BRITISH BROADCASTING CORPORATION
RADIO FOUR
CHECK UP Programme No. 5 - Hands
TX. DATE: 20TH DECEMBER 2007 1500-1530
PRESENTER: BARBARA MYERS
CONTRIBUTORS: MR RUPERT ECKERSLEY
PRODUCER: BETH EASTWOOD
NOT CHECKED AS BROADCAST
MYERS
Hello. It's only when you can't do up buttons or open a jar that you realise just how much we depend on our nimble fingers and strong flexible hands. Arthritis of the hands can severely restrict our manual dexterity but so too can other hand conditions, such as carpel tunnel syndrome, that's where the nerve of the hand gets trapped at the wrist, it causes pins and needles, numbness and muscular weakness. Trigger finger is another common complaint in which a finger gets stuck in a bent position. While physiotherapy and splinting to rest the hand may help some people but for others surgery may be the only answer.
For advice about your treatment options I'm pleased to welcome into the Check Up studio today Mr Rupert Eckersley, he's a hand surgeon specialist at the Chelsea and Westminster Hospital in London. And we're not short of calls for him, the first on the line is Lucy and she's in Leicestershire, I think complaining about arthritis in both hands. Painful, swollen?
LUCY
Well they swell up, the joints of my fingers swell up but is it arthritis? I can't clench my fingers properly when they are swollen and it seems to abate a bit, it's not painful just uncomfortable.
MYERS
And how long have you had this?
LUCY
Oh months - a few months. But I'm not that old - I'm only - well I haven't reached 40 yet.
MYERS
You're not that old, let's put you over to our expert. Rupert, I mean we obviously can't do a diagnosis over the air but on the other hand is this symptomatic of arthritis of the hand?
ECKERSLEY
It can be symptomatic of arthritis in the hands and it's important to recognise that arthritis may start very slowly and then gradually progress with time. This is in both hands?
LUCY
It is yes, middle fingers - middle and ring fingers.
ECKERSLEY
Middle and ring fingers...
LUCY
Do you put up with or do you do something about it?
ECKERSLEY
I think it's probably important to go and at least discuss it with your general practitioner because if it was, for example, an arthritis - a rheumatoid type arthritis - then it's a good idea to have that diagnosis made and receive the appropriate treatment quickly. Now it's more likely than not that that's not the case for you and it's simply a question of checking that.
MYERS
You're making the distinction, if I may say there, between rheumatoid arthritis and osteoarthritis - is that based on perhaps the age?
ECKERSLEY
I think age is important, as you've said you're young, and the rheumatoid arthritis tends to affect - does affect women in middle to young age rather than in older age when you tend to see more of the osteoarthritis. So I think that's why we distinguish that, that's how our thinking progresses along those lines.
LUCY
So can you do anything about either?
ECKERSLEY
Yes definitely. If you have a diagnosis of a rheumatoid arthritis then the modern drug treatment is extremely effective now in controlling the disease and in fact from a surgical perspective we see perhaps fewer and fewer people now for surgery for rheumatoid because the medical treatment is so good. And to some extent the same applies with the osteoarthritis, that if you receive appropriate treatment for that you may well negate the need for surgical treatment, though of course it's an option at the end of the day.
MYERS
But either way advice to Lucy then - go and at least get a diagnosis?
ECKERSLEY
Yeah I would certainly go and seek some advice, at least go and see your GP and allow him to see the hands, do any appropriate tests that he thinks is important.
MYERS
Thank you Lucy. We'll move to Cambridge and Jean and I hope she won't mind me saying but is in the older age group wondering whether her symptoms are arthritis - in the hands again - and possibly osteoarthritis in this case, tell us a little bit about your symptoms Jean.
JEAN
Well I get pain in the base of my thumb, it's been like this for about two or three years when I do certain movements like grasping, twisting and lifting heavy objects. And it appears to be slightly swollen and it's certainly restricted the stretch of my hands which is frustrating for playing the piano. I'm told it's arthritis and the only thing to do is to rest it, which as I say is frustrating as my enthusiasm includes making sculptures, playing the piano and lots of gardening.
