This patient is a 22-year-old gentleman, who works as a barista in a coffee shop. Over the course of  two-and-a-half weeks, he developed increasing numbness and tingling in his left small finger. It wakes him up at night. He has not noticed weakness. He has done some stretching exercises and taken naproxen. This has not improved his symptoms significantly. He does not recall any particular injury or incident in the past.  He reports similar symptoms on the right side, but to a lesser degree.

Physical examination:

Physical exam of the upper extremities demonstrates strong thenar and intrinsic muscles. He has a negative Froment’s sign, negative Wartenberg’s sign. Carpal tunnel compression test produces paresthesias. There is some vague tenderness over the hook of the hamate. Cubital tunnel compression does not produce paresthesias, but compression at Guyon’s canal at the wrist produces tingling in the small finger.

Two point discrimination on the right side is 4 mm and small finger is 6 mm. On the left side, two point discrimination is 4 mm in all fingertips. There is normal finger range of motion bilaterally. All fingers are well-perfused. Allan’s test shows an open palmar arch.

Radiographs of the wrists including a carpal tunnel view suggested a nonunited fracture of the hook of the hamate bilaterally. Further evaluation with MRI scan confirmed the diagnosis.

Hook of hamate fracture nonunion on carpal tunnel view

Electrodiagnostic tests revealed a mild degree of carpal tunnel syndrome.

Treatment:

The patient underwent operative excision of the ununited fragments of the hook of the hamate, combined with endoscopic carpal tunnel release.  No other pathology within Guyon’s canal was noted.

The patient was symptom free after recovery and a course of about 6 weeks of occupational hand therapy.

Review:

Hook of the Hamate fractures are rare, but often missed resulting into nonunion.  The mechanism of injury is often athletes that use rackets or bats or clubs.  In the acute phase simple cast or splint immobilization of the wrist will result into union.

Patient present with pain in the hypothenar eminence, tenderness to palpation, weak grip, and paresthesias of the ring and small fingers. Pain with resisted finger flexion is greater with the wrist in ulnar than in radial deviation. Because the hook of the hamate constitutes the ulnar wall of the carpal tunnel acting as a tendon pully, the flexor tendons of the ring or small finger can attenuate and even rupture, causing loss of active finger flexion.

Radiographically, the fracture can be demonstrated by a carpal tunnel view, or a view in slight supination with the wrist radially deviated and dorsiflexed.   

Treatment of acute fractures is usually cast immobilization.  If the fracture results into nonunion and is symptomatic, then excision rather than fixation of the fracture fragment is recommended.  Complications such as flexor tendon subluxation, weakness, and rupture have been reported but are rare.

The human skeleton is made of 206 bones linked by joints and soft tissue. Those bones hold us upright, assist in propelling us through our daily lives, and protect our vital organs.  On any given day, most of us probably don’t give our bones a second thought – but we should. Keeping your bones strong and healthy is a cornerstone in living an active and fulfilling life.

We hear a lot today about “fragility fractures”. Frequently this conjures up the image of an elderly person falling and breaking a hip (“I’ve fallen and I can’t get up.”). But you don’t have to be elderly to be at increased risk for a fracture. Truth be known, up to half of all women and a quarter of men over the age of 50 can expect to break a bone related to low bone density or osteoporosis. And studies have shown that if you have one broken bone related to low bone density, you are four times more likely to have another fracture compared to those who have not had a fracture.

So what can you do? Regardless of your age, make sure you get adequate Calcium and Vitamin D in your diet. Starting as early as age 4, children should get at least 1000mg of Calcium daily to build a good bone density base. Young women need to increase that intake to 1300mg per day during childbearing years. Both men and women over age 50 should continue to take 1200mg per day to aid in maintaining bone density.

Vitamin D is key in helping the body absorb and utilize Calcium. While you can get some Vitamin D from sunlight, here in the Northwest, our lack of sun makes depending on it as a source a dicey proposition. Currently, there is some debate about the optimal recommended dosage, but at least 600 IU daily should be a minimum.

As for medications that help with decreasing bone loss such as bisphosphonates (eg. Fosamax, Reclast, Boniva etc), these are not without side effects including increasing the risk of certain type of hip fractures. Before trying any of these have a full discussion with your doctor about the pros and cons.

