Hand Conditions

Dr. Donnelly and his staff understand how vital healthy hands are to his patients. Our hands are necessary for achieving our most basic needs and performing our most complex actions. Any hand condition or injury can significantly affect the quality of your life.

Below you’ll find general information about the most common hand conditions, how they are diagnosed and how they are treated.

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome is basically a pinched nerve in the wrist.  The median nerve and nine tendons travel from the forearm to the wrist.  The nerve passes under the transverse carpal ligament at the wrist to give sensation to the thumb, index, middle, and inner portion of the ring fingers.  When pressure builds up in the space between the nerve and the ligament, a condition known as carpal tunnel syndrome (CTS) develops.  Patients with CTS typically experience tingling and numbness in the hand, and often times pain, particularly at night.

What Causes Carpal Tunnel Syndrome?

Pressure on the nerve can be from several different factors, and often times involve a combination of the following:

  • Swelling of the lining of the tendons – tenosynovitis
  • Acute injures (fractures/dislocations)
  • Arthritis
  • Fluid Retention during pregnancy
  • Health conditions – diabetes, rheumatoid, thyroid gland imbalance
  • Heredity – anatomically smaller carpal tunnel

How is CTS Diagnosed?

CTS is diagnosed using the following:

  • A thorough examination of the arm
  • A detailed history, that includes your symptoms, medical conditions, activities and prior injuries

X-rays may also be taken to check for arthritis or a fracture.  In some cases, electro diagnostic studies (nerve conduction tests) are performed to confirm the diagnosis.  A diagnostic steroid injection into the carpal tunnel can be used, as another confirmatory test, which also may help relieve the symptoms.

How is CTS Treated?

As is the case with most orthopedic injuries/conditions, conservative, non-surgical options are tried first.  Initial treatments include the following:

  1. Activity modification. Decreasing or stopping activities that require excessive wrist movement may decrease symptoms.
  2. By holding the wrist straight, a brace is able to decrease the pressure on the nerve from flexion or extension of the wrist.
  3. Nonsteroidal anti-Inflammatory drugs (NSAIDS). Over the counter, or prescription medications such as ibuprofen or naproxen can relieve pain and inflammation.
  4. Corticosteroid injections. A combination of anesthetic and anti-inflammatory medications can be administered via injection into the area where the nerve is pinched. Although these often relieve symptoms, or calm a flare up, their effect is sometimes just temporary.

Surgical Treatment

If the symptoms of carpal tunnel are not relieved by these treatment options, surgical intervention might be necessary. During a 10-15-minute outpatient procedure, pressure on the nerve is decreased by cutting the ligament that forms the top of the tunnel.  There are two standard techniques for this, open and endoscopic.  A discussion with your physician will determine which may be best for you.

After surgery, many patients experience quick symptom relief, however in severe cases the numbness and tingling may takes several months to resolve.  The soreness around the cut may last for several weeks and even a few months, but most people are able to return to their normal activity within a month of surgery.

What is Cubital Tunnel Syndrome?

Cubital tunnel syndrome is a pinched nerve at the elbow and occurs when your “funny-bone nerve”, known as the ulnar nerve, is compressed on the medial (inside) portion of the elbow.

Similar in concept to carpal tunnel, cubital tunnel is typically caused by chronic pressure or stretch being placed on the nerve. This can be positional, leaning on the inside of the elbow, bending the elbow for long periods such as when on the phone.

Symptoms usually consist of:

  • Tingling and/or numbness in the ring and small fingers
  • Pain over inside aspect of elbow
  • Forearm pain
  • Hand weakness in more severe cases

Most people notice this affects them worse at night and often times can wake them up from sleep.

How is Cubital Tunnel Syndrome Diagnosed?

Cubital Tunnel is diagnosed using the following:

  • A thorough examination of the arm
  • A detailed history, that includes your symptoms, medical conditions, activities and prior injuries

X-rays may also be taken to check for deformities about the elbow.  In some cases, electro diagnostic studies (nerve conduction tests) are performed to confirm the diagnosis.

