TIP OF THE MONTH: Spring 2015
Carpal Tunnel Syndrome
Third-Place Article, 2014 Paper of the Year Competition
by Crystal Folds, Orthopaedic Technologist Student
Carpal Tunnel Syndrome (CTS) is a disorder that is caused by compression of the median nerve in the wrist creating a sensation of numbness, tingling and pain in the first, second, third, and half of the fourth digit. Its alternate names are Median Nerve Dysfunction or Median Nerve Entrapment/Partial Thenar Atrophy.
Let’s look at this beginning with the bones and work our way out. The bones involved in CTS include the ulna, radius, the eight small carpal bones, (the hamate, triquetrum, pisiform, lunate, scaphoid, trapezium, trapezoid, and capitate) metacarpals and phalanges. The transverse carpal ligament attaches medially to the pisiform and hamate. It attaches laterally to the scaphoid and trapezium. The flexor tendons are covered with tenosynovium. They are attached to the intrinsic muscles of the hand. The median nerve innervates these muscles. They include the abductor pollicis brevis muscle, opponens pollicis muscles, and lumbrical muscles of the index and long fingers. The radial and ulnar arteries provide blood supply to the hand.
The carpal tunnel is an opening formed by the bones in the wrist (on the dorsal side) and the transverse carpal ligament (on the volar side). The median nerve and the flexor tendons run through the carpal canal (tunnel). The median nerve sits on top of the flexor tendons, right under the transverse carpal ligament. This canal serves as protection to the nerve and tendons.
Carpal Tunnel Syndrome happens when there is too much pressure on the median nerve. This pressure could be from swelling of the tissues that surround the median nerve. Many different health conditions, such as hypothyroidism, Rheumatoid Arthritis, diabetes, pregnancy, obesity, repetitive hand movements, wrist injuries, bone spurs, and smoking could cause the median nerve to become compressed.
There are factors to take into consideration when looking at the incidence rate of Carpal Tunnel Syndrome. It usually affects 3% of females and 2% of males. The peak onset age is 55. In countries that are developed, there is a higher prevalence rate than in countries that are underdeveloped. This study shows that there is a higher rate in Carpal Tunnel Syndrome in the working population than in the non-working population.
The risk factors for CTS include previous fractures or dislocations of the wrist. Women are more likely to get Carpal Tunnel Syndrome than men because their carpal area is smaller than the carpal area in men. Having certain health issues could also attribute to the risk of getting CTS. Pregnancy attributes to an increase in bodily fluids, which may cause the median nerve to be compressed. Other conditions such as alcoholism, diabetes, thyroid disorders, RA, or even an infection could cause the space in the carpal area to be reduced. There are also work place factors to take into consideration. Repetitive motions or working with hand tools, such as a power drill, could cause CTS.
Carpal Tunnel Syndrome can be mild to severe. If it is treated early, it can be reversed. The longer the symptoms persist untreated, the more severe the damage to the nerve, muscles, and tissues could potentially become. Delay in seeking treatment can result in permanent damage.
Signs and symptoms of Carpal Tunnel Syndrome include pain in the wrist and the palm of the hands. A feeling of numbness, tingling and/or burning in the first, second, third, and half of the fourth digits might be present. Weakness in the hand would be evident. It would be difficult to hold or grasp things without dropping them. Night pain or pain with repetitive use of the hand would be noticeable as well.
There are several different diagnostic tests that can be performed for Carpal Tunnel Syndrome. The Direct Compression Test is one. This is when the thumb is used to put pressure over the median nerve for sixty seconds. A positive result is noted if the patient experiences paresthesia or a replication of pain. Tinel’s Sign is another test to perform. This is done by tapping firmly over the median nerve at the carpal canal. A positive result is noticed when there is a shocking sensation in the wrist/arm/hand. Phalen’s Maneuver is when the patient flexes their wrist for sixty seconds. Paresthesia or a replication of previous pain shows a positive result for Carpal Tunnel Syndrome. Inspecting the hand for atrophy and strength testing are also good diagnostic tests that can be performed. An x-ray is used if a decrease in range of motion is noticed. An EMG/NCV can be performed to determine the diagnosis. It tests the function of the median nerve to diagnose and clarify the best treatment option for the patient.
After positive results from diagnostic tests have been determined, appropriate treatments follow. For mild to moderate cases of Carpal Tunnel Syndrome a cock-up wrist splint should be worn (especially at night), NSAID’s, and a corticosteroid injection are given. If these methods fail or if symptoms worsen, surgery might be considered. Either an Open or an Endoscopic Carpal Tunnel Release Surgery would need to be performed to restore function of the hand.
Carpal Tunnel Release Surgery is usually an outpatient procedure. An incision is made in the palm of the hand. With an Endoscopic surgery, the incision is much smaller than it is if it is an Open surgery. The transverse carpal ligament is divided at the incision site. This decreases the pressure that is on the median nerve, and allows more space inside the carpal tunnel for the nerve and flexor tendon. The more space there is in the carpal tunnel, the less pressure there is on the nerve. The patient will wake up in a Volar splint. They are instructed to elevate the wrist at a level above the heart, and keep a clean, dry bandage on it. Ice should be used for swelling and mild analgesics for pain. After having the sutures removed, the patient wears a cock-up wrist brace for up to three weeks, or as instructed by their doctor. The patient will likely go to occupational therapy for strengthening. They may resume normal activities shortly after surgery as long as extreme pain doesn’t occur. Minor pain is to be expected for several months, as well as weakness in grip and pinch strength for up to six months.
The prognosis is excellent for those treated with non-operative techniques and for those that have had surgery. Significant improvement of symptoms has been noted for all treatments of CTS.
There are complications that may arise from treatment of Carpal Tunnel Syndrome. These include stiffness, swelling, numbness around surgical incision, infection, and damage to the blood vessels or nerves. It is possible for treatment of Carpal Tunnel Syndrome to fail.
There are ways to prevent Carpal Tunnel Syndrome. Staying at a healthy weight can reduce the chance of getting CTS. Exercising regularly helps maintain a healthy weight and it is a way of strengthening the hand, arm, and fingers. Making a choice not to smoke will help as well. Office ergonomics, resting between repetitive motions, and retraining yourself on how to do things differently can reduce the probability of getting CTS. The older you are, the more preventative measures should be taken to reduce the chance of getting Carpal Tunnel Syndrome. If it CTS cannot be prevented, it is important to be proactive and seek the necessary treatment to restore function of the hand, wrist, and arm.
About the Author:
Crystal C. Folds, OTC, recently graduated from Southern Crescent Technical College, under the instruction of Sam Brown, OTC. Having majored in Orthopaedic Technology, Crystal earned her Associate of Applied Science degree in August of 2014. She was an Honor Graduate with distinction, ranking #1 in her class. Along with being a member of NAOT, Crystal is a member of the National Technical Honor Society.
After completing her clinicals at OrthoAtlanta, in Stockbridge GA, Crystal is now employed at the facility as an OTC. She is thrilled to have the opportunity to work with such an extraordinary group of Orthopaedic Surgeons, and is looking forward to helping patients and their families with her knowledge and skills.