16. October 2015 · Comments Off on Trigger Finger · Categories: Finger Injuries

Trigger finger , the more common name for stenosing tenosynovitis, is a rather annoying hand condition in which a finger “locks” in a flexed position and becomes very difficult to bend or straighten.

This condition usually occurs when the pulley thickens at the base of the finger thereby narrowing the canal thorough which the flexor tendons glide. The resistance to gliding causes pain as well as a feeling of popping or catching. The repetitive catching of the tendon causes irritation of the flexor tendons and swelling of the pulley.

Etiology

The cause of trigger finger is often unclear. The condition is sometimes associated with rheumatoid arthritis, gout or diabetes. Often, the first sign is discomfort or tenderness in the region opposite the knuckle at the base of the digit. Later, a nodule may form in this area.

Diagnosis

Diagnosis in rather straight forward without the need for elaborate test. It is based on a simple physical examination of the fingers. The patient will open and close the hand while checking for pain and observing for unrestricted motion.

Treatment

Treatment focuses on alleviating the triggering and achieving painful and unrestricted range of motion. A decrease in swelling will facilitate gliding of the tendons. Oral anti-inflammatory drugs, splintage and/or modifying activities that exacerbate the condition provide conservative measures. In other cases, steroid injection in the region of the pulley may decrease the swelling and alleviate symptoms. As a last resort, surgery is performed in which the A1 pulley in the finger, opposite the knuckle, is released allowing unrestricted motion of the tendons. Relief often occurs immediately after the procedure.

12. October 2015 · Comments Off on Capal Tunnel Syndrome (CTS) 101 · Categories: Uncategorized

Introduction

Carpal Tunnel Syndrome (CTS) is one of the most common hand afflictions. It is also a diagnosis that is often incorrectly termed for patients presenting with a variety of very different signs and symptoms. To dispel some of the misconceptions about Carpal Tunnel Syndrome, this article will address CTS from the perspective of Chicago hand surgeon Dr. Norman Weinzweig taking into account the confusion that often exists about this condition.

What is Carpal Tunnel Syndrome

Carpal Tunnel Syndrome is a condition that results from a “pinched nerve” in the wrist. This nerve, better known as the median nerve, is surrounded by nine (9) tendons as it travels from the forearm into the wrist through a canal hooded by the transverse carpal ligament. Constriction of the canal by a thickened transverse carpal ligament or swelling within the canal compresses the median nerve causing pain, numbness and tingling of the hand and digits.

Symptoms of Carpal Tunnel Syndrome

These symptoms usually affect the thumb, index, middle and radial half of the ring finger (side closest to the thumb). However, any or all of these digits may be involved since the median nerve supplies all of them with sensation. Different parts of the median nerve can be compressed and to different degrees, however, the most common and classic presentation involves most, if not all, of these digits.

Symptoms of CTS may vary but general invole pain, tingling or numbness or some combination of all three. The thumb, index, middle and radial half of the ring finger are most commonly involved. Often, the patient relates how he or she wakes up several times during the night with these symptoms. Patients often drop things due to diminished grip strength.  Symptoms may occur during driving or hold a newspaper due to the flexed position of the wrist.

Involvement of the Ulnar Nerve in Carpal Tunnel Syndrome

Often, similar symptoms are seen in the ulnar half of the ring finger (closest to the little finger) and the little finger. This is not due to Carpal Tunnel Syndrome but rather compression of the ulnar nerve in Guyon’s Canal at the level of the wrist. Often, the two (2) conditions coexist as the median and ulnar nerves are in close anatomic proximity at the level of the wrist. In approximately 75% of cases, carpal tunnel release will also relieve the ulnar nerve symptoms. Nonetheless, if all digits demonstrate pain, numbness and tingling, the ulnar nerve should be released or decompressed at the same time that carpal tunnel release is performed.

