Definition
Hand surgery refers to procedures performed to treat traumatic injuries or
loss of function resulting from such diseases as advanced arthritis of the
hand.
Purpose
The purpose of hand surgery is the treatment of a broad range of problems
that affect the hand, whether they result from cuts, burns, crushing
injuries to the hand, or disease processes. Hand surgery includes
procedures that treat traumatic injuries of the hands, including
closed-fist injuries; congenital deformities; repetitive stress injuries;
deformities caused by arthritis and similar disorders affecting the
joints; nail problems; and
tendon repair
.
The central priority of the hand surgeon is adequate reconstruction of the
skin, bone, nerve, tendon, and joint(s) in the hand. Proper repair of any
cuts, tears, or burns in the skin will help to ensure a wound free of
infection and will provide cover for the anatomical structures beneath the
skin. Early repair and grafting is an essential component of hand surgery.
Nerve repair is important because a delay in reconnecting the nerve fibers
may affect the recovery of sensation in the hand. Restoration of sensation
in the hand is necessary if the patient is to recover a reasonable level
of functionality. Next, the bones in the hand must be stabilized in a
fixed position before the surgeon can repair joints or tendons. Joint
mobility may be restored by specific tendon repairs or grafts. In some
cases, the patient's hand may require several operations over a
period of time to complete the repair.
Demographics
The demographics of hand injuries and disorders depend on the specific
injury or disorder in question. Repetitive stress injuries (RSIs) of the
hands are often related to occupation; for example, nurse anesthetists,
dental hygienists, keyboard instrumentalists, word processors, violinists,
and some assembly line workers are at relatively high risk of developing
carpal tunnel syndrome or tendinitis of the fingers related to their work.
Nearly 17% of all disabling work injuries in the United States involve the
fingers, most often when the finger strikes or is jammed against a hard
surface. Over 25% of athletic injuries involve the hand or wrist.
In terms of age groups, children under the age of six are the most likely
to be affected by crushing or burning injuries of the hand. Closed-fist
injuries, which frequently involve infection of the hand resulting from a
human bite, are almost entirely found in males between the ages of 15 and
35. Pain or loss of function in the hands resulting from osteoarthritis,
however, is found most often in middle-aged or older adults, and affects
women as often as men.
Some specific categories of conditions that may require hand surgery
include:
Congenital malformations. The most common congenital hand deformity is
syndactyly, in which two or more fingers are fused together or joined by
webbing; and polydactyly, in which the person is born with an extra
finger, often a duplication of the thumb.
Infections. Hand surgeons treat many different types of infections,
including paronychia, an infection resulting from a penetrating injury to
the nail; felon, an inflammation of the deeper tissue under the fingertip
resulting in an abscess; suppurative tenosynovitis, an infection of the
flexor tendon sheath of the fingers or thumb; and deeper infections that
often result from human or animal bites.
Tumors. The most common tumor of the hand is the ganglion cyst, which is a
mass of tissue fluid arising from a joint or tendon space. Giant cell
tumors are the second most common hand tumor. These tumors usually arise
from joints or tendon sheaths and are yellow-brown in color. The third
type of hand tumor is a lipoma, which is a benign tumor that occurs in
fatty tissue.
Nerve compression syndromes. These syndromes occur when a peripheral nerve
is compressed, usually because of an anatomic or developmental problem,
infection or trauma. For example, carpal tunnel syndrome develops when a
large nerve in the arm called the median
nerve is subjected to pressure building up inside the carpal tunnel,
which is a passageway through the wrist. This pressure on the nerve may
result from injury, overuse of the hand and wrist, fluid retention during
pregnancy, or rheumatoid arthritis. The patient may experience tingling or
aching sensations, numbness, and a loss of function in the hand. The ulnar
nerve is another large nerve in the arm that runs along the little finger.
Compression of the ulnar nerve at the elbow can cause symptoms that
typically include aching pain, numbness and paresthesias.
Amputation
. Some traumatic injuries result in the loss of a finger or the entire
hand, requiring reattachment or replantation. Crushing injuries of the
hand have the lowest chance of a successful outcome. Children and young
adults have the best chances for recovery following surgery to repair an
accidental amputation.
Fractures and dislocations. Distal phalangeal fractures (breaking the bone
of a finger above the first joint towards the tip of the finger) are the
most commonly encountered fractures of the hand. They often occur while
playing sports.
Fingertip injury. Fingertip injuries are extremely dangerous since they
comprise the most common hand injuries and can lead to significant
disability. Fingertip injuries can cause damage to the tendons, nerves, or
veins in the hands.
Description
There are a number of different procedures that may be involved in hand
surgery, with a few general principles that are applicable to all cases:
operative planning; preparing and draping the patient; hair removal;
tourniquet usage; the use of special
surgical instruments
; magnification (special visualization attachments); and
postoperative care
. The operative preplanning stage is vitally important since it allows for
the best operative technique. The hand to be operated on is shaved and
washed with an antiseptic for five minutes. A tourniquet will be placed on
the patient's arm to minimize blood loss; special inflation cuffs
are available for this purpose.
