Information for Patients about Hand & Elbow Surgery

Clinical Professor Allan Wang FRACS PhD FAOrthA Shoulder and Upper Limb Surgeon www.allanwangorthopaedics.com.au

MURDOCH SUBIACO Murdoch Orthopaedic Clinic St John of God Subiaco Clinic St John of God Murdoch Clinic Suite 302, 25 McCourt St Suite 10, 100 Murdoch Drive Subiaco WA 6008 Murdoch WA 6150

Telephone: 08 6332 6390 Page | 2

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Information for Patients about Hand and Elbow Surgery

Introduction

We have put this information booklet together to educate our patients about their Hand and Elbow condition, treatment options and post-surgical care.

Please keep this booklet for future reference. It is not a detailed source of information and you may also wish to refer to our website www.allanwangorthopaedics.com.au for animated videos of surgical procedures. If you require further information or have concerns regarding your treatment please contact the office to discuss with Dr Wang or his staff.

Contents Pages

1. Carpal Tunnel Syndrome 4

2. Cubital Tunnel Syndrome 6

3. Trigger Finger 7

4. De Quervain’s Tenodonitis 8

5. Ganglion Cysts 9

6. Arthritis at the Base of the Thumb 10

7. Wrist Arthroscopy 11

8. Dupuytren’s Disease 12

9. Lateral Epicondylitis 13

10. Elbow Arthroscopy 14

11. Post-Operative Instructions Hand & Elbow Surgery 15

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arpal Tunnel Syndroe

at is it

igure

arpal tunnel syndroe is a ondition aused by opression o te edian nerve at te level o te wrist oint Here te edian nerve passes into te arpal tunnel along wit leor tendons and te tendon lining alled tenosynoviu arpal tunnel syndroe ours wen pressure builds up in te tunnel and tis an be due to swelling o te tenosynoviu ratures artritis luid retention during pregnany and ertain onditions su as diabetes and tyroid disease Syptos en te pressure on te edian nerve beoes severe you ay notie wrist pain tingling and nubness and lusiness in and oveents Te tingling usually aets te tub inde and iddle ingers and is worse at nigt or gripping ativities eg driving a ar en arpal tunnel syndroe is severe and longstanding peranent nerve daage ay our ausing peranent nubness in te ingers and te tub tenar usles ay waste away

Diagnosis arpal tunnel syndroe is usually diagnosed ro your syptos and eaination o your and Soeties eletrial studies nerve ondution veloity and eletroyogra are perored Tese studies are unoortable but ay need to be done as your syptos ay be due to nerve opression elsewere in your ar or in your ne

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Treatent on operative treatent is oten suessul in less severe ases splint ay rest te wrist and allow te swelling in te arpal tunnel to settle ntiinlaatory tablets also elp or inetions o ortiosteroid diretly into te arpal tunnel ltering te worplae ay elp i you do a lot o repetitive wor wit your ands

n ore severe ases surgery is reuired ressure on te edian nerve is released by surgially utting te transverse arpal ligaent Tis an be done via a diret inision over te ront o te pal (Fig 2) or by te endosopi etod were a telesope is passed via two ini inisions under te ligaent Fig 3), and te ligaent is released ro it’s under surae

Figure 2 Figure 3

ollowing surgery te nigt tie tingling in your and usually settles uite uily edution in grip strengt and soreness over the palm where the ligament has been divided (“pillar pain”) may last for wees or even soe onts espeially i you do eavy wor Te endosopi etod as an advantage over te diret inision etod in tat te reovery o untion is uier However it as te disadvantage tat opliations ay our Tese are very unoon and inlude inetion bruising o te nerve or daage to te blood vessels or tendons in te pal

ter surgery eep your and elevated and do gentle inger eerises eep te bandage lean and at two wee stites are reoved Heavy ativities are avoided or wees

