Hand and Wrist Conditions

Carpal Tunnel Syndrome

Carpal tunnel syndrome is probably one of the commonest presentations in a hand surgery service. The anatomical basis for the problem comes from compression of the median nerve under the carpal ligament in the palm at the heel of the hand. This nerve supplies sensation to all of the digits in the hand except for the little finger and part of the ring finger although there is variability in this. It also plays an important role in supplying the muscles at the base of the thumb. Dependent upon the severity of the compression of the nerve, the symptoms vary from intermittent numbness and tingling to permanent loss of feeling in the hand. If the nerve entrapment is more advanced than that patients can notice weakness in the use of the thumb and inability to do sustained activities.

Carpal Tunnel Syndrome

Mr Yanni has operated on both my right and left hands for Carpal Tunnel.Both operations were carried out in a very professional manner and I am looking forward to full recovery in both hands within 6-9 months.Mr Yanni’s secretary Caroline was also very professional and helpful in every way.I would highly recommend Mr Yanni if you require Carpal Tunnel Surgery.

Carpal Tunnel Syndrome, Carpal Tunnel Release

Features on history

Typical features on history are numbness and tingling in the hand which occur at night time.  Patients very characteristically complain of pain in the forearm which is often described as a toothache-like pain.  Though the compression is at the wrist there is referred conduction of pain  that is perceived in the forearm.  Patients often give a characteristic history though not always.  Typical features are can include  waking up at night time and having to shake the hand free; pain, numbness and tingling during overhead activities eg painting a ceiling; putting the hand on a steering wheel; holding up a telephone for long periods are a few typical examples.  If there is motor involvement then weakness in the hand and in particular the thumb occurs.

Features on Examination

Patients have tenderness and pain over the mouth of the carpal tunnel the so called tinel test which simulates the compression and gives a lancinating electrical pain which can confirm he diagnosis.  There are other challenge tests which also indicate compression of the carpal tunnel as well.  Attention is always paid to the neck because problems from the neck can co-exist or can simulate the symptoms in the hand.

Investigations

The diagnosis of carpal tunnel syndrome can be made clinically without any investigations although it can also be augmented by a conduction test as a measure of severity but also to confirm the diagnosis as well as when it occurs in conjunction with neck problems.

Treatment

Treatment consists of simple measures such as wearing a splint at night time.  The rationale for this being that we all assume the clenched fist flexed position during our sleep and that causes compression of the nerve.  By wearing a splint this is prevented.  Nerve tension releasing exercises are also used by physiotherapy.  Injections into the mouth of the carpal tunnel can be administered and ultimately if these measures do not work out together with modifications of activity in daily living then a decompression is considered.

Recovery

Following surgery which is undertaken under local anaesthetic, it can take 6-9 months for the ultimate plateau of recovery to come through.  There is a very small risk of recurrence, infection in the wound, tenderness in the scar in relation to a neuroma of a cutaneous branch of the nerve. Pain and stiffness (reflex sympathetic dystrophy) can occur in a tiny percentage of interventions on the hand.  If motor changes have occurred with wasting of the muscles around the thumb for example, then there is a chance that the changes may be irreversible.  Whilst we would embark on surgery to improve symptoms and function, it may well be that this recovery is therefore incomplete.  In patients where the entrapment of the median nerve in the wrist is a longstanding one, it may be that the early aftermath of surgery can lead to some unpleasant sensations, which paradoxically can be worse than the pre-operative state.  However, in general these tend to settle down. If osteoarthritis of the hand co-exists with carpal tunnel syndrome and in particular if it is at the base of the trapeziometacarpal joint then it can lead to some delay in recovery and in particular in relation to the thumb movements.

Carpal tunnel syndrome over the age of 40-50 can co-exist with problems in the cervical spine. The purpose of carpal tunnel decompression is to remove from the sum total of the picture the contribution coming from the carpal tunnel but it may well be that there is a residue of symptoms coming from the neck which needs to be addressed.  The clinical examination is essential in identifying, which is the more dominant contributor to the sum total of the clinical picture.

