Hand Surgery

Introduction:

The hand is an anatomical masterpiece. It is more highly developed in humans than in any other animal. As a tactile organ it enables us to appreciate touch. We are able to feel and appreciate endless objects in our environment, surfaces, textures, living and non-living. As a motor organ we are able to use our hands in the performance of the most skilled tasks with great precision and dexterity.

We tend to take our hands and hand function for granted. We may not think of the hand as being essential in a similar sense to the heart or other vital organs. Our hands are essential for the performance of activities of daily living (A.D.L.) and thus our independence. It is only when we suffer an injury to one of our hands or some other impairment that we appreciate our hands. We also come to appreciate that we need two functioning hands – one good hand alone leaves us seriously deficient

There are conditions of the hand which if left untreated could lead to impairment of the hand, sometimes severe. Such conditions may take the form of swellings, contractures, nerve entrapment or painful lesions. In general such conditions affect adults in middle age and the elderly, they are much less common in young adults and children. Normal functioning hands are essential in people of working age as they are vital for their livelihood and they are essential in maintaining independence in old age.

The following are common conditions of the hand which can be successfully treated surgically.

Common Conditions Affecting the Hand:

  • Trigger finger
  • Carpal tunnel syndrome
  • Ganglion
  • Dupuytren’s contracture

Trigger Finger:

In this condition a finger locks in a flexed (bent) position. Usually the finger can be straightened and it tends to release with a clicking sensation. The condition is often painful. It can affect any finger including the thumb but it most commonly affects the ring and middle fingers. Index finger triggering is uncommon. The condition is most commonly an isolated finding without any underlying condition. However it is occasionally seen in association with Diabetes, Rheumatoid Arthritis and Gout. It occurs more commonly in women.

Treatment:

There are two treatment options:

  • Steroid injection into the finger.
  • A small surgical procedure under local anaesthesia.

Steroid injection is not guaranteed, recurrence is common.

Surgery is simple and reliable, quickly and permanently relieving locking of the finger. The procedure is carried out under local anaesthesia with or without sedation (optional) as an out-patient. The procedure lasts 15-20 minutes. Post operatively you must refrain from heavy work for at least one week – heavy lifting, gripping, repetitive hand or finger activities. You should be able to drive within one week. The sutures dissolve and you therefore do not need to return to the clinic for removal of sutures. Only a light dressing is required.

Ganglion:

This is a swelling which appears under the skin usually in the region of the wrist joint. Smaller ganglia can appear elsewhere in the hand including the fingers.

Features:

• Commoner in females (F/M = 3/1)

• Second to fourth decades (70%)

• Usually single

• Often painful, cause weakness of the wrist

• Cosmetically unsightly, especially in females

• May enlarge or subside

• May rupture or disappear spontaneously

• Majority have no known cause or associated conditions

Treatment:

Surgery is the only reliable treatment. Recurrence is uncommon if properly excised. Greater than 50% will recur if not properly excised. Excision of the ganglion is carried out under local anaesthesia or nerve block with or without sedation (optional). General anaesthesia is rarely required. Under tourniquet an incision is made in the skin overlying the ganglion. The ganglion cyst, filled with a clear gel fluid similar to joint fluid, is dissected and removed. The cyst will invariably have a connection with the underlying joint. Dissolving sutures are used to close the wound. A light dressing and splint are applied. The splint is worn for one week and intermittently thereafter for a further week or two. Time off work will vary depending on your occupation. You should be able to resume driving within the first week. Specific advice regarding aftercare will be given to each patient individually.

Carpal Tunnel:

This is probably the most common nerve entrapment in the limbs. In this condition the median nerve becomes trapped as it courses across the wrist into the hand. As it crosses the wrist it is enclosed in a tight compartment under the flexor retinaculum ligament. It is at risk of entrapment at this point.

