DOCSLIB.ORG

Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011 An Original Study Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011 Brian C. Werner, MD, Andrew B. Bridgforth, MD, F. Winston Gwathmey, MD, and A. Rashard Dacus, MD ligament reconstruction and tendon interposition (LRTI).4-20 Abstract The authors of a recent systematic review concluded there is We conducted a study to investigate current trends no evidence that any one surgical procedure for CMC-OA is in carpometacarpal (CMC) interposition arthroplasty superior to another in terms of pain, function, satisfaction, across time, sex, age, and region of the United States; range of motion, or strength.4 Nevertheless, a recent survey per-patient charges and reimbursements; and the as- found that 719 (62%) of 1156 US hand surgeons used LRTI as sociation between this procedure and concomitantly the treatment of choice for advanced CMC-OA.21 performed carpal tunnel syndrome (CTS) and carpal Our detailed literature search yielded no other database tunnel release (CTR). studies characterizing current trends in the practice patterns Patients who underwent CMC interposition arthro- of US orthopedic surgeons who perform interposition arthro- plasty (N = 41,171) were identified in a national data- plasty for CMC arthritis. Analysis of these trends is important base. Between 2005 and 2011, the number of patients not only to patients but also to the broader orthopedic and who had CMC interposition arthroplasty increased health care community.22 46.2%. Females had the procedure more frequently We conducted a study to investigate current trends in CMC than males at all time points, though theAJO percentage interposition arthroplasty across time, sex, age, and region of of patients who were male increased throughout the the United States; per-patient charges and reimbursements; study period. Of the patients who had CMC interposi- and the association between this procedure and concomitantly tion arthroplasty, 40.9% also had a diagnosis of CTS. performed carpal tunnel syndrome (CTS) and carpal tunnel Between 15.5% and 17.3% of these patients had CTR release (CTR). In addition, we compared incidence of CMC performed concomitantly. interposition arthroplasty with that of CMC arthrodesis. Despite a lack of evidence that thumb CMC inter- DOposition arthroplasty is superior NOT to other surgical treat- Patients COPY and Methods ment options, the number of patients who are having All data were derived from the PearlDiver Patient Records Data- this procedure has increased significantly. The impetus base (PearlDiver Technologies), a publicly available database of for these trends requires additional investigation. patients. The database stores procedure volumes, demograph- ics, and average charge information for patients with International Classification of Diseases, Ninth Revision (ICD-9) diagnoses and proce- dures or Current Procedural Terminology (CPT) codes. Data for the common entity, osteoarthritis (OA) at the base of the present study were drawn from the Medicare database within thumb is largely caused by the unique anatomy and the PearlDiver records, which has a total of 179,094,296 patient Abiomechanics of the thumb carpometacarpal (CMC) records covering the period 2005–2011. This study did not re- joint.1 Radiographically evident CMC degeneration occurs in quire institutional review board approval, as it used existing, 40% of women and 25% of men over age 75 years, making the publicly available data without identifiers linked to subjects. thumb CMC joint the most common site of surgical reconstruc- PearlDiver Technologies granted us database access for tion for upper extremity OA.2,3 academic research. The database was stored on a password- Over the past 40 years, numerous surgical techniques for protected server maintained by PearlDiver. ICD-9 and CPT codes managing thumb CMC-OA have been described. These include can be searched in isolation or in combination. Search results volar ligament reconstruction, first metacarpal osteotomy, yield number of patients with a searched code (or combina- CMC arthrodesis, CMC joint replacement, and trapeziectomy. tion of codes) in each year, age group, or region of the United Trapeziectomy can be performed in isolation or in combina- States, as well as mean charge and mean reimbursement for tion with tendon interposition, ligament reconstruction, or the code or combination of codes. Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com August 2015 The American Journal of Orthopedics® 363 Trends in Thumb Carpometacarpal Interposition Arthroplasty B. C. Werner et al We used CPT code 25447 (arthroplasty, interposition, inter- Throughout this period, females underwent CMC interposi- carpal, or CMC joints) to search the database for patients who tion arthroplasty more frequently than males at all time points underwent thumb CMC interposition arthroplasty. Although (P < .0001). Overall ratio of female to male patients, however, this code does not specify thumb, we are unaware of any pro- changed significantly. In 2005, 18.1% of all CMC interposition cedure (other than thumb CMC interposition arthroplasty) arthroplasties were performed on male patients; this increased typically given this code. Our search yielded procedure vol- to 23.9% of all procedures by 2011 (P < .0001) (Figure 2). Table umes, sex distribution, age distribution, region volumes, and 1 presents an age-group analysis. There were no significant mean per-patient charges and reimbursements for each CPT differences in relative percentage of patients in any given age code. We then searched the resulting cohort for CTS (ICD-9 group who underwent CMC interposition arthroplasty over code 354.0), endoscopic CTR (CPT code 29848), and open CTR the study period. (CPT code 64721) to find CTR performed concomitantly with Analysis of overall procedure incidence by region revealed CMC interposition arthroplasty. Last, patients were tracked significant increases in all regions P( < .0001), ranging from in the database past their surgery date to evaluate for postop- 18.5% (West) to 54.5% (Northeast) (Figure 3). At all time erative physical or occupational therapy evaluations within points, the incidence of CMC interposition arthroplasty was 6 months (using CPT codes appearing in at least 1% of the significantly lower in the Northeast than in any other region cohort: 97001, 97003, 97004, 97110, 97112, 97124, 97140, and compared with the overall average. 97150, 97350, 97535) and postoperative thumb, hand, or wrist Between 2005 and 2011, there were significant increases radiographs within 6 months (using CPT codes appearing in in both per-patient charges and reimbursements for CMC in- at least 1% of the cohort: 73140, 73130, 73110). To ensure terposition arthroplasty (Figure 4). Mean per-patient charge adequacy of 6-month postoperative data, we included in this increased from $2676 in 2005 to $4181 in 2011 (P < .0001), portion of the study only those patients with surgery dates and mean per-patient reimbursement increased from $1445 in between 2005 and 2010. 2005 to $2061 in 2011 (P < .0001). The discrepancy between For comparative purposes, we also searched the database for charge and reimbursement increased throughout the study patients who underwent thumb CMC arthrodesis within the period: Reimbursement in 2005 was 54.0% of the charge; this same period—using CPT codes 26841 and 26842 (arthrodesis decreased to 49.3% by 2011 but was not statistically significant CMC joint thumb, with or without internal fixation; with or (P = .08). without autograft) and CPT code 26820 (fusionAJO in opposition, Overall, 40.9% of patients who underwent CMC interpo- thumb, with autogenous graft). sition arthroplasty also had a CTS diagnosis. Between 15.5% Overall procedure volume data are reported as number of and 17.3% of these patients had concomitant open or endo- patients with the given CPT code in the database output in a scopic CTR at time of CMC interposition arthroplasty (Table given year. Age-group and sex analyses are reported as number 2). Percentage of patients who underwent concomitant CTR of patients reported in the database output and as percentage did not change significantly from 2005 to 2011 P( = .139). of patients who underwent the CPT code of interest that year. Use of postoperative occupational and/or physical therapy MeanDO charges and reimbursements NOT are reported as results by increased significantlyCOPY over the study period, from 33.5% of the database for the code of interest (CPT 25447). Data for the patients in 2005 to 50.7% of patients in 2010 (P < .0001). Use region analysis are presented as an incidence, as there is an of postoperative thumb, hand, and/or wrist radiography also uneven distribution of patient volumes among regions. This increased throughout the study period, from 7.4% of patients incidence is calculated as number of patients in a particular in 2005 to 18.7% of patients in 2010 (P < .0001). region and year normalized to total number of patients in the We identified 1916 unique patients who underwent thumb database for that particular region or year. Regions are defined CMC arthrodesis between 2005 and 2011. Over the 7-year as Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, SD, study period, there was a 19.1% decrease in number of patients WI), Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT), South who underwent CMC arthrodesis, from 309 in 2005 to 250 (AL, AR, DC, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, in 2011 (P < .0001) (Figure 5). Significantly fewer patients TX, VA, WV), and West (AK, AZ, CA, CO, HI, ID, MT, NM, had CMC arthrodesis compared with CMC interposition ar- NV, OR, UT, WA, WY). throplasty at all time points, ranging from 6.5% (thumb CMC Chi-squared linear-by-linear association analysis was used arthrodesis:CMC interposition arthroplasty) in 2005 to 3.6% to determine statistical significance with regard to trends over in 2011 (P < .0001). time in procedure volumes, sex, age group, and region.
