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Surgical Instructions

Carpal Tunnel Surgery

Richard A. Bernstein, MD

When conservative measures fail, surgery is also an option for a carpal tunnel syndrome with success rates in the 85% to 95% range. Surgery is done on an outpatient basis under a local anesthetic. I do it with the anesthesiologist present, who can let you be as awake as you want or you could also be somewhat sleepy. In most cases, the surgery takes under 10 minutes and it involves a small incision in the middle of the palm to release the ligament over the nerve. After surgery, you will be in a bulky dressing for two days after surgery. Then, you will see the therapist who will remove the dressing, place a lighter dressing, and begin an exercise program. Approximately one week after the surgery, you will see me for suture removal. At that time, you can let the incision get wet and begin wrist exercises.

Most of the surgery I do is performed on an outpatient basis. I operate at Saint Raphael's Hospital, Temple Surgical Center, Shoreline Surgery Center, Milford Hospital and Yale. My secretary organizes my surgical schedule and will find the location that works best for the surgery. I feel equally comfortable at all facilities. If you have any questions, please talk to me or my staff.

To assure your understanding, I recommend a preoperative appointment to discuss the surgery, risks and benefits and answer any questions. You will also see me the day of surgery. If any questions come up, we will answer them then. Though the surgery is quite safe, there are some inherent risks. Please see the surgery section. These risks include the risk of anesthesia, infection, nerve, vessel, or tendon injury, stiffness, and pain. Usually, surgery goes very well and the success rate is high but unfortunately, the results of surgery cannot be guaranteed.

For five to seven days before surgery, you should stop taking Aspirin or antiinflammatories such as Advil, Aleve, or Motrin unless recommended otherwise by your primary care doctor or cardiologist. These medications can prolong your bleeding and can lead to complications. If it is medically safe, you should avoid these medications, Tylenol (Acetaminophen) is usually okay. Unfortunately, the surgical facilities do not tell me until the day before what time your surgery will be. Though you can request the specific time for surgery, unfortunately, this is usually outside of our control. The facility will call you the day before surgery, tell you where and when to come and will give the details.

Surgery: As with any surgical procedure, you should not have to eat or drink after midnight the night before; this includes coffee, orange juice or even water in the morning. For most surgeries, daily medications prescribed by your regular physician can be taken with a sip of water, but please discuss this with me and my staff if you have any questions.

Most patients will receive an intravenous dosage of an antibiotic at the time of surgery; this does keep the risk of infection under 1%. These procedures are considered "clean" procedures and if you have artificial joints or heart valves, the antibiotic given at surgery will generally suffice, unless the surgeon who implanted your device has told you otherwise, please let us know.

The day of surgery, you will have a very large bulky dressing that looks like a boxing glove. Please wear a loose-fitting garment since the dressing is big, to help control swelling. In most cases, the therapist will remove it in two days, and you will be placed in a smaller dressing to. For a complex surgery, the dressing may stay on up to 10 days, but this will be clearly noted in your postoperative appointment cards. When you leave surgery, you will have a packet that includes a prescription for pain medication, two appointment cards; one to see the therapist for the dressing and the second to see me for your postoperative check. You will also be given a series of instruction sheets that is also included in this website, postoperative instructions.

Two days after surgery, I encourage you to return as quickly as you can to normal activities using your fingers and a week later, the wrist. Most people ask "how long does it take to recuperate after the surgery?" There is no hard and fast answer. As I mentioned, two days after the surgery, you should begin moving your fingers and a week later, your wrist. I encourage you to return to normal activities as quickly as you can, progressively use the hand more and more every day. Driving is fine once you feel you have control of the car and you are off narcotic medications. Keyboarding is fine as soon as you start to get comfortable; heavy lifting usually takes three to four weeks.

