Raleigh Hand to Shoulder Center in Raleigh, NC

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Numbness and Tingling Hands at Night? It could be Carpal Tunnel Syndrome

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What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) is the most common compression neuropathy in the upper extremity. It results from increased pressure on the median nerve at the wrist, within the carpal tunnel.  Symptoms such as numbness, tingling, weakness, and pain can result if the nerve is compressed or “pinched.”

The word “carpus” is derived from the Greek word karpos, which means “wrist.” The carpal tunnel is a passageway in the wrist through which the median nerve and tendons of the hand travel. The carpal tunnel is a narrow, confined space: the floor of the tunnel is made up by the carpal bones of the wrist, and the roof is created by the transverse carpal ligament. The median nerve is at risk for compression within this tunnel. If there is abnormal swelling, altered wrist anatomy, or injury to this area, the function of the median nerve may be affected. 

What causes carpal tunnel syndrome? 

In most cases, the cause of CTS is unknown. Thyroid disorders, rheumatoid arthritis, pregnancy, vitamin deficiencies, diabetes, fluid retention, and trauma can be associated with CTS. Women are more commonly affected than men. Repetitive, forceful gripping and heavy use of vibratory tools may increase a person’s risk of CTS.

How do I know if I have carpal tunnel syndrome?

Patients with CTS commonly report “numbness” or “tingling” in the fingers. Some patients feel that the fingertips are “asleep” or report “poor circulation” in the hands. Symptoms are often worse at night and people tend to shake their hands for relief. Some patients report increased symptoms while gripping a steering wheel.  Dropping objects, clumsiness with the hands, or a weak grip are also common complaints. Some people also report pain in the forearm, wrist or fingers. In severe cases, the muscles at the base of the thumb (thenar muscles) can become weak and atrophy, sometimes permanently. 

Often the diagnosis can be made on the basis of your symptoms, medical history, and physical examination. An electrodiagnostic study (nerve conduction study and/or electromyogram) can be ordered to confirm the diagnosis.

What are the treatment options?

Not everyone with carpal tunnel syndrome needs surgery. Fortunately, many people with CTS improve with non-operative treatment. Wearing a wrist brace at night supports the wrist in neutral alignment and takes pressure off the median nerve. Avoiding prolonged wrist flexion and forceful or repetitive gripping may also help. Corticosteroid injections provide an anti-inflammatory effect and can be effective in many patients. 

Should these measures fail to improve the condition, or if nerve compression is severe, surgery may be recommended. A carpal tunnel release (CTR) is performed to decrease pressure on the median nerve. During this procedure, the “roof” of the carpal tunnel (the transverse carpal ligament) is divided. Cutting the transverse carpal ligament increases the size of the carpal tunnel and provides more room for the median nerve. 

The length and type of incision varies among surgeons; however, the common goal is to reduce pressure on the median nerve. The length of incision used for CTR has decreased in size since the procedure was invented decades ago due to advancement in surgical techniques. Open CTR and endoscopic CTR are two surgical options. The recommended procedure will be discussed with you in the clinic. 

What is the recovery from surgery?

The surgery is performed as an outpatient under local anesthesia. Oral or intravenous sedation medication may also be used. Patients may use their hands for light activities soon after the surgery. Many people can return to light duty work in a few days. Patients should avoid heavy use of the hand for approximately 3-4 weeks after surgery. As the pain from surgery subsides, normal use of the hand is resumed.

What are the results from carpal tunnel surgery?

Most patients are very satisfied with their outcome after CTR surgery. Many patients report dramatic improvement in their symptoms in just a few days, but others may take longer. Some patients do not have complete relief of symptoms, especially in severe or long-standing cases. Temporary soreness or tenderness in the palm can occur. There is less than 5% recurrence rate after CTR surgery.

What are the complications from surgery?

Complications from carpal tunnel release surgery are uncommon. Possible complications include persistent symptoms, pain, bleeding, infection, stiffness, and damage to the median nerve. 

