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Ganglion Cysts

        Ganglion Cysts

What are ganglion cysts?

Cysts are pouches of fluid.  Ganglion cyst is the name typically used to refer to cysts that arise from the fluid in joints and around tendons.  The most common location for cysts in the upper extremity is the back of the wrist. 


What do ganglion cysts look and feel like?

Patients often note a painless bump that appears with no history of trauma to the area.  Ganglions may fluctuate in size as fluid moves from the cyst back into the joint and back.  Some cysts cause no pain at all others cause discomfort.  For cysts on the back of the wrist (dorsal wrist ganglion), patients frequently have pain with weight bearing on a fully extended wrist such as doing a push up.


What causes ganglion cysts?

No one knows exactly why cysts form.  A weak spot in the joint capsule allows the joint fluid to push out and form it’s own space.  Often the connection to the joint is maintained and fluid can move back and forth which means the cyst can fluctuate in size sometimes depending on activity.  


How are ganglion cysts diagnosed?

Ganglion cysts can usually be diagnosed by history and physical exam alone.  Since ganglion cysts are filled with fluid, a light 


What treatment options are there for ganglion cysts?

Ganglion cysts cause variable symptoms.  In many patients, they are noticeable but cause no pain and do not interfere with wrist range of motion or activities.  For these patients, often observation alone is sufficient.  For other patients, ganglions can cause discomfort and limit their activities.  An individual patient’s symptoms will determine the best treatment for them.  For cysts that are painful and interfering with regular activities, aspiration (removing the fluid from the cyst with a needle) or surgical excision are likely to be considered. 




What is DeQuervain’s Tenosynovitis?

Tendons are like ropes connecting the muscles to the bone.  Many of the muscles responsible for wrist, thumb and finger motion are located in the forearm.  The tendons travel across the wrist through tunnel like compartments.  DeQuervain’s tenosynovitis occurs when the tendons that bring the thumb up and out become inflamed as they run through this tunnel.


What are the symptoms of DeQuervain’s Tenosynovitis?

Patient’s with DeQuervain’s complain of pain on the thumb side of the wrist.  This is often aggravated by activities that put stress on the thumb especially if it is being held away from the rest of the hand.


What does DeQuervain’s release surgery entail?

The procedure consists of a small incision just over the bony prominence on the thumb side of your wrist.  The tendon compartment is incised to free up the tendons that are being irritated.  


How long does the surgery take?

Patients are typically in the operating room for about forty five minutes to an hour.  The procedure itself takes about 10-15 minutes.


What kind of bandage will I have?

Patients have a rigid dressing that extends from the thumb to the forearm after surgery.  The fingers will be free.  The dressing should stay on until the patient is seen in the office about one week after surgery.  


What are the possible risks and complications of surgery?

As with any surgery, there is a risk of infection, nerve injury, and post op stiffness.  A small nerve to the skin over the back of the thumb runs in operative area called the dorsal radial sensory nerve.  Irritation of this nerve resulting in a small area of numbness and/or sensitivity directly over the nerve is the most common complaint after deQuervain’s surgery.  It is often caused by moving the nerve out of the way during the surgery and typically resolves with time.


What is recovery like?

The initial bandage is rigid and will limit wrist and thumb motion.  Your fingers will be free and you will be able to use the hand for very light tasks.  Moving your fingers immediately after surgery and in the first few days postoperatively is very helpful in limiting swelling and preventing stiffness.  Some mild discomfort with finger movement is to be expected.


When can I shower?

The surgical bandage should be kept dry.  You may shower with the bandage while using a plastic bag to keep the bandage dry.  Once the operative bandage has been removed, the wound may get wet.  After showering, pat it dry and apply a new dry bandaid or gauze.

Will I need to go to hand therapy?

While most patients do not need formal therapy to regain motion and strength after deQuervain’s surgery, some patients develop more stiffness than others.  We will decide together at the first post operative visit whether you may benefit from formal therapy.  


DeQuervain's Tenosynovitis

Carpal Tunnel

Carpal Tunnel Syndrome

What is carpal tunnel syndrome?

