Got Pain?
Tying a shoe, typing an email, opening a jar, texting on a Blackberry. The mobility of our fingers and wrists can often be taken for granted. That is until the throbbing pain begins, and interferes with simple, everyday tasks. According to new research presented at the 2009 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), there are new alternatives other than surgery for hand and wrist pain.
“Outside of the brain, the hand is the most versatile part of the body,” stated A. Lee Osterman, MD and professor of orthopedic and hand surgery at Thomas Jefferson University Hospital. “When the 27 bones, cartilage, joints, tendons and nerves in the hand do not work as they should, deformity, motion loss and disability become a painful reality for many people.”
According to the latest numbers available, in 2006 -
• More than 3 million people visited their physician due to wrist pain and more than 7 million for hand and finger pain.
Common hand and finger problems can include arthritis in the base of the thumb, Dupuytren’s Disease (the tissue just beneath the skin of the palm) and nerve pain, explains Dr. Osterman. But new treatments, like arthroscopy, collagenase injections, nerve wraps, desensitization techniques, therapeutic techniques and neuroleptic medications – both oral and injectable – (examples include Vitamin C and Botulinum injections) have aided a hand surgeon’s ability to combat these problems and get patients back to full function.
Arthritis of the Base of the Thumb and Finger
- The second most common joint in the hand to develop arthritis. More common in women over 40.
- Past injuries to the joint, such as a fracture or sprain, increase likelihood of arthritis.
- Previous treatment options included - surgical and non-surgical care, splinting and/or pain medication.
“Arthroscopic treatment is a viable, newer option for people with thumb and finger arthritis,” said Scott P. Steinmann, MD, professor of orthopaedics at Mayo Clinic in Rochester, Minnesota. His recent study in the Journal of Hand Surgery showed that 94 percent of patients undergoing arthroscopic debridement procedures were partially or completely satisfied.
Figure 1: Dupuytrens disease may present as a small lump, pit, or thickened cord in the palm of the hand
Dupuytren’s Disease
- Often starts with lumps in the palm. Firm cords begin to develop underneath the skin, stretching from the palm to the finger. Gradually, the cords cause the fingers to bend into the palm.
- Dupuytren’s contracture is more common in men over the age of 40.
- Previous treatment included observation and surgery.
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.
Figure 3: Table Top TestAccording to a recent study by Lawrence C. Hurst, MD, professor and chairman, Department of Orthopaedics, SUNY at Stony Brook School of Medicine, “injection therapy, such as Clostridial collagenase (a substance intended to reduce the collagen buildup in the palm and disrupt the contracted cord) has now shown promising results for patients with Dupuytren’s contracture.”
Nerve pain
- Nerves in the hand can be damaged by pressure, stretching or cutting.
- Injury to the nerves can stop the transmission of signals to and from the brain and be painful when touched. Abnormal muscle function and injury can produce hand pain such complex regional pain syndrome (CRPS 1), or formally known as reflex sympathetic dystrophy (RSD).
- Previous treatments included surgery and therapy.
Figure 2: In advanced cases, a cord may extend into the finger and bend it into the palm
L. Andrew Koman, MD, professor and chair of the Department of Orthopaedic Surgery at Wake Forest University School of Medicine and president of the American Society for Surgery of the Hand (ASSH) is successfully using another type of injection therapy, Botulinum Toxins on patients with nerve pain. The results of this type of less invasive procedure are very favorable. Additionally, Koman said, “nerve pain may be diminished by environmental changes and newer biological materials.”
Dr. Osterman concluded that “injuries, arthritis and aging affect hand mobility and these newer alternatives offer a bright outlook for patients.”
Note - This topic will be the focus of a Media Briefing entitled - “Handling the Hand - New Treatments in Hand and Wrist Pain” on Thursday, February 26, in the Sands Expo Center, Venetian Hotel, Level One, Room 904 at 10 - 45 AM. Panelists include - Moderator - A. Lee Osterman, MD; L. Andrew Koman, MD; Scott P. Steinmann, MD and Lawrence Hurst, MD.
Source - American Academy of Orthopaedic Surgeons (AAOS)