CONSULTANT PLASTIC SURGEON
HAND SURGERIES
Dramatic advances have been made in recent years in treating patients with congenital defects, degenerative disorders, and injuries to the hand. Dr Ricardo has been at the forefront of these advances, committed to improving hand function and appearance.
"Surgeons who have the necessary training, expertise, and experience in reconstructive surgery are fit to perform cosmetic surgeries with excellent outcomes. Those surgeons only trained in aesthetic procedures will have much more difficulty doing the same. The more tools and training in plastic surgery the surgeons have, the more qualified they are! "
CARPAL TUNNEL SYNDROME
What is carpal tunnel syndrome?
Carpal tunnel syndrome is when the median nerve is squeezed (compressed) as it passes through the carpal tunnel. The carpal tunnel is an opening in your wrist that is formed by the carpal bones on the bottom of the wrist and the transverse carpal ligament across the top of the wrist. The median nerve provides sensory and motor functions to the thumb and 3 middle fingers. If it gets compressed or irritated, you may have symptoms. Always see Dr Ricardo for a diagnosis.
What causes carpal tunnel syndrome?
Most cases of carpal tunnel syndrome have no specific cause. But any or all of the following may be part of the cause: frequent, repetitive, small movements with the hands such as with typing or using a keyboard; frequent, repetitive, grasping movements with the hands such as with sports and certain physical activities; joint or bone diseases, such as arthritis, osteoarthritis, or rheumatoid arthritis; hormonal or metabolic changes, such as menopause, pregnancy, or thyroid imbalance; changes in blood sugar levels with type 2 diabetes; other conditions or injuries of the wrist, such as strain, sprain, dislocation, break, or swelling and inflammation and family history of carpal tunnel syndrome.
What are the symptoms of carpal tunnel syndrome?
Most common symptoms of carpal tunnel syndrome include weakness when gripping objects with one or both hands, pain or numbness in one or both hands, "pins and needles" feeling in the fingers, swollen feeling in the fingers, burning or tingling in the fingers, especially the thumb and the index and middle fingers and pain or numbness that is worse at night, interrupting sleep
How is carpal tunnel syndrome diagnosed?
Dr Ricardo will check your health history and give you a physical exam. He may advise electrodiagnostic tests on your nerves. These tests are the best way to diagnose carpal tunnel syndrome. Electrodiagnostic tests stimulate the muscles and nerves in your hand to see how well they work.
How is carpal tunnel syndrome treated?
Dr Ricardo will discuss different treatment options with you. Treatment will depend on your symptoms, age, and general health. It will also depend on how severe the condition is and may include:
-
Splinting your hand: this helps keep your wrist from moving. It also eases the compression of the nerves inside the tunnel.
-
Anti-inflammatory medicines: these are taken by mouth (oral) or injected into the carpal tunnel space. These ease the swelling.
-
Worksite changes: changing the position of your computer keyboard or making other ergonomic changes can help ease symptoms.
-
Exercise: stretching and strengthening exercises can help when your symptoms are better. A physical or occupational therapist may watch you do the exercises.
-
Surgery: you may need surgery if the condition doesn’t get better with other treatments or go away on its own. This surgery is called carpal tunnel release. This eases compression on the nerves in the carpal tunnel.
CUBITAL TUNNEL SYNDROME
What is cubital tunnel syndrome?
Cubital tunnel syndrome happens when the ulnar nerve, which passes through the cubital tunnel (a tunnel of muscle, ligament, and bone) on the inside of the elbow, is injured and becomes inflamed, swollen, and irritated. Cubital tunnel syndrome causes pain that feels a lot like the pain you feel when you hit the "funny bone" in your elbow. The "funny bone" in the elbow is the ulnar nerve, a nerve that crosses the elbow. The ulnar nerve starts on the side of your neck and ends in your fingers.
The symptoms of cubital tunnel syndrome may seem like other health conditions or problems, including the golfer's elbow (medial epicondylitis). Always see Dr Ricardo if you have pain or trouble moving that affects your regular daily activities, pain doesn’t get better or gets worse with treatment and numbness, tingling, or weakness in the arm or hand.
What causes cubital tunnel syndrome?
Cubital tunnel syndrome may happen when a person bends the elbows often (when pulling, reaching, or lifting), leans on their elbow a lot, or has an injury to the area. Arthritis, bone spurs, and previous fractures or dislocations of the elbow can also cause cubital tunnel syndrome. However, in many cases, the cause is not known.
What are the symptoms of cubital tunnel syndrome?
