No matter how old you are or what you do for a living, you are always using your hands. When there is something wrong with them, you may not be able to do your regular activities.

Hand problems include

• Carpal tunnel syndrome - compression of a nerve as it goes through the wrist, often making your fingers feel numb
• Injuries that result in fractures, ruptured ligaments and dislocations
• Osteoarthritis - wear-and-tear arthritis, which can also cause deformity
• Tendinitis - irritation of the tendons
• Disorders and injuries of your fingers and thumb

The distal part of the arm beyond the wrist in humans and primates, that includes the palm, fingers, and thumb.

Carpal Bones

The wrist and base of the hand are formed by a series of eight small carpal bones (see Figure 8.7). The carpal bones are arranged in two rows, forming a proximal row of four carpal bones and a distal row of four carpal bones. The bones in the proximal row, running from the lateral (thumb) side to the medial side, are the scaphoid (“boat-shaped”), lunate (“moon-shaped”), triquetrum (“three-cornered”), and pisiform (“pea-shaped”) bones. The small, rounded pisiform bone articulates with the anterior surface of the triquetrum bone. The pisiform thus projects anteriorly, where it forms the bony bump that can be felt at the medial base of your hand. The distal bones (lateral to medial) are the trapezium (“table”), trapezoid (“resembles a table”), capitate (“head-shaped”), and hamate (“hooked bone”) bones. The hamate bone is characterized by a prominent bony extension on its anterior side called the hook of the hamate bone.

A helpful mnemonic for remembering the arrangement of the carpal bones is “So Long To Pinky, Here Comes The Thumb.” This mnemonic starts on the lateral side and names the proximal bones from lateral to medial (scaphoid, lunate, triquetrum, pisiform), then makes a U-turn to name the distal bones from medial to lateral (hamate, capitate, trapezoid, trapezium). Thus, it starts and finishes on the lateral side.

Figure 8.7 Bones of the Wrist and Hand The eight carpal bones form the base of the hand. These are arranged into proximal and distal rows of four bones each. The metacarpal bones form the palm of the hand. The thumb and fingers consist of the phalanx bones.

The carpal bones form the base of the hand. This can be seen in the radiograph (X-ray image) of the hand that shows the relationships of the hand bones to the skin creases of the hand (see Figure 8.8). Within the carpal bones, the four proximal bones are united to each other by ligaments to form a unit. Only three of these bones, the scaphoid, lunate, and triquetrum, contribute to the radiocarpal joint. The scaphoid and lunate bones articulate directly with the distal end of the radius, whereas the triquetrum bone articulates with a fibrocartilaginous pad that spans the radius and styloid process of the ulna. The distal end of the ulna thus does not directly articulate with any of the carpal bones.

The four distal carpal bones are also held together as a group by ligaments. The proximal and distal rows of carpal bones articulate with each other to form the midcarpal joint (see Figure 8.8). Together, the radiocarpal and midcarpal joints are responsible for all movements of the hand at the wrist. The distal carpal bones also articulate with the metacarpal bones of the hand.

Figure 8.8 Bones of the Hand This radiograph shows the position of the bones within the hand. Note the carpal bones that form the base of the hand. (credit: modification of work by Trace Meek)

In the articulated hand, the carpal bones form a U-shaped grouping. A strong ligament called the flexor retinaculum spans the top of this U-shaped area to maintain this grouping of the carpal bones. The flexor retinaculum is attached laterally to the trapezium and scaphoid bones, and medially to the hamate and pisiform bones. Together, the carpal bones and the flexor retinaculum form a passageway called the carpal tunnel, with the carpal bones forming the walls and floor, and the flexor retinaculum forming the roof of this space (Figure 8.9). The tendons of nine muscles of the anterior forearm and an important nerve pass through this narrow tunnel to enter the hand. Overuse of the muscle tendons or wrist injury can produce inflammation and swelling within this space. This produces compression of the nerve, resulting in carpal tunnel syndrome, which is characterized by pain or numbness, and muscle weakness in those areas of the hand supplied by this nerve.

Figure 8.9 Carpal Tunnel The carpal tunnel is the passageway by which nine muscle tendons and a major nerve enter the hand from the anterior forearm. The walls and floor of the carpal tunnel are formed by the U-shaped grouping of the carpal bones, and the roof is formed by the flexor retinaculum, a strong ligament that anteriorly unites the bones.

The palm of the hand contains five elongated metacarpal bones. These bones lie between the carpal bones of the wrist and the bones of the fingers and thumb (see Figure 8.7). The proximal end of each metacarpal bone articulates with one of the distal carpal bones. Each of these articulations is a carpometacarpal joint (see Figure 8.8). The expanded distal end of each metacarpal bone articulates at the metacarpophalangeal joint with the proximal phalanx bone of the thumb or one of the fingers. The distal end also forms the knuckles of the hand, at the base of the fingers. The metacarpal bones are numbered 1–5, beginning at the thumb.

