The Milwaukee Hand Center

De Quervain’s Tendinitis describes a painful inflammation of the extensor tendons as they cross the thumb side of the wrist. The tendons normally glide freely through a fibrous tunnel or compartment at the level of the wrist which keeps them in alignment. Swelling of the tendons or the thin lining around each tendon (called synovium) causes the tunnel to become too tight for the tendon to glide freely. Friction and rubbing in this tunnel causes pain especially with excessive thumb or wrist motion. Although each of the 12 tendons which lay on the back side of the wrist may become inflamed, the most common site is on the thumb side of the wrist in the first extensor compartment. This is referred to as de Quervain’s tendinitis.

What are some causes? Any activity which involves repetitive thumb or wrist motion may lead to this swelling. Medical conditions which result in water retention and hand swelling may also contribute. Many women will notice symptoms during pregnancy or shortly after childbirth.
What are the symptoms? Swelling or pain on the thumb side of the wrist is the most frequent complaint. Some patients describe a sharp pain or pulling feeling which travels from the back side of the thumb up to the mid-forearm. Occasionally, numbness on the top of the thumb will occur from irritation to the nerves in the area. Most patients feel relief with rest. People with deQuervain’s tendinitis may also develop small fluid filled cysts overlying the area of inflammation.
How does the doctor diagnose it? A medical history and physical examination will usually confirm this diagnosis. Tenderness over the radial styloid when the thumb is bent into the palm and wrist rotated is referred to as Finkelstein’s maneuver. If there is a history of trauma or the pain is not clearly arising from the tendons, an x-ray may be ordered to examine the underlying wrist joint. Pain at the base of the thumb may also arise from arthritis or an old unhealed fracture. Although much less common, inflammation in the region of the second tendon compartment can occur irritating adjacent nerves and is referred to as intersection syndrome.

What is the treatment? Early treatment includes avoidance of repetitive thumb and wrist activities which cause pain. A thumb-spica splint also helps minimize tendon rubbing. Oral anti-inflammatory medicine may help reduce swelling in the first dorsal compartment which is the goal of treatment. Patients who have significant swelling or continue to have pain are usually benefited by a cortisone injection into the fibrous tunnel. If symptoms persist, release of the fibrous sheath over the tunnel relieves pressure on the tendons. A new, looser fibrous layer then forms over the tendons which is less constrictive. Light hand activities can be safely started shortly after surgery but return to heavier hand use takes longer.

Ganglion and Tendon Sheath Cysts are fluid filled lumps which form beneath the skin on the hand or fingers. They arise from a small slit or area of weakness in the fibrous covering over a joint or tendon. With hand use, joint fluid or tendon sheath fluid may then leak into the fat beneath the skin. The body responds to this leak by forming a fibrous wall around the fluid. These cysts usually have a firm feel and may vary in size from week to week. Occasionally, they may disappear completely or arise again months or years later. The most common sites include the back or front side of the wrist or the base of the fingers. Cysts which arise near the nailbed are referred to as mucous cysts and arise from the small finger joints. What are some common causes? Most ganglions arise without a previous injury or underlying hand problem. They are common in persons of all ages. Mucous cysts, on the other hand, are more common in older persons who have underlying joint arthritis.

What are the symptoms? Most patients either notice a visible lump or experience pain. Small ganglion cysts near the wrist joint can be painful because of pressure on surrounding tissues and nerves before they are visible. Cysts on the back of the wrist may cause pain with wrist extension while cysts on the front of the digits are uncomfortable with grip activities.

How does the doctor diagnose it? A medical history and physical examination noting the location of the pain or lump lead to a diagnosis. A wrist or hand x-ray is sometimes viewed to rule out underlying joint problems. If the cyst is difficult to feel or in an unusual location, an MRI study may also be suggested. Drawing fluid from the cyst with a needle may occasionally be done as well. What are the symptoms? Most patients either notice a visible lump or experience pain. Small ganglion cysts near the wrist joint can be painful because of pressure on surrounding tissues and nerves before they are visible. Cysts on the back of the wrist may cause pain with wrist extension while cysts on the front of the digits are uncomfortable with grip activities.

What is the treatment? Cysts which are small and non-painful may be observed for any changes. Early after their formation, these cysts may resolve on their own. Although cancer in the hand is very uncommon, some patients with a family or personal history may desire excision of these lumps for review by a pathologist. Similarly, cysts which are painful or limit hand function are best excised. Drawing the thick fluid out of the cyst alone (aspiration) usually is followed by recurrence but may be a good option for the patient wishing to avoid surgery.  Surgical excision involves removing both the cyst and the narrow stalk from which the cyst arises. A mucous cyst at the end of the finger usually has underlying bone spurs which are also removed at the time of surgery. This helps prevent additional joint leaks and cysts from forming.

