Wrist and hand

Carpal Tunnel Syndrome (CTS) occurs when there is too much pressure on the median nerve, as it passes through the wrist. This causes aching, numbness or tingling in the thumb, some of the fingers and palm aspect of the hand.

The carpal canal is the passageway on the palm side of the wrist that connects the forearm to the middle compartment of the hand. The tunnel consists of bones, connective tissue, several tendons and the median nerve. As a result it is relatively crowded, so if swelling occurs, it causes pressure to build up leading to the symptoms listed above. Not pleasant!

Occurrence/Frequency of Injury
It is estimated that 3% of males and 5% of females will suffer from Carpal Tunnel Syndrome at some point in their lives. The explanation for the greater prevalence among females isn`t clear, but it believed to be related to the smaller size of the carpal canal.

Workers who use their hands and wrists repetitively are at greater risk of developing CTS, particularly if they work in cold temperatures and have risk factors or medical conditions that make them susceptible. Research has shown that those working in meat packing or production lines are at significantly greater risk of developing CTS.

Treatment and Recovery Timeframes
Mild symptoms can usually be treated with home care. The sooner treatment is started, the better the chances of stopping symptoms and preventing long-term damage to the median nerve. A few things that can help include:

- Stopping activities that cause numbness and pain, resting the wrist between activities, icing the wrist for 10 to 15 minutes once or twice an hour, taking non-steroidal anti-inflammatory drugs (NSAIDs) to relieve pain and reduce swelling, and wearing a night splint to keep the wrist in a neutral position.
- In more severe cases, carpal tunnel release surgery may be required. This works by dividing a ligament in the wrist to relieve pressure on the median nerve. It is a relatively simple procedure with excellent long term outcomes.

Interesting Facts
A woman's chance of suffering from CTS increases following pregnancy, which is believed to be related to hormonal changes.

De Quervain Syndrome (also known as gamer's thumb or washerwoman's sprain) is a tenosynovitis (inflammation) of the sheath or tunnel that surrounds two tendons that control movement of the thumb.

It is particularly noticeable when forming a fist, grasping or gripping things, or when turning the wrist.

Occurrence/Frequency of Injury
The cause of de Quervain's syndrome is unknown and therefore n medical terms, it remains idiopathic. Some say that this diagnosis should be included among over-use injuries and that repetitive movements of the thumb are a contributing factor, but there is no scientific data to support this link between hand use and de Quervain's Syndrome. Symptoms include:

- Pain felt over the thumb side of the wrist which may either appear gradually or suddenly and can travel up the forearm. The pain is usually worse when the hand and thumb are in use and this is especially true when forcefully grasping objects or twisting the wrist.
- A "catching" or "snapping" sensation may be felt when moving the thumb
- Tenderness
- Swelling over the thumb side of the wrist
- Difficulty gripping.

Treatment and Recovery Timeframes
De Quervain's Syndrome is often caused by the activities we complete at work or during our every day lives, so avoiding aggravating factors and changing work roles can help the symptoms settle more quickly. Following diagnosis, a number of techniques can be used in conjunction to try and treat the condition such as:

- A period of rest or reduced use of the thumb/wrist should be carried out for up to a week to help the symptoms settle down.
- Anti-inflammatory medication (NSAIDs) can be taken to reduce the swelling and relieve pain.
- In more severe cases, a splint may be required to rest the thumb and wrist or even steroid injections to reduce the inflammation. A physiotherapy programme to stretch the affected region can help reduce the chance of the injury recurring.
- If the condition is diagnosed early and the steps above are followed, a period of rest or modified duties should only be required for 3-6 weeks. Employers need to encourage early reporting of such conditions to prevent them from becoming chronic long standing issues, which can become more challenging to manage in the work place.

Interesting Facts
It can often develop with pregnancy and is common amongst new mothers, typically 4-6 weeks after delivery. The old theory that it was caused by wringing out cloth nappies has been replaced by concerns about holding the baby, but changes in hormones and swelling seem more probable.

Dupuytren's Contracture is a disorder of the fingers that is due to the thickening of the underlying skin tissues of the palm. The disorder results in a deformed finger which appears thin and has small bumps on the surface. The fingers bend towards the palm and cannot be fully extended (straightened). The small and ring fingers are often more commonly affected.

Occurrence/Frequency of Injury
Dupuytren's Contracture often starts with nodules developing in the palm of the hand and may extend to a cord in the finger. The palmar fascia becomes abnormally thick due to the fact that a change of collagen type occurs within this area.

The contracture sets in slowly and treatment is indicated when the so-called 'table top test' is positive. With this test, the patient places their hand on a table. If the hand lies completely flat on the table, the test is considered negative. If the hand cannot be placed completely flat on the table and there is a space between the table and a part of the hand as big as the diameter of a ballpoint pen, the test is considered positive. This is when treatment options need to be explored.

It is believed to affect 3% of the population with men being 10 times more likely to develop the condition than women. There is some evidence that it does run in families, but is also associated with diabetes, smoking, liver cirrhosis, epilepsy recurrence and vascular disorders.

