Sir James Paget | Pathologist
Sir James Paget and James Putnam
Although we may think that carpal tunnel syndrome is a relatively new disorder, which came about during the computer age, it was actually originally described by Sir James Paget in 1854. James Putnam, a Boston neurologist, published the first clinical study of 37 patients with carpal tunnel syndrome in 1880 and Learmonth performed the first carpal tunnel release surgery at Mayo in 1933.
Open Carpal Tunnel Release Surgery Or Open Release
However, up until the 1960s, when carpal tunnel syndrome and its treatment options became fairly well defined, there was still no clear consensus on how to treat the condition. In fact, up until the late 1940s, resection of the first rib was a common treatment for this diagnosis! Once medical opinion coalesced about the cause of the disorder, a standard surgical treatment quickly developed, known as “open carpal tunnel release surgery,” or “open release.”
Open Release Surgery
During open release surgery, the transverse carpal ligament is cut, which releases pressure on the median nerve and subsequently relieves the symptoms of carpal tunnel syndrome. A 1 – 1 ½ inch incision is made at the base of the palm of the hand, allowing the surgeon to see the transverse carpal ligament. After the ligament is cut, the skin is closed with stitches. The ligament is left open, and this decreases the pressure on the median nerve in the carpal tunnel. This sectioning of the ligament does not result in any loss of function.
With the traditional open release surgery, the hand can remain swollen and tender for a couple of months. Full use of the hand, especially during gripping and grasping activities, can sometimes take up to 6 to 8 weeks, or possibly longer.
Endoscopic release is a relatively new technique, which uses a thin tube with a camera attached (endoscope). The endoscope is guided through a small incision in the wrist, allowing the surgeon to see the transverse carpal ligament without opening the entire area with a large incision. A miniature blade, inserted through the tube, is used to cut the transverse tunnel ligament.
MicroAire® SmartRelease® Endoscopic Carpal Tunnel Release System Image: microaire.com
MicroAire® SmartRelease® Endoscopic Carpal Tunnel Release System Image: microaire.com
Here is a quick video of the endoscopic release procedure.
Relief Of Symptoms Of Endoscopic Release
The relief of symptoms of endoscopic release are similar to the traditional open technique. However, you can expect a less post-operative pain and a shorter recovery period after endoscopic carpal tunnel release, because the procedure does not require cutting the palm open and disturbing a large area of the hand. As a result, you can return to work or practicing sports earlier, especially sports that require gripping, such as golf and tennis. Endoscopic release also produces a smaller scar with less swelling and scar-related pain.
If you suspect that you have carpal tunnel syndrome, please give us a call and let one of our physician’s determine the cause of your pain, and know that should you need surgery, we will offer you the most innovative and safe treatment available.
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A couple of weeks ago, our very own Dr. Klion competed in a mountain bike race. As he had increased his training mileage for the event, he had noticed that his wrist was sore, but didn’t find this unusual as almost all cyclists often experience pain in the hand, wrist, and finger region due to excessive pressure placed on the handle bars. It was only after the event that he learned he had broken a bone in his wrist.
Other symptoms that can occur from pressure and overuse include numbness and tingling. Common cycling syndromes are described below.
Ulnar neuropathy – known to cyclists as “handlebar palsy” – results from compression of the ulnar nerve, which controls sensation in your ring and little finger, as well as hand strength with gripping. Holding the lower section of drop-down handlebars can compress the ulnar nerve.
The constant pressure on the hand’s median nerve that comes when resting one’s hands on the top of the handlebars can lead to carpal tunnel syndrome. In this case, typical symptoms are numbness or tingling in the thumb, index, middle and ring fingers, as well as a general weakness in the hand.
As with handlebar palsy, the most immediate and effective action is to change your hand position, use well-padded gloves and lessen the pressure by loosening your grip.
It may take months for the symptoms to resolve; rest, stretching exercises, and anti-inflammatories usually help to relieve the symptoms.
More importantly, you must adjust your equipment and habits! Proper bike fit is essential; adjusting the handlebars, seat, and pedals to your fit is the key to preventing most cycling overuse injuries, a third of which happen to the hands and wrist.
By sitting in a more upright position, you will take weight and pressure off your hands and wrists. During long rides, take rest stops, and change your hand position often. As often as possible, shift your weight from the center of your palms to the outside edge. Padded gloves and good shock-absorbent handlebar grip/tape will help protect your hands from injury.
Like any other part of your body, your hands and wrists will benefit from a short session of hand and wrist stretches before you hit the road.
In order to prevent injury, listen to the moral of Dr. Klion’s story; pay attention to any signs of physical discomfort and seek medical advice if the symptoms do not abate.