How is Cubital Tunnel Syndrome Treated?

Initial treatments are conservative, and involve decreasing the pressure and stretching of the nerve. They include:

  1. Activity Modification. Avoiding leaning on elbow when sitting at desk or in chairs with armrest. An elbow pad can be helpful with this.  Avoiding prolonged flexion of elbow, such as using an ear piece for phone.
  2. Towel or pillow wrapping. When wrapped around the elbow, a soft bath towel will pad the elbow, and prevent it from full flexion.  This can be especially helpful at night during sleep.
  3. Bracing. Wearing a brace during the day and/or at night takes pressure off the nerve by keeping the elbow straight.
  4. Hand therapy. Stretching and strengthening the muscles of the forearm, wrist, and hand may help decrease pain.
  5. Anti-inflammatory medications. Over-the-counter and prescription medications are used to decrease inflammation and pain.

When symptoms do not respond to conservative treatment options, surgical intervention may be required.

There are several ways to surgically remove the pressure from the nerve. A simple release of the nerve may be sufficient.  In revision surgery or in severe cases moving the nerve to the front of the elbow, and/or removing a part of the bone can be necessary.

Like carpal tunnel, the numbness and tingling may improve quickly or slowly. It may take many months for recovery after surgery. Cubital tunnel symptoms may not totally go away after surgery, especially if symptoms are severe.

What is Basilar Thumb Arthritis?

The basilar joint is located at the base of the thumb where it meets up with the wrist. This joint, is also known as the CMC (carpometacarpal joint) or trapeziometacarpal joint, is a specialized saddle-shaped joint that is formed by a small bone of the wrist (trapezium) and the first bone of the thumb (metacarpal). The saddle shaped joint allows the thumb to have a wide range of motions, including up, down, across the palm, and the ability to pinch. Because it is constantly used when pinching and gripping objects, it is susceptible to degenerative arthritis (osteoarthritis).

Arthritis at the base of the thumb is more commonly seen in women over the age of 40. Common symptoms of basilar thumb osteoarthritis include:

  • Pain at the base of the thumb when pinching or gripping, such as opening jars or turning doorknobs
  • Swelling
  • Tenderness
  • Weakness
  • Loss of motion

The exact cause is unknown, but genetics, previous injuries such as fractures or dislocations, and generalized joint laxity may predispose towards development of this type of arthritis.

How is Basilar Thumb Arthritis Diagnosed?

A patient history including previous injuries to the hand and thumb is obtained.  Activity level, hobbies, and occupation are noted.  A thorough examination of the hand and thumb is performed.  Stability of the thumb CMC joint and stressing of joint assessing for grinding often reproduces the pain.  The next joint above the CMC is also tested, as severe cases can lead to compensatory hyperextension instability of this joint known as the metacarpophalangeal joint (MCP).

X-rays are taken to evaluate the severity of arthritis, and assess neighboring joints for involvement.

How is Basilar Thumb Arthritis Treated?

Treatment is dependent on severity.  Less severe cases are often amenable to non-surgical treatments such as:

  1. Activity modification. Slowing down or stopping movements that produce pain.
  2. Nonsteroidal anti-inflammatory drugs. Over-the-counter and prescription medications that decrease inflammation and pain.
  3. Ice. Icing the joint and painful areas.
  4. Splinting. A splint supports the thumb and takes pressure off the joint. Ideal splints support the base of the thumb, while keeping the wrist and finger free.
  5. Steroid injections. Fast acting anti-inflammatory medication are injected into the arthritic joint to help relieve pain.  Pain relief is often unpredictable, but often several months of relief are possible.

Patients who have failed conservative treatments are candidates for surgical treatment.  A variety of surgical techniques are available that can successfully reduce or eliminate pain. Surgical procedures include removal of arthritic trapezium bone and joint reconstruction (arthroplasty), joint fusion, bone realignment, and even arthroscopy in select cases.

