The hand is a complex structure that is made up of many small bones and the muscles responsible for the movement of the fingers and the wrist. The hand bones are attached firmly to each other by ligaments. Fractures in hand bones may occur only as a result of severe injuries. There can be fractures on the inside of the outside of the joints.
Falling down, hitting the hand on hard items or dropping a heavy object on the hand may lead to fractures.
Swelling, bruising, deformity and pain are the main symptoms of a hand fracture.
When the patient voices these kinds of complaints after a trauma, an experienced doctor should be consulted. Diagnosis can be made after examining x-rays. A computed tomography may be needed in unclear situations.
Type of treatment changes according to the type and shape of the fracture, and other accompanying injuries. A splint or partial plaster can be used for the treatment if the fractured bones are not displaced.
Stabilizing the fractured bone with cerclage wire in closed fracturesIf the fractured bones have been dislocated, in order to see the fractured epiphysis without cutting through the skin, a skopi x-ray machine that allows us to do a radiological examination on the instant is used to put them back to their place and stabilize them with cerclage wire.
Stabilizing the epiphyses with plates, screws and cerclage wiresIf an open fracture has occurred and the broken bones and epiphyses cannot be put together, or if the fracture has reached the joints, in order to put the bone back together, the skin is opened and the fracture is stabilized with plates, screws and cerclage wires.
External stabilization (external fixation)If the wound is unclean or fracture is comminuted, the fracture is stabilized with the help of the bars that are positioned on the outside of your skin from below and above the fracture site.
Complications can differ according to the type and shape of the fracture. Limited finger movement and nonunion in the fracture may be observed. Therefore, physical therapy should be started as soon as possible.
The scaphoid bone is one of the eight carpal bones that provide the transition between the carpus (hand bones) and the forearm. The scaphoid bone that links together the main rows of the carpal bones close to the forearm and the hand is situated in a central position. Consequently, it is frequently exposed to trauma.
It may be the result of trauma directly to the wrist. Falling onto an outstretched hand is one of the most common causes.
After the trauma, there is a very painful period. The pain will decrease daily. Deformities and swelling in wrist may not be observed in some patients. Bruising is rare. Some patients may only get diagnosed many months or even years later when they consult a doctor.
Pain can be detected by pressing the thumb towards the wrist and pressing the wrist near to the thumb during the examination. (Snuffbox method). For patients where a fracture is suspected, the scaphoid bone should be carefully examined using x-rays. An existing scaphoid fracture may not be detected by graphs taken on the first day. In such cases, a new x-ray should be taken in ten days while the patient’s wrist is immobilized using a splint. If possible, the diagnosis can be clarified by having an MR or CT scan taken before the ten days have passed.
Orthopedic Cast Treatment
For fractures where there is no bone displacement, an orthopedic cast is to be used for the forearm and thumb. Treatment with an orthopedic cast will take approximately six to ten weeks. Depending on the area where the fracture occurred, the recovery time will change. The reason for this is that blood builds up differently in every part of the scaphoid bone. After a fracture, the blood buildup around the fractured bone determines how long healing will take. Surgery is recommended especially for scaphoid fractures which occur in the proximal 1/3, i.e. close to the forearm.
Surgical TreatmentSurgery is the most appropriate course of treatment for fractures where the bones have been displaced. The goal of surgical treatment is to internally stabilize the fracture with screws and pins. (Image) On occasion, taking and using bone fragments from other parts of the body may be necessary. Sometimes surgical implementation of implants can be recommended for simple fractures as well without seeing the fracture line because of the long casting period.
Non-union of the bone
Due to a poor blood supply in portions of the scaphoid bone, fractures may not join. If bone union has not occurred after six months, it is called nonunion. When the fractured bones take longer to unite than expected, it is termed delayed union. X-rays, a computerized tomography (CT) or MRIs are helpful for a diagnosis. For the treatment, surgical intervention is needed to prevent early arthritis and it is done by placing a bone graft to the fracture line.
Bone death (Osteonecrosis)
Because of the poor blood supply in the bone, bone death may take place. Though surgical intervention, the epiphyses are tried to be revitalized.
Arthritis associated with a fracture
If arthritis develops in the wrist due to a fracture, it should be surgically treated. The appropriate type of surgery is determined by the hand surgeon depending on the severity of the arthritis.
There is an area in the wrist called the carpal tunnel. Passing through the tunnel there are nine tendons that extend from the forearm up to the hand and also the median nerves that permit the thumb, index finger, middle finger and ring finger to have the sense of feeling and provide certain mobility functions for the thumb. The roof of the tunnel consists of transverse carpal ligaments. Carpal tunnel develops when the nerves are prevented from functioning as a result of increased pressure. Carpal Tunnel Syndrome presents itself with pain, numbness and electric feeling in the hand and fingers.
