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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



of the




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


Diabetes mellitus

Rheumatoid Gout



Nonspecific tenosynovitis Infection

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.




tests, including


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

Sensibility testing in peripheral nerve compression syndromes was investigated by Gelberman et 50 control Semmes-Weinstein sensibility testing. who found that threshold tests of sensibility correlated accurately with symptoms of nerve compression and electrodiagnostic studies. whereas nerve percussion was the most specific and the least sensitive. According to some authors. decreased motor recruitment. Nerve conduction studies are reported to be 90% sensitive and 60% specific for the diagnosis of carpal tunnel syndrome. and night pain has a probability of 0. pain. found that this testing did not increase the diagnostic value of the four above-mentioned tests (i. evaluated the validity of tests for carpal tu nnel syndrome. which gives detailed images of bones and soft tissues. operative findings correlated with MRI evidence of synovial disease. Because of its insensitivity and nonspecificity. abnormal Semmes-Weinstein testing. and they may be abnormal in asymptomatic patients. reported long-term benefit in 10% of patients treated with corticosteroid injection and splinting. Tinel nerve percussion. Most of these cases are probably caused by a nonspecific synovial edema. 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. abnorn. Weiss.5 ms are considered abnormal. Durkan nerve compression. limits the usefulness of this type of testing to determine treatment. and median nerve compression in 10. They also are helpful in evaluating the upper extremity for nerve compression at the elbow. These authors also found that with the wrist in neutral position. carpal tunnel stenosis. 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. and patient symptoms were assessed. This finding. and reported that the response to injection treatment was faster in men and in patients older than 40 years old. however. These authors concluded that a patient with an abnormal hand diagram. and cervical spine. Koris et al. electrodiagnostic studies including nerve conduction velocities and electromyography are reliable confirmatory tests. outlet structures. The most specific tests were the hand diagram and Tinel sign. The pressures in the control subjects were 25 mm Hg with the wrist in neutral position. the hand diagram score. the use of night splints and injection of cortisone preparations into the carpal tunnel may provide temporary relief.5 ms and a sensory latency of more than 3. Braun and Jackson showed that electrodiagnostic testing provided no significant data for prediction of functional recovery or reemployment after carpal tunnel release. but does not define the soft tissues accurately.0068. and for showing changes of peripheral neuropathy. and Gendreau compared the efficacy of steroid injection with splinting. Hg... This combined test was reported to have 82% sensitivity and 86% speci ficity.86 of having carpal tunnel syndrome. and SemmesWeinstein monofilaments. the tourniquet test was not recommended. thoracic proxI- If mild symptoms have been present. 31 mm Hg with the wrist in flexion. axilla. the carpal compression test was more specific (90%) and more sensitive (87%) than either of these tests. Early reports of MRI in carpal tunnel syndrome are promising. including increased insertional activity. and Semmes-Weinstein testing after a Phalen test had the highest sensitivity. A major advantage of MRI is its high soft-tissue contrast. they found that if all four of the above-mentioned examinations were normal. combined the SemmesWeinstein monofilament test with the wrist flexion test for a "quantitative provocational" diagnostic test.. and 30 mm Hg with the wrist in extension. positive Durkan compression.e. This syndrome should not be confused with nerve compression caused by a cervical disc herniation. night pain. Graham et al. abnormal hand diagram. positive sharp waves. and these seem to respond . and median nerve compression mally in the forearm and at the elbow. and complex repetitive discharges. a positive Durkan test. the probability of the patient having carpal tunnel syndrome was 0. Sachar. a hand diagram. They found Semmes-Weinstein monofilament pressure testing to be the most accurate in determining early nerve compression. the mean pressure within the carpal tunnel in 15 patients with carpal tunnel syndrome was 32 mm. or paresthesia in the median nerve distribution. when clinical signs of carpal tunnel syndrome are present. Ultrasonography has been used to show the movement of the flexor tendons within the carpal tunnel. CT scanning displays the bony structures clearly. These studies occasionally are normal. A distal motor latency of more than 4. Szabo et aI. Electromyography may show signs of nerve damage. including Phalen wrist flexion. Injection also can be used as a diagnostic tool in patients without osteophytes or tumors in the canal. and there is no thenar muscle atrophy. Conversely. Patients with carpal tunnel syndrome usually have symptoms of numbness. The most sensitive test was the wrist flexion test. fibrillations at rest. and night pain). Postoperative electrodiagnostic testing may be helpful in assessing recurrent symptoms. combined with published false-negative rates of 10%. Szabo et al. Compared with the Tinel nerve percussion and Phalen wrist flexion tests. Table 73-1 summarizes the various tests for nerve compression in the carpal tunnel. but it does not clearly show softtissue planes. acknowledging the value of electrodiagnostic tests as confirmatory studies. Care should be taken not to inject directly into the nerve. Durkan compression. Healy et al. reported that of 11 wrists with carpal tunnel syndrome evaluated with MRI. Grip and pinch strength.

specificity 090) of Paresthesia in response to position Site of nerve lesion or median to ulnar in . specificity 047) Probable CTS if positive at the wrist (sensitivity 060. From Abrams R. forearms vertical.5 ms or asymmetry of conduction >1 m/s Fibrillation potentials. 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. sharp waves. 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. specificity 067) Probable CTS (sensitivity 087. In Trumble TE. conduction velocity of motor fibers of median nerve Denervation muscles of thenar Orthodromic stimulus and Latency.96. ed: Hand surgery update 3. Amencan Society for Surgery of the Hand.5 m/s versus opposite hand Latency >4. 2003. increased to threshold of perception. carpal tunnel syndrome. Rosemont. negative predictive value 091) Hand volume measured by displacement. increased insertional activity CTS. 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.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. without markings in palm Hand volume increased by 210 mL Probable CTS (sensitivity 0. specificity 073. compare median and ulnar bilaterally Semmes-Weinstein monofi laments Monofilaments of increasing Threshold of slowly adapting fibers Value >2. 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. Meunier M: Carpal tunnel syndrome.5 ms or asymmetry of conduction velocity >0. conduction of sensory fibers Latency >3. amplitude 120 Hz. III.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.

