Patient Care at the Medical College of Wisconsin Hand Center

Arthritis in the hand occurs when joints are inflamed and may occur at the base of the thumb (the trapeziometacarpal joint), the middle joint of a finger, (the PIP joint) or in the metacarpophalangeal (MP) joint. The most common forms include osteoarthritis, post-traumatic arthritis and rheumatoid arthritis.

To diagnose Arthritis, the Hand Center must conduct a physical exam and depending on your findings perform imaging tests. 

Symptoms of arthritis include stiffness, swelling and pain.

Treatment of arthritis may include anti-inflammatory medications, cortisone injections and individualized hand therapy involving a combination of exercises and splints. Surgery is indicated when these more conservative treatments fail and the patient has too much pain or cannot function well. Surgery can involve joint fusion or joint reconstruction. Your hand surgeon will help determine the best course of treatment for you.

Learn More at the Arthritis Foundation website

In children, the most common brachial plexus injuries occur at birth, when the brachial plexus is damaged in a baby’s shoulder during delivery. About one or two babies out of 1,000 will have a brachial plexus injury when born, and about 10 percent of these babies will need surgery. In adults, the most common causes of trauma to the brachial plexus include motor vehicle crashes, sports injuries, industrial accidents, falls and severe over-extension of the arm.

Brachial plexus injuries are diagnosed by a thorough examination of muscle function and sensation. It takes a physician experienced in treating many brachial plexus injuries to notice subtle changes in muscle function. In addition, electrical testing of the muscles and nerves is done to determine the severity and location of the injury. This testing is done with an electromyogram (EMG) to test the muscles along with nerve conduction velocity (NCV) and evoked potential to test the nerves. Imaging of the neck and shoulder using X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) may be done as well.

The symptoms of brachial plexus resulting from an injury may produce numbness or tingling, pain, weakness, limited movement and paralysis in the shoulder, arm and hand. Left untreated, muscles associated with the damaged nerves will atrophy (waste away). If a person waits too long for treatment, the muscle will become permanently dysfunctional.

Following diagnosis, patients are monitored over a period of time to see if the function has returned in their hand, arm and shoulder. During this time, the patient may undergo occupational therapy. If it is determined that there is insufficient improvement, surgery may be needed. The best results for surgical repair are obtained within one year of the injury.

Burns are caused by prolonged exposure to heat. Causes can be fire, chemical, or electrical. Severe burns to the skin cause wounds and high risk of infection. Severe hand burns may result in poor function, loss of the hand, and even death.

To diagnose burns, the Hand Center team will perform a visual inspection. 

The symptoms and severity of a burn are dependent on the temperature of the heat source, the type of skin that was burned, and how long the skin was exposed to the heat. Symptoms of burns may include swelling, blisters, and changes sensation or tingling in the burned areas. The appearance and symptoms of a burn depends on how deeply the burn injures our tissues.

Superficial or first degree burns involve the top layer of skin (epidermis) only. They are red, painful, and dry. There is no blistering. Healing occurs on its own. Mild sunburns are superficial burns.

Second degree burns are more accurately described as superficial or deep partial thickness burns. Superficial partial thickness burns involve up to half of the skin depth. Blisters are present. The wound is pink or red, and blanches (turns white) with pressure. These burns are painful and wet appearing. These generally heal on their own in 1-2weeks. Deep partial thickness burns destroy most of the skin depth. These burns are red or white and appear dry. Pain is variable.

Full thickness, third degree, burns destroy all of the skin layer. These burns are black or white, dry, and leathery. These are usually not painful, because the nerves are damaged.

Fourth degree burns destroy all of the skin and even the deeper structures including muscle, tendon, and bone.

The immediate treatment of burns involves removing the heat, gently washing the burned area, and applying dressings.

If a burned hand is not getting enough blood to the fingertips, emergent surgery may be needed to open the tight burned tissue and allow blood to get to the fingers. This should be assessed by a medical professional as soon as possible.

Rehabilitation with a hand therapist is recommended early on in the treatment of the person with burns. The initial focus in rehabilitation includes wound care, maintaining range of motion, and management of swelling. Splints are often used to help prevent stiffness. Hand therapist will also work with you on scar management, pain reduction, and strengthening after the wounds are healed.

