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All right. Um Good evening everyone. Um So before we begin, I just wanna check that you all can hear me. Ok, so if you can hear me just put in the chart, um, just saying that you can and then we'll get right to it. All right. That's great. Um So yeah, hi, my name is Aaron and I'm one of the teaching officers for to this year and thank you so much for joining us on a Tuesday evening. We appreciate all of you for taking time out of your busy schedules to attend this talk on hand surgery as part of our Subspeciality series. So just before we get right to it, it's just a reminder to keep all your questions towards the end as MS Simpson will be addressing them um in A at the Q and A at the end. So, yeah, so without further ado, I'm gonna invite Miss Claire Simpson to the stage to give her presentation. Thank you very much. Lovely to be here and uh absolute pleasure to be invited. So we will just go back to the start of the um presentation. And ok, so I thought when I asked Well, when I was asked to do this talk, I thought, well, what can I actually tell you all? And I thought, well, I could talk about why I actually have the best job in the world and why I absolutely love it. Next page, please. So, just a little bit about my background. It took me ages to get through training. Um, probably part of that is because it was the old style training. So I went to medical school in 1993 which is probably before most of you were born. Um I finished medical school in 98 and then from there, my training was all within Mersey Deanery. Uh It, it, it did take me a little while to get through. So if you are a little bit slower than average, it's not a big issue. Um What I felt at the end of my training was that I was fully trained and ready to be a consultant. Um So I, yeah, so basically Mersey Deanery training, I did 10 months in Surrey and came scurrying back up north, back to Liverpool for my registrar job in Mersey. Uh during that time, I was both a publicity officer once I'd got my exam. Um I did my fellowship in hand surgery at Birmingham. And then in 2013, I was appointed as a consultant at Saint John's Hospital, which is where I am now. Next page. So why orthopedics? Um it it was a combination of things I did orthopedics in my second year at medical school and my first placement was at this wonderful hospital. It's now completely changed. Uh, but this is the old, old Alder Hay Hospital and the two chaps at the top of the screen, John Dorgan and Colin Bruce, absolute legends, pediatric orthopedic surgeons. Just such lovely, lovely people. And I just thought they look like they're enjoying their jobs. So that was what sort of piqued my interest. And then I was lucky enough to have support from Simon Frost, er, who was our professor in Mersey Deanery. He's a chap at the bottom. Sadly, he's died now, but he was a big influence on getting me into, um, uh registrar training next page. So during my ha my orthopedic rotation, I had to do some hands as part of that. And in the end I ended up doing an awful lot of hands just because I loved it. Hand surgery is beautiful. It's all about anatomy, all about function. It's pretty clean. Unless you get a handful of pus, patients are normally well and you can treat people from cradle to grave. So you, you know, congenital hands is a whole specialty on its own, but I'm treating sort of 8090 year olds as well. Uh It's a huge team effort. It's not just about me as a surgeon. I have to work with so many other people, neurophysiologists, rheumatologists, hand therapists, and I get to deal with all of the soft tissue, soft and hard tissues. Um, I've stuck to hands because I never had any major confidence in general orthopedics. I didn't really like hip and knee surgery. Um, I did and I didn't think I was particularly good at general trauma. So I thought the speciality that I can sort of hone down on that gives me a vast amount of variety is hand surgery. I've been lucky to have so many superb mentors throughout my training and all the people on the, the right of the screen are just a, just a few of them, um, who have been there for me when I've needed them in my training and in my consultant jobs, um, the patients are pretty wonderful. II do enjoy my patients. They're, they're, they're good people and the hand surgery you need a, a variety of skills, um, which I enjoyed. So things is, it's pretty, it can be pretty delicate and I do enjoy that sort of sitting down that sort of mindfulness of having to, um, be very gentle in what you're doing and what you're stitching. And again, the, just to reiterate it is a team sport. Um I really enjoy that sort of multidisciplinary aspect to hand surgery next page. So what do I as a hand surgeon do all day? Well, quite a lot really when you think about it. Um, so you've got the, the normal sort of clinics and theater and I do a lot of training. So all of my clinics, if, if my trainees, uh see patients, they come and talk to me about it. We learn a bit about the condition, we talk a bit about management. Uh, so it's not just a, a sort of churning through them. Uh Most of the operations I do will, I'll get the trainees doing it as well. So it's not just the, the junior trainer, junior surgeons that I'm training, I'm also training hand therapists. We train the um uh the nurse practitioners from the emergency department and have got a role in teaching GPS as well. But on top of that, I am clinical lead for hands in our department. So there's service delivery and service growth. I've got opportunities to work on a committee. Um So the British Society for Surgery of the hand sit on, on their training and education committee. And through that I sit on the Association of Surgeons in primary Care committee as well. Um I think when I was a trainee, some of my trainers were worried that I wouldn't get through the exit exam, the FRCS orthopedic exam. Uh I now sit as an examiner and I now write questions and part of that is standard setting for the exam as well. So, and that's a huge joy uh to see that the future of orthopedics is in good hands. Um, research and audit. All doctors should be involved in some sort of research and audit. Um and we've got some trials going on here at Saint John's. Um and I'm lead for M and M so my, my day to day job is really busy. Um I don't stop. Um and I work with really busy colleagues as well next page, but you've got to have some sort of work life balance. Um And I really didn't as a trainee, it was, it was hard going long hours in those