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CASE NOTES
Tuesday 7 March 2006, 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION


RADIO SCIENCE UNIT



CASE NOTES
Programme 9. - Hands



RADIO 4



TUESDAY 07/03/06 2100-2130



PRESENTER:

MARK PORTER



REPORTER: LESLEY HILTON



CONTRIBUTORS:

JEREMY FIELD

DAVID WARWICK

FIONA JONES

MAGGIE BELLEW
STEWART FLEMING



PRODUCER:
DEBORAH COHEN


NOT CHECKED AS BROADCAST





CLIP

Getting up out of bed to try and bring it back to life again. And then you have pain in your arm all day long and then it's back to no sleep again at night because it's so bad. I was like this for 15 years until I managed to get something done about it. It was done under a local anaesthetic. I was out of action for about a month for it to heal and since then it's been fine - I've not had any repercussions at all from it. So it's been a wonderful operation, I just wish I could have had it earlier.



PORTER
You don't have to be a concert pianist, brain surgeon - or a hairdresser like Andrea Glanville - to be dependent on your hands. Most of us take manual dexterity for granted, and never appreciate how important it is until we lose it through illness or injury.



Today's programme is all about the hands and, as well as learning more about the problem that was interfering with Andrea's ability to do her clients' hair I'll be finding out about the latest treatments for arthritis of the wrist and hand, I'll be talking to a plastic surgeon about a new minimally invasive technique for treating Dupuytren's Contracture - a common scarring of the palm that leads to curling of the little and ring fingers. And I'll be finding out why physiotherapy, and psychotherapy, can make all the difference to people recovering from injuries to the hand.



My guest today is Jeremy Field a consultant hand surgeon at Cheltenham General and the Glenn Hospital in Bristol.



Jeremy - our ability to perform skilled tasks with our hands has given us quite an evolutionary advantage over other mammals - what is different about the human hand compared to that of the chimpanzee or the ape?



FIELD
Well the hand is the most important organ that we have in the body - we touch with it, we can feel shape, roughness, smoothness, we can talk with it, communicate with it, we can also show aggression - thump people with it and show affection by stroking people with it. But the only thing that really differs is the fact that we have the use of a thumb and the thumb - our thumb is different to the ape's thumb in the fact that we are able to do what is called oppose the thumb. Now the movement of opposition is the moving of the soft bit at the end of your thumb to touch the soft bit at the end of the little finger and this enables us to pick up fine objects.



PORTER
So that's the pincer movement that we actually use - we're using all of the time. For the sake of orientation let's have a brief overview of the anatomy. Let's assuming I've got my hand - lying down on the table - facing palm up. First of all, the bones.



FIELD
There are eight little bones in the wrist, these are called the carpal bones. Underneath the palm itself there are bones going down towards the fingers called the metacarpals. And in each of the fingers there are three bones called the phalanges, the thumb has only two of those phalanges.



PORTER
Now although there are muscles in the hand and the lion's share of the work is actually done by muscles in the forearm yeah?



FIELD
It is. The muscles that allow us to roll up our fingers towards the palm actually lie in the forearm and then the front of the forearm, if we've still go our palm uppermost. The muscles that allow us to straighten our fingers or unroll our fingers are on the back of the forearm.



PORTER
And presumably a lot of your work is related to trauma - injury to the hand?



FIELD
A lot of my work is trauma and people think of hand surgeons as being - just dealing with mangled hands that have been put into ghastly pieces of machinery. And that's certainly some of our work but not all. I see quite commonly from where I come from in Cheltenham a lot of riding accidents with people getting their hands and fingers caught in reins and also simple fractures and perhaps ligament avulsions and perhaps commonly we see thumb injuries from anywhere that has got a dry ski slope because people often stick their thumbs into those. Apart from that there are a lot of other things, apart from trauma, that I deal with. For instance, carpal tunnel syndrome and trigger fingers are my bread and butter. We then have arthritis which we're going to deal with, Dupuytren's that we're going to deal with and things like tennis elbow and golfer's elbow.



