Hand Surgery in Melbourne – Plastic Surgeon David Ross

The human hand is an extremely complex structure and the management of hand and wrist disorders requires the precision and skill of a highly trained plastic surgeon. Melbourne physician Dr. David Ross has undergone extensive training in the surgical management of hand conditions. As a part of his post-fellowship training in plastic surgery, Dr. Ross spent time undertaking additional hand surgery training at the Kleinert Institute for Surgery of the Hand in Louisville, United States, where he studied with several of the world’s leading reconstructive hand surgeons.

Since completing his training in hand surgery in 1996, Dr. Ross has been undertaking both elective and emergency hand surgery over the past 10 years through his appointments as Plastic Surgeon at Monash Medical Centre, Dandenong Hospital and Frankston Hospital. At his Melbourne based private practice, Bayside Plastic Surgery, Dr. David Ross is able to offer the most innovative and advanced surgical procedures for the treatment of common and more rare hand disorders, including degenerative disorders like arthritis, congenital differences of the hand, overuse pain syndromes and injuries as well as emergency treatment of hand trauma and reconstructive surgical procedures on the hand.

If you are considering hand surgery, contact plastic surgeon Dr. David Ross at Bayside Plastic Surgery in Melbourne, Victoria.

» Hand Overuse Syndromes
» Carpal Tunnel Syndrome
» Other Nerve Compression Syndromes
» Musculo-Tendinous Overuse Syndromes
» Dupuytren's Disease
» Arthritis of the Hand
» Ganglions and Other Hand Tumors
» Traumatic Injury of the Hand

Hand Overuse Syndromes

Hand overuse syndromes are also called repetitive strain injuries (RSI) or cumulative trauma syndromes. Normally the hand copes well with the stresses of everyday living due to the body’s remarkable healing abilities. However there is a threshold for injury above which some residual tissue damage occurs. Repeated stress applied beyond this threshold can result in cumulative trauma in excess of the body’s reparative capacity. This disease process is termed an overuse syndrome and is most frequent in the upper limb. Most overuse syndromes involve musculo-tendinous and ligamentous structures or peripheral nerves at sites of irritation or weakness. The common features of all these conditions are symptoms that appear some time after the stress has been initiated and then resolve with rest, only to recur after resumption of stressful activity. With time, pathological changes will occur that result in persistent symptoms even at rest. Intermittent symptoms of pain, swelling, crepitus, muscle weakness or numbness will become constant with time.

There are a number of named syndromes that result from overuse or repetitive strain injury, including neurological syndromes and musculo-tendinous and ligamentous syndromes:

Neurological syndromes:

Carpal Tunnel Syndrome (median nerve compression)

Pronator Syndrome (median nerve compression)

Radial Nerve Entrapment Syndrome (superficial radial nerve compression or posterior interosseous nerve compression)

Cubital Tunnel Syndrome (ulnar nerve compression)

Thoracic Outlet Compression (brachial plexus compression)

Musculo-tendinous and ligamentous syndromes:

Trigger Finger (stenosing tenovaginitis of flexor tendon)

DeQuervain's Disease (stenosing tenovaginitis of thumb extensor tendons)

Tennis Elbow (lateral epicondylitis)

Rotator Cuff Tendonitis of shoulder (rotator cuff muscles and biceps)

Hypothenar Hammer Syndrome

Ganglion cysts of the hand and wrist

If you have been diagnosed with a repetitive strain injury, contact Dr. David Ross, plastic surgeon in Melbourne.

Conservative and Surgical Treatment of Overuse and Repetitive Strain Injuries

The principle of treatment is based on identifying the injured structure and removing the stress that produced the injury while the tissues recover. Oral anti-inflammatory agents, steroid injections, immobilization, and physiotherapy can help relieve symptoms and aid healing. Hand surgery is used as an adjunctive treatment modality in the management of repetitive strain injuries in two situations. If there is an anatomical defect such as a tight fibrous tunnel around a nerve or tendon it can be decompressed surgically (as in a carpal tunnel release) or if inflamed tissue is affecting hand function it can be removed (as in a synovectomy). When symptoms have been resolved by hand surgery or a combination of treatment modalities it is important that a graded exercise program be commenced to strengthen the injured tissues gradually so that they can resist the stress of return to prior activities. If this is not successful, alternative work activities will need to be considered. Correct diagnosis and management is essential for a satisfactory outcome in the treatment of hand overuse syndromes. It is important that your assessment is undertaken by an experienced hand surgery specialist.

