Hand surgery

Interventions on the hand are an important focus of the operational spectrum of the practice. Common hand disorders, that can be treated surgically, are e.g.: Dupuytren’s contracture, Cranberry tunnel syndrome (KTS or CTS), painful osteoarthritis, z.B. Rhizarthrose (Thumb saddle joint osteoarthritis), Tendinitis (so-called. Snap fingers), Extensor tendon ruptures on the thumb (often spontaneously or after a broken spoke) and much more. We also treat fresh or old injuries to the bones and soft tissues of the hand, such as. Fractures of the fingers, Metacarpal, Handwurzel (Kahnbein / Scaphoid) and the spoke (Radiusfrakturen), fresh or outdated tendon cuts and corrective interventions for incorrectly healed fractures on the wrist and hand.

Dupuytren's contracture is a disease of the palm and fingers with benign neoplasm of knots and strands, which can lead to flexion contracture of the finger joints. All variations can occur, from the formation of a single knot in the palm of the hand to the extensive curvature of several fingers. Individual fingers can also be affected in isolation.
Treatment depends on the stage of the disease, d.h., how far the finger flexion and thus the disability has progressed, after the progression, d.h., how quickly the flexion contracture has worsened recently, and also according to the individual circumstances and ideas of the patients. Example of a degree 3 Our contractor (above) and after surgery (below) Conservative treatment (without surgery) is usually not very successful, at best, the progress of the disease in the early stages can be slowed down by consistently stretching the affected finger. However, there are no reliable studies on this hypothesis. An operation is only indicated, if a significant flexion has occurred in a finger. The most common removal of the diseased tissue is common. If the finger joints have been flexed for a long time, this is sometimes no longer sufficient, and the joint must also be loosened. In the case of severe flexion contractures, skin grafts may also be required. If a regular operation is not desired or not possible, In individual cases, the strand can only be severed. There are also different approaches for this.

The carpal tunnel syndrome is the most common. Bottleneck syndrome in the arm and causes a decrease in sensation ('Furiness') the palm of the hand on the thumb, Show-, medium- and ring finger. Not all fingers have to be affected at the same time. Burning pain in the hand can also occur and radiate into the arm. The symptoms often appear at night or in the morning, or for specific stresses with hyperextension in the wrist (Cycle, To phone).

The cause of the discomfort is a narrow point in the area of ​​the wrist, where the median nerve (Median nerve) through a constriction limited by connective tissue and bones (‚Carpaltunnel’) runs from forearm into palm, along with 9 Flexor tendons and their sliding tissue. Slight swellings of the tendon sliding tissue or other causes can lead to an additional narrowing of the carpal tunnel and trigger the symptoms described above by pressure on the nerves.
Often, conservative treatment with anti-inflammatory drugs and immobilization of the wrist using a forearm wrist splint can be used (v.a. during the night, so-called. Night splint) achieve a decrease in symptoms. Very advanced nerve damage can often be recognized by the muscle weakening of the ball of the thumb, the picture shows a dent on the ball of the thumb of the left hand. This is the visible correlate of the decrease in strength, which many patients complain about.

If this does not lead to a sufficient improvement in the complaint, the median nerve can be relieved by a small operation. The principle of operation consists in this, to cut through the firm connective tissue covering the nerve and flexor tendons in the area of ​​the carpal tunnel and thereby relieve the nerves. A neurophysiological examination by a neurologist before the operation is essential to confirm the diagnosis and correctly assess the indication for surgery.
The operation to relieve the median nerve can be performed openly or endoscopically. Both OP- The results of procedures are comparable and usually lead to freedom from symptoms. In the so-called. open surgery is performed over an approx. 3 cm long skin incision in the area of ​​the palm-side wrist of the nerve exposed under sight, after all constricting structures have been completely removed, only the skin is closed again.

In the endoscopic procedure, an approx. 2 cm long transverse skin incision in the flexor crease of the wrist, an endoscopic knife is inserted under the constricting ligament in the wrist and the ligament is severed in sight. The advantage of the endoscopic procedure is a somewhat faster restoration of resilience.

