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 CARPAL TUNNEL SYNDROME
Case History
Mrs T.L.H. aged 48 years old presents to her doctor with complaints of pain and tingling in her right hand, often on waking up in the morning. Her doctor diagnosed her to have carpal tunnel syndrome.
Where is The Carpal Tunnel ?
The carpal tunnel lies in your wrist. The floor of this tunnel is formed by the small bones of your wrist and the ligaments bridging across your wrist from the roof of the tunnel. The tendons from the muscles in your forearm which move your fingers pass through this tunnel. The median nerve, one of the three major nerves bringing sensation and movements to your hand also passes through this tunnel just beneath the wrist ligaments.
What is Carpal Tunnel Syndrome?
"Carpal" is a medical term referring to the wrist. A "syndrome" is a combination of symptoms and signs which doctors recognize as belonging to a particular disease or medical condition. In the carpal tunnel syndrome, the median nerve is compressed within the carpal tunnel and causes the signs and symptoms as described.
What Are The Symptoms?
Symptoms experienced are
- Pain, aching, tingling or numbness over the thumb, index and middle fingers
- Aching pain which may sometimes extend up into the forearm
- Usually worse at night or in the morning on waking up
- Relieved by hanging affected hand out of bed, shaking it around or immersing it in hot water
- Usually one hand and it is often the dominant hand which is affected
- Considered severe if associated with clumsiness and tendency to drop things
What Activities Aggravate The Symptoms?
Symptoms are often aggravated or occurs with
- Writing
- Typing
- Knitting
- Housework such as scrubbing, ironing
What Are The Signs?
At the early stage, the doctor may not find any abnormal signs.
As the condition progresses, the following may be found on examination:
- Swollen wrist
- Loss of sensation to light touch and pin prick over the thumb, index and middle finger.
- Loss of prominence of muscle bulk over the base of the thumb
- Tingling in the fingers when the median nerve is tapped over the wrist
What Are The Causes?
In most cases there is no obvious cause but the doctor would consider as likely causes
- Fractured wrist if there is distortion of the carpal tunnel
- Arthritis of the wrist, in particular Rheumatoid arthritis
- Fluid retention especially in women during pregnancy
- Diabetes mellitus
- An underactive thyroid gland
- Acromegaly, a condition with increase growth of soft tissue due to excessive growth hormon
- Long term haemodialysis
Who Gets Carpal Tunnel Syndrome?
It can affect people of all ages but is
- Three times more common in women than in men
- More common in middle aged women
- More commonly seen in older people
How Do Doctor Diagnose Carpal Tunnel Syndrome?
The diagnosis is usually obvious from your presenting complaints. A useful test called the Tinel's test which is performed by the gentle tapping with the finger over the median nerve at the wrist and will reproduce the tingling sensation in the thumb, index and middle fingers.
How Can The Diagnosis Be Confirmed?
A nerve conduction test is often done to confirm the diagnosis. Small electrodes are placed on to the skin just above the wrist to stimulate the median nerve. If you have carpal tunnel syndrome there will be a delay in the impulse reaching your thumb and this delay can be easily measured. The longer the delay the more compressed is the median nerve.
Is There Any Treatment?
Treatment depends on the severity of the symptoms.
For mild and moderate symptoms:
- Avoid movements such as overgripping, wringing or squeezing
- Wear a splint to keep the wrist in a neutral position at night
- Diuretics ( water tablets ) are useful if the condition is caused by swelling of the wrist due to water retention
- Nonsteroidal anti-inflammatory drugs are useful if you have arthritis
- Steroid injection is often given into the carpal tunnel if symptoms persist despite wearing a splint. Following injection of a small amount of steroid into the tunnel, many patients notice a significant improvement in symptoms within a few hours. There is usually relief of symptoms for several weeks and some patients are cured.
For more severe symptoms:
When Do I Need Surgery?
Surgery may be needed if you
- Have severe symptoms
- Persistent symptoms despite treatment
- Have little relief following steroid injection
- Require more than two to three injections
- Have weakness of your thumb, index and middle fingers causing you to drop things
- Have increasing loss of feeling over your thumb, index and middle fingers
The operation is simple. Surgery usually takes place as a day case and is carried out under a local anaesthetic agent. You will not require general anaesthesia. The operation reduces the pressure on your median nerve and usually leaves a small scar. Surgery is usually effective and you will recover completely with relief of pain and normal hand function in less than a month. However for those who have had symptoms for over a year, particularly if there is loss of prominence of the muscle at the base of your thumb (as seen in the picture on the cover of this handout ) there may be only partial recovery. A few of those patients who do not improve may also have diabetes mellitus with nerve involvement.
Conclusion
Carpal tunnel syndrome is a common condition which can be easily diagnosed and treated with good outcome. It is important that you consult your doctor early if you have any of the symptoms or signs as described.
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