Upper Limb Reconstructive Surgery

Reconstructive surgery is conducted to repair or mend irregular parts of the anatomy which may have been as a result of birth defects, developmental condition, traumatic event, injury, infection, tumours, or disease. The procedure aims at improving the function of the affected part but also seeks to surgically improve appearance.

Upper limb operations address these conditions in the arm, forearm and the hand. Depending on the severity and desired outcome, it is often necessary to use extremely complex surgical methods including microsurgery, nerve and/or tendon transfer, soft tissue grafts, bone grafts and flaps.

This surgery is indicated in the following:

• Tendon and nerve injuries
• Soft tissue defects
• Amputations and replantations
• Carpal tunnel syndrome
• Brachial plexus injuries
• Tumours
• Post-burn reconstruction
• Compound fractures

In the hand, there are 2 groups of tendons. The extensor and flexor tendons:

Extensor Tendons

The Extensor tendons extend all the way from the forearm, across the back of your hand, to your fingers and thumb. On the hand, they are situated right beneath the skin and next to the bones. Their job is to straighten the wrist, fingers and thumb. The most common injuries occur from being cut or suffering severe impact to the hand and fingers. This may either sever the tendons or rip their anchor off the bone.

Flexor Tendons

The Flexor tendons are attached to the Flexor muscles and extend from the inside of your forearm, through the wrist and across the palm of your hand. This group of tendons allows you to bend (flex) your fingers.

Common causes of tendon injuries include sports injuries, cuts, animal bites, crushing injuries and rheumatoid arthritis. Often deeper cuts, which look fairly straightforward on the surface are very complex on the inside due to damage to the nerves and fine blood vessels

Following burns infection, trauma or the removal of tumours, soft tissue defects are treated using skin grafts or flaps, for optimal functionality and aesthetic outcomes. 

The open wound of an amputation stump can be covered by a skin graft harvested from the hip or thigh. Local skin flaps can be used to resurface and re-contour the digit when painful scars have been surgically removed.

Replantation's are vastly more complex especially when it comes to reattaching a hand or a finger. There are a large array of nerves and blood vessels which get smaller and smaller as they travel to the fingertips. This involves using microsurgical techniques to rejoin the nerves and the blood supply.

As with most medical emergencies, time is of the essence. It is vital to get the patient to the hospital as quickly as possible to ensure the amputated part is still viable.

The Trauma Unit at the Netcare Milpark Hospital is Level 1 accredited to deal with these types of injuries. Dr Slabbert is highly skilled as a reconstructive surgeon and has operated on multiple patients requiring replantations.

Carpal Tunnel Syndrome develops when the nerves and tendons become inflamed by the pressure on the median nerve in the wrist. The carpal tunnel is a relatively narrow space and the nerve starts swelling which hampers the blood flow and damages the nerve. This causes pain in the palm, fingers, wrist and forearm. You will experience more pain at night than during the day. Tingling, numbness and weakness of the hand may also be experienced. Surgery may be advised if symptoms last longer than 6 months. 

The brachial plexus is a system of nerves that controls movement and feeling in the arm and hand. Injury or damage to these nerves may cause loss of sensation or movement, or weakness in the hand and the arm.

Nerve damage can occur as a result of a sports, car or motorbike accident. Typically where there is impact trauma to the head and neck. This extreme pressure occurs when there is a fracture or dislocation which causes the brachial plexus to be crushed between the first rib and the collarbone.

Fractures most often cause immediate pain and swelling in the forearm, wrist, or hand. You may not be able to move or flex the affected part at all. In general, the symptoms of a fracture may include:

• Severe pain
• Bruising
• Numbness
• Loss of motion

Frequently the fingers, wrist, or forearm may look as if they are out of line or appear deformed. This indicates the bones have been unnaturally forced into an odd position. In the case of a compound fracture, the broken bones have been forced through the skin and are clearly visible.

There are different types of fractures:

1. Simple (the broken bone is aligned and stable)
2. Complex (the bone may have shifted or become displaced)
3. Comminuted (bones broken or crushed in more than one place)
4. Compound (the broken bone has broken through the skin)

Treatment will depend on the type of break. For simple breaks, a cast or a splint is often used, whereas pins, wires, or plates may be needed for more complicated fractures. Surgery is required to set and realign the bone.

Dr Slabbert uses various procedures to ensure a return of the function and appearance as best as possible for the injured body part. In every case, he will use the procedure which is conservative and achieves the required result with the least risk to the patient.

The size and complexity of the injury or abnormality will guide him in choosing the best procedural option available. The other factor is time – is the patient's life in danger?

Reconstructive surgery oftentimes necessitates extensive planning and consultation to achieve the end-result. This may require a number of different surgical procedures done in stages allowing each to heal.

Depending on the extent of your surgery, you most often will require a general anaesthetic and an overnight stay in hospital. Your specific requirements will be communicated to you before your surgery takes place. However, even if your procedure is a day procedure, you should arrange for someone to collect you from the hospital and drive you home afterwards.

Straight after your procedure, Dr Slabbert and his nursing team will make sure that you are as comfortable as possible. Pain medication may be prescribed and administered. Recovery time from an upper limb reconstructive procedure depends on the extent of the procedure. This will be specified before your surgery.

Post-operative care differs depending on the type of procedure. Dr Slabbert and his nursing team will provide you with comprehensive post-surgery instructions which you should follow very carefully. This will allow for the best possible outcome in functionality and physical appearance.

With skin grafts, “bolster” dressings are generally required for the first 3 – 5 days, to ensure that the skin graft does not move. This type of dressing encourages the graft to ‘stick’ to the wound so that healing can begin. Smaller surgeries may only require a small, soft dressing. You will be advised if there are stitches that need to be removed, and when this should take place. In the case of surgery of the hand, a larger dressing may be required by way of a plaster splint.

To achieve full recovery of function, physical and occupational therapy may be required for some time after your procedure. Certain exercises will be prescribed for you to do at home. After your procedure, you may need to enlist the help of someone to assist you with wound care at home for a few days. Be sure to avoid strenuous exercise and lifting heavy objects during your recovery.

You will continue to have consultations with Dr Slabbert so that he can assess your long-term results and address any concerns that you may have.