In Search of Cost-Effective Treatments for Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a major work-related problem. Work that requires the same hand movements over and over is the most common proposed cause. The workload on a few small groups of muscles in the wrist and hand is high with assembly line work, typing, or operating some types of machinery. Pressure on the median nerve with wrist pain and hand numbness may result.

Surgery is done in 40 to 45 percent of work-related CTS. The surgeon releases pressure on the median nerve by cutting the ligament that goes across the wrist crease. After surgery, one-third of the patients still have pain and loss of hand function. Less than half get full motion and normal function back.

In California, it costs about $5,000 to treat one case of CTS without surgery. With surgery, the cost goes up to around $21,000. Across the United States, the average cost to treat one case of CTS is $12,000. A less expensive and more successful treatment is needed.

Such a treatment may be on the horizon. One study with 11 people showed that using low-level laser therapy and electrical stimulation works. Stimulation was given to acupuncture points in the arm and wrist. Almost 90 percent of the people had pain relief after a series of treatments. Everyone was able to return to work with less or no pain.

The cost of 15 sessions with laser and electrical stimulation is approximately $1,000. This is a $4,000 savings before surgery. This form of treatment is best used in the early stages of CTS before prolonged pressure damages the nerve. The next step for researchers is to conduct a study with a larger number of people.

The Carpal Tunnel Connection

Researchers are taking another look at carpal tunnel syndrome (CTS). Until now, CTS has been viewed as a painful condition of the wrist and hand brought on by repetitive motion. There has been general agreement that this is mainly job-related.

A large study of over 250 people from four industrial sites shows that other factors may be just as important. These are personal factors such as weight, being female, and cigarette smoking. Women are four times more likely to have CTS than men. Overweight people (men and women) are five times more likely to get CTS.

How are these factors related to CTS? This remains unknown and will be the subject of future research. Overweight and cigarette smoking are the two most important causes of death and disability that can be changed in the United States. These two problems will continue to get a lot of focus and attention, which may eventually explain the link to CTS.

Changing personal habits may reduce the amount of CTS in the workplace. Wellness programs that combine weight loss, smoking cessation, and stress reduction are recommended. Since changing the workplace and work style has had limited success in reducing CTS, perhaps promoting changes in personal factors will make a bigger difference.

A Closed Case for Carpal Tunnel Syndrome

There is usually more than one way to get something done, even in surgery. Doctors are finding this out with surgery for carpal tunnel syndrome (CTS).

When surgery is needed to release pressure from the median nerve in the wrist, doctors have two choices. They can cut an opening in the palm and wrist, or they can use an instrument called an endoscope to look inside the wrist and release the pressure. The endoscope is slid into the carpel tunnel area through a tiny opening in the skin.

Open surgery, requiring a large incision, has been the first choice for CTS for a long time. However, there have been problems with this surgery. Patients have had muscle weakness, scar tenderness, and pain after open methods of surgery. Sliding an endoscope through the incision and releasing pressure from the nerve has fewer problems afterwards.

The final outcome of CTS surgery (after one year) with either method is the same, but there are two major advantages of endoscopy. Healing time is faster, and people return to work quicker. Since there is no cost difference between these two methods of surgery, more doctors are beginning to recommend endoscopic surgery for CTS.

Thumbs Up for Silicone Joint Replacement

Arthritis can cause severe problems in the thumb. The small wrist bone at the base of the thumb (trapezium) can become painful and may begin to slide out of place, called joint subluxation. This can make it difficult and painful to pinch or grip.

Treatment for this problem includes rest, a splint or brace, drugs, and surgery. The surgeon may remove the trapezium or fuse it to another bone to keep it from moving. Sometimes, the tendons and ligaments around the thumb are used to separate and hold the joint.

The best treatment option may be a silicone implant. Silicone is a chemical substitute for rubber that is stable and doesn’t react or heat up. It can be formed into the shape of the trapezium and inserted into the thumb to replace it. The first silicone implant for the thumb was done in 1965. Since then, the implant and the surgery have both been changed and updated many times.

In the early days of silicone implants, swelling of the joint lining and fracture of the implant itself were problems. Sometimes, the implant would bend out of shape. This led to joint subluxation. Over time, doctors learned better ways to do the surgery.

The kind of patient selected for this surgery is also important. Patients with jobs that have low activity are good candidates. The new joint works well for patients who have advanced arthritis in the base of the thumb.