days and um weekends, if I wasn't working were probably spent in the raz or sleeping the next day. But now as a consultant, um I have and now living in Scotland as well, I've got the opportunity to get out scuba diving. So um that, yeah, I'm, I'm happy when I'm in on or under the water. So, scuba diving, we breath diving is now a massive passion of mine. Um I did do my instructor course, but I tend to do it for myself. Now, next, please. Same. I thought I would run through the sort of stuff I can see in one day. Um And the the cases I deal with, well, if you think about it in anatomical terms, um and there's a lot packed into a little area to deal with things involving skin, the tendons and muscles, nerves, arteries, bones, joints, ligaments. So the neck, the the rest of the presentation is basically a run through. Um what could come in to my clinic or trauma service. The first of those conditions is Gibran's disease. Um Gyton disease is a fib proliferative disorder of the palmar aosis. And it basically um causes the fingers to curl into the palm of the hand. Now, this is where it comes down to function. This is a completely benign condition harmless. But you can see the um, the thickened cords in the palm of the hand, these develop over time and over time, the finger can start curling and curling in. Now, um, it stops the patient from putting their hand flat. And if you look at the chap on the right of the screen, his um, little finger will poke him in the eye. When he's trying to wash his hands, it'll get caught on his pockets and things like that. Um So this is one of those conditions, although it's harmless and pain free, it's all about function. Next page, we did have some advances in duress disease with an injection called Zyr, um, also known as Collagenase. Um, it comes from uh Clostridium bacteria. Um, it was an injection, you injected it into that thickened cord. And um, a couple of days later you'd come back and forcibly straighten the finger. You'll hear a snap, like snapping a carrot and the cord that you've injected it in, um, had been dissolved away was weakened and then snapped. And the idea of that was that it was less invasive than having quite big surgery to a finger, it worked quite well. Um, it sort of sat between just using a needle to divide the cord and the, the bigger surgery. But a couple of years ago, uh, I think the patent was coming up and the, uh, drug company decided that rather than having the product just for a limited amount of patients, um, for, uh, Gyptians disease, it could make a lot of more money by using it for cellulite in America. So ZP is now off the market for us, but you can go and get your cellulite treated in America if you like. So that now leaves us with um, the needle fasciotomy just using the tip of the needle to scrape across the cord, which will inevitably divide it. Um We only use it for cords that are affecting the MCP joint rather than in the finger or then you've got surgery, surgery, um, is called a fasciectomy because we're going in and taking out a portion of that cord. It's just fibrous, it's quite tough tissue. Um So we literally just take a knife to it. Chop, chop, chop, don't chop out the nerves, don't chop out the arteries, chop, chop, chop the cord and uh your fingers should straighten if you've got quite severe disease or if you're young or if you've had surgery in the past, then the picture on the bottom, right shows what we call a dermofasciectomy. So, um, the, the problem with GRS is you're never gonna cure it. Um, but if you take away the skin that's involved, then you've got a better chance of it not coming back. Um, so we often take the skin graft from the inside of the forearm, put it in the hole that we've created in the finger, stitch it down and then hopefully it integrates and hopefully your dryness doesn't come back in that area. Next, skin cancers all around. I work in a plastic surgery unit. So, um, skin cancers can present on the hands. So, um, we've got sec, we've got that typical, which is sorry, sec, the top left, the top right is ABC. Um, with that typical Perles rolled edge and then the bottom one is a malignant melanoma and they're becoming more common. Um, I, I'm an orthopedic trained hand surgeon, but, um, my plastics colleagues tend to deal with the skin cancers, but they can crop up anywhere next, please. Yeah. So good. All flexor tendons. So this is a relatively young person. You can see that somebody stitched their wound in the palm of their hand. Um, so flexor tendon injury, um, is relatively common and we all get very excited about flexor tendons. There has been a vast amount of research on management, um, of flex tendon injuries back when, um, surgery, hand surgery started. Um, and certainly sort plastic surgery back in, um, the early 19 100s. Uh, the area in the hand that sits between towards the end of the finger in the middle of the palm was called No Man's land. Basically because the results of trying to repair a tendon initially with, um uh with laceration was so awful that it was, it was probably better to leave them and come back to them at a later date and uh tendon graft them instead time's moved on. Uh We've got better uh what's it called, er, materials, stitch materials? And we have a better understanding of how tendons heal and what we can and can't do with them. So you can see from this picture that yes, you've got the wound in the palm of the hand, but the little finger is not straightening, uh, sorry, not curling in the natural posture of your hand is to sort of sort of sit slightly with your fingers bent. So if you've got a finger that's straight when it shouldn't be. Oh, that must probably mean that you've got a discontinuity in the tendon itself. Uh, next page. So Flexor Tendon anatomy, I hope you all know and understand your flexor Tenon anatomy. Excuse me. My Alexa is uh, playing up. I'm afraid she's trying to play me music. Sorry. Um, so Flexor Tendon anatomy, um, can be, can be quite, um daunting at first. Uh, but once you sort of work your way through it, it becomes more, um, clear. Our fingers are, are, are each of our digits has, well, each of the digits apart from the thumb has two tendons that bends the fingers. The first tendon, the superficialis, the flexor digitorum superficialis F DS travels um through the carpal tunnel into the palm and sits on top of the FDP, which at this level is deep. Your F DS then sort of splits goes up, the finger turns around and inserts onto the base of the middle phalanx of the digit. So the F DS on its own will