HAND AND UPPER EXTREMITY SURGERY

How important are your hands? Imagine how radically different a day would be if your sense of touch, ability to move your fingers, or even the presence of your entire hand were taken from you. How would you feed your­self? Could you clothe yourself? Drive to work? Have a job to go to?

From birth to death, our hands are one of our principle receptors, and are the single major manipulator of our environment. So versatile are they that they even read for the blind, speak for the mute and listen for the deaf. Without them, or even without one of their functions, our lives would be considerably more difficult. Yet, because of their many uses, they are continually subject to excesses of trauma and the rages of degeneration, and it seems that few people survive an active lifetime without some significant injury or degenerative insult to one or both hands.

The subspecialty of hand and microsurgery grew out of an awareness of these problems and a curiosity for understanding the intri­cacies of hand function.

Special attention to hand surgery took its first major step with the efforts of Dr. Sterling Bunnell and others prior to World War II and resulted in the founding of the American Society for Surgery of the Hand in 1946. Monumental progress has been made since those beginnings, particularly with the recent advent of peripheral microsurgical techniques. These microsurgical procedures have allowed hand surgeons to perform operations virtually inconceivable at the time of the Society’s founding. Techniques, such as replantation of amputated limbs (including legs and feet), transfer of complete body parts from one area to another to correct traumatic defects (such as toe-to-thumb), and the precise anatomic repair of divided nerves and arteries, were unheard of in 1946, yet are commonplace today, and comprise only a part of today’s hand surgical armamentarium. This has become possible through the development of the operating microscope (Fig.1), which can magnify small vessels and nerves to forty times their original size (enlarging, for example, a 0.5 millimeter vessel to appear 2 centimeters in diameter).

Figure 1: The binoculars of the operating microscope allow both
the surgeon and the assistant to view a magnified operating field.

The ability to magnify and repair tiny structures also stimulated the development of specialized instruments and techniques requiring fingertip control to prevent damage to these fragile tissues (Fig. 2).

Figure 2: The operating microscope magnifies small vessels and nerves to 40x their original size. Suture shown is actually one half the diameter of a human hair!

In addition to microsurgery, the scope of hand surgery includes such diverse problems as congenital deficiencies, trauma, tumors, nerve compression and arthritis.

Congenital Abnormalities

The earliest problems for which hand sur­gery might be considered are birth defects. The most common hand problems of infants are syndactyly (webbed fingers) (Fig. 3) and polydactyly (extra fingers) (Fig. 4), though partial or complete con­genital amputations (Fig. 5) were more frequent in the thalidomide era. Restoration of normal archi­tecture at an early age (before 12-18 months) is advantageous if no other major health matters interfere. This allows the developing infant to begin using an improved hand before he/she has established right or left hand dominance, and does not interrupt the progress of developing dexterity as would occur by delaying surgery.

In all hand surgery, but especially in children, atraumatic technique is essential. Pediatric hand surgery is enhanced by magnifying the operating field, which also allows gentler handling of the child’s tissues. Similarly, absorbable sutures are used to eliminate the additional trauma of suture removal.

When appropriate surgical procedures are performed at the right time, the results of pediatric hand surgery are among the most aesthetically and functionally gratifying.

Figure 3: Syndactyly (fused fingers), before and 4 months after separation.

Figure 4: Thumb duplication (left) seen 15 months after operation (right).

Figure 5: Absence of the thumb treated by transferring the adjacent
index finger into a position for pinch and grasp (pollicization).

Trauma

Since the hand is generally our first line of defense against bodily injury, and is our most versatile probe of the environment, there is little wonder that it is such a frequent subject of both penetrating and blunt trauma. As a result, the hand surgeon often faces late con­sequences of apparently minor injuries, as well as the tragedy of mutilation, which is fre­quently seen in industrial trauma.

