News Category: Hand

Ever felt nervous, jittery, or just plain irritable? You might think those are all emotional responses but in fact, that’s your nervous system responding to whatever is happening in your life. The central nervous system (CNS) is made up of the brain and spinal cord. But there’s another part of the nervous system called the peripheral nervous system (PNS). It’s made up of all the nerves coming from the spinal cord and going out to the rest of your body. The peripheral nerves can be sensory only, motor only, or mixed (both sensory and motor).

Nerves in the peripheral nervous system can also become irritated when they are impinged or pressed upon by bone spurs, protruding discs, tumors, inflammation, and so on. In other situations, those nerves are damaged by injuries that cause chronic (long-term) changes in nerve function. It’s the chronic nerve compression (CNC) injuries also known as compressive neuropathies that are the focus of this review article.

Nerve injury or damage of this type can occur as a result of trauma – the nerve gets pinched (compressed), crushed, cut, or stretched. When sensory nerves are affected the result can be symptoms of pain, burning, altered sensation, numbness and tingling, or even complete loss of sensation (paresthesia). Muscle weakness and atrophy are more likely to develop with motor nerve impairment. And a combination of these two sets of symptoms occur with compression of mixed nerves. Chronic nerve compression can also develop as a result of degenerative conditions or health problems like diabetes and chronic alcohol abuse that lead to nerve damage.

Diagnosis and treatment of compressive neuropathies have presented quite a challenge to physicians. The best treatment is always one that provides a cure for the problem. But what we understand about how nerves function and what’s happening biologically at the cellular level in these injuries is very limited right now. In fact, we only really have theories and models of what scientists think is going on to use when planning treatment.

Part of the problem is that there are so many different parts to the nerve that could be affected. For example, there’s the lining around the nerve and the connective tissue between the lining and the nerve. There are individual nerve cells that could be damaged. The nerve can be injured anywhere from where it connects to the spinal cord all the way down to where the nerve integrates with the skin or muscle it communicates with.

Treatment and prognosis vary depending on which part of the nerve is damaged and how severe is the damage. But it’s not like a cut on the finger that can be seen and a bandaid applied. You can’t see the nerves. They can’t be X-rayed. So how does the physician diagnose the problem? Well, first the patient’s symptoms help identify which nerve is affected. Sensory or motor changes (or both) provide helpful information.

Then special electrodiagnostic tests can be applied. There are nerve conduction velocity (NCV) tests that measure the speed that messages are sent along the nerve. Another test called compound muscle action potential (CMAP) measures the messages sent along nerves to the muscles. Sensory nerve action potential (SNAP) tests are used to assess nerves that only pick up sensory (not motor) input. There’s also the compound nerve action potential (CNAP) used to test nerves that are both sensory and motor nerves. The results of these tests can help determine where the nerve is damaged and how serious the injury might be.

The authors of this article go into great depth discussing each one of these test measures, the results, and the interpretation of the results. Electrodiagnostic findings are also compared for trauma (both the acute and chronic phases) as well as in chronic compressive injuries from diabetes. From what scientists have found so far, it looks like the biologic and physiologic responses within the damaged nerve(s) differs depending on how the injury occurred.

What can we expect to get from all these nerve studies? Physicians hope to find ways to treat nerve injuries without surgery. Understanding the underlying biology of healing for each type of injury may help scientists find faster and more successful ways to foster healing and full recovery. At the very least, if a way can be found to prevent nerve pain or stop it once it gets started, patients would be eternally grateful.

Right now, scientists are very focused on healing central nervous system damage from spinal cord injuries. The spinal cord injury of the late actor Christopher Reaves (Superman) spurred that research on in a big way. It’s possible that some of the techniques used in spinal cord research such as cell transplantation and the use of growth factors to foster nerve regrowth might work with the peripheral nervous system as well.

An open dislocation of the interphalangeal thumb joint (the joint in the middle of the thumb) occurs when there is not only dislocation, but also a wound that exposes the dislocated area. Because of the strength and stability of this thumb joint, this injury isn’t common. When doing a search of the medical literature, this is backed up by there being relatively few discussions and descriptions of irreducible dislocation of the joint. Irreducible means the inability to set the joint properly to its pre-injury state.

The authors of this article presented a case of a 32-year-old man who had an open thumb interphalangeal joint dislocation, which was caused by a combination of factors after he twisted and hyperextended his left thumb during an altercation. The thumb had a 2-centimeter cut on top of the joint and his thumb was obviously deformed. The end of the lower bone in the thumb was seen sticking out of the wound. It appeared that the blood circulation was still intact but the patient did say that the top of the thumb felt numb.

The doctors cleaned out the wound and tried to close it using a local anesthetic, which did not work. The patient was then put under a general anesthetic so the surgeon could try to reduce the joint, or put it back into place. This was not successful either so the surgeons extended the wound for a clearer view of the joint and bones. They found that a tendon, the FPL tendon, had moved and was out of place. The surgeons dissected the area and found that the ulnar digital nerve, the nerve that help the thumb move, was wrapped around the end of the bone. The surgeons then untangled the joint and returned it to its natural position alongside the joint. Once this was done, the surgeons could see the volar plate, the “floor” of the joint, which had been jammed into the joint. They were then able to remove the volar plate and the joint then went back into place easily.

The authors wrote that thumb dislocations such as this one can be difficult to treat because of the different structures inside the thumb that can become injured, moved, or trapped when the joint is dislocated. For this reason, surgery is usually the only method that allows for a successful outcome. By opening the thumb further, if necessary, the surgeons may see exactly what is causing the dislocation from being reset and provides room for the area to be corrected.

Osteoarthritis, often referred to as the wear-and-tear arthritis, can affect the joints in your fingers. The result can be not only pain, but difficulty performing every day tasks. Treatment of osteoarthritis depends on where the joint is and how severe the impact is on the patient. When the osteoarthritis affects the distal interphangeal joints, the joints closest to your finger tip, treatment may involve splinting or surgery, depending on the severity. In early-stage osteoarthritis with early symptoms, physicians generally prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) and/or immobilization with the splint. There are two reasons for the splinting. One is to reduce the movement of the joint, thus limiting the pain, but the splint also protects the finger from accidentally striking objects.

There have not been many studies that looked into the effectiveness of commercially made splints compared to custom-made splints. In fact, a textbook, published recently, claims that splints for the distal interphalangeal joints are not well tolerated. The authors of this article designed a custom-made splint that was made to provide the support and protection needed, but allowed for the fingertip to come out over the top, leaving the patient the ability to touch and feel with the affected finger.

Researchers recruited 25 patients (24 women) who had been diagnosed with osteoarthritis of the distal interphalangeal joints, some of whom required treatment for more than one digit. They ranged in age from 42 to 76 years and they had experienced pain and difficulty for between two months and two years prior to entering the study. Only six patients required one splint, while the remaining 19 patients had splints on two or more. In all, there were eight thumbs, 20 “pointing” and middle fingers, and 21 ring and “little” fingers.

Each joint was graded by a researcher, on a scale of zero to 4:

0: normal joint
1: small build up of bone (osteophyte) that did not seem significant
2: definite osteophyte
3: osteophyte and joint space narrowing
4: severe joint space narrowing

The splint was molded and fit onto the finger of each patient. The plastic is then and allows for a slight bend, which makes it easier for the patient to use the other fingers. The splints were to be worn all day, but the patients were allowed to remove them if they became too uncomfortable and stop using them when the pain went away. The patients did not take any NSAIDs during the course of the study.

The patients were assessed before and after treatment through interviews, physical examinations, and using questionnaires, such as the visual analog scale (VAS), which measures pain on a scale of zero to 100, with 100 being the worst possible pain. Function was assessed with the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) measure.

Upon gathering the data, the researchers found that, on average, patients rated pain at 56 out of 100, with a range from 24 to 75. After the treatment, the average pain rating was only 17, with a range from zero to 50. The disability scoring moved decreased from an average of 28 (range of nine to 64) down to 17 points (range zero to 59). When asked, most of the patients said they were satisfied with appearance of the splint and more than 76 percent of the patients did not refuse to use the splint. None of the patients removed the splints during social occasions and no patient complained of skin irritation from the splint. Three patients did report sweating under the splint when wearing it for extended periods. Other findings were:

– 19 patients wore the splint to immobilize the joint and protect it
– 9 patients used the splint as a protective device when performing manual labor
– No patients reported loss of fingertip sensation
– 4 patients reported splint loosening when using soap and water
– 1 patient reported that he was able to do fine motor tasks (such as turning a page or pinching), while wearing the splint
– Some patients reported limited ability to use their ring finger or little finger if they were splinted

The authors concluded that this type of splint would be useful for patients who had a flare-up of symptoms (pain, swelling) resulting from mild to moderate osteoarthritis.The splint is not designed to correct any deviation or dislocation of the joint, so it would not be used for this problem in patients with stage 4 grading. It could, however, help relieve pain.

