Hand Specialists at Steadman Hawkins Clinic of the Carolinas
6 Doctors Drive
Greenville, SC 29605
The most common types of hand, wrist & elbow problems that we treat are:
- Carpal Tunnel Syndrome – We provide conservative treatment with splinting and injections as well as surgical carpal tunnel release if necessary
- Arthritis (hand, wrist & elbow) – We provide conservative treatment with splinting and corticosteroid injections as well as joint replacement procedures for the fingers, thumb, wrist, and elbow.
- Trigger Fingers – We provide corticosteroid injections as well as surgical release if necessary
- Wrist Sprains – We provide conservative treatment with splinting and therapy as well as wrist arthroscopies and ligament repairs if necessary
- Fractures of the Hand, Wrist, & Elbow – We treat all fractures in the hand, wrist, and elbow. Many fractures can be treated non-surgically with immobilization. However, we also frequently fix fractures surgically with pins, plates, or screws as indicated.
- Tendon Injuries – We treat all tendon injuries of the hand and wrist, from tendinitis to flexor and extensor tendon lacerations.
- Nerve Injures – We treat all nerve injuries in the extremities, from digital nerves in the fingers to larger nerves in the upper arm.
- Dupuytren’s Disease – We provide non-surgical intervention with Xiaflex (collagenase) as well as surgical treatment with partial fasciectomy.
- Replantation of Amputated Fingers – We provide microvascular reattachment of amputated digits as indicated.
- Congenital Hand Defects – We treat virtually all congenital hand defects, including webbed fingers, extra digits, and thumb malformations.
At Steadman Hawkins Clinic of the Carolinas, we are able to diagnose and treat this wide array of hand and upper extremity conditions for both pediatric and adult patients. We currently have two fellowship trained hand and upper extremity surgeons, Dr. Timothy Allen and Dr. Nick Pappas, both of whom are located at our Cross Creek office. Drs. Allen and Pappas work closely with our Certified Hand Therapists at Proaxis Occupational Therapy to provide patients with non-surgical treatment options as well as post-operative care for the various hand and upper extremity conditions they treat. To make an appointment with one of our hand surgeons, please request an online appointment or call (864) 797-7060.
For more information related to specific disorders of the hand feel free to visit the website of the American Society for Surgery of the Hand (ASSH) @ http://www.assh.org
Carpal Tunnel Syndrome
Carpal tunnel syndrome is pressure on the median nerve — the nerve in the wrist that supplies feeling and movement to parts of the hand. It can lead to numbness, tingling, weakness, or muscle damage in the hand and fingers.
Median nerve dysfunction; Median nerve entrapment
The median nerve provides feeling and movement to the “thumb side” of the hand (the palm, thumb, index finger, middle finger, and thumb side of the ring finger).
The area in your wrist where the nerve enters the hand is called the carpal tunnel. This tunnel is normally narrow, so any swelling can pinch the nerve and cause pain, numbness, tingling or weakness. This is called carpal tunnel syndrome.
Carpal tunnel syndrome is common in people who perform repetitive motions of the hand and wrist. Typing on a computer keyboard is probably the most common cause of carpal tunnel. Other causes include:
- Assembly line work
- Use of tools (especially hand tools or tools that vibrate)
- Sports such as racquetball or handball
- Playing some musical instruments
The condition occurs most often in people 30 to 60 years old, and is more common in women than men.
