Carpal Tunnel Syndrome & other Hand Medical Conditions

This condition often occurs when the median nerve, which provides feeling to the thumb, index and middle fingers, as well as a portion of the “ring” finger and several muscles in the hand, malfunctions as a result of pressure and subsequent swelling.

The median nerve is located in the carpal tunnel - a narrow passage inside the wrist. In this tunnel, the nerve is accompanied by nine tendons and is covered with a tight ligament called the transverse ligament. CTS results when the membranes, which lubricate the tendons as they glide in the tunnel, begin to swell.

Carpal Tunnel Syndrome is a repetitive strain condition - most often resulting from a constant, repetitive motion associated with a job. It is most often diagnosed between the ages of 40 and 60. Symptoms can range from mild numbness and tingling on the palmar surface of a finger, to a pain that radiates up to the shoulder. If left untreated, symptoms will usually worsen – affecting wrist, hand, or finger movement, reducing grip strength, and disrupting sleep.

Risk Factors
Those most likely to suffer from CTS include people with occupations that entail repetitive tasks with the hands such as keyboard operators, assembly line workers, typists, barbers, musicians, and drivers. Also at risk are labor workers using vibrating tools such as jackhammers, chain saws, chippers, grinders, drills and sanders.

Women are diagnosed with CTS three times more often than men. Individuals with hormone-related conditions such as pregnancy, breastfeeding, menopause, hypothyroidism, and excess growth hormones are at risk. And certain medications can increase risks as well, such as birth control pills, high blood pressure drugs, and cortisone pills or shots. Some medical conditions may also increase the likelihood of an individual to suffer CTS - including arthritis, diabetes, Raynaud's disease and tumors and cysts in the carpal tunnel.

Genetics may also play a role, as inheriting a narrow carpal tunnel can increase a person's chance of developing CTS.

Treatment
Before determining the most effective treatment for CTS patients a number of tests may be performed. Among the simple tests developed for the diagnosis of CTS is a Tinel's Sign test, which involves a few firm taps on the patient's wrist in order to determine if it sends an electric shock feeling into their hand. A Compression Test is another simple test that involves the bending of the patient's wrist in order to have the thumb positioned down as closely to the forearm as it can go - holding for a brief period and determining if tingling or numbness results in the hand.

Other tests may involve x-rays, a computed tomography (CT) scan, or a magnetic resonance imaging (MRI) scan, in order to more precisely identify the cause of a patient's CTS and any other problems that are either resultant of the condition, or responsible for prompting the condition.

Generally, this condition can be treated with non-invasive methods if diagnosed early, including a period of rest from the repetitive activity and the use of Ibuprofen or Advil to ease pain and reduce inflammation. In more severe cases, a minimally invasive surgical procedure called an Endoscopic Caral Tunnel Release is performed.

Rehabilitation
After a period of rest, patients are encouraged to begin a series of stretching exercises to improve range of motion and grip strength. Depending on the treatment and severity of the condition, the resumption of daily activities and work may range from several days to several weeks. Though, the chance of a recurrence is minimal and complications extremely rare.

Focal dystonia syndrome is a poorly understood musculotendinous overuse condition often affecting musicians such as piano players. It is also found in writers and is commonly referred to as "writer's cramp" or graphospasm as well.

It is thought that the condition is the result of muscular overuse in task-specific activities that generally causes cramping in the hand. Symptoms usually occur when trying to do a task that requires fine motor movements -initially only during specific tasks and eventually spreading to affect many other tasks. Unlike other over-use conditions for which it is often mistaken such as Carpal Tunnel - prompting muscle cramps and pain, Focal Dystonia Syndrome is more likely to affect coordination and cause mild discomfort.

When Focal Dystonia affects only one task, such as writing, it is called simple. But when it affects other activities requiring similar hand posture, it is called dystonic. Sometimes the disorder progresses to include the elevation of shoulders or retraction of the arm while writing. The most common symptoms include slight aching in the fingers, wrist, or forearm.

