De Quervain’s Syndrome, also known as De Quervain’s Tenosynovitis are actually the same condition. Both terms refer to an inflammation of the tendons in the wrist and thumb, specifically the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. This inflammation causes pain and swelling at the base of the thumb and wrist, making it difficult to move the thumb and wrist. Patients with de Quervain syndrome have painful tendons on the thumb side of the wrist. Tendons are the ropes that the muscle uses to pull the bone. You can see them on the back of your hand when you straighten your fingers. With de Quervain’s syndrome, the tunnel (the first extensor compartment) (see Figure 1) where the tendons run narrows due to the thickening of the soft tissues that make up the tunnel. Hand and thumb motion cause pain, especially with forceful grasping or twisting.

Causes of de Quervain’s syndrome

Doctors are not sure what causes de Quervain’s syndrome. Patients often describe a feeling of inflammation, but studies have shown that the process is not inflammatory. People of all ages get it. When new mothers develop de Quervain syndrome, it typically appears 4 to 6 weeks after delivery. The old theory that it was caused by wringing out cloth diapers has been replaced by concerns about holding the baby, but changes in hormones and swelling seem more probable.

De Quervain’s Syndrome Treatment

Treatments that can relieve symptoms of De Quervain’s Syndrome include:

Treatments that attempt to change the course of the disease include:

© 2012 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee

What many people call the “funny bone” really is a nerve. This ulnar nerve runs behind a bone in the elbow through a space called the “cubital tunnel” (Figure 1). Although “banging the funny bone” usually causes temporary symptoms, chronic pressure on or stretching of the nerve can affect the blood supply to the ulnar nerve, causing numbness or tingling in the ring and small fingers, pain in the forearm, and/or weakness in the hand. This is called “cubital tunnel syndrome.”

Signs and Symptoms

Cubital tunnel syndrome can cause pain, loss of sensation, and/or tingling. “Pins and needles” usually are felt in the ring and small fingers. These symptoms are often felt when the elbow is kept bent for a long time, such as while holding a phone or while sleeping. Some people feel weak or clumsy. Loss of sensation and loss of strength or muscle in the hand is serious.

Diagnosis of Cubital Tunnel Syndrome

Your doctor will be able to tell a lot by asking you about your symptoms and examining you. S/he might test you for other medical problems like diabetes or thyroid disease. A test called electromyography (EMG) and/or nerve conduction study (NCS) might be needed to see how much the nerve and muscle are being affected. This test also checks for other problems like a pinched nerve in the neck, which can cause similar symptoms.

Cubital Tunnel Syndrome Treatment

The first treatment is to avoid actions that cause symptoms. Wrapping a pillow or towel around the elbow or wearing a splint at night to keep the elbow from bending during sleep can help. Avoiding leaning on the “funny bone” part of the elbow can help also. A hand therapist can help you learn ways to avoid pressure on the nerve.

When symptoms of Cubital Tunnel Syndrome are severe or not getting better, surgery may be needed to relieve the pressure on the nerve. This can involve releasing the nerve, moving the nerve to the front of the elbow, and/or removing a part of the bone. Your surgeon will talk to you about what is the right option for you and guide your care.
Therapy sometimes is needed after surgery, and the time it takes to recover varies. Numbness and tingling may improve quickly or slowly, and it may take many months for the strength in your hand to improve. Cubital tunnel symptoms may not totally go away after surgery, especially if symptoms are severe.

© 2012 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee

What are the signs and symptoms?

Pain, swelling, bruising, and stiffness in and around the elbow suggest a possible fracture. A snap or pop at the time of injury may be felt or heard. Skin openings
may reflect communication between the bone and the outside environment. Visible deformity would indicate displacement of the bones or a dislocation of the elbow joint. It is always important to check for possible nerve and/or artery damage.

How are elbow fractures diagnosed?

X-rays are used to confirm if a fracture is present and if the bones are displaced. Sometimes a CT scan might be necessary to get further detail, especially of the
joint surface.

