A multi-disciplinary approach is adopted for many common hand and wrist conditions. The hand therapist is a valuable asset in this respect. Many of these conditions can be managed in the primary care setting. There have been recent advances in therapy modalities and surgical techniques available, to better care and advise our patients.
Singapore is one of two countries in the world where Hand Surgery exists as a specialty, recognising that hand and wrist conditions can be complicated. There is a need for the preservation of both form and function when it comes to the management of hand and wrist conditions.
Our hands are the primary tools we use to interact with our surroundings, be it activities at work or play, or even activities of daily living (ADL).
Managing Wrist and Hand Conditions in Primary Care
Our primary care physicians will encounter in their daily practice many patients who present a multitude of hand and wrist conditions.
Common conditions include:
- Trigger Digits
- De Quervain’s Tenosynovitis
- Carpal Tunnel Syndrome
- Ganglion Cysts
- I nflammatory Arthropathy
- Simple Lacerations
Primary care settings possessing adequate equipment and setups can usually deal with simple lacerations by careful cleaning and suturing the wound. Similarly, simple paronychia can be derided and treated through appropriate antibiotics and regular dressings.
Enthesopathies and tendinopathies can be managed in the primary care setting with non-steroidal anti-inflammatory drugs (NSAIDs) and subsequent referral to the hand therapists in Tan Tock Seng Hospital (TTSH) for splints or other treatment modalities for pain management. Steroid based injections can also be carried out in the primary setting for these conditions.
Treatment Options and Medical Developments
Recalcitrant, chronic or specialised cases requiring specific opinions should be referred to Hand Surgeons.
We approach most conditions to do with hand and wrist complications in a multidisciplinary approach. We aim to provide a one-stop clinic experience, integrating the doctor’s consultation rooms, hand therapist room, x-ray imaging facilities and pharmacy within the same compound. This makes the management of the patient and condition seamless.
In 2012, TTSH’s Hand Procedure Suite (HPS) was established. HPS is a certified operating theatre with similar sterile conditions as the main operating theatre, located within the clinic. This allows suitable operations to be carried out under local anesthesia, or regional blocks, within the compound. Sometimes, these operations may be carried out on the same day as the patient’s consultation visit to the clinic.
Advances in Hand Surgery
Hand Surgery has seen major advances in recent years. There is a move towards minimally invasive surgery, to allow for faster wound healing and for earlier rehabilitation to occur.
In the HPS, we routinely perform endoscopic carpal tunnel release, which has been shown to cause lower pain intensity and yield shorter recovery times, as compared to traditional open carpal tunnel release. We have been offering patients, where possible, the option of a percutaneous release of their trigger digits as well. The patients start their rehabilitation immediately, post-operation, and there are no open surgical incisions to contend with.
Other minimally invasive procedures that we perform in the major operating theatres include wrist arthroscopy for both diagnostic and therapeutic management of chronic wrist conditions. There are usually four to six small stab incisions to allow for instrumentation and camera placement. Our scopes range in diameters of 1.9mm to 2.4mm for the wrist, and there are conditions where we are able to perform entire operations through these multiple small incisions.
Endoscopic decompression of other peripheral nerves in the upper limb are also becoming more commonplace. After carpal tunnel syndrome, ulnar nerve compression at the elbow is the next most common peripheral nerve to be compressed.
Occasionally, the ulnar nerve will need to be transposed anteriorly after decompression, to prevent the recurrence of symptoms. This whole procedure can now be performed endoscopically.
Total joint replacement in the finger and wrist are also available for patients with arthritic or dysfunctional joints. Silicone, pyrocarbon or metal-onpolyethylene implant types are now available. Each has specific indications, depending on the patient’s condition and requirements.
With these advances, there are now more treatment options for patients to wave goodbye to hand and wrist pain.