Cubital Tunnel – Numb hand from nerve pinched at the Elbow

Facts about Cubital Tunnel Syndrome / Ulnar Nerve Compression

What is Cubital Tunnel Syndrome?
Cubital tunnel syndrome is a condition brought on by increased pressure on the ulnar nerve at the elbow. The ulnar nerve controls muscles used for gripping and the coordination of fine movements. The nerve passes through the cubital tunnel, a bony passageway. Cubital tunnel syndrome occurs when the ulnar nerve is compressed as it passes through this tunnel behind the elbow. When compressed, the ulnar nerve causes the sharp, tingling sensation that you feel when you hit your “funny bone.”

Cubital Tunnel Syndrome is the second most common peripheral nerve compression syndrome (after carpal tunnel syndrome).

What are the symptoms?
Common symptoms include pain and numbness in the hand, including the ring and small fingers. More severe cases may also lead to a weak grip and pain at the elbow. Often patients suffering from cubital tunnel syndrome have difficulty sleeping at night due to the pain and numbness.

What causes Cubital Tunnel Syndrome?
While the majority of cases of cubital tunnel syndrome are idiopathic, the syndrome has been termed “cell phone elbow,” as it can result from prolonged hyperflexion of the elbow (holding the elbow in a bent position for a long time). Bending the elbow increases the pressure on the ulnar nerve. Sustained bending of the elbow also tends to occur during sleep.

What are the treatment options?
Treatment usually begins with splinting the elbow, especially at night, and anti-inflammatory medications. Surgery may be necessary. Surgery involves either releasing the ulnar nerve from the compression, or actually moving the nerve (an ulnar nerve transposition) to allow more room for the nerve to move behind the elbow.

Carpal Tunnel Syndrome

The Carpal Tunnel – The Median Nerve’s Path to the Hand

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome is a common condition in the adult hand, affecting nearly 3% of the population and is the most common peripheral nerve compression syndrome. The carpal tunnel is a bony passageway in the wrist, housing both the median nerve along with nine wrist flexor tendons.

Due to the nonconforming shape of the tunnel, any increase in the pressure of the tunnel causes compression on the median nerve, thereby decreasing its ability to function properly. The median nerve controls important muscles in the hand, giving sensation to many of the digits.

Carpal tunnel syndrome occurs when the median nerve is compressed as it passes through this tunnel in the hand. When compressed, the median nerve causes numbness, tingling, weakness and pain in the hand and wrist. The pain is often positional, meaning that extreme flexion or extension of the wrist exacerbate the symptoms.

What are the symptoms?
Compression of the median nerve reliably causes numbness in the thumb, index finger, middle finger and half of the ring finger. In addition, if the median nerve is compressed for a critical period of time, the nerve loses its ability to power key muscles of the thumb and hand, causing a loss of strength and dexterity for fine movements.
Other common symptoms include hand pain which is often worse at night or while driving, and a need to shake the hand to allow the hand to “wake up”.

What causes Carpal Tunnel Syndrome?

Contrary to much of the information readily available for patients, it is important to emphasize that the vast majority of patients have no known cause for their carpal tunnel syndrome. While it is tempting to attach blame to repetitive activity such as typing, or blame a particular injury, many well designed objective studies have consistently failed to show any effect of repetitive activity on the development or exacerbation of carpal tunnel syndrome.  

The best evidence suggests that some patients likely have a genetic predisposition to the development of carpal tunnel syndrome, despite intuitive interventions such as ergonomic workplace environments or other similar modifications.

Caveat: This is not to say that ergonomic improvements in the way we live and work are not positive improvements. Many significant advances have been made in workplace safety, and certainly in a patient with known carpal tunnel syndrome, minor modifications can be made which can decrease one’s symptoms. However it is important to underscore the fact that though these interventions may help symptomatic management, the lack of such interventions are not the cause of carpal tunnel syndrome.

What are the treatment options?
Treatment usually begins with wrist splints, especially at night, anti-inflammatory medications, and activity modifications.  Steroid injections into the carpal tunnel may also provide relief of symptoms, but unfortunately no interventions short of surgery give adequate space for the nerve in the carpal tunnel once there is too much pressure.  Ultimately, surgery may be necessary to relieve the pressure on the median nerve in the carpal tunnel.

