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Carpal Tunnel Syndrome

What is carpal tunnel syndrome?

The carpal tunnel is a canal formed of bones on the dorsal or floor of the canal and the sides of the canal. The roof or volar side of the canal is formed of the thick, transverse carpal ligament. The flexor tendons to each of the digits and the median nerve pass through the canal. The median nerve gives sensation or feeling to the thumb, index, middle, and one-half of the ring finger. It also supplies muscle function to the thenar muscles (muscles at the base of the thumb that allow the thumb to abduct, flex, and oppose to the adjacent digits). It is within this tight space that from various causes swelling builds up putting pressure on the median nerve causing symptoms.


What causes carpal tunnel syndrome?

Increased canal contents

Tumors, anomalous muscles, bleeding, and hematoma, arthritis, and inflammatory conditions (most commonly, flexor tenosynovitis).

Decreased size of the canal

Most commonly arises from congenital abnormalities of the carpal bones.

Conditions that alter fluid balance or conditions that cause general breakdown of the peripheral nerves

Pregnancy, medications, thyroid disease, diabetes, alcoholism, and amyloidosis.

Overuse of the wrist

Repetitive wrist flexion and extension; repetitive gripping, pushing, or pulling; repetitive finger motion; paraplegia.


What are the symptoms of carpal tunnel syndrome?

  • Pain or burning in the hand, forearm, and fingers.
  • Numbness and paresthesias (tingling) in the thumb, index, middle, and one-half of the ring.
  • Symptoms are increased at night.
  • Symptoms awaken the patient to a point where the patient has to shake their hands to try to relieve the symptoms.
  • Increased symptoms with activity.
  • The patient feels their hands are swelling.
  • Weakness and clumsiness, particularly with fine motor movements such as buttoning clothes or picking up objects; the patient will admit to dropping things
  • Muscle wasting.

How to diagnose carpal tunnel syndrome?

In addition to a careful history of the symptoms described above, an examination will reveal:

  • Tinel’s test (thumping the skin over an irritable nerve or wrist crease in this case causes shocks or tingling in the area of distribution of that nerve).
  • Phalen s wrist flexion test (with the wrist maximally flexed, symptoms are produced within 60 second).
  • Tenderness at the wrist and distal forearm overlying the median nerve.
  • Swelling at the distal forearm volar surface.
  • Sensation  or feeling diminished to all fingers.
  • Muscle weakness: Resisted movement or pinching of the thumb to the little finger.

Additional tests may be helpful:
X-rays of the wrist with an additional carpal tunnel view

To assess for fractures, arthritis, or soft tissue calcification.

Lab analysis

Thyroid, ANA, rheumatoid factor, glucose.

Electrodiagnostic tests (NCV/EMG)

Used to grade the severity of the CTS; can also pick up other abnormalities such as cervical nerve root compression; a normal test does not rule out carpal tunnel syndrome as approximately 20% of patients with surgical lesions have normal tests; this is not to replace the clinical exam and is purely an adjunct to the clinical evaluation.

Celestone injection

A temporary response is diagnostic for CTS; I will typically inject those patients with normal electrodiagnostic tests to help confirm the diagnosis.

Electromyography (EMG) Animation Video
Nerve Conduction Study (NCS) Animation Video

 


What are the types of carpal tunnel syndrome?

Acute (uncommon):

Usually due to trauma; symptoms are rapid secondary to swelling, bleeding, or displaced fracture; if symptoms don t resolve within several hours following reduction of the fracture and elevation, then surgical decompression is warranted.

Chronic:

(Mild) Intermittent pain and paresthesias; responds frequently to conservative care; (Moderate) constant numbness and paresthesias; conservative measures are less likely to help and surgery is ultimately necessary; (Severe) loss of sensation and muscle function; requires surgical intervention; there is usually either partial or complete relief depending on the severity of the problem.


Treatment Options

Non-surgical treatment for carpal tunnel syndrome

Night splinting or splinting during activities; rest; work modifications; NSAIDs (i.e. Advil); steroids; Celestone injections (I reserve these for patients who are adamant about not having surgery; patients with negative electrodiagnostic tests, to help in the diagnosis; or if the patient is pregnant as the symptoms will ultimately recover within six months following delivery).

Surgical Treatment for carpal tunnel syndrome

There are two acceptable procedures.

  1. Endoscopic Procedure:
    The endoscopic procedure involves either one or two small incisions; a telescope is placed to visualize the undersurface of the transverse carpal ligament; additional instruments are used to divide the ligament; skin glue is placed and a dressing is added.Click Here to read more about Endoscopic Carpal Tunnel Release Procedure.
  2. Open Procedure:
    The open procedure involves an approximately 5 to 6 centimeter incision at the base of the palm; the ligament overlying the transverse carpal ligament is divided; the contents of the canal are explored and the nerve is inspected; inflamed flexor tenosynovium is resected from the tendons if necessary; the skin is then sutured and a splint is placed.


How can Dr. Knight help you with carpal tunnel syndrome?

Dr. Knight has significant experience in the treatment for carpal tunnel syndrome. He will quickly diagnose your problem and make recommendations to resolve your symptoms starting with the most conservative measures.


Carpal Tunnel Syndrome Animation Videos

Carpal Tunnel Syndrome Animation Video



Endoscopic Carpal Tunnel Release (Lins) Animation Video



Open Carpal Tunnel Release Surgery Animation Video




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