Dr. Ross will be happy to answer any questions you have about hand surgery and the treatment of repetitive strain injuries. If you feel you have a hand overuse syndrome or repetitive strain injury, please contact our Melbourne practice to schedule a consultation.

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Carpal Tunnel Syndrome

The carpal tunnel is an area near the front of the wrist that houses the median nerve, one of the major nerves of the hand. The tunnel is a rigid structure surrounded by bones and a ligament called the flexor retinaculum, which acts as a pulley for the underlying tendons to the fingers. When pressure builds up within the tunnel because the tendons surrounding the median nerve are inflamed, there is pressure on the nerve. This produces symptoms of numbness or tingling sensations as well as pain in the areas of the hand controlled by the median nerve, namely the first three fingers and thumb – a condition known as carpal tunnel syndrome. Carpal tunnel syndrome, which is a compressive neuropathy, requires a thorough hand assessment by a hand surgery specialist to verify the diagnosis as multiple levels of nerve compression are possible.

Carpal tunnel syndrome can be caused by any number of factors, including repetitive wrist and hand movement (generally work-related), injury to the hand, awkward sleeping positions, arthritis, obesity, diabetes, and more. Patients who are experiencing abnormal feeling in their fingers, particularly at night, may be suffering from the early stages of carpal tunnel syndrome. Anyone with an office job that requires significant use of a computer keyboard is at a higher risk for developing carpal tunnel syndrome.

Carpal tunnel hand surgery - Candidates

Carpal tunnel syndrome can vary in intensity. Nerve compression symptoms can sometimes be alleviated with anti-inflammatory medication, steroid injections or wrist splinting. However, if these conservative measures prove to be ineffective, then surgical decompression of the median nerve, "carpal tunnel release," may be the most effective treatment option.

During a hand surgery consultation with Dr. David Ross at one of our Melbourne offices, patients will have their wrist and hand examined for strength, function, and sensitivity to ensure a correct diagnosis. Usually electrodiagnostic testing is also arranged in the form of a nerve conduction study, which will indicate the presence of an electrical nerve conduction block, significant in carpal tunnel syndrome. After a thorough diagnostic session, Dr. Ross may recommend a procedure known as carpal tunnel release.

“Carpal Tunnel Release”

Carpal tunnel release is a surgical procedure on the hand, which decompresses the median nerve at the level of the carpal tunnel. The procedure can be performed using a number of different techniques, depending on the clinical circumstances. Dr. David Ross undertakes 4 different surgical techniques to decompress the median nerve at the carpal tunnel and can advise which would be most applicable in your situation. The surgery can be undertaken either under local or general anaesthesia in hospital or a day surgery facility, requiring only a short 2-3 hour stay.

The procedure can be undertaken as a traditional open carpal tunnel release, which is recommended in severe or recurrent nerve compression syndromes, but has the disadvantage of longer recovery and higher complication rate. Endoscopic carpal tunnel release involves a smaller incision and therefore more rapid recovery, but risks direct damage to the nerve as the endoscope is inserted into the carpal tunnel. Dr. Ross’s favoured procedure is the minimal access carpal tunnel release, where the carpal ligament is divided under full vision through a 2cm incision in the palm, which also allows a rapid recovery and low complication rate. Finally, in heavy manual workers, the median nerve can be decompressed and carpal ligament preserved by flexor synovectomy procedure, allowing preservation of grip strength.

Carpal tunnel hand surgery is performed as a day surgery procedure allowing patients to return home the same day. There may be some mild discomfort following surgery, but recovery is quick and normal activities can be resumed almost immediately. For most patients, there will be an immediate improvement in their nerve compression symptoms.

If you have been diagnosed with carpal tunnel syndrome, you may be a candidate for carpal tunnel release hand surgery. Contact plastic surgeon David Ross at his Melbourne practice to schedule a consultation.

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Other Nerve Compression Syndromes

As well as carpal tunnel syndrome there are a number of other areas of nerve compression in the upper limb. These all occur at points where there is dynamic compression of nerve against unyielding structures or excessive movement of nerves through normal structures. Each of these syndromes will cause symptoms similar to carpal tunnel syndrome, with pain, numbness and tingling in the nerve distribution, which can progress with increased severity to permanent muscle weakness and sensory loss. Many of these syndromes must be differentiated from carpal tunnel syndrome by their clinical features and this is where an experienced hand surgery specialist can make that diagnosis.

