Carpal Tunnel, Ulnar Tunnel, and Stenosing Tenosynovitis

Chapter 73

Carpal tunnel syndrome Diagnosis Treatment

Surgical Elldoscopic release of carpal tllllllel release of carpal tl//Illel

4285 . 4286 . 4287 . 4289 . 4291

Unrelieved or recurrent tunnel syndrome

carpal 4298

de Quervain disease Trigger finger and thumb Bowler thumb

. 4299 4300 . 4304

Described in 1854 by Paget, carpal tunnel syndrome (tardy median palsy) is the result of compression of the median nerve within the carpal tunnel. A cylindrical, inelastic cavity connecting the volar forearm with the palm, the carpal tunnel is bounded by the transverse arch of the carpal bones' dorsally; the hook of the hamate, triquetrum, and pisiform medially; and the scaphoid, trapezium, and fibroosseous flexor carpi radialis sheath laterally. The ventral (pal nul') aspect, or "roof," of the carpal tunnel is formed by the flexor retinaculum, consisting of the deep forearm fascia proximally, the transverse carpal ligament over the wrist, and the aponeurosis between the thenar and hypothenar muscles distally. The ITlOStventral (palmar) structure in the carpal tunnel is the median nerve. Lying dorsal (deep) to the median nerve in the carpal tunnel are the nine flexor tendons to the fingers and thumb. Carpal tunnel syndrome consists predominantly of tingling and numbness in the typical median nerve distribution in the radial three and a half digits (thumb, index, long, and radial side of ring). Pain, described as deep, aching, or throbbing, occurs diffusely in the hand and radiates up the forearm. Thenar muscle atrophy usually is seen later in the course of the nerve compression. It occurs most often in patients 30 to 60 years old and is two to three times more common in won1.en than in men. Carpal tunnel syndrome may affect 1% to 10% of the U.S. population. According to Nathan and Keniston, older, overweight, and physically inactive individuals are more likely to develop carpal tunnel syndrome. Nathan et al. subsequently

reported that increased age, female gender, obesity, cigarette smoking, and vibrations associated with job tasks were carpal tunnel risk factors in industrial workers studied over an 11-year period. Elevation of carpal tunnel pressures greater than 20 to 30 mm Hg impedes epineurial blood flow, and nerve function is impaired. Any condition that crowds or reduces the capacity of the carpal tunnell11.ay initiate the symptoms. A malaligned Colles fracture and edema from infection or trauma are obvious causes, and of conditions, ganglion, lipoma, and common. In the treatment of a Colles ing the wrist in marked flexion and tumors or tumorous xanthoma are more fracture, immobilizulnar deviation can

cause acute compression of the median nerve within the carpal tunnel immediately after reduction. Systemic conditions, such as obesity, diabetes mellitus, thyroid dysfunction, amyloidosis, and Raynaud disease, sometimes are associated with the syndrome. Occasionally, a patient has symptoms of carpal tunnel syndrome caused by a habitual sleeping posture at night in which the wrist is kept acutely flexed. Trauma caused by repetitive hand motions has been identified as a possible aggravating factor, especially in patients whose work requires repeated forceful finger and wrist flexion and extension. Laborers using vibrating machinery also are at risk. The causative effect of light, repetitive activities experienced by office workers is controversial and unresolved. Many factors are implicated in the causation and aggravation of carpal tunnel syndrome

(Box 73-1).
When women, carpal tunnel the symptoms syndrome occurs in usually resolve after pregnant delivery.

Box 73-1 Factors Involved in the Pathogenesis of Carpal Tunnel Syndrome

Anatomy Decrease in Size of Carpal Tunnel
Bony abnormalities Acromegaly Flexion or extension of wrist of the carpal bones

Aberrant

muscles

of the

forearm

and

thrombosis

of the

median artery contribute to median nerve compressIOn. The cause may be obscure in some patients. In children, carpal tunnel syndrome is unusuaL According to a review by Lamberti and Light, macrodactyly, lysosomal storage diseases, and a strong family history of carpal children. tunnel syndrome may be predisposing factors in Symptoms in children may be confusing and

Increase in Contents of Canal

Forearm and wrist fractures (Colles fracture, scaphoid fracture) Dislocations and subluxations volar dislocation) Posttraumatic Aberrant cysts) Persistent medial artery (thrombosed Hypertrophic synovium anticoagulation therapy, trauma) Hematoma (hemophilia, or patent) arthritis (osteophytes) variants palmaris longus, palmaris profundus) Musculotendinous (scaphoid rotary subluxation, lunate

muscles (lumbrical,

Local tumors (neuroma, lipoma, multiple myeloma, ganglion

include decreased dexterity and diffuse pain. Findings such as thenar muscle atrophy and weakness suggest that the condition is severe by the time of presentation. The Phalen test and Tinel sign may be absent if the nerve con'lpression has been present for a long time. Bilateral electrodiagnostic tests are recommended because this may be the best way of localizing the site of compression. Carpal tunnel syndrome frequently is associated with nonspecific tenosynovial edema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease. Schuind et al. studied biopsy specimens of the flexor tendon synovium from 21 patients with "idiopathic" carpal tunnel syndrome. The findings were similar in all specimens and were typical of a connective tissue undergoing degeneration under repeated mechanical stress. Kerr et aL reported that 96% of flexor synovial biopsy specimens from 625 patients with idiopathic carpal tunnel syndrome had benign fibrous tissue without inflammatory changes. Pickering et aL and Ettema et al. reported similar histological findings comparing synovial histological changes in 30 patients with idiopathic carpal tunnel syndrome with findings in 10 cadavers. The tenosynovium in patients with carpal tunnel disease showed increased fibroblast density and collagen fiber size and vascular proliferation greater than that in the control group. The carpal tunnel group also showed more type !II collagen fibers than the controls.

Physiology Neuropathic
Alcoholism Double-crush syndrome Exposure to industrial solvents

Conditions

Diabetes mellitus

Inflammatory
Rheumatoid Gout

Conditions

arthritis

Nonspecific tenosynovitis Infection

Alterations
Pregnancy Menopause Eclampsia

of Fluid Balance

Thyroid disorders (especially hypothyroidism) Renal failure Long-term Obesity Lupus erythematosus Scleroderma Amyloidosis Paget disease hemodialysis Raynaud disease

Paresthesia over the sensory distribution of the median nerve is the most frequent symptom; it occurs more often in women and frequently causes the patient to awaken several hours after falling asleep with burning and numbness of the hand that is relieved by exercise. The Tinel sign also may be shown in most patients by percussing the median nerve at the wrist. Atrophy to some degree of the median-innervated thenar muscles has been reported in about half of patients treated by operation. Acute flexion of the wrist for 60 seconds (Phalen test) in some, but not all, patients or strenuous use of the hand increases the paresthesia. Application of a blood pressure cuff on the upper arm sufficient to produce venous distention may initiate the symptoms. Gellman et aL evaluated the clinical usefulness of com-

External Forces
Vibration Direct pressure From Kerwin G, Williams CS, Seiler JG: The pathophysiology of carpal tunnel syndrome, Hand Clin 12:243, 1996.

