Dr. Halikis Answers Key Orthopedic Questions

Torrance Orthopaedic & Sports Medicine Group
Orthopedic Doctors
Physical, Hand & Aquatic Therapy

Two locations:

23456 Hawthorne Blvd.,
Suite 300
Torrance, CA 90505-4716

El Segundo

Phone: 310-316-6190
Fax: 310-540-7362

Nicholas M. Halikis, MD has been an orthopedic surgeon since 1992. He has a special certification in hand and upper extremity care and complex surgery. He is board certified and fellowship trained.

Below, Dr. Halikis discusses the wrist repair surgery of Air Force Maj. John. You can read John's Story here. Dr. Halikis also talks about what patients can expect from their orthopedic doctor if they sustain an injury or have an issue that requires surgery, or if, like most people, they have a problem that can be better addressed with non-surgical treatments.

Why did you become an orthopedic doctor?
Dr. Halikis: I had a lot of interest in sports and I come from a medical family. My dad was a doctor and I had a lot of exposure to the medical world. I was athletic growing up, and so I gravitated towards sports medicine.

Why are you passionate about being an orthopedic doctor?
Dr. Halikis: A big part of it is that I like helping people. It's great to do something to make people's lives better. No matter what we do in life, we do that at some capacity. I like building things and I like the science of medicine. I really loved school, especially math and science, and that led me to the problem solving and thinking aspects of medicine. The other thing I like about orthopedics is getting to see the whole spectrum of people, from 2 to 102, female and male, all different types of people. I really love kids, too.

How does your background and your interest in sports affect how you relate to your patients?
Dr. Halikis: Because I've done a lot of sports in my life, I understand the mindset better. I know what it's like to be hurt and what it's like to push yourself in sports to become better. I understand the demand that sports put on a person—it's both a physically and mentally disciplined life. I'm a musician, too. I play guitar, so I get musicians in my office with hand problems, and I can communicate with them. Since I'm in tune with playing an instrument, many of my musician patients feel more comfortable with an orthopedic hand doctor and surgeon who understands the nuances of playing an instrument. A patient who plays guitar and is having trouble finger fretting has a very specific problem that most orthopedic doctors wouldn't understand. Hand motions are different with strumming versus playing a D chord where the middle finger is tucked in and the patient can't flex the DIP joint. I understand these more detailed things, like what's really important for a piano player trying to hit that octave, trying to get that spread in the hands.

What types of conditions do your hand and upper extremity patients have?
Dr. Halikis: Number one is arthritis, whether it's rheumatoid arthritis or osteoarthritis. There are various forms of treatment for that: mini joint replacements, scoping to clean joints out, fusions, and other reconstructive surgeries. My trauma patients come in with broken bones, cut tendons and nerves, and other issues that need repair, usually from a sudden injury but sometimes from chronic problems.

I also have patients with different types of lumps, bumps, and cysts that I either drain or occasionally remove surgically. Overuse syndromes are common, like tennis and golfer's elbow tendinitis or tendinosis, caused by wear and tear on the body. There are nerve problems, like carpal tunnel syndrome and cubital tunnel syndrome, where the nerves get compressed and cause numbness, tingling, and pain into the arm. Less often I see patients needing congenital hand surgery. There are also some infections and other conditions.

Talk about treating Air Force Maj. John for his wrist injuries.
Dr. Halikis: He came to me very late following a fracture of the distal radius, which is one of the most common fractures there is in the human body. John had seen another doctor who had missed some subtle but ultimately important issues. John's fracture was tough to diagnose, and I think many doctors would have missed the issues, too. The fracture line locations and how much the bone was displaced were very complex. I investigated it further and saw that it was healing in a position that was not normal and would cause him pain all his life. There was also a loose bone fragment floating around. I reconstructed the whole thing and fixed it in a better position.

Do you typically investigate this thoroughly for all of your patients?
Dr. Halikis: Yes.

How did you know what to look for?
Dr. Halikis: Experience. It's the nuances and details of being a hand doctor and surgeon.

Do you treat all bone displacements with surgery?
Dr. Halikis: It's a consideration because a bone that is not lined up right usually causes problems. Once it heals, the joint won't move correctly a lot of times, so the patient can have stiffness and pain from that. A common long-term effect can be an earlier onset of post-traumatic arthritis, which is arthritis that develops as a result of an injury.

