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Hand SurgeryDr. Waters has a particular interest in hand surgery, ranging from: Carpal tunnel surgery | Dupuytren's contracture | Tenosynovitis | Sports injuries. Carpal TunnelCarpal tunnel syndrome occurs when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist. The median nerve controls sensations to the palm side of the thumb and fingers (although not the little finger), as well as impulses to some small muscles in the hand that allow the fingers and thumb to move. The carpal tunnel - a narrow, rigid passageway of ligament and bones at the base of the hand - houses the median nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed. The result may be pain, weakness, or numbness in the hand and wrist, radiating up the arm. Although painful sensations may indicate other conditions, carpal tunnel syndrome is the most common and widely known of the entrapment neuropathies in which the body's peripheral nerves are compressed or traumatized. What are the symptoms of carpal tunnel syndrome?Symptoms usually start gradually, with frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers. Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent. The symptoms often first appear in one or both hands during the night, since many people sleep with flexed wrists. A person with carpal tunnel syndrome may wake up feeling the need to "shake out" the hand or wrist. As symptoms worsen, people might feel tingling during the day. Decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks. In chronic and/or untreated cases, the muscles at the base of the thumb may waste away. Some people are unable to tell between hot and cold by touch. How is carpal tunnel syndrome treated?Treatments for carpal tunnel syndrome should begin as early as possible, under a doctor's direction. Underlying causes such as diabetes or arthritis should be treated first. Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms, and immobilizing the wrist in a splint to avoid further damage from twisting or bending. If there is inflammation, applying cool packs can help reduce swelling. Non-surgical treatmentsDrugs - In special circumstances, various drugs can ease the pain and swelling associated with carpal tunnel syndrome. Nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, and other nonprescription pain relievers, may ease symptoms that have been present for a short time or have been caused by strenuous activity. Orally administered diuretics ("water pills") can decrease swelling. Corticosteroids (such as prednisone) or the drug lidocaine can be injected directly into the wrist or taken by mouth (in the case of prednisone) to relieve pressure on the median nerve and provide immediate, temporary relief to persons with mild or intermittent symptoms. (Caution: persons with diabetes and those who may be predisposed to diabetes should note that prolonged use of corticosteroids can make it difficult to regulate insulin levels. Corticosterioids should not be taken without a doctor's prescription.) Additionally, some studies show that vitamin B6 (pyridoxine) supplements may ease the symptoms of carpal tunnel syndrome. Exercise - Stretching and strengthening exercises can be helpful in people whose symptoms have abated. These exercises may be supervised by a physical therapist, who is trained to use exercises to treat physical impairments, or an occupational therapist, who is trained in evaluating people with physical impairments and helping them build skills to improve their health and well-being. Alternative therapies - Acupuncture and chiropractic care have benefited some patients but their effectiveness remains unproved. An exception is yoga, which has been shown to reduce pain and improve grip strength among patients with carpal tunnel syndrome. SurgeryCarpal tunnel release is one of the most common surgical procedures in the United States. Generally recommended if symptoms last for 6 months, surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. Surgery is done under local anesthesia and does not require an overnight hospital stay. Many patients require surgery on both hands. The following are types of carpal tunnel release surgery: Open release surgery, the traditional procedure used to correct carpal tunnel syndrome, consists of making an incision up to 2 inches in the wrist and then cutting the carpal ligament to enlarge the carpal tunnel. The procedure is generally done under local anesthesia on an outpatient basis, unless there are unusual medical considerations. Endoscopic surgery may allow faster functional recovery and less postoperative discomfort than traditional open release surgery. The surgeon makes two incisions (about ½" each) in the wrist and palm, inserts a camera attached to a tube, observes the tissue on a screen, and cuts the carpal ligament (the tissue that holds joints together). This two-portal endoscopic surgery, generally performed under local anesthesia, is