MYERS
Well let's ask Rupert in that case, is the only option to rest arthritic joints if that's what it is - osteoarthritic - wear and tear arthritis?
ECKERSLEY
It sounds very much like an osteoarthritis at the base of the thumb, which is a very common place for people to get arthritis in the hand. And it's certainly - rest is important if a joint is acutely inflamed but if you're having persisting problems then it's important to recognise actually there are other treatments that can be given to you, not just obviously drug treatments for relief of pain. But I work very closely with my hand therapy colleagues who see a lot of patients with arthritis at the base of the thumb and can provide very good support with splints, both rigid splints and soft splints, which allow you to support the hand whilst doing your activity.
MYERS
Including playing the piano?
ECKERSLEY
Perhaps playing the piano might be difficult, I think one of the problems when you develop arthritis at the base of the thumb is you do lose some of the movement at the base of the thumb and clearly that is difficult then with activities such as playing the piano and there probably isn't anything that can restore that completely, unfortunately. But I certainly think you should certainly be able to seek advise from a therapist who specialises in hand conditions. And ultimately if things are painful there are other treatments - you can, for example, inject cortisone into this joint, one of the few joints where you get a very good response from the point of view of relieving pain. So I think it's important perhaps that you don't just take rest as the only solution, it's not the only solution. And I think the other thing is that you shouldn't necessarily think that it will inexorably progress and become worse and worse with time, that may not necessarily be the case.
MYERS
Jean, thank you for that, good luck with seeking treatment for your hands and getting back to the piano all being well. Let's move though to June, our next caller, and June's got something growing at the base of her thumb, can you tell us a bit more about it June?
JUNE
Yes it's a ganglion, I got it about four or five years ago when I was doing a lot of digging and shovelling in the garden.
MYERS
And what's it look like or feel like?
JUNE
Well it's a large lump basically that's sort of come out at the base of my thumb, in the wrist.
MYERS
And have you had any treatment for it?
JUNE
No I went to see my GP and he said really there was nothing that could be done for it, just to live with it but it can be extremely painful at times when I'm trying to lift things or grab things or - movements with my wrist.
MYERS
Well you've got an expert here to advise you, I mean perhaps you would advise all of us in the first place, if you would Rupert, about these ganglia - these growths - what are they?
ECKERSLEY
A ganglion is a completely benign cystic swelling and they occur in two age groups, as it were, they occur in the young adult population and then as we get older and our joints get a bit more worn and torn they can also be associated with that. Now inside the ganglion is a very sort of clear thick viscous material, which is a normal bodily fluid but it's lost all its water, hence it is almost like clear toothpaste or petroleum jelly. Now I think most ganglions themselves are sort of painless lumps and tend to cause problems if they get in the way and it may be that the pain that you're feeling may be more associated possibly with arthritis underlying it which again ...
JUNE
I do have arthritis at the base of my thumb as well.
ECKERSLEY
And I would think that the treatment should be aimed at not only the ganglion but also the arthritis in your thumb and I think it would be perfectly reasonable for you to seek attention - again as I mentioned to Jean in the previous call to see a hand therapist. But ganglions can be dealt with certainly surgically, you can aspirate a ganglion where you put a needle in and you suck the fluid out but generally they come back quite quickly so it's not something I particularly favour but it's an interesting way of finding out whether by doing that you relief the pain that you have.
JUNE
Because originally I was able to sort of squeeze it back in.
ECKERSLEY
Yeah so it's gradually got bigger with time.
JUNE
It's got bigger and harder yes, I can't sort of push it back in as I used to be able to do.
ECKERSLEY
No, and I think that's again a common situation where a ganglion starts as a small relatively soft and then as it gets more tense and bigger you really - it's there all the time. So my advice to you would be to seek attention, I think you should seek attention not only for the ganglion but also for the underlying arthritis in the thumb, which I think is more likely to be the cause of your pain than the ganglion directly itself.
