SURGERY PROCEDURES - Hand surgery
The basis of this pathological condition is a contracture of the palm fascia or fibrodysplasia of the subcutaneous palm connective tissue which forms nods and strips, a flexion contracture of the affected fingers occurs. More frequently the disease hits the men between 40 and 60 years, and most frequently IV and V finger are affected, as well as I interdigital commissure. Node-like lumps appear on the palm, sometimes the pain as well, and very often both hands are affected. The skin at the contracture level is thick, firm and immobile due to lack of subcutaneous fat tissue. The treatment is operational, when the pathologically modified palm subcutaneous tissue causing the contracture is removed by surgical excision.
Compressive neuropathies They represent pathological conditions where peripheral nerves of the upper limbs are compressed in non-stretchable bone-connective and muscle-connective channels through which they pass. A pressure increase in these channels leads to nerve damage and strong pain. Numerous reasons cause compressive neuropathies and they can be anatomic, postural, developmental, inflammatory, traumatic and metabolic nature. The symptoms occurring can be various, from transitory paresthesias to complete damage of neural function. N. Medianus compressions 1. Carpal tunnel syndrome The carpal tunnel syndrome occurs at pressuring the n. medianus in the carpal tunnel. The smallest increase of tissue mass from a particular reason can cause compression and nerve ischaemia. It is more frequent in women in menopause, pregnancy, suffering from rheumathoid arthritis. The symptoms occurring as a consequence of compression of this nerve are pain, paresthesias and hypoesthesias in the region of the first three fingers. Treatment The carpal tunnel syndrome is treated surgically. In the local anaesthesia, through the wrist level incision, the flexor retinaculum of the wrist is cut which liberates the nerve from the pressure and the symptoms retreat. The operation lasts about 30 minutes, the hospital is abandoned the very same day, the sutures are removed after ten days. 2. Pronator teres syndrome (PTS) In this syndrome, compression of the n. medianus occurs at the level of m. pronator teres i.e. at the elbow level. The symtoms characterizing it are the pain on the flexor side of the lower arm, sensor deficit of the thumb and the first three fingers, total and partial loss of flexion of the proximal interfalangeal thumb joint. The symptoms get stronger with physical activity. A surgical therapy includes the nerve decompression at the level of the muscle pronator teres. The elbow is immobilised in mildly bent position for a week, after which starts the physiotherapy. 3. Front interoseal syndrome, compression of the n. medianus-n. interosseus branch The syndrome is characterised by mild, deep pain in the lower arm which is impaired with physical activity, and vanishes in rest. Sensor incident in the fingers can be absent, and the main characteristic is weakness of the muscle flexor of the thumb and index finger (m. flexor pollicis longus and m. flexor profundus indicis). The treatment is surgical, it implies liberation of the nerve from compression. A function improvement occurs already in the first two to three months.
Congenital hand anomalies can occur in various forms – disorders in formation of the parts or their differentiation, duplications, over- or undergrowth, as well as various generalised skeletal abnormalities. As many as 50% of congenital hand anomalies go on polydactyly and syndactyly. Polydactyly. It signifies the existence of one finger too many, which most frequently occurs in the area of the little or 5th finger or in the thumb area. A finger too many can be just a soft tissue pendulum or can contain all the bone, tendon and neurovascular structures just like the normal finger. The treatment is surgical and is recommended in the 1st year of age for achieving an optimal hand function. Syndactyly. It is a congenital anomaly which signifies joined fingers in children. It occurs in 1 out of 1000 children born alive, and is twice more frequent in boys. It can be incomplete or complete, and most frequently the 3rd and 4th finger are joined. It is surgically treated at the age of 6 months to 4 years, depending on the type of syndactyly. In the first surgical procedure, only one side of the finger is liberated, and the plastic-reconstructive procedure includes multiple «Z»-plastics and application of free skin transplants of full skin thickness in order for the hand to be fully reconstructed. Adactyly. It represents a congenital lack of fingers, while aphalangia represents a lack of phalanges. It is treated by extension of the finger or transplantation (microsurgical) of a toe to the hand. Overgrowth (gigantism). It represents a pathological extension of the skeleton and soft tissue finger casing, while hypoplasia (undergrowth) most frequently affects the thumb which is reduced and underdeveloped. The treatment is surgical and creation of the new thumb by pollicisation (transposition of one of he fingers instead of the thumb).
Most frequently it occurs for the rupture of the distal linking of the extensor tendon with the subsequent mallet deformity. It is treated with immobilisation with the finger in mild hyperextension in duration of 8 weeks.
The hand injuries can be roughly divided into: • bone injuries – fractures, • joint and ligament injuries, • tendon injuries. The most frequent bone fracture mechanism occurs after a fall or a hit in the hand. Direct hits often cause the fracture of one or more metacarpal bones, and the fractures are most frequently transversal, and in extreme cases spiral. A large number of fractures is treated traditionally – by lacing a plaster longuette in duration of three weeks. If the dislocation is larger, an operative treatment is necessary. A “boxer’s fracture” or a ’’bad street fighter’’ fracture is a fracture which most frequently occurs in fights. By inadequate hit, a fracture of the neck of V metacarpal bone occurs. It is treated by immobilisation in duration of 3 to 4 weeks or a fracture reposition is required in bigger angulation. The finger bone fractures are also frequent, especially of proximal and medial phalanx. The fractures are usually treated by reposition and fixation. For the diagnostics of all these fractures and further therapy, it is necessary to make an adequate X-ray of the injured hand. Carpometacarpal, metacarpophalangeal and interphalangeal dislocations can occur in the hand. The diagnosis is set by clinical exam with radiographic confirmation. Most injuries are easily repositioned and immobilised with a protective longuette.
Digital stenosing tendovaginitis represents a phenomenon of difficult extension (stretching) of the fingers followed by the sound phenomenon of triggering. It occurs due to disproportion between the flexor tendons and tendon casing. It is more frequent in women, and mostly III and IV fingers are affected. Operational treatment is efficient and it leads to permanent healing.
Benign tumours 1. GIGANTOCELLULAR TUMOUR of the tendon casings has benign origin, but it also has a high recidivism rates. Most frequently it appears on the palm side of the fingers, and it represents a slow-growing tumour. 2. GLOMUS TUMOURS are often located in the nail bed and give a classical triad of symptoms – pain, palpation sensitivity and cold sensitivity. 3. ENCHONDROMA represents the most destructive benign bone tumour which usually affects the proximal phalanx of the finger. It often causes a pathological fracture. 4. LIPOMAS usually occur in women between 30 and 60 years of age. They are mobile and painless and when enlarged, they can lead to compressive neuropathies. Tumour-like creations 1. GANGLION-HYGROMAS are the most common tumefactions on the hand. These changes are soft and painless. The treatment consists of aspiration of the content, but with 50% recidivism appearance or of surgical elimination after which the recidivism is also possible, but in smaller percentage. 2. MUCOUS CYSTS appear on the dorsum of the distal interfalangeal joint, and they are often connected with osteoarthrosis.