The first metacarpal bone, at the base of the thumb, is separated from the other metacarpal bones. This allows it a freedom of motion that is independent of the other metacarpal bones, which is very important for thumb mobility. The remaining metacarpal bones are united together to form the palm of the hand. The second and third metacarpal bones are firmly anchored in place and are immobile. However, the fourth and fifth metacarpal bones have limited anterior-posterior mobility, a motion that is greater for the fifth bone. This mobility is important during power gripping with the hand (Figure 8.10). The anterior movement of these bones, particularly the fifth metacarpal bone, increases the strength of contact for the medial hand during gripping actions.

Figure 8.10 Hand During Gripping During tight gripping—compare (b) to (a)—the fourth and, particularly, the fifth metatarsal bones are pulled anteriorly. This increases the contact between the object and the medial side of the hand, thus improving the firmness of the grip.

The fingers and thumb contain 14 bones, each of which is called a phalanx bone (plural = phalanges), named after the ancient Greek phalanx (a rectangular block of soldiers). The thumb (pollex) is digit number 1 and has two phalanges, a proximal phalanx, and a distal phalanx bone (see Figure). Digits 2 (index finger) through 5 (little finger) have three phalanges each, called the proximal, middle, and distal phalanx bones. An interphalangeal joint is one of the articulations between adjacent phalanges of the digits (see Figure).

Bones of the Wrist and Hand

The eight carpal bones form the base of the hand. These are arranged into proximal and distal rows of four bones each. The metacarpal bones form the palm of the hand. The thumb and fingers consist of the phalanx bones.

Bones of the Hand

This radiograph shows the position of the bones within the hand. Note the carpal bones that form the base of the hand. (credit: modification of work by Trace Meek)

Muscles That Move the Wrist, Hand, and Fingers

Wrist, hand, and finger movements are facilitated by two groups of muscles. The forearm is the origin of the extrinsic muscles of the hand. The palm is the origin of the intrinsic muscles of the hand.

Muscles of the Arm That Move the Wrists, Hands, and Fingers

The muscles in the anterior compartment of the forearm (anterior flexor compartment of the forearm) originate on the humerus and insert onto different parts of the hand. These make up the bulk of the forearm. From lateral to medial, the superficial anterior compartment of the forearm includes the flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis. The flexor digitorum superficialis flexes the hand as well as the digits at the knuckles, which allows for rapid finger movements, as in typing or playing a musical instrument (see image and image). However, poor ergonomics can irritate the tendons of these muscles as they slide back and forth with the carpal tunnel of the anterior wrist and pinch the median nerve, which also travels through the tunnel, causing Carpal Tunnel Syndrome. The deep anterior compartment produces flexion and bends fingers to make a fist. These are the flexor pollicis longus and the flexor digitorum profundus.

The muscles in the superficial posterior compartment of the forearm (superficial posterior extensor compartment of the forearm) originate on the humerus. These are the extensor radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and the extensor carpi ulnaris.

The muscles of the deep posterior compartment of the forearm (deep posterior extensor compartment of the forearm) originate on the radius and ulna. These include the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis (see image).

The tendons of the forearm muscles attach to the wrist and extend into the hand. Fibrous bands called retinacula sheath the tendons at the wrist. The flexor retinaculum extends over the palmar surface of the hand while the extensor retinaculum extends over the dorsal surface of the hand.

Intrinsic Muscles of the Hand

The intrinsic muscles of the hand both originate and insert within it (image). These muscles allow your fingers to also make precise movements for actions, such as typing or writing. These muscles are divided into three groups. The thenar muscles are on the radial aspect of the palm. The hypothenar muscles are on the medial aspect of the palm, and the intermediate muscles are midpalmar.

The thenar muscles include the abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and the adductor pollicis. These muscles form the thenar eminence, the rounded contour of the base of the thumb, and all act on the thumb. The movements of the thumb play an integral role in most precise movements of the hand.

The hypothenar muscles include the abductor digiti minimi, flexor digiti minimi brevis, and the opponens digiti minimi. These muscles form the hypothenar eminence, the rounded contour of the little finger, and as such, they all act on the little finger. Finally, the intermediate muscles act on all the fingers and include the lumbrical, the palmar interossei, and the dorsal interossei.

At a saddle joint, both of the articulating surfaces for the bones have a saddle shape, which is concave in one direction and convex in the other (see Figure 9.10c). This allows the two bones to fit together like a rider sitting on a saddle. Saddle joints are functionally classified as biaxial joints. The primary example is the first carpometacarpal joint, between the trapezium (a carpal bone) and the first metacarpal bone at the base of the thumb. This joint provides the thumb the ability to move away from the palm of the hand along two planes. Thus, the thumb can move within the same plane as the palm of the hand, or it can jut out anteriorly, perpendicular to the palm. This movement of the first carpometacarpal joint is what gives humans their distinctive “opposable” thumbs. The sternoclavicular joint is also classified as a saddle joint.

