Award Winning Research on Tendon Repairs

Research performed at Maimonides Medical Center Department of Orthopedic Surgery recently won an award for best basic science research at the at the Brooklyn and Long Island chapter of the American College of Surgeons and the Brooklyn Surgical Society. This groundbreaking research evaluated the use of connective tissue growth factor (CTGF) added to a collagen scaffold to help with tendon healing. The ultimate goal of the research is to use biological augmentation in flexor tendon repairs so that early mobilization programs can be utilized. The results showed that adding CTGF to a wound gap led to improved cellular healing, proliferation and angiogenesis. Ultimately this research can lead to stronger repairs of flexor tendons that will improve patient outcome after these devastating injuries. the researchers Kevin Kang M.D., Jinny Jacob MS and Jack choueka M.D. are to be congratulated for their efforts in winning this prestigious award.

Ganglion cysts

Ganglion cysts are extremely common conditions that occur about the hand and wrist. They can be found on on nearly every part of the hand and wrist. Ganglion cysts are usually painless and people may wait long periods of time before noticing them. They can be large or small usually painless but sometimes they can cause problems.

Ganglion cysts usually originate from a joint. Every  joint is covered with a capsule and connected with ligaments and sometimes because of trauma, or for no reason at all, a small hole in the in the covering of the joint develops and the fluids in the joint starts to escape. This forms a balloon or sack with fluid entering the sack.  Over time the sack  can become thickened  and the fluid within it can become thickened as well. In fact the fluid within the cyst becomes gelatinous jelly like.



Volar ganglion cyst



Ganglion cysts that appear in the back of the wrist are called dorsal ganglionic cysts  and those that occur on the palm side of the wrist they are called volar ganglionic cysts. Cysts can occur within the tendons of the hand and these are called retinacular cysts.  When they appear at the tip of the finger beneath the nail they are called mucous cysts.

Ganglion cysts can usually be diagnosed easily with a history and physical examination. X-rays and MRIs are usually not needed however if there is any question your Dr. will likely order an MRI to rule out any other conditions that may be more serious. Often a simple flashlight test can help diagnose the ganglionic cyst. Since the cyst is filled with fluid placing a light at the base of the mass will cause the ganglionic cyst to illuminate and this is helpful in making the diagnosis.

There are a variety of treatments available for ganglionic cysts but the most important decision is whether to treat it at all.  Reasons for treating ganglionic cyst include cysts that are painful, cysts that are causing damage to structures in the area such as nerves, arteries or tendons, uncertainty about the diagnosis, and cosmesis. Many people have the cyst removed because they don't like it or don't like the way it looks and this is reasonable.

The main treatments available for ganglionic cysts include aspiration or excision. Aspiration of the cyst involves putting a needle in the cyst cavity and removing the fluid. As you can imagine while this removes the fluid it leaves the sack in place which is sometimes absorbed by the body but other times it refills with fluid. A more definitive way to remove the cyst is to take it out surgically. This is often done under local anesthesia with a small incision however in certain places it can be done arthroscopically



MRI showing ganglion cyst (white ball)



The most important take-home message about ganglionic cyst is making the correct diagnosis.  If there is any question that it is not a cyst you should see your doctor.

Dr. Jack Choueka

Adult and Pediatric Upper Extremity Surgeon 

Chairman of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at theHospital for Joint Diseases Orthopaedic Institute and his fellowship in upper extremity and microvascular surgery at the University of Chicago

 Dr. Choueka can be reached at 718-283-7400.

Arthritis

ARTHRITIS

Osteoarthritis, or degenerative joint disease, is one of the most common causes of pain. This condition is caused by the deterioration of the cartilage at the ends of your bones. As this hard, yet slippery, material wears away, the bone edges can be exposed and can rub against each other, causing swelling, fluid build up, loss of motion and pain. Osteoarthritis can affect all joints in the body, most commonly the hips, knees, shoulders, fingers and spine. Often described as the result of “wear and tear,” this painful grinding sensation may stop people from doing the activities they enjoy.

