Platelet-rich plasma (PRP) is blood plasma that has been enriched with platelets. As a concentrated source of autologous (patient’s own) platelets, PRP contains and releases several different growth factors and other cytokines that stimulate healing of bone and soft tissue.

A study published in the American Journal of Sports Medicine in November 2006 showed that over 90% of patients with tennis elbow were “completely satisfied” with the results of their PRP treatments and avoided surgery [1].

WHAT ARE TENDONS?

Tendons are the structures that attach muscle to bone.  They often bear significant force, and as a result are vulnerable to injury. Tendons have a limited blood supply, which limits their ability to heal.

Current treatments for chronic tendon injuries are temporary in nature and do not provide long-term relief. In fact, cortisone injections have been shown to increase the risk of tendon rupture and are not recommended for repeated use. Anti-inflammatory medications are temporarily helpful but have adverse side effects.

WHAT IS PLATELET RICH PLASMA THERAPY?

Platelet Rich Plasma Therapy, or PRP, is a treatment option for non-healing tendon injuries such as tennis elbow, achilles tendonitis and knee tendonitis. PRP technology was initially developed 20 years ago for heart surgery to aide with wound healing and blood loss. Its benefits are now being applied towards the facilitation of healing tendon injuries. In fact, PRP has been widely used for years in Europe to treat various tendon injuries.

HOW DOES A PRP PROCEDURE WORK?

Using the patient’s own blood, specially prepared platelets are taken and then re-injected into the tendon of the affected area. These platelets release substances known as “growth factors” that lead to tissue healing. For example, when you cut yourself, the body’s natural response is to attract platelets that release growth factors and facilitate the healing. By concentrating the platelets we increase the growth factors up to eight times which promotes the healing of tendons. While other tendon injury treatments such as corticosteroid injections may provide temporary relief and stop inflammation, PRP injections actually heal the tendon over a period of time.

The human body has a remarkable ability to heal itself and by re-injecting concentrated platelets we are facilitating the natural healing process.

IS PRP RIGHT FOR ME?

Patients should consider PRP treatment if they have been diagnosed with a tendon injury in which conservative treatment such as anti- inflammatories, physical therapy and bracing have not provided symptomatic relief.

For most patients PRP offers a solid, alternative treatment for those who do not wish to have surgery. An initial evaluation will determine if PRP is a viable treatment option.

HOW DO I PREPARE FOR AN INJECTION?

Patients will be scheduled for an evaluation to determine if PRP is a viable treatment option. An MRI may be done prior to the injection to insure a proper diagnosis and that there is not a major tear in the tendon that might best be treated surgically.

The PRP injection usually takes an hour and is performed on an outpatient basis. Do not take anti-inflammatories one week prior to the injection as this will limit the treatment benefits.

HOW DO I CARE FOR MY INJECTION SITE AFTER TREATMENT?

Initially the procedure may cause some localized soreness and discomfort. Patients may apply ice and elevation as needed. After one week the patient will likely begin a rehabilitation program with physical therapy. It is not advisable to take anti-inflammatory medications following the injection. Notify your physician if you have an allergy to epinephrine or bupivicaine (marcaine). If you are unsure, contact your primary care physician.

WHAT ARE POTENTIAL BENEFITS OF PRP TREATMENT?

Patients can expect to see significant improvement in symptoms; elimination of the need for more traditional treatments such as medications, cortisone injections or surgery; and a dramatic return of function.

WHAT ARE THE SIGNIFICANT SIDE EFFECTS?

Although uncommon, the risks include those signs/symptoms associated with an injection including: pain, infection, no relief of symptoms, worsening of symptoms, blood clot, nerve injury, skin discoloration, calcification, scarring, loss of fat to the affected area, and allergic reaction.

After the injection, if you experience any of the above side effects, please contact your doctor.

HOW SOON CAN I GO BACK TO REGULAR PHYSICAL ACTIVITY?

This treatment is not a “quick fix” and is designed to promote long-term healing of the tendon. The process of PRP requires time and rehabilitation to allow the injured tendon to heal. Prior studies on tennis elbow have demonstrated at six months, an 81% improvement in pain scores and at follow up at 1-3 years, 93% reduction in pain. [1]

Through regular follow-up visits your doctor can determine when you are able to resume regular physical activities.

News clips on PRP treatments in athletes:

• PRP on LA Dodgers pitcher Saito
• PRP on Stanford football player on ABC News
• PRP on CBS News

To find out if you are a suitable candidate for PRP, and to find out more about how it can help you, Call +65 6440 1200 or +65 6737 1100 to schedule an appointment with Hand Surgery Specialist, Dr. Jonathan Y. Lee.

Tennis elbow is a condition that results in pain around the outside of the elbow. It often occurs after strenuous overuse of the muscles and tendons of the forearm, near the elbow joint. As its name suggests, tennis elbow is sometimes caused by playing tennis. However, it is usually caused by a number of other physical activities.

Lateral Epicondylitis causes pain on the outside of the elbow

What causes of Tennis Elbow?

Tennis elbow is caused by small tears in the muscles of the forearm due to overuse of the muscles or minor injury. It can also occur as the result of a single, forceful injury.

Excessive or repeated use of the muscles that straighten your wrist can injure the tendons in your arm and elbow and lead to tiny tears, which cause rough tissue to form near the bony lump on the outside of your elbow.

