Scheduling Surgery
To schedule surgery at NYU Langone Medical Center, the NYU Orthopedic Outpatient Surgery Center, or NYU Hospital for Joint Diseases please call Andry at 646-501-0740. She can provide you with Dr. Yang's operating schedule. She will help you with authorizations from your insurance company as well as organizing your pre-operative medical testing and clearance. The medical clearance is usually done at the NYU PAT but in some circumstance can be done by your internist/family doctor. You might require additional specialty clearance depending on your medical history. If you will have not seen Dr. Yang in two months prior to your surgery, please schedule an office appointment for reevaluation as your condition can change over time.
The day before your scheduled surgery you will be contacted with the exact time of your surgery and any final instructions. Any questions regarding the procedure itself must be directed to Dr. Yang. Please bring with you any relevant x-rays, MRI, or CT scans you may have at home.
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Surgery
Most hand, upper extremity, and shoulder surgery is done as an outpatient procedure. It is performed in an ambulatory surgery unit of the hospital or surgery center. Larger operations may require an admission to the hospital after surgery. You will be told whether or not the surgery will necessitate hospital admission and what will be the anticipated length of stay.
You are not to eat or drink after midnight prior to your surgery. Exceptions might be made for late day surgeries. All your preoperative testing and your medical clearance must be completed before the day of surgery. If you have x-rays, MRI scans, or CT scans relevant to your procedure, you must bring them with you.
You will be seen by Dr. Yang before being brought into the operating room to discuss any last issues and to review the consent form. You will also be interviewed by the anesthesiologist. He will answer any questions regarding the choice of anesthetic and effects of anesthesia.
Depending on the specific surgery, an assistant may be required. Either an orthopedic resident or a physician's assistant (PA) will act as the assistant. Sometimes a second surgeon is required in complex cases to perform certain portions of the surgery. You will know beforehand whether a second surgeon will be necessary.
The details and duration of surgery depends on the particular procedure and will be discussed with you prior to the surgery day. If a local or regional anesthetic is used you may be alert enough to discuss the progress of surgery as it is performed. Dr Yang may or may not be able to respond to intraoperative inquiries depending on the phase of the procedure.
After surgery the patient is brought to the recovery room. The duration of stay in the recovery room will depend on the kind of anesthetic used. Usually, general anesthesia requires a longer stay. If you underwent an ambulatory procedure you will be discharged directly from the recovery room, and your escort must be present. Inpatients will be taken to their hospital rooms.
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Post-Surgery
Before you are discharged from the hospital, whether from ambulatory surgery or the hospital unit, you will be given post-operative instructions. These directions will also be written down for you. A prescription for pain medication written by Dr. Yang or by one of his residents will be given to you by the nurse. Sometimes additional prescriptions will also be given. Please follow the instructions closely. Pain medicine should be taken only when necessary. If you are experiencing only mild pain or discomfort you may take over-the-counter Tylenol or Extra Strength Tylenol.
Do not be alarmed if after surgery you are experiencing numbness and tingling sensations in the extremity operated on. If you had a regional anesthetic or any local anesthetic injected around the surgical site (even if you had general anesthesia), you could have numbness lasting for several days. If an axillary block anesthesia was performed, you may also have discomfort and "tightness" around your arm pit where the injection was administered. This also will subside over time.
The most important instruction for patients who have had hand or arm surgery is to elevate the extremity. There is a tendency for swelling after an injury or surgery that can be counteracted by elevation. When you are discharged from the hospital you might be given a sling to wear. This is acceptable elevation when ambulating, but when sitting or lying down the arm ideally should be elevated higher on pillows. The hand should be higher (closer to the sky) than your heart.
Except when otherwise instructed, dressings and post-operative splints or casts should not be removed. They should be kept dry. If they become dirty, stained with blood, or loose, they can be reinforced with standard medical tape and/or gauze. If the dressing becomes lightly wet, a hair dryer may be sufficient to dry it. Otherwise, you may have to come to the office or emergency room for a complete dressing change.
