Oliver Hall

Okay, good evening, everyone and welcome to our hand and wrist surgery webinar. My name is Oliver and I'll be your host for this evening.

Our expert presenter here is Mr Chris James and this presentation will be followed by a Q&A session, if you'd like to ask a question during the presentation you can use the Q&A icon that's at the bottom of your screens and this can be done with or without giving your name and this session is being recorded, so, if you do provide your name that will be included in the recording.

If you'd like to book your consultation, we'll provide some contact details at the end.

I'll now hand over to Chris for the presentation.

Mr Christopher James

Right, hello there everyone. I'm Chris James, I’m one of the hand surgeons at Benenden hospital and I specialize entirely with the hand and wrist so it really is something that I live and breathe. I'm going to be talking to you a little bit today about the common things that you may have or you may see, or you may have friends that have that come up to the hospital that can usually be treated in fairly easily manageable ways. So, first off I put a background for myself, I’m an orthopaedic consultant so if you qualified as a doctor 23 years ago through the usual training schemes and then went on to specialize in orthopaedics and then subsequent hand surgery, involving micro surgery over in over in Australia back in 2012-13. I now work full time within the NHS and privately and I work alongside my hand surgery esteemed colleague Mr Yanni at the Benenden Hospital. I'm going to move on a little bit but if you have any questions it would be nice if you can let me know at the end of this session.

Right, what I'll be talking about are six conditions. First one is a trapeziectomy, now I'm going to put my hand up here, it's very common to get arthritis in this bone here going to I'm just going to stop the sharing for a moment. I'm a bit bigger there now and this is the base of the thumb this is a little bone called the trapezium and it rubs against the long bone of the thumb here which goes into the hand this is extremely common especially in ladies and becomes more common with age so, it's something that we see a lot of and it causes intense pain, similar pains to the pains one gets with hip arthritis, knee arthritis, ankle arthritis, spinal arthritis which I'm sure you're all aware of.

The next thing I'll be focusing on is Dupuytrens Disease, now this is a condition that curls the fingers over and forms thick cords which feel a little bit like tendons down the palm of the hand. It's very common, although little talked about until you actually have possibly the disease.

Next is the two nerve symptoms that we commonly see the one is called cubital tunnel syndrome which is a compression at the elbow of the nerve where the nerve it's actually the funny bone nerve although they're not that funny for most people and it causes disturbance down the hand into the little in the ring fingers from the elbow. And then a condition called carpal tunnel syndrome, which is a compression of a different nerve in the palm of the hand and that affects the other side of the hand the thumb the index and the middle digits and causes sort of pain numbness and I'll go into more detail regarding these.

Trigger finger is a condition where the finger locks and gets stuck over but is able to straighten out with a little click and that can be very painful and then I'll be talking about ganglions which ultimately are cysts which come from the joints.

So, this is the same picture that I showed you with my hand the trapezium is this bone outlined here and it's called the trapezium because it's shaped like a trapezium, it makes sense doesn't it? And it is extremely common to have arthritis against the thumb which the arthritis is the wear and tear type of arthritis rather than other forms that you may see with rheumatoid arthritis although it can happen in these diseases as well and it is actually the second commonest type of hand arthritis to be found second only to the ends of the fingers which are quite a common occurrence if somebody comes to see me with trapezium arthritis then the first step would be to go forwards with some conservative treatments I.E non-surgical.

Now before coming to see some someone like myself at the Benenden I would normally expect patients to have tried some painkillers maybe avoided some activities that would upset the hand and possibly have had some physiotherapy or you tried a little splint around the thumb.

