Your hands and wrists are specialized tools of the body that allow us to interact with the world. They help us eat, dress, write, earn a living, and do many other activities as well. In order to do these tasks and activities, our hands and wrists provide movement and sensation, such as movement of the finger joints through muscle contractions. When a problem occurs, care must be given to all the different types of bones, muscles, tendons, and tissues that make function of the hand and wrist possible.
Is Hand or Wrist Surgery For You?
Not all patients need hand or wrist surgery. Most types of pain or discomfort can be treated using splints, taping, medications, injections, and hand physiotherapy. The decision to have hand or wrist surgery should be a cooperative one between you, your family, and your hand/orthopedic surgeon.
Conditions that may be helped with surgery
At Washington Hospital, our hand surgeons specialize in treating problems relating to the hand and wrist. When surgery is needed, the hand surgeon will visualize and repair the affected areas through small incisions. This type of surgery will reduce the possibility of injury to surrounding healthy tissues, will aid in a speedier recovery, and will minimize scarring.
There are several reasons why your doctor will recommend surgery. People who benefit from hand or wrist surgery often suffer from:
Flexor Tendon Injuries
Tendons are what let you bend and straighten your fingers. In a sense, you operate your fingers by remote control - the muscles which move your fingers are located up in your forearm, not in your fingers.
The most common and difficult problem that people have after a tendon injury is stiffness - losing the ability to either fully bend or straighten the finger - which can be permanent. This is a possible problem for anyone who has had a flexor tendon injury. Surgery and other special treatment is usually needed to make this as little a problem as possible.
Most often, flexor tendons are damaged from a cut. Fingers have special creases which let the skin fold when you make a fist - at these points, the tendons are just beneath the skin, and are easily injured by even a small cut in the skin. Less often, flexor tendons may tear or be torn off the bone by a sudden pull against a strong grip, without tearing the skin.
After injury, if surgery is needed, there is a limited amount of time to operate and get the the best possible result. Surgery delayed for more than two weeks has less of a chance of having a satisfactory outcome.
After a flexor tendon injury, most people lose some movement in the finger, despite all efforts. However, if all goes well, the hand will work better after surgery than if surgery were not done, and that's the reason for doing it.
Extensor Tendon Injuries
Extensor tendons, located on the back of the hand, allow you to straighten your fingers and thumb. These tendons are attached to muscles in the forearm. As the tendons continue into the fingers, they become flat and thin. In the fingers, these tendons are joined by smaller tendons from the muscles in the hand. It is these small muscle tendons that allow delicate finger motions and coordination.
Extensor tendons are just under the top surface of the skin, directly on the bone, on the back of the hands and fingers. Because of their location, they can be easily injured even by a minor cut. Jamming a finger may cause these thin tendons to rip apart from their attachment to the bone. After this type of injury, you can have a hard time straightening one or more joints. Treatment is necessary to get back use of the tendon.
Surgery is usually the treatment for tendon injuries and is very successful.
In trigger finger, also known as stenosing tenosynovitis (stuh-NO-sing ten-o-sin-o-VIE-tis), one of your fingers or your thumb gets stuck in a bent position and then straightens with a snap — like a trigger being pulled and released. If trigger finger is severe, your finger may become locked in a bent position.
Often painful, trigger finger is caused by a narrowing of the sheath that surrounds the tendon in the affected finger. People whose work or hobbies require repetitive gripping actions are more susceptible. Trigger finger is also more common in women and in anyone with diabetes.
Trigger finger treatment varies depending on its severity and duration. Though less common than other treatments, surgical release of the tendon may be necessary for troublesome locking that doesn't respond to other treatments.
Carpal Tunnel Syndrome
Carpal tunnel syndrome is the effect of pressure on the median nerve, one of the main nerves of the hand. It can result in a variety of problems, including pain, tingling, numbness, swelling, weakness or clumsiness of the thumb, index, middle and ring fingers. During surgery, the transverse carpal ligament is cut in order to relieve the pressure on the median nerve, therefore alleviating the symptoms of carpal tunnel. Surgery for carpal tunnel syndrome is intended to provide more space for the nerve and tendons, so that swelling will not put dangerous amounts of pressure on the nerve. It is usually done through an incision on the palm or the front of the wrist. An incision is made to open the carpal tunnel, the tunnel opens up and it heals with more space inside.
Carpal tunnel syndrome associated with other medical conditions, such as rheumatoid arthritis, may require a more extensive cleaning out of the tissue around the tendons, referred to as a synovectomy.
After surgery the healing edges of the ligament beneath the skin are usually tender for at least four to six weeks after the procedure. Temporary tenderness on each side of the palm where the ligament is attached to the bones on each side of the palm these bones is common after surgery and is called “pillar pain”. This generally resolves gradually. Hand therapy is often helpful during recovery.
Cubital Tunnel Syndrome
Cubital tunnel syndrome is the effect of pressure on the ulnar nerve, one of the main nerves of the hand. It can result in a variety of problems, including pain, swelling, weakness or clumsiness of the hand and tingling or numbness of the ring and small fingers. It also often results in elbow pain on the side of the arm next to the chest.
The ulnar nerve is a connection between the spinal cord and muscles of the forearm and hand as well as the skin on the pinkie side of the hand. The ulnar nerve passes across the back of the elbow, behind a bump on the inner side of the upper arm bone. This bump is called the medial epicondyle. The "funny bone" is actually the corner of the nerve as makes the bend around the elbow. Hitting the elbow at this spot tickles the nerve and gives a brief feeling of a shock or tingling. When the elbow is bent, the nerve may be stretched and push against the bony bump.
