Hand and Microvascular Surgery

Hand injuries include lacerations, dislocations, ligament tears, fractures, infections and burns. The injury could affect the nails, fingers, hands or wrist. The hands are the part of the body people use for most of their day-to-day activities and work, so any hand injury must be given immediate medical attention to minimise loss of function of the hands. The overall functional recovery and healing, largely depends on the initial management of the wound. Gleneagles Global Health City has a dedicated 24x7 Hand Injury Clinic. Our team consists of plastics and microvascular specialists, neurosurgeons, orthopaedic surgeons, vascular surgeon and physiotherapists. The doctors work together to develop a holistic treatment plan. The aim is to regain maximum function of the hand, minimise pain and improve the aesthetic appearance.

Replantation is the surgical re-attachment of severed toes or fingers. The aim of replantation is to re-join the cut part and restore maximum function. On reaching the hospital, the surgeon will immediately examine the severed part under high magnification microscope and determine if it is possible to attach it. To re-attach the severed finger or toe, the surgeon cleans the damaged tissue from the injury site and aligns the bones using steel pins / Plates and Screws. Then the arteries, veins, nerves and tendons are connected. Joining the blood vessels is the most important part of the surgery which is done under microscope using sutures thinner than the hair. The patient is kept under observation and the re-joined part is monitored continuously to check the perfusion. During recovery, the patient will be recommended physiotherapy to help regain normal function of the injured body part.

The viability of the severed organ depends on the duration since injury, the method of preservation while coming to the hospital and the extent of damaged tissue at the site of injury, especially the condition of the nerves and the blood vessels. Availability of Hand surgeon 24 x 7, helps us to reattach the amputated part in the Golden period of six hours, which has a higher success rate.

If the amputated organ cannot be restored, the doctor may recommend a reconstruction using local flaps and tissues. Sometimes skin and bone from the amputated part can be used as a spare parts graft. Hence it is always prudent to bring the cut part.

The hand is made of 27 bones. One or more of the bones in the hand could break as a result of an accident, a fall or an injury while engaged in contact sports. A fractured hand is unlike a sprain, which are soft tissue injuries. A fractured hand may result in severe pain, swelling, tenderness, bruising, difficulty in moving the fingers or crooked fingers. After initial clinical examination, an X-Ray will be taken in the emergency department to assess the nature of fracture and the bones involved. Fracture can be simple or Compound. In simple fractures, the skin is intact and in compound fractures there is wound and the fracture segment is exposed. If you suspect that your hand is fractured, immediate first aid must be given – Stop the bleeding; Raise the hand above your heart level, Apply ice and keep the hand immobilised. The broken hand must be treated for the bones to heal in correct alignment. Misaligned bones could affect normal hand function and would require surgical correction. The Plastic surgeons who are trained in Hand surgery, assess the injury and suggest the treatment to ensure that the hand retains full function and an aesthetic appearance. Depending on the injured bones and the type of fracture, the various options of management are

• Closed reduction and immobilisation using splint or POP
• Closed Reduction and Fixation using Steel pins
• Open Reduction and fixation using Steel Pins / Plate & Screws

Traumatic injuries caused to the hands by blunt force trauma, sharp objects, chemical or electrical fires or sudden impact can cause deformities. Most deformities are the result of malunions, which occur when a fractured bone heals in a misaligned position. Post-traumatic hand deformities must be surgically repaired by an orthopaedic surgery specialist. In children, malunions can be corrected over time with external manipulators. Each malunion is unique, so the surgeon studies the patients X-rays and prepares a customized treatment plan for the patient. Malunions are of two types – rotational and angular. The surgeon corrects the defect by breaking the bones at the site of the malunion and realigning them. The realigned bone segments may be fixed in place with plates, bone grafts or any other technique the surgeon deems appropriate. The plastic surgeon takes care to match the skin grafts (used to close the wound) with the surrounding skin to give the patient a hand that feels natural and familiar.

The hands have a unique anatomy that results in the formation of many “compartments”. Infections of the hand can build up in one part of the hand, say a finger, and fester. These infections can grow very quickly and result in loss of function in the finger. Infections that are deep inside the fingers may not respond to antibiotics and will hence require surgical drainage. The hand infection usually causes inflammation and excruciating, throbbing pain. In more serious cases, the patient may also experience fevers. The patient should seek medical treatment immediately if they suspect a hand infection, as early treatment could make the difference between regaining full function of the hand and amputation. The plastic surgeon debrides the infected wound. This cleans the wound, removes dead tissue to allow the wound to heal faster with less scar tissue formation.

An abnormal lump on the hand is considered a hand tumour. Most hand tumours are non-cancerous. Hand tumours can occur on the skin, such as warts or raised moles, or in the soft tissues or bones of the hand. As there are many types of tissues (skin, nerves, muscle, tendon, ligament, vascular and bone tissue) in the hand, there are a range of tumours that could occur. The most commonly occurring hand tumours are ganglion cysts, giant cell tumours of the tendon sheath, epidermal inclusion cyst, lipomas, neuromas, and bone spurs. The tumour is carefully studied to identify the type of tumour and plan a surgical strategy for tumour extraction. The doctor may perform a needle biopsy to extract a tissue sample from the tumour for analysis. The tumour extraction can be performed as an out-patient procedure if the tumour is small. The surgeon will advise the patients of their options depending on the type and size of their tumour.

The brachial plexus is a network of nerves that send electrical impulses from the spinal cord to the shoulders, arms and hands. A brachial plexus injury occurs when these nerves are stretched, compressed or torn from the spinal cord. Minor brachial plexus injuries are common in athletes who play contact sports. Accidents and car crashes are the main cause of serious brachial plexus injuries, in which the brachial plexus tears. Babies sometimes sustain brachial plexus injuries during birth. Depending on the level and severity of the nerve injury, Brachial plexus injuries can range from reversible weakness in the limbs to total palsy (Pan Palsy) of the upper limb. The arms may feel numb or they may feel a tingly sensation passing through them. In case of severe brachial plexus injuries, the patient will also feel severe pain.

Minor brachial plexus injuries respond well to electrical stimulation, physiotherapy, medication and assistive devices like splints and compression sleeves. However, brachial plexus injuries that do not heal on their own will require surgical intervention. The surgeon may opt for a nerve repair, nerve graft or nerve transfer procedure after evaluation of the nerve injury. Prompt and early intervention is important to give the patient the highest chances of recovering full function in the arms. The follow-up treatment is as important as surgery itself and has to be followed meticulously. Nerve recovery is slow and hence the patient may take months to recover, depending on the severity of the case. Regular physical therapy and self-motivation can help speed up this process.