The Upper Limb Clinic

Hand surgeon in Kingston, Wimbledon or Syon

Hand Surgery Factsheets

New to Hand Surgery?

The fact sheet below provide most of the information you should need about a range of surgical procedures that are commonly performed on the hand.

Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome is due to compression of the median nerve within a bony tunnel that has a ligament across the top of it. Pressure on the nerve causes the nerve function to deteriorate. If left untreated this can cause permanent loss of sensation and wasting of the thumb muscles. Once the nerve is permanently damaged the recovery is obviously limited. There is a simple local anaesthetic day case procedure that can be performed to relieve the pressure on the nerve within the tunnel.

Carpal Tunnel Syndrome Operation

Local anaesthetic is injected around the site of the operation. Patients find that this is the most uncomfortable part of the procedure and the operation itself is not painful at all. The operation is performed with a tourniquet on the arm. This is a tight band around the arm which stops the flow of blood while the procedure is being carried out. The time the tourniquet is on your arm is kept to an absolute minimum for your comfort. The local anaesthetic that was injected in your hand can last for up to 12 hours. When sensation starts to return to the hand it is a good idea to take the tablets you have been given to take home, as the hand can be sore for the first day or two.

A bulky dressing is put on the hand initially but it is put on so that the thumb and fingers are left entirely free. This dressing is left on for five days. It can be removed at home without the supervision of a nurse or doctor. If the wound looks healthy, all we ask you to do is apply a self-adhesive dressing which is supplied by the hospital. You then need to keep the wound clean and dry for a further five days. At this stage it is safe to get the hand wet in a bath or shower. It is very common for the skin around the wound to become dry and an application of a moisturiser and regular massage will help the wound settle down.

Carpal Tunnel Syndrome Recovery Time

Most patients are back driving a car about one week after surgery, so long as they are fully in control of the vehicle. Return to work depends on your occupation and you can discuss this with your surgeon. The stitches are absorbable and will fall out on their own within a few days of the wound being exposed. It is common to have both hands operated on at the same time. Because the bandages that are applied leave the thumb and fingers completely free, this does not cause significant problems. Most patients find that the unpleasant tingling they get at night time which wakes them up, settles immediately. Should you have had reduced sensation in the fingers this can take time to recover. If this has been long standing a full return of normal sensation cannot be guaranteed.

Diabetic Cheiroarthropathy

Diabetes and Hand Problems

Diabetic cheiroarthropathy is a cutaneous condition characterised by thickened skin and limited joint mobility of the hands and fingers. Diabetics have a higher incidence of hand problems than the general population. The reasons are not well understood but possible factors include:

Abnormal accumulation of proteins in the tissues. This particularly involves collagen, which is the key contributor to the strength of tissues including skin, tendons, and ligaments. The composition of collagen is slightly altered, which can make it stiffer than normal.

Loss of blood flow in the tissues (ischaemia). Diabetes is complicated by abnormalities of the small blood vessels (micro-angiopathy). This is responsible for some of the most serious complications of diabetes, such as eye problems (retinopathy). Nerves may be affected (neuropathy) causing loss of sensation as well as muscle weakness. Small blood-vessel disease may cause scarring in any of the tissues in the hand. This can interfere with the normal gliding of tendons and flexibility of joints.

About “Diabetic Hand Syndrome” and Symptoms

Diabetic Hand Syndrome, Diabetic Stiff Hand or diabetic cheiroarthropathy often causes a general sensation of “stiffness” or “slowness” in the hand. There is often some real loss of mobility in the joints, particularly the middle finger joints. This makes it difficult for you to bend the fingers right into the palm or to straighten them fully.

The condition is characterised by a number of specific problems. All are seen in non-diabetics but they are more common in diabetics. These can occur singly or together.

