“Let’s start at the very beginning a very good place to start”
Do-Re-Mi from “The Sound of Music” by Richard Rodgers and Oscar Hammerstein II
If we’re going to talk Hand Surgery there’s no better place to begin than with Carpal Tunnel Syndrome. Carpal Tunnel Syndrome (or CTS for short) is far and away the most common reason that patients see a hand surgeon. CTS is well known among the lay public and almost everyone has heard about it in one way or another. It certainly seems that I am seeing more and more patients with CTS every year. There is also a large amount of misinformation about CTS out there as well, so what I would like to do is cover as many aspects as I can in four separate posts. First we’ll look at exactly what CTS is and isn’t. In Part 2 we’ll talk about how you get it, and the most recent medical data will probably surprise you. In part 3 we’ll talk about how to diagnose CTS. In Part 4 I’ll discuss the treatment of carpal tunnel syndrome and tell you what I thinks works and what doesn’t.
Simply put, carpal tunnel syndrome is a compression of one of the nerves that goes to your hand at the level of the wrist. Carpal is a Latin word that means wrist, so it simply means wrist tunnel. The tunnel is located in the palm of your hand and starts at the point where your wrist bends. There is tight ligament that connects the wrist bones and forms a tunnel. The nerve that gives you feeling in the thumb, index and middle fingers (and also usually half of the ring finger as well) goes through this tunnel. This is called the median nerve. Packed into the tunnel as well are structures called tendons. These come from the muscles in your forearm and attach to your fingers allowing you to bend your fingers. The tendons have a lot of movement (or excursion) so they are covered in a soft tissue called synovium which allows the tendons to glide and move without restriction.
So what then, is carpal tunnel syndrome? Basically there is too much pressure in the tunnel which winds up cutting off the blood flow to the median nerve. The cause of the increased pressure isn’t exactly clear, and I’ll talk about that more in Part 2. Suffice to say for now your nerves are very sensitive creatures and they don’t like it all to have their blood supply decreased or cut off.
The most common reaction of the nerve is to cause numbness and tingling in the hand. This is usually, but not always, in the area the nerve goes to, specifically the thumb, index and middle fingers and half of the ring finger. The most common time this occurs is at night and patients tell me they awaken from a deep sleep with their hands numb and tingling. They usually have to shake their hands (probably to get the blood flowing into the nerve) to get their hands to quit tingling so they can get back to sleep. People also relate that their hands go to sleep while they’re driving a car, working on their hair, reading a book ,working with heavy tools as well as any number of other activities. Some patients have pain, but if the patient has pain without numbness I’m very nervous about making the diagnosis of carpal tunnel syndrome. Patients do have pain with the numbness, and it can occur from the hand all the way up to the shoulder. Interestingly a lot of patients main problem is their pain and it’s not until I ask them about the numbness do they put things together.
In summary, the main thing I’m listening for to see if a patient has carpal tunnel syndrome is whether or not their hand wakes them up from sleep by being numb. This doesn’t happen in every case but it is so common it’s the main thing I look for.
In Part 2 I would like to talk about factors that cause carpal tunnel syndrome and give you an update on what the thinking is now among hand surgeons in the USA.