Figure 9.10 Types of Synovial Joints The six types of synovial joints allow the body to move in a variety of ways. (a) Pivot joints allow for rotation around an axis, such as between the first and second cervical vertebrae, which allows for side-to-side rotation of the head. (b) The hinge joint of the elbow works like a door hinge. (c) The articulation between the trapezium carpal bone and the first metacarpal bone at the base of the thumb is a saddle joint. (d) Plane joints, such as those between the tarsal bones of the foot, allow for limited gliding movements between bones. (e) The radiocarpal joint of the wrist is a condyloid joint. (f) The hip and shoulder joints are the only ball-and-socket joints of the body.

The first digit on the radial side of the hand which in humans lies opposite the other four.

Figure 9.13 Movements of the Body, Part 2 (g) Supination of the forearm turns the hand to the palm forward position in which the radius and ulna are parallel, while forearm pronation turns the hand to the palm backward position in which the radius crosses over the ulna to form an "X." (h) Dorsiflexion of the foot at the ankle joint moves the top of the foot toward the leg, while plantar flexion lifts the heel and points the toes. (i) Eversion of the foot moves the bottom (sole) of the foot away from the midline of the body, while foot inversion faces the sole toward the midline. (j) Protraction of the mandible pushes the chin forward, and retraction pulls the chin back. (k) Depression of the mandible opens the mouth, while elevation closes it. (l) Opposition of the thumb brings the tip of the thumb into contact with the tip of the fingers of the same hand and reposition brings the thumb back next to the index finger.

Flexion and Extension

Flexion and extension are typically movements that take place within the sagittal plane and involve anterior or posterior movements of the neck, trunk, or limbs. For the vertebral column, flexion (anterior flexion) is an anterior (forward) bending of the neck or trunk, while extension involves a posterior-directed motion, such as straightening from a flexed position or bending backward. Lateral flexion of the vertebral column occurs in the coronal plane and is defined as the bending of the neck or trunk toward the right or left side.. These movements of the vertebral column involve both the symphysis joint formed by each intervertebral disc, as well as the plane type of synovial joint formed between the inferior articular processes of one vertebra and the superior articular processes of the next lower vertebra.

In the limbs, flexion decreases the angle between the bones (bending of the joint), while extension increases the angle and straightens the joint. For the upper limb, all anterior-going motions are flexion and all posterior-going motions are extension. These include anterior-posterior movements of the arm at the shoulder, the forearm at the elbow, the hand at the wrist, and the fingers at the metacarpophalangeal and interphalangeal joints. For the thumb, extension moves the thumb away from the palm of the hand, within the same plane as the palm, while flexion brings the thumb back against the index finger or into the palm. These motions take place at the first carpometacarpal joint. In the lower limb, bringing the thigh forward and upward is flexion at the hip joint, while any posterior-going motion of the thigh is extension. Note that extension of the thigh beyond the anatomical (standing) position is greatly limited by the ligaments that support the hip joint. Knee flexion is the bending of the knee to bring the foot toward the posterior thigh, and extension is the straightening of the knee. Flexion and extension movements are seen at the hinge, condyloid, saddle, and ball-and-socket joints of the limbs.

Hyperextension is the abnormal or excessive extension of a joint beyond its normal range of motion, thus resulting in injury. Similarly, hyperflexion is excessive flexion at a joint. Hyperextension injuries are common at hinge joints such as the knee or elbow. In cases of “whiplash” in which the head is suddenly moved backward and then forward, a patient may experience both hyperextension and hyperflexion of the cervical region.

Abduction and Adduction

Abduction and adduction motions occur within the coronal plane and involve medial-lateral motions of the limbs, fingers, toes, or thumb. Abduction moves the limb laterally away from the midline of the body, while adduction is the opposing movement that brings the limb toward the body or across the midline. For example, abduction is raising the arm at the shoulder joint, moving it laterally away from the body, while adduction brings the arm down to the side of the body. Similarly, abduction and adduction at the wrist moves the hand away from or toward the midline of the body. Spreading the fingers or toes apart is also abduction, while bringing the fingers or toes together is adduction. For the thumb, abduction is the anterior movement that brings the thumb to a 90° perpendicular position, pointing straight out from the palm. Adduction moves the thumb back to the anatomical position, next to the index finger. Abduction and adduction movements are seen at condyloid, saddle, and ball-and-socket joints.

Opposition and Reposition

Opposition is the thumb movement that brings the tip of the thumb in contact with the tip of a finger. This movement is produced at the first carpometacarpal joint, which is a saddle joint formed between the trapezium carpal bone and the first metacarpal bone. Thumb opposition is produced by a combination of flexion and abduction of the thumb at this joint. Returning the thumb to its anatomical position next to the index finger is called reposition.

