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Reconstructive Procedures

Reconstructive Procedures

HAND SURGERY

HAND SURGERY

What is hand surgery?

Hand surgery is a field of medicine that treats problems of the hand, wrist, forearm and peripheral nerves of the upper limb, and as such, covers many different types of procedures. The hand contains many delicate structures that afford it co-ordinated fine motor function. Plastic surgeons are specially trained to perform the intricate surgery required to restore hand and finger function, whilst also ensuring that the hand looks as normal as possible. Conditions which may require reconstructive hand surgery include:

  • Hand injuries
    • Tendon Injuries
    • Nerve Injuries
    • Fractures
    • Fingertip and Nail injuries
    • Compartment Syndrome
  • Infections of the hand
  • Rheumatic diseases, that change and damage the structures in the hand
  • Nerve Compressions like Carpal Tunnel and Cubital Tunnel Syndrome
  • Tenosynovitis
  • Dupuytren's disease
  • Tumours such as Ganglia
  • Tennis Elbow
  • Congenital abnormalities - problems or defects of the hand that are present at birth

What does hand surgery involve?

Operations to treat specific conditions in the hand may involve one or a variety of surgical procedures/techniques. Some of these procedures and techniques are discussed briefly below. Your plastic surgeon will discuss with you the treatment or surgery that you require for your specific hand condition.

Typically, most hand surgery may be performed as a day-case under local or regional anaesthetic block with the patient either awake or lightly sedated. In some cases, General anaesthesia and/ or an overnight stay may be necessary- this is usually the case for children, or for complex and prolonged cases.

Debridement and Surgical drainage

Debridement is a procedure that aims to thoroughly clean a wound by removing any foreign material, infected tissue, and non-viable (dead or necrotic) tissue. This may be necessary following injury or hand infection. Hand infections are common and where an abscess or overt pus is present, surgery may be required to open up the septic area, drain and washout the pus (surgical drainage). Surgical drainage and debridement aid in preventing further infection, promotes healing and prepares the wound for reconstruction.

Reduction and fixation

When there is a broken bone (fracture), in part of the hand or fingers, it is necessary to reduce and fixate the fracture. This kind of surgery involves realignment of the broken bone (reduction) followed by immobilisation (fixation) to allow the fracture to heal. Immobilisation is achieved through the placement of wires, rods or plates and screws, within the bone or splints and casts on the outer surface of the finger, hand or wrist.

Tendon repair

Tendons are gliding cord-like structures/fibres that join muscle to bone and effect movement across the wrist and finger joints. Tendon repair in the hand is difficult because the tendons of the hand have complex structures and gliding mechanisms, which must be restored to maintain proper gliding, strength and function. Tendon injuries can occur due to infection, trauma, or sudden rupture. Other more complex procedures such as tendon transfers, tendon grafts or the temporary insertion of a silicone rod to reconstruct the tendon sheath may also be required.

Nerve repairs

The brain receives sensory information from and controls movement of the fingers, hand and upper limb via nerves. These nerves exit the central nervous system via several areas in the neck and subsequently join and divide in a complex structure known as the Brachial plexus. The terminal branches of the branches of the Brachial Plexus travel into the upper arm, forearm and hand to enable co-ordinated function of the arm and hand.

Injuries to nerves can result in a loss of hand function and /or feeling in the hand. If a nerve is merely bruised, it may heal in time, even without treatment. A nerve that is badly crushed, torn or severed will need to be repaired by delicately stitching the two ends of the nerve back together. If there is a long area of damage to the nerve, or if a gap exists, a nerve graft may be done. This involves taking a less important nerve from another area of the body and using it to replace the damaged nerve.

Skin grafts

Mechanical injuries, tumour excision, or burns to the hand may result in areas of missing skin. Skin grafts replace this missing skin by surgically taking a thin layer of healthy skin from another area of the body (donor site) and transferring this skin to the wound on the hand. The skin graft is sutured in place and will take 10- 14 days to heal. A skin graft does not have an intact blood supply and must rely on the growth of new blood vessels at the recipient site. The donor site is able to heal up on its own.

