Understanding Hand Surgery: What You Need to Know

Hand surgery is a specialized field that focuses on treating conditions affecting the hand, wrist, and forearm. Whether due to injury, disease, or congenital issues, hand surgery can significantly improve a person's quality of life. In this post, I will explore the various aspects of hand surgery, including common procedures, recovery expectations, and when to seek help.

What is Hand Surgery?

Hand surgery encompasses a range of surgical procedures aimed at restoring function and alleviating pain in the hand and wrist. This field combines elements of orthopedic surgery, plastic surgery, and microsurgery. Surgeons in this specialty are trained to handle both complex and simple conditions.

Hand surgeons works very closely with Hand therapists, who are equally specialized in the rehabilitation of the hand.

Types of Hand Surgery

Hand surgery can be divided into

1. Surgery of the skin and soft tissues of the hand - for cancers, lacerations and Dupuytren's disease, ganglions, Giant Cell Tumours etc

2. Tendons - when they are cut, or used to help move the fingers, when the nerves powering muscles no longer work, or whether they need re-alignment in Rheumatoid Hand disease

3. Nerves - are repaired and released, when they are pinched

4. Bones - can be broken, and suffer from tumours within the bone (e.g. Enchondroma etc), which leads to fractures

5. Joints - wear out due to OsteoArthritis

Common Conditions Treated (more to come!)

Several conditions may require hand surgery. Here are some of the most common:

• CARPAL TUNNEL SYNDROME:

• This condition occurs when the median nerve is pinched at the wrist, leading to pain, numbness, and weakness in the hand.

• What is carpal tunnel syndrome? 

  The Median nerve supplies the palmar aspect of the thumb, index and middle fingers with sensation and the short muscles of the thumb with motor function. It passes through the Carpal tunnel at the wrist together with all the tendons to the fingers. The carpal tunnel is found at the base of the palm. It is formed by the bones of the wrist and the transverse carpal ligament. Increased pressure in the tunnel affects the function of the median nerve. If the Median nerve is compressed (pinched) at the wrist you may experience tingling of these fingers, increased clumsiness and perhaps pain especially at night; this is called Carpal Tunnel Syndrome (CTS). 

  What causes carpal tunnel syndrome? 

  Usually the cause is unknown, but CTS is associated with Rheumatoid Arthritis, Diabetes, Thyroid disease, Pregnancy, joint dislocations and fractures. 

  Diagnosis of carpal tunnel syndrome 

  The diagnosis can usually be made on the history and simple examination. Sometimes you will  also be examined by a physiotherapist to exclude any pinching of the nerve in the neck. Neuro-physiological tests (Nerve Conduction Study or Electro-myogram), bloodtests and xray may be done to make sure and to measure the severity of the CTS. 

  Treatment of carpal tunnel syndrome 

  CTS can be treated with or without surgery: steroid injections, splinting and surgery. Your doctor  will guide you to which option is best for you. 

  Carpal Tunnel Syndrome 

  Symptoms can sometimes be controlled with straight night-splints and or Steroid injections in the wrist. The splint prevents the wrist bending at night, as this position produces a pressure on the nerve. The Steroid injection reduces the pre-existing swelling of the nerve and thereby reduces the pressure in the nerve. The injection can be done at the consultation under Local Anaesthesia, but you must take some pain killers when you return home as the hand will be painful, once the local anaesthesia wears off. During the injection, you may feel tingling in the fingers or even a sharp pain radiating to the fingers. This happens if the nerve is accidentally touched. The needle is then withdrawn a little before the injection is done. Surgery makes more space for the nerve and is usually done under Local Anaesthesia as a Day Case. The Transverse Carpal Ligament (see above) is divided through a small incision in the palm and the skin is stitched up with dissolvable sutures.  

  You will wear a bulky dressing for the next 5 days only, but the scar will take two full weeks to heal and you should have normal hand function after four to 6 weeks. 

