Animal Bites

Each year millions of people in the United States-most of them children—are bitten by animals. Most animal bites are from dogs; cat bites are second most common. However, the risk of infection from a cat bite is much higher than that from a dog bite. Most bites occur on the fingers of the dominant hand, but children may also be bitten about the head and neck area.

A major concern about an animal bite is the possibility of rabies. Because most pets in the U.S. are vaccinated, most cases of rabies result from the bite of a wild animal such as a skunk, bat or raccoon. However, in other countries, dog bites are the most common source of rabies. If you are bitten by a dog outside the U.S., consult a doctor immediately.

Signs and Symptoms of Animal Bites

In some cases, the bite will not break the skin but may cause damage to underlying tendons and joints. If the skin is broken, there is the additional possibility of infection as well as injury to tendons and nerves. Dogs have powerful jaws and can cause crushing injuries to bone, muscles, tendons, ligaments and nerves.

Signs of an infection include:

  • Warmth around the wound
  • Swelling
  • Pain
  • A pus discharge
  • Redness around the puncture wound

Signs of damage to tendons or nerves include:

  • An inability to bend or straighten the finger
  • A loss of sensation over the tip of the finger

First aid

  • Don’t put the bitten area in your mouth! You will just be adding the bacteria in your mouth to that already in the wound.
  • If the wound is superficial, wash the area thoroughly. Use soap and water or an antiseptic such as hydrogen peroxide or alcohol. Apply an antibiotic ointment and cover with a non-stick bandage. Watch the area carefully to see if there are signs of damaged nerves or tendons. Some bruising may develop, but the wound should heal within a week to 10 days. If it does not, or if you see signs of infection or damage to nerves and tendons, seek medical help.
  • If there is bleeding, apply direct pressure with a clean dry cloth. Elevate the area. Do not clean a wound that is actively bleeding. Cover the wound with a clean sterile dressing and always seek medical help.
  • If the wound is to the face and/or head and neck area, seek medical help immediately.
  • Contact your physician to see whether additional treatment is needed.
  • Report the incident to your public health department. They may ask your assistance in locating the animal so that it can be confined and observed for symptoms of rabies.

Medical assistance

Tell your doctor how you got the bite. Your physician will wash the wound area thoroughly and check for signs of nerve or tendon damage. The doctor may examine your arm to see if there are signs of a spreading infection. Your physician will probably leave the wound open (without stitches), unless you have a facial wound. You may need to get X-rays and a blood test. You may also need to get a tetanus shot and a prescription for antibiotics. If the tendons or nerves have been injured, you may need to see a specialist for additional treatment.

More about Rabies

Rabies is a disease that affects only mammals (such as raccoons, bats, dogs, horses, and humans). It is caused by a virus that attacks the nervous system. Without treatment, it is 100 percent fatal. Rabies develops in two stages.

During the first stage, which can last up to 10 days, the individual may have a headache, fever, decreased appetite, vomiting and general malaise, along with pain, itching, and tingling at the wound site. Symptoms of stage two include difficulty in swallowing, agitation, disorientation, paralysis, and coma. At this point, there is no known, effective treatment.

If rabies is identified early, a series of highly effective vaccinations can be administered. That’s why it’s important to capture and observe the animal that bit you. If the animal cannot be captured, but must be killed, the head should be kept intact so the brain can be examined for signs of rabies.

Preventing Animal Bites

Follow these recommendations to prevent animal bites and rabies.

  • Do not try to separate fighting animals.
  • Avoid animals that appear sick or act strangely. Call animal control.
  • Leave animals, even pets or other animals you know, alone when they are eating or sleeping.
  • Keep pets on a leash when out in public.
  • Never leave a young child alone with a pet. Don’t allow children to tease an animal by waving sticks, throwing stones, or pulling a tail.
  • Be sure your pet is vaccinated.
  • Do not approach or play with any kind of wild animal. Teach children not to pet strange animals, even pets on a leash, without asking permission of the owner first.