Skin flaps

Flap surgery is a reconstructive technique where skin (or any other type of tissue) is lifted from a donor site with an intact blood supply and moved to a recipient site. Skin flaps are used to reconstruct wounds or defects that cannot be sutured closed or will not be able to accept a skin graft, usually because the wound bed has a poor blood supply. A skin flap procedure involves elevating a portion of skin in an area where there is relative excess and transferring it, along with its own blood supply, to the wound/ defect. Skin flaps can be considered local or distant, depending on their location relative to the wound being reconstructed.

Joint replacement

In cases of severe hand arthritis, arthroplasty (joint replacement) may be necessary to replace a joint that has been destroyed by arthritis. An artificial joint made of metal, plastic, or silicone is used to surgically replace the damaged joint and restore function.

Replantation

Replantation is a highly complex type of surgery that aims to reattach a body part, such as a finger, hand, or toe, which has been completely cut or severed from the body. Successful replantation surgery in the hand requires that the severed parts, including bone, tendons, blood vessels and nerves, must all be reattached. Surgery to reattach these delicate structures is performed using a specialised microscope and tiny microsurgical instruments and sutures. The primary goal is to restore as much function as possible, while also restoring a normal appearance of the hand. It is not uncommon for these complex injuries to require multiple surgeries.

Thumb reconstruction

There are various techniques used for reconstructing a thumb. This depends on the general health of the individual, the level of amputation of the thumb and the donor site concerns of the patient. The Plastic Surgeon might perform a pollicisation where an index finger is moved, shortened and rotated to design a new thumb. Thumb lengthening or webspace deepening is occasionally advised if not much extra length is needed to regain opposition (the primary function of the thumb).

Microvascular reconstruction is a highly specialised Plastic Surgery technique whereby tissue is brought in from another part of the body. The local blood supply is joined to the new tissue under the microscope. Microvascular second toe transfer is the most commonly employed free flap technique for reconstructing a severed thumb. Sensate, similar tissue with glabrous skin and nail complex plus tendons make this the ideal thumb replacement.

Tendon Injuries

  • Tendon Injuries and Transfers
    Tendon injury can be the result of infection, trauma or rupture due to arthritic conditions. Primary repair is done within 24 hours of sudden injury and delayed primary repair is done a few days after injury. Secondary repair is done 2 – 5 weeks from injury and may include a tendon graft. This is when a tendon is removed from another part of the body and inserted in place of the damaged tendon.

Nerve Injuries

  • Nerve Injuries
    Nerve repair is used when nerves have been damaged, causing loss of hand function and feeling in the hand. Although some partial nerve injuries heal on their own others may require surgery. If a nerve has been severed, it may be immediately reattached using microscopic techniques, or a nerve graft is performed if a gap exists.
  • Brachial Plexus Injuries
    The Brachial plexus is the complex of nerves exiting the spine at the neck and travelling beneath the clavicle, through the armpit and into the upper limb. These nerves supply the muscles of the upper limb and bring back sensation.

    Injury can be from birth trauma (Erb’s Palsy), from penetrating injuries or traction injuries to the neck or arm. Primary repair is occasionally possible. Some may require nerve grafts or muscle transfers.

Fractures

  • Fractures and Dislocations
    South Africans love the outdoors and sport. Not surprisingly, this comes with its share of hand and upper limb fractures and dislocations. A doctor, preferably a hand surgeon, should relocate dislocations. Self-relocation of a dislocation can cause a fracture and further injure torn ligaments. An Xray is always required before treatment. Fractures can occasionally be treated conservatively but some may require manipulation and fixation. Your Plastic Surgeon is likely to refer you to a Hand Therapist, an integral and necessary part of your treatment.

Fingertip and Nail injuries

  • Fingertip and Nail injuries
    The fingertips have been described as "second eyes". Incredibly sensate, the fingertip anatomy is intricate and complex, from it’s specialised skin to the nerve endings, pressure sensors and the relationship to the nail. Plastic Surgeons are specialists in helping with disorders and injuries of the fingers.

Compartment Syndrome

  • Compartment Syndrome
    This is a sudden, painful condition which is usually the result of blunt trauma or a bleed into a muscle compartment. It can be associated with a fracture.A fasciotomy is an emergency procedure used to treat compartment syndrome by releasing the increased pressure within the compartment, thereby restoring blood flow to the ischaemic muscles. This pressure can cause severe pain, muscle death and destroy function.

