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.