monly

administered

provocative

tests, including

wrist

flexion, nerve percussion, and the tourniquet test, in 67 hands with electrical proof of carpal tunnel syndrome and

in 50 control hands. The most sensitive test was the wrist

flexion test, whereas nerve percussion was the most specific and the least sensitive. Because of its insensitivity and nonspecificity, the tourniquet test was not recommended. These authors also found that with the wrist in neutral position, the mean pressure within the carpal tunnel in 15 patients with carpal tunnel syndrome was 32 mm. Hg. This pressure increased to 99 mm Hg with 90 degrees of wrist flexion and to 110 mm Hg with the wrist at 90 degrees of extension. The pressures in the control subjects were 25 mm Hg with the wrist in neutral position, 31 mm Hg with the wrist in flexion, and 30 mm Hg with the wrist in extension. Durkan described a carpal compression test in which direct compression is applied to the median nerve for 30 seconds with the thumbs or an atom izer bulb attached to a manometer. Patients with carpal tunnel syndrome usually have symptoms of numbness, pain, or paresthesia in the median nerve distribution. Compared with the Tinel nerve percussion and Phalen wrist flexion tests, the carpal compression test was more specific (90%) and more sensitive (87%) than either of these tests. Szabo et al. evaluated the validity of tests for carpal tu nnel syndrome, including Phalen wrist flexion, Tinel nerve percussion, Durkan compression, and SemmesWeinstein monofilaments. Grip and pinch strength, a hand diagram, and patient symptoms were assessed. Durkan nerve compression, the hand diagram score, night pain, and Semmes-Weinstein testing after a Phalen test had the highest sensitivity. The most specific tests were the hand diagram and Tinel sign. These authors concluded that a patient with an abnormal hand diagram, a positive Durkan test, abnorn,al Semmes-Weinstein sensibility testing, and night pain has a probability of 0.86 of having carpal tunnel syndrome. Conversely, they found that if all four of the above-mentioned examinations were normal, the probability of the patient having carpal tunnel syndrome was 0.0068. Sensibility testing in peripheral nerve compression syndromes was investigated by Gelberman et aI., who found that threshold tests of sensibility correlated accurately with symptoms of nerve compression and electrodiagnostic studies. They found Semmes-Weinstein monofilament pressure testing to be the most accurate in determining early nerve compression. Koris et al. combined the SemmesWeinstein monofilament test with the wrist flexion test for a "quantitative provocational" diagnostic test. This combined test was reported to have 82% sensitivity and 86% speci ficity. According to some authors, electrodiagnostic studies including nerve conduction velocities and electromyography are reliable confirmatory tests. A distal motor latency of more than 4.5 ms and a sensory latency of more than 3.5 ms are considered abnormal. Electromyography may show signs of nerve damage, including increased insertional

activity, positive sharp waves, fibrillations

at rest, decreased

motor recruitment, and complex repetitive discharges. These studies occasionally are normal, however, when clinical signs of carpal tunnel syndrome are present, and they may be abnormal in asymptomatic patients. Nerve conduction studies are reported to be 90% sensitive and 60% specific for the diagnosis of carpal tunnel syndrome. They also are helpful in evaluating the upper extremity for nerve compression at the elbow, axilla, and cervical spine, and for showing changes of peripheral neuropathy. Braun and Jackson showed that electrodiagnostic testing provided no significant data for prediction of functional recovery or reemployment after carpal tunnel release. Szabo et aI., acknowledging the value of electrodiagnostic tests as confirmatory studies, found that this testing did not increase the diagnostic value of the four above-mentioned tests (i.e., abnormal hand diagram, abnormal Semmes-Weinstein testing, positive Durkan compression, and night pain). This finding, combined with published false-negative rates of 10%, limits the usefulness of this type of testing to determine treatment. Postoperative electrodiagnostic testing may be helpful in assessing recurrent symptoms. Table 73-1 summarizes the various tests for nerve compression in the carpal tunnel. CT scanning displays the bony structures clearly, but does not define the soft tissues accurately. Ultrasonography has been used to show the movement of the flexor tendons within the carpal tunnel, but it does not clearly show softtissue planes. Early reports of MRI in carpal tunnel syndrome are promising. A major advantage of MRI is its high soft-tissue contrast, which gives detailed images of bones and soft tissues. Healy et al. reported that of 11 wrists with carpal tunnel syndrome evaluated with MRI, operative findings correlated with MRI evidence of synovial disease, carpal tunnel stenosis, and median nerve compression in 10. This syndrome should not be confused with nerve compression caused by a cervical disc herniation, outlet structures, and median nerve compression mally in the forearm and at the elbow. thoracic proxI-

If mild symptoms have been present, and there is no thenar muscle atrophy, the use of night splints and injection of cortisone preparations into the carpal tunnel may provide temporary relief. Graham et al. reported long-term benefit in 10% of patients treated with corticosteroid injection and splinting. Weiss, Sachar, and Gendreau compared the efficacy of steroid injection with splinting, and reported that the response to injection treatment was faster in men and in patients older than 40 years old. Care should be taken not to inject directly into the nerve. Injection also can be used as a diagnostic tool in patients without osteophytes or tumors in the canal. Most of these cases are probably caused by a nonspecific synovial edema, and these seem to respond

Table 73-1 Tests for Nerve Compression

Interpretation Test Phalen test Percussion test (Tinel sign) Carpal tunnel compression (Durkan) Hand diagram Patient marks site of pain or altered sensation on outlined Hand volume stress test hand diagram Hand volume test How Performed Elbows on table, forearms vertical, wrists flexed Lightly tap along median nerve from proximal to distal Direct compression of median nerve at carpal tunnel Paresthesia in response to compression Patient's perception of symptoms Markings on palmar side of radial digits, without markings in palm Hand volume increased by 210 mL Probable CTS (sensitivity 0.96, specificity 073, negative predictive value 091) Hand volume measured by displacement, min rest Direct measurement carpal tunnel pressure Static 2-point discrimination Moving 2-point discrimination Vibrometry Determine minimal separation of two distinct points when applied to palmar finger tip As above, with movement of the points Vibrometer placed on palmar at Innervation density of fast-adapting fibers of Wick or infusion catheter placed in carpal tunnel Hydrostatic pressure in resting and provocative positioning Innervation density of fibers Failure to determine separation of at least 5mm Failure to determine separation at least 4mm Threshold of fastadapting fibers Asymmetry compared hand Probable CTS (sensitivity 087) side of digit, amplitude 120 Hz, increased to threshold of perception, compare median and ulnar bilaterally Semmes-Weinstein monofi laments Monofilaments of increasing Threshold of slowly adapting fibers Value >2.83 Median nerve impairment (sensitivity 083) diameter touched to palmar side of digit until patient can determine which digit is touched Distal sensory latency and conduction velocity Distal motor latency and conduction velocity Electromyography Needle electrodes placed in muscle Orthodromic stimulus and Latency, conduction velocity of motor fibers of median nerve Denervation muscles of thenar Orthodromic stimulus and Latency, conduction of sensory fibers Latency >3.5 ms or asymmetry of conduction velocity >0.5 m/s versus opposite hand Latency >4.5 ms or asymmetry of conduction >1 m/s Fibrillation potentials, sharp waves, increased insertional activity CTS, carpal tunnel syndrome. From Abrams R, Meunier M: Carpal tunnel syndrome. In Trumble TE, ed: Hand surgery update 3, Rosemont, III, 2003, Amencan Society for Surgery of the Hand. Advanced motor median nerve compression velocity Probable CTS recording across wrist Probable CTS recording across wrist with contralateral ipsilateral hand Advanced nerve dysfunction Advanced nerve dysfunction slow-adapting Resting pressure 225 mm Hg (variable and technique related) Hydrostatic compression is believed to be probable cause of CTS repeat after 7-min stress test and 10Probable dynamic CTS Paresthesia within 30 s Condition Tested Positive Result Numbness or tingling on radial digits within 60 s "Electric" tingling response in fi ngers Positive Result Probable CTS (sensitivity 075, specificity 047) Probable CTS if positive at the wrist (sensitivity 060, specificity 067) Probable CTS (sensitivity 087, specificity 090) of

Paresthesia in response to position Site of nerve lesion

or median to ulnar in

more favorably to injection.

nate the possibility

Injection also helps to elimiespecially cervical

deep transverse carpalligamem

is indicated.