Load more

Recommended publications
  • Carpal Tunnel Syndrome
    Information O from Your Family Doctor Carpal Tunnel Syndrome What is carpal tunnel syndrome? hands a lot. You may notice that over time your Carpal tunnel syndrome (KAR-pal TUN-el grip gets weaker and you tend to drop heavy SIN-drome) is a common, painful disorder objects. of the wrist and hand. It happens when the median nerve, which runs through the wrist, How is it diagnosed? gets squeezed under a band of tissue called a Talk to your doctor if you are having these ligament. This causes pain and other symptoms symptoms. He or she will ask questions about along the nerve (see drawing). the ways you use your hands and about specific What causes it? Anything that increases Shading indicates area pressure on the median where symptoms are felt nerve can cause carpal tunnel syndrome. Sometimes pregnancy and health conditions like arthritis and diabetes can increase the pressure. People who use their hands and wrists repeatedly in the same way (for example, Transverse typists, carpenters, and carpal cashiers) are more likely to get ligament carpal tunnel syndrome. What are the symptoms? Carpal tunnel syndrome Thenar may cause pain, numbness, muscles Wrist or tingling in your wrist and bone hand, mostly in the middle finger, index finger, and Tendon thumb. The symptoms are Median usually worse at night and nerve when you use your wrists and ILLUSTRATION BY KATHRYN BORN continued O Page 1 of 2 Information O from Your Family Doctor Carpal Tunnel Syndrome (continued) symptoms in each part of your hand and wrist. He or she may also test how your nerves and Notes: muscles respond to electrical stimulation.
    [Show full text]
  • Table 9-10 Ligaments of the Wrist and Their Function
    Function and Movement of the Hand 283 Table 9-10 Ligaments of the Wrist and Their Function Extrinsic Ligaments Function Palmar radiocarpal Volarly stabilizes radius to carpal bones; limits excessive wrist extension Dorsal radiocarpal Dorsally stabilizes radius to carpal bones; limits excessive wrist flexion Ulnar collateral Provides lateral stability of ulnar side of wrist between ulna and carpals Radial collateral Provides lateral stability of radial side of wrist between radius and carpals Ulnocarpal complex and articular Stabilizes and helps glide the ulnar side of wrist; stabilizes distal disk (or triangular fibrocartilage radioulnar joint complex) Intrinsic Ligaments Palmar midcarpal Forms and stabilizes the proximal and distal rows of carpal bones Dorsal midcarpal Forms and stabilizes the proximal and distal rows of carpal bones Interosseous Intervenes between each carpal bone contained within its proximal or distal row Accessory Ligament Transverse carpal Stabilizes carpal arch and contents of the carpal tunnel Adapted from Hertling, D., & Kessler, R. (2006). Management of common musculoskeletal disorders: Physical therapy principles and methods. Philadelphia, PA: Lippincott, Williams & Wilkins.; Oatis, C. A. (2004). Kinesiology: The mechanics and pathomechanics of human movement. Philadelphia, PA: Lippincott, Williams & Wilkins.; Weiss, S., & Falkenstein, N. (2005). Hand rehabilitation: A quick reference guide and review. St. Louis, MO: Mosby Elsevier. The radial and ulnar collateral ligaments provide lateral and medial support, respectively, to the wrist joint. The ulnocarpal complex is more likely to be referred to as the triangular fibro- cartilage complex (TFCC) and includes the articular disk of the wrist. The TFCC is the major stabilizer of the distal radioulnar joint (DRUJ) and can tear after direct compressive force such as a fall on an outstretched hand.