The four basic instruments used in hand surgery include a knife, small
forceps, dissecting scissors, and mosquito hemostats. A standard drill
with small steel points is used to drill holes in bone during
reconstructive bone surgery. Additionally, visualization of small
anatomical structures is essential during hand surgery. Frequently, the
hand surgeon may use wire loupes (a special instrument held in place on
top of the surgeon's head) or a double-headed binocular microscope
in order to see the tendons, blood vessels, muscles, and other structures
in the hand.
In most cases, the anesthesiologist will administer a regional nerve block
to keep the patient comfortable during the procedure. The patient is
usually positioned lying on the back with the affected arm extended on a
hand platform. If the surgeon is performing a bone reconstruction, he or
she may require such special instruments as a drill, metal plates and/or
screws, and steel wires (K-wires). Arteries and veins should be
reconnected without tension. If this cannot be done the hand surgeon must
take out a piece of vein from another place in the patient's body
and use it to reconstruct the vein in the hand. This process is called a
venous graft. Nerves damaged as a result of traumatic finger injuries can
usually be reconnected without tension, since bone reconstruction prior to
nerve surgery shortens the length of the bones in the hand. The surgeon
may also perform skin grafts or skin flaps. After all the bones, nerves,
and blood vessels have been repaired or reconstructed, the surgeon closes
the wound and covers it with a dressing.
Diagnosis/Preparation
With the exception of emergencies requiring immediate treatment, the
diagnosis of hand injuries and disorders begins with a detailed history
and
physical examination
of the patient's hand. During the physical examination, the doctor
evaluates the range of motion (ROM) in the patient's wrist and
fingers. Swollen or tender areas can be felt (palpated) by the clinician.
The doctor can assess sensation in the hand by very light pinpricks with a
fine sterile needle. In cases of trauma to the hand, the doctor will
inspect the hand for bite marks, burns, foreign objects that may be
embedded, or damage to deeper anatomical structures within the hand. The
tendons will be evaluated for evidence of tearing or cutting. Broken bones
or joint injuries will be tender to the touch and are easily visible on
x-ray imaging.
The doctor may order special tests, including radiographic imaging (x
rays),
wound culture
, and special diagnostic tests. X rays are the most common and most useful
diagnostic tools available to the hand surgeon for evaluating traumatic
injuries. Wound cultures are important for assessing injuries involving
bites (human or animal) as well as wounds that have been badly
contaminated by foreign matter. Such other special tests as a Doppler
flowmeter examination can be used to evaluate the patterns of blood flow
in the hand.
Before a scheduled operation on the hand, the patient will be given
standard blood tests and a physical examination to make sure that he or
she does not suffer from a general medical condition that would be a
contraindication to surgery.
Aftercare
Aftercare following hand surgery may include one or more of the following,
depending on the specific procedure: oral painkilling medications;
anti-inflammatory medications;
antibiotics
; splinting;
traction
; special dressings to reduce swelling; and heat or massage therapy.
Because the hand is a very sensitive part of the body, the patient may
experience severe pain for several days after surgery. The surgeon may
prescribe injections of painkilling drugs to manage the patient's
discomfort.
Exercise
therapy is an important part of aftercare for most patients who are
recovering from hand surgery. A rehabilitation hand specialist will
demonstrate exercises for the hand, instruct the patient in proper
wound care
, massage the hand and wrist, and perform an ongoing assessment of the
patient's recovery of strength and range of motion in the hand.
Risks
According to the American Society of Plastic Surgeons, the most common
complications associated with hand surgery are the following:
-
infection
-
poor healing
-
loss of sensation or range of motion in the hand
-
formation of blood clots
-
allergic reactions to the anesthesia
Complications are relatively infrequent with hand surgery, however, and
most can be successfully treated.
Normal results
Normal results for hand surgery depend on the nature of the injury or
disorder being treated.
Morbidity and mortality rates
Mortality following hand surgery is virtually unknown. The rates of
complications depend on the nature of the patient's disorder or
injury and the specific surgical procedure used to treat it.
Alternatives
Some disorders that affect the hand, such as osteoarthritis and rheumatoid
arthritis, may be managed with such nonsurgical treatments as splinting,
medications, physical therapy, or heat. Fractures, amputations, burns,
bite injuries, congenital deformities, and severe cases of compression
syndromes usually require surgery.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Hand surgery is usually performed by a microsurgeon, who may be a plastic
surgeon (a surgeon with five years of
general surgery
training plus two years of plastic surgery training and another one to
two years of training in microneurovascular surgery) or an orthopedic
surgeon (a surgeon with one year of general surgery training, five years
of
orthopedic surgery
training and additional years in
microsurgery
training).
Hand therapists are usually occupational therapists who have received
specialized training in hand rehabilitation and are certified in hand
therapy.
QUESTIONS TO ASK THE DOCTOR
-
Are there any alternatives to surgery for treating my hand?
-
Is the disorder likely to recur?
-
Will I need a second operation?
-
How many patients with my condition have you treated, and what were
their outcomes?
-
Can I expect to recover full range of motion in my hand?
-
What will my hand look like after surgery?
POSTED
BY ATTORNEY RENE G. GARCIA
Some of our clients have suffered
these kinds of injuries due to a serious accident or malpractice. The Garcia
Law Firm, P.C. was able to successfully handle these types of cases. For
a free consultation please call us at 1-866- SCAFFOLD or 212-725-1313.
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