Movements of the Joints

You're working at your desk, trying to ignore the tingling or numbness you've had for some time in your hand and wrist. Suddenly, a sharp, piercing pain shoots through the wrist and up your arm. Just a passing cramp? It could be carpal tunnel syndrome.

The carpal tunnel is a narrow passageway of ligament and bones at the base of your hand. It contains nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the nerve to be compressed. Symptoms usually start gradually. As they worsen, grasping objects can become difficult.

Often, the cause is having a smaller carpal tunnel than other people do. Other causes include performing assembly line work, wrist injury, or swelling due to certain diseases, such as rheumatoid arthritis. Women are three times more likely to have carpal tunnel syndrome than men.

Early diagnosis and treatment are important to prevent permanent nerve damage. Your doctor diagnoses carpal tunnel syndrome with a physical exam and special nerve tests. Treatment includes resting your hand, splints, pain and anti-inflammatory medicines, and sometimes surgery.

Carpal tunnel syndrome (CTS) occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. The carpal tunnel—a narrow, rigid passageway of ligament and bones at the base of the hand—houses the median nerve and the tendons that bend the fingers. The median nerve provides feeling to the palm side of the thumb and to the index, middle, and part of the ring fingers (although not the little finger). It also controls some small muscles at the base of the thumb.

Sometimes, thickening from the lining of irritated tendons or other swelling narrows the tunnel and compresses the median nerve. The result may be numbness, weakness, or sometimes pain in the hand and wrist (some people may feel pain in the forearm and arm). CTS is the most common and widely known of the entrapment neuropathies, in which one of the body’s peripheral nerves is pressed on or squeezed.

What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes pressed or squeezed at the wrist. The carpal tunnel is a narrow, rigid passageway of ligament and bones at the base of the hand that houses the median nerve and the tendons that bend the fingers. The median nerve provides feeling to the palm side of the thumb and to most of the fingers. Symptoms usually start gradually, with numbness, tingling, hand weakness, and sometimes pain in the hand and wrist. CTS makes it difficult for some people to drive, read a book, grasp small objects, or do other tasks. Sometimes no direct cause of CTS can be found; contributing factors include trauma or injury to the wrist that causes swelling, as well as thyroid disease, rheumatoid arthritis, and fluid retention during pregnancy. Women are three times more likely than men to develop carpal tunnel syndrome. The disorder usually occurs only in adults.

Is there any treatment?

Initial treatment generally involves wearing a splint at night to keep the wrist from bending, over-the-counter and prescription drugs including non-steroidal anti-inflammatory drugs to temporarily reduce swelling and ease pain, and injections of corticosteroid drugs (such as prednisone). For more severe cases, surgery may be recommended. Underlying causes such as diabetes or arthritis should be treated first. Alternative therapies such as yoga can reduce pain and improve grip strength in some people with CTS.

What is the prognosis?

In general, carpal tunnel syndrome responds well to treatment, but less than half of individuals report their hand(s) feeling completely normal following surgery. Some residual numbness or weakness is common. Most people may need to modify work activity for several weeks following surgery. Stretching exercises, taking frequent rest breaks, wearing splints to keep wrists straight, and using correct posture and wrist position can help prevent or worsen symptoms. Making changes in the workplace may help but may not prevent the occurrence of carpal tunnel syndrome.

You use your fingers and thumbs to do everything from grasping objects to playing musical instruments to typing. When there is something wrong with them, it can make life difficult. Common problems include

• Injuries that result in fractures, ruptured ligaments and dislocations
• Osteoarthritis - wear-and-tear arthritis. It can also cause deformity.
• Tendinitis - irritation of the tendons
• Dupuytren's contracture - a hereditary thickening of the tough tissue that lies just below the skin of your palm. It causes the fingers to stiffen and bend.
• Trigger finger - an irritation of the sheath that surrounds the flexor tendons. It can cause the tendon to catch and release like a trigger.

Your toenails and fingernails protect the tissues of your toes and fingers. They are made up of layers of a hardened protein called keratin, which is also in your hair and skin. The health of your nails can be a clue to your overall health. Healthy nails are usually smooth and consistent in color. Specific types of nail discoloration and changes in growth rate can be signs of lung, heart, kidney, and liver diseases, as well as diabetes and anemia. White spots and vertical ridges are harmless.

Nail problems that sometimes require treatment include

• Bacterial and fungal infections
• Ingrown nails
• Tumors
• Warts

Keeping your nails clean, dry, and trimmed can help you avoid some problems. Do not remove the cuticle, which can cause infection.

General or unspecified injuries involving the fingers.

