Newton Wellesley Orthopedic Associates in Newton and Wellesley, MA addresses many conditions that cause wrist pain and hand pain, including carpal tunnel syndrome and arthritis.
Conditions Affecting the Hand and Wrist
Triangular Fibrocartilage Tear and Arthritis of the Wrist
TFC surgery is sometimes necessary for a triangular fibrocartilage tear and arthritis of the wrist and is performed by Newton Wellesley Orthopedic Associates in Newton and Wellesley, MA.
Conditions Affecting the Wrist
Carpal Tunnel Syndrome
Carpal tunnel syndrome is one of the most common causes of pain in the hand, wrist, and fingers. It is caused by compression of the median nerve in the wrist. Symptoms typically include burning, tingling, and numbness in the fingers and pain in the wrist shooting down into the fingers. The symptoms may be much worse at night or in the early morning hours and some patients wake up feeling like they need to “shake the hand out” in order to get the pain and numbness to improve.
Patients with certain conditions such as diabetes, thyroid disease, kidney disease, or hormonal changes (pregnancy or menopause for example) may experience carpal tunnel syndrome more often than others. Diagnosis is usually established with a simple physical examination and if in doubt, an electrical test of the nerves may need to be performed.
Treatment usually starts with usage of wrist splints at night. The splint keeps the wrist from falling into a flexed or extended posture for hours at a time, therefore relieving some of the nerve compression that may be caused by wrist positioning. Cortisone injections into the wrist may also be useful for severe cases. In patients who still have major symptoms even after a reasonable trial of splinting and cortisone injections, carpal tunnel release will almost always take care of the problem. This is a simple 10-minute outpatient procedure that is done under local anesthesia. Open and endoscopic (“minimally invasive”) carpal tunnel releases are both equally effective, though endoscopic carpal tunnel release does leave a smaller scar and can result in faster return to work and sports. Patients are free to use the hand immediately after surgery, and most of the postoperative discomfort resolves in a few days. Patients are usually back to full manual labor two weeks after endoscopic surgery or 6 weeks after open surgery.
See a Demonstration of Endoscopic Carpal Tunnel Release
Ganglion Cyst/Wrist Mass
Ganglion cysts are benign, fluid-filled masses that form on the tendons or joints of the wrists. These cysts are often small and painless. Pain may occur if the cyst presses on a nerve. Many times, these cysts go away without treatment but occasionally must be drained or surgically removed.
Triangular Fibrocartilage Tear
When cartilage or ligaments tear on the pinky side of the wrist, it is called a triangular fibrocartilage tear. Depending on the severity of the tear, the injury may be treated with a simple splint or cast or, in serious cases, surgery.
Fractures of the Distal Radius (Colles Fracture)
About Distal Radius Fractures
A fracture of the distal radius refers to a fracture occurring at the lower end of the forearm (where the forearm meets the wrist). These are usually caused by a fall on an outstretched hand (palm of the hand hits the floor as the patient tries to break a fall). These are also the third most common large-bone fractures requiring surgical treatment by a hand surgeon (second to hip fractures and ankle fractures).
Nonsurgical (Cast) Treatment of Distal Radius Fractures
Treatment of fractures of the distal radius varies greatly depending on age of the patient. Children and young teenagers very seldom require surgery. Very frequently, the fracture may be very minimally displaced (a “buckle fracture”). These very often heal with a brace or a cast for 3 weeks and have no long-lasting problems. A significantly displaced wrist fracture in a child may require a closed reduction of the fracture (manually straightening the bone with the patient under anesthesia), application of a cast, and occasionally insertion of temporary pins to stabilize the fracture until the bone heals (typically 3-6 weeks depending on age of the patient). Treatment of the elderly patient who is not very physically active usually also involves cast application with or without closed reduction.
