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Interviewer: If you have carpal tunnel syndrome, it might seem like surgery is the only means of relief from your symptoms. But what about simple splinting? Could that be an effective, non-invasive alternative? Dr. Douglas Hutchinson is a hand surgeon. Does splinting work for carpal tunnel syndrome?

Dr. Hutchinson: You know, it's very effective actually, and splints alone are the mainstay of our treatment. And if a person can sleep at night and not wake up with numb fingers, they're going to feel a lot better, they're going to do better during the day, their hands are not going to hurt them, and/or go to sleep on them as much during the day as well, and they're going to get several years out of that type of treatment before they may get to the point where despite splinting they're still getting numbness, and that's when they probably should talk about surgery.

updated: November 23, 2020
originally published: March 28, 2018

Interviewer: Starting to get some wrist pain. Maybe it's carpal tunnel. Well, maybe not. Dr. Douglass Hutchinson, what is carpal tunnel syndrome, and what are the symptoms?

Dr. Hutchinson: Carpal tunnel syndrome is a common diagnosis, and, frankly it's commonly misdiagnosed. Carpal tunnel syndrome, primarily, is numbness in your fingers. Carpal tunnel syndrome is not primarily wrist pain, so if you have wrist pain, it's a different story. Carpal tunnel syndrome is numbness in most your fingers. Sometimes they feel as though it's all their fingers. Usually, it's the thumb, index, and third finger primarily. It usually comes at night because of the way we sleep, and that is part of the treatment right there is to change the way we sleep with our wrists bent.

Interviewer: So if you have numbness in your hand like that, visit your primary care provider for treatment options.

updated: January 8, 2021
originally published: March 6, 2019

Dr. Miller: Are there surgical solutions for your painful hand arthritis? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Doug Hutchinson. He's a Professor of Orthopedic Surgery here at the University of Utah. Doug, I have a lot of patients that come to see me with arthritis in their hands as they get older. They're asking me from time to time if there are any surgical solutions for their pain.

Dr. Hutchinson: Everyone gets arthritis in the hand at some point in time as long as we last long enough. Most arthritis in the hand is something that people live with and I think that's appropriate. Surgery is not going to solve everything that comes down the road, but there's no question that some people have certain fingers that get arthritic changes that hurt them on a daily basis and really get in their way of doing certain things in the kitchen, doing certain things in the garden, doing certain sports activities, and those we probably in some situations can help a lot.

Dr. Miller: How do we do that?

Dr. Hutchinson: For example, in the fingers the most common place to get arthritis is near the tips in the last joint, called the distal interphalangeal joint, right underneath your nail. Some people get cysts that grow out of those that become a problem on the nail and they're painful. Those can be taken care of if we get rid of some of the arthritis there.

Primarily, if the joint of the finger is stiff and painful and has arthritis on x-ray, which is common, one of the things we'll do the most commonly is fuse that joint. That just means putting a screw across the one bone into the other bone and making that joint effectively go away. You can't bend it at the end, but it stays straight the whole time.

Dr. Miller: And that eliminates the pain?

Dr. Hutchinson: That totally eliminates the pain, and the other joints still make you use your hand very well. Functionally, you're normal without that last joint working.

Dr. Miller: Are there any particular joints in the hand that are more amenable to surgery than others?

Dr. Hutchinson: Yeah, other than the DIP joint of the fingers, which is the last joint near the nail, the base of the thumb, which is all the way back closer to your wrist. Some people even think that they have wrist pain but in fact it's the base of the thumb that's hurting them. Typically a patient will really have a hard time with certain grips. They won't want to shake hands as much. They really hate the fact that they can't open a jar at home. They've got to give it to their wife or their husband to figure that out. It's generally a thumb pain problem that is really, in the world of humans the thumb is overwhelmed by what we do with our hands, and there are more forces put through our thumb joint than was originally intended.

Dr. Miller: Do you perform a similar stabilizing surgery where you put a pin or screw in the joint?

Dr. Hutchinson: Yeah. For a thumb arthritis, the most common solution is to remove a bone at the base of the thumb, which means the two ends of the bone that were grinding on each other causing pain, now one of them is gone. There's no longer a bone grinding on a bone. The word arthritis means "arth" which is joint, and "itis" which is inflammation. I tell my patients that if you don't have an "arth" you can't have arthritis. The getting rid of the "arth" is either a fusion, like we do in the distal joint of the finger, or a resection of the bone which means it can still move very well as opposed to a fusion. The pain is gone and we use a tendon to help stabilize the joint.

Dr. Miller: Would you recommend conservative therapy prior to considering surgery for either a distal interphalangeal arthritis or base of the thumb arthritis?