The cause is generally unknown. However, it is known that some factors cause the pressure in the tunnel to increase. The fact that
- The tendons going through the tunnel are worn out throughout the years with repetitive hand movements and consequently a thickening that may put pressure on the nerve occurs
- Fractures and dislocations in this area may cause bumps on the tunnel
- Fluid retention seen especially during pregnancy increases the pressure
It starts with numbness, tingling and pain that may even wake you up from your sleep in the area where the median nerves provide the sense of touch. In the long run symptoms can be felt during routine activities like driving or reading the newspaper. You may not be able to hold your grip on objects. In the advanced stages, loss of feeling in the fingers and muscle weakness in the thumb develops.
Early diagnosis and treatment will ease the pain and prevent the nerve damage from getting worse. For diagnosis; various clinical evaluations and electromyography (EMG) techniques are used. During treatment; symptoms that are diagnosed early can be treated with certain methods.
- Learning the right ways of using your hand at home or the workplace.
- A suitable splint to regularize the pressure on the nerve
- Medicinal treatment
When the symptoms are severe or the other treatment methods do not prove to be effective for healing, loosening the transverse carpal ligaments with a surgical procedure will relax the nerves. Surgical treatment is possible by cutting the ligament located above the tunnel. Cutting this ligament leads to the decrease of pressure in the tunnel. In the open surgery method, surgery is performed by completely cutting off the skin over the tunnel. Employing endoscopic method (that involves the use of an endoscope with a tiny video camera), the ligament can be cut from a smaller entry point.
The disorder is also known as ‘Stenosing Tenosynovitis’. It presents itself in the form of trigger finger or trigger thumb. It can also be detected in children as congenital (pediatric) trigger finger. During infancy, in some cases, self-recovery is possible. Trigger finger concerns a structure called pulley, which is a pliant tube and controls the gliding motions of the tendons. Tendons are chord like structures that make the gliding motions possible. These gliding motions are controlled by pulleys which keep tendons on the bone tissue.
Trigger finger/thumb occurs when the tendons display a nodule (stiffness-thickening) or swelling. When the tendons swell, the tendon sheath gets narrower. It is painful since it causes the fingers or thumb to catch or lock when bent. When the tendon locks, the pain, inflammation and swelling increase. Consequently, a vicious cycle emerges. Sometimes it is hard for the locked finger to loosen up and it will stay clutched.
The cause of this disease is unknown. It can be accompanied by diseases like rheumatoid arthritis, gout and diabetes mellitus. Trigger finger/thumb starts with discomfort in the finger. A swelling might be observed. When the finger is bent, it can lock and stay clutched.
The goal of the treatment is to eliminate the locking and clutching of the finger. By doing this, the finger regains its movement. With the elimination of pain and inflammation around the flexor tendon, the gliding motion of the tendon returns to normal. In order to eliminate the inflammation and swelling around the tendon, using anti-inflammatory drugs, getting an injection or the use of a finger splint may be helpful. If the patient shows no response to these treatments, then surgery should be considered. Surgery is a one-day procedure. During the surgery, the pulley where the inflexibility occurs is cut. Active finger movements start right after the surgery. Pain, discomfort and swelling in the operation site may vary from patient to patient. Generally, hand physiotherapy may be required to gain better use of the fingers.
Ganglion Cysts are the lumps within the hand and wrist that show similar growth. The most common locations of these cysts are the top of the wrist. Less commonly, it may cause pain on the palm side of the wrist, the top of the end joints of the fingers, and when the base of the fingers is on the palm side, and also with the activities constantly straining the hand. Their size can change in time and sometimes they can disappear by themselves. These cysts are not malignant tumors.
A ganglion cyst is diagnosed depending on its location and appearance. A radiological examination is performed to inspect possible joint problems.
Ganglion cysts not causing any complaints do not require treatment, only regular follow-ups are sufficient. However, if a cyst is painful and limits daily activities, or if it is aesthetically unpleasing, it needs to be treated. Emptying the liquid in the cyst with a needle or splinting the wrist are the nonsurgical treatment options. It is common for the same symptoms to reemerge after these treatments. If the nonsurgical treatments fail, it may be recommended by a hand specialist to have the cyst removed surgically. The goal of this surgery is to remove the cyst along with its root. As a result, part of the involved joint capsule or tendon sheath may need to be removed during surgery. If the ganglion has been removed from the wrist, the use of a splint application to immobilize the wrist after surgery may prevent symptoms like sensitivity and swelling observed in some patients. The surgical removal of ganglions is the most successful treatment method and the possibility of reemergence for these cysts is very low.
The muscles that originate from elbow and forearm regions, turn into tendons (chords) just past the middle of the forearm and attach to the bones of the fingers. These tendons that are located on the palm of your hand are called flexor tendons because of the twisting motion they enable the fingers to perform. When the tendons reach the fingers, for a better twisting motion, they are tightly surrounded by tunnels called pulleys. These tunnels keep the tendons in place next to the bones and they also help to bend the joints.
Flexor tendons might get injured by deep cuts that occur on the forearm, wrist, palm or fingers. Tendon injuries can be accompanied by nerve and vein injuries, especially in the hand, palm, and fingers.