Dr Edwards III discusses Metacarpal Fractures at Conference

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Dr. George Edwards III discusses treatment of metacarpal fractures of the hand at WakeMed orthopedic hand conference on August 24, 2020. Diagnosis, non-operative treatment, modern surgical techniques, and rehabilitation programs are discussed.

Dr Erickson discusses Hand Tumors at Conference

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Dr John Erickson

Dr John Erickson gave hand conference at WakeMed Hospital for UNC orthopedic residents and hospital staff on August 10, 2020. He discussed Tumors of the Hand and Wrist and presented several illustrative cases. Local area hand surgeons, radiologists, occupational therapists, and Physicians Assistants were in attendance in-person and viewing online.

COVID-19 Prevention at Raleigh Hand to Shoulder

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At Raleigh Hand to Shoulder Center, we care about the well-being of our patients, staff, and community. We have been taking extra precautions against the Coronavirus during the COVID-19 pandemic. Here are some of the policies we have in place:

Raleigh Hand Center Physicians

Face masks are required for all patients, visitors, employees, therapists, and doctors in our office.

All employees, therapists, and physicians check their temperatures prior to arriving at work for the day and monitor themselves for COVID-19 symptoms. Our staff are required to stay home if they have any concerning symptoms or if they have a close contact with a patient with COVID-19. 

All patients, guests and visitors in our office are screened for fever, COVID-19 symptoms, or recent exposure to a person with COVID-19. Patients will be asked to reschedule if there are concerns for COVID-19 infection. 

We are limiting one guest to accompany a patient to their appointment.

We are enhancing our office cleaning procedures, and we are frequently disinfecting commonly touched surfaces. 

Hand hygiene is emphasized for all staff and physicians. Hand sanitizer is available in multiple areas of the practice including in each exam room, at the front lobby, and at the hand washing sinks throughout the office. 

Social distancing is practiced whenever possible during the examination and office visit.

We regularly review CDC guidelines and stay up-to-date with local and state COVID-19 cases to make the best decisions for our practice. 

We provide medically necessary treatment for patients with hand and upper extremity problems to reduce pain, increase function, and improve quality of life.

Can’t Straighten your Fingers? It could be Dupuytren’s Disease

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Dupuytren’s Contracture is a common condition affecting the hands. Patients with this condition develop nodules in the palms followed by fibrous cords extending into the fingers. In many patients, the cords gradually contract and cause the fingers to bend or flex. If left untreated, the fingers may remain permanently bent and impair hand function. Afterwards, the patient cannot straighten their fingers. Activities such as shaking hands, wearing gloves, and reaching into a pocket can be difficult. Fortunately, if treated in the early stages of contracture, the results are usually good to excellent and the results frequently last many years.

In mild forms of the disease, intervention is not always required. Once a finger contracts to the extent where the palm cannot be placed flat on a table top, it is usually time for treatment. Evaluation by a hand specialist is helpful to correctly make the diagnosis and to provide the patient with treatment options.

Dupuyrens contracture

There is no cure for Dupuytren’s disease. The goal of treatment is to remove or break up the contracted palmar cords to allow for improved finger range of motion and better hand function. Recurrence of the contracture is possible with any of the available treatments. There are 3 main techniques used by hand doctors today:

Surgical excision (Dupuytren’s fasciectomy): this surgery is performed by the hand doctor in the operating room under the care of an anesthesiologist. During surgery the diseased, contracted Dupuytren’s tissue is removed through incisions in the palm. Patients are treated with splinting, wound care, and hand therapy for a few weeks during the recovery process. Results from surgery can last a lifetime and typically the results last many years.

Needle aponeurotomy (also called “NA” or percutaneous fasciotomy): this less-invasive procedure is performed by the hand doctor in the office using the tip of a needle to perforate the Dupuytren’s cord using local anesthesia. Once the Dupuytren’s cords are weakened, the finger can be manipulated and straightened. Recurrence is common with this technique, but it is the least expensive option and has minimal downtime. The technique can be repeated for recurrent contractures in the future. Not all patients are good candidates for this procedure.

