Hand Reconstruction

What is “Carpal Tunnel Syndrome”

We all normally have a carpal tunnel but we do not necessarily have “Carpal Tunnel Syndrome”. The Carpal Tunnel is an arch formed by the wrist bones and the carpal ligament on top. This anatomical structure resembles a tunnel with a road + the hole in the mountain.

The Carpal tunnel is normally very crowded. Many structures traverse it on their way from the forearm to the hand. Nine tendons from the forearm muscles (two per finger except the thumb) traverse the tunnel to flex the digits. But the most sensitive and the most delicate structure traversing it is the MEDIAN NERVE. In some predisposed people, the tunnel is rather narrow and any slight swelling of the tendons (tendinitis) inside this unyielding structure can increase the pressure and compress the median nerve. This typically occurs at night when we normally accumulate fluid or after extensive use of the hand when the tendons swell.

When the nerve is compressed, the patient feels pain, tingling, pins & needles, numbness, clumsiness, weakness. With time, the nerve ceases to function well and the fingers become numb, the hand weak and more clumsy. Typically patients will complain that they are dropping objects from their hand or that they have trouble buttoning their clothes. When we find evidence that the nerve is not functioning normally, we recommend release of the carpal tunnel to relieve the symptoms, prevent more permanent damage and muscle loss.

Carpal Tunnel Symptoms

The main symptom of carpal tunnel is tingling in the fingers (except for the little finger). The sensation is often similar to the tingling sensation experienced when your feet fall asleep. People suffering from carpal tunnel have worse symptoms at night and often wake up with the need to shake up their hand at night. As the carpal tunnel problem worsens, the pain becomes more constant and the hands become weaker and clumsier. As the disease progresses, the fingertips become more numb and hand function deteriorates. The median nerve innervates the muscle that causes the thumb to oppose to the other fingers. Weakness and then atrophy of this muscle which is irreversible significantly impairs hand function. Unfortunately, because the problems develop slowly over time, many patients accommodate to the problem and present with very advanced disease when the nerve is dead and the muscles are gone.

Treatment for Fingertip Injury

Finger tip injuries are very common hand injuries orthopedic doctors deal with on a daily basis. finger tip injuries can occur from a car door, lawn mower, cutting up vegetables and etc. Dr Goravanchi offers strategic flaps to reconstruct finger tip wounds.

A fingertip injury can be determined by examining the extent of the amputation using the joints as a reference point. If the injury does not extend beyond the joint closest to the cuticle, the injury is labeled a fingertip amputation.

Solutions for Fingertip Injuries

A Finger Flap is skin tissue taken from appropriate areas of the patient’s body such as the hand, love handles, the back, and the gluteus maximus to patch areas of a finger tip injury. The flap used is completely dependent on the patient’s circumstances.

There are a variety of finger flap procedures that are utilized by orthopedic surgeons. Cross finger flaps are most popular when more than one third of tissue is absent from a finger tip amputation. Tissues like the flexor tendon, joint, or bone. The cross finger flap allows the orthopedic surgeon to cover more areas. Thumbs can be covered by the middle finger and small fingers can be supported by the ring finger.

Trigger Finger

Trigger finger is a painful condition that causes the fingers or the thumb (then called trigger thumb) catch or lock when bent. In the early stages there might be just some discomfort at the base of the digit and the locking may be only in the morning but the digits can then pop out and extend without much pain. As the condition worsens, the catching sensation, the locking, the popping, and the pain become more constant and it becomes more and more painful to straighten the digit. Eventually, the finger becomes more permanently locked or stiff, unable to fully extend or to flex without excruciating pain. Trigger finger is also called stenosing tenosynovitis because it is a stenosis (from ancient Greek meaning abnormal narrowing) that causes inflammation of the tendon (teno-) and its surrounding synovial tissue (-synovitis).

Symptoms Associated with Trigger Finger

Symptoms linked to trigger finger are as follows:

• Random lockup in the finger
• Pain straightening or bending
• Difficulty extending the finger
• Swelling & Stiffness

Cortisone Injection

An injection of cortisone into the area of inflamed tendon is the first step in the treatment of trigger finger. Cortisone injections and rest of the affected digit have a 50/50 chance of successfully treating trigger finger when the condition has only been present for less than 2-3 months and the locking is mild. However, if the condition is more long standing and the locking is more severe, cortisone injections are less effective and surgery is indicated.

Surgery

Ideally we should replace the worn out cable with a new one. Unfortunately, the Lord does not send us spare parts. But since the main problem is catching of the tendon knot over a pulley at the base of the finger, surgery can restore painless gliding of the tendon and stop the triggering effect. Surgery consists of removing or opening the culprit sheath in order to allow the affected tendon to glide freely though. It is important to realize, however, that surgery is only patch-work repair. We are not putting a new cable and we cannot stop the ongoing degeneration of the tendon. 

Most hand surgeons treat trigger finger by making an incision in the palm, dissecting the very delicate nerves that surround the tendon, and then cutting the pulley to free up the tendon. This involves a wound in the hand that needs to be stitched back and a prolonged recovery period.

Microvascular Surgery

Microvascular surgery is a broad term for surgery that involves the use of an operating microscope. Microvascular surgery (or microsurgery)is performed when a patient suffers from a detached body part such as extremities, limbs,genetalia, ears, and nose. Through the use of microvascular surgery it is possible to reattach severed body parts such as the hand or other amputated parts of the body. With extensive therapy it is also possible to regain functionality of previously amputated parts.

Emergency Replantation Assistance

Dr Goravanchi can return function to amputated parts, transfer less-injured digits to new locations to maximize function and achieve other positive results even when massive soft tissue injury has occurred. Our replantation team is capable of reattaching:

• Extremities, such as arms, legs, hands, fingers and feet
• Facial structures, such as ears, nose, lips and scalp
• Skin degloving injuries and massive wound defects

When Amputation Occurs

Proper care at the primary hospital is critical to the success of replantation. In case of a partial or complete amputation or avulsion injury, follow these steps:

1. Stabilize the patient: 
   Apply steady pressure to the stump and elevate it.
2. Collect all severed tissue, regardless of its condition:
   Wrap tissue in damp, saline-soaked gauze and place in a plastic bag on top of ice bath in preparation for the surgeons’ arrival. Successful replantation often depends on using as much original tissue as possible