  The possible complications of this surgery are: 

  Infection (very rare) 

  A bleed in the palm after the surgery 

  Wound dehiscence (wound comes apart, this will be treated with dressings until the wound is healed) 

  Pillar pain (pain on using the palm of the hand to get up from a sitting position, this is usually treated with a splint) 

  Painful scar (the scar will be red and ittitated for 2 months)

  Complex Regional Pain Syndrome (pain disproportionate with the procedure, needs urgent attention) – very very rare 

  Incomplete recovery of the sensation and muscle function of the hand (if the nerve compression has been very long-standing pre-operatively)

• Recovery : 4-6 weeks, sometimes 8 weeks,

• Driving: 4-6 weeks, once you can make an emergency manoeuvre

• Lifting anything heavy/gym: 8-12 weeks

Another nerve which is commonly pinched is the Ulnar nerve:

CUBITAL TUNNEL OR GUYON'S CANAL RELEASE  

The ulnar nerve provides sensation to the little and ring fingers and activates many of the  small muscles in the hand. The nerve passes behind the elbow where it can be felt and is  referred to as the “funny bone”. At the elbow, it runs through a tight tunnel (cubital tunnel).  

In some people, this tunnel is too tight for the nerve. Mild  

pressure causes occasional "pins and needles". Severe pressure  

causes the fingers to become numb and the muscles of the hand  

waste away which causes weakness and difficulty in straightening  

the fingers.  Occasionally the nerve is alos pinched where it passes to the hand through the wrist, next to the median nerve, but in a different compartment (Guyon's canal).

The nerve gradually withers if the condition is not treated. This  

causes permanent loss of sensation and wasting of hand muscles  

which cannot be relieved by surgery.  

Correction of this problem involves opening the roof of this tunnel  

to relieve the pressure within the tunnel. Occasionally, when  

there is arthritis or scarring in the area, some bone needs to be  

trimmed and/or the nerve has to be moved to the front of the elbow.

Nerve transfers If you have severe nerve wasting, I perform a nerve transfer, which means taking a nerve and connecting it to the ulnar nerve at the wrist, boosting the number of nerve fibres and impulses to the nerve. 

Tendon transfers If you are unable to bring your pinky to the side of the ring finger, and it continues to stick out, this can be corrected by a tendon transfer from the pinky to the ring finger and if you already have “clawing” of the ring and little fingers, this too can be corrected by a simple tendon transfer from the ring finger flexor tendon. There are lots of options here to improve your function.

The operation is usually performed under regional anaesthetic, but can be performed under local anaesthetic only. 

Hand movement should be continued and you should perform  

normal light activities after the operation.  

You will be discharged with a bulky dressing, consisting of wool and a crepe bandage over a light compressive. The dressing can be removed after five days and the wound covered with a BandAid. Once all  dressings are removed, it is safe to get the hand wet in a bath or shower. There obviously  will be some swelling and bruising. Look out for any redness or tenderness in the area  around the wound that might indicate an infection. Do not apply antiseptic but please contact the office if you are worried. 

You should try to move the elbow carefully but normally. You can drive a car after 2 weeks as long as  you are comfortable. Timing of your return to work is variable according to your  occupation and you should discuss this. Possible complications include: -  

Wound Possible problems include swelling, bruising, bleeding, blood collection under the  wound (haematoma), infection and splitting of the wound (dehiscence).  

Scar You will have a scar on the inside of the elbow, which will be firm to touch and  tender for some months. This can be helped by firm massage with the moisturizing cream.  

Neuroma A small nerve running in the region can be damaged during the surgery and  form a painful spot in the scar (neuroma). This complication is very rare but may require a  further operation to correct.  

Numbness There are two nerves which supply the area on your elbow and sometimes they are divided during surgery which leads to a permanently numb elbow.

Regional pain syndrome About 3% of people are sensitive to hand surgery and have pain disproportionate to the surgery afterwards, please contact the office as soon as possible if you feel this is the case.

Outcome Improvement after surgery can be modest, particularly in patients who have  more severe compression. Muscles that have wasted rarely recover. Recovery of feeling  is slow and often incomplete. The operation is intended to prevent further deterioration. 

