Hand Surgery in Mumbai

Hand surgery is a broad phrase that encompasses a wide range of operations. Hand surgery performed by plastic surgeons with the aim of restoring hand and finger function. Hand surgeons, on the other hand, seek to make the hand appear as normal as feasible.

Fingertip injuries/ Finger pulp injuries

Fingertip injuries are common occurrences that can be presented in various ways. The anatomy of the fingertip comprises the nail plate, pulp, and bone. 

Many fingertip amputations can be classified as consistent with the normal functional anatomy of the tip and perionychium. Injuries can be classified according to where the amputation has occurred or whether the injury primarily involves the pulp (soft tissue) or nail bed.

The treating plastic surgeon focuses on :

  • Restoration of the fingertip- soft tissue and bone
  • Stability
  • Pain-free

Lastly, as normal looking as possible through a comprehensive treatment protocol. 

Psychosocial factors such as cultural traditions, professions and hobbies play a vital role in the restoration of the fingertip. Deformed fingertips, painful tips and/ or limited functionality of the fingers can be long-term problems if not addressed well at the time of the initial injury.

 

Treatment for Fingertip injuries 

1. Non-surgical

 

Non-surgical- In cases of soft tissue loss less than 0.5cm, it heals with dressings and may not require surgery.

 

2. Surgical Treatment

  • Flap Surgery: Most cases of pulp injuries need a soft tissue replacement to restore the contour and appearance of the pulp of the finger. This is done by mobilizing tissues in the form of a flap, from the same finger or adjacent finer depending upon the tissue requirement. Flaps give a good functional and aesthetic restoration of the fingertip.
  • Composite Graft is considered a good option in young children if the cut-off pulp is brought to the hospital. It can be put in place and sutured. Its take-up is known in 8-10 days.

 

Note: Surgeries for fingertip injuries are daycare surgeries. In children, general anesthesia will be required while adults can undergo this surgery under local anesthesia.

 

Nail injuries

Nail injuries are usually caused either by crush injury and less option by a or sharp cut to the fingertip, causing injury to the nail bed. Crush injuries are most commonly due to the finger tip getting crushed in the hinge of a door, common in children and adults.

 

Injury to the nail, essentially means injury to the nail bed- structure beneath the nail which gives rise to the nail and makes it grow throughout life.  Being tightly attached to the underlying bone, nail bed injury is almost always associated with a small fracture of the tip of the bone.

 

The simplest form of a nail bed injury is a hematoma: can be drained by a needle and evacuated.

 

Other nail bed injuries include:

  • Multiple cuts in the nail bed
  • Crush of nail bed
  • Loss of nail bed

 

Nail bed can be repaired with a simple surgery; when done well, it ensures uninterrupted nail growth. If not done, it may result in a deformity of the future nail that will grow.

 

Loss of nail bed can also be corrected by a nail bed graft.These surgeries are done under local anesthesia, on daycare.

 

Note: Surgeries for fingertip injuries are daycare surgeries. In children, general anesthesia will be required while adults can undergo this surgery under local anesthesia.

 

Nail/Nail bed injuries

Nail bed is the structure beneath the nails from which the nail grows. When injured, its repair or reconstruction of nail bed is vital as it determines the appearance of the overlying nail.

 

Nail and/or nail bed injuries include subungual haematoma, nail bed laceration, nail bed avulsion and loss.. The diagnosis includes clinical examination and imaging of the injured digit to ascertain fracture, presence of foreign bodies and dislocations. The treating surgeon will then present a comprehensive treatment plan for recovery from nail related injury. 

 

Subungual haematoma refers to the collection of blood between the nail and the nail bed and the nail looks bruised with haematoma changing its discoloration from red/purple. This injury is due to heavy impact or related to a door crush injury. When it is >50% of surface area it needs to be treated by trephination- making an opening in the nail to let out the collected blood.

 

Nail bed avulsion is when the nail and a part of the nail bed are pulled away from the finger due to traction and crushing forces. This injury occurs in the ring finger along with distal phalanx dislocations and fractures.

 

Nail Bed Laceration refers to the compression of the nail bed between the nail and distal phalanx Laceration may be simple or complex. Repair of the laceration is required for it to heal well. Very commonly seen in children due to hinge door injuries- when the finger gets compressed in the hinge of the door.

 

Treatment of Nail/Nail bed injuries

The treatment for Nail/Nail bed injuries is Surgery. It is a Daycare surgery that can be done under local anesthesia in adults while children will require general anesthesia.

 

Surgery consists of removal of the nail plate and nail bed repair when lacerated with fine absorbable sutures and splinting the eponychial fold to allow growth of the new nail. 

 

Nails grow slowly and will take about 6months to 1 year to grow to a fully normal appearance.

 

Loss of Nail/ Absent Nail

Nails not only protect the tip of the fingers but also provide dexterity and functionality when used. Crush injuries result in loss of nail or absent nail. Also, there are high incidences of distal phalangeal fractures occurring in fingertip injuries. 

