Hand Surgery

Hand surgery treats the following pathologies:

  • Peripheral neuropathies due to compression (Carpal tunnel syndrome and ulna and/or radio nerve compression)
  • Tenosynovitis (“trigger finger syndrome, DeQuervain’s syndrome)
  • Dupuytren’s contracture
  • Rhizarthrosis, hand or wrist arthrosis
  • Rheumatoid arthritis with fingers or wrist deformities
  • Congenital defects
  • Flexor and/or extensor tendon lesions, “trigger finger” syndrome, Segond avulsion fracture
  • Stener lesion (ulnar collateral ligament lesion)
  • Congenital hand deformities
  • Hand tumors (epithelioma, xantoma, schwannoma, lipoma, angiomas, etc…)
  • Hand and/or wrist complex trauma with tendon, nerve and bone lesions
  • Re-implant with microsurgical techniques
  • Hand post-traumatic consequences, hand burn consequences

Some more info

Carpal Tunnel Syndrome (CTS)

Carpal Tunnel Syndrome (CTS) is one of the most common neuropathies and is a median entrapment neuropathy that causes paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel. The mechanism is not completely understood but can be considered compression of the median nerve traveling through the carpal tunnel. It appears to be caused by a combination of genetic and environmental factors. Some of the predisposing factors include: diabetes, obesity, pregnancy, hypothyroidism, and heavy manual work or work with vibrating tools. There is, however, little clinical data to prove that lighter, repetitive tasks can cause carpal tunnel syndrome. Other disorders such as bursitis and tendinitis have been associated with repeated motions performed in the course of normal work or other activities.

An electromiography is needed before considering the surgical treatment of the Carpal Tunnel Syndrome.

The traditional surgical treatment is carried out with an incision at the base of the palm of the hand; this allows the doctor to see the transverse carpal ligament.

During endoscopic carpal tunnel release surgery, the transverse carpal ligament is cut. This releases pressure on the median nerve, relieving carpal tunnel syndrome symptoms.

Endoscopic surgery uses a thin, flexible tube with a camera attached (endoscope). The endoscope is guided through a small incision in the wrist (single-portal technique) or at the wrist and palm (two-portal technique). The endoscope lets the doctor see structures in the wrist, such as the transverse carpal ligament, without opening the entire area with a large incision.

The cutting tools used in endoscopic surgery are very tiny. They, also, are inserted through the small incisions in the wrist or wrist and palm. In the single-portal technique, one small tube contains both the camera and a cutting tool.

This innovative minimally invasive technique is very precise and safe and it allows patients to go home the same day of the treatment, with no need for hospitalization.

The “trigger finger” or Notta’s syndrome

Trigger finger, trigger thumb, or trigger digit (also a sub-set of stenosing tenosynovitis), is a common disorder characterized by catching, snapping or locking of the involved finger flexor tendon, associated with dysfunction and pain, and it results in difficulty flexing or extending the finger and the “triggering” phenomenon. The label of trigger finger is used because when the finger unlocks, it pops back suddenly, as if releasing a trigger on a gun.

The surgical treatment of “trigger finger” is a tenosynovectomy, an operation usually performed under local anaesthetic taking about half an hour: the pulley which restricts the tendon’s excursion is divided. In absence of pain, fingers mobility is absolutely required for a quicker recovery.

De Quervain’s tenosynovitis

De Quervain syndrome, also known as de Quervain’s stenosing tenosynovitis, is a tenosynovitis of the sheath or tunnel that surrounds two tendons that control movement of the thumb. The two tendons concerned are the tendons of the extensor pollicis brevis and abductor pollicis longus muscles. The tendons run, as do all of the tendons passing the wrist, in synovial sheaths, which contain them and allow them to exercise their function whatever the position of the wrist. Evaluation of histological specimens shows a thickening and myxoid degeneration consistent with a chronic degenerative process.

Finkelstein’s test is used to diagnose de Quervain syndrome in people who have wrist pain. To perform the test, the examining physician grasps the thumb and the hand is ulnar deviated sharply. If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist; see image), de Quervain’s syndrome is likely.