PORTER
Well let's stop there. As well as being prone to injury, the hand is also the part of the body most likely to be affected by arthritis, that you mentioned there. And the resulting pain and stiffness often impairs function to such a degree that surgical intervention may be the only option. David Warwick is a hand surgeon at Southampton General Hospital and I met him in his office, surrounded by x-rays of some of the techniques he uses to treat the more severe degrees of arthritis.



WARWICK
As people get older it's more common in females than males, as it happens, for reasons we don't quite know, the joints at the tips of the fingers quite often become swollen and stiff, we call those Heberden nodes. And usually they get a bit swollen, a bit stiff, but people don't mind, they adapt and there's no pain. Occasionally they get painful as well and then the finger can't be used because there's pain on use. And the most suitable treatment for that, if the pain's too severe, is that we can fuse the joint.



PORTER
And looking at the x-ray that's simply some sort of pin that goes through the end of the finger just through the joint?



WARWICK
It's a pin. In old days you'd use wires to try and hold these joints but the wires would stick out of the bone and they caused problems and might get germs in. Nowadays what we would use is these buried pins, which are a special thread each side and we can excise the joint and then compress it with these buried pins which stay in forever. And they're so strong that we can get the hand moving straight away afterwards.



PORTER
So presumably the person loses the function at the end of their finger is straight but they can use it because it doesn't hurt.



WARWICK
Exactly. So the whole judgement in surgery is that you need to discuss with the patient whether the loss of movement in that one little joint would compensate for the fact they can't use the joint properly because of pain.



PORTER
Okay moving on, a slightly more complex operation, we're now looking at the next joint down the finger, the joint in the middle of the finger, and that - looks like you've totally replaced it there.



WARWICK
That's right the joints in the middle finger we call the PIP joints - proximal interphalangeal joint. And arguably that's one of the most important joints at least in the fingers, rather than the thumb base, because that joint has to move through a good range of pain free movement to allow you to pick things up, to allow you to grip securely. And when that joint becomes arthritic management is difficult, now you can excise the joint but it is so floppy it'll be of no value, so we can't do that. We can fuse the joint and if you fuse the joint the pain will go, you'll have a nice strong pinch grip against the thumb but you won't have movement, so it'll be very difficult ....



PORTER
... permanently pointing the whole time.



WARWICK
Permanently pointing. So although we can fuse them perhaps the index finger we do fuse, in order so that you can pinch firm against your thumb. The other fingers we prefer to replace them when possible. And we've now got really quite new technology available, until recently we really just had little floppy silastic plastic implants but now we have implants which are made of solid material, either metal on one side of the joint and plastic on the other, very, very similar to a knee replacement, much, much smaller. Or a material called pyrolytic carbon, which is a heat treated carbon graphite type material, which almost never wears out, in fact the same material's used in heart valves as bearings because it just doesn't wear out and which has other biomechanical properties - it can stick to the bone and can be carved into a really beautiful shape that works like a real joint. So when possible we may replace these joints now rather than fuse them.



PORTER
And the return to function afterwards is what? I mean how quickly - do you get normal function after you've had one of these joints?



WARWICK
I don't think it's ever normal function, we try and get these fingers moving as quickly as possible, you have to have very, very specific hand therapy afterwards, it's not just the operation, you have to have the proper therapy afterwards to get the joint moving. Some of these joints do very well, they have a good range of pain free movement, we don't quite know yet how long they're going to last - these haven't been around for long, so we don't really know if they're going to last for three years, five years, 10 years, but we're hoping they will, we don't yet know.



PORTER
And how available is this, I mean obviously you're a specialist centre here, but how available is this sort of replacement surgery, it's not routine?



WARWICK
No, I don't think it is routine, I think it may become routine as these options become available and as they prove themselves that they do last, and they don't go - have problems early on, then hopefully they'll be successful enough to spread as a technique.



PORTER
Okay, let's move on to the wrist here. We've got familiar options here, here's some x-rays of the wrist showing what can be done. Presumably this one here, you've got a big plate running down the back of the wrist, that's fixing it is it?



