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.
Tendons are cord-like extensions, which connect muscles to bone. As the muscles tighten, the attached tendons will pull on certain bones and elicit motion. Tendon anatomy in the hand is delicate and intricate and so is the surgery required to restore it after injury.
Tendon injuries are common. Our hands are constantly involved in daily activities and relatively superficial location of tendons in the hand, especially in the fingers, renders them susceptible to trauma.
In brief, the palm and inner side of the forearm mainly contain tendons which bend (flex) fingers and wrist (flexor tendons). On the back of the hand and forearm lie tendons which straighten (extend) fingers and wrist (extensor tendons). Most of these long muscles originate at the elbow and forearm regions, turning into tendons just past the middle of the forearm, and attach to the bones of the fingers and palm. In the finger, the tendons pass through very narrow tunnels that keep them close to the bones and facilitate their action and gliding.
Only partially divided tendons (less then 50% of the tendon diameter) can just about heal spontaneously. A completely cut tendon can rarely heal without surgery. The severed ends separate from each other due to inherent tension present in all tendons. An injury that appears simple on the outside can be much more complex on the inside.
It is important to repair these injuries early (within few days from an accident) in order to facilitate good long term results. Specialist expertise in dealing with these sophisticated structures, as well as dedicated hand therapy help such goal.
Many tendon injuries are not associated with breach in the skin. Tendon insertions onto the bones can be disrupted during forceful twists, pulls and blunt trauma imposed onto the fingers. Not surprisingly, such closed injuries are associated with delayed referal and diagnosis making surgical treatment even more difficult and treatment outcomes often compromised. Inability to fully straighten or bend your finger(s) should alarm you to seek specialist advise as soon as possible. Please refer to Pictures in the Photo Gallery below which just few clinical examples.
After an extensor tendon repair you should predictably have well working finger or thumb. The outcome is often better when the injury is a clean cut to the tendon, rather than one that involves crushing or damage to the bones and joints.
A flexor tendon injury is generally more serious because they’re often put under more strain than extensor tendons. The flexor tendon system in the hand, especially fingers, is based on intactness of a fascinating, complex, smooth, gliding mechanism (example illustarted in the Photo Gallery below). Therefore, any scarring (inevitably associated with either injury or surgery) interferes with such fine physiology and needs to be managed carefully. Specialist input from the beginning, however provides the best chances for good recovery.
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
Tendon surgery is carried out on a day care basis.
Extensor tendons are easier to reach, so repairing them is relatively straightforward. Many can be done under local anaesthetic, but more extensive ones will require general or regional anaesthesia. The simplest and smallest extensor tendon cuts can sometimes even be fixed in the Accident and Emergency department.
Repairing flexor tendons is more challenging because the flexor tendon system is more complex and responds worse to consequences of injury and scarring. Flexor tendon repair usually needs to be carried out under either general or regional anaesthesia, ideally by an experienced hand surgeon.
Tendons ends need to be stitched together in a very particular way: repair must be robust enough to withstand future strong forces, but also neat and elegant not to compromise gliding of the tendon within the narrow tunnel. At the end of operation hand is bandaged and splinted from the tip of the fingers up to the elbow.
Unfortunately, complications are common after tendon surgery, especially flexor mechanism. Please note below the commonest complications:
- Infection and wound breakdown
- Repair failure/ rupture (5-15% cases) requiring additional surgery
- Adhesions/scarring around tendon repair requiring further surgery
- Stiffness (reduced range of motion)
- Complex Regional Pain Syndrome (CRPS) – rarely people are sensitive to hand surgery and their (seen in 5% of surgery) hand may become very swollen, painful and stiff after any operation.
- Scar sensitivity
Rehabilitation most commonly includes wearing a custom made splint for minimum of 6 weeks. During that time fingers however have to be mobilised to stop repaired tendons sticking to nearby tissues i.e. prevent adhesions around tendon which can compromise tendon gliding and ideal outcome. Specialist hand therapist guidance is indispensible in conducting this process.
It takes 6-8 weeks for repaired tendon ends to bond together and another 6-8 weeks for that repair to regain full biomechanical strength. During those 3 months hand therapy is essential yet demanding, but without compliance and dedications with therapy there is no successful recovery from tendon surgery.
Return to work will depend on your job and exact injury details, but tendon injury and its surgery (especially flexor tendon repairs) can affect your work for a considerable length of time. Light activities can often be resumed after 6-8 weeks and heavy activities and sport after 10-12 weeks.
|Hospital stay||Day care|
|Anaesthetic||General or Regional|
|Surgery time||30-90 minutes|
|Skin healing||2 weeks|
|Tendon healing||12 weeks|
|Shower / Bath||from week 2|
|Time off work||8-12 weeks those involved in manual activities | 2-3 week for office based work|
|Sports and exercise||from 3 months|
|Driving||4-6 week; please check details with your insurance company|
|Full recovery||12-16 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