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hand

conditions

There are very few dedicated hand surgeons in this country, though most orthopaedic and plastic surgery departments have someone with an interest in hand problems. Generally, an orthopaedic hand surgeon will be more suitable for treating wrist and carpal bone problems while a plastic surgeon is better for soft tissue problems, though there is a great deal of overlap of skills.

The patient with multiple joint arthritis or hand problems that are part of a systemic disease process (eg rheumatoid arthritis) should be referred initially to a rheumatologist, who will also be skilled in steroid injection techniques. Hospitals with a hand surgeon will have a hand therapy service that may accept referrals directly, particularly when splintage or physiotherapy is indicated; cases that they are not happy to manage will be referred to the hand surgeon.

This is compression of the median nerve at the wrist. Most cases are idiopathic. It may occur in pregnancy, thyroid disease, diabetes, and after a wrist fracture.

There is numbness and tingling, usually in the thumb, index and middle fingers, sometimes the ring finger; the little finger is often not affected. There may be pain in the hand and forearm. Symptoms are typically worse at night. They may be improved by shaking the hand or dangling it out of bed.

Except in pregnancy, symptoms tend to get progressively worse. A history of neck problems or a neck injury, particularly if symptoms are bilateral, should make you suspicious of cervical root compression.

Examination

It is useful to compare both sides.

·Appearance ­ wasting of thenar muscles (pad of muscle at the base of the thumb); this occurs in advanced cases only.

·Sensation ­ reduced or altered feeling of thumb, index, middle and ring finger tips. Sensation of the little finger tip is usually normal.

·Power ­ reduced power of thumb abduction. Test by asking the patient to lift the thumb perpendicular to the palm against resistance.

·Tinnel's test: tap firmly over the carpal tunnel. Tingling in the fingers and thumb is a positive test.

·Phalen's test: the patient flops the wrists into a flexed position and holds it for one minute. If symptoms are exacerbated or brought on, test is positive. This is quite sensitive in establishing the diagnosis.

Investigations

Carpal tunnel syndrome is a clinical diagnosis in most cases and investigations are not required unless an underlying cause is suspected (such as hypothyroidism).

If the history and examination are equivocal the patient should be referred to neuro-physiology for nerve conduction studies. There is often a long waiting time for these, and organising them early will minimise

delays.

Differential diagnosis

Compression of median nerve at higher

level; ulnar nerve compression; sensation

altered little and ring-weakness of abductor digiti minimi (fingers spread apart against resistance); cervical root compression

(often bilateral) neurology outside of hand.

Treatment

·Early symptoms: wrist splint at night (see suppliers, opposite page). If there is no improvement, or if there is expected to be a long wait for surgery: steroid injection.

·Established syndrome: surgery

Surgery

Under local anaesthetic ­ 4cm incision on palm. Flexor retinaculum (thick ligament compressing median nerve) is divided. A splint or bulky dressing is applied. Patient needs two weeks off work after operation.

Symptoms are usually resolved. In longstanding cases, progression stops. Serious complications are rare. A tender scar is quite common, and may require massage to desensitise it.

This is thickening of the palmar aponeurosis (fibrous sheet just below the skin); it leads to contractures of the digits. Causes are genetic, or liver disease, or drugs ­ particularly anti-epileptics. The history shows thickening in the palm, progressive contracture of the digits which starts to interfere with activities. The condition is not painful.

Examination

Assess whether there are nodules only or contracture of the digits. Nodules are not an indication for surgery. Check which joints are affected (MCP or PIP joint) and degree of contracture.

Investigations

Not useful at this stage.

When to refer

·Interfering with manual activities

·Rapidly progressive disease ­ PIP joint contractures cause permanent joint stiffness

Surgery

·Fasciectomy ­ diseased tissue is removed

·'Open palm' technique ­ incision in palm not stitched, and heals well in four weeks

·Full thickness skin graft is used when the disease is advanced, involving the skin extensively, or if the disease is aggressive, for instance in a young patient or in recurrent disease.

·Amputation of little finger may be indicated in severe or longstanding contractures.

Surgery usually corrects contractures of the MCP joint, improves contractures of the PIP joint. Diabetic patients often have poorer outcomes. Surgery does not cure the disease, but sets it back ­ it will recur eventually.

Common cystic lumps that arise from a joint or tendon sheath. They contain clear gel. It is thought they are caused by mucoid degeneration of collagen after a minor injury. They are usually painless, develop over a few months, may change in size, rarely interfere with function, but their appearance is undesirable.

Examination

Sites are the wrist, dorsum of the hand, the volar aspect of the finger (flexor sheath ganglion). They are firm; smooth or bosselated; not stuck to the skin; are tethered deeply and are not tender.

Investigations

Not usually required. Beware of large lumps (5cm+) and atypical features such as pain. They could be sarcoma.

Management

·Usually spontaneously resolve in 12 months

·Aspirate1 ­ most require three aspirations over weeks or months (picture 6 shows ganglion after aspiration).

·Surgery is a last resort. It is not a trivial procedure. It is usually done under general anaesthetic. Two-to-three weeks off work are needed and recurrence rate is 30-50 per cent. The scar may be as unsightly as the lump!

The CMC joint is a common site for arthritis. It most frequently presents in middle-aged women. Features are an ache around the base of the thumb that is poorly localised. Pain when opening jars, grasping door handles and knitting. The grip is weak.

Examination

·Tender most around CMC joint

·Crepitus (grating) on grinding joint (pushing / twisting the thumb along its axis)

Investigations

An X-ray is needed of the CMC joint, looking for joint narrowing, osteophytes or irregularity of the joint surface.

Management

The sequence of management is to do simple things first ­ modify activities, splint the thumb and refer to a hand therapist for thenar cone strengthening exercises.

Next stage is steroids ­ a three-month trial of NSAIDS, then try steroid injection into CMC joint. This is often effective, typically gives several months' relief and may be repeated.

Trapeziectomy is indicated if there is little relief after steroid injection. The carpal bone (trapezium ­ circled in picture 2) at the base of the thumb is removed. It is performed under general anaesthetic with a 4cm incision over the snuff box. The plaster cast is on for three weeks and a removable splint for three weeks.

It is effective in relieving pain. The thumb may end up a little shorter, the grip will be weaker and the scar may be tender.

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