ORTHOPEDICS

Dr. Patricia Baumann

CARPAL TUNNEL syndrome is the most common and widely known of the entrapment neuropathies in which the body’s peripheral nerves are compressed or traumatized, is a major cause of hand numbness and pain, and affects about ten percent of our population.

What is Carpal Tunnel Syndrome?

The carpal tunnel, a narrow, rigid passageway of ligament and bones at the base of the hand, is bordered on three sides by the carpal bones that make up the wrist.  The top of the tunnel is formed by the flexor retinaculum, a ligament.  The median nerve as well as the flexor tendons to the fingers passes through this tunnel.  Carpal tunnel syndrome occurs when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist. The median nerve controls sensations to the palm side of the thumb and fingers (although not the little finger), as well as impulses to some small muscles in the hand that allow the fingers and thumb to move.

THE MOST COMMON symptoms are burning, tingling or itching numbness in the palm of the hand and the fingers, especially thumb, index and middle fingers, that often first appear in one or both hands during the night, since many people sleep with flexed wrists.

What Are the Causes of Carpal Tunnel Syndrome?

Carpal tunnel syndrome is usually the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. In many cases the disorder is due to a congenital predisposition - the carpal tunnel is simply smaller in some people than in others.

Other Contributing Factors Include:

• Trauma or injury to the wrist such as sprain or fracture
• Overactivity of the pituitary gland
• Diabetes
• Low thyroid hormone
• Rheumatoid arthritis
• Mechanical problems in the wrist joint
• Work stress
• Repeated use of vibrating hand tools
• Fluid retention during pregnancy or menopause
• Development of a cyst or tumor in the canal.

What Are Symptoms of Carpal Tunnel Syndrome?

Symptoms may come and go and do not have to be associated with an injury.  The most common symptoms are burning, tingling or itching numbness in the palm of the hand and the fingers, especially thumb, index and middle fingers, that often first appear in one or both hands during the night, since many people sleep with flexed wrists.

The numbness can get worse as the syndrome progresses leading to constant numbness, tingling and weakness. Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent. Decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks, and dropping cups is a very common complaint. In chronic and/or untreated cases, the muscles at the base of the thumb may waste away. Some people complain of a stinging, electric shock-like sensation, and many are unable to tell between hot and cold by touch.

THE CARPAL TUNNEL, a narrow, rigid passageway of ligament and bones at the base of the hand, is bordered on three sides by the carpal bones that make up the wrist.

How is Carpal Tunnel Syndrome Diagnosed?

It is important to be evaluated medically at an early stage of the syndrome to definitively diagnose and treat carpal tunnel syndrome and avoid permanent damage to the median nerve. A physical examination of the hands, arms, shoulders, and neck can help determine if the symptoms are related to daily activities or to an underlying disorder, and can usually identify other conditions that may mimic carpal tunnel syndrome. The wrist is examined for any signs of inflammation such as tenderness, swelling, warmth, and discoloration. Each finger is tested for sensation, and the muscles at the base of the hand are examined for strength and signs of atrophy.

Physical Tests Specific to Carpal Tunnel Syndrome Are:

• Phalen, or wrist-flexion, test where both hands are held together tightly in a reverse prayer position causing increased tingling.
• Tinsel test where the examiner taps over the median nerve at the wrist causing shooting pain or increased tingling.
• Routine laboratory tests and X-rays can reveal diabetes, arthritis, and fractures.

An electro-diagnostic test, such as an EMG, will often be performed to evaluate the nerve conduction of the median nerve, determine the severity of damage and confirm the diagnosis.

Treatment Options

For best outcomes, treatments for carpal tunnel syndrome should begin as early as possible, under a doctor’s direction. Underlying causes such as diabetes or arthritis should be effectively managed first. Initial treatment generally involves resting the affected hand and wrist for at least 2 weeks, avoiding activities that may worsen symptoms, and immobilizing the wrist in a cock up splint at nighttime that helps hold the carpal tunnel open as it keeps the wrist extended.  The splints can be worn all the time if daily activities allow for their use. If there is inflammation, applying cool packs can help reduce swelling.

Non-surgical Treatments

In special circumstances, various medications can ease the pain and swelling associated with carpal tunnel syndrome. Non-steroidal anti-inflammatory (NSAIDS), such as aspirin, ibuprofen, and other nonprescription pain relievers can be prescribed to help decrease the inflammation and may ease symptoms that have been present for a short time or have been caused by strenuous activity. Orally administered diuretics (“water pills”) can decrease swelling. Corticosteroids (such as prednisone) or a local anesthetic like lidocaine can be injected directly into the wrist or taken by mouth (in the case of prednisone) to relieve pressure on the median nerve and provide immediate, temporary relief for mild or intermittent symptoms.

Improving the ergonomics associated with specific work-place repetitive tasks is key to decreasing symptoms.  This is especially true in patients whose primary tasks are computer and keyboard oriented.

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.

Surgical Treatments

Carpal tunnel release is one of the most common surgical procedures in the United States. Surgery involves severing the flexor retinaculum to allow for the roof of the carpal tunnel to be open therefore decreasing the pressure on the median nerve. The procedure can be performed by two techniques:

• Open release surgery – The traditional procedure used to correct carpal tunnel syndrome, consists of making an incision up to 2 inches in the wrist on to the palm and cutting the flexor retinaculum (carpal ligament) to enlarge the carpal tunnel and release the pressure on the nerve. I prefer open carpal tunnel as it allows for what I think is better visualization of the nerve and ensures complete release.
• Endoscopic surgery is performed through two incisions (about 1⁄2” each) in the wrist and palm. A camera attached to a tube is inserted so that the carpal ligament can be visualized and cut, but the actual nerve is not visualized.

What Does My Recover Entail?

Post operative recovery includes a splint put on in surgery that remains in place until the stitches are removed about ten days after surgery.  Once the stitches are removed, a carpal tunnel splint (cock up splint) must be worn during the day for another 2 weeks, then at night for another 3 weeks.  Wearing the splint allows the hand to heal with the carpal tunnel open.  Nerves are very sensitive to pressure and often take a long time to fully recover after the pressure is relieved. Most patients see a gradual relief of their symptoms over time. Although symptoms may be relieved immediately after surgery, full recovery from carpal tunnel surgery can take months.

Patients should undergo physical and occupational therapy after surgery to restore wrist strength. Some patients may need to adjust job duties or even change jobs after recovery from surgery.  At the workplace, workers can do on-the-job conditioning, perform stretching exercises, take frequent rest breaks, wear splints to keep wrists straight, and use correct posture and wrist position. Recurrence of carpal tunnel syndrome following treatment is rare, and the majority of patients recover completely.

Dr. Baumann is fellowship trained in adult reconstructive total joint replacements, which is a subspecialty of orthopedic surgery.  She is Board Certified.  Her practice, Premier Orthopedics, is located in Port St. John and she is on staff at Parrish Medical Center and Cape Canaveral Hospital. Please call 321-433-1439 for information.

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