Hand Surgery

What is it?

A fracture of the distal phalanx of the finger beneath the nail.

What is the cause?

• crush injury
• axial trauma eg hit by a netball

What are the symptoms?

• pain
• subungual haematoma (bleed under the nail)
• deformity

What are the treatment options?

• tuft fracture – small distal crush fracture. Hand therapy splint for 3 weeks.
• undisplaced fracture – hand therapy splint for 3-4 weeks.
• displaced fracture – may need surgery and a temporary pin (K-wire)

When should I see a Surgeon?

• all fractures require a surgical review

What is it?

A fracture of the middle phalanx of the finger between the first (PIP joint) and second finger joints (DIP joints).

What is the cause?

• crush injury
• axial trauma eg hit by a netball
• twisting rotational trauma eg football tackle

What are the symptoms?

• pain
• deformity
• loss of movement

What are the treatment options?

• undisplaced fracture – hand therapy splint or buddy tape for 3-4 weeks.
• displaced fracture – may need surgery

When should I see a Surgeon?

• all fractures require a surgical review

What is it?

A fracture of the proximal phalanx of the finger between the knuckle (MCP joint) and the first finger joint (PIP joint).

What is the cause?

• crush injury
• twisting rotational trauma eg football tackle

What are the symptoms?

• pain
• deformity
• loss of movement

What are the treatment options?

• undisplaced fracture – hand therapy splint or buddy tape for 3-4 weeks.
• displaced fracture – may need surgery

When should I see a Surgeon?

• all fractures require a surgical review

What is it?

A fracture of one of the five main hand bones.

What is the cause?

• axial load (eg punch injury)
• direct trauma

What are the symptoms?

• pain
• deformity
• loss of movement

What are the treatment options?

• undisplaced fracture – hand therapy splint for 3-4 weeks.
• displaced fracture – may need surgery

When should I see a Surgeon?

• all fractures require a surgical review

What is it?

A fracture of the growing part of a bone.

What is the cause?

• axial load (it is the weakest part of the bone)
• forced radial or ulna deviation

What are the symptoms?

• pain
• deformity
• loss of movement

What are the treatment options?

• undisplaced fracture – immobilisation
• displaced fracture – may need surgery

When should I see a Surgeon?

• all fractures require a surgical review

What is it?

Hyperextension of the finger, usually at the proximal interphalangeal joint.  This may be associated with subluxation (partial joint dislocation), or complete dislocation. Three stabilising structures of the interphalangeal joint are progressively injured: the volar plate; radial collateral ligament; and ulna collateral ligament.

What is the cause?

• a fall on an outstretched hand, hyperextending the fingers
• axial load on the finger eg a ball forcing the finger backwards

What are the symptoms?

• pain, particularly over the palmar side of the joint
• subluxation or dislocation will cause deformity and loss of movement

What are the treatment options?

• reduction of a dislocation can usually be achieved in the Emergency Department
• stable injuries – sometimes require a hand therapy splint
• unstable injuries – always require a hand therapy splint
• fractures – sometimes need an operation

When should I see a Surgeon?

• if the joint cannot be reduced immediately
• if there is a fracture

What is it?

A crush injury to the tip of the finger results in a tear of the pale pink nailbed (sterile matrix), beneath the nail.  An accumulation of blood develops under the nail (subungual haematoma).  The injury is often associated with a small fracture of the distal phalanx (tuft fracture).

What is the cause?

• crush injury eg crushed in a car door or hit with a hammer

What are the symptoms?

• pain
• subungual haematoma
• partial or complete nail avulsion

What are the treatment options?

• no treatment – small subungual haematoma < 25% of nail area
• trephine (pinhole to drain the accumulated blood) – 25-50% of nail area (often performed in the Emergency Department)
• surgery – subungual haematoma > 50% of nail area or underlying fracture

When should I see a Surgeon?

• if there is a fracture
• subungual haematoma > 50% of the nail area
• if a patient has concerns about the future nail appearance. A nailbed laceration can heal with a gap or step due to scar tissue.  This can cause temporary or permanent ridging or changes to the overlying nail.

What is it?