The results of

of other syndron'les,

disc or thoracic outlet syndrome. Some patients prefer to receive injections two or three times before a surgical procedure is done. If the symptoms and physical findings improve, and there is no muscle atrophy, conservative treatment with splinting and injection is reasonable. In a study of 331 patients with carpal tunnel syndrome, Kaplan, Glickel, and Eaton identified five important factors in determining the success of nonoperative treatment: (1) age older than 50 years, (2) duration longer than 10 months, (3) constant paresthesia, (4) stenosing flexor tenosynovitis, and (5) a positive Phalen test result in less than 30 seconds. Two thirds of patients were cured by medical treatment when none of these factors was present; 59.6%, with one factor; and 83.3%, with two factors. Of patients with three factors, 93.2% did not improve. No patient with four or five factors was cured by medical management. On the basis of experimental and clinical observations, Gelberman et al. proposed that carpal tunnel syndrome be divided into early, intermediate, advanced, and acute stages. Patients with early carpal tunnel syndrome and mild symptoms responded to steroid injection. Patients with intermediate and advanced (chronic) syndromes responded to carpal tunnel release. Extensive neurolysis was not shown to have any significant effect. In a prospective, randomized study comparing carpal tunnel release with and without internal neurolysis, MacKinnon et al. reported that internal neurolysis did not add significantly to the motor or sensory outcome of carpal tunnel release. In a similar prospective, randomized evaluation of epineurotomy, Foulkes et al. showed that epi neurotomy offered no cli nical benefit to carpal tunnel release. Treatment of acute carpal tunnel syndrome should be individualized, depending on its cause. For carpal tunnel syndrome caused by an acute increase in carpal tunnel pressure (e.g., after a Colles fracture treated with flexed wrist immobilization), relief may be obtained by a change the tunnel. in wrist position without surgical release of

surgery are good in most instances (in 85% according to Lipscomb), and benefits seem to last in most patients. According to a prospective study by Guyette and Wilgis, maximum improvement was seen in the first 6 months after carpal tunnel release. After 6 months, there was no significant improvement in the Tinel and Phalen tests, pinch strength, motor latency, symptom severity, or functional scoring. Although thenar atrophy may disappear, it resolves slowly, if at all. Surgical release might not achieve complete relief of all symptoms for patients older than 70 years old with advanced nerve compression according to Leit et al. When symptoms of median nerve compression develop during treatment of an acute Colles fracture, the constricting bandages and cast should be loosened, and the wrist should be extended to neutral position. When median nerve palsy develops after a Colles fracture and has not improved after several weeks, surgery is indicated without further delay.

Surgical Release of Carpal Tunnel

We describe our standard approach to open carpal tunnel release. Limited approaches, such as the "double incision" of Wilson (Fig. 73-1A) and the "minimal incision" of Bromley (Fig. 73-1 B) offer the rapid recovery ascribed to the endoscopic technique and less risk. Similarly, the use of the "carpal tunnel tome" through a small palmar incision is advocated by Lee, Plancher, and Strickland as a technical modification that minimizes the soft-tissue trauma of the traditional open technique and provides better exposure than that of endoscopic techniques. The benefits of a knife with its attached light source remain to be seen. Regardless of the technique selected, all structures to be incised should be seen and identified first (Fig. 73-2).

TECHNIQUE

73-1

Make a curved incision ulnar to and paralleling the thenar crease. Avoid making the incision in the thenar crease if the crease is deep to minimize the skin maceration with postoperative drainage of edema fluid.

Ancillary procedures sometimes done at the time of carpal tunnel release include flexor tenosynovectomy, epineurotomy, internal neurolysis, and tendon transfers. Epineurotomy and internal neurolysis do not seem to provide a benefit. Flexor tenosynovectomy adds no benefit for a patient with idiopathic carpal tunnel syndrome according to Shum et al. Patients with florid tenosynovitis caused by rheumatoid should benefit arthritis or other inflammatory conditions from tenosynovectomy at the time of carpal

Extend the incision proximally to the flexor crease of the wrist, where it can be continued farther proximally if necessary. Angle the incision toward the ulnar side of the wrist to avoid crossing the flexor creases at a right angle, but especially to avoid cutting the palmar sensory branch of the median nerve, which lies in the interval between the palmaris longus and the flexor carpi radialis tendons (Fig 73-3) Maintain longitudinal orientation so that the incision is generally to the ulnar side of the long finger axis or aligned with the palmaris longus. When severed, the palmar sensory branch frequently causes a painful neuroma that may later require excision from the scar Should this nerve be severed, do not attempt to repair it, but section it at its origin.

tunnel release. The palmaris longus opponensplasty of Camitz can be beneficial, particularly in an elderly patient with thenar muscle wasting and weakness. Trapeziometacarpal arthroplasty and carpal tunnel release may be done safely through two incisions. If signs and symptoms are persistent and progressIve, especially if they include thenar atrophy, division of the

Flexor carpi ulnaris

Flexor carpi radialis Palmaris longus

mill.

A, Transverse incision proximal to anterior wrist crease between flexor carpi ulnaris and flexor carpi radialis tendons. Distal longitudinal incision made between proximal palmar crease and 1 cm distal to hamate hook in line with radial border of ring fll1ger. B, Incision used for minimal-incision approach. (A redrawn from Wilson KM: Double incision open technique for carpal tunnel release: an alternative to endoscopic release, J Hand 5nrg 19A:907, 1994; B redrawn from Bromley GS: Minimal-incision open carpal tunnel decompression, J Hand 5nrg 19A:119, 1994.)

I'm!l'lll

A, Anteroposterior radiograph of dissected right hand. Wires mark proximal and distal extents of classic flexor retinaculum, which includes middle portion of flexor retinaculum (transverse carpal ligament) and distal portion of flexor retinaculum. Note proximal limit is at distal aspect of pisiform (P), and distal limit is distal to hook of hamate (H). B, Three portions of flexor retinaculum (1 to 3) consist of thick aponeurosis between thenar (A) and hypothenar (B) muscles. Thenar muscles attach to radial half of classic flexor retinaculum, composed of distal portion of flexor retinaculum (3); transverse tubercle of trapezium (T) and tubercle of scaphoid (5) also are shown. Proximal portion of flexor retinaculum (1) courses deep to flexor carpi ulnaris (U) and flexor carpi radialis (R). Flexor carpi radialis tendon is shown as it pierces

~1:~'l!i

flexor retinaculum at junction of proximal and middle portions to enter its flbroosseous canal.
F, Antebrachial

fascia; M, third metacarpal. (A from and B redrawll fro III Cobb TK, Dalley !:lK, Posteraro R, et al: Anatomy of the flexor retinaculum, J Hand 5111"g18A:91, 1993.)

TECHNIQUE 73-1-cont'd

Identify the deep fascia of the forearm proximal to the carpal tunnel by subcutaneous blunt dissection proximally, and incise the fascia, avoiding the median nerve beneath it. Place a blunt dissector beneath the fascia to dissect the carpal tunnel contents from the transverse carpal ligament. Identify the distal end of the transverse carpal ligament, and carefully divide the transverse carpal ligament along its ulnar border to avoid damage to the median nerve and its recurrent branch, which may perforate the distal border of the ligament and may leave the median nerve on the volar side (Fig. 73-4). The strong fibers of the transverse carpal ligament extend distally farther than is generally expected (Fig. 73-5). As emphasized by Cobb et aI., the flexor retinaculum carpal ligament at the true carpal tunnel, and the thick aponeurosis between the thenar and hypothenar Release all components of the flexor retinaculum. between the flexor profundus; muscles, lumbrical muscles. includes

me,.

Incidence of extraligamentous, subligamentous, and transligamentous course of thenar branch. (From Lanz U: Anatomical variations of the median nerve in the carpal tunnel, J Hand Surg 2:44, 1977.)

the distal deep fascia of the forearm proximally, the transverse

AFTERTREATMENT A compression dressing and a volar splint are applied. The hand is actively used as soon as possible after surgery, but the dependent position is avoided. A smaller dressing can be applied after 1 week, and gradual resumption of normal use of the hand is encouraged. The sutures are removed after 10 to 14 days. The splint is continued for comfort as needed for 14 to 21 days.