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. MacKinnon et al. Trapeziometacarpal arthroplasty and carpal tunnel release may be done safely through two incisions. Two thirds of patients were cured by medical treatment when none of these factors was present. Patients with early carpal tunnel syndrome and mild symptoms responded to steroid injection. where it can be continued farther proximally if necessary. and acute stages. 59.g. internal neurolysis. Glickel. (4) stenosing flexor tenosynovitis. Treatment of acute carpal tunnel syndrome should be individualized. Gelberman et al. When severed. but especially to avoid cutting the palmar sensory branch of the median nerve. In a study of 331 patients with carpal tunnel syndrome. Angle the incision toward the ulnar side of the wrist to avoid crossing the flexor creases at a right angle. depending on its cause. and tendon transfers. The benefits of a knife with its attached light source remain to be seen. it resolves slowly. On the basis of experimental and clinical observations. TECHNIQUE 73-1 • Make a curved incision ulnar to and paralleling the thenar crease. Plancher. and (5) a positive Phalen test result in less than 30 seconds. and 83. 93. the use of the "carpal tunnel tome" through a small palmar incision is advocated by Lee. and benefits seem to last in most patients. do not attempt to repair it. Flexor tenosynovectomy adds no benefit for a patient with idiopathic carpal tunnel syndrome according to Shum et al. symptom severity. 73-2). Some patients prefer to receive injections two or three times before a surgical procedure is done.. there was no significant improvement in the Tinel and Phalen tests. the constricting bandages and cast should be loosened. randomized evaluation of epineurotomy. and the wrist should be extended to neutral position. No patient with four or five factors was cured by medical management. Foulkes et al. Ancillary procedures sometimes done at the time of carpal tunnel release include flexor tenosynovectomy. 73-1 B) offer the rapid recovery ascribed to the endoscopic technique and less risk. (3) constant paresthesia. If signs and symptoms are persistent and progressIve. and Eaton identified five important factors in determining the success of nonoperative treatment: (1) age older than 50 years. especially if they include thenar atrophy. disc or thoracic outlet syndrome. such as the "double incision" of Wilson (Fig. Epineurotomy and internal neurolysis do not seem to provide a benefit. In a similar prospective. or functional scoring. after a Colles fracture treated with flexed wrist immobilization).2% did not improve. surgery is indicated without further delay. If the symptoms and physical findings improve. Extensive neurolysis was not shown to have any significant effect. intermediate. 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. 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.more favorably to injection. When median nerve palsy develops after a Colles fracture and has not improved after several weeks. nate the possibility Injection also helps to elimiespecially cervical deep transverse carpalligamem is indicated. with one factor. the palmar sensory branch frequently causes a painful neuroma that may later require excision from the scar Should this nerve be severed. 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. Of patients with three factors. When symptoms of median nerve compression develop during treatment of an acute Colles fracture. with two factors. After 6 months. advanced. conservative treatment with splinting and injection is reasonable.6%. Similarly. particularly in an elderly patient with thenar muscle wasting and weakness. motor latency. (2) duration longer than 10 months. Regardless of the technique selected. but section it at its origin. The results of of other syndron'les. reported that internal neurolysis did not add significantly to the motor or sensory outcome of carpal tunnel release. The palmaris longus opponensplasty of Camitz can be beneficial. Kaplan. In a prospective. Avoid making the incision in the thenar crease if the crease is deep to minimize the skin maceration with postoperative drainage of edema fluid. 73-1A) and the "minimal incision" of Bromley (Fig. Patients with intermediate and advanced (chronic) syndromes responded to carpal tunnel release. pinch strength. Limited approaches. division of the . randomized study comparing carpal tunnel release with and without internal neurolysis. in wrist position without surgical release of surgery are good in most instances (in 85% according to Lipscomb).3%. and there is no muscle atrophy. epineurotomy. proposed that carpal tunnel syndrome be divided into early. maximum improvement was seen in the first 6 months after carpal tunnel release. showed that epi neurotomy offered no cli nical benefit to carpal tunnel release. For carpal tunnel syndrome caused by an acute increase in carpal tunnel pressure (e. all structures to be incised should be seen and identified first (Fig. Surgical Release of Carpal Tunnel We describe our standard approach to open carpal tunnel release. Although thenar atrophy may disappear. tunnel release. According to a prospective study by Guyette and Wilgis. relief may be obtained by a change the tunnel.

