Hand Surgery Part Two?
April 16, 2013 4:58 PM   Subscribe

About 8 weeks ago I sliced the flexor profundus tendon that allows the tip of my right pinky to function. I had surgery and have now subsequently re-severed the healing tendon, requiring ANOTHER round of surgery to try to repair again. Should I go through with this? Issues related to post-operative depression, unemployment, and general existentialist angst inside. See previous.

After previous surgery to repair my lacerated flexor digitorum profundus I, due to my own foolishness, re-tore the repaired tendon after about 5-6 weeks of recuperation. My own disappointment with any meaningful indications of progress led me to over-exert my physical therapy exercises and try to do things well beyond what I should have, way earlier than I should have. I am scheduled for the same surgery again Monday and I oscillate between thinking that I might cancel the surgery, or sitting here worried about what I will do with myself if I have to start recuperation from day one again...

Why would you cancel surgery?

This injury affects the tip of my pinky...the last joint (the distal joint). If not fully repaired I will only be able to use the middle joint of my pinky, the farthest joint will be non-functional and my pinky tip will stick straight out from that joint, unable to curl, for life. This is the state it is in now and while enough to present its own issues (possible joint hardening, catching on things, reduced grip strength) is hardly completely life-changing.

My hands are important to me in that I make money with them (vfx artist, photography) and I execute my passions with them (building, photography DIY, biking, fitness, etc.). My hands are my life...but there is no guarantee that this surgery will ever allow me to use my pinky tip again anyway, and for the most part I can do the things I normally like to do even if the tip no longer works. I think pull ups might be more of a challenge, if not impossible with my right hand, but other than that I believe I will adapt.

My hand surgeon is obviously upset that I have necessitated re-operation, and he has indicated that there is even less of a chance that this surgery will be successful than the last due to a possible frayed tendon, or retracted tendon, or jellified tendon...not to mention that the tissues of my finger underwent the knife only 6 weeks ago and are still traumatized to a degree. His own thinking is that if he gets in there and there is not a relatively straightforward re-suture, then he will just sew me up and tell me to live with it, rather than Doing Everything Possible which would require surgery incommensurate with saving a pinky tip.

So if this surgery works...MAYBE in three months I MIGHT have some motion back...But it equally possible that it remains non-functional and I have to undergo months of recuperation again anyway.

Work

I work as a contractor in vfx and use my right hand, the injured hand, to use a mouse and stylus and keyboard stuff. I generally need BOTH hands working to do my job. Working with one hand is not really a viable option given what I do. The skillset I am hired for needs two hands.

Since my initial injury I have literally been turning down jobs because I can't use my hand, and was about to go back to work because my hand was well enough to use a mouse...that is until this week when I ruptured it. After surgery on Monday I will need to turn down work until mid July to recover enough to work a mouse again. Problem is that due to the nature of my industry, summers are slow and I may not realistically be able to find work again until October / November. I have not been employed since February...and while I generally take time off each year to backpack, travel, work on personal projects...the thought of not working for several months more on end, possibly not at all this year, makes me queasy. I have savings that can handle the time off...but I have been burning them already and further using them would set me back to a place that adversely affects future life plans. I could potentially afford it, but would rather not...and the thought of being unable to work should I choose too is really stressing me out. I was so close, and if I go for another attempt at fixing this thing I'm back to square one.

Not to mention I have not thought about how much this will cost me AGAIN.

Depression

I did not and have not adjusted well to the initial post-operative period, and the thought of going through all of this again as really taken the wind out of me. I have struggled with depression / anxiety in the past and during the last 6 weeks of recuperation I have slid into a depression that began to lift as my hand was healing. Now, of course it is back with a vengeance and after Monday will likely get worse as the weeks tick by. The cabin fever of recuperation has had me going insane. I am normally a very active person - my free time is spent working out, camping, hiking or - most of all - building things. Normally I would relish this time off, but without the use of my hand, half a dozen personal projects that requiring sewing, sanding, lifting and screwing sit unfinished and drive me insane. The fact that I haven't been able to get a good workout in with weights is also contributing to my depression. I've never been able to sit still...and the thought of immobilizing my hand for 3 more months for another unlikely outcome has me literally panicking.

I want my life back and if I cancel the surgery I can get back to work, back to doing things I enjoy and start adapting to life without full use of my pinky...whereas if I go through with the surgery I reset the clock and may not save the pinky tip anyway...or might get some use back someday. I really don't know what to do.

Stray questions:


1. If I undergo the surgery again is there any sort of disability / unemployment I can get on as an independent contractor unable to work due to disability? I am in California.

