January 2025 - Bones and Nerves

Carpal Tunnel Myths and truths

Posted on January 31, 2025 by bonesandnerves

The Silent Struggle of the Carpal Tunnel

Our bodies are extraordinarily complex yet beautifully crafted, with every structure serving a specific purpose. The carpal tunnel is no exception. Though infamous for causing carpal tunnel syndrome, this natural marvel is a hypothetical tunnel, a narrow passageway thats formed by a ligament and two bones and 10 structures pass through this tunnel including 9 tendons and a nerve – Median Nerve. This nerve provides sensation to the thumb, index, middle, and part of the ring finger, while also controlling some of the small muscles at the base of the thumb that allow for fine motor movements.The ligament which is specifically called Transverse carpal ligament is a part of the flexor retinaculum which is a thick band under wrist on the side of palm to make the wrist stronger and keep underlying structures in place.

Carpal tunnel syndrome often begins insidiously, with symptoms so subtle that patients remain unaware of the problem until it becomes severe. Left untreated, it can progress to a point where surgical intervention becomes the only option. Many patients delay seeking specialized care, often consulting a general physician or neurologist. However, carpal tunnel syndrome is best treated under the expertise of an orthopaedic surgeon—and even more effectively, by a specialist in hand surgery.

Understanding the Pressure Within: The Origins of Carpal Tunnel Syndrome

The symptoms of carpal tunnel syndrome arise due to a narrowing of the canal, which can occur for two main reasons. Primary causes involve thickening of the transverse carpal ligament, while secondary causes stem from conditions that encroach upon the tunnel. These might include soft tissue changes from arthritis leading to synovitis, enlargement of the nerve, tendons, or tendon sheaths, or even bony issues like tumors, fractures, or implants.

Our bodies are incredibly adaptive and always strive to heal. In carpal tunnel syndrome, the tendons within the tunnel try to adjust to the increased pressure caused by the narrowing. However, the Median Nerve, being far more sensitive, struggles to cope. This results in classic symptoms such as tingling in the fingers, numbness, and weakness.

Interestingly, this is not unlike our own lives. We constantly adjust to the pressures of daily existence, adapting to the push and pull of circumstances. But sometimes, like the Median Nerve, we reach a breaking point. The strain catches up with us. And just as in life, there comes a moment when we must step back, assess the situation, and take corrective action to heal.

And so, let’s delve into how we identify, address and fix this remarkable yet challenging condition: the journey from discomfort to recovery.

The Progression of Carpal Tunnel Syndrome

Carpal tunnel syndrome often begins innocuously—a fleeting tingle in the fingers while holding a phone or performing everyday tasks. At first, it seems harmless, but as the condition progresses, it can disrupt sleep, with patients waking up due to severe tingling. Over time, symptoms escalate to include a weakening grip, difficulty holding objects, and even frequent dropping of items.

To diagnose and assess the severity of this condition, we typically perform a Nerve Conduction Study (NCS)—a noninvasive test that measures how quickly electrical impulses travel through the nerves. The results help us grade the severity of the syndrome on a scale of 1 to 6, with higher grades indicating more advanced disease and the need for more intensive intervention.

There is a theory that conservative treatments, such as steroid infiltration or hydrodissection, can provide relief for carpal tunnel syndrome. While these methods may work in mild to moderate cases, my experience has shown that for more severe cases—typically with an NCS grade greater than 3—surgical intervention becomes necessary. A surgical release effectively decompresses the nerve, providing a lasting solution to alleviate symptoms and prevent further damage.

Advancements in Carpal Tunnel Surgery: Precision and Recovery

Over the years, carpal tunnel surgery has seen significant advancements in precision and technique. I feel privileged to have performed hundreds of these surgeries, each one a learning experience shaped by the feedback and outcomes of my patients. The procedure I now perform involves a remarkably small incision—smaller even than those used in endoscopic techniques.

This refined approach not only minimizes scarring but also accelerates recovery. Most patients are able to resume dry activities as early as the day after surgery, and by the 12th day, they are typically back to their normal routines without complications or morbidities. It’s a testament to how far we’ve come in providing effective and patient-friendly solutions.

Nature’s Unexpected Miracle in Carpal Tunnel Syndrome

I often marvel at the wonders of nature, especially when it comes to carpal tunnel syndrome. Interestingly, most patients experience the condition on both hands, but one side is usually more severe. What’s fascinating—and deeply satisfying—is that after performing surgery on the more affected side, the symptoms on the opposite hand often resolve on their own within 3-4 months.

Many patients, thrilled by the relief they feel after surgery, are eager to undergo the procedure on the other hand as well. However, I usually counsel them to wait and allow time for nature to work its magic. More often than not, their symptoms improve without further intervention, reaffirming the body’s incredible ability to heal itself when given the chance.

