Carpal tunnel syndrome is the most common upper limb neuropathy; it consists of compression or pinching of the median nerve due to narrowing of the carpal tunnel.
When the transverse carpal ligament becomes inflamed, it swells and presses against the structures in the tunnel, including the median nerve.
Tendonitis in the flexor tendons can also cause this condition, because when the tendons swell, the tunnel diameter is reduced and the metacarpal nerve is pinched off.
Carpal tunnel neuropathy affects women three times more often than men, particularly women going through menopause . In the population , it is mainly the age group between 50 and 65 who suffers from carpal tunnel syndrome. In most cases, the disease occurs bilaterally and together with the trigger finger.
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What is the carpal tunnel? Anatomy of the bones, nerves and tendons
The carpal tunnel is an anatomical passage at the level of the wrist and is also known as the carpal canal. It is bounded behind by the carpal bones and in front by the carpal ligament.
This ligament has its origin in the bones scaphoid and major polygonal bone on one side and joins are in hookbone and peabone. The carpal band runs transversely and resembles half a bracelet. The tendons of the flexor muscles of the hand, fingers, and thumb pass through the carpal tunnel. The median nerve and blood vessels run through the tunnel, along with the tendon structures.
What Are the Causes of Carpal Tunnel Neuropathy?
There are various causes of carpal tunnel syndrome, predisposition plays an important role in the occurrence of this disease.
Most patients are women in the postmenopausal period, which has a negative effect on the tendons. Repetitive activities involving wrist and finger flexing and extending movements are the most common cause when employment and work are involved.
Young men suffering from carpal tunnel syndrome often do heavy work, such as that of bricklayers. Affected women are found particularly in the professional groups of tailors, housewives, cooks, packers and factory workers.
While breastfeeding, the mother can develop inflammation of the hand flexor tendons because they are often overstrained by holding the child.
Other factors can influence the occurrence of carpal tunnel syndrome: hypothyroidism, pregnancy, connective tissue diseases, rheumatic diseases such as rheumatoid arthritis , diabetes mellitus , arthrosis and wrist fractures .
There is a popular belief that long hours of computer use can cause carpal tunnel syndrome, however, PC mouse use is not responsible for this disorder.
What Are the Signs and Symptoms of Carpal Tunnel Syndrome?
Carpal tunnel disease has a slow, gradual development and begins with tingling, a feeling of swelling and pain in the first three fingers and the inner part of the ring finger. In the first stage of the disease, numbness occurs only at night and an hour after getting up.
If not treated, there may be a reduction and loss of tactile sensitivity, even during the day. The thumb, index finger, middle finger and ring finger are affected, corresponding to the supply area of the median nerve; if there are complaints in only one or two fingers, one cannot speak of carpal tunnel syndrome, in this case the cause would have to be looked for elsewhere. In advanced stages, the inflammation of the median nerve causes pain in the wrist and can extend to the forearm, similar to epicondylitis .
Over time, there is increased hand muscle weakness, particularly of the thenar. This leads to difficulty in grasping objects, suturing, clenching a fist, etc. It is common for someone suffering from carpal tunnel syndrome to have poor sleep at night and wake up with pain and tingling; typically, these individuals also have weaker and more disease-prone tendons than others. Often these patients go to the doctor for illnesses such as ” De Quervain “, tendon injuries, or trigger fingers.
How is carpal tunnel syndrome diagnosed?
In this case, the responsible doctor is the orthopedist. Carpal tunnel syndrome is diagnosed based on an analysis of medical history and physical examination. The doctor asks questions about symptoms and related diseases. He must examine the entire upper limb and neck to see if symptoms are due to overuse or other medical conditions. Thus, he can rule out other pain conditions that are similar to carpal tunnel syndrome.
The doctor examines the wrist visually and manually for any disorders; then he checks the range of motion of the wrist and fingers looking for limitations. Usually, the doctor can diagnose carpal tunnel syndrome by examining the wrist by analyzing stiffness , swelling, and reflexes.
The fingers also need to be evaluated to determine which are affected by the tingling. The doctor examines the muscle strength of the thenar thenar and looks for signs of muscle wasting (atrophy); he can compare the diseased and the symptom-free wrist with each other.
There are two methods of testing to produce the symptoms of carpal tunnel syndrome:
- Tinel’s test : The doctor taps the median nerve on the inside of the wrist with a mallet or two fingers; if the patient feels a tingling or electrifying sensation, the test is positive.
- Phanel maneuver : keep elbows at shoulder level and forearms vertical; to bring the fingers down, the backs of the hands must be joined, the wrists must be square.