Which procedure is best is determined based on several factors, including severity of disease, occupation, and activity level.

What Are Fingertip Injuries?

Fingertip injuries are one of the more common injuries in the hand as the fingertips are exposed in many of our activities.

A fingertip injury can result in damage to the nail, skin, bone, nailbed, tendons, and the pulp (the padded area of the fingertip). The nerves at the tip of the finger may also be injured.

Fingertip injuries can be caused by many things. They can be crushed, closed in a door, or hit by a hammer. They can also be cut by a kitchen knife, power tools, lawn mower, or another sharp object.

How Are Fingertip Injuries Treated?

Fingertip injuries are one of the more common injuries in the hand as the fingertips are exposed in many of our activities.

A fingertip injury can result in damage to the nail, skin, bone, nailbed, tendons, and the pulp (the padded area of the fingertip). The nerves at the tip of the finger may also be injured.

Fingertip injuries can be caused by many things. They can be crushed, closed in a door, or hit by a hammer. They can also be cut by a kitchen knife, power tools, lawn mower, or another sharp object.

What to Expect During Recovery?

Your finger may be sensitive for many months. Sometimes, you will have altered feeling in the fingertip. The quality and texture of the skin may be different and the nail may heal with some deformity.  Most patients with fingertip injuries will also develop some cold intolerance to that finger.  This is worse during the first year but may persist afterwards.

Hand and wrist pain is very common with numerous causes.  The most common causes of hand pain are traumatic injuries (joint sprains, fractures, and tendon injuries), carpal tunnel syndrome, trigger finger, and arthritis.

One important point regarding hand and finger pain due to an injury is not to assume the injury is just a sprain.  Many significant injuries to the hand and fingers may initially present with just mild pain and maintained motion.

Some red flags that your injury may benefit from evaluation by a hand surgeon:

  • significant mechanism of injury
  • deformity or instability
  • marked swelling
  • bruising
  • pain that worsens 1-2 days after injury
  • persistent pain despite rice, rest/immobilization, OTC meds for a few days

 Just because you can move it, does not mean it is not broken. This unfortunate assumption can lead to delay in both diagnosis and treatment, which can ultimately impair function, as many bad fractures are very difficult to treat after just a few weeks.

What Are Hand Masses and Tumors?

Lumps and bumps in the hand are very common.  Fortunately, most of these are benign (not cancer).  These are generically referred to as tumors.

Tumors can occur on the skin, such as a mole or a wart, or underneath the skin in the soft tissue or even the bone. Because there are so many types of tissue in the hand (e.g. skin, fat, ligaments, tendons, nerves, blood vessels, bone, etc.), there are many types of tumors that can occur.  Depending on the type, a mass or cyst may or may not produce symptoms.

The most common hand masses are:

  • Ganglion cysts are benign fluid-filled masses that are typically seen on the wrist, hand, and fingers.  This is most common mass occurring in the hand.  There are several treatment options for a ganglion cyst, including observation (doing nothing), aspiration (puncturing with a needle) or surgically removing it.
  • Dupuytren’s nodules are hard, visible knots that form due to the thickening of the tissue beneath the skin in the palm of the hand. They are often painless, but may cause discomfort with gripping.  Nodules themselves do not alter function; however, development of a chord may lead to contracture of the finger.
  • Epidermal inclusion cysts are benign and form just underneath the skin where there may have been a cut or puncture. The cyst is filled with keratin, a soft, waxy material.
  • Giant cell tumors of the tendon sheath are benign tumor masses most commonly found on the palmar surface of index, middle, and ring fingers. Over time, some giant cells tumors of the tendon sheath may become symptomatic and need to be excised.

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

How are Tumors of the Hand Diagnosed?

A physical exam and review of your medical history can help to determine the type of hand or wrist tumor you may have.  X-rays might be taken to evaluate the bones, joints and possibly the soft tissue. Further studies such as ultrasound, CT, MRI, or bone scans may be done to help narrow down the diagnosis. A biopsy may be considered confirm diagnoses.

