Hand & Elbow Services

Osteoarthritis and Post-traumatic Arthritis

Osteoarthritis (OA), or degenerative joint disease (DJD), is a form of arthritis characterized by the loss of joint smoothness and range of motion without major joint inflammation. Post-traumatic arthritis is similar to osteoarthritis, but the cause is clearly evident (usually the result of a trauma to the joint sometime in the past).

Osteoarthritis is the most common type of arthritis, affecting over 20 million people in the United States. It probably affects almost every person over age 60 to some degree, but symptoms are often mild.

Signs of osteoarthritis include joint pain and aching, limited range of motion and instability, erosion of the joint's cartilage and formation of bone spurs. Other symptoms include stiffness and roughness on motion; these symptoms are worse after heavy use. OA pathological changes involve both the cartilage and the bones.

If degenerative joint disease is related to abnormalities of cartilage surrounding joints (articular cartilage), it may involve many of the joints of the body. On the other hand, if the degenerative joint disease is caused by an injury, only one joint may be involved. The hips, knees, spine, and shoulders are most commonly involved. This condition may also affect some finger joints, the joint at the base of the thumb, and the joint at the base of the big toe.

In osteoarthritis, the normally smooth cartilage surface softens and becomes pitted and frayed. As the cartilage breaks down, the joint may lose its normal shape. The bone ends thicken and form bony growths, or spurs, where the ligaments and capsule attach to the bone.

Stiffness and joint deformity usually progress slowly without general body symptoms. By contrast, rheumatoid arthritis (RA) usually begins earlier, often developing more suddenly. RA usually affects the same joint on both sides of body (e.g. both knees), causing redness, warmth, and swelling of many joints. RA is often accompanied by a general feeling of sickness, fatigue, weight loss, and fever.

In the hip, OA may produce pain around the groin or in the inner thigh. Some people feel referred pain to the buttocks, the knee or along the side of the thigh. Degenerative joint disease of the hip may cause a limp and may limit range of motion, for example making it difficult to spread the legs.

Degenerative joint disease of the knees may produce pain and stiffness of the knee associated with a grating or catching sensation in the joint when it is moved. It may make it difficult to walk up and down stairs and lumps may be noted particularly along the medial (inner) side of the knee. If the pain prevents you from moving or exercising your knee, the large muscles around the knee area will become weaker.

Degenerative joint disease of the fingers may produce bony lumpiness around the joints of the finger and perhaps pain and stiffness of these joints as well. In the fingers, the breakdown of joint tissue in the fingers causes bony growths (spurs) to form in these joints. If spurs occur in the end joints of the fingers, they are called Heberden's nodes. If they occur in the joints in the middle of the fingers they are called Bouchard's nodes.

Degenerative joint disease of the feet most commonly affects the large joint at the base of the big toe. Stiffness, lumpiness and pain may be associated. Wearing tight shoes and high heels can make this pain worse.

Degenerative joint disease of the spine may produce stiffness of the back and at times, symptoms of pressure on the spinal cord and nerves running through the spine. The latter are particularly important to notice and may include numbness or weakness of the arms or legs, difficulty with controlling the bowel or bladder, loss of balance and pain radiating out the arms or down the legs.

"Wear and tear" is a widely accepted explanation of the cause of OA. It should be noted that OA is the result of an interlocking pathophysiologic malfunction of cartilage and bone metabolism. Interpreting "wear and tear" of the joints in OA from a biomechanic perspective allows patients to understand how OA differs from age-associated degeneration and overuse of the joints. There are ways to reduce the OA "wear and tear" effects which include weight control, muscle strengthening exercises, and increased proprioception accuracy (the ability to feel your joint's position in space).

The effects of degenerative joint disease can often be controlled by a few basic measures, such as diet, exercise, medication, and surgery.

If you have OA, your diet should optimize your body weight so that the joints do not bear large loads which would cause them to wear more quickly. Joints in a person with OA should be protected from rough use, particularly those involving sudden impacts. Canes or walkers may help protect the hip and knee and prevent limping. Physical therapy can help maintain joint ranges of motion, strength and stability. Your doctor may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) which are also effective in relieving pain.