Causes of Carpal Tunnel Syndrome

There is no one cause for Carpal Tunnel Syndrome. There are a variety of activities that have been associated with CTS, some of them repetitive in nature (though there is significant controversy in the literature) as well as several medical conditions such as diabetes, thyroid disease and arthritis that can be associated with CTS. Even pregnancy has been associated with CTS due to increased water retention with the symptomatology often spontaneously resolving after pregnancy.

Diagnosing Carpal Tunnel Syndrome

Dr. Norman Weinzweig looks at a detailed history before making the diagnosis. This should include past injuries, daily activities at home and at the workplace, and history of diabetes, throid disease or arthritis. Physical examination will entail evlaluation of fingertip sensation, grip strength, testing for Phalen’s sign (manifestation of symptoms with flexion at the wrist) and Tinel’s sign (radiation of symptoms with tapping of the median nerve at the level of the wrist). X-rays should be done to evaluate for arthritis or fractures. Other more proximal entrapment neuropathies such as Pronator Syndrome (compression of the median nerve more proximally in the forearm) or Cervical Radiculopathy (often due to injury of the nerve at the level of the neck such as after an automobile accident) should be ruled out. Lastly, the diagnosis should be corroborated by using Electrodiagnostic Studies such as Nerve conduction velocity and electromyogram.

Carpal Tunnel Syndrome Treatment Options

Surgery is not always indicated to treat symptoms. Often, treat,ment may be as simple as using a wrist splint or avoiding activities that aggravate symptoms, such as repetitive motion. Non-steroidal anti-inflammatory agents may also reduce swelling and reduce symptoms. Steroids may be injected into the carpal tunnel to reduce swelling and thereby eliminate symptoms. When this works, it is usually prognostic of a favorable outcome following surgery. Lastly, surgery may be required if these non-surgical methods don’t relieve symptoms. The goal of surgery is to relieve nerve pressure by cutiing the constricting transverse carpal ligament. It must be completely cut or symptoms may not be relieved. Symptoms may be relieved immediately or in progressive fashion over several weks. Restoration of hand strength may take several months. In severe cases, this recovery may be limited dure to irreversible injury to the nerve and/or the tiny intrinsic muscle that are innervated by the nerve. Usually, symptoms are improved, often times, dramatically.

While Carpal Tunnel Release is a very commonly performed procedure, it must be done very carefully to avoid possible injury to the median nerve. Postoperative rehabilitation is also very important. At the CHICAGO INSTITUTE FOR HAND SURGERY, Dr. Norman Weinzweig has performed hundreds of these procedures. Certified hand therapist or occupational therapist assist with the postoperative rehabilitation to get the patient back to normal activities and the workplace as soon as possible.

28. September 2015 · Comments Off on The Mutilated Hand: Tic-Tac-Toe, a Sophisticated Game of Chess or Both? · Categories: Severe Hand Injuries

Interestingly, classification of mutilating injuries of the hand can be as simple as Tic-Tac-Toe. In fact, more than a decade ago, Drs. Norman and Jeffrey Weinzweig designed a classification scheme to simplify the description of these complex injuries, allowing a more direct approach to communicating the nature of these injuries from one surgeon to another. This classification is based upon the pattern of involvement of the bones, involvement of soft tissue, bones or both, and vascular integrity.

However, while this classification scheme facilitates the description of the injury, management is far more complex, both in acute and chronic settings. Initially, the goal is to maximize the survivability of the digits. These can be tedious and lengthy operative procedures requiring microsurgical expertise. Often, 6 or 8 sutures are placed around the circumference of a vessel no larger than the tip of a pencil or less than 1mm in diameter. Surgical precision and flawless technique is mandatory to maximize the probability of survival of the digit. Frequently, intraoperative decisions have to be made to optimally utilize the viable tissues. Fractures are reduced and fixed, tendons and nerves are repaired and hopefully, blood perfusion is restored. This is the “opening game”, as in chess. Dr. Norman Weinzweig has extensive experience in the management of these injuries throughout his career.