The outer layer of skin in the palm is keratinised skin, which has no blood supply and which is dry. Thus when the sutures are removed this area is very dry and it flakes.  This is absolutely normal and is not a sign of infection.  This can leave a slight groove in the wound known as “canoeing” and which always heals up without any problem.  Patients often notice a pain over the site of the incision, the so-called heel of the hand. That is normal and due to the surgery that has been undertaken.

It is also  common to notice bruising tracking down the forearm.  This is accentuated by the fact that we always ask patients to elevate their hand and this causes any bleeding to track downwards towards the elbow. This bruising always settles down.

The procedure involves releasing the carpal ligament, which is the roof of the tunnel through which the median nerve and the tendons runs through.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

I had hand surgery. Done by doctor Yanni I found the experience very calm and he excellent in what he does.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Trigger Finger

The tendons supply the digits on the palm side of the hand.  They are responsible for actively curling up the fingers into the palm.  It can be seen that these tendons would bowstring if there was not a mechanism to control them.  This mechanism is a series of belts/sheath which runs over the tendon from the palm right to the tip of the finger.  These are described by hand surgeons as pulleys and there are several of them.  The first pulley in the palm over the tendon can contract down and there can be some wear and tear changes such that the space available for the tendon to run through the pulley is diminished thus resulting in impingement which can cause pain and intermittent triggering where the finger gets locked and trapped and patients have to physically release it.  In advanced cases this may cause the finger to be permanently locked.

“I cannot praise Mr. Yanni enough, he has been very thorough explaining the procedure from day one! Many thanks Mr. Yanni”

Features on history

Dependent upon the severity of the symptoms, patients may complain of tenderness in the palm, pain on flexing the finger and carrying objects or mechanical locking where they have to physically release it.  In extreme cases the finger can be locked permanently.

Features on Examination

These usually concentrate on identifying the tenderness in the palm of the hand and trying to simulate the triggering mechanism.

Investigations

Investigations are not normally required for this condition although arthritic changes in the finger can co-exist and occasionally an x-ray may be required

Treatment

The treatment starts with modifications of activities of daily living and occasional splintage.  Physiotherapy with heat and ultrasound can also be used.  If these simple measures do not work out then the next port of call would be injections into the palm and if these do not achieve any long lasting breakthrough then  a surgical release is undertaken under local anaesthetic.

Recovery

There are small risks in relation to wound infection, reflex and sympathetic dystrophy, pain and stiffness in the hand, tenderness in the scar and a very small risk of nerve damage.

Very often patients complain of pain and discomfort over the PIPJ over the dorsal aspect of the PIPJ of the affected finger following surgery, rather than at the site of incision. This is extremely common and that is because the hand is getting used to the freedom afforded to it by the surgical release and this places pressure on the PIPJ knuckle.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“This is the second time that I have had surgery carried out by Mr Yanni and I would highly recommend him. I feel that everything is always explained to me so I know what to expect when I come in for the procedure. Mr Yanni is very charming and has a great sense of humour which always helps to put you at ease, especially if you are feeling nervous/anxious.”

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Thumb Arthritis

This is a common condition in hand clinics.  It is slighter commoner in women than in men and it is slightly commoner in the non-dominant hand which may appear surprising.  However, the non-dominant hand is often used for the coarse tripod activities which stabilise the object whereas the dominant hand is used for fine activity.  The fact that the non-dominant hand is used for more coarse powered activities places more pressure on the thumb.  The fact that ligamentous laxity is commoner in women is also considered a factor in development of thumb arthritis.  The trapezium articulates with 4 joints in the hand and most importantly it articulates with the wrist joint itself through the scaphoid over and above the articulation it has in the base of the thumb.  In some instances the arthritis can involve all joints of the trapezium.

Thumb Arthritis

“Absolutely lovely, puts you at ease and a very good hand surgeon”

Features on history

Patients complain of pain and discomfort at the base of the thumb together with swelling and alteration of the contour of the thumb.  Patients feel that the thumb appears weak and movements such as wringing a cloth, turning a key, picking a pin or indeed pulling out a big book from the shelf are very problematic.  Sustained activity is also very difficult.