Burns that are deep partial thickness or deeper will require reconstructive surgery, which moves healthy tissue to the burned area. The depth, size and location of the wound will influence what kind of surgery is needed. Your surgeon will review all available reconstructive options with you and help you decide the type of reconstruction needed for your burn.

The cause is unknown. There are several factors that contribute to CTS: joint dislocations, fractures, and arthritis can narrow the tunnel in which the median nerve travels through; and awkward wrist postures such as keeping the wrist bent for long periods of time. Fluid retention during pregnancy can also cause swelling in the carpal tunnel which lead to CTS symptoms that usually go away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes can also be associated with CTS.

To diagnose carpal tunnel syndrome, we will use a combination of your medial history, a physical examination, and tests.  

Symptoms from carpal tunnel syndrome include tingling, numbness, and pain are the most common symptoms. Typically the numbness or tingling occur in the thumb, index, middle, and ring fingers. It can progress to hand weakness and eventually limit hand function.

The first step for treatment of carpal tunnel syndrome is an evaluation by your doctor where they will perform an exam to learn more about your symptoms and gather a detailed history including medical conditions and how the hands are being used. X-ray may be taken to check for other causes of the symptoms such as fracture or arthritis. EMG test may be performed to confirm the diagnosis of carpal tunnel syndrome and to check out other nerve related problems.

Symptoms may be treated without surgery by changing the patterns of hand use or keeping the wrist in neutral position in a splint to reduce nerve pressure. A steroid injection into the carpal tunnel may also help with reducing the swelling around the nerve.

If symptoms do not improve then surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms a roof over the tunnel. Symptoms may not go away quickly after surgery.

Learn more about Carpal Tunnel Syndrome

Complex hand injuries may be caused by machinery, farm equipment, or motor vehicle accidents.

Diagnosing complex hand injuries is usually straightforward. 

Symptoms of complex hand injuries include pain and swelling in the hand. 

Treatment for complex hand injuries following a significant traumatic injury requires special surgical expertise.  Microscopic surgery is required to repair the small nerves and blood vessels in the hand. Fixation of bones may be completed through the use of plates, screws, wire, pins or external fixators. Injured tendons may be directly repaired, or if injured more seriously may require a tendon graft (spare piece of tendon sewed into the gap caused by injury), or may require tendon transfer (nearby tendon is redirected to perform function similar to injured tendon. Missing skin tissue may be replaced using various types of skin grafts (layers of skin donated from other area on body), or may be temporarily covered by manufactured tissue. Restoration of appropriate circulation to the hand may require significant medical interventions, and close monitoring by medical staff.

Hand Therapy for Complex Hand Injuries
An appropriate and timely hand rehabilitation program is critical to restoration of functional use of the hand. Skilled hand therapists make customized splints or “orthoses” to position and protect the hand during the healing period. Early Hand Therapy interventions may also include wound care, edema control, and initiation of motion exercises very specific to your type of hand injury. Therapy in the later phases of healing may incorporate scar management, active motion exercises, functional use and strengthening of the hand.

Long-Term Outcomes following Complex Hand Injury
Severe traumatic injuries can be very difficult to treat, and in most cases full normal motion and sensibility does not return following the injury. Extensive scarring on the inside of the hand may cause the tendons to lose their ability to bend and straighten the joints, or may cause the joints to be stiff and less mobile. Sometimes additional surgery may be required to improve motion, sensation, or functional use of the hand.

Cubital tunnel syndrome occurs when there is significant pressure placed over the nerve. Since the ulnar nerve is positioned right next to the bone and has very little padding over it, pressure on the elbow will put pressure on the nerve. Bending the elbow will also irritate the nerve by compressing it inside the tunnel thus creating inflammation which leads to pain or numbness. Pressure at the elbow can develop in several ways:

• Keeping the elbow in a bent position for a long time (i.e. holding the phone)
• Leaning on the elbow for a long time
• Sleeping with arms tightly bent
• Sudden elbow injury
• Previous elbow fracture

Cubital tunnel syndrome symptoms usually include:

• Numbness/tingling into the ring and little fingers
• Weakness while gripping and pinching with a tendency to drop things
• Inability to straighten the fingers
• Tenderness with sharp pain with touch to the elbow

Nonsurgical treatment: can include rest, medication, and activity modification. You can also try the following:

• Take medication to reduce swelling
• Incorporate rest breaks during activities
• Wear elbow pad
• Wear an elbow splint at night to avoid keeping the elbow bent
• Switch to a headset phone

Surgical treatment includes shifting the ulnar nerve to the front of the elbow, which relieves pressure and tension on the nerve. The nerve may be placed under a layer of fat, under the muscle, or within the muscle. Surgery may also involve removing part of the bone.

