09 March 2020
Carpal tunnel syndrome
Carpal tunnel syndrome is a condition where one of the nerves passing into the hand becomes compressed in a short tunnel at the wrist. The main symptom is altered feeling in the hand, especially the thumb, index and middle fingers. The tingling or numbness is often worse at night or first thing in the morning and can be provoked by activities such as gripping the car steering wheel or bike handlebars. If the condition progresses the altered feeling may become permanent and result in weakness of the muscles to the thumb. This can cause difficulty with fine dexterous activities such as buttons on clothing.
Carpal tunnel syndrome commonly affects women in middle age but can occur at any age in either sex. In most cases an underlying cause is not identified however, carpal tunnel syndrome may be associated with any swelling of the tunnel at the wrist including inflammation of the tendons, fractures of the wrist or arthritis. Carpal tunnel syndrome can occur with pregnancy, diabetes, thyroid problems or rheumatoid arthritis.
The treatment of carpal tunnel syndrome in the early stages involves the use of a wrist splint and exercises. In more established cases Mr Brigstocke may suggest a localised steroid injection and in some cases a surgical procedure to release the pressure within the carpal tunnel. This condition responds best to early management to help prevent permanent damage to the nerve and also give the best chance of success with any treatment.
A carpal tunnel release is a short procedure under a local anaesthetic, meaning that the patient can be awake throughout. A small incision (2.5cm) is made at the base of the palm and under direct vision the ligament that forms the roof of the tunnel is divided to relieve the pressure on the nerve. The skin incision is closed with dissolving stitches.
The outcome is usually a permanent resolution of the symptoms with a relief of the night pain and tingling within days. In severe cases improvement of the constant numbness and muscle weakness may be slow or incomplete.
Trigger finger is a painful condition in which a finger or thumb clicks during movement or sometimes locks as it bends into the palm. The triggering is caused as the tendon that moves the digit catches at the entrance to the tendon tunnel. Patients often experience pain in the palm and the symptoms are usually worse on waking in the morning when the digit may become locked in a bent position. In such cases patients may have to pull the finger straight and this can be painful.
Trigger finger is more common in patients with diabetes and rheumatoid arthritis, but can occur in anybody and sometimes is seen following an injury to the hand. It is not a result of osteoarthritis.
Trigger finger (or trigger thumb) is not harmful but can be a really painful nuisance. In the early stages trigger finger can resolve with hand therapy techniques including splinting, stretching and massage. In more established and painful cases it will often respond to a localised steroid injection. If triggering persists Mr Brigstocke may suggest minor surgery to release the tight opening of the tunnel.
Surgical release is a short minor procedure usually performed under local anaesthetic with the patient awake and the hand numb. Through a small incision in the palm, the roof of the tendon tunnel is opened to allow the tendon to glide more freely. The wound is closed with dissolving sutures and light use of the hand can start immediately. The pain relief is rapid and triggering should cease immediately.
Dupuytren’s contracture or Dupuytren’s Disease is a common condition usually arising in middle age and is seen more frequently in men. Firm tender nodules appear within the ligaments just under the skin of the palm and can extend to form cords that can sometimes shorten – resulting in fixed contractures and an inability to fully straighten the fingers.
The cause of Dupuytren’s contracture has been extensively investigated and is most commonly seen in Northern Europeans of Viking descent. Many patients can recollect a relative who may have had contracted fingers at a later stage of life.
There is no cure and unfortunately stretching and exercises cannot prevent the condition from progressing. In cases where the contracture is causing difficulties with daily activities, an early consultation with a hand surgeon is recommended as depending on the nature and extent of the condition, different procedures may be recommended.
Surgery may be carried out under a local anaesthetic or regional anaesthetic and often with the patient awake and the hand numb. Surgery can be broadly classified into a fasciotomy – when the cord is divided with a minimally invasive technique – or a fasciectomy – when the cord is excised with a more extensive open procedure. Mr Brigstocke can advise on the type and timing of any procedure best suited to each individual.
The recovery and outcome from any intervention depends upon the extent and behaviour of an individual’s disease and the type of surgery performed.
Mr Brigstocke is a specialist hand surgeon with a busy practice across the NHS and private sectors. Further information regarding Mr Brigstocke, his consulting hours and locations can be found at www.jointreaction.co.uk.