Clinical Work


In the photograph: Dr. Samra (left) and Dr. Thomson (right) in clinic.
Brachial Plexus Injury

What is the Brachial Plexus?

The brachial plexus is a bundle of nerves commencing from the spine from above the fifth cervical vertebra in the neck to under the first thoracic vertebra at the top of the rib cage (C5-T1) and proceeding through the neck, under the clavicle, through the underarm, and into the arm.

How is the Brachial Plexus injured?

Nerves in the brachial plexus may be injured by excessive stretching or avulsion. Injuries may be classified as traumatic, resulting from physical impact such as in high-velocity motor vehicle accidents, or obstetric, resulting from abnormal stretching of the neck or shoulder during delivery.

What are signs and symptoms of Brachial Plexus Injuries?

Because the brachial plexus innervates the entire arm, signs and symptoms may include

  • weakness in the shoulder, elbow, wrist, or hand,
  • inability to move at any of these joints,
  • clawing of the hand or other deformed position,
  • diminished reflexes in any part of the arm, or
  • diminished sensation in any part of the arm.

How are Brachial Plexus Injuries treated?

Treatment is tailored to the extent of the injuries and to the functional requirements of the arm depending on the patient's occupation and activities. By borrowing from adjacent anatomy, nerve transfers may be performed to restore motor function or sensation, and muscle transfers may also be performed to restore motor function.

Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

This is one of the most common problems that hand surgeons treat. The carpal tunnel is a space in the wrist that is formed by several structures. Bones make up three sides of the tunnel and a ligament runs across the top of this tunnel. Nine tendons and the median nerve travel through this space. The tendons control the movement of the fingers while the median nerve supplies sensation to the thumb, index, middle and half of the ring finger. It also provides motor supply to the thumb. If there is swelling in this space, the median nerve will be trapped against the ligament and become compressed. This compression is what causes the symptoms of carpal tunnel syndrome.

What are symptoms and signs of Carpal Tunnel Syndrome?

The most common complaint is that of numbness and tingling in the hand localized to the thumb, index, middle and half of the ring fingers. The symptoms are often worst and night and awaken the patient from sleep. Symptoms may also occur while performing routine daily activities. There may also be numbness or tingling in the forearm or upper arm areas. Eventually, there may be weakness or clumsiness of the hand, especially when grasping small objects. Finally, there may be profound weakness of the muscles at the base of the thumb. In some cases, your doctor may recommend a special test called a electrophysiologic study or nerve conduction study to help determine the severity of your carpal tunnel syndrome.

What is it is caused by?

Carpal tunnel syndrome can be caused by anything that causes swelling within the carpal tunnel resulting in increased pressure on the median nerve. For example, carpal tunnel syndrome has been associated with:

  • Trauma
  • Tumors
  • Rheumatoid arthritis
  • Scleroderma
  • Diabetes mellitus
  • Pregnancy
  • Gout
  • Repetitive motion

In many cases the actual cause of this syndrome cannot be found, however this does not usually affect the treatment or outcome.

How is it treated?

Depending on the severity of the problem, carpal tunnel syndrome can be treated in two basic ways. For very mild forms of carpal tunnel syndrome, the patient may be treated without an operation. Treatment includes work modification, wrist splints or anti-inflammatory medications.

In patients who do not gain relief from this type of therapy or who have much more severe disease, it may be necessary to perform surgery. The surgery can be performed in one of two ways. An endoscope, a small television camera with a light, can be inserted into the hand through a very small incision in the wrist crease. The ligament that lies over the carpal tunnel can be cut using this technique. In some patients it is necessary to make an incision in the palm in order to release this ligament. Your doctor will explain which type of treatment is most appropriate for you. The surgery is performed in an outpatient setting and the patient is able to go home that same day.

Dr. Thomson is skilled in performing endoscopic carpal tunnel release, and has been offering it as a minimally invasive treatment for patients with carpal tunnel syndrome for the last 20 years. Endoscopic carpal tunnel release involves making a small (approximately 2 cm) transverse incision on the wrist instead of the palm. Through this tiny access point, a camera is inserted into the carpal tunnel, and the transverse carpal ligament is visualized and released from its underside.