Tennis elbow often occurs after you do an activity that uses your forearm muscles when you have not used them much in the past. However, even if you use your forearm muscles frequently, it is still possible to injure them and develop tennis elbow.

Activities that might cause Tennis Elbow

The tendons in your elbow can be injured by overusing your forearm muscles in repeated actions, such as:

• gardening – e.g. using shears
• playing racquet sports, such as tennis or squash
• sports that involve throwing, such as the javelin or discus
• swimming

Tennis elbow can also develop in the workplace through carrying out repetitive tasks and actions, such as:

• manual work that involves repetitive turning or lifting of the wrist, such as plumbing or bricklaying
• repetitive, fine movements of the hand and wrist, such as typing or using scissors

Your risk of developing tennis elbow increases if you regularly play racquet sports, such as tennis or squash, or if you play a racquet sport for the first time in a long time. However, despite its name, only 5 out of 100 people develop tennis elbow through playing racquet sports such as tennis.

The medical name for tennis elbow is lateral epicondylitis. This is because the pain usually occurs on the bony lump on the outside of the elbow, known as the lateral epicondyle. Pain can also occur on the inner side of the elbow, which is known as golfer’s elbow.

The Elbow Joint

The elbow joint is surrounded by muscles that move the elbow, wrist and fingers. The tendons in your elbow join the bones and muscles together and control the muscles of your forearm around the lateral epicondyle.

When a person gets tennis elbow, one or more of the tendons in their elbow becomes painful. The pain occurs at the point where the tendons of the forearm muscle attach to the bone. Twisting movements, such as turning a door handle or opening the lid of a jar, are particularly painful.

In around three quarters of cases of tennis elbow, the dominant hand (the one that is used the most) is affected.

What are the symptoms of Tennis Elbow?

The main symptom of tennis elbow is pain and tenderness on the outside of your elbow. You may also feel pain travelling down your forearm.

The pain is often worse when you use your arm and elbow, particularly for twisting movements. Repetitive wrist movements, such as wrist extension and repeated gripping, can also make the pain worse.

Tennis elbow can vary in severity, but you will usually have the symptoms listed below.

• Recurring pain on the outside of your upper forearm, just below the bend of your elbow.Sometimes, you may also feel pain down your forearm towards your wrist.
• Pain caused by lifting or bending your arm.
• Pain when writing or when gripping small objects. This can make it difficult to hold small items, such as a pen.
• Pain when twisting your forearm – for example, when turning a door handle or opening a jar.
• Difficulty fully extending your forearm.

On average, a typical episode of tennis elbow lasts between six months and two years. Most people (90%) make a full recovery within a year.

The pain of tennis elbow can range from mild discomfort when using your elbow to severe pain that can be felt even when your elbow is still or when you are asleep. You may have stiffness in your arm that gets progressively worse as the damage to your tendon increases.

As your body tries to compensate for the weakness in your elbow, you may also have pain or stiffness in other parts of the affected arm or in your shoulder and neck.

How common is tennis elbow?

Tennis elbow usually occurs in adults. Men and woman are affected equally. The condition tends to affect people who are around 40 years old.

Outlook

Tennis elbow is a self-limiting condition. This means that in most cases the symptoms eventually improve and clear up without treatment. Anti-inflammatory painkillers can often reduce mild pain that is caused by tennis elbow. However, if your pain is severe or prolonged, a corticosteroid injection may be recommended. Occasionally, surgery may be used to treat very severe and persistent cases of tennis elbow. Most cases of tennis elbow last between six months and two years. However, in around 9 out of 10 cases, a full recovery is made within one year.

The pain caused by tennis elbow can last for some time. As tendons are slow to heal, the symptoms often last for a number of weeks or months. In severe cases, tennis elbow can persist for more than a year.

However, tennis elbow is a self-limiting condition, which means it will eventually get better with or without treatment.

There are non-surgical and surgical treatment options for tennis elbow. Before surgery is considered, managing the symptoms using non-surgical treatment is recommended. Surgery will only be recommended as a treatment of last resort, after non-surgical methods have not worked.

Non-surgical treatments for Tennis Elbow

If you have tennis elbow, you should rest the affected arm as much as possible and avoid doing any activities that put more stress on the tendons. Such activity modifications can be an effective way of reducing your painful symptoms. Examples of ways that you can modify activities include:

• avoid lifting, gripping or rotating the affected arm
  if you need to lift a heavy object, making sure that your palms are facing upwards to reduce the strain on your wrist muscles
• take regular breaks when you are at work
• discuss with your employer altering any strenuous activities that could cause you pain and aggravate your affected arm

Painkillers for Tennis Elbow

Taking painkillers, such as paracetamol and ibuprofen, may help to reduce mild pain that is caused by tennis elbow. Children under 16 years old should not take aspirin.

Non-steroidal anti-inflammatory drugs (NSAIDs)

As well as tablets, anti-inflammatory painkillers are also available as creams and gels. These are often known as topical NSAIDs because they are applied directly to a specific area of your body, such as your forearm or elbow.

Some NSAIDs are available at pharmacists over the counter. Others are only available on prescription. Your pharmacist or GP can advise you about which NSAID is most suitable for you. Examples of topical NSAIDs include ibuprofen, ketoprofen and piroxicam.

These have been proven to provide some pain relief for musculoskeletal conditions (those that affect the muscles or bones), such as tennis elbow.