Be aware of anomalous connections anomalous flexor digitorum

Endoscopic Release of Carpal Tunnel

Advocates of endoscopic carpal tunnel release, including Okutsu et aI., Chow, Agee et aI., and Trumble et aI., cite the advantages of less palmar scarring and ulnar "pillar" pain, rapid and complete return of strength, and return to work and activities at least 2 weeks sooner than for open release. Prospective studies by Ferdinand and MacLean and by Macdermid et al. comparing open and endoscopic carpal tunnel release found no significant differences in function. Immediate postoperative advantages of the endoscopic

pollicis longus and the index flexor digitorum anomalies in the palmaris longus, hypothenar muscles, and median and ulnar nerves.

superficial is muscle bellies; and

Avoid injury to the superficial palmar arterial arch, about 5 to 8 mm distal to the distal margin of the transverse carpal ligament. Inspect the flexor tenosynovium. rheumatoid arthritis. Tenosynovectomy

occasionally may be indicated, especially in patients with

Flexor carpi ulnaris

JJJ
.I
:,,!~

"~':....:._.

Palmar branch of median nerve Transverse carpal ligament Radial artery Median nerve

Flexor carpi radialis Median nerve

Ulnar nerve Ulnar artery'

:,.~

." '1, i
~,;A\

mQ.,

Care should be taken In any wrist inCISIOn to avoid cutting palmar branch of median nerve.

mi,I,
ligament.

Anatomical relationships of deep transverse carpal

technique in grip strength and pain relief disappeared after 12 weeks according to Macdermid et al. Reports including large multicenter prospective studies by Agee et al. and Brown et al. and the report by Chow and Hantes of their series of 2675 endoscopic releases suggest that the procedure can be done safely by trained and experienced surgeons. Anecdotal reports of intraoperative injury to flexor tendons; to median, ulnar, and digital nerves; and to the superficial palmar arterial arch emphasize the need to exercise great care and caution when performing the endoscopic procedure. Cadaver studies have shown the close proximity of the median and ulnar nerves, superficial palntar arterial arch, and flexor tendons to the endoscopic instruments. Problems related to endoscopic carpal tunnel release include (1) a technically demanding procedure; (2) a limited visual field that prevents inspection of other structures; (3) the vulnerability of the median nerve, flexor tendons, and superficial palmar arterial arch; (4) the inability to control bleeding easily; and (5) the limitations imposed by mechanical failure. Agee, McCarroll, and North developed the following 10 guidelines to prevent injury to the carpal tunnel structures: 1. Know the anatomy. properly.

unresolved or recurrent carpal tunnel syndrome; (2) anatomical variation in the median nerve, suggested by clinical findings of wasting in the abductor pollicis brevis without significant median sensory changes; and (3) previous tendon surgery or flexor injury that would cause scarring in the carpal tunnel, preventing the safe placement of the instruments for endoscopic carpal tunnel release. The general scheme of the techniques is shown in Figs. 73-6 and 73-7. Before any surgeon attempts endoscopic carpal tunnel release, thorough familiarization with the technique through participation in "hands-on" laboratory practice sessions is recommended.

Endoscopic Carpal Tunnel Release through a Single Incision

TECHNIQUE 73-2 Agee
room setup is satisfactory (see Ascertain that the operating

Fig. 73-6A). Ensure that there is an unobstructed patient's hand and the television monitor. Use general or regional anesthesia. Although

view

of the

the procedure

can be done safely using local anesthesia, the increase in tissue fluid can compromise endoscopic viewing. Exsanguinate the limb with an elastic wrap, and inflate a pneumatic tourniquet applied over adequate padding. Leave the arm exposed distal to the tourniquet. In a patient with two or more wrist flexion creases, make the incision in the more proximal crease between the tendons of the flexor carpi radialis and flexor carpi ulnaris. Use longitudinal blunt dissection to protect the subcutaneous

2. Never overcommit to the procedure. 3. Ascertain that the equipment is working

4. If scope insertion is obstructed, abort the singleincision procedure. 5. Ascertain that the blade assembly is in the carpal tunnel and not in the Guyon canal. 6. If a clear view cannot incision procedure. be obtained, abort the single-

7. Do not explore the carpal canal with the scope. 8. If the view is not normal, abort the single-incision procedure. 9. Stay in line with the ring finger. 10. "When in doubt, get out." Although this technique has proved to be effective, it

nerves and expose the forearm fascia. Incise and elevate a U-shaped, distally based flap of forearm fascia (see Fig. 73-6B), and retract it palmarward to facilitate dissection of the synovium from the deep surface of the ligament, creating a mouth like opening at the proximal end of the carpal tunnel. When using the tunneling tools and the endoscopic blade assembly, keep them aligned with the ring finger, hug the hook of the hamate, and keep the tools snugly apposed to the deep surface of the transverse carpal ligament, maintaining a path between the median and ulnar nerves for the instruments. Use the synovium elevator to scrape the synovium from the deep surface of the transverse carpal ligament. Extend the wrist slightly; insert the blade assembly to the carpal tunnel, pressing the viewing window snugly against the deep surface of the with transverse carpal ligament (see Figs. 73-6C and 0). While advancing the blade assembly distally, maintain alignment ulnar side. Make several proximal-to-distal the ring finger, and hug the hook of the hamate, staying to the passes to define the

may not be applicable to every patient with carpal tunnel syndrome. Consideration always should be given to an open technique if endoscopic release cannot be accomplished safely. Although there are variations, the two methods in use in the United States are the Agee "single portal" and the Chow "two portal" techniques. According to Chow, contraindications to endoscopic carpal tunnel release include the following: (1) the patient requires neurolysis, tenosynovectomy, Z-plasty of the transverse carpal ligament, or decompression of the Guyon canal; (2) the surgeon suspects a space-occupying lesion or other severe abnormality of the muscles, tendons, or vessels in the carpal tunnel; and (3) the patient has localized infection or severe hand edema, or the vascular status of the upper extremities is tenuous. Fischer and Hastings added the following contraindications to the use of endoscopic technique: (1) revision surgery for

distal edge of the transverse carpal ligament with the fat

overlying it.

.\

Median nerve Disposable blade assembly

Skin

Transverse carpal ligament

m-'ii

Agee technique. A, Setup of operating room offers optimal view of video monitor. B, U-shaped flap elevated in palmar direction. Synovium elevator prepares wrist for optimal endoscopic view by separating synovium from deep side of ligament. C, Safe zone of blade elevation is triangle defined by a, ulnar half of distal edge of transverse carpal ligament; b, ulnar border of median nerve (i.e., its common digital branch to long/ring web space); and c, superficial palmar arch. D, Longitudinal cross section through carpal tunnel depicts blade elevation in triangular safe zone. COlltilllled

Forearm fascia

Superficial palmar arch

Communicating of ulnar nerve

branch

Transverse carpal ligament Remaining transverse fibers of palmar fascia with intervening fat Palmaris brevis

Release distal 1/2 to 2/3 of transverse carpal ligament completely before making a final pass to release the remainder of the ligament. This prevents fat located superficial to the proximal portion of the ligament from dropping into the wound and compromising the surgeon's endoscopic view of the extent of the ligament division.

E, Initial release facilitates accurate viewing and division of ligament. F, Inspection of incised transverse carpal ligament in which left view depicts incomplete release as V-shaped defect, with superficial fibers of transverse carpal ligament remaining intact. Cel/ter view depicts complete release of ligament after reinsertion of blade assembly. Fat and transverse fibers of palmar fascia that remain palmar to divided ligament can be noted. View on right shows that rotating blade assembly approximately 20 degrees in either direction causes separated cut edges of ligament to fall into window. G, Tenotomy scissors used to release forearm fascia proximal to skin incision. (Redrawn from Agee JM, McCarroll HR, North ER: Endoscopic carpal tunnel release using the single proximal incision technique, Hal/d Clil/ 10:647, 1994.)

