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 hand consists of no less then 19 small bones (excluding another 8 in the wrist joint itself) which form a skeletal platform upon which muscles and tendons attach making the wrist and fingers move. Fractures of these bones are common and present with pain, swelling, bruising and inability to use the hand. If treated early and adequately, outcomes are generally very good.
Fractures patterns vary greatly – some are simple with bone pieces being stable and aligned favorably; others are unstable with bone fragments likely to displace or shift during healing process. The former ones are usually managed without surgery, the latter often need operative fixation in order to achieve good long term outcome and speedy recovery.
When bone is shattered into many pieces, fracture is called comminuted and as such is often very unstable. If fractures involve the joint surface (so called intra-articular) they may lead to premature joint arthritis. Sometimes, the bone fragment breaks through the skin, so the fracture becomes open with increased risk of infection.
As fracture patters differ greatly, so do the treatment options. Each and every break has to be assessed carefully and treatment tailored pending exact clinical presentation, X rays findings and most importantly, individual circumstances (jobs, lifestyles, hobbies etc). Main objective of any treatment is to restore alignment, stability and function of affected bone.
Most fractures can be treated successfully by conservative, non-operative measures i.e. immobilisation (rest and splint). This is predictably the case with fractures which are stable, not displaced badly and tend to heal well on their own, without a need to reset fragments in better position.
Perfect alignment of the bone on x-ray is not always necessary in order to restore good hand function. A bony lump may appear at the fracture site as the bone heals. This is a proof of bone healing and new bone being laid down. The lump eventually gets smaller over time.
Picture Gallery below illustrates few examples of hand splintage used either as the main modality of treatment or in support of operated hand.
The operation is usually performed on a day care basis under general or regional (numb the whole arm but you stay awake) anaesthetic. Some finger fractures can even be fixed under local anaesthesia.
It always helps to plan things in advance of surgery and adjust work and life activities accordingly. Therefore, please consider the following issues prior to your operation:
- Please make sure that you arrange to be collected from the hospital as you will not be able to drive after the surgery
- Plan your time off school / work / sports
- Allow at least few weeks after surgery before considering holiday
Below are the commonest clinical scenarios which require more then just a splint wearing i.e. surgical input to improve the fragments positions:
- finger is rotated and/or shortened (example presented in the Picture Gallery)
- bone pieces are unstable to be held in place with splint only
- bone pieces are too far apart so will bond together
- open (compound) fractures which need rigorous irrigation to reduce high risk of infection in such
- fractures extending into the joint surface (intra-articular fractures) which usually need to be set
more precisely to restore the smooth joint surface
- severe crushes resulting in loss of the bone substance so a bone graft needs to be taken from
another part of the body (or synthetic bone replacement used) to restore skeletal substance
Broken bone segments can be reposition either by external manipulation (closed method) or by accessing the bone inside, after making cut in the skin (open method). Sometimes, a combination of both is necessary. Once the bone fragments are set, they can be held together with pins, plates, or screws. Each method has its advantages and disadvantages, but in most cases a clear clinical indications exist which will preclude one option or another. Decision is generally based on various clinical facts, fracture type visible on the x-rays/bone scan and principles of bone fixation.
In general, fixation of fracture with external pins allows less aggressive treatment with less scarring as everything is managed from outside (no skin opening, scarring and internal bone surgery). Stabilisation of bone fragments is however, not as rigid as with internally placed screws and plates, so mobilisation of the fixed bone has to be delayed, splint worn longer and return to full activities/sports deferred. Pins are removed in outpatients facilities between 4-6 weeks, depending on exact fracture. Splint is abandoned gradually over the subsequent 2 weeks. Whilst pins are in, hand should be protected with the splint all the time.
Insertion of screws and/or plates around the fracture is technically more demanding, associated with skin scars (although those are usually very delicate), damage to the nearby structures or potential problems with the metalwork. Internal fixation is generally more aggressive way of treatment, but in return, it offers more precise (anatomical) relocation of bone fragments, stable, rigid fixation from the onset which allows more aggressive mobility, earlier return to daily activities and often no need for postoperative splints.