Following successful replantation or revascularization, the “middle game” begins. This consists of careful monitoring of the digit, various procedures to restore early function and satisfactory appearance and occupational therapy to optimize function of the surviving digit. A normal appearing digit without useful function fails to achieve the maximal benefit of the surgery. Often, there are setbacks in the “middle game” and while there may be a normal appearing digit, it may be stiff, painful and unable to function appropriately.

This brings us to the “end game”, where the hand surgeon’s experience is often limited. At The Chicago Institute for Hand Surgery, Dr. Weinzweig has patients referred to him from all over the country, These patients have limited function and require surgery, intense occupational therapy, the Continuous Passive Motion Machine and gentle intraoperative manipulations of the joints under anesthesia to optimize the long-term functional outcome. The occupational therapists at The Chicago Institute for Hand Surgery are uniquely trained to care for these patients. Furthermore, close supervision under Dr. Norman Weinzweig optimizes the eventual functional outcome.

28. September 2015 · Comments Off on Management of the Patients with Stiff Digits and Developing Contractures · Categories: Stiff Hand

At The Chicago Institute for Hand Surgery, Dr. Norman Weinzweig often treats patients presenting with stiff and functionless digits and developing or fixed developed contractures as a result of devastating work injuries. These patients are injured while operating machinery, power tools, or agricultural machines. These patients have usually had their initial surgery performed elsewhere and have a poor functional outcome. This in relatively commonplace considering the devastating nature of these injuries. However, few hand surgeons have the necessary experience in taking a functionless hand and making it functional.

A significant portion of Dr. Norman Weinzweig’s hand surgery practice is specifically dedicated to the care of the “stiff hand”. Following extensive evaluation, Dr. Weinzweig will proceed with a combination of various procedures to lyse or remove the scar tissue preventing motion of these digits. This will entail extensor and flexor tenolyses, joint capslotomies for adhesive capsulitis of the joints also called “arthrofibrosis”, and intrinsic releases. Often, all these procedures are performed in multiple digits with outstanding clinical results. The “stiff hand” is converted into a useful hand requiring rigorous occupational therapy, use of the Continuous Passive Motion (CPM) Machine and occasionally intraoperative manipulations under anesthesia.

The occupational therapists at The Chicago Institute for Hand Surgery are extremely well trained in the management of these debilitating problems. They work with the patients almost immediately postoperatively to obtain the optimal functional result.

 

28. September 2015 · Comments Off on Fireworks Injuries of the Hand · Categories: Severe Hand Injuries

Fireworks injuries of the hand commonly occur not only on July 4th but throughout the year. These injuries range from soft tissue injuries often with loss of skin and subcutaneous tissue to disruption of the flexor and extensor tendons to fractures with or without bone loss to mutilating injuries of the hand with need for possible revascularization or replantation. In the more severe cases, replantation and revascularization are not even feasible due to tremendous destruction to the soft tissues and bone with amputation being the only option.

As with other injuries, prevention is key. Safety in the use of fireworks is of the upmost importance. Even among fireworks professionals, these injuries occur.

In dealing with fireworks injuries, it is important to assess the extent of damage to the body in addition to the hand. While the hands are most frequently involved by the very nature of the injury mechanism, other parts of the body such as the face, torso and legs may be involved. Some of these injuries resemble burns and may be treated as such.

After the accident, the hand surgeon carefully evaluates the injured hand and proceeds to salvage as much viable tissue as possible. It is important to consider not only the injury but the different steps in future reconstruction and the rehabilitative process. In the more severe and extensive injuries, patients often require multiple staged procedures in hope of regaining as much useful function as possible. Often, the patient is stabilized in the Emergency Department and surgery is performed to salvage as much soft tissue and bone as possible. At this time, it is critical that the patient seek out a hand surgeon experienced in dealing with these complex injuries. Few hand surgeons have this type of experience.

