The information outlined below on common hand conditions is provided as a guide only and it is not intended to be comprehensive. Discussion with Ms Moon is important to answer any questions that you may have. For information about any additional hand and wrist conditions not featured within the site, please contact us for more information.

Common Hand Conditions

Arthritis

Terminal finger joint arthritis

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What is it?

The terminal joint of the finger is called the distal interphalangeal joint (DIPJ) (see diagram). Osteoarthritis often affects these joints, and can also affect the joint at the base of the thumb (Basal thumb arthritis). Osteoarthritis is loss of the smooth cartilage surface covering the ends of the bones in the joints. The cartilage becomes thin and rough, and the bone ends can rub together. Osteoarthritis can develop at any age, but usually appears after the age of 45. It may run in families.

What are the symptoms?

• Pain
• Swelling
• Deformity
• Stiffness
• Loss of function

Many peoples notice small bony bumps on the back of the joint. These are osteophytes, which are bony swellings associated with an osteoarthritic joint. In the hand they are called Heberden's Nodes.

Many people with osteoarthritis of these joints have very little pain. Even though the joints may become lumpy and bent, the hands usually continue to work quite well.

What is the treatment?

Episodes of pain, redness and swelling frequently settle spontaneously over some weeks or months, and can be managed by avoiding painful activities (if possible), simple painkillers, anti-inflammatory gels or anti-inflammatory medication. Steroid injections are sometimes given.

Surgery can be used to fuse (stiffen permanently) a joint that is persistently painful, but the potential benefit needs to be balanced against the loss of movement. The joint is usually fused in a straight or slightly bent position.

There are various surgical techniques used to obtain fusion and your surgeon will explain the technique he or she plans to use for you. After the surgery you may need to wear a splint to support and protect the joint for several weeks.



Arthritis at the base of the thumb

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What is it?

The universal joint at the base of the thumb, between the metacarpal and trapezium bones, often becomes arthritic as people get older. It is osteoarthritis, which is loss of the smooth cartilage surface covering the ends of the bones in the joints. The cartilage becomes thin and rough, and the bone ends can rub together.

Osteoarthritis can develop at any age, but usually appears after the age of 45. It may run in families, and it sometimes follows a fracture involving the joint many years before.

Arthritis of the basal joint of the thumb is common in women and rather less common in men. X-rays show it is present in about 25% of women over the age of 55, but many people with arthritis of this joint have no significant pain.

What are the symptoms?

1. Pain at the base of the thumb, aggravated by thumb use.

2. Tenderness if you press on the base of the thumb.

3. Difficulty with tasks such as opening jars, turning a key in the lock etc.

4. Stiffness of the thumb and some loss of ability to open the thumb away from the hand.

5. In advanced cases, there is a bump at the base of the thumb and the middle thumb joint may hyperextend, giving a zigzag appearance.

What is the treatment?

The options for treatment include:


1. Avoiding activities that cause pain, if possible.

2. Analgesic and/or anti-inflammatory medication. A pharmacist or your family doctor can advise.

3. Using a splint to support the thumb and wrist. Rigid splints (metal or plastic) are effective but make thumb use difficult. A flexible neoprene rubber support is more practicable.

4. Steroid injection improves pain in many cases, though the effect may wear off over time. The risks of injection are small, but it very occasionally causes some thinning or colour change in the skin at the site of injection. Improvement may occur within a few days of injection, but often takes several weeks to be effective. The injection can be repeated if needed.

5. Surgery is a last resort, as the symptoms often stabilise over the long term and can be controlled by the non-surgical treatments above. There are various operations that can be performed to treat this condition. These are listed below:
a. Osteotomy, which means cutting and realigning the metacarpal bone next to the arthritic joint.

b. Removal of the trapezium which is removal of the bone at the bottom of the thumb, which forms one surface of the arthritic joint, sometimes combined with reconstruction of the ligaments.

c. Fusion of the joint, so that it no longer moves.

 d. Joint replacement, as in a hip replacement.

e. Denervation, which means cutting small nerve branches that transmit pain from the arthritic joint. 

