SURGERY OF THE HAND Posted in: Reconstructive Surgery

History of Surgery of the Hand

The unique functional and psychological attributes of the hand have been recognized since ancient times. It is said that Julius Caesar during the Gallic wars, rather than killing captured enemy warriors, ordered their thumbs to be amputated.  These mutilated men were unable effectively to bear arms again and served as a warning to others. Similarly, in the Peloponnesian War the same practice is cited, carried out by the Athenians, upon the oarsmen of hostile galleys before these prisoners were sent home.

The specialty of Hand Surgery developed out of necessity during World War II. Hand injuries required special expertise from several surgical disciplines to repair injured bones, joints, nerves, and blood vessels. Gathering together many different specialists to treat a single injured soldier was not practical or even possible during wartime and it quickly became obvious that a select group of surgeons needed to be trained to care for all components of the arm and hand.

Dr. Sterling Bunnell, a consultant to the US Army, developed a training program that taught interested surgeons the multiple skills needed to care for all of the parts of the arm and the surgical specialty of hand surgery was born.

Current training requires that Hand Surgeons first complete training in Orthopedic Surgery, General Surgery or Plastic Surgery in order to qualify to write the certifying board exams of their specialty. Aspiring hand surgeons then complete another year of training called a Hand Surgery Fellowship where they learn microsurgery and receive intensive training in the diagnosis and treatment of arm problems. Hand Surgeons may choose to become certified by passing a certifying examination: the Certificate of Added Qualifications in Hand Surgery.

Hand Surgery, as we see, is in itself one specialty within another.

By the same token, its field is broad and very interesting, as it helps recover form, function and aesthetics of the hands whose parts have suffered birth deformities, trauma, tumors or accidents.

These are some of the many facets of hand surgery

  • Surgery of injuries to tendons
  • Nerve lesions surgery and its resulting paralysis
  • Surgery of bone fractures of the hand
  • Surgery for congenital deformities
  • Surgery of lesions of the veins and arteries
  • Surgery of burns and scars
  • Replantation and transplantation surgery
  • Surgery in rheumatoid arthritis
  • Surgery of soft tissue injuries
  • Surgery of tumors of the hand

This variety of injuries and procedures will give you an idea of the vast territory of Hand Surgery. Some Plastic Surgeons cover the full range of hand problems and there are some who deal with only a limited range of injuries.

Below, I have detailed the most common injuries and illnesses of the hand that I have encountered over the years in my private practice.

Tendon and Nerve Injuries

Tendons are cords that can bend and stretch our hands and fingers. They are not the same as nerves or veins. Nerves are similar structures, but with a completely different component and function. Both structures are strong, robust, and are non-elastic.

Any sharp object, such as knives and glass shards can produce nerve or tendon damage to the hand or fingers. Injuries to these structures require immediate specialist care. There is a 6 hour window of opportunity, known as the golden period, in which to reconnect the damaged nerves and tendons in order to prevent infection and promote optimum healing.

If you sustain a deep wound to the hand, wrap the hand in a clean cloth and head to the hospital for treatment as quickly as possible. There, the wound will be cleaned with normal saline and a course of antibiotics will be started.

The cases I most often operate on involve the flexor and extensors tendons of the fingers and thumb and the nerves of the fingers and wrists.

If the injury is treated by a knowledgeable Hand Specialist within the ‘golden period’ of 6 hours recovery should be optimal. A rehabilitation program is initiated after approximately 3 weeks of healing.

 Baseball Finger or Mallet Finger

This is a fairly common finger injury that is often produced by catching a ball with the open hand with the fingers pointing towards the object. The tiny extensor tendon of the finger ruptures and it is necessary to splint the finger in a special position for 4 weeks, so the tendon can heal.

Special plastic splints are available in the office. The results are splendid if the case is immediately cared for. Full recovery takes about 6 weeks.

Bone Fractures of the Hand and Fingers

The bones are solid structures, exposed to strong shocks, falls, and excessive force. Any force that exceeds the strength of a bone, especially in the elderly and children, may cause the bone to break. A good supply of calcium in the bones increases resistance to fractures.

Bone fractures require immediate specialist care. Again, the most important thing is to protect the wound and seek prompt medical attention. As in any wound of hand, there is a 6 hours maximum limit to set the broken bones, otherwise there are increased risks of infection in the wound and bone, as well as possible improper mending of the bone ends

Currently, we use titanium screws and plates to stabilize the fracture under regional anesthesia, i.e. just anesthetize the arm alone down to the hand. This numbness can be recovered within minutes. A cast or splint may be applied to further stabilize the fracture.

