WHAT IS HAND SURGERY?

Hand surgery is a sub-specialty of medicine which deals with diseases of the hand covering the area of the elbow and below.  Hand surgeons have either a Plastic or Orthopedic surgery background.  The hand has a complex and delicate anatomy and extra training and surgical experience is required for surgeons who deal with diseases of the hand.  The purpose of hand surgery is the treatment of a broad range of problems that affect the hand, whether they result from cuts, burns, crushing injuries to the hand, or disease processes. Hand surgery includes procedures that treat traumatic injuries of the hands (such as tendon lacerations, nerve injuries, bone fractures, amputations) congenital deformities, repetitive stress injuries, deformities caused by arthritis and similar disorders affecting the joints, nail problems etc.

The central priority of the hand surgeon is adequate reconstruction of the skin, bone, nerve, tendon, and joint(s) in the hand.  Proper repair of any cuts, tears, or burns in the skin will help to ensure a wound free of infection and will provide cover for the anatomical structures beneath the skin.  Early repair and grafting is an essential component of hand surgery. Nerve repair is important because a delay in reconnecting the nerve fibers may affect the recovery of sensation in the hand.  In some cases, the patient’s hand may require several operations over a period of time to complete the repair.

It is very important any hand injury or disease to be treated by a hand specialist, so the patients will have the best outcome and treatment.  Hand surgeons treat the vast pathology of the hand combining plastic surgery and orthopedic surgery skills.

WHAT IS CARPAL TUNNEL SYNDROME?

Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. In effect, it is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand. Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel and puts pressure on the nerve. When the pressure from the swelling becomes great enough to disturb the way the nerve works, numbness, tingling, and pain may be felt in the hand and fingers.

WHAT CAUSES CARPAL TUNNEL SYNDROME?

Usually the cause is unknown. Pressure on the nerve can happen several ways: swelling of the lining of the flexor tendons, called tenosynovitis; joint dislocations, fractures, and arthritis can narrow the tunnel; and keeping the wrist bent for long periods of time. Fluid retention during pregnancy can cause swelling in the tunnel and symptoms of carpal tunnel syndrome, which often go away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes also can be associated with carpal tunnel syndrome. There may be a combination of causes.

SIGNS AND SYMPTOMS OF CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome symptoms usually include pain, numbness, tingling, or a combination of the three. The numbness or tingling most often takes place in the thumb, index, middle, and ring fingers. The symptoms usually are felt during the night but also may be noticed during daily activities such as driving or reading a newspaper. Patients may sometimes notice a weaker grip, occasional clumsiness, and a tendency to drop things. In severe cases, sensation may be permanently lost and the muscles at the base of the thumb slowly shrink (thenar atrophy), causing difficulty with pinch.

DIAGNOSIS OF CARPAL TUNNEL SYNDROME

A detailed history including medical conditions, how the hands have been used, and whether there were any prior injuries is important. An x-ray may be taken to check for the other causes of the complaints such as arthritis or a fracture. In some cases, laboratory tests may be done if there is a suspected medical condition that is associated with CTS. Electrodiagnostic studies (NCV–nerve conduction velocities and EMG–electromyogram) may be done to confirm the diagnosis of carpal tunnel syndrome as well as to check for other possible nerve problems.

TREATMENT OF CARPAL TUNNEL SYNDROME

Symptoms may often be relieved without surgery. Identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position may help reduce pressure on the nerve. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. A steroid injection into the carpal tunnel may help relieve the symptoms by reducing swelling around the nerve.

When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand. Incisions for this surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve. Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.

Cubital tunnel syndrome is a condition brought on by increased pressure on the ulnar nerve at the elbow. There is a bump of bone on the inner portion of the elbow (medial epicondyle) under which the ulnar nerve passes. At this site, the ulnar nerve lies directly next to the bone and is susceptible to pressure. When the pressure on the nerve becomes great enough to disturb the way the nerve works, then numbness, tingling, and pain may be felt in the elbow, forearm, hand, and/or fingers.

