News Category: Hand

You’ve probably heard of carpal tunnel syndrome (CTS) — hand and wrist pain with numbness and tingling of the thumb, index, and middle finger. Pressure on the median nerve in the wrist can produce these symptoms. But have you ever heard of a technique called cupping to treat it?

Cupping is a healing method used in folk medicine in countries such as China, India, Arabia, Central Europe, and parts of Africa. Glasses applied to the skin create suction of the underlying skin and soft tissue. The stimulation helps improve circulation to the area.

The technique can be done dry or wet. Dry cupping is just as described here. Wet cupping adds an additional step of making tiny cuts in the skin that bleed. When the cups are partially filled with blood, they are removed (usually after five to 10 minutes).

In this study from Germany, patients with neurologically tested and confirmed cases of carpal tunnel syndrome were treated with wet cupping or the application of a heating pad (local heat). A heating pad was used as the control treatment since this is a commonly used tool in Germany for chronic musculoskeletal pain.

The area treated with both modalities was the skin over the trapezius muscle. That’s the large muscle that looks like a cape or mantle across the top of the shoulders and down the upper-to-middle back. The effectiveness of treatment was measured in a couple different ways.

First, patients in both groups rated the severity of their pain and other symptoms on a scale called the Visual Analog Scale. The patient draws a vertical line along a horizontal line 100-millimeters long (about four inches) to indicate the intensity of pain (numbness, tingling). The left end of the line is no pain. The far right end of the line is the most severe pain.

Then they completed two well-known surveys (DASH, SF-36) to assess general health (mental and physical), function, and quality of life. They also kept a daily diary for seven days to record the effects of their treatment. Any adverse events were written down along with any amount of pain medication used.

Analysis of the results showed that cupping therapy was more helpful than local heat. Symptoms were immediately improved — even neck pain, which most of the patients complained of in addition to symptoms of carpal tunnel syndrome. Function, ability to complete daily activities, and quality of life all improved significantly more with cupping than with local heat. There were no negative effects of either treatment reported by anyone.

The authors comment that new treatments are needed for carpal tunnel syndrome. The condition is very common and the treatments used to date have not been proven effective. Although cupping is an uncommon method, it may prove to be worth investigating further based on the results of this first study.

Of course the question comes up: how does cupping work? We are just going off of some theories so far — the actual physiologic mechanism remains unknown. The first theory is called the double-crush hypothesis.

The idea behind this theory is that carpal tunnel syndrome occurs when there has been nerve injury (irritation, compression) in the neck. Carpal tunnel symptoms are then the result of damage to flow of messages along the entire length of the nerve. The cupping applies vacuum pressure to the soft tissues and stimulates blood and lymph flow to the area. This, in turn, improves overall nerve function, even at the median nerve further down the arm.

A second theory is that wet cupping applies a noxious stimulus or counterirritation. The nervous system stops paying attention to the chronic pain of carpal tunnel syndrome and switches instead to this new, local source of nerve signals. The result is to override the chronic nerve pain long enough to turn it off permanently.

And finally, it has been suggested that cupping works simply because the person received some form of treatment and expected it to work. That’s called the placebo effect. There is a certain amount of placebo effect with any treatment.

Why some placebos are more powerful than others remains another unknown factor. In this study, the local application of heat was already viewed favorably by the control group — they frequently used heat for pain relief themselves. This suggests that the positive results of cupping was more than just placebo. Otherwise, the local heat group would have likely had just as good of results.

There’s plenty of room for further scientific research in this area. This study only performed the wet cupping technique one time and measured results over a seven-day time period. Long-term results remain to be investigated.

Comparing the results to local heat application as the control group isn’t the same as comparing it to a group of patients with carpal tunnel syndrome who received no treatment (or even some other modality). Future studies can take those factors into consideration and continue exploring this technique as a potentially safe and effective method of treating carpal tunnel syndrome.

Specialists such as hand surgeons and hand therapists treating hand disorders will be interested in the results of this study. Researchers from the Netherlands took the time to review studies published and listed in PubMed (search engine for the U.S. government’s record of publications in the National Library of Medicine). They confined themselves to four specific hand disorders: 1) trigger finger, 2) Raynaud’s phenomenon, 3) Dupuytren’s disease, and 4) De Quervain’s disease.

Taking the time to review the evidence collected so far on the treatment of these conditions is an important activity. How else will the worker bees in the trenches know what is working and what’s not for patients with these problems? Having each clinician involved in the treatment of these hand disorders search PubMed for studies, analyze those studies, and come up with a summary of the evidence supporting or refuting treatment techniques just isn’t going to happen. Everyone is too busy treating the patients!

But this kind of information is very useful and important. In any review of the literature like this one, the authors must come up with words that help them search for articles on the topic of interest. In this case, it was fairly easy to choose the names of the four conditions as the primary search words.

Once the articles of interest are found, it’s necessary to examine them closely to decide whether or not the study has merit. Is the design of each study and are the methods used of high enough quality to count on the results as reliable and true evidence to support that particular methodology? The authors of this review include a list of the six categories of questions they considered when looking at each study.

They limited their search to randomized controlled trials (RCTs). Patients in such studies are assigned to a group without knowing which group they are in. A double blind RCT means the clinicians treating the patients don’t know who the real patients are and who is getting the placebo treatment versus the real treatment.

For each of the six categories, they came up with a list of questions to help assess the quality of each study. For example, they asked if the patient, clinician, and person who assessed the results were truly blinded to the treatment? They looked to see if patients in the groups being compared to one another were similar before treatment began. How was the data handled for patients who dropped out of the study? Every possible source of bias was examined carefully.

In the end, what they found was that the number of published RCTs for any of these hand conditions was very low — usually only one or two for each one. That’s not enough to argue that one treatment was clearly better than another. At best they could say that a lack of evidence points to the need for more RCTs for these four hand disorders. The authors reminded us that a lack of evidence is NOT the same as evidence that the treatment doesn’t work or should/should not be used.

The four hand conditions included in this study form a distinct group of musculoskeletal complaints of the arm, neck, or shoulder, also known as (CANS). There are all kinds of treatments out there for CANS. Physical therapy, pharmacotherapy (prescription drugs), steroid injections, and surgery top the list. But the question must be asked: which one (or combination of treatment) works best for each of the four common conditions.

If physical therapy is successful, why is it? Is there a particular modality or two approaches used together that help? There’s a wide range of tools available from ultrasound and laser therapy to joint manipulation, soft tissue mobilization, and exercise. Here’s what they found so far. Let’s take the conditions one at a time.

Trigger finger (or trigger thumb) causes swelling and painful movement when straightening out the affected finger. The sheath or lining around the tendon is involved. The name trigger finger refers to the fact that when the finger unlocks, it pops back suddenly, as if releasing a trigger on a gun.

More than one finger may be affected at a time, though it usually affects the thumb, middle, or ring finger. The triggering is usually worse in the morning, or while gripping an object. Steroid injections might be useful in the treatment of this condition, but there was only one (very small) study that compared steroid injections with a placebo injection, so more study is needed in this area.

Raynaud’s phenomenon (RP) is a change in color (white, blue, red) of the fingers and/or toes often accompanied by pain. The cause is a spasm of the blood vessels triggered by emotional stress or extremes in temperature (hot or cold). Scientists have investigated the use of medications such as calcium channel blockers (to lower the blood pressure by keeping the blood vessels open), special thermoflow gloves to keep the hands warm in the cold, acupuncture, and low-level laser therapy.

Evidence was strongest in favor of the calcium channel blockers with laser therapy coming in second. For behavioral therapy with biofeedback (for temperature control) and the use of supplements like Ginkgo Biloba, there was limited evidence to support their effectiveness with Raynaud’s.

Dupuytren disease describes a condition with one or more fingers (usually the ring and little fingers) stuck in a flexed position. It is named after a surgeon (Dr. Dupuytren) who described an operation to correct the problem back in the 1800s. There were only four randomized controlled trials centered on treatment of this condition. Those all had to do with surgery, type of incision made, and postoperative procedures to control swelling. There was no evidence that any one particular approach worked best or had the most positive effects.

De Quervain’s disease is an inflammation or a tendinosis of the sheath or tunnel that surrounds two tendons that control movement of the thumb. It was also named after a physician, a Swiss surgeon Fritz de Quervain who first wrote about it in the late 1800s.

