Hand

Hand Pain and Problems

Anatomy of the hand

The hand is composed of many different bones, muscles, and ligaments that allow for a large amount of movement and dexterity. There are three major types of bones in the hand itself, including the following:

• Phalanges. The 14 bones that are found in the fingers of each hand and also in the toes of each foot. Each finger has three phalanges (the distal, middle, and proximal); the thumb only has two.

• Metacarpal bones. The five bones that compose the middle part of the hand.

• Carpal bones. The eight bones that create the wrist. The carpal bones are connected to two bones of the arm, the ulnar bone and the radius bone.

Numerous muscles, ligaments, and sheaths can be found within the hand. The muscles are the structures that can contract, allowing movement of the bones in the hand. The ligaments are fibrous tissues that help bind together the joints in the hand. The sheaths are tubular structures that surround part of the fingers.

What are some common hand problems?

There are many common hand problems that can interfere with activities of daily living (ADLs), including the following:

• Arthritis. Arthritis is joint inflammation and can occur in multiple areas of the hand and wrist. The pain associated with arthritis may be from many different sources, including inflammation of the following:

  • Synovial membrane (joint lining). A clear, sticky fluid that is released by the synovial membrane and acts as a lubricant for joints and tendons.

  • Tendons. The tough cords of tissue that connect muscles to bones.

  • Ligaments. A white, shiny, flexible band of fibrous tissue that binds joints together and connects various bones and cartilage.

  Osteoarthritis, a degenerative joint disease, is the most common type of arthritis in older people. It is a slow-progressing disease that primarily affects the hands and the large weight-bearing joints of the body, such as the knees and hips. Osteoarthritis in the hands or hips may run in families, or be caused by injuries, overuse, muscle strain, or fatigue.

  Heberden nodes, abnormal enlargements of the bone or cartilage--about the size of a pea or smaller--may occur in the finger joints, and may be aggravated by osteoarthritis.

• Carpal tunnel syndrome. Carpal tunnel syndrome is a condition in which the median nerve is compressed as it passes through the carpal tunnel in the wrist, a narrow confined space. Since the median nerve provides sensory and motor functions to the thumb and three middle fingers, many symptoms may result.
  
  The following are the most common symptoms for carpal tunnel syndrome. However, each individual may experience symptoms differently. Symptoms may include:

  • Difficulty gripping objects with the hand(s)

  • Pain and/or numbness in the hand(s)

  • "Pins and needles" feeling in the fingers

  • Swollen feeling in the fingers

  • Burning or tingling in the fingers, especially the thumb and the index and middle fingers

  The symptoms of carpal tunnel syndrome may resemble other conditions such as tendonitis, bursitis, or rheumatoid arthritis. Always consult your physician for a diagnosis.

  Treatment may include:

  • Splinting of the hand (to help prevent wrist movement and decrease the compression of the nerves inside the tunnel)

  • Oral or injected (into the carpal tunnel space) anti-inflammatory medications (to reduce the swelling)

  • Surgery (to relieve compression on the nerves in the carpal tunnel)

  • Changing position of a computer keyboard, or other ergonomic changes

• Ganglion cysts. Soft, fluid-filled cysts can develop on the front or back of the hand for no apparent reason. These are called ganglion cysts - the most common, benign (noncancerous), soft-tissue tumor of the hand and wrist.

  The following are the most common symptoms for ganglion cysts. However, each individual may experience symptoms differently. Symptoms may include:

  • Wrist pain that is aggravated with repeated use or irritation

  • A slow growing, localized swelling, with mild aching and weakness in the wrist

  • An apparent cyst that is smooth, firm, rounded, and/or tender

  The symptoms of ganglion cysts may resemble other medical conditions or problems. Always consult your physician for a diagnosis.

  Initially, when the cyst is small and painless, treatment is usually not necessary. Only when the cyst begins to grow and interferes with the functionality of the hand is treatment usually necessary. Treatment may include:

  • Rest

  • Splinting

  • Nonsteroidal anti-inflammatory medications

  • Aspiration

  • Cortisone injections

  • Surgery

• Tendon problems. Two major problems associated with tendons include tendonitis and tenosynovitis. Tendonitis, inflammation of a tendon (the tough cords of tissue that connect muscles to bones) can affect any tendon, but is most commonly seen in the wrist and fingers. When the tendons become irritated, swelling, pain, and discomfort will occur.

  Tenosynovitis is the inflammation of the lining of the tendon sheaths which enclose the tendons. The tendon sheath is usually the site which becomes inflamed, but both the sheath and the tendon can become inflamed simultaneously. The cause of tenosynovitis is often unknown, but usually strain, overuse, injury, or excessive exercise may be implicated. Tendonitis may also be related to disease (i.e., diabetes or rheumatoid arthritis).

  Common tendon disorders include the following:

  • Lateral epicondylitis (commonly known as tennis elbow). A condition characterized by pain in the back side of the elbow and forearm, along the thumb side when the arm is alongside the body with the thumb turned away. The pain is caused by damage to the tendons that bend the wrist backward away from the palm.

  • Medial epicondylitis (commonly known as golfer's or baseball elbow). A condition characterized by pain from the elbow to the wrist on the palm side of the forearm. The pain is caused by damage to the tendons that bend the wrist toward the palm.

  • Rotator cuff tendonitis. A shoulder disorder characterized by the inflammation of the shoulder capsule and related tendons.