Dupuytren’s disease is a condition where the tissue just under the skin in the palm of your hand becomes thick and shrinks, pulling very tight. In some cases, this causes lumping or uneveness of the palm of the hand and in others, it can cause a signficant contracture of the hand, making the hand look as if it is permanently holding on to something. Right now, the regularly accepted treatment for Dupuytren’s is surgery, but despite surgical intervention, there is a high recurrence rate for the disease.

Surgery for Dupuytren’s, as with all surgery, has its risks, such as skin complications, hematoma (blood collecting in one area under the skin) and skin necrosis (dead skin), injury to the fingers, and complex regional pain syndrome, another condition that causes intense pain and burning sensations in the affected area. Nerve injuries were reported to occur from zero to nine percent of the time. As well, the recurrence following surgery was found to range from 41 percent to 54 percent after five years, with about 15 percent of the patients require a repeat surgery for treatment. Repeat, or revision, surgeries are more difficult and come with a 12 percent chance of nerve injury. Because of this relatively high complication rate, surgeons are constantly looking for ways to treat Dupuytren’s without surgery.

Nonsurgical treatments that have been tried include radiation, vitamins, corticosteroids, and ultrasound, but nothing has yet been found to be consistently successful. One other type using collagenase injection, an enzyme that causes changes through chemical interaction. This procedure was first tried in 1996. Complications included pain at the injections site and from manipulating the hand, edema (swelling), lymphadenopathy (swelling of the lymph glands), and tears in the skin. However, the initial trials showed that 90 percent patients experienced results that reduced their contractures to zero to 5 degrees of normal. The authors of this article provide an eight-year follow-up of patients with Dupuytren’s who had received collagenase injections in a phase II clinical trial.

Researchers were able to assess eight of the 23 patients who had participated in the trial. Two patients received treatment in the proximal interphalangeal (PIP) joint, the so-called middle joint of the fingers. The six other patients received treatment in a metacarapophalngeal (MCP) joint, the one closest to the hands, that allow the entire finger to bend into the palm of the hand.

The researchers reviewed the patients’ records, noting the angles of the contractures before the injections, their response to the injection, and dose response to the injection. The mean age at time of the injection for PIP joint was 74 years, ranging from 70 to 78, while for the MCP joint, it was 60 years, ranging from 46 to 62. The mean degree of contraction before the injection in the PIP joint was 45 degrees, ranging from 35 to 55 degrees; for the MCP joint, it was 57 degrees, ranging from 30 to 76 degrees. One week following the injection, the mean angle for the PIP joint was eight degrees, ranging from zero to 15 degrees; for the MCP, it was nine degrees, ranging from zero to 35 degrees. One year after, the mean angle for the PIP joint was 15 degrees, ranging from zero to 30 degrees; for the MCP joint, it was 11 degrees, with a range of zero to 35 degrees.

The patients were asked to rate the success of their procedure on a scale of zero to 100, with 100 being the most satisfied possible, with maximum benefit and resolution of the contracture. The overall average reported was 60 percent and seven of the eight patients said they would have another injection to treat the disease if it recurred or worsened. Measuring the angles eight years after, the researchers found that the mean angle for the PIP joint was 60 degrees, with a range from 50 to 70 degrees and for the MCP joint, it was 22 degrees, with a range of zero to 55 degrees.

The findings showed a long-term recurrence rate of 100 percent among the PIP joints and 67 percent among the MCP joints. Although the rates are high, the contractures for the MCP joints were not as severe as before the injection and 88 percent of the patients said they would undergo the procedure again. Among the PIP contractures, the recurrence was significant but the group was very small (two patients), so larger studies need to be done before drawing any concrete conclusions.

Acute mallet finger is a condition where the finger joint closest to the finger tip cannot straighten out. This is caused by damage to the extensor tendon, the tendon that allows you to straighten that part of the finger. It is often referred to as a baseball finger or dropped finger. It is most often caused by something – often a ball – hitting the tip of the finger or thumb. The authors of this article discuss Doyle I mallet injuries, which may include the tendon coming away from the bone.

As early as 1930, surgeon M.L. Mason advocated immediate surgery to treat mallet fingers. However, because surgery is avoided whenever possible, the usual nonsurgical treatment for mallet finger is to use a splint. The type of splint used is controversial with each splint having its advantages and disadvantages. Some studies have shown the malleable aluminum splint to be effective, but it also may cause complications with the finger’s soft tissue because of pressure. A volar (beneath the finger, palm side) padded aluminum splint, not customized for the patient, helps prevent pressure on the dorsal or top side of the finger, but it doesn’t appear to control the correction of the deformity, as the padded dorsal aluminum splint does. As well, patients often don’t like the splints because having their finger tip covered prevents them from touching things. The doctors who feel that the custom splint is superior feel that it works better because of the better fit on the finger. However, these dorsal splints also put pressure where the tendon rupture occurred, increasing the risk of complications.

There have been studies that looked at different types of splints (plaster of paris, Stack, wire, aluminum, and thermoplastic), but more research needs to be done in order to identify the best type of splint.

For the study, researchers recruited 87 patients with Doyle I mallet fingers. Seventy seven were available for follow-up at the end of the study. The patients were randomized to be treated with one of three splints:

1- Volar aluminum splint (30 patients)
2- Dorsal aluminum splint (29 patients)
3- Custom thermoplastic splint (28 patients)

Four patients dropped out of the dorsal group, two out of the volar group and four out of the custom group.

The splints were applied by an occupational therapist who taught the patients about the importance of the splinting. If the patients had any concerns or the splints needed readjusting, the patients could call the therapists for help. Treatment went on for six weeks, with the affected finger fully extended. After the six week period was over, if the angle of the bend was still more than 20 degrees or the patient was unhappy with the bend, another four weeks of splinting was done. This happened to nine patients. The patients were assessed at weeks 7, 12, and 24.

The doctors compared the x-rays from before treatment to those taken at follow-up. They also assessed the angle of the finger’s bend, the results of the Michigan Hand Outcome Questionnaire, and any complications. Between the three groups, the researchers found there was no lag difference 12 weeks after splinting, but there was a slight superiority with the custom thermoplastic splint. The dorsal padded aluminum splint showed a difference of -16.2 degrees, the volar padded aluminum splint showed a -13.6 degrees and -9.0 degrees was seen with the thermoplastic splint. There were also no differences between the groups in the questionnaire or complications.

The authors note that their study had several limitations. For example, despite the randomization process, there were more smokers in the dorsal group than in the others. This may have influenced the outcomes. As well, the follow-up period was shortened so the researchers could decrease the chances of patients dropping out of the study. The researchers were also not able to determine how compliant the patients were with their splinting, nor did they determine if there were any other problems, such as difficulty with motion in the joint, stiffness, or deformity.

In conclusion, the authors wrote that further study is needed to determine any splint superiority.

Repetitive strain injuries are occurring more frequently with today’s lifestyles, but the most common one that affects the hand or arm is carpal tunnel syndrome. According to statistics, every year, one million adults in the United States are diagnosed with carpal tunnel syndrome and around 200,000 surgeries to correct the problem are performed each year.

Carpal tunnel syndrome occurs when the median nerve, the nerve that runs from your forearm through your wrist and into your hand, becomes compressed as it passes through the carpal tunnel, in the wrist. The compression is most often due to inflammation in the tendon, because of constant use and wear of the tendon by repetitive motions.

Usually, surgery is not the first step approach to dealing with carpal tunnel syndrome. Nonsurgical management, such as taking anti-inflammatory drugs, using splints to immobilize the wrist, and taking a break from the tasks that may be making the situation worse are the usually first treatments. However, if these don’t work, then surgery may be necessary. Carpal tunnel surgery is like all surgery, meaning that it has risks as any other, including the risk of infection. Although the risk of infection is low with carpal tunnel surgery, it is important to understand how it happens and to learn how to prevent it, if possible.

The authors of this article found that not much research had been done regarding how often infections occurred at the site of carpal tunnel surgery and if preventative (prophylactic) antibiotics would help reduce the rate. To address this, the authors reviewed surgical cases involving carpal tunnel syndrome that took place over a 20-month period. They were looking at both superficial infections and those that occurred deep in the incision.

