18 Elective Hand Surgery Abstract This chapter will review common hand conditions for which elective surgery can provide treatment. Readers will be able to explain the management of each, and select appropriate postoperative hand therapy protocols. Keywords: hand surgery, Dupuytren’s contracture, first web space contracture Six Key Points • Elective hand surgery involves making a correct diagnosis and identifying all involved structures. • Release of contractures may require soft-tissue coverage—know several options for coverage of the hand. • Release of contractures requires night splinting to prevent recurrence. • Postoperative assessment should include evaluation for inadvertent injury to critical structures. • Postoperative protocols often include hand therapy. • Indications for operative intervention always include a functional deficit. A patient presents the following in Fig. 18.1. 1. What do you see? The photograph shows a flexion deformity of the finger with a visible cord. This is most consistent with Dupuytren’s disease. 2. What do you do? A history is taken that elicits concurrent pathology and factors associated with Dupuytren’s, which include diabetes mellitus, alcoholism, smoking, and AIDS. In addition, factors associated with Dupuytren’s diathesis are a family history of the disease, bilateral disease, multiple anatomic foci (such as plantar and penile lesions), and age younger than 50 years. 3. What are your indications to intervene? Indications for intervention are a metacarpophalangeal joint contracture of greater than 30 degrees or a proximal interphalangeal joint (PIPJ) contracture of greater than 20 degrees, or a positive Hueston’s tabletop test, in which the patient cannot put his hand flat on the table. Difficulty with activities of daily living often coincide with contractures of this degree. 4. What do you do? With a palpable cord, collagenase injection can be administered. This is performed in the clinic, and the patient is consented for the procedure. The solution is injected into the cord, and the patient’s hand is bandaged, and the patient is instructed his hand will swell and become bruised. The patient returns 1 to 3 days later for rupture. 5. After rupture, the patient has an appearance of the finger as in Fig. 18.2. What do you do? Skin tears are common after cord release. One first checks for sensation if no digital block has been performed, to excluded nerve injury, and then independently checks flexor digitorum profundus and flexor digitorum superficialis function. An unidentified flexor digitorum superficialis injury can lead to a late swan neck deformity.
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