MYERS
June thanks for that and just for the record the plural then of ganglion is ganglions not ganglia.
ECKERSLEY
Probably ganglia is the right...
MYERS
Well we've got another ganglion related question from Mrs Dannett, who's suggesting that - well she says that she's got a conical shaped growth, she calls it a wart, on her right thumb joint which grows to a large point and then erupts and it gives way to colourless clear liquid which leads to instant pain relief - is it a wart or is it a ganglion?
ECKERSLEY
This is almost certainly a ganglion and in this situation it's often called a mucus cyst but it is essentially exactly the same as I've been describing before which is a cyst with this clear viscous fluid in it. And it's not an uncommon situation for me to see patients who have been described as having warts on their thumb or on their fingers and even to have had treatment applied with cryotherapy, where you freeze it or even wart treatment and find that actually it doesn't get rid of the problem. Now if Mrs Dannett's is behaving in this way, where it enlarges and then discharges and then settles it's probably sensible for her to seek attention for it, it's a perfectly treatable condition - it can be removed under a local anaesthetic - and that is generally quite a successful procedure and would get rid of the problem for her.
MYERS
Well she admits to being 85 years old, so she'll be pleased to know that it's a simple procedure I dare say.
ECKERSLEY
I don't think age matters.
MYERS
Very good. Let's go to another caller - Pat is in Somerset with problems in her middle - well with her middle finger, suspect trigger finger, or have you been told it is trigger finger Pat, what's the story?
PAT
Well I've had trigger finger in the fourth finger on my - on the left hand and the right hand for about 10 years, it gets - the fingers get stuck and then you have to use your other hand to unstick them. I have had them treated with injections by my doctor every few years but the last time it didn't seem to last very long and so I've just been sort of putting up with the inconvenience really. It's not desperately, desperately painful but it's just - frequently does get stuck and some days I continually seem to be lifting one finger up to - so that I can move it properly. And I just wondered as recently I have noticed that one or two other fingers - I've thought ooh gosh that's the same sort of feeling - can it go to the other fingers as well?
ECKERSLEY
It can, it's quite a common condition - trigger finger - so you're not alone. For most people it does affect usually a single finger but some people do get multiple trigger fingers, so it may well be that the other fingers could be progressing in that way. I think the important thing actually for you to know is that if it's behaving like this there's a perfectly simple and straightforward small operation that can be done, under local anaesthetic, as a day case, so you're in and out of hospital the same day, that will deal with this problem and get - essentially get rid of it for you forever and a day. And the problem is that the tendon is catching on the tunnel that it has to run in and simply by dividing the beginning of that tunnel, which is in the palm of the hand, you will release the tendon and by doing it under local anaesthetic you will be able to demonstrate to your surgeon or your surgeon may ask you to, to show you that you are able to freely bend and straighten the fingers without it catching. So I would suggest very strongly that you go and seek attention for that and I think you will get good resolution because injections certainly are the standard treatment to start off with but if they're not being successful for a long period of time then it's probably better to move on to surgery at that point.
PAT
Oh that's very interesting, thank you very much.
MYERS
Thank you for your call. This is Check Up, I'm Barbara Myers and today we're talking about hands with hand surgeon Mr Rupert Eckersley and it's coming up to half past three. We've got another caller on the line, we go now to Patrick. Hello Patrick what's your question please?
PATRICK
Hello. Good afternoon. About - I'm 51 years old and about a year or so ago I noticed a small growth on the palm of my hand and over the last year or so it's developed into several larger lumps. Looking on your website it looks like it might be Dupuytren's Syndrome - if that's the right pronunciation.
MYERS
We've all been struggling with that pronunciation.
ECKERSLEY
Even I struggle with it.