Researchers found 3,003 cases (2,067 women) to review, performed by 98 surgeons in 11 medical centers. This group was dubbed Group A. The patients ranged in age from 48 to 66 years and there were 546 patients who had diabetes. Using the files, the researchers looked for information on infections: if the patients received antibiotics before the surgery, how many patients developed infections, other health issues among the patients, and how the infections were treated. To clarify the infection types, superficial infections were defined as infections that occurred within a month of surgery and were restricted to the skin or superficial, subcutaneous, tissue. Deep incisional infections were infections that occurred within 30 days, but came from deeper within the wound, may have caused the wound to open, or caused symptoms of infection, such as fever, pain, and/or tenderness at the site.

The first part of the study involved determining who had received prophylactic antibiotics and this rate varied considerably between the facilities. In one hospital, only 12.3 percent of the patients received the prophylactic antibiotics, while in another, 89.9 percent did. The surgeons also varied as to whether they would prescribe them. One surgeon never prescribed the antibiotics (0 percent) while another did for all patients (100 percent). This resulted in 2,336 cases, which were put into Group B.

In group A, 2,974 of the cases were done as outpatients, the remaining were in the hospital. Of all the 3003 patients, there were 11 surgical site infections : four were in an organ or the space below the tissue and seven were superficial or deep. Three of the 11 patients had diabetes. One of these patients had extra surgery done at the same time as the carpal tunnel release, on the thumb, so the infection could have begun in that area instead of the carpal tunnel. All the infections occurred in patients who were operated on as outpatients.

In group B, 1,419 (of 3,003) patients received prophylactic antibiotics, 917 did not and researchers could not be sure if 617 did or didn’t. Among the patients who did receive antibiotics, five developed infections. Six patients who didn’t take antibiotics developed infections too.

The researchers concluded that the overall infection rate after this type of surgery was low and more severe infections, in the organs, for example, was even lower than originally thought and reported. While using antibiotics before surgery is a good idea for some types of surgery, such as on the colon, it doesn’t seem to be necessary for carpal tunnel syndrome, because there were no significant differences in infection rates between patients who had received these antibiotics and those who didn’t.

As carpal tunnel syndrome becomes increasingly common in the developed world, doctors are trying to find more effective methods to diagnose the syndrome. Carpal tunnel syndrome occurs when the medial nerve, the nerve that runs down the arm, through the wrist and into the hand, becomes inflamed or irritated, usually due to pressure or rubbing from repetitive actions.

In the early 1900s, a doctor named Paul Hoffman discovered that if you tap lightly over superficial nerves, you could cause a pins-and-needles sensation in the area fed by the nerve. This was shown by tapping the so-called funny bone, the ulnar. Other researchers followed and used the technique, but some felt that using it could tell them that there were problems with the nerves, as did Jules Tinel in 1915. He not only noted the results of tapping on the area, but he felt it was important that doctors tell the difference between the tingling sensation and actual pain. Throughout the years, this test became known as Tinel’s test and it became widely used in diagnosing carpal tunnel syndrome after G.S. Phalen did so in the 1950s.

Despite Phalen’s enthusiastic use and promotion of Tinel’s test to diagnose carpal tunnel syndrome, recent studies are questioning how effective it really is, with varying sensitivity rates. One possible reason for this is there exists no standard for the test. Some people use a pencil (eraser end) or their middle finger to tap on the end part of the nerve on the wrist, while others use a tendon hammer on the other side of the wrist. To understand how the accuracy of the testing can vary according to the different techniques, the authors of this study measured the force applied by several doctors while performing the Timel’s test, using three different techniques.

The researchers tested nine doctors: three who were experienced hand and nerve surgeons, three who had only been in practice for three years, and three who were in the latter stages of their training. The subjects were told to use their usual strength and techniques when performing the tests, doing three sets of five strikes per technique. Using specialized machines the researchers measured the striking load of the dominant hand middle finger, striking with the dominant hand index and middle finger together, and the thumb of the dominant hand.

After the researchers compiled the data from the recordings of the Tinel’s tests, they found a wide variety in the findings, depending on which technique was being used among all doctors. According to the article, “All three senior surgeons and one subject from each of the two other groups preferred the single-finger strike.” The others preferred the double-finger strike. The practiced surgeons were most consistent with how much force they used when tapping, coming in at about two pounds of force.

In conclusion, the authors state that there are no standards when it comes to performing the Tinel’s sign and this leads to a great variability in how it is performed, causing significant differences in its accuracy in diagnosing carpal tunnel syndrome.

Improved technology and smaller surgical instruments have changed the way hand surgeons repair Bennett fractures of the thumb. In this article, hand surgeons review those changes and describe how and when to use arthroscopy and fluoroscopy together to get the best results.

Bennett fractures are named for a physician who first wrote about them in the medical literature way back in 1885. The specific bone that’s affected is the thumb metacarpal. Metacarpal is another word for the bone in the thumb that is closest to the wrist. The joint that is affected is the carpometacarpal (CMC) joint. This is where the base of the thumb is connected to the wrist.

A Bennett fracture is a break along the bottom side of the thumb metacarpal closest to the wrist bone. The location at the base of the thumb metacarpal next to the wrist is why it affects the carpometacarpal joint. And because this is a pivotal joint that contributes to all the movements of the thumb, a close and careful fracture reduction is important.

Reduction refers to putting the broken pieces of bone back together so that the bone surfaces line up exactly and the carpometacarpal joint is fully restored. The surgeon uses wires, pins, or screws (called fixation) to hold the bone in place while it heals. Until small-joint arthroscopy became available, surgeons used open incisions and fluoroscopy (real time 3-D X-rays) to guide the reduction and fixation.

But there have been problems just using traction and fluoroscopy because sometimes it looked like the bone is reduced and properly in place when it wasn’t. Even a slight rotation of the bone can make a difference. Without an anatomic reduction, patients ended up with a painful, arthritic thumb. Combining arthroscopy with the fluoroscopy has changed all that. Now the hand surgeon can replace the bone fragments where they belong, apply the appropriate fixation, and make sure everything is lined up perfectly before putting the hand in a splint.

All that sounds so simple but the surgeon still has many challenges coordinating these two tools. The arthroscope must be inserted into the joint without hitting nerves, blood vessels, or tendons. The broken fragment must be rotated and slipped back into place carefully with a tiny probe. While holding the probe in place and keeping the bone in its perfect spot, the surgeon then fixes the bone in place. When using screws, the surgeon must be careful that the tip of the screw doesn’t go inside the joint.

But the good news is that Bennett fractures of the thumb can be surgically repaired in this fashion and provide patients with a much better long-term result. The authors caution that more complex fractures may still require an open surgery. If the shaft of the bone is broken and/or the soft tissues around the area have been torn, then a more extensive reconstructive procedure may be needed that requires a full incision.

Reading the news about carpal tunnel syndrome (CTS) is a lot like watching ping-pong. The ball keeps bouncing from side to side. What do we mean by this ping-pong analogy? Well, for a long time physicians relied upon clinical tests to make the diagnosis. But the evidence was back and forth in support and against these tests. They weren’t reliable enough. They weren’t valid. They didn’t really prove there was compression on the median nerve causing the symptoms of hand pain and finger numbness and tingling that come with carpal tunnel syndrome.

Then a study group from the American Academy of Orthopaedic Surgeons released a report that recommended electrodiagnostic testing in order to confirm the diagnosis — especially before doing any surgery. So everyone jumped from the side of long held beliefs that carpal tunnel syndrome could be diagnosed with a few special tests performed in the clinic to an understanding that the evidence pointed to the need for nerve conduction velocity (NCV) tests and electromyography (EMGs) studies to know for sure that the problem was carpal tunnel syndrome.

Now, electrodiagnostic tests have been called into question. The ping-pong ball has been lobbed onto the other side of the table again. There is now additional evidence that some people can have normal electrodiagnostic tests but clearly have carpal tunnel syndrome. Concern has been expressed that not treating patients (withholding treatment) because they have normal nerve conduction velocity and electromyography studies is not an acceptable approach.

In the meantime, another researcher explored the possibility of finding clinical criteria that can be used successfully to diagnose this condition. As a result, six items have been put together as clinical proof that carpal tunnel is the underlying problem causing the patients painful neurologic symptoms.

These include some of the former tests (e.g., Phalen’s, two-point discrimination, Tinel’s sign, numbness at night, muscle weakness) physicians used for years to diagnose carpal tunnel syndrome. Numbness at night and weakness of the thumb muscles are two additional criteria that can be used to diagnose carpal tunnel syndrome. A panel of experts agreed that these tests are reliable and further statistical analysis further validated the findings. The ball has just popped back over the net.