An avulsion of the flexor tendon insertion onto the distal phalanx.  May be associated with a fracture.

What is the cause?

• forced hyperextension whilst gripping eg tackling a rugby player’s jersey

What are the symptoms?

• pain
• loss of flexion

What are the treatment options?

• surgery

When should I see a Surgeon?

• all flexor tendon avulsions require a surgical review

What is it?

An avulsion of the extensor tendon insertion onto the distal phalanx.  May be associated with a fracture.

What is the cause?

• hyperflexion of the distal interphalangeal joint

What are the symptoms?

• pain
• loss of finger extension (extensor lag)

What are the treatment options?

• pure tendon avulsion or small fracture – mallet (extension) splint for up to 8-12 weeks
• large fracture – may need surgery

When should I see a Surgeon?

• all mallet injuries require a surgical review

What is it?

Tendons are like ropes which flex and extend the wrist, hand, and fingers.  Sharp injuries such as a knife laceration commonly injure the tendons.  Partial tendon injuries can rupture with ongoing use.

What is the cause?

• laceration with sharp object eg a knife

What are the symptoms?

• pain
• loss of movement

What are the treatment options?

• open tendon injury – always needs surgery

When should I see a Surgeon?

• all tendon injuries require a surgical review

What is it?

A partial or complete tear of the ulna collateral ligament of the MCP joint of the thumb.  This ligament is important in stabilising the thumb during pinching.  The ligament injury may be associated with an avulsion fracture.

What is the cause?

• forced abduction of the thumb eg a ski pole being pulled out of the hand

What are the symptoms?

• pain
• instability

What are the treatment options?

• Partial tear – hand therapy splint for 6 weeks
• Complete tear, stable joint – hand therapy splint for 6 weeks
• Complete tear, unstable joint – surgery (open ligament repair)
• In some complete tears a Stener lesion occurs where the ulna collateral ligament is unable to heal back to its insertion. Surgery is always required with a Stener lesion.

When should I see a Surgeon?

• all UCL injuries require a surgical review

What is it?

Compression of the median nerve as it passes through the wrist (carpal tunnel).

What is the cause?

• Most are unknown (idiopathic)
• Some are related to conditions that increase the contents of the carpal tunnel eg pregnancy, thyroid disease, or inflammatory arthritis

What are the symptoms?

• MILD: Intermittent paraesthesia (pins and needles) or numbness in the thumb, index, and middle finger. Classically at night waking patients up
• MODERATE: Persistent numbness or paraesthesia
• SEVERE: Numbness and thumb weakness/ wasting

What are the treatment options?

• • MILD – night splints, activity modification. Non-urgent surgical review
  • MODERATE – surgery. Urgent surgical review
  • SEVERE – surgery. Urgent surgical review

When should I see a Surgeon?

• • • • all moderate and severe carpal tunnel requires surgical review

For more information click here

What is it?

Compression of the ulnar nerve at the elbow (cubital tunnel).

What is the cause?

• unknown (idiopathic)
• can be related to repeated pressure on medial elbow eg resting elbows on a desk at work

What are the symptoms?

• paraesthesia/ numbness in the little and ring fingers
• weakness of the small muscles of the hand

What are the treatment options?

• sensory symptoms only – hand therapy, lifestyle modification
• motor symptoms – surgery to release +/- transpose the ulnar nerve

When should I see a Surgeon?

• persistent sensory or motor symptoms

What is it?

Compression of the abductor pollicis longus and extensor pollicis brevis tendons within the 1^st extensor compartment.

What is the cause?

• overuse (wrist extension/ radial deviation)
• swelling of the extensor retinaculum

What are the symptoms?

• pain over the dorsal radial wrist and base of thumb

What are the treatment options?

• Step 1: rest, splint, Voltaren gel, NSAIDs
• Step 2: steroid injection
• Step 3: surgery

When should I see a Surgeon?

• symptoms persist after step 1

What is it?

A synovial cyst originating from the scapholunate ligament.

What is the cause?

• trauma
• incidental ganglions diagnosed on a CT or MRI are extremely common and most do not require any treatment

What are the symptoms?