A number of medical problems are associated with carpal tunnel syndrome, including:
- Bone fractures and arthritis of the wrist
- Kidney failure and dialysis
- Menopause, premenstrual syndrome (PMS), and pregnancy
- Rheumatoid arthritis, systemic lupus erythematosus (SLE), and scleroderma
- Numbness or tingling in the thumb and next two or three fingers of one or both hands
- Numbness or tingling of the palm of the hand
- Pain extending to the elbow
- Pain in wrist or hand in one or both hands
- Problems with fine finger movements (coordination) in one or both hands
- Wasting away of the muscle under the thumb (in advanced or long-term cases)
- Weak grip or difficulty carrying bags (a common complaint)
- Weakness in one or both hands
Exams and Tests
During a physical examination, the doctor may find:
- Numbness in the palm, thumb, index finger, middle finger, and thumb side of the ring finger
- Weak hand grip
- Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand (this is called Tinel’s sign)
- Bending the wrist forward all the way for 60 seconds will usually result in numbness, tingling, or weakness (this is called Phalen’s test)
Tests may include:
- Nerve conduction velocity
- Wrist x-rays should be done to rule out other problems (such as wrist arthritis)
You may try wearing a splint at night for several weeks. If this does not help, you may need to try wearing the splint during the day. Avoid sleeping on your wrists. Hot and cold compresses may also be recommended.
There are many changes you can make in the workplace to reduce the stress on your wrist:
- Special devices include keyboards, different types of mouses, cushioned mouse pads, and keyboard drawers.
- Someone should review the position you are in when performing your work activities. For example, make sure the keyboard is low enough so that your wrists aren’t bent upward while typing. Your doctor may suggest an occupational therapist.
- You may also need to make changes in your work duties or recreational activities. Some of the jobs associated with carpal tunnel syndrome include those that involve typing and vibrating tools. Carpal tunnel syndrome has also been linked to professional musicians.
Medications used in the treatment of carpal tunnel syndrome include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen. Corticosteroid injections, given into the carpal tunnel area, may relieve symptoms for a period of time.
Carpal tunnel release is a surgical procedure that cuts into the ligament that is pressing on the nerve. Surgery is successful most of the time, but it depends on how long the nerve compression has been occurring and its severity.
Symptoms often improve with treatment, but more than 50% of cases eventually require surgery. Surgery is often successful, but full healing can take months.
If the condition is treated properly, there are usually no complications. If untreated, the nerve can be damaged, causing permanent weakness, numbness, and tingling.
When to Contact a Medical Professional
Call for an appointment with your health care provider if:
- You have symptoms of carpal tunnel syndrome
- Your symptoms do not respond to regular treatment, such as rest and anti-inflammatory medications, or if there seems to be a loss of muscle mass in your fingers
Avoid or reduce the number of repetitive wrist movements whenever possible. Use tools and equipment that are properly designed to reduce the risk of wrist injury.
Ergonomic aids, such as split keyboards, keyboard trays, typing pads, and wrist braces, may be used to improve wrist posture during typing. Take frequent breaks when typing and always stop if there is tingling or pain.
Jarvik JG, Comstock BA, Kliot M, Turner JA, Chan L, Heagerty PJ, et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomized parallel-group trial. Lancet. 2009;374(9695):1074-1081.
Keith MW. American Academy of Orthopaedic Surgeons clinical practice guidelines on the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2009;91(10):2478-2479.
Keith MW. American Academy of Orthopaedic Surgeons clinical practice guidelines on the treatment of carpal tunnel syndrome. J Bone Joint Surg Am. 2009;91(1):218-219.
Review Date: 5/25/2010
Reviewed By: A.D.A.M. Editorial Team: David Zieve, MD, MHA, and David R. Eltz. Previously reviewed by C. Benjamin Ma, MD, Assistant Professor, Chief, Sports Medicine and Shoulder Service, UCSF Dept of Orthopaedic Surgery (10/10/2009).
Rheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can also affect other organs.
RA; Arthritis – rheumatoid
The cause of RA is unknown. It is considered an autoimmune disease. The body’s immune system normally fights off foreign substances, like viruses. But in an autoimmune disease, the immune system confuses healthy tissue for foreign substances. As a result, the body attacks itself.
RA can occur at any age. Women are affected more often than men.
RA usually affects joints on both sides of the body equally. Wrists, fingers, knees, feet, and ankles are the most commonly affected. The course and the severity of the illness can vary considerably. Infection, genes, and hormones may contribute to the disease.
The disease often begins slowly, with symptoms that are seen in many other illnesses:
- Loss of appetite
- Low fever
- Swollen glands
Eventually, joint pain appears.