transverse tubercle of trapezium (T) and tubercle of scaphoid (5) also are shown. J Hand 5nrg 19A:907.Flexor carpi ulnaris Flexor carpi radialis Palmaris longus mill. J Hand 5nrg 19A:119. Posteraro R. which includes middle portion of flexor retinaculum (transverse carpal ligament) and distal portion of flexor retinaculum. Incision used for minimal-incision approach. F. Thenar muscles attach to radial half of classic flexor retinaculum. 1993. B redrawn from Bromley GS: Minimal-incision open carpal tunnel decompression. Wires mark proximal and distal extents of classic flexor retinaculum. third metacarpal. A. (A redrawn from Wilson KM: Double incision open technique for carpal tunnel release: an alternative to endoscopic release.) I'm!l'lll •• A. 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. 1994. B.) . Proximal portion of flexor retinaculum (1) courses deep to flexor carpi ulnaris (U) and flexor carpi radialis (R). composed of distal portion of flexor retinaculum (3). Transverse incision proximal to anterior wrist crease between flexor carpi ulnaris and flexor carpi radialis tendons. J Hand 5111"g18A:91. Three portions of flexor retinaculum (1 to 3) consist of thick aponeurosis between thenar (A) and hypothenar (B) muscles. 1994. B. (A from and B redrawll fro III Cobb TK. Anteroposterior radiograph of dissected right hand. and distal limit is distal to hook of hamate (H). Note proximal limit is at distal aspect of pisiform (P). M. Distal longitudinal incision made between proximal palmar crease and 1 cm distal to hamate hook in line with radial border of ring fll1ger. Dalley !:lK. et al: Anatomy of the flexor retinaculum. Antebrachial fascia.

i ~. muscles. Incidence of extraligamentous. • As emphasized by Cobb et aI. includes me.. the flexor retinaculum carpal ligament at the true carpal tunnel.I. A smaller dressing can be applied after 1 week. about 5 to 8 mm distal to the distal margin of the transverse carpal ligament.. and gradual resumption of normal use of the hand is encouraged. 73-5). and • Avoid injury to the superficial palmar arterial arch. Prospective studies by Ferdinand and MacLean and by Macdermid et al. • Be aware of anomalous connections anomalous flexor digitorum Endoscopic Release of Carpal Tunnel Advocates of endoscopic carpal tunnel release.. avoiding the median nerve beneath it. 1977.. The hand is actively used as soon as possible after surgery.TECHNIQUE 73-1-cont'd • Identify the deep fascia of the forearm proximal to the carpal tunnel by subcutaneous blunt dissection proximally. (From Lanz U: Anatomical variations of the median nerve in the carpal tunnel.A\ mQ. the transverse AFTERTREATMENT A compression dressing and a volar splint are applied.. which may perforate the distal border of the ligament and may leave the median nerve on the volar side (Fig.I :. and the thick aponeurosis between the thenar and hypothenar Release all components of the flexor retinaculum.~ ...:. and median and ulnar nerves. • Place a blunt dissector beneath the fascia to dissect the carpal tunnel contents from the transverse carpal ligament. between the flexor profundus. comparing open and endoscopic carpal tunnel release found no significant differences in function. • Inspect the flexor tenosynovium.) the distal deep fascia of the forearm proximally._. The sutures are removed after 10 to 14 days. and carefully divide the transverse carpal ligament along its ulnar border to avoid damage to the median nerve and its recurrent branch. including Okutsu et aI. and Trumble et aI. Agee et aI. ligament.. 73-4). • Identify the distal end of the transverse carpal ligament. Palmar branch of median nerve Transverse carpal ligament Radial artery Median nerve Flexor carpi radialis Median nerve Ulnar nerve Ulnar artery' :. subligamentous. and return to work and activities at least 2 weeks sooner than for open release. Anatomical relationships of deep transverse carpal . cite the advantages of less palmar scarring and ulnar "pillar" pain. The splint is continued for comfort as needed for 14 to 21 days. mi. rapid and complete return of strength. J Hand Surg 2:44.!~ "~':. and transligamentous course of thenar branch. Immediate postoperative advantages of the endoscopic pollicis longus and the index flexor digitorum anomalies in the palmaris longus. but the dependent position is avoided. The strong fibers of the transverse carpal ligament extend distally farther than is generally expected (Fig. hypothenar muscles.. Care should be taken In any wrist inCISIOn to avoid cutting palmar branch of median nerve. and incise the fascia. superficial is muscle bellies.. Chow. rheumatoid arthritis. lumbrical muscles.. especially in patients with Flexor carpi ulnaris JJJ .." '1. Tenosynovectomy occasionally may be indicated.

