Carpal Tunnel Release

Carpal tunnel syndrome is a common condition that causes pain, numbness, and tingling in the hand and forearm.

The condition occurs when one of the major nerves to the hand — the median nerve — is squeezed or compressed as it travels through the wrist.

Surgical treatment for carpal tunnel syndrome is relatively simple and patients generally get very satisfying results.

Carpal tunnel syndrome often gets worse over time, so early diagnosis and treatment are important. Early on, symptoms can often be relieved with simple measures like wearing a wrist splint or avoiding certain activities.
If pressure on the median nerve continues, however, it can lead to nerve damage and worsening symptoms. To prevent permanent damage, surgery to take pressure off the median nerve may be recommended.

Anatomy

The structures forming the boundaries of the carpal tunnel are the carpal bones and the transverse carpal ligament. The contents of the carpal tunnel include the median nerve, the flexor tendons of the hand and the tissues surrounding the tendons (tenosynovium).

The space for the median nerve in the carpal tunnel may therefore be reduced by arthritis and other issues with the bones and joints of the wrist or thickening of the tendons or tenosynovium passing through the tunnel.

Certain postures of the wrist will also result in more pressure on the median nerve.

The median nerve originates from nerve roots in the neck. The nerve develops from branches of a network of nerves known as the brachial plexus then passes down the arm and forearm to the hand. It supplies skin and muscles in the forearm and hand. It specifically supplies the palmar skin of the thumb, index and middle fingers. It supplies the muscles at the base of the thumb.

Causes

Carpal tunnel syndrome (CTS) is very common. It is however more common in women and older people. Inherited factors that produce a small tunnel will increase the risk of CTS. Some positions of the hand which involve wrist flexion for a prolonged period (driving, reading, use of the telephone increase pressure on the nerve. Repetitive hand actions may result in swelling of the tendons and tenosynovium passing through the tunnel. Pregnancy causes generalized fluid retention. Carpal tunnel syndrome in pregnancy is very common. Certain medical conditions like rheumatoid arthritis, diabetes and thyroid disease are also associated with carpal tunnel syndrome.

Symptoms

The symptoms of carpal tunnel syndrome include numbness and tingling in the digits of the hand. Typically the symptoms are worse at night and can disturb sleep. Pain or electric shock like symptoms can be experienced in the hand or up the forearm. On rare occasions discomfort may radiate up the upper arm.

Difficulty with fine movements such as doing up buttons may be affected by numbness and weakness of the thumb. Dropping objects such as coffee cups can also occur due to weakness and numbness.

Examination

Dr Hutabarat will look for wasting of the thenar muscles at the base of the thumb and numbness in the thumb, index and middle fingers. Tinel’s test (tapping on the nerve) and Phalen’s test (flexion of the wrist) also may cause some symptoms.

Laboratory tests like nerve conduction tests and EMGs may help to determine if other causes of numbness like peripheral neuropathy are present.

An XR may show arthritis of the carpal bones and an MRI may be useful if other lesions in the wrist are suspected.

Treatment

Treatment varies depending upon the cause of the CTS. If the cause is temporary like pregnancy a temporary solution like a splint may be all that is required. If the cause is a temporary flare of rheumatoid disease an injection and modification of rheumatoid medications may settle the symptoms. 

Medications like non-steroidal anti-inflammatories may decrease pain. Modification of activities to avoid aggravating factors, if this is possible, may be all that is required.

Longstanding carpal tunnel syndrome will result in permanent weakness and a delay in recovery of sensation. Prompt surgical treatment may therefore be preferred in most cases.

There are two surgical operations:

  1. Open carpal tunnel release
  2. Endoscopic carpal tunnel release

Open carpal tunnel release gives good access to the structures in the tunnel and enables visualization of other pathologies that may be involved. Endoscopic release avoids a scar in the palm but does not allow for other structures to be examined. A slightly higher risk of damage to nerves in the hand has also been reported.

At the end of the procedure the tissues are infiltrated with local anaesthetic which will make the wound and the hand numb for a number of hours. The wounds are closed with a horizontal mattress suture that makes the skin edges sit up.

Recovery

After surgery, you will be moved to the recovery room and should be able to go home within 1 or 2 hours. Be sure to have someone with you to drive you home and check on you that first evening. While recovery from knee arthroscopy is faster than recovery from traditional open knee surgery, it is important to follow your instructions carefully after you return home.

  • Pain Management

    After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster. Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anaesthetics. A combination of these medications may improve pain relief, as well as minimise the need for opioids.

    Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to the orthopaedic team if your pain has not begun to improve within a few days of your surgery.

  • Medications

    In addition to medicines for pain relief, you may also be recommended medication such as aspirin, clexane or Xarelto to lessen the risk of blood clots.

  • Swelling

    Keep your leg elevated as much as possible for the first few days after surgery. Apply ice as recommended by your doctor to relieve swelling and pain.

  • Dressing Care

    You will leave the hospital with a dressing covering your knee. Keep your incisions clean and dry. Instructions will be given which will tell you when you can shower or bathe, and when you should change the dressing (usually 1 week). The orthopaedic team will see you in the office a few days after surgery to check your progress, review the surgical findings, and begin your postoperative treatment program.

  • Bearing Weight

    Many patients need crutches or other assistance after arthroscopic surgery. In most cases you will be able to weight bear. If thing differ, Dr Hutabarat will tell you when it is safe to put weight on your foot and leg. If you have any questions about bearing weight, please call the hospital or the rooms.

  • Rehabilitation Exercise

    You should exercise your knee regularly for several weeks after surgery. This will restore motion and strengthen the muscles of your leg and knee. Therapeutic exercise will play an important role in how well you recover. A formal physical therapy program may improve your final result.

  • Driving

    Dr Hutabarat will discuss with you when you may drive. Typically, patients are able to drive from <1 to 3 weeks after the procedure.

Frequently Asked Questions (Knee Arthroscopy)

  • How long am I in for?

    Just the for part of the day. There is a bit of time waiting around before and after the surgery so allow about 4 hours

  • How much does it cost?

    Surgeons charge different fees for many different reasons so it pays to ask around and get other opinions! We do a quote for all our patients. Don’t be afraid to ask questions. We like questions and are happy to answer them.

  • When can I return to sport?

    This depends upon the sport, the level of its intensity and the damage in your knee. We want to get you back as soon as we can and will tailor your return to your situation.

  • When can I get it wet? Or swim? Or surf?

    Generally wounds need to stay dry for two weeks and then we may give a bit more time as a precaution. Dr Hutabarat has his personal method of an early return to the ocean if it’s pumping. This can be discussed on a case by case basis.

  • What about timing for my holidays/travel?

    This is a very important question! Its best to allow 3 weeks before a trip… again it depends on the situation.

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