Risks of hand and wrist surgery
In general hand surgery is very safe and the overwhelming majority of surgeries don’t encounter complications. However, there are some risks that you need to be aware of before you agree to undergo an operation:-
- Pain: There will be post operative pain for at least a few days after the operation. You will be prescribed painkillers before you are discharged, and I generally recommend you take these in a tiered approach: regular paracetamol, then adding in ibuprofen if you are allowed to take it, then dihydrocodeine, and then morphine based pain killers
- Infection: The hand has a good blood supply and so the infection risk is lower than for other areas of the body, but it is still there. When we are implanting metal infection can be very serious because antibiotics cannot penetrate the metalwork, and so this can lead to the need for long term antibiotics and further surgery
- Bleeding: The risk of significant bleeding is very low, and for many procedures we are able to use a tourniquet to limit the bleeding. But there can often be some bleeding that strikes through the dressings and requires a dressing change. It is very rare that anyone should lose a dangerous amount of blood from hand surgery
- Scar: Any time surgeons make an incision there will be a scar, which I control by using the smallest sutures possible, and taking tension off the wound to reduce the risk of an expanding scar. However, some people are prone to abnormal scarring from their genetics (keloid) and scars in some areas where there is a lot of movement or pressure can become expanded in appearance (hypertrophic). These usually settle with time, but the scars will be visible especially on the back of the hand. You need to do scar massage once the wound has been checked, with your usual moisturiser, and apply high factor sun cream to reduce the risk of the scar burning.
- Stiffness: Any time surgeons place an incision in the hand the scar tissue forming deep to the skin will try to make the joints stiff. This particularly happens in response to swelling and inflammatory fluid (oedema) which is common after hand surgery. The hand is very susceptible to stiffness because it has a number of delicate supporting tendons and ligaments which can limit the movement of small joints when scarring occurs around them. It is therefore very important that you do the exercises that the hand therapist or I recommend after the surgery, to reduce the risk of stiffness. In general my approach is to make everything as stable as possible during the operation, in order to allow early movement and so to limit stiffness.
- Failure to alleviate symptoms: very occasionally the procedure doesn’t help with symptoms. Examples of when this can happen include if there are lots of painful joints and we are targeting the most painful; or if a patient has numbness in the hand caused by both carpal tunnel syndrome and a disc bulge in the neck (double crush phenomenon).
- Damage to blood vessels/nerves/tendons: the hand has a number of small and delicate blood vessels, nerves and tendons which are all at risk any time surgeons operate. However, they tend to run in a predictable pattern, and my approach is to find them and hold them gently out the way so that I know they are protected during the surgery. Some procedures such as Dupuytren’s procedures carry a higher rate of numbness than other procedures, and this is probably because the dupuytren’s tissue tends to move the blood vessel and nerve in a less predictable way. If a nerve is damaged this usually leads to a patch of numbness which may be temporary (if the nerve has been stretched) or permanent (if the nerve is cut). If I encounter a cut nerve I will always repair it using microscopic sutures to give it the best possible chance of recovery.
- Metalwork irritation: whenever we are implanting metal there is a chance it can cause irritation to the surrounding tendons or joints, or even be palpable underneath the skin. For the majority of operations I do the intention is for the metalwork to stay permanently in position, unless it causes irritation in which case I can remove it at a same time point after healing. There are some circumstances where I routinely suggest taking out metal plates after an operation, for example where I have fixed a wrist fracture close to the wrist joint and the thumb tendon could rub over the plate and rupture with time.
- Chronic pain/complex regional pain syndrome: On rare occasions the surgery can go perfectly and yet the patient can develop pain that surgeons cannot explain. This can be accompanied by colour changes in the hand and abnormal sweating responses. It usually settles with hand therapy treatments but it can take many months to get over. For common operations such as carpal tunnel syndrome the quoted rate of CRPS is around 1 in 3000.
- Rupture of a repaired structure: whenever I do a repair of a ligament or a tendon, or a tendon transfer there is a small risk of rupture. For these procedures there is a difficult balance between wanting the joints around the repair site to be moved, to limit stiffness; but not wanting to put too much force through the repair. I always test this on the operating table, so that I know the movement exercises should be safe afterwards. Nonetheless if I have put on a protective plaster cast or splint, it is vital that the patient keeps that on when they are told to, and does not do anything to risk falling onto the operated side.
- Pillar pain: a particular issue occasionally seen after carpal tunnel surgery can be pillar pain. When I divide the thick compressive ligament in the palm there will always be a very small change in the shape of the bones. For the overwhelming majority of people this causes not issues, but on rare occasion patients can get pain when they push up on the palm of their hand, which usually settles with time, but can be an annoyance while it is active.
- Recurrence: For most of my operations the recurrence rates are very low. Following carpal tunnel surgery on rare occasions patients can form scar tissue in the tunnel which starts to push on the nerve again. This could require a further steroid injection or a repeat surgery, but this is rare. However, some conditions such as Dupuytren’s procedures carry a much higher recurrence rate. In truth this is often not a true recurrence as the scar tissue has not grown back in the operated area, but rather the disease has progressed to involve other parts of the hand. For open Dupuytren’s surgery about 1 in 2 patients will have had another procedure by ten years; and for needle fasciotomy this is about 1 in 2 at five years.