 

The initial diagnosis involves physical examination and x-rays to view and understand the extent of nail trauma. In case of lacerations of the nail bed, distal phalangeal fractures, shearing of the nail bed, evaluation is done under anesthesia. At times, the nail plate is removed to evaluate the condition of the nail bed and the fractures in the distal phalange

 

Treatment of subungual hematoma caused on account of trauma to vascular nail bed below either due to injuries or repeated injuries involves the drainage of the hematoma while care should be taken not to damage the nail bed. 

 

Nail bed repair and reconstruction is done through microsurgery using a synthetic nail plate to enable the normal contour of the nail at the maximum.

 

Microsurgical reconstruction of the nailbed and placement of a synthetic nail plate to allow the maximal return of normal contour. While treatment of large fragment distal phalangeal fractures involves internal fixation as a procedure within the plan of nail bed reconstruction

 

Surgical reconstruction is essential to treat the entire nail bed or a part of it. The surgery involves grafts sourced from other digits mainly the nail bed of the toe.

 

The restoration of the anatomy of a normal nail and its final appearance depends upon the restoration surgery. Crushing nail injuries lead to nail bed scarring with a deformed nail condition. On the other hand, sharp nail injuries can be treated with better outcomes with the nail restored in normal shape and condition in most cases. Overall, such treatments take up to 6 months for completion and total recovery.   

 

Finger Contracture

Contracture Release is to release or remove a tight scar or scar band to:

  •  To restore the true length of the affected part 
  •  To increase the range of movement of the affected joint.
  • To correct the deformity
  • To prevent any growth disturbances 

 

Reasons for contractures in the upper limb:

  • Burns
  • Infection
  • Trauma/Injury
  • Congenital or by birth
  • Even after surgery at times

 

Sites of contractures in upper limb:

  • Axilla
  • Elbow
  • Wrist
  • Fingers
  • Web spaces

 

Tissues affected in a contracture: depending o the depth of burns or injury, tissues injured usually are skin, soft tissue, ligaments and tendon sheaths. With continued growth of the body, the growth of structures near the contracture becomes restricted and hence, stunted. Thus while, doing a surgery to release the contracture, normal structures can limit the degree of release due to their stunted growth.

 

Problems arising due to contractures

Contractures of the finger cause curving of the affected fingers, inability to straighten the fingers and reduced movements of the affected joints of the finger. The restriction in straightening also affects the longitudinal growth of the fingers. In the upper limb, contractures can affect the shoulder, elbow, wrist, or finger joints severely affecting hand function and quality of life. 

 

To state with an example the consequences of limitation of movements is an elbow contracture – inability to bend the forearm at the elbow disables the patient to eat with his or her own hand. 

 

A serious handicap can result from first web space contracture- contracture between thumb and index finger, as it restricts the thumb to be opposed to the other fingers.

 

To summarise, contractures cause the following:

  • Range of movements reduced
  • Growth disturbances- affects longitudinal growth
  • Deformity of fingers or joints
  • Aesthetically it looks abnormal hence can cause social embarrassment

 

Treatment of Contractures

Non- surgical Treatment

 In very early stages following healing of the wounds, the affected fingers or joints can be splinted with customized splints to keep it straight- this needs to be done for at least 4-6 weeks and thereby contracture development can be prevented.

Surgical Treatment

In established contractures, surgery is the only answer. 

 

In children, contractures have to be released early so that the growth of the affected part is not diminished resulting in reduced length and girth of fingers. Timely release of contractures ensures a normal growth of the affected body part.

 

Surgery involves pre-operative assessment of the degree of contracture, the joints affected and the availability of surrounding issue. Surgery involves release of the contracture and resurfacing of the defect created with flap or graft. Release of the contracture is done so as to release all the tight bands without affecting the vital structures like nerve and blood vessels.

 

Flap surgery prevents recontracture and gives a superior result. After surgery the release is maintained by a splint used for 6-8 weeks.         

 

Dupuytrens’ Contracture/ Dupuytrens’ Disease

This is a specific type of contracture seen in middle age and elderly population. Starts insidiously and usually involves a ring and little fingers; can then involve the middle finger. Patients notice a hard nodule at the base of the finger in the palm and progressively the finger starts bending due to a tight pulling band.

 

In a majority of people, both hands are affected sequentially or simultaneously. In some people, the sole of the foot may also be affected.

 

Affected races are usually Africans and Indians; uncommon in the West.

 

The basic pathology in Dupuytrens disease is that all normal bands present in the palm and finger become taut-like cords entangling the nerve and blood vessel in them and causing the finger to bend.

 

  • Treatment: Surgery
  • Anesthesia: General or regional
  • Procedure: Here the bands are released meticulously so as to not injure the nerve or blood vessel while doing so. We prefer doing this surgery under magnification using the microscope to enable us to release all tight cords and straighten the finger reasonably well.

 

Post-surgery: A splint is given till the suture line heals in about 10 days and then exercises are started. The surgery and post-operative physiotherapy is expected to give a good long-term outcome regaining hand function.