An occupational therapist has several modalities to work with the patient having a painful fingertip. The hand surgeon also has various options to restore useful function to the injured finger. While seemingly minor, compared to more extensive injuries involving multiple structures, they still require appropriate care from an experienced hand surgeon.

At The Chicago Institute for Hand Surgery & Rehabilitation, Dr. Norman Weinzweig has treated hundreds of similar injuries with excellent clinical and aesthetic results, allowing patients to get back to the workplace or to their recreational activities as soon as possible.

 

28. September 2015 · Comments Off on Comprehensive Management of the Worker’s Compensation Patient · Categories: Workers Compensation

Challenges of Workers Compensation Patients for Reconstructive Hand Surgeons

The Worker’s Compensation patient presents a unique challenge to the reconstructive hand surgeon. Management of this specific type of patient entails a comprehensive team approach. First, the hand surgeon must be tremendously experienced in the care of complex traumatic hand injuries, often of a mutilating nature, requiring replantation and revascularization be it of the thumb, fingers, hand or even upper arm. Following optimal surgery, the functional result is dependent upon factors beyond the surgery. The very best surgery will not compensate for limited postoperative care. It is critical that the patient come under the care of the occupational therapist. This is usually a Certified Hand Therapist (CHT) who has specific training in care of these complex injuries. Compliance with a rigorous hand therapy protocol is critical to obtaining the optimal functional result. Achieving the very best functional result will hopefully allow the patient the opportunity to get back to his former occupation and/or avocation. Additionally, clear and continual communication with the nurse case manager, rehabilitation nurse, employer and insurance company facilitates this patient’s follow-up care.

Workers Compensation Patients at the Chicago Institute for Hand Surgery & Rehabilitation

At The Chicago Institute for Hand Surgery & Rehabilitation, Dr. Norman Weinzweig coordinated the care of Worker’s Compensation patients, ranging from those with relatively minor injuries, such as crush injuries to the fingertips, to multiple digit replantations and revascularizations as well as care of the mutilated hand. In fact, Dr. Weinzweig co-edited the text THE MUTILATED HAND which deals specifically with management of complex industrial type injuries. While Dr. Norman Weinzweig covers the entire gamut of hand problems, both non-surgical and surgical, his specific niche within the realm of hand surgery is care of the mutilated hand.

Dr. Weinzweig has treated thousands of patients over the past 27 years with a wide range of traumatic injuries, both in the acute traumatic setting as well as in the delayed setting. Patients are referred to Dr. Norman Weinzweig from other hand surgeons in Chicago, the Midwest, other parts of the country and even internationally. Dr. Weinzweig often treats patients for sequelae and complications of these injuries, often with excellent results. Patients will present with stiff, functionless hands and within months are using their hand for the activities of daily living and at the workplace.

 

25. September 2015 · Comments Off on Secondary Reconstruction of the Severely Injured Hand · Categories: Severe Hand Injuries

Hand injuries are commonly seen in the Emergency Department. These injuries range from simple lacerations to complex wounds involving multiple structures such as skin, tendons, nerves, and bone. In severely injured hand cases, digits or even the entire hand may be incompletely or completely amputated or badly crushed to the point where replantation or revascularization isn’t even feasible.

When these patients initially present, their care may be relegated to a physician inexperienced in the care of the severely injured hand, especially the more complex ones. Even when the initial care is provided by an experienced hand surgeon, there are often sequela and complications that can only be appropriately addressed by the most experienced of hand surgeons.