The extremity which has undergone surgery should be rested. No heavy or repetitive tasks with that limb should be attempted during the healing period. You should not drive a car if your arm or hand is in a splint, cast, or bulky dressing. Instructions for any necessary exercises will be given before discharge. Physical or occupational therapy may be required depending on the procedure, but generally is not started immediately and is not prescribed until the first post-operative follow-up visit.
Instructions for a post-surgery follow-up appointment will be given to you before leaving the hospital. It is generally between one to two weeks after surgery depending on the operation. Call the office to confirm your appointment. If you have any problems after surgery you can always reach Dr. Yang or a covering physician.
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Anesthesia
Some form of anesthesia is necessary in surgery so that the patient experiences no pain during the procedure. For most hand and arm surgery there is a choice of anesthesia. In the absence of medical contraindications, a patient can have either local, local with sedation, regional, or general anesthesia. Which form of anesthesia a patient will have depends on several factors that need to be considered by the surgeon, anesthesiologist, and patient.
Local anesthesia is the least amount of anesthesia and can be given for small procedures. It is sometimes given in combination with intravenous sedation medication. Only the area being operated on is injected with a local anesthetic such as lidocaine. The sedation is given to reduce the normal anxiety experienced by patients in the operating room and also to minimize the discomfort of administering the local.
A regional anesthetic numbs the entire limb. An axillary block is an example of regional anesthesia. An injection is given by the anesthesiologist at the base of the neck near the shoulder to block the nerves giving sensation to the arm, shoulder and hand. Although sedation is also given, the patient can remain somewhat awake.
General anesthesia is what patients usually refer to as "going to sleep." It is accomplished with a combination of intravenous and inhalational medication. The depth of anesthesia can be varied by the anesthesiologist depending of the needs of the case. A very short or minimally invasive case may require only very little anesthetic.
The decision about which anesthesia is best for you will depend on the type of surgery you are undergoing, your medical history, and your level of anxiety. It will be made in consultation with the anesthesiologist.
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Casts and Splints
A cast or splint is used to immobilize a fractured or dislocated bone or joint. A splint may also be used after surgery during the healing period or may be employed in certain conditions such as tendonitis, carpal tunnel syndrome or arthritis.
A cast can be made of plaster or fiberglass. It is applied to an extremity circumferentially to immobilize it. In the upper extremity, it can be a finger cast, hand cast, short arm cast (below the elbow) or long arm cast (above the elbow) depending on need. Generally, casts are applied quite snug so that they can most effectively immobilize a fracture. Since swelling can occur after a fracture, it is critical that the extremity be elevated as much as possible. This counteracts the tendency for swelling by utilizing gravity. A sling is usually provided for use while walking, but ideally the limb should be elevated even more than is possible with a sling. When sitting or lying down, the hand should be kept above the level of the heart. It can be propped up using pillows or folded blankets. If the fingers are not injured and they are not immobilized in the cast, they should be straightened and flexed (fist) at one hour intervals to prevent stiffness and to reduce edema. No heavy or repetitive work should be performed by the injured limb.
A splint can be made of plaster, fiberglass, aluminum or moldable plastic. In cases of fracture, a splint, rather than a cast, is sometimes applied in the emergency room. It is sometimes referred to as a "soft cast". Such a splint is usually wrapped with an elastic bandage and the rigid portion does not envelope the limb circumferentially. It allows some expansion of the dressing if significant swelling is anticipated. Nonetheless, elevation is just as critical. After an appropriate amount of time, a splint may be replaced by a cast. Both casts and "soft casts" must be kept dry by whatever means possible.
Finger splints used for broken or dislocated digits or in tendon injuries are usually made of alumafoam (an aluminum strip padded on one side with sponge-like foam). Sometimes plaster can also be used either alone or in combination with alumafoam. These should not be removed after they are applied in the emergency room until you are seen by Dr. Yang.
