Louise

Once again, good evening, and a very warm welcome to our webinar on wrist and hand treatments.

My name is Louise; I'm your host for this evening.

I'm delighted to be joined by our expert speaker, Mr Andrew Smith, Consultant Orthopaedic Surgeon here at Benenden Hospital.

Tonight's session will begin with a presentation from Mr Smith, followed by a live Q&A session.

If you have any questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You're welcome to ask these questions anonymously, or include your name.

Just a quick note that this session is being recorded, so any names shared may be visible in the recording.

To help us get through as many questions as possible, please do keep them brief.

If you're interested in booking a consultation, we'll share the relevant contact details at the end of the session.

I'll now hand over to Mr Smith to present.

Mr Andrew Smith

Hi, good evening. Thanks for joining me. My name's Andrew Smith, I'm a Hand Surgeon, I've been working in East Kent for nearly 20 years. I've been working at Benenden for the last five years or so.

I've always had an interest in hand surgery, I think it's absolutely fascinating, and it's one of the parts of the body we really can't do without when interacting with the world. And any problems with the hand cause significant dysfunction.

My particular areas of interest are joint replacement in the hand and wrist, as well as the more common problems.

I did my fellowship training in America which was a fascinating place to do such a thing.

I'm going to spend most of this presentation talking about the more common problems in the hand, so arthritis at the base of the thumb, Dupuytren’s disease, peripheral nerve compression, trigger finger, trigger thumb, and ganglions. There's plenty of other things that are present in the hand, and I'm very happy to answer questions around the less common bits and pieces I could take care of as well.

So, we'll start with osteoarthritis at the base of the thumb. This is a really, really common problem. It predominantly affects females over the age of about 55, and if you x-ray that group of people between 20 and 30% of them will have changes of arthritis on x-ray, and probably half of those will be symptomatic, so it is a really common problem.

Osteoarthritis is where the bearing surface wears, and that then produces quite or can produce quite significant pain.

Not all of the treatments that I'm going to discuss revolve around surgery. You can try splinting, medication, and pain relief, as you can with any osteoarthritic joint. Steroid injections have a place, and so does specific physiotherapy to look after the thumb base.

The most widely offered surgery in the UK is trapeziectomy, and that's where the small bone at the base of the thumb is removed.

This then, by default, removes the arthritic joint. The body then forms a new scar tissue, false joint over time, and this works well for relieving pain. Probably 85% to 90% of people think this is a good operation.

But because the joint isn't as mechanically well reconstructed as it could be, for example, with some of the bigger joints, like a hip replacement or a knee replacement, some people find they have a weak grip, and their recovery is a lot longer and I'll talk about my preferred option in a moment, but briefly mentioned on this slide is joint fusion, which certainly in very young people with post-traumatic arthritis, can be a really good option.

But it does, by default, remove the movement of the joint so my preferred option is to replace the joint at the base of the thumb.

This is done, hopefully you can see it there, with an implant, which looks like a tiny hip replacement. It's a ball and socket joint.

This preserves the length of the thumb.

So, and by default, the joint is reconstructed, so grip strength and pinch strength tend to be good. And one of the really good advantages of this treatment over a trapeziectomy procedure for example is that the recovery is within three or four weeks in the majority of people. With a trapeziectomy, the recovery is usually three or four months, or sometimes longer.

It's done as a day case. It can be done under a short general anaesthetic. You go home the same day, and you will need some rehabilitation afterwards, but because it reconstructs the joint, the actual level of input from the physiotherapy team is less than it would be for a trapeziectomy.

Some people use plaster, I have to say. I've moved away from that and don't any longer use plaster to support the thumb, and just a big bulky soft dressing, which comes off after about 10 days or so and you can use the hand straight away.

Anything heavier should probably wait about six weeks or so but you can use the hand straight away. This is the standard of care in continental Europe.

Where colleagues there have been carrying out joint replacement for the thumb-based arthritis for probably 20 years and I've really got through most of the learning issues with how to use this implant.

