Hand surgery with Adam Greenbaum
Looking back, my training allowed me to spend time and learn from some of the most outstanding hand surgeons in Britain in living memory. I worked first in the North East Thames Regional Plastic Surgery Unit to which several of Auckland’s most notable Orthopaedic and Plastic surgeons made “pilgrimages” to spend time learning as postgraduate Hand Fellows before returning to practice in New Zealand.
As a senior specialist registrar in Manchester, Britain’s busiest Burn and Plastic Surgery Centre at the time, I was trained by Professor Gus McGrouther who taught me most of what I know about the nuances of Dupuytren’s disease and surgery to correct and manage its progression to allow patients to maintain optimum function throughout their lives.
I have an extensive knowledge of emergency hand surgery, reconstruction and microsurgical repair, but these days, although I cover the full range of an elective hand surgery practice, I specialise and particularly enjoy the challenges of managing patients with Dupuytren’s contracture.
Dupuytren’s Contracture (DC) is a fibro-proliferative disease of the fascial tissue under the skin of the palm of the hand(s). It is one of several variants of superficial, fascial fibromatoses that can cause similar contractors in other parts of the body and is a similar pathological process to that which causes “Frozen Shoulder”
If left to progress, it produces a relatively characteristic flexion contracture deformity of the fingers, winding and curling them into the palm.
There is a strong inherited tendency and patients will often be aware of parents, grandparents and uncles and aunts who had it. Sadly, they may often assume that because their relatives seemed to have to accept increasing deformity, interference with function and ultimately sometimes, amputation of digits, they will follow the same path. Too often, I have known this be the reason why patients have put off seeking help.
Times have changed, surgical techniques (and access to these techniques) has changed and so these days, spotting DC at an early stage and engaging early on is often the difference that leads to a functional hand in old age after prompt intervention and periodic further surgical procedures if needed to prevent progression and lost function.
Carpal Tunnel and other nerve compression syndromes
There are several possible causes of numb and painful fingers and grip weakness. A common cause is compression of a nerve as it travels from the spinal cord, dividing and branching as it progresses down the arm to reach the finger tips. Differentiating between the other causes and nerve compression – and then diagnosing which nerve and where it is being compressed is what makes the difference between successful and unsuccessful treatment.
There are several places in that pathway from the spinal cord at which the nerves in the arm can be compressed, but most commonly it is at the wrist. The median nerve can be compressed as it passes into the hand through a tunnel made up of the bones of the wrist and and a thick ligament that won’t expand. This is the “carpal tunnel” and compression her is called Carpal Tunnel Syndrome.
Carpal tunnel syndrome may not require surgery. Sometimes compression is transient and caused by fluid retention (for example, during pregnancy or after trauma) or when there is inflammation. In these situation, splinting the wrist or an injection of an anti-inflammatory steroid may solve the problem. If not, then surgery is generally simple in skilled hands and can be done under local anaesthetic block.
Next to the carpal tunnel is a canal called “Guyon’s canal” through which the ulnar nerve travels to the fingers and in which it can also be compressed. The distribution of numbness and pain among other signs and symptoms is what gives me the clue as to which nerve is being compressed and steers me towards any other tests I need to to do to be sure that compression is happening at the wrist, rather than in the arm, and getting this correct can be the difference between success and failure in surgery for nerve compression.
These cysts are the commonest cause of patients seeking help with a swelling in the hand. They affect women 3 times more commonly than they appear in men and tend to present in early adult life (from ages 20-50). They are much commoner in gymnasts – which suggests a repetitive strain-like injury as the mechanism for their formation and they are also more common in people with arthritis (but having one does not herald future arthritis).
Their cause is not precisely understood, but seems to follow some form of repeated microinjury that produces a hernia of synovial tissue for a joint or a tendon sheath. Ganglion cysts may appear (and disappear) suddenly and similarly, may increase and decrease in size for no obvious reason. When they are not visible, but are present in deeper tissues, they may compress nerves and other structures and so cause pain, tingling or muscle weakness and only come to light after a scan reveals them.
