Dr Gautam Tawari is one of best trained hand surgeons in Mumbai,India. He has trained at the Pulvertaft Hand Centre (UK) which is an apex institute for Hand surgery training in the United Kingdom and the world.
We use our hands extensively for many simple yet essential tasks like – eating, maintaining hygiene, carrying. An injury or condition that affects one or both of our hands usually turn these routine tasks into big challenges.
Hand surgery is about restoration of hand function, Dr Tawari offers a comprehensive evaluation, diagnosis and treatment of both simple and complex conditions of the hand, thumb, fingers, wrist and forearm.
Common Hand Problems and Related Information
Fingers can bend due to action of tendons, these tendons are supported along their length by tunnels of ligaments called pulleys. Inflammation of this tendon sheath (teno-synovium) leads to snapping when the finger is straightened, this is called trigger finger or trigger thumb.
Presence of nodule
Repetitive Motion – Individuals who perform heavy, repetitive hand and wrist movements or prolonged gripping.
Medical Conditions – Hypothyroidism, Rheumatoid arthritis, diabetes, and sometimes Tuberculosis.
- Pain and tenderness over inflamed tendon nodule.
- Sudden popping sensation and straightening of finger.
- Feeling of stiffness in finger joints.
- Locking with inability to straighten the finger/thumb.
Long-term complications of untreated trigger finger/thumb can include permanent digital swelling and joint stiffness or tearing of the tendon.
Non surgical treatment is used in early stages of the condition. This includes :-
- Activity modification – Rest, avoiding repetitive gripping actions.
- Occupational therapy – massage, heat, exercises to improve the finger movements.
- Non-steroidal anti-inflammatory drugs (NSAIDs) may help to relieve pain and inflammation.
- Steroid injections may help reduce the inflammation.
Surgery is advocated in case of nodule, late stage of condition on presentation, recurrence or failure of non-surgical treatment.
Trigger finger/Thumb release surgery is performed under local anaesthesia or Wrist Block. The pulley resulting in tightness is released to allow free movement of the tendon. Recovery takes 2 weeks after surgery, residual stiffness may take unto 3 months to settle fully.
In a normal thumb joint, known as the carpo-metacarpal (Thumb CMCJ) joint, cartilage covers the ends of the bones acting as a cushion and allowing the bones to glide smoothly against each other. With thumb arthritis, the cartilage that covers the ends of the bones is lost. The bones then rub against each other, resulting in friction and joint damage.The damaged joint can produce noticeable lumps on the thumb joint.
- Previous trauma or injury to the thumb joint.
- Certain hereditary conditions, such as joint ligament laxity and malformed joints.
- Medical Conditions – Rheumatoid arthritis, Psoriasis.
- Activities and jobs that put high stress on the thumb joint.
- Pain at the base of the thumb on griping, grasping, pinching or loading of the thumb.
- Swelling & stiffness at the base of thumb
- Reduced strength when pinching or grasping objects
- Reduced range of motion
- Enlarged or bony prominence of the joint at the base of your thumb
Non surgical treatment can help in the early stages of the disease. This includes :-
- Activity Modification
- Painkiller – Non steroidal Anti-inflammatory Medications.
- Thumb Spica Splint
- Steroid Injection
Surgery is advocated when the pain is intractable or on failure of non surgical treatment. Options include:
- Joint fusion (arthrodesis) – The bones in the affected joint are permanently fused. The fused joint can bear weight without pain, but has no flexibility.
- Trapeziectomy – The bone at the base of the thumb (trapezium) is removed. This a gold standard procedure and provides excellent results.
- Joint replacement (arthroplasty) – Trapezium is removed and replaced, this is at preliminary stages and results are good only in the pioneering institutions.
After surgery, a cast or splint is worn over the thumb for up to 6 weeks. Physiotherapy is started after removal of cast or splint to help regain the hand strength and movement.
Metacarpo-phalangeal joint Arthritis (Knuckle Joint)
The knuckle joints of the hand are called the metacarpophalangeal joints (MP joints). These joint are important for both power grip and pinch activities. The MP joints are often affected by arthritis either from routine wear and tear, injury or medical conditions like Rheumatoid Arthritis, Gout or Psoriasis. This results in pain and loss of function of the hand.
