Surgery Plus Therapy can be
Winning Combination with Hand Injuries

ot long ago, all patients who had wrist or hand surgery were required to immobilize the wrist or hand during the healing process. That's no longer the case.

"We now realize that in a significant number of cases, immobilization did more harm than good," said Anne S. Rosenthal, MD, an orthopaedic surgeon fellowship trained in hands. "The surgery itself causes soft tissue trauma, so we want to get the patient moving early in order to prevent stiffness and further loss of function."

But getting patients to cooperate can be a challenge. According to Dr. Rosenthal, "they're in pain and the natural tendency is to protect the traumatized site. We have to convince them to move through the pain. Sometimes it takes plenty of pain medicine. If surgery involves nerves or tendons, I'll try to have them in therapy two or three days after surgery. For patients with fractures, it's about a week after."

And with some injuries, therapy begins even before surgery. Dr Rosenthal recently treated a carpenter who took a fall and broke his wrist. When she saw him the next day, his hand was extremely swollen. "We started him on exercises to reduce the swelling, and then went in and set the bone. We knew the therapy would improve his outcome, and he's doing great."

With this particular patient, attitude was also a key. "He loves his work, and even with a broken wrist, he stayed on the job and did what he could with one hand," she said. "He'll probably have some arthritis in that wrist when he gets older, but he'll still be able to work."

Both Physician and Coach

Convincing patients of what they can continue to do after wrist or hand problems is part of Dr. Rosenthal's job. "I see myself as a patient's physician, but I'm also their coach," she said. "It's my job to encourage them to get back to using their hands as much as possible.

"Many people's self worth is based on what they do for a living, and patients with good mental attitudes want to get better, so I do what I can to help them with that psychological process," she said. "Sometimes you run into a patient looking for a reason not to go back to work, but that's the exception. Most people know they're better off in every way if they can continue to work."

While Dr. Rosenthal sees a wide variety of hand and wrist problems, the majority of her cases involve lacerations, fingertip amputations, broken bones, repetitive trauma issues, carpal tunnel syndrome, and trigger finger (fingers that become stuck because of swelling in the tendons).

"Diagnosis of traumatic injuries is fairly straight forward," she said. With most other injuries, she can assess the problem by taking a careful history of the patient. X-ray and nerve conduction tests are reliable in revealing still other injuries and problems.

"Closed versus open is a controversial topic in hand surgery right now," she said. "While there are different indications, I favor the open release for carpal tunnel syndrome because I believe it is safer and more reliable. I am trained in the endoscopic method, and the two scars that are left from closed carpal tunnel release are the same length as the scars I have from open releases for carpal tunnel on my own wrist, and I wouldn't treat my patients any differently than I was treated."

Treatments for patients who have experienced failed carpal tunnel surgery include going back in to release the nerve again and surgically creating a tiny fat graft of muscle flap over the affected nerve to help keep the nerve supplied with blood and to keep the nerve healthier.

People with arthritic hands can also find relief through surgery. Today's techniques include replacing swollen deformed knuckles with artificial joints. Patients with injured tendons and muscles may be appropriate candidates for a tendon and muscle transfer from another part of the body.

When patients have suffered an injury in which a nerve is severed, Dr. Rosenthal does a microscopic repair using thread finer than a human hair to reconnect the nerve ending. "Then," she said, "the body regenerates the nerve. It's an amazing process."

The Artistry of Hands

Dr. Rosenthal has always found hands fascinating. She loves art and struggled with the decision to pursue an art degree or study her other love, medicine. "I finally decided I could be a surgeon whose hobby was art," she said. During the course of her medical studies, she thought first that she would be a plastic surgeon.

"That changed when I discovered pediatric orthopaedics. And then, when I got to my residency, I saw hands. Suddenly everything made sense. I knew I would be a hand surgeon," she said. "As an artist, I truly appreciate the functional quality of hands. As a surgeon, I am intrigued by the artistry of the surgery."

A native of St. Louis, Dr. Rosenthal received her medical degree from Northwestern University. She completed her orthopaedic residency at the University of Pennsylvania, and her hand and upper extremity fellowship at Massachusetts General Hospital. She was in practice for three years in the Boston area before moving to Kansas City last summer with her husband, Scott Sher, MD, a radiologist, and their two daughters.

With a full time practice at Rockhill Orthopaedics and two very young children, Dr. Rosenthal has little time for art right now, but she still is able to do some knitting, needlepoint and glass work. She also enjoys medical illustration.

"Whether it's art or medicine, I like the fineness of the work," she said. "Regarding my work as a hand surgeon, I love what I do. Hands define us, and I can make such a difference for people."

For selected articles from previous issues of "On Track" and other publications, visit the Orthopaedic Health Library.

Return to "On Track" Spring 2000