WARWICK
Yeah, the wrist is really important to hand function. You can have the most perfect fingers in the world but if your wrist is painful, every time you try and do anything with your fingers the pain from your wrist will stop you gripping properly and stop you using your fingers. So if someone's got wrist arthritis it really does change the way their hand works. And traditionally the way of fixing an arthritic wrist would be to fuse the wrist, so you stiffen the whole wrist - it still rotates but doesn't bend up and down or tilt. But we're now able, in some circumstances in wrist arthritis, to not fuse the whole wrist but only fuse part of the wrist. So we work out which - there are seven articulating bones in the wrist, it's a very complex joint - but we work out which joints are arthritic and we can sometimes fuse just the arthritic joints but leave the others, which means you've still got some movement in your wrist. And even more recently we're becoming a little bit more confident in wrist replacement and just occasionally there are patients who are suitable actually to have a replacement wrist put in, made of metal and plastic.



PORTER
David Warwick talking to me in Southampton. You are listening to Case Notes, I am Dr Mark Porter and I am discussing hands with my guest, hand surgeon, Jeremy Field.



Jeremy, we didn't mention the thumb there, that's another common side of arthritis.



FIELD
It is, David's mentioned the end joints of the fingers where these Heberden's nodes are, that the most common joint to be affected by arthritis in the body. The second most common joint to be affected by arthritis in the body is the base of the thumb.



PORTER
Now presumably that's important because of this opposing movement, this pincer movement, we're using it all the time.



FIELD
As we said earlier the only thing that makes us different from the apes, therefore it is vitally important. And the things that people complain of are things like peeling potatoes or unscrewing lids on jars, commonly, and ladies again, unfortunately, clobber most of this, it's far more common in ladies than it is in gentlemen. But there are various things that one can do with this. Initially one can try conservative treatment, which would mean some form of anti-inflammatory drug or then potentially move on to injections or they move on to surgery.



PORTER
And you can replace that joint presumably?



FIELD
You can replace that joint, the problem is we can put a little mini hip replacement in it but the trouble is the hip replacement has got a ball and a socket and the socket is difficult to actually maintain in the base of the thumb. So we're trying at the moment what are called hemiarthroplasties, which are half replacement joints.



PORTER
Okay, David also mentioned the role of physiotherapy - hand therapy - there in helping people recover after injury of in his case hand surgery. Of course physios have very good relations with orthopaedic surgeons right across the board for knees and hips and all sorts of other things but it's particularly important when it comes to the hand.



FIELD
This is absolutely right. I think that physio is much more vital in hand surgery than it is in any form of orthopaedics. In fact a physiotherapist is really there to make your excellent surgery look even more excellent and one has to say that it can make bad surgery look good too.



PORTER
So if you don't follow the physio course you will not get the use of function back?



FIELD
You will never get reasonable function in the hand. As David said we cannot create normal function but to get the best that we possibly can the physiotherapy is as important I think as the surgery.



PORTER
Well we sent Lesley Hilton to St James' Hospital in Leeds to find out more about the difficulties people face when recovering from surgery to the hand.



ACTUALITY - PHYSIOTHERAPY SESSION
Is that okay?



That's really painful.



Just try and hold it there, just for a second. One, two, three ...



HILTON
Bridget Hopton is an ambulance technician. Nearly two years ago, while answering an emergency 999 call, her ambulance was hit by a bus. She was trapped in the wreckage for an hour and left with serious damage to her hands for which she is still having intensive physiotherapy.



HOPTON
The main injuries to my hands were my middle and ring finger on my left hand were both degloved and fractured and also the tendon was snapped in the ring finger and also the knuckle joint on my thumb was shattered as well. And then I also had various other abrasions and cuts to both hands.



ACTUALITY - PHYSIOTHERAPY SESSION
Just want to stretch this bit out at the bottom. It's probably the best it's been to be honest.



You're killing me today.



Hence the name physio-terrorist.



HILTON
Hand injuries and their subsequent rehabilitation can often be quite painful. There can also be mental trauma involved. Fiona Jones, superintendent physiotherapist for hands and plastic surgery at St James' Hospital in Leeds.