Pronator Syndrome is an entrapment of the median nerve in the proximal forearm, just past the elbow due to compression of the nerve by fibrous bands and muscle fibres against the underlying bone. Its symptoms are similar to carpal tunnel syndrome but differences are that the symptoms are more often brought on by manual work (due to muscle contraction in gripping and repetitive hand use) and relieved by rest. Often there is more proximal pain and tenderness not seen in carpal tunnel syndrome.

Electrodiagnostic tests often cannot distinguish this syndrome from carpal tunnel syndrome, although a conduction block will be observed. Treatment involves avoidance of aggravating activities, particularly gripping and repetitive hand use. Splints and steroid injections are less likely to be effective and hand surgery is more often required to remove anatomical causes of compression.

Cubital Tunnel Syndrome is a nerve compression syndrome affecting the ulnar nerve at the elbow. Its symptoms differ in distribution with tingling and numbness of the small finger of the hand. Initially the symptoms are intermittent but with progression there is weakness of the small muscles of the hand resulting in clumsiness and reduced hand dexterity. The symptoms are usually caused by overuse and cumulative trauma resulting in scarring around the nerve, reducing natural nerve glide on elbow movement and resulting in dynamic nerve compression. Treatment is usually rest and elbow splinting to remove tension and localized pressure form the inflamed nerve. Steroid injections are usually not beneficial as they can increase scarring around the nerve and hand surgery is reserved for the more severe case.

Radial Nerve Entrapment Syndromes occur from compression of this nerve in the proximal forearm. Superficial radial nerve syndrome occurs where the nerve passes between the extensor muscles in the forearm and results in pain and numbness over the first webspace of the hand. It is aggravated by pronation of the hand and can be difficult to distinguish from DeQuervain's disease. Treatment involves rest, splinting, steroid injections and rarely surgical decompression of the nerve. Posterior interosseous nerve compression occurs when this nerve is trapped in the radial tunnel (between the two heads of supinator muscle and the arcade of Frohse) in the proximal forearm. It is aggravated by forced supination of the hand and is characterised by tenderness over the nerve, pain in the proximal forearm and possibly weakness of digital extension. It can be difficult to distinguish from lateral epicondylitis (tennis elbow) Again treatment revolves around rest splinting and occasionally surgical decompression of the nerve.

Thoracic Outlet Syndrome results from compression of the brachial plexus nerves which run from the spine in the neck to the area of the armpit (axilla) where they enter the upper arm. Often, like other overuse syndromes, this condition results from repetitive strenuous work in awkward positions. Other causes can be a whiplash neck injury or fall on the shoulder. Symptoms vary depending on the nerves involved but usually feature pain, numbness, and muscle weakness in various distributions. Trigger points in the neck are common and provocative tests will confirm the diagnosis. Treatment is usually conservative involving physiotherapy, neck traction and muscle relaxants. Surgical intervention is rarely recommended but involves the removal of cervical rib or scalene muscle to alleviate the compressive force on the nerves.

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Musculo-Tendinous Overuse Syndromes

Under normal circumstances, the friction produced by a healthy tendon gliding through normal tissues is minimal, as synovial fluid lubricates the tendon and pulley surfaces. However, injury to the tendon or abnormal repetitive stress can damage the smooth gliding surface. When the tendon becomes swollen a cycle of inflammation occurs resulting in pain and restricted movement. The symptoms can resolve with rest but recur when the activity is resumed. With time the resisted motion can become severe due to scaring resulting in triggering and locking of the digit. Treatment of the many types of tendonitis is essentially the same. Initial treatment involves rest of the injured part with the use of oral anti-inflammatory agents or local cortisone injections to allow natural healing. Hand surgery can then be necessary to release constrictions or inflamed muscular insertions.

Trigger Finger (or Trigger Thumb) is the most common tendonitis involving the flexor tendon as it passes through the fibrous flexor tendon sheath to enter the finger or thumb. Inflammatory swelling due to overuse causes restriction of the digit movement resulting in triggering or even locking. Treatment initially involves rest and possibly a steroid injection into the region of the tendon sheath. In most cases this will lead to an improvement of symptoms but recurrence is usually best treated by surgical release as a quick local anaesthetic daycase.