Dr. Hutchinson: Yes. We always recommend conservative care first, and most times that usually works for a lot of people for a good bit of time. A thumb arthritis, the mainstay for treatment is to get them a splint. The splint is something no one wants on their hand and no one wants on their thumb in particular, but it's worn at night when no one theoretically is using their thumb in the middle of the night. It allows the thumb to rest. That may make it better during the day when you take the splint off and use your thumb for normal activities.

We always want them to avoid certain activities. You don't want to open a can with a hand crank if you have thumb arthritis. You want to go out and buy an automatic can opener. That's something our hand therapists insist on. They think that should be done; at age 20 we should all get automatic can openers.

Dr. Miller: In your opinion, what would be the best conservative therapy? What do you advise patients to take?

Dr. Hutchinson: We generally tell them to wear a splint during the night that's fairly rigid that holds their thumb. We give them a strap type of a splint that's easy to wear during the day that they can wear when they want. When they don't want to they can not wear it at all. It sometimes helps when they're gripping things and gives them a little bit more support and decreases their pain.

If they get to the point where it's worse, we'll often inject them which helps them for two to three months at a time and really makes their pain go away, again, can delay the surgery if they want to have the surgery. Some people come back to me every six months and say, "Give me another injection. I don't want that surgery. I ain't got time for that. Let me just have three, five, six months of peace, please."

Dr. Miller: What is the durability of the surgery? Is it long-lasting?

Dr. Hutchinson: Yes. The surgery for base of the thumb arthritis is actually one of the best we have in our armamentarium. It works well in most any surgeon's hands. There are different procedures that can be done, all of which work about the same or as well as the others. I would caution a patient that it takes three months of being good and wearing a splint, and therefore it's a longer rehabilitation than they would like.

Other than that being a negative, the rest of it is positive. They maintain their motion. They actually increase their grip strength a little bit. Their pain is effectively 100% resolved at that particular joint. Again, a person with a lot of arthritis in their hand is not going to get the rest of their arthritis to go away, but that one is usually the one that is causing the most problem.

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updated: May 16, 2019
originally published: January 19, 2016

Dr. Miller: What is carpal tunnel syndrome? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope. Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Doug Hutchinson. He's a Professor of Orthopedic Surgery here at the University of Utah. Doug, what is carpal tunnel syndrome? What is that?

Dr. Hutchinson: Tom, carpal tunnel syndrome is a common diagnosis, and frankly, it's commonly missed diagnosed in the lay public. Carpal tunnel syndrome primarily is numbness in your fingers. Carpal tunnel syndrome is not primarily wrist pain. That's the first misconception I'd like to solve. So if you have wrist pain, it's a different story. If you primarily have numbness, sometimes it comes with pain, but mostly it's numbness.

Dr. Miller: What causes that numbness?

Dr. Hutchinson: What's happening is the median nerve, with is a main nerve that goes into your hand through your wrist, goes through a tight tunnel where all the tendons for your fingers are also located, and basically our assumption is that the space is so limited that if you use your tendons a lot, which we all do over the course of years, there will be a little bit of a buildup of tissue in there, and maybe a little bit of inflammation, though it's not much, but enough to make it so that the nerve feels claustrophobic, if you will, and pressured. Therefore, pressure on a nerve creates numbness where that nerve is going or coming from, and in this case that nerve is coming from those fingers.

So carpal tunnel syndrome is numbness in most of your fingers. Sometimes they feel as though it's all their fingers. Usually it's the thumb, index and third finger primarily. It usually comes at night because of the way we sleep on our wrists, and that is part of the treatment right there, is to change the way we sleep with our wrists bent. Dr. Miller: Now, are some people at greater risk of developing carpal tunnel than others?

Dr. Hutchinson: The common person who has carpal tunnel is 40s, 50s, 60s, and a little bit more often in a female than in a male. There's a lot of history of whether these come from repetitive activities and computers, and probably the bias and my answer is it doesn't. It's primarily genetic. It's primarily something that you were going to get anyhow even if you lived in rubber room your entire life and didn't do anything with your hands. It's just something that eventually can happen to some people because the nerve's in a tight spot in the wrist, and certain movements and certain positions will make that nerve a little bit unhappy over time and it will want a little bit of a bigger house.

Dr. Miller: Does it usually occur in the dominant hand or in both hands?

Dr. Hutchinson: Usually it's in the dominant hand first, but it usually occurs in both hands eventually.

Dr. Miller: Now, I heard that it's more common in pregnant women. Is that true?

Dr. Hutchinson: Pregnant women are very common, and anybody else who has major fluid changes, etc., and even can come in some women around their periods because of that type of change. Post-menopausal women are clearly the most common when it comes in. So yeah, there are changes that can occur. Some people will have something like a ganglion cyst that will actually put pressure in that area, and that can cause carpal tunnel syndrome. But usually it's idiopathic, and that means that there's no real cause for it, it just is happening to them.

