CARPAL TUNNEL SYNDROME
Version II
Sometimes people may experience numbness or tingling in the hand, more so at night, and clumsiness handling objects such as glasses or cups. Also there tends to be a pain that goes up the entire arm, in some cases all the way to the shoulder. These symptoms may be all due to what’s known as Carpal Tunnel Syndrome.
What is it?
The carpal tunnel is an anatomical region in the wrist through which a major nerve (the median nerve) travels. When this tunnel (through which the nerve travels) becomes compressed there gradually builds up pressure on the nerve itself. When the nerve is compressed it causes symptoms of numbness, tingling, and weakness of the affected muscles supplied by this nerve. These are important muscles in the hand and the result can be minor to major disability, depending on the severity.
Prognosis
If left untreated, gradual impairment of the nerve function can occur to the point where permanent damage can be sustained if left too long. This could result in hand weakness to the point where objects can no longer be grasped firmly and fine detail work is impossible. Occasionally, if the underlying cause of the carpal tunnel is an acute incident, such as a hard blow to the hand, it can subside with simple treatment. Commonly, however, it has to be surgically released especially if it has built up over a period of time and is of unknown cause.
Some underlying causes of carpal tunnel are pregnancy, rheumatoid arthritis, any inflammatory condition, and repetitive trauma to the hand such as heavy manual labor. Quite often, however, no underlying cause is found.
Diagnosis
The diagnosis is often made from the following symptoms and signs :
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Numbness and tingling in the hands
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Decreased feeling in your thumb, index, and long finger
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An electric-like shock feeling in your hand when the doctor taps over the course of the median nerve at the wrist
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Reproduction of symptoms when holding wrists in a bent down position for one minute.
Also in some cases the doctor may want a special test performed called a nerve conduction study, which will determine the severity of the pressure on the median nerve and finalize the diagnosis.
Treatment
Non-Surgical
A brace or splint may be applied to mild cases which are usually worn at night to keep the wrist from bending. Resting the wrist allows the swollen and inflamed synovial membranes to shrink; which takes some of the pressure off of the nerve. Also the use of anti-inflammatory medications can take away some of the inflammation and swelling. In more severe cases the treatment may entail the use of a cortisone injection into the carpal tunnel. What the injection does is spread medicine around the swollen synovial membranes and shrinks them, again relieving the pressure on the nerve. The usual dosage of cortisone is small and has no harmful side effects. Non-surgical treatment is effective if diagnosis is early, thus treatment is relatively soon after onset.
Other non-surgical methods of treatment include putting up with the problems, changing jobs, anti-inflammatories, physiotherapy, rest, etc.
Surgical
In some patients non-surgical treatment doesn’t relieve the pain and symptoms, so the next step is to operate. The operation is called a "release" because the ligament that forms the roof of the carpal tunnel is cut to relieve the pressure on the median nerve. The operation is performed under a local anesthesia that is injected into either the wrist or hand, or higher up the arm. The ligament, which forms the roof of the carpal tunnel is the volar carpal ligament. This has to be sectioned through a small incision which then relieves the pressure on the nerve and allows it to recover. This is performed as a day surgery and can quite often be performed under a local or regional anesthesia without involving the patient going to sleep. Occasionally, however, it does require general anesthetic, but as mentioned above, this can usually be avoided. The release can now be performed arthroscopically, so that a smaller incision and a shorter recovery period can be obtained.
Most of the time the surgery is performed in an outpatient facility and overnight stay at the hospital isn’t required.
Outcome of Surgery
The long-term surgical results are usually excellent. It must be remembered, however, that the length of time for the nerve to recover depends on how long the nerve has been compressed. If extensive damage has been done to the nerve through a long period of pressure over several months, it may take as many months for the nerve to fully regain its function. During this period of time the hand will gradually get stronger and sensation will return to the hand. If there has been no underlying permanent damage to the nerve, however, 100% function should return to the hand. Occasionally there is such severe damage that there may be only partial or no improvement.
Risks to Surgery
There are risks to any surgical procedure, some of which are infection, damage to nerves, blood vessels, or tendons, persistent symptoms, anesthetic problems, etc. Make sure you understand the risks and alternatives prior to surgery.
Prognosis
As stated previously early recognition and treatment are optimal, but treatment is the key even if it’s later rather than sooner. If left untreated, gradual impairment of the nerve function can occur to the point where permanent damage can be sustained. This can result in hand weakness to the point where objects can no longer be grasped firmly and fine detailed work will be impossible.