The most common symptoms of cubital tunnel syndrome are numbness and tingling in the hand or ring and little finger, especially when the elbow is bent, numbness and tingling at night, hand pain, weak grip and clumsiness due to muscle weakness in the affected arm and hand and aching pain on the inside of the elbow
How is cubital tunnel syndrome diagnosed?
In addition to a complete medical history and physical exam, diagnostic tests for cubital tunnel syndrome may include:
-
Nerve conduction test: a test to find out how fast signals travel down a nerve to find a compression or constriction of the nerve.
-
Electromyogram (EMG): this test checks nerve and muscle function and may be used to test the forearm muscles controlled by the ulnar nerve. If the muscles don't work the way they should, it may be a sign that there is a problem with the ulnar nerve.
-
X-ray: this is done to look at the bones of the elbow and see if you have arthritis or bone spurs in your elbow.
How is cubital tunnel syndrome treated?
The most effective treatment for cubital tunnel syndrome is stopping the activity that is causing the problem. Treatment may include resting and stopping any activity that aggravates the condition, such as bending the elbow; a splint or foam elbow brace is worn at night (to limit movement and reduce irritation); using an elbow pad (to protect against chronic irritation from hard surfaces); anti-inflammatory medicines (such as ibuprofen or naproxen) and nerve gliding exercises. If these treatments don't work, Dr Ricardo may talk to you about steroid injections to help reduce swelling and pain, and surgery.
To prevent cubital tunnel syndrome, you may keep your arms flexible and strong, don't rest on your elbows, especially on a hard surface, and warm up before exercising or using your arms for sports or other repetitive movements.
DE QUERVAINS TENDINITIS
What is De Quervains tendinitis?
De Quervain's tendinitis is a condition that develops from irritation or swelling of the tendons along the thumb side of the wrist. This irritation causes the compartment (lining) around the tendon to swell, changing the shape of the compartment and making the movement of the tendons difficult. The swelling can cause pain and tenderness along the thumb side of the wrist, usually noticed when forming a fist, grasping items, or turning the wrist.
What are the symptoms of De Quervain's tendinitis?
Pain over the thumb side of the wrist is the primary symptom of De Quervain's tendinitis. The pain may appear either gradually or suddenly, and it can be felt in the wrist or forearm. The pain is usually worse with the use of the hand and thumb, especially when forcefully grasping items or twisting the wrist.
Swelling over the thumb side of the wrist is noticed and may be accompanied by a fluid-filled cyst in this region. An occasional "catching" or "snapping" may also be noticed when moving the thumb. The pain and swelling may make moving the thumb and wrist difficult, and irritation of the nerve lying on top of the tendon sheath may cause numbness on the back of the thumb and index finger.
How is De Quervain's tendinitis diagnosed?
A Finkelstein test is generally performed to diagnose this condition. In this test, the patient makes a fist with the fingers over the thumb, and the wrist is bent in the direction of the little finger. This test can be quite painful for the person with De Quervain's tendinitis, but tenderness directly over the tendons on the thumb side of the wrist is the most common finding.
How is De Quervain's tendinitis treated?
The goal of treatment is to relieve the pain caused by the irritation and swelling. In some cases, Dr Ricardo may recommend resting the thumb and wrist by wearing a splint. Anti-inflammatory medication taken by mouth or injected into the tendon compartment may help reduce the swelling and relieve the pain. In some cases, simply not doing the activities that cause pain and swelling may allow the symptoms to go away on their own.
When symptoms are severe or do not improve, surgery may be recommended. The surgery performed opens the compartment (covering) to make more room for the irritated tendons. Normal use of the hand can usually be resumed once comfort and strength have returned.
DUPUYTREN CONTRACTURE
What is Dupuytren contracture?
Dupuytren contracture, also called Dupuytren disease, is an abnormal thickening of the skin in the palm of your hand at the base of your fingers. This thickened area may develop into a hard lump or thick band. Over time, it can cause one or more fingers to curl (contract), or pull sideways or in toward your palm. The ring and little fingers are most commonly affected. In many cases, it affects both hands. Rarely, feet may also be affected. The symptoms of Dupuytren contracture may look like other health problems. Always see Dr Ricardo for a diagnosis.
What causes Dupuytren contracture?
Dupuytren contracture is believed to run in families (be hereditary). The exact cause is not known. It may be linked to cigarette smoking, alcoholism, diabetes, nutritional deficiencies, or medicines used to treat seizures.
You may be at greater risk for Dupuytren contracture if you are older as the condition starts in middle age, you are a man if your family comes from Scandinavian or Northern European; you have a family history, you take seizure medicine, smoke or abuse alcohol and have diabetes.
What are the symptoms of Dupuytren contracture?
