25 Feb Teaching common hand surgery topics during the pandemic

Mr Bhatia has continued teaching during the pandemic. Although face to face teaching is not currently permitted, Raj recently gave a virtual on-line presentation to over 100 General Practitioners. He covered common hand surgery topics including carpal tunnel syndrome, trigger finger, small joint arthritis of the hand and Dupuytren’s disease.

Raj discussed aetiology, symptoms and presentation, diagnosis including examination and special investigations. Non-operative and surgical treatments were discussed with an emphasis on evidence-based outcomes. The primary aim was to teach GPs when to refer patients for specialist intervention.

The presentation was well received with active participation by the GPs and a lively discussion. This was reflected in the excellent feedback following the session and an invitation for further presentations in the future.

From a patient perspective the following points are worth remembering:

CARPAL TUNNEL SYNDROME

A steroid injection only gives temporary relief. Should symptoms recur then referral to a hand surgeon is mandatory. Nerve conduction studies are only performed when the diagnosis is in doubt. Surgery is mostly performed under local anaesthetic as a day-case procedure. The outcomes from surgery are very good with studies reporting full resolution of symptoms in over 90% of patients.

TRIGGER FINGER

The underlying problem is a tightening of the mouth of the tunnel that the flexor tendon runs through. We call this the A1 pulley. Because of the narrow tunnel, the tendon becomes inflamed and there is pain in moving and locking of the finger. A steroid injection can reduce inflammation and pain but does not affect the tight A1 pulley. Therefore symptoms can recur. Day-case surgery under local anaesthetic has excellent outcomes.

DUPUYTREN’S DISEASE

This is genetic and more common in Celtic and Viking races. Dupuytren’s is characterised by the development of excess scar tissue in the palm and fingers eventually causing finger contractures. The finger contractures are not caused by a tight tendon and this is a common misconception. It is important to seek specialist help as soon as your fingers start to contract, as outcomes from surgery are better when performed early. Do not wait until your fingers are severely contracted affecting your function. Demand an early referral from your GP!

Mr Bhatia has published extensively on Dupuytren’s disease and has won the International Dupuytren’s Society award for his research.

ARTHRITIS OF HAND JOINTS

Surgical procedures for hand joints are common with good outcomes. Raj performs joint replacement and fusions in fingers and thumbs regularly with good pain relief and return to function.

GPs often tell their patients nothing can be done for arthritis in the hand. Mr Bhatia is trying to educate GPs about treatments he can offer. Patients can also ask for a referral to see a hand surgeon.

STEROID INJECTIONS

A single injection is safe and two into one site is maximum. Too many steroid injections can cause harm. This includes fat loss, skin depigmentation, tendon, ligament and nerve damage as well as joint damage. If you are offered more than two steroid injections into the same site then ask to see a hand specialist.

You must seek the advice of a hand and wrist specialist surgeon and not a general orthopaedic or plastic surgeon!