Hand surgery





Definition

Hand surgery refers to procedures performed to treat traumatic injuries or loss of function resulting from such diseases as advanced arthritis of the hand.


Purpose

The purpose of hand surgery is the treatment of a broad range of problems that affect the hand, whether they result from cuts, burns, crushing injuries to the hand, or disease processes. Hand surgery includes procedures that treat traumatic injuries of the hands, including closed-fist injuries; congenital deformities; repetitive stress injuries; deformities caused by arthritis and similar disorders affecting the joints; nail problems; and tendon repair .

The central priority of the hand surgeon is adequate reconstruction of the skin, bone, nerve, tendon, and joint(s) in the hand. Proper repair of any cuts, tears, or burns in the skin will help to ensure a wound free of infection and will provide cover for the anatomical structures beneath the skin. Early repair and grafting is an essential component of hand surgery. Nerve repair is important because a delay in reconnecting the nerve fibers may affect the recovery of sensation in the hand. Restoration of sensation in the hand is necessary if the patient is to recover a reasonable level of functionality. Next, the bones in the hand must be stabilized in a fixed position before the surgeon can repair joints or tendons. Joint mobility may be restored by specific tendon repairs or grafts. In some cases, the patient's hand may require several operations over a period of time to complete the repair.


Demographics

The demographics of hand injuries and disorders depend on the specific injury or disorder in question. Repetitive stress injuries (RSIs) of the hands are often related to occupation; for example, nurse anesthetists, dental hygienists, keyboard instrumentalists, word processors, violinists, and some assembly line workers are at relatively high risk of developing carpal tunnel syndrome or tendinitis of the fingers related to their work. Nearly 17% of all disabling work injuries in the United States involve the fingers, most often when the finger strikes or is jammed against a hard surface. Over 25% of athletic injuries involve the hand or wrist.

In terms of age groups, children under the age of six are the most likely to be affected by crushing or burning injuries of the hand. Closed-fist injuries, which frequently involve infection of the hand resulting from a human bite, are almost entirely found in males between the ages of 15 and 35. Pain or loss of function in the hands resulting from osteoarthritis, however, is found most often in middle-aged or older adults, and affects women as often as men.

Some specific categories of conditions that may require hand surgery include:

Congenital malformations. The most common congenital hand deformity is syndactyly, in which two or more fingers are fused together or joined by webbing; and polydactyly, in which the person is born with an extra finger, often a duplication of the thumb.

Infections. Hand surgeons treat many different types of infections, including paronychia, an infection resulting from a penetrating injury to the nail; felon, an inflammation of the deeper tissue under the fingertip resulting in an abscess; suppurative tenosynovitis, an infection of the flexor tendon sheath of the fingers or thumb; and deeper infections that often result from human or animal bites.

Tumors. The most common tumor of the hand is the ganglion cyst, which is a mass of tissue fluid arising from a joint or tendon space. Giant cell tumors are the second most common hand tumor. These tumors usually arise from joints or tendon sheaths and are yellow-brown in color. The third type of hand tumor is a lipoma, which is a benign tumor that occurs in fatty tissue.

Nerve compression syndromes. These syndromes occur when a peripheral nerve is compressed, usually because of an anatomic or developmental problem, infection or trauma. For example, carpal tunnel syndrome develops when a large nerve in the arm called the median nerve is subjected to pressure building up inside the carpal tunnel, which is a passageway through the wrist. This pressure on the nerve may result from injury, overuse of the hand and wrist, fluid retention during pregnancy, or rheumatoid arthritis. The patient may experience tingling or aching sensations, numbness, and a loss of function in the hand. The ulnar nerve is another large nerve in the arm that runs along the little finger. Compression of the ulnar nerve at the elbow can cause symptoms that typically include aching pain, numbness and paresthesias.

Amputation . Some traumatic injuries result in the loss of a finger or the entire hand, requiring reattachment or replantation. Crushing injuries of the hand have the lowest chance of a successful outcome. Children and young adults have the best chances for recovery following surgery to repair an accidental amputation.