Common symptoms may include not being able to lay your hand flat on a table, palm down (called the tabletop test), one or more small, sore lumps (nodules) in the palm, thick bands of tissue under the skin in the palm (the nodules may thicken and contract or tighten), pits or grooves in the skin compressed by the contracted finger (these areas can become very sore and can lead to skin loss if they don’t heal well), fingers are pulled forward and your hand is not able to work as well.
How is Dupuytren contracture diagnosed?
Dr Ricardo will examine your hand, testing the flexibility and feeling in your thumb and fingers. Your grip and pinch strength may also be tested and he will measure and record the locations of nodules and bands on your palm. Using a special tool, Dr Ricardo will measure how much your fingers are curling or contracting. The range of motion in your fingers may also be measured. These measurements will be compared to later measurements to see if the disease gets any worse. They can also be used to see if treatment is working.
How is Dupuytren contracture treated?
Dr Ricardo will create a care plan for you based on your age, overall health, past health, how serious your case is, how well you handle certain medicines, treatments, or therapies if your condition is expected to get worse and what you would like to do. There is no cure for Dupuytren contracture. The condition is not dangerous and many people don’t get treatment. However, over time, you may have trouble using your hand for certain tasks such as grasping large objects or straightening your fingers. Treatment for Dupuytren can slow the disease or help ease your symptoms and may include:
-
Surgery: this is the most common treatment used for advanced cases. It may be done when you have limited use of your hand. During surgery, the surgeon cuts (incision) in your hand and takes out the thickened tissue. This can improve the mobility of your fingers. Some people have contractures return. They may need surgery again.
-
Steroid shot (injection): if a lump is painful, a steroid injection may help ease the pain. In some cases, it may stop your condition from getting worse. You may need repeated injections.
-
Radiation therapy: low energy X-rays are directed at the nodules. This works best in the early stage of the disease. It can soften the nodules and help keep contractions from happening.
-
Enzyme injection: this is a newer, less invasive procedure done by specially trained surgeons. Medicine is injected into the area to numb the hand. Then the enzyme is injected into the lump of tissue. Over several hours, the enzyme breaks down and dissolves the tough bands. This lets the fingers straighten when the cord is snapped by the surgeon, usually the next day.
-
Needle aponeurotomy: this is another newer, less invasive procedure. Medicine is injected into the area to numb the hand. The surgeon uses a needle to divide the diseased tissue. No incision is made.
GANGLION CYSTS
What are ganglion cysts?
Ganglion cysts are very common masses (lumps) that sometimes grow in the hand and wrist. The cysts are generally found on the top of the palm side of the wrist, the end joint of a finger (mucous cysts), or at the base of a finger. Ganglion cysts often have a specific cause and usually come from nearby joints or tendon sheaths. These cysts can be painful, especially when they first appear or with constant or strenuous use of the hand. Ganglion cysts often change in size and may disappear completely. They are not malignant (cancerous). The diagnosis of a ganglion cyst is usually based on where the cyst is and what it looks like. X-rays may be recommended ruling out problems in nearby joints.
How are ganglion cysts treated?
Treatment of ganglion cysts may be simply watching for any changes. However, if the cyst is painful, limits activity, or has an unacceptable appearance to the patient, other treatment may be recommended. Nonsurgical treatments may include removing fluid from the cyst with a needle or wearing a splint to keep the hand or wrist from moving. If these treatments fail, surgery to remove the cyst may be recommended.
The goal of surgery is to remove the source of the cyst, which may require the removal of a portion of the joint capsule or tendon sheath next to the ganglion. If the ganglion is removed from the wrist, a splint may be recommended following surgery. Some patients may feel tenderness; discomfort and swelling at the site of surgery, but full activity can be resumed once comfort permits. While surgery offers the best success in removing ganglions, these cysts may return.
POLYDACTYLY
What is polydactyly?
Polydactyly is a condition in which an extra digit is present on the hand. It is the second most common hand anomaly. It can range from a small extra bump on the side of the hand to a finger that widens to end in two fingertips, an extra finger that dangles by a thin cord from the hand, or a hand that has a thumb and five fingers.
How is polydactyly treated?
The main treatment for polydactyly is surgery to remove the extra parts and correct associated problems. Surgery can be complicated because many variations are possible in the structures of the digit that is kept, from twisted bones and crooked joints to missing or extra tendons, nerves, and blood vessels. Abnormalities in the fingers that are kept may be more obvious after surgery than before, but with careful planning, Dr Ricardo can anticipate and correct these problems at the time of surgery.
After surgery, protecting the hand in a large bandage is usually necessary for weeks to months, depending on what is done. Surgery performed in childhood may need to be adjusted for growth with touch-up surgery when the child is older.
