The hand is a wondrously complex structure of bones, muscles, ligaments, and tendons which work together to perform tasks. The wrist and elbow are stabilizing joints that support the steady use of the hand and provide attachment points for the muscles that control the hand and wrist. All three of these areas are prone to injury from overuse or trauma. Their complexity requires the skills of an expert for proper diagnosis and recover from injury.
Most Common Syndromes
Injuries to the elbow, specifically humeral epicondylitis, occur frequently as a result of the repetitive loads encountered in athletes from both repetitive and forceful muscular activations inherent in throwing, hitting, serving, and spiking. Management involves early diagnosis and treatment coupled with a total arm strengthening or kinetic chain rehabilitation emphasis. The entire upper extremity kinetic chain must be evaluated and integrated into the treatment process. Understanding the treatment basis for tendinitis versus tendinosis is a very important distinction for the treatment of humeral epicondylitis. Initial treatments are to reduce pain and increase range of motion, muscular strength, and overall function of the injured upper extremity.
Pronator teres syndrome (also called pronator syndrome) is one of three common median nerve entrapment syndromes. Signs and symptoms result from compression of the median nerve in the upper forearm. Patients may present with volar pain of the proximal lower arm and paresthesia of the volar forearm and the radial three digits and radial aspect of the fourth digit.
Radial Tunnel Syndrome is a compressive neuropathy of Posterior interossei nerve (PIN) in the proximal forearm. It is commonly seen among female patients and athletes with repeated activities involving pronation and supination of forearm. The site of compression of PIN is most commonly seen under the proximal tendinous edge of supinator which is also known as Arcade of Frohse. The most common presentation is lateral elbow pain radiating along the distribution of the radial nerve without neurological deficits. If there is presence of neurological deficit which manifests as weak finger and thumb extension it is termed as PIN syndrome. The pain aggravates on activities and night. Pain occurs more frequently in the dominant arm. Middle aged women (age 30 to 50 years) are predominantly affected.
Cubital tunnel syndrome is a constellation of symptoms referable to ulnar nerve dysfunction in the elbow region, more often around the cubital tunnel. Physical examination is the gold standard for localizing the disease process, and electrodiagnostic studies often sort out secondary issues. Cubital tunnel syndrome symptoms usually include pain, numbness, and/or tingling. The numbness or tingling most often occurs in the ring and little fingers. The symptoms are usually felt when there is pressure on the nerve, such as sitting with the elbow on an arm rest, or with repetitive elbow bending and straightening. Often symptoms will be felt when the elbow is held in a bent position for a period of time, such as when holding the phone, or while sleeping. Some patients may notice weakness while pinching, occasional clumsiness, and/ or a tendency to drop things. In severe cases, sensation may be lost and the muscles in the hand may lose bulk and strength.
Carpal tunnel syndrome is the most frequent of the compressive syndromes and is defined by compression and/or traction of the median nerve at wrist level. Possible causes include: swelling of the tendon lining, joint dislocations, fractures, or arthritis. Fluid retention in pregnancy can also cause swelling in the tunnel. The clinical syndrome is characterized by pain, numbness, or tingling in the distribution of the median nerve: the palmar aspect of the thumb, index, long finger, and radial side of the ring finger. The symptoms tend to be worse at night and can disturb sleep, but may be noticed most when waking up in the morning. Hanging and shaking the hand will often relieve the pain and tingling. The problem may be noticed during the day because certain activities – such as writing, typing or housework – can bring on symptoms.
de Quervain’s tenosynovitis predominantly impacts the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) tendons, which pass through the first dorsal compartment of the wrist. The etiology of this disease is due to repetitive and continued strain of the APL and EPB tendons as they pass under a thickened and swollen extensor retinaculum. Patients present with complaints of pain and inflammation in the region of the radial styloid. This pain is exacerbated by motion and activity requiring ulnar deviation with a clenched fist and thumb metacarpophalangeal joint flexion. Specific activities that may incite complaints include wringing a washcloth, gripping a golf club, lifting a child, or hammering a nail. Inflammation is increased with continued performance of these or similar functional activities. Physical examination may reveal swelling and tenderness in the region of the first dorsal compartment.
A ganglion cyst is the most common soft tissue mass of the hand and wrist. The cyst is a collection of fluid that is gelatinous in nature. The fluid filled sac may arise from a joint or tendon sheath. These cysts can be very small or enlarge to become unsightly. They are not cancerous and may arise as a single cyst or have multiple lobes. Some cysts feel quite hard and may be mistaken for a bony prominence. Ganglion cysts can occur in a variety of locations but they most commonly arise from the back of the wrist. Other locations the cysts are found include the front of the wrist, in the palm at the base of the finger or just behind the fingernail. The exact cause of a ganglion cyst is not known. Ganglion cysts are usually painless although they may cause localized discomfort. Mechanical symptoms such as limited joint motion are dependent upon size and location. They may remain stable, increase in size or resolve over time.
Rheumatoid arthritis is a chronic autoimmune disease mainly affecting the small joints of the hands and feet. It is characterized by persistent synovitis, accompanied with systemic inflammation, the destruction of cartilage and underlying bone, and sometimes the presence of autoantibodies rheumatoid factor and anti-citrullinated protein antibodies. The main environmental risk factor is smoking and 50% of the risk of developing RA may be related to genetic factors. Stiffness, swelling, and pain are symptoms common to all forms of arthritis in the hand. In rheumatoid arthritis, some joints may be more swollen than others. There is often a fusiform swelling of the finger. Other symptoms of rheumatoid arthritis of the hand include: a soft lump over the back of the hand that moves with the tendons that straighten the fingers; crepitus during movement; a shift in the position of the fingers as they drift away from the direction of the thumb; swelling and inflammation of the tendons that bend the fingers, resulting in clicking or triggering of the finger as it bends.
Corticosteroids medications are used to reduce pain and inflammation and can be taken oral or through an injection.
Peripheric Nerve Block
This minimally invasive procedure, as radiofrequency ablation and cryoablation, should be guided for ultrasound or fluoroscopy.
Cryoablation uses cold temperatures and is a minimally invasive procedure guided for ultrasound or fluoroscopy.
Radiofrequency ablation is a minimally invasive procedure guided for ultrasound or fluoroscopy.
PRP (platelet rich plasma) contains 2-5 times the usual number of platelets and have a regenerative effect on the tissues.
Pharmacological management pain is commonly part of the treatment and a wide range of drugs can be used to manage pain.
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