Hand and Wrist Surgery
Some of the more common hand problems include:
Ganglion
A ganglion is a cystic swelling which is entirely benign in nature, filled with a clear jelly-like substance and associated with either a joint or tendon sheath. They occur commonly over the back of the wrist, the front of the wrist over the radial pulse, the base of the fingers on the palmar aspect and on the back of the fingers near the joints. In the latter position the pressure they exert may cause grooving of the nail. The underlying joint in this situation often has a little wear-and-tear damage to it and they thus occur in slightly older people. Otherwise they occur commonly in younger people and besides a little pain when they first appear are usually symptom free besides just “being there”. Some deeper ones are painful and may cause other problems such as pinching of nerves.
Why do you get ganglia?
The precise cause is not known although it is postulated that some degenerative changes of the tissues around joints and/or tendons occurs possibly as a result of trauma. They often come and go and may even disappear – most will eventually disappear if you wait long enough! It depends how patient you are and how much problem your ganglion is giving you.
What can be done about it?
Waiting may be the most sensible option. A good slap with the family bible was the recommended treatment for millennia! This will spread it out but it will be painful and the ganglion will almost certainly come back. Other options include sucking the jelly out of the cyst, this may include putting a steroid injection back in, but both of these lead to high recurrence rates. Surgery is the next step but it is important to realise that even this procedure does have a certain recurrence rate. This does not mean the surgery was inadequate; they just tend to come back again
What operations may be suggested to you?
This is a day-case procedure. Under either local or regional anaesthetic the arm or finger will be numbed. The scar left after excision of the ganglion will depend on where the ganglion is – often a transverse scar over the back of the wrist and base of the finger, maybe a little flap on the back of the finger.
What about potential complications?
Infection Any operation can be followed by infection and this would be treated with antibiotics and dressings.
Scar You will have a scar that will be somewhat firm to touch and tender for 6-8 weeks. This may be helped by massaging the area firmly with a moisturizing cream.
Stiffness This can occur if the hand is not used and exercised after the operation. About 5% (1 in 20) of people are sensitive to hand surgery and their hand may become swollen, painful and stiff after any operation (algodystrophy). This problem cannot be predicted but will be watched for afterwards and treated with physiotherapy
Recurrence Up to 10% (1 in 10) of ganglions return after being removed.
Nerve Nerve damage can occur during your surgery and this results in either a painful spot in the scar (neuroma) or some loss of feeling in the hand. This complication is very rare but may require a further operation to correct.
Artery Ganglions on the front of the wrist are often very close to major arteries. Damage to the arteries is very rare and can be immediately repaired.
Nail Ganglions on the tip of the finger often cause a groove in the nail. It usually settles after the operation but occasionally it can persist after or result from the surgery.
Carpal Tunnel Syndrome
What is the Carpal Tunnel and Carpal Tunnel Syndrome?
The carpal tunnel is a tight tunnel lying beneath the base of the palm, which carries all the flexor tendons from the forearm to the hand. It also carries the important ‘median nerve’ – a nerve carrying fibres that supply some of the small muscles of the hand and sensation to the thumb and next 2½ fingers. The tunnel is surrounded by very tough ligament.
In normal circumstances, this tunnel is a very snug fit of tendons and nerve. However, if anything happens to increase the volume of the tunnel contents, or decrease the size of the tunnel itself, ‘carpal tunnel syndrome’ may occur. The nerve becomes ‘trapped’, resulting in numbness and tingling (pins and needles) of the thumb and next 2 ½ fingers. In many cases this is worse at night-time and may even cause a pain which can radiate up the whole length of the arm.
In the early stages, the symptoms are reversible but, over time, the muscles at the base of the thumb can become weak and wasted, causing major functional problems for the hand. Some permanent numbness, especially of the finger tips, may also always remain.
Why would I get Carpal Tunnel Syndrome?
Carpal Tunnel Syndrome (CTS) can affect anyone, rarely children, at any time in life. The most common cause is fluid-retention, hence the syndrome occurs more commonly during pregnancy and in middle-aged women in response to hormonal changes. The syndrome is also associated with under-function of the Thyroid gland (myxoemedema), and any thickening of the tendon sheaths in this area (as a result of rheumatoid arthritis, ganglions or wrist-fracture) may also contribute to CTS.
