If your hand or wrist is impaired in any way, surgery may improve your condition. This type of very specialized surgery can treat diseases that cause pain and impair the strength, function and flexibility of your wrist and fingers. Surgery seeks to restore to near normal the function of fingers and hands injured by trauma or to correct abnormalities that were present at birth.
How We Can Help
Adult brachial plexus injury/upper limb paralysis
Paralysis affecting the upper limb (shoulder, elbow, wrist, hand or combination of any) can be the result of a number of different conditions. While some of these conditions may resolve on their own with close observation and care to the joints, other conditions may be helped with surgery.
Nerve transfers can be performed in some patients to restore stability to the shoulder and use of the elbow as well as function in the forearm, wrist, and hand. The procedure is done by borrowing nerves from muscles that are working well and connecting them to nerves that are not functioning due to a disease or injury.
Tendon transfers are another option, especially for cases where the injury to the nerves occurred a long time ago. In these procedures, tendons (tissue that connect muscle to bone for movement) are used to restore motion by connecting it to tendons that are attached to a paralyzed or non-functioning muscle.
Amputation and prosthetic
After traumatic or surgical amputation (removal) of a limb, some patients may experience chronic pain in the limb or the sensation that the limb is still part of the body (phantom limb). While these symptoms are often managed by medication alone, surgery may be helpful to some patients.
Targeted muscle reinnervation (TMR) is a procedure that can be performed on the upper or lower body that redirects cut nerves to muscles that may help reduce pain and phantom limb sensation. In addition, the surgery may allow for fitting of more advanced prosthetic devices that can help with every day activities.
Hand and wrist arthritis
Hand and wrist arthritis may be caused by normal wear and tear of aging, previous injury, or in some cases conditions caused by the body’s own immune system.
A rheumatologist may be the first person to help with the arthritis symptoms especially if caused by the immune system.
When symptoms get too severe, splinting can be of help. Additionally, steroid injections into the joint may provide some temporary relief.
Surgery is reserved for patients where therapy, oral pain medication, and steroid injections have no longer helped. Options can include joint replacement surgery (arthroplasty), or joint fusion surgery where the bones around the joint are united to improve pain.
The thumb is one of the most common joints affected by arthritis. The joint at the base of the thumb (carpometacarpal joint or CMC joint) has a wide range of motion which makes it prone to arthritis as we age. Fortunately, solutions for thumb base arthritis are available which may include a simple brace for activities that cause the most discomfort or a steroid injection that we provide in the office for some temporary relief.
When splinting interferes with daily activity and steroid injections no longer provide pain relief, then surgery may be the next best option. Surgery typically involves a brief period of splinting, stitches don’t typically need to be removed, and tends to be reliable with regarding to improving pain with thumb motion and pinching.
Carpal tunnel syndrome
Numbness in the hand is frequently due to compression of the Median nerve that functions to provide sensation to the thumb, index, and middle finger. Additionally, it aids in thumb, index, and middle finger fine motion. The nerve often gets pinched in the wrist in a location called the carpal tunnel.
Symptoms can include numbness in the thumb, index, and middle finger, or pain in the hand. In later stages of the disease, weakness can also occur. Often, symptoms are worse during certain activities (typing) or during sleep.
If treated early, many cases of carpal tunnel syndrome can be treated with splinting alone.
When splinting isn’t working or interferes with hand use for daily activities or work, or if the symptoms are severe, then surgery may be the best solution.
Surgery can be done in two ways, through a single incision in the palm (mini-open) or an incision in the wrist (endoscopic carpal tunnel).
The procedure is typically finished within a half an hour, patients are encouraged to use the hand right away, and stitches come out in 10 days in the mini-open technique. In the endoscopic (wrist incision) technique, stitches are all dissolvable.
Light activities involving the hand can usually begin the following day. Heavy labor usually in 2 weeks.
Congenital hand differences and cerebral palsy
Not all hands are the same. Some hands may have more or fewer fingers than the usual five. Additionally, some fingers, thumbs, or hands may work differently for different people. The goal of the hand surgeon is to provide patients and families with information on how patients can use their hands to the fullest degree possible.
Examples of common hand differences seen at birth or at young age:
- Syndactyly (fingers that have long webs between them or conjoined fingers)
- Polydactyly (extra fingers)
- Trigger thumbs (locking and snapping of the thumb)
- Thumb hypoplasia (smaller or weaker thumbs)
Patients with cerebral palsy often use their hands differently. By studying how the patient uses the hands for daily activities, a treatment plan can be developed so that he/she can use the hands more efficiently. Surgery may sometimes help to release contractures or make motion more efficient by tendon transfers (re-routing of muscle from one area to another).
