Michael Smith, MD (Host): Welcome to Southwest General Health Talk, the podcast from the specialists at Southwest General Health Center. I'm Dr. Mike. And with me is Dr. Ayesha Punjabi, a plastic and reconstructive surgeon. And today, we're going to be exploring hand conditions such as carpal tunnel and trigger finger. Dr. Punjabi, welcome to the show.

I want to know, like, right off the bat, you know, as a specialist, what are the most common hand conditions that you deal with?

Ayesha Punjabi, MD: So, absolutely. As you already mentioned, carpal tunnel and trigger finger are very common in the elective hand surgery space. The other one that I would add is hand arthritis. Arthritis especially the base of the thumb is kind of the most common site for arthritis in the body. And then, in the trauma space, tendon injuries, fractures, nerve injuries. I kind of tell people every structure in the hand can be injured from a trauma. So, definitely in the trauma space, all of that.

Host: Well, let's start with, I think one of the more common ones, right? That's carpal tunnel syndrome. What exactly is happening in the hand and wrist with carpal tunnel?

Ayesha Punjabi, MD: Yes, absolutely. So, I have to start by talking about the median nerve, which is a nerve that originates in the neck, runs down the arm. And then, what it does is it innervates the muscles in the arm that flex the fingers. And then, it provides sensation to the thumb, index, and middle fingers. And finally, it innervates some of the small muscles in the hand.

So, what's happening in carpal tunnel is at the level of the wrist, the median nerve is traveling through a tunnel, the roof of which is a ligament called the transverse carpal ligament. So when there is inflammation under that ligament in the wrist, the median nerve becomes compressed and people start to experience, number one, sensory changes in the thumb, index, and middle fingers. And as the condition progresses, even weakness in the hand muscles on that side of the hand.

Host: Let's back up just a little bit first, what age are we talking about that this starts to happen? And what are those early signs that there may be something on?

Ayesha Punjabi, MD: Yes, absolutely. So, the age can vary and conditions can vary sometimes. Pregnancy, for example, can kind of cause the swelling and inflammation that flares carpal tunnel up. So, the age can be kind of along the spectrum. And definitely, the early signs are the numbness and tingling, especially in the morning. Patients describe waking up and having to shake their hand to get the pins and needles out. Those are kind of the early signs.

Host: I always picture—and please tell me if this is completely off, right? But I always kind of picture that the office worker who's, you know, in their mid-30s or something like that. And they're constantly, you know, on the computer and doing the mouse and they got weird angles with their wrist. Is that a common scenario right there?

Ayesha Punjabi, MD: So, jobs with a lot of repetitive motion. So, typing, gripping, manufacturing jobs can kind of predispose people to carpal tunnel. Because when you think about it, when the wrist is flexed, that increases the pressure in that tunnel, that the median nerve is going through. Typing types of positions and poor ergonomics with that can be a risk factor for the development of carpal tunnel.

Host: So, you said some of the earlier signs are kind of tingling, numbness. So people, like you said, I've seen that before too, right? They wake up and they're, you know, trying to get things moving, right, in a way. But when do those early signs kind of become concerning?

Ayesha Punjabi, MD: Number one for any hand condition, and this will probably come up a few times, I tell people with the hand, if something is interfering with your day-to-day life, it's a problem. If it's interfering with your hobbies, with your work, with just something you want to be doing in your day-to-day life, then it's a problem and that's concerning.

And then, as I mentioned, after exiting the wrist, the median nerve innervates some of the small muscles in the hand, including the muscles that help the thumb reach the other fingers. And as we all know, the thumb is really critically important to the function of the hand. So as the condition progresses and those muscles become weak, that can be very concerning and really affect the function of the hand negatively.

Host: So, people shouldn't assume then, and I think this happens a lot, especially in the older age group. I'm in my mid-50s. You know, a lot of aches and pains, you know, nothing too crazy. But little things start to kind of happen a little bit. We shouldn't automatically assume that's just normal, right? If you really feel like you said, just to reiterate, if you really feel like your daily life is being affected, we need to go see a specialist like you, right?

Ayesha Punjabi, MD: Absolutely. Absolutely.

Host: So, that's carpal tunnel, a very common condition that you see. But also upfront, we said trigger finger. What exactly is that? I think a lot of people have heard this trigger finger, but I don't think a lot of people understand what it is.

Ayesha Punjabi, MD: So again, I'm going to start with a tiny bit of anatomy. So, the flexor tendon that curls your fingers in, from kind of the first knuckle of your fist to the last knuckle of your finger, it travels in a sheath. Now, why does it do that? Why do you have a tunnel around your tendon? It's so that when you flex your finger, the tendon doesn't separate from the finger. It keeps the tendon kind of attached to the finger. However, in trigger finger at the entrance of that sheath, patients again experience some inflammation, And so the tendon can literally become stuck and not able to move through the tendon sheath or glide through the tendon sheath smoothly. So, the finger can lock in a flexed position and patients have to manually pull the finger extended, because the tendon is kind of too inflamed for the tunnel it needs to glide through.