NSAID creams or gels should be gently rubbed into the area that is causing pain and discomfort. Make sure that you read the patient information leaflet that comes with your cream or gel to check how often the treatment should be applied.

Anti-inflammatory creams and gels are often recommended for tennis elbow rather than anti-inflammatory tablets. This is because gels and creams provide effective pain relief and reduce inflammation without causing side effects, such as nausea and diarrhoea.

However, photosensitivity reactions can sometimes occur while using ketoprofen. Therefore, avoid exposing the affected area to sunlight while using ketoprofen and for two weeks after the treatment has finished.

Avoid using topical NSAIDs during pregnancy and breastfeeding. Many topical NSAIDs are also unsuitable for children. Ask your GP or pharmacist for advice if you are not sure about whether a topical NSAID is suitable for you or your child.

Corticosteroid injections for Tennis Elbow

A corticosteroid injection may be recommended if you have particularly painful tennis elbow that is making movement difficult. Corticosteroids are a medication that contain steroids (a type of hormone). A corticosteroid injection will reduce the pain in your arm.

The injection will be made directly into the painful area around your elbow. Before you have the injection, you may be given a local anaesthetic to numb the area so you do not feel any further pain while the injection is being given.

Most people who have a corticosteroid injection find that their pain initially improves significantly. However, a study of 198 people has shown that corticosteroid injection treatment is only effective in the short-term (around six weeks), and its long-term effectiveness is poor.

Research has shown that when compared to physiotherapy and a ‘wait and see’ approach to see if symptoms disappear naturally, corticosteroid injections were not as effective at 52 weeks. They were effective in the short term, at six weeks after the treatment. High recurrence rates have also been reported in people who have corticosteroid injections.

The recommended time in between corticosteroid injections is six weeks.

Potential side effects of corticosteroid injections include:

• pain in the affected area after having the injection
• skin depigmentation – the loss of colour (pigment) around the injection site
• wasting away of the surrounding subcutaneous tissue (the layer of tissue beneath the surface of the skin)

Before you decide to have corticosteroid injections to treat tennis elbow, discuss the effectiveness and potential side effects with your GP. This will enable you to make a well-informed decision about this type of treatment.

After having a steroid injection (or injections), take care to rest your arm. Avoid putting too much strain on it too quickly. As with any injury, you should gradually build up to your normal activity levels to help prevent the problem reoccurring.

Physiotherapy for Tennis Elbow

If your tennis elbow symptoms are particularly severe or persistent, your GP may refer you to a physiotherapist (a healthcare professional who is trained to use physical methods, such as massage and manipulation, to promote healing).

A physiotherapist will be able to show you exercises to help stretch and strengthen your forearm muscles. They may also recommend that you wear a splint (an elasticated band that is positioned just below the elbow joint) to help support your elbow and encourage the tendons to heal.

Shock wave therapy for Tennis Elbow

Shock wave therapy is where high-energy sound waves are passed through the skin of the affected area to help relieve the pain of tennis elbow and improve mobility (movement).

Depending on the severity of your pain, shock wave therapy may be given once or it may be repeated. You may have a local anaesthetic during the procedure to prevent you feeling any pain while the shock waves are being passed through your skin.

Following shock wave therapy, potential side effects include:

• bruising
• red skin
• inflammation (swelling) of the skin
• skin damage around the area being treated

Research has shown that shock wave therapy is safe. However, NICE states that there is a lack of evidence of its effectiveness in treating tennis elbow, and more research is required.

Your GP may recommend shock wave therapy if other non-surgical treatments have proved to be ineffective in relieving your symptoms of tennis elbow. Discuss the potential risks, benefits and side effects with your GP.

Acupuncture for Tennis Elbow

Acupuncture is a type of complementary treatment where fine needles are inserted into the skin around the affected area. In some cases, this may reduce pain and improve movement. However, there is a lack of evidence that it relieves the symptoms of tennis elbow.

Surgery for Tennis Elbow

Surgery may be recommended as a last resort treatment option in rare cases of severe or persistent tennis elbow. Surgery aims to relieve the painful symptoms by removing the damaged part of the tendon.

If you think you might be having Tennis Elbow, call for an appointment (+65 64401200 / 67371100) to have it assessed by Dr. Jonathan Y. Lee.

For more information on Tennis Elbow and New approaches to the treatment of these tendon injuries, read our next post.

Dr. Jonathan Y. Lee is elected to membership of the American Association of Hand Surgery

The American Association of Hand Surgery (AAHS) was founded in 1970 to provide an educational forum to increase the professional expertise and knowledge of surgeons involved in hand surgery. The association also provides endowments for the support of educational and research programs. The Association remains a leader in the worldwide community of hand surgery organizations.

Today, the association has over 1100 members that include Hand Surgeons and Microsurgeons, as well as hand therapy and other health professionals who care for patients with hand and upper extremity problems. This represents a diverse but cohesive mixture of highly respected professionals who work in all disciplines related to hand surgery, and fosters improved communication and the sharing of ideas.

The AAHS has the highest standards of excellence for its membership, and election to membership is based upon training, board certification, scientific and professional accomplishment, and the degree of active interest and experience in the disciplines related to hand surgery.

Dr. Jonathan Y. Lee is also currently an active board member of the Chapter of Hand Surgeons, College of Surgeons, Academy of Medicine, Singapore.

