Chronic Conditions

Carpal Tunnel Syndrome

What is it?

Compression of the median nerve as it passes through the wrist (carpal tunnel).

What is the cause?

  • Most are unknown (idiopathic)
  • Some are related to conditions that increase the contents of the carpal tunnel eg pregnancy, thyroid disease, or inflammatory arthritis

What are the symptoms?

  • MILD: Intermittent paraesthesia (pins and needles) or numbness in the thumb, index, and middle finger. Classically at night waking patients up
  • MODERATE: Persistent numbness or paraesthesia
  • SEVERE: Numbness and thumb weakness/ wasting

What are the treatment options?

  • MILD – night splints, activity modification. Non-urgent surgical review
  • MODERATE – surgery. Urgent surgical review
  • SEVERE – surgery. Urgent surgical review

When should I see a Surgeon?

  • all moderate and severe carpal tunnel requires surgical review

Cubital Tunnel Syndrome

What is it?

Compression of the ulnar nerve at the elbow (cubital tunnel).

What is the cause?

  • unknown (idiopathic)
  • can be related to repeated pressure on medial elbow eg resting elbows on a desk at work

What are the symptoms?

  • paraesthesia/ numbness in the little and ring fingers
  • weakness of the small muscles of the hand

What are the treatment options?

  • sensory symptoms only – hand therapy, lifestyle modification
  • motor symptoms – surgery to release +/- transpose the ulnar nerve

When should I see a Surgeon?

  • persistent sensory or motor symptoms

De Quervain’s Tenosynovitis

What is it?

Compression of the abductor pollicis longus and extensor pollicis brevis tendons within the 1st extensor compartment.

What is the cause?

  • overuse (wrist extension/ radial deviation)
  • swelling of the extensor retinaculum

What are the symptoms?

  • pain over the dorsal radial wrist and base of thumb

What are the treatment options?

  • Step 1: rest, splint, Voltaren gel, NSAIDs
  • Step 2: steroid injection
  • Step 3: surgery

When should I see a Surgeon?

  • symptoms persist after step 1

Dorsal Wrist Ganglion

What is it?

A synovial cyst originating from the scapholunate ligament.

What is the cause?

  • trauma
  • incidental ganglions diagnosed on a CT or MRI are extremely common and most do not require any treatment

What are the symptoms?

  • dorsal wrist swelling
  • pain (note there are many causes of wrist pain and the ganglion may be incidental)

What are the treatment options?

  • needle aspiration (+/- steroid injection) – high recurrence rate
  • rupture cyst (hit it with a bible) – high recurrence rate
  • surgery – excise cyst and debride scapholunate ligament

When should I see a Surgeon?

  • if the cosmetic deformity or pain is bad enough to require surgery

Mucous Cyst

What is it?

A ganglion arising from the distal interphalangeal joint.

What is the cause?

  • osteophytes from osteoarthritis

What are the symptoms?

  • grooved nail deformity
  • swelling under the skin which may discharge clear mucin

What are the treatment options?

  • surgery – excise the cyst (symptom), and debride the osteophytes (cause)

When should I see a Surgeon?

  • if the cosmetic deformity is bad enough to warrant surgery
  • if the cyst is draining through the skin or the skin is very thin over the cyst – there is a risk of septic arthritis of the distal interphalangeal joint if left untreated

Ganglion of Finger or Tendon Sheath

What is it?

Synovial cyst originating from the tendon sheath.

What is the cause?

  • idiopathic

What are the symptoms?

  • lump
  • pain

What are the treatment options?

  • surgery – excise cyst and debride tendon sheath

When should I see a Surgeon?

  • if the cosmetic deformity or pain is bad enough to require surgery

Dupuytren’s Disease

What is it?

Contracture of the palmar fascia between the skin and underlying flexor tendons.

What is the cause?

  • genetic (northern European ancestry)

What are the symptoms?

  • lumps, cords
  • finger contracture
  • other sites of contracture: dorsal fingers (Garrod’s pads), soles of feet (Ledderhose disease), and penis (Peyronie’s disease)

What are the treatment options?

