All About the Hand and Wrist

What is the hand and how does it work?

The hand is one of the most active—and complex—parts of the body.

• Each hand has 29 major joints and at least 29 major and minor bones.
• 34 muscles control movement in the fingers and thumb: 17 in the palm and 18 in the forearm.
• Each hand has 48 named nerves and at least 123 ligaments.

Humans are the only species whose fourth and fifth fingers can rotate across the palm of the hand to meet the thumb—giving us grip, grasp and torque abilities like no other species. About one-fourth of the human brain's motor cortex is devoted to the muscles of the hands.

What kinds of injuries can affect the hands and wrists?

• Arthritis. Statistics show that nearly 90% of women and 80% of men ages 75-79 have osteoarthritis in their hands.
• Sports injuries. 25% of athletic injuries involve the hand and wrist.
• Workplace injuries. Work injuries to the upper extremities make up more than one-fourth of all disabling work injuries. One out of six of these injuries involves the fingers.
• Carpal tunnel syndrome
• Trigger finger
• Ganglion cysts
• Dupuytren's contracture
• DeQuervain's tenosynovitis

Dr. John Krebs at the Center for Orthopedics is a fellowship-trained, board-certified orthopedic and hand surgeon. He completed a Cleveland Combined Hand Fellowship at the University Hospitals of Cleveland and the Cleveland Clinic Foundation. Dr. Krebs specializes in hand and upper extremity surgery, total joint replacement and sports medicine.

Dr. Krebs answers questions about hand and wrist conditions

Basal joint (thumb) arthritis

Which joint in the hand is most often affected by arthritis?

“The thumb is the workhorse of the hand, and the carpal-metacarpal (CMC) or basal joint at the base of the thumb is the most mobile joint of the thumb. If you're doing things that require a lot of pinching—such as knitting, crocheting or certain kinds of factory work that require fine-tuning—the CMC joint is more likely to wear out, leading to basal joint arthritis.”

‘Basal joint arthritis is probably the most common type of arthritis seen in the upper extremities.’

Is basal joint arthritis commonly misdiagnosed?

“Yes. Sometimes patients are told they have carpal tunnel syndrome, when they actually have basal joint arthritis. That's why they have pain—and pain is the issue.”

Isn't wrist pain a sign of carpal tunnel syndrome?

“Not necessarily. There's not that much pain associated with carpal tunnel syndrome—it's mainly numbness and tingling and having trouble picking up things.”

Can an arthritic basal joint be replaced?

“Yes. When conservative treatment for basal joint arthritis fails—pain medication, cortisone injections, physical therapy—a surgical procedure called a CMC arthroplasty can replace the arthritic thumb joint and help restore normal function.”

Finger arthritis

Who is most likely to develop arthritis in their fingers?

“Finger arthritis is more common in patients with rheumatoid arthritis— people who have disorders where their joints are destroyed. I see more finger arthritis now in degenerative arthritis patients because rheumatoid arthritis patients are able to control their side-effects so much better now with medication.”

If conservative treatment fails, can finger joints be replaced?

“Yes. We use a material called pyocarbon for finger joint replacement. It's not a metal; it's more like a ceramic, hard surface that replaces the side of the joint. It works very well.”

Wrist arthritis

Who is most likely to develop wrist arthritis?

“If you have suffered a wrist injury, you may develop post-traumatic wrist arthritis. When the wrist's carpal bones and ligaments are injured, the bones' movements become abnormal and can ear away at the cartilage in your wrist joint.

“Rheumatoid arthritis, or RA—a systemic auto-immune condition—is also a common cause of wrist arthritis. RA causes inflammation of the joints that can lead to destruction of the normal bones and cartilage in the wrists.”

Trigger finger

What is trigger finger?

“Trigger finger, also called tenosynovitis, is an inflammation of tissue in your finger or thumb. The flexor tendons, which you use to flex your fingers into your palm, swell and get stuck. There is also swelling in the synovium, a slick membrane that normally allows the tendons to move easily.”

What causes trigger finger?

“Often the cause of trigger finger is unknown. In other cases, trigger finger occurs when repeated use of a tool, such as a drill or wrench, irritates and inflames the tendons and synovium. Arthritis or an injury to the palm of the hand can also result in trigger finger.”

What are the symptoms of trigger finger?

“The first sign of trigger finger is often pain and swelling where the affected finger or thumb meets the palm of your hand. As inflammation in the tendon gets worse, your finger might start to catch when you try to straighten it. And when the locked tendon releases, your finger will jump as if you were firing the trigger of a gun.”

How is trigger finger diagnosed?

“I can normally tell from examining your finger or hand whether you have an inflamed tendon. During your exam, I will ask you to make a fist, then straighten your fingers. If you have trigger finger, that finger or thumb may stay curled—then suddenly pop to a straightened position.