As many 50% of new mothers experience this condition, but this condition also commonly occurs in many people who engage in activities with repetitive hand or wrist movements, such as gardening, knitting, cooking, playing a musical instrument, carpentry, walking a pet on a leash, lifting a baby, etc.

WHAT IS DeQUERVAIN’S TENDONITIS ?

DeQuervain’s tendonitis involves thumb extensor tendons that run through a canal at the base of the thumb at the back of the hand. Specifically, the protective synovial sheath of the tendon becomes inflamed. In most cases, the condition is not serious and can be easily treated.

When you grip, grasp, clench, pinch or wring anything in your hand, you use two major tendons in your wrist and lower thumb. These tendons run side-by-side from your forearm through the thumb side of your wrist. They normally glide unhampered through the small tunnel that connects them to the base of the thumb. In DeQuervain’s tendonitis (sometimes also called tenosynovitis), the tendons’ protective gliding sheath (covering) becomes inflamed, restricting movement of the tendons. It is this inflammation of the tendon sheath that must be treated.

WHAT CAUSES DeQUERVAIN’S TENDONITIS?

DeQuervain’s Tendonitis is an example of an over-use (repetitive strain injury, RSI) injury. Examples of over-use activities that can cause DeQuervain’s Tendonitis include:

• Gardening:  Repetitive hand weeding (grasping/pinching and pulling), hand-troweling, and pruning with small hand clippers
• Playing a musical instrument:  Repetitive practice and performance by pianists, guitarists, harpists and string players who rely heavily on thumb and wrist movement
• Knitting & crocheting:  Repeated wrist and thumb motions for hours at a time
• Cooking:  Constant chopping with a knife and lifting cookware
• Carpentry:   Hammering, sawing, using tools, lifting quantities of wood and materials
• Walking a Pet on a Leash:  Continuous yanking and pulling at the wrist while holding the leash
• Office work: Repetitive work tasks such as typing, lifting, organizing files, etc.
• Hobbies:   Any hobby or craft that relies on constant use of the thumb and wrist
• House Cleaning, Maid work:  Constant gripping, wrist bending and wringing out of a cloth or sponge from day-to-day
• Sports:   Tennis, golfing, bowling, baseball, archery, hockey, etc. that involves gripping

Now back to ‘Mommy Thumb’ …

In short, ‘Mommy Thumb’ is due to overuse of the wrist and thumb (by repetitive movements) while performing activities of daily living (ADL). Because up to 50% of the hand’s function requires involvement of the thumb, overuse injury can significantly hamper everyday functions.

WHY DO MOTHERS GET DeQUERVAINS’S TENDONITIS (& Fathers, & Grandparents too!)

How it happens:

The most common cause of ‘Mommy Thumb‘ occurs when infants are lifted with improper technique. Many mothers reach down and place their thumbs in their child’s armpits to lift them. This causes extra strain on the thumb and its tendons. A mother will describe it as a sharp, shooting pain starting at the thumb, through the wrist, and darting up the forearm. This improper lifting affects up to 50% of new mothers, who are their infant’s primary caregivers.

Naturally, the heavier the child is, the more likely this condition will occur. Also, repeatedly lifting a child from a lower position (e.g. from the ground or a low crib) further increases the risk of this condition.

The repetitive motion of placing the thumb and index finger in the shape of an “L” to lift young children causes the pain and inflammation. Similarly, cradling the child with the L-shaped thumb and index finger beneath its head can also cause discomfort, as can other awkward hand positions while carrying a baby.

While this condition can affect any mother, research suggests that mothers over the age of 40 are at increased risk for developing ‘Mommy Thumb’, and there are several possible reasons for this; women are having children at a later age, and generally newborn babies weigh up to 10% more than they did 30 years ago; crib heights are lower (therefore requiring mothers to bend over to lift the child up, with awkward wrist positioning); many new mothers also use a Blackberry and other devices for frequent text messaging. Lastly, hormonal changes associated with nursing and pregnancy can contribute to tendon swelling and weaker thumb and wrist function.

The proper way to lift a child:

Mommy thumb can be avoided by modifying your lifting technique. When picking up your child, do not use your thumb and fingers. Instead, place your hands on both sides of their rib cage and gently squeeze the child to lift. Alternatively, place one hand under the child’s bottom and one behind their head to lift the child. Make sure you aren’t bending down farther than necessary. Remember to bend your knees and use your legs to lift heavier children, to avoid bending the back or stooping over while lifting your child.

OTHER CAUSES OF DeQUERVAIN’S TENDONITIS

Although the primary cause of De Quervain’s tendonitis is overuse, occasionally the condition may be caused by aging, disease, or direct injury:

• Direct injury to the wrist (such as a fracture) or tendon that causes scar tissue to build-up and restrict movement of the tendons
• Inflammatory arthritis, such as rheumatoid arthriti
• Metabolic conditions such as diabetes, hyperuricemia, hypothyroidism

WHAT ARE THE SYMPTOMS of DeQUERVAINS’S TENDONITIS ?