The condition is believed to result from the improper functioning of the basal ganglia, which are deep brain structures involved in the control of movement. The cause of this improper functioning is unknown. The treatment options generally focus on alleviating the symptoms.

Those at Risk
Evidence of the condition is generally seen in both men and women between the ages of 30 and 50. The condition is often diagnosed in musicians who play the piano as well as those who play the violin. It has also been seen in athletes such as golfers and in typists as well.

Diagnosis
Patient history combined with a physical, and sometimes neurological, examination will confirm a focal dystonia. An electromyogram (EMG) can help determine which muscles are overactive and to what extent.

Treatment
The condition can be treated with a period of rest and refrain from the activity that prompted it. In persistent cases, either oral medication, botulinum toxin injections or surgery is indicated. Additionally, physical therapy and muscular retraining may be beneficial, depending on the form of dystonia.

Guyon's Canal Syndrome is a common nerve compression affecting the ulnar nerve as it passes through a tunnel in the wrist called Guyon's Canal. Though less common than carpal tunnel syndrome, it is the same type of compression that results in the carpal tunnel, which affects the median nerve.

The ulnar nerve, which runs from the neck and down the arm to the hand and fingers, crosses the wrist with the median and radial nerves. The ulnar nerve and ulnar artery run through the Guyon's canal - a tunnel formed by two bones, the pisiform and hamate and the connecting ligaments. Once it passes through the canal, it branches out to supply feeling to the little finger and half of the ring finger. Other branches of this nerve supply the small muscles in the palm, as well as the muscle that pulls the thumb toward the palm.

Those at Risk
There are a number of causes for this condition including: strenuous tasks involving the wrist, such as heavy gripping or twisting; constant pressure placed on the palm such as in cycling and weightlifting; and uncommon or unnatural activities placing great pressure on the wrist such as using a jackhammer or crutches.

A traumatic injury to the wrist may cause swelling and place pressure on the ulnar nerve within the canal. And arthritis in the wrist bones and joint may also irritate and compress the nerve.

Diagnosis
Those suffering from Guyon's Canal Syndrome experience numbness in the little finger and half of the ring finger. Gradual weakening of the muscles controlled by the ulnar nerve eventually makes it hard to spread the fingers out and pinch the thumb.

A physical examination and possible nerve conduction velocity (NCV) test are performed to determine the type of compression and its exact location. The NCV is a test that measures how fast nerve impulses travel along the nerve. Occasionally this test is combined with an electromyogram (EMG). The EMG can determine if the forearm muscles controlled by the ulnar nerve are functioning properly. And if the symptoms were the result of a traumatic wrist injury, an X-ray may be taken to check for a fracture or dislocation.

Treatment
Often times the symptoms can be eliminated if the activity that caused it is changed or eliminated - such as repetitive hand motions or positions. Physical therapy may help to facilitate this process. A wrist brace may also be used to alleviate the symptoms by keeping the wrist in "resting position" and decreasing the pressure placed on the nerve.

If nonsurgical treatment is unsuccessful, a surgical procedure to release the ligament above the canal and reduce the pressure on the ulnar nerve is performed.

One of the conditions identified as a neurovascular overuse condition, Hypothenar Hammer Syndrome (HHS) is an overuse injury that is often the result of a constant pounding on the ulnar side of the palm of the hand affecting the hypothenar region. It is often related to excessive biking, karate, and lacrosse - as well as the use of a jackhammer or constant hammering required in roofing.

It is generally prompted by a trauma to the ulnar artery distal to Guyon's canal, which leads to ischemia, or thrombosis of the ulnar artery in the hand. Symptoms often include sensitivity to cold and pain in the palm, as well as ulnar digital numbness and tingling. In more severe cases, patients may experience a weakness of grip, finger discoloration and ulcer of the fingertip.

Those at Risk
Manual labor workers involved in activities that subject their hands to a harsh, constant pounding are most frequently diagnosed with the condition. Though, it can also affect some athletes as well.

