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Carpal Tunnel Syndrome Cubital Tunnel Syndrome Trigger Finger Carpal Tunnel Syndrome What is carpal tunnel syndrome? Carpal tunnel syndrome is a condition characterized by numbness and tingling and pain of the hand as a result of compression of one of the nerves (the median nerve) as it passes through the wrist. The median nerve, as it travels from the forearm to the hand, passes through the wrist in a narrow, rigid tunnel, which is called the carpal tunnel. The tunnel is made up of the wrist bones, which are arranged in the form of a “C”. On the palm side there is a very strong ligament that connects these bones together and create a tunnel between that ligament and the bones. Through that tunnel, the median nerve passes with other flexor tendons, which are 9 (two for each finger and one for the thumb). The tendons are surrounded by a flimsy, spongy tissue called the tenosynovium.
Anything that increases the volume of the structures passing through the carpal tunnel, will cause pressure against the median nerve. A non-specific inflammatory swelling of the tenosynovium (tendon linings) can cause an increase in the pressure inside the carpal tunnel, causing pressure against the nerve. Several causes have been linked to the development of carpal tunnel syndrome, such as tasks that require rapid repetitive use of the hands, the use of vibrating tools, or prolonged power grip. Bone dislocations, fractures and arthritis can also cause narrowing of the tunnel, but they are usually not as common. Other conditions such as hypothyroidism, rheumatoid arthritis and diabetes can increase the likelihood of developing carpal tunnel syndrome. Fluid retention during pregnancy can sometimes cause swelling in the tunnel and produce symptoms of carpal tunnel syndrome, which are usually reversible after the pregnancy is over. 1. Numbness and tingling, usually in the distribution of the median nerve involving the thumb, index and long fingers. However, sometimes it may involve one digit or sometimes it involves all the digits. 2. Pain in the form of aching pain in the wrist or forearm that may radiate to the elbow and sometimes to the shoulder. 3. Weakness and clumsiness. 4. The symptoms may increase with driving or with elevation of the hand, such as using a hair dryer. 5. In severe or advanced cases, the sensation may be markedly decreased or even lost. Patients also may develop severe weakness of the use of the thumb with wasting of the thumb muscles. An accurate medical history and detailed clinical examination will establish the diagnosis in most cases. A nerve test, called a nerve conduction study and electromyography (EMG) is often obtained to confirm the diagnosis. Other tests may be needed, depending on the patient’s symptoms. The risk of developing carpal tunnel syndrome may be reduced by modifying the way you use your hands. Keep these suggestions in mind during daily activities. 1. Keep your wrists in neutral. Avoid keeping the wrist in a bent or twisted position for a long period of time. Instead, try to maintain a straight position. 2. Watch your grip. Increased stress is put on the wrist when you grip, grasp or lift with your index finger and thumb. Instead use the whole hand and all the fingers to grasp an object. 3. Minimize repetition. If possible avoid repetitive movements or holding an object in the same way for extended periods of time. 4. Rest your hands. Take a break! Alternate easy and hard tasks, switch hands or rotate work activities. 5. Reduce speed and force. By reducing the speed when doing forceful repetitive movements, the wrist has time to rest from the effort. 6. Conditioning exercises. Certain types of exercises may help weak muscles in the hand and wrist. I. Conservative (non surgical). 1. Changing activities to reduce repetitive or strenuous use of the hand or keeping the wrist in a straight position may help reduce the swelling within the tunnel, allowing more room for the nerve. 2. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. The main purpose of wearing splints at night is to avoid flexion of the wrists that most of us assume during sleep. When the wrist is flexed, the pressure inside the carpal tunnel increases and thereby the pressure on the median nerve increases as well. 3. Vitamin B6. There is some evidence that may suggest that Vitamin B6 may be helpful in improving the symptoms of carpal tunnel syndrome. 4. Occasionally anti-inflammatory medications may be helpful. 5. In certain patients, a local injection of steroids into the carpal tunnel may provide help by reducing the swelling within the carpal tunnel. Your physician will decide whether this is suitable for you or not. 6. Some people claim that manipulating the wrist, or “aligning” the bones of the wrist, may help carpal tunnel syndrome patients. This is absolutely not true. There is no scientific evidence whatsoever to indicate that manipulating the wrist bones can, in any way, improve carpal tunnel syndrome. The bones of the wrist are extremely rigid and the transverse carpal ligament is extremely rigid, and there is no way that anyone can manipulate those bones to open the carpal tunnel space. Beware of people who provide this kind of claim. Ask questions to know whether that person knows what he or she is doing or not. II. Surgical. 