The common complaint of de Quervain’s tenosynovitis is a pain and swelling near the base of, or over the thumb. The pain may appear suddenly or may increase over time, spreading farther into the thumb and wrist, and up the forearm. Pinching, grasping, lifting and other movements of the thumb and wrist aggravate the pain. Look for these potential signs of discomfort:

• Pain near the base of your thumb
• Swelling near the base of your thumb
• A fluid-filled cyst in the same region as the swelling and pain
• Difficulty moving your thumb and wrist when you’re doing activities that involve grasping or pinching
• A “sticking” or “stop-and-go” sensation in your thumb when trying to move it
• A squeaking sound as the tendons try to move back and forth through the inflamed sheaths
• Pain and/or swelling on the wrist’s thumb side at the back of the wrist
• Increased pain while forming a fist, grasping or holding objects, or turning the wrist
• A snapping or catching feeling when moving the thumb, much like a trigger finger.

DIAGNOSIS OF DeQUERVAIN’S TENDONITIS

Besides a review of possible aggravating activities, the most common diagnostic procedure is the Finkelstein maneuver.

You can try this test at home. Make a fist with the fingers placed over the thumb (the thumb is tucked in and bent towards the little finger; see photograph). You may feel tenderness at the base of, or over the thumb, or even a swelling or thickening. You may also bend your fist downward to further test for discomfort. A common finding with this test is the tenderness or pain felt over the thumb, which confirms tendonitis. Occasionally the pain may shoot (radiate) up the forearm.

TREATMENT OPTIONS FOR DeQUERVAIN’S TENOSYNOVITIS

The primary goal is to relieve the ache that is caused by the inflammation of the tendon sheath that the tendons pass through. Return to normal function usually occurs within 2-4 weeks. Most approaches are non-surgical, with surgery reserved for severe cases and those that don’t respond to non-surgical measures.

• Activity Modification: Limit and avoid activities that may directly aggravate thumb and wrist discomfort.
• Modify lifting activities of an infant
• Wear a wrist brace or splint: These are specially molded to protect and limit thumb and wrist movement.
• Apply ice or cold packs: Applied for 5-15 minutes to affected hand several times a day can help relieve discomfort.
• Use ergonomically designed tools: kitchen, gardening or handyman tools
• Do rehabilitation exercises such as wrist extension and flexion stretch, and supination and pronation of the affected forearm only if these do not cause further discomfort or pain.
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, naproxen or the newer COX-2 inhibitors (Celebrex/Arcoxia). Use in consultation with your doctor as prolonged use can cause gastrointestinal problems, ulcers, heartburn, etc.
• Cortisone injections: A cortisone-type injection can be administed by your doctor into the tendon compartment to rapidly reduce the tendon swelling (tendonitis). This may be used alone or in combination with other non-surgical treatments. This treatment should not be used more than twice to avoid any adverse effects that may occur with chronic steroid use.
• Surgery (compartment release): When symptoms are severe or do not improve, Surgery may be recommended. The surgery opens the compartment to make more room for the inflamed tendons, which breaks the cycle that occurs when the tight space causes repeated inflammation. The operation is performed through only a small incision, under local anesthesia and usually takes less than 20 minutes, usually as a Day-Surgery procedure. Pain relief is rapid and normal use of the hand is often restored in 1 to 3 weeks. The results of surgery are permanent and recurrence of the condition is rare.

One last word…

DeQuervain’s Tendonitis or ‘Mommy Thumb’ is a very common condition and in fact is very easily treated. Most mothers we’ve treated manage very well with non-surgical treatments, and as baby grows up in the first year and starts to crawl or walk, many of the aggravating factors are removed. During this period, proper advice and protection with splinting may be all that is required. Early treatment and intervention improves results. So don’t suffer in pain. Consult your doctor today.

To see if you have this condition, or what we can do to help relieve your wrist pain, contact our Specialist Hand Surgeon, Dr. Jonathan Y. Lee for a consultation at +65 6440 1200 or +65 6440 737 1100.

Dr. Jonathan Y. Lee also recently participated in the Wrist Dissection Course and Cadaveric Workshop, organized by the Singapore General Hospital on 14^th January 2011, to coincide with their hosting of the 2011 HMDP visiting expert for Hand Surgery, Dr. Marc Garcia-Elias.

The most recent wrist arthroscopy and reconstruction workshop was held at Tan Tock Seng Hospital where the facilities were excellent; the program well run and transitions were smooth. Having a ‘wet’ lab neatly tucked away in the basement, yet only footsteps away from a well-appointed conference room, dining and vendor display facilities made it clean and convenient, a definite plus point over the usual workshops where cadaveric labs are a bus ride away from the meeting venue.

There were more than 20 participants, hailing from Singapore, Malaysia, Indonesia, Hong Kong, Thailand and India, with both local faculty and an esteemed international faculty from Singapore, Switzerland, Australia and Hong Kong.

The packed and exciting program ran over 2 full days, and covered wrist arthroscopy techniques from basic to advanced, as well as the surgical management of distal radius fractures and scaphoid fractures. The material provided food for thought for both novice and experienced participants.

Participants were given ample opportunities to use wrist arthroscopy systems from both Karl Storz and Stryker. Various TFCC repair techniques were demonstrated including Smith & Nephew TFCC Mender disposable suture system. Fluroscopic equipment was available for percutaneous scaphoid fixation, and participants were able to work with and familiarize themselves with Synthes’s most recent 2.4mm volar and dorsal distal radius variable angle locking compression plates. As well as their headless counter-sinkable compression screw (HBS).

