Hand Osteoarthritis: Causes, Symptoms, Diagnosis, and Treatment

Osteoarthritis is a degenerative joint disease that causes the cartilage covering the bones at the joints to wear out. While it can result from simple “wear and tear” on the joints, it may also develop after an injury.

Common Areas of Hand Osteoarthritis

In the hand, osteoarthritis typically develops in three key areas:

• Base of the Thumb: Where the thumb and wrist come together (trapezio-metacarpal or basilar joint).
• End of the Finger: The distal interphalangeal (DIP) joint, closest to the fingertip.
• Middle Joint of the Finger: The proximal interphalangeal (PIP) joint.

Osteoarthritis may also affect the wrist.

Signs and Symptoms of Hand Osteoarthritis

Common symptoms of osteoarthritis in the hand include:

• Stiffness, Pain, and Swelling
• Bony Nodules: Found at the middle joint (Bouchard’s nodes), end joints (Heberden’s nodes), or the DIP joint.
• Deep, Aching Pain: Typically at the base of the thumb.
• Swelling and a Bump: Noticed at the base of the thumb.
• Diminished Grip and Pinch Strength
• Wrist Pain: Swelling, stiffness, and reduced strength.

Diagnosing Hand Osteoarthritis

Your doctor will evaluate your hand to check for similar symptoms in other joints and determine the impact of arthritis on your daily activities. The diagnosis is based on:

• Appearance: The visual examination of your hands and fingers.
• X-rays: These can reveal joint space narrowing, bony outgrowths (osteophytes), and hard bone areas along joint margins, which are characteristic of osteoarthritis.

Treatment of Hand Osteoarthritis

The treatment of hand osteoarthritis focuses on relieving pain and maintaining joint function. Options include:

• Anti-inflammatory Medications: To help relieve pain and inflammation.
• Wrist Splints: Worn at night or during specific activities. Soft sleeves may be an alternative if rigid splints are too restrictive, particularly for arthritis at the base of the thumb.
• Heat Therapy: Warm wax or paraffin baths may help reduce swelling.
• Hand Therapy: Engaging in therapy helps maintain finger motion and function.
• Cortisone Injections: These can provide temporary relief from pain but do not cure the condition.

Hand Surgery for Osteoarthritis

Surgery is typically recommended only when conservative treatments fail or when pain is unmanageable. Surgical options may include:

• Joint Fusion: Involves removing the arthritic surface and fusing the bones on either side of the joint, eliminating motion and pain, but reducing joint flexibility.
• Joint Reconstruction: The damaged joint surface is removed to eliminate rough bone contact, and may be replaced with soft tissue (like tendon) or a joint replacement implant.

The choice of surgery depends on the specific joint(s) affected, your activity levels, and personal needs. Your hand surgeon will guide you in selecting the best surgical approach for your condition.

Hand Tumors: Types, Diagnosis, and Treatment

A hand tumor, also referred to as a mass, is an abnormal lump or bump. Most hand tumors are benign, meaning they are not cancerous. These tumors can occur on the skin, underneath the skin in the soft tissue, or even within the bone.

Common Types of Hand Tumors

Ganglion Cyst

• The most common hand tumor.
• A benign, fluid-filled sac that forms off a joint or tendon sheath.
• Usually occurs in the wrist but can develop around finger joints.
• Forms when a portion of the joint capsule or tendon sheath balloons out, filling with the fluid that lubricates the joint or tendon.

Giant Cell Tumor of Tendon Sheath

• A solid mass, unlike the fluid-filled ganglion cyst.
• Develops near a tendon sheath.
• Slow-growing and benign, it spreads through the soft tissue beneath the skin.

Epidermal Inclusion Cyst

• A benign tumor that forms beneath the skin.
• Occurs when skin cells, producing keratin, get trapped under the surface, forming a cyst as keratin and dead skin cells accumulate.