Removal of the trapezium is the most commonly performed operation. Ms Moon will advise you on the best options for your thumb.

Carpal Tunnel Syndrome

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What is it?

Carpal tunnel syndrome (CTS) is a condition where the median nerve is compressed where it passes through a short tunnel at the wrist. The tunnel contains the tendons that bend the fingers and thumb as well as the nerve (see diagram). CTS commonly affects women in middle age but can occur at any age in either sex. CTS can occur with pregnancy, diabetes, thyroid problems, rheumatoid arthritis and other less common conditions, but most sufferers have none of these. CTS may be associated with swelling in the tunnel which may be caused by inflammation of the tendons, a fracture of the wrist, wrist arthritis and other less common conditions. In most cases, the cause is not identifiable.



What are the symptoms?

The main symptom is altered feeling in the hand, affecting the thumb index, middle and ring fingers; it is unusual for the little finger to be involved. Many people describe the altered feeling as tingling. Tingling is often worse at night or first thing in the morning. It may be provoked by activities that involve gripping an object, for example a mobile telephone or newspaper, especially if the hand is elevated. In the early stages the symptoms of tingling intermittent and sensation will return to normal. If the condition worsens, the altered feeling may become continuous, with numbness in the fingers and thumb together with weakness and wasting of the muscles at the base of the thumb. Sufferers often described a feeling of clumsiness and drop objects easily. CTS may be associated with pain in the wrist and forearm.

In some cases, nerve conduction tests are needed to confirm the diagnosis. Blood tests and x-rays are sometimes required.

What is the treatment?

Non-surgical treatments include the use of splints, especially at night, and steroid injection into the carpal tunnel. CTS occurring in pregnancy often resolves after the baby is born.

Surgery is frequently required. The operation involves opening the roof of the tunnel to reduce the pressure on the nerve (see diagram: the roof of the carpal tunnel is called the transverse carpal ligament). The most common method involves an incision over the tunnel at the wrist, opening the roof under direct vision. In an alternative keyhole method (endoscopic release) the roof is opened with instruments inserted through one or two small incisions. The outcomes of the two techniques are similar and your surgeon can discuss the most appropriate method. The surgery may be performed under local anaesthesia, regional anaesthesia (injected at the shoulder to numb the entire arm) or general anaesthesia.

The outcome is usually a satisfactory resolution of the symptoms. Night pain and tingling usually disappear within a few days. In severe cases, improvement of constant numbness and muscle weakness may be slow or incomplete. It generally takes about three months to regain full strength and a fully comfortable scar, but the hand can be used for light activities from the day of surgery.

Cubital Tunnel Syndrome

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What is it?

Cubital tunnel syndrome is compression or irritation of the ulnar nerve in a tunnel on the inside of the elbow (where your 'funny bone' is). The ulnar nerve provides sensation to the little finger and part of the ring finger, and power to the small muscles within the hand.

What are the causes?

Most cases arise without an obvious cause, but the tunnel can be narrowed by arthritis of the elbow joint or by an old injury.

What are the symptoms?

Numbness or tingling of the little and ring fingers are usually the earliest symptom. It is frequently intermittent, but may later become constant. Often the symptoms can be provoked by leaning on the elbow or holding the elbow in a bent position (e.g. on the telephone). Sleeping with the elbow habitually bent can also aggravate the symptoms.

In the later stages, the numbness is constant and the hand becomes weak. There may be visible loss of muscle bulk in severe cases, particularly noticeable on the back of the hand between the thumb and first finger, with loss of strength and dexterity.

Investigations may include x-rays of the elbow and nerve conduction studies.

What is the treatment?

Avoid or modify any provocative activity where appropriate. For example, wear a headset for using the telephone; avoid leaning on the inside of the elbows or wear protective pads. Excessive bending of the elbow at night can be minimised by a folded towel wrapped around the elbow, or by a splint provided by a therapist. These manoeuvres may be curative in early cases.