Diagnosis:

Your doctor will first listen to the story of how the pain affects you. Following this, you will be examined. X-rays are also a main part of the diagnostic process. Your doctor may also order other tests, such as an MRI or blood tests.

Treatment:

Many treatments exist for arthritis. Doctors most often start with non-operative treatment, including oral or topical medications, activity modification, assistive devices that include a brace or cane, and physical therapy (exercises to strengthen muscles, keep the joint limber and keep your whole body in shape). Often, with a combination of settling the inflammation with medication and exercise to strengthen the muscles around the joint, the pain from mild to moderate arthritis can be controlled. Eventually your doctor may offer an injection, either of a steroid containing mixture (a “cortisone shot”), or a series of synthetic joint fluid supplementation into the joint.

Ultimately, there is no way to build up diseased cartilage once it is diseased. As pain progresses, surgery might be an option. Arthroscopy (minimally invasive surgery with a camera) is sometimes used in arthritis to “clean up” an inflamed joint. Eventually, joint replacement will be offered as a solution. In this procedure, the diseased cartilage is removed, and both sides of the joint are capped with metal. Patients often feel relief within weeks, and are back to their previous level of activity in a month or two.

Knee Replacement Surgery

What you can do:

• Stay active: walking and low impact exercise keeps joint mobility, blood pumping and good general condition. Start with a slow warm up and rest frequently
• Eat well: This can help reduce your weight (which will decrease stress on your joints) and help prevent other health problems
• Stop smoking
• Talk to your doctor about all aspects of treatment

Dr. Howard J. Goodman

Adult and Pediatric Musculoskeletal Oncology and Joint Replacement Surgery

Telephone:  718-283-7450

Dr. Goodman is an orthopaedic surgeon who is specially trained in taking care of benign and malignant bone and soft tissue tumors in both children and adults. He has experience in limb preservations techniques, including massive endoprostheses, expandable prostheses for growing children, and allograft. He also performs hip and knee replacement and revision surgery. Dr. Goodman treats hip, knee, and shoulder arthritis, malignant and benign bone tumors, bony metastatic disease from other cancers, soft tissue “lumps and bumps” – benign and malignant masses in the extremities, and salvage of “accidental sarcoma resections.”

 

Fluoroscopy better than x-rays in diagnosing certain wrist conditions

Fluoroscopy Vs. X-rays

Fluoroscopy using a low radiation dose mini C-arm has many advantages.  It is easier to manipulate and position the injured arm in order to obtain the necessary images. It is more efficient and safer than traditional x-rays since it uses less radiation, and now researchers at Maimonides Medical Center have shown that fluoroscopy is better at diagnosing ligament injuries in the wrist compared to traditional x-rays.

Dr. Jack Choueka,  Chairman of the Department of Orthopedic Surgery at Maimonides Medical Center in collaboration with one of his residence Dr. Philip Lahey evaluated 26 patients to determine which allowed for a better diagnosis of a ligament tear in the wrist. Dr. Choueka says "fluoroscopy allowed minor corrections in the position of the wrist that made diagnosis of ligament tears much more apparent"

Flouroscopy of the wrist

The study was presented at the American Academy of Orthopedic Surgery Las Vegas. Dr. Choueka now uses fluoroscopy almost exclusively for diagnosis of these conditions in his office. "There's less radiation, no processing time and it allows perfect positioning of the wrist to make an accurate diagnosis"

The research showed that gaps in the bone as small as 2mm could be diagnosed with the fluoroscopy and not with standard x-rays.

Dr. Choueka positioning the wrist for flouroscopy

As for the use of fluoroscopy in other areas Dr. Choueka says "is has become an invaluable tool for the safe accurate diagnosis of innumerable conditions in the upper extremity". It is used to diagnose fractures, ligament injuries, look for tumors and makes comparison to the other arm much easier. For kids it makes the x-ray experience much easier and even fun since the kids can see their bones moving on the screen.

Dr. Jack Choueka

Adult and Pediatric Upper Extremity Surgeon 

Chairman of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at theHospital for Joint Diseases Orthopaedic Institute and his fellowship in upper extremity and microvascular surgery at the University of Chicago

 Dr. Choueka can be reached at 718-283-7400.