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Dr. Miller: Your primary care doctor is referring you for treatment of carpal tunnel to a specialist. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, I'm here today with Dr. Doug Hutchinson. Doug, tell us what happens when you receive a referral for carpal tunnel syndrome and I send you a patient that I think has carpal tunnel. What are the next steps?

Dr. Hutchinson: Well, of course, you're always right, so I wouldn't have to worry about any diagnostic situations at that point in time.

Dr. Miller: That's what my wife always tells me.

Dr. Hutchinson: Yes. In general, the story is that a patient will come to us and say, "I've got numbness and Dr. Miller: thinks I have carpal tunnel syndrome," and we'll talk to them merrily because what they tell us is happening to them is more important than anything else. Their history is the most important thing. We'll do a few physical exam maneuvers that will confirm our suspicions.

And if they're a typical patient who is complaining of numbness more than pain and who is 40 or 50 and not 20, then we're going to pretty much be able to diagnose this as carpal tunnel syndrome in our office without any further studies, without any need for electrical studies or other things that have been routinely done for this problem.

Dr. Miller: Which patients might need electro-diagnostic studies?

Dr. Hutchinson: In my opinion, those that need it are those that things don't fit, the nerve doesn't seem like it's the right distribution in the hand, they don't wake up at night with numbness, a splint doesn't help them, they think it's work related. Things like that are a little bit different than the normal and those are ones that we might want a little bit more information to make sure we're not missing something else.

A patient with a lot of neck pain as well as having carpal tunnel syndrome could easily have a compression of the nerve somewhere else, like in the neck, and it would be obviously smart to know the difference between this coming from the neck or from in the wrist since wrist surgery won't help the neck problem.

Dr. Miller: Let's say you agree with the diagnosis of carpal tunnel. How effective is conservative therapy using splints and other treatments?

Dr. Hutchinson: It's very effective, actually, and splints alone are the mainstay of our treatment and if a person can sleep at night and not wake up with numb fingers, they're going to feel a lot better, they're going to do better during the day, their hands are not going to hurt them and/or go to sleep on them as much during the day as well.

And they're going to get several years out of that type of treatment before they may get to the point where, despite splinting, they're still getting numbness and that's when they probably should talk about surgery.

Dr. Miller: Are there any other conservative measures aside from splinting? Are there any exercises?

Dr. Hutchinson: For the most part, in my opinion, there are not a lot of exercises that can help. Taking a vitamin B complex can be helpful for any nerve issues and that may benefit some people and again, it's probably going to delay things. It may delay things upwards of a year or two if you can get a little bit of symptom relief.

The other main thing we use is an injection of cortisone. An injection of cortisone, most of us feel, is not going to ever cure carpal tunnel syndrome but it could last even all the way up to a year of symptom free, so I use that a lot to get people to where they want to be for their surgery.

For example, if they're a big skier, they want to wait until ski season's over, that's a reasonably good thing to do. If they're going to go on vacation and they don't want to wake up every night with their hands numb, that helps them do that.

And the other major person for that is a pregnant female who will eventually not be pregnant. And therefore if we can make their symptoms diminish while they're in their third trimester then when they deliver the baby usually their hands get better and they won't need surgery. Some question about whether they'll need surgery in 10 years from now or not, but they don't need it right then which is not when they want it anyhow.

Dr. Miller: When conservative methods are ineffective, how effective is surgery?

Dr. Hutchinson: Surgery for carpal tunnel syndrome is, in my opinion, probably the best surgery on the planet.

Dr. Miller: No doubt.

Dr. Hutchinson: It makes more people happy and few people, very few people are unhappy. Every surgery has risks and every surgery doesn't work some of the time. This surgery is simple, fast, easy to get over, and many, 99% or so, of the patients are not just happy, they're ecstatic. They think it's the easiest and greatest thing they ever did from a surgical standpoint, and they wonder why the heck they waited with a splint on the last month or the last year or whatever of their lives. They feel as though they should have gone ahead and done it sooner.

Dr. Miller: Is there any new special technique that you use surgically now?

Dr. Hutchinson: There really isn't much new there for the last 20 years, we've been doing an endoscopic carpal tunnel release, which is decreasing the size of the scar. The truth is, when I was in training the scar was about four times the size of what it is now anyhow. So we've learned to get smaller scars, not spend much time; it takes about nine minutes to do a carpal tunnel release. The patient can be completely awake during that time.

We do most of our carpal tunnels with them, more or less, in a procedure room, not even in the operating room anymore because they can avoid the anesthesia hangover, they can avoid changing clothes, getting an IV. They can even avoid not having to eat something the night before. Some of my patients will come in with their cup of coffee in the morning, get their carpal tunnel done, and pick up their coffee and go back to work.

Dr. Miller: So is that surgery effective long-term? Does it recur?

Dr. Hutchinson: It's really effective mostly long-term and, on a rare situation, someone will need another redo carpal tunnel release down the road.

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