Flexor tenosynovitis is due to a thickening of the tissue lining the tendons that bend the fingers. This tissue is present from the wrist to the finger-tips. Thickening causes swelling of the palm and fingers. Rings may feel tight and the hand may ache. The palm and fingers may be tender to pressure. Tenosynovitis contributes to the finger stiffness. The symptoms are often worse in the night or on awakening. This is because fluid collects in the arms whilst you are asleep and inactive. When severe, it can cause a clicking sensation and even catching or “triggering” of the tendon.

Carpal tunnel syndrome is due to compression of the median nerve within a tunnel comprising a “U” shaped collection of bones with a tight ligament at the top. This causes ‘pins and needles’ in the area supplied by the nerve (thumb, index, middle and ring fingers). The condition is mainly caused by the tenosynovitis that squashes the nerve as it swells. It may also be contributed to by neuropathy (see ‘Loss of blood flow’ above).

Dupuytren’s contracture is a thickening of deep tissue (fascia), which passes from the palm into the fingers. Shortening of this tissue causes ‘bands’ which pull the fingers into the palm.

Other common conditions such as “tennis elbow” and “frozen shoulder” are more common in diabetic patients.

Treatment of these Hand Conditions

Once established, the background stiffness will persist and cannot be cured. The tenosynovitis will vary from week to week. ‘Flare-ups’ may respond to anti-inflammatory medications or gels. Specific problems, such as triggering, are usually treated by steroid injections. Carpal tunnel syndrome and Dupuytren’s contractures often need to be treated by surgery.

Dupuytren’s Disease

What is Dupuytren’s Disease?

Dupuytren’s disease is a thickening of the layer of tissue which lies just underneath the skin of the palm and extends into the fingers. When this tissue thickens it tends to shorten as well and can form nodules and cords in the hand. Most people who have Dupuytren’s disease have inherited it from their parents. The disease is particularly common in Northern Europe and has therefore been linked to Viking ancestry.

The condition is completely benign but does progress slowly and the main treatment is surgical. If left untreated the fingers will gradually contract down into the palm.

What does Surgery involve for Dupuytren’s Disease?

Surgery for this condition involves removing the layer of tissue from just underneath the skin. The tendons that move the fingers are not involved in the disease process and therefore finger function is not normally compromised. A zig-zag incision is performed on the palm and up into the finger to allow removal of the thickened tissue. This is usually closed immediately afterwards but sometimes a segment of the wound is left to heal by itself if the skin has been very tight. The palm is very good at growing new skin and this takes place over a three week period after surgery.

Sometimes the skin is so heavily involved in the process that the skin needs to be removed. Should this be the case a piece of skin can be taken from the upper arm and grafted onto the finger. This is more commonly performed for recurrent disease or in patients who are very young and have severe contractures.

Post-operative Recovery

It is very important to realise that Dupuytren’s disease can recur in the finger that has been operated on or any other digit. Sometimes the nerves running up the fingers are so closely involved with the abnormal tissue that they can be divided during surgery. Usually the nerve can be repaired immediately and there can be a slight loss of sensation in the area supplied by that nerve.

Thumb Basal Arthritis

What is Thumb Base Arthritis?

Thumb base arthritis involves the trapezium which is the wrist bone which lies at the bottom of the thumb. Arthritis in this joint is very common and is a progressive condition that leads to stiffness and deformity of the thumb with a corresponding loss of function. In the early stages treatment may be by use of anti-inflammatory medication. Using flexible splints that allow hand function whilst providing some support, can also be useful. Injection of steroid preparations into the joint can sometimes alleviate symptoms temporarily. However, the definitive form of treatment is removal of the arthritic bone at the bottom of the thumb.

The Thumb Arthritis Surgery

The operation is usually performed by giving an anaesthetic to numb the arm. This is commonly combined with a degree of sedation or a general anaesthetic as required. The anaesthetic in the arm lasts for several hours and it can often be the next day before the hand function returns.

Thumb Surgery Recovery

After surgery, you will be provided with a sling, but this is only usually used for the first day. You will be encouraged to use the fingers to encourage movement and help to reduce the swelling in the hand. The bandage that you wear after surgery has a splint incorporated in it to protect the thumb. Two weeks after surgery the wound should have healed and the absorbable sutures will start to fall out.

