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Hand surgery

Hand surgery is an area of general surgery that deals with operations of the hand, wrist and peripheral nerves of the upper limb, as well as operations that improve its function after nerve damage. Most hand injuries can be treated without surgery by using splints, bandages, injections and physiotherapy.

Hand surgery is usually performed in a single day under conduction anaesthesia (the drug is injected into the armpit or above the shoulder to suppress the sensation in the entire arm). The patient is conscious or under the influence of mild sedatives, depending on his or her wish. General anaesthesia and/ or hospital stays until the next day are not common practice, but they are necessary, for example, when treating children or if the surgery takes longer than planned. Some operations may be performed under local anaesthesia (the drug is injected subcutaneously into the area of the intervention).

While performing surgery on small structures of the hand, the surgeon uses thin instruments and can employ magnifying glasses (loupes) or an operating microscope to repair small nerves or arteries. Postoperative therapeutic treatment is necessary for better recovery after certain types of operations.

When is this surgery necessary? Wrist surgery is a procedure with an individual approach that can be performed at any age and is suitable in the following cases:

  • there are no concomitant diseases,
  • the patient does not smoke,
  • the patient is positive and has realistic expectations concerning the outcome of the operation,
  • the patient is undergoing a course of treatment prescribed by a plastic surgeon,
  • wrist surgery is sometimes necessary to heal wounds and relieve pain.

Wrist Surgery and Anaesthesia

There are several options for anaesthesia for wrist surgery: local, conduction and general. The type of anaesthesia depends on the type and duration of the operation, the patient’s condition, as well as the patient’s, the surgeon’s and the anaesthesiologist’s preferences.

Local Anaesthesia

“Local anaesthesia” usually means anaesthesia of a small area. In this case the anaesthetic drug is injected into the area of the surgery. Other means may be used with the purpose of calming the patient. They are most often administered intravenously via a drip set.

Conduction Anaesthesia (Nerve Block)

Conduction anaesthesia “lulls” part of the body to sleep as a result of the administration of an anaesthetic drug through a needle placed along the nerve. The drug is injected in the region of the clavicle or neck, into the armpit or into the arm via a drip set. There are several different types of conduction anaesthesia. Sometimes ultrasound instruments or nerve stimulators are used to choose the correct placement of the needle. As with local anaesthesia, anaesthesia can be accompanied with intravenous administration of sedatives.

General Anaesthesia

With general anaesthesia, the patient sleeps during surgery. Modern drugs and methods are less likely to cause side effects (nausea, dizziness, drowsiness) than before, although such reactions may still occur. General anaesthesia can be used instead, or in combination with a nerve block.

What does the type of anaesthesia depend on?

The type of anaesthesia depends on the type and duration of the operation, the patient’s condition, as well as the patient’s and the doctor’s preferences (they decide it together in each particular case).

Types of hand surgery. Nowadays, there are many types of operations on the hand, depending on the underlying cause of the problem. Here is a brief overview of some types of surgical interventions.

Skin Transplantation

This operation involves skin transplantation over the area of ​​the hand devoid of cutaneous covering. The most common injuries requiring skin transplantation are finger amputation or its injury. The operation is carried out by taking part of healthy skin from some other part of the body, called donor, and putting it over the area that needs it.

Flap Plasty

Flap plasty is similar to skin transplantation in which part of the skin is taken from other areas. However, with flap plasty the skin that is taken for transplantation has its own blood supply. Thus, they use skin with blood vessels, fat and muscles that are under it. Flaps are applied when the area with missing skin lacks its own blood supply because of vascular damage or extensive tissue damage.

Closed Reduction and Fixation

This operation is performed when there is a fracture of a part of the hand, including the fingers. During it, an attempt is made to align the broken bone and then immobilize the affected area for the healing period. Immobilization is done by using internal immobilization devices, such as wire, rods or splints.

Tendon Repair

Tendons are formations of connective tissue which attach muscles to bones. Their repair is still a surgical problem because of the structure of the tendon.

Infection, trauma and spontaneous rupture are the causes of tendon damage. Its repair may be primary, delayed primary or secondary. Primary repair after acute injury is usually carried out within 24 hours after it. Delayed primary repair is performed several days after the injury, but there is still a wound hole in the skin at the site of the injury.

Secondary repair surgery may be performed 2-5 weeks or more after the injury. Primary repair usually involves direct surgical intervention at the site of the injury, while secondary repair involves tendon transplantation or other more complex operations.

Nerve Repair

Three main nerves run through the hand. They are ulnar, median and radial nerves. Damage to them can lead to a deterioration of the motor and tactile abilities of the hand. Some nerve injuries pass on their own, while others require surgery. In general, the best time to repair nerves if the injury is complex is 3-6 weeks after the injury.

