Malta Plastic Surgery Institute  - Beauty through Science and Innovation
Hand Surgery
 
Dupuytren’s disease
 
Introduction
Dupuytren’s disease is an abnormal thickening of the fascia (the tissue just beneath the skin of the palm). It often starts with firm lumps in the palm. In some patients, firm cords will develop beneath the skin, stretching from the palm into the fingers. Gradually, these cords may cause the fingers to bend into the palm. Although the skin may become involved in the process, the deeper structures—such as the tendons—are not directly involved.
The cause of Dupuytren’s disease is unknown but may be associated with certain biochemical factors within the involved fascia. The problem is more common in men over age 40 and in people of northern European descent. There is no proven evidence that hand injuries or specific occupational exposures lead to a higher risk of developing Dupuytren’s disease.
The surgery
In some cases, only observation is needed for nodules and cords that are not contracted. Patients with more advanced contractures may require surgery in order to improve function.
Surgery for Dupuytren’s Disease is performed in hospital under general or regional anaesthesia.
Various surgical techniques are available in order to correct finger position. The surgeon will discuss the method most appropriate for your condition based upon the stage of the disease and the joints involved. The goal of surgery is to improve finger position and thereby hand function.
As with any surgery, although uncommon there are risks. These include infection, haematoma, slow wound healing, stiffness, nerve injury and swelling. Despite surgery, the disease process may recur and the fingers may begin to bend into the palm once again.
After your Surgery
In most situations you will able to go home on the day of your surgery, however the length of your hospital stay will depend on your general health, the extent of the procedure, and your surgeon's advice.
At the time of discharge your hand will be in a splint and covered in a bandage. Within the first week following the operation, an appointment will be made for you to see a hand therapist who will start mobilising the fingers and remove the splint. A new splint will be made for you at that time, which is to be worn at night for up to 6 months.
Returning to normal activities is an individual matter, but most people return to work within two to four weeks and to more vigorous activities after six weeks.
 
Carpal Tunnel Syndrome
 
Introduction
Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers.
The carpal tunnel is a space in the wrist where the median nerve and nine tendons pass from the forearm into the hand. Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel and puts pressure on the nerve. There are a number of conditions known to increase the pressure in the carpal tunnel but usually the cause is unknown.
Treatment of Carpal Tunnel Syndrome
Symptoms may often be relieved without surgery.
Non operative options may include:
 
  • Identification and treatment medical conditions causing the swelling
  • Changing the patterns of hand use
  • Keeping the wrist splinted in a straight position
  • Steroid injection into the carpal tunnel to reduce swelling around the nerve
When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand.
Surgery is performed in hospital as a day surgery procedure, usually with only a light anaesthetic.
After your Surgery
At the time of discharge your hand will be wrapped in a bandage, which is removed the following day. Normal use of the hand can usually be resumed
when comfortable.
Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases
Returning to normal activities is an individual matter, but most people return to work within two to four weeks and to more vigorous activities after six weeks.
 
Ganglions
 
Introduction
Ganglion cysts are very common lumps within the hand and wrist that occur adjacent to joints or tendons. The most common locations are the back of the wrist, the front of the wrist, the base of the fingers, and the back of the end joint of the finger. The ganglion cyst often resembles a water balloon on a stalk, and is filled with clear fluid or gel. The cause of these cysts is unknown although they may form in the presence of joint or tendon irritation or mechanical changes. These cysts may change in size or even disappear completely, and they may or may not be painful. These cysts are not cancerous, do not cause arthritis and will not spread to other areas.
Treatment of Ganglion Cysts
Treatment can often be non-surgical. In many cases, these cysts can simply be observed, especially if they are painless. The natural history of most cysts is to disappear on their own over a 5 year period. If the cyst becomes painful, limits activity, or is cosmetically unacceptable, other treatment options are available.
Aspiration of the cyst can be performed to remove the fluid from the cyst and decompress it. This requires placing a needle into the cyst, which can be done in the office at the time of consultation.
If non-surgical options fail to provide relief or if the cyst recurs, surgical alternatives are available. Surgery involves removing the cyst along with a portion of the joint capsule or tendon sheath.
Surgical treatment is generally successful although cysts may recur.
After your Surgery
In most situations you will able to go home on the day of your surgery, however the length of your hospital stay will depend on your general health, the extent of the procedure, and your surgeon's advice.
At the time of discharge your hand will be in a splint and covered in a bandage.
The bandage and splint will be removed at your first postoperative appointment and you will be encouraged to start using the hand at this stage.
As with all operations although uncommon, there are some risks involved. These include wound infection, painful scar, swelling and stiffness. If stiffness and swelling persist it may be necessary to refer you to a hand therapist to regain your mobility.
Returning to normal activities is an individual matter, but most people return to work within two to four weeks and to more vigorous activities after six weeks.
 
