Handsurgery

• 24h Replantationservice (operative salvage of severed limbs and fingers with reconstruction of bone, tendons, soft tissue, nervous- and vascular structures)
• Reconstructions after open fractures on hands and forearm
• Bone elongation using distraction devices
• Vascularised bone implants
• Delayed reconstruction of severed peripheral nerves via transplantation
• Tendon transfers
• Surgical treatment of nerve compression problems
• Reconstruction for congenital deformities of the hands
• Rheumatic arthritis surgery (eg replacement arthroplasty)

Dupuytren's Contracture

Dupuytren's contracture is a disorder of the skin and underlying tissue on the palm side of the hand (palmar aponeurosis). Thick, scar-like tissue forms under the skin of the palm and may extend into the fingers, pulling them toward the palm and restricting motion. The condition usually develops in mid-life and has no known cause (though it has a tendency to run in families). Surgery is the only treatment for Dupuytren's contracture. The surgeon will cut and separate the bands of thickened tissue, freeing the tendons and allowing better finger movement. Occasionally the tight bands around the joints will need to be freed as well. The operation must be done very precisely, since the nerves that supply the hand and fingers are often tightly bound up in the abnormal tissue. The results of the surgery will depend on the severity of the condition. You can usually expect significant improvement in function, particularly after physical therapy, and a thin, fairly inconspicuous scar.

Carpal Tunnel Syndrome

The carpal tunnel is a passageway through the wrist carrying tendons and one of the hand's major nerves (Medianus nerve). Pressure may build up within the tunnel because of disease (such as rheumatoid arthritis), injury, fluid retention during pregnancy, overuse, or repetitive motions. The resulting pressure on the nerve within the tunnel causes a tingling sensation in the hand, often accompanied by numbness, aching, and impaired hand function. This is known as carpal tunnel syndrome. Compression of the nerve can also be diagnosed using special investigations that a neurologist performs. In some cases, splinting of the hand and anti-inflammatory medications will relieve the problem. If this doesn't work, however, surgery may be required. In the operation, we make an incision from the middle of the palm to the wrist. We will then cut the tissue that's pressing on the nerve, in order to release the pressure. A large dressing and splint are used after surgery to restrict motion and promote healing. The scar will gradually fade and become barely visible. The results of the surgery will depend in part on how long the condition has existed and how much damage has been done to the nerve.

Scaphoid fracture

The scaphoid bone (also called navicular bone) which lies at the base of the thumb, is one of the functionally most important bones in the wrist. It can fracture when a large force is put on the wrist, such as falls onto the hand. This will cause pain and swelling of the wrist, although sometimes it will go unnoticed as it will merely feel like a minor sprain. Therefore it is very important to present early to the hospital, where X-rays will be made in order to visualize the bone. In some cases, the fracture will not be detectable, but if the diagnosis is supported clinically, a special plaster cast will still be applied. Follow-up X-rays 2 weeks later will then be made, at which time the fracture lines will be visible. CT or MRI scans can also aid in making the correct diagnosis when patients complain of persistent pain in the wrist. When diagnosed, undisplaced fractures can be treated conservatively in a plaster cast for about 10-12 weeks. Operative techniques include screw fixation if the fragments need to be put together again. Non-union of the scaphoid bone is a complication that can occur if the two fragments don’t heal properly. In these cases, a more complex operation will be performed in order to reduce the risk of arthritic changes in the long-term.

Hand Injuries

The most common procedures in hand surgery are those done to repair injured hands, including injuries to the tendons, nerves, blood vessels, and joints; fractured bones; and burns, cuts, and other injuries to the skin. Modern techniques have greatly improved the surgeon's ability to restore function and appearance, even in severe injuries. Among the techniques now used by plastic surgeons: Grafting - the transfer of skin, bone, nerves, or other tissue from a healthy part of the body to repair the injured part; Flap surgery - moving the skin along with its underlying fat, blood vessels, and muscle from a healthy part of the body to the injured site; Replantation or transplantation - restoring accidentally amputated fingers or hands using microsurgery, an extremely precise and delicate surgery performed under magnification. Some injuries may require several operations over an extended period of time. In many cases, surgery can restore a significant degree of feeling and function to injured hands. However, recovery may take months, and a period of hand therapy will most often be needed.
Some fractures of the hand can be treated conservatively with immobilisation in a plaster cast for 4-6 weeks. Sometimes, early active physiotherapy is necessary to optimise the outcome and prevent contractures of joints and tendons. Open, complicated or fractures involving the joints need to be operated on. Techniques include wires, screws and plates, which hold the bones in the natural position in order to heal. The material will need to be removed in some in order to optimize rehabilitation of motion and function after the fractures have healed.
We as Plastic Surgeons are also involved in restoring damaged tendons, nerves and blood vessels in the hand. Using microscopic techniques, nerves are sutured together to allow a gradual regeneration to regain sensation in the affected part (nerves grow about one millimetre per day). Tendons can be sutured, but these regain near complete strength only after a few weeks. Therefore it is extremely important to follow the post-operative instructions of the surgeon and physiotherapist very closely.
Trigger finger
Trigger finger (stenosing tenovaginosis) affects the movement of the tendons of the hand. The tendons are held in place on the bones by a series of ligaments called pulleys. These form a tunnel-like ‘sheath’ on the surface of the bone through which the tendons run. The sheath is lined with a slippery coating called tenosynovium, which helps to prevent friction and keeps the tendons running smoothly. This is essential to allow the fingers and thumb to bend normally. The opening of the sheath is in the palm, at the base of the fingers. In trigger finger, the smooth running of the tendon can be damaged because the opening of the sheath has thickened. In most cases the cause is unknown. As a result of this thickening, the tendon gets caught in the opening of the sheath when the finger is bent and gives a painful click, like a trigger, as it is straightened. In some instances the finger simply won’t bend properly and, in others, the tendon develops a nodule (bump), which can also catch at the mouth of the sheath. Surgical intervention is indicated if other medical treatments have not improved the problem. In a minor procedure, the affected pulley is cut allowing free gliding of the tendon thereafter.

