What does hand surgery cover?
The hand is an organ in which bone, joint, tendon, nerve and vessel are densely gathered together within a small area. A problem in any one of these structures soon affects the function of the whole hand. Hand surgery addresses the injuries, the compressions and the congenital differences of these structures; it is a subspecialty field in its own right.
The topics within its scope:
- Tendon, nerve and vessel injuries; injuries from sharp implements and accidents at work
- Bone fractures and joint dislocations
- Nerve compression syndromes
- Problems of the tendon sheath and restriction of movement
- Congenital differences of the hand
- Benign and malignant growths in the hand
- Repair after burns and loss of tissue
Which situations are emergencies?
In the conditions below, waiting can lead to permanent loss of function:
- Amputation. The severed part is wrapped in a clean cloth and placed in a closed bag; the bag is then put into a mixture of ice and water. The part must not come into direct contact with the ice. An appropriate centre should be reached as quickly as possible.
- Impaired circulation. A finger becoming cold, turning dusky or growing pale.
- Deep cuts. Inability to bend or straighten the finger, and numbness; these point to a cut tendon or nerve.
- Signs of spreading infection. Swelling, redness, pain that worsens with movement, fever.
- High-pressure injection of a substance. Injuries such as those from a paint gun may look small from the outside, yet they require emergency intervention.
Common conditions
| Condition | Typical complaint |
|---|---|
| Carpal tunnel syndrome | Numbness of the hand that wakes the patient from sleep at night, tingling in the region from the thumb to the middle finger, and reduced grip strength at a later stage |
| Trigger finger | The finger catches as it bends and has to be forced open, with pain over the tendon sheath |
| De Quervain’s tenosynovitis | Pain in the wrist on the thumb side; it worsens on gripping the thumb and tilting the wrist sideways |
| Dupuytren’s contracture | Hardened bands in the palm, with the fingers gradually becoming impossible to straighten |
| Ganglion cyst | A soft, well-defined swelling on the back of the wrist or on a finger; its size may vary |
| Ulnar nerve compression | Numbness in the little and ring fingers, and tenderness on the inner side of the elbow |
Diagnosis
On examination, joint range of movement, grip strength, the map of sensation and tendon function are each assessed separately; examination of the hand is comparative, with the other hand taken as the reference.
Where required, X-rays (bone and joint), ultrasound (tendon and cyst), MRI (soft tissue and cartilage) and EMG (the level and the degree of nerve compression) are used. In nerve compressions, EMG contributes directly to the decision to operate and to its timing.
Treatment
Not every condition requires surgery. The sequence of treatment is usually as follows:
- The non-surgical approach. Splints, modification of activity, medication, injection in selected cases, and hand therapy. This is often sufficient in early-stage nerve compressions and in problems of the tendon sheath.
- Surgery. It is undertaken if the complaint persists, if loss of strength or wasting of the muscle has begun, or if restricted movement is affecting daily life. In nerve compressions the aim is to relieve the pressure on the nerve; in cases that come late, recovery of the nerve may not be complete.
- Microsurgery. Reattaching a severed finger, repair of nerves and vessels, nerve grafting and free tissue transfer are carried out by this means. Working under magnification makes it possible to repair structures measured in millimetres.
- Treatment of fractures. In undisplaced fractures a splint may be sufficient; where there is displacement, and in fractures involving the joint, fixation with a screw, a plate or wires is required. In fractures of the hand the aim is not union alone, but to allow early movement.
Rehabilitation: half of the result
In the hand, the success of an operation depends on the rehabilitation that follows it. A hand that stays immobile for a long period becomes stiff; tendon adhesions and joint restriction develop.
For this reason hand therapy is an obligatory part of treatment in most cases: control of oedema, a programme of controlled movement, scar care and graded strengthening. Adherence to the programme affects the outcome as much as the surgical technique does.
In cases where a sensory nerve has been repaired, recovery takes months and is gradual; knowing this from the outset sets expectations correctly.
Assessment
In the hand, early diagnosis and correct timing are decisive. In nerve compressions, an intervention carried out before wasting of the muscle has begun gives a far better result than a delayed one; in tendon and nerve cuts, it is important that the repair be made within the first few days.
If you have numbness, loss of strength or restricted movement in your hand, or a persistent complaint following an injury, you are welcome to book an appointment for assessment.