Hand surgery is a challenging specialty. It needs precision and combines knowledge and skills of orthopaedic, neuro, plastic and vascular surgery. Hand anatomy is very complicated, structures are small and biology of healing is very often discouraging. We cannot overestimate the necessity of a healthy and functional hand. It enables us to live our lives with full potential. For every human being upper extremity is needed in everyday life, to eat, to write, to perform in their profession. Every part of the hand is important too, every finger has its functions, with the thumb being especially valuable. Every nerve, even the smallest, is responsible and involved in most of our activities. Every joint and its movement adds to the precision of our skills.
Unfortunately, hand injuries often have severe consequences and very often are quite complex. Hand anatomy is such that even a simple fracture can be accompanied with tendon, nerve or blood vessels injury. Posttraumatic deformities which hand surgeons face in their practice are often very challenging and difficult to treat. How to help the patients? How to restore the proper function of the hand? It is so extremely important to restore the possibility for precise movements, powerful grip and decent range of motion. Unfortunately, very often biology works against the patient.
Hand injuries are very well known for their common complications. The biology of healing is such that stiffness develops very quickly and insidiously. The more severe and extensive the injury, the more probability for loss of function, precise movements and grip strength. That is why the problem of surgical hand reconstruction is a real challenge for the surgeon and the patients. Very often we have to perform several procedures, reconstructions and even teno- or arthrolysis to resolve adhesions and scars, which are the result of previous surgeries. So far we cannot predict the healing. Some patients will heal without excessive scarring and adhesions, some will develop them very quickly.
The decision and planning of the whole treatment is a real challenge. It requires not only surgical skills of the surgeon but also a lot of involvement and understanding from the patients. When we discuss the treatment plan, it may be discouraging for the patient to hear about few surgeries combined with periods of physiotherapy. It all takes a long time and patience. The result is not always predictable but most of the times rewarding and resulting with the patient getting his/hers hand back. Before the treatment, the proper set of expectations is important together with very close cooperation between patient, surgeon and physiotherapist. This is teamwork, for sure.
Different stages
When we plan the treatment, the most important thing is to analyse the initial injury. The proper physical examination gives the idea of how much of hand function is lost. The quality of modern diagnostic imaging is very high and together with initial physical examination, gives a good understanding of what needs to be repaired and what cannot be.
There is no specific algorithm of how and when to start but usually the first stage are bones and joints, to provide a basis for the rest of the structures and movement. Most of the bony deformities can be treated with osteotomies and fixations. With the use of new anatomic plates and screws, bone grafts and different kinds of bone substitutes, we can restore the proper alignment of the bone and have a stable fixation to allow early rehabilitation.
Very often injuries involve the joints, which become arthritic or even completely damaged. Almost all joints of the hand and wrist may be either fused or replaced. With the help of modern implants, the replacement is quite easy and reliable and gives a decent range of motion. When it’s necessary we combine the osteotomy and joint replacement in the first reconstructive procedure. The joint may be also addressed with arthroscopy to fix the ligament, to assist with bone fixation or to remove the adhesions and scarring which block the proper movement. The new small arthroscopes can reach even the smallest of hand joints.
The next stages usually involve reconstruction of tendon and nerves. Few weeks or months after injury, all damaged or cut tendons are not suitable for simple repair. Already they are retracted or not viable. Usually we use silicon rods to deal with this problem. We insert the rod and wait a few weeks to allow the body to recreate tendon sheath and obtain the space for a graft. Next step is to replace the rod with a tendon graft. This approach enables active range of motion and good function of the hand.
For the nerve reconstruction, we can either repair them in a separate stage or to combine it with the first stage of tendon reconstruction. We can obtain good help with recovery and prevention of neuromas, using neuro tubes to protect repair sites. To set the order of reconstruction is always a challenge and there is no one protocol of how to do it. Surgeon choice and experience is a key.
For the whole treatment and all stages of reconstruction, patients’ compliance is extremely important. They have to accept months of treatment and the necessity of strict protocols of exercises, physiotherapy and muscle strengthening. Psychological factors play an important role – the more trust in the treatment, the better the result is.
Dr Katarzyna Papiez
This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.