Patient Resources

Carpal tunnel syndrome is the most common compressive neuropathy (Pinched nerve) in the upper extremity. It typically presents with numbness in the thumb, index, and middle finger, although the whole hand involvement may be present.   Though symptoms are typically worse at night, many people will complain of waking in the morning with their hands numb or tingly.  In addition, activities that require more forceful grip such as driving can worsen these symptoms. Other associated factors include diabetes, hypothyroidism, tobacco use, and inflammatory arthritis such as rheumatoid arthritis.

A nerve is a wire that conducts electricity. The median nerve, which is involved in carpal tunnel, provides sensation to the thumb index and middle finger, and tells the thumb muscle to fire.  The carpal tunnel is quite literally a tunnel in the wrist.  The floor and sides are composed of bone, with a thick piece of tissue forming the roof.  Through this tunnel run the tendons that move the fingers and thumb, as well as the median nerve. As the tendons swell, they occupy more space in the tunnel, and eventually will increase pressure strangling the blood vessels that feed the nerve. When this occurs, patients will often experience tingling in their fingers.  When we sleep at night our wrists are commonly bent which increases the pressure in the tunnel.  With prolonged strangulation of the nerve, eventually the nerve conducts electricity more slowly.  If the nerve is compressed long enough, eventually the muscles that are told what to do by the nerves do not fire.  Over time those muscles will become lazy and eventually die. An electrical test, called an EMG, can be useful in testing the speed with which the nerve is conducting electricity, as well as evaluate for muscle health.

Early treatment consists of wearing wrist braces, most commonly at night, to maintain the wrist in a neutral position minimizing compression of the nerve as it runs through the tunnel.  Several weeks of consistent bracing can be very useful to reverse the course, particularly in early cases of carpal tunnel syndrome. Other potential nonoperative remedies include the use of anti-inflammatory medications and activity modification.  A steroid injection for carpal tunnel syndrome may be used in selective cases, although typically the results of steroid injections for carpal tunnel typically diminish within the first year.

Surgical treatment of carpal tunnel syndrome may be indicated.  The surgery involves opening the tunnel and creating a pressure release valve through the thick piece of tissue forming the roof, called the retinaculum. This is most typically accomplished on an outpatient basis utilizing twilight sedation and an IV placed in the arm replacing the blood with a short acting numbing medicine. An incision about an inch long is placed vertically at the base of the palm.  Through that incision the tunnel is opened, and the nerve visualized.  The skin is most typically closed with absorbable sutures.  Long-acting numbing medicine is injected so that you are comfortable after surgery.  Surgery time is approximately 30-45 minutes, although with the medication that you are given it may feel much longer.

A bulky dressing with a well-padded splint is placed.  The fingers and thumb are typically left free and range of motion and light use of your hand is allowed immediately.  Pain medication, such as tramadol, is prescribed.  Over-the-counter ibuprofen (200-800 mg 3 times a day with food) can be very helpful in assisting with pain control and can be taken at the same time as Tylenol and tramadol.  In addition, keeping an ice pack over the palm and keeping the fingers moving and elevated can also be helpful to diminish the swelling and discomfort. When you are discharged home, you are asked not to drive for a period of 24 hours because of the sedation medication having a more prolonged effect. You can resume a normal diet. For the first 3 days you can use your hand for light activities, such as eating and getting ready in the morning.  You will need to cover the initial postoperative dressing for showering and self-care.  The dressing can be removed on the third postoperative day and the hand can get wet with running water, but it is not allowed to be submerged in baths, hot tubs, swimming pools, or dishwater. The sutures are buried beneath the skin and not visible when the dressing is removed, and the paper tape that is placed over the wound often falls off, and this is ok. Some superficial opening of the wound is occasionally seen, but rarely causes a problem. You will return to see a member of our team, either myself or my nurse practitioner, around the 10^th day after surgery.  Until that time, you can use your hand for approximately 1 pound of weight as a guideline.  At 10 days you can increase the weight to 10 pounds. At one months’ time you can resume almost all normal activities, but it is common to have soreness in the palm that can last for a few months.  This will most likely go away. Occupational therapy is uncommonly needed, although in some circumstances such as Worker's Compensation it is required more commonly.