    [Show full text]
  • Musculoskeletal Ultrasound Technical Guidelines III. Wrist
    European Society of MusculoSkeletal Radiology Musculoskeletal Ultrasound Technical Guidelines III. Wrist Ian Beggs, UK Stefano Bianchi, Switzerland Angel Bueno, Spain Michel Cohen, France Michel Court-Payen, Denmark Andrew Grainger, UK Franz Kainberger, Austria Andrea Klauser, Austria Carlo Martinoli, Italy Eugene McNally, UK Philip J. O’Connor, UK Philippe Peetrons, Belgium Monique Reijnierse, The Netherlands Philipp Remplik, Germany Enzo Silvestri, Italy Wrist Note The standard US examination of the wrist begins with evaluation of its dorsal aspect, followed by the palmar one. Depending on the specific clinical presentation, US images can be obtained in different position of the wrist (flexion and extension, radial and ulnar deviation, pronation and supination), with the patient seated in front of the examiner. 1 DORSAL WRIST: compartments of extensor tendons Place the transducer on a transverse plane over the dorsal aspect of the wrist to allow proper identification of the extensor tendons. In general, one should first recognize a given tendon and then follow it on short-axis planes down to the distal insertion. Long- axis US images of the extensor tendons are less useful: they may help to evaluate the integrity of tendons and assess their dynamic motion in detail. Dynamic scanning of the extensor tendons can be performed by placing the hand on a gel tube with the fingers hanging outside its edge to allow easy fingers movements. Legend: APL, abductor pollicis longus; EPB, extensor pollicis brevis; ECRL, extensor carpi radialis longus; EPCB, extensor carpi radialis brevis; EPL, extensor pollicis longus; EIP, extensor indicis proprius; EDC, extensor digitorum longus; EDQ, extensor digiti quinti proprius; ECU, extensor carpi ulnaris 2 first compartment Keeping the patient’s wrist halfway between pronation and supination, place the probe over the lateral aspect of the radial styloid to examine the first compartment of the extensor tendons - abductor pollicis longus (ventral) and extensor pollicis brevis (dorsal).
    [Show full text]
  • Versus Arthritis Carpal Tunnel Syndrome Information Booklet
    Carpal tunnel syndrome Carpal tunnel syndrome information booklet Contents What is carpal tunnel syndrome? 4 What are the symptoms of carpal tunnel syndrome? 5 What causes carpal tunnel syndrome? 7 How is carpal tunnel syndrome diagnosed? 8 What treatments are there for carpal tunnel syndrome? 10 Self-help and daily living 15 Research and new developments 15 Where can I find out more? 16 Talk to us 17 We’re the 10 million people living with arthritis. We’re the carers, researchers, health professionals, friends and parents all united in our ambition to ensure that one day, no one will have to live with the pain, fatigue and isolation that arthritis causes. We understand that every day is different. We know that what works for one person may not help someone else. Our information is a collaboration of experiences, research and facts. We aim to give you everything you need to know about your condition, the treatments available and the many options you can try, so you can make the best and most informed choices for your lifestyle. We’re always happy to hear from you whether it’s with feedback on our information, to share your story, or just to find out more about the work of Versus Arthritis. Contact us at [email protected] Registered office: Versus Arthritis, Copeman House, St Mary’s Gate, Chesterfield S41 7TD Registered Charity England and Wales No. 207711, Scotland No. SC041156. Page 2 of 20 Page 3 of 20 Carpal tunnel syndrome information booklet What is carpal tunnel syndrome? What are the symptoms of carpal Carpal tunnel syndrome is a condition that happens when the tunnel syndrome? median nerve is compressed or squeezed as it passes through Carpal tunnel syndrome causes a tingling feeling or pins and needles, the wrist (see Figure 1).
    [Show full text]
  • Wrist Problem Or Neck Problem? 8:00Am - 7:00Pm Wednesday - Carpal Tunnel Syndrome Is One of the and Arm Pain Or Tingling
    ACTIVE P.T. SOLUTION S ...BECAUSE LIFE SHOULD BE ACTIVE APTS Monthly Office Hours: VOLUME VI, ISSUE IX SEPTEMBER 2016 Monday - 8:00am - 5:30pm Tuesday - Wrist Problem or Neck Problem? 8:00am - 7:00pm Wednesday - Carpal tunnel syndrome is one of the and arm pain or tingling. There are When the shoulders round and the most common nerve entrapments of some that get temporary relief but the head shifts forward, the muscles in 8:00am - 5:30pm the upper extremity. It occurs when problem recurs frequently with symp- the neck and shoulders compress Thursday - the median nerve is compressed in toms of higher intensity. Other pa- the nerves that course from the the wrist. However, it is not uncom- tients develop symptoms similar to neck to the hand. The hand re- 8:00am - 5:30pm mon for compression of the median carpal tunnel syndrome following neck quires a stable base at the neck and nerve to occur in several different injury. They may not have had a wrist shoulders in order to function Friday - sites in the forearm. Over the course injury but still experience pain in the properly. Weakness caused by 8:00am - 4:00pm of time, the general population has hand. inactivity and poor posture ulti- come to accept that hand and wrist mately causes the hand and fore- Location: pain, numbness, or tingling adds up to Since the body is a complex network arm muscles to be overworked. carpal tunnel syndrome. In fact, hun- of joints, nerves, ligaments, muscle, This results in “double crush syn- 91 Columbus Street dreds of people each year have wrist and fascia, it is possible that a symp- drome” or nerve compression in Auburn, NY 13021 decompression surgery in hopes of tom from one area of the body may be the neck and shoulders proximally relieving these symptoms.