They can appear anywhere on the the arms or legs where there is synovial tissue (which surrounds joints and tendons to make them glide smoothly when they move), but the commonest sights on the hand are the back and front of the wrist, in the palm just before the fingers start and at the finger tips near the fingernail.
You don’t have to have a ganglion removed if it doesn’t cause you problems. They are not a malignant growth and you can take one to your grave quite safely – and many do if it gives them no bother. Treatment is generally indicated for functional reasons:
- because a ganglion cyst is pushing on a nerve or blood vessel
- because it is interfering with functional movement of your hand (or foot) or,
- when cysts are so large that they are unsightly and cause concern.
Aspiration of the gelatinous contents may be a reasonable first step depending on your circumstances. After aspiration, a ganglion is as likely to recur as not, whereas after competent surgery the recurrence rate should be 5-15% because surgery should remove the stalk-like projection of synovial tissue that attaches the cyst to the synovial tissue that it herniated from and this is the best way to stop it coming back.
"Triggering" or "locking" of a finger or thumb
Triggering of a finger happens when a tendon that bends the finger gets progressively more stuck as it passes through a tendinous pulley at the junction of the affected finger and the palm. Early on, bending the finger generally succeeds in pulling the nodule through the constriction on to the palm-side and allows the finger to bend, but once there, it lodges and won’t allow the tendon to return and allow the finger to straighten.
Initially, forcibly straightening the finger by using the other hand to pull on the bent finger tip succeeds, but with a sudden snap – analogous to the trigger mechanism that cocks a revolver hammer and then suddenly releases it to fire the revolver after a set tension is reached. This is why it is called “trigger finger”. If this problem is left untreated and allowed to worsen, the affected finger will eventually lock and become fixed in its bent hook-like position.
Women seem more prone to this problem than men. It is generally started by doing things repeatedly that require force to grip and people who also have diabetes or rheumatoid arthritis are more likely to have this problem, than those who do not.
Unless you have rheumatoid arthritis, which makes things more complicated, treatment depends on how soon it is addressed. If I see a patient soon after they notice the nodule developing, I can often treat it with a simple injection of anti-inflammatory corticosteroid. If this doesn’t succeed, or succeeds once, but later the problem returns, then a very simple surgical procedure than can be done under local anaesthetic block will cure the problem.
de Quervain's and other troublesome inflamed tendon syndromes
“de Quervain’s” tenosynovitis (along with the less common inflammatory problems with two other flexor tendons on either side of the wrist – Flexor carpi Ulnaris tenosynovitis and Flexor carpi radialis (FCR) tunnel syndrome – has the common cause of inflammation that develops as result of something damaging the tendons as they try to glide through the anatomical tunnels of connective tissue in the body that usually make movement smooth and functional. These tendons generally become inflamed after repetitive (over) use – commonly during work or sport – although if you have arthritis, this may often predispose you to developing these problems too. The simplest preventative strategy, therefore, is to be meticulous about technique and optimizing the ergonomics of the aspects of your work or sport that necessitate you making strong movements with your wrist repeatedly.
De Quervain’s tenosynovitis affects the abductor pollicis longus (APL) tendon which pulls on the thumb to move it away from the palm at right angles to the plane of the palm. The condition can make the area around the base of the thumb exquisitely tender and in common with the other two conditions, it is made worse by any activity that repetitively moves the wrist.
The diagnostic test de Quervain’s tenosynovitis is illustrated in the diagram opposite. Clasping the thumbing the palm and moving the wrist away from the thumb side of the arm – as you would when using a hammer – elicits the pain.
All three conditions may respond to resting the wrist, splinting it and hand therapy with a course of pain killers and an injection of corticosteroid to dampen down the inflammation at source. If this fails, surgical decompression is the best treatment and can generally be done as a day case procedure under local anaesthetic block.
How can I help you?
Whatever the problem: painful numb fingers; deformity or diminished function, I will listen, examine and assess you and then discuss with you the options I think you have – surgical and non-surgical – to come to an agreement about how I can best help you regain the function you have lost.
