Congenital anomalies are hand or finger deformities that are present at birth. Any type of deformity in a newborn can become a challenge for the child as he or she grows. Hand deformities can be particularly disabling as the child learns to interact with the environment through the use of his or her hands. The degree of deformity varies from a minor deformity, such as unequal or uneven fingers or thumb deformity, to a severe deformity, such as total absence of a bone.
What are the different types of congenital hand deformities?
The classifications for hand deformities can vary. There are currently 7 groups of deformities of the hand:
PROBLEMS IN FORMATION OF THE PART This occurs when parts of the body stop developing while the baby is in the womb. This causes either a complete absence of a part of the body, such as the hand, or a missing structure, such as part of the arm bone. In the case of the complete missing part, surgery is not done. Instead, these children may get a prosthetic devices early in their childhood. Types of these classification include:
Radial clubhand. A radial clubhand is a deformity that involves all of the tissues on the thumb side (radial side) of the forearm and hand. There may be shortening of the bone, a small thumb, or absence of the thumb. Deformities of the wrist are usually operated on around 6 months of age.
Ulnar clubhand. An ulnar clubhand is less common than a radial clubhand. This deformity may involve underdevelopment of the ulnar bone (the bone in the forearm on the side of the little finger), or complete absence of the bone.
FAILURE OF PARTS OF THE HAND TO SEPARATE
With this type of deformity, the parts of the hand, either the bones or the tissues, fail to separate in the womb. The most common type of this classification is syndactyly. Syndactyly is when 2 or more fingers are fused together. There is a familial tendency to develop this deformity. If the fingers are completely fused together, it is considered complete.
There are 2 types of syndactyly:
Simple syndactyly. This involves fusion between only the tissues of the fingers.
Complex syndactyly. This involves fusion between the bones.
Another example of failure of the hand to separate is seen in contractures of the hand. Contractures of the hand may also develop as a result of a problem with the cells in the womb. A contracture is an abnormal pulling forward of the fingers of the hand. It is usually caused by problems with the muscles or skin. One of the common types of this classification includes congenital triggering. Congenital triggering occurs when one of the fingers is unable to extend.
It is usually seen in the thumb. It may take some time in the child’s development before it is noted that the child can’t extend the thumb. Some of these cases improve on their own. Surgery is usually not done until the second year of life, but preferably before the age of 3.
DUPLICATION OF FINGERS Duplication of fingers is also known as polydactyly. The little finger is the finger that is most often affected.
UNDERGROWTH OF FINGERS
Underdeveloped fingers or thumbs are associated with many congenital hand deformities. Surgical treatment is not always required to correct these deformities. Underdeveloped fingers may include the following:
The finger is small
Muscles are missing
Bones are underdeveloped or missing
There is complete absence of a finger
OVERGROWTH OF FINGERS
Overgrowth of fingers is also known as macrodactyly, which causes an abnormally large finger. In this situation, the hand and the forearm may also be involved. In this rare condition, all parts of the finger (or thumb) are affected; however, in most cases, only one finger is involved (usually the index finger). Surgical treatment of this condition is complex and the outcomes may be less than desirable. Sometimes, amputation of the enlarged finger is recommended.
CONGENITAL CONSTRICTION BAND SYNDROME
This occurs when a tissue band forms around a finger or arm, causing problems that can affect blood flow and normal growth. Ring constrictions are congenital (present at birth). This condition may be associated with other birth defects, such as clubfoot, cleft lip, or cleft palate. The cause of the ring constrictions is unknown. Some theories suggest that amniotic banding may lead to ring constrictions around a finger or limb. In a few cases, the finger may need to be amputated.
OTHER GENERALIZED PROBLEMS WITH THE SKELETAL SYSTEM
These are a rare and complex group of problems.
Treatment for congenital hand deformities
Specific treatment for congenital hand deformities will be determined by your child’s doctor based on:
Your child’s age, overall health, and medical history
Extent of the condition
Cause of the condition
Your child’s tolerance for specific medications, procedures, or therapies
Expectations for the course of the condition
Your opinion or preference
Treatment may include:
Limb manipulation and stretching
Splinting of the affected limbs
External appliances (to help realign misshapen fingers or hands)
Physical therapy (to help increase the strength and function of the hand)
Correction of contractures
Skin grafts. These involve replacing or attaching skin to a part of the hand that is missing skin or has been removed during a procedure.
Prosthetics. These may be used when surgery is not an option, or in addition to surgical correction.
Wounds And Infections
A wound is a type of injury which happens relatively quickly in which skin is torn, cut, or punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound).
Wounds can be classified according to causal mechanism in:
Most wounds are accidental. Some wounds are intentional (as a result of aggression or, less frequently, self-aggression); surgical wounds are also intentional wounds.
Local wound treatment includes wound cleaning, hemostasis, debridement, suturing, drainage and dressing. Local anesthesia is often required to perform these therapeutic measures.
Suturing is practiced to speed up wound healing (primary healing). However, the maneuver is indicated only in the case of uncontaminated or low-contamination wounds. Suturing contaminated wounds would create conditions for bacteria to develop and lead to an abscess; this would determine the dehiscence of the wound or the therapeutic opening of the suture to evacuate the pus.
The dressing consists of isolating the wound with sterile materials (usually gauze bandage) to reduce exogenous contamination with microbial germs.
Postoperative recovery: Removal of sutures is performed after 2 weeks, during which time the patient must strictly follow the recommendations established by the surgeon.
Hand infections are common. They can affect patients of all ages. There are multiple types and causes of infections. Therefore, the treatment of these infections varies. It is important to recognize that long-term complications from hand infections can occur. The unfortunate ongoing problems may occur even with proper and rapid treatment.
Hand infections can be:
localized – panarithium, abscess
diffuse, extensive – phlegmon, tenosynovitis.
The complexity of the cases with infections determined individualized therapeutic approaches (ranging from simple incision – debridement, to serial resections with resection – reconstructive character).
