Saturday, May 21, 2011

articles references links

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ARTICLES, REFERENCES AND LINKS

This list includes articles that address  certain patient questions as well new and current issues that may arise in the context of patient care.
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2010 Article discussing  Collagenase (Xiaflex)  and Needle Aponeurotomy for Dupuyten's Disease
MANAGEMENT OF FRACTURE DISLOCATION OF THE PROXIMAL INTERPHALANGEAL JOINTS BY EXTENSION BLOCK SPLINTING
WORK RELATED CARPAL TUNNEL IN MASSACHUSETTS fact sheet
HAND SURGERY AND PREVIOUS MASTECTOMY
DUPUYTREN's DISEASE
ENDOSCOPIC SINGLE PORTAL CARPAL TUNNEL SURGERY in WIKIPEDIA
CARPAL TUNNEL RELEASE VS. SPLINTING
CARPAL TUNNEL RELEASE QUESTIONS AND ANSWERS FROM WWLP WEBSITE
SINDROME DEL TUNEL  CARPIANO
CARPAL TUNNEL ENDOSCOPIC or "small incision" FAQ
Single-Portal Endoscopic Carpal Tunnel Release Compared with Open Release
LATERAL EPICONDYLITIS or TENNIS ELBOW
FOSAMAX AND CARPAL TUNNEL SYNDROME
EMERGENCY ROOM  NATIONAL  STATISTICS FOR UPPER EXTREMITY INJURY
ARIMIDEX, JOINT PAIN ( arthralgia) and TENDINITIS
Prevalence of JOINT SYMPTOMS WITH ARIMIDEX
WIKIPEDIA: ENDOSCOPIC CARPAL TUNNEL RELEASE
CARPAL BOSS
JBJS hand search
JBJS hand and wrist collection

American Society for Surgery of the HAND (ASSH )

SNOWBLOWER INJURY
Power saw Safety TIPS
THE HAND STORE
PREVENT HAND INJURY
AAOS The American Academy of Orthopedic Surgery

ORTHOGATE  Orthogate is an Orthopedic web portal that enables internet searches on any orthopedic topic

CONGENITAL LIMB DIFFERENCES  Limb Differences.org  is a web site for children and families with congenital limb differences.Information and support groups dealing with amputation, finger and hand abnormalities, fused fingers, absent fingers and hands, radial club hand, thumb pollicization and other topics.  Lower extremity problems of the leg, and foot are also discussed

HAND ANATOMY  An electronic listing of hand anatomy  from e-hand

 
CARPAL TUNNEL AND ENDOSCOPIC CARPAL TUNNEL
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Patient Questions and their Answers from a Hand Surgeons Perspective
Carpal Tunnel Surgery: Patient Questions and their Answers from a Hand Surgeons Perspective
Carpal Tunnel Surgery is one of the most common operations done today.  Of course there are many questions that arise. While a lot has been written about what carpal tunnel is, it is rare to get a surgeon's answers to these questions.  Here are some common questions  that Dr.  Jeffrey C.  Wint at the Hand Center of Western Massachusetts gets asked by his patients and their answers.
Will my sensation come back or be normal after surgery?
While the goal of carpal tunnel surgery is to relieve the pressure on the nerve not everyone will respond the same to surgery
Some patients will have immediate return of sensation while some will take longer. Some will notice an improvement right away but still feel tingling and will describe this as "numb" The return of sensation is dependent on many factors including age, general health, duration of symptoms, circulation and the actual mechanical severity of compression.
In very severe cases while decompressing the nerve stops the carpal tunnel syndrome from getting worse, full recovery of sensation may not be possible.  Often this is seen in patients who have muscle wasting noted prior to surgery and in those with longstanding complete numbness and elevated two-point discrimination.  Of course there are many in these categories that improve despite having very severe cases.
Having a severe case where you are not sure if you'd have full recovery is not a reason to put off surgery, as progression is likely if nothing is done.
How about my strength?
This is a very difficult question as there are many reasons why a hand with carpal tunnel may not feel as strong.  It may be that the decreased sensation in the fingers prevents someone from knowing how tight to hold and object and that object is dropped more easily.  With return of sensation or even a slight improvement in sensation, dropping objects becomes less of a problem.   Some severe cases of Carpal Tunnel can be associated with atrophy in the muscles of the hand.  In some severe cases, this muscle will never fully recover.  However despite loss of muscle, function can still be preserved.  In very severe cases a suregon may recommend a tendon or muscle transfer to improve function.
What do you actually do?
What is actually "released" is the hard ligament in your palm that covers the median nerve.  Together with the bones in your wrist this ligament forms a ring or tunnel that surrounds the median nerve and the tendons to your fingers and thumb.  When this "release" is done it is much like making a ring bigger and there is less pressure on the median nerve.  The body heals the cut in this enlarged ring.   But it takes time until your palm feels comfortable.  With the pressure reduced on the nerve, healing can occur.  How the nerve heals is different in everyone.
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Is there more than one way to have carpal tunnel surgery?
There are two methods that are in use here in Western Massachusetts.  One method is the traditional open palm method and the other is an endoscopic limited incision method?
What is the difference between these two methods?
In a standard open carpal tunnel release the surgeon carefully makes an incision in the proximal portion of the palm. Exposing the tough tissue in the  palm called   palmar fascia which is then released.  Deeper down is the transverse carpal ligament which is then released to take pressure off the median nerve.
Endoscopic carpal tunnel release uses an endoscope, an instrument attached to a video monitor to visualize the undersurface of the transverse carpal ligament.  This avoids the need to make an incision in the palm.  Instead the surgeon makes the incision in the wrist crease near the base of the palm.

