Trauma to soft tissue
Soft tissue injuries need to be urgently assessed and, when necessary, surgically repaired as soon as possible after the trauma.
Following injury and/or surgery, the hand therapist will assess the affected area and provide specific exercises and general advice about the injury and healing timescales. If indicated, the therapist will also fabricate a protective splint. There are usually specific precautions that the patient must follow for several weeks after the injury/surgery to allow the damaged structures to heal. These will be taught and explained by the hand therapist during each session.
On-going hand therapy is normally required and may last several weeks or months, depending on the severity of the injury and the recovery made by the patient. Please see the hand therapy section for further information about different hand therapy treatments.
A fracture (broken bone) is normally the result of a traumatic injury and should be assessed and treated immediately.
Fractures are classified in to different groups according to the severity, stability, alignment and the specific bone that has been damaged. For example, the fracture may be extra-articular (away from the joint) or intra-articular (through the joint surface).
The aims of fracture treatment are to restore the anatomical positioning of the bone, ensure stability at the fracture site and regain movement and function. This sometimes requires surgery. Most fractures (including those that have been managed operatively) require a short period of immobilisation in a cast or splint, followed by specific early active movement to ensure the best functional outcome. The LHWU uses a multi-disciplinary approach, calling on the skills of specialist hand surgeons and hand therapists, working together with the patient to achieve optimal fracture healing and upper limb function.
Dupuytren's disease takes its name from Baron Guillaume Dupuytren, a celebrated French surgeon who first described the condition in 1831.
Dupuytren's disease (also referred to as Dupuytren's contracture) is commonly found in individuals with northern European ancestry. In addition to these inherited components, there may also be an association with other soft tissue diseases, trauma or surgery.
The first sign of Dupuytren's disease is often a lump or nodule in the palm of the hand, commonly at the base of the little or ring finger. This may be followed by an indentation in the skin, known as a dermal pit, which occurs as the connective tissue fibres contract. Later, a cord, known as a longitudinal fibrous band, may form and extend from the palm into the finger(s). This cord can pull the finger joints into a flexed (bent) position and hand function may become compromised as the fingers become more flexed. The speed and nature of this process varies considerably between individuals.
Treatment of Dupuytren's disease involves release of the contracted tissue. This may be with surgery, or for less severe contractures, with a Collagenase injection. The aim of both interventions is to regain maximal hand function rather than curing the disease; therefore treatment may be delayed until some deformity has developed, or hand function becomes affected. Your hand surgeon will be able to discuss treatment options and expected outcomes with you.
Following Collagenase or surgical treatment for Dupuytren's disease, you will be referred to hand therapy. Your therapist will fabricate a splint to hold your finger straight and will provide appropriate movement exercises.
Carpal tunnel syndrome and other peripheral nerve conditions
The nerves that run from the neck to the hands and fingers can become compressed at various places along their route. This can cause altered sensation, strength and movement. The hand surgeons and hand therapists at LHWU regularly assess and treat these conditions.
Carpal tunnel syndrome occurs when the median nerve becomes compressed as it passes through the palm at the wrist. The symptoms include:
- Waking at night with tingling and numbness in the thumb, index and middle fingers
- Increased swelling in the hand
- Aggravation of symptoms with increased hand use
- Reduced pinch grip strength
- Difficultly with fine tasks
Mild carpal tunnel syndrome can be treated with splints or corticosteroid infections. More severe carpal tunnel syndrome may require surgery. All of these treatments are available at LHWU.
Other peripheral nerve problems commonly seen at LHWU:
- Guyon's canal syndrome / handlebar palsy (compression of the ulnar nerve at Guyon's canal in the hand/wrist)
- Cubital tunnel syndrome (compression of the ulnar nerve at the elbow)
- Radial nerve palsy (compression of the radial nerve in the upper arm)
- Traumatic nerve injury
The term 'tenosynovitis' includes conditions associated with inflammation and swelling of the tendon, the synovium (the lubricating fluid that surrounds the tendon) or the tendon sheath (the tunnel through which the tendon passes).
