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December 2011

December 30, 2011

Hand Surgery #5: Ganglion Cysts

The most common tumor of the hand is not a cancer.  It's a ganglion cyst....

 

Anatomy

Bones meet at joints.  Joints are lubricated by synovial fluid.  Escape of the fluid is prevented by a joint capsule.

Likewise, tendons are lubricated and nourished by synovial fluid from their surrounding tenosynovium.

 

Pathology - The Ganglion Cyst

If some of that synovial fluid escapes from a joint or tendon sheath, it stimulates an encompassing scar.  The resulting fluid-filled sac is a ganglion cyst.

Gangions are common, and they are benign (meaning that they are not cancer).

A ganglion can arise from almost any joint or tendon sheath in the wrist and hand, but they are most common at the back of the wrist, on the front of the wrist below the thumb, along the palmar surfaces of the proximal fingers, and at the last knuckles of the fingers (the distal interphalangeal joints, which are just proximal to the nails; ganglion cysts at the distal interphalangeal joints are sometimes erroneously referred to as mucous cysts).

 

Causes

The exact cause of ganglions remains uncertain. Why does the fluid leak in the first place?  The most popular theory is that ganglions form after trauma or degeneration of the capsule around the joint or tendon sheath.

 

Signs and Symptoms

Ganglion cysts can frequently be diagnosed simply by their location and shape. They are usually not adherent to the overlying skin and are firmly attached to the underlying joint or tendon sheath. X-rays are sometimes helpful in diagnosing ganglion cysts, particularly about the distal interphalangeal joint, where associated degenerative arthritis is often found. As other lesions can produce swelling in the same sites as ganglions, a 100% accurate diagnosis cannot be provided without aspiration or excision of the mass.

Ganglions may limit motion in the adjacent joints, or produce discomfort from compression or distention of local soft tissues. Particularly large ganglions can be cosmetically unpleasant. Ganglion cysts of the distal interphalangeal joint may produce grooving or ridging of the fingernails. Ganglion cysts arising from the flexor tendon sheath at the base of the finger may produce pain when grasping. On rare occasions, ganglion cysts (particularly those associated with the wrist) may cause changes in the bone.

 

Treatment

  • Conservative treatment:
    • Ganglion cysts often change in size and may even disappear spontaneously. For this reason, if the ganglion is asymptomatic, it may be best to simply observe the mass for a period of time. Ganglions about the wrist may respond well to a temporary period of immobilization.
    • Aspiration of a ganglion may diagnose the lesion and may temporarily or permanently treat the condition. This consists of first numbing the area with a local anesthetic, and then inserting a needle to withdraw the clear, jelly-like fluid from the ganglion sac. A compressive dressing or splint may be applied following aspiration. Aspiration is extremely useful in minimizing symptoms when surgery is not desired. Recurrence of the ganglion can be expected in >50% of cases following aspiration.
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • small incision over the ganglion cyst
    • The cyst is carefully freed from the surrounding structures.
    • Care is taken to identify its site of origin, and to excise a small portion of the joint capsule or tendon sheath from which it has arisen.
    • In the treatment of a "mucous cyst" at the distal interphalangeal joint,I remove the osteophytes (bony spurs) that may be associated with the origin of this type of ganglion.

 

Recovery

Following ganglion cyst removal, a bulky compressive dressing is applied. Within 1-2 weeks, exercises are initiated to prevent the development of stiffness. Usual recovery time following surgery for ganglion cysts ranges from 2-3 weeks for small ganglions of the finger, and 6-8 weeks for ganglions involving the wrist.

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December 27, 2011

Hand Surgery #4: De Quervain's Stenosing Tenosynovitis

While trigger fingers involve inflamed flexor tendons (which bring the fingers into the fist) in their digital sheaths, de Quervain's stenosing tenosynovitis refers to inflamed extensor tendons of the thumb (which help you to hitch hike) as they traverse the back of the wrist.

