DUPUYTREN`S DISEASE

It is abnormal thickening of the fascia which is just under the palmar skin and protects the passing tendon, nerve and vessel structures. Fascia thickening starts from palm and extends to the fingers. In advanced terms of the disease, distortion through the palm and some hardness called nodules arise. (Figure 1)

This disease may be also seen in the sole and penis.

It is usually observed in men over 40. While observation frequency is more in diabetic patients, relationship with other occupational diseases is not proven. It may affect all fingers as well as frequent in small and middle finger.

Swelling and bending increase are seen in the examination. Cord shaped thickened indurations related with swellings are handled in the palm. Distortion due to cord pulling occurs in finger in advanced terms of the disease. Both hands are affected in most patients. If the disease starts in the early age, it progresses more serious.

Palmar nodules formed due to dupuytren`s disease are typically painless. The disease is first noticed with disability to put the palm on flat surfaces. When distortion increases more and more, difficulty in some movements such as hand washing, hand shaking, wearing gloves, holding something etc. occurs. Progress rate changes from patient to patient.

If functions of the patient in the initial term are not affected, the patient is followed. If there is no distortion on fingers, existence of nodules does not require the surgery. Steroid injection on nodules may decrease the progress rate of the disease in these cases. In cases that fingers distort 70 degrees and over, surgery is considered. The purpose for surgery is to remove hardened fascia extending to the palm and fingers by protecting the vessel and nerve structures. Deficiencies that may arise in the skin cover after removal of the hardened bands are solved by skin grafts taken from other parts of the body. Brace application after the surgery and physical treatment are very important in terms of success of the treatment.

Source: dupuytren's disease

DE QUERVAIN TENOSYNOVITIS (COMPRESSION OF THUMB TENDON)

Our tendons that allows us to lift the thumb and to move away from other fingers pass under a tunnel which is near the thumb base in the wrist. By thickening and hardness in this tunnel, swellings occurred in sheath of the tendon make This table with pain and sensibility in the wrist is called with the name of the surgeon (Fritz de Quervain) who described the disease first.

It is mostly seen after forcible and recurrent movements which are just started to be done. Especially the position of the hand of which new mothers make during carrying their baby; and effects of hormonal fluctuations in pregnancy and lactation period facilitates this situation to be arisen. De Quervain tendinitis may occur after old wrist fractures, traumas, and exercises after unusual weights.

The most typical symptom is pain in the thumb side of the wrist. The pain diffuses to the thumb in downwards and to the front arm in upwards. The pain increases in strong clutching and wrist twisting that the thumb is used. (Figure 1)Also swelling may be observed in the pain area of the wrist. The pain which occurs when we twist the wrist in the direction of the little finger by taking the thumb in the fist is typical for diagnosis.

To relax the hand by using a splint which inactivates the painful movements of the thumb in the beginning period is very important. (Figure 2) Besides, swellings of the tunnel and the tendon are tried to be decreased by using non-steroid anti-inflammatory drugs. If symptoms are persistent or getting worse, the tunnel which compresses tendons should be opened surgically. This surgery may be performed by local anesthesia to whole arm or only to the wrist.

Source: de quervain tenosynovitis

CUBITAL TUNNEL SYNDROME

Cubital tunnel syndrome is a condition where the ulnar nerve is exposed to a compression or pressure and causes some problems such as pain, swelling, numbness and loss of force. The nerve progresses between the two distinct starting point of the muscle (flexor carpi ulnaris) that bends our wrist. As nerve is very superficial in this area, it is open to the pressure and trauma.

When we bend our elbow, ulnar nerve stretches and compresses by being pushed to the bone projection that we call medical epicondyl. When a long time passes with this position, for example those who sleep by putting their hands under their heads (by bending the elbow) and those who has to lean the elbow; cubital tunnel syndrome formation is easy. The connective tissue that covers the nerve thicken by reacting against to the recurrent. When transmission quality of nerve fibers between the thickened connective tissue decreased, symptoms of the syndrome appear.

Symptoms of cubital tunnel syndrome include pain, weakness, numbness especially in 4th and 5th fingers and electric shock even after small crushes on the elbow level (Figure 2). In advanced phases, it is observed that it is difficult to move fingers to each other, and 4th and 5th fingers bend reversely while the person tries to hold the hand flat.

The disease is diagnosed by detection for the findings above and EMG (Electromyography) and nerve transmission test which will be performed by neurologists.

In early cases, less trauma is tried to be provided by describing positions that stretches the nerve and revealing these symptoms. In some cases, splinter which flattens the elbow helps to moderate symptoms. Surgery is required in long term and advanced patients. Only the arm is narcotized in the surgery (axillary block anesthesia). Ulnar nerve is carried to the front of the elbow by exiting from two projecting bones in the elbow. Numbness and electrification sense may disappear within several weeks-months. Physiotherapy is needed in some cases after the surgery.

Source: cubital tunnel syndrome

TRIGGER FINGER

Also known as stenosing tenosynovitis in medical literature, trigger finger is a pulley system disorder of finger flexor tendons functioning to bend the fingers of the hand and their bridges that they run under on certain points.