Often, secondary reconstruction is mandatory in order to achieve a functional hand. The hand surgeon may need to perform tenolyses or breaking up of the dense scar adhesions between the tendon. This can involve the flexor or extensor tendons or both. Occasionally, the scarring is so severe that the tendons cannot adequately be lysed to provide useful motion and a staged flexor tendon reconstruction needs to be performed. Dr. Norman Weinzweig frequently performs the two-stage procedure for these cases. In the first stage, all densely scarred tendon is completely excised and a silastic Hunter rod is placed. Pulleys can be reconstructed at this time around the silastic rod. During this time, the patient undergoes occupation therapy to maintain excellent passive range of motion. At 3 months, the rod is removed and a tendon graft is threaded through the newly formed tendon sheath. The new tendon sheath forms as a reaction to the rod, which acts as a foreign body. The donor tendon can be the palmaris longus or other tendon. Patient then undergoes a specific protocol to facilitate passive, and later, active range of motion.

If there is sufficient stiffness prior to the tendon grafting, this must first be addressed to maximize passive range of motion. This may entail joint capsulotomies or capsulectomies for arthrofibrosis of the respective joints. Occasionally, tendon transfers are performed where tendons have been injured or even destroyed.

In many cases, there has been severe injury to the nerves. This can result in permanent loss of sensation or motor function. Usually, there is little sensory recovery in adults following nerve injuries and limited recovery of motor function. For example, following laceration of a digital nerve in an adult, there is rarely, if ever, recovery of sensation beyond protective sensation. In some case, simple neurolysis of the nerve will dramatically improve motor or sensory function. This happens when the nerve is intact but scar tissue envelopes the nerve. In more sever cases of injury to major peripheral nerves, such as the median, or ulnar nerves, tendon transfers must be performed to restore useful function.

A severely injured  or mutilated hand may require a number of surgical procedures to restore useful function. This may entail procedures such as thumb reconstruction or even great toe or second toe-to-thumb transfers. In cases of extensive soft tissue loss or scarring, various soft tissue procedure smay need to be performed. These procedures include contracture releases, such as by four-flap Z-plasty, full-thickness skin grafting or even local and distant flap reconstruction, tenolyses or tendon reconstruction, neurolyses, tendon transfers, and bony reconstruction.

At The Chicago Institute for Hand Surgery & Rehabilitation, Dr. Weinzweig and his staff regularly evaluate and treat the entire gamut of hand surgery patients. Furthermore, Dr. Weinzweig’s specialty within the field of hand surgery is the care of complex hand injuries entailing knowledge and use of all these procedure to obtain the optimal functional outcome. Dr. Norman Weinzweig co-edited the textbook entitled THE MUTILATED HAND which specifically addresses these complex issues.

 

25. September 2015 · Comments Off on Crush Injuries to the Fingertip · Categories: Finger Injuries

About Crush Injuries to the Fingertip

While crush injuries to the fingertip are very common and often appear insignificant, they can cause serious disability to the patient if inappropriately or inadequately treated. These injuries occur when someone accidentally has a door slammed on his or her finger, their finger gets caught in a car door, something heavy falls on the finger, or the fingertips are accidentally caught in a snow blower or lawnmower. Often, these fingertips can be very painful prohibiting useful function not only of the finger but of the entire hand. Inadequate padding over the bony distal phalanx can result in a very painful fingertip. Neuromas, composed of bundles of nerve tissue, can form at the ends of the injured nerves causing sever pain and disability. Additionally, inappropriate care of the nail bed structures can result in nail growth abnormalities, hangnail or an exquisitely painful fingertip.

Treatment for Crush Injuries to the Fingertip

There are various non-surgical and surgical procedures that can be performed to minimize the disability following crush injuries to the fingertip, allowing patients to return to work much soon. Furthermore, the non-injured hand is cared for during this time to prevent problems with stiffness from disuse.

The occupational therapist has several modalities to work with the patient having a painful fingertip. The hand surgeon also has various options to restore useful function to the injured finger. While seemingly minor, compared to more extensive injuries involving multiple structures, they still require appropriate care from an experienced hand surgeon.

At The Chicago Institute for Hand Surgery & Rehabilitation, Dr. Norman Weinzweig has treated hundreds of similar injuries with excellent clinical and aesthetic results, allowing patients to get back to the workplace or to their recreational activities as soon as possible.