Features on Examination

There is usually tenderness on the base of the trapezium where the examiner conducts the grind test to simulate the symptoms.  There is also evidence of contracture in the web span between the thumb and the index finger due to the alteration on the contour of the thumb (subluxation).

Investigations

Investigations usually required are those of x-rays of the thumb and also the rest of the wrist.

Treatment

Treatment consists of modification of activities of daily living as well as non-steroidal anti-inflammatories in the early stages.  Following on from that splints can be given to support the thumb and injections can be administered into the trapeziometacarpal joint.  Failing that the next port of call would be surgery on the base of the trapezium which is routine work undertaken in a hand surgery service.  The surgery for this is an excision arthroplasty of the trapezium.  Dependent upon the ligamentous laxity and how stable the thumb ray is stabilisation options may be considered as well.

Recovery

Trapeziometacarpal arthritis is a condition, which will have taken some time to develop, and consequently it will take about 6-9 months of rehabilitation before the ultimate plateau of recovery comes through. Like any surgical intervention there are risks in general and specific to the procedure,  amongst them are wound infection, pain, reflex sympathetic dystrophy (pain and stiffness), recurrence of symptoms, tenderness in the scar an also the occurrence of  neuromata in relation to the superficial branch of the radial nerve.  The arthritis can at times co-exist with arthritis in other parts of the wrist and consequently whilst we would never embark upon surgery unless we felt we had an excellent chance of improving symptoms and function, recovery may not be complete although we are always aiming for a better pain relief and improvement of function than was the case prior to surgery.  Following on from the surgery  an attendance at hand physiotherapy is always necessary and this will involve the fashioning of splints.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Tendonitis

Many tendons run around the hand both on the palm side and also on the back of the hand.  These can be involved in inflammation and any inflammation of a tendon is described as a tendonitis.  These are often related to overuse syndromes through manual work, repetitive activity, sporting endeavours and also in the workplace due to repetitive keyboard use.  They can also occur against the backdrop of inflammation in the joints and systemic arthritis.

Features on history

The history will vary according to where the tendonitis is present.  Thus if it is a tendon over the back of the hand it may well be that certain manoeuvres will be painful during cocking the wrist up (dorsiflexion).  The reverse is true if they are on the palm side.

Features on Examination

The examination consists of various manoeuvres to stress the tendon to reproduce the symptoms and to palpate its course to see if there is any tenderness along that area.

Investigations

Investigations usually consist of some blood tests to exclude any systemic arthropathy as well as x-rays and ultrasound/MRI to define the extent of the inflammation.

Treatment

Treatment consists of modification of activities of daily living.  These can also be supported through splintage as well as physiotherapy with heat and ultrasound.  Injections can be considered and surgery can be considered in certain cases although not all of them are amenable to this.

Nuggets of Wisdom

CO-EXISTENT PROBLEMS WITH CARPAL TUNNEL SYNDROME:

Carpal tunnel syndrome often co-exists with neck problems, diabetic neuropathy and even multiple sclerosis.  Once the diagnosis is confirmed, it is always a good policy to remove from the sum total of the picture the contribution coming from the carpal tunnel syndrome and then to deal with the more complicated issues (MS/neck problems) after that.

“Mr Yanni treats you like a personal friend. I felt extremely comfortable in his company & confident in his expertise. He is the utmost professional at all times.”

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“Dr Yanni is a wonderful surgeon, very reassuring with his bedside manner. Very courteous and generally a lovely man  “

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Ganglion/Ganglia

A ganglion(plural ganglia) is a benign sac filled with jelly-like fluid arising around the wrist or the hand. They are benign with no sinister implications whatsoever. The commonest sites for them to occur are on the back of the hand and along the palm side of the hand at the base of the thumb by the wrist crease between one of the tendons known as FCR and the radial pulse. They can also occur in the rest of the hand but less frequently. They can also present in the palm where they are known as pearl ganglia which can be exquisitely tender nodules. Ganglia occurring in young patients are usually without any aetiology although they can be related to certain movements.

