Hand Procedures – Reconstructive Surgery

Dr. Koumanis performs a significant amount of hand surgery in the Capital Region here in New York with patients coming from Syracuse, Albany, Saratoga Springs, Glens Falls and Surrounding areas.

 

Hand Procedures

Carpal Tunnel Release

Wrist pain-De Quervain’s Release

Trigger Finger Release

Ulnar Cubital Tunnel Syndrome (Ulnar Cubital Tunnel Release at Elbow)

Dupuytren’s Contracture Excision

Ganglions and Growths

Hand Injuries:

Tendon Repairs

Nerve Repairs

Bone Repairs

 

Carpal Tunnel Release (Carpal Tunnel Syndrome)

 

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome has patients complaining of symptoms of numbness, weakness and tingling in the arm, hand and fingers.

What is the carpal tunnel?

 

The carpal tunnel is a narrow passage starting at the wrist and going into the palm of your hand. Its boundaries are made up of bones and ligaments of the wrist in hand. In the hand the carpal tunnel  is located between the two humped areas at the base of the hand. A vertical wrist crease is usually found here. The carpal tunnel houses the flexor tendons that move the fingers and thumb and also the Median Nerve. The carpal tunnel roof is called the transverse carpal ligament. This is what is released during a carpal tunnel.

What causes Carpal Tunnel Syndrome (CTS)?

Excess pressure In the carpal tunnel can compress and irritate, and even damage the median nerve. Overtime, this can cause tingling and numbness in the hand and later on possible hand weakness and nerve damage.

 

Causes of carpal tunnel syndrome include anything that narrows or compresses the carpal tunnel itself.

 

This can include:

Diabetes

Rheumatoid Arthritis

Osteoarthritis

Thyroid Dysfunction

High Blood Pressure

Fractures of the hand or wrist

Retained fluid, swelling from pregnancy or menopause

Kidney Diseases

Tumors or Ganglions (rare)

 

One of the most common causes of carpal tunnel syndrome is prolonged use or exposure to power tools in your hands. These vibrations can cause chronic changes, fibrosis and swelling within the carpal tunnel. Positioning of your wrists in a flexed position and repetitive hand and wrist movements that overextend your wrists can also be a factor. Examples are playing the piano, typing, using a computer mouse etc.

 

People at risk for carpal tunnel syndrome may include smokers, obesity, high alcohol intake, and high caffeine and salt intake.  Women are 2-5 times more likely than men to be diagnosed with CTS.

 

How is Carpal Tunnel Diagnosed?

• History of your symptoms: Dr. Koumanis will go over the pattern of symptoms from tingling in your fingers to numbness when you wake up in the morning etc.
• Physical exam: A Phalen’s test and Tinel’s sign test is performed along with full examination of the wrist, hand and fingers. These tests will attempt at temporarily reproducing some of the symptoms associated with CTS.
• Xrays: Dr. Koumanis may ask for a an Xray if there is suspicion of a fracture, arthritis or mass in the carpal tunnel.
• Nerve conduction studies and Electromyelogram (EMG): This test measures nerve function and electrical impulses over the forearm and across the carpal tunnel into the digits. It can identify nerve damage and muscle damage in the affected areas. It also helps to rule out compression of nerves in other areas starting from the neck and down to the hand and fingers.

 

What is the treatment of carpal tunnel syndrome?

Non-surgical treatments:

• Wrist splints: Mostly worn at night while you sleep to help alleviate morning symptoms of pain and numbness. This can help in the early stages of the disease mostly.
• Pain relievers and anti-inflammatories: Non-steroidal anti-inflammatories such as ibuprofen (Advil, Motrin) or Celebrex type medicine, and acetaminophen can help relieve discomfort from CTS but does not have any curative effect.

• Steroid injections: sometimes Dr. Koumanis will recommend a cortisone shot (i.e. corticosteroid) to help relieve the pain, inflammation and swelling in the area.

 

Surgical Treatment:

Dr. Koumanis performs both minimally invasive and short scar open surgical techniques to release the Carpal Tunnel. The surgery is short and the wrist is infused with local anesthetic before you wake up to help keep you as comfortable as possible immediately in the postoperative recovery room.