Slightly different, but very common problem is Dupuytren’s disease. This is a condition where the body makes a hard, fibrous tissue that gets deposited in the hand, predominantly, that can affect other areas. This causes lumps, bumps, and these progress into cords or

 Almost like strands of fibrous tissue, which slowly pull the finger over itself, it's harmless, but you can imagine, if you can't open your hand fully, this can significantly impact on how you use your hand.

The cause is largely genetic, it runs very, very strongly in families.

In the Scottish population, some time ago is referred to as the Curse of the MacCrimmons, because those guys couldn't play their bagpipes because their fingers were so curled in.

Random silly fact. So that's the predominant cause of it, is your genetics, so you can't change your parents. But there is an interaction with alcohol, some of the old-fashioned anti-epileptic medications. People that have diabetes tend to get worse disease as well.

So, when it's not causing a contracture, it's best left alone, because you cannot cure it. You can, however, treat it.

The least invasive way of treating Dupuytren’s contracture. If the cord is very thin, and predominantly in the palm, like in this example.

That cord can be divided using a needle under local anaesthetic and that doesn't remove the bulk of the tissue from the hand, but does allow the finger to come to a much better position and this is a very easy, quick way of getting a better improvement in your finger position.

If the finger is contracted further up towards the proximal joint, and the cord is thicker than the needle procedure is much less reliable.

This is an example of what's called a fasciectomy, where that hard, fibrous tissue is removed from the hand to allow the finger to come straight and in very,

In relatively rare cases, maybe the finger's so contracted, you can't actually sew the skin back together in a meaningful fashion, and you need to replace it. And that's an example of that in the bottom picture there.

This is referred to as a derma fasciectomy and you can see an outline there with somebody planning to do that. That's less common, and is not performed that widely, but if your disease is severe, or it's come back, and come back again, then this may be the answer for getting a better position.

But the majority of patients with thick, heavy disease

Just excising it from the hand gives a good result. This, again, is done as a day case, typically under a short general anaesthetic. You will need quite a lot of hand physiotherapy afterwards to get the hand limbered up, but the majority of people get, again, get a really good result from this surgery if it's not if the patient hasn't waited too late. Severe contractures are more difficult to treat.

We then move on to peripheral nerve compression. There are two of the most commonly compressed nerves in the upper limb, the ulnar nerve, which is cubital tunnel syndrome, and the other most commonly, or the most commonly compressed nerve in the upper limb is the big median nerves. It comes through the carpal tunnel, and we'll go on to that in a moment.

The ulnar nerve comes from all the way up from the neck down to the small finger. It provides the sensation in the small and ring fingers, and it also supplies the muscles in the hand.

So compression of that nerve will result in numbness and pins and needles that can be quite dense in the small and ring finger and if it's left, and that compression gets worse, the hand can get quite weak, and positioning of the fingers can become increasingly difficult. And if it's left a lot for a long period of time, you can get a deformity referred to as an ulnar claw hand. Most people have a seek treatment well before that happens.

It's best treated in the majority of cases surgically.

This is done, again, under a short general anaesthetic, and there's a small cut made just on the inside of the elbow, where you can see that highlighted with the little arrow that says cubital tunnel. That's the area where the nerve gets compressed and if you've ever hit your funny bone, it's not really a bone you're hitting, it's the actual it's the ulnar nerve where it's getting where it runs through that tunnel, and it's very superficial.

Most people recover from this usually pretty well, but the total recovery in terms of sensation completely returning to the tip of the finger can take really some time, and it's usually gradual because the nerve has to regenerate if it's severely squashed from the elbow all the way to the tip of the finger.

But in terms of arm function, that's pretty much, straight away.

Carpal tunnel's the most common compression neuropathy in the upper limb. It probably affects about one% of the population and it's something that any pan-surgeon does an awful lot of. It's really, really common.

The symptoms can be really very disabling. The early symptoms, with just a little bit of numbness and pins and needles intermittently, are often ignored, and not unreasonably so.