Surgery to decompress the nerve is required in severe cases, or in those that do not respond to the non-surgical treatments above. Surgery frequently improves the numbness, but its chief objective is to prevent the progressive muscle weakness and wasting that tends to occur in severe untreated cases. Several operations are used, including simple opening of the roof of the tunnel (decompression), moving the nerve into a new location at the front of the elbow (transposition) and widening the tunnel by removing some of its bony floor (medial epicondylectomy). Your surgeon can advise on the technique most appropriate to your problem.



What is the outcome?

The outcome depends upon the severity of the compression being treated. Numbness frequently improves, though the improvement may be slow. Surgery generally prevents worsening of the muscle weakness, but improvements in muscle strength are often slow and incomplete.

In the mild cases you can expect there to be full resolution of symptoms in most cases, the more severe the case the less predictable the long term outcome in regard to the nerve function fully recovering. Your surgeon and therapist should discuss the potential outcome with you.

Dupuytren's Contracture

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What is it?

Dupuytren’s contracture (also referred to as Dupuytren's disease) is a common condition that usually arises in middle age or later and is more common in men than women. Firm nodules appear in the ligaments just beneath the skin of the palm of the hand, and in some cases they extend to form cords that can prevent the finger straightening completely. The nodules and cords may be associated with small pits in the skin. Nodules over the back of the finger knuckles (Garrod's knuckle pads) and lumps on the soles of the feet are seen in some people with Dupuytren's disease.

Why does it occur?

The cause is unknown, but it is more common in Northern Europe than elsewhere and it often runs in families. Dupuytren's disease may be associated with diabetes, smoking and high alcohol consumption, but many affected people have none of these. It does not appear to be associated with manual work. It occasionally appears after injury to the hand or wrist, or after surgery to these areas.

What are the symptoms?

Dupuytren's disease begins with nodules in the palm, often in line with the ring finger. The nodules are sometimes uncomfortable on pressure in the early stages, but the discomfort almost always improves over time. In about one affected person out of every three, the nodules extend to form cords that pull the finger towards the palm and prevent it straightening fully. Without treatment, one or more fingers may become fixed in a bent position. The web between thumb and index finger is sometimes narrowed. Contracture of fingers is usually slow, occurring over months and years rather than weeks.



What is the treatment?

There is no cure. Surgery can usually make bent fingers straighter, though not always fully straight; it cannot eradicate the disease. Over the longer term, Dupuytren's disease may reappear in operated digits or in previously uninvolved areas of the hand. But most patients who require surgery need only one operation during their lifetime. Published evidence does not support the use of radiotherapy. Injection of collagenase is helpful in some cases.

Surgery is not needed if fingers can be straightened fully. It is likely to be helpful when it has become impossible to put the hand flat on a table, and should be discussed with a surgeon at this stage. The surgeon can advise on the type of operation best suited to the individual, and on its timing. The procedure maybe carried out under local, regional (injection of local anaesthetic at the shoulder) or general anaesthetic.

Surgical options are:

1. Fasciotomy. The contracted cord of Dupuytren’s disease is simply cut in the palm, in the finger or in both, using a small knife or a needle (needle fasciotomy).
2. Segmental fasciectomy. Short segments of the cord are removed through one or more small incisions.
3. Regional fasciectomy. Through a single longer incision, the entire cord is removed. This is the most common operation.
4. Dermofasciectomy. The cord is removed together with the overlying skin and the skin is replaced with a graft taken usually from the upper arm or groin. This procedure is usually undertaken for recurrent disease, or for extensive disease in a younger individual.

After surgery, the hand may be fitted with a splint to be worn at night and a hand therapist may help with rehabilitation of the hand. The recovery is variable with regard to the degree of improvement achieved and the time to achieve the final position. The final outcome is dependent on many factors including the extent and behaviour of the disease itself and the type of surgery required.

Hand and Wrist Fractures

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What is a fracture ?

