Carpal Tunnel Release

The carpal tunnel is a thin passage in the wrist. The floor and sides of the tunnel are formed of small wrist bones known as carpal bones.  The roof of the tunnel is made up of strong connective tissue called the transverse carpal ligament.  The tendons that bend the thumb and fingers, known as the flexor tendons, also travel through the carpal tunnel.

Carpal tunnel syndrome (CTS) develops when the median nerve, which runs from the forearm into the palm of the hand and becomes constricted at the wrist.

Carpal tunnel syndrome occurs when the tunnel becomes narrowed or when the tissues around the flexor tendon swell, causing excess pressure in your wrist and on the median nerve.  Usually, a number of factors causes CTS.  Women and the elderly are generally more likely to develop the condition.  Other factors that can lead to carpal tunnel syndrome may include:

Genetics

An important factor in the cause, is that the carpal tunnel may be smaller in some people; a trait that can run in families.

Repetitive hand use

Performing repetitive hand and wrist movements or activities for a prolonged period of time can irritate the tendons in the wrist, resulting in swelling which puts pressure on the nerve.

Positioning of the hand and wrist

Carrying out activities that include extreme flexion or extension of the hand and wrist over an extended period of time can lead to increased pressure on the nerve.

Pregnancy

Hormonal changes throughout pregnancy can result in swelling.

Medical and health conditions

Rheumatoid arthritis, an underactive thyroid gland and diabetes are conditions that are linked with CTS.

Trauma to the wrist

Injury such as a sprain or a fracture can result in swelling and can contribute to the development of carpal tunnel syndrome.

CTS is caused by pressure on a nerve within the wrist.  Usually, the symptoms of carpal tunnel syndrome start gradually without specific injury. However, as the condition worsens, your symptoms can occur more regularly and for longer periods.

Symptoms at night time are very common due to the fact that many people sleep with their wrists bent.  Symptoms often occur during the day if you hold something for an extended period with your wrist bent forward or backward, such as when reading a book.  Symptoms of carpal tunnel syndrome may include:

Numbness or tingling sensations

In some cases, you may notice tingling and numbness in your fingers or hand.  Typically, the thumb and the index, middle or ring fingers will be affected, possibly even experiencing electric shock like sensations in these fingers.

Weakness

Weakness and numbness in your hand can cause you to drop things and create difficulty when performing fiddlier movements such as buttoning up a shirt.  

Make an appointment to see your doctor if you believe you are showing symptoms of CTS, especially if they start to interfere with your normal activities and sleep patterns.

There are no proven approaches to preventing carpal tunnel syndrome, although minimising stress on your hands and wrists can help.  Methods to minimise stress include:

• Relaxing your grip and limiting force
• Avoiding heavy-handed work, typing lightly and using a big pen with a soft grip for long periods of writing.
• Taking small, regular breaks
• Periodically, stretching and bending your hands and wrists.  If you use equipment that vibrates, it is important that you alternate tasks wherever possible.  Even just a few minutes every hour can be helpful. 
• Maintaining a healthy, balanced lifestyle 
• Paying attention to your form.  Try to avoid bending your wrist all the way up or down.  It is advised to keep your keyboard at elbow height. 
• Improving your posture.  Improper posture causes the shoulders to hunch forward, shortening your shoulder and neck muscles and constricting nerves in your neck, resulting in pain. This can affect your wrists, fingers and hands. 
• Using a correct computer mouse.  Ensure your computer mouse is comfortable and does not cause stress or strain to your wrist. 
• Keeping your hands warm.  You are more likely to develop pain and stiffness in your hand if you work in a cold environment. If you are unable to control the temperature, fingerless gloves can keep your hands and wrists warm.

During your assessment, your doctor will discuss your general health and take a full medical history, along with questions regarding your symptoms.  A physical examination will be carried out to determine whether you have carpal tunnel syndrome.

History of symptoms

Your doctor may ask about the symptoms you have experienced, when they started and if there is anything in particular that triggers them.  Be sure to list all of your symptoms and possible causes to enable your doctor to make an accurate diagnosis.

Physical examination

Your doctor will carry out a physical examination to measure the feeling in your fingers and the strength of the muscles in your hand.  The examination will allow your doctor to look at your wrists for signs of tenderness, deformities and swelling.  They will examine your hand, wrist, neck and shoulder to unearth any other causes of nerve pressure.

