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The specialty trained hand-wrist surgeons at Cedars-Sinai Marina del Rey Hospital evaluate patients with hand and wrist disorders and provide an individualized treatment advice for each patient. They can choose from the various non-surgical and surgical treatment options available. The treatment that works best for you is considered.
Hands are very important to perform our everyday activities at home and in office. Hands are supported by our wrists, which help our hands to perform complex tasks including lifting heavy weights. The wrist joint consists of eight small bones called carpals. These carpals support a tube running between them called carpal tunnel, which houses nerves, blood vessels, and tendons running into it that are held in place by ligaments. Repetitive actions involving the hand such as typing, chopping, sports activities, sewing, playing musical instruments, and impacts due to fall can injure your hands and wrists.
Hand and wrist injuries cause damage to the bones, resulting in restricted movements, severe pain on movement and even when your hands are at rest. The bones of wrists and hands may break when people fall, more often these injuries occur when people try to restrict their fall by landing on their outstretched hands. If you feel pain while writing, typing, lifting moderate weights, you tend to lose grip while holding objects, or if your wrists are swollen, it clearly indicates a wrist injury.
The need to opt for surgery depends on how bad the symptoms are, and it also depends on how the patient reacts to non-surgical treatments such as medications, exercises, splinting, and physiotherapy. Early treatment is very important, if not treated at the correct time, the healing of broken bones and alignment of other associated structures will be improper leading to restrictive and awkward movements of your hands while performing everyday activities.
The most common hand and wrist surgeries are discussed below:
Carpal Tunnel Surgery: This surgery is performed to treat carpal tunnel syndrome. In this surgical procedure, the carpal tunnel ligament is split to ease the pressure on the median nerve. It is carried out under local anesthesia and the tunnel is enlarged to provide more space to the nerves.
Dupuytren’s Contracture Fasciectomy: In this surgical procedure, the excess tissues on the palms and fingers are removed, enabling proper positioning and finger hand movements.
The release of the trigger finger: In this procedure, the tendon that is stuck in the tunnel is released to enable it to retract to normal position.
Tendon Repair: In this surgical procedure, undamaged tendons from other fingers are partially taken to repair the damaged tendons. The rough edges of the bones are smoothened to avoid further damage. This surgery is more successful when done at the earliest stage of the injury. The healing of repaired tendon can take more than six weeks. The use of the operated hand should be restricted to enable a quicker recovery.
Ganglion surgery: Ganglions are cysts formed when the synovial fluid from the joints of bones, move into the tendon sheath and become thick to form a cyst. They are commonly found on the wrists and fingers. These ganglions can be hard when pressed and do not allow the fingers to move freely, the shape and position of the fingers get abnormally changed. Arthritis is the common cause for this disorder.
In this surgical procedure, needles are used to remove the fluids, or else a minor surgery will be done to remove the thickened fluids. When there is a severe restriction of movement and distortion of fingers, knuckle replacement surgery will have to be done.
Trapeziectomy: Trapezium bone is located at the base of the thumb and arthritis can cause pain and restriction in moving this part. If the pain lasts for a long time and hand movements get severely restricted, the joint and the trapezium bone will be removed surgically. Either tendon is used or scar tissues are allowed to grow in the empty space of the trapezium bone. After surgery to restrict and support thumb movements, splints will be given for six weeks. Specific exercises will have to be done for a few months as suggested by the medical practitioner to strengthen and retain normal movements.
Triangular fibrocartilage repair: Triangular fibrocartilage provides a cushion to the bones of radius and ulna in the hand. It can get damaged due to a fall on an outstretched hand. In this procedure, the surgeon will use an arthroscope inserted through a small incision to view the damaged area. The debris of damaged tissue is removed, the area is cleaned, made smooth and torn cartilage and ligaments are joined by stitches.
Replacement of wrist joints: Wrist joints are more complex than hip or knee joints. Here, the complete joints can be removed and replaced by artificial materials known as prosthesis, thus improving hand movements and relieving pain. Prosthetic materials can be metals, ceramics, or plastics designed to replace the joints. A cast with splint is worn after the surgical procedure for around six weeks.