Symptoms can include localised pain and swelling in the area of the tendon, and reduced movement if the normal glide of the tendon becomes restricted. These symptoms can lead to difficulty with functional use of the hand, such as gripping objects and completing work related activities.
Common conditions seen at LHWU include:
- Trigger finger / trigger thumb
- Wrist flexor / extensor tendonitis.
Treatment is usually conservative (non-operative). Conservative management focuses on resting the affected area for a number of weeks before gradually building up movement and strength. Treatment may include the provision of a custom-made splint, ultrasound, and heat or ice to settle the inflammation. Graded exercise is slowly re-introduced along with activity modification to prevent recurrence of symptoms.
In more severe cases, corticosteroid injections may be recommended by your hand surgeon in addition to the treatment outlined above.
Ganglions & tumours
Ganglions are benign fluid-filled sacs, often arising from a joint capsule, ligament or tendon sheath. The exact cause of ganglion development remains uncertain, but one suggestion is they form following trauma or degeneration of the tissue. Ganglions can occur in almost any location in the wrist and hand.
The presence of a ganglion may limit joint movement and cause local discomfort as soft tissues become stretched or compressed. Large ganglions can often be seen as a visible lump on the wrist or hand, and ganglions in the small joints of the fingers may cause deformities of the fingernail.
Your hand surgeon will be able to diagnose a ganglion by examining its location and shape. This may require different imaging techniques.
Ganglions often change size and may even disappear spontaneously. If the ganglion is asymptomatic, it may be best to simply observe it for a period of time. Surgical management is normally considered when the ganglion is causing pain, restricting range of movement and having an impact on functional use of the affected hand.
Lumps and Bumps
Several other benign and malignant growths (tumours) can occur in the hand and wrist. These need to be assessed by a hand surgeon to determine the type of tumour and whether surgery is needed.
Rheumatoid arthritis and osteoarthritis
Arthritis is a broad definition given to conditions that cause inflammation in and around the joints. There are many different types of arthritis; the main two are described below.
Rheumatoid arthritis is an inflammatory disease which affects the whole body. The membranes surrounding joints and tendons become inflamed, leading to irritation and damage of the joint surface and nearby soft tissues.
Rheumatoid arthritis is usually diagnosed by a combination of clinical history and presentation, blood tests and x-rays. Early diagnosis is vital to ensure treatment can start as soon as possible.
Symptoms can include:
- Hot, swollen, painful, stiff joints
- Joint and muscle stiffness in the morning
- Reduced grip strength and function
- Joint deformities
- Reduced sensation related to nerve compression
Osteoarthritis is a degenerative disease where the articular (joint) surfaces become damaged over time. The normal joint cartilage becomes worn, narrowing the space between the two bones and causing pain as the joint moves. Small cysts and osteophytes (extra spurs of bone) may form on the joint surfaces, which also limits normal joint movement.
Osteoarthritis may be linked to a previous injury, including fractures through the joint or damage to the surrounding ligaments. It is also thought to have a hereditary component.
- Joint pain and stiffness
- Reduced range of movement
- Localised swelling
- Joint deformity (normally seen in later stages)
How can a Hand Therapist or Hand Surgeon help with arthritis affecting the hand and hand function?
Hand therapists are able to advise patients on how to look after their joints, with the aims of promoting function and preventing deformity. Therapists can also provide advice about managing pain and the use of energy conservation techniques. If necessary, your hand therapist will also fabricate custom-made splints for rest and pain relief or to provide functional support.
Hand surgeons may be consulted regarding specific joint or soft tissue damage that may be helped with surgery or injection therapy, for example: inflamed joints, tendons that have ruptured or damaged joints that require replacement with a prosthetic joint.
Congenital hand abnormalities are not unusual and can take many forms. Hand surgery and hand therapy aim to optimise the patient's functional use of the hand and upper limb.