Diagnosis
Often the patient's medical and job history will contribute to the diagnosis of HHS. The location of the discomfort combined with appropriate scans to determine blood vessel obstruction will confirm it and help determine treatment.

Treatment
Refraining from the activity that prompted the condition is the first course of action. Medication to help restore blood flow may also be indicated. And surgery is required in severe cases.

Trigger Finger or Trigger Thumb results from constriction of the flexor tendon sheath, which produces swelling of the corresponding tendon. The flexor tendon helps the finger or thumb to bend, and its sheath is the tunnel-like opening that the tendon glides through. Irritation as the tendons slip into the tunnel causes the opening of the tunnel to constrict, or the tendon to thicken in order to facilitate passage through the tunnel. Repetitive trauma or friction may sometimes result in the formation of a tender "nodule" at the base of the affected finger over the metacarpophalangeal joint. While flexion can be attained, extension is usually difficult and painful - producing a "trigger" or flicking motion as the nodule passes through the constricted area.

Stiffness and "catching" may become worse after a period of inactivity, such as in the morning. When it loosens throughout the day, it may feel unstable. In severe cases, the finger may become stuck in a bent position.

Those at Risk
A trigger finger is a common problem that most often affects women - between the ages of 40 and 60. While the cause is unclear, it appears to commonly affect patients with other medical problems such as diabetes and rheumatoid arthritis, as well as those with a history of repeated injury to the area.

Diagnosis
Trigger finger or thumb is easy to diagnose and is usually suspected when the symptoms are described. A physical examination of the affected area can usually confirm it without further tests.

Treatment
In mild cases, resting the affected hand will usually eliminate the problem. Over the counter anti-inflammatory medication such as Tylenol® or Advil® may be recommended for pain. In more severe case, a splint may be used to force the finger or thumb to remain at rest and cortisone treatments may be used. For those non responsive to conservative treatment, surgery may be necessary.

Osteoarthritis (OA) is among the most common forms of arthritis in the United States. Also known as degenerative joint disease, it starts with a breakdown of joint cartilage that results in pain and stiffness.

Among the upper body joints, it most frequently affects the fingers. Nearly 90 percent of women and 80 percent of men between the ages of 75 and 79 have X-ray evidence of osteoarthritis in their hands. Read more about Arthritis.

Arthritis affecting the basilar joint of the thumb, or the first carpometacarpal joint located near the wrist bone, is called Basilar joint arthritis.

A form of osteoarthritis, Basilar joint arthritis affects women more commonly than men. It generally occurs after the age of 40, as a result of many of the same joint conditions prompting osteoarthritis of other joints - joint instability, cartilage deterioration, wear and tear.

The unique shapes of the small bones of the thumb permit its movement in and out of the plane of the palm to oppose the other fingers. The stability of the carpometacarpal joint of the thumb depends on several small ligaments, which allow movement but remain close to the joint surfaces. If the ligaments loosen and permit too much sliding of the joint surfaces, increased wear on the joint cartilage may occur - leading to arthritis. A fracture or injury can also lead to joint dysfunction and deterioration, ultimately leading to arthritis as well.

Inflammation may occur as joint degeneration progresses. Pain is prominent when pressure is applied to the joint in pinching and grasping activities. If left untreated, joint surfaces are eventually destroyed and bony spurs may develop around the joint. In severe cases, there may be complete joint destruction, an inward collapse of the metacarpal, and deterioration around the trapezium. Other joints may also become affected as they react to the changes.

Basilar joint arthritis will produce pain that progresses over time, eventually discouraging use of the thumb. This correspondingly results in joint weakness and muscle loss. Upon examination, there may be swelling at the base of the thumb as a result of joint inflammation.

Diagnosis
After assessing a patient's history and a physical examination of the thumb, an X-ray may help show the degree of joint damage. And a series of X-rays can help determine the rate of progression.