Repair of wrist fracture: Scaphoid is a cashew nut shaped bone associated with the thumb, forefinger and the large forearm bone in the wrist. There can be small bits of broken bones that will have to be removed surgically. Bigger pieces of bones will have to be aligned and stabilized with the help of pins, screws, and wires. If the stabilizing is done from outside it’s called external fixation, and if done from inside, it is called internal fixation.
Open reduction internal fixation (ORIF): This is a specialized surgery where a large incision is made and with the help of pins, plates, screws and wires the broken bones are stabilized and positioned.
Osteotomy: In this surgical procedure, the size of the bone is changed by cutting to have the bones aligned correctly. This is usually done when the healing of the bone happens abnormally or distorts due to osteoarthritis.
Synovectomy: This is a minimally invasive procedure where the excess synovial membrane grown between the wrist and finger joints is removed. The swelling of the synovial membranes often occurs due to rheumatoid arthritis.
Proximal Row Carpectomy: In this surgical procedure, the carpal bones of the wrist are removed to ease wrist movements. This is done when the patient undergoes severe pain with limited wrist movements.
Bones fusion surgery: This is done when the movement of hands and wrists become very difficult. Here, the carpal bones of the wrist are fused together as a solid single bone. The fusion can be complete or partial depending on the symptoms of the patient. Here, the movements can get limited comparing to normal actions, but the pain can be relieved and partial hand movements can be restored.
Other types of therapies include:
Hot and cold therapy: This therapy can be used to relieve pain and increase the mobility of the joints. Most often, this therapy is combined with physical exercise for better results. Gel packs can be used by either keeping it in the freezer or in a microwave oven to cool or heat it.
Hot therapy: Applying bearable heat upon the affected area will increase the blood flow, improve movements, reduce joint pains and relax muscles. This therapy is more often used before exercising.
Cold therapy: Cold therapy after exercise or exertion of the joints will alleviate pain, decrease blood flow, swelling, and inflammation.
Nutritional supplements: Supplements such as chondroitin, glucosamine, Vitamin C, D, and calcium are more popularly used to alleviate the symptoms of joints, strengthen the bones, and growth of tissues.
Aquatic therapy: Swimming is very helpful in solving the problem of the joints; the buoyancy of water avoids impact on the joints and restricts painful movements.
Discuss with your doctor before taking up any of the above therapies.
Physical assessment: Your doctor will ask you questions related to the symptoms of the hand. The affected area will be physically examined for swelling, pain, tenderness, and indications of bone damage.
Laboratory tests: Blood tests may be done to identify the level of rheumatoid factor, indicating the presence or absence of arthritis. Tests done using the fluid withdrawn from bone joints can reveal if there is gout or bacterial infection of the joints.
X-ray: An X-ray beam is projected on the affected area to view the condition of the bones and joints. At times, a contrast dye is injected into the joint to give a clear view on the X-ray. This process is called arthrography.
Magnetic resonance imaging (MRI): Using a strong magnetic field and a contrast dye, a clearer picture of bones, cartilages, tendons and ligaments can be viewed.
Computerized axial tomography (CAT) / computed tomography CT scan: X-rays and computers are used to have a much clearer view of fractures of bones than a normal X-ray.
Video-fluoroscopy: With the help of X-Ray and fluorescent dye, the internal structure and movements can be viewed in the form of a video.
Electromyography: Your doctor will connect electric nodes at different points on your hands and wrist through which low voltage electric shocks will be passed, and the speed of electric conduction by the nerves are recorded. This is a nerve conduction test that is done to find out if there are nerve compressions especially if one suffers from carpal tunnel syndrome.
Bone scan: In this procedure, a small amount of radioactive material is injected into the blood stream. These radioactive materials get settled where there is bone damage, which can be viewed with a scanner.
Participation in sports: Wrist and hand injuries are more commonly seen in people who are active in sports. Certain sports such as badminton, tennis, and volleyball will exert a lot of pressure on the hands and wrists. Chances of falls and injury are high in sports.
Repetitive activities: Performing repetitive activities using the hands and wrists such as chopping, knitting, typing, playing musical instruments for a long time can damage the nerves and ligaments.
Diseases or other conditions: Diseases such as arthritis, other infections of joints, pregnancy, and obesity can result in joint related disorders.
