31 Aug Talking Hands
An interview with Dr. John Casalletto – Orthopaedic Surgeon.
First published in A&H Magazine – August 2015
Our upper limbs, or as they are more commonly referred to – our arms and hands – are a very important and essential extension of our brain. However, although we depend heavily on their good use, we tend to take their function for granted. It is only when we are injured or in pain that we realise just how much we depend on them even for our most basic needs.
A lot of hand and arm ailments are related to degenerative disease, age and accidental injuries. Repetitive overuse, which is tightly related to factory jobs, can also cause RSI (repetitive strain injuries) as well as several other conditions involving tendons. Some conditions and injuries can be prevented by careful use and proper precautions when using sharp instruments such as Stanley knives, power tools and industrial machinery.
FOUR most common conditions
- Carpal Tunnel Syndrome
This is probably the commonest hand condition. It is more likely to affect people who are over 50, but it can also occur in younger patients especially during pregnancy and in those who regularly use power tools. This is when the median nerve which provides sensation to the thumb, the index finger, the middle finger, and half of the ring finger, becomes compressed in the carpal tunnel. This is the space where all the tendons and the nerve enter the hand. The compression can be due to swelling but very often no cause is ever found.
Symptoms
Typical symptoms of Carpal Tunnel Syndrome are pins and needles as well as numbness in the fingers and hand. These are felt mostly at night and early morning. Sometimes patients are woken up having to shake their hands in order to relieve the symptoms. As the condition progresses the pins and needles start to occur also during the day and especially when doing certain activities such as holding a phone or a steering wheel. Eventually the symptoms increase and are pretty much constant day and night.
Treatment
Sometimes the condition can improve with weight loss or the use of a splint, but many times relief is only temporary. In the case of more persistent symptoms a steroid injection can be administered, but once again relief is often short-lived. Surgery is the only definitive solution for this condition. The ligament causing pressure on the nerve is released and this can be now done through a keyhole operation. However, it is important that a carpal tunnel release procedure is done before constant symptoms set in in order to avoid irrevocable damage to the median nerve.
- Tennis Elbow
Tennis elbow is an inflammation of the lateral point of the elbow where all the tendons to the hand attach to the bone. It the most common reason why people complain of elbow pain and it occurs mostly in people over forty. Whilst it can be caused by playing tennis, more often than not it is other repetitive movements that cause this condition. Sometimes a particular injury kicks-off the symptoms resulting in a chronic condition.
Symptoms
There isn’t much one can do to prevent Tennis Elbow. The inflammation causes pain and tenderness around the bony part on the outside of the elbow where the tendons connect. Sometimes pain radiates up and down the arm and it becomes worse when lifting or griping an object.
Treatment
Initial treatment with topical gels and creams can help. Sometimes exercises to stretch of the tendons (eccentric loading) can improve and even heal the condition. If symptoms persist a steroid injection can be administered to help the inflammation. Another more recent treatment is a PRP (platelet rich plasma) injection. This is when a portion of the patients own blood that include growth factors is injected in the area in order to help with inflammation. Sometimes, when everything else fails, surgery is performed to excise the inflamed area and allow the tendons to heal.
- Trigger finger and thumb
Trigger finger and thumb is another common condition affecting the hand. In this condition the tendons attached to the digit finger become trapped whilst going through the pulleys in the hand, which hold it in place. This can be caused by thickening of the tendons or the pulley, or as a result of inflammation. The condition can also be caused by repetitive movement and is also very common in patients who suffer from diabetes. Often however, no specific cause is found.
Symptoms
This condition usually presents itself with finger stiffness and pain in the hand, particularly in the morning. It is sometimes accompanied by a clicking sensation and/or tenderness in the palm at the base of the finger. Sometimes a visible bulge can be felt in the area under the finger. At worse the affected finger will sometimes lock in place with the patient being unable to straighten it without assistance.
Treatment
Trigger finer and thumb can sometimes respond to rest, however, often a steroid injection to the pulley is usually needed. This is often very successful and can be repeated once before minor surgery is needed. This procedure is easily done under local anaesthetic. During surgery the pulley is released and most often this solves the problem entirely.
- Arthritis at the base of the thumb
As we grow older thumb arthritis becomes very common. It occurs when cartilage starts to wear away from what is known as the carpometacarpal joint. This condition is more common in older people and particularly women, because they tend to have laxer joints.
Symptoms
This condition can cause severe pain, swelling, and often results in decreased strength and range of motion. Simple tasks such as turning doorknobs, holding utensils and opening bottles become very difficult.
Treatment
Initially a splint round the thumb can alleviate symptoms and along with anti-inflammatory medication the pain can be kept under control. With more advanced discomfort and disease a steroid injection into the joint can help but eventually surgery may still be necessary. This can include excision of the arthritis, surgical bending of the bone or even joint replacement.
Four most common injuries and how to avoid them
- 1. Stanley knife injuries are some of the most common avoidable injuries encountered. Most patients are DIY enthusiasts who are rushing through jobs with improper or no use of protective gloves. Besides wearing protective gear, cutting away from the direction of the other hand can help avoid many of these injuries. The laceration often cuts through tendons and nerves and with the hand being very intricate and delicate these injuries often require urgent specialist attention for meticulous repair. With such injuries tendons tend to heal to near normal strength albeit with some stiffness, but nerve recovery is never normalised and at best gets to around three-fifths of its original state.
- Knife stab injuries are also very common and easily avoided. Such injuries are most often caused whilst trying to separate frozen slices of meat or burgers. The small puncture wound caused by the tip of the knife does not readily reveal the severe injuries to the tendons and nerves which can be caused. These wounds always need to be surgically cleaned as deep infection in the spaces of the hand can lead to hand threatening sepsis.
- Nail biting or overzealous manicuring can lead to chronic nail bed infections. These result in fungal infections and are not easily treated. Once the cuticle fails, infection can be very difficult to eradicate. Careful use of gloves during prolonged water immersion and use of caustic solutions can help avoid reoccurrence.
- Ring avulsion injuries are caused when a ring catches onto something whilst the hand violently moves away from it peeling the soft tissues away from the bones of the finger. These can be prevented by avoiding loose rings and by removing rings all together when doing DIY, gardening, moving heavy objects or dealing with machinery with moving parts. Ring avulsion injuries can cause devastating de-gloving of the skin and soft tissues including nerves from the finger. In severe cases the finger might need to be amputated.
Dr. John Casaletto is an orthopaedic surgeon with 14 years training and experience in the UK. He obtained his FRCS (Trauma and Orthopaedics) and is fellowship trained at The Wrightington Centre of Orthopaedic Excellence where the first ever hip joint replacement was performed. In the last 5 years he’s served as a consultant in the UK and is now a consultant in Malta specialising in disorders and injuries of the hands elbows and shoulders.
