment is tailored to the severity of disease. In mild cases lifestyle modification, simple analgesia and possible splintage may suffice. In others, a steroid injection into the basal thumb joint can be helpful. In fact the majority of patients who get as far as presenting to a hand surgeon will probably have a steroid injection as most will have already tried the simpler treatments. The risks of steroid injections are post-steroid flare, depigmentation and skin atrophy. Yours surgeon will discuss these with you.

In advanced cases, surgery is offered when other treatments have failed. The gold standard operation remains a trapeziectomy – excision of the arthritic bone at the base of the thumb. The market has been flooded with various arthroplasties (artificial thumb base joints) and many have been withdrawn over time. Some implants have shown good survivorship beyond 10 yrs however the overall published evidence does not support their use over a trapeziectomy. After trapeziectomy, you will require a splint and some hand therapy. Your surgeon will discuss this with you.

This injury is the result of disruption to the extensor mechanism at the top of the finger causing the finger tip to ‘droop’ down giving the appearance of a ‘mallet’. The patient is unable to straighten the tip of the finger fully. The injury is commonly sustained in cricketers and rugby players.

An X-ray  is important as it will distinguish between a bony or non-bony component . It there is subluxation of the joint or a large chunk of the articular surface is affected then occasionally surgery is recommended . This involves an anaesthetic – general or local – and fixation with wires usually . The wires are removed after 6-8 weeks .

they can mostly be treated non-operatively using a custom made splint by the hand therapist . The splint is worn constantly for 6 weeks followed by 6 weeks of night time splinting alone

 Carpal Tunnel Syndrome is a common hand condition whereby the median nerve is compressed at the level of the wrist causing symptoms of numbness, pain and paraesthesia. In severe cases the hand can become weak with loss of dexterity as well as loss of protective sensation (inability to feel the difference between hot and cold). The symptoms can vary with severity and in mild cases a splint will suffice as treatment. In more established cases especially where there is evidence of neurological deficit (eg established numbness, reduction in dexterity, weakness and wasting of hand muscles) surgical release of the carpal tunnel is advised (carpal tunnel decompression (CTD)

See guidance to British Society for Surgery of the Hand re Carpal Tunnel Syndrome

https://www.bssh.ac.uk/userfiles/pages/files/Patients/Conditions/CTS/cts_leaflet_2016.pdf

Treatment options

Splint – wrist splint holding wrist at neutral worn at night for 8 weeks. This is the first line treatment for mild cases

Steroid Injection – your clinician will inject the carpal tunnel with local anaesthetic and steroid and this can be effective in mild cases where a splint has not helped. In more significant cases of CTS steroid injections only help temporarily. They can be used in a diagnostic manner (ie symptomatic but negative Nerve Conduction Study). They are not usually advised repeatedly or for significant compression.

Surgical Treatment – Carpal Tunnel Decompression (CTD)

CTD is a day surgical procedure performed in the operating room under local anaesthesia (you will be awake). The procedure usually takes about 20 mins to perform in total (anaesthetic and procedure time). An incision is made in the palm and the nerve is released and the wound closed with sutures (removed or trimmed at 2 weeks). A single post-operative visit for a wound review is required for most patients.

A bulky dressing is applied (fingers are free to use) and this is removed by the patient at 3- 5 days and the wound covered with a clean dry dressing.

Postoperatively, you are advised to elevate the hand most of the time for the first 5 days (put hand on pillow at night-time if possible). Finger movement is advised (fully straighten and make a full fist) to avoid stiffness. Using the hand for light tasks is advised but heavy lifting and vigorous use is discouraged for the first 2 weeks. No driving for c2 weeks

Consent – risks, alternatives to surgery, what happens if not treated?

All operations minor or major have some risks. For CTD there are small risks of infection, bleeding, tender scars, stiffness, swelling, nerve or vessel injury, and failure to improve. The chances of a poor outcome are very low (<1%) and the vast majority (>90%) will have an excellent result.

