Complications following surgery
Here is a list of complications that may occur in hand surgery.
The majority of my cases do not have complications but you need to be aware that they can occur. I would be discussing these with you in person should you require surgery at the time of our consultation but also I am more than happy to see you for a separate consent clinic if you require more information over and above what we discussed and what is contained below.
This list is not designed to scare you or put you off surgery as the majority of my patients are very pleased with the results but do help explain what can go wrong.
A discussion always required and is useful as it makes us all appreciate that things can go wrong, and surgery should always be viewed as a last resort having explored non operative options including.
Do nothing and the natural history of the condition unfold
Rest and Splinting
Injections – cortisone etc.
Here are some of the commonly discussed complications but fortunately in the hand they are all quite rare.
Failure to resolve symptoms
Our aim is to improve your symptoms. On rare occasions unfortunately, this may not occur and maybe related to your case complexity.
The hand has an excellent blood supply and therefore post-operative infections are rare. Signs of infection would be redness, pain and swelling around the surgical site and developing after a few days (3-10 days) rather than immediately post operation (1-2 days) which may be a normal reaction to surgery. Very occasionally, about 1 in 20 patients develop a small pin head size of puss around the white dissolvable suture. This usually needs popping. It seems to be a poorly understood reaction to the dissolving stitch rather than an infection. If this occurs simply send me a photo for reassurance
If you have any concerns, please do not hesitate contact me to review your wounds.
Most infections are superficial and can be easily treated with dressings or oral antibiotics. More severe cases may have a deep infection that require a further operation to clean the wound or intra venous antibiotics as an inpatient.
After any operation there will be some pain. I would hope that the majority of discomfort will settle within the first few days of the operation. Depending upon the operation will will depend upon the duration of post operative pain. I will discuss this with you in clinic if needed.
All wounds swell after an operation and the majority of swelling will have settled within the first week. Swelling after 1-2 weeks would need reviewing.
General ooze into the dressings may occur after an operation and is preferable than to allow the blood to remain in the wound developing a haematoma (collection of blood) which can be prone to infection. Continuing bleeding after a few days would be very rare and would need review. A haematoma is a collection of blood under the skin and if very large, rare in the hand would need releasing.
Scar’s on the hand heal very well and often barely noticeable. I tend to use a stitch called vicryl rapide that dissolves after 2-4 weeks. On the palm of the hand the stitches are usually interrupted and exposed stitches whereas on the back of the hand they are under the skin and called subcuticular and cannot be seen, apart from two small knots at either end of the wound. My carpal tunnel stitch however tends to be subcuticular.
Bleeding is inevitable after an operation and sometimes this comes to the skin as a bruise. This will be red after a few days turning black and blue before fading after a week or 10 days.
Weakness can be caused by ongoing pain or a restriction of movement. Most operations we do would hopefully maintain or increase strength, but occasionally patients can experience a mild degree of weakness. Severe weakness would be very rare.
After an operation you may develop internal scarring, which in turn can restrict the range of movement of a joint. We would hope that most of the movement would return but there may sometimes be a permanent restriction of movement. This does not usually cause much in the way of functional problem.
Nerves are small soft electrical “wires” that transport information to and from the brain from the periphery.
Most nerves are mixed and have motor (movement) and sensory (sensation) roles.
The motor component sends information to a muscle to tell it to contract, while the sensory component carries information back from the skin about a variety of sensations including touch and pain.
Nerves may be injured as part of an injury but in very rare occasions can be injured during surgery. I take particular care to identify all important nerves during your surgery and retract them out of harms way. Despite this very rarely they can still be injured.
If a nerve is injured, then the function may be affected. Some nerves are bruised (neuropraxia) and recovery may occur over a few months. Some nerves are permantly injured and therefore recovery is not possible leaving areas of numbness and weakness to a muscle or group of muscles.
A neuroma occurs when a nerve is injured. The end of the nerve that is cut or damaged overgrows and forms a knot of nerve tissue that is very painful. Neuromas can be difficult to treat. Common treatments include hand therapy to desensitise the area, neuromodulation (using variety of techniques including vibration to re-educate and settle the nerve end) and ultimately surgery to locate the neuroma and bury into a protective environment such as an adjacent bone or muscle.
Numbness may occur if a sensory nerve is bruised after an operation and recovers over a 3-6-month period. If a nerve is cut, then sensation may never recover.
Tendons are cord like structures that connect muscles to bone allowing the contraction of the muscle to pull on the tendon and move the bone and joint. Tendons can be injured in surgery and this would affect the joint(s) moving. Tendons are identified during the operation and protected but very rarely they can be injured. Some tendons can rupture spontaneously and this can occur after a wrist fracture treated in a POP, or if a tendon passes over a rough sharp edge of bone or in some diseases such as rheumatoid arthritis.
Complex Regional Pain Syndrome (CRPS)
CRPS can occur after any injury including surgery. As its name suggests it is a complex condition with may factors at play. To reduce the risk of it occurring we always recommend to move the hand and fingers as soon as possible after surgery and keep them moving. Sometimes fingers and wrists are immobilised after an injury or operation and cannot be moved but all the other joints should be kept moving.
CRPS causes redness, swelling and pain. In severe cases the hand may become red and shiny and abnormal hair growth forms. In my personal practice this is very rare and much less that 0.5% - based on last three years’ cases.
I often use hand therapists post operatively and I am sure they are the reason for my low rates of CRPS.
Joints are connected to each other by ligaments. Ligaments can be injured in an accident or during surgery. I am aware where the important ligaments are in the hand and will avoid injuring them. However sometimes after operations such as joint replacements or joint reconstructions the ligaments do not function as well causing instability (abnormal excessive movement of a joint) and ultimately dislocation when the joint comes out of socket.
This occurs when a joint – artificial or the original joint comes out of place. Pain and reduced movement occur. The treatment is usually to put the joint back into place and stabilise with either a splint or in rare occasions another operation to revise the artificial joint or stabilise it.
Joints that are replaced are artificial and may wear out over time. In such cases they may need revising to a new implant.
Furthermore, when placing an implant into the body the surrounding bone can be fractured and so great care is taken to avoid this. Depending upon which bone is affected would depend upon what is required to resolve the situation.
After an injury or major operation swelling can occur in the limb. The swelling may be conscripted by the surrounding firm fibrous bags inside the hand and arms.
Pain starts to develop along with swelling and each hour gets worse and worse and is disproportional to the pain one would normally expect. Tingling in the fingers is a very late stage and extreme pain is the main symptom particularly on moving the fingers. This is a surgical emergency and the pressure needs relieving by a trained doctor often removing the dressings and cast but sometimes releasing the tight fibrous bags in the arm with open surgery.
Cold intolerance is poorly understood and can occur as a result of injury to the fingers including surgery. An abnormal response may occur to cold environments and cause colour change, pain, stiffness and altered sensation. It generally improves after injury but symptoms after 18 months may be permanent.
Non union / Mal union
Bones usually heal without problems.
Bones need to heal in a variety of situations including after a fracture, after an operation to fuse a joint or after an osteotomy (intentional operation to cut of a bone to improve its shape). However, some bones are prone to not healing either as a result of an injury or after an operation. If a bone fails to heal it is called a non union and if it heals in an abnormal position it is called a malunion. Non unions can be either painful or painless.
If after a joint fusion operation, the bone does not heal and is painful they this may need further surgery. If a non union is painless it may be stable and not require intervention. Smoking is known to affect bone healing and should be stopped several moths before surgery if outcome is to be optimised.