Studies of cortisone injections (with or without antiinflammatory drugs) and splinting did not show either one to be effective in treating the symptoms of this condition. Wearing a splint reduced pain for some patients but it didn’t last. As soon as the splints were removed and the thumb moved, the pain came right back. Injections seem to help, as two-thirds of the group was better three weeks later. But that was the same result as in the placebo group.

All of these studies had different periods of treatment and follow-up, but most were of short duration. That doesn’t answer the question of whether or not any of these modalities has long-lasting effects. That’s important from a cost-effective point-of-view.

There are always questions raised about pursuing treatment that isn’t going to make a long-term difference. If there is a benefit, is it reducing the frequency (how often it happens), the severity or intensity of symptoms, or duration (how long the symptoms last)?

Research on any given problem takes time and thought. There are many variables and factors to consider in conducting high-quality research looking for evidence to support specific treatment approaches. The authors of this review point out the obvious: there is a big need for some decent research in the area of effective treatment for painful conditions of the hand.

No matter how you slice it, hand injuries from electric saws are expensive and devastating. Table saws, electric band saws, and hand-held electric saws are involved in thousands of hand injuries every year. People of all ages from young to old are affected.

In this study from the Mayo Clinic, the cost of these injuries is calculated in terms of dollars and cents. Lost wages, physician charges, emergency room treatments, rehab, and hospitalization costs are some of the major costs incurred.

The study was done by reviewing the records of 134 patients who came to the Mayo Clinic, a regional medcial center in Rochester, Minnesota. Data was collected on type of patients treated (age, gender, occupation, educational level) as well as on the type of injury (number of fingers involved, type of treatment, complications). Chain saw accidents and injuries from hand-powered saws were not included.

Time lost from work and the economic value of that factor was calculated as well. The authors used the mean income from Minnesota to make calculations for their patients. But they also used some additional figures to calculate the nationwide cost of electric saw hand injuries.

They further divided the patients into three groups based on the severity of the injury and analyzed the data from that perspective. The three groups were 1) minor lacerations without damage to nerves, blood vessels or tendons; 2) finger amputation (at least one) but without repair of the blood vessels or tendons); and 3) patients who could have the finger reattached or who needed microsurgery to repair tiny blood vessels, nerves, or tendons.

Most people in group one who were employed were off work for an average of three weeks. Lost wages were around $2,700. Medical costs were an additional $2,900. These numbers all increased for the second group with a 60-day time span before being able to return-to-work and triple the lost wages. Medical costs were six times higher than for the first group.

The third group experienced a delay in return-to-work of 125 days (four months). Lost wages were around $14,000 with average medical costs just above the $40,000 mark. When added all together for the three groups, the total economic costs of electric saw hand injuries was slightly more than four million dollars.

The Consumer Product Safety Commission publishes a Hazard Screening Report from time to time. The most recent report was put out in 2003. Even at that time, the number of injuries from saws was increasing as more people use power tools in their at-home workshops. And with more and more high-powered technology, the injuries have gotten more severe. Most required the skills of a hand surgeon. Many of the more challenging injuries of the soft tissues with reimplantation or revascularization required the services of a microvascular hand surgeon.

The financial cost is just one aspect of electric saw hand injuries. Some of these patients were under the age of 18, which could mean limiting career or occupational choices. Self-employed skilled laborers unable to be as productive as before their injuries experienced long-term economic hardship. Others required vocational retraining or were disabled.

What can be done to prevent these kinds of injuries? The authors made several suggestions such as federal mandates requiring improvements in power tool technology. Perhaps some type of protective mechanism could be devised as part of the tool to make them more safe. In the meantime, education is imperative for employers, schools, and any individuals where spinning saw blades are in use. Training and supervision is advised for students, inexperienced users, and at-risk users.

A common problem affecting the wrist called de Quervain’s tenosynovitis causes pain on the inside of the wrist and forearm just above the thumb. Dr. A.M. Ilyas from the Temple Hand Center in Philadelphia uses this case report to bring us up-to-date on the evidence on how to treat this problem.

The patient in question was a 33-year-old woman with functional left wrist pain. Functional means it hurt whenever she tried to use the hand and wrist to accomplish daily tasks. She couldn’t lift her children, open jars, turn doorknobs, or twist off bottle tops. The first step in treating this problem is always conservative (nonoperative) care. But which to choose: steroid injection, splinting, or antiinflammatory drugs?

De Quervain’s tenosynovitis affects two thumb tendons. These tendons are called the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). On their way to the thumb, the APL and EPB tendons travel side by side along the inside edge of the wrist. They pass through a tunnel near the end of the radius bone of the forearm. The tunnel helps hold the tendons in place, like the guide on a fishing pole.

This tunnel is lined with tenosynovium. The tenosynovium is a slippery covering that allows the two tendons to glide easily back and forth as they move the thumb. Inflammation of the tenosynovium and tendon is called tenosynovitis.

In de Quervain’s tenosynovitis, the inflammation constricts the movement of the tendons within the tunnel. But more recent data shows that in some cases, there isn’t any active inflammation. This is considered a tendinosis, not a tendinitis.

Instead of finding cells that show an inflammatory process, scientists have discovered that the collagen fibers making up the tendons and tenosynovium are laid down in a haphazard fashion (every which way). Changes in the mucous cause these normally slippery structures to dry out. The tendons can no longer slide and glide smoothly. The dryness causes a painful catching of the tendon over the bone.

If there’s no inflammation, then should we be using antiinflammatory drugs to treat this problem? Maybe not but we need some research into this question to know for sure. Studies already done using nonsteroidal antiinflammatory drugs (NSAIDs) haven’t compared the use of NSAIDs with a placebo (pretend) drug. And more often than not, when NSAIDs are used, they are combined with some other treatment, so we don’t know if the results are based on the effects of the NSAIDs or both treatments given together.

What about a steroid injection? Will that help? The results of several studies suggest that with careful application, steroid injection can be very helpful. But the surgeon must advance the needle administering the drug through the soft tissues into the first dorsal compartment. The medication must be delivered inside the tendon sheath to be effective. The steroid drug must reach inside the sheath of both the abductor pollicis longus and the extensor pollicis brevis tendons.

In the case of the patient treated in this study, her primary care physician put her on antiinflammatory drugs and gave her a wrist splint. When the symptoms did not go away, she was referred to the Temple Hand Center where Dr. A. M. Ilyas evaluated her.

A review of the literature showed that use of a splint alone can be helpful. More patients get pain relief when splinting is combined with NSAIDs. But these folks have minimal pain. Anyone with more moderate or severe symptoms will only have a one in three chance of getting relief with splinting and NSAIDs. Still, it may be worth it to prescribe a trial of this type before considering a steroid injection.

Dr. Ilyas prefers to start with a steroid injection. Anyone with moderate-to-severe pain may want to use a splint for a few weeks until the pain settles down. Splinting and NSAID-use appears to give comfort and improve the patient’s quality of life. If it helps them get through the initial phase of de Quervain’s then it has some limited value.

There’s no evidence that it is the splinting and drug-use that’s really making a difference in the disease process. Most people with de Quervain’s just get better on their own over time. Surgery may be recommended if symptoms remain extremely painful even after six months of conservative care.

In this article, hand surgeons from the Philadelphia Hand Center at Jefferson University (Philadelphia, Pennsylvania) review injuries that cause forearm instability. They present normal anatomy and biomechanics of the forearm affected by these injuries and discuss treatment for forearm instability.

What is forearm instability? Forearm instability is the disruption of the joints of the two forearm bones where they join at the top (elbow) or bottom (wrist). Traumatic events strong enough to send a compression force through the forearm can result in bone fractures and tears of the soft tissues of the forearm. The specific areas of damage that cause a disruption of forearm stability affect the radial head, the triangular fibrocartilage complex (TFCC), and the interosseous membrane.

A quick look at normal forearm anatomy will help understand this injury. First, the forearm is made up of two major bones: the radius and the ulna. They are held together by joints at either end and ligaments and cartilage from one end to the other. The interosseous membrane connects the two bones together from top to bottom.

The triangular fibrocartilage complex (TFCC) is an articular disc where the radius and ulna meet at the wrist. This triangle-shaped structure binds the radius and ulna firmly together and prevents dislocation while still allowing free motion. The outside margins of the complex are attached to the ligaments of the wrist joint.

