Is it a Lump or Bump? Find out What You Should Do About Ganglion Cysts of the Wrist and Hand

Perhaps it starts as a very low grade aching in the wrist, barely enough to get your attention. Then the pain becomes more frequent and persistent. As you roll your wrist around in circles trying to figure out the cause, you notice a small bump on the back of the wrist. Of course, your next move is to do the same with the opposite wrist to see if it’s present on both sides. Nothing. No bump. Time to see the doctor.

Finding a lump on your body that you know was not there previously is generally concerning. Most bumps on the hand are not cancerous, but are important to have checked out promptly by a hand surgeon. In this case, a common cause is a ganglion cyst, a small mass that can develop around the joints of the wrist and hand. Ganglion cysts are benign, fluid filled sacs that may or may not cause pain in the affected area. They are the most common form of mass found in the hand and are generally found in younger individuals between the ages of 15-40.

The most common location is on the back of the wrist, but they may also be found on the palm side of the wrist or at the base of the fingers. The cause is not known, but often times there is a correlation between their development and chronic, mechanical stress in the wrist or hand. Athletes that have repetitive stress on the wrist and hand such as gymnasts have been found to have a higher incidence of these cysts developing.

These cysts may also develop at the most distal joint of the finger. This type of cyst, called a mucous cyst, is associated with wear and tear in the finger joints and is more common with age.

In my practice, ganglion cysts are a relatively common occurrence. The diagnosis is generally straightforward, usually requiring only a physical exam and occasionally an X-ray. The size and shape of the lump, along with its location, are generally sufficient to make an accurate diagnosis, but I sometimes will order an MRI if there is any uncertainty.

In most cases, these cysts are harmless and the treatment can be as simple as periodic observation for any changes that impact movement or function of the wrist or hand. Sometimes, the ganglion can disappear by itself. In cases where the cyst causes pain or becomes an impediment to movement and function, there are more aggressive treatments available. Often, the cysts are simply persistent and unsightly, requiring removal.

First of all, if you have been surfing the internet you may have read that ganglion cysts used to be called “Bible cysts” because in times past, a treatment was to slam a bible or other heavy book over the cyst, causing it to burst. DON’T DO IT. It is not effective and you could end up with a broken bone in your hand. It is just not worth trying.

Aspiration is usually the first treatment method used to reduce a ganglion. A small needle is inserted into the cyst and the fluid is drained. This produces an immediate reduction in the size of the lump. This is performed in the office setting, and there are no significant restrictions following the procedure. The downside is that the ganglion cyst may return in at least 50% of patients. This is because the root and capsule of the cyst is left intact. An analogy would be to think of deflating a balloon. With fluid production, the balloon can simply re-inflate. Even though the permanent success of aspiration is relatively low, given the ease and simplicity of the aspiration procedure, it is still often worth a try.

Should the cyst return following needle aspiration, surgery may be required that removes the capsule and root completely. This is an outpatient surgical procedure performed under a light anesthesia – usually a combination of a local anesthetic and a sedating medicine administered by the anesthesiologist. The ganglion plus a small amount of the joint capsule or tendon sheath from which the cyst stems is removed. Following surgery, the hand will be splinted for a short duration, and the patient will be able to return to normal activities within 2-4 weeks. Physical or occupational therapy is usually not needed, but a referral may be made in instances where a patient has significant stiffness in the hand or wrist joints. Although there is a small risk of the cyst returning, my patients enjoy a high success rate, with over 90% of all excisions being permanent.

It is important to have any persistent mass checked out by a physician. He or she can perform the appropriate physical exam and testing to confirm the diagnosis and refer you to the appropriate specialist if necessary. If you should have any questions regarding this or any other conditions of the hand, wrist or elbow, please feel free to contact our office at (206) 633-8100, ext. 18133 to schedule a consultation.

