Carpal Tunnel Syndrome

 

  1. Carpal Tunnel Syndrome (CTS) is characterized by numbness and tingling in the hand, especially at night. It can cause one to wake from sleep and need to “shake the hand out” in order to make the tingling stop. The numbness and tingling from carpal tunnel syndrome is on the touch surfaces of the thumb, index, middle, and usually half of the ring finger. It can also cause weakness in the muscles used for opposition (the act of bringing the thumb pad to face the pads of the other fingers.)
  2. It is caused by compression on the median nerve as it crosses the wrist underneath the transverse carpal ligament. The ligament compresses the nerve causing a decrease in blood supply. Much like a foot falling asleep with crossed legs, the hand goes to sleep when the nerve is compressed.
  3. Left untreated, it can go on to cause irreversible nerve damage. Special nerve tests can be performed to assess the degree of damage or compression to the nerve. It can often be managed nonoperatively with splints and when necessary, surgery has a high rate of success in correcting the problem. The carpal tunnel release procedure consists of surgically dividing the ligament which is compressing the nerve. Once decompressed, the nerve can heal and often begins functioning normally again.
  4. In some cases, the scar can become thick and tender after carpal tunnel release.  This is usually temporary and resolves with stretching exercises and scar massage.  A silicone pad can also help.  In an attempt to minimize scar pain, endoscopic carpal tunnel release can be performed which involves dividing the ligament from the inside out.  This avoids the need to cut the skin overlying the ligament.  In my opinion, there is a slight increase in the risk of incomplete release with this procedure which in some cases, could require an open procedure later.1  Choosing which procedure is right for you is something that you should take the time to discuss preoperatively.

What is it? Prevention Carpal Tunnel Release Surgery – Krames

What is it? Carpal Tunnel Release – Ebsco (check out the video on carpal tunnel release)

What is Carpal Tunnel Syndrome? Carpal Tunnel Fundamentals – Cleveland Clinic (includes the famous “myths/ facts” about carpal tunnel syndrome)

AAOS information page

1. Concannon, M. J.; Brownfield, M. L.; and Puckett, C. L.: The incidence of recurrence after endoscopic carpal tunnel release. Plast Reconstr Surg, 105(5): 1662-5, 2000.

Fragility Fractures

Fragility fractures are defined as those resulting from a low trauma event such as a fall from a standing height or less.  They are most commonly associated with osteoporosis.  They may occur at any site although the hip, spine, wrist, and proximal humerus are the most common.  A previous fracture is among the strongest risk factors for new fractures.  The best treatment for fragility fractures is prevention, especially prevention of a second fracture after one has already occurred.  This may require an evaluation for osteoporosis which could lead to treatment which can reduce the risk of future fractures.

Once someone has been identified as having had a fragility fracture, steps to insure proper evaluation and treatment are recommended.  Evaluation consists of first identifying risk factors for osteoporosis.  These include:

Not Modifiable Risk Factors: Advanced age, female sex, personal history of adult fracture, history of fracture in first degree relative, dementia, poor health/ frailty, and Caucasian or Asian race.

Possibly Modifiable Risk Factors: Low bone mineral density, oral glucocorticoids, recurrent falls, cigarettes, alcoholism, estrogen deficiency (menopause <45 yo), low body weight, sedentary lifestyle.

Next, a history and physical are performed.  Any loss of height from vertebral fractures are noted.  Lab studies, radiographs, and a DEXA test to measure bone mineral density may also be needed.

Once identified, patients at risk for osteoporotic fractures are approached with a four part strategy: General recommendations, treatment of osteoporosis using pharmacologic agents, prevention of falls, and/ or injury site protection.

General recommendations are primarily reductions in risk factors.  Regular weight bearing, smoking cessation, alcoholism treatment, and insuring adequate calcium (>1200 mg/day) and vitamin D (>800 IU/day) can all reduce the risk of osteoporosis.

Pharmacologic intervention may include: Bisphosphonates, hormone therapy, selective estrogen receptor modulation, calcitonin, and parathyroid hormone.

Fall prevention (or at least reducing the risk of falling) is accomplished with regular weight-bearing exercises, possible physical and occupational therapy, and minimizing the use of sedative medications.

Injury site protection refers to the use of hip protectors which have been shown to be effective in preventing hip fractures in institutional settings.

These measures can reduce the risk of an additional fragility fracture and spare someone from having to go through the pain and potential complications of such events, “all over again.” 

Bouxsein, M. L.; Kaufman, J.; Tosi, L.; Cummings, S.; Lane, J.; and Johnell, O.: Recommendations for optimal care of the fragility fracture patient to reduce the risk of future fracture. J Am Acad Orthop Surg, 12(6): 385-95, 2004.