How are they treated?

Stiffness is a major concern after any elbow fracture. Treatment is therefore focused on maximizing early motion. Conservative treatment (sling, cast) is usually used when the bones are at low risk of moving out of place, or when the position of the bones is acceptable. Age is also an important factor when treating elbow fractures. Casts are used frequently in children, as their risk of developing stiffness is small; however, in an adult, elbow stiffness is much more likely. Fractures that are displaced or unstable are more likely to need surgery to realign and stabilize the fragments, or sometimes to remove bone fragments, and ideally allow for early motion. Whenever a fracture is open (skin broken over the fracture), urgent surgery is needed to clean out the tract and bone so as to minimize the risk of a deep infection.

Therapy is often utilized to maximize motion. This might include exercises, scar massage, modalities such as ultrasound, heat, ice, etc., and splints that stretch the joint (static progressive or dynamic splints).

Material modified from the American Society for Surgery of the Hand.

Golfing Wrist & Hand Injury

Hand, wrist, and elbow injuries are common for golfers of all skill levels. The golf swing is a complex, coordinated series of motions. Common golf injuries can result from poor technique, overuse, or a single event. Many single-event injuries happen when the club hits the ground by accident.

There are many ways to prevent golf injuries and enjoy the game:

Types of Golf Injuries

Golf injuries can affect any part of the upper extremity. Structures of the neck, shoulder, arm, elbow, wrist, fingers, and thumb can be irritated, stretched, or broken. The diagnosis and treatment of the most common golf-related upper extremity injuries are discussed below.

Diagnosis
Diagnosis of medial epicondylitis is often made by history and physical exam. In cases that are not responding to treatment, it may be helpful to obtain an imaging study. Ultrasound or magnetic resonance imaging (MRI) are the most common studies ordered.

Treatment
Medial epicondylitis will almost always be treated without surgery. Non-surgical treatments usually include:

Wrist Tendonitis

Golfers who play too much or too aggressively can develop tendon irritation at the wrist. This is called wrist tendinitis and is similar to medial epicondylitis (discussed above). This irritation can occur on either the front or back of the wrist. It is more common in the leading hand (left hand for a right-handed player and vice versa).

Signs and Symptoms

Diagnosis
Diagnosis of wrist tendonitis is made by history and physical examination by a doctor. X-rays do not show tendonitis but may be obtained to rule out other injuries. Other imaging such as ultrasound or MRI could be ordered.

Treatment
Wrist tendonitis is treated similarly to medial epicondylitis–almost always without surgery. Usual treatments include activity modification, anti-inflammatory medications, bracing, and therapy. If these do not work, your doctor may recommend injection of a stronger anti-inflammatory medication called a steroid.

Hamate Bone Fracture

The hamate is a small bone in the wrist. It is located on the outside of the wrist on the pinky side. It is shaped like a wedge with a hook sticking out of it (Figure 2). The hook is located on the palm side of the hand. It is narrow and can break off. This can happen when a club strikes the ground, forcing the hard handle to kickback against the hook and sometimes break or crack the hook (Figure 3).

Signs and Symptoms

Diagnosis
Diagnosis of hamate fracture starts with history and physical examination by a doctor. X-rays are often enough to show the fracture. However, it may be missed on common screening x-rays as the hook can be hard to see. Therefore, if the initial x-rays do not show the fracture your doctor, may order other specialized angled views. If these x-rays are still normal, but the surgeon is still suspicious, they may order a computerized tomography (CT) scan (Figure 2) or MRI.

Treatment
Some simple hamate fractures are treated without surgery. This involves a cast or splint for six weeks followed by hand therapy to regain range of motion. This may allow pain to improve, but the fracture may not have complete healing on x-rays. If the injury is not responding to non-operative care, the most common surgery is to remove the broken hook and smooth any remaining rough edges of bone. Without the hook, the hand, wrist, and fingers can work normally. Your surgeon can also consider trying to fix the fracture with a screw to get it to heal. However, fixing surgery has a lower success than many other fractures due to the small surface area available for healing and the high forces pulling on the hook that prevent it from healing.

