Infection and rheumatic conditions of the hand requiring surgery should be performed by a specialist hand surgeon.

Absess drainage or removal of dead/contaminated tissue:

Hand infections may require surgery. An abscess may need to be drained to remove pus or, in more severe cases, debridement may be used to remove dead or contaminated tissue. This prevents infection spreading and promotes healing.

Carpal Tunnel / Entrapment:

Nerves pass through tunnels which can compress a nerve or the nerve can swell within the tunnel. This can cause pain, loss of sensation and loss of muscle function. The median nerve is the most commonly involved and is most often compressed in the carpal tunnel at the wrist, known as Carpal Tunnel Syndrome.

The ulnar nerve can be compressed at 4 different sites while the radial nerve entrapment is more rare.

These symptoms can also be caused by neck injury or disc degeneration.

Depending on the severity of the symptoms I might try a conservative approach first (splinting, lifestyle changes, steroid injections), otherwise surgery for widening the tunnel.

Stroke / Spasticity / Plegia:

There are a number of hand procedures that can help a stroke patient with hand function. These include joint fusions and tendon transfers. Hand therapists are an important part of treatment.

Dupuytren’s Contracture:

This is mainly a genetic condition. The fascia of the hand (a layer just beneath the skin) is affected. This layer gradually contracts causing the fingers to permanently flex. There are various forms of treatment depending on how far the fingers have flexed and how this has affected your function. For example, I may be able to perform a needle release, or use an injected medication to help dissolve the bands, or suggest various forms of surgery.

Hand tumours:

Like any part of the body the upper limb can develop tumours of the skin, soft tissues, tendons, fat, muscle, nerve or bone. These can be benign (eg: a Lipoma or Giant Cell Tumour) or malignant (eg: a Squamous Cell Carcinoma or Sarcoma). Unusual swellings and skin changes should be investigated by a plastic surgeon.

Imaging techniques (Ultrasound, CT and MRI) and biopsies are helpful in making an initial diagnosis and planning management. Surgery plays an important role.

A hard swelling around a joint might be a Ganglion, a sac of fluid attached to the joint capsule. Excision gives the most reliable long lasting result.

Vascular Malformations / Anomalies and Haemangiomas are a common cause of hand masses in children. These can involve blood vessels or lymphatic tissue.

Arthritis:

  • Rheumatoid Arthritis (RA) – this is an autoimmune condition. Symptoms include pain, joint stiffness and swelling, fatigue, weight loss and stiffness. The medical side of this condition should be managed by a specialist physician or rheumatologist. Rheumatoid hand conditions include bent fingers at the finger joints; classically boutonniere and swan-neck deformities of the PIP Joint and DIP Joint; and Ulnar deviation of the MP Joint Knuckles. Various surgical options are designed to improve hand function and decrease deformities, including joint replacements. Joint replacement or arthroplasty is the artificial replacement of a joint that has been destroyed by arthritis. RA is one of the causes of trigger fingers.
  • Osteoarthritis (OA) – This is a degenerative condition associated with ageing. The cartilage of the joints wears thin and the joints become painful and swollen. Osteophytes form adjacent to the joint making the joint area hard and swollen. Mucous Cysts/Ganglions are associated with OA of the joints. Treatment is largely symptomatic using anti-inflammatories, steroids and exercises. Joint fusions and joint replacement surgery might be necessary later in the disease process.
  • Gout – Gout can affect any joint. It is characterized sometimes by extreme pain, red and swollen joints. It can be confused with infection. Crystals in the joint cause inflammation. Treatment is designed to decrease production of the joint crystals and anti-iflammatory medication to reduce swelling and pain.

Reflex Sympathetic Dystrophy:

Reflex Sympathetic Dystrophy Syndrome (RSD) / Complex Regional Pain Syndrome (CRPS) is a chronic pain disorder, usually in a limb. It appears occasionally after stroke or injury. The severity of pain is typically worse than the original injury itself. The pain is often deep inside the limbs with a burning, sensation. Sensory and skin changes plus swelling are also common, and may include pain from stimuli that are usually non-painful. Sensory loss can also occur.

As RSD / CRPS continues, the affected extremity may more often feel cool with dark or bluish skin. Weakness associated with decreased movement is also common.

The cause of this condition is not completely known. It seems that there is a complex multifactorial association involving the sympathetic nervous system, blood flow, the inflammatory system and genetic predisposition. Psychological factors may also make symptoms worse.

Physiotherapy and occupational therapy are the first line treatment for this condition which typically occurs 4 to 6 weeks after injury. Proper hand therapy and exercise after injury is indeed strongly preventative of this condition.

Your Plastic Surgeon might prescribe a range of pain medication designed to decrease nerve pain peripherally in the limb and centrally in the brain. Nerve blocks with anaesthetia are occasionally helpful.

Volkmann’s Contracture:

Volkmann’s contracture is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. Passive extension of fingers is restricted and painful.

Any fracture in the elbow region or upper arm may lead to Volkmann’s ischemic contracture, but it is most commonly associated with supracondylar fracture of the humerus. It can also be caused by tourniquets or tight plaster casts causing the brachial artery to be occluded for a prolonged time period. It results from acute ischaemia (decreased blood flow) following the fracture trauma. Necrosis of the muscle fibres of the flexor group of muscles of the forearm, especially the FDP (flexor digitorum profundus – deep flexors) and FPL (flexor pollicis longus). The muscles become fibrosed and shortened.

Trigger finger / Tenosynovitis / De Quervain’s:

Tenosynovitis is inflammation of the tendon sheath that surrounds a tendon. This results in pain and decreased motion of the involved tendon. Repetitive strain is commonly a cause but tenosynovitis is also associated with arthritis and infection.

Trigger Fingers/ Stenosing Tenosynovitis is a common clinical manifestation of synovitis.

De Quervain’s Synovitis involves the thumb tendons and can be painfully debilitating.

Treatment is firstly symptomatic with splinting and anti-inflammatory medication. Steroid injections might provide second line relief. Surgery is reserved for conditions not responding to the more conservative measures.

Surgical release involves widening of the associated tight tunnel/ pulley involved. This can frequently be performed under local anaesthesia.

Ischaemia / Raynaud’s Phenomenon:

Ischamia of the upper limb might involve the large blood vessels or the smaller arteries and capillaries. Large vessel disease is occasionally seen in patients who suffer from severe hypercholesterolaemia. These patients develop claudication of the limb. A painful condition due to globally decreased blood flow in the area.

Spasm of the small arteries causing reduced blood flow to the fingers or toes is known as Raynaud’s Phenomenon / Syndrome. The affected area turns white.

Primary Raynaud’s is where the cause is unknown. Secondary Raynaud’s is when the cause is due to another disease process like scleroderma or lupus, or trauma associated with vibrating machinery prolonged use or, for example, thyroid conditions.

The condition is usually precipitated by cold or emotional distress but can be associated with a wide range of disease conditions. These warrant investigation in a patient who frequently experiences these symptoms.

Treatment depends on the cause but might involve conservative measures such as avoiding cold and avoiding smoking. Medications such as calcium channel blockers are occasionally indicated. Botox has also been described for reducing the pain which can be associated with Raynaud’s. Surgery is usually a last option.