When used properly, the silicone implant is a very good treatment choice for thumb arthritis. Very few problems occur, and most patients have good, painfree motion for years.

Is Dupuytren’s Disease Handed Down through Your Genes? Scientists Search Northern Norway for Clues

Dupuytren’s disease happens when tissues in the palm of the hand become shorter and thicker. It often causes the small and ring fingers to curl into the palm. The cause of this condition is unknown. Because it is common in white populations but not in other races, scientists think there may be a genetic component to the disease. Dupuytren’s disease is especially common in people of northern Europe. In Norway, 18 percent of men and six percent of women over age 50 are affected by the disease.

There is an aboriginal population in northern Norway called the Sami. Originally from the northernmost part of Scandinavia, the Sami are ethnically distinct from most Norwegians and have no reported cases of Dupuytren’s disease. Researchers decided to look for Dupuytren’s disease in Sami and ethnic Norwegians. Differences between the two groups might shed light on the genetic nature of the disease.

Researchers examined 456 people over the age of 50 who lived in northern Norway. Dupuytren’s disease was found in 31 men and three women. Sami men were somewhat less likely than Norwegian men to have Dupuytren’s disease. Eight percent of Sami men showed the disease, versus 16 percent of Norwegians. In addition, Sami grandparents were less likely than Norwegian grandparents to have a grandson with Dupuytren’s disease.

The researchers were surprised to find that Dupuytren’s disease wasn’t that uncommon among Sami, after all. The presence of the disease among Sami could come from mixing with the general Norwegian population. Still, the disease was less common among Sami than among Norwegians, confirming the importance of genetics in Dupuytren’s disease.

Treating Hand and Wrist Injuries in Athletes: The Player Comes First

Athletes injure their hands and wrists in many different ways. They jam fingers, dislocate thumbs, tear ligaments, sprain joints, break bones, and more. Treatment for an athlete may be very different from treatment for a nonathlete. The “wait and see” approach sometimes used for nonathletes just won’t work for someone in competitive sports.

Everything about the diagnosis, treatment, and return to activity (sport) is more intense for the athlete. Suddenly, it’s not enough to identify a sprain. The degree of sprain and any other injuries must also be identified. This means more imaging studies, such as bone scans or magnetic resonance imaging (MRI). Additional X-rays may be required. Even minor injuries in athletes must be examined carefully to prevent problems later on.

Decisions about protecting the injury must be made. What’s better for the player, taping the joint or using a splint? The sport and position played must be considered. For example, a football player with a cast on the thumb could return as a lineman, but not as a quarterback or receiver. And each sport has its own regulations for protective equipment on the field. It’s necessary to protect the injured athlete without hurting other players.

Decisions about surgery must also be made. Sometimes surgery can be put off until after the season. Other times, waiting too long can mean a permanent injury or more extensive surgery later. Athletes whose bones are still growing must be given special care. Scholarship status and other financial concerns get thrown into the mix and affect how decisions are made.

Physicians treating competitive athletes are faced with many difficult decisions when planning the best treatment. The physician must plan the athlete’s return to sport carefully. Parents, team owners, agents, coaches, and even the athletes themselves put pressure on the physician to make choices that may not be in the player’s best interests.

The physician makes decisions based on a careful diagnosis. He or she must also understand the sport and the individual player’s needs. What’s best for the individual player and his or her future well-being are paramount. A safe return to competition is the final goal.

A Rare Case of Dupuytren’s in a Newborn

Parents can still be heard telling their children “don’t point.” Yet when a child is born with a bent finger that can’t point, there may be cause for concern.

A condition found only in humans, Dupuytren’s disease most often affects the ring or little finger, sometimes both, and often in both hands. Cords of scar-like tissue form and pull one or more fingers into a permanently bent position. The condition is genetic, meaning it is usually present in other family members, too.

Dupuytren’s in children is rare. This single case is the first to show that this condition can occur at birth. The deformity was present at birth and wasn’t caused by birth trauma. None of the other family members ever had Dupuytren’s.

What can be done about the bent finger? Sometimes no treatment is necessary, and doctors watch the person over time. In this case, a splint was used to hold the finger straight. After three months, the bent finger was worse even though the child had kept the splint on.

The cord of tissue had to be removed with surgery. Since the skin was not connected to the extra tissue, the opening was closed easily. The surgery was successful, but it is not certain if the child will have similar problems again. For the moment, this child can point as much as he wants!