just bend your f your proximal interphalangeal joint. The FDP, the deeper one of the two initially comes through the carpal tunnel. It has a muscle that attaches that originates from the tendon itself called the lumbrical. It keeps traveling to through the tunnel and where the F DS is split, your F GP comes through the middle. So your F GP becomes more superficial um around about half the way up to the proximal phalanx. It then travels up the finger and inserts into the base of the distal inter phalangeal joint. Mm by and then that the FDP will flex the D IP joint, but also have an action on the P IP joint, the tendons run through a sheath um that keep the tendons slapped down into the palm of the hand to give us mechanical advantage. And part of the research that has been done over the years is working out which stitch to use, which can, what how to actually stitch it as you can see on the bottom, right there's so many different um ways of putting your stitches in. But the aim of the of stitching them is to bring the tendons together, but make them strong enough that we can start moving them early. The idea of moving them early means that the tendon glides so it moves up and down, it can travel through that tunnel and allow um and basically stop adhesions or scar tissue from forming in that finger. Um Other things that people have tried, we've tried, uh, sort of gels or, or, um, coverings to try and stop these adhesions from forming. There's so many different ways to rehabilitate the f the hand after surgery. Um, and again, long history, um, starting with various different splints. Uh, next page please. The, um, the splint that shown here is the, the latest of the, um, the rehab regimes and this is called a Manchester Short Splint. Um Normally the splints. Well, previously, the splints have been pretty long. Uh, so they did cover to the end of the fingers and they came most of the way down the forearm. Uh, but in Manchester, apparently the, the, the patients were somewhat less compliant with being told what to do. Um, so patients that were sort of removing their splints more often, uh, were getting better results. Uh So the team down there, I think it was Fiona Pecker decided to shorten the splint and see if A, they got better compliance and B they got better movement after rehabilitation and they did. So, um, we've, we've now instituted the, um, Manchester Short Splint in our service. Um, the picture on the right is of a, apparently a hand therapist doing their job and it's nice to see a bloke doing hand therapy because the vast majority of them are women. Um, it's, um, they're a great team and my operations won't work without hand therapy. Input next page, please. So, um probably less sexy than flexor tendon injuries. And some of the other stuff I'm going to show you, trigger finger is one of the most common conditions that we treat. Um It's very common in diabetic people, but it can happen in anyone. And it is basically where that tunnel that we we were talking about before the tunnel that keeps the tendons slapped down against the finger, the base of the tunnel, the A one pulley, the b the base of the tunnel, the pulley gets thickened. Nobody really knows why it happens. It gets thickened and, and I think as a result of the thickening or is it chicken or egg that um the tendon um expands. So it feels like it's, the tendon has got a little bubble on it. Uh That bubble then travels through the, the tunnel and then because it's wider, it gets stuck. Um So that patients end up, they, they make a fist and then their finger won't straighten. It's a and again, an A harmless condition but really annoying. If your finger is not getting out of the way, sometimes it clicks itself. Sometimes it needs help to be straightened. Um, nothing too exciting in trigger finger management. Most of them will be cured with a bit of steroid which is, um, given in, in clinic. But there's, um, but if, if it doesn't settle down or if it comes back, we can operate and that's what's happening in the bottom, right? Little trigger finger release done under local anesthetic. Um We open up the skin and then go down and find that tunnel. Um You don't cut the nerves which are sitting either side of it, but you cut the tunnel, you ask the patient to make a fist on the table just to make sure they're not sticking any more job done. Stitch them up off. They go, it's a really satisfying uh operation for both me and the patient. Uh next stroke, queer veins, disease less common than trigger finger. But again, um one of our bread and butter uh conditions. So, again, anatomy, the first extensor compartment, you've got six of them across the back of the wrist. But the first one has the Apla to Poly Longus and the EPB extensor pollicis brevis, which pull the thumb out into extension at the corner of your radius at the radial styloid. Again, you've got that, that um sort of tunnel that's holding those tendons in place. And again, that tunnel can get thickened and the friction on the thing on the tendons gives people pain. It tends to be in young mothers. Um, they're the, the, the typical patient, they're lifting up the baby a lot. They're doing a lot of twisting, holding the baby changing nappies, et cetera. Um, they get pain at the radial styloid and the test that's being done up here is called coughs test. So, if you put the, uh, thumb into the palm of the hand, uh and then put the wrist into ulnar deviation, it's usually a little bit uncomfortable anyway. But yeah, you can see the patient wincing treatment again, good old steroid injections. Um And because I use local anesthetic with my steroid injection, if I inject the area, get them to do that test again and then the smile on their face because they're pain free for a, for an hour while the um locals working is fantastic. You know, the diagnosis, you know what's wrong with them, you know, that your steroid is probably gonna make them better. But if it comes back or it doesn't work, then we can always operate again under local anesthetic. Make a little cut over where that tunnel is job done next. Excuse me. So again, ex I, if we've got flexor tendons on the fingers, we've got extensor tendons as well and extensor tendon issues probably cause more bother than flexor tendons. Um They're extensor tendons a little bit more intricate. Um a little less forgiving than flex attendances. A lot of extent closed extensor tendon injuries can just be managed with splints, which is again where your hand therapist comes in. So, um, at the end of the finger near the