Ganglion cysts are swellings that most commonly develop along the tendons or joints of wrists or hands. They can be found either at the top of the wrist, palm side of the wrist, end joint of a finger, or at the base of a finger. Ganglion cyst is not cancerous and will not spread to the other parts of the body. It looks like a water balloon on a stalk and contains a clear fluid or jelly material. Ganglion cysts can be found in people of all ages.
Although the exact cause of a ganglion cyst remains unknown some theories suggest that small cysts are formed when trauma damages the tissue of a joint. The most likely reason might be that these cysts occur because of a defect in the joint capsule or tendon sheath that permits the joint tissue to bulge outwards.
Ganglion cysts generally appear as a mass measuring from 1 to 3 centimetres in diameter. The swelling is usually soft and immobile. It may develop suddenly or gradually over time, vary in size or even disappear or reappear. Ganglion cyst may or may not be painful. If painful, the pain may be continuous and may worsen with the movement of the joint. If the cyst is attached to a tendon, one might feel weak in the affected area.
Your doctor will diagnose a ganglion cyst by performing various examinations starting with physical examination. The diagnosis is confirmed by needle aspiration or ultrasound. Needle aspiration is a process where some amount of the fluid in the cyst is withdrawn using a sterile needle. An ultrasound imaging can reveal whether the lump is solid or fluid filled (cystic). It can also determine if an artery or any blood vessel is causing the lump.
Magnetic resonance imaging (MRI) of the wrist may also be employed to diagnose ganglion cysts.
In many cases, these cysts may disappear without any treatment. Aspiration is performed to drain the fluid from the cyst using a needle. After aspiration, an anti-inflammatory steroid is injected into the empty cyst and a splint is placed to immobilise the area. If the cyst becomes painful or limits your activity, causes numbness or tingling of the hand or fingers, your doctor may recommend surgery to remove the ganglion cyst.
Tendons in your fingers connect the finger bones to finger muscles and help bend and straighten the finger at the joint when the muscles contract. Boutonnière deformity is a condition in which a tendon injury to the middle joint of the finger results in the inability to straighten the affected finger.
Boutonnière deformity can occur because of forceful trauma to the top of the middle joint when bent, laceration to the middle joint or from arthritis. Symptoms associated with this deformity may appear immediately or after a few weeks and may include swelling, pain and restricted movement. In severe cases, a fragment of the bone may be displaced from its original position.
The condition can be diagnosed by physical examination of the hand, and an X-ray may be recommended to confirm diagnosis.
Boutonnière deformity can be treated both surgically and non-surgically.
Non-surgical treatments include:
- Application of a splint to the middle joint of the affected finger to straighten it and allow the tendon to heal
- Exercises to improve the flexibility and strength of your fingers
- Protecting your finger by taping it or using protective splints
- Use of oral medications or corticosteroid injections
Surgery is performed when the injury is caused due to rheumatoid arthritis, the tendon is severed, presence of bone displacement, or if non-surgical treatments fail to provide relief. Surgical treatments improve the functioning of the finger but may not always correct the appearance depending on how soon surgery is initiated.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome is a common, painful, progressive condition that is caused by compression of the median nerve at the wrist area.
Common symptoms of carpal tunnel syndrome include numbness and tingling sensation in all the fingers except little finger; pain and burning sensation in hand and wrist that may radiate up the arm and elbow; and weakness in hand with diminished grip strength.
Exact causes of the condition are not known. However certain factors increase the risk of developing carpal tunnel syndrome and they include congenital abnormalities, repetitive motion of hand and wrists, fractures and sprains, hormonal imbalance, and other medical conditions such as hypothyroidism, rheumatoid arthritis, diabetes, obesity, gout, overactive pituitary gland, or the presence of a cyst or tumour in the canal.
Conservative Treatment Options
Carpal tunnel syndrome may be treated using conservative approaches or surgery. The conservative treatments include:
- Treating underlying medical conditions
- Immobilisation of the hand and wrist with a splint or wrist brace for 4-6 weeks
- Rest the hand for 2 weeks or more
- Ice packs to avoid swelling
- Avoid activities that tend to worsen the symptoms
- Medications such as non-steroidal anti-inflammatory drugs and steroid injections
- Strengthening and stretching exercises once symptoms diminish
If conservative treatment options fail to resolve the condition your surgeon may recommend surgical procedure.