• TENOSYNOVITIS/TRIGGER FINGER

• This is a very common and very painful condition, which we think arises because of some kind of injury to the flexor tendon, which then swells and cannot pass under the pulley (the structures in the hand designed to keep the tendon gliding close to the finger bones, when we bend the fingers, instead of bowstringing). This turns into clicking, locking and pain.

  Trigger fingers can be treated with Cortisone injections or surgery. Cortisone injections carry the risk of a flare, tendon rupture, infection and if you are diabetic, fluctuations in your blood sugars for the first 24 hours.

  Cortisone may not be a permanent solution for you, although 60-70% patients respond favourably long term. If you have a poor result from a cortisone injection, or you have many trigger fingers, it may be better to proceed to a surgical release, which is done under local anaesthesia in the clinic. All surgery to the hand carries risks, and these are detailed on this page further down.

• DE QUERVAIN'S TENOSYNOVITIS

  What is De Quervain's tenosynovitis or “washerwoman’s sprain”? 

  De Quervain's tenosynovitis is an inflammation of the sheath surrounding the tendons and  the tendons themselves, which moves the thumb on the side of the wrist and at the base of  the thumb. It can be brought on by a simple strain injury or repeated stresses of the tendons  of the thumb. It causes pain on movement, especially turning a key, wringing out clothes or  any movement which puts strain on the thumb. Occasionally a painful swelling in the area is  seen and felt. 

  How is De Quervain's tenosynovitis diagnosed? 

  De Quervain's tenosynovitis is diagnosed based on the typical appearance, location of the  pain, and tenderness in certain hand positions. There are many other problems which can  cause pain in this area and an accurate diagnosis by a specialist hand surgeon is therefore  paramount for the correct treatment. 

  How is De Quervain's tenosynovitis treated? 

  In the first instance it is treated with rest in a brace. Regular analgesia in the form  of NSAIDs (Non Steroid Anti Inflammatory Drugs), such as Voltarol or Ibuprofen is very  beneficial. Because the pathology of this condition is inflammation it takes a minimum of 6 weeks before a conservative treatment plan is effective. Some cases do not respond to  conservative treatment and surgery is advised. This is performed under local anesthesia in ambulatory care. The sheath surrounding the tendons is opened through a very small  skin incision, allowing the tendons to run freely. You will have to wear a bandage following the operation as well, but only for two weeks. 

  Early diagnosis and treatment is paramount.

• 
  

• DUPUYTREN'S DISEASE

• 
  

  Dupuytren's contracture/disease is a thickening of connective tissue (fascia), which passes from the palm into the fingers, and is more superficial than the tendons. In the palm, the characteristic nodules and cords are visible, as are palmar pits (indrawing of the skin). Some people have Garrod's pads which are a thickening of the knucklepads. The disease is related to two other conditions : Ledderhosen's disease, which consists of plantar nodules on the sole of your foot, and Peyronie's disease, which gives you a curvature of the penis. 

  The disease is genetic, which means that often, but not always , you have a positive family history of Dupuytren’s disease. It is more common in men and in people with diabetes, epilepsy, liver disease. HIV or those who have injured the hand/forearm previously. Both alcohol consumption and smoking increase the risk of its appearance. Its progression is unpredictable but its appearance at an early age (<40years), particularly combined with a strong family history, predicts an aggressive course with multiple operations.  

  
  

  The condition continues to evolve and depending on the stage of disease, and the degree of contracture present there are a number of potential treatments, most of which include some form of surgery.

  Nodules can be treated with radiotherapy, best discussed with a radiation oncologist (available in Ottawa at The Ottawa Hospital, specifically at the General Campus and the Irving Greenberg Family Cancer Center). 

  Surgery is delayed until you are unable to place your hand flat on the table (table top test). 

  Results are poor if the fingers are allowed to become very bent. There are a number of techniques that can be combined.  

  Collagenase Injection is not available in Canada. 

  Fasciotomy The cords are cut through small cuts in the palm with the bevel of a needle (needle  aponeurotomy) in the clinic. This is suitable for very well-defined cords, palmar involvement, mild contractures or patients who are unfit/unsuitable or who do not wish more complicated surgery. Recovery is fast, the complications are few and the recurrence rate high.  