“My hand hurts; I think I have carpal tunnel syndrome.” Orthopedists all over America hear this from their patients everyday, often followed by the patient’s assertion that their pain has been caused by typing on a computer keyboard all day. Entire mini-industries have sprung up to support this myth that carpal tunnel syndrome is a work-related injury, rather than a medical condition, yet numerous scientific studies have shown that there is no relationship between typing and the incidence of carpal tunnel syndrome. And although using a badly positioned computer keyboard or mouse can lead to wrist pain from strain or tendinitis, it is not necessarily carpal tunnel syndrome.
Carpal tunnel syndrome (CTS) is a compression neuropathy – a condition of the peripheral nervous system – that is caused by an increase in pressure on the median nerve in the hand and wrist. The carpal tunnel is actually a space in the wrist surrounded on 3 sides by bone and covered with a ligament through which 9 tendons and one nerve – the median nerve – travel to the fingers. This nerve supplies sensation to the thumb, index, middle, and half of the ring finger, while conducting nerve impulses to the muscles that control the thumb.
Numbness, tingling, or burning in the hand, particularly at night, localized pain over the carpal tunnel in the palm and wrist, or pain that periodically radiates towards the shoulder are all potential indicators of carpal tunnel syndrome. Symptoms are oftentimes aggravated by grasping activities, such as driving a car, holding a book or newspaper, and grasping a telephone.
When the median nerve is compressed, it results in increased sensitivity, tingling, pain, weakness, or numbness in the fingers, hand, and wrist; the pinky remains largely unaffected. The predisposing factors that cause median nerve compression and carpal tunnel syndrome are still largely unknown, but there is a higher incidence of carpal tunnel syndrome in patients with diabetes or rheumatoid arthritis. Pregnant women are the group at highest risk for CTS.
A clinical examination and review of a patient’s history is the best way to diagnose CTS. Your physician may perform simple sensory and strength testing, along with some more specialized diagnostic tests, such as Tinel’s sign, Phalen’s test, or Durkan’s compression test. In some cases, electrodiagnostic examination (EMGs) may be recommended.
Treatment options range from low-tech solutions – avoiding pressure on the median nerve by altering one’s movements, or splinting or bracing the wrist to avoid prolonged flexion or extension (especially at night) – to corticosteroid injections (in most cases this only provides temporary relief of pain). If these treatments do not resolve symptoms, then surgical release is indicated, which decreases the pressure in the carpal tunnel, thereby improving blood flow and nourishment to the median nerve. Surgical treatment generally leads to excellent outcomes in patients who have failed non-operative therapies, but above all, the key is a correct diagnosis.
If you suspect you may have carpal tunnel syndrome, feel free to give us a call and let one of our experts determine the cause of your pain. You don’t have to suffer!
When is a wrist sprain more than a simple sprain? If you followed the Yankees during the pre-season, you may have asked yourself the same thing. When Mark Teixera injured his wrist while swinging a bat, the initial diagnosis was that of a simple sprain. Soon after, however, it was revealed that the star first baseman’s injury was a torn tendon sheath, an injury that put him on the disable list for an unplanned couple of months. He has still not yet returned to Yankee Stadium.
It goes to show that even at the highest level, wrist injuries can be, well, complicated. So what sowed such confusion? Sprains themselves refer to ligament injuries, but it’s often hard to tell at first glance whether a wrist injury requires a little TLC versus professional intervention.
That’s because most wrist injuries, whether simple or complicated, are going to involve a little swelling and stiffness. But when wrist injuries don’t get better after two or three weeks, it’s usually a sign that the injury may be worse than a mild sprain. These nagging injuries shouldn’t be taken lightly either. Persistent pain, clicking in the wrist, or excessive swelling, are red flags that could indicate either a torn ligament, or even a broken bone, both of which require immediate treatment.
The wrist’s anatomy lends itself to a range of injuries, depending on the forces at work. The most common side for sprains to pop up is on the dorsal, or back, side of the wrist. The ligaments along the outside of the wrist, just below the small finger, are also frequent sites of sprains.
So how do you go about healing yourself when your sprain is just a mild simple sprain? Rest, ice, splinting, and anti-inflammatory medicine are the simplest and most effective treatments of minor to moderate wrist sprains. Over the counter wrist splints may not always match a three-piece suit, but it’s worth sporting a simple brace that stabilizes the wrist and gives it the support it needs to properly heal.
A simple regimen of the aforementioned ice and rest routine should lead to a complete recovery in two to four weeks, in most mild sprains. If the pain or swelling persists after three weeks or longer, then you should make an appointment to see your local orthopedist for further assessment.