Learn more about Cubital Tunnel Syndrome

Cysts are caused by a bulge of the lining of joints and tendon sheaths. It is suspected that cysts form at a point of focal weakness in this lining. Normal joint or sheath fluid then fills the bulge, creating a mass or balloon appearance.

To diagnose a cyst in your hand, the Hand Center will have to conduct a physical examination as well as an X-Ray. 

Symptoms of cysts are usually painless, soft lumps just under the skin of the hand. If the mass grows large enough to press on surrounding nerves or tendons, you may develop pain, numbness, or limited range of motion.

Treatment options for cysts are are not dangerous and therefore can be observed. However, in some patients the cyst causes pain when they press on the surrounding structures. In these cases, the cyst can be treated with aspiration or surgical excision.

Following surgical removal of a ganglion cyst, a therapist will educate the patient on wound care, safe range of motion exercises, and edema control.

Learn more about Ganglion Cysts

The cause of DeQuervain’s Tenosynovitis is unknown but there are factors that may contribute to it such as: repetitive motions of unscrewing jar lids, forceful grasping or twisting, or picking up a child under the arms.

Symptoms of DeQuervain’s Tenosynovitis includes pain on the thumb side of the wrist. Pain occurs during pinching or grasping tasks as well as during forceful twisting motions. Tenderness with a “knot” may develop on the thumb side of the wrist.

There are two methods of treatment for DeQuervain’s Tenosynovitis which are nonsurgical and surgical.

Nonsurgical Treatment options include:

• Wearing a splint for a few weeks to prevent you from moving the wrist and thumb
• Eliminating or decrease the activities that cause your pain
• Oral anti-inflammatory medication – Aspirin, Tylenol, or Ibuprofen
• Anti-inflammatory injection such as cortisone to the tendons at the thumb side of wrist.

Surgical treatment options include:
Releasing the sheath that surrounds the tendons so that they can move easily which will then reduce the inflammation and allow you to straighten the thumb without pain. After surgery you will be placed into a splint or dressing for a few days and may begin gentle wrist and thumb motion.

Learn more about De Quervain's Tenosynovitis

The cause of Dupuytren’s is unknown. However, it does have a genetic component and people of Scandinavian or Northern European ancestry are more likely to be affected. Other predisposing factors for developing Dupuytren’s include: male gender, over age 40, family history of disease, liver cirrhosis and rock climbers.

Symptoms for Dupuytren’s usually begins as a thickening of the skin in the palm. Gradually over time the thickened cords progress toward the fingers. The fingers then become bent toward the palm and cannot be fully extended. The ring finger and little finger are most commonly affected

Dupuytren’s has no cure, however, there are many different options for treatment of Dupuytren's. A discussion with your physician will help you select which one is right for you.

Surgical options include: fasciectomy, fasciotomy, Percutaneous needle fasciotomy (also called needle aponeurotomy).

Non-surgical options include: enzyme injection into the chording of the palm/digit to weaken it/break it. (Xiaflex)

Learn more about Dupuytren's

Overuse is the most common cause of golfer’s elbow and can be work related. It is associated with a variety of activities in addition to golfing. Repetitive activities that involve flexing your wrist or rotating your forearm with gripping such as shaking hands or lifting with the palm up may worsen the pain. In addition, direct trauma to the area can make someone more susceptible to an overuse injury.

The most common symptom of golfer’s elbow is pain at the inner side of the elbow and down the forearm. This can also lead to swelling and pain to touch over the area (picture). Your elbow may feel stiff with associated feeling of weakness of the hand and wrist, making it difficult to form a fist. Pain can occur during or after activities, more commonly with gripping or lifting.