The endoscopic  carpal tunnel  view gives the surgeon performing carpal tunnel release a  detailed magnified high resolution view. Here a simple gauze bandage as viewed through the endoscope


The surgeon essentially releases the ligament from the inside out, avoiding damaging the tough tissues called fascia in the palm that give the palm its shape and contour. In addition the palm skin incision is avoided.  For many this reduces the immediate problem of using the hand more fully in the early post operative period.  It does not mean that there will be absolutely no discomfort but many feel it is less.  Typically however one must realize that there are many people who undergo so called regular open carpal tunnel release who have very little pain and many do not need to take pain medicine at all.  However those who have endoscopic release who do well, do well a little bit sooner.
Can I see a demonstration of the endoscopic method?
You can watch this embedded video from You tube.
 
Can I use my hand right away?
After surgery you may be able to use your hand right away, especially your fingers to do light things.  You must keep your dressing dry until it is changed or removed in the office.  For showers or baths keep your dressing covered with a plastic bag.  Using your fingers to do light things right away is important.  While the dressing will cover your palm, your fingers will be free to use.
How long will it take to heal?
The time for healing is variable as no two people are alike and no one heals exactly the same.  However most feel comfortable doing light activities that require palm pressure in 2 - 3 weeks and very heavy activities 4 -5 weeks.  Those with lighter sedentary jobs can often go back sooner.  Those with very heavy jobs may take longer.  Other conditions such as arthritis, tendonitis and fibromyalgia may delay comfort after surgery.  Sometimes you do not complain of or notice other problems until after your carpal tunnel is betterWhile 5-6 weeks down the line most patients with either an open or endoscopic release are at nearly the same place with respect to activities,  the endoscopic released hands seem to be more comfortable sooner. .  While endoscopic release may feel better earlier it is still advisable not to overdo it.  Doing too much too early can delay full recovery, while not doing enough with hand can have the same effect.  It is important to use your hand but not overdo it.
Do I need to go to sleep to have the surgery?
The type of anesthesia used is typically is known as "local with monitored anesthesia care "(or IV sedation). This means that you get an intravenous dose of medicine to relax or lightly sedate you. An anesthesiologist, a physician, who is in charge of this part of your operation, gives the sedation. Then the surgeon injects your palm to "numb it up".  The sedation usually makes you forget that you had the palm injection. When the surgery starts you do not feel the incision but you know that something is going on because the back of your hand and your fingers still are awake (Some fall gently asleep at this point but many stay awake and are indifferent to what is happening.)
Does it have to be done in the hospital?
Most carpal tunnel is done as day surgery and most patients can have it done at the surgicenter without the need to go to the hospital. It is usually a 20 -25 minute procedure with total time in the surgery center about 2 hours.  You need to have a ride from surgery and cannot drive for 24 hours.  After 24 hours you may drive as long as you feel safe and are not taking pain medicine, which can impair your judgment. The requirement of insurance carriers and some people because of other medical problems or sometimes because of scheduling need to go to the hospital for surgery.  Then you would expect to spend about 4 - 5 hours at the hospital.  The surgicenter has you arrive 80 minutes prior to your scheduled surgery time while at the hospital you need to get there 2 hours ahead of the surgical time.
Will I be in a lot of pain?
While  typically everyone who has carpal tunnel surgery gets a prescription for pain medicine, most state that they did not need it or used it minimally.  Many get by with Tylenol, Advil, Alleve or a similar over the counter medication. Others feel the need to take pain medication such as  codeine or percocet for a few days. Remember that everyone will not respond to surgery the same way with respect to pain after the surgery.
Overall carpal tunnel surgery can work well.  While these answers do not apply to everyone and everyone will not react the same way to surgery, they represent a more common experience. For more information you can come to our website at http://www.handctr.com.
Additional resources
http://www.handctr.com/articles.htmEndoscopic Carpal Tunnel Release SURGERY in WIKIPEDIA
BAYSTATE HEALTH SYSTEMS ALPHASIGHTS: ENDOSCOPIC CARPAL TUNNEL SPEEDS RECOVERY
Endoscopic carpal tunnel release speed recovery
 