The things that I can do are either an injection a guided injection inside the joint with steroid and if that doesn't work or if the arthritis is deemed too severe then there are a few operations which are very commonly performed one is a trapeziectomy and that is the removal of the trapezium bone this is really the gold standard operation and it's been around for a long time and works very well. It improves pain function as well as patients general happiness and mood now this can be augmented with tendons if this is necessary or there are other methods such as a fusion of the joint. Some younger male individuals would probably find that more beneficial especially if they're laborers or work heavily with their hands and there is a more novel procedure now, a joint replacement which it looks very similar to the joint replacement that one gets in the hip it's a ball and socket joint and the results from this are very promising and ultimately there's some very good operations for base of thumb arthritis.

The second condition I'm going to talk about is this Dupuytrens Disease it sounds bad the word disease but ultimately it is actually an inherited type of disease I.E it's in your gene pool and it's more than likely if you have it or someone you know has it then their parents or grandparents or aunts or uncles may have had it because it does stem back to the earlier times and hence the name Viking hand because there is a Scandinavian influence so, if you have some ancestry from the Nordic countries or the North of England this is something that you probably are more likely to get it is a condition causes thickening just below the skin and often this gives the appearance of the tendon being palpable or visible but it actually isn't it's new growth of us almost a grisly type of tissue and as this gristly tissue continues to grow it acts a little bit like the flexor tendon of the hand that and pulls the finger slowly over now once the fingers pull over they don't go straight again unlike the tendon pulling them over and then that can be quite functionally disabling for patients such as brushing your teeth putting your hands in your pockets putting your hand in a glove and general dexterity issues.

So, the treatments again are a little bit varied but all involve a removal of this gristle tissue or a portion of the bristle tissue and there are a whole variety of operations here starting with a local anaesthetic procedure with a needle if patients are suitable for this it's a very good quick recovery procedure which has quite low risks but not all patients are suitable and the more severe types of disease will need an operation called a fasciectomy which means opening up the finger with some cuts usually under a general anaesthetic and cutting away the the actual diseased tissue which then allows the finger to straighten up. Sometimes it is necessary to do a procedure called a dermo fasciectomy and this and this is used in very severe first-time operations or if the or if the procedure is required for a second time now for a second time it sounds as though the operation doesn't work very well but in fact the operation generally works very well but because the disease is inherited and is in your gene pool the surgery does not get getting rid of the disease it is only a symptom of the disease and so, this does usually come back with time but the dermo fasciectomy is removal of the tissue alongside with the skin adjacent to the tissue of the finger and this would then be covered with a skin graft so, better type of skin and tissue will then heal up and this reduces the risk of recurrence.

Cubital tunnel syndrome this is a nerve compression syndrome and is very common it affects both young and old and usually is what we call idiopathic in that we don't know the true cause of it although there are lots of different reasons it can happen such as overuse injuries trauma to the elbow patients who sleep with their arms in a bent position such which is what most people do because this is the inherit the inherent foetal position with bent wrists and bent arms what the nerve does is it supplies the pinkie finger and the side of the ring finger it also, supplies some of the muscles within the hand so, if the nerve is being squashed at the elbow and it can be thought of often similar to a I I use the analogy of a garden hose with a transmission of information or water and if you kink the garden hose no information or transmission goes along and the more bent the gun hoses or the nerve the less information travels to the hand or back from the hand.

Again the treatments initially begin with conservative treatments I.E non-surgical and I would normally recommend patients look very carefully when this happens this is a condition as mentioned with flexion of the elbow and so patients can often get this when driving heavy computer use as I say sleeping reading playing the piano playing the guitar things where you sit for long periods of time and the elbow is bent thus kinking the nerve and often patients can be improved with simple reductions of these activities if this does not improve the situation then surgery is a possibility and this would incur a small cut to the elbow I usually do this procedure under a local anaesthetic but sometimes a general anaesthetic depending upon each and every patient and the release of the nerve occurs and then some dissolvable stitches. Usually, it may take up to a few weeks to settle down it is important to realize that the nerve can be non-recoverable if left too long so, I would not normally get patients to sit which sometimes they do for years with symptoms of cubital tunnel because it can be irreversible.