    [Show full text]
  • Complications in the Treatment of Carpal Tunnel Syndrome
    Complications in the treatment of carpal tunnel syndrome Philip Henkin, M.D., and Allan H. Friedman, M.D. Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina Complications may result from every facet of the management of carpal tunnel syndrome. The authors review the common errors in diagnosis, nonoperative management, and operative treatment, with emphasis on prevention and resolution of complications. In general, surgeons can minimize complications by taking a thorough patient history, performing a comprehensive physical examination, and possessing a precise knowledge of the appropriate anatomy. Endoscopic techniques appear to offer some advantage over conventional open techniques with regard to the patient's postoperative incision pain, preservation of grip strength, and time to return to work; however, these advantages may be potentially negated by the risk of injury to neurovascular structures and tendons. Key Words * carpal tunnel syndrome * carpal tunnel release * transverse carpal ligament Release of the transverse carpal ligament (TCL) has become the most commonly performed peripheral nerve operation. The widespread popularity of the procedure is largely a consequence of the ubiquitous nature of the syndrome, the pervasive awareness of the syndrome by clinicians and patients, and the excellent response in most patients to surgical treatment. Since surgical decompression of the TCL was first performed by Learmonth in 1933[49] many authors have reported a high success rate performing the procedure in several large series of patients.[2,12,13,23,37,44,72,82] Concomitant with the increased volume of carpal tunnel releases (CTRs), complications have become more prevalent. MacDonald, et al.,[57] reported 34 complications in 22 patients (12%) undergoing 186 operations for carpal tunnel syndrome (CTS).
    [Show full text]
  • Carpal Tunnel Release Surgery
    FACT SHEET FOR PATIENTS AND FAMILIES Carpal Tunnel Release Surgery What is carpal tunnel release surgery? Carpal tunnel release is surgery to treat carpal tunnel syndrome. Carpal tunnel syndrome is pain, weakness, tingling, and numbing in the thumb and fingers. It’s caused by pressure on the median nerve in the wrist. In carpal tunnel release surgery, the surgeon cuts the transverse carpal ligament, a band of tissue on the Transverse carpal palm side of the carpal tunnel. This takes pressure off ligament the median nerve and relieves symptoms. You will Released still be able to use your wrist and hand, and in time, Median carpal nerve they should work as if you never had a problem. tunnel Why do I need it? Before carpal tunnel release surgery, the transverse Most cases of carpal tunnel syndrome are treated carpal ligament is putting pressure on the median nerve and causing pain and weakness. During without surgery. Your doctor may recommend surgery, the ligament is cut to take pressure off surgery if: the nerve. • You have tried nonsurgical treatments for several weeks or months and your symptoms have not improved. Talking with your doctor • Your symptoms are severe and interfere with The table below lists the most common potential your daily activities. benefits, risks, and alternatives for carpal tunnel release • Your median nerve is damaged. surgery. There may be other benefits or risks in your • Other tissue, such as a tumor, is putting pressure unique medical situation. Talking with your doctor is on the median nerve. the most important part of learning about these risks and benefits.