Surgical treatment for OA may include removing joint spurs, realigning the joint, fusion of the joint, and joint replacement. In the past several years, these operations have become very effective, and many people have benefited from joint reconstruction or replacement.

Rheumatoid arthritis

Rheumatoid arthritis (RA) primarily affects the synovium, the membrane that lines and lubricates a joint. It is the most common form of inflammatory arthritis.

There is no cure for rheumatoid arthritis at present. Until the cause of RA is known, it will not be possible to eliminate the disease entirely. The goals of current treatment methods, therefore, are to relieve pain, reduce inflammation, stop or slow down joint damage, and improve function and patient well-being.

Initial symptoms of rheumatoid arthritis are generally pain and stiffness in the morning and few symptoms with activity. The pain and swelling will usually progress on to obvious joint swelling and the level of stiffness in the morning increases. Other symptoms include fatigue and difficulty sleeping due to joint stiffness.

Rheumatoid arthritis can be distinguished from other forms of arthritis by the location and number of joints involved. The areas affected include the neck, shoulders, elbows, wrists, and hands, especially the joints at the base and middle of the fingers but not the joints at the end of the fingers. In the lower extremities, RA can affect the hips, knees, ankles, and the joints at the base of the toes. RA tends to spare the low back. The joints affected tend to be involved in a symmetrical pattern. That is, if knuckles on the right hand are inflamed, it is likely that knuckles on the left hand will be inflamed as well. This symmetry is not found as often in most other types of arthritis.

Inflamed joints will be warm, swollen, tender, often red, and painful or difficult to move. These physical signs of arthritis are due to inflammation of the lining of joints and tendons in a layer of tissue that is called synovium. The cells of the immune system within the synovium appear active and capable of causing tissue damage. If this inflammation persists or does not respond well to treatment, destruction of nearby cartilage, bone, tendons, and ligaments can follow. This leads to deformity and disability that can be permanent.

Anyone can get rheumatoid arthritis, including children and the elderly. However, the disease usually begins in the young to middle adult years. Among people with RA, women outnumber men by 3 to 1. In the United States, approximately one percent of the population, or 2.5 million people, have rheumatoid arthritis. It occurs in all ethnic groups and in all parts of the world.

The goals of current RA treatment methods are to relieve pain, reduce inflammation, stop or slow down joint damage, and improve function and patient well-being. There is no single standard treatment that applies to all people with RA. The disease may be very different from person to person. Instead, a treatment program should be designed to best meet each person's needs, taking into account how severe the arthritis is, other medical problems, and individual lifestyle and preferences. Often the use of two or more medications at a time, each serving a distinct purpose, is necessary. Some of these medications affect the immune system, making careful monitoring a requirement for treatment.

Treating rheumatoid arthritis usually involves a teamwork approach, using health professionals from different disciplines to help an individual deal with the disease. Treatment most often is directed and coordinated by an arthritis specialist, who is a physician with special training in arthritis and other diseases of the bones, muscles, and joints. Other health professionals, such as physical therapists, occupational therapists, nurses, psychologists, orthopaedic surgeons, and social workers, often play other roles in implementing the treatment plan.

It often is difficult to be patient when suffering from rheumatoid arthritis. People with rheumatoid arthritis might be tempted to try unproven treatments. A treatment that promises "a quick cure" or "miraculous relief" can sound wonderful. But remember, these unproven treatments usually are expensive and will do nothing. The sensational successes advertised are usually illusions. They even may be harmful and often keep people from getting the medical care they really need. For example, magnet therapy has not been proven to work for rheumatoid arthritis. New or alternative treatments should be discussed with your doctor.

Medical management may include the use of non-steroidal antiinflammatory medication, corticosteroids, injectable gold salts (Myochrysine, Solganal), methotrexate (Rheumatrex), hydroxychloroquine (Plaquinil) and antimalarial drugs, Sulfasalazine (Azulfidine), D-Penicillamine (Depend, Cuprimine), and various other immunosuppressive agents.