Moving on to carpal tunnel syndrome now this is the commonest syndrome that I see personally it is caused by pressure upon the nerve the other main nerve to the hand and this nerve supplies I will show you on my hand supplies the skin on this side of the Palm not the little finger and not the back of the hand usually it also, supplies the muscle here and one of the muscles that comes along here. I'll share my screen again.

Now there is a link as if you look on this picture you can see that there is a ligament that's or a band of tissue that goes across the palm and this is called the transverse carpal ligament and this is a ligament that thickens up with a variety of conditions and then pushes down upon the nerve causing the nerve to not transmit towards the fingers very well and back from the fingers very well thus impeding the sensitivity and often the strength and dexterity within the hand it is a common condition as I say and can come with age can come following trauma can occur in conditions such as arthritis diabetes thyroid disease rheumatoid disease but most commonly occurs with age and I'll probably see at least a dozen people a week with carpal tunnel what can be done again we try to avoid surgery if we can but reminding ourselves that we don't want to leave this for too long because as mentioned in the previous condition the nerve can sometimes be irrecoverable if left too late. So, the first line treatment would usually be something to stop the wrist from bending over and this is a in the usually in the form of a wrist splint which you can get online physiotherapists have or you can get actually often from your local chemist or supermarket and these can be worn at night time usually which is when the symptoms can be at their worst. If that fails to be sufficient, then a steroid injection can be attempted into the carpal tunnel. Now this has the benefit of settling down the inflammation and thus the pressure upon the nerve but has the disadvantage that it is usually not curative and may last for a good period of time, but is usually repeated and if there is a constant repetition of injection then I would normally recommend surgery upon the nerve which is all done under local anaesthetic usually with a small injection at the base of the palm which then numbs the palm and a small three to four centimetre incision along the palm and going down and releasing the nerve this is one of the best operations that we have in orthopaedics and hand surgery because it's highly effective if done at the  right, time. So, if you feel you have carpal tunnel it's a very quick easy assessment in clinic.

Shall we move on now to your finger this is a condition which is tendon based again it's very common and can occur after again traumatic episodes overuse I saw a lot of this in covid when people would do a lot more gardening using a lot more secateurs and grip activities and thus irritate the tendons in their hand and the tendon runs in a little tunnel which is secured to the bone and it's important for the finger to bend the excuse me the tunnel has to be nice and smooth and the tendon has to glide in a nice and smooth fashion within the tunnel if following repetitive injury or trauma or those grip activities I'm talking about the tendon has a small nodule upon it or swelling then it stops running and gliding within the tunnel and can cause the finger to bend in a or catch which is usually quite painful and the fingers the pain it would normally be at about this level in the palm which is exactly where the tendon tunnel is and the patient would find that as they're bending over the nodule suddenly gets caught on one side of the tunnel and the finger clicks over and doesn't go back or may be clicking back with a little bit of a forceful manoeuvre

We try to do non-operative treatments, although I would usually use an injection as my first line treatment, the reason for this is that a simple injection which can be done in clinic has 40 to 50 percent cure rate for this disease and and that's very good because it obviously doesn't impede patients or certain too much obviously painkillers modification of activities can be attempted prior to this but the usual would be a steroid injection. If this becomes a recurrent theme then there is the option of surgery and the surgery is done again under local anaesthetic with a small cut in the palm, usually about a centimetre, and a release of the tendon sheath. So, if you think of the tendon as a tunnel it would be removing the roof of the tunnel to allow the the tendon to glide within it.