There are varying degrees of injury and disruption of forearm stability. Injuries range from fracture of the radial head without tearing of the supportive soft tissues to fracture plus complete rupture of the TFCC and interosseous membrane. Immediate surgical repair is needed for this type of injury. But the problem is, the extent of the injury might not be recognized and treatment is delayed. The longer the delay, the worse the final outcome.

Working together, these three anatomical structures make it possible for the forearm to remain stable while under various types of load from the wrist and hand up to the elbow. The interosseous membrane is especially good at transferring loads between the two bones of the forearm. That helps take some of the stress off the elbow.

What kind of trauma is powerful enough to disrupt these anatomical structures? Well, a fall from a height onto an outstretched hand with the elbow extended will do it. And if it’s so traumatic, why doesn’t it get properly diagnosed? The fracture is easy enough to see on X-ray.

Usually the head of the radius is either removed or replaced. Removal without replacement results in migration (movement) of the radius up slightly (toward the shoulder). Tears of the interosseous membrane have the same effect. Without the membrane holding the two bones together and without the head of the radius butting up against the epicondyle, the bone starts migrating. So it’s easy to think the changes occurred because of the radial migration without realizing there’s a problem with the interosseous membrane. And swelling in the forearm often limits motion as well, further confusing the picture.

It isn’t until the patient experiences continued pain at the elbow and wrist that the full extent of the injury is recognized. The interosseous membrane accounts for the majority of forearm stiffness. Without this important protective feature, the forearm can’t resist force from the wrist to the elbow. And for every one millimeter of radial migration that occurs, the load at the wrist increases by 10 per cent. You can see why wrist pain is the result.

What can be done? The patient must be re-evaluated. A more comprehensive diagnosis is determined. Additional X-rays, ultrasound studies, and MRIs will help pinpoint the area of damage and degree of soft tissue disruption. Once the injuries are fully identified, then a treatment plan can be determined.

Treatment options are broken down into two groups based on how much time has gone by since the injury occurred. Immediate recognition of the problem and treatment right away describes the acute phase of injury. As already mentioned, the fractured radial head is attended to first.

Sometimes the fractured pieces of bone can be wired back together. If the interosseous membrane and triangular fibrocartilage complex (TFCC) are okay, it’s best to try and save the radial head. If repair isn’t possible, then replacement is considered. A metal implant is used. For a while silicone radial head implants were tried, but they didn’t hold up under the load and force that is put through the wrist, forearm, elbow unit.

If the interosseous membrane and/or the TFCC can be repaired, there’s a better chance of maintaining forearm stability. The goal is to restore as normal of anatomy and biomechanical function as possible in order to prevent forearm instability. But these ideas for treatment come mostly from cadaver studies. Long-term results in live patients are fairly limited at this time.

What about treatment for chronic injuries? Results are slowly improving as our understanding of the way the forearm unit is put together and works increases. Surgeons are finding better ways to reconstruct the soft tissues. The interosseous membrane is a unique band of tissue. It’s natural construction as at an angle, not just straight across between the two bones. Tendon grafts from half a dozen different tendons have been tried with various results. Getting the right angle and tension to allow for normal loading patterns hasn’t been 100 per cent successful.

Another big challenge is to keep the radius and the ulna level with each other and prevent radial migration. Sometimes the surgeon has to cut out a piece of the longer (ulna) bone to match it up to the shorter (radius) bone. This procedure is called an ulnar-shortening osteotomy.

All of these surgical options have potential complications that make the procedures less than ideal. Patients can end up with a stable but painful wrist, forearm, and/or elbow. Loss of motion in any of these three areas can affect function. Sometimes there are issues with cosmesis (how the forearm looks) because of deformities caused by surgery.

Some surgeons are experimenting with a one-arm forearm. By removing one of the bones altogether, it’s possible to avoid some of the problems with migration, impaction, impingement, and instability. Despite the variable patient responses to surgery, there is general agreement among surgeons that the earlier the surgery is done, the better the results.

The authors conclude that we have a long way to go in the treatment of forearm stability at any phase (acute or chronic). Long-term studies are needed to document what happens with each of the more common treatment procedures. We are still far away from finding the best way to restore forearm stability after severe destabilizing injuries of this type.

As a patient with symptoms of hand and arm pain, numbness and tingling, and muscle weakness, you should expect to get the same exam and diagnosis no matter what physician examines you. That’s the reason the American Academy of Orthopaedic Surgeons (AAOS) published these guidelines for the diagnosis of carpal tunnel syndrome (CTS).

Carpal tunnel syndrome (CTS) 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.

It’s easy for anyone to develop their own opinions and biases that might influence outcomes and results in the diagnosis and treatment of CTS. To combat this and to ensure similar results for all patients with carpal tunnel syndrome, groups like the AAOS put together committees of experts to review the current published studies on topics like carpal tunnel syndrome. Then they develop guidelines for all to use. This helps produce an accurate diagnosis early on. An early and accurate diagnosis usually means better results from treatment.

As a result of reviewing 224 full articles (24 of which were chosen as acceptable), five key guidelines have been developed for the diagnosis of carpal tunnel syndrome. Briefly, these are:

The average lifetime cost of carpal tunnel syndrome (CTS) is about $30,000. That’s for an injured worker so it includes medical costs, lost wages for the worker, and the cost of lost productivity for the employer. That explains why effective treatment is important all the way around. Reducing those costs and improving worker health and productivity is a key goal.

Toward that end, the American Academy of Orthopaedic Surgeons has published a Clinical Practice Guideline (CPG) for physicians to use when planning treatment for patients with diagnosed carpal tunnel syndrome. The guideline has nine specific recommendations covering nonsurgical and surgical treatment. Efforts were made to address various topics studied including timing of surgery (early vs. late) and the use of local steroid injections, splinting, or ultrasound treatment.

The experts reviewed current studies published on this condition and tried to guide surgeons as to when surgery should be done and the best postoperative approach for optimal results. The recommendations are only guidelines at the present time because most of the evidence was inconclusive or from poorly designed studies.

The Board of Directors who issued this clinical practice guideline urged that research must continue. Better quality studies are needed. Specific topics for research include risk of carpal tunnel syndrome for specific job categories, best treatment options for patients who want to return to those jobs, and whether or not modifications in the workplace are worth the time and money. In other words, do they help prevent carpal tunnel syndrome?

These guidelines are for a specific subgroup of patients who have reversible carpal tunnel syndrome. They do not apply to patients with diabetes-induced CTS or other microscopic nerve damage from disease rather than compression. Most of the time conservative (nonsurgical) care is recommended first. But there are some patients who will be choose to go right to surgery rather than try the nonsurgical approach.

Quality of life is just as important as any other measure of outcome and should be included in the assessment. To get an idea of before and after treatment results, the authors suggest that physicians, surgeons, and researchers use one of several tools to test patient responses. Besides quality of life, other areas of change caused by the treatment can be function, pain, motion, and strength. The Boston Carpal Tunnel Questionnaire and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire are two good instruments used by many physicians for this purpose.

Now, as to the recommendations actually made by the Academy. Number 1: nonsurgical treatment is tried first. This can include local steroid injections, oral steroids, or physical therapy. The therapist may use ultrasound, splinting, nerve and tendon gliding exercises, and joint mobilization to help take pressure off the nerve. Surgery may be done early when it looks like the nerve is already damaged. The goal is to prevent irreversible nerve damage.

Number 2: If the selected treatment does not reduce or eliminate the symptoms after seven weeks, then another form of conservative (nonoperative) care should be tried. This could be any of the approaches already mentioned but not already tried. There is fair evidence that different patients benefit from a variety of nonsurgical approaches. It may be just a matter or trial and error to find the right mix for each patient.

Number 3: Evidence for the optimal approach in treating CTS caused by other medical conditions such as diabetes, pregnancy, or hypothyroidism is fairly limited. The authors could not give specific guidelines for this area.

Number 4: There is fair evidence that local steroid injection and splinting can help and should be tried before opting for surgery. These measures are more likely to benefit patients with mild to moderate carpal tunnel syndrome. Injections seem to work better than oral steroids (pill form). Severe symptoms or symptoms that have been present for a long time may not respond to this approach and will require more aggressive (surgical) treatment.