JONES
Hand injuries can be traumatic for the patient because they often see it happen or perhaps they've been in a situation where they've done something a bit silly so they've perhaps opened a can the wrong way or cut a piece of bread in the wrong way and they've actually just watched it happen. Industrial injuries as well, there's often a situation where somebody does something a little bit unsafe and they end up with a problem or a machine fails and their hand gets crushed and trapped. So there is often a huge psychological factor attached to the actual injury itself - either blame for the institution that it happened in or blame for one's self.



HILTON
Physiotherapy is vital in regaining the use of the hands and often a lot of movement can be restored. But the success of the physical treatment can often depend on the patient's emotional state



JONES
In my experience the motivation and the state of mind of the patient is absolutely vital in achieving the best result from hand trauma. Patients who are well motivated invariably do well, patients who have psychological issues and problems ongoing usually need to have these addressed alongside their physical rehabilitation to get a good result.



HILTON
Dr Maggie Bellew is a consultant clinical psychologist at St James'. She agrees with Fiona that a determined and positive outlook from a patient is a big element in their successful rehabilitation.



BELLEW
Compliance and motivation in hand rehab can depend a lot on the perceived value of the hands prior to the injury. So it's a far bigger loss for people whose livelihood and whose recreation involved their hands. So typically surgeons would find it a very big loss, or people who are very keen on sports or DIY as their hobbies and pastimes. There can be patients whose perceived value of their hands was less - they didn't really work with their hands and they weren't interested in hand related pastimes may have less motivation to fully gain what they could do from their rehab.



HILTON
Hand trauma patients are often treated for post traumatic stress disorder. And counselling is offered to those who find it hard to come to terms with the fact that they can no longer do the activities or even the job that they had before. A sense of profound loss can cause patients to become depressed and some need help to accept the fact that they may need to reinvent their lives in order to move forward.



Bridget Hopton has just had a third round of surgery on her hands. A keen piano player she always said that if there was any bone in her body that she didn't want to break it would be in her hands. She has managed to start playing again now, although there are still things she can't do.



HOPTON
I can't French plait my hair anymore because my fingers don't bend enough to be able to hold the hair. I also used to play the guitar and I can't do that any more because I can't wrap my fingers round the fretboard anymore and also my piano playing is slower than it was although it has improved and it's certainly not stopped me from playing. I can just about manage everything else now - you just kind of learn to adapt and use different fingers and different techniques to fasten your trousers or tie your shoe laces or anything like that. You certainly - you don't realise how important your hands are until you can't use them anymore.



PORTER

Bridget Hopton talking to Lesley Hilton in Leeds.



Jeremy, we haven't talked about the nerve supply to the hand - and the problems that can arise there. We heard at the beginning of the programme from Andrea, retired hairdresser, who had something called carpal tunnel syndrome, which is probably the most common nerve problem I would imagine.



FIELD
It certainly is the most common nerve compression syndrome that we see and it's the bread and butter of what we do as hand surgeons. It probably occurs in about 2% of the population. And Andrea gives some very classical symptoms, I mean patients most commonly complain of pain tingling at night and they have to get up at night and dangle their hand down outside the bed and shake it - I call it the dangle and shake dance. But they also get it when they're elevating their hand - reading a broad sheet newspaper, when they're driving, ladies get it more on the telephone and perhaps washing your hair. So it's the elevation of the hand that so important.



PORTER
And it's called carpal tunnel syndrome because?



FIELD
The nerve - the median nerve - which is the nerve that supplies the index - thumb, index, middle and ring finger - travels through a little tunnel at the base of the wrist. And that is half bony and half floored by a ligament. And that ligament thickens and presses on the nerve and gives the symptoms of carpal tunnel which Andrea classically describes.



PORTER
So it's literally the nerve being squeezed.



FIELD
The nerve squeezed indeed.



PORTER
And why does it happen in the middle of the night, do we know?



FIELD
Well we don't know but there's a theory of the fact that we all try and climb into our mother's wombs at night and we all curl up and our wrists bend or flex forwards and this actually increases the pressure within the carpal tunnel and if the pressure increases the pressure on the nerve increases and the symptoms.



