Symptoms
Carpal tunnel syndrome is a compression syndrome of the median nerve in the area of the carpus. This area is called carpal tunnel. It is bordered by various bony and muscular structures and a ligament.
The nerve in question runs through it, which, among other things, supplies parts of the hand with motor and sensory information. An incarceration here leads to loss and restriction of motor and sensitive functions of the hand. In order to better understand the symptoms, it is a good idea to find out more about the functions and tasks of the median nerve.
This nerve supplies the first three fingers, i.e. the thumb, middle finger and index finger, with motor functions in parts and the skin in this area is sensitive. In the case of sensitive care, the symptoms show a very characteristic pattern of failure. The nerve supplies the skin of the palm on the thumb side, the skin of the first three fingers and the skin of the ring finger on the thumb side.
On the back of the hand, it supplies the end phalanges of the first three fingers and, to a small extent, the ring finger. In carpal tunnel syndrome, the above-mentioned area of care is subject to sensitive sensory deprivation and even numbness of the skin. The degree of severity depends on the degree of compression.
In addition, the closure of the fist is more difficult in carpal tunnel syndrome because the muscles are no longer properly innervated. In the case of a very pronounced symptomatology and a far advanced compression syndrome, the so-called “oath hand” occurs when the patient is asked to clench his fist. The thumb, index and middle finger can no longer be bent completely and are always in an extended position.
Although this clinical picture is very concise, it does not always correspond to reality. In most cases, only the patient’s motor skills and strength are restricted to such an extent that he or she is no longer able to close the fist as forcefully.The carrying of objects or physical activities, which mainly use the thumbs, is becoming increasingly difficult for those affected. The failures just described show the clinical full picture of a median compression syndrome.
At the beginning of the pinching, symptoms such as diffuse pain and sensations of discomfort (falling asleep, formication) occur mainly during and after the strain on the wrists. The pain primarily affects the hand, but also radiates into the arm. With increasing compression, the complaints occur at night and finally also during the day at rest.
Due to the reduced supply to the muscles, they develop a so-called atrophy, a muscle atrophy. The ball of the thumb flattens out or becomes dented. This can be seen and felt from the outside.
In the further course of the nerve damage, a weakness in gripping occurs, which initially manifests itself mainly in the morning, but then also during the day. In the end, the fine motor skills also suffer from the damage to the median nerve. In this stage of compression, the pain decreases again, as pain fibers are also destroyed.
The diagnosis of carpal tunnel syndrome is first made by means of various tests, such as the Phalen test, the carpal compression test, or the Hoffmann-Tinel sign. In order to understand the diagnostics used when carpal tunnel syndrome is suspected, it is first necessary to understand the cause: Excessive compression of the median nerve in the wrist causes it to swell and is unable to transmit nerve impulses from the brain sufficiently. The median nerve is responsible for the sensitive and motor supply of large parts of the hand.
In order to find out whether carpal tunnel syndrome is present, it is relatively easy to measure the nerve conduction velocity of the median nerve in a side-by-side comparison. To do this, small electrodes are attached to the forearm and an electrical impulse is applied at the level of the elbow. The measurement and the side comparison with the other hand provide information about the presence of a functional disorder.
If – as is usual in many cases – no side comparison is possible because carpal tunnel syndrome is present on both sides, the muscle and nerve logs on the wrist can still be examined using ultrasound. For this purpose, the head of the ultrasound device is placed on the wrist and the cross-section of the arm is shown. The picture shows the individual muscles, vessels and nerves that run along the examined area.
A comparison of the median nerve with the nearby structures allows conclusions to be drawn about any swelling of the nerve. Finally, the diagnosis of carpal tunnel syndrome can of course also be made by clinical examination, in which the various symptoms are examined and intensive research into the causes is carried out. There are, for example, various factors that promote carpal tunnel syndrome.
After pregnancies, it is relatively typical to suffer from carpal tunnel syndrome due to a change in the hormonal balance. However, obesity, trauma or edema in the wrist area can also indicate carpal tunnel syndrome – with the additional presence of restricted mobility and numbness in the hand. However, the diagnosis is not difficult to make.
Furthermore, since no particularly unusual equipment is required for the examination, the examination can usually be performed without prior appointment. The examination is usually completed within half an hour. There are various clinical tests for the examination of carpal tunnel syndrome: The “Phalen test”, named after its inventor George Phalen, is very easy to carry out: the patient bends the hand for a maximum of one minute to check whether there is any loss of sensation in the finger area.