Arthritic Thumb Joints May Need a Little Space

Arthritis at the base of the thumb is a common condition that mostly affects postmenopausal women. This condition can cause pain, swelling, and loss of motion with serious consequences. The symptoms from this type of arthritis can prevent simple, everyday tasks. Picking up a cup of coffee, fastening buttons, or holding a book can be agonizing or even impossible. Some people are unable to continue working at their jobs. What can be done about this?

When pain, weakness, and loss of motion cause difficulties, surgery may be necessary. The joint in question is between the base of the thumb and the trapezoid bone, the small wrist bone next to the thumb. Together these two bones form the trapeziometacarpal joint (TM). Different surgical methods are used to repair or restore this joint.

One method of fixing the TM joint is to fuse the bones together, a procedure called arthrodesis. Wire and bone chips taken from the patient’s hip are used to hold the bones together. A second method is called interposition arthroplasty. The joint surfaces of the TM joint are shaved off, creating a space between the joint. The doctor takes a strip of tendon from a nearby muscle, rolls it into a ball, and places it into the joint space. The tendon ball acts as a “spacer” to keep the sore parts of the joint from rubbing together.

A study compared 24 arthroplasties to 32 joint arthrodeses to determine which operation had the best results.

Interposition arthroplasty was clearly the winner! Compared to fusing the joint, using a spacer between the joint brought less pain, fewer problems with changes in temperature, and better thumb and hand function. There were also fewer complications after surgery, fewer reoperations, and a shorter time in a cast after surgery. The only advantage of the joint arthrodesis was that more people returned to their jobs or daily activities. Researchers think this was because more people in the arthrodesis group were still working before surgery.

Although both groups with arthritis of the thumb benefited from surgery, using a spacer has many more advantages over fusing the joint. There are still some cases where fusion could be used, such as when movement is good in the rest of the thumb. Overall, however, joint arthroplasty is the preferred treatment for disabling arthritis at the base of the thumb.

Go Ahead, Make My Trigger Finger Better

If Clint Eastwood had a trigger digit, his adversaries might have avoided his smoking gun. A trigger digit refers to a finger or thumb joint that gets locked in a bent position. When this occurs, the other hand is needed to reach over, grab it, and unlock and straighten it.

Trigger digits mostly occur where the finger or thumb tendon crosses the palm in front of the main knuckle. When the digit bends, the tendon normally slides easily back and forth through a small sheath, called the tendon pulley. A nodule forms where the tendon or its covering swells. The inflamed nodule goes through the pulley when the digit is bent but gets stuck on the other side, causing the finger or thumb to lock in a bent position.

Doctors may treat the trigger by injecting cortisone into the nodule. By reducing the size of the nodule, the digit can bend and straighten freely. Unfortunately, in two of every three cases, the nodule will return again within one year.

Surgery may be required to release the tendon pulley. This keeps the nodule from getting stuck when the finger or thumb is bent. Surgeons have used an “open” technique with good results. This involves making a large incision just over the tendon pulley. The open method allows doctors to see inside to cut the tendon pulley.

A newer way to release the tendon pulley is to use a percutaneous (across the skin) method. Eastwood (not Clint) first described this technique in 1992. The doctor simply inserts a needle through the skin, just under the tendon pulley. By twisting the needle, the tendon pulley is cut, and the nodule is free to move. The challenge with this surgery is the surgeon is unable to see the tendon pulley. Until now, no studies have compared the results of the open and percutaneous forms of surgery for this condition.

One hundred trigger digits were surgically treated. Just under half (46) were treated with the open method; the others were treated percutaneously. Surgery time was markedly longer using the open method. By comparison, people got quicker results when treated with the percutaneous method. Their pain went away almost twice as fast, and they got back to work within four days, compared to nearly eight in the open group.

Along with its cost effectiveness (the price of a disposable needle), these authors conclude that “when surgery is indicated, the percutaneous method is a quicker procedure with significantly better results in rehabilitation.”

Making Older Hands New Again: A Surgical Fix for Arthritic Thumbs

Fusion surgery, also called arthrodesis, is useful for treating advanced arthritis. Connecting the joint into one solid bone keeps the joint surfaces from rubbing together, causing pain.

This surgery works well for patients who have arthritis in the joint that forms the base of the thumb. This joint is named the trapeziometacarpus (TM) joint. In the past, fusion of the TM was only recommended for younger patients who had hand deformities or arthritis following a trauma. Doctors usually wouldn’t recommend it for patients over 50. This mainly had to do with concerns that fusing the TM in older patients would cause arthritis in the nearby joints.

