Hand and Microsurgery
Hand surgeon starts from shoulder and extends to finger tip of our body and is a surgeon field related a section named as upper extremity. Many problem requiring surgical treatment and concerning upper extremity notably treatments of hand injuries, which occurred depending upon trauma and various accidents.
Microsurgeon is a surgeon technique applied by means of expanding of operation field by using special auxiliary equipment called as operation microscope or loop. By this means, problems in structures such as nerve, vein normally seen difficulty with naked eyes are possible to be treatet. Microsurgeon technique is a technique used in many branches such as plastic surgeon, ortopedics, neurosurgery, eye diseases and gynaecology.
As a result of occupational accident, trafic accident, glass cut, fallings or such accidents showing increase in our daily life, suture of broken organs are carried out successfully in our hospital.
Hand and microsurgeon staff presenting only in a few center in Istanbul has carried on business in our hospital since 1995. The staff, which has carried thousands successful operations up to the present, is able to perform critical operations (broken finger, arm and leg operations), for 24 hours.
In addition, treatment of form and function disorders resulting of ambustions, natural-born anormalities in arm and legs are also able to be performed.
Our objective is not only provide our patients with therapeutical services but also to present our patients protective health services. Our Hospital provides free of charge consulting service for work place and business health and organizes training studies.
Arm, underarm and hand injuries, cuts;
- Hand, finger, wrist fractures;
- Elde uyuşma şikayetleri (sinir sıkışması)
- Pins and needles complaints in hand (nerve compression)
- Stucking complaints in finger
- Mass in hand, wrist and arm
- Congenital hand deformities
- Rheumatic diseases of the hands and feet
- Apoplexies, congenital and traumatic sensation and movement defects depending upon function disorders of arm nerve;
- Ligament problems and pains of hand and wrist joints
- Wrist arthroscopy;
- Hand vascular problems;
- Overcome the lack of tissue in the upper extremities
Carpal Tunnel Syndrome
The median nerve progresses with 9 tendons in the space called carpal tunnel inside of wrist. Ailments resulting of compression and entrapment of the nerve on this area are called as carpal tunnel syndrome.
Often the exact cause can not be found. Stenosis of carpal tunnel for any reason causes a pressure on the nerve and then this causes symptoms to come out. Thickening of traverse carpal ligament consisting of the roof of tunnel, swelling of tendon sheath, bulks causing stenosis in tunnel, pregnancy and some hormonal changes are the most common reasons leading to this syndrome.
Carpal tunnel syndrome leads to mostly pain, quick fatigue when doing manual works, pins and needles in thumb, index finger, middle finger and the ring finger. Thinning may be seen on the vertex of muscle at the base of thumb. It is typical that symptoms occur or increase especially in the evenings. In severe cases, begins to spread throughout the day.
Diagnosis is made mostly through EMG (electromyography) by neurology specialists. In suspected cases, additional radiologic examinations may be required in order to reveal old bone fractures or probably bulks.
In some cases, wrist splints symptoms may be relieved or removed. Steroid injections may help regressing of symptoms by decreasing swellings around the nerve.
Despite of conservative measures continuing during several months, operation is needed in ongoing carpal tunnel syndromes. Tunnel is reached with a cut made between palm and wrist and transvers carpal ligament forming the roof of tunnel is liberalised. Neurolysis (nerve liberalization) should be done under microscope to the thickened nerve sheath of median nerve in advanced cases. Thus pressure around the nerve has become removed. Endoscopic carpal tunnel (closed method) may be applied in selected cases. However, the whole of symptoms may not be removed after operation in some very heavy and late in the day cases.
Ganglia (ganglion, Cystic Hygroma)
They are cystic neurinoma filled with a liquid gel consistency coming over the joint capsule, tendon or tendon sheath. They are benign tomors common in hand. In general, they occur mostly in women and between the 20-40 years of age. They come out in a single cyst form and mostly in wrist and certain places in hand, they can settle in almost every joint of wrist and hand. According to frequency of ganglion, they may occur on the dorsal side of the wrist (dorsal ganglion), on the inside of the wrist (volar ganglion), on the section where palm is close to fingers (volar retinakuler ganglion) and at the level of the end joints of fingers, in feet.