Carpal tunnel syndrome occurs when there is too much pressure on the median nerve as it passes through a space in the wrist called the carpal tunnel.  The median nerve provides sensation to the three digits on the thumb side of the hand.  The floor of the carpal tunnel are the bones of the wrist and the ceiling is a thick band of tissue called the transverse carpal ligament.  

What does carpal tunnel feel like?

Since the median nerve provides sensation to the thumb side of the hand, the most classic symptom is numbness and tingling in those three digits.  Often it occurs at night, waking the patient from sleep.  Many people report the sensation of needing to shake their hand out.  The symptoms may also occur with specific activities such as driving, holding a phone for a prolonged time or any activity that requires the hand to be elevated for a long period of time.


What causes carpal tunnel?

The tissue that creates the boundaries of the carpal tunnel are rigid.  When any of the structures of the carpal tunnel increase in size, the space in the tunnel will become too tight putting pressure on the nerve.  Along with the nerve, the nine tendons that bring the fingers down into a fist position also run through the carpal tunnel.  Often increased swelling in the tissue that lines these tendons takes up more space in the tunnel putting pressure on the nerve.  This can occur with overuse such as with repetitive activity or can result from conditions such as diabetes, rheumatoid arthritis, thyroid disease and with pregnancy.


How is carpal tunnel diagnosed diagnosed?

Some patients have classic symptoms of carpal tunnel and the diagnosis can be made easily based on the patient’s symptoms and physical exam findings.  Other patients have more confusing symptoms or have patterns that suggest there might be other areas of nerve compression such as in the neck or at the elbow.  A nerve study is often ordered to help confirm the diagnosis of carpal tunnel as well as evaluate the severity of the damage to the nerve.  

How is carpal tunnel treated?

Wearing splints at night can often relieve night time waking symptoms.  The splint keeps the wrist in a semi neutral position minimizing pressure on the nerve.  Anti inflammatory medications such as Naprosyn (Alleve) and Ibuprofen (Advil) can decrease some of the swelling around the tendons which subsequently takes the pressure off the nerve.  Steroid injections are effective at relieving the symptoms but do not typically provide lasting relief.  Steroid injections are a helpful tool if the diagnosis is not clear or to help minimize symptoms when surgery must be delayed.

What is trigger finger?

Tendons are like ropes connecting the muscles to the bone.  In the fingers and thumb, the tendons that bring the fingers down, such as when you make a fist, run through a pulley system.  The pulleys are bands of connective tissue that hold the tendon close to the bone.  Trigger finger occurs when the tendons become irritated as they enter the pulley system.  Due to thickening of the pulley and/or swelling in the tendon, the tendon can no longer glide smoothly through the pulley and starts to catch and eventually lock.


What do trigger fingers feel like?

Trigger finger typically starts as a non painful catching of the tendon.  The normal smooth gliding of the tendon with finger motion is disrupted.  While the usual point of constriction is at the base of the finger in the palm, many people feel like the finger is catching further down the finger.  If triggering progresses, the finger starts becoming stuck eventually requiring use of the other hand to open the finger.  At that point, the mechanical symptoms are usually accompanied by pain and soreness in the area of the pulley.  A tender nodule often develops in the tendon at this level as well.  If triggering is not addressed, it may progress to the point that the finger stays stuck and can not be bent all the way down or fully opened.


What causes trigger finger?

Most trigger fingers are what we call idiopathic, which means we don’t know what causes them.  Conditions such as rheumatoid arthritis, diabetes and thyroid disorders are associated with higher rates of trigger finger.


How is trigger finger diagnosed?

Trigger finger is diagnosed based on patient’s history and physical exam findings.  Radiographs (x-rays) are occasionally required if symptoms are atypical or there is concern for other conditions such as arthritis that may be contributing to finger stiffness.


How is trigger finger treated?

