Excellencies - Hand Surgery

Degenerative Pathologies

Carpal Channel Syndrome

What it is

It is an inflammation of the median nerve caused by the compression, inside the carpal canal, of the flexural tendons of the fingers contained in it. Symptoms are: tingling and/or crampy pain from the extended hand to the forearm, mainly at night, decreased strength and sensitivity to the first three fingers. The causes of this disease are not yet known.
Useful diagnostic completion is the electromyography examination, an instrumental investigation aimed at identifying the site and quantifying the severity of nerve compression.

How to care

Conservative therapy (guardian) is indicated in selected cases. The resolutive treatment is the nerve decompression surgery, which, except in specific cases, is performed with endoscopic technique in local anaesthesia and at Day Hospital. The surgery, which lasts about 5 minutes, involves a small cutaneous incision on the wrist.
Physiotherapy, through simple exercises to be performed alone during the day, is an integral part of the treatment and allows you to use your hand immediately for normal daily activities and resume work in just a few weeks.

Finger snap in

What it is

Also called stenosant tenosynovitis of flexor tendons, it is an inflammation of the flexural tendons of a finger, which manifests itself with pain and sometimes with the formation of a painful tendon nodule at the base of the affected finger. This causes the characteristic trigger in the bending and extension movements of the finger, due to the mechanical difficulty encountered by the nodule to slide below the basal pulley.
Shooting is often accompanied by pain and consequent difficulty in movement. The causes are not always clear; it is often due to excessive tendon stress.

How to care

The conservative treatment (guardian) is effective in reducing symptoms, but is not always a solution to eliminate the shot. In case of persistence or reappearance of symptoms, surgery is indicated, which frees the tendon through the section of the pulley, with an incision at the base of the finger.
In selected cases it is possible to treat the disease in endoscopy by performing the procedure through two small cutaneous incisions at the base of the finger. The surgery lasts about 5 minutes and is performed under local anaesthesia and Day Hospital. After the operation it is useful to perform some simple physiotherapy exercises to avoid the formation of tendon adhesions.

Wrist cyst

What it is

Cyst is a benign swelling containing synovial fluid. This fluid is a lubricant that is located inside the joints and in the tendon sleeves. Cysts are an extremely common pathology; in most cases the neoformation appears on the back of the wrist, less frequently on the handheld side or at the base of the thumb. These swellings can be painful, especially after an effort.
The dimensions vary in time and sometimes, they are reduced until the temporary disappearance of the cyst. A specialist’s examination is sufficient for diagnosis and in some cases an ultrasound examination may be useful.

How to care

If the cysts do not cause pain or restrict movement, simply check that the volume does not increase. The aspiration with a needle does not eliminate the communication peduncle with the joint, thus often leading to an early reappearance of the cysts.
If symptoms are frequent or intense, surgical removal of the cysts is indicated. The surgery is performed in Day Hospital with the anaesthesia of the upper limb alone. In selected cases it is possible to treat the disease with an arthroscopic approach.
Although surgery is the most reliable method of treatment, reappearance of swelling is still possible, although rare. Some rehabilitation sessions are necessary to ensure an early recovery of motility and to treat the surgical scar.

Tendinitis by De Quervain

What it is

It is an inflammation of tendons, which extend and abduct (remove) the thumb from the hand. It causes very intense pain, located on the wrist, at the base of the thumb during grip movements, and makes everyday activities difficult. This tendinitis hardly resolves spontaneously and tends to become chronic. Among the most common causes are the stress of the new mother holding the child in her arms, musculo-tendine and hand tension of the musicians, and some work activities.

How to care

Preservative treatment with guardian is initially indicated. In resistant cases, the surgical procedure of releasing tendons is performed by means of a small incision on the wrist. The duration of the surgery is about 10 minutes, is performed under local anaesthesia and Day Hospital regime. Following the surgery, simple physiotherapy exercises are recommended to promote optimal healing of scar scar and tendon inflammation.

