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Auckland Regional Plastic Reconstructive and Hand Surgery

Public Service

Hand Surgery

Problems with the appearance or function of the hand can be the result of injury, birth defects or degenerative conditions.
 
Arthritis
Arthritis is a condition in which a joint and the surrounding tissue become swollen and painful. If surgery is necessary, it may involve replacement of the joint with an artificial joint or removal or repair of swollen or damaged tissue.
 
Birth Abnormalities
Surgery may sometimes be required for hand abnormalities that are present at birth such as too many or too few fingers, webbed fingers or joints that won’t bend.
 
Carpal Tunnel Syndrome
A pinched nerve in the wrist that causes tingling, numbness and pain in your hand may require surgery to make more room for the nerve. This operation is usually performed under local anaesthetic (the area being treated is numb but you are awake).

Problem:
  • Numbness and tingling affecting thumb, index, middle and ring fingers.

Cause:

  • Compression of the median nerve as it passed through the carpal tunnel at the level of the wrist.

Diagnosis:

  • Characteristic night-time waking with numbness
  • Characteristic distribution of numbness in the hand sometime wasting of the thenar (thumb) muscles in the hand
  • Positive Tinel's (tapping) and Phalen's (compression tests)
  • Nerve conduction tests can be used to confirm diagnosis if required.

Treatment:

  • Non-operative night splinting, nerve glide exercises, steroid injection for temporary relief.

Operative Treatment:

  • Open carpal tunnel release usually under local anaesthetic
  • 4cm incision
  • Release of transverse carpal ligament
  • Skin closure.

Potential Postoperative Complications:

  • Infection
  • Haematoma
  • Wound sensitivity
  • Pillar pain (thenar and hypothenar areas)
  • CRPS (exaggerated pain response)

Postoperative Care:

  • Day surgery
  • Keep fingers moving
  • Elevation
  • Wound check at 10 days
  • Return to desk work at 10 days
  • Return to manual work at one month
 

We have a fast-track scheme to treat this problem that may be suitable for you. We call this the Direct Access to Carpal Tunnel Surgery scheme, DACTS. In this scheme, suitable patients may be booked directly for an operation for their hand problem without needing to see a surgeon first.

Your family doctor/practice nurse will help you to complete the forms for this scheme. It is very important that you read the information sheet and answer every question in the questionnaires so that we can decide if this will be suitable for you.

There are 6 forms:

  1. Carpal Tunnel Syndrome Surgery Information Sheet
  2. Consent for Surgery Form
  3. Boston Carpal Tunnel Questionnaire
  4. Diagnostic Questionnaire
  5. Health Questionnaire
  6. Patient Registration Form

Once you have read the information it is very important to clearly mark an option on Form 2 to indicate whether you would like to have an operation through the DACTS system. The options are:

  1. To be booked directly for an operation for Carpal Tunnel Syndrome through the DACTS scheme under local anaesthetic. Your arm will be numbed, but you will be awake during the surgery.
  2. To have an appointment to see the surgeon. Choose this option if you would like further discussion with the surgeon before you are booked to have an operation.
  3. To have an appointment to discuss non-surgical management of your problem for example the use of a wrist splint at night.

If you choose option 1, the advantage is that you may not have to wait for a clinic appointment and go directly to having an operation. You will receive a phone call to discuss your hand problem before the operation, however you will not see a surgeon before the day of your operation.

This scheme is not suitable for everyone. Once we have received the paperwork we will assess your information to decide if this scheme is suitable for you. We will keep you informed of the outcome of our assessment.

 

Cubital Tunnel
Problem:
  • Numbness and tingling affecting the little and ring fingers.
Cause:
  • Compression of the ulnar nerve as it goes around the elbow.
Diagnosis:
  • Numbness and tingling in the distribution of the ulnar nerve
  • Weakness and wasting to the small muscles of the hand
  • Positive Tinel's (tapping) sign at the elbow
  • Nerve conduction tests can help but are often normal as the problem is usually intermittent.
Treatment:
  • Non-operative splinting with the elbow out straight.
Operative Treatment:
  • Operative GA day case usually simple release incision on the inside of the elbow joint
  • Release of Osborne's ligament over the ulnar nerve
  • Occasionally if nerve subluxes from its groove, it needs to be transposed to the front of the elbow. This can either be subcutaneous (beneath the skin) or some submuscular (beneath the muscle).
Potential Complications:
  • Infection
  • Haematoma
  • Nerve injury
  • Incomplete recovery of the nerve.
Postoperative Care:
  • Day surgery
  • Bulky bandage for 10 days
  • Removal of sutures at the 10 day mark
  • If simple release mobilise as comfortable
  • If transposition restriction of elbow movement for three to four weeks either in a bulky bandage or plaster.
 
De Quervain's
Problem:
  • The extensor tendons are inflamed over the radial side of the wrist.
Cause:
  • Inflammation of the tendons overlying the radial aspect of the wrist usually occurs after the repairs of activity, repetitive activity, for example lifting newborn baby.
Diagnosis:
  • Pain on the radial side of the wrist
  • Sometime obvious swelling
  • Pain is exacerbated with thumb flexion and ulnar deviation (Finkelstein's test).
Treatment:
  • Splintage through the hand therapist
  • Activity modification
  • Steroid injection of 10mg of Kenacort into the first compartment usually gives good relief in 80% of cases
  • If recurrence after injection then consider surgery.
Surgery:
  • General anaesthetic, local
  • Direct release of the 1st compartment.
Potential Complications:
  • Infection
  • Neurovascular injury
  • Further stiffening and inflammation
  • Instability of the 1st compartment tendon.
Postoperative Care:
  • Light dressing and splintage
  • Hand therapy to regain active and passive range of motion
  • Wound check at 10 days.
 