Number 5:When surgery is advised, the authors recommend cutting completely through the flexor retinaculum. This band of fascia or connective tissue crosses the wrist on the palm-side of the wrist/hand. Releasing the retinaculum takes pressure off the median nerve immediately. Various methods can be used to accomplish this (open incision, endoscopic approach, minimally invasive). It’s not as clear which surgical technique gives the best results as the fact that whatever way it’s done, the retinaculum release is a huge benefit.

Number 6: Certain procedures are not advised when performing surgery for carpal tunnel release. These include preserving the nerve to the skin and epineurotomy defined as surgical release of the epineurium. The epineurium is the outermost layer of connective tissue surrounding the nerve. It includes the blood vessels supplying the nerve.

Number 7: Surgeons may prescribe antibiotics for their patients before having carpal tunnel surgery. But studies to support or negate this idea have been inconclusive. The rate of infections after surgery may vary depending on the presence of other health problems such as diabetes. Usually studies exclude patients with other health issues. So, comparisons between patients with and without these comorbidities are not available.

Number 8: Immobilizing the wrist after surgery in a cast or splint isn’t necessary. Evidence to support or negate rehab after surgery is missing. No recommendation could be made about postoperative rehab. Immobility can increase stiffness, prevent nerve and tendon gliding, and actually delay return-to-work.

Number 9: As already mentioned, it is important to compare before and after treatment to quantify any changes. That way, researchers can look back and see what treatments worked the best. There are many different questionnaires and patient self-report measures available to accomplish this. Only tests that have proven reliability and validity should be used. This report includes a table of 10 commonly used tools to assess patients and an idea of how reliable and responsive each one is. Tools of this type that are specifically designed and tested for with a problem like carpal tunnel syndrome have the greatest amount of responsiveness.

There are some treatments for which the Academy could not speak for or against. There simply wasn’t enough evidence to make conclusions about activity modifications, acupuncture, cognitive behavioral therapy, cold laser, diuretics (water pills), or stretching exercises. Likewise, no recommendation could be made for or against such things as massage therapy, magnet therapy, nutritional supplements, therapeutic touch, or vitamin B6. Losing weight, quitting smoking, practicing yoga or other types of lifestyle changes have not been adequately studied either.

Despite the many, many studies already done on carpal tunnel syndrome, there is still a need for high-quality evidence-based studies to identify specific treatments (or combinations of treatment modalities) that are effective. The role of work hardening, work simulation, or some other program to prepare patients to return to their work setting has not been studied. This would be another good area to research.

Carpal tunnel syndrome (CTS) is a common problem affecting the thumb, hand, and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist. The result 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. This includes diabetes, kidney failure, rheumatoid arthritis, pregnancy, thyroid disease, and many others.

The main symptoms of carpal tunnel syndrome are wrist and hand pain, finger and hand numbness, tingling, weakness/clumsiness, and nighttime pain. Since the median nerve supplies the thumb, index, middle, and half the ring finger, these are the areas affected most often. Conservative (nonoperative) care can be effective in reducing symptoms and limiting disability. Splints (especially used at night) seem to help. Nerve and tendon gliding exercises can also make a difference.

Some medications are used to reduce inflammation and swelling. Steroid injections given locally into the carpal tunnel have been proven helpful in the short-term, but don’t seem to have much long-term effect. Oral steroids are better than nonsteroidal antiinflammatory drugs, but they have some negative side effects. Since there are some adverse effects from steroids, acupuncture is getting a second look as a possible treatment technique.

In this study, the use of acupuncture for mild-to-moderate carpal tunnel syndrome was compared with oral steroid use. Patients were tested with nerve conduction tests to confirm that they really did have a true nerve entrapment causing their symptoms. They were then placed randomly in one of two treatment groups.

The first group received four weeks of daily steroid treatments. The first two weeks were with 20 mg of prednisolone followed by two more weeks with a reduced dosage (10 mg daily). The steroids were administered orally (pill form), which has been shown to be more effective than local steroid injections or oral nonsteroidal antiinflammatory medications. The second group received acupuncture twice a week for four weeks. Everyone was followed for four weeks after treatment with the intention of seeing what were the short-term effects of these two treatments.

Measures used to compare the results of treatment included before and after (individual) ratings of the five major categories of symptoms. When combined together, these ratings form the global symptom score (GSS). The before and after treatment GSS was also analyzed and compared between the two groups. Nerve conduction tests were repeated at the end of four weeks. These tests show how well the median nerve is firing to send motor messages to the muscles controlled by the median nerve.

The results showed that acupuncture is as effective and safe as oral steroids for short-term relief of mild-to-moderate carpal tunnel syndrome. That’s good news for anyone looking to avoid adverse side effects of either steroids and/or surgery. All ages from 18 to 55 were included without any apparent age-based differences.

There are adverse side effects associated with either type of treatment. Needles used in acupuncture can cause local pain, bleeding, and numbness and leave bruising of the skin. Oral steroids can also cause nausea, epigastric pain (lower chest/upper abdominal area), leg edema (swelling), increased blood sugar, and difficulty regulating blood sugar.

The global symptom score (GSS) improved for all patients in both groups. The biggest difference was in night pain awakening the patient. The acupuncture group had much better improvement in this symptom compared with the steroid group. Motor function seemed to improve faster in the acupuncture group as well.

The authors conclude that acupuncture treatment for confirmed mild-to-moderate carpal tunnel syndrome is safe and effective with few side effects. Compared with oral steroids, acupuncture had slightly better results.

The one major disadvantage of acupuncture is that it is time-consuming. It requires the skill of an experienced acupuncturist spending 30 minutes per session with each patient over a number of weeks. Taking an oral steroid just requires the patient to pop a pill in the mouth every day. However, compared to five per cent of the acupuncture patients who had any side effects of treatment, there was an 18 per cent complication rate for the oral steroid group.

No one is quite sure how or why acupuncture works. Studies show that there are both central (brain) changes and peripheral (nerve) effects of acupuncture that may explain the results. Stimulating acupuncture points may release antiinflammatory agents into the bloodstream. Stimulating one particular point (Neiguan) is known to help with sleep problems. That may be why acupuncture helps reduce night pain. More study is needed to understand how and why acupuncture works for carpal tunnel syndrome.

The next question is whether or not there are significant long-term differences. If the beneficial effects of acupuncture last much longer than oral steroids, then maybe the extra time in treatment is worth it. Patients do describe the acupuncture sessions as pleasant, relaxing, and rewarding.

To you it’s a sprained thumb. To the hand surgeon, it’s an injury of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. In the old days it was called a gamekeeper’s thumb. Today, it’s more likely to be a sports injury, sometimes referred to as skier’s thumb. Jamming the web of the thumb into the ski pole tears the ulnar collateral ligament (UCL). It’s a common problem that orthopedic surgeons and primary care physicians deal with routinely.

This review article will bring us all up-to-date on the anatomy, mechanism of injury, diagnosis, and treatment of this injury. Rupture of the ligament away from the bone usually means the ligament won’t heal without surgery. So a careful examination and accurate diagnosis is important before a plan of care can be established.

The ulnar collateral ligament of the thumb is a strong band of tissue attached to the middle joint of the thumb, the joint next to the web space of the thumb. The joint that is affected is called the metacarpophalangeal joint, or MCP joint.

Any hard force on the thumb that pulls the thumb away from the palm of the hand (called a valgus force) can cause damage to the ulnar collateral ligament. The most common way for this to happen is to fall on your hand with your thumb stretched out. If the force is too strong, the ligaments can tear. They may even tear completely. A complete tear is also called a rupture.

When the collateral ligaments actually tear, the MCP joint becomes very unstable. It is especially unstable when the thumb is bent back. If one of the ligaments pulls away from the bone and folds backwards, it won’t be able to heal in the correct position. When this happens, surgery is needed to fix the ligament.

After taking a patient history, the physician checks the patient’s thumb range-of-motion. This is a telltale sign because too much motion can be an indication of joint instability. But further testing is needed to identify whether the muscles, tendons, ligaments, and/or joint capsule are involved. With a severe enough trauma, the ligament can pull away a small piece of bone with it when it ruptures. Such an injury is called an avulsion fracture.