contraindications to endoscopic carpal tunnel release include the following: (1) the patient requires neurolysis. Although view of the the procedure can be done safely using local anesthesia. superficial palntar arterial arch. the increase in tissue fluid can compromise endoscopic viewing. 3. creating a mouth like opening at the proximal end of the carpal tunnel. (4) the inability to control bleeding easily. • When using the tunneling tools and the endoscopic blade assembly. • Incise and elevate a U-shaped. and retract it palmarward to facilitate dissection of the synovium from the deep surface of the ligament. 73-6A). and (3) the patient has localized infection or severe hand edema. (2) the surgeon suspects a space-occupying lesion or other severe abnormality of the muscles. Although there are variations. hug the hook of the hamate." Although this technique has proved to be effective. tenosynovectomy. • Use the synovium elevator to scrape the synovium from the deep surface of the transverse carpal ligament. Before any surgeon attempts endoscopic carpal tunnel release. the two methods in use in the United States are the Agee "single portal" and the Chow "two portal" techniques. and superficial palmar arterial arch.technique in grip strength and pain relief disappeared after 12 weeks according to Macdermid et al. make the incision in the more proximal crease between the tendons of the flexor carpi radialis and flexor carpi ulnaris. properly. According to Chow. McCarroll. 8. thorough familiarization with the technique through participation in "hands-on" laboratory practice sessions is recommended. Cadaver studies have shown the close proximity of the median and ulnar nerves. and inflate a pneumatic tourniquet applied over adequate padding. Z-plasty of the transverse carpal ligament. or the vascular status of the upper extremities is tenuous. and Brown et al. . and keep the tools snugly apposed to the deep surface of the transverse carpal ligament. Ascertain that the blade assembly is in the carpal tunnel and not in the Guyon canal. Know the anatomy. "When in doubt. unresolved or recurrent carpal tunnel syndrome. Stay in line with the ring finger. get out. and North developed the following 10 guidelines to prevent injury to the carpal tunnel structures: 1. If the view is not normal. Do not explore the carpal canal with the scope. Never overcommit to the procedure. and hug the hook of the hamate. If a clear view cannot incision procedure. Extend the wrist slightly. 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. maintaining a path between the median and ulnar nerves for the instruments. and digital nerves. flexor tendons. 73-6B). abort the single-incision procedure. abort the singleincision procedure. Endoscopic Carpal Tunnel Release through a Single Incision TECHNIQUE 73-2 Agee room setup is satisfactory (see • Ascertain that the operating Fig. The general scheme of the techniques is shown in Figs. 73-6 and 73-7. 6. abort the single- 7. 9. While advancing the blade assembly distally. be obtained. Ensure that there is an unobstructed patient's hand and the television monitor. pressing the viewing window snugly against the deep surface of the with transverse carpal ligament (see Figs. Consideration always should be given to an open technique if endoscopic release cannot be accomplished safely. 73-6C and 0). • Exsanguinate the limb with an elastic wrap. 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. tendons. Ascertain that the equipment is working 4. and to the superficial palmar arterial arch emphasize the need to exercise great care and caution when performing the endoscopic procedure. Reports including large multicenter prospective studies by Agee et al. it nerves and expose the forearm fascia. • In a patient with two or more wrist flexion creases. Make several proximal-to-distal the ring finger. Agee. Problems related to endoscopic carpal tunnel release include (1) a technically demanding procedure. and (3) previous tendon surgery or flexor injury that would cause scarring in the carpal tunnel. suggested by clinical findings of wasting in the abductor pollicis brevis without significant median sensory changes. (2) anatomical variation in the median nerve. keep them aligned with the ring finger. ulnar. distally based flap of forearm fascia (see Fig. 5. insert the blade assembly to the carpal tunnel. preventing the safe placement of the instruments for endoscopic carpal tunnel release. • Use longitudinal blunt dissection to protect the subcutaneous 2. maintain alignment ulnar side. and flexor tendons to the endoscopic instruments. or decompression of the Guyon canal. (2) a limited visual field that prevents inspection of other structures. to median. 10. Leave the arm exposed distal to the tourniquet. or vessels in the carpal tunnel. staying to the passes to define the may not be applicable to every patient with carpal tunnel syndrome. If scope insertion is obstructed. Anecdotal reports of intraoperative injury to flexor tendons. (3) the vulnerability of the median nerve. and (5) the limitations imposed by mechanical failure. • Use general or regional anesthesia.

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

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

C. Correctly position the blade assembly. to release distal edge of carpal ligament. accurately complete the distal ligament division with good viewing. Complete proximal ligament division with a final proximal pass of the elevated blade. Second cut made with triangle knife. and light transilluminated through the skin. Carpal ligament is identified by transverse fibers. 73-6E) • Using the unobstructed path for reinsertion of the instrument. cutting distal to proximal. ballottement. COl/til/lled . E. B. Avoid this by first releasing only the distal one half to two thirds of the ligament (see Fig. D. Incision for exit portal. First cut made with probe knife. Ulnar artery and nerve Radial artery Median nerve ml'!llllll IftI:'1'~j Chow technique.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. incising the ligament. •• A. Incision for entry portal. 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. with cut made in midsection of carpal 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.

and muscle. in selected patients. H. Proximal section of carpal ligament is identified. ligament abruptly "flop" into the window. AFTERTREATMENT The splint and sutures are removed at about 10 to 14 days if the wound has healed suitably. or.) 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. obstructing the view.F. G. Third cut made by placing retrograde knife in second cut and drawing it distally to join first cut. fat. Apply a well-padded volar by complete division as the two halves of the ligament spring apart. leave the wrist unsplinted. • Confirm complete division by rotating the blade assembly in radial and ulnar directions. Hand Clin 10:637. Forceful pulling with wrist flexion is discouraged . Active finger motion is allowed early in the postoperative period. ligament separates on the deep surface. 73-6G). observing motion between the divided transverse carpal ligament and the more superficial palmar fascia. and proximal edge is released. noting that the edges of the splint. by releasing the • Through the endoscope. 73-6F). • Apply a nonadhering dressing. (Redrawn from Chow JCY: Endoscopic carpal tunnel release: two-portal technique. • Close the incision with subcuticular or simple stitches. note that the partially divided • Palpate the palmar skin over the blade assembly window. Force these by pressing on the palmar skin. probe knife is used to make fourth cut. observe the transverse fibers of the palmar fascia intermingled structures to protrude with fat and muscle. avoiding nerve and tendon injury (see Fig. creating a V-shaped • Make subsequent cuts viewing the trapezoidal defect created • Use small right-angle retractors to view the fascia directly. defect (see Fig. • Ensure complete median nerve decompression forearm fascia with tenotomy scissors. Through this defect. 1994. Final cut is made by reinserting retrograde knife into midsection and drawing it proximally to complete release of carpal ligament.