2. Is life without use of a distal phalange that bad? Anyone with experience?

3. If surgery...what do I do with myself while recuperating? I did it once...took lots of walks, listened to audiobooks, meditated, etc...but still became terribly depressed because I find it hard not to be active / always doing something. Suggestions? Are there places around LA that accept one-handed volunteers?

I apologize for the length, but would really appreciate some sage advice...my emotions are clouding my own good sense...Thanks all!
posted by jnnla to Health & Fitness (11 answers total)
 
i cannot speak to your personal state of mind (or the disability/experience), but personally, i would have the surgery and try like hell not to bust it again during recuperation. but i am the sort of person who, if i didn't do it, would ALWAYS wonder if i'd missed out on getting that function back by not doing it.

as for what to do while you're getting back again, i would get out. look for museums that have free days. look for summer festivals. wander around neighborhoods that aren't your own. try to eat (and blog about) all the ramen/pot stickers/pastrami sandwiches/grilled cheese/insert thing here and compare/review. work on being ambidextrous (i found this took my mind off a lot of things when i was a kid and broke my dominant hand). ride the bus from the start of a route to the other, and see what you can see that you may not have noticed before.
posted by koroshiya at 5:10 PM on April 16, 2013


oh! maybe look at ucla children's and see if they need volunteers to read books/hang out with kids. check museums to see if you can be a volunteer tour guide. see if there's a volunteer program at your local school (you may need to be fingerprinted and background checked for this).
posted by koroshiya at 5:12 PM on April 16, 2013


I feel like I'm missing some information here.

1/ If you don't have the second surgery, how long until you can return to work? If you do have the second surgery, how long until you can return to work?

2/ How much will not being able to flex the last joint of your little finger actually impact you in ways for which you cannot easily compensate?

I ask #2 because the goal is not perfection or even functional extremities but functional living. When I ripped all the tendons in my knee, surgery was a no-brainer because I couldn't walk, surgery was low-risk, and prognosis was excellent. But when I ripped tendons in my shoulder 15 years later, even though surgery was low-risk and prognosis was middling, the practical trade-off wasn't that appealing because the impact of the injury was not anything like not being able to walk. (Basically, I can't hang up towels, I can't reach up on shelves, I can't lift heavy things with that arm, and if I had small children I'd be unable to lift them.)

I don't know; to me this sounds like a low-risk surgery with a low chance of a good outcome but I'm really unclear on the third element to consider: the practical, functional impact of not being able to bend this joint.
posted by DarlingBri at 5:20 PM on April 16, 2013


My dad has something kind of similar, except his pinky is permanently curled. And my cousin was born with a number of very short (toe-length) fingers. They are both happy, highly accomplished, well-adjusted people who do not struggle with daily tasks. Obviously, my cousin cannot play piano, but she became a world-touring musician on another instrument.

This isn't meant to convince you to cancel, but to lessen your fears of permanently damaging your hand. I think you should seek a second opinion, and talk to a mental health professional while you're at it.
posted by acidic at 5:21 PM on April 16, 2013


I have no experience with this kind of injury, but I do with depression. See your GP and get a scrip for some medication. It will be short term, and it will help, promise. Consider it medicine necessary for your recuperation, regardless of whether or not you have surgery again.

I personally would go through the surgery again.
posted by Specklet at 5:25 PM on April 16, 2013


PS: Have you seen this NYT article?

I could not make a fist, swing a tennis racket with control, or securely grasp a dumbbell or the handle of a vacuum cleaner. Because the injury occurred in my dominant hand, writing was cumbersome.

So yes you'd loose some hand strength. but not mousing or keyboarding ability. And, none of those things would be a big deal to me. I have no idea if they are for you.
posted by DarlingBri at 5:25 PM on April 16, 2013


I can't decide for you whether or not to have the surgery. (I would do it if it was me.) But you would be surprised how well you can adapt. Many years ago I had a benign tumor in my right index finger that was painful when I, say, pressed buttons. It would have continued to grow so I had it out. Less than a week later I started my first "real" job at Walmart, and because of the huge splint on my index finger, I simply used my middle finger to press the buttons on my cash register. I didn't quit when I recovered... it was ingrained habit by then. To this day I often find myself doing things (tapping my iPhone or iPad) with my middle finger out of habit, even though my index finger is there and perfectly capable of working, without pain.
posted by IndigoRain at 6:28 PM on April 16, 2013


I would book another appointment to talk with your hand surgeon and/or get a second opinion. If your guy is miffed because you messed up his work he might be giving a grimmer prognosis than is completely accurate. Seeing him again and asking, specifically, what the odds of a good outcome are might help. Seeing someone who doesn't feel like they have to re-do work that you wrecked might yield a different prognosis altogether. FWIW, I probably wouldn't go through with surgery on a pinky that didn't have a much better than 50% chance of an excellent outcome, but I also think I use my pinky less than you do (no weight lifting or chin-upping for me, thanks).