Hand Masses-Lumps and Bumps on the Hand and Wrist

I see many patients with different types of lumps and bumps of the hand and wrist. The vast majority of hand and wrist tumors are benign (non-cancerous), but they should all be evaluated by an orthopedic hand specialist. Any abnormal mass or growth is considered to be a “tumor”. These can occur on the skin, like a mole or a wart, or can be underneath the skin in the soft tissue, the fat layer, the muscle, or even the bone. There are many different types of tissues in the hand and wrist, so many types of tumors can occur.

What are the most common hand and wrist masses?

Ganglion cysts – These are the most common type of mass that represents around 50% of all hand and wrist growths. A ganglion cyst occurs when the tough lining of the small joint forms a pouch where joint fluid collects resulting in a “ballooning-out” of the lining of the tendon sheath or joint. This fluid is very thick, with a molasses-like consistency and when it fills the cyst, it makes it feel very firm. These cysts can also form as pouches off a knuckle joint or tendon sheath and are often referred to as mucous cysts.  The treatment options I offer for these  include aspiration, where the mass is punctured and the fluid is removed with a needle, or removal by means of surgery.

Giant Cell Tumor of the Tendon Sheath – Giant cell tumors are not true tumors as much as they are firm masses, and they are the second most common types of hand and wrist masses. These masses develop from joint lining known as synovium or from a tendon sheath. Giant cell tumors grow slowly and are quite painful. I can usually easily remove these lesions, but they often come back. Though these growths sound bad but they are slow growing and benign.

Epidermal Inclusion Cysts – I see these masses after an injury to the hand or finger and they often show up years later. An inclusion cyst develops just underneath the skin and is often quite firm. When an injury such as a deep cut occurs, the surface cells are pushed into the deep layers of the palm or finger resulting in the formation of a cyst in the area of injury. Skin cells produce a protective, way substance called keratin and when skin cells get trapped under the surface, they will continue to grow and make this keratin, which forms the cyst.

Carpal Boss – This common type of mass isn’t a tumor, but rather is an overgrowth of bone on the back of the hand. Carpal bosses are similar to bone spurs and often are often misdiagnosed as ganglion cysts. This type of mass is firmer and not movable, however. Occasionally the bump of a carpal boss is problematic, I might recommend removal of the symptomatic bone spur.

Enchodroma – When the cartilage grows inside the bone, an enchodroma occurs. These masses are non-cancerous but can present a problem when the bone becomes weakened and can lead to a fracture from weak bone. Usually I can fix the fracture while bone grafting the lesion to treat the lesion. Again, these are usually benign.

Lipomas, Neuromas, and Fibromas – These masses are all usually benign growths. Lipomas are fatty tumors, neuromas are nerve tumors, and fibromas are tumors of the fibrous connective tissue material of the hand and wrist. They can occur on the hand and wrist regions and are usually benign but often symptomatic. Many patients request removal of these lesions which not only treats the lesion, but provides a firm diagnosis.

Should I worry about cancer?

Though uncommon, the most common kinds of cancer that affects the hand and wrist include squamous cell carcinoma, basal cell carcinoma, and melanoma. While cancer seldom originates in the hand and wrist region, there are rare cases of bone and cartilage tumors that could result. When cancer originates in the hand, it is called sarcoma and is due to abnormal growth of the bone, cartilage, or soft tissues. While sarcomas are rare, it is always best to come to my office for an evaluation if you have a concerning mass of the hand or wrist.

What will an orthopedic specialist do for a lump or bump of the hand or wrist?

First of all, I will perform a careful history and physical examination to help determine the type of hand or wrist tumor you have. Often, x-Rays may be necessary to evaluate the bones, joints, and soft tissues. Further diagnostic studies, such as CT, MRI, or Bone Scan, might narrow down the diagnosis. Treatment will depend on the type of mass you have. Generally, definitive treatment with the lowest recurrence rate involves the surgical removal of the mass. This will allow me to send the tissue off to a pathologist to analyze it and determine what exact type of growth you have.

In general, I recommend evaluation of all hand masses to establish a firm diagnosis and a reasonable treatment plan. Most tumors are benign, but can often be symptomatic.  Usually excision of the lesion is curative and can help provide a reassuring diagnosis.