PATRICK
Alright, okay, good, it's not just me then. So my question was is this condition likely to continue to grow because now it's starting to be quite visible and the second question is, is there anything that one can do about it, is surgery effective or are there any exercises I could do to kind of reduce it?
ECKERSLEY
Right. Well Dupuytren's Disease is a - that's my pronunciation - is a very common condition so you're not alone out there and it's a condition that affects the skin and the tissues that hold the skin firmly in place. So it's not a condition of the tendons or anything else underneath it.
PATRICK
Oh I see right.
ECKERSLEY
And it usually starts as a nodule, it may then progress into what's called a cord which may progress towards the base of the fingers and with time pull the fingers down. And it's at that point that a lot of people then seek attention. Now unfortunately as it stands at the moment there isn't any medical treatment for this, I think exercising the hands is a good thing to do but it probably won't affect the condition in the sort of long term. So I think you shouldn't - you don't need to worry about it, it's a benign problem, it behaves differently in different people, it can be - appear and then just progress very slowly be very benign and not really cause any problems.
PATRICK
Is it hereditary because my mother had this?
ECKERSLEY
It certainly is hereditary.
PATRICK
Right and also interestingly enough I had a blood test recently, in fact I had the results back today, and whilst I'm not diabetic my doctor did say that my glucose sugar is slightly high and I just noticed on the website there's a possible link there.
ECKERSLEY
There is. So Dupuytren's as a condition tends to affect men more than women, it tends to - it's commoner in the Northern European races, it does run in families and it is associated with diabetes and in fact diabetics often have other conditions such as carpel tunnel syndrome and trigger finger as well associated with that. There is probably a relationship to drinking too much and perhaps smoking but ...
PATRICK
Well that's not me.
MYERS
Surely not.
ECKERSLEY
But that's something we sort of always enquire about discretely. But the answer is that you don't need to worry about it as it stands at the moment.
PATRICK
Is it worth bringing up with my doctor next time I see him or ...
ECKERSLEY
Yes I think it's worth mentioning so he can at least see what the situation is and then he can refer you on as appropriate when it's appropriate.
MYERS
Patrick, if you don't mind I'll go to another caller because I think Mike has also got this condition and wants to talk about the possibility of having it dealt with through surgery. Mike, is that what's behind your call today?
MIKE
Yes I've got Dupuytren's - I had Dupuytren's Contracture causing the right - three smaller fingers of the right hand to bend over. That was dealt with successfully in 1992 in straightening them out. I had a metallic heart valve fitted in 1997 and since that time I've developed Dupuytren's on the left hand and the doctors are reluctant to do any operation on the left hand as a result - they don't want to take me off the wafarin and risk any strokes. So is there any other non - any reason why I have to be taken off the warfarin to do the operation?
ECKERSLEY
Well it's an interesting subject and in fact one of my colleagues has done a study to show that it's quite safe to do surgery on patients taking warfarin, obviously providing that the - your blood count levels as regards your clotting is at a safe level, which would be tested, it's perfectly safe to have surgery to the hand whilst taking warfarin and not to have to stop taking it. It may produce a little bit more bruising and swelling but if your Dupuytren's is causing you significant problem with using your hands I would say to you that it would be perfectly reasonable for you to have the surgery. And you don't - surgery for Dupuytren's can vary from the very simple procedures to the more complex and one can take account of the medical - other medical problems people have to tailor the surgery to that a little bit as well, so I think in my view you should feel that you can go and seek attention for this condition.
MYERS
Mike, thanks for your question, hope that's good news. We'll go to another caller who wants to remain anonymous but is interested in Dupuytren's and the treatments for them and I think Rupert you've already said there are various levels at which you can treat this particular condition. What's - what procedure are you considering having, our caller in Purley?
ANONYMOUS CALLER
Oh hello good afternoon. I have Dupuytren's Contracture, I've been to see a hand surgeon and he gave me various options but he explained to me that you can have an operation which is not always the end of the matter, apparently you often need - can need several operations even if they turn out to be unsuccessful you might even need a skin graft I was led to believe.