But at the other end of the spectrum, patients can present with severe pain at night that stops them from sleeping and that can be really troublesome.

Again, if no treatment is sought, ultimately the fingers can end up almost completely numb, so that picking up small objects can be difficult and the hand use, again, becomes really quite compromised.

Carpal tunnel syndrome is predominantly a clinical diagnosis, although if there's any doubt, neurophysiology testing, so proper formal nerve testing can be carried out, that's available here at Benenden and that can help in some cases, but a lot of people, it's pretty obvious what the problem is. And if the symptoms are comparatively minor, steroid injection close to the nerve is really useful, and for a lot of people, that will allow the situation to settle.

But if symptoms are more severe, more constant, then a carpal tunnel release is a good operation, in terms of it works well, it's easy, it's quick, and the rate of complication from carpal tunnel release is really very small.

It's done under local anaesthetic, takes probably between 10 and 15 minutes and you go home pretty much as soon as it's finished. Now, you can use the hand.

It's important to use the hand to keep it nice and mobile. That doesn't mean you can go and dig the garden up or go to the gym the following day, but using it around the house, light everyday activity, is completely fine, and I would fully encourage people to do that, so the hand doesn't stiffen up and as I said, it's a good operation that works well.

Trigger finger or trigger thumb is another really very common presentation in the hand. For reasons you don't completely understand, the tendons that bend the fingers down or bend the thumb down can develop nodules, and these nodules mechanically lock or stick in the fibrous sheath that runs in the digit, and you can see that on the, on the presentation here, just there.

Why this happens, we don't really know, but it's more common, again, in diabetic patients, and that's usually, if there's a cause, it's diabetes.

The diabetic patients tend to have this worse than non-diabetic patients and it can be a real nuisance. It can be inconvenient, just having your finger stick in the palm of your hand and you manually unlocking it. It can be quite dangerous if your finger sticks and catches around steering wheel of a car, or the handle on a kettle and it can be a real problem if that movement is permanent, because sometimes a small number of people would present with their finger locked into the palm of their hand. If that happens, it's one of those things that

ideally is dealt with really very quickly, because if it isn't, the joint can be permanently stiff, even after a trigger finger release. That's unusual, and the overwhelming majority of people can be treated with a steroid injection. This is a very easily administered, quick injection.

That can be done in clinic without any particular special preparation, or need to rest the hand, particularly afterwards.

You can drive home after it, for example, but equally, I wouldn't suggest, again, a heavy workout in the gym or anything like that afterwards. But again, the following day, you should be able to use the hand pretty much normally, and the steroid injection will get most people's symptoms to settle within two weeks.

If you're unlucky, and probably 10% of people or so are unlucky after a trigger finger or trigger thumb injection then the option is there for a trigger finger, trigger thumb release. Again, this is not dissimilar to the process involved in a carpal tunnel release. It's a local anaesthetic operation that takes about 10 minutes, and it's overwhelmingly successful. It's pretty straightforward.

The chance of complication and problem from this surgery is really very small and most people don't make a great recovery, their sutures dissolve, and their hand function returns to normal in a couple of weeks.

That's just an example of some exercises that can help, and that's just a mention of the steroid which I think it probably is slightly higher than that, probably 80-90% of people have their symptoms resolved.

Moving on, ganglions are the most common lump in the hand and wrist they are a pressurized collection of fluid.

When you operate on them, it's almost like a sort of wallpaper paste or gel and it looks like a little balloon, with the neck of it attached to the joint where the fluid comes from and then it's much bigger above, as you can see in that person that's got a wrist ganglion, which is probably the most common lump it lump position for ganglions.

They're completely harmless in themselves, for some people, they're a cosmetic issue and for a smaller percentage of people, they can be quite uncomfortable. If they're on the front of the hand across here where you would grip.

They can be really quite uncomfortable and a nuisance for people that use their hands for heavier manual work, play tennis or golf, and it feels like they're gripping onto a little pea. And these are often called a pearl or pea ganglion in the palm of the hand.