nail, you've got your distal interphalangeal joint. The picture at the top, right, um, is called a mallet finger. So, the typical history is that, and, um, is that somebody's been changing their bed and they've been pushing their sheet into the side of the bed and then their finger is forcefully bent, they can hear a pop or a snap and then they pull their finger out and the end of their finger has drooped. It can be that the tendon has pulled off the bone at the base of the distal THX. Um, but you can get, um, fractures involved with these as well. Um, as long as the joint is in joint and not subluxed off, you can manage these quite happily with a splint, but the outcome at the end is not, it's not fantastic. Often you'll take the splint off and then within a couple of hours the finger starts drooping again. Um, so, you know, it's the best treatment but the outcome isn't perfect. Um, the picture in the middle shows a bonia deformity. Now that is a, er, caused by an injury to the central slip, the, the tendon that straightens the finger comes up, the finger, it's fixed at various points. So on the back of the hand. Um It is, it's nice and free, it's beautiful tendon at the MCP joint. It's fixed in place, it's held in place by um things called sagittal bands that hold that tendon over the middle of metacarpal head. The tendon then travels up the finger in the proximal phalanx. It gets um its contribution from the intrinsic tendons. Um And then uh just before the P IP joint, the, the, the main tendon splits into three. It has a central bit that goes and inserts onto the base of the middle pharynx. And then the two side bits ignore the middle pharynx and go up to the distal pharynx and they're called lateral bands. So the only part of the tendon that's straightening your P IP joint is actually your central slip. If the central slip gets detached or becomes nonfunctional, that means that you can't physically straighten your P IP joint, but your lateral bands are doing their best. They're really, really gonna start working overtime to straighten the fingers. So the lateral bands then slip down either side of the finger and instead of um straightening this joint, they, they bend it, but hyperextend the end of the finger and that's called a bonia deformity treatment of that splintage. We can put them in a splint for six weeks and at the end of six weeks, we take them out of the splint and their finger is straight. Um, and it works really well, it's a really hard condition to sort out surgically. So most of the time is splinting. The, the finger deformity at the bottom of the page is called swan necking. And that's why that's the opposite of the bouton deformity. Um Swan necking is hyperextension at the P IP joint with flexion at the D IP joint and it can be normal. I'm getting a bit old now and a bit creaky, but I used to be able to, to do swan neck on my fingers just from a bit of hyperlaxity. So some people are just hyper lax and this is the way their fingers are. It's nothing pathological. It's just one of those things, but you can get swollen necking as a result of injuries and those injuries can be things like mallet, mallet injuries. You can get injuries around the pip joint like rupture of your F DS or rupture of your roller plate. Um You can get MCP joint problems causing swo necking. Um and intrinsic tightness can cause swo necking as well. So sometimes it's a bit difficult to work out what's going on. Um It's rewarding, treating these injuries though because if you're um correcting deformity, patients are generally happy next page, please. So sometimes you get tendons with joint problems. Um The photograph is a clinical photograph of a person with an inflammatory arthropathy. Uh So the commonest of those is rheumatoid arthritis and if you look at the posture of the hand, she can't lift her two f her little finger and her ring finger up. So, why has that happened? Well, there's several causes of it. But if we look at her, if we look a little bit more proximal at her wrist, you can see that big massive bump where the ulnar head is. So, in this patient, um, she's got an inflammatory arthritis which has caused initial problems with the, the, the extensor tendon on the ulnar side of the wrist, the ec U that has come out of its slot, it's, it's, it's dropped underneath the ulnar head, which then sets up this huge uh process of developing something called caput ulnar syndrome, which is basically where the ulnar head dislocates out of the radius, the carpus then sort of sublux and it doesn't, it doesn't always sublux it. Um it sates off the, the radius and you end up with this really prominent ulnar head, which is right where your tendons are tightly um held against the bone over time. And what can happen and the, the ulnar head becomes sharp because of erosions into it. And then as those poor tendons are, are moving over that ulnar head all that time. It's a bit like a rope over the edge of a wall and they snap. So you end up with dropped fingers. So one of the things that we, we see is this condition, we have to then think about treating the wrist and we then have to think about restoring those tendons, giving the patient new tendons to, to make their hand more functional. Um Sometimes we borrow tendons from the same hand. So we do what's called a tendon transfer. Um Hopefully, you know that you've got two tendons going to your index finger, the EDC and the E IP is the extra one. So we steal E IP um and then move it over to the little finger so that uh you can restore little finger extension. And then if the ring finger is gonna again as well, then you can just stitch the ring finger onto the middle finger, which is normal. So quite an involved operation, but again, beautiful anatomy. Uh you can see what's going on and if you restore function, the patients are incredibly grateful. Next, please. Nuts. So the bane of the bane of my life with uh lots of, lots of patients with uh nerve compression syndromes. So, the commonest thing I see in my clinic is something called carpal tunnel syndrome. Your carpal tunnel is basically the space at the heel of the hand. Um It's on the dorsal aspect. It's you've got these bones which don't move over the top. You've got a really thick ligament um which doesn't have any give in it. So they, you've got this potential space which through which your your nine tendons to your fingers and thumb and the median nerve travel and space is pretty tight in there. So any sort of condition like hypothyroidism, pregnancy, rheumatoid arthritis, any