Basilar joint arthritis refers to degenerative arthritis with loss of normal cartilage at the base of the thumb. The thumb is different from the other fingers in the way it can swivel and rotate for pinch and grip activities. Most of this motion occurs between the thumb metacarpal bone and the trapezium bone. Over many decades of use, the cartilage between these two bones may slowly wear thin. Eventually, this results in loss of the normal joint space and pain from bone rubbing on bone. Bone spurs often then form at the edges of the joint and are an additional cause of pain. The ligaments which surround the joint may weaken which leads to collapse of the joint
What are some common causes? Most patients have no history of previous fracture or trauma. This common form of hand degenerative arthritis often runs in families and is most common in people over 50 years of age.

What are the symptoms? Pain with pinch activities is the most common complaint. Opening a tight jar or turning a key in a car ignition becomes painful. Changes in weather or excessive hand use may cause temporary aggravation. As the arthritis progresses, the thumb base may begin to look swollen. It may become difficult to open the the hand widely in order to hold a jar or can. Some patients may develop swelling of the tendons which overlay the arthritic joint and lead to pain with wrist motion.

How does the doctor diagnose it? A medical history and physical examination along with a wrist and thumb x-ray help confirm this hand problem. The x-ray is used to evaluate joint space for narrowing, roughness, or spurring.

What is the treatment? The treatment plan is based on severity of joint degeneration and level of pain. Many patients with early disease are well treated with a thumb-spica splint and oral anti-inflammatory medication. A cortisone injection may significantly help reduce the pain but unfortunately pain relief is short-lived in patients with bone spurs and bone rubbing. Persons who have daily pain which interferes with their work or home activities are best treated with surgery. The arthritic joint is removed and reconstructed with the patient’s own tendons. The metacarpal bone then glides over the tendon spacer instead of rubbing bone on bone. Early after surgery, patients are begun on therapy to increase thumb motion. Several months elapse before significant pinch strength returns. Follow-up studies of patients who have undergone this operation show that these reconstructions give long-lasting pain relief.

Trigger Finger and Flexor Tendinits both describe swelling of the finger tendons or the lining surrounding them. Each finger has one or two tendons which connect the bones of the finger to muscles in the forearm so that you can bend them. The tendons glide through a series of pulleys which hold them closely to the bones. The pulleys begin in the palm and extend the length of each finger. There is little extra room between the tendons and surrounding pulleys therefore if swelling of the tendon or tendon lining occurs, then rubbing or locking will result. The most common place for rubbing to begin is in the palm or base of the thumb with locking of the tendon on the A1 pulley. The thumb or ring finger is affected most often and the index finger least often.

What are some causes? Most commonly, patients can not identify any precipitating cause. Occassionally, a period of increased use at work or with sports such as golf, cycling, or weight lifting may precede this condition. Hand injuries or surgery which lead to swelling may also cause some locking. Medical conditions such as diabetes, gout, or rheumatoid arthritis may as well. Trigger digits are more common in people beyond their fourth decade of life.

What are the symptoms? The two most common symptoms are pain and locking. When the fingers are involved, the pain is usually beneath the palmer skin creases. You may feel a firm swelling in this area. When the thumb is involved, the pain is usually near the base of the thumb. The knot which forms on the tendon may cause the finger to lock in a bent position after making a fist. Gentle massage or pulling on the finger can usually straighten the finger. The thumb, on the other hand, will often become stuck in a straight position with difficulty bending. Locking is usually worse in the morning or after forceful hand activity but eventually may occur throughout the day. Diabetics or patients with more severe tendinitis may notice swelling along the length of the finger.
How does the doctor diagnose it? A patient history and physical examination are all that are usually necessary to diagnose this condition. Occasionally, laboratory studies are ordered if there is a suspicion of diabetes, gout, or pseudogout. A hand x-ray is ordered if there are signs of underlying arthritis or a history of rheumatoid disease.

What is the treatment? Early treatment includes reducing forceful, repetitive grip activities. A padded bicycle-type glove may reduce direct pressure on the tender area. Oral anti-inflammatory medicine can help in mild tendinitis, however, patients with advanced locking or swelling benefit more from a cortisone injection into the inflammed tendon sheath. If swelling or locking persist, then surgical release of the A1 tendon sheath is usually curative. Although locking usually resolves the day of surgery, the palmer tenderness subsides more slowly. The surgery is done as an outpatient and a small bandage is worn until the sutures are removed. In the weeks after surgery, your body heals with a looser fibrous covering around the tendon. Patients with more advanced tendinitis may require several visits with a hand therapist following surgery to help instruct you on motion and massage.