Exactly why they happen, we're not really sure but they are very common, and comparatively easy to treat.

They can be aspirated, and some people would advocate this. This has a relatively limited success rate, and it's not my personal, favourite choice, choice of, treatment for these, although if a patient really wants an attempt at aspiration, I'm very happy to do it.

But the lowest rate of recurrence is to surgically remove the ganglions. Now, depending on exactly where they are, it depends whether you need a tourniquet, whether it's done under local anaesthetic, which the majority of them are.

Or whether you should, use a general anaesthetic and a tourniquet to just see exactly where the ganglion is, and if it's close to one of the arteries or some other key structure to ensure that you don't damage that.

But the majority aren't, the majority are easily dealt with under local anaesthetic, and they're easily removed.

It's a comparatively minor operation, the biggest risk of the procedure is the ganglions come back, and they do in 15-20% of cases. But if you're an optimist, there's an 85% chance you're going to be fine and that stops them from coming back, it removes them, and the hand heals up pretty quickly.

It's one of the good things about operating on the hand. It has a great blood supply, which, generally speaking, means it heals really well and those are the main bits that I was going to talk about, really.

Sorry if I rattled through that a little bit, but I'm very happy to take questions and talk about those particular problems or indeed, anything else that people want to ask.

Louise

Great. Thank you, Mr Smith.

So, let's move into our Q&A session.

Really pleased to have lots of questions already, so, that's great. And, if you have do have them and you haven't asked them yet, please do like we said, just try and keep them brief so we can get through as many as possible.

So our first question from Maureen. She's had, sorry if I can't say it properly. Dupuytren’s contraction for over 30 years. She's had one successful operation on her right hand, and she's had two operations on her left hand, both from different surgeons, and both unsuccessful.

Can she have a third operation, or is there an alternative? She also has spasms and cramps in both hands for the past three years. Is this connected?

Mr Andrew Smith

So I'll take the last part of that. It can be connected, but that's largely because the fingers aren't in a normal position, so you're trying to use your hand in an abnormal fashion, which can put additional stresses and strains on the small muscles in the hand. So they can be connected, although they're not absolutely definitive.

With regard to the Dupuytren’s disease, the biggest problem with Dupuytren’s disease is it recurs. So

To say that it's unsuccessful might mean that the finger was never ever strayed to start with, or that the contracture has come back, which are slightly different, endpoints to the finger being bent.

If the finger were never straightened to start with, I wouldn't have thought a further attempt would help.

That doesn't seem likely, because it sounds like the joint would be sort of intrinsically stiff and solid.

If, however, the finger's been made straight, and it's just recurred, then you can have as many operations to straighten the finger as is necessary. Each time, it does become more difficult.

The results are probably less good and the chance, as I say, the chance of complication goes up. But certainly, if a finger's re-contracted, it definitely can be re-straightened. And it's that situation where I talked about a derma fasciectomy, where a skin graft is used, may be a sensible alternative in that situation.

But you certainly can have as many operations as you need to get your fingers straight if there's function if the finger is in a position where it's functionally a problem.

Louise

Great, thank you. Raymond asks, what determines the operation on the back of a palm for carpal tunnel? How long does it take to recover from carpal tunnel? And what degree of functionality is expected to be to achieve be achieved after a carpal tunnel?

Mr Andrew Smith

So the carpal tunnel is on the palm side of the hand, so that's where the incision goes for carpal tunnel release.

If you can they see that? Can I go back? Yes. Okay, I'm just gonna go back through the slides.

Just so you can see where it is. Well, there we go. So that's supposed to be looking down on the front of the hand with the fingernails on the back, and where the big yellow nerve is, the incision is made, as you're looking at it, just to the left of the where the yellow nerve is. It's about 3cm long, just at the heel of the hand.

Recovery, in terms of just everyday hand use, is pretty much straight away, so you could help yourself get undressed, dressed, make a cup of tea the same day. Going back to heavier work, probably three weeks, maybe four weeks, something along those lines.