Other Benign Tumors

• Lipomas (fatty tumors), neuromas, nerve sheath tumors, fibromas, and glomus tumors are also common, though rarer.

Hand Cancer

Cancer in the hand is very rare. The most common cancers affecting the hand are skin cancers like squamous cell carcinoma, basal cell carcinoma, or melanoma. Other rarer cancers may include sarcomas of the soft tissue or bone.

Evaluation and Treatment of Hand Tumors

• Physical Exam & Medical History: A hand doctor will begin by performing a thorough physical exam and evaluating your medical history to identify the tumor type.
• Imaging: X-rays may be taken if there is concern about bone involvement or to assess the soft tissue.
• Surgical Excision: This is the most common treatment for hand tumors, offering the lowest recurrence rate. The surgery removes the tumor and allows for a biopsy to determine its type. It is often performed on an outpatient basis without the need for general anesthesia.
• Aspiration or Injection for Ganglion Cysts: For ganglion cysts, a hand doctor may try to aspirate (drain) the cyst or inject it if the patient prefers to avoid surgery.

Living with Hand Tumors

If a tumor is benign and does not cause pain or discomfort, some patients may choose to do nothing and live with it. However, tumors can grow over time, and your doctor will discuss the potential risks and benefits of removal based on the tumor’s type and behavior.

In summary, most hand tumors are benign and treatable. Early evaluation and treatment can help prevent complications and ensure the best outcome for your hand health.

Hand Nerve Injuries and Their Treatment

Nerves are crucial for transmitting messages from the brain to the body, much like telephone cables carry signals. Nerve injuries, whether caused by pressure, stretching, or cutting, can disrupt these vital messages, leading to loss of function or feeling in the affected area.

Causes of Nerve Injury

• Pressure Injuries: Pressure can break nerve fibers without damaging the insulating cover, halting the transmission of signals.
• Cut Nerves: When a nerve is cut, both the nerve fibers and their insulation are damaged, often resulting in a loss of feeling and muscle function.

When a nerve fiber breaks, the section farthest from the brain dies, but the insulating cover remains intact, allowing the nerve to potentially regenerate. However, if both the nerve and its insulation are severed, nerve fibers may form a painful growth called a neuroma, which can cause electrical sensations when touched.

Treatment for Nerve Injury

Surgical Repair:

• If a nerve is cut, the doctor may sew together the ends of the nerve, using very fine stitches. The goal is to align the nerve’s insulation so that the nerve fibers can grow into the empty tube, restoring function.
• In some cases, if there is a gap in the nerve, a nerve graft may be required, taken from another part of the body.
• For smaller gaps, conduits made from veins or cylinders may be used to bridge the space.

Recovery Timeline:

• Nerve fibers can begin to grow across the repair site after 3–4 weeks, and they grow up to 1 inch per month, depending on factors such as age. Complete recovery could take several months to over a year.
• Sensory Nerve Recovery: Sensory nerves may need re-education therapy once they begin to heal to improve function and feeling.

Post-Treatment Care

• Physical Therapy: To maintain joint flexibility and prevent stiffness, which could limit the function even after the muscles have recovered.
• Care for Sensory Nerve Injuries: Special attention is needed for injuries to sensory nerves, as the lack of feeling increases the risk of burns or cuts.
• Recovery Variation: Age, injury type, and location all influence the healing process, with some nerve injuries potentially causing long-lasting effects.

In summary, while nerve injuries in the hand can be serious, with proper surgical intervention and rehabilitation, recovery is possible, leading to the restoration of hand function and sensation.

Early and Aggressive Treatment of Hand Infections

Early and aggressive treatment of a hand infection is essential. Failure to treat a hand infection can cause serious problems that may persist after the infection has cleared, including stiffness, loss of strength, and loss of tissue such as skin, nerve, or bone.

Some types of infection can be treated with antibiotics, rest, and soaking. However, many infections can cause serious problems, even after a day or two, if not treated with antibiotics, surgical drainage, and removal of the infected tissues.