Endoscopic Carpal Tunnel Release through a Single Incision

TECHNIQUE 73-2
Agee-cont'd Define the distal edge of the transverse carpal ligament by viewing the video picture, ballottement. and light transilluminated through the skin. Correctly position the blade assembly, and touch the distal end of the ligament with the partially elevated blade to judge its entry point for ligament division. Elevate the blade and withdraw the device, incising the ligament.

Fat from the proximal palm may compromise viewing by protruding

endoscopic

through the divided proximal half of the

ligament. leaving an oil layer on the lens. Avoid this by first releasing only the distal one half to two thirds of the ligament (see Fig. 73-6E) Using the unobstructed path for reinsertion of the instrument,

accurately complete the distal ligament division with good viewing. Complete proximal ligament division with a final proximal pass of the elevated blade.

Ulnar artery and nerve

Radial artery Median nerve

ml'!llllll IftI:'1'~j Chow technique.

A, Incision for entry portal. B, Incision for exit portal. C, Carpal ligament is identified by transverse fibers. D, First cut made with probe knife, cutting distal to proximal, to release distal edge of carpal ligament. E, Second cut made with triangle knife, with cut made in midsection of carpal ligament. COl/til/lled

F, Third cut made by placing retrograde knife in second cut and drawing it distally to join first cut. G, Proximal section of carpal ligament is identified, and proximal edge is released; probe knife is used to make fourth cut. H, Final cut is made by reinserting retrograde knife into midsection and drawing it proximally to complete release of carpal ligament. (Redrawn from Chow JCY: Endoscopic carpal tunnel release: two-portal technique, Hand Clin 10:637, 1994.)

Endoscopic Carpal Tunnel Release through a Single Incision

TECHNIQUE 73-2
Agee-cont'd Assess the completeness of ligament division using the following endoscopic observations. note that the partially divided

Palpate the palmar skin over the blade assembly window, observing motion between the divided transverse carpal ligament and the more superficial palmar fascia, fat, and muscle. Ensure complete median nerve decompression forearm fascia with tenotomy scissors. by releasing the

Through the endoscope, defect (see Fig. 73-6F).

ligament separates on the deep surface, creating a V-shaped Make subsequent cuts viewing the trapezoidal defect created

Use small right-angle

retractors to view the fascia directly,

avoiding nerve and tendon injury (see Fig. 73-6G). Close the incision with subcuticular or simple stitches. Apply a nonadhering dressing. Apply a well-padded volar

by complete division as the two halves of the ligament spring apart. Through this defect, observe the transverse fibers of the palmar fascia intermingled structures to protrude with fat and muscle. Force these by pressing on the palmar skin. noting that the edges of the splint, or, in selected patients, leave the wrist unsplinted.

Confirm complete division by rotating the blade assembly in radial and ulnar directions,

ligament abruptly "flop" into the window, obstructing the

view.

AFTERTREATMENT The splint and sutures are removed at about 10 to 14 days if the wound has healed suitably. Active finger motion is allowed early in the postoperative period. Forceful pulling with wrist flexion is discouraged

for about 4 to 6 weeks to allow maturation

of soft-tissue

healing. Progression of light activities of daily living is allowed at about 2 to 3 weeks, and more strenuous activities are gradually added in the next 4 to 6 weeks.

Apply a lifting force to the dissector to test the tightness of the ligament and to ensure that the dissector is deep to the ligament, rather than in the tissues superficial to the ligament. Ensure that the dissector and trocar are oriented in the longitudinal axis of the forearm.

Endoscopic Carpal Tunnel Release through Two Incisions

TECHNIQUE 73-3
Chow Perform the procedure using the anesthetic believed most appropriate infiltration by the patient and the anesthesiologist, supplemented with intravenous midazolam hydrochloride (Alfenta). usually a regional block or, as preferred by Chow, local anesthetic hydrochloride (Versed) and alfentanil

Touch the hook of the hamate with the tip of the assembly; lift the patient's hand above the table, extending the wrist and fingers over the hand holder. Gently advance the slotted cannula assembly distally, and direct toward the exit portal. Palpate the tip of the assembly in the palm. Make a second small incision as marked for the exit portal in the palm. Pass the assembly through the exit portal, and secure the hand to the hand holder. Insert the endoscope at the proximal opening of the tube. Examine the entire length of the slotted cannula opening to ensure that there is no other tissue between the slotted cannula and the transverse carpal ligament. If there is any doubt, remove the tube and reinsert. With the endoscope, having been inserted from the proximal direction, remaining in the tube, insert a probe distally, and identify the distal edge of the transverse carpal ligament (see Fig. 73-7C). Use the probe knife to cut from distal to proximal to release the distal edge of the ligament (see Fig. 73-7D). Insert the triangle knife to cut through the midsection of the

With the patient supine, place the hand and wrist on a hand table. The surgeon should be on the axillary side of the upper extremity, and an assistant should be on the cephalad side. Apply a well-padded pneumatic tourniquet to use if needed.

At least one television monitor should be placed on the side of the extremity opposite the surgeon (toward the head of the table), or, as preferred by Chow, two monitors should be used, one for the surgeon and the other for the assistant. With a skin pencil, mark the entry and exit portals. Begin at the pisiform and, depending on the size of the hand, draw a line extending 1 to 1.5 cm radially. From the end of this line, extend a second line 0.5 cm proximally. From the end of the second line, draw a third line extending about 1 cm radially. The third line is the entry portal (see Fig. 73-7A). Passively, fully abduct the thumb. Draw a line along the distal border of the fully abducted thumb across the palm toward the ulnar border of the hand. Draw another line extending proximally from the web space 1 cm proximal to the intersection between the long finger and the ring finger, intersecting the line drawn from the thumb. About of these lines, draw a third line about 0.5 cm long transverse to the long axis of the hand (see Fig. 73-7B)

transverse carpal ligament (see Fig. 73-7E). Insert the retrograde Draw the retrograde 73-7F) Remove the endoscope from the proximal opening of the open tube, and insert the endoscope into the distal opening. Insert the instruments from the proximal opening. knife, and position it in the second cut.

knife distally to join the first cut,

completely releasing the distal half of the ligament (see Fig.

Make an incision in the previously marked entry portal, and bluntly dissect to explore the fascia and make a longitudinal incision through the fascia Identify the proximal edge of the transverse carpal ligament. Gently lift the distal edge of the entry portal incision with a small right-angle retractor, revealing the small space between the Choose the proper knife to make additional transection of the ligament as needed. cuts to complete transverse carpal ligament and the ulnar bursa. Bluntly dissect and develop the space between the transverse carpal ligament and the ulnar bursa. Use the curved dissector obturator-slotted cannula assembly Identify the uncut proximal section of the ligament, and use the probe knife to release the proximal edge (see Fig. 73-7G) Draw the retrograde knife proximally to complete the release of the ligament (see Fig. 73-7H).