When confronted with an acute injury, consideration must be given first to the salvageability of the injured part if all tissues, including arteries and nerves, are repaired. With today’s microsurgical techniques, loss of an injured part or even impaired function, is no longer determined by the degree of injury to the arterial system, as virtually all arterial injuries can be repaired-even in most avulsing (tearing) injuries where vein grafting can restore blood flow through a torn segment of artery. The critical surgical decision concerns a careful prediction of final usefulness or degree of permanent pain after restoring blood flow to the injured or amputated part. Many ill-advised replantations or reconstructive surgeries have left painful useless limbs where prosthetic limbs would function more effectively and painlessly. It is for this reason that not all amputees are con­sidered appropriate candidates for replantation.

Replantation

The ideal replantation candidate fits many rigid criteria, and any deviation from those criteria can detract from the ultimate outcome. The illustration below serves as a nearly ideal indication for replantation.

An 18-year-old man sustained a clean, sharp amputation of his left hand just above the wrist (Fig. 6). When called, alert paramedics placed his amputated hand in iced-saline solution and transported him to the emergency room within minutes. The emergency room staff evaluation took only minutes, as did the operating room crew in preparing the microsurgical equipment necessary for replantation. As a result, the surgical procedure was initiated less than 90 minutes from the time of his injury. Keeping the hand in a cold environment (though not frozen) allowed approximately 12-18 hours before irreversible tissue damage would occur.

At the time of the operation, all tendons, muscles, bones, nerves and arteries were identified and prepared for repair, as were several major veins. The sharp amputation allowed for minimal removal of crushed tissue. The bones were stabilized with rigid plates and all tendons were repaired before the vessels, since efficient preoperative preparations allowed for extra time. Using an operating microscope, the two major arteries, several veins and major nerves were repaired with suture measuring roughly one half the diameter of a human hair. Blood flow was established within eight hours of injury, and the operation was completed after ten hours of surgery.

Figure 6: Severed hand (above) was successfully replanted after ten hours of surgery.

After his original operation, this young man required four additional surgical procedures to free his hand from inevitable scarring, and allow better motion and sensation. He actively participated in a continuous and regimented therapy and sensory re-education program under the supervision of a specialized Hand Therapist. Now, years after his original surgery, he has normal sensation in all fingers, fine motor control, excellent strength and normal motion (Fig.7). He is a successful businessman, and participates in a full range of recreational activities, from golf to fishing.

Figure 7: Following extensive therapy and follow-up operations, the hand functions fully.

While this patient experienced excellent results and is a good example of what today’s techniques can produce, it must be remem­bered that the spectrum of amputations is wide. Not all replantations will have this result and some should not even be attempted.

Fractures

“Some people get all the breaks.” Unfortunately, for some people this seems to be a real problem. Whether from falls, vehicular accidents, athletics or just “goofing around” (or even fights) fractures are among the most common (or at least the most frequent) problems which Hand and Upper Extremity Surgeons face. The types and locations of fractures, from open and comminuted (multiply fragmented) to subtle and nearly invisible, are as varied as the individuals who sustain them, and the methods by which the suffer them. From the elbow to the fingertips, specific techniques have been developed to assure the earliest possible return to normal bony alignment and joint function.

Casting or splinting alone can successfully treat many simple fractures. More significant or unstable injuries require surgical fixation to maintain correction, and to allow early return of motion to adjacent joints (Fig. 8). When fractures extend into a joint, the combination of surgical fixation and intense postoperative therapy are often critical to the successful recovery of normal use.

(a)		(b)		(c)		(d)

Figure 8: A comminuted fracture of the radius includes marked distortion of the
wrist joint (a). After reduction and plate fixation the joint surface and stability
have been restored (b). The plate has been removed (c), compared to normal (d).