WHAT CAUSES CUBITAL TUNNEL SYNDROME?

Pressure on the ulnar nerve at the elbow can develop in several ways. The nerve is positioned right next to the bone and has very little padding over it, so pressure on this can put pressure on the nerve. For example, if you lean your arm against a table on the inner part of the elbow, your arm may fall asleep and be painful from sustained pressure on the ulnar nerve. If this occurs repetitively, the numbness and pain may be more persistent. In some patients, the ulnar nerve at the elbow clicks back and forth over the bony bump (medial epicondyle) as the elbow is bent and straightened. If this occurs repetitively, the nerve may be significantly irritated.

Additionally, pressure on the ulnar nerve can occur from holding the elbow in a bent position for a long time, which stretches the nerve across the medial epicondyle. Such sustained bending of the elbow may tend to occur during sleep. Sometimes the connective tissue over the nerve becomes thicker, or there may be variations of the muscle structure over the nerve at the elbow that cause pressure on the nerve. Cubital tunnel syndrome occurs when the pressure on the nerve is significant enough, and sustained enough, to disturb the way the ulnar nerve works.

SIGNS AND SYMPTOMS OF CUBITAL TUNNEL SYNDROME

Cubital tunnel syndrome symptoms usually include pain, numbness, and/or tingling. The numbness or tingling most often occurs in the ring and little fingers.

The symptoms are usually felt when there is pressure on the nerve, such as sitting with the elbow on an arm rest, or with repetitive elbow bending and straightening. Often symptoms will be felt when the elbow is held in a bent position for a period of time, such as when holding the phone, or while sleeping. Some patients may notice weakness while pinching, occasional clumsiness, and/or a tendency to drop things. In severe cases, sensation may be lost and the muscles in the hand may lose bulk and strength.

DIAGNOSIS OF CUBITAL TUNNEL SYNDROME

Your physician will assess the pattern and distribution of your symptoms, and examine for muscle weakness, irritability of the nerve to tapping and/or bending of the elbow, and changes in sensation. Other medical conditions may need to be evaluated such as thyroid disease or diabetes. A test called electromyography (EMG) and/or nerve conduction study (NCS) may be done to confirm the diagnosis of cubital tunnel syndrome and stage its severity. This test also checks for other possible nerve problems, such as a pinched nerve in the neck, which may cause similar symptoms.

TREATMENT OF CUBITAL TUNNEL SYNDROME

Symptoms may sometimes be relieved without surgery, particularly if the EMG/NCS testing shows that the pressure on the nerve is minimal. Changing the patterns of elbow use may significantly reduce the pressure on the nerve. Avoiding putting your elbow on hard surfaces may help, or wearing an elbow pad over the ulnar nerve and “funny bone” may help. Keeping the elbow straight at night with a splint also may help. A session with a therapist to learn ways to avoid pressure on the nerve may be needed.

When symptoms are severe or do not improve, surgery may be needed to relieve the pressure on the nerve. Many surgeons will recommend shifting the nerve to the front of the elbow, which relieves pressure and tension on the nerve. The nerve may be placed under a layer of fat, under the muscle, or within the muscle. Some surgeons may recommend trimming the bony bump (medial epicondyle). Following surgery, the recovery will depend on the type of surgery that was performed. Restrictions on lifting and/or elbow movement may be recommended. Therapy may be necessary. The numbness and tingling may improve quickly or slowly, and it may take several months for the strength in the hand and wrist to improve. Cubital tunnel symptoms may not completely resolve after surgery, especially in severe cases.

The large joints in the hand at the base of each finger are known as the metacarpophalangeal (MP, or MCP) joints. They act as complex hinge joints and are important for both power grip and pinch activities. Arthritis is the wearing away of the cartilage at a joint. Cartilage is the coating layer of tissue on the end of a bone that acts as a shock-absorber. Loss of cartilage can lead to joint destruction and a shift in the finger position towards the small finger side, which is called ulnar drift. When arthritis affects the MP joints, the condition is called MP joint arthritis.