Example: Closed Reduction (Manipulation) and Cast Treatment of 8-Year Old Boy with Displaced Distal Radius and Ulna Fractures
Example: Displaced Distal Radius Fracture in 89-Year Old Woman Treated by Closed Reduction
Surgical Treatment of Distal Radius Fracture
When a fracture is displaced in a younger adult, or when the patient is elderly but physically active, surgery is usually necessary. This typically involves straightening the fracture in the operating room and application of a steel or titanium plate to the palm surface of the wrist. The fracture is usually quite stable after application of such a plate and no cast is necessary unless the fracture is particularly severe or the patient’s bone density is very poor. Hand therapy is sometimes necessary to help adult patients regain motion and strength after these fractures, whether or not surgery was performed.
Displaced Distal Radius Fracture in a 42-Year Old Man, Treated by Plate Fixation
The most severe fractures may require application of more than one plate (See also: Repair of wrist fractures using fragment-specific fixation) or application of an external fixator, which is a carbon-fiber rod attached by skeletal pins to span the fracture site to keep it from collapsing.
Surgical Fixation of Distal Radius Fracture
Nicky Leung, MD demonstrates the technique of distal radius ORIF (warning: graphic content).
Fractures of the Scaphoid (Navicular)
About Scaphoid Fractures
The scaphoid is a small peanut-shaped bone that lies at the base of the thumb where it joins the wrist. Fractures of the scaphoid usually occur in younger patients after a fall on an outstretched hand. Pain and swelling are most pronounced in the “snuff box” at the base of the thumb. The great difficulties with scaphoid fractures is that many of them are non-displaced (e.g. a “hairline crack”) and are extremely difficult to detect on regular X-rays. Because of this, other studies (such as a CT scan or MRI) are sometimes necessary to diagnose these.
It is not uncommon for these fractures to be completely missed by the doctor who sees this patient immediately after the injury, even with adequate X-rays. Furthermore, these fractures have a lower rate of healing than most other fractures of the wrist. To make matters even worse, when these fractures go on to non-union (i.e. the bone fails to heal) they predictably result in development of arthritis of the wrist at a premature age. Since these injuries most often occur in young people, the arthritis develops at a time in their lives when they are most likely to experience loss of ability to work or participate in leisure activity due to the arthritis.
Nonsurgical (Cast Treatment) of Scaphoid Fracture
Because of the great potential for significant complications if the fracture goes on to non-union, every attempt is made to protect or stabilize the fracture. Cast treatment alone is reserved for only those fractures that are completely nondisplaced, and the cast may have to be worn for two, three, or even more months to get the bone to heal. Sometimes a bone stimulator (an electromagnetic or pulsed ultrasound generator) is prescribed to increase the chances of healing, especially in a fracture that is diagnosed late.
Example: 23-Year Old Man, Scaphoid Fracture Treated With Cast And Bone Stimulator
Surgery for Scaphoid Fracture
Most scaphoid fractures that have any displacement whatsoever are treated by surgery because the odds of healing are much greater with this type of treatment. In this surgery, a special headless screw is placed across the bone using a small incision in the wrist. Once the screw is placed, most patients do not require a cast unless the fracture was very severe or if there are concerns about bone quality. The screw is countersunk and therefore does not protrude from the bone. It very seldom causes any irritation of the wrist or needs to be removed.
Preop and Postop X-Rays Of Scaphoid Fracture Treated by Screw Fixation
X-ray of displaced scaphoid fracture at time of injury
X-ray of same fracture 2 months after surgery showing healing
Due to its poor blood supply, even despite cast treatment, approximately 10% of scaphoid fractures fail to heal (a scaphoid nonunion). This predictably leads to altered wrist mechanics and eventually, arthritis of the wrist. If cast treatment of a scaphoid fracture fails, then bone graft (bone removed from another part of the body, transplanted to the scaphoid nonunion site) and screw fixation is the preferred method of treatment. The source of this bone may be the patient’s wrist (distal radius) or hip (iliac crest graft).