Arthroscopy

Advances in optical equipment and miniaturization have also brought the benefits of arthroscopy into the Hand and Wrist Surgical Armamentarium. Surgical procedures that previously required complete exposure of the wrist can now be done through a series of tiny “holes” in the skin. Insertion of a scope only a few millimeters in diameter can explore regions of the wrist that can’t be seen even with the widest of surgical exposures. Elusive injuries can be diagnosed, injured structures can be repaired, fractures can be stabilized, and damaged tissues can be removed, all through arthroscopic portals (Fig. 9). These techniques minimize the trauma of surgery and frequently allow much earlier return to normal activities.

(a)		(b)		(c)		(d)

Reconstructive Surgery

Ganglion

Less dramatic, but no less important, are the many forms of hand surgery which alleviate pain and deformity from tumors, nerve com­pression and arthritis. Many of the benign tumors of the hand and wrist are pain free but interfere with precision or power activities. Among the most common are ganglia of the wrist and hand (Fig.10). In many cases, these benign degenerative cysts, which often appear as firm masses, are pain free or subside spontaneously. However, when pain persists or limits necessary function, removal is recommended and almost universally curative.

Figure 10: A typical ganglion, presenting as a lump on the back of the wrist.

Carpal Tunnel

Similarly, many adult patients, especially women of childbearing age, are bothered by symptoms of numbness or a sensation of “loss of circulation” in the thumb, index, and middle fingers especially at night or upon arising in the morning. Though there may be many sources for these symptoms, by far the most common is compression of the median nerve at the wrist where it passes through a narrow area called the carpal tunnel (Fig. 11). When the diagnosis has been established, relief can be expected by releasing the constriction surgically, which can now be done endoscopically or through limited incisions.

Arthritis

In adult hand surgery, few procedures produce the degree of gratification found in the successful reconstruction of painful arthritic deformities. Though there are many forms of arthritis of the hands, the symptomatic types all produce some degree of pain with use, defor­mity and/or loss of function secondary to the first two (Fig.12). Over the years, reconstructive surgery of the hand has become more and more refined as understanding of the precise biomechanical bases for deformity have become more apparent. Procedures made popular only a few years ago have since been discarded on the basis of inadequate restoration of normal forces in the hand. All this suggests that there are many methods for reconstructing a particular problem, de­pending on the precise reason(s) for its presence. The technical challenge lies first in selecting the appropriate procedure, then in executing it with precision. In many instances, the appropriate “procedure” is non-surgical, and all patients should have adequate medical management before considering surgery.

Occasionally, synovectomy (removal of inflamed joint tissue) may be all that’s nec­essary to adequately arrest the progress and pain of arthritis in the wrist or hand. Often, however, tendon transfers, muscle releases, joint replacement or fusion may be necessary to bal­ance or stabilize a hand.

Figure 12: Rheumatoid arthritis can cripple hand function as shown
in this patient’s attempt to straighten and bend his fingers.

When irreversible bone damage has occurred, joint fusion or joint replacement, asso­ciated with other soft tissue procedures and a subsequent regimental splinting and therapy program, may be required. Today, artificial joints are available for virtually every joint or bone in the wrist and hand. When their use is indicated, properly executed and followed by a well- supervised splinting program, pain free restoration of alignment and balance, and preservation (or even improve­ment) of joint motion can be achieved. When successful, these procedures can restore such simple but essential functions as feeding and clothing oneself, caring for one’s personal hygiene, writing a letter or cooking a meal. These may not appear to be dramatic activities except to that person who has been deprived of them by the pain, instability and deformity of arthritis. Dr. Bunnell once expressed this view­point quite well by stating, “When you have nothing, a little is a lot.”

The examples expressed here suggest that hand surgery encompasses a broad spectrum of problems in all age groups. It’s a strong weapon in combating the disabilities of deformity and pain, but it does not stand alone. It’s also necessary to include appropri­ate pre-operative medical care, post-operative therapy and medical follow-up in order to achieve maximum results. The physicians at Hand Care Associates have the requisite training, skill, and most importantly the judgment to execute all phases of the care of your hand or upper extremity problems with precision and understanding.

John F. Showalter, M.D.

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