Ask the Experts
Carpal Tunnel Syndrome
What is Carpal Tunnel?
The carpal tunnel is a small narrow channel in the wrist that contains nerves, vessels and muscle tendons. The “median nerve” that relays sensations to the brain and controls your thumb, index and middle fingers, and half of the ring finger passes through this tunnel.
What happens in Carpal Tunnel Syndrome?
The carpal tunnel is a tiny space, and in some people, the median nerve gets squeezed in the tunnel. When this happens, it causes pain as well as interrupting these important nerve signals that control your hand movement. This is called Carpal Tunnel Syndrome (CTS).
Symptoms of CTS begin slowly and can occur at anytime. It can include progressively worsening numbness, tingling, weakness and pain in the hand and wrist, this can end up disrupting your sleep and impairing the function of your hand. You might find it hard to use your hand for small tasks such as gripping a steering wheel or holding a book, which can then worsen to dropping objects or difficulty in buttoning a shirt.
Why does this happen to some people?
People at risk for carpal tunnel syndrome are those who do activities or jobs that involve repetitive finger use.
Motions that can place people at risk of developing carpal tunnel syndrome include:
- High-force (hammering).
- Long-term use.
- Extreme wrist motions.
Many other factors can also contribute to the development of carpal tunnel syndrome. These factors can include:
- Heredity (smaller carpal tunnels can run in families).
- Hemodialysis (a process where the blood is filtered).
- Wrist facture and dislocation.
- Hand or wrist deformity.
- Older age.
- Arthritic diseases such as rheumatoid arthritis and gout.
- Thyroid gland hormone imbalance (hypothyroidism).
- A mass (tumor) in the carpal tunnel.
- Amyloid deposits (an abnormal protein).
The common factor in these conditions is that they all lead to increased swelling in the fibrous passageway and decreased space for the median nerve. In this situation, the nerve remains in continuity but is its outer lining and blood supply can be damaged by the pressure caused by this tight passageway. In response, scar tissue replaces the natural outer insulation of the nerve, called myelin. Myelin is critical in speeding the transmission of electrical signals to the muscle to cause contractions or from the skin to the brain to produce feeling. With scar replacing myelin, electrical signals cannot easily travel across the nerve.
Carpal tunnel syndrome is also more common in women than in men.
How is Carpal Tunnel Syndrome diagnosed?
Your expert hand and upper limb specialist orthopaedic consultant, Mr. Richard Dias will take a detailed history of your symptoms and carry out a physical exam looking for signs of thumb and finger numbness, loss of muscle mass in the palm, or nerve inflammation.
As part of your assessment clinical tests called Phalen’s test, Tinel’s test, Durkan’s test and others are performed to ascertain the symptoms you develop during various wrist and hand movements. In situations where the diagnosis is unclear, a nerve conduction and muscle study can be ordered to obtain more information on the health of the median nerve and its muscles.
- Tinel’s sign: In this test, the physician taps over the median nerve at the wrist to see if it produces a tingling sensation in the fingers.
- Wrist flexion test (or Phalen test): In this test, the patient rests his or her elbows on a table and allows the wrist to fall forward freely. Individuals with carpal tunnel syndrome will experience numbness and tingling in the fingers within 60 seconds. The more quickly symptoms appear, the more severe the carpal tunnel syndrome.
- X-rays: X-rays of the wrist may be ordered if there is limited wrist motion, or evidence of arthritis or trauma.
- Electromyography (EMG) and nerve conduction studies: These studies determine how well the median nerve itself is working and how well it controls muscle movement.
What are the treatments for Carpal Tunnel Syndrome?
You are likely to see your physiotherapist initially who will try wrist splinting to minimize repetitive wrist motion, non-steroidal anti-inflammatory drugs to reduce the swelling and inflammation, diet and exercise in obese patients, and strict glucose control in diabetics. If these measures fail to eliminate persistent pain, numbness, and/or muscle weakness, a carpal tunnel release is recommended. In some patients, steroid injections to the wrist can provide relief from inflammation.
You can choose to be referred to the NHS, or if you wish to get prompt treatment without further compromising the nerves and muscles of your hand, you can choose to see Mr. Dias Privately at Paragon Clinic.
The goal is to provide space for the nerve and its blood supply, giving it a chance to regenerate. Doing so in a timely fashion should lead to speedier electrical signals and return of movement, feeling, and function.
If not addressed, carpal tunnel syndrome can lead to constant numbness and wasting of your thumb muscles, which can become irreversible.
Surgical Treatment: Carpal tunnel release surgery
When CTS isn’t responding to non-surgical treatments or is quite severe, carpal tunnel release surgery can help. This surgery is done under local anaesthetic, which means you will be awake during the operation but the wrist will be numbed from an injection so you won’t feel anything. Through a small incision, a ligament called the transverse carpal ligament at the top of the carpal tunnel will be cut to relieve pressure on the median nerve and this should permanently cure your symptoms. After the surgery your hand will be bandaged and supported by a sling to reduce post operation swelling.
