Arm and Hand Pain Overview | Causes and Treatment for Arm and Hand Pain

What hurts? - Arm and Hand

Upper extremity problems can come from causes as diverse as the trauma of a ski accident, to the gradual wear and tear of life or an active lifestyle. While problems that stem from trauma are often quite obvious. This is not always the case. Sometimes a seemingly small injury can represent an injury to a ligament or tendon that can be quite serious. Other hand, arm, elbow, and shoulder injuries can take time to develop and can be in the form of arthritis, or gradual increasing numbness, such as carpal tunnel syndrome. Below you will find some helpful information about common hand conditions. Additional resources can be found at the American Academy of Orthopedic Surgeons website and the American Society for Surgery of the Hand website.

Arm and Hand Pain Quick Links:

• Fractures and sprains
• Carpal tunnel syndrome
• Thumb injuries
• Dupuytren’s contracture
• Tendonitis
• Arthritis
• Nerve and tendon injuries or lacerations
• Ganglion cysts
• Congenital anomalies
• Tennis Elbows

Fractures and sprains

Distal Radius (wrist) fractures are one of the most common fractures that orthopaedic surgeons treat. Many can be treated in a cast with close observation. Others need surgery to maximize patient function.

There are times when a wrist “sprain” just doesn’t get better. It is important to determine if these problems are actually a fracture of one of the wrist bones or a significant wrist ligament tear. Some of the less obvious causes of a wrist pain that doesn’t improve over the typical time course include occult (“hidden”) scaphoid fractures and ligament injuries between the wrist bones, such as triangular fibrocartilage complex tears (TFCC) and scapholunate ligament (SL) tears. These three diagnoses are often difficult to diagnose often require more advanced imaging techniques, such as MRI or CT scans. Scaphoid fractures are particularly difficult problems to treat because of the poor blood supply to the bone. Combined with other factors, this predisposes the scaphoid to not heal, often despite long periods of casting and bracing. In addition, the scaphoid bone can develop of condition called avascular necrosis, which means part of the bone dies due to the poor blood supply. If this is not treated promptly it can have serious consequences in terms of wrist function and pain.

The Scapholunate Ligament coordinates a significant amount of the motion that occurs between the bones in the wrist. If this ligament is injured it can lead to the bones moving in ways in which they should not. This malalignment can lead to wrist stiffness, pain, loss of strength and an aggressive premature form of arthritis if not treated. If caught early enough, the ligament can be repaired. It can also be rebuilt, similar to the ACL in the knee, borrowing other tissues around the wrist.

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Carpal tunnel syndrome

Despite the popular sentiment that you have to spend all day using a computer to get carpal tunnel syndrome is not true. Carpenters, nurses, business people, and athletes can all have the troubling numbness and discomfort from the nerve compression that occurs in carpal tunnel syndrome. There are minimally invasive treatment options that can dramatically improve your symptoms as well as traditional open approaches that can remove the pressure from the nerve. Typical recovery from this surgery depends on the severity of symptoms, but usually the majority of the recovery is within a few days to weeks.

Carpal tunnel syndrome is caused by pressure on the median nerve traveling through the carpal tunnel.

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Thumb injuries

The thumb plays a critical role in the function of the hand and can easily be injured from sports as well as work. The most common types of injuries are fractures and ligament injuries. Because many tendons attach to the thumb to help it move in so many different ways, when the thumb is broken these tendons continue to pull on the broken pieces, and often cause it to move out of alignment (become displaced). Simple fractures can be treated in specialized casts, called spica casts. Fractures that are out of alignment often require surgery.

The ulnar collateral ligament (UCL) and the radial collateral ligament (RCL) help stabilize the thumb.

The most common ligament injury in the thumb is Skier’s Thumb. Skier’s thumb occurs when the thumb is forcefully pulled away from the rest of the hand tearing the ligament that holds the joint stable. Most patients experience pain on the inside of the thumb and a sensation of instability, or lack of confidence in the thumb when trying to pick things up or pinch. Sprains or partial tears can often be treated with casting or splinting. More severe injuries often require surgery to reconnect the torn ligament. It is often difficult to tell a partial tear from a full tear. Ultrasound and MRI are commonly used to distinguish these and to identify tissue that becomes trapped in the tear, called a Stener lesion, which can prevent healing.