Drainage or pus is sent for laboratory testing to determine the type of bacteria causing the infection and the appropriate antibiotic for treatment.

Types of Hand Infections and Treatment Options

Paronychia

A paronychia is an infection of the cuticle area around the fingernail. Acute paronychia is caused by bacteria and results in redness, swelling, pain, and later on, pus. Early cases can be treated with soaking and antibiotics, but if pus is seen or suspected, drainage is required.

Chronic paronychia is caused by fungus. The cuticle area becomes mildly red and swollen, with little or no drainage and mild tenderness. People whose hands are frequently wet are prone to this infection. It can be treated with special medications and reduction or elimination of constant exposure to moisture. On occasion, surgery is necessary to remove the infected tissue.

Felon

A felon is a more serious, and usually more painful, throbbing infection. It occurs in the closed space of the fatty tissues of the fingertip and pulp. This usually requires surgical drainage and antibiotics. If not treated early, deconstruction of the soft tissues and even bone can occur.

Herpetic Whitlow

Herpetic whitlow is a viral infection of the hand, usually on the fingers, caused by a herpes virus. This is more common in healthcare workers whose hands are exposed to the saliva of patients carrying herpes. It is characterized by small, swollen, painful blood-tinged blisters, and sometimes numbness. It is typically treated conservatively and resolves itself in several weeks without many after-effects.

Septic Arthritis/Osteomyelitis

A wound in or near a joint, or a drainage cyst from an arthritic joint, can cause severe infection for the joint. This is known as septic arthritis. Within a few days, the joint can be destroyed by the bacteria eroding the cartilage surface of the joint. Surgical drainage is required, in addition to antibiotics.

Delayed treatment can result in the infection of the bone, a complication called osteomyelitis. It typically requires one or more operations to remove the infected tissue and may require weeks of intravenous antibiotics.

Deep Space Infections

The spaces in between the different layers of structures in the hand can become infected, even from a small puncture wound. It may affect the thumb area (thenar space), the palm (deep palmar space), or even the web area between the bases of fingers (collar-button or web space abscess). Treatment involves surgical drainage, as the infection has the potential to spread to other areas, even to the wrist and forearm.

Tendon Sheath Infection

An infection in the flexor tendon can occur due to a small laceration or puncture wound over the middle of a finger, especially near a joint on the palm side. It can cause severe stiffness, even destruction and rupture of the tendon. These symptoms present acutely with stiffness of the finger in a slightly bent posture, diffuse swelling, and redness of the finger, tenderness on the palm side of the finger, and severe aggravation of pain with attempts to straighten the finger. This infection requires immediate surgical drainage of the tendon sheath and antibiotics.

Atypical Mycobacterial Infections

In rare instances, a tendon sheath infection can be caused by an “atypical mycobacterium.” The infection develops gradually and is often associated with swelling and stiffness without much pain or redness. It is treated with special antibiotics for several months. Surgical removal of the infected lining of the tendons is sometimes necessary. Many patients experience residual stiffness despite treatment.

Mycobacterium marinum is a common form of infection. It usually develops from puncture wounds from fish spines, or contamination of a simple wound or abrasion from stagnant water (in nature or from aquariums). Identification of the cause can be difficult.

Patients with impaired immune systems (AIDS patients, cancer patients) are more susceptible to atypical mycobacterial infections.

Infections From Bite Wounds

Infections from bites (from humans or animals) are associated with several bacteria.

• Although Streptococcus and Staphylococcus can be involved (driven in from the skin by a tooth), other organisms common to the mouth may be present and typically require other or additional antibiotics.
• Eikenella corrodens is often seen with human bite injuries.
• Pasteurella multocida is seen with dog and especially cat bite wounds.

Wounds are usually not closed after treatment, allowing the infection to drain out. Surgical trimming of infected/crushed tissue is often required.