The most effective conservative treatment is the local injection of corticosteroids associated with the use of a splint, but the resolving surgical treatment is a little cutaneous incision that allows the surgeon to broaden the channel and remove the synovitis, thus easing pain rapidly.

Dupuytren’s contracture

Dupuytren’s contracture (also known as morbus Dupuytren, or Dupuytren’s disease), is a fixed flexion contracture of the hand due to a palmar fibromatosis, where the fingers bend towards the palm and cannot be fully extended (straightened). It is an inherited proliferative connective tissue disorder that involves the hand’s palmar fascia.

The ring finger and little finger are the fingers most commonly affected; the middle finger may be affected in advanced cases, but the index finger and the thumb are not affected as frequently. Dupuytren’s contracture progresses slowly and is often accompanied by some aching and itching. In patients with this condition, the palmar fascia thickens and shortens so that the tendons connected to the fingers cannot move freely. The palmar fascia becomes hyperplastic and contracts. Incidence increases after age 40; at this age, men are affected more often than women.

Selective aponeurotomy still represents the surgical method of choice and it must be carried out by expert surgeons, as the hand palm is rich in vascular and nervous structures and cutaneous plastic is needed.

After the surgical intervention, some physiotherapy is always highly recommended.

Rhizarthrosis

The thumb basal joint, also called the trapeziometacarpal (TMC) joint, is a specialized saddle-shaped joint that is formed by a small bone of the wrist (trapezium) and the first bone of the thumb (metacarpal). The saddle shaped joint allows the thumb to have a wide range of motions, including up, down, across the palm, and the ability to pinch. In osteoarthritis (or “degenerative arthritis”) the cartilage layer wears out, resulting in direct contact between the bones and producing pain and deformity. One of the most common joints to develop osteoarthritis in the hand is the base of the thumb.

Less severe thumb arthritis will usually respond to non-surgical care such as avoiding activities that cause pain (if/when possible), analgesic and/or anti-inflammatory medication, splinting (rigid and non-rigid splints), steroid or jaluronic acid injections.

Surgery is a last resort, as the symptoms often stabilise over the long term and can be controlled by the non-surgical treatments above: suspension arthroplasty takes advantage of a slip of tendon to reconstruct elements of the ligament supports at the base of the thumb.

This kind of surgical treatment does not imply the use of prosthesis or syntetic materials. A plaster cast will be needed for the 3 weeks following the surgical intervention; subsequently, some physiotherapy will make recovery easier.

Rheumatoid Arthristis

Rheumatoid arthritis (RA) is a chronic, autoimmune, systemic inflammatory disorder that primarily affects joints. It may result in deformed and painful joints, which can lead to loss of function. The disease may also have signs and symptoms in organs other than joints.

The process involves an inflammatory response of the capsule around the joints (synovium) secondary to swelling of synovial cells, excess synovial fluid, and the development of fibrous tissue in the synovium. It also affects the underlying bone (focal erosions) and cartilage (thinning and destruction).

Women are affected three to five times as often as men. The age at which the disease most commonly starts is in women between 40 and 50 years of age, and for men somewhat later.

Most commonly involved are the small joints of the hands, feet and cervical spine, but larger joints like the shoulder and knee can also be involved. Synovitis can lead to tethering of tissue with loss of movement and erosion of the joint surface causing deformity and loss of function.

RA is a chronic disease, and although rarely, a spontaneous remission may occur, the natural course is almost invariably one of persistent symptoms, waxing and waning in intensity, and a progressive deterioration of joint structures leading to deformations and disability.

In early phases of the disease, an arthroscopic or open synovectomy may be performed. It consists of the removal of the inflamed synovia and prevents a quick destruction of the affected joints. Severely affected joints may require joint replacement surgery, such as knee replacement.

Extra-articular complications may include tendon lesions – that may be treated with solidarization or tendon transfer – while bone and articular lesions call for prosthesis or arthrodesis.

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