Ganglion/Ganglia

Thus dorsiflexion movements (cocking the wrist upwards) as occurs in use of mountain bikes, lifting weights, sustained use of keyboards, press-ups etcetera can pump mucinous fluid into the neck of the sac which overlies the scapholunate ligament. It is thought that these ganglia are related to mucinous degeneration in this ligament although that is not always the case. The ganglia at the base of the thumb are often not related to any cause although in the older age group they are often due to arthritic changes in the wrist, or the trapeziometacarpal and scaphotrapezial articulations which are the tendons at the base of the thumb. Because of the development of the arthritis at the base of the thumb the body secretes more of the biological lubricant which is synovial fluid which tracks down and pops out as a small ganglion. Broadly speaking ganglia occurring in the young are without any cause though in the older age group 50 plus they are virtually always related to arthritic changes in the wrist or at the base of the thumb.

“Hand Surgery May 2021. Very friendly, extremely professional and answered all of my questions and concerns with utmost respect and confidence before, during and after procedure. “

Features on history

Features on history consist of examining the ganglion to confirm that this is the diagnosis and also establishing its relationship as well as excluding any underlying pathology such as damage to the scapholunate ligament, arthritis in the wrist as well as a fracture to the wrist.

Features on Examination

The examination of the ganglion to confirm its nature, its source and whether or not it is reducible.

Investigations

Investigations will depend on the circumstances of the patient and their age.  In the younger patient no investigation is usually indicated although it can be considered if ligamentous injury is suspected.  In the older age group x-rays are often taken to exclude arthritis and these may be combined with scans.

Treatment

Treatment usually starts with symptomatic management and with modification of activities of daily living.  Thus for a ganglion on the back of the hand patients are requested to stop doing press-ups, lifting weights, bicycle handlebars etcetera.  Failing this, some splints can work and after that an aspiration of the ganglion with multiple puncture is considered.  In previous generations, hand surgeons  used to do open surgery on ganglia but we now prefer aspiration as a favoured method for this.  In extreme cases where aspirations have failed on 2 to 3 occasions the ganglion can be excised arthroscopically.

The arthroscopic excision is particularly suited to the ganglion along the palm between the FCR and the vessels at the base of the thumb.  If the ganglion is pre-disposed to by arthritic changes for example at the base of the thumb or at the wrist then the treatment is to target the arthritis rather than the ganglion itself which is nothing more than a manifestation of the arthritic problem.

Recovery

It is not my policy to consider open surgery as a first line of treatment for two types of ganglia which can occur, namely the dorsal(back of hand) and distal volo-radial (palmar ganglia by the wrist crease) ganglia simply because there is evidence in the medical literature that the recurrence rate can be as high as anything from 10-30% depending upon the different reports in the hand surgery literature.  Consequently, we like to consider simple interventions first before we embark on surgery.

If aspiration and multiple puncture has been undertaken on numerous occasions with subsequent return of ganglia then in certain very specific cases these may be amenable to arthroscopic excision thus obviating the need for any open surgery.  This is undertaken as a last resort rather than a first port of call.  The surgery is undertaken arthroscopically and involves excising the stalk of the ganglion, which can be over the back of the hand, roughly in the central area overlying the scapholuante ligament or along the volar aspect of the wrist where the ganglion is decompressed internally by doing an internal aperture between the long radiolunate ligament and the radioscaphocapitate ligament.  The quoted recurrence rates in the literature are in the order of 10-20%, which is probably lower than the published rates for open surgery and aspiration. However, formal randomised studies are still awaited.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Mr Yanni has operated on both my right and left hands for Carpal Tunnel.Both operations were carried out in a very professional manner and I am looking forward to full recovery in both hands within 6-9 months.Mr Yanni’s secretary Caroline was also very professional and helpful in every way.I would highly recommend Mr Yanni if you require Carpal Tunnel Surgery.

Carpal Tunnel Syndrome, Carpal Tunnel Release

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Dupuytren’s Contracture

Dupuytren’s is a extremely common condition in Northwest Europeans and it is known as the Viking Claw. There is evidence that where the Vikings went they took it with them. It is extremely uncommon in the Mediterranean basin, African and Indian continents. The condition is benign and it consists of thickening in the palm. This starts with nodules which progress to the development of cords. As the condition progresses it can cause joint contractures which debilitate the patient. It is commoner in men than in women and there is often a family history for the condition.