Hand Numbness – Common, but Usually Worth Investigating

Many people, both young and old, find hand numbness quite bothersome. Hand numbness is sometimes persistent, but often becomes worse in specific situations – waking up at night, driving, talking on a cell phone, sporting events, fishing, at work, ect.  Usually, patients come to my office thinking that a numb hand is a part of life, but in reality, a numb hand usually means that a nerve is being choked off by abnormal positions and usually abnormal anatomy.  

Though many feel that the numbness can be managed, my concern is that the same nerves which provide sensation, also provide valuable strength and dexterity for hand function, which often is already compromised by the time that a patient comes in for evaluation.

How is it diagnosed?

The two most common nerves that are compressed are the median nerve at the wrist, typically known as Carpal Tunnel Syndrome, and the ulnar nerve at the elbow, called cubital tunnel syndrome.  There are certainly many other areas of nerve compression which can give a sense of numbness, which can be evaluated with a simple clinical exam or an electrical nerve study.  Typically, I perform a full examination of all the nerves of the upper extremity and based on the findings, may order further studies such as a nerve conduction test, X-ray or an MRI to confirm or rule out my diagnosis.

What can be done?

The first key in treatment is to establish the correct diagnosis. Based on the particular nerve at risk, sometimes simple activity modifications or splinting can prevent a particular nerve from being susceptible to compression.

Sometimes, the nerve has been compressed for a long period of time or the nerve is at particular risk and I may offer a nerve decompression to permanently relieve the damaging effects of nerve compression and the numbness and muscle dysfunction that is likely to worsen if left untreated.  These surgeries are day surgeries and usually are quite well tolerated.  

Most of my patients compare them to dental type procedures, where soreness for several days occurs, but you are able to continue with your routine life. The decompression surgeries can be performed with modern minimally invasive techniques that can greatly minimize the pain and disability resulting from the procedure.

If you have numbness symptoms that you would like evaluated, do not hesitate to contact my office at 206-633-8100

Trigger Finger-Symptoms, Treatment, and Surgical Release

Trigger finger is a common condition that results in pain and snapping of the tendons at the base of the finger or thumb. These tendons are like pulleys that attach to the ends of the fingers to allow for finger movement. As the forearm muscle contracts, the tendons pull each finger into a fist. With trigger finger, this mechanism is not smooth and a snapping sensation can be felt, causing pain.

What causes trigger finger to occur?

The cause of trigger finger not clear, and this condition can appear without any particular cause. It is thought to be genetic and often occurs in one or more fingers and at different times in different locations. Trigger finger results from a difference between the size of the tendon and the entrance to the tendon sheath, usually at the base of a particular finger. … read more

Does Your Shoulder Hurt at Night? It could be a Rotator Cuff Tear

Shoulder pain is common, but it is not normal.  Perhaps you have a rotator cuff tear?  How would you know? 

Here are a few questions may highlight common symptoms that are common to those with rotator cuff tears –

Have you recently injured your shoulder?
Do you have pain with overhead activities? 
Do you have shoulder pain at night? 
Does your shoulder feel weak?

Don’t worry, not all rotator cuff tears need surgery, but it is important to identify the particular source of your shoulder painbecause the particular treatment and rehabilitation can drastically reduce your suffering.

One note – there is no anatomic structure called the “Rotatory Cup”!  You are right, the spherical end of the humerus does rotate in the glenoid (cup), and is actually the most mobile joint in the body. However, the “Rotator Cuff” is not directly involved with the joint surface, so problems with your rotator cuff do not necessarily mean that you have shoulder arthritis.

Common demographics of a patient with a rotator cuff tear include age 30-60, a specific traumatic episode or chronic heavy use of the shoulder, specifically difficulty with overhead activity. Symptoms include pain and weakness with initiating activities about the shoulder, night pain, pain on the side of the shoulder radiating down the arm.  Symptoms that suggest another disorder include grinding shoulder or popping shoulder, shoulder dislocation, pain in the front of the shoulder, stiff shouder, numbness, neck pain.

Once again, shoulder pain is common, but not normal. Proper systematic evaluation is critical identify your particular diagnosis to lead you down a rational treatment pathway with maximal chance of success.

For an appointment, call 206-633-8100 or you can submit a question that I will answer here.