Trigger Finger Causes and Treatment

One of the more recent national trends in the fitness industry is the rise of Crossfit, and with at least 12 of these fitness gyms located throughout the city, Seattle is no exception. This is a high intensity workout method that focuses on major body movements to train multiple muscle groups simultaneously. One of the movements performed regularly by avid Crossfitters is the pull up. Of course, a strong grip on the overhead bar is required to complete this exercise, especially the “kipping” variety, where the athlete rocks the body and uses the shifting body weight to assist in the lift. With its emphasis on pull-ups as a foundational exercise, Crossfitters have started to see their share of wrist and hand injuries, one of them being trigger finger.

The hand and wrist are often susceptible to overuse injuries, especially those who perform repetitive tasks related to sports activities or various occupations. One common condition that may arise as noted above is trigger finger, which is characterized by restricted movement in one or more fingers in the hand. With this repetitive use injury the affected finger typically becomes stuck in the bent, or flexed position.

Trigger finger, medically termed stenosing tenosynovitis is an inflammation of the finger tendon sheath located in the palm of the hand and can be present in any of the fingers or even the thumb. The tendons in the hand are encased in a layer of tissue called a sheath, which allows the tendon to glide easily as the finger is bent and straightened. The action is similar to a bicycle’s brake cable sliding within the outer casing as the brake lever is depressed and then released. However, at times the sheath may become inflamed, causing a restricted gliding action.

Generally the hand will be able to close and grasp objects without difficulty, but when the fingers are straightened, the tendon will become stuck within the sheath, leaving one bent finger. The person will then usually exert more force to straighten the finger, causing the tendon to snap through the sheath and rapidly straighten. The connotation is that of the hammer on a firearm snapping closed, and is where trigger finger gets its common name.

What causes Trigger Finger?

Trigger Finger is generally caused from repetitive use of the fingers. Those individuals whose occupations require repeated and forceful grasping of tools such as tradesmen may be susceptible to this injury. Others such as rock climbers, with their forceful use of the finger flexors, are also at risk.

Clinically, I generally see this condition in those between 40-60 years of age and it is more common in women than in men. Those individuals with diabetes or rheumatoid arthritis may be at increased risk for developing trigger finger. Because it is an inflammatory condition, trigger finger usually produces local pain over the affected area in addition to the hallmark trigger effect. You may also feel a small bump in the palm of the hand where the tendon is inflamed.

The first step in treating trigger finger is to see a physician who specializes in hand injuries. Your doctor will be able to diagnose the extent of the injury and guide you toward the most effective treatments, reducing recovery time.

How is Trigger Finger Treated?

Conservative steps such as anti-inflammatory medications and rest are usually advocated initially.  However, if the condition persists, I usually will treat with a steroid injection, which is a much more potent anti-inflammatory. This is a highly effective treatment modality for most patients and relief may last several months or longer. Should symptoms return after the injection wears off, surgical release of the tendon sheath may be indicated. This is a minimally invasive day surgery in which the sheath is widened, allowing the tendon to glide freely through the previously restricted area. This procedure has excellent long-term success and potential to return to 100% functional use of the hand.

There is usually a quick recovery time and post-operative physical therapy is not always needed. However, if you have had trigger finger for a long time, then there may be some underlying stiffness in the finger joints themselves. Should this be the case, I may refer you to a therapist who specializes in hand rehabilitation in order to expedite recovery and full range of motion in the hand.
Should you have any questions or concerns regarding trigger finger or any other issues concerning the hand, elbow, or shoulder, please feel free to contact my office for a consultation at (206) 633-8100 ext. 18133.

Hand Tumors and Cysts

Hand Tumors and Cysts We see many patients who have lumps and bumps in their hand that are painful, growing, affect function, and are often worry some for the patient due to the concern for cancer. If you are concerned about a hand tumor, wrist mass, or finger cyst, you should schedule a consultation to put your mind at ease with a diagnosis and to discuss treatments available. … read more

Meniscus Tears and Repairs

Meniscus tears occur on the C-shaped disc that supports and cushions the knee. When this structure is damaged or torn, there may be pain, swelling, stiffness, and limited range of motion. Twisting or turning incorrectly can bring on a meniscus tear or injury. Knee arthroscopy is a safe procedure the orthopedic specialist may perform to resect or repair a meniscus tear and diagnose the extent of the injury to the knee.