Once called washer woman's sprain, this painful inflammation of the thumb side of the wrist now bears the name of the Swiss surgeon Fritz de Quervain, who wrote about this condition in 1895.  Stenosing refers to the narrowing of an opening or passageway in the body. Tenosynovitis refers to inflammation of the outer covering of the tendons that bend and extend any finger or thumb.

 

Anatomy

Passing over the back (or dorsal surface) of the wrist are the tendons for muscles that extend and straighten the fingers and thumb, and lift the hand at the wrist. These tendons run through 6 lubricated tunnels (compartments) under a thick fibrous layer called the extensor retinaculum.

The 1st dorsal compartment lies over the bony bump at the base of the thumb. Through it, pass the tendons for the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) muscles. Both of these muscles help spread and extend the thumb away from the rest of the hand.

 

Pathology - De Quervain's Stenosing Tenosynovitis

De Quervain's stenosing tenosynovitis is a painful inflammation of the tendons in the first dorsal compartment of the wrist. The lubricating synovial sheath lining this compartment thickens and swells, giving the enclosed tendons less room to move, and produces extra synovial fluid. A painful cyst may also form.

 

Causes

This inflammation may be caused by anything that changes the shape of the compartment or causes swelling or thickening of the tendons.  De Quervain's occurs most often in individuals between the ages of 30 and 50. Women are afflicted with this condition 8-10 times more often than men. People who engage in activities requiring sideways motion of the wrist while gripping with the thumb--as in hammering, skiing, and some assembly line jobs--may be predisposed to developing this disorder.

 

Signs and Symptoms

Pain over the thumb side of the wrist is the primary symptom. This condition may occur "overnight" or very gradually, and it may radiate pain into the thumb and up the forearm. It is worse with the use of the hand and thumb, especially with any forceful grasping, pinching, or twisting. Swelling over the thumb side of the wrist may be present, as well as some "snapping" when the thumb is moved. Because of the pain and swelling, there may be some decreased thumb motion.

Besides pain and swelling over the first dorsal compartment, having a positive Finkelstein's Test is a good indication the patient has this problem. In this test, the patient makes a fist with his or her thumb placed under the fingers. Then, the patient bends the wrist away from the thumb and towards the little finger side of the hand. This test is mildly painful to many of us, but to someone with de Quervain's stenosing tenosynovitis, it is very painful.

 

Treatment

  • Conservative treatment:
    • avoidance of activities that may provoke further symptoms
    • wearing a thumb spica splint to restrict movement of the wrist and thumb
    • a cortisone injection into the 1st dorsal compartment to decrease swelling
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • small incision over the back of the wrist, at the base of the thumb
    • cut (release) the ligaments forming the roof and interior walls of the 1st dorsal compartment
    • The pressure on the APL and EPB tendons is relieved.
    • The whole surgery takes less than 30 minutes.

 

Recovery

A bulky post-operative dressing is worn for 1-2 weeks.  Then, an exercise program for the thumb and wrist is started. It usually takes several weeks for a full recovery.

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December 22, 2011

Hand Surgery #3: Trigger Finger

A carpal tunnel release is the most common hand surgery that I perform.  The second most common is a trigger finger release.

A trigger finger (or trigger thumb) involves painful snapping or locking of the fingers or thumb. The medical name for this condition is stenosing tenosynovitis. Stenosing refers to the narrowing of an opening or passageway in the body. Tenosynovitis refers to inflammation of the outer covering of the tendons that bend and extend the fingers and thumb.

 

Anatomy

  • The tendons are tough, fibrous cords that connect the muscles of the forearm to the bones of the fingers and thumb.
    • This muscle and tendon system enables one to bend the fingers inward when making a fist, and extend them out straight.
  • The tendons glide through a protective covering called the tendon sheath.
    • The sheath is like a tunnel.
    • It is lined with a thin membrane called synovium. The synovial lining helps reduce friction as the tendons glide through the tendon sheath.
    • Areas of dense fibrous tissue called annular bands or pulleys are also part of the tendon sheath.