It is highly unlikely that you have contributed personally to CTS or that you could have prevented it in any way. Sometimes, similar patterns of symptoms can be produced as a result of repetitive strain injury (RSI), but this, and its treatment, is quite separate from CTS.
What can be done about CTS?
In the early stages of the syndrome, considerable relief can be provided, especially at night-time, by wearing a simple wrist-splint. In patients who have a potentially reversible cause, such as pregnancy, a steroid injection can also provide temporary relief of the symptoms. Where the syndrome is more pronounced, however, surgery to decompress the tunnel is necessary. The surgery will relieve the feeling of pins and needles and pain, but numbness and weakness could well take longer to recover, especially in the elderly. The surgery involves the cutting of the tough ligament around the tunnel and is usually performed under local anaesthetic as a day case procedure.
How long will it take to recover?
Recovery times vary considerably depending on the exact nature of your symptoms at the time of the operation. Sutures are normally removed by the Hand Therapist a week to ten days post-operatively.
Where the symptoms are treated early, a full recovery of grip strength and sensation is common, and, after time, all symptoms of tingling, pain and numbness will disappear. Recovery can be very slow (6-12 months) and as the nerves grow back, the fingers may feel tingly and even slightly unpleasant. Your grip will be slightly weaker than usual, but this will improve gradually over six months. You will be left with a scar across the palm, and sometimes also the wrist, that may be tender for 6-8 weeks after the operation.
Dupuytren's Contracture
What is Dupuytren’s Contracture?
Dupuytren’s Disease describes a thickening of the deep tissue that passes from the palm into the fingers, that causes the fingers to be bent back towards the palm over time - Dupuytren’s Contracture. It frequently affects the palm with nodules and contractures of the little and ring fingers, but may affect any fingers (or thumbs) of either hand.
It may also affect the soles of the feet.
Symptoms usually start as a small nodule or pit in the palm of the hand, which can then develop into bands of shortened tissue that effectively pull the fingers back towards the palm (the Contracture). Dupuytren was a French surgeon of the early 19th Century.
Why would I get Dupuytren’s Contracture?
There is no known cause for the contracture, although it does tend to run in families. It may also be noticed after trauma to the hand (including surgery), in some diabetics, epileptics or in some individuals with liver disease.
There is no truth, however, that the condition is related to excess alcoholic intake.
What can be done about Dupuytren’s Contracture?
A considerable amount of research is taking place to create a drug treatment for the condition. Recently the injectable drug Xiapex – a collagenase enzyme - has been developed which is now licensed in the UK.
Surgery is still the mainstay of treatment once the condition becomes progressive with finger contractures. Untreated, Dupuytren’s Contracture can result in all affected fingers being pulled into the palm and significant loss in hand function.
The three most common operations to treat this condition are:
Needle Fasciotomy
Under local anaesthetic the Dupuytren’s bands in the palm are cut using a needle. This is especially suitable for elderly or infirm patients who cannot tolerate any more formal anaesthetic. Other busy working people may think this is a simpler, quicker alternative but the problem is that it is associated with a very high recurrence rate.
Fasciectomy
This involves the removal of the affected tissue to correct the bent joints. The entire wound is then stitched up in a ‘zig-zag’ manner, but a segment of the wound in the palm may be left open to facilitate physiotherapy and will heal by itself (open-palm technique).
The operation is usually performed as a day-case under an anaesthetic that numbs the entire arm. Occasionally a general anaesthetic and overnight stay are necessary.
Dermofasciectomy
In some cases it is also necessary to remove the skin overlying the affected tissue. This may be because the skin is stuck to the bands/nodules of affected tissue and cannot be moved over them, or where the problem has recurred after previous surgery. The skin may also be removed in younger patients (20-40) who can be prone to further problems after a simple fasciectomy.
In this procedure, the removed skin is replaced by skin grafted from the elbow crease or groin.
