WARNING: The following article contains graphic images that may be disturbing to some readers. Discretion is advised.
The hand is an indispensable tool in our interactions with the world. As a key anatomical feature that defines us as humans, losing a hand or its functioning can be debilitating and incredibly traumatic. Hand reconstruction specialist Dr Chetan Patel explains how existing techniques and advances in hand surgery offer hope for restoring physical ability and psychological well-being.
The hand is the primary instrument with which we experience our surroundings. It can be argued that our body has been configured around our hands. Taken for granted, the hand is the body equivalent to the sum of all the greatest engineering machines ever created. It combines strength, tactile sense, neurosensory feedback, positional adjustment, and utmost dexterity, allowing a wide range of functions we use in our daily lives and vocations. It is the intersection of physiology, neuroscience, computer science, and biomechanical engineering.
Taking a quick look at the cortical homunculus below, which shows a slice of the brain dedicated to motor and sensory areas of different areas of the body, it is starkly evident just how much input and output goes to the hand.
Image courtesy of ANATOMY & PHYSIOLOGY, CONNEXIONS WEB SITE.
The discipline of hand surgery
It should come as little surprise then that the discipline of hand surgery has evolved as a subspecialty stemming from both plastic and reconstructive surgery and orthopaedic surgery. Pathologies of the hand, like many other systems, can be broadly classified into congenital and acquired.
Acquired problems can be further divided into those associated with other diseases (e.g. rheumatoid arthritis or lupus) that affect the whole body or trauma (from accidents or other treatments). Congenital deformities equally affect other systems in the body and the genes that result in hand/upper limb deformities may also affect other systems embryologically. Sometimes, genetic abnormalities express themselves by only affecting the hands or feet and no other organ systems.
Managing hand deformities
Surprisingly, congenital hand deformity management currently centres around not actually correcting the deformity to create a normal hand, but rather assisting the afflicted child to better cope with the abnormality. This is because a large proportion of children adapt to their abnormalities better than any surgery could improve function. This phenomenon is known as cortical plasticity.
When it comes to acquired deformities of the hand – whether due to the wear and tear of ageing osteoarthritis or an unfortunate traumatic incident – much can be done to improve the quality of the person’s existence due to advances in treating these conditions.
An important tenet of hand surgery is that many of the operations performed today have long histories of evolution, and any new “advance” requires thorough, time-driven scrutiny to evaluate its true potential before being lauded as the next best thing.
Therefore, a word of caution in seeking advice from anyone apart from a professional when it comes to your hands and potential cures for all those aches and pains.
There is no “best treatment” or “best surgeon” – simply what works reliably for a particular doctor for their individual patients at a specific point in time.
Advances in hand surgery
The biggest advances in hand surgery in the last decade have come in the form of improvements in implant technology and the advancement of microsurgery.
Joint replacements in the hand/finger joints are now reliable and lasting in effect. Hand trauma can now be treated with greater skill and better outcomes due to the skill of microsurgeons in repairing blood vessels and nerves at a microscopic level. The ability to replant amputated digits and hands, as well as replace tissue lost in the hand with tissue from other parts of the body, is a remarkable achievement in the advancement of hand surgery.
When considering that robotic hands are still not completely at the point where they can mimic the function and sensory input of a real hand, a well-performed and timely surgery that can save or reconstruct an injured hand is far superior in terms of long-term recovery and outcome, both psychologically and functionally.
Hand reconstruction: A brief case study
Below are images of a reconstructed hand, both immediately after injury and post-recovery. The patient’s dominant right hand suffered a five-finger amputation caused by industrial machinery at his place of work. An immediate three-finger replantation on the day of injury was followed by a delayed second-stage, big-toe-to-thumb transfer, all with microsurgical techniques. The goal and outcome were to create a more functional hand for a person whose livelihood depended on some function of their dominant right hand. The total time to recovery was around 18 months.
The impact of this surgery, which included creating something functional out of a devastating loss, is immeasurable. The psychological and functional worth of a limb that allows this patient not only to regain some form of gainful employment but, in his case, return to his previous job is profound.
Managing patient expectations and recovery
Often, the recovery period is grossly underestimated by patients suffering hand injuries. Expectations of outcomes and the need for stringent and often regular hand therapy cannot be overemphasised. Half of the work in these injuries after the surgery is up to the patient and a qualified occupational hand therapist. Psychological support plays an important role, while social adjustment, as well as occupational adjustment and negotiations with employers, all form a part of the treatment of major upper limb injuries.
Without a holistic care plan, false expectations, disappointment, and depression are common natural outcomes and inordinately difficult to treat. Many patients feel a sense of loss of self-worth and purpose. Therefore, as a hand surgeon, the overriding role of management spans multiple disciplines and the decision-making begins the minute the patient presents to you.
Strides in management have arguably also been made in sports injuries. With an ever-increasing population of young and old engaging in routine repetitive sporting activities, the long-term management of these injuries centres around knowing when to operate versus when to reassure and leave alone, or suggest modifications to assist in the relief of symptoms. These decisions are best made by a specialist hand surgeon in conjunction with the patient after a period of time reviewing symptoms and adjustments.
The future of hand surgery
3D printing is slowly but surely making inroads into the world of hand surgery, with devices being able to print key anatomical features, particularly bony structures that need to be carpentered finely to fit into areas such as the wrist joint. In the coming years, we are sure to see an increased use of technology in the form of 3D printing and artificial intelligence, aiding our decision-making and improving our ability to provide better medical outcomes for our patients.
From improved genetic mapping that allows us to identify and correct gene deletions in utero to improved artificial intelligence algorithms affording us better auditing of our management algorithms and improving our decision-making, a lot of the art and science of hand surgery will still boil down to the experience of a practitioner who has been plying their trade for many years.
In summary
There are still no miracle cures on the horizon. The competent clinical judgement of a specialist hand surgeon and therapist team will continue to be the foundation for predictable outcomes in hand surgery and patients with hand/upper limb problems.
Plastic and Reconstructive Surgeon
MBBCh, FCS (SA), MMed (Plast Surg)
Dr Chetan is in private practice based in George, at the George Surgical Centre. He qualified at WITS in 2009. Areas of interest: skin cancer surgery, hand surgery, oculoplastic surgery and cosmetic surgery.