Any palpable or visible deformities should be noted. X-rays help reveal any fractures. Stress testing is done by placing the thumb in various positions and having the patient try to hold it there while the examiner pushes against the thumb trying to move it. The role of other advanced imaging studies such as MRIs, arthrography, or ultrasound has been debated. These are not always accurate enough to warrant the cost.

Partial tears can be treated nonoperatively with conservative care. Complete ruptures of the ulnar collateral ligament often require surgical repair. The surgery can be done on an outpatient basis under a regional or general anesthesia. The authors provide a step-by-step description of the surgical repair from incision to restoration of the anatomy.

Sometimes the ligament can be repaired by reattaching it to the bone. Small avulsion fractures can also be repaired this way with special sutures used to anchor the bone fragment in place. Any damage to the other soft tissues or joint capsule can be repaired at the same time. If the damage is too great to repair the problem, then a tendon graft may be needed to reconstruct the joint. No matter whether it’s a surgical repair or reconstruction, the goal is to return everything to as normal an anatomical orientation as possible. This will ensure a return of normal joint kinematics (movement).

The patient is put in a cast and immobilized for six weeks after surgery. When the cast is taken off, the pins and wires holding everything together can be removed. A hand therapist helps the patient get started with range-of-motion exercises. The therapist progresses the rehab program through strengthening and return to full activities without restrictions. All of this takes at least three months for a safe and effective result.

Studies show that this approach is quite successful. The earlier the repair is made, the better the results. Returning to activities when the thumb is unstable can cause further damage that could have been avoided with early diagnosis and treatment. Ninety per cent of the time, the results are good-to-excellent with surgical repair.

In a small number of cases problems can occur following surgery such as a nerve palsy affecting motion, joint stiffness, and chronic instability. There is some evidence that these poor results are more likely when treatment was delayed or the diagnosis was missed. Studies to determine the best surgical technique to use for optimal outcomes are underway.

When the surgery is unsuccessful and joint instability persists, it may be necessary to fuse the joint. This procedure is called an arthrodesis. Arthrodesis works well for patients who have developed post-traumatic arthritis. But the hope is to avoid such long-term complications with early and appropriate intervention.

The focus of this study was the treatment of a nonunion (didn’t heal) fracture of the scaphoid bone in the wrist. A loss of blood supply to the area led to a condition called avascular necrosis (AVN). Avascular means without blood and necrosis refers to the death of bone.

After immobilization with a cast did not yield a healed fracture and necrosis was identified, 30 patients with a nonunion scaphoid fracture had surgery. None of the patients had a previous surgery for this problem. This was the first or index procedure. The hand surgeon conducting the study looked back over a period of eight years and reviewed the charts of all his patients who had the same operation for the same problem.

The primary (main) author did all of the operations. The broken bone was put back together and held in place with a screw. This procedure is called internal fixation. In the second part of the surgery, the surgeon performed a vascularized bone-graft. This means the surgeon used a branch of the radial artery as a graft to bring blood to the nonunion site. The surgical technique was fairly simple with a single incision to open the site. The results were impressive.

All but two of the patients returned to work and recreation (including sports). The two who did not heal after the vascularized bone graft were smokers. There is a known link between tobacco use and delayed wound healing or nonunion in bone fractures. A second surgery was done with successful healing after these two patients had quit smoking (confirmed by a urine test before the operation).

The value of this study is in the fact that there were 30 total participants and before and after measures of motion, strength, and function were recorded. Most other studies done in the past have included a handful of patients. Validated measures before and after were not taken for those other studies.

Results of all 30 patients in this study for grip strength, wrist and forearm range-of-motion, and the Disabilities of the Arm, Shoulder, and Hand (DASH) test were compared before and after treatment. Patient satisfaction was also measured.

The surgeon used X-rays, CT scans, and MRIs to measure bone angles, height-to-length ratios, and width of the joint space. The bone angles and height-to-length ratio are ways to measure how much the bone fragments has collapsed on itself or how far apart the pieces of bone have shifted or moved.

Imaging studies were also used to document the presence of avascular necrosis. The authors provide photographs of a few of these images to help show the reader the location of the bone, the nonunion fracture, the necrosis, and the pin holding the bone together.

The data was also analyzed for any differences between patients based on the location of the nonunion fracture. Two-thirds of the patients had nonunions of the waist (middle) of the scaphoid bone. In the other one-third, the proximal pole (upper portion of the bone) was involved.

The results did not show a significant difference before and after surgery in function between patients with nonunions of the waist versus nonunions of the proximal pole. Total wrist range-of-motion did not change. Patients in both groups did have improved grip strength from before surgery. Patients with both kinds of nonunions were very happy with the overall improvement they experienced after surgery and successful healing

The authors support the continued use of the particular surgical technique they used to perform this bone fixation and vascularized graft procedure. They suggest that advising all patients to quit smoking before surgery really made a difference in the results. Only the two nonquitters failed to heal (until after they quit smoking and had a second surgery). Patients can expect a four to five month period of time before complete bone healing occurs.

This study represents the results of long-term outcomes in patients treated for carpal tunnel syndrome with two different surgical approaches. One group had the more traditional open carpal tunnel release. The second group had an endoscopic release, which is an accepted, but not widely used, surgical procedure.

The first study published by this group of researchers involved the same two groups of patients. They reported on the short-term results using symptom severity and function (measured by return to work status) as the main measures of outcome.

The short-term period of time was one year. At that time, they could see that patients in the endoscopic group had less pain after the surgery. But there was no difference in number of days off work or functional status.

Using those same measures, the two groups were followed for another four years (total of a five-year follow-up period). The results after five years are the subject of this second, updated report. And here’s what they found: there was no difference between the two groups using symptom severity, function, and work status as the reference standard.

Symptom severity included how often the pain woke the patient up at night, the presence of numbness or tingling, and the presence of pain in the scar or along the palm. Everyone in both groups got significant relief from the surgery. The majority of patients in both groups reported being very satisfied with the results of their treatment.

Patients in both groups were equally matched by age, preoperative work status (all were employed), symptoms lasting more than three months, and failure to respond to conservative care with wrist splinting. All patients had a positive nerve conduction test showing that the median nerve was sending motor or sensory messages through the carpal tunnel more slowly than normal.

After surgery, both groups were treated the same in terms of a rehab program. They were told to start moving the fingers and using the hand and wrist in anyway that was not painful. A supervised hand therapy program was not part of the rehab or recovery process.

This study is different from other studies done comparing these two surgical techniques. And that’s because it was both a randomized controlled trial (RCT) and a long-term (five years) study. Randomized controlled trials place people in groups based on a computer generated list. That helps remove bias from the study and makes the results more reliable and valid.

The authors looked at a couple of other results in the long-term study that weren’t available in the short-term. Symptom recurrence and need for a second surgery were two of those additional factors. Here again, the results were the same in the two groups. A small number of patients in both groups had to have a second (repeat) surgery because of persistent symptoms or symptoms that came back after surgery.

They found that patients who still had moderate to severe pain a year after the initial carpal tunnel release (no matter how it was done) did not get better. The reasons for the continued pain vary from patient to patient and aren’t always clear.

Sometimes incomplete release of the transverse carpal tunnel ligament is the problem. In other cases, it may be injury to small sensory nerves to the skin. Scar tissue around the median nerve can tether (hold) it down and keep it from sliding and gliding as it should through the carpal tunnel.

The authors conclude that endoscopic carpal tunnel release is less invasive and thus has a small benefit when it comes to postoperative pain. But in regards to complication rate, return-to-work status, or function, the endoscopic approach was not superior to the open technique.

Community-acquired methicillin-resistant staphylococcus aureus (MRSA) is becoming more common in among the general population, not just those who are ill. While most healthy people aren’t affected by MRSA, the high rate of community-acquired MRSA can be dangerous to those who are weaker and those with chronic illnesses, like diabetes. Sixty percent of people with diabetes develop complications from MRSA compared with only 11 percent of people who don’t have diabetes.

Risk factors for developing community-acquired MRSA include living in crowded quarters, taking antibiotics within the previous year, having broken skin (cuts, lesions, scrapes, etc), and sharing equipment like sports equipment or showers. If you develop MRSA infection in the hospital or clinic setting, this is called nosocomial MRSA. Patients who have this type of MRSA infection have been found to have higher rates of death (up to three times higher) if there is a delay in giving antibiotics.