With hand surgery fellowship training at Children’s Hospital in Dallas, Texas and the world-renowned Texas Scottish Rite Hospital, Dr. Naram can help you understand your child’s hand and provide you with options for treatment as it is needed.
Contracture from traumatic brain injury, stroke, or spinal cord
After a patient suffers and injury to the nervous system (brain or spinal cord), patients may develop changes in the ability to use the upper limb.
While some patients may experience weakness or difficulty with everyday tasks, other patients may develop severe spasm (tightening) of the muscles causing the elbow, forearm, wrist, or hand to feel tight. Sometimes, the tightness can make it difficult to clean the palm of the hand or use the limb for simple activities like holding a piece of paper on a table or keeping a dinner plate steady.
Splints can be made to keep the hand from getting contracted in this posture, but sometimes these can be come painful, or muscles can overpower the splint.
Medicine (Botox) can sometimes be used to weaken certain muscles to relieve the tightness.
In cases where the tightness or contracture is too strong, surgery may be able to help place the hand in a position that is helpful to the patient and/or relieve the tightness so that the hand or joint creases can be cleaned with less difficulty.
Cubital tunnel syndrome
Numbness in the hand can be caused by compression of the Ulnar nerve which provides motion within the hand as well as sensation to the little and ring fingers. The nerve can get pinched commonly around the elbow (cubital tunnel) or in the wrist (ulnar tunnel or Guyon’s canal).
When the nerve is pinched around the elbow, often the symptoms include numbness in the little and ring finger with or without weakness in the hand. Symptoms are often worse when patients rest on the elbow on a chair or at night time. In most cases, symptoms can be prevented by paying attention to elbow position so that the elbow is not too bent or too straight. These positions can put pressure and strain on the nerve which cause symptoms.
When the nerve is pinched around in the wrist, symptoms include numbness in the little and ring finger, and sometimes weakness in the hand. Splinting may be helpful to improve symptoms.
When splinting isn’t working or interferes with hand use for daily activities or work, or if the symptoms are severe, then surgery may be the best solution.
If the nerve is pinched at the elbow, surgery involves relieving the pressure on the nerve with an incision (surgical cut) over the inner side of the elbow. Stitches are placed that are dissolving and patients are encouraged to move the elbow right away.
If the nerve is pinched at the wrist, surgery involves a small incision in the palm. Stitches are removed in 10 days and the patient is encouraged to use the hand immediately after surgery.
Light use of the hand can usually begin the following day, with heavy use beginning at 2-3 weeks depending on activity and personal recovery.
Caused by scarring in a layer of tissue under the skin in the palm of the hand, Dupuytren’s Disease (Dupuytren’s contracture) can be as mild as a small pit in the hand or a tough nodule (bump). Patients may also have pads on the knuckles. In more advanced cases, thick cords of tissue may form in the palm that cause the thumb or fingers to become stiff and contracted. If this is causing difficulty with daily activities and/or the patient can’t place the hand flat on the table, options are available to release the tethered chord and improve motion in the hand.
A number of different treatments exist for this disease including in-office treatments and surgeries performed in the operating room.
Ganglion cysts typically occur over the joints or tendons of the hand. They are sacs of tissue filled with synovial fluid which come from joints or tendon sheaths (the covering around the tendons). While these are benign growths (not cancerous), they can be bothersome or even painful. Treatment depends on the location. This may include removing fluid from the sac with a needle in the office. The cyst may also be removed with surgery.
In order to optimize hand function, comprehensive hand treatment often involving the expertise of a certified hand therapist is critical. Most hand and wrist conditions that we treat are managed in collaboration with our partners in hand therapy to provide the best possible outcomes.
Patients with certain types of hand or wrist arthritis may be good candidates for joint replacement surgery. Operations are performed as same-day surgery with the goal of reducing pain from arthritis while preserving motion.
Kienböck’s disease is also known as avascular necrosis of the lunate. The lunate is one of the small bones in the wrist. In Kienböck’s disease, this bone loses blood supply which causes the bone to die. The damage bone can lead to pain, stiffness, and potentially arthritis of the joint.
Diagnosis is often made by a combination of x-ray, CT-scan, or magnetic resonance imaging (MRI) to look at the shape of the bone and the blood supply going into it.
When diagnosed, treatment depends on the severity of the disease and can range from hand therapy to surgery.
Scaphoid fractures and scaphoid non-union
The scaphoid is one of the small bones of the wrist. Its function is critical to normal wrist motion as it connects the 3 rows of bones from the forearm to the hand. Breaks in the bone (fractures) need to be treated early to prevent long term issues caused by non-healing of the bone.
If the scaphoid bone has not healed, surgery is often recommended to prevent further changes in the movement of the wrist bones that can lead to arthritis, pain, and stiffness in the wrist.