A fracture (break) can occur in any of the bones in the hand. Each bone is named (See diagram). The fracture can be simple (two fragments) or comminuted (many fragments). The fracture can be closed (no break in the skin) or open (compound) where there is a break in the skin over the fracture. Fractures can be complicated by the involvement of the joints at either end of the bone (Intra-articular fracture). Fractures may occur as part of a more complex injury where there has been damage to other tissues such as tendons, nerves and blood vessels.

What is the cause ?

Fractures occur because a force is applied to the bone which is strong enough to break it. The site and pattern (shape) of the fracture depends on how that force has been generated and applied. So how the injury happened is important information and your doctor will ask you about this. Some people may be embarassed by what happened to them but it is important to be truthful as treatment can be influenced by how the injury occurred.

What are the symptoms ?

Most patients will have pain, swelling, bruising and loss of movement. There may be numbness or pins and needles. There may be an obvious deformity of the fingers or thumb. In an open fracture there will be a wound.

What should you do ?

If you suspect you or someone you are with may have a fracture in the hand you should: Remove any rings or jewelleryElevate the handCover any woundAttend for further medical care either at a hospital A&E department or your own GP.

What is the treatment ?

The aim of treatment is to restore function to the hand as quickly as possible. There may be a number of people involved in your care as part of the Hand Surgery team. This includes doctors, nurses and hand therapists.

When you are first seen an assessment will be made of the injury. This includes a physical examination and x-rays. Treatment will depend on the nature of the fracture sustained this includes assessment of which bone is involved, the site of the fracture in the bone, the amount of any deformity, whether more than one bone has been broken and any other associated injuries that may have occurred. The treating doctor will also take other factors (handedness, occupation, medical conditions) into account when discussing the best form of treatment for each patient. Your treating surgeon will discuss the options for treatment and advise on the most appropriate for you. Other investigations, such as a CT scan, ultrasound or MRI scan, may be required before a definitve plan of treatment is made.

The initial treatment is likely to be given in an accident and emergency department. The hand will be rested which may require the hand to be immobilised in a plaster of paris splint and elevated using a sling. It is important to elevate the hand to help reduce the swelling. Rings on any of the fingers of the injured hand should be removed.

Many fractures can be treated without an operation. The simplest treatment may be to move the fingers straight away. A splint may be needed for a period of time. It is likely that a programme of exercises will be given for you to follow.

Some fractures will be treated by an operation. The details of the operation will be provided by your surgeon, this includes whether the procedure will be performed under local, regional or general anaesthetic. The operations can be grouped into two methods:

In the first method the fracture is reduced into a satisfactory position by manipulation and the hand is then either splinted or thin pins (k-wires) inserted through the skin and across the fracture to hold it in the right position. Occasionally a special splint is made to produce traction of the fracture. In the second method the fracture is exposed by an incision through the skin. The fracture is reduced by direct vision and then held in place with either pins (k-wires), screws, and plates.

In an open fracture and occasionally in a closed fracture an external fixator may be used to hold the bones. An external fixator is a frame on the outside of the skin connected to the bones by pins (k-wires) inserted through the skin.

There are many different ways implants can be used and this will depend on the configuration of the fracture and any associated soft tissue injuries. Your surgeon will explain which method has been used and why. Pins are usually removed. This is done either in the clinic or, if they are left under the skin, by a second small operation. Screws and plates may need removing and your surgeon will be able to advise you in regard to this.

Following any operation you are likely to be in a plaster of paris or splint. You will receive instruction on any exercises to do. The rehabilitation will be carried out by a Hand Therapist.

What is the outcome?

The outcome following any fracture depends on many factors including how you and your hand responds to the injury. The outcome will generally be worse in those injuries which involve joints and if other structures such as tendons and nerves have been damaged. You should ask the team treating you to explain what the expected outcome may be and how long it may take to get there. The final outcome may not be easy to predict as there are so many variables that can affect the end result and the surgeon's and therapist's view may change during the treatment.

As a general rule fractures in the hand take 6-8 weeks to unite. The strength in the hand takes approximately 3-4 months to return to near normal levels. The fingers and thumb will often be quite stiff to begin with, after a fracture, but with exercise and use this problem gradually settles.