  • DeQuervain's tenosynovitis. The most common type of tenosynovitis disorder characterized by the tendon sheath swelling in the tendons of the thumb.

  • Trigger finger/trigger thumb. A tenosynovitis condition in which the tendon sheath becomes inflamed and thickened, thus preventing the smooth extension or flexion of the finger/thumb. The finger/thumb may lock or "trigger" suddenly.

  Treatment for most tendon problems may include:

  • Activity modification

  • Ice

  • Splinting or immobilization

  • Steroid injections

  • Nonsteroidal anti-inflammatory medications

  • Surgery

Overview of Hand Surgery

What is hand surgery?

Hand surgery is a broad term that incorporates a vast array of different types of surgery on the hand. Plastic surgeons who perform hand surgery attempt to restore not only the function of the hand, but try to maximize the cosmetic appearance of the hand, as well. Surgery on the hand may be done for many reasons, including, but not limited to, the following:

• Trauma to the hand

• Rheumatic changes to the structures in the hand

• Congenital (present at birth) deformities

• Infections

What are the different types of hand surgery?

Many different types of surgeries can be performed on the hand, depending on the underlying cause of the problem. The following is a brief overview of some of the types of surgery that may be performed:

• Skin grafts. Skin grafts involve replacing or attaching skin to a part of the hand that has missing skin. The most common type of injury requiring a skin graft is fingertip amputations or injuries. Skin grafts are performed by taking a piece of healthy skin from another area of the body (called the donor site) and attaching it to the needed area.

• Skin flaps. A skin flap is similar to a skin graft, in which a part of the skin is taken from another area. However, with a skin flap, the skin that is retrieved has its own blood supply. The section of skin used includes the underlying blood vessels, fat, and muscles. Flaps may be used when an area that is missing the skin does not have a good supply of blood because of the location, damage to the vessels, or extensive damage to the tissue.

• Closed reduction and fixation. This technique may be used when there is a fracture in part of the hand, including the fingers. This type of surgery attempts to realign the fractured bone and then immobilize the area during the healing phase. Immobilization can be done with internal fixtures, such as with wires, rods, splints, and casts.

• Tendon repair. Tendons are the fibers that attach muscle to bone. Repair of tendons remains a surgical challenge because of the structure of the tendon. Tendon injuries can occur due to infection, trauma, or spontaneous rupture. Repair of a tendon may be classified as primary, delayed primary, or secondary. Primary repair of an acute injury is usually completed within 24 hours of the injury. Delayed primary repair is usually performed a few days after the injury, but while there is still an opening in the skin from the wound. Secondary repairs may occur two to five weeks or longer after the injury. Primary repairs usually involve direct surgical correction of the injury, while secondary repairs may include tendon grafts (inserting tendons from other areas of the body in place of the damaged tendon) or other more complex procedures.

• Nerve repairs. There are three main nerves that innervate the hand, including the ulnar nerve, the median nerve, and the radial nerve. Damage to these nerves from injury may result in decreased ability to move the hand and experience feeling. Some nerve injuries may heal on their own, while others require surgery. Overall, about three to six weeks after the injury is the best time for nerve repairs that are associated with other, more complicated, injuries. Surgery to investigate a damaged nerve that is not complicated by other injuries is usually performed early after the trauma, to increase the likelihood of a full recovery. If severed, the nerve may be repaired by reattaching it directly to the other end of the nerve, or by using a nerve graft (inserting nerves from other areas of the body in place of the damaged nerve) to repair the damaged section.

• Fasciotomy. This procedure is performed to help treat compartment syndromes. A compartment is a three-dimensional anatomic space in the body that is surrounded by fascia or bone and contains arteries, nerves, and veins. A compartment syndrome is a condition that arises when there is an increase in intracompartmental tissue pressure within a space in the body, usually caused by trauma, which can interfere with the circulation to the body tissues and destroy function. In the hand, a compartment syndrome may lead to severe and increasing pain, muscle weakness, and, eventually, a change in color of the fingers or nailbeds.
  Fasciotomy is the treatment for the early stage of compartment syndromes. Surgical incisions are placed in the hand or arm to allow a release of the pressures that are increasing inside the body. Any tissue inside the body that is already damaged may be removed at this time. A fasciotomy will help prevent a further decrease in function and damage of the affected extremity.

• Surgical drainage and/or debridement. Our hands are constantly at risk for injury and infection. Infections of the hand are a common reason people seek treatment. The treatment for infections to the hand may include rest, use of heat, elevation, antibiotics, and surgery. Surgical drainage may be used if there is an abscess in the hand to help remove the collection of pus. Debridement, or cleansing of a wound to prevent further infection and to help promote healing, may be used if the infection or wound is severe.

• Joint replacement. This type of surgery, also called arthroplasty, may be used in people with severe arthritis of the hand. This involves replacing a joint that has been destroyed by the disease process with an artificial joint. This artificial joint may be made out of metal, plastic, silicone rubber, or the patient's own body tissue (such as a tendon).

• Replantation. This type of surgery replaces fingers or hands that have inadvertently been amputated, usually by some type of trauma. Replantation uses microsurgery, which is an intricate and precise surgery that is performed under magnification. Some severe injuries may require more than one surgery for optimal recovery.

What are the risks of hand surgery?

Most surgery carries the risks of anesthesia and bleeding. Additional risks associated with surgery depend greatly on the type of surgery being performed and may include, but are not limited to, the following:

• Infection

• Incomplete healing

• Loss of feeling or movement of the hand or fingers

• Blood clots may form