Imaging tests

You may be referred for imaging tests if a diagnosis cannot be determined through the above methods. These can include:

• X-rays.  An X-ray is not necessarily helpful in diagnosing carpal tunnel syndrome, but may be suggested to rule out any other causes of wrist pain such as arthritis or a fracture. 
• Ultrasound Scan.  Your doctor may suggest an ultrasound of the wrist to evaluate the median nerve for signs of compression.

You may not require carpal tunnel release surgery if your symptoms are mild, you are pregnant or under the age of 30 as they may go away on their own.  You may even be able to ease your symptoms with some lifestyle adjustments such as maintaining a healthy weight and avoiding activities that make the pain or discomfort worse.

If your symptoms are interrupting your everyday life, your doctor may recommend non-surgical treatments such as wrist splints and steroid injections. Wrist splints are more likely to help if you are experiencing mild symptoms and will help support the wrist and keep it in position.  Steroid injections are commonly suggested to treat most mild to moderate cases if a splint has not eased your symptoms.

If your symptoms from CTS are affecting your quality of life and causing daily problems, your doctor may recommend you undergo carpal tunnel release surgery.  Carpal tunnel release surgery takes approximately 20 minutes to perform, usually under a local anaesthetic to ensure you do not feel any pain.  Carpal tunnel release surgery is usually carried out as an outpatient procedure, meaning you will not require an overnight stay in hospital.

Open surgery – Carpal Tunnel Release

Open surgery is a traditional technique used in the treatment of CTS.  The surgeon will begin by making a small incision in the wrist and then cutting the carpal ligament to enlarge the carpal tunnel, releasing pressure on the median nerve.  Following the surgery, the ligament should gradually grow back together.  There will be more space and pressure on the median nerve will be relieved.

Once the procedure has been carried out, the surgeon will close the cut in your skin with stitches and apply a dressing.

After having a local anaesthetic, it may take several hours before any feeling returns to your wrist and hand.  You may feel a tingling sensation in your hand as the anaesthetic wears off, before the feeling in your wrist and hand returns.  You should expect some pain, swelling, and stiffness following your procedure, although this is entirely normal.  Over the counter painkillers such as ibuprofen or paracetamol can be taken to ease any discomfort you may be experiencing.  Elevating your arm will help reduce any swelling and moving your fingers regularly will keep blood flowing that will help with any stiffness.

You will be given advice and instructions on caring for your wound after your operation, along with a date for your follow-up appointment.  This is generally 6 – 8 weeks following your procedure.  It is important that you keep your dressing clean and dry, particularly when bathing or showering as this will reduce your risk of infection.

You may be encouraged to wear a splint or wrist brace for several weeks following carpal tunnel release surgery.  However, driving, light activities, gripping and light lifting may be allowed fairly soon after surgery.  Your doctor will advise you when you can return to work and whether you will have any restrictions on your work duties.

In most cases, the surgery will improve the symptoms of CTS.  Recovery however, may be gradual with complete recovery taking a few days to a few months, or, in some cases, up to a year.

Complications from carpal tunnel release surgery are rare, but as with every invasive surgical procedure, there is a risk of certain complications.  If you are unsure about any of the complications listed below, ask your surgeon to explain how these may apply to you.  For both types of surgery, the risks could include:

• Bleeding or blood clots
• Damage to your median nerve or nearby nerves and blood vessels.  This may result in pain and numbness, which should gradually disappear
• Infection of your wound.  A fever, inflammation and a warm wound may indicate infection
• A scar that hurts to touch.  This minor complication is unlikely to interfere with daily activities
• Re-occurrence of symptoms.  Most people find their painful symptoms disappear after carpal tunnel release surgery; however, there is a chance that they may continue or return.  If this happens, you may need to undergo an additional surgery.

Carpal tunnel release is generally considered a successful surgery, and you will not require any further treatment following your procedure.  However, there is a chance that you will need additional surgery if you experience continued symptoms.

We can book you in to see a Consultant Orthopaedic Hand and Wrist Surgeon for an initial consultation, usually within 48 hours.   In addition to surgery, we perform a number of different hand and wrist surgeries at One Ashford Hospital, including excision of ganglion surgery, Dupuytren’s fasciectomy and trigger finger release.  We are ideally placed to see patients based in Ashford, Kent, Maidstone, Dover, Canterbury, Folkestone and all nearby areas.