1. Carpal tunnel syndrome
Carpal tunnel syndrome initially presents with an indefinite feeling of heaviness in the wrist. This is gradually evolving into numbness which reaches the first three fingers, mainly the thumb and forefinger, sometimes the fourth (middle) and still never the little finger. The numbness is initially occasional and in some movements but then becomes permanent.
Many patients wake up at night and shake their hand to get rid of numbness. Daily movements that reproduce the symptoms are: holding a book or phone, driving and so on. Carpal tunnel syndrome can also have pain in the hand , which extends to the fingers but also over the wrist, sometimes up to the shoulder. weakness in fine movements .
Situations that cause or worsen this pressure are:
• local injury to the wrist, either immediate in an accident, or (most often) mild and everyday eg in front of computers, compressor workers, etc.
• pregnancy, menopause and treatment with contraceptives
• other conditions such as rheumatoid arthritis, diabetes mellitus, hypothyroidism, gout, rheumatic polymyalgia. Especially if the syndrome is in both hands, the chance of such a disease is high
• kidney patients with arteriovenous fistula.
The diagnosis of the syndrome is made by the history and the clinical examination and is confirmed by the neurophysiological examination (electromyogram).
The same or similar symptoms may occur in:
1. nerve pressure in the neck eg in intervertebral disc herniation . If there is such a suspicion, you need to check the neck with magnetic resonance
2. thoracic outlet syndrome
3. pressure of the median nerve not in the wrist but more centrally eg in the area of the forearm (pronator teres syndrome)
* in rare cases there may be pressure on the nerve at two points (double crush syndrome) ie in the neck and wrist
In the initial stages the treatment is conservative , with rest, splints and medications (painkillers, anti-inflammatory, antiepileptic or cortisone). If daily work strains the wrist, it is good to take breaks to rest.
Cortisone injections are sometimes used topically in the area.
When the symptoms are severe and permanent and especially when there is weakness in the arm, the solution is surgery, with decompression of the median nerve.
2. Wrist ganglion
The etiology of simple ganglion still remains unclear today and most researchers have come up with three main versions:
The ganglia are derived from serous membrane projections,
They are cystic formations,
The ganglia are the most common cystic swellings of the soft tissues of the hand and wrist and correspond to 2/3 of the benign tumors of the hand, which are closely connected to the joints or tendon sheaths and contain myxoid material.
The most common ganglia are located on the dorsal surface of the wrist, at a rate of 60-70% and protrude from the scapular joint. Next are the ganglia of the anterior surface of the wrist which protrude from the carpus-carpal joint or from the boat-polygonal joint.
The third most common area comes from the sheath of the flexor tendons of the fingers. The ganglia of the wrist area most often cause cosmetic disorders and pain when they "emerge". Many patients, despite being assured that they are benign nodules, are terrified of their tumor, fearing some malignancy. It can be noticed suddenly or appear gradually, while my size fluctuates, depending on how tired our hand is. The ganglia have a smooth and transparent surface of fibrous tissue and a wall of various thicknesses, which contains a clear myxoid substance, consisting of glucosamine, albumin, globulin and high density hyaluronic acid.
The ganglion is relatively easy to diagnose due to its location, softness and light transparency. Sometimes it is necessary to take x-rays to rule out arthritis or bone tumor and to perform an ultrasound to determine the texture of the formation (hemangioma, lipoma, etc.).
Treatment of ganglia is conservative and surgical . The ganglia have a high rate of recurrence, ie recurrence. The reasons that will lead us to deal with them are:
Pain from the pressure of the nerves or from the friction of the tendons
Conservative treatment is done by puncturing the ganglion with a fine needle, filling the ganglion with local anesthetic and steroids, and splitting the wall with multiple holes from the needle in different directions. This treatment is satisfactory, very fast and leaves no scars. Relapses are treated in the same way.
Surgical treatment is the radical excision of the ganglion, usually in superficial ganglia, under local anesthesia, in a fully equipped clinic. It usually takes about 20 minutes. The patient does not need to stay in the clinic and leaves immediately afterwards for home. Finger movements are encouraged from the first moment.
In the ganglia, there is always the possibility of their recurrence, at the same or a different point.