    [Show full text]
  • Carpal Tunnel Syndrome
    Oxford University Hospitals NHS Trust Hand & Plastics Physiotherapy Department Carpal Tunnel Syndrome Information for patients page 2 What is the Carpal Tunnel? The carpal tunnel is made up of the bones in your wrist and a ligament which runs across the base of your palm. Several tendons and your ‘median nerve’ run through the tunnel to supply movement and sensation to your fingers. What causes Carpal Tunnel Syndrome? Symptoms occur when the nerve becomes ‘pinched’ by pressure within the tunnel. The reason is usually unknown, but possible causes can include: swelling of the lining of the tendons, joint dislocation, fractures or arthritis. Fluid retention during pregnancy can also sometimes cause swelling in the tunnel. Symptoms are made worse by keeping the wrist bent for long periods of time. What are the symptoms? Symptoms include numbness, tingling and/or pain in the arm, hand and/or fingers of the affected side. The symptoms are more often felt during the night, but may be noticed during the day when the wrist is bent for long periods of time. You may have noticed a weaker grip, or clumsiness when using your hand. In severe cases sensation may be permanently lost, and the muscles at the base of the thumb may reduce in size. Diagnosis A clinician may do a test such as tapping along the line of the nerve or bending your wrist to see if your symptoms are brought on. You may also be sent for nerve conduction studies to give an accurate measure of the degree of pressure that is affecting the nerve.
    [Show full text]
  • Information for Patients About Hand & Elbow Surgery
    Information for Patients about Hand & Elbow Surgery Clinical Professor Allan Wang FRACS PhD FAOrthA Shoulder and Upper Limb Surgeon www.allanwangorthopaedics.com.au MURDOCH SUBIACO Murdoch Orthopaedic Clinic St John of God Subiaco Clinic St John of God Murdoch Clinic Suite 302, 25 McCourt St Suite 10, 100 Murdoch Drive Subiaco WA 6008 Murdoch WA 6150 Telephone: 08 6332 6390 Page | 2 Page | 3 Information for Patients about Hand and Elbow Surgery Introduction We have put this information booklet together to educate our patients about their Hand and Elbow condition, treatment options and post-surgical care. Please keep this booklet for future reference. It is not a detailed source of information and you may also wish to refer to our website www.allanwangorthopaedics.com.au for animated videos of surgical procedures. If you require further information or have concerns regarding your treatment please contact the office to discuss with Dr Wang or his staff. Contents Pages 1. Carpal Tunnel Syndrome 4 2. Cubital Tunnel Syndrome 6 3. Trigger Finger 7 4. De Quervain’s Tenodonitis 8 5. Ganglion Cysts 9 6. Arthritis at the Base of the Thumb 10 7. Wrist Arthroscopy 11 8. Dupuytren’s Disease 12 9. Lateral Epicondylitis 13 10. Elbow Arthroscopy 14 11. Post-Operative Instructions Hand & Elbow Surgery 15 Page | 4 Carpal Tunnel Syndrome What is it? Figure 1 Carpal tunnel syndroe is a condition aused by copression o te median nerve at te level o te wrist oint Here te edian nerve passes into te arpal tunnel along wit leor tendons and te tendon lining called tenosynoviu Carpal tunnel syndroe ocurs wen pressure builds up in te tunnel and tis an be due to swelling o te tenosynoviu ratures artritis luid retention during pregnany and certain conditions suc as diabetes and tyroid disease Symptoms en te pressure on te edian nerve becoes severe, you ay notice wrist pain tingling and nubness and lusiness in and oveents.
    [Show full text]
  • Carpal Tunnel Syndrome and Ulnar Neuropathy at Elbow
    PERIPHERAL NERVE ENTRAPMENTS CTS Ulnar Neuropathy at elbow CARPAL TUNNEL SYNDROME • Compression of the median nerve in a fibro- osseus canal on the palmar surface of the wrist: the carpal tunnel. • Most common entrapment neuropathy • 2-3% of the population. • Variations in prevalence data is likely due to variations in occupational exposure. • 90% have a good outcome and are able to work again and 10 % are permanently disable. Carpal Tunnel Anatomy • Fibro-osseus tunnel bounded by the carpal bones, the interosseus ligaments and the transverse carpal ligament (the flexor retinaculum). • Content: Median nerve, tendons of flexor digitorum superficialis (FDS), tendons of flexor digitorum profundus (FDP), and tendon of flexor pollicis longus (FPL). The Flexor Retinaculum • Extends 1 cm or more proximal to the most distal wrist crease distally at least 3 to 4 cm into the palm. • Constituted by the fusion of the TCL and deeper transverse fibers of the palmar aponeurosis. Palmar Cutaneous Branch • Originates from the median nerve before it enters to the carpal tunnel. • Exits the median nerve along its anterolateral quadrant about 3 to 4 cm above the distal wrist crease. • Passes superficial to the TCL. • Supplies sensation to the proximal surface of the thenar eminence. Recurrent Motor Branch • Leaves the radial side of the median nerve distal to the flexor retinaculum. • Curves back around to enter the thenar muscle mass. • Multiple anatomical variations. • 31% of cases: leaves the ulnar side of the median nerve beneath the TCL • 20 % of cases: transligamentous course. Surgical Anatomy Kaplan’s Cardinal Line: • Apex of the First web space (between the thumb and index finger) • Parallel with the proximal palmar crease.
