CARPAL TUNNEL SYNDROME


Carpal tunnel syndrome is a painful progressive condition caused by compression of a key nerve in the wrist. It occurs when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist. Carpal tunnel syndrome is more common in women than men.

The carpal tunnel is a narrow, tunnel-like structure in the wrist. The bottom and sides of this tunnel are formed by wrist (carpal) bones. The top of the tunnel is covered by a strong band of connective tissue called the transverse carpal ligament.

The median nerve travels from the forearm into the hand through this tunnel in the wrist.

The median nerve controls feeling in the palm side of the thumb, index finger, and long fingers.

The nerve also controls the muscles around the base of the thumb. The tendons that bend the fingers and thumb also travel through the carpal tunnel. These tendons are called flexor tendons.


Median nerve distribution in the hand.


Photo by Operative technique "Hand and wrist Surgery' Chung, Saunders Publication

Cause

Most likely the disorder is due to a congenital predisposition - the carpal tunnel is simply smaller in some people than in others. However, the risk of developing carpal tunnel syndrome is especially common in those performing assembly line work. 

In some cases no direct cause of the syndrome can be identified.  Sporting activities that predispose athletes to carpal tunnel syndrome include those that involve repititive or continuous extension/flexion of the wrist, as seen in cycling, throwing sports, raquet sports, gymnastic and wheelchair activities

Symptoms

Patients describe intermittent or persistent numbness and paresthesias mainly affecting the three radial fingers and the radial half of the ring finger.

Pain occurs chiefly at night, causing many patients to awaken in the early morning hours. Many patients report a tendency to drop objects held in the hand (loss of grip strength) or an inability to unlock doors with a key (loss of pinch strength).


Area of nambness and pain (red area), on hand.

How is carpal tunnel syndrome diagnosed?

Early diagnosis and treatment are important to avoid permanent damage to the median nerve. A physical examination of the hands, arms, shoulders, and neck can help determine if the patient's complaints are related to daily activities or to an underlying disorder, and can rule out other painful conditions that mimic carpal tunnel syndrome.

The wrist is examined for tenderness, swelling, warmth, and discoloration.

Each finger should be tested for sensation, and the muscles at the base of the hand should be examined for strength and signs of atrophy. Routine laboratory tests and X-rays can reveal diabetes, arthritis, and fractures.

Plain X-rays often are not helpful in the diagnosis of carpal tunnel syndrome.
Electrodiagnostic studies are necessary to confirm the diagnosis.

Electromyography show evidence of acute or chronic denervation of the thenar musculature.

CONSERVATIVE TREATMENT
THERAPY: 

Conservative treatment

Conservative management includes:

• Oral anti-inflammation drags (Non steroidal pain killer)
• Local ointment
• Wrist splint
• Physiotherapy
• Corticosteroids local injection


Local cortisone solution injection in carpal tunnel.

A brace or splint worn at night keeps the wrist in a neutral position. This prevents the nightly irritation to the median nerve that occurs when wrists are curled during sleep. Splints can also be worn during activities that aggravate symptoms.

Activity changes. Changing patterns of hand use to avoid positions and activities that aggravate the symptoms may be helpful. If work requirements cause symptoms, changing or modifying jobs may slow or stop progression of the disease.

Physical therapy. Stretching and strengthening exercises can be helpful in people whose symptoms have abated. These exercises may be supervised by a physical therapist, who is trained to use exercises to treat physical impairments, or an occupational therapist, who is trained in evaluating people with physical impairments and helping them build skills to improve their health and well-being.

OPERATIVE TREATMENT
THERAPY: 

Surgical treatment


Carpal tunnel surgery is done on an outpatient basis under local anesthesia. Generally recommended if symptoms last for 6 months and the conservative treatment has failed. As evidence by electrodiagnostic studies that show moderate to severe crippling of the median nerve. Numerous types of carpal tunnel release procedures can be performed. Open microsurgical technique and endoscopic technique are the most popular. Both of the previous techniques have advantages and the Orthopaedic surgeon decide which of these procedures is optimal for the patient personally.

 

Transverse carpal ligament released.  Open techniques.

Local anesthesia with Xylocaine.

The open procedure begining. 

Release of transverse ligament.

Release of transverse ligament.

Median nerve release (final phase)



The transverse ligament has already released.  The median nerve freely moved in carpal tunnel.  The nerve (white band) has edema due to delay of surgical intervention.

Woman 45 years old with severe hand pain due to carpal tunnel syndrome.  Nerve edema due to chronic nerve compresion.  Transverse ligament release.  The patient relief from the symptoms imediatelly after nerve decompresion

REHABILITATION: 

Postoperative care consists of a period of wrist immobilization about 10 days, during which time the patient is encouraged to use her or his digits actively in order to prevent digital joint stiffness. The sutures are removed 2 weeks postoperatively and immobilization is discontinued. Normal use of the hand is approved 20 days postoperatively, but the patient is warned to avoid placing direct heavy pressure on the scar area, such as performing pushups, which can be uncomfortable for a total of 2 months after surgery.