Clinical Issues

Below you will find some information and explanations from the field of hand surgery and the latest publications of our department.

 Arthrosis

Arthrosis is a degenerative joint disease that that can be caused by age and also as a result of an accident involving the articular surface or a disruption of normal movement processes (e.g. scapholunate ligament injury). The therapeutic possibilities here range from an arthroscopic joint flushing via denervation operations to partial or full fusion interventions. The main focus is to make the loading capacity as painless as possible, whereby the overall mobility of the hand is maximised. For this reason artificial joints (total endoprostheses) are also used.

 CRPS / Chronic Regional Pain Syndrome / Morbus Sudeck / reflex dystrophy

This is a very complex disease/complaint. After often simple injuries (e.g. broken radius) circulatory disorders, swelling, pain and functional limitations can occur but the precise mechanism of this disease is still unclear. While CRPS is very difficult to treat in cases of late diagnosis, a good treatment result can nonetheless often be achieved in the early stages and through interdisciplinary collaboration (hand surgery, hand therapy, consisting of occupational therapy and physical therapy, psychotherapy and anesthesia). Such therapy is, however, very time consuming, so it should be conducted with sensible hospitalisation.

 Dupuytren's Contracture

In this very common illness, a reduction in the so-called palmar aponeurosis, a connective tissue layer under the skin in the palm, occurs. The patient displays an apparent shortening of the flexor tendons which protrude and are clearly visible and palpable under the skin. The fingers are pulled into the palm of the hand, which can continue indefinitely until the gripping function is significantly impaired. The altered fasciae can be carefully separated and removed from the underlying flexor tendons and the neurovascular bundles under magnifying loupes. In many cases full finger extension can be achieved again. If, in advanced cases, a shortening of the skin covering has occurred, some minor flap surgery may be required. The procedure can be performed on an outpatient basis in most cases.

 Ganglia

This is an absolutely benign cyst formation in proximity of the joints and tendon sheaths with gelatinous content that occurs in patients at any age. Most commonly, the finger-end joints, flexor tendon sheaths and especially the extensor-side of the wrist are affected. Patients complain of a hard-elastic protrusion / swelling (lat .: tumor), which occasionally can also change in size. The skin above is mostly very easily displaced, in many cases, the tumor is asymptomatic, movement pain occasionally occurs or patients feel affected cosmetically. The removal of a ganglion can be accomplished in the context of an outpatient procedure. Postoperative immobilization is not necessary in many cases. With ganglion of the wrist, which is at the joint of the capsule, immobilization for a period of two to three weeks make sense, however, due to damage of the wrist capsules. Ganglia are absolutely benign, but may form again and cause nerve compression syndromes.

 Vasular Injuries

Vascular lesions ranging from the small occasional opening of a vessel right up to destruction of a long segment of a vessel section. In most cases they occur in the context of more extensive hand injuries. Here, the simple stitching of the vessel to the segment replacement is sufficient.

 Carpal Injury (bone and ligamentous)

Carpal injuries are far more common than it is assumed. The insidiousness of these injuries is that they can be easily overlooked if not targeted and investigated. An injury to the carpus, both boney and to the connecting sides of the ligaments, has a significant impact on the overall functioning and load capacity of the affected hand. One of the most common injuries here is the so called SL-ligament injury (ligament that connects the scaphoid and lunate), leading to a complete breakdown of the wrist (carpal collapse) which can thus lead to a lack of function of the affected hand, if are not detected in time. In addition to the diagnostic imaging facilities such as computer tomography and magnetic resonance imaging the gold standard here is wrist arthroscopy, in which the entire extent of injury can be diagnosed safely and the further therapeutic steps taken. The treatment of such an injury requires great hand surgery experience and should only be performed in specialized treatment centers.

 Hand and Forearm Infections

Even the slightest damage to the skin, for example from a thorn or bite of a cat, can, under adverse conditions, lead to severe infections with acute danger to the affected limb or even to the life of the patient, within a short time. In certain cases, immediate surgery is the only option to save a limb, if not a life. The assessment of when an infection requires surgery or merely conservative treatment requires a great deal of experience.

 Scaphoid Pseudarthrosis

The scaphoid is in many respects a special bone in the wrist. It is firstly the connection between the proximal and distal carpal rows, on the other hand fractures of the scaphoid are very difficult, sometimes impossible to detect in conventional x-rays, and are therefore often overlooked. After a brief period of freedom from symptoms significant discomfort may occur and the biomechanics of the wrist deteriorates in the long run.