Certain tendonitis and arthritis conditions and nerve compression syndromes require wearing a removable splint. This can sometimes be an off-the-shelf type or a custom molded splint. These can be taken off when bathing and dressing. The custom fabricated splints are made by the occupational therapist and a prescription is generally required. The directions for using the splint will be given to the patient when the splint is prescribed. If a custom made splint is not fitting properly, it should be taken back to the therapist for modification.
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Congenital Deformities
Congenital hand deformities are those abnormalities of the hand that are present at birth. There is a wide range of deformities that can affect a child’s hand, some very minor and others that can significantly impact the function and appearance of the hand. Most congenital hand deformities are not inherited nor are they preventable. Some deformities are part of a syndrome that might be diagnosed at birth.
Early evaluation by an NYU Langone hand surgery specialist will ensure the best outcome possible. Immediate and correct diagnosis of a condition will enable the specialist to initiate early interventions and mobilize the extensive experience and resources of NYU Langone Medical Center to tailor an ideal treatment plan. Often this is a collaboration between surgeons, hand therapists, geneticists, pediatricians, neurologists, and prosthetists.
Diagnosis:
The accurate diagnosis and classification of a hand anomaly is an important first step. Most crucial is a careful clinical examination of the hand but often x-rays are also necessary. Sometimes more sophisticated imaging is required such as MRI scans, CT scans, and arteriograms. Although there are numerous variations of hand deformities, there are some more commonly seen.
Duplication of digits, or too many fingers, is one of the most common. Polydactyly can be as minor as a small skin tag that is treated in the newborn nursery by being tied at its base with a suture. Conversely, there can be multiple excess digits and significant potential compromise of the normal fingers.
Webbing of the fingers, or syndactyly, is also frequently seen. Some involve only skin connections between fingers, but others involve bone connections as well. In complex cases several fingers can be encased in skin and the bones significantly abnormal.
Undergrowth of fingers can occur where the digit is small, bones are underdeveloped or missing, or muscles are absent. A hypoplastic thumb is an example of this kind of deformity. Sometimes entire digits are missing, such as an aplastic thumb.
Overgrowth of fingers, or macrodactyly, is exceedingly rare. These are difficult to treat and outcomes can be less than ideal.
Radial club hand is a deformity which causes the limb to be short and the wrist severely angulated due to the shortness or absence of the radial bone in the forearm along with underdevelopment of the structures on the thumb side of the forearm and wrist. Radial club hand can be associated with blood, heart, intestinal, or spinal abnormalities.
Ulnar club hand is much less common than radial club hand and involves shortness or absence of the ulnar bone in the forearm as well as the other tissues on the little finger side of the hand and wrist. It also causes the wrist to be angulated. This can be associated with other muscle or bone abnormalities in other limbs or the spine.
Treatment:
Some minor hand differences need no treatment if they are not likely to cause functional limitations of the hand or if aesthetically acceptable. The wishes and expectations of the family are taken into consideration when formulating a treatment plan. The child’s general health and coexisting medical conditions may be a factor in determining the extent of treatment.
Occupational therapists and physical therapists are often involved early in the evaluation and treatment of children with congenital hand deformities. Stretching exercises and splinting are useful in some conditions. Manipulations and training by experienced therapists can sometimes correct mild deformities or allow children to adapt to certain conditions.
Orthotics and prosthetic are sometimes appropriate for children with some upper limb deformities. The quality and sophistication of prosthetics continues to improve. The Rusk Institute of NYU is at the forefront of developing more technologically advanced devices for limb function.
Surgery is often necessary to correct or improve congenital deformities of the hand. The experts at NYU Langone can provide state-of-the-art surgical care for the most complex reconstructions as well as for more simple procedures. Among the techniques used are skin grafting, skin flaps, ablations, limb lengthenings, muscle and tendon transfers, toe-to-hand transfers, corrective osteotomies, bone grafting, microvascular reconstructions, and others.