1. If conservative treatment is not successful in treating the carpal tunnel syndrome, then surgical treatment would be the treatment of choice. 2. The main purpose of the surgery is to divide the transverse carpal ligament and therefore open the carpal canal and increase the volume of the carpal tunnel, and therefore relieve the pressure from the median nerve. 3. Achieving division of the transverse carpal ligament can be done in two techniques: A. Open carpal tunnel release, in which the surgeon makes an incision at the base of the hand and releases the transverse carpal ligament openly. B. Endoscopic carpal tunnel release, in which an endoscope is introduced into the hand through 1-2 small incisions, and the transverse carpal ligament is divided from inside out, without opening the skin in the palm. 4. The two techniques have been very successful in improving the symptoms. The success rate is in excess of 98%. Your surgeon will discuss with you the two options and will select the most appropriate method of treatment. 5. Surgery is performed under a block anesthesia, which is essentially a local anesthesia on same-day surgery basis.
1. After surgery the hand is placed in a dressing for one week. Sutures are removed in 1-2 weeks. 2. After removal of the sutures, the site of the incision may remain swollen and tender for a period of 3-8 weeks. During this time gentle massage of the scar is helpful to decrease the swelling and the soreness. 3. Active movements of the fingers is extremely helpful in keeping the tendons that move the fingers from becoming stuck to the surrounding tissue by the scar. 4. Hand therapy is occasionally needed to help the hand regain its softness, movements and strength. 5. The numbness and tingling may disappear quickly or slowly, depending on the degree of compression of the nerve before the surgery. The strength of the hand may take a few months to return to normal. Cubital Tunnel Syndrome What is cubital tunnel syndrome? Cubital tunnel syndrome is a condition characterized by numbness and tingling of the ring and little fingers associated with weakness of the hand, as a result of compression of the ulnar nerve at the elbow, where the “crazy bone” is. What causes cubital tunnel syndrome? The ulnar nerve passes behind the medial epicondyle, which is the inner bone at the elbow. The nerve goes into a special tunnel called the cubital tunnel. The nerve can be compressed in that area behind the inner bone of the elbow, resulting in cubital tunnel syndrome. 1. Numbness and tingling usually in the ulnar nerve distribution involving the ring and little fingers. 2. Weakness of the hand. 3. Pain of the inner side of the elbow. 1.
Nerve conduction study and electromyography (EMG) are usually
obtained to verify the diagnosis.
I. Non-surgical. 1.
An elbow pad to be worn around the elbow to protect the ulnar
nerve. II. Surgical. 1.
Surgical treatment may be indicated if conservative treatment fails
to improve the symptoms. III. Postoperatively. 1.
Patients are placed in an above-the-elbow splint for one week.
Trigger Finger
Trigger finger is a painless or painful clicking, snapping or locking of a finger. How does that happen? The flexor tendons, which are the tendons that bend the fingers toward the palm, as they go from the hand to the fingers pass through a sleeve that is called the flexor tendon sheath. That sleeve starts at the level of the final crease of the hand that is close to the bases of the fingers. At that level the first part of the sleeve is called the A1 pulley. The pulley gets thickened as a result of inflammation. The flexor tendon itself starts to swell slightly, and when the swollen part of the tendon goes inside the tight part of the sheath, the finger starts to lock or snap with bending and straightening of the finger. In the advanced stages, the finger may become completely locked in the bent position, and cannot be unlocked either by the patient or by the physician. Trigger finger may occur in one or more fingers at the same time, or may occur in different digits at different times. I. Non surgical : 1.
Most of the patients will improve without surgical intervention.
Usually the flexor tendon sheath is injected with cortisone in the
office. The success rate is in excess of 80-85%.
II. Surgical : 1.
Patients who do not improve after one or more injections, may need
surgical release of the A1 pulley.
III. Postoperatively : 1.
Patients are placed in a dressing for one week. |
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