Mr Erman Melikyan
Consultant Orthopedic Surgeon
European Board Diploma in Hand Surgery, FRCPS, Diploma in Orthopaedic Engineering, Honorary Clinical Lecturer, FRCS,
Practices at: Circle Reading Hospital
He has published several papers in peer-reviewed journals, authored many book chapters and presented at various national and international meetings attaining international certification through the European Diploma in Hand Surgery.
Erman is a fellow of the Royal College of Surgeons, the Academy of Medical Educators and the British Society for Surgery of the Hand. He was awarded the title of senior clinical lecturer at the University of Southampton in 2012 and an overseas associate professorship in 2014.
Erman has a postgraduate degree in orthopaedic engineering. He is interested in innovation and design in healthcare. His other interest areas are electronics, computing, music and economics.
His special clinical interests are hand Surgery in general, entrapment neuropathies, wrist surgery and arthroscopy, arthritis surgery including small joint arthroplasty.
His research interests extracorporeal shockwave treatment in orthopaedics, medical education and training.
Royal College of Surgeons of England: FRCS
British Society for Surgery of the Hand
Academy of Medical Educators: MAcadMed
European Board Diploma of Hand Surgery
The carpal tunnel is the name given to a space within your wrist which contains tendons and the median nerve, one of the major nerves in the forearm. Should anything cause an increase in the pressure within the carpal tunnel, the median nerve may become compressed or irritated. This can cause numbness or tingling in the hand of varying degrees, depending on the extent of the injury to the nerve. This change in/loss of sensation is known as carpal tunnel syndrome.
Diagnosing carpal tunnel syndrome
Carpal tunnel syndrome can occur at any age and for a number of reasons, including:
Degenerative changes to the joint,
Wrist fractures or trauma,
The most common symptoms are a tingling or numbness in the hand, and these can be more pronounced at night. Some people will choose to seek medical advice as soon as they start experiencing these symptoms while others will put up with their symptoms until they become more severe to ignore.
Before coming to see me, I find that people have often visited their GP first to get some advice. A GP can help, certainly when symptoms are reasonably mild, and they may arrange non-surgical treatments such as splinting of the hand and wrist or a cortisone injection to hopefully relieve the symptoms.
When I first see somebody, I will want to know about the feeling in their hand and fingers; in particular whether there is difference in the sensation between their various fingers and between the two hands.
One of the particular challenges in diagnosing carpal tunnel syndrome is that the symptoms can come and go; some days may be symptom-free while others can be really challenging. This means that sometimes when I see a patient, they may not have any symptoms at that exact time, although it is possible to ‘trigger’ the symptoms with certain clinical maneuvers that irritate or constrict the nerve, such as tapping on the nerve or moving the wrist into a flexed position.
Where the symptoms are more severe, I would expect to see more established numbness or tingling, either across the entire hand or only in certain fingers.
Treating carpal tunnel syndrome
As mentioned above, a GP can be very helpful in arranging conservative (non-surgical) treatments such as splints or cortisone injections. I frequently advise patients with mild symptoms to try these options first. There may be benefits in having the injections done by a specialist rather than your family doctor. The anatomy around the wrist can be pretty confusing and the danger of hitting an important structure inadvertently with the tip of the needle is real.
For people suffering with more severe symptoms, I would discuss the possibility of surgery to ‘release’ the trapped nerve in the carpal tunnel. This surgery can help prevent any further deterioration of the symptoms.
Carpal tunnel syndrome surgery also known as carpal tunnel release (CTR) relieves the pressure upon the median nerve in order to restore normal feeling in the hand.
CTR is normally done under a local anesthetic and only takes around 20 minutes. Once the surgery has finished, you will be able to go home very quickly. It will normally take around 4-6 hours for the anesthetic to wear off. This gives you time to take some pain killers.
You will have a well-padded dressing on to help cover and protect your hand and wrist and this will need to be changed after about a week. This dressing change can be done locally at your GPs or here in Circle if you prefer.
One thing I always tell people to expect is for their palm to be slightly tender for at least 4 weeks. You’ll be more aware of this when gripping or pushing with your hand. Depending on your job, you may need to take some time off work in order to avoid irritating the nerve again before you have fully recovered.
A session of hand physiotherapy can be helpful after this surgery, and that’s something I can arrange for you to have at Circle if you choose. I will then see you again in clinic between 4-6 weeks to review your healing and to talk with you about how your symptoms are to ensure everything is healing nicely.
