Hand Surgery

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

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, 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,

KEY TERMS

Congenital— Present at birth.

Felon— A very painful abscess on the lower surface of the fingertip, resulting from infection in the closed space surrounding the bone in the fingertip. It is also known as whitlow.

Hemostat— A small surgical clamp used to hold a blood vessel closed.

Lipoma— A type of benign tumor that develops within adipose or fatty tissue.

Loupe— A convex lens used to magnify small objects at very close range. It may be held on the hand, mounted on eyeglasses, or attached to a headband.

Paresthesia— An abnormal touch sensation, such as a prickling or burning feeling, often in the absence of an external cause.

Paronychia— Inflammation of the folds of tissue surrounding the nail.

Polydactyly— A developmental abnormality characterized by an extra digit on the hand or foot.

Skin flap— A piece of skin with underlying tissue that is used in grafting to cover a defect and that receives its blood supply from a source other than the tissue on which it is laid.

Syndactyly— A developmental abnormality in which two or more fingers or toes are joined by webbing between the digits.

• 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.

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.

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.

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?

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.

Resources

BOOKS

Canale, S. T., ed. Campbell’s Operative Orthopaedics, 10th ed. St. Louis: Mosby, 2003.

DeLee, J. C., and D. Drez. DeLee and Drez’s Orthopaedic Sports Medicine, 2nd ed. Philadelphia: Saunders, 2005.

Khatri, V. P., and J. A. Asensio. Operative Surgery Manual, 1st ed. Philadelphia: Saunders, 2003.

Townsend, C. M., et al. Sabiston Textbook of Surgery, 17th ed. Philadelphia: Saunders, 2004.

ORGANIZATIONS

American Association for Hand Surgery. 20 North Michigan Avenue, Suite 700, Chicago, IL 60602. (321) 236-3307. http://www.handsurgery.org (accessed March 31, 2008).

American Society of Plastic Surgeons (ASPS). 444 East Algonquin Road, Arlington Heights, IL 60005. (847) 228-9900. http://www.plasticsurgery.org; (accessed March 31, 2008).

American Society for Surgery of the Hand. 6300 North River Road, Suite 600. Rosemont, IL 60018. (847) 384-1435. http://www.assh.org (accessed March 31, 2008).

OTHER

American Society of Plastic Surgeons. http://www.plasticsurgery.org (accessed March 31, 2008).

Laith Farid Gulli, MD, MS

Bilal Nasser, MD, MS

Robert Ramirez, BS

Nicole Mallory, MS, PA-C

Rosalyn Carson-DeWitt, MD

HCT seeHematocrit

Head and neck surgery seeEar, nose, and throat surgery