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Dupuytren’s contracture

Dupuytren’s contracture is a thickening of the tissue on the palm, called the fascia. It often runs in families most commonly from people of Northern European heritage. While it can simply cause lumps in the palm, called nodules, it can also progress to form bands, called cords, that extend into the fingers and can cause them to curl down into the palm and become difficult to straighten.

Dupuytren's Contracture begins with pits and nodules and can progress to making cords which pull the fingers into the palm

Dupuytren's Contracture surgery, about to release the tissue so that the finger can straighten

Tendonitis

Overuse or traumatic injuries of the tendons can present with pain with the certain movements of the hand or arm. These can typically be treated with braces and therapy. However, some resistant cases can be treated with injections, such as cortisone and even surgery if the condition persists despite less invasive options.

DeQuervain’s Tendonitis

Arthritis

The most common types of arthritis in the hand are located at the base of the thumb (basilar joint arthritis) and at various locations in the wrist. Patients with arthritis typically notice stiffness, pain, especially with pinching and gripping, or opening jars and gradual loss of strength in their hands.

Examining the thumb for pain, abnormal motion, and weakness

In addition to the treatment of this painful degenerative condition with custom braces, oral and injected anti-inflammatories, motion preserving reconstructive arthritis surgery is available for most hand and wrist arthritis. These include joint replacement for the fingers, wrist and elbow, as well as partial fusions. Unfortunately some arthritis is so severe that only a complete fusion will help. It is important to see a specialist to determine which option is best suited for you.

Diagram of the normal thumb anatomy

There are several surgical procedures to rebuild an arthritic joint. The choice between these depends on the patient’s age, activity level and the specific joint that is involved. Options range from prosthetic joint replacement with small implants made of silicone or a wear-resistant material called pyrocarbon, to procedures that use patient’s own tissue to rebuild and resurface the joint. The most common of these for the thumb is called Ligament Reconstruction Tendon Interposition (LRTI).

Examples of prosthetic implants for joint replacement in the hand

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Nerve and tendon injuries or lacerations

A cut nerve or tendon typically must be repaired soon (usually within 1 week) after the injury in order to regain the most function. While sometimes it is quite evident that the finger can no longer bend, sometimes the nerve or tendon damage is not obvious. Even small cuts on the hand can hide an important injury.

The flexor tendons allow you to bend your fingers. When the tendons are cut the finger is difficult or impossible to bend depending on the severity of the injury.

Ganglion cysts

Lumps and bumps on the hand are extremely common things to be seen by a hand surgeon. Ganglion cysts are essentially a fluid-filled sack of tissue that grows near a joint in the hand or wrist or fingers. Sometimes they are attached to tendons and move and other times are stationary. They typically fluctuate in size and can become tender if in particular locations such as the back of wrist and get pinched with wrist movements or if bumped. Options for treatment include observation, puncturing and draining the cysts in the office, or surgical removal. Discussing the matter with a specialist is the way to ensure you choose the option best suited for you. The vast majority of these masses are benign (not cancer). However, it is important for a specialist to help you identify which ones are safe to watch and which ones are more suspicious. If it comes to removing these, hand specialists are familiar with the complex anatomy in the hand to remove these safely.

Cross-section of wrist showing stalk (or root) of ganglion

Ganglion top side (dorsum) wrist.

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Congenital anomalies

Fingers and hands can come in many shapes and sizes. The most common differences are fingers that have failed to separate (syndactyly) or too many fingers (polydactyly). Surgeons can help guide decision making about the appropriate reconstructive surgical options and timing based on the age of the child to help restore the normal appearance and function of hands that start out different.

An example of fingers that have failed to divide (syndactyly)

Tennis elbow

Lateral epicondylitis (tennis elbow) is a painful condition of the elbow caused by overuse. Racquet sports, in addition to many other repetitive activities can cause this condition. Although tennis elbow is usually due to inflammation of the attachment site of the tendons on the outside of the elbow that help to extend the wrist and fingers. In the chronic setting, the inflammation subsides and the tendon attachment site can start to tear. Fortunately, most cases of tennis elbow can resolve without surgical treatment. Often a team approach involving primary doctors and physical therapists is the most effective.

Lateral epicondylitis (tennis elbow) involves degeneration of the muscle attachments on the outside of the elbow

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Material modified with permission from the American Society for Surgery of the Hand (www.assh.org) and the American Academy of Orthopedic Surgeons (www.aaos.org).