Common Conditions
Common conditions of the hand and upper extremity.
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problems from the bite.
When an animal bites, bacteria from its mouth can contaminate the wound. These bacteria may grow within the wound and cause an infection. The consequences of infection range from mild discomfort to
life-threatening complications.
Many factors may contribute to the infection, including the type and location of the wound, pre-existing health conditions in the bitten person that impair immunity, such as diabetes, HIV, etc., the extent of delay before treatment, the presence of a foreign body in the wound, and the animal causing the bite.
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The brachial plexus is a network of nerves that originate near the neck and shoulder. These nerves begin at the spinal cord in the neck and control the hand, wrist, elbow, and shoulder (see Figure 1). Nerves are the electrical wiring system in all people that carry messages from the brain to the rest of the body. A nerve is like an electrical cable wrapped in insulation.
Motor nerves carry messages from the brain to muscles to make the body move. Sensory nerves carry messages to the brain from different parts of the body to signal pain, pressure, and temperature. The brachial plexus has nerves that are both motor and sensory.
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When the skin comes in contact with something hot, it may be damaged, with death of cells in the skin. The depth of the injury depends on the intensity of the heat and the length of time that it is applied. If sufficiently severe, the full thickness of the skin can be destroyed, as well as tissues under it. Burns can also result from contact with certain chemicals.
What are the degrees of burn injury?
Burns are classified by the depth of injury, which helps determine the appropriate treatment (see Figure 1-2).
1st Degree: superficial—redness of skin without blisters
2nd Degree: partial thickness skin damage—blisters present
3rd Degree: full thickness skin damage—skin is white and leathery
4th Degree: as in third degree but with damage to deeper structures, such as tendons, joints, bone
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Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. In effect, it is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand. Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel and puts pressure on the nerve. When the pressure from the swelling becomes great enough to disturb the way the nerve works, numbness, tingling, and pain may be felt in the hand and fingers.
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Babies born with hands that are different than the normal hand have a congenital hand difference.
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Cubital tunnel syndrome is a condition brought on by increased pressure on the ulnar nerve at the elbow. There is a bump of bone on the inner portion of the elbow (medial epicondyle) under which the ulnar nerve passes. This site is commonly called the “funny bone” (see Figure 1). At this site, the ulnar nerve lies directly next to the bone and is susceptible to pressure. When the pressure on the nerve becomes great enough to disturb the way the nerve works, then numbness, tingling, and pain may be felt in the elbow, forearm, hand, and/or fingers.
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First dorsal compartment tendonitis, more commonly known as de Quervain’s tendonitis or tenosynovitis after the Swiss surgeon Fritz de Quervain, is a condition brought on by irritation or inflammation of the wrist tendons at the base of the thumb. The inflammation causes the compartment (a tunnel or a sheath) around the tendon to swell and enlarge, making thumb and wrist movement painful. Making a fist, grasping or holding objects—often infants—are common painful movements with de Quervain’s tendonitis.
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Dupuytren’s disease is an abnormal thickening of the fascia (the tissue just beneath the skin of the palm). It often starts with firm lumps in the palm. In some patients, firm cords will develop beneath the skin, stretching from the palm into the fingers. Gradually, these cords may cause the fingers to bend into the palm.
Although the skin may become involved in the process, the deeper structures—such as the tendons—are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).
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The elbow is a hinge joint comprised of 3 bones – humerus, radius and ulna. Ligaments hold the bones together to provide stability to the joint. Muscles and tendons originate and insert onto the bones around the elbow to provide force to move the bones and perform activities.
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Extensor tendons, located on the back of the hand and fingers, allow you to straighten your fingers and thumb (see Figure 1). These tendons are attached to muscles in the forearm. As the tendons continue into the fingers, they ecome flat and thin. In the fingers, these tendons are joined by smaller tendons from the muscles in the hand. It is these small-muscle tendons that allow delicate finger motions and coordination.
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Injured components may include skin, bone, nail, nailbed, tendon, and the pulp, the padded area of the fingertip (see Figure 1). The skin on the palm side of our fingertips is specialized in that it has many more nerve endings than most other parts of our body. These nerve endings enable the fine sensation we have in our fingertips, and they can also be damaged. When this specialized skin is injured, exact replacement may be difficult.