In very rare cases, a finger amputation may be necessary or even preferable, if the condition has returned many times with repeated nerve and vessel damage.
How long will it take to recover?
Recovery times vary dramatically dependent on the severity of the condition, but a splint may be needed for some weeks after the operation, usually only at night, to maintain the surgical correction of the finger(s). You will be left with a scar across the palm and finger(s), and also in the elbow crease if you require a skin-graft. These scars may be tender for 6-8 weeks after the operation.
Potential pitfalls
Prolonged stiffness of the entire hand is a possibility after any hand surgery. Dupuytrens disease also tends to come back to affect either the operated finger(s) or other fingers after surgery. The time-span for this is variable and not consistent.
Injury to the small nerve(s) supplying sensation to the tip of the finger pulp is a rare complication of surgery.
Painful hand and wrist problems
Trigger finger / thumb
Trigger finger or Stenosing Tenosynovitis, is an acquired condition where the flexor tendon catches on the proximal flexor sheath in the palm producing pain, snapping (or “triggering”) or locking (in flexion or extension) of the affected finger/thumb. This is commonly worse first thing in the morning and more often seen in diabetic patients.
About a third of patients will settle without the need for any intervention but most of the rest will settle down with a simple steroid injection around the tendon in the palm – this is done under local anaesthetic control. Very rarely it will be necessary to suggest a simple day-case local anaesthetic release of the pulley in the palm.
De Quervain’s Tenosynovitis
This painful condition affects the inside of your wrist (thumb side) on certain movements – it commonly occurs after an episode of overuse in young women and leads to local swelling and pain. Young sports people and mothers with their first baby are commonly seen. Again the cause would appear to be a discrepancy between the size of the tendons moving the thumb and the little tunnel they pass through at the wrist.
Hand physiotherapy with ultrasound and splinting often helps but a simple local steroid injection provides relief in the vast majority of cases. Again very rarely it will be necessary to suggest a simple day-case local anaesthetic release of the constriction.
Glomus tumour
This little benign tumour is in fact very rare but so distinctive and difficult to diagnose that people may have lived with them for years. They commonly occur under the nail-bed and are difficult to see; perhaps a bluish/red blush is all that is apparent. They are terribly painful however with spasmodic shooting pain, cold intolerance and a noticeably tender single spot.
Once diagnosed they are relatively simple to remove with a simple day-case local anaesthetic removal of the tiny lump.
Chronic Regional Pain Syndrome
About 5% of patients may present with a troubling, inappropriately painful hand after either a relatively trivial hand injury or after any hand surgery or intervention. This is potentially devastating for the patient and their hand and presents typically with pain, swelling, colour changes, sweating and poor movement. For some reason the autonomic nervous system (supplying all parts of the body and controlling your automatic or autonomic responses to e.g. temperature, pain) becomes over-active.
In the early stages and when promptly recognised treatment can be effective and involves intensive hand physiotherapy, appropriate pain-killers (often under the guidance of a pain anaesthetist) and specific targeted drugs acting on the sympathetic autonomic nervous system. If left late or with poor response to treatment the hand can be left in a very poor condition.
Any other persistent, painful hand condition should be seen by your GP and/or experienced Hand Surgeon.
Hand Injuries
The human hand is a unique tool in constant use and prone to injuries in the home, work-place and during leisure activities.
Tendon and nerve injuries
Tendons are commonly cut in domestic accidents with glass or knives in the kitchen. At the same time the little nerves supplying sensation to the fingers may be divided causing numbness and tingling in a finger.
These should ideally be repaired as soon after the accident as possible. With early repair and dedicated time spent with the hand physiotherapist these injuries do well. The rehabilitation process may however take months and may involve swearing a splint for the first 6 weeks or so.
Other common tendon injuries occur on the sports field (often closed injuries and may have associated fractures) or work-place.
Fractures
Often hand and wrist fractures need no more treatment than a splint for a few weeks but, with more complex injuries your consultant may need to operate and open the fracture and fix it with either pins or plate/screws.
If you would like more information about our Hand and Wrist Surgery service, please get in contact with us by phoning 020 8971 8000 or use our contact page.