If the Phalen test is positive, this is a sign of carpal tunnel syndrome. Another test is the carpal compression test, in which the examiner applies pressure to the middle of the wrist with both thumbs. After a short time, the examiner stops applying pressure and – as with the phalen test – any loss of sensation in the hand is determined.
This loss of sensation is also known as paresthesia, and in everyday medical practice is known as the “Hoffmann-Tinel sign”. The Hoffmann-Tinel sign is therefore also considered to be an indication of carpal tunnel syndrome. The above-mentioned tests are very simple and can also be carried out without medical help, for example together with your spouse.However, if carpal tunnel syndrome is suspected, a doctor should be consulted for final diagnosis and treatment.
Although carpal tunnel syndrome cannot be diagnosed by means of an X-ray examination, this examination is nevertheless useful. Other diseases associated with carpal tunnel syndrome are often found (e.g. arthrosis of the thumb saddle joint). In most cases, magnetic resonance imaging (MRI) is not useful.
Only in the case of a concrete suspicion of a tumor is such a complex examination useful. A carpal tunnel syndrome does not always require surgery. In the so-called early stages, the administration of vitamin B6 is often sufficient.
Under certain circumstances, the therapy can be additionally intensified by a specially adapted nocturnal positioning splint. In the event that there is no improvement in pain in the medium term and to prevent irreversible damage to the nerves, surgery should be considered. The decision as to whether or not surgery is appropriate should be weighed up carefully.
An experienced nerve specialist (neurologist = specialist for neurology) or hand surgeon can help you with this. Carpal tunnel syndrome causes compression of the nerves and blood vessels in the wrist area. This compression is promoted by bending the hands, for example when gripping or lifting.
In the beginning, one can “shake out” the hands to get rid of the annoying tingling sensation, but in advanced stages this hardly provides any relief. If the carpal tunnel syndrome is not yet too far advanced, conservative therapy by means of immobilization can be used in addition to surgery. The aim is to reduce the pressure on the nerves and blood vessels in the wrist.
For this purpose there are several different splint systems that splint and fix the hand. In principle, splints and bandages do not differ in their function, but in their material and wearing comfort. Each manufacturer naturally advertises its product with different advantages, but in the end it is of course the patient’s own decision whether to choose a bandage or a splint.
Different models can be tried on in specialist stores. It is also possible to adapt them individually. However, it is important to make sure that – regardless of which type of immobilization is ultimately chosen – the original purpose of the splint is not forgotten.
Fixation of the wrist is inevitably uncomfortable, as it restricts the patient’s physiological freedom of movement. Splints have the advantage that they can be easily removed with a Velcro fastener and the area underneath can be washed. In addition, the firm plastic plates in the splint protect the wrist from external influences.
However, there is a risk that the splint is not worn consistently enough and that the possibility of easy removal may cause a worsening of carpal tunnel syndrome. Bandages, on the other hand, enclose the wrist tightly and protect it against injuries from external influences by means of integrated fabric pads. If a rigid plastic plate is too uncomfortable for splinting, a bandage is certainly a good idea.
However, it should be borne in mind when choosing a bandage that it is not an “accessory”, but a medical product that must also fulfill a certain purpose. Neither the bandage nor the splint should fit so tightly that it causes pain or further numbness. However, immobilization of the wrist must have top priority, since further deterioration of carpal tunnel syndrome can usually only be treated with surgery.
Carpal tunnel syndrome requires therapy, as the nerve damage can progress, especially if it is severe and the compression persists for a long time. In general, a conservative therapy may be sufficient for mild compression and mild symptoms. This includes gentle measures and immobilization of the hand, which can be achieved, for example, with a splint and painkilling and anti-inflammatory medication.
If the symptoms persist or the compression of the nerve is already well advanced, surgical treatment is necessary. There are two common surgical techniques used in carpal tunnel syndrome. In the following, the procedures, complications and postoperative treatment of the surgical therapy are explained in more detail.Carpal tunnel syndrome surgery is a relatively unproblematic, quick procedure and is rarely associated with complications.
For this reason, the surgery is usually performed under regional anesthesia, so that the patient is conscious during the entire procedure, while pain elimination only occurs in the arm. An alternative is a local anesthetic procedure directly on the nerve plexus that supplies the arm. The nerve plexus passes through the armpit and can usually be anaesthetised without any problems with the aid of an ultrasound device.
General anesthesia is very unusual for carpal tunnel syndrome surgery, however, and is usually used when the patient feels very anxious about the procedure. The operation can be performed open or endoscopically. With the open surgical technique, the surgeon has a direct view of the surgical field.