Raynaud's disease is a rare disorder of the blood vessels, usually in the fingers and toes. It causes the blood vessels to narrow when you are cold or feeling stressed. When this happens, blood can't get to the surface of the skin and the affected areas turn white and blue. When the blood flow returns, the skin turns red and throbs or tingles. In severe cases, loss of blood flow can cause sores or tissue death.

Primary Raynaud's happens on its own. The cause is not known. There is also secondary Raynaud's, which is caused by injuries, other diseases, or certain medicines.

People in colder climates are more likely to develop Raynaud's. It is also more common in women, people with a family history, and those over age 30.

Treatment for Raynaud's may include drugs to keep the blood vessels open. There are also simple things you can do yourself, such as

• Soaking hands in warm water at the first sign of an attack
• Keeping your hands and feet warm in cold weather
• Avoiding triggers, such as certain medicines and stress

Raynaud's is a rare disorder that affects the arteries. Arteries are blood vessels that carry blood from your heart to different parts of your body.

Raynaud's sometimes is called a disease, syndrome, or phenomenon. The disorder is marked by brief episodes of vasospasm (VA-so-spazm), which is a narrowing of the blood vessels.

Vasospasm of the arteries reduces blood flow to the fingers and toes. In people who have Raynaud's, the disorder usually affects the fingers. In about 40 percent of people who have Raynaud's, it affects the toes. Rarely, the disorder affects the nose, ears, nipples, and lips.

Overview

There are two main types of Raynaud’s—primary and secondary.

In primary Raynaud’s (also called Raynaud’s disease), the cause isn't known. Primary Raynaud's is more common and tends to be less severe than secondary Raynaud's.

Secondary Raynaud’s is caused by an underlying disease, condition, or other factor. This type of Raynaud's is often called Raynaud's phenomenon.

If you have primary or secondary Raynaud's, cold temperatures or stress can trigger "Raynaud's attacks." During an attack, little or no blood flows to affected body parts.

As a result, the skin may turn white and then blue for a short time. As blood flow returns, the affected areas may turn red and throb, tingle, burn, or feel numb.

In both types of Raynaud's, even mild or brief changes in temperature can cause Raynaud's attacks. For example, taking something out of the freezer or being exposed to temperatures below 60 degrees Fahrenheit can cause your fingers to turn blue.

Most people who have Raynaud's have no long-term tissue damage or disability. However, people who have severe Raynaud's can develop skin sores or gangrene from prolonged or repeated Raynaud's attacks. "Gangrene" refers to the death or decay of body tissues.

Outlook

About 5 percent of the U.S. population has Raynaud's. For most people who have primary Raynaud's, the disorder is more of a bother than a serious illness. They usually can manage the condition with minor lifestyle changes.

Secondary Raynaud's may be harder to manage. However, several treatments are available to help prevent or relieve symptoms. With secondary Raynaud's, it's important to treat the underlying disease or condition that's causing it.

Researchers continue to look for better ways to diagnose and treat Raynaud's.

Raynaud’s phenomenon is a condition that causes the blood vessels in the extremities to narrow, restricting blood flow. The episodes or “attacks” usually affect the fingers and toes. In rare cases, attacks occur in other areas such as the ears or nose. An attack usually happens from exposure to cold or emotional stress.

There are two types of Raynaud’s phenomenon—primary and secondary. The primary form has no known cause, but the secondary form is related to another health issue, especially autoimmune diseases like lupus or scleroderma. The secondary form tends to be more serious and to need more aggressive treatment.

In most people, lifestyle changes such as staying warm keep symptoms under control, but in severe cases, repeated attacks lead to skin sores or gangrene (death and decay of tissue). The treatment depends on how serious the condition is and whether it is the primary or secondary form.

Who Gets Raynaud’s Phenomenon?

Anyone can get Raynaud’s phenomenon, but some people are more likely to have it than others. There are two types and the risk factors for each are different.

The primary form of Raynaud’s phenomenon, which is of unknown cause, has been linked to:

• Sex. Women get it more often than men.
• Age. It usually occurs in people younger than age 30 and often starts in the teenage years.
• Family history of Raynaud’s phenomenon. People with a family member who has Raynaud’s phenomenon have a higher risk of getting it themselves, suggesting a genetic link.

The secondary form of Raynaud’s phenomenon occurs in combination with another disease or an environmental exposure. Factors that have been linked to secondary Raynaud’s phenomenon include:

• Diseases. Among the most common ones are lupus, scleroderma, inflammatory myositis, rheumatoid arthritis, and Sjögren’s syndrome. Conditions such as certain thyroid disorders, clotting disorders, and carpal tunnel syndrome have also been linked to the secondary form.
• Medications. Medications used to treat high blood pressure, migraines, or attention-deficit/hyperactivity disorder may cause symptoms similar to Raynaud’s phenomenon or make underlying Raynaud’s phenomenon worse.
• Work-related exposures. Repeated use of vibrating machinery (such as a jackhammer), or exposure to cold or certain chemicals.