Scoliosis....Early detection can prevent late problems

SCOLIOSIS

The sooner it’s detected, the better the chances of correcting it

Scoliosis is a common condition found in both children and adults, and it is most often diagnosed in adolescence.  Fortunately, it can usually be treated, especially when it’s diagnosed early.

Scoliosis usually presents itself as some form of asymmetry, from uneven shoulders to an uneven waist or hips.  An X-ray can confirm the diagnosis and help the doctor assess the shape and the degree of the abnormal curvature.  Often, the cause of the scoliosis is idiopathic (no underlying cause); however, it typically runs in families and girls are more prone to this than boys.   Most children with scoliosis do not require treatment because the curve in their spine is so minor.  However, they should still be checked by a physician on a regular basis as they continue to grow to make sure that the condition does not worsen. 

A back brace, which is a common treatment for scoliosis, does not reverse the condition, but can prevent it from progressing.   Severe scoliosis, if allowed to progress, can cause serious problems down the road, from back pain to pulmonary problems that cause difficult breathing.  In rare cases, surgery may be necessary.  In the surgical procedure, the spine is encouraged to fuse so that it will stabilize and not continue to curve abnormally.

The key to fixing scoliosis is early detection and intervention.  The younger and more flexible a spine is, the better the chance of encouraging it to keep its normal shape. 

Dr. Juan Carlos Rodriguez

Adult and Pediatric Spine Specialist

Tel: 718-283-6520

Trained in complex spine surgery, Dr. Juan Carlos Rodriguez treats pediatric and adult patients with pain or back deformities. Dr. Rodriguez graduated with MD and PhD degrees from Universidad de Salamanca and Universidad Complutense de Madrid, respectively. He is fellowship trained in Surgery from the Hospital for Special Surgery and in Spinal Surgery from New York University Hospital for Joint Diseases.  Dr. Rodriguez specializes in treating scoliosis.

Is too much texting dangerous...

  

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Do you over-text?   Will your thumb, hand, arm and neck suffer due to the “must send” messages that you type on the tiny keypad of your phone daily?    Orthopaedic hand surgeon David Edelstein claims that avid texting may cause pain not only to your thumbs, but also to your hand, arm and neck.

Because of the nonstop usage of phones, laptops and handheld gaming devices, repetitive stress injuries are more common than ever.   In the predigital age, people took breaks from typing; nowadays people don’t stop typing (or texting).  People are on the computer all day at work, text at their lunch break, and go online at home.   Excessive texting and typing can lead to pain in hands (especially the thumbs), arms, shoulders and neck.

To prevent pain from texting, Dr. Edelstein recommends:

• Avoid sitting in the same position for extended periods.
• Get up and take breaks.
• Pay attention to posture. When seated at a desk, your monitor should be at eye level, your arms should be bent at a 90-degree angle, your knees should be bent at 90 degrees and your feet should rest on the floor.
• Many people hunch over when texting because they're trying to see the tiny keyboard. To keep from putting added pressure on your neck and upper back, rest the mobile device on your desk and lean against the chair's backrest.
• Use both thumbs and give your thumbs a break when typing long messages.
• If you experience soreness, stop texting. Anti-inflammatory medications such as Advil or Motrin can also help.

Dr. David Edelstein

Upper Extremity Surgeon

Tel: 718-283-8927

Dr. David M. Edelstein specializes in orthopaedic surgery of the hand and upper extremity and treats arthritis, broken bones, congenital hand problems, tendon injuries, and pain in hands, wrists, or elbows. Having graduated from Albert Einstein College of Medicine, Dr. Edelstein completed his Orthopaedic Surgery Residency at Maimonides Medical Center and his Fellowship in Hand Surgery at the Hospital for Joint Diseases. Because of Dr. Edelstein’s expertise, he was quoted by Forbes and MSN in articles about text messaging.