3. De Quervain disease
Two of the main tendons for the thumb run through a tube (sheath) located at the level of the wrist on the side of the thumb. The tendons are covered by a layer of thin, slimy tissue that resembles the synovial membrane, the peritoneum. This layer of tissue allows the tendons to slide easily into the fibrous tubes called sheaths.
Due to a swelling of the tendons and / or thickening of the sheath, there will be increased friction and consequently pain when specific movements of the thumb or wrist are made.
Repeated minor injuries, rheumatoid arthritis, but also overuse of the hand are the most common causes of the condition. De Quervain syndrome usually occurs in people aged 30 to 60 years. Women are affected more often than men.
The primary symptom is pain in the thumb at the level of the wrist. in the "anatomical cigarette case". It can develop suddenly or gradually. It can start progressively with reflection on the thumb and forearm or even cause sleep arousal. The pain becomes more intense with the use of the thumb (abduction and the extension of the thumb) and mainly in the intense grip, the lateral grip and turning, as, for example, in the use of the key. Slight swelling may also occur on the groin side of the wrist. Due to the pain and swelling, the movement of the thumb is limited.
Sensation on the "anatomical cigarette case" is palpable. Pain during abduction or and the length of the thumb and a snort can be felt along the lumbar surface of the forearm. The Finkelstein's test is positive. In this test, the patient makes a fist with the thumb placed on the palm and bends the wrist. This test will cause pain to patients with this problem.
Initial treatment consists of:
Anti-inflammatory medication. Oral anti-inflammatory drugs. However, their long-term use is not recommended.
Avoid activities that cause pain and swelling. This fact alone can eliminate the symptoms.
Cortisone. In many cases, the affected area is injected with a steroid (cortisone) and because it is a powerful anti-inflammatory, it helps reduce swelling. But cortisone abuse is harmful.
If the conservative treatment does not address the pain and dysfunction of the patient, the surgery will give the final treatment.
The purpose of the surgery is to release the tendons from their sheath so that they can function normally without the friction that creates the vicious cycle of inflammation.
After the end of the surgery, the wrist and the hand are covered with a special cotton tape and an elastic bandage.
4. Trigger finger
It is called stenotic tendonitis of the flexor tendons in the palm. The tendon may show some friction and irritation as it moves through the canal. As it becomes more intense, the tendon itself and its sheath can thicken, making it difficult to move through the canal. In fact, small nodules can form which can make it almost impossible to enter the canal.
In the protruding finger, the tendon may stick into the canal and temporarily make it impossible to extend the finger. You may need the help of the other hand to open the finger and jump suddenly.
The causes in most cases are unknown. There are some predisposing factors such as:
More common in women
After manual work
The most common symptoms include:
Pain when moving the affected finger
Bending of the finger during flexion that is often ejected in an attempt to extend it
A palpable and sensitive formation - a ball in the palm
In advanced cases the finger remains in flexion
The symptoms are usually worse in the morning and after a long period of immobility.
Diagnosis is made by history and clinical examination.
Treatment with non-steroidal anti-inflammatory drugs can reduce symptoms along with a period of rest.
The decision for surgery depends on the patient himself and his symptoms. In advanced cases where there is permanent stiffness, surgery is inevitable.
The operation is performed under local anesthesia. It does not require hospitalization and lasts about 10 minutes.
During the operation, a small incision is made about 1cm in the palm near the base of the finger. The canal is then opened and the tendon is released.
5. Dupuytren disease
It presents in 3 forms (acute, subacute and chronic) mainly in adults over 40-60 years and is bilateral in half of the cases. There is also an inherited predisposition and it is more common in people suffering from chronic diseases such as epilepsy, diabetes and alcoholism. It affects women to a lesser extent and often the hands are used less, so it is not considered work-related. It also affects the sole of the foot (Ledderhosen disease), as well as the penis (Peyronie's disease).
The clinical picture evolves chronically . At first there is a small subcutaneous nodule on the palm at the base of the middle or little finger and to a lesser extent on the thumb and forefinger. Gradually the palmar denervation thickens and the nodule adheres to the skin. In part of the denervation, an elongated string appears, which extends from the palm to one or more fingers. At the same time, narrowing of the metacarpophalangeal and then the first phalangeal joints begins. Prolonged contraction usually leads to real joint stiffness and thinning of the skin.