Treatment
Treatment is determined based on the affect the arthritis has had on a patient's joint at the time of diagnosis. It may involve conservative treatment - including anti-inflammatory medications such as aspirin or ibuprofen, refrain from inflammatory activity, corticosteroid injections, rehabilitation and occupational therapy, as well as splinting of the thumb to help support it - reducing pain and preventing deformity.

In more advanced cases arthroplasty is indicated in order to remove the damaged joint surfaces and create a substitute joint - eliminating pain, and improving strength and range of motion.

The earlier the diagnosis, the greater the chance of preventing irreversible damage.

While there is no known cause for Dupuytren's disease, it is usually painless - simply causing an abnormal thickening of the fascia (the tissue between the skin and the tendons in the palm). Though, the tendons are not affected.

The thickening may limit movement of one or more fingers and commonly occurs in both hands. Often times a knot will form beneath the skin, which causes the fingers to bend into the palm and prevents the complete straightening of the fingers. This thickening can also occur over the knuckles of the finger and in the soles of the feet.

More serious forms of the disease may be found in those who develop the disease at a young age, or those who have the disease in other areas.

Dupuytren's disease occurs slowly and usually starts with a small lump or pit in the palm near the crease of the hand closest to the base of the ring and little fingers. When the cord develops - which could be years following the lump in the palm - it is difficult to place the palm flat on an even surface. The fingers are drawn into the hand as a result of contracture of the fascia near the joints in the fingers (referred to as Dupuytren's Contracture).

Treatment
While there is no permanent cure for Dupuytren's disease, surgical excision of the fibrous bands in the palm have over the years provided temporary relief of the contracture causing the fingers to bend into the palm - restoring use of the fingers. A new minimally invasive procedure developed by a physician in France is today proving promising for Dupuytren patients as well. Read more about the Needle Aponeurotomy Fasciotomy (PNF) procedure for Dupuytren contractures.

Navicular Avascular Necrosis is the result of an insufficient flow of blood to the bone. This can happen to a carpal bone as a result of a trauma that disturbs the blood supply to the bone. It has also been associated with repetitive motion trauma.

Among some of the conditions associated with Navicular Avascular Necrosis include: Kienbock's disease (Lunate Avascular Necrosis), Preiser's Disease and Carpal Avascular Necrosis - each resulting from trauma to a different area of the carpal, though all accompanied by similar symptoms. Those suffering from the condition generally have a history of a single major wrist injury, or multiple minor occupational injuries. They suffer from chronic wrist pain, tenderness and swelling - and experience limited range of motion.

Kienbock's disease
When the affected carpal bone is the lunate, patients are diagnosed with Kienbock's disease or Lunate avascular necrosis - with pain and tenderness experienced in the middle finger. This is a rare condition, which is seen in patients from 20 to 40 years of age with a history of engaging in manual labor. Often there is a history of trauma.

Carpal Avascular Necrosis
Associated with scaphoid fractures, Carpal Avascular Necrosis can often go undetected. Patients frequently assume that the injury is a simple sprain and opt to let it heal on its own rather than seek medical attention.

In some cases the wrist does get better on its own, though often times the bone fails to heal and results in a non union. A simple non union consist of two pieces of a broken bone that fail to heal together. Another more serious type of non union consist of the lower half of the broken bone losing its blood supply and dying. This condition is called avascular necrosis.

There is only one small artery that enters the scaphoid bone - at the end closest to thumb - which if torn in a fracture deprives the bone of a necessary blood supply.

Diagnosis
While X-rays can often time times identify areas of vulnerability, ongoing pain in certain fingers will further indicate possible navicular avascular necrosis. X-rays in advanced stages will show changing bone shape and possibly bone fragmentation and collapse depending on the severity and stage of the condition.

Treatment
In the early stages, intermittent immobilization for several months may be indicated in order to allow for reconstitution of normal bone architecture. And a series of range of motion exercises are established.

In the later stages, surgery may be necessary to address bone fragments and collapse.