Carpal tunnel syndrome is a condition affecting one of the main nerves in the wrist area. The carpal tunnel is a space created by the natural arch of the wrist bones. A thick band called the transverse carpal ligament creates a roof to the tunnel. This means that the size of the tunnel cannot change, as the bones and ligaments act like solid walls. Nine tendons that bend the fingers and thumb and the median nerve pass through the tunnel. The median nerve provides feeling (sensation) to the skin of the thumb, index, and middle fingers, as well as half the ring finger. The nerve also provides the communication line to the muscles at the base of the thumb (thenar muscles).

Some of the symptoms of carpal tunnel syndrome may include:

• Numbness and tingling that is often worse at night
• Waking up at night having to shake hands or hold over the side of the bed
• Fingers feeling swollen or fuzzy
• Dropping objects
• Weak pinch
• Discomfort in wrist, hand, or fingers

Conservative approaches to treatment include splinting, oral anti-inflammatory medications, and corticosteroid injections. If these measures fail to provide relief, outpatient surgery may be necessary. Surgical release of the carpal tunnel ligament is one of the most effective treatments. There are several different surgical techniques to cut the transverse carpal ligament, both open and endoscopic (with the use of a small camera). By opening the ligament, there is more room for the tendons and the nerve to pass through the tunnel without pressure.

The flexor tendons that bend the fingers have a lining on the outside. This lining is called tenosynovium. The tendon and lining are covered by a series of thick, soft tissues called pulleys. The tendon and its lining are designed to glide through the pulleys without friction. The pulleys are similar to how a line is held on a fishing rod. A trigger finger, sometimes referred to as a trigger thumb or stenosing tenosynovitis, can occur when the tendon enlarges or the pulley becomes thicker. Symptoms of trigger finger include:

• Finger pain
• Swelling
• Stiffness
• Locking

In severe cases, the finger may become “locked” in a flexed position.

The goal of treatment for a trigger finger is to reduce or eliminate the swelling and catching/locking, allowing full, painless movement of the finger or thumb. Nonsurgical management includes nighttime splinting, anti-inflammatory medications, and corticosteroid injections, which are effective treatments in most cases. When nonsurgical management fails, surgery may be recommended. The goal of surgery is to open the pulley at the base of the finger through a small incision so that the tendon can glide more freely. Often times the condition may be present in multiple fingers that can be addressed with a single surgery.

Movement in the hand and fingers is controlled by a system of muscles and tendons located in the forearm, wrist, and hand. Tendons connect muscles to bone. When a muscle contracts or tightens, the muscles power the tendons to move our bones. The ability to bend our fingers to make a fist is controlled by the flexor tendons, and the ability to open our fingers is controlled by the extensor tendons.

Most commonly, a flexor tendon injury results from lacerations (cuts). A laceration to the forearm, hand, or wrist can result in injury to the flexor or extensor tendons. When a flexor tendon injury happens, there can be an inability to move the fingers, thumb, or wrist.

If you are worried about a tendon injury, please see a hand surgeon right away. It is often easier to treat these injuries early after injury. Tendon injuries do not heal by themselves and frequently require surgery to put the injured tendon back to its normal position and restore hand function. When surgery is required, a splint and hand therapy may be used after the procedure to protect you and to aid in recovery.

Nerves are the body’s “telephone wiring” system that carries messages between the brain and the rest of the body. Some nerves carry messages from the brain to muscles to make the body move. Other nerves carry messages about pain, pressure, or temperature from the body to the brain. The nerves of the hand, wrist, and forearm carry vital information that enables fine motor function, such as buttoning a shirt. They also transmit sensory feedback giving us our sense of “touch” and allowing us to interact carefully with our environment.

Causes of nerve injury may be either acute or chronic. Nerve injury may occur in association with tendon injury following a laceration (cut) to the hand, wrist, or forearm. Chronic compressive conditions, such as carpal tunnel syndrome, may also lead to irreversible nerve damage if not treated promptly.

Some nerve injuries can get better without help, but some injuries need to be repaired. In acute nerve injuries, where the nerve is cut, the nerve ends may be sewn back together. This often requires the use of microsurgical techniques and an operating microscope for precise repair. In chronic conditions, where the nerve is compressed, the nerve may be carefully decompressed by releasing overlying tight bands, which may include muscle, fascia, or blood vessels. Where there is irreversible nerve damage, nerve or tendon transfers are also options to restore hand and wrist function.

A wrist fracture is a medical term for a broken wrist. The wrist is made up of eight small bones which connect with the two long forearm bones called the radius and ulna. Although a broken wrist can happen in any of these 10 bones, by far the most common bone to break is the radius. This is called a distal radius fracture by hand surgeons.

Some wrist fractures are stable. “Non-displaced” breaks, in which the bones do not move out of place initially, can be stable. Some “displaced” breaks (which need to be put back into the right place, called “reduction” or “setting”) also can be stable enough to treat in a cast or splint. Other fractures are unstable. In unstable fractures, even if the bones are put back into position and a cast is placed, the bone pieces tend to move or shift into a bad position before they solidly heal. This can make the wrist appear crooked and may lead to chronic wrist pain.

