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HAND SURGERY

Hand Surgery Finger injuries

To ascertain the consensus regarding the management of different fingertip injuries or amputations and to evaluate potential statistical variances among treatment options based on the hand surgeon’s experience in the field of hand surgery.

Methodology:

A cross-sectional survey was conducted during the 37th Brazilian Congress of Hand Surgery, where a total of one hundred and twenty questionnaires were randomly distributed. Ninety fully completed questionnaires that met the inclusion and exclusion criteria were considered for analysis. The responses underwent descriptive and inferential analysis with a significance level set at p < 0.05.

Findings:

The study revealed a 63.3% agreement for treating dorsal oblique injuries less than 1 cm with bone exposure using the VY advancement flap, 46.7% for volar tip oblique injuries with bone exposure less than 1 cm using the Cross Finger approach, 47.8% for oblique thumb volar injuries greater than 1 cm with no bone exposure managed with the Moberg approach, 54.4% for thumb pulp injuries up to 2.5 cm with bone exposure managed using the Moberg approach with proximal release, and 92.2% agreement for antibiotic use, specifically with the “cephalexin” alternative.

Conclusion:

The findings suggest a lack of consensus regarding the treatment approaches for most types of fingertip lesions, with an overall agreement rate of 45.4%. However, when stratified by the duration of specialization in hand surgery, there was an increase in agreement to 54.5% within specific subgroups. Further comparative studies are warranted to thoroughly assess and establish a consensus among surgeons regarding the management of fingertip injuries.

Arm, hand, and finger injuries

Arm, hand, and finger injuries resulting in complete detachment can potentially undergo a surgical procedure called “replantation,” which involves reattaching the
separated body part (refer to Figure 1). The primary aim of replantation surgery is to restore function and appearance. However, its recommendation hinges on the potential success of reattachment.

In instances where replantation is unfeasible due to severe damage to the lost part or residual limb, surgeons may opt for a “completion” or “revision amputation.” This involves cleaning, smoothing, and covering the cut end. Sometimes, this approach leads to a swifter and more effective recovery compared to replantation. Thus, while replantation may be possible, it may not always be the optimal treatment choice.

Replantation necessitates specialized medical expertise and a comprehensive support team in the emergency room, operating room, and hospital. However, not all medical facilities can provide this level of care, potentially requiring coordination to transfer the injured patient and body part to a trauma center capable of handling such injuries.

Timeliness in initiating treatment post-injury is critical as the severed body part lacks essential blood supply, oxygen, and nutrients, resulting in progressive tissue damage over time. Swift rinsing of the separated part with water or saline followed by wrapping it in wet gauze and placing it in a sealed plastic bag immersed in ice water can help preserve the part for potential replantation.

Accurately measuring the duration without blood flow (ischemia time) is crucial. Warm ischemia time refers to the interval between injury and cooling of the separated part, while cold ischemia time denotes the duration from cooling to replantation. These timeframes significantly impact treatment decisions and surgical success.

The replantation procedure comprises three primary steps:

  • Careful removal of damaged tissue
  • Reconnection of bone ends or fractured parts using pins, wires, or plates and screws
  • Repair of muscles, tendons, arteries, nerves, and veins; sometimes, grafts or artificial spacers from tissue banks or the patient’s body are necessary

During recovery, patients typically spend days or weeks in the hospital for continuous monitoring of the reattached part’s blood flow. Additional surgeries may be required to address blood flow issues. Transfusions or medicinal leeches might be employed to aid blood flow to the reattached part.

Post-hospitalization, patients play a crucial role in their recovery by avoiding smoking, ice, and maintaining the replanted part above heart level to enhance circulation. Factors like age, injury location, joint involvement, the severity of the injury, weather conditions, and nerve regrowth impact the recovery and use of the replanted part.

Physical therapy and temporary bracing are integral to the rehabilitation process, ensuring joint mobility, muscle flexibility, and minimizing scar tissue. Customized devices may assist patients in performing specialized activities or hobbies. Many replant patients can eventually return to their previous jobs, but some may require guidance in transitioning to new types of work if returning to their previous occupation isn’t feasible.