Dupuytren's Disease
Problem:
  • Curling down of the fingers into the palm due to cords of fibrous tissue.
Cause:
  • Cords of fibrous tissue form beneath the skin and they track down into the fingers causing contractures to develop. There is usually a strong family history found with individuals that have Celtic ancestry.
Diagnosis:
  • Usually the contractures are obvious and simple examination will confirm the diagnosis of Dupuyren's disease
  • A positive family history is usually obtained
  • Patients have difficulty washing their face due to contracture
  • Difficulty placing their hands in their pockets
  • Usually unable to get their hand flat on the table.
Treatment:
  • Mainstay of treatment is surgical
  • Currently collagenase injections are unavailable in New Zealand.
Surgery:
  • Usually done as a Day Surgery procedure
  • Skin incisions made over the palpable cords and diseased tissue is removed
  • Z plasties break up the line of the scar
  • Occasionally skin grafts are required to replace contracted skin.
Surgical Referral Criteria:
  • Patient with >30 degree contracture to the MCP joint
  • Unable to get their hand flat on the table
  • PIP joint involvement
  • Clinical photographs to assist appropriate clinical prioritisation
Potential Complications:
  • Infection
  • Haematoma
  • Neurovascular injury
  • Postoperative stiffness
  • Recurrence of contracture.
Postoperative Care:
  • Patient is usually discharged in a plaster slab
  • Referral to hand therapy for mobilisation +/- splinting for up to three months
  • Wounds are reviewed at 10 days
  • Usually dissolving stitches are utilised.
 
Injuries
Damage to tendons, nerves, joints and bones in the hand may require surgical repair. In some cases, tissue may be transferred from a healthy part of your body to the injured site (grafting).
 
Replantation
Fingers or hands that have been accidentally cut off can be reattached by very detailed surgery that is performed under a microscope (microsurgery) and involves reconnecting tendons, blood vessels and nerves. 
 
Soft Tissue Lump in the Hand
Problem:
  • A discrete swelling is felt or seen in hand.
Cause:
  • There  are many causes for soft tissue lumps in the hand:
  • Fluid filled cysts (ganglion) are the most common
  • Benign solid lumps.
Diagnosis:
  • The location and appearance of the swelling can be diagnostic
  • X-rays can be performed to look for degenerative joints or bony masses
  • An ultrasound will often delineate whether something is solid or cystic
  • Complex lesions sometimes require an MRI scan.
Treatment:
  • Generally all solid lumps should be surgically removed
  • Ganglions if present for >6 months and causing enough symptoms that the patient wants surgical removal are considered for excision.
Surgical Treatment:
  • Usually performed under general anaesthetic
  • The lump is shelled out, while protecting surrounding structures.
Potential Complications:
  • Infection
  • Haematoma
  • Wound breakdown
  • Stiffness
  • Recurrence of the cyst or lump.
Postoperative Care:
  • Patient is usually in a protective dressing, possibly a slab
  • Specialist review at 10 days for wound inspection and stitch removal and chasing of histology.

Trigger Finders/ Thumb
Problem:
  • Painful finger or thumb that locks in a flexed position.
Cause:
  • Swelling/inflammation around the tendon causes it to lock as it enters the pulley system of the digit.
Diagnosis:
  • Pain is felt in the palm at the base of the digit
  • A palpable click is felt on examination.
Treatment:
  • Steroid injection with local anaesthetic - 10mg of Kenacort injected in the region of the A1 pulley will settle the problem in 70 - 80% of cases.  This procedure can be done at most GP practices. Recurrent triggering or multiple digits require surgery.
Surgery:
  • General anaesthetic or local anaesthetic
  • Release at the entrance to the pulley system
  • Occasionally the tendons need to be debrided or debulked.
Potential Complications:
  • Infection
  • Haematoma
  • Neurovascular injury
  • Stiffness
  • Recurrence.
Postoperative Care:
  • Light bandage for 5 - 10 days
  • Early mobilisation of the digits
  • Back to most activities by two to three weeks.
 
See and Treat Service
Covering common hand problems such as Carpal Tunnel Syndrome.  If suitable, your GP will write a letter to the Department requesting an appointment in our fully integrated one-stop "See and Treat" clinic, where patients could have their treatment on the same day as their first specialist appointment. Surgery will be performed under local anaesthetic and you will be given instructions on medication prior to your arrival.

Patients will be asked to make contact with their GP prior to arriving so that their GP can advise them on the management of their anticoagulants prior to their appointment.

As patients may require a biopsy or surgical procedure in the See and Treat Facility, please let us know if the patient is taking any medication to thin their blood such as warfarin, aspirin, clopidogrel, dabigatran or dipyridamole.

Guidelines for anticoagulant management prior to surgery for the See and Treat patients will be made available soon.

Clinics are held in Middlemore Hospital, Level 1 of Galbraith Building.  For further information please see your local GP or contact us for more information.

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This page was last updated at 3:24PM on December 12, 2018.