Researchers have also looked for other ways to reliably diagnose carpal tunnel syndrome. Ultrasound imaging has come up as one possibility. It’s easy to use. It’s inexpensive and it doesn’t hurt. Ultrasound images show the inside of the carpal tunnel. Narrowing of the carpal tunnel, increased size of the nerve through the tunnel, and the presence of cysts or tumors or other anatomic changes can be seen. But we don’t have normal values for cross-sectional views like this for the general (normal, healthy) population to use for comparison yet. That’s a potential area for future study.

Okay, so we’ve got some updated clinical criteria now to use based on evidence when making the diagnosis. Patients always ask, “What’s causing this problem?” Is it work related? Genetic? Structural? Despite many attempts to answer this question, we still don’t know.

There is an ingrained belief in our country that typing on a computer keyboard for hours every day and using the hands for repetitive clerical activities is the root cause of carpal tunnel syndrome in the majority of cases. This hasn’t ever been proven. We know for sure that regular, prolonged use of handheld vibratory tools like jackhammers and forcefully gripping tools like drills can contribute to carpal tunnel syndrome from pressure on the median nerve. But that’s the extent of our scientific evidence that the work place is to blame.

Once the diagnosis has been made and confirmed, what next? Treatment for carpal tunnel syndrome has often been broken down into two categories: conservative (nonoperative) care and surgery. Nothing has changed here except new guidelines have been set forth by the American Academy of Orthopaedic Surgeons (AAOS) to help physicians decide when to recommend one over the other.

Here’s where we pick up that game of ping-pong again. Until the recommendation came out that surgery should only be done when electrodiagnostic tests were positive, patients were treated conservatively for a period of weeks to several months. Surgery was done when conservative care failed to produce the desired results. But for a while now the recommendation has been for surgery as soon as electrodiagnostic testing proved positive.

Further study of the problem has yielded more evidence that conservative care is still the best approach. The chance that splinting, use of steroids (local injection or oral pills), and ultrasound treatments could work is worth the wait in terms of overall financial cost and outcomes. Sometimes a single steroid injection is all it takes. In other cases, several injections are needed. It’s only when injections are no longer effective (or not effective at all) and other conservative measures fail to bring about results that surgery is advised.

We are almost to the end of the ping-pong game! It sounds like sorting out the best treatment is clear enough. That is until we realize there are two different ways to approach the surgery: open incision versus minimally invasive with endoscopic surgery. Studies are currently being done to compare the results using one method over the other. Results are measured using pain, function, return-to-work, and patient satisfaction.

For the most part, it looks like the long-term results are fairly equal between the two surgical approaches. After five years, the majority of patients come out looking about the same when using these measures. Early results might favor the endoscopic procedure simply because patients get their grip and pinch strength back faster and that translates to a faster return-to-work for some people.

When endoscopic techniques for carpal tunnel release first came out 20 years ago, there was some concern that patients would have more complications. Nerve and blood vessel damage were cited as the two major potential problems with the endoscopic approach. But once again, studies just haven’t shown that there’s a difference in safety between the two surgical methods. In the end, it becomes a personal decision by the patient based on the surgeon’s best advice.

In summary, the current evidence available regarding the diagnosis and treatment of carpal tunnel syndrome boils down to these key guidelines:

Carpal tunnel syndrome, a repetitive strain injury is increasingly common in the developed world. Each year, one million adults in the United States are diagnosed with carpal tunnel syndrome. About 200,000 surgeries each year performed to correct the problem. The syndrome occurs when the median nerve, the nerve that runs from your forearm through your wrist and into your hand, becomes compressed as it passes through the carpal tunnel, in the wrist. The compression is most often due to inflammation in the tendon, because of constant use and wear of the tendon by repetitive motions.

Although carpal tunnel syndrome is often thought of as striking people of working age, seniors also develop the problem or continue to have the problem after it developed earlier in life. In fact, seniors can be at risk for having more severe symptoms of the syndrome. Unfortunately, often, treatment for some health issues begins to come into question after a patient reaches age 65. For certain procedures, such as carpal tunnel release, there is some question as to whether it is effective and a viable treatment. The authors of this study looked into the issue.

Researchers followed up with 66 patients who had been diagnosed with carpal tunnel syndrome and who were 65 years old or older at the time of diagnosis and surgery in 2000 or 2001. Of the original 66 patients, the researchers were able to contact 54 who, among them, had 92 hands treated for carpal tunnel syndrome. Nineteen of the patients (29 hands) agreed to participate by undergoing a repeat history and physical examination, and to answer questions about their health status and use of their hand.

The researchers checked for pain and physical performance by performing Tinel’s sign, Phalen’s sign, medial nerve compression test, two-point discrimination, grip and pinch strength measurements and by checking to see if there was any weakening or wasting away of the thenar muscle (muscle in the thumb). They also rated symptoms on a scale of one (none) to five (very severe). The symptoms included:

– tingling, pins-and-needles sensation (parasthesia)
– day pain
– night pain
– numbness at night, while sleeping

The patients’ hand performance was assessed through the Michigan Hand Outcomes Questionnaire (MHQ), which evaluates overall hand function, activities of daily living, work performance, pain, aesthetics, and satisfaction with hand function in both hands. The higher the scores, the better the results. The patients had been asked to rate their satisfaction with their surgery results six months following the surgery and were again for this study, five years after. This was assessed on a scale of one to five, with one meaning dissatisfied and five being completely satisfied.

After reviewing all the test and questionnaire results, the researchers found that at this point, the participants ranged from 75 to 81 years old. All of the patients said that their carpal tunnel syndrome symptoms had decreased significantly. They had resolved completely at six months in many cases:

– 84 percent no longer experienced parasthesia after six months, 76 percent after five years
– 70 percent no longer experienced numbness after six months, 86 percent after five years
– 83 percent no longer experienced day pain after six months, 90 percent after five years
– 89 percent no longer experienced night pain after six months, 83 percent after five years
– 83 percent no longer experience numbness at night after six months, 72 percent after five years

One patient had to have repeat surgery after the six-month follow-up because the symptoms had returned.

When comparing the physical aspects, the researchers found that, overall, there was significant improvement in sensation to the hands after six months but not much between six months and five years. For strength, there was also a significant improvement at six months, but a drop between six months and five years.

Although the results of this study show that patients who were over 65 years old when they had surgery to repair carpal tunnel syndrome maintained their good results after five years, the authors of the study caution that the results may be a little skewed by the lack of participation of the others initially in the study, who refused to participate. The researchers have no way of knowing how they fared with their hand function and sensitivity, nor if they were satisfied with the surgery results.

The news media has brought it to our attention that the overuse of antibiotics has led to a new problem called MRSA (pronounced Mersa). MRSA stands for methicillin-resistant staphylococcus aureus. Staphylococcus aureus is known more commonly as a staph infection.

MRSA is a potentially serious problem (it can be fatal) because the staph bacteria have mutated (changed) enough that antibiotics can no longer kill it. Staph can usually be treated with antibiotics. But over many years, some strains of staph — like MRSA — have become resistant to antibiotics that once destroyed it. Staph is now resistant to methicillin as well as amoxicillin, penicillin, oxacillin, and many other antibiotics.

MRSA doesn’t affect everyone. There are certain people who seem to be more susceptible (more likely to get MRSA). These at-risk groups include people involved in contact sports, athletes sharing equipment, and individuals who are immunosuppressed (poor immune system function). The very young and the very old are two age-related groups at increased risk for developing MRSA. But there’s also been a disturbing trend of MRSA infections in patients who have no obvious risk factors.

This study focuses on MRSA in one particular part of the body: the hand. Hand surgeons reviewed the medical charts for 159 patients treated at their trauma center for a hand infection to find out two things: 1) How often do MRSA infections of the hand occur? and 2) Are there any specific risk factors related to the hand?

The MRSA infections included in this study were called community acquired, which is to say the person was exposed to the bacteria somewhere out in their work, home, or recreational environment. In other words, they didn’t pick up the bacteria while being hospitalized. They were, however hospitalized because of this community-acquired hand infection that required surgical intervention (infection drainage).

These cases occurred over a period of 11 years so the authors were able to see a trend of ever increasing numbers of community-acquired MRSA (CA-MRSA). At the same time, the number of patients with non-MRSA hand infections remained steady. During the chart review, the researchers collected data on what types of infections were treated, how many surgical procedures were needed to get control of the infection, and the antibiotics used to treat each patient.

What puts people at risk of CA-MRSA hand infections? Intravenous drug use was the number one risk factor. This refers to shooting up illegal drugs, not the administration of intravenous medications. A second possible risk factor was the use of antibiotics for a similar hand infection prior to this one. Age and gender (male versus female) were not risk factors. And neither was being homeless or incarcerated (in jail).