 

Anesthesia: Carpal tunnel release surgery can be performed under local anesthesia by injecting the area fully with lidocaine. More commonly the procedure is performed under heavy sedation and local anesthetic combined. Patients remain comfortable and unaware of the surgery. Some patients require general anesthesia but not frequently.

 

Endoscopic Carpal Tunnel Release: the carpal tunnel is released through a small horizontal incision in or near the wrist crease. A small camera device is inserted into the carpal tunnel and with a direct view of the transverse carpal ligament and its surroundings. This provides the surgeon with a direct view and less of a chance of injury to the median nerve.

 

The Microaire release system which Dr. Koumanis uses also makes the procedure quick with less discomfort. Once in a while however the surgeon needs to convert the procedure to an open incision if the view is not clear on what is to be cut or the device cannot be properly used due to scarring or obstruction of the tunnel.

MicroAire® Smart Release System, courtesy MicroAire®

Notice the small incision at the wrist when undergoing the MicroAire® Endoscopic Carpal Tunnel Release

After Carpal Tunnel Surgery

• Keep your hand elevated above your heart to keep swelling down.
• Rest.
• May need to ice pack it on and off throughout the first day if instructed to do so.
• Move your fingers and thumb about 5 times throughout the day.
• Do not use the affected hand or wrist for any strenuous activity, tugging or pulling until cleared by Dr. Koumanis.
• Keep you hand/wrist dry and dressings intact; bag hand and wrist to shower keeping incision line dry.
• Stitches are removed around 10-14 days after surgery.
• More rigorous movement is allowed about 6 weeks after surgery.
• It may take a few months for hand and wrist to feel strong again and fully healed.
• Some patients require hand occupational therapy after carpal tunnel release

 

Complications

AS with any surgery, complications have been known to occur even though they are generally infrequent with carpal tunnel release. Please contact Dr. Koumanis with any concerns as delaying treatment can lead to damage to tissues and nerves.

 

Common complications include:

Infection

Bleeding

Scarring

Pain along incision

Nerve damage

Hand weakness

 

Signs and symptoms of infection:

Redness and swelling at incision site

Increasing pain not relieved by medication

Warm swollen hand or near incision

Fever over 100.4 degrees Farenheit

 

I strive to use a minimally invasive technique for carpal tunnel releases. This allows for a small incision at the wrist and therefore no incision is made in the hand where we grip and grab things. Dr. Koumanis prides himself in performing this procedure as he does all others with the utmost care and precision.

 

Please call for an appointment or you may be given a referral to us from your primary care physician for your carpal tunnel syndrome. We look forward to meeting you!

 

Wrist pain-De Quervain’s Release

 

What is DeQuervain’s tenosynovitis?

Tenosynovitis literally means inflamed tendons. Dequervain’s tenosynovitis is a painful condition affecting the extensor tendons on the thumb-side of the wrist. Patients may complain of pain at the wrist during grasping, gripping or while making a fist.

 

Signs and Symptoms of DeQuervains tenosynovitis

Pain on moving the wrist or thumb

Pain that radiates into the thumb, hand and sometimes up the forearm

Redness

Swelling

 

You may have or several of these symptoms.

 

Causes

The cause of  Dequervains tenosynovitis is uncertain for the most part. However, it may be linked to repetitive or overuse of the thumb,grasping, sports and possible workplace activities. Whether these cause the issue or make it worse is unclear.

 

Diagnosis

I will perform a hand exam including a “Finkelstein test.” You will be asked to place your thumb in your palm and curl your fingers around it making a fist.Then you will be asked to bend your wrist down towards your small finger. If there is DeQuervain’s tenosynovitis, this may elicit some discomfort in the wrist and thumb as the tendons are pulled through a tight and inflamed tendon sheath. Sometimes you will be required to get hand and wrist xrays to rule out any underlying arthritis that may be causing the issue.

Finkelstein Test

Treatment

Non-surgical treatment such as wearing a splint 24 hours a day for 4 to 6 weeks  may be recommended first. Resting the wrist and refraining from aggravating activities is also recommended.

 

You may require anti-inflammatory medication and icing the area or possibly a corticosteroid inject at the site. This may help alleviate some of the pain and swelling.

