Treatments

Arthritis is very common, wear and tear upon a joint that presents as pain and stiffness. The most common causes of a joint wearing out are trauma and genetics. Some people will fracture into a joint, and that joint is then likely to develop post-traumatic arthritis at some point. With genetics, though, some people will never develop arthritis well into their 90s, while others' joints wear out in their 30s, or even younger.

Osteoarthritis

Very common, and can affect any joint, with the small joints of the hand being particularly prevalent. Therapy and anti-inflammatories are the best initial treatments, with splinting appropriate for certain joints, namely the base of the thumb. If and when these measures fail, function and pain relief become the primary goals. Depending on the joint, excision, replacement, or fusion may be the best option, tailored to the individual's needs, as some treatments maintain range of motion at the expense of power, while others maintain power at the expense of range of motion.

Base of Thumb Arthritis

One of the most common arthritic conditions in the body, occurring across most age groups but most commonly affecting middle-aged women. It starts with pain at the base of the thumb, on either the palm or back side, along with a loss of the thumb's normal contour. Patients often notice problems opening jars, turning door handles, or with strong gripping motions.

For more information: Base of Thumb Arthritis.

Finger Arthritis

Any of the joints in the fingers can become arthritic, often across multiple digits. Treatment depends on exactly which joint is involved and what the individual patient wants: replacement is a good option for some joints, while fusion suits others better.

For more information: Arthritis of the Hand.

Scapholunate Advanced Collapse (SLAC)

This pattern of arthritis is the natural history of a torn scapholunate ligament in the wrist. The initial injury is often fairly benign, but the wrist is never quite right afterwards, and the process typically takes a decade or more to develop. It occurs because abnormal wrist kinematics let the bones move independently, causing abnormal stresses that lead to arthritic degeneration; occasionally it can be symptom-free until the arthritis develops. Treating the underlying injury acutely is the best way to prevent this process starting, using either an anatomic or non-anatomic surgical reconstruction. As the arthritis progresses, an excision, a Proximal Row Carpectomy (PRC), or a partial (four-corner) fusion may become the more appropriate option.

SLAC wrist follows a predictable pattern of progression, from the radial styloid, to the whole radio-scaphoid joint, and lastly to capitolunate arthritis.

Scaphoid Non-Union Advanced Collapse (SNAC)

This pattern of arthritis is the natural progression of a scaphoid fracture left untreated, very similar to a SLAC wrist in its cause, presentation, and treatment. As with a SLAC wrist, the lunate is no longer held in a fixed position, so it starts to tilt backwards (dorsally), leading to a DISI (dorsal intercalated segment instability) deformity that reflects the altered kinematics of the wrist.

Carpal Boss

A carpal boss is an enlargement of the bone at the base of the second or third metacarpal. It's a firm swelling, often mistaken for a ganglion. Treatment is splinting and/or steroid injections and anti-inflammatories; operative debridement is rarely needed.

Rheumatoid Arthritis

The mainstay of treating rheumatoid arthritis is non-surgical, supervised by a rheumatologist. There does come a point, though, when function starts to deteriorate due to tendon rupture, deformity, or loss of function. Surgery is often very successful in rheumatoid patients and can restore significant lost function; it's important not to wait too long before having surgery for this condition, as leaving it too late can shift the goals of surgery from regaining function to simply stopping progression, due to soft tissue and bony destruction.

Surgery can achieve many different things, from making the hand look and align like a hand again, to something as small as relocating dislocated tendons, through to repairing ruptured tendons or a total wrist fusion or replacement. Since rheumatoid arthritis often involves many joints, the exact combination of treatments differs for each person.

Nerves are very sensitive to compression. When a nerve is compressed at any point along its length, it can produce symptoms further down, numbness, tingling, pins and needles, or a "dead" feeling. Simply relieving the pressure often resolves the problem, though the degree of recovery depends on several factors, particularly how long the symptoms have been present.

Median Nerve (Carpal Tunnel Syndrome)

Usually presents as numbness and tingling in the thumb, index, middle, and half of the ring finger, often starting at night or during specific activities. Left untreated, this can progress to constant numbness, muscle wasting, and weakness. Initial treatment is nocturnal splinting; if this doesn't resolve it, a straightforward surgical release of the ligament across the wrist is very effective.

Ulnar Nerve (Cubital Tunnel Syndrome / Guyon's Canal)

Less common than carpal tunnel syndrome, presenting as numbness and tingling in the little finger and half of the ring finger, sometimes affecting the palm depending on where the compression occurs. It can affect the small muscles that spread and cross the fingers, and in chronic cases these muscles can visibly waste away. Compression most commonly occurs at the elbow, less often at the wrist. Surgical release is very successful where non-surgical management hasn't worked.