Hand tendon repair surgery

Hand tendon repair surgery is performed when the tendons responsible for finger and thumb movements have been damaged or ruptured, affecting the ability to bend or straighten fingers. Such injuries, whether to flexor (finger bending) or extensor (finger straightening) tendons, can result from cuts or blunt trauma, making these tendons vulnerable due to their superficial location.

Non-surgical treatment may be considered for tendons less than 50% damaged. In cases restricting hand function, surgery becomes necessary. Reattachment of the tendon to the bone or sewing together the cut ends of the tendon are two common surgical approaches for both flexor and extensor injuries.

The post-surgery recovery period lasts about 12 weeks. Pre-operative physiotherapy aims to protect the initial injury and reduce complications. This involves cryotherapy to minimize swelling, protective bracing for support, and pain management.

After surgery, symptoms like swelling, bruising, pain, stiffness, decreased range of movement, and sensory changes may occur. Physiotherapy immediately post-surgery focuses on hand function restoration and preventing complications. The initial phase involves wound monitoring, cryotherapy, pain management, controlled passive movements, and active exercises for adjacent joints.

In the subsequent weeks, therapy continues with scar management, increased passive and active-assisted movements, soft tissue mobilization, and active exercises for improved range and strength. The final stage emphasizes strengthening exercises, full passive and active movements, progressive strengthening of the repaired tendon, hand dexterity, soft tissue massage, and functional activities.

By the end of the 12-week rehabilitation, patients typically witness substantial improvements in movement and strength, enabling maximal hand function. Physiotherapists provide guidance and exercises tailored to maximize surgical success and restore optimal hand function.

hand surgery nerve repair

The hand comprises three main nerves that supply specific areas, responsible for sensory perception, muscle stimulation, and finger movement. These nerves—Radial, Ulnar, and Median—are vital for feeling pain, temperature, and touch while controlling finger muscles. Nerve injuries may result from cuts, excessive pressure, stretching, or fractures, causing varying degrees of damage categorized into Neuropraxia, Axonotmesis, or Neurotmesis.

Neuropraxia involves mild stretching without breaking the nerve. Axonotmesis indicates nerve compression leading to temporary dysfunction, and Neurotmesis results in complete nerve severance. Surgical intervention becomes crucial in
Neurotmesis cases. Surgery options include End-to-End Closure, Nerve Grafting, Vascularized Nerve Grafting (suitable for areas with no local blood supply, like burns), and Nerve Transfer.

Post-surgery, the hand is typically placed in a protective splint for at least three weeks to support healing and minimize complications like swelling, pain, numbness, sensory, or motor deficits. Immediate physiotherapy plays a pivotal role in recovery, focusing on sensory and motor function restoration.

The initial phase of physiotherapy concentrates on managing pain, swelling, and wound care while incorporating passive range of motion exercises and splint use to protect the repair. Following the initial phase, treatment escalates to sensory and motor restoration, including sensory and motor stimulation, passive and active movements, strength work, electrical stimulation, and neural mobilization.

As therapy progresses, emphasis increases on sensory and motor stimulation, combined with strength training, neural mobilization, scar management, and functional activities. Due to nerve injuries’ complexity and slow healing, rehabilitation might span up to 12-18 months, aiming for optimal recovery and functional hand use. Throughout this period, comprehensive monitoring and therapy from professionals like Physio.co.uk are crucial for achieving maximal recovery.

Hand vessel repair surgery

Hand vessel repair surgery involves the surgical restoration of damaged or injured blood vessels in the hand. This procedure aims to repair vessels that have been cut, damaged, or ruptured due to trauma, lacerations, or other injuries, enabling proper blood flow to the hand tissues. Hand vessel repair is crucial for maintaining adequate blood supply to promote tissue healing and prevent complications such as tissue death (necrosis) or loss of hand function.

