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December 13, 2011

Hand Surgery #1: Carpal Tunnel Syndrome

Many people are surprised to learn that plastic surgeons are trained to evaluate and to treat hand disorders.  Around the USA, about 1/3 of all the hand surgery is performed by plastic surgeons.

So, for the next few blog posts, I will forego discussions of Botox, facelifts, and tummy tucks, and will instead focus on common hand problems, such as carpal tunnel syndrome....

 

Anatomy

The carpal tunnel is the passageway in the wrist formed by...

  • 8 carpal (wrist) bones, which make up the floor and sides of the tunnel
  • the transverse carpal ligament, which is a strong ligament stretching across the roof of the tunnel

Inside the carpal tunnel are...

  • 9 flexor tendons, which flex (bend down) your fingers and thumb
  • the median nerve, a cord about the size of a pencil containing thousands of nerve fibers supplying sensation (feeling) to your thumb, index and middle fingers, and half of the ring finger

 

Pathology - The Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by increased pressure in the carpal tunnel resulting in compression of the median nerve. When the median nerve is pushed up against the ligament, blood flow to the nerve is restricted, causing a sensation often described as "pins and needles" to the fingers. In severe or chronic cases, numbness can be constant.

 

Causes

Carpal tunnel syndrome can be caused by a variety of problems. Certain medical conditions that may lead to compression of the median nerve include:

  • Inflammation or swelling about the tendons
  • Fluid retention
  • Wrist fractures and dislocations
  • Crushing injuries to the wrist
  • Rheumatoid/degenerative arthritis
  • Diabetes
  • Tumors and tumor-like conditions
  • Hypothyroidism
  • Pregnancy

There is considerable debate as to whether specific work activities may lead to carpal tunnel syndrome. Certain occupational activities which involve repeated flexing of the fingers or wrist, or prolonged use of vibrating tools may contribute to the development of carpal tunnel syndrome.

Determining whether or not carpal tunnel syndrome is a work-related condition can be very difficult. Each case must be considered individually and must be based on documentation of specific work-related activities which may contribute to this condition.

Non-work related activities of daily living and leisure may also provoke symptoms of carpal tunnel syndrome. Lawn mowing, long distance driving, or hobbies such as knitting or wood carving are activities which involve prolonged or repetitive grasping and wrist flexion and may elicit symptoms of carpal tunnel syndrome.

 

Signs and Symptoms

Numbness, burning, or tingling of one or more of the fingers (excluding the little finger) is the most common symptom of carpal tunnel syndrome. This numbness can happen at any time; often these symptoms occur at night and may awaken the individual from sleep. Partial relief can sometimes be gained by shaking, massaging, or elevating the hands. At times, the numbness may extend up the arm, into the elbow, and as far up as the shoulder and neck.

A decrease in sensation or feeling may result in clumsiness and weakness of the affected hand. Patients may find themselves dropping objects and less capable of performing tasks requiring gripping or pinching strength.

On the palm side of the hand, just below the thumb, is a bulging pad of muscle called the thenar muscle group. Some of these muscles are controlled by the median nerve. With advanced carpal tunnel syndrome, this muscle group may begin to waste away, giving a flattened appearance to the palm when compared to the other hand.

 

Treatment

  • Conservative treatment:
    • avoidance of activities that may provoke further symptoms
    • wearing a splint to restrict movement of the wrist
    • a cortisone injection into the carpal tunnel to decrease swelling
  • When conservative treatment fails, or when symptoms are severe and/or longstanding, I usually recommend surgery....
    • outpatient
    • small incision on the palm of the hand
    • cut (release) the ligament forming the roof of the tunnel
    • The pressure on the median nerve is relieved.
    • The whole surgery takes less than 30 minutes.

 

Recovery

With the blood flow to the median nerve restored, the symptoms of burning and tingling are usually relieved soon after surgery. Patients can expect soreness from the incision for 4 – 6 weeks and discomfort from deep pressure for as long as several months. Improvements in strength and sensation depend on the extent of the nerve damage prior to treatment. Normal grip strength may not return for several months following surgery. The natural healing process and regeneration of nerve fibers will occur throughout the following six months to a year.

Formal physical therapy is not usually required.  However, in certain instances, I recommend a program of hand therapy to regain strength, reduce discomfort, and increase range of motion to the fingers and hand.

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