Physical therapy treatments are helpful for most individuals with rheumatoid arthritis. Physical therapists can teach you how to exercise appropriately for your physical capabilities. They will give you valuable instruction on how best to use heat and cold treatments to reduce joint stiffness and swelling and make movement easier. At times, therapists may use special machines to apply deep heat or electrical stimulation to reduce pain or improve joint mobility.

Therapists construct splints for the hand and wrist and teach people how to best protect and use their joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations that may be caused by RA. Sometimes this includes the use of practical tools and items that help individuals perform their day-to-day activities. It is important to remember that people with RA can and should be able to do most of the normal or usual things everyone else can, except that it takes them a little bit longer to do it.

For individuals with severe joint damage, surgery such as total joint replacement can mean the difference between being dependent on others and independent life at home or in the community. Such procedures are performed by orthopaedic surgeons with special training in joint replacement. The damaged parts of the joints are replaced with metal or plastic components. Some people with RA will benefit from replacement of other joints and from other types of surgery for hand and foot problems caused by the disease. Patients with early rheumatoid arthritis, however, should be placed on a program of medications and therapy before surgery is considered.

Dupuytren's disease was first described in 1831 by Baron Guillaume Dupuytren, a brilliant but despised French surgeon. Dupuytren's contracture is a condition commonly afflicting people in all northern European countries, Scandinavia and Russia, and their descendants.

There is a strong familial tendency to develop Dupuytren's disease, and some propose that the condition is a result of a single dominant gene. The exact cause of this disease is unknown. While the development of Dupuytren's cords or nodules may occur following trauma or surgery, the exact relationship is unclear.

The most common evidence of the disease is a "lump" or nodule in the palm near the flexion crease, most often at the base of the ring or small finger. This lump or nodule may also occur at the base of the thumb. Although the appearance of these nodules in the finger usually occurs within the course of the disease, these nodules may be evident as the very first symptom.

Another sign or symptom of Dupuytren's contracture is known as a dermal pit. The pit may be single or multiple, and appears as a small, local, deep indentation of the skin. This may be the first finding, it may come later, or it may never appear at all. The pit usually is located in the palm but also can be in the fingers. This indentation occurs due to a contraction of the connective tissue fibers from the palmar fascia to the skin. The skin is drawn down to form the pit.

The cord is a longitudinal fibrous band, which extends from the palm into one or more fingers. It most often appears with a nodule, but it can be separate. It may appear as a single or multiple band. The cord or band creates a flexion contracture at the finger joints as it crosses the joints; or, in other words, the cord pulls the finger into a bent position. Once the contracture has started, the process may proceed (either slowly or rapidly) to a severe deformity of one or several fingers. Even if only one or two fingers are involved, this condition may become so advanced that daily activities are embarrassingly awkward.

Early diagnosis and treatment is essential to a positive outcome of this potentially debilitating disease. The ring and small fingers are the most frequently affected, the long finger is next, followed by the thumb. The index finger is seldom involved. Although physical therapy may help maintain flexibility of the fingers, neither therapy nor splinting will change the course of the disease. At this time, surgery is the only cure.

Dupuytren's Disease Animation

Ganglion cysts (lumps) can occur all over the body, but are very common in the hand. Ganglion cysts are benign lesions. Although they may grow in size, they are not tumors or cancer.

A ganglion can be described simply as a fluid-filled sac arising from an adjacent joint capsule or tendon sheath. A ganglion can form from almost any joint or tendon sheath in the wrist and hand.

You will see the lumps appear and they will most likely be very painful, although they may be painless. Pain will increase with extended use of the hand, and range of motion may be restricted. Ganglions often change in size and may spontaneously disappear completely.

Treatment is indicated by the pain you are experiencing, the limits the cysts are placing on your daily activities, and/or your discomfort with the physical appearance of the cysts. Treatment can range from simply monitoring the cysts for changes to wearing a splint to immobilize the hand, fingers or wrist. Another non-surgical, but more invasive option is to remove fluid from the cyst with a needle. If non-surgical treatments are not successful, surgery to remove the cyst may be recommended by your hand surgeon.

