When Can a Hand Surgeon Return to Work after Undergoing Carpal Tunnel Repair?

Sir: I recently underwent left nondominant carpal tunnel repair. I have performed more than two thousand of these operations in my lifetime, and I had always wondered how it would affect me and my ability to work if I had to have it done myself. Therefore, I am sharing this experience with my fellow hand surgeons. In my office, I had an open (not endoscopic) palm incision with epinephrine hemostasis, no tourniquet, and no sedation, also known as the “wide awake” approach.1 My surgeon/colleague used 2% lidocaine with 1:100,000 epinephrine. I was surprised by how minimal the pain of the injections was (1 out of 10). I have had significantly more pain from injections at the dentist. After the anesthesia, the surgery was pain-free and very relaxing with the absence of the tourniquet. I was reassured that the “no sedation” policy in my own carpal tunnel practice is very reasonable. I am also aware that many surgeons still use a tourniquet for carpal tunnel repairs, and even 4 minutes of tourniquet use, which was my average tourniquet time before I quit using it 8 years ago, may be enough to require sedation in their patients. Four hours after my operation, despite keeping my hand elevated and despite the fact that my colleague had applied a small plaster splint that was certainly not too tight, I found the veins of my hand to be quite dilated. I removed the splint and was immediately more comfortable. I never put the splint back on. I knew that this would not upset my surgeon, as he and I both have a loose splinting policy anyway. I tell my patients that the splint is there mostly to remind them and those around them that they cannot do all of the things that they would normally do, such as shake hands, make a sandwich, and so on. I had allowed my patients to take the splint off to shower the day after the operation and to move the hand and fingers in the quiet of the evening. I have always told my patients that they can do whatever does not hurt, provided that they are not taking painkillers. That turned out to be excellent advice for my own hand. It is worth mentioning that for the entire 10 hours of the median nerve block, my hand was strikingly red and very noticeably warm to the touch compared with my other hand, likely because of a sympathetic nerve knockout. I am tempted to try blocking the median nerve with lidocaine and epinephrine with my next frostbite case (no shortage of those in Canada). The median nerve block lasted about 10 hours and wore off at about 2 a.m. I slept quite well most of the night, except for the occasional times when my hand woke me up to remind me to change its position. I was awakened at 3:30 a.m. when the pain peaked (3 out of 10). Normally, I might have taken 400 mg of ibuprophen or 1000 mg of acetaminophen for a similar headache situation, and that would have been plenty. However, I had not taken any medication so far and I wanted to stay medication-free throughout this experience to see how bad it got. All that happened was that I fell back asleep and awoke at 6 a.m. with the pain gone, and it stayed gone unless I made movements that my hand was telling me I should not, with short jabs of “Do not do that!” pain that would go away immediately. At 7:30 a.m., I went to the hospital, where I had a very busy clinic (the usual). I worked a normal day, seeing patients and doing paperwork with no problem. However, I performed no procedures and the affected hand was not my dominant hand. I may well have had some difficulty writing chart notes and signing my name had it been my dominant hand that had undergone repair. All surgeons wonder what “lies” they are telling patients when they give them preoperative and postoperative advice about operations the surgeons themselves have never had (at least I often wonder about that). The only significant big “lie” I had been telling them was the following: I used to tell my patients, “Your fingers will be fine tonight; it’s your thumb that will give you a lot of trouble for several weeks.” To my surprise, my fingers were stiff for 2 to 3 days. However, by day 5, I was typing full speed (eight-finger typing) on my keyboard with no residual finger stiffness. By day 7, I could perform small procedures without difficulty. On day 12, I had a full day of general anesthetic procedures, including a latissimus breast reconstruction, in which I helped to turn the patient without difficulty. I was also surprised by how quickly my thumb recovered. Although most of the little “Do not do that!” jabs of pain that I had were all related to major movement of the thenar muscles (and therefore movement of the transverse carpal ligament), I feel that I would not have had any difficulty with limited amounts of writing or using a computer mouse by day 5 if it had been my dominant hand, because flexor pollicis longus thumb movement was pain-free and, therefore, safe. This brings me back to the splint. For years I have used a short, light wrist splint. I now realize that may have been useless, as I had no pain whatsoever moving my wrist, although operative edema and stiffness made it difficult to get full wrist extension with fingers hyperextended until about day 4. It has now occurred to me that if I am going to use a splint on my patients at all, I should only splint the thenar muscles with a short opponens splint, as moving those muscles was the only thing that jarred the transverse carpal ligament to produce what little pain I had with this procedure. As a result, I will now start to use this new thumb splinting in my own practice. I will now also be even looser about splinting my own patients. I will still tell them that the splint is mostly there to remind them and those around them that they cannot do all of the things that they would normally do. However, I will now also tell them that if they are more comfortable without the splint, they do not need to use it at all. It is important to mention that my skin was closed with buried dermal Monocryl sutures and not with nylon. In the more than 15 years that I used nylon, my carpal tunnel patients would often come back with stitch irritation (either redness or little white pustules right where the nylon entered the skin on either side of the wound), especially patients who moved their hand a lot in the days following the surgery. With movement, the nylon irritates the skin like a string going through butter. Five years ago, I stopped using simple nylon sutures and moved to buried dermal sutures. It has been a major improvement. I have not had one dehiscence, and I almost never see suture irritation, unless the dermal suture gets too close to the epidermis, which is very rare. I am certain that I would have had a lot more trouble with early movement in my own hand had my colleague used simple nylon sutures. I showered with the wound open the morning after surgery. I wore a bulky bandage for 2 days, and then a Band-Aid for 3 more days. On day 6, my wound was open to the air. If you still use nylon in the skin, you will be amazed at how many fewer skin problems you will have with buried Monocryl. In my patients, I have used long and short open palm incisions as well as both the Chow and the Agee endoscopic techniques. I have often wondered how bad it really is to cut the skin of the palm and how much that really affects one’s ability to work. After all, that is the essence of the big debate between open and endoscopic surgery that is currently raging on to the point of being chronic. Although my experience is entirely anecdotal (n = 1), and many patients may have an experience different from mine, I have to say that having an open approach was very, very benign for me. I almost feel silly that I was worried about having the surgery and about whether it would affect my ability to work for a long period of time. I have one final note. I am writing this letter from the American Association for Hand Surgery meeting in Tucson, Arizona, where the president of the society, Dr. Susan Mackinnon, has been talking about the scratch collapse test for carpal tunnel surgery. Today, I asked her to examine my carpal tunnel repair without telling her about my history. My left hand, which had severe compression by nerve conduction studies 4 weeks earlier before the surgery, did not collapse. My right hand, which had not been operated on and which is symptomatic for numbness but had normal nerve conduction study results, collapsed immediately and repeatedly. She looked at me and said, “Don, I’m sorry, but I think you have a carpal tunnel in the right hand.” Her scratch collapse test was more sensitive than the nerve conduction studies in my n = 1 case. I am going home to begin to evaluate the scratch collapse test in my own patients. I may some day write again to describe the results for the dominant hand. Donald H. Lalonde, M.D. Division of Plastic Surgery Dalhousie University 3D North 400 University Avenue P.O. Box 2100 Saint John, New Brunswick E2L 4L2, Canada, [email protected]

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