Carpal Tunnel Syndrome
What is it?
Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. In effect, it is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand (see Figure 1). Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel and puts pressure on the nerve. When the pressure from the swelling becomes great enough to disturb the way the nerve works, numbness, tingling, and pain may be felt in the hand and fingers (see Figure 2).
What causes it?
Usually the cause is unknown. Pressure on the nerve can happen several ways: swelling of the lining of the flexor tendons, called tenosynovitis; joint dislocations, fractures, and arthritis can narrow the tunnel; and keeping the wrist bent for long periods of time. Fluid retention during pregnancy can cause swelling in the tunnel and symptoms of carpal tunnel syndrome, which often go away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes also can be associated with carpal tunnel syndrome. There may be a combination of causes.
Signs and symptoms
Carpal tunnel syndrome symptoms usually include pain, numbness, tingling, or a combination of the three. The numbness or tingling most often takes place in the thumb, index, middle, and ring fingers. The symptoms usually are felt during the night but also may be noticed during daily activities such as driving or reading a newspaper. Patients may sometimes notice a weaker grip, occasional clumsiness, and a tendency to drop things. In severe cases, sensation may be permanently lost and the muscles at the base of the thumb slowly shrink (thenaratrophy), causing difficulty with pinch.
A detailed history including medical conditions, how the hands have been used, and whether there were any prior injuries is important. An x-ray may be taken to check for the other causes of the complaints such as arthritis or a fracture. In some cases, laboratory tests may be done if there is a suspected medical condition that is associated with CTS. A nerve conduction study (NCV) and/or electromyogram (EMG) may be done to confirm the diagnosis of carpal tunnel syndrome as well as to check for other possible nerve problems.
Symptoms may often be relieved without surgery. Identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position may help reduce pressure on the nerve. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. A steroid injection into the carpal tunnel may help relieve the symptoms by reducing swelling around the nerve.
When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand (see Figure 3). Incisions for this surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve. Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.
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What is a wrist fracture?
The wrist is made up of eight small bones and the two forearm bones, the radius and ulna (see Figure 1). The shape of the bones allows the wrist to bend and straighten, move side-to-side, and rotate, as in twisting the palm up or down. A fracture may occur in any of these bones when enough force is applied, such as when falling down onto an outstretched hand. Severe injuries may occur from a more forceful injury, such as a car accident or a fall off a roof or ladder. Osteoporosis, a common condition in which the bone becomes more brittle, may make one more susceptible to getting a wrist fracture.
The most commonly broken bone of the wrist is the radius (see Figure 1). Many people think that a fracture is different from a break, but they are the same. When the wrist is broken, there is pain, swelling, and decreased use of the hand and wrist. Often the wrist appears crooked and deformed. Fractures of the small wrist bones, such as the scaphoid, are unlikely to appear deformed (see Figure 1). Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to displace or shift, in which case the wrist is more likely to appear crooked. Some fractures break the normally smooth, ball bearing-like joint surface; others will be near the joint but leave the joint surface intact. Sometimes the bone is shattered into many pieces, which usually makes it unstable. An open (compound) fracture occurs when a bone fragment breaks through the skin. There is some risk of infection with compound fractures.
How are they evaluated?
Examination and x-rays are needed so that your doctor can tell if there is a fracture and to help determine the treatment. Sometimes a CT scan or MRI may be used to get better detail of the fracture fragments and associated injuries. In addition to the bone, ligaments (the structures that hold the bones together), tendons, muscles, and nerves may be injured as well when the wrist is broken. These injuries may need to be treated in addition to the fracture.
How are they treated?
The pattern of the fracture, whether it is displaced or non-displaced, and whether it is stable or unstable are all factors in determining the treatment. Other important considerations include your age, overall health, hand dominance, work and leisure activities, the presence of any prior injury or arthritis, and any associated injuries.
A splint or cast may be used to treat a fracture that is not displaced, or to protect a fracture that has been set. Other fractures may need surgery to properly set the bone and/or to stabilize it. Fractures may be stabilized with pins, screws, plates, rods, or external fixation (see Figure 2). External fixation is a method in which a frame outside the body is attached to pins which have been placed in the bone above and below the fracture site, in effect keeping it in traction until the bone heals. Sometimes arthroscopy is used in the evaluation and treatment of wrist fractures. Your hand surgeon will determine as to which treatment is the most appropriate in your individual case.
On occasion, bone may be missing or may be so severely crushed that there is a gap in the bone once it has been re-aligned. In such cases, a bone graft may be necessary. In this procedure, bone is taken from another part of the body to help fill in the defect. Bone from a bone bank or synthetic bone graft substitutes may also be used.
While the wrist fracture is healing, it is very important to keep the fingers flexible, provided that there are no other injuries that would require that the fingers be immobilized. Otherwise, the fingers will become stiff, hindering the recovery of hand function. Once the wrist has enough stability, motion exercises may be started for the wrist itself. Your hand surgeon will determine the appropriate timing for these exercises. Hand therapy is often used to help recover flexibility, strength, and function.
What kind of results can I expect?
Recovery time varies considerably, depending on the severity of the injury, associated injuries, and other factors as noted previously. It is not unusual for maximal recovery from a wrist fracture to take several months. Some patients may have residual stiffness or aching. If the surface of the joint was badly injured, arthritis may develop. On occasion, additional treatment or reconstructive surgery may be needed.
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*All information provided by American Society for Surgery of the Hand