Alright, so, moving on to ganglions. Ganglions are quite common they're not just found in the wrist and the Hand they can be around any of the joints of the body often in the feet as well they are simply cysts that are connected to the joint and are filled with fluid and they form almost a little balloon which sits under the skin now because there is a connection to the Joint which has fluid in it they can sometimes get bigger and smaller depending how much fluid is pushed into it they can become painful although often are not and if they do cause symptomatic issues for patients then they can cause pain weakness and cosmetic issues especially if on the back or the front of the hand when I say they're filled with a fluid it's a very gelatinous fluid almost like a a jelly material and occasionally they pop and the jelly comes out which is interesting for patients these can be treated non-surgically if they are not affecting anything it's it's important when you have a lump anywhere on the body obviously to have it looked at by somebody who may know what they're talking about because as much as these are benign lumps sometimes and I'm not just talking in the hand and wrist but if there are masses that are found that it's important to rule out more Sinister pathology such as cancers which sometimes can happen but are very rare so, the treatment of ganglions there is an old treatment which is sometimes fed to patients which is to hit them with a big book typically a Bible you can see that this is probably a treatment rationale that was given a few centuries ago we don't recommend that now if there is a symptomatic ganglion I would normally suggest going forwards with surgery because that is the most likely way to stop this from coming back again and this can all be done under local anaesthetic once more.

If you feel that there are any hand or risk conditions that I've talked about it's very difficult to make a self-assessment sometimes there's lots of information on the internet there are hordes of information and some people say and apologize for using Dr Google I'm actually very keen that people do use Dr Google because it gives you some information and gives you an informed choice but it is good to see a specialist and be given a concrete diagnosis.

I would suggest that if you feel you have any of these conditions come up to the Benenden hospital and we'd be more than happy to see you in the clinic and provide some treatment or management if required.

I think I'm going to move to question and answer session here. Now is that okay Oli?

Oliver Hall

Yes. thank you, Christopher. We've got some questions that have come through.

Mr Christopher James

Okay so, I'm going to start with the top question which is anonymous. What can I be given for arthritic joints in the fingers? I'm not going to type the answer, I'm going to tell you the answer. Arthritis is a wear and tear process, it doesn't get better with time it usually gets worse with time. It is progressive and degenerative in the fingers, it is very similar to shoulders, backs, hips, knees, ankles, the first treatment we would suggest would be hand or specialist hand physiotherapy hand therapy and following this I would normally inject with steroid painful joints and that can help settle down the inflammation and settle down the pain. But this doesn't change the underlying fact that the cartilage I.E the smooth surface has eroded and if further treatment is required then there are a variety of treatments such as joint replacements for the fingers or fusion procedures to sort of stop the joint from moving itself. The results of this are usually very excellent actually and can be discussed at depth if necessary so I'm going to move on.

Oliver Hall

Chris, sorry to interrupt. Do you mind just moving to the next slide just so we have the contact details for everyone, and shall I read out the questions to you?

Mr Christopher James

That's alright, I can read it out. Anonymous attendee says I've been advised I have a trapezium bone arthritis. Can surgery with a tendon sling cause other issues with mobility?

Okay so, I talked about that trapeziectomy and there are different ways of stabilizing the thumb after removing a small bone it doesn't there isn't actually great evidence to show that using a tendon sling improves the result afterwards although that is usually my preferred choice it doesn't cause any other issues with mobility or loss of strength and is purely down to the sort of technical experience of the surgeon

So, the next thing do you cover full wrist replacement?

Wrist replacements are a more novel procedure that we do but we do not do or have not yet done at the Benenden in all honesty and this is certainly something that can be talked about but at present it's not something that is offered by myself at Benenden however I do this in other hospitals.

Next attendee, hi I'm in my early 30s and get pins and needles in my hand, it doesn't affect my day-to-day life but could putting off treatment cause other complications?

Well the pins and needles is likely to be caused by this carpal tunnel or the cubital tunnel if it's not affecting your day-to-day life and is intermittent then I would suggest it's very reasonable to try splints possibly go and see somebody locally for or at the Benenden for an injection and it's very reasonable to hold off surgery at that point if it starts troubling you then I would think more about surgical intervention.

The next thing, what is the recovery time for a trapeziectomy?