Fractures and dislocations. Distal phalangeal fractures (breaking the bone of a finger above the first joint towards the tip of the finger) are the most commonly encountered fractures of the hand. They often occur while playing sports.

Fingertip injury. Fingertip injuries are extremely dangerous since they comprise the most common hand injuries and can lead to significant disability. Fingertip injuries can cause damage to the tendons, nerves, or veins in the hands.


Description

There are a number of different procedures that may be involved in hand surgery, with a few general principles that are applicable to all cases: operative planning; preparing and draping the patient; hair removal; tourniquet usage; the use of special surgical instruments ; magnification (special visualization attachments); and postoperative care . The operative preplanning stage is vitally important since it allows for the best operative technique. The hand to be operated on is shaved and washed with an antiseptic for five minutes. A tourniquet will be placed on the patient's arm to minimize blood loss; special inflation cuffs are available for this purpose.

The four basic instruments used in hand surgery include a knife, small forceps, dissecting scissors, and mosquito hemostats. A standard drill with small steel points is used to drill holes in bone during reconstructive bone surgery. Additionally, visualization of small anatomical structures is essential during hand surgery. Frequently, the hand surgeon may use wire loupes (a special instrument held in place on top of the surgeon's head) or a double-headed binocular microscope in order to see the tendons, blood vessels, muscles, and other structures in the hand.

In most cases, the anesthesiologist will administer a regional nerve block to keep the patient comfortable during the procedure. The patient is usually positioned lying on the back with the affected arm extended on a hand platform. If the surgeon is performing a bone reconstruction, he or she may require such special instruments as a drill, metal plates and/or screws, and steel wires (K-wires). Arteries and veins should be reconnected without tension. If this cannot be done the hand surgeon must take out a piece of vein from another place in the patient's body and use it to reconstruct the vein in the hand. This process is called a venous graft. Nerves damaged as a result of traumatic finger injuries can usually be reconnected without tension, since bone reconstruction prior to nerve surgery shortens the length of the bones in the hand. The surgeon may also perform skin grafts or skin flaps. After all the bones, nerves, and blood vessels have been repaired or reconstructed, the surgeon closes the wound and covers it with a dressing.


Diagnosis/Preparation

With the exception of emergencies requiring immediate treatment, the diagnosis of hand injuries and disorders begins with a detailed history and physical examination of the patient's hand. During the physical examination, the doctor evaluates the range of motion (ROM) in the patient's wrist and fingers. Swollen or tender areas can be felt (palpated) by the clinician. The doctor can assess sensation in the hand by very light pinpricks with a fine sterile needle. In cases of trauma to the hand, the doctor will inspect the hand for bite marks, burns, foreign objects that may be embedded, or damage to deeper anatomical structures within the hand. The tendons will be evaluated for evidence of tearing or cutting. Broken bones or joint injuries will be tender to the touch and are easily visible on x-ray imaging.

The doctor may order special tests, including radiographic imaging (x rays), wound culture , and special diagnostic tests. X rays are the most common and most useful diagnostic tools available to the hand surgeon for evaluating traumatic injuries. Wound cultures are important for assessing injuries involving bites (human or animal) as well as wounds that have been badly contaminated by foreign matter. Such other special tests as a Doppler flowmeter examination can be used to evaluate the patterns of blood flow in the hand.

Before a scheduled operation on the hand, the patient will be given standard blood tests and a physical examination to make sure that he or she does not suffer from a general medical condition that would be a contraindication to surgery.


Aftercare

Aftercare following hand surgery may include one or more of the following, depending on the specific procedure: oral painkilling medications; anti-inflammatory medications; antibiotics ; splinting; traction ; special dressings to reduce swelling; and heat or massage therapy. Because the hand is a very sensitive part of the body, the patient may experience severe pain for several days after surgery. The surgeon may prescribe injections of painkilling drugs to manage the patient's discomfort.

Exercise therapy is an important part of aftercare for most patients who are recovering from hand surgery. A rehabilitation hand specialist will demonstrate exercises for the hand, instruct the patient in proper wound care , massage the hand and wrist, and perform an ongoing assessment of the patient's recovery of strength and range of motion in the hand.