Example: 46-Year Old Woman with Longstanding Scaphoid Nonunion Treated by Bone Graft from Distal Radius
Arthritis of the Wrist
Osteoarthritis of the wrist is inflammation of one or more joints in the wrist, which causes the destruction of cartilage. When cartilage is gone, the bones rub together resulting in pain, stiffness and weakness.
Conditions Affecting the Hand
When the tendons in the fingers or thumbs become inflamed due to repetitive movements or force, it is called trigger finger. Pain at the base of the finger is a typically symptom and sometimes the finger may even lock in a bent or straight position. Splints may be used along with steroid injections to treat the condition.
Flexor/Extensor Tendon Laceration
Flexor tendons are in the palm side of the hand and extensor tendons are in the knuckle side of the hand. Lacerations to these tendons can cause difficulty or inability to bend or straighten the fingers, depending on the severity.
Infections in the hands have many causes from a tiny puncture wound to bacteria exposure. Pain and stiffness in the hands and fingers may be a sign of infection.
A lacerated nerve in the hand can cause pain, numbness or weakness and sometimes requires surgical repair. Like any wound, cuts to the hands should be cleansed and dressed properly to prevent infection.
The fingertips can be injured in many different ways including crushing and cutting. Fingertip injuries can affect the skin, bone, nail, nailbed, tendon and the fleshy part of the tip. Treatment depends on the type and severity of the injury.
Fractures of the Fingers
Fractures of the hand and fingers are the most common fracture leading to an emergency room visit. These are often caused by crush injuries, finger-twisting injuries, or axial loading (such as from punching an object). Many of these injuries do not require surgical treatment. These fractures are further divided into:
- Metacarpal Fractures
- Proximal and Middle Phalanx Fractures
- Distal Phalanx Fractures
Fractures of the metacarpal often occur from an impact to a closed fist (such as punching an object) or a twisting injury to the fingers. They may also occur from a crushing injury to the hand. When nondisplaced, these fractures heal reliably with 3-4 weeks in a cast. Occasionally, a closed reduction (“straightening” of the bone under anesthesia) may be required prior to placing the cast. If the fracture is more severe and unstable, it is best treated surgically. This may be accomplished with any combination of pins, plates, or screws followed by hand therapy. When pins are used, these are usually temporary and are removed in the office 3-4 weeks after surgery (this is fairly painless and hurts no more than having stitches removed). Often, pins can be inserted without even making an incision. When screws and plates are used, an incision is necessary and the implants are usually permanent, but this allows the patient to begin moving the hand and fingers within a few days after surgery. A few examples of these treatment options are shown below.
Video: How a Cast for Treatment of Metacarpal Fractures is Made
Example 1: 60 year-old woman who struck the hand on the ground after tripping on a tree root. X-rays show a comminuted and displaced 5th metacarpal fracture, which was treated by plate and screws. She began hand therapy 3 days after surgery.
Proximal and Middle Phalanx Fractures
Like metacarpal fractures, proximal phalanx fractures are also extremely common. Many of these are also treated with splinting or casting, when the deformity is not great. However, when there is significant deformity or the fracture is unstable, internal fixation (surgery to realign and stabilize the fracture) is necessary. Whether or not surgery is chosen, stiffness of the fingers are a major problem with fractures of this type, and hand therapy is usually necessary to help the patient recover motion. Examples of treatment of these fractures are pictured below.
Example 1: Fracture of small finger proximal phalanx in a 65 year old woman with Dupuytren’s contracture affecting the same finger. Notice the obvious rotational deformity with the small finger pointing completely away from the ring finger. This was treated by closed reduction under local anesthetic followed by application of a specialized cast for 3 weeks. The healed fracture is seen at the right.
Example 2: Fracture of small finger proximal phalanx, rugby injury. This is an unstable fracture pattern with malrotation of the finger and was treated by plates and screws. The patient began hand therapy within 5 days of the surgery and did very well. Photos of the patient’s hand 4 months postop are seen at right.