Many patients notice symptoms of aching associated with cold damp conditions, with heavy use and if the injured area is accidentally knocked or jarred. These symptoms usually improve with time and do not interfere with normal use of the hand. Some fractures may result, in the long term, in arthritis; this particularly applies to fractures involving the joint surface. Your surgeon or therapist will be able to advise on whether you have such a risk.

Ganglion cyst

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What is it?

Ganglion cysts are the commonest type of swelling the hand. They contain a thick clear liquid called synovial fluid, which is the body's lubricant in joints and in the tunnels through which some tendons run. Although ganglion cysts can arise from any joint or tendon tunnel, there are four common locations in the hand and wrist - in the middle of the back of the wrist, on the front of the wrist at the base of the thumb, at the base of a finger on the palmar side, and on the back of an end joint of a finger.

What is the cause?

A ganglion cyst arises when the synovial fluid leaks out of a joint or tendon tunnel and forms a swelling beneath the skin. The cause of the leak is generally unknown.

What are the symptoms?

A swelling becomes noticeable. It may or may not be painful.

How is the diagnosis made?

The diagnosis is usually straightforward as ganglion cysts tend to be smooth and round, change in size from time to time and occur at characteristic locations in the hand and wrist. If the diagnosis is uncertain, x-rays or scans may be helpful.

What is the treatment?

Ganglion cysts are harmless and can safely be left alone. Many disappear spontaneously and many others cause little trouble. For ganglion cysts in general, the possibilities for treatment:

1. Explanation, reassurance, wait to see if the cyst disappears spontaneously
2. Removal of the liquid contents of the cyst with a needle (aspiration) under local anaesthetic
3. Surgical removal of the cyst

For any individual cyst, the recommendations for treatment will depend on the location of the cyst and on the symptoms that it is causing.

Dorsal wrist ganglion cyst. Typically occurs in young adults and often disappears spontaneously. Aspiration can reduce the swelling but it often returns. The risk of recurrence after surgery is around 10%, and problems after surgery include persistent pain, loss of wrist movement and painful trapping of nerve branches in the scar.

Palmar wrist ganglion cyst. May occur in young adults, but also seen in association with wrist arthritis in older individuals. Aspiration may be useful, but care is needed as the cyst is often close to the artery at the wrist (where you can feel the pulse). The risk of recurrence after surgery is around 30%, and problems after surgery include persistent pain, loss of wrist movement and trapping of nerve branches in the scar. For these reasons, many surgeons advise against operation for these cysts.

Flexor tendon sheath ganglion cyst. Typically occurs in young adults, causing pain when gripping and feeling like a dried pea sitting on the tendon sheath at the base of the finger. Puncture of the cyst with a fine needle can disperse it – like puncturing a balloon - and fewer than half return. Persistent cysts can be removed surgically and the risk of recurrence is small.

Dorsal digital ganglion cyst. Usually in middle-aged or older people and associated with wearing out of the end joint of a finger. Pressure from the cyst may cause a furrow in the fingernail. Occasionally the cyst fluid leaks through the thin overlying skin from time to time. The risk of recurrence after surgery is around 10%, and problems after surgery include infection, stiffness and pain from the worn out joint.

Microsurgery

Microsurgery is a technique whereby surgery is performed on very small structures utilizing intra-operative magnification (with an operating microscope), very fine instruments and sutures, and specific techniques.

Microsurgery allows for very precise surgery on small objects, which would not be possible with the unaided eye. In the hand and wrist, blood vessels and nerves are commonly no larger than one to two millimeters in diameter (equivalent to the thickness of a pencil lead). By employing contemporary microsurgery techniques, instruments, and the operating room microscope, we can increase the prognosis for successful blood vessel and nerve repairs, as well as digital replantation.

Nerve Damage / Nerve Compression

A nerve injury can occur when the finger, hand, or wrist is cut, overstretched, crushed or burned. Symptoms include numbness and difficulty moving the affected area.

Treatment depends on the severity of the injury, and may include rest, immobilization, physical therapy, and in some cases, surgery.