Any infection begins with an inflammatory phase (characterized by edema, hyperemia, local hyperthermia, pain), in this phase goes to conservative treatment – broad-spectrum antibiotic treatment, anti-inflammatory, analgesic, sedative, alcoholic dressings and immobilization of the hand.
In case of maintaining the initial symptomatology, specialized surgical treatment is recommended.
Post-traumatic And Post-combustion Sequelae
POST-COMBUSTION SEQUELAE Surgery applies to patients whose burn injury has been completely healed.
The purpose of reconstructive surgery in these patients is to improve both the functionality and aesthetics of the area affected by the existence of post-combustion scars. This involves the modification of scar tissue by both non-surgical and surgical methods.
The treatment of post-combustion scar tissue must be applied for several months to be beneficial, it is good to mention the possibility of recurrence of new scar contracture resulting from a post-combustion accident, despite extremely efficient treatment, especially in young patients who have deep burns and on a large surface.
The ideal patients are those who realize that their scars cannot disappear completely, that only an improvement of the functionality of the respective area and of its aesthetic aspect can be achieved. If the scar contracture limits the active mobility at the level of the neck, hands or feet, the surgical relaxation of the scar results in a real benefit.
Surgical methods refer to scars’ release by Z-plasty, the closure of skin defects by grafting with free split skin graft or in complex cases with flaps.
Non-surgical methods refer to scar massage, wearing elastic buttocks (pressure therapy), using local topics, using scar injections with specific substances, physiotherapy on burned hands.
Communication is crucial in achieving goals, patients need to be informed about what should be expected from these surgeries in both: short and long term.
Each patient is different from the others, he is unique and that is why the surgeon will have to choose a specific therapeutic plan for each one, depending on the medical complexity of each one.
Reconstruction of the malformed nail matrix (ingrown nail) in order to avoid finger infections and recurrence.
Surgical treatment of ingrown nails involves:
Removal of granulation tissue;
Excision of the ingrown nail;
Excision of the malformed nail matrix;
The surgery is performed with local anesthesia, lasts about 30 minutes, the patient being discharged on same day.
The first stage of the surgery consists in removing the infected tissue from the nail fold, and then the ingrown nail fragment is excised (DO NOT REMOVE THE NAIL FULLY). Recurrence’s prophylaxis is achieved by extracting the germinal nail matrix, which is the main cause of ingrown nails. Postoperatively, the patient can resume daily activity, avoiding prolonged orthostatism as much as possible.
NAIL BED INJURY SURGERY
Nail bed injuries are the result of direct trauma to the fingertip.
When your fingertip or your nail bed is pinched, crushed, or cut, it causes a nail bed injury.
Crushing can happen when your finger gets caught between two objects or in a doorway. Heavy objects falling on your finger can also cause injuries to the nail bed, as can being hit by a hammer.
Cuts to your fingertip, nail bed, or the tendons that you use to straighten and bend your fingertip can all cause nail bed injuries. Cuts to nerve endings in your fingertip can also cause nail bed injuries.
There are many types of nail bed injuries, including:
Nail bed laceration
Nail bed avulsion
Open fingertipfractures/ amputations with nail bed injury
Nail bed repair
Repairing a nail bed injury will differ depending on the type of injury. If your injury is serious, your doctor might take an X-ray to check for broken bones. You may also get anesthesia so your doctor can look at your nail more closely and treat your injury without causing more pain.
Many injuries to your nail bed can be fully repaired. For example, your nail should return to normal after a subungual hematoma is drained. However, some severe injuries can lead to a deformed nail. This is more likely when the base of your nail bed is injured.
The most common complications of nail bed injuries are hook nail and a split nail. A hook nail occurs when your nail doesn’t have enough bony support and curves around your finger. It can be treated by removing your nail and trimming some of the nail matrix, which is the tissue your nail rests on.
A split nail happens because your nail can’t grow over scar tissue. It’s treated by removing the nail that’s already grown and treating or removing the scar so new nail can grow properly.
If all or part of your nail is removed, it will grow back. It takes approximately a week for a fingernail to start growing back and three to six months for it to totally grow back. After the nail’s removed, you’ll need to keep your fingertip covered while your nail starts to grow back.
If any of the tendons in your hand are damaged, surgery may be needed to repair them and help restore movement to the affected fingers or thumb.
Whar are tendons?
Tendons are the tough fibers that connect muscle to bone. When a group of muscles contracts (tightens), the attached tendons will pull certain bones, allowing you to make a wide range of movements.
There are 2 groups of tendons in the hand:
extensor tendons – running from the forearm on the back of the hand to the fingers and thumb, allowing you to straighten the fingers and thumb
flexor tendons – that run from your forearm through your wrist and palm, allowing you to bend your fingers
Surgery can often be performed to repair damage to both tendon groups.
When is it necessary to repair the hand’s tendons ?
Repair of the tendons of the hands is performed when one or more tendons in your hand break or are cut, which leads to the loss of normal hand movements.
If the extensor tendons are damaged, you will not be able to straighten one or more fingers.
If the flexor tendons are damaged, you will not be able to bend one or more fingers.
Damage to the tendons can also cause pain and inflammation (swelling) in your hand.
In some cases, damage to the extensor tendons can be treated without the need for surgery, using a rigid support called a spur that is worn around the hand.
Common causes of tendon injuries include:
cuts – cuts in the back or palm of the hand can damage the tendons
sports injuries – extensor tendons can rupture when a finger is stuck, such as trying to catch a ball; Sometimes the flexor tendons can be pulled off the bone when you grab an opponent’s shirt, such as in rugby; and pulleys with flexor tendons may rupture during activities involving intense grip, such as mountaineering
bites – animal and human bites can cause tendon damage and a person can damage the tendon of the hand after hitting another person in the teeth
Crush Wounds – Locking a finger in a door or crushing a hand in a car accident can split or rupture a tendon
rheumatoid arthritis – rheumatoid arthritis can cause the tendons to become inflamed, which can lead to tendon cracking in severe cases
Tendon repair surgery
Tendon repair may involve the surgeon making a cut (incision) in the wrist, hand, or finger so that they can locate the ends of the split tendon and join them.