Dupuytren’s Contracture

“I have just had a procedure on my hand by Mr Yanni. Mr Yanni takes time to explain the background to your condition and explains in detail the procedure he will carry out and the recovery time and any specialist physio required. At the follow up appointments he takes great care to ensure you are happy with the healing and do not have any worries. Mr Yanni is a surgeon with great compassion and understanding and I cannot recommend him highly enough.”

Features on history

The symptoms of the patient will depend on the severity of the joint contractures.  The more advanced this is the more difficulty might occur.  Patients have difficulty manipulating objects, shaking hands, putting their hands in their pocket, wearing gloves ,shaving and also undertaking sustained activity.

Features on Examination

The purpose of examination is to identify the site of the cords and nodules as well as measuring the extent of the deformity as this will influence the management. The table top test is usually performed whereby the patient is asked to put their hand flat on a table. The greater the gap between the palm and the table top the more likely it is that operative intervention will be required.

Investigations

No investigations are usually necessary.

Treatment

Treatment will depend on the extent of the deformity.  The more severe the deformity the more likely it is for intervention to be required.  There is a wide range of treatments available ranging from splinting for patients without joint contractures to interventions undertaken under local anaesthetics to other modalities of surgery which require a general anaesthetic and which may also involve skin grafts.  The two commonest modalities in Mr Yanni’s practice are needle fasciotomy and open surgery for Dupuytren.

Recovery

Needle fasciotomy:

Dupuytren’s contracture is an inherited condition, which is unmasked by environmental factors.  When the joint starts causing problems in terms of stiffness in the joints or a sensation of tightness then intervention can be indicated dependent upon the circumstances.  There are many options in relation dealing with Dupuytren’s.  These range from splintage to open surgery.  Whatever is done for Dupuytren’s is associated with a recurrence, which can be as high as 30%.  The younger the age of presentation and at the time of surgery then the more likely it is to recur.  Be that as it may all treatment is tailored according to the needs of the patient.  The purpose of the needle fasciotomy is to have a procedure which can be done under local anaesthetic and which is easy to achieve without too much interruption of the patient’s daily life.  The aim of the needle fasciotomy is to interrupt the cords and the nodules, which have formed in the palm, rather than to fully excise them.  The purpose of this is to improve the joint contractures.  There are small risks in relation to infection, which are very low compared to open surgery, and there is also a small risk to damage to underlying tendons and neurovascular bundles.  There are small risks in relation to reflex sympathetic dystrophy, which is pain and stiffness afterwards.  It must be stated, however, that needle fasciotomy undertaken under local anaesthetic is exceptionally well tolerated and the risks are extremely low.  However, there is a definite recurrence rate and patients may require further surgery following a needle fasciotomy which may include further needle fasciotomies or open surgery.

Open Surgery:

With Dupuytrens itself, the risks of recurrence can be as high as 30%.The younger the patientia at presentation  then the more likely it is that the condition will recur  and thus requiring further surgery on the same operated hand.  Patients have zigzag incisions which are often alarming for patients unless they have been prepared to expect this.  There are definite risks in relation to any intervention and amongst them are wound infection, pain and stiffness in the hand, reflex sympathetic dystrophy, recurrence, tenderness in the scar, nerve damage and very rarely ischaemia of the digit. The recurrence rate is statistically quoted in hand surgery literature as high as 30%.  We deliberately do not aim to get a full correction, particularly on the little finger in the PIPJ and at times we combine this with soft tissue releases on the joint to obtain better movement.  It takes 6-9 months for the ultimate plateau of recovery to come through.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

“Full 5 star rating for Mr Yanni, could not fault anything in my procedure at the Sloane Hospital”

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

De Quervain’s Tenosynovitis

This is a condition which broadly speaking occurs in two groups of people; either recently delivered mothers or in overuse situations.  The reason it is common in new mothers is that during pregnancy, the placenta secretes hormones such as progesterone, oestrogen and relaxin one of whose biological functions is to relax the pelvis so that the baby can come out comfortably during delivery.  In so doing it causes relaxation of all the ligaments within the body.  When the hormonal support from the placenta goes after delivery then the tissues contract down and it is very often the case that the ligament overlying the tendons at the base of the thumb contracts thus causing exquisite pain.  This is often accentuated by the various activities which a mother has to undertake in caring for her new born.