PORTER
I mean certainly we see a lot of it in general practice, as you can imagine, and my perception is it's a lot more common in women. Who actually is most likely to get it?



FIELD
Women are definitely much more common to get it, they're more likely to get it than gentlemen, again poor ladies clobber it. It's common in pregnancy, or it can certainly occur in pregnancy. And it classically occurs in 40-60 year old ladies but it can also occur in men.



PORTER
So what can we do about it? Do people have to come and see you or is there an option that we can use in general practice?



FIELD
I think that you can in general practice give someone a splint at night and that stops them bending the wrist at night and sometimes that can be helpful. Some GPs seem to try diuretics, which is sort of water ...



PORTER
They never work for me.



FIELD
It certainly never works for any patients that I see either. Then one would have to come and see a hand surgeon and I think coming to see a hand surgeon's the right person to go and see. And potentially we can try injections sometimes, although I don't really like using them as a form of treatment because the operation is such a good operation and as Andrea says she's had it done under local anaesthetic and the morbidity, i.e. the problems that occur with the operation are so small, there's a 95% successful operation.



PORTER
And that's basically decompressing that canal ...



FIELD
Indeed.



PORTER
Well thank you for now Jeremy.



I want to move on to Dupuytren's Contracture - that's scarring and shortening of the tissues in the palm that can lead to curling of the little and ring fingers. Think of the Pope's hand when he blesses the crowd in St Peter's Square. His thumb, index and forefinger are extended straight, but his ring and little finger are curled over. Well the papal hand of benediction is the classic deformity caused by advanced Dupuytren's, and one that can significantly impair day to day tasks.



Named after the French surgeon Baron Dupuytren, it can affect the feet as well as the hands. It tends to run in families, and is often more of a problem in men and people with diabetes. Around two million people in the UK are thought to have some degree of Dupuytren's.



Stewart Fleming is a plastic surgeon at Broomfield Hospital in Chelmsford.



FLEMING
There are two parts to the disease - there's nodule formation, where you get thickened lumps of tissue in the palm and this has got a lot of what's called type 3 collagen. This is a type of scar tissue that contracts very actively. And in addition to this you get cords and these cords are bands of scar-like tissue that once they've become established you can't then straighten the finger out, so they prevent the finger from going straight once they've developed.



PORTER
And what sort of problems might that cause to someone who is developing the condition?



FLEMING
It's very difficult and it varies. I've had patients who've come to me with really very mild contracture, one woman that I remember who used to ice cakes, it was her work to decorate cakes for people, and she had about 10 degrees of contracture, she wanted something done because every time she iced the cake it would leave a furrow in it. By contrast I had another patient who came to me, said you've got to get it done doc, I can't get my golf club underneath it.



PORTER
So they were pushing the golf club up through the little finger to hold it.



FLEMING
Absolutely right.



PORTER
So the conventional surgical approach is what?



FLEMING
The standard surgical approach is to operate and remove the bands, remove the nodules, get the finger straight and use certain techniques of moving the skin around, called Z-plasties to elongate the skin in the fingers and then sew it up.



PORTER
Which is exactly what David Glanville had done when he developed a Dupuytren's Contracture in his left hand.



GLANVILLE
My little finger and finger next to the index finger started pulling back into a claw and I couldn't straighten the hand. Driving was sometimes difficult, changing gear and that sort of thing. Couldn't grip things. Hand wasn't as strong as it should have been. And general things where your hand needed to be flat your fingers got caught on things. And I went to my GP and for that operation I had to stay in overnight, that was classed as a major operation, I had a general anaesthetic for that. Which was successful but I was out of action for a few weeks.



PORTER
Perhaps I shouldn't be asking a surgeon this but is there anything that can be done medically, in other words is there any medication - any creams, any stretching, any physiotherapy - that can help?



FIELD
Stretching of the fingers anecdotally is helpful but you have to be really obsessional

about it, you have to do it three or four times a day and I have a surgical colleague who because he doesn't want to have surgery, because it will interfere with his operating for two or three months, he works very hard at stretching his fingers and has managed to keep it under control. There's been some work on something that dissolves collagen and this was popularised in the 1990s by people in France and sort of had a little flourish of activity but then this died away and there's recently been a paper on it in the States but nobody's quite sure how long it works for. And then finally there's what's called percutaneous release, which - or needle fasciotomy - where the bands of disease can be divided through the skin under local anaesthetic with a needle but that works best in the palm and although it can be done in the fingers there are problems with it.