Lateral epicondylosis is commonly known as tennis elbow even though most persons who develop this problem do not regularly play racquet sports. Epicondylosis refers to degeneration of the tendons near where they insert on the bone of the outer elbow. With repetitive stress, small tears within these tendons lead to pain. Many persons develop this problem in their 40’s however it may occur at any age with overuse. A related condition known as golfer’s elbow causes a similar pain on the inner side of the elbow.

What are some common causes? Repetitive use of the arm in an outstretched position or repetitive forceful grip tenses the extensor muscles in the forearm .

What are the symptoms? Pain on the outer side of the elbow or in the forearm just below the elbow is the most common complaint. Grip weakness is often a secondary complaint. Direct pressure over the site reproduces the pain. Lateral epicondyloisis may occur in persons who also have a pinched nerve in the forearm. This condition, known as radial tunnel syndrome, may cause pain with wrist rotation activities (such as using a screwdriver) and in advanced cases results in difficulty bringing the fingers up straight. How does the doctor diagnose it? The description of pain along with a physical examination are sometimes all that is necessary to diagnose this condition. If there is a history or concern for elbow joint problems, an x-ray or MRI study may be ordered to rule out underlying joint problems. If symptoms are more indicative of radial tunnel syndrome, a nerve test may be suggested. Response to treatment such as a cortisone injection is also helpful in diagnosing this condition.

What is the treatment? Early treatment includes avoidance of activities which stress the extensor tendons. Changing the type of tennis racquet, string tension, or stroke technique can help if you regularly play. Changing your work environment so that most activities are performed with a bent (rather than straight) elbow also reduces strain on these tendons. Oral anti-inflammatory medication can help reduce swelling and pain. Therapy is also directed toward reducing swelling and teaching stretching exercises to reduce tightness in the involved muscles. A counter-force brace on the forearm helps relieve stress on the origin of the extensor tendons.

Patients with significant or long-standing lateral epicondylitis may respond well to a cortisone injection at the site of inflammation. The injection begins to work within 3-5 days and has its peak effect within 3 weeks. During this time, rest and gentle stretching can help reduce return of symptoms. Dry needling is another technique we perform for patients wishing to avoid injections. Surgery for lateral epicondylosis is reserved for those patients who have pain which limits their strength or activities over a long period of time. The procedure is performed as an outpatient and is followed by therapy and slow return to activities.

Dupuytren’s Contracture is a thickening of the normal fibers in the palm and fingers. Normally, these fibers help anchor the skin of the palm to the bones beneath for stability. In Dupuytren’s disease, these fibers thicken into nodules or cords and may cause pitting of the skin or inability to straighten the fingers. The nodules are not malignant but will continue to slowly grow over time. It is more common in men than in women.

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What are some common causes? Genetics plays a role in Dupuytren’s disease. Many patients will describe a parent or sibling with similar problems. Long-term exposure to heavy vibration such as pneumatic hammers or grinders has been implicated as well. Patients who consume large amounts of alcohol also seem to be at increased risk. Rarely, a patient with a predisposition to Dupuytren’s disease may develop a nodule or cord after a hand injury or surgery for an unrelated hand problem such as carpal tunnel syndrome or finger tendinitis.

What are the symptoms? Most patients first notice a painless cord or nodule in the palm or side of the small finger. As the disease progresses, pitting of the overlying skin may occur and additional fingers become involved. Tightnening of the cords can lead to difficulty straightening the fingers. It becomes difficult to lay the hand flat on a table, wear gloves, or retrieve coins from a tight pants pocket. Both hands usually become involved however decades may pass before appearance in the less affected hand. In severe or recurrent disease, there may be numbness in the involved fingertips since the Dupuytren’s cords wrap around the nerves of the fingers.
How does the doctor diagnose it? Physical examination and history are usually sufficient to make the diagnosis. Occasionally, a hand x-ray is ordered to evaluate the underlying joints.

What is the treatment? Patient’s with early disease where there is no loss of hand function nor joint contracture may only require proper diagnosis and reassurance. A needle aponeurotomy (NA) or enzyme injection is a minimally invasive way to release the tension on the fingers in selected patients.  Surgery is recommended when larger nodules are present that are not amenable to the these procedure. Medication, nutritional suppliments and therapy do not seem to improve this condition. The goal of surgery is to improve hand function by releasing or removing the abnormal cords and nodules. Surgery does not cure the disease which usually recurs slowly over subsequent years. Older patients who develop the disease tend to have slower recurrence over a period of decades and may not need additional surgery. Younger patients tend to have a more aggressive form of the disease which recurs more quickly. Severe finger joint contractures can be improved with surgery but not fully. Joints which are stuck in a flexed position for long periods develop permanent tightness.