How are Hand Tumors Treated?

Typically, the most successful treatment is removing the tumor with surgery. This allows a pathologist to analyze it and to determine the type of tumor. Often, surgery is done on an outpatient basis.

Some patients may choose to do nothing and simply live with the tumor once they learn that it is non-cancerous. However, if the tumor changes (e.g. skin discoloration, pain, increased size) or if it causes other problems such as numbness or pain from pressure on a nearby nerve, then re-evaluation is recommended.

What Are Retinacular Cysts?

Retinacular cysts are a type of small ganglion cyst found on the palm or base of the finger, the size of a BB.  It arises from the retinaculum or tendon sheath of the finger.  They are firm, and often quite tender, especially with gripping. They can be associated with an underlying tendonitis or trigger finger.  These cysts are benign and easily treated when painful.

How Are Retinacular Cysts Treated?

As retinacular cysts are benign, observation is warranted if non-painful.  Painful retinacular cysts may be treated via aspiration or rupture performed in the office using a small needle and local anethestic. This is often successful.

Cysts that do not resolve with aspiration or that recur may be surgically removed during a quick outpatient procedure where the cyst and small square of tendon sheath are removed. This can be done under local anesthetic or a light sedation.  Light activity is recommended until the sutures are removed around one week.  Recurrence after surgical excision is rare.

What Are Mucous Cysts?

Mucous cysts are a type of small ganglion (fluid filled) cyst found near the end joint of an arthritic finger joint. The cyst is caused by a small bone spur that irritates the lining of the finger joint that causes an outpouching of this lining underneath the skin. They often start as a small firm bump, but may increase in size.  As the cyst gets larger, it may rupture, leaking a clear fluid.  There is usually little pain from the cysts themselves; however, discomfort can be from the underlying arthritis.  In larger, long-standing cysts, the fingernail may develop a ridge deformity.

How Are Mucous Cysts Diagnosed?

The cyst is diagnosed by physical exam, as they have a typical appearance.  X-rays are used to evaluate the joint for arthritis and identify the offending bone spur.  Advanced imaging is rarely needed.

How Are Mucous Cysts Treated?

Most small cysts are treated with simple observation.  It is not recommended to “pop” the cyst as this may lead to an infection of the finger joint.  Surgery is reserved for cysts that are larger in size and at risk for rupture due to the thinning of the overlying skin.

Excision of the cyst is performed with a short outpatient procedure done under either local anesthesia or light sedation.  It is important to remove the bone spur as well as the cyst to prevent recurrence.   The finger is immobilized in a splint for approximately a week, after which the sutures are removed and return to normal activity follows over the next few weeks.

What Is Dupuytren’s Disease?

A condition that affects the fascia – the thick fibrous layer of tissue that lies just underneath the skin.  In patients with Dupuytren’s, the fascia in the palm thickens, and can tighten over time causing, pits, nodules, or cords (thick lines) to develop. This can cause the fingers to pulled inward, towards the palm, resulting in a “Dupuytren’s Contracture.”

The cause of Dupuytren’s disease is unknown; however, there is a strong hereditary component.  It is more common in men over age 40 and people of northern European descent.  The nodules can be uncomfortable in some people, but Dupuytren’s contracture is not typically painful.

The disease is often first noticed by the thickened nodules, but this does not usually affect function.  The severity of disease and its progression is variable.  Some people will have only small lumps or cords, while others will develop a severely bent finger.  It is difficult to predict how the disease will progress.  Most times progression is noted by the inability to lay the hand flat on a table.  As the fingers draw into the palm, it may be more difficult to wear gloves, shake hands, and get hands into pockets.

How Is Dupuytren’s Disease Diagnosed?