Reinsert the trocar, and remove the slotted cannula from the hand. If a tourniquet is used, deflate it, and ascertain hemostasis and

with the pointed side toward the transverse carpal ligament to enter the space and to push the ulnar bursa free from the deep surface of the transverse carpal ligament. Avoid entering the ulnar bursa (the "extrabursal" approach).

that there is no pulsatile or excessive bleeding. Suture the incisions with nonabsorbable dressing. suture; apply a soft

Use the curved dissector to feel the curved shape of the deep surface of the transverse carpal ligament. Move the dissector back and forth to feel the "washboard" fibers of the transverse carpal ligament. effect of the transverse

AFTERTREATMENT Active movement IS encouraged immediately after surgery. The sutures are removed at 7 to 10 days, wound healing permitting. Direct pressure to the

palm area and heavy lifting should be avoided weeks or until discomfort disappears.

for 2 to 3

tunnel consist of the superficial transverse carpal ligament anteriorly, the deep transverse carpal ligament posteriorly, and the pisiform bone and pisohamate ligament medially (Fig. 73-8). Similar to the median nerve within the carpal tunnel, the ulnar nerve is subject to compression within this tunnel. Compared with carpal tunnel syndrome, ulnar tunnel syndrome is much less common because the space occupied by the ulnar nerve at the wrist is much more yielding. The more common location of ulnar nerve constriction is at the elbow. The exact level of compression determines whether symptoms are motor or sensory or both. Compression just distal to the tunnel affects the deep branch of the nerve that supplies most of the intrinsic muscles. A spaceoccupying lesion, such as a ganglion or tumor, can cause compression in this area. True or false aneurysm of the ulnar artery (Fig. 73-9), thrombosis of the ulnar artery, or fracture of the hamate with hemorrhage may be the cause of pressure on the ulnar nerve. Other reported causes are lipoma and aberrant muscles. Occasionally in rheumatoid disease, carpal tunnel and ulnar tunnel syndromes develop in the same hand. In the differential diagnosis, herniation of a cervical disc, thoracic outlet syndrome, and peripheral neuropathy must be considered. Treatment consists of exploration of the ulnar nerve at the wrist and removal of any cause of compression. Should the ulnar artery be occluded for several millimeters, Raynaud syndrome may be produced in the ulnar three digits because the sympathetic nerve fibers to these digits pass along the ulnar artery. Segmental resection of the occluded section and replacement with a vein graft is the preferred procedure when it is feasible (see Chapter 65). Usually symptoms are relieved, and weakened or atrophic intrinsic muscles may recover in 3 to 12 months after surgery. For the technique of exploration, see the approach described for repair branch of the ulnar nerve (see Chapter 65). of the deep

Unrelieved or Recurrent Carpal Tunnel Syndrome

I n a series of explorations of patients who had undergone previous carpal tu nnel surgery, Langloh and Linscheid reported good results in one half and fair results in one third. They estimated a recurrence rate of

1.7% after

primary carpal tunnel release. Complications and failures are estimated to be 3% to 19%. Symptoms may lead to repeat operation in 12% of patients. Because most patients obtain relief in the early postoperative period, it is difficult to attribute one anatomical cause to recurrent symptoms. Findings reponed at reoperation include incomplete release of the transverse carpal ligament, reformation of the flexor retinaculum, scarring in the carpal tunnel, median or palmar cutaneous neuroma, palmar cutaneous nerve entrapment, recurrent granulomatous or inflammatory tenosynovitis, and hypertrophic scar in the skin. Botte et a1. categorized procedures for recurrent problems after carpal tunnel release as follows: Incomplete ligament release-reexploration, re-release transverse carpal ligament, eXCISIon, release reformed retinaculum of of

Fibrosis or painful scar-epineurolysis, local muscle flaps, loca 1 or remote free fat grafts, excision, Z-plasty of painful scar, nerve wrapping or interposition materials (silicone sheet, vein wrap) Reo/rmlt tellos)'l1ovitis-tenosynovectomy, appropriate medical management (appropriate antibiotics III patient with infectious granulomatous tenosynovitis from fungi or mycobacteria) In a review of 131 patients who underwent for carpal tunnel syndrome, Cobb et al. found reoperation that patients

who had normal preoperative electrodiagnostic studies, patients who had filed for compensation, and patients who had ulnar nerve symptoms had results significantly worse than patients without these findings. Careful patient evaluation must be done when considering reoperation for recurrent symptoms and complications after initial carpal tunnel release. Cobb et a1. found that about one fourth of patients who had reoperation were completely satisfied. Conversely, about one fourth of patients who had reoperation had persistent symptoms, requiring a third operation, or were dissatisfied with the result.

Ulnar ulnar about

tunnel

syndrome

results

from

compression

of the

nerve within a tight triangular fibroosseous tunnel 1.5 cm long located at the carpus. The walls of the

mw,:,
ulnar

Anatomical tunnel.

relationships

of

structures

within

by other conditions,
be worsened

such as gout or infection, that could

injections.

by steroid

WHii
in hand. artery. Green report

Two A,

types

of traumatic "false"

aneurysms of ulnar aneurysms

of ulnar from artery. in the

artery ulnar (From hand:

Saccular and

aneurysm

arising

B, "True" DP: True

fusiform

aneurysm

false traumatic

of two cases and review

of the literature,

J BOlle Joillt

Surg

55A:120, 1973.)

Stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons occurs typically in adults 30 to 50 years old. WonLen are affected six to 10 times more frequently than men. The cause is almost always related to overuse, either in the home or at work, or is associated with rheumatoid arthritis. The presenting symptoms usually are pain and tenderness at the radial styloid. Sometimes a thickening of the fibrous sheath is palpable. The Finkelstein test usually is positive: "on grasping the patient's thumb and quickly abducting the hand ulnarward, the pain over the styloid tip is excruciating." Although Finkelstein stated that this test is "probably the most pathognomonic objective sign," it is not diagnostic; the patient's history and occupation, the radiographs, and other physical findings also must be considered. Arthritis in the trapeziometacarpal, scaphotrapeziotrapezoid, and radiocarpal joints; superficial radial nerve entrapment or neuroma; and tenosynovitis at the crossing of the extensor pollicis brevis and abductor pollicis longus over the extensor carpi radialis longus and brevis (intersection syndrome) also can cause similar symptoms. Conservative treatment, consisting of rest on a splint and the injection of a steroid preparation, is most successful within the first 6 weeks after onset. Harvey et aI. reported 63 wrists initially treated with injections of steroids and local anesthetic into the tendon sheath. In 45 wrists, pain relief was complete (71.4%), and pain was relieved after a second injection in seven. Only 11 (17.4%) required surgery. Christie in 1955, Lapidus in 1972, and Weiss et aI. in 1994 reported similar experiences. is the treatment of choice. When pain persists, surgery

Stenosing tenosynovitis occurs more often in the hand and wrist than anywhere else in the body. When the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartment are affected, the condition is named after the Swiss physician, de Quervain, who described his experience in 1895. A peritendinitis also may affect these tendons proximal to the extensor retinaculum, causing pain, swelling, and crepitus in some patients. When the long flexor tendons are involved, trigger thumb, trigger finger, or snapping finger occurs. Less often, the extensor pollicis longus may be affected at the level of Lister tubercle. Any of the other tendons that pass beneath the dorsal wrist retinaculum also may be involved. The tenosynovitis that precedes the stenosis may result from an otherwise subclinical collagen disease or recurrent mild trauma, such as that experienced by carpenters and waitresses. Some case histories indicate that acute trauma may initiate the pathological condition. In others, the condition on gradually. The stenosis occurs at a point direction of a tendon changes, for here a fibrous as a pulley, and friction is maximal. Although may come where the sheath acts the tenosy-

Anatomical variations are common in the first dorsal compartment. When the findings of anatomical dissections by Stein, Ramsey, and Key (11%); Keon-Cohen (33%); and Leao (24%) are combined, an incidence of 21 % with separate compartments results. Reports of separate compartments found at surgery vary from 20% to 58%. More than half of patients may have "aberrant" or duplicated tendons, usually the abductor pollicis longus. These tendons sometimes insert more proximally and medially than usual, into the trapezium (Fig. 73-10), the abductor pollicis brevis muscle (Fig. 73-11), the opponens pollicis muscle, or the muscle fascia. The extensor pollicis brevis is considered a "late" tendon phylogenetically and is absent in about 5% of wrists. The presence of these variations and failure to deal with them at the time of surgery may account for any persistence of pain. In the report of Harvey et aI., 11 of 63 patients treated with injections required surgery; 10 of these were found to have the extensor pollicis brevis in a separate compartment. A longitudinal septum may subdi-

novium lubricates the sheath, friction can cause a reaction when the repetition of a particular movement is necessary, as in winding a fine coil of wire or stacking laundry. Many cases of tenosynovitis in various locations, even stenosing tenosynovitis, respond favorably to injections of a steroid preparation. Pain may increase temporarily during the initial 24 hours after loss of the local anesthetic effect; the patient should be warned about this possibility. It may be 3 to 7 days before the steroid becomes effective, but surgery is avoided in many instances. Before injection, it should be determined that the tenosynovitis is not caused