Getting help for carpal tunnel syndrome
As a Consultant Hand and Wrist Surgeon, I talk with people struggling with hand and wrist problems every day. I hear about their challenges and frustrations, as well as their hopes for effective treatment to get them out of pain and to relieve their symptoms.
Carpal tunnel syndrome can be debilitating to live with, but effective and straightforward treatment which causes minimal or no disruption to your daily life is available. It would be a real pleasure to help you. It’s easy to arrange a consultation with me at Circle; just contact my private secretary to book a time that is most convenient for you.
The hand and wrist contain a number of tendons and these play an important part in providing movement, dexterity and function.
Inflammation of a tendon is known as tendinitis. While tendinitis can affect any tendon in the hand or wrist, De Quervain’s tendinitis (also known as De Quervain’s tenosynovitis) is a condition in which two of the tendons attached to the thumb become painful and inflamed where they cross at the base of the thumb.
De Quervain's tendinitis can often be managed well using conservative (non-surgical) methods although surgery may be needed in certain circumstances.
What causes De Quervain's tendinitis?
The exact cause of De Quervain's tendinitis is not yet fully understood, although there are some things that increase the risk of experiencing it. It often occurs as a result of doing something unusual which has aggravated the tendons, such as five hours of gardening where you usually do none.
It is also very common in mothers of young babies between birth and six months. While breastfeeding, they will often hold the head of the baby firmly against the breast. This action, done repetitively over a period of time, will irritate the two tendons
How do you know you have De Quervain's tendinitis?
De Quervain's tendinitis tends to cause pain specific to the base of the thumb, where the wrist and lower forearm meet.
This area may be a bit swollen and there might be some creaking or crackling when you move your thumb. This can be quite alarming, especially if you haven’t had this happen before, but it is a very common occurrence. Known as crepitus, it occurs when an inflamed tendon moves through the tendon sheath. Some people say crepitus feels a bit like having bubble wrap in the wrist.
These symptoms are often aggravated by any movement that involves the tendons and muscles in the thumb, which can be as varied as carrying a bag through to using a smartphone. We use our thumbs and wrists so much more than we think we do as part of our everyday activities and this is what can make De Quervain's tendinitis such a challenging problem to live with.
How is De Quervain's tendinitis diagnosed?
Diagnosis is made by clinical examination. When people first come to see me, they will often complain of pain on the outside of the wrist (this is known as the radial aspect). This pain can be made worse when they extend their thumb against resistance (resisted extension).
If there is any doubt about the diagnosis, I will arrange for either an ultrasound or an MRI scan. An ultrasound can show fluid around the tendons in the sheath. In some cases, there won’t be any fluid, and the ultrasound may not pick anything up. In these cases, an MRI scan can be helpful as it will show inflammation even if it's dry. If there is increased tissue circulation it will pick up any tissue swelling (oedema).
Treating De Quervain's tendinitis
In advance of seeing me, most people will already have gone to their GP for help and advice. They may already have tried non-surgical treatments such as splinting to help reduce inflammation and pain. Their GP may also have given them a cortisone injection, and this can often help to alleviate symptoms, although the effects of this may wear off over time.
There may be benefits in having these injections done by a specialist rather than your family doctor. The anatomy around the wrist can be pretty confusing and the danger of hitting an important structure inadvertently with the tip of the needle is real.
If you come to see me and you haven’t already had a cortisone injection, I would generally recommend you have one to see if it helps. Should these injections not be of much help, or if they’ve stopped having an effect, I would talk with you about surgery to release the tendon sheath.
This surgery is carried out under local anaesthetic. I will make a small cut in the skin of your wrist and then in the tendon sheath. This will ‘release’ the tendons i.e. it will enable them to move freely without being impinged on. It will also allow me to carefully inspect the tendons.
After the operation, your wrist will be covered with a cotton wool dressing and elastic bandage. You should expect to be a bit stiff and sore in the wrist after the operation, and it’s important to give yourself time to recover properly. If you have a manual job, you may need to take some time off work.
Can I help you?
For anybody with De Quervain’s tendinitis, even simple jobs such as lifting something up, holding a bag or using a smartphone can become difficult and extremely painful.
It’s important to get expert help in managing any tendinitis. My priority is always to help to get you out of pain first, and then to work on restoring function to your hand and wrist. It’s easy to arrange a consultation with me at Circle; please contact my private secretary to book a time that is most convenient for you.
Dupuytren's contracture is an inherited condition, far more prevalent in people with Nordic ancestry. There is no way to remove any genetic predisposition to developing Dupuytren's contracture you may have, but there are a number of ways I can help to restore the range of movement in the fingers and the palm.