Unstable fractures requiring surgery may be fixed with many devices. Pins, screws, plates, rods, or external fixation can all be used. With advances in plate and screw technology, most wrist fractures can be fixed with low-profile wrist plates that allow for immediate wrist motion.

Patients with De Quervain’s tenosynovitis have painful tendons on the thumb side of the wrist. Tendons are rope-like structures that the muscles used to pull the bone. In De Quervain’s tenosynovitis, the tunnel with the tendons run can be narrow. In this condition, hand and thumb motion can cause pain, especially with forceful gripping and twisting. The cause is most likely secondary to repetitive movements, changes in hormones, and swelling. It is very common in mothers with newborns, typically appearing about a month after delivery.

Patients with De Quervain’s tenosynovitis have a feeling of sharp or dull pain and swelling, usually at the base of the thumb or at the wrist. This is a problem that can affect people of all ages. Treatments for this problem include splinting and anti-inflammatory medications or an injection. When these less invasive options have not provided relief, surgery may be recommended to open the tunnel and make room for the tendons

Dupuytren’s Contracture

Dupuytren’s is a disorder of the palm of the hand and the fingers. In the normal hand, there is fibrous tissue called fascia. Fascia covers the:

• Nerves
• Blood vessels
• Muscles
• Tendons

Fascia also stabilizes the skin, and in Dupuytren’s disease, this fascia can become abnormal, and it becomes thicker, forming cords. Most people with Dupuytren’s contracture will also have nodules or bumps in the hand. When they are first noticed, these nodules and cords may not change for a long time. They can have a slow or fast change. Cords and nodules may become bigger and thicker over time. They may begin to bend the finger into a bent position, so the fingers are bent toward the palm. This makes it difficult to fully open the fingers and can become bothersome and limit the use of the hand in many people.

The cause of Dupuytren’s disease is unknown and very complex. Symptoms of Dupuytren’s contracture include lumps, nodules, bands, and cords on the palm side of the hand. These lumps are generally firm and stuck to the skin and can be uncomfortable in some people. However, in most people, Dupuytren’s contracture is not typically a painful disease. They may be first noticed due to difficulty in placing the hand flat on a surface. One may find it more difficult to wash hands, wear gloves, or hold large objects. It’s difficult to predict how the disease will progress. Not all lumps in the palm are Dupuytren’s disease, and not all Dupuytren’s lumps need treatment. Sometimes an ultrasound or MRI may be indicated. For contractures that are bothersome, treatment includes splinting injection and surgery.

A ganglion cyst is a lump at the hand or wrist that occurs near the joints or tendon. It may be described as a mass, a swelling, or a bump. Ganglion cysts are common and are frequently found in common locations, such as on the back of the wrist or near a finger joint. The ganglion cysts may be filled with a clear gel-like fluid, which may cause the cyst to increase or decrease in size; some cysts may disappear completely over time. A ganglion cyst is not cancerous and will not spread to other areas. The cause of ganglion cysts is unknown, but it may be related to tendon irritation, arthritis, or injury. Your ganglion cyst may or not be painful; the cysts are typically oval and round. Sometimes the cysts can cause pain as they push on underlying structures, including tendons, ligaments, and nerves.

The diagnosis of a ganglion cyst is usually based on the location and its appearance. X-rays may be recommended to look for evidence of problems in adjacent joints. Other tests, such as ultrasound or MRI, may be helpful in diagnosing a ganglion cyst. Treatment for ganglion cysts can often be non-surgical. In many cases, the cyst can simply be observed especially if they are painless. Ganglion cysts can disappear spontaneously. Other treatments for a ganglion cyst include splinting and anti-inflammatories, as well as aspiration. Aspiration is when fluid is removed from the cyst to decompress it. The cyst may recur after aspiration. If non-surgical options fail to provide relief or a cyst recurs, surgical excision may be recommended.

A congenital hand difference is a hand that is different than expected at birth. These differences can be congenital, meaning present at birth, or they can be acquired, meaning the person picks up the difference after birth. There are many types of hand differences; some include webbed or fused parts of the hand, curved parts of the arm or hand, extra parts in the hand, missing parts, or parts that are larger or smaller than expected.

Many steps are needed to form an arm and a hand, and there could be any number of factors that affect the developing limb. Some of these differences have genetic causes, but many of these differences occur without a known cause.

Treatment involves a multidisciplinary approach, bringing together hand surgeons, occupational therapists, and prosthetists to help increase the function of a limb with a difference. Examples of surgery include separating webbed fingers to provide more effective grips, the removal of an extra finger that is in the way, and moving the first finger to the thumb position for children who do not have a thumb, which can help facilitate power grips and opposition. Other options include moving tendons and bones to maximize the strength behind a certain movement.