Types of Raynaud’s Phenomenon

There are two types of Raynaud’s phenomenon.

• Primary Raynaud's phenomenon has no known cause. It is the more common form of the condition.
• Secondary Raynaud's phenomenon is associated with another problem, such as a rheumatic disease like lupus or scleroderma. Factors such as exposure to cold or certain chemicals may also underlie this form. The secondary form is less common but typically more serious than the primary form due to damage that occurs to the blood vessels.

Symptoms of Raynaud’s Phenomenon

Raynaud’s phenomenon happens when episodes or “attacks” affect certain parts of the body, especially the fingers and toes, causing them to become cold and numb, and change colors. Exposure to cold is the most common trigger, such as grabbing hold of a glass of ice water or taking something out of the freezer. Sudden changes in ambient temperature, such as when entering an air-conditioned supermarket on a warm day, can lead to an attack.

Emotional stress, cigarette smoking, and vaping can also trigger symptoms. Parts of the body besides the fingers and toes, such as the ears or nose may be affected as well.

Raynaud’s attacks. A typical attack progresses as follows:

• The skin of the affected part of the body turns pale or white due to lack of blood flow.
• The area then turns blue and feels cold and numb, as the blood that is left in the tissue loses its oxygen.
• Finally, as you warm up and circulation returns, the area turns red and may swell, tingle, burn, or throb.

Only one finger or toe may be affected at first; then, it may move to other fingers and toes. The thumbs are less likely to be affected than the other fingers. An attack may last a few minutes or a few hours, and the pain associated with each episode can vary.

Skin ulcers and gangrene. People with severe Raynaud’s phenomenon can develop small, painful sores, especially at the tips of the fingers or toes. In rare cases, an extended episode (days) of a lack of oxygen to tissues can lead to gangrene (cellular death and decay of body tissues).

For many people, especially those with the primary form of Raynaud’s phenomenon, the symptoms are mild and not highly troublesome. People with the secondary form tend to have more severe symptoms.

Causes of Raynaud’s Phenomenon

Scientists do not know exactly why Raynaud’s phenomenon develops in some people, but they do understand how attacks happen. When a person is exposed to cold, the body tries to slow the loss of heat and maintain its temperature. To do so, blood vessels in the surface layer of the skin constrict (narrow), moving blood from vessels near the surface to those deeper in the body.

In people with Raynaud’s phenomenon, blood vessels in the hands and feet react to cold or stress, narrowing quickly and staying constricted for a long period. This causes the skin to turn pale or white, then bluish as the blood left in the vessels becomes depleted of oxygen. Eventually, when you warm up and the vessels expand again, the skin flushes and may tingle or burn.

Many factors, including nerve and hormonal signals, control blood flow in skin, and Raynaud’s phenomenon happens when this complex system gets disrupted. Emotional stress releases signaling molecules that cause blood vessels to narrow, which is why anxiety can trigger an attack.

More women than men are affected by primary Raynaud’s phenomenon, suggesting that estrogen may play a role in this form. Genes may also be involved: The risk of the condition is higher in people with a relative who has it, but the specific genetic factors have not yet been definitively identified.

In secondary Raynaud’s phenomenon, damage to the blood vessels from certain diseases, such as lupus or scleroderma, or work-related exposures likely underlies the condition.

Diagnosis of Raynaud’s Phenomenon

There is no single test to diagnose Raynaud’s phenomenon. Doctors usually diagnose it based on symptoms, in particular, on a description of a typical attack upon exposure to cold. Your doctor will likely also take a medical history and perform a physical exam.

Your doctor may perform additional tests to distinguish between the two forms of the condition. These include:

• Nailfold capillary microscopy. During this test your doctor uses a magnifier to look at the base of your fingernails for signs of changes in capillaries (extremely small blood vessels), a sign of secondary Raynaud’s phenomenon.
• Blood tests. If your doctor suspects that you have the secondary form, they may order blood tests that may indicate you have a disease that has been linked to Raynaud’s phenomenon, such as lupus or scleroderma. One of the more common of these tests is the antinuclear antibody (ANA) test.

Treatment of Raynaud’s Phenomenon

The goals of treatment for Raynaud’s phenomenon are to:

• Reduce how many attacks you have.
• Make attacks less severe.
• Prevent tissue damage.

For most people with Raynaud’s phenomenon, avoiding getting cold prevents attacks and keeps symptoms under control. But if this is not enough, medications and, in some cases, surgical procedures can help.

Secondary Raynaud’s phenomenon is more likely to be serious and to need more aggressive therapy. If you have the secondary form, you may need to seek treatment for an underlying condition, if you have not already done so.