Surgery to examine the damaged nerve, which is not complicated by other injuries, is usually carried out early after the injury, in order to improve the chances of complete recovery. In case of complications, the nerve can be repaired by attaching it directly to the other end or by transplanting a nerve from some other part of the body.

Fasciotomy

This procedure is carried out in order to alleviate the so called compartment syndrome. A compartment is a three-dimensional anatomical space in the human body, surrounded by a connective tissue membrane (fascia) or bone and containing arteries, nerves and veins. Compartment syndrome is a condition that occurs when the pressure in the intra-compartment tissue within the anatomical space increases, which is usually caused by trauma that can impair blood circulation. Compartment syndrome of the hand can cause severe, increasing pain, muscle weakness and, ultimately, discoloration of fingers or nail beds.

Fasciotomy is a technique of treating compartment syndrome at an early stage of its development. Surgical incisions are made in the hand or arm to relieve the increasing pressure in the body. At the same time, the surgeon can remove any damaged tissue. Fasciotomy helps prevent a further loss of function and damage to the limb.

Surgical Drainage and/ or Debridement

A person is constantly faced with the risk of injury to the hand and infection. Hand infection is a common cause of seeking medical attention. Treatment may include rest, applying a heat source, placing the limb in an elevated position, taking antibiotics, and surgery. Surgical drainage is performed when an abscess is observed in the hand and it is necessary to remove the accumulation of pus. In the event of a serious infection or injury, wound debridement or cleaning of the wound is carried out to prevent further spread of the infection and speed up recovery.

Joint Replacement (Prosthesic Arthroplasty)

This type of surgery, arthroplasty, is performed on a patient with a severe form of arthritis of the hand. During it, the joint destroyed by the disease is replaced with an artificial one. The material of an artificial joint can be metal, plastic, silicone rubber, or the patient’s own tissue (for example, a tendon).

Replantation

During this operation, fingers or hands that have been amputated, usually as a result of some injury, are reattached. Replantation is based on microsurgical techniques ‒ carrying out an extremely high precision operation that is performed at a high magnification. Some serious injuries may require more than one surgical procedure for optimal recovery.

In Germany hand surgery clinics use the most modern treatment techniques that meet international standards:

  • Treatment of acute injuries of the hand and forearm, including replantation and revascularization of abjuncted limb segments.
  • Treatment of the consequences of severe hand injuries using single-stage combined surgical interventions, including the reconstruction of an adactylous hand by means of free toe to hand transplantation.
  • Treatment of false joints and defects of tubular bones of the extremities of various aetiologies, both by traditional methods and using vascularized bone autografts transplantation.
  • Treatment of cicatricial deformities, trophic ulcers, osteomyelitis of the bones of the upper and lower extremities in combination with the defect of the skin by using vascularized skin grafting, skin-fascia, skin-fascial-muscular and osteocutaneous grafts.
  • Surgery to restore motor activity in case of damage to the brachial plexus, individual nerve trunks of the upper and lower extremities, including in patients with spinal cord injury at the level of the cervical spine.
  • Suture or plasty of great vessels and nerves of the extremities by using microsurgical techniques.
  • Treatment of extensive injuries of the elbow joint by means of single-stage endoprosthesis replacement and skin or skin-muscular plasty.
  • Finger joint replacement.
  • Treatment of patients with hand deformities caused by rheumatoid polyarthritis, systemic lupus erythematosus.
  • Treatment of Dupuytren’s disease and other finger contractures.

A hand is a person’s main working organ, so no wonder that the injury of the tendons in the hand is a case that is quite frequent and all the more difficult because medicine knows a considerable number of types of upper limb injuries. Injuries of the ligaments of the hand and fingers are accompanied with persistent pain in the wrist joint. The pains are caused by the pathological mobility of the wrist bones. Injuries of the ligaments of the finger joints become evident due to swelling at the site of the joint damage and excessive mobility of the finger. Such patients often get conservative treatment for a long time, although surgery is required.

The tendons of the hand often suffer from various injuries: hand tendon injuries, inflammations. This requires accurate diagnosis, without which it is impossible to prescribe the correct treatment. As for tendon inflammations, if you feel pain and see swelling in the hand, this may indicate the beginning of the inflammatory process. In addition, a high degree of sensitivity in this area is also indicative of inflammation. With such symptoms, the best solution would be to reduce the load on the hand and control movements. They should not be abrupt and fast. If pain and swelling do not go away, we urgently recommend consulting a specialist.

If you do not pay due attention to the treatment of injured tendons of the hand and fingers, the consequences may be the most severe, up to disability! Therefore, in the event of a hand injury, you should immediately consult a doctor who will make the correct diagnosis and prescribe treatment. A rehabilitation period is of great importance in the restoration of the functions of the hands and fingers.