Carpal tunnel release surgery has been going on since the 1930s, and currently has a very high success rate of over 90%. The success rate of any surgery depends on the skills, training and expertise of your surgeon. At Paragon Clinic, you are in the best of hands as Mr. Richard Dias is a highly experienced senior hand surgeon with many thousands of these procedures under his belt with excellent outcomes.
A lot of the symptoms such as the tingling sensation in the hands are relieved quickly after the surgery, and you’ll find that the pain won’t be waking you up at night anymore. The numbness may take a while longer to be relieved, possibly up to three months.
Recovery and aftercare
You can expect to be in discomfort for around 2-3 days after the surgery. Your stitches will be removed 10-24 days after the surgery and you can gradually regain and restore the use of your hand and wrist by specific exercise programmes, such as slowly clenching and unclenching your fist. You won’t be able to do heavier activities with your hand for around 4-6 weeks, depending on your age, general health, how long you had symptoms and how severe the CTS was.
Complications of carpal tunnel surgery
As with all surgeries, there are some side effects of excess scarring, bleeding and pain, as well as possible infection. Here at Paragon clinic, we have an excellent surgeon in Mr. Dias to make sure the risk is low. Specific issues with carpal tunnel surgery are not very common but can include recurrence of symptoms, numbness in the thumb, index and middle fingers, wrist pain and severe stiffness and loss of use of the hand.
How can carpal tunnel syndrome be prevented?
Carpal tunnel syndrome can be difficult to prevent. The condition can be caused by so many different activities in a person’s daily life that prevention can be challenging. Workstation changes—proper seating, hand and wrist placement—can help decrease some factors that can lead to carpal tunnel syndrome. Other preventative methods include:
- Sleeping with your wrists held straight.
- Keeping your wrists straight when using tools.
- Avoiding flexing (curling) and extending your wrists repeatedly.
- Decreasing repetitive/strong grasping with the wrist in a flexed position.
- Taking frequent rest breaks from repetitive activities.
- Performing conditioning and stretching exercises before and after activities.
- Older age.
- Monitoring and properly treating medical conditions linked to carpal tunnel syndrome.
Can my hand pain be something else and not carpal tunnel syndrome?
While carpal tunnel syndrome is a common condition, it has a different set of symptoms from many other sources of hand pain. There are actually several similar conditions that cause hand pain. These include:
- De Quervain’s tendinosis: A condition where swelling (inflammation) affects the wrist and base of the thumb. In this condition, you will feel pain when you make a fist and simulate shaking someone’s hand.
- Trigger finger: This condition causes soreness at the base of the finger or thumb. Trigger finger also causes pain, locking (or catching) and stiffness when bending the fingers and thumb.
- Arthritis: This is a general term for many conditions that cause stiffness and swelling in your joints. Arthritis can impact many joints in your body and ranges from causing small amounts of discomfort to breaking down the joint over time (osteoarthritis is one type of degenerative arthritis).
This is why an expert opinion from a specialist hand surgeon will help clarify the diagnosis.
More about the surgeon, Mr. Richard Dias
|MBBS, FRCS Glasg (Tr & Orth)
|Areas of Expertise
Mr. Richard G. Dias
Consultant Orthopaedic Hand & Upper Limb Surgeon
Richard Dias developed an interest in Hand and Upper Limb Surgery very early in his career while doing Plastic Surgery as an Intern in 1990. After his basic surgical training he completed his Specialist Training on the Birmingham Orthopaedic Training Programme.
He went on to do a Hand Fellowship at the Pulvertaft Hand Centre under the mentorship of Professor Frank Burke, followed by an Upper Limb Fellowship and finally took up post as a Consultant Orthopaedic Hand and Upper Limb Surgeon in Wolverhampton.
During his hand fellowship he had the opportunity to work with Professor F Burke and Dr M. Garcia-Elias, both of whom are internationally renowned for their contributions to the development of hand and wrist surgery.
He is a perfectionist by nature and tailor-makes his treatment and rehabilitation to his patients needs so as to give them the best possible outcome.
This becomes increasingly important in the treatment and rehabilitation of elite athletes where their sporting requirements and training schedules demand an accelerated phase of rehabilitation following surgery.
- Specialist Training on the Birmingham Orthopaedic Training Programme.
- He has travelled around Europe to learn and evaluate new techniques in hand and upper limb surgery.
- He is an Honorary Senior Lecturer, University of Birmingham and the Clinical Lead for orthopaedic undergraduate education at his institution.
- He also mentors physiotherapists for their MSc degree.