effective and minimizes scarring and scar tenderness, if any. One-portal endoscopic surgery for carpal tunnel syndrome is also available. Although symptoms may be relieved immediately after surgery, full recovery from carpal tunnel surgery can take months. Some patients may have infection, nerve damage, stiffness, and pain at the scar. Occasionally the wrist loses strength because the carpal ligament is cut. Patients should undergo physical therapy after surgery to restore wrist strength. Some patients may need to adjust job duties or even change jobs after recovery from surgery. Recurrence of carpal tunnel syndrome following treatment is rare. The majority of patients recover completely. Dupuytren's ContractureIs a painless thickening and contracture of tissue beneath the skin on the palm of the hand and fingers. CausesThe cause is unknown, but minor injury and your genes may make you more likely to develop this condition. One or both hands may be affected. The ring finger is affected most often, followed by the little, middle, and index fingers. A small, painless nodule develops in the connective tissue on the palm side of the hand and eventually develops into a cord-like band. In severe cases, it's difficult or even impossible to extend the fingers. The condition becomes more common after the age of 40. Men are affected more often than women. Risk factors are alcoholism, epilepsy, pulmonary tuberculosis, diabetes, and liver disease. Symptoms
Exams and TestsA physical examination of the palm by touch (palpation) confirms the presence of thickened scar tissue (fibrosis) and contracture. Restriction of motion is common. TreatmentExercises, warm water baths, or splints may be helpful. Surgery may be performed to release the contracture, depending on the severity of the condition. Normal movement of the fingers is usually restored by surgery followed by physical therapy exercises for the hand. Outlook (Prognosis)The disorder progresses at an unpredictable rate. Surgical treatment can usually restore normal movement to the fingers. The disease can recur following surgery in some cases. TenosynovitisTenosynovitis is inflammation of the lining of the sheath that surrounds a tendon (the cord that joins muscle to bone). CausesThe synovium is a lining of the protective sheath that covers tendons. Tenosynovitis is inflammation of this sheath. The cause of the inflammation may be unknown, or it may result from:
The wrists, hands, and feet are commonly affected. However, the condition may occur with any tendon sheath. Note: An infected cut to the hands or wrists that causes tenosynovitis may be an emergency requiring surgery. Symptoms
Fever, swelling, and redness may indicate an infection, especially if a puncture or cut caused these symptoms. Exams and TestsA physical examination shows swelling over the involved tendon. The health care provider may touch or stretch the tendon, or have you move the muscle where it is attached to see whether you experience pain. TreatmentThe goal of treatment is to relieve pain and reduce inflammation. Rest or keeping the affected tendons still is essential for recovery. You may want to use a splint or a removable brace to help immobilize the tendons. Applying heat or cold to the affected area should help reduce the pain and inflammation. Nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen can relieve pain and reduce inflammation. Local injections of corticosteroids may be useful as well. Some patients need surgery to remove the inflammation surrounding the tendon, but this is not common. For tenosynovitis caused by infection, your health care provider will prescribe antibiotics. In some severe cases, surgery may be needed to release the pus around the tendon. After recovery, do strengthening exercises using the muscles around the affected tendon to help prevent the injury from coming back. Outlook (Prognosis)Most people fully recover with treatment. However, if the condition is caused by overuse and the activity is not stopped, tenosynovitis is likely to come back. In chronic conditions, the tendon may be damaged and recovery may be slow or incomplete. Sports InjuriesExercising is good for you, but sometimes you can injure yourself when you play sports or exercise. Accidents, poor training practices or improper gear can cause them. Some people get hurt because they are not in shape. Not warming up or stretching enough can also lead to injuries. The most common sports injuries are
If you get hurt, stop playing. Continuing to play or exercise can cause more harm. Treatment often begins with the RICE (Rest, Ice, Compression and Elevation) method to relieve pain, reduce swelling and speed healing. Other possible treatments include pain relievers, keeping the injured area from moving, rehabilitation and sometimes surgery. Other Procedures
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Linda M. Waters, MD
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