Hand and Wrist Conditions

Trigger Finger

The tendons supply the digits on the palm side of the hand.  They are responsible for actively curling up the fingers into the palm.  It can be seen that these tendons would bowstring if there was not a mechanism to control them.  This mechanism is a series of belts/sheath which runs over the tendon from the palm right to the tip of the finger.  These are described by hand surgeons as pulleys and there are several of them.  The first pulley in the palm over the tendon can contract down and there can be some wear and tear changes such that the space available for the tendon to run through the pulley is diminished thus resulting in impingement which can cause pain and intermittent triggering where the finger gets locked and trapped and patients have to physically release it.  In advanced cases this may cause the finger to be permanently locked.

Recovery

There are small risks in relation to wound infection, reflex and sympathetic dystrophy, pain and stiffness in the hand, tenderness in the scar and a very small risk of nerve damage.

Very often patients complain of pain and discomfort over the PIPJ over the dorsal aspect of the PIPJ of the affected finger following surgery, rather than at the site of incision. This is extremely common and that is because the hand is getting used to the freedom afforded to it by the surgical release and this places pressure on the PIPJ knuckle.

Thus dorsiflexion movements (cocking the wrist upwards) as occurs in use of mountain bikes, lifting weights, sustained use of keyboards, press-ups etcetera can pump mucinous fluid into the neck of the sac which overlies the scapholunate ligament. It is thought that these ganglia are related to mucinous degeneration in this ligament although that is not always the case. The ganglia at the base of the thumb are often not related to any cause although in the older age group they are often due to arthritic changes in the wrist, or the trapeziometacarpal and scaphotrapezial articulations which are the tendons at the base of the thumb. Because of the development of the arthritis at the base of the thumb the body secretes more of the biological lubricant which is synovial fluid which tracks down and pops out as a small ganglion. Broadly speaking ganglia occurring in the young are without any cause though in the older age group 50 plus they are virtually always related to arthritic changes in the wrist or at the base of the thumb.

Recovery

It is not my policy to consider open surgery as a first line of treatment for two types of ganglia which can occur, namely the dorsal(back of hand) and distal volo-radial (palmar ganglia by the wrist crease) ganglia simply because there is evidence in the medical literature that the recurrence rate can be as high as anything from 10-30% depending upon the different reports in the hand surgery literature.  Consequently, we like to consider simple interventions first before we embark on surgery.

If aspiration and multiple puncture has been undertaken on numerous occasions with subsequent return of ganglia then in certain very specific cases these may be amenable to arthroscopic excision thus obviating the need for any open surgery.  This is undertaken as a last resort rather than a first port of call.  The surgery is undertaken arthroscopically and involves excising the stalk of the ganglion, which can be over the back of the hand, roughly in the central area overlying the scapholuante ligament or along the volar aspect of the wrist where the ganglion is decompressed internally by doing an internal aperture between the long radiolunate ligament and the radioscaphocapitate ligament.  The quoted recurrence rates in the literature are in the order of 10-20%, which is probably lower than the published rates for open surgery and aspiration. However, formal randomised studies are still awaited.

Features on history

The symptoms of the patient will depend on the severity of the joint contractures.  The more advanced this is the more difficulty might occur.  Patients have difficulty manipulating objects, shaking hands, putting their hands in their pocket, wearing gloves ,shaving and also undertaking sustained activity.

Recovery

Needle fasciotomy:

Dupuytren’s contracture is an inherited condition, which is unmasked by environmental factors.  When the joint starts causing problems in terms of stiffness in the joints or a sensation of tightness then intervention can be indicated dependent upon the circumstances.  There are many options in relation dealing with Dupuytren’s.  These range from splintage to open surgery.  Whatever is done for Dupuytren’s is associated with a recurrence, which can be as high as 30%.  The younger the age of presentation and at the time of surgery then the more likely it is to recur.  Be that as it may all treatment is tailored according to the needs of the patient.  The purpose of the needle fasciotomy is to have a procedure which can be done under local anaesthetic and which is easy to achieve without too much interruption of the patient’s daily life.  The aim of the needle fasciotomy is to interrupt the cords and the nodules, which have formed in the palm, rather than to fully excise them.  The purpose of this is to improve the joint contractures.  There are small risks in relation to infection, which are very low compared to open surgery, and there is also a small risk to damage to underlying tendons and neurovascular bundles.  There are small risks in relation to reflex sympathetic dystrophy, which is pain and stiffness afterwards.  It must be stated, however, that needle fasciotomy undertaken under local anaesthetic is exceptionally well tolerated and the risks are extremely low.  However, there is a definite recurrence rate and patients may require further surgery following a needle fasciotomy which may include further needle fasciotomies or open surgery.

Open Surgery:

With Dupuytrens itself, the risks of recurrence can be as high as 30%.The younger the patientia at presentation  then the more likely it is that the condition will recur  and thus requiring further surgery on the same operated hand.  Patients have zigzag incisions which are often alarming for patients unless they have been prepared to expect this.  There are definite risks in relation to any intervention and amongst them are wound infection, pain and stiffness in the hand, reflex sympathetic dystrophy, recurrence, tenderness in the scar, nerve damage and very rarely ischaemia of the digit. The recurrence rate is statistically quoted in hand surgery literature as high as 30%.  We deliberately do not aim to get a full correction, particularly on the little finger in the PIPJ and at times we combine this with soft tissue releases on the joint to obtain better movement.  It takes 6-9 months for the ultimate plateau of recovery to come through.