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bital nnel elease

hat is it bital nnel yndrome ors when the lnar nerve is ompressed at the ba of the elbow (“funny bone”). This ases tingling and nmbness in the small and ring fingers pain along the inner forearm and sometimes weaness in sing the hand ymptoms are sally worse when the elbow is held in a fleed position eg holding a phone sleeping at night et he nerve may be tingly when tohed and an be nstable slipping forward and bawards when the elbow is fleed then straightened

hat investigations are needed sally an eletrial test () is ordered to determine the severity of lnar nerve ompression and also to rle ot nerve ompression at the wrist (eg arpal tnnel syndrome) or a pinhed nerve in the ne rays maybe reired if there is an arthriti bone spr pressing on the nerve n ltrasond san will show if the nerve is nstable or if there is adaent tendon inflammation (medial epiondylitis)

hat are the treatment options inor bital tnnel syndrome responds to rest antiinflammatories and a resting splint ore severe lnar nerve ompression often needs srgery as permanent nerve damage an or withot treatment rgery involves an inision over the inner aspet of the elbow ometimes the ligament overlying the nerve is released to deompress the nerve (nerolysis) sally the nerve is released and shifted forwards, creating some “slack” in the nerve, so that it is nor stretched when the elbow is held fleed (transposition)

fter rgery sling is reired for wees and only light hosewor or offie ativities are permitted for the following si wees ring this time gentle finger and wrist eerises are enoraged to prevent pain and stiffness (dystrophy) ifting the arm overhead several times daily will prevent froen sholder he srgial sar maybe swollen brised and tender early after srgery eovery following lnar nerve deompression srgery may tae plae over many months f nerve ompression was severe reovery may be inomplete and therapy may be presribed by r ang if progress is slow Page | 7

Trigger inger

hat is it Trigger inger or Trigger Thumb are conditions caused by swelling of the fleor tendons (tenosynovitis) which bend the fingers into the alm. The tendons glide through a series of tunnels, and when the tendons swell they cause a ainful clunk or trigger when they sueee through the oening of the tunnel (fleor sheath).

The triggering is usually felt at the base of the digit. lum may also be felt at the base of the thumb. ccasionally the finger becomes stuck (locked) and will not straighten or bend on its own accord.

hat causes it

Trigger inger may arise with overuse of the hand or an inury, which cause the fleor tendon to swell. ertain medical conditions including diabetes, gout or rheumatoid arthritis may also cause triggering at the digits.

ow is it treated Treatment includes antiinflammatory tablets and a eriod of rest, to reduce the swelling of the fleor tendons. n inection of cortisone at the base of the finger may also hel. hen triggering is more severe, with regular and ainful catching when the finger is bent, surgery is usually reuired. nder a , a small incision is made in the alm at the base of the affected finger. The fleor tendon is located and the tunnel surgically oened. This allows smooth gliding of the swollen tendon. The tendon swelling (tenosynovitis) may need to be surgically removed. The digital nerves are carefully rotected during surgery. ecause they are immediately adacent to both the fleor tendons and tunnel, there is a very small ossibility of the nerve being damaged during surgery, causing some numbness at the fingerti. hat can eect after surgery r ang alies a sterile dressing which should remain intact, clean and dry until he reviews you at days after surgery. ou should kee your hand elevated in a sling to minimie swelling. entle finger, wrist, elbow and shoulder eercises are encouraged to minimie stiffness. ou can resume light work or activity at days after surgery but any heavy work should be avoided for at least weeks. Page | 8

De Quervain’s Tendonitis

hat is it De Quervains yndroe is a condition caused y inlaation and swelling o the thu tendons at the wrist level. hen you gri or twist the wrist these tendons glide in a tunnel and when the tendons ecoe very swollen they cannot glide reely.

ytos ain over the thu side o the wrist. ytos are worse on reetitive or heavy activity.

Treatent ten resting the thu and wrist in a sot slint or even a hard lastic Surgery opens the compartment slint will relieve sytos. ntiinlaatory talets cortisone over the inflamed tendon inections and odiying wor activities also hel.

hen sytos are severe surgery is reuired. general anaesthetic is reuired ut surgery is done as a “daystay”. The tunnel enclosing the swollen tendons is oened. This relieves the ressure and as the inlaation settles down the ain and wrist otion will gradually irove. The swollen lining o the tendon tenosynoviu is also ecised. andage is worn or one wee then the stitches are reoved. ight activity can start at wees ater surgery and heavier activity can egin at wees ater surgery.