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The muscles that bend or flex the fingers are called flexor muscles. These flexor muscles move the fingers through cord-like extensions called tendons, which connect the muscles to bone. The flexor muscles start from the elbow and forearm regions, turn into tendons just past the middle of the forearm, and attach into the bones of the fingers.
In the finger, the tendons pass through fibrous rings called pulleys, which guide the tendons
and keep them close to the bones, enabling the tendons to move the joints much more effectively. Deep cuts on the palm side of the wrist, hand, or fingers can injure the flexor tendons and nearby nerves and blood vessels. The injury may appear simple on the outside, but is actually much more complex on the inside. When a tendon is cut, it acts like a rubber band, and its cut ends pull away from each other. A tendon that has not been cut completely through may still allow the fingers to bend, but can cause pain or catching and may eventually tear all the
way through. When tendons are cut completely through, the finger joints cannot bend on their own.
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Ganglion cysts are very common lumps within the hand and wrist that occur adjacent to joints or tendons. The most common locations are the top of the wrist, the palm side of the wrist, the base of the finger on the palm side, and the top of the end joint of the finger. The ganglion cyst often resembles a water balloon on a stalk, and is filled with clear fluid or gel. The cause of these cysts is unknown although they may form in the presence of joint or tendon irritation or mechanical changes. These cysts may change in size or even disappear completely, and they may or may not be painful. These cysts are not cancerous and will not spread to other areas.
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The hand is made up of many bones that form its supporting framework. This frame acts as a point of attachment for the muscles that make the wrist and fingers move. A fracture occurs when enough force is applied to a bone to break it. When this happens, there is pain, swelling, and decreased use of the injured part. Many people think that a fracture is different from a break, but they are the same. Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to displace or shift. Some fractures occur in the shaft (main body) of the bone, others break the joint surface. Comminuted fractures (bone is shattered into many pieces) usually occur from a high energy force and are often unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin. There is some risk of infection with compound fractures.
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Hand Therapy is a type of rehabilitation performed by an occupational or physical therapist on patients with conditions affecting the hands and upper extremities. Such therapy is performed by a provider with a high degree of specialization that requires continuing education and, often, advanced certification. This enables the hand therapist to work with patients to hasten their return to a productive lifestyle.
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Any abnormal lump or bump is considered a tumor. A tumor can also be referred to as a “mass”. The term “tumor” does not necessarily mean it is malignant or it is a cancer. In fact, the vast majority of hand tumors are benign or non-cancerous. Any lump or bump in your hand is a tumor regardless of what causes it.
Hand tumors can occur on the skin, like a mole or a wart, or can occur underneath the skin in the soft tissue or even the bone. Because there are so many tissue types in the hand (e.g. skin, tendon, fat, ligaments, bone, etc) there are many types of tumors that can occur. However, only a few of them are seen commonly.
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Hand infections can cause severe problems that persist even after the infection has resolved, such as stiffness, loss of strength, and even loss of tissues such as skin, nerve and even bone. Thus early and aggressive treatment of hand infections is essential. When seen early, some types of infection can be treated with antibiotics and local rest and soaking. However many infections begin to cause severe problems, even after a day or two, if not treated with antibiotics, surgical drainage, and removal of infected tissues. Any drainage or pus should be sent for laboratory testing to determine the type of bacteria causing the infection and the appropriate antibiotic for treatment.
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In a normal joint, bones have a smooth, glistening surface made of a substance called articular cartilage on their ends that allows one bone to glide easily against another. Joints are lubricated by a thin layer of fluid (synovial fluid) that acts like oil in an engine to keep moving parts gliding smoothly. When the articular cartilage wears out or is damaged or the joint fluid is abnormal, problems develop and joints often become stiff and painful – that’s arthritis. There are many types of arthritis, but the basic problem is the same in all types: the joint surfaces are worn out or not moving properly. In some cases, it may be possible to treat arthritic joints surgically, including “joint replacement” procedures.