Extension tendons are more easily accessible, so their repair is relatively simple.
Depending on the type of injury, it may be possible to repair tendon extensors in an emergency department and with the help of a local anesthetic to cushion the affected area.
Flexor tendon repair is more difficult because the flexor tendon system is more complex.
Restoration of the flexor tendons should usually be performed either under general anesthesia or under regional anesthesia (where the entire arm is braced) in an operating room by an experienced plastic or orthopedic surgeon who specializes in hand surgery.
Both types of tendon surgery require a long period of recovery (rehabilitation), as the repaired tendons will be weak until the ends heal together.
Depending on the location of the injury, it may take up to 3 months for the repaired tendon to regain its previous strength.
Rehabilitation involves protecting your tendons from overuse by using a hand funnel. You will usually need to wear a hand-held funnel for a few weeks after surgery.
You will also need to perform hand exercises regularly during your recovery to stop the repaired tendons from sticking to nearby tissue, which can prevent you from being able to fully move your hand.
When you can return to work will depend on the job. Light activities can often be resumed after 6 to 8 weeks, and heavy activities and sports after 10 to 12 weeks.
After a restoration of the extensor tendon, you should have a finger or working finger, but you may not regain full movement.
The result is often better when the injury is a clean cut of the tendon, rather than one that involves crushing or damaging bones and joints.
An injury to the flexor tendon is generally more serious because they are often subjected to more tension than the extensor tendons.
After a restoration of the flexor tendons, it is quite common for some fingers not to regain full movement. But tendon repair will still give a better result than not being operated on.
In some cases, complications occur after surgery, such as infection or the repaired tendon attaching or sticking to nearby tissue.
Under these conditions, additional treatment may be required.
Trigger fingeris a condition in which one of your fingers gets stuck in a bent position. Your finger may bend or straighten with a snap — like a trigger being pulled and released.
Trigger finger is also known as stenosing tenosynovitis. It occurs when inflammation narrows the space within the sheath that surrounds the tendon in the affected finger. If trigger finger is severe, your finger may become locked in a bent position.
People whose work or hobbies require repetitive gripping actions are at higher risk of developing trigger finger. The condition is also more common in women and in anyone with diabetes. Treatment of trigger finger varies depending on the severity.
Trigger finger occurs when the affected finger’s tendon sheath becomes irritated and inflamed. This interferes with the normal gliding motion of the tendon through the sheath.
Prolonged irritation of the tendon sheath can produce scarring, thickening and the formation of bumps (nodules) in the tendon that impede the tendon’s motion even more.
Factors that put you at risk of developing trigger finger include:
Repeated gripping. Occupations and hobbies that involve repetitive hand use and prolonged gripping may increase your risk of trigger finger.
Certain health problems. People who have diabetes or rheumatoid arthritis are at higher risk of developing trigger finger.
Your sex. Trigger finger is more common in women.
Carpal tunnel syndrome surgery. Trigger finger may be a complication associated with surgery for carpal tunnel syndrome surgery, especially during the first six months after surgery.
Trigger finger treatment varies depending on its severity and duration.
Conservative noninvasive treatments may include:
Rest. Avoid activities that require repetitive gripping, repeated grasping or the prolonged use of vibrating hand-held machinery until your symptoms improve. If you can’t avoid these activities altogether, padded gloves may offer some protection.
A splint. Your doctor may have you wear a splint at night to keep the affected finger in an extended position for up to six weeks. The splint helps rest the tendon.
Stretching exercises. Your doctor may also suggest gentle exercises to help maintain mobility in your finger.
Surgical and other procedures
If your symptoms are severe or if conservative treatments haven’t helped, your doctor might suggest:
Steroid injection. An injection of a steroid medication near or into the tendon sheath may reduce inflammation and allow the tendon to glide freely again. This is the most common treatment, and it’s usually effective for a year or more in most people treated. But sometimes it takes more than one injection.
For people with diabetes, steroid injections tend to be less effective.
Percutaneous release. After numbing your palm, your doctor inserts a sturdy needle into the tissue around your affected tendon. Moving the needle and your finger helps break apart the constriction that’s blocking the smooth motion of the tendon.
This treatment may be done under ultrasound control, so the doctor can see where the tip of the needle is under the skin to be sure it opens the tendon sheath without damaging the tendon or nearby nerves. This procedure is usually done in the doctor’s office or in an office procedure room.
Surgery. Working through a small incision near the base of your affected finger, a surgeon can cut open the constricted section of tendon sheath. This procedure is usually done in an operating room.
Recovery after finger surgery in the spring is very fast with regaining the functionality of the fully affected finger.
The delay of the specialized medical consultation and therefore of the adequate treatment leads to the appearance of some irreversible injuries at the level of the spines and tendons that make impossible the total recovery of the finger functionality.
De Quervain’s tenosynovitis
De Quervain’s tenosynovitis is a painful condition affecting the tendons on the thumb side of your wrist. If you have de Quervain’s tenosynovitis, it will probably hurt when you turn your wrist, grasp anything or make a fist.
Although the exact cause of de Quervain’s tenosynovitis isn’t known, any activity that relies on repetitive hand or wrist movement — such as working in the garden, playing golf or racket sports, or lifting your baby — can make it worse.
Treatment for de Quervain’s tenosynovitis is aimed at reducing inflammation, preserving movement in the thumb and preventing recurrence.
If you start treatment early, your symptoms should improve within four to six weeks. If your de Quervain’s tenosynovitis starts during pregnancy, symptoms are likely to end around the end of either pregnancy or breast-feeding.
