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Carpal and Cubital Tunnel Syndrome

Carpal tunnel syndrome is a common condition caused by the entrapment of the median nerve in the carpal tunnel, resulting in numbness and significant pain in the hand, fingers and wrist.

Carpal Tunnel Syndrome

The carpal tunnel is located in the wrist. The median nerve and the tendons that connect the fingers to the muscles of the forearm pass through the tunnel. The median nerve provides sensation to the palm side of the thumb, index, middle fingers, as well as the inside half of the ring finger and muscle power to the thumb.
Carpal tunnel syndrome occurs when the median nerve becomes compressed due to swelling of the nerve or tendons or both. It is unclear what causes this problem. When this occurs, numbness, tingling, and sometimes pain of the affected fingers. In advanced cases, atrophy of the thumb muscles occurs resulting in weakness and dropping of objects, difficulty opening jars, etc.


There is evidence that excessive repetitive movements of the arms, wrists, or hands can aggravate the structures of the carpal tunnel, triggering the symptoms of carpal tunnel syndrome. 
Also, several conditions as pregnancy, hypothyroidism, wrist fracture (Colles), space-occupying lesions within the carpal tunnel (eg, flexor tenosynovitis, ganglions, hemorrhage, aneurysms, anomalous muscles, various tumors, edema), diabetes, rheumatoid arthritis, renal dialysis, and menopause among others.

Symptoms of Carpal Tunnel Syndrome

The first symptoms usually are tingling and numbness, many times waking patients up at night with numbness and sometimes pain in the hand. Up to 40% of patients suffering from this condition also experience symptoms in the forearm and even up to the shoulder. As carpal tunnel syndrome becomes more severe, symptoms are noticed during the day.

In advanced cases, when the motor branch of the median nerve is affected, there is loss of strength and coordination at the base of the thumb, and there may be permanent numbness of the fingers supplied by the median nerve. (Thumb, Index, Long and half of the Ring fingers.)

Diagnosis of Carpal Tunnel Syndrome

Compression tests are very reliable, reproducing the symptoms experienced by the patients who suffer from carpal tunnel syndrome. They all apply pressure on the median nerve via direct compression over the nerve. When there is significant deficit of the median nerve, the thumb muscles become atrophied and weak, which is evident in the clinical exam.

Once there is clinical evidence, most patients undergo an electromyogram and nerve conduction studies to confirm the diagnosis and the extent of nerve damage. These tests, however, may not become positive until there is significant nerve damage. There is documented evidence that up to 30% of patients with clinical evidence of carpal tunnel syndrome will have a negative electromyogram study. 

Treatment of Carpal Tunnel Syndrome

There are several ways to treat symptoms of carpal tunnel syndrome:    

Immobilization. Immobilizing the wrist in a splint that support the wrist in a comfortable neutral position. This position will provide the least amount of compression of the nerve relieving painful numbness or tingling. The current recommendations are to wear the splint only at night since the results are similar as wearing them through the entire day and night. 

Medication. Patients may be given short courses of anti-inflammatory drugs (NSAIDS) and Vitamins B1 and B6 which have been shown to provide some improved in the healing of the damaged nerves. Steroid injections are typically not recommended and only indicated as temporizing measures for people with symptoms that are not controlled with conservative management and require surgery but for certain circumstances cannot undergo surgery at that time. Cortisone injections have demonstrated poor long-term effects and potential significant side effects such as Median neuritis.

Surgery. During surgery, your surgeon will open the carpal tunnel and cut the ligament, relieving the pressure. Carpal tunnel surgery is quite effective at relieving painful symptoms when the condition involves only nerve constriction.

Operative Treatment

There are two ways to perform carpal tunnel syndrome: Open and Endoscopic:

- The Open technique is a safe and effective surgical technique.

-- An incision is made over the carpal ligament in the palm of the hand. Dissection is carried out until reaching the carpal ligament, and with much care, the carpal ligament is incised. The patient is instructed in range-of-motion exercises for the fingers, wrist, and arm; and a splint in a wrist neutral position is used at night for 3 weeks for patient comfort. the sutires are removed 12 to 14 days, postoperatively. At one month after surgery, patients can return to work with a 2-lb weight restriction; and at 6 to 8 weeks after surgery, they are allowed full activity without restrictions. 

 - Endoscopic technique decrease the length of the incision, decreasing postoperative pain and providing a faster recovery. A small incision is made in the wrist, and the endoscope is introduced under the carpal ligament. Once the ligament is fully visualized, a blade is raised, and the ligament is incised. Once the ligament is released, the wound is closed. 

The patients can use the hands immediately after the surgery, no splint is needed. Usually the patient can return to work 3 days later and have unrestricted use of the hand in most cases in 4 to 6 weeks. Most patients do not require occupational therapy.

Nerve Injuries

Nerves can be damaged by too much pressure, by stretching, or by a cut. The signs and symptoms of nerve injuries can be different depending on the nerve injured, the type and the severity of injury. Some may include numbness, weakness, and pain.

Prognosis

Factors affecting recovery following nerve repair:

 - Age

 -- most important factor

 - Level of injury

 -- the more distal, the better the chance of recovery

 - Sharp transections have better prognosis

 - Repair delay

 -- worsen prognosis of recovery (time limit for repair is 18 months)

 - Return of function

 -- pain is first modality to return

Treatment

Non-operative treatment options include observation with sequentialEMG. The conservative treatment indications are neuropraxia (1st degree) and axonotmesis (2nd degree).

In many instances, nerve injuries require surgical reconstruction, such as nerve grafting.

Physical therapy is sometimes needed after a nerve injury. Factors that may affect results after nerve repair include age, the type of wound and nerve, and location of the injury. 

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