Carpal Tunnel Syndrome is the most common nerve compression syndrome with characteristic symptoms and signs due to pressure on one of the main nerves of the hand, the median nerve, at the wrist.

Most commonly there is no specific cause identified, known as idiopathic. The tunnel in the syndrome is formed by a tough ligament (transverse carpal ligament or flexor retinaculum) and by the curved carpal bones. The ligament helps keep the structures (9 tendons and 1 nerve) that pass under it in place and provide protection for the nerve. It can arise due to swelling of the contents of the canal or thickening of the ligament.

• Age – may occur at any age but increases with age.
• Genetic – female > male.
• Degenerative – arthritis (Osteoarthritis or inflammatory).
• Hormonal – pregnancy, postmenopausal, thyroid problems, growth hormone.
• Trauma – wrist and scaphoid fractures, dislocations.
• Fluid retention – pregnancy, kidney problems.
• Neck Problems – double crush phenomenon.
• Medical Conditions – obesity, diabetes, high cholesterol.
• Toxic – smoking (poor circulation), alcohol.
• Postural – prolonged position of the wrist in flexion or extension.
• Work – controversial.

• Numbness and tingling in the thumb, index, middle and half of the ring finger on the palm side especially with activities that require prolonged positions of wrist flexion or extension.
• Waking from sleep with tingling in the hand, sometimes pain, often relieved by shaking the hand with it hanging over the side of the bed.
• Difficulty with fine motor activities, for example, doing up buttons, due to loss of sensation.
• A weakness of the hand, due to loss of muscle power in the muscles at the base of the thumb.
• May develop pain radiating up into the forearm.

• A decreased sensation on testing with “monofilaments” in the distribution of the median nerve.
• Decreased muscle power in the thumb.
• Reproduction of symptoms with pressure over the nerve or flexing the wrist.
• Electric shock like sensation when tapping over the nerve.

• Often none required, as is a clinical diagnosis.
• May perform nerve conduction study (NCS) or electromyography (EMG) to test how the nerve is working if symptoms are not typical or to give a guide as to severity.

• Treat the underlying cause.

Steroid injections have the best results if the symptoms are intermittent and have been present for less than a year. The literature suggests about 80% success rate in relieving symptoms. They may however recur. Splinting avoids the positions that reproduce the symptoms. They hold the wrist in a position of slight wrist extension and are made out of a lightweight plastic material. It also can be worn at night.

• Open or endoscopic carpal tunnel release.
• My preference is to perform a mini-open carpal tunnel release. The incision is usually less than 2cm in length – it is done as a day procedure often under local anaesthetic.
• A soft dressing is used post operatively and the hand can be used for light activities from day 1. The sutures are removed at 2 weeks post op and heavy lifting is avoided for 6 weeks.

The most common sites are:

• The back of the wrist. (Dorsal Wrist Ganglion) see opposite.
• Palm side of wrist (Volar Wrist Ganglion).
• Near the tip of the finger around the nail (Mucous Cyst).
• Around the tendons in the finger (Flexor Sheath Ganglion).

The cause is usually not clear but they may appear after an injury. Often they cause no symptoms but can be painful if pressed on by surrounding structures. This may occur with heavy activities or extremes of motion.

• Usually clinical.
• Ganglions tend to occur in characteristic locations.
• Often plain x-rays are obtained to ensure no bony abnormalities.
• Ultrasound will help with diagnosis, location and likely place where the cyst arises from. Occasionally an MRI for deep-seated cysts.

• Based on symptoms and location.
• The reasons to remove ganglions are for pain, dysfunction and cosmesis.
• They may spontaneously resolve so observation is an option if it is not symptomatic.
• Aspiration / Injection, quoted 50% recurrence rate.
• Surgical Resection, 5-10% recurrence rate.
• This can be done open or arthroscopically.

The old fashioned treatment (especially dorsal wrist ganglions) was to hit with a large book to “pop” the cyst, traditionally a bible.

A bending force to the tip of the finger leads to the tendon that straightens the tip becoming incompetent. This can be due to the tendon itself being pulled off the bone or a fracture of the bone with the tendon attached to it.

This leads to the tip of the finger “sagging” which can worsen with time and importantly can lead to a problem with the joint adjacent to it which can be even more disabling “swan neck deformity”.

Initially clinical with a loss of extension of the tip of the finger. An x-ray should be obtained to determine if there is a bony fracture and to make sure that the joint is reduced.

The majority of these injuries can be treated non-operatively with splinting alone. The length of time the splint is worn depends on whether the injury involves the bone or not.

Tendon takes longer to heal than bone, therefore:

Tendon only: Splint for 8 weeks full time than night splint for a further 4 weeks.

Bone: Splint for 6 weeks full time and then night splint for 4 weeks.

During the period of splinting the other joints in the finger need to be moved to maintain motion.

As the splint is weaned, motion should be gradually regained to protect the tendon, especially in tendon avulsions.

Not usually needed. The main need for surgery is if the joint is unstable and starts to dislocate, usually due to a relatively large fracture fragment. The results of surgery in simple cases are inferior to non-operative treatment.