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
For more information click here
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.
For more information click here
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