Simultaneous Cardiac and Hip Surgery

 Simultaneous Cardiac and Hip Surgery at Maimonides Medical Center

Patients with cardiac disease have double the risk of developing hip fracture and hip fractures often occur in patients that have symptomatic heart disease. These patients often need cardiac surgery before their hip fracture can be addressed. This requires patients to have two major operations in one hospital stay. Since it is imperative that patients undergo hip surgery as quickly as possible in order to decrease complications, having to  undergo cardiac surgery first can increase complication rates. There is a theoretical benefit of combining both cardiac and hip fracture procedures. This can decrease exposure to anesthesia, decrease the hospital stay and decrease the time of patient immobilization. The prospect however of doing both surgeries simultaneously is daunting for patients and surgeons as well.

At Maimonides Medical Center patients identified with needing both surgeries have been having them simultaneously with excellent results. A total of eight patients in the last several years have gone through this procedure combining the cardiac and hip surgery during the same operation. The results have been excellent with no increased complications seen in this group of patients and no extended hospital stays were needed. These results have been presented at several National Orthopedic Meetings. Maimonides Medical Center continues to stay on the cutting edge of both cardiac and orthopedic surgery providing even the most complex of patients with exceptional state-of-the-art care.

Dr. Jack Choueka Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Is computer use as dangerous as drinking...

"Saturday Night Palsy" revisited

"Saturday at night palsy" is generally used to refer to a nerve compression that happens to people when they fall asleep inebriated or intoxicated on their arm. They wake up in the morning with numbness and weakness of the hand and wrist. This results from pressure on the nerves in the arm pushing against the solid surface. The condition usually involves the radial nerve which runs right along the humerus which is the large upper bone in the arm. Researchers at Maimonides Medical Center and the University of California at San Diego have teamed up to reinvestigate this phenomena. Using a longitudinal prospective nationwide epidemiological database researchers have been able to identify patients who present to emergency rooms with these complaints and determine the causes. Surprisingly a similar number of people presented to emergency rooms with these complaints not after falling asleep on their arm when drunk but rather falling asleep on their arm while on the computer.

 “It's a sign of the times” says Dr. Jack Choueka, Chairman of Orthopedic Surgery at Maimonides Medical Center. “People sitting at the computer can lose track of time and fall asleep at their desks, which can lead to many problems including nerve compressions and the arm. This can lead to temporary or even permanent loss of function in the hand” The researchers caution patients to be careful about spending long hours at the computer especially at night.

Dr. Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon and Chair of Orthopaedic Surgery at Maimonides Medical Center.  Award winning hand surgeon Dr. Jack Choueka provides treatment for all disorders of the upper extremity, including carpal tunnel syndrome, arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements.

Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400

Preparing For Your Visit with the Doctor

Preparing For Your Visit with the Doctor

Thank you for choosing us for your Orthopedic healthcare needs. We know you have numerous options for your healthcare and therefore want thank you for entrusting your care to us. We continually strive to provide the highest level most compassionate care available.

For many people coming to the doctor's office can be frightening, however a little preparation and having proper expectations can make the experience more pleasant. You and your doctor are partners when it comes to your health and therefore it is important that you are prepared for your office visit.

The Day Before Your Visit

The day before your visit someone from the office will contact you to confirm your appointment time. If you need to cancel or reschedule we will do our best to accommodate you.

Your Visit

Paperwork:  As in most other doctor’s offices on your first visit you will be given several forms to fill out mostly concerning your current complaints,  your past medical and surgical history and your medications. It is important to fill these out accurately and that the Doctor know about your medical problems and current medications so that appropriate and safe treatments can be rendered.

The History: The first thing the doctor will do when you meet him is to take a detailed history of your condition. Be prepared to answer questions concerning the location of the pain, how long it's been present, any aggravating  or alleviating factors and any treatments that you may have received.  If you have had any studies such as x-rays or MRIs, have them available for the doctor to review. You know your condition better than anyone, so this is the time to tell the doctor so that he could render an accurate diagnosis.

The Physical Examination: Following the history the Doctor will perform a physical examination in order to help them determine your diagnosis. He may examine parts of the body that you may not think are involved but may have impact on your diagnosis. For instance, if you have numbness in your hands the doctor will examine your neck to see if the condition is coming from a pinched nerve. It is helpful to come dressed appropriately to avoid having to undress completely. For instance if you're coming complaining of elbow pain, wear a tank top underneath your shirt to allow access to your entire arm.