Looking at the results of treatment from this and other studies may shed some light on how to prevent community-acquired MRSA. Surgical treatment to drain the wound without using antibiotics afterwards produced positive results for most of the patients studied. That suggests that drainage may be all that’s needed to treat these kinds of soft-tissue infections.

The authors suggest that some groups of patients with hand infections may still benefit from the post-operative use of antibiotics but this must be studied further. For example, it is widely believed that living in close quarters (e.g., jails, dormitories, barracks) is a risk factor for CA-MRSA. Patients in any of these population groups may need a post-operative course of antibiotics to prevent further infection.

Injuries of the ulnar collateral ligament of the metacarpophalangeal
joint in the thumb sometimes referred to as “skier’s thumb” are very
common and account for well over half of all thumb injuries. These
injuries, especially prevalent in skiers (representing nearly a third
of all skiing injuries), commonly affect participants in volleyball,
soccer, handball, basketball, and rugby as well. They are typically
the result of a fall. As people attempt to catch themselves, the
ligaments exceed their weight-bearing ability and the thumb pulls away
from the hand. In these conditions, the strong band of tissue attached
to the middle joint of the thumb sustains significant stress and
eventually tears.

Determining whether an individual suffers from skier’s thumb requires
a comprehensive physical examination as well as thorough review of
one’s patient history. Early diagnosis is paramount to successful
outcomes. Ulnar colateral ligament injuries are frequently overlooked
in initial diagnosis, and this inattention can limit the potential
stability of the restored joint. As such, it is necessary to pay close
attention to a patient’s symptoms. Patients typically present with
swelling and pain around the joint, as well as difficulty holding or
grasping objects. Stress testing is crucial for accurate diagnosis and
may require local anesthesia to elicit full patient cooperation.
Patients suffering acute injuries may be extremely guarded, making
palpitation and, therefore, diagnosis difficult.

Much of the image diagnosis of skier’s thumb relies solely on
radiographs. Though MRIs have proven accurate, there is some debate as
to whether they are cost-effective. Ultrasound, on the other hand,
holds promise. While its effectiveness can be limited by several
factors like examiner skill, quality of equipment, and the time
elapsed from injury, ultrasound has the potential to be both accurate
and cost-effective. However, more studies are necessary before
ultrasound may replace radiographs as the preferred form of imaging in
these cases.

Treatment options for ulnar collateral ligament injuries rely solely
on whether the ligament has been ruptured or only partially torn. In
cases of rupture, surgical repair is required, but partially torn
ligaments can only be treated with nonoperatively. Much of the
literature concerning treatment options has remained the same,
however, there has been rising debate concerning the management for
avulsion fractures. Some studies have demonstrated good result with
nonoperative treatment, while others have emphasized the need to
determine the stability before nonoperative treatment can be deemed
appropriate. Again, further study is required before one approach is
recognized to be superior to the other.

As common as cases of skier’s thumb are, it is disheartening how often
outcomes are compromised by misdiagnosis. Hopefully, the recent
research outlined in this article offers hope for administering more
effective care for the injury in the future.

At first glance, finger fractures can seem like a no big deal kind of problem–until you are the one with the injury. That’s what happened to the hand surgeon who wrote this review article. He was out skiing during a break from a medical conference he was attending when he fell and suffered mallet fractures to two fingers. You might think he was really lucky to be with all those other hand specialists because they could fix him right up.

But what really happened was a lively debate about the best way to treat such an injury. You may have seen someone with a mallet fracture without realizing it. The tip of the affected finger is stuck in a bent or flexed position giving the finger a look like a wooden hammer called a mallet. So what was all the fuss about among the group?

Well, mallet injuries can be fairly complex. The surface of the finger joint can be involved. There is avulsion (rupture) of the tendon. The joint may become subluxed (partially dislocated) or fully dislocated. Depending on the location and severity of the injuries, treatment may be accomplished either with a splint to immobilize the joint or surgery to repair the damage.

Okay, so that’s sounds easy enough. Why so much argument over that? It turns out that studies have shown surgery involves using a pin to hold the bone fragments together. And there are often many problems associated with the pin such as infection, failure to hold the fractured bone together while it heals, and loss of skin as a result of the infection. But there are times when a pin functions like an internal splint to allow the patient to keep using the hand (such as in the case of a surgeon!).

External splinting is a reasonable conservative (nonoperative) approach, but there are many different kinds of splints to choose from. Some are prefabricated. That means the surgeon can take one off the shelf and slip it on the patient. Those are handy but not always the best choice for patients with special needs. In those cases, the splint may need to be custom made or if already made, custom molded by a hand therapist. There are aluminum splints, rubber coated splints, the Stack splint, the Pryor splint, the Howard splint, and so on. You get the idea that there are many possible choices.

When making a treatment decision, the surgeon must consider many factors such as patient comfort, patient compliance (cooperation), skin problems, and final outcomes. To get to the bottom of what works best, the author of this article reviewed studies done comparing different splints and comparing splints versus surgery for mallet finger injuries. He found some large studies reviewing cases of mallet injuries after treatment was over. There were also a few studies where patients were treated with two different splints and the results compared.

There were a few major findings from these studies:

Arthroplasty (joint replacement) can be done on many joints now, including the fingers. Metacarpophalangeal joints, or the knuckles at the base of the fingers, that have been damaged by rheumatoid arthritis can be replaced using silicone arthroplasty, but some studies have shown that this may not be as effective in some fingers than in others. The authors of this study wanted to see if different fingers reacted differently to the silicone arthroplasty in how they were able to move, extend, and move in an arc motion.

To do the study, researchers studied 68 patients who were between 18 and 65 years old; all had rheumatoid arthritis and had hand deformities due to arthritis. The researches were looking for deviations and lags in movement in the index, middle, ring and little fingers. All the patients received the same implant, using the same technique.

To measure the function of the fingers, hand therapists measured the arc of motion of the fingers, and ulnar drift, which was how the finger moved while in a resting position.

The drift angle before surgery for the index finger was 26 degrees before the surgery and 13 degrees one year after surgery. For the middle finger, it was 33 degrees before surgery, 12 degrees one year later. The ring finger had an angle of 40 degrees before surgery and 23 degrees after, and the little finger had 48 degrees before surgery and 14 degrees after. This means that the biggest improvement was with the little finger (30 degrees improvement) and the least amount of improvement was the index finger with only 12 degrees improvement.

The same type of finding was noted with the extension lag. The index finger had 53 degrees before surgery, 32 degrees after; middle finger had 65 degrees before surgery, 35 degrees after; ring finger had 68 degrees before surgery, 27 degrees after, and the little finger had 72 degrees before surgery and 47 degrees after. Again, the better improvement was seen with the little finger at 47 degrees and the least amount of improvement in the index finger at 21 degrees.

When measuring the arc of motion, there was a slight change in which finger did best. The least amount of improvement was still with the index finger (8 degrees), but the best was the ring finger (15 degrees) followed by the little finger (13 degrees).

In conclusion, the researchers found that the ulnar fingers, the ring and little fingers had the best improvement after the surgery, despite having the most damage, while the radial fingers, the index and middle fingers, didn’t do quite as well. The differences could well have to do with the mechanics of the different knuckles. The authors had thought that the ulnar fingers would not do as well with the silicone arthroplasty because the knuckles don’t have the same stability as the knuckles of the radial fingers, but they were proved wrong in this case.

If you’ve ever been so cold that your fingers tingled or hurt, you know how bad it can feel. Some people, however, don’t have to be in extreme cold to feel those sensations. They have what is called thermal hyperalgesia or cold sensitivity. This abnormal pain to the hand and fingers can be very disruptive, taking away enjoyment from activities and also making it hard to do work involving the hands and fingers.

People who have upper extremity injuries (arms, hands, fingers) can develop a nerve injury called a neuroma, a growth of nerve tissue. Forty two percent to 100 percent of people who have this neuroma end up developing cold intolerance. This happens because when there is damage to a peripheral nerve, a nerve not in the spinal cord, the nerve tries to fix itself. To do this, it tries to regenerate and may end up sending axons, nerve fibers, where there shouldn’t be any. This can cause sensitivity and pain.

Earlier studies have found that there is a connection between traumatic injury and cold intolerance in the upper extremity, even with amputations and re-attachment of fingers. However, there doesn’t seem to be consistency between various studies as to the best way to measure cold intolerance. Some studies depend on questionnaires, while others depend on the patients reporting their symptoms. The authors of this study wanted to clarify the issue by seeing how frequently cold sensitivity occurs in people with neuromas that were caused by injuries, and if the the symptoms improve after surgery to remove the neuroma. They also wanted to see if they could predict who would develop the cold sensitivity.

