The hand is a complex structure. Tightly packed beneath the skin are arteries, veins, nerves, tendons, ligaments, and bones, which work together to deliver sensation, dexterity, strength and suppleness. Should anything interfere with these functions, it is essential that your diagnosis and treatment be performed by a surgeon with specialised knowledge of the anatomy and training in surgery of the hand.
Trigger Finger (Stenosing Tenosynovitis)
The tendons which move the fingers and thumb, run in special lubricated tunnels called sheaths. Within the sheath walls are strong fibrous bands called pulleys which confine the tendons close to the bones of the finger so that they do not “bowstring” when the fingers are flexed (curled).
“Trigger finger” arises when the smooth running of the tendon is blocked by a thickening of the tendon jamming against the constriction of the first pulley as it enters the finger. The flexed finger can no longer smoothly straighten and this causes pain and tenderness. When it suddenly straightens there may be a painful “click”. In severe cases, patients may need to use the other hand to straighten the affected finger.
The initial treatment of trigger finger may involve splinting, and avoiding activities that worsen the condition. Steroid injections can be performed in the outpatient clinic, and can provide a complete resolution in mild cases, and relief in more severe cases.
The surgical treatment of trigger finger is usually carried out under local anaesthetic. A small incision is made at the base of the finger. Whilst protecting the nerves to the finger, the surgeon releases the tight pulley, and after checking that the tendon moves freely, the skin is sutured. A dressing is required for 10-14 days, but light activities can be performed during this time. As with all hand surgery, we recommend elevating the hand as much as possible during the recovery period.
A ganglion is a cyst containing synovial fluid that has leaked from a joint. Patients notice a swelling, which is sometimes uncomfortable or painful. Many ganglion cysts will resolve spontaneously, but treatment can be carried out for those which are causing problems.
The simplest method of treatment is aspiration of the cyst, in which the contents are removed with a needle. Steroid can be injected in at the same time. Unfortunately, recurrence of the cyst is not uncommon after simple aspiration.
Even with surgical excision, there is a risk of recurrence of the ganglion in approximately one in three cases. Depending upon the location of the ganglion, nearby nerves can be at risk during surgery. All surgery carries a risk of stiffness or persistent pain.
In the palm of the hand there is a three dimensional fibrous structure whose function is to anchor the skin of the palm to the underlying skeleton. This “palmar fascia” prevents the skin sliding about when the hand grips an object. Elsewhere in the body the skin is freely mobile.
Dupuytren’s Disease is a contracture of this palmar fascia. The reason for this contracture is unknown but it can run in families especially of Northern European origin. The condition sometimes occurs after trauma or surgery, and is slightly associated with diabetes, smoking and alcohol consumption, although most sufferers have none of these risk factors.
Dupuytrens is not usually painful, but it can be extremely debilitating. In its early stages, it presents with lumps and pits in the skin of the palm. Bands of fibrous tissue develop within the fascia and as they tighten and contract, the fingers may be forced to flex and curl up. The speed with which this happens varies. Surgery is generally of benefit if the palm can no longer be laid flat on the table but constraints on NHS funding may require greater deformity to be established.
The aim of surgical treatment is to remove diseased fascia and skin and to allow straightening of the fingers before permanent deformity develops. Some cases can be treated with a simple division of a fibrous cord using a needle, and this can be done in the outpatient clinic. In mild cases requiring surgery, all that might be needed is the removal of a small section of diseased fascia. In severe cases skin grafts may be required, and if joints have been bent for prolonged periods, then the ligaments to those joints might need to be released to allow straightening. Sometimes it is not possible to fully correct the deformity
The progress of Dupuytrens contracture cannot be cured but, by removing the affected tissue, the fingers can be straightened and function restored. Depending upon the individual rate of progress, the disease will eventually recur and half of patients require surgery again within five years.
Carpal Tunnel Syndrome
Most of the tendons and one of the major nerves passing from the forearm and entering into the hand traverse a channel bounded behind by the wrist bones and roofed in by a strong and firm fibrous band. This is known as the carpal tunnel. In this confined space, the large median nerve is vulnerable to compression should any of the other structures swell. This gives rise to “carpal tunnel syndrome”.
The symptoms consist of tingling and numbness in the thumb and fingers, usually sparing the little finger. In severe cases patients may find that their hand becomes clumsy and weak. In the worst cases the muscles in the thumb base waste away, and the tingling or numbness become continuous.
Many conditions such as diabetes, pregnancy, thyroid problems and rheumatoid arthritis can pre-dispose patients to this condition but in most cases there is no such cause.
Carpal tunnel syndrome may respond to splinting, especially if it is only a problem at night. Steroid injections performed in clinic may settle the problem, but many patients require surgery. The operation known as Carpal Tunnel Decompression is generally performed under local anaesthetic. A cut is made in the palm of the hand, and the tight fibrous band or ligament is divided. The surgery is generally straightforward, although in severe cases the recovery can be incomplete. If the nerve has been severely crushed for a long period of time, then sensation and muscle function may not fully return. Patients usually return to light duties after about two weeks, although it takes about three months to return to full normal pain free activities such as heavy lifting.