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anglions and ysts hat are they anglions are swellings which grow on the hand and wrist. They are coon and usually arise ro a neary oint or tendon sheath. anglions are illed with luid and ay eel hard and e ainul when they are under ressure or with constant use o the hand or wrist. anglions ay arise due to a seciic inury heavy reetitive use o the hand or ay e due to an underlying arthritis rocess. They are not alignant igure oon locations or anglion cancerous. ysts Ganglion Cyst ow are they treated anglions ay luctuate with sie occasionally they ay even disaear on their own accord. your ganglion is causing sytos it ay reuire treatent. Dorsal ganglions can e asirated and inected with cortisone. alar ganglions ay eneit ro rest or wearing a slint. Volar Ganglion

Radial Artery

Radius igure

igure

arge ganglions usually reuire surgical reoval. urgery reoves not only the ganglion ut also the root into the oint or tendon sheath o origin. (Fig 2) This hels to revent the ganglion recurring. evertheless a sall nuer o ganglions ay recur esecially with reetitive or strenuous use o the hand. Fig 2. urgery is est erored under a . r ang oerates under oue agniication. owever as soe ganglions grow around arteries and sall sin nerves there is still a sall ris o daage to these structures in trying to coletely reove the ganglion. (Fig 3) hat haens ater surgery urgery is usually done as a daystay and you will e discharged ro the hosital as soon as you are coortale. lease ee your hand elevated wear a sling or the irst wee and do gentle eercises to sto your ingers elow or shoulder getting sti. lease also ee your andage dry and clean until r ang reviews you in aout days ater surgery. ou ay e ale to do light wor with your hand one wee ater surgery ut anything heavy should e avoided or at least one onth. Page | 10

rthritis at the ase o the Thu

hat is it ny condition that inlaes or destroys a oint is called arthritis. n a noral oint cartilage covers the one ends allowing the to glide soothly and ainlessly against each other. n osteoarthritis o the ase oint o thu the cartilage layer wears through and one ends grate causing ain and stiness. (Fig 1) ater the one ends start to sli out o the oint and a one u and deority occur.

ytos MCP Joint ou ay have ain and eel a grating sensation at the ase thu oint Diseased CMC aroetacaral oint when you inch or gri strongly. ou ay have joint diiculty turning tas or using a ey in a sti loc. ater deority Figure 1 occurs at your thu oints and weaness develos. aral tunnel syndroe ay occur with nuness in your ingers esecially occurring at night. Treatent n the early stages antiinlaatory talets or cortisone inections ay hel the arthritic thu oint. resting slint ay allow the inlaation to settle. ater on surgery ay e necessary. n early stages an arthroscoy “keyhole” surgery debridement can clean out the damaged joint and irove sytos. ater the asal thu oint can e treated y usion with steel ins causing soe stiness ut local ain is iroved. n osteotoy where the etacaral one is cut and realigned is also helul in early cases. ery good results are achieved y reoving the arthritic caral one traeiu altogether ecision arthrolasty. The oint is reconstructed with a wrist leor tendon. This tendon cushions the ase o the etacaral reventing ainul one grating and iroving oint oveent (Fig 2). ecent advances include the use o a ceraic sacer instead o a wrist tendon. n severe cases soeties the adacent oint scahotraeoid or etacarohalangeal oints develo arthritis and deority. These oints ay also reuire treatent to reduce ain in the thu region.

Fig .2 ter surgery a laster slint is worn or wees. rotective lastic slint is worn art tie or another onth and then eercises can e done to regain oveent. The thu will ecoe stronger over several onths.