The Hand Therapist will make you a thermoplastic splint which does up with velcro strapping. This is convenient as it allows you to take a bath or a shower and rest the hand out of the splint. You will be given exercises to do at this stage. Hand therapy aims to recover movement of the thumb and improve grip strength. A typical patient has approximately one-third of normal grip strength prior to the surgery and is able to return to two-thirds of normal grip strength after the surgery.

It is important to be aware that the splinting and physiotherapy process lasts a number of weeks and you may not return to all normal activities until this time has elapsed.

Trigger Fingers

Trigger Fingers

Triggering of the digits is caused by a thickening on the tendon which catches as it runs through a pulley at the base of the fingers or thumb. The most common symptom is a finger that seems to catch or stick down in the palm and then has to go back to its normal position with a clunk or even need help from the other hand. Sometimes you can feel this nodule in the palm of the hand as you move the finger.

Treating Trigger Fingers

The majority of trigger fingers can settle with a steroid injection around the tendon. This reduces the size of the nodule and allows it to glide freely in and out of the sheath again. Up to 90% of patients settle with a single injection. After the steroid injection the hand is usually sore for a day or two before it starts getting better. Most patients notice an improvement by two weeks after the injection but as the action of the steroid lasts for six weeks the injection is not deemed to have failed until you get to this stage and still have symptoms. Should the symptoms recur then a simple local anaesthetic procedure can be performed to release the sheath. This stops the tendon catching at the base of the finger and it will therefore no longer catch or trigger. It is unusual for the surgery not to cure the condition completely, but it can come in other fingers.

Recovering from Surgery

After surgery the hand has a dressing on it which will leave the thumb and fingers free enough for light activities. The bulky dressing can be taken down after five days and replaced with a small adhesive dressing which we will give you. At ten days the hand can be used again normally. The absorbable sutures will fall out on their own once the wound is exposed. Sometimes the finger feels a bit stiff for a few weeks after this surgery although it is not catching any more. These symptoms settle as the hand is used normally.

Complications of Hand Surgery

General:

Most hand surgery has a low complication rate but as with any form of surgery there is always a potential for things to go wrong. Some complications of hand surgery are listed here.

Scars

Scars around the hand and wrist can sometimes be slightly thickened and tender. They benefit from being massaged and moisturised as soon as the wound has healed. Sometimes this is actually uncomfortable to do but it does help enormously with the recovery of the skin and underlying tissues.

Infection

Infection can occur after any operation. The hand and wrist have a very good blood supply and therefore the incidence of infection is very low. Should you get an infection this is usually treated with antibiotics and only rarely requires further surgery.

Return of Function

The hand and wrist are complex structures. Therefore, operations in this area often cause a loss of function during the recovery period. Depending on the type of surgery you have this may cause an enforced period of time off work. Do ask your Surgeon how your particular operation will affect your line of work and your ability to get back to it.

Stiffness

The hand and wrist are highly mobile and any surgery can cause stiffness in the joints. This usually settles rapidly with exercises and physiotherapy after surgery. A very small percentage of patients get a condition called Complex Regional Pain Syndrome (CRPS). It is difficul to predict who is likely to get this but if it does occur it is a nuisance because the recovery time tends to take months rather than weeks. Virtually all patients who get this condition do eventually return to normal function but they require more therapy than usual.

Nerve Injury

There are small nerves that run around the hand and wrist. Should they be stretched or injured during surgery they may give post-operative symptoms. The most common thing to happen is that a nerve gets stretched and becomes hypersensitive for a while. This means that touching the area supplied by that nerve causes discomfort or a tingling sensation. These symptoms usually settle spontaneously as the nerve recovers. Should a nerve be particularly hypersensitive hand therapy can be beneficial to speed up the recovery. Only rarely is surgery required as most nerves settle down on their own. Occasionally a nerve may be divided at surgery. This would be followed by immediate repair at the time of operation. Nerves repaired in this way normally regain most of their function but a small loss of sensation may be permanent.