Initial treatment of de Quervain’s tenosynovitis may include:
Immobilizing your thumb and wrist, keeping them straight with a splint or brace to help rest your tendons
Avoiding repetitive thumb movements as much as possible
Avoiding pinching with your thumb when moving your wrist from side to side
Applying ice to the affected area
If your case is more serious, your doctor may recommend outpatient surgery. Surgery involves a procedure in which your doctor inspects the sheath surrounding the involved tendon or tendons, and then opens the sheath to release the pressure so your tendons can glide freely.
Your doctor will talk to you about how to rest, strengthen and rehabilitate your body after surgery. A physical or occupational therapist may meet with you after surgery to teach you new strengthening exercises and help you adjust your daily routine to prevent future problems.
A mallet finger is a deformity of the finger. It occurs when the tendon that straightens the finger (the extensor tendon) is damaged at the fingertip. This can commonly happen when an object (like a ball) strikes the tip of the finger or thumb. It can also happen when forceful bending of the fingertip occurs. This force tears the tendon at the back of the finger (the tendon that straightens the finger)
Most mallet finger injuries (in both adults and children) can be treated without surgery. They can initially be treated with splinting. A cold treatment (ice) should be applied immediately, and the hand should be elevated (fingers toward the ceiling.) A tongue depressor or a clean popsicle stick can be taped to the finger to keep it straight.
Surgery may be considered when a mallet finger injury has a large bone fragment or the joint is not properly aligned. In these cases, wires or small screws are used to realign the joint (see Figure 4). Surgery may also be considered if wearing a splint is difficult or was not previously successful. Surgery may involve applying a wire in the finger to keep it straight, stitching the tendon together or making a new tendon, or fusing the joint so it stays straight. Your hand surgeon will help recommend the proper treatment that is specific to you.
Peripheral Nerve Injuries
Peripheral nerves send messages from your brain and spinal cord to the rest of your body, helping you do things such as sensing that your feet are cold and moving your muscles so that you can walk. Made of fibers called axons that are insulated by surrounding tissues, peripheral nerves are fragile and easily damaged.
A nerve injury can affect your brain’s ability to communicate with your muscles and organs. Damage to the peripheral nerves is called peripheral neuropathy.
It’s important to get medical care for a peripheral nerve injury as soon as possible. Early diagnosis and treatment may prevent complications and permanent damage.
With a peripheral nerve injury, you may experience symptoms that range from mild to seriously limiting your daily activities. Your symptoms often depend on which nerve fibers are affected:
Motor nerves. These nerves regulate all the muscles under your conscious control, such as walking, talking, and holding objects. Damage to these nerves is typically associated with muscle weakness, painful cramps and uncontrollable muscle twitching.
Sensory nerves. Because these nerves relay information about touch, temperature and pain, you may experience a variety of symptoms. These include numbness or tingling in your hands or feet. You may have trouble sensing pain or changes in temperature, walking, keeping your balance with your eyes closed or fastening buttons.
Autonomic (aw-tu-NOM-ik) nerves. This group of nerves regulates activities that are not controlled consciously, such as breathing, heart and thyroid function, and digesting food. Symptoms may include excessive sweating, changes in blood pressure, the inability to tolerate heat and gastrointestinal symptoms.
You may experience a range of symptoms because many peripheral nerve injuries affect more than one type of nerve fibers.
When to see a doctor
If you experience weakness, tingling, numbness or a total loss of feeling in a limb, see your doctor to determine the cause. It’s important to treat peripheral nerve injuries early.
Peripheral nerves can be damaged in several ways:
Injury from an accident, a fall or sports can stretch, compress, crush or cut nerves.
Medical conditions, such as diabetes, Guillain-Barre syndrome and carpal tunnel syndrome.
Autoimmune diseases including lupus, rheumatoid arthritis and Sjogren’s syndrome.
Other causes include narrowing of the arteries, hormonal imbalances and tumors.
Your doctor will review your medical history, ask about any accidents or previous surgeries, and discuss your symptoms with you. Your doctor will also conduct a physical and neurological examination. If your neurological examination shows signs of a nerve injury, your doctor may recommend diagnostic tests, which may include:
Electromyography (EMG). In an EMG, a thin-needle electrode inserted into your muscle records your muscle’s electrical activity at rest and in motion. Reduced muscle activity can indicate nerve injury.
Nerve conduction study. Electrodes placed at two different points in your body measure how well electrical signals pass through the nerves.
Magnetic resonance imaging (MRI). MRI uses a magnetic field and radio waves to produce detailed images of the area affected by nerve damage.
If a nerve is injured but not cut, your injury is more likely to heal. Injuries in which the nerve has been completely severed are very difficult to treat and recovery may not be possible.
Your doctor will determine your treatment based on the extent and cause of your injury and how well the nerve is healing.
If your nerve is healing properly, you may not need surgery. You may need to rest the affected area until it’s healed. Nerves recover slowly and maximal recovery may take many months or several years.
You’ll need regular checkups to make sure your recovery stays on track.
If your injury is caused by a medical condition, your doctor will treat the underlying condition.
Depending on the type and severity of your nerve injury, you may need medications such as aspirin or ibuprofen (Advil, Motrin IB, others) to relieve your pain. Medications used to treat depression, seizures or insomnia may be used to relieve nerve pain. In some cases, you may need corticosteroid injections for pain relief.
Your doctor may recommend physical therapy to prevent stiffness and restore function.
Sometimes a nerve sits inside a tight space (similar to a tunnel) or is squeezed by scarring. In these cases, your surgeon may enlarge the tight space or free the nerve from the scar.
Sometimes a section of a nerve is cut completely or damaged beyond repair. Your surgeon can remove the damaged section and reconnect healthy nerve ends (nerve repair) or implant a piece of nerve from another part of your body (nerve graft). These procedures can help your nerves to regrow.
If you have a particularly severe nerve injury, your doctor may suggest surgery to restore function to critical muscles by transferring tendons from one muscle to another.
A number of treatments can help restore function to the affected muscles.
Braces or splints. These devices keep the affected limb, fingers, hand or foot in the proper position to improve muscle function.