The surgery takes approximately 15 minutes to perform and can be completed under local anesthesia, minimizing recovery time the day of surgery. Studies show that patients who undergo endoscopic carpal tunnel release have less short term scar tenderness and discomfort in their hands than those who undergo traditional open release which places an incision onto the palm.

Cubital Tunnel Syndrome

What is the Cubital Tunnel?

The cubital tunnel is a tunnel formed by bones and ligaments on the inside of the elbow. The ulnar nerve passes through this tunnel on its way from the upper arm into the forearm. This nerve is in the area of your "funny bone" and is the reason why you have a tingling sensation in your ring and little fingers when you accidentally hit it.

What is the cause of Cubital Tunnel Syndrome?

Cubital Tunnel Syndrome is caused by increased pressure on the ulnar nerve as it passes through this tunnel. The ulnar nerve normally stretches a few millimeters every time the elbow is flexed. When this is done repeatedly or for prolonged periods of time, the nerve can become irritated and inflamed. Direct pressure on the elbow and trauma are other causal factors. The nerve can also move from its original position in the tunnel to a place outside the tunnel, leading to continued irritation and inflammation.

What are the symptoms of Cubital Tunnel Syndrome?

Common symptoms are numbness of the little and half of the ring fingers as well as electrical shock sensations down to the fingers by tapping this area of the elbow. The characteristic pain may also be recreated by bending the elbows sharply. Finally, in the more severe forms of cubital tunnel syndrome, there may be weakness of the hand muscles.

How is Cubital Tunnel Syndrome treated?

Your doctor may recommend nerve testing to confirm the severity of the nerve compression. In mild cases of cubital tunnel syndrome, treatment consists of elbow immobilization, work modification, protection of the elbow and anti-inflammatory medications. If there is weakness of the hand, atrophy of the hand muscles or permanent numbness, surgery is the recommended treatment of choice. In this type of surgery, the regions of nerve compression are released and the nerve is relocated to an area that is better protected and causes less stretch on the nerve when the arm is straightened. At the end of the operation the elbow is splinted for one week.

Ganglion Cyst

Ganglion cysts are the most common soft tissue swellings of the hand and wrist. They can occur at any age, in either sex, or from any joint or tendon sheath. They are non-cancerous cysts that are filled with fluid. Some will disappear and others may cause problems due to large growth. It is unclear what causes the formation of ganglion cysts, but there is some evidence that they may be related to prior trauma or arthritis.

Not all ganglion cysts need to be removed surgically; some resolve spontaneously while others remain small and asymptomatic. This type of ganglion can be observed without surgery. The larger ganglia that do not disappear or are painful, symptomatic or cosmetically undesirable should be treated. Fluid may be drawn off the cyst but the cyst may still return. The ganglion may also be removed surgically with a lower rate of recurrence. This is performed as an outpatient procedure.

De Quervain's Tenosynovitis

Also known as DeQuervain's Stenosing Tenosynovitis, tendonitis of the wrist is an irritation and swelling of the wrist tunnel that the tendons of the thumb pass through on the way into the hand. The most common symptoms of DeQuervain's are a pain over the tunnel in the wrist when pinching, grasping or stretching the wrist towards the small finger. Sometimes a swelling can be felt over this inflamed tunnel. More common in women, aged 30-50, this condition may be associated with repetitive stress, pregnancy or rheumatoid arthritis.

The primary treatment for tendonitis of the wrist consists of splinting to immobilize the base of the thumb and part of the wrist. Work modification and anti-inflammatory medications are also helpful. Steroid injections can also be used to help decrease the inflammation in this tunnel. More severe cases that are unresponsive to conservative treatments may require surgery.

Lateral Epicondylitis (Tennis Elbow)

Lateral Epicondylitis, or known colloquially as Tennis Elbow, is a tendonitis of the tendons that come off of the elbow. It is not necessarily a result of playing tennis; it may also be associated with repetitive movements and work related activities.