DeQuervain's Disease is stenosing tenosynovitis of the extensor tendons of the first dorsal compartment to the thumb. The stenosis usually occurs at the wrist and is often due to repetitive movement of the thumb. Often differential gliding of the two extensor tendons causes stress between the tendons resulting in synovitis that restricts motion and causes pain. Diagnosis is confirmed by tenderness over the first dorsal compartment and a positive Finkelstein's test. The mainstay of this overuse syndrome is rest, and immobilization of the thumb and wrist in a splint is very important. Again a steroid injection can also be beneficial, but avoidance of the precipitating factors is most important. Hand surgery may also be beneficial releasing the constriction on the tendon, but will require postoperative splinting to avoid recurrence. This is also a small local anaesthetic daycase procedure.

Tennis Elbow (Lateral Epicondylitis) involves a degenerative tendonitis of the extensor muscle origin on the lateral epicondyle of the elbow. It can be confused with radial tunnel syndrome due to compression of the radial nerve nearby passing through the two heads of supinator. The condition is caused by repetitive elbow and wrist movement producing stress around structures in the proximal forearm. Treatment is usually nonsurgical involving rest, splinting and steroid injections. A tennis elbow strap and neoprene elbow support will be helpful to alleviate symptoms. Avoidance of precipitating factors is very important to make a complete recovery. Hand surgery is usually reserved for the more recalcitrant situation and involves postoperative therapy including stretching and strengthening exercises before normal use can be resumed.

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Dupuytren’s Contracture

Dupuytren's disease is a benign condition of the hand, which results in tumorous thickening of palmar tissues leading to flexion contractures that limit finger motion. When this tissue extends into the fingers, it begins to pull the fingers towards the palm, restricting motion. Though the condition is not painful, it may progress until the fingers become deformed or completely disabled. It is a condition usually diagnosed after age 50 and affects mainly men of European background. Often a family history of the condition can be established. Usually the natural history of the disease is a slow progression of the condition from a palmar nodule to severe finger contractures over a 5-10 year period, however is some cases the development may be more rapid. The condition may affect other body areas such as the sole of the foot, knuckle pads of fingers and the penis (Peyronie's disease). Dupuytren's disease is often associated with diabetes, epilepsy, alcoholism, and chronic lung disease but the reasons why are unknown.

Treatment – Hand Surgery

The only treatment for advanced stage contracture of the fingers is hand surgery. Because there are several important nerves that may become intertwined with diseased tissue in the palm, surgical procedures to correct contractures must be handled by an experienced plastic surgeon. At our Melbourne practice, we select the appropriate surgical technique based on the severity of the contracture. The goal of contracture hand surgery is to increase the motion of affected fingers by removing the thickened Dupuytren’s tissue and releasing the tendons. Hand surgery to correct contractures can be performed at any of Dr. Ross’s affiliated hospitals in Melbourne on a daycase basis. During the procedure, small incisions are made along the palm and fingers that follow the cords of contracted tissue and allows visualization of other important structures in the hand. Plastic surgeon David Ross then creates skin flaps that can expand to allow the fingers to extend. After surgery, patients can expect to see a significant improvement in their finger movement. The usual postoperative course would involve 2 weeks in a protective dressing and then 2-4 weeks of hand therapy to return to full hand function.

To determine if you would benefit from surgery for Dupuytren’s disease, schedule a hand surgery consultation with plastic surgeon David Ross. Contact our Melbourne plastic surgery practice today to make the arrangements.

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Arthritis of the Hand

Arthritis of the hand is a condition that is characterised by stiffness, swelling, deformity, and loss of motion in the thumb and finger joints. The two common forms of arthritis affecting the hand are osteoarthritis (a degenerative joint disease), and rheumatoid arthritis (an inflammatory joint disease). Both conditions are progressive and can be extremely painful and debilitating.

Arthritis - Hand Surgery

There are many beneficial surgical procedures that can be used in the management of patients with arthritis of the hand. Often these can complement the medical management of arthritis suggested by rheumatologists and arthritis physicians. It is suggested that patients discuss the role of hand surgery in the treatment of their arthritis with their rheumatologist or contact a hand surgeon directly to determine if hand surgery may be of benefit. Hand surgery can restore movement in the thumb and fingers, ease painful swelling and inflammation, and also remove deformities of bone and/or tissue. There are several hand surgery procedures used to treat rheumatoid arthritis and osteoarthritis. Surgery is usually recommended after the disease process is established but can also have a role in prevention of disease progression by surgical removal of the diseased tissue (synovectomy) when medical treatments have not been effective. Surgery for joint pain can involve joint fusion (arthrodesis) or joint replacement with natural tissues or artificial joints (arthroplasty). Plastic surgery of the hand can also be beneficial in improving the deformities of the hand caused by the arthritic process resulting not only in a more natural hand appearance but also improved hand function.