Infections of the hand

  • Hand Infections
    Hand infections may require surgery. If there is an abscess, it may be drained to remove pus or, in more severe cases, debridement may be used to remove dead or contaminated tissue. This prevents infection spreading and promotes healing.


Arthritis

  • Rheumatoid Arthritis (RA)
    this is an autoimmune condition. Symptoms include pain, joint stiffness and swelling, fatigue, weight loss and stiffness. The medical side of this condition should be managed by a specialist physician or rheumatologist. Rheumatoid hand conditions include bent fingers at the finger joints; classically boutonniere and swan-neck deformities of the PIP Joint and DIP Joint; and Ulnar deviation of the MP Joint Knuckles. Various surgical options are designed to improve hand function and decrease deformities, including joint replacements. Joint replacement or arthroplasty is the artificial replacement of a joint that has been destroyed by arthritis. RA is one of the causes of trigger fingers.
  • Osteoarthritis (OA)
    This is a degenerative condition associated with ageing. The cartilage of the joints wears thin and the joints become painful and swollen. Osteophytes form adjacent to the joint making the joint area hard and swollen. Mucous cysts/ganglions are associated with OA of the joints. Treatment is largely symptomatic using anti-inflammatories, steroids and exercises. Joint fusions and joint replacement surgery might be necessary later in the disease process.
  • Gout
    Gout can affect any joint. It is characterised sometimes by extreme pain, red and swollen joints. It can be confused with infection. Crystals in the joint cause inflammation. Treatment is designed to decrease production of the joint crystals and anti-inflammatory medication to reduce swelling and pain.

Nerve Compressions like Carpal Tunnel and Cubital Tunnel Syndrome

  • Entrapment Syndromes
    Nerves pass through various tunnels in the body. The upper limb is no exception. These tunnels can compress a nerve or the nerve can swell within the tunnel, causing pain, loss of sensation and loss of muscle function. The Median Nerve is the most commonly involved; it is most often compressed in The Carpal Tunnel at the wrist. This is widely known as Carpal Tunnel Syndrome. The ulnar nerve can be compressed at 4 different sites. Radial nerve entrapment is more rare. These symptoms can also be caused by neck injury or disc degeneration.Depending on the severity of the presenting signs and symptoms your surgeon might try a conservative approach (splinting, lifestyle changes, steroid injections) or surgery for widening the tunnel may be indicated.


Tenosynovial Disorders

  • Hand Infections
    Tenosynovitis is inflammation of the tendon sheath that surrounds a tendon. This results in pain and decreased motion of the involved tendon. Repetitive strain is commonly a cause but tenosynovitis is also associated with arthritis and infection.Trigger fingers/stenosing tenosynovitis is a common clinical manifestation of synovitis. De Quervain’s synovitis involves the thumb tendons and can be painfully debilitating. Treatment is firstly symptomatic with splinting and anti-inflammatory medication. Steroid injections might provide second-line relief. Surgery is reserved for conditions not responding to the more conservative measures. Surgical release involves widening of the associated tight tunnel/ pulley involved. This can frequently be performed under local anaesthesia.

Dupuytren's disease

  • Dupuytren’s Fasciitis/ Disease
    This is mainly a genetic condition. The fascia of the hand (a layer just beneath the skin) is affected. This layer gradually contracts, causing the fingers to permanently flex. There are various forms of treatment, depending on how far the fingers have flexed and how this has affected your function. Your surgeon might be able to perform a needle release, might use an injected medication to help dissolve the bands or might suggest various forms of surgery.


Tumours (such as Ganglia)

  • Hand Tumours
    As in all other parts of the body, the upper limb can develop tumours of the skin, soft tissues, tendons, fat, muscle, nerve or bone. These can be benign (e.g. a lipoma or giant cell tumour) and some malignant (e.g. a Squamous Cell Carcinoma or Sarcoma). Unusual swellings and skin changes should be investigated by a plastic surgeon. Imaging techniques (ultrasound, CT and MRI) and biopsies are helpful in making an initial diagnosis and planning management. Surgery plays an important role. A hard swelling around a joint might be a ganglion, a sac of fluid attached to the joint capsule. Excision gives the most reliable long-lasting result.Vascular Malformations/ Anomalies and Haemangiomas are a common cause of hand masses in children. These can involve blood vessels or lymphatic tissue.


