BOMOH TULANG talks about Back Pain - RAPI magazine

RAPI magazine contacted the Bomoh Tulang the other day, and enquired whether would he be kind enough to write about back pain and prolapsed disc? Well of course I obliged.

The April issue of RAPI mag is already at the newsstands and features a four-page spread on all you need to know about back pain and prolapsed disc. So ladies and gents, if you have any questions about back pain, head over to your nearest newsagent and get your copy now. I'll be signing copies at MPH. ;)

..and no, this is not an April Fool's joke..

  

- the BomohTulang -

TRIGGER FINGER - your finger is catching

Trigger finger (stenosing tenosynovitis),  is one of the common causes of pain and dysfunction in the hand.
The initial symptom is of a painless "click" in the hand on moving the fingers which might eventually progress into a locked finger. The finger might be locked in flexion, whereby a forceful extension of the finger is required to unlock the finger , causing a feeling of "triggering" at the base of the finger (the metacarpo-phalangeal joint). Patients may or may not notice a lump or knot in the palm of the hand, again typically at the base of finger.

The problem occurs when there is a constriction where the finger flexor tendon enters the tendon sheath at the base of the finger. It is caused either by a thickening (hypertrophy) of the tendon sheath, or a nodular swelling of the tendon itself just proximal to the sheath. Either way, the basic problem lies in the discrepancy between the size of the tendon nodule and the thickened tendon sheath. This means that the tendon can no longer slide easily through it and it becomes harder to bend or straighten the affected finger or thumb as a result. 

Trigger finger occurs two or three times more frequently in women than in men and has a peak incidence of around 40- 60 years of age (the demographics sounds similar to carpal tunnel syndrome... ) The ring finger is the most frequently involved, followed by thumb and ring finger.Frequently one finds that multiple fingers are affected and bilateral hand involvements are not uncommon.

As many as 85% of trigger finger can be successfully treated non-operatively. These include activity modification, splinting, anti-inflammatory drugs (NSAIDs) and steroid injections.

Steroid injection around the flexor sheath can be an effective treatment, and in my experience, for the patients with mild triggering and short duration of symptoms, one can expect a complete resolution of symptoms.

Surgical release of trigger finger is reserved for patients not responding to conservative management, the chronically locked finger, long duration of symptoms, and multiple digit involvement. As with most of my minor hand surgery cases, this can be done as a daycare procedure under local anaesthesia and takes about 15 minutes. However, in instances where multiple fingers need to be operated upon, general anaesthesia may be a more comfortable option.

Similar to carpal tunnel release, a small incision about 1cm is made at the base of the affected finger and the constricting sheath is then cut open longitudinally under direct vision. Care is taken to ensure that the nerves running alongside the tendon is not disturbed, and this can only be done if the surrounding structures are well visualized; this is the reason that I am not in favour of percutaneous release of trigger finger, although the proponents say that it is a reasonably safe option.

A surgical loupe is frequently needed to identify the structures

Incision at the base of the finger

the constricting sheath (A1 pulley) is visualized and divided

sutured up

Trigger finger in infants or children almost always involves the thumb and could be a different entity from the adult type. Most authors recommend observation as children below 6 months can have spontaneous resolution of symptoms ( I know, because my nephew had the same problem - it resolved spontaneously!). Surgery, as with adults, could be considered if symptoms persist.

- the BomohTulang - 

References: 

Trigger digits: diagnosis and treatment.   J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):246-52.

Trigger digits: principles, management, and complications. J Hand Surg Am. 2006 Jan;31(1):135-46.

The Natural History of Pediatric Trigger Thumb. The Journal of Bone and Joint Surgery-American Volume

Issue: Volume 90-A(5), May 2008, pp 980-985

Core Knowledge in Orthopaedics: Hand, Elbow, and Shoulder. Trumble, Budoff, Cornwall. Mosby 2005

BOMOH TULANG - a bit about me

*ehem* I have taken the liberty to "cekup" my profile from the ColumbiaAsia's blog and put it here, just for you loyal readers.

Dr Saiful Akhtar Shamsuddin - Consultant Orthopedic Surgeon

Dr Saiful Akhtar Shamsuddin

Consultant Orthopedic Surgeon

Columbia Asia Hospital, Bukit Rimau, Malaysia

MBBS (UM), MS Ortho (UKM), CMIA (NIOSH)

Fellowship in Lower Limb Arthroplasty & Reconstruction (Aus)

AO Fellowship in Hand Surgery (USA)

saiful.akhtar@columbiaasia.com

Dr Saiful Akhtar Shamsuddin is an orthopedic surgeon, with a keen interest in Hand surgery and also Arthroplasty surgery as a sub-specialty.

He brings to Columbia Hospitals a wealth of experience and knowledge in orthopedics, having had 18 years of orthopedic experience and more than a decade of specialist orthopedic experience, serving in one of the busiest hospitals in Malaysia.