Radial Nerve

The radial nerve doesn't supply any muscles in the hand, only sensation. Compression can cause tingling on the back of the hand between the thumb and index finger, or a dull ache at the back of the wrist from compression near the elbow. Therapy is usually effective, and surgery is not commonly required.

Osteonecrosis is an unusual condition where the blood supply to a bone stops and the bone dies. There are a number of modifiable risk factors that treatment aims to address.

Kienböck's Disease (Avascular Necrosis of the Lunate)

Associated with having a relatively short ulna. Treatment depends on the degree of symptoms present, and even quite advanced arthritis can sometimes cause relatively few symptoms.

For more information: Kienböck's Disease.

Preiser's Disease (Avascular Necrosis of the Scaphoid)

Much less common than Kienböck's disease. Non-operative management with splinting and oral medication is often successful; where this doesn't resolve it, a SNAC wrist procedure gives good results.

Soft tissue injuries of the hand and wrist cover a range of ligament and cartilage conditions that can be easily missed on initial assessment, particularly when x-rays appear normal. Below are some of the more common conditions seen and treated.

Scapholunate Tear

Often misdiagnosed as a simple wrist sprain. Standard x-rays can look normal unless stress views are taken (imaging the wrist while making a fist), which can reveal widening between the lunate and scaphoid, along with a rounded outline in the scaphoid indicating it is flexing separately from the lunate. Left untreated, this injury will typically progress to a SLAC wrist over roughly a decade. Common symptoms are a dull ache in the wrist and a sensation of the wrist giving way. Acute tears are generally treated surgically.

Lunotriquetral Tear

Less common than a scapholunate tear, but carries the same long-term risk of arthritis from disrupted wrist mechanics. Presentation is similar, pain around the wrist, weakness, and a sense of the wrist giving way. X-rays may show the "delta sign" (a triangular-appearing lunate) and loss of the normal Gilula's arcs, with lateral views showing a VISI deformity (Volar Intercalated Segment Instability). Treatment is surgical stabilisation.

Ulna Collateral Ligament Injury (Thumb)

Commonly known as skier's thumb when it occurs acutely, or gamekeeper's thumb when it develops chronically. The ulna collateral ligament stabilises the thumb during pinch and grip. A tear causes pain and instability when the joint is loaded. Initial treatment is bracing to allow healing; in cases that don't settle, surgical reconstruction of the ligament may be required.

TFCC Injury and DRUJ Instability

The Triangular Fibro-Cartilage Complex (TFCC) stabilises the distal radius and ulna, playing a role similar to the meniscus in the knee. Certain anatomical variations can increase the risk of injury, for example, when the ulna is longer than the radius ("ulna positive"), increasing impingement against the wrist bones. Treatment typically starts non-operatively, with splinting and anti-inflammatories. An MRI helps visualise the TFCC, as it isn't visible on plain x-ray, and arthroscopy remains the gold standard for diagnosis. Where the ulna is positive, an ulna shortening osteotomy, tailored to the individual patient, may be recommended. TFCC tears unrelated to ulna length can also be addressed arthroscopically.

Soft tissue pathologies of the hand, wrist, and elbow cover a wide range of common conditions affecting tendons, fascia, and joint linings. Below are some of the more common conditions seen and treated.

Dupuytren's Disease

A very common genetic condition, thought to originate from the Vikings of old northern Europe. It's a disease of the tissue just under the skin, causing pits and lumps in the palms and fingers, and in advanced stages, curling of the fingers downwards. Splinting and other non-operative management won't cure or slow the condition, and it's important not to intervene too early, as operating before it becomes a problem can make things worse. The right time to treat is once it becomes a functional problem, for example when it starts poking you in the eye while washing your face, or you can no longer put your hand in your pocket. Treatment options range from needle fasciotomy and enzyme injection through to complete surgical excision, chosen depending on severity and the patient's wishes. Recurrence is higher with the less invasive treatments, though recovery is much quicker.

There are two related conditions involving the same thickening of connective tissue elsewhere in the body: Ledderhose disease, affecting the soles of the feet, and Peyronie's disease, affecting the penis.

For more information: Dupuytren's Disease.

