Jan 4, 2021

Hand surgery: The wrist a complex but fragile machine...

What is hand surgery?

Hand surgery is a branch of surgery and follows the study of human medicine. It deals with the surgical treatment of diseases and traumas of the hand and forearms. Hand surgery has developed from orthopedics and general and trauma surgery. Reconstructive and plastic surgery also belong to hand surgery.

Which doctors and clinics are specialists in hand surgery?

Those who need a doctor, of course, want the best medical care. That is why patients ask themselves, where can I find the best hospitals and clinics for hand surgery in the world? Since this question cannot be answered objectively and a reputable doctor would never claim to be the best. Therefore, you can rely on the experience of caresocius.


The wrist. What you need to know:


The wrist, due to its anatomical and biomechanical complexity, is an essential functional crossroads for the proper functioning of the entire upper limb. A stiff or sore wrist leads to the entire upper limb function being impacted and diminished. The wrist is a collection of bones, ligaments, tendons, nerves and arteries that work in perfect synergy without allowing any hitch.

Many issues can affect the proper functioning of the wrist: osteoarthritis, that is the wear-down of the cartilage allowing the good movement of the bones between them, fractures and their own consequences, ruptures of the ligaments, these cords which maintain physiological tension between the bones and finally the tendons attached to the muscles which allow the active mobilization of the wrist. Despite its essential function, the wrist is often still left to hazardous and inappropriate care.
In fact, lesions of the wrist are too often poorly or even misdiagnosed. This delay in treatment leads to catastrophic irremediable anatomical and functional consequences. Through some frequent pathologies on the wrist we will see its complexity and the need for optimal management.

Pseudarthrosis of the scaphoid
Scaphoid bone - Wikipedia

The scaphoid is the most important bone in the wrist. Indeed, its central position on the wrist gives it a major role in the transmission of force and the balance of movements. Unfortunately scaphoid fracture, although common, is often misdiagnosed and therefore suffers from a delay in its management. The progression will then be towards a non-union called pseudarthrosis. The patient will complain of pain at the slightest movement, progressive stiffness of the wrist will appear and the progression will inevitably be towards osteoarthritis of the wrist.
The treatment of pseudarthrosis, although delicate, has greatly improved with the contribution of arthroscopic techniques: the treatment consists of a bone sample from the wrist on a non-essential area (lister's tubercle), an arthroscopic debridement of the pseudarthrosis area and placing the bone graft in the area of pseudarthrosis. Well-conducted treatment provides excellent long-term functional results.

The rupture of the scapholunate ligament
scapholunate ligament

The scapholunate ligament is a major stabilizer of the wrist. Fixed between the scaphoid and the semilunate bone, it regulates the torsion and flexion stresses on these two bones and helps coordinate the different forces present during wrist movements. When it is ruptured functional complaints will be mainly with forceful movements and pressure on the wrist. Its ruptures are often diagnosed at a late so-called static stage where the therapeutic solutions are palliative and stiffening.
With the improvement of diagnostic tools, in particular arthroMRI and the benefits of arthroscopy for its treatment, these lesions are being treated more and more early and with very promising results.

Fracture of the distal radius
Distal radius fracture - Wikipedia

The wrist fracture and more particularly that of the radius is one of the most frequent traumas. In general, it preferably concerns two types of patients, the elderly person with a fragile bone (osteoporosis) who falls from his height and the young person victim of a high energy accident (road accident, fall from a height).

The diagnosis is primarily clinical and fairly obvious with a deformity of the wrist and inability to move the wrist. These fractures may be associated with ruptured ligaments or nerve damage. The emergency x-ray can confirm and refine the diagnosis.
Depending on the displacement of the fracture, the functional demand of the patient, orthopedic (immobilization) or surgical (pins, plate) treatment may be offered. The goal of treatment is to restore the original shape of the radius and allow the patient to move quickly.

With the improvement of techniques and in particular the development of new plates, it is now possible both to operate with small incisions and to avoid any postoperative immobilization. In cases where there is no downtime, the resumption of routine activities can be done from the first postoperative week.

On the other hand, when there is a fracture, there is still a rest period to be observed for carrying heavy loads. It will include the actual healing time, for a wrist it takes about six weeks for the bone to be strong. In theory, 6-8 weeks is enough to confidently resume physical activity. Pain can persist for a year after the trauma and be related to the change in weather and temperature, it is called barometric pain.

Carpal tunnel syndrome

The carpal tunnel is not a disease, everyone has two, it is a tunnel in the wrist made up of bones and ligaments through which tendons, nerve and artery pass to join the hand. Under certain conditions that are still poorly explained, the space in this inextensible channel decreases (inflammation of the tendons for example), the median nerve (main nerve crossing this channel and located in the middle of the wrist as its name suggests) will be compressed.

The clinical signs are tingling (acroparesthesia), loss of sensitivity especially on the thumb, index and middle fingers (hypoaesthesia), at an advanced stage we can also find muscle wasting at the base of the thumb (thenar amyotrophy). The diagnosis is above all clinical but it must be confirmed by an electromyogram. This exam will measure the speed of passage through the nerve above and below the carpal tunnel, if the speed is greatly decreased below the carpal tunnel, the nerve is compressed. An ultrasound or even an MRI may be requested but for more rare indications.

The treatment is primarily medical (analgesic, wrist splint, infiltration) and if this is not successful, the treatment becomes surgical. Treatments following the evolutionary stage range from immobilization with a splint at night, infiltration or even surgery. The surgery will cut the ligament that closes the carpal tunnel to give more space to the nerve. The ligament section can be done under endoscopy (use of a camera).

After this short review of the most frequent pathologies of the wrist, it is important to underline the need for recourse to a specialist in wrist surgery, familiar with the latest minimally invasive techniques in the slightest doubt in order to direct as quickly as possible to the appropriate treatment.



About the Author:
Dr. Chihab Taleb



Driven by a surgical vocation that appeared at a very young age and after a university course at the Faculty of Medicine in Strasbourg, Dr. Taleb was appointed as an intern in orthopedic surgery at the University Hospitals of Strasbourg. Doctor Chihab Taleb then specialized in hand surgery in Strasbourg (Pr Liverneaux), Bordeaux (Pr Pelissier) and Lille (Pr Fontaine).

Because hand surgery is a complex and extremely varied specialty, Dr. Taleb furthered his surgical training by completing a 12-month post-doctoral program in Brazil (Sao Paulo Handcenter), the United States (Shoulder surgery unit, Johns Hopkins Hospital) and Japan (Juntendo University, Tokyo). He was then appointed Head of Clinic at the University Hospitals of Strasbourg.

In parallel to his care activity, Dr. Chihab Taleb regularly participates in numerous national and international congresses and scientific sessions in the field of hand surgery and wrist arthroscopy as a speaker, expert or trainer. Dr. Chihab Taleb maintains a strong professional link at the national and international level with numerous colleagues.