What is swelling?
Swelling is a common condition caused by increased fluid in the area e.g. a bruise, soft tissue thickening and bone enlargement. Swelling may come on suddenly such as following in injury or it may come on gradually over months to years.
Increased fluid in the area: The fluid can be diffuse such a bruise or fluid swelling around and in an arthritic joint or it can be quite localised such as cyst the most common being a ganglion (see information sheet). The body has well developed mechanisms to dissipate fluid collections but if there are continuing underlying problems then the swelling may not change or may even increase. The swelling tightens the tissue which can be uncomfortable but in particular causes stiffness. Possibly the most important time this swelling needs resolving is following injury particularly following swelling (see treatment below).
Soft tissue thickening: Soft tissue thickening builds up slowly either as a response to local irritation such as arthritis or due to a benign growth (see information sheet on solid lumps). Diffuse soft tissue swelling often never resolves fully. It can contribute to stiffness and a cosmetic abnormality. The swelling itself is usually not painful but the underlying cause may be. Benign growths often take a long time to cause problems greater then just being there but can do particularly Dupuytren's disease (see information sheets of solid lumps and on Dupuytren's).
Bone enlargement: Bone enlargement always takes a long time to develop unless it follows injury. It is typically associated with arthritis (see information sheet) but can be due to an underlying bony growth (see information sheet on solid lumps). The bone enlargement like soft tissue thickening is usually not painful but the underlying cause may be. It can however cause a reduced range of movement by blocking full straightening or bending.
The typical symptoms are of diffuse or localised swelling which may be associated with pain or stiffness. Swelling can present at any age from birth to late adulthood.
Considerable swelling due to neck arthritis
Why does it occur?
The pathology i.e. the abnormality is dependent on what is swollen as noted above
It can be due to almost all types of medical causes including congenital (at birth), developmental (occurring during growth), injury (trauma), infection, arthritis, tumours (typically benign but rarely sinister) and inflammatory e.g. rheumatoid arthritis.
What happens if nothing is done?
(This is referred to as the natural history i.e. what happens if Nature runs its own course). Some people's symptoms resolve especially if the underlying cause also settles. Some patients however progress and become increasingly intrusive.
Making the diagnosis
The Hand specialist who sees the patient will ask questions about their symptoms, when they started, how they progressed, what treatment (if any) they have had and other questions relevant to the problems. They will then examine the patient looking at the wrists and hands. Stressing i.e. pushing on the affected area is usually painful. It is necessary to demonstrate some tenderness to confirm the site of the symptoms but this should not be too painful.
What test(s) might be performed?
Tests (also known medically as Investigations) include X-rays, scans, blood tests and particularly in the hand electrical tests (known as EMGs or Neurophysiology). These may be used to help make or confirm a diagnosis after a patient has described their symptoms and been examined.
The diagnosis is usually obvious after listening to and examining a patient. Typically an X-ray is requested on the same day to delineate the extent of joint damage, although the X-ray findings do not correlate well with the symptoms with some patients having few X-ray changes but marked symptoms and vice versa.
Sometimes an MRI scan will be necessary to look at the soft tissue or a CT scan may be requested to delineate bone abnormalities.
An MRI scanner is usually a short tunnel which the patient's arms and top half of the body go into. Usually the arms are stretched out in a "superman" pose which is a little uncomfortable but generally well tolerated. Once in the tunnel a loud magnet is spun around and images of the bones and soft tissues created. Some people find the tunnel rather claustrophobic. If any patient doubts whether they would tolerate the scan they are best advised to visit the scanner department in advance. The films will be reported by a radiologist but also reviewed by the Hand specialist who will advise the patient accordingly.
A CT (or CAT) scanner is a short large open tunnel. The patient lies on a bed and passes through the tunnel whilst X-rays are shone from various directions at the area of the body being investigated. It is particularly useful for showing bone abnormalities but less good at investigating soft tissue problems. The films will be reported by a radiologist but also reviewed by the Hand specialist who will advise the patient accordingly.
X-ray Synovial cyst
What are the non-operative treatments?
