Carpal Tunnel, UlnarTunnel, and Stenosing

TenosynovitisChapter 73

Carpal tunnel syndromeDiagnosis .Treatment .Surgical release of carpal tllllllel .Elldoscopic release of carpal tl//Illel .

Unrelieved or recurrent carpaltunnel syndrome 4298

42854286428742894291

de Quervain disease .Trigger finger and thumbBowler thumb .

429943004304

Described in 1854 by Paget, carpal tunnel syndrome (tardymedian palsy) is the result of compression of the mediannerve within the carpal tunnel. A cylindrical, inelasticcavity connecting the volar forearm with the palm, thecarpal tunnel is bounded by the transverse arch of thecarpal bones' dorsally; the hook of the hamate, triquetrum,and pisiform medially; and the scaphoid, trapezium, andfibroosseous flexor carpi radialis sheath laterally. The ventral(pal nul') aspect, or "roof," of the carpal tunnel is formedby the flexor retinaculum, consisting of the deep forearmfascia proximally, the transverse carpal ligament over thewrist, and the aponeurosis between the thenar and hypo-thenar muscles distally. The ITlOStventral (palmar) structurein the carpal tunnel is the median nerve. Lying dorsal(deep) to the median nerve in the carpal tunnel are thenine flexor tendons to the fingers and thumb.

Carpal tunnel syndrome consists predominantly of tin-gling and numbness in the typical median nerve distribu-tion 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 andradiates up the forearm. Thenar muscle atrophy usually isseen later in the course of the nerve compression. It occursmost often in patients 30 to 60 years old and is two tothree times more common in won1.en than in men. Carpaltunnel syndrome may affect 1% to 10% of the U.S. popula-tion. According to Nathan and Keniston, older, overweight,and physically inactive individuals are more likely todevelop carpal tunnel syndrome. Nathan et al. subsequently

reported that increased age, female gender, obesity, ciga-rette smoking, and vibrations associated with job tasks werecarpal tunnel risk factors in industrial workers studied overan 11-year period.

Elevation of carpal tunnel pressures greater than 20 to30 mm Hg impedes epineurial blood flow, and nerve func-tion is impaired. Any condition that crowds or reduces thecapacity of the carpal tunnell11.ay initiate the symptoms. Amalaligned Colles fracture and edema from infection ortrauma are obvious causes, and of tumors or tumorousconditions, ganglion, lipoma, and xanthoma are morecommon. In the treatment of a Colles fracture, immobiliz-ing the wrist in marked flexion and ulnar deviation cancause acute compression of the median nerve within thecarpal tunnel immediately after reduction. Systemic condi-tions, such as obesity, diabetes mellitus, thyroid dysfunc-tion, amyloidosis, and Raynaud disease, sometimes areassociated with the syndrome. Occasionally, a patient hassymptoms of carpal tunnel syndrome caused by a habitualsleeping posture at night in which the wrist is kept acutelyflexed. Trauma caused by repetitive hand motions has beenidentified as a possible aggravating factor, especially inpatients whose work requires repeated forceful finger andwrist flexion and extension. Laborers using vibratingmachinery also are at risk. The causative effect of light,repetitive activities experienced by office workers is con-troversial and unresolved. Many factors are implicated inthe causation and aggravation of carpal tunnel syndrome(Box 73-1).

When carpal tunnel syndrome occurs in pregnantwomen, the symptoms usually resolve after delivery.

Box 73-1 • Factors Involved in thePathogenesis of Carpal Tunnel Syndrome

Anatomy

Decrease in Size of Carpal TunnelBony abnormalities of the carpal bonesAcromegaly

Flexion or extension of wrist

Increase in Contents of CanalForearm and wrist fractures (Colles fracture, scaphoid fracture)Dislocations and subluxations (scaphoid rotary subluxation, lunate

volar dislocation)Posttraumatic arthritis (osteophytes)Musculotendinous variantsAberrant muscles (lumbrical, palmaris longus, palmaris profundus)Local tumors (neuroma, lipoma, multiple myeloma, ganglion

cysts)Persistent medial artery (thrombosed or patent)Hypertrophic synoviumHematoma (hemophilia, anticoagulation therapy, trauma)

Physiology

Neuropathic ConditionsDiabetes mellitusAlcoholismDouble-crush syndromeExposure to industrial solvents

Inflammatory ConditionsRheumatoid arthritisGoutNonspecific tenosynovitisInfection

Alterations of Fluid BalancePregnancyMenopauseEclampsiaThyroid disorders (especially hypothyroidism)Renal failureLong-term hemodialysisRaynaud disease

ObesityLupus erythematosusSclerodermaAmyloidosisPaget disease

External ForcesVibrationDirect pressure

From Kerwin G, Williams CS, Seiler JG: The pathophysiology of carpaltunnel syndrome, Hand Clin 12:243, 1996.

Aberrant muscles of the forearm and thrombosis of themedian artery contribute to median nerve compressIOn.The cause may be obscure in some patients.

In children, carpal tunnel syndrome is unusuaLAccording to a review by Lamberti and Light, macrodac-tyly, lysosomal storage diseases, and a strong family historyof carpal tunnel syndrome may be predisposing factors inchildren. Symptoms in children may be confusing andinclude decreased dexterity and diffuse pain. Findings suchas thenar muscle atrophy and weakness suggest that thecondition is severe by the time of presentation. The Phalentest and Tinel sign may be absent if the nerve con'lpressionhas been present for a long time. Bilateral electrodiagnostictests are recommended because this may be the best wayof localizing the site of compression.

Carpal tunnel syndrome frequently is associated withnonspecific tenosynovial edema and rheumatoid tenosyno-vitis, as are trigger finger and de Quervain disease. Schuindet al. studied biopsy specimens of the flexor tendonsynovium from 21 patients with "idiopathic" carpal tunnelsyndrome. The findings were similar in all specimens andwere typical of a connective tissue undergoing degenera-tion under repeated mechanical stress. Kerr et aL reportedthat 96% of flexor synovial biopsy specimens from 625patients with idiopathic carpal tunnel syndrome had benignfibrous tissue without inflammatory changes. Pickering etaL and Ettema et al. reported similar histological findingscomparing synovial histological changes in 30 patients withidiopathic carpal tunnel syndrome with findings in 10cadavers. The tenosynovium in patients with carpal tunneldisease showed increased fibroblast density and collagenfiber size and vascular proliferation greater than that in thecontrol group. The carpal tunnel group also showed moretype !II collagen fibers than the controls.

Paresthesia over the sensory distribution of the mediannerve is the most frequent symptom; it occurs more oftenin women and frequently causes the patient to awakenseveral hours after falling asleep with burning and numb-ness of the hand that is relieved by exercise. The Tinel signalso may be shown in most patients by percussing themedian nerve at the wrist. Atrophy to some degree of themedian-innervated thenar muscles has been reported inabout half of patients treated by operation. Acute flexionof the wrist for 60 seconds (Phalen test) in some, but notall, patients or strenuous use of the hand increases theparesthesia. Application of a blood pressure cuff on theupper arm sufficient to produce venous distention mayinitiate the symptoms.