Exercise! Weight bearing activities strengthen bones naturally. You don’t need to be a triathlete – just go for a walk.

 For more information, a great resource is www.ownthebone.org. Here’s to your health!

Anne P. McCormack, MD
Orthopedic Surgeon
Northwest Hand & Orthopedics

www.nwhandortho.com

Anne P. McCormack, MD, joins Northwest Hand and Orthopedics

Shoreline, WA, September, 2011 – Northwest Hand & Orthopedics is pleased to announce that Dr. Anne P. McCormack has joined their practice and will begin seeing patients in Oct., 2011.  Dr. McCormack is a board certified orthopedic surgeon specializing in Surgery of the Foot and Ankle, Sports Medicine, and Knee Arthroscopy. Prior to joining Northwest Hand & Orthopedics, Dr. McCormack practiced in Bellevue, WA.

Dr. McCormack earned her medical degree from the University of Washington School of Medicine and her undergraduate degree fromBostonUniversityin Aerospace Engineering.  After medical school she completed a residency in orthopaedic surgery at Albert Einstein College of Medicine inBronx,NY.  She has completed fellowships in sports and reconstructive knee, foot and ankle surgery at UT Houston, Baylor andTexasOrthopedicHospitals, as well as an AO/ASIF foot and ankle fellowship fromHarborviewMedicalCenter,SeattleWA.

“We are so pleased to have Dr. McCormack join our group. Adding to our orthopedic surgeons already in our practice, she will not only bring her expertise and experience to our group but will also help us meet the needs of our growing number of patients,” states President and Founder, Dr. Edwin Vyhmeister.

Northwest Hand & Orthopedics has a non-hospital affiliatedAmbulatorySurgeryCenterin Shoreline, as well as offices in Woodinville and Mill Creek/Everett. Dr. McCormack will work in the Shoreline and Woodinville offices. The practice also offers occupational medicine, physical therapy and occupational (hand) therapy. “I am delighted to be joining Northwest Hand & Orthopedics. It is an honor to become a part of a highly recognized group of surgeons here in the Northwest,” says Dr. McCormack.

Prior to medicine, Dr. McCormack worked as an aerospace engineer in theSeattlearea.  Her personal interests include running, hiking, skiing, gardening and travel. She is a member of the National Ski Patrol volunteering at Summit West at Snoqualmie every winter. She provides charity care through Project Access to local residents, and works internationally giving free care in developing countries.

Dr, McCormack will begin seeing patients in October and appointments are being scheduled now by calling Northwest Hand & Orthopedics at 206-363-6947.

Contact Information:
Danna Beal
dbeal@nwhandorth.com

206-957-8135
Northwest Hand & Orthopedics
19930 Ballinger Way
Shoreline, WA 98155
www.nwhandortho.com

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Dr. Anne P. McCormack
Board Certifed Orthopedic Surgeon
Foot and Ankle, Knee Arthroscopy and Sports Medicine

The health benefits of  regular walking are widely known – weight control, improved mood, decreased blood pressure, lowered LDL (bad cholesterol), raised HDL (good cholesterol, increased overall fitness. We’ve all been walking since we were toddlers, so it would seem as easy as lacing up your tennies and heading out the door, or hopping on the nearest treadmill, to get a program going.

But walking shoes and shoe technology have come a long way since we all wore our first pair of Keds or Chuck Taylor’s. We are endlessly bombarded with advertising about shoes that will make walking easier, or less stressful to our joints, or maybe even give us more shapely posteriors. We’d all like a shoe  that will be comfortable and protective when we walk, but are these fancy new shoes worth their generally high price tag?

Shaper or toner shoes have a rocker bottom, instead of a flat sole. The manufacturers claim that these  shoes will change your gait in a way that will activate more muscles, allowing you to burn more calories and decrease stress on your joints Their ads also indicate that regular use of these shoes will give you a more toned and curvy “caboose”. Unfortunately, hard science does not bear these claims out.  A recent biomechanical study by the American Council on Exercise (ACE) showed that although the initial use of these shoes activates some additional and different muscles groups, the body quickly adapts to the gait change, and no significant increase in calorie expenditure is noted. In a written release, their chief science officer Dr. Cedric Bryant was quoted as stating “Toning shoes appear to promise a quick-and-easy fitness solution, which we realize people are always looking for. Unfortunately, these shoes do not deliver the fitness or muscle-toning benefits they claim.”

