Carpal Tunnel Syndrome:
Carpal tunnel syndrome is formed between carpal bones of the wrist and the transverse carpal ligament, ligament is unyielding thick fibrous tissue which does not allow for changes in volume within the carpal tunnel.
Carpal tunnel symptoms:
CTS is a collection of symptoms and signs that occurs following entrapment of the median nerve within the carpal tunnel, usual symptoms may include numbness and pain in median nerve distribution.
- Tingling in fingers
- Numbness in fingers
- Aching in thumb
- Burning pain from wrist to fingers
- Change in touch Sensation
- Change in temperature sensation
- Clumsiness in hands
- Swelling of hand
- Swelling of forearm
- Change in sweat function of hand
Causes of Carpal tunnel:
Carpal Tunnel Syndrome is associated with many different factors:
Non-work related causes:
- Increasing age, Females gender, Dominant hand, Race (white).
- Square wrist, Thickened transverse ligament, short stature, Pregnancy.
- Diabetes, Thyroid disease, hereditary neuropathy, Arthritis.
- Gout, Wrist cyst, Gynecological surgery.
Work related causes:
- Due to repetitive movements, Knitting, Scrubbing, Typing.
- Lock smith, Clerical work, Injury or trauma.
Whites at highest risk of developing CTS.
Very rare in some racial groups. (Non-white, south Africans)
Female to male ratio is 3:1.
Peak age range for development of CTS is 45-60 years. Only 10% of patients of Carpal tunnel syndrome are younger than 31 years.
CTS is a clinical diagnosis.
Abnormalities in sensory modalities may be present on the palmer aspect of first 3 digits and radial one half of the fourth digit.
Gentle tapping over median nerve in carpal tunnel region elicits tingling in nerve’s distribution.
Tingling in median nerve distribution is induced by full flexion or full extension of the wrist for up to 60 seconds. This test has 80% specificity but lower sensitivity.
Carpal compression test:
This test involves applying firm pressure directly over carpal tunnel, usually with thumbs for up to 30 seconds this test have sensitivity of up to 89% and specificity of 96%.
Square wrist sign:
Ratio of wrist thickness to wrist width is greater than 0.7 this test has modest sensitivity/specificity of 70%.
Electrodes are placed on forearm and mild electrical current is passed through arm. Measurement of how fast and well median nerve responds indicates if there is damage to nerve this test helps :
- identify peripheral neuropathy
- locate sites of compression
- establish severity
- Non surgical
- Specific stretching and strengthening program for hand and wrist may be useful in improving strength and dexterity although it can exacerbate symptoms.
- Wrists splints are recommended for use either at night, day or both which help to keep wrist straight and reduce pressure on compressed nerve.
Patients with severe carpal tunnel syndrome should be considered for surgery there are two types of surgery:
Open carpal tunnel release:
- Surgeon makes 2-5 inch incision in lower palm and wrist area.
- Carpal ligament is opened which frees the median nerve.
- Incision is closed with stitches bulky bandage is applied to wound and digits movements are not restricted.
Endoscopic Carpal Tunnel Release:
- A tiny 1/2 inch incision is made on palm side of wrist.
- Optic camera is passed through which allows surgeon to view inside of carpal tunnel.
- Another tiny incision is made and surgical tools are passed through these instruments are passed to release median nerve.
- After camera and instruments are removed a few stitches are necessary to close incisions and bandage is placed.
- NSAIDs in case of inflammation and pain relief, for 1-2 weeks.
- Diuretics in case of Edema.
- Steroidal injections in carpal tunnel.
- Overuse of legal drugs can contribute to CTS so overuse should be reduced.
Rehabilitation after Surgery:
- Gentle massage for scar tissue and sanitize incision.
- Modalities to decrease pain, inflammation and swelling (heat, cold)
- Progressive exercises for Strengthening and stabilizing exercises.
- Exercises to improve fine motor control and dexterity.