Abductor pollicis longus tendon inserted into first metacarpal

AFTERTREATMENT

The

small

pressure

dressing

IS

removed after 48 hours, and a patch dressing is applied. Motion of the thumb and hand is immediately encouraged and is increased as tolerated. Failure to obtain complete relief after surgery may result from (1) formation of a neuronn in a severed branch of the superficial radial nerve, (2) volar subluxation of the tendon when too much of the sheath is removed, (3) failure to find and release a separate aberrant tendon within a separate

Extensor pollicis brevis tendon

Abductor pollicis longus tendon inserted into greater multangular

m';I'"

compartment, and (4) hypertrophy of scar from a longitudinal skin incision. For recurrent subluxation of the extensor pollicis brevis and abductor pollicis longus tendons, McMahon et al. used a distally based slip of brachioradiaJis tendon to tether the first dorsal compartment tendons. Ramesh and Britton used the extensor retinaculum to prevent subluxation (Fig. 73-13). Littler et al. also described a reconstruction for the first compartment. In their technique, the septum dividing the first extensor compartment is removed, the extensor poll icis brevis is removed from the compartment, and the retinacular sheath is reapproximated loosely over the abductor polJicis longus tendon to prevent tendon subluxation (Fig. 73-14). Wilson et al. had success using a radial forearm fascial flap for recurrent de Quervain disease in a patient who had three unsuccessful procedures on the right side and two on the left. This procedure requires an extensive forearm dissection (Fig. 73-15).

Often, abductor pollicis longus inserts on greater multangular and base of first metacarpal through two tendons. During surgery for de Quervain disease, at least one aberrant tendon often is found.

vide the according

first compartment in 44% to 73% of wrists, to reports by Weiss et al. and Witt et al.

Surgical Treatment
TECHNIQUE 73-4 Use a local anesthetic and a tourniquet. After sterile skin preparation and draping, use a tourniquet as needed, and infiltrate the skin in the area of the first dorsal compartment with sufficient local anesthetic. Make a skin incision that runs from dorsal to volar in a transverse-to-oblique direction, parallel with the skin creases over the area of tenderness in the first dorsal compartment (Fig. 7312). The longitudinal incision advocated by some surgeons creates a longer area in which skin scar may adhere to the cutaneous nerves and the tendons. Carry sharp dissection just through the dermis and not into the subcutaneous fat, avoiding the branches of the superficial radial nerve. After retracting the skin edges, use blunt dissection in the subcutaneous fat. Find and protect the sensory branches of the superficial radial nerve, usually located deep to the superficial veins. Identify the tendons proximal to the stenosing dorsal ligament and sheath, and open the first dorsal compartment on its dorsoulnar side. With the thumb abducted and the wrist flexed, lift the abductor pollicis longus and the extensor pollicis brevis tendons from their groove. If they cannot be easily freed, look for additional "aberrant" tendons and separate compartments.

Trigger thulTlb in adults is a distinctly separate entity from "congenital" trigger thumb (see Chapter 76). Stenosing tenosynovitis, leading to inability to extend the flexed digit ("triggering") usually is seen in individuals older than 45 years of age. When associated with a collagen disease, several fingers may be involved-the long and ring fingers

Extensor pollicis longus tendon

Close the skin incision only, and apply a small pressure

dressing.

mw'"
fascia of metacarpal.

Extensor pollicis brevis tendon

Abductor pollicis longus tendon with insertion on abductor pollicis brevis muscle

In rare cases, abductor pollicis longus inserts on

abductor pollicis brevis and base of first

First dorsal carpal compartment opened

Separate compartment for abductor pollicis longus tendon

Separate compartment for extensor pollicis brevis tendon

mQIFJ

Surgical treatment of de Quervain disease. A, Skin incision. B, Dorsal carpal ligament has been exposed. C, First dorsal compartment has been opened on its ulnar side. D, Occasionally, separate compartments are found for extensor pollicis brevis and abductor pollicis longus tendons. most often. Patients may note a lump The lump may be the thickened area part of the flexor sheath or a nodule of the flexor tendon just distal to it. palpated by the examiner's fingertip tendon. tendon or knot in the palm. in the first annular or fusiform swelling The nodule can be and moves with the

The tendon nodule usually is at the entry of the into the proximal anulus at the level of the meta-

carpophalangeal joint; however, in a rheumatoid patient, a nodule distal to this point may cause triggering that would not always be relieved by sectioning the proximal anulus alone. Sherman and Lane reported that patients may experience persistent triggering of catching of the tendon after operative release because on the transverse fibers of the

palmar aponeurosis. Occasionally, a partially lacerated flexor tendon at this level heals with a nodule sufficiently large to cause triggering. Local tenderness but is not a prominent complaint. Pressure snapping or triggering of the distal joints. the thumb, the constriction is opposite the langeal joint, although the interphalangeal may be present, accentuates the Particularly in metacarpophajoint is the one

iftilil

Part of extensor retinaculum is used to create U-shaped sling to retain tendons of extensor pollicis brevis and abductor pollicis longus. (R.edrawn from Ramesh R, Britton JM: A retinacular sling for subluxing tendons of the fltSt extensor compartment: a case report, J Balle Jaillt 511rg 82B:424, 2000.)

that appears to lock or snap. Treatment of trigger digits usually is nonoperative in an uncomplicated patient who presents a short time after onset

Technique of Littler, Freedman, and Malerich for reconstruction of first extensor compartment for de Quervain disease. Dotted lil/e, Transverse incision at level of margin of first extensor compartment in line with extensor creases. 1, Superficial radial nerve is protected; retinacular sheath is incised along dorsoulnar margin to allow exploration of sheath and identification of extensor pollicis brevis tendon. 2, If present, septum is excised. 3, Extensor pollicis brevis (b) is retracted from first dorsal compartment. (a), abductor pollicis longus. 4, Retinacular sheath is repaired over abductor pollicis longus tendon with 5-0 absorbable sutures. Wrist is immobilized in splint for 2 weeks. (Redrawn from Littler JW, Freedman DM, Malerich MM: Compartment reconstruction for de Quervain's disease, J Hal/d 5111g 27B:2-i2,
2002.)

mAIIO

Extensor pollicis brevis

~~,

3~ 1st Compartment

of symptoms. Nonoperative methods include stretching, night splinting, and combinations of heat and Ice. Corticosteroid injection is effective with 60% achieving success after one injection according to Benson and Ptaszek. Patients with diabetes mellitus may be more refractory to nonoperative management according to Griggs et al. Surgical release reliably relieves the problem for most patients. Turowski, Zdankiewicz, and Thomson found that 97% of patients had complete resolution after operative treatment. Finsen and Hagen reported recurrence in two of 84 operated digits, and two patients had transient neurapraxias. Several reports document the safety and effectiveness of percutaneous release of trigger fingers using a 19-9auge needle, or a push knife. Concerns about this technique include the possibilities of incomplete release and damage to the flexor tendons and digital nerves, in the index finger and thumb. especially

Surgical Release
TECHNIQUE 73-5
in the palm or a nerve block at the Local anesthetic infiltration wrist usually is sufficient. may be helpful. Make a transverse incision about 2 em long just distal to the distal palmar crease for trigger finger (Fig. 73-16A) or just distal to the flexor crease of the thumb at the metacarpophalangeal joint for trigger thumb (Fig. 73-17). Alternative fingers may be made obliquely or longitudinally metacarpophalangeal across the thumb metacarpophalangeal incisions for the between the

The use of a pneumatic arm tourniquet

and distal palmar creases and obliquely flexion crease.