Carpal Tunnel Release Surgery
Carpal tunnel syndrome can be treated with carpal tunnel release Surgery Traditional surgery involves up to a 2- inch incision in the palm and wrist area, whereas endoscopic surgery involves one or two half-an-inch incisions and the use of an endoscope. During the surgery, the transverse carpal ligament will be dissected to release the pressure on the median nerve and enlarge the carpal tunnel. Your surgeon will decide which options are best for you based on your general and medical conditions.
Your surgeon may suggest you practice certain post-operative procedures for better recovery and to avoid further complications.
- Elevate the hand above heart level to reduce swelling.
- A splint may be worn
- Ice packs to the surgical area to reduce swelling.
- Keep the surgical incision clean and dry. Cover the area with plastic wrap when bathing or showering.
- Physical therapy may be ordered to restore wrist strength.
- Eating a healthy diet and not smoking will promote healing
Risks and Complications
Most patients suffer no complications following carpal tunnel release surgery. However, some patients may suffer from pain, infections, scarring, and nerve damage causing weakness, paralysis, or loss of sensation and stiffness in the hand and wrist area.
De Quervain’s Tendinosis
The muscles and bones of the hand are connected by thick flexible tissue called tendons. Tendons are covered by a thin soft sheath of tissue known as synovium. Extensor pollicis brevis and abductor pollicis longus are two tendons located on the thumb side of the wrist. Inflammation and swelling of the tendon sheaths puts pressure on the adjacent nerves and leads to pain and numbness in the thumb side of the wrist.
Strain on these tendons can cause swelling and irritation and lead to a condition called De Quervain's tenosynovitis, which is characterised by inflammation. The condition is also referred to as De Quervain’s tendinitis, De Quervain’s tendinosis, De Quervain syndrome, or De Quervain’s disease.
The exact cause of De Quervain’s tenosynovitis is unknown, but is usually seen in individuals with repetitive hand or wrist movements, injury to the wrist or tendon, and inflammatory conditions such as rheumatoid arthritis and inflammatory arthritis. De Quervain’s tenosynovitis is most common in pregnant and middle age women.
Signs and Symptoms
The symptoms of De Quervain's tenosynovitis include pain and tenderness on the side of the wrist at the base of the thumb. You may also have a little swelling and redness in the area. Your symptoms may get worse while making a fist, grasping or gripping things, or turning the wrist. You may experience a "catching" or "snapping" sensation while moving your thumb.
Your physician diagnoses De Quervain’s tenosynovitis by observing your symptoms, medical history, and performing a physical examination of the wrist. De Quervain’s tenosynovitis can be confirmed through the Finkelstein test. For this test, your doctor will ask you to make a fist with your fingers covering the thumb and bend the wrist towards the little finger. Pain during this movement will confirm the condition.
Treatment of De Quervain’s syndrome consists of both non-surgical and surgical therapy.
Non-surgical therapy includes avoiding activities that increase pain and swelling, applying ice, using a splint to support and immobilise the hand, and physical therapy. Anti-inflammatory drugs are helpful in relieving pain and swelling. Your physician may also recommend a corticosteroid injection to reduce the swelling of the tendon sheath.
Surgical therapy: Your physician will recommend surgery based on the severity of your pain symptoms and response to non-surgical treatment methods. The outpatient surgical procedure involves opening or cutting the inflamed part of the tendon sheath to relieve the pressure on the tendon and allow free movement of the wrist. After the surgical procedure, a wrist splint with your thumb and fingers free and mobile is applied for a month. Your surgeon will also instruct you on exercises to strengthen your wrist.
Dupuytren’s Contracture is a hand condition where thickening of the underlying fibrous tissues of the palm cause the fingers to bend inward. Patients with this condition are unable to fully straighten the affected fingers.