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Kienbock’s disease is a problem in the wrist caused by the loss of blood supply to the lunate. The lunate is one of the eight small bones that make up the “carpal bones” in the wrist (see Figure 1). There are two rows of bones: one closer to the forearm, the “proximal row;” the other closer to the fingers, the “distal row.” The lunate bone is in the center of the proximal row. It is next to the scaphoid bone, which spans the two rows.
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Injuries to the nail are often associated with damage to other structures that are in the same location. These include fractures of the bone (distal phalanx), and/or cuts of the nailbed, fingertip skin (pulp), tendons that straighten or bend the fingertip, and nerve endings.
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It may not be Carpal Tunnel syndrome (CTS). Although carpal tunnel syndrome is common, it is not the only cause of numbness, tingling, and pain in the forearm and hand. Most of the lay public and some of the medical community are not aware of other causes, so numbness, tingling and pain may be mistakenly thought to be coming from carpal tunnel syndrome. These symptoms can be caused by many other conditions.
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Arthritis literally means “inflamed joint”. Normally a joint consists of two smooth, cartilage-covered bone surfaces that fit together as a matched set and that move smoothly against one other. Arthritis results when these smooth surfaces become irregular and don’t fit together well anymore and essentially “wear out.”
Arthritis can affect any joint in the body, but it is most noticeable when it affects the hands and fingers. Each hand has 19 bones, plus 8 small bones and the two forearm bones that form the wrist. Arthritis of the hand can be both painful and disabling. The most common forms of arthritis in the hand are osteoarthritis, post-traumatic arthritis (after an injury), and rheumatoid arthritis. Other causes of arthritis of the hand are infection, gout, and psoriasis.
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“Replantation” refers to the surgical reattachment of a finger, hand, or arm that has been completely cut from a person’s body (see Figure 1). The goal of replantation surgery is to give the patient back as much use of the injured area as possible. In some cases, replantation is not possible because the part is too damaged. If the lost part cannot be reattached, a patient may have to use a prosthesis (a device that substitutes for a missing part of the body). In many cases, a prosthesis may give a person without hands or arms the ability to function better than they would without the prosthesis.
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Arthritis literally means “inflamed joint.” Normally a joint consists of two smooth, cartilage-covered bone surfaces that fit together as a matched set and that move smoothly against one other. Arthritis results when these smooth surfaces become irregular and don’t fit together well anymore and essentially “wear out.” Arthritis can affect any joint in the body, but it is most noticeable when it affects the hands and fingers. Each hand has 19 bones, plus 8 small bones and the two forearm bones that form the wrist.
Arthritis of the hand can be both painful and disabling. The most common forms of arthritis in the hand are osteoarthritis, post-traumatic arthritis (after an injury), and rheumatoid arthritis. Other causes of arthritis of the hand are infection, gout, and psoriasis.
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The rotator cuff is the confluence of the tendons of four muscles that encompass the ball joint (humeral head) of the shoulder (see Figures 1, 2). The muscles originate on the shoulder blade (scapula) and attach (insert) on the arm bone (humerus). The rotator cuff has two functions. It provides stability to the shallow shoulder (glenohumeral) joint. Its second function is to provide motors (muscles) to move the shoulder. As time passes and we age, so does the rotator cuff. The rotator cuff tendon degenerates with age. It may also undergo wear and tear as
it rubs between the acromion (tip of the shoulder blade) and the humeral head. It may become thickened and inflamed, which may be described as impingement syndrome. Changes can vary from microscopic tears and bursitis to large tears. The symptoms include pain, weakness, restricted motion, a feeling of instability, catching, and locking. Rotator cuff pathology is really a continuum or a spectrum of abnormalities ranging from a normal, asymptomatic aging process to endstage arthritis and instability caused by absence of the rotator cuff.
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Reflex sympathetic dystrophy (RSD), also known as chronic regional pain syndrome, is characterized by pain, swelling and abnormal sympathetic nerve activity in the affected hand or extremity. The pain is out of proportion to the injury that triggered it. RSD is usually associated with an injury, which can sometimes be as minor as a paper cut or small bruise. It causes nerves to misfire and send frequent or constant pain signals to the brain. The sympathetic nerves become overactive, causing intense burning or aching pain, along with swelling and changes in skin color, moisture, and temperature.