condition that reduces the space in that tunnel can put pressure on the nerve in most patients. We don't know why it happens. It's just one of those things. The most common cause is idiopathic. Otherwise we know we don't, we don't really know. I don't know what's in the water around Edinburgh, but everyone seems to have carpal tunnel syndrome. I'm amazed at how many people can actually have this condition on the, on the patient on the left of the screen, you can see that the arrows are pointing towards their thenar eminences. If you look at your own cleaner eminence, you've got nice bulk there. It's nice and con it's nice and convex. But if the messages are not getting through because your nerve has lots of pressure on it, then the messages are slowed across the carpal tunnel and the messages don't meet, don't. So those nerve impulses don't reach the, the muscles at the base of the thumb. So they waste away. They don't, there's no point in them staying nice and bulky if they're not receiving messages to contract, so they waste away. So some. So if you've got somebody with pretty severe carpal tunnel syndrome, you can see this wasting of the thenar eminences that can be combined with tin pins and needles, tingling or numbness in their thumb, index, middle and usually half of the ring finger and that's because, er, anatomically your little finger and the ulnar half of the ring finger are supplied by a different nerve. The ulnar nerve, the photograph on the right hand side of the screen is an ulnar nerve. Uh, neuropathy, the ulnar nerve gets trapped at the elbow trapped, pressured gets pressure on it around the elbow and, and that can be because people lean on their elbows an awful lot. Um, keep their elbows over fex for long periods of time or that they've got tight bits of anatomy um ranging from the medial intermuscular septum up in the upper arm to the covering over the um cubital tunnel in the groove where it sits behind the um medial epicondyle or even excess pressure from your flex carpi ulnaris where it dives between the heads of that muscle. So different muscles don't get their messages in ulnar neuropathy. Um If you look at the back of your hand, the first web space is the first place to see wasting. Um it's the last muscle to be um innervated by the nerve and it wastes away pretty quickly. So they end up with um a AAA hollow there. You can see in this patient, they've got slight ulnar chlorine um because they um the intrinsics are wasting away um as well. And you may see guttering on the back of the, the hand next page, excuse me. Um So there's our carpal tunnel on the left and our cubital tunnel on the right. And again, it all comes down to anatomy. If you're gonna treat these patients, you've gotta understand the anatomy of what you're dealing with. Next patient, next page even. Sorry. So what can we do? Well, carpal tunnel syndrome can range from very mild to very severe. The vast majority of patients I would argue will probably end up needing what we call a nerve decompression. So the commonest operation I do is actually a carpal tunnel release. And I have the joy of doing about 10 in a day uh on a waiting list. Um Basically go down through the skin and the fat and the palmar neurosis. And you find the transverse carpal ligament that really thick ligament um over which sits on top of the nerve, the nerve sits literally just underneath that ligament. So we cut that ligament from top to bottom and it springs open. So it takes pressure off the nerve. And amazingly, the vast majority of patients get rid of their pins and needles. If they've already got numbness in the fingertips or wasting of the thumb, that's not gonna come back. But the it's the pins and needles that distressing waking up in the middle of the night, having to shake your hand to try and get the feeling back into it that um that is improved with this operation. It's one of the best operations in the world. Um Ulnar nerve decompression on the right. Um Not the patients aren't quite as happy with this as they are with the carpal tunnel. Um, purely probably because the nerve is much more proximal where we're treating it. So if patients have numbness or weakness from that ulnar nerve compression, then they're not gonna get much, uh benefit from surgery other than stopping the nerve from getting worse. And if they've got pins and needles, hopefully that will go as well. Uh, next picture the, the flip side, the trauma side of nerves. And again, this is where there's a huge amount of um work and research being done. So we get a lot of lacerations in nerves. So, um, patients will fall on glass and cut through their major nerves and arteries, um, or finger cuts or the good old avocado injury. The avocado hand I II have to admit I have my own avocado hand. I um yeah, we'll, we'll brush over that. So, um, cut nerves are, are a nuisance because they, they, they um stop being able to send the impulses to their target areas like the skin for feeling or the muscles for power. So, um, if they, if you leave them alone, what they tend to do is create what we call neuromas. So the, the far end of the nerve will die off, leaving the myelin sheaths intact, but the nerve cells themselves will die off. You've got then got a hole, the nerve on the proximal side of the injury then wants knows it's been injured and wants to reconnect with the opposite side. So it starts growing nerve cells at the cut end. Now, if those nerve cells haven't got anywhere to go, they're just gonna form a lump, they're just gonna form a, form a mass which is called a neuroma, which can be exquisitely sensitive and really sore for the patient. So, if we recognize and find a nerve laceration, the current thinking is that we probably should join them together. We join them together. Well, depending on the size of the nerve, but with these teeny, teeny tiny little er stitches, the, the stitch, the stitch material is probably finer than a hair. Uh We use, we, we, we, it's called AO or Nino. So um it's tiny, you can only see it effectively sometimes uh under a microscope. So what we do is see the, the, the top left picture, we basically put the two ends together and put these tiny little stitches in. Um you don't need many, you're just trying to tack them together. Um And hopefully your nerves from the proximal end will find tubes on the distal end and grow up them. That process, it sort of goes to sleep for 1010 days or so and then they start growing and they grow at about a millimeter a day. Um You've got probably 1 to 2 years in which symptoms