Our hands are designed for exploring and interacting with our environment. As such they are the body part most likely to be injured.
We see a range of hand injuries including lacerations, burns, fractures, injuries to tendons, ligaments, nerves and arteries. Some of these injuries will heal well given rest and elevation but some injuries are best treated with surgical repair.
Most hand injuries will benefit from the expertise of a hand therapist. They will manufacture a custom made splint if appropriate and oversee the rehabilitation of the hand. There is inevitable stiffness in the joints of the hand following any period of immobilisation, but particularly following the trauma of injury or surgery. An essential part of the rehabilitation process is the use of supervised exercises to increase the range of movement and strength when the hand has adequately healed.
Nail bed injuries
This usually results from a crush to the tip of the finger, typically a child catching their finger in a closing door or an adult striking the finger with a hammer. The impact lifts the nail from the finger, tears or bursts the underlying nail bed (pink area underneath nail) and will often fracture the bone. If left untreated the finger tip may become infected, unstable or develop a secondary nail deformity. The nail bed holds the nail onto the underlying bone. If a wide laceration of the nail bed is not accurately repaired it leaves a large scar which will not hold the new nail securely. The result is a deformed nail that may be ridged, strangely shaped or lifting at the edges and frequently caught on things. This can be difficult to fix secondarily so is much better treated immediately after the injury has occurred. Surgery involves removing the nail, cleaning the wound and repairing the lacerations with fine dissolving sutures under magnification. If the bone is broken it may require a wire to stabilise it for 4-6 weeks but frequently can be managed in a plastic splint for this period. This keeps the bone still and thus heals nicely in the correct position. The old nail may be replaced at the time of surgery and used as a splint whilst the new nail is forming. This new nail will gradually push out the old nail over the next few weeks. It takes about 3 months for the new nail to reach the tip of the finger. The resulting nail may look deformed whilst it is growing but usually settles over the next 6 months.
It is possible to break any of the 27 bones in the hand depending on the mechanism of injury and position of the hand. The fractures are usually diagnosed with a plain x-ray but occasionally a CT scan is useful to further delineate the fracture pattern. Many fractures will heal nicely if kept immobilised in a plaster / splint for 4-6 weeks. Some fractures are best treated with an operation to reset the broken bones and hold them together with metal wires or internal plates and screws. This surgery should be performed within 2 weeks of the injury before the bones have stuck together in the wrong position. With all fractures it is essential that the broken bones are kept still whilst they are healing. This will usually mean no use of that hand for about 6 weeks. This may mean no work, depending upon occupation, but certainly means no sport, no driving and no lifting / carrying for this period. Certificates can be provided for this time away from normal duties (including washing the dishes) if necessary.
Glass and knife lacerations to the fingers frequently damage the tendons on the front (flexors) or back (extensors). Without the functioning tendon the finger will not bend / straighten. Most tendon lacerations are managed with a surgical repair to stitch the two ends back together. Following the repair you will be referred on to our hand therapist for a carefully supervised rehabilitation regime. The tendon repair is usually strong enough to allow gentle movement of the finger which is essential to prevent scar tissue forming around the tendon, sticking it to the surrounding structures. However, moderate or forceful movement will snap the tendon sutures and require a secondary repair in the operating theatre, and usually a worse long term outcome.
The nerves in the hand and wrist may be cleanly cut by glass or blade lacerations or may be stretched / avulsed by excessive traction. The result of this trauma will depend on which nerve is injured but will cause numbness and / or muscle weakness downstream. Surgical repair will increase the chance of the nerve recovering function and will also reduce the occurrence of a painful ball of scar / sensitive nerve endings (neuroma) at the cut end of the nerve. The aim of surgery is to approximate the cut ends of the nerve to allow the internal nerve filaments (axons) a passage to grow down. The nerve fibres downstream of the injury will die following a laceration but the cut end will send sprouts of new fibres that can be guided to the correct destination if the ends are accurately joined together. The repair if performed using a microscope and very fine sutures. The results of surgery vary considerably depending on the level of the nerve injury, the mechanism and the age of the patient. Generally speaking, young patients with a clean cut of a distal nerve do best. The repaired nerve will take many months to years to heal.