 

Pathology - The Trigger Finger

A trigger finger (or trigger thumb) is often caused by inflammation of the synovial sheath surrounding the tendons. It may also result from enlargement of the tendon itself, or narrowing of the first annular band (A1 pulley).

When inflamed, the normally thin covering of the sheath may be thickened to several times its normal size. This reduces the amount of space through which the tendons are able to pass. The tendon is no longer able to glide freely through the sheath, and the tendon itself may swell up in a balloon-like mass at the point where it tries to pass through the tunnel.

Upon forceful bending of the finger or thumb, the enlarged portion of the tendon is dragged through the constricted opening. This motion is often accompanied by a painful snap, and the finger or thumb may be locked in a bent position. Straightening the finger or thumb may require using the non-affected hand to actually pull the finger back into an extended position, causing another painful snap as the swollen portion of the tendon passes back through the sheath.

 

Causes

The exact cause of trigger finger or thumb is not always readily apparent. In many cases, however, this condition may be the result of repeated strain of this area due to work or hobby activities. Tasks that require repetitive grasping or the prolonged use of tools (scissors, screwdrivers, etc.) which press firmly on the tendon sheath at the base of the finger or thumb may irritate the tendons and result in thickening of the tendons themselves or the tendon sheath. Symptoms of trigger finger may also be associated with conditions such as...

  • rheumatoid arthritis
  • gout
  • diabetes

 

Signs and Symptoms

One of the first symptoms may be discomfort in the area of the palm directly beneath the affected finger or thumb. This region marks the entrance of the tendon sheath (the A1-pulley area).

As the disease progresses, patients notice painful snapping sensations during finger motion.  If the disorder is not treated, the finger or thumb may actually become locked in a bent position (or less often, in an extended position).

This joint may appear to jump or lock, but the true problem is found in the tendon sheath. It is here that the smooth gliding of the tendon becomes obstructed.


Treatment

  • Conservative treatment is worthwhile, unless the finger or thumb is in an unmovable locked position:
    • avoidance of activities that provoke triggering
    • oral anti-inflammatory pain medications
    • a cortisone injection into the tendon sheath to decrease inflammation
  • When conservative treatment fails, or when the finger or thumb remains in a locked position, I usually recommend surgery....
    • outpatient
    • small incision in the palm at the base of the finger or thumb
    • cut (release) the first annular band of the tendon sheath
    • The constriction of the tendon is relieved.
    • If the surgery is done under local anesthesia without heavy sedation, I usually ask the patient to actively move the tendon during the surgery to confirm that the triggering has resolved.
    • The whole surgery takes less than 20 minutes.
  • In rare cases, such as in patients with rheumatoid arthritis, the surgery may be more extensive.  A portion of the tendon or the synovial covering may require removal.

 

Recovery

Following surgery, a light dressing is applied to protect the incision yet allow for motion of the finger or thumb. The dressing is removed 10-14 days following surgery. Activities requiring normal use of the affected hand may be restricted depending on your specific activity level.

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December 19, 2011

Hand Surgery #2: Cubital Tunnel Syndrome

Carpal tunnel syndrome is, far and away, the most common nerve compression disorder of the upper extremity.  The second most common is cubital tunnel syndrome....

 

Anatomy

The cubital tunnel is...

  • a passageway between...
    • the bony prominence of the inside elbow (medial epicondyle)
    • the tip of the elbow (olecranon process).
  • The roof of this tunnel is formed by a firm tissue called fascia.

Through this passageway travels the ulnar nerve as it crosses behind the elbow. After exiting the tunnel, the ulnar nerve passes between the two origins of the flexor carpi ulnaris muscle.

The ulnar nerve...