Prevention
In order to prevent something from happening one must know the etiology, and since there isn’t a single specific reason for Carpal Tunnel Syndrome there really isn’t a good way to prevent it. What we do know is that anything that causes swelling, thickening, or irritation of the synovial membranes around the tendons in the carpal tunnel can result in pressure on the median nerve.
Some associated conditions are the following:
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Grasping with the hands forcefully and repetitively
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Constant bending of the wrist
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Broken or dislocated bones in the wrist which produce swelling
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Arthritis
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Sugar diabetes
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Thyroid gland imbalance
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Menopause (hormonal changes)
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Pregnancy
DE QUERVAIN'S SYNDROME
What is it?
This condition consists of a tenosynovitis of the first dorsal compartment. Within this compartment at the wrist is contained the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons. It is manifested by pain at the base of the thumb that migrates up the wrist and forearm. It gets worse with thumb movement or grip. It is especially bothersome when trying to open large-mouth jars such as pickles. The pain is crescendo in nature often precluding the ability to continue to hold the object.
Cause
It is felt that this syndrome occurs from overuse combined with a sub-acute injury to the wrist. It can be seen in the terminal stages of pregnancy and post-partum. Patients with fluid retention disorders can present with de Quervain’s Tenosynovitis.
Diagnosis
The history and physical exam is crucial in making this diagnosis as several other conditions may mimic this syndrome. The history is usually one of chronically increasing pain at the wrist that migrates into the thumb and forearm. On exam, localized tenderness will be palpable over the wrist where the tendons cross under the extensor retinaculaum into their tunnel. There are 6 tunnels on the backside of the wrist (dorsal). The tunnel involved will be the first dorsal compartment. A sensitive test is the Finklestein Test in which the fingers grip the thumb, and then the whole wrist is ulnar deviated (pushed toward the little finger). Pain on resisted thumb extension or abduction can also be seen. X-rays are usually not indicated.
Treatment
Conservative treatment is usually begun with splinting the wrist and thumb. (Please note; a carpal tunnel splint does NOT adequately immobilize the thumb)
Non-steroidal anti-inflammatory drugs (NSAID’s) are utilized to reduce the inflammation. On occasion, your Orthopedic Surgeon may inject a steroid solution into the first dorsal compartment. If symptoms persist your surgeon may recommend a surgical procedure. In this 10-minute procedure, the roof of the tunnel is released, allowing the tendons to glide freely. A splint is applied that allows movement at the tip of the thumb to keep the tendons gliding. Usually the patient returns to full activities at two weeks post-operatively.
Trivia
Fritz de Quervain first described this syndrome in 1895. He was a distinguished general surgeon who was Professor of Surgery at Berne, Switzerland. He was born at Sion in the Valais Canton of Switzerland, where his dad was the pastor. After his surgical training he settled in the watch-making district of La Chaux-de-Fonds. He worked extensively on Thyroid Goiter and is responsible for the introduction of iodized table salt to help prevent goiter. Initially this tenosynovitis syndrome was thought due to tuberculosis.
TRIGGER FINGER
What is it?
Trigger Finger describes a condition in which the finger gets caught either in bringing it down (flexion) or in straightening it out (extension). At first it may be painless and intermittent, but progressively gets painful and occurs with regularity. The pain is located at the base of the involved finger. True locking may occur which requires the opposite hand to break it free. At first the trigger finger is little more than an annoyance, which gradual progresses to interfere with most activities of daily living.
Cause
Trigger finger usually results from an overuse phenomenon. It comes on gradually. It usually is worse first thing in the morning. Repeated vibratory forces in the palm of the hand have been implicated.
Diagnosis
The diagnosis usually can be made on the basis of a good history and physical exam. Oftentimes the finger will not “lock” in the doctor’s office, however tenderness can be palpated (felt) at the base of the involved finger.
Treatment
Treatment begins with conservative therapy. If an offending agent is identified, it is removed from daily activities. Non-steroidal anti-inflammatory drugs (NSAID’s) are used to reduce the inflammation in the palm of the hand. Your Orthopedic Surgeon will inject a steroid solution directly into the tendon sheath that is inflamed. Splinting of the metacarpal-phalangeal joint (MCPJ) is sometimes used in severe cases. Surgery is usually reserved for the refractory cases that remain symptomatic and painful. The surgical procedure involves a 1-inch incision to release the tight pulley under which the swollen tendon traverses. This often takes less then 10 minutes and is done as same-day surgery. The patient is encouraged to move the fingers almost immediately post-operatively. Symptomatic relief is immediate, and recurrence is very rare.