X-rays: After doing a history and physical examination the doctor may need additional studies in order to make a diagnosis and offer an appropriate treatment. The office has an x-ray and fluoroscopy suite, where many of these tests can be performed. Sometimes certain studies need to be taken at an outside facility and the office will help you make arrangements.

Ask questions: After formulating an opinion and offering a treatment plan, the doctor will ask if you have any questions.  It helps if you prepared questions beforehand and have them written down. The doctor's office can be intimidating and often people forget the questions they had in mind.

Bring a friend or family member:  It is always helpful to have someone with someone with you at the doctor's office. They can help you remember questions you may have had and fill in important information that you may have forgotten

Take notes: There will be a lot of information exchanged during your visit including your diagnosis, treatment plans, potential outcomes, possible complications and so on.  It can be very difficult to remember all of this, and taking notes can be helpful.

Repeat what you've heard:  One of the best ways to let your doctor know that you want understand his opinions, is to repeat what you’ve heard in your own words. This is an excellent way of avoiding any miscommunications or misinformation during your visit.

Second opinions: Medicine is an art as much as it is a science and therefore if you feel you want a second opinion after hearing the doctor's advice, tell him so, do not be embarrassed. The Dr. can be very helpful in guiding you in.

Patient forms: Many patients have forms they need for work, disability, insurances and so on. We will do the best we can to fill out your forms in a timely fashion. If we cannot do it during your visit, leave it with us and we will mail it to you as soon as possible.

Thank you for taking the time to read this and preparing yourself for your visit with the doctor. We hope it will be a pleasant and educational experience for you and we welcome all your comments and concerns.

Thank you

Dr. Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon and Chair of Orthopaedic Surgery at Maimonides Medical Center.  Award winning hand surgeon Dr. Jack Choueka provides treatment for all disorders of the upper extremity, including carpal tunnel syndrome, arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements.

Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400

Trigger Finger

Trigger Finger



So you been diagnosed with the trigger finger now what.....

When patients first notice a trigger finger they’re usually very concerned. Trigger finger causes a snapping and sometimes pain in the hand and often leads to decreased movement in the finger. Most people think that this is a very uncommon condition. The truth is that is it is one of the most common conditions that hand surgeons treat.

In order to understand what a trigger fingers is you first have to understand a little bit about the anatomy of the hand. Muscles in the forearm become tendons in the hand that eventually insert into the bone. When the muscles contract, they pull on the tendons which subsequently move the bones across the joints. These tendon run through structures called pulleys. The purpose of the pulleys is to keep the tendons near the bone in order to allow more motion. Sometimes the tendons get irritated and thickened and sometimes the pulleys get thickened and this can cause a snapping as the tendon moves through the pulley. This is trigger finger. Sometimes it goes away on its own but sometimes it doesn’t and sometimes the finger can actually get stuck in one position.

There are several treatment options have been described for this including splinting injections and even surgery. Most likely on the first visit the Dr. will offer you an injection. This is a steroid injection given directly into the tendon sheath that will help decrease inflammation. At first you may notice increased snapping and clicking in the finger, but eventually it should decrease. The results of steroid injections are quite good depending on the severity of your condition. Sometimes if these measures do not work then surgery is indicated. The procedure can sometimes be done in the office with a needle but often needs to be done in the operating room under a local anesthetic. The results of this treatment are excellent and most people go back to normal without any evidence of anymore triggering.

Dr. Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400

Carpal Tunnel Syndrome and Sleep

Carpal Tunnel Syndrome and Sleep

The Department of Orthopedic Surgery at  Maimonides Medical Center recently completed a study evaluating the impact of carpal tunnel syndrome on sleep quality and duration. This study was presented at the American Society for surgery of the hand as well as the New York Society surgery for surgery of the hand.