The surgery is successful in most cases. There are risks included, but are not limited to the risk of anesthesia, infection, nerve, vessel, or tendon injury, recurrent scar tissue, pain, reflex sympathetic dystrophy, (abnormal pain output); these complications occur less than 5% of the time.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10
Updated 11/10/2015

Peri-Operative Information

Richard A. Bernstein, MD

Most hand surgery is performed on an outpatient basis. I operate at Saint Raphael’s Hospital, Temple Surgical Center, Milford Hospital, Goose Lane Medical Center and Yale New Haven Hospital. My secretary organizes my surgical schedule and will find the location that works best for the surgery, as well as clearing it with your insurance company. I feel equally comfortable at all facilities to do surgery. If you have any questions, please talk to me or my staff.

For five to seven days before surgery, you should stop taking Aspirin or anti-inflammatories such as Advil, Aleve, or Motrin unless recommended otherwise by your primary care doctor or cardiologist. These medications can prolong your bleeding and can lead to complications. If it is medically safe, you should avoid these medications, Tylenol (Acetaminophen) is usually okay. Unfortunately, the surgical facilities do not tell me until the day before what time your surgery is going to be. Though you can request with the specific time for surgery, unfortunately, this is usually outside of our control. The facility will tell you the day before surgery where to come and when to come and they will call you to give the details.

As with any surgical procedure, you should not eat or drink after midnight the night before but this includes coffee, orange juice or even water in the morning. For most surgeries, daily medications prescribed by your regular physician can be taken with a sip of water that morning, but please discuss this with me or my staff if you have any questions.

To assure your understanding, I recommend an appointment in the office to again discuss the surgery, risks and benefits and answer any questions that you have. You will also see me that day of surgery, so if any questions come up, we will answer them then. Though the surgery is quite safe, there are risks that do go along with this. These risks include the risk of anesthetic agents, infection, nerve, vessel, or tendon injury, stiffness, and pain. Usually, surgery goes very well and the success rate is high but unfortunately, the results of surgery cannot be guaranteed.

Most patients will receive an intravenous dosage of an antibiotic at the time of surgery; this does keep the risk of infection under 1%. These procedures are considered “clean” procedures and if you have artificial joints or heart valves, the antibiotic that is given at the time of surgery will generally suffice unless the surgeon who implanted your device has told you otherwise.

After surgery, you will leave in a very large bulky dressing that looks like a boxing glove. When you come to surgery, please wear a loose-fitting garment because the dressing is big. It is intentionally made this way to help control swelling. Usually, the therapist will remove it in two days, at which time you will be place in a smaller dressing to begin range of motion. For a complex surgery, the dressing may stay on for 5 to 10 days, but this will be clearly noted in your postoperative appointment cards.

When you leave surgery, you will have a packet that includes a prescription for pain medication, two appointment cards; one to see the therapist for the dressing and the second to see me for your first check. You will also be given a series of instruction sheets that are also included on this website under post operative instructions.

Copyright © 2010, TOG All rights reserved.
Revised 12/21/10

Post-Operative Hand Surgery Information

Richard A. Bernstein, MD

We will see you back in the office approximately ten days after surgery for dressing and suture removal. Steri - strips will be placed across your wound. These will come off in 7 - 10 days on their own, or you can peel them off when they start to come off. You will often be placed in either as splint or a cast, depending upon the nature of your surgery. If you are out of a cast you can shower tomorrow.

Frequently, occupational therapy will be instituted at the same times to help restore the range of motion and strength in those areas of your hand or arm that were not immediately involved in surgery.

Peak Reaction: Healing of the incision is a continual process of remodeling and body healing. Four to six weeks after surgery our wound reaches what we call “peak reaction". What this means is that the wound will look its worst at this time, being raised, purplish and swollen. From six weeks on, the wound will continue to mature and its appearance will become less and less obvious.

Plateau Phase: Therapy involves a gradual remodeling process, and you will reach what we term the “plateau phase.” Initially, you will notice significant improvements of your motion and swelling. However, as the peak reaction time arises, you may initially notice less and less progress after your therapy sessions and exercise. This does not mean that you have reached your best result. As a matter of fact, this is a stage of continued remodeling of your hand, and it is important to continue your exercises at home and with your therapist. You will notice improvements after therapy; however, you may find that when you wake up in the morning, your hand may be stiff. You will notice an up and down kind of progress during this time, but within four to six weeks the strides that you achieve during therapy will be obtained and maintained indefinitely and you will not notice the ups and downs that you had during the plateau phase.