  • provides sensation to the little finger and half of the ring finger
  • innervates several muscles in the forearm
  • controls many of the small muscles in the hand responsible for coordinating finger motion and pinch

 

Pathology - The Cubital Tunnel Syndrome

Cubital tunnel syndrome is caused by increased pressure in the cubital tunnel resulting in compression of the ulnar nerve. When the ulnar nerve is pushed up against the fascia or bones, blood flow to the nerve is restricted, causing a sensation often described as "pins and needles" to the small and ring fingers. In severe or chronic cases, numbness can be constant.

 

Causes

There are many ways in which the ulnar nerve may be injured or compressed in the cubital tunnel:

  • Either a severe, direct impact to the inner aspect of the elbow or chronic pressure to this area (such as supporting the arm by resting on the elbow) may produce swelling and inflammation within the cubital tunnel irritating the ulnar nerve. Over time, this may lead to the formation of scar tissue in and about the ulnar nerve.
  • The fascial covering of the cubital tunnel may lose its ability to stabilize the ulnar nerve with elbow motion. The nerve then becomes exposed to repetitive trauma as it slides in and out of its normal position.
  • Injury to the bones of the elbow joint may produce changes in the alignment or carrying angle of the joint. This may place tension on the ulnar nerve or narrow the size of the cubital tunnel.
  • As the floor of the cubital tunnel is formed by the elbow joint, arthritis may produce swelling or enlargement of the joint which in turn narrows the cubital tunnel compressing the ulnar nerve.
  • Tumors such as ganglion cysts or anomalous structures such as an extra muscle may compromise the space available for the ulnar nerve within the cubital tunnel.

 

Signs and Symptoms

Most cubital tunnel syndrome victims report intermittent numbness or tingling in the ring and little fingers.  These symptoms may occur with prolonged flexion of the elbow or resting against the elbow. There may be an associated aching discomfort along the inner forearm or elbow. If nerve damage persists, there is loss of sensation in the ring and little fingers.

Eventually there is loss of strength in the muscles supplied by the ulnar nerve.  Patients usually note a loss of pinch and grip strength.  There may be difficulty crossing the index finger and middle fingers. Severe cases will reveal loss of muscle bulk or wasting over the little finger aspect of the palm and along the back of the first web space or base of the index finger.

Other conditions resembling cubital tunnel syndrome include compression of the nerves in the neck and shoulder area, or compression of the ulnar nerve in the wrist. These conditions can often be excluded by physical examination; however, it may be necessary to obtain special x-rays, vascular tests, or nerve testing to help with the diagnosis.

 

Treatment

  • Conservative treatment:
    • avoidance of activities that may provoke further symptoms, such as minimizing elbow flexion
    • wearing a splint at night to restrict elbow flexion
    • during the day, wearing an elbow pad
    • oral anti-inflammatory medications
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • incision on the inner elbow
    • cut (release) the fascia forming the roof of the tunnel
    • possibly move the nerve out of the cubital tunnel to the front of the elbow
    • The pressure on the ulnar nerve is relieved.

 

Recovery

Following surgery, the arm is immobilized in a long-arm bulky dressing with a plaster splint.

Elevation and finger motion is important to prevent swelling during the post-operative period. The splint is usually removed at 10 to 14 days after surgery to permit suture or staple removal. Additional elbow immobilization may be required up to 3 weeks following surgery. Once therapy is started at the elbow, splinting between exercises is sometimes helpful for comfort and protection until normal motion has been restored. Strengthening of the extremity begins 4 to 8 weeks after surgery depending upon the procedure performed.

Recovery from cubital tunnel surgery requires 2 to 3 months before resuming unrestricted use of the extremity. Several months may be required before the maximum benefits of surgery are achieved. In severe cases with loss of sensation and muscle wasting, complete recovery may not be possible. With proper diagnosis and appropriate treatment, progression of this condition may be prevented.

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December 13, 2011

Hand Surgery #1: Carpal Tunnel Syndrome

Many people are surprised to learn that plastic surgeons are trained to evaluate and to treat hand disorders.  Around the USA, about 1/3 of all the hand surgery is performed by plastic surgeons.