Treatment and Recovery Timeframes
There is no cure for Dupuyren's contracture, but there are a number of treatment options that can help to reduce the associated symptoms, which may include:

- Corticosteroid injections, a strong anti-inflammatory drug, which can reduce the associated swelling and inflammation.
- Radiotherapy can be used to treat nodules, cords and early finger deformations.
- If symptoms persist, surgery may be required, which involves cutting or removing the thick bands of tissue in the palm of the hand to help restore proper finger motion (known as a fasciotomy).

Interesting Facts
- It has been called the "Viking disease" or "Celtic hand' as it is more prevalent in Scandinavian countries.
- There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren's Contracture, although there is some speculation that Dupuytren's may be caused by, or at least the onset may be triggered by, physical trauma such as manual labour or other over-exertion of the hands

The scaphoid bone is one of the carpal bones in the hand around the area of the wrist.

The injury is most commonly caused by a fall on to an outstretched hand (FOOSH), causing a compression fracture.

Occurrence/Frequency of Injury
The scaphoid is most susceptible to injury because of its size and location in the middle of the wrist.

This type of injury is most common among men aged between 20 to 30 years old, as it often happens during sporting activity. The frequency also increases during icy, winter conditions when we are more likely to suffer a fall when we are out and about.

The symptoms of a Scaphoid Fracture include swelling, tenderness and pain over the thumb area.

Treatment and Recovery Timeframes
If a Scaphoid Fracture is suspected, the injured party must go to A+E and have an X-Ray to confirm the diagnosis. It is important to be aware that X-Rays do not always show a Scaphoid Fracture so an MRI scan may be required to confirm the injury.

Treatment of Scaphoid Fractures is guided by the location of the fracture (proximal, waist, distal), displacement (or instability) of the fracture.

Surgery may be required to stabilise the fracture - metal implants such as screws and wires are used to hold the fracture in place and allow healing, but in simple cases the wrist will be placed in a cast to allow healing to occur.

Healing generally takes 6-12 weeks, but a full recovery can take six months due to the period of immobilisation required for the wrist to heal. This leaves the wrist weak and tight. A stretching and strengthening programme should be followed in order to restore normal function post injury.

Return to work timeframes are governed by the type of work undertaken. Those in sedentary roles should only require 4-6 weeks off work, but those working in heavy roles will need a graded return to work programme and additional time to recover.

Complications do occur with this injury, for example avascular necrosis where the bone gets starved of blood, resulting in bone tissue death and the bone collapsing.

Interesting Facts
- Also known as a navicular fracture (the scaphoid is also known as the carpal navicular bone) although not to be confused with the navicular bone in the foot!

- 10 times more common in men and in sports such as football, basketball, weight lifting, gymnastics and motor racing.

- David Beckham suffered a Scaphoid Fracture after a tackle resulted in him falling badly.

Tendons are tissues that connect muscles to bone. When muscles contract, tendons pull on bones. This causes parts of the body (such as a finger) to move. The flexor tendons allow you to bend your fingers and the extensor tendons allow you to straighten your fingers. The muscles that move the fingers and thumb are located in the forearm with long tendons extending from these muscles through the wrist and attach to the small bones of the fingers and thumb. Put simply, if one of these tendons is severely injured through a cut or sporting injury, the finger it connects to cannot move.

Occurrence/Frequency of Injury
There are two types:

Flexor Tendon Injuries
The most common causes of flexor tendon injuries are cuts and sports injuries. Flexor tendons may also rupture spontaneously in people with rheumatoid arthritis.

Extensor Tendon Injuries
Injuries to the extensor tendons can result in a number of different problems. One of the most common is:

- Mallet finger - a drooping of the end of the finger that occurs when an extensor tendon becomes separated from the bone. This can happen if the finger is cut or jammed and is also known as baseball finger.

The most common signs of a flexor tendon injury include:

- An open injury, such as a cut, on the palm side of your hand, often where the skin folds as the finger bends
- An inability to bend one or more joints of your finger
- Pain when your finger is bent
- Tenderness along your finger on the palm side of your hand
- Numbness in your fingertips

Treatment and Recovery Timeframes
- Cuts that split the tendon may need stitches, but tears caused by jamming injuries are usually treated with splints. Splints stop the healing ends of the tendons from pulling apart and should be worn at all times until the tendon is fully healed.
- In some cases scar tissue may develop, leading to a permanent deformity that requires surgical intervention. In serious cases of motion loss surgery to free scar tissue may sometimes by helpful.
- Physiotherapy can be used to prevent the build up of scar tissue in the first place or aid recovery after surgery. Exercises can help restore the range of movement and also prevent the development of scar tissue.
- Expected recovery from a simple injury would be within 4-8 weeks. Activities that put unnecessary strain on the fingers, such as typing, should be avoided. Long periods off work should not be necessary as, after the acute stage, many activities can be completed without using the injured finger.

Interesting Facts
In addition to cuts on the arm, hand, or fingers, certain sports activities can cause flexor tendon injuries. These injuries often occur in football, wrestling, and rugby.