What is a Meniscus Tear?

The meniscus is a rubbery, C-shaped disc that supports and cushions the knee. Injury to this part of the knee is common. There are two menisci in each knee. One is at the outer, or lateral side of the knee and the other is at the inner, or medial, side. These structures keep the knee steady by allowing for balance of weight across the knee. If one of these menisci is torn, the knee does not function properly and the torn meniscus can scuff and damage the surfaces of the knee resulting in arthritis.

What are the symptoms of a Meniscus Tear?

The symptoms associated with meniscus tears vary greatly depending on the severity. Minor tears may result in slight pain and swelling. If there are no mechanical symptoms, such as catching or locking, these tears may resolve on their own in around 2 or 3 weeks. More moderate tears can lead to pain at the side and back of the knee. The swelling of a moderate tear slowly gets worse over a 2 or 3 day period.

The knee will feel stiff with this type of injury and there will be limitations to how far the knee can be bent. The symptoms may go away after a week or two but can come back anytime there is re-injury or overuse of the knee. The pain of a moderate tear could go on for years if the tear is not treated properly.

The third type of tear is a severe tear. With these, pieces of the meniscus are torn and can displace into the joint space. This will make the knee pop, catch or lock without notice. It will be difficult to straighten the knee as well. The knee may be described as “wobbly” and give way without any warning. Most people who suffer a severe tear have pain, swelling, and stiffness immediately following the injury and it gets worse over the next few days.

What is the Cause of a Meniscus Tear?

Twisting or turning quickly can lead to a meniscus tear. Oftentimes, the foot is planted while the knee is bent. These types of tears occur when the person is lifting something really heavy or playing sports. As people get older, the likelihood of meniscus wear and tear increases.

How is a Meniscus Tear Diagnosed?

Most of the time, the orthopedic specialist inquires with the patient regarding past injuries and accidents. The doctor will also perform a physical examination to help find out if the meniscus is torn and causes pain. Testing may involve X-Rays and/or an MRI so the doctor can see if the meniscus is torn and how serious the injury actually is.

How is a Meniscus Tear Treated?

The orthopedic specialist will treat the tear based on the severity of symptoms, where the tear is located, how serious the tear is, your age, and how active you are. Treatment could involve rest, ice therapy, non-steroidal anti-inflammatories, elastic bandage wrapping, and elevating the leg up on pillows. The doctor may order physical therapy, too.

Sometimes, surgery is necessary to repair the meniscus or remove parts of the torn tissue. Surgical repair is usually the best choice for younger people who need to continue working and participating in sports.

What is Knee Arthroscopy?

Knee arthroscopy is one of the most commonly performed surgical interventions for repair of the meniscus. The orthopedic specialist inserts a small lens into the knee area through a tiny incision that is hooked up to a sterile camera and light source. This allows him a clear view of inside of the knee. Then, the doctor can use miniature surgical instruments to trim and repair the meniscus tear.

After the surgery, the doctor may put a brace on the knee to allow it to be immobilized to heal if the meniscus tear has been repaired rather than removed. If the tear is removed, patients generally are able to fully weight bear immediately following surgery. If necessary, a prescribed rehabilitation program will help you get back on your feet after the procedure.

Common Hand Problems

No matter what your age or occupation your hands are always working. Since your hands are so important any abnormality can be a cause for concern. Many common hand problems that interfere with your daily activities can be diagnosed and treated by your orthopedic surgeon.

Ganglion Cysts
cons1_8_8Ganglion cysts are the most common mass or lump in the hand. They are most common on the back of the wrist. These non-cancerous, fluid-filled cysts arise from the ligaments, joint linings, or tendon sheaths when they are irritated or inflamed.