Electrical stimulator. Stimulators can activate muscle served by an injured nerve while the nerve regrows. However, this treatment may not be effective for everyone. Your doctor will discuss electrical stimulation with you if it’s an option.
Physical therapy. Therapy involves specific movements or exercises to keep your affected muscles and joints active. Physical therapy can prevent stiffness and help restore function and feeling.
Exercise. Exercise can help improve your muscle strength, maintain your range of motion and reduce muscle cramps.
Bone Tumors Surgery
The diagnosis and treatment of bone tumors requires a multidisciplinary approach, which involves the close collaboration of a team of physicians from different medical specialties.
There are numerous studies showing that early detection of tumors and multidisciplinary therapeutic approach to cases could improve outcomes and chances of survival in patients with bone tumors.
The management of a bone tumor depends on several factors, such as the type, size and stage of the tumor, family history and the presence or absence of a genetic predisposition. In general, most benign bone tumors are kept under observation, while surgical treatment is the main therapeutic approach for malignant bone tumors. Ideally, however, each suspected case of bone tumor should be evaluated by an oncology commission (Tumor Board), which establishes an order and priority in the recommended treatments.
The main symptom of a primary bone tumor is pain, pain that is not usually associated with movement and physical exertion and that manifests itself especially at night. As the tumor grows, a mass of tissue (nodule) may be visible or palpable, and a disturbance of local circulation or local sensitivity may occur in a particular area – lower limb (foot) or upper limb (hand). Also, another sign associated with bone tumors is the functional deficits, the inability to do certain things, installed relatively suddenly, within one or two months, compared to the functional deficits associated with osteoarthritis that sets in in a few years.
Regarding the accurate determination of the diagnosis of a bone tumor, it is essential that the patient who reaches the doctor perform a series of imaging investigations. It starts with an X-ray, after which, depending on the type of tumor – bone or soft tissue tumor – a CT scan or MRI is performed, investigations that must be done to establish the differential diagnosis.
Surgery – the main option and rescue in most bone cancers
Most bone tumors are usually treated with surgery. And the type of surgery depends on the type of tumor, its stage and location.
When it comes to bone tumor surgery, there is a great emphasis on curative surgery, in the sense that surgeons opt for surgery that allows them to remove as much or completely of the tumor.
We have the surgical techniques currently used in the world in the treatment of bone cancers: classic tumor excision, about resections followed by stents with tumor reconstruction prostheses.
As for benign bone tumors, the vast majority of them – chondromas, solitary bone cysts, nonosifying syndrome – are life-threatening tumors. Therefore, some benign tumors need to be monitored and supervised.
However, there are also benign bone tumors that require surgery. For example, a myeloplaxis tumor or a giant cell tumor that is theoretically a bordeline tumor that has the potential for malignancy and can lead to complications. Giant bone cysts or aneurysmal cysts can also lead to bone fractures and affect quality of life.
Ganglion cysts are noncancerous lumps that most commonly develop along the tendons or joints of your wrists or hands. They also may occur in the ankles and feet. Ganglion cysts are typically round or oval and are filled with a jellylike fluid.
Small ganglion cysts can be pea-sized, while larger ones can be around an inch (2.5 centimeters) in diameter. Ganglion cysts can be painful if they press on a nearby nerve. Their location can sometimes interfere with joint movement.
If your ganglion cyst is causing you problems, your doctor may suggest trying to drain the cyst with a needle. Removing the cyst surgically also is an option. But if you have no symptoms, no treatment is necessary. In many cases, the cysts go away on their own.
The lumps associated with ganglion cysts can be characterized by:
Location. Ganglion cysts most commonly develop along the tendons or joints of your wrists or hands. The next most common locations are the ankles and feet. These cysts can occur near other joints as well.
Shape and size. Ganglion cysts are round or oval and usually measure less than an inch (2.5 centimeters) in diameter. Some are so small that they can’t be felt. The size of a cyst can fluctuate, often getting larger when you use that joint for repetitive motions.
Pain. Ganglion cysts usually are painless. But if a cyst presses on a nerve — even if the cyst is too small to form a noticeable lump — it can cause pain, tingling, numbness or muscle weakness.
Factors that may increase your risk of ganglion cysts include:
Your sex and age. Ganglion cysts can develop in anyone, but they most commonly occur in women between the ages of 20 and 40.
Osteoarthritis. People who have wear-and-tear arthritis in the finger joints closest to their fingernails are at higher risk of developing ganglion cysts near those joints.
Joint or tendon injury. Joints or tendons that have been injured in the past are more likely to develop ganglion cysts.
During the physical exam, your doctor may apply pressure to the cyst to test for tenderness or discomfort. He or she may try to shine a light through the cyst to determine if it’s a solid mass or filled with fluid.
Your doctor might also recommend imaging tests — such as X-rays, ultrasound or magnetic resonance imaging (MRI) — to rule out other conditions, such as arthritis or a tumor. MRIs and ultrasounds also can locate hidden (occult) cysts.
Ganglion cysts are often painless, requiring no treatment. Your doctor may suggest a watch-and-wait approach. If the cyst is causing pain or interfering with joint movement, your doctor may recommend:
Immobilization. Because activity can cause the ganglion cyst to get larger, it may help to temporarily immobilize the area with a brace or splint. As the cyst shrinks, it may release the pressure on your nerves, relieving pain. Avoid long-term use of a brace or splint, which can cause the nearby muscles to weaken.
Aspiration. In this procedure, your doctor uses a needle to drain the fluid from the cyst. The cyst may recur.
Surgery. This may be an option if other approaches haven’t worked. During this procedure, the doctor removes the cyst and the stalk that attaches it to the joint or tendon. Rarely, the surgery can injure the surrounding nerves, blood vessels or tendons. And the cyst can recur, even after surgery.
Dupuytren’s contracture is a hand deformity that usually develops over years. The condition affects a layer of tissue that lies under the skin of your palm. Knots of tissue form under the skin — eventually creating a thick cord that can pull one or more fingers into a bent position.
