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.
You may well be puzzled: you have been diagnosed with a ‘tennis elbow’, yet you might have never lifted a tennis racquet in your life! Naturally, a strenuous game of tennis can be the cause, but condition can be triggered by number of other activities.
People who are firmly gripping and/or twisting hand and forearm – athletes, labourers, cleaners, gardeners – are particularly prone to this painful condition. Each year in the UK, about five in every 1,000 people go to see their GP because of tennis elbow.
The medical name for tennis elbow is ‘lateral epicondylitis’. The lateral epincondyle is the bony part you can feel on the outer aspect of the elbow joint. A identical condition occurs on the medial (inner) side of the elbow and it’s bony prominence called ‘medial epicondyle’. Then it is named ‘golfer’s elbow’, although, again, it is by no means confined only to those who play golf. Pathophysiology is identical in both conditions – micro tearing of the tendons and muscles at the point of their merging with the bone. The only difference is the group of muscles affected i.e. in patients with tennis elbow’s an origin of extensor muscles which straighten the wrist and fingers is painful on the outer elbow, whereas in golfer’s elbow, the bony insertion of the flexor muscles which bend wrist and fingers get affected on inner side of the elbow.
The below content applies to both conditions:
Problem arises when the tendons coming from the muscles of the forearm become inflamed at the point where they attach to the bone. The tendons that enable you to straighten your fingers and wrist (the extensor tendons) and those that bend the wrist and fingers (the flexor tendons) all merge together before inserting into the bony epicondyles. Repetitive exertion and straining of particular muscle groups leads to tiny tears within the muscle and tendon with consequent inflammation. Unless adequately treated, alternating sequence of repeated injury and body’s attempt to heal it, leads to the formation of a chronically painful scar tissue.
Although it is painful, the pathology is localised and does not lead to deteriorating disability. This condition can be readily diagnosed in the clinic without the need for investigations. There is no arthritis hence X -rays are not necessary.
Different people experience varying degrees of pain, ranging from a mild discomfort when the arm is used to an ache severe enough to prevent you sleeping. The pain is made worse by gripping or twisting movements. Repeated movements of the hand and wrist, especially those meeting resistance will make matters worse. Every time you strain the tendons with healing tear, will naturally, be uncomfortable.
Pain often extends further down into the forearm. Normally, there is no swelling around the elbow joint itself, but patients are usually able to quite accurately pin point the painful spot.
The condition is likely to get better by itself, especially if you cut out excessive or repetitive movement of hand. Rest usually works if you act soon after the beginning of symptoms. Most people are able to recall the activity that triggered symptoms in the first place.
Some people find help from warmth (from a hot water bottle, heated jelly pads etc), mild painkillers (Paracetamol or similar) and anti-inflammatory gels (Ibuprofen or similar). Elasticated bandages around the elbow are usually very comforting.
Physiotherapy may be recommended in more severe and persistent cases. Massaging and manipulating the affected area may help relieve the pain and stiffness, and improve the range of movement in your arm. A custom made splint created by hand therapist can immobilise affected muscle group effectively, allowing them a ‘proper’ rest.
If pain shows no sign of lessening following simple measures described above, the treatment might need to become more ‘invasive’. The first step would be to administer a cortisone (steroid) injection into the tender area. Since the drug is injected only into the affected area, there should be no effects to the rest of the body, occasionally seen when people are consuming steroids by mouth.
After injection, it is likely that pain will get worse for a day or two before it gets better. Steroids do predictably help, by reducing inflammation and pain in a rather short period of time, but their long-term effectiveness has been shown to be poor. In my experience, only one injection permanently solves the problem rarely. This is perhaps the case only in patients with a short history of elbow pain, when the diagnosis is established early i.e. pathological tissue is only limited and sub-acute, rather then chronic. Steroid injections should always be supplemented with few weeks of ‘proper’ rest of the hand and complete avoidance of activities which led to the condition in the first place. Sometimes, splint is required.
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:
- Anticoagulation medication (Aspirin, Brufen, Warfarin, Clopidrogel) should ideally be stopped few days before the operation to reduce the risk of bleeding, but advise from the clinician who prescribed them is wise beforehand. I would strongly advise you to stop smoking prior to surgery as this can badly affect the outcome of surgery and increase complication rates.
- 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 travel
Failing the treatment measures above, surgery is recommended. The operation is performed on a day care basis; it lasts approximately 30 minutes and requires general or regional (arm is numbed, but you remain awake) anaesthesia. Incision is made over the painful side of the elbow and painful tendon insertions released of the bone. Abnormal, painful scar tissue is removed too. Following this, muscles remain attached under less tension, area regains blood supply and the pain eventually disappears.
Recovery is rather straight forward: elbow is bandaged in semi-bent position for 1-2 weeks. Wound is checked by the nurse in one week and dressings reduced. Sutures are removed at 2 weeks. After 3-4 month, scar is likely to be hardly noticeable and of no cosmetic concern.
Hand and elbow movement should be limited and activities sensibly reduced in the first few weeks. Splint is not always required postoperatively, but some patients find them comforting for approximately 3 weeks.
Tennis/golfer’s elbow release predictably leads to high patient’s satisfaction rate. It is commonly reported as “a great sense of relief following several months of annoying discomfort”.
Unfortunately, complications can occur following any surgery and patients need to be fully aware of this. Below the most common complications associated with surgery for the tennis/golfer’s elbow:
- Delayed wound healing
- Skin numbness
- Residual pain
- Scar sensitivity
- 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. This problem cannot be predicted but will be watched for afterwards and can be treated with medication and hand therapy
|Hospital stay||Day care|
|Anaesthetic||General or regional|
|Surgery time||30 minutes|
|Wound healing||2 weeks|
|Shower / Bath||from week 1|
|Time off work||3- weeks those involved in manual activities 1 week for office based work|
|Sports and exercise||from week 4|
|Full recovery||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