Too soon for surgery?

JulieS
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I broke my right elbow six months ago and it's now full of screws and a metal brace. I can't get my wrist into a neutral position when my arm is by my side because I can't straighten my elbow (even when it hangs at my side, the elbow is bent and so flexes the wrist).

I've had numbness and tingling in my fingers (especially index) ever since the op and thought it was all part of the injury. Recently, I reported it on a fracture clinic visit and was given a steroid injection which made no difference whatsoever (although it left me with a very tender wrist and bruising at the injection site).

Because the injection didn't work, I had nerve function tests. They showed that the nerve problem was not in my elbow but lower down. I was told this confirms CTS and put on the list for surgery. I haven't had wrist splints or similar treatment options.

My worries are these: I'm not woken at night by the tingling (although the elbow pain still gives me grief); I don't have any pain in my hands - just tingling and numbness (which is constant but varies in severity); if the injection had no beneficial effect, can surgery work?; I see that pregnant women can have CTS which ends with the pregnancy - my hand still gets very swollen sometimes - could the problem simply be oedema from the original injury?

Should I be risking surgery (which carries no guarantee of success and does have risks of further problems)? Could the cause be residual problems from my (very bad) elbow fracture (my elbow is still swollen six months later and my hand swells when I go for long walks)? I don't know how to resolve this.

JulieS
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Sorry, forgot to add: I have been very zealous about my rehab exercises although my elbow still doesn't bend much. One of the tendons in my wrist has become very prominent. Could I have CTS as a result of RSI from overdoing my elbow rehab exercises?

jeremydpbland
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It certainly could be CTS and swelling, continued flexion of the wrist, and too much exercise could all, theoretically be contributing to the problem. It would be worth running through the symptom questionnaire on here to see what you score. The lack of response to injection is of some concern but does not preclude the problem being CTS. I would want to know what the nerve conduction tests showed before being able to say much more than that and I doubt if they have given you a copy. JB

JulieS
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I did complete the questionnaire but it was hard to separate out the elbow fracture information so I don't know if that has slanted the CTS score (which came out at 52% and 53%).

If I don't have the surgery, is nerve damage inevitable? Is there anything I can do to reduce the chance of permanent damage if I wait to see if the swelling etc reduces as my elbow injury heals?

Having looked at your helpful list of tests, I see that they used the Tinel's sign (which produced no response in me) and I have tried the Phalen test and the hand elevation test at home with no noticeable effect.

You're right - I don't have a copy of the nerve conduction test results, I was just told they confirmed CTS and asked if I wanted injections or surgery. I'm still pretty taken aback that they would jump straight to a listing for surgery as that implies the situation is serious but maybe I'm over-reacting..

jeremydpbland
Online

It's a very difficult one to advise on here on the web. The answer to your first question is that no, nerve damage is not inevitable. Some cases of CTS will resolve spontaneously even if not treated, the problem lies in predicting which ones. There is a little section here in the non-surgical prognosis pages summarising what little is known about untreated CTS.

My own approach to this would be that it is reasonable to wait if your nerve conduction studies show only mild abnormalities (up to about grade 3 on my scale), but that there are fairly good reasons for getting on and treating if it is above that. Given the atypical features of negative Phalen's and hand elevation tests and lack of response to injection I would probably want to look at the ultrasound imaging too. JB

JulieS
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That's very helpful, thank you. It's given me the confidence to make another appointment and ask about the level of severity, results of the tests, etc.

I've also noticed a new symptom, which is a pronounced indentation in the inner edge of my forearm about an inch above the elbow crease which seems to go with sever tightness in the muscle which wraps across my forearm from the elbow towards the thumb side of my wrist. So I think I need a return visit.

jeremydpbland
Online

I'm not sure what to make of the forearm indentation - certainly nothing to do with CTS and presumably connected with your fracture, assuming it was that side.

If your nerve conduction studies were done in a department of clinical neurophysiology then most places in the UK will have at least heard of the severity scale described on here and will have done the necessary tests to work out the grade, even if they do not use it for their own reporting. If on the other hand the tests were done by a non-neurophysiologist you may not have any useful information beyond normal/abnormal.

The other issue that may arise from conversations like this is that your surgeon may feel, perhaps justifiably, that I am interfering in your treatment. I should therefore repeat that the judgement of the doctor who has the patient in front of them should always take precedence over anythiing I write on here as they are in a much better position to fully assess the clinical problem. JB

JulieS
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I haven't actually seen my surgeon for several appointments - I've been seen by other, different staff instead. In the circumstances (being asked if I opt for surgery with very little information on which to base that decision) he would surely think it reasonable of me to ask him for his view and more information. I also need to ask him about this indentation (especially as someone has told me they think it's muscle wasting) as I haven't mentioned it before because I hadn't noticed it.

I've never broken my elbow before (thank goodness!) and so had no idea of what was normal or abnormal (I just assumed all my symptoms were as a result of the injury). Thanks to your website and your very helpful replies, I feel I have a better understanding of what I should to put my mind at rest. I now have a clearer idea of things which I may not have mentioned at previous appointments (being unaware of their potential significance) which I do want to highlight now to ensure that my surgeon has all the information necessary for diagnosis. I'm also better placed to ask intelligent questions (and perhaps understand the answers!) about the NCS rather than simply asking to be told more.

My GP has also encouraged me to deal with my doubts and confusion by going through things with my consultant. I'll explain that I have tried to find out more in order to inform my decision about surgery and I need his help to resolve my doubts about what I should do. I certainly won't say anything which could lead him to think that anyone has interfered in his treatment (but thanks for the caution).

jeremydpbland
Online

Good luck! - I would be interested to hear how it turns out. JB

JulieS
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Well, I can't thank you enough for all the information and support on your website, which helped me make best use of my clinic visit to my consultant.

I saw him today and he was lovely. I told him that I have no actual pain in my fingers, my symptoms are no worse at night and that tapping my wrist (which the registrar had done), raising my hands above my head and the injection had made no noticeable difference to my symptoms and I was worried about having surgery for CTS. He said that these are exactly the checks he would want to know the answers to before diagnosing CTS. He said that of particular concern was the lack of any response to the injection - although it was possible that it wasn't given in the right place, he thought that highly unlikely as an explanation for its lack of effect and that, in the circumstances, CTS surgery was unlikely to have any beneficial effect.

He looked at the NCS and said that the conclusion was that the result of the assessment was "mild". He thought there could be a whole host of explanations for my symptoms, all of which linked most plausibly to the consequences of my (very bad) elbow fracture. He said that it can take up to two years for nerves to recover from that sort of trauma. I said that, provided that I wasn't risking nerve damage by delaying anything, I would quite happily put up with the numbness and tingling in the hope that they might eventually go. Surgery cancelled.

Thank you again.

jeremydpbland
Online

Sounds like a satisfactory outcome for the present. Thankyou for the update. JB

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