You may experience pain on the outside of your elbow that is often described as deep and aching, but there may also be sharp pain with movement. Pressure on the side of the elbow reproduces the pain.

Initially, tennis elbow is treated with rest and activity modification, as many patients do seem to get better over time. Some mild cases do resolve spontaneously but this may take several months. Steroids can also be injected into the area of maximal pain with some relief. During this time, the patient may take anti-inflammatory medications and wear an elastic forearm support to help reduce the symptoms of the tendonitis. If these measures are not successful, surgery may be warranted to treat the tennis elbow. Your doctor will decide which treatment is most appropriate for you.

Trigger Finger

Stenosing Tenosynovitis of the flexor tendons is also known as Trigger Finger, one of the most common problems of the hand. Tendons glide through a pulley system in each finger, similar to the way that a fishing wire glides through pulleys along a fishing pole. Just as this system keeps the fishing wire next to the pole, the tendons are held next to the bones of the finger, to prevent bowstringing of the tendon. Sometimes the tendons can become inflamed in areas, making it difficult for the tendon to easily glide past the pulleys, as in straightening or bending the fingers. When the swollen part of the tendon is forced through the pulley, the patient experiences a characteristic triggering sensation. Trigger finger can occur in any finger, however it is most common in the thumb or ring fingers.

Trigger finger is first treated with direct injection of steroids into the tendon sheath. This is successful in a large number of patients. However, if this treatment is ineffective or if the patient has multiple fingers that trigger, surgical release of the pulleys is warranted. Long-term prognosis for cure is excellent.

Arthritis

Arthritis of the hand can manifest in many locations. Osteoarthritis, or degenerative joint disease, commonly occurs at the base of the thumb, resulting in debilitating pain. The trapezium (a bone in the wrist) and the thumb metacarpal (a bone in the hand) lose their normal relationship as cartilage wears down, and when the two bones make contact with each other a grinding, aching, pain can occur. This can prevent people from using their hands to perform basic daily activities, such as opening jars.

Other degenerative arthritic conditions of the wrist can occur from remote traumas and undiagnosed ligament or bone injuries. As normal joint relationships break down and the arthritic process progresses, pain worsens. Finally rheumatoid arthritis, a specific type of chronic progressive arthritis that affects the whole body, has specific manifestations in the hand that can disrupt normal joint and tendon relationships.

Here at Yale we are skilled in the management of the various types of arthritic pathologies that affect the hand. We offer both nonsurgical and surgical treatments depending on the patient's needs. From steroid injections and splinting, to complex joint replacements and reconstructions we offer the latest techniques in surgery of the hand to relieve pain and restore function.

Dupuytren's Contracture

What is Dupuytren's Contracture?

Dupuytren's Disease is due to a thickening of the fascia that lies just below the skin in the subcutaneous layer of the palm and fingers. The tissues become thickened into nodules or cords that may eventually pull the fingers into the palm.

Who does Dupuytren's Disease affect?

This disease occurs mainly, but not exclusively in Caucasians. A strong family history may be present. Males are more commonly affected. There are several diseases that may be associated with this disease, such as diabetes, epilepsy, alcoholism, trauma and Peyronie's disease. Despite this, a simple cause and effect relationship has never been established. The vast majority of patients with Dupuytren's disease have no identifiable cause.

What are the symptoms of Dupuytren's Contracture?

This disease is usually painless. An early sign might include swellings over the knuckles, or knuckle pads. As the fascia, the tough layer of tissue under the skin, becomes thick, the fingers may be pulled into the palm. The fingers most commonly affected are the ring and little fingers. Eventually the joints may become stiff from being in this position.

How is Dupuytren's Contracture treated?

Surgery is the primary treatment for this disease. If the contractures or knuckle pads are very mild, surgery may not be required right away. On the other hand, if there is a loss of function of the hand or worsening of the disease, surgery will be needed. In this procedure, the abnormal tissues and nodules are removed. The hand is splinted at the end of the procedure. After the operation, hand therapy is started early on to maintain the contracture release. Eighty percent of patients can expect to regain near normal range of motion of the affected fingers within 2-3 months after surgery.