The critical relationship between sleep, health and well-being is gaining greater attention. The national sleep foundation recommends 7 to 9 hours of sleep per night. Unfortunately sleep curtailment has become increasingly prevalent in modern day society do higher demands, long longer working hours and introduction of radio television and the Internet. There is growing evidence that significant correlations exist between poor sleep quality and the development of conditions such as obesity, hypertension diabetes. Patients with carpal tunnel syndrome consistently report nighttime symptoms and multiple awakenings. There are few studies that have looked at the effect of sleep in carpal tunnel patients and the purpose of this study was to evaluate patients with carpal tunnel syndrome and the impact on their sleep.

Carpal tunnel syndrome is the most common nerve compression syndrome affecting millions of people. This study established a clear relationship between carpal tunnel syndrome and the effect on sleep quality. We found that patients with carpal tunnel syndrome were sleeping 2 1/2 hours less than national sleep foundation recommendations. They were taking more sleeping pills and there was a direct relationship between the severity of carpal tunnel syndrome and the effect on sleep duration and quality.

We recommend that patients with carpal tunnel syndrome or any condition that affects their sleep, seek attention from their Doctor.

Dr. Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400

Steroid Injections: Myths and Truths

Steroid Injections: Myths and Truths

One of the most common treatments offered to my patients is a steroid injection. A steroid injection is offered either as a primary treatment or in an attempt to avoid more significant treatments such as surgery. There is however, an unrealistic  fear of steroid injections that patients often have.  Some fears and concerns patients have about steroid injections are founded but most unfounded. Many believe that there is an upper limit of steroid injections that they can receive.  For instance if they received a steroid injection in a particular year they feel they cannot have another one. Some feel that the steroid injection will destroy their bones and others believe it will make them fat. While all treatments have an element of risk, is important to understand the true risks and benefits of any procedure.

We all produce steroids in our bodies. The adrenal gland produces steroids that increases in times of stress. These are naturally produce steroids. The steroids given in the Dr.'s office are synthetically produce steroids, some of the common names being Cortisone and Kenalog. The purpose of these medications is purely to decrease inflammation. Naturally occurring steroids go into the bloodstream while synthetic steroids are injected into a particular area of inflammation. While there is some absorption by the body most of the steroid medication remains in the area that it was injected acting decrease inflammation and thus pain. There is no upper limit to the amount the steroid injections patients can have however repeated injections to one particular area can lead to problems.

Steroid injections are used to treat a variety of problems in the musculoskeletal system. Some of these include bursitis of the shoulder, tennis elbow, trigger fingers, carpal tunnel syndrome, knee pain, and heel spurs. For these and other similar problems 1 to 3 steroid injections as an attempt to treat these conditions without surgery is reasonable. When these do not work your Dr. will discuss surgery with you.

Although rare, it is important to understand that there are some risks with steroid injections. The most common one is a steroid flare. This is an increase in the amount of pain that that commonly occurs the night of, or a day after an injection and usually goes away by the second day. As with any invasive type procedure the risk of infection is always present. A particular risk exists for diabetic patients as steroid injections can increase your glucose levels substantially. This is dependent on the dose and on your particular sensitivity to the medication. Diabetic patients should inform their physician about their condition before receiving an injection.

The injection is usually not as bad as people think is given with a small needle with a  large percentage of the medication being  lidocaine or Marcaine  which are numbing medicines. It is therefore not usually necessary to give a numbing agent prior to the injection. The injections usually last anywhere between one and ten seconds and the numbness in the area begins almost immediately. Is important to discuss with your Dr. how you feel immediately after the injection since if there is still pain there may be problems in other areas. It takes sometimes several days or even weeks for the full effect of the steroid injection so be patient.

Dr. Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400

Tennis Elbow.....But I don't play tennis

Tennis elbow.... But I don't play tennis

Tennis elbow also known as lateral epicondylitis, is a painful condition that occurs on the outside part of the elbow. Although described in tennis players who obtain this condition from a poor backhand stroke the vast majority of people who suffer from tennis elbow to not play and may have never played tennis. The problem arises from overuse of the arm. It can happen with any sport and even those who don't participate in any sports.

Lateral epicondylitis is a very specific condition that involves a tendon  named the extensor carpi radius brevis (ECRB) which originates on the outside or lateral part of the elbow. With overuse the EC RB tendon can become weak and small microscopic tears begin to appear at the elbow leading to inflammation and pain. Over time the tendon can even rupture.