The diagnosis is clinical.  Family and medical history, along with physical examination are usually sufficient to diagnose Dupuytren’s disease.  Radiographs may be taken to evaluate the bones and joints for other associated pathology that affects treatment, such as arthritis.

How Are Dupuytren’s Contractures Treated?

With good hand motion and function, mild cases require just observation.  A lump or pit in the palm does not mean treatment is needed, or that the disease will progress to a contracture.

In more severe cases, such as when you are unable to lay the hand flat, various treatment options are available to straighten the finger(s).  These include needles, injectable medicine, or surgery.  Unfortunately, conservative treatments such as bracing and therapy have not been shown effective in treating these more severe cases.

The goal of treatment is to improve finger motion and hand function; however, complete correction may not always happen.  In addition, even with treatment, the disease may also come back.

Not everyone is a candidate for each treatment method, and the most appropriate method is based upon the stage and pattern of disease and the joints involved.  This, along with realistic goals and risks are discussed prior to any treatment.

 

What Are Flexor Tendon Lacerations?

The long flexor tendons attach muscles in the forearm to the finger bones. These structures are responsible for flexing the fingers (pulling them toward the palm). The flexor tendons are responsible for common, everyday movements like gripping objects and making a fist. A cut or injury to the palm side of the forearm or hand can partially or completely lacerate one or more of the flexor tendons. When this happens, any, all, or any combination of the following symptoms may present:

  • Inability to move the wrist, hand and/or fingers
  • Pain
  • Weakness
  • Tenderness

How are Flexor Tendon Injuries Diagnosed?

Any injury or cut to the hand/wrist that results in the inability to move the finger should be evaluated.  Most times a thorough history and physical examination can diagnose these injuries.  X-rays are often used to evaluate bone injuries or foreign bodies in the cut.  MRI or ultrasound studies can be used to confirm diagnoses or in the case of partial injuries

How Are Flexor Tendon Lacerations Treated?

Partial flexor tendon lacerations. When hand and finger function remains intact, partial flexor tendon lacerations may be treated with immobilization—a splint holds the hand, wrist, and forearm in place so the tendons can heal.

Complete flexor tendon lacerations. Surgical intervention is often necessary. A flexor tendon repair is a procedure that uses special sutures and suturing techniques to re-attach the ends of the torn tendons. The procedure is usually done on an outpatient basis. Surgical and recovery time depends on the severity of the injury.

What Are Extensor Tendon Lacerations?

The extensor tendons lie on the back side of the hand and fingers.  They attach muscles in the forearm to the finger bones and have the important job of extending or straightening the fingers. The extensor tendons can be injured sharply with cuts or with crushing type injuries.  When one or more of the tendons are injured, patients may experience the following symptoms:

  • Inability to extend the fingers
  • Pain
  • Weakness

How Are Extensor Tendons Lacerations Diagnosed?

Any injury or cut to the hand/wrist that results in the inability to move the finger should be evaluated.  Most times, a thorough history and physical examination can diagnose these injuries.  X-rays are often used to evaluate bone injuries or foreign bodies in the cut.  MRI or Ultrasound studies can be used to confirm diagnoses or in the case of partial injuries.

How Are Extensor Tendon Lacerations Treated?

Partial tendon tears that do limit finger and hand function may be treated non-surgically—a splint is used to immobilize the fingers, hand, wrist, and arm so the tendons can heal.

Complete tendon injuries often times need to be surgically repaired. An extensor tendon repair is a procedure that uses special sutures and suturing techniques to re-attach the ends of the torn tendons. The procedure is usually done on an outpatient basis. Recovery time depends on the severity of the injury.

What is a Mallet Finger?

Mallet finger occurs when the tendon that straightens the tip of the finger (usually the middle, ring, or small) is torn or ruptured. The injury is typically caused by an object, such as a ball, hitting the tip of the finger. The most noticeable symptoms are drooping of the fingertip and inability to straighten without assistance. Additional symptoms may include pain, swelling, and/or bruising. 

How is a Mallet Finger Diagnosed?