Trigger Finger

A very common condition presenting with pain in the palm near the base of the fingers, at the A1 pulley over the MCP joint. Thickening of the A1 pulley narrows the entrance to the flexor sheath, and the flexor tendon can catch as it passes through, causing the finger to click, or lock, as it's extended, sometimes needing help from the other hand to straighten. Occasionally there's a palpable nodule in the tendon, though this is much less common than textbooks suggest. Treatment starts non-operatively, with a steroid injection and nocturnal splint, curing 60-70% of cases. A second injection, if needed, has a similar success rate. If this also fails, surgical release is performed. Patients with multiple trigger fingers, or with diabetes, are less likely to respond to non-surgical treatment.

De Quervain's Tenosynovitis

Inflammation of the first dorsal compartment tendons at the wrist, extensor pollicis brevis (EPB) and abductor pollicis longus (APL), which run along the thumb side of the wrist. It causes pain with thumb and wrist movement, particularly gripping or twisting motions. Treatment is typically splinting, anti-inflammatories, and a steroid injection; surgical release of the compartment is reserved for cases that don't settle.

For more information: De Quervain's Tendinosis.

Intersection Syndrome

Another tenosynovitis, similar to De Quervain's but much less common, caused by friction where the first dorsal compartment tendons cross the second compartment tendons (ECRL and ECRB) as they travel through the forearm. It's most commonly caused by repetitive wrist movement, particularly making a fist and bending the wrist, and typically presents with pain and swelling a few centimetres up from the wrist on the back of the forearm. It rarely needs surgery, and usually responds to a splint and modification of activities.

ECU Instability

The extensor carpi ulnaris (ECU) is a muscle that extends the wrist, moving it backwards. Its tendon, along with the other tendons that extend the fingers, thumb, and wrist, passes under the extensor retinaculum, a fibrous band that holds the tendons in place. The ECU tendon can become loose and dislocate around the head of the ulna, which can become symptomatic. Anti-inflammatories and a brace can often minimise symptoms; if this fails, the tendon can be stabilised surgically using a small slip of the extensor retinaculum.

Mid-Carpal Instability

More common than previously recognised, presenting as vague wrist pain and weakness, often in young women who are ligamentously lax (double-jointed). It's a dynamic condition that can only be appreciated on physical examination; in most people, the mid-carpal joint can be subluxed (partially dislocated) without pain, but in this condition the same movement recreates the presenting pain. Treatment starts with non-operative management: splinting, steroids, and activity modification. This condition is self-limiting and tends to improve with time, though a minority of patients benefit from surgical tightening (plication) of the wrist capsule.

Tendonitis

There are many tendons around the wrist, any of which can become tender and inflamed. Patients can often identify this themselves, as the pain sits along a palpable tendon. Splinting, steroids, anti-inflammatories, and activity modification will usually help, depending on the specific tendon involved, and surgery is rarely required.

Tennis / Golfer's Elbow

Pain on the outside of the elbow (tennis elbow) or inside of the elbow (golfer's elbow) are common conditions, causing localised pain around the bony prominences of the elbow. Despite the name, this is a degenerative change within the tendon just off the bone rather than true inflammation. Steroids, anti-inflammatories, and bracing will treat most cases, though surgical debridement can be performed for those that don't settle.

For more information: Tennis Elbow.

Ganglion

The most common "tumour," or swelling, seen in the hand. Ganglions are not cancerous and not dangerous, they're a fluid-filled outpouching of a joint or tendon sheath. Their size can fluctuate, and they can disappear on their own from time to time. They commonly occur around the back of the wrist, the underside of the wrist, or the tips of the fingers, where they're known as mucous cysts, and can also occur along the tendons of the fingers. Classical treatment was hitting it with a large book (the bible), though this had a high recurrence rate. Today, if it isn't bothering you, the best option is to leave it alone. If it's painful, restricts activity, or is unsightly, it can be aspirated (drawn out with a needle) or removed surgically. Aspiration has a high recurrence rate; removal also carries some risk of recurrence, though this is much less likely.

For more information: Ganglion Cyst.

Therapy is a core part of treating hand conditions, whether or not surgery is involved. Physiotherapists and occupational therapists support the non-operative, pre-, and post-operative management of most hand conditions. Any injury, surgery, or period of immobilisation, especially in the hand, can lead to stiffness, which can significantly affect a person's ability to function normally. For this reason, care is delivered as a team, involving the patient, surgeon, and therapists together.

