Hand and peripheral nerve surgery

Dupuytren's disease is a benign disease of the connective tissue of the palm of the hand. The disease is characterized by the appearance of nodules and cords on the palm of the hand. The fourth and fifth finger rays are usually affected. Tensile forces on the connective tissue fibers of the nodes and cords can ultimately lead to flexion contractures (retractions with stiffening) of the metacarpophalangeal and metacarpophalangeal joints.

Causes

Since 1832, the year in which Baron G. Dupuytren (1777<wbr />-1835) presented this disease named after him in Paris, the triggering cause has remained unknown to this day.
Dupuytren's disease usually occurs in middle age, typically earlier in men and eight times more frequently than in women. It may run in families.

Symptoms and progression

The disease usually begins at the base of the ring finger or little finger with the formation of nodules. Both hands are usually affected. An intermittent course of the disease over several years is typical: months to years can pass before cord formation and contracture occur. The condition never actually improves on its own, but it is possible to slow down the course of the disease. The only promising therapy is surgical release of the contractures, i.e. an operation.

Surgery

The operation varies depending on the severity and exact localization of the findings. Normally, the skin of the affected fingers and palm is opened and the cords and nodes removed. The shortened joint capsules often also have to be loosened. To close the affected area, a skin graft or a so-called flap plasty is sometimes necessary.

Due to the high relapse rate, premature surgery should be avoided. As long as you can still lay your hand flat on a table with the palm facing downwards, no operation is necessary. However, it is also important how much you are bothered by the flexion contracture and feel restricted in your everyday life. Waiting too long can also lead to a poor result, as the entire soft tissue shrinks and full extension of the fingers can hardly be achieved after the operation. This risk increases significantly from a flexion position of the finger joints of 30 degrees, which is why this condition is determined as the time for surgery.

Depending on the severity of the contracture, cords can also be treated with pinpricks.

Follow-up treatment

In order to achieve the best possible result, occupational therapy instruction is necessary. You will be given a stretching splint to prevent scarring. You should follow the exercises described in the leaflet "Aftercare for outpatient hand operations".

Carpal tunnel syndrome is formed by the bones of the wrist and a strong ligament structure (carpal ligament) on the inside of the wrist. The flexor tendons of the hand run through the carpal tunnel together with a nerve, the median nerve. This nerve is responsible for the sensation of the thumb, index finger, middle finger and half of the ring finger. Carpal tunnel syndrome is caused by an entrapment of the median nerve, which results in reduced blood flow and thus a functional disorder. Long-term damage can lead to sensory disturbances and muscle atrophy in the ball of the thumb.

Symptoms

Symptoms such as pain, numbness/feeling of falling asleep and weakness of the hand often occur at night. Shaking or massaging the hand can reduce the symptoms. Difficulties may occur with the pointed grip and sensory impairment of the hand may also occur. The pain can radiate into the arm and shoulder. If the symptoms persist for a longer period of time, the muscles in the ball of the thumb may atrophy.

Causes

Rheumatic diseases, inflammation due to overuse, wrist fractures, tumors (ganglion, neurinoma), pregnancy, diabetes mellitus, hypothyroidism, metabolic diseases (e.g. gout, mucopolysaccharidosis).

Examinations

Electromyography (EMG) can be used to assess the damage to the affected nerves. In some cases, X-ray or ultrasound examinations of the wrist may also be necessary.

Therapy

The aim of therapy is to eliminate the compression of the nerve and its consequences (pain, numbness, weakness of the hand). Conservative therapy is an option for patients with less pronounced symptoms and involves wearing a wrist splint and anti-inflammatory medication. In addition, the wrist should be protected. Triggering work should be avoided. If conservative therapy remains unsuccessful over a longer period of time or the CTS has progressed to such an extent that pronounced symptoms occur with a reduction in the muscles of the ball of the thumb, weakness and numbness, surgical intervention is unavoidable.

Surgery

The carpal ligament, which forms the roof of the carpal tunnel, is surgically severed. This can be done in an open or endoscopic operation. The operation is performed on an outpatient basis under anesthesia of the hand (hand block).

Special follow-up treatment

After splitting the ligament, the nerve can recover very quickly. Symptoms often improve as early as the day after the operation. The recovery phase lasts 4-12 weeks; if the nerve is severely damaged, complete recovery is not always possible. The natural healing process can take 6 months.

The thumb saddle joint is one of the most frequently used joints. The thumb is positioned opposite the other fingers with almost every movement. This movement mainly takes place in the saddle joint. Osteoarthritis is a degenerative disease of the joint cartilage and is one of the rheumatic diseases If the thumb saddle joint is affected by osteoarthritis, this is referred to as rhizarthrosis. This leads to deformation of the thumb saddle joint with cartilage abrasion and instability of the joint ligaments. This leads to local inflammation with swelling and pain during movement or strain.

In addition to the thumb saddle joint, other hand or finger joints can also be affected. Rhizarthrosis occurs in around 10% of the population and usually occurs on both sides and after the age of 40. Women are affected significantly more often than men.

Causes

Very often, the development of rhizarthrosis cannot be attributed to a clear cause (idiopathic). However, there are some known causes:

• Injuries with fractures or ligament lesions
• Overloading
• Hormonal causes (after the menopause)
• Familial occurrence

Signs and symptoms

Not every saddle joint arthrosis causes symptoms. The onset of the disease is slow, with pain dependent on weight-bearing, which subsides at rest.