The aim of surgery is to reduce the symptoms of numbness and tingling. Sometimes patients experience other symptoms such as pain which are not attributed to CTS and may continue after surgical release and you should discuss this with your clinician.

If symptoms are severe or there is established neurological deficit it is unlikely that the symptoms will improve without surgery and the longer the compression, the less likely it is that the symptoms will improve. Therefore, in such cases prompt surgical release is advised (matter of weeks). If the nerve remains severely compressed then the hand can become weak and protective sensation can be lost (ability to tell difference between hot and cold).

Splints and injections are alternative to surgery for mild cases and your clinician will advise when surgery is the best course of treatment.

Before embarking on surgery ensure you understand the following 

Benefit of surgery for you

Alternatives to surgery

What will happen if you don’t have surgery

The risks of surgery

Post-op care Elevate your hand above heart level most of the time but especially for the first few days and move and use your fingers. Avoid heavy lifting but typing and light use is permitted. Excessive post-op pain is not expected and usually paracetamol and ibuprofen for the first few days will suffice.

Remove the bulky dressing at 3-5 days post-op.

Keep the wound clean and dry until the 2 week post-op review when the stitches will be trimmed or removed by the nurse.

No driving for 2 weeks. Most patients require 1-2 weeks off work but some heavy physical workers may require 3-4 weeks.

No hand-held sports for about 4 weeks. Although quite a lot of activity is possible after 2 weeks, the hand will feel weaker than usual for c8 weeks. Swimming and running are fine after c 2 weeks.

Scars can sometimes be tender but the vast majority will become less sensitive with time and scar massage with moisturiser or baby oil can be therapeutic.

Overall the hand should improve day by day and if this is not the case get in touch with your clinician.

This is entrapment of the ulnar nerve at the level of the medial epicondyle of the elbow (‘funny bone’) and is characterised by numbness of the little and ring fingers, tingling, weakness and wasting of the small muscles of the hand, depending on the severity.  The cause is usually not usually obvious; occasionally it develops in patients who lean on their elbows a lot, have had trauma to the elbow or who have arthritis.

Diagnosis and Treatment

This is usually confirmed with nerve conduction studies. Treatment if mild, may simply involve lifestyle modifications (avoiding sleeping with elbows bent/avoidance of leaning on elbows) or in patients with significant symptoms, surgical decompression of the ulnar nerve at the level of the ‘funny bone’.

In mild/moderate cases the sensory symptoms often resolve with surgery but in advanced cases, the aim of surgery is to prevent further damage to the nerve.

Named after the Swiss Surgeon De Quervain who originally described this painful condition as ‘washerwoman’s sprain’ and by described rather unflatteringly by Finkelstein as a condition affecting the ‘labouring classes’!

De Quervain’s syndrome is characterised by pain and swelling on the radial aspect of the wrist with painful thumb movements and weakness in grip. There is a fairly strongassociation with pregnancy and the post-partum period – it is likely that this is due to hormonal and fluid changes.

The pain results from degenerative changes affecting the strap like tunnel around the tendons on the radial aspect of the wrist. The tunnel narrows and constricts (hence the condition is sometimes called stenosing tenosynovitis) and as a result the tendons fail to glide normally resulting in pain and swelling.

Treatment

Mild cases may settle without any treatment. Sometimes a splint will suffice. In the more symptomatic, a steroid injection into the painful area will have a 70-80% success rate. The side effect of steroids are depigmentation and skin changes which your surgeon will discuss with you.

Surgical decompression of the tunnel (s) around the tendons is offered in when symptoms do not settle. This is performed under regional or general anaesthesia, via a tranverse incision under loupe magnification protecting the nerve branches. The sheath surrounding the tendons to released so that the tendons can glide freely. Your surgeon will discuss this with you in greater detail.