Common congenital deformities include:
- The failure of formation (such as radial club hand)
- The failure of differentiation or separation of parts (such as syndactyly)
- Duplications (such as polydactyly)
- Overgrowth (gigantism)
- Undergrowth (hyperplasia)
- Constriction band syndrome
- Skeletal abnormalities
The therapist works closely with the parents and surgeon to:
- Assist with pre operative assessment to determine the suitability of a surgical procedure,
- Provide splints to correct deformity
- Assist in the development of functional grips
- Teach stretches where relevant
- Provide post-operative therapy including: wound and scar management, splinting, movement and functional rehabilitation
The wrist is a particularly complex structure comprising a multitude of bones, ligaments and joints. The mechanics of the wrist are highly complex. Effective movement and function is dependent on the wrist being flexible, pain free and stable. Many diseases or injuries can cause immediate or secondary wrist problems.
The problems we commonly see at the London Hand and Wrist Unit include:
- Soft tissue injuries e.g.
- TFCC problems
- Scapholunate and lunotriquetral ligament injuries
- Mid carpal instabilities
- Degenerative conditions
Some of our surgeons specialise in the management of wrist conditions.
The hand therapists work with patients with wrist conditions to promote strong, pain-free movement and function. There are many different treatment modalities used, including a plethora of different types of exercise. Patients attending the LHWU have the advantage of using the Primus RS Simulator which is ideally suited to wrist rehabilitation. This machine has been instrumental in the recovery of several professional sportsmen who have attended for their rehabilitation.
Burns and scars
Scars consist of blood vessels and fibrous tissue (collagen) and are part of the body's normal healing process.
After an injury, burn or surgical incision, it can take up to two years for a scar to fully mature. Over time, the scar fades, becomes flatter and any localised swelling gradually resolves.
Specific massage techniques can help in the maturation of your scar. This works by increasing the blood supply to the scarred area and reducing tethering to the underlying structures. Additionally, silicone gels can be used to assist this process. Various silicone products are available at LHWU and your hand therapist will advise which product is most suitable for your scar.
For larger or more persistent scars, pressure garments can be supplied. These are tailor made lycra body garments for the affected area that apply a specific pressure to the underlying skin, helping to produce a flatter scar.
The hand therapists are experienced in the application of all these techniques and can help you make a change to scars that are still immature (have some red / pink colour in them).
Whether you play for fun or are a professional sportsperson... accidents happen!
The hand surgeons and hand therapists at LHWU treat many sports injuries, including:
- Finger, hand, wrist and elbow fractures
- Soft tissue injuries to ligaments and tendons e.g. Skier's Thumb
- Wrist strains and sprains
- Tendon ruptures
- Nerve compression
- Epicondylitis (tennis elbow and golfer's elbow)
- Muscle tears
Some conditions need to be treated with surgery, but many are able to be managed by a hand therapist using non-operative methods, such as casting and splinting. Our hand therapists have specialised splinting skills and are able to fabricate custom-made removable thermoplastic, neoprene or softcast splints.
Following periods of immobilisation (when required for healing), exercise programmes are created to help restore range of movement and strength, and functional rehabilitation is provided to help patients return to their chosen sport(s).
There is a rapidly increasing need for management of work related upper limb disorders (WRULDs).
These overuse type conditions typically have a gradual onset, and may have a history associated with a change in work practice and/or increased stress. Symptoms include: tiredness, heaviness, general aching, diffuse pain, feelings of weakness or stiffness and loss of function. This condition is also known as repetitive strain injury (RSI), cumulative trauma disorder or non specific arm pain (NSAP).
Hand therapists are often involved in managing these conditions, and use a variety of treatment approaches:
- Pain education and management
- Ergonomic advice
- Work Pattern advice/task modification
- Time and self-management techniques
- Neck and thoracic exercises
- Activity level monitoring
- Exercise and reconditioning