Preventing Attacks

• Medications. While there are no medications approved by the U.S. Food and Drug Administration for Raynaud’s phenomenon, medications that have been approved for other conditions are routinely used to treat it.
• Surgery. If you have severe Raynaud’s phenomenon, your doctor may recommend a procedure called a sympathectomy to destroy the nerves that trigger blood vessel narrowing in the affected areas. This is usually done by incision or injections. The procedure often relieves symptoms, but it may need to be repeated after a few years.

Treating Tissue Damage

In serious cases, repeated attacks can lead to skin sores or gangrene (death and decay of tissue). If this happens, you may need to be admitted to the hospital for a few days and receive intravenous medications to rapidly improve blood flow and to treat infection. In rare cases, you may need surgery to remove dead tissue.

Who Treats Raynaud’s Phenomenon?

Raynaud’s phenomenon is primarily treated by:

• Rheumatologists, doctors who treat diseases of the joints, muscles, and bones. Rheumatologists are also specialists in autoimmune diseases. They treat Raynaud’s phenomenon because it sometimes occurs in association with rheumatic diseases, like lupus.

Other specialists who may be involved in your care include:

• Cardiologists, who specialize in treating heart and blood vessel problems.
• Dermatologists, who specialize in conditions of the skin, hair, and nails.
• Mental health professionals, who can help people cope with difficulties in the home and workplace that may result from their medical conditions.
• Primary care doctors, such as family physicians or internal medicine specialists, who coordinate care between the different health care providers and treat other problems as they arise.
• Surgeons, including hand specialists, who may be orthopaedists, plastic surgeons, or vascular surgeons.

Living With Raynaud’s Phenomenon

In most people, Raynaud’s phenomenon can be controlled by making lifestyle changes. The following tips can decrease the number and severity of attacks you have.

• Keep warm. Keeping your hands and feet, as well as your entire body, warm is important. It is often not enough to keep your hands and feet warm and you need to keep your “core body” (chest, abdomen, and head) warm, too.
  • If it is cold outside, try not to go out.
  • If you go out when it is cold, dress warmly, wearing several layers of clothing. Be sure to use a hat or hood, because you lose a lot of body heat through your head. Consider heated gloves or hand warmers.
  • Protect your hands with gloves when you handle cold or frozen items.
  • Bring a sweater or jacket if you go to an indoor setting that may be air-conditioned.

• If you smoke, talk to your doctor about making a plan to quit. Nicotine in cigarettes and some vaping solutions can cause blood vessels to narrow, increasing the chance of an attack. Smoking also may cause permanent damage to blood vessels, which is particularly dangerous for people with Raynaud’s phenomenon.
• Some medications can bring on attacks, so talk to your doctor about those you take and before starting any new ones. Medications that can bring on attacks include:
  • Decongestants that contain phenylephrine or pseudoephedrine.
  • Appetite suppressants that contain pseudoephedrine.
  • Beta blockers for high blood pressure.
  • Migraine medications that contain ergotamine.
  • Certain stimulant medications, such as methylphenidate, for attention deficit-hyperactivity disorder.
• Act quickly to end an attack. If an attack occurs, place your hands or feet in a warm place, such as under warm (not hot) water or under a heating pad. You can also warm your hands by whirling your arms in a windmill pattern or placing them under your armpits.
• Cope with stress. Because stress can bring on an attack, learning how to manage it is important. Meditation, deep breathing, or other relaxation techniques may help. Seek help from a mental health professional if these approaches do not work and you continue to experience high stress levels.

Remember to visit your health care providers regularly and to follow their recommendations.

Some of the more common types of wrist injuries and disorders are

• Carpal tunnel syndrome, which happens when a nerve that runs from your forearm into your palm becomes squeezed at the wrist
• Ganglion cysts, which are noncancerous lumps or masses
• Gout, which is a form of arthritis caused by a buildup of uric acid in your joints
• Fractures (broken bones)
• Osteoarthritis, the most common type of arthritis. It is caused by wear and tear of the joints.
• Sprains and strains, which are injuries to ligaments and injuries to muscles or tendons
• Tendinitis, inflammation of a tendon, usually due to overuse

Dupuytren contracture is characterized by a deformity of the hand in which the joints of one or more fingers cannot be fully straightened (extended); their mobility is limited to a range of bent (flexed) positions. The condition is a disorder of connective tissue, which supports the body's muscles, joints, organs, and skin and provides strength and flexibility to structures throughout the body. In particular, Dupuytren contracture results from shortening and thickening of connective tissues in the hand, including fat and bands of fibrous tissue called fascia; the skin is also involved.

In men, Dupuytren contracture most often occurs after age 50. In women, it tends to appear later and be less severe. However, Dupuytren contracture can occur at any time of life, including childhood. The disorder can make it more difficult or impossible for affected individuals to perform manual tasks such as preparing food, writing, or playing musical instruments.

Dupuytren contracture often first occurs in only one hand, affecting the right hand twice as often as the left. About 80 percent of affected individuals eventually develop features of the condition in both hands.