I want to emphasis that it is important during this plateau phase to continue your aggressive work on your own. Your work is not for naught; you will notice your progress and success at the end, if you have done your exercises as outlined.

Copyright © 2010, TOG All rights reserved.
Revised 12/21 /10

Post-Operative Information

Richard A. Bernstein, MD

Your post-operative recovery period is an essential part of the entire process of surgery and a return to optimum function. Your recovery is very important to me and I know it is important to you. I discussed your recovery period with you at the time we decided that surgery was the option for you, but I want to give you some written guidelines and instructions to take home. I think that these will help you through your recovery period.

I will discuss the nature of your surgery, the findings, and what I think that the future holds when you come in for your first post-operative checkup. For now, here are some instructions for a successful recovery!

1) Pain is usually one of a patient's first thoughts about surgery: Is this going to hurt? How much is it going to hurt? I know that post-operative pain is important to you and I want you to know that it is important to me, too. I have studied the postoperative pain of my patients for several years and have worked out a system that has been highly satisfactory to the patients. I will almost certainly give you a long-acting numbing shot just before we leave the operating room. This means that your arm or hand should be profoundly numb for about 8 to 12 hours after surgery, and somewhat numb for longer. Do not let this alarm you. Numb right after surgery sounds like a great idea to me!

2) You should already have filled a prescription for post-operative pain medication that is prescription-strength. This is usually Vicodin or Tylenol with codeine. (If you have not gotten it filled, please do so, even if you think that you will not need it. I would hate for you to have to send someone out in the middle of the night if your hand starts to hurt!). The chief side effect of the prescriptionstrength pain relievers is constipation, and they have other side effects (drowsiness, addiction, etc.). Use the prescription-strength medication only if needed. Don't take it just because I gave it to you. Many patients find that the long-acting numbing shot and elevation are all they need. Take it only if you need it. If you truly need it, take it and don't be overly concerned. I just don't want you to take it unnecessarily. Use it only as directed on the bottle. If you are taking Vicodin or Tylenol #3, note that it has Tylenol in it, take that into account and do not take the maximum dose of Tylenol in addition.

3) In non-fracture cases, you can also try anti-inflammatories such as Motrin, Aleve and Advil. Obviously if you have a known allergy to these medications or have any history of ulcers or stomach bleeding you should avoid these medications. On the other hand, the anti-inflammatory nature of these medications can help diminish post operative pain.

For cases involving bone work, fusions or fractures, please avoid antiinflammatories. Some studies have suggested that these medications interfere with the early phase of bone healing and will therefore interfere with the success of your surgery. Furthermore, cigarette smoking has the same negative effect on these types of surgeries, so please, not only for the overall health benefits, please stop smoking for any type of bony procedures.

4) My patients tell me that elevating their arm above the level of their heart is more effective in relieving pain than any medication. Elevation also helps to prevent swelling, which will decrease your ability to move your fingers later on. Therefore, keep your arm elevated above your heart for two to three days after surgery. If putting it up at shoulder level is not sufficient to help the pain, put it up higher (the "Statue of Liberty" position). I know that it is hard to keep your arm elevated once you fall asleep. Just do the best you can. A sling does not keep your hand above your heart, so I usually don't recommend one unless you cannot control your arm due to the anesthetic.

5) You should already have a follow-up appointment card given to you by the nurse in the recovery room, usually about 7-10 days after your surgery. If not, please call the office to schedule one. We try to make this appointment in the office most convenient for you; however this visit is generally to also remove the sutures. The 7-10 day period is generally the best time to maximize healing and minimize scarring.

6) Keep the dressing clean and dry. Use a plastic bag while showering.

7) You will also usually get an appointment card with the hand therapist. This visit is anywhere from 2-10 days depending upon the surgery performed. The therapist will usually be the first one you will see after surgery. They will remove the dressing, check the wound, place a smaller dressing and instruct you on what you can and cannot do. They will also teach you exercises to do to begin your therapy. You can get your incision wet once we remove the sutures. Do not get it wet in a pool, tub, lake, aquarium, etc.

