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Dramatic advances have been made in recent years in
treating patients with hand injuries, degenerative disorders, and birth
defects of the hand to improve both function and appearance. Plastic
surgeons (along with orthopedic surgeons and general surgeons) treat
patients with a wide range of hand problems.
All surgery carries some uncertainty and risk. While the procedures are
generally safe when performed by a qualified and experienced plastic
surgeon, complications can arise. In all types of hand surgery, the
possible complications include infection, poor healing, loss of feeling
or motion, blood clots, and adverse reactions to the anesthesia. These
complications are infrequent, and they can generally be treated.
Hand injuries
The most common procedures in hand surgery are those done to repair
injured hands, including injuries to the tendons, nerves, blood
vessels, and joints; fractured bones; and burns, cuts, and other
injuries to the skin. Modern techniques have greatly improved the
surgeon's ability to restore function and appearance, even in severe
injuries.
Among the techniques now used by plastic surgeons:
Grafting- the transfer of skin, bone, nerves, or other tissue from a healthy
part of the body to repair the injured part;
Flap surgery-moving the skin along with its underlying fat, blood
vessels, and muscle from a healthy part of the body to the injured
site;
Replantation or transplantation-restoring accidentally amputated
fingers or hands using microsurgery, an extremely precise and delicate
surgery performed under magnification. Some injuries may require
several operations over an extended period of time.
In many cases, surgery can restore a significant degree of feeling and
function to injured hands. However, recovery may take months, and a
period of hand therapy will most often be needed.
Carpal tunnel syndrome
The carpal tunnel is a passageway through the wrist carrying tendons
and one of the hand's major nerves. Pressure may build up within the
tunnel because of disease (such as rheumatoid arthritis), injury, fluid retention during pregnancy, overuse, or
repetitive motions. The resulting pressure on the nerve within the
tunnel causes a tingling sensation in the hand, often accompanied by
numbness,
aching, and impaired hand function. This is known as carpal tunnel
syndrome.
In some cases, splinting of the hand and anti-inflammatory medications
will relieve the problem. If this doesn't work, however, surgery may be
required. The surgeon makes an incision from the palm to the wrist,
providing access to the tissue that's causing pressure on the nerve. He
or she will then cut the tissue that's pressing on the nerve, in order
to release the pressure. A large dressing and splint are used after
surgery to restrict motion and promote healing. The scar will gradually
fade and become barely visible. A section of tissue is cut, relieving
pressure on the nerve and restoring feeling and function to the hand.
The results of the surgery will depend in part on how long the
condition has existed and how muchdamage has
been done to the nerve.
Rheumatoid arthritis
Rheumatoid arthritis, an inflammation of the joints, is a disabling
disease that can affect the appearance and the function of the hands
and other parts of the body. It often deforms finger joints and forces
the fingers into a bent position that hampers movement. Disabilities
caused by rheumatoid arthritis can often be managed without surgery-for
example, by wearing special splints or using physical therapy to
strengthen weakened areas. For some patients, however, surgery offers
the best solution. Surgeons can repair or reconstruct almost any area
of the hand or wrist by removing tissue from inflamed joints,
repositioning tendons, or implanting artificial joints. While your hand
may not regain its full use, you can generally expect a significant
improvement in function and appearance. Rheumatoid arthritis can
continue to cause damage to your hand, sometimes requiring further surgery,
and you'll still need to see your rheumatologist for continuing care.
Dupuytren's contracture
Dupuytren's contracture is a
disorder of the skin and underlying tissue on the palm side of the
hand. Thick, scar-like tissue forms under the skin of the palm and may
extend into the fingers, pulling them toward the palm and restricting
motion. The condition usually develops in mid-life and has no known
cause (though it has a tendency to run in families).
The surgeon may make zig-zag incisions across
this band of tissue, creating small skin flaps. Surgery is the only
treatment for Dupuytren's contracture. The
surgeon will cut and separate the bands of thickened tissue, freeing
the tendons and allowing better finger movement. The operation must be
done very precisely, since the nerves that supply the hand and fingers
are often tightly bound up in the abnormal tissue. In some cases, skin
grafts are also needed to replace tightened and puckered skin. The
results of the surgery will depend on the severity of the condition.
You can usually expect significant improvement in function,
particularly after physical therapy and a thin, fairly inconspicuous
scar.
