OrthoBethesda - Restoring Function
OrthoBethesda - Restoring Function

Guide To Hands

Arthritis of the Base of the Thumb

What is arthritis at the base of the thumb?

In a normal joint, cartilage covers the ends of the bones and allows them to move smoothly and painlessly against one another. In osteoarthritis (or degenerative arthritis), the cartilage layer wears out, resulting in direct contact between the bones. In the hand, the second most common joint to develop osteoarthritis is the joint at the base of the thumb. The thumb basal joint, also known as the carpometacarpal (CMC) joint, is a specialized saddle-shaped joint that is formed by a small wrist bone (trapezium) and the first of the three bones in the thumb (metacarpal). The specialized shape of this joint allows the thumb its wide range of movement—up and down, across the palm, and the ability to pinch with the fingers (see Figure 1)

Who gets arthritis at the base of the thumb?

Arthritis at the base of the thumb is more common in women and usually starts after age 40. The cause of this form of arthritis is unknown in most cases. Past injuries to the joint, such as fractures or severe sprains, and generalized joint laxity may increase the chances of developing this form of arthritis at a younger age.

What are the symptoms and signs of arthritis at the base of the thumb?

The most common symptom of thumb basal joint arthritis is a deep, aching pain at the base of the thumb. The pain is often worsened with activities that involve pinch, including opening jars, turning door knobs or keys, and writing. As the disease progresses, patients may experience pain at rest and at night, and patients often note loss of pinch and grip strength. In severe cases, progressive destruction and mal-alignment of the joint occurs and a "bump" develops at the base of the thumb, which is caused by the thumb metacarpal moving out of position in relation to the trapezium. At this point, thumb motion becomes limited and the space between the thumb and index finger narrows, making pinch activities difficult (see Figure 2). The next joint up may hyper-extend to compensate.

How is the diagnosis made for arthritis at the base of the thumb?

The appearance of the thumb and the location of the pain are usually very helpful in identifying this condition. Applying longitudinal pressure along the thumb and twisting or grinding the basal joint is also helpful in reproducing symptoms (see Figure 3). Although x-rays help confirm the diagnosis, symptom severity often does not correlate directly with the joint’s appearance on the x-ray.

What are the treatment options for arthritis at the base of the thumb?

Less severe thumb arthritis will usually respond to non-surgical care. Pain medication, topical agents, splinting, and limited use of corticosteroid injections may help alleviate pain. A hand therapist might provide a variety of rigid and non-rigid splints to support the thumb during activities.

Patients with advanced arthritis or who do not respond to non-surgical treatment may be candidates for surgical reconstruction. A variety of surgical techniques are available that can successfully reduce or eliminate pain and improve thumb position and function. Common surgical procedures include removal of arthritic bone and joint reconstruction (joint arthroplasty), bone fusion or realignment techniques, and even arthroscopic procedures in select cases. A consultation with your treating surgeon can help decide the best options for you (see Figure 4).

Thumb Basal Joint
Figure 1:  Thumb Basal Joint

Arthritis at the Base of the Thumb
Figure 2:  In severe cases, the thumb collapses into the palm, causing a zig-zag deformity

Test for arthritis of thumb
Figure 3:   Grind Test

Metacarpal, basal joint, & trapezium
Figure 4:  Treatment Diagram

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Carpal Tunnel Syndrome

What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. In effect, it is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand (see Figure 1). Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel and puts pressure on the nerve. When the pressure from the swelling becomes great enough to disturb the way the nerve works, numbness, tingling, and pain may be felt in the hand and fingers (see Figure 2).

What causes carpal tunnel syndrome?

Usually the cause is unknown. Pressure on the nerve can happen several ways: swelling of the lining of the flexor tendons, called tenosynovitis; joint dislocations, fractures, and arthritis can narrow the tunnel; and keeping the wrist bent for long periods of time. Fluid retention during pregnancy can cause swelling in the tunnel and symptoms of carpal tunnel syndrome, which often go away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes also can be associated with carpal tunnel syndrome. There may be a combination of causes.

Signs and symptoms of carpal tunnel syndrome

Carpal tunnel syndrome symptoms usually include pain, numbness, tingling, or a combination of the three. The numbness or tingling most often takes place in the thumb, index, middle, and ring fingers. The symptoms usually are felt during the night but also may be noticed during daily activities such as driving or reading a newspaper. Patients may sometimes notice a weaker grip, occasional clumsiness, and a tendency to drop things. In severe cases, sensation may be permanently lost and the muscles at the base of the thumb slowly shrink (thenaratrophy), causing difficulty with pinch.