Shoes with built in springs that give extra forward propulsion also do not provide any benefit in protecting the joints or increasing your caloric output. On the downside, both of these type of shoes have been associated with lawsuits wherein the individuals have claimed a variety of injuries related to these shoes including ankle fractures, back pain and even hip fractures due to instability and increased stress on bones and joints. So, let the buyer beware!

What shoes should you wear when you walk for exercise? First, you don’t have to break the bank to get a good shoe. According to a recent consumer rating organization, a good, supportive walking shoe can be purchased for about $30. Make sure whatever shoe you buy (rocker bottom, leaf-spring, or traditional flat sole) that it fits your foot well and is comfortable. You will want your arch and heel to be well supported. Check for seams or other bumps that might cause pressure points. Breathability of the shoe is important. You’ll need more if your feet tend to sweat, less if you are walking outdoors in cold weather. If you want to try out an alternative sole, go to a walking or running shoe store and try them on first. Walk around the block, up and down a hill and make sure you feel sure-footed. If you feel unsteady or have discomfort in any joint then these are probably not the shoes for you. Happy walking!

We are now realizing that when a patient receives excellent pain control after a surgery, especially in the first 10 days they are less likely to suffer chronic pain in the future at that operative site.  The goals at Northwest Hand and Orthopedics are to improve your structural pain and range of motion with surgery and subsequent physical therapy but then also work with you to optimize post-operative pain management such that you are less likely to develop chronic pain and hypersensitivity from nerves that represent that site.  Remember, pain is inevitable after surgery but suffering is optional.

Dr. Rajni K. Jutla, MD

MIND YOUR BODY CLINIC (206) 957 7246 (PAIN) fax: 206 957 6922

Boarded Certified in Anesthesiology and Pain Management

Medical Acupuncture & Interventional and Surgical Pain Procedures

http://www.mindyourbodyclinic.com

FOR IMMEDIATE RELEASE:

Danna Beal, Northwest Hand & Orthopedics Marketing Director, Speaks at National Meetings and Healthcare Organizations

Danna Beal, M.Ed., author of “The Extraordinary Workplace: Replacing Fear with Trust and Compassion” and marketing director for Northwest Hand & Orthopedics speaks to audiences on “Enlightened Healthcare Leadership”.

Seattle, WA April 25, 2011 – Danna Beal, marketing director for Northwest Hand & Orthopedics released her new book, “The Extraordinary Workplace:  Replacing Fear with Trust and Compassion” and is speaking to audiences throughout the country.  She has been on over 60 radio and TV shows and has spoken to over 300 businesses and organizations discussing “Enlightened Leadership”, and “Healing the Workplace Culture”.

“During these times of economic uncertainty, fear increases which impacts open and honest communication.  Enlightened leaders understand that trust and respect are the key components to creating an extraordinary workplace,” explains Danna Beal.

The workplace is often filled with fear, gossip, territorialism, backbiting and ego drama. No one can work well in these circumstances.  “As leaders learn to give up the ego and demonstrate respect for everyone at all levels, a dramatic transformation will occur. Happy employees are more productive, creative and work at their highest potential,” says Beal.

Some of her recent and upcoming speaking engagements include:

• Grand Rounds:  Kaiser Permanente Medical Center-Richmond, CA & Oakland, CA
• Case Management Society of America, San Francisco, CA 
• Association for Medical Imaging Management, Seattle, WA
• Washington State Chiropractic Association, Seattle, WA

Ms. Beal has spoken throughtout the Puget Sound area to physician groups and hospital employees on “Extraordinary Service in Today’s Healthcare Practice”. For more information about her workshops and keynote addresses visit her website at http://www.dannabeal.com. There you can view videos and access free articles on creating and Extraordinary Workplace. In addition, she will be doing a book event in September at “Third Place Books” in Lake Forest Park. She also speaks frequently for local Rotaries because of their philosophy of integrity and service.