Host: So with carpal tunnel, you mentioned jobs where people have lot of repetitive motion and stuff like that. What about trigger finger? Is there any specific occupation or activity?

Ayesha Punjabi, MD: So first of all, I do want to say people should live their lives. None of this should make people hesitant to use their hands, because I would never want to discourage someone from doing their activities and hobbies. But because it's again, kind of inflammatory-related and we're talking about the tendon becoming a little too swollen to glide through its sheath, it's again related to use. So, just any, you know, heavy manual activities.

Host: Now, when symptoms do start and, and I want to kind of ask this question for both carpal tunnel and trigger finger, okay? When symptoms start, are there things people can try at home that you know maybe are effective before giving you a phone call?

Ayesha Punjabi, MD: For carpal tunnel, as we mentioned, there is more pressure on the median nerve under that transverse carpal ligament when the wrist is flexed. So, the first step can be to buy a wrist brace that kind of holds the wrist in a neutral position, especially during sleep. Because sometimes when people sleep with their wrist curled up, they wake up with the numbness and tingling because the median nerve has been under pressure overnight. So, wrist bracing.

And then, similarly, there can be small braces for the finger to kind of prevent the finger from curling in. And even sometimes, for the finger, you can stack bandaids on top of each other to prevent the finger from curling in, again, especially overnight because when we sleep, we tend to flex, and then we can wake up kind of really swollen.

Host: And that may even make it hard to sleep a little bit if your finger's doing that, right? And we don't want to disrupt sleep. That's so, so important. But regardless of all that, regardless of the home remedies people might try, even if they help a little bit, again, going back to what you said, if this situation when your finger or your hand is keeping you from doing daily life stuff, they should go see you right off the bat.

Ayesha Punjabi, MD: Absolutely. Absolutely.

Host: Now, if treatment is needed from your standpoint, what are my options?

Ayesha Punjabi, MD: Number one is steroid injections. So especially for trigger finger, about half the time, we can actually kick it with a steroid injection. Just in my clinic, it's a small shot about one milliliter of fluid, which is a steroid and decreases the swelling in the tendon. And again, half the time, we can actually kick the trigger finger with that. We can try steroid injections for carpal tunnel too. They're a little less reliable for carpal tunnel than for trigger finger.

And so, kind of once we move beyond the steroid injections, we start to talk about the surgeries. Now, surgery for carpal tunnel involves about a one-and-a-half, one-inch incision right near the wrist, up and down. It's honestly about a 10-minute surgery just to release that transverse carpal ligament, so that median nerve is not under pressure anymore. So, that's the carpal tunnel release. And then, for trigger finger, it's about a seven-minute surgery to release the entrance of that little tendon sheet so that the tendon can glide a little better.

One thing I would really like listeners to know is, of course, I always tell people there's no small surgery. But on the scale of surgeries, these are very kind of well-tolerated and we can take care of you without too much drama from the surgery.

Host: First, let's back up to the steroid injections. Because people want to know this, right? How often do I have to get that? Or is it just a one-time injection?

Ayesha Punjabi, MD: I would say I would not get a steroid injection more often then every three months. And then, for these hand conditions, this is a little bit different than when we're talking about knee arthritis and stuff. For these hand conditions, I would say, once you've tried two steroid injections and you still kind of have the trigger finger or the carpal tunnel, we've really got to start thinking about surgery.

Host: And when you do the surgery, you mentioned they're pretty quick. So, I would assume these are maybe like done in a day surgery clinic and they're going to go home that same day, that same afternoon.

Ayesha Punjabi, MD: Yep. Absolutely. Depending on the patient's preference, they may not even need general anesthetic for the surgery. Or even just, I can numb up the wrist or the finger really well, and if the patient wants to be awake and not deal with sedation at all, we can put on whatever music they like and get them through it, because they'll be nice and numb for the surgery.

Host: What kind of recovery are we looking at for? Well, let's talk about both of them. So if they get a steroid injection, so that's pretty quick, right? They're going to be able to use their fingers, their hands pretty quickly. Is that the case?

Ayesha Punjabi, MD: Yep. Yep. Pretty much they can go back to their lives. Yep.

Host: What about surgery? What kind of recovery?

Ayesha Punjabi, MD: I would say no heavy lifting, pushing or pulling for either for the carpal tunnel, trigger finger. Nothing heavy for a minimum of one month. But in terms of gentle activities, typing, eating, drinking, writing, you absolutely can use the hand and finger for that.

Host: Well, this has been fantastic. A lot of great information. I really appreciate it. I learned a lot.

Ayesha Punjabi, MD: Oh good.

Host: Thank you so much for coming on. If you'd like to talk with Dr. Ayesha or make an appointment with her, you can visit swgeneral.com. That's swgeneral.com. Now, if you found this episode helpful, please share it and check out our full library of topics that might be of interest to you. This has been another episode of Southwest General Health Talk. Thank you so much for listening.