can I can improve after a nerve repair. Um the bottom left picture is a picture of a, of the median nerve which has been stitched together. But what happens if, if it's a few days old or it's a, been a missed injury or it's a double cut. So you've got a gap. Well, you've got other options. Um, the top right three pitches is what's called a nerve graft. A cabled nerve graft. Um, you w we're pretty good at borrowing from elsewhere. Um, and so you've got a very long nerve in your leg called the chiral nerve, which just supplies the feeling to the outside of the foot. So if we steal that, chop it up, put them all together, you can create this cable which you can then use to fill in a hole. Bottom, right picture is uh is fancy stuff, expensive stuff, nerve conduits. So we've now got um uh allografts that we can use to fill holes. Um I don't have any particular experience with this, but if you need quite a bit of tissue and you don't want to borrow from elsewhere in the body, then using fake stuff is definitely your option. Uh Next, next page arteries are the good old amputations or devascularization. Um II, I'm very grateful for not doing this on a day. I'm on call because I'm very superstitious about uh revasc and replants. So yes, we can salvage fingers that have been almost cut up off. Um But what do they need? They need a blood supply and stability. For me, the stability is not, not a massive issue. You can plate them, wire them whatever, but you've got to reestablish your blood supply. Um The, the picture on the right shows sorry, top right is a very damaged finger and you can see the white piece of tissue just under the artery repair, artery repairs, done under microscopes. It takes, it, it depends on how slick you are, but it does take about an hour per artery to repair in my hands. Uh If you're doing it all the time, obviously, you're gonna be quicker at it. Um We do a lot of amputations for trauma um for the patient at the bottom. Right? I just put this in because it, it amused me and it's very clever. Um He's obviously lost tips of his left index and sorry, his left index and middle fingers. But what he's done is gone to a tattoo artist who's tattooed um nails onto his skin and a, a cursory look from a general me, me, a member of the general public. They won't recognize that he's lost his fingers. It's very easy to trick the brain. Uh Next slide bones, I put these in because these came in over the weekend. So big part of my practice, especially for trauma is fractures, loads of people uh injure their fingers. Most of them don't need an operation chap on the left, didn't turn up yesterday. So I can't show you any pictures of fixing them, uh, chap on the right. He's got a long oblique fracture of his finger. It was a bit rotated but he didn't really want an operation. So I've put him in a splint and we'll see him tomorrow and hopefully it'll be ok. Next slide, next slide. So, how do I fix bones? Well, I've got loads of toys, um, K wires, er, Kirschner wires or, or I could describe them like kebab wires to my patients. Er, basically they're, they're stainless steel wires that I can use to just skewer the bones in the position. I want to hold them. So you got to reduce the bone, you gotta hold the bone and then you have to rehabilitate the patient afterwards. But, um, I do also use quite a lot of internal fixation. So we've got our own little tiny plates and screws, um, which range from 1.3 millimeters to 1.5 millimeters to two millimeters. So they're small and they're fiddly and there's nothing more fiddly than trying to fix, um, a phalangeal fracture. Um, when your trainees had to go already. Um, I love fixing things but fixing things carries the highest risks and the main risk is stiffness. Uh, the tendons that's, uh, are very close to these, uh, plates and screws can get stuck onto them. So you need to get the fractures stable enough to move them quickly with your hand therapists. Next page are the bones I deal with. Well, the scaphoid is, um, a massive issue for us with scaphoid nonunion. A lot of the patients don't realize they've broken their scaphoid. They're pretty stoical upper here in west of, sorry, the east of Scotland. And they just think they've had a sprain. So they turn up six months a year and sometimes several years after they've injured their wrists and never had any input. Um, unfortunately, scaphoids don't heal well, unless they're treated well, the vast majority will heal with the plaster. But if you've not had a plaster on when you injured it, then it's not gonna heal. The majority of it is cartilage, it's mobile. And so you just get that continual micromotion. So there's no ability of the bone to heal. But scaphoid non unions will go on to develop arthritis. So the current thinking is if you pick up a scaphoid nonunion and there's no arthritis, then you come, you, you actually get in there early on to fix the bone to reduce the risk of arthritis. So the arthritic picture is on the right. So that will have happened sort of 20 years ago. That's painful. It's, it gives them stiffness. So the only option I have when they've developed arthritis is a salvage operation usually in the form of a wrist, a total or partial wrist fusion. Next page. So we have different ways of fixing things. If it's a non union, sometimes we'll borrow bone from either the end of the forearm or your hip. Um We use a screw to hold it all in place and stabilize it and hopefully you won't get arthritis. Now, um, next page. But if they do get arthritis, then I've got different salvage operations ranging from on the left is a scaphoid ectomy. So I've taken out the scaphoid and put a plate in joining the four of the bones of the carpus together, that's called a four corner fusion. Um The middle picture looks a bit weird because I've, we've taken out the proximal carpal row and literally thrown it in the bin. So taken out the scaphoid, the lunate, the triquetrum and that capitate head has sunk back and is now sitting in the lunate fossa. And that is, I think it's a good operation as low risk. There's no risk of nonunion. It, they get a reasonable range of movement which will hopefully serve them well for 20 odd years. The one on the right is probably um one of the biggest operations I do and that's a total wrist fusion. So we're joining the radius to the lunate, to the capitate to the metacarpal. Um And it's a really reliable operation for pain relief, but it gets rid of all um the flexion and extension at the wrist, they should still have rotation. Patients don't, well, patients