The affected fingers can’t be straightened completely, which can complicate everyday activities such as placing your hands in your pockets, putting on gloves or shaking hands.
Dupuytren’s contracture mainly affects the two fingers farthest from the thumb, and occurs most often in older men of Northern European descent. A number of treatments are available to slow the progression of Dupuytren’s contracture and relieve symptoms.
Dupuytren’s contracture typically progresses slowly, over years. The condition usually begins as a thickening of the skin on the palm of your hand. As it progresses, the skin on your palm might appear puckered or dimpled. A firm lump of tissue can form on your palm. This lump might be sensitive to the touch but usually isn’t painful.
In later stages of Dupuytren’s contracture, cords of tissue form under the skin on your palm and can extend up to your fingers. As these cords tighten, your fingers might be pulled toward your palm, sometimes severely.
The two fingers farthest from the thumb are most commonly affected, though the middle finger also can be involved. Only rarely are the thumb and index finger affected. Dupuytren’s contracture can occur in both hands, though one hand is usually affected more severely.
Doctors don’t know what causes Dupuytren’s contracture. There’s no evidence that hand injuries or occupations that involve vibrations to the hands cause the condition.
A number of factors are believed to increase your risk of the disease, including:
Age. Dupuytren’s contracture occurs most commonly after the age of 50.
Sex. Men are more likely to develop Dupuytren’s and to have more severe contractures than are women.
Ancestry. People of Northern European descent are at higher risk of the disease.
Family history. Dupuytren’s contracture often runs in families.
Tobacco and alcohol use. Smoking is associated with an increased risk of Dupuytren’s contracture, perhaps because of microscopic changes within blood vessels caused by smoking. Alcohol intake also is associated with Dupuytren’s.
Diabetes. People with diabetes are reported to have an increased risk of Dupuytren’s contracture.
Dupuytren’s contracture can make it difficult to perform certain functions using your hand. Since the thumb and index finger aren’t usually affected, many people don’t have much inconvenience or disability with fine motor activities such as writing. But as Dupuytren’s contracture progresses, it can limit your ability to fully open your hand, grasp large objects or to get your hand into narrow places.
If the disease progresses slowly, causes no pain and has little impact on your ability to use your hands for everyday tasks, you might not need treatment. Instead, you can wait and see if Dupuytren’s contracture progresses. You may wish to follow the progression with a tabletop test, which you can do on your own.
Treatment involves removing or breaking apart the cords that are pulling your fingers toward your palm. This can be done in several ways. The choice of procedure depends on the severity of your symptoms and other health problems you may have.
This technique uses a needle, inserted through your skin, to puncture and break the cord of tissue that’s contracting a finger. Contractures often recur but the procedure can be repeated.
The main advantages of the needling technique are that there is no incision, it can be done on several fingers at the same time, and usually very little physical therapy is needed afterward. The main disadvantage is that it can’t be used in some places in the finger because it could damage a nerve or tendon.
Injecting a type of enzyme into the taut cord in your palm can soften and weaken it — allowing your doctor to later manipulate your hand in an attempt to break the cord and straighten your fingers. The FDA has approved collagenase Clostridium histolyticum (Xiaflex) for this purpose. The advantages and disadvantages of the enzyme injection are similar to needling. Enzyme injections are not offered at all medical institutions.
Another option for people with advanced disease, limited function and progressing disease is to surgically remove the tissue in your palm affected by the disease. The main advantage to surgery is that it results in a more complete and longer-lasting release than that provided by the needle or enzyme methods. The main disadvantages are that physical therapy is usually needed after surgery, and recovery can take longer.
In some severe cases, especially if surgery has failed to correct the problem, surgeons remove all the tissue likely to be affected by Dupuytren’s contracture, including the attached skin. In these cases a skin graft is needed to cover the open wound. This surgery is the most invasive option and has the longest recovery time. People usually require months of intensive physical therapy afterward.
Upper Limb Lymphedema
Lymphedema is a condition characterized by painful swelling in the extremities (arms and/or legs). The swelling occurs when lymph nodes are no longer facilitating the proper drainage of lymph fluid from an area of the body. Primary lymphedema is a congenital condition; however, in the developed world, secondary lymphedema is the most common type of lymphedema. This condition may be caused by infection, trauma or, most commonly, treatment of cancer.
What causes lymphedema?
Lymphedema affects some cancer survivors who have been treated for breast cancer, gynecologic cancers, melanomas and other types of skin and urologic cancers. Lymphedema may impact cancer survivors on a daily basis and is a constant reminder of the disease that they have fought. The onset of symptoms may be delayed by months or even years after the initial injury.
There are a number of symptoms that affect patients with lymphedema that typically worsen over time:
Extremity swelling caused by lymphatic fluid
Change in skin quality such as skin fibrosis
Extremity tenderness or pain
Intermittent redness of the extremity, known as cellulitis
Excess fat in the extremity
Once the diagnosis of lymphedema is established, nonsurgical treatment is initiated as soon as possible including extremity elevation, skin care, elastic stockings, physical therapy and pneumatic compression devices. These treatments, although beneficial, can be burdensome to patients and require lifelong commitment. Surgery for lymphedema may be appropriate when nonsurgical therapy is inadequate to control the symptoms.
There are several options of surgical treatment for lymphedema:
Liposuction: Once lymphatic fluid spills into your surrounding tissues, it can cause inflammation and stimulate fat stem cells to grow. Your surgeon removes this extra fat caused by lymphedema. Liposuction for lymphedema is typically an outpatient procedure with a very short recovery time.
Lymphaticovenous anastomosis (also referred to as lymphovenous bypass): Your surgeon uses microsurgical techniques and equipment to reroute your lymphatic system, bypassing damaged nodes and connecting lymphatic channels directly into your veins. The lymphovenous bypass is an outpatient surgery. You can return to regular activity within a few days.