Named after the French Napoleonic Surgeon Baron Dupuytren, this is a common condition affecting the hand characterised by nodules or cords starting in the palm. In a third of patients the nodules will progress into cords which can cause digital contracture. The little and ring fingers are most affected. The aggressive form of Dupuytren’s, is characterised by radial (thumb and index) sided disease,bilaterality, ectopic disease (eg in the feet) and early age onset and strong family history.

The cause is unknown but we know that there is a genetic predisposition and people of Northern European (‘Viking’) heritage are particularly affected. It was previously thought to be associated with the ’good life’ (heavy smoking and alcohol consumption) but there is not enough evidence to back this up. There is an association with diabetes. Trauma /injury can accelerate the onset.

Treatment

If function is unaffected then no treatment is necessarily required. The interventional options are:

Xiapex (collagenase) injections – depending on disease severity
Needle fasciotomy
Selective fasciectomy
Total fasciectomy
Dermofasciectomy (usually in the revision setting)- skin grafting

The available evidence does not support the use of radiotherapy for Dupuytren’s. Surgery is usually followed with splintage and hand therapy.

Surgery for Dupuytren’s Disease

This involves an anaesthetic – regional ‘wide awake’ (whole arm numbed by an anaesthetist) or General Anaesthetic depending on patient preference. Usually day surgery. An extensive dissection is performed in order to identify and remove as much diseased tissue as possible and to visualise and protect the neurovascular (nerves/blood vessels) bundles. Post-operative elevation for a few days is required, plaster removal and splint application at 1 week, Hand Therapy to commence (and splint) at 1week post -op, wound check and removal of sutures 2 weeks. Hand therapy is an important component of treatment post-operatively and is required for several weeks/months depending on severity of disease.

After the basal thumb joint the commonest joint affected by arthritis in the hand is the distal interphalangeal joint (end joint) of the index finger. This can present with pain, swelling and deformity.

They can frequently be associated with pearl ganglions or mucous cysts whereby the underlying arthritis results in a ganglion being formed. It is important to realise here that the ganglion is secondary to the underlying arthritis. Simple excision of the ganglion may well not treat the arthritis which can continue to cause pain.

Treatment depends on the severity of disease. In mild cases simple analgesia will suffice. This is a particularly painful joint to inject with steroid so this is not routinely offered. In severe cases, the most reliable surgical treatment will be a fusion. This is usually done using wires in a tension band fashion which require removal at a later stage.

Digital arthritis affecting the proximal interphalangeal joint (PIPJ) ie the middle joint and the metacarpophalangeal joint (MPJ) can be treated surgically with joint replacement or fusion depending on the individual case and also the location of disease. Your surgeon will discuss this with you.

These are common fluid filled sacs presenting as swelling around joints or tendons, typically on the back of the wrist, near the ends of fingers (mucous cysts or pearl ganglia) or at the front of the wrist. The cause is usually unknown and several theories are postulated including wear and tear of the underlying joint or tendon resulting in synovial or joint fluid leaking out presenting as a swelling.

Ganglia may or may not be painful. They can become bigger or smaller and can disappear with time.

Treatment

If the ganglion is not painful then reassurance and confirmation of the diagnosis is all that is required. If symptomatic then the first line treatment is needle aspiration, or steroid injection which has a 50% success rate.

Surgery is offered if the ganglion is persistently painful despite aspiration.

This is a condition whereby the ulnar nerve (nerve that supplies sensation to the little finger and half of ring finger plus small muscles of the hand) is compressed at the level of the wrist. It is characterised by numbness and tingling affecting the little and half of the ring fingers as well as weakness affecting the small muscles of the hand. The patient may notice loss of strength and dexterity in the hand which can be truly debilitating.

