Expert diagnosis and management of common upper limb conditions
The small bones which form the universal joint of the wrist are arranged in an arc. A big strong ligament sits across the front of this arc forming the roof of the carpal tunnel. Through the carpal tunnel, pass the tendons that drive the fingers and thumb together with the main nerve that supplies the thumb side of the hand – this is the median nerve.
Carpal tunnel syndrome results from increased pressure in the carpal tunnel causing pressure on the median nerve. It presents as numbness and tingling on the thumb side of the hand and sometimes weakness in the thumb.
Ageing can cause thickening of the lining of the carpal tunnel and pressure on the nerve, but sustained physical activity or pregnancy can cause thickening around the tendons which also compromise the volume of the carpal tunnel and cause pressure on the nerve.
The hand may go to sleep with sustained activity through the day or, as we tend to sleep with our wrist flexed, this further compromises the carpal tunnel and not infrequently causes waking at night. Splinting can be effective in reducing the wakening. Surgery is sometimes indicated.
Dupuytrens Disease is a condition which affects the tissue just under the skin (the fascia) of the palm of the hand and fingers. The fascia thickens, causing dimpling of the skin and usually presents as a thick nodule or shortened cord in the palm of the hand preventing the fingers from fully straightening.
The contracture most commonly affects the ring and little fingers and is most prevalent in men, diabetics, smokers, people suffering from seizures and those of northern European descent. There is no known cause for this disease.
This condition tends to slowly worsen and evidence suggests that conservative management including massage, stretches, splinting and ultrasound are ineffective in preventing progression. If the band progress to the point where you are unable to flatten your hand against a flat surface, then surgery is likely to be required to remove the diseased tissue. the procedure is called a fasciectomy.
Post-operative physiotherapy is necessary to avoid contracture of the scar tissue and also to restore full range of motion to the fingers. This may include exercises and stretches to restore range of motion, and scar massage and silicon products to soften the scar. Splintage may be required to maintain the correction achieved surgically.
Trigger finger is a common condition caused by the inability of the tendon in the palm of the hand to glide freely within its sheath (protective covering). This is thought to be caused by either thickening of the tendon or narrowing of the sheath due to inflammation.
Work or recreational activities which require repetitive or sustained gripping put pressure on the tendon and sheath at the base of the fingers or thumb. This may irritate the tendon or the sheath which results in thickening of the tissue. Trigger finger is more common in females and most frequently in people between 40-60 years old. It can also occur in toddlers, where it is a painless condition with the thumb becoming fixed in a bent position.
Symptoms usually begin with pain at the base of the finger or thumb with clicking that can worsen after periods of inactivity, and tend to loosen with movement. If the condition progresses the finger or thumb can become locked in a bent position and must be straightened using the opposite hand.
Treatment initially entails limiting the aggravating activities and may involve using a splint to limit movement of the tendon and reduce swelling. This splintage is usually continuous and can be necessary for 6 weeks or longer. Your doctor may also suggest a steroid injection, which is a strong anti-inflammatory, to reduce the swelling. If symptoms persist or if the finger is locked, surgery is recommended. In infants most cases resolve spontaneously, however if not corrected by 3 years of age surgery is advised.
De Quervain's Tenosynovitis
De Quervain's TSV is a painful condition affecting two tendons at the base of the thumb as they travel side by side along the inside of the wrist. They pass through a soft tissue channel or sheath, with the inner walls of the channel producing a slippery fluid to lubricate the tendons as they slide back and forth.
Repetitive or excessive movements may cause the lubrication system to malfunction allowing friction to develop between the tendons of the thumb and the soft tissue sheath. The friction leads to thickening and constriction of the sheath, which interferes with the smooth gliding of the tendons.
Pain over the thumb side of the wrist is the main symptom, and this pain can also radiate down the thumb or up to the forearm. As the friction persists the tendons can start to 'squeak' as they move through the constriction, and is called crepitus. Other specialised tests can be performed by your physiotherapist to confirm the diagnosis, and an ultrasound scan can also provide additional confirmation.
Treatment initially consists of splinting to support the wrist and thumb and allow the tendons to rest and heal. Anti-inflammatory medications, massage, ultrasound and laser may be used to help control the swelling, and as the symptoms settle the splint may be taken off the do light pain-free activities as tolerated. Stretches for the thumb may also be introduced to ensure good glide of the affected tendons, as well as other conditioning exercises.
If symptoms persist, you doctor may suggest a cortisone injection into the irritated tunnel to reduce swelling of the tendons. If conservative measures do not provide a satisfactory outcome, surgery may be necessary.
Osteoarthritis occurs when the smooth cartilage that covers the ends of the bones begins to wear out prematurely. This may be caused from normal wear and tear, and previous injury to the joint. In the hand the joints at the base of the thumb and the small joints of the fingers are particularly susceptible to developing osteoarthritis. The joint at the base of the thumb allows swivelling and pivoting movements and is subject to unusual amounts of stress during gripping.
Symptoms usually start with pain during gripping or pinching activities such as opening jars, holding cutlery, manipulating small objects and turning keys, taps and door handles. Eventually strength will be effected, movement restricted and the joint will begin to look bigger with some obvious deformity.
Your therapist can provide advice on avoiding aggravating activities and how to live with the conditions, as well as suggesting special tools or aids to help perform normal daily activities. A supportive splint, worn during the day (and sometimes at night if needed) may help to support or rest the joint. Treatment to settle the pain and swelling and an exercise programme to ensure that your hand does not become stiff or weak is sometimes helpful and your therapist can advise you on these.
A mallet finger describes deformity where there is an inability to straighten (extend) the last joint of the finger or thumb. This means that the last segment of the finger including the fingernail, droops. The deformity results from the tendon that straightens the joint tearing (avulsing) away from the base of the bone. Sometimes a small chip of bone can be pulled off. This happens when something strikes the tip of the finger and forces it into a bent (flexed) position, such as a cricket ball, but may also happen in a situation where the finger is accidentally driven into something more solid such as tucking the sheet in under a heavy mattress. The initial injury may be surprisingly pain free and may not even be noticed until the deformity becomes apparent.
Fortunately, this tendon does not retract and if the bone is kept in kept in contact with the tendon by splinting in extension for usually six weeks, it will re-attach and restore normal function. Occasionally surgery may be indicated to achieve this in specific circumstances, more often than not, involving fracture or where the diagnosis has been delayed. Your therapist will make a custom fitting thermoplastic splint which is easy to wear and supervise you through the process.