As for what to do if you do have the surgery, I'd say see a doctor about post-operative depression, which is totally a thing, and get some medicine to help you through that period. I had surgery a few years ago and the resulting depression was so severe I was off work for a long time. My father recently had surgery and depression hit him like a hammer afterwards. In my limited experience, surgeons don't do a great job of preparing you for what life post-surgery is going to be like, and healing often takes longer than they say it will, so feelings. A short round of anti-depressants could make a really big difference here.

Another tip is to be upfront with a physiotherapist about how you are likely to want to use your hand during healing. They might have tips and tricks about how to be more active without re-injuring yourself. I'm always bossy with my physiotherapist and make my limitations really clear. In my case, I don't drive, and so need to walk for a half hour at a time, twice a day, every day, at minimum, and that's non-negotiable. There's no point pretending I'm not going to walk, so she'll adjust her treatment plan--and ask me to adjust my expectations--accordingly.
posted by looli at 8:06 PM on April 16, 2013


Did you get a referral to an occupational therapist after you were injured? A consultation could go a long way to helping you find practical coping strategies and ways of working in the short, medium and long term. Also, you should definitely consider seeing a psychologist to find ways to deal with the depression.
posted by nerdfish at 4:05 AM on April 17, 2013


A rupture at 6 weeks is crazy unusual, so sorry for that, most occur 10-14 days after the repair. Permanent loss of FDP function in a small finger will result in permanent weakness although to what degree is anyone's guess, unfortunately. The ring and small fingers are what provides power while your index and middle are for dexterity. I always tell my patients that revision surgery is a 50/50 prospect with respect to recovery. Your finger will not be normal but it will be better than by not having it fixed. That said, a small finger with no FDP is still functional, assuming your FDS is intact, which by your description it is. If your FDS is out too, meaning you can't bend the next joint down, then that finger will be nothing but a liability to your hand.

There really isn't a wrong answer here. We all use our hands to make a living but all of us use them differently. I would recommend spending these next few days doing the things that you do and seeing if the dysfunction you have limits you to any appreciable degree. If it does, then surgery is a no-brainer. If it really doesn't, then the waters are more murky. Unfortunately, there is a window of opportunity that will close on you if you wait too long. If you decide you want it fixed a month from now, it's too late.

If you don't get it fixed and you develop instability at the DIP joint, it can be fused to overcome that. Most patients after a DIP fusion report some gains in strength, but not all. I know I'm not really helping to make your decision, but I guess that's the point. You do have a choice here, both of which have consequences. It's sounds as though you didn't really tolerate the post-op protocol very well and following a re-repair, everything progresses more slowly. For a primary repair, I tell my patients it will be three months until they can expect unrestricted hand function. For a revision, it's double.
posted by karlos at 5:03 AM on April 17, 2013


Post-operative depression is indeed a very real thing. I had neck surgery about ten years ago, and while it was a fairly common procedure and my actual recovery timeline was right on track, I had a year of severe depression that came out of nowhere and rattled me hard. Everything in you wants to get back to normal, and right now - and sometimes that's just not possible. Add in the depression that almost inevitably comes with unemployment, and it's no wonder you're having trouble making this decision.

This is hard stuff you're going through, and you shouldn't talk down to yourself about it just because it's "just" a single joint on your pinky. Pain is hard; not functioning properly is hard; thinking things might now be different for ever is really hard. I can't say if you should get the surgery or not, but I will say you should talk to your doctor about the way you're feeling. Impress upon him *hard* that you're having emotional trouble adjusting to recovery and you need some help. It doesn't even have to be medication - I think just having someone tell me what I was going through was normal would have been a big help to me back then.

I thought my life was over, that I had nothing to look forward to, that everything was always going to hurt and be hard forever. Those thoughts had very little relationship to reality, but they felt real, and the emotions they sparked felt real. If you need help dealing with this in the short term, you owe it to yourself to get it. As much as pain and stiffness is, those kinds of thoughts and feelings are surgical side effects that can and should be treated.
posted by kythuen at 7:46 AM on April 17, 2013 [1 favorite]


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