What is involved in surgery?
Carpal tunnel surgery involves an incision in the base of the palm to gain access to the carpal tunnel. The goal of surgery is to provide more space to for the constricted nerve, which the 30 minute procedure reliably accomplishes. I perform the procedure typically in an outpatient setting and most patients have only a few days of discomfort from the incision are able to use their hand fully by 2 weeks after the sutures are removed. Many patients are able to return to work within 1-3 days, and the dressing stays in place until the sutures are removed.

It is important to note that in severe cases, the nerve has sustained permanent injury from years of compression. Though the surgery reliably relieves pressure on the nerve, sometimes the damage is irreversible and persistent numbness or weakness remain. Interested in learning more about your symptoms?  Contact Dr. Scott Ruhlman’s office at 206-633-8100.

What is Dupuytren’s disease?

Dupuytren’s (pronounced “duh-pwee-trahns”) disease changes the way your hand looks and makes it impossible to use one or more of your fingers. With Dupuytren’s contracture the tissue under the skin of the palm of your hand thickens and becomes shorter.

This leads to the fingers bending in toward the palm and it becomes difficult to straighten them. This condition occurs more in people who are older than fifty years and is more common in men.
Dupuytren’s disease, sometimes referred to as Viking’s disease often affects both hands, too. Our orthopedic specialists can treat this condition but there is no cure for it. … read more

Anterior Hip Replacement

Anterior hip replacement is a surgery that has been performed for twenty years. Currently, Dr. Watt is one of only a few orthopedic surgeon performing this technique in the Seattle area. This technique allows the orthopedic specialist to provide you with the same procedure as the standard hip replacement, but with less disruption to the surrounding soft tissues and muscle tissues.

The surgery is performed through a smaller incision and there is less tissue dissection and this allows you to get back on your feet sooner and allows unrestricted motion of the hip immediately after surgery. This guide informs you of what to expect during the hip evaluation, what to be aware of before the surgery, and what you should know about after the procedure.

What to Expect during Hip Evaluation

An orthopedic specialist is a surgeon who specializes in problems that affect the bones and joints. When you go in for a hip evaluation, the doctor will ask you many different questions about your general health, your symptoms, and your expectations. This way he can determine if an anterior hip replacement is right for you.

The evaluation will include careful examination and review of your X-Rays and other preoperative tests. This is done to allow the surgeon to better understand your physical limitations and the exact progression of your hip problem. The orthopedic specialist will take a medical history and perform a detailed physical examination.

This will include range of motion tests of your hips and knees and evaluation of your muscle strength. The doctor will take X-Rays of your hip to evaluate the joint and plan for a new hip if needed.

What to Expect Before your Surgery

Before you undergo an anterior hip replacement, you will have to see your family doctor for a thorough medical evaluation. It is essential that you bring all your medications and supplements to the visit so the doctor can make a note of them and tell you which ones you must stop taking before the surgery.

If you are taking aspirin or anticoagulants, be sure you tell your doctor so he can advise you whether or not to continue these as directed. With this procedure it is usually not necessary to donate your own blood ahead of time.

What to Expect During Surgery

With the anterior approach, the surgeon will be replacing the top of the thighbone and socket through a small incision. Basically, the surgeon will get to the hip by means of a muscle-splitting approach. Rather than removing the muscle, he goes between the muscle tissues.

Because the incision is minimally invasive, you will be back on your feet sooner. The anterior approach to hip replacement has a lower rate of dislocation, too.

What to Expect After your Surgery

Once the surgery is over, you will be monitored in the post-anesthesia recovery room. You will stay there until your blood pressure, pulse, and breathing has stabilized and your pain is under control. You will be asked to move both legs as soon as you wake up and the nurse will help you find a comfortable position to lay in.

To protect you against development of blood clots, you may be asked to do ankle pumping exercises every hour and you will have sleeves on your legs to help prevent blood clots by pumping the blood for you. You will begin to take in regular food and fluids soon after your operation.

There will be a dressing on your surgical site that will be changed and checked frequently. The nurse will have you cough and deep breathe frequently and use an incentive spirometer after your surgery to expand your lungs. Remember, it is normal to have minimal discomfort after the procedure so ask your nurse for pain medication, as you need it.