- Morning stiffness, which lasts more than 1 hour, is common. Joints can even become warm, tender, and stiff when not used for as little as an hour.
- Joint pain is often felt on both sides of the body.
- The fingers (but not the fingertips), wrists, elbows, shoulders, hips, knees, ankles, toes, jaw, and neck may be affected.
- The joints are often swollen and feel warm and boggy (or spongy) to the touch.
- Over time, joints lose their range of motion and may become deformed.
Other symptoms include:
- Chest pain when taking a breath (pleurisy)
- Eye burning, itching, and discharge
- Nodules under the skin (usually a sign of more severe disease)
- Numbness, tingling, or burning in the hands and feet
Joint destruction may occur within 1 – 2 years after the disease appears.
Exams and Tests
A specific blood test is available for diagnosing RA and distinguishing it from other types of arthritis. It is called the anti-CCP antibody test. Other tests that may be done include:
- Complete blood count
- C-reactive protein
- Erythrocyte sedimentation rate
- Joint ultrasound or MRI
- Joint x-rays
- Rheumatoid factor test (positive in about 75% of people with symptoms)
- Synovial fluid analysis
Regular blood or urine tests should be done to determine how well medications are working and whether drugs are causing any side effects.
RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction.
Disease modifying antirheumatic drugs (DMARDs): These drugs are the current standard of care for RA, in addition to rest, strengthening exercises, and anti-inflammatory drugs.
- Methotrexate (Rheumatrex) is the most commonly used DMARD for rheumatoid arthritis. Leflunomide (Arava) may be substituted for methotrexate.
- These drugs may have serious side effects, so you will need frequent blood tests when taking them.
Anti-inflammatory medications: These include aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.
- Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding, and possible heart problems.
- Celecoxib (Celebrex) is another anti-inflammatory drug, but it is labeled with strong warnings about heart disease and stroke. Talk to your doctor about whether COX-2 inhibitors are right for you.
Antimalarial medications: This group of medicines includes hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine), and is usually used along with methotrexate. It may be weeks or months before you see any benefit from these medications.
Corticosteroids: These medications work very well to reduce joint swelling and inflammation. Because of long-term side effects, corticosteroids should be taken only for a short time and in low doses when possible.
Biologic drugs are designed to affect parts of the immune system that play a role in the disease process of rheumatoid arthritis.
They may be given when other medicines for rheumatoid arthritis have not worked. At times, your doctor will start biologic drugs sooner, along with other rheumatoid arthritis drugs.
Most of them are given either under the skin (subcutaneously) or into a vein (intravenously). There are different types of biologic agents:
- White blood cell modulators include: abatacept (Orencia) and rituximab (Rituxan)
- Tumor necrosis factor (TNF) inhibitors include: adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), golimumab (Simponi), and certolizumab (Cimzia)
- Interleukin-6 (IL-6) inhibitors: tocilizumab (Actemra)
Biologic agents can be very helpful in treating rheumatoid arthritis. However, people taking these drugs must be watched very closely because of serious risk factors:
- Infections from bacteria, viruses, and fungi
- Possibly psoriasis
Occasionally, surgery is needed to correct severely affected joints. Surgeries can relieve joint pain and deformities.
The first surgical treatment may be a synovectomy, which is the removal of the joint lining (synovium).
At some point, total joint replacement is needed. In extreme cases, total knee, hip replacement, ankle replacement, shoulder replacement, and others may be done. These surgeries can mean the difference between being totally dependent on others and having an independent life at home.
Range-of-motion exercises and exercise programs prescribed by a physical therapist can delay the loss of joint function.
Joint protection techniques, heat and cold treatments, and splints or orthotic devices to support and align joints may be very helpful.
Sometimes therapists will use special machines to apply deep heat or electrical stimulation to reduce pain and improve joint mobility.
Occupational therapists can create splints for the hand and wrist, and teach how to best protect and use joints when they are affected by arthritis. They also show people how to better cope with day-to-day tasks at work and at home, despite limitations caused by RA.
Frequent rest periods between activities, as well as 8 to 10 hours of sleep per night, are recommended.