Researchers sent out questionnaires to 34 patients who were to have surgery to treat a neuroma of the upper extremity. The questionnaires were sent out when the patients were scheduled for their surgery and again three months after their surgery. The patients were followed for about 24 months after. The researchers were looking for information on the age, sex, body size, smoking, employment, which hand was affected (dominant or non-dominant), if they were off work, if there were any law suits involved, and if the patients had had any previous surgeries.

To test for cold intolerance, the patients were asked to complete the Blond McIndoe CISS questionnaire, which asked about symptoms (pain, numbness, stiffness, swelling and change in skin color). They were also asked about the types of pain (spontaneous, on pressure, on movement, or hyperesthesia (intense sensitivity), and they completed the Visual Analog Scale (VAS), which is a scale of zero to 10, with zero being no pain at all and 10 being the most excruciating pain possible. Finally, a questionnaire called the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), which involves a 30-item disability scale. Each is rated from zero (no disability) to 100 (most severe disability).

Of the original 33 patients, average age 43 years, 18 were men. The length of time that they had pain varied, but it was a mean of 42 months. Twenty-five of the patients reported that their dominant hand was affected by the neuroma. Of all 33 patients, 18 neuromas were the result of a sharp laceration (cut), nine from being crushed, and five from avulsion (tearing away). Twelve patients needed repeat procedures to help treat the neuroma pain and nine patients ended up having a partial finger amputation.

The researchers received questionnaires back from 33 of the patients before the surgery and 30 after the surgery. Before surgery, the problems were reported 28 times for cold-induced pain, 14 times for stiffness, seven times for cold-induced numbness and seven for change in skin color, and two for swelling. Most of these decreased after surgery. The results showed that 91 percent of the patients experienced cold intolerance before they had their surgery, using the CISS scale. After the surgery, there wasn’t much difference using this CISS scale, but while they had scored experiencing high pain using the Visual Analog Scale before the surgery, this pain dropped significantly after the surgery.

The authors concluded that while surgery may help relieve the pain of neuromas, the cold sensitivity may not improve. This, unfortunately, is a difficult thing to treat.

Little by little, researchers are coming to understand what’s behind the problem of trigger finger. Trigger finger (and trigger thumb) are conditions affecting the movement of the tendons as they bend the fingers or thumb toward the palm of the hand. This movement is called flexion. The tendons that move the fingers are held in place on the bones by a series of ligaments called pulleys. These ligaments form an arch on the surface of the bone that creates a sort of tunnel for the tendon to follow along the bone. To keep the tendons moving smoothly under the ligaments, the tendons are wrapped in a slippery coating called tenosynovium. The tenosynovium reduces the friction and allows the flexor tendons to glide through the tunnel formed by the pulleys as the hand is used to grasp objects. When the flexor tendon gets pinched or stuck under the A1 pulley, a trigger digit develops.

A series of studies have been done examining this pulley mechanism called the A1 pulley under high-powered microscope called light microscopy. So far, the scientists have found that normal pulleys have three layers: an outer, middle, and inner layer. Each layer is made up of different types of cells and a different mixture of those cells. For example, the outer layer is formed by loose connective tissue with a good blood supply. The middle layer contains dense connective tissue. And the inner layer is the gliding layer made up of fibrous chondrocytes (cartilage cells).

In this study, hand specialists take a closer look at the histology of these three layers with four things in mind. Histology refers to the cellular make up of the tissues. The four areas of study focused on 1) histology of normal A1 pulleys, 2) histology of the abnormal A1 pulleys seen in trigger fingers, 3) creating a way to classify trigger finger based on histology, and 4) looking at how the histology compares with patient’s symptoms and clinical presentation.

In order to examine normal pulleys from human fingers, the authors relied upon human cadavers (hands preserved after death for study). They were able to obtain 55 normal A1 pulleys from adult fingers this way. The abnormal pulleys came from 80 live patients who had surgery to release a total of 104 trigger fingers. The pathologic pulleys were removed at the time of surgery and sent to the lab for close inspection and analysis.

Any time a comparative study like this is done, the researchers must also take a look at the patients to see if there are any major differences in the two groups or factors that might be linked with the problem. In this case, background data on the cadavers was not available. But the patient profile showed an even mix between men and women ranging in ages from as young as 18 up to nearly 80 years old. Two-thirds of the group had been involved in light-to-heavy manual labor. At least half of the group had some other problem affecting the hand such as diabetes, carpal tunnel syndrome, or Dupuytren’s disease.

Dupuytren’s first shows up as a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger. More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. Dupuytren’s contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized (unable to move).

For each patient with a trigger finger, before surgery, the severity of symptoms was labeled as Stage I, II, or III. Stage I patients had tenderness and pain at the surface of the A1 pulley along the palm side of the hand. No nodules or triggering were present. Patients considered in Stage II had tenderness, swelling, and/or tendon nodules that got caught under the pulley when the finger was actively flexed. And Stage III was a more severe form of stage II with more catching and possibly a flexion contracture (finger stuck in a bent position).

The authors described their findings for each of the three normal layers of A1 pulleys examined. Most notable is the fact that the first two layers form a fibrocartilaginous portion of the lining or sheath around the tendon right where the pulleys are located. This helps them move, slide, and glide more smoothly. Very few (if any) blood vessels were present in those two layers. The outermost layer on the palm side of the pulley had very tiny capillaries to bring blood supply to the area. This layer is right next to the tendon sheath and helps bring blood to the area.

Light microscopy made it possible to look at the tissues with increasing magnification. The borders between each layer were visible, thickness of the layers could be measured, and the surfaces were easy to see, too. Pulleys from the trigger fingers showed various amounts of damage and destruction of the fibrocartilaginous layers of the pulley. Sometimes it was so thin, it disappeared. Tiny cracks called fissures were common along with scar tissue and increased blood supply to the damaged area. Despite all of those changes, there was no sign of inflammation anywhere in the area.

Using the histologic findings, a three-grade classification model was proposed. Grade 1 included mild abnormalities. The fibrocartilaginous gliding surface was still fairly normal. There was no swelling, no cysts, no fissures, and no evidence of blood vessels forming in the area. Grade 2 had more moderate changes. The gliding surface was fissured and thinning. The middle layer did not appear to be getting thicker yet (from scar tissue) but the inner layer was replaced with fibrous (scar) tissue. And in Grade 3 (severe) lesions, the gliding surface was very thin with skips in the fibrocartilaginous layer and places where it was missing (destroyed) altogether.

In summary, this study takes a closer look at the A1 pulley mechanism associated with trigger finger. Other studies have focused on the flexor tendon instead. Histologic abnormalities of the pulley are described. Because of these findings, a greater appreciation for the role of A1 pulleys in trigger finger is reported. It appears that increased mechanical stress from repetitive use of the fingers results in abnormalities that can be graded 1 to 3 (mild to severe). As the condition gets worse, more and more of the gliding surface is destroyed and replaced by fibrosis (scar tissue) that has its own blood supply. As the pulley gets thicker and thicker, the tendon is less able to slide and glide underneath it.

The authors report that they have changed how they treat trigger finger as a result of their findings. Now they try steroid injection(s) before surgery. They plan to report on results of patients who have injection therapy for trigger fingers compared with those who do not. Placement of the injection may make a difference in outcomes if the pulleys are treated instead of the flexor tendons. Time will tell!

One out of every 200 adults in the United States suffers from carpal tunnel syndrome (CTS). Carpal tunnel syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.

Carpal tunnel syndrome (CTS) causes pain, numbness, tingling, and weakness of the hand and wrist. Symptoms begin when the median nerve gets squeezed or pinched inside the carpal tunnel of the wrist. CTS is also referred to as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on one side and the transverse carpal ligament on the other. The median nerve passes through the carpal tunnel into the hand. It gives sensation to the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the thenar muscles of the thumb. The thenar muscles form the thick pad at the base of the thumb and let you touch the pad of the thumb to the tips of each finger on the same hand, a motion called opposition.

Hand therapists such as specially trained physical and occupational therapists often treat patients with carpal tunnel syndrome. A wide variety of treatment techniques are used such as splinting, activity modification, and stretching of the soft tissues. Neurodynamics, a relatively new treatment method has become very popular in the last 10 years and is the focus of this study.

Neurodynamics was developed in Australia by a physical therapist by the name of David Butler. It is the study of how the nervous system slides and glides as we move. Nerves such as the median nerve involved in carpal tunnel syndrome can become pinched, obstructed, or bound down by scar tissue, swelling, or other soft tissues surrounding the nerve. The neurodynamic technique is a way of restoring the free flowing movement of nerve tissue as the joint moves.