Surgery for cubital tunnel syndrome is intended to provide more space for the nerve and tendons, and permanently reduce the amount of pressure on the nerve. There are several ways to do this, including the two following approaches:
One common type of surgery is to move the nerve in front of the bump so that it doesn’t catch and stretch when the elbow is bent. This is called an ulnar nerve transposition. The nerve will be moved just under the skin or beneath the muscle in the area.
Another type of operation is to remove the bump, allowing the nerve to glide forward and back as the elbow bends and straightens. This is also called medial epicondylectomy.
Other operations are also available and your doctor can discuss your options at your office visit.
Lateral Epicondylitis (Tennis or Golfer’s Elbow)
Tennis elbow (also known as golfers elbow) is a type of painful tendinitis. It results in pain on the outer side of the elbow and forearm. Pain is usually aggravated by gripping and lifting with the hand in certain positions. There may be swelling on the side of the elbow.
Although tennis elbow can arise for no obvious reason, the most common situation in which tennis elbow develops is following unaccustomed strenuous activity involving the arm and hand.
Some of the stronger muscles involved with lifting and gripping attach to the side of the elbow.
These muscles are connected to the bone through a tendon which looks like a flat strap of gristle. The tendon is hard and pushes against the side of the bone. It does not stretch or easily accommodate swelling, and if irritated by sudden overuse, pressure may build up and cut off the blood supply to the middle of the tendon. The tendon wraps around an area where the bone sticks out, and pressure between this bone and the hard outer layer of tendon may squeeze the inner parts of the tendon. Once this happens, the tendon may not be able to heal, or may heal very slowly over many months. This slow healing may have to do with circulation, but also because the area is stretched and twisted by normal movement of the elbow, making it hard for irritated areas to rest.
Surgery for tennis elbow is usually recommended it only when someone has persistent problems and has exhausted all other treatment. Surgery helps the majority of people - somewhere between 70 and 90 percent of people have a satisfactory improvement from surgery. When surgery is the solution, the procedure will remove the chronically irritated tissues, possibly shave down the bone, and possibly cut some of the small nerves which transmit pain signals from the area. The goal of surgery is pain relief, and there are several different operations currently performed for this problem.
DeQuervain's tendinitis is a painful problem which results from irritation of tendons on the side of the wrist which move the thumb sideways away from the palm. It can result in wrist and forearm pain on the side of the thumb, particularly with certain positions and movements of the wrist.
Many people with mild symptoms will improve with a limited period of anti-inflammatory medication and avoiding painful activities, especially if the problem developed during unaccustomed strenuous activities. It is less likely to resolve if it is related to light repetitive work activities.
A cortisone shot into the sore area helps most people - at least temporarily. When temporary, relief usually lasts about two months. One or two shots provide permanent relief for as many as two out of three people with this problem.
Surgery helps over four out of five people with this problem, but as many as one out of five will have a new problem after surgery, such as numbness on the back of the hand or tenderness of the scar.
Osteoarthritis is a deterioration of the moving parts of the joints. In the hand, osteoarthritis most often affects the small joints of the fingers and the joint at the base of the thumb - the basal joint. This is sometimes referred to a degenerative arthritis or degenerative joint disease. Osteoarthritis is primarily treated by medical doctors, and may require treatment by an arthritis specialist.
There are two types of surgery commonly performed for joints affected by arthritis, fusion and arthroplasty. Surgery is a consideration when all else has failed.
Fusion (arthrodesis) is an operation to make bones on each side of the joint grow together. Fusion can be very helpful for joints which are stiff and painful, awkwardly crooked, or unstable. Fusion also can reduce the size of an enlarged joint, although this alone is not usually reason enough for surgery.
Arthroplasty, or joint reconstruction, in osteoarthritis is most often performed for thumb basal joint arthritis. Artificial joints have also been developed for the small joints of the fingers. Finger joint replacements made of pyrolytic carbon (the same material used in most artificial heart valves) were FDA approved for use in 2002. These new implants are a reasonable alternative to fusion, and in some cases can be used to restore motion to a joint which has been fused.
The ligaments between the bones of the hand or wrist can tear, causing pain, swelling, and a weak grip. If a full tear occurs, the bones may pull apart and limit motion. A surgeon can surgically repair these tears to increase motion and decrease pain.
Injury or overuse can cause a tear in the TFCC (triangular fibrocartilage complex). This can lead to pain, discomfort, and a decrease in movement. Surgeons can restore movement and decrease pain by shaving off or repairing the tears. Bone or cartilage fragments may be removed to improve motion and lessen the pain.
Over time, the cartilage in the hand or wrist can deteriorate (arthritis). This can cause great discomfort and pain. A surgeon will shave off or smooth the worn area to help restore smooth, pain-free movement.
After surgery, patients will be given specific instructions on how to care for their hand or wrist. Patients will also receive medications and directions on how to address their bandages.
Exercise therapy is an important part of recovery. Patients will have a hand specialist and specialized therapists called occupational therapists demonstrate exercises that will aid in restoring strength, flexibility, and movement. Do not attempt to return to normal function too soon, as it will increase the risk of re-injury.
It will take time to fully regain the use of the hand or wrist after surgery. Recovery times differ based on the type of operation, but regular hand therapy exercises and routine check-ups with your surgeon will greatly increase hand and wrist restoration.