Therefore, this problem can become a surgical emergency. The decrease in blood flow may also occur slowly so that the body has some time to adapt. If it occurs more slowly over time, then symptoms may be less severe while gradually there is no blood flow to the hand or fingers.

Signs and Symptoms

Diagnosis
Diagnosis of hypothenar hammer syndrome starts with history and physical examination by a doctor. An ultrasound is often the first test to check for vessel damage. If this is concerning, your doctor may order an angiogram. An angiogram injects dye into the vessels so they can be seen under x-ray (fluoroscopy), CT scan, or MRI.

Treatment
Treatment of hypothenar hammer syndrome depends on the severity. Some patients may get better with modification of their golf grip or swing. If your vessel is very damaged or has developed a clot, surgery may be required. Depending on multiple factors, surgery may include excision of the aneurysm with or without a graft to reconstruct the artery, blood clot removal (thrombectomy), or medical treatment with blood-thinning (anticoagulation and anti-platelet) medications.

Wrist Sprains

Some golfers develop wrist sprains from overuse or hitting the ground before the ball. A sprain is an incomplete injury to a ligament in the wrist. Ligaments are strong structures that hold bone together. A sprain can be anything from a mild stretch to a partial or complete tear. This usually causes pain and popping in the wrist. It may also cause swelling, motion, and loss of grip strength. Please refer to our article on wrist sprains for discussion of symptoms, diagnosis, and treatment of this condition.

Non-upper extremity injuries worthy of mention include sprains and strains of the back, especially the lower back called the lumbar spine. Proper warm-up and stretching is important to decrease the chances of injury. Gradual increase in length and intensity of play should be exercised as the season progresses.

Material modified from the American Society for Surgery of the Hand.

What causes Tennis Elbow?

Overuse – The cause can be both non-work and work related. An activity that places stress on the tendon attachments, through stress on the extensor muscle-tendon unit, increases the strain on the tendon. These stresses can be from holding too large a racquet grip or from “repetitive” gripping and grasping activities, i.e. meat-cutting, plumbing, painting, weaving, etc.

Trauma – A direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity could also injure the tendon.

Who gets Tennis Elbow?

The most common age group that this condition affects is between 30 to 50 years old, but it may occur in younger and older age groups, and in both men and women.

Signs and symptoms

Pain is the primary reason for patients to seek medical evaluation from tennis elbow. The pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle. This area becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.

Tennis Elbow Treatment

Conservative (non-surgical) Treatment

Activity modification – Initially, the activity causing the condition should be limited. Limiting the aggravating activity, not total rest, is recommended. Modifying grips or techniques, such as use of a different size racket and/or use of 2-handed backhands in tennis, may relieve the problem.

Medication: Anti-inflammatory medications may help alleviate the pain.

Brace: A tennis elbow brace, a band worn over the muscle of the forearm, just below the elbow, can reduce the tension on the tendon and allow it to heal.

Physical Therapy: may be helpful, providing stretching and/or strengthening exercises. Modalities such as ultrasound or heat treatments may be helpful.

Steroid injections: A steroid is a strong anti-inflammatory medication that can be injected into the area. No more than (3) injections should be given.

Shockwave treatment: A new type of treatment, available in the office setting, has shown some success in 50–60% of patients. This is a shock wave delivered to the affected area around the elbow, which can be used as a last resort prior to the consideration of surgery.

Tennis Elbow Surgery

Surgery is only considered when the pain is incapacitating and has not responded to conservative care, and symptoms have lasted more than six months. Surgery involves removing the diseased, degenerated tendon tissue. Two surgical approaches are available; traditional open surgery (incision), and arthroscopy—a procedure performed with instruments inserted into the joint through small incisions. Both options are performed in the outpatient setting.