PORTER
And how successful is that long term?



FIELD
Our own theories, we looked at 110 patients that we'd operated on, and I think 60% had maintained the correction that we got for them at a year. But it usually only lasts for two to three years.



PORTER
Well patient David Glanville's left hand may have been fixed by the classical open surgical approach, but when he started getting problems with his right hand, Stewart Fleming suggested the less invasive percutaneous option.



GLANVILLE
I had three injections in that area, just a local anaesthetic. The first two weren't very nice but once it was dead I didn't feel a thing, just this scrunching feeling as he cut through it. And slowly as the feeling came back that evening it just felt as though I've had quite a bad cut across my hand, but just take a couple of painkillers if it does affect me. And I feel as though I can use my hand quite normally now. And it's only two days.



PORTER
David Glanville.



Jeremy, there is another common problem that I wanted to cover - trigger finger?



FIELD
Trigger finger is another very common condition which occurs much more in ladies, I'm afraid, than gentlemen.



PORTER
They have a rough time when it comes to hands don't they.



FIELD
I'm afraid the ladies do yes, Dupuytren's the only thing that the chaps get clobbered with. It occurs in between 40-60 year olds and it's not associated with any kind of trauma or repetitiveness or anything like that. And what happens is that the finger either clicks or gets locked down. I saw a patient today who was obviously a farmer's wife and she was a bit hacked off because everybody else in the family shot and she didn't but she got the trigger finger.



PORTER
Because basically what happens is when you make a fist and you extend your fingers again the affected finger stays locked down.



FIELD
Stays locked down. And it classically occurs in the morning and it's associated with a stiff feeling of the fingers as well. The analogy of the trigger finger is a little bit like a bicycle brake cable, remember the old bicycle brake cable - bone cable it's called - white plastic sheath and a metal cord that runs in the middle. If you have a lump in the metal cord then the lump doesn't go into the white plastic sheath and the brakes don't go on. If the lump gets into the white plastic sheath and gets stuck then the brakes get stuck on and that's essentially what's happening with the trigger finger.



PORTER
And surgical only - anything else that can be done?



FIELD
No, you can inject them and I think the injection of a little bit of steroid, little bit of anti-inflammatory agent, which is the steroid, can help in about 50% of cases. And the steroid tends to work after about two weeks. And I tend to see people at about three months and see if it's worked, fine, if it hasn't then one might give another injection but I wouldn't give more than two. And if after that they've still got a triggering then I would advise surgery, which is a very simple operation.



PORTER
And these people are getting it because of - I mean is it associated with past damage or trauma or working heavily with your hands?



FIELD
Lots of people try and find a cause for problems with the hand and unfortunately it is just bad luck ...



PORTER
Bad luck and being a woman in many cases.



FIELD
Indeed.



PORTER
Briefly Jeremy, to finish on, hand surgery's obviously an important sub-specialty in orthopaedics, does every hospital have somebody like you - a dedicated hand surgeon?



FIELD
No, but there are more and more. I did a hand fellowship in Sydney about 12 years ago and in that one city there were 25 full time hand surgeons. When I got back to this country there were about five or less here. My feeling is that if you have a hand problem go and see a hand surgeon because that's the person who will deal with it best. Breast lumps are not dealt with by bowel surgeons anymore, they're dealt with by breast surgeons.



PORTER
We must leave it there. Jeremy Field, thank you very much.



If you want further details on anything that we have talked about today then do try the website at bbc.co.uk/radio4, or you can call our action line on 0800 044 044.



Next week's programme is all about asthma, including a look at how breathing exercises could help alleviate symptoms in some people. A new GP based breath test that could help ascertain whether you are taking too little, or too much medication, and I'll be meeting a doctor at the forefront of the effort to develop new treatments that could one day even lead to a cure.




ENDS

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