  Fasciectomy Correction is usually done by removal of the diseased fascia. The entire wound is stitched up in a zigzag manner which lengthens it but occasionally, a segment of the wound in the palm is not stitched,  being left open to heal by itself (open-palm technique).

  Dermatofasciectomy - If the disease is stuck to the overlying skin or you have a contracture > 50 degrees, you may be a candidate for dermatofasciectomy. A small full thickness skingraft if taken form usually the same upper inner forearm and this donor site is closed directly. The whole shin including the underlying disease is removed from the finger, which is then straightened. The skin graft is stitched in place and takes about 4- 6 weeks to take fully, at which point you can do without any dressing at all.

  
  

  The more encompassing operation , the lower the recurrence rate, but the higher the complication rate and the longer the rehab. Which operation is suitable for you, depends on how bent your fingers are, how much the skin is involved and whether the disease presents as a single cord or a more diffuse disease. This is all things we can talk about at the consultation.

• Amputation of a finger(s)

The amputation of a finger or thumb may be the result of trauma, or may be required to treat advanced deformity, which cannot be corrected, or because of cancer. The level of amputation is variable and may be dictated by the presenting problem although there may be several options: It is good to preserve as much length as possible particularly for the thumb, and this can be done with moving skin and soft tissue around at the thumb or importing it from the hand or forearm. For the fingers, the options exist of a ray amputation, which removes the finger AND the bone it sits on (the metacarpal), for a more aesthetic result and sometimes a more functional result).

Simple finger amputations are performed under local anaesthetic unless there are other injuries or if there is strong patient preference. Amputations at the palm level are more complex and require either a regional (block) or a general anaesthetic. 

Finger amputation is often followed by complications and revision rates of 20% are reported  after trauma. Tenderness and pain is a frequent problem and reasons include loss of soft-tissue padding,  bony protrusion, neuromas, altered sensation and nail problems (keeps growing in a spike). 

Potential complications:

Wound Possible problems include swelling, bruising, bleeding, blood collection under the wound  (haematoma), infection and opening of the wound (dehiscence). 

Scar The finger-tip will be firm to touch and tender for some months. This can be helped by a desensitization programme, led by Hand Therapy)

Suboptimal function Mainly due to loss of length and sensation, also tenderness and other issues such  as altered skin quality due to skin-grafting. 

Stiffness May result from direct damage to joints and tendons but more often is due to adhesions  forming whilst the finger(s) is swollen, dressed and not moving. It can affect more than just the  injured finger and is prevented by hand elevation and exercises. 

Nail Remnants can persist causing nail-spikes and discomfort. Nail ablation (total removal of the nailplate) is usually required. 

Inclusion cysts Small fragments of skin can be driven into the wound at the time of injury. Later,  they cause a cyst due to the normal shedding of cells and skin oil. Removal is required. 

Neuroma When a nerve is cut, it tries to repair itself. The nerve fibres continue to grow from  the cut end, and produce as a swelling that is called a neuroma. If the  

nerve ending is superficial and/ or some of the nerve fibres grow into scar  

tissue, the area can be very painful. This may require shortening and  

separation of the nerve ending away from the tip of the finger. 

Sensory change Touch sensation is often reduced or altered, being  

described as “numb”, “pins and needles”, “funny”. The tip may never feel normal and this is  permanent and irreversible. 

Cold intolerance An exaggerated or abnormal reaction of the finger to cold exposure causing  discomfort, stiffness, altered sensibility and colour change, which may appear in isolation or in any  combination. This is very common after trauma, may be permanent or only last a few years. To avoid this, please keep your hands warm in winter) 

Regional pain syndrome About 3% of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after the operation. If you experience pain which is beyond your expectations, please let me know sooner rather than later. It is important that you take your painkillers regularly post operatively, and not only when you feel pain. The better your pain is controlled in the first week post operatively, the fewer painkillers you take all in all. CRPS cannot be predicted,  is variable in severity and is principally treated with hand therapy and painkillers, by a chronic pain specialist. 