Recovery

Recovery from surgery includes physical therapy to regain motion of the arm. A strengthening program will be necessary in order to return to prior activities. Recovery can be expected to take 4–6 months.

Material modified from the American Society for Surgery of the Hand.

If you do not have pain, your doctor might recommend a resting splint and compression to rest the bursa and help speed recovery. Sometimes elbow pads can help, especially if you find that you are one of those people who tend to lean on the tip of the elbow a lot.

Your doctor might want to use a needle to draw fluid out of the bursa (aspiration), especially if s/he is worried that there might be an infection. If there is an infection, antibiotics and fluid removal might cure the infection. Sometimes the infection is hard to cure with antibiotics and surgery is needed. If the bursa is not infected, and the bursitis continues to be a problem, additional treatment options may include repeated aspiration, cortisone injection and surgery.

Material modified from the American Society for Surgery of the Hand.

A congenital condition is one that a child is born with. Any type of deformity in a newborn infant can become a challenge for the child as he or she grows. Early consultation with a hand surgeon is an important part of the treatment process for the child born with a hand or upper extremity deformity.

Dr. Van Wyk commonly treats the following Pediatric and Congenital conditions including:

• Acute Injuries
• Fractures
• Syndactyly
• Thumb duplication
• Failure of formation
• Hypoplastic thumb
• Radial club hand
• Constriction bands
• Obstetrical palsies
• Vascular anomalies
• Trigger Thumb

To obtain more detailed information about conditions of the hand, wrist, forearm and elbow, visit our Patient Resources page.

If you require care and treatment for the hand and upper extremity, call the Van Wyk Hand Center at (817) 877-3131 to schedule an appointment.

Please Note: The medical information contained on this website is provided to increase your knowledge and understanding of hand and upper extremity problems or conditions. This information should not be interpreted as the Van Wyk Hand Center’s recommendation for a specific medical or surgical treatment plan.

What is Psoriatic Arthritis?

Psoriasis is a skin disease in which patients have dry, red and scaly skin rashes that can occur on any part of the body. Between 5-20% of patients with psoriasis may develop an associated arthritis. Arthritis means inflamed joint. A normal joint consists of two cartilage-covered bone surfaces that glide smoothly against one another. In psoriatic arthritis, the lining of the joint the synovium becomes inflamed and swollen. The swollen tissues stretch supporting structures of the joints, such as ligaments and tendons. As these supporting structures stretch out, the joints become deformed and unstable. The gliding surface wears out, and joint cartilage and bone erode. In addition to the hands, psoriatic arthritis can affect joints in the spine, feet, and jaw.

There is no lab test specifically for psoriatic arthritis. Patients thought to have psoriatic arthritis often will have labs drawn to make sure they do not have rheumatoid arthritis or gout. Patients with psoriatic arthritis will often have an elevated inflammatory marker known as the sedimentation rate (ESR) but a negative rheumatoid factor (RF). Psoriasis is part of a larger group of inflammatory arthritis called spondyloarthropathies. On occasion, other lab tests may be requested to further characterize your arthritis. Sometimes a skin biopsy may be performed in a patient with hand symptoms and a skin lesion suspicious for psoriasis, without a known history of the disease.

Treatment of Psoriatic Arthritis:

Treatment for psoriatic arthritis aims to decrease inflammation, relieve pain, and maintain function. While there is no cure for psoriatic arthritis, medications are available to lessen symptoms and improve function. Optimal care involves a team approach among the patient, physicians, and therapists. The care of the psoriatic patient requires not only a hand surgeon but also a hand therapist, rheumatologist, and the patient s primary care physician. The rheumatologist is often the physician that monitors and decides the specific type of medicine that is felt to be the most effective at that stage in the patient s disease process.

The hand therapist will provide instruction on how to use your hands in ways to help relieve pain and protect joints. They may provide exercises, splints, wraps, and adaptive devices to help you cope with activities of daily living.