    [Show full text]
  • Carpal Tunnel Syndrome
    healthy living Carpal Tunnel Syndrome Causes and Risk Factors Prevention Pressure on the median nerve causes To help prevent carpal tunnel syn- carpal tunnel syndrome. This pressure drome or keep it from coming back, can come from swelling or anything take care of your basic health. Stay that makes the carpal tunnel space at a healthy weight. If you smoke, smaller. Sometimes it is not possible consider quitting. Exercise to stay to tell what causes the increased strong and flexible. If you have a pressure. However, certain lifestyle long-term health problem, such as and medical risk factors that may arthritis or diabetes, follow your contribute to carpal tunnel syndrome doctor’s advice for keeping your include: condition under control. • Illnesses such as hypothyroidism, Also, take good care of your wrists rheumatoid arthritis, and diabetes and hands by: • Pregnancy • Keeping your wrist in a neutral What is Carpal Tunnel • Obesity position as much as possible. Your Syndrome? • Forceful gripping or grasping activi- wrist is in a neutral position when ties with your hands it is straight or only slightly bent. Carpal tunnel syndrome (CTS) is • Making the same hand or wrist Holding a glass of water is an pain, tingling, and weakness due movements over and over, especially example of your wrist in a neutral to pressure on the median nerve in if the wrist is bent down (your position. your wrist. The median nerve and hands lower than your wrists) • Keeping your wrist straight while: several tendons run from your fore- – Using the computer, typing, or arm to your hand through a small • Wrist injuries and bone spurs using the mouse space in your wrist called the carpal • Smoking, because it can reduce – Writing tunnel.
    [Show full text]
  • Surgical Approaches to the Distal Radioulnar Joint Gregory I
    Techniques in Hand and Upper Extremity Surgery 11(1):51–56, 2007 Ó 2007 Lippincott Williams & Wilkins, Philadelphia | DISTAL RADIOULNAR JOINT SYMPOSIUM | Surgical Approaches to the Distal Radioulnar Joint Gregory I. Bain, MBBS, FRACS and Nicholas Pourgiezis, MBBS Modbury Public Hospital, Modbury and University of Adelaide North Terrace, Adelaide South Australia, Australia James H. Roth, MD, FRCSC, FRCS Hand and Upper Limb Centre St Joseph’s Health Centre Division of Orthopaedic Surgery Department of Surgery and the University of Western Ontario London, Ontario, Canada | ABSTRACT retinaculum and used as an interposition flap stabilizing 2 The distal radioulnar joint (DRUJ) is classified as a the DRUJ. In a simplified technique, a composite interposition flap comprising extensor retinaculum and uniaxial synovial pivot joint between the convex head of dorsal capsule is used for reconstruction. This technique the ulna and the concave ulnar notch of the radius. was first described by Stanley and Herbert3 for The DRUJ can be approached from 3 sides with a reconstruction of the DRUJ with a Swanson ulnar head refined dorsal approach retaining a robust retinacular- spacer and subsequently reported by Bain et al2 for dorsal capsular layer preferred by most surgeons. matched hemiresection interposition arthroplasty of the Recent descriptions of safe and extensile volar 4 approaches have broadened indications for a volar DRUJ and van Schoonhoven and Herbert for use in approach to the DRUJ. A subcutaneous ulnar approach conjunction with an ulnar head prosthesis. Exposure of the volar aspect of the distal forearm is remains an option particularly when dealing with most commonly required for the management of distal additional distal ulnar pathology.
    [Show full text]