Rizoarthrosis

What it is

It is a form of degenerative osteo-arthritis, more common in women after the age of 40 years, that affects the base of the thumb at the level of the trapeziometacarpal joint. This pathology causes a deformation of the thumb, which loses its characteristic morphology and functional capacity, and makes gripping movements very painful. Pain is caused by bones rubbing, cartilage wears out and bone “beaks” occur which act as thorns, irritating the tissues. To diagnose the disease and its stage, a simple hand X-ray is performed.

How to care

Learning gestures that help to save joints and use a night rest brace can alleviate discomfort. The position of occupational therapist intervenes for this purpose. If the pain becomes unbearable and does not respond to conservative treatment, surgery is indicated, which is performed in Day Hospital and requires anaesthesia of the whole arm. Depending on the gravity, the procedure can be performed with open technique or arthroscopy technique. The thumb remains immobilized for two weeks, and then limited in movements for another 4 weeks.
Physiotherapy, which is as important as surgery, is very demanding and lasts about 3 months.

Dupuytren’s disease

What it is

Dupuytren’s disease, a shrinkage of handheld aponeurosis, is an abnormal thickening of the palm of the hand that can cause a restriction on finger movement. In more advanced cases, the presence of a cord under the skin is noticeable, which makes it increasingly difficult for the fingers to extend completely, until the fingers close. In some patients, the disease can also affect other parts of the body, such as the footplant or fingertips. The cause is unknown, but there is a certain familial predisposition. The disease is harmless and painless.

How to care

It is important to know that the presence of a nodule in the palm is not an absolute indication of intervention. The surgical treatment, which involves the removal of pathological tissue with consequent stretching of the fingers, is indicated if the function of the hand is compromised (it is not possible to fully extend the affected finger). It is also possible that after surgery, the disease may reappears in a period ranging from several months to many years.
The surgery is generally performed in Day Hospital with anesthesia of the upper limb alone. Post-operative treatment can be long and includes dressings and physiotherapy cycles, necessary to ensure the effectiveness of surgical treatment.
Guards are always necessary.

Collagenase: new frontiers in the treatment of Dupuytren’s disease

Among the treatments offered for Dupuytren’s disease, collagenase therapy is a recent acquisition.

The procedure, which ranks among non-surgical techniques, involves the local administration of an enzyme derived from the beat Clostridium Istoliticum. The drug, composed of two types of collagenase, injected into the cord, causes a weakening that allows subsequent mechanical rupture of the same iatrogenic by simple traction of the finger concerned.

It results in an active and passive extension reset and function recovery. Compared to surgery, when there is an indication, it has the advantage of being a treatment with reduced invasiveness that allows a rapid recovery of hand mobility.
Due to the absence of wounds and therefore of surgical scars following collagenase treatment, no medication cycles and prolonged rehabilitation treatments are necessary.

The procedure described represents, according to the first studies, a safe and effective alternative to surgery. Dupuytren’s collagenase treatment for contracture of Dupuytren’s disease is very similar to the surgical treatment of cordotomy or needle aponeurtomy. Both techniques are indicated for digital contractures at MF or RU with a well-defined aponeurotic cordon.

The cordotomy causes a mechanical interruption of the cord by means of a needle; collagenase weakens the cord, in this case exerting not a mechanical effect but a chemical effect of degradation of collagen type 4 characteristic of the pathological cord. In both cases, the second step is the forced finger extension with subsequent breakage of the rope. Therefore, the difference between cordotomy and collagenase injection is primarily the different way in which the cord weakens before it breaks.

It is almost possible to define the administration of colleganesis as an enzymatic fasciotomy to be contrasted with needle fasciotomy. The main difference between the two treatments seems to be the reoffending time which seems to be longer for collagenase although long-term statistics are needed to confirm the data and judge the actual different potentiality of the two techniques.