Causes of hand & wrist nerve damage Injury to nerves in the hand or wrist is often caused by trauma, such as the area being cut, overstretched, crushed or burned, damaging the nerve or nerve ending.

Symptoms of hand & nerve damage

The nerves located in the hand and wrist affect motor and sensory functions. If a nerve in the hand or wrist is cut, severed, stretched, or otherwise damaged, it will not function properly (or at all).

Damage to motor nerves can cause weakness, twitching, and paralysis in the hand, wrist and arm. Sensory nerve damage symptoms include pain, numbness, tingling, increased sensitivity, burning, and problems positioning the hand correctly.

Similarly, when a nerve in the hand or wrist is pinched or compressed (such as in carpal tunnel syndrome), there can be pain and loss of feeling through the hand and fingers.

Treatment of hand & nerve damage

If the nerve is pinched or compressed, surgery may be able to release the nerve and restore functionality, depending on the severity of damage and how long the nerve was compressed.

Sports Injuries

Injuries caused playing tennis or skiing may not seem serious at first, but left untreated, can put athletes of all levels on the sidelines for months—and have a lasting effect on function. Sports-related hand injuries range from these apparently "minor" problems to those whose gravity is immediately evident, such as a fracture or dislocation to the wrist or finger joint. As noted, those associated with a specific activity or activities include:

Skierʼs thumb (sometimes referred to as Game Keeperʼs Thumb), a highenergy injury in which the ligament at the base of the thumb is torn. This occurs when the patient falls forward and the thumb is bent backward.

Tennis elbow, in which a tendon on the outside of the forearm fails and begins to tear away from the bone. While this injury originates near the elbow, pain may extend down the forearm.

Golferʼs elbow, similar to tennis elbow, this injury affects the tendon on the inner side of the elbow.

De Quervainʼs tendonitis, inflammation of the tendon that runs down the forearm, through the wrist, to the thumb. This injury is brought on by many activities including using a keyboard, golfing and fishing (particularly flyfishing).

Wrist fractures, which can occur with many athletic activities; one of the most frequently seen injuries in beginning rollerbladers or snowboarders who tend to fall backward on their hands.

• Jamming a finger, or "basketball finger," occurs during any athletic activity where the hand comes in contact with a ball. This injury ranges in severity from a sprain to a simple dislocation that may be corrected when the patient pulls on the finger to a more complex, serious dislocation or fracture of the joint.

• Tendonitis may also be seen in weight lifters with poor technique or in those who attempt to lift too much weight too soon. Similarly, beginning yoga practitioners may develop the problem by attempting postures that place too much stress on tendons that are not yet ready to accommodate it.

Regardless of the severity of the injury, prompt attention from an orthopedist can make an important difference in the patientʼs long-term recovery and ability to continue participating in sports. If the hand, wrist or finger is fractured, failure to get timely treatment will eventually result in arthritis and considerable pain.

Treatments

Fortunately, many of the injuries described can be treated with simple procedures that yield excellent long-term results. Jammed fingers that are dislocated can be relocated, that is, put back in proper alignment, often in the orthopaedic surgeonʼs office. If the finger is broken, the joint may need to be immobilized. A program of rehabilitation exercises helps patients prevent or reduce debilitating stiffness.

Skierʼs thumb can be treated with a simple procedure in which the ligament is reattached. This operation is done under regional anesthesia (the arm is numbed) and requires no hospitalization. Repairing this ligament is crucial since the thumb is responsible for about 50% of hand function, specifically for any movement that requires opposition, such as holding a cup or using a key. As with jammed fingers, timely treatment is essential. At three months following the injury, an orthopaedic surgeon may not be able to reattach the ligament and more complex surgery may be necessary.

