Three things I learned from hand surgery

In early 2019 I sustained a traumatic injury to my hand that would lead to a surprising level of disruption to work, leisure and normal life for nearly 4 months. I have 3 reasons for writing this article.

  1. Even a small injury to a flexor tendon of the hand can lead to extensive consequences to overall function and performance of the hand as a whole.
  2. Tendon injuries to the hand can disrupt every aspect of your life to a degree you may not imagine.
  3. These kind of hand injuries are on the rise! Accidents happen when we least expect, but we can protect ourselves when the likelihood is higher.

ONE: To quote my surgeon “a small wound but a big injury”

This was his assessment as he examined my limp and unmoving little finger that was all but detached. I knew what he was saying. I had known the instant the injury happened that I would be requiring surgery.

 

He was correct about the wound. It was small indeed. The knife had slipped only a short distance but with great velocity. Only the very point had caught the base of my little finger in my palm. Enough to inflict a small puncture wound that hardly bled and gave no real pain. Sufficient enough however to completely sever both the flexor tendons that serve the finger. A so called ZONE 2 injury.

Due to space constraints in this small intricate area it is only possible to repair the longest tendon, the Profundus, that runs all the way to the end of the finger. This gives the best chance of regaining full function of the finger while sacrificing the shorter tendon.

Although I had cleanly severed both tendons I had fortunately missed the nerves. I had full normal sensation. Unfortunately the surgery itself unavoidably caused some damage to the medial collateral nerve leaving me with numbness up the inside of the finger.

ZONE 2 injuries are very difficult to repair

Emergency surgery was required within 2 days of the accident. The Flexor Digitorum Profundus was successfully stitched using the cruciate repair outlined below. As it turns out, many of us don’t have much of  flexor digitorum superficialis anyway. In my case it was vestigial – present but not really doing much for me. It was no great loss.

 

 

Pully Injuries – a rock climbers worst nightmare!

The stitching of the repaired tendon obviously leaves a greater degree of bulk and an uneven surface that still needs to glide freely through the pully below for normal functioning of the finger to be possible.

It was therefore necessary to vent  (partially split) the pully to allow greater space for the bulky repair to slide through. In all my years of technical rock climbing pully injuries like these were desperately avoided. Now a damaged pully was to work to my advantage.

TWO – SUPRISING DISRUPTION TO ALL ASPECTS OF NORMAL LIFE

I was heartened at the notion that those who were diligent with their rehab had achieved a return to full function and strength in time. I had been told that by week 12 the tendon should be as strong as it ever was. In reality it is only at about 80% strength by week 12. Even making a full fist under your own strength is still difficult.

The potential for this kind of repair to have very good outcomes was high. But the journey was tenuous. The end result dependent on the quality of rehab and the care to avoid mishap. The first 2 weeks are extremely vulnerable to rupture and failure of the cruciate repair.

The nightmare stories of total re-rupture at 8 weeks simply by opening a stiff drawer were a constant reminder not to overdo it or get complacent even in the later stages of rehab. A second repair is never as good if at all possible.

Balance between regular movement and mobilisations is important. Strengthening exercises and soft tissue work while avoiding trying to use the hand ‘normally’ was essential. Complacency is the enemy.

 

‘The flexors of the hand have a common origin. This is a vital point and the main reason why an injury to the little finger is actually an injury to the whole hand’

3 months splinted is no fun! Note the use of lymphatic drainage Kinesiotape to aid in fluid management.

Performing everyday tasks must in no way involve the damaged hand. The temptation to use a finger here or the palm there can result in disaster even if not directly using the little finger. The hand is quite simply out of action. Totally and completely.

Ultimately, this vastly restricted scenario leads to other issues. The effect of immobilisation on all of the joints in the hand is dramatic. One small cut to the base of the small finger culminated in swollen painful joints throughout the whole hand, even 8 months post injury.

The result of the toxic, inflamed, static environment the hand was held in for so long and highlighting the necessity of soft tissue work to keep fluids circulating while mobility is severely restricted.

Swelling of the whole hand can create adhesions and joint issues throughout the rest of the hand, not limited just to the area that needs to repair.

 

The thought ‘it is just my little finger I can work around this’ turned out to be very inaccurate. The Insight? It is never ‘just a finger’. There is no safe place to sustain this kind of injury and no corners that can be cut in correcting the mistake. It is going to take time, commitment and patience. For me a whole summer of work, leisure and DIY was halted. As a self-employed commuter living remotely in the Welsh mountains the inability to legally drive or earn enough income was particularly arduous.

THREE – ‘Flexor tendon Injuries are on the rise’

My hand therapist at Oswestry Orthopaedic Hospital would inform me some weeks later that she had rehabbed people with a similar injury caused by a simple slip with a pair of nail scissors.  

She went on to highlight a very valid observation; We all use knifes and we all handle glass. Gripped into the palms of our hands every single day. She was amazed that in her lifelong career she had seen many more extensor tendon injuries (back of the hand) than flexor injuries.

However, It is worth noting that flexor tendon injuries may be becoming more common place with rise of so called ‘Avocado Hand’. I hasten to add I was not processing an avocado at the time!

“Recently the health benefits of avocado have been advocated, with an increase in their popularity – and a consequent increase in related injuries,” – David Shewring, vice-president of the British Society for Surgery of the Hand, The Times.

The British Association of Plastic, Reconstructive and Aesthetic Surgeons  went on to add;

“Avocado hand injuries are much worse than just small cuts, many people have caused themselves serious nerve and tendon injuries which require surgery and can leave you without full use of your hand”.

In Summery; A warning about using sharp tools. Accidents happen when you least expect

I have many passions and partake in many indoor hobbies and outdoor pursuits. Some of them are moderately high risk. That’s ok. Many risks can be calculated and managed. I wear a helmet when mountain biking. Pay attention to my knots when climbing, I don’t wade into flood water when fly fishing and I adhere to strict protocols in shooting sports.

I wear chainmail slash proof gloves when butchering meat or filleting fish (an extensive range of food friendly safety gloves for the kitchen can be found at www.safetygloves.co.uk).

When using chainsaws I use all the necessary PPE. As a fine art wood carver using incredibly sharp tools (sometimes in the palm of the hand) I wear grade 5 slash resistant / grade 4 puncture resistant gloves.

 

(check out https://tornadogloves.com/gloves/aura-ff they are comfortable and the only gloves I have found that are grade 5 slash proof as well as grade 4 puncture resistant. Good fitting, dexterous protection even for super detailed fine wood carving).

The point is we protect ourselves during the high risk activities when accidents are expected. It is when accidents are not expected that we are led to the frustrating realisation that performing a normal routine kitchen task unprotected can lead to mishaps. Mishaps that can cost your summer, your fishing season and importantly your income! I am not suggesting we should all wear PPE to prepare dinner every night. We can all have bad luck.

When we are aware of the risk of accidents though, it is definitely better to protect yourself. Avocados, filleting fish or boning out the Sunday roast. Slash proof food preparation gloves for the kitchen are now an affordable essential for me.

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