How does it develop?
When you compare the skin on the back of the hand with that on the palm of the hand, you will see they are noticeably different. The skin on the back of the hand is thinner but also a lot more mobile; you can move it about without too much force.
The skin on the front of your hand is a bit tougher and is more fixed in place, less easily moved. This is because the palm of your hand contains a layer of tissue called the palmar fascia, which helps hold the skin firmly in position on the palm of the hand. When you hold something in your palm, it doesn't move about because the skin itself is being held firmly in place.
Dupuytren's contracture causes changes to the protein of specific cells in the connective tissue. It is these changes which cause the tissues in the palm to start contracting. In practice, this usually means you will see little lumps and bumps start to appear in the palm. Sometimes these can be quite painful, especially when you grip something tight, like a steering wheel when driving.
Although most common in the hands, Dupuytren’s contracture can also affect the soles of the feet. Very rarely it can also affect the penis.
As the disease progresses, the nodules in the palm tend to merge together over time, forming bands that run from the palm into the finger. The speed with which these develop varies from person to person and depends on a number of factors, including the expressivity of the gene.
The vast majority of people I see tend to experience problems in their 40s and 50s. They start to notice one or more of their fingers is beginning to contract, curling inwards towards the palm. While they may be able to ignore it in its early stages, as the contraction in the finger becomes more pronounced it, people tend to see a doctor for help.
Most people will choose to see a doctor when the fixed curl of their finger (this is known as the ‘flexion contracture’) is beginning to interfere with their daily tasks and activities.
When people come to see me for help, the curl in their finger is usually at least 30 degrees, often more. Any less than this is usually fairly manageable (although obviously still frustrating). If only one finger is affected it may not be as much of a problem, but when more than one finger is affected, things become more problematic.
Treating Dupuytren's contracture
When I first you, we will talk about the condition and I will assess the extent of the contraction. I will want to know if there is any family history of this condition as well as how quickly it has progressed, as this can help determine how aggressive it is.
I will be able to make a diagnosis based on your history and clinical observation, there is usually no need for any additional diagnostic investigations.
While splinting the fingers may seem an obvious choice of treatment, this can actually make the contracture even worse. Unfortunately, the only non-surgical treatment for Dupuytren’s contracture in the form of an injection (clostridium histolyticum collagenase) was recently withdrawn from general use after undergoing many years of research. This was mainly due to lack of evidence of it performing better than other established treatments.
The mainstay of treatment is surgical, and there are a few different options available:
In cased of a painful nodule or where there's no major extension into the fingers, often all that is needed is a small procedure done under local anesthetic in which I remove the nodule or the central part of the core. This is a bit like cutting a very tight string; you're just removing the little bit in the middle and it releases the tension.
For more severe cases, I would carry out a procedure called a limited fasciectomy. This involves carefully removing the areas of tissue that are contracted.
Reliable, effective help for Dupuytren’s contracture
It is important not to ignore early signs of Dupuytren’s contracture. If surgery is left too late, the joints will often have become very stiff and may have difficulty opening up, even when the tight tissue has been removed.
A consultation with me is a simple way of learning whether surgery would be helpful or not at this particular time. If not, we can keep a watchful eye on things. If surgery would be of help, I will talk you through everything so that you can make an informed choice about treatment.
Arthritis in the hand can cause pain, a loss of grip, stiffness in the fingers and sometimes seizing up of a finger joint. All of these can be incredibly frustrating to manage, especially when they become more frequent or severe as the arthritis progresses.
If you are experiencing any of these symptoms, an expert assessment will be helpful. Your symptoms may have another cause, but an expert assessment can help to give you peace of mind. It’s easy to book a consultation with me here at Circle.
The particular challenge of hand arthritis
A joint is formed in the body wherever bones need to move around or over one another. The hand and wrist contain a number of joints and it is these joints that provide our hands with such remarkable dexterity and function. It is also these joints that can cause such debilitating problems in people suffering from arthritis in the hand.
Most of us use our hands every day without conscious thought. We pick up a cup of tea, wash our faces, tie our shoelaces without noticing just how much are hands are involved in carrying our such common tasks. Arthritis in the hand, especially as it progresses, can have a big impact on our quality of life and our ability to do things. Even a simple task such as opening a jar can become incredibly difficult, if not impossible.
Types of arthritis
There are a number of different types of arthritis. The two that I see most commonly in the hand are osteoarthritis and rheumatoid arthritis.