Gellman et aL evaluated the clinical usefulness of com-

monly administered provocative tests, including wristflexion, nerve percussion, and the tourniquet test, in 67hands with electrical proof of carpal tunnel syndrome and

in 50 control hands. The most sensitive test was the wristflexion test, whereas nerve percussion was the most specificand the least sensitive. Because of its insensitivity and non-specificity, the tourniquet test was not recommended.These authors also found that with the wrist in neutralposition, the mean pressure within the carpal tunnel in 15patients with carpal tunnel syndrome was 32 mm. Hg. Thispressure increased to 99 mm Hg with 90 degrees of wristflexion and to 110 mm Hg with the wrist at 90 degrees ofextension. The pressures in the control subjects were25 mm Hg with the wrist in neutral position, 31 mm Hgwith the wrist in flexion, and 30 mm Hg with the wrist inextension.

Durkan described a carpal compression test in whichdirect compression is applied to the median nerve for 30seconds with the thumbs or an atom izer bulb attached toa manometer. Patients with carpal tunnel syndrome usuallyhave symptoms of numbness, pain, or paresthesia in themedian nerve distribution. Compared with the Tinel nervepercussion and Phalen wrist flexion tests, the carpal com-pression test was more specific (90%) and more sensitive(87%) than either of these tests.

Szabo et al. evaluated the validity of tests for carpaltu nnel syndrome, including Phalen wrist flexion, Tinelnerve percussion, Durkan compression, and Semmes-Weinstein monofilaments. Grip and pinch strength, a handdiagram, and patient symptoms were assessed. Durkannerve compression, the hand diagram score, night pain, andSemmes-Weinstein testing after a Phalen test had thehighest sensitivity. The most specific tests were the handdiagram and Tinel sign. These authors concluded that apatient with an abnormal hand diagram, a positive Durkantest, abnorn,al Semmes-Weinstein sensibility testing, andnight pain has a probability of 0.86 of having carpal tunnelsyndrome. Conversely, they found that if all four of theabove-mentioned examinations were normal, the probabil-ity of the patient having carpal tunnel syndrome was0.0068.

Sensibility testing in peripheral nerve compression syn-dromes was investigated by Gelberman et aI., who foundthat threshold tests of sensibility correlated accurately withsymptoms of nerve compression and electrodiagnosticstudies. They found Semmes-Weinstein monofilamentpressure testing to be the most accurate in determiningearly nerve compression. Koris et al. combined the Semmes-Weinstein monofilament test with the wrist flexion test fora "quantitative provocational" diagnostic test. This com-bined test was reported to have 82% sensitivity and 86%speci ficity.

According to some authors, electrodiagnostic studiesincluding nerve conduction velocities and electromyogra-phy are reliable confirmatory tests. A distal motor latencyof more than 4.5 ms and a sensory latency of more than3.5 ms are considered abnormal. Electromyography mayshow signs of nerve damage, including increased insertional

activity, positive sharp waves, fibrillations at rest, decreasedmotor recruitment, and complex repetitive discharges.These studies occasionally are normal, however, whenclinical signs of carpal tunnel syndrome are present, andthey may be abnormal in asymptomatic patients. Nerveconduction studies are reported to be 90% sensitive and60% specific for the diagnosis of carpal tunnel syndrome.They also are helpful in evaluating the upper extremity fornerve compression at the elbow, axilla, and cervical spine,and for showing changes of peripheral neuropathy. Braunand Jackson showed that electrodiagnostic testing providedno significant data for prediction of functional recovery orreemployment after carpal tunnel release. Szabo et aI.,acknowledging the value of electrodiagnostic tests as con-firmatory studies, found that this testing did not increasethe diagnostic value of the four above-mentioned tests(i.e., abnormal hand diagram, abnormal Semmes-Weinsteintesting, positive Durkan compression, and night pain). Thisfinding, combined with published false-negative rates of10%, limits the usefulness of this type of testing to deter-mine treatment. Postoperative electrodiagnostic testingmay be helpful in assessing recurrent symptoms. Table 73-1summarizes the various tests for nerve compression in thecarpal tunnel.

CT scanning displays the bony structures clearly, butdoes not define the soft tissues accurately. Ultrasonographyhas been used to show the movement of the flexor tendonswithin the carpal tunnel, but it does not clearly show soft-tissue planes. Early reports of MRI in carpal tunnel syn-drome are promising. A major advantage of MRI is its highsoft-tissue contrast, which gives detailed images of bonesand soft tissues. Healy et al. reported that of 11 wrists withcarpal tunnel syndrome evaluated with MRI, operativefindings correlated with MRI evidence of synovial disease,carpal tunnel stenosis, and median nerve compression in10. This syndrome should not be confused with nervecompression caused by a cervical disc herniation, thoracicoutlet structures, and median nerve compression proxI-mally in the forearm and at the elbow.

If mild symptoms have been present, and there is no thenarmuscle atrophy, the use of night splints and injection ofcortisone preparations into the carpal tunnel may providetemporary relief. Graham et al. reported long-term benefitin 10% of patients treated with corticosteroid injection andsplinting. Weiss, Sachar, and Gendreau compared the effi-cacy of steroid injection with splinting, and reported thatthe response to injection treatment was faster in men andin patients older than 40 years old. Care should be takennot to inject directly into the nerve. Injection also can beused as a diagnostic tool in patients without osteophytes ortumors in the canal. Most of these cases are probably causedby a nonspecific synovial edema, and these seem to respond

Table 73-1 • Tests for Nerve Compression

Interpretation ofTest How Performed Condition Tested Positive Result Positive Result

Phalen test Elbows on table, forearms Paresthesia in Numbness or tingling on Probable CTS (sensitivity

vertical, wrists flexed response to position radial digits within 60 s 075, specificity 047)Percussion test Lightly tap along median Site of nerve lesion "Electric" tingling Probable CTS if positive at

(Tinel sign) nerve from proximal to response in fi ngers the wrist (sensitivity

distal 060, specificity 067)Carpal tunnel Direct compression of median Paresthesia in Paresthesia within 30 s Probable CTS (sensitivity

compression test nerve at carpal tunnel response to 087, specificity 090)(Durkan) compression

Hand diagram Patient marks site of pain or Patient's perception of Markings on palmar side Probable CTS (sensitivityaltered sensation on symptoms of radial digits, without 0.96, specificity 073,

outlined hand diagram markings in palm negative predictivevalue 091)

Hand volume stress Hand volume measured by Hand volume Hand volume increased by Probable dynamic CTS

test displacement, repeat after 210 mL7-min stress test and 10-min rest

Direct Wick or infusion catheter Hydrostatic pressure in Resting pressure Hydrostatic compression is

measurement of placed in carpal tunnel resting and 225 mm Hg (variable believed to be probablecarpal tunnel provocative and technique related) cause of CTSpressure positioning

Static 2-point Determine minimal separation Innervation density of Failure to determine Advanced nervediscrimination of two distinct points when slow-adapting fibers separation of at least dysfunction

applied to palmar finger tip 5mmMoving 2-point As above, with movement of Innervation density of Failure to determine Advanced nerve

discrimination the points fast-adapting fibers separation at least dysfunction4mm

