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Carpel Tunnel Syndrome


OVERVIEW OF Carpel Tunnel Syndrome :

       Carpel Tunnel syndrome is a common condition that causes pain, numbness, tingling, and weakness in the hand and wrist. It takes place when there is increased pressure within the wrist on a nerve called the median nerve. This nerve provides sensation to the thumb, index, and middle fingers, and to half of the ring finger.


STRUCTURE of Carpel Tunnel Syndrome :

The carpal tunnel is a narrow canal or tube in the wrist. Similarly to a tunnel you could travel through by car, this part of the wrist allows the median nerve and tendons to connect the hand and forearm. The parts of this tunnel include:

  • Carpal bones: These bones make up the bottom and sides of the tunnel. They are formed in a semi-circle.
  • Ligament: The top of the tunnel, the ligament is a strong tissue that holds the tunnel together.

Inside the tunnel are the median nerve and tendons.

  • Median nerve: This nerve provides feeling to most of the fingers in the hand (expect the little finger). It also adds strength to the base of the thumb and index finger.
  • Tendons: Rope-like structures, tendons connect muscles in the forearm to the bones in the hand. They allow the fingers and thumb to bend.


CAUSES :

  • Heredity (smaller carpal tunnels can run in families).
  • Pregnancy.
  • Hemodialysis (a process where the blood is filtered).
  • Wrist facture and dislocation.
  • Hand or wrist deformity.
  • Arthritic diseases such as rheumatoid arthritis and gout
  • Thyroid gland hormone imbalance (hypothyroidism)
  • Diabetes
  • Alcoholism.
  • A mass (tumor) in the carpal tunnel.
  • Older age.
  • Amyloid deposits (an abnormal protein).

 


PATHOPHYSIOLOGY :

The tendons of the hands are wrapped with a lining that produces a synovial fluid which lubricates the tendon. With repetative movemnets of the hands the lubrication system might malfunction. This reduction in the fluid results in inflammation and swelling of the tendon area. Abnormally high pressure area is created with the carpel tunnel syndrome patients. This pressure causes obstruction to venous outflow, back pressure, edema formation and ultimately ischemia to the nerve.


COMMON CLINICAL SIGNS AND SYMPTOMS :

Pain

Paraesthesia

Numbness

Tingling

Patient often awake to shake their hand to provide the relief to the symptoms and this is known as flick sign

Inability to move the wrist and hands

Weakness and clumsiness in the hand—this may make it difficult to perform fine movements such as buttoning your clothes

Dropping things—due to weakness, numbness, or a loss of proprioception

 


DIAGNOSTIC :

                 The doctor might do physical evaluation and find out the diagnosis.

The physician might carefully examine your hand and wrist and perform a number of physical test:

  • Press down or tap along the median nerve at inside of your wrist to see if it causes any numbness or tingling in your fingers (Tinel sign)
  • Bend and hold your wrists in a flexed position to test for numbness or tingling in your hands
  • By lightly touching the wrist and hand with a special instrument when your eyes are closed and examining the sensitization of the hand.
  • Check for weakness in the muscles around the base of your thumb
  • Look for atrophy or shortness in the muscles around the base of your thumb. In severe cases, these muscles may become visibly smaller.

 

Electrophysiological tests:

The doctor might check for the median nerve damage and examine the thumb finger.

 Have another nerve condition, such as neuropathy, or other sites of nerve compression that might be contributing to your symptoms.

 

Electrophysiological tests may include:

  • Nerve conduction studies. These tests measure the impulses transmitted to the nerves of your hand and arm and can detect when a nerve is not conducting its signal effectively. Nerve conduction studies can help your doctor determine how severe your problem is and help to guide treatment.
  • Electromyogram (EMG). An EMG measures the electrical activity in muscles. EMG results can show whether you have any nerve or muscle damage.

Ultrasound:

An ultrasound uses high-frequency sound waves to help create pictures of bone and tissue. Your doctor may recommend an ultrasound of your wrist to evaluate the median nerve for signs of compression.

X-rays:

X-rays provide images of dense structures, such as bone. If you have limited wrist motion or wrist pain, your doctor may order x-rays to exclude other causes for your symptoms, such as arthritis, ligament injury, or a fracture.

Magnetic resonance imaging (MRI) scans:

 These studies provide better images of the body's soft tissues. Your doctor may order an MRI to help determine other causes for your symptoms or to look for abnormal tissues that could be impacting the median nerve. An MRI can also help your doctor determine if there are problems with the nerve itself—such as scarring from an injury or tumor.

 


TREATMENT AND PROGNOSIS :

 It is a gradual process, for most people carpal tunnel syndrome, it will get worsen over time without some form of treatment.

Nonsurgical Treatment:

If it is diagnosed early then no surgical intervention of treatment is needed and it can be cured early.

Wearing a splint or brace reduces pressure on the median nerve by keeping your wrist straight.

Nonsurgical treatments may include:

Bracing or splinting during night times reduces the pressure on the median nerve which is present in the carpal tunnel.

Non steroidal inflammatory drugs such as ibuprofen and naproxen might provide better benefits and reduces the pain.

Maintain the wrist in the neutral positions.

A steroid such as corticosteroid injection into the carpal tunnel can relieve symptoms for a period of time.

Nerve gliding exercises can help to move the wrist freely without causing much damage to the tissues.

 

Surgical treatment:

If non surgical treatment does  not provide any relief then surgical treatment can be considered.

Surgical Procedure

The surgical procedure performed for carpal tunnel syndrome is called a "carpal tunnel release." There are two different surgical techniques for doing this, but the goal of both is to relieve pressure on your median nerve by cutting the ligament that forms the roof of the tunnel. This increases the size of the tunnel and decreases pressure on the median nerve.

 

In most cases, carpal tunnel surgery is done on an outpatient basis. The surgery can be done under general anesthesia, which puts you to sleep, or under local anesthesia, which numbs just your hand and arm. In some cases, you will also be given a light sedative through an intravenous (IV) line inserted into a vein in your arm.

Open carpal tunnel release. In open surgery, your doctor makes a small incision in the palm of your hand and views the inside of your hand and wrist through this incision. During the procedure, the physician  will divide the transverse carpal ligament (the roof of the carpal tunnel). This increases the size of the tunnel and decreases pressure on the median nerve.

Endoscopic carpal tunnel release. In endoscopic surgery, your doctor makes one or two smaller skin incisions—called portals—and uses a miniature camera—an endoscope—to see inside your hand and wrist. A special knife is used to divide the transverse carpal ligament, similar to the open carpal tunnel release procedure.

 


PROGNOSIS :

             The pain might get subside within two to three months. But the complete recovery might take 1 year.


PREVENTION :

  • Minimize repetitive hand movements.
  • Alternate between activities or tasks to reduce the strain on your hands and wrists.
  • Keep wrists straight or in a neutral position.
  • Avoid holding an object the same way for long.
  • If you work in an office, adjust your desk, chair, and keyboard so that your forearms are level with your work surface.
  • Wear a splint at night to keep your wrist straight while sleeping.