Returning to work following carpal tunnel surgery has many variables and is typically addressed on a case by case basis.  Most jobs that do not involve heavy lifting, or repetitive gripping and twisting, can be resumed as early as a few days with work restrictions in place.  Many employers will not allow patients to return to work if they are on work restrictions, which will be addressed at your visit.

The outcome for carpal tunnel surgery is generally favorable.  Resolution of tingling is more immediate than return of sensation.  Depending on the amount of nerve compression, as well as other factors such as age, diabetes, and other medical comorbidities, return to full sensation may be variable. Some patients will feel their hand is weak for several months following surgery, but this usually resolves with resumption of normal activities.

Arthritis is a loss of cartilage, the shiny end of the chicken bone.  There are many reasons for the cartilage to degenerate, including prior fracture, inflammatory arthritis (such as rheumatoid arthritis), or a history of infection. In most instances however there is no direct cause that can be identified, and many times this arthritis can be seen in a parent.

The symptoms often begin near the meaty part of the thumb and can be a burning, or a dull ache.  Frequently this is worse with grip and use.  The pain can also be present at night making sleep challenging.

Treatment of osteoarthritis at the base of the thumb is frequently aimed at symptom minimization through 3 tiers of treatment.

The first tier consists of immobilization with one or 2 different kinds of braces which may be provided from our office.  A flexible thumb sleeve is often helpful during activities.  This sleeve supports the arthritic joint preventing excess mobility which can aggravate the pain.  It is recommended that this brace be used with activities that provoke the symptoms.  While it can be worn full time, most people prefer to wear it only for selective activities that require repetitive gripping.  A rigid brace is most helpful if symptoms are present at night. In addition, judicious use of anti-inflammatories is often helpful.  Common over-the-counter anti-inflammatory such as ibuprofen (Advil, Motrin), which comes in 200 mg tablets, allow flexibility and dosing of anywhere from 1-4 tablets 3 times a day (taken with food).  Naproxen (Aleve) Comes in 220 mg tablets, and 1-2 tablets twice a day can be utilized as an alternative.  It is recommended that these medications be taken around the time of activities that may aggravate the symptoms.  This is often a trial and error process. The highest dose tolerable is taken for a brief period, usually 24-36 hours, and then it is stopped for a period of one to 2 days.  This intermittent use of anti-inflammatories can help protect the kidneys and stomach from adverse effects.  If you have questions about use of anti-inflammatories with other medical conditions, please contact your primary care physician. Acetaminophen (Tylenol) can be used in concert with anti-inflammatories and should be dosed according to the instructions on the package.

The second tier of treatment is the use of steroid injections. A steroid as powerful anti-inflammatory, which helps alleviate the symptoms of arthritis.  It does not work to regrow cartilage, and therefore often works but does not last.  The duration of relief varies with everyone.  Often the past use of a steroid injection is with acute exacerbation such as a fall or forced movement of an arthritic thumb.  Given the potential for steroids to weaken adjacent soft tissues, I do not recommend repeated steroid injections for thumb osteoarthritis.

The third tier of treatment is surgical.  The surgery is performed on an outpatient basis, usually with a nerve block placed in the shoulder or arm pit. The surgery involves removing the arthritic bone and using a tendon to reconstruct the joint.  The surgery is aimed at pain relief, and this often results in increased strength.  In a few instances, patients may feel that they have prolonged weakness following the surgery.  The timing of surgery is dependent on the symptoms as there are 2 important things to note about the surgery.  First is that no activity will “wear the cartilage out faster.” The sleeve and anti-inflammatories can be helpful to perform activities that you wish to pursue.  The second point is that it is never too late to perform the surgery; there is no benefit to “getting to it early.” Recovery for the surgery to perform most activities is 3 months, and duration of time away from work is highly variable based on your job activities. 