Degenerative arthritis is a condition in which the surface of a joint wears out (undergoes degeneration). This usually happens slowly, over many years. The term “arthritis” means inflammation of a joint, which is manifested by pain, swelling, redness and an increase in skin temperature over the affected joint. The term “degenerative arthritis” means the inflammation of a joint caused by its wear. Degenerative arthritis is commonly referred to as osteoarthrosis or osteoarthritis. Sometimes you can hear the expression “degenerative arthrosis”.

A joint injury, such as a sever sprain of soft tissues or a bone fracture, can lead to damage to the articular cartilage. Any injury of a finger joint, even if it does not directly affect the cartilage, can affect its performance. Sometimes fragments of a broken bone knit in the wrong position, which is somewhat different from the original. In this case, the bones in the joint are located differently relative to each other. If the injury leads to a change in the configuration of the joint and the direction of its movement, the cartilage begins to be subjected to a greater load than before. Like any unbalanced mechanism, such a joint wears out more quickly.

Over time, the unbalance of the joint can lead to articular surface damage. Since the articular cartilage is not able to recover quickly and intensively enough, the consequences of its damage gradually accumulate. Eventually, the joint ceases to cope with the accumulated damage, and then the symptoms of arthritis appear. Damage to the joint begins long before the onset of the symptoms.

Dupuytren’s Disease

A characteristic feature of this hand condition is abnormal induration of the subcutaneous tissues (fascia). It arises on the palm and can spread to the fingers. Dense constrictions and bumps may be formed; the fingers bend and press against the palm (Dupuytren’s contracture). The reason is unknown. It is more common in European men over 40 years old. The symptoms include bumps and impressions on the palm. In mild cases, supervision is enough; in more severe cases surgery may be necessary.

De Quervain’s Tenosynovitis

Tenosynovitis of the first dorsal compartment, caused by irritation or inflammation of the tendons of the wrist at the base of the thumb. The inflammation causes oedema of the tendon canal; movements of the thumb and wrist become painful. It is painful for the patient to make a fist or hold objects. The main symptom of this condition of the hand is pain in the wrist along the thumb side. Pain arises gradually or suddenly. Treatment involves wearing a splint, anti-inflammatory drugs or corticosteroid injections.

Ulnar Tunnel Syndrome

It is caused by pressure on the ulnar nerve in the area of the elbow. The symptoms of this hand condition are numbness, tingling, pain in the elbow, forearm, hand and/ or fingers. Numbness or tingling more often occur in the middle and fourth fingers. The symptoms usually arise with pressure on the nerve, for example, when the patient puts his or her hand on the armrest or repeatedly bends and straightens the elbow. The symptoms may disappear with the postural change. In more severe cases, surgery is necessary to reduce the pressure on the nerve.

Trigger Finger Syndrome

Stenosing tenosynovitis (trigger finger syndrome) affects the flexor tendons of the fingers and their canals. It occurs when the tendon canal at the base of the finger becomes too narrow and compresses the tendon, preventing it from moving freely. The symptoms of this hand disorder are pain and snapping or a sensation of pinching. When tendon entrapment occurs there is also inflammation, and oedema is even more visible. Sometimes the finger becomes wedged, and it is difficult to bend or unbend it. Treatment involves wearing a splint, changing the type of activity, anti-inflammatory drugs, corticosteroid injections or an operation to open the canal at the base of the finger.

Hygroma

This is a series of indurations in the hand and wrist joints and tendons. The most frequent localizations are the outer and inner side of the wrist, the base of the fingers on the side of the palm, the upper part of the distal joints of the fingers. It resembles a bubble on a crus, filled with clear liquid or jelly-like substance. The cause is unknown, though hygroma can emerge as a result of irritation or mechanical changes in the joint. It occurs in patients of all ages; over time it may change in size or disappear; it can be painful or not. It is benign and not prone to extension. Supervision of the patient is enough, especially if the cysts are painless; they often disappear on their own. If cysts are painful or impede movement, they are treated by applying a splint, anti-inflammatory drugs, suctioning the contents or operatively.

Carpal Tunnel Syndrome

It occurs as a result of pressure on the median nerve in the wrist area (wrist nerve entrapment). The symptoms include numbness, tingling, and pain in the arm, hand, and fingers. The cause is usually unknown, though pressure on the nerve may occur with swelling of the flexor tendon lining, displacement in the joint, cracks, arthritis, and wrist clamping for a long time. Usually, treatment is carried out without surgery by using a splint and/ or corticosteroid injections. If the symptoms are severe and the condition does not improve, surgery may be necessary.

Arthroplasty is replacement of elements of the musculoskeletal system with implants (endoprostheses). It is possible to replace soft tissue (ligaments and tendons) and bones and joints of the hand with endoprostheses.