This can occur fairly acutely and has been seen in patients using crutches in a prolonged fashion and also in keen cyclists. In both cases it is probably related to direct pressure effects. In cyclists, the wrist is flexed and ulnar deviated in a prolonged fashion resulting in increased pressure in the Guyon’s canal and subsequently the nerve undergoes ‘damage’ resulting in the symptoms. In occasional cases the hand can become profoundly weak and wasted.

Nerve conduction studies are obtained to confirm the diagnosis, assess severity and exclude a double crush phenomenon where the same nerve is compressed in a second location along it’spath. If the condition is refractory to non-operative treatment then surgical decompression is offered.

Treatment

This is initiated with splints, hand therapy exercises to prevent clawing of the fingers and anti-inflammatories if pain is an issue. If recovery does not occur day on day then surgical release would be considered.

Most hand fractures can be treated non-operatively. Surgery is indicated if there is rotational deformity, significant angular deformity or for open fractures.
The commonest fractures are metacarpal (MC) neck fractures especially the little finger – also known as Boxer’s Fractures (punching hard surfaces).

Non-operative treatment entails elevation, controlled early range of motion within the limits of pain, neighbour strapping and hand therapy.

The aim of surgery is to correct deformity if present and enable early range of motion. After surgery you will be given advice re elevation, analgesia, early range of motion and scar management.

Occasionally metalwork especially wires are removed at a later date, as they can cause local irritation.

This is a common hand condition characterised by pain and clicking of the digit. Sometimes the finger gets stuck in the palm (locking) and the patient has to pull it straight. The cause is related to degenerative change in part of the palmar pulley system which undergoes wear and tear thus narrowing. As a result the tendon fails to slide smoothly in it’s tunnel; instead triggering or locking occurs

Patients with diabetes are frequently affected but it is important to note that most patients with triggering are not diabetic.

Treatment

Steroid injections into the palm around the pulley has a success rate of 70-80 %. This is lower for diabetics.

If steroid injections fail then surgical decompression is offered. This involves a small cut in the palm and release of the pulley at the mouth of the tendon sheath. A light dressing is applied to the wound for 10-14 days and the hand is initially elevated whilst maintaining good finger movements.

A hyperextension injury of thumb can result in an ulnar collateral ligament (UCL) injury. The UCL is a stout, thick and strong ligament on the inside of the thumb at the level of the metacarpophalangeal joint. It is essential for the stability and patients who have completely ruptured this will notice instability on key grip pinch. It can be quite debilitating and depending on the degree of rupture surgery may be advised.

If the UCL is partially sprained or damaged, it may be successfully treated with splint immobilisation. However a completely ruptured UCL may well required surgical repair. The anatomy is such that is possible for the ligament to rupture and each end of the ligament end up on either side of a covering fascial structure known as the adductor aponeurosis resulting in what is called a Stena lesion – in this situation , the UCL will never heal well and surgery is usually recommended.
Sometimes the UCL is avulsed taking a bony fragment with it. If the bony fragment is displaced away form it’s origin then the bony fragment is fixed back onto it’ s origin.

After surgical repair, splintage and hand therapy is often required.

UCL Reconstruction using Free Tendon graft

In the unusual situation of a delay in treatment foran ulnar collateral ligament rupture (beyond weeks/months), direct repair may not be possible and sometimes a reconstruction of the ligament using a tendon free graft is performed.

Steroid injections (also called corticosteroids) are powerful anti-inflammatories which are  

commonly used to treat a range of conditions including trigger digit, de Quervain’s, arthritis at the base of thumb and sometimes ganglia.

Your hand specialist will inject the steroid close to the problematic site (tendon sheath, carpal tunnel joint etc) and may sometimes use X ray or Ultrasound guidance eg basal thumb joint.

Many patients will experience some localised pain or swelling at the injection site but this should settle fairly quickly and paracetamol can be helpful.

The injections can take a few days to start working (average 1 week) and their effects can be very long lasting. For trigger and De Quervain’s 75% of patients will not require any further treatments. A minority of patients will require a second injection and even fewer may require surgical treatment if the injections have not helped.