The intensity of the symptoms increases over the course of months and years until even minor strain causes pain and the symptoms no longer subside completely, even at rest. Particularly characteristic is the weakness of the thumb grip and pain, especially when turning (e.g. unscrewing a lid, opening a door lock). In order to partially compensate for the restricted movement of the affected joint, there may be a misalignment of the neighboring joints, such as hyperextension of the metacarpophalangeal joint of the thumb.

Osteoarthritis often manifests itself through a loss of strength (e.g. when opening bottles). In the area of the thumb saddle joint, there is pronounced pain at rest and/or on exertion, later sometimes also nocturnal pain. The joints may be swollen, painful and restricted in their mobility. Loosening of the joint ligaments can lead to subluxation (incomplete dislocation) of the thumb. Another effect of joint wear in the thumb saddle joint is the progressive destruction of the joint over time. A frequent consequence in the final stage is stiffening and loss of function of the joint.

Treatment

Conservative forms of treatment include immobilization in a cuff and taking painkillers and anti-inflammatory medication. In addition, a painkiller can be injected directly into the joint. However, these measures usually only help temporarily and are not successful in advanced stages.

In advanced cases, a so-called trapeziectomy with a suspension plasty is indicated. In this procedure, the carpal bone involved in joint formation, the os trapezium (polygonal bone), is removed. Part of a tendon from a nearby muscle is inserted into the resulting space, which is transformed into scar tissue over time.

An alternative surgical procedure is joint fusion (arthrodesis).
The mobility of the joint is more restricted by an arthrodesis than by a trapeziectomy and can lead to osteoarthritis of neighboring joints over time.
In particular, the treatment of long-term complications of these treatments poses major challenges for patients and surgeons. Sometimes a reconstructive bone transfer is necessary.

Follow-up treatment

During the surgical treatment, a splint is applied to the thumb and wrist in the operating room. On the first day after the operation, the first dressing is changed and any drains are removed. This fixation remains in place for two weeks. A thumb cap is then fitted for a further ten weeks. This small splint protects the operated joint and immobilizes it permanently for a further four weeks. The thumb cap can then be removed for movement exercises. After six weeks (twelve weeks after the operation), no further splint is required. Occupational therapy is continued to improve thumb mobility and build up strength.

A snapping finger is a snapping phenomenon that occurs when the tissue of the tendon sheath of the finger flexor muscles is thickened and only just fits through the so-called annular ligaments when the finger is extended.

Symptoms

This snapping when trying to stretch the finger can be painful, but can also be completely painless and occurs mainly in the morning. In later stages, the finger can only be stretched forcibly or not at all. A painful hardening can sometimes be felt in the palm of the hand. The disease is therefore often confused with Dupuytren's contracture. The ring finger, middle finger or thumb are most frequently affected.

Causes

Temporary overloading or inflammation leads to a thickening of the annular ligament and the flexor tendon at the level of the metacarpophalangeal joint. As a result, the tendon gets "stuck" and the typical "snapping" occurs when the resistance is overcome. Rare causes are rheumatic diseases, in small children the tightness can also be congenital.

If the finger remains bent at all times, the tendons shorten with corresponding consequences and the position remains fixed. The flexor tendon can be damaged by the constriction and ultimately rupture.

Treatment

If the symptoms are relatively minor, it is sometimes worth waiting 4-6 weeks. The tightness often disappears again during this period and the finger can move freely. However, you should not wait any longer. Surgical intervention is then necessary. Under local or arm anesthesia, a small incision is made over the constriction and the ligament is simply severed ("ring ligament splitting"). Any inflamed tendon sheath tissue is also removed. The procedure is hardly stressful and can be performed at any age. If a skin incision is not required, the procedure can also be performed using minimally invasive skin stitches without an incision, although the recurrence rate is somewhat higher.

Follow-up treatment

Rest for 2-3 days, then the operated finger should and must be moved to avoid adhesions.

Tenosynovitis de Quervain corresponds to tendonitis in the first extensor tendon compartment. The inflammation causes crepitating (crunching) and pain, especially during the so-called Finkelstein test. This involves closing the fist around the thumb and tilting it towards the little finger. Pain occurs over the thumb side of the wrist.

Causes

Tendonitis is caused by overloading the thumb extensors and incorrect posture in the wrist. The swollen tendons due to the inflammation become irritated in the narrow channel of the first extensor tendon compartment on the wrist. This is where the inflammation causes pain and crunching phenomena.

The reason for the tendonitis is overloading of the thumb extensors and incorrect posture in the wrist. The tendons, which are swollen due to the inflammation, become irritated in the narrow channel of the first extensor tendon compartment in the wrist. This is where the inflammation causes pain and crunching phenomena.

Signs and symptoms

The pain over the thumb side of the wrist can occur suddenly or develop slowly. It can spread to the elbow. Sometimes swelling of the affected area is also observed.

If no treatment is given, the inflammatory reaction continues. The inflammation causes a nodule to form in the tendon and sometimes causes the thumb to snap. The function of the nerve located above the extensor tendon compartment can be impaired, resulting in loss of sensation over the extensor side of the thumb.

Treatment

As long as the symptoms are not yet pronounced, conservative anti-inflammatory therapy can be promising. This includes cooling, immobilization in a splint and medication. In more severe cases, cortisone infiltration is possible. If the symptoms are severe or conservative treatment has been unsuccessful, surgery is recommended. During the operation, the first extensor tendon compartment is split while protecting the nerve.

Follow-up treatment

As a rule, movement exercises should be started 1-2 days after the operation.
Please also refer to the information sheet "Follow-up treatment for outpatient hand operations".