  • needle fasciotomy
  • collagenase injections
  • surgery

When should I see a Surgeon?

  • when you are unable to place the fingers flat on the table
  • when the finger flexion impairs function eg playing golf
  • Dupuytren’s is incurable, so the aim of surgery is to make the fingers straight. Recurrence is expected.

Trigger Finger & Thumb

What is it?

The flexor tendons are swollen and catch (trigger) in the tendon tunnel at the A1 pulley in the palm (site of maximum pain).

What is the cause?

  • idiopathic
  • more common in diabetics

What are the symptoms?

  • pain
  • clicking, triggering, and occasionally a locked digit in flexion

What are the treatment options?

  • steroid injection (50% of patients have no symptoms at 12 months)
  • surgery

When should I see a Surgeon?

  • when it is bad enough to need a steroid injection or it’s causing functional impairment

Inflammatory Arthritis eg Rheumatoid Arthritis or Psoriatic Arthritis

What is it?

Autoimmune arthritis with synovitis

What is the cause?

  • autoimmune
  • psoriasis

What are the symptoms?

  • hand and wrist pain
  • swelling
  • finger and wrist deformity

What are the treatment options?

  • medical therapy (immunosuppression): directed by a Rheumatologist
  • surgery (when failing medical treatment)

When should I see a Surgeon?

  • when directed to by a Rheumatologist

Finger Osteoarthritis

What is it?

The cartilage articular surfaces of the joints erode away, and the underlying bony surfaces come into contact.

What is the cause?

  • trauma
  • genetic
  • age

What are the symptoms?

  • pain
  • bony lumps (osteophytes) around the distal and proximal interphalangeal joints

What are the treatment options?

  • “the aim is to manage the pain in the simplest possible way”
  • Step 1: rest, activity modification, splints, Voltaren gel, NSAIDs
  • Step 2: steroid injection
  • Step 3: surgery
    • joint fusion (arthrodesis): (the downside is loss of mobility)
    • joint replacement (arthroplasty): (the downside is loss of stability)

When should I see a Surgeon?

  • when the pain recurs after Step 1

Thumb Osteoarthritis

What is it?

The cartilage articular surfaces of the joints erode away, and the underlying bony surfaces come into contact

What is the cause?

  • trauma
  • genetic
  • age

What are the symptoms?

  • pain
  • squaring off at the base of the thumb

What are the treatment options?

  • “the aim is to manage the pain in the simplest possible way”
  • Step 1: rest, activity modification, splints, Voltaren gel, NSAIDs
  • Step 2: steroid injection
  • Step 3: surgery
    • trapeziectomy: (downside is loss of stability)
    • CMC joint fusion (arthrodesis): (downside is loss of mobility)

When should I see a Surgeon?

when the pain recurs after Step 1

Wrist Osteoarthritis

What is it?

The cartilage articular surfaces of the joints erode away, and the underlying bony surfaces come into contact

What is the cause?

  • trauma
  • genetic
  • age

What are the symptoms?

  • pain
  • swelling
  • stiffness

What are the treatment options?

  • “the aim is to manage the pain in the simplest possible way”
  • Step 1: rest, activity modification, splints, Voltaren gel, NSAIDs
  • Step 2: steroid injection
  • Step 3: surgery
    • arthroscopy: diagnostic and therapeutic
    • limited wrist fusion (midcarpal fusion)
    • total wrist fusion
    • excision arthroplasty (proximal row carpectomy)
    • joint replacement arthroplasty (limited role)

When should I see a Surgeon?

  • when the pain recurs after Step 1

Ulnocarpal Abutment Syndrome

What is it?

Some people are born with the ulna bone more prominent (longer) than the radius (ulna positive variance).

What is the cause?

  • genetic

What are the symptoms?

  • ulna side wrist pain
  • clicking

What are the treatment options?

  • arthroscopy: diagnostic and therapeutic
  • surgery: ulna shortening osteotomy

When should I see a Surgeon?

  • all patients should have a surgical review