We interact with the world by using our hands. Consequently, hands are the most commonly injured part of the body. Given the functional importance of our hands, it is critical to seek medical attention when a hand or part of a hand is injured. Failure to appropriately treat hand injuries in a timely fashion may result in irreversible damage and resulting disability.

Hand surgeons and hand therapists are specially trained to treat all injuries to the hand. Injuries may involve bones, ligaments, tendons, muscles, nerves, blood vessels, and skin. Hand surgeons possess the technical skills to repair or reconstruct all combinations of these injured tissues. Hand therapists are prepared to address all injuries to the hand in order to regain as much function as possible for the patient.

Raynaud's (pronounced "ray-NODES") phenomenon refers to episodic color changes in the skin of the fingers and toes during exposure to cold or in response to emotional stress. In some people, the ears, lips, and nose may also be affected. Although it is normal for blood flow to the fingers to be reduced in extreme cold, people with Raynaud's phenomenon have difficulty on mild days, in air-conditioned rooms, or when holding a cold drink. Episodes may last for several minutes after the body becomes warm again.

Without treatment, secondary Raynaud's phenomenon can damage the affected part of the body. When blood does not flow adequately to the tissues, sores called ulcers may develop. If left untreated, these sores can become infected and may take a long time to heal.

The goal of treatment of Raynaud's phenomenon is to prevent episodes and, in secondary Raynaud's phenomenon, to prevent tissue damage. This can be done by protecting the body from cold and avoiding aggravating factors, such as excessive emotional stress, smoking, certain medications like nonselective beta-blockers, use of industrial tools with violent vibration, and use of narcotics. In some cases, a doctor may prescribe medication.

In rare cases, a doctor may recommend sympathectomy to treat Raynaud's phenomenon. This operation involves removing the nerves that contribute to further narrowing of the blood vessels.

Tennis elbow (or lateral epicondylitis) refers to a degenerative or traumatic tear of the of the tendons that attach the muscles of the forearm to the arm bone at the elbow joint. The muscle group involved, the common extensors, function to cock the wrist back.

Often tennis elbow is caused by repeated strain on the muscles of the forearm that extend the wrist and fingers. Activities such as tennis, golf, or repeated twisting or extension of the wrist during work or hobby activities, may strain these muscles and irritate their attachment at the bone on the outside of the elbow.

The type of treatment will depend upon the severity and length of time the condition has been present. Initial treatment of tennis elbow involves limiting the activities in which the muscles and tissues of this region may be stressed. Often this is accomplished by the use of a splint which immobilizes the wrist. Use of a counter force brace or air cast (sometimes referred to as a "tennis elbow band") may be used to provide localized pressure and support to the area. Your orthopaedic surgeon may also use anti-inflammatory medications, physical therapy, or injections. In cases where conservative treatment is not effective, surgery may be recommended.

Tennis Elbow (Lateral Epicondylitis) Animation

DeQuervain's Tendonitis

This painful inflammation of the thumb side of the wrist bears the name of the Swiss surgeon, Fritz de Quervain, who first described it in 1895.

Passing over the back of the wrist are the tendons for muscles that extend or straighten the fingers and thumb and lift the hand at the wrist. These tendons run through six lubricated tunnels (compartments) under a thick fibrous layer called the extensor retinaculum or dorsal carpal ligament.

The first dorsal compartment lies over the bony bump at the base of the thumb. Through it pass the tendons for the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles. Both of these muscles help spread and extend the thumb away from the rest of the hand. They are necessary for a powerful grasp and also help to move the wrist.

DeQuervain's stenosing tenosynovitis is a painful inflammation of the tendons in the first dorsal compartment of the wrist. The lubricating synovial sheath lining this compartment thickens and swells, giving the enclosed tendons less room to move. The tendons, in turn, may swell beyond this constriction. Fine fibers of scar (adhesions) may form between the sheaths and tendons.

This inflammation may be caused by anything that changes the shape of the compartment or causes swelling or thickening of the tendons. Repetitive trauma, overuse, or an inflammatory process are likely causes, but frequently, the cause of the disease is unknown.