The surgery typically follows a series of steps:

Evaluation and Preparation: The surgeon evaluates the extent and location of the vascular injury through clinical examination and imaging studies. Before the surgery, the patient undergoes preoperative assessments to ensure they are fit for the procedure.

Anesthesia: The surgery is performed under regional or general anesthesia, ensuring the patient remains comfortable and pain-free throughout the procedure.

Incision and Exposure: The surgeon makes an incision at the site of the injured blood vessel to gain access to the damaged area. The incision allows the surgeon to carefully access and repair the damaged blood vessel.

Repair Technique: The specific repair technique depends on the nature and severity of the vessel injury. Techniques may involve suturing the vessel ends back together (end-to-end anastomosis), using grafts to bridge gaps in the damaged vessel (grafting), or using other specialized repair methods.

Closure: Once the repair is completed, the surgeon closes the incisions using sutures or staples. Sterile dressings are applied to the surgical site to protect it from infection.

Postoperative Care: Following surgery, the patient is monitored in a recovery area. Postoperative care may involve elevating the hand, administering pain medication, and monitoring blood circulation and hand function.

Rehabilitation and recovery after hand vessel repair are essential. Patients often undergo physical therapy or rehabilitation to regain hand strength, mobility, and function. Recovery time can vary based on the extent of the injury, the complexity of the repair, and individual healing rates.

Hand vessel repair surgery aims to restore blood flow to the hand, preserve hand function, and promote optimal healing of the affected tissues. It requires precision and expertise to ensure successful repair and rehabilitation for the patient’s overall recovery.

Hand Carpal tunnel surgery

Carpal tunnel surgery, known as carpal tunnel release (CTR), is a surgical procedure aimed at alleviating the symptoms of carpal tunnel syndrome (CTS). This condition occurs when the median nerve, which runs from the forearm into the palm of the hand, becomes compressed at the wrist within the carpal tunnel. The compression leads to pain, numbness, tingling, and weakness in the hand and fingers.

Here’s an outline of the procedure:

Incision: The surgeon makes an incision at the base of the palm or wrist, allowing access to the carpal tunnel area.

Release of Ligament: To relieve pressure on the median nerve, the surgeon carefully cuts the transverse carpal ligament (the roof of the carpal tunnel). This widens the tunnel, creating more space for the nerve and tendons passing through it.

Endoscopic Technique: Some surgeries use an endoscope (a thin tube with a camera) to guide the procedure through a smaller incision. This minimally invasive approach may result in a quicker recovery and less scarring.

Closure: Once the ligament is released, the surgeon closes the incision with sutures or staples and applies a dressing.

Recovery: Following the surgery, patients typically return home the same day. Some may need a wrist splint to support the area. Hand therapy or physical therapy might be recommended to aid in regaining strength and flexibility.

The goal of carpal tunnel release surgery is to reduce pressure on the median nerve, relieve symptoms, and restore normal hand function. Recovery time varies among individuals, but many patients experience relief from symptoms within several weeks to a few months after the surgery.

hand Cubital tunnel surgery

It’s important to note that while carpal tunnel release surgery is effective in relieving symptoms for many people, it’s not a guarantee that all symptoms will disappear entirely. Additionally, as with any surgical procedure, there are risks involved, including infection, nerve damage, and incomplete relief of symptoms. Consulting with a healthcare professional is essential to determine if surgery is the best course of action for your specific case of carpal tunnel syndrome.

Cubital tunnel syndrome occurs when the ulnar nerve becomes compressed or irritated as it passes through the cubital tunnel, located on the inner side of the elbow. Surgical intervention for cubital tunnel syndrome, known as ulnar nerve decompression or cubital tunnel release surgery, aims to alleviate pressure on the nerve and relieve associated symptoms like pain, tingling, and weakness in the hand and fingers.

Here’s an outline of the procedure:

Incision: The surgeon makes an incision at the inner side of the elbow, exposing the cubital tunnel and the ulnar nerve.

Nerve Release: The surgeon carefully releases any structures (such as ligaments or tissues) that might be compressing the ulnar nerve within the cubital tunnel. This helps to free the nerve and relieve pressure.

