The doctors at Raleigh Hand to Shoulder Center have received 2 doses of the COVID-19 vaccine. Vaccines for employees in the office are underway. We will continue mask wearing and hygiene protocols — we are doing our part to slow the spread of the coronavirus.
A ganglion cyst is a very common bump in the hand and wrist. These cysts usually arise near a joint or tendon in the hand and wrist. The most common location is the back of the wrist (see image below). They can occur in people of all ages and are common in young adults. The cause of a ganglion cyst is unknown in most cases. One theory is that the cyst arises from joint fluid which has leaked from a small opening in the joint capsule. The cyst is filled with a thick, jelly-like fluid and usually has a connection with a joint or tendon below. Many patients report that the cyst fluctuates in size, and in some cases the cyst can go away on its own.
Most ganglion cysts are diagnosed by history and physical exam by a trained physician. Since ganglion cysts are fluid-filled, a light shined directly on the mass will illuminate the cyst. X-ray, ultrasound, and MRI testing are not usually required to make the diagnosis in typical cases.
What are the treatment options? There are three common treatments for a ganglion cyst in the wrist:
OBSERVATION: Also known as watch and wait. Since ganglion cysts are benign (not cancer), surgery is not required to remove them. Cysts which are not painful and do not interfere with function can be left alone and monitored. Some cysts can go away on their own. If the cyst becomes larger, painful, or interferes with function, further options should be discussed.
ASPIRATION: Also known as drainage with a needle. The cyst can be punctured and the thick fluid removed using a needle under sterile conditions. This is a quick procedure which is performed in the office. There is a high chance that the cyst comes back, however. There is a small risk of bleeding, pain, and infection from this procedure. Do NOT try this at home!
SURGICAL EXCISION: Excision of a ganglion cyst is performed in the operating room and requires an incision. During surgery, the cyst is removed including the base which goes down to the joint below. Removal of the connection to the joint reduces the chance of recurrence. Gardeners realize that the roots of the weed need to be removed, or else it will grow back.
In the past, some physicians have recommended simply popping the cysts by hitting them with a heavy book or Bible. For this reason ganglion cysts have been called “Bible cysts.” This is not recommended since damage can be done to the surrounding area and most cysts recur with this technique.
What is the recovery from ganglion cyst excision surgery? Ganglion cyst excision is performed on an outpatient basis. Most people can return to light duty work in a few days as the pain and swelling subside. Hand therapy is sometimes helpful after this procedure to improve range of motion and strength. Patients should avoid forceful use of the hand for approximately 4 weeks after surgery. Normal use of the hand is resumed as comfort allows. Complications from surgery include cyst recurrence (5-10%), wrist stiffness, scar tissue, and infection.
The ganglion cyst images are copyright Dr John Erickson and the cyst aspiration drawing is copyright AAOS OrthoInfo. The video is courtesy of American Society for Surgery of the Hand.
Boxer’s fractures are very common hand injuries. The typical cause is punching a wall with a clenched fist. These injuries are most common in young adult males. They can also occur from a variety of ways such as a fall, sports injury, or car accident. A “boxer’s fracture” is defined as a fracture of the 5th metacarpal neck. “Fracture” is simply the medical term for “broken bone.”
There are five metacarpals — one for each finger and the thumb. The 5th metacarpal is at the base of the pinkie. Bruising, swelling, pain, and finger stiffness are common symptoms at first. The knuckle may look abnormal or out of place as well.
The recommended treatment of this injury depends on the alignment of the fracture as noted on the x-rays and the patient’s medical condition and activity level. Most patients have boxer’s fractures which have mild to moderate angulation and, therefore, do not require surgery. Angulation is measured in degrees and this defines how “crooked” the bone is. A firm “bump” is often noticed at the fracture site during healing. This is composed of new bone formation, the body’s normal response to heal the fractured bone. This can be seen on x-ray and is called the “fracture callus.”
Mild to moderate angulation in a boxer’s fracture typically results in a good long term outcome. Our hands can naturally compensate for this deformity and still function very well due to the motion at the base of the 5th metacarpal. This is because the joint at the base of the 5th metacarpal has a high degree of mobility. Treatment in these cases is typically rest and protection in a splint or cast for 4-6 weeks. Ice, compression, elevation and oral NSAIDs are helpful to reduce hand swelling. Follow-up x-rays are obtained in clinic to evaluate how the fracture is healing, and therapy is often helpful to improve finger range of motion and hand strength.
If the fracture angulation is excessive, or the metacarpal alignment is poor, the bone can be re-aligned with manipulation. This procedure is called a “closed reduction” and is performed in the office with local anesthesia numbing medicine. These patients can be treated without surgery and achieve a good result.
Occasionally, surgery is recommended to fix the fracture with metal implants such as pins, screws, or a plate. Surgery is most beneficial if there is significant angulation or if the finger is mal-rotated (twisted). Surgery has the potential complications of infection, stiffness, scar tissue formation, and need for removal of the metal implants.
Your doctor will explain the options to you and recommend individual treatment based on your specific type of injury.
Capital City Surgery Center (CCSC) was recently named the #1 Ambulatory Surgery Center in North Carolina! The Raleigh Hand to Shoulder Center physicians use CCSC for the majority of their outpatient surgeries and they are pleased with the national and state recognition. The doctors have financial interest in the surgical facility. Read the article here.
At Raleigh Hand to Shoulder Center, we care about the health of our patients, staff, and community. We have implemented several strategies to reduce the risk of COVID-19 in our office:
Patients, visitors, and staff must wear a mask or face covering while in our office at all times. A mask can be provided to a patient who does not have one. The mask must fully cover the nose and mouth.
We request that only one visitor accompany the patient to the office visit to reduce the number of people in the building.
Patients are screening for signs and symptoms of COVID-19. Temperature checks at the office front desk are required. Patients will be asked to reschedule if they have had a recent exposure to a known COVID positive individual or if they are experiencing signs or symptoms of possible COVID infection.
Everyone is encouraged to use hand sanitizers, which are located in exam rooms and accessible in several locations within the office.
Exam room tables are wiped with disinfectant between patients by our office staff.
Commonly touched surfaces in the office are wiped with disinfectant regularly.
HEPA air filters have been installed in several locations within our office.
Clear barrier shields are available for use in the therapy department to minimize transmission of respiratory droplets.
Social distancing guidelines are followed whenever possible. Physical examinations of the patient will be performed as appropriate for diagnosis and treatment.
Employees are required to stay home if they have signs or symptoms of infection or if they have an elevated temperature.
Telemedicine is available for patients who are not able to have an in-person visit.
We review the CDC and NC Department of Health guidelines for recommendations. We routinely monitor local and state COVID-19 case counts.
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. 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 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.
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.
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.
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.