Recovery and Support:
Occupational and physical therapy are typically involved in the healing and recovery after surgery. Additional splinting and exercises are often necessary to regain optimal function. The exact kind of therapy and duration of treatment is dictated by the surgeon depending on the type and magnitude of surgery.
Social workers are available to help families with children who have congenital hand deformities. They are frequently instrumental in identifying resources available to support families with the care necessary for their child. Often school based services, such as occupational therapists, are engaged to provide ongoing care.
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Fractures
Fractures (broken bones) usually result from trauma such as a fall or a twisting or crushing injury. They can also be caused by overuse, especially in the weight bearing bones of the lower extremity (stress fractures). Tumors, benign or malignant, as well as metabolic abnormalities such as osteoporosis can predispose bones to fracture.
A fracture can be quite obvious with deformity and dysfunction of the injured part, but sometimes it can be very difficult diagnose. If you have suffered an injury which could have broken a bone, the only way to make an accurate diagnosis is to get an x-ray. Fractures that are diagnosed and treated late generally do worse. The old wives tale that "if you can move the limb or joints it can't be broken" just is not true. In fact, some fractures require sophisticated imaging modalities such as CT scan, MRI scan, or bone scans to identify.
Usually, fractures are treated in the emergency room. A cast or splint might be applied. You will be given instructions for making a scheduled follow-up appointment with Dr. Yang. The limb must be elevated as much as possible after a fracture since there is a tendency for swelling. A sling should be worn when walking. When sitting or lying down, the arm and hand should be propped up with pillows so that the hand is above the level of the heart. Pain medication is sometimes prescribed.
Most fractures are treated ultimately in just a cast. However, many fractures require surgery to achieve the best outcome. These are most often displaced or angulated fractures or fractures involving a joint. Joint fractures often need to be fixed surgically so that its hinge function can be restored. In the upper extremity, fractures may require pinning with wires, external fixation with pins and metal frame, or internal fixation with plates and screws or rods. In general, a fracture that needs surgery should be operated on within the first two weeks before the healing progresses too far. Some fractures need surgery immediately such as those that are associated with open wounds or significant soft tissue injuries.
The healing time of fractures depends on the bone injured, the severity of the break, the age of the patient, and medical condition of the patient among other factors. Often a fracture that is fixed surgically will have a shorter immobilization time. A simple non-displaced fracture of a hand metacarpal may need only three weeks of immobilization whereas a complicated scaphoid (carpal navicular) fracture may require three or more months of casting. Regular follow-up visits for x-rays and examination are necessary during the healing period.
In most cases, physical or occupational therapy is needed to restore mobility, strength, and coordination of the limb. It is started as soon as enough healing has occurred so that motion will not displace the fracture. Often, some simple exercises done by the patient alone will be started immediately. The duration of supervised therapy will depend on many factors such as the severity of the injury, the age of the patient, duration of immobilization, and others. Physical and occupational therapists are licensed health professionals not to be confused with athletic trainers who perform an important but different function.
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Nerve Injuries
Nerves are the electrical wires that carry signals from the brain to the rest of the body. A nerve is like a telephone cable wrapped in insulation. An outer layer of tissue forms a cover to protect the nerve, just like the insulation surrounding a telephone cable. A nerve contains millions of individual fibers grouped in bundles within the “insulated cable.”
Motor nerves carry messages from the brain to muscles to make the body move. Sensory nerves carry messages to the brain from different parts of the body to signal pain, pressure, and temperature. While the individual axon (nerve fiber) carries only one type of message, either motor or sensory, most nerves in the body are made up of both.
CAUSES
Nerves are fragile and can be damaged by pressure, stretching, or cutting. Pressure or stretching injuries can cause the fibers carrying the information to break and stop the nerve from working, without disrupting the insulating cover. When a nerve is cut, both the nerve and the insulation are broken. Injury to a nerve can stop the transmission of signals to and from the brain, preventing muscles from working and causing loss of feeling in the area supplied by that nerve.