Psoriatic arthritis can be a progressive disease. Surgical interventions need to be appropriately timed in order to maximize function and lessen pain. Patients with psoriatic skin lesions are at increased risk for a surgical infection, so good control of the skin lesions is an important consideration when scheduling surgery.

There are many types of procedures to treat joints affected by psoriatic arthritis. The procedures range from joint replacements to joint fusions. The specific procedure(s) depends on many factors. These factors include the particular joint(s) involved, the degree of damage present, and the condition of surrounding joints. One of the most important factors in deciding the correct surgical procedure is the needs of the patient. There are often many ways to treat hand deformities in psoriatic arthritis. Your hand surgeon can help you decide on the most appropriate treatment for you.

What happens if you have no treatment?

Psoriatic arthritis can manifest itself with different joint findings and symptoms, and these symptoms can change over time. Consequently it has been difficult to identify an individual marker for the disease. Psoriatic skin lesions do not correlate with the severity of joint involvement. Many studies show that appropriately prescribed medication can improve function and decrease pain and swelling. Studies looking at newer agents have shown delays in X-ray changes which are felt to demonstrate a slowing of the disease process. Further work is needed to understand how and to what extent medication alters the disease process.

© 2009 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee

Vascular Disorders

Vascular disorders of the upper extremity are uncommon, but ones that may have lasting implications.

Anatomy

Arteries bring oxygenated blood from the heart to the fingertips and veins return the used blood back to the heart and lungs.

or sometimes a blunt injury can bruise the vessels enough to cause a clot and stop the blood from flowing to the fingertips, which turn white, cold, and painful. Immediate reconstruction is usually necessary if blood flow has stopped. Other injuries may not be as severe, since there may be a variety of different arteries that can continue to provide blood flow to the area.

Aneurysms: An aneurysm is a localized weakness of the vessel wall that results in an isolated expansion of the vessel, like a balloon popping up (Fig. 4). Usually these present as a soft painless mass over the vessel. The vessel may become blocked through the formation of a blood clot or may even shower small clots to the fingertips. Aneurysms of the wrist may cause cold intolerance, pain or numbness as they enlarge, and can occasionally cause gangrene of the fingertips.

Vascular malformations: When an abnormal connection exists between the veins and arteries, excess blood is shunted through these small vessels, which may become large and produce symptoms. When a significant volume of blood is re-directed through these small connecting vessels, patients can experience pain, sweating in the area, heaviness, increased temperature and hair growth, and spontaneous bleeding. When small, treatment may be as simple as a compression glove. However, when large and destructive, treatment might require surgical excision.

Raynaud’s Phenomenon/Disease: This describes a condition in which the arteries in the fingers go into spasm, depriving the finger of blood flow. The fingers typically change color, going from white to blue, then red as the spasm resolves and blood flow returns. It often occurs when the hand is exposed to cold or tobacco. Treatment entails cessation of smoking, avoiding cold weather, use of protective garments (e.g. mittens, gloves), and occasionally medicines that can help dilate the vessels and improve blood flow to the fingertips. When unresponsive to these measures or a non-healing ulcer is present, surgery to separate the nerves from around the vessels may be considered, to relieve the effect of the sympathetic nerves that contributes to spasm of the arteries

© 2012 American Society for Surgery of the Hand.

Wrist injuries can happen suddenly, as in a fall, or from wear and tear from everyday activity. Dr. Van Wyk works closely and communicates regularly with our on-site Certified Hand Therapists to monitor the patients’ progress to ensure our patients receive the most appropriate care for their wrist condition.

Dr. Van Wyk commonly treats the following wrist conditions including:

To obtain more detailed information about conditions of the hand, wrist, forearm and elbow, visit our Patient Resources page.

If you require care and treatment for the hand and upper extremity, call the Van Wyk Hand Center at (817) 877-3131 to schedule an appointment.

Please Note: The medical information contained on this website is provided to increase your knowledge and understanding of hand and upper extremity problems or conditions. This information should not be interpreted as the Van Wyk Hand Center’s recommendation for a specific medical or surgical treatment plan.