• dorsal wrist swelling
• pain (note there are many causes of wrist pain and the ganglion may be incidental)

What are the treatment options?

• needle aspiration (+/- steroid injection) – high recurrence rate
• rupture cyst (hit it with a bible) – high recurrence rate
• surgery – excise cyst and debride scapholunate ligament

When should I see a Surgeon?

• if the cosmetic deformity or pain is bad enough to require surgery

What is it?

A ganglion arising from the distal interphalangeal joint.

What is the cause?

• osteophytes from osteoarthritis

What are the symptoms?

• grooved nail deformity
• swelling under the skin which may discharge clear mucin

What are the treatment options?

• surgery – excise the cyst (symptom), and debride the osteophytes (cause)

When should I see a Surgeon?

• if the cosmetic deformity is bad enough to warrant surgery
• if the cyst is draining through the skin or the skin is very thin over the cyst – there is a risk of septic arthritis of the distal interphalangeal joint if left untreated

What is it?

Synovial cyst originating from the tendon sheath.

What is the cause?

• idiopathic

What are the symptoms?

• lump
• pain

What are the treatment options?

• surgery – excise cyst and debride tendon sheath

When should I see a Surgeon?

• if the cosmetic deformity or pain is bad enough to require surgery

What is it?

Contracture of the palmar fascia between the skin and underlying flexor tendons.

What is the cause?

• genetic (northern European ancestry)

What are the symptoms?

• lumps, cords
• finger contracture
• other sites of contracture: dorsal fingers (Garrod’s pads), soles of feet (Ledderhose disease), and penis (Peyronie’s disease)

What are the treatment options?

• needle fasciotomy
• collagenase injections
• surgery

When should I see a Surgeon?

• when you are unable to place the fingers flat on the table
• when the finger flexion impairs function eg playing golf
• Dupuytren’s is incurable, so the aim of surgery is to make the fingers straight. Recurrence is expected.

For more information click here

What is it?

The flexor tendons are swollen and catch (trigger) in the tendon tunnel at the A1 pulley in the palm (site of maximum pain).

What is the cause?

• idiopathic
• more common in diabetics

What are the symptoms?

• pain
• clicking, triggering, and occasionally a locked digit in flexion

What are the treatment options?

• steroid injection (50% of patients have no symptoms at 12 months)
• surgery

When should I see a Surgeon?

• when it is bad enough to need a steroid injection or it’s causing functional impairment

What is it?

Autoimmune arthritis with synovitis

What is the cause?

• autoimmune
• psoriasis

What are the symptoms?

• hand and wrist pain
• swelling
• finger and wrist deformity

What are the treatment options?

• medical therapy (immunosuppression): directed by a Rheumatologist
• surgery (when failing medical treatment)

When should I see a Surgeon?

• when directed to by a Rheumatologist

What is it?

The cartilage articular surfaces of the joints erode away, and the underlying bony surfaces come into contact.

What is the cause?

• trauma
• genetic
• age

What are the symptoms?

• pain
• bony lumps (osteophytes) around the distal and proximal interphalangeal joints

What are the treatment options?

• “the aim is to manage the pain in the simplest possible way”
• Step 1: rest, activity modification, splints, Voltaren gel, NSAIDs
• Step 2: steroid injection
• Step 3: surgery
  • joint fusion (arthrodesis): (the downside is loss of mobility)
  • joint replacement (arthroplasty): (the downside is loss of stability)

When should I see a Surgeon?

• when the pain recurs after Step 1

What is it?

The cartilage articular surfaces of the joints erode away, and the underlying bony surfaces come into contact

What is the cause?

• trauma
• genetic
• age

What are the symptoms?

• pain
• squaring off at the base of the thumb

What are the treatment options?

• “the aim is to manage the pain in the simplest possible way”
• Step 1: rest, activity modification, splints, Voltaren gel, NSAIDs
• Step 2: steroid injection
• Step 3: surgery
  • trapeziectomy: (downside is loss of stability)
  • CMC joint fusion (arthrodesis): (downside is loss of mobility)

When should I see a Surgeon?

when the pain recurs after Step 1