Tuesday, May 17, 2011

HAND SAFETY Fireworks Danger Stressed from Springfield July 1, 2004

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Fireworks danger stressed

Thursday, July 01, 2004
By NANCY H. GONTER
ngonter@repub.com

NORTHAMPTON - Hand surgeon Jeffrey Wint isn't expecting a quiet Fourth of July weekend.
"Unfortunately, I face the prospect of being called in at any time," said Wint, who hopes to take in a parade and spend some time in his back yard during the holiday.
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Wint, other medical professionals, law enforcement and fire officials yesterday held a press conference calling on area residents to "leave fireworks to the professionals." Members of the state police bomb squad exploded illegal fireworks using mannequins to show the damage they can cause.

A surgeon at the Hand Center of Western Massachusetts who works at Baystate Medical Center in Springfield, Wint said he has already seen hand injuries caused by fireworks this season.

In one case, a teenage boy was clenching a firecracker in his hand and it blew up before he threw it. The tip of his index finger had to be amputated. In another case, a 14-year-old boy didn't realize the cherry bomb in his hand was lit. He suffered burns to his palm, deep lacerations and several fractures.

"He has the prospect of months of therapy and rehabilitation in order to regain normal function," Wint said.

Of injuries caused by fireworks 57 percent are to the hand and upper extremities, Wint said.

Patrick C. Lee, a trauma surgeon at Baystate Medical Center, said burn injuries are tragic for children and their families.

"They are a life-changing event. Burns and their treatment are painful, leave surgical and emotional scars, and most of all they are preventable," Lee said.

State Fire Marshal Stephen D. Coan said many people ask him why children shouldn't play with sparklers.

"I ask them if they would give their children a lighter to play with. Sparklers can burn at 1,800 degrees Fahrenheit, three times the temperature of a lit match, and hot sparkler fires have ignited clothing, burned bare feet, poked eyes out and started tragic holiday fires," Coan said.

Coan noted that all fireworks are illegal in Massachusetts and it is illegal to bring fireworks into the state, even though they are legal in Connecticut and New Hampshire. It is also illegal to purchase fireworks on the Internet or through catalogs and have them delivered to homes in Massachusetts, he said.

"Remember, the use of fireworks by anyone other than a licensed professional is illegal," Coan said.

The press conference featured a table loaded with fireworks in colorful packaging, much of it clearly intended to attract children. The fireworks were seized by law enforcement authorities. Coan noted children 10-14 are at the greatest risk of fireworks injuries.

Fireworks can be deadly. In December 2003, a 45-year-old Gloucester woman died when fireworks ignited her Christmas tree, starting a house fire. In May 1997, a 26-year-old Watertown man was killed when lighting fireworks in a hallway. On July 4, 1993, a 27-year-old Framingham man was killed when his backyard fireworks exploded in his face, according to the state Department of Fire Services.