DeQuervain's stenosing tenosynovitis occurs most often in individuals between the ages of 30 and 50. Women are afflicted with it 8 to 10 times more often than men. People who engage in repetitive activities requiring sideways motion of the wrist while gripping the thumb may be predisposed to developing this disorder.

Pain over the thumb side of the wrist is the primary symptom. It may occur "overnight" or gradually, and it may radiate into the thumb and up the forearm. It is worse with the use of the hand and thumb, especially with any forceful grasping, pinching, or twisting. Swelling over the thumb side of the wrist may be present, as well as some "snapping" when the thumb is moved. Because of the pain and swelling, there may be some decreased thumb motion.

Your doctor may first try to reverse the course of the disease with a 3 to 6 week trial on an anti-inflammatory medication while the thumb and wrist are rested by wearing a wrist and thumb spica splint made by your physical therapist. The physician may also inject the inflamed area with a steroid to help decrease the inflammation.

If the symptoms of DeQuervain's stenosing tenosynovitis disease are long-standing or unresponsive to conservative management, surgery is indicated. This is usually performed on an outpatient basis.

DeQuervain's Tendonitis Animation

Trigger Fingers

A trigger finger (flexor stenosing tenosynovitis) is a common disorder of the hand which causes a painful snapping or locking of the fingers or thumb.

The tendons are tough, fibrous cords that connect the muscles of the forearm to the bones of the fingers and thumb. Because the tendons are covered by a sheath, the swelling causes pressure to build up in the sheath and a knot or nodule is formed. The tendon is then prevented from gliding smoothly.

The painful snapping sensation during finger motion is the most common symptom. As the condition progresses, the finger or thumb may actually become locked in a bent position, or less often in an extended position. The problem is sometimes incorrectly thought to exist in the middle joint of the thumb. This joint may appear to jump or lock. The true problem, however, is found in the base of the finger or thumb. It is here that the smooth gliding of the tendon becomes obstructed.

Nonsurgical treatment is an appropriate first step, unless the finger or thumb is in an unmovable, locked position. Initial treatment involves avoiding or modifying those activities that have caused the inflammation.

The physician may decide to restrict movement of the joint by means of a splint. Oral anti-inflammatory medications are often used to reduce inflammation and discomfort. Anti-inflammatory medication may also be administered directly into the tendon sheath by means of an injection to reduce the soft tissue swelling.

In cases that do not respond to conservative treatment, or if the finger or thumb remains in a locked position, surgery may be recommended. Surgery is performed on an outpatient basis under a local anesthetic.

Carpal Tunnel Syndrome

The carpal tunnel is a passageway in the wrist formed by the eight carpal (wrist) bones, which make up the floor and sides of the tunnel, and the transverse carpal ligament, a strong ligament stretching across the roof of the tunnel. Your orthopaedic surgeon will further explain this anatomy to you, in order that you may understand your condition.

Inside the carpal tunnel are nine flexor tendons which flex (bend down) your fingers and thumb. Also running through the carpal tunnel is the median nerve, a cord about the size of a pencil containing thousands of nerve fibers supplying sensation (feeling) to your thumb, index and middle fingers, and half of the ring finger. The median nerve lies directly beneath the transverse carpal ligament and comes in contact with the ligament when bending or straightening the wrist or fingers. Carpal tunnel syndrome occurs when swelling in the tunnel compresses the median nerve.

Tingling, numbness and pain in the thumb, index and middle fingers are the most common symptoms of carpal tunnel syndrome. These symptoms are usually experienced at night, but also accompany prolonged gripping. Patients may also experience clumsiness when handling objects or weakeness in grip.

There are many non-surgical courses of treatment for carpal tunnel syndrome, such as splints or braces to immobilize and rest the wrist, activity modifications, oral anti-inflammatory medications, and steroid injections.

If non-surgical treatment is not successful or if treatment is sought too late, surgery may be required. This surgery involves enlarging the carpal tunnel, which in turn will relieve the swelling and pressure on the nerve. This is an outpatient procedure done under local anesthesia. In severe cases, even surgery may not reverse the effects of carpal tunnel syndrome. Carpal tunnel surgery is followed by hand therapy which varies per person, but usually lasts from 1 to 3 months.