Vascularized lymph node transfer surgery (lymphovenous transplant): Your surgeon transplants a group of lymph nodes from a healthy part of your body to the affected area, effectively rewiring the lymphatic system. This is an inpatient procedure with a recovery time of a few days before resuming regular activity.
Charles procedure (skin grafts): Affected tissue is removed and your surgeon uses part of it as skin grafts to repair the area. Skin grafts require more extensive care of the surgical site after your procedure, and it can take up to one month to return to normal activity.
Surgical treatment options for lymphedema include Lymphatic Bypass Procedures, where lymphatic vessels are connected and drained into the body’s venous system and Vascularized Lymph Node Transfer, where lymph nodes are harvested from one part of the body and surgically implanted in the affected area to rebuild a failed system.
Who is a good candidate for lymphedema surgery?
You are able to cope well with your diagnosis and treatment
You do not have additional medical conditions or other illnesses that may impair healing
You have a positive outlook and realistic goals for restoring your extremity and body image
You have maximized all nonsurgical therapies for lymphedema
Although lymphedema surgery can improve the symptoms of lymphedema, the results are highly variable:
Visible incision lines will always be present on the extremity, depending on the type of procedure
Certain surgical techniques will leave incision lines at the donor site, commonly located in less exposed areas of the body such as the neck, abdomen or groin region.
What results should I expect after lymphedema surgery?
The long-term results of lymphedema surgery can help lessen the physical and emotional impact of lymphedema. Many patients experience reduction in extremity circumference or volume over several months after surgery. In addition, other symptoms such as extremity tightness and heaviness may improve after surgery. Aggressive nonsurgical therapies are advised after surgery to maintain the best outcomes, depending on the type of procedure performed. If the lymphedema improves, patients may gradually decrease their dependence on nonsurgical strategies. If lymphedema worsens, additional surgical interventions can be considered.
Revascularization Of The Hand
In most cases, your hands are seen and not heard. Each day you use your hands to perform numerous tasks, large and small. When they are healthy and functioning, you often take them for granted. However, should you experience pain or any other type of potentially debilitating problem, your life could prove far more challenging.
Occasionally, blood vessels might experience injury or damage. If such conditions are serious enough, proper circulation is disrupted, and your hands do not receive adequate blood supply. This is a serious health issue requiring specialized treatment. Fortunately, if these circumstances ever apply to you, a procedure known as hand revascularization might prove beneficial.
During hand revascularization, a skilled and experienced hand surgeon repairs damaged or injured blood vessels. The goal of the surgery is to fix damaged tissue and restore blood flow to as normal a level as possible.
CAUSES OF BLOOD VESSEL DAMAGE
A variety of factors can cause blood vessel damage. Injured hand blood vessels are often the result of a traumatic event, such as an automobile accident or a fall. These occurrences can result in serious emergencies, including torn blood vessels that need immediate repair. Significant damage to surrounding structures, like, bones, muscles, and soft tissues may ultimately impact nearby blood vessels.
Certain diseases also often lead to blood vessel damage. Issues, such as infections or immune system disorders, produce a condition known as inflammation. This problem typically causes the blood-carrying tubes to swell. Should you experience significant swelling, vessel walls can sustain damage. Moreover, illnesses like cancer can eat away at blood vessels as they advance.
Another vessel-damaging issue is high blood pressure. This condition places significant stress on blood-transporting channels and over time can lead to potentially serious damage.
Another problem common to blood vessels is obstruction. Obstruction, known also as blockage, occurs when some type of object or substance accumulates in large enough quantities to prevent normal blood flow.
Typically, blockages in blood vessels are caused by the buildup of a substance known as plaque. Plaque is made up of cholesterol and other potentially harmful bodily by-products. It is hard and sticky and attaches to vessel walls. If left unchecked, a buildup of plaque can eventually result in partial or complete blood flow interruption.
In many cases, elevated levels of plaque are the result of lifestyle choices, such as a poor diet and lack of exercise. However, if you have a family member with a history of high cholesterol, heart, or blood vessel diseases, you may also be at an increased risk of developing this condition.
SYMPTOMS OF DAMAGED BLOOD VESSELS
Symptoms of injured hand blood vessels vary depending upon the specific underlying problem and that condition’s severity. Common indications often include pain, movement difficulties, skin discoloration, in addition to tingling and numbness in the fingers. In the presence of an underlying illness, you might experience events, such as:
A general feeling of being unwell.
In cases of significant blockages, you might experience issues like coldness in the hands or fingers because adequate blood supply is not reaching the area.
Your Florida Orthopaedic Institute physician will first perform a thorough physical evaluation where they will likely perform tasks such as:
Measuring your vital statistics.
Asking about your personal and family’s medical history.
Examining your hand.
Inquiring about your lifestyle or if you had been in a traumatic event.
If your doctor suspects blood vessel problems are caused by a disease, you might need blood tests or other diagnostic tools designed to detect specific infections or diseases.
There are several different types of revascularization procedures. Your surgeon will consider which one is most appropriate for you after considering important factors, such as your age, general health, the specific underlying problem, and the damage’s severity.
SPECIFIC VASCULARIZATION PROCEDURES
Direct vascular suture. Sutures work by stitching together sides of a blood vessel and then tightening the stitch to pull open the lumen, or the inner part of the vessel, so the blood can flow through.
Bypass Surgery. During this procedure, your hand surgeon uses the portion of an existing blood vessel or creates an artificial structure called a graft to redirect blood flow away from the blocked channel.
Angioplasty. Your surgeon inflates a tiny balloon inside the blocked vessel to clear the obstruction and restore a normal degree of blood flow. In certain circumstances, your surgeon might additionally insert a stent, which is a metal object designed to ensure the vessel in question remains open and clear.
Atherectomy. Using a tiny device called a catheter fitted with a rotating blade or a laser, surgeons enter the blocked vessel to clear and remove obstructing materials.
HAND & FINGER REPLANTATION
Your hands are vital to almost all your everyday functions. You need them to execute practically every task. Without them, you would experience significant disability, and life would likely be far more challenging.
