«Thank God it's not a leg!». This is the first thought that comes to mind after falling on your hand. The second time we breathe a sigh of relief, realizing that there is no bone fracture. And then we let things go. And absolutely in vain. Distinguished by its most complex structure and high functionality, the hand is one of the most vulnerable organs and is often prone to injuries that are fraught with serious consequences.
About injuries and various diseases of the hand, which people initially underestimate, and how modern medicine is struggling with their consequences, we will talk with the head of the Clinic for Hand Surgery of the Russian Gerontological Scientific and Clinical Center, Professor of the Department of Traumatology, Orthopedics and Military Field Surgery of the Russian National Research Medical University. N. I. Pirogova Irina Chulovskaya. 
Traumatologist-orthopedist, hand surgeon, professor, MD Chulovskaya Irina Germanovna.
What «implicit» damage to the hand occurs most often, and what are they fraught with
In addition to obvious fractures, there are those that cannot be immediately identified even with an X-ray examination. For example, one of the many small bones in the wrist area — the scaphoid — does not give a pronounced pain syndrome and swelling during a fracture, and the fracture zone itself is not visualized on the radiograph. And you can see the fracture only after a week, when the resorption of bone tissue occurs at the site of the fracture. Therefore, if a patient falls on an outstretched arm, a competent doctor will prescribe not only the treatment of a bruise and immobilization, but also a second x-ray in 5-7 days to clarify the diagnosis.
Other subtle but dangerous injuries include damage to the ligamentous apparatus in any joint, small or large. Damage to the ligaments of the wrist joint is also not accompanied by a pronounced pain syndrome. But subsequently it leads to the development of a whole chain of pathological degenerative-dystrophic changes in the joints, which are characterized by osteoarthritis and aseptic bone necrosis. Even a banal bruise of the joint can become a trigger for the development of arthrosis. In addition, the consequences of the injury can be a variety of neuropathies, some problems with movement. In combination, all this leads to serious dysfunction of the joint and pain syndrome.
If the pain does not go away, you need to see a doctor again. And if we are talking about the hand, wrist or the lower third of the forearm, which is a continuation of the hand, then it is better to go to a specialist — a hand surgeon. Many diseases of the hand are difficult not only in treatment, but also in diagnosis — you need to know the anatomy and physiology of the hand well, understand what pathological changes are and how to interpret them. At the same time, the patient does not always need such complex and expensive examinations as MRI, sometimes ultrasound provides much more information.
At an early stage, many problems of the hand can be solved with the help of conservative treatment, but with a long course of the disease, changes in the tissues of the hand can only be corrected by surgical treatment. Moreover, the operation must be completed in a timely manner. This applies not only to injuries, but also to other diseases of the hand, the progression of which in many cases can deprive a person of the possibility of self-care.
The most common diseases of the hand
The main complaints of our patients are dysfunctions of the hand and pain caused by excessive muscle load, diseases or injuries. These violations look different: limited mobility, decreased sensitivity, muscle weakness (“everything falls out of hand”). Pain can disturb at night or after physical exertion, and in complex and neglected cases, constantly: from morning to evening. And all these details are very important for the diagnosis. As a rule, dysfunction begins with some minimal restrictions, and with the further course of the disease, severe contractures develop that can limit not only professional and domestic activity, but also lead to the impossibility of self-service. That is why it is necessary to start treatment in a timely manner: already at an early stage of the development of the disease.
In general, a large number of diseases of the connective tissue of the hand can be divided into five main groups: osteoarthritis, stenosis of the bone-fibrous canals and tunnel syndromes, tumors and tumor-like diseases, Dupuytren's contracture.
Among the diseases of the hand, stenosis of the bone-fibrous canals and tunnel syndromes are especially widespread. There are a lot of narrow channels on the hand, in which tendons and nerves pass. With stenosis of such canals located on the palm at the base of the fingers, finger flexion becomes difficult and is accompanied by a “click”. Over time, a contracture develops: when a person has bent a finger, and then for a long time cannot unbend it, the finger seems to “snap”. With a long course of such a disease, spontaneous tendon rupture may occur.