MORE ON FIREWORKS









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AAOS FIREWORKS PRESS RELEASE 2008
  
For more information, contact:
For Immediate Release
06/27/2008
Fireworks should be Breathtaking, Not Bone-Shattering 
Orthopaedic surgeons provide safety tips for Fourth of July celebrations
Rosemont, IL

Fourth-of-July fireworks always draw a crowd but those beautiful bursts of color can lead to catastrophic injuries if not used with care. This Independence Day, the American Academy of Orthopaedic Surgeons (AAOS) advises Americans to enjoy the spectacular celebrations but urges adults and children to exercise extreme caution by leaving fireworks to the professionals.
According to the U.S. Consumer Product Safety Commission:
  • More than 21,000 fireworks-related injuries were treated in hospitals, doctor’s offices, clinics, ambulatory surgery centers and emergency rooms in 2007. Children under 17 accounted for approximately 11,000 of those injuries.
  • The total cost for medical expenses, legal expenses, work loss, and pain and suffering due to fireworks injuries equaled more than $615 million.

“Fireworks can be used safely by trained adults, but illegal firecrackers or ones that are used improperly present substantial risks,” said Clifford Jones, MD, orthopaedic surgeon specializing trauma and member of the Academy’s Leadership Fellows Program. “If fireworks misfire or explode prematurely, the extreme force can tear or destroy bones, tissue and nerves, causing permanent damage to the body."
In an effort to reduce the number and severity of firework-related injuries treated by orthopaedic surgeons, the AAOS recommends the following safety guidelines for trained adults who choose to use fireworks:
  • Check with your local police department to determine if fireworks can be discharged legally in your area. If so, determine which types are legal.
  • Never buy illegal fireworks. Their quality cannot be assured.
  • Only adults should light fireworks.
  • Never hold lighted fireworks.
  • Never allow young children to play with or go near fireworks, including sparklers. They seem harmless but sparklers can reach temperatures of more than 1,000 degrees.
  • Never play with fireworks if you are under the influence of drugs or alcohol.
from a Baystate Heath Systems 2005 press release regarding Lawnmower Safety

Strategic Communications and Marketing Group
Springfield, MA 01199

Contact:  Keith J. O’Connor, Public Affairs Manager
                 tel. - (w) 413-794-7656  (h) 413-533-5910  (cell) 413-537-7596
                 fax - 413-794-4333                 email: keith.o’connor@bhs.org
               Melissa Sheehy (w) 794-7633  fax - 794-4333
  FOR IMMEDIATE RELEASE
6-21-05-388
  

LAWNMOWERS CAN BE DANGEROUS TO YOUR HEALTH
Devastating accidents to the hand and fingers can occur when used improperly
SPRINGFIELD- Every summer, lawnmowers are constantly running as homeowners try to keep their yards trim and beautiful. Unfortunately, “lawnmowing season” brings many people, especially children, with devastating hand injuries to emergency departments such as Baystate Medical Center.
            According to the American Society for Surgery of the Hand, every year more than 74,000 small children, adolescents and adults are injured by rotary, hand and riding power mowers due to the improper handling of lawnmowers.
            “Every summer we see patients, both adults and children, who come into our office with severe injuries to their hand and fingers,” said Dr. Jeffrey Wint of the Hand Center of Western Mass.
“Often parents will give their children a ride on the lawnmower as a treat, but this can be very dangerous, as kids can fall off and get injured. Adults who attempt to maintain mowers without taking proper safety precautions often get injured, too,” added Dr. Wint, who is a member of the medical staff at Baystate Medical Center.
  According to Dr. Wint, 20 percent of lawnmower injuries are to the hand, wrist or fingers and about 25 - 50 percent of those injuries result in amputation. He noted that injuries from lawnmower accidents can be devastating and extremely hard to treat.
“Injuries can become contaminated from soil or dirt from the mower, which can lead to serious infections resulting in amputations,” Dr. Wint warned.
Most injuries can be avoided by using common sense and practicing safe mowing. To stay safe while mowing:
*       Children under age 6 should remain indoors when the lawn is being mowed.
*      Safety training is essential for those old enough to operate a lawnmower.  Supervise your children until you are satisfied they understand how to safely operate the mower and can manage the task alone.
*      Never service mowers while in operation and always keep them in good working order.
*       Do not use hands or feet to clean mower, especially around the blade, because even with the mower off, there can still be tension on the blade, which can spin rapidly once cleared. Always use a stick or broom handle to remove any obstruction
*       When mowing a slope with a walk-behind mower, mow across the face of the slope, not up and down.
*       When using a riding mower, go up and down the slope rather than across to avoid tipping over.
*       Read mower's instruction manual and do not remove safety devices or guards.
*       Do not mow in bad weather, in poor light, or on wet grass.
*       Never allow passengers, other than the operator, on riding mowers.
*       Do not operate lawnmower while barefoot and wear gloves, long pants and goggles.
          
