WELCOME to Coastal Connections.
Coastal Orthopaedics provides advanced orthopedic care for adults, children and athletes. We have the finest orthopedic specialists that care for all your musculoskeletal needs. To help you understand what services we can provide, we have grouped our surgeons and services under five Orthopedic Centers of Excellence: Hand, Spine, Foot & Ankle, Sports Medicine & Shoulder and Total Joint Replacement. In this edition of Coastal Connections, we are showcasing our Hand Center. This Center of Excellence focuses on the treatment of the hand, wrist and elbow. It features articles from our two hand surgeons, Dr. Protomastro and Dr. Soojian, and an article from Lisa Cyr, one of our hand therapists.
If you have a problem or injury with your elbow, wrist or hand, call upon the experts at our Coastal Hand Center. Treatment begins with an evaluation by one of our experienced physicians. You can call the office and ask to be seen by one of our hand surgeons. You can also be seen if you fell or have acute pain in one of our two Ortho Express Urgent Care Centers located in Norwalk and now another in Darien. Once the diagnosis is made, a treatment plan is initiated and the Hand Center care team starts your road to recovery. Specialty trained occupational hand therapists run our Hand Therapy Center. They have a dedicated treatment area in our Norwalk office where they treat injuries and conditions of the upper extremity: shoulder, arm, elbow, forearm, wrist and hand.
We take tremendous pride in providing outstanding medical care and delivering a rewarding experience to each and every one of our patients. Our Ivy League trained physicians deliver exceptional care right in your own backyard. The entire staff of Coastal Orthopaedics is caring and committed to keeping our patients on the move.–Richard Lyon, Executive Director
The Hand Center
Hand, Wrist and Elbow Surgery and Treatment
THE HAND CENTER at Coastal Orthopaedics offers expertise from fellowship-trained board-certified and specialty-certified orthopaedic surgeons. Our doctors treat all problems related to the upper extremity – from the shoulder to the finger tip–and are subspecialists in hand surgery.
The Hand Center at Coastal Orthopaedics makes use of a multidisciplinary approach to hand and upper extremity care. Treatment begins with evaluation by an experienced physician. Dr Paul Protomastro and Dr Michael Soojian have provided hand and upper extremity related care in the greater Norwalk area for over 10 years. Whether the ailment they are presented with is simple or highly complex, the doctors and their support staff work with their patients to make an accurate diagnosis. On site diagnostic tools such as standard X-ray, musculoskeletal ultrasound and nerve conduction testing/electromyography are utilized on a case by case basis.
Our doctors pride themselves on creating thorough and conservative treatment plans. If and when surgery becomes necessary, it is typically performed on an outpatient basis in a nearby ambulatory surgery center.
Treatment at Coastal Orthopaedics’s Hand Center begins with a thorough evaluation to uncover the most difficult diagnoses and to formulate a personalized treatment plan.
Also integral to our patients’ care is our highly skilled team of certified hand therapists who help guide our patients toward fast and complete recovery. After an evaluation by one of our hand therapists, a comprehensive therapy program can be instituted to aid in recovery from injuries and surgery, to relieve pain from arthritis and tendonitis, and to educate in proper ergonomic adjustments in the work place.
de Quervain’s Tendonitis
By Michael G. Soojian, MD
IF YOU ARE experiencing a shooting pain from your wrist into your thumb, you may be suffering from a common form of tendonitis called de Quervain’s tendonitis. This condition gets its name from Dr Fritz de Quervain who first described it in 1895, and is often referred to by other names such as texting thumb, gamer’s thumb, and mother’s wrist. Anatomically, two separate tendons start in the forearm and pass through a small sheath or tunnel as they cross the wrist, before they attach to the thumb. Repetitive movements can cause these tendons to experience friction and lead to a build-up of inflammation within this sheath, which manifests as pain, swelling and a feeling of weakness with routine daily activities. This condition usually occurs as a result of repetitive gripping and lifting, and other activities such as swinging a hammer, using a cell phone, working in the yard or even carrying a baby. Less commonly, this problem can result from trauma, i.e. a direct blow or a sudden yank to the hand or wrist.
This condition usually occurs as a result of repetitive gripping and lifting, and other activities such as swinging a hammer, using a cell phone, working in the yard or even carrying a baby.
DeQuervain’s tendonitis can usually be diagnosed by physical examination which can detect swelling and tenderness over the tendon sheath. Many patients feel as though their “bone is sticking out” but in actuality it is a thickening of the soft tissue sheath they are feeling. X-rays can be taken to rule out other sources of pain, but in most cases end up being normal. In its early stages, DeQuervain’s tendonitis can often be successfully treated with bracing and oral anti-inflammatories such as ibuprofen. Occupational/Hand Therapy can also help some patients. When these simple treatment options fail to provide relief, cortisone injection is usually recommended and can cure this problem about 75% of the time. When all else fails, a minor surgery can decompress the tendons and definitively treat the problem. This surgery entails a brief trip to the operating room and is performed under local anesthesia that is usually combined with an intravenous sedative (“twilight anesthesia”). After the surgery, the hand and wrist are wrapped in a soft bandage for a few days and routine activities are encouraged. The majority of the symptoms usually resolve within two weeks, and most patients are pain free within four to six weeks.
By Lisa M. Cyr, OTD, OTR/L, CHT
Occupational Therapist/Hand Therapist
OSTEOARTHRITIS (OA) is one of the most common joint disorders and is one of the leading causes of disability in the United States. It affects as many as 12% of the American population over 25. One in 4 women and at least 1 in 12 men will suffer from the pain and loss of function caused by osteoarthritis (OA) of the carpometacarpal joint (CMC) of the thumb during their lifetimes. When the smooth cartilage covering the ends of the bones in the thumb wears away, the bones rub against each other, causing friction and damage to the bones and the CMC joint. This can cause severe pain, swelling, and decreased strength and range of motion, making it difficult to do simple daily tasks. This may lead to loss of function, depression and decreased quality of life, causing many people to ultimately seek surgical intervention for relief.
