Pearls and Challenges: Carpal tunnel, practice efficiencies, and the ulnar wrist

Chuck and Chris discuss the ulnar wrist, some listener submitted pearls on carpal tunnel release and close with a discussion of practical tips for an efficient practice.  Join us to hear our thoughts and always feel free to share yours at handpocast@gmail.com

We mentioned this article as a key physical exam assessment:

Ruland RT, Hogan CJ.  The ECU synergy test: an aid to diagnose ECU tendonitis.
J Hand Surg Am. 2008 Dec;33(10):1777-82. doi: 10.1016/j.jhsa.2008.08.018.

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Transcript

Pod Summary

Surgeon Tips and Upcoming Episodes

Christopher and Charles discussed listener feedback and tips for carpal tunnel surgery, including using a nasal speculum for retraction and a weatlaner for exposure. They agreed that Ragnell retractors are better than Senn retractors for trigger finger surgery. Christopher shared pearls on using the Guardian nerve stimulator, emphasizing the importance of the grounding lead and yellow light for proper function. They also mentioned upcoming episodes on distal biceps surgery and tennis elbow, with a potential guest appearance by Macy Stonner.

Wrist Pain Injection Techniques

Christopher and Charles discussed injection techniques for treating wrist pain. They agreed that steroid injections should be done carefully, with consideration of the injection location based on the type and location of pain. Charles emphasized the importance of keeping ecu injections proximal to the wrist joint to avoid complications. They also discussed the risks of repeated injections and the potential for fat atrophy at the injection site.

ECU Tendonitis Treatment Strategies

Charles and Christopher discussed the use of injections for patients with ECU (extensor carpi ulnaris) tendonitis, focusing on the ECU synergy test as a diagnostic tool. They agreed that conservative treatments, including anti-inflammatory medications, wrist braces, and physical therapy, are often the first line of treatment, though Charles noted limited success with these methods. Christopher suggested the use of a wrist widget as a supportive tool, while Charles emphasized its versatility in treating various ulnar-side wrist issues. Both agreed on the importance of activity modification and proper fitting of the wrist widget for optimal results.

Ulnar-Sided Wrist Pain Examination

Charles described his clinical examination approach for ulnar-sided wrist pain, focusing on palpation of specific points including Lister's tubercle, the lunotriquetral joint, and the fovea, which he identified as a critical area for assessing TFCC tears. He explained that forced supination is more likely to recreate pain than pronation, and discussed various stress tests including ulnar carpal impaction maneuvers. Christopher noted that while impaction maneuvers are not particularly useful in his experience, dynamic assessments with live fluoroscopy can provide valuable insights into bone impingement.

TFCC Tears: Diagnosis and Treatment

Charles and Christopher discussed the role of MRI and arthroscopy in diagnosing and treating wrist conditions, particularly TFCC tears. Charles emphasized the importance of a thorough clinical assessment and arthroscopy in diagnosing TFCC tears, stating that arthrograms are not necessary and can be uncomfortable for patients. He noted that most patients with ulnar-sided wrist pain and presumed TFCC tears have foveal tears, which he treats with debridement, repair, or ulnar shortening. Christopher asked about the percentage of patients undergoing arthroscopy who receive different treatments, but Charles suggested saving that topic for another time.

Surgical Workflow and Consent Strategies

Christopher and Charles discussed surgical workflow and patient consent processes. They shared their approaches to scheduling surgeries, completing consent forms, and ensuring necessary equipment is available. Charles emphasized keeping consent forms broad and specific to the planned procedure, while Christopher noted the importance of including details for insurance and authorization purposes. They also discussed strategies for ensuring a good night's sleep after surgeries, including calling patients postoperatively and preparing customized patient handouts.