Collagenase enzyme (Xiaflex brand name): this medication is used to treat Dupuytren’s contracture and was FDA approved in the United States in 2010. Xiaflex is an enzyme which dissolves the collagen fibers in Dupuytren’s cords. The Xiaflex injection is performed by the hand doctor in the office, and later that week the patient returns for a manipulation procedure under local anesthesia. The surgeon then manually pops the cord once it has been weakened by the Xiaflex medication. Patients are instructed in home exercises and splinting by therapy, and there is minimal downtime required after the procedure. Recurrence is common with this technique, but it can be repeated for recurrent contractures. Not all patients are good candidates for this procedure

As with any medical procedure, there are possible complications from these treatments. Complications from Dupuytren’s surgery include infection, poor wound healing, bleeding, swelling, hand stiffness, and nerve/artery injury. Complications from needle aponeurotomy (NA) include skin tears, nerve injury, and infection. Complications from Xiaflex include flexor tendon rupture, allergic reactions, hand swelling, bruising, lymph node swelling, and skin tears.

Avocados are delicious but take care when cutting them

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Avocado related hand injuries are on the rise. Chefs and celebrities recently have been injured while attempting to cut the fruit, bringing increased attention to the risks involved. Most people accidentally cut their non-dominant hand which is holding the avocado. The knife can slip quickly through the soft flesh and into the hand which is holding the fruit. Nerve and tendon damage are common with this type of injury. This can result in several weeks or months of recovery after surgical repair of the lacerated structures.

In order to avoid a hand injury, cut the avocado only on a stable, flat surface. Do not cut towards your hand.

If you have a hand laceration, clean the wound in running water, place a clean bandage on the wound and hold pressure to stop bleeding. If the bleeding does not stop after 5-10 minutes of firm pressure on the wound, or if you have numbness in your hand or finger, or limited finger range of motion, seek medical attention promptly. 

https://www.cbsnews.com/news/avocado-hand-injuries-on-the-rise/

Face masks required in Raleigh and NC

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The Mayor of Raleigh has issued a requirement starting 6/19/2020 that all people in public wear a face covering. Since April, the Center for Disease Control has also recommended that all people should wear a face covering such as a mask, cloth, or homemade face covering when out in public. This is because it is possible to spread COVID-19 even if you do not feel sick. Wearing a mask reduces the chances that you will unintentionally spread the virus to someone. According to Raleigh Mayor Mary-Ann Baldwin, “The message I want to send is: You are not wearing a face mask for yourself, you’re wearing it to protect others,” Baldwin said.

Additionally, Governor Roy Cooper has also stated that face coverings must be worn in public places in North Carolina, effective 6/24/2020.

Raleigh Hand to Shoulder Center will continue to require face masks for doctors, therapists, staff, patients, and visitors in our office to reduce the COVID-19 risk for everyone in our practice.

Pictures of Mucous Cyst in Finger

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A mucous cyst is a fluid-filled sac that occurs on the finger joint closest to the nail. The fluid is clear, thick, sticky, similar to mucous. The cyst may thin the skin and may cause a groove to form in the nail. Most patients who develop a mucous cyst have wear and tear arthritis (osteoarthritis) of the involved joint. The cyst has a stalk that is connected to the joint. It is thought that underlying bone spurs from the arthritis weakens the joint lining allowing the cyst to form.

How is a mucous cyst diagnosed?

The mucous cyst typically has a characteristic appearance, and the diagnosis is straight-forward for most hand specialists. Radiographs are usually ordered to confirm underlying arthritis of the joint and associated bone spurs (also known as osteophytes).

Does the mucous cyst need to be treated?