MYERS
Can we cut to the chase and perhaps if I could ask Rupert Eckersley just to lead us through the two or three different options there, we've got a sort of odd line there I'm afraid to our caller in Purley.
ECKERSLEY
I think that the surgical treatment for Dupuytren's can range from a simple procedure, such as a needle fasciectomy right up to the more complex surgery that you have mentioned which is removing the skin and replacing it with a skin graft. Now it is important to recognise that Dupuytren's is not a curable condition and that if you develop it at a young age you may require repeated surgery but for the majority of people it tends to be that you need just the one operation and once you've rehabilitated from that you should then be able to feel free of the disease, though it may recur to a small extent. And I think that the treatment that you opt for very much depends on how aggressive your Dupuytren's Disease is behaving, I think it does depend to a certain extent on the surgeon that you see and their particular preference. So I think those are matters to discuss with your treating surgeon.
MYERS
And what's good news is that there are now real specialist hand surgeons who do nothing but hands, you're one of them obviously but there are others in the country, which is rather good news isn't it.
ECKERSLEY
Yeah absolutely, I think there's a lot of criticism of sub-specialisation but I think for hand surgery it's been a good thing.
MYERS
Let's go to our next caller, we want to squeeze in a couple more, we've got Sam who's got carpel tunnel syndrome and your question Sam?
SAM
Hi there, yes, I'm just phoning up because I had very numb hands a couple of years ago, went to the doctor, had a test for thyroid problems and came back as nothing and then following a few more years of it still coming back - I do a lot of gardening, it gets very, very numb and had a diagnosis and surprise, surprise I've got an underactive thyroid. But despite being on levothyroxine it doesn't seem to go away, it seems to be exacerbated by - you know when I'm doing my digging and all of that sort of thing, even holding a telephone my hands go numb, I get woken up in the middle of the night with real dead hands and I have to hang it at the side of the bed. But I'm wondering do you think I should have an operation or am I always going to have that?
MYERS
Okay good questions.
ECKERSLEY
I think you give a very classic description for carpel tunnel syndrome and it is of course associated with conditions such as an underactive thyroid and diabetes and other hormonal problems, not that pregnancy is a problem but pregnancy is one of them. And it's important to treat the underlying condition, if there is an abnormality, and clearly you've had that done but the symptoms are continuing. And from your description of the symptoms it would seem sensible if you did actually seek treatment and consider having surgical decompression because surgery to release the carpel tunnel, which is where the nerve is compressed, just at the palm of the hand, is generally very successful and would give you good relief of your symptoms. So I would suggest that that would be your next step.
MYERS
And we won't have time to go to Trisha who has been waiting on the line but I know she's concerned about the possibility of surgery for her arthritis in her thumb. Can you quickly outline a surgical option?
ECKERSLEY
Yes, surgery at the base of the thumb for arthritis, the commonest procedure is called a Trapeziumectomy, where you remove the arthritic bone at the base of the thumb. And you can do that very simply by removing the bone but a lot of surgeons will do some additional procedures where they try and strengthen the false joint that is formed at the base of the thumb. But it's a very good operation for relief of pain, it won't restore the strength in the thumb completely back to normal but it generally improves it because pain will have inhibited function in the thumb. So I would suggest that that's a good option.
MYERS
Thank you, sorry we didn't get you on the air Trisha but I hope that was useful advice. And I hope that the advice we've had today has been useful to all our callers, thank you very much to those who have phoned and those who've e-mailed. If we haven't managed to answer your particular question do contact our free and confidential help line, the number, as usual, 0800 044 044. You can also get more information on our website, that's at bbc.co.uk follow the prompts to Check Up. You can listen again, you can download the programme as a podcast.
And I hope you'll join me next week when in a special edition of Check Up we'll be out and about to meet a group of overweight youngsters who are determined to fight the flab and to get fit for the new year, maybe they'll inspire us all to do the same.
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