Vibrometry Vibrometer placed on palmar Threshold of fast- Asymmetry compared Probable CTS (sensitivity

side of digit, amplitude at adapting fibers with contralateral hand 087)

120 Hz, increased to or median to ulnar in

threshold of perception, ipsilateral handcompare median and ulnarbilaterally

Semmes-Weinstein Monofilaments of increasing Threshold of slowly Value >2.83 Median nerve impairmentmonofi laments diameter touched to palmar adapting fibers (sensitivity 083)

side of digit until patientcan determine which digit

is touchedDistal sensory Orthodromic stimulus and Latency, conduction Latency >3.5 ms or Probable CTS

latency and recording across wrist of sensory fibers asymmetry ofconduction conduction velocityvelocity >0.5 m/s versus

opposite handDistal motor Orthodromic stimulus and Latency, conduction Latency >4.5 ms or Probable CTS

latency and recording across wrist velocity of motor asymmetry ofconduction fibers of median conduction velocityvelocity nerve >1 m/s

Electromyography Needle electrodes placed in Denervation of thenar Fibrillation potentials, Advanced motor medianmuscle muscles sharp waves, increased nerve compression

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 ofthe Hand.

more favorably to injection. Injection also helps to elimi-nate the possibility of other syndron'les, especially cervicaldisc or thoracic outlet syndrome. Some patients prefer toreceive injections two or three times before a surgical pro-cedure is done. If the symptoms and physical findingsimprove, and there is no muscle atrophy, conservativetreatment with splinting and injection is reasonable.

In a study of 331 patients with carpal tunnel syndrome,Kaplan, Glickel, and Eaton identified five important factorsin 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 treatmentwhen none of these factors was present; 59.6%, with onefactor; and 83.3%, with two factors. Of patients with threefactors, 93.2% did not improve. No patient with four orfive factors was cured by medical management.

On the basis of experimental and clinical observations,Gelberman et al. proposed that carpal tunnel syndrome bedivided into early, intermediate, advanced, and acute stages.Patients with early carpal tunnel syndrome and mild symp-toms responded to steroid injection. Patients with interme-diate and advanced (chronic) syndromes responded tocarpal tunnel release. Extensive neurolysis was not shownto have any significant effect. In a prospective, randomizedstudy comparing carpal tunnel release with and withoutinternal neurolysis, MacKinnon et al. reported that internalneurolysis did not add significantly to the motor or sensoryoutcome of carpal tunnel release. In a similar prospective,randomized evaluation of epineurotomy, Foulkes et al.showed that epi neurotomy offered no cli nical benefit tocarpal tunnel release. Treatment of acute carpal tunnelsyndrome should be individualized, depending on its cause.For carpal tunnel syndrome caused by an acute increase incarpal tunnel pressure (e.g., after a Colles fracture treatedwith flexed wrist immobilization), relief may be obtainedby a change in wrist position without surgical release ofthe tunnel.

Ancillary procedures sometimes done at the time ofcarpal tunnel release include flexor tenosynovectomy, epi-neurotomy, internal neurolysis, and tendon transfers.Epineurotomy and internal neurolysis do not seem toprovide a benefit. Flexor tenosynovectomy adds no benefitfor a patient with idiopathic carpal tunnel syndrome accord-ing to Shum et al. Patients with florid tenosynovitis causedby rheumatoid arthritis or other inflammatory conditionsshould benefit from tenosynovectomy at the time of carpaltunnel release. The palmaris longus opponensplasty ofCamitz can be beneficial, particularly in an elderly patientwith thenar muscle wasting and weakness. Trape-ziometacarpal arthroplasty and carpal tunnel release maybe done safely through two incisions.

If signs and symptoms are persistent and progressIve,especially if they include thenar atrophy, division of the

deep transverse carpalligamem is indicated. The results ofsurgery are good in most instances (in 85% according toLipscomb), 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 aftercarpal tunnel release. After 6 months, there was no signifi-cant improvement in the Tinel and Phalen tests, pinchstrength, motor latency, symptom severity, or functionalscoring. Although thenar atrophy may disappear, it resolvesslowly, if at all. Surgical release might not achieve completerelief of all symptoms for patients older than 70 years oldwith advanced nerve compression according to Leit et al.When symptoms of median nerve compression developduring treatment of an acute Colles fracture, the constrict-ing bandages and cast should be loosened, and the wristshould be extended to neutral position. When mediannerve palsy develops after a Colles fracture and has notimproved after several weeks, surgery is indicated withoutfurther delay.

Surgical Release of Carpal TunnelWe describe our standard approach to open carpal tunnelrelease. Limited approaches, such as the "double incision"of Wilson (Fig. 73-1A) and the "minimal incision" ofBromley (Fig. 73-1 B) offer the rapid recovery ascribed tothe endoscopic technique and less risk. Similarly, the useof the "carpal tunnel tome" through a small palmar inci-sion is advocated by Lee, Plancher, and Strickland as atechnical modification that minimizes the soft-tissue traumaof the traditional open technique and provides better expo-sure than that of endoscopic techniques. The benefits of aknife with its attached light source remain to be seen.Regardless of the technique selected, all structures to beincised should be seen and identified first (Fig. 73-2).

TECHNIQUE 73-1

• Make a curved incision ulnar to and paralleling the thenarcrease. Avoid making the incision in the thenar crease if thecrease is deep to minimize the skin maceration with

postoperative drainage of edema fluid.

• Extend the incision proximally to the flexor crease of the wrist,where it can be continued farther proximally if necessary. Anglethe incision toward the ulnar side of the wrist to avoid crossingthe flexor creases at a right angle, but especially to avoid cuttingthe palmar sensory branch of the median nerve, which lies in the

interval between the palmaris longus and the flexor carpi radialistendons (Fig 73-3) Maintain longitudinal orientation so that theincision is generally to the ulnar side of the long finger axis oraligned with the palmaris longus. When severed, the palmarsensory branch frequently causes a painful neuroma that maylater require excision from the scar Should this nerve be severed,do not attempt to repair it, but section it at its origin.

Flexor carpiulnaris

Flexor carpiradialis

Palmarislongus

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

I'm!l'lll••~1:~'l!i·A, Anteroposterior radiograph of dissected right hand. Wires mark proximal anddistal 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 atdistal aspect of pisiform (P), and distal limit is distal to hook of hamate (H). B, Three portionsof 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 ofdistal portion of flexor retinaculum (3); transverse tubercle of trapezium (T) and tubercle ofscaphoid (5) also are shown. Proximal portion of flexor retinaculum (1) courses deep to flexorcarpi ulnaris (U) and flexor carpi radialis (R). Flexor carpi radialis tendon is shown as it piercesflexor retinaculum at junction of proximal and middle portions to enter its flbroosseous canal.F, Antebrachial fascia; M, third metacarpal. (A from and B redrawll froIII 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 carpaltunnel by subcutaneous blunt dissection proximally, and incisethe fascia, avoiding the median nerve beneath it.

• Place a blunt dissector beneath the fascia to dissect the carpaltunnel contents from the transverse carpal ligament.