Because of the increased costs due to community-acquired MRSA and the health risks, the authors of this article wanted to see if they could determine a set of steps or rules (an algorithm) that would help doctors know when to start antibiotic therapy and for how long to give it.

Researchers reviewed the cases of people who were seen in a local emergency room for hand infections over the course of a year. The patients had to be between 18 and 89 years old, have tests to confirm the infection, couldn’t have a history of MRSA infection, were admitted for treatment, and were not exposed to nosocomial MRSA.

The researchers then examined the types of infections the patients had, which antibiotics were used, if they worker or had to be changed, how long the antibiotics were given for, and how long the patients were kept in the hospital, among other pieces of data. In gathering the data, the researchers found that 85 patients were eligible for the study. Forty seven patients had community-acquired MRSA and 38 had infections caused by other bacteria.

The most common injuries had been caused by cuts (16 patients), puncture wounds (12 patients), and human bite (9 patients). On average, the patients were in the hospital for four days if they had community-acquired MRSA and 3.5 days if they had an infection from a different bacteria. Those patients with the MRSA infection were usually treated within 12 hours of coming to the emergency, while those with other types of infection were treated within 2.64 hours. The delay was due to the culture, testing, process where it is determined which antibiotics would be most likely to treat the infection.

An interesting finding from this study showed that intravenous drug abuse significantly raised the risk of developing community-acquired MRSA infection – by almost 15 times.

In conclusion, the authors say that hand infections “must be treated aggressively” with antibiotics and, if needed, draining of the wound. But, having a set step-by-step guideline doesn’t seem to affect how long it takes for community-acquired MRSA infections to heal over other types of infections of the hand.

Ganglion cysts, swellings at the top of a joint or on a tendon, can cause pain and affect your movement. For example, if one is on the joint at the base of your finger, you may have trouble moving that finger. The cyst may feel firm or spongy when you touch it. Generally, these cysts are removed arthroscopically, a surgery technique in which the surgeon makes tiny incisions and uses long, narrow instruments to reach inside.

Arthroscopic surgery has been a boon for many types of surgeries because the smaller incisions and minimal invasiveness usually mean fast recovery and fewer complications than traditional surgeries. In arthroscopic ganglion cyst surgery, surgeons have also noticed that the cysts have a lower chance of coming back as well. That being said, there are no studies to back this up. The authors of this study wanted to evaluate the outcomes and identify certain characteristics of the cysts through arthroscopic surgery.

Researchers found 55 patients who had ganglion cysts on the back of their hand (the dorsal part) and they had all tried nonsurgical methods to remove them. The average age of the patients was 42 years. Some of the patients had had trauma to the wrist, but many didn’t. Ten of the patients had had open surgeries before, but the cysts recurred, came back. Twelve of the patients were treated by having the fluid removed from the cyst with a needle and syringe (aspirated). Among the patients who had never tried surgery, 34 had tried medications, splinting, aspiration or steroid injections, while the others didn’t try any other treatment and opted to go straight to surgery.

The researchers evaluated the patients by measuring their grip strength, pinch strength, and wrist motion. The patients were asked to complete two questionnaires: the preoperative visual analog pain scale, which gave the researchers an idea of how much pain the patients were feeling, on a scale of one to 10, and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH). Because 10 patients had had surgery before, the patients were divided into two groups: those who had had surgery (10) and those who hadn’t (45). The tests and questionnaires were repeated six weeks, six months, and two years after surgery. The patients were also asked about any problems such as infection, pain, scarring and other issues that may have come up.

During the surgery, the surgeons looked to see if they could identify the properties of the ganglion cysts. Using the camera inserted through the small incisions, the surgeons examined the cyst’s tissue (thicker than the tissue around it) and in 11 of the cases where the surgery was the first one, the cyst came off the radiocarpal joint, the section of the wrist where several small carpal bones line up in two short rows. In 29 cases, the cyst extended from the midcarpal joint, between two of the rows of carpal bones. For 29 patients, the cyst went from the radiocarpal joint to the midcarpal joint, other joints were involved in the rest of the cases.

The results of the study showed that at six weeks, the patients had an average improvement of by 5.9 kilograms in grip strength and 2.3 kilograms in pinch strength. Their wrist movement improved and their pain decreased. In fact, after reporting an average of 4 on the pain scale before surgery, all patients reported 0 at six weeks after surgery. The DASH scores improved significantly as well.

At six months after surgery, strength continued to improve and this continued up to two years. The researchers didn’t find any noticeable differences between the two groups. Complications were painless tenosynovitis, inflammation of the sheath that covers the tendon and this only affected three patients. Two of the patients had surgery to improve how it looked.

It appears that this type of surgery is successful for many patients with ganglion cysts, and examination of the cysts didn’t find a connection between findings and outcome. However, being able to see and assess the midcarpal joint is important in order to be able to remove the entire cyst.

Surgery for the repetitive stress injury, carpal tunnel syndrome, isn’t always the best approach. Some patients, for a variety of reasons, either shouldn’t have, don’t yet need, or can’t have surgery. For this reason, it’s important to look for alternative, nonsurgical approaches to treatment. The author of this article asks the question, “What is the best nonsurgical treatment for carpal tunnel syndrome?”

Treating carpal tunnel syndrome starts with looking at the goal. What is the outcome the doctor and patient expect from the treatment plan? While it may seem that the goal is the same for everyone, this isn’t always so. For example, if your priority is to return to your previous activities without any symptoms as soon as possible, surgery may be the answer. But if you have the time to work on your treatment, your doctor may want to try the other options. These include medications, either injected directly into the area (such as steroids) or oral medications to help relieve pain and inflammation, to lifestyle changes and splinting.

Splinting your wrist makes it so you can’t move your hand in the motion that irritates the nerve that is running through the carpal tunnel. This allows the inflammation to go down and relieve pain and symptoms. Several studies have been done to see how effective splinting is in treating carpal tunnel syndrome and the results aren’t clear. The studies were too small or didn’t have enough evidence to come to a strong conclusion.

Some doctors have used ultrasound to treat carpal tunnel syndrome and at least two studies have found that, compared with fake ultrasound (placebo), the ultrasound helped the patients. Another study compared ultrasound to laser and the ultrasound came out ahead. Other treatments didn’t show any impressive results or hadn’t been studied enough to provide good results. These include treatments such as heat therapy, therapeutic touch, chiropractics, and iontophoresis (electrical currents).

Medications such as steroids can be given either by mouth or injection directly to the problem area. Both aim to reduce inflammation. Oral steroids compared against placebos did show good effect at reducing symptoms, but the long-term effects weren’t there. Plus, doctors have to be wary of providing steroids for long periods because of the effects steroids can have on the rest of the body. The injectable type of steroids has been looked at in several studies. There have been good effects in the short-term (two to four weeks) and have been found better at three months than oral steroids. One study found that combining steroid injections with splinting provided good responses as far as six months down the road, when compared to just splinting alone. There is debate as to whether injecting steroids is worth it because the long-term effects aren’t well known.

Diuretics (so-called water pills) may be tried, along with nonsteroidal anti-inflammatory drugs (NSAIDs). The studies for this treatment have been too short or too small to draw any conclusions.

The author writes that there is precious little in the way of consisted research into the treatment of carpal tunnel syndrome. He cites a case that he uses and example, of a 45-year-old patient who sought help because she had intermittent pain and numbness in her right hand, bothering her more at night than during the day. Although her family doctor had tested her and found that there was a problem with the nerve that passes through the carpal tunnel, her doctor hadn’t yet suggested any treatments.

By not having adequate studies and not being able to measure outcomes, doctors are at a disadvantage. They can’t learn what has worked for others and different approaches that may fit their particular patient. Another area lacking in research is the history of the disorder. While some people are at higher risk of developing a repetitive stress disorder, some people are more at risk than others. Why is that? Studies on this would provide valuable information to both treating doctors and other researchers.

In conclusion, using the knowledge that is provided by the studies, the author explains that to treat the patient in the case study, he would choose night-time splinting for six weeks. If this splinting was successful in relieving symptoms, the splint would be gradually removed over time until it wasn’t needed any more. The splint could be reused over the next six to 12 weeks if needed. If, however, the splinting didn’t work, then he would likely recommend surgery or, although he’s not in favor of it himself, steroid injection in addition to splinting, for a longer period.

