19 Del. Admin. Code § 1342-C-7.0
Current through Register Vol. 27, No. 12, June 1, 2024
Section 1342-C-7.0 - Operative TreatmentTHE FOLLOWING SURGICAL GUIDELINES ARE NOT INTENDED TO REPLACE THE SURGEON'S JUDGMENT.
Operative treatment may be indicated when the individual component diagnoses that make up CTD prove unresponsive to the full complement of non-operative options, including job site analysis and modification. Physical exam findings should be well localized and consistent with the diagnosis. Severe neurologic findings are an exception to these indications, and may suggest earlier surgical intervention. Surgical results must anticipate objective functional gains and improved activities of daily living.
Surgery in CTD usually falls into two broad categories: peripheral nerve decompression and muscle or tendon sheath release or debridement. The treating surgeon must determine the appropriate procedure and timing for the individual case. The most common surgical procedures that are performed in CTD patients are listed below; other procedures may be indicated in certain cases.
Since CTD often involves several areas in an upper extremity, surgical treatment of one problem should be performed in conjunction with conservative treatment of other problems in the upper extremity.
7.1 PERIPHERAL NERVE DECOMPRESSION Surgery may be considered when findings on history and physical exam correlate specifically with the diagnosis being considered. Subjective complaints should be localized and appropriate to the diagnosis, neurologic complaints should be consistent with the nerve distribution in question, and physical exam findings should correlate with the history. Surgery may be considered as an initial therapy in situations where there is clinical and/or electrodiagnostic evidence of severe or progressive neuropathy. Objective evidence should be present in all cases in which surgery is contemplated. Objective evidence may include: electrodiagnostic (EDX) studies, diagnostic peripheral nerve block which eradicates the majority of the patient's symptoms, or a motor deficit commensurate with the suspected neurologic lesion. Refer to Physical Examination Findings (section D.2, physical examination) for objective diagnostic findings. Job modification should be considered prior to surgery. Refer to the "Job Site Alteration" section for additional information on job modification. When no objective evidence is present and the patient continues to have signs and symptoms consistent with the diagnosis after six months of conservative treatment including a psychological evaluation, a second opinion should be obtained before operative treatment is considered.
Specific procedures and their indications are outlined below:
7.1.1 Median Nerve Decompression at the Wrist (carpal tunnel release): Please refer to the Division's, Carpal Tunnel Syndrome Medical Treatment Guidelines.7.1.2 Median Nerve Decompression in the Forearm (pronator teres or flexor digitorum superficialis release): Please refer to Physical Examination Findings Table (section D.2, physical examination) Electrodiagnostic (EDX) studies may show delayed median nerve conduction in the forearm. If nerve conduction velocity is normal with suggestive clinical findings, the study may be repeated after a 3-6 month period of continued conservative treatment. If the study is still normal, the decision on treatment is made on the consistency of clinical findings and the factors noted above.7.1.3 Ulnar Nerve Decompression at the Wrist (ulnar tunnel release or Guyon's canal release) Please refer to Physical Examination Findings Reference Table (section D.2, physical examination) Electrodiagnostic testing may confirm the diagnosis and differentiate from ulnar entrapment neuropathy at the elbow.7.1.4 Ulnar Nerve Decompression/Transposition at the Elbow: Please refer to Physical Examination Findings Reference Table (section D.2, physical examination) Electrodiagnostic studies (EDX) may indicate an ulnar neuropathy at the elbow. In general, patients with minimal symptoms or without objective findings of weakness tend to respond better to conservative treatment than patients with measurable pinch or grip strength weakness. If objective findings persist despite conservative treatment, surgical options include: simple decompression, medial epicondylectomy with decompression, anterior subcutaneous transfer, and submuscular or intramuscular transfer.7.1.5 Sensory Nerve Decompression at the Wrist: Please refer to Physical Examination Findings Reference Table (section D.2, physical examination) of these guidelines. Electrodiagnostic (EDX) studies can be useful in establishing a diagnosis but negative studies do not exclude the diagnosis7.1.6 Radial Nerve Decompression at the Elbow: Please refer to Physical Examination Findings Reference Table (section D.2, physical examination) Electrodiagnostic (EDX) studies are helpful when positive, but negative studies do not exclude the diagnosis.7.1.7 Thoracic Outlet Syndrome: Please refer to the Division's Thoracic Outlet Syndrome Medical Treatment Guidelines.7.2 TENDON DECOMPRESSION OR DEBRIDEMENT Surgery may be considered when several months of appropriate treatment have failed, and findings on history and physical exam correlate specifically with the diagnosis being considered. Subjective complaints should be localized and appropriate to the diagnosis, and physical exam findings should correlate with the history. Refer to the Physical Examination Findings Table (section D.2, physical examination). Job modification should be considered prior to surgery. Refer to Job Site Alteration (Section F.4) for additional information on job modification. Specific procedures and their indications are outlined below:
7.2.1 Subacromial Decompression: Please refer to the Division's Shoulder Injury Medical Treatment Guidelines.7.2.2 Medial or Lateral Epicondyle Release/Debridement: Please refer to Physical Examination Findings Reference Table (section D.2, physical examination). It is generally accepted that 80% of cases improve with conservative therapy. Intermittent discomfort may recur over six months to one year after initial conservative treatment. Surgery should only be performed to achieve functional gains on those with significant ongoing impaired activities of daily living. X-rays may be normal or demonstrate spur formation over the involved epicondyle.7.2.3 First Extensor Compartment Release (de Quervain's Tenosynovitis): Please refer to Physical Examination Findings Reference Table (section D.2, physical examination). Surgery should be performed to achieve functional gains on those with significant ongoing impaired activities of daily living.7.2.4 Trigger Finger/Thumb Release: Please refer to Physical Examination Findings Reference Table (section D.2, physical examination). Surgery should be performed to achieve functional gains on those with significant ongoing impaired activities of daily living.7.3 CONSIDERATIONS FOR POST-OPERATIVE THERAPY 7.3.1 Immobilization: Controlled mobilization, and/or formal physical/occupational therapy should begin as soon as possible following surgery at the discretion of the treating surgeon. Final decisions regarding the need for splinting post-operatively should be left to the discretion of the treating physician based upon his/her understanding of the surgical technique used and the specific conditions of the patient.7.3.2 Home Program: It is generally accepted that all patients should receive a home therapy protocol involving stretching, ROM, scar care, and resistive exercises. Once they have been cleared for increased activity by the surgeon, patients should be encouraged to use the hand as much as possible for daily activities, allowing pain to guide their level of activity.7.3.3 Supervised Therapy Program: may be helpful in patients who do not show functional improvements post-operatively or in patients with heavy or repetitive job activities. The therapy program may include some of the generally accepted elements of soft tissue healing and return to function:7.3.3.1 Soft tissue healing/remodeling: May be used after the incision has healed. It may include any of the following: evaluation, whirlpool, electrical stimulation, soft tissue mobilization, scar compression pad, heat/cold application, splinting or edema control may be used as indicated. Following wound healing, ultrasound and iontophoresis with sodium chloride (NaCl) may be considered for soft tissue remodeling. Diathermy is not an acceptable adjunct.
7.3.3.2 Return to function: Range of motion and stretching exercises, strengthening, activity of daily living adaptations, joint protection instruction, posture/body mechanics education. Job site modifications may be indicated.
. Time to produce effect: 2-4 weeks
. Frequency: 2-5 times/week
. Maximum duration: 36 visits
19 Del. Admin. Code § 1342-C-7.0
11 DE Reg. 1661 (06/01/08)
12 DE Reg. 67 (07/01/08)