Recovery

There are small risks attendant to surgery such as wound infection, subluxation of the tendon within the group following release and neuroma from the exposure due to the profusion of branches of the cutaneous division of the radial nerve.

Like any hand intervention, there are risks with regards to pain and stiffness, so-called RSD.

Investigations

Investigations usually consist of x-rays combined with scans which can be CT scan or MRI to define the extent of the involvement.

Treatment

Treatment is according to severity as well as the causes.  It is difficult to give one specific treatment as there are a variety of treatments available due to the variety of causes.  Broadly speaking initial measures consists of symptomatic modifications of activities of daily living and keeping a diary of which movements in a patient’s daily life bring about the symptoms.  These can be combined with splintage and physiotherapy which will involve heat and ultrasound.  Following from that patients can be evaluated by means of wrist arthroscopy which is also useful in debriding the wrist and undertaking measures which involve shaving the overgrowths (osteophytes) as well as part of the radius itself known as the radial styloid (radial styloidectomy).  These measures can be undertaken either through open surgery or by means of the wrist arthroscope.  Dependent on the severity and the patient’s response the treatment is escalated accordingly in discussion with the patient and this can involve limited fusions in the wrist and can extend to a full wrist fusion.

Diabetic Hand

It is recognised that patients with diabetic hands are more prone to the so-called slowness and stiffness.  What this means is that they are more likely to develop tenosynovitis which involves triggering, stiffness, slowness of the diabetic hand, carpal tunnel syndrome, numbness and Dupuytren’s contracture.  It is also well documented in the literature that on operating on a diabetic hand, for whatever reason, patients are more vulnerable to developing reflex sympathetic dystrophy RSD/chronic regional pain syndrome as a complication of surgery which can occur in up to 5% of patients.

Lumps and Bumps in the Hand

Growths can occur in the hand.  The vast majority of growths in the hand are usually ganglia.  These are followed by growths which are known as giant cell tumours which are also equally benign.  Malignancies, though exceptionally rare, can nevertheless occur and the purpose of the clinical assessment is to exclude this.  Apart from a ganglion occurring on the back of the hand or along the wrist crease the lumps usually occur in the fingers and they can include giant cell tumours which are benign, sebaceous cysts, implantation dermoids and other growths which require a proper clinical assessment.  Depending on the site of the lump further imaging may be indicated.  Though examining surgeon always gives consideration to the possibility of a malignancy it must be stated that these are extremely rare and patients should not necessarily think of malignancy as a first diagnosis with most lumps.  A proper assessment by a trained health professional usually dispels any fears very quickly.

Recovery

There are small risks in relation to wound infection, nerve damage, recurrence and pain and stiffness post operatively, (so-called reflex sympathetic dystrophy.)  Dependent on the nature of the histology there can be a recurrence rate.  Thus a giant cell tumour can recur in up to 10% even though it is benign.  The same can be applied to lesions which are ganglia.  Other complex and rare growths are dealt with according to what the examination under the pathologist’s microscope indicates.

In the early stages of a fracture these are treated symptomatically by plaster although if they are associated with major force or great disruption of any surrounding ligaments then fixation can be considered. There is a sub-group of patients who do present with injuries to the scaphoid which had previously occurred many decades prior to the presentation. These are often due to an un-united fracture of the scaphoid giving arthritis (scaphoid non-union advanced collapse SNAC) or ruptures of the scapholunate ligament also giving arthritis (scapholunate advanced collapase SLAC). The management of scaphoid fractures will vary upon the length the scaphoid has been fractured and whether or not there are arthritic changes. Thus in a fresh fracture the management is aimed at getting the fracture to heal up and unite whereas in the other groups SNAC and SLAC these patients are managed to control the arthritis and limit its effects.

Mucous Cysts in the Digit

With increasing age degenerative changes develop in the terminal knuckle of the digits, the so call distal interphalangeal joint thus giving so called Heberden’s Nodes.  In the purest definition of a Heberden’s node this is an osteoarthritis of the terminal joints which comes to everybody with age.  As in any situation where there is an arthritis the body secretes more of the biological lubricant which is synovial fluid and this can escape on either side of the extensor tendon on the back of the finger thus causing cysts.  These cysts can be problematic in that they can keep rupturing or get infected.  The substance produced is usually straw like jelly.  They can also cause pressure on the nail thus causing an alteration of its shape.

Recovery

Surgery involves an excision of the cyst and the overlying poor skin, triangulating the defect and turning a small tongue of tissue, the so-called transposition flap, to obtain cover.  There are small risks attendant to the procedure in relation to wound infection, recurrence rate which can be up to 10%, tenderness in the scar.  There is also a small risk in relation to grooving in the nail which may not improve and may rarely be caused or aggravated by the intervention itself.