Diagnosis of carpal tunnel syndrome

A detailed history including medical conditions, how the hands have been used, and whether there were any prior injuries is important. An x-ray may be taken to check for the other causes of the complaints such as arthritis or a fracture. In some cases, laboratory tests may be done if there is a suspected medical condition that is associated with CTS. A nerve conduction study (NCV) and/or electromyogram (EMG) may be done to confirm the diagnosis of carpal tunnel syndrome as well as to check for other possible nerve problems.

Treatment of carpal tunel syndrome

Symptoms may often be relieved without surgery. Identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position may help reduce pressure on the nerve. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. A steroid injection into the carpal tunnel may help relieve the symptoms by reducing swelling around the nerve.

When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand (see Figure 3). Incisions for this surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve. Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.

Carpal tunnel
Figure 1:  The carpal tunnel is found at the base of the palm. It is formed by the bones of the wrist and the transverse carpal ligament. Increased pressure in the tunnel affects the function of the median nerve.

Median nerve function
Figure 2:  Aspects of median nerve function.

Carpal tunnel surgery
Figure 3:  The goal of surgery is to free the ligament to allow more room for the median nerve in the carpal tunnel.

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deQuervain’s Tendonitis

What is deQuervain's tendonitis?

First dorsal compartment tendonitis, more commonly known as de Quervain’s tendonitis or tenosynovitis after the Swiss surgeon Fritz de Quervain, is a condition brought on by irritation or inflammation of the wrist tendons at the base of the thumb (see Figure 1, 1A). The inflammation causes the compartment (a tunnel or a sheath) around the tendon to swell and enlarge, making thumb and wrist movement painful. Making a fist, grasping or holding objects—often infants—are common painful movements with de Quervain’s tendonitis.

What causes deQuervain's tendonitis?  

The cause of de Quervain’s tendonitis is an irritation of the tendons at the base of the thumb, usually caused by taking up a new, repetitive activity. New mothers are especially prone to this type of tendonitis: caring for an infant often creates awkward hand positioning, and hormonal fluctuations associated with pregnancy and nursing further contribute to its occurrence. A wrist fracture can also predispose a patient to de Quervain’s tendonitis, because of increased stresses across the tendons.

Signs and symptoms of deQuervain's tendonitis

Pain over the thumb-side of the wrist is the main symptom. The pain may appear either gradually or suddenly, and pain is located at the first dorsal compartment (see Figure 1, 1A) at the wrist. Pain may radiate down the thumb or up the forearm. Hand and thumb motion increases pain, especially with forceful grasping or twisting. Swelling over the base of the thumb may include a fluid-filled cyst in this region. There may be an occasional “catching” or “snapping” when moving the thumb. Because of the pain and swelling, motion such as pinching may be difficult. Irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger.

Diagnosis of deQuervain's tendonitis

Tenderness directly over the tendons on the thumb-side of the wrist is the most common finding. A test is generally performed in which the patient makes a fist with the fingers clasped over the thumb. The wrist is then bent in the direction of the little finger (see Figure 2 and 3). This maneuver can be quite painful for the person with de Quervain’s tendonitis.

Treatment of deQuervain's tendonitis

The goal is to relieve the pain caused by the irritation and swelling. Your doctor may recommend resting the thumb and wrist by wearing a splint. Oral anti-inflammatory medication may be recommended. A cortisone-type of steroid may be injected into the tendon compartment as another treatment option. Each of these non-operative treatments help reduce the swelling, which typically relieves pain over time. In some cases, simply stopping the aggravating activities may allow the symptoms to go away on their own.

When symptoms are severe or do not improve, surgery may be recommended. The surgery opens the compartment to make more room for the inflamed tendons, which breaks the vicious cycle where the tight space causes more inflammation. Normal use of the hand can usually be resumed once comfort and strength have returned.
Your hand surgeon will advise the best treatment for your situation.

First and Third Dorsal Compartment
Figure 1:  The first dorsal compartment. There are six compartments on the dorsal, or back, side of the wrist. The first and third compartments house tendons which control the thumb.