Example 3: Example of a severe index finger middle phalanx fracture caused by crushing injury in a teenage girl, treated by closed reduction and pinning. From left to right: Xray taken at time of injury; Xray taken in the operating room after pin stabilization (no incision was made for this surgery – the large metal instrument coming in from the right is a tool holding the finger in position just for the Xray); Xray taken 4 months later after pin removal (pins were removed 3 weeks postop, in the office) and complete healing.
Distal Phalanx Fractures
These fractures usually occur from a crushing injury (see fingertip injuries) and often also have a major soft tissue injury or nail injury associated with them. Treatment is often more dictated by the soft tissue injury than by the fracture itself and may include simple splinting or pinning of the fracture. A special subtype of this injury is a “mallet fracture,” in which a small piece of bone is pulled up with the extensor tendon. Mallet fractures are usually treated with 4-6 weeks in a special splint to keep the fingertip straight, or in rare cases surgery if the fracture is large enough to cause joint dislocation.
Mallet finger, sometimes called baseball finger, is caused by injury to the tip of the finger in which the tendon that straightens the fingertip is damaged. If the fingertip will not straighten, medical treatment is needed to restore movement.
Dupuytren’s contracture is a condition in which the palmar fascia (the tough fibrous tissue just beneath the skin) contracts and tethers the skin, producing dimples, lumps, and cords in the palm of the hand and fingers. Occasionally this is seen on the soles of the feet, a condition known as Ledderhose’s Disease. The condition is benign (i.e. not a tumor) but the tissues can cause such severe contraction of the skin that the joints of the hand become curled and unable to straighten. Patients may notice difficulty placing the hand flat on a table, shaking hands, or sliding the hand into a glove or a pants pocket.
It is unknown why some people develop Dupuytren’s contracture and some do not. However, it most often occurs in middle-aged and older males, usually of Northern European descent. Once Dupuytren’s contracture occurs, it does not spontaneously resolve and the contractures are permanent unless treated by a hand surgeon.
Photographs of Dupuytren’s Contracture
This is a surgical procedure where the finger is straightened and the cords and nodules in the palm are removed. Usually this is followed by some hand therapy. Patients usually have excellent results and the rate of recurrence (fingers curling again in the future) is the lowest of all treatment options. The primary disadvantage of this treatment is that it involves surgery. Visual details of this surgery can be seen here (warning: graphic content).
This is a minimally invasive procedure done in the office, in which an enzyme is injected into the cord in the palm of the hand. Over the next 48 hours, the enzyme dissolves a portion of the cord. The patient returns the day after the injection or even the day after that, and under local anesthesia the surgeon forcibly manipulates the fingers into a straightened position, rupturing the cord. This is an attractive option because it is least invasive and offers the fastest recovery with no scarring. However, the rate of recurrence is higher than for surgical fasciectomy. This procedure is also much less effective when multiple fingers are involved or multiple joints are contracted, or when the proximal interphalangeal joint (“small knuckle”) is involved. Also, the cord is ruptured but not removed so patient still have a significant mass in the palm of the hand. Finally, at the present time for most patients, this option carries the highest out-of-pocket expense.
This involves numbing the hand and then using a large needle to repeatedly puncture the hand until the “cords” rupture, allowing the hand and fingers to straighten. The advantages of this treatment are that it does not leave scars on the hand and may be considered “minimally invasive”. The disadvantages are that only a few surgeons offer this form of treatment, and the rate of recurrence is the highest of all of the treatment options. Furthermore, the cord is simply broken up, but it remains in the hand and is not removed.
Last but not least, “watchful waiting” is a perfectly acceptable and harmless treatment option as long as the contractures are not interfering with the patient’s ability to use the hand or getting worse. To help decide which treatment is right for you, please make an appointment with one of our hand surgeons.
Arthritis of the Fingers and Thumb
Arthritis in the joints of the fingers and thumbs can be extremely painful and hinder a person’s ability to complete simple tasks. Finger and thumb arthritis may also cause deformities. Treatment includes heat application, exercise, anti-inflammatory medication and even surgery.