Avoid the digital nerves, which on the thumb are more palmar

and closer to the flexor sheath than might be anticipated The

thumb radial digital nerve is especially vulnerable

Retracted lateral antebrachial cutaneous nerve

mr.nIll"~~!lB!'I''!I' Distally based radial forearm fascia-fat flap. A, Flap is harvested and turned over
180 degrees. B, Vascularized fascial tube is created to wrap abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. C, Flap is anchored distally with tacking sutures. (Redrawn from Wilson IF, Schubert W, Benjamin CI: The distally based radial forearm fascia-fat flap for treatment of recurrent de Quervain's tendonitis, ] Hand Slirg 26A:506, 2001.)

Identify with a small probe the discrete proximal edge of the first annular pulley of the flexor sheath. Place a small knife blade or one blade of a pair of slightly opened blunt scissors just under the edge of the sheath, and gently push it distally, cutting the first annular pulley to the interval between the first and second annular pulley of the flexor sheath (see Fig. 73-168). There may not be a clear demarcation between the first and second pulleys. Incise the sheath from proximal to distal, approximately for triggering. sheath. Evaluate the distal end of the palmar fascia and the proximal flexor tenosynovium to release all structures proximally that Ensure that all neurovascular might bind on the tendon. be incised are seen. 1 cm, and reassess the finger If the finger triggers when the patient actively

flexes and extends the digit, release 4 to 5 mm more of the

I'm-"~~!!I'''!ii'!lA,

Surgical treatment of trigger finger (see text). B, One blade of scissors has been placed beneath proximal edge of tendon sheath.

structures are retracted out of the way, and that all structures to

millE'

A, Percutaneous release of long finger A1 pulley. Metacarpophalangeal joint hyperextended and 19-9auge needle inserted just distal to the flexor crease. Bevel of needle oriented longitudinally with tendon. Skin markings indicate path of flexor tendons. B, Needle stabilized and pulley released from proximal to distal. Loss of grating sensation as pulley is cut indicates completion of release. TECHNIQUE 736
Before attempting (Fig. 73-17) the percutaneous release, it is helpful to

Surgical Release
TECHNIQUE 73-S-cont'd
After the tendon sheath has been released, encourage the patient actively to flex and extend the digit to ensure that the release is complete. Close the skin, and apply a small, dry, compression dressing.

have the patient understand that the procedure might fail, and subsequent open release may be necessary. Using sterile technique, inject local anesthetic into the skin flexion crease

over the palm between the metacarpophalangeal

and the proximal palmar crease for the index finger, and the distal palmar crease for the long, ring, and small fingers.

AFTERTREATMENT The compression dressing is removed after 48 hours, and a patch dressing is applied. Sutures are removed at 10 to 14 days. Normal use of the finger or thumb is advised after wound healing.

Maintain an orientation

to the palmar midline of the digit.

Use an 1S-gauge or 19-9auge needle for the release. Turn the palm up, resting the hand on a folded towel to permit slight hyperextension of the metacarpophalangeal joint.

Insert the needle into the A 1 pulley, and orient the bevel of the needle so that it is longitudinally tendon. Move the needle proximally and distally in the A1 pulley, pressing firmly proximally and distally. Feel for a scraping or grating sensation as the sheath is incised. When the grating is eliminated, for triggering Proper ulnar digital nerve Proper radial digital nerve additional remove the needle, and check aligned parallel to the flexor

as the patient flexes and extends the digit. An

pass of the needle might be needed. is optional.

Injection of corticosteroid

AFTERTREATMENT with
First common palmar digital nerve

Encourage

active

use

of the

finger

stretching

exercises.

'm'!lll!ll"In~!'II"r"":1 Bowler thumb. Distal sensory branches

of median nerve in hand and location of perineural fibrosis of proper ulnar digital nerve of thumb are shown. (From Minkow FV, thumb,
Clin Orthop Relat Res 83:115,

Bowler thumb is a perineural fibrosis caused by repetitious compression of the ulnar digital nerve of the thumb while grasping a bowling ball (Fig. 73-18). Bowlers with this condition usually are those who bowl three or four times a week. Tingling and hyperesthesia around the pulp accom-

Bassett FH Il\: Bowler's 1972.)

pany this condition.

A palpable lump that is exceedingly

tender and at times accompanied by distal skin atrophy is usually present. Early awareness of the cause can lead to protection of the thumb by a shield or splint and rest from bowling to help reduce the symptoms and to prevent the condition from becoming chronic. Occasionally, neurolysis and dorsal transfer of the nerve become necessary.

Carpal Tunnel Syndrome Agee JM, McCarroll HR, North ER: Endoscopic carpal tunnel release using the single proximal incision technique, Halld Clill 10:647, 1994. Agee JM, McCarroll HR, Tortosa RD, et al: Endoscopic release of the carpal tunnel: a randomized prospective multicenter study,) Halld SIIIX 17A:987, 1992. Agee JM, Peimer CA, Pyrek JD, et al: Endoscopic carpal tunnel release: a prospective study of complications and surgical experience,) Halld SlIrg 20A:165, 1995. Agee JM, Tortosa RD, Palmer CA, et al: Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. Paper presented at 45th annual meeting of the American Society of the Hand, Toronto, Sept 24-27, 1990. Aghasi MK, Rzetelny V, Axel' A: The flexor digitorum superficialis as a cause of bilateral carpal-tunnel syndrome and trigger wrist,) BOlle )oillt SlIrg 62A:134, 1980. Ahcan U, Arnez ZM, Bajrovic F, et al: Surgical technique to reduce scar discomfort after carpal tunnel surgery,) Halld SlIrg 27A:821,2002. Atroshi I, Gummesson C, Johnsson R, et al: Severe carpal tunnel syndrome potentially needing surgical treatment in a general population,) Halld SlIrg 28A:639, 2003. Avci S, Sayli U: Carpal tunnel release using a short palmar incision and a new knife,) Halld SlIrg 25B:357, 2000. Avramidis K, Lewis JC, Gallagher P: Reduction in pain associated with open carpal tunnel decompression, ) Halld SlIrg 26B:503, 2001. Bauman TD, Gelberman RH, Mubarak SJ, et al: The acute carpal tunnel syndrome, Clill Orthop Relat Res 156:151, 1981. Belcher HJ, Varma S, Schonauer F: Endoscopic carpal tunnel release in rheumatoid patients,) Halld SlIIg 25B:451, 2000. Bhatia R, Field J, Grote J, et al: Does splintage help pain after carpal tunnel release?) Halld Surg 25B:150, 2000. Bhattacharya R, Birdsall PD, Finn P, et al: A randomized controlled trial of knife light and open carpal tunnel release,) Halld SlIrg 29B: 113, 2004. Borisch N, Haussmann P: Neurophysiological recovery after open carpal tunnel decompression: comparison of simple decompression and decompression with epineurotomy,) Halld SlIrg 28B:450, 2003. Botte MJ, von Schroeder HP, Abrams RA, et al: Recurrent carpal tunnel syndrome, Halld Clin 12:731, 1996. Braun RM, Jackson WJ: Electrical studies as a prognostic factor in the surgical treatment of carpal tunnel syndrome, J Halld SlIrg 19A: 893, 1994. Braun RM, Rechnic M, Fowler E: Complications related to carpal tunnel release, Halld Clill 18:347, 2002. Bromley GS: Minimal-incision open carpal tunnel decompression, J Hand SlIrg 19A:119, 1994. Brown FE, Tanzer RC: Entrapment neuropathies of the upper extremity. In Flynn JE, ed: Hand sll~<;ery, 3rd ed, Baltimore, 1982, Williams & Wilkins.

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