Hand Plastic Surgery Consultation Note - CTS/Dupy/trigger

Thank you for your referral of this patient for Plastic Surgery Consultation. The patient was seen on 2026-02-02.

The patient presents for follow-up after right carpal tunnel release performed on May 7th. The patient reports resolution of preoperative numbness and paresthesia. However, significant pain persists in the right wrist three months postoperatively, which is exacerbated by movement and use of the right hand, particularly during activities such as sewing or opening a car door. The patient has been compensating by using the left hand for these tasks. Persistent tenderness, firmness, and swelling are noted at the surgical site. The patient inquired about the presence of internal sutures and expressed concern regarding ongoing discomfort and whether this is typical at this stage of recovery. There have been no reported issues with compliance to postoperative instructions or use of topical agents or specific interventions prior to this visit.

Past Surgical History:
- Right carpal tunnel release performed on May 7th.

Physical Examination:
The surgical site on the right wrist is firm and swollen, with tenderness noted upon palpation. Pressing on the area does not elicit pain. No signs of infection or erythema are observed.

Assessment:
- Pain in right wrist (M25.531)
- Scar conditions and fibrosis of skin (L90.5)

Plan:
The patient was advised to begin gentle massage of the surgical site to help soften the scar tissue. The use of topical anti-inflammatory creams was recommended as needed to manage inflammation. It was explained that exercises are unlikely to alleviate the pain at this stage and may, in fact, worsen it. If no significant progress is observed within a couple of months, a steroid injection may be considered, with a thorough discussion of associated risks, including nerve damage and skin thinning. It was clarified that there is no cream or method available to further soften deeper scar tissue. The patient was encouraged to return for follow-up if symptoms do not improve, so the treatment plan can be reassessed and adjusted as necessary.