The degree of functional recovery you should get, as long as the nerve is not irreversibly compressed and therefore damaged, you should return to pretty much normal function.

There's a small number of people where the nerve is severely compressed and has been for a prolonged period of time.

That the recovery is more difficult to predict, and as one gets older, nerve recovery is also slower and less likely to be complete.

But if somebody's nerve is not particularly compressed, they should make a full recovery.

Louise

Thank you. Malcolm asks, is there a connection between osteoarthritis and Dupuytren’s in the hand?

Mr Andrew Smith

So there's a short version of that note, they're both extremely common.

It's quite common for hand surgery patients that come and see me that they have more than one thing wrong with their hand. They may have carpal tunnel, they may have Dupuytren’s disease, and if you're much over 55, you're very likely to have one or two arthritic joints, even if they're not particularly symptomatic.

So they're not they're not caused by each other, but they are what’s the word? They're very commonly seen in the same patient.

Louise

Thank you, okay.

Marina says she's had carpal tunnel syndrome diagnosed about nine years ago, with limited symptoms, occasional pins and needles, and numbness first thing in the morning. She's reluctant to have an operation, and has not heard of steroid injection as an option. Could you expand on that?

Mr Andrew Smith

Yeah, so steroid injections, in my view, are useful for treating carpal tunnel syndrome, and there's two uses for them. One is if you're not sure if the patient's symptoms are carpal tunnel syndrome, you place a steroid injection close to the nerve.

If they have carpal tunnel syndrome, because not everybody has absolutely classic symptoms, but if that patient has carpal tunnel syndrome, they will get better, even if it's for a relatively short period. So they can be used in diagnostic terms.

For treatment purposes, they are extremely useful, again, for people with relatively minor symptoms, I guess a bit like Marina. And they can relieve those symptoms completely.

If you use neurophysiology to try and help plan who should have a steroid injection.

There's a scoring system that was developed in Canterbury, which scores patients from 0 to six, depending on how badly functioning their nerve is. And certainly, patients with a grade one or two carpal tunnel syndrome will usually derive significant lasting benefit from a steroid injection, and that would be my preferred treatment option with people with minor symptoms.

Louise

Thank you. Gwen says, I've been hearing a lot about CMC joint replacement horror stories. What is the success rate of the operation, and what are the complications?

Mr Andrew Smith

So, I'm well, I'm surprised to hear horror stories. I think it's one of the biggest advances, certainly in the last five years within hand surgery. Historically, some of the older implants didn't function that well, and I suppose the French population put up with a lot of that, because the arthroplasty techniques for the thumb base were predominantly developed in France and Belgium.

Some of the earlier implants did have a high failure rate. Modern implants seem to work extremely well.

But, of course, any operation, including a hip replacement, a knee replacement, you know, which are carried out by the hundreds of thousands in the world, can wear out. They can come loose. They can dislocate.

The modern thumb-based joint replacements dislocate about one in 200 cases.

I've only had it happen once, and that was in a young guy opening a car bonnet as a mechanic. It popped back and we popped it back in for him, and it hasn't come out since.

I've been doing this for five years; I haven't had to revise any.

So the complication rate with modern implants, I think, is really quite low. And that's what the published data would suggest. So I'm surprised she's heard horror stories, but like anything,

You know, operations can have complications, and they can be bad, but they're infrequent. The rate of infection, for example, in CMC joints is less than one%.

Louise

Thank you. Before I go on to the next question, do you want to just put the slides forward again to the penultimate one? I think there's just a few details on the screen for people to read.

Mr Andrew Smith

That one or the next one.

Louise

One next one.

Louise

There we go. Thank you. Okay, so, Stephen has a question, and he says, will exercise involving wrist and fingers aggravate Carpal Tunnel and trigger finger?

And he also says he's type one, assumed diabetes, for 40 plus years, but he's fit and exercises regularly. He's now 72 and he's had steroid injections. Must he resign himself to the issue continuing?

Mr Andrew Smith

In terms of carpal tunnel?

Louise

Yes, I believe so.