DeQuervain's Tendonitis
Figure 1A:  De Quervain’s Tendonitis

Finkelstein manuever
Figure 2 and 3:  Finkelstein maneuver, a helpful test to diagnose de Quervain’s Tendonitis. Figure 2 shows the first dorsal compartment relaxed; Figure 3 shows the compartment stretched when the fist is bent toward the little finger.

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Dupuytren’s Disease

What is Dupuytren's disease?

Dupuytren’s disease is an abnormal thickening of the fascia (the tissue just beneath the skin of the palm). It often starts with firm lumps in the palm. In some patients, firm cords will develop beneath the skin, stretching from the palm into the fingers (see Figure 1). Gradually, these cords may cause the fingers to bend into the palm (see Figure 2). Although the skin may become involved in the process, the deeper structures—such as the tendons—are not directly involved. Occasionally, the disease will cause thickening on top of the finger knuckles (knuckle pads), or nodules or cords within the soles of the feet (plantar fibromatosis).

What causes Dupuytren's disease? 

The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.

What are the symptoms and signs of Dupuytren's disease?

Symptoms of Dupuytren’s disease usually include a small lump or series of lumps and pits within the palm. The lumps are generally firm and adherent to the skin. Gradually a cord may develop, extending from the palm into one or more fingers, with the ring and little fingers most commonly affected. These cords may be mistaken for tendons, but they actually lie between the skin and the tendons. In many cases, both hands are affected, although the degree of involvement may vary.

The initial nodules may produce discomfort that usually resolves, but Dupuytren’s disease is not typically painful. The disease may first be noticed because of difficulty placing the hand flat on an even surface, such as a tabletop (see Figure 3). As the fingers are drawn into the palm, one may notice increasing difficulty with activities such as washing, wearing gloves, shaking hands, and putting hands into pockets. Progression is unpredictable. Some individuals will have only small lumps or cords while others will develop severely bent fingers. More severe disease often occurs with an earlier age of onset.

What are the treatment options for Dupuytren's disease?

In some cases, only observation is needed for nodules and cords that are not contracted. Patients with more advanced contractures may require surgery in order to improve function.

Various surgical techniques are available in order to correct finger position. Your treating surgeon will discuss the method most appropriate for your condition based upon the stage of the disease and the joints involved (see Figure 4). The goal of surgery is to improve finger position and thereby hand function. Despite surgery, the disease process may recur and the fingers may begin to bend into the palm once again. Before surgery, your treating surgeon will discuss realistic goals and results.

Specific surgical considerations:
1. The presence of a lump in the palm does not mean that surgery is required or that the disease will progress.
2. Correction of finger position is best accomplished with milder contractures and contractures that affect the base of the finger. Complete correction sometimes can not be attained, especially of the middle and end joints in the finger.
3. Skin grafts are sometimes required to cover open areas in the fingers if the skin is deficient.
4. The nerves that provide feeling to the fingertips are often intertwined with the cords.
5. Splinting and hand therapy are often required after surgery in order to maximize and maintain the improvement in finger position and function.

Dupuytren's disease on hand
Figure 1: Dupuytrens disease may present as a small lump, pit, or thickened cord in the palm of the hand

Dupuytren's disease into finger
Figure 2: In advanced cases, a cord may extend into the finger and bend it into the palm

Examination for Dupuytren's disease
Figure 3: Table Top Test

Treatment for Dupuytren's Disease
Figure 4: Treatment Diagram

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Ganglion Cysts

What are ganglion cysts?

Ganglion cysts are very common lumps within the hand and wrist that occur adjacent to joints or tendons.  The most common locations are the top of the wrist (see Figure 1), the palm side of the wrist, the base of the finger on the palm side, and the top of the end joint of the finger.  The ganglion cyst often resembles a water balloon on a stalk (see Figure 2), and is filled with clear fluid or gel. The cause of these cysts is unknown although they may form in the presence of joint or tendon irritation or mechanical changes. These cysts may change in size or even disappear completely, and they may or may not be painful.  These cysts are not cancerous and will not spread to other areas.

How are ganglion cysts diagnosed?

The diagnosis is usually based on the location of the lump and its clinical appearance. They are usually oval or round and may be soft or very firm. Cysts at the base of the finger on the palm side are typically a very firm, pea-sized nodule that is tender to applied pressure, such as when gripping. Light will often pass through these lumps (trans-illumination) and this can assist in the diagnosis. Your physician may request x-rays in order to investigate problems in adjacent joints; cysts at the end joint of the finger frequently have an arthritic bone spur associated with them.