Tendon injuries that result from persistent gripping of a racquet or golf club (or poor technique) or from numerous repetitions during weight lifting may be treated in a variety of ways. The affected joint may need to be immobilized. Therapy to decrease inflammation and swelling can include ultrasound treatments or iontophoresis. In the latter procedure cortisone cream is spread on the skin covering the affected area. A small electric charge is applied to get the cream to sink in and treat the muscles and tendons below. A cortisone injection or other antiinflammatory medication may also be needed. If these measures fail, surgery to open the tunnel or sheath that the tendon runs through, or in some cases remove the diseased tissue, may provide relief. Following surgery and recovery the patient receives instruction on how to alter their activities to avoid recurrence of the injury.

Treatment for fractures of the wrist or finger joints varies with the severity of the break. High energy, severe impact fractures, are often the most complex and may be comminuted (the bone is broken into many fragments.) These fractures may also be open, that is, the bone pierces the skin, and can carry a greater risk of infection. A range of treatments are available to patients. In the case of severe and otherwise untreatable fractures, including those not treated promptly, joint reconstruction or replacement may be viable options.

Tendon/Ligament Repair

If any of the tendons in your hand are damaged, surgery may be needed to repair them and help restore movement in the affected fingers or thumb.

What are tendons?

Tendons are tough cords of tissue that connect muscles to bones. When a group of muscles contract (tighten), the attached tendons will pull on certain bones, allowing you to make a wide range of movements.

There are two groups of tendons in the hand:

▪ extensor tendons – which run from the forearm, across the back of your hand to your fingers and thumb, allowing you to straighten your fingers and thumb

▪ flexor tendons – which run from your forearm, through your wrist and across the palm of your hand, allowing you to bend your fingers.

Surgery can often be carried out to repair damage to both these groups of tendons.

When hand tendon repair is needed Hand tendon repair is carried out when one or more tendons in your hand rupture or are cut, leading to loss of normal hand movements.

If your extensor tendons are damaged, you'll be unable to straighten one or more fingers. If your flexor tendons are damaged, you'll be unable to bend one or more fingers. Tendon damage can also cause pain and inflammation (swelling) in your hand.

In some cases, damage to the extensor tendons can be treated without the need for surgery, using a rigid support called a splint thatʼs worn around the hand.

Common causes of tendon injuries include:

• cuts – cuts across the back or palm of your hand can result in injury to your tendons

• sports injuries – extensor tendons can rupture when stubbing a finger, such as trying to catch a ball; flexor tendons can occasionally be pulled off the bone when grabbing an opponent's jersey, such as in rugby; and the pulleys holding flexor tendons can rupture during activities that involve lots of strenuous gripping, such as rock climbing

• bites – animal and human bites can cause tendon damage, and a person may damage their hand tendon after punching another person in the teeth

• crushing injuries – jamming a finger in a door or crushing the hand in a car accident can divide or rupture a tendon

• rheumatoid arthritis – rheumatoid arthritis can cause tendons to become inflamed, which in severe cases can lead to tendons rupturing

Tendon repair surgery

Tendon repair may involve the surgeon making an incision in your wrist, hand or finger so they can locate the ends of the divided tendon and stitch them together. Extensor tendons are easier to reach, so repairing them is relatively straightforward. Depending on the type of injury, it may be possible to repair extensor tendons in an accident and emergency (A&E) department using a local anaesthetic to numb the affected area.

Repairing flexor tendons is more challenging because the flexor tendon system is more complex. Flexor tendon repair usually needs to be carried out under either general anaesthetic or regional anaesthetic (where the whole arm is numbed) in an operating theatre by an experienced plastic or orthopaedic surgeon who specialises in hand surgery.

Recovering from surgery

Both types of tendon surgery require a lengthy period of recovery (rehabilitation) because the repaired tendons will be weak until the ends heal together.

Depending on the location of the injury, it can take up to three months for the repaired tendon to regain its previous strength.

Rehabilitation involves protecting your tendons from overuse using a hand splint. You'll usually need to wear a hand splint for several weeks after surgery.

You'll also need to perform hand exercises regularly during your recovery to stop the repaired tendons sticking to nearby tissue, which can prevent you from being able to fully move your hand.

When you can return to work will depend on your job. Light activities can often be resumed after 6-8 weeks and heavy activities and sport after 10-12 weeks. Read more about recovering from hand tendon repair.

