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Gold, incentives and meh

Advances in surgery for hand conditions

GP Dr Stefan Cembrowicz and Mr Donald Sammut discuss the broad range

of problems and how they are best managed

A GP quizzes an expert to take a topical issue beyond the textbook

Managing common hand conditions

What are commonest conditions referred to you?

Most are degenerative. Tendons and joints are prone to wear and tear. They need surgery to undo contractures, like Dupuytren's disease, or blockages such as trigger finger, or to repair or even replace joints. The most dramatic degenerative disease is rheumatoid arthritis.

The incidence of severe destruction of architecture in rheumatoid disease is diminishing because medical regimes are much more effective. Surgeons who treat rheumatoid hands will tell you severely deformed, ulnar-deviated fingers are becoming less common. I have a particular interest in reconstruction after trauma and in congenital hand problems.

What is the best current management of the common conditions?

Carpal tunnel syndrome is the most common of the many nerve compressions that occur in the upper limb. This involves compression of the median nerve in the carpus just past the wrist. Steroid injections can be used to treat milder forms. This thins the synovial membrane around the tendons that share the tunnel with the nerve, easing compression of the nerve.

But this treatment only gives temporary help or no help at all to patients with severe symptoms.

It is unwise to repeat injections too many times because steroids will cause atrophy of other important structures such as tendons. The mainstay of treatment is surgical release under local anaesthetic. Despite the arrival of endoscopic techniques, release is still most commonly performed as an open technique.

Dupuytren's disease is a common benign condition where fibrous tumours form in the hand. Gradually, as the tumours extend and expand, they constrict and contract the fingers so the patient is unable to fully straighten them. Many factors have been implicated but few have withstood statistical analysis. Heredity is the only definite aetiological factor. You are much more likely to inherit the tendency if you have a strong Celtic bloodline. It is much more aggressive and appears at a much younger age in parts of Scotland and Scandinavia. Further south in Europe it presents as a much more benign condition and in countries like India is virtually unheard of.

What therapies have been tried for

Dupuytren's disease?

Surgery is the mainstay of treatment. The indication is any contracture that prevents the fingers from straightening fully.

If a patient is unable to lay the hand flat then there is an indication for surgery that is more urgent if the proximal interphalangeal (PIP) joint, rather than the metacarpophangeal (MP) joint is involved.

Many other treatments have been tried, largely along the lines of trying to get fibroblasts to develop more slowly and not differentiate into these nodule-forming cell lines. Anti-mitotic agents such as

5-flurouracil have been injected locally but results are inconclusive.

Other non-medical techniques have achieved some popularity, such as an external fixation of the finger that is gradually winched out so the finger becomes straighter. By and large these do not produce dramatic improvements and should perhaps be reserved for patients who will not stand surgery or have relatively mild disease.

A newer approach involves minimal surgery, by small stabs in the palm to try to divide the fibrous cords that are bringing the fingers down. This is popular in France and has even been marketed in this country, with patients travelling there for treatment.

We should be guarded about this technique: it is only suitable for people with very discrete bands that can be felt through the skin and therefore addressed directly with a mini scalpel. Also there is an incidence of nerve division that can be avoided with open surgery. The treatment of Dupuytren's disease is essentially surgical, preferably by open methods and should be early enough to avoid secondary changes such as joint contractures.

How do you deal with trigger fingers?

Trigger fingers arise because tendons run in very restricted sheaths where there is no spare space. Segments of sheaths are reinforced into pulleys. If you have an area of degeneration in the tendon, this heals with a scar, effectively a nodule. The tendon tends to be tight where the nodule impinges on a pulley. As you flex and extend your finger, the nodule is forced backwards and forwards through the pulley and there is a toggle effect as the nodule is shoehorned through the narrow space.

Treatment is to inject it if it is mild, so the nodule shrinks, or to release surgically the restricting effect of the pulley.

Should ganglia be treated surgically?

Ganglia are a manifestation of weakness in a joint or tendon sheath. The probable mechanism of formation is the joint capsule or sheath wears, fluid leaks out and forms a cyst. The ganglion in itself is not significant but the wear and tear that produced it may be.

This might be a sign of wrist instability, of wear and tear or synovitis in the sheath. If you remove the ganglion it may reform since the original cause has not been addressed.

A hand surgeon should see ganglia at the back of the carpus because a small percentage of these patients will have a mild wrist instability. They are also unattractive in an area constantly on display. Treatment is essentially surgical.

Many advocate bursting them, either by direct trauma or by using a needle. Hitting them with a heavy object is unwise since the ganglia frequently recur and are then more difficult to remove radically. Injection of steroids has little logic to commend it.

Surgery to remove the ganglion and trace its origin down to the sheath or joint is most effective.

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