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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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