Rheumatoid arthritis occurs when the immune system attacks the joints. In the hand, this can cause the finger joints to become visibly swollen and disfigured or misshapen.
Osteoarthritis is the most common type of arthritis in the hand. Each of the bones in our hand and wrist have a smooth lining of cartilage at their ends, known as articular cartilage. This cartilage helps the bones to move over one another freely. Osteoarthritis causes areas of this cartilage to thin. This means that the bones start to rub against one another when they move. Over time, this causes damage to the joint, leading to the pain, stiffness and swelling associated with osteoarthritis.
Diagnosing hand arthritis
When we first meet, I will talk with you about your symptoms and how your life is being affected by them.
I will examine your hands and wrists to assess the extent of any arthritis. I may also arrange for you to have additional tests to help confirm diagnosis, ranging from a simple blood test or X-ray through to an MRI, CT or ultrasound scan.
Once we have an accurate idea of the presence and extent of arthritis, we will be able to talk through treatment options together.
How do you treat hand arthritis?
It’s important to say that there is currently no cure for arthritis. There are however a number of treatments I can offer to help manage your hand arthritis. Often, conservative (non-surgical) treatment options can be really helpful in keeping symptoms like pain under control. In more severe cases, I may advise you to have surgery to effectively treat the problem.
I will always talk with you fully about any treatment options that would be suitable for you, but the decision to have any treatment is always yours to make.
Conservative treatment options include pain medication, physiotherapy, splinting and corticosteroid injections. All of these can be helpful in the right circumstances and certainly, a treatment plan should start with one of these.
Where these non-surgical treatments have stopped working as well, or when pain or stiffness in the joint has increased significantly, hand surgery may be needed to relieve your symptoms. There are a few of surgical options available, ranging from operations to preserve movement in the joints to ones that fix joints permanently in place. The type of operation carried out will depend on the extent and severity of your arthritis.
Expert help for hand arthritis
As a consultant who specialises exclusively in problems of the hand and wrist, I have seen the frustrations, challenges and pain caused by arthritis in the hand. It is, however, a condition that most of us will almost certainly experience to a certain extent in our lives.
Good, effective treatment is available that can help manage your symptoms. If you’d like to discuss treatment options, why not book a consultation with me here at Circle? With no waiting lists, you’ll be able to see me at a time most convenient to you.
Despite their names, these are not conditions experienced exclusively by tennis players and golfers! Most people develop one of these conditions following an increased period of strenuous activity involving the muscles of the forearm; gardening or twisting and gripping a screwdriver when carrying out some DIY around the house, for example.
What are the symptoms?
Nobody understands your pain and the effect it is having on you better than you. When we meet for a consultation, I will talk with you about your symptoms, when they came on and whether you have tried any treatments up to this point.
For both conditions, localised pain is felt in the elbow. In practice, this means that people with tennis elbow will feel pain or tenderness on the inside of their elbow while those with golfer's elbow will feel it on the outside.
Both conditions tend to develop over time. The tendons become inflamed and painful, usually because you have used the muscles in your forearm and upper arm more than you are used to. Other times, small tears can develop in the tendon over time, gradually becoming worse.
Usually, people feel pain at a specific point in the elbow; either the outside or the inside. They may notice it starts to hurt when they pick up a shopping bag or lift a chair from the floor. Sometimes, even small things like clicking a button on a computer mouse or typing on a laptop can set off the pain.
From my experience, many people seem to struggle on a little bit with their elbow pain, hoping it will resolve itself naturally. While this can happen, often people will realise they need to see me when the pain reaches a certain level or has been going on for a period of time.
How is it diagnosed?
In terms of diagnosing golfer's elbow and tennis elbow, I would expect my clinical examination to show tenderness over the specific tendon.
There are some additional tests I can carry out, such as resisted finger extension tests and resisted wrist extension tests. These can be very helpful in giving me a good understanding of the cause of your pain and the extent of the problem.
Sometime, the diagnosis is not clear from a clinical examination and I would then arrange additional diagnostic tests through either an ultrasound or MRI scan. Both of these can show changes in, or damage to, the tendon, giving me the ability to confirm a diagnosis.
How is it treated?
There are different treatment options available, and I will work with you to ensure you receive the one most suitable for you and your needs. Two are conservative (non-surgical) treatments and one is surgical.
Physiotherapy: When done properly, physiotherapy has been shown to be quite effective, often resulting in longer-term pain relief. Along with certain exercises, the physiotherapist may also prescribe or fit you with a tennis elbow brace, which is a bit like having a pressure point strapped onto the tendonitis. It stabilizes the tendonitis and usually helps with pain relief.