8) A little swelling and redness is normal. If you have redness, swelling, or drainage like an infected scratch or pimple, this may not be normal and may be a sign of infection. If you still have a question, you should call the office and discuss it with me.

9) A fever greater than 101.5°F is abnormal. If you think that you have a fever, take your temperature with a thermometer. Call me if it is over 101.5°F.

10) You will usually get some black and blue discoloration around the area of the incision. It will travel down your arm over the next few days (from gravity and elevating your arm). This is normal and comes from blood seeping through the tissues. If you feel that it is an abnormal amount, call me.

11) Nausea and vomiting are unusual after hand surgery, due to the nature of the surgery and the nature of the anesthetics that we use. Most often it is occasioned by eating just before leaving the hospital and then bouncing around in a car. Give yourself some time between eating and leaving the hospital. If you get nauseated or vomit, give yourself some quiet time and it usually resolves.

12) I have tried to cover the usual questions that my patients have asked me over the years with the usual answers. I cannot cover all questions and all situations. Use your judgment: complications are rare, and serious complications are very rare. If you need to call, try to do so during office hours, but I am always available to help you or discuss your recovery with you.

Copyright © 2010, TOG All rights reserved. Revised 12/21/10

Wide-Awake Hand Surgery

By Richard A. Bernstein, M.D

A recent advance in the operative care of patients undergoing hand surgery is the use of wide-awake local anesthesia. The popularity and efficacy can best be attributed to Dr. Donald Lalonde, a Canadian hand surgeon, who has reported on over 1400 hand surgery cases performed with wide-awake anesthesia.  The local anesthetic is administered 30 to 45 minutes before the surgery, which allows the anesthetic to take the best effect.  By giving the medication time to work, the procedure can be comfortably performed with the patient being wide awake.  Avoiding intravenous medications minimizes postoperative nausea, vomiting, sore throat, shivering, possible damage to teeth or eyes, postoperative confusion, and some of the rare complications from intravenous sedation.  Furthermore, patients on anticoagulants or blood thinners such as Coumadin, Plavix, or aspirin can maintain and continue their anticoagulant medication up to, and through surgery.  Fragile diabetic patients, who worry about changes in their blood glucose levels and insulin, can actually eat and drink the morning of surgery.

The local anesthetic is a combination of epinephrine and lidocaine, the latter of which has been used for years in all aspects of medicine.  Historically, there was a belief that epinephrine should not be used in hand surgery.  This myth has been scientifically disproven, and studies demonstrate that epinephrine can be safely used in the hand and digits. 

Epinephrine diminishes bleeding and potentiates the effect of the lidocaine allowing the medication to last longer.  Consequently, anticoagulated patients benefit since epinephrine helps control bleeding by causing vasoconstriction.  By buffering lidocaine with a solution called sodium bicarbonate, the discomfort from the injectate is lessened significantly; it is believed that much of the pain from a lidocaine injection is based on its low pH value.  By adding bicarbonate, the pH is neutralized making the administration of the anesthetic more comfortable. 

The risks during surgery are lessened when the procedure is done under a local anesthetic, without intravenous sedation. This minimizes the extent of necessary preoperative evaluations and testing making it more convenient and less costly. Elderly patients or those with multiple medical problems are potentially at risk with sedating medications and/or general anesthesia.   

Procedures I typically perform with a wide-awake anesthesia technique are carpal tunnel surgery, trigger finger release, flexor and extensor tendon repair, de Quervain’s tenosynovectomy and mucous cyst and ganglion excisions.

A review from the United Kingdom reported 99% of patients experienced a high satisfaction rate.  By injecting the anesthetic medications slowly, most patients in general tolerate it well.  Wide-awake anesthesia is not appropriate for everyone, nor is it applicable for every surgical procedure.  It is an advance in surgical technique that is a new option available to our patients.

Finally, with larger deductibles and copayments, the cost can be significantly less, patients to not require complex medical clearance and testing, they spend significantly less time in the recovery room and usually go home immediately after surgery.