The day of the surgery you are typically quite comfortable being discharged home because of the nerve block.  Staying ahead of the pain with the medications prescribed prior to the block wearing off is very helpful.  In addition, icing and elevating the hand for the first 48-72 hours is important.  You may be prescribed an anti-inflammatory to take in conjunction with the opioid pain medication.  In certain instances, an anti-nausea pill may be prescribed as well. You will go home in a bulky soft dressing that has a rigid splint that will allow for swelling and must cover this while bathing until the return for your first postoperative visit. I will encourage you to use your exposed fingers for light activities in the postoperative dressing until you return on or about the 10th postoperative day. At that visit, the dressing will be removed, and x-rays obtained, sutures most likely removed, and you will be placed into a waterproof cast.  You can perform most activities in the cast. Based on your job you may be able to return to work at this point.

When you return to see us approximately a month after your surgery, the cast will be removed and an occupational therapist will fabricate a splint for you and instruct you on home exercises to perform for the next 2 weeks.

Beginning around the sixth postoperative week, you will visit occupational therapists and begin formal therapy which is important to optimize your result.  At six weeks you will also begin weaning your use of the splint as directed by the therapist.

Then you will return to see us around the eighth week.  At this point you are encouraged to discontinue use of the splint and begin resuming normal activities.  It is common to have soreness and fatigue while attempting these activities.  It is not until about the third month that many people will find there able to resume normal activities with only mild discomfort.   Improvement can be seen for up to a year following the surgery.

Trigger fingers are the most common tendon pathology seen in the hand and upper extremity.  Risk factors for development include female gender, diabetes, rheumatoid arthritis, thyroid issues, and occupational use.  Most of the time however, there is no discrete answer for why these occur.  A tendon is a rope that connects the muscle to the bones in the finger to make a fist, and as it passes through the hand near the base of the digit there is a pulley (A1) that it passes beneath.  When the tendon swells and causes friction running through the pulley, the pulley becomes more swollen and thicker.  This typically causes pain in the palm, that may be associated with clicking, catching or locking, and many patients will feel that their grip is substantially weaker.

 It is common for the triggering to occur more in the morning as the tendon swells at night.  In the morning when you begin moving your finger, the swelling often gets caught on one side of the pulley, the digit triggers.  As the hand is more repetitively used, the pulley system "wrings out the washrag" getting rid of the excess fluid that was accumulated overnight.  Initial treatment includes anti-inflammatories, activity modification (such as increasing the girth of implements used in the affected hand) and observation.  Many trigger fingers will resolve with these measures.  If the finger remains symptomatic, splints and supervised therapy have provided inconsistent relief.  Often a steroid injection, which removes the inflammation from the tendon allowing it to glide smoothly beneath the pulley, can give relief on a permanent basis.  The steroid injections can be up to 90% successful in some reports, although patients with diabetes, multiple digits, rheumatoid arthritis and other medical comorbidities have a higher likelihood of only temporary relief from steroid injections.  The duration of relief, as well as other patient factors, will help guide our decision on the use of a second steroid injection. 

Another option is surgical intervention which is performed in the operating room under “twilight” sedation.  An incision is made in the crease of the hand overlying the pulley, and rather than attempting to remove the inflammation from the tendon, the A1 pulley is divided allowing the tendon to pass through with no friction.  Because there are other pulleys further on in the finger, sacrifice of the A1 pulley does not cause weakness.

Following this outpatient surgery, you will be given exercises to perform while in your dressing.  The hand can be used for light activities, and for the first 3 days must be covered while bathing.  On the third day after surgery, the dressing will be removed at home and the black stitches will be visible.  At that point, the hand can be cleansed with regular soap and running water, but the wound is not to be submerged.  A general guideline for use of the hand is 1 pound, which allows you to perform most activities of daily living.  When you return to see us at around day 10, the sutures will be removed, and you will be allowed to advance your activities with a general guideline of 10-pound use with that hand.  It is not uncommon for the wound to gap slightly once the sutures are removed, and this will typically heal uneventfully in a few days.   Full activities are gradually resumed after the sutures are removed and by a month after surgery, most patients are back doing most of the normal activities.  Ability to return to work is dependent upon several factors but can be as fast as 48 hours following surgery, although this will be discussed in your preoperative counseling session.  The long-term results of surgical intervention are good with a 2-3% complication rate, most commonly tingling or numbness in the fingers which resolves over time.  Recurrence of triggering is quite rare following surgical release.  Few patients will require formal occupational therapy following surgical treatment as many of the exercises and scar management techniques can be performed in the home setting.