Mr Andrew Smith

So I think.

Mr Andrew Smith

Either condition can be treated surgically, and surgical treatment for carpal tunnel and trigger finger works really well. There's a very low chance of problem, but it's not impossible, as the previous question suggested.

But it's really very low, and the success rate for carpal tunnel is very high, even in patients that are diabetic. And the same with trigger finger. Steroid injections are less likely to work in trigger finger in diabetic patients.

But they're not but they still have a high success rate. But if they fail, surgery's just as successful.

 So things that will tend to make carpal tunnel symptoms worse.

Doesn't make the condition worse, but will make the symptoms worse are things like holding an object for a prolonged period of time. For example, using a hammer extensively during the day, riding a bike for several hours can make the numbness and pins and needles worse. Doesn't tend to make the condition itself worse, but it'll make you more symptomatic, that's pretty much for sure.

Louise

Okay, thank you. We have another question from a different Stephen. He has Dupuytren’s runs in the right hand and has had one removed from a long finger.

More recently, he now has it in his little finger, which has caused an ulnar deviation, which led to a dislocation of the first knuckle.

Then in February 2025, it was removed, and the second knuckle replaced, as in an arthroplasty.

Regrettably, this was not successful, and resulted in Littlefinger

With as little as or no movement, little at the base, and the same deviation, which, as you described, it catches in other near items causing pain and calamity.

So, quite a lot is going on.

Mr Andrew Smith

anything else about this. I think without really seeing the hand and examining it, and really having a better understanding, I think that's quite a difficult thing to answer. It's clearly quite a difficult situation.

You've had surgery for Dupuytren’s disease, and a knuckle replacement, so again, it depends on the type of knuckle replacement as to whether and how well that's aligned, because, for example, you can

Like any joint replacement, the joint may not be aligned right, which is why you've got the problem. Or it could be that the Dupuytren has come back or wasn't completely released at the time. So without seeing the hand, I think that's really very difficult to say, but it does sound like that's potentially fixable.

But I wouldn't like to say so definitively without seeing, seeing it.

Louise

Yeah, that makes sense. Can, can rejection sorry, can injections be repeated for carpal tunnel?

Mr Andrew Smith

Short version, yes.

There are some patients that have had, sort of, yearly, two yearly injections for years and years and years.

There's no such thing as about how many injections you can have, and how close together they can be.

But, if you find that a steroid injection is helpful, reduces your symptoms significantly.

having them very close together probably isn't a good idea, in that steroid injections have to everything has a downside. Steroid injections can cause a degree of weakness of the tissue.

So if you have a lot of steroid injections put in the same place over a relatively short space of time, you can get issues such as tendon ruptures or ligament ruptures, that that is possible.

So if you have a steroid injection once every 18 months, year, and that holds your symptoms at bay, and you're happy dealing with it like that, I think that's perfectly reasonable.

Equally, if you get fed up with them, then it's very, very likely that a small operation under local anaesthetic would deal with the problem definitively.

Louise

Okay, thank you.

Malcolm had carpal tunnel a carpal tunnel operation in 2017, which was very successful. The classic thumb-worth night numbness is coming back again. How successful is another operation on this hand likely to be?

Mr Andrew Smith

So, carpal tunnel syndrome can recur. It is not common, but it certainly can and I in this situation, I think nerve conduction studies are extremely useful, just to be sure about

The diagnosis, and also the severity of the nerve compression.

But the answer to that is yes, I think assuming that the diagnosis is correct, and this is a recurrence of the carpal tunnel syndrome.

It's something that does work, and does work well. It's not something that's performed on a

Very regular basis because recurrence is really quite rare.

I probably do maybe one recurrence case, a month, something like that, compared to, I don't know, maybe 20.

25 primary carpal tunnels. So it can be done again, and it is likely to be successful as long as the diagnosis is correct.

Louise

Thank you.

Talking about being correct in the diagnosis, how accurate are conductive tests in diagnosing whether someone has Cubital tunnel or carpal tunnel?