• At least one television monitor should be placed on the side of the extremity opposite the surgeon (toward the head of the table). 73-7E). Move the dissector back and forth to feel the "washboard" fibers of the transverse carpal ligament. Direct pressure to the . apply a soft • Use the curved dissector to feel the curved shape of the deep surface of the transverse carpal ligament. and secure the hand to the hand holder. Draw a line along the distal border of the fully abducted thumb across the palm toward the ulnar border of the hand. fully abduct the thumb. and identify the distal edge of the transverse carpal ligament (see Fig. 73-7D). Palpate the tip of the assembly in the palm. effect of the transverse AFTERTREATMENT Active movement IS encouraged immediately after surgery. Ensure that the dissector and trocar are oriented in the longitudinal axis of the forearm. insert a probe distally. • Gently lift the distal edge of the entry portal incision with a small right-angle retractor. • Suture the incisions with nonabsorbable dressing. extend a second line 0. and insert the endoscope into the distal opening. extending the wrist and fingers over the hand holder. revealing the small space between the • Choose the proper knife to make additional transection of the ligament as needed. mark the entry and exit portals. • Make an incision in the previously marked entry portal. as preferred by Chow. supplemented with intravenous midazolam hydrochloride (Alfenta). lift the patient's hand above the table. 73-7H). knife. The surgeon should be on the axillary side of the upper extremity. • If a tourniquet is used. remaining in the tube. intersecting the line drawn from the thumb. Bluntly dissect and develop the space between the transverse carpal ligament and the ulnar bursa. knife distally to join the first cut. cuts to complete transverse carpal ligament and the ulnar bursa. one for the surgeon and the other for the assistant. two monitors should be used. • Insert the retrograde Draw the retrograde 73-7F) • Remove the endoscope from the proximal opening of the open tube. • With a skin pencil.5 cm long transverse to the long axis of the hand (see Fig. and bluntly dissect to explore the fascia and make a longitudinal incision through the fascia Identify the proximal edge of the transverse carpal ligament. 73-7C). Draw another line extending proximally from the web space 1 cm proximal to the intersection between the long finger and the ring finger. remove the tube and reinsert. and direct toward the exit portal. • Use the curved dissector obturator-slotted cannula assembly • Identify the uncut proximal section of the ligament. If there is any doubt. Avoid entering the ulnar bursa (the "extrabursal" approach). From the end of the second line. • Insert the instruments from the proximal opening. • Make a second small incision as marked for the exit portal in the palm. From the end of this line. • With the endoscope. • Reinsert the trocar. • Use the probe knife to cut from distal to proximal to release the distal edge of the ligament (see Fig. • 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. place the hand and wrist on a hand table. that there is no pulsatile or excessive bleeding.for about 4 to 6 weeks to allow maturation of soft-tissue healing. usually a regional block or. 73-7A). 73-7G) Draw the retrograde knife proximally to complete the release of the ligament (see Fig. Pass the assembly through the exit portal. • Insert the endoscope at the proximal opening of the tube. draw a third line about 0. Gently advance the slotted cannula assembly distally. and position it in the second cut.5 cm proximally. as preferred by Chow. rather than in the tissues superficial to the ligament. suture. or. wound healing permitting. • Apply a well-padded pneumatic tourniquet to use if needed. 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. • Insert the triangle knife to cut through the midsection of the • With the patient supine. About of these lines.5 cm radially. draw a line extending 1 to 1. deflate it. and an assistant should be on the cephalad side. • 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. depending on the size of the hand. Begin at the pisiform and. local anesthetic hydrochloride (Versed) and alfentanil • Touch the hook of the hamate with the tip of the assembly. Passively. 73-7B) transverse carpal ligament (see Fig. and use the probe knife to release the proximal edge (see Fig. and remove the slotted cannula from the hand. having been inserted from the proximal direction. completely releasing the distal half of the ligament (see Fig. The third line is the entry portal (see Fig. The sutures are removed at 7 to 10 days. 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. 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. draw a third line extending about 1 cm radially.

carpal tunnel and ulnar tunnel syndromes develop in the same hand. Botte et a1. For the technique of exploration. or were dissatisfied with the result. Segmental resection of the occluded section and replacement with a vein graft is the preferred procedure when it is feasible (see Chapter 65). Compared with carpal tunnel syndrome. reformation of the flexor retinaculum. thrombosis of the ulnar artery. Complications and failures are estimated to be 3% to 19%. Z-plasty of painful scar. release reformed retinaculum of of Fibrosis or painful scar-epineurolysis. the ulnar nerve is subject to compression within this tunnel. median or palmar cutaneous neuroma. Conversely. re-release transverse carpal ligament. local muscle flaps. such as a ganglion or tumor. thoracic outlet syndrome. patients who had filed for compensation. eXCISIon. it is difficult to attribute one anatomical cause to recurrent symptoms. and hypertrophic scar in the skin. Findings reponed at reoperation include incomplete release of the transverse carpal ligament. relationships of structures within . Similar to the median nerve within the carpal tunnel.7% after primary carpal tunnel release. True or false aneurysm of the ulnar artery (Fig. can cause compression in this area. ulnar tunnel syndrome is much less common because the space occupied by the ulnar nerve at the wrist is much more yielding. categorized procedures for recurrent problems after carpal tunnel release as follows: Incomplete ligament release-reexploration. Occasionally in rheumatoid disease. herniation of a cervical disc. and peripheral neuropathy must be considered. or fracture of the hamate with hemorrhage may be the cause of pressure on the ulnar nerve. palmar cutaneous nerve entrapment. 73-8). about one fourth of patients who had reoperation had persistent symptoms. 73-9). 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. Symptoms may lead to repeat operation in 12% of patients. found that about one fourth of patients who had reoperation were completely satisfied. The walls of the mw. nerve wrapping or interposition materials (silicone sheet. Compression just distal to the tunnel affects the deep branch of the nerve that supplies most of the intrinsic muscles. Other reported causes are lipoma and aberrant muscles. Usually symptoms are relieved. The exact level of compression determines whether symptoms are motor or sensory or both. recurrent granulomatous or inflammatory tenosynovitis. 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. and weakened or atrophic intrinsic muscles may recover in 3 to 12 months after surgery. Because most patients obtain relief in the early postoperative period. see the approach described for repair branch of the ulnar nerve (see Chapter 65).palm area and heavy lifting should be avoided weeks or until discomfort disappears. loca 1 or remote free fat grafts. Raynaud syndrome may be produced in the ulnar three digits because the sympathetic nerve fibers to these digits pass along the ulnar artery. ulnar Anatomical tunnel. requiring a third operation.5 cm long located at the carpus. the deep transverse carpal ligament posteriorly. vein wrap) Reo/rmlt tellos)'l1ovitis-tenosynovectomy. Careful patient evaluation must be done when considering reoperation for recurrent symptoms and complications after initial carpal tunnel release. and patients who had ulnar nerve symptoms had results significantly worse than patients without these findings.:. In the differential diagnosis. found reoperation that patients who had normal preoperative electrodiagnostic studies. and the pisiform bone and pisohamate ligament medially (Fig. excision. The more common location of ulnar nerve constriction is at the elbow. They estimated a recurrence rate of 1. A spaceoccupying lesion. Should the ulnar artery be occluded for several millimeters. Langloh and Linscheid reported good results in one half and fair results in one third. scarring in the carpal tunnel. Cobb et al. Treatment consists of exploration of the ulnar nerve at the wrist and removal of any cause of compression. for 2 to 3 tunnel consist of the superficial transverse carpal ligament anteriorly. Cobb et a1. Ulnar ulnar about tunnel syndrome results from compression of the nerve within a tight triangular fibroosseous tunnel 1.