Tunnel syndrome is when the disease develops in the canal in which the nerves pass. Initially, due to compression, there are transient changes in the function of the nerve, which can be treated conservatively, and if this does not help, surgery should be done in time. But over time, irreversible sensory disturbances and movement disorders develop inside the nerve trunk, since the thin and complex structure of the nerve is subject to the rapid development of morphological changes. Such an outcome of the disease should not be allowed. At this stage, it is most often impossible to completely restore the function of the nerve, and the operation can only stop the further aggravation of changes in the nerve and eliminate or alleviate the pain syndrome.
Another group of hand diseases includes a huge number of tumors and tumor-like formations .About 60% of them are tumor formations, united by the names «hygroma», «ganglia», «synovial cysts». The other 40% are already true tumors. And although predominantly (more than 98.7%) tumors of the hand are benign, 1.3% of malignant neoplasms in absolute numbers are also quite a lot. In addition, even among benign ones, there are very dangerous ones, for example, a giant cell tumor, which becomes malignant, that is, turns into a malignant one, in 10% of cases.
The most numerous group of diseases of the hand, as well as all departments of the upper and lower extremity are osteoarthritis of the joints of the hand and wrist (synonym: osteoarthritis)which are characterized by joint deformity. They are often confused with arthritis, the result of systemic diseases (such as rheumatism), which are based on the inflammatory process. But an important difference between osteoarthritis lies in the leading component of the disease — the development of degenerative-dystrophic changes in the tissues of the joint. Therefore, a patient with osteoarthritis should be assisted by an orthopedist (or a hand surgeon in the case of a hand).
Dupuytren's contracture— a disease that affects the palmar aponeurosis, which is a dense connective tissue membrane located under the skin of the palm. Subcutaneous scars form on the hand, which lead to deformation of the fingers, fixation in an unnatural flexion position and the inability to fully straighten them.
Causes of neglected cases, errors in diagnosis and treatment
People know very little about the pathology of the hand, one often hears: “Oh, do hands also heal?”. This is a question that shocks experts. That is, everyone knows that it is possible to treat knee and hip joints, that there are endoprostheses for them, but the fact that hands can be treated and it must be done on time — alas!
With diseases of the hand, patients turn to a variety of doctors: general practitioners, neurologists, surgeons, and general orthopedic traumatologists. But the trouble is that many of them treat problems with their hands rather dismissively. And the complaints of patients are reduced to age-related changes and do not refer them to specialized specialists. Age-related changes in the human body are undoubtedly present, but these are not diseases. And the confusion of these concepts only disorientates both the patient and the doctor himself, prevents him from making a diagnosis.
Unfortunately, the opinion that elderly patients should not be operated on will only get worse. But if the operation is performed by specialists, the correct technique and tactics of treatment are chosen, the correct rehabilitation, then even in advanced cases the results will be positive
What modern hand surgery can do
We have many older patients, even 80-90 year olds who we in fact, we return the possibility of a full life. We perform surgical interventions on bones, joints, tendons, nerves for almost any disease and consequences of hand injuries, we restore long-damaged tendons, we perform various operations on the joints of the hand for arthrosis, we treat neuropathies of various etiologies.
Nowadays, anesthesiology, minimally invasive technologies, methods of postoperative management and rehabilitation have stepped forward. More effective and safer drugs have appeared, so the patient's advanced age has ceased to be an obstacle to his treatment.
Today, conduction anesthesia is considered the gold standard in hand surgery — the introduction of anesthetics in close proximity to the nerve trunk, as a result which “turns off” the operated arm. The blockade is carried out under ultrasound control at different levels — depending on the location of the pathology and the duration of the operation. Such anesthesia saves the patient from the negative consequences of the use of mask anesthesia and general anesthesia.
The quality of the anesthetics themselves does not stand still. At one time, novocaine was replaced by a much less toxic lidocaine. But it also causes complications associated with intoxication, and today we are already abandoning it in favor of more modern anesthetics, the use of which does not have such consequences.