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There is a wide range of ailments and conditions that affect the hand and wrist. Here are several that we treat at Baylor St. Luke's Medical Center.


CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome is becoming more and more common. It is a condition that is caused by increased carpal tunnel syndromepressure on a nerve in the wrist. This nerve is called the median nerve. The median nerve (nerve affected in carpal tunnel syndrome) lies within a tunnel along with nine other tendons.

For various reasons, this nerve becomes squeezed in this tunnel.The compression of this median nerve causes symptoms consistent with carpal tunnel syndrome.

Symptoms
Symptoms may include numbness, tingling, pain in the hand, wrist and arm.  Sometimes, the pain may radiate up the arm to the shoulder.  The numbness or tingling most often involves the thumb, index, middle and ring fingers. 

These symptoms are often worse at nighttime or during the morning time.Some people complain of either pain or numbness or tingling when they are at the computer or driving a car. 

It is important to remember that carpal tunnel syndrome is not always associated with pain. As carpal tunnel syndrome worsens, some patients develop a weaker grip, occasional clumsiness, and may drop things.In severe cases, the sensation may be permanently lost and the muscles at the base of the thumb may shrink (thenar atrophy).

The cause of carpal tunnel syndrome is still elusive.We do know that pressure on the nerve cause carpal tunnel syndrome.But, we do not know what causes the pressure on the median nerve.Theories include: swelling of the lining of the flexor tendons (flexor tenosynovitis), fractures of the hand or wrist, arthritis, joint dislocations, and keeping the wrist bent for a long period of time.Fluid retention during pregnancy can cause swelling in the tunnel and symptoms of carpal tunnel syndrome (which may improve after delivery).  Other conditions, such as thyroid disease, rheumatoid arthritis and diabetes can be associated with carpal tunnel syndrome.median nerve in wrist

Diagnosis
A detailed history and physical examination is crucial in diagnosing carpal tunnel syndrome.  X-rays will be done in the office to rule out other causes for these symptoms. 

Typically, your Physician will order an EMG-NCV (electromyogram nerve conduction study) to corroborate the diagnosis of carpal tunnel syndrome. This study will eliminate some other nerve problems, which may mimic carpal tunnel syndrome. 

Treatment
Symptoms can often be relieved without surgery.  Identifying and treating medical conditions, changing the patterns of hand use, adjusting the ergonomics at work, using carpal tunnel supports at nighttime may relieve some symptoms from carpal tunnel injections.  At times, we will consider anti-inflammatory medications to improve carpal tunnel syndrome.In certain cases, a cortisone injection may be utilized to improve carpal tunnel syndrome.

When the symptoms are advanced, surgery may be needed to make more room in the carpal tunnel for the median nerve.There are many different options to perform this surgery.Many of us utilize the mini-open technique. This is performed under either a local block or regional anesthesia.This means that in most cases, general anesthesia is not employed during the surgery.The surgery takes less than 30 minutes.It is an outpatient surgery.Some of our doctors use a splint for a couple of weeks after surgery. 

Some patients experience some soreness in the wrist area for 3-6 months after the surgery.It may take several months for strength in the hand and wrist to return to normal.After the surgery, many patients will feel improvement in the numbness or tingling and pain.However, for patients with severe carpal tunnel syndrome, these symptoms may not abate.The design of the surgery is to decrease the chance of the carpal tunnel syndrome worsening, and to give the patient a chance for improvement.

Please consult your doctor (FIND A DOCTOR AT BAYLOR ST. LUKE'S MEDICAL CENTER) for any additional questions.For symptoms that are left untreated, permanent nerve damage, weakness and muscle atrophy may ensure.Therefore, if you have any of the above-mentioned symptoms, please let your doctor know.

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TRIGGER FINGERS
A trigger finger or trigger thumb is a condition, which involves the pulleys and the tendons in the hand. These tendons are used in flexing our fingers. The tendons work like long strings that connect the muscles of the forearm with the bones of the finger and thumb.
finger
In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone.

Trigger finger/thumb occurs when the pulley at the base of the finger (A1 pulley) is too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining.

Because of the size discrepancy between the tendon and the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb. When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend.

Causes of Trigger Finger
The causes of trigger finger are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.

Signs of Trigger Finger
Patients with trigger finger/thumb may experience discomfort felt at the base of the finger or thumb, where they join the palm. There may be tenderness noted at this area. A nodule may sometimes be felt in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints.

Treatment of Trigger Finger
The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. There are nonoperative ways to approach the trigger finger/thumb. Anti-inflammatory medications may be effective in some cases. Often times, wearing a night splint can decrease some of the symptoms of trigger fingers. A cortisone injection into the hand can also help decrease or eliminate the symptoms of trigger finger/thumb. If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended.

We perform these surgeries as an outpatient. The anesthesia is local anesthesia with some intravenous sedation. The surgery takes less than 30 minutes to complete. During surgery, a small incision is made over the A1 pulley (in the palm of the hand). The pulley is released. Immediately after surgery, active range of motion of the fingers is initiated. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use. A consultation with your treating surgeon can help decide the best options for you.

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ARTHRITIS OF THE THUMB 
Arthritis refers to any condition that irritates or destroys a joint. The most common type of arthritis is degenerative or osteoarthritis. This occurs when the normal joint lining (cartilage) wears out. The joint space then narrows. Bone spurs may form as a result of the process. During the transformation of the normal thumb joint to an arthritis joint, patients may experience increasing pain, weakness, stiffness and deformity. Patients with arthritis at the base of the thumb often complain of difficulty with pinching, including opening jars, turning doorknobs or keys, and writing.

As the disease worsens, some patients may describe pain at rest and at night, and patients often note loss of pinch and grip strength. In severe cases, progressive destruction and mal-alignment of the joint occurs and a “bump” develops at the base of the thumb, which is caused by the thumb metacarpal moving out of position in relation to the trapezium. The picture below demonstrates a patient with arthritis at the base of the thumb. The arrow is pointing to a bump that may form in severe cases of thumb arthritis.

An xray of this patient is below. One can appreciate the narrowing of the joint along with spuring. The picture on the left is an arthritic thumb joint. The picture on the right is a thumb joint without any arthritis. If you compare where the arrows are pointing to, you can perhaps tell the difference in the radiographic appearance of arthritis.


Arthritis at the base of the thumb is more common in women and usually starts after age 40. The cause of this form of arthritis is unknown in most cases. Past injuries to the joint, such as fractures or severe sprains, and generalized joint laxity may increase the chances of developing this form of arthritis at a younger age. The diagnosis of thumb arthtritis can be made with a good history, physical examination and the use of x-rays. The appearance of the thumb and the location of the pain are usually very helpful in identifying this condition. The treatment options for thumb arthritis vary depending upon several factors. arthritis of the hand

For less severe thumb arthritis, some patients will usually respond to non-surgical care. Pain medication, topical agents, splinting, and limited use of corticosteroid injections may help improve pain. Patients with advanced arthritis or who do not respond to non-surgical treatment may be candidates for surgical reconstruction. A variety of surgical techniques are available that can successfully diminish or eliminate pain and improve thumb position and function. 

Common surgical procedures include: removal of arthritic bone and joint reconstruction (joint arthroplasty), bone fusion or realignment techniques. A consultation with your treating surgeon can help decide the best options for you.

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