Dupuytren contracture typically first appears as one or more small hard nodules that can be seen and felt under the skin of the palm. In some affected individuals the nodules remain the only sign of the disorder, and occasionally even go away without treatment, but in most cases the condition gradually gets worse. Over months or years, tight bands of tissue called cords develop. These cords gradually draw the affected fingers downward so that they curl toward the palm. As the condition worsens, it becomes difficult or impossible to extend the affected fingers. The fourth (ring) finger is most often involved, followed by the fifth (little), third (middle), and second (index) fingers. Occasionally the thumb is involved. The condition is also known as Dupuytren disease, and "Dupuytren contracture" most accurately refers to later stages when finger mobility is affected; however, the term is also commonly used as a general name for the condition.

About one-quarter of people with Dupuytren contracture experience uncomfortable inflammation or sensations of tenderness, burning, or itching in the affected hand. They may also feel pressure or tension, especially when attempting to straighten affected joints.

People with Dupuytren contracture are at increased risk of developing other disorders in which similar connective tissue abnormalities affect other parts of the body. These include Garrod pads, which are nodules that develop on the knuckles; Ledderhose disease, also called plantar fibromatosis, which affects the feet; scar tissue in the shoulder that causes pain and stiffness (adhesive capsulitis or frozen shoulder); and, in males, Peyronie disease, which causes abnormal curvature of the penis.

Metacarpal fractures account for 40% of all hand fractures. A Boxer’s fracture is a fracture of the fifth metacarpal neck, named for the classic mechanism of injury in which direct trauma is applied to a clenched fist.  This represents 10% of all hand fractures. Treatment for a Boxer’s fracture varies based on whether the fracture is open or closed, characteristics of the fracture including the degree of angulation, shortening, and rotation, and other concomitant injuries. Immobilization with an ulnar gutter splint may be the definitive treatment for closed, non-displaced fractures without angulation or rotation, while open fractures, significantly angulated or malrotated fractures or those involving injury to neurovascular structures may require operative fixation.

Treatment / Management

The appropriate treatment for a Boxer’s fracture on initial presentation varies based on whether the fracture is open or closed, the degree of angulation, rotation, and other concomitant injuries. Due to the risk of infection from "fight bite," even very small wounds should be thoroughly irrigated, and there should be a low threshold for antibiotic treatment.

Immobilization Alone

For a Boxer’s fracture that is closed, not angulated, and not malrotated or otherwise displaced, splinting is used for initial immobilization. A Boxer’s fracture should be immobilized with an ulnar gutter splint. Alternatively, a pre-made Galveston splint or a custom orthosis may be used.

The hand should be positioned in the intrinsic plus position for splinting: mild wrist extension, 70 to 90 degrees of flexion at MCP joint, and slight flexion at the DIP and PIP joints. Flexion of these joints is important to prevent shortening of the collateral ligaments and subsequent loss of range of motion and functional impairment.

Closed Reduction

Closed reduction is required for a Boxer’s fracture with significant angulation greater than 30 degrees.

Analgesia options for the procedure include a hematoma block or an ulnar nerve block. Younger children or very anxious patients may require procedural sedation, but this procedure typically is tolerated well without sedation.

Closed reduction of a Boxer’s fracture is accomplished by using the “90-90 method.” The MCP, DIP, and PIP joints should all be flexed to 90 degrees. The clinician should then apply volar pressure over the dorsal aspect of the fracture site while applying pressure axially to the flexed PIP joint. This axial pressure to the PIP applies dorsal force to the distal fracture fragment. The clinician should be able to feel the reduction when it has been achieved. The injury should be immobilized with an ulnar gutter splint, and post-reduction films should be taken to assess for adequate reduction. The fifth metacarpal neck can tolerate angulation of up to 50-60 degrees and management may be continued non-operatively if remains within the acceptable tolerances.

Surgical Referral

Surgical referral is indicated for fractures that are open, severely comminuted, associated with neurovascular injury, and for fractures with any malrotation. Surgical referral is also appropriate for fractures with significant angulation if the initial provider is unsuccessful in achieving adequate reduction and alignment outside acceptable parameters.  Surgical options include open reduction internal fixation, or closed reduction percutaneous pinning. 

Follow-Up

Boxer’s fractures should be sent for repeat radiographs within one week to assess alignment. Radiographs should be obtained every two weeks following, until clinical and radiographic healing are present, typically between four to six weeks. Even with the adequate reduction, some cosmetic deformity may persist, with loss of the normal knuckle contour. After a short period of immobilization, the passive and active range of motion exercises should be performed to alleviate stiffness of the MCP and PIP joints. Literature supports early mobilization of these injuries rather than prolonged immobilization. If any loss of function persists after several weeks of these exercises, referral to occupational therapy is warranted.