So, for the next few blog posts, I will forego discussions of Botox, facelifts, and tummy tucks, and will instead focus on common hand problems, such as carpal tunnel syndrome....

 

Anatomy

The carpal tunnel is the passageway in the wrist formed by...

  • 8 carpal (wrist) bones, which make up the floor and sides of the tunnel
  • the transverse carpal ligament, which is a strong ligament stretching across the roof of the tunnel

Inside the carpal tunnel are...

  • 9 flexor tendons, which flex (bend down) your fingers and thumb
  • the median nerve, a cord about the size of a pencil containing thousands of nerve fibers supplying sensation (feeling) to your thumb, index and middle fingers, and half of the ring finger

 

Pathology - The Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by increased pressure in the carpal tunnel resulting in compression of the median nerve. When the median nerve is pushed up against the ligament, blood flow to the nerve is restricted, causing a sensation often described as "pins and needles" to the fingers. In severe or chronic cases, numbness can be constant.

 

Causes

Carpal tunnel syndrome can be caused by a variety of problems. Certain medical conditions that may lead to compression of the median nerve include:

  • Inflammation or swelling about the tendons
  • Fluid retention
  • Wrist fractures and dislocations
  • Crushing injuries to the wrist
  • Rheumatoid/degenerative arthritis
  • Diabetes
  • Tumors and tumor-like conditions
  • Hypothyroidism
  • Pregnancy

There is considerable debate as to whether specific work activities may lead to carpal tunnel syndrome. Certain occupational activities which involve repeated flexing of the fingers or wrist, or prolonged use of vibrating tools may contribute to the development of carpal tunnel syndrome.

Determining whether or not carpal tunnel syndrome is a work-related condition can be very difficult. Each case must be considered individually and must be based on documentation of specific work-related activities which may contribute to this condition.

Non-work related activities of daily living and leisure may also provoke symptoms of carpal tunnel syndrome. Lawn mowing, long distance driving, or hobbies such as knitting or wood carving are activities which involve prolonged or repetitive grasping and wrist flexion and may elicit symptoms of carpal tunnel syndrome.

 

Signs and Symptoms

Numbness, burning, or tingling of one or more of the fingers (excluding the little finger) is the most common symptom of carpal tunnel syndrome. This numbness can happen at any time; often these symptoms occur at night and may awaken the individual from sleep. Partial relief can sometimes be gained by shaking, massaging, or elevating the hands. At times, the numbness may extend up the arm, into the elbow, and as far up as the shoulder and neck.

A decrease in sensation or feeling may result in clumsiness and weakness of the affected hand. Patients may find themselves dropping objects and less capable of performing tasks requiring gripping or pinching strength.

On the palm side of the hand, just below the thumb, is a bulging pad of muscle called the thenar muscle group. Some of these muscles are controlled by the median nerve. With advanced carpal tunnel syndrome, this muscle group may begin to waste away, giving a flattened appearance to the palm when compared to the other hand.

 

Treatment

  • Conservative treatment:
    • avoidance of activities that may provoke further symptoms
    • wearing a splint to restrict movement of the wrist
    • a cortisone injection into the carpal tunnel to decrease swelling
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • small incision on the palm of the hand
    • cut (release) the ligament forming the roof of the tunnel
    • The pressure on the median nerve is relieved.
    • The whole surgery takes less than 30 minutes.

 

Recovery

With the blood flow to the median nerve restored, the symptoms of burning and tingling are usually relieved soon after surgery. Patients can expect soreness from the incision for 4 – 6 weeks and discomfort from deep pressure for as long as several months. Improvements in strength and sensation depend on the extent of the nerve damage prior to treatment. Normal grip strength may not return for several months following surgery. The natural healing process and regeneration of nerve fibers will occur throughout the following six months to a year.

Formal physical therapy is not usually required.  However, in certain instances, I recommend a program of hand therapy to regain strength, reduce discomfort, and increase range of motion to the fingers and hand.

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