are quite accepting of losing movement. Um If they've got no pain. Next picture, this is a wrist replacement. And this is what's now sort of being developed uh for patients uh with arthritis, not something I've tried yet done the training. We're just looking for our patient. Next, please. Um This is a condition called Kimbo disease. You can see uh 1010 years between the two x rays. And if you look carefully on the right, you'll see that, that lunate, the bone in the middle, um next to the radius has sort of collapsed down and is looking really unhappy. It's basically where the the lunate has lost its blood supply and it's called Comox disease. We don't really understand why the the blood supply disappears. Next patient, next picture, what I do is I look inside the wrist with a camera, so an arthroscopy. So I can see what's actually happening to the cartilage surfaces. If it looks great, then I can try and salvage the lunate. I can bring a blood supply back into it. Next page. Um So we can use what's called a vascularized bone graft. So I'm taking a chunk of bone with a blood vessel going into it, move it around from the end of the radius and basically scrape out the lunate and shove this bit of bone into that and hopefully it brings a blood supply back to the lunate. Um It's, it's, yeah, it it works in some cases, but sometimes it's more advanced than I can salvage. So they get one of the salvage operations. Next, page joints. What's happening in thumb based arthritis, one of the most common conditions uh or common areas for arthritis in the hand. Um more common in women than men. Um and it will settle down if left alone, but people are becoming less tolerant of having pain. So what options have we got? What we can take out the trapezium at the base of the thumb, uh throw that in the bin which creates a space, but it doesn't really give you any better function of the hand. So these thumb based joint replacements based on, they look like mini hip replacements that have been flipped upside down. Um Yeah, so they basically replaced the CMC joint and the patient seemed to be very happy. Um It remains to be seen how long they last for because they're pretty new. Next page, please. And another big group of patients who am I coming to my clinic and presenting for the first time is the patients with inflammatory arthropathy. You can see her fingers are deviated off ulnarly. They all look a bit swollen and her x rays look pretty grotty in uh the wrists and the MCP joints as well. So, uh next page. So these patients need medical management, but occasionally they'll come to surgery. And what can I do? Well, I can fuse their wrists or replace it and I can replace their MTP joints with what we call. Well, they so elastic or Swanson replacements also known as rubber knuckles. Uh they access spaces, they relieve pain. They're a good option but they only last so long. Uh Next page ligaments. Well, loads of ligaments that I deal with the, the ligament between the scaphoid and the lunate can either be repaired or um reconstructed. The ulnar collateral ligament of the thumb, skier's thumb, er, is coming into season. Um an incredibly important stabilizing uh ligament of the base of the thumb, um which can either be treated with a plaster if it's not too bad, but if it's opening all the way, I often go in and repair the ligament. Next page bones, ligaments and joints are, this is the X ray you don't want to see on call. Um This is a massive high energy injury to the wrist. You've got fractures and dislocations and it's an utter disaster. Uh Patient is gonna have a knackered wrist for the rest of their life. Um But it's quite good fun to just put all the bits back where they belong and repair the ligaments and um bones and stuff. Uh Next patient, next X ray, please. Congenital hands are a, it's a, it's basically a specialty on its own and this is where I'm saying, cradle to grave these babies born with um these differences in their hands and there's so many different things that can go wrong in development of the hand. Um You can have things like syndactyly at the top left where the skin hasn't developed between the fingers can have extra digits, like the extra little finger on the right or the extra thumb on the top right, your thumb might not develop properly, um which is called a hyperplastic thumb on the bottom left, your radius may not develop properly, uh which is called radial longitudinal deficiency. Um your fingers may not develop properly. So, symbrachydactyly and then sometimes you can have these things called cleft hands. Basically, anything that can go wrong in a hand can go wrong in its development in utero. So, you know, trying to develop a hand that's functional and cosmetically pleasing for a kid is really big part of some, some hand surgeons. Um lives next page. So what's changing in hand surgery? Well, I'm, I'm sure you couldn't have missed that. The mentors that I had through my training and, and bearing in mind are old. They, they're pretty much all white men, white m middle aged men. And that was a reflection that there weren't that many women in orthopedic surgery at that time. I think hand surgery is quite an interesting one because it is quite well represented um across with diversity. I think women are um quite a high proportion of our, our, of our workforce and diversity is improving as time goes on, but it's nowhere near where it needs to be. We need lots more diverse people coming into the, the the area. I love my job. One of the things is it's always changing. There's always improvements that are going on, um, that I can start incorporating into my practice for my patients. But the, the downside at the moment is the limited resources and it is becoming much more difficult and more challenging to actually deliver a good service next page. So why have I got the best job in the world? Well, it's beautiful and the, the anatomy is stunning. Um, it's relatively keen. Patients are usually, well, what I do is about pain and function and I can treat a vast variety of patients. I get to work with a fantastic team and deal with all the different soft tissues. Never ever gonna be out of a job. Ok. Thank you. Um, any questions? I think you can stop the presentation now? Yeah. Thank you so much Claire for that wonderful presentation on hand surgery. That was really insightful. Um, definitely need to brush up on my anatomy, but I certainly had a much better understanding of the day to day cases in your field and I believe, um, everyone would agree as well. So we'll