Medication (NSAIDS) are helpful in relieving pain and may also reduce worsening joint destruction.
Injection of a steroid in the joint also helps to control pain.
If the joint is completely destroyed, then joint replacement or joint fusion are effective surgical options. These joints can be replaced with a silicone implant or other material (metal, pyrocarbon). Joint replacement is very useful, especially for older or less active individuals. Fusion (making the joint solid) is an effective treatment of thumb MP arthritis.
Inter-phalangeal Joint Arthritis (IPJ)
The joints between the bones of the finger (phalanges) are known as Interphalageal joints (IPJ). Loss of cartilage cover over the ends of these bones result in arthritis of these joints. There are 2 interphalangeal joints in each finger except thumb which has one interphalangeal joint. These are called the proximal interphalangeal joint (PIPJ) and the distal interphalangeal joint (DIPJ).
- Proximal Interphalangeal Joint Arthritis (PIPJ)
This joint is the next joint from the knuckle in the fingers. Arthritis of this joint presents with similar symptoms as the MC joint arthritis.
Treatment of arthritis in these joints is replacement of the joints with silastic/pyrocarbon/metal implants. This provides pain relief and movement. Another option is fusion of the joint which provides pain relief but motion at the joint is lost.
- Distal Interphalangeal Joint Arthritis (DIPJ)
This joint is end joint of the fingers. Arthritis of this joint presents with similar symptoms as the MC joint or PIP joint arthritis. The movement in these joint is lesser than other finger joints.
Treatment of arthritis in these joints is fusion of the joint which provides good pain relief.
Tendon lacerations can lead to permanent disability, these injuries need to be diagnosed and treated early with proper follow-up arrangements.
All hand lacerations (cuts) should be explored to confirm injuries to joint, bone, nerve, tendon, or vascular injury.
- Flexor Tendon Injuries
Flexor tendon injuries are divided into five zones, and are often associated with joint, nerve, or vascular injury.
Flexor zone II injuries are the most complex tendon injuries with variable outcome to repair. The other zonal repair do well with primary repair. It is recommended that all flexor tendon injuries should be repaired by a hand surgeon, owing to the high rate of complications that can occur even after an optimal repair.
Following repair, it is paramount to undergo physiotherapy as advised. Delayed or non compliance in physiotherapy has a poor outcome following repair.
- Extensor Tendon Injuries
Extensor tendon injuries are divided into eight zones. These tendon fibers are thin and flat that do not hold sutures well, therefore, it is recommended that a hand surgeon undertakes the repairs. Following the repair, rehabilitation is paramount with the help of physiotherapy to achieve optimal movement of the fingers.
- Rupture of the Central Slip
Central slip is a structure of extensor tendon complex at the PIP joint. It is a common sports injury and typically rupture following forced flexion of the PIP joint or dislocation of the PIP joint. This often results in a boutonniere deformity.
- Swelling of the PIP joint over its dorsal surface.
- Limited extension at the PIP joint, with hyperextension of the DIP joint.
Initial treatment requires splinting of PIP joint, chronic deformity requires reconstruction of the Central Slip with surgical procedure.
- Extensor Hood Rupture
Extensor hood is a tissue structure that allows in line position of the tendon with the MCP joints are extended. Rupture commonly due to blunt trauma and results in subluxation of the central tendon, preventing full extension.
The middle (long, third) fingers is most commonly affected, followed by the index (second) finger. Pain overlying the MCP joint with loss of full extension at the MCP joint. Popping sensation or/and instability of the MCP joint when it is actively flexed and extended.
Extensor hood injuries require surgical repair/reconstruction and is associated with a favorable functional outcome and decreased pain.
Ulnar Collateral Ligament is an important stabilising ligament of the MP joint of the thumb. Rupture of the ulnar collateral ligament (UCL), also known as “gamekeeper’s thumb” is a sports injury commonly seen with skiing, basketball, wrestling, and martial arts.