Imaging is one of a doctor’s most powerful tools in making a diagnosis about wrist injuries, but individuals should also take note of how the injury happened. Tennis players, golfers, and baseball players are prone to the type of twisting injuries seen in Teixera’s wrist. The forceful rotating motion of swinging a tennis racket or baseball bat may injure the ligaments of the wrist, as opposed to direct traumatic injuries such as a fall to the outstretched hand, where it’s more likely for a fracture to result. Significant ruptured ligaments may require surgery. Some ligament ruptures can be directly repaired, while others require more complex procedures involving grafts and screws.
The reality is that any injury is never going to be as straightforward as you think, and as we get back on the courts or on the baseball diamonds this spring, a number of us are going to feel that all-too-familiar twinge somewhere in our wrist. The important thing to remember is to never underestimate a wrist injury. And even when it’s worse than you think, the pros at Manhattan Orthopedic will always have you covered.
We sacrifice many things for our children—sleep and a small slice of sanity are just two examples that come to mind. But for many new mothers, the constant lifting and toting of a young child can lead to a condition much more agonizing and confusing than a few sleepless nights.
If you’ve never heard of it before, “New Mom’s Syndrome” may sound like a good description of overprotective mothers. In reality, it is a painful form of tendonitis that affects the tendons on the outside of the thumb and wrist. This occurs when the repetitive stresses of carrying a child results in inflammation of the tendons in this region.
Most of the people who are affected by “New Mom’s Syndrome”—known clinically as De Quervain’s Tendonitis—have often never experienced this type of pain or discomfort in their hands or wrists. Some of the blame can be placed on the natural swelling associated with the later part of pregnancy and after delivery, which intensifies the natural strains on one’s ligaments and tendons.
Indeed, some pregnant women develop carpal tunnel in the last trimester, due to the increased swelling of the wrist tendon’s that sit next to the nerve within the carpal tunnel. And if that weren’t enough, just as a new mother’s carpal tunnel syndrome is receding, De Quervain’s Tendonitis starts kicking in after delivery.
It’s true, however, that “New Mom’s Syndrome” is not exclusive to new moms. De Quarvain’s tendonitis can affect both genders, both the young and the old, but rarely do men’s bodies swell after their wives pregnancy—unless they’ve been sneaking in a few too many candy bars.
Luckily for everyone, “New Mom’s Syndrome” can be easily treated. In some cases, pain can improve by modifying the way one hold’s the child and by wearing a splint to relieve some of the strains on the wrist tendons. Physical or occupational therapy can be helpful as well. The most common and effective treatment, however, is usually a simple cortisone shot, which permanently solves the issue in most patients. If that doesn’t work, well, you might want to get your child a scooter to cruise around on. We’re totally kidding, but at least then you wouldn’t have to carry them as much!
For those of us with a few gray hairs, it’s about now in the middle of the summer that all those pickup games from May and June are starting to show their wear. An ache in the knee or a pulled bicep; these are pretty normal for an older sportsman on the weekend pitch. As frustrating as these injuries are, the real rub is how your kids can go full speed all summer long without some nagging pain to remind them of their age.
The tortoise did beat the hare, however, so a little insight into what type of injuries we get at different ages will hopefully lead to a longer and stronger summer season. The most important place to start is with conditioning. Gentle stretching goes along with any type of cardiovascular as a good base, but with games like softball or tennis, resting and icing your favored arm will help you recover faster and guard against the chance of future strains.
Once you start to hit middle age, those strains become measurable. The effects of age on the body are such that older athletes tend to experience bursitis and rotator cuff injuries at a much higher rate than their younger counterparts. Comparatively, younger athletes are affected by injuries such as labrum tears and other such trauma; in other words, there’s usually no doubt about the injury.
The good news is that as long as we stay fit at any age, we can usually sweat the small stuff out with some rest and ice. But as we get older, the small stuff should still be watched. Amazingly, it’s been found that 10% of patients 50 years and older have rotator tears—and most don’t’ even realize it. At 60 years old, that percentage goes up 20%. And at 70 years old, the percentage of people with rotator cuff injuries rises to an astounding 40%.
When a pain persists, it’s always best to see your doctor. If it’s a rotator cuff injury, a quick cortisone shot will sometimes be prescribed for the short term, while some form of physical therapy can provide for a lasting recovery. And while it’s never good to be out of the game, the recovery from a rotator cuff strain or inflamed bursa takes about as long as the recovery of a labrum tear, which often requires MRI’s, therapy, and sometimes surgery. The recovery from a full rotator cuff tear that requires surgery will put you out of the whole season.
Staying fit and watching those aches goes a long way to staying in the game, so know your limits. Lamenting the young for their youth is as old as the hills, but that doesn’t mean you can’t compete.