Transposition: In some cases, the surgeon might reposition or transpose the ulnar nerve to a location where it is less likely to experience pressure or irritation. This might involve moving the nerve to the front of the elbow or a different position within the arm.

Closure: After the procedure, the surgeon closes the incision with sutures or staples and places a dressing over the area.


Recovery:
Patients typically return home the same day or shortly after the surgery. A splint or brace might be recommended to protect the elbow during the initial healing phase. Physical therapy or exercises may also be prescribed to aid in regaining strength and mobility in the arm.

The goal of cubital tunnel release surgery is to relieve pressure on the ulnar nerve and alleviate symptoms. Recovery time varies among individuals, and while many experience improvement in symptoms following surgery, full recovery may take several weeks to months.

 As with any surgical procedure, there are risks involved, including infection, nerve injury, and recurrence of symptoms. Consulting with a healthcare professional is crucial to determine the most suitable treatment approach based on the severity of symptoms and individual circumstances.

Dupuytren's contracture

Trigger finger release surgery, medically known as “tenosynovectomy” or “trigger finger release,” is a procedure performed to address a condition called “trigger finger” or “stenosing tenosynovitis.” This condition occurs when one of the fingers or the thumb gets stuck in a bent position and then straightens with a snapping or popping sensation, often accompanied by pain.

Here’s an overview of the surgery:

Incision: The surgeon makes a small incision at the base of the affected finger or thumb.

Release of Tendon Sheath: The surgeon carefully accesses the affected tendon sheath, which has become inflamed or thickened, restricting the movement of the tendon. The surgeon opens or releases the constricted part of the sheath, allowing the tendon to move more freely.

Closure: After releasing the tendon sheath, the surgeon closes the incision with stitches or adhesive strips.

Recovery: Patients can usually return home the same day. Post-surgery, the finger might be wrapped or splinted to protect and support it during the initial healing period. Physical therapy or exercises may be recommended to restore finger mobility and strength.

The goal of trigger finger release surgery is to alleviate the catching or locking sensation and associated pain by allowing the tendon to move without obstruction within the sheath.

Recovery time varies from person to person, and most individuals experience improvement in symptoms following the surgery. However, complete healing may take several weeks to months.

As with any surgical procedure, there are risks involved, including infection, stiffness, and recurrence of symptoms. Consulting with a healthcare professional is essential to determine if trigger finger release surgery is the appropriate treatment based on the severity of symptoms and individual circumstances.

Dupuytren’s contracture is a condition where the tissue underneath the skin in the palm of the hand thickens and forms nodules or cords. This thickening and tightening can cause the fingers to bend inward towards the palm, making it challenging to straighten them fully. When this condition progresses, it’s referred to as Dupuytren’s contracture.

Treatment options for Dupuytren’s contracture may vary depending on the severity and progression of the condition:

Observation: In mild cases where the contracture doesn’t significantly affect hand function, no immediate treatment may be necessary. Regular monitoring and observation are recommended.

Non-Surgical Treatments: In the early stages or when the condition is not severe, treatments like hand therapy, steroid injections, or collagenase injections (enzymatic injections to dissolve the contracture) might be considered.

Surgery: For advanced cases where the fingers are significantly bent, surgery may be recommended to release the tightened tissue (fasciotomy or fasciectomy). There are different types of surgical approaches:

  • Needle Fasciotomy: This minimally invasive procedure involves puncturing and breaking up the cords using a needle.
  • Partial Fasciectomy: The surgeon removes part of the thickened tissue (fascia) causing the contracture while preserving healthy tissue.
  • Total Fasciectomy: In severe cases, the surgeon removes all the affected tissue, which may lead to longer recovery times but potentially better outcomes.
After surgery, rehabilitation or hand therapy might be necessary to regain hand function and strength. Recovery time varies from person to person, but it can take several weeks to months to regain full function of the hand. It’s essential to discuss treatment options with a healthcare professional who can assess the severity of Dupuytren’s contracture and recommend the most suitable treatment plan based on individual circumstances