However, not all patients are suitable for this procedure. An individual decision is made in each case in a personal conversation.
The chances of complete resolution of symptoms are all the better, the less severe the nerve damage before the operation. In the case of advanced nerve damage, the recovery of the nerve and thus the return of feeling can take more than a year or remain incomplete, but even then there is usually a clear improvement in the symptoms, so that the operation is recommended even with a complete loss of sensitivity.

The occupation can in general after 2-6 Weeks (wide range depending on the load) to be resumed.

Rhizarthrosis is the most common arthritis in the hand and affects 70-90% the population. It is arthrosis of the thumb saddle joint, that is, between the metacarpal bone of the thumb and the large polygonal bone (x in the X-ray image below). Usually the joint is swollen (Fig.) and hurts, often the pain cannot be precisely localized to the joint, the symptoms often affect the whole thumb and often radiate to the forearm.

The joint space is on the x-ray (arrow) canceled, the metacarpal has already shifted.

As long as pain only occurs under particular stress and subsides after a short recovery period, no intervention is required. Conservative treatment methods such as. a supporting saddle joint orthosis, anti-inflammatory medications or poultices can help here. Injections or X-ray stimulation can also be temporary, however, it does not provide permanent relief. However, if the pain occurs on a daily basis and interferes with almost all activities in daily life, an operation makes sense. Depending on age, Work demands and expectations as well as the severity of osteoarthritis on the saddle joint and on the neighboring joints are used in various surgical methods. The most frequently used surgical procedure is the so-called Resection arthroplasty. This means the removal of the large polygonal bone and the filling of the resulting gap with tendon tissue from the environment. The drawing shows the OP technology schematically, the filled space appears empty in the X-ray image, because the soft tissue is not radiopaque.

Scheme drawing of the resection arthroplasty: FCR: Flexor carpi radialis (Wrist flexion on the spokes side), APL: Abduktor thumb (Long thumb abductor tendon) and x-ray.

Because the so-called APL tendon is used as a replacement for the removed carpal bone (long thumb abductor tendon) is used, The operation is also called APL plastic. The advantage of this procedure is the simple operating principle, the preservation of the full mobility of the thumb and the extensive absence of complications. In everyday life there is usually extensive freedom from symptoms. A minor disadvantage is a certain loss of strength, when gripping firmly or when there is constant need for a firm grip e.g.. noticeable during professional activity.

Therefore, the process is not suitable for people who work in a manual or otherwise difficult manner. For this group of patients, the Arthrodese, thus a stiffening of the saddle joint. Thereby the two bones, between which there is painful osteoarthritis, firmly connected, so that they form a unit, so to speak. Then the pain will also go away. The advantage of the firm, pain-free grip comes at the expense of a certain restriction of movement, which is hardly noticeable in everyday life, and the additional low risk compared to resection arthroplasty, that the bony connection between the two bones does not occur. This would require revision surgery, but it rarely happens.

The images show the x-ray after arthrodesis of the saddle joint and illustrate the functional result with good preservation of the mobility of the operated thumb, which is by far sufficient for everyday activities.

Other possible surgical procedures are ligament surgery for early osteoarthritis in patients under 40 Years, which is rarely used. Artificial joint replacements and the implantation of placeholders have so far not found their way into routine hand surgery due to high complication rates and should primarily be reserved for use within scientific studies.

Which surgical procedure is most suitable in each individual case, should be discussed in an individual interview.