CAUSES

The MP joints are often affected by arthritis either from routine wear and tear, an injury, or medical conditions. The most common medical condition causing arthritis at the joint is termed rheumatoid arthritis. Rheumatoid arthritis affects the inner coating of the joint, called the synovium, and can result in the loss of the cartilage between the joints. The cause of rheumatoid arthritis is not known. Other conditions that can cause loss of the cartilage include previous injuries and other medical conditions such as gout, psoriasis, or infection.

DIAGNOSIS

Arthritis may cause pain, loss of motion, swelling, and a joint that appears larger than normal. Also, especially in MP joint arthritis, the fingers can shift. Pain in the joint is made worse by hard use of the hand in gripping and grasping activities. People with arthritis may notice weakness when trying to use their hands. The diagnosis of arthritis is confirmed by taking x-rays. The x-ray shows narrowing of the space between the bones, which is a sign that cartilage has been lost.

TREATMENT

There are many treatments available depending on the amount of pain and loss of function. Medication can be very helpful in relieving pain and preventing worsening joint destruction. Sometimes joint injections of a steroid medication can also help. If medical treatment fails, then surgery can be considered. There are many surgical options.

One option is synovectomy, which is the removal of destructive tissue. Also, since this disease can cause loosening of the tissues around the joint, these tissues can sometimes be tightened to provide relief. If the joint is completely destroyed, then joint replacement or joint fusion are effective surgical options. The joints can be replaced with a silicone implant or metal. Joint replacement is very useful, especially for older or less active individuals. Fusion – or making the joint solid – is an effective treatment of thumb MP arthritis. Problems can occur after any type of surgery, including infection, loosening, or breakage of the artificial joint. Research is continuing to try to improve joint replacement and reconstruction in the hand.

WHAT IS IT?

In a normal joint, cartilage covers the end of the bones and serves as a shock absorber to allow smooth, pain-free movement. In osteoarthritis (OA, or “degenerative arthritis”) the cartilage layer wears out, resulting in direct contact between the bones and producing pain and deformity. One of the most common joints to develop OA in the hand is the base of the thumb. The thumb basal joint, also called the carpometacarpal (CMC) 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.

WHO GETS IT?

Osteoarthritis at the base of the thumb is more commonly seen in women over the age of 40. The exact cause is unknown, but genetics, previous injuries such as fractures or dislocations, and generalized joint laxity may predispose to-wards development of this type of arthritis.

WHAT ARE THE SYMPTOMS AND SIGNS?

The most common symptom is pain at the base of the thumb. The pain can be aggravated by activities that require pinching, such as opening jars, turning door knobs or keys, and writing. Severity can also progress to pain at rest and pain at night. In more severe cases, progressive destruction and mal-alignment of the joint occurs, and a bump develops at the base of the thumb as the metacarpal moves out of the saddle joint. This shift in the joint can cause limited motion and weakness, making pinch difficult.

The next joint above the CMC may compensate by loosening, causing it to bend further back (hyperextension).

HOW IS THE DIAGNOSIS MADE?

The diagnosis is made by history and physical evaluation. Pressure and movement such as twisting will produce pain at the joint. A grinding sensation may also be present at the joint. X-rays are used to confirm the diagnosis, although symptom severity often does not correlate with x-ray findings.

WHAT ARE THE TREATMENT OPTIONS?

Less severe thumb arthritis will usually respond to non-surgical care. Arthritis medication, splinting and limited cortisone injections may help alleviate pain. A hand therapist might provide a variety of rigid and non-rigid splints which can be used while sleeping or during activities.

Patients with advanced disease or who fail non-surgical treatment may be candidates for surgical reconstruction. A variety of surgical techniques are available that can successfully reduce or eliminate pain. Surgical procedures include removal of arthritic bone and joint reconstruction (arthroplasty), joint fusion, bone realignment, and even arthroscopy in select cases. A consultation with Dr. Andreas Skarparis can help to decide the best option for you.