The test is positive if numbness or tingling in the fingers and hands increases within a minute. In this position, the median nerve is lengthened. For differential diagnosis, the doctor must rule out other pathologies, especially fractures and arthritis . He may advise seeing a neurologist or a hand surgeon if specialized treatment is needed.
What diagnostic tests are necessary to confirm carpal tunnel syndrome?
An X-ray of the wrist can be helpful to rule out other causes of pain, such as fractures or arthritis. Magnetic resonance and ultrasound show the tissues of the wrist but are not helpful in diagnosing carpal tunnel syndrome. The doctor may order a blood test to detect diseases associated with carpal tunnel syndrome, such as diabetes or arthritis.
The best tests to confirm the diagnosis are:
- EMG (electromyography) : measures the small surges of electricity produced in the muscles and shows the extent of nerve damage. Small needles have to be inserted into the muscle. Current activity in the resting phase and how the muscle is tensed provide information about the severity of the injury to the median nerve.
- Nerve conduction velocity test : measures the speed at which nerves conduct electrical impulses. The doctor attaches two electrodes to your hand and wrist and emits small bursts of electricity. If the impulse in the carpal tunnel slows down, the test is positive.
Treatment, natural remedies and surgery for carpal tunnel syndrome
There are different treatment methods:
- Initially rest your hand, wrist and forearm for 3 weeks. It is important to change lifestyle habits to avoid the repetitive movements that would make symptoms worse. Ice packs (cold therapy) can help reduce swelling . The doctor may recommend a splint to immobilize the wrist. Avoid bending the wrist as this position increases pressure on the median nerve and worsens symptoms. If the splint is worn at night, pain , tingling and numbness can be avoided; it is available in pharmacies or on the Internet.
- There are several medications used to treat carpal tunnel syndrome . Vitamin B6 can relieve some symptoms, but there is no scientific evidence that it does. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Brufen or Voltaren can reduce pain and inflammation , but their effectiveness is questionable and side effects such as abdominal discomfort and stomach ulcers can occur. Cortisone-based medications (like Bentelan) can be taken in pill form or injected directly into the wrist. They help reduce swelling and take pressure off the median nerve, but beware: steroids can make diabetes worse by making it harder for insulin to regulate. Taking cortisonemust be prescribed by the doctor. The orthopaedist can inject cortisone into the wrist, which in milder cases can lead to the patient healing.
- For temporary relief of symptoms, it’s good to flex your fingers, rock your hand, and let your wrist hang out of bed while you sleep. A physical therapist can be helpful in assisting the patient by teaching them wrist strengthening and stretching exercises and correcting their posture, especially when working at a computer. All these remedies relieve the symptoms without pharmacy and surgery.
Kinesio taping for the carpal tunnel
Effect: draining. Shape: an ”I” stripe. Length: 20-25cm. Anchor the strip using two holes on the middle and ring fingers. Apply the band without tension with the wrist stretched.
Surgical intervention for carpal tunnel syndrome
If conservative treatment methods or medication do not bring the desired success and the symptoms last longer than six months, surgical intervention should be considered. The operation consists of freeing or relieving pressure in the carpal tunnel. The surgeon opens the carpal tunnel and cuts the band of tissue (ligament) at the wrist to relieve pressure on the median nerve.
Carpal tunnel decompression is one of the most common surgical procedures.
The incision is performed under local anesthesia as it is a minor surgical procedure. The patient can go home the same day (outpatient surgery).
There are two different ways to widen the carpal tunnel:
- In open surgery, the doctor makes a single incision on the palm of the hand, freeing the transverse ligament of the wrist.
- During an arthroscopy, the surgeon makes a double incision: in the palm and in the wrist. A small tube is then inserted to visualize the internal tissue on a screen, as well as a knife to cut the tape. This process can be described as minimally invasive and results in less scarring and stiffness .
What complications can occur with carpal tunnel syndrome?
- Infection ;
- nerve damage;
- error during the procedure when cutting the tape;
- Stiffening; bleeding ;
- constant pain in wrist;
- recurrence of carpal tunnel syndrome;
- Scar.
How is the aftercare done?
The doctor has to apply a hand bandage for a few days. It’s a good idea to hold your hand up for 2 days to allow the swelling to go down .
The wrist can be iced (moderate cold) for the first 24-48 hours to reduce inflammation.
After carpal tunnel surgery, physical therapy can be done to regain strength and range of motion and to loosen the surgical scar. In most cases, the carpal tunnel procedure is completely successful or there is a significant improvement in symptoms.
What is the prognosis for healing after an operation?
Approximately 60% of carpal tunnel operated patients are able to carry out activities of daily living without the occurrence of symptoms, only 20% retain chronic pain. Full recovery times are 10-15 days for any type of surgery.
