- Post Op Care:
- following surgery, the wrist is splinted in neutral or slight extension;
- this avoids anterior displacement of
median nerve w/ entrapment between divided margins of the
TCL;
- some believe early motion (with in days after surgery) actually may promote prolonged hypersensitivity;
- keeping the wrist in a dorsiflexion night splint may prevent the median nerve from adhering to the anterior scar;
- encourage digit motion to prevent adhesions, but do not allow simultaneous wrist and finger flexion;
- consider prescribing vit B6 (50 mg PO tid) for 2-3 weeks postop;
-
post op splinting:
- in the report by V. Finsen et al, the value of of postoperative splinting after open carpal tunnel surgery;
- the authors randomly selected 82 wrists for 4 weeks of postop immobilization or no immobilization;
- distributions of scar discomfort or pain and "pillar pain" were equal in the two groups both
at 6 weeks and 6 months;
- median sick leave was 6 weeks in both groups;
- grip strength was reduced compared to preoperative values by about 20% and keypinch strength by about 10% in both groups at 6 weeks and
had returned to normal by 6 months;
- authors conclude that 4 weeks of postoperative immobilization confers no detectable benefit.
- ref: No advantage from splinting the wrist after open carpal tunnel release. A randomized study of 82 wrists. Acta Orthop Scand - 1999 Jun; 70(3): 288-92
-
expected return to work:
- in the report by Agee et al (J. Hand Surg Vol 17-A. 1992, p 987) workers compensation was the major determinant for length of recovery;
- workers compensation patients: avg return to work was 71 days for endoscopic patients vs 78 days for open release;
- non compensation patients: avg return to work was 16.5 days for endoscopic patients and 45.5 days for open release;
- in the report by Brown et al (JBJS Vol 75-A. 1993), in non workers compensation patients the average return to work was
14 days in the endoscopic group vs 28 days in the open release group;
- in this study, more than half of the patients has signficant scar tenderness at 3 months;
- in the report by RM Braun MD et al (JHS 1999), 225 patients were studied retrospectively over a 10 year period;
- recovery to preoperative levels occurred at about 3-4 months;
- mean return to work was 20 weeks, and in patients represented by lawyers mean time to work was 24 weeks;
- references:
-
Prediction of the outcome 24 hours after carpal tunnel decompression.
- The effect of legal representation on functional recovery of the hand in injured workers following carpal tunnel release.
RM Braun MD et al. Journal of Hand Surg. Vol 24-A. p 53-58.
- Complications:
-
recurrent symptoms:
- recurrent symptoms following open release may occur in up to 20% of patients;
- most common cause of failure of surgery is the incomplete division of the proximal part of the ligament and scarring of the
median nerve to the divided transverse carpal ligament;
- appearance & presence of multiple flexion creases at wrist usually may indicate accessory ligaments at wrist,
which if not relieved at time of sectioning of deep
transverse carpal ligament, will secondarily
produce at compression of median & or ulnar nerve at wrist and recurrent symptoms;
- second most common cause of failure, is incomplete release of the distal edge of the transverse carpal ligament;
- pillar pain: may result from division of the terminal branches of the palmar cutaneous nerve and/or scar between the divided TCL and skin;
- in the study by Isam Atroshi MD et al 1999, most patients showed large improvement in symtpoms (pain and sensory) and function at 6 weeks after surgery, and
further moderate improvements may occur over 6 months (improvements in pain were delayed as compared to improvement in sensory symptoms);
- in contrast, sensibility and strength measures showed much smaller postoperative changes;
- references:
-
Prediction of the outcome 24 hours after carpal tunnel decompression.
-
Year Book: Carpal Tunnel Decompression: 16 Second Look Operations.
- Factors that determine reexploration treatment of carpal tunnel syndrome. O'Malley MJ, et al. J Hand Surg (Am) 1992;17:638-41.
- Outcome for reoperation for carpal tunnel syndrome. TK Cobb. J. Hand Surg. Vol 21-A. 1996. p 347-356.
- Recurrent carpal tunnel syndrome. MJ Botte et al. Hand Clinics. Vol 12. 1996. p 731-743.
-
bowstringing of flexor tendons:
- bowstringing of flexors tendons, and subluxation of the flexor tendons over the hook of the hamate may occassionally occur;
- the former is treated w/ maintenece of the wrist in slght extension for the first post-operative week (upto 10 days);
- the later is treated by excision of the hook of the hamate;
- reference:
The transverse carpal ligament. An important component of the digital flexor pulley system.
-
infection:
- references:
Deep postoperative wound infection after carpal tunnel release.
- References:
Symptoms, disability, and qualitity of life in patients with carpal tunnel syndrome. I. Atroshi MD et al. Journal of Hand Surgery. Vol 24-A. 1999. p 398-404.
Comparing the Outcome of a Carpal Tunnel Decompression at 2 Weeks and 6 Months
A reliable and simple solution for recalcitrant carpal tunnel syndrome: the hypothenar fat pad flap.