WHAT ARE CONGENITAL HAND DIFFERENCES?

Babies born with hands that are different than the normal hand have a congenital hand difference.

WHAT CAUSES CONGENITAL HAND DIFFERENCES?

The upper limb is formed between four and eight weeks after the sperm and egg unite to form an embryo. The embryo develops an arm bud at four weeks. The tip of the arm bud sends messages to each cell as the upper limb forms. Millions of steps are followed to form a normal arm. Failure of any of these steps to occur can result in a congenital hand difference. Research continues into further understanding of this embryonic process. Some congenital hand differences may occur due to a genetic cause. Many congenital hand differences just occur without an apparent cause.

WHAT ARE DIFFERENT TYPES OF CONGENITAL HAND DIFFERENCES?

One in twenty children is born with some difference from normal, either major or minor. The different groups of congenital hand differences include missing parts of the arm (failure of formation), webbed or fused parts of the hand (failures of separation), extra parts present in the hand (duplication), undergrowth or overgrowth of parts of the hand, or constriction band syndrome.

WHAT ARE COMMON CONGENITAL HAND DIFFERENCES?

The most common congenital hand difference in the Caucasian population is webbed fingers (syndactyly). The most common congenital hand difference in the Asian population is an extra thumb (thumb polydactyly).

WHICH CONGENITAL HAND DIFFERENCE DOES MY CHILD HAVE?

Because there are so many different congenital hand differences, it is important that your child be evaluated by a hand surgery specialist to help determine if any treatment is needed. Some congenital hand differences are associated with genetic disorders or other medical problems. Dr. Andreas Skarparis may request further genetic evaluation by a geneticist, or may request further medical testing by your paediatrician or family physician.

HOW DO PARENTS FEEL IF THEIR CHILD HAS CONGENITAL HAND DIFFERENCES?

Immediately after the birth of a child with a a congenital abnormality, the patents may feel shock, anger and guilt. These are normal emotions. All the dreams of a perfect baby did not take place. Each family member must cope with their feelings. Rarely is there anything parents or doctors could have done differently.

Your newborn doesn’t realise that he or she is different. The baby has all the normal needs of any newborn. The way the baby has formed is normal for him or her, without pain and without a sense of loss. Talk to your physician about support groups or professional help.

CAN CONGENITAL HAND DIFFERENCES BE TREATED?

All babies born with congenital hand differences should be evaluated by a hand specialist to make an individual assessment of the type. Depending on the type of congenital hand difference, treatment may be recommended. For example, webbed fingers are surgically separated. Extra digits can be surgically removed with reconstruction of the remaining digit if necessary. Hand function can be improved if the functions of thumb pinch or finger grasp is compromised. Some congenital hand differences may need therapy to help improve hand function. In some cases, no intervention is necessary.

Patients with De Quervain syndrome have painful tendons on the thumb side of the wrist. Tendons are the ropes that the muscle uses to pull the bone. You can see them on the back of your hand when you straighten your fingers. In De Quervain syndrome, the tunnel (the first extensor compartment) where the tendons run narrows due to the thickening of the soft tissues that make up the tunnel. Hand and thumb motion cause pain, especially with forceful grasping or twisting.

CAUSES

Doctors are not sure what causes De Quervain syndrome. Patients often describe a feeling of inflammation, but studies have shown that the process is not inflammatory. People of all ages get it. When new mothers develop de Quervain syndrome, it typically appears 4 to 6 weeks after delivery. The old theory that it was caused by wringing out cloth diapers has been replaced by concerns about holding the baby, but changes in hormones and swelling seem more probable.

TREATMENTS THAT CAN RELIEVE SYMPTOMS INCLUDE:

• A splint that stops you from moving your thumb and wrist.
• Panadol or aspirin type medications (Ibuprofen).