  Parents need to remember that lawnmowers are not toys and must be used appropriately. Many children have died from accidents on or around mowers. Dr. Wint warns that lawnmowers can be “a potential lethal weapon and just as dangerous as giving a child a loaded gun.”
He said there is a need to create an awareness of the potential dangers of lawnmowers, as many of the accidents are preventable.
“It is heartbreaking to see some of these children’s injuries,” said Dr. Wint. “Remembering these few safety precautions and using sound judgment can keep everyone safe and lawns looking great this summer.”

                                         

AAP lawnmower safety bulletin

AAP PARENT PAGES
This information is based on the American Academy of Pediatrics’ policy statement Lawn Mower Injuries to Children, published in June 2001. Parent Pages offers parents relevant facts that explain current policies about children’s health.
Lawn Mower Safety
Each year many children are injured severely by lawn mowers. Power mowers can be especially dangerous. However, most lawn mower-related injuries can be prevented by following these safety guidelines.
When is my child old enough to mow the lawn?
Before learning how to mow the lawn, your child should show the maturity, good judgment, strength and coordination that the job requires. In general, the American Academy of Pediatrics rec- ommends that children should be at least
• 12 years of age to operate a walk-behind power mower or hand mower safely
• 16 years of age to operate a riding lawn mower safely
It is important to teach your child how to use a lawn mower. Before you allow your child to mow the lawn alone, spend time showing him or her how to do the job safely. Supervise your child’s work until you are sure that he or she can manage the task alone.
Before mowing the lawn:
1. Make sure that children are indoors or at a safe dis- tance well away from the area that you plan to mow. 2. Read the lawn mower operator’s manual and the
instructions on the mower. 3. Check conditions
• Do not mow during bad weather, such as during a thunderstorm.
• Do not mow wet grass.
• Do not mow without enough daylight. 4. Clear the mowing area of any objects such as twigs, stones, and toys, that could be picked up and thrown
by the lawn mower blades. 5. Make sure that protective guards, shields, the grass
catcher, and other types of safety equipment are placed properly on the lawn mower and that your mower is in good condition.
6. If your lawn mower is electric, use a ground fault cir- cuit interrupter to prevent electric shock.
7. Never allow children to ride as passengers on ride-on lawn mow- ers or garden trac- tors.
While mowing:
1. Wear sturdy closed-toe shoes with slip-proof soles, close-fitting clothes, safety goggles or glasses with side shields, and hearing protection.
2. Watch for objects that could be picked up and thrown by the mower blades, as well as hidden dan- gers. Tall grass can hide objects, holes or bumps. Use caution when approaching corners, trees or any- thing that might block your view.
3. If the mower strikes an object, stop, turn the mower off, and inspect the mower. If it is damaged, do not use it until it has been repaired.
4. Do not pull the mower backwards or mow in reverse unless absolutely necessary, and carefully look for children behind you when you mow in reverse.
5. Use extra caution when mowing a slope. • When a walk-behind mower is used, mow across
the face of slopes, not up and down, to avoid
slipping under the mower and into the blades. • With a riding mower, mow up and down slopes,
not across, to avoid tipping over. 6. Keep in mind that lawn trimmers also can throw
objects at high speed. 7. Remain aware of where children are and do not
allow them near the area where you are working. Children tend to be attracted to mowers in use.
Stop the engine and allow it to cool before refueling.
Always turn off the mower and wait for the blades to stop completely before • Crossing gravel paths, roads or other areas • Removing the grass catcher
• Unclogging the discharge chute • Walking away from the mower
The information contained in this publication should not be used as a substitute for the medical care and advice of your pedi- atrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.
This page may be printed and reproduced by subscribers to Pediatrics exclusively for not-for-profit patient education use.