Arthritis: There are many types of arthritis that can affect the joints. The cartilage that supports and cushions the bones gets damaged with arthritis. In rheumatoid arthritis, the immune system of the body starts attacking the tissues of the joints and the wrist joint is more commonly affected.
Carpal tunnel syndrome: It occurs due to excess pressure on the median nerve that is passing through the carpal tunnel in the wrist.
Ganglion cysts: Cysts can develop behind the palm and fingers causing a restriction in the hand movements and pain.
Kienbock's disease: Young people are more often affected by this disorder due to lack of blood supply to the bones. The smallest bone in the wrist will collapse if not treated on time.
Osteoporosis: When the bone density decreases, the bones start chipping away leading to problems in movements and damaging nerves and ligaments around it.
Sudden impact on the wrist due to a fall on the outstretched arm can damage the bones, tendons or ligaments of the wrist and hands. There can be fractures of bones, sprains, and strain on nerves, tendons, and ligaments.
Long-term repetitive stress on your hands and wrists may weaken the nerves, tendons, ligaments, and joints.
You will be advised to try alternative treatment before considering the surgical means of treatment. Alternative therapies include:
Herbal remedies: Herbs such as arnica, bromelin found in the enzymes of pineapple, flaxseed oil, and turmeric can reduce inflammation when applied on the wrist. St. John’s wort can repair nerves and cure carpal tunnel syndrome. Avocado oil, soyabean oil combination, black currant oil, borage oil, Boswellia, evening primrose oil, ginger, Gamma-Linolenic Acid (GLA), and ginkgo have been proven effective in treating the symptoms of arthritis.
Massage therapy: Massaging the joints with aromatic oils can relieve pain and stress. It helps deliver higher levels of oxygen and enables better movement. Massage therapy may not be suitable for people with medical conditions such as osteoporosis, open wounds, skin infections, deep vein thrombosis (DVT), and arthritis.
Acupuncture: In this ancient Chinese treatment, very fine needles are inserted into specific points of the body. Depending on your problem, the practitioner will decide to insert multiple needles, which remain in the body for around 30 minutes. This method triggers the release of endorphins (natural pain relievers) into the blood circulation.
Yoga and meditation: Practicing yoga and meditation relieves your stress, keeps your mind calm, enables good blood circulation, and activates all the physical entities of the body. Care has to be taken to make sure yoga poses are practiced under the supervision of a yoga instructor.
Acupressure: It restores the healthy flow of energy through the body by stimulating certain points. Acupressure uses only fingers, hands, and elbows to exert pressure rather than needles (acupuncture). It can be done on people of any age except pregnant women and individuals with high blood pressure.
Trying to be safe during work and play, using proper lifting techniques and maintaining proper weight can help avoid injuries. Some of the preventive measures are as follows:
Exercises: Perform muscle strengthening exercises.
Safe movements: Learn the art of moving the hands and wrists in a safe manner.
Change positions: When performing a certain activity for a long time, change positions as often as possible.
Reduce repetitive movements: Try avoiding repetitive movements as much as possible, if unavoidable, take a break every 20 – 40 minutes. Reduce the force and speed of repetitive movements. Stretch your fingers, wrists, hands, shoulders, and neck while you take a break.
Maintain a healthy weight: Being overweight exerts excess pressure on the body, and also makes your hands more susceptible to damage.
Maintain a good posture: Good posture helps reduce the pressure on the wrist. Use a keyboard tray, if you are using a keyboard for an extended duration. The arms have to be slightly lower and should be parallel to each other, make sure the fingers are lower than the wrist.
Ergonomic design: The work environment has to be ergonomically designed to avoid stress on hands and wrist.
Use protective gears: Use of protective gears such as wrist guards, gloves to absorb shocks and vibrations while participating in sports and working with power tools. Play safe and avoid falls.
Distribute the weight evenly: When holding or lifting heavy objects use the complete hand or both hands if possible, instead of one or few fingers.
Are you suffering from painful hand and wrist movements? For any questions, information or guidance related to hands and wrists, consult our specialty-trained, skilled orthopedic surgeons at Cedars-Sinai Marina del Rey Hospital.
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