Infection of the palmar nerve and its shedding can affect its part towards any finger. In chronic conditions, the fingers can be bent towards the palm tightly, due to the secondary contraction of the joint pockets and the joints of the finger joints, but also the thinning of the skin, which is infiltrated by the affected vertical fibers.
When the palmar nerve is affected, it causes local pain and at the beginning, a mass of infiltrating fibroblasts is produced in the superficial part of the palm. The thickening may be nodular and resemble a rope-like abnormal tendon or callus, which constantly holds the metacarpophalangeal joint of the finger in flexion, infiltrates the skin and shrinks it. Gradually the fingers "close" tightly in the palm and the patient is unable to rest his whole palm on the table.
The treatment is the surgical removal of all the affected palmar nerve, as well as its extension to the superficial palmar nerve, the lateral finger part of the Grayson ligament spiral band, which together cause the 1st phalangeal joint to collapse. The surgery is performed under local or local anesthesia. Patients leave the clinic after surgery. The incisions for accessing and removing the palmar denervation from the height of the peripheral end of the transverse ligament of the wrist, follow the palmistry lines and in the fingers make elongated incisions starting from the palmar transverse fold to the middle of the 2nd phalanx. This incision is modified into a Z shape to lengthen the skin and better stitch without tension.
When removing the affected palmar vein and extending it to the sides of the fingers, great care is needed in the preparation and release of the finger vessels and nerves that are surrounded by the fascia.
When the disease affects only one finger, then it is possible to remove only the affected part of the palmar nerve and many times in diabetics the skin incision is not sutured but left to heal for the second purpose. After the operation the patient leaves the clinic with a bandage or splint in severe cases and returns for a change at the doctor's office 2-3 days later.The sutures are usually removed 15 days after surgery.
Complications that can occur are:
sometimes severe stiffness of the finger joints
reflex sympathetic dystrophy
Recurrence after surgical removal of the denervation is common in patients with a strong inherited predisposition to Dupuytren's disease, due to the fact that the upper skin is full of vertical fibers, which cause the skin to harden and shrink.
6. Arthritis at the base of the thumb
The basic joint of the thumb (wrists) is the one that allows the thumb to come opposite (contrast movement) from the other fingers and to cooperate with them in order to perform all the complex movements of the hand.
This joint, due to its very high mobility and usability, leads to rapid wear. The two surfaces of this joint, the bone of the 1st metacarpal and the major polygon, lose their smooth texture, become thinner and the two surfaces rub against each other, resulting in the patient complaining of pain and difficulty in his daily life.
Arthritis of the thumb is the second most common arthritis of the hand. Women are more affected than men and the most common age of onset is after forty-five.
Heredity is to blame as it is in osteoarthritis. Injuries to the area such as severe sprains and fractures can cause the disease to appear. It usually occurs in manual workers and in patients with recurrent injuries of the area due to their work (frequent use of tools, eg scissors).
The main symptom is severe pain at the base of the thumb. In the early stages there is a local tenderness at the base of the thumb that worsens when grasping an object. There is swelling in the area and inability to hold objects.
Climate change exacerbates the discomfort.
A typical complaint of patients is that they are weak or in pain when they unlock a door, when they open a jar, when they squeeze clothes, sew or also complain that objects fall from their hand.
At an advanced stage, a characteristic symptom is nocturnal pain.
In severe cases, the deformity of the area is clearly visible, with the thumb being in a subluxation with a characteristic "Z" type deformity.
At an advanced stage, dynamic x-rays.
Intra-articular infusions of cortisone, which offer excellent results but do not inhibit the progression of the disease.
Local injection of autologous PRP (Platelet Rich Plasma) growth factors.
In the advanced stages of the disease with destruction of the articular cartilage, the treatment is surgical. It is desirable to perform the surgery before the appearance of permanent deformities.
Types of operations:
Simple removal of the major polygon or combined with stabilization of the 1st metacarpal with a tendon section (long abductor of the thumb) in the area.
Insertion of synthetic material (Spacer).