Tendonitis can manifest itself in very different ways. The most common phenomenon is the so-called snap finger or snap thumb, if it concerns this one. Due to an inflammatory swelling of the sliding tendon tissue (this is not shown in the diagram for the sake of simplicity) the ring ligaments of the fingers become relatively tight, so that pain occurs due to the increased friction. The cause of the swelling of the tendon sliding tissue is generally the genetic predisposition to it, more rarely there are other causes such as overload. Because of the sustained friction between the tendon and the ring ligament (on the metacarpus directly below the metacarpophalangeal joint) In the further course, inflammatory tendon thickening can occur. When this then passes through the narrow belt, the well-known snap phenomenon occurs. The snapping is often not even at the place of origin, but perceived on the finger, because the vibration along the tendon is transmitted into the finger. A typical symptom is tenderness on the affected ring ligament, than in the palm below the metatarsophalangeal joint. Before the snap phenomenon occurs, there is only pain, at an advanced stage, when the thickened tendon can no longer pass through the constriction, the finger can only be bent to a limited extent. Sometimes the inflammation goes away on its own, one can use anti-inflammatory drugs (z.B. Ibuprofen) treat short term, A cortisone injection can also bring relief or even relief from symptoms. Most of the time, however, the improvements are temporary or incomplete. If the symptoms are persistent, the surgical splitting of the ring ligament is a simple and uncomplicated option, permanently eliminate the problem. In local anesthesia (Injection just above the ring ligament) the flexor tendon sheath with the ring ligament reinforcement is cut through a transverse skin incision, the flexor tendons can then run freely again, there is no recurrence if the ligament is completely split. Tendonitis also occurs on the extensor tendons. The most common form here is the so-called DeQuervain tendovaginitis De Quervain's tendovaginitis is an inflammation of the so-called first extensor compartment (see illustration) on the wrist on the spoke side. The extensor tendons run partially through extensor fans on the wrist, each enclosing one or more tendons, in the illustration the compartments are numbered. The first extensor compartment is particularly prone to inflammation (Red circle). The inflammation causes pain on the wrist on the side of the spoke and, over time, usually also a visible swelling (s. Photo below). The snap so typical of the flexor tendons- However, there is no phenomenon here, however, one can sometimes feel or feel a grinding rub. A classic symptom is the so-called 'Finkelstein mark', this is understood to mean a severe increase in pain, when the examiner completely grips the patient's hand with the thumb included and leads it to the side of the elbow. Conservative therapy consists of immobilization, external and internal use of anti-inflammatory substances and temporary rest. The definitive therapy consists in simply splitting the first extensor compartment, this will remove the tightness and allow the inflammation to heal. Sometimes the inflammatory swelling of the tendons in the first extensor compartment is so pronounced, that after splitting the tendons they almost swell and no longer slide stably in the intended groove, but would leave their place with wrist movements. In such severe cases it can be necessary, that one must reconstruct the roof of the first stretch compartment, to ensure the stability of the tendon path. However, this has no effect on the follow-up treatment after the operation.
Tendon severance caused by an injury naturally requires immediate surgical treatment, the injured person should immediately seek surgical treatment. The variety of injury patterns is too great, to be shown in detail here. Spontaneous tendon ruptures occur most frequently on the extensor mechanisms of the long finger end joints (‚Mallet-Finger‘) and at the thumb joint (Long extensor tendon ruptured) on. Mallet fingers The cause is usually a banal touch of a finger, which leads to an acute stretch deficit. In the acute phase there is usually no pain worth mentioning. The treatment is conservative by consistently immobilizing the end joint in a special finger splint (so-called. Stack’s rail) For 8 Weeks without a break. The duration of treatment can often extend to several months if unsuccessful. Complete healing with restoration of the original condition before the injury is rare, however, a stretching function can usually be restored, which is functionally and cosmetically acceptable. If the stretching deficit persists, surgery can also be used. There are different surgical methods, none is really reliable, therefore, the operation is only recommended in very stubborn cases. Long extensor tendon ruptured (Extensor EPL Sehnt) The rupture of the EPL tendon leads to an acute extension deficit of the thumb, this is a clear handicap, therefore surgical treatment is always indicated. The cause of the rupture is usually spontaneous degeneration and weakening of the tendon, which ultimately leads to a rupture with loss of extension of the thumb for no particular reason. The affected patient usually only feels a brief, slight pain on the spinal side of the wrist. Suturing the tendon is usually not possible, the function of the ruptured tendon is restored by repositioning the extensor tendon of the index finger (Extensor indicis Sehne) on the EPL tendon, relearning the function usually takes place in the context of physiotherapy without any problems. The extension function of the index finger does not suffer from this measure, because the index finger has another extensor tendon (so-called. Extensor digitorum Sehnt)

will follow shortly…