Invited faculty Dr. Ho Pak-Cheong (Hong Kong) shared his pioneering experiences extending the scope and application of wrist arthroscopy as a therapeutic and diagnostic modality; and impressed with his ideas and innovations, including arthroscopic assisted management of Distal Radius fractures, arthroscopic carpal fusions, bone grafting and ligament repairs while personally tutoring each participant in percutaneous scaphoid fracture fixations under fluroscopy.

Both Dr. Ladislav Nagy (Switzerland) and Dr. Jeff Ecker (Australia) are well known to our Hand Surgery community, having both contributed widely to the international hand surgery literature and leadership. Dr. Nagy through his long involvement AO Switzerland and the AO hand expert group, and Dr. Ecker being a leading hand and microsurgery educator in Australia, has visited and lectured in Singapore on many previous occasions. They demonstrated arthroscopic approaches and technique as well as open surgical approaches in the treatment of scaphoid and distal radius fractures. Attentive, approachable and knowledgeable, the faculty shared pearls from their experience in their lectures and bench-side teaching.

The workshop concluded with a lively case discussion, where participants contributed their own difficult cases for expert opinion and viewpoint. The discussion highlighted the ‘real-world’ application of principles presented during the workshop and was a powerful summary conclusion to a fruitful 2 days.

Participants and Faculty, at the TTSH 2nd Wrist & Distal Radius Arthroscopy and Reconstruction workshop 2011

Both the SGH wrist dissection course and the TTSH wrist and distal radius arthroscopy and reconstruction workshop compliment each other very well; with the Wrist Dissection course emphasizing open approaches to the wrist and surgical reconstruction of carpal instability, while the Wrist Arthroscopy Workshop demonstrates the rapidly expanding potential for minimally invasive therapeutic approaches to the wrist. Together, these courses form a comprehensive and detailed overview of current knowledge in management of wrist pathology.

Both courses had a robust didactic program, an experienced local and international faculty, balanced views and most importantly, the rare opportunity for surgeons to hone their skills and techniques on cadaveric specimens – giving them the confidence to apply these skills presently, towards improving the care of their patients.

These courses are an excellent addition to the regional hand surgery educational offerings, and we hope they will become regular recurring meetings. With their continued success and evolution, these courses will no doubt be a crucial platform to inform, update, innovate and elevate the standards of care in hand surgery.

[Dr. Jonathan Y. Lee]

viagra

In line with the seminar theme on managing pain, Dr. Jonathan Lee’s talk was on Managing Hand and Wrist Pain. Speaking to a full auditorium, Dr. Jonathan Lee spoke on causes of common causes of chronic finger, hand and wrist pain, focusing on commonly encountered conditions as Trigger Finger, Ganglion Cysts, DeQuervain’s Tendonitis, Carpal Tunnel Syndrome, Osteoarthritis and Wrist Instability. As well as other less common causes of hand and wrist pain such as tumors, TFCC (triangular fibrocartilage complex) injuries and repetitive strain injuries causing tenosynovitis.

Dr. Jonathan Y. Lee Speaking at the SPH Public Seminar on Hand and Wrist Pain.

Dr. Jonathan Y. Lee Speaking at the SPH Public Seminar on Hand and Wrist Pain.

Dr. Jonathan Y. Lee speaking to a full auditorium.

Starting with a brief introduction to the scope of the Hand Surgery as a surgical specialty, Dr. Lee described the evolution of the specialty from its origins in world war 2 to recent advances internationally such as hand transplantation. Applying recent improvements to our knowledge and concepts in hand conditions, to their application with new solutions and technology to improve patient outcomes. Dr Lee emphasized the complex anatomy of the hand and wrist, and how injuries and degenerative changes can result from overuse, occupation, sport, hobby or even your household chores. Hand and wrist pain can be debilitating and disabling, impairing function and affecting our ability to complete simple everyday tasks that we take for granted.

Topical issues like ‘blackberry thumb’, ‘cellphone elbow’ and ‘guitar hero wrist’, and long hours at the keyboard, highlighted how modern day habits can cause age-old hand overuse syndromes. While bringing a little humor to the conference hall, it also highlighted that we continue to injure our hands through common everyday activities.

Besides discussing causes, diagnosis and treatments for common hand conditions, Dr. Jonathan Lee also updated the audience on modern advances in Hand and Wrist surgery, such as the use of wrist arthroscopy and improvements in fracture fixation which have greatly improved the diagnosis and treatment of hand and wrist injury, and have allowed patients to regain the function faster, reducing time away from work and hobbies.

Emphasing the role of the hand surgeon in listening to patient’s individual needs and complaints, making an accurate diagnosis, often in the light of multiple concurrent hand problems, formulating a management plan (utilizing not only surgical but also non-surgical techniques) and supervising treatments. A good relationship with a knowledgeable and empathetic doctor can be very important in treating chronic long term conditions like arthritis.

The afternoon was concluded with a lively and enthusiastic response from the attendees who fielded many questions in the Q&A session following the talk.

Dr. Jonathan Y. Lee answering questions from the audience members after the talk.

Dr. Jonathan Y. Lee answering questions from the audience members after the talk.

