By Ray



This is one of a number of Medical Checkpoints giving information about common conditions and what you can do about it. Your opinion and reaction to these Medical Checkpoints would be valued and appreciated. Medical Checkpoints are published periodically by NEWSTART Healthcare and are provided as a free service.



from Campbell's Operative Orthopaedics, 8th edition, edited by A. H. Crenshaw, page 3435:


Carpal tunnel syndrome, also known as tardy median nerve palsy, results from compression of the median nerve within the carpal tunnel. It occurs most often in patients between 30 and 60 years old and is five times more frequent in women than in men. Any condition that crowds or reduces the capacity of the carpal tunnel may initiate the symptoms; malaligned Colles' fracture and edema from infection or trauma are among the more obvious, and tumors or tumorous conditions such as a ganglion, lipoma, or xanthoma are among the more frequent.. . . Trauma caused by repetitive hand motions has been identified as a cause of carpal tunnel syndrome, especially in patients whose work requires repeated forceful finger and wrist flexion and extension. Laborers using vibrating machinery are at risk, as are office workers, especially typists and data entry clerks, who spend long hours with the wrists flexed.


What is going on:

The median nerve is a large motor and sensory nerve that lies quite superficially in the center of the wrist before it goes through the narrow confines of the carpal tunnel. The carpal tunnel is about an inch and a half long. The median nerve shares the tunnel with the long flexor tendons that move the fingers. The tunnel is all bone and joints except for the roof which is made of the strong fibrous ligament called the carpal ligament. It is this strong carpal ligament that keeps the contents of the carpal tunnel in place with strong use of the hand and wrist in the flexed wrist position. None of the structures making up the carpal tunnel are pliable or flexible, but rigid and strong. The tendons are the strongest tissue of the body to resist stretch, and so if any encroachment on the space of the carpal tunnel occurs, it is the median nerve that is the most vulnerable tissue to compression. Being a nerve, and all nerves are connected to the brain, it has a direct line to the pain centers and it lets you know about it.


What to do:

1. What to do depends entirely on how much of a problem the pain and paresthesia (tingling, burning etc.) is. It is perfectly normal for the nerve to voice minor discomforts in the rough and tumble of every day life. Most people have hit their "funny bone" at the elbow and experienced pain and paresthesias from trauma to the ulnar nerve at the elbow. This is a usual and customary experience that means that the nerve is working well. This kind of discomfort is not evidence of anything wrong. If the pain wakes you up at night or is constant, then professional medical advice should be sought.


2. Conservative Treatment means treatment other than surgery. The most simple treatment is surgery to give more space to the carpal tunnel, however there are a number of things that are worthwhile to try first in the hopes that they will solve the problem.

a) Pregnancy is often associated with swelling in many tissues of the body. Pregnancy ends, and so does the swelling in the median nerve and usually within a few months after delivery, the wrist pain is a thing of the past.

b) Splints for Rest: One of the most fundamental treatments for any ill is rest. Putting the wrist at rest in a removable velcro strapped on splint will in many cases resolve the pain and paresthesias. The splints are best worn day and night. Often a person sleeps with the wrists flexed which put pressure on the median nerve. The splint helps to prevent this.

c) Hot and Cold Water anti-inflammatory treatments are often useful to reduce the swelling and inflammation in the median nerve. These treatments are best performed with two basins of water into which the hand and wrist is alternately immersed, in the hot water first, then into the cold. Local heat will have the effect of making it feel better while promoting healing and reducing the inflammation. Alternate hot and cold applied locally will increase the blood flow to the part and have the effect of "washing out" the collection of pain chemicals while bringing in the needed repair substances. Heat will ease the pain and help reduce swelling allowing for more normal local blood flow. The best time sequence is about 3 to 1 (e.g. 3 min. hot and 1/2 min. cold). Use a thermometer to measure the heat of the hot water. Start the hot water about 100F (37.7C) and increase the temperature by adding more hot water (without burning yourself) to a maximum temperature of 110F (43C). Add ice to the cold water to keep it cold and end the treatment with cold (at least three hots and three colds). If you have diabetes, peripheral neuritis, or other disease that makes your body part insensitive to temperature consult your professional medical providers before attempting to use hot and cold on yourself.

d) Vitamin B complex: There is some published evidence that taking B complex vitamins by mouth have helped to relieve the pain and paresthesias of carpal tunnel syndrome. We know that B vitamins are used in nerve metabolism. If the patient has a relative deficiency of B vitamins, supplying this lack may improve nerve function and cure the carpal tunnel syndrome.

e) Removing mechanical causes of median nerve irritation such as repetitive wrist motion or improvement of hand and wrist position at typing e.g. instead of resting the weight of the arm on the wrist during typing, to lift the arms and type with the wrists in the air. Use the posture of a pianist at typing. Persons doing heavy work with vibrating tools such as an air hammer, may need temporary or permanent change in working details or change in occupation.


3. Surgery: While surgery is taken as a last resort, it is a simple, rational approach. The surgery consists in dividing the carpal ligament to give the carpal tunnel more room. The carpal ligament heals again giving the carpal tunnel more space. It is not wise to delay surgery until there is nerve damage. Loss of innervation of muscle and nerve damage may be permanent if too far advanced. There are new arthroscopic forms of surgery being developed for carpal tunnel syndrome. The standard open methods have proved their value. In the future some of the newer methods may become of proved value. Time will tell.