Treating carpal tunnel syndrome with the neurodynamic approach requires the therapist to understand the anatomy of the median nerve. Before applying the technique, the therapist must conduct an examination of the median nerve including palpation and movement of the nerve. Tests are also performed to see if the nerve is involved, blocked, or obstructed in any way.

Altered nervous system movement is restored through a series of joint and limb positions and movements referred to as neurodynamic technique (NDT). In order to see if this technique really works or not, the authors designed a study to compare a very believable sham technique with the real neurodynamic approach. Patients were completely blinded as to which group they were in (receiving neurodynamic technique or receiving a very believable sham). Patients in both groups had high expectations that the treatment they received would be helpful. Expectations were measured using a specific questionnaire (the Patient-Centered Outcome Questionnaire or PCOQ) designed for that purpose.

To give an idea of what a neurodynamic technique looks like, the authors provided photographs and a written description of the physical maneuver performed on the patient (depending on which group he or she was in). All treatments were conducted with the patient lying down on his or her back.

For the neurodynamic technique, the patient bent his or her head away from the side the therapist was mobilizing. The shoulder was pressed down by the therapist. The arm was lifted up away from the side, the forearm was turned up in a movement called supination (palm up as if asking for a bowl of soup). The therapist kept the downward pressure on the shoulder while moving the arm through a specific pattern of passive elbow, wrist, and hand motion. The purpose of these specific movements is to position the upper extremity in such a way that movement of the joints stresses the targeted nerve pushing it along its intended pathway.

Patients in the sham group kept the head in the middle. The therapist did not raise the patient’s arm away from the body, and did not depress the shoulder down while moving the wrist and hand. None of the movements in the sham treatment stressed or moved the nerve. In fact, the movements were carefully designed to minimize any anatomical stress across the nerve. Patients in both groups received two sessions each week for three weeks.

Patients with carpal tunnel syndrome (all women) were randomly chosen by a computer program to be in one of the two groups. Two thirds of the group had carpal tunnel syndrome in both wrists/hands. The patients had no way of knowing which group they were in and whether or not the treatment received was the neurodynamic technique or the sham until the study was over. Only the therapist performing the techniques knew which technique was being used on patients.

Results were measured by pain intensity, pressure pain, thermal pain, grip strength, and self-report measure of arm disability (loss of function in daily activities). The pain measurements were carefully taken using various measuring tools and instruments (e.g., Visual analog scale for pain intensity, pressure algometer for pressure pain, handheld neurosensory analyzer for thermal pain). Another handheld tool called a dynamometer was used to measure grip strength.

Specific tests of neurologic status of sensory function were also performed. The reserachers used standard Semmes-Weinstein monofilament testing of fingertip sensation and electrodiagnostic nerve conduction study (NCV) of the median nerve. All tests were done before treatment (baseline testing) and again three weeks later after treatment. Pain intensity, pressure pain, and thermal pain were measured right after each treatment session to assess for within-session treatment effect.

Analysis of results showed no difference in immediate or delayed outcomes between the two groups. Patients in the sham group got just as much pain relief and change in perceived pain pressure, temperature, and sensitivity. The authors suggest this shows how much pain and symptom relief depends on patient expectations. Testing showed no difference in the two groups in terms of expectations for treatment results. In other words, they all expected the treatment to work and to get better and they did. That is a true indication of how believable the sham treatment was.

The authors conclude that like many manual therapy hands on techniques, it’s not the specific method used that works as much as the patient’s response to being touched and their expectations of getting better as a result. The results of this study are consistent with other similar studies using a variety of different manual therapy techniques. This study shows that the success of the neurodynamic technique may not be related to movement of the nerve at all.

The authors also pointed out there are some caveats (yes, buts) in this study. First, all of the patients were women, so the results don’t necessarily apply to men (similar testing must be done to observe response in men). Second, all patients in the study did use a splint on the forearm, wrist, and hand at night while sleeping and during any activities that provoked or aggravated the carpal tunnel syndrome symptoms.

Third, there were no control groups (group(s) who receive no treatment at all or group with splints but no hands on treatment). Without a control group for comparison, it is uncertain that the results are completely accurate. The patients could have gotten just as much relief from symptoms just with the passage of time. And finally, with only a three-week follow-up period of time, the results do not show whether the treatment effect is long-lasting. But this was the first study to even look at results from neurodynamic technique, so the findings are important. More studies are planned by this group to take a look at other factors and variables as suggested.

Thinking about having surgery for carpal tunnel syndrome? Need some help deciding? Making a decision about the best way to treat carpal tunnel syndrome isn’t always easy. The results of this study help point out patient concerns and considerations when mulling over whether or not to have surgery.

Two groups of Korean women (all homemakers, none on Worker’s compensation) with confirmed carpal tunnel syndrome of unknown cause were included in the study. Electrodiagnostic tests (e.g., nerve conduction velocity, electromyography) were used to make sure that the pain, numbness, and weakness (typical signs of carpal tunnel syndrome) were indeed caused by compression on the median nerve in the wrist. Those tests aren’t always 100 per cent accurate (there are false positive or false-negative results) but research shows they are reliable for the majority of patients.

Recent studies have shown that patients with electrodiagnostically confirmed carpal tunnel syndrome are candidates for decompressive surgery. The surgeon releases pressure on the nerve by cutting through the band of connective tissue that crosses the wrist over the nerve. The tissue that is released is called the carpal ligament or retinaculum. Some patients may opt to try conservative (nonoperative) care first with antiinflammatory medications, steroid injections, and hand therapy. But failure to improve with nonoperative care is another indication that surgery might be warranted.

Today’s patient is more of a health-care consumer. Surgeons advise and educate about the condition and treatment options, but patients make the final decision. In this study, consumer concerns and factors influencing treatment decisions were explored. Patients usually have a specific reason why they go ahead with the surgery or why they choose to avoid (even cancel a scheduled) operation. But surgeons don’t always know what motivates patients to go ahead with surgery or cancel it all of a sudden. The results of this study might shed some light on that subject.

Everyone in the study had been given at least eight weeks of conservative care including antiinflammatories, steroid injections, and a rigid brace to hold the wrist in a neutral position (not bent or extended). Once the decision had been made to have surgery, there was a four-week waiting period. At the end of the month’s time, 13 per cent of the women canceled the upcoming surgery. They said the number one reason for the cancellation was that their symptoms were better. Since none of these women were Worker’s Comp patients, they said that their secondary concern about having the surgery was financial. They also mentioned some concern about having a scar across the wrist.

For those who went ahead with the scheduled operation, they were asked what was the main reason they pressed on and didn’t cancel the surgery. They listed symptom severity as the number one reason for having the surgery. Everyone in both groups was worried about symptoms coming back but at the final follow-up results were equally good in both groups.

The authors also analyzed characteristics of women in both groups by age, marital status, symptom duration, income, and education. The groups were very similar in all ways, which lends to the validity of comparing one group to the other. If there were big differences in any of these factors, it might not be clear which factors really contributed to the decision-making process.

The results of this study show that concern about finances and appearance are more important factors in canceling carpal tunnel surgery than fear of having the operation. The cancellation group did express more concern about how the surgery would affect their ability to care for their family. Testing done before the scheduled surgery showed equal functional abilities between the groups, so these concerns on the part of the cancellation group were not necessarily based on worse function compared with the surgical group.

The authors conclude that this is the first study to attempt to understand patients’ thinking about surgery for carpal tunnel syndrome. It appears that concerns and feelings are more influential than the objective electrodiagnostic test results when making the decision to have surgery for carpal tunnel syndrome — at least in this particular group of women. Further studies repeating this analysis with other potential carpal tunnel surgical patients may help confirm these results. Different age groups of varied ethnicity/racial background may have other ways of looking at this decision.

It’s entirely possible that patterns of surgery avoidance vary depending on the underlying problem. In the case of carpal tunnel syndrome, the condition is not life-threatening and not even likely to cause permanent paralysis. Some women may decide to avoid surgery and see what happens over time. This study only included patients who were initially signed up for surgery. It didn’t include women who never considered surgery as a possible treatment option and what they might say about their concerns.

With health care costs soaring, everyone is looking for ways to trim the budget. Taking common problems like carpal tunnel syndrome (CTS) and doing a cost analysis between operative and nonoperative treatment makes a lot of sense. It can help patients and surgeons in the decision-making process.

Carpal tunnel syndrome is a problem affecting the hand and wrist with pain, numbness, and weakness occurring when the median nerve gets squeezed inside the carpal tunnel of the wrist. This condition is also known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of carpal tunnel syndrome.