SIGNS AND SYMPTOMS TREATMENT
To fix a cut nerve, the insulation around both ends of the nerve is stitched together. A nerve in a finger is only a millimeter or two thick, so the stitches have to be very tiny and thin. The repair may need to be protected with a splint for the first few weeks to protect it from stretching apart. The goal in fixing the nerve is to repair the outer cover so that nerve fibers can grow down the empty tubes to the muscles and sensory receptors and work again. If a wound is dirty or crushed, you may need to wait to fix the nerve until the skin has healed. If there is a gap between the ends of the nerve, Dr. Yang may need to take a piece of nerve (nerve graft) from another part of the body to fix the injured nerve. This may cause permanent loss of feeling in the area where the nerve graft was taken. Smaller gaps can sometimes be bridged with “conduits” made from a vein or special cylinder.
Once the nerve cover is fixed, the nerve fibers generally begin to start growing across the repair site after three or four weeks. The nerve fibers then usually grow down the empty nerve tubes up to one inch every month, depending on the patient’s age and other factors. This means that with an injury to a nerve in the arm 11 or 12 inches above the fingertips, it may take as long as a year before feeling returns to the fingertips. The feeling of pins and needles in the fingertips is common during the recovery process. While this can be uncomfortable, it usually passes and is a sign of recovery.
You may need therapy to keep joints flexible. If the joints become stiff, they will not work even after muscles begin to work again. When a sensory nerve has been injured, the patient must be extra careful not to burn or cut their fingers since there is no feeling in the affected area. After the nerve has recovered, the brain gets “lazy,” and a procedure called sensory re-education may be needed to improve feeling to the hand or finger.
Factors that may affect results after nerve repair include age, the type of wound and nerve, and location of the injury. While nerve injuries may create lasting problems for the patient, proper surgery and therapy help return to more normal use.
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Tendon Injuries
Flexor tendons bend the wrist and fingers, while extensor tendons straighten the wrist and fingers.
Extensor tendons are just under the skin. They lie next to the bone on the back of the hands and fingers. They can be injured by a cut or jamming a finger, which may cause the thin tendons to rip from their attachment to bone. If not treated, it may be hard to straighten one or more joints.
Tears caused by jamming injuries are usually treated with splints. Splints hold the tendon in place and should be worn at all times until the tendon is healed. The tendon may take six to eight weeks to heal completely. Longer periods of splinting are sometimes needed.
Other treatment may include surgery to repair cuts in the tendon. Also, a pin may need to be placed through the bone across the joint as an internal splint. Surgery to free scar tissue afterward is sometimes helpful in cases of severe motion loss.
After treatment, therapy may be necessary to improve motion.
Flexor tendons bend the wrist and fingers. The flexor muscles move the fingers through cord-like extensions called tendons, which connect the muscles to bone. The flexor muscles start at the elbow and forearm regions, turn into tendons just past the middle of the forearm, and attach to the bones of the fingers. In the finger, the tendons pass through tunnels that keep them close to the bones, which helps them work better.
CAUSES
Deep cuts can injure the tendons and nearby nerves and blood vessels.
An injury that looks simple on the outside can be much more complex on the inside.
SIGNS AND SYMPTOMS
When the tendon is cut, you cannot bend your finger.
TREATMENT
A cut tendon cannot heal without surgery. Nearby nerves and blood vessels may need to be repaired as well. After surgery, the injured area will need to be moved to limit stiffness, but the repair must be protected. Post-operative therapy will be necessary to regain the best range of motion and strength possible.
There is scarring as the tendon heals, and most people do not regain normal motion. In some cases, if motion is less than expected after months of exercises, then your surgeon might offer you surgery to release scar tissue around the tendon.
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