Cortisone injection: In cases where physiotherapy has been tried but has not been as effective as required, or when a patient needs pain relief as quickly as possible, I can inject the tendon with cortisone and local anesthetic. This can be a good way of getting pain controlled quickly. The cortisone has an anti-inflammatory effect.
Surgery: Most people I treat for golfer's elbow or tennis elbow find that conservative treatment works well. Only very few people will need surgery to treat these conditions. The surgical treatment is carried out under general anaesthetic and involves releasing the tendon from the bone. It's a broad tendon so only a part of it is released. This means that you won't have any reduction in strength after surgery. Following your surgery, we will wait around 3-4 weeks before starting you on some stretching exercises. We don't start the stretching earlier because we want to allow the tendon to heal back onto the bone. Range of motion exercises are allowed from day one, but the strengthening exercises start later.
Getting help for your tennis elbow or golfer's elbow
As a consultant who specialises exclusively in problems of the hand and wrist, I have helped a lot of people with golfer's elbow or tennis elbow to successfully recover and to live free of pain once again.
If you would appreciate a consultation with me to discuss suitable treatment options, why not book a consultation with me here at Circle? Just contact my private secretary who will be delighted to book you in for a day and time that is most convenient for you.
These tendons are held firmly in position on the bone by thin bands of connective tissue, known as tendons sheath or pulleys. When our fingers move, the tendons pass smoothly through these thin bands. Occasionally, repetitive use or disease such as rheumatoid arthritis can cause a nodule to develop on the tendon. When this thickening restricts the regular smooth movement of the tendon through the tendon sheath it is known as trigger finger (or trigger thumb).
This can be best imagined as the tendon being a bit like a rope passing through a pulley. Should a knot be tied in the rope, its passage through the pulley will not be as smooth or may be prevented entirely.
Do you have trigger finger?
The severity of symptoms you may experience with trigger finger will depend upon a number of factors, including the location and size of the tendon nodule. Generally, the larger the nodule, the more pronounced the symptoms will be, although this is not an absolute rule.
You can have trigger finger in more than one finger, and in one hand or both. Depending on the size of the tendon nodule, you may be able to feel a hard lump when you press on the part of your finger that is painful.
Many people find that it becomes harder to bend the affected finger or thumb, often saying that it feels much stiffer than usual. It can make you feel clumsy, as you may drop things more frequently as a result of your finger(s) locking.
You may have a regular clicking and/or locking in your finger several times each day. This often happens when you have been gripping something tightly,
Sometimes the finger can only be moved back into position with the help of the other hand. When the condition is more severe, your finger may become locked in a bent position which can be quite unnerving to experience.
How do you treat trigger finger?
Trigger finger is one of those frustrating medical conditions where symptoms can vary dramatically from day to day. Some days it may be a real problem, while other days the issues are only minor. This means that sometimes when people come to see me, they won’t have any symptoms of triggering or only have very mild triggering.
The first thing I always tell people (and this is often a big relief for them to hear) is that trigger finger or trigger thumb can often be treated very effectively without the need for surgery. Although I am a hand surgeon, I only ever advise surgery when all other treatment options have been exhausted. In fact, I often advise people not to have surgery!
Most people will have gone to their GP to get some advice before coming to see me. Non-surgical treatment they may have suggested often include avoiding tight gripping and flexing the hand as much as possible (although I appreciate this is easier said than done).
A cortisone injection will alleviate symptoms in most cases, although the effects of this may wear off over time.
If you have had one or more cortisone injections and are still having symptoms of trigger finger, I would advise surgery to settle the problem. Also, when the tendon surfaces could have become damaged, surgery would be needed to prevent further deterioration.
Surgical ‘trigger finger release’
This operation is usually done under local anaesthetic, meaning you will be awake but unable to feel anything in your hand while I operate. I will make a small cut in your palm (usually 1.5 - 2 cm) and carefully inspect the tendon to determine the extent of the problem. I’ll then split or ‘release’ the tendon sheath to enable the tendons to move freely. As you are awake, you will be able to test and confirm that the problem has been eliminated before we even stitch up the skin.
We will carry out what is known as an ‘active test’ during the operation, where I will ask you to move your finger. This helps to check that you are able to move your finger freely once more, allowing you to see the result of the operation pretty much immediately.
Your hand may be sore especially with tight gripping around 2-3 weeks after the operation, so you may need some time off work if you have a manual job. I will see you again in clinic for a check-up around 4-6 weeks after your operation.
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