Dr Saiful was born, raised and schooled in Klang, Selangor,  making him a native Klang-ite. After Form Five, he furthered his studies in Pusat Asasi Sains and henceforth continued to study medicine in University Malaya.

Having completed his undergraduate studies, he went on to work mainly in the Orthopedic and Surgical departments throughout his career. His first ever posting as a houseman was in the Orthopedic Department in Hospital Kuala Lumpur, where he made the decision to pursue Orthopedics as a career. He had the priviledge to work in various hospitals throughout his career; namely Hospital Seremban, Hospital Kuala Pilah, Hospital Kuala Lumpur and Hospital UKM, prior to completing his Masters Progamme in Orthopedic surgery. He last served Hospital Tengku Ampuan Rahimah Klang before joining Columbia Asia Hospital, Bukit Rimau as a Consultant Orthopedic Surgeon

During the earlier part of his career as a specialist, he was attached to the Hand and Micro-Surgery Department of Hospital Selayang, under the guidance of Dato’ Dr Pathmanathan, where he developed a keen interest in Hand Surgery as a sub-specialty. He continued his involvement in hand surgery while in Hospital Klang and was instrumental in setting up the hand services there.

Dr Saiful later obtained a fellowship in Lower Limb Arthroplasty and Reconstruction from the Gold Coast Hospital, Australia  to strengthen his knowledge in Joint replacement surgery.

Besides hand surgery and arthroplasty surgery, he also manages various orthopedic problems, ranging from simple backache to congenital deformities to severe limb and spine trauma.

Dr Saiful is married, and is blessed with three wonderful children. In his spare time he can be found scuba diving beneath the tropical waters off Malaysia’s east coast islands. He is also passionate about photography, a hobby he picked up during his student days.

Contacts or appointments?
click here


- the BOMOH TULANG -

At the AO principles course 2011

The AO principles and advanced course Malaysia 2011 was held at the Dorsett Regency, Subang, and attended by more than 70 local and international participants. Held over a period of two days, it encompasses lectures, case discussions and hands-on workshops on fixation techniques.

The Bomoh Tulang has been fortunate to be a part of the teaching faculty for past few years, and this year was not an exception. 

The AO Foundation - Arbeitsgemeinschaft für Osteosynthesefragen (German for: Association for the Study of Internal Fixation) - is a non-profit organization based in Davos Switzerland, dedicated to the advancement of the treatment of musculoskeletal injuries. Founded in 1958, the AO foundation promotes the understanding of fracture management through research, meetings and education. 

As an integral part of education, the AO foundation through AO Education conducts courses on the principles and techniques of fracture fixation,  for Orthopedic surgeons and also operating room personnel. These courses are held on a regular basis throughout the world and is a great place for trainee orthopedic surgeons or even senior surgeons to learn, exchange notes and at the same time update their skills on the latest fixation techniques.

Dr Ivan explaining the finer points of external fixation to the participants

Plating the fibula

Dr Rashdeen and Dr Hazrin trying out some fixation techniques. This was at the 2010 course.

Also at the 2010 course. Dr Azfar was a participant.

Interested in next year's AO course?
Click here for registration. Spaces are limited so better hurry!

- the BOMOH TULANG -

Surgery for CARPAL TUNNEL SYNDROME

Continuing from the previous post, lets talk a bit about SURGERY for CARPAL TUNNEL SYNDROME.

Surgery entails cutting or transecting the transverse carpal ligaments that overlies the median nerve and can be done as an outpatient basis or a day care procedure in the OT.

The surgery itself can be accomplished in two ways:

The traditional approach is by open carpal tunnel surgery, whereby a longitudinal skin incision is made in the wrist and the carpal ligament cut to relieve the pressure on the median nerve. Incisions generally have become smaller over the years, and the so-called "mini" 2cm skin incision have become the standard length now.


Surgery takes about 20 minutes and can be done under  local anaesthesia although my preference is to do it under general anaesthesia, unless there are contraindications.

Torniquet applied to prevent bleeding

Local anaesthesia injected

Checking for the landmarks

Incision over the wrist

Incision deepened

The carpal ligament is cut

The underlying median nerve could be seen

Wound washed and closed 

Post operatively, the patient will feel relief from the night pain, as early as the day after surgery. Numbness of the fingers will take a bit more time to disappear, as is wasting of the hand muscles which will be the last to recover.

Sutures are usually taken off at two weeks and patients are advised not to lift heavy objects or to grip tightly for the next 4-6 weeks. There might be some weakness of the hand grip but this will also recover over time.

Another, more minimally invasive method would be through the endoscopic method. A small incision is made at the wrist and a small camera, together with a knife, introduced into the wound to see the carpal tunnel. The ligament is then cut below the skin by the knife. Proponents of this technique claim shorter recovery time and less post operative pain. The downside is the complexity of the procedure as it necessitates more (expensive) equipment and has a steeper learning curve on the part of the surgeon.