the condition is named after the Swiss physician. trigger thumb. 1973. in the artery ulnar (From hand: Saccular and aneurysm arising B. who described his experience in 1895. is most successful within the first 6 weeks after onset.) Stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons occurs typically in adults 30 to 50 years old. usually the abductor pollicis longus. The cause is almost always related to overuse. and crepitus in some patients. When the long flexor tendons are involved. Many cases of tenosynovitis in various locations. reported 63 wrists initially treated with injections of steroids and local anesthetic into the tendon sheath. the extensor pollicis longus may be affected at the level of Lister tubercle. The presenting symptoms usually are pain and tenderness at the radial styloid. de Quervain. superficial radial nerve entrapment or neuroma. into the trapezium (Fig. and Key (11%). Lapidus in 1972. When the findings of anatomical dissections by Stein. an incidence of 21 % with separate compartments results. The Finkelstein test usually is positive: "on grasping the patient's thumb and quickly abducting the hand ulnarward.. by steroid WHii in hand. Harvey et aI. the patient's history and occupation. Keon-Cohen (33%). 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." it is not diagnostic. The extensor pollicis brevis is considered a "late" tendon phylogenetically and is absent in about 5% of wrists. Christie in 1955. either in the home or at work. artery. and friction is maximal. In the report of Harvey et aI. and pain was relieved after a second injection in seven. swelling. Although may come where the sheath acts the tenosy- Anatomical variations are common in the first dorsal compartment. These tendons sometimes insert more proximally and medially than usual. as in winding a fine coil of wire or stacking laundry. the opponens pollicis muscle. In others. that could injections. The tenosynovitis that precedes the stenosis may result from an otherwise subclinical collagen disease or recurrent mild trauma. and Leao (24%) are combined. be worsened such as gout or infection. and Weiss et aI. Reports of separate compartments found at surgery vary from 20% to 58%. and radiocarpal joints. Only 11 (17.4%) required surgery. Green report Two A. or is associated with rheumatoid arthritis. the patient should be warned about this possibility. Pain may increase temporarily during the initial 24 hours after loss of the local anesthetic effect. pain relief was complete (71. 73-11). "True" DP: True fusiform aneurysm false traumatic of two cases and review of the literature. or snapping finger occurs. in 1994 reported similar other conditions. 10 of these were found to have the extensor pollicis brevis in a separate compartment. WonLen are affected six to 10 times more frequently than men. and other physical findings also must be considered. 11 of 63 patients treated with injections required surgery. the condition on gradually. friction can cause a reaction when the repetition of a particular movement is necessary." Although Finkelstein stated that this test is "probably the most pathognomonic objective sign. but surgery is avoided in many instances. for here a fibrous as a pulley. When the extensor pollicis brevis and the abductor pollicis longus tendons in the first dorsal compartment are affected. 73-10).4%). is the treatment of choice. Any of the other tendons that pass beneath the dorsal wrist retinaculum also may be involved. even stenosing tenosynovitis. When pain persists. Ramsey. Sometimes a thickening of the fibrous sheath is palpable. The stenosis occurs at a point direction of a tendon changes. More than half of patients may have "aberrant" or duplicated tendons. or the muscle fascia. causing pain. it should be determined that the tenosynovitis is not caused . surgery Stenosing tenosynovitis occurs more often in the hand and wrist than anywhere else in the body. A peritendinitis also may affect these tendons proximal to the extensor retinaculum. Some case histories indicate that acute trauma may initiate the pathological condition. the abductor pollicis brevis muscle (Fig. the pain over the styloid tip is excruciating. Before injection. The presence of these variations and failure to deal with them at the time of surgery may account for any persistence of pain. trigger finger. J BOlle Joillt Surg 55A:120. the radiographs. A longitudinal septum may subdi- novium lubricates the sheath. respond favorably to injections of a steroid preparation. In 45 wrists. scaphotrapeziotrapezoid. Conservative treatment. Less often. Arthritis in the trapeziometacarpal. such as that experienced by carpenters and waitresses. types of traumatic "false" aneurysms of ulnar aneurysms of ulnar from artery. It may be 3 to 7 days before the steroid becomes effective. consisting of rest on a splint and the injection of a steroid preparation.