First, a small skin incision is made approximately in the middle of the palmar side of the wrist. Palmar means “facing the palm of the hand”. The incision runs along the wrist and is about 3 cm long.
The surgeon must be careful not to cut too far on the thumb side or too far on the little finger side in order not to injure important nerves. Caution is required especially on the small finger side, as this is where the so-called Guyon’s box is located. This is an anatomical area, a loge, in which the important ulnar nerve is located.
It supplies the muscles of the hand and the skin, sometimes sensitively. In principle, the surgeon can vary the incision technique during the operation, e.g. there is also the short incision technique. In the end, however, the ligament that delimits the carpal tunnel hollow-handed and spans the carpal bones must be cut in every operation.
This ligament is called retinaculum musculorum flexorum. The severing of the ligament leads to an immediate relief of pressure in the carpal canal and consequently to a recovery of the compressed median nerve, provided the damage has not progressed too far. No further surgical intervention on the nerve itself is necessary.
This operation is a routine procedure for hand surgeons, and is usually performed without complications. In the endoscopic procedure, the surgeon has an indirect view of the surgical field. He sees it through the endoscope.
The course of the operation is the same as with the open technique. However, this procedure seems to be more comfortable for the patients due to less scar pain. On the other hand, there may be higher complication rates.
How long the surgical treatment of carpal tunnel syndrome takes depends on many factors. On the one hand, the procedure and experience of the doctor play a major role. On the other hand, the individual anatomical conditions of the patient are always important.
In general, an uncomplicated carpal tunnel syndrome operation hardly takes more than a few minutes. Once the operation is completed, the patient remains in the practice for some time for observation. To ensure that the surgical wound heals without complications, the wrist remains in a firm bandage or possibly even a plaster cast for the next 7 to 10 days.
Threads are removed about 8 to 14 days after the operation. About 6 weeks after the operation, in most cases there is hardly any scar left. Moving the hand is possible and also recommended for the first few weeks after the operation, but more than a light load should be avoided in order to ensure good wound healing.
In general, complications that can generally occur during surgery, such as post-operative bleeding and infections, are quite rare. In very rare cases, a so-called algodystrophy can occur, which is characterized by severe pain. Too small skin incisions can lead to complications during surgery, as the ligament to be separated (Retinaculum musculorum flexorum) cannot be completely split.
In addition, the risk of complications is higher with endoscopic procedures than with the open surgical technique. On the other hand, the scars heal faster in this case. It may also be necessary to switch to an open technique during an endoscopic procedure due to complicated anatomical conditions.
Overall, however, these are operations with low risks and few complications. The long-term success is also very good. Most patients are very satisfied to complain free after the operation.The more other illnesses there are, for example diabetes, rheumatism or arthrosis, the poorer the surgical result.
In case of pain, pain-relieving medication can be taken. Cooling also helps against swelling and pain. The hand should not be completely immobilized, but moved slightly to avoid joint stiffness.
Overloading and heavy physical activity should be avoided for the first few weeks, however. Once the operation has been performed, the patient remains in the practice for some time for observation, for example to rule out side effects of the anesthesia. Since the effect of the anesthesia can last up to several hours, depending on the type of anesthesia chosen, it is not recommended that you go home alone or even drive a car afterwards.
In addition, unproblematic healing of the surgical wound is only guaranteed if the hand is spared for the next 7 – 10 days, so that for this reason, too, independent driving is not recommended for the time after the operation. As with all operations, scarring problems can occur. In addition, there may be a reduction in strength in the first six months after the operation.
In the rarest cases, there is a possibility of algodystrophy developing. This algodystrophy includes both motor and sensitive disorders. Homeopathic healing approaches exclude conventional medical treatment for carpal tunnel syndrome per se.
Patients there are often advised against surgery and advised to use alternative methods such as massage, acupuncture and treatment by a chiropractor. In general, there is nothing wrong with massage, but acupuncture or treatment by a chiropractor can also alleviate the symptoms. However, it is questionable whether such methods are really effective, especially in cases of advanced nerve compression.
They cannot permanently eliminate the cause of the compression, namely the bottleneck in the carpal tunnel. Furthermore, homeopathic remedies, which are produced on a herbal basis and are available in the form of globules, drops or ointments, are used in homeopathy. The recommended remedies are Arnica D4, Ruta D4 and Hekla lava D4. There is also a complex remedy called Traumeel®. This is available both as an ointment and in the form of tablets.
