- Hand Fractures
- Wrist Fractures
- Wrist Arthroscopy
- Dupuytrens Contracture
- Small Finger Joint Fusion
The following is a list of common Hand and Wrist conditions:
- Hand Fractures
- Wrist fractures
- Carpal tunnel syndrome
- Lumps around the hand and wrist
- Ligament injuries
- Tendon injuries
- Arthritis affecting hand and wrist
- Wrist arthroscopy
- Dupuytrens contracture
Fractures of the hand are very common following a twisting injury, crush or direct contact in sports. Accurate assessment and prompt treatment with early mobilisation are essential to ensure full recovery without residual deficit in function.
Some examples of common hand fractures include:
Wrist fractures are very common following a fall. Often, the fracture is significantly displaced and if left untreated, will result in permanent deformity and loss of function. Significantly displaced fractures are often manipulated (reset) in the A&E department and a backslab (half plaster) is applied.
This represents first aid treatment only and almost certainly definitive treatment is required later. This is because certain fractures are inherently unstable and will predictably displace again once the acute swelling settles. Early treatment is therefore recommended to restore the fractured wrist back to its original position and alignment, before the fracture starts to heal in a suboptimal position.Treatment options include:
This is suitable only for certain fracture patterns which are minimally displaced and stable. It involves the application of a light weight fibreglass cast which immobilises the wrist for 6 weeks. It avoids the need for an operation but cannot adequately stabilise unstable complex fractures which may redisplace at later time. Hence, weekly x ray checks are essential to monitor the position carefully.
This involves placing smooth pins across the two fractured bone ends and supplementing the fixation afterwards with a plaster cast for 6 weeks. This technique has drawbacks including the need for plaster cast afterwards and therefore increased wrist stiffness as well as increased risk of infection as the pins are left protruding outside skin. Furthermore, the smooth pins cannot hold the reduction for complex fractures and redisplacement is likely.
With advances in surgical technology, small titanium plates with accompanying locking and non locking screws are now available to stabilise the bony skeleton and allowing it to heal in the correct position. With the improved stability, there is no need to be in plaster afterwards and early movement of the wrist is encouraged to prevent stiffness.
Through a small surgical incision of about 4-5cm, Mr Lam uses a small precontoured titanium plate which allows precise screw placement and creates an extremely stable construct that helps early movement while minimizing soft tissue irritation. It provides excellent fixation for acute fractures, malunions and nonunions of the distal radius.
Arthroscopic keyhole surgery for the wrist can be carried out for a variety of conditions including:
- Cartilage tear of the Triangular Fibrocartilage Cartilage complex (TFCC)
- Wrist arthritis
- Injury to the carpal ligaments and instability
- Wrist synovitis
The procedure involves two tiny little stab incisions of about 2-3mm. Through these small holes, a needle like telescope (actual size is 1.9mm) and a variety of other instruments which are also of similar size can be passed into the wrist joint. Because the instruments are so small, only a very small incision needs to be made and following surgery, no suturing is required and the wound heals well with steristrips alone.
As the surgery is minimally invasive, patients have less pain afterwards and recover more quickly than with open surgery. Usually all patients following a wrist arthroscopy can go home on the day of surgery.
What is Dupuytrens contracture?
This is a debilitating condition in which the fibrous tissue underneath the skin of the palm and fingers become progressively thickened, forming nodules in the palm and eventually progress into longitudinal bands which cause the fingers to curl (flex). It most commonly affects the ring and little fingers. It is named after Baron Guillaume Dupuytren, the surgeon who described an operation to correct the affliction in the Lancet in 1831.
What causes Dupuytren's contracture?
The cause is not known. It is not caused by an injury or heavy usage. Certain groups of people are at higher risk of developing this disorder
- Ethnic origin ( Northern European (English, Irish, Scottish, French, Dutch) or Scandinavian (Swedish, Norwegian, Finnish) ancestry
- Family History (about 10%)
- It may be associated with drinking alcohol
- It is associated with certain medical conditions, such as diabetes, seizures and chronic lung disease
Can it occur elsewhere?
In addition to the palm of the hand and fingers, it can also occur in the dorsum of the hands in the form of knuckle pads, in the feet and in the penis.
There is no way to stop or cure Dupuytren's contracture. However, Dupuytren's contracture usually progresses very slowly and may not become troublesome for years.
Can the disorder be treated non-surgically?
If the condition progresses very slowly, nonsurgical treatment may be considered. Specially made to measure splints can be worn. However, they do not reverse or prevent the finger contracture. Forceful stretching of the contracted finger will not be helpful and may even worsen the speed of the progression of contracture.
When should surgery be considered?
Most doctors would agree that surgery should be considered if the function of the hand is compromised, this may include difficulty with grasping objects, writing, washing face or putting their hands in their pockets. When there are significant contractures present, the palm and fingers are no longer possible to be placed simultaneously flat on the table.
What is new with the treatment of Dupuytrens contracture?
Needle Aponeurotomy or fasciotomy
Needle aponeurotomy is a new minimally invasive procedure which can divide the Dupuytrens tissue without making an open surgical incision. It is done with the patient wide awake and after numbing the hand with a small amount of local anaesthetic, the dupuytrens cord is divided using a small hypodermic needle. The advantage of this technique is that the recovery is very quick and patients can wash their hands the day after surgery and there are no stitches or open wound to cover. The procedure takes approximately 10 – 15 minutes and patients can go home very soon after the procedure with a lot less pain and swelling immediately after the procedure, compared to traditional open surgery.
An enzyme injection is now available for treatment of Dupuytren's contracture for surgeons trained in the technique. The enzyme is able to break down the collagen bands and improve motion without surgery.
After numbing the hand with a local anaesthetic injection, the surgeon injects the enzyme directly into the diseased tissue. During the several hours following the injection, the enzyme dissolves the contractile tissue, allowing the finger to straighten.
This procedure is performed in the doctor's office, and is associated with less pain and swelling than with surgery. Early results for this injection appear to be as good as surgical results. Although rare, the injection may cause allergic reactions or flexor tendon tears. Other complications include the same as those listed above for surgery. Early results are promising, but long-term recurrence rates have not yet been reported.
What types of open surgery are there?
Surgery for Dupuytren's contracture involves dividing and removing the thickened bands to help restore finger motion. In a limited fasciectomy, the diseased cords and fascia are excised. When the contracture is severe or when one is dealing with a recurrence of this disorder, sometimes a dermofascicetomy is carried out whereby in addition to the fasciectomy, the overlying skin is also excised. Part of the wound may be left open and allowed to heal gradually. Skin grafting may be needed.
What are the risks of open surgery?
These are fortunately rare but can include injury to nerves and blood vessels, residual stiffness and infection. A small proportion of patients, particularly those with strong family history, may develop recurrence of this disorder.
What is the post op care after surgery?
After surgery, elevating your hand above your heart and gently moving your fingers will help to relieve pain, swelling, and stiffness. If you have had an open procedure, the stitches will need to be removed at 12-14 days. A removable night splint is worn to maintain the movement of the finger achieved through surgery. Regular hand therapy would be necessary.
Mr Lam is a member of the British Dupuytrens Society and further information about the condition and the Society can be found here. http://dupuytrens-society.org.uk/index.html
Appearance and function of the little finger following fusion for long standing arthritis of the tip of the finger