What are the treatment options for ganglion cysts?

Treatment can often be non-surgical.  In many cases, these cysts can simply be observed, especially if they are painless. If the cyst becomes painful, limits activity, or is cosmetically unacceptable, other treatment options are available. The use of splints and anti-inflammatory medication can be prescribed in order to decrease pain associated with activities. An aspiration can be performed to remove the fluid from the cyst and decompress it.  This requires placing a needle into the cyst, which can be performed in most office settings.  If non-surgical options fail to provide relief or if the cyst recurs, surgical alternatives are available. Surgery involves removing the cyst along with a portion of the joint capsule or tendon sheath (see Figure 3). In the case of wrist ganglion cysts, both traditional open and arthroscopic techniques may yield good results. Surgical treatment is generally successful although cysts may recur. Your surgeon will discuss the best treatment options for you.

Ganglion cyst
Figure 1:  Ganglion top side (dorsum) wrist

Ganglion end joint of finger
Figure 2:  Ganglion end joint of finger (mucous cyst)

Root of ganglion cyst
Figure 3:  Cross-section of wrist showing stalk (or root) of ganglion.

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Tennis Elbow (Lateral Epicondylitis)

What is tennis elbow/lateral epicondylitis?

Lateral epicondylitis, commonly known as tennis elbow, is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons anchor the muscle to bone. The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist (see Figure 1). With lateral epicondylitis, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can then lead to pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different types of activities, athletic and otherwise.

What causes tennis elbow/lateral epicondylitis?

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/lateral epicondylitis?

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 of tennis elbow/lateral epicondylitis

Pain is the primary reason for patients to seek medical evaluation. 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. 

Treatment for tennis elbow/lateral epicondylitis

Conservative (non-surgical)

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.

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.

Image

Figure 1:  The muscle involved in this condition, the extensor carpi radialis brevis, helps to extend and stabilize the wrist

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Trigger Finger (Stenosing Tenosynovitis)

What is trigger finger or stenosing tenosynovitis?

Stenosing tenosynovitis, commonly known as “trigger finger” or “trigger thumb”, involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the finger, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone. The tendons and the tunnel have a slick lining that allows easy gliding of the tendon through the pulleys (see Figure 1).

Trigger finger/thumb occurs when the pulley at the base of the finger becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb (see Figure 2). The catching or triggering action is distinctive, as seen in this brief video clip of a ring trigger finger: video demonstration (may take up to two minutes to load).  When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend. 

What causes trigger finger / stenosing tenosynovitis? 

Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause.

Signs and symptoms of trigger finger / stenosing tenosynovitis

Trigger finger/thumb may start with discomfort felt at the base of the finger or thumb, where they join the palm. This area is often tender to local pressure. A nodule may sometimes be found in this area. When the finger begins to trigger or lock, the patient may think the problem is at the middle knuckle of the finger or the tip knuckle of the thumb, since the tendon that is sticking is the one that moves these joints. 

Treatment of trigger finger / stenosing tenosynovitis

The goal of treatment in trigger finger/thumb is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort. Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. The wearing of a splint or taking an oral anti-inflammatory medication may sometimes help. Treatment may also include changing activities to reduce swelling. An injection of steroid into the area around the tendon and pulley is often effective in relieving the trigger finger/thumb.

If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended. This surgery is performed as an outpatient, usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits. Some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Occasionally, hand therapy is required after surgery to regain better use.

Normal anatomy flexor sheath
Figure 1:  Normal anatomy flexor sheath showing pulley, tendon, and tenosynovium.

Abnormal anatomy, trigger finger
Figure 2:   Abnormal anatomy showing tendon catching thick, tight pulley. Sometimes the tendon will be locally enlarged and thicker.

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More Information
MedlinePlus® 
National Library of Medicine
National Institutes of Health


Related Files
Arthritis: Base of the Thumb (PDF File)
Carpal Tunnel Syndrome (PDF File)
deQuervain's Tendonitis (PDF File)
Dupuytren's Disease (PDF File)
Ganglion Cysts (PDF File)
Tennis Elbow Lateral Epicondylitis (PDF File)
Trigger Finger (PDF File)