Most mucous cysts are not painful. If they are not causing pain or hand dysfunction, they do not require treatment. In these cases, observation for changes in the cyst is all that is needed. Some cysts can go away on their own. If a patient develops pain, recurrent drainage, or nail deformity, surgery may be recommended. Even if not painful, diagnosis should be confirmed by a physician, as other diseases may mimic a mucous cyst or ganglion cyst. These cysts should not be drained at home with a needle because a serious infection in the joint can occur. See images below for examples:

Mucous Cyst with Nail Deformity
Mucous Cyst in finger with thinning of skin
Large Mucous Cyst
Osteophyte Bone Spur

Images from Dr John Erickson

Elective Surgery is Allowed in North Carolina

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COVID-19 Update: Effective May 1, 2020, North Carolina Governor Roy Cooper and NCDHHS Secretary Dr. Mandy Cohen have allowed elective and non-urgent procedures and surgeries to be performed in our state. Certain guidelines have to be followed including: an assessment of the medical necessity of the procedure, maintaining protective personal equipment, protecting the exposure of patients and staff, and screening for COVID-19 related symptoms. Our physicians will be resuming surgery as recommended by state guidelines.

We will continue to take precautions in our office by screening our patients and staff for COVID-19 symptoms, limiting visitors accompanying patients, asking patients and staff to wear a face covering, practice social distancing when possible, and disinfecting frequently touched surfaces. We are requiring all patients and visitors to wear a mask or face covering when in our office. We are also offering TELEMEDICINE for patients who do not wish to come in to the office.

COVID-19 symptoms include: fever, chills, shortness of breath, cough, difficulty breathing, muscle pain, sore throat, headache, new onset loss of taste or smell. Please notify your primary care physician if you are having any of these symptoms. Learn more at www.cdc.gov.

Nerve Repair in the Hand

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Nerves are fragile and can be injured in many ways — including compression, lacerations, or blunt trauma. Compression is caused by prolonged pressure on a nerve, such as in carpal tunnel syndrome. Nerve lacerations are caused by a sharp object such as a knife or broken glass. A cut nerve in the finger will make it feel constantly numb often with tingling and electric pain. A nerve can also be injured by a sudden blunt force or “contusion” such as the thumb being hit with a hammer.

Treatment of a nerve injury depends on the type of injury, timing of the injury, and specific nerve involved. Nerves which are contused due to blunt trauma will often recover function gradually on their own, if the nerve injury is not too severe.

Surgery is recommended for most cut nerves in the hand in order to improve function and decrease the chance for neuroma formation. Without surgery, the two ends of the nerve have difficulty joining together and the numbness can be permanent. A neuroma is a thickened end of a cut nerve which can be hypersensitive to touch.  Nerve repairs in the hand are common procedures performed by hand specialists.

During nerve repair surgery, the nerve ends are brought back together and the nerve sheath is repaired using fine sutures. This is known as a “primary repair.” Magnification improves the ability to see the nerve and its tiny internal bundles called fascicles. Injured tendons are also repaired if needed. This surgery is ideally performed within a few days of the injury. 

If there has been a delay in treatment or if the nerve has been injured over a wide area, it may not be possible to bring the ends of the nerve back together. In this case a “nerve graft” can be used for nerve reconstruction to bridge the gap. There are many available sources for nerve graft reconstruction.  The three most common ways to bridge the gap are:

  1. Autografts: An autograft is a nerve graft obtained from the same patient’s body using another skin incision. Some numbness can be expected from the donor site, depending on the location of the graft.
  2. Allografts: An allograft is a nerve obtained from a person who has donated their body tissues. The grafts are cleaned and prepared carefully for this purpose. There is a very small risk of both disease transmission and graft rejection with use of allografts, but they do not require a second incision on the patient. These are commonly used today.
  3. Synthetic tubes: Synthetic hollow tubes are designed to guide the reconnection of nerve gaps. They do not require nerve harvesting from the patient but there is a small risk of graft rejection with any manufactured material.

Nerve repair surgery is not a “quick fix.” Recovery of the nerve is slow and can take 6-12 months for the feeling to come back. Recovery time varies among patients, depending on the severity of the injury, patient age, possible complications, and medical history of the patient. Not all patients regain full function after a nerve repair or reconstruction.

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