What is Hand Surgery

Hand surgery is a broad term that incorporates a vast array of different types of surgery on the hand. Hand surgeons who perform hand surgery attempt to restore not only the function of the hand, but try to maximize the cosmetic appearance of the hand, as well.

What are the different types of hand surgery?

The following is a brief overview of some types of surgical procedures that I perform;

1. Closed Reduction and Cast
   This is the most desirable option to realign a fractured bone. Reduction may have to be repeated if there is severe swelling around the fracture due to bleeding or fluid accumulation. The swelling subsides as the blood and fluid are absorbed back into the circulation and this creates extra space in the cast and bone pieces move as marbles would in a jar.
2. Closed reduction and external fixationThis is possible when a fracture can be realigned but would not stay ‘put’ in a cast because the bones not unstable. Pins are put on either side of the fracture and cut or connected by a rod like device outside the finger, wrist or forearm. Pins are removed after the fracture heals. Infection around the pin sometimes occurs and we have to remove pins as soon as possible.
3. Open reduction and internal fixation
   This is the last option in surgery because there are risks of infection, blood vessel and nerve injury during surgery, unusual scarring due to inherent differences in healing power of different people, complications from anesthesia and unpredictable bleeding after surgery from a variety of causes. There are additional complications specific to the type of tissues, injury and surgery. Pins, wires, screws and plates are some of the devices that I use to fix the broken pieces of bone depending upon the nature of the fracture. These may be removed at a later date if necessary.
4. Tendon Repair
   Tendons are the fibers that attach muscle to bone. Repair of tendons remains a surgical challenge because of the structure of the tendon. Tendon injuries can occur due to infection, trauma, or spontaneous rupture. Repair of a tendon may be classified as primary, delayed primary, or secondary. Primary repair of an acute injury is usually completed within 24 hours of the injury. Delayed primary repair is usually performed a few days after the injury, but while there is still an opening in the skin from the wound. Secondary repairs may occur two to five weeks or longer after the injury. Primary repairs usually involve direct surgical correction of the injury, while secondary repairs may include tendon grafts (inserting tendons from other areas of the body in place of the damaged tendon) or other more complex procedures.
5. Nerve Repair
   There are three main nerves that innervate the hand, including the ulnar nerve, the median nerve, and the radial nerve. Damage to these nerves from injury may result in decreased ability to move the hand and experience feeling. Some nerve injuries may heal on their own, while others require surgery. Overall, about three to six weeks after the injury is the best time for nerve repairs that are associated with other, more complicated, injuries. Surgery to investigate a damaged nerve that is not complicated by other injuries is usually performed early after the trauma, to increase the likelihood of a full recovery. If severed, the nerve may be repaired by reattaching it directly to the other end of the nerve, or by using a nerve graft (inserting nerves from other areas of the body in place of the damaged nerve) to repair the damaged section.
6. Ligament repair
7. Limited fasciectomy for Dupuytren’s contracture
8. Fasciotomy
   This procedure is performed to help treat compartment syndromes. A compartment is a three-dimensional anatomic space in the body that is surrounded by fascia or bone and contains arteries, nerves, and veins. A compartment syndrome is a condition that arises when there is an increase in intracompartmental tissue pressure within a space in the body, usually caused by trauma, which can interfere with the circulation to the body tissues and destroy function. In the hand, a compartment syndrome may lead to severe and increasing pain, muscle weakness, and, eventually, a change in color of the fingers or nailbeds.
   Fasciotomy is the treatment for the early stage of compartment syndromes. Surgical incisions are placed in the hand or arm to allow a release of the pressures that are increasing inside the body. Any tissue inside the body that is already damaged may be removed at this time. A fasciotomy will help prevent a further decrease in function and damage of the affected extremity.
9. Surgical Drainage and/or Debridement
   Our hands are constantly at risk for injury and infection. Infections of the hand are a common reason people seek treatment. The treatment for infections to the hand may include rest, use of heat (soaking hand in warm, not hot water for less than 2-3 minutes) , elevation (keep your elbow by your flank and hand by the same shoulder so that extra water in the soft tissues, as we call it edema resolves or does not increase), antibiotics, and surgical drainage. Surgical drainage may be used if there is an abscess in the hand to help remove the collection of pus. Debridement, or cleansing of a wound to prevent further infection and to promote healing, may be used if the infection is severe.
10. Joint Replacement
    This type of surgery, also called arthroplasty, may be used in people with severe arthritis of the hand. This involves replacing a joint that has been destroyed by the disease process with an artificial joint. This artificial joint may be made out of metal, plastic, silicone rubber, or the patient’s own body tissue such as a tendon. Replacement with patient’s own tendon is the most durable and lasting procedure for arthritis at the base of the thumb. Silicone rubber is my preferred choice for arthritis at the finger knuckles as it has the longest track record and is considered a gold standard by many hand surgeons including Dr. Edward Nalebuff who wrote the final chapter in the Hand Bible “Green’s operative Hand Surgery” published by Elsevier from Philadelphia.

WHAT ARE THE RISKS OF HAND SURGERY? All Surgery Carries Some Risk
http://www.abms.org/News_and_Events/Media_Newsroom/features/feature_Tips_forConsumers.aspx
http://www.facs.org/public_info/operation/consent.html

Surgery carries the risks of surgery itself and risks of anesthesia. Risks of surgery include, but are not not the only ones.

• Infection
• Incomplete healing
• excessive scarring
• loss of feeling of the hand or fingers
• loss of movement of the hand or fingers
• Bleeding during and after surgery

Additional risks associated with surgery depend greatly on the type of injury, type of surgery, and differences in tissues of each patient and my competence. I am not perfect and I am not capable of predicting every possible variable in injury, procedure or patient variation. I have taken these risks and succeeded most of the time but not all. IF YOU ARE NOT A RISK TAKING PERSON, I UNDERSTAND. You should not take the risk of surgery after you have discussed risks as well as benefits of surgery with me.