They have no definite reason. After repetitive microtrauma they may occur. They have no direct relationship with the profession of patient. As they can suddenly occur, they may develop slowly over months. Patients usually come to medical attention because of the swelling. Swelling may be decreased with rest and increased with activity. Sometimes they may be eliminated as a result of cysts explosion. Cysts, which overgrow, may cause pain during motion of joints. These cysts are not malignant and do not spread to other regions.
During the examination, diagnosis is made by detecting the bulk occurring on the cysts area. They may be oval or circular; soft or too hard consistency. Small nodules are generally hard consistency. When pressure is coming over them or making punch, they can be painful. In order to eliminate joint mechanics pathologies below and bone lesions, to make radiological examinations is beneficial.
Treatment must be carried out in order to observe most patients. Sometimes bulks are progressing painless. Some of them may be lost over time. When the cyst becomes painful; in case of occurrence of restriction in movements and functions; when there is too much swelling and in case of a bad appearance aesthetically, surgical treatment must be applied. The operation is performed in the environment without bleeding by using tourniquet under axillary block anesthesia when entire operated arm is anaesthetized. To minimize the likelihood of risk of recurrence of the cyst, to reach joint space where the origin is obtained and to create and remove a window here is necessary. Brace use may be required for a period of 10 days after operation in some cases. Patients return to normal activities as soon as possible.
Trigger finger (trigger finger, trigger thumb) also known as stenosing tenosynovitis in medical terminology is a disorder of tendons providing fingers in hand to be bend and disorders of pulleys they are passing under certain points.
Tendons are in a long rope form beginning from forearm muscles continuing to fingers. Pulleys are structures providing a motion order of tendon and under which tendons are passing at certain points. These pulleys approximate tendon to the bone. There is a fine structure providing easy sliding of tendons around within the tunnels (tenosinovyum).
Trigger finger refers to thickening of pulley existing at the base of finger, sometimes stucking and pain presence of fingers during movement due to swellings occurred in the tendon sheath. After this problem started, use of finger cause generally fingers to be worsening by leading to swelling of structures here.
Sometime complete stucking and finger lockings may occur.
Generally reason of occurrence cannot be detected. Rheumatoid arthritis is more common in systematic diseases such as gout, diabetes. Rarely traumas in the palm and base of finger may be factor.
Trigger finger starts with discomfort in the joint place of fingers with palm. With pressure feeling, there is sensitivity to this area. On this area, sometimes nodule (hard swellings) may be sensed. In the future, finger starts to be stucked and locked.
The purpose of the treatment is to eliminate feeling of disorder during movement by preventing stucking of finger. During movement for decreasing of swelling of flexor tendon and tendon sheath, this provides much easier sliding. For this purpose, oral anti-inflammatory medicines and brace use symptoms, activity decreasing is preferred in patients, who have started newly. Steroid injection to the area may help symptoms to be decreased, but we do not use steroid injection because steroid damages tendon structures in the long term.
In cases long-continued and not receiving response with medical treatment, loosing of pulley causing compressio, is the treatment option which should be selected. Operation is carried out under a local anesthesia with a small cut in the palm. In operation, preservation of vein nerves structures progressing close around tendon sheath is important. Symptoms usually regress completely in the postoperative period and recurrence does not occur after well-performed surgery. In some patients, hardness of the wound area may occur due to excessive scar tissue. This regresses generally in the course of time with the massage made at home.
Cubital Tunnel Syndrome
Cubital Tunnel Syndrome is causing problems such as pain, swelling, numbness and loss of power as a result of exposure to compression or pressure of ulnar nerve, which is one of the three main nerve of hand. Nerve progresses through two starting point of its muscle bend wrist (flexor carpi ulnaris) by passing through two osteophytes in our elbow.
When we bend our elbow, ulnar nerve is stressed and is compressed by being pushed to the osteophyte called as medial epicondyle. When passed a long time in this position, forming of cubital tunnel syndrome is easy in persons, who have to base upon continuously their elbow when working , in sleeping persons, who sleep in the way that their hands are under their head (their elbow are in twisted form). As conduction quality of nerve fibres between thickened connective tissue is being spoiled, symptoms of syndrome come out.
