HAND

Carpal Tunnel Syndrome

Carpal tunnel syndrome is a common source of hand numbness and pain. The tendons in the wrist swell and put pressure on the median nerve, one of three major nerves responsible for supplying feeling in the hand. It is more common in women than men and affects up to 10 percent of the entire population.

Anatomy

The carpal tunnel is a narrow, tunnel-like structure in the wrist. The bottom and sides of this tunnel are formed by wrist (carpal) bones. The top of the tunnel is covered by a strong band of connective tissue, called a ligament.

The median nerve travels from the forearm into the hand through this tunnel in the wrist. The tendons that bend the fingers and thumb also travel in this tunnel.

Carpal tunnel is caused by pressure on the nerve traveling through the carpal tunnel.

Cause

Carpal tunnel is caused by increased pressure on a nerve entering the hand through the confined space of the carpal tunnel. There are many causes of carpal tunnel.

• Heredity is the most important factor.
• Hand use over time can play a role.
• Repetitive motions of the hands or wrist; that is, when the same motion is repeated over and over again over a very long period of time.
• Hormonal changes related to pregnancy and menopause.
• Medical conditions, including diabetes, rheumatoid arthritis, and thyroid gland imbalance.

In some cases of carpal tunnel, there is no known cause.

Symptoms

Symptoms usually begin gradually, without a specific injury.

• Numbness, tingling, and pain in the hand are common.
• An electric-like shocking feeling in the fingers or hand.

The thumb side of the hand is usually most involved.

Symptoms may occur at any time. Symptoms at night are common and may awaken you from sleep. During the day, symptoms frequently occur when holding something, like a phone, or when reading or driving. Moving or shaking the hands often helps decrease symptoms.

Sometimes strange sensations and pain will travel up the arm toward the shoulder. Symptoms initially come and go, but over time they may become constant. A feeling of clumsiness or weakness can make delicate motions, like buttoning buttons, difficult. These feelings may cause you to drop things. If the condition is very severe, muscles in the palm may become visibly wasted.

Diagnosis

Your doctor will make the diagnosis by discussing your symptoms and by performing a number of physical tests, such as the following:

• Ask you to straighten the thumb while it is being held to determine whether there is any weakness in the median nerve (thumb abduction strength test)
• Ask you to extend the arms and relax the wrists to see whether you experience any numbness or tingling in the wrists (Phalen maneuver)
• Press down on the median nerve in the wrist to determine whether there is any sign of numbness or tingling. (Durkan carpal tunnel compression test)
• Tap along the median nerve in the wrist to see whether tingling is produced in any of the fingers
• Tell you to close your eyes and ask you whether you feel the pressure of two light pin-point touch on the fingertip of the affected hand. If you have carpal tunnel syndrome, you may be unable to distinguish two pin-point touches that are closer than 5 mm as separate points

Your doctor may order X-rays of the wrist if you have limited wrist motion. If symptoms continue to bother you, electrical testing of the nerve function (electrophysiological tests) is often performed to help confirm the diagnosis and clarify the best treatment option in your case.

Treatment

If diagnosed and treated early, carpal tunnel syndrome can be relieved without surgery.

Nonsurgical Treatment

Treatment often begins with a brace or splint worn at night to keep the wrist in a natural position. Splints can also be worn during activities that aggravate symptoms.

Simple medications can help decrease pain. These medications include anti-inflammatory drugs (NSAIDs), such as ibuprofen.

Changing patterns of hand use to avoid positions and activities that aggravate the symptoms may be helpful.

A corticosteroid injection will often provide temporary relief, but symptoms may come back.

Surgical Treatment

Surgery may be considered if carpal tunnel syndrome continues to bother you and you do not gain relief from nonsurgical treatments. The decision whether to have surgery is based mostly on the severity of the symptoms.

• If the symptoms are severe and won’t go away, your doctor may consider surgery.
• In more-severe cases, surgery is considered sooner because other treatment options are less helpful.
• In very severe cases, surgery may be recommended to prevent irreversible damage.

Technique. Generally, carpal tunnel surgery is done on an outpatient basis under local anesthesia.

During surgery, a cut (incision) is made in the palm or wrist. The roof of the carpal tunnel is cut. This increases the size of the tunnel and decreases pressure on the nerve.

Some surgeons use a smaller incision and use a small camera (endoscope) to carry out the surgery.

Considerations. Risks from the surgery include bleeding, infection, and nerve injury. Some pain, swelling, and stiffness can be expected. Minor soreness in the palm is common for several months after surgery. Severe problems are rare. You may be instructed to elevate your hand and move your fingers after surgery. This helps minimize swelling and stiffness.

Recovery. Most patients see their symptoms improve after surgery, but recovery may be gradual. On average, grip and pinch strength generally return by about 2 months after surgery. Complete recovery may take up to a year. If significant pain and weakness continue for more than 2 months, your physician may instruct you to work with a hand therapist. If carpal tunnel syndrome has been present longer and the nerve is more severely affected before treatment is attempted, recovery is slower and less complete

SHOULDER

The shoulder is composed of three bones, three joints, and the muscles, tendons and ligaments that connect them. The three bones are the humerus (arm bone), the scapula (shoulder blade) and the clavicle (collarbone). The three joints are the glenohumeral, acromioclavicular, and sternoclavicular.