De Quervain’s Tenosynovitis

“Dr Yanni is an extremely professional and skilled doctor. He made me feel so comfortable and assured me that all would be ok with my surgery and arm. I will recommend my family and friends to him if they ever had issues with their hands Last but not least I am happy I was in the capable hands of a very good and caring doctor “

Features on history

Patients report pain during certain thumb manoeuvres.

Features on Examination

Features on examination consist of tenderness at the base of the thumb as well as significant discomfort on passively flexing the thumb (the Finkelstein manoeuvre) as well as on resisted activity.

Investigations

Investigations may include ultrasound or a scan together with x-rays.

Treatment

Treatment consists of modification of activities of daily living together with splintage.  These can be combined with injections which very often is all that is required.  In a small number of cases we have to consider surgery after failure of non-operative treatment.

Recovery

There are small risks attendant to surgery such as wound infection, subluxation of the tendon within the group following release and neuroma from the exposure due to the profusion of branches of the cutaneous division of the radial nerve.

Like any hand intervention, there are risks with regards to pain and stiffness, so-called RSD.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Wrist Arthritis

When wrist arthritis occurs in the hand it can do so in varying degrees dependent upon its causes.  These causes can be related to osteoarthritis following on from a previous fracture, previous fractures of the scaphoid (scaphoid non-union advanced collapse SNAC) or following on from a disruption of the scaphoid lunate ligament (scapholuate advanced collapse SLAC).

Features on history

These will depend on the severity of the condition.  The more advanced the arthritis in the wrist the more symptomatic the patient can be.  There are many small bones which make up the wrist joint and the greater the number of these joints which are involved then the more likely it is for the patient to be debilitated by these symptoms.  Enquiry during clinical examination is to establish to what extent this is interfering with the patient’s daily life.

Features on Examination

Examination may identify a ganglion which may be a secondary manifestation of this as well as alteration of the contour of the joint. These ganglia are often nominated as the problem but in reality the ganglion is a secondary manifestation of the primary problem i.e. the arthritis. The range of movement is measured and various joints are stressed to establish which of them are affected

Nuggets of Wisdom

BASE OF THUMB ARTHRITIS:

Trapeziometacarpal arthritis is a relatively common condition. It gives pain on key pinch and pin pinch.  Patients lose the first web space span (i.e cannot pull a large book from a shelf).  Early treatment consists of anti-inflammatories, injection and splintage.  The results of surgery are extremely good.

“Dr Yanni has been delightful from start to finish, I actually look forward to seeing him! He answered all my questions and was also very patient with me being very nervous about the procedure. A highly recommended doctor overall.”

Investigations

Investigations usually consist of x-rays combined with scans which can be CT scan or MRI to define the extent of the involvement.

Treatment

Treatment is according to severity as well as the causes.  It is difficult to give one specific treatment as there are a variety of treatments available due to the variety of causes.  Broadly speaking initial measures consists of symptomatic modifications of activities of daily living and keeping a diary of which movements in a patient’s daily life bring about the symptoms.  These can be combined with splintage and physiotherapy which will involve heat and ultrasound.  Following from that patients can be evaluated by means of wrist arthroscopy which is also useful in debriding the wrist and undertaking measures which involve shaving the overgrowths (osteophytes) as well as part of the radius itself known as the radial styloid (radial styloidectomy).  These measures can be undertaken either through open surgery or by means of the wrist arthroscope.  Dependent on the severity and the patient’s response the treatment is escalated accordingly in discussion with the patient and this can involve limited fusions in the wrist and can extend to a full wrist fusion.

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123

Contact on d.h.yanni@btinternet.com (email preferable) OR telephone Caroline on 020 8460 0123