Carpal tunnel syndrome
Carpal tunnel syndrome is a common condition that causes pain, aching, numbness, tingling and weakness in the hands and wrist.
The condition is as a result of the median nerve being squeezed where it passes through the wrist.
This nerve provides sensation to the thumb, index and middle fingers, and to half of the ring finger. The small finger (the pinky) is typically not affected. The median nerve also provides strength to some of the muscles at the base of the thumb.
The symptoms tend to be worse at night and may disturb sleep. Hanging the hand out of bed or shaking it around will often relieve the pain and tingling.
Symptoms may not be noticeable at all during the day, although certain activities such as writing, typing, or housework can bring on symptoms.
Sometimes the condition can be mistaken for something else. For example, pressure on nerves in the neck due to disc problems or stenosis.
A nerve conduction test will help confirm the diagnosis.
Non-surgical treatments are usually tried first. Treatment begins with wearing a wrist splint at night and taking analgesic medication, such as ibuprofen, to relieve pain.
Steroid injections into the carpal tunnel can also be given although they provide only temporary relief of symptoms.
In addition, changes to lifestyle can be made. Examples include raising or lowering the chair or the computer keyboard to bring the arm and wrist into proper alignment. Changes in the hand/wrist positions used in jobs and other activities can also be tried, along with activity modification.
Surgery is recommended when carpal tunnel syndrome does not respond to non-surgical treatments or has already become severe. The goal of surgery is to increase the size of the tunnel in order to free the median nerve, which runs through the carpal tunnel in the wrist.
This is done by cutting (releasing) the band of tissue (ligament) that covers the carpal tunnel at the base of the palm. This ligament is called the transverse carpal ligament.
Surgery for carpal tunnel syndrome is a day-case procedure that is usually performed under local anesthesia.
After surgery, brief discomfort may last for 1-2 days. However, patients often experience complete night-time symptom relief early after surgery. Stiches are removed 10 to 14 days after surgery. Following surgery, the hand is dressed with wool and crepe bandages. They must be kept clean and dry until the stitches are removed.
Heavier activities with the affected hand are restricted for 4 to 6 weeks. Recovery times vary depending on the patient’s age, general health, severity of carpal tunnel syndrome, and the duration the symptoms have been present. Numbness and weakness can also take a few months to improve, and even up to one year.
Finger exercises should start immediately after surgery and repeated frequently. Fully straighten and bend the fingers for a few minutes every hour. This helps to prevent stiffness.
Hand elevation is important to prevent swelling and stiffness of the fingers. A sling can be used when walking, and pillows to elevate the arm at night.
Hand movement should be continued and normal daily activities performed after the bandages removed.
If the scar is somewhat firm or tender, this can be helped by massaging the scar with moisturising cream e.g. Aloe Vera and Vitamin E.
We can also organise a referral to a hand therapist for scar management, range of motion strengthening and rehabilitation.
Many patients who undergo carpal tunnel release surgery achieve nearly complete relief of all symptoms. Recovery in some individuals with severe carpal tunnel syndrome may be slow and may not be complete. Carpal tunnel syndrome can reoccur, but this is not common.
Ulnar Neuropathy (Cubital tunnel syndrome)
Ulnar Neuropathy occurs when the ulnar nerve becomes entrapped and damaged as it passes across a narrow passageway on the inside of the elbow formed by bone, muscle, and ligaments forming the cubital tunnel at the base of the elbow. The condition is also called cubital tunnel syndrome.
The ulnar nerve provides sensation to the little and ring fingers as well as controlling most of the hand muscles.
In general signs and symptoms of Cubital Tunnel Syndrome arise gradually, including tingling and progressive numbness particularly involving the ring and little fingers and inside of the hand. Symptoms may be more apparent at night, and with elbow bending or prolonged resting on the elbow. As it becomes more advanced, patients lose grip strength with dropping of objects. The hand muscles can waste with clawing particularly involving the little finger
The common causes responsible for cubital tunnel syndrome, include:
- Habits such as leaning on the elbows e.g. desk workers, use of chairs with elbow rests, wheelchair users with hard elbow supports.
- Repetitive motion
A nerve conduction test will help confirm the diagnosis.
Early diagnosis and treatment of cubital tunnel syndrome can greatly help in reducing symptoms and avoiding muscle atrophy, wasting or clawing of the hand.
The type of treatment recommended will depend on the severity. Mild cases (with no weakness or wasting) can resolve with conservative measures including:
- Lifestyle changes, avoiding frequent bending of the elbow and avoiding pressure to the elbow by not leaning on it. Elbow pads may be worn to decrease pressure when working at a desk.
- A brace or splint at night to keep the elbow in a straight position while sleeping.
- Avoiding activities that tend to bring on the symptoms.
- NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) such as ibuprofen
Surgery maybe recommended to patients not responding to conservative management and in moderate – severe cases (muscle weakness/ wasting). The goal of surgery is to free the ulnar nerve by providing more space for the nerve to move freely. The nerve can either be released from the tunnel (decompressed) or can even be moved away (transposed). In some instances the surgery may also involve a medial epicondylectomy, this involves removing the medial epicondyle, the bony bump on the inside of the elbow, enabling the ulnar nerve to glide smoothly when the elbow is flexed and straightened.
The operation is usually done under a general anaesthetic and takes around 1 hour. Nerve recovery can take some months following this and dependant on the severity and duration of nerve compression.
A bulky dressing with wool and crepe bandage is usually applied following surgery for 10-14 days.
Hand/ wrist exercises should start immediately after surgery and repeated frequently. Arm elevation is important to prevent swelling and stiffness of the fingers. A sling can be used when walking, and pillows to elevate the arm at night. The arm dressing is removed after 10-14 days for removal of the sutures. Elbow immobilisation for 3 weeks after surgery is usually advised, longer depending on the repair performed. Keep the surgical incision clean and dry for the first 14 days.
We can also organise a referral to a therapist for range of motion strengthening and rehabilitation.
Recovery will usually take several weeks if not months. Generally pain and tingling are more likely to recover early. Numbness and weakness improvement can take several months.