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.

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.

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.

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.

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.