These authors began doing the procedure in patients over 40. They looked at surgery results of 49 patients (59 joints) with TM arthritis. There were 42 women and seven men. The average age was 54. (Ages ranged from 41 to 73.) Ten patients had surgery on both hands.

The authors followed up within 20 years to see how their patients were doing. Some of the patients had X-rays to make sure the bones had grown together and to check for signs of arthritis.

Of the 59 joints, four (seven percent) didn’t heal back together properly. These four patients were all women who’d had bone grafts during surgery to improve the chances that the bones would heal together. Fortunately, three of the four patients were not in pain. The one in pain went on to have another surgery, which was successful.

X-rays of 27 patients showed that seven had signs of developing more thumb arthritis. However, these seven patients weren’t having symptoms.

Pain was generally low at follow-up. When patients were asked to rate their pain on a 10-point scale, with one being no pain, the average response was 1.5. No patient said pain was higher than a six. The average for the patients whose X-rays showed arthritis was even a little lower than the norm at 1.4.

Patients were very satisfied with the surgery. All but one of them said they would have the surgery again given the same circumstances. The authors feel that this procedure provides excellent, lasting pain relief. Based on their results, the authors believe fusion surgery may be the right choice for older patients with arthritis in the base of the thumb.

Hand Census 1998: Mapping Hand and Wrist Fractures across the US

Hand and forearm injuries are common in the emergency room (ER). But how common? And who’s most at risk?

To answer these questions, these authors examined the results of a large national survey of nearly 400 hospitals. In 1998, the survey included reports from about 24,000 cases seen in the ER.

There were 352 cases of hand and forearm fractures. From this number, the authors estimate that there are 1,465,874 hand and forearm fractures seen in ERs across the US each year. These kinds of fractures make up about 1.5 percent of all ER visits.

Most of the fractures (44 percent) happened to the bones on the thumb and little-finger sides of the forearm. These bones (the radius and ulna) allow the hand to rotate.

Fractures of the finger were the next most common (23 percent). Fractures of the bones in the top of the hand (metacarpus) and wrist (carpus) made up 18 and 14 percent of the injuries, respectively. Less than one percent of the injuries involved more than one part of the hand. 

Hand and forearm fractures were most likely to happen at home (30 percent). A smaller proportion of the injuries happened on the street or in recreational and sports areas (14 percent each). The injuries were generally not work related (75 percent).

Accidental falls were the most common cause of injury (47 percent). Being hit by a person or object was the next most common cause (15 percent); this included sports-related injuries.

Children ages 5 to 14 had more hand and forearm injuries than any other age group (26 percent). This group had the highest rate of radius/ulna fractures. Young adults (ages 15 to 24) had the highest rate of metacarpal fractures. And young children (ages 0 to 4) had the highest rate of multiple hand fractures. However, patients over 85 had the highest rate of wrist and finger fractures, possibly because of accidental falls.

Hand and forearm injuries happened equally to men and women. But women were more likely to hurt their forearms and wrists, whereas men were more likely to hurt the tops of their hands and fingers.

Of the racial groups, whites had the most fractures. They also had the most ER visits overall. There were no differences between blacks and Asians in hand and forearm fractures. American Indians had the lowest rate of fractures.

Hospitals in the South and Midwest saw the most hand and forearm fractures (30 and 31 percent, respectively). Hospitals in these locations also treated more cases overall.

Though almost half of the injuries were covered by insurance, patients paid for their own medical care about 16 percent of the time. This reflects the national statistic that 15 percent of US residents are uninsured.

The authors hope that this information will be used to prevent hand and forearm fractures in high-risk groups, such as children and the elderly.

First-Hand Results of Hand Surgery

Do you ever wonder how doctors come up with new ways of doing surgery? Would you want to be the first one they tried a new method on? Fortunately, you won’t have to. Tests are done first using animals or cadavers (human bodies preserved for study). One example is a new repair method for tendons in the hand.Recent studies have shown that early movement after hand surgery has the best results. Knowing this, doctors have used cadavers to try out different ways to make stitches (sutures). It is important to tie sutures that will not tear during early movement. The sutures must be thin enough to allow the tendon to move or glide. A stronger but less bulky repair and smoother tendon motion keep scar tissue from forming.By using cadavers, doctors can try different repair methods and see the results right away. They can observe how well the tendon glides. The strength of the repaired tendon can also be measured. Using cadavers allows doctors to test how much load the sutures can handle. New computer technology and software allow a step-by-step process to gradually increase the pressure placed on the repaired tendon. Improved methods in surgery mean earlier and faster rehabilitation and recovery for patients.