It is caused from excessive production of collagen which is deposited under the skin. It commonly occurs in the ring finger and little finger. Occasionally the middle finger is affected but the thumb and index finger are rarely affected. Dupuytren’s contracture is a condition that usually progresses slowly over many years and is not usually painful. However, some cases may progress rapidly and be painful to the patient.
The most commonly observed symptoms of Dupuytren's contracture are lumps or nodules in the palm of the hand, difficulty in straightening the fingers, and contracture of the nodules which form tough bands under the skin.
Causes and risk factors
The cause of Dupuytren’s contracture is unknown. However, there are certain risk factors that may increase your chance of developing the condition. These can include the following:
- Age: It occurs more frequently around age 40.
- Social Habits: Smoking and drinking alcohol may increase your risk of developing the condition.
- Medical Conditions: Patients with diabetes, alcoholism, cirrhosis of the liver, and seizure disorders appear to be at increased risk of developing the condition.
- Gender: The condition is more common in males than females.
- Heredity: The condition tends to run in families.
- Ancestry: Most commonly affected are northern Europeans and people of Scandinavian descent.
Dupuytren's contracture is diagnosed based on the patient's history and physical examination without any special tests required. The physical examination may involve pressing on different parts of your hands and fingers to assess for hardened knots or tough bands of tissue.
You may not need treatment for Dupuytren’s contracture if the condition is not affecting your ability to perform daily activities. However, if you are experiencing pain or are having difficulty using your hands for everyday activities, your surgeon will recommend conservative treatment options to treat your condition. Treatment options will vary depending on the severity of the condition. The conservative approaches include:
- Heat: Applying heat to the palms of the hand prior to massage or exercise can help to loosen the tissues.
- Massage: Gently massage the thickened tissues of the palm.
- Exercises: Stretching exercises such as bending the fingers away from the palm may be useful.
- Injections: Steroid injections in the palm may be done to relieve local inflammation.
- Collagenase Injection: An enzymatic drug that breaks down collagen can be injected into the corded tissue to soften and weaken the contracture. The physician then manipulates the area manually to break up the tissue.
- Needle Aponeurotomy: This procedure involves inserting a small needle into the thickened palm tissue and manipulating it to loosen and break up the contracting tissue. Ultrasound may be used to guide the needle to avoid hitting nerves or tendons.
If conservative treatment options fail to resolve the condition and symptoms persist for 6 months or more and your quality of life is adversely affected, your surgeon may recommend a surgical procedure to open the tendon sheath and allow more room for tendon movement.
This surgery is usually performed in an operating room under local or regional anaesthesia on an outpatient basis as day surgery. Your surgeon makes a small incision to the affected palm area.
The surgeon then removes the thickened fibrous tissue causing the contracture.
The incision is then closed with sutures and covered with a sterile dressing.
Complications can be medical (general) or specific to hand surgery. Medical complications include those of the anaesthetic and your general well-being. Some of the complications associated with hand surgery include:
- Nerve damage causing weakness, paralysis, or loss of feeling in the hand area
- Injury to the arteries of the fingers/hand
- Recurrence of the condition
The ability to bend the fingers is governed by supportive tendons that connect muscles to the bones of the fingers. The tendons run along the length of the bone and are kept in place at intervals by tunnels of ligaments called pulleys. When the fingers bend, or are straightened, a slippery coating called tenosynovium helps the tendons smoothly glide through the ligaments with reduced friction.
Inflammation in the tenosynovium leads to a condition called trigger finger, also known as stenosing tenosynovitis or flexor tendonitis, where one of the fingers or thumb of the hand is caught in a bent position. The affected digit may straighten with a quick snap, like pulling and releasing the trigger on a gun, hence the name trigger finger.
Trigger finger is caused by inflammation of the tenosynovium. Inflammation forms a nodule and makes it difficult for the tendon to glide smoothly within its sheath causing "catching" of the finger in a bent position and then suddenly releasing the finger straight.
Other causes of trigger finger can include the following:
Repetitive Motion: Individuals who perform heavy, repetitive hand and wrist movements with prolonged gripping at work or play are believed to be at high risk for developing trigger finger.