Post Operation

After an extensor tendon repair you should have a working finger or thumb, but you may not regain full movement. The outcome is often better when the injury is a clean cut to the tendon, rather than one that involves crushing or damage to the bones and joints.

A flexor tendon injury is generally more serious because they're often put under more strain than extensor tendons. After a flexor tendon repair, it's quite common for some fingers to not regain full movement. However, the tendon repair will still give a better result than not having surgery.

In some cases, complications develop after surgery, such as infection or the repaired tendon snapping or sticking to nearby tissue. In these circumstances, further treatment may be required.

Trigger Finger/Thumb

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What is it?

Trigger finger is a painful condition in which a finger or thumb clicks or locks as it is bent towards the palm.



What is the cause?

Thickening of the mouth of a tendon tunnel leads to roughness of the tendon surface, and the tendon then catches in the tunnel mouth. People with insulin-dependent diabetes are especially prone to triggering, but most trigger digits occur in people without diabetes. Triggering occasionally appears to start after an injury such as a knock on the hand. There is little evidence that it is caused by work activities, but the pain can certainly be aggravated by hand use at work, at home, in the garden or at sport. Triggering is sometimes due to tendon nodules in people known to have rheumatoid arthritis. It is not caused by osteoarthritis.

What are the symptoms?

1. Pain at the site of triggering in the palm (fingers) or on the palm surface of the thumb at the middle joint, usually in a person over the age of 40.
2. Tenderness if you press on the site of pain.
3. Clicking of the digit during movement, or locking in a bent position, often worse on waking in the morning. The digit may need to be straightened with pressure from the opposite hand.
4. Stiffness, especially in trigger thumb where movement at the end joint is reduced.

What is the treatment?

Trigger finger and trigger thumb are not harmful, but can be a really painful nuisance. Some mild cases recover over a few weeks without treatment. The options for treatment are:

1. Avoiding activities that cause pain, if possible

2. Using a small splint to hold the finger or thumb straight at night. A splint can be fitted by a hand therapist, but even a lollipop stick held on with tape can be used as a temporary splint. Holding the finger straight at night keeps the roughened segment of tendon in the tunnel and makes it smoother.

3. Steroid injection relieves the pain and triggering in about 70% of cases, but the success rate is lower in people with diabetes. The risks of injection are small, but it very occasionally causes some thinning or colour change in the skin at the site of injection. Improvement may occur within a few days of injection, but may take several weeks. A second injection is sometimes helpful, but surgery may be needed if triggering persists.

4. Percutaneous trigger finger release with a needle. Some surgeons prefer to release the tight mouth of the tunnel using a needle inserted under a local anaesthetic injection, but others feel that open surgery is more effective. The needle method is not suitable for all cases and all digits.

5. Surgical decompression of the tendon tunnel. The anaesthetic may be local (injected under the skin at the site of operation) regional (injected in the armpit to numb the entire arm) or a general anaesthetic. Through a small incision, and protecting nerves that lie near the tunnel, the surgeon widens the mouth of the tendon tunnel by slitting its roof. The wound will require a small dressing for 10-14 days, but light use of the hand is possible from the day of surgery and active use of the digit will aid the recovery of movement. Pain relief is usually rapid. Although the scar may be red and tender for several weeks, it is seldom troublesome in the longer term. Recurrence of triggering after surgery is uncommon.

Wrist Injuries

Your wrist is made up of eight small bones known as carpals. They support a tube that runs through your wrist. That tube, called the carpal tunnel, has tendons and a nerve inside. It is covered by a ligament, which holds it in place.

Wrist pain is common. Repetitive motion can damage your wrist. Everyday activities like typing, racquet sports or sewing can cause pain, or even carpal tunnel syndrome. Wrist pain with bruising and swelling can be a sign of injury. The signs of a possible fracture include misshapen joints and inability to move your wrist. Some wrist fractures are a result of osteoporosis.

Other common causes of pain are

• Sprains and strains
• Tendinitis
• Arthritis
• Gout and pseudogout

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