Congenital defects
Congenital deformities of the hand-that is, deformities a child is born
with-can interfere with proper hand growth and cause significant
problems in the use of the hand. Fortunately, with modern surgical
techniques most defects can be corrected at a very early age-in some
cases during infancy, in others at two or three years-allowing normal
development and functioning of the hand.
One of the most common congenital defects is syndactyly,
in which two or more fingers are fused together. Surgical correction
involves cutting the tissue that connects the fingers, then grafting
skin from another part of the body. (The procedure is more complicated
if bones are also fused.) Surgery can usually provide a full range of
motion and a fairly normal appearance, although the color of the
grafted skin may be slightly different from the rest of the hand. If
you need further information please read the detailed information that
follows.
Other common congenital defects include short, missing, or deformed
fingers, immobile tendons, and abnormal nerves or blood vessels. In
most cases, these defects can be treated surgically and significant
improvement can be expected.
Syndactly
What is it?
Syndactyly describes the joining together of
two or more fingers, due to a failure of differentiation of parts in
the upper limb. The separation failure occurs between the sixth to
eighth week of intrauterine life, and the condition may recur in
affected families.
How common is it?
Syndactyly is the commonest of all congenital
hand deformities (i.e.. present at birth),
with an incidence approaching 1/600 live births. The ring and middle
fingers are the most frequently affected, followed by the little and
ring, the middle and index, and the index and thumb.
The condition frequently presents as an isolated anomaly, but may occur
in association with other conditions (e.g.. Apert's syndrome, which also involves craniofacial
malformations which are usually given surgical priority).
How is it classified?
Syndactyly is said to be complete when the
entire web between two digits is fused, and
incomplete when it is not. It is complex when the underlying bones of
the fingers are also joined, and simple when only soft tissues are
involved.
How is it treated?
The treatment of syndactyly is the surgical
separation of the affected digits by a specialist in hand surgery.
When should the surgery be done?
It is advisable to perform surgery early, and one should aim to have
all the webs divided before the child is subjected to peer curiosity at school. Joined fingers may
adversely affect the growth of the hand, and there are situations (e.g.. webbing between the index and thumb) when surgery
is performed sooner, to allow the natural development of hand function
(grasping objects in infancy).
What are the principles of this type of surgery?
Although many different techniques have been described to treat syndactyly, all of them share the concept that a
skin deficiency exists at the base of a fused web that has been fully
separated. It is therefore usually necessary to introduce a skin graft
taken from another part of the body, such as the groin which leaves a cosmetically
acceptable scar. In order to re-surface the borders of affected digits
using local tissue, several Z-shaped skin flaps are used, which result
in a scar which has the shape of a zig-zag.
The surgical principles of syndactyly
release are:
1: To provide a good web between the fingers
2: To provide adequate skin cover either side of the web space
3: To separate all tissues completely
4: To minimise the potential for later scar
contracture
Other important aspects of the operation include:
1: The need to correct all skeletal abnormalities in the digits
2: The release of only one side of any digit at any one time
3: The need for meticulous dissection under loupe magnification
Skin grafts need to be immoblised to 'take',
and the dressings following syndactyly
release are often bulky and left in place for the first 7-14 days
(depending on the climate: dressings are removed earlier in hot
countries). It is frequent practice for the first change of dressing to
be performed under general anaesthesia.
N.B. Sometimes an incomplete result is obtained at a first surgical
setting, and a re-release of syndactyly is
planned during adolescence.
Recovery and rehabilitation
Since the hand is a very sensitive part of the body, you may have mild
to severe pain following surgery. Injections or oral medication will
make you more comfortable.
How long your hand must remain immobilized and how quickly you resume
your normal activities depends on the type and extent of surgery and on
how fast you heal.
To enhance your recovery and give you the fullest possible use of your
hand, your surgeon may recommend a course of rehabilitation (physical
and occupational therapy) under the direction of a trained hand
therapist. Your therapy may include hand exercises, heat and massage
therapy, electrical nerve stimulation, splinting, traction, and special
wrappings to control swelling.
The information on this web site is only intended as an
introduction to this procedure and should not be used to determine
whether you will have the procedure performed nor as a guarantee of the
result.
The best method of determining your personal options is to schedule a
personal consultation with Dr. Makki. He will be able to answer
specific questions related to your situation.
Please don't hesitate to call for any questions that you might have
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