In cases of non-healing bone fractures (pseudoarthrosis) it is possible to promote healing through surgical measures. Here the range of options extends from a simple screw connection through to the combination of cancellous bone graft (cancellous = tissue from the medullary canal of the bone) and the introduction of a cortico- cancellous iliac crest bone through to the pedicled and free vascularized bone graft. Surgery on the scaphoid should be performed in a subsequent specialized hand surgery center, as this requires extensive and specific experience.

 Scaphoid Fracture

The scaphoid is in many respects a special bone in the wrist. It is firstly the connection between the proximal and distal carpal rows, on the other hand fractures of the scaphoid are very difficult, sometimes impossible to detect in conventional x-rays, and are therefore often overlooked. Fractures of the scaphoid are therefore prone to pseudarthrosis (lack of healing of bone fractures), which is why an early diagnosis and the initiation of appropriate therapy is even more important. Many scaphoid fractures require surgical treatment with a screw, but for the most part, undisplaced scaphoid fractures can heal without surgical intervention in many cases. In some cases immobilization can be completely dispensed with or at least  reduced to three weeks. Nowadays a computer tomography should be performed for treatment planning of every scaphoid fracture.

 Capsular ligament injuries (eg. Skier's thumb)

Skier's thumb is a rupture of the ligaments on the ulna-side of the metacarpophalangeal joint. The injury typically occurs during a fall with a pole in the hand, but can also occur in many other injury mechanisms. The result is an instability in the metacarpophalangeal joint, which is particularly painfully noticeable when grasping of cylindrical objects (opening a bottle or a marmalade jar). In the long this can result in the functional impairment and wear of the metacarpophalangeal joint. As the torn ligament, often called the adductor aponeurosis, crosses over a tendon structure in the 1st. interdigital fold it can not heal spontaneously. An operational reinsertion (reattachment of a ligament / of a tendon to the bone) of the ligament is therefore required. The procedure can be performed on an outpatient basis. After surgery, immobilization in a special skier's thumb plastic cast is necessary for a period of five weeks, in which the tripartite finger, as well as the wrist and thumb joint remain free. In some cases it is highly probable that the tendon is bruised over the adductor aponeurosis, which also allows a completely conservative therapy over a period of five weeks.

 Paediatric Malformations

The malformations range from simple ring tendon tightness on the thumb to the most complex congenital anomalies. A detailed consultation and personal presentation is essential here.

 Fractures of fingers, metacarpal, carpal, wrist and forearm

All fractures and fracture forms can be provided for with modern techniques and implants. The ultimate goal is to produce a situation that allows the functional aftertreatment without cast or cast immobilization.

 Lunate Osteonecrosis

Lunate osteonecrosis is the partial or complete withering away of the lunate (carpal bones). The exact origin of the disease is unknown; different mechanisms are discussed. The disease proceeds in several stages and if untreated, leads to the complete dissolution of the bone. There is therefore a loss of power and loss of motion of the wrist. After very careful diagnosis is provided all treatment options are available here. Careful preoperative planning is essential as a conservative (non-surgical) treatment may possibly also still be beneficial. An individual consultation and comprehensive diagnostics are indispensable.

 Tumors of the hand and forearm

Fortunately, the most common tumors of the hand are benign and can often be removed in the context of an outpatient surgical procedure. Also, the exploration for and removal of a so-called sentinel lymph nodes is possible if necessary. Of course, larger tumors can be removed and elaborate reconstructions can be performed.

 Burns

A burn is an injury to our largest organ, the skin. In more extensive cases, it is an injury affecting all organ systems, but which at first glance, only appears to have affected the body surface area. The severity of the injury is made up of the combustion depth and the proportion of body surface area burned. In hand surgery, we focus on function-preserving and reconstructive procedures on the hands and forearms. Small burns are treated on an outpatient basis in emergency assistance. In more extensive cases, the burn center is available to us headed by Dr.med. Markus Öhlbauer. Both the acute phase as well as the function disabling consequences of injuries through extensive scarring (Kelloid) belong to this range of treatments. In collaboration with the Department of Plastic and Reconstructive Surgery and Burn Treatment , as well as anesthesia, intensive care and orthopedic technology, we have all the treatment options available, from burns treatment bath and intensive care to HBO (hyperbaric oxygen therapy), laser treatment and supply of customized compression garments.