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The scaphoid bone is one of the eight small bones that comprise the wrist joint. The two rows of small wrist bones act together to allow the wide variety of wrist positions and motions that we take for granted. The scaphoid bone spans or links these two rows together and, therefore has a special role in wrist stability and coordinating wrist motion.
The scaphoid bone is vulnerable to fracture because of its position within the wrist and its role in wrist function. When the scaphoid bone is broken, it may not heal properly because it has a very fragile blood supply. Scaphoid fractures that do not heal are referred to as a scaphoid non-union. Ultimately, scaphoid nonunions can lead to loss of wrist motion and eventual wrist arthritis.
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The scaphoid bone is one of eight small bones that make up the “carpal bones” of the wrist. There are two rows of bones, one closer to the forearm (proximal row) and the other closer to the hand (distal row). The scaphoid bone is unique in that it spans the two rows (see Figure 1). This puts it at extra risk during injury, which accounts for it being the most commonly fractured carpal bone by far.
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The shoulder is a joint suspended by many muscles surrounding the upper extremity. The shoulder bones include the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone). (see Figure 1) The only connection of the shoulder girdle to the remainder of the skeleton is the clavicle. The scapula is an important part of the shoulder joint as it serves as an anchor for many muscles and contains the socket part of the shoulder (glenoid). The upper end of the humerus has a ball-like shape that articulates with the socket, and the humerus also serves as an attachment point for many muscles and tendons. One of the most important is the rotator cuff. Disruption of any of these parts can create difficulty with the function of the shoulder.
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The hands, being composed of many types of tissue, including blood vessels, nerves, skin and skin-related tissues, bones, and muscles/tendons/ligaments, may show changes that reflect a disease that affects other parts of, or even the whole body (systemic diseases). The hands may show changes noticed by the patient or his/her hand surgeon
even before the systemic disease is detected.
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Tendon transfer surgery is a type of hand surgery that is performed in order to improve lost hand function. A functioning tendon is shifted from its original attachment to a new one to restore the action that has been lost.
Who Needs Tendon Transfer Surgery?
Many different conditions can be treated by tendon transfer surgery. Tendon transfer surgery is necessary when a certain muscle function is lost because of a nerve injury. If a nerve is injured and cannot be repaired, then the nerve
no longer sends signals to certain muscles. Those muscles are paralyzed and their muscle function is lost. Tendon transfer surgery can be used to attempt to replace that function. Common nerve injuries that are treated with tendon transfer surgery are spinal cord, radial nerve, ulnar nerve, or median nerve injury.
Tendon transfer surgery may also be necessary when a muscle has ruptured or been lacerated and cannot be repaired. Common muscle or tendon injuries that are treated with tendon transfer surgery are tendon ruptures due to rheumatoid arthritis or fractures. Also, tendon lacerations that cannot be repaired after injury may be treated with tendon transfer surgery.
Tendon transfer surgery may also be needed if a muscle function has been lost due to a disorder of the nervous system. In this situation, the nervous system disease or injury prevents normal nerve signals from being sent to a muscle, and imbalance in hand function occurs. The muscle imbalance or muscle loss due to nervous system disease may be treated with tendon transfers.
Common nervous system disorders treated with tendon transfer surgery are cerebral palsy, stroke, traumatic brain injuries, and spinal muscle atrophy. Finally, there are some conditions in which babies are born without certain muscle functions. In these situations, the missing muscle functions can sometimes be treated with tendon transfer surgery. Common conditions treated this way include hypoplastic thumbs and birth brachial plexopathy.
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Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons anchor the muscle to bone. The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist. With lateral epicondylitis, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.
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In a normal joint, cartilage covers the ends of the bones and allows them to move smoothly and painlessly against one another. In osteoarthritis (or degenerative arthritis), the cartilage layer wears out, resulting in direct contact between the bones. In the hand, the second most common joint to develop osteoarthritis is the joint at the base of the thumb. The thumb basal joint, also known as the carpometacarpal (CMC) joint, is a specialized saddle-shaped joint that is formed by a small wrist bone (trapezium) and the first of the three bones in the thumb (metacarpal). The specialized shape of this joint allows the thumb its wide range of movement—up and down, across the palm, and the ability to pinch with the fingers.