What was unique about John's case?
Dr. Halikis: It was more complicated and severe than I see every day. The most common fracture like this is usually in older people, often women, because they tend to be more prone to osteoporosis and breaks from simple falls. They don't always need surgery, but John's fall was more traumatic. I see it with athletes, like some of the snowboarders and skateboarders, and poeple playing traditional sports as well.

Would you call John a success story?
Dr. Halikis: Yes, because he's regained almost all his function and has little to no pain. It's likely that he would have had a better outcome if he hadn't been misdiagnosed at first, though. But he's very happy, all things considered. Success is relative. Not everybody walks away pain free, full motion, no problems at all, but it's my goal to help patients get as close to 100% as possible.

John wanted an immediate "fix" for his wrist and wasn't interested in conservative treatments. What do you say to patients like him?
Dr. Halikis: Certain orthopedic problems need to be fixed, and John was in that category. He's also an athlete, and they tend to want to quickly get back to the level they were at before, which I take into consideration. The important thing is to not make a problem worse with the wrong treatment for the wrong person. Every patient I see gets a treatment plan that's just for them. With chronic conditions—tennis elbow is a perfect example—some people want more aggressive treatment and some want less aggressive treatment. Since it has a gradual onset, patients have more time and choice in how it's treated. People with arthritis also have more options. As a general rule of thumb, I don't like to delay treatment because that may ultimately be a detriment to the patient's final outcome. I like to start conservatively and see how people do with less intervention, and then progress as needed.

What did John's case have in common with other patients you've treated?
Dr. Halikis: His was a common injury. He is a young, active man who wanted to get back to what he loves to do, which is motorcycle riding, fixing jet airplanes, and generally being adventurous.

Are any two cases exactly alike?
Dr. Halikis: No. There are similarities, but that's where it ends.

What do you say to patients in a similar situation as John's?
Dr. Halikis: Get expert opinions and treatment right from the beginning. That's the most important thing. Get looked at by the right person, quickly.

Is it okay to see a specialist first and not later? A lot of people will start with their primary care physician just to see what's wrong.
Dr. Halikis: If a patient goes to a primary care physician first, that doctor would normally refer the patient to a specialist. It doesn't happen every time, though. I can't tell you how many fractures I see that are treated by primary care physicians that really should have been treated differently from the beginning. I've seen everything from nerve and tendon lacerations to broken bones that were treated with a splint or cast and weren't aligned perfectly. The patients have problems down the line as a result. The sooner proper treatment is initiated, the better.

You're known in the South Bay as a "doctor's doctor." What does that mean?
Dr. Halkis: I treat a lot of doctors in the community for hand and upper extremity problems. I've operated on several doctors, including some of the doctors here at Torrance Orthopaedic & Sports Medicine Group, so they have a lot of faith and trust in my abilities to diagnose and treat. It's nice to have that kind of respect in your own field, no matter what it is. I also try to educate the local South Bay rheumatologists and primary care physicians about conservative treatments for chronic conditions. There are a few things they can treat before a patient needs to see me.

I go to a fair amount of conferences, where I talk to colleagues about issues and stay current, and I teach when I can as well. I've been asked to teach at some of the universities around Los Angeles, but traffic is so bad I can't justify taking that time away from my patients here in the South Bay.

Talk about what kind of pain people shouldn't ignore.
Dr. Halikis: Severity matters. If pain is severe from the beginning, like if you think you've sprained a wrist or fractured something, get in as soon as you can. I don't expect everybody to jump into the doctor's office with every little bump and bruise, though. If pain lingers or your elbow hurts a little bit, you can go a few days and see if it just gets better, if you're comfortable with that. Give it a little time, ice it, and rest it, but if it persists, you should probably get an x-ray or imaging scan. Sometimes I do see people that should have been in earlier, particularly kids whose parents aren't sure if they should bring them in or not. They'll come in and something's broken and the parent feels terrible about it. Most of the time I try to reassure them. I say it's very common, don't worry about it, this happens all the time.

Should people see an orthopedic doctor before seeing a physical therapist?
Dr. Halikis: You want to have the correct diagnosis, number one, and it comes with training and experience. Ultimately the buck stops here, and I think if people started seeing physical therapists first and then have problems that presented late, that could be an issue.