Medical Conditions: Conditions associated with developing trigger finger include hypothyroidism, rheumatoid arthritis, diabetes, and certain infections such as Tuberculosis.
Gender: Trigger finger is more common in females than males.
Signs and Symptoms
Commonly reported symptoms associated with trigger finger include the following: -
- Pain and tenderness over inflamed tendon nodule
- Bent finger suddenly pops out and straightens
- “Popping” or “clicking” sound or sensation when the nodule moves through the pulley
- Finger feels stiff and sore
- Finger get locked with inability to straighten when the nodule grows large and gets stuck in the pulley
- Symptoms are worse in morning
Long-term complications of untreated trigger finger can include permanent digit swelling and contracture, as well as tearing of the tendon or rupture
Hand and wrist conditions should be evaluated by an orthopaedic hand surgeon for proper diagnosis and treatment. Trigger finger is diagnosed based on the medical history and physical examination and without any special testing required.
Your surgeon will recommend conservative treatment options to treat trigger finger symptoms. Treatment options will vary depending on the severity of the condition.
Conservative treatment options may include the following:
- Treating any underlying medical conditions that may be causing the problem, such as diabetes or arthritis
- Rest the hand for 2-4 weeks or more by avoiding repetitive gripping actions. Avoid activities that tend to bring on the symptoms.
- Strengthening and stretching exercises with the affected finger may be suggested.
- Occupational therapy may be recommended for massage, heat, ice and exercises to improve the finger.
- Ice over the affected finger may help symptoms. Apply ice over a towel for 5-15 min, 3-4 x daily.
- Non-steroidal anti-inflammatory drugs (NSAIDs) may help to relieve pain and inflammation.
- Steroid injections into the affected finger may help reduce the inflammation.
If conservative treatment options fail to resolve the condition and symptoms persist for 6 months or more and your quality of life is adversely affected, your surgeon may recommend you undergo a surgical procedure to release the tendon.
Percutaneous trigger finger release surgery is a minimally invasive procedure performed under local anaesthesia. Your surgeon makes one small incision to the affected finger area, about inch long, and releases the tight portion of the flexor tendon sheath.
Congenital Defects of the Hand and Wrist
The hand and wrist are formed during the 8th week of gestation. This process consists of various steps and failure in any one or more of these steps may cause congenital or birth defects. The deformities may be major (absence of a bone) or minor (disproportion of a finger). The various types of hand and wrist defects include:
- Missing parts of the hand
- Webbed or fused fingers (syndactyl)
- Presence of extra fingers (polydactyl)
- Congenital constriction band syndrome (band of tissue forms around a finger, restricting normal growth and blood flow)
- Undergrowth or overgrowth of the different parts of the hand
Congenital conditions of the hand and wrist are treated based on various factors such as your child’s age, severity of the condition and cause of the condition. The different treatments include:
- Surgical separation of the webbed fingers
- Removal of the extra finger
- Use of splints to realign the fingers
- Tendon transfers
- Physical therapy to increase the strength in your hand
- Skin grafts to fill in the missing parts of the hand
- Correction of contractures
Hand pain is characterised by distress in the joints and tissues of the hand or fingers. Hand pain can be depicted as pulsating, aching, increased warmth, prickling, irritation and inflexibility. The hand is composed of nerves, bones, blood vessels, muscles, tendons and skin. Each part has its specific function such as nerves transfer sensation, joints control movements, blood vessels maintain circulation, muscles provides motion, tendons anchor the muscles to the bones and skin receives sensations.
Injury or inflammation of any of these structures, due to a disorder or disease condition, may produce hand pain. Even compression of the nerves supplying these structures may cause hand pain.
The conditions and disorder that frequently play a role in hand pain are:
- Accidental injury and trauma
- Serious infections in the blood (Septicaemia)
- Fracture of the hand bones
- Nerve compression
- Incident of conditions such as tenosynovitis and carpal tunnel syndrome
- Strains in muscles and ligaments
- Osteoarthritis and rheumatoid arthritis
- Suffering from diabetes and peripheral neuropathy
- Tedious lifting, twisting or gripping
- Long-term use of keyboards
Hand pain can be treated normally by resting the hand, medications, bracing, heat or ice application, compression, stretching and strengthening exercises, and by treating the underlying cause or condition. In cases of chronic hand pain unresponsive to conservative treatment measures, hand surgery may be recommended.
