Carpal tunnel syndrome
Carpal tunnel syndrome is a common condition affecting the hand and usually presents as tingling and/or loss of sensation over the thumb, index and middle fingers. Symptoms occasionally can be severe enough to wake you up at night. Repetitive activities such as holding the phone, using a steering wheel and typing can trigger the symptoms. The condition is caused by compression of the median nerve as it enters from the wrist into the hand. In some patients there can be an associated problem such as compression of the nerve in the neck which can mimic the symptoms of carpal tunnel syndrome.
Assessment by a hand surgeon would help identify the diagnosis. In certain instances, patients are referred for special tests following the assessment, aimed at assessing the nerve to confirm the diagnosis. Once the diagnosis is confirmed, your hand surgeon will discuss treatment options which include non-surgical options such as splints, hand therapy, and steroid injections. In cases of severe nerve compression, the hand surgeon may wish to offer surgery, performed under local anaesthesia with the patient fully awake, as first line of treatment. Please read the blog section for further information.
Trigger finger and thumb
Trigger digit is described as a sensation of clicking in the palm due to tightness of a passage for the tendon in the palm, called the “pulley.” Tendon of the individual finger and the thumb passes through the pulley, and in normal circumstances the tendon glides through the tunnel without much resistance. In case of triggering, the space around the tendon along the course of the pulley gets narrow thereby not allowing the tendon to glide smoothly. In initial stages, triggering is intermittent and one can straighten the finger from a bent position with the other hand. In extreme conditions, triggering can result in the finger being stuck in a bent position, requiring an urgent visit to the hand surgeon.
Treatment for trigger digit or thumb can be non-surgical in the initial stages. This involves a trial of over the counter anti-inflammatories, splints and a steroid injection. It is advisable not to have repeated injections around the pulley as there is a risk of tendon rupture. In cases of failure of alleviation of symptoms with a trial of non-surgical methods, one can opt for surgery by a specialist hand surgeon. Surgery is done under local anaesthesia as a day case procedure, patient fully awake.
Dupuytren’s contracture is disorder of the hand due to the thickening of the layer of a tissue, called the fibrous tissue located immediately beneath the skin. This results in the finger(s) being drawn closely to the palm. Although the little and ring fingers are affected the most, Dupuytren’s can affect any finger, and even the thumb. The cause of this condition is not clearly known. As a general rule, Dupuytren’s contracture does not cause pain in the hand. However, in early stages some patients can present with painful and tender lump in the palm which usually does not need any surgical treatment.
As the condition progresses, the finger(s) curls into the palm and cannot be straightened. In advanced stages, patients complain of difficulty washing their face; struggling to wear gloves during winter; IT professionals find it difficult to use the computer mouse and keyboard and musicians find it awkward to play the instrument. As the saying goes “one size does not fit all,” treatment of Dupuytren’s varies from individual to individual. This largely depends on the stage of the disease, part of the finger involved, and last but not the least patients’ preference. Please read the blog section for further information.
Base of the thumb arthritis
The thumb accounts for a significant proportion of function in the hand and loss of function due to pain is highly noticeable. The base of the thumb joint often referred as basal joint is a complex joint made of total of five joints, the main joint is located between the trapezium (one of the small bone of the wrist) and the metacarpal (long bone of the thumb). Basal joint arthritis is present in up to 60% of adults over the age of 65 and is one of the commonest cause of pain around the base of the thumb. Fortunately, everyone with this condition does not need surgery. However, careful evaluation by a specialist hand surgeon is necessary to exclude several other causes of pain around the base of the thumb.
Treatment of basal joint arthritis depends on the stage of the arthritis, occupation and age of the patient. Often patients are offered non-operative measures in the early stages of arthritis. These include thumb wrap splint and hand therapy aimed at strengthening the muscles surrounding the basal joint and “offloading” the joint. Patients who do not respond to these interventions can be offered a course steroid injection into the basal joint. Patients who have failed to respond non-surgical measures can be offered surgery, and procedure can be tailored to their individual needs. Please read the blog section for further information.
Cubital tunnel syndrome
This is a condition caused by the compression of the ulnar nerve around the elbow where it passes close to the ‘funny bone’. Patients usually present with altered sensation or feeling of “electric shocks” along the little and ring finger. Like carpal tunnel syndrome, symptoms are aggravated by activities such as holding the phone, steering wheel and playing certain musical instruments. Symptoms should be distinguished from nerve compression in the neck and compression of the ulnar nerve at the level of wrist. If unsure of the diagnosis, the hand surgeon would order special tests such as MRI scan and “needle examination” of the ulnar nerve.
Once the diagnosis is established, a trial of non-surgical measures such as activity modification and splints aimed at avoiding a bent posture of the elbow are recommended. Occasionally, when patients present with severe pain, steroid injection can be administered around the elbow to reduce any associated inflammation of the nerve. In case of failure of alleviation of symptoms one can consider surgical release of the ulnar nerve around the elbow, performed as a day case procedure.
De Quervain’s tenosynovitis
De Quervains tenosynovitis is a painful condition around the base of the thumb extending along the wrist and into the forearm. This is caused due to tightness and inflammation along the tendons responsible for movements of the thumb and wrist. The cause of this condition is not known, however, overuse of the wrist is thought to be a contributing factor. Although the diagnosis is usually straightforward, it can mimic several other causes of painful base of the thumb and wrist.
Treatment options of this condition are usually non-surgical. Activity modification, careful use of over the counter anti-inflammatories and resting the wrist in a splint remains the first line of treatment. If these interventions fail to improve the symptoms, steroid injection around the tendon should ease the pain. After a course of treatment with non-surgical options, should symptoms not settle fully or they recur, one could consider surgery. This is performed under local anaesthesia, with patient fully awake. During surgery, the hand surgeon releases the tightness around the tendons so that the tendons can move freely along the wrist.