• Identify the distal end of the transverse carpal ligament, andcarefully divide the transverse carpal ligament along its ulnarborder to avoid damage to the median nerve and its recurrentbranch, which may perforate the distal border of the ligamentand may leave the median nerve on the volar side (Fig. 73-4).The strong fibers of the transverse carpal ligament extend distallyfarther than is generally expected (Fig. 73-5).

• As emphasized by Cobb et aI., the flexor retinaculum includesthe distal deep fascia of the forearm proximally, the transversecarpal ligament at the true carpal tunnel, and the thickaponeurosis between the thenar and hypothenar muscles.

Release all components of the flexor retinaculum.

• Be aware of anomalous connections between the flexorpollicis longus and the index flexor digitorum profundus;anomalous flexor digitorum superficial is muscle bellies; andanomalies in the palmaris longus, hypothenar muscles, lumbricalmuscles, and median and ulnar nerves.

• Avoid injury to the superficial palmar arterial arch, about 5 to8 mm distal to the distal margin of the transverse carpalligament.

• Inspect the flexor tenosynovium. Tenosynovectomyoccasionally may be indicated, especially in patients withrheumatoid arthritis.

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

.IFlexor carpi :,,!~

ulnaris :,.~." '1, i~,;A\

Palmar branchof median nerve

Flexor carpi radialis

Median nerve

mQ., Care should be taken In any wrist inCISIOn toavoid cutting palmar branch of median nerve.

me,. Incidence of extraligamentous, subligamentous,and transligamentous course of thenar branch. (From LanzU: Anatomical variations of the median nerve in the carpaltunnel, J Hand Surg 2:44, 1977.)

AFTERTREATMENT A compression dressing and a volarsplint are applied. The hand is actively used as soon aspossible after surgery, but the dependent position is avoided.A smaller dressing can be applied after 1 week, and gradualresumption of normal use of the hand is encouraged. Thesutures are removed after 10 to 14 days. The splint is con-tinued for comfort as needed for 14 to 21 days.

Endoscopic Release of Carpal TunnelAdvocates of endoscopic carpal tunnel release, includingOkutsu et aI., Chow, Agee et aI., and Trumble et aI., citethe advantages of less palmar scarring and ulnar "pillar"pain, rapid and complete return of strength, and return towork and activities at least 2 weeks sooner than for openrelease. Prospective studies by Ferdinand and MacLean andby Macdermid et al. comparing open and endoscopic carpaltunnel release found no significant differences in function.Immediate postoperative advantages of the endoscopic

Ulnarnerve

Transversecarpalligament

Radialartery

Median nerveUlnar

artery'

mi,I, Anatomical relationships of deep transverse carpalligament.

technique in grip strength and pain relief disappeared after12 weeks according to Macdermid et al. Reports includinglarge multicenter prospective studies by Agee et al. andBrown et al. and the report by Chow and Hantes of theirseries of 2675 endoscopic releases suggest that the proce-dure can be done safely by trained and experienced sur-geons. Anecdotal reports of intraoperative injury to flexortendons; to median, ulnar, and digital nerves; and to thesuperficial palmar arterial arch emphasize the need to exer-cise great care and caution when performing the endo-scopic procedure. Cadaver studies have shown the closeproximity of the median and ulnar nerves, superficialpalntar arterial arch, and flexor tendons to the endoscopicinstruments. Problems related to endoscopic carpal tunnelrelease include (1) a technically demanding procedure; (2)a limited visual field that prevents inspection of other struc-tures; (3) the vulnerability of the median nerve, flexortendons, and superficial palmar arterial arch; (4) the inabil-ity to control bleeding easily; and (5) the limitationsimposed by mechanical failure. Agee, McCarroll, andNorth developed the following 10 guidelines to preventinjury to the carpal tunnel structures:

1. Know the anatomy.2. Never overcommit to the procedure.3. Ascertain that the equipment is working properly.4. If scope insertion is obstructed, abort the single-

incision procedure.5. Ascertain that the blade assembly is in the carpal tunnel

and not in the Guyon canal.6. If a clear view cannot be obtained, abort the single-

incision procedure.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, itmay not be applicable to every patient with carpal tunnelsyndrome. Consideration always should be given to anopen technique if endoscopic release cannot be accom-plished safely.

Although there are variations, the two methods in usein the United States are the Agee "single portal" and theChow "two portal" techniques. According to Chow, con-traindications to endoscopic carpal tunnel release includethe following: (1) the patient requires neurolysis, tenosyno-vectomy, Z-plasty of the transverse carpal ligament, ordecompression of the Guyon canal; (2) the surgeon suspectsa space-occupying lesion or other severe abnormality of themuscles, 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 contraindicationsto the use of endoscopic technique: (1) revision surgery for

unresolved or recurrent carpal tunnel syndrome; (2) ana-tomical variation in the median nerve, suggested by clinicalfindings of wasting in the abductor pollicis brevis withoutsignificant median sensory changes; and (3) previous tendonsurgery or flexor injury that would cause scarring in thecarpal tunnel, preventing the safe placement of the instru-ments for endoscopic carpal tunnel release. The generalscheme of the techniques is shown in Figs. 73-6 and 73-7.Before any surgeon attempts endoscopic carpal tunnelrelease, thorough familiarization with the techniquethrough participation in "hands-on" laboratory practicesessions is recommended.

Endoscopic Carpal Tunnel Release througha Single IncisionTECHNIQUE 73-2 Agee

• Ascertain that the operating room setup is satisfactory (seeFig. 73-6A). Ensure that there is an unobstructed view of thepatient's hand and the television monitor.

• Use general or regional anesthesia. Although the procedurecan be done safely using local anesthesia, the increase in tissuefluid can compromise endoscopic viewing.

• Exsanguinate the limb with an elastic wrap, and inflate apneumatic tourniquet applied over adequate padding. Leave thearm exposed distal to the tourniquet.

• In a patient with two or more wrist flexion creases, make theincision in the more proximal crease between the tendons of theflexor carpi radialis and flexor carpi ulnaris.

• Use longitudinal blunt dissection to protect the subcutaneousnerves and expose the forearm fascia.

• Incise and elevate a U-shaped, distally based flap of forearmfascia (see Fig. 73-6B), and retract it palmarward to facilitate

dissection of the synovium from the deep surface of theligament, creating a mouth like opening at the proximal end ofthe carpal tunnel.

• When using the tunneling tools and the endoscopic bladeassembly, keep them aligned with the ring finger, hug the hookof the hamate, and keep the tools snugly apposed to the deepsurface of the transverse carpal ligament, maintaining a pathbetween the median and ulnar nerves for the instruments.

• Use the synovium elevator to scrape the synovium from thedeep surface of the transverse carpal ligament. Extend the wristslightly; insert the blade assembly to the carpal tunnel, pressingthe viewing window snugly against the deep surface of thetransverse carpal ligament (see Figs. 73-6C and 0). Whileadvancing the blade assembly distally, maintain alignment withthe ring finger, and hug the hook of the hamate, staying to theulnar side. Make several proximal-to-distal passes to define the

distal edge of the transverse carpal ligament with the fatoverlying it.