Symptoms are often felt when the elbow is held in a bent position for a period of time, such as when holding the phone, or while sleeping, or after repetitive bending and straightening. When the pressure on the nerve becomes great enough to disturb the way the nerve works, then numbness, tingling, and pain may be felt in the elbow, forearm, hand, and/or fingers (usually the ring and little fingers). Some patients may notice weakness while pinching, occasional clumsiness, and/or a tendency to drop things. In severe cases, sensation may be lost and the muscles in the hand may lose bulk and strength.

Cubital Tunnel Syndrome - Ulnar Nerve compression at the Elbow

Surgical treatments for severe cubital tunnel syndrome traditionally required long recovery times, and minimally invasive approaches have been investigated.

Dr. Jonathan Y. Lee recently participated in the Endoscopic Peripheral Nerve Decompression workshop, held on 11^th March 2011, at the Advanced Surgery Training Centre, National University Hospital Singapore, organized by the Hand Surgery Department NUH and Karl Storz Endoskope.

Focusing primarily on Endoscopic Cubital Tunnel Release for Cubital Tunnel Syndrome, visiting experts Dr. Reimer Hoffman and Dr. Peter E. Bleuler shared their rationale, basis and experience of this minimally invasive technique.

Dr. Hoffman has himself performed more than 700 cases of endoscopic release of the Ulnar nerve for Cubital Tunnel Syndrome, and was instrumental in developing and describing the technique.

Utilizing special illuminated speculum, and endoscope with an optical dissector, Dr. Hoffman describes the evolution of his idea, adapting plastic surgical endoscopic facelift instruments to peripheral nerve surgery. This technique is simple yet elegant, significantly reducing the length of the resulting scars, potentially reducing morbidity and recovery times, while still providing magnification and accurate visualization of the ulnar nerve along its length, allowing safe decompression of the nerve over extended distances.

Dr. Hoffman describes Cubital Tunnel Syndrome as a multifocal compression neuropathy of the ulnar nerve, and espoused his personal philosophy and concept of ‘long distance decompression’ that he believes is the key to getting consistently good results in cubital tunnel surgery, regardless whether this is followed by other methods such as epicondylectomy or anterior transposition of the nerve.

Lectures by Dr. Hoffman on the anatomy of the ulnar nerve, pathology of ulnar nerve compression, surgical technique, results and clinical outcomes, was followed by Dr. Bleuler’s talk on technical tips and pearls to effectively and confidently perform the surgery, avoiding common pitfalls. Dr. Hoffman and Bleuler then went on to demonstrate their technique, both on video and on cadaver specimens, before personally mentoring the participants in practical cadaver surgery.

Dr. Hoffman speaking on Endoscopic Cubital Tunnel Release and Dr. Bleuler teaching the practical sessions.

In addition to Cubital Tunnel Release, Dr. Hoffman also demonstrated the potential for endoscopic approaches to DeQuervain’s release (1^st dorsal extensor compartment), pronator tunnel decompression, medial epicondylitis debridement; and endoscopic sural nerve and great saphenous vein harvest.

Drs. Aymeric Lim, Peter Bleuler, Jonathan Y. Lee, Reimer Hoffman, Peng Yong-Peng, Tan Ter-Chyan

Jonathan Y. Lee, who has been performing endoscopic carpal tunnel release surgery for carpal tunnel syndrome for many years, notes that endoscopic surgery can provide significant benefits in patient comfort and speed of recovery, while still providing safety and effective treatment of the condition. Dr. Lee sees great potential in the use of endoscopic techniques for other conditions, and cubital tunnel syndrome is indeed one area where there may be significant benefit, compared to traditional surgeries that took patients many weeks to recover from. “While we have to be selective and this technique may not be suitable for all patients with Cubital Tunnel Syndrome, it can offer significant benefits, reducing surgical morbidity when performed competently.” ” This will be an important addition to the available treatments for this difficult and painful condition.”

References:

Hoffmann R, Siemionow M. The endoscopic management of cubital tunnel syndrome. J Hand Surg [Br]. 2006 Feb; 31(1): 23-9. PMID: 16225971

Related Topics:

Mallet finger refers to the droop of the end joint where an extensor tendon has been cut or separated from the bone. Sometimes a piece of bone is pulled off (avulsion fracture) with the tendon, but the result is the same: an inability to actively straighten the fingertip.

Mallet Injury of the Index finger with loss of extension

Mallet finger commonly occurs in athletic injuries, and basketball players for example, routinely experience ‘jammed’ fingers. This injury may also occur due to a crush injury of the fingers on the job, or when fingers are accidentally cut while working in the kitchen for example. It sometimes follows a relatively minor injury, for example stubbing the finger. In mallet finger, the tendon that straightens the fingertip is disrupted, the fingertip ‘drops down’ and the ability to straighten the finger is lost.

Early treatment should be sought for this problem. If ignored, the tip of the finger will catch on things (causing further injury) and the first joint in the finger may compensate by bending backwards (swan neck deformity). If the injury is old, or if treatment is delayed, there may be permanent deformity and loss of finger extension.

Diagnosis

The diagnosis is often easily recognized from the history of the problem and by examining the finger, as the fingertip has a typical posture. An X-ray is performed to demonstrate whether or not there is an associated avulsion fracture.

Mallet Finger | Hand Surgery Singapore

Non-Surgical Treatment (Splinting)

Most mallet finger injuries can be treated without surgery, using a custom made splint that holds the tip of the finger in a straight position while the tendon or bone heals. Tendons heal slowly, and it is necessary to splint the finger for 6 to 8 weeks. At the end of the period of splinting, our hand therapists will initiate a simple exercise program to restore the movement of the fingertip, as initial temporary stiffness is expected after a period of immobilization. Splints may require regular checks and adjustments by our hand therapist to ensure that they fit well and are effective.