TREATMENTS THAT ATTEMPT TO CHANGE THE COURSE OF THE DISEASE INCLUDE:

• A cortisone-type of steroid injection into the tendon compartment. It has not been clearly established that these injections change the course of the disease and response to the injection varies.
• Surgery to open the tunnel and make more room for the tendons.

Dupuytren’s disease is an abnormal thickening of the tissue just beneath the skin known as fascia. This thickening occurs in the palm and can extend into the fingers. Firm pits, nodules and cords may develop that can cause the fingers to bend into the palm, in which case it is described as Dupuytren’s contracture. Although the skin may become involved in the process, the deeper structures – such as the tendons – are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).

CAUSES

The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.

SIGNS AND SYMPTOMS

Symptoms of Dupuytren’s disease usually include lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Thick cords may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. These cords cause bending or contractures of the fingers. In many cases, both hands are affected, although the degree of involvement may vary.

The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop. As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets. Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

TREATMENT

In mild cases, especially if hand function is not affected, only observation is needed. For more severe cases, various treatment options are available in order to straighten the finger(s). These options may include collagenase injection, needle aponeurotomy or open surgery.

Collagenase injection is a technique where a small amount of medicine is injected into the Dupuytren’s tissue, weakening it so that the finger can be manipulated manually to make it straighter. Needle aponeurotomy is a method where a needle is placed through the skin and used to cut the Dupuytren’s tissue. Both collagenase injection and needle aponeurotomy are office procedures. Dr. Andreas Skarparis can describe these options in more detail, including potential risks and benefits, to help you decide what treatment method is best for you.

SPECIFIC SURGICAL CONSIDERATIONS INCLUDE THE FOLLOWING:

• The presence of a lump in the palm does not mean that surgery is required or that the disease will progress.
• Correction of finger position is best accomplished with milder contractures that affect the base of the finger. Complete correction sometimes can not be attained, especially of the middle and end joints in the finger.
• Skin grafts are sometimes required to cover open areas in the fingers if the skin is deficient.
• The nerves that provide feeling to the fingertips are often intertwined with the cords.
• Splinting and hand therapy are often required after surgery in order to maximize and maintain the improvement in finger position and function.

Ganglion cysts are very common lumps within the hand and wrist that occur adjacent to joints or tendons. The most common locations are the top of the wrist, the palm side of the wrist, the base of the finger on the palm side, and the top of the end joint of the finger. The ganglion cyst often resembles a water balloon on a stalk and is filled with clear fluid or gel.

CAUSES

The cause of these cysts is unknown although they may form in the presence of joint or tendon irritation or mechanical changes. They occur in patients of all ages.  These cysts may change in size or even disappear completely, and they may or may not be painful. These cysts are not cancerous and will not spread to other areas.

DIAGNOSIS

The diagnosis is usually based on the location of the lump and its appearance. They are usually oval or round and may be soft or very firm. Cysts at the base of the finger on the palm side are typically very firm, pea sized nodules that are tender to applied pressure, such as when gripping. Light will often pass through these lumps, (trans-illumination) and this can assist in the diagnosis. Cysts at the far joint of the finger frequently have an arthritic bone spur associated with them.

TREATMENT

Treatment can often be non-surgical. In many cases, these cysts can simply be observed, especially if they are painless, as they frequently disappear spontaneously. If the cyst becomes painful, limits activity, or is otherwise unacceptable, several treatment options are available. The use of splints and anti-inflammatory medication can be prescribed in order to decrease pain associated with activities. An aspiration can be performed to remove the fluid from the cyst and decompress it. This requires placing a needle into the cyst, which can be performed in most office settings. Aspiration is a very simple procedure, but recurrence of the cyst is common. If non-surgical options fail to provide relief or if the cyst recurs, surgical alternatives are available.

Surgery involves removing the cyst along with a portion of the joint capsule or tendon sheath. In the case of wrist ganglion cysts, both traditional open and arthroscopic techniques usually yield good results. Surgical treatment is generally successful.