After having the bone removed at the base of the thumb you would normally be in a splint which is a custom-made splint for the hand which limits motion at the base of the thumb for six weeks following that exercises and strengthening so, up to three months to get back to most activities for most people sometimes longer if somebody has high level or high impact activities and sometimes a lot less if obviously you've got more sedentary activities.

Right, for surgery to treat carpal tunnel I am very panicky of surgery would you do a general anaesthetic for a short operation instead of local?

That can be that can be discussed and can be done, although I would normally go through the treatment in detail in a clinical setting to really allay your fears because it is a completely safe nothing has to be seen and nothing has to be felt but yes it can be done.

Next. I'm quite nervous when it comes to surgery, as you mentioned surgery is quite short could this be done in an operating theatre or clinic room?

Your surgery is always done in an operating theatre, although we do have a fantastic theatre which is a rapid flow theatre where patients will come in and they would flow around from being seen to having an operation to recovery to act usually within about an hour for the whole process and that usually has excellent feedback from patients so, it's a short procedure and a short recovery and then out of hospital so, not to worry too much.

Next, for trigger finger how long does a steroid injection last and how many times can it be repeated?

How long is a piece of string unfortunately the I would normally say anything from 3 to 12 months for an injection the first injection lasts better than the next injection which lasts better than the next injection I would never do more than three injections usually two sometimes one depending on the patient do you recommend supplements for arthritis turmeric etc I'm a fan of what works for people there is limited evidence in the literature to show that a lot of the adjuvant treatments such as turmeric and glucosamine and sulphonamides and metal bracelets and collagen supplements work significantly but they do work in some people and some people praise these treatments and as such I'm very happy especially with turmeric to to say to people try it and if it works fantastic certainly doesn't do any harm but you do have to try it for a few months next in the treatment of trigger thumb what are the other differences between the percutaneous and open surgery.

Next, I had carpal tunnel on my right, hand in October I still have bruised lumps on my hand is this normal at this stage please?

Sometimes the scar can still be a little bit swollen at this stage and sometimes the where the stitches which are usually dissolvable have been you can get little bumps they will go down generally with time it's important after any surgery to realize that it can take up to one year for the symptoms to settle in their entirety.

Next and final question, I had trigger fingers some years ago and now I find it comes back on occasions would surgery again be useless?

It's it's difficult to say if this has truly come back but I also, am very aware that patients know their bodies best and if you feel it's come back then that probably is the case surgery can be performed again it there may be some Scar Tissue there but it's ultimately the same process so, if it is triggering or re-triggering or in fact some other pathology usually that can be dealt with and I will go to the last person I have pins and needles in my thumb and forefinger for a year and a half I'm told it's a trapped nerve in the spine look the the nerves ultimately all come from your spinal cord and they travel down through your neck through your armpit and then they travel these tubes down to the hand it is very difficult you may have had tests you may have had scans and if if you have had an MRI scan of your cervical spine which confirms that it is a trapped nerve in the spine then that may be treated by spinal surgery or injections if you have not had these it may in fact be a trapped nerve down the arm sometimes there is confusion so, it's difficult without seeing you to give you the answer here but I'd like to say this should be able to be quickly ascertained in clinic.

Right, thank you very much. I hope that was useful to you and maybe see some of you in the clinic.

Oliver Hall

I'd like to say thank you and that's all the questions that we appear to have had come through but sorry if we didn't answer any of your questions and we'll do so via email if you've provided your name for those and if you do want to discuss or book a consultation, our Private Patient team will be available between eight and six and that's Monday to Friday and for joining this session we're offering a small discount on the consultation and that's for seven days so, until the 1st of March.

We also, have a short survey so, after this closes you'll be able to fill that out and we really appreciate that so, we can sort of shape our future events and your feedback is really great for all of our webinars.

Our next webinar is on hip knee surgery and that's on the sixth of March and you can visit our website to sign up for that one.

So, on behalf of Benenden Hospital, I'd like to thank you for joining us and we hope to see you again on on one of our future webinars. Thank you very much everyone, bye.