Ischaemia of the Hand

  • Ischaemia of the upper limb might involve the large blood vessels or the smaller arteries and capillaries. Large vessel disease is occasionally seen in patients who suffer from severe hypercholesterolaemia. These patients develop claudication of the limb. A painful condition due to globally decreased blood flow in the area.
  • Spasm of the small arteries causing reduced blood flow to the fingers or toes is known as Raynaud's Phenomenon or syndrome. The affected area turns white.
  • Primary Raynaud’s is where the cause is unknown. Secondary Raynaud’s is when the cause is due to another disease process like scleroderma or lupus, or trauma associated with vibrating machinery prolonged use or, for example, thyroid conditions.
  • The condition is usually precipitated by cold or emotional distress but can be associated with a wide range of disease conditions. These warrant investigation in a patient who frequently experiences these symptoms.
  • Treatment depends on the cause but might involve conservative measures such as avoiding cold and avoiding smoking. Medications such as Calcium Channel Blockers are occasionally indicated. Botox has also been described for reducing the pain, which can be associated with Raynaud's. Surgery is usually the last option.


Congenital abnormalities- problems or defects of the hand that are present at birth

  • Congenital Hand Deformities
    Children with congenital hand differences are amazingly adaptive and learn to do things differently. Reducing the hand differences through surgery can not only improve function but also engenders self-confidence.

    Congenital hand surgery is performed on children that are born with structural hand and/ or foot differences. These differences can be corrected early to maximise the restoration of form and function. Examples are:

    • Extra fingers or thumbs (polydactyly)
    • Fused fingers or thumbs (syndactyly)
    • Absent fingers or thumbs or limbs (Symbrachydactyly)
    • Short fingers (Brachydactyly) or bent fingers (Clinodactyly and Camptodactyly)
    • Other Hand Anomalies such as trigger fingers
    • Short forearm (Radial and Ulnar Club)
    • Stiffness in the hand, wrist or elbow caused by a shortening, thickening, and/or excess of connective tissue
    • Skin changes or infections may occur if the fingers are significantly contracted into the palm.

What are the risks of hand surgery?

All surgery carries risk. Every patient should, together with their surgeon, balance the risks of surgery against the potential benefits.

Most surgery carries the risks of anaesthesia and bleeding. Additional risks associated with surgery may be specific to the type of surgery being performed. Some general risks of hand surgery may include:

  • Anaesthetic risks
  • Infection
  • Bleeding (hematoma)
  • Injury to blood vessels, nerves or tendons
  • Damage to deeper structures (such as nerves, blood vessels, muscles and lungs) can occur and may be temporary or permanent.
  • Allergies or skin reactions to tapes, suture materials, glues, blood products, topical preparations or injected agents.
  • Blood clots may form
  • Deep Vein Thrombosis (DVT), cardiac and pulmonary complications
  • Poor scarring
  • Incomplete healing
  • Loss of feeling or movement of the hand or fingers
  • Skin contour irregularities
  • Skin discolouration
  • Unexpected hand swelling
  • Prolonged swelling
  • Chronic pain that can persist as a pain syndrome
  • A need for revisional surgery

What is hand therapy?

Hand therapy is the non-surgical management of hand disorders and injuries using physical therapies including passive and active hand exercise (hand physiotherapy), splints, taping, injections, wound care and scar management. Hand therapy is often employed as adjunct treatments either before or after hand surgery to achieve the best possible functional outcome. Hand therapy is often essential for optimal recovery. Hand therapy is usually managed in conjunction with a specialist hand therapist (occupational therapist). Some hand disorders and injuries may be treated by non-surgical hand therapy alone.


WHEN YOU CHOOSE A DOCTOR WHO IS A MEMBER OF APRASSA, YOU CAN BE ASSURED THAT YOUR SURGEON IS QUALIFIED IN ALL ASPECTS OF COSMETIC AND RECONSTRUCTIVE SURGERY.

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The Association of Plastic, Reconstructive and Aesthetic Surgeons of Southern Africa was formed in 1956. It currently has over 169 members from all around South Africa. All our members are fully qualified Plastic surgeons that have been approved for APRASSA membership and will endeavour to provide you with excellent care throughout your plastic surgery journey.









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