There are many potential causes for arthritis at the base of the thumb. Since the thumb is involved in at least 40% – 50% of every task that we do with our hands, it is subjected to many forces and strains throughout each day. Each time we pinch something between the fingertip and thumb tip, there is up to 25 times more force at the CMC joint than at the tip! Straining to open a new jar, holding a pen tightly when writing, buttoning tight buttons, pulling tight weeds, twisting a key in a stiff lock, trying to pull open a new bag of cereal or chips, holding pliers or other tools or overly large cups are all examples of ways we repeatedly strain our thumbs each day. Texting, with its repeated thumb motion, can irritate an already inflamed CMC joint.
These techniques are most effective when incorporated early in the disease when people first notice twinges of pain at the base of the thumb with pinching or gripping activities.
Research shows that the disabling effects of basal joint disease can be minimized with conservative interventions such as joint protection strategies, short term immobilization to rest the painful joint, and hand exercises.
A referral to a skilled Occupational Therapist/Hand Therapist for two or three sessions can help significantly decrease pain at the base of the thumb, and enable people to continue doing the activities most important for their quality of life. A skilled Occupational Therapist/Hand Therapist accomplishes this by educating the patient in joint protection techniques and adaptive equipment. Patients are either fitted with a custom thumb stabilizer or educated about an over the counter soft support to help rest the painful CMC joint. The patient is given a home exercise program to help delay the progression of the arthritis. These simple techniques have been shown to dramatically improve pain and function for many people with basal joint arthritis.
Find more information and detailed educational video clips in the “Occupational Therapy” tab under the “Providers” section at www.CoastalOrthoCT.com
By Paul D. Protomastro, MD
TENNIS AND GOLFER’S elbow are common orthopaedic conditions that lead to pain, weakness and disfunction of the elbow. Both conditions actually represent tears of the forearm tendons off of the humerus bone at the elbow. A tear on the outside (lateral) part of the elbow is known as Tennis elbow. A tear on the inside is known as golfer’s elbow. The muscles involved in this condition help to extend (tennis) and flex (golfer’s) the wrist. With both disorders there is degeneration of the tendon attachment usually following repetitive grasp or lifting activities and subsequent weakening of the anchor site leading to tendon detachment. Patients usually experience the insidious onset of elbow pain associated with activities in which this muscle is active, such as lifting, gripping, and/or grasping. Sports such as tennis, golf and weight training are common causes. The problem can occur with many different types of activities such as home renovation and gardening.
A direct blow to the bony prominence of the elbow may result in an acute tear or swelling of the tendon that can lead to degeneration. A sudden extreme action, force, or activity, such as starting a lawn mower, can also injure the tendon. The most common age group that this condition affects is between 30 to 50 years old. It affects both men and women with equal frequency. Pain is the primary reason for patients to seek medical evaluation. With tennis elbow the pain is located over the outside aspect of the elbow, over the bone region known as the lateral epicondyle, and is exacerbated by overhand lifting or power grip activities. With golfer’s elbow the pain is on the inside part of the elbow (medial epicondyle) and exacerbated by resisted wrist flexing or underhand lifting. The bone and tendon insertion often becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand. Occasionally, any motion of the elbow can be painful.
The bone and tendon insertion often becomes tender to touch. Pain is also produced by any activity which places stress on the tendon, such as gripping or lifting. With activity, the pain usually starts at the elbow and may travel down the forearm to the hand.
There are several theories as to why the elbow is so prone to these tendon injuries. Firstly, these tendons are taut and under great stress with repetitive wrist and hand activity. Secondly, the tendon origin is very small relative to the muscles that attach to them which leads to high forces on a tiny insertion site. Thirdly, these tendons have a very poor blood supply and take a long time to heal. All these factors result in prolonged pain and dysfunction in most cases. On average a case of tennis or golfer’s elbow takes 12-18 months to fully heal. On rare occasions people can be pain free and return to their sports, work or hobbies in 2-3 months.
TENNIS ELBOW TREATMENT OPTIONS
Initially, the activity causing the condition should be limited. Limiting the aggravating activity, not total rest, is recommended. Modifying grips or techniques, such as use of a different size racket and/or use of 2-handed backhands in tennis, may relieve the problem.
Anti-inflammatory medications may help alleviate the pain temporarily to make the tendon tear heal.
A tennis elbow brace, a band worn over the muscle of the forearm, just below the elbow, can reduce the tension on the tendon and decrease pain while using the arm and possibly allowing the tendon to heal.
May be helpful, providing stretching and/or strengthening exercises. Ultrasound, lasers, deep friction massage and heat treatments may be helpful by increasing blood flow and decreasing pain.
A steroid is a strong anti-inflammatory medication that can be injected into the area. These injections have been shown to temporarily decrease the pain of elbow tendonitis but do not help the tear heal. In fact, steroids may further harm the tendon and lead to chronic tendon damage. No more than (3) injections should be given.
Surgery is considered when the pain is incapacitating, has not responded to conservative care, and symptoms have lasted more than six months. Surgery involves removing the diseased, degenerated tendon tissue and then repairing healthy tendon back to the humerus bone. This 15-20 minute procedure is performed in the outpatient setting under sedation and local anesthesia. Recovery from surgery requires physical therapy to first regain motion of the arm and then a strengthening program after 6 weeks. Most patients can return to usual activities by 3-4 months. Complete recovery, including a return to tennis, golf and high impact/repetition work, can be expected to take 4–6 months. The success rate of this surgery is over 90%.