 

If any of the above treatments don’t help then we recommend surgical release of the extensor compartment and sheath. This is a minor procedure performed with a small incision over the wrist below the thumb.

 

Sometimes Dr. Koumanis will recommend surgery right away depending on the situation and how long you have had the symptoms.

 

Trigger Finger

What is trigger finger?

Trigger finger causes the finger or thumb to click or lock when flexing it. The finger can remain in a flexed position due to it being locked. This can sometimes be painful. When it involves the thumb it is called trigger thumb. The tendon glides through a sheath or canal as we flex and extend the finger. In the canal there is a lubricating membrane called synovium which helps nourish the tendon and facilitate glide.

If the tendon sheath or tendon becomes inflamed, the tendon will have difficult time gliding smoothly through the sheath and overtime can become scarred or swollen. When this occurs, flexing the finger or thumb can cause it to lock, click or pop.

 

Causes of Trigger Finger

Trigger finger can be caused by repetitive movements or hard labor (eg. use of power tools). Medical conditions such as gout, arthritis and diabetes can also contribute to the condition.

Trigger finger occurs in women more often than in men. IT is most common in 40-60 year olds. Children can also be affected by trigger finger. Musicians, manual labor jobs, farmers have a higher incidence of trigger finger due to repetitive movements involved in their day to day work.

 

Symptoms of Trigger Finger

Pain or tenderness at the base of the palmar surface of the finger or thumb. This sometimes extends slightly onto the pam of the hand directly beneath the affected digit. Patients will often complain of discomfort on bending the finger as well as snapping, clicking or locking of the affected thumb or finger. If the digit becomes locked patients must often use the other hand to gently release the locked finger.

 

Diagnosis of Trigger Finger

Trigger finger is diagnosed with a physical exam of the thumb and fingers. The base of the finger may be swollen and a hard nodule is sometimes palpable.  This represents swelling and possibly scarring of the tendon sheath.

The finger may also have a palpable click, pop or snap when bending it actively and sometimes passively.  The finger may lock into place in a flexed position as well.  X-rays or other tests are usually not required to diagnose a trigger finger or thumb.

 

Treatment of Trigger Finger

Resting the finger and using a splint to keep the finger from bending sometimes helps early signs of a trigger finger.  He may need anti-inflammatory medication such as ibuprofen or naproxen.  A corticosteroid injection sometimes helps to alleviate the trigger finger in early stages as well and that is injected into the tendon sheath usually with minimal discomfort.

If the trigger finger has been long-standing, Dr. Koumanis may suggest surgery.  The surgical incision is small and the procedure is considered a minor procedure.  It usually takes less than 30 minutes.

 

Recovery Time for Trigger Finger

It usually takes about 2-4 weeks to recover from conservative treatment such as splinting and corticosteroid injection.  Full recovery from surgery can take about 4 weeks and sometimes patients require some occupational hand therapy for few weeks as well.  However, most patients can perform the exercises at home on their own.

Please fill out the online consult form and request an appointment with Dr. Koumanis for more information and treatment options or call our office at 518-203-2593.   We look forward to taking care of you.

 

Ulnar Cubital Tunnel Release

 

What is Ulnar Cubital Tunnel Syndrome?

This is a syndrome caused by compression of the nerve at the elbow near the funny bone,causing  pain, numbness, tingling and sometimes muscle weakness in the forearm, wrist and hands.  It is also known as ulnar neuropathy.

 

Causes of Ulnar Cubital Tunnel Syndrome?

Repetitive use or bending of the elbow for long periods of time or putting pressure on the elbow against a hard surface. Sometimes bone spurs or other structures at the elbow may be causing nerve compression.

 

Symptoms of Ulnar Cubital Tunnel Syndrome

Pain in the elbow, forearm, or hand

Numbness or tingling in the ring and small finger

Weakness in the ring and small fingers affecting hand grip

Difficulty in performing pinch between the thumb and little finger

Claw deformity of the hand

Atrophy or muscle wasting of the hand

 

Diagnosis of Cubital Tunnel Syndrome

Diagnoses can sometimes be performed solely with physical exam. Dr. Koumanis may order a nerve conduction study to confirm the diagnosis.  This is called an electromyography procedure or EMG.  This is the same procedure used to diagnose carpal tunnel syndrome  with small electrodes placed into the skin and muscles of the arm, forearm and hand to identify nerve conduction and any nerve damage. Sometimes it may be helpful to get an x-ray to make sure there are no bone spurs or arthritis in the elbow joint compressing the ulnar nerve.