Treatment of golfer’s elbow depends on how inflamed the tendon is. Several conservative options are:

• Activity changes – limiting aggravating activities, using your other hand, gripping with the palm up, lifting with two hands, or modifying grip.
• Oral medication - Anti-inflammatory medications by mouth can be helpful but need to be taken consistently.
• Therapy - Stretching and/or strengthening exercise regimen along with things like heat and ultrasound. Concentration on prevention in the future.
• Steroid injection – strong anti-inflammatory injected into the area of pain. Usually not performed more than three times.

Surgery is reserved only for those in which the pain remains severe despite the above treatments. Surgery involves removing the diseased and degenerated tendon tissue. Recovery includes therapy to regain motion and can take up to 4-6 months.

Hand fractures can be caused by trauma, sports injury, disease process, fall, MVA, or crush injury. Many additional causes of fracture are possible.

To diagnose a hand fracture the Hand Center typically identifies the fracture using x-ray, although sometimes additional imaging such as MRI and CT scans are necessary to correctly diagnose the fracture. 

Common symptoms of a hand fracture include but are not limited to: pain, swelling, bruising, and muscle spasm.

Treatment of hand fractures usually requires a splint and/or cast.

Learn more about hand fractures

Nerves may become injured from a variety of mechanisms such as stretch, pressure, or laceration. The resulting deficit is dependent on the degree of injury to the nerve.

It is most important to be evaluated by a peripheral nerve specialist, such as the Plastic and Microsurgery specialists in The Hand Center to obtain an appropriate diagnosis regarding the extent of injury, and the best option for recovery of function.

Symptoms of nerve injuries in the hand include pain, loss of movement and function, and numbness.

Although some injuries such as a low-level stretch or contusion can heal on their own, most others do not, and surgery is required to repair them. Sharply cut injuries may be directly repaired, however with more involved injuries, more extensive surgery may be required.

Nerve Grafting
Nerve grafting, where a segment of nerve tissue or a connecting tube is inserted into a gap in the nerve, is necessary when a segment of nerve is missing. The graft length will vary depending on the amount of deficit, and longer grafts require more time for return of function.

Neurolysis
When there is an injury that causes internal bleeding or a severe contusion or stretch to a nerve, scar may form internally around the site of nerve injury, causing nerve impairment. In this case, a neurolysis, or clearing the nerve out of the scar is performed.

Nerve Transfer
More serious nerve injuries may require more intensive surgery such as a nerve transfer, where a nearby nerve is redirected to replace some of the function of the injured nerve.

Nerve regeneration, or regrowth with or without surgery is not perfect, however and some patients experience only a partial recovery of function or no recovery at all. New nerve fibers need to regrow from the point of injury out to the skin and muscle they innervate. Nerve healing may be adversely affected by the extent of injury, distance the nerve has to regrow, the amount of time that has expired since the injury occurred, the age and general health status of the patient. Therefore, the sooner a nerve is repaired following injury, the better. In severe injuries an EMG/NCS test (Electromyelogram/Nerve Conduction Study -an electrodiagnostic test) may be ordered to help determine the extent of injury. In many cases, only during the surgery itself can the extent of injury be seen. The best opportunity for functional recovery occurs if necessary surgery is completed within the first year after injury.

Sports injuries can be caused falls, direct contact, awkward positioning of joins and overuse.  

To diagnose a sports injury, the Hand Center will examine your medial history, and conduct a physical examination, which may include tests.  

Symptoms of sports injuries will vary depending on the location, type, and severity of injury.  The following are common symptoms experienced after an injury to the hand, wrist and elbow: pain, swelling, bruising, clicking or popping, numbness, deformity, and bleeding.

Treatment options for sports injuries will vary based on the type, severity and duration of symptoms that are present and may include: rest, ice, compression, elevation, taping, splinting/bracing, casting, therapy and/or surgery. It is best to seek advice from a medical professional to ensure you receive proper treatment for your injury.

Acute strains and sprains are caused from the sudden stretch of a tendon or ligament, often caused by a fall, lifting heavy objects, or a sudden twist.

Chronic strains and sprains are caused from overuse during prolonged, repetitive movements, often during sports or job tasks.