The fingers may not perform the bending movement for patients with flexor tendon injuries. If the injury is diagnosed too late, the ends of the tendon will pull far apart and it then becomes harder to get it back to its previous state through surgery. With a partial tendon tear, patients may be able to bend their fingers; however, over time the tendon may tear completely from the thinning areas.
With surgery, the ends of the tendon which has been cut should be placed together and stitched with special stitching methods. If the tendons are not stitched, the fingers cannot perform the bending motion again. The protection of the tunnels, called pulleys, through which the tendons pass is very important for the tendons to be able to perform their functions after recovery. Vein and nerve injuries that have occurred along with the tendon cut should also be treated by using microsurgical methods. In order to protect the stitched tendons, physical therapy will start three to four weeks after the operation, whereas for tendon cuts on fingers it may begin right after the surgery. In order to prevent tendons from tearing again, the forearm is protected with a cast for six weeks and, generally, functions and movement are not regained immediately when the cast is removed. Physical therapy prevents the tendons from sticking onto other surrounding tissues during recovery period. In flexor tendon injuries, it is just as important that the physical therapy is performed by experienced professionals as the surgery is done properly and on time. Sometimes, movements may be deficient despite the physical therapy. In this case, physical therapy should be reinitiated right after removing the adherence from the tendons through surgery.
Dupuytren is a disease that frequently presents itself with the thickening of the layer called ‘fascia’ which is located under the skin of the palm. It can also be seen on the feet or the penis. Because of the thickening of the fascia layer, wrinkles in the skin and adherence in tendons are observed. This disease is named after the French Surgeon Baron Dupuytren, who lived in the early nineteenth century and defined the disease.
While the cause is unknown, it is believed that it occurs as a result of biochemical changes in the fascia. It is frequently seen on both hands and in men older than 40 and people of North European descent. The occurrence of the disease increases in alcoholics and people with diabetes.
It is an insidious disease as it is hard to detect at the initial stage. It starts with painless swelling that occurs inside the palm in line with the fourth and fifth fingers. The swelling increases gradually and starts to become thicker in the form of a band. As the swelling and thickening in the skin increases, the flexibility of the fingers is affected. When the patients put their hand on a flat surface, the palm does not touch the surface and it takes a dome-like shape. As the disease worsens, it can affect the tendons and the neighboring veins and nerves. Fully opening the fingers gets harder. Consequently, it is hard for a patient to wash his hands, wear gloves, clap or grasp objects.
Surgery is not necessary for nodules that do not cause any tension or restriction of movement in the fingers. In order to slow down the progression, cortisone injections can be given to suitable patients. However, the patient should always be closely monitored by a doctor and when the disease reaches the stage when the fingers cannot not be opened, surgical intervention becomes necessary.
While there are numerous surgical methods, the one to be used can change depending on the surgeon and the patient. The later the surgery is performed, the less chance the fingers have of regaining their full motion.
The surfaces of both bones at joints are covered with cartilage. This cartilage structure enables bones to glide easily inside the joint and prevents bone ends from rubbing against one another during movement. Osteoarthritis ‘calcification’ is a chronic disease that causes joint pain and stiffness triggered by deterioration and erosion in the joint cartilage and adjoining bone tissues. Thumb basal joint (carmometacarpal joint) arthritis is the second most common osteoarthritis of the hand. The thumb basal joint, which looks like a saddle, is formed by the trapezium bone of the wrist and the first metacarpal bone of the thumb. Because of the saddle-like shape of the joint, a wide range of motion for the thumb, such as rotational movements, bending back and forth, and opening to the sides for pinching, is allowed.
It is largely thought that osteoarthritis is caused by abnormal functioning of the cells that produce the substance of the connective tissue in the cartilage. Thumb basal joint arthritis is more frequently seen in women than men and often after the age of 40. Joint cartilage damage, a ligament injury, or a joint fracture increases the chance of developing arthritis.
As the arthritis progresses, the pain intensifies. A pain increase is observed especially when the pinching maneuver is used in actions such as locking and unlocking the door, writing, or opening a jar. Pain can occur especially during the night and when resting. Patients usually complain about not being able to grasp or pinch. Deformity caused by swelling or sensitivity to pressing may be detected in the base of the thumb. As the movement of the thumb decreases, loss of movement develops. A clicking sensation may be felt in the joint.
While the patients’ symptoms often lead to a diagnosis, increase in pain when it is pressed on while rotating and having the clicking sensation reinforces the diagnosis. X-ray images taken are helpful in evaluating the severity of arthritis in the thumb basal joint.
Tumb basal joint calcification does not require surgery at the beginning. The pain can be controlled by ice applications, medication, splinting applications or corticosteroid injection into the joints. Recently, glucosamine is also recommended to be used as medication.
When nonsurgical treatment proves to be insufficient for the patients who experience decrease in joint movements and increase in night pains, cleaning of the cartilages in the joint or removing the trapezoid bone and filling the void left behind the with various tendons may be optional surgical methods. Patients do not normally have to spend the night at hospital for the surgical operation. They usually start physical therapy after one month and start to reuse their finger.