 

Treatment of Cubital Tunnel Syndrome

 

Nonsurgical Treatment

Nonsteroidal anti-inflammatory medication: If it is early on and only recent, he may be started on an anti-inflammatory medicine such as ibuprofen or naproxen.  This will help reduce swelling and inflammation and pain around the joint and the nerve.

Splints: He may be asked to wear a padded splint to keep the elbow joint straight or extended.  This protects the joint and decreases compression of the nerve.

Physical therapy: Sometimes exercises with physical therapy help reduce inflammation in the area and allow the nerve to move in and out of the canal and improved symptoms.

 

Surgical Treatment

Surgical treatment is recommended when the non-surgical treatments have failed to improve the condition.  The ulnar nerve is very compressed nothing is helping or the patient is experiencing muscle weakness and nerve damage.

The procedure involves an incision around the elbow to release pressure of the ulnar nerve.   This is usually done by cutting the ligaments that house the ulnar nerve.  After cutting the ligaments if it is felt that the now still too tight the nerve may be transposed from the medial epicondyle or funny bone area to more lateral outside area in the front of your forearm.

 

Postoperative Recovery

Recovery time for this surgery is anywhere from 3-6 weeks.  He may be recommended to wear splint from a 2 weeks to approximately 6 weeks depending on how involved this surgery is and if the nerve needed to be transposed removed.

We may also recommend physical therapy exercises to help with range of motion and strengthening of the forearm and elbow joint.  We will talk to you in detail depending on your condition on when you will be able to return to work in normal activities.

The surgery method is a true try technique and the results are usually good.  However everyone is different and it depends how much nerve and muscle damage was already done whether function can return to normal.  Nerves to take time to recover and can sometimes take up to a year to realize the full extent of nerve healing. But again, most people are back to performing full activities by 6 weeks.

Please fill out the online consult form and request an appointment with Dr. Koumanis for more information and treatment options or call our office at 518-203-2593.   We look forward to taking care of you.

 

Dupuytren’s Contracture Excision

 

What is Dupuytren’s contracture?

Dupuytren’s contracture is a disease of 1 of the layers of the palm of her hand just beneath the skin called the fascia.  The skin usually thickens as the underneath layer contracts and becomes hard.  As the disease progresses skin  on the palm of the handMay revealed pitting or dimpling.

As this fascia thickening and contracture progresses records form and can tighten your fingers and pulled them in a flexed or bent position towards your  palms.  If left unchecked, this can sometimes be a debilitating condition to the hand and fingers.

The most common areas affected are the palms, the ring and small fingers.  However other fingers have been shown to be involved and rarely the thumb.  It can occur in both hands however usually one hand is more severe than the other.

 

What is the cause of Dupuytren’s contracture?

The exact cause of Dupuytren’s contracture is unknown.  However, there are certain risk factors associated with this condition.

 

Risk factors:

• Gender: Menarche 3 times is likely to develop Dupuytren’s and their contractures are more severe

• Age: Dupuytren’s contracture commonly occurs after the age of 50 however can be later for women

• Ancestry:  There is an increased incidence in people from Northern Europe including Celtic in her we can ancestry.

• Genetics: Dupuytren’s disease can cluster around generations of families.

• Smoking tobacco

• Alcoholism

• Diabetes.

• Hypothyroidism

• Seizure disorder

• Medications: Dilantin

Dupuytren’s contracture can also affect the knuckle pads, plantar fascia were soled feet and contractures of the penis ( Peyronie’s disease)

 

Diagnosis

The diagnosis is usually made by physical examination of the hands.  Other tests are rarely needed.  Sometimes hand x-rays are taken to make sure that the joints are free and healthy from disease and arthritis so that when surgical release is completed the patient can experience maximal benefit and stretching out the finger across the joints.

