Hand & Wrist Surgery
Healthy hands are essential to our everyday functioning and wellbeing – Just consider how few are the moments when you are not using your hands to do something. Yet usually we only recognise how invaluable our hands are once they are injured or in pain. Repetitive loading of the wrist, hands and/or fingers over the years may easily lead to premature wear of joints and tendons. Bear that in mind whenever you feel pain in your hands during demanding tasks – perhaps jobs can be done differently and hands nurtured for a change.
The small bones in the finger are called phalanges. They are connected with fine joints which have a pair of ligaments of the either side and a strong volar plate on the palm (volar) side of the finger (see Gallery below). Joints are further reinforced and stabilised by the surrounding capsule, tough, gristle-like wrapping around the joint. Together, ligaments and capsule form a tough, yet elastic capsulo-ligamentous layer whose integrity is vital for finger mobility and strength. Sprains lead to its partial or complete tearing and usually a long lasting pain, swelling and potential deformity if not treated early and adequately.
Injuries to the joint that connects the first and second phalanx known as The Proximal Interphalangeal Joint (PIPJ), are particularly at risk of leading to late finger deformities because of late diagnosis and complex anatomy of this particular joint.
As capsulo-ligamentous layer around the joint typically has scarce blood supply, its injuries lead to a rather slow recovery, usually very frustrating for the patient and surgeon alike. If not recognised and treated early and adequately, finger ligaments have a particular propensity to shorten and lead to progressive bending of the finger i.e. contracture (finger cannot be straighten properly). On the contrary, if recognised and diagnosed early, management is simple and efficient. It however, has to be delieverd adequately and in a timely manner.
Time is of essence! Early ligament scarring is responsive to stretching and splintage, but requires patience and supervising expertise. Scar manipulation is often painful and therefore unpleasant, but pain indicates that improvement is still feasible. After 6-8 weeks from injury, scar tissue becomes less painful, but also less responsive to stretching and conservative management. As the time elapses further, treatment becomes less effective. Beyond 5-6 months after injury, structures around the joint might become irreversibly shortened. Such outcome is very difficult to treat, even operatively.
It is much easier to prevent contracture then treat it ! Early diagnosis and treatment are essential.
Majority of finger sprains are mild, self-limiting and will settle spontaneously in 2-3 weeks. If the force imposed upon finger was not just trivial, capsulo-ligamentous injury should be suspected. More forceful impacts and damages, may need supervision for up to 3-6 months.
Symptoms include pain, swelling, bruising and stiffness. Common scenario is that a patient does seek help soon after significant injury. X-rays are likely to be ordered, but once the fracture is excluded (which is commonly the case), patient is reassured and discharged without active treatment and follow up. Ongoing pain, swelling and stiffness might prompt this patient to seek secondary help much later, often weeks and months following injury. At this point possible treatment is either not possible or significantly less effective.
Occasionally, X-rays may show an avulsion of a tiny piece of bone which unmistakably points to the tearing of the ligament at point of its insertion into the bone. Management is usually the same, but abnormal X-ray often speed up referral process.
Stretching and micro-tearing of ligament tissue, but the joint remains stable
Partial tearing of ligament tissue with mild instability of the joint
The vast majority of finger flexion deformities are treated successfully without surgery. Active, specialist input most commonly involves, splintage of the joint in adequate position, controlled exercises and tissue stretching. These measures might appear simple, but they should be conducted in a knowledgeable way. The most optimal position for recovery varies between different finger joints due to variations in their anatomy. Finger should be mobilised early to control swelling and stretch the capsule, but not overzealously to compromise ligament healing. So balance between rest and mobility is what most therapists aim for in order to preserve finger function in the long term.
Hand therapy is essential, but can be tedious. C ompliance and discipline predictably lead to good results and avoid the need for surgery.
Surgery is rarely required, but in some instances, it can be the only way to improve finger deformity and prevent further deterioration. This is usually the cases if there is:
- Complete tearing of the ligament
- Avulsion fracture i.e. a large piece of bone has broken off and is being displaced by the ligament pull
- Old, fixed flexion deformity of the joint which failed to improve despite prolonged physiotherapy and other measures (see above)
Surgery aims to straightened the finger by dividing the shortened volar plate which lies on the palm side of the PIP joint, allowing straightening of the joint and its surrounding soft tissues. Please refer to Gallery below with pictures illustrating how the cut in the shortened volar plate allows finger straightening. A lot of postoperative rehabilitation and physiotherapy is necessary to support operative steps.
Urgent concern after your surgery ?
Please ring the hospital where you have been operated on or my secretary and they will get in touch with me