If they cannot be easily freed. Failure to obtain complete relief after surgery may result from (1) formation of a neuronn in a severed branch of the superficial radial nerve. Extensor pollicis brevis tendon Abductor pollicis longus tendon with insertion on abductor pollicis brevis muscle In rare cases. 73-14). avoiding the branches of the superficial radial nerve. and (4) hypertrophy of scar from a longitudinal skin incision. • After retracting the skin edges. the extensor poll icis brevis is removed from the compartment. 73-13). (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'. The longitudinal incision advocated by some surgeons creates a longer area in which skin scar may adhere to the cutaneous nerves and the tendons. For recurrent subluxation of the extensor pollicis brevis and abductor pollicis longus tendons. When associated with a collagen disease. and Witt et al. • After sterile skin preparation and draping.Abductor pollicis longus tendon inserted into first metacarpal AFTERTREATMENT The small pressure dressing IS removed after 48 hours. Littler et al. During surgery for de Quervain disease. and open the first dorsal compartment on its dorsoulnar side. In their technique. 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. (2) volar subluxation of the tendon when too much of the sheath is removed. leading to inability to extend the flexed digit ("triggering") usually is seen in individuals older than 45 years of age. several fingers may be involved-the long and ring fingers Extensor pollicis longus tendon • Close the skin incision only. • Carry sharp dissection just through the dermis and not into the subcutaneous fat. Find and protect the sensory branches of the superficial radial nerve. mw'" fascia of metacarpal. Wilson et al. • Identify the tendons proximal to the stenosing dorsal ligament and sheath. also described a reconstruction for the first compartment. the septum dividing the first extensor compartment is removed. and the retinacular sheath is reapproximated loosely over the abductor polJicis longus tendon to prevent tendon subluxation (Fig. 7312). abductor pollicis longus inserts on greater multangular and base of first metacarpal through two tendons. 73-15). and a patch dressing is applied. Surgical Treatment TECHNIQUE 73-4 • Use a local anesthetic and a tourniquet. look for additional "aberrant" tendons and separate compartments. at least one aberrant tendon often is found. use blunt dissection in the subcutaneous fat. abductor pollicis longus inserts on abductor pollicis brevis and base of first . Trigger thulTlb in adults is a distinctly separate entity from "congenital" trigger thumb (see Chapter 76). lift the abductor pollicis longus and the extensor pollicis brevis tendons from their groove. • With the thumb abducted and the wrist flexed. usually located deep to the superficial veins. parallel with the skin creases over the area of tenderness in the first dorsal compartment (Fig. Stenosing tenosynovitis.I'" compartment. and apply a small pressure dressing. to reports by Weiss et al. use a tourniquet as needed. 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. Often. McMahon et al. This procedure requires an extensive forearm dissection (Fig. Motion of the thumb and hand is immediately encouraged and is increased as tolerated. vide the according first compartment in 44% to 73% of wrists. 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.

Pressure snapping or triggering of the distal joints. the constriction is opposite the langeal joint. B. First dorsal compartment has been opened on its ulnar side.edrawn from Ramesh R. in a rheumatoid patient. Occasionally. although the interphalangeal may be present.) that appears to lock or snap. Dorsal carpal ligament has been exposed. A. palpated by the examiner's fingertip tendon. (R. 2000. the thumb. Occasionally. most often. D. 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. Skin incision.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. however. Treatment of trigger digits usually is nonoperative in an uncomplicated patient who presents a short time after onset . C. a partially lacerated flexor tendon at this level heals with a nodule sufficiently large to cause triggering. a nodule distal to this point may cause triggering that would not always be relieved by sectioning the proximal anulus alone. J Balle Jaillt 511rg 82B:424. Local tenderness but is not a prominent complaint. 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. Britton JM: A retinacular sling for subluxing tendons of the fltSt extensor compartment: a case report. tendon or knot in the palm. 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. separate compartments are found for extensor pollicis brevis and abductor pollicis longus tendons. 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.

Dotted lil/e. Corticosteroid injection is effective with 60% achieving success after one injection according to Benson and Ptaszek. abductor pollicis longus. • Make a transverse incision about 2 em long just distal to the distal palmar crease for trigger finger (Fig.) mAIIO Extensor pollicis brevis ~~. and combinations of heat and Ice. J Hal/d 5111g 27B:2-i2. 2002. septum is excised. Malerich MM: Compartment reconstruction for de Quervain's disease. Retinacular sheath is repaired over abductor pollicis longus tendon with 5-0 absorbable sutures. Turowski. 2. Freedman DM. 3~ 1st Compartment of symptoms. Freedman. Extensor pollicis brevis (b) is retracted from first dorsal compartment. Transverse incision at level of margin of first extensor compartment in line with extensor creases. night splinting. 4.Technique of Littler. If present. (a). 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 . Concerns about this technique include the possibilities of incomplete release and damage to the flexor tendons and digital nerves. 73-17). especially Surgical Release TECHNIQUE 73-5 in the palm or a nerve block at the • Local anesthetic infiltration wrist usually is sufficient. and two patients had transient neurapraxias. Zdankiewicz. • Avoid the digital nerves. Wrist is immobilized in splint for 2 weeks. Patients with diabetes mellitus may be more refractory to nonoperative management according to Griggs et al. 1. (Redrawn from Littler JW. or a push knife. in the index finger and thumb. Nonoperative methods include stretching. 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. and Thomson found that 97% of patients had complete resolution after operative treatment. Finsen and Hagen reported recurrence in two of 84 operated digits. may be helpful. Several reports document the safety and effectiveness of percutaneous release of trigger fingers using a 19-9auge needle. 3. retinacular sheath is incised along dorsoulnar margin to allow exploration of sheath and identification of extensor pollicis brevis tendon. Surgical release reliably relieves the problem for most patients. 73-16A) or just distal to the flexor crease of the thumb at the metacarpophalangeal joint for trigger thumb (Fig. and Malerich for reconstruction of first extensor compartment for de Quervain disease. Superficial radial nerve is protected.