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A sprain is an injury to a ligament. Ligaments are the connective tissues that connect bones to bones across a joint.
How do thumb sprains occur?
These types of injuries are common in sports and falls. The thumb is jammed into another player, the ground, or the ball. The thumb may be bent in an extreme position, causing a sprain. The thumb will usually swell and may show bruising. It is usually very painful to move.
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Stenosing tenosynovitis, commonly known as “trigger finger” or “trigger thumb”, involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm
with the bones of the fingers and thumb. 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. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys.
Trigger finger/thumb occurs when the pulley at the base of the finger becomes 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 increased resistance to the gliding of the tendon through 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.
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Vascular disorders of the upper-extremity are uncommon, but ones that may have lasting implications.
Anatomy
Arteries bring oxygenated blood from the heart to the fingertips and veins return the used blood back to the heart and lungs. At the level of the wrist 2 major arteries bring blood into the hand: the radial and ulnar arteries. Variations in the anatomy are common, though, which may affect the way blood flow ultimately reaches each finger.
Causes
There are many causes of vascular problems. They can be classified into 5 groups: traumatic, compressive, occlusive, tumors/malformations and vasospastic (spasm of the artery, which reduces its diameter and thus its blood flow). Vascular problems may occur more commonly in individuals with certain diseases such as diabetes, hypertension, or kidney failure, or in dialysis patients. Occupational exposure (vibrating tools, cold) can be a factor, and smoking also can aggravate and cause vascular disease.
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Arthroscopy is a minimally invasive technique of visualizing the inside of a joint. The word arthroscopy comes from two Greek words, “arthro” (joint) and “skopein” (to look). The wrist is a complex joint made up of many bones and ligaments, which hold the bones together. Wrist arthroscopy allows the surgeon to diagnose and treat many problems of the wrist through a series of very small incisions (portals).
In the last 5 years, the wrist has become the third most common joint to undergo arthroscopy, after the knee and shoulder. Because the incisions used with wrist arthroscopy are smaller and disrupt less soft tissue than conventional open surgery, pain, swelling and stiffness are minimized and recovery is often faster.
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The wrist is made up of eight small bones and the two forearm bones, the radius and ulna (see Figure 1). The shape of the bones allows the wrist to bend and straighten, move side-to-side, and rotate, as in twisting the palm up or down. A fracture may occur in any of these bones when enough force is applied, such as when falling down
onto an outstretched hand. Severe injuries may occur from a more forceful injury, such as a car accident or a fall off a roof or ladder. Osteoporosis, a common condition in which the bone becomes more brittle, may make one more susceptible to getting a wrist fracture.
The most commonly broken bone of the wrist is the radius (see Figure 1). Many people think that a fracture is different from a break, but they are the same. When the wrist is broken, there is pain, swelling, and decreased use of the hand and wrist. Often the wrist appears crooked and deformed. Fractures of the small wrist bones, such as the
scaphoid, are unlikely to appear deformed. Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to displace or shift, in which case the wrist is more likely to appear crooked. Some fractures break the normally smooth, ball bearing-like joint surface; others will be near the joint but leave the joint surface intact. Sometimes the bone is shattered into many pieces, which usually makes it unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin. There is some risk of
infection with compound fractures.
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A sprain is an injury to a ligament. Ligaments are the connective tissues that connect bones to bones; they could be thought of as tape that holds the bones together at a joint.
How do wrist sprains occur?
These types of injuries are common in falls and sports. The wrist is usually bent backwards when the hand hits the ground such as when someone slips or trips and falls. These injuries also frequently occur during sports such as football and snowboarding. After injury, the wrist will usually swell and may show bruising. It is usually very painful to move.
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Nerves are the “telephone wiring” system that carries messages from the brain to the rest of the body. A nerve is like a telephone cable wrapped in insulation. An outer layer of tissue forms a cover to protect the nerve, just like the insulation surrounding a telephone cable (see Figure 1). A nerve contains millions of individual fibers grouped in bundles within the “insulated cable.”
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