Carpal Tunnel Syndrome Animation

Cubital Tunnel Syndrome

Cubitus is Latin for elbow. The cubital tunnel is an anatomic passageway between the bony prominence of the inside of the elbow (medial epicondyle) and the tip of the elbow (olecranon process). Through this passageway travels the ulnar nerve as it crosses behind the elbow. To keep the nerve from displacing with motion of the elbow, the tunnel is completed by a covering of tissue called fascia. There are several other tunnels that the ulnar nerve passes through while traveling down the arm. Cubital tunnel syndrome occurs when there is compression or injury of the ulnar nerve in the cubital tunnel or in surrounding smaller tunnels.

The ulnar nerve provides sensation to the little finger and half of the ring finger. It also supplies several muscles in the forearm but most importantly it controls many of the small muscles in the hand responsible for coordinating finger motion and pinch. Patients with this condition commonly exhibit symptoms of intermittent numbness or tingling in the ring and little fingers of the affected extremity. These symptoms may occur with prolonged flexion of the elbow or resting against the elbow. There may be an associated aching discomfort along the inner forearm or elbow. If nerve damage persists, there is loss of sensation in the ring and little fingers. Eventually there is loss of pinch and grip strength.

In early stages of cubital tunnel syndrome, symptoms may be alleviated by avoiding activities requiring prolonged or repetitive elbow flexion or resting against the elbow. To prevent elbow flexion, particularly at night, it may be necessary to use a long-arm splint. An elbow pad worn during the day can be beneficial in protecting the cubital tunnel from direct pressure. At times, an oral anti-inflammatory is helpful in alleviating symptoms. When cubital tunnel syndrome is severe or fails to improve with conservative management, surgery may be indicated.

Cubital Tunnel Syndrome Animation

Thoracic Outlet Syndrome

Thoracic outlet syndrome is a repetitive stress disorder that involves the shoulder and upper arm. The thoracic outlet is a triangular area through which nerves and blood vessels pass from the neck to the arm. The area is bordered by the collar bone, the first rib, and the anterior and middle scalene muscles. Thoracic outlet syndrome occurs when the nerves and blood vessels between the neck and shoulder are compressed. Activities such as pulling your shoulders back and down, sleeping with your arms above your head, carrying items such as a backpack or suitcase, or work that requires frequent overhead lifting may increase the risk of this syndrome.

Symptoms are similar to carpal tunnel syndrome: numbness in the fingers and hand, tingling in the arm as if it is "asleep", and pain that begins in the base of the neck and radiates into the arm or hand. Your orthopaedic surgeon must differentiate between the two conditions. Often with thoracic outlet syndrome, numbness and tingling may be in other parts of the upper extremity depending on which nerves are involved.

The mainstay of treatment is physical therapy. The goals are to modify postural habits, relieve muscle tension, improve alignment and increase nerve gliding. Rest, adjustments to how you perform daily activities, oral anti-inflammatory medications and steroid injections may be recommended. If non-surgical treatment is not successful or treatment is sought too late, surgery may be required. The two procedures available are release of the scalene muscles or excision of the first rib. Both procedures provide improvement in approximately 80% of properly selected patients, but over time 10% of the patients develop recurrent symptoms. The procedure is performed as an inpatient and generally requires several months for full recovery.

In cases of violent trauma, fingers, hands, or even arms may be amputated. In certain situations, these body parts may be reattached, or replanted. Surgery is performed with very small instruments under a microscope. The sudden loss of a finger or hand can be a devastating injury. But with emergency surgery performed by trained microsurgeons, dramatic recovery of the use of one's hand is possible.

This surgery is complicated and requires a prolonged recovery time. Several factors must be carefully evaluated and discussed prior to committing to such an endeavor. How much time has lapsed between injury and surgery, type and location of injury, the patient's age and associated medical problems must be considered in order to predict the outcome of the procedure. After replantation surgery, intensive hand therapy is required. Replantation surgery offers a miraculous alternative to a traumatic amputation.