Use It or Lose It: Does This Hold True after Flexor Tendon Repair in the Hand?

Have you ever heard the expression
“Motion is lotion?” In the world of surgery and rehabilitation, this phrase is known to be true. When a tendon is torn and then repaired, early passive motion helps speed up healing. Passive motion means that the injured joint is carefully moved without using the muscles. No one knows exactly how or why early movement has a healing effect.

While scientists continue to study the hows and whys of early motion and faster healing, others are asking, “If early motion works so well, can added force increase the strength of the tendon fibers?” Researchers used dog models to see the effects of two different levels of force on the tendon that bends the animal’s paw and lower leg.

By applying a force three to six weeks after surgery, the researchers expected to see many new tendon fibers. They also thought they’d find more links or connections between the fibers, as well as thicker tendon fibers and faster healing of the repaired tendon. None of these changes were seen. Despite added forces, no major differences were found in the size, shape, or number of tendon parts.

This study actually raised more questions than it answered. Would a different force work better? Does the tendon heal faster with a force applied earlier (or later) during healing? If force doesn’t change the tendon, what does? This experiment will help scientists plan other studies to answer these questions. Knowing how tendon strength increases will help doctors and other rehabilitation specialists decide the best way to treat someone after flexor tendon surgery.

The Unnerving Effects of Ganglion Cysts in the Palm of the Hand

Doctors know that many ganglion cysts are benign and need only be watched. Most ganglions tend to go away by themselves. But some can get in the way of how the body works. Especially when they form in the palm of the hand, an area rich in nerve pathways.

Two cases are reported in which patients developed nerve problems from ganglion cysts in the palms of their hands. The first was a 31-year-old woman who started having weakness in her left hand. A small bump could be felt in her palm. Ultrasound and MRI tests confirmed the lump. Other tests indicated that the median nerve of the wrist was somehow being squeezed by the ganglion in the palm of her hand. She had surgery to remove the ganglion. Ten weeks later, she had a full return of hand function and improved strength.

The second patient, a 71-year-old woman, also started noticing weakness in her left hand. As time passed, some of the muscles in her hand withered, and her ring and pinky fingers started to bend into the shape of a claw. Doctors determined that something was putting pressure on the ulnar nerve where it goes into the hand. During surgery, the doctors found a small round mass of tissue in the palm of the patient’s hand. It was pressing against the ulnar nerve. The mass was removed and tested; it was a ganglion. Two months after surgery, the patient could grip and open her hand, but it was a full six months before she could straighten her fingers again.

Nerve pressure caused by a ganglion in the palm is not very common. But it can provide doctors with another avenue to explore when patients seek help for problems with hand weakness and function. Both patients in this case study benefited from surgery to remove the ganglion cysts that were causing nerve pressure.

Thumbs-Up Results after Thumb Ligament Reconstruction Surgery

The trapeziometacarpal (TM) joint is located at the base of the thumb. When it is loose and painful, people struggle to do everyday activities. Thus, the health of this important joint can determine if a person has a thumbs-up or thumbs-down day.

When the TM joint is mildly loose and hasn’t developed arthritis, doctors can do surgery to tighten and protect the thumb joint. Sections of two nearby tendons are weaved in and around the sore joint. The idea is that the tendons will take over the function of the injured and loosened thumb ligaments.

How well does the procedure work? The authors followed up on 35 patients an average of five years after surgery. Most were women (29), and the average age was 33. Ninety-seven percent had either an “excellent” or “good” result. Only one patient required another surgery because of ongoing pain. All patients showed stable thumb joints after surgery. And all but two resumed their jobs and sports.

This form of surgery is best used when the TM joint is mildly loose–but not arthritic. When arthritis is present, the authors recommend the use of other surgical procedures. When these guidelines are used, this surgery also appears to keep the joint from eventually becoming arthritic. X-rays taken years after the surgery in this study showed no signs of thumb arthritis.

Along with the exceptional benefits shown in this study, the thumbs-up results support the notion that tightening up this joint before arthritis occurs may prevent future problems with thumb arthritis.