Mr Andrew Smith

So, any neurophysiology has what’s called a false negative rate. So, the test says the nerve is functioning fine, but the person has the condition. And that's the case in probably only about 5% of cases and that's the same for carpal tunnel or cubital tunnel. So there is a small error rate with that test.

The most important thing, really, is looking at the patient, listening to them, understanding their symptoms.

The majority of people with a peripheral nerve compression will accurately describe their symptoms. If it's their ulnar nerve, they'll tell you it's the small finger that's numb, they get shooting pains down the inside of the forearm into the little finger, and they begin to struggle with, potentially, how they place their fingers when using a keypad, for example.

So, the most important thing is listening to the patient.

I think neurophysiology is helpful for cubital tunnel because the nerve can be compressed elsewhere. It can be compressed

an anatomical structure called Guillaume's Canal, which sits next to the carpal tunnel. So the same the big ulnar nerve is actually compressed in the hand, and that's one of the reasons to get neurophysiology before operating on Cubital tunnel syndrome, because there are a couple of places where the nerve can be compressed, albeit the Guillen's Canal compression is really quite rare.

But yes, accurate how accurate is it in basic terms? It's about 95%.

Louise

Thank you.

Jennifer has a small lump on the side of her little finger at the base of the nail, causing a ladder-like deformation on that side of the nail. Should she do something about it?

Mr Andrew Smith

So should she do something, I think that's really a personal decision.

Almost certainly, you have a thing called a mucous cyst, which is a variation of a ganglion, so there's a small, pressurized bubble of fluid coming from the distal joint in the finger, which is sitting just where the what's called the germinal matrix of the nail bed is.

That puts pressure on it and causes the nail to grow with a deformity.

It can be relatively easily sorted out with a small operation under local anaesthetic which is highly likely to be successful.

It has a very low complication rate, and is something that people do have surgery for, without question.

Louise

Thank you.

I believe Maureen asked a question earlier, so she's asking about the angle of a contractor. For referrals previously, her doctor said it had to be more than 45% angle for a contractor to be then operated on. Is that measurement still used she says.

Mr Andrew Smith

So different funding bodies put restrictions in place. Historically, what was it called? Not the ICB, whatever it was before. People that pay the money for National Health Service operations put specific guidelines in place.

Used to be 30 degrees, your local one may be 45 degrees.

I think the more useful measure is, is it functionally a problem for you? And if it's functionally a problem for you, and the angle's about 45 degrees, that seems a reasonable point at which to operate. It's not what I would call a severe contracture.

Severe contractures, to me to my mind, and most hand surgeons' minds, are where the tips of the fingers are almost touching the palm of the hand. That is very difficult. But a 45 degree contracture at the main knuckle, that should be relatively easy to correct.

Louise

Thank you.

Mr Andrew Smith

Even as a second operation, or a third operation, if it's You know, if it's recurred.

Louise

Is there any point in having steroid injections for a thumb joint pain, if as it's only a temporary fix?

Mr Andrew Smith

Again, I think that's a very personal situation.

Steroid injections can be useful in taking pain away. They do not change the worn joint surface, so they don't solve the problem. They reduce inflammation and some osteoarthritic joints do have a significant degree of associated inflammation.

Trying to predict which ones those are, at the moment at least, is impossible. So some people will get a great response from a steroid injection and find they're pretty much symptom-free for six, eight months, or even longer sometimes.

So, can it be useful? I think so.

I think that does depend on your own personal mentality. If you want to delay surgery as long as possible, if you're young or just want to delay the surgery anyway, then they're a perfectly reasonable thing to do. Again, should you have it done more than once.

I think each time you have a steroid injection into an arthritic joint, it becomes less and less successful, because the inflammatory component to that joint pain has been resolved.

So the steroid has less to do, and the joint surface is arthritic, and that's what's causing the pain. So there can be a temporary fix, but again, is there any point in it? I think that's very much a personal

Yeah. Personal decision, really.

Louise

Thank you.