Treatment should start with non-operative options. The first step is activity modification which the patient may well already have tried. Pain killers (analgesics) particularly anti-inflammatory analgesics, such as Ibuprofen (Nurofen) and Diclofenac (Voltarol) can be very helpful for pain if present. These can be applied as a gel, massaging the area, or taken orally, assuming there is no history of indigestion. A splint for certain activities can also be of value. Some patients find splints very helpful, other not at all. If these measures are insufficient then a steroid injection may be recommended depending on the underlying problem. An injection is given of a long-acting steroid, such as Depomedrone or Triamcinolone, with some local anaesthetic into the joint at the bottom of the thumb. The body naturally produces steroids to help dampen down inflammation. This appears to be one of the actions at this site. Success cannot be guaranteed but in 70-80% of patients there is some significant benefit. How long this lasts is unpredictable. Some people only have a few weeks or months of benefit. Others may have years or even life-long benefit such that they do not require further treatment, although may still have some mild on-going symptoms. If one injection provides only short term benefit then it may well be repeated. Patients often ask how many injections can be given. There is no set rule about this. Typically, however, a second injection will work a little less well than the first (although this is not inevitable). By the time three injections have been given, if this is over a shortish period, i.e. less than 1 year, then it is unlikely the third injection will be successful and most surgeons would recommend an alternative approach. If, however, injections are only required infrequently, perhaps once every 2-3 years, then having a fourth or fifth injection would, in themselves, be a lot safer than having an operation, and if they give benefit this is reasonable. There are risks. The biggest risk is of failure. There are risks of some pain for a few days, although that is usually minimised by taking pain-killers, starting while the area is still numb from the local anaesthetic. In theory there is a risk of infection, but this seems very rare and has not occurred in our Practice in over 10 years. The main other risk is some thinning of the skin. This can present with some pallor and a little less bulk at the site and occasionally an increased tendency to bleeding if the area is knocked. This is not common with this injection but is common with some other injections. If it does occur then that is a relative contra-indication to further injections, i.e. the patient's surgeon would probably decide not to go ahead with further injections because of the risks of further local damage.
What does the operation involve?
There are various operations depending upon the specific problem (see information sheets).
What happens in the next few weeks?
The care of the hand in the post-operative period is very important in helping to ensure a good result. Initially the aims are comfort and elevation. These are met by keeping the hand up (elevated) especially in the first few days and by use of a long acting local anaesthetic (Bupivicaine). The local anaesthetic lasts at least 12 hours and sometimes 48 hours. Patients should start taking painkillers before the pain starts i.e. on return home and for at least 24 hours from there. This way most of our patients report little or any pain.
Most of the movement gained following surgery occurs in the first 6 weeks and this time must be used productively to ensure a good result. The key is regular long gentle stretches both into straightening and into bending. Ideally these should be performed for 5 mins in each direction (feeling the stretch but without pain) once an hour. In practical terms most people mange 5-6 times a day. Elevation and icing also help reduce swelling and thus pain and improve movement.
Are there any risks?
All interventions in medicine have risks. In general the larger the operation the greater the risks. The risks depwnd upon the nature of the operation but in general they include:
- The scar may be tender, in about 20% of patients. This usually improves with scar massage, over 3 months.
- Aching at the site may last for several months
- Grip strength can also take some months to return to normal.
- Stiffness may occur in particular in the fingers. This is usually short-term and only infrequently requires physiotherapy. But it is very important that it is resolved quickly to avoid permanent stiffness. This occurs rarely but can do associated with CRPS (see below)
- Numbness can occur around the scar but this rarely causes any functional problems.
- Wound infections occur in about 1% of cases. These usually quickly resolve with antibiotics.
- Recurrent swelling and pain is reported but has never occurred in our practice.
- For joint replacement there is a risk of long-term joint replacement failure requiring reoperation.
- For joint fusion there is a risk of failure to achieve bone to bone union of to gain union with some malalignment. Either may (but not of necessity) require reoperation.
- Chronic Regional Pain Syndrome "CRPS". This is a rare but serious complication, with no known cause or proven treatment. The nerves in the hand "over-react", causing swelling, pain, discolouration and stiffness, which improve very slowly.
- Any operation can have unforeseen consequences and leave a patient worse than before surgery.