Complex Regional Pain Syndrome (CRPS)

A poorly understood condition that affects the hand more commonly than other parts of the body, presenting as pain out of proportion to the original injury, sometimes following surgery or even a minor knock. The skin can take on a dull, mottled appearance, and normally non-painful contact, such as light stroking, can cause significant pain. Treatment centres on early, consistent therapy alongside medication, the sooner this starts, the better. Most cases resolve within about 18 months, though beyond 2 years the nervous system's response can become more difficult to reverse, which is why early, active treatment matters. Deep tissue massage, although intensely painful in the short term, doesn't cause any tissue damage, just as it wouldn't in someone without CRPS, and is one of the best ways to recover; patients can carry this out themselves. Protecting or avoiding use of the affected area tends to make outcomes worse, not better, and is much more likely to lead to long-term problems.

For more information: Complex Regional Pain Syndrome.

Wrist Arthroscopy

A surgical procedure used to both diagnose and treat wrist conditions, particularly useful when the diagnosis isn't clear from imaging alone. A small (2.7mm) fibre-optic scope is inserted through tiny incisions at the back of the wrist, allowing direct visualisation of the bones and soft tissues, often with treatment carried out at the same time, or the pathology identified for further discussion in clinic.

For more information: Wrist Arthroscopy.

Wrist Arthroplasty

An option for significant wrist arthritis where other treatments haven't helped, offering an alternative to wrist fusion. It's far less common than hip or knee replacement, and correspondingly less well studied, so its long-term longevity isn't as well established and at this point may be considered experimental. The main benefit is preserved range of motion; the trade-off is uncertainty about how long it will last. If it does fail, conversion to a fusion remains possible, though outcomes aren't quite as good as a fusion performed as the first procedure.

For more information: Wrist Arthroplasty.

Carpal Bones

Hook of Hamate Fracture
An uncommon bone to fracture, usually from repetitive impact rather than a single traumatic event, common in sports involving a bat or stick, such as baseball or hockey, and in New Zealand, cricket. It presents as pain at the base of the palm in line with the little finger, difficult to see on standard x-rays, a carpal tunnel view or CT scan is often needed. Treatment starts with stopping the causative activity; if that isn't possible or doesn't resolve it, the hook can be excised through a small incision in the palm.

Scaphoid Fracture
A very common fracture, typically resulting from a fall onto an outstretched hand. The scaphoid is particularly vulnerable since it spans from the proximal row of carpal bones across much of the distal row. Most common in young adults, it's uncommon in older people, whose weaker bones make a distal radius fracture more likely instead.

Bite Wounds

Fight bites are both common and can be particularly problematic. A simple tooth wound over the knuckle can become infected very quickly, and without early, aggressive treatment, can lead to multiple operations and significant morbidity.

For more information: Scaphoid Fracture, Finger Fractures, Hand Fractures, Distal Radius Fracture, Thumb Fractures, Human Bites.

Antibiotics are routinely given around the time of surgery. A total hip replacement also carries a risk of blood clots, and the right balance of preventive medication is chosen carefully, guided by the American Academy of Orthopaedic Surgeons' guideline on preventing thromboembolic disease in elective hip and knee arthroplasty. Warning signs of a clot, pain or swelling below the knee, or of a pulmonary embolus, chest pain or shortness of breath, should prompt immediate medical attention.

Pain is initially managed through an IV line, moving to oral medication before discharge, alongside stool softeners and anti-nausea medication as needed. Staying mobile both in and out of bed in the first few days is important for recovery, with guided in-bed exercises to help.

The average stay is 2–5 days, some people take a little longer, which is entirely normal. At home, small changes make a real difference, commonly used items within easy reach, clear walkways for a walker if needed, rugs and trip hazards removed, a higher chair with armrests, and a chair in the shower.

Driving generally isn't recommended until around 6 weeks, and sexual activity should also be avoided during this time. Sleeping is best done on your back with legs slightly apart, a pillow between them can help. Walking is encouraged as much as comfortable, along with swimming once the wound is dry (around 4 weeks) and cycling on a stationary bike. Follow-up appointments are typically at 2 weeks, 6 weeks, 6 months, and periodically thereafter. Most people are close to their best by 6 months, though some variation between individuals is entirely normal; pain persisting beyond a year is worth fully investigating.

Do: stay active; kneel on the operated leg if needed; keep your leg in front of you when getting up.

Don't: cross your legs at the knees; bend your hip past 90 degrees; sit on low chairs; pick things up off the floor; stop doing your exercises.

A replaced hip is a mechanical device, it's yours to use as you like, but it can wear out, and the more it's used, the sooner that happens. Modern plastic liners are far more durable than older versions, but no sport is generally recommended for the first 6 months, with a gradual, individual approach after that based on what you're hoping to get back to.