Figure 2 Page | 11

rist rthroscoy

hat is it rist arthroscoy is keyhole surgery o the rist joint rthroscoy o the rist joint is less common comared to knee and shoulder arthroscoy because o its small sie and the reuirement or secial miniaturised instruments hen is it reuired rist arthroscoy is used to treat a number o conditions including ractures arthritis and sot tissue injuries such as ligament disrution to the small caral bones o the hand and tears o the triangular ibro cartilage rthroscoic debridement and reconstruction can imroe rist symtoms and due to the keyhole nature o surgery recoery is aster ometimes rist arthroscoy is accomanied by oen surgery including surgical reair and inning o ligament tears deneration rocedures or ulnar bone shortening osteotomy hich decreases load across the damaged joint he rehabilitation and recoery rom oen rist surgery is longer than or arthroscoic surgery alone o is rist arthroscoy erormed nder a general anaesthetic the rist joint is distracted by susending the hand by its ingers in a secial traction toer he rist joint is insected ia seeral ieing ortals hich are uncture incisions oer the back o the hand nstruments are assed ia these ortals to surgically treat abnormalities he back o the hand has a large number o ine skin neres any o hich may be damaged by any o the uncture incisions his may cause a small atch o numbness hich is usually temorary on the back o the hand he uncture incisions can also deelo an inection hese comlications o surgery are ery uncommon hat can eect ater rist arthroscoy he ostoeratie rogram deends on the underlying condition being treated rist ractures and some sot tissue reairs ill need laster cast immobiliation Arthritic Damage rthritic roblems only need a bandage and can be Scaphoid mobilied early to minimie stiness n all cases lease Lunate kee the oerated area eleated to reduce selling and ear a sling or the irst eek o gentle inger elbo and shoulder moements r ang ill need to reie you days ater surgery

Radius Ulna Debridement Triangular Fibrocartilage Tear ith regards to ork ery light actiity can begin one eek ater your rist surgery eay ork should ait until the eek stage Page | 12

Dupuytren’s Disease

hat is it Dupuytrens isease is an anoral thickening o the palar ascia, hich is a sheet o irous tissue in the pal ater in lie, the ascia ay thicken an or cors o gristle hich cause the ingers to en on into the pal here ay also e groth into the skin itsel, causing noules an pits to or hat causes it Dupuytrens isease ostly aects people o nglosaon escent t tens to run in ailies t usually egins in ile age t ay e orse i the isease starts at a young age (Dupuytren iathesis) ith ultiple igits aecte in oth hans an een eet, or hen associate ith epilepsy eication, ecess alcohol usage or lier isease reatent his is a painless conition, ut it tens to orsen ith age an ay aect any ingers an oth hans here is no peranent cure or Dupuytrens isease or sall Dupuytren ans, a liite release or an injection o a collagenase (iale) can soten the isease tissue an iproe the contracture urgery is usually require i the ingers hae ent on into the pal an get in the ay urgery reoes the thickene anoral ascia (asciectoy) ut alone ay not ully correct the contracture urgical techniques such as “Z plasty” (to lengthen the skin incision), joint releases, or skin grats (eratoasciectoy) ay e require he igital neres hich supply eeling to the ingertip ay e inole ith the Dupuytrens isease, an raical surgery ay aage these neres oor skin healing an inection ay also occur

ter urgery eep your han eleate in a sling to preent selling Knuckle pad plaster splint ay e necessary or the irst eeks until Knuckle Pad the stitches coe out an therapy ill e require Web here you ill e shon stretching eercises an ho to Contracture Fibrous Cord assage the scar oe scars are quite lupy ater Dupuytren surgery ut sloly iproe ith silicon pas an regular application o rich itain or ioil crea hen seere contractures hae een treate, use o a plastic etension splint at night an ongoing han therapy Fibrous Nodule are usually necessary or seeral onths ater surgery Dupuytrens isease ay return in the sae place or at another site soe years later, an urther surgery ay e Skin Pitting require

Dupuytren’s Contracture 13

ateral piconylitis

hat is it ateral epicondylitis, commonly known as “tennis elo, is inlaation o the tenons in the upper orear hich straighten the ingers an eten the rist ain ay e elt here these tenon ires attach to the one on the outsie o the elo, or along the uscles in the orear ain is usually ore noticeale uring stressul an repetitie use o the ar n seere cases, grasping or liting ith the pal on ay e iicult ecause people ho play tennis or other racquet sports soeties eelop this prole ro iproper playing technique, it has ecoe knon as tennis elbow”. Figure 1

igns an syptos he area o ost iscoort is usually oun oer the ony proinence on the outer sie o the elo knon as the lateral epiconyle (Fig 1). here ay e tenerness in the neary uscles here ay also e soe nere copression (raial tunnel synroe) hich causes eakness on etening the rist an ingers scan ay sho aage to the etensor tenon here it attaches to one reatent he goal o treatent is to reliee the pain reatent inclues restricting the actiities causing pain such as liting ith the pal on lso earing a orear an, antiinlaatory eication, etensor uscle stretching eercises, physiotherapy an cortisone injections are helpul ost patients ake progress oer seeral onths o nonoperatie treatent