Hand and Wrist Fractures are one of the most common reasons to see a hand specialist. Each year we treat hundres of patients with broken wrists, fingers, and forearms. Early recognition is important to get the best outcome since bones begin the process of healing soon after the injury which makes it more difficult to treat when treatment is delayed. This is especially true in young children who can begin to show new bone growth within a week to 10 days.

What are some common causes? Falls, whether on the sports field or on a slippery sidewalk are the most common cause of hand and wrist fractures. Ball sports such as football and basketball are also frequent causes of finger fractures. In Wisconsin, snowboarding, skiing, and skating injuries result in thumb and wrist injuries as well.

What are the symptoms? Pain, swelling, bruising, and visible deformity of the hand or wrist are the most common. Important fractures of the wrist, however, sometimes result in little swelling or pain. Fractures of the small bones of the wrist, especially the scaphoid bone often have low levels of pain and do not show up on x-rays initially. These fractures if left untreated lead to pain and arthritis in subsequent years.

How does the doctor diagnose it? Physical examination and x-ray studies are usually sufficient to make the diagnosis. Occasionally, when x-rays are normal but the pain persists, an MRI is recommended. This is especially true if the doctor feels that a ligament tear may be part of the injury.

What is the treatment? Most fractures heal uneventfully with proper casts or braces and activity limitations. Some fractures have to be reset and then a metal pin or plate inserted in the operating room to hold the bone fragments back in position. Often the the pins and plates are removed once bone healing has occured.
Emergency Care If you just broke your wrist or hand and are in the emergency room, ask the doctor for a copy of your x-rays (film or disc) so that we can see you with your x-rays in the next day or two. Most fractures do not require emergency surgery but instead a cast or brace once the swelling goes down. Whether we are the hand specialist on call that day or not, we are also happy to talk with the emergency doctor while you are there if the injury is more severe. We have x-ray in our office, therefore, if you have chosen not to be seen or get an x-ray yet, call us so we can see you sooner than later.

Carpal tunnel syndrome is a pinched nerve in the wrist. Several nerves travel down the arm, across the wrist, and into the fingers to give us feeling in our fingers. The median nerve is one of these nerves and gives feeling to the thumb, index, long, and ring fingers. This nerve also helps move the thumb. As the median nerve crosses the wrist into the hand, it travels through a tight tunnel called the carpal tunnel. The tunnel is between 1 and 2 inches long and is surrounded by wrist bones on the back side, and a tight ligament on the top side. If swelling occurs inside this tunnel or the tunnel becomes tighter, the median nerve gets pinched and does not function properly. This loss of median nerve function causes numbness, tingling, or pain.


What are some causes? There are many known causes of carpal tunnel syndrome. Any injury to the wrist including a fracture, dislocation, or crush may cause swelling around the nerve. If the swelling is sufficient, you will feel numbness. Medical conditions which cause swelling or nerve dysfunction such as rheumatoid arthritis, diabetes, and thyroid disease may cause carpal tunnel syndrome. Swelling from pregnancy may cause this as well. Prolonged exposure to heavy vibration or direct impact to the palm can cause direct injury to the nerve. Despite all of these known causes, over half of patients who develop this condition have no identifiable cause.

What are the symptoms? Tingling in the thumb, index, long, or ring fingers is the most common complaint. It usually begins at night time and may awaken you from sleep. Many people also notice tingling while driving or reading the newspaper. Weakness sometimes leads to dropping items and in severe cases you may notice loss of muscle bulk in your palm which is referred to as thenar atrophy. Pain is an uncommon complaint early in carpal tunnel syndrome but may occur as pressure on the nerve increases.

How does the doctor confirm the diagnosis? A detailed patient history and exam including a description of your symptoms and other medical conditions are sometimes all that is needed. An x-ray is performed if there is any concern for trauma or arthritis. Confirmation of carpal tunnel syndrome is usually made with a nerve conduction study (NCT). This test measures the health of all of your nerves from upper arm to fingertip in order to rule out other possible causes of numbness.

What is the treatment? The goal of treatment is to reduce pressure on the nerve. This may be achieved with anti-inflammatory medication, vitamin B6, or wrist splints. Occasionally, a cortisone injection is recommended. If your symptoms don’t improve or your nerve conduction study shows severe compression, then surgery is recommended. The surgery involves opening the roof of the carpal tunnel so that it heals with less pressure on the nerve. A variety of surgical techniques may be used but all patients will initially have tenderness over the palm. Numbness may go away quickly in mildly pinched nerves but will take longer in patients with advanced symptoms. In severe cases or in elderly or diabetic patients, the numbness may not go completely away.