Risks

According to the American Society of Plastic Surgeons, the most common complications associated with hand surgery are the following:

  • infection
  • poor healing
  • loss of sensation or range of motion in the hand
  • formation of blood clots
  • allergic reactions to the anesthesia

Complications are relatively infrequent with hand surgery, however, and most can be successfully treated.


Normal results

Normal results for hand surgery depend on the nature of the injury or disorder being treated.

Morbidity and mortality rates

Mortality following hand surgery is virtually unknown. The rates of complications depend on the nature of the patient's disorder or injury and the specific surgical procedure used to treat it.


Alternatives

Some disorders that affect the hand, such as osteoarthritis and rheumatoid arthritis, may be managed with such nonsurgical treatments as splinting, medications, physical therapy, or heat. Fractures, amputations, burns, bite injuries, congenital deformities, and severe cases of compression syndromes usually require surgery.


Resources

BOOKS

"Common Hand Disorders." Section 5, Chapter 61 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Townsend, Courtney, et al., eds. Sabiston Textbook of Surgery , 16th ed. Philadelphia, PA: W. B. Saunders Company, 2001.

PERIODICALS

Chu, M. M. "Splinting Programmes for Tendon Injuries." Hand Surgery 7 (December 2002): 243-249.

Diaz, J. H. "Carpal Tunnel Syndrome in Female Nurse Anesthetists Versus Operating Room Nurses: Prevalence, Laterality, and Impact of Handedness." Anesthesia and Analgesia 93 (October 2001): 975-980.

Johnstone, B. R. "Proximal Interphalangeal Joint Surface Replacement Arthroplasty." Hand Surgery 6 (July 2001): 1-11.

Perron, A. D., M. D. Miller, and W. J. Brady. "Orthopedic Pitfalls in the ED: Fight Bite." American Journal of Emergency Medicine 20 (March 2002): 114-117.

Rettig, A. C. "Wrist and Hand Overuse Syndromes." Clinics in Sports Medicine 20 (July 2001): 591-611.

ORGANIZATIONS

American Association for Hand Surgery. 20 North Michigan Avenue, Suite 700, Chicago, IL 60602. (321) 236-3307. http://www.handsurgery.org .

American Society of Plastic Surgeons (ASPS). 444 East Algonquin Road, Arlington Heights, IL 60005. (847) 228-9900. http://www.plasticsurgery.org .

American Society for Surgery of the Hand. 6300 North River Road, Suite 600. Rosemont, IL 60018. (847) 384-1435. http://www.assh.org .

OTHER

American Society of Plastic Surgeons. Procedures: Hand Surgery . [June 29, 2003]. <www.plasticsurgery.org/public_education/procedures/HandSurgery.c m> .


Laith Farid Gulli, M.D., M.S.
Bilal Nasser, M.D., M.S.
Robert Ramirez, B.S.
Nicole Mallory, M.S., PA-C

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


Hand surgery is usually performed by a microsurgeon, who may be a plastic surgeon (a surgeon with five years of general surgery training plus two years of plastic surgery training and another one to two years of training in microneurovascular surgery) or an orthopedic surgeon (a surgeon with one year of general surgery training, five years of orthopedic surgery training and additional years in microsurgery training).

Hand therapists are usually occupational therapists who have received specialized training in hand rehabilitation and are certified in hand therapy.

QUESTIONS TO ASK THE DOCTOR


  • Are there any alternatives to surgery for treating my hand?
  • Is the disorder likely to recur?
  • Will I need a second operation?
  • How many patients with my condition have you treated, and what were their outcomes?
  • Can I expect to recover full range of motion in my hand?
  • What will my hand look like after surgery?


User Contributions:

stephen dubois
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Apr 17, 2006 @ 12:12 pm
Very informative site. I would like to see more statistics on docs performing hand surgery. what is the learning curve and how many should they be doing a year to make them proficient.

I was also told that Bone stimulation would help with the healing process. Can you elaborate?