Symptoms of Carpal Tunnel Syndrome:

  1. Weakness or clumsiness in the hand
  2. Numbness or pins and needles in the distribution of the median nerve
  3. Symptoms are aggravated by using the hand
  4. Being awakened by pain and tingling in the wrist / hand and an inclination to shake the hand which tends to bring relief
  5. Pain radiating upwards towards the elbow
  6. Muscle wasting, when condition is advanced
  7. The condition may be bilateral (may involve both hands)

The condition is seen in:

  • Women more than men
  • Individuals between forty and sixty
  • Following wrist injury or fracture

It may be associated with the following conditions:

  • Rheumatoid arthritis
  • Underactive thyroid
  • Diabetes
  • Hormonal changes of the menopause
  • Pregnancy
  • Symptoms similar to carpal tunnel syndrome may be seen in individuals who have arthritis of the cervical spine (neck). In this condition the symptoms tend to be bilateral.

Treatment:

The treatment options are as follows:

  • Rest and Splintage

These measures are often helpful but frequently the condition recurs when the individual resumes normal work and activities.

  • Injection of Steroid into the carpal tunnel

This frequently gives relief for a number of months. Unfortunately 65 – 90% of individuals get recurrence of symptoms.

  • Surgery

This entails open release of the median nerve. The surgery can also be carried out as an endoscopic (closed) release.

Either open or endoscopic release of the nerve can be carried out under local anaesthesia as an out-patient. The procedure takes approximately half an hour to perform. The incision is closed with dissolving sutures. A padded dressing and a splint are worn for seven days. The splint may be used for two to three weeks depending on the rate of recovery. The individual is encouraged to use the fingers while wearing the splint.

Surgery is curative in 90 – 95% of individuals.

Time off work will vary depending on your occupation. You should be able to drive as soon as it is comfortable to remove the splint – approximately one week following the procedure.

Dupuytren’s Contracture:

This is an extremely common condition of the hand. The condition usually begins with thickening of the sinew tissue under the skin of the palm or fingers. In time the fingers will contract. Dupuytren’s contracture is a genetically transmitted condition. The Dupuytren’s gene is prevalent in white North Europeans, however the gene has been carried by migrating Europeans throughout the world.

Features of Dupuytren’s Contracture:

  1. It occurs predominantly in middle age and elderly. It is unknown in childhood and uncommon in young adults.
  2. There is strong genetic linkage, many patients will be aware of a parent or a relative who had the condition.
  3. There are no other proven causative factors – injury, heavy manual work and excessive alcohol may hasten the onset in individuals who are genetically predisposed.
  4. Men are affected more than women.
  5. One or more fingers may be affected.
  6. The ring and little fingers (fourth and fifth fingers) are affected far more commonly, followed by the middle finger and thumb with the index finger being the least commonly affected.
  7. The condition may affect both hands.
  8. Surgery is the treatment of choice. There are no other treatment options.

Treatment:

At The Clinic, Sandymount Green Duputyren’s contracture is usually corrected under local anaesthesia as an out patient. In certain cases the Anaesthetist may suggest that the procedure be performed under sedation and local anaesthesia as a day case. Following sedation you will be fit for discharge within one to two hours of completion of the procedure.

The incisions in the palm and / or fingers are sutured with dissolving sutures, which therefore do not have to be removed. A padded dressing is applied which may be removed or reduced after forty eight hours. Most patients wear a sling for elevation, rest and comfort. Post operative medications include mild to moderate pain relief – essentially what you would normally stock in your medicine cabinet for aches and pains. The local anaesthesia under which the procedure is carried out will last for up to twenty four hours following the procedure by which time the post operative pain will be receding. You will be reviewed one week following the procedure for removal of the remaining dressings.

Physiotherapy / Hand Therapy:

Physiotherapy is only required in a small number of cases – those where the degree of finger contracture was severe and were the correction at operation was incomplete. The assistance of a physiotherapist will be important in helping you maintain or improve the correction achieved by surgery. It is very important that physiotherapy be carried out in the initial two to four weeks following surgery while the fingers remain malleable. Physiotherapy carried out at a later stage has limited potential.