Treatment Options: Hand and Upper Extremity

Endoscopic Carpal Tunnel Surgery is One Minimally Invasive Option
This article originally appeared in Pathways, a magazine published for physicians and the community by UMass Memorial Medical Center.

There is a saying that when the only tool you have is a hammer, everything looks like a nail. The toolbox at the UMass Memorial Hand and Upper Extremity Center, however, offers numerous diagnostic and therapeutic "tools," giving referring physicians and their patients an array of options for addressing problems of the elbow, wrist and hand.

"We really are a one-stop shop for the treatment of problems from the elbow down," said Thomas Breen, MD, associate professor of orthopedics and physical rehabilitation and chief of the UMass Memorial Hand and Upper Extremity Service. "We have four hand surgeons, an on-site Hand Therapy Center staffed by certified hand therapists (see sidebar), state-of-the-art diagnostic equipment for nerve conduction studies as well as electromyelography, digital radiography, ultrasound and MRI.

Surgery Is Not the Only Option

"So a referral to us doesn't automatically mean surgery," he emphasized. "We have excellent surgeons, and we do a lot of surgical cases, but not all patients with hand and upper extremity issues need surgery. We can provide a comprehensive evaluation and diagnostic workup, then develop a treatment plan that might include splinting, hand therapy, cortisone injections or activity modification. It all depends on what's best for the patient."

When surgery is appropriate, either as primary treatment or when more conservative measures fail to resolve the problem, the clinic, located on the UMass Memorial Hahnemann Campus, has outstanding surgical bench strength. "Two of our surgeons, Dr. Marci Jones and myself, completed orthopedic surgical residences, and Drs. Ed Calkins and John Shufflebarger did plastic surgery residencies," Dr. Breen explained. "And all of us completed postgraduate fellowships in hand surgery."

Hands-on Approach to Treatment Planning

What also sets the UMass Memorial center apart is the surgeons' hands-on approach to treatment planning and follow-up. "In some clinics, a patient's initial evaluation is performed by a physician extender - a nurse practitioner or physician assistant," Dr. Breen noted. "Here, we believe that the best care results when a qualified surgeon - a fellowship-trained subspecialist - sees the patient on presentation. It requires a certain level of experience to conduct the appropriate tests, make a correct diagnosis, plan the proper treatment and know when surgical intervention is warranted. If we're personally following the patient, we know when they're progressing or have plateaued."

The Region's Most Extensive Surgical Experience

The most common procedure performed at the UMass Memorial Hand and Upper Extremity Center is carpal tunnel surgery to relieve compression of the median nerve. This is the most frequent compressive neuropathy in the upper extremity and one of the most common surgical procedures in the United States, Dr. Breen noted. The four hand surgeons at UMass Memorial perform more than 600 of these procedures annually - more than at any other hospital in Central Massachusetts. Further, Dr. Breen performs more of these procedures endoscopically than any other hand surgeon in the region.

Carpal tunnel surgery involves dividing the transverse carpal ligament around the wrist to reduce pressure on the median nerve. Open release surgery, the traditional procedure in use for decades to correct carpal tunnel syndrome, consists of making a curved incision of up to two inches in the palm, going through fascia and muscle to reach the transverse carpal ligament, then dividing it to decompress the median nerve. The procedure generally is performed under local or regional anesthesia on an outpatient basis.

Endoscopic Approach Offers an Alternative

With advances in endoscopic technology and techniques, however, patients now have a minimally invasive surgical option. "The single-portal endoscopic technique I use obviates the need to go through all those layers of tissue," Dr. Breen explained. "Instead, a small incision is made in the wrist, then a fiberoptic scope, containing both a camera and a blade, is inserted. Coming underneath the transverse carpal ligament, the ligament is visualized and cut, eliminating the need to cut through vital tissues in the palm."

Studies show that outcomes from the open release and endoscopic carpal tunnel procedures are essentially the same at one year post surgery, Dr. Breen noted. "The real difference is during the first couple of months after surgery," he added. "With the endoscopic procedure, there is less downtime, less pain, reduced loss of pinch and grip strength, an easier functional recovery and an earlier return to work and play."

Carpal tunnel surgery generally is recommended if symptoms last for six months or conservative, nonoperative treatments fail. The most common symptoms are pain and weakness or numbness in the hand and wrist, radiating up the arm. There are nonsurgical therapeutic interventions, such as splinting, hand therapy and corticosteroid injections, that can prevent the progression of carpal tunnel syndrome and improve some symptoms - possibly eliminating the need for an operation.

Why Early Intervention Is Important

"This is why it's so important for us to see a patient early when they present with complaints of discomfort in the hand and wrist," Dr. Breen said. "In a lot of carpal tunnel cases, there are therapeutic options that haven't yet been tried, and it's not uncommon for the problem to resolve without surgery."

Early treatment often involves resting the affected hand and wrist, avoiding activities that may worsen symptoms, and splinting to immobilize the wrist and avoid further damage from bending or twisting. Nonsteroidal anti-inflammatory drugs (NSAIDs) and other nonprescription pain relievers may ease symptoms that have been present for a short time or are caused by strenuous activity.

Comprehensive Resources, Close to Home

"What's more, not all arm pain is carpal tunnel syndrome," Dr. Breen noted. "This further underscores the value of a comprehensive evaluation by a hand and upper extremity specialist," he said.

Among the other conditions treated at the UMass Memorial Hand and Upper Extremity Clinic are nerve and tendon injuries; fractures and dislocations; osteoarthritis and rheumatoid arthritis of the hand, wrist and elbow; tumors of the hand; congenital conditions; Dupuytren's contracture; tendonitis; and trigger finger.

"There's a great deal of hand and upper-extremity expertise here at UMass Memorial and, equally important, there's tremendous convenience for the patient, having all these diagnostic and treatment resources in one place, close to home," Dr. Breen said. "If a physician has any questions about when or if a referral is appropriate, we're just a phone call or e-mail away."