A rabies infection from an infected animal may be serious, even fatal. Treatment is determined by risk. Fortunately, the reported cases of rabies in humans are rare, and the incidence of rabies is small in domestic animals.

What is a Fracture?

Simply put, a fracture is a broken bone. It may be simple, with bone pieces aligned and stable, or unstable, with the bones shifting or displaced. Some fractures occur in the shaft (main body) of the bone, while others occur along the joint surface. When the bone is fractured into many pieces, this is known as a comminuted fracture. An open, or compound, fracture occurs when a bone fragment breaks through the skin. There is some risk of infection in these cases.

Hand Fractures

Because your hand is made of many bones, hand fractures are common. Common signs of a fracture include:

• Pain
• Swelling
• Stiffness
• Decreased use of your hand

Some fractures result in an obvious deformity, such as a crooked finger, but many do not. Due to the close relationship of bones to ligaments and tendons, your hand may be stiff and weak after the fracture heals. Fractures that involve surface joints can lead to early arthritis in the joint involved.

How Are Hand Fractures Treated?

Your hand doctor will perform a medical evaluation and take an X-ray to determine if your hand is fractured. Depending on the type of fracture, he will recommend one of several treatment methods.

• If the fracture is not displaced, your hand doctor may use a splint or cast. This also protects a fracture that has been set.
• In some cases, a displaced fracture needs to be set and then held in place with wires or pins without making an incision (closed reduction and internal fixation).
• Other fractures may need surgery to set the bone (open reduction). Once the bone fragments are set, they are held together with pins, plates, or screws.
• If the fracture disrupts the joint surface (articular fracture), it usually needs to be set more precisely to restore the joint surface as smooth as possible.
• If a bone is missing or so severely crushed that it cannot be repaired, it may require a bone graft. This procedure involves taking bone from another part of the body to provide more stability.

Once the fracture has enough stability, motion exercises may be started to try to avoid stiffness. Your surgeon will determine when the fracture is sufficiently stable.

What Results Can You Expect?

Perfect alignment of the bone on x-ray is not always necessary. You may develop a bony lump at the fracture site as the bone heals. This is known as a “fracture callus,” which functions as a “spot weld.” This is a normal healing process, and the lump should get smaller over time.

Problems with Fracture Healing

Problems with fracture healing include:

• Stiffness
• Shift in position
• Infection
• Slow healing or complete failure to heal

You can ease the chances of complications by carefully following your surgeon’s advice during the healing process and before returning to work or sports activities. Your doctor may recommend a hand therapy program with splints and exercises to speed and improve the recovery process.

Hand Burns Treatment at South Florida Hand and Orthopaedic Center

In addition to many other conditions, South Florida Hand and Orthopaedic Center treats hand burns.

Degrees of Burn Injuries

Burns are classified by the depth (degree) of injury to help determine the appropriate treatment.

• 1st Degree: Superficial—redness of skin without blisters
• 2nd Degree: Partial thickness skin damage –blisters present
• 3rd Degree: Full thickness skin damage –skin is white and leathery
• 4th Degree: Similar to 3rd degree, but with damage to deeper structures such as tendons, joints, and bone

Burn Treatment

The depth and extent of your burn injury will determine your treatment needs. In most cases, South Florida Hand and Orthopaedic Center can treat hand burns on an outpatient basis if the pain can be controlled.

Treatment will focus on preventing further problems with stiffness and infection.

1st Degree (Superficial Burns)

These burns usually heal within a week and can be treated for pain with local analgesics and pain medications.

2nd Degree (Partial Thickness Burns)

We may or may not trim blisters, but the hand and forearm should be splinted in a position of safety to prevent later stiffness. If there are open, raw surfaces, we recommend cleaning with frequent dressing changes and the application of local topical antibiotics until the wounds are healed. Wounds should begin healing within two to three weeks. Some 2nd degree burns may need excision of damaged skin followed by skin grafting.