Skin cancer of the hand and upper limb
Cancers on the skin in the hand and upper limb are typically related to a history of sun exposure.
When identified early, they may be treated by simple removal in the office or operating room.
If the skin cancers become too large, they may require reconstruction of the skin by use of skin grafts (skin taken from one part of the body and encouraged to heal in the area where it is missing), or by flaps (moving skin and soft tissue with the blood supply into the area where skin and soft tissue is missing).
Sunscreen (SPF 15 or higher), protective clothing, and avoidance of sun exposure are critical to preventing development of skin cancer. Patients who are high-risk are encouraged to establish care with a physician who will be able to check their skin periodically for potential skin cancers.
Injuries to the hand during sports are extremely common. Many of these conditions may be treated with simple splints and activity modification until the injury heals. More complicated injuries may require surgery to bring the athlete back in the game. At our practice, we are mindful of the needs of the athlete in terms of recovery and downtime.
Stiffness of hand and wrist
Loss of motion to the hand and wrist may be caused by a number of different conditions. Tightness in the skin, scarring around the tendons or ligaments, and changes to the bone can all affect how the fingers, thumb, and wrist move.
A careful physical examination is key to identifying the cause of the stiffness and may require further imaging through x-ray, CT-scan, or magnetic resonance imaging (MRI) to evaluate the soft tissues and bones that contribute the stiff joint.
Hand therapists can often be the best ally in trying to preserve or restore motion. If therapy reaches a plateau, some patients may benefit from surgery to address the underlying causes of stiffness. Therapy after surgery is critical to prevent return of stiffness.
Sudden loss of motion in the fingers or thumb are typically caused by a direct injury to the tendon. This may be from a cut, a finger jam (rupture from resisted motion), or even from arthritis or other conditions that cause repeated ware on the tendon.
If caught early, these tendon injuries can often be repaired by putting the tendon back together with stitches in the operating room or in the office.
More complicated cases may need to be treated by tendon transfers (borrowing a tendon from one part of the hand or wrist and attaching it to the cut end of the other), or by tendon grafts (using a tendon from the leg or the wrist to repair the cut tendon). This may need to be done with more than one surgery depending on how complex the injury is.
Inflammation of the tendons (tendonitis) can occur anywhere in the body. In the hand, it can be particularly problematic for work, hobbies, or everyday use. Over-the-counter anti-inflammatory medicine can work well to treat the condition. Rest, cooling or warming, and gentle braces can be used as well. In certain cases, the tendonitis can be caused by an issue with anatomy that can be treated by surgery, or at least helped with a steroid injection in the office.
Locking and popping of the finger is most frequently caused by a type of tendonitis (inflammation of the tendon) on the palm side of the hand. The tendon develops a nodule that gets caught in the normal tunnel that exists in each finger that serve as a pully system to bring movement to the fingers. These may be painful, but not always. Treatment includes rest and anti-inflammatory medication (ibuprofen etc.), steroid injection, or a small in-office procedure to release part of the pully system where the tendon is triggering.
The in-office procedure involves a small incision (cut) on the palm side of the hand. The incision is closed with stitches that are removed in 10 days. Light activity is encouraged the same day. Heavy activity can usually begin in 2 weeks.
Ulnar sided wrist pain
Pain on the wrist on the side of the small finger can be caused by a number of different problems. Diagnosis is often challenging for even the most experienced provider. Careful physical examination is key, but testing including x-ray, CT-scan, or magnetic resonance imaging (MRI) may be needed to evaluate the bones and soft tissue to identify the underlying cause and offer advice for treatment.
Low blood flow to the fingers or hand can cause symptoms including cold and painful fingers. If blood flow is too low for too long, then ulcerations (wounds) may occur in one or multiple fingers.
A number of conditions can cause changes in blood flow into the hand including build-up of plaque in the arteries (arterial sclerosis), compression of the arteries from injury or tumors, clots within the arteries, or spasm (clamping down) of the arteries often during cold weather often causing color changes to the fingers (Raynaud’s disease and Raynaud’s phenomenon).
Using small cameras, the joints of the wrist, thumb, and hand can be evaluated to help identify problems leading to pain or instability. Certain conditions may also be treated with wrist arthroscopy including tears within the soft tissues of the joint or ganglion cysts.
The wrist is one of the most common places to have a broken bone. Often falling on an outstretched hand is enough to cause a break in the distal radius (distal radius fracture).
This type of injury is often seen in younger patients due to higher-risk activity, as well as in older patients due to weakening of the bones with age.
When injuries involve the joint, or if a cast prevents a patient from returning to work or activities of daily living, surgery can eliminate the need for a cast and get patients back to light and household activities faster.
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