The course of rheumatoid arthritis differs from person to person. For some patients, the disease becomes less aggressive over time and symptoms may improve.
Other people develop a more severe form of the disease.
People with rheumatoid factor, the anti-CCP antibody, or subcutaneous nodules seem to have a more severe form of the disease. People who develop RA at younger ages also seem to get worse more quickly.
Treatment for rheumatoid arthritis has improved. Many people with RA work full-time. However, after many years, about 10% of those with RA are severely disabled, and unable to do simple daily living tasks such as washing, dressing, and eating.
Rheumatoid arthritis is not only a disease of joint destruction. It can involve almost all organs.
Problems that may occur include:
- Anemia due to failure of the bone marrow to produce enough new red blood cells
- Damage to the lung tissue (rheumatoid lung)
- Injury to the spinal cord when the cervical spine (neck bones) becomes unstable as a result of RA
- Rheumatoid vasculitis (inflammation of the blood vessels), which can lead to skin ulcers and infections, bleeding stomach ulcers, and nerve problems that cause pain, numbness, or tingling. Vasculitis may also affect the brain, nerves, and heart, which can cause stroke, heart attack, or heart failure.
- Swelling and inflammation of the outer lining of the heart (pericarditis) and of the heart muscle (myocarditis). Both of these conditions can lead to congestive heart failure.
- Sjogren syndrome
The treatments for RA can also cause serious side effects. If you experience any side effects, immediately tell your health care provider.
When to Contact a Medical Professional
Call your health care provider if you think you have symptoms of rheumatoid arthritis.
Rheumatoid arthritis has no known prevention. However, it is often possible to prevent further damage to the joints with proper early treatment.
Yazici Y. Treatment of rheumatoid arthritis: we are getting there. Lancet. 2009;374:178-180.
Deighton C, O’Mahony R, Tosh J, Turner C, Rudolf M; Guideline Development Group. Management of rheumatoid arthritis: summary of NICE guidelines. BMJ. 2009;338:b702.
Harris ED Jr, Firestein GS. Clinical features of rheumatoid arthritis. In: Firestein GS, Budd RC, Harris ED Jr, et al., eds. Kelley’s Textbook of Rheumatology. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 66.
Review Date: 2/7/2010
Reviewed By: Mark James Borigini, MD, Rheumatologist in the Washington, DC Metro area. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
A hand x-ray is a medical image of one or both hands.
X-ray – hand
How the Test is Performed
X-rays are a form of electromagnetic radiation like light, but of higher energy. They can pass through the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray.
A hand x-ray is taken in a hospital radiology department or your health care provider’s office by an x-ray technician. You will be asked to place your hand on the x-ray table, and keep it very still as the picture is being taken. You may need to change the position of your hand, so additional images can be taken.
How to Prepare for the Test
Inform the health care provider if you are pregnant. Remove all jewelry.
How the Test Will Feel
Generally, there is little or no discomfort associated with x-rays.
Why the Test is Performed
Hand x-ray is used to detect fractures, tumors, or degenerative conditions of the hand. Hand x-rays may also be performed to assist in determining the “bone age” of a child in order to determine if metabolic or nutritional disorders are interfering with proper growth.
What Abnormal Results Mean
Abnormal results may include fractures, bone tumors, degenerative bone conditions, and myelitis (inflammation of the bone caused by an infection).
There is low radiation exposure. X-rays are monitored and regulated to provide the minimum amount of radiation exposure needed to produce the image. Most experts feel that the risk is low compared with the benefits. Pregnant women and children are more sensitive to the risks of x-rays.
Mettler FA. Skeletal system. In: Mettler FA, Jr, ed. Essentials of Radiology. 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2005:chap 8.
Rogers LF, Taljanovic MS, Boles CA. Skeletal trauma. In: Adam A, Dixon AK, eds. Grainger & Allison’s Diagnostic Radiology. 5th ed. New York, NY: Churchill Livingstone; 2008:chap 46.
Review Date: 8/3/2010
Reviewed By: Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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