Hand Reconstruction

Hand Reconstruction2021-05-06T16:03:33+02:00

What is a hand reconstruction?

Hand reconstruction surgery is a broad term for a number of procedures that can:

  • correct congenital (birth) defects or differences;
  • restore hand and finger function;
  • reconstruct after injury; and
  • eradicate infections.

Dr Mark van der Velde is highly regarded as a Specialist Hand Surgeon in Cape Town. His extensive experience includes correcting congenital defects and restoring hand and finger function from work-related injuries, infections, and arthritis.

Congenital Hand Surgery is a special interest of Dr van der Velde. Children with congenital hand differences are amazingly adaptive and learn to do things differently. Reducing the hand differences through surgery can not only improve functionality but also allow children to grow up with less emotional stress.

Read this inspiring story about how his experience and determination made a huge difference to this remarkable child.

Both Plastic and Orthopaedic Surgeons have the same hand surgery training and are both able to perform hand surgery. The level of expertise comes with experience.


What surgery treats hand injuries?2021-03-24T17:54:00+02:00

Surgery that treats major hand injuries should always be done by a specialist hand surgeon to not only repair the damage done but to restore function to the hand and fingers as soon as possible.

Soft tissue cover, grafts & flaps:

Skin grafts or flaps replace missing skin often associated with finger amputation or injury. During this procedure a piece of healthy skin is removed from somewhere on the body (the donor site) and used to cover the injured area.

Compartment Syndrome:

This is a sudden painful condition which is usually the result of blunt trauma or a bleed into a muscle compartment. It can also be associated with a fracture. A fasciotomy is an emergency procedure used to treat compartment syndrome by releasing the increased pressure within the compartment, thereby restoring blood flow to the ischaemic muscles. Untreated this pressure can cause severe pain, muscle death and destroy function.

Finger tip & nail Injuries:

The finger tips have been described as “second eyes”. Incredibly sensate, the finger tip anatomy is intricate and complex, from it’s specialised skin to the nerve endings, pressure sensors and the relationship to the nail. Plastic Surgeons are specialists in helping with disorders and injuries of the fingers.

Fractures & dislocations:

South Africans love the outdoors and sport but this comes with its share of injuries. In particular fractures and dislocations to the hands and upper limbs. It is preferable that a hand surgeon relocate any dislocations. Self relocation of a dislocation can cause a fracture and further injure a torn ligament. An x-ray is always required before treatment.

Fractures can occasionally be treated conservatively but some may require manipulation and fixation. Your plastic surgeon is likely to refer you to a hand therapist for an integral and necessary part of your treatment.

Tendon injuries & transfers:

Tendon injury can be the result of infection, trauma or rupture due to arthritic conditions. Primary repair is done within 24 hours of sudden injury and delayed primary repair is done a few days after injury. Secondary repair is done 2 – 5 weeks from injury and may include a tendon graft. This is when a tendon is removed from another part of the body and inserted in place of the damaged tendon.

Nerve injuries:

Nerve repair is used when nerves have been damaged causing loss of hand function and feeling in the hand. Although some partial nerve injuries heal on their own others may require surgery. If a nerve has been severed it may be immediately reattached using microscopic techniques, or a nerve graft is performed if a gap exists.

Brachial Plexus injuries:

The Brachial Plexus is the complex of nerves exiting the spine at the neck and traveling beneath the clavicle, through the armpit and into the upper limb. These nerves supply the muscles of the upper limb and bring back sensation.

Injury can be from birth trauma (Erb’s Palsy), from penetrating injuries or traction injuries to the neck or arm. Occassionaly primary repair is  possible. Some may require nerve grafts or muscle transfers.

Amputation, replantation & prosthetics:

Replantation is done to reattach a finger or hand that has been severed from the body. The goal is to restore as much function as possible. This is a surgical emergency and your plastic surgeon will usually need 6 hours or longer in the operating room. Complex microvascular surgery is required. Depending on the mechanism of injury and a host of other factors success is varied. Your surgeon might favour amputation if your  prognosis is poor, especially if a single non-dominant digit is involved. An attempt at saving a severed thumb is usually worth while.

Thumb reconstruction:

There are various techniques used for reconstructing a thumb. This depends on the general health of the individual, the level of amputation of the thumb and the donor site concerns of the patient. The plastic surgeon might perform a politicization. This is where an index finger is moved, shortened and rotated to design a new thumb. Thumb lengthening or webspace deepening is occasionally advised if not much extra length is needed to regain opposition (the primary function of the thumb).

Microvascular reconstruction is a highly specialized plastic surgery technique whereby tissue is brought in from another part of the body. The local blood supply is joined to the new tissue under the microscope. Microvascular second toe transfer is the most commonly employed free flap technique for reconstructing a severed thumb. Sensate, similar tissue with glabrous skin and nail complex plus tendons make this the ideal thumb replacement.

Surgery to treat infection or rheumatic conditions?2021-03-24T18:01:23+02:00

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.


  • 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.

Surgery for congenital hand differences?2021-04-09T17:02:11+02:00

Congenital (birth) hand differences can often be improved with surgery. Children are amazingly adaptive and learn to do things differently when born with hand defects, or differences as we prefer to call them. But, we can make a huge difference in their lives by improving the function of their hands and feet with surgery. Not only does surgery improve function but also engenders self-confidence.

I have performed many congenital hand surgeries on children born with structural hand or foot differences. If we correct these differences early in the child’s life we can maximise the restoration of form and function.

Examples are:

  • Extra fingers or thumbs (Polydactyly)
  • Fused fingers or thumbs (Syndactyly)
  • Absent fingers or thumbs or limbs (Symbrachydactyly)
  • Short fingers (Brachydactyly) or bent fingers (Clinodacyly and Camptodactyly)
  • Other hand anomalies such as Trigger fingers
  • Short forearm (Radial and Ulnar Club)
  • Stiffness in the hand, wrist, or elbow caused by a shortening, thickening, and/or excess of connective tissue
  • Skin changes or infections caused by fingers that are significantly contracted into the palm

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