Hands become infected more frequently as it is one of the commonly injured parts of our body. Hand infections, if left untreated or treated improperly can cause disabilities such as stiffness, contracture, weakness, and loss of tissues (skin, nerve and bone) that persist even after the infection resolves. Therefore, prompt treatment of hand infections is important.
Infections of the hand include:
Paronychia is an infection of the nail fold or cuticle area present around the fingernail. Paronychia may be acute or chronic infection. Acute paronychia is a bacterial infection and causes pain, redness, and swelling around the nail. It is caused by superficial trauma that may occur during nail biting or finger sucking. It can be treated with antibiotics and if pus forms, it needs to be drained. Chronic paronychia is a result of fungal infection and it causes milder symptoms such as mild pain, redness or swelling, with little or no pus. It occurs most commonly in people whose hands are often wet or are immunocompromised. The treatment for chronic paronychia consists of avoiding constant exposure to moisture and application of topical steroid and antifungal ointments.
Felon is a serious infection of the fatty tissues of finger tips which results in throbbing pain. It is caused due to direct entry of bacteria during a penetrating injury or by spread of infection from untreated paronychia. If there is an abscess, surgical drainage is done following which antibiotics will be prescribed.
Herpetic whitlow is a herpes simplex virus infection of the fingers. It is more common in healthcare workers whose hands are exposed to the patient’s saliva which may carry the virus. Herpetic whitlow presents small, swollen, painful blisters. Conservative treatment for herpetic whitlow involves application of a dry gauze dressing to the affected finger to avoid spread of infection.
Septic arthritis is a severe infection of the joint caused by a wound or a draining cyst. The bacterial infection may cause destruction of the joint by eroding away the joint cartilage. Surgical drainage should be done as soon as possible because the condition may get complicated if the infection spreads to the bone causing osteomyelitis.
Deep space infections
Deep fascial spaces are the potential spaces in between the different structures of the hand. These spaces tend to get infected through penetrating wounds or spread of infection from blood. Deep space infections may occur in the thumb, the palm or in the area between the bases of fingers. Treatment for deep space infections includes antibiotic therapy, pain relieving medications, and surgical drainage.
Tendon sheath infection
Tendon sheath infection is the infection of the flexor tendon which occurs because of a small laceration or penetrating wound on the finger, near a joint. It causes severe stiffness of the finger accompanied by redness, swelling and pain. This condition may also lead to destruction and rupture of the tendon. Therefore, it demands the immediate surgical drainage.
Atypical mycobacterial infections
Atypical mycobacterial infections are tendon sheath infections caused by an atypical mycobacterium. These infections cause stiffness and swelling without much pain and redness. Antibiotic treatment is given for several months following which surgical removal of the infected tendon sheath may be done.
Infections from bite wounds
Infections from animal or human bite are associated with bacteria such as Streptococcus and Staphylococcus, Eikenella corrodens (human bite injuries) and Pasteurella multocida (dog and cat bite injuries). These wounds are given initial treatment and left open to allow the infection to drain out. Surgical trimming of infected or crushed tissue may be done.
The wrist is a commonly seen injured joint in the body. Problems include sprains and strains as well as fractures which can occur with lifting and carrying heavy objects, while operating machinery, bracing against a fall, or from sports-related injuries.
Some of the common wrist injuries include:
Sprains and Strains: Sprains and strains are the two most common types of injuries affecting the wrist. A sprain refers to an injury to a ligament and a strain refers to a muscle injury. Sprains and strains occur due to excessive force applied during a stretching, twisting, or thrusting action. Most sprains and strains will repair themselves with adequate rest, ice application, compression, and elevation. Surgery is occasionally required to repair the damage.
Ligamentous Injuries: Ligaments are tissues that connect bones to other bones. They are made up of several fibres and one or all the fibres may be involved. Complete ligament injury occurs when all the fibres are torn. A ligament injury may cause pain and swelling and limit the movement of wrist joints. Ligament injuries are effectively treated with splinting and taping with restriction of movement of the injured structures.