During surgery on the hand a microsurgical technique is used which has no alternative if it is necessary to transplant not only a bone, but also a muscle or osteomyocutaneous graft, usually in the treatment of neoplastic diseases of this localization.

Since massive allografts (the articular surfaces of the humerus and femurs) do not adequately make up for the limb function, nowadays alloplasty is replaced by arthroplasty almost everywhere.

Other diseases when joint arthroplasty of the hand is performed are posttraumatic arthrosis, rheumatoid arthritis, and osteoarthritis. Post-traumatic arthrosis accompanied by comminuted intra-articular fractures (for example, of the ankle and wrist joints) which preclude the full restoration of the function of the joints and lead to their ankylosis (immobility).

Rheumatoid polyarthritis is a disease in which immune inflammation leads to chronic destructive arthritis of the hand and foot joints. As a rule, the lesion occurs symmetrically.

In the long run, fibrous changes in the synovial membrane and bone and cartilage destruction lead to deformation of the joints with atrophy of the adjacent muscles, formation of persistent contractures and impaired function. There are also cases of progressive course, when ankylosis (immobility in the joint) occurs only 1-2 years after the onset of the disease.

In this case, arthroplasty can restore the function of the limb and prevent disability. Osteoarthritis of the interphalangeal joints of the hand accounts for up to 60% of all cases.

Endoprosthesis of the Trapezium-Metacarpal Joint of the Thumb

Clinical benefits:

  • Rapid disappearance of pain
  • Preservation and restoration of mobility
  • Optimum biocompatibility
  • Lack of attrition
  • Cementless fixation
  • Simple surgical technique

Indications:

  • Rhizarthrosis

Postoperative treatment period:

  • Immobilization in a plaster bandage for 3 weeks
  • Immobilization in a CMC-1 orthosis of the joint for 2 weeks
  • Physiotherapy
  • Full load is possible 12 weeks after surgery

Endoprosthesis of the Metacarpophalangeal Joint of the Finger

Clinical benefits:

  • Rapid disappearance of pain
  • Recuperation
  • Restoration of pinch power
  • Preservation and restoration of mobility
  • Optimum biocompatibility
  • Lack of attrition
  • Cementless fixation
  • Restoration of subtle movements (playing musical instruments)
  • Simple surgical technique

Indications:

  • Idiopathic and posttraumatic arthrosis
  • Degenerative and postinfectious arthrosis
  • Bony ankylosis
  • Malposition (for example, in case of arthritis, because of injury, improper load, etc.)

Postoperative treatment period:

  • Full stress is allowed 12 weeks after surgery

Endoprosthesis of the Proximal Interphalangeal Joint of the Finger

Clinical benefits:

  • Rapid disappearance of pain
  • Recuperation
  • Restoration of pinch power
  • Preservation and restoration of mobility
  • Optimum biocompatibility
  • Lack of attrition
  • Cementless fixation
  • Restoration of subtle movements (playing musical instruments)
  • Simple surgical technique

Indications:

  • Idiopathic and posttraumatic arthrosis
  • Degenerative and postinfectious arthrosis
  • Bony ankylosis
  • Malposition (for example, in case of arthritis, because of injury, improper load, etc.).

Postoperative treatment period:

  • Three months after surgery full functional load is possible.
  • If necessary, follow-up rehabilitation.

Endoprosthesis of the First Metatarsophalangeal Joint

Clinical benefits:

  • Rapid disappearance of pain
  • Preservation and restoration of mobility
  • Optimum biocompatibility
  • Lack of attrition
  • Cementless fixation
  • Simple surgical technique

Indications:

  • Hallux Rigidus
  • Hallux Rigido-Valgus
  • Idiopathic and posttraumatic arthrosis
  • Degenerative arthrosis
  • Ankylosis
  • Postinfectious arthrosis after complete sanitation of bone infection
  • Gout
  • Rheumatoid polyarthritis

Postoperative treatment period:

  • Immediately after surgery, unloading shoes are worn for 4 weeks
  • Sutures are removed 10 days after surgery
  • Two weeks after surgery, self-mobilization is carried out according to instructions (if necessary)
  • For this purpose, it is recommended to use a toe splint which enables painless movement in the range from the starting point to 30º inclusive in the plantar direction and up to 55º during dorsal flexion
  • Alternative physiotherapy under supervision
  • Four weeks after surgery ‒ careful walking in hard wide standard shoes
  • Six weeks after surgery ‒ the load is increased. Peak loads should be avoided
  • Twelve weeks after surgery ‒ full load is allowed
GermanMedicalGroup + 49 (7221) 39-65-785 Flugstrasse 8a
76532 Баден-Баден
Германия
Hand surgery is the field of medicine that deals with problems of the hand, wrist and forearm. Hand surgeons care for these problems without surgery, and they are specially trained to operate when necessary. 2019-05-02 Hand Surgery
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