Thank you,
Stephen
Marion Wolfe
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Sep 6, 2010 @ 12:12 pm
I had RT CMC arthroplasty c FCR transfer: hemitrapeziodectomy 3.5 weeks ago

I would like to know if after my thumb heals, will be able to touch the tips of my two middle fingers. I am a violinist and I am asking if I will be able to hold and use my bow again.
Gary Henkaline
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Dec 28, 2010 @ 10:10 am
I had surgery to release three fingers in my right hand affected by dupuytrens contracture seven weeks ago. Although the fingers have been straightened and are functional, I am still experiencing a lot of pain in my hand in my palm at the base of my fingers and along the suture lines. Additionally, swelling prevents me from making a fist. My surgeon seems unconcerned. To me the recovery time seems excessive. Comments?
Rob Weaver
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Jan 17, 2011 @ 3:15 pm
I went through surgery for 'trigger finger' on my left middle finger back in late October 2010. Though I can move my finder freely now, I am experiencing a very agrravating ache in my palm near the base of the affected finger. My affected finger is also very stiff (I'm a guitarist)and still has swelling. My scar area is very painful as well. Massaging seems to help somewhat (though very painful at first). I also experience a bluing of my hand, very much what it looked like right after the surgery. This comes on after putting pressure on my hand such as carrying something heavy in my hand, shovelling, etc. I'll be seeing my surgeon next week to ask what I've written here, and will post.
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Jan 24, 2011 @ 10:22 pm
I finally made it to the surgeon for a follow up. He thinks everything is as it should be. He says this surgery can take up to a year to 'settle out'. He didn't have an answer for the bluing of the hand, and asked whether it blued when it was exposed to cold (which it doesn't). So it's fine as he sees it; the swelling and pain (take an anti-inflammatory), work the hand to keep it from stiffening, massage the area to keep the internal scarring down (?). He assured me the swelling on my palm at the base of my affected finger(s)will recede in time. One thing that struck me was that he mentioned that the original trigger finger was gone. He repeated this more than once. I believe he wanted me to remember that that was what I went to him for in the first place. So one has to be patient I suppose and not give the good Doctor too much hassle.
Gbenga
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Feb 3, 2012 @ 5:17 pm
When i was less than a year old, i accidentally deeped my left hand into a boiling water, and i was treated but now that i am 20
year old the fist of the hand is always folded and its not like the other right hand that
has no defects, please can i get help from you guys ? I am from Nigeria.
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Apr 26, 2012 @ 6:06 am
recently my husband injured and his artery of right hand has been cut and operated. Lots of blood has lost and he admitted for 4 days in hospital. After 10 days also he has lots of pain in his hand and the hand is hung from his neck. My questions is k- will he fully recover ever and what are the post care that we need now? Please suggests. Thank you.
James Ehlers
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Oct 12, 2012 @ 6:18 pm
? What can be done about the loss of fingers(left hand as well) from infection ???
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Apr 1, 2013 @ 9:09 am
had surgery on left middle and ring finger after being crushed. ring finger was also fractured but could not be splinted so that fingers could heal. 3 yrs later here i am waking up and cant move hands arm or fingers. it comes and goes..some days worse than others. right now as iam typing my two fingers are numb.
Kenneath
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Oct 14, 2013 @ 5:17 pm
How can a folded finger due to hot oil restored to normal
Bharani
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Jul 20, 2014 @ 2:02 am
Hi,

Recently, my right hand index finger bone has broken due to the bike accident and same has been healed completely now. But I can’t able to fold the finger like before even completing the 10 days physiotherapy. May I know the reason for this and please advise what type of treatment required to get the normal finger activity?

Thanks,

Bharani
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Sep 17, 2014 @ 6:06 am
My right hand's little fingers tendon was cut on wrist .It was repaired and 2 weeks later my plaster was open and i was hurt without plaster and exercised now i feel swallowing hot water kind of inside my hand then i was plastered again . But i feel no improvement. Is there any way to know my tendon is damaged again due to hard exercise and hurt only after 2 weeks platering? please let me know how to get well from swallowing feeling and hot feeling inside ?

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