sall proportion o patients require surgery general anaesthetic is required but surgery is done as a “daystay”. The aage tenon is cleane up here it attaches to one, an asiotoies are ae to lengthen the uscles an ecrease the pulling orce on the aage tenon ter surgery, ost patients iproe steaily an graually resue noral actiity the tenon aage is longstaning an etensie, soe patients ill still hae a egree o pain ith heay actiity

s s 14

lbow rthroscoy

hat is it lbow arthroscoy is keyhole surgery o the elbow oint. rthroscoy o the elbow is less common than the knee and shoulder arthroscoy, as it is a relatiely smaller and more comle oint and smaller instruments are required. hen is it required lbow arthroscoy is used to treat a number o conditions, including remoal o loose bodies, debridement o arthritis or synoial swellings, remoal o bone surs and to assist in the treatment o certain ractures. rthroscoic surgery can imroe elbow symtoms, and due to the keyhole nature o surgery, recoery is aster. ow is elbow arthroscoy erormed general anaesthetic is required. The elbow oint is insected ia seeral iewing ortals which are uncture incisions on the inner, outer and osterior asect o the oint. nstruments are also assed ia these ortals to surgically treat any abnormalities.

any imortant structures cross in ront o the elbow oint, including tendons, neres and blood essels and there is a ery small ossibility o damage to these structures during elbow arthroscoic surgery. uch comlications are ery rare. ikewise inection o these uncture incisions may occur but are also ery uncommon.

hat can eect ater elbow arthroscoy The ostoeratie rogramme deends on the underlying condition being treated. lbow ractures may need laster slint immobilisation. sually only an elbow bandage is required with eleation o the arm on illows or in a sling until the swelling subsides. entle moements o the elbow, ingers and wrist are encouraged to minimie stiness. lease kee your bandage clean and dry until r ang reiews you in about days ater surgery.

lbow stiness may occur and some hysiotheray may be necessary deending on your rogress. ith regards to work, ery light actiity can begin with the oerated arm one week ater surgery. eay actiity should wait until at least the week stage. 15

osteratie nstructions or and lbow urgery . lease eleate your hand and orearm on illows to reduce swelling.

. ee your bandage or laster cast intact, dry and clean. se a lastic bag to rotect your cast in the shower.

. a sling was roided, lease wear i when you are u and about.

. your bandage or laster is too tight you may notice increasing and seere ain, and inger swelling, dusky colouration, or increasing numbness in your ingers. this occurs, continue to eleate your hand, cut through the bandage with scissors and loosen the laster slint, and notiy the hosital or r ang i things do not imroe.

. entle eercises are helul, to reduce stiness. o these eercises slowly, to the oint o discomort, not ainul. o two eercise sessions daily.

These eercises are a ently clench and unclench your hand ie times.

b ently reach your hand aboe your head as i you are trying to touch the ceiling.

c you are T in a laster cast ently le and etend your wrist ie times.

d ee your bent elbows tucked into your side. Turn your orearm only so that your alms aces uwards, then turn slowly so the alm ace downwards.

e Touching the tip of the thumb to each fingertip in turn, making an “O” sign.

ithin the conines o your elbow bandage, le and etend your elbow gently.

n the irst day or two ater surgery – erorming some general eercises will aid recoery. These include cough and dee breathing to kee your chest healthy and requent short walks to reent dee ein thrombosis.

. ain anagement rescrition or ain tablets will be roided by the hosital on discharge. enerally take aracetamol regularly to mg tablets three times a day will reduce the need or stronger mediation. or breakthrough ain eg. ater eercise or at bedtime, take ycodone tradename ndone or ynorm to mg tablets twice but no more than three times a day. This is a narcotic rescrition, ycodone should be taken saringly. t may make you lightheaded and nauseous and should not be combined with alcohol or sleeing ills. nti inlammatory medication eg arosyn, obic, oltaran etc can be taken as well i necessary.

. ith regards to work, generally only ery light actiity with the oerated hand is aroriate and this could commence at days ater surgery. ou should not drie a motor ehicle or oerate machinery until ater your ostoeratie aointment.