Painful swollen thumb that is tender over the ulnar side of the MCP joint. May be associated with instability with use of thumb. The finger may be deviated radially.
Acute UCL injuries are treated with a thumb spica splint or custom splinting to maximize functional outcomes and prevent long-term disability.
Rupture of the ligament requires surgical repair or reconstruction and should be undertaken preferably by hand surgeon only.
Dupuytren’s contracture is thickening of the palmar fascia resulting in contracture of the fingers. It typically appears after age 40 and grows more common with age. It more common in men than women and is often hereditary.
Younger age at presentation is associated with a severe disease condition. Initial presentation is with small nodules or indentations followed by development of thick cords that curl the affected fingers.
Dupuytren’s disease requires surgical removal of the thickened, contracted tissue. Following surgery hand physiotherapy is required to regain strength and range of motion. A full recovery and return to activities can take 6 – 8 weeks.
Recent advance in treatment includes use of Xiaflex injection. Xiaflex is an enzyme made from the bacterium clostridium that dissolves collagen.
Treatment with Xiaflex is a clinic based procedure with injection directly given into the thickened tissue. Two days later, the patient require manipulation under local anaesthesia to straighten the fingers. Patients are required to wear a splint at night to hold the finger straight and prevent it from curling up again.
Mallet finger is a flexion (bent) deformity at the end joint of the finger. It usually results from a direct blow to the fingertip which causes disruption of the extensor tendon as it inserts into the base of the distal phalanx. Occasionally, an avulsion fracture of the base of the distal phalanx can be seen on radiographs.
Pain at the base of the distal phalanx (End bone of the finger)
Inability to extend (straighten) the fingertip fully
Permanent flexion of the fingertip may lead to a swan-neck deformity
Initial treatment is with a mallet finger splint with the distal interphalangeal (DIP) joint in full extension for 8 weeks. Despite adequate splintage, there can still be some bend at the finger tip.
Surgery is advocated if a bony avulsion (fragment) is present or on failure of non surgical treatment. Reconstruction surgery for mallet finger deformity has an average to good outcome, hence should be advocated cautiously.
- Bennett’s Fracture
Bennett’s fracture is an intra-articular fracture dislocation of the thumb metacarpal at the carpometacarpal joint. It is caused by a direct blow to the thumb in a partially flexed metacarpal. The thumb metacarpal is typically displaced radially and dorsally due to the pull of thumb extensors.
If adequate reduction can be achieved, than the fracture can be treated non surgically in a thumb spica splint.
This fracture typically requires surgery to ensure good alignment and reduction of the fracture as this reduces the risk of osteoarthritis and permanent disability.
- Rolando Fracture.
This is a complex intra-articular fracture of the thumb. The fracture has a similar ulnar fragment as seen in Bennett’s fracture but also has a large dorsal fragment that gives the fracture lines a “Y” or “T” shape.
The Rolando fracture almost always requires surgery to obtain good anatomic alignment. The overall outcome depends on alignment of the fracture at the time of surgery and stability of surgical fixation.
Little Finger Fracture (Boxer’s Fracture)
This is the commonest fracture of hand and occurs through the neck of the fifth metacarpal, typically after punching a hard object. Patient presents with pain over the “knuckle” (distal metacarpal) and a palpable depression or loss of the normal “knuckle” contour. This fracture requires reduction and application of a plaster/splint.
Metacarpal Shaft Fracture
These fractures can lead to significant long-term disability if not reduced and treated properly. It is important to ensure that there is no rotational deformity and that any significant angulation is reduced at the time of reduction.
Patients with displaced, angulated, comminuted, spiral, or oblique fractures of the metacarpal shafts should be treated by a hand surgeon. Oblique, spiral, comminuted fractures, fractures with significant angulation or rotation require surgical treatment.
Proximal and middle phalanx fractures are unstable and can result in significant angulation or rotational deformities. Formation of scar tissue around the tendons result in additional complications and a significant functional decline. These fractures often require dynamic splinting, finger splinting or surgery undertaken by expert hand surgeon.
Distal phalanx fractures can often be treated with an appropriate splint, except when there is an intra-articular component that requires surgical correction by a specialist hand surgeon.