Anthony has tendon problems on both hands. One is at the base of the little finger, and the other he's had for about 15 years on the palm of the fourth finger.

He doesn't actually ask a question after this. What would you advise he does?

Mr Andrew Smith

what the tendon problems are. If they're trigger finger, for example, they can easily be treated. If you have what's called a tendinitis, again, that's something that's open to treatment.

I'm not sure what else to say really, if he's happy to be more specific, I can try.

Louise

I guess a best consultation's probably a good idea?

Mr Andrew Smith

Yes, yes.

Louise

More detail and then we just have one last question, which is, is surgery and general anaesthetic necessary for Dupuytren’s conditions, and would you advise it for an 82-year-old?

Mr Andrew Smith

So, I think there's, again, that comes down to a few things. Depends how fit, active, what you want to do with your hand will all come into this.

It also depends on how bad the contracture is, and where that tissue is. If the tissue's quite thin and in the palm, the needle procedure that I mentioned towards the start of the talk is eminently usable and gives great results.

More significant surgery can be done with what's called an auxiliary block. So the arm is made numb, and you can carry out really very extensive surgery using that technique.

So if you're concerned about having a general anaesthetic and have quite significant contractures, but otherwise fit and healthy, and it's interfering with your hand use.

Then that extensive surgery can be carried out with what's called an axillary block, where the nerves to the arm are made numb, and you can't feel your hand at all, and we can use a tourniquet, but you don't need to go to sleep, and that can work very well.

Or if you, as I say, if the contracture's not as bad, a needle fasciotomy works very nicely.

Louise

Thanks. We do actually have a couple more questions. Jeff had carpal tunnel release operation in his right hand some years ago. More recently, he's had Jupiter's contraction operated on the same hand, which seems to have caused some carpal tunnel symptoms. Is it likely that the symptoms resolve over time?

Mr Andrew Smith

So, one of the things that can happen, as I said before, is that you can get a recurrence of carpal tunnel syndrome and people can get post-operative carpal tunnel syndrome, in that the swelling caused by the Dupuytren’s surgery causes more general swelling in the hand, and that fluid puts pressure around the nerve.

That should resolve relatively rapidly after the surgery. If, for example, that's still there at three to four months, I think that's likely to be a proper recurrence of the carpal tunnel syndrome, and probably should get checked out with a view to potentially doing the carpal tunnel again.

So it can be caused by the secondary surgery for the Dupuytren’s.

But again, that's difficult to know without looking at timeframes.

Louise

Thank you. David says the middle finger of his right hand has the trigger finger problem, which is fairly mild, but he's recently noticed that the upper finger is bending to the left side. Is that a different problem?

Mr Andrew Smith

Yes, probably.

Trigger finger, if it's causing the finger to stick, will cause the finger to stick towards the palm, and only pulls the finger in fingers down into flexion, so towards the middle part of the palm. If the finger's being

pushed sideways away from the rest of the hand, that's likely to be Dupuytren’s disease, but again, without seeing the hand, it's difficult to be absolutely sure. But that would be my best guess as to that.

Louise

Thank you.

And someone says they've had carpal tunnel they had a carpal tunnel operation December 23, which went very well. Unfortunately, they now have developed trigger finger in their ring finger. It becomes very looked at times. Do you think it looked very good? Locked at times. Do you think surgery would be necessary?

Mr Andrew Smith

So I would definitely try a steroid injection first. That is successful in the overwhelming majority, so unless you've already had a steroid injection, I would definitely recommend a steroid injection. There's a 90% chance that that will fix the situation. So, surgery's not absolutely necessary, no.

Louise

Thank you.

So thank you again for all the questions, and for being part of this evening's session. If we haven't covered your question, and you have provided your name, we'll be able to follow up with you via email.

If you could just move on to the final slide?

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So, on behalf of Mr Smith and all of us here at Benenden Hospital, I'd like to say thank you once again for joining us, and we hope to hear from you soon. So, take care, and goodbye.

Mr Andrew Smith

Thank you.