Fractures: A fracture is a break in the bone which occurs when more force than the bearable limit is applied against a bone. Crushing injuries to the wrist occur due to high degrees of force or pressure and may also cause fractures. A fracture may cause severe pain, swelling, bruising or bleeding, discoloration of the skin and limit the mobility of the limb. Fractures of the wrist bones can be treated by using a cast or splint while the bone heals. Sometimes surgery may be needed where plates, pins or screws may be placed to keep the joint stable while healing.
Repetitive Trauma Syndrome: Repetitive stress injury occurs because of repeated similar movements for long periods of time. This often causes pressure on the joints resulting in inflammation, pain, and decreased function in the extremity. The condition is more likely to develop with repetitive, rapid, forceful and prolonged movements of the wrist, or from vibration or frequent pushing, pulling or carrying heavy objects. Carpal tunnel syndrome is the most common of these syndromes.
Carpal Tunnel Syndrome: Carpal tunnel syndrome is a condition characterised by numbness or pain in the thumb and first two fingers and occurs when the median nerve is compressed at the wrist. Carpal tunnel syndrome is often a common complaint in individuals who use their hands for prolonged periods of time in an occupation such as computer work. Immobilisation of the affected part for a certain period may help heal the condition. Medications, physical therapy, and surgery may also be recommended. Often, splinting for a short period of time can treat the condition.
Any problem causing pain, swelling, discoloration, numbness or a tingling sensation, or abnormal position of the wrist that persists for more than two or three days should be evaluated by your doctor to establish the cause and obtain the best treatment as early as possible.
A tumour is a lump or abnormal growth formed due to unregulated cell division. Wrist tumours can occur on or underneath the skin. They are most often benign (non-cancerous). Common tumours include:
- Ganglion cysts: Fluid-filled growths generally found at the wrist joint. It is characterised by the swelling of a joint or tendon sheath (supportive lining of tendons) and leakage of the fluid that lubricates the joint forms the cyst.
- Giant cell tumours: These are solid tumours formed because of trauma caused to a tendon sheath, which stimulates the abnormal growth of cells.
- Epidermal inclusion cyst: Keratin-filled sac formed beneath the skin. Skin cells produce keratin, a waxy substance to protect its surface. Epidermal inclusion cysts develop when skin cells are trapped under the surface of a cut or puncture of the skin and continue to produce keratin, which forms the cyst.
Other wrist tumours include fat cell tumours (lipomas), nerve cell (neuromas) and nerve sheath tumours, and connective tissue tumours (fibromas).
Wrist tumours may be associated with pain, swelling, loss of flexibility and weakness or numbness. They can be diagnosed with physical examination and imaging tests such as X-rays, MRI and CT scan. Your doctor may also order a biopsy to confirm the diagnosis of the tumour and ascertain if they are benign or malignant.
Treatments mainly involve anti-inflammatory medications, use of splints and draining of the fluid from the cyst. Surgical treatment includes excision of the tumour. Excision is usually performed under local anaesthesia and is an outpatient procedure.
Gamekeeper's thumb, also known as skier's thumb, is a tear of the ulnar collateral ligament, a band of tissue that supports the joint at the base of the thumb. Damage to the ulnar collateral ligament may lead to chronic instability of the thumb, creating problems in its normal functioning. Gamekeeper's thumb can result from sports activities (while stopping a ball with a bare hand) or a fall on your outstretched thumb (especially while holding onto something like a ski pole). Symptoms include pain, bruising and swelling at the base of the thumb. You may also experience loss of strength when pinching or gripping with the thumb.
To diagnose gamekeeper’s thumb, your doctor may numb your thumb and perform a physical examination. If the tear is associated with the fracture of a bone, your doctor may order an X-ray or ultrasound.
Your doctor may suggest applying ice to reduce swelling and will prescribe pain relieving medications. For a partially torn ligament, your doctor may order a splint or cast for about six weeks followed by an exercise program to improve the thumb’s range of motion. If the ligament is completely torn, surgery is usually recommended for repair.