Plastic Surgery Consultation Note - carpal Tunnel Syndrome

Thank you for your referral of Fiona Campbell - SL Ligament Reconstruction - LN/ML for Plastic Surgery Consultation. She was examined on January 12, 2026.

Fiona Campbell - SL Ligament Reconstruction - LN/ML, a right-handed female, presents with chronic left wrist pain persisting for approximately three years. The pain began during training for a handstand challenge at the age of 60 and has progressively worsened. It significantly impacts her daily activities, including the inability to perform yoga poses such as downward dog and high plank, lift her grandchildren, or shift gears while cycling. She describes the pain as a constant ache, exacerbated by wrist extension and pressure-related activities. She denies any acute injury or trauma at the onset of symptoms. She reports no relief from prior corticosteroid injections and found splint use impractical due to positioning and functional limitations. She avoids medication for pain management but uses positional adjustments, such as resting the wrist on a pillow, for relief. She has a history of scapholunate ligament rupture with associated widening noted on imaging. Previous MRI findings indicate a perforation of the central focal disc of the TFCC, which has not been surgically addressed. She expresses concern about the potential progression to arthritis and functional impairment if untreated. The dominant right hand is unaffected.

Physical Examination:
On physical examination, the patient rests the elbow on the table without experiencing pain during motion. Palpation of the scar reveals no pain underneath. MRI findings indicate a complete tear of the scapholunate ligament and a perforation of the central focal disc of the TFCC. X-ray results show scapholunate widening, with no significant arthritis, cartilage loss, signs of Kienbock's disease, or immediate issues with the lunate bone. Anatomically, a short ulna relative to the radius is observed.

Assessment:
- Complete rupture of the scapholunate ligament in the left wrist, confirmed by MRI. This is a chronic condition with a history of approximately three years, progressively worsening. Imaging does not reveal significant arthritic changes. There is a potential concern for vascular compromise of the lunate bone, though no definitive signs are present on X-ray. Differential diagnoses include ligament rupture secondary to anatomical variations, such as a short ulna.

Plan:
Surgical reconstruction of the ruptured wrist ligament using a tendon graft from the forearm is planned. The procedure will involve making an incision on the dorsal wrist, reconstructing the ligament with a tendon graft, and securing it with three anchors. A temporary pin will be placed to support the repair and will be removed after approximately six weeks. Postoperative care will include wearing a brace for six weeks, followed by gradual range of motion exercises and physiotherapy. Pain management will involve prescribing tramadol as needed. The patient is advised to avoid activities that place stress on the wrist during recovery. No wrist fusion procedure is planned unless reconstruction fails. A plate is not required for this procedure. The patient will be contacted by the hospital for scheduling, and no additional paperwork is necessary.

Surgical Discussion:
- Purpose of the Surgery: The main objective of the surgery is to reconstruct the ruptured scapholunate ligament in the left wrist to restore stability, prevent further deterioration, and reduce the risk of progression to arthritis.
- Risks and Complications: Risks include infection, failure of the reconstruction, need for future procedures such as partial wrist fusion if the reconstruction fails or if significant cartilage loss is found intraoperatively, and possible complications related to the temporary pin (such as infection or early pin removal).
- Anesthesia: The procedure will be performed under a regional block (subclavian block), with the patient awake and sedated as needed.
- Alternatives: Non-surgical options such as continued splinting and corticosteroid injections have been attempted without relief. Wrist fusion is reserved as a salvage procedure if reconstruction fails or if significant cartilage loss is found.
- Recovery: The patient will be in a brace for six weeks postoperatively, with a temporary pin in place. After pin removal, gradual range of motion and physiotherapy will begin. Full recovery is expected to take up to a year, with the first few months being the most intensive for rehabilitation.
- Follow-Up Care: The patient will return for pin removal at six weeks and will be monitored throughout recovery with ongoing physiotherapy.
- Longevity: The reconstruction is expected to restore function and delay or prevent the onset of arthritis. If the reconstruction fails or arthritis develops, further surgical options such as partial wrist fusion may be considered in the future.