Trigger Fingers
 
Introduction
Stenosing tenosynovitis, or “trigger finger” or involves a narrowing of the space that the tendons of the fingers run within. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers. Each tendon runs under a set of pulleys in the finger which are a series of rings that form a tunnel through which the tendons must glide. The tendons and the tunnel have a smooth lining that allows easy gliding of the tendon through the pulleys.
Trigger finger occurs when the pulley at the base of the finger becomes too thick around the tendon, making it hard for the tendon to move freely under the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb. When the tendon catches, it produces inflammation and more swelling. This causes a vicious cycle of triggering, inflammation, and swelling. Sometimes the finger becomes stuck or locked in a bent position and is hard to straighten.
Causes for this condition are not always clear. Some trigger fingers are associated with medical conditions such as rheumatoid arthritis, gout, and diabetes. Local trauma to the palm/base of the finger may be a factor on occasion, but in most cases there is not a clear cause. It may also be associated with carpal tunnel syndrome.
 
 
 
 
 
Treatment of trigger finger
Treatment of trigger finger is generally non surgical and may involve both of the following:
  • Steroid injection into the tendon sheath
  • Splints
If non-surgical forms of treatment do not relieve the symptoms, surgery may be recommended.
Surgery is performed in hospital as a day case, usually with a light anaesthesia. The surgery involves division of the pulley at the base of the finger so that the tendon can glide more freely.
Active motion of the finger generally begins immediately after surgery.
Normal use of the hand can usually be resumed when comfortable.
Returning to normal activities is an individual matter, but most people return to work within two to four weeks and to more vigorous activities after six weeks.
 
Arthritis
 
Introduction
Arthritis literally means “inflamed joint.” Normally a joint consists of two smooth, cartilage-covered bone surfaces that fit together as a matched set and that move smoothly against one other. Arthritis results when these smooth surfaces become irregular and don’t fit together well anymore and essentially “wear out.” Arthritis can affect any joint in the body. Arthritis of the hand can be both painful and disabling. The most common forms of arthritis in the hand are osteoarthritis, post-traumatic arthritis (after an injury), and rheumatoid arthritis. Other causes of arthritis of the hand are infection, gout, and psoriasis.
Osteoarthritis is the most common cause of arthritis seen in this practice. Osteoarthritis is a degenerative joint disease in which the cushioning cartilage that covers the bone surfaces at the joints begins to wear out. It may be caused by simple “wear and tear” on joints, or it may develop after an injury to a joint. In the hand, osteoarthritis most often develops in three sites:
  • at the base of the thumb (basal joint)
  • at the end joint closest to the finger tip (the distal interphalangeal or DIP joint)
  • at the middle joint of a finger (the proximal interphalangeal or PIP joint)
Arthritis of the hand irrespective of the cause, presents with stiffness, swelling, and pain over the involved joint. Grip and pinch strength may be diminished, causing difficulty with activities such as opening jars or turning keys.
An X-ray will required to show certain characteristics of arthritis, such as narrowing of the joint space, the formation of bony outgrowths (osteophytes or “nodes”), and the development of dense, hard areas of bone along the joint margins. Blood tests or referral to a rheumatologist may required to exclude other causes of arthritis.
Treatment of Arthritis
Treatment is designed to relieve pain and restore function. The initial treatment is non surgical and includes
  • Anti-inflammatory or other analgesic medication
  • Finger or wrist splints at night and for selected activities.
  • Hand therapy
  • Activity modification
  • Steroid injection into the joint
Surgery is usually not advised unless these more conservative treatments fail.
Surgery is indicated when the patient either has too much pain or too little function. In most cases, the patient knows best and actually tells the doctor when it is time for surgery. The goal is to restore as much function as possible and to eliminate the pain or reduce it to a tolerable level.
The type of surgery used depends on the particular joint(s) involved, your activities, and your own needs. The surgeon can help you decide which type of surgery is the most appropriate for you. The surgical options include:
  • Arthrodesis or joint fusion
  • Arthroplasty or Joint reconstruction, in which the degenerated joint surface is removed in order to eliminate the rough, irregular bone-to-bone contact that causes pain and restricts motion. Once the degenerated portion of the joint surface is removed, it may be replaced with rolled-up soft tissue, such as a tendon, or with a joint replacement implant.
 
 
 
 
 
 
 
 
 
 
 
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