Residing in Bellevue, she has been an international speaker for over twenty years. She has been the keynote speaker at national and international meetings in a multitude of industries. Although she has a special interest in healthcare, she is dedicated to helping leaders in all industries build organizations that are healthy and successful.

Contact Information:
Danna Beal, M.Ed.

425-785-2862
Northwest Hand & Orthopedics
19930 Ballinger Way
Shoreline, WA 98155
www.nwhandortho.com

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FOR IMMEDIATE RELEASE:

Dr. Michael Santoro Wins National Award for Video Essay

American College of Occupational & Environmental Medicine announces Michael Santoro, MD, as the winner of its inaugural video essay contest.

Seattle, WA, April 19, 2011 –Dr. Michael Santoro

Dr. Michael Santoro, Board Certified Occupational and Environmental Medicine specialist, a physician with Northwest Hand & Orthopedics in Shoreline, Everett/Mill Creek and Woodinville, was selected as the national winner of the American College of Occupational & Environmental Medicine’s inaugural award

According to the panel, Dr. Santoro’s video most effectively conveyed why OEM is a “stimulating and engaging field.”  In his video he explains how during the course of treatment, an occupational medicine physician coordinates the team of caregivers, from medical assistants to physicians, surgeons, therapists and rehabilitation specialists, all focused on helping the patient get better and back to work as quickly as possible. In addition, Dr. Santoro discusses how the various workers’ compensation programs require many complicated steps and what is necessary to facilitate this process.

Commonly known as “L&I,” the workers’ compensation system in the State of Washington is a very detailed program that has been designed to accomplish its mission in a progressive way.  The goal is to provide necessary medical care and wage loss payments to injured workers in order to return them to the job as expeditiously as possible. Dr. Santoro is able to coordinate the complex system to benefit employees and companies.

 “I am dedicated to helping injured workers obtain needed treatment for their work-related orthopedic injuries and cumulative trauma disorders,” explains Dr. Santoro. He became interested in occupational medicine and gained his experience in the industrial Midwest, including his work as a company physician for Ford Motor Company.

Dr. Santoro’s video can be seen on the Northwest Hand & Orthopedics website:

http://www.nwhandortho.com/michael-a-santoro-md-mph/

Contact Information:
Danna Beal
dbeal@nwhandorth.com

206-957-8135
Northwest Hand & Orthopedics
19930 Ballinger Way
Shoreline, WA 98155
www.nwhandortho.com

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 http://www.nwhandortho.com.

Contact Information:
Danna Beal
dbeal@nwhandorth.com

206-957-8135
Northwest Hand & Orthopedics
19930 Ballinger Way
Shoreline, WA 98155
www.nwhandortho.com

History: 25 year old male whose left hand was crushed between 2 football helmets a day prior to presentation.  He complained of pain and swelling and radiographs demonstrated an oblique fracture of the 4^th metacarpal shaft. There were no complaints of numbness or tingling. The fracture was displaced dorsally.

Exam:

Left hand demonstrated edema and some ecchymosis. He had active finger motion limited by edema only. Sensation was normal in all fingertips.  All fingers were well-perfused. There was no malrotation noted of the ring finger in flexion. The skin was intact.

PRE-OP XRAY

Treatment options:

Treatment may be accomplished by cast fixation or operative treatment.  In this case operative treatment was chosen in order to ensure anatomical alignment of the fragments, and at the same time allow for early range of motion exercises.  Fingers tend to rapidly loose range of motion when immobilized for prolonged periods of time.  Operative treatment allows for rigid internal fixation by placing 3 lag screws perpendicularly across the fracture.  This patient was allowed active finger and wrist range of motion at 1 week post-op.  The result was no loss of finger or wrist, while the fracture healed in anatomical alignment. 

POST-OP XRAY

 FOR IMMEDIATE RELEASE:

Northwest Hand & Orthopedics Adds Physical Therapy

Northwest Hand & Orthopedics has now added physical therapy, treating a broader range of injuries, including lower extremities, in addition to the specialized hand therapy that has traditionally been offered at their three Seattle area locations.

