Jonas L. Matzon

Treatment of Carpal Tunnel Syndrome by Members of the American Society for Surgery of the Hand: A 25-Year Perspective

PURPOSE In 1987, Duncan et al.(1) reported on a survey of the members of the American Society for the Surgery of the Hand (ASSH) about their practices in treating carpal tunnel syndrome (CTS). To better understand changes in the treatment of CTS over the past 25 years, we repeated the survey while incorporating present-day controversies. METHODS With the approval of the ASSH, an Internet-based survey was e-mailed to all members of the Society. This included 33 primary questions focusing on 4 areas of study: surgeon demographic information, nonoperative treatment, surgical technique, and postoperative care. A total of 1,463 surveys were delivered and 707 surveys were completed and returned, for a response rate of 48%. Responses were compared with the responses from Duncan et al. published 25 years ago.(1) RESULTS In contrast to the practice patterns identified 25 years ago, this survey identified several changes in current clinical practices including the following statistically significant findings: Preoperatively, surgeons have increased the use of splints and corticosteroid injections, treat nonoperatively longer, and have narrowed their surgical indications. Regarding surgical technique, surgeons now are using tourniquets less, infiltrate the carpal tunnel with corticosteroids less, and place deep sutures less often. Furthermore, performing concomitant procedures along with release of the transverse carpal ligament has decreased. Orthotic use and duration postoperatively also decreased. CONCLUSIONS Although significant differences are evident between management of CTS between 1987 and 2011, no consensus has emerged.

Extensor tendon injuries.

The extensor mechanism of the fingers, hand, wrist, and forearm is extremely intricate. Disruptions to the extensor system are common and can be associated with poor patient outcomes when not treated appropriately. Although extensor tendon injuries receive much less attention in the literature than flexor tendon injuries do, several recent studies have examined this topic. This article presents an overview of the treatment of extensor tendon injuries, with a focus on recent developments.

Carpal Tunnel Syndrome in Pregnancy

During pregnancy, hormonal fluctuations, fluid shifts, and musculoskeletal changes predispose women to carpal tunnel syndrome. While the clinical presentation is similar to other patients, the history obtained must include information regarding the pregnancy itself. Currently, the indication for electrodiagnostic testing is not clearly defined. Given that symptoms often improve with conservative treatment and abate after delivery, EMG/NCV testing can often be avoided. However, if symptoms are severe or persist, carpal tunnel release is indicated and is considered a safe procedure for both mother and fetus.

Hardware-Related Complications After Dorsal Plating for Displaced Distal Radius Fractures

There has been a trend away from dorsal fixation of distal radius fractures secondary to a historically higher complication rate. However, the literature on low-profile dorsal plates and titanium implants for the treatment of these fractures is limited. The goal of the current study was to evaluate hardware-related complications and removal rates after open reduction and internal fixation of unstable, displaced distal radius fractures using a dorsal approach with a low-profile titanium plate. A single surgeon treated 125 patients with isolated, unstable, dorsally displaced distal radius fractures by open reduction and internal fixation using a low-profile titanium dorsal plating system. A total of 110 patients were followed for a minimum of 1 year, and mean follow-up was 27 months (range, 12-74). Outcomes were assessed radiographically and clinically. Satisfactory alignment was achieved in all cases, and no fracture went on to nonunion. Nine patients (8%) required removal of hardware at an average of 12 months (range, 6-34). Six patients (5%) had evidence of extensor tenosynovitis intraoperatively, but no extensor tendon ruptures were identified. Overall, using the Gartland and Werley score, results were excellent in 82 patients, good in 22 patients, fair in 5 patients, and poor in 1 patient. Six complications accounted for the fair and poor results. The average Disabilities of the Arm, Shoulder and Hand (DASH) score at latest follow-up was 6 (range, 0-25). This series showed that the technique of dorsal plating with a low-profile titanium plate is safe and effective.

Adherence to the AAOS upper-extremity clinical practice guidelines.

The American Academy of Orthopaedic Surgeons (AAOS) recently developed several clinical practice guidelines (CPGs) involving upper-extremity conditions. The purpose of this study was to evaluate the adherence to these CPGs by members of the American Society for Surgery of the Hand (ASSH). An e-mail containing a brief study description and access to the survey was sent to ASSH current and candidate members. The survey contained questions involving the existing upper-extremity AAOS CPGs: diagnosis and treatment of carpal tunnel syndrome, treatment of distal radius fractures, and treatment of glenohumeral arthritis. Overall, 469 responses were obtained, for a response rate of 32%. Descriptive statistics were used to evaluate the responses. Members of ASSH do not universally adhere to the AAOS CPGs. For patients with carpal tunnel syndrome, 53% of respondents wait the recommended time to change nonoperative treatment after failure of a given modality, and 32% of respondents always order electrodiagnostic testing when considering surgery. Furthermore, 30% of respondents immobilize the wrist postoperatively. In regard to distal radius fractures, 11% of respondents always prescribe vitamin C after treatment, and 49% respondents never do so. However, ASSH members follow some of the recommendations. These include nighttime splinting (98%) and corticosteroid injections (85%) in the nonoperative treatment of carpal tunnel syndrome. For distal radius fractures, almost 85% of respondents consider the suggested postreduction criteria when determining operative versus cast treatment. Further study is warranted to understand the reasons for and possible solutions to the inconsistent adherence to the AAOS CPGs.

