Harvard Women's Health Watch

Hands don't work like they used to? Help is on the way

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Hand pain and stiffness, often tolerated without medical attention, can be successfully treated.

If you've ever awakened with numb hands, had your finger lock while filling out a crossword puzzle, or tried in vain to open a jar, you know what it's like to have your hands fail you. Yet you don't have to accept discomfort and disability as a consequence of aging. There are a host of treatments that can alleviate pain and improve function with minimal recovery time.

"Many conditions can be treated conservatively, and when surgery is necessary, you can often use your hands immediately afterward," says Dr. Tamara Rozental, associate professor of orthopedic surgery at Harvard Medical School. Dr. Rozental was in the national spotlight last year for saving the hand of a man injured in the Boston Marathon bombings. Ordinarily, she specializes in helping people get relief and regain function lost because of more common hand and wrist disorders like those listed below.

Carpal tunnel syndrome

The median nerve and several tendons pass through the carpal tunnel, a channel formed by bones and cartilage that runs from your forearm to your hand. Carpal tunnel syndrome occurs when the transverse carpal ligament, which forms the roof of the tunnel, thickens, narrowing the space and compressing the median nerve. This causes numbness and often pain in your fingers, especially at night.

In mild cases, carpal tunnel syndrome can be treated with a nighttime brace or cortisone injections. When the numbness and pain are intermittent, surgery is typically very effective in relieving symptoms and preventing progression. If you have these symptoms, you should get an evaluation sooner rather than later, Dr. Rozental advises.

Surgery to release the tunnel can be performed through small incisions that allow the surgeon to see the nerve directly, or endoscopically, in which a tiny camera relays an image of the nerve. The surgery is done under a local anesthetic with sedation and takes approximately 15 minutes to complete.

"If you get to the point where your hands are constantly numb and weak, it's probably too late to reverse the nerve damage associated with carpal tunnel syndrome, even with surgery," Dr. Rozental says. "However, surgery can still prevent the condition from getting worse, although the improvement may not be as great as you'd like," she adds.

Trigger finger

The muscles that operate your fingers are located in your lower arm and are connected to your finger bones by long tendons that glide through the finger joints like a clothesline running through a pulley. When a tendon or the sheath surrounding it is inflamed and thickened, the tendon can't move through the joint smoothly, and it can become stuck as the finger flexes. Your finger may lock in either a straight or flexed position, and you may have to use your other hand to bend it or pry it open. You may hear a popping sound as your finger unlocks.

If your finger locks only occasionally, nonsteroidal anti-inflammatory drugs (NSAIDs) may alleviate the inflammation. Trigger finger can also be treated with cortisone injections. Although the injections may need to be repeated two or three times, the treatment is successful about 60% of the time. If cortisone treatment doesn't help, minor surgery, in which a needle or thin scalpel is used to open the sheath, can help the tendon go through the joint more easily.

Arthritis

Two of the most common problems with arthritis occur at the joints nearest the fingertips and those at the base of the thumbs. Treatment for arthritis of either joint usually begins with an NSAID to reduce pain and inflammation and splints to immobilize the joint. "Although there isn't a cure for arthritis, there is a lot we can do to relieve pain and improve function," Dr. Rozental says.

Arthritis in the joint closest to the fingertip may be limited to painless bony overgrowths called Heberden's nodes. "We usually don't treat these because they are largely cosmetic," Dr. Rozental says. But when the joint is so painful and deformed that the finger becomes difficult to use, surgery to fuse it can alleviate pain and straighten the finger. Although you won't be able to curl the tip of your finger after a joint fusion, the pain relief may be worth it.

Arthritis at the base of thumb can be even more disabling, making it hard to open jars, turn keys, and do finer work like sketching or knitting. -Occupational therapy—in which you are taught techniques that put less pressure on the joint and are introduced to assistive devices like pens with rubber grips and kitchen implements with thick handles—can be helpful.

When more conservative treatments are inadequate, cortisone shots may also relieve pain and inflammation in the short term. Corrective surgery to remove the arthritic bone can keep bones from rubbing against each other and provide significant pain relief. Your surgeon may also use a tendon from your wrist to stabilize the joint. "Recovery takes several weeks, but the improvement can be substantial. Most people are very happy with the results," Dr. Rozental says.

Wrist fractures

Fragility fractures, which usually occur with a fall, are increasingly common as women age. Because wrist fractures are often the earliest of fragility fractures, they can be useful indicators of bone loss. After a wrist fracture it is often helpful to get a bone density test.

"If you aren't taking a bone-building medication and your history or your scan shows you need one, you can start a bisphosphonate two weeks after a fracture," Dr. Rozental says. If you are already taking a bisphosphonate, such as alendronate (Fosamax), there is no evidence that it's necessary to discontinue the drug while the bone heals, she adds. Recent studies have shown that fractures in women using bisphosphonates, which were once thought to inhibit bone repair, heal just as quickly as those in women who aren't taking them.

It usually takes several weeks for the bone to heal. During that time, the wrist can be immobilized in a cast. It can also be treated with surgery in which screws, pins, or—more commonly—a thin metal plate with screws can be inserted to hold the bone together until the fracture heals. "Surgery allows you to use your wrist and hand during healing, which can be really important, especially if you're living alone," Dr. Rozental says.

Raynaud's phenomenon

The body normally reacts to extreme cold by constricting blood vessels in the hands and feet to divert blood flow to the internal organs to keep them functioning. If you have Raynaud's phenomenon, it doesn't take subfreezing temperatures to provoke that reaction. Sitting in an air-conditioned room, or even a stressful event, can render your fingers cold and numb.

During a Raynaud's episode your fingers may turn white, then blue, as spasms in small vessels restrict blood flow to them. Your sense of touch may be blunted, making it hard to grasp objects. When the spasm ends and the vessels open up, blood will rush in and your fingers may flush bright red. They are likely to throb and tingle as feeling is restored.

How Raynaud's phenomenon progresses

In Raynaud's phenomenon, fingers turn white (A) as small arteries in the fingers (arterioles) tighten, restricting the
flow of blood to the skin. As oxygen in the blood is depleted, the fingers turn blue (B) and become painful. Eventually, the arterioles relax, and blood once again enters the fingers, warming the skin and turning it red (C).

Raynaud's can be aggravating and painful, but you can often abort an episode by running your hands under warm water or waving your arms in circles to get the blood flowing. Some people have success using biofeedback techniques to dilate blood vessels. You may also want to keep reusable gel warming packets in your bag or pocket to use when you feel an attack coming on. You may also minimize attacks by avoiding common triggers like caffeine, beta blockers, and cold medications containing pseudoephedrine.

More severe cases, which often occur in people with scleroderma, lupus, or rheumatoid arthritis, may require medical treatment. Drugs to dilate blood vessels, such as calcium-channel blockers or other blood pressure medications, are often effective. Botox injections may also reduce the number of Raynaud's episodes.