Seattle, WA 2/3/11 –Northwest Hand & Orthopedics, with offices in Shoreline, Woodinville, and Everett/Mill Creek, is happy to announce the addition of a physical therapist to its team of experienced hand therapists.  Doug Brand, a long-time Puget Sound physical therapist, has practiced in the area for over 33 years.  In his early career, he has worked in sports medicine settings, from college level to amateur sports. He also worked as a staff trainer for the Department of Intercollegiate Athletics at the University of Washington for football, wrestling, soccer, and track. Doug then spent much of his career in various outpatient orthopedic clinics, focusing on musculoskeletal issues.  “I have a special interest in rehabilitation of the post-operative patient and enjoy helping people restore their physical functionality.”

 Northwest Hand & Orthopedics has an outpatient surgery center in their Shoreline office, where they provide upper and lower extremity treatments and surgery. Doug states, “I spend a considerable amount of time educating the patient to understand his/her condition and rehabilitative process, as well as time developing a comprehensive therapy program.”  Doug is practicing at the Shoreline office, but future plans include physical therapy at all three locations, including Woodinville and Everett/Mill Creek.  For more information on Doug and Northwest Hand & Orthopedics, visit their website at http://www.nwhandortho.com.

Northwest Hand & Orthopedics is pleased to provide patients with the needed rehabilitative services along with their medical services.  Patients are often able to combine appointment times with their doctor and therapist which is a convenience patients appreciate.

Contact Information:
Danna Beal
dbeal@nwhandortho.com

206-957-8135
Northwest Hand & Orthopedics
19930 Ballinger Way
Shoreline, WA 98155
www.nwhandortho.com

After Plane Trips

Should a second conductor arrive at a symphony orchestra, there will be misalignments among the instruments and the result may not sound like music, but rather like noise.  A similar thing happens to our body when we travel to a different time zone.  JET LAG refers to the lag between the time frame of our “Biological Clock” (main conductor) and that of our destination time zone (Zeitgeber or second conductor).  Because our Biological Clock is resistant to time change and slow to adjust, there will be several days after arrival in the new time zone before our biological clock catches up with the new clock.  During the adjustment period, one may suffer from impaired sleep, nocturnal hunger, a need to void, and daytime fatigue and malaise, i.e. suffer from jetlag.  These symptoms are worse with an Eastward compared to Westward travel.

To align our biological clock to the destination clock or time zone, there are three approaches:  1) behavioral modification, 2) light therapy, and, 3) medication.

Behavioral Modification:

1.      Adjust your sleep schedule prior to the travel to match the destination sleep schedule:  If you travel eastward, go to bed and get up one hour earlier each day for three days before the travel.  If you travel westward, go to bed and get up later for each day for three days before the travel.

2.      Choose daytime flight.  Select a schedule/flight that arrives at early evening time of the destination, so you could sleep afterwards.  If it is not possible, do not sleep until 10 PM their time.  If you cannot resist sleeping, take an early afternoon nap.

3.      Upon boarding the plane, change your wristwatch to the destination time zone.

4.      Follow the destination time zone, stay awake during their daytime, and sleep when they do. Avoid remaining indoors.

5.      Avoid caffeine and alcohol, particularly before sleep time.

6.      Drink a lot of water.

7.      Avoid making critical decisions or driving long distances on the first day after arrival.

Should the trip be short (<3 days), stick to your home schedule, and do not do any of the above.

Light Therapy:

To move the biological clock, light exposure after arrival is the key.

If you travel eastward, get exposed to intense bright light early morning (destination time), and use dark goggles late afternoon/ early evening (destination time).

If you travel westward, avoid bright light in the morning, and get exposed to light early evening (19:00 destination time).

Medication:

Melatonin is the natural sleep hormone in our body.  Consider taking 0.5 to 5 mg Melatonin for 3 days prior to and 3 days after arrival.  It should be taken 2-4 hours before (home) bedtime for 3 days prior to the trip and 2-4 hours before (destination) bedtime for the 3 days upon arrival.  Similarly, Ambien has been tried.

Mehrdad Razavi, MD, DABSM, DABPN
Diplomate, American Academy of Sleep Medicine
Diplomate, American Academy of Psychiatry and Neurology

Northwest Neurology and Memory Clinic
17924 140th Ave. NE, Suite 100
Woodinville, WA 98072
 425-984-6322
http://www.nwneurologyandmemoryclinic.com