- the BOMOH TULANG -

Numbness in your hand - CARPAL TUNNEL SYNDROME?

Do you have numbness in your hands? Worse in the early hours of the morning, painful too? pain wakes you up at night? Or, do you notice that sometimes your hands get all clumsy and you start dropping things, like a coffee cup for instance?

Well, you have come to the right place. Today let's talk  a bit about CARPAL TUNNEL SYNDROME, a condition that affects between 1 to 10% of the population.

Lets start with the textbook description:

CARPAL TUNNEL SYNDROME (CTS) , by definition, is a syndrome characterized by pain, tingling, and numb sensations in your hand, typically involving the lateral (radial) 3 ½ digits (ie the thumb, index and middle fingers) caused by compression of the median nerve at the wrist, by whatever reasons. 

 

Shaking the hands to make it better

Patients usually complain of numbness and tingling at night that wakes them up;  they often find that they have to shake their hands to make it better. They can also experience numbness  when driving, reading the newspaper or a book, when typing on a keyboard, or any activity that requires the hands to be kept flexed for a period of time. Sometimes they can also have referred pain radiating to the forearm and arm, in which case the condition could be misdiagnosed by other health care professionals.




Where is the CARPAL TUNNEL?


The carpal tunnel is located at the wrist; the concave bottom part is created by the bony structures of your small bones of the wrist (the carpal bones), and tunnel completed on the top by a non-yielding structure called the transverse carpal ligament. Traversing the crowded tunnel are the tendons that go to your fingers and the median nerve, which supplies sensation to the thumb, index finger, middle finger, and the radial side (thumb side) of the ring finger

What causes CARPAL TUNNEL SYNDROME?

 Carpal tunnel syndrome is due to median nerve compression within the carpal tunnel, as increased pressure causes decreased blood flow to the nerve.  This increased pressure comes from swelling (edema) of the tissues surrounding the tendons called the synovium. This swelling may be due to injury to the synovium from overuse, trauma, or other causes such as metabolic disturbances (endocrine disorders, pregnancy, menopause). Increased pressure in the tunnel could also be due to anything that decreases the volume available in the tunnel, such as a lipoma or neuroma.

Having said that, do keep in mind that most of the time no cause could be found.


How does the doctor know I have CARPAL TUNNEL SYNDROME?

Well, as per the usual way, through questioning and thorough clinical examination.
A variety of special tests involving the wrist could be performed ie the Tinel's test and Phalen's test.

Additional tests such as X rays, MRI and nerve conduction tests could be called upon to make the diagnosis or rule out other conditions

What happens next

Usually once a firm diagnosis is made, the doctor could start the patient on a trial of conservative measures, typically lasting a month or two, and best results are obtained with early onset of symptoms. These might include:

• Activity modification
• Splinting - to rest the joint, and keep it in a neutral position
• Addressing the primary cause of CTS - treating hypothroidism for example
• Oral medications - NSAIDS and oral steroids
• injections into the carpal tunnel

 
Well, I have I tried all that, and it still doesnt seem to work..

Failed conservative treatment indicates that the patient is a candidate for the next step: SURGERY.
Surgery is also indicated for worsening symptoms and evidence of atrophy of the small muscles of the hand.
There are various techniques in doing surgery on the carpal tunnel , which i will discuss in the next entry.

Till then,

-The BomohTulang -

NB: there a literally tons of info on the net about CTS, so I have compiled some links which i think could be useful:

The  American Academy of Orthopedic Surgeons (AAOS) has an article about CTS here

Additionally, you can download the American Society for Surgery of the Hand (ASSH) brochure on CTS here (PDF file)

Closer to home, the Arthritis Foundation Malaysia (AFM) has an article on CTS here

Happy CNY!!

So we are about to celebrate the dawn of another year (reader: err I thought we already did, about a month ago?)
February 3 this year marks another year on the Chinese calendar, and this year we usher in the year of the rabbit, with 2011 being the year of the metal rabbit. If you are a believer of Feng Shui, head on here to see what the future holds for you. Otherwise, I would like to wish all our Chinese readers a happy and prosperous year ahead!

Speaking of prosperity, we had Yee Sang for lunch the other day - down the road at Kota Kemuning.
This dish is traditionally available during the new year and is symbolic of good luck, prosperity, health and all things auspicious.

The ingredients - err can you see the salmon?

You toss em and mix them up real good.

Apa lagi.. makan time!

Yes you (together with your friends / family members) need to mix the ingredients together and toss them up real high - the significance of the tossing is to wish for abundant luck and happiness for all.

Yee Sang Wiki can be found here
Someone was busy researching the origins of Yee Sang

Happy CNY to all!

-the Bomoh Tulang -