.\

Median nerveDisposableblade assembly

m-'ii Agee technique. A, Setup of operating roomoffers optimal view of video monitor. B, U-shaped flapelevated in palmar direction. Synovium elevator prepareswrist for optimal endoscopic view by separating synoviumfrom deep side of ligament. C, Safe zone of blade elevationis triangle defined by a, ulnar half of distal edge of trans-verse 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 sectionthrough carpal tunnel depicts blade elevation in triangularsafe zone. COlltilllled

TransverseSkin carpal ligament

Forearmfascia

Superficialpalmar arch

Communicating branchof ulnar nerve

Transversecarpal ligament

Remaining transversefibers of palmar fascia

with intervening fat

Palmaris brevis

Release distal 1/2 to 2/3 of transverse carpal ligamentcompletely before making a final pass to release theremainder of the ligament. This prevents fat locatedsuperficial to the proximal portion of the ligament fromdropping into the wound and compromising the surgeon'sendoscopic view of the extent of the ligament division.

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

Endoscopic Carpal Tunnel Release througha Single IncisionTECHNIQUE 73-2 Agee-cont'd

• Define the distal edge of the transverse carpal ligament byviewing the video picture, ballottement. and light transilluminated

through the skin. Correctly position the blade assembly, andtouch the distal end of the ligament with the partially elevatedblade to judge its entry point for ligament division. Elevate theblade and withdraw the device, incising the ligament.

Ulnar arteryand nerve

• Fat from the proximal palm may compromise endoscopicviewing by protruding through the divided proximal half of theligament. leaving an oil layer on the lens. Avoid this by firstreleasing 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 goodviewing. Complete proximal ligament division with a finalproximal pass of the elevated blade.

Radialartery

Mediannerve

ml'!llllll•• IftI:'1'~j Chow technique. A, Incision for entry portal. B, Incision for exit portal. C, Carpalligament is identified by transverse fibers. D, First cut made with probe knife, cutting distalto 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 placingretrograde knife in second cut and drawing it dis-tally to join first cut. G, Proximal section of carpalligament is identified, and proximal edge is released;probe knife is used to make fourth cut. H, Finalcut is made by reinserting retrograde knife intomidsection and drawing it proximally to completerelease of carpal ligament. (Redrawn from ChowJCY: Endoscopic carpal tunnel release: two-portaltechnique, Hand Clin 10:637, 1994.)

Endoscopic Carpal Tunnel Release througha Single IncisionTECHNIQUE 73-2 Agee-cont'd

• Assess the completeness of ligament division using thefollowing endoscopic observations.

• Through the endoscope, note that the partially dividedligament separates on the deep surface, creating a V-shapeddefect (see Fig. 73-6F).

• Make subsequent cuts viewing the trapezoidal defect createdby complete division as the two halves of the ligament springapart. Through this defect, observe the transverse fibers of thepalmar fascia intermingled with fat and muscle. Force thesestructures to protrude by pressing on the palmar skin.

• Confirm complete division by rotating the blade assembly inradial and ulnar directions, noting that the edges of the

ligament abruptly "flop" into the window, obstructing theview.

• Palpate the palmar skin over the blade assembly window,

observing motion between the divided transverse carpalligament and the more superficial palmar fascia, fat, andmuscle.

• Ensure complete median nerve decompression by releasing theforearm fascia with tenotomy scissors.

• 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 volarsplint, or, in selected patients, leave the wrist unsplinted.

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

for about 4 to 6 weeks to allow maturation of soft-tissuehealing. Progression of light activities of daily living isallowed at about 2 to 3 weeks, and more strenuous activi-ties are gradually added in the next 4 to 6 weeks.

Endoscopic Carpal Tunnel Release throughTwo IncisionsTECHNIQUE 73-3 Chow

• Perform the procedure using the anesthetic believed mostappropriate by the patient and the anesthesiologist, usually aregional block or, as preferred by Chow, local anestheticinfiltration supplemented with intravenous midazolamhydrochloride (Versed) and alfentanil hydrochloride (Alfenta).

• With the patient supine, place the hand and wrist on a handtable. 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 sideof the extremity opposite the surgeon (toward the head of thetable), 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 atthe pisiform and, depending on the size of the hand, draw a lineextending 1 to 1.5 cm radially. From the end of this line, extenda 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 isthe entry portal (see Fig. 73-7A). Passively, fully abduct thethumb. Draw a line along the distal border of the fully abductedthumb across the palm toward the ulnar border of the hand.Draw another line extending proximally from the web spacebetween the long finger and the ring finger, intersecting the linedrawn from the thumb. About 1 cm proximal to the intersection

of these lines, draw a third line about 0.5 cm long transverse tothe long axis of the hand (see Fig. 73-7B)

• Make an incision in the previously marked entry portal, andbluntly dissect to explore the fascia and make a longitudinalincision through the fascia Identify the proximal edge of thetransverse carpal ligament.

• Gently lift the distal edge of the entry portal incision with asmall right-angle retractor, revealing the small space between thetransverse carpal ligament and the ulnar bursa. Bluntly dissectand develop the space between the transverse carpal ligamentand the ulnar bursa.

• Use the curved dissector obturator-slotted cannula assemblywith the pointed side toward the transverse carpal ligament toenter the space and to push the ulnar bursa free from the deepsurface of the transverse carpal ligament. Avoid entering theulnar bursa (the "extrabursal" approach).

• Use the curved dissector to feel the curved shape of the deepsurface of the transverse carpal ligament. Move the dissector

back and forth to feel the "washboard" effect of the transversefibers of the transverse carpal ligament.

• Apply a lifting force to the dissector to test the tightness ofthe ligament and to ensure that the dissector is deep to theligament, rather than in the tissues superficial to the ligament.

Ensure that the dissector and trocar are oriented in thelongitudinal axis of the forearm.

• Touch the hook of the hamate with the tip of the assembly;lift the patient's hand above the table, extending the wrist andfingers over the hand holder. Gently advance the slotted cannulaassembly distally, and direct toward the exit portal. Palpate thetip of the assembly in the palm.

• Make a second small incision as marked for the exit portal inthe palm. Pass the assembly through the exit portal, and securethe hand to the hand holder.

• Insert the endoscope at the proximal opening of the tube.

• Examine the entire length of the slotted cannula opening toensure that there is no other tissue between the slotted cannulaand the transverse carpal ligament. If there is any doubt, removethe tube and reinsert.

• With the endoscope, having been inserted from the proximaldirection, remaining in the tube, insert a probe distally, andidentify the distal edge of the transverse carpal ligament (seeFig. 73-7C).

• Use the probe knife to cut from distal to proximal to releasethe distal edge of the ligament (see Fig. 73-7D).

• Insert the triangle knife to cut through the midsection of thetransverse carpal ligament (see Fig. 73-7E).

• Insert the retrograde knife, and position it in the second cut.Draw the retrograde knife distally to join the first cut,completely releasing the distal half of the ligament (see Fig.73-7F)

• Remove the endoscope from the proximal opening of theopen tube, and insert the endoscope into the distal opening.

• Insert the instruments from the proximal opening.

• Identify the uncut proximal section of the ligament, and usethe probe knife to release the proximal edge (see Fig. 73-7G)Draw the retrograde knife proximally to complete the release ofthe ligament (see Fig. 73-7H).