The largest joint is the glenohumeral joint which is a ball and socket joint made up by the shoulder blade and the arm bone. The socket, or glenoid, is part of the shoulder blade and is very shallow, resembling a golf tee in appearance. The humerus, or arm bone, has a ball on the upper end that rolls in the socket to allow arm motion. Because the socket is not deep, the ball can move freely without the shaft of the arm bone hitting the edge of the socket, which would limit motion. Instead, the shoulder relies on ligaments and a group of tendons called the rotator cuff to hold the ball in the socket. Because the shoulder relies primarily on soft tissue for stability, its range of motion is substantially greater than other joints. However, this also makes the shoulder prone to injury.

The acromioclavicular joint is made up of the collarbone and a part of the shoulder blade called the acromion. It is located almost directly over the glenohumeral joint. In contrast to the glenohumeral joint, there is very little motion at this joint. It is held together by the acromioclavicular and coracoclavicular ligaments. Injuries to these ligaments are known as a ‘separated shoulder’.

The sternoclavicular joint connects the collarbone to the sternum, or breastbone, and helps support the shoulder. It is rarely injured, except in high-velocity trauma, but arthritis may develop in the joint leading to the appearance of a tender bump where the bones connect.

The deltoid muscle is a large powerful muscle, which attaches the shoulder blade and collarbone to the arm bone. Its function is to lift, flex and extend the shoulder joint. It provides most of the power in the shoulder.

The rotator cuff is a group of four muscles that surround the humeral head. They are the supraspinatus, infraspinatus, teres minor and subscapularis. Their job is to stabilize the humeral head in the socket and to assist in elevation and rotation of the shoulder. The portion of a muscle that attaches to bone is referred to as a tendon, and the rotator cuff has four tendons, which are located in a small space between the humeral head and the acromion. If the rotator cuff becomes injured and swells, this small space may lead to further injury and possible tearing, or detachment, of the rotator cuff.

The biceps is a muscle that flexes the elbow and turns the forearm up. It has two attachments to the shoulder blade. One to the coracoid process in the front, which is seldom injured, and one inside the shoulder joint to the top of the socket, which is frequently injured.

Other muscles that attach near the shoulder include the latissimus dorsii in the back and the pectoralis major in the chest. These large muscles act to internally rotate the humerus.

Inside the shoulder joint, the labrum is a cartilage ring that surrounds the socket and makes it deeper. The labrum is soft and flexible, so it can provide an extra layer of stability without interfering with motion. Several ligaments, or fibrous connective tissue that hold bones in position, assist the rotator cuff by helping to hold the ball in the socket.

Mechanism of Injury

The shoulder can be injured as a result of trauma, repetitive use, or degeneration that occurs with age. Trauma is a leading cause of injury in the young. Falls on to an outstretched hand, or falls that lead to a sudden twisting injury to the shoulder can lead to fractures or dislocations. Repetitive use is a common cause of shoulder injury. People whose occupations require a large amount of overhead work, such as plumbers, electricians, carpenters and mechanics are particularly susceptible. Athletes who play sports that require overhead use of the shoulder, such as baseball, tennis, volleyball and swimming, can develop shoulder pain. Finally, as the body ages, it loses flexibility. The same is true for the rotator cuff and ligaments that hold the shoulder in to the socket. They become stiffer and more easily torn. Normal wear and tear on the joint can accumulate over a lifetime, and can lead to tears of the rotator cuff without any specific injury.

ELBOW

The elbow is composed of three bones and the muscles, tendons and ligaments that connect them. The three bones are the radius and ulna, which make up the forearm, and the humerus, or upper arm bone. The elbow is used to carry heavy loads and to position the hand in space. These contrasting tasks require the elbow to be both stable and mobile.

The elbow is a hinge joint, the end of the humerus fits into a notch in the ulna. This allows stable flexion and extension of the elbow. The radius attaches to the humerus at a ball and socket joint, allowing rotation of the forearm and making the hand more mobile.

Four groups of muscles provide motion to the elbow. The flexor-pronator group attaches to the inside of the humerus and flexes the wrist and turns the palm of the hand down. The extensor-supinator group attaches to the outside of the humerus. Its function is to extend the wrist and turn the palm of the hand up. The triceps muscle acts to straighten the elbow, while the brachialis and the biceps muscles flex the elbow. Although the biceps is responsible for some elbow flexion, its primary job is to turn the palm of the hand up. It does this by rotating the radius when it contracts.

Mechanism of Injury

The elbow can be injured as a result of trauma, repetitive use, or degeneration that occurs with age. Trauma is a leading cause of injury in the young. Falls on to an outstretched hand, or falls that lead to a sudden twisting injury to the elbow can lead to fractures or dislocations. Repetitive use is a common cause of elbow injury. People whose occupations require repetitive work, such as carpenters, machinists and typists are particularly susceptible. Athletes who play sports that place stress across the elbow, such as baseball, tennis, golf and softball, can develop elbow pain. Finally, normal wear and tear on the joint can accumulate over a lifetime, and lead to tears of the tendons and ligaments without any specific injury.