Healing in Harmony with the Body

As a surgeon, I believe our role extends beyond simply performing procedures—it’s about working in harmony with the body’s remarkable ability to heal itself. Every time I step into the operating room, my goal is not only to treat but to support and amplify the body’s natural defenses and healing mechanisms. By striving to align my efforts with this innate resilience, I aim to deliver the best possible outcomes for my patients. It’s this synergy, this partnership with nature’s design, that brings me fulfillment and makes every day in this profession deeply rewarding.

The Mystery of the Blue Finger

Posted on January 10, 2025January 10, 2025 by bonesandnerves

This particular case involved a girl in her late teens who came to me with her father, seeking help for a bluish discoloration of the ring finger on her right hand—a condition she had lived with since early childhood. Logic might suggest that health concerns should be addressed as soon as they appear, but reality often tells a different story. Whether it’s the fear of medical procedures or a hopeful belief that time will heal all, I frequently encounter cases where patients delay seeking treatment. This was one such instance, and it underscored how important it is to approach every case with empathy and a readiness to address long-standing issues

Now, let’s dive into some technical details. Upon examining her clinically and reviewing her MRI and other reports, I diagnosed her condition as a slow-growing vascular malformation, most likely a hemangioma. Treating this type of case is anything but straightforward—it’s a risky procedure with significant challenges.

As doctors, our ultimate aim is always to achieve the best outcomes, but the truth is, we can’t always guarantee them. In this case, the malformation was entwined with the neurovascular bundle and surrounding tissues, making complete excision potentially impossible. There was also a remote but real risk of finger loosing its blood supply and eventually losing the finger altogether. While patients often perceive these warnings as routine, the risks are very real. For surgeons, the delicate balance between ensuring the best possible outcome and preventing worst-case scenarios is what makes this work so compelling—and, admittedly, nerve-wracking. It’s this intersection of precision, uncertainty, and responsibility that defines the art and science of surgery

We prepared the patient for surgery with the necessary investigations, premedication, and consent. Once in the operating room, our anesthetist administered a supraclavicular regional block to ensure effective analgesia and temporary paralysis of a sort. The surgical area was prepped and draped, and a tourniquet was applied to create a bloodless field—though, paradoxically, this is more of a surgery dealing with blood vessels and small pools of blood(sinuses),to be specific and one needs to see the vessels feeding the lesion.

A zigzag incision was made along the palmar side of the finger to explore the lesion. I often marvel at how medical techniques evolve. How did someone figure out that a zigzag incision is not only elegant but also preserves better function. It must have been the result of countless trials by some dedicated doctor or an entire generation of doctors who tested and refined their methods. As continuous learners, we take pride in mastering these techniques, but I also feel immense gratitude toward those who innovate and pave the way for progress. In my practice, I strive to contribute my own small innovations, hoping to improve patient outcomes and leave a positive impact.

Returning to this case, the lesion was intricately wrapped around the radial neurovascular bundle and other tissues, presenting a delicate challenge causing no damage to these vital structures and also to remove abnormal tissue as much as possible to avoid recurrence. The abnormal tissue extended through various layers, spanning from the middle phalanx to the distal palmar crease. During the procedure, we also encountered several ‘phleboliths’—calcified clots that had formed into hard,

pearly-white, oval or round structures. These phleboliths, found at specific intervals, helped us trace the path of the abnormal tissue and further confirmed the diagnosis. After excising all visible tissue, we achieved hemostasis and carefully closed the wound using fine sutures to preserve the skin creases. The excised tissue was sent for histopathological evaluation to further confirm the findings.

Hemangioma Overview: A hemangioma is a condition where the cells of the veins begin to multiply abnormally, leading to the formation of large, blood-filled vessels called sinuses. These vessels tend to grow tortuously, winding around the normal soft tissues. It’s a very slow-growing lesion, often taking years to develop, and it is reducible in nature. While this explanation may sound a bit technical, the key takeaway is simple: if you notice any bluish discoloration under the skin, particularly over palm or a finger, it could be a sign of such a condition.This is often coupled with pain, abnormal sensation or decreased sensation, feeling of heaviness etc.

Blog: Ruminations of a hand surgeon

Posted on January 10, 2025January 31, 2025 by bonesandnerves

Hand surgery is the art and science of restoring the delicate functions of the hands and upper limbs, which are central to our daily lives. Whether it’s repairing fractures, treating nerve injuries, tumors or addressing congenital deformities, the goal is always the same: to return functionality and improve quality of life.

As a Hand Surgeon, My job is endlessly fascinating because no two days are ever the same. Every surgery presents a unique challenge, an opportunity to solve complex problems of hand and make a tangible difference in someone’s life. Whether it’s restoring function to an injured hand, making unresponsive digits move again, or alleviating pain, I witness the incredible resilience of the human body—and the profound impact of precision and care. This ever-changing, deeply rewarding journey is what drives me every day

Through this series, I will be chronicling a few of my experiences to share with others, but also, in my heart, to thank the Almighty for allowing me to be His instrument in making a difference in people’s lives.