De Quervain´s tendonitis

Tendonitis is inflammation or irritation of a tendon. Some tendons are covered with a protective and lubricating sheath of tissues, called the synovium. In many cases the sheath is more affected by inflammation than the tendon is. This condition is called tenosynovitis, although both conditions often happen at the same time. In de Quervain`s, the tendons of the thumb are affected. When the sheath is narrowed because of inflammation, movements of the thumb will be painful. During operation, the sheath is opened to release the tendons and allow better and pain free gliding. Inflamed tissue will be excised to prevent the condition from recurring.

Ganglion

A ganglion is a small cyst that contains a thick jelly-like material. It looks and feels like a smooth lump under the skin. It is usually attached to a joint or tendon, and the fluid inside is like a thicker version of the fluid which 'lubricates' the joint and tendon sheaths (synovial fluid). The two common sites where they are found are on the back of the wrist and on the top of the foot next to the small joints. Other sites of the body are affected less commonly. Sometimes they are mildly painful, particularly if they lie next to a nerve. They can very gradually enlarge to the size of about 1-2 cms. This can make them unsightly which is why most people want them removed. Occasionally, they go away on their own without any treatment.  Surgical removal of the ganglion is the most successful and permanent cure. This is a relatively minor operation. Rarely, after a ganglion is removed, one recurs again at the same site. However, after having it surgically removed a recurrence is much less likely to occur than after other treatments like aspiration.

Rheumatoid Arthritis

Rheumatoid arthritis, an inflammation of the joints, is a disabling disease that can affect the appearance and the function of the hands and other parts of the body. It often deforms finger joints and forces the fingers into a bent position that hampers movement. Disabilities caused by rheumatoid arthritis can often be managed without surgery-for example, by wearing special splints or using physical therapy to strengthen weakened areas. For some patients, however, surgery offers the best solution. Surgeons can repair or reconstruct almost any area of the hand or wrist by removing tissue from inflamed joints, repositioning tendons, or implanting artificial joints. While the hand may not regain its full use, one can generally expect a significant improvement in function and appearance. Still, it's important to remember that surgical repair doesn't eliminate the underlying disease. Rheumatoid arthritis can continue to cause damage to the hand, sometimes requiring further surgery, and regular follow-up with the rheumatologist for continuing care.

Thumb base arthritis

The trapezium is one of the eight carpal bones and lies at the base of the thumb. Arthritis in this joint is very common. It is a progressive condition that leads to increasing stiffness and deformity in the thumb. Pain is common especially in women over the age of 50yrs. Loss of power in the thumb is one of the early signs of the disease, affecting for example the ability to open a bottle. Methods for relieving discomfort in any arthritic joint, whether it is the hip, knee, shoulder or base of the thumb are the same. Surgery is the only definitive treatment for persistent symptoms where conservative measures have failed, such as pain-killers, splints or steroid injections.  There are several options available, two of which are commonly performed by us: Trapeziectomy with ligament reconstruction involves the complete removal of the trapezium bone and suspension of the bone to the thumb using one of the tendons. Joint Replacement is another option.

Cubital tunnel syndrome

Cubital tunnel syndrome occurs when the ulnar nerve is pressed at the level of the elbow on the inner side of the joint (funny bone area). The nerve passes through a narrow tunnel called the cubital tunnel. This causes pins and needles in the little, and ring fingers and the inner side of the forearm. This commonly occurs at night and the patient is often awakened from sleep with the pins and needles and has to shake their hands to gain relief. Occasionally in severe cases the muscles on the front of the palm on the little finger side can become wasted causing a hollow. In such severe cases the thumb may be weak or clumsy. Nerve conduction studies are used to record the speed of the nerve across the elbow joint to help with the diagnosis. Operative treatment aims to divide the thick band of tissue called the transverse ligament at the elbow in order to allow the contents of the cubital tunnel to be decompressed. Having released this ligament the elbow is bent and straightened to ensure that the nerve is stable and does not pop out from behind the funny bone. If it does the nerve needs to be brought forward in front of the funny bone permanently.

Congenital Deformities

Congenital deformities of the hand can interfere with proper hand growth and cause significant problems in the use of the hand. Fortunately, with modern surgical techniques most defects can be corrected at a very early age-in some cases during infancy, in others at two or three years-allowing normal development and functioning of the hand. One of the most common congenital defects is syndactyly, in which two or more fingers are fused together. Surgical correction involves cutting the tissue that connects the fingers, then grafting skin from another part of the body. The procedure is more complicated if bones are also fused. Surgery can usually provide a full range of motion and a fairly normal appearance, although the colour of the grafted skin may be slightly different from the rest of the hand. Other common congenital defects include short, missing, or deformed fingers, immobile tendons, and abnormal nerves or blood vessels. In most cases, these defects can be treated surgically and significant improvement can be expected.