Symptoms of cubital tunnel syndrome forms pain, weakness, numbness especially in fourth and fifth fingers, an electric shock feeling even after small throbbing occurred in the level of elbow to the nerve (figure 2.) In the future, it is seen that fourth and fifth fingers are bend backwards when trying to keep hand smoothly and persons having these symptoms have difficulty in approaching of fingers to each other.
Diagnosis, detection of new findings above in the physical examination is made with nerve conduction test and EMG (Electromyography) performed by neurology specialists.
In early cases, nerve is provided to be traumatized at the very least by describing firstly patients positions revealed by these symptoms and positions, in which nerve is stressed. In some cases, splints, which hold the elbow straighter, help to relive symptoms. However, operation is required in long standing and advanced patients. In the operation, arm is numbed usually (axillary block anesthesia). Ulnar nerve is moved to the front of the elbow by removing from two protruding bones in the elbow (figure 3.)Numbness and tingling feelings may take several weeks-months. In some patients, the postoperative physiotherapy is needed.
De Quervain's tenosynovitis Thumb Tendon Compressio)
Our tendons with which we make movements lifting thumb and moving it from other fingers pass under a tunnel on the area close to the base of thump on the wrist. With thickness and harnesses occurring in the tunnel, swellings occurred in sheaths of tendons make movements of tendons difficult by sliding under tunnel during movements of thumb. This situation encountered with pain and sensitivity in wrist, is mentioned with the name of Swiss surgeon (Fritz de Quervain), who have for the first time described.
Mostly, this tendon compression is seen after new-started, compelling and repeater movements. Especially, hand position of new mothers when they are carrying their babies; the effects of hormonal fluctuations during pregnancy and lactation make easy occurrence of this situation. Quervain's tenosynovitis may be encountered after wrist fractures, traumas suffered, weight exercises made with unusual weights.
Pain seen in the side of the wrist is the most typical symptom. Pain shows mostly spread to the forearm above and to the thumb below. Pain increases in twisting motions of wrist and strong grip when thumb is used (Figure 1). On the area of wrist having pain, swelling may also occur. Pain occurring in the wrist when we twist little finger in direction of finger by taking thumb in punch is typical for diagnosis.
Rest of hand by using splinter deactivating painful movements of thumb in the initial period is very important (Figure 2). Swellings of the tunnel and tendon sheaths are tried to be decreased by supporting with no steroidal anti-inflammatory pain killers in this period. If symptoms are not recovered and are being intensifying, the tunnel compressing tendons should be opened surgically. This operation may be carried out by making local anesthesia to all arm or only wrist.
This is a situation occurring with abnormal thickening of structure (fascia) undertaken the protection task for tendon nerve and vein structures passing under and locating immediately under the skin of the palm. Fascia thickening extends from palm to the fingers. Some harnesses called as nodular occur on the skin and twists occur towards palm in the fingers in the future.This disease also can be seen in the soles of the feet and penis.
Generally, the disease is encountered in males over the 40 years of age. As the incidence was higher in diabetic patients, relation of it with hand injuries and other diseases has not been proven. Though more common in small and middle finger, all the fingers may be affected.
Swelling in the palm and increase in crasises is observed in the examination. Hardnesses thickened associated with swellings come to hand in the palm. Twisting depending on drawing of cord in the advanced stages of the disease in the fingers occurs. Both of hands are affected together in most patients. If disease starts early, it proceeds more severe.
Plam nodules forming dependent upon Dupuytren disease are painless. Disease is firstly realized with difficulty in putting palm on smooth surfaces. While twisting in fingers is increasing, difficulty is formed in restriction in daily activities and hand washing, hand shaking, pulling on glove, gripping something etc. movements. The development speed of disease differs from patient to patient.
If functions are not affected in patients being in the initial phase, the patient is followed-up. If there is not any twisting in fingers, the presence of nodules in palm do not singly arise requirement of operation. In these cases, steroid injection may reduce the rate of disease progression over the nodules. Surgical treatment is considered in cases finger are twisted 70 degrees and over. The aim in the surgery is to remove the whole hardened fascia extending to the palm and fingers by protecting vein nerve structures.In some cases, after removal of the hardened strips, deficiencies, which may occur on the structure of skin coverage are removed with skin grefts obtained from other parts of the body. Splint application is very important in terms of success of physical surgical treatment.