release 4 to 5 mm more of the I'm-"~~!!I'''!ii'!lA. sheath. (Redrawn from Wilson IF. Flap is harvested and turned over 180 degrees. Flap is anchored distally with tacking sutures. A. cutting the first annular pulley to the interval between the first and second annular pulley of the flexor sheath (see Fig. Incise the sheath from proximal to distal. ] Hand Slirg 26A:506. structures are retracted out of the way. and reassess the finger If the finger triggers when the patient actively flexes and extends the digit. Surgical treatment of trigger finger (see text). B. 2001.nIll"~~!lB!'I''!I' Distally based radial forearm fascia-fat flap. 73-168). approximately for triggering. Vascularized fascial tube is created to wrap abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons.) • Identify with a small probe the discrete proximal edge of the first annular pulley of the flexor sheath. and gently push it distally. C. Benjamin CI: The distally based radial forearm fascia-fat flap for treatment of recurrent de Quervain's tendonitis. • 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. Schubert W. 1 cm. be incised are seen. and that all structures to . • Place a small knife blade or one blade of a pair of slightly opened blunt scissors just under the edge of the sheath. One blade of scissors has been placed beneath proximal edge of tendon sheath. B.Retracted lateral antebrachial cutaneous nerve mr. There may not be a clear demarcation between the first and second pulleys.

pressing firmly proximally and distally. compression dressing. encourage the patient actively to flex and extend the digit to ensure that the release is complete. 73-17) the percutaneous release. and subsequent open release may be necessary. • Use an 1S-gauge or 19-9auge needle for the release. Loss of grating sensation as pulley is cut indicates completion of release. • Close the skin.) . • Insert the needle into the A 1 pulley. (From Minkow FV. and apply a small. have the patient understand that the procedure might fail. Tingling and hyperesthesia around the pulp accom- Bassett FH Il\: Bowler's 1972. and check aligned parallel to the flexor as the patient flexes and extends the digit. AFTERTREATMENT The compression dressing is removed after 48 hours. and a patch dressing is applied. Clin Orthop Relat Res 83:115. Skin markings indicate path of flexor tendons. 73-18). B. inject local anesthetic into the skin flexion crease over the palm between the metacarpophalangeal and the proximal palmar crease for the index finger. and small fingers. • Using sterile technique. thumb.millE' A. Bevel of needle oriented longitudinally with tendon. • Move the needle proximally and distally in the A1 pulley. • Turn the palm up. Bowler thumb is a perineural fibrosis caused by repetitious compression of the ulnar digital nerve of the thumb while grasping a bowling ball (Fig. for triggering Proper ulnar digital nerve Proper radial digital nerve additional remove the needle. • Injection of corticosteroid AFTERTREATMENT with First common palmar digital nerve Encourage active use of the finger stretching exercises. and the distal palmar crease for the long. Sutures are removed at 10 to 14 days. dry. and orient the bevel of the needle so that it is longitudinally tendon. it is helpful to Surgical Release TECHNIQUE 73-S-cont'd • After the tendon sheath has been released. ring. Distal sensory branches of median nerve in hand and location of perineural fibrosis of proper ulnar digital nerve of thumb are shown. Metacarpophalangeal joint hyperextended and 19-9auge needle inserted just distal to the flexor crease. 'm'!lll!ll"In~!'II"r"":1 Bowler thumb. Needle stabilized and pulley released from proximal to distal. Normal use of the finger or thumb is advised after wound healing. An pass of the needle might be needed. Maintain an orientation to the palmar midline of the digit. Percutaneous release of long finger A1 pulley. Feel for a scraping or grating sensation as the sheath is incised. TECHNIQUE 73·6 • Before attempting (Fig. Bowlers with this condition usually are those who bowl three or four times a week. is optional. • When the grating is eliminated. resting the hand on a folded towel to permit slight hyperextension of the metacarpophalangeal joint.

1992. 1990. Dellon AL: Clinical use of vibratory stimuli to evaluate peripheral nerve injury and compression neuropathy. 2003. 20A:18. Birdsall PD.) Halld SlIIg 18A:91.) BOlle )oillt SlIIg 82B:818.) BOlle )oillt SlIrg 62A:134. Abrams RA. Brown FE. McCarroll HR. Hantes ME: Endoscopic carpal tunnel release: thirteen years' experience with the Chow technique. et al: Recurrent carpal tunnel syndrome. et al: Anatomy of the flexor retinaculum. Paper presented at 58th annual meeting of the American Academy of Orthopaedic Surgeons. et al: Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. Braun RM. Stein AB. Wildin CJ. Halld Clin 12:731. Cotton P: Symptoms may return after carpal tunnel surgery. Plast Recollstr SlIrg 105:1662. Borisch N. 2000.) Halld SIIIX 17A:987. DeSmet L. Bromley GS: Minimal-incision open carpal tunnel decompression. Toronto. A palpable lump that is exceedingly tender and at times accompanied by distal skin atrophy is usually present. 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