Phantom limb sensation: Sometimes it is just an awareness of the finger (which is no longer there),  but occasionally it can be painful, particularly if previous treatment has been prolonged and/or the finger was  painful before amputation. This affects 60-80% of patients to a variable degree.

EXTENSOR TENDON INJURY (MALLET FINGER)  

• The tendon that straightens the very tip of your finger has been damaged. This causes the  finger to “droop” across the joint at the end of the finger (DIPJoint). This is called a “mallet” deformity. If the injury is not corrected, the tendon will not heal and you will not be  able to straighten the tip of that finger again. The injury may be “open” due to a cut or “closed” due to the tip of  the finger being stubbed or crushed, and the injury is called a bony mallet, if the underlying bone is fractured.

  Open The injury is likely to have passed through the  

  tendon into the joint. The cut will be explored and  

  washed out with saline under local anaesthetic. The  

  tendon is stitched together and the joint braced 8 weeks.

  Closed The tendon is usually pulled cleanly off the  

  bone. These injuries are best treated by splinting, the  

  results of which are generally better than surgery with  

  fewer complications. The tendon should heal if kept in  

  the right position for 8 weeks constantly.  

  You will be provided with a splint, which must be worn continuously for 8 weeks. If the splint is removed and finger is allowed to droop during this time, the snapped area will re-open. If  you wish to remove the splint in order to wash the finger, support the tip of the finger on a surface..

  During this time, whilst you are wearing the splint, you can continue to use the hand almost normally. It is important not to let the central joint (PIPJ) get stiff and this should be actively exercised each day. If the splint prevents this joint from moving, is uncomfortable or loose, it must be refitted.  

  I refer you to a hand therapist who will take you through all of this.

  This form of non-surgical treatment is not always successful. It is common to be left with a slight loss of the ability to straighten the finger-tip and slight stiffness at the DIPJoint compared with the other fingers. In general, the more conscientious you are about following this program, the more likely it is you will have a good result. A minority of  patients require an operation if the tendon fails to heal with splinting.  

  Fractures A small fragment of bone pulled off with the tendon is braced as above. Bigger and/or more complicated fractures damage the joint surface, and can cause translation (slippage) of the bone. This can lead to persistent  deformity and later arthritis and may need fracture fixation surgery.

  
  

  Where does it hurt and where is your problem? This can give you an idea what the problem is.

• 

  CMCJ= CarpoMetaCarpalJoint - Osteoarthritis

• DIPJ= Distal Interphalangeal Joint - Osteoarthritis, mallet fingers,

• A1 pulley= trigger finger (usually)

• Carpal Tunnel (at the base of the hand)

• To Be Continued!

  
  

Preparing for Hand Surgery

Preparation is key to a successful surgery. Here are some steps to take before your procedure:

• Consultation: Meet with your surgeon to discuss your condition, treatment options, and what to expect.

  
  

• Medical History: Please provide a complete medical history, including any medications you are taking.

  
  

• Arrange for Help: Plan for someone to assist you after surgery, as you may have limited use of your hand. Do your shopping in advance, arrange help with cleaning, pet care etc

  
  
  
  

Recovery After Hand Surgery

• Follow-Up Appointments: Attend all scheduled follow-up appointments to monitor your progress.

  
  

• Hand Therapy: Depending on the procedure, Hand therapy is recommended to regain strength and range, and the hand therapist will also help make splints or braces for you to protect the surgery.

  
  

• Pain Management: You should take regular painkillers after surgery. There is no benefit in you having pain, and whilst not all pain can be eliminated, you should be comfortable.

  
  

• Activity Restrictions: The surgery you have had, will determine how long you have to wait until you can drive, play sports etc

  
  
  
  

When to Seek Help

It is essential to know when to contact your surgeon after hand surgery. Here are some signs that may require immediate attention:

• Increased Pain: If your pain worsens instead of improving, reach out to the office, or is outside working hours, go to the nearest Emergency Department

  
  

• Swelling or Redness: Significant swelling, redness, or warmth around the surgical site may indicate an infection.

  
  

• Numbness or Tingling: If you experience new numbness or tingling, it could be a sign of nerve compression.

  
  

• Fever: A fever may indicate an infection and you should be seen asap