A Intermediate Evaluation and Paitient Management 1 Obtain focused history and performs focused exam night pain, paresthesias Median nerve motor/ sensory evaluation MN numbness thumb abduction provocative maneuvers: Tinel tap the median nerve over the volar carpal tunnel Phalen wrist flexed with elbow extended for ~60 sec produces symptoms Durkins compression test is the most sensitive test to diagnose carpal tunnels syndrome press thumbs over the carpal tunnel and hold pressure for 30 seconds. onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result. 2 Orders and interprets required diagnostic studies EMG and NCV studies often the only objective evidence of a compressive neuropathy (valuable in work comp patients with secondary gain issues) not needed to establish diagnosis (diagnosis is clinical) NCV increase latencies (slowing) of NCV distal sensory latency of > 3.2 ms motor latencies > 4.3 ms decreased conduction velocities less specific than latencies velocity of < 52 m/sec is abnormal EMG test the electrical activity of individual muscle fibers and motor units detail insertional and spontaneous activity potential pathologic findings increased insertional activity sharp waves fibrillations fasciculations complex repetitive discharges 3 Prescribes and manages nonoperative treatment night splints steroid injections attempts trial of physical therapy 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides simple post operative management and rehabilitation postop: 2-3 Week postoperative visit wound check remove sutures remove plaster splint diagnose and management of early complications<br /> postop: ~ 3 month postoperative visit diagnosis and management of late complications<br /> postop: 1 year postoperative visit B Advanced Evaluation and Patient Management 1 Complex postop management worsening numbness worsening pain additional radiating symptoms C Preoperative H & P 1 Obtain basic preoperative history and physical exam identify medical co-morbidities that might impact surgical treatment screen medical studies to identify and contraindications for surgery 2 Perform operative consent describe complications of surgery including suboptimal tendon transfer due to stiff joints selection of suboptimal or weak muscle-tendon unit for transfer incorrect vector of pull rupture of transferred tendon tendon adhesions loss of grip strength after FDS ring transfer difficulty with muscle-tendon reeducation
E Preoperative Plan 1 Execute surgical walkthrough resident to repeat steps to the attending verbally prior to the beginning of the case describe the potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Loupes recommended 2 Room setup and equipment standard OR table with a hand table 3 Patient positioning place in supine position with shoulder abducted and hand on hand table G Superficial Dissection 1 Identify landmarks and draw incision. make a palmar skin incision over the first annular pulley of the ring finger 2 Identify the A1 pulley 3 Incise A1 pulley longitudinally this isolates the FDS tendons H Isolate the FDS 1 Divide the FDS tendon apply traction to the FDS to flex the PIP joint divide the FDS transversely do this 4 cm proximal to its bifurcation while protecting the FDP tendon I Isolate the FCU 1 Expose the FCU tendon make a zigzag incision over the volar ulnar distal forearm in the region of the FCU tendon insertion 2 Isolate the FCU and the ring finger FDS tendons protect the ulnar neurovascular bundle 3 Divide the FCU tendon transversely cut the radial half of the FCU tendon about 4 cm proximal to its insertion on the pisiform separate the radial half of the tendon longitudinally from the other half this creates a distally-based strip of tendon graft J Create Pulley 1 Loop the tendon graft distally pass it through the distal portion of the FCU near the pisiform insertion 2 Pass the FDS tendon pull the cut ring finger FDS tendons into the volar ulnar forearm incision pass it through the constructed pulley K Create Tunnel 1 Expose thumb MCP joint make an incision on the radial aspect of the thumb MCP joint 2 Create a subcutaneous tunnel between this incision and the wrist incision 3 Pass the ring FDS tendons through this tunnel to the thumb incision L Suture Tendon 1 Align digits place the thumb into opposition with the small finger 2 Suture tendon suture the FDS tendons to the thumb with a 3-0 or 4-0 braided polyester suture The attachment site usually include the abductor tendon plus or minus the dorsal capsule and extensor pollicis brevis tendon N Wound Closure 1 Irrigation, hemostasis, and drain copiously irrigate both incisions 2 Superficial closure use 3-0 nylon for closure 3 Dressing and immediate immobilization place a bulky dressing and short arm plaster cast with the wrist in flexion and the thumb in full opposition
O Perioperative Inpatient Management 1 Discharges patient appropriately prescribe outpatient physical therapy immediate hand therapy pain meds wound care schedule follow up in 2 weeks