• Choose the proper knife to make additional cuts to completetransection of the ligament as needed.

• Reinsert the trocar, and remove the slotted cannula from thehand.

• If a tourniquet is used, deflate it, and ascertain hemostasis andthat there is no pulsatile or excessive bleeding.

• Suture the incisions with nonabsorbable suture; apply a softdressing.

AFTERTREATMENT Active movement IS encouragedimmediately after surgery. The sutures are removed at 7 to10 days, wound healing permitting. Direct pressure to the

palm area and heavy lifting should be avoided for 2 to 3weeks or until discomfort disappears.

Unrelieved or Recurrent Carpal TunnelSyndromeIn a series of explorations of patients who had undergoneprevious carpal tu nnel surgery, Langloh and Linscheidreported good results in one half and fair results in onethird. They estimated a recurrence rate of 1.7% afterprimary carpal tunnel release. Complications and failuresare estimated to be 3% to 19%. Symptoms may lead torepeat operation in 12% of patients. Because most patientsobtain relief in the early postoperative period, it is difficultto attribute one anatomical cause to recurrent symptoms.Findings reponed at reoperation include incomplete releaseof the transverse carpal ligament, reformation of the flexorretinaculum, scarring in the carpal tunnel, median orpalmar cutaneous neuroma, palmar cutaneous nerve entrap-ment, recurrent granulomatous or inflammatory tenosyno-vitis, and hypertrophic scar in the skin. Botte et a1.categorized procedures for recurrent problems after carpaltunnel release as follows:

Incomplete ligament release-reexploration,transverse carpal ligament, eXCISIon,reformed retinaculum

Fibrosis or painful scar-epineurolysis, local muscle flaps,loca 1 or remote free fat grafts, excision, Z-plasty ofpainful scar, nerve wrapping or interposition materi-als (silicone sheet, vein wrap)

Reo/rmlt tellos)'l1ovitis-tenosynovectomy, appropriatemedical management (appropriate antibiotics IIIpatient with infectious granulomatous tenosynovitisfrom fungi or mycobacteria)

re-release ofrelease of

In a review of 131 patients who underwent reoperationfor carpal tunnel syndrome, Cobb et al. found that patientswho had normal preoperative electrodiagnostic studies,patients who had filed for compensation, and patients whohad ulnar nerve symptoms had results significantly worsethan patients without these findings. Careful patient evalu-ation must be done when considering reoperation forrecurrent symptoms and complications after initial carpaltunnel release. Cobb et a1. found that about one fourth ofpatients who had reoperation were completely satisfied.Conversely, about one fourth of patients who had reopera-tion had persistent symptoms, requiring a third operation,or were dissatisfied with the result.

Ulnar tunnel syndrome results from compression of the

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

tunnel consist of the superficial transverse carpal ligamentanteriorly, the deep transverse carpal ligament posteriorly,and the pisiform bone and pisohamate ligament medially(Fig. 73-8). Similar to the median nerve within the carpaltunnel, the ulnar nerve is subject to compression withinthis tunnel. Compared with carpal tunnel syndrome, ulnartunnel syndrome is much less common because the spaceoccupied by the ulnar nerve at the wrist is much moreyielding. The more common location of ulnar nerve con-striction is at the elbow.

The exact level of compression determines whethersymptoms are motor or sensory or both. Compressionjust distal to the tunnel affects the deep branch of thenerve that supplies most of the intrinsic muscles. A space-occupying lesion, such as a ganglion or tumor, can causecompression in this area. True or false aneurysm of theulnar artery (Fig. 73-9), thrombosis of the ulnar artery, orfracture of the hamate with hemorrhage may be the causeof pressure on the ulnar nerve. Other reported causes arelipoma and aberrant muscles. Occasionally in rheumatoiddisease, carpal tunnel and ulnar tunnel syndromes developin the same hand. In the differential diagnosis, herniationof a cervical disc, thoracic outlet syndrome, and peripheralneuropathy must be considered. Treatment consists ofexploration of the ulnar nerve at the wrist and removal ofany cause of compression. Should the ulnar artery beoccluded for several millimeters, Raynaud syndrome maybe produced in the ulnar three digits because the sympa-thetic nerve fibers to these digits pass along the ulnarartery.

Segmental resection of the occluded section and replace-ment with a vein graft is the preferred procedure when itis feasible (see Chapter 65). Usually symptoms are relieved,and weakened or atrophic intrinsic muscles may recover in3 to 12 months after surgery. For the technique of explora-tion, see the approach described for repair of the deepbranch of the ulnar nerve (see Chapter 65).

mw,:, Anatomical relationships of structures withinulnar tunnel.

WHii Two types of traumatic aneurysms of ulnar arteryin hand. A, Saccular "false" aneurysm arising from ulnarartery. B, "True" fusiform aneurysm of ulnar artery. (FromGreen DP: True and false traumatic aneurysms in the hand:report of two cases and review of the literature, J BOlle Joillt Surg55A:120, 1973.)

Stenosing tenosynovitis occurs more often in the hand andwrist than anywhere else in the body. When the extensorpollicis brevis and the abductor pollicis longus tendons inthe first dorsal compartment are affected, the condition isnamed after the Swiss physician, de Quervain, whodescribed his experience in 1895. A peritendinitis also mayaffect these tendons proximal to the extensor retinaculum,causing pain, swelling, and crepitus in some patients. Whenthe long flexor tendons are involved, trigger thumb, triggerfinger, or snapping finger occurs. Less often, the extensorpollicis longus may be affected at the level of Lister tuber-cle. Any of the other tendons that pass beneath the dorsalwrist retinaculum also may be involved. The tenosynovitisthat precedes the stenosis may result from an otherwisesubclinical collagen disease or recurrent mild trauma, suchas that experienced by carpenters and waitresses. Somecase histories indicate that acute trauma may initiate thepathological condition. In others, the condition may comeon gradually. The stenosis occurs at a point where thedirection of a tendon changes, for here a fibrous sheath actsas a pulley, and friction is maximal. Although the tenosy-novium lubricates the sheath, friction can cause a reactionwhen 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, evenstenosing tenosynovitis, respond favorably to injections ofa steroid preparation. Pain may increase temporarily duringthe initial 24 hours after loss of the local anesthetic effect;the patient should be warned about this possibility. It maybe 3 to 7 days before the steroid becomes effective, butsurgery is avoided in many instances. Before injection, itshould be determined that the tenosynovitis is not caused

by other conditions, such as gout or infection, that couldbe worsened by steroid injections.

Stenosing tenosynovitis of the abductor pollicis longus andextensor pollicis brevis tendons occurs typically in adults30 to 50 years old. WonLen are affected six to 10 timesmore frequently than men. The cause is almost alwaysrelated to overuse, either in the home or at work, or isassociated with rheumatoid arthritis. The presenting symp-toms 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 thepatient's thumb and quickly abducting the hand ulnarward,the pain over the styloid tip is excruciating." AlthoughFinkelstein stated that this test is "probably the mostpathognomonic objective sign," it is not diagnostic; thepatient's history and occupation, the radiographs, and otherphysical findings also must be considered. Arthritis in thetrapeziometacarpal, scaphotrapeziotrapezoid, and radiocar-pal joints; superficial radial nerve entrapment or neuroma;and tenosynovitis at the crossing of the extensor pollicisbrevis and abductor pollicis longus over the extensor carpiradialis longus and brevis (intersection syndrome) also cancause similar symptoms.