Tendons are like long strings that start from muscles of forearm and continue to the fingers, while pulleys are structures that tendons pass under at certain points and provide the tendon movements. These pulleys bring the tendons closer to the bone. Around the tendons, there is a thin structure enabling it to run through the tunnels. (tenosinovyum)

Trigger finger is called as the thickening of the pulley found in the base of the finger and sometimes called as the dysfunction and pain during finger movements due to swellings occurred on tendon sheath. Using the finger after the problem has started causes more swelling of the structures there and even makes it worse. Sometimes finger dysfunction and locking may occur.

Usually the main cause is unknown. It is more frequently seen in systemic diseases such as Rheumatoid arthritis, Gout, diabetics. Traumas to palm and finger base can rarely cause trigger finger.
The trigger finger begins with a feeling of discomfort at the connection point of fingers in palm. There is sensitivity to pressure on this point where sometimes nodules are felt. In following periods the finger starts to dysfunction and lock.

The aim for the treatment is to prevent dysfunctioning of the finger and to remove the feel of discomfort during its movement. Reducing the swelling of flexor tendon and the tendon sheath enables it to run easier during its movement. Following this aim, reducing the activities, usage of oral anti-inflammatory drugs and cast are preferred for the patients who have earlier symptoms. Injection of the location with steroids may help reducing of the symptoms, but we do not use them due to their harms to the structures of tendons on the long view.

In cases that lasted long and have not responded to medical treatment, the surgical loosening of the pulley that caused the incarceration is the necessary treatment option to choose. The operation is performed with a small cut in the palm under local anaesthesia. It is important to take vessel nerve structures that are close to the tendon sheath under protection during the operation. In post-operational period, the symptoms reduces and never repeat especially after a successful surgery. In some patients, hardness on injury point may occur due to extremely improved tissue, which usually recedes in time by the massages performed at home.

Source: trigger finger

GANGLIA (GANLION, CYSTIC HIGROMA)

They are benign tumors in a cystic nature including gelatinous fluid, oriented from the joint capsule, tendon or tendon sheath. It is the most frequent benign tumor of hand. It is generally observed in women between ages of 20-40. As well as it is observed as a single cyst and oriented from the wrist and certain places in the hand, it may place to anywhere in the hand and the wrist. According to ganglion frequency, it may be in the back of the wrist (dorsal ganglion),

in palmar side of the wrist (volar ganglion), in finger side of the palm (volar retinacular ganglion)

and in the farthest joint line of fingers and in the feet.

It does not have certain cause. It may be formed after recurrent little traumas. It is not directly related with the occupation of the patient.○ It may arise immediately or develop slowly. Patients generally apply to the doctor because of the swelling. Swelling may decrease with rest and increase with activity. It may totally disappear after cyst exposure. Over grown cysts may cause pain during joint movements. These cysts are benign, so they do not diffuse.

The disease is diagnosed by detection of the mass in the cyst area during the examination. They may be elliptical or round; soft or very hard. Generally small nodules in the finger bottom are hard. They may be painful when compression comes on or by fisting. Radiological examination is useful to exclude underlying joint mechanic pathologies and bone lesions.

Treatment should be observation in many patients. Some masses are painless. Some of them may disappear in time. When cysts become painful; when limitation arises in movements and functions; when excessive swelling and aesthetically bad view form, surgical treatment should be applied. The surgery is performed under axillary block anesthesia that whole arm is narcotized under non-bleeding conditions. To decrease recurrence possibility to minimum, to reach to the joint space and to remove it by forming a window are required. In some cases, brace using may be required for 10 days after the surgery. Patients return to their normal activities within a short time.

Source : ganglia

CARPAL TUNNEL SYNDROME

Nervus medianus develops, along with 9 tendons, in a cavity called carpal tunnel on the innards of carpus. Ailments due to nerve compression in here is called carpal tunnel syndrome.

Median nerve passes through the space called carpal tunnel in the inner side of the wrist among with 9 tendons. The diseases caused by compression of the nerve in this region or exposure to a pressure are called carpal tunnel syndrome.

Mostly exact reason can not be found. Carpal tunnel obstruction by any reason causes a pressure on the nerve and this causes symptoms appearing. Thickening of transverse carpal ligament which forms the roof of the tunnel, swelling of tendon sheathes in the tunnel, masses that causes obstruction, pregnancy and some hormonal changes are most frequent reasons of this syndrome.

Carpal tunnel syndrome causes pain, quick exhaustion when doing hand works, numbness and loss of sense in the thumb, index finger and ring finger. Lysis may be seen in the muscle stigma on the bottom of the thumb. Existence or increase of symptoms especially in the night is typical. In advanced cases symptoms diffuse to whole day.

The disease is generally diagnosed by EMG (electromyography) test by neurologists. In suspicious cases, additional radiological examination may be required to reveal old bone fractures or possible masses.

In some cases, wrist splinter may moderate or abolish symptoms. Steroid injections may decrease swellings around the nerve and help regressing the symptoms.

Surgery is required for carpal tunnel syndrome which progresses against conservative preventions and lasts for a couple of months. Carpal tunnel Access is performed with a cut between the palm and the wrist and transverse carpal ligament which forms the roof of the tunnel is liberalized. In advanced cases, neurolysis (nerve liberalization) to the thickened nerve sheath of the median nerve under the microscope. Therefore, the pressure around the nerve is put away. Endoscopic carpal tunnel surgery (closed method) may be applied in selected cases. But, all of the symptoms may not be removed in some severe and delayed cases.

Source : hand surgery