nerve. Flexor tendonitis can give you carpal tunnel symptoms over time if swollen tendons crowd the nerve in the carpal tunnel.” He adds, “If there is no numbness in the fingers, it’s usually not CTS. Arthritis in the base of the thumb is common, especially in women over age 50, but that causes pain without numbness. A less common possibility is that it’s a slipped disc or pinched nerve in the neck, which can mimic the symptoms of CTS.” In addition to the history and physical exam, “EMG and nerve conduction velocity studies are often useful in making the diagnosis,” Dr. Deitch comments. “They measure the speed of the nerve impulses, and slowing at the level of the wrist usually indicates carpal tunnel syndrome. Many insurers require this test before they will pay for surgery. “If a primary care physician suspects CTS, he or she can prescribe a wrist brace at night for several weeks,” he continues. “Then, refer them to a hand specialist if symptoms don’t subside. If the patient has increasing pain, grip weakness or constant numbness, they need a faster referral to decrease the risk of permanent nerve damage.” Dr. Deitch stresses that wrist braces generally should not be worn during the day for CTS, as they can create other problems such as soreness in the upper arm or shoulder. Treatment
Treatment is initiated with conservative measures that, in addition to a night brace, may include avoidance of activities that cause symptoms, and when needed, injection of cortisone in the carpal tunnel area. “Injections can serve as both a diagnostic measure and treatment,” he notes. “Patients can have a pinched nerve in their neck as well as carpal tunnel – if the cortisone injection eradicates the symptoms, it’s more likely the hand numbness is due to CTS. I also stress the importance of proper body positioning rather than special devices – the hips and elbows should be at 90 degrees and the elbow to hands should be neutral. Ideally, the forearm is supported by the chair armrest. And laptops go on your lap, not the table top!” Surgery may be appropriate when: z Persistent symptoms are not relieved by injection or bracing z Symptoms worsen z Constant numbness is present z Thenar muscle atrophy is present
Mark Deitch, M.D., hand and upper extremity orthopaedic surgeon, OrthoMaryland.
Both open and endoscopic surgeries offer patients similar long-term results, though Dr. Deitch has performed primarily endoscopic surgeries for the last 10 years. “It provides patients a faster return to work by several weeks. After a 30-minute outpatient procedure, patients return home with a soft dressing. They can resume most daily light activities within a week.”
Managing Complex ACL Tears Anterior cruciate ligament (ACL) tears are common injuries in young athletes, especially females, affecting about
100,000 to 150,000 Americans each year. A patient with a torn ACL and significant functional instability has a high risk of developing further knee damage, and should therefore consider ACL reconstruction. A surprisingly high percentage of ACL injuries also involve damage to other knee structures, including the meniscus cartilages (50%), articular (joint surface) cartilage (30%), collateral ligaments (30%), joint capsule, or a combination of the above. James York, M.D., orthopaedic surgeon at Chesapeake Orthopaedic & Sports Medicine Center, JULY/AUGUST 2013
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