Indications for surgical input should always be very carefully gauged. Picture Gallery below illustrates a variety of fixation methods used in modern hand surgery. In trained hands, fixation with screws and plates leads to excellent overall results, but every operation leaves scarring behind which can be more detrimental then the fracture itself. Careful steps should be undertaken to minimise such risks.
Regardless of the surgical method used, bone healing requires time. Even in the simplest fracture patterns, recovery is measured in weeks, not days.
You need to take it easy and get plenty of rest when you get home for the first 2-3 days. Hand should be elevated most of the time in a position whereby the wrist is at the higher level than the elbow! This significantly reduces swelling and pain.
Once the fracture has enough stability, motion exercises may be started to avoid stiffness.
Rehabilitation is a fine balance between splintage (immobilisation) and supervised, controlled movement of the wrist, hand and fingers. The former is required to prevent movements between healing bone pieces yet the later is essential to prevent stiffness of neighboring fingers and tissues – joints, tendons, ligaments which are prone to stiffness during rest. Sometime, secondary contractures and stiffness remain as a permanent side effect, despite well united bone ends.
Most hand fractures require period of immobilisation of the hand with external splint. Duration of this period vary between 3-5 weeks depending on extact fracture pattern and method of treatment. Plaster of Paris applied at the time of surgery is exchanged for a lighter, theroplastic, custom made splint few days after operation when the swelling subsides by the hand therapist. These modern casts, based on velcro strips fixation are very easy to handle. You will quickly learn how to remove and put them back on on your own at home. Picture 4 illustates one of the commonest positions of the hand and a look of thermoplastic splint so that you have a clear picture what to expect postoperatively.
You can start to do your usual activities, being led by the common sense and feeling comfortable. Most patients return to work within two weeks but if your job involves physical activity of lifting it will be longer. Taking part in any strenuous activities and return to sport should be discussed at your follow up pending intra-operative findings and speed of recovery. It is usually 6-8 weeks after the surgery.
Hand as an organ is very unforgiving towards injury and violation of its anatomy. Stiffness and scarring invariably accompany any trauma, accidental or surgical. This is why, in case of less then optimal long term outcome, it can be difficult to differentiate between devastating consequences of injury itself or ‘side effects’ of surgery.
The commonest complications associated with hand fractures are:
- finger contractures (flexion deformities)
- Complex Regional Pain Syndrome (CRPS) – (seen in 5% of patients) hand may become very swollen, painful and stiff after any operation. This problem cannot be predicted but will be watched for afterwards and can be treated with medication and hand therapy
- shift in position of fragments during splintage (injuries managed by non-surgical means)
- infection (bone or joint)
- slow bone healing (delayed union), or complete failure to heal (non-union); smoking has been shown to slow fracture healing
You can lessen the chances of complication by carefully following advices during the healing process and before returning to work or sports activities. Hand therapy is essential and often extends over the period of 2-4 months. It is not unusual that swelling and some discomfort exists even 6-8 months post accident.
For two days following a general anaesthetic you should not:
Drive a car or ride a motorbike, do not attempt to drive until you are in complete control of your hand. If you are unsure at all you should discuss this with your doctor. It is also advisable to check with your car insurance company, as some policies state that you must not drive for a specified period of time after an operation.
Things to look out for
- Disproportionate swelling and pain in your hand
- Signs of infection in vicinity of the operated area i.e. hand/wrist are very hot, prominent redness, pain, swelling, puss collection
- Grazing of the skin (and possibly fluid leaking/oozing from the wounds)
- Increased temperature in the area
- Strange smells coming from the wounds.
If you notice any of above symptoms in the first few days, feel free to contact the team on numbers below.
|Hospital stay||Day care|
|Anaesthetic||General or Regional (the whole arm is numbed)|
|Surgery time||30-90 minutes|
|Wound healing||2 weeks|
|Bone healing||4-6 weeks|
|Splintage||3-4 weeks in most cases|
|Hand therapy||ESSENTIAL! 6-8 weeks|
|Washing||from week 2|
|Time of work||1-2 weeks for office based work 3-4 weeks for manual work|
|Contact Sports||from week 12|
|Driving||until splint is off please check details with your insurance company|
|Full recovery||4-6 weeks|
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