The hands are made up of finger bones, muscles, and a host of soft tissues, including joints, ligaments, and tendons. Also, your hands have blood carrying channels known as veins and arteries.
A partially or completely severed hand is a significant trauma. But with quick action and prompt evaluation followed by a treatment known as hand replantation, you might not only be able to have the severed feature reattached but regain a significant amount of strength and mobility.
Replantation is often performed to reposition severed hands or components like fingers or other separated tissues or structures.
In most cases, replantation is used following a traumatic injury, such as an automobile accident. Hands and fingers are often severed as the result of sharp, slashing actions or crushing.
The goal of reattachment is to not only replace the severed body part but attempt to restore all lost movement. Unfortunately not everyone will be a suitable candidate. Your Florida Orthopaedic Institute surgeon will determine your eligibility for replantation based upon your injury’s severity. Certain detached parts are simply too damaged to be attached.
If your doctor determines you are not a good candidate for replantation, there are other treatment options, such as prostheses insertion or revision amputation. A prosthesis is an artificially created finger or hand. During revision amputation, a surgeon might remove lingering tissue from the accident site to prevent potentially serious consequences like infections.
THE REPLANTATION PROCESS
Replantation is a delicate, multi-step procedure. Before your hand or finger or other tissue is reinserted, you go through several phases.
Phase One. Any remaining damaged tissue at the trauma site is carefully and thoroughly removed.
Phase Two. The bone ends of the severed site must be joined together. Typically, this process is performed using objects, such as:
The purpose of this undertaking is to provide a stable base, which will enable the reinserted hand or finger to fit into place.
Phase Three. During this final stage of replantation, a surgeon repairs whatever damage exists in the severed feature. For example, injuries to muscles, soft tissues, or blood vessels will be fixed.
THE RECOVERY PROCESS
Following replantation surgery, expect to undergo an extensive recovery process. The specific time you need to regain movement and strength varies depending upon several factors, including:
Joint involvement. Injuries that do not involve damage to joints stand a better chance of regaining mobility.
Age. Typically, younger persons experience quicker and more efficient nerve regrowth, which is crucial to regaining movement and strength.
Trauma Type. Many surgeons suggest that cleanly severed hands or fingers are more likely to regain a significant degree of movement than crushed or mangled body parts.
Climate. Colder climates tend to slow the recovery process.
Patients who smoke can speed up their recovery by stopping smoking. This habit interrupts circulation and limits blood flow to the replanted region. Additionally, you may be encouraged to hold the replanted body part above your heart. Performing this action can improve blood circulation to the affected area.
Once surgical wounds have sufficiently healed, you will need to undergo a course of physical therapy. In coordination with your surgeon, these are exercises designed by a medical professional known as a physical therapist. Physical therapy improves your hand’s mobility and strength.
Orthopedic and vascular surgeons stress that you should not expect to regain full mobility in the replanted hand, digit, or tissues. Recovery is gradual, and most medical professionals maintain that ultimately recapturing anywhere from 60 to 80 percent mobility is considered a good result.
Complications do not always occur and may be minor. Specific issues of concern that might need additional surgical intervention include scar tissue removal, the release of stiff or locked joints, or the repair of damaged or scarred nerves.
WHEN ADDITIONAL SURGERY IS NEEDED
Some patients who have undergone replantation surgery may need additional surgery to regain full use of their hand or finger. Some of the most common procedures are:
Tenolysis: Freeing tendons from scar tissue.
Capsulotomy: Releasing stiff, locked joints.
Tendon or muscle transfer: Moving tendons or muscles to an area that needs the tendon or muscle more.
Nerve grafting: Replacing a scarred nerve or a gap in the nerves to improve how the nerve works.
Late amputation: Removing a part later because it does not work or has become painful.
Thumb Reconstruction Surgery
THUMB RECONSTRUCTION SURGERY
The thumb plays an important role in hand function. Daily tasks involving pinch, grip, grasp, and precision handling are more easily accomplished with an opposable thumb.
Traumatic loss, congenital absence, or hypoplasia diminishes or eliminates the thumb’s prehensile abilities and may affect overall hand function.
The goals of thumb reconstruction consists of the following:
Sensate and nontender thumb tip
Stability at the interphalangeal (IP) and metacarpophalangeal (MCP) joints
Adequate strength to resist the forces of the fingers
Correct posture and positioning of the thumb with a wide webspace
Mobility of the carpometacarpal (CMC)
Whether an indication for surgery is related to injury or congenital malformation of the thumb, the ultimate goal is optimal function of the hand.
Selecting the most appropiate technique for thumb reconstruction depends on multiple factors, including the following:
Level of injury
Status of the remaining hand
Presence or absence of the thenar musculature
Age, occupation, overall health, and functional demands of the patient
The goal of thumb reconstruction is to restore function, as well as to provide the hand with an acceptable appearance and to keep donor-site morbidity to an acceptable level. The level of amputation determines the reconstruction plan. The predicted outcome of surgery generally favors reconstruction when an amputation has occurred distal to the MCP joint and has therefore left the first web space, as well as the thenar muscles (including their insertions), preserved
Sequelae to finger trauma may include edema, hypertrophic scarring, nail deformity, cold intolerance, abnormal sensitivity, joint stiffness, and generally decreased function. Complications that are directly related to reconstructive surgery include postoperative bleeding, infection, anesthesia-related problems, complex regional pain syndrome, and the loss of a skin flap, a replanted or transferred part, or a pollicized digit.
Outcome and Prognosis
As reported by Buncke and others, toe-to-hand transfer for thumb reconstruction can provide excellent end results and a high degree of patient satisfaction. [2, 43, 44, 45] The survival rate of these transfers has been reported to be as high as 98%, with 2-point discrimination of 8 mm or less in 80% of cases and, following reconstruction of the dominant thumb, a grip strength that is equal to 80% of the noninjured hand’s grip strength.