Following arthritis hand surgery, there usually will need to be a period of hand rehabilitation to achieve an optimal functional result from the procedure. This therapy is usually supervised by a qualified hand therapist who works with Dr. Ross during the postoperative period, and may involve splinting to protect the surgery during healing and then mobilization to optimize hand function. It is important to understand that neither medical nor surgical treatment can cure arthritis; however hand surgery can certainly improve hand function to minimize disability and prevent much of the pain involved with this condition. Following hand surgery, our Melbourne surgeon may recommend physical therapy to regain function in the thumb and hand.

If you are interested in finding out about hand surgery for the treatment of arthritis, contact our Melbourne practice to undergo an assessment to determine the specific surgical procedures that may be beneficial in your situation.

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Ganglions and Other Hand Tumors

Ganglions are the most common tumours identified in the hand. A ganglion is a fluid-filled cyst that is commonly found on the wrist, at the base of the fingers, or at the end joint of the fingers. Ganglion cysts usually arise adjacent to joints or synovial lined tendons. They occur commonly as a result of an overuse syndrome, but may be related to arthritis or follow a hand injury. They first appear as a swelling under the skin and may feel soft or firm. A ganglion cyst can become apparent gradually or immediately and then often changes in size, but generally starts out the size of a pea. Ganglion cysts can cause aching near the affected joint, which is made worse with repetitive motions of the hand and fingers. The cysts sometimes disappear spontaneously, but surgical removal by a plastic surgeon may be recommended if the ganglion becomes painful, uncomfortable, or unsightly. There are other less common hand tumours, most of which are harmless. These include lipomas, inclusion cysts, giant cell tumours, neuromas and enchondromas. If you do have a hand tumour it should be assessed by an experienced plastic surgeon to ensure it is not dangerous.

Treatment - Hand Surgery

Surgical removal of ganglion cysts and other tumors of the hand is a safe and effective treatment option. This type of hand surgery can usually be performed as an outpatient procedure, under local, rather than general anaesthesia.

In some cases prior to surgery, plastic surgeon Dr. David Ross may recommend radiological assessment of the tumour to verify the diagnosis and to rule out any damage to surrounding joints, tissues, etc. In the majority of cases, the tumor can be safely excised from the hand without damage to surrounding structures. Following removal, the recurrence rate of a ganglion is usually minimal. Often a period of hand splinting is required to protect the hand while healing occurs.

Please contact the office of plastic surgeon Dr. David Ross in Melbourne if you are considering surgical treatment of a hand tumour. Dr. Ross will help you determine the best treatment for your situation.

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Traumatic Injury of the Hand

Hand trauma is a broad term that includes any sort of damage or injury to the nerves, tendons, soft tissues, bones, or joints of the hand. Injury to the hand and upper limb is one of the most common reasons for requiring medical attention. There are many causes of hand injury including lacerations, crush injury, burns, fractures and other traumatic events. Often hand injuries will require emergency surgical intervention. In most instances treatment is best provided by a hospital emergency department, who will involve a hand surgeon if necessary. In some situations plastic surgeon Dr. David Ross can assist with emergency treatment of hand injuries depending on the urgency of treatment. Usually in these situations your general practitioner will contact our office to determine whether emergency treatment might be possible. There are some hand injuries (fractures and nerve injuries) where delayed surgical treatment may be feasible. It is probably best to discuss this situation with your primary physician.

Dr. David Ross has extensive experience in the treatment of traumatic hand injuries through his appointments as senior plastic surgeon at the Dandenong Hospital campus of Southern Health and the Frankston Hospital campus of Peninsula Health in Melbourne. Following surgery for the treatment of hand injuries there may need to be a prolonged period of hand rehabilitation to achieve the best functional result supervised by a specialist hand therapist working with Dr. Ross.

If you are considering hand surgery, contact Dr. David Ross, plastic surgeon in Melbourne, Victoria.

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