What is a fracture?

The hand is made up of many bones that form its supporting framework. This frame acts as a point of attachment for the muscles that make the wrist and fingers move. A fracture occurs when enough force is applied to a bone to break it. When this happens, there is pain, swelling, and decreased use of the injured part. Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to displace or shift. Some fractures occur in the shaft (main body) of the bone, others break the joint surface. Comminuted fractures (bone is shattered into many pieces) usually occur from a high energy force and are often unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin. There is some risk of infection with compound fractures.

How does a fracture affect the hand?

Fractures often take place in the hand. A fracture may cause pain, stiffness, and loss of movement. Some fractures will cause an obvious deformity, such as a crooked finger, but many fractures do not. Because of the close relationship of bones to ligaments and tendons, the hand may be stiff and weak after the fracture heals. Fractures that injure joint surfaces may lead to early arthritis in those joints.

How are hand fractures treated?

Medical evaluation and x-rays are needed. Depending upon the type of fracture, Dr. Andreas Skarparis may recommend one of several treatment methods. A splint or cast may be used to treat a fracture that is not displaced, or to protect a fracture that has been set. Some displaced fractures may need to be set and then held in place with wires or pins without making an incision. This is called closed reduction and internal fixation.Other fractures may need surgery to set the bone (open reduction). Once the bone fragments are set, they are held together with pins, plates, or screws.

Fractures that disrupt the joint surface (articular fractures) usually need to be set more precisely to restore the joint surface as smooth as possible. On occasion, bone may be missing or be so severely crushed that it cannot be repaired. In such cases, a bone graft may be necessary. In this procedure, bone is taken from another part of the body to help provide more stability. Sometimes bone graft substitutes may be used instead of taking bone from another part of the body. Once the fracture has enough stability, motion exercises may be started to try to avoid stiffness.

WHAT TYPES OF RESULTS CAN I EXPECT FROM SURGERY FOR HAND FRACTURES?

Perfect alignment of the bone on x-ray is not always necessary to get good function. A bony lump may appear at the fracture site as the bone heals and is known as a “fracture callus. This is a normal healing process and the lump usually gets smaller over time. Problems with fracture healing include stiffness, shift in position, infection, slow healing, or complete failure to heal. Smoking has been shown to slow fracture healing. Fractures in children occasionally affect future growth of that bone. A hand therapy program with splints and exercises may be recommended by Dr. Skarparis to speed and improve the recovery process.

WHAT IS ARTHRITIS?

Arthritis means an inflamed joint. A joint normally consists of two cartilage-covered bone surfaces that glide smoothly against one another. When joints become inflamed, the joint swells and does not move smoothly. Over time, the gliding surface wears out. There are many types of arthritis. Rheumatoid arthritis is just one type. Wear and tear arthritis (osteoarthritis), gouty arthritis, and psoriatic arthritis are three other common types. Rheumatoid Arthritis is considered a systemic disease. That is, it can affect many parts of the body. Patients often awaken with stiff and swollen joints. Early on, many patients feel tired. Two thirds of patients with rheumatoid arthritis have wrist and hand problems.

RHEUMATOID ARTHRITIS OF THE HAND

Rheumatoid arthritis affects the cells that lubricate and line joints. This tissue – synovium – becomes inflamed and swollen. The swollen tissues stretch supporting structures of the joints such as ligaments and tendons. As the support structures stretch out, the joints become deformed and unstable. The joint cartilage and bone erode. Often the joints feel hot and look red. Rheumatoid arthritis of the hand is most common in the wrist and knuckles. The disease is symmetric, thus what occurs in one hand usually occurs in the other.