Risks of steroid injections include:

Depigmentation or blanching of the skin. This can be especially prominent in dark skinned people and is sometimes permanent.

Skin atrophy (thinning). The steroid damages fat cells so can cause a divot or depression in the skin contour which can be unsightly.

Steroid flare – excessive pain and swelling at the injection site. This is due to crystallisation of the steroid. Will usually settle with analgesia and ice packs

Elevated blood sugar – diabetics should monitor their blood sugars post injection. Rarely causes any serious issues.

Tendon damage – steroid can weaken a tendon and therefore your specialist will take care not to inject into the tendon. Patients are advised to rest a joint for a few days after the injection. It is thankfully rare.

Infection (deep) is thankfully rare (5 per 100,0000)  but immunocompromised patients should inform their clinicians nonetheless.

Cartilage loss research – repeated injections can thin the articular cartilage. This is less relevant when joints are already damaged but nonetheless repeated and frequent injection of the same joint is usually avoided.

 Frequently asked questions relating to steroid injections

 How many injections can I have?

Usually about 3 well-spaced apart ( at least 3-4 months apart) injections are possible during the course of a year if necessary. Your clinician will advise on this.

Will I gain weight?

No, this is most likely with oral steroids only.

I have an infection – should I avoid the steroid?

Yes. Most clinicians will not want to inject a site where there is active infection so its best to defer.

I have recently been vaccinated – can I have an injection?

You could have the steroid injection about 2 weeks after the vaccine. This is to avoid the potential immunosuppressive effects of a steroid injection interfering with the body mounting a immune response to the vaccine.

 I am breastfeeding or pregnant – should I avoid a steroid injection?

Discuss with your clinician but steroid injections are usually safe for women who are pregnant or breastfeeding. The injections are commonly used in these situations when pregnant women present with severe carpal tunnel or De Quervain’s syndrome.

I am on blood thinners, should I avoid steroid injections?

Discuss with your clinician but this would not usually preclude a steroid injection. Ensure the anticoagulation is well controlled to avoid excessive bleeding or bruising at the site.

I am diabetic/ epileptic/ hypertensive – can I still have a steroid injection?

Inform your clinician but these conditions would not usually preclude having a steroid injection. Blood sugar levels can be a bit high for a few days after the injections and diabetics are advised to monitor their blood sugars.

I am allergic to steroid injections?

This is rare but you must inform your clinician.

There is a lot of interest in the relatively new and emerging area of biologics – platelet rich protein (PRP). It has been made ‘fashionable‘ by the likes of Rafael Nadal and Tiger Woods. The healing of damaged, injured or inflamed tissues involves a complex inflammatory / healing response. Platelets release growth factors at the injured site and these are involved in the healing response. PRP is a high concentration of platelets and therefore growth factors which are involved in the healing response.

What is PRP?
PRP is obtained from the patient by taking a sample of their blood, spinning it down in a centrifuge machine which separates the blood into various components – red cells, white cells and the plasma rich layer. The latter is taken and injected into the patient’s injured region. It contains a high concentration of active platelets which release growth factors involved in the healing of damaged tissues – tendons, ligaments, joints (including degenerative or arthritic joints).

Sample of blood taken from patient

Centrifugation separates blood into different components

PRP (top layer) is taken and injected into damaged tissue

Benefits
The main advantage is that the substance injected is from the patient him/herself so there is a negligible risk of any adverse reaction. It is only as invasive as having a blood test and is a fairly quick procedure done in the outpatient setting usually.
Studies have confirmed the effectiveness of PRP for tennis elbow, jumper’s knee, plantar fasciitis and osteoarthritis of the knee. Studies around the hand and wrist do exist but it is not as well established. Miss Umarji is currently the Principle Investigator for an important study looking at the effectiveness of PRP for base of thumb arthritis.
In select  cases surgery can be potentially avoided if PRP is successful.