The diagnosis is evident by the appearance of the finger.  However, x-rays are taken to determine if a piece of bone pulled away with the tendon, and to see if joint is aligned.

How is Mallet Finger Treated?

Mallet finger is—in the majority of cases—treated without surgery using a small finger splint. When properly and consistently worn, the splint holds the fingertip straight, which gives the tendon time to heal. After about 8-weeks splinting, the injury is re-evaluated and, depending on the amount of healing that has taken place, the splint may be removed.  Many different types of splints are available, and the “right one” is individualized to the patient.

Surgery is reserved for patients who have a displaced fracture or joint that needs to be realigned.  Alternatively, in rare instances, if it is not feasible to wear the external splint,  a surgery using a small pin to keep the finger straight is performed.

What Are Finger Fractures?

Fourteen finger bones (phalanges) provide the framework for the muscles and tendons that make the hand and fingers move and allow us to grip, grab, and manipulate objects. When one or more of the bones are broken (fractured), it can prevent use of the hand and fingers in a normal manner.

Many people think that a fracture is different from a break, but they are the same. Another misconception is the thought that “it can’t be broken because I can move it”.

Typical symptoms of finger fractures may include:

  • Pain
  • Swelling
  • Bruising
  • Stiffness
  • Deformity

To alleviate symptoms, the fracture must be treated appropriately.

How are Finger Fractures Diagnosed?

Early diagnosis is important in the successful treatment of finger fractures. Clinical evaluation and X-rays are used to diagnose fractures. In some cases, advanced imaging techniques, such as CT scans may be used.

How Are Finger Fractures Treated?

As each finger fracture can be different, treatment is catered to each injury.  Fortunately, most fractures may be treated without surgery. Nonsurgical treatment of stable finger fractures involves the use of a brace or splint to immobilize the bone while it heals.

Surgical treatment may be needed for fractures that are displaced or unstable. The goal of surgery is to align and hold the bone in place while it heals.  This is accomplished using a combination of small pins, screws, plates, or wires.

What is Finger Arthritis?

Each of the fourteen finger joints play an important role in everyday movements like gripping, grabbing, and manipulating objects. Because of this, each is susceptible to disease or injury-related arthritis.

Osteoarthritis (OA) refers to the degeneration of the cartilage and bone of the fingers with age.

Rheumatoid arthritis (RA) is a disease in which the body’s immune system slowly destroys its own cartilage and bone. The finger joints are very commonly affected by RA.

Post-traumatic arthritis (Injury related arthritis) occurs when a fracture extends into the finger joint, damaging the cartilage and causing early onset arthritis.

How is finger Arthritis Diagnosed?

After a history and physical examination, X-rays are taken to evaluate the joints for arthritis or other injuries.  MRI is rarely needed in the routine diagnoses of arthritis.

In cases of rheumatoid arthritis, or other autoimmune diseases (Lupus, psoriatic arthritis) blood work is obtained.

How is Finger Arthritis Treated?

Finger osteoarthritis may be treated using a combination of the following non-surgical treatment options:

  1. Bracing or splinting. Short term immobilization of the joint can decrease pain and inflammation.
  2. Nonsteroidal anti-inflammatory drugs (NSAIDs). Over-the-counter and prescription medications used to decrease inflammation and pain. These come in both pill, and topical forms.
  3. Fast acting medications are injected into the joint to help alleviate pain, swelling, and inflammation that does not respond to less invasive treatments.
  4. Activity Modifications. Altering activities or using adaptive devices can help ease the discomfort caused by arthritis.

Treatment of Rheumatoid Arthritis involves a multi-disciplinary approach.  A rheumatologist is usually involved, and may prescribe medications to help control the rheumatoid disease.

When conservative treatments failed to resolve the symptoms, surgery may be recommended.  As each finger joint performs a different function, surgical options are individualized to the particular finger and joint.  These options can range from simple debridement of bone spurs, to joint replacements and even joint fusions.