Carpal tunnel syndrome is becoming increasingly common among people in the western world. It’s caused by an irritation of the nerve, the median nerve, that runs from your forearm into the hand. It’s most often a repetitive stress injury, an overuse injury of the hand, although it may have other causes. Once it’s been diagnosed, treatment can consist of splinting, pain medications, injections of steroids, or even surgery.

The authors of this article investigated how effective steroid injections were for the treatment of carpal tunnel syndrome. To do this, researchers studied 32 patients who, between them all, had 48 hands with carpal tunnel syndrome. The researchers assessed the patients’ pain using the visual analog scale (zero to 10 rating, zero being no pain and 10 the worst pain ever), and the Korean version of the Boston Carpal Tunnel Syndrome Questionnaire (one to five rating, one is mildest function disruption and five is worst).

The researchers also evaluated the hands using electrodiagnostics, recording the electrical activity and electromyography (EMG), which measures how the electrical impulses are transmitted.

When the patients received the steroid injections, they all received it with the same technique and solution.

The results of the study showed that although the steroid injection was helpful, there were limitations to the treatment. Patients with moderate or severe carpal tunnel syndrome did show good improvement when they were assessed for pain an function at four weeks and eight weeks after the injection. But, for patients with moderate carpal tunnel syndrome, testing with the electrodiagnosis showed improvement at four weeks but this was gone by eight weeks. For those with severe carpal tunnel syndrome, it wasn’t improved at either time period.

The authors concluded that steroid injections “are safe and effective treatment for temporary relief of symptoms associated with [carpal tunnel syndrome] in patients who have failed to improve with splinting and activity modification.” They point out, however, that the treatment doesn’t provide long-term results.

Trapeziometacarpal arthritis (arthritis below the base of the thumb), the second most common site for arthritis in the hand and is not only painful, but can cause great disability, impacting on quality of life. Usually, once the damage to the joint is severe enough that pain can’t be managed without surgery, the options are arthroplasty (replacement) or arthrodesis (fusing the bones).

The choice of which procedure depends on several factors, one of which is age. Patients under 50 years old or who need to have a strong grip are usually candidates for fusion and older patients or those who don’t place a lot of demand on the joint are usually given a replacement. That being said, the study findings about how successful fusion is are confusing. Some studies report fusion rates as high as 100 percent, while others only report half that. Some studies report patients with fusions being very pleased with the results, but others report a greater increase of arthritis in surrounding joints after fusion surgery.

The authors of this article evaluated the outcomes of patients over 33 years of the procedure in their particular institution. Researchers found eligible records of 241 TM fusions on a total of 126 thumbs on 114 patients. The average age of the 79 women and 35 men was 57 at the time of the surgery; the youngest was 32, the oldest 77. The surgical techniques included fixing with or without wires, using supplemental bone grafts, and compression screws.

Before surgery, the patients were tested on their strengths for tip-to-tip pinch (called oppositional pinch). and grip strength, compared to their unaffected hand. The patients rated their pain scores on a scale from zero to 10, with zero being no pain and 10 being the worst possible. The average pain score was 6.6 before surgery. Range of motion, how many degrees, of the thumbs were measured as well.

After surgery, the patients were tested again and more x-rays were taken to check for fusion and if any arthritis had appeared in neighboring joints. The patients were also asked to rate how satisfied they were with the outcome. The researchers also evaluated complications, both during and after surgery.

The results of the study showed that 17 of the thumbs were “nonunions,” which meant that the fusion didn’t take. Eleven of the nonunion thumbs had bone grafting, six didn’t. Nine of the patients with nonunions had another surgery – six for redo of the fusion and three for correction. In measuring the oppositional pinch and grip strengths, the researchers found improvement in both, as did the patients’ report of pain. X-rays showed that arthritis did progress in neighboring joints in 39 cases (the scaphotrapeziotrapezoid), but only eight had symptoms of the arthritis. The remaining were detected by x-ray. As well, 16 thumbs developed arthritis in the metacarpophalangeal joint, but the patients didn’t have symptoms.

Complications included 11 patients who had infections with the wires, or loosing or movement of the hardware. Six thumbs had irritation along the nerve or inflammation of the nerve (neuritis). Three of the thumbs had to have surgery to remove the hardware because of the increased pain. As well, two patients who had increased pain after surgery were diagnosed with complex regional pain syndrome or a similar syndrome.

The authors pointed out that fusion limits use and function of the joint, although it is usually a preferred treatment for the chosen patient groups. The complication rate was low as was the nonunion rate. Considering that the majority of patients appeared to be satisfied following the fusion surgery, pain was reduced, and function was improved, fusion for this type of arthritis does improve the long-term patient outcome.

Imagine not being able to use your thumb because of intense pain. Suddenly, even the simplest of daily activities becomes an agony. That’s the plight of many people with osteoarthritis of the thumb. The main joint involved is the carpometacarpal (CMC). This is at the base of the thumb where the thumb meets the wrist. It’s a common problem in postmenopausal women but others can be affected, too. For example, anyone with laxity (looseness) of the ligaments can develop a painful CMC joint of the thumb.

In this study, one surgeon followed eight patients over a period of six to 13 years after surgery for this condition. The specific procedure done was an extension osteotomy of the first metacarpal. First refers to the thumb as the digits on the hand are numbered from one to five, starting with the thumb. The metacarpal bone is the long bone of the thumb from the base of the wrist to the first knuckle on the thumb.

These two causes of thumb pain (ligamentous laxity and degenerative changes) have different pathways by which the person ends up with a need for surgery. Injury to the ligaments around the CMC joint lead to joint instability. Over time, load and compressive force through the joint leads to a degenerative process that ends in disability. The same thing can happen in the aging process that results in degenerative joint changes and osteoarthritis.

Rather than jump right to a joint replacement, this surgeon has tried a different option. The extension osteotomy is considered extra-articular (outside the joint). It is done by removing a wedge- or pie-shaped piece of bone from the metacarpal above the CMC joint. A wire was used to pull the opening (made by removing the bone) closed. This procedure changes the angle of the metacarpal bone where it connects with the wrist and brings it more into a neutral position (normal alignment).

Younger patients and anyone with less advanced disease can qualify for an extension osteotomy. The main advantage of this procedure is that it doesn’t mess with the joint itself. That means patients can still have joint reconstruction or joint replacement sometime in the future should they need it.

The extension osteotomy hasn’t been studied very closely. The few studies published haven’t followed the patients long-term. They also didn’t collect much information before and after about the patient (e.g., demographics such as age, gender, education, marital status and so on) or about the patients’ outcomes. So, although this study is small, it offers some insight into the long-term results of this little used management technique for CMC arthritis.

Measures used to determine the benefits of this procedure included pain, grip strength, pinch strength (thumb to index finger), oppositional pinch strength (thumb to any other finger), and function (e.g., lifting, opening jars, turning doorknobs).

Patients included in the study were those with Eaton stage I to III disease. They were all treated by extension osteotomy after conservative (nonoperative) care failed to resolve pain or improve function. Eaton classification of CMC osteoarthritis uses X-rays to grade the disease as normal, mild, moderate, or severe. The classification is done without taking the patient’s symptoms into consideration.

Grade I is a normal appearing joint on X-ray. With grade II, there is a narrowing of the joint space (less than two millimeters) and the presence of bone spurs. Grade III has more than two millimeters of joint narrowing along with bone cysts, bone spurs, and bone sclerosis (hardening). Grade IV is referred to as pantrapezial arthritis. This means there is evidence of arthritic changes affecting the wrist bones (scaphoid, trapezium, trapezoid) around the CMC joint.

None of the eight patients were candidates for just ligament reconstruction. But joint replacement wasn’t needed yet either. So the extension osteotomy was an acceptable alternative.

Before surgery, pain levels were reported as moderate to severe in all eight patients. Moderate pain was defined as present with daily tasks. Severe pain was constant and occurred at rest as well as with daily activities. Half the patients reported instability in the CMC joint. Sometimes this type of instability is referred to as a subluxation or shifting of the joint causing a partial dislocation.