Splinting for Mallet Finger Injuries

It is absolutely important that the splint be worn all the time during the first 6 to 8 weeks of treatment to ensure maximum effectiveness and permanent injury or deformity to the finger. If you do need to take it off (for example to wash) then you must keep that finger straight and not allow it to bend. This allows the two ends of the torn tendon or bone to stay together and heal. About 3 in 4 cases heal well with this treatment.

Surgery for Mallet Finger

Surgery may be required to repair the torn tendon if non-surgical treatment is unsuccessful in restoring the ability to extend the finger.  Surgery may also be recommended immediately if there is an open wound.

In cases where there is an avulsion fracture and the piece of bone is quite large (causing significant joint surface irregularity), surgery may be advised to reattach the bone fragment using a small screw or stiff wire (K-wire).

Surgery may also be considered for patients who would be unable to work or would have significant difficulty if they had a splint on the finger; this includes patients who need to wash their hands frequently for example nurses or chefs and mothers with babies. The alternative treatment to a splint is a small operation where a fine stiff wire is passed across the finger joint to hold it in a straight position while the injury heals. The wire is buried under the skin at the tip of the finger, and removed at the end of the treatment. Insertion of the wire is a quick, minor operation performed under local anesthetic.

Mallet Finger injuries with large avulsion fractures are best treated with surgery

If you clip your fingers while stacking chairs, or your finger gets hit by baseball or basketball end-on, or you twist the end of your finger while tucking in the bed-sheets remember it could be a mallet finger injury. If you’re unable to straighten your finger after the injury, seek expert medical advice early, to avoid disability and maximize the success of treatment.

[For more information on surgical treatment, see our paper on treatment of bony avulsion mallet finger injuries]

Teoh LC, Lee JYL  J. Hand Surg (Br.) Feb 2007; 32(1): 24-30 Mallet Fractures: A novel approach to internal fixation using a hook plate.

The seminar is held in conjunction with the annual mega Health & You Exhibition, organized by The Straits Times Mind Your Body, Singapore’s leading weekly source of health news.

Dr. Jonathan Lee’s topic will be Managing Hand and Wrist Pain. Focusing on the common causes of chronic finger, hand and wrist pain, Dr. Lee will touch on such commonly encountered conditions as Trigger Finger, Ganglion Cysts, DeQuervain’s Tendonitis, Carpal Tunnel Syndrome, Osteoarthritis and wrist instability.

Besides discussing their causes and how to avoid them, Dr. Jonathan Lee will also present tips on First Aid for Hand Pain and outline when you need to seek medical help, how these conditions are diagnosed, how they can be treated with surgical and non-surgical methods; and how advances in Hand and Wrist surgery can help you.

Whether you suffer from hand and wrist pains because of your occupation, sport, hobby or even your household chores – help is at hand! If you suffer from hand and wrist pain, or know a friend or relative who does – Be sure to join us for our public seminar. See you there!

For an outline of what non-surgical treatments are available for Carpal Tunnel Syndrome, read our previous post.

Do I need Conservative (non-surgical) or Surgical Treatment for Carpal Tunnel Syndrome?

Treatment recommendations for carpal tunnel syndrome are based on several factors including symptom severity, duration of symptoms, evidence of nerve damage, presence of other medical conditions, and whether other non-surgical treatments have worked.

One useful research paper entitled Predictive factors in the non-surgical treatment of carpal tunnel syndrome, by Kaplan et al [published in Journal of Hand Surgery (Br.) 1990 Feb; 15(1): 106-8] proposed a way to identify patients that are likely to respond to the medical (non-surgical) management of carpal tunnel syndrome. 331 hands in 229 patients were evaluated in this study. Medical treatment included wrist splints and anti-inflammatory medication. These patients were followed-up for a period of an average of 15.4 months with a minimum of six months in some patients.

The average treatment success rate with this approach was 18.4%. However, when they stratified these patients into groups based on their symptoms and clinical tests, they manage to identify 5 factors that were important in predicting response to non-surgical treatment. These were:

1.  Age over 50 years,

2.  Duration of symptoms greater than 10 months,

3.  Constant paraesthesiae (numbness),

4.  Stenosing flexor tenosynovitis, and

5.  A Phalen’s test that is positive in less than 30 seconds.

When none of these factors was present, two-thirds (67%) of these patients were cured by medical (non-surgical) therapy. When any one factor was present, only 40% improved. When any 2 factors were present, only 16% of these patients improved and when 3 factors were present, those 7% of those patients improved. When a patient had four or five of these factors present, none of them were cured by medical management alone!

Simply put – the older you are, the longer you’ve had your symptoms, the more severe those symptoms are, and if you have other tenosynovitis conditions in the hand (e.g. trigger finger), then the less likely you are to improve with non-surgical treatments alone. In these cases, early surgical treatment provides better results and a more complete and rapid recovery.

Surgery decompresses the carpal tunnel, relieves the pressure on the median nerve and prevents the condition from progressing. This prevents permanent damage to the nerve that can sometimes lead to thumb muscle weakness and permanent numbness of the fingers.