Carpal tunnel syndrome and finger swelling

Carpal Tunnel Syndrome (CTS) is a condition that causes numbness and aching in the hand and arm.

CTS becomes worse with excessive or repetitive use of the wrist. The carpal tunnel is a passageway in the wrist formed by eight carpal (wrist) bones, which make up the floor and sides of the tunnel, and the transverse carpal ligament, a strong ligament stretching across the roof of the tunnel.

Within the carpal tunnel are nine tendons which are each about the size of a pencil. These tendons join the muscles of the forearm to the fingers and thumb. As the forearm muscles contract, these tendons move toward the elbow and bend the fingers toward the palm. One other structure within the carpal tunnel is the median nerve which supplies nerve fibers that allow sensation to the thumb, index and middle fingers, and half of the ring finger. In a healthy wrist, the tendons, median nerve, and transverse ligament work in harmony, but in the case where the carpal tunnel contents may swell, the patient can experience a sensation of “pins and needles,” numbness and aching in the fingers, wrist and arm due to increased pressure on the median nerve.

Carpal Tunnel Syndrome can be caused by a variety of problems. Certain medical conditions that may lead to compression of the median nerve include:

• Tenosynovitis (inflammation or swelling involving the tendons) not only causes carpal tunnel syndrome but also may cause swelling in the fingers
• Fluid retention which may be accompanied by finger swelling
• Wrist fractures and dislocations
• Crush injuries
• Rheumatoid arthritis causes significant tenosynovitis as well as swelling and pain involving the fingers
• Other types of arthritis such as gout and pseudogout
• Diabetes
• Tumors
• Hypothyroidism
• Pregnancy
• Repetitive motion or excessive pressure on the carpal tunnel

The most common cause of carpal tunnel syndrome is probably tenosynovitis of the tendons in the carpal tunnel. This causes swelling of the tendons and puts pressure on the nerve. Motions that involve repetitive use of the fingers and wrist cause swelling and an increase in pressure in the tunnel. The fluid retention that accompanies pregnancy also causes pressure on the median nerve and can lead to the symptoms of Carpal Tunnel Syndrome. These symptoms often resolve after pregnancy.

Certain work activities aggravate and produce carpal tunnel. Non-work related activities such as lawn mowing; long-distance driving; knitting; and wood carving may also provoke symptoms of CTS.

Numbness, burning, or tingling of one or more fingers (excluding the little finger) is the most common symptom of CTS. The pain and numbness can happen at any time, but it often occurs at night and may awaken the patient from sleep. At times, the pain may extend up the arm, into the elbow, and as far up as the shoulder and neck. Shaking, massaging or elevating the hands can sometimes provide partial relief. Some patients will drape their hands over the side of the bed.

On the palm side of the hand, just below the thumb, is a bulging pad of muscle called the thenar muscle group. These muscles are controlled by the median nerve. With CTS, this muscle group may begin to atrophy (waste away), giving a flattened appearance to the palm when compared to the other hand.

An accurate history of the onset and duration of symptoms as well as prior injuries and how the hand was used is very important. Several diagnostic tests will be done during the examination that usually recreate the symptoms of numbness and tingling. Sometimes x-rays or magnetic resonance imaging will be required if there is a possibility of fracture or arthritis. Specific laboratory tests may be indicated if an unproven medical condition is suspected. Many patients are referred for electrical tests (nerve conduction and electomyograms-EMG) to assure that there are no other sites of compression of the median nerve.

Sometimes the symptoms can be relieved without surgery. Non operative treatment includes avoiding repetitive use of the hand and keeping the wrist in a straight position with a splint. Most patients sleep better if the splint is worn at night. Non steroidal anti-inflammatory agents decrease the swelling around tendons and may help patients. An injection of cortisone into the carpal tunnel can also relieve the symptoms by reducing the swelling around the nerve.

In cases of severe compression of the nerve or symptoms that persist, surgery may be necessary to open the carpal tunnel. All surgical procedures are designed to open the roof of the carpal tunnel and provide more room for the median nerve. After surgery, the wrist will be sore around the incision for several weeks. Sometimes endoscopic surgery can be performed. The recuperation period is much shorter. The numbness and tingling often disappears quickly but several months are necessary for strength of the hand and wrist to return to normal. Some symptoms may continue after surgery. Returning to repetitive or strenuous work with the hand may cause symptoms to return.

Carpal tunnel surgery, per se, may be a thing of the past. Here’s why…

A much newer and much less invasive technique that has excellent results is percutaneous ultrasound guided release. In this technique, a small needle is inserted using local anesthetic. Using ultrasound guidance, multiple small holes are made in the flexor retinaculum (the tough fibrous roof over the carpal tunnel that compresses the median nerve). At the same time, fluid is injected into the retinaculum to spread and weaken the fibers. At the end of the procedure, the wrist is flexed (bent) and the weakened retinaculum is released. A splint is applied and the patient has full use of their hand by the next day.

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