Dr. Thomson is now offering patients Xiaflex injections as a new nonsurgical approach to certain patients with Dupuytren's contracture. Xiaflex is a new FDA approved medication to treat Dupuytren's cords. It is injected in the office and does not require open surgery to administer. Learn more about Xiaflex here.

Syndactyly

What is Syndactyly?

Syndactyly is the most common congenital hand deformity. Most commonly affecting the third and fourth web spaces of the hand, it involves the fusion of the skin or bones of the fingers. If the fusion of the fingers involves only the skin and soft tissues, the syndactyly is considered to be simple. If there is any bony fusion, the syndactyly is defined as complex. If the entire length of the fingers is fused, it is regarded as a complete syndactyly while a partial fusion is considered to be incomplete. A detailed physical examination as well as X-rays helps to classify the syndactyly.

Who is born with Syndactyly?

Syndactyly shows a strong familial tendency with up to 10-40% of cases showing familial inheritance. It may be in both hands and affects males twice as often as females. It may also be seen in combination with other birth anomalies.

Why and when does Syndactyly have to be treated?

It is not mandatory to treat incomplete syndactyly, but most parents do have it surgically corrected early in life for cosmetic reasons. The child may also develop physical limitations to certain activities as he/she grows, such as playing the piano, etc., therefore it may become necessary to correct an incomplete, simple syndactyly. Complex syndactyly should be treated in order to allow proper growth of the bones and skin of the fingers. The timing of surgery will be based upon the particular digits involved and the complexity of the webbing. Therefore a web may be corrected as early as 6 months or as late as 3-4 years of age.

How is Syndactyly corrected?

The fingers are released using small skin flaps from each finger. If more than two fingers are fused, only one side of a finger is released in a single operation. In incomplete syndactyly the creation of these skin flaps is usually sufficient to cover both sides of the previously fused fingers. If the fusion is complete and complex, the main problem stems from a deficiency of skin. Usually, full thickness skin grafts taken from the groin will be required in order to cover both sides of the finger. After the operation the dressing will be left intact for 2 weeks.

Polydactyly/Thumb Duplication

Polydactyly refers to having excess digits (more than 8 fingers and 2 thumbs). Many newborns are born with an extra digit or remnant of a digit which can be quite distressing to parents. The extra digit can be on the pinky-side or the baby may have an extra thumb.

Sometimes the extra digit can be a problem for function, sometimes it is just a cosmetic problem, but in either case, parents usually want the deformity addressed. Removing a supernumerary digit or digit remnant can involve a combination of excisional and reconstructive surgery and is best addressed by a hand surgeon with experience in dealing with congenital deformities of the hand.

Here at Yale we have been active in treating newborns and children with polydactyly and have conducted research evaluating clinical outcomes. We are able to deal with complex and simple congenital hand anomalies to restore function and aesthetic form.

Thumb Hypoplasia/Aplasia

Children born with underdevelopment or absence of the thumb have a condition called thumb hypoplasia/aplasia. As the thumb is critically important to the function of the hand, this condition needs to be addressed urgently by a skilled hand surgeon. Precise diagnosis and appropriate intervention is key.

For patients who have underdeveloped thumbs, surgeries to strengthen the thumb can be performed if the anatomy is sufficient. In others, the remnant thumb is not salvageable for function and a complex procedure called "index pollicization" needs to be performed. This surgery involves moving and reconstructing the index finger so that it becomes a neo-thumb.

At Yale we are skilled in the management of children born with thumb hypoplasia/aplasia and can provide the right diagnosis and treatment that each child needs. From muscle and tendon rebalancing, to pollicization, we have the experience and skills to help improve function.

More Information

Additional useful information about hand anatomy, conditions, treatments, and surgery can be found at these websites:


Yale University School of Medicine

Yale-New Haven Hospital