Trapeziometacarpal joint arthritis

Trapeziometacarpal (TM) joint arthritis is a common cause of radial-sided wrist pain that preferentially affects women. It is diagnosed by a thorough history, physical examination, and radiographic evaluation. While radiographs are used to determine the stage of disease, treatment is dependent on symptom severity. Nonoperative treatment frequently consists of activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), splinting, and corticosteroid injections. After failure of conservative treatment, various surgical options exist depending on the stage of disease. This article reviews the literature supporting the various surgical treatment options. Special consideration is given to the comparison of trapeziectomy with and without tendon interposition and ligament reconstruction.

Flexor Tendon Injury, Repair and Rehabilitation

Injuries to the flexor tendons remain among the most difficult problems in hand surgery. Historically, lacerations to the intrasynovial portion of the flexor tendons were thought to be unsuitable for primary repair. Despite continuing advances in our knowledge of flexor tendon biology, repair, and rehabilitation, good results following primary repair of flexor tendons remain challenging to achieve.

Distal Interphalangeal Joint Bony Dimensions Related to Headless Compression Screw Sizes

PURPOSE To determine the radiographic dimensions of the distal interphalangeal (DIP) joint and to compare these measurements with commonly used headless compression screws. METHODS Using standard posteroanterior and lateral radiographs of the hand, we measured the dimensions of the distal and middle phalanges in 60 index, middle, ring, and little fingers. We then compared these measurements with the diameters and lengths of 16 commercially available headless compression screws commonly used to perform DIP joint arthrodesis. Percent compatibility and risk factors for incompatibility were determined. RESULTS In general, commercially available screw diameters were too large given the anatomic dimensions of the DIP joint. The distal phalanx shaft as measured on the lateral view was the narrowest determinant of fit. When the dimensions of all fixation devices were combined, screws were oversized relative to the bony anatomy in 66% of index fingers, 53% of middle fingers, 49% of ring fingers, and 72% of little fingers. This mismatch was greater in women than in men. Only 1 of the compression screw types demonstrated a compatibility rate greater than 90% for the index and little fingers, respectively. A multivariate analysis of independent risk factors showed the likelihood of a compatible fit to vary directly with patient height and to be less likely in the little and index fingers. Interobserver reliability analysis revealed excellent x-ray measurement correlation between observers. CONCLUSIONS A size mismatch existed between the anatomic dimensions of the DIP joint and commercially available headless compression screws. Caution must be used when considering these screws for DIP joint arthrodesis, to avoid problems related to screw prominence in the narrow aspects of the distal and middle phalanges. CLINICAL RELEVANCE Headless compression screws are frequently oversized for use in DIP arthrodesis.

Risk Factors for Ulnar Nerve Instability Resulting in Transposition in Patients With Cubital Tunnel Syndrome

PURPOSE To assess the incidence of ulnar nerve instability in patients undergoing in situ decompression and to identify preoperative risk factors to predict the need for transposition. METHODS Using our surgical database, we retrospectively identified 363 patients who were candidates for in situ ulnar nerve decompression for the treatment of cubital tunnel syndrome over a 5-year period. During this time, the 3 participating surgeons considered ulnar nerve instability to be a contraindication for in situ ulnar nerve decompression. We collected demographic data including sex, age, weight, height, and body mass index. We recorded the number of patients who underwent ulnar nerve transposition owing to ulnar nerve instability and evaluated whether ulnar nerve instability was diagnosed before, during, or after surgery. RESULTS Of the 363 patients who were considered for in situ ulnar nerve decompression, 76 patients (21%) underwent ulnar nerve transposition secondary to ulnar nerve instability. Twenty-nine patients (8%) were identified with instability before surgery, and 44 patients (12%) were identified with instability during surgery following in situ decompression. Three patients (1%) were not diagnosed with instability until after surgery and subsequently underwent secondary transposition. Patients who underwent transposition owing to instability were more likely to be male and to be younger. CONCLUSIONS A notable percentage of patients with a stable nerve before surgery will have ulnar nerve instability following decompression. Identification of factors correlating to instability and the potential need for transposition can aid surgeons and patients in preoperative planning.

Elevated Hemoglobin A1C Levels Correlate with Blood Glucose Elevation in Diabetic Patients following Local Corticosteroid Injection in the Hand: A Prospective Study.

Background: Diabetic patients develop hand conditions that are managed with local corticosteroid injections. Injections can result in a transient elevation in serum glucose in diabetic patients. Hemoglobin A1c is the accepted measure of long-term plasma glucose control in diabetics (levels ≥7 percent reflect poor blood glucose control). The purpose of this study was to assess the relationship between hemoglobin A1c levels and increased blood glucose levels after corticosteroid injections. Methods: Twenty-five diabetic patients were evaluated prospectively. One milliliter containing 10 mg of triamcinolone acetonide was used. The most recent hemoglobin A1c level and normal average blood glucose levels were obtained. Glucose levels were obtained from patient recall of their daily blood glucose self- monitoring on the day of the injection. Postinjection blood glucose levels were recorded until levels returned to preinjection baseline. Results: Twenty patients (80 percent) had elevation of their blood glucose level from baseline. No patient had elevated blood glucose levels after 5 days. Patients with hemoglobin A1c levels greater than or equal to 7 percent had a higher blood glucose elevation and maintained this for longer than those who had a lower hemoglobin A1c level. Patients in the higher hemoglobin A1c group also had a higher number of hyperglycemic events. There was a strong or moderate correlation between hemoglobin A1c and elevated blood glucose levels during days 1 to 4. Conclusions: Patients with hemoglobin A1c levels greater than or equal to 7 percent have elevations in blood glucose that are higher and last longer than patients with lower levels. Hemoglobin A1c levels can be used to roughly predict the degree of blood glucose elevation after corticosteroid injections into the hands of diabetic patients.