Why start with a cost analysis of treatment for carpal tunnel syndrome? Well, it is one of the most common hand problems surgeons see, affecting as much as nine per cent of the adult population at any given point in time. And although it’s recommended that anyone with carpal tunnel symptoms start with conservative (nonoperative) care first, the results of this study suggest just the opposite. Surgery should be the standard of care for anyone with electrodiagnostically proven carpal tunnel syndrome.

That phrase electrodiagnostically proven is the important key. Symptoms of wrist pain and numbness of the thumb, first two fingers, and half of the ring finger come with carpal tunnel syndrome. But unless electrodiagnostic tests are done, the patient does not have a confirmed, proven case of carpal tunnel syndrome.

What tests are we talking about? Several tests are available to see how well the median nerve is functioning, including the nerve conduction velocity (NCV) test and an electromyogram (EMG). The NCV test measures how fast nerve impulses move through the nerve. Slow or absent impulses is a sign that the nerve is not firing properly.

The EMG is done by testing the muscles of the forearm and wrist that are controlled by the median nerve to determine if they are working properly. If the test shows a problem with the muscle, the nerve that goes to the muscle might not be working correctly. This is similar to checking whether the wiring in a lamp is working. If the light still doesn’t work after you’ve put in a new bulb, you can begin to tell if there’s a problem in the wiring.

Knowing that nerve function is affected helps steer patients to surgery right away because this is not something that responds well to treatment with splinting or hand therapy. Rather than spending money on conservative care and still ending up with surgery, costs can be cut up front by beginning with surgery first.

To prove this, the authors divided a group of 120 patients with carpal tunnel syndrome into two groups. People in the two groups were matched so there was no difference between the groups based on gender, age, body mass index, tobacco use, type of employment, and insurance coverage. They were also equally matched based on the results of nerve conduction testing. No one in either group had a previous history of surgery for carpal tunnel syndrome.

The first group had at least two weeks of therapy with a hand therapist and then continued their exercises at home on their own. The program included wrist splinting at night and tendon/nerve gliding exercises. Steroid injections were also available for anyone in this group who were not improving. Group two had surgery without conservative care first. The surgeon performed an open incision and release of the transverse carpal ligament, sometimes referred to as the retinaculum. The procedure is called a carpal tunnel release.

Patients in group one could opt for surgery at any time if their symptoms were not improving with therapy or getting worse despite therapy. Anyone who switched from conservative care to surgical care was called a crossover patient. Patients in group two could have supervised hand therapy after surgery if needed to regain motion, strength, and function but this was not ordered routinely. Everyone was followed at regular intervals (two weeks, six weeks, three months, and six months after treatment).

As a measure of outcome, the authors added up all of the reimbursement received for services rather than the actual charges (since this was a study to compare actual costs). Items for which actual dollars were paid included surgeons’ fees, anesthesia, operating room costs, splints, therapists, injections, and testing. Reimbursement came through one of three sources: Medicare, private insurance, and Workers’ Compensation. The number of crossover patients was also added up. Patient characteristics were compared between those who crossed over and those who did not to help identify who should opt for surgery as the initial form of treatment.

Here’s what they found. More than half of the patients in group one (nonsurgical care) crossed over and had surgery. Half of the crossovers tried everything including steroid injections but gained no improvement in their symptoms. They were able to delay surgery by several months compared with those who did not have the injections. Patients who had the most severe symptoms and who had jobs with the heaviest type of labor were the most likely to cross over.

Cost of conservative care varied depending on who was paying for it. Costs were the highest for Workers’ Compensation patients and lowest for Medicare patients. Remember, these figures aren’t based on what was charged for services. These dollars paid reflect what the various organizations would pay for the services (i.e., reimbursement).

As might be expected, the patients who started in group one and crossed over to group two had the highest costs. Patients who had conservative care with successful results usually had only mild symptoms of carpal tunnel syndrome. Their average costs were the lowest ($2,000 as opposed to $8,500 for surgery). It should be noted that all the patients in group one who did not cross over had continued symptoms that improved with conservative care, but did not go away completely.

The authors also took a look at the results of other cost-studies and found that there are different results depending on how the studies are done. For example, some studies included direct and indirect costs. Things like lost productivity, disability payments, and time and cost driving to and from treatments were factored in. Then there’s the difference in costs from one region to another and one surgeon to another. Clearly, the payment structure (Medicare vs. Workers’ Compensation vs. private insurance) makes a difference.

The authors conclude that patients with electrodiagnostically identified carpal tunnel syndrome are best served by having surgery as their first treatment approach. Those who do not want surgery may opt for conservative care but the results may be less than satisfactory and the costs will be higher if they end up having surgery in the end.

Imagine this patient scenario: a 50-year-old woman had surgery for carpal tunnel syndrome (CTS) but didn’t get better. She now goes to a different surgeon for help. What should the surgeon do? Is another surgery needed? This is a report of a case just like this at the Mayo Clinic in Rochester, Minnesota. Knowing that this happens from time to time, and there have been no studies to guide surgeons, Dr. Peter Amadio wrote up the case. He presented the various factors to consider and his final decision about the best way to treat this particular patient for other surgeons to consider when faced with similar situations.

Carpal tunnel syndrome is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist. This is a medical condition known as nerve entrapment or compressive neuropathy. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of CTS.

The patient in question had symptoms very typical of CTS. There was numbness in the thumb, index finger, and middle finger. The symptoms came on with activities like holding a book or driving the car. They were especially bothersome at night, waking her up and keeping her awake. Over time, the symptoms got worse and worse until she finally had surgery to release the retinaculum. The transverse carpal ligament (also known as the flexor retinaculum) is a strong band of connective tissue normally present across the palmar side of the wrist. Cutting through the retinaculum takes pressure off the nerve underneath it. This procedure is called nerve decompression.

At first, there was improvement in her symptoms after surgery. But it didn’t last and six months later, she went to the Mayo Clinic for help. The surgeon evaluated her and then asked himself several questions. First, did she really have carpal tunnel syndrome or was something else going on? Second, if the diagnosis was correct, why wasn’t the surgery successful? When considering this second question, there are several possibilities to consider.

Even though her first surgery was performed as an open procedure with a half inch long incision, it’s possible the retinaculum was not cut completely through. This is referred to as an incomplete release. It’s also possible that scar tissue called fibrosis formed around the nerve as a result of the tissues being disrupted by the surgery. New symptoms or symptoms that are worse after surgery might suggest a third potential source of symptoms: injury to the nerve as a result of surgery.

One place to look for some answers is with the results of electrodiagnostic tests done before surgery. These tests show how well the nerve is firing and give an indication of how much the nerve’s function has been affected by the compressive forces on the nerve. Repeating the tests after surgery and getting a before and after picture of nerve function can help diagnose intraoperative nerve injuries. But, in this case, the woman did not have any preoperative electrodiagnostic tests performed, so there was no way to make this comparison.

Another way to look at this case is to review the timing of the recurrent symptoms. She reported some relief after the first surgery, but it wasn’t 100%. Her same symptoms came and went, and then got worse. That type of clinical picture suggests to the surgeon that the symptoms are more likely persistent rather than recurrent. In other words, the problem wasn’t fully corrected with the surgery and the symptoms present were still from the original carpal tunnel syndrome.

There’s really no way to know if fibrosis is an issue without opening up the wrist and taking a second look inside. If a second release is done, the surgeon can confirm or rule out scar tissue as a potential cause at that time. It’s also possible to check to see if the nerve was indeed injured and treat that problem as well when the revision operation is performed.

There is one more thing surgeons must take into consideration in cases like this. And that’s the mental health status of the patient. Patients who are not happy with the results of their first CTS surgery are often those who have another diagnosis: mood disorders. Depression is the most common mood disorder and seems to be linked with a lack of improvement or even increased symptoms after surgery for CTS. If depression is present, a second surgery may not be in the patient’s best interests.

So, what happened with this patient? Well, Dr. Amadio went ahead and ordered electrodiagnostic tests. Even though there was no before test to compare with this new after test, he could tell by the results that nerve function was not affected. Combining the results of the patient interview (history) with current signs and symptoms, a simple repeated nerve decompressive procedure was advised. The surgeon approaches such a procedure knowing that careful observation of the structures during the operation would also guide further treatment (e.g., if there was a nerve injury or further need to protect the exposed nerve).

This case from the Mayo Clinic points out the need to define once and for all what to do in cases where carpal tunnel syndrome is not helped by surgical release. Since it doesn’t happen very often (less than five per cent of all cases), large studies to help figure out what treatment works best have not been possible. Surgeons are forced to rely on case studies like this one with expert opinion to guide them when making the treatment decision(s) on a case-by-case basis.