just give a couple of minutes for people to ask any questions they might have in the chat. And, um, MS Simpson will just go through them, um, as they come. Oh, my favorite procedure. What's my favorite procedure? God, I like, I just love being in theater. Um, you, um, it, you can get reward from, um, any procedure. So, doing carpal tunnel release. Um, I, you do them under local anesthetic. I, um, I often of, uh, once I've decompressed the nerve, I ask the patients, do they want to see in the inside of their hand and, and loads of times they're like, oh, they're like, uh, no, no, thank you. But, um, some of them are really, really excited about actually looking at their median nerve. Um, I like fixing fingers. I find it really challenging. I find it, I find it quite therapeutic. I've got to really concentrate on what I'm doing. Um But II, like, I like taking something that looks a bit mangled to looking um normal. Uh So let's just go back any crossover with vascular for amputation. Um uh sometimes um the uh it depends who the vascular surgeon is. Sometimes they've, uh in Edinburgh, I think they've tried to do some amputations of fingers. Um And then they've decided to send them on to us. Um, peripheral vascular disease causing um, necrosis in fingers. Yeah, we, we'll see them, we'll be happy to see them. Um We get quite a number of patients off the ICU who've had noradrenaline and sepsis with necrosis of fingers and toes. So, um but yeah, um, surgeries, I think I have the greatest room for development. Um Yeah, I think the arthritis patients like with our joint replacements, that's, that's a massive area of growth. Um uh we're way behind hip and knee replacements. Um But having said that the thumb CMC joint is such complex joint that we uh we're only just getting to the point of getting a replacement that is replicating the function of the CMC joint, um reconstruction after trauma, um Possibly, um I think there's probably room for um more rehab uh development. Uh You can make things look pretty. It's just getting it to work well. Um toughest challenge about my job. Um It's not treating the patients. The patients are great. The conditions that I treat are great doing the surgery is great. At the moment, we've po post pandemic, we've got the most enormous waiting lists which is heartbreaking and makes me very angry. Um So I think part of the issue is dealing with my, um II saw a, a name for it, moral injury after, after the COVID pandemic. Um It's ma mainly managing a service without enough people and resources crossover with plastics. Um I didn't go into um this but so you can come at hand surgery from either orthopedics or plastics. Um You do your basic surgery, so you do your basic training, your, your specialist training. And then um if you want to do hands, most people will do a hand fellowship which then crosses over between your parents specialty and the other specialty. So, um if you're an orthopedic, you'll get exposed to plastics. If you plastics, you'll get exposed to orthopedics. Um I'm in a very enviable position of just doing hands and that I absolutely love, love it. Um uh genital abnormalities of hand do often fix when very young or wait until they more than sure. So, um it depends on what you, what you're doing and what the condition is. Uh little extra digits. If they're little floppy things, you can do that as um on almost straight a well within a few weeks of birth. Um, but sometimes it, it depends on the condition. You're gonna have to wait till they're a bit older, mainly because of anesthetic risks. Um, you don't want to be putting a brand new baby off to sleep. Uh, so some things will wait until they're like two or three or a little bit older. Um, mentioned that extensor tendon can be fixed with a splint. Is it the thumb or ro procedure? Most cases should be treated like. Um, so treating extensor closed, closed tendon injuries can generally be treated closed. Extensor tendon injuries can mostly be treated with a splint. A closed flexor tendon rupture needs surgical fixation. Um, if you've got an open injury on the back or, or to an extensor tendon, it needs an operation, um, ruptured grade. Uh, so laceration of grade in Z zone two. Yeah, we, we, we try and get them into theater as quickly as we can, um, which is sometimes a couple of days or a few days. Um, but you've got several, you've you've got probably about 5 to 7 days window the sooner the better. But we wouldn't do it overnight. We would just, um, as long as it's stitch, as long as it's repairable straight away, we'll just repair it. It's unusual for it to not be repairable straight away. And I think that's all the questions. All right. So if there's no more questions, uh, thank you for joining our hand surgery talk. But just before leaving kindly, just help us fill out our feedback form and you receive a certificate of participation for the event and I am putting the feedback form into the chat right now and you should be able to um provide the feedback. And I believe there's another question, Miss Simpson if you don't mind during that, um What it so uh back to the extension, what degree shall I take? Keep the hand of the patient on? Um Sorry, I'm not quite sure. Um I think it would depend on which injury you're talking about. Uh Basically, um if, if it's just one finger that's injured, I treat that injured finger and I keep the other fingers moving because otherwise they get really stiff. But if you want to keep a finger straight, then you, you're gonna need the input of your hand therapy colleagues usually as well or advice to give to the patient. But you know, uh yeah, sorry. II can't be specific with to, to answer that. I'm sorry, I saw Ok. Um, but yeah, uh, if there's no further questions, thank you so much for joining this talk. I think Osama wanted to clarify. Is it 3045 or 60 degree? Depends on what to, what you, what injury you're talking about. Um, extens tendons tend to be, um, uh, splinted straight. Ok. And I hope that clarifies things for us as well. So just remember if you manage to join all the talks in our Subspeciality Series, we'll generate a separate certificate of completion for you at the end. And don't forget to look up at our social media platforms as we're having our arthroplasty talk mix and our spine talk on the fourth of December. So, yeah, we're just gonna give you guys a couple of minutes to um, click onto the feedback form. Uh Thank you so much for joining and I hope you guys have a great evening. Thank you. Thanks a lot. See you around. Thank you guys.