“In some cases, you might have to straighten the affected finger or thumb with your other hand. I will also feel for tenderness and swelling at the base of the thumb or finger.”

What are the treatments for trigger finger?

“If you have mild trigger finger symptoms, I may advise you to rest your finger or thumb and take oral anti-inflammatory medication such as an NSAID. If this doesn't help, a cortisone injection may decrease the swelling and help free the joint.”

Is surgery ever necessary for trigger finger?

“Yes. If anti-inflammatory medications and cortisone injections don't work for you, I can make a small incision under a local anesthetic and release the beginning of the tunnel that houses the tendon. This surgery takes only about 20 minutes and can be done right in the office.”

Ganglion cysts

What is a ganglion cyst?

“A ganglion cyst is a firm, fluid-filled lump on the front or back of the wrist or at the base of a finger. These cysts, which grow from normal wrist and finger tissue, can appear suddenly and grow from the size of a pea to that of a peach pit.”

Can ganglion cysts spread or become cancerous?

“No. Sometimes ganglion cysts develop after a wrist or hand injury; other times, it's not understood what causes them. They may change in size, and sometimes ganglion cysts go away without treatment.”

Do ganglion cysts hurt?

“A ganglion cyst can be painful, especially when it first appears. The cyst can grow and become more painful if you constantly use your affected hand or wrist. You might also find it difficult to grasp things or perform some hand or wrist movements.”

How are ganglion cysts diagnosed?

“I can usually diagnose a ganglion cyst by examining the lump. In some cases, I might draw a little bit of fluid or order an x-ray to rule out other conditions.”

How do you treat ganglion cysts?

“Some ganglion cysts shrink and go away by themselves. If you find your ganglion cyst embarrassing or painful, or it makes using your hand difficult, I can treat it by removing the fluid with a needle. A cortisone injection can help relieve the inflammation and relieve the pain. After these treatments, I will wrap your hand to help keep the cyst from coming back.”

Is surgery ever necessary for ganglion cysts?

“If your ganglion cyst comes back after non-surgical treatment, I can remove it surgically under local anesthetic in a simple office procedure.”

Dupuytren's contracture

What is Dupuytren's contracture?

“Dupuytren's contracture is a hand condition that occurs when the tough, fibrous tissue called fascia in your palm thickens and pulls in. Small, hard knots called nodules may also form under the skin near the base of your fingers.

“When this happens, your fingers—especially the ring finger and the little finger—bend toward the palm, making it difficult to use your hand in a normal way.”

Who is most likely to get Dupuytren's contracture?

“Dupuytren's contracture occurs most often in people of northern European descent. Symptoms are most likely to develop in men ages 50 to 60, although some women also get Dupuytren's contracture.”

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

“These signs and symptoms of Dupuytren's contracture start slowly and progress, or stop before they limit the use of your hand:

• A hard lump on the palm of the hand
• Inability to flatten your palm
• Scar-like bands across the palm of your hand
• Fingers bent toward your palm”

Is Dupuytren's contracture painful?

“Not always. But while Dupuytren's contracture often does not cause pain, it can make it hard for you to straighten your fingers, and make simple movements like shaking hands awkward.”

Does Dupuytren's contracture require surgery?

“Yes. In fact, hand surgery is the only way to correct Dupuytren's contracture.”

De Quervain's tenosynovitis

What is De Quervain's tenosynovitis?

“De Quervain's tenosynovitis is a condition where the tissue on the thumb side of the wrist becomes inflamed and painful. This condition occurs when the tendons and the synovium, a slippery membrane that allows the tendons to move easily, become irritated.”

What causes De Quervain's tenosynovitis?

“DeQuervains tenosynovitis can develop when the tendons in the wrist become irritated from repetitive motions, or when you injure the thumb side of your wrist.”

What are the symptoms of De Quervain's tenosynovitis?

“If you have De Quervain's tenosynovitis, you will most likely feel pain on the thumb side of your wrist. You may also feel pain when you make a fist, pinch or grasp objects or turn or twist your wrist. At times, your thumb may ‘catch’ when you bend it. You might feel a small knot at the thumb side of your wrist and that area may be tender to the touch.”

How is De Quervain's tenosynovitis treated?

“In some cases, De Quervain's tenosynovitis can be relieved by conservative treatment methods such as:

• Temporarily stopping the repetitive wrist movements that caused your pain and trying to keep your wrist in a neutral alignment
• Taking over-the-counter NSAIDs such as ibuprofen to help relieve pain and inflammation
• Wearing a splint that keeps the wrist and lower joints of the thumb from moving to help the inflamed tendons heal

“If your pain persists, a cortisone injection can help reduce the inflammation of De Quervain's tenosynovitis. Although you might have more pain at first, you should notice a definitely improvement in a few days.”

Does De Quervain's tenosynovitis ever require surgery?

“If conservative treatment methods for De Quervain's tenosynovitis don't work for you, or if your pain is severe, surgery may be needed.