If fractures are managed within the golden period of 6 hours, and by a specialist mastering hand surgery, recovery is optimal. The arm or hand must rest in an elevated position for 10 days. Stitches are removed after 2 weeks. A rehabilitation program can commence after four weeks.

Carpal Tunnel Syndrome

This is a fairly common medical condition in which the median nerve is compressed at the wrist, leading to tingling, intermittent numbness and muscle weakness in the hand especially the index, middle and ring fingers. Occasionally the thumb is affected as well. It is common in people who use repetitive hand movements. It’s more common in women, and usually occurs at younger ages.

Once diagnosed, evidenced by the characteristic symptoms and by physiological tests, the only treatment is surgery. The operation consists of opening the tunnel, under anesthesia, and releasing the median nerve.  This is effective at relieving symptoms and preventing further nerve damage.

Today you can have the operation with the conventional open technique or by endoscopy. Anesthesia is done through a regional block. The procedure takes about 20 minutes and you can go home once recovered, and basically without pain. The recovery period is approximately 7 days.

Dupuytren’s Disease

This is not really a disease but rather a thickening and shrinking of the strong layer of tissue just under the skin of the palm called the superficial palmar fascia. It can cause lumps or dimples in the skin of the palm, and can draw the fingers down into a bent position causing limited movement. It is more common in people over 50 years and affects both men and women.

Treatment involves opening the skin of the palm and removing the diseased fascia allowing the fingers to return to their original position. The procedure is done under regional anesthesia and recovery is approximately 10 days.

Synovial Cysts

These are hard, round masses that appear on the back of the wrist and sometimes in the fingers.  They can be painful especially in cold weather. They’re not dangerous and they are not tumors, but patients may be bothered by pain and functional limitation of the wrist on account of them.

Surgical treatment involves opening the skin and completely removing the cyst.  Anesthesia is done through a regional block in the short stay clinic or in some cases under local anesthesia in the office.  The wrist is rested for about 6 days and stitches are removed 14 days after surgery.

Benign and malignant tumors

Tumors are not common but they can appear in the hand as benign masses, derived from any tissue, such as the blood vessels, bones, soft parts, and so on. Benign tumors are removed using a regional anesthetic and patients are discharged the same day. Recovery time varies between 2 – 3 weeks.

Malignant tumors may also occur but these are very rare. If a tumor is diagnosed as malignant, treatment is planned in partnership with an Oncologist (cancer specialist). Treatment will be planned taking into consideration the diagnosis, the degree of disease progression and the prognosis.

Foreign bodies in the hand

Although it does not happen often sometimes people can accidentally introduce needles, nails, wood splinters or glass etc. in their palm of the hand. Trying to extract foreign bodies embedded in the hand by an untrained individual can be painful and damaging to the tissues. Often they are unable to locate the foreign obstacle at all. However, when extracted by a hand surgery specialist, the object can be removed quickly and safely, without much trouble.

Following are ‘before’ and ‘after’ instructions:

BEFORE SURGERY:

  • Do not take aspirin or aspirin products for 2 to 3 weeks before surgery; (click Medicines not recommended for more details).
  • Thoroughly wash your entire arm once a day for three consecutive days before surgery with Isodine (Betadine) foam.
  • The day before surgery, the armpit should be shaved to prepare for regional anesthesia.
  • Do not eat or drink anything after midnight prior to your surgery.
  • Bring a change of clothes and wear comfortable shoes.
  • If you get a cold or any infection, call the office immediately please.

AFTER SURGERY:

  • Return directly home and remain on bed rest for 24 to 48 hours. You may get up for meals and to use the toilet only.
  • Keep the operated arm in the prescribed sling for 10 days. When lying down, keep the hand elevated by resting it on two large pillows.
  • Take any prescribed medications as directed. Do not consume any alcohol during this time.
  • You may take a shower or bath but the covering the arm must be covered with a plastic bag.

FINGER PROSTHESIS

Typically you are asked to come to the office at the 5th, 10th and 15th days and thereafter every week. You will be sent to a rehabilitation office, depending on your diagnosis and your operation, and usually for at least a month before complete recovering.


The finger prosthesis are custom made, depending the case. They are hand made by a skillet artist, using his own techniques in sculpting and experience to imitate a living finger.

The finger prosthesis are custom made, depending the case. They are hand made by a skillet artist, using his own techniques in sculpting and experience to imitate a living finger.

Our recommendation is the fine work of Mr. Pablo Walls. His web page is:

www.manosydedos.com

To view some hand surgery cases from these surgeries click on Photo Gallery.
Please, feel free to call the office for this or other topics concerning your Plastic Surgery request. Phone: 684-2551 (619) 730-1917 or cell phone: 664-283-0976

Or, if you prefer, click Contact us

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