Conservative treatment, consisting of rest on a splint andthe injection of a steroid preparation, is most successfulwithin the first 6 weeks after onset. Harvey et aI. reported63 wrists initially treated with injections of steroids andlocal anesthetic into the tendon sheath. In 45 wrists, painrelief was complete (71.4%), and pain was relieved after asecond injection in seven. Only 11 (17.4%) required surgery.Christie in 1955, Lapidus in 1972, and Weiss et aI. in 1994reported similar experiences. When pain persists, surgeryis the treatment of choice.

Anatomical variations are common in the first dorsalcompartment. When the findings of anatomical dissectionsby Stein, Ramsey, and Key (11%); Keon-Cohen (33%); andLeao (24%) are combined, an incidence of 21 % with sepa-rate compartments results. Reports of separate compart-ments found at surgery vary from 20% to 58%. More thanhalf of patients may have "aberrant" or duplicated tendons,usually the abductor pollicis longus. These tendons some-times insert more proximally and medially than usual, intothe trapezium (Fig. 73-10), the abductor pollicis brevismuscle (Fig. 73-11), the opponens pollicis muscle, or themuscle 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 todeal with them at the time of surgery may account for anypersistence of pain. In the report of Harvey et aI., 11 of 63patients treated with injections required surgery; 10 ofthese were found to have the extensor pollicis brevis in aseparate compartment. A longitudinal septum may subdi-

Abductor pollicis longustendon inserted into

first metacarpal

Abductor pollicislongus tendon insertedinto greater multangularExtensor pollicis

brevis tendon

m';I'" Often, abductor pollicis longus inserts on greatermultangular and base of first metacarpal through twotendons. During surgery for de Quervain disease, at leastone aberrant tendon often is found.

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

Surgical TreatmentTECHNIQUE 73-4

• Use a local anesthetic and a tourniquet.

• After sterile skin preparation and draping, use a tourniquet asneeded, and infiltrate the skin in the area of the first dorsalcompartment with sufficient local anesthetic.

• Make a skin incision that runs from dorsal to volar in atransverse-to-oblique direction, parallel with the skin creases overthe area of tenderness in the first dorsal compartment (Fig. 73-12). The longitudinal incision advocated by some surgeonscreates a longer area in which skin scar may adhere to thecutaneous nerves and the tendons.

• Carry sharp dissection just through the dermis and not intothe subcutaneous fat, avoiding the branches of the superficialradial nerve.

• After retracting the skin edges, use blunt dissection in thesubcutaneous fat. Find and protect the sensory branches of thesuperficial radial nerve, usually located deep to the superficialveins.

• Identify the tendons proximal to the stenosing dorsal ligamentand sheath, and open the first dorsal compartment on itsdorsoulnar side.

• With the thumb abducted and the wrist flexed, lift theabductor pollicis longus and the extensor pollicis brevis tendonsfrom their groove. If they cannot be easily freed, look foradditional "aberrant" tendons and separate compartments.

• Close the skin incision only, and apply a small pressuredressing.

AFTERTREATMENT The small pressure dressing IS

removed after 48 hours, and a patch dressing is applied.Motion of the thumb and hand is immediately encouragedand is increased as tolerated.

Failure to obtain complete relief after surgery may resultfrom (1) formation of a neuronn in a severed branch of thesuperficial radial nerve, (2) volar subluxation of the tendonwhen too much of the sheath is removed, (3) failure to findand release a separate aberrant tendon within a separatecompartment, and (4) hypertrophy of scar from a longitu-dinal skin incision. For recurrent subluxation of the exten-sor pollicis brevis and abductor pollicis longus tendons,McMahon et al. used a distally based slip of brachioradiaJistendon to tether the first dorsal compartment tendons.Ramesh and Britton used the extensor retinaculum toprevent subluxation (Fig. 73-13). Littler et al. also describeda reconstruction for the first compartment. In their tech-nique, the septum dividing the first extensor compartmentis removed, the extensor poll icis brevis is removed fromthe compartment, and the retinacular sheath is reapproxi-mated loosely over the abductor polJicis longus tendon toprevent tendon subluxation (Fig. 73-14). Wilson et al. hadsuccess using a radial forearm fascial flap for recurrent deQuervain disease in a patient who had three unsuccessfulprocedures on the right side and two on the left. Thisprocedure requires an extensive forearm dissection (Fig.73-15).

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

Extensor pollicislongus tendon

Abductor pollicis longustendon with insertion on

abductor pollicis brevis muscleExtensorpollicis

brevis tendon

mw'" In rare cases, abductor pollicis longus inserts onfascia of abductor pollicis brevis and base of firstmetacarpal.

First dorsal carpalcompartment opened

Separate compartmentfor abductor pollicislongus tendon

Separate compartmentfor extensor pollicisbrevis tendon

mQIFJ Surgical treatment of de Quervain disease. A, Skin incision. B, Dorsal carpal liga-ment 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 pollicislongus tendons.

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

most often. Patients may note a lump or knot in the palm.The lump may be the thickened area in the first annularpart of the flexor sheath or a nodule or fusiform swellingof the flexor tendon just distal to it. The nodule can bepalpated by the examiner's fingertip and moves with thetendon. The tendon nodule usually is at the entry of thetendon into the proximal anulus at the level of the meta-carpophalangeal joint; however, in a rheumatoid patient, anodule distal to this point may cause triggering that wouldnot always be relieved by sectioning the proximal anulusalone. Sherman and Lane reported that patients may expe-rience persistent triggering after operative release becauseof catching of the tendon on the transverse fibers of thepalmar aponeurosis. Occasionally, a partially laceratedflexor tendon at this level heals with a nodule sufficientlylarge to cause triggering. Local tenderness may be present,but is not a prominent complaint. Pressure accentuates thesnapping or triggering of the distal joints. Particularly inthe thumb, the constriction is opposite the metacarpopha-langeal joint, although the interphalangeal joint is the onethat appears to lock or snap.

Treatment of trigger digits usually is nonoperative in anuncomplicated patient who presents a short time after onset

mAIIO Technique of Littler,Freedman, and Malerich for reconstruc-tion of first extensor compartment forde Quervain disease. Dotted lil/e,Transverse incision at level of margin offirst extensor compartment in line withextensor creases. 1, Superficial radialnerve is protected; retinacular sheath isincised along dorsoulnar margin toallow exploration of sheath and identi-fication of extensor pollicis brevistendon. 2, If present, septum is excised.3, Extensor pollicis brevis (b) is retractedfrom first dorsal compartment. (a),abductor pollicis longus. 4, Retinacularsheath is repaired over abductor pollicislongus tendon with 5-0 absorbablesutures. Wrist is immobilized in splintfor 2 weeks. (Redrawn from LittlerJW, Freedman DM, Malerich MM:Compartment reconstruction for deQuervain's disease, J Hal/d 5111g 27B:2-i2,2002.)