Tips to Prevent Injuries

 originally from BAYSTATE MEDICAL CENTER
Strategic Communications and Marketing Group
Springfield, MA 01199

FOR IMMEDIATE RELEASE
7-9-01-211
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LAWNMOWERS CAN BE DANGEROUS TO YOUR HEALTH
Devastating accidents to the hand and fingers can occur when used improperly

SPRINGFIELD- This summer, lawnmowers are running constantly as people try to keep their grass trim and beautiful. Unfortunately, this also means the chance for devastating hand injuries from lawn mower accidents, especially to children.
"Every summer we see patients, both adults and children, who come into our office with severe injuries to their hand and fingers," said Dr. Jeffrey Wint of the Hand Center of Western Mass.
According to the American Society for Surgery of the Hand, more than 74,000 small children, adolescents and adults are injured by rotary, hand and riding power mowers due to the improper handling of lawnmowers every year.
"Often parents will give their children a ride on the lawnmower as a treat, but this can be very dangerous, as kids can fall off and get injured. Adults who attempt to maintain mowers without taking proper safety precautions often get injured too," added Dr. Wint, who is a member of the medical staff at Baystate Medical Center.
According to Dr. Wint, 20 percent of lawnmower injuries are to the hand, wrist or fingers and about 25 - 50 percent of those injuries result in amputation. He noted that injuries from lawnmower accidents can be devastating and extremely hard to treat. "Injuries can become contaminated from soil or dirt from the mower, which can lead to serious infections resulting in amputations," Dr. Wint warned.
Most injuries can be avoided by using common sense and practicing safe mowing. To stay safe while mowing:
Keep young children away from mowers and mowing area at all times
Educate older children on safely operating mowers and caution them of potential dangers
Never service mowers while in operation and always keep them in good working order
Do not use hands or feet to clean mower, especially around the blade, because even with the mower off, there can still be tension on the blade, which can spin rapidly once cleared
Always use a stick or broom handle to remove any obstruction
Read mower's instruction manual and do not remove safety devices or guards
Never cut grass when wet or when ground is damp and be cautious on hills or slopes
Never allow passengers, other than the operator, on riding mowers
Do not operate lawnmower while barefoot and wear gloves, long pants and goggles.
Parents need to remember that lawnmowers are not toys and must be used appropriately. Many children have died from accidents on or around mowers. Dr. Wint warns that lawnmowers can be "a potential lethal weapon. It is the same caliber as letting kids play with a loaded gun."
There is a need to create an awareness of the potential dangers of lawnmowers, as many of the accidents are preventable.
"It is heartbreaking to see some of these children’s injuries," said Dr. Wint. Remembering these few safety precautions and using sound judgment can keep everyone safe and lawns looking great this summer.





Endoscopic carpal tunnel release surgery speeds reovery for carpal tunnel syndrome : from baystate medical center springfield, ma

Endoscopic Surgery Speeds Recovery for Patients with Carpal Tunnel Syndrome

The bane of data processors, carpenters, musicians, lumberjacks -- anyone whose job requires frequent, repetitive bending of the wrist -- carpal tunnel syndrome has been called the "new industrial epidemic."  Although the prevalence of the condition is not known, the National Institute of Occupational Safety and Health reports that 15 to 25 percent of workers employed in construction, food preparation, clerical work, production, fabrication and mining are at risk for cumulative trauma disorders like carpal tunnel syndrome. The traditional surgical treatment for the condition required an incision in the palm.

While this procedure successfully relieved the wrist pain, tingling and numbness that characterize carpal tunnel syndrome, it often created incisional problems. The location of the incision increased the chances that small nerve branches in the hand might be cut, producing discomfort in the scar. Thanks to a new surgical procedure used at Baystate Medical Center, many of these problems are being eliminated. Baystate hand surgeons are the first in the area to utilize endoscopic surgery to treat carpal tunnel syndrome -- a technique that markedly reduces the size of the necessary incision, resulting in a faster recovery and, for many patients, a more rapid return to work.

"Although carpal tunnel surgery has been performed successfully for years, some of the minor problems associated with the open-palm method have prevented patients from receiving the full benefit of the procedure," says Jeffrey Wint, M.D., an orthopedic hand surgeon at Baystate who uses the endoscopic technique. "For people who work with their hands, the time spent recovering from a major incision in their palm can be a significant setback."