 

Treatment

 

Nonsurgical

 

Enzyme injections: An enzyme called collagenase Clostridium histolytica him or trait name Xiaflex is injected into the cords of the palm and the fingers or any affected areas.  The surgeon then manipulates the fingers and hand to break the cord and straighten the fingers after the enzyme has dissolved some of the diseased cord  or fascia.

 

Needle technique: a needle is inserted through the skin to puncture and break the cord causing the contracture of the palmar finger. The recurrence rate for this are similar to enzyme injection but higher than surgical excision.  However this can be repeated multiple times.

 

Surgical

People with more severe or advanced disease require surgical removal of all affected tissues in the palm and fingers. This is done in the operating room.  In some cases if the skin is diseased it is excised and a skin graft is needed to cover the open wound of the finger palm of the hand.  Surgical excision of Dupuytren’s contracture is the most invasive of all the treatments however is associated with less recurrence.

 

Recovery

Recovery from the surgical procedure is approximately 4 weeks.  The first dressing change occurs at the doctor’s office and wound care instructions are usually simple and straightforward from that point on.  Patient’s are usually asked to keep the hand dry for the first 2 weeks until things heal well.  At about 3 weeks physical hand therapy is begun in order to optimize range of motion and stretching of the palm and fingers.

 

Please fill out the online consult form and request an appointment with Dr. Koumanis for more information and treatment options or call our office at 518-203-2593.   We look forward to taking care of you.

 

Ganglions and Growths

Ganglions are usually small benign fluid-filled sacs found most commonly at the wrist and hand. They are essentially small lumps under the skin.  They usually do not cause pain but when they grow large enough to ruband compress against a nerve patients do complain of discomfort. Especially on movement of the wrist or fingers.

 

How do they form?

It is unclear how they form. One theory is that they occur after trauma, or after banging the area against something but this is not proven. Since ganglion cysts are filled with similar synovial fluid found in joints and tendons, one theory states that a break in the joint capsule causes the fluid to leak and form a sac outside of its original location. Since most ganglions are attached to a joint surface this is a reasonable explanation.

 

How is it Diagnosed?

For the most part, a simple physical exam by Dr. Koumanis will diagnose the problem. Rarely do Xrays help and an MRI is rarely ordered unless there is a suspicion of another type of mass. This is extremely rare however.

Usually you can make the diagnosis by shining a flashlight into the cyst to reveal its fluid filled sac.

 

What is the treatment?

Options:

1. Watch and wait approach if no pain or discomfort
2. Splinting in order to deter it from growing
3. Surgical excision

 

Many patients choose surgical excision as the procedure is a minor one performed as an outpatient surgery. There are minor risks to the surgery for the most part. Dr. Koumanis will explain all of this during your visit.

 

Other Hand Growths:

1. Skin cancers
2. Glomus tumor of the finger
3. Giant cell tumor
4. Nerve Tumors

 

Dr. Koumanis examines and treats all types of hand and finger growths. After examination, diagnostic tests such as Xrays or an MRI may be needed for diagnosis. Once all of the examinations are complete, a treatment plan is discussed in detail.

Please fill out the online consult form and request an appointment with Dr. Koumanis for more information and treatment options or call our office at 518-203-2593.   We look forward to taking care of you.

 

HAND INJURIES

Dr. Koumanis is an expert at hand trauma.It has been an essential part of his training and practice for the last 15 years. He deals with bones, tendons and nerve injuries in the hand and fingers and repairs tendon, nerve and muscle injuries of the forearm as well.

 

The following hand injuries are seen and treated in our practice:

1.Tendons

2. Nerves

3. Bones

4. Ligaments

5. Nail Bed

6. Finger Amputations

7. Soft tissue defects of the hand and fingers

 

Most hand injuries occur due to:

1. Work-related accidents
2. Machine related injuries (e.g. snowblower, table saw)
3. Sports injuries
4. Kitchen accidents
5. Home or gardening accidents

 

Dr. Koumanis may see you as a follow up after the ER physicians have closed the wounds temporarily if they are able to. You will then be evaluated in the office for need of surgical repair. From time to time some injuries require emergency surgery to be performed immediately after evaluation in the Emergency Department.

 

Please fill out the online consult form and request an appointment with Dr. Koumanis for more information and treatment options or call our office at 518-203-2593.   We look forward to taking care of you.