After surgery, pinch and grip strength improved more than 100 per cent when compared with the other hand. Five of the eight patients were able to maintain status quo. In other words, their joint did not get worse as measured by the Eaton stages. The osteotomy healed without problems. Pain was improved. Activities improved with only mild pain occasionally when lifting heavy objects. The two patients who needed additional surgery had a lag time of at least seven years before the next procedure was done.

The authors conclude that extension osteotomy is a safe and effective way to treat thumb osteoarthritis in patients with Eaton grade I, II, or III. The procedure can be done early before painful symptoms even develop. Stabilizing the joint sooner than later can reduce the load and compressive forces through the joint that later lead to osteoarthritis.

Using the osteotomy procedure described here changes the distribution of force and shear stresses on joint cartilage. It doesn’t require cutting into the joint so it provides an alternative way for young patients to preserve the joint. It works well for all patients except for those who already have severe, advanced arthritis. It is certainly worth considering in younger, active patients.

Dr. Brent Graham at the Toronto Western Hospital (Canada) has been working on finding the best way to diagnose carpal tunnel syndrome (CTS). Currently, there isn’t a clear consensus on the best clinical tests to use in making this diagnosis.

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. Carpal tunnel syndrome 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.

In the past, Dr. Graham tested and validated a new clinical tool called the CTS-6. This instrument is a diagnostic scale for carpal tunnel syndrome. It includes six tests from the history and physical exam to estimate the likelihood that carpal tunnel syndrome is present. The CTS-6 has been tested and validated as a reliable instrument.

Now, in this study, Dr. Graham compared the results of the CTS-6 with electrodiagnostic testing. Electrodiagnostic testing consisted of sensory nerve conduction velocity (NCV). A segment of the median nerve was tested from the wrist to the middle finger.

There were several steps in this study. First, a hand therapist tested all new patients referred to the center for possible upper extremity peripheral nerve problem. The CTS-6 test was used to determine the pre-test chances the patient had carpal tunnel syndrome. Then these same patients were tested using a standard nerve conduction velocity test.

With the CTS-6 scale, each of the six items is given a point value. The six items include 1) numbness in the hand and fingers supplied by the median nerve, 2) muscle atrophy and/or weakness, 3) a positive Phalen test (standard clinical test used to diagnose carpal tunnel syndrome), 4) loss of two-point discrimination (feeling two separate points touched on the skin), 5) numbness at night that wakes the patient up, and 6) a positive Tinel sign (another standard clinical test used to diagnose carpal tunnel syndrome).

A total score of 12 or more suggests a strong probability (80 per cent chance) that the patient has carpal tunnel syndrome. A total score less than five indicates a very small chance (25 per cent) that the patient has carpal tunnel syndrome.

Comparing the results of the CTS-6 test with the results of the nerve conduction velocity test, the authors report the added information from the electrodiagnostic test was not enough to change the diagnosis or warrant the expense. A low probability of carpal tunnel syndrome (judged by the CTS-6) in a patient whose nerve conduction velocity was negative only lowered the chances of the diagnosis being carpal tunnel syndrome. There wasn’t much value added by the electrodiagnostic test — not enough to support the cost and discomfort to the patient.

With the availability of the CTS-6, there is much less need to use electrodiagnostic studies. The goal in making any diagnosis is to do so in the least amount of time,with minimal discomfort to the patient, and at the lowest cost. The right diagnosis is important in planning treatment that will bring the most successful results.

The authors conclude that a plan of care can be established for carpal tunnel patients just using the CTS-6 test. Adding electrodiagnostic tests may be helpful when the CTS-6 results give the patient a 60 to 80 per cent probability of having carpal tunnel syndrome. But for the most part, the value added by electrodiagnostic testing is minimal when the CTS-6 score predicts carpal tunnel syndrome.

The next step in this process is to independently validate the CTS-6 test in a clinical setting. This means some other group(s) of researchers must use the CTS-6 and come up with the same results as the Graham group. This step is necessary before the CTS-6 can be adopted for use in the clinic as a standard diagnostic tool for carpal tunnel syndrome.

One good way to decide what’s the best course of treatment in hand therapy is to do a search of articles published on a topic of interest. In this case, the focus is on rehab for surgically repaired extensor tendon injuries. What works best: immobilization (no movement), early but controlled mobilization (some movement), or early and active mobilization (full movement)?

Researchers from the Department of Rehabilitation at the University of Amsterdam in the Netherlands conducted a search of four major and well-known databases (Cochrane Library, PEDro, CINAHL, EMBASE) to answer this question. The search covered a period of 20 to 50 years, depending on how long the database had been in existence.

In the recent past, a summary of this type was researched, summarized, and published on flexor tendon injuries of the hand. This is the first time a similar study has been done on extensor tendon injuries. Patients with hand and wrist injuries involving the extensor tendons that were surgically repaired were included.

Evidence on the effects of different rehab protocols after this type of surgery can be very helpful information for hand therapists. It helps them keep up on what’s the latest — what works, what’s outdated? In the past, immobilization was the standard post-operative treatment. But that has been replaced with early controlled mobilization and early active mobilization in many places.

There are different schools of thought on the best approach to use. The goal is to protect the repair site until it heals while preventing scar tissue and adhesions from forming. Movement is usually the best way to prevent scar formation — but it’s also the best way to disrupt the newly forming tissue needed for a successful repair.

Active finger motion keeps the healing tendons sliding and gliding through the tendon sheath (outer covering) and strengthens the tendon faster than a program of controlled motion. The decision about which way to go is usually made by the team, which is made up of the hand surgeon, the hand therapist, and the patient.

Without evidence to provide a consensus on what protocol gives the best outcomes, there can be a wide range of treatment programs designed for the same problem. If there’s one program that’s most effective, everyone wants to know about it!

After searching the four databases, the authors found 40 possible articles. Analyzing the data and reviewing details of the articles narrowed this down to seven that were acceptable quality to be included. An independent review of these seven articles excluded two of the seven articles for a final tally of five articles offering best evidence about this topic.

The studies were divided into the three treatment groups mentioned. Rehabilitation method was the key target area. Here’s what they found:

Surgeons from the Plastic and Reconstructive Surgery department at the University of Pittsburgh present the case of a rare chondroma. A chondroma is a benign tumor made up of cartilage cells. They are usually benign but can cause painful swelling. The most common location is in the hands and feet (fingers and toes).

In this report, an older man (in his mid-70s) put off having the finger evaluated. It was on his nondominant hand and had been growing for several years. It only affected the distal phalanx (tip) of the index finger.

At first, the surgeons thought it was malignant, so the patient decided to have it surgically removed. The procedure to remove the tip of the finger along with the joint is called a disarticulation. But it turned out to be a chondroma under the nail and wasn’t malignant after all. The presentation was very unusual. Even with X-rays and MRIs, it looked like a malignant tumor.

Part of the confusion was in the location of the tumor. The type of chondroma he had was extraosseous. That means outside of bone (in this case, under the nail bed). It was very close to the bone and didn’t look like a classic chondroma. The nail bed was no longer visible, which is usually a sign of malignancy. None of the X-ray findings were typical for an extraosseous chondroma. An accurate diagnosis wasn’t made until it was removed and examined under a microscope.

There are three types of extraosseous chondromas: 1) intra-articular/para-articular, 2) juxtacortical, and 3) chondromas of the soft parts. As the names suggest, these are grouped by location. Intra- or para-articular refers to in or around the joint. Juxtacortical means next to the bone. And of course, chondromas of the soft parts occur in the soft tissues of the fingers or toes.

The authors provide a detailed description of the histology of each type of extraosseous chondroma. Histology refers to the microscopic analysis of the tissue by the pathologist. They advised surgeons to be familiar with these three types of chondromas in order to avoid surgically removing benign lesions (such as occurred in this case).

The patient wasn’t disturbed by losing the distal joint when, in fact, disarticulation wasn’t necessary after all. He wasn’t interested in a complete reconstruction of the finger. So only the minimal amount of surgery was done. Usually, a chondroma is removed with clear margins to prevent local recurrence. Clear margins means when viewed under the microscope, the tumor is completely surrounded by a layer of normal cells. This patient healed well and had a good outcome.

Looking back on the case, the surgeons suggest that a correct diagnosis could have been made if a portion of the nail bed had been removed and examined under the microscope before surgery. The patient may have still had the tip of the finger and the joint removed, but the fear of malignancy would have been put to rest before the procedure was done.