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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 (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): 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 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.

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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/

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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.

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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

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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.

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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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SLAC Wrist Arthritis Treatment in Raleigh

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SLAC wrist is a type of wrist arthritis. SLAC stands for “Scapho-Lunate Advanced Collapse.” This occurs when the bones of the wrist abnormally wear down the cartilage surfaces, causing osteoarthritis. SLAC wrist can occur after injury to the ligaments which stabilize the wrist bones, most commonly the scapholunate ligament. Many patients had an injury which they thought was “just a sprain.” Some patients cannot remember a specific injury, since it may have occurred many years ago.

Patients with SLAC wrist notice limited range of motion, grip weakness, wrist pain, and swelling. It may be harder to use hand tools and lift heavy objects. Clicking and popping in the wrist may also occur.

Treatment options are aimed at reducing pain. Using a wrist brace during activity can reduce pain. Taking oral anti-inflammatory medications such as ibuprofen and oral Tylenol can reduce pain. Topical anti-inflammatory creams or using heat or ice can also help. Avoiding heavy use of the hand can reduce symptoms. Nutritional supplements such as turmeric and glucosamine/chondroitin sulfate may help.

Corticosteroid injections (cortisone shots) can reduce pain and inflammation in many patients, and are safe if used sparingly. Hand therapy and physical therapy does not seem to help very much.

If the pain is not well controlled and the patient cannot tolerate the symptoms, surgery may be recommended. There are several surgical options available, each with risks and benefits. The type of surgery recommended is often based on the pattern of arthritis seen on the x-rays and specific patient factors.

SLAC wrist arthritis
  • Partial wrist denervation: This surgery is designed to reduce wrist pain by removing nerves in the wrist which supply pain signals to the brain. Only selected nerves which transmit pain are cut. The nerves which provide feeling to the fingers and the nerves which control muscle movement of the hand are protected. This procedure has a quick recovery, low complication rate, but it may not fully relieve pain in some patients.
  • Proximal row carpectomy: This surgery is designed to reduce pain by removing the arthritic bones in the wrist, specifically the scaphoid, lunate, and triquetrum bones. Occasionally the tip of the radius bone is also removed if needed. This surgery allows the remaining non-arthritic bones to serve as the new wrist joint. The surgery can take 4-6 weeks to heal and not every patient gets full pain relief. About 50% of wrist motion can be maintained afterwards. In some patients this surgery can wear out and require a total wrist fusion in the future.
  • Partial wrist fusion: This surgery reduces pain by fusing together specific arthritic bones in the wrist. Often the scaphoid bone is removed during this surgery as well. Screws, staples, or a plate are options used to fix the bones, which require several weeks to heal in a cast. Smokers are at higher risk of healing complications with this procedure. About 50% of wrist motion can be maintained. In some patients, this surgery can wear out and require a total wrist fusion in the future.
  • Total wrist fusion: This surgery is the most effective at reducing wrist pain but all wrist motion is eliminated. Because the major wrist bones are fused together, the wrist does not move anymore. A plate and screws are typically used to fix the bones. As in other fusion surgeries, smokers are at higher risk of healing problems. Revision surgery in the future is not common after this procedure.
  • Wrist joint replacement (total wrist arthroplasty): This surgery replaces the arthritic joint with an artificial implant, similar to a knee replacement. This surgery is the least common option in our practice, as there are very few patients who are good candidates for this option. There is a high complication rate, such as implant loosening, breakage, infection, and revision surgery.

Your surgeon at Raleigh Hand to Shoulder Center will discuss the options which are best for your particular condition.

Article by Dr. John Erickson

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Please wear face mask when in public

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UPDATED 4/15/2020: The CDC has recently updated their recommendations about wearing face masks. There is now a recommendation that healthy 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. Medical-grade masks do not need to be used by the public.

Our office now requires that patients and their guest cover their faces when in our facility. Please bring a mask or face covering from home.

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COVID-19 in Raleigh, North Carolina, Update on 4/15/2020

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COVID-19 Update on 4/15/2020: Our office remains OPEN during the COVID-19 outbreak in Raleigh, NC. Medical practices are considered “essential” in North Carolina. Elective surgeries have been canceled, but urgent or emergent surgeries can be performed safely. For patients who do not wish to visit the office, Telemedicine or “Virtual Visits” are available. If you have a smart phone or home computer, this service can be used from the comfort of your home. Please call our office to learn more.

The Raleigh Hand to Shoulder Center physicians and staff are concerned about the spread of Coronavirus, COVID-19 disease. We are following recommendations by the Center for Disease Control and Prevention by frequently washing our hands with soap and warm water, using hand sanitizer, wiping down frequently touched surfaces, using face masks, and maintaining 6 feet distance between others when possible. We are screening patients on the phone and at the check-in area for symptoms and fevers. Our office staff are wearing face coverings and we request that patients and their guest also cover their faces with a mask or scarf, based on new CDC guidelines.

We are asking patients to reschedule their appointment if they are having fever, cough, shortness of breath or other flu-like symptoms, or if they have been in close contact with someone suspected of having Coronavirus. Our physicians and staff are monitoring themselves for symptoms and will stay home if they are showing concerning symptoms. We are asking patients to bring only one other person with them to their appointment to limit the potential spread of the virus.

We are all doing our best to keep the community safe and healthy while taking care of patients with hand, wrist, elbow and shoulder problems.

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What is elective surgery?

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Updated 3/26/2020: Governor Roy Cooper has declared a state of emergency in North Carolina due to the spread of the novel Coronavirus, COVID-19 illness. Additionally, he has suspended all “elective” surgery in the state in hospitals and surgery centers. Just what is an elective surgery? The Department of Health and Human Services in North Carolina has defined this as any surgery which if not done within 4 weeks would cause harm to the patient. At this time only surgery that is time-sensitive and needs to be done within 4 weeks will be allowed in North Carolina. 

Many surgeries in orthopedics are urgent or non-elective. These surgeries ideally should be done sooner rather than later in order to achieve the best outcome. Delay of a few weeks can result in a worse outcome. Examples of urgent procedures in hand surgery include: fracture repair, tendon repair, nerve repair, drainage of infections, stabilization of dislocated joints, ligament repair, treatment of burns, among others. If you have an injury, please seek prompt evaluation. Your doctor will decide which treatment is best, and surgery can be performed if this procedure is considered urgent.

For most patients, Raleigh Hand to Shoulder Center doctors can perform surgery at an ambulatory surgery center as an outpatient outside the hospitals. 

Urgent Conditions in the hand and arm:

  • Fractures
  • Tendon injuries
  • Nerve damage
  • Infections
  • Joint dislocations 
  • Skin lacerations
  • Ligament injuries
  • Burns
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