Causes and Cures Carpal tunnel syndrome arises when repetitive wrist motion causes swelling of the tissues within the carpal tunnel. The transverse carpal ligament is unyielding and the median nerve is compressed. The initial symptoms are wrist pain and a tingling sensation in the fingers, usually felt when the hand is at rest. If not corrected, the condition can produce numbness and weakness throughout the hand, making simple tasks such as holding a newspaper or turning on a faucet painful or impossible.

Surgery has been able to alleviate these symptoms by cutting the ligament that overlies the median nerve at the juncture of the wrist and hand. Until recently, however, the only means of access to the ligament has been through an incision in the palm.

Wednesday, May 11, 2011

DUPUYTREN'S DISEASE: UPDATE, needle aponeurotomy or xiaflex?

DUPUYTREN'S DISEASE UPDATE



GOUT (from medscape)

  • Gout has 2 clinical phases: (1) a first phase of intermittent acute attacks that spontaneously resolve during 7 to 10 days with asymptomatic periods between attacks, and (2) a second phase of chronic tophaceous gout involving polyarticular attacks with crystal deposition (tophi) in the soft tissues or joints.
  • Risk factors include use of thiazide diuretics, cyclosporine, and low-dose aspirin (< 1 g/day); insulin resistance metabolic syndrome; renal insufficiency; hypertension; congestive heart failure; and organ transplantation.
  • Increased dietary intake of purines, ethanol, soft drinks, and fructose also increase the risk for gout. Intake of coffee, dairy products, and vitamin C reduces the risk for gout.
  • Triggers for gout attacks include alcohol intake, diuretic use, hospitalization, and surgery.
  • The diagnostic standard is synovial fluid examination for negatively birefringent monosodium urate crystals under polarizing microscopy.
  • Hyperuricemia may not be present in an acute attack and may not be helpful in diagnosis.
  • The differential diagnosis of acute gout includes other crystal-induced arthritides, rheumatoid arthritis, and a septic joint.
  • The main aim of treatment is rapid pain relief and prevention of disability.
  • Options include the use of NSAIDs; colchicine; glucocorticoids; and, sometimes, corticotrophin.
  • Adjunctive measures include applying ice and resting the affected joint.
  • NSAIDs and colchicine are first-line treatments of acute gout.
  • Colchicine, given at 1.2 mg at the start of an attack and repeated at 0.6 mg 1 hour later, is more effective than placebo for pain relief within 24 hours.
  • Glucocorticoids and corticotrophins may be used, but the evidence for intramuscular injections is limited.
  • A 5-day course of prednisolone has been shown to be equivalent to indomethacin and naproxen.
  • 7 to 10 days of treatment of gout may be needed for symptom control.
  • Lowering urate levels may prevent acute flares of gout and development of tophi.
  • Urate-lowering therapy for hyperuricemia is recommended for those with at least 2 gout attacks per year or tophi, but such therapy should not be initiated during acute attacks.
  • Urate-lowering therapy should be started 2 to 4 weeks after flare resolution, with a low initial dose increased for weeks to months.
  • The dose should be adjusted to achieve a urate level below 6 mg/dL, which is associated with a reduced risk for acute attacks and tophi.
  • Allopurinol, a xanthine oxidase inhibitor, is the most commonly prescribed agent to lower urate levels.
  • Febuxostat is another xanthine oxidase inhibitor approved by the FDA in 2009. At daily doses of 80 mg and 120 mg, has been shown to be 2.5 to 3 times more likely to achieve urate levels less than 6 mg/dL at 1 year.
  • Uricosuric drugs (probenecid, sulfinpyrazone, and benzbromarone) block renal tubular urate reabsorption.
  • Uricase and pegloticase were FDA approved in 2010 for chronic gout refractory to conventional treatments.
  • Lifestyle changes such as avoidance of alcohol and diet modification may not be sufficient to control attacks.
  • Intake of vitamin C and dairy products have been shown to reduce urate levels.
  • For patients starting allopurinol therapy, the use of colchicine at a dose of 0.6 mg twice daily for an average of 5.2 months has been shown to reduce the risk for gout attacks and severity of flares.
  • The optimal duration of treatment of tophi is uncertain, and ongoing prophylaxis until resolution of tophi occurs may be necessary.
  • The author concluded that patients suspected of having gout should have the diagnosis confirmed by synovial fluid examination, and acute treatment after multiple attacks should be followed by allopurinol for urate lowering, with colchicine prophylaxis to prevent recurrence of attacks.