The first step to diagnose a sprain or strain is to get evaluated by your doctor, who will assess your injury and determine whether you would benefit from further testing, such as an x-ray to rule out a fracture or an MRI to get a better view of the tendons or ligaments. If your injury is accompanied by severe pain or deformity you should seek immediate medical attention.

Symptoms of sprains and strains are pain, bruising, swelling, and decreased motion. Muscle spasms and weakness may also occur after a strain.

Treatment for mild sprains and strains can often be conducted at home through rest, ice, compression and elevation. The length of time needed to recover from a strain or sprain depends on the severity of injury. More severe injuries may require formal therapy with an occupational therapist and/or surgery to repair the injured tendons or ligaments.

Repetitive activities and/or overuse of the arms can cause tendinitis. Tendinitis is not always work-related. Sports, hobbies, and trauma can cause tendinitis. Everyone is susceptible, but hormonal changes and medical conditions such as arthritis may influence tendinitis.

Patients dealing with symptoms of tendinitis will report aching pain running up or down the hand. Pain is mild at rest, and worse during and after use of the arm. Mild swelling over the irritated areas may be noticeable. When severe, tendinitis may limit range of motion and cause stiffness.

Conservative treatment for tendinitis includes wearing splints, taking oral anti-inflammatory medication (NSAIDs), and modifying activities to reduce inflammation. When tendinitis is limited to a focal spot, a corticosteroid injection may be useful. Modifications in posture and hand position with use (ergonomics) should help prevent recurrence.

Formal hand therapy may be beneficial when symptoms do not improve with the options above. Your therapist will work with you on a stretching and strengthening exercise regimen. Additionally, they may use other modalities like heat and ultrasound to speed resolution of the pain.

Symptoms should improve slowly over time with rest, stretching, and activity modifications. Surgery is rarely indicated for generalized tendinitis.

Tennis elbow can affect anyone. Overuse is the most common cause of tennis elbow. Activities that involve extending your wrist, rotating your forearm such as twisting a screwdriver, lifting heavy objects with your palm down, or repetitive gripping are common causes. A history of trauma to the elbow may make you more prone to tennis elbow.

Tennis elbow symptoms are usually pain at the outer side of the elbow that runs down the back of the forearm. Pain is usually aggravated during or after gripping or lifting activities and improves with rest.

Tennis elbow treatment depends on the level of tendon inflammation. Several conservative options are:

• Activity changes – limiting aggravating activities, using your other hand, gripping with the palm up, lifting with two hands, or modifying grip.
• Stretching
• Anti-inflammatory medications
• Bracing
• Steroid injection

Formal hand therapy may be beneficial when symptoms do not improve with the options above. Your therapist will work with you on a stretching and strengthening exercise regimen. Additionally, they may use other modalities like heat and ultrasound to speed resolution of the pain.

Surgery is controversial and reserved only for those in which severe pain remains despite all the above treatment options. Surgery involves removing the diseased and degenerated tendon tissue. Recovery includes formal therapy to regain motion and can take up to 6 months.

Learn more about Tennis Elbow

In most cases, the cause is unknown with Trigger Finger. Repetitive activities that involve gripping, such as use of a tool of lifting exercises, may incite trigger finger. It may also be associated with hormonal changes, weather, and medical problems including rheumatoid arthritis, gout, and diabetes. In rare cases, trauma to the palm or base of finger may cause triggering.

To diagnose trigger finger, the Hand Center will perform a series of physical examinations. 

Symptoms of trigger finger are indicated when a flexor tendon becomes inflamed and thickened causing the finger to feel stiff and start to catch when you try to bend or straighten it because it can no longer slide within its sheath. The finger will stick or lock when trying to straighten it. When the locked tendon releases, the finger jumps or “triggers.” You may also notice a painful lump at the base of your finger/thumb.

Treatment for trigger finger at the Hand Center usually involves an injection. 70% of people will improve with cortisone steroid injections at the base of the finger. If conservative treatment fails, your doctor may recommend surgery to release part of the tunnel around your swollen tendon, so that the tendon can move freely. Surgery is usually performed within 20 minutes under local anesthetic. Your hand will be wrapped in a soft bandage and stitches will be removed in 2-3 weeks. Normal use of the hand can be resumed once comfort permits.

Learn more about Trigger Finger