Physical therapists are not as attuned to hand and upper extremity problems than with problems in other parts of the body, and in fact most of them are not adequate for the particular problems that I see. I have my patients see certified hand therapists (CHT's). I have two of them here in my office, and I love them! They make splints, which for hand problems is a big part of hand therapy. It takes a level of expertise, knowledge, and experience unique to really good hand therapists. Physical therapists don't do it, and occupational therapy is different than certified hand therapy, so CHT's are very important.

What do you say to people who are scared of surgery?
Dr. Halikis: I think fear is mainly of the unknown. It understandably applies to surgery until I explain the expectations and risks and just be frank and truthful with my patients. Having done thousands of surgeries in my career, I have very little fear of having surgery on myself. My family has had surgery, and I have no qualms about it at all. Even though I mentioned earlier that I like to start with conservative treatments, there are some things that are best handled surgically right from the start. Patients can trust that my expertise in how best to treat them comes from years of experience and also staying current with medical advances. I know a lot of people get on the internet and come in having Googled their symptoms and talked to their friends and family, which is great because they have lots of questions and opinions I can help them sort out. So in the end you just have to go to the right doctor who has a lot of years of experience and who can make it clear to you what to expect and what the best treatment options are for you.

What are the non-surgical courses of treatment you recommend to patients who are not surgery candidates?
Dr. Halikis: Sometimes I check people and they don't need to have any treatments, just to come back in a few months or a year to get checked if things get worse. For instance, with Dupuytren's patients with mild contractures in their palms, if it's not causing problems and I reassure them it's not cancer or anything dangerous, I can check them at a later date. A big part of hand care is splinting. We make braces and splints for our patients, and there are many types. Different medications, from anti-inflammatories to nerve medications, are also non-surgical options.

There are injections both for diagnostic and therapeutic purposes. Corticosteroids (Cortisone) can help alleviate pain. Platelet Rich Plasma injections (PRP), where I take the patient's own blood and extract healing factors from it, then re-inject the concentrated plasma and platelets into the affected area, is also becoming more common and has shown favorable results. Certified hand therapy is a big part of things, of course. CHT's work on strengthening, range of motion, mobilization of joints in different parts, modalities such as ionotophoresis and phonophoresis, paraffin, and more.

Some patients follow their certified hand therapy instructions exactly, and some don't. What's the difference in outcomes?
Dr. Halikis: Therapy protocols are designed based upon a lot of years of research and studies that show what works best, so we don't just pull recommendations out of the air. They're laid out nationally and even internationally, so if a patient deviates from that, it compromises their results. A perfect example is a tendon repair after someone cuts a tendon in their hand. They need to have the right amount of movement, which prevents adhesions and scarring that limit motion and immobilize them. Too much movement could rupture the repair because there is too much force on the suture. That's why we follow protective therapy protocols. This is all based on studies, literature, and my own experience as well.

Does age have anything to do with considering surgery?
Dr. Halikis: Kids with open growth plates can accept more deformity in broken bones because over time, they will correct themselves. They heal a lot faster, so they don't always have to be immobilized. I tend to be less aggressive with recommending surgery because of those things. Beginning in the late teens for women and after high school for men, growth won't naturally correct a deformity, so surgery becomes more likely after an injury. Older people also tend to have thinner bones sometimes and don't heal as fast. That also weighs into whether surgery is a consideration. Beyond that, all of my patients are individuals, and I care for each one with their own treatment plan that's custom-designed just for them.

Nicholas M. Halikis, MD specializes in the non-surgical and surgical treatment of hand and upper extremity orthopedic trauma (sudden injuries) and chronic problems. He is board certified and fellowship trained.

He treats osteoarthritis, rheumatoid arthritis, broken bones (fractures), cut or lacerated tendons and nerves, all types of lumps, bumps, and cysts, tennis elbow, golfer's elbow, tendinitis, tendinosis, nerve problems, carpal tunnel syndrome, cubital tunnel syndrome, numbness, tingling, and pain in the arm and hand, infections, and more.

Treatment options include mini joint replacements, scoping, fusions, reconstructive surgery, drainage, steroid injections, PRP injections, hand therapy, physical therapy, splinting, medication, rest, lifestyle modification, and more.

Dr. Halikis has offices in Torrance, CA and he sees patients from all over the Beach Cities area, the Los Angeles area, and the South Bay, including Manhattan Beach, Hermosa Beach, Redondo Beach, the cities of the Palos Verdes Peninsula, Carson, Lomita, Hawthorne, Gardena, Lawndale, El Segundo, and San Pedro.

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