The symptoms of tennis elbow include pain and burning and sometimes stiffness at the elbow. Many people complain of difficulty even shaking hands. The symptoms can appear suddenly or gradually and often several weeks or even months go by before patients seek medical attention.

The doctor makes the diagnosis from the patient's history and physical exam. An x-ray or MRI is usually not needed unless other causes are suspected.

Initial treatments include rest, anti-inflammatory medication, adjusting grip for those who play tennis and attempts at avoiding repetitive activities. Physical therapy and steroid injections may also be used.

Unfortunately symptoms of tennis elbow can persist even up to a year. While most people improve a small percentage of patients do not improve. For those patients surgery is recommended. There are a variety of surgical procedures that have been described for treatment of tennis elbow including arthroscopy of the elbow. The doctor will discuss these options with you.

Dr. Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400

Carpal Tunnel Surgery....What to expect

So you're about to have carpal tunnel surgery…. What to expect

The most important thing to have before undertaking carpal tunnel surgery or any surgery is the proper expectations. Your doctor should have explained to you that carpal tunnel surgery while successful in alleviating many or most of the symptoms of carpal tunnel syndrome, cannot guarantee a complete recovery. The goal of carpal tunnel surgery is to relieve the pressure on the median nerve in the palm and stop further nerve damage. The type of recovery you receive is dependent on the amount of damage that has occurred to the nerve up to this point. The good news is that most people obtain very satisfactory results that allows them to have normal use of their hands without continued a nighttime awakenings.

Depending on your overall condition your doctor may ask for certain tests before surgery. These may include a nerve conduction study and depending on your medical condition the doctor may ask for certain blood tests, an EKG or even a chest x-ray. Depending on where you're having surgery you may have to be NPO which means having not eaten at some period of time before surgery.

Carpal tunnel surgery although considered minor by some, is still surgery that requires some type of anesthetic, which ranges from local anesthesia where a numbing agent is placed directly in the hand to general anesthesia where you are sleep for the surgery. Various levels of sedation can be given to keep you comfortable. A discussion with the surgeon and anesthesiologist will clarify these issues.

There are various techniques used in performing carpal tunnel surgery including endoscopic and open. Long-term outcomes in numerous studies show that there is little difference between the two techniques. The endoscopic procedure offers smaller incisions and the quicker return to work however may have additional risks as compared to the standard open procedure. Your doctor will discuss these options with you.

After the surgery you will be taken to a recovery room area for a short period of time. There will be a bandage on your arm and you'll likely feel numbness in your fingers. You may not have any pain depending on the type of anesthesia that was used. At this point you should try to keep your arm elevated in order to decrease swelling.

When you get home the anesthesia will start to wear off and you may experience some discomfort in your palm or fingers. You probably would have been given a prescription for pain medication and if you feel uncomfortable you should take it as needed. Keeping the arm elevated will help decrease swelling and decrease pain. Ice packs can also be used to help decrease swelling and also help with the pain.

Although there will be a bandage about your wrist should you should have full use of your fingers and be able to use your hand for basic activities such as eating dressing and using the computer. Dressings stay on for usually no more than a week and stitches come out between the first and second week.

Two weeks after surgery you should be able to get back to most of your activities except those that require direct pressure on the palm. By six weeks there should be no restrictions on your activities. However it is not uncommon to feel a little bit of discomfort with more aggressive activities such as push-ups even up to 4 to 6 months after surgery.

As was mentioned previously the type of recovery you have is highly dependent on how much nerve damage was present before the surgery. Nerve recovery occurs even up to a year after surgery and symptoms can improve even up to that point.

Carpal tunnel syndrome is a highly effective procedure for treating the symptoms of carpal tunnel syndrome however it is a surgical procedure that has inherent risks. Before proceeding with this or any surgery a discussion concerning the risks and benefits of the procedure should be discussed with your doctor.

 

 

 

Dr.  Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached at 718-283-7400

Rotator cuff problems

What is the rotator cuff and rotator cuff pathology?