SIGNS AND SYMPTOMS OF RHEUMATOID ARTHRITIS OF THE HAND

While stiffness, swelling, and pain are symptoms common to all forms of arthritis, there are some symptoms that are classic features of rheumatoid arthritis. They are:

• Firm nodules along fingers or the elbow
• Soft lump on the back of the hand that moves as the fingers straighten
• Angulation or collapse of fingers
• Sudden inability to straighten or bend a finger because of a tendon rupture
• Deformity in which the middle finger joint becomes bent (Boutonniere deformity)
• Deformity where the end of the finger is bent and the middle joint over extends (Swan-neck deformity)
• Prominent bones in the wrist

In addition, patients with rheumatoid arthritis often have problems with numbness and tingling in their hand (Carpal Tunnel Syndrome) because the swelling of the tendons causes pressure on the adjacent nerve. They may make a squeaky sound as they move joints (crepitus) and sometimes the joints snap or lock because of the swelling.

HOW ARTHRITIS IS DIAGNOSED

The diagnosis of rheumatoid arthritis is made based on clinical examination, x-rays, and lab tests. Dr. Andreas Skarparis will ask questions about your symptoms and how the disease has affected your activities. Rheumatoid arthritis may have a hereditary component, thus doctor will ask whether other family members have had rheumatoid arthritis or symptoms similar to yours. Dr. Skarparis will do a detailed examination of your hands. The clinical appearance helps to diagnose the specific type of arthritis. X-rays are often helpful; certain findings are characteristic for rheumatoid arthritis. These findings include swelling of non-bony structures, joint space narrowing, decreased bone density, and erosions near joints. There are several blood tests that are often ordered to confirm the clinical diagnosis. These are the rheumatoid factor, sedimentation rate and sometimes the anti-CCP (cyclic citrullinated peptide). MRI – a special imaging study – has also been used to help confirm the diagnosis.

TREATMENT OF RHEUMATOID ARTHRITIS

Treatment for rheumatoid arthritis aims to decrease inflammation, relieve pain and maintain function. While there is no cure for rheumatoid arthritis, medications are available that slow the progression of the disease.

The hand surgeon will provide instruction on how to use your hands in ways that help relieve pain and protect joints. Dr. Skarparis also can provide exercises, splints, and adaptive devices to help you cope with activities of daily living.

Rheumatoid arthritis can be a progressive disease. Surgical interventions need to be appropriately timed in order to maximize function and minimize deformity. In certain cases, preventive surgery may be recommended. Preventative surgery may include removing nodules, decreasing pressure on joints and tendons by removing inflamed tissue, or removing bone spurs that may rub on tendons or ligaments. If a tendon ruptures, a hand surgeon may be able to repair the tendon with a tendon transfer or graft.

There are several types of procedures to treat joints affected by rheumatoid arthritis, including removal of inflamed joint lining, joint replacements, and joint fusions. The specific procedure(s) chosen depends on many factors. These factors include the particular joints involved, the degree of damage present, and the condition of surrounding joints.  One of the most important factors in deciding the most appropriate surgical procedure is the needs of the patient. There are often many ways to treat hand deformities in rheumatoid arthritis. Hand surgeon can help you decide on the most appropriate treatment for you.

WHAT IS TRIGGER FINGER OR STENOSING TENOSYNOVITIS?

Stenosing tenosynovitis, commonly known as “trigger finger” or “trigger thumb”, involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys.

Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb. When the tendon catches, it produces irritation and more swelling of the pulley. This causes a vicious cycle of triggering and thickening of the pulley. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend.

WHAT CAUSES TRIGGER FINGER / STENOSING TENOSYNOVITIS?

Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.

SIGNS AND SYMPTOMS OF TRIGGER FINGER / STENOSING TENOSYNOVITIS

Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb, where they join the palm. This area is often tender to local pressure. A nodule may sometimes be found in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints.

TREATMENT OF TRIGGER FINGER / STENOSING TENOSYNOVITIS

The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. The wearing of a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may also include changing activities to reduce swelling. An injection of steroid into the area around the tendon and pulley is often effective in relieving the trigger finger/thumb.

If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use.