What to Expect during Recovery

Because the anterior approach to hip replacement is a tissue sparing operation, you will be able to freely bend the hip and bear full weight immediately after surgery. This is done so you can enjoy a much faster recovery than with traditional hip replacement. Isometric exercises begin while you are still in the bed.

These are muscle-tightening exercises done without moving the joint. You will be assisted in doing these a number of times each day during your waking hours.

A physical therapist will work with you to help you move your joints so they remain strong during your recovery. The therapist will document your progress and keep your surgeon well informed of your condition. It is important for you to follow both the therapist’s instructions and the orthopedic specialist’s advice to enjoy a healthy, full recovery.

In patients that are in good shape and good general health before the surgery a discharge from the hospital can be achieved in 2-3 days and frequently patients go home on the afternoon after surgery. Patients are only discharged when they are ready and both the surgeon and therapists feel it is safe.

The Anatomy of the Wrist

The wrist is a complex joint with two intricate rows of bones at the base of the hand. There are a total of eight small wrist (carpal) bones and five longer metacarpal bones, which support the fingers and thumb bones (phalanges). The ulna and the radius are the two long bones that form the forearm and these attach to the first row of the carpals. Each bone end is covered with cartilage, an elastic tissue that creates a cushioned smooth surface that allow the bones to glide smoothly against each other.

Wrist and Hand Arthritis

Arthritis comes in many forms, but the three main forms that affect the hand and wrist are osteoarthritis (OA) and rheumatoid arthritis (RA), and post-traumatic arthritis. Arthritis simply means joint inflammation, and usually causes pain, stiffness, and swelling of a particular joint, depending on the cause. Osteoarthritis is a progressive form of arthritis that destroys the smooth articular cartilage covering the ends of the bones and is generally known as “wear and tear” arthritis.

The cartilage wears away in this form of arthritis resulting in the well-known “bone on bone” pain of osteoarthritis. Rheumatoid arthritis is a chronic autoimmune disorder that affects multiple joints throughout the body. With RA, the arthritis is not limited to a particular joint of the hand or wrist, also involving inflammation of the tendons and ligaments, meaning these structures soften and erode which can lead to tearing of the tendons that are necessary to straighten the fingers. This results in a deformed joint with gnarled fingers and bent wrists.

Treatment for Wrist and Hand Arthritis

There are many treatments for wrist joint arthritis, depending on the location and severity of the condition.  Wrist bracing, activity modifications and over the counter pain medication such as ibuprofen and Tylenol are the first line of treatment. With wrist arthritis, there is often diagnostic and treatment value to an intra-articular steroid injection as many patients find months to years of relief with such treatments.

When symptoms persist despite these treatments, surgical management can be quite successful. The procedures for wrist arthritis include arthritis bone excision called a proximal row carpectomy, which requires no hardware.  Other patients benefit from partial wrist fusions depending on the location and cause of the arthritis. Still other patients eventually need a wrist fusion that limits the painful wrist flexion and extension that typically accompanies advanced wrist arthritis.

A newer type of treatment that I offer in select situations is a wrist replacement, known as wrist arthroplasty. The typical candidate for a wrist joint replacement is someone who has severe arthritis but doesn’t rely on the wrist for heavy daily use. I primarily perform this procedure to relieve pain and to maintain function of the hand and wrist.

Wrist replacement surgery will help recover and retain wrist movements and also will improve the ability to perform activities of daily living. During this procedure, the worn-out ends of the bones are removed and replaced with an artificial joint, which allows for smooth painless motion. This will help reduce or eliminate pain and improve grip strength. It is important to note that if the bones are fused together, the wrist will not be able to bend.

Wrist Joint Replacement Surgery

This procedure is done usually on an outpatient basis, but some patients require on overnight stay. An incision is made on the back of the wrist and the damaged ends of the arm bones are removed. Sometimes the first row of carpal bones must be removed also. Then, the prosthesis is inserted into the center joint region and held in place with a combination of screws and press fit that allows for bony in-growth.

After the surgery, a cast will be worn for several weeks. Once this is removed, a protective splint may be necessary for up to two months. I will prescribe pain relief medications and an exercise program to restore movement gradually by increasing power and endurance. Wrist arthroplasty often improves motion to around fifty to sixty percent of normal motion.