The rotator cuff is the group of four muscles and tendons that surround the shoulder joint, providing strength and stability. Above the rotator cuff there is a bursa, or sac of tissue, that covers and protects the rotator cuff as it comes into close contact with bones around the shoulder. (see Figure 1) When the rotator cuff is injured or damaged it can lead to inflammation of the bursa (bursitis) causing pain and loss of motion. Thickening of the rotator cuff and its bursa can lead to an impingement syndrome where the tissues impinge against the bones around the shoulder. This can cause pain and further damage to the rotator cuff.  

While some rotator cuff injuries occur in younger people secondary to trauma, most injuries result from aging and degeneration of the cuff tissues. Damage to the rotator cuff can vary from microscopic tears to large irreparable tears. The symptoms of rotator cuff tears include pain, weakness, restricted motion, catching, locking and a feeling of instability. Rotator cuff pathology ranges from a normal, asymptomatic aging process to endstage arthritis and instability caused by absence of the rotator cuff.

Who gets it?

Rotator cuff tears increase in incidence with age, however not all rotator cuff tears are painful and many individuals with rotator cuff pathology are completely asymptomatic. When it does become symptomatic it can present in a variety of ways ranging from minor problems to severe pain and limitation of function. Onset of symptoms can be related to ordinary activities of daily living, or they can be attributed to a single event. The symptoms are usually

aggravated in certain positions, such as reaching back, for example, to fasten a seat belt or picking up a briefcase out of the back seat. Symptoms are worse when the arm is elevated overhead, especially if the elevated

arm is loaded, such as picking up a stack of plates out of a cupboard. Overhead activities (pitching, throwing, tennis, or racquetball) commonly worsen symptoms.

How is rotator cuff pathology diagnosed?

History and physical examination are the best way to initially evaluate rotator cuff pathology. It is important for the doctor to differentiate shoulder pain that may not be coming from places other than the shoulder such as the neck or even the heart. On the exam, pain can be provoked by overhead maneuvers, and there may be weakness of the shoulder muscles. Although plain x-rays do not show the rotator cuff muscles, they are helpful to look for calcifications, arthritis, or bone problems such as spurs that can cause rotator cuff tears. MRI is the most utilized imaging method to diagnose rotator cuff tears.(see figure 2) They can be used to look for tears, inflammation of tissues and to help determine the size and quality of the tear which helps direct proper treatment. Injections and even arthroscopy may be used to diagnose rotator cuff tears.

What are the treatment options?

Alterations in activities and learning to use the shoulder in a safer, more comfortable manner is important. Physical therapy may help improve mobility and strengthen shoulder muscles. Anti-inflammatory medications and injections are used for pain relief and to decrease inflammation. If these treatments fail, then surgical intervention is a reasonable option. Arthroscopy is most often the surgical treatment of choice to remove inflamed bursa and impinging bone spurs. The end of the clavicle (collarbone) may be removed if it has impinging spurs. Often rotator cuff tears can be repaired with arthroscopic techniques. Other tears require a larger incision and surgical exposure. Some large tears, particularly those associated with resultant arthritis, simply cannot be repaired and require major surgical options such as joint replacement surgery.

Rehabilitation

Postoperative treatment depends on the operation done, but therapy is a critical part of the recovery, which can take from three to twelve months. A coordinated effort between the patient, surgeon, and physical or occupational therapist is required.

Rotator Cuff Pathology

Dr.  Jack Choueka is an Adult and Pediatric Upper Extremity Surgeon

and Chair of Orthopaedic Surgery at Maimonides Medical Center. 

Award winning hand surgeon Dr. Jack Choueka provides treatment for

all disorders of the upper extremity, including carpal tunnel syndrome,

arthritis, trauma, rotator cuff disease, and sports-related shoulder, elbow and wrist problems. He performs state-of-the-art surgery, including shoulder, elbow and wrist replacements. Dr. Choueka is a summa cum laude graduate from State University of New York Health Science Center’s Medical School; he completed his residency in Orthopaedic Surgery at the Hospital for Joint Diseases Orthopaedic Institute.

Dr. Choueka can be reached 718-283-7400