3rd Degree (Full Thickness Burns)

We will remove the dead skin and replace it with skin grafts. The timing of this procedure depends on the size and location of the burns. The doctor usually removes dead skin as soon as it is evident that the burn is at full thickness, and grafts immediately. Your hand will probably be splinted until the grafts are healed, and then mobilization begins (ideally within two to three weeks after the injury).

Small full thickness burns may be treated like the partial thickness but will take longer to heal and will leave scarring. A burn that goes around the full circumference of the limb can sometimes constrict it like a tourniquet. If this is the case, the doctor may release the constriction with a procedure known as escharotomy.

Therapy and Rehabilitation

The need for therapy depends on the depth of the burn and any other factors that may lead to stiffness in the hand. Superficial burns generally do not require hand therapy. Deep burns or burns that occur in conjunction with other injuries may require extensive therapy and rehabilitation. The doctor will coordinate therapy with a therapist if he feels you would benefit from rehabilitation.

Additional Surgery

Many patients with burn injuries will require more than one operation. Burned hands may develop contractures months or years after the original injury. The doctor will plan your long-term follow up to evaluate the possibility of further surgery to improve hand function.

Carpal Tunnel Syndrome (CTS)

Carpal tunnel syndrome (CTS) is a condition caused by increased pressure on the median nerve at the wrist. Simply put, it is a pinched nerve at the wrist.

The carpal tunnel is a space in the wrist where the median nerve and nine tendons pass from the forearm to the hand. When pressure builds from the swelling in the tunnel, it puts pressure on the nerve. When the pressure becomes great enough, you may experience one or all of the following symptoms:

• Numbness
• Tingling
• Pain in the arm, hand, and fingers

What Causes Carpal Tunnel Syndrome?

The cause is often unknown, but pressure on the nerve can occur in several ways:

• Swelling of the lining of the flexor tendons (tenosynovitis)
• Joint dislocations, fractures, or arthritis narrowing the tunnel
• Keeping the wrist bent for long periods of time
• Fluid retention during pregnancy (this often goes away after delivery)
• Thyroid conditions, rheumatoid arthritis, and diabetes
• Carpal tunnel is sometimes due to a combination of causes

Signs and Symptoms

Symptoms usually include pain, numbness, tingling, or a combination of the three, with tingling and numbness most often in the thumb, index, middle, and ring fingers.

You will most likely experience symptoms at night, but some notice them during daily activities. Some patients also notice a weaker grip, occasional clumsiness, or a tendency to drop things.

In severe cases, it’s possible to lose sensation permanently while the muscles at the base of the thumb slowly shrink (thenar atrophy).

Carpal Tunnel Diagnosis

In order to diagnose carpal tunnel, one of our doctors will complete a detailed history, which will include any previous medical condition, how you’ve used your hands, and whether there were any prior injuries. He will also take an X-ray to check for other causes of your symptoms, such as arthritis or a fracture.

In some cases, a laboratory test may be needed if your doctor suspects a medical condition associated with CTS. Your doctor may also perform a nerve conduction study (NCV) and/or electromyogram (EMG) to confirm your diagnosis, as well as to check for other possible nerve problems.

Carpal Tunnel Treatment

It is often possible to relieve carpal tunnel symptoms without surgery. By identifying and treating the underlying medical condition, changing the patterns of hand use, or keeping the wrist splinted in a straight position, you may be able to reduce pressure on the nerve.

Other treatment options include:

• Wearing wrist splints at night to relieve symptoms that interfere with sleep
• Adjusting your workstation to alleviate a possible cause
• Carpal tunnel surgery

If your symptoms are severe or do not improve, a hand surgeon may recommend surgery to make more room for the nerve. By cutting the ligament that forms the top of the tunnel on the palm side of the hand, it is possible to decrease the pressure on the nerve. The incision allows the doctor to enlarge the tunnel and decrease pressure on the nerve.