They may disappear or change size quickly. Many ganglion cysts do not require treatment.

However, if the cyst is painful, interferes with function or the patient does not like the appearance, your orthopaedic surgeon can remove the fluid with a needle (aspiration) or remove it surgically.

Carpal Tunnel Syndrome
cons1_9_8Common symptoms of carpal tunnel syndrome are numbness and tingling in the hand, especially at night; pain with prolonged gripping such as holding a steering wheel; or clumsiness in handling objects. Sometimes the pain can go all the way up to the shoulder.

These symptoms are caused by pressure on the median nerve as it enters the hand through a tunnel in the wrist. The tendons that bend your fingers and thumb also travel in this tunnel.

Mild cases can be treated with a splint or brace to rest the wrist. Steroid injections into the carpal canal to decrease swelling may be used in addition to splinting.

Those cases that do not respond to nonsurgical treatment and those that are diagnosed late often require surgery. This is generally done in an outpatient setting under local anesthesia.

Tendonitis of the Wrist
cons1_10_8DeQuervain’s stenosing tenosynovitis is an irritation and swelling of the sheath or tunnel which surrounds the thumb tendons as they pass from the wrist to the thumb. Pain when grasping or pinching and tenderness over the tunnel are the most common symptoms.

Sometimes a lump or thickening can be felt in this area. If the hand is made into a fist with the thumb “tucked in” and bent towards the little finger, the pain gets worse (Finkelstein test).

Tendonitis may be caused by overuse and also can be seen in association with pregnancy or inflammatory arthritis such as rheumatoid disease.

If treated early, many cases improve with short periods of rest in a splint, followed by stretching exercises designed to get the tendons gliding. Injection with steroids and/or taking anti-inflammatory medications. More severe cases or those that do not respond to other treatment may require surgery.

Modification of the activities which caused the symptoms initially also may be required.

“Wear and Tear” Arthritis of the Hand
cons1_11_8Wear and tear arthritis is very common at the base of the thumb. Pain localized to the base of the thumb, particularly with use, is a very common early symptom.

Early disease can be treated with anti-inflammatory medication, steroid injections into the joint, or splinting.
As the wear and deformity progress, surgery is frequently required. There are many procedures to relieve pain and improve function.

Heberden nodes are “bumps” which occur at the last joint of the finger or thumb due to wear and tear arthritis (osteoarthritis). As the joints deteriorate, small bone spurs form over the back of the joints and make them appear “lumpy.”

Since most Heberden nodes are not painful and seldom interfere with function, no specific treatment is usually required. Patients with pain can be treated with anti-inflammatory medications. All patients should continue moving their hands; disuse frequently results in stiffness.

Dupuytren’s Contracture
cons1_12_8Dupuytren’s contracture is a hereditary thickening of the tough tissue called fascia that lies just below the skin of your palm.

This condition may vary from small lumps or bands to very thick bands which may eventually pull the fingers into the palm.

Dupuytren’s disease is familial, and may be associated with cigarette smoking, vascular disease, epilepsy, and diabetes.

The mainstay of treatment is surgical and is recommended if there is progressive contracture drawing the fingers into the hand. Sometimes a steriod injection will be used in a painful nodule. Small nodules or lumps in the palm do not need treatment until they are very large and interfere with hand function. Even with successful surgical removal, the bands may reappear or occur in other fingers.

Trigger Finger
cons1_13_8Trigger finger is an irritation of the digital sheath which surrounds the flexor tendons. When the tendon sheath becomes thickened or swollen it pinches the tendon and prevents it from gliding smoothly.

In some cases the tendon catches and then suddenly releases as though a “trigger” were released.

Sometimes the swelling can be treated with rest, activity modification, oral anti-inflammatories, or steroid injections. The tendon sheath will then return to its normal, pain-free condition. More severe cases may require surgery to release the tendon.

This can be done as an outpatient procedure. Normal activity can be resumed as pain allows.