SYNDACTYLY
What is syndactyly?
Syndactyly is a term used to describe webbed or conjoined fingers. Incomplete syndactyly refers to webbing or connection between adjacent digits that involves only part of the affected fingers. Complete syndactyly refers to fingers that are joined out to the fingertip. Simple syndactyly refers to fingers that are joined by the skin and soft tissue only. Complex syndactyly refers to fingers in which the underlying bones are also joined together.
Syndactyly is thought to be the most common congenital hand difference, occurring in approximately one out of every 2,500 live births. It tends to occur in males more than females and Caucasians more than people of African or Asian descent. The third webspace (between the middle and ring fingers) is most commonly involved.
How is syndactyly treated?
Syndactyly is treated by surgically separating the joined digits. In most cases, a skin graft taken from the same arm or groin is required to provide adequate skin coverage of the newly separated digits. Fingers of different lengths are separated first to allow for normal growth and prevent deformity. These procedures are typically performed between the sixth and eighteenth months of life.
In general, only one side of a finger is separated at a time to avoid complications related to the blood supply of the affected digit. For this reason, patients with multiple fingers involved will often require more than one surgical procedure. In rare instances involving minimal functional or cosmetic problems, surgery may not be required.
TRIGGER FINGER
What is trigger finger?
Trigger finger, also known as stenosing tenosynovitis, occurs when any finger, including the thumb, becomes stuck in a bent position as if holding onto a trigger. After becoming stuck, the finger may snap into a straight position as if a trigger is being released. This condition is the result of a narrowed space around the tendon caused by inflammation. The tendon cannot move as freely in the narrowed area and can become stuck. Trigger fingers can recur but the condition generally corrects itself after a short while. More severe cases may become locked in the bent position and require surgery to correct it.
When the condition occurs in children as young by the time they are one year of age, the condition is known as congenital trigger finger. In these cases, the affected finger is most commonly the thumb and the condition is therefore often referred to as congenital trigger thumb.
What are the symptoms of trigger finger?
The most common symptom of a trigger finger is stiffness in the joints of the finger, especially in the morning. Other symptoms may include popping or clicking is felt when moving the finger, tenderness, sometimes accompanied by a lump in the palm at the base of the affected finger, swelling, and finger locked in a bent position, and unable to straighten.
Symptoms are usually worse in the morning and after periods of inactivity. Maintaining mobility and activity in the fingers will keep them from becoming too stiff. In some cases, more than one finger may be affected. In children with the congenital form of the condition, there is often no pain associated with the bent finger position and there is generally no history of trauma or repeated use of the joint. In about one-fourth of all congenital cases, the condition occurs in both hands.
How is trigger finger diagnosed?
To diagnose the trigger finger, Dr Ricardo will perform a physical examination and discuss the symptoms. This may include feeling for lumps in the palm, checking for how smooth mobility is in the affected finger, and looking for areas of pain. Usually, a physical exam is enough to make a diagnosis, however, further tests to determine any underlying conditions, such as arthritis, may be used. This may include blood tests to look for certain indicators of underlying conditions or magnetic resonance imaging to see the structure of the finger or hand.
How is trigger finger treated?
Depending on the severity, the condition may be treated with non-surgical methods including anti-inflammatory medications or local injections of a steroid into the joint. Splinting the affected finger or "buddy taping" it to the finger directly next to it can allow the finger to rest and heal.
If the condition is unable to be successfully treated with non-surgical methods and is affecting the patient’s quality of life, surgical treatments may be needed. Surgical treatment is usually an outpatient procedure that uses only local anaesthetic and may be done either in the office or in an operating room. Surgery will focus on removing or breaking up the constricting material that is causing the tendon to catch and lock in place.
For children with congenital trigger fingers, the condition may spontaneously correct itself before one year of age in many cases. If the condition does not correct itself, surgery is often performed to release the finger when the child is between the ages of 1 and 3 years old.
Recovery from hand surgery
Since the hand is a very sensitive part of the body, patients usually acquire pain medications following surgery. Injections or oral medication will be prescribed to make you more comfortable. How long your hand must remain immobilized and how quickly you resume your normal activities depends on the type and extent of surgery and on how fast you heal.
To enhance your recovery and give you the fullest possible use of your hand, Dr Ricardo may recommend a course of rehabilitation (occupational therapy) under the direction of a trained hand therapist. Your therapy may include hand exercises, heat and massage therapy, electrical nerve stimulation, splinting, traction, and special wrappings to control swelling. Keep in mind that surgery is just the foundation for recovery. It's crucial that you follow the therapist's instructions and complete the entire course of therapy if you want to regain the maximum use of your hand.