Extensorpollicisbrevis

~~,

3~1st Compartment

Surgical ReleaseTECHNIQUE 73-5

of symptoms. Nonoperative methods include stretching,night splinting, and combinations of heat and Ice.Corticosteroid injection is effective with 60% achievingsuccess after one injection according to Benson and Ptaszek.Patients with diabetes mellitus may be more refractory tononoperative management according to Griggs et al.Surgical release reliably relieves the problem for mostpatients. Turowski, Zdankiewicz, and Thomson found that97% of patients had complete resolution after operativetreatment. Finsen and Hagen reported recurrence in twoof 84 operated digits, and two patients had transient neura-praxias. Several reports document the safety and effective-ness of percutaneous release of trigger fingers using a19-9auge needle, or a push knife. Concerns about thistechnique include the possibilities of incomplete release and

damage to the flexor tendons and digital nerves, especiallyin the index finger and thumb.

• Local anesthetic infiltration in the palm or a nerve block at thewrist usually is sufficient. The use of a pneumatic arm tourniquet

may be helpful.

• Make a transverse incision about 2 em long just distal to thedistal palmar crease for trigger finger (Fig. 73-16A) or just distalto the flexor crease of the thumb at the metacarpophalangeal

joint for trigger thumb (Fig. 73-17). Alternative incisions for thefingers may be made obliquely or longitudinally between themetacarpophalangeal and distal palmar creases and obliquelyacross the thumb metacarpophalangeal flexion crease.

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

and closer to the flexor sheath than might be anticipated Thethumb radial digital nerve is especially vulnerable

Retracted lateralantebrachial cutaneous

nerve

mr.nIll"~~!lB!'I''!I' Distally based radial forearm fascia-fat flap. A, Flap is harvested and turned over180 degrees. B, Vascularized fascial tube is created to wrap abductor pollicis longus (APL) andextensor 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 flapfor treatment of recurrent de Quervain's tendonitis, ] Hand Slirg 26A:506, 2001.)

I'm-"~~!!I'''!ii'!lA, Surgical treatment of trigger finger (see text).B, One blade of scissors has been placed beneath proximaledge of tendon sheath.

• Identify with a small probe the discrete proximal edge of thefirst annular pulley of the flexor sheath.

• Place a small knife blade or one blade of a pair of slightlyopened blunt scissors just under the edge of the sheath, andgently push it distally, cutting the first annular pulley to theinterval between the first and second annular pulley of the flexorsheath (see Fig. 73-168). There may not be a clear demarcation

between the first and second pulleys. Incise the sheath fromproximal to distal, approximately 1 cm, and reassess the finger

for triggering. If the finger triggers when the patient activelyflexes and extends the digit, release 4 to 5 mm more of the

sheath.

• Evaluate the distal end of the palmar fascia and the proximalflexor tenosynovium to release all structures proximally thatmight bind on the tendon. Ensure that all neurovascularstructures are retracted out of the way, and that all structures to

be incised are seen.

millE' A, Percutaneous release of long finger A1 pulley. Metacarpophalangeal joint hyper-extended and 19-9auge needle inserted just distal to the flexor crease. Bevel of needle orientedlongitudinally with tendon. Skin markings indicate path of flexor tendons. B, Needle stabilizedand pulley released from proximal to distal. Loss of grating sensation as pulley is cut indicatescompletion of release.

Surgical ReleaseTECHNIQUE 73-S-cont'd

• After the tendon sheath has been released, encourage thepatient actively to flex and extend the digit to ensure that therelease is complete.

• Close the skin, and apply a small, dry, compression dressing.

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

Proper ulnardigital nerve

Proper radialdigital nerve

First common palmardigital nerve

'm'!lll!ll"In~!'II"r"":1 Bowler thumb. Distal sensory branches of mediannerve in hand and location of perineural fibrosis of properulnar digital nerve of thumb are shown. (From Minkow FV,Bassett FH Il\: Bowler's thumb, Clin Orthop Relat Res 83:115,1972.)

TECHNIQUE 73·6 (Fig. 73-17)

• Before attempting the percutaneous release, it is helpful tohave the patient understand that the procedure might fail, and

subsequent open release may be necessary.

• Using sterile technique, inject local anesthetic into the skinover the palm between the metacarpophalangeal flexion creaseand the proximal palmar crease for the index finger, and thedistal palmar crease for the long, ring, and small fingers.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 topermit slight hyperextension of the metacarpophalangeal joint.

• Insert the needle into the A 1 pulley, and orient the bevel ofthe needle so that it is longitudinally aligned parallel to the flexor

tendon.

• Move the needle proximally and distally in the A1 pulley,pressing firmly proximally and distally. Feel for a scraping orgrating sensation as the sheath is incised.

• When the grating is eliminated, remove the needle, and checkfor triggering as the patient flexes and extends the digit. An

additional pass of the needle might be needed.

• Injection of corticosteroid is optional.

AFTERTREATMENT Encourage active use of the fingerwith stretching exercises.

Bowler thumb is a perineural fibrosis caused by repetitiouscompression of the ulnar digital nerve of the thumb whilegrasping a bowling ball (Fig. 73-18). Bowlers with thiscondition usually are those who bowl three or four timesa week. Tingling and hyperesthesia around the pulp accom-

pany this condition. A palpable lump that is exceedinglytender and at times accompanied by distal skin atrophy isusually present. Early awareness of the cause can lead toprotection of the thumb by a shield or splint and rest frombowling to help reduce the symptoms and to prevent thecondition from becoming chronic. Occasionally, neurolysisand dorsal transfer of the nerve become necessary.

Carpal Tunnel SyndromeAgee JM, McCarroll HR, North ER: Endoscopic carpal tunnel

release using the single proximal incision technique, Halld Clill10:647, 1994.

Agee JM, McCarroll HR, Tortosa RD, et al: Endoscopic releaseof the carpal tunnel: a randomized prospective multicenterstudy,) Halld SIIIX 17A:987, 1992.

Agee JM, Peimer CA, Pyrek JD, et al: Endoscopic carpal tunnelrelease: a prospective study of complications and surgical expe-rience,) Halld SlIrg 20A:165, 1995.

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Gilberts EC, Beekman WH, Stevens HJ, et al: Prospective ran-domized trial of open versus percutaneous surgery for triggerdigits, j Hand Surg 26A:497, 2001.

Griggs SM, Weiss A-PC, Lane LB, et al: Treatment of triggerfinger in patients with diabetes mellitus, J Hand Surg 20A:787,1995.

Ha KI, Park MJ, Ha CW: Percutaneous release of trigger digits,j Bone joint Surg 83B:75, 2001.

Itsubo T, Uchiyama S, Takahara K, et al: Snapping wrist aftersurgery for carpal tunnel syndrome and trigger digit: a casereport, J Hand Surg 29A:384, 2004.

Le Viet D, Tsionos 1, Boulouednine M, et al: Trigger fingertreatment by ulnar superficialis slip resection (U.S.S.R.), jHand Surg 29B:368, 2004.

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