The most conservative interventions for trigger finger are night time splinting and anti inflammatory medications.  Many people sleep with their fists closed and wake with pain and catching that resolves as the day progresses.  A night splint can help eliminate these morning symptoms as long as the splint is worn.  Triggering typically returns if one stops using the splint.  Steroid injections are a mainstay of treatment for trigger fingers and will completely resolve about half of trigger fingers.  If the symptoms return after the injection, a second injection is typically given.  If the symptoms still return, we move on to surgery as repeated injections around the tendon do put patients at risk for tendon rupture.


Thinking about surgery?

      Thumb Osteoarthritis


Osteoarthritis, particularly at the base of the thumb, commonly develops as people age.  Often referred to as, “wear and tear” arthritis, osteoarthritis is the result of increased fragility of the cartilage in our joints.  This leads to small cracks in the cartilage surface starting a cascade of joint inflammation.  For the patient, this is experienced as pain, joint swelling and sometimes loss of range of motion.


Thumb osteoarthritis specifically manifests as pain at the base of the thumb aggravated by pinching.  It can be painful to complete simple tasks such as holding a pen, opening a jar, pulling up socks or turning a key in the door.  


Interventions for basal joint arthritis include the full spectrum of treatment options including splints, anti inflammatory medications, adaptive techniques, cortisone injections and surgery.  Often times, pain from basal joint arthritis is not constant but rather occurs episodically.  People commonly find that they will have flares sometimes precipitated by overuse or trauma but other times for no apparent reason.  These flares can often be managed by a combination of conservative measures.


What should I do when I have a flare?


The first place I usually start with patients is an over the counter thumb support.  I recommend the Futuro thumb stabilizer because it is readily available at almost any pharmacy, is relatively inexpensive and easy to use.  This splint and other similar products provide rigid support to the thumb.  While immobilizing the joint will help decrease inflammation, it can also be very difficult to wear a rigid splint on one’s thumb during the day.  Many people find that wearing the splint in the evening and at night can provide some relief.  For patients who would like support throughout the day but need some mobility of their thumb, the neoprene support from North coast medical is a great option.  It is available through their website, comfortable and frequently helpful when used in combination with more rigid support at night.


Is there medication that I can take?


Over the counter pain medications can be very effective in alleviating the symptoms of arthritis.  Please refer to the separate page that addresses over the counter pain medications.


Is there anything I can do to prevent aggravating my thumb?


There are many adaptations that can help minimize stress on your thumb.  Pinching small, narrow items such as a skinny pen can cause pain.  Avoiding this by using rubber grips that slide over a pen to enlarge the circumference or buying larger grip pens can help.  Additionally, gripping with the thumb open wide such as to open a jar is often painful as well.  Many products that can help with this task are available.  The simplest is a silicone sheet available from Williams Sonoma.  The OXO Good Grips jar opener decreases the force needed to open a jar making the task easier for anyone with pain anywhere in the upper extremity.  Writing and opening jars are just two common examples of activities that can cause pain.  Everyone has different tasks and activities that may aggravate their symptoms.  Spend a day or two taking an inventory of the things that are painful.  You may be able to figure out reasonable adaptations on your own.  It may be helpful to visit with a certified hand therapist who can offer their experience and expertise.


Would a steroid injection help?


Some patients symptoms remain manageable with splints, anti inflammatories and activity modification.  For other patients, the joint may become increasingly painful and inflamed.  If the initial management isn’t working, the next step is often a steroid injection.  Steroids are the bodies own most powerful anti inflammatory and injections directly into the joint are often effective in reducing pain and inflammation.  It typically takes a week or two for the injection to work and the duration of relief is unpredictable.  While most patients have relief for a few months, some will have relief for many months or may not have return of symptoms at all.  


How do I know if I need surgery?


When all of the previously mentioned treatments have been unsuccessful in alleviating your pain, it may be time to consider surgery.  Surgery for basal joint arthritis is elective and the decision of if and when to proceed is up to the patient.  I can make recommendations based on what you have told me but I can not feel the pain and I only see you in the office for a short time.  Often close friends and family members can be helpful in making the decision to proceed as they are aware of how your pain may be interfering with your regular activities.  Please see the page on CMC arthroplasty for more information about the surgery and recovery.

Trigger Finger

Trigger Finger

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